Mexico Attempts to Tackle Obesity: the Process, Results, Push Backs and Future Challenges

obesity reviews doi: 10.1111/obr.12096

Latin America Mexico attempts to tackle obesity: the process, results, push backs and future challenges

S. Barquera, I. Campos and J. A. Rivera

Centro de Investigación en Nutrición y Salud, Summary Instituto Nacional de Salud Pública, Mexico’s obesity prevalence is one of the world’s highest. In 2006, academics, and Cuernavaca Morelos, México federal and state government agencies initiated efforts to design a national policy for obesity prevention. The Ministry of Health (MOH) established an expert Received 13 August 2013; accepted 14 panel to develop recommendations on beverage intake for a healthy life in 2008. August 2013 Subsequently, the MOH, with support from academia, initiated the development of the National Agreement for Healthy Nutrition (ANSA). ANSA was signed by Address for correspondence: Dr JA Rivera, all relevant sectoral actors in 2010 and led to initiatives banning sodas and Av. Universidad no. 655. Col. Sta. Ma. regulating unhealthy food in schools and the design of other yet to be imple- Ahuacatitlan, Cuernavaca, Mor., Mexico CP. mented initiatives, such as a front-of-package labeling system. A main challenge of 62100, México. the ANSA has been the lack of harmonization between industry interests and E-mail: [email protected] public health objectives and effective accountability and monitoring mechanisms to assess implementation across government sectors. Bold strategies currently under consideration include taxation of sugar-sweetened beverages, improvement of norms for healthy food in schools, regulation of food and beverage marketing to children and implementation of a national front-of-pack labeling system. Strong civil society organizations have embraced the prevention of obesity as their goal and have used evidence from academia to position obesity prevention in the public debate and in the government agenda.

Keywords: Health policy, Mexico, national programmes, obesity.

obesity reviews (2013) 14 (Suppl. 2), 69–78

Public Health (INSP). Varying age–gender groupings were Introduction collected in the 1988, 1999, 2000, 2006 and 2012 national An estimated 75% of all deaths in Mexico are caused surveys. We combined these surveys to present an overall by noncommunicable diseases (NCDs), and obesity and picture of trends in overweight plus obesity (OW + O) unhealthy diet were among the six main risk factors for across time and the various age–gender groupings. We used mortality in 2010 (1). Projected healthcare costs of 13 the World Health Organization (WHO) deﬁnitions for obesity-related diseases in 2013 were estimated at US$880 risk of OW + O in children under 5 years (y) and OW + O million, with alarming projections for the next few years. in children 5 years and older and adolescents (>1 standard According to this study, if an effective policy does not deviation [SD] of the body mass index [BMI] 2006 WHO control this trend, in only 7 years, direct healthcare costs growth standards) (3) and the conventional cutoff point of will rise above US$1 billion (2). BMI ≥ 25 for adults. We use a common indicator, shifts in The prevalence of obesity in Mexico has been estimated the percentage points annualized (population prevalence from a number of national surveys implemented by the change per year). The prevalence of OW + O among Ministry of Health (MOH) and the National Institute of children under 5 years increased from 26.6% to 33.6%

© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd 69 on behalf of the International Association for the Study of Obesity. 14 (Suppl. 2), 69–78, November 2013 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. 70 Obesity prevention policies in Mexico S. Barquera et al. obesity reviews

Figure 1 Prevalence of overweight and obesity in children <5 years, children 5–11 years, adolescents (12–19 years), women (20–49 years) and adults (≥20 years), 1988–2012. between 1988 and 2012 (0.3 percentage point per year), lescents (12–19 years) the combined OW + O prevalence that among children 5–11 years increased from 28.2% to was 35.8% in women and 34.1% in men. Among adults 20 36.9% between 1999 and 2012 (0.7 percentage point per years and older, the prevalence of OW + O was 73.0% in year), and that among girls 5–11 years increased from women and 69.4% in men. The prevalence of abdominal 25.5% to 32.0% between 1999 and 2012 (0.5 percentage obesity (waist circumference ≥ 90 cm in men and ≥80 cm in point per year). Among female adolescents (12–19 years), women) (7) was 82.8% in women and 64.5% in men. the combined OW + O grew from 11.1% to 35.8% With these surveys we have been able to identify the between 1988 and 2012 (1.0 percentage point increase per regional distribution of obesity and the association with year), and among male adolescents (12–19 years) the com- other risk factors, sex, age group and socioeconomic status. bined OW + O grew from 33.0% to 34.1% between 2006 Some of the main conclusions of these studies are summa- and 2012 (0.2 percentage point increase per year). Among rized in Table 1A. adult women (20–49 years) it increased from 34.5% to To understand the environmental drivers of the increase 70.6% between 1988 and 2012 (1.5 percentage points per in the prevalence of obesity and mortality attributed to year), and among adult men (≥20 years) it increased from NCDs in Mexico, the INSP analysed national income and 60.7% to 69.4% between 2000 and 2012 (0.7 percentage expenditure surveys and other databases to explore trends point per year) (4–6). and patterns in food expenditure, transportation, leisure While no decline has been observed in spite of some time activities, and other factors associated with obesity attempts to control the problem, the rate of increase has and NCDs. One of the first findings (2002) was a dramatic dropped among adults in recent years, with an annual rise in consumption of sugar-sweetened beverages (SSBs). increase of 0.2% per year in women and 0.5 in men for the Between 1984 and 1998 we found significant decreases 2006–2012 period, in contrast to 1.2% per year in women in expenditures on some food groups, such as fruits and for the 1999–2006 period and 1.0% per year in men for the vegetables (−29.3%), dairy products (−26.7%), and meats 2000–2006 period. However, the prevalence has positioned (−18.8%), and an increase in expenditures on refined car- Mexico among the countries with the highest obesity rates bohydrates and sugars (6.3%) together with a very high (Fig. 1). increase in expenditures on SSBs (37.2%) (8). These studies According to the latest national health and nutrition identified important changes associated with the nutrition survey (ENSANUT 2012), the prevalence of OW + O transition that are summarized in Table 1B. (BMI >+2 SD) in Mexico among children under 5 years In this context researchers from the MOH identified the was 9.7% in 2012. Among the school-age population (chil- urgent need to develop and implement programmes to dren 5–11 years) the combined OW + O prevalence was control the increase in the prevalence of OW + O. In con- 34.4% (19.8% overweight and 14.6% obese). Among ado- trast with the comprehensive undernutrition, vaccination

© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd 14 (Suppl. 2), 69–78, November 2013 on behalf of the International Association for the Study of Obesity obesity reviews Obesity prevention policies in Mexico S. Barquera et al. 71

Table 1 The obesity problem in Mexico, nutrition transition–related factors, and opportunities for action

A. Characteristics of obesity in Mexico identiﬁed from surveys and mortality registries

1. Obesity is a highly prevalent health problem in all regions, age groups, and genders in Mexico (31). 2. The increasing obesity prevalence trends in 1999–2006 were among the highest documented in the world (32). However, between 2006 and 2012, this trend increased at a lower rate, probably because of a saturation of susceptible population effect (33). 3. Obesity’s prevalence is increasing at more alarming rates in the most vulnerable populations, such as those living in poverty and children (34). 4. Mortality associated with obesity is a significant percentage of the total national mortality (12.2%) (35). 5. The generalized obesity problem appeared in Mexico before the undernutrition problem was solved, and they still coexist. Undernutrition still affects important sectors of the country (36). 6. Obesity coexists with undernutrition within the most vulnerable communities of the country, within households, within families, and even within individuals (e.g. obesity with iron deficiency) (37). 7. Health expenditure is increasing at a significant rate because of obesity, and even small reductions in the prevalence of this condition would mean notable savings to the country (38).

B. Changes in the Mexican diet associated to the nutrition transition

1. Increase in the availability of low-cost processed foods with high quantities of sugar, fat and sodium (8). 2. Increase in fast food consumption and food consumption outside the home for a growing sector of the population (39). 3. Decrease in available time for food preparation (8). 4. Signiﬁcant increase in exposure to food and beverage marketing and to technology that decreases physical activity (40). 5. Increase in per capita income (38). 6. Increase in the availability and supply of ready-to-eat foods and processed foods in general (41).

C. Identiﬁed opportunities for action that could contribute to obesity prevention policies

1. Mexico is among the countries with the highest consumption of caloric beverages in the world. Caloric beverages contribute 20–23% of the total energy intake in the population (14,15). 2. Children spend only a few hours at school (about 4.5 h per day), but they have many opportunities to eat unhealthy energy-dense foods while there (42). 3. Food and beverage marketing to young children is not regulated to protect this vulnerable sector of the population (43). 4. Nutrition literacy is poor among the general population. Current labeling schemes are not useful, and the current Guideline Daily Amounts are confusing and misleading. There is a clear need for a labeling system that promotes better nutritional choices for the population (44). 5. Physical activity is very low across the country. Physical inactivity prevalence has increased since 2006 (45).

and infectious diseases programmes in Mexico, very little Mexico was invited to the Bellagio Conference on the nutri- was known about obesity-related NCD prevention (9,10). tion transition (11) and to the Inter-American Economic Diverse intervention opportunities were identified from the Forum (12) to prevent obesity. Later, the U.S. Institute of preliminary descriptive studies (Table 1C). Medicine and the INSP of Mexico conducted a workshop Thus, in 2006 various institutions, including the INSP, on preventing obesity in children and youth of Mexican the Mexican Social Security Institute (IMSS), one of the origin on both sides of the United States–Mexico border three main health systems in Mexico covering about one- (13). This consensus recognized the need to focus on pre- third of the Mexican population, and other federal and vention and use a multifaceted approach and highlighted state government agencies, initiated efforts to design a the importance of targeting children, because interventions national policy for the prevention and control of obesity- on other age groups had not achieved positive results at the and nutrition-related diseases. The objective of this paper time of the workshop. Also the IMSS started its own pre- was to briefly describe some of the main efforts in Mexico ventive programme (PrevenIMSS) with a significant invest- to control the problem and the processes and challenges ment in the media, including TV advertising, but there was involved. little coordination with similar actions developed by the other two main health systems in Mexico (the MOH and the system covering government employees). Although the Attempts to tackle obesity PrevenIMSS programme achieved recognition among the In 2005, in response to the increase in obesity in Mexico population, investing in a unified national campaign that and the high mortality rates attributable to obesity-related included the three main health systems would have pro- diseases, some important programmes were put in place. duced even more noticeable and sustainable results.

© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. 2), 69–78, November 2013 72 Obesity prevention policies in Mexico S. Barquera et al. obesity reviews

Figure 2 Healthy beverage pitcher.

the effects of caloric beverages on health, building on and Mexican beverage guidelines for healthy hydration updating a review in which two of the panel members had In 2007, using a recent national survey (ENSANUT 2006), participated. In addition it reviewed the patterns of beverage we analysed beverage consumption trends between 1999 consumption in Mexico using ENSANUT 2006 and other and 2006 among children, adolescents and adults. We databases. The committee developed Mexican recommen- documented that over 20% of the total energy intake in the dations for healthy hydration (17). The report recom- Mexican population was provided by beverages. Moreover mended that less than 10% of an individual’s energy intake a very high increase in consumption of caloric beverages for should come from beverages and that SSBs should be the 1999–2006 period was documented (226% increase avoided or consumed sparingly. One of the unexpected among children and adolescents and 252% among adults) successes of this initiative was the development of a graphic (14,15). The 2006 survey documented a significant contri- representation of the recommendations called the ‘healthy bution of sodas to total energy intake starting at 12 years of beverage pitcher’ (Fig. 2). This representation was immedi- age. In addition there are many other caloric beverages in ately distributed through social networks and other media the Mexican diet, such as fruit juices, sugar-sweetened in spite of strong opposition and pressure on government coffee and sugar-sweetened flavored drinks (such as lemon- officials from the soda and other beverage industries. The ade and hibiscus- or rice-flavored drinks, called aguas healthy beverage pitcher is now part of the textbooks and frescas). Using this evidence and international studies asso- curricula of the national primary education system. ciating SSB consumption with obesity, scholars proposed This experience provided some preliminary lessons that actions to promote water consumption as the best hydra- were useful for subsequent initiatives. Among the most tion alternative. important factors that contributed to the success of this Responding to concerns about the increasing rates of process were: obesity and chronic diseases and given that SSB consumption was already a known risk factor for obesity, the MOH 1. The international independent expert panel appointed in 2008 established an expert panel to develop recommen- by the MOH based on scientific merit worked pro bono dations on beverage intake for a healthy life (16). This panel and without conflict of interest. This gave legitimacy to the conducted an extensive review of the published evidence of proposed decisions.

2. The characterization of beverage consumption was facilitating the regulatory and educational work of the based on nationwide representative dietary data and was government. In conclusion, much positive feedback has published in international journals (14,15). been generated, and the Mexican minister of health has 3. The expert panel published its conclusions in the expressed his commitment to maintaining these recom- most widely read public health journal in Mexico (17) mendations (16). and received positive comments from Latin American experts (18). 4. The analysis was presented at international scientific National agreement for healthy nutrition meetings, giving it exposure and providing opportunities The MOH, with support from the INSP and other scholars, for scholars from various countries to discuss the issues. developed the National Agreement for Healthy Nutrition 5. The beverage recommendations received important (ANSA). The ANSA is founded on the WHO Global Strat- attention from healthcare professionals and the soft drink egy on Diet, Physical Activity and Health (19). The process and milk industries. The Mexican minister of health con- included a review of the risk factors for obesity and NCDs tributed an editorial in which he endorsed the recommen- and recommendations from international agencies and dations by the panel and underlined the importance of governments and an international meeting of experts to water as the principal source of hydration (16). discuss the reviews and identify lines of action. They agreed 6. The healthy beverage pitcher was promoted via on the need to create a comprehensive, multisectoral, posters and publications for all health sectors. multilevel policy with participation of the government and In general the support of the Mexican medical community civil society, including industry, non-governmental organi- was unprecedented, and the Inter-American Heart Foun- zations (NGOs), and academia. dation, the Society of Endocrinologists and Nutritionists, Ten objectives were identified for a national policy aimed the Mexican Diabetes Federation, the College of Internal at preventing obesity and NCDs (Table 2). Some objectives Medicine, the Mexican Association of Cardiologists, and require government programmes aimed at behavioral the Academy for the Study of Obesity in Mexico all changes at the individual level. Others require that the endorsed the healthy beverage pitcher. This endorse- federal and state governments work with the food industry ment from the most influential medical societies in turn to achieve healthy food alternatives. Most of the govern- encouraged strong support among physicians and health ment sectors and agencies related to food and nutrition professionals. identified goals and deadlines. Although special interest groups, such as associations of One of the main challenges of the ANSA has been the soda and milk producers, voiced opposition, consumer lack of harmonization between industry interests and groups in Mexico welcomed this initiative and provided public health objectives. This has been a barrier to agree- support through their communications networks and ments with the food industry regarding specific goals and media productions. We expect that in the future the afore- deadlines to achieve the ANSA objectives. Regulation of mentioned efforts will stimulate consumer demand for advertising and sugar, fat, and sodium content and other healthier beverage products from the food industry, proposed actions are perceived by industries as a threat to

Table 2 National Agreement for Healthy Nutrition: Ten strategic objectives that address the obesity problem integrally

1. Promote physical activity among the Mexican population in the school, work, community and recreation environments through the collaboration of the public, private and social sectors 2. Increase the availability, accessibility and consumption of plain drinking water 3. Reduce fats and sugars in beverages 4. Increase daily intake of fruits and vegetables, legumes, whole grain cereals, and ﬁber by increasing their availability and accessibility and promoting their consumption 5. Improve the public’s ability to make informed decisions about a proper diet through useful, easy-to-understand labeling, thereby promoting nutritional and health literacy 6. Promote and protect exclusive breast-feeding for the ﬁrst six months of life and complementary adequate feeding afterward 7. Reduce consumption of sugars and other caloric sweeteners added to foods and increase the availability and accessibility of low- or no-calorie sweeteners 8. Decrease daily consumption of saturated fats and minimize consumption of trans fats from commercial sources 9. Educate the public about controlling the recommended portion sizes in foods prepared at home and in permitted processed foods and encourage restaurants and food outlets to offer smaller portion sizes 10. Reduce daily sodium intake by reducing the amount of added sodium in foods and increasing the availability and accessibility of low- or no-sodium products

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their profits. This is not necessarily true. With innovation, to MOH and MOE negotiations with the food industry and creativity, standardization of rules, and gradualism, the other interest groups, which resulted in the elimination of food industry could handle the challenges of more controls the energy–density criterion and changes in the upper limits and at the same time accelerate the development of prod- for sugar and saturated fat. Although soda was banned ucts with a better nutritional profile. The economic impact from schools, despite strong opposition from the soda of high consumption of energy-dense food high in sugar, fat industry, other SSBs, including juices and flavored waters and sodium is of critical importance. The state cannot with some amount of juice, and milk were allowed. abdicate its responsibility to protect the health of the popu- The public hearing and the negotiations stimulated the lation through the implementation of mechanisms and con- interest of NGOs engaged in preventing obesity and pro- trols similar to those suggested by the ANSA. moting children’s rights, among other convergent problems. Recent evaluations of the implementation of this initiative have identified challenges, including (i) the need to reduce School guidelines for foods and beverages the sales of salty snacks from the average of more than three One of the direct results of the ANSA was the development times per week in most schools; (ii) banning the sales of SSBs of school food and beverage guidelines by the Ministry of that are currently not banned; (iii) increasing water avail- Education (MOE) and the MOH based on criteria sug- ability and promoting its consumption; (iv) assuring funding gested by scientific evidence and the consensus of a group for comprehensive evaluations of the programme and (v) of nutritional experts from more than 15 national and guaranteeing the commitment of the new administration to international institutions and organizations. These guide- maintaining and improving the programme. lines promote the daily intake in schools of healthy foods, such as fruits, vegetables, and water; ban sodas; limit the Front-of-package (FOP) labeling system availability of other SSBs, whole milk, salty and sweet snacks, and desserts that comply with nutritional criteria The FOP labeling systems are a new trend in the promotion developed by the expert group to a maximum of two days of healthier food choices among consumers, regardless of per week; and eliminate the products that do not comply their levels of education. Internationally, these systems are with the nutritional criteria. The gradual implementation one of the key tools. The evidence demonstrates that con- of the guidelines was initiated in January 2011 with the sumers have difficulty interpreting the labels on the backs expectation that implementation will be completed in of processed foods. Thus a number of FOPs have been 2014. This gradualism was designed to allow time for created around the world. A group of transnational food the parties involved to improve the nutritional quality of industries created a system known as the Guideline Daily school foods. Amount (GDA) to be a rapid guide for consumers and as an The process from the development of the proposed regu- alternative to other FOPs. A useful FOP must be simple and lations to their approval highlights the role of the food must be established by a group independent from the food industry in opposing regulation aimed at improving the industry. In developed nations GDAs have been criticized health of the population. For example, the experts pro- for their complexity (20–22). A recent evaluation con- posed limits for added sugar, salt, saturated fat, trans-fatty ducted by the INSP and the MOH found that the GDAs acids and total calories. They also proposed the elimination are not useful guides for better nutrition choices among of all caloric beverages and the use of an energy-density consumers in Mexico (23). This study demonstrated that criterion to limit the availability of high-energy snacks GDAs are misleading, and other authors in developed served in small portions, because children could purchase countries have arrived at the same conclusion. In response, more than one portion of these products. The legal process the Mexican government established its own independent, for new regulations in Mexico includes a public hearing pro bono, international scientific committee to develop an administered by the National Commission for the Improve- FOP. After reviewing alternatives, the Mexican expert ment of Regulations (NCIR). The public hearing resulted in group decided to develop a system similar to the one 842 comments, with almost two-thirds (63%) in support known as Choices International, but adapted to the food and one-third (37%) against the regulations. However, groups currently available in Mexico. This system awards a 99% of the food industry’s comments were against the voluntary ‘seal of recommendation’ to the top 20% of regulations, while 86% of those from the social and aca- foods in each food group with the best nutritional profiles. demic sectors supported the regulations. However, despite The criteria that define the profiles, contrary to the GDAs, the wide social support for the implementation of the origi- are determined by an independent expert group and evalu- nal proposed regulations, the NCIR made a preliminary ate contents identified by the WHO as problematic for ruling rejecting the original proposal and instructing the health (sugar, fat, and sodium) in addition to the total MOH and the MOE to address the specific questions and energy content. The INSP is working to refine the system so issues raised by industry during the hearing. The ruling led it can be launched as soon as possible.

Regulation of marketing of foods and beverages to Conclusion: evidence-based policy children and adolescents formation model

The ANSA identified food and beverage marketing, in par- The Mexican government has considered several actions ticular when it is addressed to adolescents and children, as to make it easier for the population to develop healthy a factor underlying unhealthy nutritional choices. Mexico eating habits, including (i) the Mexican national beverage is collaborating with the Pan American Health Organiza- guidelines; (ii) a multisectoral national obesity prevention tion (PAHO) task force to control food marketing to chil- strategy based on the ANSA but providing a budget, dren and adolescents. The task force recently released a accountability mechanisms, and intersectoral coordination; report on the best practices countries should adopt to (iii) the school guidelines for healthy foods; (iv) the protect children from unhealthy choices that might com- Mexican FOP and (v) the regulation of food and beverage promise their health (24). marketing to children. These recommendations were pub- In Mexico, the food industry proposed a self-regulatory lished in the position book developed by the Mexican code for marketing known as the Self-Regulatory Code National Academy of Medicine (27). In addition a national of Advertising of Food and Non-Alcoholic beverages. food and nutrition education strategy is necessary to Addressed to Children. This code is insufficient and is far educate the population about the risks of consuming SSBs for complying with the PAHO recommendations. In its and energy-dense foods, particularly ultraprocessed prod- current form it will hardly protect children and adoles- ucts, and the government must encourage the food industry cents from exposure to marketing campaigns for junk to provide healthy, low-cost alternatives. food. For instance, there is no penalty for advertising The documented processes represent, to our knowledge, unhealthy foods on TV, for products or fast food chains some of the best practices in evidence-based health policy in to give toys or incentives, or for animated characters to Mexico, characterizing the problems and opportunities by promote products to school-age children. The interna- using updated, nationally representative data; forming an tional consensus is that advertising is of strategic impor- international independent, pro bono expert panel; adapting tance for health and that it has to be regulated by international evidence to the local context; and translating the state. This has already been accomplished in some recommendations into policies and programmes. Thanks to countries. these efforts, important modifications are already taking place. These include the food and beverage regulations in the school system, including the ban on soda sales, the Soda taxation initiatives reduction of fat in the milk distributed by the government Mexico is the leading country in the world in the consump- through social programmes for vulnerable and low- tion of SSBs, with an estimated intake of 163 L per person socioeconomic populations, and the provision of nutrition per year (25). There have been attempts in Mexico to tax information to policy makers in congress who are develop- sodas as a strategy to reduce SSB consumption in the popu- ing initiatives and to consumers to make better nutrition lation and to generate revenue to use on obesity prevention choices, among many other activities. interventions among the poor, such as the introduction of Some recommendations for an effective obesity preven- potable water in schools and poor communities, where tion policy in Mexico are summarized in Table 3. Mexico is clean drinking water is not always available. The INSP has facing a burgeoning epidemic of obesity, diabetes, coronary estimated own and cross-price elasticities of the demand for heart disease and cardiovascular disease. The evidence indi- soft drinks and other SSBs and has explored the effect of a cates that this epidemic is related to changes in the social tax on beverage expenditures according to income level (26; environment that could be ameliorated with the leadership Colchero, unpublished data). Results of a recent analysis of the MOH in developing laws, norms and regulations indicate that the demand for soft drinks is elastic: a 10.0% supported by an effective nutrition education programme increase in the price of soft drinks is associated with a to encourage the population to adopt a healthy lifestyle. decrease in consumption of 10.1% (Colchero, unpublished Decreasing consumption of caloric beverages and energy- data). Consumers substituted water and milk when the dense foods is an essential part of the solution. The priority price of soft drinks rose. Higher elasticities were found programmes of the MOH and the MOE must include ini- among households in more deprived areas and from the tiatives to increase the consumption of water in schools and lowest income quintiles. Despite these results, the tax ini- to improve the quality of the food available to students. tiative so far has not been approved by the congress due to The development of evidence-based policies is essential, strong lobbing from the food industry. It is important to but it is not enough. Adequate intersectoral coordination build support and to achieve coordination between the and cooperation among governmental agencies is complex government sectors involved in the tax initiative and civil and requires the participation of key policy makers. For society to pass a bill soon. example, we have been collaborating with the Ministries of

© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. 2), 69–78, November 2013 76 Obesity prevention policies in Mexico S. Barquera et al. obesity reviews

Table 3 Recommendations for an effective policy

1. Address explicitly not only the basic causes of obesity, but also the ones related to an obesogenic environment as part of a policy specifically designed to improve nutrition and physical activity in the population across all age groups. 2. Consider the ANSA as a part of the National Development Plan, provide a budget and a plan for follow-up able to transcend administrative changes with an intersectoral commission, and create a forum with food industry oversight. 3. Achieve adequate coordination of the government sectors at the federal, state, and local levels and with civil society. The ANSA represents a good attempt to coordinate government efforts and could become a good model if a budget is assigned and instruments to monitor goals and accountability are implemented. 4. Develop a system to monitor results, the activities of the government, and compliance with the regulations by the food industry and to review periodically the ANSA commitments and their correct implementation. 5. Assure that all prevention programmes include actions during the first years of life, a window of opportunity to decrease the risk of obesity, and address all socioeconomic groups and geographic regions. 6. Assure that the prevention programme designs consider social and cultural factors that influence behavior to achieve a high utilization of health services and adoption of healthy food and physical activity habits. 7. Develop a norm to regulate food and beverage marketing to children and adolescents. This is a crucial issue in obesity prevention and should not be a self-regulatory code. Marketing strategies can influence adoption of unhealthy food patterns that might impact health throughout the life cycle. 8. Develop a healthy diet–promotion strategy through nutritional education and other actions to recover and preserve traditional culinary roots. 9. Develop a single national voluntary front-of-package labeling system that is easy for the population to understand, in particular the poor and that orients the public towards healthier food choices.

ANSA, National Agreement for Healthy Nutrition.

Education, Agriculture, Social Development and Econom- the intake of sugar, salt, fat and sodas. Several academic ics to organize unified messages to citizens and unified groups, including ours, are documenting these ongoing approaches to negotiate with the food industry. Some of the campaigns. early initiatives were not discussed extensively with nutri- Funding agencies can play an important role in the pre- tion leaders, and consequently, some felt excluded and did vention and control of obesity in low- and middle-income not support them. In contrast, when initiatives included countries. An example is the Bloomberg Philanthropy’s consultation with nutrition and health leaders, support was (BP) model in its public health programme, which has almost universal. We learned that a series of small group supported initiatives in tobacco control, road safety, and meetings to present the recommendations of the expert maternal health through funding academic institutions, panel were beneficial in obtaining valuable feedback and advocates, government offices, and networking activities. building the consensus and support required to institute BP funds academic institutions to generate evidence that governmental policies. can be useful for designing policies and programmes and Finally, despite industries’ declarations of a commitment for monitoring and evaluating such initiatives. NGOs are to health, the strong opposition from some industrial seg- funded to advocate for the implementation of evidence- ments, such as industrialized food and beverage associa- based strategies for the prevention and control of health tions, confirms that commercial interests prevail over problems, and government offices are funded to improve health concerns at both the international and the national implementation of such policies and programmes. BP has levels. However, we anticipate that the Mexican process, started a pilot programme in Mexico on obesity prevention together with similar experiences in other parts of Latin that uses this funding model that has been successful in America, will motivate both the government and the food other areas, and it has started to show promising results. industry to encourage healthier behaviors and develop In 2010, when the ANSA was approved, there were no healthier products. explicit obesity prevention policies in Mexico. Thus the NGOs have played an important role in this process. The Mexican experience is very brief. In this short time, Mexican Alliance for Healthy Nutrition (28), a consortium however, we have been able to identify accomplishments, representing more than 20 NGOs, has launched a very failures and challenges. effective media campaign against sugary beverages (29) The intersectoral agreement (ANSA) was signed by all using nontraditional media, such as social networks, bill- relevant actors with the president of Mexico as the witness; boards and posters in subway lines, as well as traditional however, its implementation has limitations because of media coverage. structural weaknesses. The school food regulations were The food industry, without independent academic approved despite the strong opposition of the food industry support, established the Alliance for a Healthy Life (30) and have been implemented during 3 years, although to promote GDAs that emphasize energy balance instead there are still some implementation challenges. The self- of the government recommendations that would limit regulatory code for marketing to children has design flaws,

because it does not comply with international standards, acknowledge the Canadian Institutes of Health Research such as the ones proposed by the WHO and the PAHO for added research support. (24). The FOP labeling and the soda tax initiatives failed to be enacted due to opposition from the food industry. The initiatives have faced two principal barriers. (i) The Conflicts of interest food and beverage industries have put up strong opposi- The authors have no potential conflicts of interest to tion. Given its economic power and the lack of harmoni- declare. zation between its economic interests and the public health objectives, this sector has opposed most government efforts and has successfully prevented FOP labeling, the regulation References of marketing to children according to international stand- 1. The Burden of Disease Project, 2010. [WWW document]. URL ards, and the soda tax bill. (ii) Government limitations, http://www.healthmetricsandevaluation.org/gbd/visualizations/ including poor planning capacity, lack of accountability gbd-arrow-diagram (accessed September 2013). and transparency, inadequate budgeting, and insufficient 2. Rtveladze K, Marsh T, Barquera S, Sanchez L, Levy D, resources, have been an obstacle for the implementation of Melendez M. Obesity prevalence in Mexico: impact on health and the ANSA and have put constraints on the implementation economic burden. Public Health Nutr 2013; 1: 1–7. 3. De Onis M, Onyango A, Borghi E, Siyam A, Nishida C, of the school regulations. In some cases unwillingness to Siekmann J. Development of a WHO growth reference for school- protect the public interest from influences that oppose aged children and adolescents. Bull World Health Organ 2007; 85: health policies has been a factor in the failure to enact some 660–667. policies. 4. 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Energy intake from beverages is increasing among support of all phases of final paper preparation. We also Mexican adolescents and adults. J Nutr 2008; 138: 2454–2461.

© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of the International Association for the Study of Obesity 14 (Suppl. 2), 69–78, November 2013 78 Obesity prevention policies in Mexico S. Barquera et al. obesity reviews

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