The rise in cardiometabolic diseases is linked to the availability of unhealthy products from industry, such as ultraprocessed foods, and studying the efficacy of intervention strategies against these products must be high on the research agenda.
In recent decades, the world has witnessed soaring rates of heart disease, diabetes and complications arising from obesity. Historically, these diseases were most prevalent in high-income countries (HICs), but they are now rising at alarming rates in low- and middle-income countries (LMICs). In this issue, Nature Medicine launches a Focus, in conjunction with Nature Metabolism, on the global epidemic of cardiometabolic diseases, touching on topics ranging from fatty liver disease to the relationship between economic factors and the rise of cardiometabolic disease in LMICs. These articles highlight what is known and unknown about the factors underlying the rise of these diseases, and what can be done to further understand these factors and reverse the current trend. Although in past analysis of this trend there has been an emphasis on personal choices contributing to cardiometabolic disease, there is increasingly discussion about societal responsibility in turning the tide against these illnesses.
Cardiometabolic diseases are linked to the consumption of ultraprocessed food and alcohol and the level of physical activity, among other factors. Many ultraprocessed foods are high in carbohydrates and, notably, the Prospective Urban Rural Epidemiology study found that higher carbohydrate intake was associated with higher morbidity across 18 LMICs and HICs. Furthermore, a recent study showed that consuming ultraprocessed foods is linked to increased caloric intake and weight gain—the latter of which is a risk factor for cardiometabolic diseases.
Although concerted research efforts have advanced our understanding of links between a diet of ultraprocessed foods and cardiometabolic diseases, there are commercial forces driving the increase in this collection of illnesses that have been far more difficult to identify and comprehend. The companies responsible for producing unhealthy foods, and making them widely available, are recognizable global brands that sit high in the Fortune 500. The strategies they use to distribute and promote their products that in turn influence global health have been dubbed the “commercial determinants” of health.
The tactics employed by companies to promote products like ultraprocessed foods are multifaceted. They range from marketing of unhealthy products to children to virtue signaling through support of vaccine distribution, as Coca-Cola has done with the Global Fund, to the infiltration of government policy making. The New York Times recently reported that a trustee of the industry-funded nonprofit International Life Sciences Institute (ILSI) advised the Indian government against going ahead with warning labels on unhealthy foods, raising concerns about the influence of ILSI’s sponsors on government policy. In the UK, the nonprofit Drinkware works with the government agency Public Health England to create public health campaigns, yet is funded by the alcohol industry, a clear conflict of interest.
Governments have sought to counteract the negative effects of commercial determinants of health, for example by influencing consumer choice by making unhealthy foods more expensive. The sugar-sweetened beverage tax in Mexico is one such example, with the tax shown to reduce consumption of sugary beverages after their introduction in 2014. Similar taxes have been introduced in Colombia and in the city of Philadelphia with similar results.
Although these initiatives are promising, they have yet to be globally adopted. Some governments argue that there is no direct evidence to show that reduced consumption leads to reductions in the incidence of obesity or diabetes. It is perhaps too soon to see direct health outcomes from interventions such as the sugary beverage tax, but policymakers are eager to have evidence about which interventions might work best. This is one reason that the attention of researchers must be directed to answering this question. The taxation of junk foods is an ongoing real-world experiment, and the research community must ensure that the effects of this and other interventions are accurately and prospectively tracked. Governments that have pushed for such interventions should ensure that they also fund this scientific work. Meanwhile, studies that conduct surveys of large cohorts to expand our understanding of the role of nutrition in disease should ask participants specifically if the food they consume is ultraprocessed or homemade. Surveys and nutrition studies will be more informative when they ask more specifically about ultraprocessed foods.
Industry also needs to further regulate itself and extract its influence from research where it is inappropriate. For example, in 2018, the food manufacturer Mars withdrew its funding from ILSI, stating that it could no longer be involved in “advocacy led studies.” At the same time, governments and international stakeholders must impose strict limits on the promotion of unhealthy products to vulnerable populations and must oversee their appropriate distribution. Most importantly, regulators need to consider who is given a seat at the table when it comes to developing guidelines and policies for health, and any potential conflicts of interest they might have. The commercial determinants of health have long been operative, and our further regulation and understanding of their influence will in turn increase our understanding of their negative influence on health, and eventually lead to prevention.