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Políticas de alimentación y actividad física para la prevención de la obesidad infantil y enfermedades crónicas en América Latina Rafael Pérez-Escamilla, PhD Profesor de Salud Pública y Director, Programa de Salud Global Escuela de Salud Pública, Universidad de Yale, EUA

rafael.perez-escamilla@ yale.edu twitter: @rperezescamilla

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Declaración de Intereses:

Trabajo financiado por el Centro Fogarty de los Institutos Nacionales de Salud de los EUA (NIH) No tengo ningún interés que declarar

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Obesity prevention policies case studies

Excise taxes on sugar sweetened beverages and energy-dense foods

(Mexico)

Trans fatty acids removal from processed foods

(Argentina)

Front-of-package food label legislation

(Chile and Ecuador)

Ciclovías recreativas or ‘open streets’

(Several LA Cities)

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Methods

• Obesity prevention policies case studies

• Developed with an expert in the specific policy

• Policies selected based on level of implementation, visibility and potential impact to reduce childhood obesity

• Case studies coded to identify components that explained successful implementation and sustainability using the Complex Adaptive Health Systems framework (Paina & Peters 2012)

• Iterative consensus process among co-authors

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Key milestones

• 2013: Senate approval

• 2014: Tax implemented

• MX$1 per liter

• Non-alcoholic SSBs

• Findings

• MX$18 billion from SSB tax revenue in 2014

• Soda price & consumption (INSP 2015)

Why taxes?

• Evidence informed policy

− e.g., tobacco experience

• Time bound congressional process for

fiscal packages

• Public pays attention to taxes

• Fast implementation with short term

results

• Evidence-based advocacy

− Lobbying; mass media campaigns

• Engagement from Ministry of

Finances

• Political support

SSB‟s Tax- Mexico

• Policy Research

− INSP (SSB‟s price elasticity; SSB‟s-

obesity/diabetes models)

• Data driven policy statements

− INSP

− Academy of Medicine

Enabling factors

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Key milestones

• 2007: First bill introduced

• 2012: Congress approves law

• 2015: Implementation policy

developed

• 2016: Implementation starts

Why FL & advertising?

• Evidence informed policies

− FL use associated with improved

dietary quality (Pérez-Escamilla)

− Marketing to children influences

unhealthy food and beverage

consumption in children (IOM)

• Political champion

• Academic champion

• Civil society champion

• High level political support

Food Labeling & Advertising Law- Chile

• Compromise with food

industry

− FOP label

− Infant formula marketing

− Junk food at universities

Enabling factors

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Key milestones

− 2004: Voluntary reduction

− 2006: Mandatory FL

− 2006: Multisectoral dialogue

− 2010: Targets and timeline set

− 2014: New regulation enforced

− 2015: Monitoring of regulation implementation by

Argentina‟s FDA

Why TFA elimination?

• Evidence informed

− Industrial TFA‟s cause CHD

− Industrial TFA‟s concentrate in processed

foods

− Oils and fats produced by just a few

companies in Argentina

• Technically feasible (international experience,

e.g. Denmark)

• Academic champion (data)

• Government

• Food industry & distributors

• Universities & scientific societies

Trans Fatty Acids elimination- Argentina

• Predictive model of CHD savings as a

result of policy implementation

• sensitivity analysis

Enabling factors

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Key milestones

• 1970: First ciclovia in Bogota • 2015: More than 100 km of car-free

streets − Sunday event: one million people

Why “ciclovias recreativas” (CRs)?

• Evidence informed

− Sedentarism causes premature disability and

death

− Car traffic/congestion causes pollution and

high stress levels

− Builds social capital

• Technically feasible

• 350 CRs in the Americas

• Strong public support

− Reaction to car-centered urban development

− Attractive to politicians

− Mayor‟s

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Ciclovias Recreativas- Colombia

• Cost-effectiveness studies − LA and beyond

• Program process evaluations − Recommended PA program along the CR

corridor

Enabling factors

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Cross-cutting Enabling Factors

• Champions

• Evidence based advocacy

• Political will & support

• Legislative process

• Intersectorial dialogue/coordination

• Strong representation from civil society

• Research & Evaluation (i.e. data)

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Bradley, Curry, Pérez-Escamilla et al. (2012)

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How did this innovation

spread happen?

Source: Diaz del Castillo et al. (2013)

Evidence/know how + civil society +

political will

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Feedback loops occur when an output of a process within the system is fed back as an input into the same system. A

central feature of al case-studies reviewed was the importance of overcoming or preventing onset of negative

feedback loops or “resistance” with positive feedback loops or “facilitators”

Examples:

• Mexico: media campaign orchestrated by El

Poder del Consumidor to counteract soda companies “scare tactics”

•Mexico: INSP evidence-based policy briefs to counteract industry lobbying

of legislators to reduce or repel the SSB‟s tax

•Chile: Reaching a compromise with food industry to be able to implement

modified FL & marketing law

• Argentina: Multisectoral dialogue to understand

different stakeholder‟s concerns to prevent negative feedback loops from

slowing process

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Emergent behavior refers to the spontaneous creation of order, which appears when smaller entities on their own jointly

contribute to organized behaviors as a collective

All four case studies are good examples of the CAS “perfect storm” that is needed to

happen for obesity prevention/ reduction policies to be implemented successfully

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Phase transitions occur when radical changes take place in the features of system parameters as

they reach certain critical or tipping points

Source: Diaz del Castillo et al. (2013)

Scientific evidence and evaluation played an important role in achieving tipping points for policies'

launch and sustain effective implementation.

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Same policies may need very different strategies to get them of the ground and then my follow very different policy

articulation and implementation patterns that are context specific (path dependence)

Examples:

• FL legislation in Chile vs. Ecuador (Lutter)

•SSB‟s taxes in Mexico vs. Berkeley CA (Falbe et al. 2015)

•Ciclovias in Bogota vs. Mexico City

Chile

Ecuador

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Conclusions

• Implementation of evidence-informed anti-obesity policies gaining momentum in Latin

America

• Translating science into policy is a highly complex multi-directional non-linear process (Pratt et al. Environment

& Behavior 2015)

• Need for multisectoral coordination of evidence-based policies that enable

environments conducive to healthy lifestyles (change the default)

• CAS scaling up frameworks needed to objectively assess readiness for and progress

with implementation of national evidence-informed anti-obesity policies

• Key goal: Shorten amount of time it takes for effective anti-obesity policy implementation to happen

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From Chile to Canada and beyond!

„New regulations, which corporate

interests delayed for almost a decade,

require explicit labeling and limit the

marketing of sugary foods to children.‟

New York Times https://www.nytimes.com/2018/02/07/health/obesity-

chile-sugar-regulations.html

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¡ Gracias!

twitter: @rperezescamilla