Public-Private Partnerships in Mexico: Implications of Engaging With the Food and Beverage Industry for Public Health Nutrition.

BACKGROUND: In the last few years, Mexico adopted public health policies to tackle non-communicable diseases (NCDs), such as front of package nutrition labelling, food marketing restrictions to children, and a soda tax. In parallel, transnational food and beverage industries (F&BIs), their allies, and the government have agreed on public-private partnerships (PPPs) to implement policies or deliver programs. However, research has questioned the benefits of PPPs and exposed its limitations as a suitable mechanism to improve public health. This study analyses how four PPPs between the Mexican government, the F&BI, and allies are working to achieve their goals. We critically assessed the objectives, scope, reported impacts, governance principles and perceived risks and benefits for the public health agenda of these PPPs. METHODS: This qualitative study is based on 26 interviews with key actors, and 170 publicly available documents, including 22 obtained through freedom of information (FOI) requests related to four purposively selected PPPs aiming to improve health. RESULTS: We found that the four PPPs studied had minimal public information available on their implementation and impact. The private partners tend to dictate the design, information management, and implementation of the programs, while promoting their brands. Few independent evaluations of the PPPs exist, and none reported on their effectiveness or public health benefits. Good governance principles, such as accountability, transparency, fairness, participation, integrity, and credibility, were barely followed in each of the cases studied. Public officials did not automatically question the conflict of interest (CoI) of such arrangements. When there were COI, the potential risks these posed did not always outweigh the financial benefits of working with the F&BI and its allies. CONCLUSION: The four PPPs studied produced minimal gains for public health while boosting credibility for the participating transnational F&BIs. It shows the lack of awareness of how these PPPs might be hindering public health gains.

Policy networks and competing interests in the development of the Mexican sugar-sweetened beverages tax.

INTRODUCTION: Sugar taxes threaten the business models and profits of the food and beverage industry (F&BI), which has sought to avert, delay or influence the content of health taxes globally. Mexico introduced a sugar-sweetened beverage (SSB) tax in 2014 and other regulatory measures to improve population diets. This paper examines how policy networks emerged within and affected the development and implementation of the Mexican SSB tax. METHODS: This qualitative study analyses 31 interviews conducted with key stakeholders involved in the soda tax policy process and 145 documents, including grey literature and peer-reviewed literature. The policy network approach was used to map contacts, interconnections, relationships and links between the state, civil society and commercial actors involved in the SSB tax. These findings were used to examine the responsiveness, participation and accountability of the soda tax policy formulation. RESULTS: Complex interconnections were identified between state and non-state actors. These included advisory relationships, financial collaborations and personal connections between those in high-level positions. Relationships between the government and the F&BI were not always disclosed. International organisations and academics were identified as key financial or technical supporters of the tax. Key governance principles of participation, responsiveness and accountability were undermined by some of these relationships, including the participation of non-state actors in policy development and the powerful role of the F&BI in evaluation and monitoring. CONCLUSION: This case study exemplifies the importance of links and networks between actors in health policymaking. The F&BI influence endangers the primary aim of the SSB tax to protect health. The identified links highlight the normalisation of connections among actors with competing aims and interests toward health, thereby jeopardising attempts to tackle obesity rates.

Barriers to Overcoming Child Hunger and Malnutrition: Applying a Human Rights Approach to Improve Policy and Action.

Objective: Analyze key barriers to achieving children's right to food under Colombia's food and nutrition security policies and programs. Methods: A literature review was conducted along with 17 semi-structured expert interviews. The law framework on the right to food was applied to analyze findings. Results: Four key barriers were found. First, a reductionist approach prevails in the political narrative. This focuses on ensuring personal food access overlooking societal and environmental impacts. Second, the implementation of policies and programs is passed on to third parties, preventing civic participation and accountability. Third, there are insufficient national data sources and indicators to monitor the impact of interventions and funding. Fourth, program implementation is unequal and inadequate, which inadvertently supports illicit economies that thrive on conditions of hunger and poverty. Conclusion: Children's food and nutrition are reliant on organizations that focus on personal food supply without strengthening civic participation. Strengthening participation requires a human rights approach. International organizations can help the government to engage communities in policy and program improvement and oversight.

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries.

OBJECTIVE: To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico. DESIGN: Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022). RESULTS: In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing. CONCLUSION: Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

A policy study on front-of-pack nutrition labeling in the Americas: emerging developments and outcomes.

Poor nutrition is one of the leading causes of non-communicable diseases (NCDs), especially in the WHO Region of the Americas (AMRO). In response, international organisations recommend front-of-pack nutrition labelling (FOPNL) systems that present nutrition information clearly to help consumers make healthier choices. In AMRO, all 35 countries have discussed FOPNL, 30 countries have formally introduced FOPNL, eleven have adopted FOPNL, and seven countries (Argentina, Chile, Ecuador, Mexico, Peru, Uruguay and Venezuela) have implemented FOPNL. FOPNL has gradually spread and evolved to better protect health by increasingly adopting larger warning labels, contrasting background devices for better salience, using "excess" instead of "high in" to improve efficacy, and adopting the Pan American Health Organization's (PAHO) Nutrient Profile Model to better define nutrient thresholds. Early evidence illustrates successful compliance, decreased purchases and product reformulation. Governments still discussing and waiting to implement FOPNL should follow these best practices to help reduce poor nutrition related NCDs. Translated versions of this manuscript are available in Spanish and Portuguese in the supplementary material.

The corporate capture of the nutrition profession in the USA: the case of the Academy of Nutrition and Dietetics.

OBJECTIVE: The involvement of unhealthy commodity corporations in health policy and research has been identified as an important commercial determinant contributing to the rise of non-communicable diseases. In the USA, health professional associations have been subject to corporate influence. This study explores the interactions between corporations and the Academy of Nutrition and Dietetics (AND), and their implications for the profession in the USA and globally. DESIGN: We conducted an inductive analysis of documents (2014-2020) obtained through freedom of information requests, to assess key AND actors' dealings with food, pharmaceutical and agribusiness corporations. We also triangulated this information with publicly available data. SETTING: The USA. PARTICIPANTS: Not applicable. RESULTS: The AND, AND Foundation (ANDF) and its key leaders have ongoing interactions with corporations. These include AND's leaders holding key positions in multinational food, pharmaceutical or agribusiness corporations, and AND accepting corporate financial contributions. We found the AND has invested funds in corporations such as Nestlé, PepsiCo and pharmaceutical companies, has discussed internal policies to fit industry needs and has had public positions favouring corporations. CONCLUSION: The documents reveal a symbiotic relationship between the AND, its Foundation and corporations. Corporations assist the AND and ANDF with financial contributions. AND acts as a pro-industry voice in some policy venues, and with public positions that clash with AND's mission to improve health globally.

Behavioral and normative beliefs that influence Mexican consumers to purchase packaged food in urban supermarkets.

OBJECTIVE: To identify the behavioral and normative believes factors that might have major influence on the decision to buy packaged foods in urban Mexican families. MATERIALS AND METHODS: We performed a cross-sectional study in four urban cities of Mexico. Participants responded a self-administered questionnaire (n=3 340) outside of randomly selected supermarkets. A factor analysis was performed to identify what were the main behavioral and normative believes explaining consumers' decision when buying packaged foods. RESULTS: Three factors explained the behavioral beliefs: the quality assessment of packaged foods explained 61% of the variance, products that maintain weight explained 25%, and the emotional experience with foods explained 13%. Three factors explained the normative beliefs: expectations of chil-dren and partner explained 46% of the variance, expectations from the participants' closest friends 23%, and expectation from other family members explained 14%. CONCLUSION: Behavioral and normative beliefs related to assessing the qual-ity of foods and meeting family expectations respectively are the main beliefs factors affecting consumers' packaged food purchase decisions in urban consumers.

Applying a Commercial Determinants of Health Lens to Understand, Expose and Counter Industry Co-option, Appeasement and Partnership Comment on "'Part of the Solution': Food Corporation Strategies for Regulatory Capture and Legitimacy".

Lacy-Nichols and Williams' examination of the food industry illustrates how it altered its approach from mostly oppositional to regulation to one of appeasement and co-option. This reflection builds upon this by using a commercial determinants of health (CDoH) lens to understand, expose and counter industry co-option, appeasement and partnership strategies that impact public health. Lessons learned from tobacco reveal how tobacco companies maintained public credibility by recruiting scientists to produce industry biased data, co-opting public health groups, gaining access to policy elites and sitting on important government regulatory bodies. Potential counter solutions to food industry appeasement and co-option include (i) understanding corporate actions of health harming industries, (ii) applying mechanisms to minimize industry engagement, (iii) dissecting industry relationship building, and (iv) exposing the negative effects of public private partnerships (PPPs). Such counter-solutions might help to neutralise harmful industry practices, products and policies which currently threaten to undermine healthy food policies.

Acknowledge the Elephant in the Room: The Role of Power Dynamics in Transforming Food Systems Comment on "What Opportunities Exist for Making the Food Supply Nutrition Friendly? A Policy Space Analysis in Mexico".

A paradigm shift is required to transform food systems, so they are more equitable, environmentally friendly, and healthy. This requires acknowledging which factors change or maintain the status quo. In this commentary, we reflect upon the Cervantes et al study findings and discuss the role of power dynamics in transforming food systems. This is directly relevant to Mexico in terms of (i) relationships between food system actors; (ii) the role of socio-economic political context; and (iii) opportunities for policy coherence and transformative food systems approaches. We suggest that the power dynamics that drive the food produced, sold, and consumed should be recognised in all (inter)national governance decision-making. The 2021 United Nations Food System Summit - when interest groups were perceived to overly influence the summit proceedings - is an example of how neglecting the role of power dynamics can undermine and slow food system transformation.

Behavioral and normative beliefs that influence Mexican consumers to purchase packaged food in urban supermarkets / Influencia de creencias conductuales y normativas en consumidores mexicanos para la compra de comida empaquetada en supermercados urbanos

Abstract: Objective: To identify the behavioral and normative believes factors that might have major influence on the decision to buy packaged foods in urban Mexican families. Materials and methods: We performed a cross-sectional study in four urban cities of Mexico. Participants responded a self-administered questionnaire (n=3 340) outside of randomly selected supermarkets. A factor analysis was performed to identify what were the main behavioral and normative believes explaining consumers' decision when buying packaged foods. Results: Three factors explained the behavioral beliefs: the quality assessment of packaged foods explained 61% of the variance, products that maintain weight explained 25%, and the emotional experience with foods explained 13%. Three factors explained the normative beliefs: expectations of children and partner explained 46% of the variance, expectations from the participants' closest friends 23%, and expectation from other family members explained 14%. Conclusion: Behavioral and normative beliefs related to assessing the quality of foods and meeting family expectations respectively are the main beliefs factors affecting consumers' packaged food purchase decisions in urban consumers.

Resumen: Objetivo: Identificar las creencias de comportamiento y normativas que tienen mayor influencia en las decisiones de familias urbanas en México para comprar alimentos empaquetados. Material y métodos: Se realizó un estudio transversal en cuatro ciudades urbanas de México. Los participantes respondieron un cuestionario auto-administrado (n=3 340) a la salida de los supermercados que fueron seleccionados aleatoriamente. Se realizó un análisis factorial para identificar los principales factores de las creencias de comportamiento y normativas que explican la decisión de comprar alimentos empaquetados. Resultados: Tres factores explicaron las creencias conductuales: la evaluación de la calidad de los alimentos empaquetados explicó el 61% de la varianza, productos para control de peso explicaron el 25% y la experiencia emocional con los alimentos el 13%. Tres factores explicaron las creencias normativas: las expectativas de la pareja e hijos explicaron el 46% de la varianza, las expectativas de amigos cercanos el 23% y las expectativas de otros familiares explicaron el 14%. Conclusión: En las creencias conductuales, la evaluación de la calidad de los alimentos y en las creencias normativas, la expectativa de la pareja y los hijos tienen gran influencia en la decisión de compra de alimentos empaquetados en los consumidores de los supermercados urbanos en México.

Conflicts of interest for members of the U.S. 2020 Dietary Guidelines Advisory Committee.

OBJECTIVES: To measure incidence of conflicts of interest (COI) with food and pharmaceutical industry actors on the advisory committee for the 2020- 2025 U.S. Dietary Guidelines for Americans (DGA) and assess the adequacy of current mechanisms to disclose and manage COI among the committee's members. DESIGN: We compiled longitudinal data from archival sources on connections between members of the DGA's advisory committee and actors. We hypothesed that these committee members, who oversee the science for the most influential dietary policy in the U.S, might have significant COI that would be relevant to their decision making. Disclosure of COI on this committee was recommended in 2017 by the National Academies of Sciences in order to increase transparency and manage bias, but public disclosure of the committee's COI does not appear to have taken place. SETTING: the committee was comprised of 20 experts. PARTICIPANTS: None. RESULTS: Our analysis found that 95% of the committee members had COI with the food, and/or pharmaceutical industries and that particular actors, including Kellogg, Abbott, Kraft, Mead Johnson, General Mills, Dannon, and the International Life Sciences had connections with multiple members. Research funding and membership of an advisory/executive board jointly accounted for more than 60% of the total number of COI documented. CONCLUSIONS: Trustworthy dietary guidelines result from a transparent, objective, and science-based, process. Our analysis has shown that the significant and widespread COI on the committee prevent the DGA from achieving the recommended standard for transparency without mechanisms in place to make this information publicly available.

Hollow Threats: Transnational Food and Beverage Companies' Use of International Agreements to Fight Front-of-Pack Nutrition Labeling in Mexico and Beyond.

In October 2019, the Mexican government reformed its General Health Law thus establishing the warning approach to front-of-pack nutrition labeling (FOPNL), and in March 2020, modified its national standard, revamping its ineffective FOPNL, one preemptively developed by industry actors. Implementation is scheduled for later in 2020. However, the new regulation faces fierce opposition from transnational food and beverage companies (TFBCs), including Nestlé, Kellogg, Grupo Bimbo, Coca-Cola, PepsiCo through their trade associations, the National Manufacturers, American Bakers Associations, the Confederation of Industrial Chambers of Mexico and ConMéxico. Mexico, as a regional leader, could tip momentum in favor of FOPNL diffusion across Latin America. But the fate of the Mexican FOPNL and the region currently lies in this government's response to three threats of legal challenges by TFBCs, citing international laws and guidelines including the World Trade Organization (WTO), Codex Alimentarius, and the North American Free Trade Agreement (NAFTA)/US-Mexico-Canada Agreement (USMCA). In this perspective, we argue that these threats should not prevent Mexico or other countries from implementing evidence-informed policies, such as FOPNLs, that pursue legitimate public health objectives.

Lacking Clarity or Strategic Ambiguity? Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases".

This commentary engages with Suzuki and colleagues' analysis about the ambiguity of multi-stakeholder discourses in the United Nations (UN) Political Declaration of the 3rd High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (HLM-NCDs), suggesting that blurring between public and private sector in this declaration reflects broader debates about multi-stakeholder partnerships (MSPs) and public-private partnerships (PPPs) in health governance. We argue that the ambiguity between the roles and responsibilities of public and private actors involved may downplay the role (and regulation) of conflicts of interest (COI) between unhealthy commodity industries and public health. We argue that this ambiguity is not simply an artefact of the Political Declaration process, but a feature of multi-stakeholderism, which assumes that commercial actors´ interests can be aligned with the public interest. To safeguard global health governance, we recommend further empirical and conceptual research on COI and how it can be managed.

Food and beverage industry interference in science and policy: efforts to block soda tax implementation in Mexico and prevent international diffusion.

Mexico is the largest soft drink market in the world, with high rates of obesity and type 2 diabetes. Due to strains on the nation's productivity and healthcare spending, Mexican lawmakers implemented one of the world's first public health taxes on sugar-sweetened beverages (SSBs) in 2014. Because Mexico's tax was designed to reduce SSB consumption, it faced strong opposition from transnational food and beverage corporations. We analysed previously secret internal industry documents from major corporations in the University of California San Francisco's Food Industry Documents Archive that shed light on the industry response to the Mexican soda tax. We also reviewed all available studies of the Mexican soda tax's effectiveness, contrasting the results of industry-funded and non-industry-funded studies. We found that food and beverage industry trade organisations and front groups paid scientists to produce research suggesting that the tax failed to achieve health benefits while harming the economy. These results were disseminated before non-industry-funded studies could be finalized in peer review. Mexico still provided a real-world context for the first independent peer-reviewed studies documenting the effectiveness of soda taxation-studies that were ultimately promoted by the global health community. We conclude that the case of the Mexican soda tax shows that industry resistance can persist well after new policies have become law as vested interests seek to roll back legislation, and to stall or prevent policy diffusion. It also underscores the decisive role that conflict-of-interest-free, peer-reviewed research can play in implementing health policy innovations.

Beyond nutrition and physical activity: food industry shaping of the very principles of scientific integrity.

BACKGROUND: There is evidence that food industry actors try to shape science on nutrition and physical activity. But they are also involved in influencing the principles of scientific integrity. Our research objective was to study the extent of that involvement, with a case study of ILSI as a key actor in that space. We conducted a qualitative document analysis, triangulating data from an existing scoping review, publicly available information, internal industry documents, and existing freedom of information requests. RESULTS: Food companies have joined forces through ILSI to shape the development of scientific integrity principles. These activities started in 2007, in direct response to the growing criticism of the food industry's funding of research. ILSI first built a niche literature on COI in food science and nutrition at the individual and study levels. Because the literature was scarce on that topic, these publications were used and cited in ILSI's and others' further work on COI, scientific integrity, and PPP, beyond the fields of nutrition and food science. In the past few years, ILSI started to shape the very principles of scientific integrity then and to propose that government agencies, professional associations, non-for-profits, and others, adopt these principles. In the process, ILSI built a reputation in the scientific integrity space. ILSI's work on scientific integrity ignores the risks of accepting corporate funding and fails to provide guidelines to protect from these risks. CONCLUSIONS: The activities developed by ILSI on scientific integrity principles are part of a broader set of political practices of industry actors to influence public health policy, research, and practice. It is important to learn about and counter these practices as they risk shaping scientific standards to suit the industry's interests rather than public health ones.

The political economy of sugar-sweetened beverage taxation in Latin America: lessons from Mexico, Chile and Colombia.

BACKGROUND: In Latin America, total sales of sugar-sweetened beverages (SSBs) continue to rise at an alarming rate. Consumption of added sugar is a leading cause of diet-related non-communicable diseases (NCDs). Coalitions of stakeholders have formed in several countries in the region to address this public health challenge including participation of civil society organizations and transnational corporations. Little is currently known about these coalitions - what interests they represent, what goals they pursue and how they operate. Ensuring the primacy of public health goals is a particular governance challenge. This paper comparatively analyses governance challenges involved in the adoption of taxation of sugar-sweetened beverages in Mexico, Chile and Colombia. The three countries have similar political and economic systems, institutional arrangements and regulatory instruments but differing policy outcomes. METHODS: We analysed the political economy of SSB taxation based on a qualitative synthesis of existing empirical evidence. We identify the key stakeholders involved in the policy process, identified their interests, and assess how they influenced adoption and implementation of the tax. RESULTS: Coalitions for and against the SSB taxation formed the basis of policy debates in all three countries. Intergovernmental support was critical to framing the SSB tax aims, benefits and implementation; and for countries to adopt it. A major constraint to implementation was the strong influence of transnational corporations (TNCs) in the policy process. A lack of transparency during agenda setting was notably enhanced by the powerful presence of TNCs. CONCLUSION: NCDs prevention policies need to be supported across government, alongside grassroots organizations, policy champions and civil society groups to enhance their success. However, governance arrangements involving coalitions between public and private sector actors need to recognize power asymmetries among different actors and mitigate their potentially negative consequences. Such arrangements should include clear mechanisms to ensure transparency and accountability of all partners, and prevent undue influence by industry interests associated with unhealthy products.

Non-communicable disease governance in the era of the sustainable development goals: a qualitative analysis of food industry framing in WHO consultations.

BACKGROUND: The UN system's shift towards multistakeholder governance, now embedded in the Sustainable Development Goals (SDGs), invites a broad range of actors, including the private sector, to the policymaking table. Although the tobacco industry is formally excluded from engagement, this approach provides opportunities for other unhealthy commodity industries to influence the World Health Organization's (WHO's) non-communicable disease (NCD) agenda. Focusing on the food industry, this research maps which actors engaged with WHO consultations, and critically examines actors' policy and governance preferences as well as the framing they employ to promote these preferences in the global context. METHODS: All written responses from food industry actors to publicly available NCD-relevant WHO consultations held between September 2015 and September 2018 were identified, totalling forty-five responses across five consultations. A qualitative frame analysis was conducted to identify policy positions expressed by respondents, as well as arguments and frames used to do so. RESULTS: Though no individual companies responded to the consultations, the majority of participating business associations had some of the largest multinational food corporations as members. Respondents overarchingly promoted non-statutory approaches and opposed statutory regulation and conflict of interest safeguards. To this purpose, they framed the food industry as a legitimate and necessary partner in policymaking, differentiating themselves from the tobacco industry and referencing a history of successful collaboration, while also invoking multistakeholder norms and good governance principles to portray collaboration as required. Respondents contrasted this with the limits of WHO's mandate, portraying it as out of step with the SDGs and framing NCD decision-making as a matter of national sovereignty. CONCLUSION: We observed that the UN's call for partnerships to support the SDGs is invoked to defend corporate access to NCD policy. This highlights the need for more cautious approaches which are mindful of the commercial determinants of health. Systematic opposition to regulation and to governance approaches which may compromise commercial actors' insider role in global health by food industry actors shown here, and the strategic use of the Sustainable Development agenda to this purpose, raises questions about the value of collaboration from the perspective of international health agencies such as WHO.