This story first appeared March 2 on the Spanish version of Medscape.
Chile doesn’t necessarily spring to mind when asked to consider the nation with the highest obesity levels in Latin America. And yet it holds the dubious crown of having the most obese/overweight men on the continent, topping even its better-known neighbor in this regard, Mexico. Chile therefore decided a few years ago to tackle the food industry head-on, in what some describe as the most ambitious attempt to curb the marketing of junk and processed food in the world.
Since 2012, Chile has implemented a series of unprecedented policies to regulate labeling and marketing in schools and food promotion, going as far as to prohibit the Kinder Egg and chocolate bunny.[1][2]
The New York Times described the country’s actions in a recent report as “the world’s most ambitious attempt to remake a country’s food culture.”[2]
Meanwhile, Eve Crowley, United Nations Organization for Food and Agriculture (FAO) representative for Chile, said the country has become a “world reference” in this field and, early last month, it shared its experience at the FAO regional conference in Jamaica.[3]
The new policies — which have, as might be expected, encountered resistance from food companies — aim to help combat the high prevalence of obesity in Chile and are being used as examples for other countries in the region.
According to a 2014 study of 188 countries, Chile has the highest prevalence of obesity, at 11.9%, among boys and adolescents in Latin America and the Caribbean. It also has the highest proportion of adult men with overweight and obesity in the region, at 67.9%, and among women the figure reaches 63.9%.[4]
In 2016, the country spent an estimated 0.54% of its gross domestic product on obesity-associated costs, such as medical treatment, related illnesses, disability pensions, work absenteeism, lost productivity, and premature mortality. And it is estimated this expenditure will triple by 2030.[5]
“Faced with the obesity epidemic, Chile did not hesitate to confront the powerful economic interests of the processed food industry,” praised the Peruvian medical oncologist Elmer Huerta, MD, medical collaborator of CNN en Español and director of the Cancer Preventorium at MedStar Washington Hospital Center, Washington, DC.
Huerta added that although overweight indexes in Peru and other countries are lower, “we do not have to wait to reach that limit to act” in other Latin American nations.[6]
Tackling Several Aspects Simultaneously, Banning Tony the Tiger
The adoption of measures to effect dietary changes in Chile by reducing exposure of the population to advertising and other marketing strategies[7] has been driven by the fact that more than 20% of children and adolescents (up to age 19 years) are overweight in Chile and the rest of Latin America.
“In my opinion, the most remarkable thing about the Chilean experience is that they are trying to address several aspects of the food environment simultaneously,” Camila Corvalán, MD, PhD, Director of the Center for Prevention of Obesity and Chronic Diseases, University of Chile, Santiago, told Medscape Medical News.
The measures phased in since 2015 in Chile include:
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Restrictions on marketing of unhealthy food;
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Improvement of school environments through the prohibition of promotion and sale of these foods;
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Delivery of information at the point of sale through warning logos or compulsory octagonal “black labels” that warn of the high content of sugar, salt, saturated fats, and calories; and
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Imposition of high taxes on sugary drinks.
Some of the adopted measures within the policy framework have few precedents worldwide. For example, the picture of Tony the Tiger has been banned from cereal boxes, as have other animated figures on food packaging intended for children. At least one study has linked the presence of child-directed characters on packing with the highest sugar and calorie content.[8]
Kinder Egg has also been banned, as toys are considered a commercial hook for a product with ingredients that are not nutritious for children. The chocolate bunny suffered the same fate.
Food kiosks at Chilean schools can no longer market the snacks and drinks most children purchased during breaks, such as cookies, chocolates, sugary beverages, ice cream, potato chips, and cheese-flavored cornmeal snacks.[9]
Instead, they can offer, among other items, juices and soft drinks without added sugar, fresh fruits and vegetables, and yogurt smoothies or natural fruit ice cream without added sugar. The Chilean Ministry of Health also recommends students bring healthy snacks from home, such as a handful of almonds, a bowl of chopped fruit with yogurt, baby carrots, celery, or broccoli.
And starting next June, television, radio, and movie theatres will not be able to advertise junk or unhealthy food from 6 AM to 10 PM.
Ninety percent of some product categories, such as chocolates and cookies, carry at least one black label or warning logo.
Preliminary Indications That Policies Are Having an Impact
According to Corvalán, the first indication the strategy is having a positive impact is that around 20% of processed products were reformulated to reduce or eliminate warning labels on packaging in the past year and a half.
Last September, for example, Coca-Cola announced it would reduce sugar content by 55% to 60% in two of its leading drink brands (Fanta and Sprite) in Chile.[10]
Corvalán is conducting a 5-year study on the perception and attitudes of almost 800 adolescents and over 900 mothers of preschool children in Santiago.
The first preliminary analysis, 9 months after the enactment of the packaging law, reveals that 91% of mothers and 81% of adolescents associate the presence of logos or labels with unhealthy foods.
Meanwhile, 26% of mothers and 23% of adolescents define a healthy diet as one that does not include foods that have such labels, a higher proportion than those who judge that attribute by factors such as the brand, list of ingredients, or presence of health messages on the label.
Likewise, between 2016 and 2017 the proportion of mothers who consider the presence of labels or nutritional information the primary factor they take into account when deciding what to buy increased from 28% to 35% — above the brand or price. In adolescents, on the other hand, the relationship was reversed, and labels or nutritional information occupy third place in importance, at 11%.[11]
Other studies also suggest there have been substantial changes in consumer behavior. In the quarter after the current legislation was enacted, sales of products with ‘unhealthy’ labels fell by 3.6%. And after 1 year, 36.5% of Chileans declared having changed their choice and purchase of food and beverages.[12]
According to one news report, the law “has hit a lot of…companies,” and even Danone is considering exiting the Chilean market.[13]
Conversely, although the tax increase on soft drinks, juices, and nectars with a high sugar content (6.25 g/dL) now stands at 18% in Chile, the move doesn’t seem to have had as much impact as in Mexico, where a 10% tax on sugar-sweetened beverages led to a 6% average reduction in monthly purchases of such soft drinks.
An international study revealed that Chile is now one of four countries where a liter of Coca-Cola is most expensive, but because of the increase in income, the drink is more affordable than 25 years ago.[14]
“In truth, the [sugar] tax increase was small and accompanied by a decrease in taxes on alternative products, so our analysis shows that this translated into a lower impact,” said Corvalán.
In any case, experts acknowledge that it is still too early to document sustained modifications in eating patterns, prevalence of excess weight, or incidence of associated diseases.
Last year, Chile’s Health Minister, Carmen Castillo, stressed that regular evaluations would be needed “to show a future decline in obesity and improvement in people’s nutrition” as a result of the policy changes.[15]
Some Opposition
The Chilean initiative has faced stiff opposition from the food industry, which has classified the measures as exaggerated, confusing, paternalistic, and invasive.
For example, they criticize the fact that the black labels are based on caloric content or nutrient concentration per 100 grams or mL and not the usual portion size, arguing that they transmit an “inaccurate perception of risk.”[16]
Others have questioned the legislation, stating that the high-sugar label incentivizes organizations to replace the sugar in their products with artificial sweeteners, the long-term safety of which is not established.
The food industry and some obesity experts also denounce the fact that politicians are too focused on food and have lost sight of the importance of other risky behaviors, such as a sedentary lifestyle. They argue that it would be better to educate consumers about a healthy lifestyle that includes exercise.
Susana Socolovsky, PhD, president of the Argentinian Association of Food Technologists, says the Chilean labeling standard transgresses the Codex Alimentarius guidelines (FAO and WHO global compendium of food standards), which proposes to report nutrient content without a positive or negative connotation or rejecting a food product.
The black warning labels, Socolovsky told Medscape Medical News, “are based on arbitrary limits and do not give the consumer the chance to learn. All food is healthy in moderate quantities, and not all population groups have the same needs. What is the point of labeling that does not educate?”
Instead, she proposes a “traffic light” rating system, such as the one used in the UK.
Corvalán agrees that education is essential, but says this strategy has limitations in more vulnerable groups.
“Therefore, we must generate changes in food environments to make healthy choices easier to make and simultaneously work, especially with children, to develop healthier food preferences,” she told Medscape Medical News.
Given that these preferences are learned early in life, it is “very relevant” to intervene at a young age, Corvalán says. Studies confirm that it is more challenging to achieve long-lasting results with lifestyle modification once obesity is established.
And “the evidence suggests that actions focused on improving diet are the most likely to return us to a state of adequate nutrition. The measures focused on physical activity are relevant, but secondary,” Corvalán believes.
An Example to Follow?
The Chilean experience is being closely followed by other countries in the region, some of which are considering implementing similar measures.
Uruguay, for instance, has a labeling project that recreates the system of logos or black labels on packaging, an action that has also angered the food industry there.[17]
In Peru, the Congress Consumer Defense Committee approved in November a scheme that replaces the black octagons proposed by the health authorities for a “nutritional traffic light” that, like in Ecuador, highlights ingredients found in low (green), medium (yellow), and high (red) concentrations.[18]
On the other hand, the Peruvian minister of health continues to demand the use of octagons in the Chilean way “because they mean alert, caution…and we must have a clear message for the consumer or buyer to decide quickly.”[19]
In Corvalán’s opinion, Latin America is in a “unique position” to implement structural measures that favor healthier food environments.
“Each country has a particular reality that allows progress in some respects more quickly than in others, for example, taxes in Mexico, labeling in Uruguay, or school nutrition in Brazil.”
“I think the important thing about the Chilean experience is that we are talking about the need for a ‘package’ of actions that simultaneously address different aspects of the food environment. I believe that our countries still have a culinary wealth to which we can appeal to combat the epidemic of obesity and associated chronic diseases,” she concluded.
Corvalán has reported no relevant financial relationships. Socolovsky has worked as a technical consultant in regulatory and scientific affairs for several multinational food ingredient companies.
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