The Transition and Global Food System Dynamics: The Accelerating Speed of Change and Global Challenges We Face for Creating a Healthier Global Diet Barry Popkin W. R. Kenan, Jr. Distinguished University Professor Department of Nutrition Gilling's School of Global School of Medicine Department of Economics The University of North Carolina at Chapel Hill

THE W RLD IS FAT Outline: Why Do We Need Large-Scale Changes to Improve Our Diets?

• Introduction: the nutrition transition and major mismatches: modern technology vs. inherited biological preferences • Physical activity: a major concern but not the solution • The modern food system and how it has shaped our diet • Major dietary shifts of the past 2-3 decades • Regulatory and tax options: global lessons from Chile and Mexico • Chile may be the first country to reverse and all the -related NCDs, but there are key gaps to fill. Role of Our History

Mismatch: Biology which has evolved over the millennia clashes with modern technology

Core biochemical and Biology Evolved Over Modern Technology has taken physiologic processes 100,000 Years advantage of this biology have been preserved Sweet preferences Cheap caloric sweeteners, food from those who processing create habituation to appeared in Africa sweetness between 100,000 and Thirst, hunger/satiety Caloric beverage revolution, sweetening 50,000 years ago. mechanisms not linked of beverages consumed Fatty food preference Edible oil revolution — high yield oilseeds, cheap removal of oils, modern processed food/restaurant sector Desire to eliminate Technology in all phases of work and exertion movement reduce energy expenditure, enhance sedentarianism Stages of the Nutrition Transition

Urbanization, economic growth, technological changes for work, leisure, & food processing, mass media growth

Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 5 Collecting Food Famine Receding Famine Chronic Disease (NCD’s) Behavioral Change

• Diverse wild plants • Monoculture ag. • Starchy, low • Increased fat, , • Reduced refined carbs, sugar & animal food diet • Cereals variety, low fat, processed foods diet • Unhealthy fats↓, increased high fiber diet • Drink water dominate diet • Drink sugary fruit, veg, whole grains, • Labor-intensive • Drink water • Drink water beverages, juices legumes • Shift in technology • Labor-intensive • Labor-intensive • Drink water, low kcal bev. work/leisure of work and leisure • Sedentarianism high • Replace sedentarianism with purposeful increases in activity

Lean & Nutritional MCH deficiencies, Obesity & NR-NCD Reduced body fatness robust, tall, deficiencies weaning disease, emerge, and medical & NR-NCD’s, improved high disease emerge, stature stunting cures keep us alive disease prevention rate declines

Low fertility, High fertility, high Slow mortality Accelerated life expectancy, Extended healthy aging, low life expectancy MCH mortality, decline shift to increased NR-NCD, reduced NR-NCD low life expectancy increased % disability years

Source: © (copyright) Barry M. Popkin, 2015 The Struggle Over the Millennia to Eliminate Arduous Effort Could Not Foresee Modern Technology US Adults MET-hours/Week of All Physical Activity, and Hours/Week of Time in Sedentary Behavior: Measured for 1965-2009 and Forecasted for 2010-2030 250 45 1965: 235 MET-hr/wk

40

200 2009: 160 35 MET-hr/wk

by 2020: 142 30 MET-hr/wk 150 by 2030: 126

MET-hr/wk 25

hours per week per hours - 20 100 15

Active Leisure PA Average MET Average 10 50 Travel PA Domestic PA

Occupational PA 5 Average hours per week being sedentary being week per hours Average Sedentary Time (hrs/wk) 0 0 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 Year

Source: Ng S.W. & Popkin B.M. Time use and physical activity: A shift away from movement across the globe. Obesity Reviews 13 (8):659-80 Chinese Adults Met-hours/Week of Physical Activity & Hours/Week of Time in Sedentary Behavior: Measured for 1991-2009 and Forecasted for 2010-2030 450 30 1991: 399

MET-hr/week

400

25

350 20

300

hours per week per hours 15 - 2009: 213 MET- 250 hr/week

by 2020: 200 by 2030: 188 MET-hr/week MET-hr/week 10 200 Active Leisure PA

Average MET Average Travel PA 5

150 Domestic PA Average hours per week bring sedentary bring week per hours Average Occupational PA Sedentary Time (hrs/week) 100 0 1991 1994 1997 2000 2003 2006 2009 2012 2015 2018 2021 2024 2027 2030 Year

Source: Ng S.W. & Popkin B.M. Time use and physical activity: A shift away from movement across the globe Obesity Reviews 13 (8):659-80 Global TV Viewing Time of Adults

India China Brazil UK US 60

50

40

30

20 Sedentary Time (hrs/wk) Time Sedentary

10

0 1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011 2016 2021 2026 2030

Source: Ng S.W. & Popkin B.M. Time use and physical activity: A shift away from movement across the globe Obesity Reviews 13 (8):659-80 Physical Activity: A Major Cause, Not a Solution

• Our work in China and elsewhere has convinced me that a major component of global obesity increase is linked with reduced physical activity at work, home, and transport along with increased sedentarianism • At the same time we cannot turn back the clock on technology at work, home, transportation, leisure • Thus the need is to create new activity—marginal gains at work and home, but major increased activity must come from purposeful recreational movement, energy expenditure. Very hard to offset modern diets’ effects. Diet: Major Conflict among Diet People

• Most dietary guidelines focus on increased produce, whole grains, minimal red meat, healthy fats, more plant food. • Michael Pollan: “Eat food. Not too much. Mostly plants.” • Monteiro, PAHO guidelines, others pushing the same, possibly could interpret PREDIMED results similarly as a push for minimally or unprocessed food-based diet • The reality: the enormous rapid shift in our food system discussed next runs completely counter to these pushes. • Unanswered question: Can we have any type of highly processed foods as part of a ? Or does such a diet with excessive highly processed food even exist? • All this is being played out in nutrient profiling and FOP policies will note later but seeing negative and positive logos as separate but joint efforts emerging finally to address both sides of this issue— remove junk food, promote truly healthy food. What is driving our increased obesity globally

• The modern agricultural and entire food system has changed remarkably not only in the US and higher income countries but globally. • Every village, location in the world now faces many of the same packaged and processed junk foods and beverages Stages of Modern Global Agricultural and Food System’s Development Scientific and technological change, economic change, ,

Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6 1800’s mainly 1900-1944 Post WWII massive investments Systematically Commercial sector shifts Healthier food scientific underpinnings modern system transmitted globally major drivers of system supply (1955-2008) change (present)

Create the modern Retailers, agricultural Price incentives, taxation, Farm research, Expansion food system focused input & processing, other regulatory controls Science and extension systems, technologies; on staples, animal businesses, and food (e.g. marketing healthy institution building and education mirror food only) and system source foods, and manufacturers science those of the West investments cash crops dominate farm-level decision-making

Fossil energy, Extensive funding for Food industry Investment training, modern genetics, Expansion of major infrastructure, institutions, infrastructure, farm links drive Investments in fertilizer, beginning science; develop systems, input and CGIARC (Consortium production and infrastructure agricultural science reaper; many enhanced seeds, marketing Global International and training and experimental other technologies and major technology Agricultural Research) decisions, work, & land development incentives and grant/agricultural economic universities drivers change Farming systems High income countries see Reduced Green revolution, rapid mechanization; noncommunicable developed; irrigation, credit, farm Farming remains Production linked to diseases, reduced underpinnings post development of new food extension, and the major source of the needs of food climate footprint, WWII revolution processing technologies (e.g. agricultural institutions manufacturers and achieve total the food supply; extraction of edible mirror those of the added modernization retailers, ignoring industrial/large- oils from oilseeds); and west; modernizing of sustainability, fewer of agricultural climate, sustainability, scale monoculture investment in transportation/ food processing animal source foods production inputs and health concerns initiated irrigation/electrification/ consumed and machinery modernization of agriculture

Source: © (copyright) Barry M. Popkin, 2015 See Anand,Hawkes et al, J Am College Card (2015) 66; Popkin (2017) Nutr Reviews Major Food System Changes Occurred Different Times, Similar Now

Four big players drive food • Global agribusinesses and agricultural systems in • Retailers LMICs and the US: • Food manufacturers (agricultural economists have documented) • Large restaurant chains

• Trend in disappearing fresh markets being replaced by small stalls, convenience stores and supermarkets  all selling ultra-processed foods and beverages • Mexico and China: packaged foods with bar codes based on nationally representative 24-hour recalls surveys with questions probing this issue – 58% of kcal Mexico in 2012 and 29% in China in 2011 (growing by 50%/year) • Latin America/Gulf states: first major growth, now Asia and urban Africa; high penetration into all African and Middle East communities now • Major shifts in types of foods and integrated marketing strategies used by food industry sectors across global regions with Latin America being penetrated most completely and earlier than Africa and Asia

Source: Popkin BM. Nutrition, Agriculture, global food systems in LMIC’s Food Policy (2014) 14;47:91-96; Zhou et al (2015). The food retail revolution in China and its association with diet and health. Food Policy 55:92-100. Retail Sector and Processed Foods are a Post-WWII Phenomena: The Mega Chains and Global Growth • Walmart: completely post-WWII phenomena with all growth from 1970 onwards • Carrefour: 1960’s onward • Ahold: (began as Albert Heijn) and expanded in early 1900’s, as did Tesco with basic foods.

• Most major growth as chains occurred after WWII

• Our focus is not only on these global chains but all the domestic clones across the globe in low and middle income countries • Packaged processed food growth, especially highly or ultra-processed food is mainly a recent phenomena of the last 30-50 years with modern food science and related food manufacturer revolution. Evolution of Human Experience with Food Ultra-processing Industrial • Old and accumulative process ingredients, biochemicals, • Increase penetration of the matter genetics

• From domestic & artisanal to industrial Pasteurization, canning, roller mills Mass Pounding, Granaries, production grinding, agriculture, of oil, salt roasting, husbandry, & sugar wetting, pottery boiling, Large Butchering, fermenting granaries smoking & of seeds drying and acorns of meats Cooking

By Jean-Claude Moubarac

Paleolithic Neolithic First Industrial Post-war/global 2 mya 12 000 - 2000 BC States 1780 1950-2013 300 000 BC

From Jean-Claude Moubarac • Income • Culture • Market-Based Food Systems • Income • Modernity • Convenience Degree of processing: Classification

Category Definition Examples Unprocessed/ Single foods, no/very slight Fresh or frozen produce, milk, eggs, minimally processed modifications fresh meat Basic processed Single foods, processed – Sugar, oil, flour, pasta, white rice, A) isolated food components or unsweetened canned fruit, veggies B) modified by preservation methods canned without salt Moderately Single foods with addition of flavor Salted nuts, fruit canned in syrup, processed additives veggies canned with added salt, whole-grain breads/cereals with no added sugar Highly processed Multi-ingredient industrially Refined-grain breads, cookies, sugar- formulated mixtures sweetened beverages, salty snacks, candy, ready-to-eat cereal, ketchup, margarine, pre-prepared mixed dishes

Poti J, et al. Am J Clin Nutr 2015. Convenience classification

Category Definition Examples Requires cooking Not consumed as purchased, Flour, dry pasta or rice, oil, eggs, fresh and/or preparation requires significant input of potatoes, uncooked meat, mixes for consumer’s time, culinary skill, grain-based desserts or pancakes, energy, or attention to cook/prepare some fresh veggies Ready-to-heat Not consumed as purchased, Frozen dinners or pizza, frozen (RTH) requires only a small amount of waffles, canned soup, hot dogs, consumer’s time or effort during prep instant oatmeal, canned or frozen (e.g., by microwaving) vegetables Ready-to-eat (RTE) Can be consumed immediately with Bread, salty snacks, milk, candy, pre- no preparation made cookies, most fresh fruit, canned fruit, baby carrots, sugar-sweetened beverages, ready-to-drink beverages

SSB: sugar sweetened beverages Poti J, et al. Am J Clin Nutr 2015. Trends in CPG Food and Beverage Purchases by Degree of Processing (1.4 million barcoded products)

1400 Category Top contributors (per capita kcal/d) 10.4% 9.9% 9.9% 1200 10.5% Milk, eggs, fresh/frozen veggies, unsalted Minimally nuts, fresh/dried fruit, whole-grain hot 12.9% 12.6% 14.6% processed cereal, dried beans

1000 12.6% *

13.6% 15.3% 15.3% Basic Sugar, oil, flour, pasta, 15.9% *

800 processed unsweetened fruit juice, white rice kcal/day Salted nuts, peanut butter, potato chips, 600 Moderately cheese, butter, fruit canned in syrup, processed

Per capita capita Per sweetened juice, seasoned or cured meat 62.0% 62.3% 400 61.4% 61.0% Refined bread, grain-based desserts, Highly SSBs, salty snacks, candy, cereal, ice 200 processed cream, prepared meals, condiments, sauces, margarine, processed meat 0 2000 2004 2008 2012 Nationally representative weighted unadjusted mean kcal/d per person and % kcal/d of food and beverage purchases from each category defined by degree of processing or convenience among US households.

Poti J, et al. Am J Clin Nutr 2015. Trends in CPG food and Beverage Purchases by Level of Convenience (1.4 million barcoded products)

1400 Category Top contributors (per capita kcal/d)

Requires Oil, flour, pasta, eggs, grain-based 1200 15.9% 15.9% 16.2% dessert mixes, some fresh veggies, 16.7% cooking and/or pancake/biscuit mixes, boxed mac-and- 1000 14.3% 13.1% 15.3% preparation cheese, rice, uncooked meat 15.2% *

800 Frozen pizza, frozen meals, prepared Ready-to- mixed dishes, frozen waffles or pancakes, canned soup, hot dogs, 600 heat (RTH) instant oatmeal

Per capita kcal/day capita Per 70.9% 69.9% 68.6% 68.1% * 400 Salty snacks, bread, RTE grain-based desserts, milk, sugar, SSBs, candy, Ready-to- butter, margarine, cereal, condiments, 200 eat (RTE) nuts, peanut butter, ice cream, cheese, juice, fruit, some veggies 0 2000 2004 2008 2012 Nationally representative weighted unadjusted mean kcal/d per person and % kcal/d of food and beverage purchases from each category defined by degree of processing or convenience among US households.

Poti J, et al. Am J Clin Nutr 2015. Sources of Major Global Dietary Shifts Global increases in: • Use of added caloric sweeteners, especially beverages but increasingly all packaged foods consumed • Refined carbohydrates, ultra-refined highly processed foods. • Animal source foods • Convenience foods for snacking, away-from-home eating, precooked/uncooked ready-to-heat food • Large increase in edible oil used to fry foods (unique to LMICs) Global decreases in: • Legumes, vegetables, fruits in most countries • Food preparation time

First Major Global Shift: Sweetness, Added

• Always loved sweetness and as fruit provided unique source of nutrients. • Mattes, Rolls others showed the way on what we drink affects us differently than sugar in food. • Amount of added sugar in our food supply is surprising—not only for taste but also other properties The Proportion of CPG Products with Unique Formulations by Weight Containing Any Sweeteners in the United States (nationally representative sample of food purchases)

100% 3 2 2 2 4 5 7 9 90% 15

80% Any FJC 70% 63 58 63 60 55 66 66 51 Both NS and NNS 60% 45

50% NS only

40% NNS only 5 0 9 14 12 30% 3 6 0 0 No added

sweeteners by weight by sweeteners sweeteners 20% 34 30 32 31 31 29 28 26 28

10% % of unique formulations containing formulations unique of %

0%

2000 4,666) (N= 2006 9,371) (N=

2013 (N=16,512)

2000 40,562) (N= 2006 76,971) (N= 2000 35,896) (N= 2006 67,600) (N=

2013 (N=113,015) 2013 129,527) (N= All CPG Foods & Beverages Foods only Beverages only

NS= Nutritive/Caloric Sweetener, NNS= Non-nutritive/non-caloric sweetener, FJC= Fruit Juice Concentrate (excluding lemon/lime and when reconstituted)

Source: Popkin,Hawkes Lancet Diab: 2016 Second, Snacking: Chinese Snacking Is an Example of the Role of Marketing, Modern Food Systems

a. Ages 2-18 b. Ages 19-59 250 250

221 211 200 200

150 155 150 150 111 112 100 100 79 68

38 38 50 31 50

20 27 Per Capita Intake Kcal /DayIntakeCapitaKcalPer 14 IntakeCapitaKcal/DayPer 17 11 11 9 9 6 0 0 Rural Small Cities Large Cities Mega-Cities Rural Small Cities Large Cities Mega-Cities c. Ages 60+

250

200 1991

149 150 2000 112 2011 100 73 52 50 19 Per Capita IntakeCapitaKcal/DayPer 14 7 9 11 10 0 Rural Small Cities Large Cities Mega-Cities Fat Preference Key for Survival: Technology, Marketing Have Utilized This Preference for Fatty Food

Third Major Shift: Fatty Foods and Edible Oils in Particular, Unsure of Weight and Health Effects

• Fatty foods: smoother, affects taste in many ways • Shifts largest in Africa, Middle East and Asia but also in the Americas • Oils have and will continue to face many challenges regarding trans fat content (e.g. India’s Vanaspati; possibly palm oil) and unhealthful fatty acid components • Possibly the biggest early caloric driver in the developing world, but rapidly being replaced by SSB’s, junk food Vegetable Oils: The Third Leg Edible Oil Consumption Still Rising in China and the Proportion of Fried Food Is Rapidly Rising (Grams per Day per Capita)

Year 1989 1991 1997 2006 2011 Poorest (lowest income tertile) 11.8 19.4 26.5 30.8 37.9 Middle income tertile 15 22.4 29 35.4 39.2 Richest (highest income tertile) 17.4 26.9 32.2 33.9 41.1

Average for total adult population 14.8 22.9 29.2 33.4 39.6 % of all calories per capita from 4.9 7.8 11.3 13.2 15.4 edible oil

Oil added during cooking of rice can retrograde the rice and significantly decrease the glycemic indexurvey for adults aged 20-45 FengyingZhai et al *

Adjusted Grams/day 100 125 150 175 200 225 25 50 75 0

for for age and gender Megacities: Beijing, Shanghai, Chongqing

1991 A. Children Aged 2

1993 Obesity 2014;Obesity Reviews. 15. Fourth Major Shift Major Fourth 1997 Animal Source Foods in China China in Foods Source Animal 2000

2004 (Grams/day),1991 - 2006 18

2009

2011

mega cities

1991 B. Adults Aged 19 and Older : Daily Intake of Intake : Daily

1993

1997 - 2009* 2000

2004

2006

2009

2011

mega cities Pork & pork products & pork Pork eggs dairy All meat red other mutton, lamb, Beef, poultry fish seafood Fifth major shift: Eating Away from Home Is Associated with Urbanization in China, Most Other Low- and Middle-Income Countries

1991 2000 2011 3 mega cities 2011

30

25

20

15 25 10 20 17 16 16 12 5 11 8 3 4

0 Percentage kcal eating away home from away eating kcal Percentage Low Urbanization Middle Urbanization High Urbanization 3 mega cities

Fengying Zhai et al Obesity Reviews. 2014; 15. Total Caloric Intake Is a Combination of Three Components

• Total caloric intake = f(Meal Size(G) x Eating Frequency(#) x energy density of the meal (kcal/g)) • Meal sizes ↑: US, UK, Germany, other countries • Eating Frequency ↑↑: large increase documented in few countries, seeing new global increases. Snacks are significantly greater energy density • Energy density ↑↓ : biggest shift toward higher number & size snacks of higher energy density and excessive added sugar and refined carbs; caloric beverages increased also in total volume with comparable results for children

Duffey & Popkin (2011) Plos Medicine; Duffey & Popkin (2013) AJPM 44

Mathematical Decomposition of the Change in Total Calorie Intake

• Use classic total derivative approach by creating partial derivatives for each component and using them to create total derivative • Major finding was that the increases in energy intake in the last century were driven more by increased eating frequency than meal portion size (note we looked at total meal portion size and not one dish).

Duffey & Popkin (2011) Plos Medicine Annualized Energy Contribution of Portion Size, Energy Density, and Eating Occasions to Changes in Total Energy Intake*

Energy Density Portion Size Eating Occasions 60.0

50.0

40.0

30.0 37.2

20.0 39.4 21.7 4.3 10.0 14.8 11.7 10.1 0.0 -1.6 [VALUE] -3.7

-11.3 -1.0 total daily energy energy intake(kcal) daily total -10.0

Energy contribution to annualized change in in changeto annualized contributionEnergy -20.0 1977-78 to 1989-91 1989-91 to 1994-98 1994-98 to 2003-06 1977-78 to 2003-06

*Values represent the annualized energy (kcal) contribution of changes in the number of eating occasions, portion size or energy density of each eating occasion to changes in total daily energy (kcal) intake.

Nationally representative data. Duffey & Popkin (2011) Plos Medicine

Sodium Intake China and many low and middle income countries: Sodium intake from salt continues to dominate. The proportions of sodium from processed food and MSG small in absolute terms, but increasing. No solid data from Latin America and Africa.

1991 2009 Processed Processed Prepared Food, 1.8 Food, 6.8 at Home Regular Prepared Food, 8.8 at Home Soy Sauce, 7.7 Regular Food, 11.5 MSG, 0.9 Soy Sauce, 8.5

Salt, 80.8 Salt, 69.7 MSG, 3.4

Lee et al, J Hum Hyp (2013) S Korea 27 :298; Du (2014) China…AJCN 99: 334 What Does All This Mean for Global Obesity?

1. Adult obesity precedes child obesity: conjecture relates to the rapid decline in adult activity along with the more recent food system shifts 2. Rightward shift in BMI at all ages—age-period-cohort and other research suggests 8-10 kg increase over past 10-20 years (e.g. Jaacks et al, IJE 42:828-837) 3. Waist circumference at each BMI level is increasing 4. Remember much higher body fat proportion, visceral fat among many LMIC subpopulations. Also increased NCD susceptibility at lower BMI’s Waist Circumferences Are Going up Globally at the Same BMI, for most countries globally. Just one example for Hispanic Women (mean WC over time for females aged 20 years and BMI=25 kg/m2) 2.0 cm 88 86.4*

86 6.6.cm 84.4 84 82.8*

82

80

78 WC (cm) WC 76.2 76

74

72

70 Mexican Mexican-American 1999/1999-2002 2012/2007-2010 • *p<0.0001, comparing predicted WC in most recent survey year to predicted WC in earlier survey year for Mexican women and Mexican-American women.

• All models adjusted for age, BMI, BMI-squared, and survey year in linear regression analyses. • Age centered to age 20 years and BMI centered to BMI=25 kg/m2 Source:Albrecht et al EJCN 2015; 69: 1306-12.; Albrecht, et al AJHumBiol 26: 627–634

• Diabetes Prevalence Is Higher at Each BMI level for US Mexican Americans and US Non-Hispanic Blacks, Despite Adjustment for Socioeconomic and Demographic Factors

35 Non-Hispanic whites Non-Hispanic blacks Mexican-Americans *

30 *

25 * *

* 20 * * * 15 * * * * *

10 * * Diabetes prevalence (%) prevalence Diabetes 5

0 1988-1994 2007-2012 1988-1994 2007-2012 1988-1994 2007-2012 1988-1994 2007-2012 18.5-24.9 25.9-29.9 30-34.9 ≥35 BMI (kg/m2)

*p<0.05, compares diabetes prevalence among non-Hispanic blacks and Mexican-Americans to non-Hispanic white referent group within BMI categories and within survey years

Source: Albrecht, Mayer-Davis and Popkin (2017) from nationally representative NHANES data Regional Percent Underweight and Overweight in Most Recent Available Survey among Women Aged 19-49 by Urban and Rural Residence, Weighted by 2010 Population

Rural Urban Underweight Overweight Underweight Overweight

East Asia East Asia 7 28 9 24 and Pacific and Pacific

3 Eastern Europe and 50 3 Eastern Europe and 52 Central Asia Central Asia

4 Latin America and 50 3 Latin America and 52 the Caribbean the Caribbean

Middle East and Middle East and 2 64 1 76 North Africa North Africa

38 South Asia 9 22 South Asia 27

14 Sub-Saharan 14 9 Sub-Saharan 33 Africa Africa

50 40 30 20 10 0 0 20 40 60 80 50 40 30 20 10 0 0 20 40 60 80 Percentage Source: Jaacks and Popkin, J Nutr 2015 Sample size: 290,278 rural, 232,581 urban Regional Annualized Change Absolute Change in Percent Underweight and Overweight 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 Overweight Underweight Overweight

East Asia East Asia 0.03 0.95 0.03 0.13 and Pacific and Pacific

0.01 Eastern Europe and 1.18 -0.18 Eastern Europe and 0.77 Central Asia Central Asia

Latin America and Latin America and -0.30 1.12 -0.29 1.14 the Caribbean the Caribbean

Middle East and Middle East and 0.00 0.81 0.00 0.39 North Africa North Africa

-0.44 South Asia 0.51 -0.18 South Asia 0.53

Sub-Saharan Sub-Saharan -0.09 0.31 -0.12 0.60 Africa Africa

-0.6 -0.4 -0.2 0.0 0.2 0.4 0.0 0.5 1.0 1.5 -0.6 -0.4 -0.2 0.0 0.2 0.4 0.0 0.5 1.0 1.5 Percentage Source: Jaacks and Popkin, J Nutr 2015 The Focus is on Food system And Dietary Change • Major Tools considered to date for obesity prevention at the macro/regulatory level: – Economic tools: prices(taxation), subsidies?, trade controls? – Labeling: FOP labeling approaches being used; considering claims restrictions-ideally linked with marketing controls – Marketing controls and restrictions: kids only vs overall – Restrict foods in selected institutions(e.g. schools, hospitals,etc) but really minimal evidence in any country of major impact of major feeding changes and their impact (especially LMIC’s) • Other aspects of our food system not addressed to date: – Retailer change only via changes noted above to date – Neglect of restaurant/fast food/stall sector – Other farm system/sector changes: no sense of potential impact . – To date, know traditional nutrition education efforts small, not possible without major marketing controls, but no sense of modern mass media/social media efforts.

Our ultimate goal: How to use multiple approaches to change BOTH supply and demand? Cultural/ societal norms for healthy eating Behaviors (measureable) as Fiscal proxies for norms Measures (non-measurable) (e.g., tax) Modify choice Marketing/ Labeling regs: architecture advertising Menu, controls/FOP Package Food service & Industry’s other regulations voluntary efforts Social marketing/ nutrition education

Effectiveness potential (at population level) population (at potential Effectiveness Gov’t Spectrum of approaches for changing behaviors Indiv led driven Individuals, communities, food manufacturers, retailers, food service, policymakers, regulatory agencies all have roles to play but to date little evidence industry will play a significant role without regulatory efforts From Shu Wen Ng Mexico: History All Linked to National Institute of Pub Health

• Mexican Beverage panel 2007-8: recommended taxing sugary beverages; got all medical societies to sign on and publish document • Series of meetings on ways to reduce added sugar, bad fats, sodium • National Prevention Plan • Front-of-the-package profiling: MOH, MinFinance, Mex FDA — I chaired • New elections, new President, Min of Health with strong industry ties and Bloomberg involvement with major public campaign • 2 taxes instituted, fought off attempts to cut, constant battles with industry over SSB tax. Surprisingly little over junk food tax.

Campaign Strategy

• Media strategy: Create public debate through press conferences (1xweek), public actions/performances (1xmonth) and newspaper ads (2xweek in Oct.)

• Engagement with decision-makers 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 allied INGO’s, health advocates in the US The Mexican SSB Tax Timeline

COALITION BUILDING EARNED MEDIA EXPERT FORUMS

ALLIANCE CAMPAIGNS INDUSTRY CAMPAIGNS BORN PRINT AD BATTLE IN THE PRESS

“FIRST CAME OBESITY, “12 SPOONFULS “A HEALTHIER “SUGARY “WATER IS THEN DIABETES” OF SUGAR” MEXICO” DRINKS” LIFE”

OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV CONGRESS IN SESSION CONGRESS IN SESSION CONGRESS IN SESSION

COLLECT SSB TAX BILL KEY DIALOGUE INTENSE SIGNATORIES INTRODUCED WITH MINISTRY LOBBYING TO SSB TAX IN SENATE – OF FINANCE BILL “TABLED” UNTIL FISCAL REFORM

NEW PRESIDENT ACADEMIA PEÑA NIETO SSB TAX TAKES OFFICES LAUNCH OF ANNOUNCES SODA PASSED POLICY RECOM’S TAX IN FISCAL REFORM The Mexican tax: Leading the Way So Far and Used to Build Basis for Taxes in Many Countries, Cities

• 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%) • 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; ice-cream and ice-pops) with an energy density ≥275kcal/100g will be subject to a tax of 8%. The Mexican Tax: Leading the Way So Far

• Evaluation of price, marketing, food purchase shifts underway led by INSP with UNC major collaboration • To date, price increases are being passed along. • First year of taxes saw overall 6% decline, with 12% by month 12. – Lowest SES group (most affected by diabetes that is untreated) saw a 17% decline. – Water purchases significantly increased. • Year 2 Found an additional 4% decline • Nonessential food taxes equally impactful in similar fashion with a much larger year 2 decline (4.4% in first year, 16.6% in second year). • Fought off repeated industry legal, political and extralegal efforts to stop these efforts Chile’s Laws: Marketing to Children

• Chile has the most comprehensive set of marketing restrictions to date evaluating their impact will be crucial for learning what is working to create healthier eating patterns. Chile Law Evaluation: UNC Working with Strong University of Chile Collaborators

Strengths: 2015-16 TV where kids 22% or more of audience  Applies to all foods and beverages and uses uniform nutrition criteria across categories  Includes comprehensive in-school restrictions.  Restricts all characters on food packages deemed unhealthy based on a very comprehensive set of guidelines  Strong negative logos on junk foods/beverages high in added sodium, added sugar, added saturated fats, energy density(separate for each) (junk food—about 50% of what retailers sell) Strengths: new law 2017 and implementation guidelines ban 6am to 10pm  Builds on current law and adds total ban during those hours  Adds negative warning message to any media with ads for foods and beverages with negative logos. Planning: year later mega possibly 18% tax on all banned food-bev-

still unclear.

Chile Regulatory and Tax Evaluation: INTA and GFRP UNC

Regulations Data sources Outcomes Analysis

5% Sugar-sweetened Changes in attitude, beverages tax Focus groups of Low SES mothers knowledge, and understanding Jan 1, 2015 of regulations

Household Food Purchases Food Purchases Front-of-package Changes in regulated and warning labeling unregulated food and beverage July 1, 2016 Nutrition Facts Panel and FOP labels purchases; reformulation changes

SES, Media Exposure, and Diet Dietary Intake Changes in regulated and Marketing • GOCCs cohort of 12y-olds, n=767, additional diet and media unregulated dietary intake & Advertising • New cohort of 4y-olds, n=965 Restrictions • SES and diet • Knowledge • children 0-14y • Media • Attitudes July 1, 2016 • all ages 6am to 10pm Obesity & NCDs July 1, 2017 Changes in health outcomes Content analysis of TV The Future: Large series of countries globally instituted or seeking similar tax and other regulatory changes

• SSB taxes: Pacific & Caribbean Islands, S Africa, Thailand, Phil., others • Except Chile and Mexico—no exploration of other taxes • Will reducing junk food/beverages be enough? I doubt it • Marketing/FOP: Chile the leader, others are following • FOP: few countries combining negative Argentinean with push for Keyhole/choices type real healthy food • Ultimately we must figure a way to get to a healthy diet to truly succeed. Our Goal is to find a way to create effective public health nutrition efforts and policies in our initiatives

Short-term outcomes Changes in food purchases or diets (overall, by subpops)

Spectrum of Research approaches Longer-term outcomes Changes in health Focus on packaged food sector outcomes and need to expand ultimately (overall, by subpops) From Shu Wen Ng Our ultimate goal: How to use multiple approaches to change BOTH supply and demand? Cultural/ societal norms for healthy eating Behaviors (measureable) as Fiscal proxies for norms Measures (non-measurable) (e.g., tax) Modify choice Marketing/ Labeling regs: architecture advertising Menu, controls/FOP Package Food service & Industry’s other regulations voluntary efforts Social marketing/ nutrition education

Effectiveness potential (at population level) population (at potential Effectiveness Gov’t Spectrum of approaches for changing behaviors Indiv led driven Individuals, communities, food manufacturers, retailers, food service, policymakers, regulatory agencies all have roles to play From Shu Wen but to date little evidence they will without regulatory efforts The Struggle Over the Millennia to Eliminate Arduous Effort Could Not Foresee Modern Technology