Obesity Prevention Policies in Low and Middle Income

Obesity Prevention Policies in Low and Middle Income

Obesity Prevention Policies in Low and Middle Income Countries (LMICs) Barry Popkin W. R. Kenan, Jr. Distinguished University Professor Department of Nutrition Gillings School of Global Public Health School of Medicine Department of Economics The University of North Carolina at Chapel Hill THE W RLD IS FAT Outline: Why is this occurring? 1. Global obesity Dynamics 2. Major Global Driver: Dietary shifts, physical activity declines 3. How do we proceed: Mexican case study of comprehensive attack on obesity 4. Food sector options and examples across the LMICs 5. Future strategies and needs Over 2 billion people in the world are overweight State of Adult Female Obesity Across LMICs Large shift away from undernutrition to overweight across all regions with some critical exceptions; acceleration annualized prevalence increase in rural overweight status. The BMI distribution is shifting rightward and at high levels, increasing significantly. This represents an 8-10 kg increase in weight over a 10-18 year period in many countries Waist circumferences increasing at the same BMI level Adolescents: not presented but much more complex picture with much more undernutrition-fear of intergenerational transmission of stunting/undernutrition. [paper under review] Over 2 billion people in the world are overweight National Percent Underweight and Overweight Prevalance in Most Recent Available Survey among Women Aged 19-49 by Urban and Rural Residence, Sorted by 2010 per Capita Gross Domestic Product Rural Urban Country (GDP) 5 6 7 8

15 2 2 3 4 5 13 1 2 2 4 8 10 2 6 4 9 9 27 11 22 27 9 12 23 9 8 27 10 12 16 17 6

11 5 11 12 12 27 17 25 8 7 13 10 14 19 40 30 5 6 5 5 18 1 1 3 2 12 39 1 20 10 Underweight Country (GDP) 42 Brazil (10993) 57 Turkey (10050)

65 Mexico (9128) 36 Kazakhstan (9070) 37 Gabon (8768) 43 Maldives (6570) 54 Colombia (6186) 46 Azerbaijan (5843) 53 Peru (5283) 24 Namibia (4876) 29 China (4433) 76 Jordan (4370) 48 Albania (3701) 57 Swaziland (3503) 51 Armenia (3031) 53 Guyana (2994) 16 Congo, Rep. (2970) 30 Indonesia (2952) 38 32 Guatemala (2873) 75 Morocco (2795) 55 Egypt (2698) 51 Honduras (2019) 51 Bolivia (1979) 45 Moldova (1632) 19 Nicaragua (1456) 9 Nigeria (1443) 23 India (1375) 13 Ghana (1319) 3 Zambia (1252)

33 Vietnam (1224) 18 Sao Tome and Principe (1215) 24 Cote d'Ivoire (1161) 39 Cameroon (1144) 16 Mauritania (1045) 44 Senegal (1034) 31 11 Lesotho (1004) 23 Kyrgyz Rep. (880) 4 Cambodia (795) 4 Kenya (795) 13 Timor-Leste (766) 32 Chad (761) 13 Benin (741) 24 Tajikistan (740) 12 Bangladesh (675) 29 Haiti (664) 7 Mali (613) 13 Zimbabwe (591) 8 Burkina Faso (536) 16 Nepal (535) 17 Togo (530) 16 Rwanda (529) 9 Tanzania (527) 6 Uganda (515) 12 16 Guinea (474) 8 Madagascar (427) 24

Mozambique (394) 16 Malawi (362) 3 Niger (349) 6 Sierra Leone (325) 6 Liberia (324) Ethiopia (320) 0 0 10 20 30 40 50 60 70 80 Burundi (242) Congo, Dem. Rep. (199) Percentage Overweight close to 2 billion people overweight 4 6 5 5 3 3 8 8 7 10 10 5 2 6 7 8 15 21 14 11 3 7

7 8 8 6 9 9 4 7 6 6 20 8 18 9 Underweight 14 20 5 4 5 13 30 4 5 14 40 3 2 4 3 7 21 10 Sample size: 290,278 rural, 232,581 urban source: Jaacks and Popkin, in process 1

1 2 2 5 22 2 2 5 6 6 6 Brazil (10993) Turkey (10050) Mexico (9128) Kazakhstan (9070) Gabon (8768) Maldives (6570) Colombia (6186) Azerbaijan (5843) Peru (5283) Namibia (4876) China (4433) Jordan (4370) Albania (3701) Swaziland (3503) Armenia (3031) Guyana (2994) Congo, Rep. (2970) Indonesia (2952) Guatemala (2873) Morocco (2795) Egypt (2698) Honduras (2019) Bolivia (1979) Moldova (1632) 0 Nicaragua (1456) Nigeria (1443) India (1375) Ghana (1319) Zambia (1252) Vietnam (1224) Sao Tome and Principe (1215) Cote d'Ivoire (1161) Cameroon (1144) Mauritania (1045) Senegal (1034) Lesotho (1004) Kyrgyz Rep. (880)

Cambodia (795) Kenya (795) Timor-Leste (766) Chad (761) Benin (741) Tajikistan (740) Bangladesh (675) Haiti (664) Mali (613) Zimbabwe (591) Burkina Faso (536) Nepal (535) Togo (530) Rwanda (529) Tanzania (527) Uganda (515) Guinea (474) Madagascar (427) Mozambique (394) Malawi (362) Niger (349) Sierra Leone (325) Liberia (324) Ethiopia (320) 0 Burundi (242) Congo, Dem. Rep. (199) Percentage 0 42 58 37 52 51 51 60 61 42 23 72 44 61

45 57 38 34 48 55 61 58 44 46 34 9 41 40 46 34 18 11 21 43 32 20 44 37 36 29 30 26 29 18 51 54 32 30

16 87 60 36 27 68 31 31 32 32 46 42 39 43 43 31 10 20 30 40 50 60 70 80 Overweight Figure 2. Regional Percent Underweight and Overweight Prevalence in Most Recent Available Survey among Women Aged 19-49 by Urban and Rural Residence, Weighted by 2010 Population Rural Urban Underweight Overweight East Asia and Pacific 7 Underweight 28 East Asia and Pacific 9 3

Eastern Europe and Central Asia 50 3 4 Latin America and the Caribbean 50 3 2 Middle East and North Africa South Asia 38 14 50 40 30 20 10 0 64 1 9 Sub-Saharan Africa 0 20 9 40 60 80 24 Eastern Europe and Central Asia

52 Latin America and the Caribbean 52 Middle East and North Africa 76 South Asia 22 14 Overweight 50 40 30 20 10 0 27 Sub-Saharan Africa 33 0 20 40 60 80 Percentage close to Sample 2 billion people overweight size: 290,278 rural, 232,581 urban source: Jaacks and Popkin, in process National Annualized Absolute Change in Percent Underweight and Overweight Prevalence among Women Aged 19-49 by Urban and Rural Residence in the most recent period, Sorted by 2010 Per Capita Gross Domestic Product Rural

Urban Country (GDP) 0.00 0.00 -0.20 0.00 0.00 0.00 -0.48 0.00 0.00 -0.33 -0.40 -0.29 -0.20 -1.00 -0.23 0.00 -0.20 0.00 -0.40 -1.50 -0.86 -0.40 -0.86 -1.60 -0.40 0.00 -0.17 -0.12 -0.33 -0.50 0.00 Brazil (10993) Turkey (10050) Mexico (9128) 0.04 Gabon (8768) Colombia (6186) Peru (5283) China (4433) 0.12 Jordan (4370) Armenia (3031) 0.20 Congo, Rep. (2970) Indonesia (2952) Egypt (2698) Honduras (2019) 0.17 Bolivia (1979)

Nicaragua (1456) Nigeria (1443) India (1375) Ghana (1319) Zambia (1252) Cote d'Ivoire (1161) Cameroon (1144) Senegal (1034) 0.29 1.60 Lesotho (1004) Cambodia (795) Kenya (795) Benin (741) Bangladesh (675) Haiti (664) Mali (613) Zimbabwe (591) 0.20 Burkina Faso (536) Nepal (535) Rwanda (529) Tanzania (527) Uganda (515) 0.33 Guinea (474) Madagascar (427) Mozambique (394) 1.40 Malawi (362) Niger (349) Ethiopia (320) 1.61 1.20 -0.07 Percentage 0.00 -0.20 0.00 1.58 1.40 1.71 0.85 1.00 0.80 0.00 0.00 -0.17 0.00 0.00 -0.83

1.53 0.80 1.50 1.40 1.67 0.00 -0.40 0.00 0.00 -0.20 0.43 1.00 0.83 0.23 0.57 -0.67 -0.08 0.00 -0.20 -0.20 0.00 0.00 0.00 0.20 0.40 -0.40 -1.50 1.00 1.00 0.40 1.80 0.43 1.20 1.00 0.67 0.40 -0.29 -0.40 -0.29 -0.80 -0.40 -0.17 0.00 0.00 0.00

0.00 0.00 0.38 0.50 0.50 0.17 close 2-0.25 billion people overweight -1.75 -1.25to -0.75 0.25 0.75 -3 -2 -1 1 Underweight -0.58 -0.20 2 Overweight Brazil (10993) Turkey (10050) Mexico (9128) 0.02 Gabon (8768) Colombia (6186) Peru (5283) China (4433) 0.07 Jordan (4370) Armenia (3031) 0.40 Congo, Rep. (2970) Indonesia (2952) Egypt (2698) Honduras (2019) Bolivia (1979) 0.20 Nicaragua (1456) Nigeria (1443) India (1375) Ghana (1319) Zambia (1252) Cote d'Ivoire (1161) Cameroon (1144) Senegal (1034) Lesotho (1004) 0.60 Cambodia (795)

0.20 Kenya (795) Benin (741) Bangladesh (675) Haiti (664) Mali (613) Zimbabwe (591) 0.20 Burkina Faso (536) Nepal (535) Rwanda (529) Tanzania (527) Uganda (515) Guinea (474) Madagascar (427) Mozambique (394) 1.20 Malawi (362) Niger (349) 0.17 Ethiopia (320) -0.62 0.00 3 4 -1 .7 5 -1 .2 5 -0 .7 5 -0 .2 5 0. 25 0. 75 -0.57 Country (GDP) Underweight Percentage 1.86 0.80 -0.05

1.33 1.20 1.14 0.00 3.00 0.00 0.50 0.83 0.20 0.33 0.60 2.67 0.80 0.43 1.00 2.00 0.62 0.57 -0.40 -0.20 0.40 0.20 0.00 1.25 0.57 0.60 1.00 -0.71 1.20 1.80 0.83 0.20 0.83 0.20 0.50 1.00 1.88 0.17 -4 -3 -2 -1 1 2 3 4 Overweight source: Jaacks and Popkin, in process Figure 4. Regional Annualized Change Absolute Change in Percent Underweight and Overweight Prevalence in the most recent period in Percent Underweight and Overweight among Women Aged 19-49 by Urban and Rural Residence, Weighted by 2010 Population Rural Urban Underweight East Asia and Pacific 0.03

0.01 Overweight 0.95 Eastern Europe and Central Asia 0.00 -0.09 -0.6 -0.4 -0.2 0.0 0.2 0.4 -0.18 0.31 0.0 0.5 -0.12 1.0 1.5 -0.6 -0.4 -0.2 0.0 0.2 0.4 Percentage close to 2 billion people overweight source: Jaacks and Popkin, in process 0.13 Eastern Europe and Central Asia 0.00 0.51 Sub-Saharan Africa East Asia and Pacific 0.77

Latin America and the Caribbean -0.29 0.81 South Asia -0.44 -0.18 1.12 Middle East and North Africa Overweight 0.03 1.18 Latin America and the Caribbean -0.30 Underweight Middle East and North Africa South Asia 1.14 0.39 0.53 Sub-Saharan Africa 0.60 0.0 0.5 1.0 1.5

Difference in Annualized Prevalence [recent minus earlier] by region recent minus earlier Percent Underweight and Overweight among Women Aged 19-49 by Urban and Rural Residence, Sorted by 2010 per Capita Gross Domestic Product Rural Urban Underweight East Asia and Pacific 0.33 Underweight 0.05 Eastern Europe and Central Asia 0.00 1 Eastern Europe and Central Asia 0.40 Latin America and the Caribbean -0.17 0.48 0.52 South Asia -0.13 0.75 -2 -0.50 East and -1.26 0.12Middle North Africa Sub-Saharan Africa

0.18 0 0.19 South Asia 0.04 East Asia and Pacific -0.20 Middle East and-1.97 North Africa 0.13 Overweight 0.04 0.80 Latin America and the Caribbean -0.12 -1 Overweight -1 0 1 0.46 -2 -1 0 1 0.03 Sub-Saharan

Africa -0.20 -2 -1 0 1 Percentage close toSample 2 billion people overweight 510, 598 rural; 440, 701 urban source: Jaacks and Popkin, in process Difference in Annualized Prevalence by region [recent minus earlier] in Percent Underweight and Overweight among Women Aged 1949 by Urban and Rural Residence, Sorted by 2010 per Capita Gross Domestic Product Rural Urban Country (GDP) Country (GDP) -0.51 1.23 Brazil (10993) 0.80 Turkey (10050) 0.56 Mexico (9128) -2.01 -0.20 0.80 Colombia (6186) 0.00 1.02 Peru (5283) 0.43 -0.05 China (4433) 0.20 -0.50 Jordan (4370) -0.20

Indonesia (2952) 0.59 0.12 Egypt (2698) -2.08 0.11 Bolivia (1979) -0.27 0.10 Nigeria (1443) 2.75 0.00 Ghana (1319) -0.10 -1.22 Zambia (1252) 0.83 0.02 Cote d'Ivoire (1161) -1.27 0.46 Cameroon (1144) 0.07 1.83 Senegal (1034) -0.66 0.00 Cambodia (795) -0.40 -0.10 Kenya (795) -0.50 0.60 Benin (741) -1.80 0.32 Bangladesh (675) 0.45 -0.31 Haiti (664) 0.09 1.20 Mali (613) -0.43 -0.58 Zimbabwe (591) 1.62 -1.41 Burkina Faso (536) 0.52 -1.30 Nepal (535) 0.60 -0.40 Rwanda (529) 1.00 0.41 Tanzania (527)

0.36 -0.09 Uganda (515) -0.15 1.40 Madagascar (427) -0.50 0.21 Mozambique (394) 0.21 -0.33 Malawi (362) 0.08 -0.67 Niger (349) 0.67 0.60 Ethiopia (320) 0.17 -0.58 -0.20 Brazil (10993) Turkey (10050) -1.99 0.45 Mexico (9128) -0.20 Colombia (6186) 0.00 Peru (5283) -0.69 0.09 China (4433) 0.10 Jordan (4370) -0.16 Indonesia (2952) -1.55 0.12 Egypt (2698) -1.18 0.31 Bolivia (1979) 1.10 Nigeria (1443) -0.50 0.30 Ghana (1319) -0.78 Zambia (1252) -0.88 -0.33 Cote d'Ivoire (1161) -0.76 0.33

Cameroon (1144) 0.45 -1.02 Senegal (1034) -0.40 -0.60 Cambodia (795) -0.10 -1.30 Kenya (795) 0.80 Benin (741) -3.40 -0.14 Bangladesh (675) 0.07 -0.61 Haiti (664) 1.37 -1.40 Mali (613) -0.76 Zimbabwe (591) -0.11 Burkina Faso (536) -1.98 -0.10 Nepal (535) -0.60 -1.20 Rwanda (529) -0.25 Tanzania (527) -0.55 0.00 Uganda (515) -1.35 1.70Madagascar (427) -0.80 0.33 Mozambique (394) -1.00 0.34 Malawi (362) -0.79 Niger (349) 0.80 Ethiopia (320) -0.63 0.00 -2 -1 0 Underweight

1 Percentage -4 -3 -2 -1 0 1 2 3 4 Overweight close toSample 2 billion people overweight 510, 598 rural; 440, 701 urban -2 -1 0 Underweight 1 Percentage 2.03 0.40 0.90 0.60 2.70 0.58 0.80 2.00 0.16 1.09 3.40 0.67 1.71 -4 -3 -2 -1 0 1 2 3 4 Overweight source: Jaacks and Popkin, in process Two other major shifts Rightward shift in the BMI distribution among LMICs adults, especially women but where have male data find often similar pattern (e.g China) Mysterious challenge: WC/BMI ratio increasing in many countries Over 2 billion people in the world are overweight

Predicted BMI Increases Across Selected Countries at the 95th Centile in Age 30 and 40 Year Old Women* age 30 50 43.1 BMI level 40 30 41.3 40.2 38.5 40.2 36.5 30.2 age 40 31.5 36.8 35.5 34.4 32.9 32.0 31.3 28.7 39.3 39.1 35.4 32.9 33.3 49.0 30.7 30.8 30.7 30.7

29.0 28.7 29.5 28.4 24.8 20 10 0 *Based on quantile regression from nationally representative surveys of all countries except China Source: Popkin and Slining (2013) Obes Reviews 2013; 14: 11-20.; see Stern et al, in process. 28.3 25.6 Female Waist Circumferences are Increasing at the Same BMI Level Across Many Countries: The China Example 1993 2009 Waist circumference centimeters 100 82.2 80.0 79.0 77.0 75.7 73.0 80 68.1 66.0 88.7 85.0 76.0 73.9 66.968.4 82.5 80.4 79.9 77.9 89.6 87.3 89.1 85.9 75.276.5 85.7

83.5 83.0 81.0 79.2 77.0 83.0 81.3 79.380.9 68.268.9 60 40 20 0 See Stern et al, under revise/resubmissions status 70.071.6 92.2 89.0 Male Waist Circumferences are Increasing at the Same BMI Level Across Many Countries: The China Example 1993 Waist circumference centimeters 100 86.7 84.3 82.8 79.5 80.6 76.1 80 71.2 68.2 93.8 89.6 87.0 84.7 83.6 81.4 79.9 76.9 71.6 69.0 2009

94.2 90.4 87.9 85.6 84.4 80.8 82.1 77.6 72.5 69.7 60 40 20 0 See Stern et al, under revise/resubmissions status 95.0 91.1 88.8 86.4 85.3 83.1 81.6 78.6 73.3 70.7 95.9 92.1 2. Energy Imbalance: Physical Activity declines in LMICs represent a significant, large component of the energy imbalance. In countries with detailed longitudinal data on all components of physical activity we find very large declines in METS and any other measure of activity Slow downward shift in high income countries starting from much lower starting point relative to high METS starting point and very steep decline in LMICs See review across a number of low and high income countries by Ng and Popkin Obes Rev 2012 Over 2 billion people in the world are overweight A v e ra g e h o u rs p e r w e e k b e in g S e d e n t US Adults Met-hours Per Week of All Physical Activity, and Hours/Week of Time in Sedentary Behavior: Measured for 1965-2009 and Forecasted for 2010-2030 Active Leisure PA Travel PA

A v e ra g e M E T -h o u rs p e r w e e k 250 Domestic PA 1965: 235 MET-hr/wk 45 Occupational PA Sedentary Time (hrs/wk) 40 200 35 2009: 160 MET-hr/wk by 2020: 142 MET-hr/wk 30 by 2030: 126 MET-hr/wk 150 25 20 100 15 10 50 5 0 0 Year Source: Ng S.W. & Popkin B.M. Obesity Reviews 13 (8):659-80 Over 2 billion people in the world are overweight A v e ra g e h o u rs p e r w e e k b e in g S e d e n t A v e ra g e M E T -h o u rs p e r w e e k UK Adults Met-hours per Week of Physical Activity and Hours/Week of Time in

Sedentary Behavior: Measured for 1961-2005 and Forecasted for 2006-2030 250 1961: 216 MET-hr/ week Active Leisure PA Travel PA Domestic PA Occupational PA Sedentary Time (hrs/ wk) 60 2005: 173 MET-hr/ week by 2030: 140 MET-hr/week 50 200 by 2020: 153 MET-hr/ week 40 150 30 100 20 50 10 0 0 Year Source: Ng S.W. & Popkin B.M. Obesity Reviews 13 (8):659-80 Over 2 billion people in the world are overweight A v e ra g e h o u rs p e r w e e k b e in g S e d e n t A v e ra g e M E T -h o u rs p e r w e e k Brazilian Adults Met-hours per Week Of Physical Activity & Hours/Week Of Time

In Sedentary Behavior: Measured For 2002-2008 And Forecasted For 2009-2030 Active leisure Travel 250 35 Domestic 2008: 214 MET-hr/week Occupational Sedentary time 30 25 200 by 2020: 180 MET-hr/week 20 by 2030: 151 MET-hr/week 15 150 10 5 100 0 Year Source: Ng S.W. & Popkin B.M. Obesity Reviews 13 (8):659-80 Over 2 billion people in the world are overweight A v e ra g e h o u rs p e r w e e k b rin g s e d e n t A v e ra g e M E T -h o u rs p e r w e e k Chinese Adults Met-hours per Week of Physical Activity & Hours/Week of Time in Sedentary Behavior: Measured for 1991-2009 and Forecasted for 2010-2030 1991: 399 MET-hr/week Active Leisure PA Travel PA

450 30 Domestic PA Occupational PA Sedentary Time (hrs/week) 400 25 350 20 300 250 15 2009: 213 MET-hr/week by 2020: 200 MET-hr/week by 2030: 188 MET-hr/week 10 200 5 150 100 0 Year Source: Ng S.W. & Popkin B.M. Obesity Reviews 13 (8):659-80 Over 2 billion people in the world are overweight Why the concern about movement and activity? Important direct health benefits(other than energy balance) kids: enhances learning in a vast array of ways adults: improved bone health, prevention of diabetes and cardiovascular health, healthier aging, prevention of 4-5 different cancers Difficult to stop the major declines in energy expended in market and home production, transportation nor to control increases in sedentary activity In LMICs few systematic government attempts to increase

physical activity other than in schools to date. Little evaluation of voluntary efforts (e.g Agita Sao Paulo) Over 2 billion people in the world are overweight Sources of Major Global Dietary Shifts Global increases in: Caloric sweetener use, especially in beverages but increasingly in all consumer packaged foods animal source foods refined carbohydrates, ultra refined highly processed foods Convenience eating/foods: snacking, away-from-home eating, precooked food Global decreases in: legumes, vegetables, fruits in most countries food preparation time Only in Low and middle income world: large increased edible oil use and food frying close to 2 billion people overweight Major Food System Shifts : Linkages from Farm to Food Sales are Rapidly Shifting The value chain is rapidly shifting toward vertical integration Rapid transition to modern system varied across Latin America, Africa, Asia at various times over 1980-2010 Modern: farmer to food processors or supermarkets Consolidation of food system resources is happening in most countries Latin America: shift from 15-20% of all peso on food from modern supermarkets to 60% in 1990-2000 period Top 5 chains control two-thirds of the supermarket sector in Latin America (Wal-Mart, Carrefour, Ahold) Over 2 billion people in the world are overweight Shift In Growth and Size of Sales for a Subset of Retailers in Asia First wave South Korea($42B), Taiwan Annual compound sales growth 2001-09: 10-12% Second wave: Indonesia, Malaysia, Philippines, Thailand ($18B) Annual compound sales growth 2001-09: 13-18.5% Third wave: China($91B), India, Vietnam Annual compound sales growth 2001-09: 28-50% Current growth is very rapid in all markets where any opportunities are found. Rapid translation north-south by all

global food system playersbe they based in high or low and middle income countries Over 2 billion people in the world are overweight 3. The Global LMICs Response: Mexicos Integrated Systematic Response Faced rapid increase in obesity, high caloric beverage intake, aggressive marketing, confusing use of GDAs in food labeling by industry to confuse consumers First beverage guidelines panel led to govt action in food-related programs Second, systematic National Agreement for Healthy Nutrition (ANSA) coordinated by INSP, Cuernevaca approved by previous President, all cabinetthis was very comprehensive and specific with each agency assigned selected activities Over 2 billion people in the world are overweight Mexicos Beverage Recommendations For Adults Recommended kcals Consumed for Women 1 GLASS LOW SUGAR AGUA FRESCA (20 KCAL) Recommended kcals Consumed for Men 2 CUPS UNSWEETENED COFFEE (10 KCALS) TOTAL 187 KCALS TOTAL 231 KCALS 1/2 BEER (180ML) OR 1 GLASS RED WINE (100ML) (75 KCAL) GLASS UNSWEETENED FRUIT JUICE (54 KCALS) 2 GLASSES LOW SUGAR AGUA FRESCA (40 KCAL) 1 CUP REDUCED FAT MILK (103 KCALS) 6-8 GLASSES OF WATER (0 Kcal)

GLASS UNSWEETENED FRUIT JUICE (54 KCALS) 2 CUPS UNSWEETENED COFFEE (10 KCALS) Over 2 billion people in the world are overweight 1/2 CUP REDUCED FAT MILK (52 KCALS) 6-8 GLASSES OF WATER (0 Kcal) Ministry Of Health Response 10 Objectives to prevent Chronic Diseases 1. 2. 3. 4. Promote physical activity (in school, work community, leisure environments) Increase availability, access and consumption of water Reduce consumption of sugar and fat in beverages* Increase consumption of vegetables and fruits, legumes, hole grains and fiber in the diet 5. Improve the capacity for decision making for a healthy diet (nutrition literacy) * 6. Promote and protect exclusive breast-feeding until 6 months of age and adequate complementary feeding starting at 6 months of age 7. Reduce the quantity of added sugar in industrialized foods* 8. Reduce consumption of saturated fats and eliminate consumption and production of trans fats of industrial origin* 9. Reduce portion sizes of dishes, snacks and industrialized foods in restaurants and sale points* 10. Limit the quantity of added sodium in foods and reduce its consumption* * Actions in which industry cooperation and participation and social responsibility are needed Over 2 billion people in the world are overweight Mexico (cont) Third, very drawn out negotiations with food industry to create school guidelines for healthy nutrition with major reductions in SSBs and junk food for children Fourth, national panel formed by Ministries of Health and Finance and the Mex FDA (COFEPRIS) to develop Front-of-pack labeling system Then election, new conservative government but one senate led by more left-oriented party Over 2 billion people in the world are overweight Mexico (cont) 2012-13: funding of civil society coalition, lobbyist, and

research by Bloomberg Philanthropies provided the resources for civil society to build on national anti-SSB work and fight large Big Beverage push against taxation (previously lost 2 votes for 20% tax) A long bitter campaign ensued[see next slides] The role of very active civil society with funding for counter ads, press, very important. President forced to propose 10% tax to counter push for 20% Also surprisingly govt created 8% junk food tax Over 2 billion people in the world are overweight THE MEXICAN SSB TAX TIMELINE COALITION BUILDING EARNED MEDIA EXPERT FORUMS ALLIANCE BORN CAMPAIGNS 12 SPOONFULS OF SUGAR FIRST CAME OBESITY, THEN DIABETES OCT NOV DEC JAN CONGRESS IN SESSION COLLECT SIGNATORI ES TO SSB TAX BILL FEB MAR APR MAY JUNE JULY A HEALTHIER MEXICOSUGARY

DRINKS AUG KEY DIALOGUE WITH MINISTRY OF FINANCE ACADEMIA LAUNCH OF POLICY RECOMS Over 2 billion people in the world are overweight SEPT OCT WATER IS LIFE NOV CONGRESS IN SESSION CONGRESS IN SESSION SSB TAX BILL INTRODUCED IN SENATE TABLED TIL FISCAL REFORM NEW PRESIDENT TAKES OFFICES PRINT AD BATTLE IN THE PRESS INDUSTRY CAMPAIGNS INTENSE LOBBYING PEA NIETO ANNOUNCES SODA TAX IN FISCAL REFORM SSB TAX PASSED CAMPAIGN STRATEGY (1) Coalition building: Create the Nutritional Health Alliance with former and new allies (diverse member base) and a shared,

comprehensive agenda on malnutrition and obesity Evidence based: Reports, arguments and proposals; draw from soda tax modeling and academic policy recommendations (National Institute of Public Health, et al); forums with experts; public opinion polls Public campaigns: Expose the human drama of diabetes; stigmatize SSBs; promote soda tax and drinking fountains. Recurring theme: Soda is sweet. Diabetes isnt. Over 2 billion people in the world are overweight CAMPAIGN STRATEGY (2) Media strategy: Create public debate through press conferences (1xweek), public actions/performances (1xmonth) and newspaper ads (2xweek in Oct.) Engagement with decisionmakers and lobbying: Actor mapping Identification of champion(s) Relationship building across parties, ministries and Congressional committees Mini public campaign targeting Congress Tracking industry lobbying (responding or exposing as necessary) International support: WHO recommendations, PAHO, IASO/IOTF and other people allied in INGOs, Over 2 billion the worldhealth are overweight advocates in the US The Mexican Tax Passed Oct 31, 2013 Sugar-sweetened beverages (SSB): All flavored waters including concentrates, powders or syrups used to prepare flavored waters; that have added sugars will be subject to a tax of $ one peso per liter.( 10%) Excludes 100% juices and flavored, milk and yoghurt.> 35% for potable water fountains in schools. Junk food: All non-basic foods (chips and snacks; candies; chocolate and cacao based products; puddings; fruit-made

and vegetable-made sweets; peanut and hazelnut butters; milk and caramel-based sweets; cereal-based products; icecream and ice-pops) with an energy density 275kcal/100g will be subject to a tax of 8% Over 2 billion people in the world are overweight Factors of Success Rationale for the tax & linking it to the cause: 70% of the public in favor of a tax linked to obesity/diabetes prevention, children & water fountains Active and vocal academic community: Obesity in Mexico policy recommendations by National Academy of Medicine & INSP Permanent public debate: Presence on the streets and every few days in national newspapers through campaigns, ads and earned media Lobbying strategy: A fearless champion (Senator Marcela Torres), continuity and Congress, Whos side are you on? campaign Executive support: President Pea Nieto included the soda tax in his fiscal reform package; Ministry of Finance seeks revenue Lucky political timing for legislative support: The Pact for Mexico favored passage of the fiscal reform package Sufficient funding: For human resources & campaigning Effective collaboration: Close coordination and synergy with civil society and academia in past year, possible due to past Over collaboration 2 billion people in the world are overweight Mexico (cont) Evaluation of price, marketing, food purchase shifts underway led by INSP with UNC collaboration To date it appears as if price increases are being passed along Future longitudinal analysis of impact on prices, marketing and food purchase patterns is being initiated Over 2 billion people in the world are overweight Mexicos Critical Elements Built up across medical and public health scholars over 5 years understanding of the role of sugary beverages so major consensus among most organizations, leaders in the field despite industry attempts to divide. Built on major concerns about obesity, diabetes. Results of 2012 National Survey represented final statement. Civil society very active against very aggressive Big Beverage campaign Govt need for tax revenue but got part of SSB tax applied to potable water in schools. Over 2 billion people in the world are overweight 4. Organizing options for review of major LMIC policy initiatives: NOURISHING framework Developed by WCRF International (see Hawkes et al, A

food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework. Obesity Reviews. 2013; 14: 159-68.) Focus on food: The website is updated continuously. Useful resource. http://www.wcrf.org/policy_public_affairs/nourishing_fram ework / Also many case studies on www.bellagioobesity2013.org Over 2 billion people in the world are overweight Focus on Key Elements of food system change The food environment: Economic tools: prices, subsidies, trade controls Labeling: front-of-the-package approaches being used; claims restrictions Marketing controls and restrictions restrict foods in selected institutions(e.g. schools) Food systems: retailing, restaurant/fast food sector, farm to fork systems Information and education: large scale and counseling Over 2 billion people in the world are overweight The Food Environment: Economic Tools Taxation and Subsidies Mexico(10% SSB,8% junk food), Pacific islands, Singapore: subsidize selected foods for schools, hawker centers. other countries now considering the SSB tax Ideally want a total sugar in beverages tax as most effective [tax per gram of sugar] Import controls: problems with WTO emerged in Western Pacific Island work

Over 2 billion people in the world are overweight Activities to Improve Diets Country French Polynesia Nauru Cook Islands Fiji Fiji Fiji Fiji Type of taxation Excise and import tax on sugar-sweetened drinks, confectionaries, and ice cream Size 40 CFP*/litre local tax; 60 CFP*/litre imported tax Sugar levy on all high-sugar foods and drinks and removal of a levy on bottled water 30% Import duty on sugarsweetened drinks Import duty and local excise duty Excise on raw materials 15% with a subsequent 2% rise per year 5% import duty; 5cents/liter local excise duty 3% Import duty on palm oil and 32% monosodium glutamate Import duty on fruits and Removal of existing taxes, vegetables not grown locally which were 532% Pacific Research Centre for the Prevention of Obesity and Non-communicable Diseases Over 2 billion people in the world are overweight The Food Environment: Labeling and Claims Front-of-the-packageconfusing GDAs of industry vs.

positive health food labeling: Singapore, Malaysia, Mex., Thailand in process, others considering. negative: Ecuador exists as law(now planning implementation with its own version of negative logo) and Chile(law passed, not implemented yet) identify foods with unhealthy levels added sugar, sodium, saturated fat; ban images: Ecuador banned animal characters, cartoon personalities, celebrities to promote junk food Claims: mainly unfettered except Mexicos attempt to remove (unsuccessful implementation with current President), few countries regulate well Ideal link labeling with marketing and taxing Over 2 billion people in the world are overweight Labeling Un-healthy Foods 10 % of front surface of the package One for each high critical nutrient Over 2 billion people in the world are overweight The Food Environment: Marketing Controls Hampered by Big Food and Beverage Politics Chile: implementation of law to ban toys, control marketing of unhealthy foods high in saturated fat, add sugar and sodium stopped after became law Brazil: comprehensive exemplary law held up by attorney general after passing legislature. Peru: strong law not implemented yet Industry voluntary self-regulation seems to be the major approach and no evaluation has shown this to be successful in any LMIC South Korea: ban for TV and internet specific food categories during kids programs and 5-7pm Over 2 billion people in the world are overweight The Food Environment: School Restrictions Major Institution Idealban/allow same healthy/unhealthy foods and beverages Schools: banning of junk foods/SSBs completely(Peru, Ecuador, Costa Rico, UAE, Singapore, Western Pacific), mainly(Mexico, Thailand) In-school marketing: banned Mexico: reformulation of milk from full fat to 1.5% fat for all government programs ( 20 million affected). Mexico more detail above. Brazil: most exemplary. Note below under food systems. Also ban SSBs and snacks in many states. Philippines: banned SSBs Over 2 billion people in the world are overweight

Chiles Law: Marketing to Children Comprehensive approach: regulate all food marketing strategies such as package design, promotions, places of display, etc. Address not only infant and childhood environments (schools, day care center, playgrounds) but also family environments (malls, TV shows, etc.) Norms should focus on: 1. television 2. schools (directly and indirectly through advertisements within textbooks and educational materials) 3. visual or audio placement in films, music videos, video games, the Internet, etc. Over 2 billion people in the world are overweight Brazilian Food Marketing Law 2006: Government attempt to regulate the advertising of foods high in sugar, sodium, saturated fat, and trans fat The resolution was challenged in court by representatives of the food industry and was suspended by the federal attorney general despite the commitment of the Health Ministry and the NHSA Over 2 billion people in the world are overweight Food Systems Brazil: most effective but needs serious impact evaluation. Schools must purchase 30% of food from local smaller family farms/cooperatives. Also 70% of food must be a basic food. No idea of impact on overall diet of children let alone diet at schools. Singapore: put all hawkers into centers when can control the environment, have access to them for various programs. The push for farmers markets and farm to household sales minimal in LMICs (a high income country phenomena mainly) Urban and school gardening: limited systematic efforts Mainly ignoring retail sector and restaurant/fast food other than the Singapore effort and the front of the package labeling efforts Over 2 billion people in the world are overweight Information and Education Large-scale: Thailand unique effort at the village level with a focus on reducing waist circumference(flat belly network), also reduce sugar and fat Dominant effort: food-based dietary guidelines and classic nutrition education Nutrition education in schools in many countries pushed. No focus on cooking or other skills Few countries push for healthy food hospitals and clinical diet and physical activity counseling (e.g. Brazil, Thailand) Workplace: limited efforts (e,g Singapore) Over 2 billion people in the world are overweight

Special Programs for Controlling Overweight and Obesity Problems Sweet enough network Thai people flat belly network Over 2 billion people in the world are overweight LMICs are Beginning to Take Serious Large-scale Action While only a few countries (e.g. France, Scandinavian) take major actions among the high income countries, the need and the will to take action is increasing among LMICs Mexico, Ecuador, Thailand, Singapore, the Western Pacific Islands are just the beginning of this. Need to learn to work more with civil society groups to aid in the battles with big food and big beverage. Evidence is needed: serious push for rigorous evaluation is essential. A need to create one food and beverage standard and use across all controls: marketing, front-of-packing profiling, taxation Over 2 billion people in the world are overweight

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