nutrition in chile: global challenges, local solutions

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Nutrition in Chile Global challenges,

local solutions

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Nutrition in Chile Global challenges, local solutions

About this research 2

Nutrition in Chile: Global challenges, local solutions 3

Obesity in Chile: The challenge 3

Obesity in Chile: The response 6

Global challenges and responses 7

The path forward in Chile: An integrated approach to local solutions 8

Contents



The Nutrition in Chile: Global Challenges, Local Solutions is a white paper written by the Economist Intelligence Unit and sponsored by DuPont. The fi ndings and views expressed in this briefi ng paper do not necessarily refl ect the views of DuPont, which has sponsored this publication in the interest of promoting informed debate. Lucy Hurst, associate director of custom research for the Americas, was the research director for the project. Jamie Morgan, analyst, was the project manager and editor. Leo Abruzzese, global forecasting director and executive editor for the Americas, served as senior advisor. Jill Mead served as a contributing author and nutrition expert for the project.

About this research



Nutrition in Chile: Global challenges, local solutions

Each year, US$53.5trn in social and economic costs is lost to malnutrition—the equivalent of US$500 for every person on the planet. Although the challenges of malnutrition were once confi ned to undernourished and underweight populations, today they include the overweight and the obese as well. Indeed, global obesity rates have doubled in the last 30 years, and obesity today is the underlying cause of 2.8m adult deaths annually worldwide.1 Whereas obesity was once considered a problem of the rich world, it is now emerging in low- and middle-income countries, even among those that still struggle with underweight and undernourished populations.2,3 According to the World Health Organisation (WHO), obesity and excess weight is now the fi fth-leading risk to global health. The condition is linked to more deaths globally than underweight maladies.4

The increase in obesity is alarming public-health agencies worldwide. Excess weight is linked to higher risk of heart disease, stroke, breast cancer, colon cancer and many other health problems, including premature death.5,6 As a result, the economic burden of obesity is staggering, with treatment costs running into the hundreds of billions of dollars in the United States alone. As obesity rates rise in other countries, so, too, do costs.7 1 World Health Organization (WHO), 2013.2 Ibid.3 Ibid.4 Ibid.5 Oxford Journals, The medical complications of obesity, August 2006.6 Haslam, D. W., & James, W. P. (2005), “Obesity”. Lancet, 366, 1197-1209.7 “Economic Costs,” The Obesity Prevention Source, Harvard School of Public Health,

website, accessed June 2013.

Several trends that transcend national boundaries explain the dramatic increase in obesity worldwide. Widespread industrialisation has increased the availability of processed foods high in fat, carbohydrates and sugar, and has reduced the need for manual labour in farming and industrial production. At the same time, urbanisation has led to a relative increase in sedentary occupations, and the rising standard of living has improved access to motorised transportation and other labour-saving devices.8 The result is that people are consuming greater amounts of energy-dense foods while expending fewer calories in their day-to-day lives, leading to a global increase in body mass.

Obesity in Chile: The challengeFighting obesity has become a national struggle in Chile. Indeed, Chile in many ways epitomises the classic nutritional and health transition scholars describe in emerging markets. In the 1970s, malnutrition and infectious diseases were the primary national food-security and health challenges, particularly among the rural poor.9 The rapid modernisation and urbanisation, of the 1980s and 1990s changed the lifestyles of many Chileans and thus the country’s health profi le. By the end of the 1980s, undernutrition had virtually vanished, but obesity was on the rise.10 Today, obesity is considered one of the nation’s top health

8 “What is the Nutrition Transition?,” University of North Carolina, website, accessed June 2013.

9 Vio del Rio, F., The Nutrition Transition in Chile, 2007.10 Albala et al., Nutrition in Chile: Determinants and consequences, 2002.



*Or nearest year. Sources: OECD Health Data 2011; national sources for non-OECD countries.

Obesity globally: prevalence among select countries% of population, 2009*

India

Indonesia

China

Korea

Japan

Switzerland

Norway

Italy

Sweden

France

Netherlands

Austria

Poland

Denmark

Israel

Belgium

Brazil

Germany

Turkey

Portugal

Spain

Slovenia

OECD

Slovak Republic

Czech Republic

Estonia

South Africa

Greece

Hungary

Russian Fed.

Iceland

Finland

Luxembourg

Ireland

United Kingdom

Canada

Australia

Chile

New Zealand

Mexico

United States

2.8 1.3 3.6 1.1 3.4 2.4 4.1 3.6 3.5 4.3 7.7 8.6 8.0 11.0 9.3 11.3 10.7 11.7 11.5 10.9 12.4 11.2 12.7 12.0 12.5 12.6 13.1 13.7 14.4 13.2 14.4 13.1 14.0 13.7 13.8 15.7 18.5 12.3 16.1 14.6 14.7 17.3 15.8 17.0 17.2 16.6 16.7 17.1 17.0 18.0 18.3 17.5 27.4 8.8 18.5 17.7 18.3 20.8 11.8 16.0 21.3 18.9 21.1 19.3 19.0 24.5 24.0 22.0 23.9 22.1 23.2 25.2 23.6 25.5 30.7 19.2 27.0 26.0 34.5 24.2 35.5 32.2

2.1

2.4

2.9

3.8

3.9

8.1

10.0

10.3

11.2

11.2

11.8

12.4

12.5

13.4

13.8

13.8

13.9

14.7

15.2

15.4

16.0

16.4

16.9

16.9

17.0

18.0

18.1

18.1

19.5

20.1

20.1

20.2

22.1

23.0

23.0

24.2

24.6

25.1

26.5

30.0

33.8

Self-reported data

Measured data

Females

Males



challenges. Results of the 2010 National Health Survey found that 25.1% of Chileans are overweight, an increase of 3.2 percentage points from the last survey in 2003. Although data on current obesity levels in the country is poor, the NGO Fundación Chile this year estimated that healthcare costs associated with obesity and excess weight cost Chile nearly US$1bn a year—about 5% of total annual healthcare costs.11,12

The prevalence of obesity varies by region in Chile. The lowest level of obesity is in the densely populated central region of Valparaíso; the highest is in the nearby rural province of Libertador General Bernardo O’Higgins.13 However, more than geography determines obesity. More than 35% of Chileans living below the poverty line are obese, compared with 24.7% of middle class Chileans and 18.5% of those in the upper class.14 High-income Chileans face greater pressure to conform to fi tness and weight standards, but they also have greater access to the healthy foods, knowledge and fi tness facilities that help them do so. Gender also plays an important role: 30.7% of women are considered obese, compared with only 19.7% of men, a trend that is common worldwide.15,16 Finally, obesity in 11 Fundacion Chile, website, accessed July 2013.12 Fundación Chile, Chile Saludable, 2012.13 Encuesta Nacional de Salud ENS Chile, 2009-2010.14 Marianela Jarroud, Obesidad e hipertensión son un factor de desigualdad en Chile,

Noticias, 25 Mar 2013.15 Fundación Chile, Chile Saludable, 2012.16 R. Kanter & B. Caballero, “Global gender disparities in obesity: a review”, Advances

in Nutrition, July 2012.

Chile has a strong inter-generational component. One study found that the greatest risk factor for developing obesity in childhood is having one or more obese parents, suggesting the importance of the home environment in the development of healthy eating and physical-activity patterns.17

Chile’s rates of childhood obesity are particularly alarming. Chile ranked sixth in a survey of infant and child obesity in OECD countries, and it has one of the highest rates of infant and child obesity in Latin America, outside of Mexico.18 As with national obesity, childhood obesity has become a signifi cant problem in the past 20 years: since 1987, the number of overweight fi rst graders has more than tripled.19 The rise in childhood obesity portends an on-going struggle with obesity for at least the next several decades. Research shows that obese children are at greater risk of becoming obese adults than their peers. They are also at risk of developing the same conditions in childhood that obese adults can develop, such as high blood pressure, high cholesterol or the high blood-glucose levels that can lead to diabetes.20

Researchers who study obesity in Chile point to changes in diet and increases in sedentary behaviour as the most likely explanations for Chile’s rapid weight gain. Incomes doubled in Chile over 1987–97, increasing quality of life but also providing people with more disposable income to purchase processed foods, televisions, appliances, cars and computers.21 As with many other countries that experience this nutrition transition, the industrialisation of food production decreased the relative cost of food over time, and the cost of foods high in fat, sugar and salt decreased to a greater degree than the cost of healthier foods.22 Over time, Chileans have consumed less minimally processed foods, such as legumes and fruits, and more processed foods high in saturated fat and sugar and low in micronutrients and dietary

17 Fundación Chile, Chile Saludable, 2012.18 Ibid, page 10.19 Ibid.20 Centers for Disease Control and Prevention (CDC), Childhood Obesity Facts,

website, accessed June 2013.21 Vio del Rio, F., The Nutrition Transition in Chile, 2007.22 Fundación Chile, Chile Saludable, 2012.

Note: Regional groupings defined by the WHOSource: World Health Organisation

Obesity rate by region% of population with Body Mass Index (BMI) ≥30 kg/m2, 2008

Africa

Americas

Europe

Eastern Mediterranean

East Asia

Western Pacific

8

25

21

24

5

27



fi bre.23,24 Fat consumption rose by more than 50% over 1988–97.25

Daniela Montecinos Godoy, who grew up in the southern region of Los Lagos, explained the ways in which eating habits have changed: “Before, mothers used to pack simple foods for their children’s school lunches, things like a sandwich and a piece of fruit. Today, students are sent to school with supermarket-bought foods, like a package of crackers and a juice box, nothing that would be considered ‘natural’.” Even though Chile exports fruits, vegetables and salmon to external markets,26 only half of Chileans consume the recommended amount of fruits and vegetables and only 17% consume the recommended amount of fi sh.27

Obesity in Chile: The responseCompared with other countries, Chile’s nutritional transition has been particularly rapid.28 Having dedicated resources to the underweight and the undernourished for so many years, the Chilean government was faced with a sudden need to switch strategies. Although obesity began to increase nationally in the 1980s, it was not until 1998 that the national food policy was changed to address obesity rather than undernutrition.

The 1998 shift marked the start of an aggressive effort to combat obesity—a process that has, nonetheless, proved challenging. In 1998, the newly-created National Board for Health Promotion (VIDA Chile) introduced a calorie-reduction policy in Chilean schools. The board co-ordinated with schools and the Ministry of Education to reduce the amount of calories in the school food programme, cutting fat, sugar and salt while incorporating greater amounts of fruits, vegetables, fi sh and legumes.29 In spite of the strength of the early VIDA Chile policies and other governmental efforts, it was clear by 2005 that the country was not making

23 Chilean National Institute of Statistics, National Household Budget Survey, Nov 2006 – Oct 2007.

24 Fundación Chile, Chile Saludable, 2012.25 Mendoza et al., Evolucion de la situacion alimentaria en Chile, Revista chilena de

nutricion, Mar 2007.26 Vio del Rio, F., The Nutrition Transition in Chile, 2007.27 Fundación Chile, Chile Saludable, 2012.28 Albala et al., Nutrition in Chile: Determinants and consequences, 2002.29 Vio del Rio, F., The Nutrition Transition in Chile, 2007.

suffi cient progress in reducing obesity rates.30 The Ministry of Health launched additional initiatives in 2005 and in 2010 to reduce the prevalence of obesity, including the Global Strategy Against Obesity (EGO Chile)31 and Elige Vivir Sano (Choose to Live Healthily), a national programme to encourage healthy eating and physical activity. Elige Vivir Sano increased physical-activity requirements in schools from two to four hours a week, “active plazas” were created through the installation of exercise equipment, and media campaigns encouraged exercise at home using household items like a kilo of rice.32 Although it is too early to know the full effects of these programmes, the government considers them a success. Policymakers also enacted the Sistema Elige Vivir Sano law, which further institutionalised the programme at the national level and guarantees funding for future efforts.33

Partnerships between the private sector and non-governmental organisations (NGOs) have also offered promising results in recent years. The international programme 5 al Día (5 a Day) is an example of a partnership between university researchers, the private sector, the national government and international health organisations such as the United Nations. The programme, which began in 2004, brings together the government and food producers to create policies aimed at increasing fruit and vegetable production and quality. These include multimedia educational and marketing campaigns to encourage Chileans to eat fi ve servings of fruits and vegetables a day. As a result of the campaign, Chileans in the target group consumed more fruit and vegetables.34

Despite 15 years of concerted efforts, obesity in Chile continues to grow. In 2007, Dr Fernando Vio del Rio, an academic who has been studying nutrition in Chile for more than 20 years, noted that although governmental efforts have increased Chilean’s knowledge about nutritional eating, they

30 Ibid.31 Chilean Ministry of Health, Global strategy against obesity (EGO-Chile), accessed

online June 2013.32 Marianela Jarroud, Inter Press Service Noticias, 25 Mar 2013.33 Elige viver sano, website, accessed June 2013.34 Corinna Hawkes on behalf of the FAO, Promoting healthy diets through nutrition

education and changes in the food environment, 2013.



have been insuffi cient to change Chilean’s habits. “The population knows both what healthy eating means and the benefi ts of engaging in physical activity, but many people persist in eating foods that are high in sugar, fat and salt, and in leading inactive lives,” Dr Vio del Rio said.35,36

Global challenges and responses Chile is not alone in its challenge with obesity. A variety of approaches are being tried in other countries, and although many of them are relatively new, several promising strategies have emerged. Broadly, health research suggests that the most effective programmes combine strategies that change not only individual behaviours that lead to obesity but also the broader social, institutional and policy environment in which those behaviours occur. In environments where making a healthy choice is easier than making an unhealthy choice, individuals fi nd it easier to 35 Dr. Fernando Vio del Rio, publications available through Instituto de Nutricion y

Tecnologia de los Alimentos.36 Vio del Rio, F., The Nutrition Transition in Chile, 2007.

maintain healthier lifestyles. The transformation of the social, institutional and political environment of a country can be a slow and challenging undertaking; therefore, governments are focused on incremental changes and successes.

Because of the global emphasis on reducing and preventing childhood obesity, many governments have made schools their fi rst point of attack in the fi ght against obesity. Mexico and Peru have been particularly active in this area. In Mexico, where 26.2% of school-aged children are obese,37 a 2010 law prohibits the sale or advertisement of “junk food” in primary and secondary schools. The law also requires 30 minutes of physical activity per day and requires healthier foods in school cafeterias. Peru implemented a similar law in 2012.38 Although both laws are new and it is too early to judge the results, other research suggests that this approach has promise. A 2012 study conducted in the United States found that students living in states with 37 Barquera et al., Obesity and central adiposity in Mexican adults: results from the

Mexican National Health and Nutrition Survey 2006, Salud publica de Mexico. 2009.38 Chilean Ministry of Health, Ministerial resolution, 2012.

Note: The data measure obesity among children entering first gradeSource: Chilean National Board of Student Aid and Scholarships (Junta Nacional de Auxilio Escolar y Becas)

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Estimate

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

Childhood obesity in ChileRate of obesity among Chilean students entering first grade, %



laws regulating the nutritional value of food in schools showed a smaller body-mass index (BMI) than students living in states with weak or non-existent laws.39

Outside of schools, governments have also tried different strategies to limit the availability and consumption of high-calorie foods. In Denmark and the US, governmental policies have targeted the sale of high-calorie foods by restaurants and vendors. In 2004, Denmark became the fi rst and only country to ban the use of trans fats in all products.40 In 2007, New York city offi cials banned restaurants from using trans fats. A subsequent study found that New York’s policy signifi cantly reduced trans-fat consumption.41

In another approach, governments have tried to manipulate the cost of healthy and unhealthy foods. Denmark, France and Norway used taxes, subsidies and other methods to alter the prices consumers pay for foods.42 Perhaps the most-widely-reported recent effort was Denmark’s 2011 implementation of a “fat tax” on foods composed of more than 2.3% saturated fats. Although the tax was rescinded after only a year, because of political pressure, one study found a 10–20% drop in the sales of margarine, butter and oil, suggesting that the new, higher price may indeed have led to a healthy shift in consumer behaviour.43 Other countries, including France and Norway, tax products containing excessive sugar. Evidence from France suggests that consumption of soft drinks has decreased as a result.44 Although taxes on sugar-sweetened beverages have affected consumption patterns, little if any evidence exists on the long-term effectiveness of these policies in reducing obesity.45,46

To complement efforts to modify the food

39 Taber et al., Weight status among adolescents in states that govern competitive food nutrition content, Pediatrics, Sep 2012.

40 Caroline Scott-Thomas, Trans fat reducation policies are working to reduce consumption, says WHO, Food navigator, 09 Apr 2013.

41 Angel et al., Change in Trans Fatty Acid Content of Fast-Food Purchases Associated with New York City Restaurant Regulation: A Pre-Post Study, 2012.

42 OECD, Obesity update 2012.43 “Denmark’s food taxes: A fat chance”, The Economist, 17 Nov 2012.44 Ben Bouckley, Soft drinks stall in France as consumers trade down: Canadean,

Beverage daily, 24 Apr 2013.45 Chriqui et al., “A typology of beverage consumption,” Journal of Public Health

Policy, May 2013.46 Fletcher et al., Substitution patterns can limit the effects of sugar-sweetened

beverage taxes on obesity, Preventing Chronic Disease, 2013.

environment, a number of countries have introduced programmes and policies to encourage healthy eating and exercise. In 2008, the Mexican government launched a national campaign, Vamos Por un Millón de Kilos (Let’s Go For a Million Kilos) to encourage people to exercise. The programme, which provided Mexicans with access to personalised weight-loss and physical-activity guidance from doctors,47,48 generated considerable excitement: more than a million people participated, and they lost a collective 2.5m pounds (over 1m kilos). The US launched a similar campaign with Let’s Move!, and the UK with Change4Life. National programmes such as these emphasise the enjoyable aspects of a healthy lifestyle and, in so doing, try to shift attitudes and norms about healthy behaviour. These efforts also provide citizens with information about healthy eating and exercise. Although such programmes try to support millions of citizens in the effort to lose weight or prevent weight gain, it may be years before their effect on large-scale obesity reduction is known.

The path forward in Chile: An integrated approach to local solutions

The experiences of the past decade in the global fi ght against obesity have made it clear to governments and food and health professionals alike that an integrated approach is needed for meaningful results. Indeed, Fundación Chile’s Chile Saludable (Healthy Chile) report calls for “integrated intervention from multiple actors at multiple levels”, combining changes in individual behaviour with environmental changes in schools, homes and workplaces, along with system-wide changes in food production, transportation networks, the educational system, and urban planning.49

Perhaps the best evidence to support an

47 Jaime A. Zea, “Campaign calls for Mexicans to lose 2 million pounds,” USA Today, 28 Sep 2008.

48 Mileno, Finaliza con éxito campana nacional ‘Vamos por un million de kilos’,” 28 July 2008.

49 Fundación Chile, Chile Saludable, 2012.



integrated approach comes from a study undertaken in Finland in the 1970s. The North Karelia Project tried to reduce mortality from heart disease in Finland by curbing the intake of saturated fat, increasing the consumption of fruits and vegetables, and encouraging physical activity. The project team partnered with a trusted community organisation to create healthier versions of traditional dishes, and it successfully urged legislators to create policies to reduce the fat content of school lunches. The team also lobbied the government to reduce subsidies for the producers of high fat foods and worked with other food producers to create lower-fat versions of foods such as sausages to meet the emerging market demand for healthy food. At the same time, the project team worked with local governments to increase infrastructure that enables physical activity, such as walking paths and bike lanes.50 By altering the availability, attractiveness and affordability of healthier options, the North Karelia Project reduced deaths from premature heart disease in men by 75% and contributed to lower levels of obesity that continued into the 1990s. Although Finns have become more obese in the last decade,51,52 the programme still offers important lessons for communities trying to implement obesity-reduction policies. The success of the programme hinged on three factors: the co-operation of the national food industry, the political will to implement the project team’s recommendations and a focus on the entire population, as opposed to solely those at risk of heart disease.53

50 Joyce Hendley and Rachael Moeller Gorman, How the people of Finland took a healthy message to heart, Eating Well, website, accessed June 2013.

51 OECD, Finland country page, website, accessed June 2013.52 OECD, Health at a glance 2011.53 Karen Allen, Fighting fat the Finnish way, BBC, 5 Feb 2004.

Food-security experts in Chile and other countries face a new challenge today: develop complementary strategies to ensure that people get enough to eat while not eating too much of the unhealthy foods that lead to obesity. Although the problem of obesity is global, each country needs to develop strategies and solutions appropriate to its local context. Nonetheless, the most effective strategies share a common blueprint: they focus on understanding and changing the broader environment in which individual behaviours occur. They also target multiple settings, such as the school, home and workplace. Finally, they enjoy co-operation and collaboration among a wide group of stakeholders, both public and private. A single policy, however well-intentioned, cannot reduce a country’s obesity rates; multiple, complementary policies, however, can often create healthier environments and, by default, healthier individuals.

There is reason for optimism in Chile. Although obesity continues to rise, the rate of its ascent is slowing.54,55 A recent consumer survey in Chile showed increased interest in healthy food, opening the door for private companies to develop and market healthy, tasty products.56 Companies that do so will be helped by a new law that takes effect in July 2013, the fi rst in the world to mandate warning labels on foods with high sugar, fat or salt content. With each new policy, Chile moves towards a critical mass of successful programmes that can collectively slow, and eventually reverse, the obesity epidemic.

54 “Chile esta entre los 10 paises con mas sobrepeso del mundo” La Tercera, April 2nd 2013.

55 OECD, Obesity update 2012.56 Fundación Chile, Chile Saludable, 2012.



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nutrition in chile: global challenges, local solutions

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