The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report

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A Policy Brief for national and municipal governments, civil society, funders, businesses, and international agencies

The Global Syndemic — A Policy Brief

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The Report of the Lancet Commission on Obesity demonstrates that the pandemics of obesity, undernutrition, and climate change represent the paramount challenge for humans, the environment and our planet. As we describe below, these interacting pandemics represent The Global Syndemic with common, underlying drivers in the food, transport, urban design, and land use systems. Strong and concerted efforts are required by multiple actors to implement double-duty and triple-duty actions to address the systems that drive The Global Syndemic. These synergistic actions will be essential to achieve planetary health, which we define as the health and wellbeing of humans and the natural environments we depend on.

Societal Costs of The Global Syndemic

The health gains achieved over the past 50 years of global economic development could be reversed over the next 50 years due to the consequences of climate change. Other non-monetised costs, such as the loss of human potential, social inequities, societal disruption, environmental damage, and loss of biodiversity, are enormous and overshadow the economic costs. The societal costs of The Global Syndemic are extensive and disproportionally affect poor people and low-income countries.

Obesity: Excess body weight affects over 2 billion people worldwide and accounts for approximately 4 million deaths annually. The current estimated economic costs of obesity are approximately 2.8% of the world’s gross domestic product (GDP).

Undernutrition: In Asia and Africa, undernutrition costs 4-11% of GDP. In 2017, 155 million children were stunted and 52 million children were wasted. Two billion people suffer from micronutrient deficiencies, and 815 million people are chronically undernourished.

Climate change: Estimates of the future economic costs of climate change are 5-10% of the world’s GDP, with costs in low-income countries that may exceed 10% of their GDP.

Policy Inertia

The policy responses from national governments to obesity, undernutrition and climate change as separate problems have been slow and inadequate. This policy inertia stems from the reluctance of political decision-makers to implement effective policies, powerful opposition by vested commercial interests, and insufficient demand for change by the public and civil society. Undernutrition is declining too slowly to meet global targets, no country has reversed its obesity epidemic, and comprehensive policy responses to the threat of climate change have barely begun.

The Global Syndemic Narrative

Malnutrition in all its forms, including undernutrition, obesity, and other dietary risks for non-communicable diseases (NCDs), is by far the biggest cause (19%) of ill-health and premature death globally. In the near future, the health impacts of climate change will significantly exacerbate this high health burden. We view climate change as a pandemic (global epidemic) because of its rapid increase and extensive damage to planetary health. These three pandemics — obesity, undernutrition, and climate change — represent The Global Syndemic that affects most people in every country and region worldwide. A syndemic is a synergy of pandemics that co-occur in time and place, interact with each other, and share common underlying societal drivers. For example, food systems not only drive the obesity and undernutrition pandemics but also generate 25-30% of greenhouse gas emissions (GHGs), and cattle production accounts for over half of those. Car-dominated transportation systems support sedentary lifestyles and generate between 14-25% of GHGs. Underpinning all of these are weak political governance systems, the unchallenged economic pursuit of GDP growth, and the powerful commercial engineering of overconsumption.

The figure below shows that the common drivers of The Global Syndemic arise from within food, transport, urban design, and land use systems, which in turn draw from the natural systems and are shaped by the policies, economic incentives and disincentives, and norms established through governance mechanisms. The outer layers are the settings and social networks through which people engage. The outcomes of obesity, undernutrition, and climate change interact. For example, climate change will increase undernutrition through increased food insecurity from extreme weather events, droughts, and shifts in agriculture. Likewise, fetal and infant undernutrition increases the risk of adult obesity. The effects of climate change on obesity and vice versa are currently uncertain. Actions that re-orient the underlying systems (eg agriculture policies for health and sustainability) or the governance levers (eg redirection of taxes and subsidies) will be the double-duty and triple-duty actions necessary to address The Global Syndemic.

Double-duty and Triple-duty Actions

Many current recommendations to reduce obesity and undernutrition will also be beneficial for climate change mitigation and adaptation, and vice versa. However, to seriously address The Global Syndemic, action will be needed to address its underlying societal, political, socio-economic, and commercial drivers. These are double-duty or triple-duty actions (see examples below) because they can influence multiple parts of the syndemic simultaneously. Such actions, which seek to re-orient major systems of food and agriculture, transport, urban design, and land use that drive The Global Syndemic, need to occur locally, nationally, and globally. Implementation of actions to address these deeper drivers is politically more difficult to achieve and their outcomes are more uncertain compared to downstream actions such as health promotion programs or healthcare service provision. However, their implementation is essential for transformative, systemic changes.

Examples of triple-duty actions

The Path Forward

The Commission is under no illusion that the implementation of double-duty and triple-duty solutions will be easy to achieve. Indeed, a transformative social movement, building through the local, national, and global levels, is needed to overcome the policy inertia described above. Conceptualizing the three pandemics as The Global Syndemic, with common systemic drivers and complex interactions may contribute to the new narrative needed to catalyse that social movement. We believe that articulating the need for and benefits of double-duty and triple-duty actions will also lead to innovative insights and strategies that can be spread and scaled.

Actions for All

  1. Think in Global Syndemic terms to focus on common systemic drivers that require collective actions by multiple actors.
    • Create the narrative of common systemic drivers and double-duty or triple-duty actions to underpin the social movements at local, national and global levels.
  2. Create collaborative platforms to join up the current silos of effort into local, national and global networks working on double-duty and triple-duty actions.
    • Link initiatives to connect the silos at local (eg, health and non-health organisations), national (across health, education, social affairs, agriculture, and climate change ministries), and global levels (eg, UN Framework Convention on Climate Change and Decade of Action on Nutrition) to foster systemic thinking, share innovative solutions, and synergise efforts.

Actions for Nations and Municipalities

  1. Reduce poverty and inequities to reduce the toll of The Global Syndemic, which will disproportionately impact poor people.
  2. Fully implement human rights obligations to protect socially disadvantaged populations, especially children and women, and mobilise actions to create healthy and active environments for all people.
    • Incorporate the rights recognised by international law, including the right to health, the right to food, cultural rights, the rights of the child, and the implied right to a healthy environment, into national constitutions and laws under the umbrella of the Right to Wellbeing.
  3. Reduce the influence of large commercial interests in policy development processes to enable governments to implement policies in the interests of public health, equity, and planetary sustainability.
    • Institutionalise clear and robust conflicts of interest management for policy development.
    • Strengthen democratic institutions such as freedom of information laws, declarations of political donations, independent ombudsman and commissioner positions, and platforms for civil society engagement in public policy decision-making.
  4. Eliminate subsidies for products that contribute to The Global Syndemic and redirect funding to actions that mitigate it.
    • Increase awareness of the impact of subsidies on the true costs of food and car use to build support for sustainable agriculture and sustainable modes of transportation.
    • Redirect existing government subsidies for beef, dairy, sugar, corn, rice, and wheat (about $US0·5 trillion a year) to sustainable farming for healthful foods.
    • Redirect subsidies for fossil fuels (about $US5 trillion a year) to renewable energy and sustainable transportation systems.
  5. Provide clear and understandable information to consumers on the health and environmental impacts of food products to enable informed choices and create a demand-driven market shift for products that support sustainable food systems.
    • Use nutrition labelling to alert consumers to products high in sugar, salt, and saturated fat, and stimulate industry reformulation.
    • Add sustainability indicators, such as carbon and water footprints, to food labels to help consumers make sustainable choices.
  6. Expand municipal actions on air pollution and traffic congestion to include action on healthy and resilient urban transport and food systems.
    • Invest in urban design and transportation systems to foster walking, cycling, and public transport and build urban food systems for resilience, health and equity.
    • Strengthen national and international networks of cities to share resources and innovative strategies to address The Global Syndemic.
  7. Support community coalitions to mobilise action at the local level and to create pressure for national policies that reduce The Global Syndemic.
    • Support systems-oriented, community-based interventions that create healthy, resilient and sustainable local environments and advocate for supportive national policies.
  8. Re-orient business models to produce beneficial outcomes for people, the planet, and profits so that business shifts its focus from short-term, profit-only outcomes to sustainable models that explicitly include benefits to society and the environment.
    • Incorporate the costs of damage to health and the environment from business processes and products into the costs of doing business rather than onto taxpayers or future generations.
  9. Accelerate national commitments to achieve the UN Sustainable Development Goals to create the broad, cross- sectoral efforts needed to address The Global Syndemic.
    • Establish specific, measurable, achievable, relevant goals and a timetable for achieving them.
    • Build in accountability systems for achieving these goals.

Actions for Civil Society

  1. Act to increase demand for policies to address The Global Syndemic.
    • Build civil coalitions to advocate for specific policies, eg healthy food in schools or public transport infrastructure, and for deeper, more transformative changes, eg restricting commercial influences in public policy-making and enacting human rights legislation.
  2. Monitor policy implementation to increase independent accountability for actions to mitigate The Global Syndemic.
    • Combine existing food policy monitoring platforms with new monitoring platforms for physical activity and climate change
    • Use policy monitoring evidence to hold governments and corporations to account for addressing The Global Syndemic.
    • Prioritize research for policy-relevant, empirical and modelling studies on the dynamics of The Global Syndemic and the impacts of double-duty and triple-duty actions.

Actions for Funders

  1. Use development aid and loans as a mechanism to encourage double-duty or triple-duty actions to address The Global Syndemic.
    • Incorporate policy development to improve governance, food systems, and land use to address The Global Syndemic as an essential component of technical assistance and loans from funders such as the World Bank, development agencies, and other funders.
  2. Develop a global ‘Food Fund’ to support the efforts of civil society organisations to increase pressure to create healthy, sustainable, equitable food systems.
    • In addition to calls for a US$70 billion dollar investment over 10 years to achieve the global targets to reduce undernutrition, philanthropic investors should invest US $1 billion dollars to strengthen the social advocacy from civil societies to demand complementary policy actions to tackle The Global Syndemic.
  3. Fund research on indigenous and traditional knowledge to understand the paradigms, practices and products that promote optimal planetary health.
    • Establish a ‘Seven Generations Fund’ based on the Iroquois concept of decision-making for seven generations hence so that indigenous knowledge and worldviews can be researched, recognized internationally, and incorporated into policies that impact on human and environmental health.

Actions for International Agencies

  1. Establish a Framework Convention on Food Systems as the comprehensive, legal framework to bind countries to collectively create food systems that promote health, equity, environmental sustainability, and economic prosperity.
    • Use the constitutional provisions of UN agencies and/or regional bodies (eg, European Union, Pacific Forum) to develop a Framework Convention on Food Systems for Member States to ratify and enact nationally.
  2. Monitor the implementation of policies recommended by the UN and other authoritative bodies to address obesity, undernutrition, climate change and their determinants.
    • Work with researchers, civil society organisations and governments to build independent accountability systems for the actions of governments and the private sector to mitigate The Global Syndemic.

Lancet Commission on Obesity: Commissioners and Fellows

Boyd A Swinburn, MD
Co-Chair. Professor, School of Population Health, University of Auckland, New Zealand
Corinna Hawkes, PhD
Professor and Director, Centre for Food Policy, City University, University of London, UK
Susanna DH Mills, PhD
Researcher, Institute of Health & Society, Newcastle University, UK
William H Dietz, MD
Co-Chair. Professor, Milken Institute School of Public Health, George Washington University, USA
Mario Herrero, PhD
Chief Research Scientist, Commonwealth Scientific and Industrial Research Organisation, Australia
Gareth Morgan, PhD
Founder, The Morgan Foundation, New Zealand
Steven Allender, PhD
Professor and Director, Global Obesity Centre, Deakin University, Australia
Peter S Hovmand, PhD
Professor, Brown School, Washington University in St Louis, USA
Alexandra Morshed, MS
Researcher, Brown School, Washington University in St. Louis, USA
Vincent J Atkins, MSc
Technical Advisor, Caribbean Community (CARICOM) Secretariat, Barbados, West Indies
Mark Howden, PhD
Professor, Climate Change Institute, Australian National University, Australia
Patricia Nece, JD
Board member, Obesity Action Coalition, USA
Phillip I Baker, PhD
Alfred Deakin Postdoctoral Research Fellow, Institute for Physical Activity and Nutrition, Deakin University, Australia
Lindsay Jaacks, PhD
Assistant Professor, Harvard T.H. Chan School of Public Health, Harvard University, USA
An Pan, PhD
Professor, Tongji Medical College, Huazhong University of Science and Technology, China
Jessica R Bogard, PhD
Nutrition Systems Scientist, Commonwealth Scientific and Industrial Research Organisation, Australia
Ariadne Kapetanaki, PhD
Senior Lecturer, Hertfordshire Business School, University of Hertfordshire, UK
David W Patterson, LLM
Consultant, International Development Law Organization, The Netherlands
Hannah Brinsden, BSc
Head of Policy, World Obesity Federation, UK
Matt Kasman, PhD
Assistant Research Director, Center on Social Dynamics & Policy, The Brookings Institution, USA
Gary Sacks, PhD
Associate Professor, Global Obesity Centre, Deakin University, Australia
Alejandro Calvillo, BA
Advisor, El Poder del Consumidor, Mexico
Vivica Kraak, PhD
Assistant Professor, Department of Human Nutrition, Foods, and Exercise, Virginia Tech, USA
Meera Shekar, PhD
Global Lead, Health, Nutrition and Population Global Practice, The World Bank, USA
Olivier De Schutter, PhD
Professor, Institute for Interdisciplinary Research in Legal Sciences, Catholic University of Louvain, Belgium
Harriet Kuhnlein, PhD
Professor Emerita, Centre for Indigenous Peoples’ Nutrition and Environment, McGill University, Canada
Geoff L Simmons, BCom
Advisor, The Morgan Foundation, New Zealand
Raji Devarajan, MSc
Researcher, Centre for Chronic Disease Control, India
Shiriki Kumanyika, PhD
Research Professor, Dornsife School of Public Health, Drexel University, USA
Warren Smit, PhD
Researcher, African Centre for Cities, University of Cape Town, South Africa
Majid Ezzati, FMedSci
Professor, School of Public Health, Imperial College London, UK
Baghar Larijani, MD
Professor, Endocrinology and Metabolism Research Centre, Tehran University of Medical Sciences, Iran
Ali Tootee, MD
Researcher, Diabetes Research Centre, Tehran, Iran
Sharon Friel, PhD
Professor, School of Regulation and Global Governance, Australia National University, Australia
Tim Lobstein, PhD
Director of Policy and Programme, World Obesity Federation, UK
Stefanie Vandevijvere, PhD
Senior Research Fellow, School of Population Health, University of Auckland, New Zealand
Shifalika Goenka, PhD
Professor, Public Health Foundation of India, India
Michael W Long, SD
Assistant Professor, Milken Institute School of Public Health, George Washington University, USA
Wilma E Waterlander, PhD
Researcher, Academic Medical Center, University of Amsterdam, The Netherlands
Ross A Hammond, PhD
Senior Fellow, Center on Social Dynamics & Policy, The Brookings Institution, USA
Victor KR Matsudo, MD
Scientific Director, Physical Fitness Research Laboratory of Sao Caetano do Sul, Brazil
Luke Wolfenden, PhD
Associate Professor, School of Medicine and Public Health, University of Newcastle, Australia
Gerard Hastings, PhD
Professor Emeritus, Institute for Social Marketing, University of Stirling, Scotland, UK

The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report

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Executive summary

Malnutrition in all its forms, including obesity, undernutrition, and other dietary risks, is the leading cause of poor health globally. In the near future, the health effects of climate change will considerably compound these health challenges. Climate change can be considered a pandemic because of its sweeping effects on the health of humans and the natural systems we depend on (ie, planetary health). These three pandemics — obesity, undernutrition, and climate change — represent The Global Syndemic that affects most people in every country and region worldwide. They constitute a syndemic, or synergy of epidemics, because they co-occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers. This Commission recommends comprehensive actions to address obesity within the context of The Global Syndemic, which represents the paramount health challenge for humans, the environment, and our planet in the 21st century.

The Global Syndemic

Although the Commission’s mandate was to address obesity, a deliberative process led to reframing of the problem and expansion of the mandate to offer recommendations to collectively address the triple-burden challenges of The Global Syndemic. We reframed the problem of obesity as having four parts. First, the prevalence of obesity is increasing in every region of the world. No country has successfully reversed its epidemic because the systemic and institutional drivers of obesity remain largely unabated. Second, many evidence-based policy recommendations to halt and reverse obesity rates have been endorsed by Member States at successive World Health Assembly meetings over nearly three decades, but have not yet been translated into meaningful and measurable change. Such patchy progress is due to what the Commission calls policy inertia, a collective term for the combined effects of inadequate political leadership and governance to enact policies to respond to The Global Syndemic, strong opposition to those policies by powerful commercial interests, and a lack of demand for policy action by the public. Third, similar to the 2015 Paris Agreement on Climate Change, the enormous health and economic burdens caused by obesity are not seen as urgent enough to generate the public demand or political will to implement the recommendations of expert bodies for effective action. Finally, obesity has historically been considered in isolation from other major global challenges. Linking obesity with undernutrition and climate change into a single Global Syndemic framework focuses attention on the scale and urgency of addressing these combined challenges and emphasises the need for common solutions.

Syndemic drivers

The Commission applied a systems perspective to understand and address the underlying drivers of The Global Syndemic within the context of achieving the broad global outcomes of human health and wellbeing, ecological health and wellbeing, social equity, and economic prosperity. The major systems driving The Global Syndemic are food and agriculture, transportation, urban design, and land use. An analysis of the dynamics of these systems sheds light on the answers to some fundamental questions. Why do these systems operate the way they do? Why do they need to change? Why are they so hard to change? What leverage points (or levers) are required to overcome policy inertia and address The Global Syndemic? The Commission identified five sets of feedback loops as the dominant dynamics underlying the answers to these questions. They include: (1) governance feedback loops that determine how political power translates into the policies and economic incentives and disincentives for companies to operate within; (2) business feedback loops that determine the dynamics for creating profitable goods and services, including the externalities associated with damage to human health, the environment, and the planet; (3) supply and demand feedback loops showing the relationships that determine current consumption practices; (4) ecological feedback loops that show the unsustainable environmental damage that the food and transportation systems impose on natural ecosystems; and (5) human health feedback loops that show the positive and negative effects that these systems have on human health. These interactions need to be elucidated and methods for reorienting these feedback systems prioritised to mitigate The Global Syndemic.

Key messages

The pandemics of obesity, undernutrition, and climate change represent three of the gravest threats to human health and survival. These pandemics constitute The Global Syndemic, consistent with their clustering in time and place, interactions at biological, psychological, or social levels, and common, large-scale societal drivers and determinants. Their interactions and the forces that sustain them emphasise the potential for major beneficial effects on planetary health that double-duty or triple-duty actions, which simultaneously act on two or all three of these pandemics, will have. To mitigate The Global Syndemic, the Commission proposed the following nine broad recommendations, under which sit more than 20 actions:

  • Think in Global Syndemic terms to create a focus on common systemic drivers that need common actions.
  • Join up the silos of thinking and action to create platforms to work collaboratively on common systemic drivers and double-duty or triple-duty actions.
  • Strengthen national and international governance levers to fully implement policy actions which have been agreed upon through international guidelines, resolutions and treaties.
  • Strengthen municipal governance levers to mobilise action at the local level and create pressure for national action
  • Strengthen civil society engagement to encourage systemic change and pressure for policy action at all levels of government to address The Global Syndemic
  • Reduce the influence of large commercial interests in the public policy development process to enable governments to implement policies in the public interest to benefit the health of current and future generations, the environment, and the planet
  • Strengthen accountability systems for policy actions to address The Global Syndemic
  • Create sustainable and health-promoting business models for the 21st century to shift business outcomes from a short-term profit-only focus to sustainable, profitable models that explicitly include benefits to society and the environment
  • Focus research on The Global Syndemic determinants and actions to create an evidence base of systemic drivers and actions, including indigenous and traditional approaches to health and wellbeing

Double-duty or triple-duty actions

The common drivers of obesity, undernutrition, and climate change indicate that many systems-level interventions could serve as double-duty or triple-duty actions to change the trajectory of all three pandemics simultaneously. Although these actions could produce win-win, or even win-win-win, results, they are difficult to achieve. A seemingly simple example shows how challenging these actions can be. National dietary guidelines serve as a basis for the development of food and nutrition policies and public education to reduce obesity and undernutrition and could be extended to include sustainability by moving populations towards consuming largely plant-based diets. However, many countries’ efforts to include environmental sustainability principles within their dietary guidelines failed due to pressure from strong food industry lobbies, especially the beef, dairy, sugar, and ultra-processed food and beverage industry sectors. Only a few countries (ie, Sweden, Germany, Qatar, and Brazil) have developed dietary guidelines that promote environmentally sustainable diets and eating patterns that ensure food security, improve diet quality, human health and wellbeing, social equity, and respond to climate change challenges.

The engagement of people, communities, and diverse groups is crucial for achieving these changes. Personal behaviours are heavily influenced by environments that are obesogenic, food insecure, and promote greenhouse-gas emissions. However, people can act as agents of change in their roles as elected officials, employers, parents, customers, and citizens and influence the societal norms and institutional policies of worksites, schools, food retailers, and communities to address The Global Syndemic. Across systems and institutions, people are decision makers who can vote for, advocate for, and communicate their preferences with other decision-makers about the policies and actions needed to address The Global Syndemic. Within the natural ecosystems, people travel, recreate, build, and work in ways that can preserve or restore the environment. Collective actions can generate the momentum for change. The Commission believes that the collective influence of individuals, civil society organisations, and the public can stimulate the reorientation of human systems to promote health, equity, economic prosperity, and sustainability.

Changing trends in obesity, undernutrition, and climate change

Historically, the most widespread form of malnutrition has been undernutrition, including wasting, stunting, and micronutrient deficiencies. The Global Hunger Index (1992–2017) showed substantial declines in under-5 child mortality in all regions of the world but less substantial declines in the prevalence of wasting and stunting among children. However, the rates of decline in undernutrition for children and adults are still too slow to meet the Sustainable Development Goal (SDG) targets by 2030.

In the past 40 years, the obesity pandemic has shifted the patterns of malnutrition. Starting in the early 1980s, rapid increases in the prevalence of overweight and obesity began in high-income countries. In 2015, obesity was estimated to affect 2 billion people worldwide. Obesity and its determinants are risk factors for three of the four leading causes of non-communicable diseases (NCDs) worldwide, including cardiovascular diseases, type 2 diabetes, and certain cancers.

Extensive research on the developmental origins of health and disease has shown that fetal and infant undernutrition are risk factors for obesity and its adverse consequences throughout the life course. Low-income and middle-income countries (LMICs) carry the greatest burdens of malnutrition. In LMICs, the prevalence of overweight in children less than 5 years of age is rising on the background of an already high prevalence of stunting (28%), wasting (8·8%), and underweight (17·4%). The prevalence of obesity among stunted children is 3% and is higher among children in middle-income countries than in lower-income countries.

The work of the Intergovernmental Panel on Climate Change (IPCC), three previous Lancet Commissions related to climate change and planetary health (2009–15), and the current Lancet Countdown, which is tracking progress on health and climate change from 2017 to 2030, have provided extensive and compelling projections on the major human health effects related to climate change. Chief among them are increasing food insecurity and undernutrition among vulnerable populations in many LMICs due to crop failures, reduced food production, extreme weather events that produce droughts and flooding, increased food-borne and other infectious diseases, and civil unrest. Severe food insecurity and hunger are associated with lower obesity prevalence, but mild to moderate food insecurity is paradoxically associated with higher obesity prevalence among vulnerable populations.

Wealthy countries already have higher burdens of obesity and larger carbon footprints compared with LMICs. Countries transitioning from lower to higher incomes experience rapid urbanisation and shifts towards motorised transportation with consequent lower physical activity, higher prevalence of obesity, and higher greenhouse-gas emissions. Changes in the dietary patterns of populations include increasing consumption of ultra-processed food and beverage products and beef and dairy products, whose production is associated with high greenhouse-gas emissions. Agricultural production is a leading source of greenhouse-gas emissions.

The economic burden of The Global Syndemic

The economic burden of The Global Syndemic is substantial and will have the greatest effect on the poorest of the 8·5 billion people who will inhabit the earth by 2030. The current costs of obesity are estimated at about $2 trillion annually from direct health-care costs and lost economic productivity. These costs represent 2·8% of the world’s gross domestic product (GDP) and are roughly the equivalent of the costs of smoking or armed violence and war.

Economic losses attributable to undernutrition are equivalent to 11% of the GDP in Africa and Asia, or approximately $3·5 trillion annually. The World Bank estimates that an investment of $70 billion over 10 years is needed to achieve SDG targets related to undernutrition, and that achieving them would create an estimated $850 billion in economic return. The economic effects of climate change include, among others, the costs of environmental disasters (eg, drought and wildfires), changes in habitat (eg, biosecurity and sea-level rises), health effects (eg, hunger and diarrhoeal infections), industry stress in sectors such as agriculture and fisheries, and the costs of reducing greenhouse-gas emissions. Continued inaction towards the global mitigation of climate change is predicted to cost 5–10% of global GDP, whereas just 1% of the world’s GDP could arrest the increase in climate change.

Actions to address The Global Syndemic

Many authoritative policy documents have proposed specific, evidence-informed policies to address each of the components of The Global Syndemic. Therefore, the Commission decided to focus on the common, enabling actions that would support the implementation of these policies across The Global Syndemic. A set of principles guided the Commission’s recommendations to enable the implementation of existing recommended policies: be systemic in nature, address the underlying causes of The Global Syndemic and its policy inertia, forge synergies to promote health and equity, and create benefits through double-duty or triple-duty actions.

The Commission identified multiple levers to strengthen governance at the global, regional, national, and local levels. The Commission proposed the use of international human rights law and to apply the concept of a right to wellbeing, which encompasses the rights of children and the rights of all people to health, adequate food, culture, and healthy environments. Global intergovernmental organisations, such as the World Trade Organization, the World Economic Forum, the World Bank, and large philanthropic foundations and regional platforms, such as the European Union, Association of Southeastern Nations, and the Pacific Forum, should play much stronger roles to support national policies that address The Global Syndemic. Many states and municipalities are leading efforts to reduce greenhouse-gas emissions by incentivising less motorised travel and improving urban food systems. Civil society organisations can create a greater demand for national policy actions with increases in capacity and funding. Therefore, in addition to the World Bank’s call for $70 billion for undernutrition and the Green Climate Fund of $100 billion for LMICs to address climate change, the Commission calls for $1 billion to support the efforts of civil society organisations to advocate for policy initiatives that mitigate The Global Syndemic.

A principal source of policy inertia related to addressing obesity and climate change is the power of vested interests by commercial actors whose engagement in policy often constitutes a conflict of interest that is at odds with the public good and planetary health. Countering this power to assure unbiased decision making requires strong processes to manage conflicts of interest. On the business side, new sustainable models are needed to shift outcomes from a profit-only model to a socially and environmentally viable profit model that incorporates the health of people and the environment. The fossil fuel and food industries that are responsible for driving The Global Syndemic receive more than $5 trillion in annual subsidies from governments. The Commission recommends that governments redirect these subsidies into more sustainable energy, agricultural, and food system practices. A Framework Convention on Food Systems would provide the global legal structure and direction for countries to act on improving their food systems so that they become engines for better health, environmental sustainability, greater equity, and ongoing prosperity.

Stronger accountability systems are needed to ensure that governments and private-sector actors respond adequately to The Global Syndemic. Upstream monitoring is needed to measure implementation of policies, examine the commercial, political, economic and sociocultural determinants of obesity, evaluate the impact of policies and actions, and establish mechanisms to hold governments and powerful private-sector actors to account for their actions.

Similarly, platforms for stakeholders to interact and secure funding, such as that provided by the EAT Forum for global food system transformation, are needed to allow collaborations of scientists, policy makers, and practitioners to co-create policy-relevant empirical, and modelling studies of The Global Syndemic and the effects of double-duty and triple-duty actions. Bringing indigenous and traditional knowledge to this effort will also be important because this knowledge is often based on principles of environmental stewardship, collective responsibilities, and the interconnectedness of people with their environments.

The challenges facing action on obesity, undernutrition, and climate change are closely aligned with each other. Bringing them together under the umbrella concept of The Global Syndemic creates the potential to strengthen the action and accountabilities for all three challenges. Our health, the health of our children and future generations, and the health of the planet will depend on the implementation of comprehensive and systems-oriented responses to The Global Syndemic.

Panel 2: Definitions

The Commission used the following definitions in this report:

  • Syndemic is two or more diseases that co-occur, interact with each other and have common societal drivers.4 The Global Syndemic applies this concept to the pandemics of obesity, undernutrition, and climate change.
  • Malnutrition in all its forms refers to an abnormal physiological condition caused by inadequate, unbalanced, or excessive consumption of macronutrients or micronutrients.5 We operationalised malnutrition in burden of disease terms as the combined components of child and maternal malnutrition, high body-mass index (BMI), and dietary risks, representing a composite variable of dietary components associated with NCDs, such as diets low in whole grains, fruit, vegetables, nuts, and seeds and high in sodium, red meat, and sugar-sweetened beverages (Ashfin A, Institute for Health Metrics and Evaluation, Seattle, WA, USA, personal communication).6
  • Undernutrition encompasses stunting (low height-for-age), wasting (low weight-for-height), underweight (low weight-for-age), and micronutrient deficiencies (eg, iron, vitamin A, and iodine). In this report, we use the term to refer to child and maternal undernutrition as part of malnutrition in all its forms.
  • Obesity is defined as a BMI >30 kg/m2, but when we refer to obesity as part of The Global Syndemic, we use the term to encompass high BMI and NCD dietary risks that form part of malnutrition in all its forms.
  • Obesogenic environments are the collective physical, economic, policy, and sociocultural surroundings, opportunities, and conditions that promote obesity.7, 8
  • Policy inertia is the collective term for the combined effects of inadequate political leadership and governance to enact policies to respond to The Global Syndemic, strong opposition to those policies by powerful commercial interests, and a scarcity of demand for policy action by the public.
  • Double-duty or triple-duty actions refer to strategies that address two or three of the components of The Global Syndemic.
  • Best buys refer to WHO’s evidence-informed interventions (eg, sodium reduction) that are feasible and cost-effective for governments to implement and are likely to provide broad benefits to populations in reducing NCD risks.9
  • People-first language emphasises the individual rather than the disease consistent with the terminology used for other diseases. An obese person is an identity, and infers that the person with obesity is responsible for their condition, whereas a person with obesity is a person with a disease.
  • Sustainable food systems promote the global outcomes of human health, ecological health, social equity, and economic prosperity. They have a low environmental impact, support biodiversity, contribute to food and nutrition security, and support local food cultures and traditions.10

The backdrop for The Global Syndemic is the broader picture of global outcomes. The four major global outcomes of concern for people and the planet are the net results of the complex adaptive systems created by humans that interact with each other and the natural ecosystems (figure 2A). Human systems have been established to achieve certain outcomes, such as economic prosperity. Due to the way that these systems have been designed, the inevitable overconsumption and inequitable distribution of resources has caused negative externalities and poor outcomes for the other three outcomes of social equity, human health and wellbeing, and ecological health and wellbeing. These global outcomes will be considered in more depth later in this report in relation to the different country contexts and their priorities for action.

Figure 2: The Systems Outcomes Framework The sequence of figures below shows progressively zoomed-in views from the global outcomes view of the consequences of intersecting natural and human systems (A); to The Global Syndemic view of the interaction and common drivers of obesity, undernutrition, and climate change (B); to the Five Feedback Loops view (C); and the individual view (D).

Strengthening public sector governance

By governance we mean the organised efforts to manage the course of events in a social system.173 Governance includes the totality of “political, organisational, and administrative processes through which stakeholders, including governments, civil society and private-sector interest groups, articulate their interests, exercise their legal rights, make decisions, meet their obligations, and mediate their differences”.174

Governance challenges

We present four key governance challenges for addressing The Global Syndemic. Effective governance will require coherent action across diverse sectors from global to local levels, strong commitment from all relevant stakeholders, sufficient capacities and resources to enable and sustain such action, and the attenuation of systematic power imbalances within food systems. These challenges are contextualised against a backdrop of contemporary changes in global, national, and local governance systems.

Governance challenge 1: driving coherent action

Addressing the drivers of The Global Syndemic requires coordinated and sustained action within and across many sectors — health, agriculture, environment, finance, transportation, economic development, and urban planning among others — from global to local levels.

Achieving coherence has presented a considerable challenge. WHO and other expert bodies identify a hybrid approach to food and nutrition governance — multi-stakeholder or public-private partnerships — as a key mechanism for addressing the complexity of this challenge.175 However, such arrangements have raised concerns regarding conflicts of interest, the conflation of private interests with citizen’s interests and rights, and power asymmetries in decision making. Existing evaluations show mixed results, varying by issue, nature of the engagement, complexity of the governance structure, and diversity of partners and interactions.175176 Similar challenges exist at the global level (appendix p 32). Some actors have an explicit mandate to improve nutrition, whereas other actors do not. Some focus on undernutrition and food security, and others focus on obesity and diet-related NCDs. This institutional complexity increases the potential for divergent interests and world views, competition for resources, and duplication of efforts. It reflects broader contemporary changes in the global health governance system since the 1990s, particularly the substantial increase in the number and diversity of actors who are involved in global governance.177

At the country level, experiences suggest that a more state-anchored approach can drive multisector or multilevel actions that involve empowered government-coordinating agencies, well designed policies, and institutional systems. Successful efforts at reducing undernutrition in several countries have included governance bodies and coordinating agencies with sufficient authority, capacities, financial resources, and leadership, and line agencies (eg, health, agriculture, and education) responsible for implementation. The direct participation of high-level political champions and the existence of non-partisan parliamentary coalitions for nutrition have further strengthened and sustained responses across cycles of political change. Strong incentives have helped drive coherence, including inclusive governance bodies for civil society and stakeholder engagement, legislation that mandates cooperation, and shared indicators and targets that are sector-specific and time-bound. In some cases, performance-based or results-based budgeting has incentivised cooperation and improved transparency and accountability.178179 The UN Decade of Action on Nutrition (2016–25) provides an important umbrella framework to galvanise action, and the strengthened Committee on Food Security is a key forum to coordinate actions that address malnutrition in all its forms.

Governance challenge 2: generating and sustaining commitment

Commitment is the willingness for people and institutions to act until the job is done. Credible and sustained commitment from political leaders who champion policy initiatives, government officials who coordinate action, civil society groups who advocate for attention and resources, and affected community groups and individual citizens is crucial to drive coherent policy responses.180181 Interventions that target obesogenic food environments and food systems are frequently and systematically undermined by the coordinated efforts of powerful food and beverage industry groups.181 Rhetorical commitments to address undernutrition have not been supported by policies, coordinating structures, and financial resources owing to ineffective civil society pressure, limited visibility of the issue, and weak public demand.178180 In relation to undernutrition, policies that emphasise agricultural commercialisation, cash-cropping, and economic growth (ie, productivism) have impeded more balanced nutrition-sensitive policies that would promote dietary diversity and meet local nutritional needs.181182

Even more challenging is the inclusion of food and agriculture within the commitments on climate change under the 2015 Paris Agreement. The collective efforts to increase trade through multiple rounds, from the General Agreement on Tariffs and Trade established in 1947 to the World Trade Organization, have struggled to include agriculture in the process to reduce tariffs, quotas, and subsidies. This same political struggle happened again in climate change commitments. The enormous political power of the food and agricultural system industries has consistently overwhelmed individual and collective government efforts to promote the public interest rather than commercial interests.

What can drive and sustain commitment across all actors? Studies have identified a web of drivers, including political champions (eg, heads of state, cabinet members, and parliamentarians) and non-partisan support (ie, multi-party or multi-faction) at the highest levels.178181183 Mobilised civil society is also a considerable driver. Civil society coalitions, including non-government organisations and informal social movements, have had important roles in generating attention, informing policy processes, and sustaining political commitment for food policies.184 These civil society actors have crucial roles in governance by raising public awareness, giving voice to politically marginalised groups, holding governments accountable for public policies,178185 and informing policy development, monitoring, and evaluation.178183184 These roles are enhanced in the context of inclusive governance arrangements that connect such groups (including policy beneficiaries) with decision-makers, and by legal commitments in international human rights treaties endorsed by governments (discussed in the Right to wellbeing section). In short, an active civil society can have a key role in strengthening the accountability, inclusiveness, transparency, and responsiveness of governance systems. For example, the mobilisation of a cohesive civil society coalition was crucial in driving commitment for a sugary drinks tax in Mexico (panel 7).

Governance challenge 3: mobilising capacities and resources for impact

Governance for addressing The Global Syndemic will require commitment and coherence of action, but also the capacity and resources to act. In many countries, weak organisational capacities — including the absence of trained professional and administrative staff, the high administrative burden of working with diverse stakeholders, weak budgeting and accounting systems, and poor technical capacities — have undermined planning activities, programming efficiency, and the accountability of governing institutions related to undernutrition.178186 Another crucial and overlooked aspect is strategic capacity — the soft-power and interpersonal skills required to drive collective action across diverse actor networks. Strategic capacity includes the capacity to build coalitions, manage conflicts, respond to emerging opportunities and threats, manage complex policy processes, and undertake strategic communication.178184187 The absence of line items for undernutrition in government budgets, inadequate budgetary allocations, or the failure to use finances (particularly at subnational levels) has often resulted in policy failure.180 Panel 10 presents a case study of Kisumu Kenya showing how capacity and resource limitations and the fragmentation of governance among large numbers of stakeholders can hinder urban food governance in developing countries.

Panel 10: Challenges of collaborative local governance — urban food systems in Kenya

Urban governance in many cities throughout the developing world involves a wide range of actors, often with limited capacities and conflicting agendas, and with few processes for collaboration or reaching consensus. The city of Kisumu in Kenya, Africa, offers an example. The rushed and partial decentralisation of public authority in Africa in the past few decades has often resulted in local governments that are “weak, disorganised, inadequately trained and staffed, and often under-resourced relative to their expected range of responsibilities.”189

The food retail sector in African cities operates independently of government control, adding to the governance challenge. The wide variety of food retailers include traditional market places, shops and kiosks, and street food vendors. Market places are a particularly important element of urban food systems in Africa and are an important site of urban governance. In Kisumu, most food is bought and sold in the city’s many urban markets, which provide employment for approximately 60% of the city’s labour force. The municipality collects fees from traders but provides little in return.

Like other parts of Africa, the number of supermarkets in Kisumu has increased rapidly. Although their governance will be of increasing importance, local government control over where supermarkets are located, their design, or what they sell has been limited. The implications of this transformation for urban food security are not well understood. However, the shift from local food production and an informal retail sector to formal supermarkets with international supply chains might result in decreased food security due to higher and less flexible prices and increased amounts of processed foods.148

The diversity of actors can be both a challenge for governance and an opportunity to mobilise additional skills and resources to address urban food and nutrition problems. In this regard, there have been repeated calls for collaborative governance — bringing multiple stakeholders together in common forums with public agencies to engage in consensus-orientated decision making — and for the co-production of projects and policies by a range of urban governance actors. In Kisumu, the Kisumu Action Team and Kisumu Local Interaction Platform have convened stakeholders to pool skills and resources and develop a number of ambitious strategies for Kisumu, such as upgrading market places and improving urban food security, exemplifying the potential for stakeholders to begin to work together through collaborative governance.

The expansion of government budgetary commitments and establishing effective financing systems, through donor support and technical assistance, is important for empowering governing institutions and implementing agencies, mobilising human resources, and establishing entitlements among government officials, interest groups, and citizens that generate continued political support.178196197 Such governance might also include policy mechanisms that provide technical and financial support for under-resourced subnational governments and other implementation partners.178 As with Kisumu, collaborative governance arrangements can bring together a diverse range of stakeholders to pool resources and collaborate on developing holistic and inclusive strategies. Capacity-building initiatives might also include, interdisciplinary tertiary training and leadership programmes at country or regional levels.198

Governance challenge 4: addressing power asymmetries in food systems

The expansion in the size, reach, and concentration of transnational food corporations and their massively increased, well-coordinated, political and economic power constitutes a major challenge to governance.181199

The large, powerful food and beverage corporations (Big Food) have used multiple strategies to obstruct obesity prevention. These strategies include adopting self-regulation to pre-empt and delay state regulation, public relations to portray industry as socially responsible, undermining and contesting the strength of scientific evidence, direct lobbying of government decision makers, and framing nutrition as a matter of individual responsibility (ie, norm promotion).181 Big Polluters, such as the large, powerful fossil fuel and cattle corporations, have used these same strategies to undermine strong government commitment and public support for action on climate change.200 Big Food’s obstructive power is enhanced in the context of hybrid governance arrangements that legitimise industry participation in public policy, and their financial resources and structural importance within national economies as suppliers of jobs and tax revenue. Furthermore, trade liberalisation, and with it greater international capital mobility, enables corporate actors to punish and reward governments for their regulatory decisions by relocating or threatening to relocate investments and jobs, or through threats of legal action under provisions for settlement in investor–state disputes in trade agreements.18181199

One strategy to address power asymmetries in the food system is to strengthen antitrust (ie, competition) laws to mitigate the economic and social harms of market concentration, and to define consumer welfare by something other than low prices.199 Another strategy is to more strongly anchor food and nutrition governance within rather than outside of government, alongside inclusive structures for meaningful civil society engagement and transparent processes for mitigating conflicts of interest related to private sector involvement.176201202 Strategies for strengthening the role of small-sized and medium-sized food system actors in governance is receiving increasing recognition. This trend is illustrated by the growth of urban food governance initiatives, including inclusive structures (eg, food policy councils) and local government ordinances (eg, planning regulations) that support for-profit and for-community food system activities by these actors at subnational levels.203

Next steps for strengthening governance

Strengthened governance systems at global, national, and local levels are urgently needed to address The Global Syndemic. Governing effectively will require coherence of action across several sectors and levels of society, credible and sustained commitment by the diversity of actors who govern, and the capacities and financial resources to govern. It will also demand actions that address the skewed distribution of power within the food and transportation systems that favour the status quo. The fragmentation of responsibility among large numbers of governance stakeholders with conflicting agendas and division of interests represents a further challenge that could be addressed through collaborative governance.

The slow and patchy progress to date in controlling The Global Syndemic, especially the obesity and climate change components, indicates the urgent need for a fundamental change in today’s governance systems. Arguably, the most important challenge is considering and redefining the fundamental goals of these systems. In this regard, the structures, practices, and beliefs that underpin capitalism in its present form (ie, extractive, materialist, and neoliberal) dominate the governance system. Political economy drivers that prioritise endless growth, by default, increase consumption to the point of detrimental overconsumption. Governance activities that simply tweak the parameters of this system (eg, pricing interventions, consumer information initiatives, and industry-led responses) are positive but will do little to address these deeper drivers. To do so, we must collectively ask who does our food system and economy ultimately serve, and for what purpose? How do we firmly place human and ecological health and wellbeing (ie, planetary health) as the central goal of governance systems going forward?204

Right to wellbeing

The 193 UN Member States have the power and the duty to address the drivers of The Global Syndemic.205 International human rights are a set of universal, indivisible, interdependent, and interrelated freedoms and entitlements created by international treaties and customary international law and enforced through national and international legal systems.

The Commission proposes that five interrelated human rights collectively constitute the right to wellbeing, an integrated framework that reflects the rights recognised by international law, including the right to health, the right to food, cultural rights, the rights of the child, and the implied right to a healthy environment (figure 4). The sections below describe Member States’ legal obligations to respect, protect, and fulfil each of these rights, and explores the implications of adopting the right to wellbeing framework to address The Global Syndemic.

Figure 4: Intersection of human rights that comprise the overarching right to wellbeing framework


The central finding of the Commission’s work is that the future health of our people, environment, and planet will depend on the implementation of actions that concurrently address all aspects of The Global Syndemic. The Commission was mindful of the expansive list of evidence­ informed recommendations for actions to address obesity, undernutrition, and climate change separately, including recommendations from previous Lancet Commissions and Series. After reviewing relevant evidence from many disciplines, this Commission identified six principles and developed nine recommendations and more than 20 actions to maximise impact on The Global Syndemic.

Six underlying principles

We used six principles to identify the Commission’s recommendations for action that would underpin the existing specific policy recommendations for obesity, undernutrition, and climate change and that might help overcome the policy inertia they are facing. The actions recommended by the Commission should: (1) enhance the implementation of existing recommendations to address different aspects of The Global Syndemic; (2) be systemic in nature to influence feedback loops, power imbalances for government decision-making, policy, economic and social norms, and the purpose of the system; (3) target the underlying drivers of The Global Syndemic, especially policy inertia to implementation; (4) forge synergies within civil society across diverse movements to improve health, environmental, and social equity outcomes; (5) produce multiple benefits through double-duty or triple-duty actions; and (6) reduce inequities by addressing their causes and improve the conditions for socially disadvantaged and discriminated populations.

Actions to maximise impact on The Global Syndemic

Effective responses to The Global Syndemic will be maximised if the following recommendations and specific actions are achieved progressively over the next decade.

Think in Global Syndemic terms

Thinking in Global Syndemic terms will allow actors to focus on common systemic drivers that need common actions. The Commission recommends that all actors frame their commitments and actions on the SDGs in syndemic and systems terms to show their inherent connectedness and systemic origins. For example, defining the problems using terms like malnutrition in all its forms and The Global Syndemic and defining actions that are double-duty or triple-duty. This will enhance the synergism and collective efforts of multiple actors across settings and sectors. The Commission also recommends that national governments add urgency to their commitments to reduce poverty and inequalities. The consequences of The Global Syndemic fall disproportionally on the poor and socially disadvantaged populations, making poverty reduction a central goal for action that aligns with SDG 1.

Join up the silos of thinking and action

Silos of thinking and action need to be linked by proactively creating platforms for collaborative work on common systemic drivers and double-duty or triple-duty actions. The Commission recommend that all actors create links across components of The Global Syndemic at all levels. Linking of initiatives at a global level (eg, SDGs and UNFCCC with the Decade of Action on Nutrition), national level (across health, education, social affairs, agriculture, and climate change ministries), and local level (eg, health and non-health organisations) will foster systemic thinking and double-duty or triple-duty actions.

Strengthen national and international agency governance levers

National and international agency governance levers need to be strengthened to fully implement policy actions that have been agreed upon through inter­national guidelines, resolutions and treaties. The Commission makes the following recommendations so that this strengthening can be achieved. First, national governments should fully implement their human rights obligations to protect socially disadvantaged populations, especially children and women, and mobilise the public and a broad range of civil society organisations to create healthy and active environments for all people. Second, they should also accelerate their national commitments to, and achievement of, the UN SDG agenda and the UN Decade of Action on Nutrition by establishing SMART targets and strengthening accountability mechanisms to achieve outcomes. Third, UN agencies and regional bodies (eg, European Union and Pacific Forum) should use their constitutional provisions to develop legally binding agreements such as a Framework Convention on Food Systems. Member States should ratify the treaty, and translate the principles and guidelines into national laws to protect their populations from practices that undermine healthy food environments. Fourth, the World Trade Organisation should recognise WHO guidelines and standards for nutrient profiling, food and beverage product labelling, and restrictions on unhealthy food and beverage marketing targeted to children. This action will prevent repeated trade and investment law challenges by companies in response to countries creating policies for healthier food environments. Finally, the World Bank, development agencies, and other funders should encourage double­-duty or triple­-duty actions to address The Global Syndemic as an essential component of technical assistance and loans (appendix p 52).

Strengthen municipal governance levers

Municipal governance levers also need to be strengthened to mobilise action at the local level and create pressure for national action. Municipal governments should show leadership to implement double-duty or triple-duty actions for The Global Syndemic. Cities are already responding to immediate problems such as pollution, congestion, and food insecurity. Therefore, implementing policies that address land use, active transportation, clean energy, and healthy food systems will serve as double-duty or triple-duty actions to improve the lives of their residents and future generations. To achieve this recommendation municipal governments should network and share resources and innovative strategies to address The Global Syndemic. Many coalitions, alliances, and networks at the local level can empower and foster actions at the national, regional, and global levels.

Strengthen civil society engagement

Strengthening of civil society engagement will encourage systemic change and pressure for policy action at all levels of government to address The Global Syndemic. Philanthropic investments and investors should create a global Food Fund to support civil society pressure for healthy and sustainable diets and food systems. Alongside the calls for a $70 billion effort needed to reach the global targets on reducing undernutrition,349 a much smaller investment (eg, $1 billion) in strengthening social advocacy and social lobbying of civil society would greatly increase the demand for policy action on healthier food environments.

Reduce the influence of large commercial interests on public policy development

The influence of large commercial interests on the public policy development process needs to be reduced so that governments can implement policies in the public interest that benefit the health of current and future generations, the environment, and the planet. Governments should adopt and institutionalise clear, transparent, and robust guidelines on conflicts of interest and processes for policy development and implementation. They should also strengthen democratic institutions, such as freedom of information laws, declarations of political donations, independent ombudsman and commissioner positions, and platforms for civil society engagement in public policy decision making.

Strengthen accountability systems

To strengthen accountability systems for policy actions that address The Global Syndemic, the Commission makes the following recommendations. First, UN agencies should develop metrics for upstream monitoring of policy implementation and healthy environments to reduce malnutrition in all its forms and decrease greenhouse gas production. Parallel reporting to the UN agencies by governments and civil societies will enhance independent accountability. Second, the UN human rights treaty bodies, Human Rights Council Special Procedures, and the UN Interagency Task Force on NCDs should monitor state actions on protecting and promoting human rights in the context of The Global Syndemic. Third, NGOs and academia should scale up their monitoring systems on food policies and integrating similar approaches for physical activity policies and climate change policies. The existing food monitoring platforms, such as INFORMAS, ATNI and NOURISHING should join forces with UN agency monitoring and with monitoring platforms for physical activity and climate change policies. Finally, regional and global political and economic platforms, such as the World Economic Forum, Association of Southeastern Nations, and G20, should place The Global Syndemic high on their economic agendas. Because The Global Syndemic has enormous economic consequences, monitoring and mutual accountability systems for action at economic forums will protect national, regional, and global economies.

Sustainable and health-promoting business models for the 21st century

Creating sustainable and health-promoting business models for the 21st century will shift business outcomes from a short-term, profit-only focus to sustainable, profitable models that explicitly include benefits to society and the environment. To achieve this goal, first, national governments should eliminate or redirect subsidies away from products that contribute to The Global Syndemic towards production and consumption practices that are sustainable for human health, the environment and the planet. Reducing subsidies to oil companies and large monocultural agricultural firms would allow subsidies to be directed towards innovations in sustainable energy and transportation and healthy, local food systems. Second, government, business, and economic thought-leaders should develop economic systems that include the costs of ill-health, environmental degradation, and greenhouse-gas emissions in the costs of products. Simultaneously, investments must be made to help those on low incomes manage financially as the full costings and circular economies develop. Convening organisations like the World Economic Forum could help to redefine the business models for the 21st century and lead the shift away from narrow, profit-maximisation models into broader models better able to deliver for people, planet, and prosperity. Third, governments should ensure information is readily available to consumers on the environmental footprints and health impacts of products. Such full disclosure will allow consumers to make fully informed choices and will create a demand-driven pressure for businesses to shift to healthier and more sustainable practices and products.

Focus research on The Global Syndemic determinants and actions

Creating an evidence base of systemic drivers and actions, including traditional approaches to health and wellbeing, will require research focused on The Global Syndemic determinants and actions. The Commission recommends that collaborations of scientists, policy makers, and practitioners co-create policy-relevant, empirical and modelling studies on the dynamics of aspects of The Global Syndemic and the effects of double-duty or triple-duty actions and systems approaches. Sharing results with policy makers will help them understand the systems they seek to influence and evaluate how effective their policies might be. The Commission also recommends that agencies fund research on indigenous and traditional knowledge to understand the paradigms, practices, and products that will promote better planetary health. An international Seven Generations Fund (decision making for seven generations to come) across several research funding agencies would help to resuscitate indigenous and traditional knowledge and wisdom about food systems, use of biodiversity, world views, and collective approaches to common challenges.

Future montitoring

Monitoring the progress for the aforementioned actions recommendations will be an ongoing task for the Commission and will link well with the existing Lancet Countdown on Climate Change and Health (panel 16). Many reports are being published on achieving better human health, reducing socioeconomic inequalities, achieving sustainable agriculture and diets, and reducing anthropogenic environmental damage. The concept of The Global Syndemic has the potential to bring these closely aligned challenges together under one umbrella and to advance actions and accountability to the next level needed to achieve planetary health.

Panel 16: Accounting monitoring for propositions

Between 2008 and 2018, several Lancet Commissions examined the effects of climate change on human health and planetary health. To track progress on health and climate change, the LancetCommission on Health and Climate Change established the LancetCountdown in 2015, a broad international coalition of experts that assess and report biennially on 31 indicators distributed across five domains. The domains and indicators most relevant to The Global Syndemic are shown below.

1. Health impacts of climate hazards

Indicator 1.7. Food security and undernutrition. Indicators should also include obesity to assess the impact of double-duty or triple-duty actions.

2. Health resilience and adaptation

Indicator 2.1. Integration of health into national adaptation plans. Indicators here could also assess the extent to which national double-duty or triple-duty policy actions are established and implemented.

3. Health co-benefits of climate change resilience and mitigation

Indicator 3.7. Active travel infrastructure and uptake. Policies and environments that promote active travel through public transportation are double-duty duty actions that will increase physical activity and reduce greenhouse-gas emissions from car and other motorised vehicle use.

Indicator 3.8. Greenhouse-gas emissions from food systems and healthy diets. This indicator could also promote a plant-based diet and reduce meat consumption among populations, which represents a double-duty action to reduce obesity, heart disease, and diet-related cancers, as well as reduce methane production from agricultural livestock.

4. Economics and finance

Indicator 4.4. Value the health co-benefits of climate change mitigation and climate resilience. These indicators could also capture the financial impact of reduced comorbidities associated with increased physical activity and reduced obesity to drive the ongoing investment in double-duty and triple-duty actions.

5. Political and broader engagement

Indicator 5.1. Public engagement with health and climate change. Public mobilisation will be essential to create the political demand to reduce The Global Syndemic. This indicator could also monitor how linking the pandemics of obesity, undernutrition, and climate change could unite currently diverse and disparate constituencies worldwide.

Supplementary Material

Supplementary appendix Full PDF Document

This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors.

Supplement to: Swinburn BA, Kraak VI, Allender S, et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet 2019; published online Jan 27.

Appendixes p
Appendix 1: The Lancet Commission on Obesity and the Sustainable Development Goals  2
Appendix 2: Complex pathways from climate/weather variability to undernutrition in poor rural farming households 3
Appendix 4: Potential activities, partners and double- or triple-duty actions according to program or policy interventions 11
Appendix 5: Identifying double- or triple-duty policy actions 13
Appendix 6: Nutrition recommendations, drawn from High Level Panel of Experts Nutrition and Food Systems Report, scored for potential impact on Climate Change mitigation and adaptation* 14
Appendix 7: Public Health Responsibility Deal 17
Appendix 10: Physical activity recommendations, drawn from the WHO Global Action Plan on Physical Activity (2017), scored for potential impact on climate change mitigation and adaptation* 24
Appendix 11: Analysis of the global governance for nutrition 32
Appendix 12: Criteria for new global health treaties and counter-arguments 34
Appendix 13: Examples of influential frames used in various countries 35
Appendix 14: Policy frameworks to address obesity 36
Appendix 18: Proposed country scorecard for comparing upstream indicators on food policies and environments 40
Appendix 19: Indicators of policies to support active environments 49
Appendix 21: Role of development agencies and the flows of global aid for health 52
References 54

Appendix 1: The Lancet Commission on Obesity and the Sustainable Development Goals

The 17 Sustainable Development Goals (SDGs) were adopted in 2015 by the UN General Assembly and they set out the agenda, vision, targets and indictors for the global community to achieve global common goods. We have aligned what we have called the four main global outcomes (achieving environmental health and well-being, human health and well-being, social equity, and economic prosperity) with the SDGs. The specific focus of this report in conceptualizing malnutrition in all its forms and climate change as The Global Syndemic sits within that framework. Five of the SDGs relate directly to obesity, undernutrition, and climate change:

  • Goal 2: End hunger, achieve food security, and improve nutrition, and promote sustainable agriculture. The goal includes ending malnutrition in all its forms, and ensuring sustainable food productions systems.
  • Goal 3: Ensure healthy lives and promote well-being for all at all ages. The goal includes ending preventable deaths in children under five years, almost 50% of which are attributable to undernutrition. The goal also calls for reducing premature mortality from NCDs, such as those related to obesity.
  • Goal 11: Make cities and human settlements inclusive, safe, resilient and sustainable. This goal includes access to safe and sustainable transport systems, reducing the adverse environmental impact of cities, and inclusive and accessible green and public spaces.
  • Goal 13: Take urgent action to combat climate change and its impacts. The goal includes integrating climate change measures into policies and planning, improving awareness and institutional capacity on climate change mitigation, including in LMICs, with a particular focus on women, youth, and marginalized communities.
  • Goal 15: Protect, restore, and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and biodiversity loss. This goal includes efforts to combat desertification and restore land affected by drought. Desertification and drought are direct consequences of climate change.

However, all of the SDGs are interconnected through common deep drivers and solutions, and achieving progress for one SDG can support progress for other SDGs, as long as interactions are understood and tradeoffs are managed. The deeper the transformational changes to the political economy towards achieving better global outcomes, the greater the synergistic effects of achieving the SDG agenda.

Appendix 2: Complex pathways from climate/weather variability to undernutrition in poor rural farming households

Source: Phalkey RK, Aranda-Jan C, Marx S, Hofle B, Sauerborn R. Systematic review of current efforts to quantify the impacts of climate change on undernutrition. Proc Natl Acad Sci U S A. 2015;112(33):E4522-9 (reference 5).

Appendix 4: Potential activities, partners and double- or triple-duty actions according to program or policy interventions

Programmes / policy interventions Potential Activities and Partners Double / triple duty action
Fiscal policies such as taxation on unhealthy foods and beverages Junk-food taxes, taxes on sugar-sweetened beverages (e.g. Mexico, UK), high-fat / sugar foods, meats, (the short-lived “fat-tax” in Kerala state in India; turkey tails in Samoa; fatty meats in Poland), etc. These actions may also include intermediate steps such as passing of relevant regulations / legislation and establishing / strengthening capacities of regulatory bodies Ministry of Finance; Ministry of Commerce / Industry; civil society organisations; regulatory bodies, Ministry of Health; food industry federations, etc. Taxes on sugar-sweetened beverages is a potential triple-duty action that will likely impact both undernutrition (by eliminating empty calories from diets) as well as addressing obesity. Taxation on meats / meaty foods may reduce consumption of unhealthy meat-based foods thereby reducing obesity as well as reduced methane production by cattle.
Active Transport / built environment Urban redesign to promote walking / cycling (such as in The Netherlands; Poland); disincentivize driving with tariffs, improved public transport and subsidies for use of public transport (such as those offered by some of the corporate sector in the US) Ministry of transport, Ministry of Urban / city planning; corporate business houses. Potential double-duty actions by reducing obesity and GHG emissions by increasing physical activity and public transport.
Subsidies for production of fruits and vegetables Fiscal subsidies to producers for production of fruits / vegetables. Ministry of Agriculture; Ministry of Finance. Grocery Manufacturers associations. Subsidies are potentially triple-duty actions, with the ability to improve undernutrition, and reduce obesity and GHG produced from alternative foods such as meats.
Nutrition labelling of foods Food labels on all unhealthy processed foods (e.g in Chile; South Africa); or colour-coded labels for high / medium / low sugar beverages (such as in Sri Lanka) or labels for nutrient contents of all processed foods or all foods served in restaurants Ministry of Health, Ministry of Finance; Grocery Manufacturers Associations; restaurant associations. Potential triple-duty action, with opportunity to improve undernutrition (by encouraging consumption of healthier foods), reduce obesity (by discouraging high fat / high sugar / other unhealthy foods), and reduce GHG production linked to production of high-fat meats.
Media restrictions Media restrictions on advertisement of unhealthy food products akin to tobacco advertisements restrictions Ministry of Health, National Health promotion Agency, Ministry of Commerce / Industry, National TV / Radio associations, consumer associations; regulatory bodies to monitor media. Potential double-duty action to reduce undernutrition and overweight, especially if media restrictions are on the targeting young children;
Public awareness campaigns Population-based health promotion and mass media campaigns on diets (such as in Mexico, South Africa, Poland), physical activity and use of bicycles or public transport. Ministry of Sports; Ministry of Urban / city planning, Ministry of Health, TV / Radio associations Potential triple-duty action to reduce undernutrition: promoting a diet of healthy foods and the restriction of empty calories found in junk food can help reduce overweight / obesity as well. Physical or public transport can reduce GHG emissions by reducing car use.
School-based interventions Nutrition education, growth monitoring and screening children (such as in Poland), promoting physical activity and use of active transport options; banning sale of sugary drinks / junk foods in schools (such as in Mexico, Chile, Poland, South Africa, Thailand, Sri Lanka, USA) Ministry of Education; Ministry of Health Potential triple-duty actions by reducing both undernutrition and overweight, and reducing GHG emissions by encouraging active transport options.

Appendix 5 Identifying double- or triple-duty policy actions

The aim of this study was to identify existing policy recommendations for governments within high-level reports on obesity, undernutrition, physical activity and/or climate change and to examine the extent to which these recommendations could act as triple duty actions. The Lancet Commission on Obesity (LCO) Commissioners were invited to identify key high-level international reports on obesity, undernutrition, climate change and physical activity published between 2007 and 2017. The reports identified (n=66) were collated and prioritized according to their level of authoritative impact, aiming to achieve a balance between United Nations (UN) and independent reports, and reflecting malnutrition in all its forms. This process refined the number of reports to eleven. Reports that did not present specific recommendations for government were then excluded, leaving six final reports for analysis. Contrary to expectations, none of the climate change reports initially identified by LCO Commissioners provided specific recommendations for government. Therefore, reports addressing obesity, undernutrition and physical activity were the focus of initial analyses, and the reports were later assessed for their potential impact on climate change, as detailed below.

All individual government recommendations were extracted from the six reports, as shown in Table 1, and categorized into overarching domains. Categorization was undertaken independently for nutrition and for physical activity. The two most recent and high-level reports were used to guide this process, namely the High Level Panel of Experts on Food Security and Nutrition (HLPE) report on Nutrition and food systems (2017), and the World Health Organization (WHO) Global action plan on physical activity, draft 2 (2017). Both these reports adopt an existing overarching structure to categorize their individual policy recommendations, and this same structure was applied to the recommendations extracted from the four other reports. Following this process, it was evident that the HLPE Nutrition and food systems report and WHO Global action plan on physical activity report captured all key government recommendations and adequately covered the domains identified in the other reports. The subsequent analysis was therefore focused on these two key reports only.

Table 1: Government recommendations extracted from key high-level reports on obesity, undernutrition and physical activity

Report focus Title (year) Recommendations
Obesity Lancet Series I. Changing the future of obesity: science, policy and action (2011) 23
Obesity WHO Global action plan for the prevention and control of NCDs, 2013-2020 (2013) 71
Undernutrition IFPRI Global Nutrition Report (2016) 30
Undernutrition FAO Synthesis of guiding principles on agriculture programming for nutrition (2013) 20
Nutrition HLPE Nutrition and food systems (2017) 37
Physical Activity WHO Global action plan on physical activity, draft 2 (2017) 74

Since no specific government recommendations for climate change were identified through the reports, four LCO Commissioners and Fellows (Mario Herrera, Mark Howden, Susanna Mills and Wilma Waterlander) who had extensive expertise in climate change were invited to rate the recommendations in the remaining two reports for potential impact on climate change mitigation, and adaptation. This process was undertaken independently by the Commissioners using a five-point scale (1=no impact to 5=substantial impact). The scores were amalgamated by taking the highest score for each rating. Appendix 6 shows the scoring results for the full government recommendations for nutrition and Appendix 10 shows the scoring results for physical activity. A condensed version of the recommendations and associated ratings are shown in Table 1 for nutrition and Table 2 for physical activity in the main manuscript.

Appendix 6: Nutrition recommendations, drawn from High Level Panel of Experts Nutrition and Food Systems Report, scored for potential impact on Climate Change mitigation and adaptation*

HLPE domain Recommendation Potential climate change impact
Mitigation Adaptation
Strengthen the integration of nutrition within national policies, programmes and budgets Design context-specific policies and programmes that support the co-existence of diverse food systems and diets 5 3
Integrate a nutrition-focused food system approach into national development, health and economic plans 3 2
Facilitate an inclusive dialogue and develop nutrition strategies at national and local levels, focusing on improving food environments. 3 2
Foster policy coherence in order to improve diets and nutrition, through enhanced coordination across sectors 3 3
Increase the allocation for nutrition in national budgets and identify greatest synergies for improved nutritional outcomes within existing spend 4 2
Improve food and nutrition literacy throughout society through popular education programmes and other schemes 4 2
Improve capacity by investing in a workforce of nutrition practitioners, and educating food system professionals on nutrition 2 2
Strengthen global cooperation to end malnutrition and hunger Increase official development assistance (ODA) to support more sustainable food systems, address malnutrition, and prevent diet-related NCDs 4 4
Avert famines by strengthening local food systems and longer-term development support, and investing in appropriate humanitarian aid 3 5
Address the impacts of trade and investment agreements on food environments and diets Assess multilateral and bilateral trade and investment agreements to ensure they do not have a negative impact on food environments and diets 2 2
Ensure that trade and investment agreements are consistent with nutrition policies and favour more sustainable food systems 2 2
Address the nutritional vulnerabilities of particular groups Ensure that vulnerable and marginalized groups are able to achieve a sufficient, diverse, culturally appropriate nutritious diet 2 3
Improve nutritional outcomes by enhancing women’s rights and empowerment Ensure that laws and policies provide men and women equal access to resources 2 2
Value the importance of, and redistribute, unpaid care work within the household 1 1
Strengthen rural women’s participation and representation at all levels of policy-making for Food Security and Nutrition (FSN) 2 3
Create an enabling environment for breastfeeding, ensuring that women’s economic security and rights are promoted 2 1
Recognize and address conflicts of interest Acknowledge conflicts of interest (COIs) and imbalanced power relationships between stakeholders, and establish participatory mechanisms to address them 2 2
Ensure transparency and accountability mechanisms through coordinated, open access monitoring systems to prevent and address COIs 2 1
Protect nutrition sciences against undue influence and corruption, through appropriate rules, effectively monitored and enforced 2 1
Improve data collection and knowledge-sharing on food systems and nutrition Promote nutrition-focused, policy-relevant research on food systems and food demand 2 2
Improve the availability and quality of multi-sectoral information systems that capture diet, food composition and nutrition-related data 2 2
Invest in participatory systems for the sharing of knowledge and best practices among stakeholders in the food supply chain 3 5
Draw on the knowledge, experience and insights of those who are not usually regarded as members of the nutrition community 2 3
Enhance opportunities to improve diet and nutrition outcomes along food supply chains Support initiatives that contribute to the production of nutritious, locally-adapted foods and contribute to dietary quality and diversity 3 3
Protect and enhance nutritional value along food supply chains 2 2
Ensure the food supply is healthy for the consumer 1 2
Improve the quality of food environments Make nutritious foods more accessible and convenient in public places, school gardens, rural marketplaces and in homes 2 1
Design and implement policies and regulations that improve the built environment to promote nutritious food 3 2
Regulate health claims on food packaging and adopt an easily interpreted front labelling system 2 1
Strengthen national food safety standards and quality assurance and develop better global surveillance systems 1 1
Phase-out advertising and promotion of unhealthy foods, especially to children and adolescents 1 1
Institute policies and practices that implement the International Code of Marketing of Breast-milk Substitutes 1 1
Create consumer demand for nutritious food Develop global and national guidelines for healthy and sustainable diets and make guidelines actionable and user-friendly for consumers 2 2
Implement economic and social policies that increase demand for nutritious foods and lower demand for nutrient-poor foods 3 2
Ensure that social protection programmes such as school feeding and cash transfers lead to improved nutritional outcomes 2 1
Promote food cultures, including cooking skills and the importance of food in cultural heritage, to promote nutrition literacy 2 2

* Rating 1= no impact to 5 = substantial impact

Appendix 7: Public Health Responsibility Deal

This summary is based on an accountability framework to promote healthy food environments (6) (see Figure 1), as previously applied to the calorie reduction pledge from the Public Health Responsibility Deal (7). The INFORMAS monitoring framework (8) has also been used to structure the summary of impacts of the Responsibility Deal (see Figure 2).


  • The Public Health Responsibility Deal (RD) was a voluntary public-private partnership established by the UK Coalition Government 2011-2015, aiming to tackle public health challenges in England using a collaborative approach (9)
  • The RD involved networks for alcohol, food, physical activity and health at work, with a behaviour change network providing expert advice across the RD as a whole
  • Each network was composed of a core group including government, commercial and voluntary organisations, and academic experts, and was underpinned by iterative and collaborative development of pledges (commitments) to improve the public’s health
  • The RD was based on a premise that governmental top-down approaches do not lead to improvements in public health, and that partnerships are more effective and efficient than regulation in enacting public policy changes (10)
  • The initiative may also have been influenced by the behavioural economics theory of ‘nudging’ people to engage in healthier behaviours through small modifications to the environment in which they make choices (their ‘choice architecture’) (11)

1. Take the account (assessment)

  • Organisations self-monitored their progress against the pledges they chose to sign up to, and were requested to provide annual updates to the UK Department of Health
  • The lack of a transparent monitoring and verification process for pledges, and emphasis on ‘nudging’, caused discontent from the outset. Public health organisations were concerned that potential benefits to public health had been made subordinate to the interests of industry, and that alternative courses of action had not been identified by the government, should the pledges fail to be successful (12)
  • Independent evaluations of the RD by the Policy Innovation Research Unit (PIRU) group at the London School of Hygiene and Tropical Medicine identified major shortcomings of the initiative (13-18)
  • Key concerns across the RD networks were: absence of approaches known to be most effective in improving public health from the agreed RD pledges; small number and heterogeneity of organisations’ progress reports, leading to difficulties in assessing the quality and extent of implementation of interventions captured by pledges; and the majority of such interventions had already been initiated, or were likely to have been implemented anyway, irrespective of the RD (13-18)
  • Many organisations’ drive to participate in the RD appeared to be drawn from the opportunity to improve their reputation, achieve corporate social responsibility goals, and avoid external regulation (16)

2. Summary of key impacts of the RD, with focus on obesity

  • Food composition (no formal evaluations were undertaken as part of the RD; specific targets, where mentioned in pledges, are presented)
    • Calorie reduction (target to reduce population consumption by 5 billion calories/day, ie approximately 100 calories per person) – no significant change for adults from 1896 to 1849 kcal/day, 2008/9 to 2013/14 (19)
    • Saturated fat reduction (target for less than 11% daily food energy intake per person) – no significant change for adults from 12.8% to 12.7%, 2008/9 to 2013/14 (19)
    • Trans fat reduction (target for complete removal from products) – change for adults from 1.5g/day (0.7% total energy) to 1.0g (0.5% total energy), 2008/9 to 2013/14 (19)
    • Salt reduction (target less than 6g per person/day) – no significant reduction for adults from 8.5g to 8.0g/day, 2011 to 2014 (20)
    • Fruit and vegetable intake – no significant change for adults from 4.1 to 4.0 mean portions/day, 2008/9 to 2013/14 (19)
    • Sugar reduction programme launched in the Conservative Government’s 2016 childhood obesity strategy, aiming to reduce sugar intake by 20% by 2020, through reduction of sugar levels in products, reducing portion size and shifting purchasing towards lower sugar alternatives (21). Sugar content targets for foods and drinks will be published by Public Health England in 2017
  • Food labelling
    • Front-of-pack nutrition labelling – new voluntary labelling scheme established in 2013, with organisations accounting for almost two thirds of food on sale signed up (22)
    • Out-of-home labelling – one third of meals and takeaways sold on the high street covered by organisations signed up to calorie labelling (22)
  • Food promotion
    • No specific RD pledges developed
    • Separate Committee of Advertising Practice consultation undertaken in 2016 evaluating whether a ban on advertising junk food to children online, in the press, on billboards and poster sites should be introduced (23)
    • No guidance or legislation introduced in the 2016 childhood obesity strategy (21)
  • Food provision
    • Implementation of basic measures for encouraging healthier food availability in the workplace – no formal evaluation
  • Food retail
    • Largely covered by food composition and labelling policies
    • Some separate voluntary initiatives established, such as confectionery removed from supermarket checkouts following a non-governmental organisation (NGO) ‘Junk Free Checkouts’ campaign (24), with a precedent set in all stores by Tesco (25)
  • Food prices
    • No specific RD pledges developed
    • Separate Soft Drinks Industry Levy planned for 2018 (26)
  • Food trade and investment
    • No specific RD pledges developed
  • Physical activity
    • No formal evaluations of quantitative changes in physical activity; robust national data for comparisons not available post-2012

3. Share the account (communication)

  • Progress was noted by the UK Department of Health in terms of engagement, with 776 partner organisations signed up to the RD across 43 pledges, over four years. However, organisations’ progress reports were generally descriptive rather than providing quantitative data; largely reflected implementation instead of outcomes; and were inconsistently submitted (13, 15, 17)
  • Meeting documentation for the RD was criticised for being insufficiently transparent (15). An analysis of the calorie reduction initiative of the RD required Freedom of Information requests to access source material, which was not routinely uploaded to the RD website (27)
  • The UK Department of Health promoted successes of the RD at a celebratory event in March 2015 (22); however overall, government communications regarding RD outcomes were scant
  • Media coverage of the RD in both scientific and non-scientific fora was generally negative (for example (28-31))

4. Hold to account (enforcement)

  • An independent scoping review of 47 voluntary agreements between business and government indicated that although such agreements may provide an effective approach when appropriately implemented and monitored, the evidence base regarding their comparative effectiveness with compulsory or legislative strategies is lacking (32). Sanctions for non-compliance and disincentives for non-participation often featured in the most effective voluntary agreements (32)
  • However, incentives and disincentives were not characteristics of the RD, and the UK Government did not publicise any plans to advance progress through enforcement
  • A study of informants’ experiences of the RD concluded that in order to produce true gains to public health: “government needs to increase participation and compliance through incentives and sanctions, including those affecting organisational reputation; create greater visibility of voluntary agreements; and increase scrutiny and monitoring of partners’ pledge activities” (16)
  • The RD was criticised by several NGOs, such as Action on Sugar (33), Institute of Alcohol Studies (34), Sustain (35) and Which? (36) for lack of progress and transparency
  • Other strategies such as shareholder advocacy and litigation were not used to hold non-compliant and under-performing organisations to account

5. Respond to the account (improvements)

  • Since the election of a new UK Conservative Government in 2015, the RD has not been actively pursued
  • There has been little evidence of collaboration between RD organisations, UK Government and NGOs to achieve pledges
  • An independent monitoring system would appear necessary to ensure transparency, and guide implementation of incentives and penalties, policies and regulations, and legislation to hold organisations to account
  • Robust mechanisms to translate findings from evaluations and civil society pressure into tangible changes to government policies and organisational practices should be developed


The Responsibility Deal was a useful way of bringing stakeholders together, reaching agreement on certain issues, most of which were already underway to some extent within the industry (eg. removal of trans fats). It did, however, fail to take forward more challenging and contentious issues of appropriate and desirable reductions, for example in salt, sugar content, and labelling. There was insufficient clarity over what government expectations were and what success would look like.

There was also a lack of government ‘commentary’ on the appropriateness of the response by companies, either in terms of who was/ was not making a commitment or the appropriateness/ relevance of their response once they did pledge. The RD relied on industry members agreeing to ‘pledges’ to take actions to contribute to tackling obesity and diet-related disease. As a result the wording of the pledges was generally unambitious and allowed for a great deal of flexibility. The Royal Society for Public Health, Faculty of Public Health and several other professional bodies withdrew their interest and support from the RD at an early stage. Many public health organisations also publically withdrew from the Alcohol group. In view of recent political changes and focus on other issues such as Brexit, the RD has fallen much lower down the political priority agenda. Maintaining momentum for initiatives such as this can be challenging, and the RD is unlikely to be resurrected in its previous form.

What should be done to make it work better in other countries?

  • A clear timetable for action, and clarity over steps that will be taken if there is not enough progress, is needed at the outset
  • Voluntary initiatives alone will not achieve change on the scale needed to address issues of diet-related disease. Such action needs to be supported by other government initiatives, including legislation where necessary
  • A fair, level playing field is required for industry members. There should be public reputational sanctions for those who do not commit (eg. a naming, praising and shaming approach), in order that participation/ commitment is not de-incentivised
  • Senior level commitment by government, industry and public interest stakeholders is needed, to promote buy-in, ensure momentum, and hold participants to account.

Figure 1: Accountability framework to promote healthy food environments (6)

Figure 2: INFORMAS monitoring framework (8)

Appendix 10: Physical activity recommendations, drawn from the WHO Global Action Plan on Physical Activity (2017), scored for potential impact on climate change mitigation and adaptation*

Physical activity domain Recommendations Potential Climate Change Impact
Mitigation Adaptation
Implement communication campaigns to raise awareness of the multiple benefits of physical activity Develop a national communication strategy for the health benefits of physical activity 2 1
Implement sustained public education, awareness and behaviour change campaigns to promote physical activity 3 2
Use sport, arts, cultural, health and other participatory events to promote physical activity 2 1
Support partnerships between health and other sectors to engage in promotion events to raise awareness of physical activity 2 2
Conduct communication campaigns to increase knowledge of the multiple co-benefits of physical activity 2 2
Support national, regional and international campaigns on issues related to physical activity 2 1
Implement mass-participation initiatives and provide access to physical activity experiences Implement accessible events that provide opportunities to be active in local public spaces activities 2 2
Develop and disseminate national guidance and examples on how to implement mass participation initiatives on physical activity in public open spaces 2 2
Strengthen training of health and non-health professionals in opportunities to develop an active society Strengthen curricula of all medical and allied health professionals for effective integration of the health benefits of physical activity into formal training 2 2
Strengthen formal training for preschool, primary and secondary school teaching staff and administrators to strengthen knowledge and teaching skills on physical activity 2 2
Include physical activity in the professional education of relevant sectors outside of health to understand the value of promoting physical activity 2 2
Partner with road safety experts to strengthen stakeholders’ understanding of safe systems approaches to improving road safety for pedestrians, cyclists and public transport users 3 1
Promote active and public transport through policies and infrastructure Prioritize walking, cycling and public transport as preferred modes of travel in relevant transport, spatial and urban planning policies 4 2
Support health and economic assessments of transport and urban planning policies and interventions to assess impact on health, physical activity and environment 4 1
Support the development and implementation of planning and transport policy, guidelines and regulations that promote active and public transport 4 1
Strengthen health in all policies at the national and subnational level, focusing on issues related to physical activity in relevant policies across key sectors 2 2
Support the effective engagement of communities in direct participation in urban and transport planning processes 3 2
Increase the level of service of well-connected walking and cycling networks 3 2
Promote integrated urban design and land use policies that create highly connected, walkable neighbourhoods 3 3
Develop policies to support ‘co-location’, enabling efficient access by walking, cycling and public transport 4 2
Support the strengthening of national road safety legislation and action plans 2 1
Support the strengthening of road transport safety systems 2 1
Increase the level of service of well-connected walking and cycling networks 3 1
Implement education and social marketing campaigns aimed at increasing safe behaviours among all road users 2 1
Encourage urban planning policies and strategies that reduce crime and the fear of crime, to facilitate increased active use of open public and private spaces 2 1
Strengthen access to recreational spaces and facilities for all Promote and enforce urban planning, land use and spatial policy that enables access to open spaces, green spaces, and sports facilities 2 2
Implement health and economic assessments of open spaces to evaluate health, climate and environmental benefits, including impact on physical activity 3 3
Facilitate active engagement of community members in the location, design and improvement of open and recreational spaces 2 3
Strengthen the policy of shared use of school facilities to increase provision of open public spaces for community utilization 2 2
Strengthen the implementation of market restrictions on unhealthy food and non-alcoholic beverages in and around open public spaces and sports facilities 2 1
Strengthen guidelines and frameworks to promote physical activity in and around buildings and facilities Support the development and implementation of building design guidelines and regulations that prioritize universal access, and physical activity amongst occupants and visitors 2 2
Develop and implement design guidelines for education and child care facilities that optimise provision of environments for children and young people to be physically active 1 2
Develop and implement design guidelines for recreational and sports facilities that ensure equitable, safe and universal access by all people 2 2
Strengthen provision and enjoyment of good-quality physical education and active recreation Strengthen national education policy, implementation and monitoring to ensure provision of quality, inclusive physical education for school-aged children 1 1
Strengthen national implementation of whole-of-school physical activity programmes in all education institutions 2 1
Promote walk and cycle to school programmes 3 2
Develop and disseminate guidance for childcare regulators and providers on promoting physical activity in childcare settings through the day 1 1
Collaborate with the higher education sector to develop leadership and engagement in strengthening provision of opportunities to increase physical activity 1 1
Implement patient assessment, advice and referral for physical activity into health and social care services Develop and implement national standardized protocols on patient assessment and brief advice on physical activity in primary health and social care settings 1 2
Integrate patient assessment, brief advice and referral to opportunities for physical activity as part of the care and services for older patients, those with long term conditions, and pregnant women 1 2
Enhance provision of, and opportunities for, physical activity in wide-ranging work and leisure settings Provide national leadership by implementing whole-of-government workplace health initiatives to support increased physical activity 1 1
Develop and disseminate national guidance, and promote implementation of workplace health programmes aimed at increasing physical activity amongst employees 1 1
Partner with Ministries of Sport and the sports community to strengthen provision of universally accessible active recreation and sports programmes 2 1
Partner with subnational and local governments to promote the use of existing public community buildings and facilities for community-based physical activity programmes 2 2
In partnership with education, health and childcare sectors, implement programmes aimed at families, parents and caregivers to develop skills to help young children enjoy active play 1 1
Partner with Ministries of Finance to review and evaluate the effectiveness of fiscal instruments to promote physical activity as a way of life 1 1
Strengthen programmes and services that engage with and increase opportunities for physical activity in the least active groups Strengthen implementation of national standardized protocols for assessing physical activity capacity in older adults and providing brief advice in primary and secondary health care 1 1
Develop and implement national policy to strengthen provision of appropriate programmes to increase physical activity amongst older adults 1 1
Develop and implement interventions supporting families and caregivers to acquire the skills, competencies and confidence to support healthy ageing in and outside the home 2 2
Ensure that data are reported and used to identify the least active subpopulations, and to engage representatives in development of tailored programmes to increase participation 1 1
Support the development and implementation of programmes promoting physical activity in disadvantaged, marginalized and indigenous communities and populations 2 1
Support development of national sports policies prioritizing investment in active recreation and sports programmes targeting the least active, and disadvantaged groups 2 1
Support partnerships with the sports sector to promote universal access to opportunities for physical activity for all people with disabilities and their carers 1 1
Implement whole-of-community initiatives to promote widespread participation in physical activity Strengthen national and  subnational networks of communities implementing whole-of-community approaches to promote physical activity, and share resources and experiences 2 2
Implement city scale and whole-of community, multi-component approaches to promoting adequate physical activity for all, using principles of community engagement 3 2
Disseminate implementation guidelines and incentives to encourage whole-of-community physical activity initiatives at subnational level 2 2
Strengthen leadership, governance and policies to increase physical activity Strengthen high level national multi-sectoral coordination committees providing leadership, strategic planning and oversight of national policy actions on physical activity 2 2
Strengthen national and subnational action plans on physical activity which align with global and regional recommendations, and maximize policy coherence and synergies across key relevant sectors 2 2
Partner with other sectors to strengthen the position of physical activity within respective policy frameworks 2 2
Review, adopt and update national physical activity guidelines, and disseminate through tailored resources adapted to target audiences and local context 1 1
Foster leadership to promote policy action on physical activity and stimulate professional and community-wide shift towards positively valuing an Active Society 2 2
Enhance data systems and capabilities to support surveillance, monitoring and accountability for physical activity Strengthen population surveillance of physical activity, ensuring coverage of all ages and domains, and regular reporting of progress towards achieving targets 1 1
Strengthen data analyses and dissemination to inform priority setting, and support monitoring of progress towards reducing inequalities in participation in physical activity 2 2
Adopt a set of harmonised national and subnational targets and indicators as part of a national monitoring and evaluation framework to track progress towards reducing physical inactivity 2 2
Support partnerships to develop innovative digital technologies to strengthen surveillance of physical activity and its determinants 2 3
Strengthen research and evaluation capacity and strengthen innovations for policy solutions to increase physical activity Strengthen government and nongovernment funding support for research on physical inactivity and sedentary behaviour 1 1
Identify and disseminate a set of national research priorities for physical inactivity and sedentary behaviour 1 1
Support research institutions to ensure appropriate level of evaluation of all national and subnational physical activity policies and programmes, and disseminate findings 1 2
Strengthen innovation, evaluation and knowledge sharing to ensure that evidence on physical activity is widely accessible and can advance policy implementation and resource use 1 2
Collaborate with relevant centres and research organizations to strengthen knowledge transfer and institutional capacity for research and program evaluation on physical activity 1 2
Escalate advocacy efforts to increase action at multiple levels, targeting key audiences Support the creation of networks and collaborative actions to empower people and communities to be engaged with the development of an Active Society 2 2
Strengthen partnerships with civil society, community organisations, the media and private sector to raise awareness and support engagement to increase physical activity 2 2
Strengthen financing mechanisms to support action and policies to increase physical activity Allocate long term budgets for physical activity, taking account of national targets and priorities 2 2
Collaborate across Ministries to develop dedicated financing mechanisms to support multi-sectoral approaches and policy actions on physical activity 2 2

* Rating 1= no impact to 5 = substantial impact

Appendix 11: Analysis of the global governance for nutrition

A recent analysis completed for the UN System Standing Committee on Nutrition (UNSCN), identified 167 actors as prominent in global nutrition governance (Figure 6).(45) While no single UN agency is responsible for nutrition, agencies are tightly connected via two UN-wide platforms/networks – the UNSCN and the Committee on World Food Security (CFS). The WHO and FAO are the lead agencies mandated to coordinate actions over the ‘malnutrition in all its forms’ focused UN Decade of Action on Nutrition (2016-2025), which sits within the broader framework of the Sustainable Development Goals. A number of other influential nutrition-focused UN system platforms have emerged in recent years, each governed variously by actors from within the UN system, private sector, NGOs and national governments. These provide a convening function to harness technical expertise, financial resources, and provide on-the-ground support for policy implementation and capacity building. A significant and relatively new multi-stakeholder partnership is Scaling Up Nutrition (SUN). Established in 2010, SUN brings together governments, civil society and the private sector. The Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases (IATF) coordinates the activities of relevant UN and other inter-governmental organizations to support national governments to meet their high-level commitments on addressing diet-related NCDs.

While nutrition may not be their primary mandate, other important and economically powerful actors are active in the nutrition area. Multilateral agencies and financial institutions e.g. the World Bank, and private philanthropic organizations, particularly the Bill and Melinda Gates Foundation and Bloomberg Philanthropies, feature prominently in the global landscape, as do a number of public-private partnerships, multinational corporations and corporate foundations. The increased concentration of transnational food corporations in the global nutrition landscape poses questions of how to identify, mitigate and manage potential conflicts of interest. There is also a diverse set of non-government organizations with interests spanning food security, food sovereignty, micronutrient deficiencies, obesity and diet-related NCDs. These different foci play important roles in shaping policy agendas and enabling networks of different actors to coalesce around shared interests. Many new research institutions have emerged, a number of which bridge connections between food systems, nutrition and environmental sustainability, which have potential to facilitate a shift in the global, regional and national policy discourses and agendas.

Network map of actors involved in the global nutrition governance system, colour coded by type

Legend: Light blue = UN system; Green = civil society / non-governmental organizations; Pink = National governments / pluri-lateral organizations; Grey = Multilateral development banks / financial institutions; Yellow = Philanthropic organizations; Red = Private industry; Dark blue = Public-private partnerships / multi-stakeholder initiatives; White = Research institutes, networks, professional organizations

Appendix 12 Criteria for new global health treaties and counter-arguments

Criteria Hoffman et al. 2015 assessment Counter-arguments
Nature of the problem: significant transnational dimension (Involves multiple countries, transcends national borders, and transfers risks of harm or benefit across countries) Except for trade dimensions, mostly requires domestic action Involves multiple countries as the main conflicted businesses are multinational and unhealthy foodstuffs can be sold worldwide through imports/exports. Online marketing is cross border and difficult to regulate if policies are adopted only by one or a few countries. Trade policies, such as TTIP and CAP, are transnational.
Nature of the solution: coercive nature of treaties justified (addresses multilateral challenges that cannot practically be addressed by any single country alone, resolves collective action problems when benefits are accrued only if multiple countries coordinate their responses, or advances superordinate norms that embody humanity and reflect near-universal values) Does not meet requirements justifying coercion Added to the previous arguments is cross-border lobbying e.g. Italy complains to EU over Britain’s food labelling (traffic lights) impact on Italian products sold in UK supermarkets. Global policies can be weakened by lobbying from one Member State. If all Member States have signed up, this is less likely to happen.
Nature of likely outcome: reasonable chance of achieving benefits (Incentivizes those with power to act, institutionalizes accountability mechanisms designed to bring rules into reality, and activates interest groups to advocate its full implementation) Few incentives and likely weak accountability If a package of policies is promoted (e.g. by WHO) it will address totality of the food environment, rather than bit by bit in different countries. Accountability could be easy if a single company is internationally held to account rather than its national branches. This will also tackle the double standards between global north and south that many food companies adopt.
Nature of implementation: best commitment mechanism (Projected to achieve greater benefit for its costs than competing alternative mechanisms for facilitating commitment to international agreements) No evidence that a treaty is better than alternatives National piecemeal approaches will not work and a policy package is needed to address imports/exports, cross-border practices and trade agreements. International mechanism drives innovation for healthier food alternatives and creates incentives.

Source: Hoffman SJ, Røttingen J-A, Frenk J. Assessing proposals for new global health treaties: an analytic framework. Am J Public Health. 2015;105(8):1523-30 (reference 46).

Appendix 13: Examples of influential frames used in various countries

  • In Mexico, highlighting the health and economic burden of obesity and diabetes, and the uniquely harmful contribution of sugar sweetened beverages (e.g. portraying consumption as eating a spoonful of sugar), was influential in generating support for taxation.(52)
  • In India, a focus on children including the use of “vivid photographs of acutely malnourished children” generated widespread attention to undernutrition. The adoption of a ‘right to food’ frame was highly influential in generating broad support for the universalization of a national food distribution scheme.(53)
  • In Bangladesh infant and young child feeding was linked to the national goal of becoming a middle-income country, and in Ethiopia to the goal of stunting reduction and human capital development.(54)
  • In Brazil, nutrition goals were met when a frame of access to ‘fresh basic foods’ during the development of a national school feeding program resonated with the interests of local farmers and food suppliers.(55)
  • In England, a focus on children was seen as “critical in getting political buy-in” from a range of sectors and for “over-coming nanny-statism” arguments put forward by political opponents during the development of a national obesity strategy.(56)
  • In Australia, equating feeding junk food to children with giving them heroin resonated widely with the public.(57) The severe economic consequences of obesity for health systems and workforce productivity generated significant political attention.(58)

Appendix 14: Policy frameworks to address obesity

Source: Huang TT, Cawley JH, Ashe M, et al. Mobilisation of public support for policy actions to prevent obesity. Lancet 2015; 385(9985): 2422-31. (ref #297 in v16.3 draft) Not cited in reference section of Appendix

Appendix 18: Proposed country scorecard for comparing upstream indicators on food policies and environments

New Zealand is used as an example with data coming from a series of studies of food policies, actions and environments based on the INFORMAS protocols (


How does food environment policy implementation by the national New Zealand Government compare to international best practice?

The Healthy Food Environment Policy Index was 43% in 2014 and 48% in 2017.

What are the 2017 priorities for action by the national Government?

FOOD COMPOSITION: Set targets for nutrients of concern (sodium, saturated fat, sugar)
FOOD LABELING: Strengthen the Health Star Rating System and make it mandatory
FOOD MARKETING: Regulate unhealthy food marketing to children in all media
FOOD PRICES: Implement a 20% tax on sugary drinks
FOOD PROVISION: Ensure healthy foods in schools and early childhood education centres
LEADERSHIP: Strengthen the child obesity plan;
Set a target for reducing child obesity;
Set targets for intake of nutrients of concern (sodium, saturated fat, sugar);
Translate Eating guidelines in the social, environment and cultural contexts
MONITORING: Conduct a new national children’s nutrition survey
FUNDING: Increase population nutrition promotion funding to at 10% of obesity health care costs

How strong and comprehensive are the nutrition policies of local public sector settings?

How are the biggest food companies performing in relation to their national commitments on obesity and population level nutrition?


How healthy is the national packaged food supply?

What is the cost differential between healthier and less healthy foods and healthy and current, less healthy household diets?

Mean cost ($) of household diets
Healthy Current
Total population 723 696
Māori 655 694
Pacific 594 655


% of healthy household diets cheaper than average current diet
Total population 25.8
Māori 87.1
Pacific 96.7

How healthy are children’s food environments?

% of schools selling sugar sweetened beverages 42.1
% of schools using unhealthy foods for fundraising 81.6
% of schools only selling unhealthy foods on school grounds 8.1
Average number of unhealthy food advertisements within 500m around urban schools 8.9
Average number of convenience/fast food and takeaway outlets within 500m around urban schools 2.4
Average number of unhealthy TV food advertisements per hour during children’s peak viewing times 5.9
% of food company websites with a designated children’s section 18.6
% of ads on Facebook pages of popular fast food and packaged food/beverage brands using: promotional characters

premium offers



% sponsors of clubs for popular children’s sports that are food/beverage company/brand sponsors 9.6
% biscuits, confectionary, cereals & snack foods with promotions and/or premium offers on the front-of-pack 28.2

How healthy are other community food environments?

Average ratio of cumulative linear shelf length for healthy versus unhealthy foods 0.42
Average proportion of ‘junk food free’ end-of-aisle endcaps 47
Average proportion of promotions in supermarket flyers for junk food 25
% of supermarkets with at least 20% of check-outs that are ‘junk food free’ 27
% of fast food and takeaway outlets for which sugar sweetened beverages represent less than 50% of drink options on the menu 26
Average proportion of foods and meals promoted inside fast food and takeaway outlets that are unhealthy 64
% of hospitals selling sugar-sweetened beverages 25
Average proportion of foods and beverages for sale in public hospitals that are unhealthy foods 54
% of sport and recreation centres selling sugar-sweetened beverages 53

How equitable is access to healthy food environments?

Appendix 19: Indicators of policies to support active environments

Action Indicator Data Source
Regional planning
Design Urban design codes that prioritize, active travel (walking and cycling)

Public parks

Public transport

Urban planning and design code that requires a balance of housing to employment – ( 0.8-1.2) – (ratio to be contextualized)

Government policies that include policies related to parks, and physical and public transport

Public parks within 0.5 km radius

Public transport stops within 0.5 km radius

Government, records, Policies/Data
Destination accessibility Urban Codec-coordinated planning of land use, employment, education, art centres , residence and different modes of active and other transport Facilities, jobs, services, recreational facilities accessible within 30-45 minutes from homes by public transport or walking/ cycling Government Policies/Data GIS
Public transport accessibility, adequate capacity, comfort and safety Urban codes require public transport to be within 400-800 metres of residential and work place catchments Percentage of population living within 400-800 metres of public transport

Safe walkable access to public transport

Percentage of the population using public transport

Government Policies/Data GIS
Local urban design
Open green spaces, public parks Local urban design provides adequate, accessible, and safe public parks Percentages of population living within 0.5 kilometre radius of green space

Percentage of land allocated to open green spaces

GIS, Government data and documents
Priority for active travel Creation of complete streets Percentage of population biking or walking to destinations Ratio of roads (km) to footpaths (km)

Ratio of designated active transport lanes (or cycles and other forms of active transport) to roads

Ratio of width of foot-paths, active travel/cycling lanes and width of roads

In tropical countries-percent of roads with tree canopies, water fountains at intervals (In tropical countries) and benches, and curb cuts

Government data, surveys, policies GIS
Safety and Desirability Neighbourhood designs, green spaces and active travel designs, public transport to be made safe and desirable Traffic calming, limited width of car (all motorised transport) lanes in-city roads In tropical countries, water – fountains and green tree canopies alongside Accident/ injuries rates and crime rates in the area Government policies/data National Opinion Survey
School – design and policies Schools have play grounds, facilities, equipment and mandatory time allocation to sports and dance % of schools with open play grounds, sporting facilities and equipment, and offer them every day to the children Percentage of children who walk to school/active transport to school

% of schools which have a PE period at least 4/5 days a week, or 80% of the working days in a year

Government policies/data
Physical Inactivity Monitor prevalence of physical inactivity % of children, adolescents and adults who fail to meet PA recommendations Government survey

Appendix 21: Role of development agencies and the flows of global aid for health

As NCD burdens increase across the world in both developed and developing economies, their economic impacts are being recognized globally, as projected public health and long-term care expenditures rise dramatically. Development agencies have not seriously engaged in supporting low and middle income countries (LMICs) to address NCDs. Only 2.2% of development aid for health is allocated to NCDs, despite NCDs being responsible for two thirds of deaths in LMICs, half of which occur under the age of 60 (see figure 1). There has also been a reluctance among development agencies to support obesity prevention efforts in LMICs with almost all the nutrition focus being on reducing undernutrition. Nonetheless, development agencies such as the World Bank, the Inter-American Development Bank, the Asian Development Bank, the African Development Bank and the European Commission as well as some bilateral aid agencies have a key role to play in preventing obesity. They have the potential to make direct investments in programs or provide incentives and policy triggers for governments to enact double or triple-duty actions to address aspects of The Global Syndemic.

Development banks have several instruments they can employ to support action within countries. Investment lending is where agencies invest grant or credit resources to pay for inputs to governments to design and implement programs such as for obesity-prevention. When actions are needed at a policy level, these agencies can use other mechanisms such as Disbursement Policy Loans that include disbursement-linked indicators, wherein credits to countries can be designed with policy triggers linked to actions such as regulations on mandatory front of pack food labels mandatory or implementing fiscal policies for food. Funds are released if/when these clearly defined triggers are met. In other cases, countries, especially middle and high-income countries, sometimes request technical assistance or advisory services from these agencies to design and implement relevant policies and programs. The design and implementation of these policies is often negotiated not just with the ministries of health, but also ministries of finance, commerce, industry, and other relevant ministries including transport, city planning, education and agriculture, as well as consumer associations, media associations, regulatory and legislative bodies, academia, and the corporate sector. This large conglomeration of potential actors makes these policies and programs much harder to negotiate and equally harder to implement and to monitor.

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