To tackle obesity, World Bank looks to lessons from Latin America

WASHINGTON — Mexico is imposing a strict new set of labeling and advertising guidelines for food and beverage manufacturers aimed at reducing obesity, a problem the World Bank is calling a “ticking time bomb” that could negatively affect both health and economic development in low- and middle-income countries. “The reason we focus on [obesity] is it’s a growing problem — and not just in the developed world, as most people thought in the past, but also in the developing world.” --— Meera Shekar, global lead for nutrition, World Bank Processed food sold in Mexico will now be required to display a front-of-package warning label if it contains substantial levels of sugar, fat, salt, or calories and to advise against giving products high in artificial sweeteners or caffeine to children. The regulations also ban the use of animated characters to promote junk food to children. Juan Rivera, director of the Mexican National Institute of Public Health, said that a nutrition survey from 1999 that was conducted in Mexico showed the first sign that obesity was a growing problem in the country, particularly among women. Subsequent surveys revealed more evidence of a growing public health problem, with the latest data showing that an estimated 72% of Mexicans are overweight or obese. “Mexico, as [with] many other Latin American countries during the last 30 years, [has] experienced a reduction in undernutrition at the expense of an increase in overweight and obesity,” Rivera said. “If you live in an environment that is obesogenic, in an environment in which the default are unhealthy foods and lack of physical activity, you need, really, policies ... that will provide incentives for healthy food and beverages,” Rivera added. “You really need to have macro policies and a lot of regulations, along with nutrition education.” Mexico introduced a tax on sugar-sweetened beverages and junk food in 2014. The latest regulations will be implemented in phases, giving manufacturers a chance to avoid the warning labeling by reformulating products to reduce amounts of obesity-causing ingredients. More than 2 billion people worldwide are overweight or obese, according to the recent World Bank report “Obesity: Health and Economic Consequences of an Impending Global Challenge.” Part of this can be attributed to a shift in global food consumption patterns — not only in high-income countries — to include more foods with substantial amounts of sugar and fat, alongside decreasing levels of physical activity. More than 70% of countries now face the double burden of having high rates of both obesity and undernutrition. The World Health Organization classifies adults with a body mass index of 25-plus as overweight and with a BMI over 30 as obese. “From the bank perspective, the reason we focus on this is it’s a growing problem — and not just in the developed world, as most people thought in the past, but also in the developing world,” said Meera Shekar, global lead for nutrition at the World Bank and co-author of the obesity report. “In many ways, obesity increased much more rapidly in Latin America than in other regions, and national governments in Latin America have become quite sensitive to this issue. Given we want to work with governments, we need governments to take the lead on this. Latin America becomes the obvious first region to focus on.” The bank considers its work on obesity to be an essential part of its human capital agenda, Shekar said. Mortality is not the only negative outcome of higher obesity rates, the report notes; increased disabilities and health care costs, decreased productivity, and fewer years in the workforce all contribute to worse human capital outcomes that have negative economic consequences. Shekar said the rest of the world can learn from countries in Latin America such as Mexico and Chile — which has more comprehensive regulations in place aimed at fighting obesity than any other nation in the world — on how national governments can work to change dietary habits and improve nutrition and health outcomes. She said governments in the region are uniquely positioned because they have more capacity and political will to act against obesity than countries in other areas of the world. Barry Popkin, a nutrition and economics professor at the University of North Carolina at Chapel Hill and co-author of the World Bank’s obesity report, worked with Chilean authorities on their obesity prevention initiative that was passed in 2012. Chile has one of the highest rates of obesity in the world, with 31.2% of the adult population qualifying as obese. Chile’s law mandates that food products be labeled with a stop sign symbol if they are too high in saturated fat, sugar, sodium, or calories. Restrictions on marketing prevent techniques that would appeal to children, including the use of animated characters and toys as well as advertisements that would air during children’s programming on television. Foods high in salt, sugar, saturated fat, or calories are prohibited from being sold or advertised inside schools. “Marketing is key because it’s omnipresent in our lives. Wherever you turn, there’s a billboard, on social media, there’s stuff on TV — you see it,” Popkin said. “They’re using it in characters on the packages. Kids buy things because they have all these different characters on packages.” A study published in the International Journal of Behavioral Nutrition and Physical Activity examining the impact of Chile’s regulations a year after they were implemented in 2016 found that young children in particular were driving better eating habits in their families. “We saw among children a potential changing of food norms right away,” said Popkin, who has closely followed such changes in Chile. He said he would love to see other countries copy Chile's comprehensive policies, which is what the World Bank report aims to encourage. Next steps on the World Bank’s obesity agenda are being paused as it works to respond to the COVID-19 pandemic, Shekar said, but eventually the bank’s analytical work will be incorporated into its health sector projects. Obesity reduction, key for economic growth, can also lead to climate cobenefits, the report said, such as the reduced usage of water needed for sugar production as consumption drops. The packaged food industry frequently pushes back on obesity regulations by asking for data proving that better health outcomes actually result from reducing amounts of sugar, fat, and salt in foods and from requirements on packaging and marketing, Popkin said. But producing numbers showing declining obesity rates within a few months or years of new laws taking effect is not possible, he said. “You can’t see it in five years, and so that’s critical for people to understand. Industry always tries to say, ‘We don’t see weight decrease after a year, so it’s not working,’” Popkin said, adding that researchers expect quicker declines in conditions such as diabetes and high blood pressure when sugar and sodium are limited in foods. “Obesity takes a long time,” he said. Rivera said there are plans to conduct a study to measure the impact that the new regulations have on obesity rates in Mexico. As in Chile, he expects children to be responsible for driving behavior change as they age. “The hope is that ... if we start to see stagnation of the prevalences and then a decline [in school-age children], then you can start to really feel that there’s going to be a success. Because it will be really the next generation of Mexicans, the ones that — when they reach adulthood — they will probably have lower prevalences,” Rivera said. “If we could have a new generation with 20% less, that would be a formidable success. It’s possible. It’s possible as long as we really combine all these interventions.”