Personal responsibility and commercial determinants of health

Personal responsibility. How much control do we have over our own health, at an individual but also a population level? It might be less than you think.

Our understanding of the drivers of poor health, particularly as it relates to non-communicable disease, has evolved significantly over recent decades. It’s well accepted now that social determinants such as poverty, education and even geography play an important role in health. This has extended to a better understanding of how the built environment can influence health – for example areas with good public transport might encourage or enable people to walk to and from a train station, with the subsequent increase in physical activity likely to reduce the risk of some poor health outcomes.

An important parallel area of growing research is related to commercial determinants, the idea that large, often multinational corporations, have created an unhealthy environment, chasing corporate profit at the expense of our health.  Commercial determinants of health have been defined as the systems, practices, and pathways through which commercial actors drive health and equity. We see this most obviously in the way that foods are marketed and advertised, but it can sometimes be more insidious than that.

Over the past few decades there has been an epidemic in overweight/obesity, type 2 diabetes and tooth decay. In Australia, 1 in 3 children experience tooth decay by the age of 5-6 years, and 1 in 4 children are overweight or obese - statistics that should alarm everyone. Although the causes are multifactorial, there are common dietary risk factors, with increasing sugar consumption a significant contributor. Indeed, the average Australian child aged 4-8 years consumes 50 grams (or 12 teaspoons) of added sugar per day, well above the World Health Organisation recommendation (which for adults is to not consume more than 6 teaspoons of sugar to reduce the risk of tooth decay and other diseases, and for children it should be substantially less).

It is easy to explain this indulgence in sugar consumption away as a problem of personal responsibility – if people are consuming too much sugar (and becoming unhealthy as a consequence) then it is entirely within their control to change that. If they exercised (no pun intended) more self-control, then they too could be healthy. That is in fact the line that is constantly pushed by the food and beverage industry to deflect attention from their own role.

It’s worth exploring how the responsibility these multinational food companies have in shaping our health, noting that eating more, and not less, of their product is what underpins the entire business model for these companies. Our food environment is effectively engineered with the specific goal of increasing our consumption, regardless of the health consequences.

The first example looks at where fast food stores are located, and how that might explain some of the disparities in health outcomes. There has been an explosion of new US-style fast food chains coming to Australia, and last year McDonalds announced their intention to open 100 new stores in Australia, with a focus on regional areas. This is a concern when we already see a higher prevalence of tooth decay and overweight/obesity in regional and rural communities. Where these companies locate their stores is instructive, and helps to explain some of the link between commercial and social determinants of health.

Recently I mapped out major fast food store locations and analysed the number of stores per 100,000 people by socioeconomic status. As you can see, there is a much greater density of stores in areas of greater disadvantage. Making unhealthy food more easily accessible is one way that the food industry is able to influence consumption patterns.

One outcome of the increasing availability of fast food stores is that the proportion of people eating from major fast food outlets over a 4-week period increased from 64% in 2019 to 75% in 2020.

The second example is a little more subtle, but highlights the insidious role of commercial determinants. I decided to analyse the sugar content of menu items at McDonalds over a 10-year period. Clearly more people are consuming junk food more frequently, but what if it was also becoming more unhealthy over time as well? It might surprise you to find out that the amount of sugar in a Big Mac has increased 41% between 2011 and 2021, up from 5.6 grams to 7.9 grams. It’s easy to think that this small absolute increase – only 2.3 grams or just over half a teaspoon – is insignificant.

But it’s worth remembering the recommendation is to restrict added sugar consumption to less than 24 grams (6 teaspoons) per day. Suddenly that Big Mac is contributing 10% more to that total. Even a small Coca-Cola at McDonalds now contains 3.7% more sugar (an extra 1 gram) than in 2011. Combine a Big Mac and small drink now and you will now be consuming 33 grams of sugar (up from 30 grams in 2011) – well over the recommended daily limit of 24 grams. Not only is there a greater availability of junk food now, but it’s actually getting unhealthier too.

The triple whammy with commercial determinants is the disproportionate influence that these companies have in influencing health policy. Historically we now know that the sugar industry shaped the way that tooth decay was researched, shifting the focus away from ways to reduce sugar consumption towards ways to reduce the harms that sugar inevitably caused (reminiscent of how the tobacco industry operated). More recently industry in Australia has stymied public health initiatives such as added sugar labelling and reforming the Health Star Ratings system to help consumers make healthier choices. Ironic given that the food and beverage industry are the strongest promoters of the individual responsibility paradigm.

There is no single solution to eradicate harms from the practices of these food and beverage companies that affect our health. However the evidence is clear that there is a need for action on both specific industries and the broader systemic roles of these corporate actors.

Book Review

Recently colleagues John Rogers and Jamie Robertson published their book ‘Looking Back Looking Forward - Oral health in Victoria 1970 to 2022 and beyond.’ It is a forensic examination of changes in oral health, shifts in government policy, professional practice, technological advancements and public expectations. With a lens focussed firmly on health equity, the book proposes a pathway to achieve good oral health for all.

John Rogers is a Specialist in Public Health Dentistry with more than 45 years’ experience in management and policy development, and Jamie Robertson AM has had over 40 years in private dental practice, extensive public governance and practice experience, and is a noted historian of the dental profession. 

If you have an interest in public dental health, it’s well worth a read. You can download a free copy here, or buy a hardcopy here.