Building H #80: Have you met the Commercial Determinants of Health?

Last September, the Food and Drug Administration, eying those high-sugar, low-fat snacks and cereals labeled “healthy” in big green type, proposed a new standard for using the word. Too much sugar or salt, and manufacturers would have to remove the word “healthy” from their labels, or reformulate their products to meet the new standards.

In a flurry of public comments submitted this past February, the food industry claimed to applaud the intent but denounced the details. Cereal manufacturers like Kellogg's and General Mills, the Sugar Association, the Association for Dressings and Sauces, Campbell Soup Company, Pickle Packers International, and dozens of other groups weighed in, each with their own helpful suggestions on how the final standard should be revised, to their own advantage.

But none showed their hand so plainly as Conagra, the $11 billion food giant behind Duncan Hines, Slim Jim, Bird’s Eye, Frontera, and - ahem - the Healthy Choice line of frozen meals. “If the food does not taste good, people will not buy it,” Conagra’s comment said. Calling the new standard “unachievable,” the company threatened that “Conagra cannot continue to invest in ‘healthy’ innovation if we are not able to meet the necessary taste, eating trends, and affordability our consumers expect.”

The FDA is now officially considering the comments before issuing a final standard, a process that could still take many months. But the backlash shows just how difficult it is to shift companies away from selling people stuff that tastes good and that they will buy, regardless of whether it’s healthy. Or, in the case of Healthy Choice, selling people something that’s loaded with sugar (the Healthy Choice Barbecue Seasoned Steak With Potatoes meal has 16 grams per serving, six times the proposed new standard of 2.5 grams per serving) but pretending that it’s perfectly healthy, too.

This new standard comes as the FDA attempts to do something - anything -  to counter the growing tide of obesity in the U.S., which is projected to approach 50% of adult Americans by 2030. So yes, Conagra is 100% accurate when it laments the FDA’s new definition a “paradigm shift” - one that's long overdue.

This is not a fair fight. The products lining America’s grocery shelves represent decades of chemical engineering and industrial design and product optimization and billions of dollars in marketing and advertising. This bounty is exquisitely engineered to hack our minds, as Robert Lustig has phrased it.  Indeed, it’s fair to argue that the FDA’s mandate here falls not just under its obligation to provide nutritional guidance but under its duty to ensure food safety. Because if the foods we eat are directly leading to soaring rates of obesity, diabetes, and heart disease, then aren’t these foods in fact unsafe for the American public?

This seems like a radical argument - but it gets some support from the growing recognition in academic and policy circles that healthy is determined by the products we consume. The new academic phrase for this is the “commercial determinants of health” (or CDoH for short) - an analogy to the widely used social determinants of health. It’s a fairly new term, showing up sporadically in scholarly papers only over the last three or four years.

But a few days ago, the idea got a huge boost when the Lancet published a special issue devoted to the topic. Anchored by public health researchers from the University of Bath and University of Melbourne, the series presents a new framework for how to engage with and contest the broader commercial context that plays such a massive role in the public’s health.

“Health does not begin in clinics or hospitals any more than justice begins in law courts or peace starts on the battlefield,” writes Tedros Adhanom Ghebreyesus, the director general of the World Health Organization in a commentary. “Rather, health starts with the conditions in which we are born and raised, and in schools, streets, workplaces, homes, markets, water sources, kitchens, and in the very air we breathe.”

The report goes beyond those four “bad actor” industries - tobacco, unhealthy food, fossil fuel, and alcohol - that are believed to be responsible for at least a third of global deaths per year. Rather the authors hold a wide swath of the global economy accountable for health, including:

Pharmaceuticals

Automobiles

Weapons

Extractives

Social media

Banking

Insurance

Education

Transportation

Information technology

Software

Law

Construction

Health care

Real estate

As this paper notes, “the interests of these industries are often pursued with the support of business-friendly think tanks, lobbyists, law firms, public relations and advertising agencies, tax accountants, and other professional services. Therefore, these and other industry sectors can be conceptualised as commercial determinants of health, and their practices deserve scrutiny.”

Readers of this newsletter are well acquainted with the ideas at play here, but what’s important about the Lancet series is how it is the first significant codification of the idea in academic literature and research. This means that a discipline can emerge around the problem, and that the problem itself can be commonly and widely understood (we at Building H are especially grateful for this, since we spend a great deal of our time explaining the problem and the vector).

For instance, the series offers a succinct definition of the term “Commercial Determinants of Health”: “the systems, practices, and pathways through which commercial actors drive health and equity.” This is succinct and useful, if - like the “commercial determinants of health” term itself - a bit wonky. But again, to the extent that it offers a framework for the public health and academic community to work against, we’re all for it (even as we’ll argue that it won’t do much to inspire the lay community or the corporate audience).

Moreover, the series likely will encourage more schools of public health to build out courses, or even programs, around these forces. This lets students see that there are other vectors for attacking the problem other than traditional routes of healthcare, policy, or public health departments. Making it clear where the problem happens, making the problem visible, is a massive first step.

There’s bound to be blowback here. A huge challenge that the series rightly puts forward is that industry actors are going to use all their power to preserve the status quo. They will not shift their practices without a fight, nor without a compelling reason to pursue anything other than their “taste great so people buy it” mantra. As the tempest over the word “healthy” demonstrates, commercial industry will put their massive resources - including billions of dollars spent on investment, production, marketing, and labor - to protect their profits. This is going to take a lot of work.

All in all, the Lancet series represents a significant leap forward in codifying the Commercial Determinants of Health, and a powerful framework for how to meaningfully bring more industries and actors to account for the challenge of the public health. At Building H, we’re going to avoid leaning too much on the whole CDoH framework and jargon, since it is intended for the academic research community. Our mandate, meanwhile, is to speak in the vernacular of those whose products and services we seek to change, which we believe is an essential missing piece in this effort. That said, we consider anyone engaged in the CDoH to be a comrade in arms, and we look forward to finding more shared discourse and opportunities.

It’s dense stuff, but worth digging in to the whole series. Let us know your thoughts — comments are open.

Read the full newsletter.