Addressing the commercial determinants of unhealthy beverage exposure: a systems thinking approach

BACKGROUND: The beverage industry plays an influential role in the US. Certain beverages, such as sugar-sweetened, have long been recognized as key contributors to poor population health with inequitable impacts. In response, multiple US initiatives have attempted to address these problems through public awareness campaigns and policies, such as taxes. Yet, the persistent and increasing reliance on unhealthy commercial products produced by the beverage industry suggests additional progress is needed. Leveraging a systems thinking approach, this study aimed to map out the complex forces limiting progress and driving inequitable impacts of unhealthy commercial beverages in the US to inform innovative thinking about future actions. METHODS: We facilitated a participatory group model building project to develop a systems model that depicts the main mechanisms underlying the increasing sales, marketing, and consumption of unhealthy commercial beverages. We convened 28 national experts from government, academia, advocacy, funding agencies, and community organizations for a series of workshops and interviews and supplemented their insights with other evidence (e.g., research, public records). RESULTS: The final systems model makes visible the multiple interacting pathways through which industry protects their profits and maintains the status quo. Some are well known, such as normalizing product purchasing, influencing policymakers in their favor, and shaping public opinion to support their work. Others are less appreciated, such as how health and environmental consequences produced by beverage industry activities feedback into the system, ultimately leading to a greater reliance on beverage industry products and weakening political will for adopting equitable health promotion policies. While actions by advocates, public health departments, and others to address unhealthy beverages were identified, much of their impact is undermined by the large and influential control the beverage industry has on the system. CONCLUSIONS: Gaining traction on addressing unhealthy commercial beverages is a complex problem with reinforcing cycles that strengthen the beverage industry's power and influence. The insights gained from the model suggest an ambitious action agenda based on systems principles that also centers the commercial determinants of health.