It is well known that poor diets are a leading contributor to the prevalence of non-communicable diseases such as diabetes and hypertension. But what measures can be taken to improve diets globally? Are there ways of shifting people towards healthier diets? This is the core of the Great Diet Debate.

The WHO has taken to advocating a sugar tax, as part of a so-called STAX (sugar, tobacco and alcohol tax) to combat non-communicable diseases (NCDs). On the face of it, this is a compelling idea – large industries producing poor-quality food are able to take over markets by pricing out competitors, so a sugar tax is a straightforward way to offset that process.

A joint statement by a group of health professionals published in the World Nutrition Journal noted: “In 2016, WHO published a recommendation to include fiscal measures to limit the consumption of sugary drinks as one of several interventions to tackle obesity and diabetes. We believe this recommendation must be explicitly re-stated as a cost-effective intervention . . . as it has been proven to be so in modelling studies and in countries where it has been implemented.”

There are challenges, however.

Pushing consumers towards healthier choices is a laudable goal, but only works if healthier choices genuinely exist and are accessible. If, on the other hand, people are buying cheap food because they cannot afford any other alternative, then raising the price of their staples could well have detrimental effects.

“The ‘hard sell’ of actions to tackle NCDs continues to skew the debate on NCDs and ignores their social and economic determinants while focusing almost exclusively on changing risk factors related to individual behaviour,” wrote Claudio Schuftan in Global Health Watch. “Asking people to make better choices whilst the current against them flows faster and faster, is futile as well as condescending.”

Indeed, the health professionals quoted in the World Nutrition Journal also emphasise the importance of access to healthy foods: “Attention to food systems and the policies shaping them, from production to consumption, is crucial for producing changes in diets, preventing different forms of malnutrition— including overweight and obesity—and reducing NCDs . . . major policy reforms needed in this area [include] those policies that support and protect small and medium scale producers who produce the foods that form the base of traditional diets and culinary cultures.”

Nicholas Freudenberg, writing for the CUNY Urban Food Policy Institute, supports a sugar tax but places it within a broader programme of strengthened public oversight of the food industry.

“By strengthening the role of the public sector to make public food—institutional food, restaurant food, food available in public benefit programs—healthier and more affordable, public policy can create an alternative to a commercial food system that values profits over health,” writes Freudenberg, while also advocating an active role for local government. “This includes zoning laws, public procurement, and regulation of food retail and restaurant businesses to encourage food industry practices that support health and discourage harmful practices. For example, zoning laws can be used to limit the density of unhealthy food outlets, procurement rules can help to improve the healthfulness of school food and other institutional food and retail policies can encourage developers to locate food stores that make providing healthy affordable food in redeveloped communities a priority.”

There are initiatives being pursued around the world to address unhealthy food consumption, although most are relatively new and long-term assessments are not yet available.

In Montevideo, Uruguay, the municipality banned salt shakers, ketchup, and mayonnaise at restaurant tables. Restaurants must also have at least 10 percent of their menu contain food items with no added salt, for public health reasons.

The city of Ouagadougou, Burkina Faso “has put in a monitoring system for food sold in schools. Their long-term goal is to have a monitoring center for dietary health and beverages in the city. They also plan to monitor food labeling in restaurants and remove the sale of food products that could increase students’ risks for NCDs.”

Some advocates, such as Ilona Kickbusch, director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva, are hoping for progress despite resistance from some quarters.

On taxing sugar-sweetened beverages, Kickbusch told Devex, “some member states like Uruguay are very supportive, [and] member states like Mexico, who’ve introduced the sugar tax, already have significant experiences with it. Other member states like the United States felt there was not enough evidence on the impact of such taxes and therefore the commission should not recommend them.”