Ultra-processed Food And Drink Products In Latin America .

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Ultra-processed food and drink products inLatin America: Trends, impact on obesity,policy implications

Ultra-processed food and drink productsin Latin America: Trends, impact on obesity,policy implicationsNoncommunicable Diseases and Mental HealthWashington D.C., 2015

Also published in Spanish (2015) with the title:Alimentos y bebidas ultraprocesados en América Latina: tendencias,efecto sobre la obesidad e implicaciones para las políticas públicas978-92-75-31864-5PAHO HQ Library Cataloguing-in-Publication *****************************Pan American Health Organization.Ultra-processed food and drink products in Latin America: Trends, impact on obesity,policy implications. Washington, DC : PAHO, 2015.1. Obesity – prevention & control. 2. Public Policies. 3. Food Consumption.4. Fast Foods – adverse effects. 5. Latin America. I. Title.ISBN 978-92-75-11864-1(NLM Classification: WD210)The Pan American Health Organization welcomes requests for permission to reproduce ortranslate its publications, in part or in full. Applications and inquiries should be addressed tothe Communication Unit (CMU), Pan American Health Organization, Washington, D.C., U.S.A.(www.paho.org/publications/copyright-forms). The Department of Noncommunicable Diseases and Mental Health, Unit of Risk Factors, (ncdbulletin@paho.org) will be glad to provide thelatest information on any changes made to the text, plans for new editions, and reprints andtranslations already available. Pan American Health Organization, 2015. All rights reserved.Publications of the Pan American Health Organization enjoy copyright protection inaccordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rightsare reserved.The designations employed and the presentation of the material in this publication donot imply the expression of any opinion whatsoever on the part of the Secretariat of the PanAmerican Health Organization concerning the status of any country, territory, city or area or ofits authorities, or concerning the delimitation of its frontiers or boundaries.The mention of specific companies or of certain manufacturers’ products does notimply that they are endorsed or recommended by the Pan American Health Organization inpreference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by the Pan American Health Organization to verifythe information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for theinterpretation and use of the material lies with the reader. In no event shall the Pan AmericanHealth Organization be liable for damages arising from its use.

This Report was commissioned by the Pan American Health Organizationand prepared by Dr. Jean-Claude Moubarac of TRANSNUT, the WHOCollaborating Centre on Nutrition Changes and Development at Universitéde Montréal, Canada, and the Núcleo de Pesquisas Epidemiológicas emNutrição e Saúde (NUPENS) at Universidade de São Paulo, Brazil.Advice and comments were received from Prof. Roberto De Vogli(University of California–Davis, United States); Prof. Carlos AugustoMonteiro (Universidade de São Paulo–São Paulo, Brazil); and GeoffreyCannon (NUPENS–São Paulo, Brazil). Maria Laura Louzada, Logan Mauney,and Dr. Diana Parra Perez from NUPENS are also gratefully acknowledged.iii

ContentsForeword viiSummary ixIntroduction xi1. What are ultra-processed products? 11.1. The NOVA food classification system 11.2. Problems with ultra-processed products 61.3. Impact on nutrition, health, and well-being 92. Methodology 113. Ultra-processed products sales 143.1. Global trends 143.2. Retail sales in Latin America 193.3. Fast-food purchases 223.4. Distribution 243.5. Market concentration 263.6. Summary 304. Social and economic drivers 314.1. Urbanization 324.2. Increased income 344.3. Market deregulation 364.4. Changes in retail sector 374.5. Marketing 394.6. Summary 405. Impact on obesity 416. Discussion and recommendations 456.1. Main findings 456.2. Study limitations 476.3. Recommendations 496.4. Conclusion 51References 53Annex A: The NOVA food classification system 59Annex B: Countries included in this report (n 80) by region. 60v

ForewordThe increasing burden of ill health and premature deaths attributableto chronic non-communicable diseases (NCDs), particularly affects lowand middle income countries and the key underlying but modifiable riskfactors are tobacco, harmful use of alcohol, physical inactivity and lowquality diet. Poor nutrition is a major cause of illness and mortality asdocumented in the Global Burden of Disease Study 2010, with nutritionalfactors now being a major contributor to years of life lost and years livedwith disease in the Americas.This report is timely and provides an up-to-date comprehensiveperspective on global shifts in sales of ultra-processed food and drinkproducts over the past decade, while exploring the connection betweenthe surge in market share and the epidemic of obesity in Latin America. Itexamines trends in sales of ultra-processed products, their distribution insupermarkets and retail outlets, and market concentration. The report alsoexamines how sales are associated with socioeconomic drivers includingpatterns of urbanization, income growth and market deregulation. Whilesales volumes remain higher in high-income countries, the rate of growthwas faster in lower-income countries during the period 2000 to 2013.Consistent with previous findings, sales of ultra-processed products areassociated with weight gain and obesity in Latin America. The solutionsto this epidemic of unhealthy diets can be found in sound public policiesand this monograph provides clear guidance on the way forward.Anselm HennisDirectorDepartment of Noncommunicable Diseases and Mental Healthvii

SummaryCommercially, the most attractive markets for ultra-processed food anddrink products are no longer the fully industrialized high-income countriesof the Global North (North America, Western Europe, and developedparts of East Asia). They are the middle-and low-income countries of theGlobal South (Africa, economically developing countries in Asia, EasternEurope, and Latin America).This study has analyzed sales of ultra-processed products from retail stores(“off trade” purchases) and fast-food outlets (“on-trade” purchases) in13 countries in Latin America between 2000 and 2013. Both retail salesand fast-food transactions increased steadily in all 13 countries exceptArgentina and Venezuela, where sales fluctuated during financial crises.In Latin America, most ultra-processed products are increasingly soldin convenience stores, supermarkets, and hypermarkets (“superstores”or combination supermarket/department stores). Market of severalleading ultra-processed products is oligopolistic and often dominated bytransnational corporations.Sales of ultra-processed products increase with urbanization, and whennational governments open their countries to foreign investment andderegulate markets. While sales volume remains higher in high-incomecountries, the rate of growth was faster in lower-income countries during2000-2013. Lastly, consistent with previous findings, sales of ultraprocessed products are associated with weight gain and obesity in LatinAmerica.As stated in the Pan American Health Organization five-year Plan ofAction on childhood obesity (2014–2019), to support and encouragehealth dietary patterns, the strong increase in sales of ultra-processedproducts throughout the Americas needs to be checked by statutoryregulations and the development of market opportunities to protectand strengthen local and national healthy food systems and thus healthydietary patterns.ix

Pan American Health Organizationx

IntroductionObesity and related chronic noncommunicable diseases (NCDs) arenow epidemic throughout Latin America, among adults as well aschildren and adolescents (1,2). In response, in October 2014, PanAmerican Health Organization (PAHO) Member States approved afive-year Plan of Action on childhood obesity (2014–2019) designedto halt further increase of obesity in children and adolescents in theregion (3).PAHO identifies the current environment as one that causes overweightand obesity. It emphasizes the central importance of diet as well as tradeand agriculture policies in determining the quality of food supplies andthus of dietary patterns. Its recommendations include fiscal policies andother incentives for increased production and consumption of healthyfood; the regulation of marketing of unhealthy food; better labeling ofprocessed food and drink products; and improvement of school food andincreased physical activity among schoolchildren. The recommendationsbuild on public policies already initiated in Latin America, such as theMexican tax on sugary drinks and energy-dense snacks; regulation offood marketing to children in several countries; and the Brazilian foodand meal-based dietary guidelines (4). PAHO also emphasizes the needfor more government interventions to set, achieve, and monitor specific,quantifiable targets.The most effective policies and actions designed to improve the qualityof food supplies to reduce the incidence of overweight and obesity,include the use of public regulations and market interventions (5). Forexample, the efficacy of price, availability, and other statutory controlson use of tobacco is well-documented (6). However, recent attempts touse mandatory regulations to improve food supplies have been impededby misinformation and biased science, along with pressure fromcommercially interested parties (7). Policies and actions to improve foodsystems for healthier diets need strong political commitment, combinedwith determined and sustained support from citizens—as voters andparents—and leadership from civil society organizations and socialmovements at all levels (national, state, and municipal).xi

Public policies, recommendations and actions concerning nutrition andhealth have conventionally been based on nutrients (for example, sodiumand saturated fats) or on types of foods (for example, fruits and vegetables,and red meat). These methods of approaching and categorizing diets areinadequate and misleading because they are based on a narrow visionof nutrition (in which food are seen as the mere sum of nutrients), andneglect the role of modern industrial food processing and its impact ondiet (8). Industrial food processing is now the main driving force shapingwhat has become a global food system, as especially now affecting nowmiddle-and low-income countries (9).The most striking change in food systems of high-income countries, and nowof low- and middle-income countries, is displacement of dietary patternsbased on meals and dishes prepared from unprocessed or minimallyprocessed foods by those that are increasingly based on ultra-processedfood and drink products (10–13). The result is diets with excessive energydensity, high in free sugars and unhealthy fats and salt, and low in dietaryfiber (14–15) that increase the risk of obesity and other diet-related NCDs(16–19). The proportion of ultra-processed products in food supplies canbe seen as a measure of overall population diet quality (20).More information on the manufacture, sale, and consumption ofultra-processed products in specific countries that can be comparedinternationally is needed in Latin America. Governments will then be ableto formulate, agree on, implement, and monitor policies and programs toencourage healthy dietary patterns whose quality is strongly supported bythe evidence and directly relevant to the local context.To help fill the information gap, this study analyzed sales of ultra-processedproducts from retail stores (“off trade” purchases) and fast-food outlets(“on-trade” purchases) in 13 countries in Latin America between 2000and 2013. The resulting analyses and recommendations reported hereare based on the NOVA conceptual framework for classifying food (21)devised by a research team at the University of São Paulo in Brazil. TheNOVA system classifies foods and diets according to the nature, purpose,and extent of industrial food processing rather than in terms of nutrientsand food types.The leading international scientific work based on the NOVA system hascome from Latin America and Canada (8–11, 13–16). Assessments of therelationship between patterns of diet and patterns of obesity and relatedxii

diseases need to consider the significance of industrial food processing,with specific attention to ultra-processed products. This approach wasused in a briefing document supporting the PAHO Plan of Action (22) and isset out in guidelines issued by the Food and Agriculture Organization of theUnited Nations (FAO) (23). It is also the basis of national dietary guidelinesissued by the Brazilian Ministry of Health in November 2014 (4).Scope of this reportThis report describes trends in the sales of ultra-processed food and drinkproducts in 13 Latin American countries (Argentina, Bolivia, Brazil, Chile,Colombia, Costa Rica, Dominican Republic, Ecuador, Guatemala, Mexico,Peru, Uruguay, and Venezuela) as well as the social and economic factorsthat drive them and associated implications for the rise, control, andprevention of obesity and related diseases.Chapter 1 (“What are ultra-processed products?”) provides a briefsummary of the NOVA food classification system (21) plus an overview ofultra-processed food and drink products, their characteristics, and theirimpact on human health. Chapter 2 describes the methodology used inthis report, including data sources and analysis.Chapter 3 compares trends in sales of ultra-processed products in LatinAmerica with those in other regions of the world, and examines retailsales of ultra-processed products and fast-food transactions (number ofsingle, completed purchases) in the 13 Latin American countries studiedas well as their distribution and market concentration.Chapter 4 provides evidence from throughout the world on the correlationof the sale of ultra-processed products with urbanization, economicgrowth, and market deregulation, and briefly describes changes in theretail sector in the Americas.Chapter 5 compares changes over time in sales of ultra-processedproducts with changes over time in body mass in 12 of the 13 LatinAmerican countries (all but Argentina). Chapter 6 describes policies andactions that could help improve food supplies and dietary patterns toprotect health throughout Latin America.Annex A provides details about the NOVA food classification system.Annex B lists the countries covered in this report by region.xiii

freeimages.comxivUltra-processed food and drink products in Latin America: Trends, impact on obesity, policy implications.

Chapter 1What are ultraprocessed products?Practically all food consumed today is processed in some way. Ifprocessing is defined as methods in which raw food is made more edibleand enjoyable, or preserved for later use, food has been processedthroughout human history. Food processing has played a central role inhuman evolution and adaptation in its contribution to securing adequatenourishing food supplies and thus the development of societies andcivilizations, the protection of health and well-being, and the achievementof social and emotional well-being through the sharing of meals (24,25).Since industrialization, and particularly in the second half of the lastcentury, food processing has developed very rapidly and been profoundlytransformed through food science and other types of technology (26).This transformation suggests the need for rigorous examination of theimpact of all forms of food processing on food systems and supplies;dietary patterns; and nutrition, health, and well-being.1.1 The NOVA food classification systemFood is not healthy or unhealthy simply because it is “processed.”Meaningful discussion of food processing requires the use of specificterminology with clear definitions that apply universally. Many typesof processing are essential, beneficial or harmless. Other types of foodprocessing are harmful in terms of human health and in other ways. Aproper understanding of the significance of food processing dependson and can be derived from a classification of food supplies and dietarypatterns that distinguishes between types and uses of processing.Chapter 11

This report is based on the NOVA food classification system. The NOVAsystem groups food according to the nature, purpose, and extent of itsprocessing (21,27). It has four groups, specified below and in more detailin Annex A:1. Unprocessed or minimally processed foods2. Processed culinary ingredients3. Processed foods4. Ultra-processed food and drink productsThe NOVA system enables the study of food supplies and dietary patternsas a whole, within countries over time and between countries. It alsoenables the study of individual food groups within the system.Unprocessed or minimally processed foodsUnprocessed foods are parts of plants or animals that have not undergoneany industrial processing. Minimally processed foods are unprocessedfoods altered in ways that do not add or introduce any new substance (suchas fats, sugars, and salt) but may involve the rem

middle-and low-income countries (9). The most striking change in food systems of high-income countries, and now of low- and middle-income countries, is displacement of dietary patterns based on meals and dishes prepared from unprocessed or minimally processed foods by those that are increasingly based on ultra-processed

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