What’s Wrong with Mandatory Nutrient Limits? Rethinking Dietary Freedom, Free Markets and Food Reformulation

What’s Wrong with Mandatory Nutrient Limits? Rethinking Dietary Freedom, Free Markets and Food... Abstract Around the world, unhealthy diets are a leading cause of disease. Shifting population diets in a healthier direction will require downstream policy interventions. This means changing the composition of the processed food supply, particularly reducing salt, sugar and fat. Mandatory nutrient limits imposed by government are one way of achieving this. However, they have been criticized as a particularly intrusive regulatory option, interfering with both free markets and free choices. At the same time, voluntary industry reformulation has become an intervention favoured by national governments, the World Health Organization and the food industry. This article uses a comparison of the two interventions—which share a common public health goal, albeit achieved through different regulatory means—as a basis to evaluate the ethical charges against mandatory nutrient limits. It makes three main findings: (i) that both affect free dietary choice in very similar ways; (ii) that dominant public health ethics frameworks are not well equipped to compare mandatory and voluntary forms of regulation; and (iii) that food governance is inherently multisectoral, involving markets, governments and the public. Taking these findings into account, the article calls for a more nuanced ethical evaluation of food reformulation policies. Unhealthy Diets: A Policy Problem, and an Ethical Challenge Diet-related noncommunicable diseases (NCDs), including cardiovascular disease, stroke, type-2 diabetes and certain cancers, are now major contributors to morbidity and mortality in almost every jurisdiction on earth (Stuckler and Siegel, 2011; WHO, 2014). Accounting for more than 40 per cent of all NCD deaths, these share the underlying risk factor of unhealthy diets. As the prevalence and impact of diet-related NCDs has grown in recent decades, so has the list of preventive policy options available to governments. A key goal of prevention is to shift population diets in a healthier direction: less fat, sugar and salt, and fewer overall calories, as well as more fruits, vegetables and whole grains. However, this goal is in persistent tension with concerns about the potential for infringement on personal choice and dietary freedom (ten Have et al., 2011). One set of policy measures that have been described as particularly intrusive are mandatory nutrient limits. These are government regulations specifying upper permissible amounts of salt, fat or sugar in certain food products. In the public health law and ethics literature, they tend to be evaluated as an extreme and paternalistic state intervention, inappropriately interfering in both free markets and individuals’ right to their food choices. The essence of the critique is that removing consumers’ freedom to eat certain foods is too high a price to pay for what may only be incremental public health gains (Conly, 2014; Resnik, 2014). However, it seems that the critique does not apply when the food industry removes that same freedom. Voluntary food reformulation has become an intervention of choice for the World Health Organization (WHO), national governments and the food industry. The term tends to refer to actions of the food industry, with varying degrees of government involvement. Voluntary reformulation has the same public health goal as mandatory nutrient limits: to reduce over-consumed nutrients (salt, sugar or fat) in processed foods. And yet, it is rarely evaluated in terms of its ‘freedom’ impacts, whether on markets or individuals’ food choices. We are thus presented with two policy options that share a common goal of directly removing ingredients from the food supply, but which are assessed very differently in public health ethics terms. This provides a starting point for a critical reassessment of the ethical charges against mandatory nutrient limits. The article begins by explaining the concept of food reformulation, and why governments may seek to implement it as part of a prevention strategy on diet-related NCDs. It then sets out the two main policy approaches to reformulation, including the technical features, practical effects and ethical critiques of each. In the second half of the article, the comparison between these two approaches forms the basis for a close examination of the criticism that mandatory nutrient limits are a uniquely intrusive policy option. This leads to three key findings. First, that voluntary reformulation and mandatory nutrient limits in fact have very similar impacts on freedom of choice (the first limb of the critique). Secondly, that the dominant ethical frameworks for assessing public health policies, such as the Nuffield Ladder, are not well equipped to compare voluntary and mandatory forms of regulation. This is because they ignore the relationship between the food industry and the state. Finally, that the ‘free markets’ limb of the critique rests on a set of artificial binaries (voluntary/mandatory and market/state) that are not attuned to the context of food regulation. Drawing on the history of regulating diet-related NCDs, I argue that, as in all food governance, there is no such thing as strictly ‘government’ or strictly ‘market’ interventions. Ultimately, a meaningful comparison between mandatory and voluntary approaches to food reformulation must take place against a more nuanced understanding of the complex interactions between the state, the industry and the consuming public. Food Reformulation as Public Health Policy In the general context of food manufacturing, reformulation simply refers to changing the chemical or nutritional composition of processed foods for any reason (Garde, 2010). Manufacturers might reformulate a product to make it look or taste better (Moss, 2013) because of requirements related to the food’s ingredients, manufacture, storage or transportation (Golan and Unnevehr, 2008) or to keep up with consumer trends and demands (Watrous, 2016). However, in the context of diet-related disease, reformulation means changing the composition of processed food to achieve public health policy goals (Garde, 2010; EUFIC, 2010; National Heart Foundation of Australia, 2012). Specifically, it means removing trans fatty acids (TFAs; which have been shown to cause coronary heart disease) or limiting sodium (overconsumption of which is linked to high blood pressure and strokes) or sugar (linked to high blood sugar, diabetes and dental caries).1 While most policy approaches to diet-related NCDs focus on modifying our dietary choices and behaviours, reformulation instead aims to change the underlying food supply. This is because the determinants of unhealthy diets are environmental as well as individual: people select their diet from what is available (Hawkes et al., 2015; Roberto et al., 2015). Unlike educational or informational policies, reformulation involves a certain acceptance of the status quo of modern dietary habits. It accepts that people will continue to eat certain processed foods. Instead, it hopes that relatively minor changes to commonly consumed foods can have a major effect on population health (Swinburn, 2002). When a food is reformulated, ‘the consumer does not have to modify drastically his or her habitual dietary food pattern’ (van Raaij et al., 2009: 326), but nevertheless benefits from an improved diet. In this sense, it is an upstream intervention, modifying an environmental determinant of ill health (Rose, 1992)—or, more colourfully, ‘stealth health’ (Schwartz and Brownell, 2007: 80). Reformulation may be industry-led (voluntary reformulation) or may be government-led (mandatory nutrient limits). Mandatory Nutrient Limits What Are They? Mandatory nutrient limits are government regulations, currently in force in 25 jurisdictions worldwide. They are usually implemented as national food standards, but may also take the form of legislation or other rule types. They work by specifying permissible amounts of a given nutrient in a given food, and so force food manufacturers to reformulate if they want their food to remain on the market. Mandatory limits currently apply to fats (primarily trans fats) and salt. In 2004, Denmark was the first government to regulate an upper permissible limit, 2 per cent, on artificially produced TFAs. It has since been followed by nine other jurisdictions. The Netherlands introduced regulations in 2009 on the permissible amount of salt (sodium) in bread and flour. Eight jurisdictions followed, and in 2013 both South Africa and Argentina introduced mandatory sodium limits on a wide range of foodstuffs. Public health experts are now calling for mandatory limits on sugar (World Cancer Research Fund International, 2015), though so far no jurisdiction has implemented these. The Ethical Objection to Mandatory Nutrient Limits The literature on preventing diet-related NCDs tends to view government regulations in general as an extreme option, and mandatory nutrient limits as particularly intrusive. They are described as ‘highly paternalistic … heavy-handed, interfering with a person’s right to order what he or she wants’ (Gostin, 2008: 512), ‘the most far-reaching form of limiting choice’ (ten Have et al., 2011: 675) and ‘some of the most contentious public health laws’ (Taylor et al., 2015: 26). There are two limbs to the objection: the public is said to fear interference in free dietary choice, while the food industry fears interference in free markets, preferring non-regulatory approaches to public health (Cobiac et al., 2013). While the USA’s culture of ‘liberty of palate’ is well known (Linnekin, 2012; Semands, 2014; Wiseman, 2015), mandatory nutrient limits seem to be universally provocative. In Australia, the regulations have been described as ‘most unpopular’ (Commonwealth Department of the Parliamentary Library, 2001: 2) and ‘in the nature of a prohibition and [thus] controversial’ (Reynolds, 2011: 423). Similarly in Canada, Ries has noted that ‘regulatory interventions [on trans fats] are controversial’ and that critics view ‘food choices are fundamentally personal and an inappropriate arena for legal regulation’ (Ries, 2007: 17, 22). A European review found that mandatory nutrient limits would be effective but ‘intrusive’ (Brambila-Macias et al., 2011: 373). There is a small literature specifically addressing the ethics of mandatory nutrient limits. This has focused on trans fat limits, which have now been in the public consciousness for more than a decade (salt limits are a more recent development). Resnik’s (2010) article ‘Trans Fat Bans and Human Freedom’, and the resulting commentaries in the American Journal of Bioethics,2 is the best-known and most comprehensive treatment of the ethical charges against trans fat limits. Resnik does not dispute that TFA limits may improve health and save lives. Nonetheless, he finds their impact on freedom to be unacceptable because, first, there are other, less intrusive ways to reduce consumption of TFAs (for instance, through labelling and education, or through voluntary reformulation) and, secondly, trans fat limits are the first step on a slippery slope, which could ‘open the door to excessive government control’ over other food choices (Resnik, 2010: 29–30). For their part, defenders of TFA limits largely agree with Resnik. They agree that labelling and education are ‘softer’ alternatives to mandatory limits, but argue that these have been proved ineffective (Ries, 2007; Taylor et al., 2015). They also agree that TFA limits may pave the way for the ‘regulatory reconsideration of ingredients such as sugar, caffeine, and salt’, but they approve of this possibility (Brownell and Pomeranz, 2014: 1775). Most relevantly, they accept that TFA limits restrict our freedom to choose—but disagree on the importance of that freedom in this particular regulatory equation. They argue that other factors, core to the mission of public health, must also be considered: the very real social, physical and economic costs of NCDs to the community (Gostin, 2010; Wilson and Dawson, 2010). The Nature and Content of the Freedom Given that both critics and defenders agree that mandatory nutrient limits interfere with freedom, it is important to define the nature and content of that freedom. Questions of freedom (along with liberty and choice) lie at the heart of many debates in public health law and public health ethics (Childress et al., 2002, Dawson, 2011, Gostin and Wiley, 2016, and discussed further below). This is due to the focus of both disciplines on assessing the appropriate nature and reach of government action to protect public health. Core to this assessment is the extent to which such action might or should compromise liberty, autonomy, privacy ‘and other legally protected interests of individuals’ (Gostin and Wiley, 2016: 4). The relationship between the individual and the State—in public health or otherwise—can be described in terms of ‘freedoms’ that are broad and abstract. However, in the particular context of mandatory nutrient limits, the ‘freedom’ is quite narrow and specific. It is, as Resnik writes, ‘the freedom to choose what we eat’ (Resnik, 2010: 28). In the context of a modern, globalized, and—at least in wealthy countries—safe food supply, this freedom has become a feature of daily life, in a way that was possible at no other point in history. As Lang and colleagues write: ‘a family in Dublin, Paris, London or Berlin… can eat Italian, Japanese, Indian one moment, snack foods watching a Hollywood blockbuster film the next’ (Lang et al., 2009: 238). ‘The freedom to choose what we eat’ is a basic assumption of 21st-century capitalist culture, equally promulgated by food corporations and government health campaigns that emphasize consumer ‘choices’ (Mayes, 2014). As set out above, mandatory nutrient limits are government regulations on the amount of a particular nutrient in a particular food. They impact on the freedom to choose what we eat in the following ways: In Denmark, it is not possible to choose to eat a margarine containing more than 2 per cent artificially produced TFA (Danish Government, 2003); or In South Africa, it is not possible to choose to eat bread containing more than 380 mg of sodium per 100 g (Republic of South Africa, 2013); or In Ghana, it is not possible to choose to eat a cut of poultry with more than 15 per cent fat content (Thow et al., 2014), and so on. That is the practical effect of the regulations in each jurisdiction. The idea that food choices are fundamentally personal, and not a matter for government regulation, is at the heart of the ethical objection to mandatory nutrient limits. However, regulating food composition has been well within the scope of legitimate government activity for more than a century (French and Phillips, 2000). In jurisdictions around the world, and at the international level via the Codex Alimentarius Commission, governments already make rules about ‘what people may eat’, on food safety, consumer protection and other grounds. In the USA, for example, consumers may not purchase confectionery containing more than 0.5 per cent alcohol (Federal Food, Drug and Cosmetic Act 1938 §342(d)), or food containing the colouring additive amaranth (Federal Food, Drug and Cosmetic Act 1938 §348(a)). What makes mandatory nutrient limits controversial is not that they regulate food composition, or even that they limit certain nutrients in certain foodstuffs—but that they do so for the purpose of preventing chronic disease. Yet, even this purpose is not unique. As described below, voluntary reformulation—which has been endorsed by the WHO as an NCD-prevention strategy, and is becoming a favoured option of the food industry—has the same goal. As such, it provides a concrete comparison for examining the ethical objections to mandatory nutrient limits. Voluntary Reformulation International Policy Context: ‘All Could Become Partners’ Since the early 1990s, the WHO has encouraged the food industry to be responsible ‘partners’ in the prevention of diet-related NCDs, including by reformulating its products (WHO, 1990). By the turn of the century, public health experts were advising that ‘the food industry at all levels can be part of the solution’ (Yach et al., 2003: 276). This was formalized in 2004, with the publication of its Global Strategy on Diet, Physical Activity and Health (DPAS) (WHO, 2004). The DPAS emphasized the central role of governments, but noted that ‘all could become partners with governments and nongovernmental organizations in implementing measures … to encourage healthy eating’ (WHO, 2004: 61). The food industry was encouraged to produce products with lower levels of fats (trans and saturated), sugars and salt (WHO, 2004). The call to reformulate, and to encourage reformulation, has been consistent throughout later policy statements and guidance documents, including the United Nations (UN)’s Political Declaration on the Prevention and Control of Non-Communicable Diseases (United Nations General Assembly, 2011) and the WHO’s Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (WHO, 2013). National Reformulation Initiatives Member states have implemented the WHO’s guidance through a range of co-regulatory and quasi-regulatory arrangements. The UK’s salt reduction programme, 2003–2011—an early and successful example—is usually described as a government-led, voluntary scheme (Charlton et al., 2014), or as ‘voluntary with the threat of regulation/legislation’ (He et al., 2014: 351). Since then, a further 25 countries have implemented similar approaches to setting salt reduction targets across a range of foods (Webster et al., 2014). As documented by World Cancer Research Fund International (WCRF), most of these ‘voluntary’ industry initiatives involve the facilitation or guidance of at least one level of government (World Cancer Research Fund International, 2017). In addition, several countries and regions have implemented co- and quasi-regulatory policies to encourage reformulation across the food supply. Under the UK’s Responsibility Deal, for instance, companies are encouraged to make ‘pledges’ on reformulation ‘rather than resorting to regulation or top-down lectures’ (British Government Department of Health, 2010: 30). Similar partnership arrangements exist in the USA (New York City Health Department, 2012) and France (Sebillotte, 2013), while the European Union (EU) and Australia have established collaborative ‘platforms’ and ‘forums’, through which food companies can make voluntary commitments on food reformulation (European Commission DG Health and Food Safety, 2017; Australian Government Department of Health, 2017). In many of these cases, the state acts as little more than a facilitator—one partner among many—and official documents emphasize the voluntary nature of the reformulation. Yet, at the same time, all of these schemes are positioned as actions that the state is taking in relation to NCD prevention. If successful, reformulation is supposed to achieve improvements in the population’s diet and so reduce the modifiable risk factors of NCDs. Reformulation therefore appeals to two often-conflicting interests of 21st-century liberal democracies. On one hand, democratic governments have a duty to safeguard the health of the public (Gostin and Wiley, 2016). On the other, governments in capitalist, market-based economies face pressure to foster market freedom, and to limit their use of regulation (Cobiac et al. 2013, Lang and Heasman, 2015). Since the 1970s, government policy-making has been characterized by a preference for deregulation and market solutions, including voluntary or quasi-regulatory arrangements (Bartle and Vass, 2007). Policy-makers are encouraged to consider ‘whether an alternative approach to regulation may be a more efficient means of achieving a policy goal’ (OECD, 2009). As well as fitting in with philosophical preferences for a ‘smaller’ state, voluntary initiatives appeal to resource-constrained governments with an increasingly strong interest in containing public expenditure, including on monitoring and enforcement of industry regulation (Cobiac et al., 2013). Voluntary Reformulation and the Food Industry The other side of the ‘partnership’ equation is of course the food industry itself. Historically, reformulation has been a vexed proposition for the industry. The high levels of salt, sugar, fat and calories in processed food are closely related to the high profitability of that food (Moodie et al., 2013; Monteiro et al., 2013; Moss, 2013). However, in recent years, the contradiction between the profit motive and the epidemic of diet-related NCDs has become too glaring. With ‘business as usual’ no longer an option (Yach et al., 2010), the food industry has begun to advocate voluntary reformulation as a way to prevent diet-related disease. It has done so for several reasons. At one end of the spectrum is a profit incentive: the desire to tap into the lucrative market of consumer demand for ‘wellness’ and healthier foods (Michman and Mazze, 1998; Scrinis, 2013). At the other end of the spectrum is political pressure: the threat of governments introducing regulation, unless industry takes action of its own accord (Morris and Neering, 2008). Somewhere in the middle is corporate social responsibility—the desire of companies not only to be a ‘good corporate citizen’, but also to be seen as such (Lang and Heasman, 2015). Voluntary reformulation also involves a strong element of enlightened self-interest—recognition by companies that ‘long-term profits would be fatter if [the] customers were slimmer’ (Reingold, 2015) and that ‘cutting short the lives of your best customers isn’t much of a strategy for long-term success’ (Seabrook, 2011). In this regard, reformulation shares an important feature with another of the industry’s preferred responses to obesity, the focus on exercise and ‘energy balance’: neither implies eating, or selling, less food (Nestle, 2007; Seabrook, 2011). Indeed, far from slowing sales, there is evidence that marginal improvements to the healthiness of a product may confer a ‘halo’, ultimately assisting a company to sell more (Wansink and Chandon, 2006; Chandon and Wansink, 2007). Is There Any Ethical Criticism of Voluntary Reformulation? The constellation of factors set out above—from international health policy leadership to industry self-interest—helps to explain why reformulation has become ‘the default approach of many governments and the UN, and the preferred approach of industry’ on diet-related NCDs (Moodie et al., 2013: 675). However, it is not without its critics. The most frequent criticism of voluntary, co- or quasi-regulatory reformulation schemes is that they are not effective. In the absence of meaningful oversight mechanisms and sanctions for non-compliance, voluntary reformulation initiatives may (at best) advance slowly or (at worst) provide a smokescreen for inaction. A systematic review found that while mandatory trans fat limits ‘virtually eliminated TFAs from the food supply’, voluntary limits ‘were more variable and depended largely on the food category’ (Downs et al., 2013: 263). Further, an assessment of reformulation goals under the Australian Food and Health Dialogue (now called the Healthy Food Partnership) found that compliance on voluntary targets was patchy—likely due to the lack of accountability (Elliott et al., 2014). This effectiveness critique also has an ethical dimension: that the food industry has too great a conflict of interest to ever be a genuine ‘partner’ in public health (Norum, 2008; Monteiro et al., 2010; Moodie et al., 2013). Critics argue that voluntary food industry schemes are doomed to fail because there is ‘no evidence for an alignment of public health interest in curbing obesity with that of the food and beverage industry’ (Stuckler and Nestle, 2012: 2). Worse, handing responsibility to food companies ‘partners’ may actually provide them with access and opportunities to influence public health policy (Panjwani and Caraher, 2014). However, what is missing from such critiques of reformulation—a policy approach approvingly described as ‘stealth health’ by governments and industry (EUFIC, 2009; Jargon, 2014)—is any mention of its impact on ‘freedom to choose what to eat’. Whether reformulation is voluntary, quasi-regulatory, co-regulatory or mandatory, if it is effective, and covers all food products in a relevant category, then it must be presumed to affect consumers in the same way. That is, whether sodium in bread is reduced through voluntary reformulation or through mandatory nutrient limits, the net intended impact on consumers is that their bread is less salty. Yet, if the freedom to eat salty bread is so valuable as to override arguments for mandatory limits, it should also override arguments in favour of voluntary reformulation. Because the goal of a bona fide voluntary, co-regulatory or quasi-regulatory reformulation scheme should be the same as that of a mandatory scheme: to reduce the specified nutrient in the specified food. The intended effect of the UK’s voluntary salt reduction programme was to prevent consumers from buying bread that is saltier than 360 mg per 100 g (Charlton et al., 2014). Yet, neither academic nor popular debates tend to frame successful voluntary reformulation initiatives as an unacceptable intrusion on freedom of choice. Why, then, are mandatory limits seen as a controversial and intrusive, while voluntary reformulation is enthusiastically embraced by stakeholders at all levels? Evaluating Public Health Interventions: Ethical Frameworks Personal liberty and freedom of choice (including consumer choice) are ‘among the most firmly held desiderata of modern liberal society’ (Jackson, 2006: 109). However, they often come into conflict with the population focus and community orientation of public health (Kass, 2004; Dawson, 2011). As Geoffrey Rose noted, in public health: we are confronted by two irreconcilable opposites, yet both need to be accepted for both have authority. Personal freedom is paramount, yet every attempt to change our affairs for the better must of necessity impinge on that freedom because the aim is to influence what people do. (Rose, 1992: 114–`115) States therefore have a duty to consider whether public health interventions will be acceptable to their citizens. Accordingly, two ongoing themes in public health ethics are (i) the tension or balance between securing population health and protecting the rights of individuals, and (ii) defining the appropriate role and reach of the state. Both feed into an ongoing theoretical project of public health ethics, which is the development of frameworks or tools to evaluate the justifiability of different public health interventions (Childress et al., 2002; Gostin, 2002; Kass, 2004; Bayer et al., 2007; Nuffield Council on Bioethics, 2007; Dawson, 2011; Gostin and Wiley, 2016). Freedom (in various forms) has occupied a central role in most of these frameworks. In the policy-making context, the Nuffield Council on Bioethics’ ‘Ladder of Interventions’ (Nuffield Council on Bioethics, 2007) has been most influential. In its 2007 report ‘Public health: ethical issues’, the Nuffield Council (the Council) aimed to present ‘an ethical framework for the scrutiny of public health policies’. Its motivating question is ‘when and how the State should act’ to secure public health (Nuffield Council on Bioethics, 2007: v). Beginning with the foundation of classical liberalism, JS Mill’s harm principle, the Council adds a ‘social dimension’ to take account of the fact that individuals do not make decisions about their behaviours and choices in a vacuum, but within the context of community norms and collective goods. This produces a ‘revised liberal framework’, or ‘stewardship model’, which seeks to balance the competing interests described by Geoffrey Rose, above. Under the stewardship model, governments should assist people to live healthy lives, by giving ‘discouragement and assistance’ through ‘the provision of services through which risks are minimised and people are helped to change their behaviour’ (Nuffield Council on Bioethics, 2007: 25). However, they should stop short of coercing adults to live healthy lives, and should ‘seek to minimise interventions that are perceived as unduly intrusive and in conflict with important personal values’. The ‘Nuffield Ladder’, reproduced as Figure 1, below, gives a visual form to this guidance. The Ladder does not suggest specific kinds of interventions, but sets out broad approaches. These range from ‘do nothing and monitor the situation’ (which the Council emphasizes is still a policy choice) to ‘eliminate choice’. Importantly, the Ladder comes with guidance that ‘the higher the rung on the ladder at which the policy maker intervenes, the stronger the justification has to be’—because of the potential impact on freedom (Nuffield Council on Bioethics, 2007: 25). Figure 1. View largeDownload slide Nuffield Ladder of interventions. Figure 1. View largeDownload slide Nuffield Ladder of interventions. Where Does Voluntary Reformulation Sit on the Ladder? The Nuffield Ladder is a useful policy tool for public health because it allows different intervention options to be compared. In theory then, it should enable a comparative ethical evaluation of mandatory nutrient limits and voluntary reformulation, as illustrated by the following scenarios (Figure 2): Scenario 1 would sit right at the top of the Nuffield Ladder: ‘eliminate choice’. The state has eliminated consumers’ choice to buy foods containing more than 2% TFAs, by eliminating the food industry’s choice to sell such foods. However, the only way to describe Scenario 2 in Nuffield terms is that the state ‘does nothing and simply monitors the situation’—the lowest rung on the Ladder. And yet, the impact on consumers is the same as in Scenario 1: the choice to eat TFA-containing food has been eliminated. For a non-mandatory reformulation scheme to be taken seriously as an NCD-prevention strategy, it must be able to demonstrate effectiveness. But effectiveness, in this case, means effective at removing or reducing consumer choice. Why then are mandatory limits, but not voluntary reformulation, regarded as uniquely freedom-limiting? Figure 2. View largeDownload slide Examples of mandatory versus voluntary removal of TFA from food. (Shrapnel, 2012). Figure 2. View largeDownload slide Examples of mandatory versus voluntary removal of TFA from food. (Shrapnel, 2012). Reintroducing the Regulated Industry The reason for this disparity is that the standard bioethical models, as exemplified by the Nuffield Ladder, tend to be interested in the impact or intrusion of the state on individuals. They classify actions of the state according to the extent to which those actions will impinge on individual liberty. As such, they have been criticized by Dawson and others for retaining a Millean focus on the centrality of ‘non-interference’, inappropriately imported from medical ethics (Dawson, 2011). This, Dawson argues, is to miss the point of public health. Social justice, rather than liberty, is the core mission of public health. Only ‘someone who thinks that liberty is all that matters’ would use such a framework for public health policy decision-making (Dawson, 2016). Accordingly, ‘modified liberal’ frameworks, focused on preserving individual liberty, are not, by themselves, appropriate yardsticks for judging the merits of public health policies. To the ethicist’s critique, however, we must also add that of the regulatory theorist: that the modified liberal frameworks do not adequately reflect the range of actors and institutions involved in public health intervention, and especially in food governance. Modified liberal frameworks assume that counteracting public health risks always or usually involves regulating individuals. Yet, many threats to public health are not caused or carried by individuals (Egger and Swinburn, 1997; Swinburn and Egger, 2002), but by industries—and so, counteracting risk involves regulating those industries.3 However, the Nuffield Ladder tells us nothing about the form of the regulation, or the actors and institutions involved in its implementation and enforcement. In focusing attention on the relationship between governments and individuals, it ignores the relationship between industry and individuals, and the relationship between industry and the state—a triad crucial to understanding food governance (Lang, 2006; Lang et al., 2009). Further, classifying interventions solely according to their impact on individuals tells us nothing about the very different burdens and costs they might impose on businesses, which can often account for their very different political acceptability. Filling this gap, regulatory studies is the body of work that deals primarily with the actors and institutions involved in regulation—the state, but also non-state actors and the regulated industry itself (Freiberg, 2010). Along with the privatization of public assets and the fragmentation of traditional bureaucratic structures, the current deregulatory era has also brought about fundamental changes to the role of the state. This has been marked by decreased emphasis on traditional command-and-control apparatus, and an increased role for other, ‘softer’, ‘decentred’ or ‘networked’ forms of governance, involving a range of non-governmental and private sector actors (Moran, 2002; Bartle and Vass, 2007; Lang et al., 2009). This shift from ‘governing’ to ‘governance’ has been described as the rise of the neoliberal or regulatory state, or as the state ‘steering rather than rowing the ship of government’ (Osborne and Gaebler, 1992). In the regulatory state, power is decentralized and diffused, but the reach and number of different regulatory forms, such as guidelines, standards, codes of practice, proliferates (Bartle and Vass, 2007; Scott, 2010). Regulatory studies has closely observed these developments, analysing and classifying the new and emerging modes of regulation (Black, 2002; Drahos, 2017). It offers the language and tools to differentiate regulatory options in ways other than by focusing on freedom of (consumer) choice: for instance, by focusing on the relative costs and benefits imposed by different regulatory modes on different regulatory actors. However, only very recently have scholars begun to combine the analytical tools of regulatory studies with those of public health law and ethics (e.g. Reeve, 2011). Public health ethics frameworks are well equipped to differentiate between regulatory forms: for instance, between a labelling scheme versus taxation. However, they are poorly equipped to deal with regulatory modes, for instance, ‘a labelling scheme that is voluntary with government oversight’ versus ‘a labelling scheme that is a public-private partnership’. Once we understand this, the problem becomes clear: mandatory nutrient limits have been analysed under one lens, and voluntary reformulation under another. Mandatory nutrient limits have been understood as traditional state regulation, and thus assessed primarily for their ‘Nuffield’, or freedom-limiting, impacts. Meanwhile, voluntary reformulation has been understood as a new, decentred, ‘partnership’ mode of regulation, and evaluated accordingly. Both assessments have an ethical dimension, whether related to freedom of choice or to conflicts of interest. However, these have not, to date, permitted a true like-with-like comparison. Such a comparison would ask: What are the freedom-limiting impacts of voluntary reformulation? And, what are the relative benefits and burdens imposed on the actors involved in mandatory nutrient limits? As described above, the freedom-limiting impacts of voluntary reformulation should be very similar to those of mandatory nutrient limits. Indeed, the very definition of a successful voluntary reformulation scheme would be that it eliminated consumers’ choice to eat the specified quantity of the targeted nutrient. The freedom-of-choice argument against mandatory nutrient limits is then, if not quite a red herring, at least substantially neutralized by a comparison with voluntary reformulation. Clearly, food stakeholders—from the WHO to PepsiCo—are not unduly uncomfortable with the purpose of such regulation. If the purpose is not the real problem, we must next examine the form of the regulation. State Regulation and Free Markets in Food Regulation: A Spectrum Rather than a Binary ‘A Market Solution’ I now turn to the ‘free markets’ limb of the ethical critique of mandatory nutrient limits. While acknowledging the wide variance in free market economies around the world, I here use the term to summarize those appeals to market forces, the laws of supply and demand and a preference for less, or lighter, government regulation. The critique—often made by the food industry—is that, in addition to limiting freedom of choice, mandatory nutrient limits entail regulatory overreach by the state. Instead of government regulation, ‘market forces, driven by informed individual choice, [should] correct for negative results caused by high consumption of unhealthy commodities’ (Moodie et al., 2013: 675). Arguing against regulation, the food industry is optimistic that ‘if sufficiently many people demand food with a certain attribute, producers will respond and supply it’ (Deloitte Access Economics, 2013: 14)—all we need do is wait for ‘market readiness and business opportunity in a nation that values the healthfulness of its foods and beverages’ (Lavizzo-Mourey et al., 2014: e8). In this final section, I draw again on the comparison with voluntary reformulation to argue that such a strict state/market dichotomy is a fiction in food governance. Rather, both options—voluntary reformulation and mandatory nutrient limits—require a high degree of involvement from governments as well as the food industry. Whose Supply? Whose Demands? The ‘free market’ model assumes that companies respond only, or primarily, to consumer demand. This oversimplifies the complex entanglement of socio-economic, cultural and policy factors that shape dietary demand. Further, it ignores the influence in the opposite direction: the well-documented ways in which the industry, through marketing and through the products themselves, shapes consumer demand (Nestle, 2007; Monteiro et al., 2010; Stuckler et al., 2012; Moss, 2013). Importantly, it also ignores the extent to which, over the past half-century, government actions have shaped the dynamics of our consumption habits. Since the 1960s, for example, governments around the world have formulated and disseminated food-based dietary guidelines as a response to diet-related NCDs. In the wake of the Framingham study, which in the early 1950s provided evidence of the link between diet and cardiovascular disease, expert committees around the world began producing evidence on the link between diet and health (Truswell, 1987). To decrease the incidence of diabetes, cancer, heart disease, stroke and obesity, they recommended populations consume less fat (especially saturated fat), salt, sugar and overall dietary energy. By 1982, most high-income countries had published dietary guidelines (Truswell, 1987). Most of these did not aim to influence the food supply directly—rather, they were directed downstream, at consumers’ behaviour and ‘lifestyle’ choices (Nutrition Taskforce of the Better Health Commission, 1987; Hetzel and McMichael, 1989; Santich, 1995; Nestle, 2007). Nevertheless, these guidelines exerted a powerful, if indirect, effect on food producers, in the following way. On the basis of the scientific findings and government guidelines, ‘the low cholesterol, low fat diet [became] the cornerstone of public health nutrition’ for its supposed cardio-protective properties (Kromhout, 2015: 1). Consumers then began to seek out products that fitted in with this new, ‘low fat era’ (Santich, 2005). Skim or low-fat milk, previously considered an inferior food, was now in high demand, placing pressure on food producers to adjust the food supply. In Australia, milk processors responded by changing the system of farm-gate payments: instead of being paid for the percentage of dairy fat in their milk, as traditionally, farmers were now paid for the ratio of dairy fat to lean protein in milk (Santich, 1995). In Europe, low-fat dairy products had been considered special foods for diabetics in the 1980s; by the late 1990s, low-fat varieties made up 60 per cent of the yoghurt market and 70 per cent of the milk market (Sandrou and Arvanitoyannis, 2000). Similarly, the 2005 American Dietary Guidelines’ recommendation to consume more whole grains led to increased competition among firms to offer such products (Mancino et al., 2008). This led to increased consumption of whole grains—even in consumers who had not been demanding more grains, or were not even aware of the guidelines. After dietary guidelines, the next major policy response to diet-related NCDs was mandatory nutrition labelling: governments requiring food producers to present nutritional information, in a standardized format, on the packaging of eligible food and drink. This now applies in more than 20 national jurisdictions, as well as the European Union (Drichoutis et al., 2006; Campos et al., 2011; Kasapila and Shaarani, 2016). The primary purpose of such labels is to provide ‘the consumer with information about a food so that a wise choice of food can be made’ (FAO, 1985). But despite the language of consumer choices, here again the state has been an important actor shaping supply and demand. The first country to legislate mandatory nutrition labels was the USA, in 1990 (Federal Food, Drug and Cosmetic Act 1938 Part 101). In addition to educating consumers to make better choices, the legislation also aimed to give manufacturers an incentive to improve the nutritional profiles of their foods. A 2008 summary of the evidence found that nutrition labelling policies spur ‘competition in the food industry [which in turn] leads to fairly rapid reformulation of products’ (Golan and Unnevehr, 2008: 466). These examples illustrate that, in food governance, the concept of a ‘free market’ solution is more complicated than ‘consumers demand and producers supply’. In the cases of dietary guidelines and mandatory labelling, we observe the complex ways in which the state, the food industry and the public interact to create and respond to markets for healthier food products. In doing so they reveal that, even in ‘market’ solutions to diet-related NCDs, the state is already deeply implicated. Food Governance Is Inherently Multisectoral In its Global Action Plan for the Prevention and Control of NCDs, the WHO describes multisectoral action as involving multiple sectors of government, as well as—where appropriate—actors and institutions outside of government (WHO, 2013). When we compare voluntary reformulation and mandatory nutrient limits, both display characteristics of multisectoral action. As highlighted above, ‘voluntary’ reformulation in fact occupies a broad regulatory spectrum, from the commercial decisions of individual companies to the UK’s ‘government-led’ voluntary salt reduction. Scattered in between are the public–private partnerships and the co-regulatory and quasi-regulatory schemes. Beyond the fact of being ‘not mandatory’, these can have little in common. Governments are involved to different degrees and at different stages, and even the involvement of industry may differ, from policy-making to implementation. Their effectiveness is different, they may be ‘owned’ by different stakeholders (e.g. in the USA, the National Salt Reduction Initiative is hosted on a government website, while the Healthy Weight Commitment Foundation has a much more corporate image) (New York City Health Department, 2012; Healthy Weight Commitment Foundation, 2017). They may be supported to a greater or lesser degree by surrounding policies, such as a public awareness or education campaigns (van Raaij et al., 2009). In this context, the idea that mandatory limits are somehow unique—quite distinct from this spectrum of voluntary options—is unrealistic. Even command-and-control regulation leaves room for (and in some cases, even requires) a high degree of industry involvement. Denmark, for example, introduced its regulation on trans fats only after industry had demonstrated technical feasibility by implementing voluntary measures for some years (Katan, 1995, 2006). In the case of South Africa’s sodium regulations, the food industry was closely involved, through working groups, in setting timelines and targets that were eventually incorporated into the regulation (Charlton et al., 2014; Hofman and Tollman, 2013). In both Denmark and South Africa, there was evidence that industry members had lobbied for regulation, to ensure a level playing field among competitors. Finally, as discussed above, the common theme among suggestions for improving the effectiveness and robustness of voluntary reformulation schemes is more state involvement: adding in various ingredients of ‘mandatoriness’, such as tougher targets and timelines, and even sanctions for non-compliance (Brambila-Macias et al., 2011; Reeve and Magnusson, 2013; Réquillart and Soler, 2014; Magnusson and Reeve, 2015). Such that, when we compare a mandatory nutrient limit with an effective voluntary reformulation scheme, there is very little to separate them. As Charlton and colleagues found in their comparison of the (voluntary) UK and (mandatory) South African approaches to salt reduction, the programmes in fact had much in common in a substantive sense, including multisectoral involvement. The main difference was technical, i.e. the introduction of regulations in South Africa (Charlton et al., 2014). What this suggests is that mandatory nutrient limits belong on the same spectrum with the voluntary approaches, rather than distinct from it. The idea that one is a state intervention and the other a market solution is an artificial binary that does not reflect the evidence. Conclusion Evaluating public health interventions requires us to take multiple factors into account. As Gostin has set out, effectiveness and cost-effectiveness are relevant, but so are public acceptability and fairness (Gostin and Wiley, 2016). Faced with the ongoing, worldwide epidemic of diet-related NCDs, governments will increasingly be forced to consider measures that directly regulate over-consumed nutrients in the food supply—including mandatory and voluntary alternatives. As such, it is important to assess the criticism that mandatory nutrient limits are an unacceptably intrusive intervention. Policy-makers will need to consider how much weight to give this argument—sometimes alongside effectiveness evidence, but other times (as is often the case in public health regulation) in its absence. The objection to mandatory nutrient limits rests on two propositions: That mandatory limits interfere with freedom of (consumer) choice; and That mandatory nutrient limits interfere with free markets. As abstract philosophical propositions, these may be convincing. As policy debate, they are less so because the merits (ethical and otherwise) of mandatory nutrient limits must be assessed in the context of other policy alternatives. Voluntary reformulation, which shares the goal of preventing diet-related NCDs by limiting salt, sugar and fat in processed foods, provides an ideal comparator for this assessment. By comparing mandatory nutrient limits with reformulation, I have demonstrated that, in answer to the propositions above: If we compare like with like, the two interventions in fact have very similar impacts on freedom; and The relationship between the state and the market is complex and dynamic. As in all food regulation, the state is deeply implicated in constructing consumer ‘choice’, and even command-and-control measures involve a high degree of participation by the regulated industry. Neither of these findings overrides the ethical objection to mandatory nutrient limits. Instead, they enable a more nuanced consideration of the applicability of mandatory nutrient limits in any given setting. So, for instance, if the choice is between a voluntary and a mandatory scheme for improving the composition of food, the impact on freedom of choice can be considered moot. This paves the way for other, more decisive considerations—effectiveness, cost-effectiveness, cost to each stakeholder, potential for conflict of interest and ways to manage that conflict—to be taken into account. Reflecting free market ideals, governments’ preference for industry schemes is likely to persist. But, given the increasing evidence linking greater state involvement with more successful food reformulation outcomes, a default preference for the ‘voluntary’ may start to require a stronger justification. Acknowledgements Thanks to Prof Roger Magnusson and Dr Anne Marie Thow, who reviewed and gave valuable feedback on earlier drafts of the article. The anonymous reviewers also provided helpful and constructive comments. Funding This work was conducted as part of the author's PhD. The PhD is funded by an Australian Postgraduate Award from the Australian Government, and by supplementary scholarship funding from the Sydney Law School and the Charles Perkins Centre. Footnotes 1. In theory, reformulation can also involve adding nutrients associated with NCD prevention (fruit, vegetables, whole grains, fibre)—e.g. General Mills pledging to use whole grains in its cereals in 2004 (Schwartz and Brownell, 2007). But the more common understanding relates to removing or reducing trans fats, saturated fats, salt, sugar or energy density (van Raaij et al., 2009). 2. Note that Resnik’s article and the responses to it draw on evidence from local and state bans in the USA, as this literature predates the more recent move to regulate TFAs at the national or federal level. 3. This problem has been pointed out by the British House of Lords (HoL). In an extensive 2011 report on behaviour change regulation, the HoL criticized the British government (then a coalition between the Conservatives and Liberal Democrats) for inappropriately using the Nuffield Ladder to justify a preference for deregulation. The HoL’s Select Committee wrote that the Ladder ‘was used in [the Government White Paper on health] to justify avoiding the regulation of businesses, although the Nuffield Ladder was only intended to apply to policies directed at individuals’ (Parliament of Great Britain: House of Lords Science and Technology Select Committee, 2011) References Australian Government Department of Health. ( 2017) Healthy Food Partnership, available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/Healthy-Food-Partnership-Home [accessed March 2017]. Bartle I., Vass P. ( 2007). Self-Regulation within the Regulatory State: Towards a New Regulatory Paradigm? Public Administration , 85, 885– 905. Google Scholar CrossRef Search ADS   Bayer R., Gostin L. O., Jennings B., Steinbock B. (eds) ( 2007). Public Health Ethics: Theory, Policy, and Practice . New York: Oxford University Press. Black J. ( 2002). Critical Reflections on Regulation. Australian Journal of Legal Philosophy , 27, 1– 35. Brambila-Macias J., Shankar B., Capacci S., Mazzocchi M., Perez-Cueto F. J., Verbeke W., Traill W. B. ( 2011). Policy Interventions to Promote Healthy Eating: A Review of What Works, What Does Not, and What Is Promising. Food and Nutrition Bulletin , 32, 365– 375. Google Scholar CrossRef Search ADS PubMed  British Government Department of Health. ( 2010). Healthy Lives, Healthy People: Our Strategy for Public Health in England. London: British Government Department of Health. Brownell K. D., Pomeranz J. L. ( 2014). The Trans-Fat Ban—Food Regulation and Long-Term Health. New England Journal of Medicine , 370, 1773– 1775. Google Scholar CrossRef Search ADS PubMed  Campos S., Doxey J., Hammond D. ( 2011). Nutrition Labels on Pre-Packaged Foods: A Systematic Review. Public Health Nutrition , 14, 1496– 1506. Google Scholar CrossRef Search ADS PubMed  Chandon P., Wansink B. ( 2007). The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions. Journal of Consumer Research , 34, 301– 314. Google Scholar CrossRef Search ADS   Charlton K., Webster J., Kowal P. ( 2014). To Legislate or Not to Legislate? A Comparison of the UK and South African Approaches to the Development and Implementation of Salt Reduction Programs. Nutrients , 6, 3672. Google Scholar CrossRef Search ADS PubMed  Childress J. F., Faden R. R., Gaare R. D., Gostin L. O., Kahn J., Bonnie R. J., Kass N., Mastroianni A., Moreno J., Nieburg P. ( 2002). Public Health Ethics: Mapping the Terrain. The Journal of Law, Medicine and Ethics , 30, 170– 182. Google Scholar CrossRef Search ADS   Cobiac L. J., Veerman L., Vos T. ( 2013). The Role of Cost-Effectiveness Analysis in Developing Nutrition Policy. Annual Review of Nutrition , 33, 373– 393. Google Scholar CrossRef Search ADS PubMed  Commonwealth Department of the Parliamentary Library. ( 2001). Food Regulation in Australia—A Chronology . Commonwealth Department of the Parliamentary Library. Conly S. ( 2014). Response to Resnik. Public Health Ethics , 7, 178– 179. Google Scholar CrossRef Search ADS   Danish Government. ( 2003). Order on the Content of Trans Fatty Acids in Oils and Fats Etc., Order No. 160 of 11 March 2003, pursuant to s.13, s.55(2) and s.78(3) of Act No 471 of 1 July 1998, the Food Act. Denmark. Dawson A. (ed.) ( 2011). Public Health Ethics: Key Concepts and Issues in Policy and Practice . Cambridge: Cambridge University Press. Google Scholar CrossRef Search ADS   Dawson A. J. ( 2016). Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy. Journal of Medical Ethics , 42: 510– 513. Google Scholar CrossRef Search ADS PubMed  Deloitte Access Economics. ( 2013). Reforming Regulation of the Australian Food and Grocery Sector—Report Commissioned by the Australian Food and Grocery Council, available from: https://www2.deloitte.com/au/en/pages/economics/articles/reforming-regulation-australian-food-grocery-sector.html [accessed October 2017]. Downs S. M., Thow A. M., Leeder S. R. ( 2013). The Effectiveness of Policies for Reducing Dietary Trans Fat: A Systematic Review of the Evidence. Bulletin of the World Health Organization , 91, 262– 269. Google Scholar CrossRef Search ADS PubMed  Drahos P. (ed.) ( 2017). Regulatory Theory: Foundations and Applications . Canberra: ANU Press. Google Scholar CrossRef Search ADS   Drichoutis A., Lazaridis P., Nayga R. M. ( 2006). Consumers’ Use of Nutritional Labels: A Review of Research Studies and Issues. Academy of Marketing Science Review , 10, 1– 22. Egger G., Swinburn B. ( 1997). An ‘Ecological’ Approach to the Obesity Pandemic. British Medical Journal , 315, 477– 480. Google Scholar CrossRef Search ADS PubMed  Elliott T., Trevena H., Sacks G., Dunford E., Martin J., Webster J., Swinburn B., Moodie R., Wilson A., Neal B. ( 2014). A Systematic Interim Assessment of the Australian Government’s Food and Health Dialogue. Medical Journal of Australia , 200, 92– 95. Google Scholar CrossRef Search ADS PubMed  EUFIC. ( 2009). Reformulating Food Products for Health: Context and Key Issues for Moving Forward in Europe, available from: http://ec.europa.eu/health//sites/health/files/nutrition_physical_activity/docs/ev20090714_wp_en.pdf [accessed March 2017]. EUFIC. ( 2010). Food Innovation and Reformulation for a Healthier Europe—a Challenging Mission, available from: http://www.eufic.org/article/en/artid/Food-innovation-reformulation-healthier-Europe-challenging-mission/ [accessed 12 August 2015]. European Commission DG Health and Food Safety. ( 2017) EU Platform for Action on Diet, Physical Activity and Health, available from: http://ec.europa.eu/health/nutrition_physical_activity/platform_en [accessed March 2017]. FAO. ( 1985). Guidelines on Nutrition Labelling, CAC/GL 2-1985. FAO. Federal Food, Drug and Cosmetic Act of 1938, 21 U.S.C. ( 2006), United States of America. Freiberg A. ( 2010). The Tools of Regulation . Sydney: Federation Press. French M., Phillips J. ( 2000). Cheated Not Poisoned? Food Regulation in the United Kingdom, 1875-1938 . Manchester: Manchester University Press. Garde A. ( 2010). EU Law and Obesity Prevention . The Netherlands: Kluwer Law International. Golan E., Unnevehr L. ( 2008). Food Product Composition, Consumer Health, and Public Policy: Introduction and Overview of Special Section. Food Policy , 33, 465– 469. Google Scholar CrossRef Search ADS   Gostin L. O. ( 2008). Public Health Law—Power, Duty, Restraint , 2nd edn. Berkeley: University of California Press. Gostin L. O. ( 2010). Trans Fat Bans and the Human Freedom: A Refutation. The American Journal of Bioethics , 10, 33– 34. Google Scholar CrossRef Search ADS PubMed  Gostin L. O. (ed.) ( 2002). Public Health Law and Ethics: A Reader . Berkeley: University of California Press; Milbank Memorial Fund. Gostin L. O., Wiley L. F. ( 2016). Public Health Law: Power, Duty, Restraint , Vol. 3. Oakland: University of California Press. Hawkes C., Smith T. G., Jewell J., Wardle J., Hammond R. A., Friel S., Thow A. M., Kain J. ( 2015). Smart Food Policies for Obesity Prevention. Lancet , 385, 2410– 2421. Google Scholar CrossRef Search ADS PubMed  He F., Brinsden H., MacGregor G. ( 2014). Salt Reduction in the United Kingdom: A Successful Experiment in Public Health. Journal of Human Hypertension , 28, 345– 352. Google Scholar CrossRef Search ADS PubMed  Healthy Weight Commitment Foundation. ( 2017) About HWCF: Engaging Families, Communities and Schools to Change the Outlook of a Generation, available from: http://www.healthyweightcommit.org/about/ [accessed March 2017]. Hetzel B. S., McMichael T. ( 1989). The LS Factor: Lifestyle and Health . Australia: Penguin. Hofman K. J., Tollman S. M. ( 2013). Population Health in South Africa: A View from the Salt Mines. The Lancet Global Health , 1, e66– e67. Google Scholar CrossRef Search ADS PubMed  Jackson T. ( 2006). The Earthscan Reader in Sustainable Consumption . London: Earthscan. Jargon J. ( 2014) Less Salt, Same Taste? Food Companies Quietly Change Recipes. Wall Street Journal , available from: http://www.wsj.com/articles/food-companies-quietly-cut-salt-fat-from-recipes-1403566403 [accessed March 2017]. Kasapila W., Shaarani S. M. ( 2016). Legislation, Impact and Trends in Nutrition Labeling: A Global Overview. Critical Reviews in Food Science and Nutrition , 56, 56– 64. Google Scholar CrossRef Search ADS PubMed  Kass N. E. ( 2004). Public Health Ethics: From Foundations and Frameworks to Justice and Global Public Health. The Journal of Law, Medicine and Ethics , 32, 232– 242. Google Scholar CrossRef Search ADS   Katan M. B. ( 1995). Exit Trans Fatty Acids. The Lancet , 346, 1245– 1246. Google Scholar CrossRef Search ADS   Katan M. B. ( 2006). Regulation of Trans Fats: The Gap, the Polder, and Mcdonald's French Fries. Atherosclerosis Supplements , 7, 63– 66. Google Scholar CrossRef Search ADS PubMed  Kromhout D. ( 2015). Where the Latest US Dietary Guidelines Are Heading. British Medical Journal , 351, h4034. Google Scholar CrossRef Search ADS PubMed  Lang T. ( 2006). Food, the Law and Public Health: Three Models of the Relationship. Public Health , 120, 30– 41. Google Scholar CrossRef Search ADS PubMed  Lang T., Barling D., Caraher M. ( 2009). Food Policy: Integrating Health, Environment and Society . Oxford; New York: Oxford University Press. Google Scholar CrossRef Search ADS   Lang T., Heasman M. ( 2015). Food Wars: The Global Battle for Mouths, Minds and Markets , 2nd edn. London: Routledge. Lavizzo-Mourey R., Orleans C. T., Marks J. S. ( 2014). Cutting Calories: Trillions at a Time. American Journal of Preventive Medicine , 47, e7– e8. Google Scholar CrossRef Search ADS PubMed  Linnekin B. J. ( 2012). The Food-Safety Fallacy: More Regulation Doesn't Necessarily Make Food Safer. Northeastern University Law Journal , 4, 89– 109. Magnusson R., Reeve B. ( 2015). Food Reformulation, Responsive Regulation, and “Regulatory Scaffolding”: Strengthening Performance of Salt Reduction Programs in Australia and the United Kingdom. Nutrients , 7, 5281– 5308. Google Scholar CrossRef Search ADS PubMed  Mancino L., Kuchler F., Leibtag E. ( 2008). Getting Consumers to Eat More Whole-Grains: The Role of Policy, Information, and Food Manufacturers. Food Policy , 33, 489– 496. Google Scholar CrossRef Search ADS   Mayes C. ( 2014). Governing through Choice: Food Labels and the Confluence of Food Industry and Public Health Discourse to Create ‘Healthy Consumers’. Social Theory and Health  12, 376– 395. Google Scholar CrossRef Search ADS   Michman R. D., Mazze E. M. ( 1998). The Food Industry Wars: Marketing Triumphs and Blunders . Westport: Quorum. Monteiro C. A., Gomes F. S., Cannon G. ( 2010). The Snack Attack. American Journal of Public Health , 100, 975– 981. Google Scholar CrossRef Search ADS PubMed  Monteiro C. A., Moubarac J. C., Cannon G., Ng S. W., Popkin B. ( 2013). Ultra-Processed Products Are Becoming Dominant in the Global Food System. Obesity Reviews , 14, 21– 28. Google Scholar CrossRef Search ADS PubMed  Moodie R., Stuckler D., Monteiro C., Sheron N., Neal B., Thamarangsi T., Lincoln P., Casswell S. ( 2013). Profits and Pandemics: Prevention of Harmful Effects of Tobacco, Alcohol, and Ultra-Processed Food and Drink Industries. The Lancet , 381, 670– 679. Google Scholar CrossRef Search ADS   Moran M. ( 2002). Understanding the Regulatory State. British Journal of Political Science , 32, 391– 413. Google Scholar CrossRef Search ADS   Morris B., Neering P. A. ( 2008). The Pepsi Challenge: Can This Snack and Soda Giant Go Healthy? CEO Indra Nooyi Says Yes, but Cola Wars and Corn Prices Will Test Her Leadership. Fortune , 157, 54– 66. Moss M. ( 2013). Salt, Sugar, Fat: How the Food Giants Hooked Us . New York: Random House. National Heart Foundation of Australia. ( 2012). Rapid Review of the Evidence: Effectiveness of Food Reformulation as a Strategy to Improve Population Health, available from: https://www.heartfoundation.org.au/images/uploads/publications/RapidReview_FoodReformulation.pdf [accessed October 2017]. Nestle M. ( 2007). Food Politics: How the Food Industry Influences Nutrition and Health . Berkeley: University of California Press. New York City Health Department. ( 2012) National Salt Reduction Initiative Goals and Summary, available from: https://www1.nyc.gov/assets/doh/downloads/pdf/cardio/cardio-salt-factsheet.pdf [accessed March 2017]. Norum K. R. ( 2008). Pepsico Recruitment Strategy Challenged. Public Health Nutrition , 11, 112– 113. Google Scholar CrossRef Search ADS PubMed  Nuffield Council on Bioethics. ( 2007). Public Health: Ethical Issues, available from: http://nuffieldbioethics.org/wp-content/uploads/2014/07/Public-health-ethical-issues.pdf [accessed March 2017]. Nutrition Taskforce of the Better Health Commission. ( 1987). Towards Better Nutrition for Australians . Canberra: Nutrition Taskforce of the Better Health Commission. OECD. ( 2009). Regulatory Impact Analysis: A Tool for Policy Coherence . OECD Reviews of Regulatory Reform. Paris: OECD. Osborne D., Gaebler T. ( 1992). Reinventing Government: How the Entrepreneurial Spirit Is Transforming the Public Sector . New York: Plume. Panjwani C., Caraher M. ( 2014). The Public Health Responsibility Deal: Brokering a Deal for Public Health, but on Whose Terms? Health Policy , 114, 163– 173. Google Scholar CrossRef Search ADS PubMed  Parliament of Great Britain: House of Lords Science and Technology Select Committee. ( 2011). Behaviour Change, Session 2010-2012, available from: http://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/179.pdf [accessed March 2017]. Reeve B. ( 2011). The Regulatory Pyramid Meets the Food Pyramid: Can Regulatory Theory Improve Controls on Television Food Advertising to Australian Children? Journal of Law and Medicine , 19, 128– 147. Google Scholar PubMed  Reeve B., Magnusson R. ( 2013). ‘Legislative Scaffolding’: A New Approach to Prevention. Australian and New Zealand Journal of Public Health , 37, 494– 496. Google Scholar CrossRef Search ADS PubMed  Reingold J. ( 2015) Pepsico’s CEO Was Right. Now What?. Fortune , available from: http://fortune.com/2015/06/05/pepsico-ceo-indra-nooyi/ [accessed March 2017]. Republic of South Africa. ( 2013). Foodstuffs, Cosmetics and Disinfectants Act, 1972 (Act 54 of 1972)—Regulations Relating to the Reduction of Sodium in Certain Foodstuffs and Related Matters, No. R. 214. Réquillart V., Soler L.- G. ( 2014). Is the Reduction of Chronic Diseases Related to Food Consumption in the Hands of the Food Industry? European Review of Agricultural Economics , 41, 375– 403. Google Scholar CrossRef Search ADS   Resnik D. ( 2010). Trans Fat Bans and Human Freedom. The American Journal of Bioethics , 10, 27– 32. Google Scholar CrossRef Search ADS PubMed  Resnik D. B. ( 2014). Paternalistic Food and Beverage Policies: A Response to Conly. Public Health Ethics , 7, 170– 177. Google Scholar CrossRef Search ADS   Reynolds C. ( 2011). Public and Environmental Health Law . Sydney: The Federation Press. Ries N. M. ( 2007). Food, Fat and the Law: A Comment on Trans Fat Bans and Public Health. Windsor Review of Legal and Social Issues , 23, 17. Roberto C. A., Swinburn B., Hawkes C., Huang T. T. K., Costa S. A., Ashe M., Zwicker L., Cawley J. H., Brownell K. D. ( 2015). Patchy Progress on Obesity Prevention: Emerging Examples, Entrenched Barriers, and New Thinking. The Lancet , 385, 2400– 2409. Google Scholar CrossRef Search ADS   Rose G. A. ( 1992). The Strategy of Preventive Medicine . Oxford: Oxford University Press Sandrou D., Arvanitoyannis I. ( 2000). Low-Fat/Calorie Foods: Current State and Perspectives. Critical Reviews in Food Science and Nutrition , 40, 427– 447. Google Scholar CrossRef Search ADS PubMed  Santich B. ( 1995). What the Doctors Ordered: 150 Years of Dietary Advice , 1st edn. Melbourne: Hyland House. Santich B. ( 2005). Paradigm Shifts in the History of Dietary Advice in Australia. Nutrition and Dietetics , 62, 152– 157. Google Scholar CrossRef Search ADS   Schwartz M. B., Brownell K. D. ( 2007). Actions Necessary to Prevent Childhood Obesity: Creating the Climate for Change. Journal of Law, Medicine and Ethics , 35, 78. Google Scholar CrossRef Search ADS   Scott C. ( 2010). Standard-Setting in Regulatory Regimes. In Baldwin R., Cave M., Lodge M. (eds), The Oxford Handbook of Regulation . Oxford: Oxford University Press, pp. 104– 119. Scrinis G. ( 2013). Nutritionism: The Science and Politics of Dietary Advice . Sydney: Allen & Unwin. Google Scholar CrossRef Search ADS   Seabrook J. ( 2011) Snacks for a Fat Planet: Pepsico Takes Stock of the Obesity Epidemic. In The New Yorker, available from: http://www.newyorker.com/magazine/2011/05/16/snacks-for-a-fat-planet [accessed March 2017]. Sebillotte C. ( 2013). Efficiency of Public-Private Co-Regulation in the Food Sector: The French Voluntary Agreements for Nutritional Improvements, available from: http://econpapers.repec.org/paper/aliwpaper/2013-03.htm [accessed March 2017]. Semands E. ( 2014). Food Choice: Should the Government Be at the Head of the Table? Oklahoma Law Review , 67, 149– 190. Shrapnel B. ( 2012). Should Trans Fats Be Regulated? Nutrition and Dietetics , 69, 256– 259. Google Scholar CrossRef Search ADS   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 Medicine , 9, e1001235. Google Scholar CrossRef Search ADS PubMed  Stuckler D., Nestle M. ( 2012). Big Food, Food Systems, and Global Health. PLoS Medicine , 9, e1001242. Google Scholar CrossRef Search ADS PubMed  Stuckler D., Siegel K. ( 2011). Sick Societies: Responding to the Global Challenge of Chronic Disease . Oxford: Oxford University Press. Google Scholar CrossRef Search ADS   Swinburn B. ( 2002). Sustaining Dietary Changes for Preventing Obesity and Diabetes: Lessons Learned from the Successes of Other Epidemic Control Programs. Asia Pacific Journal of Clinical Nutrition , 11 (Suppl 3), S598– S606. Google Scholar CrossRef Search ADS PubMed  Swinburn B., Egger G. ( 2002). Preventive Strategies against Weight Gain and Obesity. Obesity Reviews , 3, 289– 301. Google Scholar CrossRef Search ADS PubMed  Taylor A. L., Parento E. W., Schmidt L. ( 2015). The Increasing Weight of Regulation: Countries Combat the Global Obesity Epidemic. Indiana Law Journal , 90, 257– 292. ten Have M., De Beaufort I., Teixeira P., Mackenbach J., van der Heide A. ( 2011). Ethics and Prevention of Overweight and Obesity: An Inventory. Obesity Reviews , 12, 669– 679. Google Scholar PubMed  Thow A. M., Annan R., Mensah L., Chowdhury S. N. ( 2014). Development, Implementation and Outcome of Standards to Restrict Fatty Meat in the Food Supply and Prevent NCDs: Learning from an Innovative Trade/Food Policy in Ghana. BMC Public Health , 14, 249– 257. Google Scholar CrossRef Search ADS PubMed  Truswell A. S. ( 1987). Evolution of Dietary Recommendations, Goals, and Guidelines. The American Journal of Clinical Nutrition , 45, 1060– 1072. Google Scholar CrossRef Search ADS PubMed  United Nations General Assembly. ( 2011). Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases, UN GAOR, 66th Sess, UN Doc a/66/L.1 (16 September). van Raaij J., Hendriksen M., Verhagen H. ( 2009). Potential for Improvement of Population Diet through Reformulation of Commonly Eaten Foods. Public Health Nutrition , 12, 325– 330. Google Scholar PubMed  Wansink B., Chandon P. ( 2006). Can ‘Low-Fat’ Nutrition Labels Lead to Obesity? Journal of Marketing Research , 43, 605– 617. Google Scholar CrossRef Search ADS   Watrous M. ( 2016) Three Trends Driving Gluten-Free Market. Food Business News, available from: http://www.foodbusinessnews.net/articles/news_home/Consumer_Trends/2016/02/Three_trends_driving_glutenfre.aspx?ID=%7BF0C580B5-8A77-433B-9C95-5B242D26520E%7D&cck=1 [accessed March 2017]. Webster J., Trieu K., Dunford E., Hawkes C. ( 2014). Target Salt 2025: A Global Overview of National Programs to Encourage the Food Industry to Reduce Salt in Foods. Nutrients , 6, 3274– 3287. Google Scholar CrossRef Search ADS PubMed  WHO. ( 1990). Diet, Nutrition and the Prevention of Chronic Diseases: Report of a WHO Study Group , Vol. 797. WHO Technical Report Series. Geneva: World Health Organization. WHO. ( 2004). Global Strategy on Diet, Physical Activity and Health . Geneva: World Health Organization. WHO. ( 2013). Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 . Geneva: World Health Organization. WHO. ( 2014). Global Status Report on Noncommunicable Diseases . Geneva: World Health Organization. Wilson J., Dawson A. ( 2010). Giving Liberty Its Due, but No More: Trans Fats, Liberty, and Public Health. The American Journal of Bioethics , 10, 34– 36. Google Scholar CrossRef Search ADS PubMed  Wiseman S. R. ( 2015). The Dangerous Right to Food Choice. Seattle University Law Review , 38, 1299– 1315. World Cancer Research Fund International. ( 2015). Curbing Global Sugar Consumption: Effective Food Policy Actions to Help Promote Healthy Diets and Tackle Obesity, available from: http://econpapers.repec.org/paper/aliwpaper/2013-03.htm [accessed March 2017]. World Cancer Research Fund International. ( 2017) Nourishing Framework, available fom: http://www.wcrf.org/int/policy/nourishing-framework [accessed March 2017]. Yach D., Feldman Z., Bradley D. G., Khan M. ( 2010). Can the Food Industry Help Tackle the Growing Global Burden of Undernutrition? American Journal of Public Health , 100, 974– 980. Google Scholar CrossRef Search ADS PubMed  Yach D., Hawkes C., Epping-Jordan J. E., Galbraith S. ( 2003). The World Health Organization's Framework Convention on Tobacco Control: Implications for Global Epidemics of Food-Related Deaths and Disease. Journal of Public Health Policy , 24, 274– 290. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

What’s Wrong with Mandatory Nutrient Limits? Rethinking Dietary Freedom, Free Markets and Food Reformulation

Loading next page...
 
/lp/ou_press/what-s-wrong-with-mandatory-nutrient-limits-rethinking-dietary-freedom-CQyX0Eq0VB
Publisher
Oxford University Press
Copyright
© The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
ISSN
1754-9973
eISSN
1754-9981
D.O.I.
10.1093/phe/phx019
Publisher site
See Article on Publisher Site

Abstract

Abstract Around the world, unhealthy diets are a leading cause of disease. Shifting population diets in a healthier direction will require downstream policy interventions. This means changing the composition of the processed food supply, particularly reducing salt, sugar and fat. Mandatory nutrient limits imposed by government are one way of achieving this. However, they have been criticized as a particularly intrusive regulatory option, interfering with both free markets and free choices. At the same time, voluntary industry reformulation has become an intervention favoured by national governments, the World Health Organization and the food industry. This article uses a comparison of the two interventions—which share a common public health goal, albeit achieved through different regulatory means—as a basis to evaluate the ethical charges against mandatory nutrient limits. It makes three main findings: (i) that both affect free dietary choice in very similar ways; (ii) that dominant public health ethics frameworks are not well equipped to compare mandatory and voluntary forms of regulation; and (iii) that food governance is inherently multisectoral, involving markets, governments and the public. Taking these findings into account, the article calls for a more nuanced ethical evaluation of food reformulation policies. Unhealthy Diets: A Policy Problem, and an Ethical Challenge Diet-related noncommunicable diseases (NCDs), including cardiovascular disease, stroke, type-2 diabetes and certain cancers, are now major contributors to morbidity and mortality in almost every jurisdiction on earth (Stuckler and Siegel, 2011; WHO, 2014). Accounting for more than 40 per cent of all NCD deaths, these share the underlying risk factor of unhealthy diets. As the prevalence and impact of diet-related NCDs has grown in recent decades, so has the list of preventive policy options available to governments. A key goal of prevention is to shift population diets in a healthier direction: less fat, sugar and salt, and fewer overall calories, as well as more fruits, vegetables and whole grains. However, this goal is in persistent tension with concerns about the potential for infringement on personal choice and dietary freedom (ten Have et al., 2011). One set of policy measures that have been described as particularly intrusive are mandatory nutrient limits. These are government regulations specifying upper permissible amounts of salt, fat or sugar in certain food products. In the public health law and ethics literature, they tend to be evaluated as an extreme and paternalistic state intervention, inappropriately interfering in both free markets and individuals’ right to their food choices. The essence of the critique is that removing consumers’ freedom to eat certain foods is too high a price to pay for what may only be incremental public health gains (Conly, 2014; Resnik, 2014). However, it seems that the critique does not apply when the food industry removes that same freedom. Voluntary food reformulation has become an intervention of choice for the World Health Organization (WHO), national governments and the food industry. The term tends to refer to actions of the food industry, with varying degrees of government involvement. Voluntary reformulation has the same public health goal as mandatory nutrient limits: to reduce over-consumed nutrients (salt, sugar or fat) in processed foods. And yet, it is rarely evaluated in terms of its ‘freedom’ impacts, whether on markets or individuals’ food choices. We are thus presented with two policy options that share a common goal of directly removing ingredients from the food supply, but which are assessed very differently in public health ethics terms. This provides a starting point for a critical reassessment of the ethical charges against mandatory nutrient limits. The article begins by explaining the concept of food reformulation, and why governments may seek to implement it as part of a prevention strategy on diet-related NCDs. It then sets out the two main policy approaches to reformulation, including the technical features, practical effects and ethical critiques of each. In the second half of the article, the comparison between these two approaches forms the basis for a close examination of the criticism that mandatory nutrient limits are a uniquely intrusive policy option. This leads to three key findings. First, that voluntary reformulation and mandatory nutrient limits in fact have very similar impacts on freedom of choice (the first limb of the critique). Secondly, that the dominant ethical frameworks for assessing public health policies, such as the Nuffield Ladder, are not well equipped to compare voluntary and mandatory forms of regulation. This is because they ignore the relationship between the food industry and the state. Finally, that the ‘free markets’ limb of the critique rests on a set of artificial binaries (voluntary/mandatory and market/state) that are not attuned to the context of food regulation. Drawing on the history of regulating diet-related NCDs, I argue that, as in all food governance, there is no such thing as strictly ‘government’ or strictly ‘market’ interventions. Ultimately, a meaningful comparison between mandatory and voluntary approaches to food reformulation must take place against a more nuanced understanding of the complex interactions between the state, the industry and the consuming public. Food Reformulation as Public Health Policy In the general context of food manufacturing, reformulation simply refers to changing the chemical or nutritional composition of processed foods for any reason (Garde, 2010). Manufacturers might reformulate a product to make it look or taste better (Moss, 2013) because of requirements related to the food’s ingredients, manufacture, storage or transportation (Golan and Unnevehr, 2008) or to keep up with consumer trends and demands (Watrous, 2016). However, in the context of diet-related disease, reformulation means changing the composition of processed food to achieve public health policy goals (Garde, 2010; EUFIC, 2010; National Heart Foundation of Australia, 2012). Specifically, it means removing trans fatty acids (TFAs; which have been shown to cause coronary heart disease) or limiting sodium (overconsumption of which is linked to high blood pressure and strokes) or sugar (linked to high blood sugar, diabetes and dental caries).1 While most policy approaches to diet-related NCDs focus on modifying our dietary choices and behaviours, reformulation instead aims to change the underlying food supply. This is because the determinants of unhealthy diets are environmental as well as individual: people select their diet from what is available (Hawkes et al., 2015; Roberto et al., 2015). Unlike educational or informational policies, reformulation involves a certain acceptance of the status quo of modern dietary habits. It accepts that people will continue to eat certain processed foods. Instead, it hopes that relatively minor changes to commonly consumed foods can have a major effect on population health (Swinburn, 2002). When a food is reformulated, ‘the consumer does not have to modify drastically his or her habitual dietary food pattern’ (van Raaij et al., 2009: 326), but nevertheless benefits from an improved diet. In this sense, it is an upstream intervention, modifying an environmental determinant of ill health (Rose, 1992)—or, more colourfully, ‘stealth health’ (Schwartz and Brownell, 2007: 80). Reformulation may be industry-led (voluntary reformulation) or may be government-led (mandatory nutrient limits). Mandatory Nutrient Limits What Are They? Mandatory nutrient limits are government regulations, currently in force in 25 jurisdictions worldwide. They are usually implemented as national food standards, but may also take the form of legislation or other rule types. They work by specifying permissible amounts of a given nutrient in a given food, and so force food manufacturers to reformulate if they want their food to remain on the market. Mandatory limits currently apply to fats (primarily trans fats) and salt. In 2004, Denmark was the first government to regulate an upper permissible limit, 2 per cent, on artificially produced TFAs. It has since been followed by nine other jurisdictions. The Netherlands introduced regulations in 2009 on the permissible amount of salt (sodium) in bread and flour. Eight jurisdictions followed, and in 2013 both South Africa and Argentina introduced mandatory sodium limits on a wide range of foodstuffs. Public health experts are now calling for mandatory limits on sugar (World Cancer Research Fund International, 2015), though so far no jurisdiction has implemented these. The Ethical Objection to Mandatory Nutrient Limits The literature on preventing diet-related NCDs tends to view government regulations in general as an extreme option, and mandatory nutrient limits as particularly intrusive. They are described as ‘highly paternalistic … heavy-handed, interfering with a person’s right to order what he or she wants’ (Gostin, 2008: 512), ‘the most far-reaching form of limiting choice’ (ten Have et al., 2011: 675) and ‘some of the most contentious public health laws’ (Taylor et al., 2015: 26). There are two limbs to the objection: the public is said to fear interference in free dietary choice, while the food industry fears interference in free markets, preferring non-regulatory approaches to public health (Cobiac et al., 2013). While the USA’s culture of ‘liberty of palate’ is well known (Linnekin, 2012; Semands, 2014; Wiseman, 2015), mandatory nutrient limits seem to be universally provocative. In Australia, the regulations have been described as ‘most unpopular’ (Commonwealth Department of the Parliamentary Library, 2001: 2) and ‘in the nature of a prohibition and [thus] controversial’ (Reynolds, 2011: 423). Similarly in Canada, Ries has noted that ‘regulatory interventions [on trans fats] are controversial’ and that critics view ‘food choices are fundamentally personal and an inappropriate arena for legal regulation’ (Ries, 2007: 17, 22). A European review found that mandatory nutrient limits would be effective but ‘intrusive’ (Brambila-Macias et al., 2011: 373). There is a small literature specifically addressing the ethics of mandatory nutrient limits. This has focused on trans fat limits, which have now been in the public consciousness for more than a decade (salt limits are a more recent development). Resnik’s (2010) article ‘Trans Fat Bans and Human Freedom’, and the resulting commentaries in the American Journal of Bioethics,2 is the best-known and most comprehensive treatment of the ethical charges against trans fat limits. Resnik does not dispute that TFA limits may improve health and save lives. Nonetheless, he finds their impact on freedom to be unacceptable because, first, there are other, less intrusive ways to reduce consumption of TFAs (for instance, through labelling and education, or through voluntary reformulation) and, secondly, trans fat limits are the first step on a slippery slope, which could ‘open the door to excessive government control’ over other food choices (Resnik, 2010: 29–30). For their part, defenders of TFA limits largely agree with Resnik. They agree that labelling and education are ‘softer’ alternatives to mandatory limits, but argue that these have been proved ineffective (Ries, 2007; Taylor et al., 2015). They also agree that TFA limits may pave the way for the ‘regulatory reconsideration of ingredients such as sugar, caffeine, and salt’, but they approve of this possibility (Brownell and Pomeranz, 2014: 1775). Most relevantly, they accept that TFA limits restrict our freedom to choose—but disagree on the importance of that freedom in this particular regulatory equation. They argue that other factors, core to the mission of public health, must also be considered: the very real social, physical and economic costs of NCDs to the community (Gostin, 2010; Wilson and Dawson, 2010). The Nature and Content of the Freedom Given that both critics and defenders agree that mandatory nutrient limits interfere with freedom, it is important to define the nature and content of that freedom. Questions of freedom (along with liberty and choice) lie at the heart of many debates in public health law and public health ethics (Childress et al., 2002, Dawson, 2011, Gostin and Wiley, 2016, and discussed further below). This is due to the focus of both disciplines on assessing the appropriate nature and reach of government action to protect public health. Core to this assessment is the extent to which such action might or should compromise liberty, autonomy, privacy ‘and other legally protected interests of individuals’ (Gostin and Wiley, 2016: 4). The relationship between the individual and the State—in public health or otherwise—can be described in terms of ‘freedoms’ that are broad and abstract. However, in the particular context of mandatory nutrient limits, the ‘freedom’ is quite narrow and specific. It is, as Resnik writes, ‘the freedom to choose what we eat’ (Resnik, 2010: 28). In the context of a modern, globalized, and—at least in wealthy countries—safe food supply, this freedom has become a feature of daily life, in a way that was possible at no other point in history. As Lang and colleagues write: ‘a family in Dublin, Paris, London or Berlin… can eat Italian, Japanese, Indian one moment, snack foods watching a Hollywood blockbuster film the next’ (Lang et al., 2009: 238). ‘The freedom to choose what we eat’ is a basic assumption of 21st-century capitalist culture, equally promulgated by food corporations and government health campaigns that emphasize consumer ‘choices’ (Mayes, 2014). As set out above, mandatory nutrient limits are government regulations on the amount of a particular nutrient in a particular food. They impact on the freedom to choose what we eat in the following ways: In Denmark, it is not possible to choose to eat a margarine containing more than 2 per cent artificially produced TFA (Danish Government, 2003); or In South Africa, it is not possible to choose to eat bread containing more than 380 mg of sodium per 100 g (Republic of South Africa, 2013); or In Ghana, it is not possible to choose to eat a cut of poultry with more than 15 per cent fat content (Thow et al., 2014), and so on. That is the practical effect of the regulations in each jurisdiction. The idea that food choices are fundamentally personal, and not a matter for government regulation, is at the heart of the ethical objection to mandatory nutrient limits. However, regulating food composition has been well within the scope of legitimate government activity for more than a century (French and Phillips, 2000). In jurisdictions around the world, and at the international level via the Codex Alimentarius Commission, governments already make rules about ‘what people may eat’, on food safety, consumer protection and other grounds. In the USA, for example, consumers may not purchase confectionery containing more than 0.5 per cent alcohol (Federal Food, Drug and Cosmetic Act 1938 §342(d)), or food containing the colouring additive amaranth (Federal Food, Drug and Cosmetic Act 1938 §348(a)). What makes mandatory nutrient limits controversial is not that they regulate food composition, or even that they limit certain nutrients in certain foodstuffs—but that they do so for the purpose of preventing chronic disease. Yet, even this purpose is not unique. As described below, voluntary reformulation—which has been endorsed by the WHO as an NCD-prevention strategy, and is becoming a favoured option of the food industry—has the same goal. As such, it provides a concrete comparison for examining the ethical objections to mandatory nutrient limits. Voluntary Reformulation International Policy Context: ‘All Could Become Partners’ Since the early 1990s, the WHO has encouraged the food industry to be responsible ‘partners’ in the prevention of diet-related NCDs, including by reformulating its products (WHO, 1990). By the turn of the century, public health experts were advising that ‘the food industry at all levels can be part of the solution’ (Yach et al., 2003: 276). This was formalized in 2004, with the publication of its Global Strategy on Diet, Physical Activity and Health (DPAS) (WHO, 2004). The DPAS emphasized the central role of governments, but noted that ‘all could become partners with governments and nongovernmental organizations in implementing measures … to encourage healthy eating’ (WHO, 2004: 61). The food industry was encouraged to produce products with lower levels of fats (trans and saturated), sugars and salt (WHO, 2004). The call to reformulate, and to encourage reformulation, has been consistent throughout later policy statements and guidance documents, including the United Nations (UN)’s Political Declaration on the Prevention and Control of Non-Communicable Diseases (United Nations General Assembly, 2011) and the WHO’s Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (WHO, 2013). National Reformulation Initiatives Member states have implemented the WHO’s guidance through a range of co-regulatory and quasi-regulatory arrangements. The UK’s salt reduction programme, 2003–2011—an early and successful example—is usually described as a government-led, voluntary scheme (Charlton et al., 2014), or as ‘voluntary with the threat of regulation/legislation’ (He et al., 2014: 351). Since then, a further 25 countries have implemented similar approaches to setting salt reduction targets across a range of foods (Webster et al., 2014). As documented by World Cancer Research Fund International (WCRF), most of these ‘voluntary’ industry initiatives involve the facilitation or guidance of at least one level of government (World Cancer Research Fund International, 2017). In addition, several countries and regions have implemented co- and quasi-regulatory policies to encourage reformulation across the food supply. Under the UK’s Responsibility Deal, for instance, companies are encouraged to make ‘pledges’ on reformulation ‘rather than resorting to regulation or top-down lectures’ (British Government Department of Health, 2010: 30). Similar partnership arrangements exist in the USA (New York City Health Department, 2012) and France (Sebillotte, 2013), while the European Union (EU) and Australia have established collaborative ‘platforms’ and ‘forums’, through which food companies can make voluntary commitments on food reformulation (European Commission DG Health and Food Safety, 2017; Australian Government Department of Health, 2017). In many of these cases, the state acts as little more than a facilitator—one partner among many—and official documents emphasize the voluntary nature of the reformulation. Yet, at the same time, all of these schemes are positioned as actions that the state is taking in relation to NCD prevention. If successful, reformulation is supposed to achieve improvements in the population’s diet and so reduce the modifiable risk factors of NCDs. Reformulation therefore appeals to two often-conflicting interests of 21st-century liberal democracies. On one hand, democratic governments have a duty to safeguard the health of the public (Gostin and Wiley, 2016). On the other, governments in capitalist, market-based economies face pressure to foster market freedom, and to limit their use of regulation (Cobiac et al. 2013, Lang and Heasman, 2015). Since the 1970s, government policy-making has been characterized by a preference for deregulation and market solutions, including voluntary or quasi-regulatory arrangements (Bartle and Vass, 2007). Policy-makers are encouraged to consider ‘whether an alternative approach to regulation may be a more efficient means of achieving a policy goal’ (OECD, 2009). As well as fitting in with philosophical preferences for a ‘smaller’ state, voluntary initiatives appeal to resource-constrained governments with an increasingly strong interest in containing public expenditure, including on monitoring and enforcement of industry regulation (Cobiac et al., 2013). Voluntary Reformulation and the Food Industry The other side of the ‘partnership’ equation is of course the food industry itself. Historically, reformulation has been a vexed proposition for the industry. The high levels of salt, sugar, fat and calories in processed food are closely related to the high profitability of that food (Moodie et al., 2013; Monteiro et al., 2013; Moss, 2013). However, in recent years, the contradiction between the profit motive and the epidemic of diet-related NCDs has become too glaring. With ‘business as usual’ no longer an option (Yach et al., 2010), the food industry has begun to advocate voluntary reformulation as a way to prevent diet-related disease. It has done so for several reasons. At one end of the spectrum is a profit incentive: the desire to tap into the lucrative market of consumer demand for ‘wellness’ and healthier foods (Michman and Mazze, 1998; Scrinis, 2013). At the other end of the spectrum is political pressure: the threat of governments introducing regulation, unless industry takes action of its own accord (Morris and Neering, 2008). Somewhere in the middle is corporate social responsibility—the desire of companies not only to be a ‘good corporate citizen’, but also to be seen as such (Lang and Heasman, 2015). Voluntary reformulation also involves a strong element of enlightened self-interest—recognition by companies that ‘long-term profits would be fatter if [the] customers were slimmer’ (Reingold, 2015) and that ‘cutting short the lives of your best customers isn’t much of a strategy for long-term success’ (Seabrook, 2011). In this regard, reformulation shares an important feature with another of the industry’s preferred responses to obesity, the focus on exercise and ‘energy balance’: neither implies eating, or selling, less food (Nestle, 2007; Seabrook, 2011). Indeed, far from slowing sales, there is evidence that marginal improvements to the healthiness of a product may confer a ‘halo’, ultimately assisting a company to sell more (Wansink and Chandon, 2006; Chandon and Wansink, 2007). Is There Any Ethical Criticism of Voluntary Reformulation? The constellation of factors set out above—from international health policy leadership to industry self-interest—helps to explain why reformulation has become ‘the default approach of many governments and the UN, and the preferred approach of industry’ on diet-related NCDs (Moodie et al., 2013: 675). However, it is not without its critics. The most frequent criticism of voluntary, co- or quasi-regulatory reformulation schemes is that they are not effective. In the absence of meaningful oversight mechanisms and sanctions for non-compliance, voluntary reformulation initiatives may (at best) advance slowly or (at worst) provide a smokescreen for inaction. A systematic review found that while mandatory trans fat limits ‘virtually eliminated TFAs from the food supply’, voluntary limits ‘were more variable and depended largely on the food category’ (Downs et al., 2013: 263). Further, an assessment of reformulation goals under the Australian Food and Health Dialogue (now called the Healthy Food Partnership) found that compliance on voluntary targets was patchy—likely due to the lack of accountability (Elliott et al., 2014). This effectiveness critique also has an ethical dimension: that the food industry has too great a conflict of interest to ever be a genuine ‘partner’ in public health (Norum, 2008; Monteiro et al., 2010; Moodie et al., 2013). Critics argue that voluntary food industry schemes are doomed to fail because there is ‘no evidence for an alignment of public health interest in curbing obesity with that of the food and beverage industry’ (Stuckler and Nestle, 2012: 2). Worse, handing responsibility to food companies ‘partners’ may actually provide them with access and opportunities to influence public health policy (Panjwani and Caraher, 2014). However, what is missing from such critiques of reformulation—a policy approach approvingly described as ‘stealth health’ by governments and industry (EUFIC, 2009; Jargon, 2014)—is any mention of its impact on ‘freedom to choose what to eat’. Whether reformulation is voluntary, quasi-regulatory, co-regulatory or mandatory, if it is effective, and covers all food products in a relevant category, then it must be presumed to affect consumers in the same way. That is, whether sodium in bread is reduced through voluntary reformulation or through mandatory nutrient limits, the net intended impact on consumers is that their bread is less salty. Yet, if the freedom to eat salty bread is so valuable as to override arguments for mandatory limits, it should also override arguments in favour of voluntary reformulation. Because the goal of a bona fide voluntary, co-regulatory or quasi-regulatory reformulation scheme should be the same as that of a mandatory scheme: to reduce the specified nutrient in the specified food. The intended effect of the UK’s voluntary salt reduction programme was to prevent consumers from buying bread that is saltier than 360 mg per 100 g (Charlton et al., 2014). Yet, neither academic nor popular debates tend to frame successful voluntary reformulation initiatives as an unacceptable intrusion on freedom of choice. Why, then, are mandatory limits seen as a controversial and intrusive, while voluntary reformulation is enthusiastically embraced by stakeholders at all levels? Evaluating Public Health Interventions: Ethical Frameworks Personal liberty and freedom of choice (including consumer choice) are ‘among the most firmly held desiderata of modern liberal society’ (Jackson, 2006: 109). However, they often come into conflict with the population focus and community orientation of public health (Kass, 2004; Dawson, 2011). As Geoffrey Rose noted, in public health: we are confronted by two irreconcilable opposites, yet both need to be accepted for both have authority. Personal freedom is paramount, yet every attempt to change our affairs for the better must of necessity impinge on that freedom because the aim is to influence what people do. (Rose, 1992: 114–`115) States therefore have a duty to consider whether public health interventions will be acceptable to their citizens. Accordingly, two ongoing themes in public health ethics are (i) the tension or balance between securing population health and protecting the rights of individuals, and (ii) defining the appropriate role and reach of the state. Both feed into an ongoing theoretical project of public health ethics, which is the development of frameworks or tools to evaluate the justifiability of different public health interventions (Childress et al., 2002; Gostin, 2002; Kass, 2004; Bayer et al., 2007; Nuffield Council on Bioethics, 2007; Dawson, 2011; Gostin and Wiley, 2016). Freedom (in various forms) has occupied a central role in most of these frameworks. In the policy-making context, the Nuffield Council on Bioethics’ ‘Ladder of Interventions’ (Nuffield Council on Bioethics, 2007) has been most influential. In its 2007 report ‘Public health: ethical issues’, the Nuffield Council (the Council) aimed to present ‘an ethical framework for the scrutiny of public health policies’. Its motivating question is ‘when and how the State should act’ to secure public health (Nuffield Council on Bioethics, 2007: v). Beginning with the foundation of classical liberalism, JS Mill’s harm principle, the Council adds a ‘social dimension’ to take account of the fact that individuals do not make decisions about their behaviours and choices in a vacuum, but within the context of community norms and collective goods. This produces a ‘revised liberal framework’, or ‘stewardship model’, which seeks to balance the competing interests described by Geoffrey Rose, above. Under the stewardship model, governments should assist people to live healthy lives, by giving ‘discouragement and assistance’ through ‘the provision of services through which risks are minimised and people are helped to change their behaviour’ (Nuffield Council on Bioethics, 2007: 25). However, they should stop short of coercing adults to live healthy lives, and should ‘seek to minimise interventions that are perceived as unduly intrusive and in conflict with important personal values’. The ‘Nuffield Ladder’, reproduced as Figure 1, below, gives a visual form to this guidance. The Ladder does not suggest specific kinds of interventions, but sets out broad approaches. These range from ‘do nothing and monitor the situation’ (which the Council emphasizes is still a policy choice) to ‘eliminate choice’. Importantly, the Ladder comes with guidance that ‘the higher the rung on the ladder at which the policy maker intervenes, the stronger the justification has to be’—because of the potential impact on freedom (Nuffield Council on Bioethics, 2007: 25). Figure 1. View largeDownload slide Nuffield Ladder of interventions. Figure 1. View largeDownload slide Nuffield Ladder of interventions. Where Does Voluntary Reformulation Sit on the Ladder? The Nuffield Ladder is a useful policy tool for public health because it allows different intervention options to be compared. In theory then, it should enable a comparative ethical evaluation of mandatory nutrient limits and voluntary reformulation, as illustrated by the following scenarios (Figure 2): Scenario 1 would sit right at the top of the Nuffield Ladder: ‘eliminate choice’. The state has eliminated consumers’ choice to buy foods containing more than 2% TFAs, by eliminating the food industry’s choice to sell such foods. However, the only way to describe Scenario 2 in Nuffield terms is that the state ‘does nothing and simply monitors the situation’—the lowest rung on the Ladder. And yet, the impact on consumers is the same as in Scenario 1: the choice to eat TFA-containing food has been eliminated. For a non-mandatory reformulation scheme to be taken seriously as an NCD-prevention strategy, it must be able to demonstrate effectiveness. But effectiveness, in this case, means effective at removing or reducing consumer choice. Why then are mandatory limits, but not voluntary reformulation, regarded as uniquely freedom-limiting? Figure 2. View largeDownload slide Examples of mandatory versus voluntary removal of TFA from food. (Shrapnel, 2012). Figure 2. View largeDownload slide Examples of mandatory versus voluntary removal of TFA from food. (Shrapnel, 2012). Reintroducing the Regulated Industry The reason for this disparity is that the standard bioethical models, as exemplified by the Nuffield Ladder, tend to be interested in the impact or intrusion of the state on individuals. They classify actions of the state according to the extent to which those actions will impinge on individual liberty. As such, they have been criticized by Dawson and others for retaining a Millean focus on the centrality of ‘non-interference’, inappropriately imported from medical ethics (Dawson, 2011). This, Dawson argues, is to miss the point of public health. Social justice, rather than liberty, is the core mission of public health. Only ‘someone who thinks that liberty is all that matters’ would use such a framework for public health policy decision-making (Dawson, 2016). Accordingly, ‘modified liberal’ frameworks, focused on preserving individual liberty, are not, by themselves, appropriate yardsticks for judging the merits of public health policies. To the ethicist’s critique, however, we must also add that of the regulatory theorist: that the modified liberal frameworks do not adequately reflect the range of actors and institutions involved in public health intervention, and especially in food governance. Modified liberal frameworks assume that counteracting public health risks always or usually involves regulating individuals. Yet, many threats to public health are not caused or carried by individuals (Egger and Swinburn, 1997; Swinburn and Egger, 2002), but by industries—and so, counteracting risk involves regulating those industries.3 However, the Nuffield Ladder tells us nothing about the form of the regulation, or the actors and institutions involved in its implementation and enforcement. In focusing attention on the relationship between governments and individuals, it ignores the relationship between industry and individuals, and the relationship between industry and the state—a triad crucial to understanding food governance (Lang, 2006; Lang et al., 2009). Further, classifying interventions solely according to their impact on individuals tells us nothing about the very different burdens and costs they might impose on businesses, which can often account for their very different political acceptability. Filling this gap, regulatory studies is the body of work that deals primarily with the actors and institutions involved in regulation—the state, but also non-state actors and the regulated industry itself (Freiberg, 2010). Along with the privatization of public assets and the fragmentation of traditional bureaucratic structures, the current deregulatory era has also brought about fundamental changes to the role of the state. This has been marked by decreased emphasis on traditional command-and-control apparatus, and an increased role for other, ‘softer’, ‘decentred’ or ‘networked’ forms of governance, involving a range of non-governmental and private sector actors (Moran, 2002; Bartle and Vass, 2007; Lang et al., 2009). This shift from ‘governing’ to ‘governance’ has been described as the rise of the neoliberal or regulatory state, or as the state ‘steering rather than rowing the ship of government’ (Osborne and Gaebler, 1992). In the regulatory state, power is decentralized and diffused, but the reach and number of different regulatory forms, such as guidelines, standards, codes of practice, proliferates (Bartle and Vass, 2007; Scott, 2010). Regulatory studies has closely observed these developments, analysing and classifying the new and emerging modes of regulation (Black, 2002; Drahos, 2017). It offers the language and tools to differentiate regulatory options in ways other than by focusing on freedom of (consumer) choice: for instance, by focusing on the relative costs and benefits imposed by different regulatory modes on different regulatory actors. However, only very recently have scholars begun to combine the analytical tools of regulatory studies with those of public health law and ethics (e.g. Reeve, 2011). Public health ethics frameworks are well equipped to differentiate between regulatory forms: for instance, between a labelling scheme versus taxation. However, they are poorly equipped to deal with regulatory modes, for instance, ‘a labelling scheme that is voluntary with government oversight’ versus ‘a labelling scheme that is a public-private partnership’. Once we understand this, the problem becomes clear: mandatory nutrient limits have been analysed under one lens, and voluntary reformulation under another. Mandatory nutrient limits have been understood as traditional state regulation, and thus assessed primarily for their ‘Nuffield’, or freedom-limiting, impacts. Meanwhile, voluntary reformulation has been understood as a new, decentred, ‘partnership’ mode of regulation, and evaluated accordingly. Both assessments have an ethical dimension, whether related to freedom of choice or to conflicts of interest. However, these have not, to date, permitted a true like-with-like comparison. Such a comparison would ask: What are the freedom-limiting impacts of voluntary reformulation? And, what are the relative benefits and burdens imposed on the actors involved in mandatory nutrient limits? As described above, the freedom-limiting impacts of voluntary reformulation should be very similar to those of mandatory nutrient limits. Indeed, the very definition of a successful voluntary reformulation scheme would be that it eliminated consumers’ choice to eat the specified quantity of the targeted nutrient. The freedom-of-choice argument against mandatory nutrient limits is then, if not quite a red herring, at least substantially neutralized by a comparison with voluntary reformulation. Clearly, food stakeholders—from the WHO to PepsiCo—are not unduly uncomfortable with the purpose of such regulation. If the purpose is not the real problem, we must next examine the form of the regulation. State Regulation and Free Markets in Food Regulation: A Spectrum Rather than a Binary ‘A Market Solution’ I now turn to the ‘free markets’ limb of the ethical critique of mandatory nutrient limits. While acknowledging the wide variance in free market economies around the world, I here use the term to summarize those appeals to market forces, the laws of supply and demand and a preference for less, or lighter, government regulation. The critique—often made by the food industry—is that, in addition to limiting freedom of choice, mandatory nutrient limits entail regulatory overreach by the state. Instead of government regulation, ‘market forces, driven by informed individual choice, [should] correct for negative results caused by high consumption of unhealthy commodities’ (Moodie et al., 2013: 675). Arguing against regulation, the food industry is optimistic that ‘if sufficiently many people demand food with a certain attribute, producers will respond and supply it’ (Deloitte Access Economics, 2013: 14)—all we need do is wait for ‘market readiness and business opportunity in a nation that values the healthfulness of its foods and beverages’ (Lavizzo-Mourey et al., 2014: e8). In this final section, I draw again on the comparison with voluntary reformulation to argue that such a strict state/market dichotomy is a fiction in food governance. Rather, both options—voluntary reformulation and mandatory nutrient limits—require a high degree of involvement from governments as well as the food industry. Whose Supply? Whose Demands? The ‘free market’ model assumes that companies respond only, or primarily, to consumer demand. This oversimplifies the complex entanglement of socio-economic, cultural and policy factors that shape dietary demand. Further, it ignores the influence in the opposite direction: the well-documented ways in which the industry, through marketing and through the products themselves, shapes consumer demand (Nestle, 2007; Monteiro et al., 2010; Stuckler et al., 2012; Moss, 2013). Importantly, it also ignores the extent to which, over the past half-century, government actions have shaped the dynamics of our consumption habits. Since the 1960s, for example, governments around the world have formulated and disseminated food-based dietary guidelines as a response to diet-related NCDs. In the wake of the Framingham study, which in the early 1950s provided evidence of the link between diet and cardiovascular disease, expert committees around the world began producing evidence on the link between diet and health (Truswell, 1987). To decrease the incidence of diabetes, cancer, heart disease, stroke and obesity, they recommended populations consume less fat (especially saturated fat), salt, sugar and overall dietary energy. By 1982, most high-income countries had published dietary guidelines (Truswell, 1987). Most of these did not aim to influence the food supply directly—rather, they were directed downstream, at consumers’ behaviour and ‘lifestyle’ choices (Nutrition Taskforce of the Better Health Commission, 1987; Hetzel and McMichael, 1989; Santich, 1995; Nestle, 2007). Nevertheless, these guidelines exerted a powerful, if indirect, effect on food producers, in the following way. On the basis of the scientific findings and government guidelines, ‘the low cholesterol, low fat diet [became] the cornerstone of public health nutrition’ for its supposed cardio-protective properties (Kromhout, 2015: 1). Consumers then began to seek out products that fitted in with this new, ‘low fat era’ (Santich, 2005). Skim or low-fat milk, previously considered an inferior food, was now in high demand, placing pressure on food producers to adjust the food supply. In Australia, milk processors responded by changing the system of farm-gate payments: instead of being paid for the percentage of dairy fat in their milk, as traditionally, farmers were now paid for the ratio of dairy fat to lean protein in milk (Santich, 1995). In Europe, low-fat dairy products had been considered special foods for diabetics in the 1980s; by the late 1990s, low-fat varieties made up 60 per cent of the yoghurt market and 70 per cent of the milk market (Sandrou and Arvanitoyannis, 2000). Similarly, the 2005 American Dietary Guidelines’ recommendation to consume more whole grains led to increased competition among firms to offer such products (Mancino et al., 2008). This led to increased consumption of whole grains—even in consumers who had not been demanding more grains, or were not even aware of the guidelines. After dietary guidelines, the next major policy response to diet-related NCDs was mandatory nutrition labelling: governments requiring food producers to present nutritional information, in a standardized format, on the packaging of eligible food and drink. This now applies in more than 20 national jurisdictions, as well as the European Union (Drichoutis et al., 2006; Campos et al., 2011; Kasapila and Shaarani, 2016). The primary purpose of such labels is to provide ‘the consumer with information about a food so that a wise choice of food can be made’ (FAO, 1985). But despite the language of consumer choices, here again the state has been an important actor shaping supply and demand. The first country to legislate mandatory nutrition labels was the USA, in 1990 (Federal Food, Drug and Cosmetic Act 1938 Part 101). In addition to educating consumers to make better choices, the legislation also aimed to give manufacturers an incentive to improve the nutritional profiles of their foods. A 2008 summary of the evidence found that nutrition labelling policies spur ‘competition in the food industry [which in turn] leads to fairly rapid reformulation of products’ (Golan and Unnevehr, 2008: 466). These examples illustrate that, in food governance, the concept of a ‘free market’ solution is more complicated than ‘consumers demand and producers supply’. In the cases of dietary guidelines and mandatory labelling, we observe the complex ways in which the state, the food industry and the public interact to create and respond to markets for healthier food products. In doing so they reveal that, even in ‘market’ solutions to diet-related NCDs, the state is already deeply implicated. Food Governance Is Inherently Multisectoral In its Global Action Plan for the Prevention and Control of NCDs, the WHO describes multisectoral action as involving multiple sectors of government, as well as—where appropriate—actors and institutions outside of government (WHO, 2013). When we compare voluntary reformulation and mandatory nutrient limits, both display characteristics of multisectoral action. As highlighted above, ‘voluntary’ reformulation in fact occupies a broad regulatory spectrum, from the commercial decisions of individual companies to the UK’s ‘government-led’ voluntary salt reduction. Scattered in between are the public–private partnerships and the co-regulatory and quasi-regulatory schemes. Beyond the fact of being ‘not mandatory’, these can have little in common. Governments are involved to different degrees and at different stages, and even the involvement of industry may differ, from policy-making to implementation. Their effectiveness is different, they may be ‘owned’ by different stakeholders (e.g. in the USA, the National Salt Reduction Initiative is hosted on a government website, while the Healthy Weight Commitment Foundation has a much more corporate image) (New York City Health Department, 2012; Healthy Weight Commitment Foundation, 2017). They may be supported to a greater or lesser degree by surrounding policies, such as a public awareness or education campaigns (van Raaij et al., 2009). In this context, the idea that mandatory limits are somehow unique—quite distinct from this spectrum of voluntary options—is unrealistic. Even command-and-control regulation leaves room for (and in some cases, even requires) a high degree of industry involvement. Denmark, for example, introduced its regulation on trans fats only after industry had demonstrated technical feasibility by implementing voluntary measures for some years (Katan, 1995, 2006). In the case of South Africa’s sodium regulations, the food industry was closely involved, through working groups, in setting timelines and targets that were eventually incorporated into the regulation (Charlton et al., 2014; Hofman and Tollman, 2013). In both Denmark and South Africa, there was evidence that industry members had lobbied for regulation, to ensure a level playing field among competitors. Finally, as discussed above, the common theme among suggestions for improving the effectiveness and robustness of voluntary reformulation schemes is more state involvement: adding in various ingredients of ‘mandatoriness’, such as tougher targets and timelines, and even sanctions for non-compliance (Brambila-Macias et al., 2011; Reeve and Magnusson, 2013; Réquillart and Soler, 2014; Magnusson and Reeve, 2015). Such that, when we compare a mandatory nutrient limit with an effective voluntary reformulation scheme, there is very little to separate them. As Charlton and colleagues found in their comparison of the (voluntary) UK and (mandatory) South African approaches to salt reduction, the programmes in fact had much in common in a substantive sense, including multisectoral involvement. The main difference was technical, i.e. the introduction of regulations in South Africa (Charlton et al., 2014). What this suggests is that mandatory nutrient limits belong on the same spectrum with the voluntary approaches, rather than distinct from it. The idea that one is a state intervention and the other a market solution is an artificial binary that does not reflect the evidence. Conclusion Evaluating public health interventions requires us to take multiple factors into account. As Gostin has set out, effectiveness and cost-effectiveness are relevant, but so are public acceptability and fairness (Gostin and Wiley, 2016). Faced with the ongoing, worldwide epidemic of diet-related NCDs, governments will increasingly be forced to consider measures that directly regulate over-consumed nutrients in the food supply—including mandatory and voluntary alternatives. As such, it is important to assess the criticism that mandatory nutrient limits are an unacceptably intrusive intervention. Policy-makers will need to consider how much weight to give this argument—sometimes alongside effectiveness evidence, but other times (as is often the case in public health regulation) in its absence. The objection to mandatory nutrient limits rests on two propositions: That mandatory limits interfere with freedom of (consumer) choice; and That mandatory nutrient limits interfere with free markets. As abstract philosophical propositions, these may be convincing. As policy debate, they are less so because the merits (ethical and otherwise) of mandatory nutrient limits must be assessed in the context of other policy alternatives. Voluntary reformulation, which shares the goal of preventing diet-related NCDs by limiting salt, sugar and fat in processed foods, provides an ideal comparator for this assessment. By comparing mandatory nutrient limits with reformulation, I have demonstrated that, in answer to the propositions above: If we compare like with like, the two interventions in fact have very similar impacts on freedom; and The relationship between the state and the market is complex and dynamic. As in all food regulation, the state is deeply implicated in constructing consumer ‘choice’, and even command-and-control measures involve a high degree of participation by the regulated industry. Neither of these findings overrides the ethical objection to mandatory nutrient limits. Instead, they enable a more nuanced consideration of the applicability of mandatory nutrient limits in any given setting. So, for instance, if the choice is between a voluntary and a mandatory scheme for improving the composition of food, the impact on freedom of choice can be considered moot. This paves the way for other, more decisive considerations—effectiveness, cost-effectiveness, cost to each stakeholder, potential for conflict of interest and ways to manage that conflict—to be taken into account. Reflecting free market ideals, governments’ preference for industry schemes is likely to persist. But, given the increasing evidence linking greater state involvement with more successful food reformulation outcomes, a default preference for the ‘voluntary’ may start to require a stronger justification. Acknowledgements Thanks to Prof Roger Magnusson and Dr Anne Marie Thow, who reviewed and gave valuable feedback on earlier drafts of the article. The anonymous reviewers also provided helpful and constructive comments. Funding This work was conducted as part of the author's PhD. The PhD is funded by an Australian Postgraduate Award from the Australian Government, and by supplementary scholarship funding from the Sydney Law School and the Charles Perkins Centre. Footnotes 1. In theory, reformulation can also involve adding nutrients associated with NCD prevention (fruit, vegetables, whole grains, fibre)—e.g. General Mills pledging to use whole grains in its cereals in 2004 (Schwartz and Brownell, 2007). But the more common understanding relates to removing or reducing trans fats, saturated fats, salt, sugar or energy density (van Raaij et al., 2009). 2. Note that Resnik’s article and the responses to it draw on evidence from local and state bans in the USA, as this literature predates the more recent move to regulate TFAs at the national or federal level. 3. This problem has been pointed out by the British House of Lords (HoL). In an extensive 2011 report on behaviour change regulation, the HoL criticized the British government (then a coalition between the Conservatives and Liberal Democrats) for inappropriately using the Nuffield Ladder to justify a preference for deregulation. The HoL’s Select Committee wrote that the Ladder ‘was used in [the Government White Paper on health] to justify avoiding the regulation of businesses, although the Nuffield Ladder was only intended to apply to policies directed at individuals’ (Parliament of Great Britain: House of Lords Science and Technology Select Committee, 2011) References Australian Government Department of Health. ( 2017) Healthy Food Partnership, available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/Healthy-Food-Partnership-Home [accessed March 2017]. Bartle I., Vass P. ( 2007). Self-Regulation within the Regulatory State: Towards a New Regulatory Paradigm? Public Administration , 85, 885– 905. Google Scholar CrossRef Search ADS   Bayer R., Gostin L. O., Jennings B., Steinbock B. (eds) ( 2007). Public Health Ethics: Theory, Policy, and Practice . New York: Oxford University Press. Black J. ( 2002). Critical Reflections on Regulation. Australian Journal of Legal Philosophy , 27, 1– 35. Brambila-Macias J., Shankar B., Capacci S., Mazzocchi M., Perez-Cueto F. J., Verbeke W., Traill W. B. ( 2011). Policy Interventions to Promote Healthy Eating: A Review of What Works, What Does Not, and What Is Promising. Food and Nutrition Bulletin , 32, 365– 375. Google Scholar CrossRef Search ADS PubMed  British Government Department of Health. ( 2010). Healthy Lives, Healthy People: Our Strategy for Public Health in England. London: British Government Department of Health. Brownell K. D., Pomeranz J. L. ( 2014). The Trans-Fat Ban—Food Regulation and Long-Term Health. New England Journal of Medicine , 370, 1773– 1775. Google Scholar CrossRef Search ADS PubMed  Campos S., Doxey J., Hammond D. ( 2011). Nutrition Labels on Pre-Packaged Foods: A Systematic Review. Public Health Nutrition , 14, 1496– 1506. Google Scholar CrossRef Search ADS PubMed  Chandon P., Wansink B. ( 2007). The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions. Journal of Consumer Research , 34, 301– 314. Google Scholar CrossRef Search ADS   Charlton K., Webster J., Kowal P. ( 2014). To Legislate or Not to Legislate? A Comparison of the UK and South African Approaches to the Development and Implementation of Salt Reduction Programs. Nutrients , 6, 3672. Google Scholar CrossRef Search ADS PubMed  Childress J. F., Faden R. R., Gaare R. D., Gostin L. O., Kahn J., Bonnie R. J., Kass N., Mastroianni A., Moreno J., Nieburg P. ( 2002). Public Health Ethics: Mapping the Terrain. The Journal of Law, Medicine and Ethics , 30, 170– 182. Google Scholar CrossRef Search ADS   Cobiac L. J., Veerman L., Vos T. ( 2013). The Role of Cost-Effectiveness Analysis in Developing Nutrition Policy. Annual Review of Nutrition , 33, 373– 393. Google Scholar CrossRef Search ADS PubMed  Commonwealth Department of the Parliamentary Library. ( 2001). Food Regulation in Australia—A Chronology . Commonwealth Department of the Parliamentary Library. Conly S. ( 2014). Response to Resnik. Public Health Ethics , 7, 178– 179. Google Scholar CrossRef Search ADS   Danish Government. ( 2003). Order on the Content of Trans Fatty Acids in Oils and Fats Etc., Order No. 160 of 11 March 2003, pursuant to s.13, s.55(2) and s.78(3) of Act No 471 of 1 July 1998, the Food Act. Denmark. Dawson A. (ed.) ( 2011). Public Health Ethics: Key Concepts and Issues in Policy and Practice . Cambridge: Cambridge University Press. Google Scholar CrossRef Search ADS   Dawson A. J. ( 2016). Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy. Journal of Medical Ethics , 42: 510– 513. Google Scholar CrossRef Search ADS PubMed  Deloitte Access Economics. ( 2013). Reforming Regulation of the Australian Food and Grocery Sector—Report Commissioned by the Australian Food and Grocery Council, available from: https://www2.deloitte.com/au/en/pages/economics/articles/reforming-regulation-australian-food-grocery-sector.html [accessed October 2017]. Downs S. M., Thow A. M., Leeder S. R. ( 2013). The Effectiveness of Policies for Reducing Dietary Trans Fat: A Systematic Review of the Evidence. Bulletin of the World Health Organization , 91, 262– 269. Google Scholar CrossRef Search ADS PubMed  Drahos P. (ed.) ( 2017). Regulatory Theory: Foundations and Applications . Canberra: ANU Press. Google Scholar CrossRef Search ADS   Drichoutis A., Lazaridis P., Nayga R. M. ( 2006). Consumers’ Use of Nutritional Labels: A Review of Research Studies and Issues. Academy of Marketing Science Review , 10, 1– 22. Egger G., Swinburn B. ( 1997). An ‘Ecological’ Approach to the Obesity Pandemic. British Medical Journal , 315, 477– 480. Google Scholar CrossRef Search ADS PubMed  Elliott T., Trevena H., Sacks G., Dunford E., Martin J., Webster J., Swinburn B., Moodie R., Wilson A., Neal B. ( 2014). A Systematic Interim Assessment of the Australian Government’s Food and Health Dialogue. Medical Journal of Australia , 200, 92– 95. Google Scholar CrossRef Search ADS PubMed  EUFIC. ( 2009). Reformulating Food Products for Health: Context and Key Issues for Moving Forward in Europe, available from: http://ec.europa.eu/health//sites/health/files/nutrition_physical_activity/docs/ev20090714_wp_en.pdf [accessed March 2017]. EUFIC. ( 2010). Food Innovation and Reformulation for a Healthier Europe—a Challenging Mission, available from: http://www.eufic.org/article/en/artid/Food-innovation-reformulation-healthier-Europe-challenging-mission/ [accessed 12 August 2015]. European Commission DG Health and Food Safety. ( 2017) EU Platform for Action on Diet, Physical Activity and Health, available from: http://ec.europa.eu/health/nutrition_physical_activity/platform_en [accessed March 2017]. FAO. ( 1985). Guidelines on Nutrition Labelling, CAC/GL 2-1985. FAO. Federal Food, Drug and Cosmetic Act of 1938, 21 U.S.C. ( 2006), United States of America. Freiberg A. ( 2010). The Tools of Regulation . Sydney: Federation Press. French M., Phillips J. ( 2000). Cheated Not Poisoned? Food Regulation in the United Kingdom, 1875-1938 . Manchester: Manchester University Press. Garde A. ( 2010). EU Law and Obesity Prevention . The Netherlands: Kluwer Law International. Golan E., Unnevehr L. ( 2008). Food Product Composition, Consumer Health, and Public Policy: Introduction and Overview of Special Section. Food Policy , 33, 465– 469. Google Scholar CrossRef Search ADS   Gostin L. O. ( 2008). Public Health Law—Power, Duty, Restraint , 2nd edn. Berkeley: University of California Press. Gostin L. O. ( 2010). Trans Fat Bans and the Human Freedom: A Refutation. The American Journal of Bioethics , 10, 33– 34. Google Scholar CrossRef Search ADS PubMed  Gostin L. O. (ed.) ( 2002). Public Health Law and Ethics: A Reader . Berkeley: University of California Press; Milbank Memorial Fund. Gostin L. O., Wiley L. F. ( 2016). Public Health Law: Power, Duty, Restraint , Vol. 3. Oakland: University of California Press. Hawkes C., Smith T. G., Jewell J., Wardle J., Hammond R. A., Friel S., Thow A. M., Kain J. ( 2015). Smart Food Policies for Obesity Prevention. Lancet , 385, 2410– 2421. Google Scholar CrossRef Search ADS PubMed  He F., Brinsden H., MacGregor G. ( 2014). Salt Reduction in the United Kingdom: A Successful Experiment in Public Health. Journal of Human Hypertension , 28, 345– 352. Google Scholar CrossRef Search ADS PubMed  Healthy Weight Commitment Foundation. ( 2017) About HWCF: Engaging Families, Communities and Schools to Change the Outlook of a Generation, available from: http://www.healthyweightcommit.org/about/ [accessed March 2017]. Hetzel B. S., McMichael T. ( 1989). The LS Factor: Lifestyle and Health . Australia: Penguin. Hofman K. J., Tollman S. M. ( 2013). Population Health in South Africa: A View from the Salt Mines. The Lancet Global Health , 1, e66– e67. Google Scholar CrossRef Search ADS PubMed  Jackson T. ( 2006). The Earthscan Reader in Sustainable Consumption . London: Earthscan. Jargon J. ( 2014) Less Salt, Same Taste? Food Companies Quietly Change Recipes. Wall Street Journal , available from: http://www.wsj.com/articles/food-companies-quietly-cut-salt-fat-from-recipes-1403566403 [accessed March 2017]. Kasapila W., Shaarani S. M. ( 2016). Legislation, Impact and Trends in Nutrition Labeling: A Global Overview. Critical Reviews in Food Science and Nutrition , 56, 56– 64. Google Scholar CrossRef Search ADS PubMed  Kass N. E. ( 2004). Public Health Ethics: From Foundations and Frameworks to Justice and Global Public Health. The Journal of Law, Medicine and Ethics , 32, 232– 242. Google Scholar CrossRef Search ADS   Katan M. B. ( 1995). Exit Trans Fatty Acids. The Lancet , 346, 1245– 1246. Google Scholar CrossRef Search ADS   Katan M. B. ( 2006). Regulation of Trans Fats: The Gap, the Polder, and Mcdonald's French Fries. Atherosclerosis Supplements , 7, 63– 66. Google Scholar CrossRef Search ADS PubMed  Kromhout D. ( 2015). Where the Latest US Dietary Guidelines Are Heading. British Medical Journal , 351, h4034. Google Scholar CrossRef Search ADS PubMed  Lang T. ( 2006). Food, the Law and Public Health: Three Models of the Relationship. Public Health , 120, 30– 41. Google Scholar CrossRef Search ADS PubMed  Lang T., Barling D., Caraher M. ( 2009). Food Policy: Integrating Health, Environment and Society . Oxford; New York: Oxford University Press. Google Scholar CrossRef Search ADS   Lang T., Heasman M. ( 2015). Food Wars: The Global Battle for Mouths, Minds and Markets , 2nd edn. London: Routledge. Lavizzo-Mourey R., Orleans C. T., Marks J. S. ( 2014). Cutting Calories: Trillions at a Time. American Journal of Preventive Medicine , 47, e7– e8. Google Scholar CrossRef Search ADS PubMed  Linnekin B. J. ( 2012). The Food-Safety Fallacy: More Regulation Doesn't Necessarily Make Food Safer. Northeastern University Law Journal , 4, 89– 109. Magnusson R., Reeve B. ( 2015). Food Reformulation, Responsive Regulation, and “Regulatory Scaffolding”: Strengthening Performance of Salt Reduction Programs in Australia and the United Kingdom. Nutrients , 7, 5281– 5308. Google Scholar CrossRef Search ADS PubMed  Mancino L., Kuchler F., Leibtag E. ( 2008). Getting Consumers to Eat More Whole-Grains: The Role of Policy, Information, and Food Manufacturers. Food Policy , 33, 489– 496. Google Scholar CrossRef Search ADS   Mayes C. ( 2014). Governing through Choice: Food Labels and the Confluence of Food Industry and Public Health Discourse to Create ‘Healthy Consumers’. Social Theory and Health  12, 376– 395. Google Scholar CrossRef Search ADS   Michman R. D., Mazze E. M. ( 1998). The Food Industry Wars: Marketing Triumphs and Blunders . Westport: Quorum. Monteiro C. A., Gomes F. S., Cannon G. ( 2010). The Snack Attack. American Journal of Public Health , 100, 975– 981. Google Scholar CrossRef Search ADS PubMed  Monteiro C. A., Moubarac J. C., Cannon G., Ng S. W., Popkin B. ( 2013). Ultra-Processed Products Are Becoming Dominant in the Global Food System. Obesity Reviews , 14, 21– 28. Google Scholar CrossRef Search ADS PubMed  Moodie R., Stuckler D., Monteiro C., Sheron N., Neal B., Thamarangsi T., Lincoln P., Casswell S. ( 2013). Profits and Pandemics: Prevention of Harmful Effects of Tobacco, Alcohol, and Ultra-Processed Food and Drink Industries. The Lancet , 381, 670– 679. Google Scholar CrossRef Search ADS   Moran M. ( 2002). Understanding the Regulatory State. British Journal of Political Science , 32, 391– 413. Google Scholar CrossRef Search ADS   Morris B., Neering P. A. ( 2008). The Pepsi Challenge: Can This Snack and Soda Giant Go Healthy? CEO Indra Nooyi Says Yes, but Cola Wars and Corn Prices Will Test Her Leadership. Fortune , 157, 54– 66. Moss M. ( 2013). Salt, Sugar, Fat: How the Food Giants Hooked Us . New York: Random House. National Heart Foundation of Australia. ( 2012). Rapid Review of the Evidence: Effectiveness of Food Reformulation as a Strategy to Improve Population Health, available from: https://www.heartfoundation.org.au/images/uploads/publications/RapidReview_FoodReformulation.pdf [accessed October 2017]. Nestle M. ( 2007). Food Politics: How the Food Industry Influences Nutrition and Health . Berkeley: University of California Press. New York City Health Department. ( 2012) National Salt Reduction Initiative Goals and Summary, available from: https://www1.nyc.gov/assets/doh/downloads/pdf/cardio/cardio-salt-factsheet.pdf [accessed March 2017]. Norum K. R. ( 2008). Pepsico Recruitment Strategy Challenged. Public Health Nutrition , 11, 112– 113. Google Scholar CrossRef Search ADS PubMed  Nuffield Council on Bioethics. ( 2007). Public Health: Ethical Issues, available from: http://nuffieldbioethics.org/wp-content/uploads/2014/07/Public-health-ethical-issues.pdf [accessed March 2017]. Nutrition Taskforce of the Better Health Commission. ( 1987). Towards Better Nutrition for Australians . Canberra: Nutrition Taskforce of the Better Health Commission. OECD. ( 2009). Regulatory Impact Analysis: A Tool for Policy Coherence . OECD Reviews of Regulatory Reform. Paris: OECD. Osborne D., Gaebler T. ( 1992). Reinventing Government: How the Entrepreneurial Spirit Is Transforming the Public Sector . New York: Plume. Panjwani C., Caraher M. ( 2014). The Public Health Responsibility Deal: Brokering a Deal for Public Health, but on Whose Terms? Health Policy , 114, 163– 173. Google Scholar CrossRef Search ADS PubMed  Parliament of Great Britain: House of Lords Science and Technology Select Committee. ( 2011). Behaviour Change, Session 2010-2012, available from: http://www.publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/179.pdf [accessed March 2017]. Reeve B. ( 2011). The Regulatory Pyramid Meets the Food Pyramid: Can Regulatory Theory Improve Controls on Television Food Advertising to Australian Children? Journal of Law and Medicine , 19, 128– 147. Google Scholar PubMed  Reeve B., Magnusson R. ( 2013). ‘Legislative Scaffolding’: A New Approach to Prevention. Australian and New Zealand Journal of Public Health , 37, 494– 496. Google Scholar CrossRef Search ADS PubMed  Reingold J. ( 2015) Pepsico’s CEO Was Right. Now What?. Fortune , available from: http://fortune.com/2015/06/05/pepsico-ceo-indra-nooyi/ [accessed March 2017]. Republic of South Africa. ( 2013). Foodstuffs, Cosmetics and Disinfectants Act, 1972 (Act 54 of 1972)—Regulations Relating to the Reduction of Sodium in Certain Foodstuffs and Related Matters, No. R. 214. Réquillart V., Soler L.- G. ( 2014). Is the Reduction of Chronic Diseases Related to Food Consumption in the Hands of the Food Industry? European Review of Agricultural Economics , 41, 375– 403. Google Scholar CrossRef Search ADS   Resnik D. ( 2010). Trans Fat Bans and Human Freedom. The American Journal of Bioethics , 10, 27– 32. Google Scholar CrossRef Search ADS PubMed  Resnik D. B. ( 2014). Paternalistic Food and Beverage Policies: A Response to Conly. Public Health Ethics , 7, 170– 177. Google Scholar CrossRef Search ADS   Reynolds C. ( 2011). Public and Environmental Health Law . Sydney: The Federation Press. Ries N. M. ( 2007). Food, Fat and the Law: A Comment on Trans Fat Bans and Public Health. Windsor Review of Legal and Social Issues , 23, 17. Roberto C. A., Swinburn B., Hawkes C., Huang T. T. K., Costa S. A., Ashe M., Zwicker L., Cawley J. H., Brownell K. D. ( 2015). Patchy Progress on Obesity Prevention: Emerging Examples, Entrenched Barriers, and New Thinking. The Lancet , 385, 2400– 2409. Google Scholar CrossRef Search ADS   Rose G. A. ( 1992). The Strategy of Preventive Medicine . Oxford: Oxford University Press Sandrou D., Arvanitoyannis I. ( 2000). Low-Fat/Calorie Foods: Current State and Perspectives. Critical Reviews in Food Science and Nutrition , 40, 427– 447. Google Scholar CrossRef Search ADS PubMed  Santich B. ( 1995). What the Doctors Ordered: 150 Years of Dietary Advice , 1st edn. Melbourne: Hyland House. Santich B. ( 2005). Paradigm Shifts in the History of Dietary Advice in Australia. Nutrition and Dietetics , 62, 152– 157. Google Scholar CrossRef Search ADS   Schwartz M. B., Brownell K. D. ( 2007). Actions Necessary to Prevent Childhood Obesity: Creating the Climate for Change. Journal of Law, Medicine and Ethics , 35, 78. Google Scholar CrossRef Search ADS   Scott C. ( 2010). Standard-Setting in Regulatory Regimes. In Baldwin R., Cave M., Lodge M. (eds), The Oxford Handbook of Regulation . Oxford: Oxford University Press, pp. 104– 119. Scrinis G. ( 2013). Nutritionism: The Science and Politics of Dietary Advice . Sydney: Allen & Unwin. Google Scholar CrossRef Search ADS   Seabrook J. ( 2011) Snacks for a Fat Planet: Pepsico Takes Stock of the Obesity Epidemic. In The New Yorker, available from: http://www.newyorker.com/magazine/2011/05/16/snacks-for-a-fat-planet [accessed March 2017]. Sebillotte C. ( 2013). Efficiency of Public-Private Co-Regulation in the Food Sector: The French Voluntary Agreements for Nutritional Improvements, available from: http://econpapers.repec.org/paper/aliwpaper/2013-03.htm [accessed March 2017]. Semands E. ( 2014). Food Choice: Should the Government Be at the Head of the Table? Oklahoma Law Review , 67, 149– 190. Shrapnel B. ( 2012). Should Trans Fats Be Regulated? Nutrition and Dietetics , 69, 256– 259. Google Scholar CrossRef Search ADS   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 Medicine , 9, e1001235. Google Scholar CrossRef Search ADS PubMed  Stuckler D., Nestle M. ( 2012). Big Food, Food Systems, and Global Health. PLoS Medicine , 9, e1001242. Google Scholar CrossRef Search ADS PubMed  Stuckler D., Siegel K. ( 2011). Sick Societies: Responding to the Global Challenge of Chronic Disease . Oxford: Oxford University Press. Google Scholar CrossRef Search ADS   Swinburn B. ( 2002). Sustaining Dietary Changes for Preventing Obesity and Diabetes: Lessons Learned from the Successes of Other Epidemic Control Programs. Asia Pacific Journal of Clinical Nutrition , 11 (Suppl 3), S598– S606. Google Scholar CrossRef Search ADS PubMed  Swinburn B., Egger G. ( 2002). Preventive Strategies against Weight Gain and Obesity. Obesity Reviews , 3, 289– 301. Google Scholar CrossRef Search ADS PubMed  Taylor A. L., Parento E. W., Schmidt L. ( 2015). The Increasing Weight of Regulation: Countries Combat the Global Obesity Epidemic. Indiana Law Journal , 90, 257– 292. ten Have M., De Beaufort I., Teixeira P., Mackenbach J., van der Heide A. ( 2011). Ethics and Prevention of Overweight and Obesity: An Inventory. Obesity Reviews , 12, 669– 679. Google Scholar PubMed  Thow A. M., Annan R., Mensah L., Chowdhury S. N. ( 2014). Development, Implementation and Outcome of Standards to Restrict Fatty Meat in the Food Supply and Prevent NCDs: Learning from an Innovative Trade/Food Policy in Ghana. BMC Public Health , 14, 249– 257. Google Scholar CrossRef Search ADS PubMed  Truswell A. S. ( 1987). Evolution of Dietary Recommendations, Goals, and Guidelines. The American Journal of Clinical Nutrition , 45, 1060– 1072. Google Scholar CrossRef Search ADS PubMed  United Nations General Assembly. ( 2011). Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases, UN GAOR, 66th Sess, UN Doc a/66/L.1 (16 September). van Raaij J., Hendriksen M., Verhagen H. ( 2009). Potential for Improvement of Population Diet through Reformulation of Commonly Eaten Foods. Public Health Nutrition , 12, 325– 330. Google Scholar PubMed  Wansink B., Chandon P. ( 2006). Can ‘Low-Fat’ Nutrition Labels Lead to Obesity? Journal of Marketing Research , 43, 605– 617. Google Scholar CrossRef Search ADS   Watrous M. ( 2016) Three Trends Driving Gluten-Free Market. Food Business News, available from: http://www.foodbusinessnews.net/articles/news_home/Consumer_Trends/2016/02/Three_trends_driving_glutenfre.aspx?ID=%7BF0C580B5-8A77-433B-9C95-5B242D26520E%7D&cck=1 [accessed March 2017]. Webster J., Trieu K., Dunford E., Hawkes C. ( 2014). Target Salt 2025: A Global Overview of National Programs to Encourage the Food Industry to Reduce Salt in Foods. Nutrients , 6, 3274– 3287. Google Scholar CrossRef Search ADS PubMed  WHO. ( 1990). Diet, Nutrition and the Prevention of Chronic Diseases: Report of a WHO Study Group , Vol. 797. WHO Technical Report Series. Geneva: World Health Organization. WHO. ( 2004). Global Strategy on Diet, Physical Activity and Health . Geneva: World Health Organization. WHO. ( 2013). Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 . Geneva: World Health Organization. WHO. ( 2014). Global Status Report on Noncommunicable Diseases . Geneva: World Health Organization. Wilson J., Dawson A. ( 2010). Giving Liberty Its Due, but No More: Trans Fats, Liberty, and Public Health. The American Journal of Bioethics , 10, 34– 36. Google Scholar CrossRef Search ADS PubMed  Wiseman S. R. ( 2015). The Dangerous Right to Food Choice. Seattle University Law Review , 38, 1299– 1315. World Cancer Research Fund International. ( 2015). Curbing Global Sugar Consumption: Effective Food Policy Actions to Help Promote Healthy Diets and Tackle Obesity, available from: http://econpapers.repec.org/paper/aliwpaper/2013-03.htm [accessed March 2017]. World Cancer Research Fund International. ( 2017) Nourishing Framework, available fom: http://www.wcrf.org/int/policy/nourishing-framework [accessed March 2017]. Yach D., Feldman Z., Bradley D. G., Khan M. ( 2010). Can the Food Industry Help Tackle the Growing Global Burden of Undernutrition? American Journal of Public Health , 100, 974– 980. Google Scholar CrossRef Search ADS PubMed  Yach D., Hawkes C., Epping-Jordan J. E., Galbraith S. ( 2003). The World Health Organization's Framework Convention on Tobacco Control: Implications for Global Epidemics of Food-Related Deaths and Disease. Journal of Public Health Policy , 24, 274– 290. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org

Journal

Public Health EthicsOxford University Press

Published: Apr 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off