FEAST - Report on policy barriers and facilitators

www.feast2030.eu Report on policy barriers and facilitators D7.1 Report FEAST is co-funded by the European Union’s Horizon Europe research and innovation programme under grant agreement number 101060536. Views and opinions expressed are those of the author(s) only and do not necessarily reflect those of the European Union. Neither the European Union nor the granting authority can be held responsible for them. UK participant in FEAST (Good Food Oxfordshire) is supported by Innovate UK grant number 10041509 and the Swiss participant in FEAST (FiBL) is supported by the Swiss State Secretariat for Education, Research and Innovation (SERI) under contract number 22.00156. This document is shared under Creative Commons Attribution 4.0 International License (CC BY 4.0). Start Date 01/07/2022, End Date 30/06/2027 Cite as: Tonello, S., & Romagosa, S. (2025). FEAST - Report on policy barriers and facilitators. Zenodo. FEAST project - Food systems that support transitions to hEalthy And Sustainable dieTs. DOI: https://doi.org/10.5281/zenodo.15512556 1 out of 98 Food systems that support transitions to hEalthy And Sustainable dieTs Deliverable Name FEAST - Report on policy barriers and facilitators Description Report on policy-based facilitators and barriers across food systems and, identified across FEAST’s work, to foster innovation towards a fair transition to healthy and sustainable diets Work Package (WP) Policy dialogues to inform food system governance (WP7) Deliverable Related No. D7.1 Lead Beneficiary open science for open societies - os4os Type Report (R) Dissemination Level Public (PU) Due Date and Project Month June 30, 2025 / Month 36 Author(s) Samuele Tonello (EuroHealthNet), Sofia Romagosa (EuroHealthNet) Revision See Table History of Changes Reviewed by (if applicable) N/A FEAST - Report on policy barriers and facilitators 2 out of 98 Table of contents Table of contents ..................................................................................................................................... 2 List of Figures ........................................................................................................................................... 4 List of Tables ............................................................................................................................................ 4 Key Facts .................................................................................................................................................. 4 ACRONYMS AND ABBREVIATIONS ........................................................................................................... 5 1 Introduction: why an analysis of power?......................................................................................... 6 1.1 A Frame analysis for the three dimensions of power .............................................................. 8 1.2 Frame Analysis methodology ................................................................................................ 11 1.3 Framing affects policy implementation and policymakers must better learn how to navigate the various frames ............................................................................................................................. 14 2 A silver bullet to resolve the obesity epidemic or an expensive waste of resources? .................. 15 2.1 Introduction ........................................................................................................................... 15 2.2 The Wegovy drug: is it all gold what glitters? ........................................................................ 17 2.2.1 It does glitter! .................................................................................................................. 17 2.2.2 No, it does not glitter ....................................................................................................... 19 2.3 How are those living with obesity framed within the Wegovy debate? ............................... 20 2.4 Why are people living with obesity unable to change their condition? ................................ 22 2.4.1 The genetic and societal cage .......................................................................................... 22 2.4.2 The obesogenic food environment .................................................................................. 23 2.5 Which are the solutions emerging from these two frames? ................................................. 25 2.5.1 The production issue ....................................................................................................... 25 2.5.2 Health Inequalities as access to the drug ........................................................................ 26 2.5.3 Production and availability in governments debate ........................................................ 28 2.5.4 Prevention and inequalities from a systemic perspective ............................................... 29 2.6 Counter frames to favour a systemic framing ....................................................................... 31 3 Necessary help to citizens’ food purchase or a hindrance to national tradition and cultures? .... 40 3.1 Introduction ........................................................................................................................... 40 3.2 Actors supporting the implementation of Nutri-Score .......................................................... 41 3.3 The opposition to Nutri-Score ............................................................................................... 45 3.4 The counter-frames ............................................................................................................... 51 4 The EU debate on the Sustainable use of Plant Protection Products regulation .......................... 57 4.1 Introduction ........................................................................................................................... 57 4.2 The SUR as a hazard to EU Food security .............................................................................. 58 4.3 SUR as integral part of a sustainable food system ................................................................. 61 4.4 Can SUR match everyone expectations? The perspective of the European Institutions ...... 62 4.5 The outcome of the SUR debate ........................................................................................... 65 FEAST - Report on policy barriers and facilitators 3 out of 98 4.6 Counter-frames ...................................................................................................................... 67 5 Zoning laws and the interaction at local level between civil society movements and food industries 73 5.1 Introduction ........................................................................................................................... 73 5.2 The McDonald battle in Florence’s Piazza del Duomo........................................................... 74 5.3 The ‘No Fry Zone 4 Kids’ movement in Wicklow ................................................................... 76 5.4 Tervuren ................................................................................................................................. 80 5.5 The Netherlands .................................................................................................................... 85 5.6 Counter frames ...................................................................................................................... 90 6 Conclusion ..................................................................................................................................... 96 7 Literature ....................................................................................................................................... 98 FEAST - Report on policy barriers and facilitators 4 out of 98 List of Figures Figure 1 Eurostat Overweight population (%) in Europe ................................................................. 15 Figure 2 Obesity in adults in the WHO European Region, 1975 to 2016 ......................................... 33 Figure 3 Front-of-pack nutrition labelling typologies and examples of corresponding schemes in the EU ....................................................................................................................................... 40 List of Tables Table 1 Document history of changes .............................................................................................. 4 Table 2 List of acronyms and abbreviations ..................................................................................... 5 HISTORY OF CHANGES Table 1 Document history of changes HISTORY OF CHANGES Version Publication Date Changes 1.0 30.06.2025 Key Facts Action Number: 101060536 Action Acronym: FEAST Action title: Food systems that support transitions to hEalthy And Sustainable dieTs Date: 30.06.2025 Document version: 1.0 FEAST - Report on policy barriers and facilitators 5 out of 98 ACRONYMS AND ABBREVIATIONS Table 2 List of acronyms and abbreviations FAO Food and Agriculture Organization of the United Nations GDP Gross domestic product GHG Greenhouse gas EU European Union EC European Commission EP European Parliament CSO Civil Society Organisation NGO Non Governmental Organisation WP Work Package BMI Body Mass Index FEAST - Report on policy barriers and facilitators 6 out of 98 1 Introduction: why an analysis of power? FEAST Task 7.2. aims to analyse policy barriers and facilitators that impede policy that can support healthier and more sustainable food systems, including the main stakeholders involved in these processes. The insights on these barriers, facilitators and stakeholders would be used to inform innovations that could help to improve our food systems. When the WP7 team began to discuss how to best approach this task, the first issue debated was that FEAST WP3 was already doing very similar work. In task 3.2, for example, WP3 is mapping government policies for healthy diets from sustainable food systems at local, national and EU levels. WP3 is also conducting semi-structured interviews with policymakers at different levels of jurisdiction (national and local), to assess barriers and facilitators to implementation of healthy diets from sustainable food systems. This work, together with the work on food companies (3.1) and vulnerable communities (3.2), will eventually feed into the policy labs organized in WP7. See here for an overview of the deliverables published by the two teams. Given this work in WP3, the WP7 team reached an agreement to structure task 7.2 to complement, rather than replicate, what was already done not only in WP3 as well as WPs 4 and 5, which worked on co-designed community and technology based innovations to support the transition to healthier and more sustainable food systems. When we debated how to best complement the work of WPs 35, the focus went to why over the last few years, especially at EU level, policies aimed at fostering healthier and more sustainable food systems have been too often dismissed and/or watered down. This reflects a policy landscape where academic partners, CSOs and NGOs struggle to promote a health and sustainability agenda. Instead, private sector is much more effective in having their businessdriven agenda promoted, while also managing to block policy implementation that would hinder their interests. This reflects an imbalance in power between different policymakers that must be further investigated if we are to better understand how to maximise the impact of FEAST outputs and foster policy innovations that can deliver healthier and more sustainable food systems. For this reason, the WP7 team decided to investigate how decisions at different levels of governance - European, national and regional levels - are influenced by power dynamics between actors involved in the food system. If we are to identify how actors influence food system policies, we first need to determine if there are inequalities across stakeholders concerning who is more likely to influence which decisions are considered in the food system. As a result, the WP7 team decided to focus this deliverable on demonstrating how power distribution between food system stakeholders can serve as a barrier and/or facilitator to influence policymaking at different levels of governance. To investigate power, we first need to define this concept. There are, of course, several definitions of power in the social sciences, but one of the most famous and widely used was given by Max Weber, who defined power as: “The probability that one actor within a social relationship will be in a position to carry out his own will despite resistance, regardless of the basis on which this probability rests.” (Weber 1978; 53). A thorough investigation of the concept of power exceeds the goals of this document. What is essential to specify is that power is not socially exercised in a unique form, but there are instead different forms of power. All these forms concern the fact that an agent X in some way affects another agent Y in a significant manner. This is an essential point for the purpose of this document, since this “in some way” FEAST - Report on policy barriers and facilitators 7 out of 98 implies that power can expressed in several forms. According to the famous categorisation by the sociologist Lukes, it is possible to identify three main forms of power (Lukes 2021): The first form is ‘Decision-making power’. This is the form of power easiest to recognise, since it is the process whereby an actor, such as an individual or a political organisation, considers its situation and acts upon a course it has determined, either coercively or non-coercively. For example, I exercise this form of power if I put a gun to your head and I order you to give me your wallet. In this situation, you must do something you would not otherwise do if you do not wish to suffer worse consequences as compared to acting according to my demand. At the same time, this form of power does not have to be coercive. For example, voting is a way of expressing your decision-making power in a political arena. This first form of power is the most common way of conceiving power and it has long been studied in political science (Dahl 1961). However, as stressed by Lukes and numerous others (Bacharach & Baratz 1970), if we considered only the first dimension of power, we would neglect that there are more subtle ways to exercise power. These other ways correspond to the second and third dimensions of power, and they are particularly relevant for the goals of WP7 and consequentially for this deliverable. The second form of power is agenda setting power, which stresses that power is not just about making decisions, but also about setting the agenda that leads to decision-making. In other words, if you can control the context within which decisions are made, then you can influence those decisions. For example, if I control the terms of the discussion, I can frame the conversation so that participants are only able to discuss topics that are to my benefit, while also making sure that controversial topics are not discussed. What is essential about this second form of power is that it stresses that power is not only about decisions, but also about non-decisions. That is, if I find myself in a decision-making process with other people, and I make sure that a certain decision X, which is contrary to my interest, is not discussed in the first place, then I have exercised a form of power. As we shall see, this form of power is very relevant when analysing food system policymaking. The third form of power is normative power (Dowding 2006). Lukes describes it as the power to prevent conflict from arising in the first place, as it concerns societal practices and how these are shaped to favour certain groups over others. This is often referred to as ideological power, since a common belief is created and maintained to conceive such belief as the best and preferable option. Thus, this power is the ability of a group to shape the beliefs and preferences of another group against the real interests of the latter. 1 For example, Sen and Nussbaum stressed that in Bengal, millions were affected by the post 1944 famine, but out of all those involved, it was primarily men who reported to relief centres for aid, despite both sexes being similarly affected. This displayed a form of power that discriminated against 1 We are aware of how problematic the concept of ‘real interest’ can be here, since determining from an external point of view which is the real interest of a certain group can sound mistaken and/or paternalistic. This will also need to be adapted to the food system to investigate whether we can define if groups, especially vulnerable ones, have real interests. According to Lukes (1921; 33): “What one may have here is a latent conflict, which consists in a contradiction between the interests of those exercising power and the real interests of those they exclude. These latter may not express or even be conscious of their interests, but, as I shall argue, the identification of those interests ultimately always rests on empirically supportable and refutable hypotheses.” FEAST - Report on policy barriers and facilitators 14 out of 98 1.3 Framing affects policy implementation and policymakers must better learn how to navigate the various frames Food systems are complex and it is too often neglected that topics and concepts involved may not be conceived in the same way by all actors involved. Different stakeholders use different definitions of even the most fundamental concepts (because they are crucial for how frames are constructed that relate to more narrowly defined issues) – e.g., sustainability, food security, health, etc. – and these differences may slow down policy implementation and may impede policy formulation. On top of this, how frames are used are unavoidably connected to stakeholders’ interests, which of course differ from one another, so each group will try to use their power to make sure that their preferred frame becomes the dominant one in the setting considered (food system policies in our case). For this reason, the development of the frame analysis will be essential to understand how power shapes food system debates at different governance levels. Furthermore, since power and prominence of frames correspond with each other, it is important to understand how actors that have been so far marginalised – small producers, local farmers, certain groups of citizens, and in particular vulnerable groups – can propose counter-frames to the conceptualizations that have so far managed to dominate food system debates and have often not been conducive to sustainability and public health. A policy toolbox could provide those citizens and policymakers that are willing to transition to healthier and more sustainable food systems with the means to counteract those frames that are currently slowing down this process, and to replace them with alternative counter-frames more compatible with the goal of transitioning to healthier and more sustainable food systems, a goal shared with the FEAST consortium. Finally, but very importantly, the FEAST WP7 structure can offer a platform to test the efficacy of innovative counter-frames proposed or identified, since some of the policy dialogues could be used as trainings where policymakers learn to identify hindering frames and to respond with the counterframes provided by the task 7.2. analysis. In this way, task 7.2. can contribute to the work carried out by all FEAST WPs, while also inspiring future EU funded projects to analyse how the more subtle dynamics of power influence the debates over food system policies. FEAST - Report on policy barriers and facilitators 15 out of 98 2 A silver bullet to resolve the obesity epidemic or an expensive waste of resources? An analysis of how different stakeholders are reacting to Wegovy, the drug that according to Novo Nordisk finally promises to resolve ever increasing obesity rates 2.1 Introduction From a public health perspective, one of the major problems of European food systems is that they are leading causes of overweight and obesity, with now more than 1 in 2 European that are overweight, and more than 1 in 6 that are obese (OECD 2019). These percentages are worrying as overweight and obesity are leading causes of several Non communicable diseases (NCDs), such as cardiovascular diseases, type-2 diabetes, and certain cancers. Moreover, obesity has a serious economic burden in Europe, with the total cost of adult obesity in the EU – considered as healthcare costs and lost productivity - estimated at in excess of 70 billion Euro per year. Figure 1 Eurostat Overweight population (%) in Europe An aspect particularly problematic about being overweight and obesity is that we have not yet been able to reverse and neither to slow down the increasing trend at population level. On the contrary, worldwide adult obesity has more than doubled since 1990, and adolescent obesity has quadrupled. The causes of this currently unstoppable trend are obviously complex and exceed the purpose of this analysis. However, for our focus on the framing of food system debates, something extremely interesting has occurred over the last couple of years. The Danish company Novo Nordisk has released a new obesity drug called Wegovy, which efficiency seems to be higher as never before. More recently, the company Eli Lilly – a long-term competitor of Novo Nordisk in the market of diabetes drugs – has also released a drug called Zepbound, which has proven similar potential to Wegovy. In what follows, FEAST - Report on policy barriers and facilitators 16 out of 98 we describe some of the most relevant frames used by different stakeholders related to Wegovy but, as we will specify, some data will also pertain to Zepbound. In a nutshell, Wegovy is based on an active substance called semaglutide, which is a glucagon-like peptide 1 (GLP-1) receptor agonist. Wegovy contains the same active ingredient – semaglutide – as the anti-diabetic drug Ozempic. Novo Nordisk discovered that this substance mimics the action of a natural hormone in the body with the power to regulate the person’s appetite. In short, Wegovy can increase a person’s feelings of fullness. This, in turn, can reduce the hunger and cravings of food in the person with overweight or obesity, thus decreasing the food intake and, in turn, leading to weight loss. The treatment requires injecting under the skin once a week a pre-filled pen containing a solution. To reduce the risk of gastrointestinal issues, the treatment starts with a lower dose, and it then gradually increases over 16 weeks. Patients can administer the medicine themselves, and the medicine can only be obtained with a prescription. Currently, Wegovy is indicated for individuals who have a BMI of 30 kg/m² or greater (obesity), or of at least 27 kg/m² but less than 30 kg/m² (overweight) who have weight-related health problems (such as diabetes, high blood pressure, etc.). It is also used in adolescents from 12 years of age whose BMI is at or above the 95th percentile for their age and gender (obesity) and who weigh more than 60 kg. As of early 2025, in Europe, weight loss drug Wegovy has only launched in Denmark, Norway, Germany and the U.K. Outside Europe, it's available in the U.S. 4 There are two important details related to this medication. First, that it still needs to be accompanied by a low-calorie diet and increased activity physical for weight management. Second, that it requires a chronic treatment to be effective. This means that once you start taking this drug, you need to continue taking it ideally for the rest of your life. Otherwise, there is a rebound effect for which hunger will come back and patients are likely to gain back weight. Over the past decades, several drugs were publicised as a way to lose weight, but none had managed to demonstrate its effectiveness over a long period of time. Conversely, after several studies published in scientific journals backed-up the results of Wegovy, this drug rapidly increased its popularity, shortly booming both in the healthcare, economic, and public sphere. In the second half of 2023, this success increased even further, after other studies proved that this drug could also lead to improvements in heart-related problems in those taking the drug. Such has been the success of the Wegovy drug, that Novo Nordisk’s share price has more than quadrupled in the past five years, making it Europe’s most valuable company by market capitalisation. Following these recent developments, it is easy to understand the hype on this drug. However, other stakeholders involved in this discussion are stressing that it is not all gold what glitters, and there may be several issues with this drug. To better understand this debate, we analysed these main points of contention, looking at how the main stakeholders framed their point of view regarding this. We start presenting the pros and cons of the Wegovy drug according to different stakeholders, which helps displaying that there are both supporters and sceptics about the real efficiency of this drug. These two views on the drug lead to two main framings of the debate. On the one side, there is the solution 4 https://www.ema.europa.eu/en/medicines/human/EPAR/wegovy FEAST - Report on policy barriers and facilitators 17 out of 98 framework proposed by Novo Nordisk. On the other side, sceptics stress that this is not a solution to a problem that is instead much more complex and involve the whole food environment. These two views lead to different framings of the debate. In the second section, we present how people living with obesity are framed in the debate, underlining that there are not many differences between stakeholders in this regard. All entities involved maintain the need to move away from a stigma for which obese have only themselves to blame, to stress instead that causes for these increasing obesity rates are to be found somewhere else. However, when the question “why is there a high prevalence of overweight and obesity in the European population?” is asked, responses differ. In the third section, we describe the responses to this question given by the two framings of the debate, explaining how there is an evident difference between a frame focused on the individual (Novo Nordisk’s one) and one that addresses instead the systemic determinants of obesity. In section four, we present how the two framings affect the public debating, stressing in particular how each framing leads to consider certain topics rather than others, and how this influences also the solutions foreseen to resolve the problem. Finally, we describe a series of counter-frames that could be used by stakeholders to counteract the individual responsibility frames and favour instead framings based on a systemic responsibility. 2.2 The Wegovy drug: is it all gold what glitters? Such has been the impact of the Wegovy drug over the last couple of years, that we could almost say that our societies have been hit by a “Wegovy storm”. This “storm” has created two sides. On the one hand, those who strongly support the widespread usage of this drug. On the other hand, some have been more cautious and are warning about the problems with the widespread use of semaglutide drugs. In this section, we provide a short overview of the main points of contention, as these are the basis of the different frames described in the following sections. 2.2.1 It does glitter! Starting with those stressing the benefits of semaglutide drugs, Novo Nordisk themselves argue that Wegovy could offer individual and societal benefits. Starting point of this argument is, according to Novo Nordisk’s CEO Lard Fruergaard, the need to recognise obesity as a disease. This can help understanding that obesity must be treated by means of a drug, thus helping all those patients that have unsuccessfully tried so far to lose weight. It is not just about the individual though, as there are benefits also for society. This is because obesity has a well-acknowledged economic impact on society in terms of direct costs to treat the related diseases (aforementioned NCDs), but also indirect costs, such as the fact that obesity is reducing the number of active people in the workforce. According to Novo Nordisk then, this is the medical intervention with the potential to have the largest return to society in history. Novo Nordisk’s thesis has received support by several other experts throughout Europe. Overall, those in favour of Wegovy stress that the demand for this drug is an indication that obesity is a significant problem in all welfare societies, and that people perceive it as a problem. In particular, it seems that within medicine, and in particular within bariatric medicine there is a consensus that this drug is a real FEAST - Report on policy barriers and facilitators 18 out of 98 breakthrough that can improve quality of patients’ life, especially if used alongside a weight management programme including diet and exercise. This group shares Novo Nordisk claim that we need to consider obesity as a medical condition, since conceiving it as a disease can help to cure the pathology by means of a drug. As stressed by a lecturer in physiology: "Effective and long-term support with losing weight with Wegovy, the results of which are unattainable for most people living with obesity to achieve through diet and exercise alone, results in significant improvements in health outcomes." For this view then, recognising obesity as a disease is a necessary precondition to allow the healthcare system to treat the problem by means of a drug. The chronic aspect of the treatment still raises some concerns in several countries. Yet, it is indicative that some agencies of medicines still stress the value of the medicament despite these concerns. For example, the Spanish Medicines Agency assessed that this is still the best solution to treat obesity or overweight, despite the reluctance of the long-term use of the drug. As stressed by other doctors, in the short term the expenses for the treatment may put a strain on the public health system, but given that obesity is the gateway to more than 200 cardiovascular diseases and problems, in the long run Wegovy will alleviate what is now a major economic burden for countries health expenditure. The success of the Wegovy has not been limited to the healthcare system. On the contrary, this success has resonated also socially, such that the ‘Wegovy frenzy’ has hit also the show business. Some now call it the ‘Hollywood drug’, with doctors confirming that other than Viagra and Botox, no other medication has so quickly become part of modern culture’s social vernacular. This popularity can also be seen on social media, where TikTok videos tagged with #Ozempic have racked up more than 600 million views. In these platforms, influencers promote this drug by showing how much thinner they are, and claiming that they did so without the need for any exercise, as they ‘just’ had to inject themselves with the drug. The usage of Wegovy in this context has come under a lot of scrutiny, since the drug is used for a different purpose than the one it was conceived for. That is, Wegovy is meant to be used by those living with obesity or overweight, while here it is mainly used to lose some weight to achieve an appealing physical appearance. This is also confirmed by the discussions around the “Ozempic face”, which is the concern about the fact that the face skin of those who have taken this drug may look saggy due to the excessively fast weight loss. The fact that celebrities are abusing this drug not for health reasons, but to achieve an ideal figure, has sparked a controversy also because it could amplify the cultural desire for thinness that is already dominating the fashion landscape. Consequently, this could set a bad example for youth that are already so vulnerable to the unrealistically filtered versions of beauty. The celebrity misuse of the weight-loss drug is not the only criticism that has been raised towards the Wegovy drug. As described blow, other voices question its actual efficiency and feasibility as a largescale public health intervention. FEAST - Report on policy barriers and facilitators 19 out of 98 2.2.2 No, it does not glitter From the beginning, the results of the Wegovy drug have been accompanied by doubts concerning the side effects of this drug. The most common concern nausea and stomach issues, but they also include possible thyroid tumours and, the most debated, an increase in depression and suicidal thoughts. The discussion on the side effects is ongoing and to determine whether they are true pertains to thorough medical research, so it is not the main focus of the frame analysis. For the time being, while there are still several concerns regarding some side effects of the drug, research seems to have proved that there is no connection between the drug and an increased tendency to commit suicide. Aside from the side effects, a point of contention concerns the availability of the drug. Given that the demand for the drug has skyrocketed (more of this in what follows), there may now be an availability problem with the medications for diabetes. That is, Wegovy and Ozempic are based on the same substance (semaglutide), so there are concerns that the medicine could go into a supply crisis because it has been used for people who do not have diabetes. Therefore, in several countries, those protecting the rights of people with diabetes are concerned that this rush on the obesity drug could cause availability problems for those living with diabetes. More in detail, there is the risk that by making it easy to buy these drugs, they may be used improperly by people who are not those most in need. For example, there could be a situation where those with diabetes are not able to get the drug because it has been used by many people who want to simply lose a bit of weight before the holidays. For some doctors, it is then necessary to address how social media and the culture of getting slim is affecting people’s demand for this drug, so that we make sure that only those who really need them – those with a very high BMI – access them. Otherwise, this could created inequalities in health. Another criticism to Wegovy concerns the excessive level of aggression with which it has been marketed. Therefore, some are trying to slow down the enthusiasm for this drug and the perception that it could be a ‘miracle drug, to stress instead that its prescription must be properly framed, that it must be sold only under the strictest possible conditions, and always be accompanied by comprehensive care and alongside other weight loss measures. Also, by focusing too narrowly on hunger, it may be forgotten that: “A big part of why we eat isn’t necessarily hunger, it might be physiological anxiety, depression, low mood, boredom, ritual, so if you are not making those changes as well, you are not going to lose weight in the same way”. On top of this, there is a concern that proposing Wegovy as an easy solution may deceive people living with obesity, making them forget that as for other chronic diseases, getting to healthy ways is a longterm process that requires repeated appointments and a lot of support. Therefore, there is the risk that by seeing this medicine as a ‘quick fix solution’ or by saying that we could resolve a chronic multifaceted problem with a simple pill, we could end up making those affected by obesity even more unwell, thus further entrenching eating disorder thoughts and behaviours. For those more sceptics, Wegovy could be framed as the solution for those already living with a very high BMI, but not as a viable solution for all those living with overweight and lower rates of obesity. FEAST - Report on policy barriers and facilitators 20 out of 98 The results on which the efficiency of Wegovy is based have also been put into question in several regards. • There are concerns over the fact that studies proving the efficiency of the drug were financed by Novo Nordisk themselves. • The persistence of side effects is not sufficiently covered - especially regarding the intestinal complaints - and there are yet no precise studies on the long-term consequences of taking this drug. • The efficiency is more related to those with higher levels of obesity, while the results and side effects for those who are ‘only’ overweight are still be properly evaluated. • This pertains also to the claims that Wegovy could also improve heart problems, which according to some doctors is an obvious and logic consequence of losing weight and not a surprising and positive result. • There are also concerns regarding the influence of Novo Nordisk over experts, health systems and other influential organisations, since this company is using its economic power to influence the obesity debate and the weight-loss services. Finally, another argument highly debated is the cost of the medication. In Europe it would cost around 300 euros a month (country differences of course), with high profits for the company, but on a larger scale it would be difficult to sustain this treatment for such a large part of the population. For Denmark alone, a country where approximately 900,000 people have a BMI ≥ 30, if everyone in need received public funding for treatment with Wegovy, it would result in regional subsidy costs between DKK 23.9 billion and DKK 27.9 billion, an amount that would be difficult to sustain for the healthcare sector. This is particularly relevant considering the need for chronic treatment, as all experts agree that when Wegovy treatment is stopped, then there is a decrease in efficiency and there could also be a rebound in weight gain. Therefore, this cost would not be limited to a few weeks or months. Rather, this intervention would involve a significant part of the population for the rest of their lives, which would entail enormous expenses for the healthcare system across Europe. In sum, as it already emerges, there is a contrast between a view for which this drug is a useful tool, and another more sceptical to jump on the ‘frenzy bus’. In terms of framing, the question now is which are the pillars on which these two positions structure they argument. 2.3 How are those living with obesity framed within the Wegovy debate? When analysing the frames used by different stakeholders to discuss Wegovy, the first aspect to consider is how those living with obesity are framed by different actors. In this regard, different stakeholders seem to agree on one aspect: we need to tackle the unfair stigma for which obese people have only themselves to blame for their condition. Novo Nordisk presents as starting point of their work on obesity the need to deconstruct the stigma for which obesity is all about lifestyle, to claim instead that we cannot tell individuals who have lived with obesity to simply change their behaviour, as: “If you ask a person that has lived with obesity for good part of her or his life, you learn that they have tried all kind of things and the body fights back”. FEAST - Report on policy barriers and facilitators 21 out of 98 This aspect of not being able to find a solution and having to face an unfair stigma by themselves is particularly stressed by Novo Nordisk, which remarks that we should not approach people living with obesity with the same indications used for people with normal weight. Instead, the former suffers this condition because of genetic and societal conditions: “And if you have developed obesity, you have a high BMI, you are not able to go exercise the same way as maybe you and I. So it's important to understand that this is a complex disease. It's not just about what you eat and how you exercise. There's a genetic component that that plays into people developing body weight and weight obesity in different ways. But there's also a socioeconomic dimension to it. And I think it's important that we look at obesity in a more comprehensive way.” Several medical doctors stress as well that obesity is the most stigmatized disease, along with mental illness, by society and even by professionals. For this reason, they argue that it is necessary to change the view for which it is a vice, to stress instead that it is a disease in itself, complex, chronic and multicausal. Even if there are concerns that drug could be misused, in the medical sphere there is thus the hope that the approval of these medications in the next several years will increase awareness of the complexity of obesity and weight regulation. In turn, this could reduce the systemic issue of “fatphobia”, which occurs when the person living with obesity is judged merely based on their weight. This prejudice leads to stereotypes according to which an obese person eats too much and/or badly and does not do physical activity. This view dehumanises individuals that struggle with this disease, thus neglecting that often people with obesity have tried different things, but they have been unsuccessful. For example, people with obesity are often described as lazy and not very sporty. Yet, this neglects that there are for example structural issues in the transportation system and sport centres that prevent obese people from exercising. These structural barriers discourage the individual, who not only finds it more and more difficult to mobilise, but also loses interested/will in seeking treatment and support. For this reason, more and more media are stressing that at an individual level everyone should become aware of our internalised fatphobia, work on it and correct it. Instead, we should convey the message that all bodies are valid, and that health is much more complex than mere weight. At the medical level, this means also that: “We have not been able to offer obese any benefits from other things that we would do for chronic diseases, which are medications, surgical interventions that sometimes people need. This is a chronic disease. And so there is no magic pill, there is no magic injection, there is no magic surgery, but we can treat that person over the long term for their disease and help them improve their overall health and just their ability to navigate earth.” Interviews with patients themselves often confirm this need to break the stigma, with patients often confirming their discouragement since they have tried several times to lose weight, but unsuccessfully. For this reason, what some patients are the most looking for is: “Something that will tell my brain you really do not need this and you really do not want it”. FEAST - Report on policy barriers and facilitators 22 out of 98 In this framing, Wegovy thus well corresponds to the patients’ needs, as exemplified by a patient currently on Wegovy: “Before I'd tried all the different kinds of diets a million times... and it was always the same story. I lost a lot of weight, and as soon as I let go of the diet just a little bit, I gained the weight in no time, and even a little bit more. But now I'm thinking, 'well, I'm gonna actually have my grandkids and I'm going to play with them'. I'm going to do all the things that a granddad should do." How some patients on Wegovy are viewing the problem is thus in line with Novo Nordisk description and advertisement of their product, where the focus is on giving patients a means to get control of their life back by stopping the cravings to indulge themselves in another meal. In this way, the drug is framed as a way out of a cage, since people living with obesity can again: “Leave their home, they can leave the refrigerator, and they can go out and be socially active.” For what concerns those suffering this condition, there thus seems to be a widespread agreement that people living with obesity cannot be held responsible for they condition, since they are trying themselves to find a solution, and they cannot be left alone with no support doing that. Either society breaks the stigma surrounding obesity, or there will be no progress on reducing obesity rates. However, especially in Novo Nordisk framing, there seems to be a specific attention on the fact that individuals are trapped in something they cannot defeat by themselves. If this is case, and if people living with obesity are fighting against something too strong for them to defeat, what is defeating them? And do all actors have the same answer to this question? As we describe in the following section, there are two different answers to this question. On the one side, there is a view that medicalises obesity as an inescapable condition that can be resolved only by means of a drug. On the other side, a systemic view for which focus should be on the systemic factors of an obesogenic food environment. 2.4 Why are people living with obesity unable to change their condition? If it is not the individuals lacking willingness to lose weight, then there must be another reason why there are increasing rates of obesity. We here present the two main framings responding to the question structuring this section. 2.4.1 The genetic and societal cage According to Novo Nordisk’s CEO, the reason why we have growing obesity rates is to be found in how society has changed: “The growth of obesity is really linked to how we live today, and how each one of us moves around in society today compared that to our childhood. I remember how I got on my bike in the morning, went to school. I feel guilty about having taken my kids in the car more nowadays.[…] Today there are a lot of cars. The bikes have been replaced by electrical bikes or scooters, so I think those are just examples of how we live nowadays.” FEAST - Report on policy barriers and facilitators 23 out of 98 However, Novo Nordisk explanation is not only focused on how society is designed, since the problem is also to be found in human bodies’ genetics: “Our bodies are designed for a much different lifestyle. One of hard physical labour and our bodies are shaped to install that energy for a long time. I think we have to understand that this is actually not something that is self-inflicted; this is something that the body is imposing on them (the obese)”. The problem is thus an unfortunate combination between how current societies are structured and the lifestyle for which our bodies were meant: “Our body is designed for a different lifestyle, as it stores fat as a survival mechanism. In ancient times, unless you could store fat until you had the financial means or you could hunt to get the next meal, you would not survive. So, those who have survived for generations are those who can store energy store fat and then burn fat off in good times. As a result of this mechanism, when we stop eating, your body will see losing weight as a health issue, and it will respond by slowing down energy consumption. This shows that obesity is a disease. Those who are genetically disposed to store more fat than others would perhaps have survived better in ancient times. Yet, nowadays where it's easier to get access to calories, if you have those desires for food the cravings you end up having to have medical intervention.” Interesting here in Novo Nordisk framing is that what in ancient societies could have been an advantage (storing more fat = more likelihood to survive) has become today a handicap to counteract. The problem is that within this framing, there is nothing the individual can do: genetics cannot be changed, and it is impossible to exercise more in urbanised settings. In short, a cage that traps some individuals into a no exit path towards overweight and obesity. In this ‘cage frame’, a drug becomes the logical way out, as it is the only way by which the victims can acquire the power to counteract this enemy they were previously unable to defeat. Moreover, it also becomes a way by which Novo Nordisk contributes not only to citizens’ lives, but to the whole society: “With ageing populations, we see less and less productive workers living with more and more chronic diseases. If we can address that in a safe and efficient way, then it is good for the whole society”. If Novo Nordisk and healthcare professionals were our only sources, then Wegovy would fit well as the solution we have all been waiting for. There is no way to change the people’s genetics, and we no longer live in past societies were manual work allowed us to burn the calories we accumulated. In this context, we can only resolve the problem by helping the victim in the form of a drug that stops the hunger cravings. However, other actors stress that this story may be neglecting essential aspects of the why we have increasing rates of obesity in Europe. 2.4.2 The obesogenic food environment Some NGOs stress that the debate is dominated by a healthcare frame for which stakeholders only focus on treatment of obesity, thus neglecting the importance of programmes focusing on preventing the onset of this problem. Moreover, addressing obesity requires important life-changes that a person dependent on a drug may not be able to achieve, as they would simply rely on the drug. Given the need FEAST - Report on policy barriers and facilitators 30 out of 98 a drug can block the hunger cravings of the individual, but it cannot transform the food system making it healthier. Despite being marginalised compared to the production and availability issues, this topic appears at times in the media, for example as mentioned in an opinion piece on a Spanish journal: “The poorest families are the ones who eat the most double hamburgers with triple cheese, industrial pastries drowned in trans fats and pancetta pizzas with German sausages, for the simple reason that their calorie/price ratio is unbeatable.” The problem stressed here is that for several families, especially those living in lower socio-economic conditions, the unhealthy choice is the most economic and rational choice. Furthermore, the kind of food itself may not favour healthy eating, as ultra-processed foods work like real designer drugs capable of releasing huge amounts of dopamine in bodies designed to react in this way to sugars and fat, which are scarce in natural foods. This framing gives a completely different meaning to health inequalities. While in the Novo Nordisk framing health inequalities correspond to difficulties in accessing the drug, the problem here is that socioeconomic barriers and an obesogenic environment favour the consumption in vulnerable groups of unhealthy foods over healthy ones. In terms of actions to be taken, increasing production and reducing price (or having it covered by healthcare system) are the ways to address the inequality in the Novo Nordisk framing. In a systemic framing, this does not resolve the problem. Addressing equity becomes a matter of systemically addressing how an obesogenic environment makes it easier for individuals to consume unhealthy products than healthy ones. To do so, requires policy implementation at different levels of governance, and cannot be done by means of a drug. Therefore, the problem stressed by a systemic framing is that a story based on a victim that can resolve his/her situation only by means of a drug neglect that obesity is also a social disease: "Obesity Is not going to be solved with drugs alone, we need the main revolution to be the change of society. It is not necessary to look for an individual solution, but a social and environmental one.” In terms of solutions then, Wegovy is not sufficient in the systemic framework, as the drug does not change the obesogenic environment influencing individuals’ dietary behaviour. On the contrary, solutions foreseen by a systemic framing concern policy regulation such as (but not limited to): • Limiting food deserts and food swamps • Limit consumption of ultra-processed foods (UPFs) • Restricting marketing of unhealthy food; • Taxing sugar, fats and salt; • Subsidise consumption of healthy products such as wholegrains, fruits and vegetables; • Enhancing healthy public procurement in schools • Food products reformulation; These are various interventions that concern the whole food system and may also pertain to different ministries, entities, etc. However, they all have one thing in common: they do not focus on “fixing” the individual, but on fixing the system. The problem here is not only that this framing is marginalised in the media, but also that a systemic perspective is neglected at governmental level. As mentioned by FEAST - Report on policy barriers and facilitators 31 out of 98 Kremlin Wickramasinghe, head of WHO Europe’s Office for Prevention and Control of NCD, advocating for a systemic perspective is complicated, since: “We can’t find a country which has implemented at least half of this comprehensive package, so we won’t be able to solve obesity or see a reduction in obesity in any single country, when they have not implemented this comprehensive package of policies”. In terms of framing then, it is now evident that there are two different ways – that we called ‘Novo Nordisk framing’ and ‘Systemic framing’ - to approach the obesity and drug debate. Here below a table summarising the two views: Novo Nordisk Framing Systemic Framing Victim Individuals with obesity Individuals with obesity Problem Genetics + Modern society where movement is no longer part of our lives Obesogenic environment Inequalities Different access to drug due to costs Unhealthy environment makes it easier for lower SES families to eat unhealthily Solutions • Produce more Wegovy • Making Wegovy more available Systemic measures to address the food environment The debate over Wegovy is of primary importance in terms of policy development for the coming years. From what we described, Novo Nordisk framing is now imposing itself as the dominant one, thus marginalising the systemic framing in the media, in governmental debate and in the overall discussion about obesity. For policy implementation, this is relevant as solutions proposed are direct consequence of how the debate is framed. If an individual framing continues to dominate the public debate, then solutions will follow this framing, and policymakers will debate only about production and cost of the drug. If, instead, this framing is challenged, then it is more likely that systemic regulations are discussed and, eventually, implemented. In the final section, we thus propose a set of counter-frames that could be used by various stakeholders and policymakers to favour a systemic framing over the ‘miracle drug’ one. These are of course general indications that need to be adapted according to the specific issue. Yet, counter-frames presented below can offer the main guidelines to spot the problems in the current debate, and to try to move the discussion towards the systemic determinants of the issue considered. 2.6 Counter frames to favour a systemic framing The contrast between the individual and systemic framing starts with the different answers to why current obesity rates are increasing and societies seem unable to stop them. First of all, a systemic framing needs to demonstrate that the ‘genetic cage’ is not sufficient to explain the problem. Two counter-frames could be used in this regard. The first one is to highlight the nurture part of the problem in the nature Vs nurture debate. FEAST - Report on policy barriers and facilitators 32 out of 98 Dramatic increase in obesity rates is due to societal changes, not changes in genetics Key Message Obesity and overweight trends have dramatically increased over the last decades. There are societal determinants explaining this trend that cannot be reduced to genetics and/or willpower. Problem The frame proposed by Novo Nordisk presents current situation as a result of genetics and societies where citizens no longer exercise as in ancient times. This is insufficient to explain why over the last decades obesity rates have skyrocketed. Counterframe Obesity rates in the European region have more than doubled in just the last 50 years, and estimates foresee a continuous increase if we continue with current food environment status quo. Providing data on the recent historical development of this condition is the first step to shift the debate towards the systemic debate, since it shows that this is not due to changes in genetic predisposition and neither in willpower. First, obesity increased in all groups in society, in each age, sex and ethnic group. These groups have considerable differences in life experience and attitudes, so it is implausible that all experienced a simultaneous decline in willpower related to healthy nutrition or exercise. Second, changes in genetic predisposition do not occur in such a short timeframe, but over a much longer period. Furthermore, these changes do not affect all age groups simultaneously. Sharp increase in obesity since the 70s thus cannot be explained by changes in genetics. Therefore, in the nature Vs nurture debate, it must be stressed that sharp increase in obesity rates over the last decades is due to societal factors. Consequentially, interventions must target the obesogenic food environment, not primarily target individual behaviour. Stressing these two points – not genetics and not willpower – can already help policymakers to frame the obesity debate towards systemic policies rather than individual behaviour interventions. FEAST - Report on policy barriers and facilitators 33 out of 98 Figure 2 Obesity in adults in the WHO European Region, 1975 to 2016 If it is society that has changed, then it is also important to stress that a systemic solution is not implementing just one ‘silver bullet’ measure, but a comprehensive set of regulations. A swallow does not make summer Key Message Systemic problems require systemic solutions. Implementing only one measure not connecting it to a series of policies will not slow down obesity rates. Food systems must make the healthy choice the easy choice for everyone and at any time from when individuals wake up in the morning to when they go to bed in the evening. Problem In public health, but we could say in contemporary society overall, the debate is always focused on finding the key single solution that will fix the issue. Wegovy well fits this need, as it is presented as the silver bullet we were looking for. However, especially in food systems, there is no silver bullet. Solutions can only be achieved by implementing a comprehensive set of regulations. Corporations are well aware of this, and they will mention every now and then a systemic measure in their interviews. For example, we described that Novo Nordisk mentioned the taxation and the removal of unhealthy food from vending machines in schools. However, as the saying that a ‘swallow does not make summer’, a single regulation is not implementing a systemic set of regulations. For the food environment to change, food system must favour the healthy option from the moment an individual wakes up in the morning, to when s/he goes to bed in the evening. FEAST - Report on policy barriers and facilitators 34 out of 98 Counterframe In interviews, public debates, conferences, etc. the debate will often be framed towards finding a silver bullet. As a consequence, it will not be a surprise that if you look for a silver bullet, the discussion will be how to find it. This framing can yet be changed by saying that there is no silver bullet, by always stressing the systemic causes of the problem and by underlining the comprehensive set of measures needed to make the food environment healthier. If this happens, then the solutions proposed will follow. If there is no silver bullet for the food system, then debate will not focus on finding one. Focusing on the daily life of a person can help making this point. For example, a child wakes up in the morning and sees unhealthy food advertisement on the smartphone, then eats breakfast that could be UPF and HFSS, then goes to school where there could be fast foods in the area and s/he could eat these foods before or after school. On the way back from school, s/he can see advertisement of food on the bus, then more advertisement on digital media, then have a dinner with HFSS food, and so on. Taking unhealthy foods away from vending machines in schools is of course positive. However, looking at the daily life of a person, it is clear that this is not sufficient. If a child goes out of schools and enters a food desert, then the damage is done. Stressing the continuity of protection required to prevent individuals from getting unhealthy food is essential to advocate for a set of systemic policies to make our food system healthier. Once the need for a systemic perspective is stressed, there are other more specific points that can favour a systemic perspective to an individual one. An important one concerns the need to counteract corporation’s strategic usage of physical activity in the obesity debate. You cannot train out a hypercaloric diet Key Message Physical activity is essential for our health on numerous regards, and the decreasing rates of physical exercise in the European population are worrying issues that need to be tackled by all public health systems. However, obesity is not the simple result of a lack of physical activity, but mostly of bad diets based on HFSS and ultra processed foods. Food system must be healthier regardless of physical activity, and the latter should not be used as an excuse to sway the debate away from unhealthy food system to individual behaviour. Problem A strategy often used by food industries, and that is prevalent also in Novo Nordisk framing, is to focus on physical activity, or better lack thereof, to explain the increasing rates of obesity. This is often combined with a criticism of modern society compared to an ideal past one that was better suited to the energy expenditure of our bodies. The problem is that this helps them to shift the debate from systemic regulations to individual behaviour change. The latter is compatible with a ‘drug solution’ frame, while FEAST - Report on policy barriers and facilitators 35 out of 98 a drug cannot address the former. It is necessary to counter-frame this strategic usage of physical activity to detach it from the discussion on obesity. Counterframe It is also often assumed that physical activity can compensate for a bad diet, but this is not the case in two main regards. Note that this counter-frame will be considered also in the chapter on zoning laws. First, for a diet to be healthy, it is necessary not only to limit the caloric intake of the individual, but also to make sure that important nutrients are absorbed via the intake of fruits, vegetables, legumes, nuts and whole grains. While physical exercise can help burning some excessive calories, it cannot replace the healthy components of a diet. Second, even if we take the caloric intake into consideration, the amount of physical activity needed to balance a hypercaloric diet is much higher than what commonly assumed. Let’s take a simplified example to explain this point. A meal (note a very basic one) in a famous fast-food restaurant such as McDonald’s – a Big Mac, a portion of fries and a medium coca cola – would provide around 1000 kcal. For an average person to burn this amount of kcal, a rough estimate that can be done with an online calculator, it would take around 2 hours and a half hours of aerobic activity. If we consider current physical activity rates in Europe, in a typical week, around 28 % of the population aged 16 or over did not do any exercise outside. Moreover, just over one quarter (27 %) of the EU population exercised for up to 3 hours, 17 % for between 3 and 5 hours and 28 % for 5 hours or more. This is of course a very oversimplified overview, but it proves that already only 1 in 2 European citizens do more physical activity in a week than it would take to burn off a single meal in a fast food chain. This is thus just one small example of the many that could be done to explain why expecting physical activity to resolve the issue of obesity in the current food system is unrealistic. Physical activity is an essential component of a healthy lifestyle and as such should be incentivised as much as possible. More in detail, there are several structural barriers that prevent people from exercising that are not due to individuals’ lack of will. Acting on these barriers can help individuals to increase their weekly amount of exercise. However, physical activity should not be used as primary measure to manage weight, as healthy eating comes first. Therefore, to contrast this framing, it is necessary to discuss first about healthy foods availability and reduction of unhealthy food intake. Note that this point could be complicates as other framings could maintain that the lack of physical activity supports the drug intervention. Yet, this is not the case. Prevention and treatment are not the same. Focus here should be on preventing unhealthy foods from being so accessible, not on justifying drug treatment because it is difficult to train out a bad diet. Another problem is that different stakeholders use same concepts and words, attaching to them dissimilar meanings. From what described above, this occurs on two specific issues: health prevention and health inequalities. FEAST - Report on policy barriers and facilitators 36 out of 98 Novo Nordisk Democratic and systemic approach Disease Prevention Using Wegovy on a largescale is a preventive measure. This is due to the fact that it can prevent healthcare expenditure in the long-term. Furthermore, Wegovy could be used in children so that they do not develop diseases later in life. Systemic framing concerns primordial and primary prevention. Wegovy can at best be conceived as tertiary prevention. The two are different and concern dissimilar interventions. There are different kinds of prevention and it is important to differentiate between the four levels of prevention: i. Primordial: targets the social conditions that promote disease onset. ii. Primary: activities to prevent diseases before they occur by implementing interventions such as vaccinations and health education. iii. Secondary: early disease detection, often in the form of screening, to prevent the progression of disease by intervening as early as possible on the disease. iv. Tertiary: this concerns the management of the disease by tackling its consequences with the aim of restoring health and providing rehabilitation. Novo Nordisk’s prevention is not primordial or primary prevention. The latter aim to prevent a disease from occurring, and this can be done only by regulating the food system and by acting on the related social determinants of health. On the contrary, Novo Nordisk refers to tertiary prevention, since Wegovy can only be used as a way to reduce the severity of the problem. In policymaking, this is a significant, as it demonstrates that if we are to reduce obesity rates we must act on the primordial and primary levels. Otherwise, the roots of the issue would not be resolved, but only tamed. At any time, those interested in fostering a systemic perspective need to stress the level of prevention needed to resolve the problem. FEAST - Report on policy barriers and facilitators 37 out of 98 Health Inequalities Wegovy is meant for all citizens who are overweight or obese. In society, there are yet two groups. Those who can afford to pay for the treatment out of their pocket, and those who cannot. Making sure that the latter can access Wegovy via the healthcare system, or that health insurance can cover this expense, is essential to prevent health inequalities. There are more structural inequalities in the system that must be addressed so that disadvantaged groups no longer develop higher rates of obesity and overweight. This is a different conception of inequalities than focusing only on who can afterwards get the Wegovy drug. Because of structural socio-economic inequalities in society, certain groups in the population are more likely to be overweight and obese than others. As for several others NCDs, lower levels of education, low socio-economic status, housing, ethnicity, etc. are all aspects that influence obesity rates. The first question that should be asked in this regard is not whether or not everyone can afford to pay for the drug, but "does everyone in our society have an equal opportunity to be healthy?” The answer to this question is negative, but already reframing the debate to address these points would change the way inequalities are framed in the obesity debate. In this frame, a drug would not resolve the problem because the conditions causing the issue are more structural and require policy implementation and regulations to address health inequalities. This would work in line with the need to stress different levels of prevention, as both would reframe the debate towards addressing the systemic causes of obesity, rather than the focus on medicalising an individual condition, which only favours an overmedicalisation of the issue where business models replace views based on public health values. Another point of contention concerns the economic aspect, as the cost of treating those in need with Wegovy is central in the public debate. Wegovy is presented by Novo Nordisk as an optimal solution also in economic terms, but from a systemic perspective, there are two counter-frames that could be adopted to prove the better value of systemic interventions rather than a medicalisation that relies on the drug only. Your country is unlikely to afford a large-scale Wegovy intervention Key Message There are several systemic interventions that can offer better health results for a much lower economic investment than the one required for Wegovy. FEAST - Report on policy barriers and facilitators 38 out of 98 Problem As stressed by the Danish debate, several countries are currently debating on whether or not it would be actually possible to sustain the expense for Wegovy on a large-scale. As described in the introduction, half of the European citizens are overweight, with 36% pre-obese and 17% obese. A treatment of Wegovy is likely to cost from €190-300 a month (country differences) for a single individual. If we take an average of €250 a month, this means that it would cost around €3000 a year to cover Wegovy for each patient. In terms of costs, this would mean that: • If Wegovy was to be given to all overweight and obese individuals (224 million individuals), the cost each year in Europe would be of around 672 billion euros. • If Wegovy was to be given only to citizens living with obesity (almost 36 million Europeans), the cost would be of around 107.5 billion euros. As mentioned by Novo Nordisk, this number would need to be compared to the cost that overweight and obesity currently have on the healthcare system. Estimates for the European Union vary due to difficulties in calculating direct and indirect cost, but recent studies calculate the economic burden of overweight and obesity in Europe to be at around 8% of the total healthcare expenditure. A very general estimate, but that equates to around 98 billion euros per year. This is of course a very oversimplified analysis, as there are several other factors to keep into consideration in terms of direct and indirect costs of obesity and overweight. However, this estimate aims to prove that – considering that even in the most optimistic scenarios Wegovy would not completely erase obesity and overweight – covering this expense at population level for a long timeframe (given the chronic treatment) would be unfeasible for many healthcare systems across the EU. The question is then, can this money be better invested? Counterframe There are several systemic interventions that can efficiently tackle the obesity issue. To mention just a few examples: • Healthy foods in schools: the EU currently spends ‘only’€250 million to ensure children at school have access to free milk, fruit and vegetables. Investing more on this projects could help children developing healthy habits since an early age, thus leading to healthier adults afterwards. • Currently, less than 3% of our health and care budgets is spent on (primary/secondary) prevention. Increasing the percentage of this budget would foster primordial and primary prevention intervention, helping reducing the number of people who get obese in the first place. • Subsidies to make healthier foods more accessible and affordable have long proven to increase the consumption of healthier foods. • All the systemic interventions cannot be fully covered here, but there is ample research proving their cost-effectiveness, especially of food reformulation, marketing regulations, front-of-package labelling, taxes on products high in sugar, fat and salt (HFSS), packaging size, etc. In sum, these are just some of the counter-frames that policymakers can adopt to promote a systemic framing to the obesity debate rather than a medicalised one that promotes the usage of a miracle drug FEAST - Report on policy barriers and facilitators 39 out of 98 to resolve problems. Once again, aim of this section was not to completely discredit Wegovy as a viable option for those who have already a high BMI and related comorbidities. If concerns over the side effects and the difficulties in remaining under treatment for several years are resolved, then there may be a space for this specific group of the population. If the focus is instead population level interventions, it is problematic that the democratic and systemic framing presented above is at best marginal in the public debate, if not absent completely. This marginality creates inequalities in how the debate is framed and, consequently, on the solutions proposed. Rebalancing the debate around obesity by promoting a systemic framing is thus necessary if we want the systemic regulations to be part of the solutions considered. This analysis provided stakeholders and policymakers with an overview of how the debate is currently framed, and what are the ways to rebalance the debate currently skewed towards a ‘miracle drug frenzy’. Counter-frames will need to be adapted according to the context and situation used, but they will help making sure that a focus on primary prevention, systemic regulations and the social determinants of health can be central features of the public debate, and not marginal issues discussed only by a few public health institutes and CSOs. FEAST - Report on policy barriers and facilitators 46 out of 98 gambling, and fossil fuels, and that are now well studied in the literature on the commercial determinants of health (CDOH). A main strategy to delay policy implementation is to always stress how the solution is more education, rather than legislations. This refers to avoid interfering with individuals’ choices, making yet sure that individuals are provided with more information to then be able to chose for themselves. This strategy is used by industries to shift responsibility for taking action towards individuals rather than themselves. That is, it becomes individuals’ personal responsibility to take the healthy choice rather than the ‘wrong’ one, and not a systemic issue that the unhealthy option is more easily accessible than the healthy one. Usually, this education strategy is used to skew the public debate, and above all to prevent measures such as marketing restrictions, taxation, legislative controls, and other systemic regulations. NutriScore an instrument to provide more information to consumers, so it was bizarre to find this strategy used against Nutri-Score. For example, the SMEunited lobby, a group representing several small and medium enterprises, stated that: “We should get the people to make informed choices and not convenient choices, and that only goes through education. As soon as you put the label as something healthy on a product that is sold in the supermarket, you get the people that want to make the informed choice, but do not want to take the time to inform themselves only into the supermarket. Then, you put small businesses, specifically bakers, butchers, and so forth, that are not only producing healthy products but sustainable regional products and are stable employers, completely aside. This, I must say from our perspective, especially with the oversimplification of Nutri-Score, for us is very very difficult to stand behind.” This argument is not only present in the frames of some lobby groups, as it can also be found in the opinions of certain academics, such as a professor at the Department of Medicine in Universidad de Barcelona, who stated that: “I don’t believe in this kind of front of package labelling, because I believe to educate the population, especially the young people. Now we have the problem of obesity. I don’t believe that this front of package labelling may help to reduce obesity. I believe more in education, into eat more healthy dietary pattern adapted to all the conditions, like your preferences, you practice this sport or not, or you have a disease or not. I think that this is out of fashion. I think that we have to move further, and try with the right people for a personal research nutrition and will be better for all the society.” In the same event, another Italian professor used frames which reveal that, more often than not, this education argument is also connected to some sort of sense of political belonging. That is, selfproclaimed liberals often argue that education is the only measure that respects individual liberty: “That’s why we need more education, we need systems that are considering our lifestyle. I am sorry, but telling me this is green, and I can eat 25 packages, it’s not making me healthier. I am also sorry to say, if we say education takes time, well then the Nutri-Score is the moral justification of a failure in educating masses. If I was a socialist, and you know I am not, I am a liberal, I would go against the Nutri-Score, because it’s a failure. It means we miss educating people that were supposed to be emancipated, and now they go to the supermarket and then they don’t have time to read […]. That is the problem in Europe. People die because they are not informed about food. That is the effort that we should do. And I don’t think that we should spend time on an old system, outdated.” FEAST - Report on policy barriers and facilitators 47 out of 98 A second strategy used to limit damages once the legislative process is already too advanced is to contrast mandatory regulations, to claim that measures should instead be implemented on a voluntary basis, following self-regulatory frameworks. The argument is that corporations cannot adapt too quickly to new regulations, so they need time to process what is requested to them. Yet, to prove their willingness to cooperate, they state their willingness to voluntarily and gradually selfregulate, to eventually get to an outcome that well matches both governmental and private interests. This strategy is used by the private sector, despite the fact that more and more literature is proving that self-regulations do not provide the results promised. A perfect example of this framing was used by Fevia, the federation of Belgian industries, who referring to Nutriscore mentioned that: “A complementary nutrition labelling system must first and foremost be harmonized at European level and must remain voluntary, as provided for by European regulations today. It is difficult to expect companies that use multilingual packaging in several countries to apply a different label system for each of these markets. So let's let our companies choose for themselves whether it is possible for them to add additional information, in addition to the legally mandatory information.” Third, industries tried in several ways to discredit the scientific validity of Nutriscore. This was done in several ways. First, the functioning of the algorithm and its ability to put each product in the correct scoring was targeted. For example, the lobby MUST & partners stressed that: “Ingredients are modified by chemical agents only to have a better Nutri-Score without [properly) informing the consumer about these changes, which is quite misleading. For example, parmigiano Reggiano has a Nutri-Score 'D', while McDonald fries have a nutriscore B, despite the fact that the cheese is made from milk, salt and rennet. The fries, on the other hand, contain potatoes, vegetable oil, natural beef flavouring, dextrose, sodium acid pyrophosphate, and salt.” This criticism has some validity, since the first versions of the Nutri-Score had some incongruencies. However, these criticisms consciously neglect that the algorithm is constantly developed and improved. Thanks to these improvements, current version of the nutriscore has already fixed many of the ‘categorisation issues’ of the first years. These criticisms have also a structural problem, since they sway attention away from the fact that nutriscore is important to make comparisons within the same food category, and not across all food purchases. More on this below in the counter-frame section. In the battle to discredit Nutri-Score, this biased comparison turned out to be very effective, as it resonates well with the public, and it was also used by the European Commission to initially justify the delays in the implementation of the measure, with commission’s first Vice President Frans Timmermans stating that: “On the Nutri-Score, we are not there yet. I have trouble understanding what it means. How can a processed product have a better Nutri-Score than a natural product?” On top of the criticism to the algorithm, Nutri-Score debate was highly affected by another well recognised commercial determinant of health: the industry funding of severely biased research to then be published in complacent scientific journals (Chapter 6). In the Nutri-Score debate, this could be seen especially in the case of a specific article published by two individuals receiving funding by the agri-food industry. This article casted doubts not only on the scientific validity of Nutri-Score, but also tried to demonstrate that there was a conflict of interests related to it, with most of the support coming from researchers related to the French team who firstly developed this FOPNL. Since its publishing, lobby groups used it in their activities to block Nutriscore implementation, despite the fact that this article has been proven to have methodological errors and several inconsistencies throughout. FEAST - Report on policy barriers and facilitators 48 out of 98 A sign of the power by agri-food business is that lobbying often occurs not only via their own lobby groups, but it is reflected in the speech of several favourable politicians. At European level, one of the arguments used by MEPs willing to block Nutri-Score was to connect the implementation of this measure to certain national interests. That is, given that Nutri-Score was developed in France, it was put under scrutiny the “Frenchness” of this measure. As the argument goes, all other countries should be wary of this FOPNL because it is an instrument used by the French government to favour their own agenda. In the words of the Spanish MEP Adrian Vazquez Lazara: “I am also concerned, because this is going to be one of the priorities of the French presidency. It's no secret that Nutri-Score is supported by the French Government in order to benefit their big conglomerates in the food sector in France. That's no secret. It is on this basis I hope that the European Commission does not fall into the trap and also considers other options." This nationality aspect is even more present in what is probably the main argument that was used to block Nutri-Score, namely that it is against traditional and local products. The way this argument was framed varied between countries. In Greece, argument centred on the ‘natural Vs artificial dichotomy’, as the Deputy Minister of Rural development & Food mentioned that: “Nutri-Score politically, from an ordinary citizen, could be characterized as the attack of the mass chemical industry against the local traditional-natural diet. Nutri-Score is a single oversimplifying scheme that tries to impose a strange unjustified discrimination of foods, with potential negative effects on the nutritional classification of certain emblematic Greek products (e.g. olive oil, olives, feta cheese, strained yogurt, honey, etc.), while ranking in the best categories are the chemically manufactured products like cola and ketchup”. And therefore: “The single EU scheme must respect the food culture and typical diets of each member state and not discriminate against traditional foods. The paradox of demonizing traditional products, which play a positive role in nutrition if consumed in the right quantity, at the right time and in the right quantities, must be avoided.” Romania focused instead on the algorithm structuring the Nutri-Score, mentioning it is too simplistic and unable to consider the size and portion of general food composition. In the words of the Romanian national authority for the protection of consumers (ANPC): “Nutriscore does not include the entire list of ingredients of a product, thus there is a risk of not providing information about components with negative health effects. Also, the system does not take into account geographical specificities, type of metabolism, effects of food association or different age and activity categories (eg: athletes). Nutriscore cannot claim to provide consumers with accurate information about the healthiness of products. The scheme is discriminatory towards Romanian products or those of other member states. The exception is France. This creates a false impression of additional information”. This problem reflects negatively, according to this argument, not only on citizens’ health, but according to the Czech Ministry for agriculture Nutri-Score could: “Discriminate against quality and traditional food with composition given by legislation.” For this reason, the Czech ministry of agriculture stressed that it would be better to look for alternative options, specifying that the Italian ‘Nutri-inform’ approach would be much better. This last point is of significant relevance, since it points to the fact that there is a common view from certain countries against Nutri-Score, and that the Italian government is at the center of this position. FEAST - Report on policy barriers and facilitators 49 out of 98 An analysis of how Nutriscore was framed by several actors in Italy shows that there is an alliance between main food industries, so called defenders of the “made in Italy” and several political actors. This is evident in how Coldiretti, the main agriculture confederation, framed the debate, namely repeatedly saying that Nutriscore ends up: “Excluding healthy and natural foods from the diet that have been present on tables for centuries in favour of artificial products". Important in this case is how Coldiretti centres its argument on a threat to traditional food in favour of the processed ones, stating that Nutriscore: "It is a system that demonizes traditions to benefit a series of industrial products exclusively to promote their sales. And so the real risk is that the tradition will simply disappear from the shelves of the shops." The argument that tradition – without clearly specifying what this is or how it has developed - needs to be defended from an external interference is developed centrally by Coldiretti, but then used efficiently by all sectorial industries. For example, the representative of one specific type of Italian cheese mentioned that: “This cheese probably contains more salt than a tasteless and industrial cheese, but it is a natural product and, thank God, in Sardinia, the main region where pecorino is produced, it is also the land with the most centenarians. This shows that this diet is absolutely not bad for your health." Coldiretti is well connected to the current Italian government, with the Italian prime minister often repeating that they are going to oppose any measure that is: "Discriminatory and penalising our agri-food system". The Italian Agriculture Minister has also been at the forefront of the battle against Nutri-Score, often repeating that this system provides no useful information to consumers: “We do not believe that there should be instruments that are not sufficient from the point of view of information and that are even dangerous from the point of view of conditioning the consumer.” In other interviews, the defence of tradition and local products, also with reference to the UNESCO, emerged again as dominant frame to oppose Nutri-Score. Furthermore, there is also a reference to a resistance against multinationals, as if Nutri-Score favoured the interests of big agri-food corporations at the expenses of the small and local producers: "The application of Nutri-Score would produce discriminatory effects towards food excellence, conditioning consumers and directing them, as many multinationals would like, towards market dynamics in open contrast with the criteria that allowed the Mediterranean Diet to be inscribed on the UNESCO Intangible Cultural Heritage List. Suffice it to say that products of absolute excellence, such as Parmesan cheese, would be qualified as unhealthy. […] We will defend Italy's strategic vision in Europe and work to build a stronger Europe that favours quality products, which are the fundamental pillar of our economy and culture”. As an alternative to Nutriscore, the Italian government also developed the “Nutrinform battery”, a system that according to the Italian government functions much better than the French alternative. In FEAST - Report on policy barriers and facilitators 50 out of 98 particular, according to the promoters, this system is better as it is not based on an algorithm and also based on portions and not on a 100-gram serving. An in depth analysis of this system exceeds the purpose of this paper, but several scientific studies questioned the scientific validity of this labelling system, and further publications proved the better efficiency of Nutri-Score than Nutrinform. For this reason, the Italian system seems more the result of political and economic interests of the Italian government rather than a system based on public health science. Interestingly, there is a discrepancy between public campaigning and official meetings even from Coldiretti itself. For example, Coldiretti admitted in meetings with the European Commission that this system is not yet properly adapted and simple to use. The Italian crusade against Nutriscore also relied on the creation of ad-hoc lobby groups. One of these was Competere.eu, a think thank which stated its intent as proving that science is against Nutriscore. In their framing, it is possible to find a mix between attacks towards the scientific validity of the algorithm, and the need to defend traditional diet, especially the Mediterranean diet: “We have once again highlighted the lack of scientific basis of the Nutri-Score, as it only aims to arbitrarily condemn or promote foods while it does not educate the consumer, forcing him towards choices based on incomprehensible and non-transparent parameters. Nutri-Score, in addition to generating paradoxical classifications of foods that are symbols of the Mediterranean Diet – scientifically considered as among the healthiest nutritional regimes in the world – represents a totally unscientific measure that jeopardizes not only a priceless social and economic heritage such as the Made in Italy agri-food, but also the wellbeing of European citizens.” As proven by Bachrach and Baratz in the 60s, power occurs not only in the manifest choices or actions. Rather, power occurs also when certain decisions are prevented from being taken and/or even considered. In the case of Nutri-Score, this is reflected by the fact that individuals willing to oppose the dominant ‘No Nutri-Score’ struggle to emerge and contest the dominant rhetoric. This difficulty can be found in the words of some important Italian scientists. For example, a former president of the Italian National Institute of Health, stated that: “Today, the anti-Nutri-Score narrative has become not only generalized but totally hegemonic in Italy and one can no longer publicly oppose it.” By supporting publicly Nutri-Score, he then mentions that “I had simply become a traitor to my country”. As for the support, the opposition to Nutri-Score focused on specific points: • The inefficiency of the algorithm: considered unable to properly determine if a product is healthy or not; • Attack to local cultures: regional and local products risk being classified as D or E, which damages local traditions and eating cultures, while favouring ultra processed foods and big chains. Particularly powerful was the Italian crusade to protect the mediterranean diet; • It does not educate: this is not how you educate the population on having healthier diets; • Self-regulation and not mandatory rules: industries mentioned that if Nutri-Score has to be implemented, then it should be on a voluntary basis so that they can decide whether it is feasible for them or not. Given that the focus of this analysis is how different actors tried to influence the policy process via different framings of the issue, we do not delve into detail in all steps that led to the failure of the Farm to Fork. However, as for almost all points of the F2F strategy, industry lobbying managed to efficiently FEAST - Report on policy barriers and facilitators 51 out of 98 halt EU plans, thanks to an efficient lobbying strategy and well developed frames to conquer the public debate. Eventually, the decision can be summarised in the few words of the representative of the European Commission, who stated that: "The Commission is not going to propose the Nutri-Score not to put on the table something that polarises the debates". From a public health perspective, this is a significant loss, as Nutri-Score could have been an important step forwards towards a healthier and more sustainable food system. In the final section, we offer a selection of counter-frames that can be used to counteract the frames used by the industry and the Nutri-Score front. 3.4 The counter-frames Compared to the carefully thought framing by Novo Nordisk on Wegovy, the framing opposition to Nutri-Score results often simplistic and generic. Concepts of tradition, culture, local, etc. are never welldefined, and often unfunded form a scientific perspective. It is worrying that simplistic frames managed to be so efficient in dominating the public debate. However, this also means that counter-frames can effectively be used to advance the public health agenda. In the tables below, we offer a series of counter-frames that could be used to facilitate policy implementation, while also de-constructing the attempts to misinform about Nutri-Score. First of all, there are three counter-frames that can be used to defend the algorithm from the attacks of the corporate lobbying 1A) It does not make sense to make random comparisons between food groups Key message Nutri-Score is primarily meant to help consumers choosing the healthier alternative within the same food category. Problem Corporate lobbying tries to discredit Nutri-Score by finding cases where the algorithm fails to indicate the correct category for a specific food. Often used is the example of olive oil, which initially was ranked D, while McDonald fries were B. Counter-Frame Choosing between the same groups means that consumer in the supermarket can, for example, look at different breakfast cereals, and according to their NutriScore rank pick the healthier one. This can also be applied to food belonging to different families, but there must be a relevance in their conditions of use or consumption. For example, it makes sense to compare a yoghurt to a dessert cream. In a nutshell, the comparison must make sense. In their food purchase, it is unlikely that consumers willing to buy parmesan cheese, after seeing an orange Nutri-Score, will drop it, leave the supermarket, and then go immediately to a McDonald to get some fries because they remember that they were a B. Comparing two different foods does not make sense, so discussions should always focus on same food categories. FEAST - Report on policy barriers and facilitators 52 out of 98 1B) Algorithm is constantly evolving Key message Algorithm can be improved, so any imperfection of the past or current version can be ameliorated if necessary. This does not mean Nutri-Score has no scientific validity, but simply that – as any scientific instrument – it can be constantly improved with time. Problem Corporate lobby framing selects specific foods that should be ranked better – or worse - to prove that Nutri-Score has no scientific validity. They use this argument to reject entirely this FOPNL, and not to ask for improvements. Counter-frame We use one specific product to explain how this counter-frame could be used with all items. A case often used to discredit the algorithm is olive oil, which was initially ranked as D. Not the focus here to delve too much into the health properties of the product, but this is a good case to show that algorithm is constantly updated and improved. Over the years, olive oil has first moved to the C category, and soon will be B. Same goes for several other products, and also the other way around. For example, in the new version drinks with sweetener are assigned to categories C to E, instead of B as before. Even in the cases in which there were indeed some imperfections in the first version of the FOPNL, researchers have managed to adapt and improve the algorithm. Therefore, the matter is ‘can – and if so how - the algorithm be improved’ and not ‘this is unscientific and does not work’. As for several other counter-frames related to public health interventions, the measure must be analysed compared to current status quo, and not to an ideal perfection. The question is whether Nutri-Score improves the status quo, not if it is an absolutely perfect instrument, and evidence proves that benefits way exceed the imperfections in the algorithm. And third and final one is that: 1C) Quantity to be consumed is relevant for the grade of the product Key Message Nutri-Score helps guiding citizens in their purchases and in the consumption of food and beverages. If a product receives an orange or red grade, it does not mean it must never be consumed, but that the quantities of the product should always be limited. Nutri-Score grading can help consumers reducing their purchase of unhealthy products, and also indicating that their consumption should be as moderate as possible. Problem Especially corporate lobbies in Southern European countries focus on how local products, as for example certain cheeses, are discriminated by Nutri-Score, as FEAST - Report on policy barriers and facilitators 53 out of 98 they receive a D or an E. As the argument goes, this would hinder the local producers, local traditions, cultures, etc. Counter-frame The fact that a product is local does not necessarily mean that it is healthy. If a product receives a D or an E on the Nutri-Score, it means that an excessive consumption of it could lead to health issues. For example, overconsumption of salt is a significant driver of cardiovascular diseases, so it is important that citizens are aware of the excessive salt content of certain products. Several cheeses have a very high salt content, so it is important that individuals know they must restrict their consumption. Nutri-Score is meant to help individuals understanding how to relate to certain foods. No one is saying that a bit of cheese every now and then is absolutely bad, as everyone agrees that olive oil can be part of a healthy diet. At the same time, no one would say that it is healthy to drink the whole bottle of olive oil, or to eat the whole piece of parmesan cheese in your fridge. Nutri-Score helps individuals making their decisions, it does not completely remove certain products. As presented above, another aspect targeted by opponents to Nutri-Score is that we must respect individual choices and not interfere with them. This argument has been used for decades now by neoliberal ideology to portray a biased conception of liberty in the public debate. Its usage here is just one of the several applications of this concept, and we will analyse it even in the following chapters. 2) Absolute freedom as non-interference exists only if you are by yourself on the moon Key message Policy regulations do not necessarily limit the people’s liberty. Public debate is dominated by a biased conception of liberty for which individuals are free only insofar as they are not interfered with in their decisions. In a societal context, this is impossible, as we must negotiate our choices with the liberty of those surrounding us. Plus, the idea for which regulations necessarily restrict individuals’ liberty is a neoliberal invention. You can regulate a system and respect individual liberty at the same time. Problem As described above, corporate lobbies argue against Nutri-Score saying that it interferes with people’s choices, thereby biasing or restricting them. This reflects a neoliberal paradigm which aims only to make sure that corporations can then act free from governmental interference. Counter-frame The neoliberal argument does not work on several regards: i. Absolute freedom as non-interference does not exist in society: living in society necessarily entails that we must negotiate our absolute liberty with those of others. To do so, we must set rules and regulations. There are several other ways to define liberty, above all the republican conception of freedom as non-domination, for which one is free when no one has the capacity to interfere on an arbitrary basis in your choices. In this framework, FEAST - Report on policy barriers and facilitators 54 out of 98 regulations and liberty are perfectly compatible. For example, wearing seat belts in the car limits your absolute freedom as non-interference, but it does not limit your freedom as non-domination. You accept that rules are set for your own and societal wellbeing, so this regulation is perfectly compatible with your life in society. Hence, the only way to have your liberty as noninterference respected is to live by yourself on the moon. On planet earth, life in society must be regulated. ii. Shall we restrict advertisement as well then? As the argument of corporates goes, we must let consumers free in their food decisions. Any argument must be coherent with its premises, so following this noninterference argument we should block all sorts of advertisement as they influence food choices. Maintaining the we should block Nutri-Score while maintaining a food system where millions and millions of euros are spent each year by industries to make sure that they can force their products into individuals’ diet is simply contradictory. A simple question asking this to corporate lobbies could change the discussion towards public health goals. iii. Nutri-Score does not interfere with liberty of choice: Grocery shops are full of dozens of products in the same category, and making sense of all that is complicated for everyone. Having a FOPNL that can simplify all this is can only help, and not restrict, individuals’ ability to pick the food they think it is better. Furthermore, this would reduce health inequalities, as a graded and coloured system helps those categories in society that find it more difficult to make sense of all the information to which they are exposed on a daily basis. Finally, an important framing brought by the Southern European coalitions against the Nutri-Score is that it would damage local food cultures and traditions. This is not new, as the defence of local food cultures is an argument often used by lobbies to prevent policy regulation. 3A) Food cultures have always changed and adapted Key message Opposing lobbies presented food cultures in a stereotypical way, and also as something that has always been the same forever. This is not true, as food cultures evolved continuously throughout history, and they can thus change now as well. Furthermore, it is not true that Nutri-Score favours ultra-processed foods, as the latter are likely to be high in fat, sugar, or salt and thus to receive a low score. Problem Lobbies present culture and tradition as two monoliths that have always been the same, and that need to be protected and preserved from an external attack. In doing so, they do not give precise definitions of what cultures and traditions are, and they also neglect the historical processes leading to what current cultures are. Counter-frame The main way to dismantle the biased used of food cultures by the lobbies is to rely on food history research. For example, Italian politicians present current food habits as something that has been like this for centuries, and that is only now coming under threat. This is historically wrong. For example, before the FEAST - Report on policy barriers and facilitators 55 out of 98 Italian migration to the United States in the 19th and early 20th century, many of the foods now considered cornerstones of the “Made in Italy” were not available to Italians. The story of Pizza well describes two important points in this regard: • Food items change: before the Italian migration to the United States, pizza was found only in Naples, but it was not the product we see today. It was originally a very poor food - a sort of sweet bread - and it had almost no toppings. With the migration to the US, tomato sauce and other ingredients were discovered, became an integral part of the dish, and then came back to Italy. This is the so called “pizza effect”, namely something that is born in one place, transforms itself in another place, and then comes back in the original place completely transformed. Same applies to the samosa in India. • Invention of tradition: there is a legend that the most famous pizza, the Margherita, is called like this because it was dedicated after queen Margherita trip to Naples in 1889. However, this is a case of an “invention of a tradition” because it would have been offensive to dedicate a pizza to a queen. This was the food of the poorest and not something to be associated to a queen. Instead, it is likely that this story was created in the 30s during fascism to push national identity also through food (with margherita resembling the colours of the Italian flag). These are just two examples of the many others that could be made to demonstrate how food cultures and traditions can be manipulated by governments or corporations to match specific interests. By demonstrating that food cultures and traditions have continuously evolved, it is possible to demonstrate that policy implementation does not necessarily hinder local traditions. Furthermore, Italian, Spanish, French and all other cuisines are the result of centuries of migrations, exchanges, etc. So it is perfectly normal, from an historical point of view, that the Italian cuisine of the future will be much different from current one. To conclude, connected to food cultures and tradition is the need to deconstruct the partisan usage of the concept of Mediterranean diet by the agri-food corporates. 3B) Protecting mediterranean diet is an unfunded chimera Key message Mediterranean diet is a recent concept that was absolutely not widespread across all southern European regions, and that is still not followed by the majority of the population. Pretending to defend this as a way to defend common dietary patterns across the whole population is an invention that benefits only agri-food corporations. Policy implementation cannot be hindered by something that, at population level, never existed. Problem Agri-food corporation lobbying uses the concept of mediterranean diet to frame a situation were policy implementation – in this case Nutri-Score – damages local traditions and cultures. As noted, countries in Southern Europe are guiding the crusade against Nutri-Score, and they are using strategically the concept of FEAST - Report on policy barriers and facilitators 62 out of 98 “It is very important that the harm is prevented not minimised so that the precautionary principle is applied and that political decision makers give a very strong signal that they are committed to a strong reduction in the use of chemical pesticides in the short term.” CSOs stressed in several occasions that if EU institutions do not prioritise this principle, then they favour industries strategies to delay the policy implementation process: “The case of thiacloprid is another example of the loose implementation of EU law to the benefit of the agrochemical industry. It will not be possible for the Commission to protect human health and biodiversity as long as such delays and improper implementation of the precautionary principle continue to be structural features of the EU approval procedure.” Moreover, as stressed by the director of the Pesticide Action Network, implementing the SUR would have been a direct response to what citizens want: “Citizens are very much aware that there is no safe use of pesticides, that they damage the environment pollinators and also health. I would add to that that what is not so much known from the public is that the main victims of pesticide use are farmers themselves who face an increase of series of pathologies due to exposure to pesticides.” The debate on the SUR included also more technical debates on the type of pesticides, specific technologies, strategies, etc., that cannot be analysed here in detail. We here decided to focus on how the points that were more politically relevant for the decisions that were afterwards taken. From these first two sections, the two sides adopted two precise strategies. On the one side, industries tried to slow down the process, cast doubts, raising concerns, asking for impact assessments, and asking time for those involved to be ready for what is to come. This can be summarised with a generic ‘let’s wait until we are ready, even though we are not sure exactly when this will be’. This frame is based mainly on food security, economic and business considerations, so the outputs from this framing are requests for deregulations, less bureaucracy, less obstacles to industries’ actions, and more funds to implement what is necessary. On the other side, CSOs focused on the now and the need to intervene as soon as possible to fix a situation that is clearly not environmentally sustainable and not respecting individuals’ health. This frame does not neglect economic factors, as there are strong claims proving that a more sustainable food production respects food security and it is also good for the economy. These frames also strongly focus on the externalities current pesticides have. The policy outputs from this framing are requests to implement mandatory regulations, which in this case translate into a strong support for the implementation of the SUR. Over the period of the Farm to Fork Strategy, EU institutions were faced with these two contrasting views. In the following section we try to summarise their framing of the debate, which should help understanding why eventually industries managed to win this ‘battle’ on the SUR. 4.4 Can SUR match everyone expectations? The perspective of the European Institutions When the SUR was launched, the initial position of the European Commission resembled very clearly the framing of the CSOs. For example the executive Vice-President for the European Green Deal, Frans Timmermans, said that: FEAST - Report on policy barriers and facilitators 63 out of 98 “We humans depend on nature. For the air we breathe, for the water we drink, for the food we eat – for life. Our economy also runs on nature. The climate and biodiversity crises are threatening the very foundation of our life on Earth. We have been making progress on tackling the climate crisis, and today we add two laws that represent a massive step forward in tackling the looming ecocide. […]. Reducing pesticide use likewise helps nature recover, and protects the humans who work with these chemicals.” Nature, health and a sustainable economy are the protagonists in this framing. To this the EC initially added two points similar to CSOs framing: the need to respond to citizens’ requests, and the need to listen to science: “Europeans are clear: they want the EU to act for nature and bring it back to their lives. Scientists are clear: there is no time to lose, the window is closing. And clear is also the business case: every euro spent for restoration will bring us at least eight in return. This is what this landmark proposal is about, restoring biodiversity and ecosystems so that we can live and thrive together with nature. It is a law for all people in Europe and for the generations to come, for a healthy planet and a healthy economy.” And finally, health was at the forefront of this strategy, as stressed by Commissioner for Health and Food Safety, Stella Kyriakides: “It is time to change course on how we use pesticides in the EU. […] We need to reduce the use of chemical pesticides to protect our soil, air and food, and ultimately the health of our citizens. For the first time, we will ban the use of pesticides in public gardens and playgrounds, ensuring that we are all far less exposed in our daily lives. […] No one will be left behind.” This support was present not only in the European Commission, but also in part of the European Parliament, with some MEPs stressing that this is both what is needed to protect the environment and citizens’ health, and what the farmers want: “We all agree to say that we need a sustainable agriculture that will take into account the human health as well as the environmental stages and that is the very objective of the new proposal that was put forward by the Commission, to cut by half the use of pesticides in Europe by 2030. Our farmers and producers are ready to commit themselves in this green transition. It is something that can no longer be questioned but to do so, those professionals need tools adapted to their constraints and realities. […] the EU now has to commit itself to support those professionals to help them to get rid of pesticides and to find alternative solutions”. Furthermore, especially from the Greens, there was a specific focus on how scientific literature clearly stresses that the current impact of pesticides on the environment, health, and biodiversity is significant: “The report that comes from the European Agency of environmental shows the effect on health and for the bees for insect and so on, and for the farmer about the disease like neurology like cancer and so on. They show also that it is very important to change the model to reduce all these pesticides because they kill life. It’s not only about insects, it’s about it’s ecosystem and after it’s a human so we must be very strict with this subject and we must have be very courageous.” At Member State level, while several countries as Italy, Polonia, and Romania, unified efforts to contrast the SUR, others like Germany spoke in favour of this legislation, stressing that: FEAST - Report on policy barriers and facilitators 64 out of 98 “The efforts to harmonise the legal framework on the use of plant protection products is important. That’s why we are much very much in favour of binding reduction goals.” The political support to the SUR was not uniform, especially in the EP, with other groups like the EEP more sceptical on this measure. Analysing the institutional debate, it is interesting to notice how the impact assessment card presented above was the favourite measure to question the SUR. For example, when DG SANTE presented the SUR to the parliament, they received criticisms for a lack of details on how this would have impacted the agri-food sector. An MEP from the EPP replied to such presentation saying that he: “Heard nothing about anybody having investigated what the impact on farm production would be.” And to that followed others asking: “What impact would the SUR have on the consumers?” and also that “The EPP group stands by the fact that there must be no further rash interventions in food safety in times of uncertainty”. The impact assessment card was also used by Member States opposing the SUR. For example, the Italian Ministry of Agriculture, who mentioned that: “We have to accept that there are still a number of issues that have not been resolved, particularly with regard to an assessment of the impact of this proposed regulation on the entire production system in Europe.” While the Polish secretary of state stressed that: “For the sake of the quality of legislation, I ask the European Commission to carry out a new reliable impact assessment, taking into account the effects of war in Ukraine, and to re-examine the proposed legal solutions.” This concern on the impact was echoed by DG AGRI, with the EU Agriculture Commissioner saying that: “Yes, we need a solid impact assessment. We need solid information about what the consequences of the use of pesticides will be.” DG AGRI was also one of the first proponents of the polarisation problem. That is, the idea for which we should pause implementation of policies affecting difficult topics because they could only exacerbate – especially in light of the farmers’ protests - tensions in society. In the words of a Head of Unit at DG AGRI: “I think there was a strong debate in society around food and farming, and this has become increasingly polarised and I think that one the lessons that we have drawn clearly from this mandate, that we need to show and we need to work to make agriculture and protection of natural resources go together and we must work with this together; we must strengthen dialogue.” This position by DG AGRI was criticised by several stakeholders, who voiced their concern that this DG was using all their power to delay the implementation of the SUR: “The AGRI Committee is not moving – they are deliberately and knowingly using the tactics to delay the file. They are creating a pressure for this to be either watered down or not adopted FEAST - Report on policy barriers and facilitators 65 out of 98 within this mandate, or spilled over to the next mandate. They do this because they know the window of opportunity in this mandate is closing very fast.” This was echoed also by the chair of the environmental committee, who mentioned that: “The intention of the AGRI committee to put on hold the parliamentary work on the proposal would put at risk the conclusion of this important legislative procedure under the current term and does not reflect the principle of good cooperation among parliamentary committees.” Other MEPs from the Green also voiced their concern about how part of the EU institutions were using the impact assessment card promoted by the industry, with Sarah Wiener from the Greens saying that: “The Council wants to delay the work on the SUR with flimsy excuses. Demands are to be rushed through that will have dire consequences for the environment and public health in the EU.” Wiener interestingly touched upon the timeframe issue as well, stressing the urgency of the SUR: “If the Commission has to withdraw the SUR now, the window of opportunity to act on this topic will remain closed for many years to come. We cannot afford that.” On this, Greens also stressed how the need for the SUR is not something new, but we have known its need for a long time. In policy terms, this is a further point to argue in favour of an immediate implementation of the SUR. In the words of Michèle Rivasi: “Why the farmers don’t reduce the use of pesticide during several years? Because it’s not today that we know the toxicity of pesticide, it makes 10-20 years ago. And in France we have some target from 2018 which say we have to reduce 50% for example and it’s not the case. We increase the use of pesticide and what is the problem? it’s a problem of knowledge? it’s a problem to follow the farmer to explain that we must we have to reduce the pesticide and to make assumption? What is the best way? Because I don’t believe you now. All the time we say we must reduce and we increase the use. When all our ecosystems are dead, how can we do?” In sum, the debate at EU level reflected well the clash in framing between the industries and CSOs. On the one side, the more conservative side favouring a cautious approach that would hinder the implementation of the SUR. On the other side, more progressive representatives stressing the need to act, and to do it as soon as possible. Eventually, the cautious side was the clear winner, as the SUR was abandoned, as most of the other points of Farm to Fork Strategy. From what presented above, it thus does not come as a surprise that some stakeholders took it as a victory, while others as a big loss. 4.5 The outcome of the SUR debate After two years of intense debate, the SUR legislation was eventually withdrawn, with president of the EC Ursula Von Der Leyen claiming that: “The SUR proposal has become a symbol of polarisation. It has been rejected by the European Parliament. There is no progress anymore in the Council either. So we have to do something. To move forward, more dialogue and a different approach 8 is needed.” 8 She was referring here to the start of the strategic dialogues on the future of agriculture. FEAST - Report on policy barriers and facilitators 66 out of 98 This decision was of course taken differently by various stakeholders. CSOs clearly saw the decision by the EC to withdraw the proposal as: “The end of an appalling opposition, led by the agro-chemical industry, against a more healthy, future-proof agriculture for the EU.[…] The rejection of the proposal shows a shocking disregard for science, the public interest and the will of EU citizens. Most votes were guided by vested interests and disinformation by the agro-chemical industry.” CSOs took the decision as a sign that lobbying from the industry got the better over the process, saying that: “Thousands of scientists and millions of citizens have demanded reduction of pesticides to protect health and the environment. By not addressing these demands, the European Parliament is sending a negative signal to voters on its ability to deal with major societal issues. It is evident that the agrilobby has taken control of our House of Democracy.” Similarly, the president of the EP Environment Committee called it a: “Missed opportunity. This is a mistake, as we were about to thoroughly revise this text to only retain the parts related to alternatives to chemical pesticides by significantly accelerating authorization procedures for biocontrol products and allowing the reasoned use of precision farming tools”. MEP from the greens, the group more active in supporting the SUR, claimed even that: “This is a very dark day for the society as a whole and for the environment, and also for farmers. […] The majority of MEPs have prioritized the profits of large agricultural companies to the detriment of the health of our children and the planet.” On the contrary, satisfaction emerged from those who had fought to prevent this legislation from being enacted. For example, members of the European People’s Party (EPP) claimed that the withdrawal decision was: “Overdue, reasonable and relieving. We have always said that it would be irresponsible to jeopardise European food production in the face of current crises through unrealistic requirements and bureaucracy.” This decision thus seemed “sensational” for the EPP, as: “The EPP Group does not support measures that reduce food production in Europe or impede farmers from producing food. Let farmers farm! Before we move towards an outright ban on plant protection products, we must find suitable alternatives.” Equally welcoming were the groups representing industrial actors, with for example Copa-Cogeca commenting that this decision clearly showed that: “This top-down proposal stemming from the Farm to Fork logic was poorly designed, poorly evaluated, poorly financed, and offered little alternatives to farmers.” In sum, from this short overview, it is clear that the hindering position to the SUR implementation won. This final decision was the result of several complex dynamics, but the fact that industries managed to impose their ‘wait and assess’ framing of the debate in the public arena definitely played a significant role. Given the complexity of the topic, it would be naïve to argue that a better reframing of the topic would have been sufficient to change the course of the debate. Yet, at the same time, the fact that industries managed to dominate the debate demonstrates that there is significant space for improvement on how counter-frames can be used to challenge hindering frames, while facilitating policy implementation. In this final section, we offer a series of counter-frames that could be used towards this goal. FEAST - Report on policy barriers and facilitators 67 out of 98 4.6 Counter-frames We described that the core of the industries’ framing was the dichotomy between a safe wait, and a perceived risky implementation. The first counter-frame, presented already in previous chapters, should thus stress better the need to immediately address the topic. 365 tomorrow make a year Key Message Delaying policy implementation favours the interests of those benefitting from the status quo, while timely policy implementation can rebalance inequalities by addressing the wellbeing of those currently neglected by the system in place. Problem During the debate on the SUR, delaying policy implementation by requesting more time to be ready for changes has been one of the most used strategies by industry lobbying. The problem is that actors currently benefitting from the system do not want change, as this would affect their interests. This delay can either be directly requested, or it can take the form of an impact assessment. The latter is necessary to understand the impact of a specific policy, but it gets to a point where it is not possible to gather sufficient information about everything and anything. Those willing to stop a policy know this, so asking for more time is always an efficient strategy to delay the process, until eventually it gets either washed down, or abandoned. Counter-Frame An output where all stakeholders’ expectations are maximised is impossible. No matter how much time we put into looking for this option, eventually we will not find the perfect solution. Policy is a zero sum game. Those currently benefitting from the system know this well, and they use delaying strategies to slow down and hinder any attempt to change societal frameworks. They mostly do so by stressing that policymakers cannot expect certain actors to change entirely their practices from one day to another. Thus, they stress that they “need more time”. However, this is an old strategy, as each day has a tomorrow. So each day we would wait for the following one, until time passes and opportunities to implement the specific policy is over. It is thus important that policymakers tackle this delaying strategy by stressing that the time to act is now, and that delays have been used for decades now to slow down policy implementation. Any transition requires changes, and these demand adaptations from those involved. Societies have structures – welfare systems, specific funds, etc. - to support those more affected by the transition, but at the same time they cannot continue defending the status quo if this favours certain actors over others. The need to act now can also be complemented by a better framing on what it entails to wait. Here, there is again the need to counteract the contrast between pure business considerations and health and environmental ones. FEAST - Report on policy barriers and facilitators 68 out of 98 Waiting has a social, human and environmental cost Key message Not implementing policies, such as the SUR, according to business considerations has an impact on other factors, such as health, environment, social issues, etc. We are conscious of the impact pesticides have on human health and biodiversity, so any day we are not acting on it, human lives are lost, and biodiversity disappears. We have the scientific evidence to demonstrate the costs of inaction, so policymakers not implementing policies required are directly responsible for the consequences involved. Problem Industry lobbying frames the discussion within a business framework where only purely economic factors are taken into consideration. Any decision must then follow a logic of how it impacts current operation of several businesses, and how much it would cost for current businesses to adapt their structure to the new requests. If this cost is the only factor considered, a cautious approach is thus often favoured as it is the most logical solution. This approach has yet a cost on health and the environment that cannot be neglected. Counter-frame Any delay in policymaking is not neutral. Inaction has a cost in terms of lives lost, environmental damage, social externalities, etc. However, this cost is often neglected because in public debates, the economic framework is often taken as reference point. Within this framework, the debate focuses only on profits and expenses by private companies, and all alternatives are considered as secondary options, if at all considered. This reflects the agenda power, namely the ability of certain actors to make sure that the discussion is framed in a way that favours their interest. However, there is now plenty of scientific literature available to prove the costs of inaction. It is possible to quantify the economic cost of inaction, the environmental impact, the health impact, and so on. All actors trying to promote policy implementation can thus deconstruct this business friendly agenda to promote instead a framework where several factors are equally balanced. Of course, in several instances this will not be easy given the dominance of the neoliberal ideology at several levels of governance. However, according to each case. Entry points can be found. For example, research proves that the pesticiderelated costs borne by Europeans amounted to €2.3 billion, which is twice as high as the net profits of the pesticide sector. Therefore, there is an urgent need to counteract this economic framework, bringing data on the cost of inaction to any debate concerning policy implementation. The second aspect necessary to deconstruct the business dominated framework is to counteract the “there is no alternative” argument. FEAST - Report on policy barriers and facilitators 69 out of 98 Only in a neoliberal framework there is no alternative Key Message There are alternative views to the current neoliberal framework in which both the economy and other factors are considered. When industry lobbying portrays a situation where it is either current status quo or an uncertain and unachievable alternative, then it is policymakers responsibility to stress that other solutions, like a wellbeing economy, are achievable. Problem We demonstrated that one of the key strategies by the industry to hinder policy implementation is to frame a dichotomy between a safe wait, and an uncertain and difficult world where the policy is implemented. This is a strategy that has been used for a long time by defendants of the neoliberal framework, and that has hindered policy implementation in several occasions. Counter-frame There is no alternative only in a neoliberal framework where business considerations are put above anything else. Furthermore, in the case of the SUR, these business indications are often favourable only to the bigger producers, while they limit opportunities for those smaller farmers who want to produce more sustainably. Scientific literature clearly demonstrate that alternative economic model can function, and they can do it better than current neoliberal view. At any time then, it is important to counteract the neoliberal framing and to provide counter-frames where alternatives are real, achievable and more equal. Lobbies will always frame the debate as if there was only one solution, with all alternatives as dangerous, irrational, irresponsible, and so on. For alternative solutions to be considered, it is then essential that policymakers aiming to promote policy implementation deconstruct the view for which only the status quo is a feasible solution. On the SUR, it was also fundamental to consider how big agri-food actors managed to strategically use the concept of food security. Environmental Sustainability is essential to food security, not opposed to it Key Message Lobbies frame food security in a way that conceives all alternatives as dangerous as they would reduce availability of food. In particular, they claim that pesticide regulation would jeopardise food production, and that alternatives would offer doubtful results. Instead, we have sufficient literature proving that we produce more than enough food to feed everyone in Europe, and that is possible to feed Europe without synthetic pesticides. FEAST - Report on policy barriers and facilitators 70 out of 98 Problem Lobbies consider only certain aspects of food security, focusing on current availability and prices, and portraying disastrous sceneries if we were to look for alternatives. During the SUR debate, the war in Ukraine was used strategically to claim that we could not afford to move to a more environmentally sustainable food production in such an historical period. Threats included higher prices due to reduced yields and higher production costs and a consequent dependency on imports. Counter-Frame Food security is usually conceived according to four dimensions: i. Food Availability: The availability of sufficient quantities of food of appropriate quality, supplied through domestic production, imports or food aid; ii. Food Access: individuals having adequate resources to acquire appropriate foods for a nutritious diet. For example, price inflation endangers food affordability, especially for the most vulnerable households (larger share of their budgets on food; diet compromised if switch to products with more calories but poorer in micronutrients) iii. Utilisation: an individual’s nutritional well-being reached through adequate diet, clean water, sanitation, and healthcare. This encompasses a number of non-food factors such as cultural practices in food preparation, feeding practices as well as intrahousehold allocation of food. iv. Stability: the system is stable, and the dimensions of availability, access and utilisation are sufficiently met. short-term instability can lead to acute food insecurity, and mediumto long-term instability can lead to chronic food insecurity. Climatic, environmental, economic, social, and political factors can all be a source of instability Agri-food industries consider only these four, to argue that any alternative would reduce availability, prevent easy access to quality food, thus hinder the utilisation by consumers, and the stability of the system. However, this is not the case, because food security can be conceived including two more dimensions: iv. Agency: the capacity of the food system’s actors to make their own decisions about food; v. Sustainability: the long-term ability of food systems to provide food security in a way that does not compromise the economic, social, and environmental bases that generate food security for future generations; These two dimensions are essential because they reframe the discussion about security proving that environmental sustainability is essential to food security, and also that power inequalities in the food systems are negative for food security. SUR was dominated by a framing that neglected these last two dimensions, so counter-frames to promote policy implementation must deconstruct the 4 dimensional conception of food security to promote FEAST - Report on policy barriers and facilitators 71 out of 98 instead a more holistic approach that considers also agency and sustainability. Connected to this point on food security, there is also the fact that farmers are not a united front, but there are significant differences between smaller and local farmers, and gig agri-food industries. Current pesticides are not a win-win for all food producers involved Key message While chemical pesticides are an excellent source of profits for the four big producers in the market, this does not apply to all actors in the food chain. Prices of pesticides have been increasing, and studies have proven that the more farmers use these products, and the lower their income. Blocking the SUR is thus a gain for big pesticide producers such as Bayern, Syngenta, Corteva and BASF, while it is not for smaller and local food producers. Problem Lobbies at EU level always pretend they are representing farmers as if this group was unite and homogeneous. Given that small farmers are a category that at societal level receives significant support, this is particularly effective, as lobbies manage to present their claims as if they were representing all these actors. Counter-frame Current production system at EU level has clear winners, which are the main pesticide producers. However, their win does not reflect in a win-win situation for the rest of society. This is the case for citizens’ health, for the environment, but especially for smaller producers. Deconstructing the frame for which farmers are a unite front can thus stress better the agency dimension in food security. In this way, inequalities in the system can be better addressed and power imbalances can be exposed. And finally, as for other policies presented before, the SUR was another case where policymakers ended up in the trap for which only a perfect policy that would have addressed all problems could have been implemented. We must have a sufficiency principle, not chasing ideal perfection Key message Policies to be implemented must be compared to current status quo, not to an ideal situation where perfection is achievable. A sufficiency principle is needed, for which when there are solid scientific grounds demonstrating that the policy to be implemented is better than the status quo, then there is a moral imperative to proceed with its implementation. Problem Industry lobbying hinders policy implementation by framing the discussion on a contrast between a perfect ideal situation, and the policy to be implemented. Following this frame, it then becomes necessary to demonstrate that a policy is flawless for it to be implemented. However, this perfection is often FEAST - Report on policy barriers and facilitators 78 out of 98 foods. This differentiation strengthens the objective by clearly identifying the type of business in scope.” The scientific community supported this aspect, specifying that for the purposes of this issue a fast food/takeaway outlet could be defined as: “Any outlet whose business will primarily be the sale of hot or otherwise prepared food that is high in fat, salt or sugar (such food being heated or prepared on the premises comprising of the outlet) for consumption on or off the premises comprising of the outlet. For the purposes of considering whether a particular food item is high in fat, salt or sugar, reference shall be had to Department of Health or other governmental guidelines or publications current at the time of considering of a planning application.” This case in Wicklow is particularly interesting for how involved civil society was, an aspect which was often stressed by the committee of the ‘No Fry Zone 4 kids’ movement: “The numbers are extremely impressive from across the spectrum and will surely influence the councillors when the time comes to vote on whether this amendment should be incorporated into the plan or not.” The strength was not only numerical, but also due to the variety of stakeholders involved. This movement received the support of several academics, who provided the scientific arguments necessary to support the movement, as for example professor Harrington from Cork University who described that zoning laws can be beneficial both from a health and an economic perspective: “The Government needs to seize an opportunity to improve the diets of the Irish population, prevent obesity and diet-related non-communicable diseases by investing in the kind of policies and programmes which have demonstrated success in a number of countries. […] The benefits are two-fold – aside from improving the health of the general population, these measures are highly cost-effective, and in the long-run can help counteract the rising healthcare costs associated with obesity and diet-related-non communicable diseases.” Parents of the children in school played a fundamental role by actively promoting the need to block McDonald’s, because: “We have a collective responsibility to protect our children and you (the local council) – as a body - can take a stand and show not only parents across the country but to our children, those are the future of these communities you work on behalf and continue to serve, this is an opportunity to put the health and well-being of children before any commercial or ‘fast food’ interests. Put the interests of our children’s long-term health first.” This responsibility was mentioned also by other stakeholders. While certain policymakers followed the industry focus on education stressing that: “There’s an element of temptation for children. But it is also down to parents to educate their children on the dangers of fast food.” Other policymakers believed they had to assume the responsibility for their actions: FEAST - Report on policy barriers and facilitators 79 out of 98 “We have a responsibility to invest and safeguard our children and young people. Adopting objective RT17 into the Wicklow County Development Plan is one step in tackling this obesity issue and will provide long-term benefits to our society and our economy.” This aspect of the responsibility was also stressed by involved academics, since: “We have a responsibility to our children to protect them from those high fat, high sugar foods and encourage healthy, accessible foods. […] It is crucial that changes are made at community level to facilitate healthier choices for our children and to make the healthy option the easiest option. The physical environment is central to this. Wicklow can now demonstrate leadership by committing to the long-term health and wellbeing of its local communities.” For this reason, it is not realistic to expect parents to be able to isolate their children from the temptations of these fast foods, since: “It has become increasingly difficult for parents and children to maintain health body weight. The actions taken by Wicklow County Council in this instance are of critical importance and should the correct decisions be made in protecting children from the impact of proximity to fast food outlets to their school, then this will represent practical and positive support of parents who are otherwise at present fighting an uphill struggle in maintaining health body weight.” Interestingly, quite a few politicians wanted to specify that they were not against the fast food chain per se, but specifically against their proximity to schools: “There is a place for everything and everything in its place. I am not adverse to fast food outlets or blocking employment, just that they be located in a sensible and suitable location.” Or similarly: “The proposed site for this McDonald's was utterly inappropriate for a fast food outlet. With childhood obesity a growing problem in Ireland, many parents, myself included, were not happy that a McDonald's would be built beside three schools. I have no opposition to any fast food restaurants opening in the town - just not in a location that close to where our children go to school.” This is similar to what discussed in Florence. In Italy, the point was that the fast food restaurant was not compatible with the cultural and historical value of the main square, but several actors involved specified that in another location it would have not been a problem. In Ireland, the main goal was to move them away from the schools, not necessarily to claim that such outlets have no space in any zone of the city. With similar arguments to the ones used in Florence, MacDonald’s tried to contrast the committee willing to block the fast food restaurants. First of all, they stressed that it was a significant economic investment that would have created more than 60 jobs locally. Second, and this will resonate in the Tervuren case described below, McDonald also aimed to explain that they never specifically aim to open a restaurant close to schools: “McDonald’s often seeks to locate new restaurants close to retail outlets which are appropriately zoned in accordance with planning guidelines. Proximity to schools is not and will not be a factor for McDonald’s in assessing suitable locations for new restaurants.” FEAST - Report on policy barriers and facilitators 80 out of 98 McDonald’s tried to point out that restricting their activities would have been unfair, given that there were a number of takeaway restaurants already providing late-night service in that area. Despite their efforts, McDonald’s eventually saw their application rejected. The local committee took this as an opportunity to expand Wicklow’s case to the whole country: “This is a nationwide problem, one which needs public policy to reverse the trend and a planned approached at every level in order to create a supportive environment in which children in particular can lead healthier lives. […] As we all know, Planning has a key role to play in the future development of our communities and as such, has a responsibility towards the health and wellbeing of the people, young and old, that reside there.” What is remarkable from this Irish case is the connection between Civil Society framing and policymakers’ ones. As mentioned in previous chapter, the frames used by policymakers can be used as reference point to see which of the other stakeholders are going to “win the framing battle”. As we described, often public health actors struggle to disseminate their framings, while industries are more effective in making sure their views are afterwards adopted at policy level. On the contrary, Wicklow case showed how powerful can be a movement if it manages to create a synergy between CSOs, local community, academics, and local and national policymakers. Developing a powerful network as the ‘No Fry Zone 4 Kids’ is of course not easy, but it can serve as an important point of reference for other countries and cities. In the coming sections, we present two further case studies. The first is Tervuren, in Belgium, where similarly to Wicklow the local community managed to stop the opening of a McDonald’s close to a school. The second one does not pertain to a single city, but more to a network of Dutch cities, as the Netherlands is one of the countries where the debate on zoning laws has been more central in the public debate in recent years. 5.4 Tervuren In 2020, McDonald’s applied to open a restaurant in Tervuren, Belgium. The location of this restaurant would have been along a main road that connects Brussels to the rest of the country, but also in proximity of a school. This application sparked the protests of the local residents, who created the “Niet in Tervuren” (Not in Tervuren) movement and started filing objections concerned that this restaurant would have both created further congestions, and been a threat to students’ health. This first application got rejected in 2020 due to concerns about the impact on traffic and the local areas. Three years later McDonald’s tried again, with a relocation of the restaurant not far from the original plan. This further application created an even stronger debate, with political parties divided, and the “Niet in Tervuren” committee mobilising even further to prevent the application from being approved. In 2024, the issue was moved to provincial authorities, who eventually denied McDonald’s the permit to open, citing unresolved issues from the previous application, such as the anticipated strain on local mobility. As of now (2025), McDonald's has the option to challenge this decision or submit a new proposal, but no further actions have been reported. This case is thus similar to the one in Wicklow, and the analysis of the frames used by different stakeholders can complement what described for the Irish case. As in Wicklow, this case saw a strong reaction from the local community, with the “Niet in Tervuren” movement which resembles the Irish “No Fry Zone 4 kids”. The arguments used to oppose the opening of the fast food restaurant varied. The first thing to stress for Tervuren is that health could not be used as an argument to prevent a restaurant from opening. As stated by one representative from the municipality of Tervuren: FEAST - Report on policy barriers and facilitators 81 out of 98 “Whether or not McDonald's offers unhealthy food, for example, is irrelevant here. The proximity of several secondary schools in the vicinity of an 'unhealthy fast food chain' cannot be cited as an argument for the refusal of an environmental permit. However, it can be said that this development at this location is an extra burden for a traffic-safe school environment." And more on this was stressed by other local policymakers, who reminded that: “There is also the European principle of 'freedom of trade'. That makes it difficult for municipalities to intervene. That is why we are asking for legislation that does offer them the option to ban fast food around schools, for example. It is already possible in London and Amsterdam." In absence of this legislation, local opposition had to find alternative arguments to oppose McDonald’s. The first argument used by local activists was the negative impact on local traffic and related safety hazards for the population that a McDonald’s would have caused: “The advice shows that the application contains many errors. But the most important thing is that the application is not appropriate for that location, and causes a negative impact on traffic. The expected increase in traffic is particularly worrying, because that would pose a danger to the many soft road users of the residential area and the adjacent four schools.” This position was stressed also by the local green party: “McDonald's itself foresees an increase in car traffic of more than 1000 extra cars per day, even more than 1600 on a Friday, and that is probably an underestimate. This makes a highly saturated N3 even more crowded, which negatively affects traffic flow, safety in the immediate vicinity of four schools and air quality. We want more safety for pedestrians and cyclists, especially near schools. With four schools within walking distance, a McDonald's branch in the Carrefour car park goes directly against our attention to road safety with a particular focus on safety on the way to and from school." Second, even if they knew it could not be picked as argument to prevent the opening of the restaurant, local activists stressed the threats for children’s health that McDonald’s would have caused: “Nevertheless, we would like to insist on a study by Sciensano that states that obesity among school-age children increases when a fast food restaurant is located within a radius of 500 meters around a school.” And also that: “Young people are often not yet fully aware of the impact that fast food can have on their health. It is precisely the presence of those different schools that will only increase the social pressure to visit the McDonald." There would thus be once again a contrast between what is eaten inside the schools, and what children can find outside: "We are committed to getting healthy schools on track. But you can serve as many healthy snacks as you want in schools, if you plan a fast food joint next to it, it's a wasted effort.” Other researchers pointed out that unhealthy restaurants are a problem not only in proximity of schools, but in all very crowded places: FEAST - Report on policy barriers and facilitators 82 out of 98 “"We need to keep unhealthy food away from city centres. For a long time, McDonald's didn't dare to venture into small towns and villages, because the competition with classic chip shops or kebabs was too strong. Those days are over.” This focus on the damages brought by the fast food restaurant was yet questioned by the major himself, who asked: “What's wrong with a McDonald's? They say it's unhealthy and competes with the chip shop, but I see it differently. If there were plans for a cultural or asylum centre, half of the village would not be happy with it either." Third, with a move very similar to Florence, the movement also stressed that the beauty of the village is not compatible with such a restaurant, with the action committee asking on their website: “What is a temple of cheap junk food doing in one of the most beautiful Flemish municipalities? It just doesn’t fit." The McDonald’s would thus not be suited for such a location where: “You would drive into the municipality here past a placard that reads 'fair trade municipality' and a few meters further you would come across a fast food chain that does not fit in with that vision at all. The municipal council likes to pat itself on the back that it is a green and quiet municipality and calls on citizens to support the local economy. However, a fast food chain like McDonald's would give our municipality a completely different look. It is at odds with the vision that the municipal council propagates.” Interestingly, this focus on the beauty of the village appealed to many, even with local and regional media who often referred to Tervuren as ‘One of the most beautiful villages in Flanders'. Fourth, the committee stressed that there is a specificity in McDonald’s products, as they are worse than other unhealthy foods sold in supermarkets or shops: “A chocolate or smos cheese is different from McDo burgers. They are so fatty, salty and sugary that they are addictive, especially for children and teenagers." The problem here is that McDonald’s products are capable of getting to children much more than other foods: “Most children are of course seduced by it. That food is full of fat and sugar so that you become addicted. We don't want a branch of theirs here." Therefore, health, safety local image dominated the frames used by the local committee against the opening of the fast food chain. The response of McDonald focused on proving that their restaurant was compatible with what requested, especially in the second attempt in 2023, when according to McDonald’s: “The restaurant is now further away from the Leuvensesteenweg and from the schools, is less prominently visible and is completely in a green jacket with a green roof, solar panels and a green façade. The safety of pedestrians and cyclists is even better guaranteed and our studies show that the impact on traffic on the Leuvensesteenweg is minimal. With this proposal, we are responding to the many valuable insights that were put forward by local residents, stakeholders, the municipality of Tervuren and the Province of Flemish Brabant.” FEAST - Report on policy barriers and facilitators 83 out of 98 The Major of Tervuren, who had stated in 2020 that the first proposal was not acceptable because: “In principle, we are not against a restaurant like McDonald's, because the freedom of economic activity is also important, but in this case too many factors were irreconcilable. […] It is not against McDonalds's, but against the impact on mobility and the environment.” in 2023 stressed that the proposal was instead fine because: “McDonald's has submitted a new plan with serious adjustments. The location is now on the other side, so it is completely hidden behind a gas station and a belt of trees; So it will hardly be visible from the N3. It is also smaller than in their first proposal. All objections in terms of location and road safety have been taken into account. The nearest house is now at least 50 meters away, whereas previously it was a few meters. There is also a new mobility study that shows that the impact is very limited. A permit could be issued on the basis of all these criteria." To which the Major added that a McDonald would be acceptable also from the health perspective, since it would be unacceptable to limit their freedom of choice: “Obesity among young people is a more complex issue. It's not just nutrition, it's also a lack of exercise and a lot of gaming that makes their lifestyle so unhealthy. […] Some say that 16-yearolds should have the right to vote, but those teenagers would not be able to resist the temptation of a hamburger? So where does it stop? That's patronizing and way over it." This point on the liberty of choice is crucial in all the locations described in this chapter. The positions are usually two. On the one hand, a position of non-interference taken by the industries, liberal politicians, and in this case by the local Major, for which we cannot limit individual’s liberty of selecting what they want to eat. On the other hand, the necessity to regulate from academics, civil society and more progressive politicians. As summarised by a nutritionist for the Flemish Institute for Healthy Living, this position maintains that: "Freedom of choice is a false argument. Children and young people in particular are not yet resilient enough to make an informed choice. And adults already know better what is good, but even they go for the axe when the unhealthy supply is omnipresent. Then it is no longer a choice. If you argue for choice, you have to make sure that there is real choice. And therefore also more healthy food, because fast food is already far in the majority." McDonald’s also tried to prove that the proximity of a school was not part of their strategy, since: “The presence in the vicinity of schools is in no way part of the strategy. The planned location is an existing commercial site with a spacious car park and by planting the restaurant here, we prevent the taking up of scarce open space.” The “Niet in Tervuren” committee did not believe this point, responding that: “In a press release, McDonald's says it does not use a deliberate strategy to target schools. I don't believe them. The plans do not show any extra parking spaces, so they mainly focus on people who come on foot. And who are they? Right, yes." As for previous cases, McDonald’s focused also on the economic benefits they bring to the local community. In this case, they stressed that in Belgium: FEAST - Report on policy barriers and facilitators 84 out of 98 “We currently have 88 restaurants in Belgium, and we have a fairly ambitious expansion plan. […] While McDonald's is of American origin, in Belgium the restaurants are 100% franchised. That is to say that there are "22 local entrepreneurs" who operate the McDonald's franchise and divide up the 88 restaurants, providing work to 5,400 employees.” To this, the American company added that they were not worried about the local opposition, framing it as an isolated case: “Since the opening of the first restaurant in Belgium in 1978, it's rare, often people are rather happy and demanding. […] It's true that there are (some opposition movements) underway, for the moment, but it's probably a coincidence that it falls at the same time.” And for what concerns the accusation of selling unhealthy foods they responded that: “We're a burger restaurant, and a burger is a burger. It's like when you eat a steak with fries and béarnaise in a restaurant. But we don't do it morning, noon and night. So those who come to us to eat a hamburger, we necessarily leave them the choice. But we offer them alternatives: salads, wraps, vegetarian hamburgers. As for the origin of the products, it is 98% European: we work with Belgian products but Belgium is a small country so there are ingredients that come from France, the Netherlands, Ireland, etc.” Finally, according to McDonald’s, even the traffic concerns were not correct, since: “Half of our customers are traditionally people who drive by. The preparatory study carried out by Antea, as a recognised EIA expert, shows that the impact on traffic is less than five percent per day. […] The location of the building will also mean that some parking spaces will disappear, but new green car parks would be built in their place. However, the studies do not show any increased parking pressure due to the arrival of the restaurant.” Despite these arguments, the application was eventually rejected, and most of the decision focused on the negative traffic impact: "The application does not comply with the criteria of good spatial planning. The strong carorientation is not in line with the municipal policy vision to focus more on pedestrian and bicycle traffic and less on the car. The increase in car traffic at busy times, after school hours, can have a negative impact on road safety for vulnerable road users." This raised concerns for the major, who stated that: “I do not yet know the reasons for the destruction, but if the deputation has followed the reasoning of the environmental officer regarding mobility, then this is still worrying. After all, that would mean that many other projects would be at stake in the future." Instead, for others more satisfied for the decision, the case in Tervuren could be used as a first step for the discussion across Flanders, with many stressing this shows the need to find legal solutions: "A local government cannot refuse unhealthy catering establishments, because they must then refuse all catering establishments. It is high time that someone takes this to themselves and that legal solutions are found in the interest of public health." FEAST - Report on policy barriers and facilitators 85 out of 98 In sum, there are several parallels between Wicklow and Tervuren. In both cases, McDonald’s applied to open one of their restaurants in an area close to a school(s), which sparked the protests from the local community. The latter mobilised efficiently in both cases, putting pressure on their local municipality to find a viable solution to prevent the fast food chain from opening in their location. In Tervuren, spatial issues, especially related to traffic, helped the local movement “Niet in Tervuren” to block two times the application of the fast food chain. However, this case also demonstrated the need to have legislations at the regional and national levels to help clarifying some of the issues and give municipalities the means to properly intervene. This is why it is interesting to look at the Dutch cases as final example. In the Netherlands, several cities acknowledged how unhealthy areas surrounding schools have become, and they thus decided to implement strategies to reduce the availability of unhealthy foods. 5.5 The Netherlands Over the last few years, the public health debate in the Netherlands devoted quite some attention to the amount of fast food places around schools. This is part of the discussion on the general impact of obesity on the Dutch population, with forecasts now predicting that 62% of the population will be overweight in 20 years if this policy status quo is maintained. This problem affects especially youth, and it is of particular concern that this number increased by around 40 percent in just the last decade, number that goes up to 48 in disadvantaged areas. These percentages concern the whole nation, but certain cities experience even bigger increases. For example, neighbourhoods in Rotterdam with a low socioeconomic status have seen an increase of 57% of fast food retails around schools, compared to the urban average of 37%. This creates health inequalities, with CSOs stressing that this is to be expected because: “Cheap, tasty but inferior convenience food is extra attractive to people with little money, time, knowledge and skills." and some politicians reminding that: “We see a gap between people with lower socio-economic status and those with higher SES. […] We also believe that municipalities should be able to intervene, for example, by easily excluding large fast-food chains and limiting the number of fast-food outlets per area. Because this free, happy liberal market has caused large American fast-food chains to profit off the health of the poorest.” In the Netherlands, several cities – in particular Amsterdam, Rotterdam, Utrecht and Ede - have decided to take action against this uncontrolled increased of fast food around schools. As stressed by a professor of obesity, regulations are necessary because obesity is a systemic problem and not an individual one: “As long as the food environment tempts us to live unhealthy lives, it is like mopping with the tap open. It is clear that more needs to be done to make the supply healthier.” Furthermore: “Living and staying healthy is not automatic, and in our society, it is incredibly difficult. […] There are temptations for unhealthy choices everywhere. We have all experienced that when you are outside and hungry, it is often much easier to grab an unhealthy snack than an apple at most places in the Netherlands. The streetscape is changing, and research shows that it is increasingly difficult to make the healthy choice.” FEAST - Report on policy barriers and facilitators 86 out of 98 All this aggravates the issues with obesity rates, as stressed by a doctor who said that: “Obesity is a socially contagious disease. The eating environment and the culture of eating and socializing makes people fat. People also get used to the fact that others are getting fatter.” The problem is that even though several municipalities acknowledge they have a responsibility to make local food environments healthier, and they would thus like to take action, they also reiterate that they have too little power to act against the opening of unhealthy fast food restaurants. Therefore, Dutch cities requested to have more legislative powers in this regard. There is not sufficient space in this analysis to give a specific overview. Yet, the core problem is that municipal regulatory tools do not allow for the exclusion of unhealthy food offerings in (parts of) a municipality solely due to the harmful effects of consuming such food on public health. According to some policymaker, this occurred since: "Health does not yet receive enough attention in municipalities. In the past, Amsterdam has also made choices that were more economically oriented than health-oriented. Health is not getting nearly enough attention." Implementing legislation would thus require to realise that: “There is a battle in the meantime. On the one hand to protect our public health. On the other hand, the often powerful multinationals that are out to sell as much bad and unhealthy food as possible. For years, the government has opted too much for protecting commercial interests and too little for protecting public health. Self-regulation and covenants have often been used to try to solve this. However, it has become apparent that the goals have not been met for years. As a consequence, some of the actions requested by the cities focused on an amendment to the environments act, in order to broaden its scope to include a definition of safe and healthy food environment. Furthermore, actions to be taken could rely on: • Zoning plans capable of establishing minimum distances between schools or other areas and the fast food restaurants. The maximum number of vendors per hospitality category could also determined via these plans. • General Local Regulation (APV): the problem is that health is not considered as a reason to refuse a permit in the APV, so changing this could bring public health into consideration. • Limit to marketing: Changing the food advertising code (RVV) could limit the amount of marketing certain food retailers can do in proximity of schools and other public places. Criteria could focus on spatial proximity, but also timing (school hours or break time). • Procurement Policy: Municipal procurement policy can set requirements for the food offerings provided to their employees and for certain groups of service users, such as in childcare and social shelters for the homeless. Politicians promoting the need to implement these measures warned that it is also important to stress firmly that we know how the zoning problem needs to be addressed. Otherwise, we may end up in a vicious cycle where we wait for more studies to be conducted, over and over again, and nothing gets implemented in the meantime: FEAST - Report on policy barriers and facilitators 87 out of 98 “Studies have already been done, and it has already been indicated what changes are needed. So, let’s not make the mistake of researching again how municipalities can do this, because that would just delay the system, while scientists have already indicated that there are options. […] We can’t wait any longer. We are now making a call to the municipalities, so let’s not delay by conducting more research, but simply seize the opportunities that are available.” The problem stressed by several organisations is that children behaviour outside school premises is difficult to influence, since as stressed by a politician: “You really don't want that excess of supply. Eating a hamburger or a döner sandwich is no problem. But I don't want those huge numbers, nor do I want to be in schools or too close to them. I want that to be a well-considered choice, not directed because there is a billboard on every street corner advertising that unhealthy food, and on every street corner there is that temptation with yet another business that sells unhealthy food. That steers your behaviour unnoticed." Schools representatives voiced as well their concern, as they have plans in place to make school canteens healthier, but they: “Recognize that there is a lot of unhealthy food available around some of the schools. Recently, there are also meal or flash deliverers, which were not there before. Many schools are active in promoting a healthy lifestyle, among other things by offering healthy food in the canteen. The development of fast food supply does not help with that. […] What students do outside of school hours is of course difficult for a school to influence." The connection between what done in the schools, and what happens outside is essential, since: “It is of course strange that we do everything within schools to make food healthier, and that there is a lot of fatty food available in the immediate vicinity. Municipalities can really do something, if they want to. […] But not enough is happening. Such a school is now at its wits' end. They cannot forbid students to leave the premises. And if they can buy such a sandwich a few meters away…”. By eating more fast food, the problem is also that students may develop a specific taste for these products, as: “The temptation is great, especially for young people. In this way they learn a wrong taste and eating pattern. The whole of society bears the enormous costs that fat people entail. Hence, the less temptation and more healthy alternatives, the better." The students themselves tend to confirm this temptation aspect of the food environment, with one student saying that: “It's nice that all those shops are there, but it does tempt me to eat more unhealthy food." And another adding that: "I don't take my debit card to school because I know I'm going to buy something." CSOs also stressed that Commercial Determinants of Health are seriously hindering municipalities’ attempts to create healthier environments. For example, some criticised that: FEAST - Report on policy barriers and facilitators 94 out of 98 Counter-frame As stressed by one politician in the Netherlands: “If there is one thing we have learned in recent years with regard to prevention, it is that the industry at the table is the biggest possible brake on any progress. We've had that for decades. Fortunately, this is no longer the case when it comes to tobacco. We have seen it with alcohol and we still see it with obesity. As long as you have to come to agreements with the industry, which has a direct financial interest in as few measures as possible, it will take forever.” Local and national policymakers must acknowledge this commercial determinant of health, and be ready to exclude industries from the decisional process. There is a precedent on this with the tobacco industries, who have been excluded from directly influencing EU-level policymakers via the WHO Framework Convention on Tobacco control. In particular, article 5.3. requires governments to protect public health policies from tobacco industry influence. There are good grounds now to compare food industries actions to the ones of the tobacco industry, so policymakers ought to avoid interacting with food industries when deciding on the implementation of the zoning laws. We know which are the unhealthy foods are, and it is possible to regulate their offering Problem Fast foods, as McDonald’s in some of the cases presented above, mention that it is not possible to implement zoning laws because there are several retailers selling both unhealthy and healthy foods. A strategy of some fast foods restaurants is to insert in their menus less unhealthy options (as the salads in McDonald’s) to demonstrate they do not only sell HFSS foods. This is used as an argument to state they should not be prevented from opening, as the customer has always the choice to for example pick the salad over the burger with fries. Counter-frame Argument here is connected to the one on the liberty of choice, and the difficulty for individuals to resist the temptations of certain foods. It is of course possible to select the salad – even if we were to overlook the actual content of some of the salads - over the burger with fries. Yet, a quick look at the purchases at McDonald’s, and one can see that for example salads constitute around 2-3% of the total purchases. Moreover, these are often bought in addition to other items less healthy. Purchases of these healthier options have been so low that McDonald has dismissed some of them, which proves once again how unlikely it is that a FEAST - Report on policy barriers and facilitators 95 out of 98 healthy option can make a difference if provided amongst many other HFSS foods. Therefore, given that we have guidelines developed to define which are the HFSS foods, it is definitely possible to single out which are the fast foods selling such products, and to then prevent them from opening in certain areas. All this, regardless whether their menu includes certain healthier options or not. To conclude, we described four case studies where local municipalities tried to implement zoning laws to prevent fast food retailers from opening in their local area, especially in proximity of schools. The main point that emerged is that, aside from Wicklow, municipalities do not have the means to implement legislation only based on public health considerations. This forces cities to find “creative” ways to prevent certain food retailers from opening in their local area. In Florence, the major relied on the cultural and artistic value of the main square. In Tervuren traffic considerations dominated the debate, and in Ireland and the Netherlands the contention focused on health arguments against economic liberty. In all cases, the debate started thanks to the creation of strong civil society movements, who managed to gather the attention of the political debate. In the three specific cases, rejection side won, and it is possible to notice how this was due especially to how unite this side became, with CSOs, NGOs, local citizens and supportive politicians working together to prevent fast foods restaurants from opening. The frames used by industries in this case resonate well with the one presented in previous chapters, especially with the debate on the Wegovy drug and Nutriscore. The counter-frames that could be used in these cases thus complement well the ones in previous chapters, offering opportunities to policymakers to respond to a series of diverse arguments. FEAST - Report on policy barriers and facilitators 96 out of 98 6 Conclusion A frame analysis can be beneficial in understanding the policy process, since how actors involved in an issue discuss it will have consequences on the actions that are taken afterwards. This happens because frames describe power dynamics, revealing who are the most influential actors, how they deploy their power, and the connections between decision-makers and other actors. That is, if decision-makers use frames similar to actor A rather than actor B, then it means that A has been more effective in disseminating their frames. It is in this respect that frames can be significant barriers or facilitators to policy implementation. While the causes for the lack of policy implementation towards healthier and more sustainable food systems both at European and national level are obviously multi-faceted and cannot be entirely connected to the framing of the issue, framing still plays a major role that is too often neglected. The analysis of the four topics considered here thus aimed to prove that this gap can be filled, even though these four topics are only a small section of the many debates currently underway in food systems. A frame analysis could be extended to several other topics, such as food reformulation, marketing on unhealthy food to children, public procurement of food. Yet, the aim of this work was not to encompass an explanation valid for the whole food system, but to demonstrate the potential of this methodology in the analysis of policy developments, and how it could well be applied to a variety of topics to understand the barriers and facilitators that influence policy development and implementation. In particular, this work aimed to demonstrate that decision-makers can be supported to identify hindering frames, and counteract them via the usage of innovative counter-frames. In turn, the usage of counterframes follows the balanced intervention ladder – namely that governments and EU institutions must assume the responsibility to make the food systems healthier and more sustainable. Hence, using innovative counter-frames to legitimise policies that better regulate the food system is a necessary step towards the implementation of required policies. Furthermore, we stressed that while private lobbies have well developed strategies to hinder policy implementation, CSOs, NGOs, public bodies and progressive policymakers seem to struggle to develop equally effective framings. This is not an easy task, since the promoters of the transition towards healthier and more sustainable food systems are a heterogeneous group. As such, they struggle to coordinate with each other. However, this occurs also because the agenda-setting form of power has been for a long time neglected at various levels of governance. This has allowed business driven ideologies to impose themselves in the public debate, while resistance to these ideologies have too often been scarce and ineffective. Developing a frame analysis such as the one presented here could thus rebalance power inequalities in actors’ ability to influence the policy and public debate. While each topic has its own specificities, it was interesting to note that certain counter-frames can be applied to a variety of topics. This is due to the fact that the hindering strategies used by private lobbying are often similar, as they follow specific methods that were already developed by the tobacco industry decades ago. If further research extended this analysis to several other topics, it could then be possible to develop a proper counter-frame manual that policymakers could use to counteract lobbying by industries. In turn, this could significantly facilitate policy implementation. The potential of a well-developed frame analysis to understand future policy implementation is significant. However, already these chapters can be put into use into the development of FEAST activities. Within the policy work package tasks, FEAST will organize four policy dialogues. In these meetings, it will be possible to dedicate some time to testing the counter-frames with relevant policymakers. This will offer a precious opportunity to gather feedback on how useful policymakers think counter-frames can be, and to adapt the work accordingly. Part of this work will also be continued FEAST - Report on policy barriers and facilitators 97 out of 98 in the communications trainings to be organised for task 7.4., and also in the policy briefs and reports that will be developed as part of WP7. To conclude, power has different faces, with each influencing policy implementation in several ways. While most debates focus on the most direct forms of power, agenda setting and related framings also have a large influence over policymaking. 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Views and opinions expressed are those of the author(s) only and do not necessarily reflect those of the European Union. Neither the European Union nor the granting authority can be held responsible for them. UK participant in FEAST (Good Food Oxfordshire) is supported by Innovate UK grant number 10041509 and the Swiss participant in FEAST (FiBL) is supported by the Swiss State Secretariat for Education, Research and Innovation (SERI) under contract number 22.00156.