Transcript Strategies to promote healthy eating and exercise

Strategies to promote healthy
eating and exercise:
What works?
Sarah L Barber, Representative
World Health Organization, South Africa
With support from Taskeen Khan, NCD officer,
WHO Country Office, AFRO HPR and HQ NCD
Outline
 Determinants and implications of overweight
 WHO Guidelines
– NCD Action Plan & Monitoring Framework
– Global Strategy on Diet and Exercise
 Strategies to address obesity: CEA
 5 Specific strategies:
– Fiscal policies
– Restrictions on food advertising and promotion
– Food labeling
– Making physical activity accessible
– Increasing availability of healthy foods
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Obesity rates
are high and
continue to
increase
(OECD 2012)
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Factors and determinants of overweight
• Industrialization
of the food
production:
agriculture to
processing
• More processed
foods: long shelflife
• Rapid growth of
supermarkets and
fast food outlets
•More
sophisticated and
aggressive
marketing and
promotion,
particularly to
children
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Food
Supply
Social
drivers
•URBANIZATION
• Decreased
physical activity
at work and at
home
• Less time for
food preparation
• Affordability of
fresh foods in
urban
environments
Government
Policies
• Agricultural
policies and subsidies
• Price and taxation measures
• Transportation policies
• Urban planning policies (i.e., places for physical activity)
NCD Action Plan includes
Target 7: halt the rise in obesity
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Indicators of the Global Monitoring Framework for NCDs
Indicator 13: Overweight and obesity in adolescents
Indicator 23: Marketing of foods to children
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WHO Commission on ending childhood obesity:
two Working Groups established
Working Group on Science and
Evidence:
 estimate the prevalence of
childhood obesity and its
consequences
 evaluate the economic impact of
childhood obesity
 examine the evidence on prevention
of childhood obesity and how to
reverse it in affected children; and
determine the best combination of
policies to put in place to achieve
these goals in different settings
 evaluate and recommend policy
options for monitoring and
surveillance.
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Working Group on Implementation,
Monitoring and Accountability will
develop:
 A framework for implementation
of and accountability for policies
recommended by the Working
Group on Science and Evidence
 Mechanisms required to monitor
recommended policy options
 Assessment of the feasibility of
monitoring recommended policy
options
Global Strategy on Diet, Physical Activity and Health
To reduce substantially the deaths
and disease burden worldwide WHO
and Member States adopted, in May
2004, the "Global Strategy on Diet,
Physical Activity and Health”
WHO Global Recommendations on
physical activity for prevention of NCDs
• 60 minutes per day of moderate intensity
physical activity for under 18s, 150 min
per week for over 18s.
www.who.int/dietphysicalactivity
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Population-wide policy options
 Restrictions on marketing and advertising of unhealthy food and beverages
to children (WHA 63.14 provides recommendations on marketing to children)
 Nutritional labelling and information on food packaging (i.e., traffic light
system, calorie posting) (Codex Alimeritius for prohibiting health claims)
 Policies for reduction of salt and trans fats, particularly i.e., particularly for
processed foods (Global Strategy on Diet and Exercise 2004)
 Increasing availability of healthy food and restricting availability of
unhealthy foods, primarily through price and tax measures:
– Subsidies to promote healthy diet, i.e., agricultural policies for production, or
price reductions to promote consumption of fruits and vegetables
– Elimination of subsidies for production of unhealthy food, i.e., sugar and
bread subsidies in Egypt, edible oils in China
– Taxes to reduce the consumption of unhealthy foods, especially SSB
 Making physical activity accessible in all settings. (Global Strategy on Diet
and Exercise 2004)
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WHO/OECD Model to assess the health and
economic impact: CE after 10 years
Fiscal measures and food labeling are ranked as the most CE interventions
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CE after 100 years (WHO/OECD)
Over the long-term, fiscal measures and regulation on food advertising generate costsavings. Food labeling continues to be highly CE, as do many of the other
interventions. School-based /workplace interventions are the most expensive and the
benefits particularly for interventions targeting youth may are not seen immediately.
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5 strategies to prevent obesity
•
•
•
•
•
Fiscal policies
Increasing availability of healthy food
Restrictions on food advertising and promotion
Food labeling
Making physical activity accessible:
encouraging exercise through changing the
physical environment
1. Fiscal policies: rationale
Impact on consumption. Consumers respond to prices by modifying
consumption.
PE of demand for major food categories (0.3-0.8); for soft drinks, juice and meats (0.70.8) (US Andreyeva et al 2010); PE of demand for soft drinks (0.9)
Will shifts in consumption impact on weight/obesity?
Size of the tax/subsidy matters: large tax increases may have a measurable
impact on weight, particularly among price sensitive groups (adolescents, less
well-off) (Powell and Chaloupka 2009)
Simulations indicate similar results, but difficult to take into account shifts to
alternative products (Thow et al 2009)
Taxes/higher prices can also be used as consumer education, to signal that the
product is unhealthy, support an individual’s own desire for self-control, and to
protect children and adolescents from behaviors with long-term consequences.
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A few initiatives: Taxes
– Sales or value-added taxes on soft drinks, sweetened beverages, candy,
snack foods, and confections (Mauritius, 40 states in the U.S., Canada,
Australia, U.K., Ireland, other countries in Europe).
– Taxes are low where their purpose is to raise revenue rather than reduce
consumption. Maine and New York have proposed large taxes on sugared
beverages to reduce childhood obesity.
– January 2014, Mexico implemented a 8% tax on food with an energy
content exceeding 275 Kcal per 100 grams, and 1 peso (EUR 0.06) per
litre on sugar-sweetened beverages. Revenues will support health
programs.
– In Oct 2011, Denmark issued taxes on foods containing 2.3% saturated
fats, which reduced the consumption of the taxed products by 10% to
15% in the first nine months.
– France introduced tax on drinks containing sugar, with earmarking for
programs to combat obesity. It is predicted that the tax would decrease
consumption by 3.4 litres per person per year.
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2. Increasing the availability of healthy foods
a) Price and tax policies can also be used to increase the
availability of healthy foods and reduce the prices of fruits and
vegetables
– Simulated 10% reduction in price of fruits and vegetables:
increased consumption by 4% (Eyles 2012).
b) Agricultural subsidies to promote production of healthy
produce
c) Restricting access to unhealthy products in certain places, i.e.,
schools and offering alternatives (Mexico’s ban of soft drinks in
schools)
d) Regulatory policies to change the composition of certain foods
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Subsidies to promote healthy eating
–Reducing the price of fresh fruits and vegetables at workplaces, and
promote farmers’ markets in cities (Europe and US).
–Making available fruit and vegetables in schools and in vending machines;
school vegetable gardens; EU: free fruit and vegetables for schoolchildren
–“Healthy Purchase” program (CA), which targets subsidies among poor
recipients of the food stamp program, whereby participants are subsidized
for their expenditures on fresh produce
–Agricultural subsidies for production of fruits and vegetables, particularly
in urban areas (PR China, WHO/FAO Arusha meeting)
–Other expert suggestions: lowering tariffs on imported fruits, vegetables;
transportation and insurance policies to assist farmers who grow fruits
and vegetables, considered a riskier crop than other agricultural products
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Examples of successful interventions for food processing
 In 1987, the MoH of Mauritius introduced a regulatory policy
to change the composition of general cooking oil, limiting the
content of palm oil and replacing it with soya bean oil. Five
years after the intervention, total cholesterol concentrations
had fallen significantly in men and women. Consumption of
saturated fatty acids had decreased by an estimated 3.5% of
energy intake.
 Denmark was the first country to implement stringent laws
restricting trans-fat content of foods. Legislation was
enacted limiting trans-fats to 2% of fats and oils content of
foods destinated for human consumption
.
 South Africa passed legislation in 2011 to limit the amount of
trans-fats in all food products to 2%.
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3. Restrictions on food advertising
 Most restrictions focus on advertising to
children. Food marketing to children is a
primary factor contributing to childhood
obesity. Young children perceive advertising
as true and accurate.
 Marketing targeted at children influences
children's food preferences, purchase
requests, and consumption – habits which
are life-long.
 Food products most frequently marketed to
children (Big 5): sugared breakfast cereals,
soft drinks, confectionary, savory snacks,
and fast-food advertising.
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Many countries are expanding on existing regulations to
restrict marketing of unhealthy food to children
Countries are initiating new comprehensive regulations:(OECD 2014)
 Mexico: recent advertising ban of unhealthy foods on radio and TV:
weekends (07:00-19:30) and weekdays (14:30- 19:30). Restrictions
apply in cinemas.
 Chile: currently implementing law limiting advertising in media, pointof-sale marketing, promotions and the school environment.
Other countries are refining and expanded on existing regulations to
make them more effective (OECD 2014)
 Norway: expanded on restrictions on broadcast advertising to children
to other communication channels.
 Turkey restricting further its broadcasting regulations to restrict the
advertising of food and beverages in programs for children.
Obesity strategy
NDOH,Pretoria,South Africa
30 July 2014
Evidence of the impact of advertising regulations
Ban on advertising to children in Quebec (1980)
Between 7.1% and 9.3% drop in the probability of purchasing fast food
Annual drop of between 11 million and 22 million fast-food meals
Impact on purchases behaviour. Baylis & Dhar (2007)
Following the food advertising regulations in France (2004)
21% of individuals changed their eating habits
17% of individuals changed their food-purchasing habits
Impact on self-reported behaviours - Ministère de la santé de la jeunesse et des sports (2008)
Ban on advertising to children in the UK (2008)
Children aged 4–9 saw 52% less advertisement on unhealthy food
Children aged 10–15 saw 22% less advertisement on unhealthy food
Change in exposure to the messages - UK Ofcom evaluation (2010)
Obesity strategy
NDOH,Pretoria,South Africa
30 July 2014
4. Compulsory nutrition labeling
• Food labeling helps people make informed decisions about what
they are eating. Overall impact from cross-country studies:
increased consumption of fruit and vegetables by average of 10
grams/ day, and reduce the proportion of total energy intake from
fats by 0.42%. This is projected to result in a reduction in BMI on
average of 0.02 points (OECD 2014).
• New evidence also suggests that food labeling leads
manufacturers to reformulate products (i.e., reduction in salt
and fat, increase in fiber).
• EU legislation (to come into force in 2016) makes labeling
compulsory for energy, fat, saturated fat, carbohydrates,
sugars, proteins and salt as guideline daily amount.
• Mexico: plans to implement food labeling that ensure visible
and standardized nutritional information across products,
with mandatory front of package labels.
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UK traffic light labeling system
In 2013, the UK Food Standards Agency
launched a voluntary labeling program that
uses “traffic light” colors to illustrate high,
medium and low levels of fat, saturated fat,
salt, sugar, and calories in food products.
Wheel of Health (WoH)
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5. Making physical activity accessible:
Urban/community planning: creating
environments and Policies that Promote
Physical Activity
Street design that makes walking and biking safe,
pleasant, and easy
–
–
–
–
Sidewalks
Bike lanes
Improved lighting
Trees
Building design to encourage
-Making stairwells accessible, clean to encourage taking the stairs
– Visual prompts to walk!
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Visual
prompts –
such as
signage at
the point-ofdecision –
can boost
stair use by
more than
50%
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Physical environment: Urban Planning
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Physical environment:
Successful example: Avenue, Manhattan
Before
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9th Avenue, Manhattan
After
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Physical environment:
Successful example: Agita São Paulo, Brazil
 Public policies to encourage physical
activity
– Reducing barriers to physical activity
– Supportive transport policies and
– Policies to increase space for
recreational activity.
 Social marketing campaigns
– Simple message with frequent exposure (30
minutes of physical activity every day)
– Combine with policies and community- based
activities (schools, workplace, elderly) to
address local environmental barriers to
participation
Obesity strategy
NDOH,Pretoria,South Africa
30 July 2014
Challenges and lessons learned
a) Combinations of policies have a synergistic effect and thus a greater
impact.
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Education and information for consumers supports fiscal and regulatory
policies. Food labeling and calorie posting has been an important factor in
acceptance of food regulation and price/tax measures, for example.
Coupling food taxes with subsidies with earmarking or subsidies can address
concerns about disproportionate impact of taxation on specific groups.
Comprehensive approaches to create healthy environment and enable people
to make easy and healthy choices: British Columbia’s ActNowBC develops
programs across all government ministries with the goal to create healthy and
economically strong communities. It is based on 4 strategies: promoting
physical activity; healthy eating; living free from tobacco; and responsible
alcohol consumption, especially during pregnancy.
Comprehensive strategy in Mexico to promote diet and exercise now being
implemented.
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NDOH,Pretoria,South Africa
30 July 2014
Challenges and lessons learned
b) Tough economic environment can help advance fiscal and regulatory
policies.
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Greater awareness of economic burden of NCDs to the economy as a whole.
UN high level summit, other meetings have emphasized the burden of illness on
premature mortality, productivity, sick days, higher health care costs, etc. and
generate support from other sectors (finance, labor, etc.)
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Economic pressures have led to increases in excises. Higher taxes, particularly
on soft drinks, have been used to generate revenue. Potential partnership to
gain increases in revenues and promote health, particularly where revenues are
needed.
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NDOH,Pretoria,South Africa
30 July 2014
Challenges and lessons learned
c) Effective regulation of industry is critical
– Processed foods have a commercial advantage over foods that
are fresh, perishable, or minimally processed. Profitable industry
– High market penetration of transnational industry in processed
food. 43% of market share for packaged foods in RSA controlled by
5 firms.
– Cannot rely on industry self-regulation, and resistance to stronger
government intervention can be expected in terms of regulation
and taxes that can have significant changes in consumption.
– Industry role/interactions and conflicts of interest. Food industry
has engaged in ways that promote the financial interests of their
industry (sponsoring studies and think-tanks, lobbying policymakers for ineffective policies), and mobilizing consumers to
oppose regulation/taxes.
Obesity strategy
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30 July 2014
Challenges and lessons learned
d) Research, monitoring and evaluation is important to monitor progress, make
adjustments in policy, and evaluate interventions.
-For fiscal policies: still many unanswered questions: Which products? Soda/pops, junk
food (little nutritional value) … high-calorie foods, dairy products, edible oils, etc. How
high? How high do taxes need to be to have an impact on weight?
-Individual react to public policies in untended ways. Are the alternatives better?
Consumers respond to public policies by changing their behaviors. Need to monitor
the effects to determine overall impact on health outcomes.
-Are the public policies regressive? Low income families spend higher share of their
incomes on food; fiscal policies would be expected to have stronger effects on
younger, less wealthy. (If poorer groups adjust their behaviors and ultimately spend
less on taxed products, is the tax progressive?)
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Conclusion
There are CE policies and programs that have worked in
other countries.
Policies and programs in non-health sectors have a large
health impact on NCDs
Make healthy choices easy: Critical to change the food
environment to make it easy for people to reduce salt,
fat, and calories; and change the physical environment
to make it easy promote physical activity.
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NDOH,Pretoria,South Africa
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Thank you
Obesity strategy
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