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Obesity Prevention: Strategies and Challenges in Latin America

Article · May 2018

DOI: 10.1007/s13679-018-0311-1

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Current Obesity Reports (2018) 7:97–104
https://doi.org/10.1007/s13679-018-0311-1

OBESITY PREVENTION (A MUST, SECTION EDITOR)

Obesity Prevention: Strategies and Challenges in Latin America

Louise Cominato 1,2,3 & Georgia Finardi Di Biagio 3,4 & Denise Lellis 3,5 & Ruth Rocha Franco 1,3 &
Marcio Correa Mancini 3,4,5 & Maria Edna de Melo 2,3,4,5

Published online: 8 May 2018

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review The purpose of this study is to present changes of policies and norms aimed to reduce obesity levels that have
been adopted in some Latin American countries.
Recent Findings The global increase of the excess weight within the population has been demanding governmental actions aimed
at preventing health impacts generated by obesity. Over recent years, many Latin American countries have established a number
of regulations aimed at reducing weight in the population using interventions that could effectively prevent childhood obesity,
including the taxation of sugar-sweetened beverages (SSBs), increasing physical activity in open spaces, and, especially, front-of-
package labeling.
Summary Some strategies are part of the Action Plan for Prevention of Child and Adolescence Obesity signed by all countries in
Latin America, which currently have among the highest prevalence of childhood obesity in the world. Among them are the
implementation of fiscal policies on energy-dense and nutrient-poor foods and taxes on SSBs; improvements in nutrition
labeling, highlighting the front-of-package (FOP) labeling to promote the choice of healthier products at the time of purchase;
and promotion of an active lifestyle, such as encouraging the use of bicycle paths or physical activity programs at school. The real
impact of these prevention strategies implemented in Latin America on the prevalence of obesity is still unknown.

Keywords Obesity, prevention . Chronic disease, non-communicable . Meals . Fast food . Physical activity . School health
services . Schools, public health . Food labeling

Introduction Overweight in children and adolescents is a worrisome

The increased prevalence of obesity and being overweight has
been described as a global epidemic that includes adults and
children in economically developed countries and in countries
that continue to face economic challenges [1].
problem and has led to changes in scientific recommendations
[2], because numerous studies have already reported that be-
ing overweight during childhood may have a strong negative
health impact that can continue into adulthood [3].

This article is part of the Topical Collection on Obesity Prevention

* Louise Cominato Maria Edna de Melo

louise.cominato@hotmail.com medna@usp.br

Georgia Finardi Di Biagio 1

Pediatric Endocrinology Unit of the Children’s Institute of the
gefinardi@gmail.com Medicine Faculty, University of São Paulo, São Paulo, Brazil
2
Denise Lellis Brazilian Association for the Study of Obesity and Metabolic
denise.lellis@gmail.com Syndrome (ABESO), São Paulo, Brazil
3
São Paulo, Brazil
Ruth Rocha Franco 4
League of Childhood Obesity of the Hospital das Clínicas of the
ruth.franco@hc.fm.usp.br
Faculty of Medicine, University of São Paulo, São Paulo, Brazil
5
Marcio Correa Mancini Obesity and Metabolic Syndrome Group of the Hospital das Clínicas,
mmancini@usp.br Faculty of Medicine, University of São Paulo, São Paulo, Brazil
98
The prevalence of childhood obesity in Latin America is
among the highest in the world; one in five people under
20 years of age is overweight or obese [4]. In 2014, all of
the Latin American countries signed the Plan of Action for
the Prevention of Obesity in Children and Adolescents, which
considers the most important factors that promote weight gain,
obesity, and diet-related and non-communicable diseases as
the following: (1) the high consumption of nutrient-poor foods
that contain large amounts of sugar, fat, and salt; (2) the rou-
tine consumption of sugar-sweetened beverages (SSBs); and
(3) insufficient physical activity [5, 6].
One distinguishing aspect of Latin American countries is
the double burden of being overweight and malnutrition. The
obesity epidemic overlaps with ongoing challenges of malnu-
trition, which continues to affect these countries and causes an
even greater challenge to obesity prevention initiatives. In this
context, public health policies are even more complex [7].
Therefore, despite being engaged and aware of their pressing
nutritional issues, few Latin American countries are ready to
implement changes in their public policies that successfully
address strategies for both malnutrition and obesity [8]. Some
of these regional and national policies attempt to promote
breastfeeding, such as (a) the Baby Friendly Hospital
Initiative, with implementation and monitoring of the protec-
tion of breastfeeding in the workplace; (b) implementation of
new policies to improve school nutrition, especially foods sold
in schools in Colombia, Chile, Peru, Ecuador, Costa Rica, and
Uruguay; and (c) regulation of food marketing to children in
Chile [8]. Against this challenging backdrop, this paper pre-
sents the most relevant changes of norms and regulation aimed
to reduce obesity levels that have been adopted in some Latin
American countries (Table 1).
Taxation and Sugar-Sweetened Beverages
In middle-income countries, higher taxation on products is
usually an effective means to reduce consumption. The imple-
mentation of fiscal policies, such as taxes on SSBs and other
energy-dense and nutrient-poor foods, is one of the strategies
included in the 2014 Plan of Action for the Prevention of
Obesity in Children and Adolescents, adopted by the Pan
American Health Organization (PAHO) affiliated with the
World Health Organization (WHO).
SSBs are defined as all beverages with added sugar, ex-
cluding dairy and yogurt. High consumption of beverages
with added sugar is quite common in Latin American coun-
tries. In January 2014, the Mexican Ministry of Finance im-
plemented taxation of SSBs and made food producers legally
responsible for the calculation, disclosure, and payment of
taxes. Preliminary monitoring indicates that the price of
sweetened beverages has increased by approximately 10% in
Curr Obes Rep (2018) 7:97–104
Table 1 Changes of norms and regulation aiming obesity prevention
adopted in some Latin American countries
Taxation and sugar-sweetened beverages
•Mexico (Jan/2014): SSBs tax implemented by 10%, with 9% reduction
in purchases.
•Chile (Jan/2015): ad valorem at a rate of 18% on SBBs with more than
6.25 g of sugar per 100 mL.
•Barbados (Jun/2015): 10% increase in purchases—beverages non-taxed
(100% juices, coconut water, and dairy drinks).
Front-of-package labels
•Mexico (Apr/2014): Guideline Daily Amount (GDA) has the
approximate amount of calories, fat, saturated fat, sugars, and sodium
per serving listed.
•Ecuador (Aug/2014): Traffic Light System, indicating the levels of fat,
saturated fat, sugars, and sodium found in processed food by colors.
•Chile (Jun/2015): Warning Octagonal Black System, indicating if the
food exceeds the amounts of saturated and total fats, sugars, sodium,
and calories allowed by nutritional recommendations using the black
octagonal.
Physical activity programs
•Colombia, Brazil: cycle paths, which increase the participation of
children and adults in daily physical activity.
School interventions
•Physical education programs
•Feeding in schools
○Lunch school children: based on unprocessed and fresh foods
○Prohibition of stores that offer mostly ultra-processed foods
(energy-rich and nutrient-poor) inside or near schools.
that country. Colchero et al. observed an 11% reduction in
consumption per 10% increase in purchase price [9].
Studies of Mexican urban households and national sales
found a 6% reduction in the consumption of SSBs in 2014
and a 9% reduction in 2015 [10]. General beverage purchases
which were not eligible for tax increased by 2.1% during this
time. Low-income families also reduced purchases of taxed
beverages in 2014 and 2015 [11, 12•]. These positive results
have created a public debate regarding the effects of the tax on
SSBs and are being used as a model for implementation in
other countries [10, 11, 12•, 13].
In June 2015, the Government of Barbados approved a
special tax, corresponding to 10%, on SSBs, including soft
drinks, juices with added sugar, and sugar-sweetened sports
and energy drinks. Beverages not taxed comprise only 100%
juice, coconut water, and dairy drinks [14].
Since January 2015, Chile has been applying an 18% ad
valorem tax on SSBs containing more than 6.25 g of sugar per
100 mL, and a 10% tax on SSBs with less than 6.25 g of sugar
per 100 mL [15].
Front-of-Package Labels
In a recent report published by the Food and Agriculture
Organization of the United Nations with PAHO, there is indi-
cation of legislative and regulatory actions and public
Curr Obes Rep (2018) 7:97–104
programs, at different levels, focused on promoting health and
healthy and adequate diets that address the supply and demand
of healthy foods, aiming at the prevention of obesity, malnu-
trition, and other priority diet-related diseases [16, 17].
Governments—and industry—need to consider and ensure
that the consumer population is fully informed about the food
they eat. Guiding choices and providing adequate access to
nutrient-rich foods from the basic and correct reading of avail-
able nutritional information labeling is considered a relevant
component in this process [17, 18]. Nutrition labels are a
means to communicate information about products to con-
sumers, making it possible for consumers to understand the
nutrition content of food products. For this reason, it is con-
sidered one of the most effective tools for influencing consum-
er behavior [19].
In recent years, the marketing of food products for children
has increased, and it is illustrated by numerous packages with
very attractive designs. Many brands use striking colors and
include pictures or cartoon characters to make the label more
appealing to young consumers and influence purchase prefer-
ence [19, 20••]. In a study that evaluated the influence of label-
ing on the acceptance of two products popularly consumed by
youth, it was verified that when a character was added to the
label, there was a significant increase in acceptance (on average
55%). In addition, 53% of the children who were interviewed
used the word “funny” to describe the label [21•].
It is important to emphasize that these foods were not those
considered “healthy”; their nutritional composition was rich in
sugar and fats. However, as expected, that aspect was not
considered by the children in their evaluation of the food
products. It seems clear that the adoption of this type of mar-
keting strategy focused on children is a predictor of negative
eating patterns, because they increase the taste, the desire, and
the purchase of food products that have low nutritional quality
[20••]. In addition, parents’ behavior in response to nutrition
labeling is not always adequate due to the limited time avail-
able when shopping to check the food labels on packages in
detail. This also makes it difficult to identify the best food
choice [21•].
Thus, to address the consumer’s right to adequate access to
clear and easily understandable information, nutrition labeling
should allow for adequate time for the food choice decision to
be positively influenced by health [21•].
Large variation in regulations and guidelines on nutrition
labeling around the world remains. In some Latin American
countries, governments have yet to develop any form of policy
or regulation [22]; in others, specific regulatory and monitor-
ing frameworks for food labeling have been implemented, as
mandatory or voluntary nutrition labeling standards [19].
Adopting the worldwide trend, most Latin American coun-
tries have mandatory nutrition labeling on the back-of-
package (BOP), and, in recent years, some have also offered
front-of-package labels (FOP) [22].
99
A simpler and easier alternative form of labeling is the
front-labeling system referred to as “Traffic Light.” Based
on a proposal from the UK Food Regulatory Agency, it has
been in use by Ecuador since November 2015. The label in-
dicates levels of total fats, saturated fats, sugars, and sodium
found in processed foods through the colors of a traffic light:
red indicates an excess level of the specific nutrient; yellow
indicates a moderate amount; and green indicates adequate or
the recommended amount, according to the WHO nutritional
recommendations [22]. It should be noted that the excess con-
sumption of ultra-processed products is directly related to the
increase in dietary fats, sugars, and sodium levels, causing
nutritional imbalance, a risk factor for the increase in the inci-
dence of chronic non-communicable diseases such as obesity,
hypertension, and type 2 diabetes mellitus [22]. This method-
ology proposed by the Food Standards Agency (FSA) assists
the consumer with choosing healthier packaged food.
Another notable front-labeling system, developed by the
Ministry of Health of Chile, is the Warning Octagonal Black
System (WOBS). This system indicates if the food product
exceeds the amounts of saturated fats, sugars, sodium, and
calories allowed by nutritional recommendations by the use
of a black stop sign with the message “high level of saturated
fats,” “high level of sugars,” “high level of sodium,” and “high
level of calories.” If no component exceeds the nutritional
recommendations, no signs are placed on the front of the label
[23]. According to research done with Chilean consumers
1 year after the implementation of the WOBS warning system,
95% of the mothers of pre-school-aged children and adoles-
cents interviewed agreed that the Ministry of Health is helping
consumers identify unhealthy foods, and 81% of the adoles-
cents began to notice the presence of warning black octagons
in these unhealthy foods [24]. More than 90% of consumers
interviewed reported that the labeling system affects the con-
sumption of certain products and two-thirds of them report
choosing foods with the fewest warning labels. In addition,
86% indicate that children should be prevented from eating
products that display the stamps [24].
In Mexico, the Guideline Daily Amount (GDA) was
established in 2014 as the bases for mandatory nutrition label-
ing. However, research has found that this type of front-
labeling system is not very clear to many Mexican consumers.
Faced with this challenge, the government has been looking
for alternatives to make labels clearer and more transparent
and sought ways to encourage the food industry to follow the
standard Mexican labeling regulations [25].
In a recent study, Arrúa et al. compared three signaling
systems, the GDA, the WOBS, and the Traffic Light. The
Chilean warning system (WOBS) was more efficient than
GDA and the Traffic Light System in identifying ultra-
processed products that were higher in energy content, satu-
rated fats, added sugars, and sodium. The excess of calories,
saturated fat, sugar, and salt signalized by WOBS was
100
perceived as being less healthy than those with the GDA or the
Traffic Light. More than 80% of the study population was able
to identify the healthiest products with the Traffic Light
System and the WOBS warning system [20••].
These findings reinforce the idea that at the time of pur-
chase, the WOBS is effective in empowering consumers to
evaluate the healthfulness of non-processed products and to
discourage consumption of unhealthy ultra-processed prod-
ucts, which have been associated with obesity and several
non-communicable diseases [20••, 25, 26].
Physical Activity
The practice of physical activity has decreased globally due to
the adoption of a sedentary lifestyle. There are a variety of
factors related to physical inactivity that have contributed to
the global obesity epidemic such as a reduction of walking
because of a greater use of motorized transportation, a decline
in occupational physical activities because of increased auto-
mation and use of technology, and an increase in leisure time
spent performing sedentary behaviors [26]. Data on adults and
adolescents indicate that Latin America is the most inactive
region in the world, with 43% of those older than 15 years of
age classified as inactive [27].
The widespread availability of new technologies in Latin
America including smartphones, tablets, and portable activity
devices such as the accelerometers provides an opportunity for
population surveillance of physical activity and also makes
them a potential vehicle to carry out interventions to promote
physical activity and encourage healthy diets, particularly
among adolescents [28].
Research in this area is encouraging. A recent study dem-
onstrated that mobile health technology, which would help
people upgrade to a better lifestyle, promoted a small decrease
in weight and improved some eating habits in individuals with
pre-hypertension who lived in low-resource urban settings in
Argentina, Peru, and Guatemala [29]. A study in a Brazilian
city indicates that the presence of leisure or cycle paths with
two or more types of recreational activities less than 500 yards
from home increases the participation of adults in physical
activity. These results are important because they support the
actions described in the new urban plan of São Paulo to in-
crease access to public open areas [30]. Recreational Ciclovias
or “Open Streets,” which temporarily closes streets to motor-
ized transportation and creates a safe place for people to cycle,
walk, run, and participate in social health promotion and cul-
tural events, are very successful programs in Latin America
[31]. Studies of these programs in Bogotá show that users are
more likely to comply with physical activity guidelines and
have a higher quality of life [32]. A cost-benefit study estimat-
ed that every dollar invested in Bogotá’s Ciclovia saves US $3
per person on healthcare costs that represents US$13 million
Curr Obes Rep (2018) 7:97–104
per year [31]. It also showed the economy of nearly US$2
million a year in the city of Medellin.
Because of the success of Ciclovia programs in Bogotá,
the initiative has spread across 461 cities in Latin America
[33]. Cycle paths are an antidote to urban diseases and con-
tribute to a collective consciousness of healthy physical en-
vironments [34].
Although there are several complex benefits of cycle paths,
physical activity represents the greatest benefit in terms of
public health. The way that cycle paths have been designed
in Latin American cities has been different according to urban
design and political considerations. Cycling policies has met
resistance from some companies and other sectors, including
transport companies that have been affected by the road clo-
sures [35]. Most of the time, these challenges have been over-
come with a strong involvement of civil society highlighting
new economic development opportunities for small business
owners and evidence-based best practices [36].
Despite some limited evaluations of physical activity inter-
ventions that have been published, there is a substantial deficit
compared to the physical activity literature in high-income
countries. International evidence on the effectiveness of inter-
ventions suggests that intervention strategies to promote phys-
ical activity at various levels are promising, even in Colombia
and Brazil [37, 38]. The results of cost-effectiveness of obesity
prevention programs are still very limited in Latin America.
School-Based Physical Programs
In developed countries, physical activity at school is an im-
portant part of childhood obesity prevention programs [39].
From US evidence, we know that most vigorous physical
activities, as well as sedentary behaviors, are concentrated in
the school environment [40, 41]. More vigorous physical ac-
tivity in school is associated with greater vigorous daily activ-
ity, suggesting that increasing physical activity at school could
be an effective intervention to increase physical activity in
youth generally [42]. A recent systematic review has shown
that school-based interventions based on mandatory physical
activity are more likely to increase moderate to vigorous phys-
ical activity in youth (i.e., 23 min per day), which is almost
40% of the recommendation of the WHO physical activity for
this age group [43].
Data on physical activity in the school environment as well
as its impact are partly absent in Latin American countries,
however. A review that presented information from five
schools included in the Physical Education Programs of
Latin America (one in Brazil, two in Chile, and two on the
US/Mexico border) showed that different types of interven-
tions have the potential to increase levels of physical activity
during physical education classes and as part of active trans-
portation to school [44].
Curr Obes Rep (2018) 7:97–104
School Feeding
The nutritional status of school-aged children and adolescents
affects physical development, learning, cognitive potential,
and subsequently, school attendance and achievement of edu-
cational work. There is strong evidence that the school envi-
ronment influences diets and, therefore, the nutritional status
of children [45, 46••, 47, 48].
Inasmuch as life skills are often established in school,
healthy eating and an active lifestyle should also be promoted
in schools to modify pathways that lead to obesity. In addition,
despite advantages of addressing obesity in schools, the lack
of compelling evidence on the effectiveness of interventions
to date has led some to question the resources for these pro-
grams [49].
School meals provide a market for opportunities to im-
prove local agricultural production and food systems, contrib-
uting to food and nutritional security. Combined interventions
can have a beneficial impact, as they can break the cycle of
poverty through better nutrition and contribute to obesity pre-
vention by providing healthy food [50].
A Brazilian study of adolescents showed that the availabil-
ity of nutrient-poor foods offered in schools, such as sugary
drinks and savory snacks, was associated with a higher con-
sumption of these products [51].
A range of factors can influence the purchase of junk food
in Latin American schools. In Brazil, the stores that offer
mostly ultra-processed foods (energy-rich and nutrient-poor
are) frequently situated near the public schools [52], and, con-
sequently, children and adolescents purchase fast foods of
poor nutritional quality [53, 54]. In addition, the sale of food
by mobile food vendors is a common practice in Latin
America [54]. Recently, a study of 60 schools in two major
Mexican cities showed that the number of mobile food ven-
dors was positively associated with children’s BMI [55].
Current research evidence demonstrates the potential effec-
tiveness of school interventions in modifying eating behavior
and preventing obesity and being overweight [56, 57]. The
Brazilian government has developed an innovative food guide
that encourages the maintenance of or a return to a diet based
on minimally processed foods and requires that the school
meal programs at schools consist of 70% of minimally proc-
essed foods [58].
Brazil offers more than 41.5 million meals for schoolchildren,
and laws established to regulate the supply of food in schools
require the proportion of the supply that must come from foods
that are unprocessed and fresh (e.g., rice, beans, vegetables, and
fruits), generating a demand for healthy foods. Likewise, the law
requires at least 30% of all food to come from local producers,
protecting these vulnerable productive sectors [59, 60].
The financing challenges increase as countries strive to
expand coverage, improve the nutritional quality and diversity
of meals, and link programs to local economies. Most
101
countries have adopted a rights-based approach and are about
to achieve universal coverage at the elementary school levels.
This is a key achievement compared to other regions. Almost
every country in the region implements school meal programs.
Today, approximately 85 million students receive school
meals every day, with an annual investment of approximately
$4.3 billion, mostly from national sources [61, 62].
Several international agencies, such as the Centers for
Disease Control and Prevention and the Institute of
Medicine in the USA, have launched campaigns with guide-
lines for health promotion in schools in order to tackle the
causes of obesity epidemic [62, 63].
In Brazil, the School Health Program is designed to pro-
mote comprehensive healthcare for students in public schools.
It has four components evaluating health conditions, carrying
out prevention, and promoting ongoing training for profes-
sionals and students [63].
The responsibility for the planning and execution of these
actions is of the primary health care team, and the objective is
to integrate the education system and the Unified Health
System (Sistema Único de Saude, SUS) [64]. However, this
government action still does not cover all schools in the
country.
Young people need appropriate information to make
healthy choices and change their sedentary behavior, even
though their parents and teachers are not always prepared to
offer this information. Therefore, the involvement of trained
health professionals specialized in the field is necessary to
adequately provide this information.
Because children are exposed to the environment created
for them, and in Brazil, they typically spend approximately
25 h in school weekly, it is important to design actions that
seek to improve the school environment and generate a
healthy growth strategy.
Indeed, school meal programs in Latin America have ad-
vanced remarkably in recent decades. Most countries have
nutritional guidelines for school meals, but their quality and
application vary. Even where standards and guidelines are in
place, their implementation and monitoring are challenged,
especially in more vulnerable areas. Innovation is ongoing
as all countries in the region implement and/or test new mo-
dalities to foster links with local small farmers and ensure that
local products are included in the school meals.
Conclusions
In Latin America, the experience of implementing obesity-
prevention policies based on taxation of foods, physical activ-
ity in open spaces, and especially, warning nutrition labeling
can even benefit the rest of the world with their models. While
the true impact of strategies of prevention implemented in
Latin America on obesity prevalence remains unknown, the
102
experience provides some insights as to where the successes
are likely to lie.
Compliance with Ethical Standards
Conflict of Interest Louise Cominato, Georgia Finardi Di Biagio,
Denise Lellis, Ruth Rocha Franco, Marcio Correa Mancini, and Maria
Edna de Melo declare they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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