A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement

Food and nutrition labelling in Thailand: a long march from subsistence producers to international traders

This paper reviews the evolution of Thai food and nutrition label policies and Thailand's international role relating to food product safety and standards. The historical record has been interpreted to identify future trends and challenges related to food labelling. These challenges are arising in Thailand and many similar emerging economies. Thailand has a good reputation in world food markets and is now becoming a global leader in food production and export. It has become deeply involved with regulations and standards applied by World Trade Organization and Codex Alimentarius while serving its own population with a safe and secure food supply. For consumers considering Thai food products, food labels can provide useful nutrition information and help build trust. Thais began a century ago with policies and laws to enhance food safety and to protect Thai consumers. During the lengthy journey from national to global standards Thai food labels have evolved and now contribute to international food labelling policies. This contribution comes from the perspective of a leading middle income south-east Asian food producer now trading with high income countries around the world. The story of that journey - a case study for many other countries in a similar situation - has not previously been told. This article provides information for policy makers dealing with food labelling, embedding trends and tensions for one middle income food exporter in a long history. Information captured here should be helpful for other middle income countries, especially those with limited records. This strategic knowledge will enable better decisions for future policies.

Free-trade agreements: challenges for global health

In this study new free-trade agreements are discussed, which are based on the breaking down of tariff and technical barriers and normally exclude most of the poorest countries in the world. Considering the current context of economic globalization and its health impacts, seven controversial points of these treaties and their possible implications for global public health are presented, mainly regarding health equity and other health determinants. Finally, this research proposes a greater social and health professionals participation in the formulation and discussion of these treaties, and a deeper insertion of Brazil in this important international agenda.

Increased food energy supply as a major driver of the obesity epidemic: a global analysis

OBJECTIVE

We investigated associations between changes in national food energy supply and in average population body weight.

METHODS

We collected data from 24 high-, 27 middle- and 18 low-income countries on the average measured body weight from global databases, national health and nutrition survey reports and peer-reviewed papers. Changes in average body weight were derived from study pairs that were at least four years apart (various years, 1971-2010). Selected study pairs were considered to be representative of an adolescent or adult population, at national or subnational scale. Food energy supply data were retrieved from the Food and Agriculture Organization of the United Nations food balance sheets. We estimated the population energy requirements at survey time points using Institute of Medicine equations. Finally, we estimated the change in energy intake that could theoretically account for the observed change in average body weight using an experimentally-validated model.

FINDINGS

In 56 countries, an increase in food energy supply was associated with an increase in average body weight. In 45 countries, the increase in food energy supply was higher than the model-predicted increase in energy intake. The association between change in food energy supply and change in body weight was statistically significant overall and for high-income countries (P < 0.001).

CONCLUSION

The findings suggest that increases in food energy supply are sufficient to explain increases in average population body weight, especially in high-income countries. Policy efforts are needed to improve the healthiness of food systems and environments to reduce global obesity.

Welcome from the policies, socio-economic aspects, and health systems research section

At BMC Obesity, the Policies, Socio-economic Aspects, and Health Systems Research Section provides an opportunity to submit research focussed on what we need to know to support implementation of obesity policies most likely to achieve substantial, sustainable and equitable reductions in the prevalence of obesity globally. Here, we present the aims and objectives of this section, hearing from each of the Associate Editors in turn. The ambition of the Policies, Socio-economic Aspects, and Health Systems Research Section is to foster innovative research combining scientific quality with real world experience. We envisage this will include research addressing the structural drivers of obesity, solution oriented research, research addressing socio-economic inequalities in obesity and obesity prevention in low and middle income countries. We look forward to stimulating research to advance both the methods and substance required to drive uptake of effective and equitable obesity reduction policies globally.

Policy space for health and trade and investment agreements

New trade agreements affect how governments can regulate for health both within health systems and in addressing health protection, promotion and social determinants of health in other policies. It is essential that those responsible for health understand the impacts of these trade negotiations and agreements on policy space for health at a national and local level. While we know more about implications from negotiations concerning intellectual property rights and trade in goods, this paper provides a screening checklist for less-discussed areas of domestic regulation, services, investment and government procurement. As implications are likely to differ on the basis of the organization and structures of national health systems and policy priorities, the emphasis is on finding out key provisions as well as on how exemptions and exclusions can be used to ensure policy space for health.

Food security for infants and young children: an opportunity for breastfeeding policy?

BACKGROUND

Increased global demand for imported breast milk substitutes (infant formula, follow-on formula and toddler milks) in Asia, particularly China, and food safety recalls have led to shortages of these products in high income countries. At the same time, commodification and trade of expressed breast milk have fuelled debate about its regulation, cost and distribution. In many economies suboptimal rates of breastfeeding continue to be perpetuated, at least partially, because of a failure to recognise the time, labour and opportunity costs of breast milk production. To date, these issues have not figured prominently in discussions of food security. Policy responses have been piecemeal and reveal conflicts between promotion and protection of breastfeeding and a deregulated trade environment that facilitates the marketing and consumption of breast milk substitutes.

DISCUSSION

The elements of food security are the availability, accessibility, utilization and stability of supply of nutritionally appropriate and acceptable quantities of food. These concepts have been applied to food sources for infants and young children: breastfeeding, shared breast milk and breast milk substitutes, in accordance with World Health Organization (WHO)/United Nations Children's Fund (UNICEF) guidelines on infant feeding. A preliminary analysis indicates that a food security framework may be used to respond appropriately to the human rights, ethical, economic and environmental sustainability issues that affect the supply and affordability of different infant foods.

SUMMARY

Food security for infants and young children is not possible without high rates of breastfeeding. Existing international and national instruments to protect, promote and support breastfeeding have not been implemented on a wide scale globally. These instruments need review to take into account the emerging trade environment that includes use of the internet, breast milk markets and globalised supply chains for breast milk substitutes. New approaches are required to handle the long-standing policy conflicts that surround infant and young child feeding. Placing breastfeeding in a food security framework may achieve the political attention and policy co-ordination required to accelerate breastfeeding rates in a range of economies.

Markets, breastfeeding and trade in mothers' milk

This introduction to a special issue on the economics of breastfeeding draws attention to the lack of economic justice for women. Human milk is being bought and sold. Commodifying and marketing human milk and breastfeeding risk reinforcing social and gender economic inequities. Yet there are potential benefits for breastfeeding, and some of the world's poorest women might profit. How can we improve on the present situation where everyone except the woman who donates her milk benefits? Breastfeeding is a global food production system with unsurpassed capacity to promote children's food security and maternal and child health, but it is side-lined by trade negotiators who seek instead to expand world markets for cow's milk-based formula. Regulators focus on potential risks of feeding donated human milk, rather than on health risks of exposing infants and young children to highly processed bovine milk. Similarly, policymakers aspire to provide universal health care access that may be unaffordable when two thirds of the world's children are not optimally nourished in infancy, resulting in a global double burden of infectious and chronic disease. Universal breastfeeding requires greater commitment of resources, but such investment remains lacking despite the cost effectiveness of breastfeeding protection, support and promotion in and beyond health services. Women invest substantially in breastfeeding but current policy - epitomised by the G20 approach to the 'gender gap' - fails to acknowledge the economic value of this unpaid care work. Economic incentives for mothers to optimally breastfeed are dwarfed by health system and commercial incentives promoting formula feeding and by government fiscal policies which ignore the resulting economic costs. 'The market' fails to protect breastfeeding, because market prices give the wrong signals. An economic approach to the problem of premature weaning from optimal breastfeeding may help prioritise global maternity protection as the foundation for sustainable development of human capital and labour productivity. It would remove fiscal subsidies for breast milk substitutes, tax their sale to recoup health system costs, and penalise their free supply, promotion and distribution. By removing widespread incentives for premature weaning, the resources would be available for the world to invest more in breastfeeding.

Trade policy and public health

Twenty-first-century trade policy is complex and affects society and population health in direct and indirect ways. Without doubt, trade policy influences the distribution of power, money, and resources between and within countries, which in turn affects the natural environment; people's daily living conditions; and the local availability, quality, affordability, and desirability of products (e.g., food, tobacco, alcohol, and health care); it also affects individuals' enjoyment of the highest attainable standard of health. In this article, we provide an overview of the modern global trade environment, illustrate the pathways between trade and health, and explore the emerging twenty-first-century trade policy landscape and its implications for health and health equity. We conclude with a call for more interdisciplinary research that embraces complexity theory and systems science as well as the political economy of health and that includes monitoring and evaluation of the impact of trade agreements on health.

Evolving trade policy and the Trans-Pacific Partnership Agreement: does it threaten Vietnam's access to medicine and its progress towards scaling up HIV prevention, treatment and care?

The Trans-Pacific Partnership Agreement (TPP) has undergone 18 rounds of secretive negotiation between the USA and 11 Asia-Pacific countries. Aiming at a free trade area, this multilateral trade proposal covers all aspects of commercial relations among the countries involved. Despite some anticipated positive impacts in trade, specific articles in this proposal's intellectual property and transparency chapters might negatively impact access to medicine, in general, and to antiretroviral (ARV) drugs, in particular, in Vietnam. Drawing on a desk review and qualitative in-depth interviews with 20 key informants from government, academia, hospitals and civil society, we analyse various provisions of the proposal being negotiated leaked after the 14th round of negotiations in September 2012. Findings suggest that the TPP could lead to increased monopoly protection and could limit technological advancements within the local pharmaceutical manufacturing industry, resulting in higher medicine prices in Vietnam. This outcome would have a significant impact on Vietnam's ability to achieve goals for HIV prevention, treatment and care, and create barriers to universal health-care coverage. This research provides unique evidence for Vietnam to advocate for more equitable pharmaceutical provisions in and to raise awareness of the implications of the TPP among the pharmaceutical stakeholder community in Vietnam.

The vulnerability of being ill informed: the Trans-Pacific Partnership Agreement and Global Public Health

The Trans Pacific Partnership Agreement (TPPA) is a regional trade agreement currently being negotiated by 11 Pacific Rim countries, excluding China. While the negotiations are being conducted under a veil of secrecy, substantive leaks over the past 4 years have revealed a broad view of the proposed contents. As it stands the TPPA poses serious risks to global public health, particularly chronic, non-communicable diseases. At greatest risk are national tobacco regulations, regulations governing the emergence of generic drugs and controls over food imports by transnational corporations. Aside from a small group of public health professionals from Australia, the academic public health community has missed these threats to the global community, although many other health-related entities, international lawyers and health-conscious politicians have voiced serious concerns. As of mid-2014 there has been no comment in the leading public health journals. This large lacuna in interest or recognition reflects the larger problem that the public health education community has all but ignored global non-communicable diseases. Without such a focus, the risks are unseen and the threats not perceived. This cautionary tale of the TPPA reflects the vulnerability of being ill informed of contemporary realities.

Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans Pacific Partnership Agreement

The Trans Pacific Partnership Agreement (TPPA) is one of a new generation of 'deep' preferential trade and investment agreements that will extend many of the provisions seen in previous agreements. This paper presents a prospective policy analysis of the likely text of the TPPA, with reference to nutrition policy space. Specifically, we analyse how the TPPA may constrain governments' policy space to implement the 'policy options for promoting a healthy diet' in the World Health Organization's Global Action Plan for Prevention and Control of Noncommunicable Diseases (NCDs) 2013-2020. This policy analysis suggests that if certain binding commitments are made under the TPPA, they could constrain the ability of governments to protect nutrition policy from the influence of vested interests, reduce the range of interventions available to actively discourage consumption of less healthy food (and to promote healthy food) and limit governments' capacity to implement these interventions, and reduce resources available for nutrition education initiatives. There is scope to protect policy space by including specific exclusions and/or exceptions during negotiation of trade and investment agreements like the TPPA, and by strengthening global health frameworks for nutrition to enable them to be used as reference during disputes in trade fora.

Processed foods and the nutrition transition: evidence from Asia

This paper elucidates the role of processed foods and beverages in the 'nutrition transition' underway in Asia. Processed foods tend to be high in nutrients associated with obesity and diet-related non-communicable diseases: refined sugar, salt, saturated and trans-fats. This paper identifies the most significant 'product vectors' for these nutrients and describes changes in their consumption in a selection of Asian countries. Sugar, salt and fat consumption from processed foods has plateaued in high-income countries, but has rapidly increased in the lower-middle and upper-middle-income countries. Relative to sugar and salt, fat consumption in the upper-middle- and lower-middle-income countries is converging most rapidly with that of high-income countries. Carbonated soft drinks, baked goods, and oils and fats are the most significant vectors for sugar, salt and fat respectively. At the regional level there appears to be convergence in consumption patterns of processed foods, but country-level divergences including high levels of consumption of oils and fats in Malaysia, and soft drinks in the Philippines and Thailand. This analysis suggests that more action is needed by policy-makers to prevent or mitigate processed food consumption. Comprehensive policy and regulatory approaches are most likely to be effective in achieving these goals.

The role of law and governance reform in the global response to non-communicable diseases

Addressing non-communicable diseases ("NCDs") and their risk-factors is one of the most powerful ways of improving longevity and healthy life expectancy for the foreseeable future - especially in low- and middle-income countries. This paper reviews the role of law and governance reform in that process. We highlight the need for a comprehensive approach that is grounded in the right to health and addresses three aspects: preventing NCDs and their risk factors, improving access to NCD treatments, and addressing the social impacts of illness. We highlight some of the major impediments to the passage and implementation of laws for the prevention and control of NCDs, and identify important practical steps that governments can take as they consider legal and governance reforms at country level.We review the emerging global architecture for NCDs, and emphasise the need for governance structures to harness the energy of civil society organisations and to create a global movement that influences the policy agenda at the country level. We also argue that the global monitoring framework would be more effective if it included key legal and policy indicators. The paper identifies priorities for technical legal assistance in implementing the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020. These include high-quality legal resources to assist countries to evaluate reform options, investment in legal capacity building, and global leadership to respond to the likely increase in requests by countries for technical legal assistance. We urge development agencies and other funders to recognise the need for development assistance in these areas. Throughout the paper, we point to global experience in dealing with HIV and draw out some relevant lessons for NCDs.

Development goals in the post-2015 world: whither Canada?

A new set of post-2015 development goals for the world is being negotiated. Several potential goals relating to sustainable development, poverty, the economy and health have been identified. Many of them have potential public health gains, although there are inadequacies in how several of them have been defined. In participating in finalization of these goals, Canada should strengthen its commitments to maternal/child health; promote its publicly funded health system as an important model for universal health coverage; incorporate stronger protections for public health in trade and investment treaties; use its foreign aid to help low- and middle-income countries build the transparent and progressive tax systems to mobilize domestic revenues for health; and promote global systems of taxation to prevent tax evasion and illicit capital flight.

Towards global benchmarking of food environments and policies to reduce obesity and diet-related non-communicable diseases: design and methods for nation-wide surveys

INTRODUCTION

Unhealthy diets are heavily driven by unhealthy food environments. The International Network for Food and Obesity/non-communicable diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) has been established to reduce obesity, NCDs and their related inequalities globally. This paper describes the design and methods of the first-ever, comprehensive national survey on the healthiness of food environments and the public and private sector policies influencing them, as a first step towards global monitoring of food environments and policies.

METHODS AND ANALYSIS

A package of 11 substudies has been identified: (1) food composition, labelling and promotion on food packages; (2) food prices, shelf space and placement of foods in different outlets (mainly supermarkets); (3) food provision in schools/early childhood education (ECE) services and outdoor food promotion around schools/ECE services; (4) density of and proximity to food outlets in communities; food promotion to children via (5) television, (6) magazines, (7) sport club sponsorships, and (8) internet and social media; (9) analysis of the impact of trade and investment agreements on food environments; (10) government policies and actions; and (11) private sector actions and practices. For the substudies on food prices, provision, promotion and retail, 'environmental equity' indicators have been developed to check progress towards reducing diet-related health inequalities. Indicators for these modules will be assessed by tertiles of area deprivation index or school deciles. International 'best practice benchmarks' will be identified, against which to compare progress of countries on improving the healthiness of their food environments and policies.

DISSEMINATION

This research is highly original due to the very 'upstream' approach being taken and its direct policy relevance. The detailed protocols will be offered to and adapted for countries of varying size and income in order to establish INFORMAS globally as a new monitoring initiative to reduce obesity and diet-related NCDs.