Accountability systems

Accountability systems

Strengthening accountability systems will be central in ensuring that recommended policies are implemented to reduce The Global Syndemic. For obesity in particular, many evidence-based policies are recommended by WHO, including the Ending Childhood Obesity reports, which have been approved at successive World Health Assemblies.22, 322 These WHO recommendations form the Account, which in accountability terms, means the agreed plan of action and responsibilities. However, these recommended actions have only been weakly implemented globally by the major actors — principally governments and food companies.2 The next accountability steps are Taking the Account and Sharing the Account through more targeted, upstream monitoring systems.86 The Commission believes that the downstream monitoring of indicators of obesity, undernutrition, climate change, and their consequences is essential for tracking outcomes, but monitoring upstream, at the policy implementation level, is also essential for strengthening accountability. An agriculture minister cannot be expected to be accountable for reducing obesity, but they can be accountable for enacting agreed agricultural policies towards healthy, sustainable, equitable, and prosperous food systems. Examples of upstream monitoring for accountability on food policies for obesity and NCDs will be used to illustrate the approach that the Commission believes should be applied more widely to The Global Syndemic.

Outcomes and risk factor monitoring

The 2013 WHO monitoring framework323 for the Global Plan of Action to Prevent and Control NCDs 2013–202022 has nine targets, two of which explicitly relate to obesity: to halt an increase in obesity rates and reduce physical inactivity by 10% by 2025.323 The first monitoring report on NCD progress, in 2015,324 also included ten progress indicators (eg, setting targets, conducting health examination surveys, implementation of comprehensive strategy, and action plan and implementation of policies to reduce unhealthy diets) and the second progress report, in 2017, included 19.325 In 2018, the WHO High-level Commission on NCDs found that progress has been slow and uneven and called for an acceleration in progress to address NCDs globally in its Time to Deliver report.20 Unfortunately, the subsequent Political Declaration at the UN High-Level Meeting on NCDs in September, 2018 showed that the world’s power brokers were far from ready to deliver action on reducing NCDs.326

The use of modelled trajectories to determine country-level obesity prevalence has helped to fill large data gaps.133 Additionally, the global dietary database has been established to measure adult diets globally (17 dietary factors extracted from 1198 nutrition surveys from 193 countries).327 The Global Observatory for Physical Activity developed country cards on the status of adult physical activity complementing the Active Healthy Kids Global Alliance report cards for children. At least 102 cities in 53 countries use WHO’s Urban Health Equity Assessment and Response Tool328 to analyse equitable urban health outcomes. Two global reports on (inequities in) urban health329 have been published jointly by WHO and UN Habitat. For many countries, collection of basic data through WHO’s STEPwise Approach to Chronic Disease Risk Factor Surveillance surveys330 is an important action.

Upstream monitoring

In addition to further strengthening the outcomes data, considerably more upstream monitoring is needed for food and physical activity policies, systems, and environments to increase the accountability of major actors for coordinated actions. The WHO conducts periodic surveys among Member States on the implementation of actions to prevent NCDs331 and national nutrition actions332 through online repositories, databases, and interactive maps.333 More than 2700 documents containing national NCD targets, policies and guidelines, have been submitted by Member States to WHO.333 However, the information is self-reported and fairly generic and no sections are included that specifically examine countries’ comprehensive monitoring efforts.

The absence of comprehensive, independent upstream monitoring has motivated several academic groups and NGOs to step in, using new methods to monitor policies and environments. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) has developed methods and indicators to measure and compare food environments and policies across countries.8 Research groups in more than 30 countries are currently implementing INFORMAS monitoring modules.

An example of an INFORMAS cross-country comparison is shown in figure 5,334 in which 11 countries used the same INFORMAS tool with about 47 indicators to measure food policy implementation by national governments. Guatemala had the highest proportion of policies at very low or no implementation, whereas Chile has the highest proportion of policies at the level of international best practice (figure 5). Across these countries, the top five priority food environment policies that were recommended for policy action by the government to fill the implementation gaps identified were: taxes on unhealthy foods, front-of-pack labelling, targets on the content of nutrients of concern in processed foods, restriction of unhealthy food marketing to children, and healthy school food policies.

Figure 5: Benchmarking the level of implementation of recommended food environment policies by national governments
The Healthy Food Environment Policy Index (Food-EPI) rates government action on policies to improve the healthiness of food environments as very little if any, low, medium, or high implementation compared to international best practice.

The World Cancer Research Fund collects examples of nutrition policies implemented globally in its NOURISHING database and is now expanding this approach into physical activity and breastfeeding.335336 ATNI measures the progress of the top food and beverage manufacturers towards creating healthier food environments,249 and the Global Nutrition Report has reported annually since 2014 on the progress of countries towards meeting their global commitments to nutrition.337 Also, robust, independent evaluations of government nutrition policies are part of the accountability system.338339

If countries collect monitoring data on food environments and policies, a national country profile can be constructed, similar to the Global Burden of Disease country profiles. New Zealand is the first country to have comprehensively surveyed national food environments and has constructed a dashboard of indicators to measure government and food industry progress and changes in the healthiness of food environments (appendix p 40). A similar dashboard, but for NCD policies more broadly, has also been developed for Pacific countries.340

Policies that promote built environments conducive to physical activity are mainly at the municipal, rather than national, level. The Global Observatory for Physical Activity country scorecard has only two national indicators that could be considered upstream, although the Active Healthy Kids Global Alliance Report Card for children contains more upstream indicators and has been implemented in around 30 countries. A more comprehensive dashboard of policy and environment indicators for physical activity is needed (appendix p 49).

WHO-level and UN-level monitoring

Although the aforementioned initiatives are valuable and measured by academics and NGOs, they are not embedded in the WHO-level and UN-level monitoring frameworks and modest funding restricts the pace, breadth, and sustainability of data collection. The SDGs, although not legally binding, are monitored by the UN using a set of 230 global outcome indicators and to date 140 national reviews have been posted online.341 The UN Decade of Action on Nutrition (2015–25)26 aims to lift global nutrition action to eradicate hunger and malnutrition in all its forms, and reduce the burden of diet-related NCDs in all age groups. It is calling on countries to establish and achieve specific, measurable, achievable, relevant, and time-bound (SMART) commitments and targets, which could form the Account around which monitoring and accountability systems can be built. Given the slow response by countries to date to create SMART commitments, upstream monitoring can still occur by including some of the upstream measures from INFORMAS, the World Cancer Research Fund, ATNI, and the Global Nutrition Report within formal UN monitoring systems. This stronger upstream monitoring system would contribute more powerfully to accountability and would stimulate governments to include such monitoring activities as a core activity.

A UN level framework should take into consideration key lessons from HIV/AIDS and tobacco prevention monitoring (appendix p 51). For example, joint reporting on government action by governments and civil society organisations to the UN and its agencies would be the most powerful. Additionally, like HIV/AIDS, the UN Convention on the Rights of People with Disabilities could provide a useful framework to address discrimination against people with obesity and diabetes. A human rights framing has also worked to increase monitoring efforts for HIV/AIDS.

WHO needs to monitor the implementation and impacts of the voluntary commitments made by transnational food and beverage companies. The International Food & Beverage Alliance (IFBA) formed in 2008 with eight of the biggest food and beverage companies with the purported aim to change their global business practices to support WHO’s 2004 Global Strategy on Diet, Physical Activity, and Health. IFBA set their own Account with global pledges in five areas: product formulation and innovation, nutrition information, promotion of healthy lifestyles, public-private partnerships, and responsible marketing to children. IFBA has reported to WHO annually and published a 10-year progress report for 12 companies in 2018.342 A proper accountability system for IFBA actions with WHO setting the Account based on its expectations of food industry actions is long overdue, and would ensure independent monitoring of progress and a much closer engagement process to effect real change within the food and beverage industry.

Sustainability of monitoring efforts

The use of existing and underused data needs to be further explored to make monitoring systems more sustainable. Several sources of existing data in a wide range of countries can be reoriented for monitoring purposes. For example, Household Consumption and Expenditure Surveys are conducted on a nationally representative sample to characterise important aspects of household socioeconomic conditions. Optimisation of this existing data collection for nutrition monitoring has previously been recommended,343 which could be done in collaboration with The World Bank and FAO. Some efforts have been undertaken to engage the lay public in crowdsourcing data on food environments for monitoring purposes.344345 Other routinely available open access datasets that assess community environments have proven to be useful proxies to measure environments, such as the walkability index and community fitness index.346 Additionally, mechanisms are needed to enable public health experts to access proprietary Big Data on food and beverage product sales, food marketing trends through social media, and geographic information systems that collect data on green spaces and food access for low-income community members in urban and rural settings.

Engagement processes

Engagement between all major actors is crucial in monitoring processes, to increase accountability. A strategic priority for UN agencies and many governments is to encourage the private sector, especially food companies, to create and implement actions that reduce obesity and diet-related NCDs. However, any such interaction has to guard against conflicts of interest. Corporations are governed by a fiduciary imperative which requires them to prioritise shareholder returns not public health. This is elaborated elsewhere in the report in relation to policy, but monitoring and accountability systems are another opportunity for action.

Some lessons on the creation of relationships between independent monitors of action (eg, academia and civil society) and the main actors (eg, governments and food companies) can be learned from the work of INFORMAS and ATNI. Healthy Food Environment Policy Index (Food-EPI)347 engages policymakers in several ways: through verification of the evidence regarding government implementation of policies, by acting as observers or raters during workshops, and by working with independent experts to propose priority policies to fill the implementation gaps. The Business Impact Assessment on Obesity (BIA-Obesity) from INFORMAS and ATNI similarly engages with companies on gathering and scoring their commitments on obesity and population-level nutrition.348

Better upstream monitoring systems are needed, with integration into the multiple UN-level commitments and implementation plans to improve accountabilities of actors and health and sustainability. An increased response to The Global Syndemic requires true multisectorial action, transparency, international accountability, and substantial investment in country-level monitoring systems. Other potential actors within accountability systems are also needed, such as investors and stock market indices.

Strategic funding

As NCD burdens increase globally, in both developed and developing economies, their projected public health and long-term medical care expenditures are rising dramatically. Development agencies have not seriously engaged in supporting LMICs to address NCDs. Only 2·2% of development aid for health is allocated to NCDs, although NCDs are responsible for two thirds of deaths in LMICs, half of which occur under the age of 60 years (appendix p 52). Development agencies have been reluctant to support obesity prevention efforts in LMICs and have focused 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 in preventing obesity and, even more broadly, to mitigate The Global Syndemic. These institutions have the potential to make direct investments in programmes or provide incentives and policy triggers for governments to enact double-duty or triple-duty actions that address The Global Syndemic (appendix p 52).

Development banks have several methods they can use to support action within countries. For example, investment lending involves agencies investing grant or credit resources to pay for inputs to governments for the design and implementation of programmes, such as obesity prevention programmes. When actions are needed at a policy level, 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 or implementation of fiscal policies for food. Funds are released if or when these clearly defined triggers are met. In other cases, countries, especially middle-income and high-income countries, sometimes request technical assistance or advisory services from agencies to design and implement relevant policies and programmes. These services are often negotiated not just with the ministries of health but also ministries of finance, commerce, industry, and other relevant ministries, 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 programmes much harder to negotiate and equally hard to implement and monitor.

A combination of financial support from philanthropy and development agencies will be needed to support the efforts of countries to implement double-duty and triple-duty actions to address the The Global Syndemic. The approach in Mexico of providing philanthropic funding to consumer and health NGOs to create public pressure for healthy policies, and to researchers, to evaluate their effects, could be applied in many other countries with adequate civil society and academic capacity. Given the funding for action in Mexico, an investment of $1 billion from philanthropic and other sources could plausibly support 100 countries of different sizes and stages of development to apply Mexico’s approach to double-duty or triple-duty actions towards mitigating The Global Syndemic. Compared with the annual $2 trillion costs of obesity alone, the return on investment will be substantial. The establishment of the Green Climate Fund has shown that tens of billions of dollars can be mobilised from high-income countries to support mitigation and adaptation actions on climate change in LMICs. Much smaller amounts of funding for civil society organisations to demand double-duty or triple-duty actions from governments could help overcome the policy inertia that bedevils action on The Global Syndemic.

Strategic research

There are three major research areas to highlight, in which important gaps exist: the application of systems science to The Global Syndemic, research on the sociocultural factors that explain the variance in obesity and thus the sociocultural barriers and enablers of societal action, and research to address the policy inertia that is preventing policy progress.

The application of systems science to obesity is nascent and should be a priority for research. In particular, system dynamics models or agent-based computational models exist for each of the components of The Global Syndemic but no models that cover all components. A repository of systems models that address one or more aspects of The Global Syndemic would provide an opportunity for them to be replicated, tested, and extended across settings to develop generalisable patterns of system structure (generic structures) that can be used to address the evolving Global Syndemic. Systems science is inherently iterative, and there is potential to take models that have been tested and validated across contexts as a way to combine scientific knowledge across multiple disciplines and ecologies. Integration can be done sequentially with results from one set of computational models being used as inputs for other models (eg, using outputs from a system dynamics model of climate change to inform a model of food systems). It can also be done by integrating computational models using several methods (eg, hybrid modelling combining an aggregate model of a natural resource system and multi-agent model of individual consumers and organisations).

Sociocultural factors are probably the least explored determinants of obesity. If they can explain, to a large degree, differences in prevalence of obesity between populations, they might also identify differences in approaches to addressing obesity. The Pacific countries, which have the highest rates of obesity internationally, need to be included in a database of cultural dimensions. Overarching theories are needed that explain how these dimensions and other cultural factors related to food, fashion, and body size perception explain the national trajectories of obesity over time.

Implementation science approaches are also needed at the policy level and the community level to understand the contexts and drivers of successful policy implementation. Similarly, at the community level, a priority question is how to implement comprehensive interventions across several settings to explain why some community programmes are effective and others are ineffective.


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 monitoring

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 Lancet Commission on Health and Climate Change established the Lancet Countdown 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.


BAS and WHD co-chaired the Commission and were the lead writers for the report. VIK was also part of the lead writing team. Commissioners and Fellows attended one or more of the three face-to-face meetings and/or the consultation workshops and all were part of several writing groups established to write the initial drafts of the sections. All Commissioners and Fellows contributed through comments on multiple versions of the report. SF, PSH, MS, CH, BL, SG, and AP hosted consultation workshops in their institutions.

Declaration of interests

SA reports grants from the Australian National Health and Medical Research Council, during conduct of the study. HB and PMN report grants from Novo Nordisk, outside the submitted work. AC reports grants from Bloomberg Philanthropies, during the conduct of the study. SG reports grants from Bernard Lown Scholars in Cardiovascular Health Program, Harvard School of Public Health, during the conduct of the study. TL reports grants from Novo Nordisk, during the conduct of the study. GS is an academic partner on a healthy supermarket intervention trial that includes Australian local government and supermarket retail collaborators. BAS, SF, GS, SV, and TL are leading several INFORMAS studies to benchmark the policies and commitments of governments and food companies related to obesity prevention and nutrition.

WHD receives consulting fees as a member of the scientific advisory committee for Weight Watchers, as a member and chair of the JPB Foundation’s Poverty Advisory Board, and as a consultant for the RTI: Feeding Infants and Toddlers Study. He received a grant from Bridgespan to analyse NHANES data on obesity in young adults. BAS is a plaintiff in a defamation case against individuals and organisations related to the food industry. All other authors declare no competing interests.


The following organisations contributed funding for meetings of the Lancet Commission on Obesity: Redstone Global Center for Prevention and Wellness, George Washington University; Faculty of Medical and Health Sciences, University of Auckland; the Morgan Foundation, Wellington; the Warehouse Foundation, Auckland; Wellcome Trust, UK (Ref 20171019_PH); and the Science and Engineering Research Board, Department of Science and Technology, Government of India (File Number SB/SS/205/17-18). The authors thank the following people who supported the work of the Commission: Bruce Kidd, Sarah Baldauf, Tina Eliott, Michelle Smith, and Jumi Aluko. We also thank the organisations that kindly hosted several consultation workshops for the Commission between 2016 and 2018, and all the participants in the workshops. BS was supported by the Gavin and Ann Kellaway Medical Research Fellowship of the Auckland Medical Research Foundation to conduct these workshops. We are grateful to those who conducted the interviews summarised in the panels, which offer unique views about people’s experience with obesity, and thank Patty Nece, Sharin Nooning-Gunning, Senator Dr Guido Giraldi, Raji Devarajan, Vitor Lippi, Ihi Heke, and Janette Lowe for their contributions.

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