Obesity Prevention Efforts in Mexico: Efforts by the National Institute of Public Health Simón Barquera, MD, MS, PhD.

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2 CDC s NOPREN network May, 2016 Obesity Prevention Efforts in Mexico: Efforts by the National Institute of Public Health (INSP) Simón Barquera, MD, MS, PhD Director, INVESTIGACIÓN EN POLÍTICAS NUTRICIONALES CENTRO DE INVESTIGACIÓN EN NUTRICIÓN Y SALUD, INSTITUTO NACIONAL DE SALUD

3 Antecedentes

5 High/ Very High Human Development Index Low/Medium Human Development Index Percentage of deaths attributable to cardiovascular disease and diabetes in mega-countries (2013) Ethiopia Nigeria Pakistan 26.7 (380.3) 21.6 (289.3) 35.6 (422.3) 1.9 (25.8) 2.4 (34.4) 4.0 (48.0) Bangladesh 40.7 (428.7) 3.5 (36.9) India 31.0 (387.6) 2.6 (32.9) Similar total mortality from CVD and Diabetes in Mexico and US, however Mexico is one of the countries with higher Diabetes Mellitus mortality. Philippines Vietnam Indonesia China 37.6 (406.4) 38.3 (207.9) 39.1 (401.1) 42.0 (304.1) 4.5 (48.6) 2.5 (17.6) 4.9 (50.5) 1.4 (10.2) Brazil 33.3 (252.0) 4.7 (35.2) Mexico 24.4 (179.5) 9.4 (69.2) Russia 55.6 (526.8) 0.5 (4.6) Japan 26.6 (109.7) 0.7 (2.9) Barquera S, Pedroza-Tobias A, Medina C. Cardiovascular diseases in mega-countries: the challenges of the nutrition, physical activity and epidemiologic transitions, and the doubleburden of disease. Current Opinion in Lipidology, 2016 (submitted) United States (183.3) 2.8 (16.6) Age-standardized Percent of deaths % (Age-standardized deaths per 100,000 habitants) Cardiovascular Disease Diabetes

6 Prevalence of Children < 5 y Stunted (%) 60 Double-burden of malnutrition in mega-countries: coexistence of stunting a and overweight/obesity b Human development Index Very High 50 India (19.7, 47.9) High Medium Low Ethiopia (17.2, 44.2) Pakistan (21.1, 43.0) Bangladesh (16.1, 41.4) 40 Indonesia (21.2, 39.3) Philippines (21.5, 33.6) Nigeria (29.8, 36.0) 30 Vietnam (17.4, 23.3) 20 Mexico (62.1, 13.6) 10 Japan (23.2, 7.1) China (30.1, 9.4) Brazil (51.1, 7.1) Russia a (56.4, 3.6) United States (65.5, 2.1) Prevalence of adults with Overweight and Obesity (%) Barquera S, Pedroza A, Medina C. Cardiovascular diseases in mega-countries: the challenges of the nutrition, physical activity and epidemiologic transitions, and the double-burden of disease. Current Opinion in Lipidology, 2016 (submitted)

7 Mortalidad atribuible a la diabetes: Carga Global de la Enfermedad The Global Burden of Disease Project 2013

K-density overweight obese Increase in obesity prevalence in

08.1 34.5% 61% 69.3% 71.28% 7% increase per year 1988-1999 1.

33 % increase per year 1999-2006 2006-2012 BMI distribution in

8 K-density overweight obese Increase in obesity prevalence in Mexico has occurred very rapidly in the last decades % 61% 69.3% 71.28% 7% increase per year % increase per year 0.33 % increase per year BMI distribution in Mexican women years of age (1988, 1999, 2006, 2012) BMI (Kg/m 2 )

9 III. Efectos en salud 9

10 % Increasing trends in consumption of SSB and refined carbohidrates. % Change in household food expenditure between 1986 y 1998 Soda Refined CH Fruits and Vegetables Dairy Meats Source: Rivera-Dommarco J, Barquera et al. Public Health Nutrition, 2002: 5(1A),

Daily Beverage Consumption Trends Among Mexican Children, 1999-2006 297 343 165 190 Children aged 1-4 Children aged 5-11 Note: Sweetened juice drinks include 100% fruit

11 Daily Beverage Consumption Trends Among Mexican Children, Children aged 1-4 Children aged 5-11 Note: Sweetened juice drinks include 100% fruit juice with sugar added and agua fresca (water, juice, sugar). Sodas include carbonated and noncarbonated sugar bottled beverages. Source: Barquera et al (2010) Nutr J 9 : 47-56

12 SUPPORTED BY MEDICAL SOCIETIES DISTRIBUTION BY MOH DISCONTINUED TO AVIOD CONFLICT FOOD INDUSTRY WS AGAINST THIS INITIATIVE COMPLAINTS AGAINST DISTRIBUTION HEALTHY BEVERAGE RECOMMENDATIONS, 2009

Change in consumption (ml/day) -50.02-53.02-46.10-11.34-10.31-11.38-1.20-1.24-0.88 2.07 2.43 2.

13 Change in consumption (ml/day) Estimated Effect of a 10% tax on soda price by income tertile in Mexico (2008) % increase in the price of soda 10% increase in the price of whole milk Overall Poor Rich Soda 1 Whole milk Whole milk Soda 1 Source: Barquera et al, (2008) J Nutr 138:

14 Mexican Big Soda vs Soda Tax initiative: Soda hydrates and provides energy empty calorie unsubstantiated concept

15 LESSONS LEARNED FROM TAX APPROVAL IN MEXICO: rise and major role of NGOs employing evidence-based policy recommendations alianzasalud.org.mx

16 LESSONS LEARNED FROM TAX APPROVAL IN MEXICO: International Support from Academia, Organizations and NGOs Open letter from IOTF congratulating president Peña for presenting the soda tax initiative. Recommendation to increase from 10 to 20% Reforma (NEWSPAPER), Sept 24 th 2013

17 Ability of NGOs to communicate effective messages to population and SIDE BY SIDE: SODA VS NGOs

Evaluation of the Soda and Sugar-Sweetened Beverages (SSBs) Tax in Mexico 6% average reduction taxed beverages 2014 compared to previous trends adjusting for

18 Evaluation of the Soda and Sugar-Sweetened Beverages (SSBs) Tax in Mexico 6% average reduction taxed beverages 2014 compared to previous trends adjusting for confounders Differences reached 12% at the end of the year 4% increase in non taxed beverages (water) Colchero MA, et al. BMJ 2015;352:h6704; doi: /bmj.h6704

19 CHALLENGES: New alliances against soda-tax and information and major investment in communication campaigns by industry

20 Modeled impact of the Mexican soda tax on CVD events and mortality * Baseline 10% with 39% cc 20% with 39% cc 40% with 39% cc 10-yr Cumulative Incident CHD 3,145,499-46,108 (-1.5%) -90,489 (-2.9%) -177,084 (-5.6%) 10-yr Cumulative Incident Stroke 930,067-6,462 (-0.7%) -12,757 (-1.4%) -24,920 (-2.7%) 10-yr Cumulative CVD Mortality 1,228,737-11,682 (-1.0%) -22,933 (-1.9%) -44,808 (-3.7%) Sánchez-Romero LM, Barquera S, Bibbins-Domingo K. Projected impact of Mexico's sugarsweetened beverage tax policy on diabetes and cardiovascular disease: a modeling study. PLOS Med (submitted).

21 Estimated savings in direct health care costs for diabetes mellitus cases avoided with the Mexican soda tax* Age Group (years) Baseline 10% 20% 40% Total 35-94* $67,193 -$530 (-0.8%) -$1,034 (-1.6%) -$1,896 (2.8%) *millions 2012 USD Sánchez-Romero LM, Barquera S, Bibbins-Domingo K. Projected impact of Mexico's sugarsweetened beverage tax policy on diabetes and cardiovascular disease: a modeling study. PLOS Med (submitted).

22 Conclusion, Challenges, Next Steps Government actions such as: regulation of advertisement, labeling and food composition as well as SSBs and junk food taxes are powerful necessary tools to support healthy lifestyles The Soda Tax in Mexico was possible thanks to participation and support from diverse sectors: Academia, NGOs, policy makers, political parties and the federal government and international groups. Although the amount of taxation approved was small (10%), researchers are finding preliminary modest but positive effects.

Conclusion, Challenges, Next Steps The Soda Tax debate has a positive educational effect on consumers. Funding for NGOs to be able to face big soda ultimately win this public debate was crucial.

23 Conclusion, Challenges, Next Steps The Soda Tax debate has a positive educational effect on consumers. Funding for NGOs to be able to face big soda ultimately win this public debate was crucial. The Federal Government supported this alternative in its search for fiscal reforms increasing government revenue. Now it is important to follow-up on investments to improve access to water and promote its consumption. Soda Tax is ONLY a component of a wider set of policy actions needed to support healthier life styles and reduce obesity and other non-communicable chronic diseases.

24 Instalation theory: Proper environment neccessary to adopt healthy behaviors Lahlou Saadi, Instalation Theory, LSE 2015

25 Antecedentes

26 Self-regulation / Pledges for ethical marketing not useful to control food and beverage marketing to children in Mexican open TV. Theodore FL, Tolentino-Mayo L, Hernandez-Zenil E, Bahena L, Velasco A, Popkin B, Rivera JA, Barquera, S. Pitfalls of the self-regulation of advertisements directed at children on Mexican television. Pediatr Obes

13, 130 recorded ads during 2014 in open

27 13, 130 recorded ads during 2014 in open TV TV marketing directed to children in Mexico, 2014 Other Ads 75.5% (n 9,907) 11% 41.7%* *Others Sweet pastries 10.4% Chocolate Sweetened beverages 9.8% Food Ads 24.5% (n 3,223) Yoghurts and dairy 8.5% 8.9% Ready made-food Savoury snacks 9.7% 85.5% Soda *Others: milks, breakfast cereals, bread products, sauces and dressings Rincón-Gallardo S, Tolentino-Mayo L, Monterrubio Flores E, Vandevijvere S, Barquera S. Marketing techniques used within food advertisements on Mexican broadcast TV. in press, BMC Public Health 2016

29 Even with school regulations to limit junk food avaliability, food vendors outside are prevalent particularly in low income public schools. Barrera LH, Rothenberg SJ, Barquera S, Cifuentes E. The Toxic Food Environment Around Elementary Schools and Childhood Obesity in Mexican Cities. Am J Prev Med

30 Publicidad de alimentos poco saludables asociados con deportes y promoción de actividad física

32 Thank you! Simón Barquera, MD, MS,

Complexity of the Global Approach to Control Obesity: Challenges for implementation in Mexico

Roundtable on Obesity Solutions National Academies of Sciences, Engineering, and Medicine Complexity of the Global Approach to Control Obesity: Challenges for implementation in Mexico Dr. Simón Barquera,