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By Matthew Rees

Food and Health Fact #198:

An interview with Trish Cotter

Trish Cotter is the global lead for the Food Policy Program at Vital Strategies, which works in partnership with governments throughout the world to reimagine evidence-based, locally driven policies and practices to advance public health. She has extensive experience aligning strategic communications to achieve policy and behavior change outcomes across several areas of public health including food policy, tobacco control, and cancer prevention and screening. She is the author of a recent article, “Time to Check Unfettered Power of Corporate Giants Over Health.” 

Are there elements of the strategy that succeeded in curtailing tobacco use that can be applied to help curtail consumption of ultra-processed foods? Absolutely. The multinational food and beverage companies have taken a page from tobacco’s playbook by using the same tactics to pull the wool over consumers’ eyes for decades. The huge opportunity for those working on nutrition policy is to recognize it cuts both ways. Public health has decimated the brand that is tobacco—we can use these successful strategies for combating ultra-processed foods.

Just like in tobacco, taxes are a win-win. They decrease consumption of sugary drinks and junk food and increase government revenue. Restrictions on marketing tobacco, such as bans on advertising, promotions and sponsorships were instrumental in de-normalizing smoking, and the same can be true for ultra-processed foods.

Front-of-package warnings labels, like the graphic health warnings and plain packaging of tobacco products, are extremely effective. Consumers usually spend only about 10 seconds selecting grocery items. Warning labels require almost no effort to read and can help consumers make healthier, split-second choices.

Finally, restrictions on where products can be sold and used, such as bans on smoking in public places, can be applied to ultra-processed foods too, such as banning ultra-processed foods, soda and sugar-filled drinks from schools.

One of the biggest lessons I learned from tobacco control was the power of strategic communication to not just reduce consumption but to shape a policy agenda. It’s all about attributing characteristics to a product. We flipped tobacco’s manufactured image of glamour and style to one of truth: That tobacco is a dangerous, addictive product that kills one in two of its long-term users.

We’ve spent over 50 years educating the public and policymakers on the harms of tobacco. We’re going to do the same for ultra-processed food products.

Are there national strategies anywhere in the world that have helped reduce ultra-processed food consumption? If so, which countries have had the greatest success? And what tactics have they used?
A great example is Chile. Their Law of Food Labeling and Advertising is one of the most progressive laws in the world. It introduced mandatory octagonal front-of-package warning labels for products high in salt, sugar, saturated fat and calories, as well as marketing restrictions and strict school sales policies for all ultra-processed foods. We’ve already seen a reduction in purchases of unhealthy products and evidence that the marketing restrictions reduced children’s exposure to unhealthy food ads.

We’ve also seen effective policies focused on a single issue like sugary drinks. Mexico was the first to tax beverages with added sugar and there have been reductions in purchases of sugar-sweetened beverages. South Africa’s tax, known as the Health Promotion Levy, was followed by reductions in the sugar, calories, and volume of beverage purchases.

Can you talk about the influx of ultra-processed foods in developing countries and what that’s doing to public health in those countries? It’s middle-income countries that are seeing the greatest rise in ultra-processed food purchases. As countries get richer, incomes rise. At the same time, fast food and other ultra-processed products are becoming both more affordable and more available. Multinational corporations have seized on a golden market opportunity.

It’s in lower- and middle-income countries that we are seeing the “nutrition transition,” or the move away from traditional diets and toward these ultra-processed, ready-to-eat foods. But as people eat more ultra-processed foods, we see an uptick in obesity and health problems like Type 2 diabetes, heart disease and stroke. Recent research even found that a large percentage of new cases of Type 2 diabetes was attributable to poor diet in 184 countries.

South Africa is experiencing this transition right now. Many multinational food and beverage companies, along with fast food chains, flocked to the country after apartheid fell, sensing the economic tide was turning. The consequences are clear. South Africa has seen the prevalence of diabetes increase from 4.5% in 2010 to 12.7% in 2019, which is approximately 4.58 million people aged 20–79.

It's happening all over the continent. Nature just published a commentary pointing to Nestlé’s hostile takeover of Africa. Faced with ballooning health care costs as a result of the health harms from poor diets, countries like South Africa are now playing catch-up. The Health Promotion Levy implemented in 2018 was a first step, and now there’s a strong push to implement front-of-package warning labels on unhealthy foods and beverages.

Can you talk about some of the victories Vital Strategies has helped deliver?
Strategic communication to spotlight the issue buoys citizens and policymakers and is the key to these policies being implemented. In all the countries where we work, we support the advocacy efforts of a dedicated, passionate and committed team of civil society organizations. The people that make up these coalitions are unrelenting in their efforts to implement healthy food policies and improve the health of their citizens.

In Barbados, South Africa and Mexico, our team at Vital supported the passage and implementation of sugar-sweetened beverage taxes through providing technical assistance to civil society and advocates in each of these countries. Specifically, in South Africa, before the tax was passed, we worked with a coalition of civil society groups and put out an extensive communication campaign to build support for the policy.

In Argentina, Brazil and Colombia, we’ve provided guidance to our partners for the implementation of front-of-package warning labels on foods and beverages high in salt, sugar, saturated fat and calories. Brazil is a good example. After the Brazil Health Surveillance Agency (ANVISA) convened stakeholders to develop a new food labeling system, Vital Strategies worked to create several years of communication campaigns with a coalition of advocates. These campaigns could be seen on billboards, heard on TV and radio and seen online to reach as many people as possible.

Can you give specific examples of misleading marketing of ultra-processed foods to the adult population? And to children? Ultra-processed food and beverage companies are guilty of selling an aspirational image or identity tied to their products, which, again, is the same as tobacco. In most markets they’re allowed to sell a fake reality to the unsuspecting consumer. Coca-Cola presents an image of happiness, a carefree life filled with parties, rather than work and responsibilities.

In real life, the product is a leading contributor to Type 2 diabetes and obesity and is a passport to a (shorter) life of health challenges. Going through a McDonald’s drive-thru with a car full of smiling kids or microwaving a meal for dinner ignores that these products may barely be foods at all. They’re also presented as a quick and easy solution to hectic schedules and busy lives. The image we see doesn’t reflect the reality of the product.

Kids are extremely vulnerable to marketing and cannot discern advertising intent. Multinational food and beverage companies have created targeted marketing strategies that influence kids through cartoons, bright colors and unnatural flavors.

How many parents realize the extent to which their kids are being bombarded by this marketing? Using kid-friendly characters on ultra-processed food and drink packaging has been shown to draw kids to certain products, like sugary yogurts or cereals. It makes sense: a child will usually want the product with Mickey on it, rather than blank packaging.

Adults are also drawn to certain ultra-processed foods and beverages through the same image-focused campaigns used by tobacco over half a century ago. Health and nutrition claims, not required to be supported by scientific evidence, are another commonly used tactic to influence adults to buy ultra-processed products, including those meant for children.

Given the widespread recognition that ultra-processed food is bad for the body, why do you think they are attracting a rising share of food spending throughout the world?
A growing middle class has been a prime target for multinational food companies. They have aggressively pursued this group of consumers by setting up fast food restaurants and filling stores with popular brands of chips and other snacks. Consumers are drawn to these products through targeted marketing practices that characterize ultra-processed foods as socially desirable, quick, easy, cheap and tasty.

I co-authored a commentary a few years back in BMJ that described how many consumers don’t even know the term “ultra-processed” because public health messaging has only focused on identifying specific nutrients (i.e., salt, sugar and fat) as unhealthy. This is why building a “brand” around the term “ultra-processed” is important. Public health experts can build meaning around the term “ultra-processed” to counter the louder industry narrative: easy, delicious foods that signify happiness and success.

Below is the label we developed along with our commentary. It clearly and succinctly identifies foods or beverages as ultra-processed, along with any other nutrients of concern. We want the ultra-processed label to be seen as just as necessary as other front-of-package warning labels to inform consumers at the point of purchase.

The companies that produce ultra-processed foods clearly don’t want their products to face new taxation or regulation. Can you talk about what they’re doing to try stifle reform?
Multinational food and beverage companies sing from the same song sheet as the tobacco companies. They’re not original, just really good at it. They use the same strategies over and over to obstruct, challenge and discredit legislation.

We’ve seen these companies draft industry-friendly policies that reach the legislature floor through mutually beneficial relationships with influential policymakers. They can also appear completely altruistic because of corporate donations or “social responsibility” campaigns tied to specific health issues.

Industry narratives are quick to blame taxation for job losses and other economic issues. When sugary drinks taxes are proposed, the industry is quick to warn consumers about future blows to employment because of the tax. However, this narrative has been disproven time and again. The beverage industry tried to push the job loss narrative in response to South Africa’s Health Promotion Levy, yet their claims were completely unfounded.

Marketing regulations, particularly those aimed at protecting children, have become a clear target. Instead of strict regulations that are supported by penalties, these companies have instituted voluntary pledges in place of real, enforceable legislation.

These agreements appear to be a step in the right direction, but they are largely ignored by influential food and beverage companies and exist in name only. This is why policymaking should be for government officials and public health experts, not food industry lobbyists.

The good news is there are policies that governments can pursue to protect consumers and improve health. As I mentioned earlier, front-of-package warning labels, sugary drink taxes and marketing restrictions are healthy food policies with demonstrated efficacy that both inform about the dangers of ultra-processed products and protect consumers from the insidious tactics of the food and beverage industry.