Big Food

PLoS Medicine Series on Big Food
The PLoS Medicine series on Big Food aims to examine and stimulate debate about the activities and influence of the food industry in global health. We define Big Food as the multinational food and be verage industry with huge and concentrated market power. The series adopts a multi-disciplinary approach and includes critical perspectives from around the world. It represents one of first times such issues have been examined in the general medical literature. The PLoS Medicine Editors begin the series with an editorial discussing the rationale and process of commissioning articles for the series. As they note, industry in health has long fascinated PLoS Medicine but the journal's focus on Big Food is new. Food, unlike tobacco and drugs, is necessary to live and is central to health and disease. And yet the big multinational food companies control what people everywhere eat, resulting in a stark and sick irony: one billion people on the planet are hungry while two billion are obese or overweight. The guest editors, Marion Nestle and David Stuckler, then lay out a background to the role of Big Food in global health, and offer three competing views of how public health professionals can respond. Subsequent articles include: a comparison of soda companies' corporate social responsibility campaigns with those of the tobacco industry; an analysis of the rapid rise of Big Food sales in developing countries; an essay on food sovereignty and who holds power over food; views from South America and Africa on the displacement of traditional diets by the incursion of multinational food companies; and a perspective arguing against an uncritical acceptance of the food industry in health. www.ploscollections.org/bigfood Image Credit: Original image by Todd Hryckowian at flickr.com, with enhancements by Lizzy Parisotto, PLoS.
ndice
Editorial
PLoS Medicine Series on Big Food: The Food Industry Is Ripe for Scrutiny
The PLoS Medicine Editors
Essays
Big Food, Food Systems, and Global Health
David Stuckler, Marion Nestle
Food Sovereignty: Power, Gender, and the Right to Food

Rajeev C. Patel
The Impact of Transnational Big Food Companies on the South: A View from Brazil
Carlos A. Monteiro, Geoffrey Cannon
Perspective
Thinking Forward: The Quicksand of Appeasing the Food Industry
Kelly D. Brownell
Policy Forums
Soda and Tobacco Industry Corporate Social Responsibility Campaigns: How Do They Compare?
Lori Dorfman, Andrew Cheyne, Lissy C. Friedman, Asiya Wadud, Mark Gottlieb
Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including Processed Foods, Alcohol, and Tobacco
David Stuckler, Martin McKee, Shah Ebrahim, Sanjay Basu
Big Food, the Consumer Food Environment, Health, and the Policy Response in South Africa
Ehimario U. Igumbor, David Sanders, Thandi R. Puoane, Lungiswa Tsolekile, Cassandra Schwarz, Chrisher Purdy, Rina Swart, Solange Duro, Corinna Hawkes
Editorial
PLoS Medicine Series on Big Food: The Food Industry Is Ripe for Scrutiny
The PLoS Medicine Editors*
This article is part of the the PLoS Medicine series on Big Food. Today we launch a major new series on Big Food in the PLoS Medicine Magazine. Over three weeks beginning 19 June 2012 we will publish seven articles that examine the activities and influence of the food and beverage industry in the health arena. These articles were commissioned by the senior Magazine editor (JC) under the guidance of our series guest editors Marion Nestle of New York University and David Stuckler of Cambridge University, and together they represent a multidisciplinary approach to exploring the role in health of Big Food, which we define as the multinational food and beverage industry with huge and concentrated market power [1]. Industry in health has long fascinated PLoS Medicine but our focus on Big Food is new. Food, unlike tobacco and drugs, is necessary to live and is central to health and disease. And yet the big multinational food companies control what people everywhere eat, resulting in a stark and sick irony: one billion people on the planet are hungry while two billion are obese or overweight [2]. The time is ripe for PLoS Medicine to shine a light on Big Food. Foremost, large food and beverage companies now have an undeniably influential presence on the global health stage. Whether its food company executives providing expertise at major conferences and high-level UN meetings (e.g., [3]) or major global health funders lecturing on what nongovernmental organizations can learn from CocaCola [4], the perspectives and experiences of Big Food are shaping the field of global health. At the same time that their expertise is elevated in global health debates, food companies are rebranding themselves as nutrition companies, offering business acumen and knowledge in food science and distribution, and asserting authority over solutions to problems not just of food production but of malnutrition, obesity, and even poverty. The legitimization of food companies as global health experts is further fueled by
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the growing number of private-public partnerships with public health organizations [5], ostensibly designed to foster collaborative action to improve peoples health and wellbeing. And yet food companies primary obligation is to drive profit by selling food. Why does the global health community find this acceptable and how do these conflicts of interest play out? Indeed, while problems of obesity and associated disease are dominating discussions and debates in health around the world, theres a concomitant gulf of critical perspectives on the food industrys role and competing interests. Despite PLoS Medicines longstanding interest in the tobacco, pharmaceutical, and other industries in health, for example, we have paid relatively little attention to the activities and influence of food and beverage companies: just two articles in 2007 [6,7] and a recent editorial on the alcohol industry [8]. Searching PubMed, only an additional seven articles examining any aspect of the food industry have been published in the major general medical journals over the past 10 years. According to Marion Nestle, these issues have been known and discussed (though not always acted upon) within the nutrition community for decades, which makes the lack of attention in the medical literature even more disappointing. In fact, Nestles 2002 book Food Politics: How the Food Industry Influences Nutrition and Health is prescient in documenting a laundry list of Big Food misdeeds that are only receiving
more widespread attention now: aggressive lobbying of regulators and governments, co-opting domestic and international nutrition experts, deceptive and illegal marketing to children, tactical targeting of minorities and emerging economies, and undisclosed conflicts of interest, among others, resulting in her conclusion 10 years ago that the food industry plays politics better than anyone [9]. More recent evidence confirms that Big Food and Big Alcohol are mimicking (and learning from) the tactics of Big Tobacco [8,1013]. In recognition, a bold move by Journal of Public Health Policy discourages studies of individual eating and activity [14,15] because, as the editors state, they have come to believe that research studies concentrating on personal behavior and responsibility as causes of the obesity epidemic do little but offer cover to an industry seeking to downplay its own responsibility. The PLoS Medicine series on Big Food is a sampler, offering perspectives on select topics relevant to how the food industry operates in health. In this first week the guest editors lay out a background and three competing views of how public health professionals can respond [1], and Lori Dorfman and her colleagues [16] compare soda companies corporate social responsibility (CSR) campaigns with those of the tobacco industry, demonstrating how CSR deftly shifts responsibility for overconsumption from corporations to individuals, forestalls regulation, and pro-
Citation: The PLoS Medicine Editors (2012) PLoS Medicine Series on Big Food: The Food Industry Is Ripe for Scrutiny. PLoS Med 9(6): e1001246. doi:10.1371/journal.pmed.1001246 Published June 19, 2012 Copyright: 2012 PLoS Medicine Editors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The authors are each paid a salary by the Public Library of Science, and they wrote this editorial during their salaried time. Competing Interests: The authors individual competing interests are at http://www.plosmedicine.org/static/ editorsInterests.action. PLoS is funded partly through manuscript publication charges, but the PLoS Medicine Editors are paid a fixed salary (their salary is not linked to the number of papers published in the journal). * E-mail: medicine_editors@plos.org The PLoS Medicine Editors are Virginia Barbour, Jocalyn Clark, Paul Simpson, and Emma Veitch. PS was on leave when this editorial was written. Provenance: Written by editorial staff; not externally peer reviewed.
June 2012 | Volume 9 | Issue 6 | e1001246
motes brand loyalty and sales. In subsequent weeks we will publish analyses of the rapid rise of Big Food sales in developing countries, an essay on food sovereignty and who holds power over food, and two perspectives from South America and Africa on the displacement of traditional diets by the incursion of multinational food companies. We decided not to provide a forum for the industry to offer a perspective on their role in global health, since this point of view has been covered many times before [1720] and fails to acknowledge their role in subverting the public health agenda, thus ignoring the deeper issues that this series aims to uncover. While our series does include perspectives from several countries around the world (including Brazil, South Africa, the
UK, and the US), our series is not as regionally diverse as would be ideal. When commissioning we had a difficult time finding authors in the developing world who had not already established links with food companies (thus disqualifying them from contributing to the series, per our Magazine competing interests policy), which might be more evidence for concerns about co-opting of international nutrition experts. The series is not comprehensive in highlighting all the relevant issues but should signal to readers our interest in considering further original research and commentary on additional areas to do with the food industry in health, including marketing to children, litigation, regulatory efforts, the impact of agriculture systems, solutions to obesity and noncom-
municable diseases, and the growth and spread of markets in emerging economies. Clearly issues of nutrition and diet are key to human health and to the health of the planet. We look forward to continuing to be part of the dialogue and invite readers to join the debate via twitter (hashtag #plosmedbigfood) and to comment on the articles, which will be published over three weeks and collected at http://www. ploscollections.org/bigfood.
Author Contributions
Wrote the first draft of the manuscript: JC. Contributed to the writing of the manuscript: VB JC EV. ICMJE criteria for authorship read and met: VB JC EV. Agree with manuscript results and conclusions: VB JC EV.
References
1. Stuckler D, Nestle M (2012) Big Food, Food Systems, and Global Health. PLoS Med 9: e1242. doi:10.1371/journal.pmed.1001242. 2. Patel R (2008) Stuffed and Starved: The Hidden Battle for the World Food System. Melville House. 448 p. 3. Cohen D (2011) Will Industry Influence Derail the UN Summit? BMJ 343:d5328. http://www. bmj.com/content/343/bmj.d5328.full 4. TEDxChange (September 2010) Melinda French Gates: What Nonprofits Can Learn from CocaCola. Available: http://www.ted.com/talks/ melinda_french_gates_what_nonprofits_can_ learn_from_coca_cola.html. Accessed 14 May 2012. 5. Freedhoff Y, Hebert PC (2011) Partnerships between Health Organizations and the Food Industry Risk Derailing Public Health Nutrition. CMAJ 183: 291292. doi:10.1503/cmaj.110085. 6. Lesser L, Ebbeling CB, Goozner M, Wypij D, Ludwig DS (2007) Relationship between Funding Source and Conclusion among Nutrition-Related Scientific Articles. PLoS Med 4: e5. doi:10.1371/ journal.pmed.0040005. 7. Katan MB (2007) Does Industry Sponsorship Undermine the Integrity of Nutrition Research? PLoS Med 4: e6. doi:10.1371/journal.pmed. 0040006. 8. The PLoS Medicine Editors (2011) Lets Be Straight Up about the Alcohol Industry. PLoS Med 8: e1001041. doi:10.1371/journal.pmed. 1001041. 9. Nestle M (2002) Food Politics: How the Food Industry Influences Nutrition and Health. Berkeley: University of California Press. 10. Brownell K, Warner KE (2009) The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died. How Similar Is Big Food? Milbank Quarterly 87: 259294. 11. Chopra M, Darnton-Hill I (2004) Tobacco and Obesity Epidemics: Not So Different After All? BMJ 328: 15581560. 12. Ludwig D, Nestle M (2008) Can the Food Industry Play a Constructive Role in the Obesity Epidemic? JAMA 300: 18081811. 13. Wiist W (2011) The Corporate Playbook, Health, and Democracy: The Snack Food and Beverage Industry Industrys Tactics in Context. In: Stuckler D, Siegel, K, editor. Sick Societies: responding to the global challenge of chronic disease. Oxford: Oxford University Press. 14. Robbins A, Nestle M (2011) Obesity as Collateral Damage: A Call for Papers on the Obesity Epidemic. J Public Health Policy 32: 143145 15. Journal of Public Health Policy (2011) Special Issue Section: Food and Obesity Collection. Available: http://www.palgrave-journals.com/ jphp/collections/food_and_obesity_collection. html. Accessed 14 May 2012. Dorfman L, Cheyne A, Friedman LC, Wadud A, Gottlieb M (2012) Soda and Tobacco Industry Corporate Social Responsibility Campaigns: How Do They Compare? PLoS Med 9: e1241. doi:10.1371/journal.pmed.1001241. Yach D, Feldman ZA, Bradley DG, Khan M (2010) Can the Food Industry Help Tackle the Growing Burden of Undernutrition? Am J Public Health 100: 974980. Alexander E, Yach D, Mensah GA (2011) Major Multinational Food and Beverage Companies and Informal Sector Contributions to Global Food Consumption: Implications for Nutrition Policy. Global Health 7: 26. doi:10.1186/17448603-7-26. Yach D (2011) Nutritional Change Is Not a Simple Answer to Non-Communicable diseases. BMJ 343. doi:10.1136/bmj.d5097. Acharya T, Fuller AC, Mensah GA, Yach D (2011) The Current and Future Role of the Food Industry in the Prevention and Control of Chronic Diseases: The Case of PepsiCo. In: Stuckler D, Siegel, K, editor. Sick Societies: Responding to the global challenge of chronic disease. Oxford: Oxford University Press.
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Essay
Big Food, Food Systems, and Global Health

David Stuckler1,2*, Marion Nestle3,4
1 Department of Sociology, University of Cambridge, Cambridge, United Kingdom, 2 Department of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, 3 Department of Nutrition, Food Studies, and Public Health, New York University, New York, New York, United States of America, 4 Department of Nutritional Sciences, Cornell University, Ithaca, New York, United States of America
This article was commissioned for the PLoS Medicine series on Big Food that examines the activities and influence of the food and beverage industry in the health arena. As the PLoS Medicine series on Big Food (www.ploscollections.org/bigfood) kicks off, lets begin this Essay with a blunt conclusion: Global food systems are not meeting the worlds dietary needs [1]. About one billion people are hungry, while two billion people are overweight [2]. India, for example, is experiencing rises in both: since 1995 an additional 65 million people are malnourished, and one in five adults is now overweight [3,4]. This coexistence of food insecurity and obesity may seem like a paradox [5], but overand undernutrition reflect two facets of malnutrition [6]. Underlying both is a common factor: food systems are not driven to deliver optimal human diets but to maximize profits. For people living in poverty, this means either exclusion from development (and consequent food insecurity) or eating low-cost, highly processed foods lacking in nutrition and rich in sugar, salt, and saturated fats (and consequent overweight and obesity). To understand who is responsible for these nutritional failures, it is first necessary to ask: Who rules global food systems? By and large its Big Food, by which we refer to multinational food and beverage companies with huge and concentrated market power [7,8]. In the United States, the ten largest food companies control over half of all food sales [9] and worldwide this proportion is about 15% and rising. More than half of global soft drinks are produced by large multinational companies, mainly CocaCola and PepsiCo [10]. Three-fourths of world food sales involve processed foods, for which the largest manufacturers hold over a third of the global market [11]. The worlds food system is not a competitive marketThe Essay section contains opinion pieces on topics of broad interest to a general medical audience.
place of small producers but an oligopoly. What people eat is increasingly driven by a few multinational food companies [12]. Virtually all growth in Big Foods sales occurs in developing countries [13] (see Figure 1). The saturation of markets in developed countries [14], along with the lure of the 20% of income people spend on average on food globally, has stimulated Big Food to seek global expansion. Its rapid entry into markets in low- and middleincome countries (LMICs) is a result of mass-marketing campaigns and foreign investment, principally through takeovers of domestic food companies [15]. Trade plays a minimal role and accounts for only about 6% of global processed food sales [15]. Global producers are the main reason why the nutrition transition from traditional, simple diets to highly processed foods is accelerating [16,17]. Big Food is a driving force behind the global rise in consumption of sugarsweetened beverages (SSBs) and processed foods enriched in salt, sugar, and fat [13]. Increasing consumption of Big Foods products tracks closely with rising levels of obesity and diabetes [18]. Evidence shows that SSBs are major contributors to childhood obesity [19,20], as well as to long-term weight-gain, type 2 diabetes, and cardiovascular disease [21,22]. Studies also link frequent consumption of highly processed foods with weight gain and associated diseases [23]. Of course, Big Food may also bring benefitsimproved economic performance through increased technology and know-how and reduced risks of undernu-
tritionto local partners [24]. The extent of these benefits is debatable, however, in view of negative effects on farmers and on domestic producers and food prices [25].
Public Health Response to Big Food: A Failure to Act

Public health professionals have been slow to respond to such nutritional threats in developed countries and even slower still in developing countries. Thanks to insights from tobacco company documents, we have learned a great deal about how this industry sought to avoid or flout public health interventions that might threaten their profits. We now have considerable evidence that food and beverage companies use similar tactics to undermine public health responses such as taxation and regulation [26,27,28,29], an unsurprising observation given the flows of people, funds, and activities between Big Tobacco and Big Food. Yet the public health response to Big Food has been minimal. We can think of multiple reasons for the failure to act [30]. One is the belated recognition of the importance of obesity to the burden of disease in LMICs [13]. The 2011 Political Declaration of the United Nations High-Level Meeting on Prevention and Control of Non-communicable Diseases (NCDs) recognized the urgent case for addressing the major avoidable causes of death and disability [31], but did not even mention the roles of agribusiness and processed foods in obesity. Despite evidence to the contrary, some development
Citation: Stuckler D, Nestle M (2012) Big Food, Food Systems, and Global Health. PLoS Med 9(6): e1001242. doi:10.1371/journal.pmed.1001242 Published June 19, 2012 Copyright: 2012 Stuckler, Nestle. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received for writing this article. Competing Interests: MN and DS are the guest editors of the PLoS Medicine series on Big Food. Abbreviations: LMIC, low- and middle-income country; SSB, sugar-sweetened beverage * E-mail: ds450@cam.ac.uk Provenance: Commissioned; not externally peer reviewed.
Engaging with Big FoodThree Views

We see three possible ways to view this debate. The first favors voluntary selfregulation, and requires no further engagement by the public health community. Those who share this view argue that market forces will self-correct the negative externalities resulting from higher intake of risky commodities. Informed individuals, they say, will choose whether to eat unhealthy foods and need not be subjected to public health paternalism. On this basis, UN secretary-general Ban Ki Moon urged industry to be more responsible: I especially call on corporations that profit from selling processed foods to children to act with the utmost integrity. I refer not only to food manufacturers, but also the media, marketing and advertising companies that play central roles in these enterprises [35]. Similarly, the UK Health Minister recently said: the food and drinks industry should be seen, not just as part of the problem, but part of the solutionAn emphasis on prevention, physical activity and personal and corporate responsibility could, alongside unified Government action, make a big difference [36]. The second view favors partnerships with industry. Public health advocates who hold this view may take jobs with industry in order to make positive changes from within, or actively seek partnerships and alliances with food companies. Food, they say, is not tobacco. Whereas tobacco is demonstrably harmful in all forms and levels of consumption, food is not. We can live without tobacco, but we all must eat. Therefore, this view holds that we must work with Big Food to make healthier products and market them more responsibly. The third approach is critical of both. It recognizes the inherent conflicts of interest between corporations that profit from unhealthy food and public health collaborations. Because growth in profit is the primary goal of corporations, self-regulation and working from within are doomed to fail. Most proponents of this viewpoint support public regulation as the only meaningful approach, although some propose having public health expert committees set standards and monitor industry performance in improving the nutritional quality of food products and in marketing the products to children. We support the critical view, for several reasons. First, we find no evidence for an alignment of public health interest in curbing obesity with that of the food and beverage industry. Any partnership must create profit for the industry, which
2
Figure 1. Growth of Big Food and Big Tobacco sales in developing countries: An example. Shaded blue line is developed countries, dashed grey line is developing countries. Source: Passport Global Market Information Database: EuroMonitor International, 2011 [12]. doi:10.1371/journal.pmed.1001242.g001
agencies continue to view obesity as a disease of affluence and a sign of progress in combating undernutrition [32]. A more uncomfortable reason is that action requires tackling vested interests, especially the powerful Big Food companies with strong ties to and influence over national governments. This is difficult terrain for many public health scientists. It took five decades after the initial studies linking tobacco and cancer for effective public health policies to be put in place, with enormous cost to human health. Must we wait five decades to respond to the similar effects of Big Food? If we are going to get serious about such nutritional issues, we must make choices about how to engage with Big Food. Whether, and under what circumstances, we should view food companies as partners or as part of the solution to rising rates of obesity and associated chronic diseases is a matter of much current debate, as indicated by the diverse views of officials of PepsiCo and nutrition scientists [24,27,28,33,34].
has a legal mandate to maximize wealth for shareholders. We also see no obvious, established, or legitimate mechanism through which public health professionals might increase Big Foods profits. Big Food attains profit by expanding markets to reach more people, increasing peoples sense of hunger so that they buy more food, and increasing profit margins through encouraging consumption of products with higher price/cost surpluses [2831,37]. Industry achieves these goals through food processing and marketing, and we are aware of no evidence for health gains through partnerships in either domain. Although in theory minimal processing of foods can improve nutritional content, in practice most processing is done so to increase palatability, shelf-life, and transportability, processes that reduce nutritional quality. Processed foods are not necessary for survival, and few individuals are sufficiently well-informed or even capable of overcoming marketing and cost hurdles [38]. Big Food companies have the resources to recruit leading nutritional scientists and experts to guide product development and reformulation, leaving the role of public health advisors uncertain. To promote health, industry would need to make and market healthier foods so as to shift consumption away from highly processed, unhealthy foods. Yet, such healthier foods are inherently less profitable. The only ways the industry could preserve profit is either to undermine public health attempts to tax and regulate or to get people to eat more healthy food while continuing to eat profitable unhealthy foods [33,39]. Neither is desirable from a nutritional standpoint. Whereas industry support for research might be seen as one place to align interests, studies funded by industry are 4- to 8-fold more likely to support conclusions favorable to the industry [40]. Our second reason to support the critical view has to do with the precautionary principle [41]. Because it is unclear whether inherent conflicts of interest can be reconciled, we favor proceeding on the basis of evidence. As George Orwell put it, saints should always be judged guilty until they are proved innocent. We believe the onus of proof is on the food industry. If food companies can rigorously and independently establish self-regulation or privatepublic partnerships as improving both health and profit, these methods should be extended and replicated. But to date self-regulation has largely failed to meet stated objectives
[42,43,44,45,46,47], and instead has resulted in significant pressure for public regulation. Krafts decision to ban trans fats, for example, occurred under pressure of lawsuits [48]. If industry believed that self-regulation would increase profit, it would already be regulating itself. We believe the critical view has much to offer. It is a model of dynamic and dialectic engagement. It will increase pressures on industry to improve health performance, and it will encourage those who are sympathetic to the first or second views to effect change from within large food and beverage companies.
Public health professionals must recognize that Big Foods influence on global food systems is a problem, and do what is needed to reach a consensus about how to engage critically. The Conflicts of Interest Coalition, which emerged from concerns about Big Foods influence on the U.N. High-Level Meeting on NCDs, is a good place to start [29,49]. Public health professionals must place as high a priority on nutrition as they do on HIV, infectious diseases, and other disease threats. They should support initiatives such as restrictions on marketing to children, better nutrition standards for school meals, and taxes on
SSBs. The central aim of public health must be to bring into alignment Big Foods profit motives with public health goals. Without taking direct and concerted action to expose and regulate the vested interests of Big Food, epidemics of poverty, hunger, and obesity are likely to become more acute.
Analyzed the data: DS. Wrote the first draft of the manuscript: DS. Contributed to the writing of the manuscript: DS MN. ICMJE criteria for authorship read and met: DS MN. Agree with manuscript results and conclusions: DS MN.
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Essay
Food Sovereignty: Power, Gender, and the Right to Food

Rajeev C. Patel*
School of Development Studies, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
This article was commissioned for the PLoS Medicine series on Big Food that examines the activities and influence of the food and beverage industry in the health arena.
Power over Food

One of the most enduring misconceptions about hunger is that it is primarily the result of a deficit in global food production. If this were so, we might expect food to be absent at times and in places where people die of hunger. Yet economist Amartya Sen has shown that in the majority of cases of widespread famine-related death since WWII, food has been available within the famineaffected area. People have died not for want of food, but for want of the entitlement to eat it [1]. Questions about hunger and its attendant pathologies, therefore, ought to begin with questions about social and political configurations around power over food, rather than about the mere presence or absence of food in the vicinity of a hungry individual. Although no single commonly agreed definition of hunger exists, two common standards prevail: undernourishment and food security. The former refers to the number of people whose dietary energy consumption is continuously below a minimum dietary energy requirement for maintaining a healthy life and carrying out a light physical activity [2]. Undernourishment is a condition suffered by individuals. It is, however, usually established not through individual surveys but through an analysis of a countrys food availability, household purchasing power, and entitlements [3,4]. Current estimates put the worldwide number of undernourished people at nearly one billion [3]. The concept of food security attempts to capture the notion of hunger as a deficit not of calories, but as a violation of a broader set of social, economic, and
The Essay section contains opinion pieces on topics of broad interest to a general medical audience.
physical conditions. In 1996, the Food and Agriculture Organization of the United Nations (FAO) established at its World Food Summit the most widely agreed definition [5] that Food security, at the individual, household, national, regional and global levels [is achieved] when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life. By definition, more people are food insecure than are undernourished, and food insecurity precedes undernourishment. Although there are few people in the United States whose calorie intake is continuously below the threshold of a maintaining healthy life, there are many who, at some point during any given year, are unable to meet their food needs. According to the United States Department of Agriculture (USDA), in 2010 there were 48.8 million US citizens living in food-insecure households. The distribution of food insecurity is uneven. In the US, 21.6 million children lived in foodinsecure households, and 35.1% of all female-headed households were food insecure in 2010, compared to 25.4% of maleheaded households [6]. Since food insecurity is a broader measure than that of undernourishment, it has been correlated both with hunger and obesity, particularly among women [7]. If hunger is a symptom of a lack of control over the socioeconomic context in
which one attempts to eat, it is not unreasonable to understand that lack of control as correlated with factors associated with obesity too. It is possible to have sufficient calories, but insufficiently nutritious food for a healthy life. Armed with this understanding, and with persistent evidence across countries of women and girls disempowerment compared to men and boys [8], it becomes easier to appreciate the systematically higher rates of food insecurity among women.
Gender and Food

The link between gender and food becomes clearer through an understanding of power and control in the food system. Giving away food does little to address the underlying causes of disempowerment that lead to hunger [9]. One group that has articulated this is an international peasant movement called La Via Campesina (see Box 1). They argue that if governments aim merely for food security as a policy goal, the politically difficult questions of inequality in power that produced food insecurity would be ignored, and a broken system would be patched up with entitlements [1]. It is possible, after all, to be food secure in prison where one might continually access safe and nutritious food, yet remain fundamentally disempowered over the process and politics of the foods production, consumption, and distribution. Instead of food security, Via Campesina has advocated for food sovereignty. Just like the definition of food security, food
Citation: Patel RC (2012) Food Sovereignty: Power, Gender, and the Right to Food. PLoS Med 9(6): e1001223. doi:10.1371/journal.pmed.1001223 Published June 26, 2012 Copyright: 2012 Rajeev C. Patel. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received to write this article. Competing Interests: RP is both a Fellow at the Institute for Food and Development Policy, and a Fellow of the Institute for Agriculture and Trade Policys (IATP) Food And Community Fellowship program. This program is funded, in part, by the W. K. Kellogg Foundation though fellows are appointed by IATP. RP has no relationship with La Via Campesina. Abbreviations: FAO, Food and Agriculture Organization of the United Nations; NCD, non-communicable disease; USDA, United States Department of Agriculture; WTO, World Trade Organization * E-mail: rcp9@cornell.edu Provenance: Commissioned; externally peer reviewed.
Summary Points
N N N N N
Understanding hunger and malnutrition requires an examination of what systems and institutions hold power over food. The concept of food security captures the notion of hunger not as a deficit of calories, but as a violation of a broader set of social, economic, and physical conditions. Gender is key to food insecurity and malnourishment, because women and girls are disproportionately disempowered through current processes and politics of foods production, consumption, and distribution. La Via Campesina has advocated for food sovereignty, through which communities have the right to define their own food and agriculture policy. Womens rights are central elements to food sovereignty. The role of the food industry demands attention within the food system, where power is concentrated in the hands of a few corporations.
sovereignty is an evolving and manyfaceted term, but it has an invariant core: communities have the right to define their own food and agriculture policy [10]. To be clear, sovereignty is not a call for self-sufficiency, for states to grow within their borders sufficient food to feed their citizens. La Via Campesina instead calls for people to be sovereign over their food systems, for people to have the power to decide what the system should look like. This is an intentionally vague call, with many questions left open-ended, so that the communities involved in claiming food sovereignty might answer issues around production, distribution, and consumption of food for themselves. It is through food sovereignty, La Via Campesina argues, that food security might be achieved, and undernourishment eradicated. The main demand in food sovereignty is that, for the first time, decisions about the shape of the food system ought to be in the hands not of powerful corporations or geopolitically dominant governments [11],
but up to the people who depend on the food system. For the discussion to be representative of the communitys desires, however, a non-negotiable element of food sovereignty is womens rights. In order for a democratic conversation about food and agriculture policy to happen, women need to be able to participate in the discussion as freely as men. Peasant movements, and those who support them, have been castigated as romantics pining for an unattainable past [12]. An insistence of womens rights places food sovereignty firmly in the twenty-first century. This has a practical purpose. Of those undernourished, 60% are women or girls [13]. It is hard to conceive a discussion about hunger without connecting the epidemiology of hunger to womens disempowerment. On the production side of the food system, women constitute 43% of the agricultural workforce, more often involved in producing food for domestic consumption than export. They are dis-
criminated against in issues ranging from land tenure to wages, from government support to access to technology. The FAO notes that if women had the same access to productive resources as men, they could increase yields on their farms by 2030 percent. This could raise total agricultural output in developing countries by 2.54 percent, which could in turn reduce the number of hungry people in the world by 1217 percent [14]. In addition, women stand to bear a disproportionate burden of the consequences of the twenty-first centurys predicted global increase in non-communicable disease (NCD) prevalence. In South Asia, for example, NCDs are projected to account for 72% of deaths by 2030, up from 51% in 2008. In Sub-Saharan Africa, the estimates are 46%, up from 28% over the same period [15]. In addition to the duties of paid work, women bear a disproportionate burden of care work in the management of morbidity associated with NCDs [16,17], especially in contexts of poverty [18]. These are the kinds of inequities to which food sovereignty calls attention.
Systemic Inequity and the Right to Food

Beyond an examination of the inequitable distribution of power at a household level, food sovereignty suggests an investigation of power relations at meso- and macroeconomic levels. La Via Campesina members are, for example, concerned about corporate power within the global economy. The food systems dysfunction continues to be lucrative for a range of food and agriculture companies. Profits often derive from the increased consumption of processed food, which in turn have driven a global obesity epidemic. Yet the distribution mechanisms within the food system that ration food on the basis of ability to pay have produced the paradox of a billion hungry during a time when there are more than 1.5 billion people overweight [19,20]. Within the food system, power is concentrated in the hands of a few corporations. In 2008, the top ten agrochemical corporations controlled almost 90% of the global sales of pesticides. Of the US$22 billion global proprietary seed market, only ten corporations controlled 67% [21]. In 2005, the top four beef packing firms controlled 83.5% of the market in the US [22], and worldwide, 40% of all groceries were sold by only 100 retailers [21]. These trends across the food industry have been on an almost-steady
Box 1. La Via Campesina

La Via Campesina is an organization of farmers, peasants, and landless workers movements with over 150 million combined members in 70 countries [46]. Its first meeting was held in 1993, and it was constituted as an umbrella organization for a range of social movements that had, through the 1980s, begun to work more closely in Asia, the Americas, and Europe. These movements had come into contact with one another through their attempts to understand, resist, and offer alternatives to free market agricultural trade. Even before the organization was officially created, La Via Campesinas member organizations had undertaken a range of actions to confront what they saw as inequality in power within the food system. In India, 200,000 farmers protested the patenting of seeds by multinational corporations. In Europe, 30,000 farmers marched on Brussels to offer an alternative policy goal to the achievement of food security. In Brazil, hundreds of thousands of people occupied farmland, upon which they built thriving communities. In 1996, at the same World Food summit at which the most recent definition of food security was written, La Via Campesina codified its vision for an alternative food system under the rubric of food sovereignty. At a 2009 La Via Campesina meeting, one of the slogans offered by the assembly was that food sovereignty is an end to all forms of violence against women.
climb since they were recorded first in the 1970s. As the US government recently found, for example, in the pork sector, the market share of the largest four hog slaughtering firms increased from 36 percent in 1982 to 63 percent in 2006. In addition, at the retail level, the share of grocery store sales held by the largest four firms more than doubled, from 16 percent in 1982 to 36 percent in 2005 [23]. This concentration of power has gendered consequences. In contexts where women perform the majority of horticultural and agronomic innovation, they can find their agroecological knowledge supplanted by the technologies of industrial agriculture. Pesticide companies own the largest seed companies, and their agricultural model, dependent on purchased supplies of hybrid seeds and chemical inputs, favors larger, more capital-intensive farms. Women have systematically less access to both land and capital than men, and despite an often sophisticated level of knowledge about farming systems, womens views seldom matter in the shaping of choices around agricultural technologies and food policy [24]. In addition, employment within agriculture consistently pays women around 25% less than men. When food is accessed through market mechanisms, this increases womens systemic risk of hunger [25]. It is for these reasons that women leaders within peasant movements have taken strong stands against multinational corporations such as Monsanto and Cargill [26]. To be sure, concentration of agricultural power is not new. At the turn of the nineteenth century, four firmsDreyfus, Cargill, Continental, and Bungedominated global grain trading [27]. Today, however, the extent to which food markets matter is far greater. Agricultural market concentration is evident not only in international trade, but across domestic production, distribution, and consumption. This concentration matters more when there are fewer alternatives to the markets in which concentration occurs.
The Role of Markets and Governments

To understand why the private sector has achieved such power, it is worth
looking at other actors roles within the food system. Philanthropic foundations have, for example, been responsible for advancing the kinds of industrial agriculture that has imperiled La Via Campesinas members [28,29]. The Green Revolution, in which farmers were encouraged and sometimes forced by governments to adopt a system of farming involving hybrid seeds, fertilizer, and pesticides, was initially funded by the Rockefeller and Ford Foundations, and is currently being encouraged by the Gates Foundation in Africa [30,31,32]. These farming systems have had gender-negative impacts, as womens knowledge is excluded, and women are systematically less able to control the capital required to participate in resource-intensive farming [33,34,35]. National governments and international organizations have also been faulted for their behavior in shaping the food system. Of particular interest to La Via Campesina is the extent to which, through international economic agreements such as the World Trade Organizations (WTOs) Agreement on Agriculture, governments have enabled private sector markets to expand their influence within the food system. A central demand in La Via Campesinas call for food sovereignty is for the WTO to get out of agriculture [36]. By this they mean not only ought the Agreement on Agriculture within the WTO be nullified, but that a range of other WTO provisions that affect agriculture, such as rules on intellectual property rights on seeds and phytosanitary measures, also be suspended. Trade agreements rules are influenced by the corporations that subsequently benefit from them [37], with demonstrated gendered impacts as a result [38,39]. Food corporations continue to attempt to shape domestic and international public policy. PepsiCo, for instance, has gone to great lengths to claim a place at the table in addressing public health issues [40]. Yet the company has since 2000 spent US$26.88 million on lobbying in the US [41], in particular in response to taxes on its products and voicing its concerns on restrictions on marketing its foods to
children [42,43]. PepsiCos behavior is emblematic of a wider trend in private sector spending within the food system. In a context of shrinking public budgets, and the transformation of public institutions such as schools into sites for the sale of obesogenic products [44], the influence of private interest in public policy matters immensely. Yet the food industry is pushing public debate toward an interpretation of the rise of NCDs as fundamentally a problem of individuals [45]. To accept this is to urge a policy response in which NCDs can be remedied by better individual behavior, rather than more regulation. With women more responsible than men for childrens diets, this has the effect of pathologizing individual women, rather than finding fault with a system that removes their freedom to make their childrens diets healthier.
Conclusion
The inequalities in power that characterize the food system can be found in households, corporations, regional and state governments, private philanthropic foundations, and international organizations. The strengths of a food sovereignty approach lie in the heuristic approach to power relations that it invites, particularly with respect to gender. For La Via Campesina, and many others, identifying inequities in power within the global food system is more than an academic exerciseit is a means not only to interpret the system, but also to change it.
Acknowledgments
The author gratefully acknowledges invaluable comments from Maninder Kahlon and the research support of Meredith Palmer.
Wrote the first draft of the manuscript: RP. Contributed to the writing of the manuscript: RP. ICMJE criteria for authorship read and met: RP. Agree with manuscript results and conclusions: RP.
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Essay
The Impact of Transnational Big Food Companies on the South: A View from Brazil
Carlos A. Monteiro1*, Geoffrey Cannon1,2
o Paulo, Brazil, 2 Editor, World Nutrition, World Public Health 1 Center for Epidemiological Studies in Health and Nutrition, School of Public Health, University of Sa Nutrition Association, Rio de Janeiro, Brazil
Summary Points
N N N N N
Introduction
Throughout human history, traditional food systems and dietary patterns have been intrinsic to social, cultural, and economic life, and to personal, community, and national identity. Although these long-established dietary patterns are rarely if ever nutritionally ideal, they are linked with low rates of obesity and chronic diseases, and can be readily improved by modifications that respect tradition and culture, and national and local resources. However, the policies and practices of transnational food and drink corporations (see Box 1), most of whose products are ultra-processed and whose headquarters are almost invariably in the US and Europe, are now steadily displacing traditional food systems around the world. This process of displacement is not merely commercial, it is also ideological. Economic globalization, systematic privatization, and minimally regulated international capital flow have all shifted the balance between governments and corporations. Governments and international institutions now tend to cede their prime duty to protect the public interest to vast transnational corporations whose primary responsibility is to their shareholders. The prevailing political, economic, and commercial policies and practices have also given these corporations freedom to expand across borders [1]. Consequently, the leading food and drink product
Traditional long-established food systems and dietary patterns are being displaced in Brazil and in other countries in the South (Africa, Asia, and Latin America) by ultra-processed products made by transnational food corporations (Big Food and Big Snack). This displacement increases the incidence of obesity and of major chronic diseases and affects public health and public goods by undermining culture, meals, the family, community life, local economies, and national identity. The penetration of transnational companies into Brazil has been rapid, but the tradition of shared and family meals remains strong and is likely to provide protection to national and regional food systems. The Brazilian government, under pressure from civil society organizations, has introduced legislation to protect and improve its traditional food system; by contrast, the governments of many industrialized countries have partly ceded their prime duty to protect public health to transnational companies. The experience of countries in the South that still retain traditional food systems provides a rational basis for policies that protect public health.
corporations are now colossal concerns. Their brands sell throughout the world in outlets that range from large supermarkets to filling stations, and from restaurants to kiosks. The individual annual revenue of the largest corporations is as high as the annual gross domestic product (GDP) of middle-size countries [28] and, unlike many national governments, these corporations are able to plan strategically and to divert or invest billions in new technologies and markets.
Big Food corporations now claim that they work in the public as well as the private interest, and even that they are in the business of protecting public health. For example, according to executives working for PepsiCo, food and drink transnationals penetrating emerging markets can at the same time support low- and middle-income countries, helping them to eliminate hunger and undernutrition and to prevent and control obesity and non-communicable diseases
Citation: Monteiro CA, Cannon G (2012) The Impact of Transnational Big Food Companies on the South: A View from Brazil. PLoS Med 9(7): e1001252. doi:10.1371/journal.pmed.1001252 Published July 3, 2012 Copyright: 2012 Monteiro, Cannon. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received for writing this article. Competing Interests: Since 1993 GC has worked for the World Cancer Research Fund International and the American Institute for Cancer Research (both not-for-profit organisations). He is an honorary Council member of the World Public Health Nutrition Association, its Publications Secretary, and editor of its journal World Nutrition. GC was an advisor to the Brazilian federal government in the period 20002002 when he worked within its Ministry of Health, and also occasionally for UN agencies including WHO. GC has occasionally advised the food and beverage industry, but not since 2007 when he advised PepsiCo on the possibility of ethicallybased products using the products of Brazilian tropical fruits. CAM has acted as advisor to the Brazilian Ministry of Health and also for WHO. * E-mail: carlosam@usp.br Provenance: Commissioned; externally peer reviewed.
The Essay section contains opinion pieces on topics of broad interest to a general medical audience.
July 2012 | Volume 9 | Issue 7 | e1001252
Box 1. Big Food, Big Snack, and Ultra-Processed Products

The term Big Food refers to the transnational and other large corporations that increasingly control the production and distribution of ultra-processed products throughout the world. These products are created from substances extracted from whole foods such as the cheap parts or remnants of animals, inexpensive ingredients such as refined starches, sugars, fats and oils, preservatives, and other additives [34,35]. The products are formulated to be intensely palatable and to fool the bodys appetite control mechanisms [36,37]. Many of these products, while legal, are in effect fakes, made to look and taste like wholesome food. They are formulated and packaged to have a long shelf life and to eliminate the need for culinary preparation. They can be consumed anywhere, immediately or almost immediately, and often dispense with the need for tables, chairs, dishes, cutlery, and cups. They are therefore often termed fast or convenience products. Some ultra-processed products, such as breads and sausages, have been part of dietary patterns in many countries since before industrialization. Others, such as burgers, chips, cookies, sweets, nuggets, energy bars, and carbonated and other sugared or sweet drinks, are more recent, at least in the quantity now manufactured. Since the 1980s, Big Snackthe transnational manufacturers of packaged, long shelf-life snacks designed to displace mealshave greatly increased their penetration first of high-income countries, and now of lowerincome countries, including Brazil [21].
[9]. In our view, this claim is part of a damage limitation exercise, which is further eroding the duty of governments to protect public health and public goods [10]. The ongoing globalization, privatization, and deregulation of food systems and supplies may have relatively little impact on public health in high-income countries whose dietary patterns are already fully industrialized. But the displacement of traditional food systems in Africa, Asia, and Latin America (the South) by the fatty, sugary, or salty long-life ultraprocessed products marketed by transnational food and drink corporations, which has been increasing rapidly since the 1980s, has the potential to undermine public health by increasing the incidence of chronic diseases and obesity. We believe that the experience and situation of those countries in the South still retaining their traditional food systems provide a rational and reliable basis for the development of international public health policies related to food. In this essay, we describe the incursion of Big Food and Big Snack into the South, based upon our experiences in Brazil, a very large country that still retains, at least in part, its traditional food systems. We outline the nature of traditional Brazilian food systems and dietary patterns and the impact of the rapid penetration of the transnational food corporations into Brazil. We identify some implications of the partnerships between food corporations and public bodies. Finally, we propose ways to protect public health and public goods in Brazil and in other countries and
regions that still retain traditional food systems and supplies.
Traditional Brazilian Dietary Patterns

Analyses of household food expenditure surveys conducted in Brazil over the past 40 years [1113] show that, in common with other Latin American countries, Brazil retains many long-established food systems and dietary patterns. These dietary patterns show the influences of native (Indian) populations, the countrys Portuguese colonizers, and African slaves and their descendants. Minimally processed food staples include rice, a variety of beans, and the root cassava (manioc). These staples form the basis of everyday main meals, and are made delicious and attractive by various methods of preparation and cooking, and by the addition of oils, seeds, leaves, herbs, and spices, some of which are rich in nutrients. (Wheat is not native to Brazil; processed wheat products such as breads, cakes, and biscuits followed relatively recent immigration of people from the Mediterranean region to the southern states of Brazil, and nationally were uncommon until well into the second half of the last century.) The amount of meat, fish, and other animal products in long-established Brazilian diets depends on availability, price, and income. In the past, these foods were usually eaten only in small amounts on a daily basis, and in large quantities only as part of feasts or other special occasions. All Brazilian cities have restaurants, bars, and popular canteens, where a good
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variety of locally sourced traditional Brazilian food is offered, often buffet-style and affordably priced on a per kilo basis. More importantly, meals prepared and eaten by the family at homeincluding the midday mealand therefore the habit of eating together, remain an integral part of the Brazilian way of life. Notwithstanding intense pressures, which include ubiquitous television and internet propaganda designed to turn eating and drinking into constant individual snacking [10], food and drink consumption is not yet dislocated and isolated from family and social life in Brazil. This is probably the most important factor protecting national and regional traditional food systems. It would be wrong, however, to romanticize Brazilian traditional food systems and dietary patternsthey are far from ideal. The influence of the seafaring Portuguese colonizers and the need to preserve animal foods by salting before the widespread availability of refrigeration mean that the typical Brazilian diet is high in salt, which has resulted in high rates of hypertension and stroke in the country [14]. The traditional diet is also sugary, the result of Brazil being for centuries the worlds largest producer of sugar, and of table sugar being the cheapest source of calories in the country. Further, while a variety of indigenous or established tropical fruits is consumed, commonly at breakfast or as desserts, consumption of green vegetables remains low, particularly among the lowest-income families. More positively, undernutrition is generally uncommon or rare at all stages of life and, as with many Asian, African, and other Latin American countries, rates of obesity in Brazil were low until the late 1970s [15].
Big Food and Big Snack Move In

During our work on this essay, we went for lunch to a workers restaurant near the University of Sa o Paulo, where a traditional freshly cooked meal of rice, beans, and a choice of meat, together with mixed salad, cost the equivalent of $US 6. We noticed that the bottled water offered was made by a once Brazilian company now owned by Coca-Cola, and that the artisanal water-based ice lollies containing fruit juice, which are still sold by pedlars on Brazilian beaches and supplied by traders to simple restaurants, had been replaced by fatty, sugary brands of Nestle ice cream. These same ice creams, together with other Nestle popularly positioned products, which are targeted at and bought by low income consumers [16],
are now being sold door-to-door in the outskirts of several Brazilian cities, on trains and subway stations, in retail chains that sell electronic and house appliances, and also on floating supermarkets that take Nestle products to remote Amazonian villages [10]. Our experience in the workers restaurant illustrates how transnational food corporations are changing dietary patterns in Brazil. For these corporations, the move into emerging markets is necessary because the market for their ultra-processed convenience, meals, dishes, snacks, and drinks is already saturated in high-income countries [17]. Research we are undertaking suggests that in any country a saturation point is reached when ultraprocessed products supply around 60% of total calories, as has been the case in the UK [18] and in Canada and the US for the last two decades (unpublished data being prepared for publication). Indeed, in the US, consumption of sugared cola and other soft drinks is now declining from a very high peak [19], and transnational corporations have moved into designer water and soft drinks for which health claims can be made because the drinks have been reformulated to contain more substances chemically identical to micronutrients or the dietary fibre found in whole foods. The saturation of developed market economies with ultra-processed products may also explain why transnationals appear to be aiming for double-digit growthsales that increase by an annual 10% or morein the South. For instance, the growth of the Nestle line of popularly positioned products is up to 25% a year, and the market for these products in Asia, Africa, and Latin America is now estimated to be over CHF 80 billion, or a little over $US 87 billion [20]. In Brazil, the consumption of ultra-processed products has already risen from less than 20% of calories in the 1980s to 28% [21], but this figure is still well short of 60%, the possible saturation level. Similarly, the current prevalence of obesity in Brazil (14% among adults in 2009) [14], has some way to go before it reaches the levels seen in countries like the UK and the US (currently 24% and 34%, respectively) [22]. More generally, the opportunities for transnational food and drink corporations to increase the penetration of ultra-processed products in very highly populated countries such as India and China, where until recently most of the populations were rural and on very low incomes, are immense. In such countries, the strategies
these corporations are employing to introduce their products undermine and displace long-established traditional food systems. The impact is not only on nutrition and risk of disease. Snacking replaces meals. Commensal family and community life is undermined. Local food producers, distributors, retailers, and caterers are driven out of business. Social networks collapse. Regional and national culture and identity are eroded [2326]. Epidemic obesity and serious chronic diseases can be seen as an integral part of economic development. Thus, Kenneth Rogoff, a former chief economist at the International Monetary Fund, recently wrote that: Highly processed corn-based food products, with lots of chemical additives, are well known to be a major driver of weight gain, but, from a conventional growth-accounting perspective, they are great stuff [27]. Given the disability caused by obesity, and the attendant diabetes, heart disease, cancer, and other diseases that need lengthy and expensive treatment, we suggest that the concept of development needs revision.
PublicPrivate Food Partnerships

It is now commonly agreed in UN, government, public health, and scientific circles that the prevention and control of noncommunicable chronic diseases can be achieved only by publicprivate partnerships, meaning collaborations with the private sector. However, this term does not refer to industry as a whole. It is code for the food, drink, and associated industries. Indeed, in practice, the term only refers to the transnational and other large suppliers, manufacturers, and distributors of ultra-processed products and their raw materials, together with allied and associated corporations and institutions. Excluded are national industries (with a few exceptions), the retail trade (unless burger chains are counted), low-input and organic producers and growers, the horticulture industries (again, with a few exceptions), food and farming cooperatives, and family and smaller manufacturers, all of which have minimal or no representation in the partnership. It is Big Food and Big Snack, above all, that have sought and achieved partnerships with the public sector. Indeed, with support from the World Economic Forum and other organisations that represent the interests of transnational industry, food corporations have already engaged in the committees convened by the UN that are tasked to set and develop the global
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agenda specified in the Political Declaration of the recent UN High-Level Meeting on prevention and control of noncommunicable diseases [28,29]. Within countries where food systems are already more or less saturated with ultra-processed products, these committees are mainly focused on proposals to adjust the formulation of ultra-processed products so that they contain, for example, less salt and trans-fats or more synthetic micronutrients. But such reformulation often allows manufacturers to advertise their products as healthy, which is likely to result in sustained or even increased purchase and consumption of such products, additional displacement of fresh and minimally processed foods, and therefore further increases in obesity, diabetes, and other chronic diseases. Moreover, the reformulation strategy of transnational corporations may have the effect of heading off legislation designed, for example, to sharply limit or prohibit the advertising and marketing of ultraprocessed products to children. The reformulation strategy is also likely to contribute to the displacement of traditional food systems in Brazil and other countries of the South, and to the replacement of shared meals with ready-to-heat or ready-to-eat dishes and snacks labelled as healthy, often with the blessing of governments and support from nutritionists and public health professionals. Partnership with industries whose interests do not conflict with those of public health is essential. But we see partnerships with Big Food and Big Snack as analogous with tobacco control or alcohol restriction policy-making in which Big Tobacco or Big Alcohol manufacturers are partners. The growth of production and therefore consumption of ultra-processed food and drink products in Brazil and elsewhere in the South is already undermining and even destroying public health and public institutions in countries that cannot afford the costs of treatment of obesity and other epidemic diseases of which unhealthy food products, consumed in typical quantities, are a major cause.
Protecting and Improving Traditional Food Systems

The long-established Brazilian diet, in common with the diets of other Southern countries, can readily be improved from the nutritional and public health points of view. Indeed, it has already improved. Because food supplies have become secure in almost all parts of the country, and because most Brazilian populations and
communities have risen up out of severe impoverishment, the consumption of meat, milk, and other animal products in Brazil has increased, undernutrition has become uncommon, and childhood stunting and wasting have ceased to be major problems [30,31]. Remaining undernutrition can be alleviated by special programs involving redistribution of cash or goods, as carried out by recent Brazilian governments [32]. Remaining faults in the Brazilian traditional dietary patterns can be addressed by a combination of fiscal and other legislation. This legislation should support cooperatives and family farmers, protect and stabilize the prices of healthy staple foods and ingredients, and make green vegetables and other fresh and minimally processed foods more attractive to produce and more affordable and available. It should also reduce the volume of salt and sugar entering food supplies, either as raw materials or as contained in ultra-processed products [21]. Programs of information and education at the national and state levels should be used to reinforce this legislation. More generally, we also advocate worldwide prohibition of the hydrogenation process that generates industrial saturated fats and trans-fats. The use of law to protect and improve food systems and supplies, and thus public health, may be difficult in parts of the world where governments have already surrendered the responsibility of governance to transnational and other corporations. However, in Brazil protection of public health still remains a prime duty of government that has not eroded as it has in other countries. Thus, by law, all Brazilian children are entitled to one daily meal at school, at least 70% of the food supplied to schools must be fresh or minimally processed, and a minimum of 30% of this food must be sourced from local family farmers [14]. Brazil also has more than 200 human milk banks, the largest such network in the world [31].
Two important principles used in legislation in Brazil and in some other betterresourced countries in the South add to the current conventional discourse about food, nutrition, and public health. First, access to adequate healthy food in Brazil is regarded as a basic human right that needs protection by the use of law in the public interest. The right of access to adequate healthy food has been part of the Brazilian Constitution since 2010, together with the right of access to health care, education, work, and social security [33]. Second, many improvements in Brazilian food suppliesfor example, those that benefit schoolchildren, the legal support provided to working mothers to breastfeed their babies, and the prohibition of any type of advertisement of commercial human milk substitutes [31]depend on sustained pressure on legislators exerted by energetic and often militant civil society organizations. Notably, in Brazil, partnership between government and civil society at all levels is a central feature of the 1988 Constitution, which was designed to ensure that Brazil would be a participatory democracy after its emergence from government by military regimes.
Conclusion
This essay is based on our experience in Brazil, a large country that, together with many other countries in the South, still retains its long-established food systems and thus dietary patterns. By contrast, the traditional food systems of fully industrialized high-income countries like the US and the UK were largely displaced generations ago. As a result, the views of many commentators and policy-makers in the South are in sharp contrast with their counterparts in the North. In countries like the US, the general tendency is to deal with food, nutrition, and public health in isolation as matters largely of information, education, and individual lifestyle adjustments designed to reduce the risk of
various disabilities and diseases. But in Brazil and other countries in the South, food is seen by most independent scholars and policy-makers as part of a much broader discourse that involves general well-being, the family, friendship, commensality, culture, sustainable livelihoods, environmental preservation, national identity and sovereignty, as well as personal and public health. In the North, the prevailing political and economic ideology, which has developed rapidly since the 1980s, has involved abandonment by governments of policies and actions designed to protect public health and public goods to private corporations. During this process of privatization and globalization, leading corporations have become transnationals. Governments and other powerful and influential institutions, and also research and public health institutions, now need to examine and document the impact on the South of Big Food and Big Snack and their associated and supportive international financial and economic organizations on public health, and also on regional and national nature and culture, independence, and identity. This work must not inhibit the implementation of policies and actions that are needed now; importantly, once enacted, the impact of these essential policies and actions needs to be carefully monitored. Brazil is one of the leading countries in the South. It has substantial remaining natural resources, and its governments at federal, state, and municipal levels remain able to govern. We propose, therefore, that the Brazilian experience provides a basis for the design of rational, comprehensive, and effective public health policies and actions designed to protect and promote nutrition in all its senses.
Wrote the first draft of the manuscript: CAM GC. Contributed to the writing of the manuscript: CAM GC. ICMJE criteria for authorship read and met: CAM GC. Agree with manuscript results and conclusions: CAM GC.
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Perspective
Thinking Forward: The Quicksand of Appeasing the Food Industry

Kelly D. Brownell*
Rudd Center for Food Policy and Obesity, Yale University, New Haven, Connecticut, United States of America
This article was commissioned for the PLoS Medicine series on Big Food that examines the activities and influence of the food and beverage industry in the health arena. It is an important time to reflect on the ways that the public and global health communities can engage with the food industry. There are divergent views [1]. Many political bodies, foundations, and scientists believe that working collaboratively with the food industry is the path for change. The assumption is that this industry is somehow different than others, and that because people must eat, the industry is here to stay, and like it or not, working with them is the only solution. Based on my 30 years of experience in the public health and policy sectors, I believe this position is a trap. When the history of the worlds attempt to address obesity is written, the greatest failure may be collaboration with and appeasement of the food industry. I expect history will look back with dismay on the celebration of baby steps industry takes (such as public private partnerships with health organizations, healthy eating campaigns, and corporate social responsibility initiatives) while it fights viciously against meaningful change (such as limits on marketing, taxes on products such as sugared beverages, and regulation of nutritional labeling). The obesity problem has industrys attention, and they are doing things. The question is whether these things are meaningful or are the predictable behavior of an industry under threat and are designed to stop rather than support public health efforts. The soft drink industry gave the Childrens Hospital of Philadelphia a US$10 million giftat a critical time the city of Philadelphia was considering a soda tax. Such public-sector interaction with industry could be predicted to undermine public health goals and protect industry interests [26]. The food industry has had plenty of time to prove itself trustworthy. It has been in high gear, making promises to behave
better, but their minor progress creates an impression of change while larger attempts to subvert the agenda carry on. Witness the massive resistance against soda taxes in the United States [7] and the wholesale attack of marketing standards proposed by the Interagency Working Group (e.g., [8]). Worst perhaps is the issue of marketing food to children. The industry launched the Childrens Food and Beverage Advertising Initiative designed to shift the mix of foods advertised to children under 12 to encourage healthier dietary choices and healthy lifestyles [9]. Objective reports, however, have shown a tidal wave of marketing of calorie-dense, nutrientpoor foods to children, and if any change is occurring, marketing is on the increase [1013]. Companies boast of introducing healthier options, and at least one report cites this as evidence that market forces (e.g., consumer demand for better foods) will be the best motivator for companies to change [14]. But introducing healthier processed foods does not mean unhealthy foods will be supplanted, and might simply represent the addition of more calories to the food supply. Furthermore, the companies have not promised to sell less junk food. Quite the contrary; they now offer ever larger burgers and portions, introduce ever more categories of sugared beverages (sports drinks, energy drinks, and vitamin waters), find ever more creative ways of marketing foods to vulnerable populations (e.g., children), and increasingly engage in promotion of unhealthy foods in developing countries [1,15,16].
The food industry, like all industries, plays by certain rulesit must defend its core practices against all threats, produce short-term earnings, and in do doing, sell more food [2,17]. If it distorts science, creates front groups to do its bidding, compromises scientists, professional organizations, and community groups with contributions, blocks needed public health policies in the service of their goals, or engages in other tactics in the corporate playbook [3,18], this is what is takes to protect business as usual. The parallel scenario most often used to justify collaboration with industry is tobacco. Often heard is that people dont have to smoke, but they must eat and that the tobacco industry was simple just a few companies and one product but food is much more complex [3]. Tobacco is an interesting parallel [3,19], but is by no means the only one. A world economic crisis was fueled in part by too little oversight of financial institutions, but we all need banks. Requiring air bags in cars was stalled for years by the auto industry, but we need cars. An emerging area in need of scrutiny is the food industrys attempts to create foods engineered in ways that thwart the human bodys ability to regulate calorie intake and weight. Whether overconsumption is a consequence simply of hyperpalatability brought about by extreme processing [15] and/or an addictive process [20,21], overconsumption is a predictable consequence of the current food environment. The arresting reality is that companies must sell less food if the population is to
Citation: Brownell KD (2012) Thinking Forward: The Quicksand of Appeasing the Food Industry. PLoS Med 9(7): e1001254. doi:10.1371/journal.pmed.1001254 Published July 3, 2012 Copyright: 2012 Kelly D. Brownell. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received to write this article. Competing Interests: The author has declared that no competing interests exist. * E-mail: kelly.brownell@yale.edu Provenance: Commissioned; not externally peer reviewed.
lose weight, and this pits the fundamental purpose of the food industry against public health goals. We need food, but the obesity crisis is made worse by the way industry formulates and markets its products. The food industry, like other industries must be regulated to prevent excesses and to protect the public good. Left to regulate itself, industry has the opportunity, if not the mandate from shareholders, to sell more products irrespective of their impact
on consumers. Government, foundations, and other powerful institutions should be working for regulation, not collaboration. If history is to look back positively on current times, the future must bring several things. Respectful dialogue with industry is desirable, and to the extent industry will make voluntary changes that inch us forward, the public good will be served. But there must be recognition that this will bring small victories only and that to take the obesity problem seriously will
require courage, leaders who will not back down in the face of harsh industry tactics, and regulation with purpose.
Wrote the first draft of the manuscript: KB. Contributed to the writing of the manuscript: KB. ICMJE criteria for authorship read and met: KB. Agree with manuscript results and conclusions: KB.
References
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Policy Forum
Soda and Tobacco Industry Corporate Social Responsibility Campaigns: How Do They Compare?
Lori Dorfman1, Andrew Cheyne1*, Lissy C. Friedman2, Asiya Wadud1, Mark Gottlieb2
1 Berkeley Media Studies Group, Berkeley, California, United States of America, 2 Public Health Advocacy Institute, Boston, Massachusetts, United States of America
This article was commissioned for the PLoS Medicine series on Big Food that examines the activities and influence of the food and beverage industry in the health arena. For the first time in 23 years, PepsiCo eschewed the biggest marketing day of the year and did not advertise during the 2010 Super bowl [1,2]. Instead, it launched the Pepsi Refresh Project, a social media cause marketing campaign. The campaign signaled a landmark turn in soda marketing, using cutting-edge social media techniques [3] to spread word-ofmouth buzz and elicit online nominations for a variety of community-based projects. In 2010, Pepsi donated more than $20 million to support causes that received the most votes, and intends to transform the Refresh Project into a global phenomenon [4]. Meanwhile, industry leader CocaCola maintains Live Positively, another corporate social responsibility (CSR) campaign that offers consumers healthy lifestyle advice and touts the firms philanthropic and sustainability efforts. Both companies campaigns occur amidst increasing pressure from consumers and public health advocates concerned about rising obesity rates [5,6], including the passage or consideration of strong legislative measures such as food taxes in many countries [7,8,9,10]. While tobaccorelated diseases remain a top public health threat [11], obesity is the fifth leading mortality risk worldwide [12], and the spread of western diets is expected to exacerbate preventable chronic conditions such as cardiovascular disease [13] and diabetes [14]. Globally, childhood obesity is one of the most serious public health challenges of the 21st century [15]. Sugar-sweetened beverage (SSB) consumption has helped fuel this crisis [16,17]; from 1977 to 2004 U.S. children
The Policy Forum allows health policy makers around the world to discuss challenges and opportunities for improving health care in their societies.
Summary Points
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Because sugary beverages are implicated in the global obesity crisis, major soda manufacturers have recently employed elaborate, expensive, multinational corporate social responsibility (CSR) campaigns. These campaigns echo the tobacco industrys use of CSR as a means to focus responsibility on consumers rather than on the corporation, bolster the companies and their products popularity, and to prevent regulation. In response to health concerns about their products, soda companies appear to have launched comprehensive CSR initiatives sooner than did tobacco companies. Unlike tobacco CSR campaigns, soda company CSR campaigns explicitly aim to increase sales, including among young people. As they did with tobacco, public health advocates need to counter industry CSR with strong denormalization campaigns to educate the public and policymakers about the effects of soda CSR campaigns and the social ills caused by sugary beverages. science, wielding political influence, deploying financial tactics, influencing legal and regulatory actions, promoting their own products and services, and investing heavily in public relations. Provocative comparisons of Big Tobacco and the food industry suggest that food companies may be using at least one of these tactics, specifically attempts to influence government policy, with similar aims [23,24]. CSR is another of these corporate tactics. CSR has been defined as an evolving concept that has come to include companies economic, legal, ethical, and philanthropic responsibilities to society in
more than doubled their caloric intake from SSBs, in 2004 they received 13% of their caloric intake from SSBs [17], and these drinks have contributed an estimated one-fifth of the weight gain in the U.S. population from 1977 to 2007 [18]. When facing crises over health concerns, many industries attempt to thwart regulation and gain popular support [19]. The tobacco industry [20] has a long history of influencing the public and policymakers, and oil companies, among others, have emulated Big Tobaccos playbook in this regard [21,22]. Wiist [23] explains how corporations aim to do this by distorting
Citation: Dorfman L, Cheyne A, Friedman LC, Wadud A, Gottlieb M (2012) Soda and Tobacco Industry Corporate Social Responsibility Campaigns: How Do They Compare? PLoS Med 9(6): e1001241. doi:10.1371/ journal.pmed.1001241 Published June 19, 2012 Copyright: 2012 Dorfman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This research was supported by the Healthy Eating Research program (http://www. healthyeatingresearch.org/) of the Robert Wood Johnson Foundation (http://www.rwjf.org/), grant #68240. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: CSR, corporate social responsibility; MSA, Master Settlement Agreement; PM, Philip Morris; SSB, sugar-sweetened beverage * E-mail: cheyne@bmsg.org Provenance: Commissioned; externally peer reviewed.
addition to the companys fiduciary responsibility to shareholders [25,26]. Proponents of CSR argue it can help companies meet these essential needs while addressing the firms higher social responsibilities [26]. Companies invest in CSR to address social demands; in an attempt to be accountable to groups beyond their shareholders, they accept ethical obligations to society at large [27]. Cause marketing is a variation of CSR that links the marketer to a specific social benefit, often a community initiative or organization that benefits from the sale of a product or brand [28]. Critics, however, portray CSR as primarily a public relations strategy designed to achieve innocence by association as corporations align themselves with good causes to burnish their public image and protect their core business [29,30]. Corporations may use CSR to improve their standing among consumers, the press, legislators, and regulators who make policy decisions about the company and its products [27,31,32]. CSR initiatives are often introduced when corporations fear a threat to their profitability [33], because CSR can boost a firms bottom line both directly through sales and indirectly by moderating the risk for regulation and improving the overall business climate. After first reviewing an emblematic tobacco CSR campaign, we examine prominent cases from recent CSR efforts by soda industry leaders PepsiCo and Coca-Cola, to compare how these two industries have implemented CSR strategies.
How Did Tobacco Companies Employ CSR?

During the 1950s, landmark scientific studies linked smoking and disease, and popular media disseminated the research [34]. The tobacco industry and its products began to suffer from reduced social acceptability and were targeted for tighter state and federal regulation [35,36]. By the late 1990s, tobacco companies faced a series of challenges, including disclosures from industry whistleblowers and formerly secret internal documents, congressional hearings, a civil racketeering lawsuit by the U.S. Department of Justice, and the Master Settlement Agreement (MSA) with 46 state attorneys general compensating the states for Medicaid payments resulting from smoking-related illnesses. Reacting to these pressures, the tobacco companies all began to implement CSR programs to improve their corporate and product images and to prevent legal and regulatory action [37,38,39]. In 1999,
industry leader Philip Morris (PM) launched the industrys most ambitious and visible CSR program, which it internally labeled PM21 [40]. In confidential documents, PM described the program as a multifaceted, cross functional effort to change the publics perception of Philip Morris and to improve the publics attitudes toward the company and the people who work for it [41]. Using paid advertisements and a dedicated website, PM21 highlighted the companys charitable contributions to causes including homelessness, domestic abuse, and the arts [42,43,44]. This continued a previous strategy to co-opt interest groups that might oppose tobacco industry programs [45,46,47,48,49,50]. While the PM21 campaign improved outlooks among the small segment of the public that had no preexisting opinions about the company, the campaign hardened the opinions of the large majority who already held negative views of PM and the tobacco industry [42,51]. PM21 was far from Big Tobaccos only CSR effort. The tobacco companies also launched CSR activities to protect areas of perceived vulnerability, which included regulation [52], litigation [20,36], and future threats to their bottom line [53], such as declining social acceptability, youth smoking and concern over secondhand smoke exposure. In response to the prevalence of underage smoking, all of the major tobacco companies instituted youth smoking prevention programs to avert increased regulation [54,55,56]. For instance, PM distributed to students book covers emblazoned with the corporate name, and Lorillard employed the slogan Tobacco Is Whacko If Youre a Teen, which emphasized the forbidden fruit aspect of youth smoking. Public officials, advocates, teachers, and students opposed these programs, which backfired because they were perceived as cynically employing reverse psychology to encourage youth smoking [57,58,59]. Through denormalization tactics that publicly exposed the tobacco industrys bad corporate behavior, tobacco control advocates joined with educators and elected officials to pressure the tobacco companies to drop their disingenuous youth smoking prevention programs.
websites; their annual CSR reports; news and trade press coverage of the campaigns; and other reports, we examine prominent campaigns from industry leaders PepsiCo and Coca-Cola, which have embraced CSR with elaborate, expensive, and multinational campaigns [62,63]. See a list of soda industry CSR-related URLs in Box 1.
PepsiCos Refresh Project and Change4Life

The Pepsi Refresh Project dominates PepsiCos CSR efforts in the U.S. The $20 million cause marketing campaign uses social media to identify philanthropic ventures [64]. Anyone may submit an idea online for a project, and PepsiCo funds the projects that generate the most votes each month, from community arts to refreshing parklands. Votes are cast on the campaign website, on its Facebook page, and on mobile devices via SMS messaging [65]. In January 2011, the Project explicitly linked the campaign to product sales by offering participants up to 100 additional Power Votes when they purchase specially marked PepsiCo beverages [66]. Globally, PepsiCo launched Project Refresh, which funds individual youths ideas to make the world more exciting and fun in at least 18 countries from Venezuela to Ukraine [67]. The Refresh Project directly involves youth in PepsiCos CSR campaign. PepsiCo has donated branded soda company items to a variety of youth-oriented causes such as childrens ball fields [68] and band uniforms [69]. PepsiCo also hired a marketing firm to conduct a multi-city tour featuring popular musicians to inform youth about the initiative and to encourage them to submit grant proposals [70]. The Refresh Project successfully targeted Millennialsthose currently aged 1131 [71]using traditional media, such as television, and new media, such as mobile devices, to drive referral marketing by leveraging Millennials social networks [72]. Instead of separating moneymaking ventures from charitable donations, the contemporary soda industry CSR blurs the traditional lines between a corporations profit-oriented and philanthropic activities. According to Shiv Singh, a marketing officer for the Refresh Project, the campaign is not a traditional nonprofit corporate philanthropy effort that we just go write checks. Its putting the DNA of doing and feeling good at the core of a brand marketing effort [73]. Moreover, while the initiative is publicly presentJune 2012 | Volume 9 | Issue 6 | e1001241
Snapshots of Soda Company CSR and Cause Marketing Campaigns

CSR and cause marketing have become industry-wide practices, including all leading SSB firms: Nestle [60], PepsiCo, CocaCola, and Dr. Pepper-Snapple Group [61]. Using information from the companies campaign, corporate, and partner
2
Box 1. Internet Presence of Soda Industry CSR Campaigns

PepsiCo CSR Campaigns
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Refresh Project homepage: http://www.refresheverything.com Refresh Project Facebook: www.facebook.com/apps/application.php?id = 301917354154 Refresh Project Twitter: http://twitter.com/#!/pepsi/pepsirefresh Shiv Singh, PepsiCos Global Head of Digital, on the Refresh Project as marketing, including to youth: http://www.youtube.com/watch?v = Xb9Kby9_NBQ UK NHS on PepsiCo UKs Change4Life partnership: http://www.nhs.uk/ change4life/Pages/national-partners-pepsico.aspx PepsiCo UK on Change4Life role: http://www.pepsico.co.uk/our-company/ media-centre/news-and-comment/pepsico-uk-partners-with-department-ofhealths-play4life-campaign
obesity rates. For example, CSR campaigns that include the construction and upgrading of parks for youth who are at risk for diet-related illnesses keep the focus on physical activity, rather than on unhealthful foods and drinks. Such tactics redirect the responsibility for health outcomes from corporations onto its consumers, and externalize the negative effects of increased obesity to the public [82,32].
Soda and Tobacco CSR: How Do They Compare?

Soda CSR campaigns echo tobacco CSR in their focus on the consumer and in their likely intent to thwart regulation. Soda CSR differs from tobacco in its explicit appeals to youth and in the aggressive launch of comprehensive campaigns soon after soda was linked to obesity.
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Coca-Cola CSR Campaigns Live Positively homepage: http://www.livepositively.com Sprites Spark Your Park: http://www.livepositively.com/en_us/spritesparkparks/ Other Sugary Drink Manufacturers CSR Campaigns : http://www.nestle.com/CSV/Pages/Homepage.aspx Nestle Dr. Pepper Snapple Group: http://www.drpeppersnapplegroup.com/values/ sustainability/
Soda and Tobacco CSR Shifts Responsibility from the Corporation to Consumers
By highlighting the importance of consumers making healthy choices instead of the companies roles in creating an unhealthy environment, soda company and tobacco industry CSR campaigns emphasize personal, instead of corporate, responsibility. For instance, the tobacco industrys youth smoking prevention programs appeared to combat youth smoking, but instead placed responsibility on parents and children for the decision to smoke [55,56]. Similarly, in its Balanced Living message on Live Positively, Coca-Cola suggests that the company is responsible only for providing health information to consumers, such as through the Clear on Calories labels that show calorie counts on the front of bottles or cans. The company suggests that health is ultimately up to consumers, because with new labels, youll know exactly how many calories are in a beverage before making a purchase whether at a store, one of our vending machines or fountain machinesmaking it easier for you to make informed choices and live a healthy, active lifestyle [83]. PepsiCos advertisement for the UKs Change4Life campaign likewise insists that active parents make active kids [84].
ed as supporting charitable causes, the program was not funded with corporate philanthropy dollars but with brand marketing dollars, because we believed fundamentally and still do that, you know, by doing good in a way thats aligned with our Pepsi brand values, you know, we can help the bottom line [73]. By this, PepsiCo intends to take advantage of Millennials desire to support or do business with companies that contribute to society [74] by associating their brand with all of the community projects they fund. PepsiCo considers Millennials a key cohort for the initiative, tracked their engagement with the campaign via new media, and used specific metrics to measure the positive effect the campaign had on their intent to buy PepsiCo products [75]. Accordingly, PepsiCo is using CSR as a marketing tool [73,76,77], in part to influence Millennials by reinforcing the view that it is a good corporate citizen. Since 2009, PepsiCo has also been a partner with the United Kingdom National Health Services Change4Life campaign. PepsiCo contributes to the marketing component [78] of that governments response to obesity, which promotes physical activity and healthy eating through traditional and new media social marketing campaigns. A commercial partner of the campaign, PepsiCo sponsored a major print ad buy for Change4Life that used
famous soccer players to encourage parents to help their children have an active lifestyle [79].
Coca-Colas Live Positively

Coca-Colas U.S. CSR activities occur under the Live Positively banner. They use educational campaigns such as Balanced Living or Exercise is Medicine to urge individual consumers to achieve healthy lifestyles; support charitable projects, such as the $2 million Spark Your Park (also called Sprite Spark Parks) initiative to refurbish basketball courts and school athletic fields in underserved communities [80]; and develop initiatives to improve the companys own business practices, e.g. reducing its water consumption. Coca-Cola promotes Live Positively through a dedicated website, full-page newspaper ads, more prominent nutrition labeling on product packaging, and a new line of 7.5ounce mini-cans. Live Positively builds on Coca-Colas existing CSR initiatives, such as the companys associations with youth organizations, including Coca-Colas relationship with the Boys and Girls Club of America dating back 65 years [81]. Even from these brief descriptions it appears that the soda CSR campaigns reinforce the idea that obesity is caused by customers bad behavior, diverting attention from sodas contribution to rising
3
Tobacco and Soda Tactics Seek to Prevent Regulation

As CSR campaigns can improve a firms standing with the public and policymakers, they are potentially a powerful mechanism to forestall regulation [47]. British AmeriJune 2012 | Volume 9 | Issue 6 | e1001241
can Tobacco, for example, used CSR to reestablish political influence with the UK Department of Health, with which its relationship had deteriorated [85]. While the Refresh Project and Live Positively have not stated such goals outrightand we have no cache of internal soda industry documents to investigate for such explicit rationalesthe campaigns employ the very tactics that companies use to influence the public and policymakers [23]. For instance, the tobacco industry used donations to cultural organizations to help enlist their support against a proposed public smoking ban in New York City [86]. From that perspective, PepsiCos Refresh Project represents $20 million in donations to community groups who publicly praise the company [73], and may be recruited to help oppose future regulatory initiatives. Moreover, PepsiCo and Coca-Cola are members of the American Beverage Association (ABA), an industry trade group that has aggressively lobbied against taxes on SSBs [87]. Following a trademark tobacco industry tactic, the soda companies and the ABA are members of the front group Americans Against Food Taxes, which, despite its name, is primarily composed of food and beverage companies. The group has aired a $10 million TV campaign against taxing beverages and promoting individual responsibility as the remedy for obesity [88].
ences from an early age and create a climate in which drinking soda is viewed as a natural, frequent activity. Soda companies also benefit from sponsorship of youth-oriented community organizations in ways that are unavailable to tobacco companies, which must avoid appearing to attract young people as a condition of the MSA [91]. Soda companies marketing to youth is not similarly constrained, and soda CSR campaigns target youth in schools or community centers. The use of cause marketing and new media facilitates the companies connection to youth. For instance, Coke uses its Spark Your Park program, with heavy emphasis on Facebook and Twitter engagements online, to promote its Sprite product while donating funds to neglected recreation facilities [92]. Moreover, these CSR campaigns provide a mechanism for soda companies to circumvent pledges not to market in schools [93,94,95]. While soda companies agreed to remove fullcalorie drinks from U.S. schools, CSR programs like the Refresh Project keep the brand in front of young people with promises of grants for childrens schools, parks, or other programs.
Tobacco, concern over soda and the obesity epidemic is growing. The World Health Organization [108] and the U.S. Surgeon General cited soda as a key contributor to obesity [109], U.S. First Lady Michelle Obamas Lets Move initiative prompted new company policies by soda marketers [110], and interest in soda taxes is growing [111,112]. The soda companies are feeling this pressure. In 2009, Coca-Cola told its shareholders that Increasing concern among consumers, public health professionals and government agencies of the potential health problems associated with obesity and inactive lifestyles represents a significant challenge to our industry [113]. Unlike tobacco, at the first signs of soda denormalization soda companies quickly launched comprehensive, well-funded, international CSR campaigns that take advantage of social media.
Implications for Public Health Advocates

Tobacco companies launched CSR campaigns to rehabilitate themselves with the public when their image had been tarnished [20]. Because the most comprehensive initiatives were introduced well after intense public outcry, however, their CSR efforts struggled to achieve their aims [42]. As soda denormalization is nascent, soda companies may enjoy benefits from CSR that Big Tobacco labored to accomplish. In addition to effectively preempting regulation and maintaining its favorable position with the public, the soda industrys CSR tactics may also entice todays young people to become brand-loyal lifetime consumers, an outcome that current social norms dictate Big Tobacco cannot explicitly seek. Without sustained denormalization of soda, it will be harder for public health advocates to see why partnering with industry may further the companies goals more than their own. While tobacco denormalization was facilitated by litigation, which used the discovery process to procure internal documents revealing the industrys duplicitous intent, it is possible to respond to the soda industry without a smoking gun. For example, one instance of tobacco industry denormalization that did not rely on internal documents was the revelation that PM spent more on publicizing its charitable efforts than it spent on the charities itself, which exposed the cynical nature of Big Tobaccos CSR [114]. The Refresh Projects $20 million price tag, and the statements from company representatives, give public health advocates a similar opportunity to argue
Soda Is Employing CSR Sooner Than Big Tobacco

The overall goal for the tobacco industrys CSR strategy has been to normalize its products and its corporate image [96,97,98], but it has struggled as public health advocates have denormalized tobacco use and challenged tobacco companies trying to rehabilitate their images. Historically, advocates countered such campaigns by stigmatizing smoking [99]. Now, denormalization characterizes the corporations activities as a disease vector [100], and highlights the disingenuous use of CSR [101]. Such industry denormalization refutes the tobacco companies argument that they are like any other legitimate industry [20], builds support for stronger regulation, and helps deter and reduce adolescent [102], young adult [103], and adult smoking [104,105]. The soda industry appears to be improving upon Big Tobaccos CSR strategy by acting sooner [28]. Although the tobacco industry responded to critics in 1954 with the nationwide newspaper advertisement A Frank Statement to Cigarette Smokers [106], decades lapsed between the publics outcry regarding tobacco and when the industry mounted concerted CSR campaigns [107]. While soda companies may not face the level of social stigmatization or regulatory pressure that now confronts Big
4
Unlike Tobacco, Soda CSR Explicitly Seeks Sales, and Sales to Youth
In contrast to the actions of Big Tobacco, soda industry CSR initiatives are explicitly and aggressively profit-seeking. Soda companies use CSR to tout their concern for the health and well-being of youth while simultaneously cultivating brand loyalty. The stated goal of PepsiCos flagship Refresh Project is to increase longterm sales [73,89] by engaging youth in the initiatives [69] and to build loyalty by associating PepsiCo with benevolent, worthwhile ventures. According to PepsiCo, after just nine months, the Refresh Project is an overwhelming success: With over 2.8 billion (with a B!) earned media impressions, the project exceeded our internal benchmarks early in the year and weve seen an improvement in key brand health metrics. Crucial to PepsiCos bottom line, when Millennials, the campaigns key demographic target, know about the Project their purchase intent goes up [90]. Such soda CSR programs focus strategically on this cohort of 11- to 31-year-olds [71] to build brand preferPLoS Medicine | www.plosmedicine.org
that this is marketing, not philanthropy [115]. Such criticism appeared in a Lancet editorial, which stated that the U.K.s Change4Life should have avoided illjudged partnerships with companies that fuel obesity [116]. Research on the health harms of sugary beverages can help advocates name these products as one of the biggest culprits [117] behind the obesity crisis. Emerging science on the addictiveness [118] and toxicity [119] of sugar, especially when combined with the known addictive properties of caffeine found in many sugary beverages, should further heighten awareness of the products public health threat similar to the
understanding about the addictiveness of tobacco products. Public health advocates must continue to monitor the CSR activities of soda companies, and remind the public and policymakers that, similar to Big Tobacco, soda industry CSR aims to position the companies, and their products, as socially acceptable rather than contributing to a social ill.
Acknowledgments
We would like to acknowledge the important research on soda company CSR tactics provided by Jeff Chester, MSW, of the Center for Digital Democracy.
Analyzed the data: LD AC LF AW MG. Wrote the first draft of the manuscript: LD AC LF AW. Contributed to the writing of the manuscript: LD AC LF AW MG. ICMJE criteria for authorship read and met: LD AC LF AW MG. Agree with manuscript results and conclusions: LD AC LF AW MG.
Supporting Information
Alternative Language Abstract S1
Spanish translation of the abstract. (DOCX)
References
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Policy Forum
Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including Processed Foods, Alcohol, and Tobacco
David Stuckler1,2,3*, Martin McKee2, Shah Ebrahim3, Sanjay Basu2,4,5
1 Department of Sociology, University of Cambridge, Cambridge, United Kingdom, 2 Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, 3 South Asian Chronic Disease Network, Public Health Foundation of India, New Delhi, India, 4 Department of Medicine, University of California San Francisco, San Francisco, California, United States of America, 5 Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California, United States of America
Introduction
Unhealthy commoditiessoft drinks and processed foods that are high in salt, fat, and sugar, as well as tobacco and alcoholare leading risk factors for chronic noncommunicable diseases (NCDs). Their consumption is thought to be rising rapidly, particularly in LMICs [1]. However, the extent of and reasons for this growth in unhealthy commodity consumption are not well understood. Many epidemiologists have argued that economic development pushes populations through a nutrition transition from undernutrition to overnutrition, shifting food preferences from traditional diets characterised by low salt, saturated fat, and glycaemic indexes to less healthy, complex western diets that lead to obesity and associated NCDs [2]. It has thus been suggested that economic growth and the resulting rising incomes are increasing the risks of unhealthy commodity consumption. Yet studies have also found evidence of the two faces of malnutrition [3]: obesity and undernutrition co-occurring in the same households. Poor nutrition among impoverished groups can result in intake of both insufficient nutrition and excess calories (particularly from cheap, non-nutritious foods) [4]. There is also a social transition in obesity and
consumption of unhealthy foods, as risks initially most prevalent among the wealthiest shift to and become embedded among the lowest-income groups [5,6,7]. Paradoxically, these findings indicate that poverty, not higher income, may be a key risk factor for consumption of unhealthy commodities. To understand why people are choosing to consume unhealthy commodities, it is necessary to study the transformations to economic and social systems that are favouring their increasing availability and affordability. Previous research had focused on the role played by urbanisation in the nutrition transition [8,9,10,11], but with the global rise of transnational food and drink companies there is a clear need to focus on the role of global producers in manufacturing and marketing the commodities implicated in NCD epidemics. Unhealthy commodities are highly profitable because of their low production cost, long shelf-life, and high retail value. These market characteristics create perverse incentives for industries to market and sell more of these commodities. Coca-Colas
net profit margins, for example, are about one-quarter of the retail price, making soft drink production, alongside tobacco production, among the most profitable industrial activities in the world. Indeed, transnational corporations that manufacture and market unhealthy food and beverage commodities, including CocaCola, PepsiCo, and Cadbury Schweppes, are among the leading vectors for the global spread of NCD risks [12,13,14]. Increasingly, they target developing countries markets as a major area for expansion [15,16,17]. Neoliberal policies, including the opening of markets to trade and foreign investment, create environments that are conducive to the widespread distribution of unhealthy commodities by multinational firms. A theory of dietary dependency [6] proposes that integration into the global economy makes countrys food systems come to depend on imports from and investments by large multinational processed food firms. When this happens in LMICs, their populations consumption choices and habits are increasingly affected by shifts in food type, price,
Citation: Stuckler D, McKee M, Ebrahim S, Basu S (2012) Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including Processed Foods, Alcohol, and Tobacco. PLoS Med 9(6): e1001235. doi:10.1371/journal.pmed.1001235 Published June 26, 2012 Copyright: 2012 Stuckler et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received for writing this article. Competing Interests: MM is a member of the Global Health Advisory Committee of the Open Society Institute and has served on advisory boards for Merck & Co (1999-2006) and Johnson & Johnson (2006-2009). He has received research funding from the Rockefeller Foundation and expenses from projects funded by the Gates Foundation to attend scientific meetings LSHTM receives funding from the Gates Foundation, and was the recipient of the 2009 Gates Award for Global Health. DS is a guest editor of the PLoS Medicine series on Big Food. All other authors have declared that no competing interests exist. Abbreviations: GDP, gross domestic product; HICs, high-income countries; LMICs, low- and middle-income countries; NCD, noncommunicable disease * E-mail: ds450@cam.ac.uk Provenance: Commissioned; externally peer reviewed.
Summary Points
than are currently available through survey-based measurements.
N N N N N N
The rate of increase in consumption of unhealthy commodities (soft drinks and processed foods that are high in salt, fat, and sugar, as well as tobacco and alcohol) is fastest in low- and middle-income countries (LMICs), with little or no further growth expected in high-income countries (HICs). The pace at which consumption is rising in LMICs is even faster than has occurred historically in HICs. Multinational companies have now achieved a level of penetration of food markets in middle-income countries similar to what they have achieved in HICs. Higher intake of unhealthy foods correlates strongly with higher tobacco and alcohol sales, suggesting a set of common tactics by industries producing unhealthy commodities. Contrary to findings from studies undertaken several decades ago, urbanisation no longer seems to be a strong risk factor for greater consumption of risky commodities at the population level, with the exception of soft drinks. Rising income has been strongly associated with higher consumption of unhealthy commodities within countries and over time, but mainly when there are high foreign direct investment and free-trade agreements. Economic growth does not inevitably lead to higher unhealthy-commodity consumption. collected market data on commodity sales from EuroMonitor Passport Global Market Information database 2011 edition, covering up to 80 countries between 1997 and 2010 with forecasts to the year 2016 [21]. Data include both per capita volumes for packaged foods, including snacks, snack bars, ice cream, oils and fats, chilled processed food, dried processed food, canned food, soft drinks, hot drinks, and ready-to-eat meals (a grouping sometimes referred to as ultra-processed foods with the exception of oils and fats). Industry data on retail sales of alcohol and tobacco were also obtained from EuroMonitor. To correct for differences in the prices of these products across countries, these data were analysed using fixed exchange rates and constant prices for the year 2011. These official market data, as reported by governments, have similar limitations to other commonly used macroeconomic data such as gross domestic product (GDP) and trade statistics. Additionally, these data capture only sales volumes, which are an imperfect measure of consumption. In particular, sales data may fail to capture important sources of consumption: food and beverage products may be wasted or produced at home [22], and alcohol and tobacco products may be smuggled. However, sales data have arguably greater validity than alternative survey-based measurements, because they are not subject to recall biases from people understating their levels of consumption (particularly problematic with regard to alcohol and tobacco use). Another advantage is that industry data are much more widely available and consistently reported for tracking across countries and over time
2
Global Trends in Unhealthy Food, Beverage, and Tobacco Commodities

As a first step, we compared trends in per capita volume of each major food category in LMICs and in HICs, as shown in Figure 1. Based on both average rates of growth between 1997 and 2010 (labelled on the figure) and projected trends from 2011 to 2016 (dashed lines), we can make the following observations (see the figure in Text S1 for disaggregation by geographic region): Observation 1. Growth of snacks, soft drinks and processed foods is fastest in LMICs (i.e. GDP #USD12,500). Little or no growth is expected in HICs in the next 5 years. At the current pace of increasing consumption in LMICs and HICs, consumption of unhealthy food commodities will converge with levels currently seen in and projected for HICs within about three decades. Further, as the size of populations in LMICs is more than five times greater than that in HICs, the bulk of unhealthy commodities is already, and will continue to be, consumed in LMIC settings. The situation with tobacco and alcohol follows a similar pattern, albeit to a less pronounced degree, as shown in Text S2. In HICs, per capita sales of alcohol and tobacco are projected to decline, partly reflecting a short-term dip associated with the economic recessions between 2007 and 2010. In contrast, in LMICs, they are projected to rise by about 20% over the next 5 years and, if current trends are sustained in both groups of countries, would take about four decades to reach the consumption rates of HICs. Another way to look at the data is to investigate which countries are projected to experience the greatest rises in unhealthy commodities in the next 5 years. The scatterplots in Text S3 disaggregate the regional trends into country-specific patterns for soft drinks and processed foods. As shown in the figure in Text S3, the countries anticipated to have the greatest increases in soft drink consumption per capita include Vietnam and India, where consumption is projected to double, followed by Egypt, China, Tunisia, Cameroon, and Morocco where increases are estimated to be about 50%. These are substantial rises of over 10% per year in population-wide consumption of unhealthy commodities in a
availability, and marketing that favour unhealthy commodities [18]. Reports suggest that when LMIC farmers and food sellers cannot compete with multinational firms, they often collapse or are integrated into processed food production [6,19]. Although preliminary evidence suggests the linkage of consumption of unhealthy commodities and systems of food trade and market integration, a systematic and global examination of this relationship is needed. In addition, debate has focused largely on HICs, neglecting the pace and scale at which food systems in LMICs are incorporating more unhealthy commodities. While studies have begun to document individual-level risk factors for consumption of such commodities (e.g., socioeconomic status, urban/rural residence, education level) [7], relatively few [20] have assessed the underlying population-wide reasons for the variations across populations in the pace and degree of these dietary transformations among LMICs using quantitative data. We begin by examining two main questions: (1) Where is the consumption of unhealthy commodities rising most rapidly? and (2) What determines the pace and scale of these increases? For comparison, we analyse data on global trends in tobacco and alcohol commodities. We conclude by identifying policy interventions that could shift dietary patterns in a healthier direction and making recommendations for future research.
Methods
To describe trends in unhealthy food, beverage, and tobacco commodities, we
Figure 1. Trends in per capita sales of unhealthy food and beverage commodities, 19972010 and projected to 2016. Mean growth rates 19972010 are labelled. Data are from the EuroMonitor 2011 dataset. LMICs defined using World Bank criteria as GDP,USD12,500 in the year 2010. Dashed lines are forecast trends between 2011 and 2016. doi:10.1371/journal.pmed.1001235.g001
very short period of time. To put the speed of these changes in perspective, it is worth noting that consumption of sweeteners and sugary beverages is increasing at a much faster pace than was observed in the United States over the past half century [23,24]. Observation 2. The pace of increase in consumption of unhealthy commodities in several LMIC is projected to occur at a faster rate than historically in HICs. Which companies are the leading manufacturers and distributors of these commodities? To shed light on this question we investigated the market shares of total packaged foods in Brazil, China, India, Mexico, Russia, and South Africa and, by way of comparison, the United States. As shown in Table 1, in LMICs, multinational corporations have already made a significant entry into food systems. In each country, one of the two market leaders is multinational, with the exception of China. All countries also have Nestle in the top three manufacturers of packaged foods, with the exception of China. Overall, in Brazil Nestle had the highest market share of any multinational company, with 8.4%
of the market. In Mexico, PepsiCo and Nestle have market shares of 5.3% and 3.8%, respectively. This level of market concentration is similar to that seen in HICs such as the US, where the leading companies were Kraft (6.8% of market share), PepsiCo (5.2%), and Nestle (4.2%). Observation 3. Multinational companies have already entered food systems of middle-income countries to a similar degree observed in HICs.
Population Determinants of Unhealthy Food, Beverage, and Tobacco Commodities

As Geoffrey Rose famously noted, to understand the reasons for sick populations, one must look not just to individual factors but also societal ones [25]. Why are unhealthy commodities manufactured by both multinational and domestic companies penetrating markets in LMICs? To investigate the population determinants of exposure to unhealthy commodities, we collected data on economic growth, urbanization, and market integration from the World Bank World Development Indicators 2011 edition [26].
3
One clue about the underlying causes of this market penetration is the observation that population consumption of unhealthy non-food commodities such as tobacco and alcohol are strongly correlated with unhealthy food commodity consumption, as shown in Figure 2. In other words, in countries where there are high rates of tobacco and alcohol consumption, there is also a high intake of snacks, soft drinks, processed foods, and other unhealthy food commodities. The correlations of these products with unhealthy foods suggest they share underlying risks associated with the market and regulatory environment. Observation 4. Tobacco and alcohol are joint risks with unhealthy food commodities. Economic development is often argued to be the main factor explaining the rising intake of unhealthy commodities in LMICs. This view garners support from the food commodity data. There was a moderately strong association of greater GDP per capita with consumption rates of soft drinks (r = 0.59, p,0.0001), snacks (r = 0.71, p,0.0001), processed foods (r = 0.66, p,0.0001), alcohol volume (r = 0.48, p,0.0001), and tobacco sales
Table 1. Top 10 manufacturers of packaged foods.
Brazil % 4.9 4.7 3.5 3.1 2.9 2.2 Kraft Foods Inc 3.1 Ganaderos Productores de Leche Pura SA Sigma Alimentos SA de CV Kellogg Co 1.8 1.7 2.1 Parle Products Pvt Ltd 4.8 Kraft Foods Inc 2.8 Mars Inc Kraft Foods Inc National Dairy Development Board 4.8 Industrial Lala SA de CV, Grupo 3.6 SA Nestle 4.9 3.8 SA Nestle SA Nestle Obiedinenye Konditery UK OOO Britannia Industries Ltd 5.0 PepsiCo Inc 5.3 Danone, Groupe 4.3 2.8 2.3 2.1 1.7 Gujarat Co-operative Milk Marketing Federation Ltd 7.9 Grupo Bimbo SAB de CV 9.1 Wimm-Bill-Dann Produkty Pitania OAO 4.7 Company % Company % Company % Company
China
India
Mexico
Russia
South Africa % 19.5 Pioneer Food Group Ltd SA Nestle Clover Ltd Parmalat Group Unilever Group 6.3 4.7 4.7 4.6 4.4
USA Company Kraft Foods Inc PepsiCo Inc SA Nestle Mars Inc Kellogg Co General Mills Inc % 6.8 5.2 4.2 3.2 2.7 2.7

Tiger Brands Ltd 2.0 1.6 GlaxoSmithKline Plc 2.7 Karnataka Cooperative Milk Producers Federation Ltd 2.8 Unilever Group Valio Oy 1.2 1.1 Dairybelle (Pty) Ltd 4.0 Kraft Foods Inc 3.4 Hershey Co, The ConAgra Foods Inc 1.7 Cherkizovsky APK 0.9 AVI Ltd 3.3 Unilever Group Conservas La a SA Costen 1.1 Yug Rusi APG 0.9 PepsiCo Inc 2.4 Campbell Soup Co 1.4 ITC Group 2.4 Unilever Group 1.3 PepsiCo Inc 2.3
Company
Company
SA Nestle
8.4
China Mengniu Dairy Co Ltd
Brf Brasil Foods SA
5.0
Inner Mongolia Yili Industrial Group Co Ltd
Kraft Foods Inc
3.9
Kuok Oils & Grains Pte Ltd (KOG)
Unilever Group
3.3
Ting Hsin International Group
Groupe Danone
2.8
Shineway Group
4
2.3 2.1 2.0 1.6
PepsiCo Inc
2.5
Hangzhou Wahaha Group
Bunge Ltd
2.0
Want Want Group
M Dias Branco SA rcio stria e Come Indu de Alimentos
1.7
Bright Food (Group) Co Ltd
Private Label
1.6
China National Cereals, Oils & Foodstuffs Imp & Exp Corp (COFCO)
SA Itambe
1.5
Mars Inc
doi:10.1371/journal.pmed.1001235.t001
Figure 2. Associations of tobacco, alcohol, soft drink and processed food markets, 80 countries, 2010. doi:10.1371/journal.pmed.1001235.g002
(r = 0.79, p,0.0001), but not oils and fats (r = 0.05, p = 0.65) in the year 2010. Observation 5. Substantial increases in consumption of unhealthy commodities are not an inevitable consequence of economic growth. Several countries do not follow the general correlation between per capita GDP and consumption in each food category, indicating that increased consumption of unhealthy commodities is not an inevitable result of economic development. The figure in Text S4 depicts the correlation between per capita soft drink consumption and GDP across 76 countries for the year 2010. South Korea, Finland, and Sweden have relatively low consumption of soft drinks per capita for their level of GDP, roughly equivalent to countries with about one-third the size of their economies such as Brazil. In contrast, Mexico is a clear outlier (followed by Argentina); its soft drink consumption exceeds that of any other country in the dataset, with the average person consuming more than 300 litres of soft drinks per year. Mexico also has the highest rate of child obesity in developing countries (.30% prevalence), second only to the US. Similar variations related to social and economic policies can be seen for trends in
tobacco consumption, as described in greater detail in Text S5. To analyse further the relationships among per capita income, market integration, and consumption of unhealthy commodities, we used statistical models of populations consumption over time in 50 LMICs (GDP#USD12,500 USD). Table 2 shows the results of ten models of the determinants of unhealthy food commodities, illustrating the following main points: 1. Rising income levels is a significant correlate of increasing exposure to unhealthy foods among low- and lowermiddle-income countries 2. Contrary to the findings from research conducted in the past, urbanization is no longer a significant correlate of exposure to unhealthy foods (with the exception of soft drinks) 3. Alternatively, greater market integration, as indicated by higher levels of foreign direct investment as a fraction of GDP, is a strong correlate of greater exposure to unhealthy food commodities, especially for soft drink, processed foods, and alcohol. The discrepancy with earlier research on urbanization is not surprising, given the
5
strenuous efforts undertaken over recent decades by transnational food and drink corporations to ensure penetration of their products into rural areas, a development now being taken advantage of in a range of partnerships to distribute antiretrovirals and condoms (Table 2) [27]. Observation 6. Foreign direct investment increases risks of rising unhealthy commodities among LMICs. Additionally, we investigated whether countries with greater levels of foreign direct investment as a fraction of GDP, reflecting greater foreign corporate entrance into countries domestic economic system, modified the effects of the association of rising GDP with population-wide consumption of unhealthy food commodities. As shown in the tables of Text S6, in periods when foreign direct investment was relatively low (,2% of GDP), there was no significant association between GDP and confectionery, ice cream, processed foods, packaged foods, and tobacco; and, in other cases, the effect size tended to diminish, particularly for soft drinks. This suggests that rising incomes with limited penetration by multinational corporations into the domestic economy do not necessarily give rise to higher intake of unhealthy commodities.
Tobacco (USD Alcohol (USD sales per sales per capita) capita)
Table 2. Determinants of the level of population exposure to unhealthy foods, beverages, and tobacco, 44 LMICs (GDP,USD12,500 per capita), 19972010.
Oils and fats Packaged (kg per Ready meals Processed foods foods (kg per capita) (kg per capita) (kg per capita) capita)
20.013 (0.019) 0.0017 (0.0039)
2.89*** (0.78)
As one further test of the dietary dependency hypothesis, we investigated whether LMICs that entered into freetrade agreements with the United States had higher levels of consumption of soft drinks than those that did not, after correcting for the countrys level of GDP per capita and urbanization. The table in Text S7 shows that such free-trade agreement is associated with about a 63.4% higher level of soft drink consumption per capita (95% CI: 24.0% to 103.3%). There is extensive research linking rates of unhealthy commodity consumption with obesity, diabetes, and chronic disease outcomes [28,29,30]. We similarly note that there is a strong statistical relationship between consumption of these unhealthy commodities worldwide and population levels of obesity, as shown in the packaged food versus obesity figure in Text S8. As in many cases, such industry data are widely available, they may act as early indicators, so-called leading indicators, for NCD epidemics.
23.0** (6.73)
0.24* (0.10)
20.41 (0.34)
63.8*** (13.5)
1.34 (0.68)
22.21 (1.22)
26.9** (8.61)
0.27 (0.15)
1.78 (1.17)
6.94*** (1.34)
0.061** (0.019)
0.16 (0.21)
0.76** (0.22)
20.027* (0.012)
20.0087 (0.014) 0.043 (0.077)
0.345
489
45
0.509
472
43
0.311
560
49
0.216
609
50
0.411
609
50
Ice cream (kg per capita)
0.0011 (0.0034)
Towards a Corporatology of Food, Beverage, and Other Unhealthy Commodities

Taken together, these data show that there is significant penetration by multinational processed food manufacturers such as Nestle, Kraft, PepsiCo, and Danone into food environments in LMICs, where consumption of unhealthy commodities is reachingand in some cases exceedinga level presently observed in HICs. Greater population consumption of unhealthy food commodities tends to occur in countries with high tobacco and alcohol consumption, suggesting a set of common tactics by industries producing all unhealthy commodities. Overall, the LMICs experiencing the highest exposure to unhealthy commodities are not just those in which growth is occurring most rapidly, but those in which such development is occurring in the context of food systems that are highly penetrated by foreign multinationals. Several middle- and high-income countries have preserved economic growth without consuming high volumes of unhealthy commodities, suggesting that domestic policy choices may be critical to mitigating future NCD risk. Previous alternative explanations for rising unhealthy commodity consumption implicating demographic changes, such as urbanization, no longer find strong support in the population-level data, apart from a significant association with
0.82** (0.26)
42.8*** (11.4)
Soft drinks (litre per capita)
0.71** (0.21)
2.20* (0.84)
0.235 R2 Notes: Robust-clustered errors in parentheses to reflect non-independence of country sampling. *p,0.05, **p,0.01, ***p,0.001. doi:10.1371/journal.pmed.1001235.t002 0.369 0.495 0.483
560
609
Confections (kg per capita)
0.0085* (0.0036) 0.0085 (0.0046)
1.60*** (0.28)
20.025 (0.019)
560
0.024 (0.021)
0.81* (0.31)
Snacks (kg per capita)
341
Percentage of Population Living in Urban Settings
Foreign Direct Investment as a % of GDP
Log GDP per capita (constant USD, purchasing power parity)
Number of Country-Years
Number of Countries
Covariate
40
49
50
49
0.278
560
49
increasing exposure to soft drinks, plausibly because these products are easier to obtain at low cost in dense, urban settings. However, even this may change in the near future. There is an increasing understanding of how unhealthy commodities might be regulated. At least three population-wide cases illustrate the potential for countries to improve regulation of food, beverage, and tobacco commodity systems, as shown in the figure in Text S9. First, Mexico, under pressure from the international financial community following its Tequila crisis in 1994, rapidly opened its markets to trade and foreign investment by entering a trade agreement with the US. It experienced a rapid rise in soft drink consumption throughout the decade with entry of multinational producers into the market, consistent with the findings reported in Text S7. In contrast, Venezuela, which does not have such an agreement with the US, has maintained steady consumption rates during the 1990s and 2000s, despite experiencing high levels of economic growth (largely from oil). Second, Brazil, despite being the second largest producer of tobacco worldwide, made tobacco control a high priority in the late 1990s [31], including adopting measures to increase the price of cigarettes and ban smoking in public places (prior to the ratification of the Framework Convention on Tobacco Control in 2003) [32]. As shown in the figure in Text S9, Brazils rate of tobacco consumption fell by 75% between 1998 and 2003 and has since remained at low levels. Meanwhile, Chile, which delayed ratification of the Framework Convention and its implementation, initially had lower levels of tobacco consumption, but steadily experienced increases so that its level is now more than twice as high as Brazil. Third, turning to data from HICs, the United Kingdom, often characterized as a having an excessive drinking culture, actually did not have high levels of alcohol consumption per capita in the late 1990s (about 30% lower than in France). However, steady increases throughout the past decade under the Labour government, which introduced a range of deregulatory policies associated with easier access and cheap sales by large supermarkets, have reversed the situation so that now consumption is about 30% higher than in France. Further research is needed in several areas to address the rise in consumption of unhealthy commodities and its associated health consequences. There is a clear need for better data to enable investigation of underlying drivers of consumption of
unhealthy food and beverages, and of tobacco commoditiesincluding retail food sector-specific foreign direct investment; accession to free-trade agreements; tariff and import duties; market concentration of transnational corporations; the percentage of retail space owned by a limited number of firms; market regulations and protections; and the capacity to produce and distribute low-cost healthy alternatives domestically. Our analysis found some evidence that free-trade agreements with the US are linked to greater consumption of soft drinks, even after correcting for the trading partners level of income per capita. Free-trade agreements typically limit trade and market restrictions on imports of unhealthy commodities and such non-tariff measures as licensing, quotas, prohibitions, bans, and other restrictions having equivalent effect [33,34]; however, these fiscal policies that increase prices and limit the availability of unhealthy products are among the most effective and low-cost strategies for preventing their consumption. Further studies are needed to test current and prior population-level experiments of trade and capital market integration, the spread of unhealthy commodities, and their links to adverse NCD outcomes. Research is also needed to find ways to identify more easily conflicts of interest involving companies that make, market, and distribute unhealthy commodities, and that can understand which models of interaction with these companies could orient food systems towards promoting improved nutritional quality and reduced risks of NCDs [35]. This work could link to the development of the Conflicts of Interest Coalition [36] that emerged from the recent advocacy of the NCD Alliance during preparation of the UN High-Level meeting on prevention and control of NCDs. Lastly, most work seeking to mitigate the rise of NCDs focuses on individual behavioural change, including lifestyle modification and, in some cases, through medical interventions such as nicotine substitutes or bariatric surgery [6]. While these interventions are highly profitable to pharmaceutical companies and some health professionals, they do little to address the conditions giving rise to consumption of unhealthy commodities and associated NCDs. There is a need to identify population-level social, economic, and political interventions that could stem the rise of unhealthy commodity consumption, and overcome the political barriers to their implementation, as has been done for tobacco control but in which progress
7
remains slow and inadequate in most LMICs. While it is important to maintain a focus on LMICs, there is also potential for progress by addressing the current and high levels of consumption of unhealthy commodities in HICs. Many transnational companies have made commitments to remove trans fats and reduce levels of salt, sugar, and fat content in foods in wealthy countries. However, in most cases, these nutritional improvements are not being applied in low- and middle-income markets. NCDs are the current and future leading causes of global ill health; unhealthy commodities, their producers, and the markets that power them, are their leading risk factors. Until health practitioners, researchers, and politicians are able to understand and identify feasible ways to address the social, economic, and political conditions that lead to the spread of unhealthy food, beverage, and tobacco commodities, progress in areas of prevention and control of NCDs will remain elusive.
Text S1 Unweighted trends in unhealthy commodities, by geographic region, 2000 2010 and 20102015. (DOC) Text S2 Trends in tobacco and alcohol
commodities, 19972010 and projected to 2016. (DOC)

Text S3
Relationship between projected percentage increase in soft drink consumption and GDP, year 20102015, 76 countries. (DOC) consumption of soft drinks and GDP, year 2010, 74 countries. (DOC)
Text S4 Relationship between per capita
Text S5
A note on economic growth and tobacco consumption. (DOC)
Text S6 Replication of Table 2, highand low-foreign direct investment/GDP. (DOC) Text S7 Free-trade agreements and soft drink consumption, 35 LMICs, year 2010. (DOC) Text S8 Association of packaged food volume (per capita) with sugar, fat, and salt consumption per capita and obesity and diabetes prevalence, 2005. (DOC)
Text S9 Three population-level quasinatural experiments of soft drinks, tobacco, and alcohol consumption. (DOC)
Analyzed the data: DS SB SE MM. Wrote the first draft of the manuscript: DS. Contributed to the writing of the manuscript: DS MM SB SE. ICMJE criteria for authorship read and met: DS MM SB SE. Agree with manuscript results and conclusions: DS MM SB SE. All authors contributed to the interpretation of the data.
Acknowledgments
The authors are grateful for helpful comments by Robert Beaglehole.
References
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Policy Forum
Big Food, the Consumer Food Environment, Health, and the Policy Response in South Africa
Ehimario U. Igumbor1*, David Sanders1, Thandi R. Puoane1, Lungiswa Tsolekile1, Cassandra Schwarz1, o3, Corinna Hawkes4 Christopher Purdy2, Rina Swart3, Solange Dura
1 School of Public Health, University of the Western Cape, Bellville, South Africa, 2 Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America, 3 Department of Dietetics, University of the Western Cape, Bellville, South Africa, 4 Centre for Food Policy, City University, London, United Kingdom
Summary Points
N N N N N
Introduction
Despite continuing high levels of underweight and nutritional deficiencies [1], overweight and obesity among both adults and children is a rapidly growing public health problem in South Africa [2,3,4,5]. In 2000, an estimated 36,504 deaths (7% of all deaths) in South Africa were attributed to excess body weight [6], and in 2004 non-communicable diseases (NCDs) linked to dietary intakecardiovascular diseases, diabetes mellitus, cancerstogether with respiratory diseases contributed 12% of the overall disease burden [7]. Paralleling this increase in overweight/ obesity, there has been a steady increase in the per capita food supply of fat, protein, and total calories in South Africa [8,9] and salt intake appears to also be in excess of recommended levels [10]. These changes of nutrient intake appear to be associated with changes in dietary patterns. So, for example, a study of adults in the North West Province showed a shift with increasing wealth from a traditional high carbohydratelow fat diet (in which maize made the largest contribution to energy intake) to a higher-fat diet in which maize was replaced by red meat and other cereal foods [11]. In recent years, there has also been an increase in the sales of almost all categories of packaged foods in South Africa (Table 1).
In South Africa, as in other jurisdictions, Big Food (large commercial entities that dominate the food and beverage environment) is becoming more widespread and is implicated in unhealthy eating. Small food remains significant in the food environment in South Africa, and it is both linked with, and threatened by, Big Food. Big Food in South Africa involves South African companies, some of which have invested in other (mainly, but not only, African) nations, as well as companies headquartered in North America and Europe. These companies have developed strategies to increase the availability, affordability, and acceptability of their foods in South Africa; they have also developed a range of health and wellness initiatives. Whether these initiatives have had a net positive or net negative impact is not clear. The South African government should act urgently to mitigate the adverse health effects in the food environment in South Africa through education about the health risks of unhealthy diets, regulation of Big Food, and support for healthy foods. Coca-Cola products per person per year, an increase from around 130 in 1992 and 175 in 1997 [13,14]. In 2010, up to half of young people were reported to consume fast foods, cakes and biscuits, cold drinks, and sweets at least four days a week [4]. Carbonated drinks are now the third most commonly consumed food/drink item among very young urban South African children (aged 1224 months)less than maize meal and brewed tea, but more than milk [15]. It can be hypothesised that various strategies adopted by Big Food to
For example, sales of snack bars, ready meals, and noodles all rose by more than 40% between 2005 and 2010. In addition, a recent assessment of the consumption of street food (sold by vendors) and fast food (from formal fast food outlets) revealed that, nationally, 11.3% of the population bought food from street vendors and 6.8% bought food from fast food outlets at least two times a week [12]. South Africans are also increasing their consumption of soft drinks. Compared with a worldwide average of 89 Coca-Cola products per person per year, in 2010 South Africans consumed 254
Citation: Igumbor EU, Sanders D, Puoane TR, Tsolekile L, Schwarz C, et al. (2012) Big Food, the Consumer Food Environment, Health, and the Policy Response in South Africa. PLoS Med 9(7): e1001253. doi:10.1371/ journal.pmed.1001253 Published July 3, 2012 Copyright: 2012 Igumbor et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: No specific funding was received for writing this article. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: CSR, corporate social responsibility; NCD, non-communicable disease. * E-mail: ehi.igumbor@gmail.com Provenance: Commissioned; externally peer reviewed.
increase the availability, affordability, and acceptability of their products have contributed to these dietary changes in South Africa and to the increased burden of obesity and NCDs (Figure 1). In this context, in this article we provide an overview of Big Food in South Africa. We use the term Big Food as shorthand for large commercial entitiesboth multinational and nationalthat increasingly dominate key components of the food and beverage environment. We include companies that have an identity with consumersmanufacturers, retailers, and food outletsrather than agribusiness and primary processors. Although many authors have written on Big Food in the US, the UK, and other developed nations, much less has been written about their operations and practices in developing countries experiencing significant transitions. As such, this article contributes to filling a gap in the literature and provides similar nations with a process for examining the role of Big Food in health and nutrition. Our article draws on information published in the academic literature, reviews of food industry documents, data compiled by market research agencies, and data from pilot studies conducted by researchers at the University of the Western Cape, South Africa.
We first present data on the presence of Big Food in South Africa, then examine some of the strategies used by large food corporations to change the consumer food environment in South Africa. We argue that these strategies aim to alter the availability, affordability, and acceptability of foods produced and sold by Big Food (Figure 1). Finally, we discuss the responses to health concerns made by both Big Food and the South African government, and briefly explore the policy implications.
which have an international presence. Pioneer Foods, for example, has a presence in four south and east African nations, is a leading exporter, and has joint ventures with Heinz (US) (as Heinz Foods South Africa) and with a UK-based ingredients company. Many other South African companies have likewise developed joint ventures with foreign companies, such as Simba with Frito-Lay (PepsiCo, USA) and Clover with Danone Groupe (France).
Soft Drinks Big Food in South Africa Packaged Foods

Although there are over 1,800 food manufacturing companies in South Africa, Big Food manufacturers account for a disproportionately large amount of sales [16]. The largest ten packaged food companies in South Africa account for 51.8% of total packaged food sales (Table 2), whereas artisanal packaged processed foods (products sold at the site of production, commonly bakery products), contribute only 7.3% of total sales [17,18]. This is greater than the global average (globally in 2007, ten companies accounted for around 26% of the processed foods market) [19]. Five of the top ten food manufacturing companies are South African, three of The top ten soft drink companies account for 79% of the total soft drink sales in South Africa. Three companies Coca-Cola Co., PepsiCo Inc., and Danone Groupe account for 64.7% of the market between them, with the other top companies each contributing less than 3.5% [20]. All three market leaders are major transnational companies but are linked with South African companies. For example, Coca-Cola is bottled by SABMiller, a division of AVI, and PepsiCo is manufactured by Pioneer Foods under license. By far the largest player is Coca-Cola (49.8% of total soft drink sales). Coca-Cola has been a dominant presence in South Africa for decades, including during the apartheid era when it distributed its products from Swaziland. After apartheid
Table 1. Volume of sales of select leading categories of packaged foods, 2010, and rate of increase 200510.
Category of Packaged Foods Bakery Meal solutions
Subcategory
Sales Volume* 2009.3 547.2
Rate of Change of Sales Volume (%), 200510 16.2 18.5 16.2 18.2 22.8 27.0 43.1 32.6
Canned/preserved food Frozen processed food Chilled processed food Sauces dressings and condiments Ready meals Soup Impulse and indulgence products Confectionery Sweet and savoury snacks Snack bars Ice cream Dried processed food Pasta Noodles Oils and fats Meal replacement Spreads Source: Euromonitor 2011 [17]. *in thousand tonnes, except for ice cream, which is million litres. doi:10.1371/journal.pmed.1001253.t001
241.8 102.1 95.9 88.1 70.1 11.1
119.4 87.9 1.9 76.0 345.4 62.9 7.4 343.6 0.6 28.8
16.3 27.5 42.6 14.7 22.8 35.0 44.5 14.9 9.6 23.9
Figure 1. Hypothesized link between Big Food and the consumer food environment. doi:10.1371/journal.pmed.1001253.g001
Table 2. Packaged Food Company Shares in South Africa, 2009.
Rank 1 2 3 4 5 6 7 8 9 10
Company Tiger Brands Ltd Unilever Group Parmalat Group Nestle SA Clover Ltd Dairybelle (Pty) Ltd Pioneer Food Group Ltd
Location of Company Headquarters South Africa UK/Netherlands Italy Switzerland South Africa South Africa South Africa
Contribution to Total Packaged Food sales (%) 17.2 4.9 4.8 4.6 4.6 4 3.7 2.8 2.8 2.4
Examples of Product Types Milling and baking, groceries, confectionery, beverages, value added meat products, fruit and vegetables, products for the food services sector Spices, sauces, dressings, margarine, teas, syrup and food solutions Dairy products including milk, yoghurt, ice cream and cheese, fruit juices Baby foods, drinks, breakfast cereals, chocolate, confectionery, coffee, dairy products, ice cream Dairy products, desserts, beverages such as fruit juices, nectars and ice teas Dairy products, fruit juices Baking aids, tea/coffee, breakfast cereals, biscuits, condiments, juices and acidic drinks, dried fruits, eggs Chocolate, candy, gum, biscuits, coffee, other grocery Coffee, tea, biscuits, potato chips, frozen fish and seafood products Drinks, savoury snacks
Cadbury Plc (bought UK/US by Kraft in 2011) AVI Ltd PepsiCo Inc South Africa US
Source: Derived from Euromonitor*, 2011 [17] In: Alexander et al 2011 [18]; company websites. *Euromonitor does not collect data on the informal sector (defined as sales that are not taxed). doi:10.1371/journal.pmed.1001253.t002
ended, Coca-Cola became a leading investor in the country [13].
(US$ 2 million) in 1993 to R80 million (US$ 11 million) in 2007 [13].
Food Service Outlets

In 2010, there were 8,661 fast food outlets in South Africa, 4,991 of which were owned by fast food chains, the remainder being independent outlets (Table S1). [17]. Although there are considerably more street stalls/kiosks than fast food outlets in South Africa, the number of transactions from fast food chains has increased significantly over past decades [13]. The fast food chains are dominated by South African companies that pre-date the presence of foreign transnationals. For example, Nandos (chicken) was established years before Yum! (which owns KFC) entered the market in 1994. Today, eight of the largest ten food service companies are South African. Two of these have expanded internationally: Famous Brands purchased Wimpy UK in 2007, and Nandos has worldwide franchising operations. Many of these fast food chains are linked with large soft drink companies through agreements concerning the drinks served in the restaurants: Wimpy and Nandos, for example, serve Coca-Cola products exclusively.
Big Food Strategies to Alter the Consumer Food Environment

Big Food manufacturers have worked to increase the market share for their products in South Africa and to increase per capita consumption by making their foods more available, affordable, and acceptable (Figure 1).
Making Their Foods More Available

Rising sales of packaged foods from large food manufacturers have gone handin-hand with the increase in market share held by Big Food retailers. Supermarket outlets have displaced traditional food retailers such as small convenience stores, public markets, and spazas (small informal shops often run from homes) as the primary place from which South Africans purchase their food in both urban and rural areas [22]. For example, a case study in the rural Ciskei region of the Eastern Cape found that 64.8% of households in villages used supermarkets [22]. The expansion of supermarkets into rural (and other lower income) areas has been greatly facilitated by their retail management and procurement models, which have allowed them to out-compete local wholesalers and small retailers on cost and quality in virtually all product offerings [23]. Big Food manufacturers depend on formal retail chains to make their manufactured products available [16]. As well as being the main source of staple products, supermarkets are the main sales channel for non-essential packaged foods such as meal solution products made by large food corporations. However, strategies to increase the availability of products made by large food manufacturers have also involved the informal retail sector. Informal traders sell soft drinks, dairy products, bakery products, and snacks such as chips (crisps) in urban settlements and rural areas [24], and Coca-Cola, in particular, has worked hard to increase product sales and consumption through this channel. Coca-Cola developed a strategy in the 1990s to double soft drinks sales by building up per capita consumption [25]. Making their products more available through informal stores was a crucial part of the strategy. They developed incentives for people to set up informal outlets in the townships, such as providing trolleys, lighting boards, point-of-sale display materials, and refrigeration equipment, and delivered the products direct to
4
the stores [17]. By 2005, around 95% of spazas were selling Coca-Cola products, with the drinks forming a large proportion of the turnover of these small outlets [26]. Similarly, although the amount of street foods purchased remains almost twice the amount purchased from formal fast food outlets [12], fast food chains have developed aggressive expansion strategies to make their products more available. For example, McDonalds only entered the South African market in 1995 but by 2001, it had 103 outlets. It now has 161 [13]. According to the company South Africa is one of the most successful markets in McDonalds international history. A record was set when South Africa opened 30 restaurants in just 23 months, at one stage opening 10 restaurants in 78 days [27].
Making Their Foods More Affordable

The presence of supermarket chains has also had an impact on food prices. When purchased through informal retailers, who usually procure their goods from wholesalers, the mark-up on some processed food products is as high as 39% [22]. This mark-up is frequently attributed to transport and distribution costs and to maintaining profit margins, but may also reflect the monopoly position of local stores in poor communities [22]. Big Food retailers have developed a completely different procurement strategy based on cutting out the traditional wholesalers, consolidating their suppliers, and dealing with larger volumes [23]. Today, as a result, food prices are lower in supermarkets than in traditional retail outlets, which makes both staple foods and the packaged foods produced by large manufacturers more affordable to local populations. Notably, however, healthier foods, which are more readily available in supermarkets than in small shops, typically cost between 10% and 60% more in supermarkets than less healthy foods when compared on a weight basis, and between 30% and 110% more when compared on the cost of food energy [28]. Refined cereals and foods with added sugar and fat are among the lowest-cost sources of energy in rural supermarkets, thus making nutrient-poor products such as biscuits, margarine, and oil-heavy snacks an effective means to cheaply consume energy while adding new and varied tastes to rural diets. Nutrient-dense foods such as lean meat, fish, fruit, and vegetables generally cost far more than these inexpensive processed food products. The price differentials among foods manufactured in South Africa by large
Retailers
One of the most dramatic changes in Big Food in South Africa has been the rise in supermarket retailers over past decades. Chain supermarkets now control over half of the retail share of the food market [20], which is dominated by four major chains (Shoprite, Pick n Pay, Spar, and Woolworths), all of which are South African (Table S2). Each of these companies owns several different supermarket brands, and all have expanded into other African countries.
Imports
South Africa is a net importer of various agricultural products and foods. In the past fifteen years, there has been a marked rise in imports of processed products. For example, the value of imported Bread, Pastry, Cakes, Biscuits and Other Bakers Wares increased from approximately R5 million (US$ 714,000; all conversions are based on the exchange rate at the relevant time) in 1992 to almost R250 million (US$ 36 million) in 2006 [21]. In addition, the import of ingredients used in processed foods has increased. For example, imports of whey, a by-product of cheese production that is used in baked products and sweet snacks, increased from R15 million
food corporations, small domestic companies, and imported equivalents have not been comprehensively studied. However, a small study of imported highly processed products (many of them produced by Big Food outside of South Africa) and locally produced equivalents (many of them made by South Africas largest food company, Tiger Brands) in the Shoprite, Pick n Pay, and Spar supermarket chains suggests a complex picture [29]. For all categories of processed food except breakfast cereals, the imported products were cheaper than the local equivalents in terms of average cost per 100 g, but the price differentials varied widely. So, for instant meals, the average cost per 100 g of imported products was R0.62 (US$ 0.09) less than locally produced products, whereas the price differential for salty snacks was R1.49 (US$ 0.21). Interestingly, although the imported products appear to be cheaper, their nutritional content appears to be better; products produced by domestic food companies tend to have higher sodium and total and saturated fat content than the imported equivalents (unpublished data) [29].
Making Their Foods More Acceptable

All the components of Big Food have marketing strategies to make their foods more acceptable to the South African population. Food manufacturers work in conjunction with supermarkets to develop sales promotions for their products. PepsiCo, for example, has specific promotions on its website for each of the large retailers [30]. Competitions are also very common on manufacturers websites. For example, the websites of both Nestle South Africa and Cadbury South Africa (now owned by Kraft Foods) contain competitions for their main chocolate brands [31,32]. Packaging is also used to promote products, with one of the more recent trends being statements on packages designed to appeal to health-conscious consumers. For example, Albany bread (a Tiger Brands company) promotes its products on the basis of health with statements like: Its a great source of fibre, and fortified with vitamins and minerals, and its cholesterol free and some of its products carry a low GI symbol [33]. Similarly, Nestle claim Simple Goodness High in Fibre on Maggi 2minute noodle packets [34], and Rama margarine (a Unilever brand) is sold with the claim Rama is a vital energy source, highly fortified with 8 GoodStartTM Vitamins, making it a highly nutritious margarine and spread [35].
Television advertising of food is widespread. According to data from the South African Advertising Research Foundation, between 2003 and 2005, children 715 years old watched 2.5 hours of TV per day, and were exposed to 24 minutes of advertising per day [36]. A study undertaken in 2006 that recorded 37.5 hours of childrens TV programming reported that 16% of the advertisements during this programming were for food products, and that 55% of these food-related advertisements were for foods of poor nutritional value such as refined breakfast cereals, sweets, and highsugar drinks [37]. In a recent pilot survey, researchers at the University of Western Cape identified eight food advertisements in 7 hours of childrens TV programming on the national TV channel SABC1 that they recorded in January 2012four for sweets, one for refined breakfast cereal, two for tea, and one for a milk product (unpublished data). Finally, although all Big Food engages in marketing in South Africa, expenditure on marketing campaigns tends to be higher by the transnationals than by South African companies. McDonalds and KFC, for example, spent more than four times than Nandos advertising their products in 2001 [13].
The generally weak national response to the influential promotion of these products is illustrative of the rudimentary status of South Africa health policy regarding regulation of the food environment. However, Dr. Motsoaledi recently convened a National Consultation on NCDs. One aspect of this consultation was a recognition of important upstream factors, including the changing food environment [40]. The government has also developed a number of limited policy responses in the key areas of product labelling, marketing to children, and product reformulation. Big Food has also responded in these key policy areas [41].
Product Labelling
Amidst concerns that claims made on food are superlatives and often ludicrous [42], the South African government changed the regulations on food product labelling in 2010. The Regulations Relating to the Labelling and Advertising of Foodstuffs, No. R. 146 of the Foodstuffs, Cosmetics and Disinfectants Act, 1972 came into effect on March 1, 2012 [41,43]. Under the regulations, nutritional labelling remains voluntary unless a claim is made on the product. However, the regulations require a standard format for the nutritional label when used, and statements such as A source of, High in, Low in, Virtually free of, or Free of specific nutrients are only permitted if strict criteria are met. Manufacturers may no longer use descriptive words such as x% fat-free, nutritious, healthy, healthful, wholesome, complete nutrition, or balanced nutrition. On a voluntary basis, several Big Food companies, including Tiger Brands, Spar, and Coca-Cola, use Guideline Daily Amount (GDA) labelling. These labels, like those used in other developed and developing countries, detail the quantity of specific nutrients in the products and the recommended daily allowance. Many Big Food companies also provide nutritional information on their websites.
Response to Health Concerns

Although it is not clear to what extent Big Food can be implicated in the changing diets and changing rates of obesity and related diseases in South Africa, it is perceived as at least partially culpable because of the strategies described in the previous section. Indeed, the South African Minister of Health, Dr. Aaron Motsoaledi, recently stated that Africans are eating more and more junk processed foods instead of their traditional diet, and wants to regulate junk food starting with reducing salt in bread and eliminating trans fats [38]. In response, Big Food has developed corporate social responsibility (CSR) programs that involve health. All the major food manufacturers and retailers in South Africa have active CSR programs, with Shoprite, Pick n Pay, Spar, and Woolworths having the most active examples. The focus of these programs varies, but they often have a strong focus on nutrition education. Fast food chains tend to focus more on sponsoring local sports teams and sports tournaments. For example, McDonalds was an official sponsor during the FIFA World Cup, which prompted critical comments by health and consumer organizations [39].
5
Food Marketing to Children

In 2007, the South African government included restrictions on food advertising to children under 16 years old in a draft Foodstuffs, Cosmetics & Disinfectants Act. The regulations envisaged that certain foods, categorized as non-essential to a healthy lifestyle (e.g., carbonated drinks, confectionery, potato chips [crisps], certain fast foods), would be prohibited from being advertised or promoted to children in any manner. The regulations would also have prohibited cartoon-type characters,
puppets, animation, tokens, or gifts in the advertisement or promotion of any foodstuff to children, and some foodstuffs such as soya and dairy products would have had to carry labels advising consumers to use the product in moderation and warning that excessive consumption on a regular basis may lead to poor health. However, the Department of Health put the implementation of its proposed regulations (which were reported to have caused much heated debate in view of the many severe restrictions that they contained and their potential far-reaching effects [44]) on hold, deciding instead to wait for the publication of the 2010 WHO Set of Recommendations on Marketing Food and Non-Alcoholic Beverages to Children [45]. The South African government has yet to publish any regulations of its own, although it is reported that it is still deliberating on its intended course of action [46]. Meanwhile, Big Food has taken voluntary action on food marketing to children. In 2009, the South Africa Pledge on Marketing to Children was established. An initiative of the Consumer Goods Council of South Africa, it has 24 signatories, including food manufacturers, retailers, and fast food chains. The Pledge is similar to pledges made in Europe (EU Pledge) and elsewhere, but covers only advertising on TV and in schools to children under age 12 [47]. Companies do not appear to have made specific commitments to the pledge, and no monitoring report has been released.
KFC South Africa says it eliminated all trans fatty acids from its food products in August 2009 [51]. Big Food is also taking voluntary action. Unilever South Africa, for example, states that: We are committed to improving the fat composition of our products by reducing saturated fat as much as possible and increasing levels of essential fats. All of our Flora margarine and our Rama Original and Spread for Bread tubs already contain less than 33% saturated fat as a proportion of total fat [47]. Fast food outlets in South Africa also have salads and other healthier items on their menus.
sales channel for the products produced by food manufacturers. Big Food in South Africa is increasingly developing health and wellness initiatives. The outcome of these initiatives is not yet clear: they may have a net positive impact but if they offset more rigorous government action they may have a net negative impact.
Conclusions
The combined processes of rapid urbanisation, concentration of ownership of food production and distribution, and globalisation of food trade have resulted in rapid changes in the South African food environment. This article has focused on Big Food and attempted to bring together what is known about large food corporations in South Africa in the context of concerns about unhealthy eating and associated ill health. Although it provides an incomplete picture, it yields the following observations about Big Food in South Africa:
N N
Product Reformulation
The Ministry of Health is currently developing a salt reduction initiative that will gradually reduce salt levels in several highly consumed products, including bread, gravies and spices, brine chicken, cereal, margarine, and salty snacks, over a ten-year period [48]. It has been estimated that reducing the salt content in bread alone could prevent 6,500 deaths [48]. The Department of Health also limited the use of artificial trans fats to a maximum of 2% of oil or fat in all foods in its Regulations Relating to Trans Fats in Foodstuffs No, R 127 published in 2011[49]. These regulations specifically refer to synthetic trans fats and apply to all foodstuffs sold, manufactured in or imported into South Africa, as well as food prepared in restaurants, fast food outlets, and the catering industry. Woolworths were reported to be the first retailer to have removed trans fats from their entire brand product range (in 2007) [50], and
It has strong similarities with Big Food in other jurisdictions: its big, its getting more widespread, and its implicated in unhealthy eating. It consists of large packaged food and soft drink manufacturers, large retailers, and food outlets. These different components of Big Food are linked through various pathways. While small food remains significant in the food environment in South Africa, it is both linked with, and threatened by, Big Food. It involves both foreign transnationals and South African companies. Many of the South African Big Food companies, particularly the supermarket chains, have invested in other African nations and around the world. This suggests that South African Big Food may become a more important global player in years to come and that global attention on Big Food should focus both on companies whose headquarters are in North America and Europe and on companies whose headquarters are in developing nations. Supermarkets must not be forgotten as a key component of Big Food in South Africa, where they constitute a major
It is clear that urgent action is required to mitigate the adverse health effects of the changing food environment in South Africa. We suggest that this action should include a combination of accelerated efforts to educate the public about the adverse consequences of consuming easily available but unhealthy foods and greater regulation of Big Food and the strategies it employs to increase the availability, affordability, and acceptability of foods associated with unhealthy diets. The policy response to Big Food should also recognise the role of local and possibly subcontinental governance (e.g., the Southern Africa Development Community governments) in addressing the issue. In conclusion, we suggest that the South African government should develop a plan to make healthy foods such as fruit, vegetables, and whole grain cereals more available, affordable, and acceptable, and non-essential, high-calorie, nutrient-poor products, including soft drinks, some packaged foods and snacks, less available, more costly, and less appealing to the South African population. Some of these approaches may require engagement with Big Food. But elsewhere, clear rules and regulations are needed. Discussions about the regulation of promotional activities and about imposing taxes on unhealthy food products would be a good place to start.
Table S1 Ten largest food service companies in South Africa. (DOC) Table S2 Supermarket value sales, number of outlets, and company shares by value in South Africa 20072009. (DOC)
Wrote the first draft of the manuscript: EUI DS LT CS CP SD. Contributed to the writing of the manuscript: EUI DS TRP LT CS CP RS SD CH. ICMJE criteria for authorship read and met: EUI DS TRP LT CS CP RS SD CH. Agree with manuscript results and conclusions: EUI DS TRP LT CS CP RS SD CH.
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PLoS Medicine Series on Big Food

Food Sovereignty: Power, Gender, and the Right to Food

June 2012 | Volume 9 | Issue 6 | e1001246

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001246

Big Food, Food Systems, and Global Health

Public Health Response to Big Food: A Failure to Act

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001242

Engaging with Big FoodThree Views

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001242

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001242

Food Sovereignty: Power, Gender, and the Right to Food

Power over Food

Gender and Food

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001223

Systemic Inequity and the Right to Food

Box 1. La Via Campesina

PLoS Medicine | www.plosmedicine.org

The Role of Markets and Governments

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001223

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001223

PLoS Medicine | www.plosmedicine.org

July 2012 | Volume 9 | Issue 7 | e1001252

Box 1. Big Food, Big Snack, and Ultra-Processed Products

regions that still retain traditional food systems and supplies.

Traditional Brazilian Dietary Patterns

Big Food and Big Snack Move In

PublicPrivate Food Partnerships

Protecting and Improving Traditional Food Systems

PLoS Medicine | www.plosmedicine.org

July 2012 | Volume 9 | Issue 7 | e1001252

PLoS Medicine | www.plosmedicine.org

July 2012 | Volume 9 | Issue 7 | e1001252

Thinking Forward: The Quicksand of Appeasing the Food Industry

July 2012 | Volume 9 | Issue 7 | e1001254

PLoS Medicine | www.plosmedicine.org

July 2012 | Volume 9 | Issue 7 | e1001254

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001241

How Did Tobacco Companies Employ CSR?

PepsiCos Refresh Project and Change4Life

Snapshots of Soda Company CSR and Cause Marketing Campaigns

Box 1. Internet Presence of Soda Industry CSR Campaigns

Soda and Tobacco CSR: How Do They Compare?

Coca-Colas Live Positively

Tobacco and Soda Tactics Seek to Prevent Regulation

Implications for Public Health Advocates

Soda Is Employing CSR Sooner Than Big Tobacco

Spanish translation of the abstract. (DOCX)

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001241

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001241

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001241

PLoS Medicine | www.plosmedicine.org

June 2012 | Volume 9 | Issue 6 | e1001235

than are currently available through survey-based measurements.