OBESITY MUST BE TREATED AS A PUBLIC HEALTH ISSUE

"The diet is killing us."

Anthony Winson, researcher at the University of Guelph (Canada) in an interview with The New York Times

INTRODUCTION

Nowadays, excess weight is a global issue. Currently, 40% of the world’s population is overweight- three times more than 40 years ago (World Health Organization [WHO], 2018). In Brazil, one in two adults and one in three children are overweight (Brazilian Institute of Geography and Statistics [Instituto Brasileiro de Geografia e Estatística, IBGE], 2010). A recent study published by Cancer Research UK (2018) showed that the generation born in the 1980s and 1990s - the so-called millennials - is about to become the group with the highest incidence of excess weight in history.

According to the National Cancer Institute (Instituto Nacional do Câncer [INCA], 2018), obesity increases the risk of deadly diseases such as diabetes, heart disease, and at least 13 types of cancer, which are among the main causes of death in Brazil. Healthy eating, regular engagement in physical activity, and maintenance of a healthy body weight are estimated to prevent approximately 33% of the most common types of cancer in Brazil. In addition, according to the WHO (2018), approximately 13% of cancer cases in the country are related to excess weight and obesity.

According to these numbers, obesity is now a public health issue that affects an increasingly significant part of the population. Nevertheless, it is still largely associated with individual behavior. It is seen as a problem that affects those who have no food discipline and who cannot resist "temptations" or are unable to establish a "balanced" diet. Not having the willpower to perform regular physical exercise, the careless individual gains weight to the point of putting their life at risk. This view on obesity - and on obese people - is wrong and needs to change.

The accelerated increase of obesity is due to changes in the dietary pattern of the population, which favors ultra-processed products with high levels of sodium, sugar, and saturated fats instead of eating homemade, fresh, or minimally processed foods (Monteiro & Louzada, 2015). An ultra-processed diet, including sugary beverages and fast foods, contains a high concentration of these critical substances and has high energy density.

There is a robust body of scientific evidence linking the consumption of these products to weight gain. Evidence also points to increasingly early exposure to poor diet in childhood (IBGE, 2015). This situation is not only part of the Brazilian reality, it also happens in other developing countries as the food and beverage industry eyes a promising consumer market in the countries of Latin America, Africa, and Asia. As their sales fall in richer countries, food multinationals are increasing their presence in developing countries and aggressively marketing their products, thus changing traditional local eating habits.

One example is the African country Burkina Faso, where the prevalence of obesity among adults has grown by 1,400%, according to a recent article in The New York Times, "In Kenya, and Across Africa, an Unexpected Epidemic: Obesity." In Ghana, Togo, and Ethiopia, this growth was 500%. According to a survey appearing in the same article, eight of the 20 global nations with the highest rates of obesity increase are in Africa (Gettleman, 2018).

Data by the international consultancy Euromonitor published in another recent article in The New York Times, "How Big Business Got Brazil Hooked on Junk Food", show that the sale of processed foods grew 25% worldwide compared to only 10% in the United States. The article says that "an even more drastic change occurred with soft drinks: sales in Latin America have doubled since 2000, exceeding consumption in North America in 2013, according to the World Health Organization." Soft drinks are considered a major cause of obesity (Jacob & Richtel, 2017).

The documentary The Industry of Obesity, produced by the German TV channel ZDF (2018), explores the industry’s strategies to induce the low-income population in low- and middle-income countries to consume ultra-processed foods such as cookies, soft drinks, and seasonings. Door-to-door sales are the central strategy of companies such as Nestlé, Unilever, and Danone in the outskirts of major cities, enabling their products to reach those who rarely go to the supermarket or cannot afford to pay cash for food products.

DISCUSSION

Because of this overwhelming issue of obesity and chronic noncommunicable diseases, most of the world’s population already lives in countries where more people die from excess weight than from problems related to undernourishment and even urban violence, which is prevalent in developing countries. An analysis of 27 Latin American countries by the United Nations Food and Agriculture Organization (UN/FAO) showed that excess weight and obesity account for 300 thousand deaths per year in these nations - compared to 166 thousand people murdered. In 2015, 117 thousand people died because of diseases caused by obesity in Brazil, a figure 2.44 times greater than the number of murders (Berdegué & Aguirre, 2018).

Obesity is a multifactorial problem, and fighting it requires an equally diversified effort. The key ingredient, however, is the role the government plays in establishing effective and innovative policies to combat the obesogenic environment created by the food industry.

Here, there is an interesting similarity with the fight against tobacco. Smoking cigarettes was once considered a habit. Today it is regarded as a deadly addiction, a public health issue. Considering the overwhelming and irrefutable evidence linking cigarettes to diseases such as cancer and other deadly medical complications, Brazil invested in efficient policies that reduced the number of smokers by a third, according to INCA (2018). Research by the same institute also showed a reduction in lung cancer mortality among men. Today, the Brazilian anti-smoking program is considered an international standard.

It is likely that many people who gave up this addiction did so out of personal motivation. However, it was only thanks to broad and deliberate measures that thousands and thousands of smokers stopped smoking. Tobacco-free environment laws (such as for bars and restaurants), raising the price of cigarettes, and warnings printed on packs caused a drastic drop in cigarette consumption - and a huge gain in health and well-being for the whole of society.

There is great resistance to dealing with the issue of obesity in the same way as for smoking. It is not a matter of comparing foods, even unhealthy ones, to cigarettes. Yet, both categories of products are associated with deadly diseases that compromise the health and well-being of millions of people, burdening public expenditures, and jeopardizing the future of entire generations. Like smoking, obesity is a public health issue that must be tackled. Here are some suggestions.

a) Front of pack nutritional labeling

This is growing in prominence on the international agenda. There is a consensus that consumer decisions need to be simplified by clearly and objectively condensing the nutritional information table and the list of ingredients. These two items are fundamental in guiding healthier choices but are not always seen or understood. The international recommendation is that relevant information be displayed on the front of the pack so that it can be easily found and assimilated (Branca, Nikogosian, & Lobstein, 2007).

To this end, an innovative approach was tried in Chile, where a new type of warning was implemented. It is a black seal in the upper left corner of packs showing that the product contains high levels of sugar, sodium, total and saturated fat, and calories.

The measure was implemented in 2016 and has been very well accepted by Chileans. In a survey conducted by the government, 92.4% of consumers rated the measure as "good" or "very good," and 37% said that the seal made them change some food choices (Ministerio de Salud - Minsal, 2018). This is the world’s first compulsory measure of this nature, a pioneering achievement recognized internationally.

The Chilean example has been spreading throughout the world. Canada, Israel, South Africa, Uruguay, and Peru are some countries that are studying or implementing the Chilean model. In Brazil, the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária [Anvisa]) is also analyzing the option, which was presented by the Brazilian Institute of Consumer Protection (Instituto Brasileiro de Defesa do Consumidor [IDEC], 2018).

It is important to note that the Chilean front of pack labeling mechanism, besides impacting consumers, has also worked as an important stimulus for change in the food industry. About 20% of products that contained one or more black seals in their packages have already been reformulated to become healthier and have the warning seals removed.

b) Restricting children's advertising

A few years ago, IDEC (2012) evaluated the nutritional quality of processed foods directed to children. It analyzed 44 products and the result was impressive, 84% of them had excessive amounts of health-critical nutrients such as sugar, sodium, and fat. Therefore, these products were considered unhealthy foods.

Foods with similar nutritional profiles are now widely marketed to children through advertising. It is estimated that 50% of all advertising aimed at children is for food and, of these, more than 80% is for unhealthy products. According to the American Dietetic Association (ADA), exposing children for only 30 seconds to food commercials can influence their food choices.

There is a great deal of literature on this subject and growing evidence linking unhealthy food consumption to obesity. The conclusion is that advertising directed at children and children being overweight go hand in hand. Tackling this issue necessarily requires restricting advertising.

This is a consensus that has been built by several sectors of society. In the medical field, the WHO and the Pan American Health Organization (PAHO, 2014) have already stated that efforts must be made to protect children from the impact of unhealthy food marketing and give them the opportunity to grow and develop in a suitable environment.

Recent landmark decisions of the highest levels of the Brazilian justice system have strengthened this point. In 2016, the Supreme Court of Justice (Superior Tribunal de Justiça [STJ]) created the first precedent that considers food advertising directly or indirectly aimed at children to be abusive. A year later, another STJ decision followed the same direction. Both legal actions were against multinationals in the food industry advertising ultra-processed products (IDEC, 2017).

c) School environment protection

In the specific case of children and adolescents, the school environment is considered a priority in the promotion of healthy and appropriate food consumption, because it is characterized as an environment for shaping the development of individuals, where people spend much of their time, live, learn, and work.

It has been proven that health promotion programs at school, such as those aimed at combating obesity, expand knowledge for families and communities, improve populational health, prevent negative health habits, reduce teacher and student absenteeism, improve knowledge about health services, and stimulate educators in their work. Due to their wide scope, schools can do more than other institutions to create healthier habits.

However, research has shown that currently the school environment contributes in a systematic way to the adoption of food practices considered unhealthy, and therefore has an important role in overweight and obesity rates. Most snacks sold and/or prepared at school canteens are low in nutrients and high in sugar, fat, and sodium (Ministério da Saúde, 2007).

The discussion of these issues leads to a debate about legal measures that can transform schools and school catering services into healthy food and meal providers, and encourage the adoption of equally healthy habits inside and outside school. The regulation of canteens, the restriction of sugary beverages in schools, and the inclusion of nutritional education in the school routine are some of these measures - many of them with a significant history at the municipal and state levels.

d) Taxing sugary beverages

The WHO (2016) already stated that the consumption of sugary beverages is one of the main causes of obesity and diabetes. It is not difficult to understand why. Most sugary beverages have no nutritional value. They contain "empty" calories that cannot be compared to the nutritional calories of other foods. For example, the fiber of an apple makes the person who eats it feel more satisfied and less hungry than someone who drinks a soft drink - even if both have the same number of calories (Mourao, Bressan, Campbell, & Mattes, 2007).

Regardless of the empty calories in sugary beverages, the sugar they contain alters the body’s metabolism, affects insulin and cholesterol levels, and can cause inflammation and high blood pressure.

The WHO recommends consuming up to six teaspoons of sugar a day. A single 355 ml can of soda has about 9.5 teaspoons - this cannot be considered healthy and safe. In addition, studies show that the human body does not respond in the same way to the intake of calories ingested in liquid and solid forms. As a consequence, liquid calories result in more rapid weight gain (DiMeglio & Mattes, 2000).

Evidence shows that raising taxes would help reduce the consumption of sugary beverages as it reduced the consumption of cigarettes. Here in Brazil, a recent survey showed that 74% of the population would decrease their consumption of soft drinks and other products, which would result in an enormous gain in health and well-being (Cancian, 2017).

FINAL CONSIDERATIONS

Obesity is a challenge for Brazil and the world. The paths to a solution are multiple, and isolated actions cannot adequately address the problem. Only integrated and articulated policies can constitute effective engagement.

However, it is well known that these paths will not be easy. The industry that promotes unhealthy foods and beverages is strong and uses a range of tactics to oppose public welfare. However, countless countries in Latin America and in the world have resisted, placing public health at the center of discussions and decisions, and adopted measures aimed to ensure a healthier and more appropriate diet for everyone.

It must be acknowledged that Brazil has formally expressed its political will in the signing of international agreements and the design of national plans. However, this is not enough. Intentions and plans need to be put into practice.

• Invited article

• Translated version

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Publication Dates

• Publication in this collection
  May-Jun 2018