Latin America’s war on obesity could be model for U.S.

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There is something Chilean kids won’t see anymore. As of June 27, cinemas and televisions no longer screen advertisements for foods high in calories, added sugar, sodium and saturated fat between 6 a.m. and 10 p.m., under new laws aimed at reducing childhood obesity in Chile.

It is one of the most recent efforts in the campaign against obesity that Latin American countries have been fully engaged with – and winning – for some time.

One country and one strategy at a time, the region has pushed back against sugary beverages and ultra-processed foods in an effort to escape the obesity epidemic that has overtaken the United States. Infectious diseases are still the leading causes of death in developing countries, but as economies grow, Western lifestyle factors such as smoking, high-fat diet, obesity and lack of exercise are emerging public health problems.

In Chile, the Senate passed strict food-labeling laws. Mexico imposed a tax on sugary drinks and junk food, and Brazil opted for voluntary measures that have proved effective.

“The obesity epidemic is relatively new in Latin America,” says Camila Corvalán, a nutrition professor at the Institute of Nutrition and Food Technology at the University of Chile, who was on the expert panel that helped the Ministry of Health develop the new policy. “But we knew exactly where we would end up. We have all the figures and numbers from the United States.”

By 2012, a quarter of schoolchildren and a third of Chile’s adult population were obese. Chile’s figures were not anomalous. In the United States, the percentage of obese children and adolescents has more than tripled since the 1970s, according to the Centers for Disease Control and Prevention. The rates of obesity among adults is no better: In 2007, 33.7 percent of American adults were obese. The most recent estimates approach 40 percent, according to the American Medical Association.

In July 2012, the Chilean Senate approved the law of food labeling and advertising, which went into effect in 2016 with comprehensive food-regulation policy in three, increasingly stringent phases. Spearheaded by Guido Girardi, a physician and former senator, the law included front-of-package warnings, restrictions on marketing unhealthful foods directly to children, and limits on what foods could be sold in schools and day-care facilities.

“The situation was producing an increase in noncommunicable chronic diseases and deaths from cancer, heart attacks, diabetes (and) hypertension,” Girardi wrote in an email. “And we have the conviction that this true tsunami of diseases affected the poorest who have a 160 percent higher risk of obesity, 380 percent higher risk of hypertension and 320 percent higher risk of diabetes and more than 100 percent [higher risk] of a heart attack . . . than people of high income.”

Foods high in added sugar, saturated fats, calories and added sodium must display black stop signs on front-of-package labels. Nothing with black stop signs can be sold or promoted in schools or included in child-targeted television ads or marketing strategies aimed at children (no characters, toys or celebrities like Tony the Tiger or the Trix rabbit).

There was pushback.

“There was a very hard lobby,” Girardi explains. In an episode that went viral on social media in Chile, a fast-food entrepreneur confronted Girardi on a Latam Airlines flight, yelling, “You are the most nefarious thing that has happened to this country.”

The country’s leading business lobby also weighed in, threatening to withhold money for sports teams and disabled citizens. “They did a real campaign of terror saying that chaos and thousands of unemployed people would be generated,” Girardi said.

Chilean President Sebastián Piñera moved to veto the law. Girardi says that a citizen scientific coalition eventually defeated the lobby but that companies such as Carozzi and Nestlé paid celebrities and athletes to malign the law.

“There were lots of arguments that it would cost too much money and be impossible to implement,” remembers Corvalán. “The Ministry of Health is very happy with the results so far. In our studies, we have seen that consumers understand the regulation very well, that more logos means less healthy foods.”

Carozzi did not respond to emailed request for comment.

Francisco Frei, a spokesman for Nestle in Chile, said the company was complying with the new regulations and making efforts to reform its products through reduction in sugars, salt and saturated fats. “For example, since 2015, we have been able to reduce more than 3000 tons of sugar in our products,” he said in an email.

Barry Popkin, a professor in the Department of Nutrition at the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill, has been involved in policy formulation for Mexico, Chile, Brazil and Colombia and helped evaluate the initiative.

He says the program resulted in a 25 percent reduction in the purchase of sugary beverages and a 9 percent decrease in the purchase of sugar-sweetened breakfast cereals. Many packaged foods have been reformulated with lower levels of sugar and sodium in an attempt to avoid the black stop sign labels.

The changes have also put children in a central role in guiding family eating patterns, he says.

“Low-income mothers reported their kids were coming home from school and saying, ‘You can’t buy these foods with the warning labels,’ ” Popkin says. “We saw large declines in the purchase of junk food.”

Uruguay and Peru have also approved warning labels similar to those in Chile.

“We have to get rid of the unhealthy food before we get people to eat the healthy food,” Popkin says. “Many of these countries have state health plans, so the financial burden of unhealthy diets and obesity is felt by the governments very quickly.”

Mexico

Chile is ranked as a high-income economy by the World Bank. Popkin says different strategies – such as a tax on sugary beverages – have proved effective in countries such as Mexico, which has a larger percentage of low-income citizens.

Between 1989 and 2006, sugary-drink consumption increased by 60 percent in Mexico. With death rates that are among the highest in the world for lifestyle-related chronic diseases such as diabetes, Mexicans drank more soda per person than residents of nearly any other country.

“We had been aware of undernutrition problems and were starting to see reductions of those, but the levels of obesity came as a shock,” Juan Rivera, director of the National Institute of Public Health of Mexico, said recently by phone. “On average, Mexicans were consuming 25 percent of all their calories from junk food and sugar-sweetened beverages.”

The reasons are interesting. Rivera says that in the 1990s, Mexico had had a cholera epidemic and consumers were leery of drinking tap water. People started buying bottled water – but if soda was even cheaper than bottled water, why not opt for the more flavorful beverage?

He says there had also been a long tradition of mothers putting a little sweet juice in baby bottles of water. It wasn’t a big leap to introduce baby bottles of Coca-Cola to children under 12 months old. Between 1995 and 2005, Rivera says, Mexico became the largest consumer of Coca-Cola (Vicente Fox, who was president from 2000 to 2006, had previously been president of Coca-Cola Mexico). Coca-Cola did not respond to questions.

“Suddenly we realized that if we had to take one single regulation, the perfect candidate would be sugar-sweetened beverages to overcome obesity,” Rivera says.

Ben Sheidler, director of external communications at Coca-Cola, said 45 percent of the company’s products in Mexico are low- or no-sugar. “We have reduced the calorie content of our portfolio by more than 20% within the last decade,” he said in an email.

In 2012, Rivera and regulators began exploring the idea of a soda tax. They found that increasing the price by 10 percent reduced consumption by 12 percent. Industry countered: This would unduly hurt low-income people, and besides, sugar-sweetened beverages are part of the Mexican food basket. The way to reduce obesity, they said, was more physical activity.

But public health groups fought back with ads and billboards featuring a photo of 12 teaspoons of sugar, the amount in a 600 ml bottle of soda, and the questions: “Would you give your child this much sugar? Then why would you give them a soda?”

A 10 percent tax went into effect in January 2014 for junk food (snacks, candy, nut butters, cereal-based prepared products and foods considered “non-essential”) and sugar-sweetened beverages. While it’s too early to assess obesity levels, Rivera says, low-income Mexicans have decreased their sugary beverage consumption by 12 percent. For those with higher incomes, it is a 5 percent reduction.

Rivera says that the food industry has tried to have the tax repealed every year but that the revenue has become important for the country, raising 23.2 billion pesos (about $1.2 billion) from sugar-sweetened beverages and 18.3 billion pesos ($967 million) from junk food.

Brazil

In Brazil, changing citizens’ nutritional behaviors has taken a voluntary route, which has also proved effective. The Dietary Guidelines for the Brazilian Population of 2015 contains strong, straightforward guidance on how to eat: “Always prefer natural or minimally processed foods and freshly made dishes and meals to over-processed foods.”

The guidelines also consider the impact of foods on the environment. The United States, in contrast, backed away from adding sustainability guidelines in 2015, bowing to pressures from the food industry. (Sustainability is also off the table for the 2020 U.S. dietary guidelines, which are being revised right now.)

“Brazil’s guidelines are simple but radical,” says Jean Weinberg, of the Bloomberg Philanthropies, which has funded and provided technical assistance for obesity prevention programs in Mexico, Colombia, Brazil, Chile and Peru. “It’s a really sensible approach. Choose whole, minimally processed foods, cook those foods yourself, and eat those foods with other people.

“The whole view of human rights is very different in Latin America. It’s built into constitutions, and often those frameworks include food and beverage. They could still go back to their traditional diets and eating whole, healthy foods, and avoid where the U.S. has gone.”