Download Mexico attempts to tackle obesity: the process, results, push backs

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
federal and state government agencies initiated efforts to design a national policy
for obesity prevention. The Ministry of Health (MOH) established an expert
panel to develop recommendations on beverage intake for a healthy life in 2008.
Subsequently, the MOH, with support from academia, initiated the development
of the National Agreement for Healthy Nutrition (ANSA). ANSA was signed by
all relevant sectoral actors in 2010 and led to initiatives banning sodas and
regulating unhealthy food in schools and the design of other yet to be implemented initiatives, such as a front-of-package labeling system. A main challenge of
the ANSA has been the lack of harmonization between industry interests and
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.
Cuernavaca Morelos, México
Received 13 August 2013; accepted 14
August 2013
Address for correspondence: Dr JA Rivera,
Av. Universidad no. 655. Col. Sta. Ma.
Ahuacatitlan, Cuernavaca, Mor., Mexico CP.
62100, México.
E-mail: [email protected]
Keywords: Health policy, Mexico, national programmes, obesity.
obesity reviews (2013) 14 (Suppl. 2), 69–78
Introduction
An estimated 75% of all deaths in Mexico are caused
by noncommunicable diseases (NCDs), and obesity and
unhealthy diet were among the six main risk factors for
mortality in 2010 (1). Projected healthcare costs of 13
obesity-related diseases in 2013 were estimated at US$880
million, with alarming projections for the next few years.
According to this study, if an effective policy does not
control this trend, in only 7 years, direct healthcare costs
will rise above US$1 billion (2).
The prevalence of obesity in Mexico has been estimated
from a number of national surveys implemented by the
Ministry of Health (MOH) and the National Institute of
Public Health (INSP). Varying age–gender groupings were
collected in the 1988, 1999, 2000, 2006 and 2012 national
surveys. We combined these surveys to present an overall
picture of trends in overweight plus obesity (OW + O)
across time and the various age–gender groupings. We used
the World Health Organization (WHO) definitions for
risk of OW + O in children under 5 years (y) and OW + O
in children 5 years and older and adolescents (>1 standard
deviation [SD] of the body mass index [BMI] 2006 WHO
growth standards) (3) and the conventional cutoff point of
BMI ≥ 25 for adults. We use a common indicator, shifts in
the percentage points annualized (population prevalence
change per year). The prevalence of OW + O among
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
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70 Obesity prevention policies in Mexico S. Barquera et al.
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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),
that among children 5–11 years increased from 28.2% to
36.9% between 1999 and 2012 (0.7 percentage point per
year), and that among girls 5–11 years increased from
25.5% to 32.0% between 1999 and 2012 (0.5 percentage
point per year). Among female adolescents (12–19 years),
the combined OW + O grew from 11.1% to 35.8%
between 1988 and 2012 (1.0 percentage point increase per
year), and among male adolescents (12–19 years) the combined OW + O grew from 33.0% to 34.1% between 2006
and 2012 (0.2 percentage point increase per year). Among
adult women (20–49 years) it increased from 34.5% to
70.6% between 1988 and 2012 (1.5 percentage points per
year), and among adult men (≥20 years) it increased from
60.7% to 69.4% between 2000 and 2012 (0.7 percentage
point per year) (4–6).
While no decline has been observed in spite of some
attempts to control the problem, the rate of increase has
dropped among adults in recent years, with an annual
increase of 0.2% per year in women and 0.5 in men for the
2006–2012 period, in contrast to 1.2% per year in women
for the 1999–2006 period and 1.0% per year in men for the
2000–2006 period. However, the prevalence has positioned
Mexico among the countries with the highest obesity rates
(Fig. 1).
According to the latest national health and nutrition
survey (ENSANUT 2012), the prevalence of OW + O
(BMI > +2 SD) in Mexico among children under 5 years
was 9.7% in 2012. Among the school-age population (children 5–11 years) the combined OW + O prevalence was
34.4% (19.8% overweight and 14.6% obese). Among ado-
14 (Suppl. 2), 69–78, November 2013
lescents (12–19 years) the combined OW + O prevalence
was 35.8% in women and 34.1% in men. Among adults 20
years and older, the prevalence of OW + O was 73.0% in
women and 69.4% in men. The prevalence of abdominal
obesity (waist circumference ≥ 90 cm in men and ≥80 cm in
women) (7) was 82.8% in women and 64.5% in men.
With these surveys we have been able to identify the
regional distribution of obesity and the association with
other risk factors, sex, age group and socioeconomic status.
Some of the main conclusions of these studies are summarized in Table 1A.
To understand the environmental drivers of the increase
in the prevalence of obesity and mortality attributed to
NCDs in Mexico, the INSP analysed national income and
expenditure surveys and other databases to explore trends
and patterns in food expenditure, transportation, leisure
time activities, and other factors associated with obesity
and NCDs. One of the first findings (2002) was a dramatic
rise in consumption of sugar-sweetened beverages (SSBs).
Between 1984 and 1998 we found significant decreases
in expenditures on some food groups, such as fruits and
vegetables (−29.3%), dairy products (−26.7%), and meats
(−18.8%), and an increase in expenditures on refined carbohydrates and sugars (6.3%) together with a very high
increase in expenditures on SSBs (37.2%) (8). These studies
identified important changes associated with the nutrition
transition that are summarized in Table 1B.
In this context researchers from the MOH identified the
urgent need to develop and implement programmes to
control the increase in the prevalence of OW + O. In contrast with the comprehensive undernutrition, vaccination
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity
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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.
2.
3.
4.
5.
6.
Increase in the availability of low-cost processed foods with high quantities of sugar, fat and sodium (8).
Increase in fast food consumption and food consumption outside the home for a growing sector of the population (39).
Decrease in available time for food preparation (8).
Significant increase in exposure to food and beverage marketing and to technology that decreases physical activity (40).
Increase in per capita income (38).
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
was known about obesity-related NCD prevention (9,10).
Diverse intervention opportunities were identified from the
preliminary descriptive studies (Table 1C).
Thus, in 2006 various institutions, including the INSP,
the Mexican Social Security Institute (IMSS), one of the
three main health systems in Mexico covering about onethird of the Mexican population, and other federal and
state government agencies, initiated efforts to design a
national policy for the prevention and control of obesityand nutrition-related diseases. The objective of this paper
was to briefly describe some of the main efforts in Mexico
to control the problem and the processes and challenges
involved.
Attempts to tackle obesity
In 2005, in response to the increase in obesity in Mexico
and the high mortality rates attributable to obesity-related
diseases, some important programmes were put in place.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity
Mexico was invited to the Bellagio Conference on the nutrition transition (11) and to the Inter-American Economic
Forum (12) to prevent obesity. Later, the U.S. Institute of
Medicine and the INSP of Mexico conducted a workshop
on preventing obesity in children and youth of Mexican
origin on both sides of the United States–Mexico border
(13). This consensus recognized the need to focus on prevention and use a multifaceted approach and highlighted
the importance of targeting children, because interventions
on other age groups had not achieved positive results at the
time of the workshop. Also the IMSS started its own preventive programme (PrevenIMSS) with a significant investment in the media, including TV advertising, but there was
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
PrevenIMSS programme achieved recognition among the
population, investing in a unified national campaign that
included the three main health systems would have produced even more noticeable and sustainable results.
14 (Suppl. 2), 69–78, November 2013
72 Obesity prevention policies in Mexico S. Barquera et al.
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Figure 2 Healthy beverage pitcher.
Mexican beverage guidelines for healthy hydration
In 2007, using a recent national survey (ENSANUT 2006),
we analysed beverage consumption trends between 1999
and 2006 among children, adolescents and adults. We
documented that over 20% of the total energy intake in the
Mexican population was provided by beverages. Moreover
a very high increase in consumption of caloric beverages for
the 1999–2006 period was documented (226% increase
among children and adolescents and 252% among adults)
(14,15). The 2006 survey documented a significant contribution of sodas to total energy intake starting at 12 years of
age. In addition there are many other caloric beverages in
the Mexican diet, such as fruit juices, sugar-sweetened
coffee and sugar-sweetened flavored drinks (such as lemonade and hibiscus- or rice-flavored drinks, called aguas
frescas). Using this evidence and international studies associating SSB consumption with obesity, scholars proposed
actions to promote water consumption as the best hydration alternative.
Responding to concerns about the increasing rates of
obesity and chronic diseases and given that SSB consumption was already a known risk factor for obesity, the MOH
in 2008 established an expert panel to develop recommendations on beverage intake for a healthy life (16). This panel
conducted an extensive review of the published evidence of
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the effects of caloric beverages on health, building on and
updating a review in which two of the panel members had
participated. In addition it reviewed the patterns of beverage
consumption in Mexico using ENSANUT 2006 and other
databases. The committee developed Mexican recommendations for healthy hydration (17). The report recommended that less than 10% of an individual’s energy intake
should come from beverages and that SSBs should be
avoided or consumed sparingly. One of the unexpected
successes of this initiative was the development of a graphic
representation of the recommendations called the ‘healthy
beverage pitcher’ (Fig. 2). This representation was immediately distributed through social networks and other media
in spite of strong opposition and pressure on government
officials from the soda and other beverage industries. The
healthy beverage pitcher is now part of the textbooks and
curricula of the national primary education system.
This experience provided some preliminary lessons that
were useful for subsequent initiatives. Among the most
important factors that contributed to the success of this
process were:
1. The international independent expert panel appointed
by the MOH based on scientific merit worked pro bono
and without conflict of interest. This gave legitimacy to the
proposed decisions.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity
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2. The characterization of beverage consumption was
based on nationwide representative dietary data and was
published in international journals (14,15).
3. The expert panel published its conclusions in the
most widely read public health journal in Mexico (17)
and received positive comments from Latin American
experts (18).
4. The analysis was presented at international scientific
meetings, giving it exposure and providing opportunities
for scholars from various countries to discuss the issues.
5. The beverage recommendations received important
attention from healthcare professionals and the soft drink
and milk industries. The Mexican minister of health contributed an editorial in which he endorsed the recommendations by the panel and underlined the importance of
water as the principal source of hydration (16).
6. The healthy beverage pitcher was promoted via
posters and publications for all health sectors.
In general the support of the Mexican medical community
was unprecedented, and the Inter-American Heart Foundation, the Society of Endocrinologists and Nutritionists,
the Mexican Diabetes Federation, the College of Internal
Medicine, the Mexican Association of Cardiologists, and
the Academy for the Study of Obesity in Mexico all
endorsed the healthy beverage pitcher. This endorsement from the most influential medical societies in turn
encouraged strong support among physicians and health
professionals.
Although special interest groups, such as associations of
soda and milk producers, voiced opposition, consumer
groups in Mexico welcomed this initiative and provided
support through their communications networks and
media productions. We expect that in the future the aforementioned efforts will stimulate consumer demand for
healthier beverage products from the food industry,
Obesity prevention policies in Mexico S. Barquera et al. 73
facilitating the regulatory and educational work of the
government. In conclusion, much positive feedback has
been generated, and the Mexican minister of health has
expressed his commitment to maintaining these recommendations (16).
National agreement for healthy nutrition
The MOH, with support from the INSP and other scholars,
developed the National Agreement for Healthy Nutrition
(ANSA). The ANSA is founded on the WHO Global Strategy on Diet, Physical Activity and Health (19). The process
included a review of the risk factors for obesity and NCDs
and recommendations from international agencies and
governments and an international meeting of experts to
discuss the reviews and identify lines of action. They agreed
on the need to create a comprehensive, multisectoral,
multilevel policy with participation of the government and
civil society, including industry, non-governmental organizations (NGOs), and academia.
Ten objectives were identified for a national policy aimed
at preventing obesity and NCDs (Table 2). Some objectives
require government programmes aimed at behavioral
changes at the individual level. Others require that the
federal and state governments work with the food industry
to achieve healthy food alternatives. Most of the government sectors and agencies related to food and nutrition
identified goals and deadlines.
One of the main challenges of the ANSA has been the
lack of harmonization between industry interests and
public health objectives. This has been a barrier to agreements with the food industry regarding specific goals and
deadlines to achieve the ANSA objectives. Regulation of
advertising and sugar, fat, and sodium content and other
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
© 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
74 Obesity prevention policies in Mexico S. Barquera et al.
their profits. This is not necessarily true. With innovation,
creativity, standardization of rules, and gradualism, the
food industry could handle the challenges of more controls
and at the same time accelerate the development of products with a better nutritional profile. The economic impact
of high consumption of energy-dense food high in sugar, fat
and sodium is of critical importance. The state cannot
abdicate its responsibility to protect the health of the population through the implementation of mechanisms and controls similar to those suggested by the ANSA.
School guidelines for foods and beverages
One of the direct results of the ANSA was the development
of school food and beverage guidelines by the Ministry of
Education (MOE) and the MOH based on criteria suggested by scientific evidence and the consensus of a group
of nutritional experts from more than 15 national and
international institutions and organizations. These guidelines promote the daily intake in schools of healthy foods,
such as fruits, vegetables, and water; ban sodas; limit the
availability of other SSBs, whole milk, salty and sweet
snacks, and desserts that comply with nutritional criteria
developed by the expert group to a maximum of two days
per week; and eliminate the products that do not comply
with the nutritional criteria. The gradual implementation
of the guidelines was initiated in January 2011 with the
expectation that implementation will be completed in
2014. This gradualism was designed to allow time for
the parties involved to improve the nutritional quality of
school foods.
The process from the development of the proposed regulations to their approval highlights the role of the food
industry in opposing regulation aimed at improving the
health of the population. For example, the experts proposed limits for added sugar, salt, saturated fat, trans-fatty
acids and total calories. They also proposed the elimination
of all caloric beverages and the use of an energy-density
criterion to limit the availability of high-energy snacks
served in small portions, because children could purchase
more than one portion of these products. The legal process
for new regulations in Mexico includes a public hearing
administered by the National Commission for the Improvement of Regulations (NCIR). The public hearing resulted in
842 comments, with almost two-thirds (63%) in support
and one-third (37%) against the regulations. However,
99% of the food industry’s comments were against the
regulations, while 86% of those from the social and academic sectors supported the regulations. However, despite
the wide social support for the implementation of the original proposed regulations, the NCIR made a preliminary
ruling rejecting the original proposal and instructing the
MOH and the MOE to address the specific questions and
issues raised by industry during the hearing. The ruling led
14 (Suppl. 2), 69–78, November 2013
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to MOH and MOE negotiations with the food industry and
other interest groups, which resulted in the elimination of
the energy–density criterion and changes in the upper limits
for sugar and saturated fat. Although soda was banned
from schools, despite strong opposition from the soda
industry, other SSBs, including juices and flavored waters
with some amount of juice, and milk were allowed.
The public hearing and the negotiations stimulated the
interest of NGOs engaged in preventing obesity and promoting children’s rights, among other convergent problems.
Recent evaluations of the implementation of this initiative
have identified challenges, including (i) the need to reduce
the sales of salty snacks from the average of more than three
times per week in most schools; (ii) banning the sales of SSBs
that are currently not banned; (iii) increasing water availability and promoting its consumption; (iv) assuring funding
for comprehensive evaluations of the programme and (v)
guaranteeing the commitment of the new administration to
maintaining and improving the programme.
Front-of-package (FOP) labeling system
The FOP labeling systems are a new trend in the promotion
of healthier food choices among consumers, regardless of
their levels of education. Internationally, these systems are
one of the key tools. The evidence demonstrates that consumers have difficulty interpreting the labels on the backs
of processed foods. Thus a number of FOPs have been
created around the world. A group of transnational food
industries created a system known as the Guideline Daily
Amount (GDA) to be a rapid guide for consumers and as an
alternative to other FOPs. A useful FOP must be simple and
must be established by a group independent from the food
industry. In developed nations GDAs have been criticized
for their complexity (20–22). A recent evaluation conducted by the INSP and the MOH found that the GDAs
are not useful guides for better nutrition choices among
consumers in Mexico (23). This study demonstrated that
GDAs are misleading, and other authors in developed
countries have arrived at the same conclusion. In response,
the Mexican government established its own independent,
pro bono, international scientific committee to develop an
FOP. After reviewing alternatives, the Mexican expert
group decided to develop a system similar to the one
known as Choices International, but adapted to the food
groups currently available in Mexico. This system awards a
voluntary ‘seal of recommendation’ to the top 20% of
foods in each food group with the best nutritional profiles.
The criteria that define the profiles, contrary to the GDAs,
are determined by an independent expert group and evaluate contents identified by the WHO as problematic for
health (sugar, fat, and sodium) in addition to the total
energy content. The INSP is working to refine the system so
it can be launched as soon as possible.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity
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Obesity prevention policies in Mexico S. Barquera et al. 75
Regulation of marketing of foods and beverages to
children and adolescents
Conclusion: evidence-based policy
formation model
The ANSA identified food and beverage marketing, in particular when it is addressed to adolescents and children, as
a factor underlying unhealthy nutritional choices. Mexico
is collaborating with the Pan American Health Organization (PAHO) task force to control food marketing to children and adolescents. The task force recently released a
report on the best practices countries should adopt to
protect children from unhealthy choices that might compromise their health (24).
In Mexico, the food industry proposed a self-regulatory
code for marketing known as the Self-Regulatory Code
of Advertising of Food and Non-Alcoholic beverages.
Addressed to Children. This code is insufficient and is far
for complying with the PAHO recommendations. In its
current form it will hardly protect children and adolescents from exposure to marketing campaigns for junk
food. For instance, there is no penalty for advertising
unhealthy foods on TV, for products or fast food chains
to give toys or incentives, or for animated characters to
promote products to school-age children. The international consensus is that advertising is of strategic importance for health and that it has to be regulated by
the state. This has already been accomplished in some
countries.
The Mexican government has considered several actions
to make it easier for the population to develop healthy
eating habits, including (i) the Mexican national beverage
guidelines; (ii) a multisectoral national obesity prevention
strategy based on the ANSA but providing a budget,
accountability mechanisms, and intersectoral coordination;
(iii) the school guidelines for healthy foods; (iv) the
Mexican FOP and (v) the regulation of food and beverage
marketing to children. These recommendations were published in the position book developed by the Mexican
National Academy of Medicine (27). In addition a national
food and nutrition education strategy is necessary to
educate the population about the risks of consuming SSBs
and energy-dense foods, particularly ultraprocessed products, and the government must encourage the food industry
to provide healthy, low-cost alternatives.
The documented processes represent, to our knowledge,
some of the best practices in evidence-based health policy in
Mexico, characterizing the problems and opportunities by
using updated, nationally representative data; forming an
international independent, pro bono expert panel; adapting
international evidence to the local context; and translating
recommendations into policies and programmes. Thanks to
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
reduction of fat in the milk distributed by the government
through social programmes for vulnerable and lowsocioeconomic populations, and the provision of nutrition
information to policy makers in congress who are developing initiatives and to consumers to make better nutrition
choices, among many other activities.
Some recommendations for an effective obesity prevention policy in Mexico are summarized in Table 3. Mexico is
facing a burgeoning epidemic of obesity, diabetes, coronary
heart disease and cardiovascular disease. The evidence indicates that this epidemic is related to changes in the social
environment that could be ameliorated with the leadership
of the MOH in developing laws, norms and regulations
supported by an effective nutrition education programme
to encourage the population to adopt a healthy lifestyle.
Decreasing consumption of caloric beverages and energydense foods is an essential part of the solution. The priority
programmes of the MOH and the MOE must include initiatives to increase the consumption of water in schools and
to improve the quality of the food available to students.
The development of evidence-based policies is essential,
but it is not enough. Adequate intersectoral coordination
and cooperation among governmental agencies is complex
and requires the participation of key policy makers. For
example, we have been collaborating with the Ministries of
Soda taxation initiatives
Mexico is the leading country in the world in the consumption of SSBs, with an estimated intake of 163 L per person
per year (25). There have been attempts in Mexico to tax
sodas as a strategy to reduce SSB consumption in the population and to generate revenue to use on obesity prevention
interventions among the poor, such as the introduction of
potable water in schools and poor communities, where
clean drinking water is not always available. The INSP has
estimated own and cross-price elasticities of the demand for
soft drinks and other SSBs and has explored the effect of a
tax on beverage expenditures according to income level (26;
Colchero, unpublished data). Results of a recent analysis
indicate that the demand for soft drinks is elastic: a 10.0%
increase in the price of soft drinks is associated with a
decrease in consumption of 10.1% (Colchero, unpublished
data). Consumers substituted water and milk when the
price of soft drinks rose. Higher elasticities were found
among households in more deprived areas and from the
lowest income quintiles. Despite these results, the tax initiative so far has not been approved by the congress due to
strong lobbing from the food industry. It is important to
build support and to achieve coordination between the
government sectors involved in the tax initiative and civil
society to pass a bill soon.
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity
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76 Obesity prevention policies in Mexico S. Barquera et al.
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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 Economics to organize unified messages to citizens and unified
approaches to negotiate with the food industry. Some of the
early initiatives were not discussed extensively with nutrition leaders, and consequently, some felt excluded and did
not support them. In contrast, when initiatives included
consultation with nutrition and health leaders, support was
almost universal. We learned that a series of small group
meetings to present the recommendations of the expert
panel were beneficial in obtaining valuable feedback and
building the consensus and support required to institute
governmental policies.
Finally, despite industries’ declarations of a commitment
to health, the strong opposition from some industrial segments, such as industrialized food and beverage associations, confirms that commercial interests prevail over
health concerns at both the international and the national
levels. However, we anticipate that the Mexican process,
together with similar experiences in other parts of Latin
America, will motivate both the government and the food
industry to encourage healthier behaviors and develop
healthier products.
NGOs have played an important role in this process. The
Mexican Alliance for Healthy Nutrition (28), a consortium
representing more than 20 NGOs, has launched a very
effective media campaign against sugary beverages (29)
using nontraditional media, such as social networks, billboards and posters in subway lines, as well as traditional
media coverage.
The food industry, without independent academic
support, established the Alliance for a Healthy Life (30)
to promote GDAs that emphasize energy balance instead
of the government recommendations that would limit
14 (Suppl. 2), 69–78, November 2013
the intake of sugar, salt, fat and sodas. Several academic
groups, including ours, are documenting these ongoing
campaigns.
Funding agencies can play an important role in the prevention and control of obesity in low- and middle-income
countries. An example is the Bloomberg Philanthropy’s
(BP) model in its public health programme, which has
supported initiatives in tobacco control, road safety, and
maternal health through funding academic institutions,
advocates, government offices, and networking activities.
BP funds academic institutions to generate evidence that
can be useful for designing policies and programmes and
for monitoring and evaluating such initiatives. NGOs are
funded to advocate for the implementation of evidencebased strategies for the prevention and control of health
problems, and government offices are funded to improve
implementation of such policies and programmes. BP has
started a pilot programme in Mexico on obesity prevention
that uses this funding model that has been successful in
other areas, and it has started to show promising results.
In 2010, when the ANSA was approved, there were no
explicit obesity prevention policies in Mexico. Thus the
Mexican experience is very brief. In this short time,
however, we have been able to identify accomplishments,
failures and challenges.
The intersectoral agreement (ANSA) was signed by all
relevant actors with the president of Mexico as the witness;
however, its implementation has limitations because of
structural weaknesses. The school food regulations were
approved despite the strong opposition of the food industry
and have been implemented during 3 years, although
there are still some implementation challenges. The selfregulatory code for marketing to children has design flaws,
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity
obesity reviews
because it does not comply with international standards,
such as the ones proposed by the WHO and the PAHO
(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
food and beverage industries have put up strong opposition. Given its economic power and the lack of harmonization between its economic interests and the public health
objectives, this sector has opposed most government efforts
and has successfully prevented FOP labeling, the regulation
of marketing to children according to international standards, and the soda tax bill. (ii) Government limitations,
including poor planning capacity, lack of accountability
and transparency, inadequate budgeting, and insufficient
resources, have been an obstacle for the implementation of
the ANSA and have put constraints on the implementation
of the school regulations. In some cases unwillingness to
protect the public interest from influences that oppose
health policies has been a factor in the failure to enact some
policies.
The factors that facilitated the approval and partial
implementation of the ANSA and the enactment of the
school food regulations include (i) support from key political leaders during the past administrations at the MOH and
the MOE; (ii) strong support and substantial backing for
these policies by effective civil society organizations; (iii)
academia’s solid support and dedication to developing the
technical framework; (iv) media coverage of the obesity
epidemic and its risk factors and (v) the use of recommendations for obesity prevention policies from international
organizations, such as the WHO Global Strategy on Diet,
Physical Activity, and Health and the World Cancer
Research Fund 2007 report.
The government sectors involved in obesity prevention
require the support of civil society and academia to develop
and implement the FOP labeling system, regulate food and
beverage marketing, promote water consumption, enact
taxes on SSBs, improve the implementation of the school
guidelines for healthy nutrition, and devise an effective
nutrition education strategy. These are urgent actions that
could contribute to reducing the obesogenic environment
and help the population choose healthier lifestyles.
Acknowledgements
We thank the Rockefeller Foundation’s Bellagio Center for
support for this meeting and funding of international
travel. We also thank the University of North Carolina
Nutrition Transition Program for funding hotel and related
surface travel costs, administrative support, editing and
funding of this publication. We also thank the International
Development Research Center, Canada for funding open
access of this paper and Bloomberg Philanthropies for
support of all phases of final paper preparation. We also
© 2013 The Authors. Obesity Reviews published by John Wiley & Sons Ltd
on behalf of the International Association for the Study of Obesity
Obesity prevention policies in Mexico S. Barquera et al. 77
acknowledge the Canadian Institutes of Health Research
for added research support.
Conflicts of interest
The authors have no potential conflicts of interest to
declare.
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