National and regional strategies for obesity prevention in Latin America

The strategies implemented at the country level in Latin America are described below.

Governmental structures for obesity prevention in Latin America

The following structures are created to support obesity prevention efforts:

Leadership: Most countries in Latin America define the Ministry of Health as the leading institution/agency for obesity prevention oversight. However, only six countries in the region have established a specific governmental office or committee specifically for obesity prevention efforts (Table 2). Details of the names of each office or committee are found in the online supplementary material.

Table 2 Governmental structures and national plans for obesity prevention in Latin American countries

* Date shown is the last survey conducted. The information was not found for countries with (−). Details of each structure or plan are found in the online supplementary material.

Funding: Specific laws or mechanism to fund these efforts in Latin America was not evidenced in our review.

Monitoring systems: In Latin America, nutrition surveillance has been developed since 1977, but the type of system developed and implemented varies widely by country. A systematic review of official sources in Latin American and Caribbean countries found that twenty-two had at least one nationally representative survey to monitor the nutritional status and among these, sixteen had at least two surveys among children^{(Reference Galicia, Grajeda and López De Romaña7)}. Our review found that all countries have a surveillance system in place and the types of surveys used to monitor the nutritional status are shown in Table 2. Details of each survey are found in the online supplementary material. In general, our review found that most surveys were conducted a few years ago. Current data are required to design appropriate interventions and measure their impact.

Workforce capacity: This was not evidenced in our review.

Networks and partnerships: Only a few countries reported this (data not shown); mostly with the Ministry of Education and Agriculture, academia and some non-governmental organisations such as WHO and PAHO.

National plans or policies for obesity prevention

At the country level, a national public health plan with a multi-sectorial and life-course approach will help guide all efforts implemented in each country. Currently, our review found that thirteen countries have obesity prevention plans/policies, and thirteen countries have a general policy to promote healthy dietary behaviours but are not specific to obesity (Table 2). Details with the names of plans or policies are found in the online supplementary material.

Regulations to support healthy diets

Many countries are planning or have implemented some of the policies and initiatives recommended by PAHO (Table 3). These include front-of-package labelling (nine countries have proposed it and seven countries have implemented it), sugar-sweetened beverage (two countries have proposed it and six countries have implemented it), restrictions on fats (seven countries have in place restrictions on trans-fatty acids and/or saturated fats), restrictions on Na level (two countries) or regulation of the school environment (fifteen countries). In addition, other regulations include regulation for the marketing of foods (one country has proposed it and six countries have implemented such regulation), regulations about nutrition education (nine countries) and about promoting physical activity (nine countries) and regulations about food security (thirteen countries). Details of each regulation are found in the online supplementary material.

Table 3 Regulations implemented or proposed in seventeen Latin American countries to support healthy diets and physical activity

The information was not found for countries with (−). Details of each regulation are found in the online supplementary material.

Guidelines for promoting healthy behaviours

All countries evaluated have local dietary guidelines to translate global dietary guidelines into the cultural, preferences and characteristics of each population (Table 4). Also, nine countries have specific guidelines for children, six countries have guidelines for promoting physical activity and five countries have other healthy behaviours guidelines for the diagnosis and treatment of obesity and other chronic diseases (Table 4). Details of each guideline are found in the online supplementary material.

Table 4 Guidelines developed in seventeen Latin American countries to support healthy diets, physical activity and obesity treatment

The information was not found for countries with (−). Details of each programme or initiative are found in the online supplementary material.

Population-wide or community-based programmes or initiatives

Several programmes or initiatives have been implemented in the countries reviewed (Table 5). These include school meal programmes to provide healthy breakfast, lunch and/or snacks to children at schools (seventeen countries), to promote nutrition education (six countries have this at the population level and eleven at the school level), to promote physical activity such as bike routes or Ciclovías (nine countries), to support family agriculture (four countries), to promote healthier environments (three countries have this at the population level and seven at the school level) and to treat obesity (four countries). Details of each programme or initiative are found in the online supplementary material.

Table 5 Population-wide or community-based programmes or initiatives in seventeen Latin American countries to support healthy diets, physical activity and obesity prevention

* At the school or population level. The information was not found for countries with (−). Details of the names of each programme are found in the online supplementary material.

There may be other interventions or strategies not mentioned in this review that were either not published or easily accessible through an online search.

It is important to note that some of the strategies mentioned in this report may be out of date or not being used by the time of this publication, as these may have changed if political changes occurred in the government.

Evidence on the evaluation of the impact of strategies implemented in these countries for obesity prevention

In general, our literature review evidenced a lack of reports and studies evaluating the strategies mentioned in the previous section. We report here the studies/reports found by strategy.

At the level of obesity strategic plans, in 2014, all countries in Latin America signed the Plan of Action for the Prevention of Obesity in Children and Adolescents^(6,8) . This plan adopts a preventive, multi-sectorial and life-course approach and considers the social determinants of health. It aims at promoting an environment that is conducive to healthy eating and a higher physical activity level and making the healthier option the easier option. To support countries in the fight against obesity, PAHO provides technical guidelines and cooperation, advocates for programmes and policies and fosters collaboration among countries. Besides PAHO has other documents to help member states in this effort⁽⁹⁾. Also, the Council of Ministries of Health in Central America developed the Plan for the Prevention of Obesity in Children and Adolescents in 2014–2025⁽¹⁰⁾. In 2015, a meeting in Panama with experts from Healthy Latin America Coalition, PAHO/WHO, the Ministry of Health of Panama, and others discussed the need for a stronger role of the civil society in supporting and promoting policies on food, tobacco, alcohol and level of physical activity in the region⁽¹¹⁾. In 2016, the Caribbean Public Health Agency and PAHO in collaboration with the Ministries of Health from countries with successful obesity prevention policies, such as Mexico and Chile, developed a roadmap to prevent childhood obesity⁽¹²⁾. This is important as lessons learned from efforts that have or have not worked in different countries should be shared. In addition, multi-national studies can provide rich information and insights into how different strategies work with different cultures, ethnic backgrounds, environments, etc. Besides, the Non-Communicable Diseases Alliance developed a Civil Society Action Plan for 2017–2021 on Preventing Childhood Obesity in the Caribbean⁽¹³⁾. Lastly, several institutions have convened experts from PAHO, FAO and the National Institutes of Health’s Fogarty International Center^{(Reference Caballero, Vorkoper and Anand14)} to evaluate the situation.

At the level of nutritional policies, there are a few successful strategies in terms of acceptance, reach or effectiveness in changing behaviours in Latin America that should be discussed:

Front-of-package label: At the Meeting of Ministers of Health of Central America in 2017, a proposed resolution to establish a front-of-package system for nutritional warnings was endorsed⁽¹⁵⁾. Also, in 2018, the Ministers of Health of MERCOSUR (the Southern Common Market) agreed on a set of principles to promote compulsory front-of-package labelling systems to indicate excessive sugar, Na and/or fat content⁽¹⁶⁾. A study evaluating different labels design for front-of-package labels in 1000 participants from all twelve countries participants of MERCOSUR in 2018 found that the change in labelling significantly improved the ability of individuals to rank products according to their nutritional quality^{(Reference Egnell, Talati and Hercberg17)}. Also, a study in Chile done 6 months after the implementation of this regulation found that 67 % of participants selected products with fewer warnings in the label and that the presence of ‘high in’ stamps influenced the purchase decision among 90 %⁽¹⁸⁾. Also, it has been estimated that food companies have modified one of every five products to make it healthier (2015–2016)^{(Reference Boza, Guerrero and Barreda19)}. In Ecuador, a study conducted a 1-year post-implementation of this strategy (2015) found that it was widely recognised and understood^{(Reference Díaz, Veliz and Rivas-Mariño20)}. In two supermarkets in Quito among seventy-three participants, 88 % reported knowing about this system and 28 % used it, which showed that it significantly influenced their shopping^{(Reference Teran, Hernandez and Freire21)}. In Mexico, a survey among parents of children in elementary schools found that 51 % used the displayed nutrient content and reported to prefer the new traffic light system compared with the traditional system⁽²²⁾. In Uruguay, a study found that 95 % of respondents saw the front of package labelling law as positive, regardless of age, gender or socio-economic status^{(Reference Ares, Aschemann-Witzel and Curutchet23)}. A greater percentage of individuals from low socio-economic groups (90 %) said the label would help them improve the quality of their diets, compared with those with a medium (86 %) and high (84 %) socio-economic status^{(Reference Ares, Aschemann-Witzel and Curutchet23)}. The evidence on the effectiveness of this strategy is considered medium as there is limited evidence from studies in different countries and most have not included a representative sample of the population.

Sugar-sweetened beverages tax: A recent review focused only on Latin American countries found that at least thirty-nine sugar-sweetened beverage regulatory initiatives have been adapted^{(Reference Bergallo, Castagnari and Fernández24)}. From these, twenty-eight regulatory initiatives were passed by legislative and executive bodies and eleven are self-regulatory initiatives by the beverage industries. Also, 86 % of regulations by the government are binding; 56 % describe how to monitor and evaluate this, 62 % call for specific sanctions and twenty three specify who the body in charge of this monitoring. In Chile, a sugar-sweetened beverage with more than 6·25 g of sugar per 100 ml is taxed at 18 %, while sugar-sweetened beverage below this threshold is taxed at 10 %. In Ecuador, a tax of USD 0·18/100 g sugar on sugar-sweetened beverages with more than 25 g of sugar per liter. In Mexico, the tax is 1 peso (which is about 0·05 USD) per liter and also an 8 % tax on snacks with more than 275 kcal per 100 g. In Peru, a tax of 50 % is imposed on beverages with more than 6 g per 100 ml. In Brazil, El Salvador and Nicaragua, this is at the proposal stage. In Colombia and Argentina, the strong industry lobbying impeded its implementation. The experience of Mexico and Chile is the most studied so far, as this was implemented a few years ago (2014 in Mexico and 2016 in Chile). In Chile, the results showed that there was a highly significant 22 % decrease in the monthly purchased volume of the higher-taxed, sugary soft drinks^{(Reference Nakamura, Mirelman and Cuadrado25)}. The reduction in soft drink purchasing was most evident amongst higher socio-economic groups and higher pretax purchasers of sugary soft drinks. In Mexico, taxed beverages purchases decreased from 200 ml/d at the end of 2013 (just before the implementation of the beverage tax) to about 160 mg/d at the end of 2014 (after about 1 year of the tax implementation), which represents a decline of 12 %^{(Reference Colchero, Rivera-Dommarco and Popkin26,Reference Colchero, Popkin and Rivera27)} . Reductions were higher among the households of low socioeconomic status (17 % decrease by the end of 2014 compared with pretax trends). Also, purchases of untaxed beverages were 4 % (36 ml/capita/d) higher, mainly driven by water. The evidence on the effectiveness of this strategy is considered medium as there is limited evidence from studies in different countries and most have not included a representative sample of the population.

Regulation for the marketing of foods: These initiatives have varied widely by country, with some having formulated guidance, while other restrictions, with some sanctions, but most do not have a clear description of their monitoring. Banning unhealthy food advertising may have a positive impact on children’s diets. A review in Brazil showed that most studies were based on law analysis or qualitative study of advertisement, and several companies had differences in ethical behaviour regarding food advertisements, showing a lack of commitment to the policies on food advertisements^{(Reference Kassahara and Sarti28)}. So far, Chile is the country that has implemented the most comprehensive regulation of food publicity, regulating 35–45 % of processed foods and beverages high in added sugar, Na or saturated fat. Also, there is a ban on the marketing of certain unhealthy foods during selected child TV programmes. In Mexico, the regulation prohibits advertising of unhealthy foods and beverages to children mainly in TV or movie theatres, with some exceptions for certain programmes. Brazil limits all publicity targeting food for children. Bolivia, Chile and Mexico also require to include messages to promote healthy lifestyles, and Brazil, Chile, Ecuador, Mexico and Peru require the inclusion of warning messages about the potential health effects of certain products^{(Reference Bergallo, Castagnari and Fernández24)}. Ecuador and Nicaragua are at the proposal stage to implement it, while in Argentina, it was vetoed by the President^{(Reference Bergallo, Castagnari and Fernández24)}. In Mexico, an analysis of children’s advertisements in 2012–2013 in the most popular public TV showed that about 75 % of the total food and beverage advertisements were aimed directly or indirectly at children^{(Reference Théodore, Tolentino-Mayo and Hernández-Zenil29)}. Even among companies that had signed the self-regulation, more than 31 % of the advertising of unhealthy products were aimed at children or adolescents. A review of twenty-three studies (six in Chile, five in Mexico, four in Brazil, three among Hispanics in the USA and one in Argentina, Peru, Colombia, Honduras and Venezuela) about food advertising directed to children on TV found a high exposure of TV food advertised for children and their family, which has been associated with preference and purchase of unhealthy foods and with overweight and obesity^{(Reference Bacardí-Gascón and Jiménez-Cruz30)}. The evidence on the effectiveness of this strategy is also considered medium.

School meal programmes: Only a few studies are evaluating the effectiveness of school-based programmes. For example, in Brazil, a study of twenty-one public schools in one region in 2014 found that about 31 % of children were overweight, that breakfast and snacks were composed of 68 % of ultra-processed foods, while 92 % of the lunch foods were unprocessed and minimally processed foods^{(Reference Batista, Mondini and Jaime31)}. In Colombia, children participating in the programme may have better school performance^{(Reference Niny32)}. In Chile, this programme has been shown to reduce school drop-out rates^{(Reference Villena33)}. In Mexico, the regional programme ‘Health to Learn (Salud para Aprender)’ found a decrease in overweight and obesity from 25 % in 2010–2011 to 19 % in 2016–2017 among preschoolers, from 32 % to 30 % in elementary children and from 38 % to 34 % in adolescents^{(Reference Trejo Hérnandez and Raya Giorguli34)}. They also found that the % of breakfast consumption increased from 84 % in 2010–2011 to 86 % in 2016–2017, consumption of fruits and vegetables 3–4 times per week increased from 34 % to 36 % and sedentarism improved by 1–2 points. In Peru, the Milk Glass Program, which impacted 61 % of children 0–6 years and 18 % of children 7–13 years, found that 63 % of those participating had a decreased risk of obesity^{(Reference Diez-Canseco and Saavedra-Garcia35)}. A systematic review of twenty-one studies (n 12 092) with different types of educational interventions in children (nutritional campaigns, physical activity level and environmental changes) in Latin America found that mixed approaches combining nutritional campaigns, physical activity level promotion and environmental changes were the most effective interventions^{(Reference Mancipe Navarrete, Garcia Villamil and Correa Bautista36)}. The evidence on the effectiveness of this strategy is also considered medium.

Regulation of the school environment: Changing the food environments can have a strong influence on the school-age population and could lead to changes in food preferences and weight status. These policies have been implemented in several countries as described previously, but they differed in their legislation and how strict they are. For example, in Brazil, Ecuador, Chile, Peru and Uruguay, the policies to limit sugar-sweetened beverages in schools are through their legislative and executive, while in Costa Rica and Mexico, this has been through executive decrees only, which may have a different impact^{(Reference Bergallo, Castagnari and Fernández24)}. Although all are mandatory, some have not specific sanctions if schools are not in compliance, such as in Ecuador. Also, some countries are very strict in the type of beverages banned. For example, in Peru, drinks with more than 2·5 g of sugar per 100 ml are not allowed, while in Ecuador and Uruguay, the limit is on beverages with more than 7·5 g of sugar per 100 ml and in Mexico almost all beverages that provide calories are banned, except on Fridays^{(Reference Bergallo, Castagnari and Fernández24)}. Therefore, most legislations allow 100 % fruit juices, which can still add to the total calories consumed per day, except for Mexico. Also, this legislation is mostly for public schools and at the elementary level. Although there are no results available yet on their impact on reducing obesity, there are a few obstacles encountered in their implementation. For example, in Mexico, the food industry has shown strong opposition, which delayed the process^{(Reference Charvel, Cobo and Hernández-Ávila37)}. Also, studies in Mexico found that the schools lacked the space, food safety measures or the structure to implement these policies^{(Reference Gallegos Gallegos, Barragan Lizama and Hurtado Barba38)}. They also lacked a strong strategy to implement this throughout and faced difficulty in changing culturally strong practices, among others^{(Reference Treviño Ronzón and Sánchez Pacheco39)}. The evidence on the effectiveness of this strategy is considered weak as there are very limited studies.

Programmes to promote physical activity: These include the modification of the school curriculum to increase physical activity level, policies in urban planning to increase access to sidewalks and areas of recreation and physical activity, among others. A global review of the impact of such policies on obesity found that individuals living in walkable communities, with access to parks and other recreational areas, with sports facilities or spaces for recreation in schools and greater access to stairs, were all associated with higher levels of physical activity^{(Reference Sallis and Glanz40)}. In Latin America, only a few studies are evaluating such programmes. In Colombia, surveys conducted in 2009 found that individuals participating in the bike route (Ciclovía) programme met the physical activity recommendation in leisure time (60 %), and most participants met it by cycling for transportation (71 %)^{(Reference Torres, Sarmiento and Stauber41)}. Another survey among current and former programme coordinators of sixty-seven bike routes in 2014–2015 found that the average number of participants per event was > 40 000 (40–1 500 000) with an average length of 9·1 km (1–113·6)^{(Reference Sarmiento, Díaz del Castillo and Triana42)}. The participation of minority populations was high (61·2 %). The current study also evaluated the sustainability and scaling-up of five programmes and they all met the most important factors for this, such as some level of government support, alliances, community appropriation, champions, organisational capacity, flexibility, perceived benefits and funding stability. However, there were several differences in their design, operations, political affiliations, funding and alliances, which may be important for the diversity and inclusion of different segments of the population. The evidence on the effectiveness of this strategy is considered weak as there are very limited studies.

Efforts to reduce fat or Na in foods: In Argentina, a law was enacted in 2013 to regulate the maximum Na levels in meat products, farinaceous foods and soups, bouillons, and dressings. If all these foods fully comply with this regulation, this would reduce Na intake by about 30 mg/d ^{(Reference Elorriaga, Gutierrez and Romero43)}. In a study conducted in 2019, more than 90 % of the food products included in the national Na reduction law in Argentina were found to be compliant^{(Reference Allemandi, Tiscornia and Guarnieri44)}. The evidence on the effectiveness of this strategy is also considered weak.

Programmes to promote nutrition education: In Chile, the 5-A-Day campaign was tested on an adult sample (n 1897), finding after 1 year that recalls of the materials was high and that the proportion of people saying that they consumed 3–4 servings a day increased from 49 % to 51 %^{(Reference Vio, Albala and Kain45)}. Another study in Chile found that 9 months after the implementation of the Santiago Sano programme found that 22 % of the participants had improved their nutritional status⁽⁴⁶⁾. The evidence on the effectiveness of this strategy is also considered weak.