Industry-sponsored business strategies

Some companies have modified business models to align with consumer demand for healthy lifestyles by identifying new target markets and marketing niches whereby healthy lifestyles can be profitable. Relevant business strategies include: developing new products with healthier nutrient profiles; reformulating existing products; using front-of-pack symbols to identify healthier products; packaging smaller portions; supporting employee and community wellness programmes; providing information to encourage healthy diets and active lifestyles; and merging with companies whose products are in healthier market segments^{(14, 53,} Reference Bennett, Boles and Crossley⁵⁴⁾. For example, Danone has produced detailed nutrition maps and modified the formulation of its products in eight countries where it has markets⁽Reference Langlois and Crossley²⁸⁾. The Walt Disney Company has committed its brands and spokescharacters to support products and healthy behaviours across all global media businesses including parks and resorts, media networks, third-party licensed products and new child-targeted branded products⁽⁵⁵⁾. Transnational companies can potentially increase their reach and influence health-related consumer behaviours by making commercial messages consistent across all media and marketing venues, and investing resources in environments that sustain mutually reinforcing behaviours (i.e. improving dietary intake, increasing physical activity levels and reducing leisure screen time)⁽⁵³⁾.

Many transnational companies have their own branded healthy-lifestyle initiatives and marketing campaigns. Such approaches may convey that a company is addressing obesity while concurrently raising brand presence and highlighting healthier portfolio products^(53, Reference Bennett, Boles and Crossley⁵⁴⁾. While most initiatives focus on influencing individual consumer behaviours, certain brand-philanthropy activities and public–private partnerships also support healthy lifestyles at the community level.

Public–private partnerships

In the USA, the Coalition for Healthy Children⁽⁵⁶⁾ and the Small Step campaign⁽Reference Arthur^{57, 58)} are two public–private partnerships that use research-based messages to ‘sell healthy lifestyles’ to Americans. The Convergence Partnership’s Healthy People in Healthy Places encourages market-based changes to create opportunities that enhance access to healthy food and physical activity⁽⁵⁹⁾. Shape Up Europe is a partnership supported by the European Commission’s Health and Consumer Protection Directorate (DG SANCO) and Kraft Cares, which promotes healthy lifestyles to children and parents through programmes in twenty-five cities within EU countries⁽¹³⁾. While these approaches are promising, their benefits will depend on addressing several pitfalls discussed in the next section.

Consumer behaviour

Several factors may limit the effectiveness of commercially marketed healthy-lifestyle initiatives and social-marketing campaigns. For child-oriented marketing these include the combination of: innate eating-related predispositions; certain culturally based child-feeding practices; and social and economic environments that reinforce dietary excess and physical inactivity. Children’s eating behaviours are now often developing under unprecedented conditions of dietary abundance, where palatable, inexpensive, energy-dense and nutrient-poor foods and beverages are readily available⁽Reference Savage, Orlet Fisher and Birch⁶⁰⁾. Infants are born with biological preferences for sweet, salty and fat flavours, and high energy-dense foods. Yet they also have inadequate behavioural control mechanisms for self-regulating their energy intake and satiety in the presence of dietary abundance⁽Reference Savage, Orlet Fisher and Birch⁶⁰⁾.

Consumer research indicates that children and their parents value taste, cost and convenience over health in making purchasing and consumption decisions, especially if the healthy choice is more expensive⁽Reference Wansink and Huckabee⁶¹⁾. Secular trends show an increase in portion sizes and consumption norms, revealed by larger product packages and portions sold in grocery stores and restaurants, and larger kitchenware at home, that collectively influence young consumers’ perceptions of what is normal and appropriate to serve their families and consume for themselves⁽Reference Wansink and van Ittersum⁶²⁾. Effective marketing of larger energy-dense food portions undermines children’s diet quality and appropriate energy intake to achieve energy balance and a healthy weight⁽Reference Colapinto, Fitzgerald, Taper and Veugelers⁶³⁾.

Industry behaviour

Despite industry innovations to promote healthy lifestyles, the predominant marketing of products, aspirations and behaviours to young people is currently inconsistent with healthy lifestyles. An evaluation of the leading twenty-five food and beverage, food retailer and restaurant companies found that not one has yet publicly conveyed a clear strategy or set of objectives applicable to its entire business to respond to consumer health and obesity issues worldwide⁽Reference Lang, Rayner and Kaelin⁶⁴⁾. An analysis of food and beverage products targeted to American children and youth by leading companies from 1994 to 2004 found that most products were high in total energy, sugar and fat and low in nutrients⁽¹⁴⁾.

Some assessments have found egregious industry practices. A tendency to alter information about potential adverse health effects of some products has been reported, where companies sponsoring research on their own products are less likely to report unfavourable effects or may modify the study design to highlight product benefits and minimize adverse effects⁽Reference Lesser, Ebbeling, Goozner, Wypij and Ludwig⁶⁵⁾. Although industry self-regulation is undergoing positive changes, some companies continue to engage in misleading advertising to children. An analysis of thirty-seven child-targeted product brands found that two-thirds of the product packages advertised to children and parents promoted images or references to fruit but contained little or no fruit and added sweeteners, thereby delivering minimal nutritional benefits⁽Reference Mikkelsen, Merlo, Lee and Chao⁶⁶⁾. Assessments of Nickelodeon, the television network most watched by American children, found that a majority of foods marketed by this entertainment company are of poor nutritional quality despite public commitments to change their marketing practices⁽Reference Batada and Wootan^{67, 68)}. Limited data are available to independently assess the speed and magnitude of industry’s progress towards achieving commitments to reformulate and promote healthier products^{(14, 53,} Reference Lang, Rayner and Kaelin⁶⁴⁾.

Food, beverage and restaurant companies may focus attention and resources primarily on physical activity, implicitly de-emphasizing the role of food quality and portion size in achieving energy balance and reducing obesity risk. An exclusive focus on physical activity is insufficient to offset the excess energy consumption associated with marketing practices that promote unhealthy diets⁽Reference Ludwig and Nestle⁶⁹⁾. Furthermore, sponsorship of international sporting events by fast food and beverage companies has raised scrutiny about whether physical activity events should be used to promote unhealthy products and behaviours. Such sponsorship may also produce other adverse effects including corporate expansion in countries with emerging markets and undermining domestic health legislation⁽Reference Collin and MacKenzie⁷⁰⁾. Corporate philanthropy motives reveal that companies support programmes to enhance corporate reputation and gain knowledge about potential new markets⁽⁷¹⁾.

Although public health practitioners and advocates recognize that social marketing can positively influence health behaviour⁽Reference Grier and Bryant^{38, 39)}, commercial marketing motives are often mistrusted. Historically this was not always the case. During the 1920s and 1930s, US public health practitioners partnered with food companies to develop reinforcing messages that strengthened emerging social norms to address childhood undernutrition⁽Reference Lovett⁷²⁾. Addressing undernutrition involves producing and distributing more food, which are more compatible responses with current industry business models than reducing food and beverage consumption to prevent childhood obesity. Childhood obesity poses a dilemma for the food, beverage and restaurant industry sectors if solutions lead to reduced food and beverage product sales, profits and market share⁽Reference Ludwig and Nestle⁶⁹⁾. In this sense, scepticism about industry motives is appropriate; companies must make a profit to remain economically viable. Sedentary entertainment company profits (e.g. advertising revenue or sales of games and devices) may also be adversely affected by initiatives that limit young people’s screen time. Interactive videogames may increase children’s physical activity levels⁽Reference Lanningham-Foster, Jensen, Foster, Redmond, Walker, Heinz and Levine⁷³⁾ but inadequately to offset excessive energy consumption to achieve a healthy weight.

Although justified, scepticism about industry motives may complicate public–private collaborations. When public health and corporate goals conflict, corporate profit imperatives often trump public health imperatives⁽Reference Lewin, Lindstrom and Nestle⁷⁴⁾. Some have questioned whether industry should be entrusted to convey public health education by using advertising as a solution to address a problem attributed to excessive advertising⁽Reference Schor and Ford⁷⁵⁾. Others have advocated for a new social norm that eliminates marketing to children⁽Reference Swinburn, Sacks, Lobstein, Rigby, Baur, Brownell, Gill, Seidell and Kumanyika^37, Reference James, Rigby, Leach, Kumanyika, Lobstein and Swinburn⁷⁶⁾, and for instituting appropriate checks and balances to align the financial interests of industry with the goals of public health⁽Reference Ludwig and Nestle⁶⁹⁾. There is also controversy over using branding, celebrity endorsement and licensed cartoon spokescharacters to market to children who are not cognitively mature enough to understand the purpose of persuasive intent^(14, Reference Swinburn, Sacks, Lobstein, Rigby, Baur, Brownell, Gill, Seidell and Kumanyika^37, Reference Gosliner and Madsen⁷⁷⁾. The concern relates to the use of these strategies to promote high-energy and nutrient-poor products⁽Reference Linn and Novosat⁷⁸⁾ and messages inconsistent with healthy lifestyles, and also to any strategy that may directly or indirectly increase children’s brand loyalty for a company’s unhealthy product line.

Companies may pressure non-profit organizations to enter cause-related marketing relationships that use co-branding to promote unhealthy food and beverage brands in exchange for unrestricted funds that support all programmes. The results may undermine the credibility of non-profit organizations and may facilitate access to clients to enhance the marketing of energy-dense products. Using non-profit organizations as marketing liaisons may be particularly problematic for organizations supporting anti-hunger, child development, education and emergency response programmes. Failure to partner with companies in ways that facilitate marketing of certain products may result in overall loss of financial support from companies or corporate foundations. Thus, non-profit organizations will need to negotiate different terms of engagement to support effective partnerships.

In the current childhood obesity context, there are examples of branded, healthy-lifestyle social-marketing campaigns funded by both public and private sources⁽¹²⁾. However, campaign messages may differ from commercial marketing messages, even those supported by the same company. Overall, social-marketing campaigns are unlikely to compete with transnational company marketing investments because most are not commercially driven and do not have comparable resources to support long-term population health goals⁽Reference James, Rigby, Leach, Kumanyika, Lobstein and Swinburn^76, Reference Kraak and Pelletier⁷⁹⁾. Social marketers also do not have easy access to proprietary commercial marketing research to design effective programmes to influence young people’s behavioural changes^{(14, 53)}. Developing a mechanism to share proprietary commercial marketing data with the public sector may help to design effective healthy-lifestyle initiatives for young people to deliver coordinated commercial and social-marketing messages and interventions with greater transparency across diverse media channels and national borders.

Emergence of obesity in low- and middle-income countries

A substantial challenge for developing countries is the unsolved problem of undernutrition (i.e. underweight, stunting and micronutrient deficiencies), which may coexist with obesity in the same communities or households⁽Reference Barquera, Peterson, Must, Rogers, Flores, Houser, Monterrubio and Rivera-Dommarco^80, Reference Garrett and Ruel⁸¹⁾. Commercial marketing should address both undernutrition and obesity prevention in a coherent and strategic manner⁽Reference Ezzati, Vander Hoorn, Lawes, Leach, James, Lopez, Rodgers and Murray^82–Reference Popkin⁸⁴⁾. Marketing strategies that encourage consumption of high-energy foods may be encouraged in communities where hunger and food insecurity exist. Transnational companies that have adopted healthy-lifestyle marketing practices in affluent countries may not employ these practices consistently in low- and middle-income countries⁽⁸⁵⁾ where there are limited self-regulatory codes⁽Reference Hawkes⁴³⁾.

Connecting healthy lifestyles to healthy communities

Institutionalizing and connecting healthy-lifestyle initiatives to those that aim to create healthy communities will assist young people to achieve energy balance and a healthy weight. Individuals and interest groups can be effectively mobilized to influence policy makers to develop healthy communities and expand the range of healthy choices⁽⁸⁸⁾. Changing people’s environments can lead to conflicts between and among different sectors and interest groups due to altering the access, use and distribution of resources or by creating constraints on preferred behaviours; however, these conflicts must be effectively addressed⁽Reference Dorfman and Wallack⁸⁹⁾.

Ensuring effective accountability mechanisms

Accountability mechanisms should be established for corporations by representatives of governments, industry sectors, public health and consumer advocacy constituencies. These mechanisms should be transparent, reinforcing and receptive to diverse stakeholder input. One mechanism is for companies to publically report progress for integrating healthy-lifestyle initiatives consistently across all business strategies and promotional activities. Available evaluations have found that few companies have established key performance indicators relating to the use of external groups to assess their progress or publicly communicated a coherent response for marketing across all product lines and divisions⁽Reference Langlois and Crossley^{28, 53,} Reference Lang, Rayner and Kaelin⁶⁴⁾.

Strengthening industry self-regulatory codes for advertising and marketing to children is a second accountability mechanism. In Canada, sixteen leading food and beverage companies pledged to market more responsibly through the Canadian Children’s Food and Beverage Advertising Initiative and focus their advertising on healthy active living by the end of 2008^(90, Reference Cook⁹¹⁾. Although Advertising Standards Canada will audit compliance and publish annual reports, concerns have been raised to increase transparency and ensure company commitments because there are no clear enforcement mechanisms or penalties for non-compliant companies, and the information used to assess compliance will not be publicly released⁽Reference Cook⁹¹⁾.

In the EU, eleven leading food and beverage companies pledged to make voluntary changes affecting advertising to children and to publish the policy commitments by the end of 2008⁽⁹²⁾. Several steps have been documented by the EU’s Platform on Diet, Physical Activity and Health to strengthen industry accountability, which include: providing training to establish self-regulatory organizations; encouraging stakeholder involvement; and raising awareness to adopt the International Chamber of Commerce’s Framework for Responsible Food and Non-Alcoholic Beverage Communications⁽⁹³⁾.

In the USA, the US Council of Better Business Bureaus (CBBB) and the National Advertising Review Council announced revisions to the Children’s Advertising Review Unit’s Self-Regulatory Guidelines⁽⁹⁴⁾ and established the Children’s Food and Beverage Advertising Initiative (CFBAI)^{(95, 96)}. The CFBAI represents fifteen of the largest food, beverage and restaurant companies advertising to children that have pledged to shift advertising messages to encourage healthy diets and lifestyles to children younger than 12 years⁽⁹⁷⁾. In July 2008, the CBBB released its first compliance report for thirteen CFBAI-participating companies⁽⁹⁸⁾. A Federal Trade Commission (FTC) report was also released, acknowledging company improvement⁽⁹⁹⁾ that aligned with recommendations in an earlier government report⁽¹⁰⁰⁾. However, the FTC Commissioner noted that further industry improvements are essential to ensure that company pledges apply to all forms of marketing directed to children⁽¹⁰¹⁾. Industry-supported self-regulatory codes that address only selected advertising practices, instead of the full range of companies’ marketing practices, are unlikely to have broad-reaching effects to reduce unhealthy products and behaviours. Independent assessments of industry commitments are critical to evaluate progress and to improve the effectiveness of healthy-lifestyle marketing.

A third accountability mechanism would be for WHO to adopt an International Code on Marketing of Foods and Non-alcoholic Beverages to Children⁽⁴⁰⁾. However, the code would need to address a vast array of energy-dense, low-nutrient food and beverage products, many types of marketing vehicles and venues, and the role of the sedentary entertainment industry in marketing products to children with unhealthy nutrient profiles. Enforcing professional codes of conduct with respect to public–private partnerships is a fourth accountability mechanism. Guidelines are available to assist organizations to clarify the purpose, terms and management of private-sector engagement⁽¹⁰²⁾. Academic institutions have developed similar guidelines for industry interactions⁽¹⁰³⁾, and foundations are establishing criteria for prospective grantees making them ineligible for obesity prevention research support if they receive funding from businesses that market low-nutrient food or beverage products to children⁽¹⁰⁴⁾.

Evaluating healthy-lifestyle outcomes

Government and private-sector healthy-lifestyle initiatives and public–private partnerships should be evaluated to assess the collective progress made towards achieving positive outcomes. Monitoring and evaluating a range of outcomes can provide insight into anticipated progress and unintended consequences. Frameworks have been developed by the WHO⁽¹⁰⁵⁾, the EU Platform⁽¹⁰⁶⁾ and the IOM⁽⁵³⁾ to assess progress made towards achieving a range of obesity prevention outcomes across different sectors and settings.

Leveraging resources to promote healthy lifestyles

Adequate resources must be identified and mobilized over the next several decades to reorient the globalized marketing and media environments to promote healthy lifestyles. Resources supporting an optimal policy response must reflect a country’s specific context, including social, political and legal environments, and must be sufficiently resilient to respond to future policy needs as the global marketplace changes. There must be potent and consistent embedding of healthy lifestyles to transform societal expectations, social norms and consumer behaviours over a sustained time frame. Resources can be generated through public–private partnerships and industry innovation but transparency and accountability mechanisms must be firmly established. If we are to have a measureable impact we must plan for a global public–private investment in healthy lifestyles and obesity prevention that is adequate to address the scope of the problem. The combined government and private-sector resources totalling more than $US 50 billion leveraged to address HIV/AIDS, tuberculosis and malaria in developing countries^{(107, 108)} provides a potentially relevant precedent for obesity prevention in resource-constrained countries experiencing undernutrition and obesity as a double burden.