H U M A N D E V E LO P M E N T PERSPECTIVES Obesity Health and Economic Consequences of an Impending Global Challenge Meera Shekar and Barry Popkin, Editors Obesity H U M A N D E V E LO P M E N T P E R S P E C T I V E S Obesity Health and Economic Consequences of an Impending Global Challenge Meera Shekar and Barry Popkin, Editors © 2020 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 23 22 21 20 This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denomi- nations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be considered to be a limitation upon or waiver of the privi- leges and immunities of The World Bank, all of which are specifically reserved. Rights and Permissions This work is available under the Creative Commons Attribution 3.0 IGO license (CC BY 3.0 IGO) http://creativecommons.org/licenses/by/3.0/igo. Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions: Attribution—Please cite the work as follows: Shekar, Meera, and Barry Popkin, eds. 2020. Obesity: Health and Economic Consequences of an Impending Global Challenge. Human Development Perspectives series. Washington, DC: World Bank. doi:10.1596/978-1-4648-1491-4. License: Creative Commons Attribution CC BY 3.0 IGO Translations—If you create a translation of this work, please add the following disclaimer along with the attribution: This translation was not created by The World Bank and should not be considered an official World Bank translation. The World Bank shall not be liable for any content or error in this translation. Adaptations—If you create an adaptation of this work, please add the following disclaimer along with the attribution: This is an adaptation of an original work by The World Bank. Views and opinions expressed in the adaptation are the sole responsibility of the author or authors of the adaptation and are not endorsed by The World Bank. Third-party content—The World Bank does not necessarily own each component of the content contained within the work. The World Bank therefore does not warrant that the use of any third- party-owned individual component or part contained in the work will not infringe on the rights of those third parties. The risk of claims resulting from such infringement rests solely with you. If you wish to re-use a component of the work, it is your responsibility to determine whether permission is needed for that re-use and to obtain permission from the copyright owner. Examples of compo- nents can include, but are not limited to, tables, figures, or images. All queries on rights and licenses should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; e-mail: pubrights@worldbank.org. ISBN (paper): 978-1-4648-1491-4 ISBN (electronic): 978-1-4648-1492-1 DOI: 10.1596/978-1-4648-1491-4 Cover image: Bill Pragluski, Critical Stages, LLC Cover design: Debra Naylor, Naylor Design, Inc. Library of Congress Control Number: 2019951800 Human Development Perspectives The books in this series address main and emerging development issues of a global/regional nature through original research and findings in the areas of education, gender, health, nutrition, population, and social protection and jobs. The series is aimed at policy makers and area experts and is over- seen by the Human Development Practice Group Chief Economist. Previous titles in this series Truman Packard, Ugo Gentilini, Margaret Grosh, Philip O’Keefe, Robert Palacios, David Robalino, and Indhira Santos, Protecting All: Risk Sharing for a Diverse and Diversifying World of Work (2019). Damien de Walque, Risking Your Health: Causes, Consequences, and Interventions to Prevent Risky Behaviors (2014). Rita Almeida, Jere Behrman, and David Robalino, The Right Skills for the Job? Rethinking Training Policies for Workers (2012). Barbara Bruns, Deon Filmer, and Harry Anthony Patrinos, Making Schools Work: New Evidence on Accountability Reforms (2011). Harold Alderman, No Small Matter: The Impact of Poverty, Shocks, and Human Capital Investments in Early Childhood Development (2011). All books in the Human Development Perspectives series are available at https://openknowledge.worldbank.org/handle/10986/2161. Contents Forewordxiii Acknowledgmentsxv About the Editors xvii Abbreviationsxix Glossaryxxi Executive Summary 1 What This Report Does 1 Obesity: The Problem Defined 2 The Health and Economic Costs of Obesity 5 Factors Affecting Obesity 6 Opportunities to Address Obesity 7 Country Experience to Date 11 Conclusions and Next Steps 14 Chapter 1: Why This Report Now? 19 Meera Shekar Overweight/Obesity: A Ticking Time Bomb 20 A Drain on National Economies and an Imperative for Government Action 21 Global Attention to Overweight/Obesity 22 What Is New in This Report? 24 Notes 26 References 26 vii viii | Contents Chapter 2: Prevalence and Trends 29 Julia Dayton Eberwein, Vanessa Oddo, Jonathan Kweku  Akuoku, Kyoko Shibata Okamura, Barry Popkin, and Meera Shekar What Is Overweight/Obesity? 30 Global Overweight/Obesity Prevalence 30 Global and Regional Trends in Overweight/Obesity over Time 34 The Equity Perspective 39 The Double Burden of Malnutrition 42 Annex 2A: Prevalence of Overweight/Obesity: Additional Tables and Figures 51 Notes 63 References 64 Chapter 3: Health and Economic Impacts of Overweight/Obesity 69 Pia Schneider, Barry Popkin, Meera Shekar, Julia Dayton  Eberwein, Charlotte Block, and Kyoko Shibata Okamura The Health Impact: Why Overweight/Obesity Matters 70 The Economic Costs of Overweight/Obesity 75 The Economic Factors That Affect Overweight/Obesity 76 The Role of Government 84 The Cost of Overweight/Obesity for Climate Co-Benefits and Water Use 87 Notes 88 References 88 Chapter 4: Factors Affecting Overweight/Obesity Prevalence 95  Barry Popkin, Julia Dayton Eberwein, and Kyoko Shibata Okamura Global Factors Associated with Increased Overweight/Obesity 97 Factors Linked to Weight Gain and Overweight/ Obesity at the Individual and Community Levels 101 The Role of Changing Diets and Food Systems 102 Impetus for Action 103 References 103 Contents | ix Chapter 5: Addressing Overweight/Obesity: Lessons for Future Actions 109 Barry Popkin, Pia Schneider, and Meera Shekar Typology of Actions to Prevent Overweight/Obesity 111 Approaches to Reducing Overweight/Obesity 111 Taxation for Sugar-Sweetened Beverages: Design, Impact, and Challenges 118 Diet-Related Taxation 129 Country Experience with Other Diet-Related Programs and Policies 138 Lessons for Overweight/Obesity Prevention Strategies from Nine Country Case Studies 149 Key Interventions with Potential for Impact 155 Notes 159 References 159 Chapter 6: Business Unusual: How Can Development Partners Support Countries to Fight Obesity? 169 Meera Shekar and Anne Marie Provo The Role of Development Partners in Supporting Countries to Prevent Overweight/Obesity 171 Is There Potential for Business Unusual? 178 Strategic Area 1: Leveraging the Range of Tools to Scale Up Investments 184 Strategic Area 2: Scaling Up Promising Interventions and Policies 190 Strategic Area 3: Building the Evidence and Knowledge Base across Sectors 199 Conclusions and Next Steps: The Opportunities and the Challenges 200 References 202 Boxes 3.1 Obesity: Both a Disease and a Risk Factor 71 5.1 The Impact of Taxes on Sugar-Sweetened Beverages and Nonessential Foods in Mexico 121 5.2 Links between Active Transport and Overweight/Obesity 147 6.1 Key Milestones for Scaling Up Global Efforts to Prevent Overweight/Obesity 172 x | Contents 6.2 What Is Human Capital and How Are Countries Engaged? 176 6.3 From Diagnostics to Dialogue to Development Finance: Building Momentum for Scaling Up Engagement on Overweight/Obesity and Non-Communicable Diseases in the Pacific 186 6.4 Learning from Experience in Global Tobacco Control 188 Figures ES.1 More Than Three-Quarters of Overweight or Obese Individuals Live in Middle-Income Countries 5 ES.2 Health Impacts of Overweight/Obesity 6 ES.3 Factors Affecting Overweight/Obesity: A Conceptual Framework 8 ES.4 Strategic Areas for Potential Development Partners Action 16 ­ 1.1 Human Capital Index and Its Links to Nutrition 25 2.1 Global Overweight and Obesity Rates: Children under 5 and Ages 5–19, and Adults Ages 20+ 31 2.2  More Than Three-Quarters of Overweight/Obese Individuals Live in Middle-Income Countries 32 2.3 Prevalence of Overweight/Obesity by Age Group and Region, 1980–2016 37 2.4 Shift in Burden of Overweight/Obesity to the Poor 40 2.5  Prevalence of Overweight/Obesity among Women Ages 15–49 by Urban/Rural Residence, Selected Low- and Middle-Income Countries 41 2.6  Country-Level Double Burden of Malnutrition, East Asia and Pacific 45 2.7  Country-Level Double Burden of Malnutrition, Europe and Central Asia 46 2.8  Country-Level Double Burden of Malnutrition, Latin America and the Caribbean 47 2.9  Country-Level Double Burden of Malnutrition, Middle East and North Africa 48 2.10 Country-Level Double Burden of Malnutrition, South Asia 49 2.11 Country-Level Double Burden of Malnutrition, Sub-Saharan Africa 50 2A.1 Prevalence of Overweight/Obesity by Region 52 2A.2 Country-Level Double Burden: Low-Income Countries 59 2A.3 Country-Level Double Burden: Lower-Middle-​ Income Countries 60 Contents | xi 2A.4  Country-Level Double Burden: Upper-Middle-​ Income Countries 61 2A.5  Country-Level Double Burden: High-Income Countries 62 3.1 Health Impacts of Overweight/Obesity 71 4.1 Factors Affecting Overweight/Obesity: A Conceptual Framework 96 Impact of Sugar-Sweetened Beverage B5.1.1  Taxes in Mexico in Year 1 122 Impact of Sugar-Sweetened Beverage Tax in B5.1.2  Mexico in Year 1 by Socioeconomic Status 123 Two-Year Impact of Sugar-Sweetened B5.1.3  Beverage Tax in Mexico 124 5.1 Chile’s Multipronged Obesity Prevention Program 152 6.1 Benefits of Investing in Human Capital 175 B6.2.1 Ingredients of the Human Capital Index 177 6.2 Human Capital Index and Its Links to Nutrition 177 6.3 Strategic Areas for Potential Development Partners Action 182 Maps ES.1 Overweight/Obesity Prevalence by Country Income Level 3 ES.2 Sugar-Sweetened Beverage Taxes around the World 12 ES.3 Countries with Mandatory or Voluntary Front-of-Package Labels 13 2.1 Proposed Public Health Significance of Overweight/Obesity by Age and Country 33 2.2 Overweight/Obesity Prevalence by Country Income Level 35 2.3 Double Burden of Malnutrition: Low- and Middle-Income Countries 44 5.1 Sugar-Sweetened Beverage Taxes around the World 114 5.2 Sugar-Sweetened Beverage Taxes: The Americas 115 5.3 Sugar-Sweetened Beverage Taxes: Europe and Northern Africa 116 5.4 Sugar-Sweetened Beverage Taxes: Sub-Saharan Africa, Asia, and the Pacific 117 5.5 Countries with Mandatory or Voluntary Front-of-Package Labels 140 5.6 Countries with Mandatory Front-of-Package Labels 141 5.7  Countries with Any Statutory Regulations on Marketing Food to Children 144 xii | Contents Tables ES.1 Key Interventions with Potential for Impact 9 2.1  Proposed Cutoff Values for Public Health Significance of Country-Level Double Burden of Malnutrition 32 2A.1 Proposed Cutoff Values for Public Health Significance of Prevalence of Overweight/Obesity, Adults and Children 51 2A.2 Level of Double Burden by Country 53 3.1 Body Fatness and Risk of Cancer Incidence: Evidence from the WCRF/AICR Third Expert Report 72 3.2 The Economic Costs of Overweight/Obesity 77 3.3 Summary of Estimated Costs of Overweight/Obesity in Selected Countries 80 5.1 Typology of Interventions 112 5.2 Diet-Related Taxes in Five Case Study Areas 113 5.3 Overview of Strategies and Processes to Prevent and Manage Overweight/Obesity 150 5.4 Key Interventions with Potential for Impact 156 6.1 Partners Engaged in Overweight/Obesity Prevention 174 6.2 An Overview of Relevant World Bank Products and Services to Support Countries 179 6.3 Summary of World Bank Experience in Overweight/Obesity Policies and Interventions 183 6.4 Overview of Options to Tax Unhealthy Foods and Subsidize Healthy Foods 191 6.5 Overview of Options for Food Labeling 192 6.6 Overview of Options for Regulating Access to Unhealthy Foods 194 6.7 Role of the Transport Sector in Addressing Overweight/Obesity 195 6.8 Working through the Education Sector to Reduce Overweight/Obesity 196 6.9 Prenatal and Early Childhood Nutrition Interventions 197 6.10 Food Systems Interventions 198 6.11 Five Key Strategies Suggested by the EAT Lancet Commission: Implications for Sectors Involved 199 Foreword Being overweight/obese has long been perceived to be a problem only in high-income countries. However, recent data show that since 1975 obesity has nearly tripled and it now accounts for 4 million deaths globally every year. In 2016, over 2 billion people globally (44 percent) were overweight or obese, and more than 70 percent of these live in low- or middle-income countries, dispelling the myth that obesity is a problem only in high-income countries. Further, somewhat unexpectedly, 55 percent of the global rise of obesity is in rural areas, highlighting the huge potential negative economic and health impacts, especially for the poor and people living in rural areas. Overweight/obesity has a large impact on national economies—through reduced productivity, increased disability, increased health care costs, and reduced life expectancy. For example, in China between 2000 and 2009, the estimates of increased health care costs associated with obesity grew from 0.56 percent to 3.13 percent of China’s annual national health care expenditure. In Brazil, obesity-related health care costs are expected to double, from US$5.8 billion in 2010 to US$10.1 billion in 2050. Today, overweight/obesity-related non-communicable diseases are among the top-three killers in every region of the world except Sub- Saharan Africa. Furthermore, as obesity increases rapidly and child stunting rates decline at relatively slow rates, many countries across the globe are now suffering from what is referred to as the “double burden of malnutrition”—high stunting and increasing obesity rates—thereby further jeopardizing human capital. xiii xiv | Foreword This report, Obesity: Health and Economic Consequences of an Impending Global Challenge, is timely as it complements some recent and forthcoming technical reports on this issue. It is also at the core of the World Bank’s Human Capital Project, which highlights the importance of investing in people to boost economic growth. The report reviews the changing epidemiology of overweight/obesity; current trends globally and by region, gender, and age; the health and economic costs and the potential impacts of failure to address it, including the impact on the climate; the potential effectiveness of policies and interventions; and country experiences and lessons learned, particularly with diet-related taxes and other preventive actions across several sectors. It puts forward a call to action for next steps in fighting this growing challenge. Reducing overweight/obesity is a global public good. While the evidence base is still emerging, many countries are already struggling to put in place new policies, such as taxation on unhealthy foods and interpretive front-of-package labels, to urgently address this looming epidemic. Governments and development partners such as the World Bank have key roles to play in supporting this effort through a transformative approach and additional financial and human resources dedicated to this agenda. Scaling up promising interventions and policies, supporting reforms through multisectoral engagement, including through the private sector, and continuing to build the evidence base are key to preventing the rise of overweight/obesity in future generations. Proactively addressing this issue will contribute significantly to building human capital, ensuring higher economic growth, and sustaining a workforce that is healthy and prepared for a productive future. Annette Dixon Vice President, Human Development World Bank Acknowledgments This report was prepared by a team led by Meera Shekar (World Bank), who conceptualized the overall report, co-authored several chapters, and provided guidance and direction for the report. Barry Popkin (UNC Chapel Hill), Julia Dayton Eberwein (Consultant), and Anne Marie Provo and Kyoko Shibata Okamura (World Bank) contributed substantially to the overall report, as well as to several chapters. Pia Schneider, Jonathan Kweku Akuoku, Georges Bianco Darido (World Bank), and Vanessa Oddo (Consultant) contributed as co-authors for specific chapters. Anne Marie Provo and Carolyn Shelton led consultations with several World Bank sectoral teams. Juan Pablo Orjuela (Consultant), and Felipe Targa and Georges Bianco Darido from the World Bank’s Transport Global Practice (GP) contributed to chapter 5. The team is grateful to Maria Eugenia Bonilla-Chacin for initiating and managing the country case studies with guidance from the Global Delivery Initiative (GDI) team. The authors also acknowledge the country case study authors, who include Ana Carolina Feldenheimer da Silva (Brazil), Ariel Azar Denecken (Chile), Arun Nair (Kerala state, India), Mireya Vilar Compte (Mexico), Michal Brzezinski (Poland), Zandile Mchiza (South Africa), Nimal Weerasinghe (Sri Lanka), Sueppong Gowachirapant (Thailand), Sutayut Osornprasop (Thailand), Sirinya Phulkerd (Thailand), and Safir Sumer (Turkey). Task Team Leaders for the country case studies include Daniela Pena de Lima (Brazil), Linda Brooke Schultz (Chile), Suresh Kunhi Mohammed (Kerala state, India), Claudia Macias (Mexico), Jakub Jan Kakietek (Poland), Anna Koziel (Poland), Carolyn Shelton (South Africa), Deepika xv xvi | Acknowledgments Eranjanie Attygalle (Sri Lanka), Sutayut Osornprasop (Thailand), and Ahmet Levent Yener (Turkey). Some of these cases are being published as GDI case studies. The team is grateful for background research by the following consultants: Vanessa Oddo, Manuela Villar Uribe, Ana Perez Esposito, Charlotte Block, and Claudia Trezza. The report was peer reviewed by Arturo Ardila Gomez (Global Lead, Urban Mobility, Transport GP); Asa Giertz (Senior Economist, Agriculture GP); Son Nam Nguyen (Lead Health Specialist, Health, Nutrition and Population GP); Veronica Silva (Senior Economist, Social Protection and Jobs GP); and Owen Smith (Senior Economist, Health, Nutrition and Population GP). The decision review meeting was chaired by Fadia Saadah (Director, Human Development) and Roberta Gatti (Chief Economist, Human Development). The team thanks Hope Steele for her incredibly skilled editing, done at rapid speed, and her patience with the technical terms and abbreviations. Thanks to Nicole Hamam for preparing the graphics. Financial support for this work was provided by the government of Japan through the Japan Trust Fund for Scaling Up Nutrition. About the Editors Barry Popkin is the W. R. Kenan, Jr. Distinguished Professor of Nutrition at the University of North Carolina at Chapel Hill (UNC). He developed the concept of the Nutrition Transition—the study of the dynamic shifts in our environment and the way they affect dietary intake, physical activity pat- communicable terns and trends, and obesity and other nutrition-related non-­ diseases. His research program focuses globally on understanding the shifts in stages of the transition and programs and policies to improve the popula- tion health linked with this transition (see www.nutrans.org). He is actively involved in work on the program and policy design and evaluation in the United States and globally, including collaborative research with colleagues in Brazil, Chile, Colombia, Mexico, and South Africa, for example (see Global Food Research Program at http://globalfoodresearchprogram.web​ .unc.edu/). He has a PhD in economics. He has received many major awards for his global contributions, including the 2016 World Obesity Society: Population Science and Public Health Award for top global public health researcher, the UK Rank Science Prize, and the Friends of Mickey Stunkard Lifetime Achievement Award of the Obesity Society. Meera Shekar is Global Lead for nutrition with the World Bank’s Health, Nutrition and Population Global Practice, managing key partnerships and firmly positioning nutrition within the World Bank’s new initiative on Human Capital. She steered the repositioning of the nutrition agenda that led to the new global Scaling Up Nutrition (SUN) movement (https://­ scalingupnutrition.org) and was a founding member of the Catalytic Financing Facility for Nutrition that evolved into the Power of Nutrition xvii xviii | About the Editors (https://www.powerofnutrition.org). She is chair of the SUN executive committee and has been one of the principals for the aid-architecture for nutrition within the G-8 and G-20 agenda-setting process. She led the devel- opment of the first global Investment Framework for Nutrition (https://open​ knowledge.worldbank.org/handle/10986/26069) and ­ co-leads (with the Bill and Melinda Gates Foundation) the Nutrition Financing working group for the Nutrition for Growth (N4G) summit (https://­ nutritionforgrowth​ .org) to be hosted by Japan in 2020. She has a PhD in international nutri- tion, epidemiology, and population studies from Cornell University; has consulted and published extensively; and is on various advisory boards and panels, including the Essential Living Standards index (forthcoming; Legatum Institute, UK; and the advisory group at Gates Ventures. Abbreviations ANSA Strategy against Overweight and Obesity (of Mexico) BMI body mass index EAT EAT Foundation FAO Food and Agriculture Organization of the United Nations GDP gross domestic product GST goods and services tax NCDs non-communicable diseases NCD-RisC NCD Risk Factor Collaboration NGO nongovernmental organization PAHO Pan-American Health Organization SSBs sugar-sweetened beverages UNICEF United Nations Children’s Fund VAT value added tax WHO World Health Organization xix Glossary adult survival The adult survival rate (ASR) is one of the four indicators included in the rate (ASR) Human Capital Index (HCI) developed by the World Bank (see page 24 for more details of the HCI). ASR is defined as the fraction of 15-year-olds that survive to age 60 and is used as a proxy for the range of non-fatal health outcomes that a child born today would experience as an adult if current conditions prevail into the future.1 body mass Body mass index (BMI) is an index of weight-for-height commonly used to index (BMI) classify overweight and obesity on a large population basis, measured in a person’s weight in kilograms divided by the square of his/her height in meters (kg/m²). In adults, overweight is defined as a BMI of 25 or more, whereas obesity is a BMI of 30 or more. diet-related Diet-related taxes are implemented as a way to use fiscal policies, tax particularly taxation, to alter retail prices in such a way that sales and consumption of foods associated with diet-related non-communicable diseases are optimized. For example, taxes are levied on foods high in specific nutrients/ingredients (salt/fats/sugar) or otherwise classified as “unhealthy,” including sugar-sweetened beverages. It could also take the form of reduced taxes (or subsidies) to promote the increased consumption of healthier food items, such as fruits and vegetables. disability- Disability-adjusted life years (DALYs) are a metric developed to quantify adjusted life the overall disease burden from mortality and morbidity. DALYs for a years (DALYs) particular disease or health condition are calculated as the sum of the years of life lost (YLL) due to premature mortality in the population and the years lost due to disability (YLD) for people living with the health condition or its consequences. One DALY can be thought of as one lost year of “healthy” life. DALYs of a population serve as a measurement of the gap between current health status and an ideal health situation—that is, disease burden—and allows us to estimate such gaps at the country, regional, and global levels. xxi xxii | Glossary double The double burden of malnutrition (DBM) is characterized by the burden of coexistence of more than one serious nutritional problem within malnutrition individuals, households, and/or populations, and across the life course. It (DBM) is often referred to as coexistence of undernutrition along with overweight and obesity, or diet-related non-communicable diseases, while it could also include other forms of malnutrition, such as anemia and wasting. The term triple burden of malnutrition is also used when a population group simultaneously suffers from high levels of undernutrition, overweight/ obesity, and micronutrient deficiencies such as anemia. Global In 2012, World Health Assembly Resolution 65.6 endorsed a Nutrition comprehensive implementation plan on maternal, infant, and young child Targets nutrition, which specified a set of six nutrition targets, known as Global Nutrition Targets, to be attained by 2025. The six targets are 1. Achieve a 40 percent reduction in the number of children under five who are stunted 2. Achieve a 50 percent reduction of anemia in women of reproductive age 3. Achieve a 30 percent reduction in low birth weight 4. Ensure that there is no increase in childhood overweight 5. Increase the rate of exclusive breastfeeding in the first six months up to at least 50 percent 6. Reduce and maintain childhood wasting to less than 5 percent non- Non-communicable diseases (NCDs) in a broader sense means diseases of communicable non-transmissible/infectious nature, yet they are more commonly referred diseases to as chronic diseases that tend to be of long duration and are the result (NCDs) of a combination of genetic, physiological, environmental, and behavioral factors. The four main types of NCDs are cardiovascular disease, diabetes, cancer, and chronic lung disease; together they are collectively responsible for almost 70 percent of all deaths worldwide. We refer to NCDs related to diet and nutrition as diet-related NCDs, which include cardiovascular disease (such as heart attacks and stroke, and often linked to high blood pressure), diabetes, and certain cancers. Unhealthy diets and poor nutrition are among the top risk factors for these diseases globally. nutrition Nutrition transition in a population describes progressive shifts in the transition stages of eating, drinking, and moving from traditional, nutrient-rich diets to energy-dense, nutrient-poor, ultra-processed foods, sugary calorie- laden beverages, and increased sedentary lifestyle that coincides with or is preceded by economic, demographic, and epidemiological changes. Sociodemographic characteristics, such as income, education, sex, and location, can often predict which segments of the population will be worst affected by the nutrition transition, but this will depend on the macro- and microeconomic forces and sociocultural aspects inherent to each region. overweight Overweight and obesity result from an imbalance between energy and obesity consumed (too much) and energy expended (too little). Globally, people are consuming foods and drinks that are more energy dense (high in sugars and fats) and engaging in less physical activity. Glossary | xxiii To define the state of overweight and/or obesity for adults ages 18 years and older, there are age- and gender-specific cutoffs delineated by the WHO, the U.S. Centers for Disease Control and Prevention (CDC), and the International Obesity Task Force (IOTF) that are used in different studies, countries, and contexts. The prevalence differences overall in these methods are small. Using the WHO’s cutoffs, overweight and/or obesity are commonly defined by the following: • Overweight: BMI ≥ 25 kg/m², < 30 kg/m² • Obesity: BMI ≥ 30 kg/m² • Overweight and obesity (overweight/obesity): BMI ≥ 25 kg/m² For children, particularly in preschool ages, overweight/obesity is defined as 2 standard deviations from the median of the WHO Child Growth Standards measured in weight-for-length/height z-scores (this definition is universally used in this report). sin tax A sin tax is an excise or ad valorem tax specifically levied on certain goods deemed harmful to society and individuals—for example, alcohol, tobacco, sugar-sweetened/soda drinks, fast foods, and gambling, among others— to increase their price in an effort to lower their use and reduce the negative impacts of the taxed substance. sugar- Sugar-sweetened beverages (SSBs) are any liquids that are sweetened sweetened with added sugars (for example, brown sugar, corn sweetener, corn syrup, beverages dextrose, fructose, glucose, high-fructose corn syrup, honey, lactose, malt (SSB) syrup, maltose, molasses, raw sugar, and sucrose), such as regular non-sugar-free soda, fruit/sports/energy drinks, sweetened waters, and coffee/tea beverages with added sugars. The calories in SSBs can contribute to weight gain and provide little to no nutritional value and lead to other health risks including obesity, tooth decay, heart disease, and type 2 diabetes. SSBs are associated with minimal effect on hunger, so consuming sugary drinks is not expected to reduce food intake. With an aim of reducing the consumption of SSBs, the sales of the defined products are regulated—for example, they are restricted on school premises or taxed as an important public health measure. stunting Stunting is a chronic form of undernutrition (as opposed to an acute form of undernutrition, called wasting), which often occurs as a result of the accumulation/recurrence of damaging conditions such as poor socioeconomic status, poor maternal health and nutrition, frequent illness, and/or inappropriate infant and young child feeding and care in early life. Stunting is known to affect children’s physical and cognitive development and consequently their health and productivity in their adulthood. A child is categorized as stunted when her/his length or height-for-age z-score is below –2 standard deviations based on the WHO Child Growth Standards. Child stunting is also used in the Human Capital Index as an indicator for the prenatal, infant, and early childhood health environment, summarizing the risks to good health that children born today are likely to experience in their early years—with important consequences for health and well-being in adulthood. xxiv | Glossary syndemic A syndemic or synergistic epidemic is the aggregation of two or more concurrent or sequential epidemics or disease clusters in a population with biological interactions, which exacerbate the prognosis and burden of disease, in this case referring to the global syndemic of undernutrition, overweight/obesity, and climate change. Note 1. Aart Kraay. 2018. “Methodology for a World Bank Human Capital Index.” Policy Research Working Paper 8593, World Bank, Washington, DC. http:// documents.worldbank.org/curated/en/300071537907028892/pdf​ /WPS8593.pdf. Executive Summary What This Report Does This report lays out why overweight and obesity is a “ticking time bomb” with huge potential negative economic and health impacts, especially for the poor and people who live in low- or middle-income countries, dispel- ling the myth that it is a problem only in high-income countries and urban areas. The report also lays out many of the current trends concerning overweight and obesity and complements all of the new and forthcoming ­ technical reports on this issue in four distinct ways: • First, it focuses on identifying evidence-based opportunities for fiscal and regulatory policy reforms and investments across several sectors that could potentially prevent overweight and obesity. In doing so, it builds on the epidemiological evidence from several technical reports to iden- tify potentially promising actions; adds new information on the eco- nomic implications of overweight and obesity, including the equity perspective, that may be useful in making the case for action; and identi- fies the growing list of “double-burden” countries to spur urgent action in these countries. • Second, it brings to bear implementation challenges and lessons learned from several country case studies where policies or interventions to pre- vent overweight and obesity have been rolled out at scale, with variable success. • Third, and perhaps most important, it identifies an action agenda—­ specifically on the unique role that client countries, with support from institutions such as the World Bank, can play in this space—and the 1 2 | Obesity instruments (policy and regulatory levers, technical assistance, and results-based financing instruments as well as investment lending) that the World Bank (and other similar institutions) can use in the near future to support countries in addressing the emerging epidemic of over- weight and obesity and related non-communicable diseases (NCDs) across sectors. • Fourth, the report reiterates research findings from recent technical reports from the Lancet that suggest that changing diets and food systems are also key to addressing the ongoing challenge of child stunting and undernutrition, along with the growing challenges of climate change. It also identifies key areas requiring further research and evaluations that may be important for future actions in this area. Obesity: The Problem Defined Overweight and obesity result from an imbalance between energy consumed (too much) and energy expended (too little). Globally, there has been a shift in food consumption patterns whereby people are consuming more energy- dense foods (those high in sugars and fats); at the same time, they are engag- ing in significantly reduced physical activity. Using the World Health Organization’s (WHO’s) cutoffs, adults with a body mass index (BMI; this is weight/height squared) of 25 or more are classified as overweight; those with a BMI of 30 or more are classified as obese. The terms overweight and obesity both identify people who are at risk for health problems from having too much body fat (see also the glossary). For simplicity, this executive summary uses the term obesity to refer to both conditions. The ticking time bomb of obesity has huge potential economic and health impacts, especially for the poor. As of 2016, an estimated 44 percent of adults (more than 2 billion) worldwide are overweight or obese, and over 70 percent of them live in low- or middle-income countries (see map ES.1 and figure ES.1). Over 70 percent of countries—the vast majority of which are low- and lower-middle-income countries—currently face a double burden: a high prevalence of both undernutrition and obesity. As per capita income increases, the burden of obesity shifts to the poor and to rural areas across low- and middle-income countries. Over 55 percent of the global rise in obesity is found in rural areas; in South East Asia, Latin America, Central Asia, and North Africa this increase is close to 80 or 90 percent of the recent shift. This has significantly closed the urban-rural gap in most regions except Sub-Saharan Africa. Today most of the countries in the world with high levels of the double burden are found in Sub-Saharan Africa, South Asia, selected South East Asian countries (Indonesia being most promi- nent), and Guatemala. This is a marked shift from the 1990s, when Mexico Executive Summary | 3 and most of Central America, Bolivia, Peru, South Africa, Francophone Africa, the Arab Republic of Egypt, parts of Central Asia, and the Philippines faced severe levels of the double burden. In addition, in many low- and middle-income countries, for an array of genetic and epi-genetic reasons, populations are more susceptible to NCDs at BMI levels lower than 25 (overweight). Map ES.1 Overweight/Obesity Prevalence by Country Income Level a. Low- and Middle-Income Countries 1990s IBRD 44469 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE LOW- AND MIDDLE-INCOME COUNTRIES, 1990s 4 Very high (≥40%) 3 High (≥30–39%) 2 1 Medium (≥20–29%) Low (<20%) 2010s IBRD 44470 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE LOW- AND MIDDLE-INCOME COUNTRIES, 2010s 4 Very high (≥40%) 3 High (≥30–39%) 2 1 Medium (≥20–29%) Low (<20%) continued next page 4 | Obesity Map ES.1 (continued) b. High-Income Countries 1990s IBRD 44471 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE HIGH-INCOME COUNTRIES, 1990s Very high (≥40%) High (≥30–39%) Medium (≥20–29%) Low (<20%) 2010s IBRD 44472 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE HIGH-INCOME COUNTRIES, 2010s Very high (≥40%) High (≥30–39%) Medium (≥20–29%) Low (<20%) Sources: Popkin, Global Food Research Program, University of North Carolina. Data are from UNICEF, WHO, World Bank, and NCD-RisC estimates, supplemented with selected Demographic and Health Surveys and other country direct national measures. Note: Based on 1990s and 2010s weight and height data. Childhood obesity is particularly damaging. It puts the child at high risk of developing debilitating NCDs earlier in life and living with them longer, denying the child her or his full health and economic potential. It also puts in place a trajectory of poor diet and activity patterns that accentuate the risks of increased weight gain. Concurrently, stunting and poor growth Executive Summary | 5 More Than Three-Quarters of Overweight or Obese Figure ES.1  Individuals Live in Middle-Income Countries 4% 11% 10% 9% 18% 25% Children Children Adults under 5 5–19 years 20+ years 79% 73% 71% Low income Middle income High income Sources: Data on overweight and obesity levels from NCD-RisC estimates for 2016, http:// ncdrisc.org/data-downloads.html; country income classifications based on World Bank criteria as of 2015. ­ during the first 1,000 days of life significantly increase children’s risks of accumulating visceral fat (obesity in central areas of the body) and many related NCDs later in life when they are exposed to a lifestyle dominated by ultra-processed foods and reduced physical activity. ­ Consequently, many low-income countries are starting to suffer from the double burden of malnutrition—increases in overweight and obesity even as the burden of undernutrition remains high. The long-term costs of obe- sity and NCDs will be significantly exacerbated by the lag in the impact of current and past stunting reduction programs. The Health and Economic Costs of Obesity Increasing health care costs linked to increasing obesity rates are a trend across the world, and both overweight and obesity are significant risk fac- tors for NCDs (see figure ES.2). The critical issue in understanding the economic impacts of obesity is that mortality, albeit significantly increased, is not the only major outcome. Reduced productivity, increased disabilities, increased health care costs, early retirement, and reduced length of disability-free healthy living across the life cycle—all of which will impact human capital outcomes in ­ countries—are also significant consequences. As obesity rates are rapidly increasing, global attention to this issue is increasing. Poor diets, a lack of physical activity, and overweight and obesity are now recognized as the top preventable causes of NCDs in all countries in the world. The estimated economic costs of obesity vary considerably, since stud- ies use different methodologies to estimate direct and indirect costs. 6 | Obesity Figure ES.2 Health Impacts of Overweight/Obesity DIABETES CARDIOVASCULAR Stroke, kidney disease, DISEASE gestational diabetes, Stroke, aneurysm, amputation, heart attack, vision loss kidney disease, preeclampsia HEALTH IMPACTS OF OBESITY CANCER OTHER Uterine, esophageal, Liver disease, liver, kidney, infection, asthma, pancreatic, colorectal pain, depression For example, estimates from the United States range from US$89 billion to US$212 billion in total costs; those from China are estimated at 3.58 and 8.73 ­ percent of gross national product (GNP) in 2020 and 2025, respectively; and Brazil projects a doubling of the obesity-related health ­ care costs from US$5.8 billion in 2010 to US$10.1 billion in 2050. The effects of obesity on productivity, early retirement, and disabilities have rarely been studied in low- and middle-income countries. In addi- tion, the same poor diets dominated increasingly by ultra-processed foods and the reduced activity patterns that affect obesity increase the risk of a wide array of NCDs directly as well as indirectly. Whatever estimates one might subscribe to, the big picture message is that increasing health care costs linked to increasing obesity rates are a trend across both the developed and the developing world. Preventing obe- sity therefore makes sense from a public finance perspective. Governments and development partners have a key role to play in this effort, including by ensuring that consumers are informed about the health and other con- sequences of their dietary and lifestyle choices. Factors Affecting Obesity Three sets of factors can affect overweight/obesity: (1) early life undernutri- tion and reduced lin­ ear growth, (2) reduced energy expendi­ ture through Executive Summary | 7 changes in technology and lifestyles in all phases of life, and (3) a set of factors linked to changing food systems and the resultant shifts in food con- sumption and eating behaviors. The analyses presented in this report suggest that a range of conditions that emerge with globalization, urbanization, and technological develop- ment are driving the rise in obesity rates globally: • Rapid reductions in physical activity in all domains of activity, from mar- ket-related work and home production (for example, water gathering, food preparation/cooking) to transportation and leisure in low- and middle-income countries in the last 15–35 years, and global access to labor-reducing technologies. • Rapid shifts in the built environment, which contributed both to reduced physical activity in many cases and to changes in the food environment. • The spread of modern food retailing and a rapidly changing food system. This has led to major shifts toward diets dominated by ultra-processed foods, and was linked to higher price increases for healthy foods than for unhealthy products. • Women entering the formal market labor force in large proportions in most high-income countries and in low- and middle-income countries, requiring changes in food consumption. • Shifts in eating patterns, which have led to increased snacking and away-from-home eating. • Increased country and household income, which have been linked to a shift to greater obesity among the poor in all high-income countries and in an increasing proportion of low- and middle-income countries. • Increased wealth in many low-income countries, which has shifted them to middle-income countries and in some cases to high-income countries. • Modern media and marketing that, along with globalization, has shifted social and cultural norms related to dietary and activity patterns. Based on these emerging conditions, the conceptual framework below highlights the actionable direct and indirect factors associated with obesity (figure ES.3). Opportunities to Address Obesity The evidence base for preventing obesity is still emerging. Table ES.1 sum- marizes the promising interventions/policies that have the potential to pre- vent obesity. These include a range of: 1. fiscal policies such as taxation and subsidies; 2. regulatory policies on marketing and advertising (including direct mar- keting to children in schools); 8 | Obesity Factors Affecting Overweight/Obesity: A Conceptual Figure ES.3  Framework COUNTRY WEALTH INDIRECT FACTORS URBANIZATION FOOD SYSTEMS DIET PHYSICAL ACTIVITY DIRECT FACTORS BUILT ENVIRONMENT TRADE LIBERALIZATION EARLY LIFE NUTRITION AND GENETICS SOCIAL AND CULTURAL NORMS TECHNOLOGY 3. food systems approaches, including the proliferation of modern food retailing and away-from-home food service options—some formal and many informal; 4. education sector policies that affect areas such as school cafeterias, mar- keting, and sales of unhealthy food in and around schools, as well as physical activity in schools; 5. transport and urban design interventions such as mass transit and city and building design; and 6. early childhood nutrition programs to address undernutrition. Unlike many other public-health interventions, very few of these poli- cies or interventions (except for early childhood programs) have been rigorously evaluated, and they have not been and cannot be tested through randomized controlled trials. Few have undergone systematic reviews because their effectiveness has not yet been demonstrated or carefully documented. Nonetheless, initial assessments, a limited number of systematic reviews, and lessons from several countries suggest that the following policies/interventions are promising—not just for their poten- tial impacts on preventing obesity, but also for potential climate co-­ benefits. In addition, there are a series of interventions that have been shown to impact undernutrition, such as breastfeeding promotion, that are also triple-duty actions in terms of their simultaneous impact on undernutrition, obesity, and climate change. Executive Summary | 9 Table ES.1 Key Interventions with Potential for Impact Policy Effectiveness Potential impact and scope of Intervention type Goal demonstrated impact on target population Fiscal policies  Taxes/subsidies Reduce Chile, Mexico, • Impact depends on the size/ consumption of United design of the tax ultra-processed Kingdom, and • Nutrient-based taxes such as foods and South Africa tiered taxes and taxes based beverages, [papers on number of grams of primary focus to forthcoming]; sugar promote reformulation date on sugar- U.S. cities • Impactful in reducing sweetened consumption among beverage high-volume consumers, reduction with potential for prevention of overweight/obesity among children/adolescents Regulatory policies on marketing and advertising Front-of-   Reduce Chile • Very impactful when package consumption of [unpublished combined with other linked warning labels ultra-processed series of policies foods and papers • Universal targeting beverages; change forthcoming] eating norms  Marketing Reduce Chile, many • Potential for impact when controls on consumption of others linked to other policies foods for ultra-processed • Can reduce child exposure; children foods and total family exposure does beverages; change not change eating norms  Regulations on Reduce Chile • Potential for changing norms total consumption of • Reaches all children; more marketing and ultra-processed impactful on younger sales of foods and children unhealthy beverages; change foods eating norms  Retailer Reduce United States, • Potential for high impact interventions consumption of United • Potential for important food ultra-processed Kingdom purchase changes foods and beverages Agriculture/food systems approaches  Agriculture Incentivize CGIAR • Potential for high impact research research on • Potential to shift relative underserved foods prices (legumes, fruits, vegetables) continued next page 10 | Obesity Table ES.1 (continued) Policy Effectiveness Potential impact and scope of Intervention type Goal demonstrated impact on target population Ensure agriculture CGIAR, • Potential high in general; research has a country only initial stages of efforts nutrition focus, programs globally not just a yield • Potential huge for shifting focus relative food prices  Agriculture Eliminate subsidies Yet to be • Potential impact unclear for subsidies for unhealthy implemented shifting relative prices; but ingredients (for could provide fiscal benefits example, sugar, for countries corn, palm oil)  Food Build awareness of Yet to be • Potential impact unclear processing unhealthy implemented ingredients used in food processing  Formal food Reduce None • Potentially impactful service sector consumption of • As income increases, the ultra-processed proportion of meals eaten foods and outside the home increases beverages rapidly, so the potential impact rises • Dependent on laws impacting pricing policies, labeling, sizing  Informal food Reduce Singapore • Great potential but requires service sector consumption of experimentation (existing ultra-processed experience shows limited foods and impact as focus is on beverages sanitation, healthy oils; no pricing/portion controls used) Education sector approaches  School food Reduce CGIAR, • Potential high; only initial service quality consumption of country stages of efforts globally and school ultra-processed programs • Potential huge for shifting premises sales foods and relative food prices regulations beverages; change eating norms for children Active transport and building/city design Mass transit   Increase None • Minimal potential for impact system movement, energy on overweight/obesity but expenditure important for health and climate • Mostly affects low- and middle-income populations continued next page Executive Summary | 11 Table ES.1 (continued) Policy Effectiveness Potential impact and scope of Intervention type Goal demonstrated impact on target population  City design: Increase Colombia, • Potential for impact among parks, cycling movement, energy Netherlands, users lanes expenditure United Kingdom  Building Increase Europe, • Minimal impact on design to movement, energy United States, overweight/obesity but enhance expenditure Australia important for health walking • Potential for increasing physical activity Early childhood nutrition programs  Breastfeeding Improve Many • Impact global as promotion breastfeeding countries documented across many rates low-, middle-, and high- income countries  Prevention of Well-documented Many • Relevant mostly for early childhood package of countries low-income countries and stunting interventions some middle-income across sectors countries Note: CGIAR = Consultative Group on International Agricultural Research. Country Experience to Date While fiscal policies linked mainly to taxation on sugar-sweetened bever- ages have dominated as key interventions in over 40 countries to reduce consumption of unhealthy foods (see map ES.2) and there is extensive experience in this area, many other regulatory options are being used by countries to improve diet quality (map ES.3). These include front-of- package labeling, nutrient profiling, school-based food regulations and education, market and retail solutions, and marketing controls and regulations. Front-of-package labeling and related nutrition profiling models with warning labels show great promise; diet-related taxes also remain a promising approach, albeit they will face challenges. The main chal- lenges to the successful implementation of these taxes are a tax system’s administrative capacity, substitution effects, tax evasion, and opposition from the food industry. These challenges need to be considered when designing effective tax policies. Countries with strong tax administra- tion generally design excise taxes based on nutrient content, albeit taxes on product volumes may be easier to implement in countries where tax administration is not so strong. Tiered tax systems based on sugar con- tent appear to be another promising approach. And experience suggests 12 | Obesity Map ES.2 Sugar-Sweetened Beverage Taxes around the World IBRD 44264 | DECEMBER 2019 EUROPE Belgium WESTERN PACIFIC Estonia Brunei Darussalam Finland Cook Islands France Fiji Hungary French Polynesia AMERICAS Ireland Kiribati Barbados Latvia Nauru Bermuda Morocco Palau Chile AFRICA, EASTERN Norway MEDITERRANEAN, Philippines Colombia Portugal AND SOUTHEAST ASIA Samoa Dominica Spain (Catalonia) Bahrain Tonga Mexico St. Helena India Vanuatu Peru U.S. (8 local) United Kingdom Malaysia Maldives Mauritius Saudi Arabia South Africa Sri Lanka Thailand Implemented United Arab Emirates Passed Source: Global Food Research Program, University of North Carolina, http://globalfood​ researchprogram.web.unc.edu/multi-country-initiative/resources/. Note: This map was created based on the dataset available as of March 2019. that a regional approach to taxation will likely reduce cross-border pur- chases and prevent resulting tax evasion. A combination of policies, such as those in Chile, promise important synergies and much larger impacts. No countries have yet considered tying the taxes to subsidies for healthier legumes, vegetables, and fruits and other healthful, less obeso- genic foods, although earmarking sin taxes for public programs brings even more challenges. Experience in marketing regulation of unhealthy foods is also limited, except perhaps what has been learned from the mar- keting of infant formulas. However, new research emerging from Chile will shed more light on this approach, suggesting that carefully designed laws may be impactful on exposure to obesogenic foods. Furthermore, emerging evidence also suggests that impacts of such obesity-prevention policies are starting to be realized. For example, the 10 percent tax on sugar-sweetened beverages in Mexico is estimated to reduce obesity by 2.5 percent by 2024 and prevent 86,000 to 134,000 new cases of diabetes by 2030; another study estimated a reduction of 189,300 fewer cases of type 2 diabetes, 20,400 fewer cases of strokes and myocardial infarctions, and 18,900 fewer deaths occurring from 2013 to 2022 in Mexico as a result of this taxation. Countries with Mandatory or Voluntary Front-of-Package Labels Map ES.3  Denmark IBRD 44261 | DECEMBER 2019 Iceland Lithuania Norway Sweden Finland Denmark United Kingdom Belgium Czech Republic Netherlands Poland Islamic Republic of Iran Mexico Thailand Slovenia Croatia France Philippines United Arab Emirates Ecuador Israel Nigeria Brunei Darussalam Peru Sri Lanka Malaysia Singapore Argentina Executive Summary | 13 Australia Chile Uruguay New Zealand Mandatory Voluntary Mandatory/voluntary To be implemented Source: Global Food Research Program, University of North Carolina, 2019, http://globalfoodresearchprogram.web.unc.edu/multi-country​ -­initiative/resources/. Note: This map was created based on the dataset available as of March 2019. 14 | Obesity Important shifts in urban planning and design are also being under- taken. All forms of design that increase physical activity—from building design that makes stairs an attractive option to urban design that incen- tivizes and enables biking and walking—are important. Reducing car use and increasing mass transit/biking/walking are major global needs, which also have significant climate co-benefits. However, current experience with improved physical activity and obesity prevention is limited to a handful of countries, mostly in the global north and South America. While these are promising strategies, future efforts need to build in ­ evaluation of large-scale urban or national programs to document their impacts. There are no evaluations as yet equivalent to the Mexican or Chilean rigorous evaluations of their food-related fiscal and regulatory policies in the physical activity domain. It is also important to note that this is the beginning of large-scale policies and regulations designed by countries to improve diet quality, ­ increase physical activity, and prevent obesity, and so to contribute to healthy living throughout the life cycle. Many of these policies and regula- tions will have significant climate co-benefits as well. In the first half of the 2010s, over 50 countries have engaged in some major fiscal policy or regu- latory action in this area. Many evaluations currently underway will assist in providing evidence on which approaches may also have the greatest impact on water use and carbon emissions, but major gaps still exist between the evidence concerning impact and best practices today. Conclusions and Next Steps The global obesity epidemic presents a formidable challenge to human capital acquisition, national wealth accumulation, and the goals of end- ing extreme poverty and boosting shared prosperity. While reductions in undernutrition are being observed globally and investments in reducing undernutrition are at an all-time high, obesity rates are rising rapidly. Continued economic growth among the world’s low- and middle- income countries will only intensify the magnitude of the devastating impacts of obesity on health, well-being, and productivity. Furthermore, as economies grow, the burden of obesity will shift even more toward the poor, making it all the more imperative for the global development com- munity, including institutions such as the World Bank, to engage. Obesity has a large impact on national economies—both through reduced productivity, increased disability, and reduced life expectancy, and through significantly increased health care costs. The effort to reduce obesity is therefore a global public good and governments have a Executive Summary | 15 key role to play in addressing this challenge through a comprehensive approach to policy formulation and intervention, including in the agri- culture, environment, transport, education, fiscal, and health care sectors. Recent technical reports from the Lancet suggest that, in addition to addressing obesity, changing diets and food systems are also key to address- ing the growing challenges of climate change as well as the ongoing chal- lenge of child stunting and undernutrition. The shift in diets and activity patterns globally linked to increased obesity are also linked to important water and carbon emissions concerns, thus perpetuating what is termed by the Lancet Commission on Obesity as the syndemic of undernutrition, over- weight/obesity, and climate change. The good news is that there are also potential double- and triple-duty actions that will provide climate co-benefits in addition to being promis- ing interventions to address obesity and undernutrition. For example, sugar is one of the more water-intensive crops, and reduced sugar con- sumption is expected to lead to important reductions in water use and related climate co-benefits. The Lancet EAT Commission report also advo- cates a shift toward more sustainable plant-based diets to address both obesity and climate change. The World Bank has the ability to work across these sectors and to help guide countries toward fiscal and regulatory policies as well as investment policies to prevent further increases in obe- sity, while also tackling undernutrition and climate change through double-duty and triple-duty actions that have an impact on undernutri- ­ tion, obesity, and climate change. Countries need to act urgently to address obesity. Development partners such as the World Bank are in a unique position to support low-, middle-, and high-income client countries to better prevent obesity. In their engage- ment with country governments, development partners can highlight the issue of obesity as one requiring corrective public action rather than one of individual responsibility. And agencies such as the World Bank can trans- form this advocacy into tangible investment opportunities through the rep- ertoire of analytical, diagnostic, policy, technical assistance, and investment tools that can be deployed to address different aspects of the obesity challenges. Given the renewed global focus on human capital, its links to the obesity epidemic, and the growing evidence base for double- and triple-duty actions, there are both an urgent need and great opportunities for advocacy and action at scale. The health sector needs to lead on diagnostics, but tack- ling this complex agenda will require both a whole-of-government and a whole-of-development-partner approach, with the agriculture, transport, macroeconomics, trade and investment, and education sectors each having a major role to play. 16 | Obesity Figure ES.4 Strategic Areas for Potential Development Partners Action STRATEGIC AREA 2 Scaling up promising interventions STRATEGIC AREAS and policies, and supporting reforms through multisectoral engagement, including through the private sector STRATEGIC AREA 1 Leveraging the range of tools at global/regional/ country levels OBESITY PREVENTION FOR POTENTIAL INVOLVEMENT OF DEVELOPMENT PARTNERS TO SUPPORT COUNTRIES STRATEGIC AREA 3 Building the evidence and knowledge base across sectors The report concludes that client countries, with support from develop- ment partners such as the World Bank, are well positioned to address the economic and health consequences of obesity. There are three key strategic areas in which these agencies, including the World Bank, can support countries to maximize their impact (figure ES.4): • Strategic Area 1: Leveraging the range of advocacy, policy, and invest- ment tools available to countries and development partners at global, regional, and country levels • Strategic Area 2: Scaling up promising interventions and policies, and supporting reforms through multisectoral engagement, including through the private sector • Strategic Area 3: Building the evidence and knowledge base across sec- tors to document impacts and best practices on how to implement these policies/interventions Executive Summary | 17 The following five key areas are identified as critical for further research and analysis by countries and development partners: • Documenting the impact of fiscal and regulatory policies and cross-­ sectoral interventions in countries where these are being applied, includ- ing a focus on how these can be adapted in different country contexts • Quantifying the climate co-benefits of investing in obesity prevention policies and programs • Building the evidence base for food systems approaches to prevent obesity • Instigating stronger engagement with the private sector • Quantifying the contribution of obesity to adult survival rates and the Human Capital Index Small tweaks to current engagement models will not be sufficient. A transformative approach and additional financial and human resources need to be dedicated to this agenda by all countries, as well as by develop- ment partners. Building internal capacity within client countries as well as within partners such as the World Bank to work across sectoral boundaries and with nontraditional partners will be crucial. The experience with tobacco suggests that this will be a long road, but it is feasible, in consulta- tion with like-minded global and national partners such as Bloomberg Philanthropies, the EAT Foundation, UN partners such as the WHO and UNICEF, and academia and civil society. 1 Why This Report Now? Meera Shekar Key Messages • Global attention to overweight/obesity has recently b ­urgeoned. Increases in the incidence of overweight/obesity are accelerating in most low- and middle-income ­ countries. The impact of overweight/ obesity on productivity and economic development is huge in terms of increased health care costs, reduced productivity, disability, early ­ xpectancy. Unhealthy diets, physical inactivity, retirement, and life e and overweight/obesity jointly represent the top preventable causes of non-communicable diseases (NCDs) in all countries in the w ­ orld. • Recent technical reports from two Lancet commissions suggest that changing diets and food systems are also key to addressing the growing challenges of climate change as well as the ongoing chal- undernutrition. lenge of child stunting and ­ • Governments have a key role to play in addressing these challenges by providing a comprehensive approach to policy formulation and intervention, including in the agriculture, environment, transport, sectors. taxation, and health care ­ • Development partners such as the World Bank, foundations, and UN agencies have the ability to help guide countries toward fiscal, regu- latory, and investment policies to prevent further increases in over- weight/obesity while also tackling undernutrition and climate change—a trilogy of effects referred to as a syndemic by the 2019 Lancet Commission on Obesity ­ (LCO). 19 20 | Obesity • This report builds on the many new and forthcoming technical reports  on overweight/obesity prevention to identify an action agenda for institutions such as the World Bank that are uniquely positioned to act across sectoral boundaries (including the health, agriculture, macro/fiscal, urban design/city planning, and education sectors, among others) and to deploy both policy and investment tools to address this wake-up ­call. Overweight/Obesity: A Ticking Time Bomb Overweight/obesity is a time bomb ready to e ­ xplode. Overweight/­ obesity rates are high and increasing rapidly across the world, in both developed and developing economies, and the burden is growing rapidly in every region of the ­ world. Worldwide, as of 2016, an estimated 44 ­ percent of adults (more than 2 billion) are overweight/obese; over 70 ­ percent of them live in low- or middle-income countries, dispelling the myth that over- weight/obesity is a problem in high-income countries a ­ lone. The burden of overweight/obesity has nearly tripled since 1975 and now accounts annu- globally (The GBD 2015 Obesity Collaborators ally for about 4 million deaths ­ 2017). And rural overweight/obesity is growing rapidly in many developing countries. Over the next several decades these trends are likely to increase ­ significantly unless urgent actions are taken to curtail this ­ progression. Furthermore, as countries grow economically and per capita incomes rise, the burden is shifting even more toward the poor, with potentially devastat- ing impacts on the health of the poor, on the need for financial protection especially for the poor, and on overall economic d ­ evelopment. In-depth and broader studies on overweight/obesity have shown how an increased shift of a higher burden of overweight/obesity among the poor has been linked with increased gross domestic product (GDP) per capita in low- and middle- income countries (Jones-Smith et ­ 2012). In addition, in the new al. 2011, ­ Lancet series on the double burden of malnutrition (DBM), the lead study shows how the bottom quartile in GDP per capita countries have been most likely to have the highest levels of DBM compared with other countries, while in the 1990s the top quartile countries were most likely to have high levels of DBM (Popkin, Corvalan, and Grummer-Strawn 2019). These are mainly countries in South Asia and Sub-Saharan Africa plus ­ Indonesia. Whichever way it is examined, increasing health care costs linked to increas- ing overweight/obesity rates are a trend across the ­ world. Why This Report Now? | 21 A Drain on National Economies and an Imperative for Government Action Estimates of the economic costs of overweight/obesity suggest a wide range because the methods used to estimate these costs vary considerably—­ some studies base their estimates on the direct medical costs of treatment while others include indirect costs linked to disability, increased mortality, and reduced productivity (often termed presenteeism in the literature; Trogdon et ­ 2008). An unpublished systematic review al. ­ of published studies conducted for this report identified 34 studies between 2007 and 2017 that estimated the national costs of overweight, obesity, or ­ both. These studies cover 13 high- and middle-income countries. The results suggest a wide range of estimated costs in terms of ­ share of GDP lost: from ­ 0.01 ­ percent in Brazil to ­ 2.08 ­percent in the United ­ States. Another estimate from the United States suggests that overweight/obesity costs the government, employers, and individuals about US$147 billion per year; further, this cost will rise significantly as medical treatment for chronic diseases becomes more ­ sophisticated. An estimate from Indonesia (Kosen 2018) suggests losses of about 3 ­ percent of GDP, equivalent to about ­ US$28.4 billion; another global estimate suggests losses of ­ percent of GDP, equal to about ­ 2.8 ­ US$2.0 ­ trillion (Dobbs et al. 2014). Whatever the final estimates, the costs are high, and—combined with the fact that overweight/obesity rates in the United States are growing and life expectancy is declining (especially compared with countries such as France, Germany, Japan, and the United Kingdom)—this should be a cause for major concern among policy ­ makers. In Germany, the direct costs of overweight/obesity were estimated at a8,647 million in 2008, correspond- ing to ­ percent of total German heath care expenditures, with addi- 3.27 ­ tional indirect costs of a8,150 million, of which two-thirds were costs of unpaid work linked to sickness-related absences, early retirement, and early mortality (Lehnert et ­ 2015). al. ­ In China, estimates of increased health care costs associated with over- weight/obesity have grown from ­ 0.56 ­ percent of China’s annual national health care expenditure in 2000 to ­ percent in 2009 (Qin and Pan 3.13 ­ 2016). Another estimate in China that looked at the total costs of over- ­ weight/obesity found that the indirect costs of overweight/obesity and overweight/obesity-related dietary and physical activity patterns ranged from ­ 3.58 ­percent of gross national product in 2000 to a projected 8.73 ­ ­ percent in 2025 (Popkin et ­ 2006). In Brazil, overweight/obesity- al. ­ related health care costs are expected to nearly double, from ­ US$5.8 billion in 2010 to ­ US$10.1 billion in ­2050. Increasing health care costs linked to increasing overweight/obesity rates are a trend across the ­ world. Investing 22 | Obesity in the prevention of overweight/obesity therefore makes sense from a pub- lic finance perspective—it would help save resources in the health sector and improve national productivity (Rtveladze et ­ 2013). al. ­ Furthermore, many proposed interventions to reduce overweight/obe- sity will have important positive implications for reducing water use and greenhouse gas emissions, thereby also providing significant climate co-benefits. For example, sugar is one of the more water-intensive crops, ­ and reduced sugar consumption is expected to lead to important reductions in water use (Constantino-Toto and Montero 2016; Ercin, Aldaya, and Hoekstra ­ 2011). The EAT-Lancet Commission report (2019) suggests that dietary shifts to less meat consumption will not only reduce ­overweight/ obesity rates but will also significantly reduce greenhouse gas p ­ roduction. The Lancet Commission report “Global Syndemic of Obesity, Undernutrition, and Climate Change” (LCO 2019) suggests a series of double- and triple-duty actions that have the potential to address ­ overweight/obesity, undernutrition, and climate change ­ ­ simultaneously. None of the estimated economic benefits of overweight/obesity prevention as yet build in these huge potential climate ­ co-benefits. Preventing overweight/obesity is therefore a global public g ­ ood from both public finance and health perspectives. Furthermore, governments have a key role to play: they can intervene to ensure consumers are informed about the health consequences of their dietary choices and can correct for large dif- ferences in relative ­prices. Equity issues and market failure present an addi- tional argument for government intervention to prevent o ­ verweight/obesity. For example, although most sin taxes or taxes on ultra-processed food and beverages may be regressive in economic terms, they are progressive from a health perspective in that they prevent overweight/obesity and the related NCDs in the population with the highest burden of NCDs overall as well as the highest burden of untreated ­ NCDs. Emerging evidence suggests that the impacts of such policies are starting to be ­ realized. For example, the 10 ­percent tax on sugar-sweetened beverages in Mexico is estimated to reduce overweight/obesity by ­ percent by 2024 and to prevent 86,000 2.5 ­ to 134,000 new cases of diabetes by 2030, while another study estimated 189,300 fewer cases of type 2 diabetes, 20,400 fewer cases of strokes and myocardial infarctions, and 18,900 fewer deaths occurring from 2013 to 2022 (Barrientos-Gutierrez et ­ al. 2017; Sánchez-Romero et ­ 2016). al. ­ Global Attention to Overweight/Obesity In recent years, overweight/obesity has come to the fore on the global development ­ agenda. The Sustainable Development Goals (SDGs) make reference to overweight and obesity under SDG target ­2.2, which aims to ­ 030. end all forms of malnutrition (including overweight and obesity) by 2 Why This Report Now? | 23 The World Health Assembly in 2012 adopted six new nutrition targets, including “to ensure that there is no increase in childhood overweight by 2025” (WHO 2 ­ 014a). The WHO has also issued several other recent reports, including the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (WHO 2013) and the “Global Nutrition Targets 2025: Childhood Overweight” Policy Brief (WHO 2014b), among others, which provide a road map of policies and interventions to meet these t ­ argets. The Global Burden of Disease (GBD) program has highlighted overweight/obe- sity as a key issue in global health and dietary risks as one of the top several risk factors for the global burden of disease in low- and middle-income countries (Institute for Health Metrics and Evaluation ­ 2016).1 And two commissions—the Lancet Commission on Obesity and the EAT Lancet Commission—released new reports in January 2019, highlighting the cata- strophic impacts of overweight/obesity on health and sustainable develop- ment (EAT Lancet Commission 2019; LCO 2 ­ 019). A third report from the Lancet Commission on the double burden of malnutrition was released in December 2019 (Popkin, Corvalan, and Grummer-Strawn 2019). The LCO report focuses on the syndemic of obesity, undernutrition, and climate change—and double- and triple-duty actions across all sectors that have the potential to address this ­ syndemic. The EAT Lancet Commission report focuses primarily on food systems and their impact on nutrition (both undernutrition and overweight/obesity) as well as on climate ­ change. The Lancet Commission report on the double burden (undernutrition and over- weight) will focus primarily on the epidemiology of the burden and dou- ble-duty policy ­ actions. The 2019 State of the World’s Children report (UNICEF 2019) also focused on childhood obesity. Global parliamentarians met in Rome at the Second International Conference on Nutrition in 2014 and noted that food system solutions are needed to address the global scourge of unhealthy diets (FAO and WHO 2018). In countries as diverse as all the small countries of the Caribbean ­ Community (CARICOM) region, most Latin American countries, South Africa, Thailand, Malaysia, many Middle Eastern nations, and the Western Pacific Islands, ministers of health and in most cases prime ministers have noted that overweight/obesity and the related consequences represent the major preventable causes of poor health and increased health care ­ costs. Recognition of the problem is slowly growing in many low- and middle- income countries, but global action that promotes healthy diets and major shifts in food systems is slow. All of the above commissions and reports are complementary and high- light the need for concerted action across sectors (health, education, agri- culture, trade, macroeconomics, and so on) to address this a ­ genda. Despite the fact that the World Bank Group is uniquely positioned to work across these sectors and use the innovative investment and policy instruments at its disposal, the World Bank’s investments in this space are still modest 24 | Obesity ­ est. This is true across the board: in the health sector and in food sys- at b tems, trade, fiscal policies, and transport as well as e­ ducation. The World Bank Group’s new World Development Report (World Bank 2019) on the future of work does not address the scourge of overweight/obesity and its potential impacts on ­ productivity. Healthy diets, along with adequate growth in stature and weight, are critical for optimal cognitive development and learning in ­ children. These links to cognitive development, along with the positive health effects of healthy diets and healthy weight, are also critical for improved productivity and reduced disability throughout the life ­ cycle. Healthy diets have pro- found effects on carbon emissions and water use globally (EAT Lancet Commission 2019; Springmann et al. ­ 2018). The authors hope that this report will spur action among both client countries and development partners such as the World Bank to invest in evidence-based strategies and actions across sectors ­ to address obesity and NCDs. Last—but perhaps most important—this report hopes to serve as a wake-up ­ call. The time to act is ­now. The data presented in the report show the enormous and rapidly growing global public health burden of overweight and obesity, but they also suggest that there is still an oppor- tunity to intervene, preventing obesity among adults and children under five—in all countries, not just in low- and middle-income ­ ones. But the opportunity to act is now, before this bomb e ­ xplodes. The World Bank has just launched a major corporate initiative on building human capital, alongside the release of a new Human Capital Index (HCI) that includes detailed information for 157 ­ countries.2 The launch of the index has gen- erated the concern and momentum it was intended to among national leaders and ministries of finance in client countries (World Bank ­ 2018b). The HCI focuses on three main i ­ngredients. The third ingredient, health, has two parts: one looks at children’s stunting; the other at adult survival rates ­(ASRs). This focus on adult survival provides a perfect entry point for scaling up country engagement on obesity prevention in order to reduce NCDs and related adult mortality (figure ­ 1.1). What Is New in This Report? This report complements all of the new and forthcoming technical reports on overweight/obesity prevention in four distinct ways: • First, it focuses on identifying evidence-based opportunities for fiscal and regulatory policy reforms and investments across several sectors that could prevent ­ overweight/obesity. In doing so, it builds on the Why This Report Now? | 25 ­ .1 Human Capital Index and Its Links to Nutrition Figure 1 HUMAN CAPITAL INDEX INGREDIENTS LINKS TO NUTRITION SURVIVAL TO AGE FIVE UNDERNUTRITION Under-five mortality rate (U5MR) underlies 45% of U5MR QUALITY OF LEARNING STUNTED/ANEMIC CHILDREN LEARN LESS Expected years of school learning and are more likely to drop out of school; Iodine deficient kids lose up to 13 IQ points HEALTH Stunting rate: Fraction of kids under 5 STUNTING is a key marker of undernutrition more than 2 reference standard deviations below median height for age Adult survival rate (ASR): Fraction of RISING OVERWEIGHT/OBESITY RATES 15-year-olds who survive to age 60 contribute to non-communicable diseases and lower adult survival rates Source: Based on World Bank ­ 2018a. epidemiological evidence from the technical reports; adds new infor- mation on the economic implications of overweight/obesity, including the equity perspective; and identifies the growing list of double-burden countries to spur urgent action in these ­countries. • Second, it brings to bear implementation challenges and lessons learned from several country case studies where policies or interventions addressing overweight/obesity have been rolled out at scale, with vari- able ­success. • Third, and perhaps most important, it identifies an action agenda that is specifically geared to the unique role that institutions such as the World Bank can play in this space as well as the instruments (including policy and regulatory levers, technical assistance, and results-based financing instruments as well as investment lending) that these institutions can use in the near future to address the emerging epidemic of obesity and related NCDs across ­ sectors. • Last, the report reiterates research findings from recent technical reports from the Lancet that suggest that changing diets and food sys- tems are also key to addressing the ongoing challenge of child stunting/ undernutrition, along with the growing challenges of climate change. It identifies key areas requiring further research and evaluations that may be important for building the knowledge base for future actions in this ­area. 26 | Obesity Notes http://www.healthdata.org/gbd. 1. See Global Burden of Disease ­ http://www.­ 2. For information about the Human Capital Project, see ­ worldbank​ .org/en/publication/human-capital#_blank. References Barrientos-Gutierrez, T R. Zepeda-Tello, ­ ­ ., ­ E. ­R. Rodrigues, ­ A. Colchero-Aragonés, ­R. Rojas-Martínez, ­E. Lazcano-Ponce, ­M. Hernández-Ávila, ­J. ­Rivera-Dommarco, and ­ R. ­Meza. ­ 2017. “Expected Population Weight and Diabetes Impact of the 1-Peso-per-Litre Tax to Sugar Sweetened Beverages in ­ Mexico.” PLOS ONE 12 (5): ­ e0176336.  Constantino-Toto, ­ M., and ­ R. ­ D. ­Montero. ­ 2016. “Water Footprint of Bottled Drinks and Food ­ Security.” In Water, Food and Welfare, edited by ­ R. ­H. Pérez-Espejo, H. ­ ­ R. Dávila-Ibáñez, and R M. Constantino-Toto, 2 ­ .­ ­ 29–39. New York: Springer Briefs in Environment, Security, Development and ­ Peace. EAT Lancet ­ Commission. ­ 2019. Willett, ­W., ­J. Rockström, ­ B. Loken, ­ M. Springmann, T. Lang, ­ ­ S. Vermeulen, ­ T. Garnett, ­ D. Tilman, ­ F. DeClerck, ­A. Wood, ­ M. Jonell, M. Clark, ­ ­ L. ­J. Gordon, ­ J. Fanzo, ­ C. Hawkes, ­ R. Zurayk, ­ A. Rivera, ­ J. ­ W. De Vries, ­L. Majele Sibanda, A ­ . Afshin, ­ A. Chaudhary, ­ M. Herrero, R ­ . Agustina, ­ F. Branca, ­ A. Lartey, ­ S. Fan, ­ B. Crona, ­E. Fox, ­ V. Bignet, ­ T. Lindahl, M. Troell, ­ ­ S. Singh, S ­. ­E. Cornell, K ­ . Srinath Reddy, S ­ . Narain, S­ . Nishtar, and C J. ­ ­. ­ L. ­ Murray. “Food in the Anthropocene: The EAT–Lancet Commission on Healthy Diets from Sustainable Food ­ Systems.” The Lancet 393 (10170): ­ 447–92. ­https:// www.thelancet.com/commissions/EAT. Ercin, ­ E., ­ A. ­ M. ­ M. Aldaya, and ­ Y. ­ A. ­ Hoekstra. ­ 2011. “Corporate Water Footprint Accounting and Impact Assessment: The Case of the Water Footprint of a Sugar-Containing Carbonated ­ Beverage.” Water Resources Management 25 (2): ­721–41. FAO and WHO (Food and Agriculture Organization of the United Nations and the World Health ­ Organization). ­ 2018. The Nutrition Challenge and Food System ­Solutions. Rome: FAO and ­ WHO. ­ https://apps.who.int/iris/bitstream​ /handle/10665/277440​/­WHO​-NMH-NHD-18.10-eng.pdf?ua=1. GBD 2015 Obesity Collaborators. 2017. “Health Effects of Overweight and Obesity in 195 Countries over 25 Years.” New England Journal of Medicine 377: 13–27. Institute for Health Metrics and E ­ valuation. ­ 2016. Global Burden of Disease Study 2015 (GBD 2015) Covariates 1 ­980–2015. Seattle: Institute for Health Metrics and Evaluation ­(IHME). Jones-Smith, ­ C., ­ J. ­ P. Gordon-Larsen, ­ A. Siddiqi, and B ­.­M. ­Popkin. ­ 2011. “Cross- National Comparisons of Time Trends in Overweight Inequality by Socioeconomic Status among Women Using Repeated Cross-Sectional Surveys from 37 Developing Countries, ­ 1989–2007.” American Journal of Epidemiology 173 (6): ­667–75. ———. ­ 2012. “Emerging Disparities in Overweight by Educational Attainment in Chinese Adults ­ (1989–2006).” International Journal of Obesity 36 (6): ­ 866–75. Why This Report Now? | 27 Kosen, S 2018. “The Economic Burden of Overweight and Obesity Reaches 3% ­. ­ of GDP in ­ Indonesia.” Asia Pathways blog post, February ­ 2. ­ https://www​ .­asiapathways-adbi.org/2018/02/the-economic-burden-of-overweight-and​ -obesity-in-indonesia/. LCO (Lancet Commission on ­ Obesity). ­ 2019. Swinburn, B ­. ­ A., ­V. ­ I. Kraak, S­. Allender, ­ V. J. Atkins, ­ I. Baker, ­ P. ­ J. R. Bogard, ­ H. Brinsden, ­ A. Calvillo, ­ O. De Schutter, ­ R. Devarajan, ­ M. Ezzati, ­ S. Friel, ­ S. Goenka, ­ R. ­A. Hammond, ­ G. Hastings, ­ C. Hawkes, ­ M. Herrero, ­ P. ­S. Hovmand, ­ M. Howden, ­ M. L. ­ Jaacks, ­ A. ­B.  Kapetanaki, ­ M. Kasman, ­ H. ­V. Kuhnlein, ­ K. Kumanyika, S. ­ B. Larijani, ­ ­ T. Lobstein, ­ M. ­W. Long, ­ V. ­ K. ­R. Matsudo, ­ D. ­ S. ­ H. Mills, ­ G. Morgan, ­ A. Morshed, ­ M. Nece, ­ P. ­ A. Pan, ­ D. ­W. Patterson, ­ G. Sacks, ­ M. Shekar, ­ L. G. ­ Simmons, ­W. Smit, ­A. Tootee, S ­ . Vandevijvere, W ­ . ­E. Waterlander, L ­ . Wolfenden, and ­ W. ­H. ­Dietz. ­ 2019. “The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission ­ Report.” The ­Lancet 393 (10173): ­791–846. ­https://www.thelancet.com/commissions/global-syndemic. Lehnert, ­ P. Streltchenia, ­ T., ­ A. Konnopka, ­ S. ­G. Riedel-Heller, and ­ H. ­ Konig. ­2015. “Health Burden and Costs of Obesity and Overweight in Germany: An ­ Update.” European Journal of Health Economics 16: ­ 957–67. Popkin, ­ B. ­M., ­C. Corvalan, and ­ L. ­Grummer-Strawn. 2019. “Dynamics of the Double Burden of Malnutrition and the Changing Nutrition Reality.” The ­Lancet. https://doi.org/10.1016/S0140-6736(19)32497-3. Popkin, ­ B. ­M., ­S. Kim, ­ E. ­ R. Rusev, ­ S. Du, and ­ C. ­Zizza. ­ 2006. “Measuring the Full Economic Costs of Diet, Physical Activity and Obesity-Related Chronic ­Diseases.” Obesity Reviews 7: ­ 271–93. Qin, ­ X., and J ­.­Pan. ­2016. “The Medical Cost Attributable to Obesity and Overweight in China: Estimation Based on Longitudinal ­ Surveys.” Health Economics 25 (10): ­1291–311. Rtveladze, K., ­ T. Marsh, ­ L. Webber, ­ F. Kilpi, ­D. Levy, ­ W. Conde, ­ K. McPherson, and M. ­ ­ Brown. ­ 2013. “Health and Economic Burden of Obesity in B ­ razil.” PLOS ONE 8 (7): ­ e68785. Sánchez-Romero, ­ L. ­M., ­J. Penko, ­ P. ­ G. Coxson, ­ A. Fernández, ­ A. Mason, ­ E. A. ­ Moran, ­ L. Ávila-Burgos, ­ M. Odden, ­ S. Barquera, and ­ K. ­Bibbins-Domingo. 2016. “Projected Impact of Mexico’s Sugar-Sweetened Beverage Tax Policy on ­ Diabetes and Cardiovascular Disease: A Modeling ­ Study.” PLOS Medicine 13 (11): ­ e1002158.  Springmann, ­ M., ­M. Clark, ­ D. Mason-D-Croz, ­ K. Wiebe, ­ L. Bodirsky, ­ B. ­ L. Lassaletta, W. de Vries, ­ ­ S. ­J. Vermeulen, ­ M. Herrero, ­ M. Carlson, ­ K. ­ M. Jonell, ­ M. Troell, ­ F. DeClerck, ­ L. ­J. Gordon, ­ R. Zurayk, ­ P. Scarborough, ­ M. Rayner, ­ B. Loken, ­ J. Fanzo, ­ H. ­C. ­ J. Godfray, ­ D. Tilman, ­ J. Rockström, and ­ W. ­Willett. ­ 2018. “Options for Keeping the Food System within Environmental ­ Limits.” Nature 562 (7728): ­ 519–25. Trogdon, ­ G., ­ J. ­ E. ­A. Finkelstein, ­ T. Hylands, ­ S. Dellea, and ­ P. ­ S. ­J. ­Kamal-Bahl. 2008. “Indirect Costs of Obesity: A Review of the Current ­ ­ Literature.” Obesity Reviews 9 (5): ­ 489–500. UNICEF (United Nations Children’s Fund). 2019. The State of the World’s Children. Children, Food and Nutrition: Growing well in a Changing World. UNICEF, New York. 28 | Obesity WHO (World Health O ­ rganization). ­2013. Global Action Plan for the Prevention and Control of Noncommunicable Diseases ­2013–2020. Geneva: ­WHO. ———. ­ 2014a. Global Nutrition Targets 2025: Policy Brief Series (WHO/NMH​ /­NHD/14.2). WHO. https://www.who.int/nutrition/global-target-2025/en/. ———. ­ 2014b. “Global Nutrition Targets 2025: Childhood ­ Overweight.” Policy ­Brief. ­WHO, Geneva. ­https://apps.who.int/iris/bitstream​/­handle/10665/149021​ /WHO​_NMH_NHD_14.6_eng.pdf?ua=1. World ­Bank. ­2018a. The Human Capital P ­ roject. World Bank, Washington, ­ DC. https://openknowledge.worldbank.org/handle/10986/30498. License: CC BY ­ ­3.0 ­IGO. ———. ­ 2018b. “If Countries Act Now, Children Born Today Could Be Healthier, Wealthier, More ­ Productive.” Press Release, October ­ 11. ­ ———. ­2019. World Development Report: The Changing Nature of ­ Work. Washington, DC: World ­Bank. ­doi:10.1596/978-1-4648-1328-3. License: Creative Commons Attribution CC BY ­ 3.0 ­IGO. 2 Prevalence and Trends Julia Dayton Eberwein, Vanessa Oddo, Jonathan Kweku Akuoku, Kyoko Shibata Okamura, Barry Popkin, and Meera Shekar Key Messages • In 2016, globally more than two out of five adults (44 percent, or more than 2 billion) and one out of five children ages 5–19 were overweight/ obese. Over 70 percent of them lived in low- or middle-income coun- tries, dispelling the myth that overweight/obesity is a problem only in high-income countries. • Between 1980 and 2016, levels of overweight/obesity increased in all regions of the world. Furthermore, there is increasing evidence that the use of the current body mass index (BMI) cutoff of 25 underesti- mates the total burden of overweight/obesity in low- and middle- income countries, so the problem may be even more acute than is presented in the global literature. • Within countries, the burden of overweight/obesity shifts toward the poor as country per capita income increases. In middle-income countries, the poor are just as likely or more likely to be overweight/ obese, whereas among low-income countries, overweight/obesity is mainly concentrated among wealthier groups. • The rapid increases in overweight/obesity in low- and middle-income countries have meant that rural areas across low- and middle-income countries are catching up on overall measures of overweight/obesity with urban areas. The exception is South Asia and most of Sub-­ Saharan Africa, where overweight/obesity remains primarily an urban phenomenon. 29 30 | Obesity • Over 70 percent of countries—the vast majority of which are low- and lower-middle-income ones—currently face a double burden: high prevalence of both undernutrition and overweight/obesity. High levels of the double burden are increasingly found in the poor- est low-income countries. What Is Overweight/Obesity? Overweight/obesity occurs when excess energy is stored in fat cells. Fat cells enlarge and increase in number, accumulating in the abdominal region, in muscle, and around organs such as the liver, kidneys, pan- creas, and heart. This proliferation of fat cells produces numerous meta- bolic, hormonal, and inflammatory chemicals that adversely affect the body’s arteries, tissues, and organ functions. The inflammatory and met- abolic changes to body processes result in high cholesterol, high blood pressure, insulin resistance, and high blood glucose, which together can develop into non-communicable diseases (NCDs) such as diabetes, car- diovascular disease, and cancer (Esser et al. 2014; GBD 2015 Obesity Collaborators 2017; WCRF and AICR 2018). Physiological changes lead to stress on joints, impaired ability to move, and breathing problems such as shortness of breath and sleep apnea. The resulting lack of sleep, stress, and impaired ability to be physically active (as occurs with osteo- arthritis) further exacerbate weight gain (Felson et al. 1988; Patel and Hu 2008). Global Overweight/Obesity Prevalence Worldwide, an estimated 44 percent of adults and 20 percent of children over five years of age are either overweight or obese, hereafter referred to as overweight/obese. Overweight and obesity are measured using BMI. Overweight/obesity has nearly tripled since 1975 and now accounts for 4 million deaths globally every year, nearly two-thirds of which are due to cardiovascular disease; it also accounts for approximately 120 million lost disability-adjusted life years (DALYs) (GBD 2015 Obesity Collaborators 2017). Once considered a public health problem only in high-income coun- tries, overweight/obesity is now highly prevalent in low- and middle- income countries. Consequently, low- and middle-income countries are now confronted with the double burden of malnutrition, characteristically defined by the coexistence of undernutrition and overweight/obesity (Dietz 2017). Prevalence and Trends | 31 This chapter presents trends in overweight/obesity prevalence globally and by region, gender, and age based on repeated cross-sectional ecological data from two data sources: (1) the NCD Risk Factor Collaboration Study (NCD-RisC 2019) for adults and children ages five years and older,1 and (2) the Joint Child Malnutrition Estimates (JME) for children under five years of age (UNICEF, WHO, and World Bank 2016).2 In 2016, approximately 6 percent of children under 5, 20 percent of children ages 5–19, and 44 percent of adults ages 20 years and older were overweight or obese (figure 2.1). There are no significant gender differ- ences among children under 5, but boys 5–19 are more likely to be over- weight/obese than girls of the same age. Among adults, the prevalence of overweight/obesity is higher among men (29 percent) than women (25 percent); however, 19 percent of women are overweight/obese as com- pared with 15 percent of men. Figure 2.2 shows the distribution of overweight/obese individuals across country income groups. In all age groups, the majority of over- weight/obese individuals reside in middle-income countries, dispelling the myth that overweight/obesity is a problem only in high-income countries. Cutoffs of public health significance have long been established for vari- ous dimensions of undernutrition such as stunting, wasting, underweight, and anemia (WHO 2011, 2012; WHO Multicentre Growth Reference Study Group 2006); these have proven useful in describing the severity of the Figure 2.1 Global Overweight and Obesity Rates: Children under 5 and Ages 5–19, and Adults Ages 20+ 50 45 Percent of overweight and obese 40 35 30 25 20 15 10 5 0 Children Children Girls Boys Adults Women Men under 5 5–19 5–19 5–19 20+ 20+ 20+ Obese Overweight Sources: Data for children under 5 are from UNICEF, WHO, and World Bank 2016; data for adults are from NCD-RisC estimates for 2016, http://ncdrisc.org/data-downloads.html. 32 | Obesity More Than Three-Quarters of Overweight/Obese Individuals Figure 2.2  Live in Middle-Income Countries 4% 11% 10% 9% 18% 25% Children Children Adults under 5 5–19 years 20+ years 79% 73% 71% Low income Middle income High income Sources: Data on overweight and obesity levels from NCD-RisC estimates for 2016, http:// ncdrisc.org/data-downloads.html; country income classifications based on World Bank criteria as of 2015. Proposed Cutoff Values for Public Health Significance of Table 2.1  Country-Level Double Burden of Malnutrition Stunting prevalence in children under 5 Overweight/obesity prevalence in adults ê 30% 20–29% 10–19% < 10% ê40% Very high High Moderate Low or none 30–39% High High Moderate Low or none 20–29% Moderate Moderate Moderate Low or none < 20% Low or none Low or none Low or none Low or none Sources: Stunting cutoffs are defined using WHO Multicentre Growth Reference Study Group 2006; overweight/obesity cutoffs are based on original recommendations and Popkin, Corvalan, and Grummer-Strawn 2019. problem across time and place and as an important impetus for public action. There are, however, currently no existing global cutoffs for determining the public health significance of overweight/obesity at the country level. To date the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have established cutoffs for countries for levels of underweight and stunting, but not for overweight. In table 2A.1, the chapter authors propose cutoffs for adults, adolescents, and children in order to identify countries facing a critical prevalence of overweight/obesity. These cutoffs for adults are the same as those in the forthcoming Lancet report on the double burden of undernutrition and overweight (Popkin, Corvalan, and Grummer- Strawn 2019), which recommends cutoffs of 19, 20 to 29, 30 to 39, and Prevalence and Trends | 33 ≥ 40 percent prevalence for determining severe overweight/obesity among adult subpopulations (see table 2.1). When viewed by age group (map 2.1), the data for 2016 show that although public health significance levels seem relatively lower for children under 5 (panel a), the public health significance of overweight/obesity becomes high and very high among older children and adults (as shown in Proposed Public Health Significance of Overweight/Obesity by Map 2.1  Age and Country a. Children under 5 IBRD 43737 | JUNE 2018 Children under 5 Very high (≥ 20%) High (≥ 15–19%) Medium (≥ 10–14%) Low (< 10%) No data b. Children Ages 5–19 IBRD 43736 | JUNE 2018 Children Ages 5–19 Years Very high (≥ 20%) High (≥ 15–19%) Medium (≥ 10–14%) Low (< 10%) No data continued next page 34 | Obesity Map 2.1 (continued) c. Adults Ages 20+ IBRD 43735 | JUNE 2018 Adults Ages 20 + Years Very high (≥ 40%) High (≥ 30–39%) Medium (≥ 20–29%) Low (< 20%) No data Source: NCD-RisC estimates for 2016, http://ncdrisc.org/data-downloads.html. panels b and c). In most countries, fewer than 10 percent of children under 5 are overweight/obese, but some countries have high rates of overweight/obesity among children 5–19 and adults. These data show the ­ enormous global public health burden of overweight and obesity, but they suggest that there is still an opportunity to intervene and prevent over- also ­ weight/obesity among children under 5, particularly in low- and middle-income countries. But the opportunity to act is now, before this ­ time bomb explodes. Global and Regional Trends in Overweight/Obesity over Time Between 1980 and 2016, prevalence rates of overweight/obesity increased dramatically in all regions of the world (see map 2.2) and in all age groups (see figure 2.3). The prevalence of overweight is higher than the preva- lence of obesity, but the increase over time in obesity prevalence (not shown) is greater. In all countries with high adult overweight/obesity levels that began in the 1990s, there was a lag of about seven years or more before child and adolescent overweight/obesity also accelerated, as shown in figure 2.3. Latin America, North Africa, and South East and East Asia, among other Prevalence and Trends | 35 regions, are beginning to show higher prevalence of child/adolescent over- weight and the rates of change are accelerating. Although these trends are alarming in and of themselves, it is impor- tant to note that these estimates of overweight/obesity prevalence ignore one critical issue. There is increasing evidence that using a BMI cutoff of 25 underestimates the total burden of overweight/obesity in Map 2.2 Overweight/Obesity Prevalence by Country Income Level a. Low- and Middle-Income Countries 1990s IBRD 44469 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE LOW- AND MIDDLE-INCOME COUNTRIES, 1990s 4 Very high (≥40%) 3 High (≥30–39%) 2 1 Medium (≥20–29%) Low (<20%) 2010s IBRD 44470 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE LOW- AND MIDDLE-INCOME COUNTRIES, 2010s 4 Very high (≥40%) 3 High (≥30–39%) 2 1 Medium (≥20–29%) Low (<20%) continued next page 36 | Obesity Map 2.2 (continued) b. High-Income Countries 1990s IBRD 44471 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE HIGH-INCOME COUNTRIES, 1990s Very high (≥40%) High (≥30–39%) Medium (≥20–29%) Low (<20%) 2010s IBRD 44472 | SEPTEMBER 2019 OVERWEIGHT/OBESITY PREVALENCE HIGH-INCOME COUNTRIES, 2010s Very high (≥40%) High (≥30–39%) Medium (≥20–29%) Low (<20%) Sources: Popkin, Global Food Research Program, University of North Carolina. Data are from UNICEF, WHO, World Bank, and NCD-RisC estimates, supplemented with selected Demographic and Health Surveys and other country direct national measures. Note: Based on 1990s and 2010s weight and height data. Prevalence and Trends | 37 Prevalence of Overweight/Obesity by Age Group and Figure 2.3  Region, 1980–2016 a. Adults Ages 20+ 100 Percent of adults ages 20+ years 80 60 40 20 0 1980 1985 1990 1995 2000 2005 2010 2016 b. Children Ages 5–19 100 Percent of children ages 5–19 years 80 60 40 20 0 1980 1985 1990 1995 2000 2005 2010 2016 Global Latin America and the Caribbean Europe and Central Asia East Asia and Pacific Middle East and North Africa North America South Asia Sub-Saharan Africa continued next page 38 | Obesity Figure 2.3 (continued) c. Children under 5 15 Percent of children ages 0–5 years 10 5 0 1990 1995 2000 2005 2010 2016 Global Latin America and the Caribbean Europe and Central Asia East Asia and Pacific Middle East and North Africa North America South Asia Sub-Saharan Africa Sources: Data for children under 5 are from UNICEF, WHO, and World Bank 2016; data for children ages 5–19 and adults are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /­data-downloads.html. low- and middle-income countries. There is a large push in Asia and selected other regions to lower the BMI cutoff for overweight to 25 because most major subpopulation groups (for example, Asians, Hispanics from Mexico south to Chile in the Andean region, Africans) experience increased risks of diabetes and hypertension at much lower BMI levels. One regional WHO-International Obesity Task Force meet- ing and subsequent work from China advocated for a lower overweight and obesity cutoff of a BMI level of 23 and 28, respectively (WHO Expert Consultation 2004). Studies in Latin America and Asia have shown larger comparative risks of hypertension and diabetes at much lower levels of BMI than among non-Hispanic whites (Albrecht, Mayer-Davis, and Popkin 2017; Bell, Adair, and Popkin 2002; WHO Expert Consultation 2004). This is also the case for South Asians with very high proportions of visceral fat (body fat around the heart and liver, also sometimes called visceral adiposity or central adiposity) and increased risks of diabetes at BMI levels of 22–23 (Wells et al. 2016). Many studies comparing South Asians to other population subgroups replicate these results (Joshi et al. 2007; Misra 2015; Nair and Prabhakaran 2012). Prevalence and Trends | 39 The Equity Perspective The sections below consider overweight/obesity prevalence by socioeco- nomic status and by urban/rural groups to provide a context for ensuring equity in the global approach to the problem. Overweight/Obesity Prevalence by Income Group within Countries Although the national-level data reported in this chapter do not allow for describing overweight/obesity rates by income group within a given country, evidence from Demographic and Health Surveys (DHS) from selected low- and middle-income countries suggests that, as country income increases, the burden of overweight/obesity shifts from the wealthy to the poor (figure 2.4) (Jones-Smith et al. 2011, 2012b). Today in most countries in Latin America, the Middle East, Eastern Europe, Central Asia, and East Asia (specifically China and Indonesia), there are now more overweight/obese individuals among the poor, lower socioeco- nomic status population than among higher income and higher socioeco- nomic status populations. This is not the case in either South Asia or Sub-Saharan Africa. These two regions have increasing proportions of overweight/obesity but also still have the bulk of the stunted populations of the world and the highest prevalence of a double burden of malnutri- tion (Popkin, Corvalan, and Grummer-Strawn 2019). The only country with both a severe level of double burden and greater overweight/obesity among the poor is Indonesia. The crossover to higher rates of overweight/obesity among poorer income groups as country income increases is not entirely captured in the selection of countries included in the DHS (Popkin, Corvalan, and Grummer-Strawn, forthcoming). However, empirical evidence from Brazil (Monteiro et al. 2000; Monteiro, Conde, and Popkin 2001, 2007) and China (Jones-Smith et al. 2012a) shows a greater burden of overweight/ obesity among the poor/lower socioeconomic status. Similar results are reported for Indonesia and Sub-Saharan Africa (Aizawa and Helble 2016; Ziraba, Fotso, and Ochako 2009). Furthermore, Jones-Smith et al. (2011; 2012a) also show that the prevalence of overweight/obesity has increased more quickly over time for the poorest (versus wealthiest) women in a number of low- and middle-income countries.3 One review that analyzes the association between household income and obesity in children shows that obesity among children and adolescents is more prevalent among the affluent in low- and middle-income coun- tries, suggesting that the shift in obesity in children from wealthier to 40 | Obesity Shift in Burden of Overweight/Obesity to the Poor Figure 2.4  GNI per capita, US$ CONGO, DEM. REP. RWANDA YEMEN, REP. BANGLADESH KENYA GHANA GNI per capita: GNI per capita: GNI per capita: GNI per capita: GNI per capita: GNI per capita: US$460 US$700 US$1,040 US$1,330 US$1,380 US$1,380 100 Prevalence of overweight/obesity in women ages 15–49 years 80 60 40 20 Average 0 Income quintiles from lowest (poorest) to highest (richest) INDIA NIGERIA EGYPT, ARAB REP. GUATEMALA COLOMBIA DOMINICAN GNI per capita: GNI per capita: GNI per capita: GNI per capita: GNI per capita: REPUBLIC US$1,670 US$2,450 US$3,410 US$3,790 US$6,310 GNI per capita: 100 US$6,390 Prevalence of overweight/obesity in women ages 15–49 years 80 60 40 Average 20 0 Income quintiles from lowest (poorest) to highest (richest) Sources: Demographic and Health Surveys from Democratic Republic of Congo 2013, Rwanda 2014, Republic of Yemen 2013, Kenya 2014, Ghana 2014, India 2015, Nigeria 2013, Arab Republic of Egypt 2014, Guatemala 2014, Colombia 2010, Dominican Republic 2013; https://dhsprogram.com/What-We-Do​/­Survey-Search.cfm/. Note: GNI = gross national income. poorer segments of the population may occur at a higher level of national income than it does for adults (Dinsa et al. 2012).4 However, further analyses specifically addressing this question among children in low- and ­ ­ middle-income countries are urgently needed. Overweight/Obesity Rates by Urban/Rural Residence within Countries Previous analyses have demonstrated higher rates of overweight/obesity in urban than in rural residents within a country, particularly in low- income countries that are in earlier phases of their nutrition transition (Jaacks, Slining, and Popkin 2015; Mendez, Monteiro, and Popkin 2005). Prevalence and Trends | 41 Prevalence of Overweight/Obesity among Women Ages Figure 2.5  15–49 by Urban/Rural Residence, Selected Low- and Middle-Income Countries CONGO, DEM. REP. RWANDA YEMEN, REP. BANGLADESH KENYA GHANA GNI per capita: GNI per capita: GNI per capita: GNI per capita: GNI per capita: GNI per capita: US$460 US$700 US$1,040 US$1,330 US$1,380 US$1,380 100 obesity in women ages 15–49 years Prevalence of overweight/ 80 60 40 Average 20 0 Urban Rural INDIA NIGERIA EGYPT, ARAB REP. GUATEMALA COLOMBIA DOMINICAN GNI per capita: GNI per capita: GNI per capita: GNI per capita: GNI per capita: REPUBLIC US$1,670 US$2,450 US$3,410 US$3,790 US$6,310 GNI per capita: 100 US$6,390 obesity in women ages 15–49 years Prevalence of overweight/ 80 60 40 Average 20 0 Urban Rural Sources: Demographic and Health Surveys from Democratic Republic of Congo 2013, Rwanda 2014, Republic of Yemen 2013, Kenya 2014, Ghana 2014, India 2015, Nigeria 2013, Arab Republic of Egypt 2014, Guatemala 2014, Colombia 2010, Dominican Republic 2013; https://dhsprogram.com/What-We-Do​/­Survey-Search.cfm/. Note: GNI = gross national income. However, DHS results from selected low- and middle-income countries show that overweight/obesity is not exclusive to urban areas. (As previ- ously stated, national-level data do not allow for describing overweight/ obesity prevalence by urban/rural residence.) The panels in figure 2.5 show the prevalence of overweight/obesity by area of residence among women, with countries ordered from lowest to highest GNI per capita. The Sub-Saharan African and South Asian countries are where the pro- portion of overweight/obesity is much greater in urban areas. Among lower-income countries, the prevalence of overweight/obesity among women is considerably higher in urban areas. However, the prevalence of overweight/obesity is still high—approximately 20 percent—even in 42 | Obesity rural areas. In higher-income countries (for example, in upper-middle- income countries), overweight/obesity prevalence is more equally distrib- uted across women living in urban and rural areas, dispelling the common misconception that the overweight/obesity burden is limited to urban areas. There is also evidence that the prevalence of overweight/obesity is increasing faster now in many rural areas among lower-income countries (Jaacks, Slining, and Popkin 2015). Greater overweight/obesity in rural areas is expected by 2025 in all regions of the world except Sub-Saharan Africa. This implies that a future focus on rural as well as urban overweight/ obesity will be required and represents a major shift in thinking for much of the world—in high-income countries, middle-income countries, and low-income ones. The Double Burden of Malnutrition This section first defines exactly what is meant by the double burden of mal- nutrition and considers how this double burden can be analyzed and described at multiple levels. It then identifies countries that experience par- ticularly high double burdens and, finally, considers trends over time. Definition The double burden of malnutrition (hereafter referred to as the double burden), defined as concurrent burdens of overweight and undernutrition (WHO 2017), is hypothesized to be driven by increased economic development and the concurrent nutrition transition that leads to changes in food and physical activity patterns (Ng and Popkin 2012; Popkin 2004; Shrimpton and Rokx 2012). The double burden can be analyzed and described at individual, ­ household/community, and national levels, and within a population of adults, children, or a combination of the two (Abdullah 2015; Doak et al. 2000; Doak et al. 2002; Doak et al. 2005; Garrett and Ruel 2005; Popkin, Corvalan, and Grummer-Strawn 2019). For this report, the double burden is defined with respect to population-level prevalence of overnutrition among adult women and prevalence of undernutri- tion among children under five. There are two primary reasons for this choice. First, the double burden is driven largely by increasing rates of overweight/­ obesity as undernutrition recedes or stagnates during the transition. Changes in food s nutrition ­ ­ ystems (production, marketing, con- sumption), urbanization, modern technology, and the built environment Prevalence and Trends | 43 are key ­ factors for the increasing prevalence of overweight/­ obesity; these are amenable to change through national-level policy making and interventions. Second, there are established guidelines for assess- ing the public health significance of undernutrition, as characterized by stunting, at the country level based on the recently revised thresholds by de Onis et al. (2018). This report proposes new cutoffs for the pub- lic health ­ significance of overweight/obesity (see table 2.1 for proposed values). Using the established cutoff guidelines for stunting and cutoff ­ this report’s proposed cutoffs for overweight/obesity, this report classifies countries according to the level of double burden. Countries Identified by WHO Undernutrition Criteria as Having Severe Levels of Double Burden Today most of the countries in the world with high levels of the double burden are found in Sub-Saharan Africa, South Asia, South East Asia (Indonesia being the most prominent), plus Guatemala. This is a marked shift from the 1990s, when Mexico and most of Central America, Bolivia, and Peru, South Africa, Francophone Africa, the Arab Republic of Egypt, parts of Central Asia, and the Philippines faced severe levels of the double burden. Map 2.3 shows this dramatic shift. Figures 2.6–2.11 present countries in each region by plotting their level of the double burden of malnutrition, consisting of prevalence of childhood stunting and overweight/obesity among women. Generally, stunting preva- lence is inversely related to women’s overweight/obesity prevalence. However, significant clusters of countries experience medium or high levels of the double burden. Guatemala, Papua New Guinea, and the Republic of Yemen have very high double burdens, with child stunting prevalence above 40 percent alongside adult female overweight/obesity in excess of 50 ­percent. Botswana, Cameroon, Djibouti, Lesotho, and the Solomon Islands also have high levels of double burden, with stunting prevalence above 30 ­ percent and overweight/obesity prevalence ranging between 41 percent and 62 ­ percent. The largest high-double-burden country is Indonesia, with about 36 percent stunting and over 40 percent female overweight/obesity. Prevalence of the double burden varies widely by region (figures 2.6 through 2.11 and figure 2A.1; country-level double burden is presented in table 2A.2; the level of double burden by country income group is shown in figures 2A.2 through 2A.5). Using the metric established in this report, most countries with a double burden are in Sub-Saharan Africa, with a significant majority of countries experiencing a medium to high double burden. Of the 48 Sub-Saharan Africa countries included, 46 (96 percent) have a medium to very high double burden. 44 | Obesity Map 2.3 Double Burden of Malnutrition: Low- and Middle-Income Countries a. 1990s IBRD 44237 | MARCH 2019 DBM level classification (1990s data) Very high High Moderate Low or none b. 2010s IBRD 44238 | MARCH 2019 DBM level classification (2010s data) Very high High Moderate Low or none Sources: Data from Joint Child Malnutrition Estimates (UNICEF, WHO, World Bank) and NCD-RisC estimates; country income classifications based on World Bank criteria as of 2015. Prevalence and Trends | 45 Country-Level Double Burden of Malnutrition, East Asia Figure 2.6  and Pacific 60 Timor−Leste Papua New Guinea Stunting prevalence (%) among children under 5 50 Lao PDR VERY HIGH 40 Indonesia Philippines Cambodia Solomon Islands 30 Myanmar Democratic People’s Republic of Korea Vanuatu HIGH Vietnam Nauru Brunei Darussalam 20 Malaysia MODERATE Thailand Tuvalu 10 Japan Mongolia China Fiji Tonga Singapore Australia Samoa Republic of Korea 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /­data​- downloads.html. In East Asia and Pacific, 17 of the 26 countries have medium to very high double burdens, driven mainly by the high prevalence of stunting and medium prevalence of overweight/obesity. Papua New Guinea has a very high double burden, with very high stunting prevalence (50 percent) and very high overweight/obesity (60 percent). In countries without a double burden, rates of overweight/obesity are alarming, with the majority rang- ing between 40 percent and more than 80 percent. The forthcoming Lancet series on the double burden will show that increas- ingly it is the low-income countries that have the greatest double burden (Popkin, Corvalan, and Grummer-Strawn 2019). Trends in the Double Burden over Time Overall, most low- and middle-income countries have experienced declines in stunting prevalence but they invariably show rising 46 | Obesity Country-Level Double Burden of Malnutrition, Europe and Figure 2.7  Central Asia 60 50 Stunting prevalence (%) among children under 5 40 VERY HIGH 30 Tajikistan HIGH Albania 20 Uzbekistan Azerbaijan Kyrgyz Republic Romania MODERATE Georgia Turkmenistan Montenegro Turkey 10 Bosnia and Herzegovina Armenia Bulgaria Moldova Kazakhstan Serbia Belarus North Macedonia Ukraine Germany Czech Republic 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /data-downloads.html. prevalence of overweight/obesity. Thus, countries have progressed from having a high stunting burden only to have a double burden, with reduced but still high prevalence of stunting along with increased prevalence of overweight/obesity. In a few countries, stunting prevalence stagnated or increased while overweight/obesity prevalence increased. When all lower-middle-income countries in the 1990s were stratified by current gross national product per capita using World Bank purchasing power parity levels, countries from the 1990s that are now in the middle- and higher-income group (but were classified as low-income countries in the burden 1990s) had significantly reduced their likelihood of being a double-­ country. Over time, the lower-income countries have been much more likely to become high-double-burden countries (map 2.3). This is once again indica- tive of the spread of overweight/obesity to lower-middle-income countries, the rapid growth in consumption of unhealthy foods and beverages, and Prevalence and Trends | 47 Country-Level Double Burden of Malnutrition, Latin America Figure 2.8  and the Caribbean 60 50 Stunting prevalence (%) among children under 5 Guatemala 40 VERY HIGH 30 Ecuador HIGH Honduras Nicaragua Haiti 20 Panama Bolivia Belize Peru El Salvador MODERATE Guyana Venezuela, RB Paraguay Colombia Mexico 10 Uruguay Suriname Argentina Cuba Dominican Republic Brazil Barbados Jamaica Trinidad and Tobago Costa Rica Saint Lucia Chile 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /­data-downloads.html. the remarkable shifts in technology, which affect activity globally (Popkin, Corvalan, and Grummer-Strawn 2019; Pries et at. 2019). It is important to note that there is a considerable lag between stunting during the preschool period and subsequent NCD complications. A large established literature on the way stunting in early childhood affects subsequent visceral fat increases and the risks of many NCDs exists ­ (Adair et al. 2013; Kuzawa et al. 2012; Stein et al. 2010; Victora et al. 2008; Wells, Wibaek, and Poullas 2018). Levels of stunting in the 1990s, for example, will be reflected right now only among those in the 20- to 30-year-old age group. Clearly there is a lag, as shown by a set of long- term birth cohort studies on the consequences of rises in visceral fat (the type of overweight with greater risks of NCDs) both because of these criti- cal biological causes and because of the reduced energy expenditure and changing food patterns discussed in the next two chapters (Adair et al. 2013; Stein et al. 2010; Victora et al. 2008). This literature suggests that 48 | Obesity Country-Level Double Burden of Malnutrition, Middle East and Figure 2.9  North Africa 60 50 Stunting prevalence (%) among children under 5 Yemen, Rep. 40 VERY HIGH Djibouti 30 Syrian Arab Republic HIGH Iraq Egypt, Arab Rep. Libya 20 Lebanon Morocco MODERATE Oman Bahrain Algeria Qatar 10 Tunisia Saudi Arabia West Bank and Gaza economy Jordan Iran, Islamic Rep. Kuwait 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /data-downloads.html. the coming generations of young adults as well as current older adults will experience an increased risk of NCDs at lower BMI levels since they were stunted ­during the vulnerable first 1,000 days. Furthermore, contin- ued intergenerational problems that lead to excessive low birthweight among infants, increased risk of stunted and subsequently overweight/ obese adults, and other adverse outcomes are expected for several future decades based on past and current levels of stunting (Wells et al., forth- coming; Wells, Wibaek, and Poullas 2018). Programs to reduce child stunting are therefore one way to prevent future increased risks of many overweight/obesity-related NCDs. The following chapters lay out some of the potential actions that can prevent overweight/obesity. Prevalence and Trends | 49 Country-Level Double Burden of Malnutrition, South Asia Figure 2.10  60 50 Stunting prevalence (%) among children under 5 Pakistan 40 Afghanistan VERY HIGH India Bangladesh Nepal Bhutan 30 HIGH 20 Maldives Sri Lanka MODERATE 10 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /data-downloads.html. 50 | Obesity Country-Level Double Burden of Malnutrition, Figure 2.11  Sub-Saharan Africa 60 Burundi 50 Stunting prevalence (%) among children under 5 Eritrea Madagascar Mozambique Niger Congo, Dem. Rep. 40 Chad Central African Republic VERY HIGH Zambia Ethiopia Sudan Sierra Leone Malawi Angola Rwanda Tanzania Benin Comoros Nigeria Lesotho South Sudan Guinea Liberia Cameroon Botswana 30 Uganda Mali Côte D’Ivoire Guinea-Bissau Burkina Faso Togo Mauritania Zimbabwe South Africa HIGH Kenya Equatorial Guinea Gambia, The Swaziland Somalia Namibia Republic of Congo Cabo Verde 20 Gabon Ghana Senegal São Tomé and Príncipe MODERATE Mauritius 10 Seychelles 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /­data-downloads.html.​ Annex 2A: Prevalence of Overweight/Obesity: Additional Tables and Figures Proposed Cutoff Values for Public Health Significance of Prevalence of Overweight/Obesity, Adults and Table 2A.1  Children Global Low-income countries Middle-income countries High-income countries Prevalence Prevalence of Number of Number of Number of Number of group overweight/obesity countries Percent countries Percent countries Percent countries Percent Adults ages 20 and older Low < 20% 1 1 0 0 1 1 0 0 Medium ≥ 20–29% 41 21 23 77 17 16 1 2 High ≥ 30–39% 23 12 6 20 14 13 3 5 Very high ≥ 40% 129 66 1 3 75 70 53 93 Total 194 30 107 57 Children ages 5–19 yearsa Low < 10% 13 7 8 27 5 5 0 0 Medium ≥ 10–14% 42 22 20 67 21 20 1 2 High ≥ 15­­–19% 18 9 0 0 18 17 0 0 Very high ≥ 20% 121 62 2 7 63 59 56 98 Total 194 30 107 57 Children under 5 yearsb Low < 10% 67 80 20 95 44 77 3 50 Medium ≥ 10–14% 13 15 1 5 9 16 3 50 High ≥ 15–19% 3 4 0 0 3 5 0 0 Very high ≥ 20% 1 1 0 0 1 2 0 0 Total 84 21 57 6 a. NCD-RisC does not disaggregate children by age; however, it may be preferable to generate cutoffs separately for adolescents ages 15–19, particularly girls since they have likely undergone menarche. 51 b. Estimated using Joint Child Malnutrition Estimates (JME) data between 2011 and 2016. Where multiple years of data are available, overweight/ obesity prevalence is averaged across time periods. 52 | Obesity Figure 2A.1 Prevalence of Overweight/Obesity by Region East Asia and Pacific Europe and Central Asia 100 100 80 80 60 60 40 40 20 20 0 0 All Women Men Children Girls Boys Children All Women Men Children Girls Boys adults 20+ 20+ 5–19 5–19 5–19 under 5 adults 20+ 20+ 5–19 5–19 5–19 Latin America and the Caribbean Middle East and North Africa 100 100 80 80 60 60 40 40 20 20 0 0 All Women Men Children Girls Boys Children All Women Men Children Girls Boys Children adults 20+ 20+ 5–19 5–19 5–19 under 5 adults 20+ 20+ 5–19 5–19 5–19 under 5 North America South Asia 100 100 80 80 60 60 40 40 20 20 0 0 All Women Men Children Girls Boys Children All Women Men Children Girls Boys Children adults 20+ 20+ 5–19 5–19 5–19 under 5 adults 20+ 20+ 5–19 5–19 5–19 under 5 Sub–Saharan Africa 100 80 60 40 20 0 All Women Men Children Girls Boys Children adults 5–19 5–19 5–19 under 5 Obese Overweight Sources: Data for adults and children 5–19 are from NCD-RisC estimates for 2016, http:// ncdrisc.org/data-downloads.html; data for children under 5 are from UNICEF, WHO, and World Bank 2016, Joint Child Malnutrition Estimates, https://www.who.int/nutgrowthdb​ estimates2016/en/, accessed July 2017. /­ Table 2A.2 Level of Double Burden by Country Stunting prevalence Overweight/ Level of (%, children obesity double Country/economy Income group under 5) (%, women) burden East Asia and Pacific Australia High income 2.0 59.8 Low or none Brunei Darussalam High income 19.7 42.9 Moderate Cambodia Lower-middle income 32.4 25.1 Moderate China Upper-middle income 8.1 31.1 Low or none Fiji Upper-middle income 7.5 69.4 Low or none Indonesia Lower-middle income 36.4 32.3 High Japan High income 7.1 22.6 Low or none Kiribati Lower-middle income — 82.9 Low or none Korea, Dem. Peoples’ Rep. Low income 27.9 31.7 High Korea, Rep. High income 2.5 27.3 Low or none Lao PDR Lower-middle income 43.8 28.9 Moderate Malaysia Upper-middle income 17.7 44.4 Moderate Mongolia Lower-middle income 10.8 57.2 Moderate Myanmar Lower-middle income 29.2 28.8 Moderate Nauru Upper-middle income 24.0 90.3 High Papua New Guinea Lower-middle income 49.5 59.7 Very high Philippines Lower-middle income 33.4 29.9 Moderate Samoa Upper-middle income 4.7 83.8 Low or none Singapore High income 4.4 28.3 Low or none Solomon Islands Lower-middle income 31.6 62.0 Very high Thailand Upper-middle income 10.5 36.8 Moderate Timor-Leste Lower-middle income 50.2 25.2 Moderate Tonga Upper-middle income 8.1 84.0 Low or none Tuvalu Upper-middle income 10.0 85.7 Moderate Vanuatu Lower-middle income 28.5 63.7 High Vietnam Lower-middle income 24.6 21.3 Moderate continued next page 53 Table 2A.2 (continued) Stunting prevalence Overweight/ Level of (%, children obesity double Country/economy Income group under 5) (%, women) burden Europe and Central Asia Albania Upper-middle income 23.1 52.7 High Armenia Lower-middle income 9.4 56.1 Low or none Azerbaijan Upper-middle income 18.0 55.7 Moderate Belarus Upper-middle income 4.5 58.0 Low or none Bosnia and Herzegovina Upper-middle income 8.9 48.6 Low or none Bulgaria Upper-middle income 8.8 56.1 Low or none Czech Republic High income 2.6 56.7 Low or none Georgia Lower-middle income 11.3 55.2 Moderate Germany High income 1.3 50.1 Low or none Kazakhstan Upper-middle income 8.0 54.3 Low or none Kyrgyz Republic Lower-middle income 12.9 50.4 Moderate Moldova Lower-middle income 6.4 51.7 Low or none Montenegro Upper-middle income 9.4 54.2 Low or none North Macedonia Upper-middle income 4.9 52.8 Low or none Romania Upper-middle income 12.8 52.8 Moderate Serbia Upper-middle income 6.0 52.2 Low or none Tajikistan Lower-middle income 26.8 47.8 High Turkey Upper-middle income 9.5 71.4 Low or none Turkmenistan Upper-middle income 11.5 53.1 Moderate Ukraine Lower-middle income 3.7 57.2 Low or none Uzbekistan Lower-middle income 19.6 50.5 Moderate Latin America and the Caribbean Argentina Upper-middle income 8.2 61.0 Low or none Barbados High income 7.7 61.7 Low or none Belize Upper-middle income 15.0 63.1 Moderate Bolivia Lower-middle income 18.1 61.3 Moderate Brazil Upper-middle income 7.1 57.1 Low or none Chile High income 1.8 63.0 Low or none Colombia Upper-middle income 12.7 63.0 Moderate Costa Rica Upper-middle income 5.6 65.0 Low or none continued next page 54 Table 2A.2 (continued) Stunting prevalence Overweight/ Level of (%, children obesity double Country/economy Income group under 5) (%, women) burden Cuba Upper-middle income 7.0 64.3 Low or none Dominican Republic Upper-middle income 7.1 67.2 Low or none Ecuador Upper-middle income 25.2 60.7 High El Salvador Lower-middle income 13.6 63.9 Moderate Guatemala Lower-middle income 46.5 61.5 Very high Guyana Upper-middle income 12.0 58.4 Moderate Haiti Low income 21.9 60.1 High Honduras Lower-middle income 22.7 61.2 High Jamaica Upper-middle income 6.2 65.0 Low or none Mexico Upper-middle income 12.4 67.6 Moderate Nicaragua Lower-middle income 23.0 63.0 High Panama Upper-middle income 19.1 63.0 Moderate Paraguay Upper-middle income 10.9 54.8 Moderate Peru Upper-middle income 14.4 61.6 Moderate Saint Lucia Upper-middle income 2.5 58.1 Low or none Suriname Upper-middle income 8.8 66.1 Low or none Trinidad and Tobago High income 5.3 56.2 Low or none Uruguay High income 10.7 62.6 Moderate Venezuela, RB Upper-middle income 13.4 65.5 Moderate Middle East and North Africa Algeria Upper-middle income 11.7 68.1 Moderate Bahrain High income 13.6 70.5 Moderate Djibouti Lower-middle income 33.5 46.1 Very high Egypt, Arab Rep. Lower-middle income 22.3 71.3 High Iran, Islamic Rep. Upper-middle income 6.8 67.4 Low or none Iraq Upper-middle income 22.6 70.0 High Jordan Lower-middle income 7.8 74.2 Low or none Kuwait High income 4.9 77.0 Low or none Lebanon Upper-middle income 16.5 71.1 Moderate continued next page 55 Table 2A.2 (continued) Stunting prevalence Overweight/ Level of (%, children obesity double Country/economy Income group under 5) (%, women) burden Libya Upper-middle income 21.0 72.0 High Morocco Lower-middle income 14.9 66.0 Moderate Oman High income 14.1 67.6 Moderate Qatar High income 11.6 75.3 Moderate Saudi Arabia High income 9.3 73.7 Low or none Syrian Arab Republic Lower-middle income 27.5 67.4 High Tunisia Lower-middle income 10.1 67.8 Moderate West Bank and Gaza Lower-middle income 7.4 71.5 Low or none Yemen, Rep. Lower-middle income 46.5 55.1 Very high North America Canada High income — 60.1 Low or none United States High income 2.1 64.8 Low or none South Asia Afghanistan Low income 40.9 27.1 Moderate Bangladesh Lower-middle income 36.1 23.0 Moderate Bhutan Lower-middle income 33.6 30.7 High India Lower-middle income 38.4 22.4 Moderate Maldives Upper-middle income 20.3 35.4 High Nepal Low income 35.8 23.7 Moderate Pakistan Lower-middle income 45.0 32.4 High Sri Lanka Lower-middle income 17.3 28.3 Moderate Sub-Saharan Africa Angola Lower-middle income 37.6 36.1 High Benin Low income 34.0 38.6 High Botswana Upper-middle income 31.4 58.3 Very high Burkina Faso Low income 27.3 30.3 High Burundi Low income 55.9 31.1 High Cabo Verde Lower-middle income 21.4 42.8 High continued next page 56 Table 2A.2 (continued) Stunting prevalence Overweight/ Level of (%, children obesity double Country/economy Income group under 5) (%, women) burden Cameroon Lower-middle income 31.7 43.0 Very high Central African Republic Low income 40.7 34.4 High Chad Low income 39.9 30.9 High Comoros Low income 32.1 36.9 High Congo, Rep. Lower-middle income 21.2 38.7 High Côte d’Ivoire Lower-middle income 29.6 40.8 High Congo, Dem. Rep. Low income 42.6 33.2 High Equatorial Guinea Upper-middle income 26.2 36.7 High Eritrea Low income 50.3 29.3 Moderate Ethiopia Low income 38.4 29.0 Moderate Gabon Upper-middle income 17.5 48.0 Moderate Gambia, The Low income 25.0 40.2 High Ghana Lower-middle income 18.8 42.3 Moderate Guinea Low income 31.3 35.4 High Guinea-Bissau Low income 27.6 38.5 High Kenya Lower-middle income 26.0 35.5 High Lesotho Lower-middle income 33.2 55.3 Very high Liberia Low income 32.1 39.6 High Madagascar Low income 49.2 30.7 High Malawi Low income 37.1 32.6 High Mali Low income 30.4 36.4 High Mauritania Lower-middle income 27.9 43.8 High Mauritius Upper-middle income 13.6 41.2 Moderate Mozambique Low income 43.1 34.8 High Namibia Upper-middle income 23.1 53.6 High Niger Low income 42.2 30.7 High Nigeria Lower-middle income 32.9 37.4 High Rwanda Low income 36.7 34.7 High continued next page 57 Table 2A.2 (continued) Stunting prevalence Overweight/ Level of (%, children obesity double Country/economy Income group under 5) (%, women) burden São Tomé and Príncipe Lower-middle income 17.2 43.0 Moderate Senegal Low income 17.0 37.1 Moderate Seychelles High income 7.9 46.6 Low or none Sierra Leone Low income 37.9 37.2 High Somalia Low income 25.3 37.2 High South Africa Upper-middle income 27.4 67.2 High South Sudan Low income 31.1 0.0 Low or none Sudan Lower-middle income 38.2 37.3 High Swaziland Lower-middle income 25.5 54.3 High Togo Low income 27.5 37.0 High Uganda Low income 28.9 31.9 High Tanzania Low income 34.4 36.7 High Zambia Lower-middle income 40.0 37.6 High Zimbabwe Low income 26.8 54.5 High Sources: Stunting cutoffs are defined in de Onis et al. (2019), Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD- RisC estimates for 2016, http://ncdrisc.org/data-downloads.html using WHO Multicentre Growth Reference Study Group 2006; overweight/obesity cutoffs are based on original recommendations and Popkin, Corvalan, and Grummer-Strawn 2019. Note: — = not available. 58 Country-Level Double Burden: Low-Income Figure 2A.2  Countries 60 Burundi 50 Eritrea Stunting prevalence (%) among children under 5 Madagascar Mozambique Niger Democratic Republic of Congo 40 Chad Central African Republic VERY HIGH Afghanistan Ethiopia Malawi Sierra Leone Nepal Rwanda Tanzania Comoros Benin South Sudan Liberia Guinea 30 Uganda Mali Democratic People’s Republic of Korea Burkina Faso Guinea−Bissau Zimbabwe Togo Gambia, The HIGH Somalia Haiti 20 Senegal MODERATE 10 0 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /data-downloads.html. 59 Country-Level Double Burden: Lower-Middle-Income Figure 2A.3  Countries 60 50 Timor-Leste Stunting prevalence (%) among children under 5 Papua New Guinea Yemen, Rep. Guatemala Pakistan Lao PDR 40 India Zambia VERY HIGH Sudan Indonesia Angola Bangladesh Bhutan Nigeria Djibouti Lesotho Cambodia Philippines Cameroon Solomon Islands 30 Myanmar Côte D’Ivoire Vanuatu Mauritania Syrian Arab Republic HIGH Kenya Tajikistan Swaziland Vietnam Nicaragua Cabo Verde Egypt, Arab Rep. Congo, Rep. Honduras 20 Uzbekistan Ghana Bolivia São Tomé and Príncipe Sri Lanka Morocco MODERATE Kyrgyz Republic El Salvador Georgia Mongolia 10 Armenia Tunisia Jordan Moldova West Bank and Gaza economy Ukraine 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /data-downloads.html. 60 Country-Level Double Burden: Upper-Middle-Income Figure 2A.4  Countries 60 50 Stunting prevalence (%) among children under 5 40 VERY HIGH Botswana 30 South Africa Equatorial Guinea HIGH Ecuador Iraq Albania Namibia Nauru 20 Maldives Panama Libya Malaysia Gabon Azerbaijan Belize Lebanon Mauritius Peru Venezuela, RB MODERATE Romania Guyana Mexico Thailand Turkmenistan Colombia Algeria 10 Bosnia and Herzegovina Paraguay BulgariaArgentina Suriname Tuvalu Turkey Tonga Montenegro Fiji China Cuba Dominican Republic Serbia Kazakhstan Iran, Islamic Rep. Samoa North Macedonia Brazil Jamaica Belarus Costa Rica Saint Lucia 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /data-downloads.html. 61 62 | Obesity Country-Level Double Burden: High-Income Figure 2A.5  Countries 60 Stunting prevalence (%) among children under 5 50 40 VERY HIGH 30 HIGH Brunei Darussalam 20 Oman MODERATE Bahrain Uruguay Qatar 10 Barbados Saudi Arabia Seychelles Japan Trinidad and Tobago Singapore Kuwait Korea, Rep. Czech Republic United States Germany Australia Chile 0 20 40 60 80 100 Overweight/obesity (%) among women Sources: Data for stunting prevalence are from UNICEF, WHO, and World Bank 2016; data for overweight/obesity are from NCD-RisC estimates for 2016, http://ncdrisc.org​ /data-downloads.html. Prevalence and Trends | 63 Notes 1. NCD-RisC is coordinated by the WHO Collaborating Centre on NCD Surveillance and Epidemiology and currently has data from over 2,545 popu- lation-based surveys from 194 countries from 1975 to 2016 for children ages 5–19 and adults (ages 20 and over). To obtain population-based surveys, NCD- RisC first accessed publicly available population-based multicountry and national measurement surveys (for example, Demographic and Health Surveys [DHS]) and then requested data from (1) ministries of health and other national health agencies to identify population-based surveys and (2) a global network of health researchers. To identify data sources not accessed through the aforementioned mechanisms, researchers also conducted a litera- ture search via Medline. Where possible, data were reanalyzed to estimate mean BMI and overweight and obesity prevalence rates in standard age groups. Participants with implausible BMI levels, defined as BMI < 10 kg/m2 or BMI > 80 kg/m2 (<0.2 percent of all subjects), were excluded from esti- mates. Some estimates are imputed based on the weighted and smoothed residuals from data for neighboring countries. Notably, the NCD-RisC data use measured (not self-reported) weight and height data to create BMI values. 2. Joint Child Malnutrition Estimates (JME) are coordinated by UNICEF, the WHO, and the World Bank Group. In 2017, the JME consisted of data for children under five from 806 national surveys. UNICEF and the WHO receive and review survey data from the published and gray literature on a continual basis. The WHO maintains the WHO Global Database on Child Growth and Malnutrition, a repository of standardized anthropometric child data that has existed for 20 years. UNICEF maintains a global database populated in part through its annual data collection exercise that draws on submissions from more than 150 country offices. Historical survey estimates based on the U.S. National Center for Health Statistics/WHO growth reference, for which no raw data are available, have been converted to WHO-based prevalence rates (that is, 2006 WHO standards). 3. Relatedly, higher GDP per capita and lower income inequality is also associ- ated with disproportionately faster increases in overweight/obesity preva- lence for the lower wealth women, compared with higher wealth women, in low- and middle-income countries (Jones-Smith et al. 2011). 4. Dinsa et al. (2012) identified 11 studies that considered children and adoles- cents in their review of studies covering low- and middle-income countries published between 2004 and 2010. The studies unanimously showed obesity among children and adolescents as being more prevalent among the affluent in low- and middle-income countries. This is in contrast to results from high- income countries, which have generally shown an inverse association with socioeconomic status (particularly education) and have concluded that child obesity is largely a problem of poverty in high-income countries (Hardy et al. 2017; Knai et al. 2012; Watts et al. 2016).   Hardy et al. (2017) who analyzed trends in child and adolescent obesity in New South Wales, Australia, between 1985 and 2015, found that disparities by socioeconomic status increased over time. Using longitudinal data for a large cohort of adolescents in the United States, Watts et al. (2016) found that 64 | Obesity the prevalence of overweight/obesity increased significantly from adoles- cence to young adulthood with a larger increase occurring among those with low socioeconomic status at baseline, as compared with those with high socioeconomic status. References Abdullah, A. 2015. “The Double Burden of Undernutrition and Overnutrition in Developing Countries: An Update.” Current Obesity Reports 4 (3): 337–49. Adair, L. S., C. H. Fall, C. Osmond, A. D. Stein, R. Martorell, M. Ramirez-Zea, H. S. Sachdev, D. L. Dahly, I. Bas, S. A. Norris, L. Micklesfield, P. Hallal, and C. G. Victora. 2013. “Associations of Linear Growth and Relative Weight Gain during Early Life with Adult Health and Human Capital in Countries of Low and Middle Income: Findings from Five Birth Cohort Studies.” Lancet 382 (9891): 525–34. Aizawa, T., and M. Helble. 2016. “Socioeconomic Inequity in Excessive Weight in Indonesia.” ADBI Working Paper 572. Asian Development Bank Institute, Tokyo. https://www.adb.org/sites/default/files/publication/183799/adbi​-wp572.pdf. Albrecht, S. S., E. Mayer-Davis, and B. M. Popkin. 2017. “Secular and Race/Ethnic Trends in Glycemic Outcomes by BMI in US Adults: The Role of Waist Circumference.” Diabetes/Metabolism Research and Reviews 33 (5): 1306–12. Bell, Colin A., L. S. Adair, and B. M. Popkin. 2002. “Ethnic Differences in the Association between Body Mass Index and Hypertension.” American Journal of Epidemiology 155 (4): 346–53. de Onis, M., E. Borghi, M. Arimond, P. Webb, T. Croft, K Saha, L. M. De-Regil, F. Thuita, R. Heidkamp, J. Krasevec, C. Hayashi, and R. Flores-Ayala. 2019. “Prevalence Thresholds for Wasting, Overweight and Stunting in Children under 5 Years.” Public Health Nutrition 22(1): 175–79. Dietz, W. H. 2017. “Double-Duty Solutions for the Double Burden of Malnutrition.” The Lancet 390 (10113): 2607–08. Dinsa, G. D., Y. Goryakin, E. Fumagalli, and M. Suhrcke. 2012. “Obesity and Socioeconomic Status in Developing Countries: A Systematic Review.” Obesity Reviews 13 (11): 1067–79. Doak, C., L. Adair, M. Bentley, Z. Fengying, and B. Popkin. 2002. “The Underweight/ Overweight Household: An Exploration of Household Sociodemographic and Dietary Factors in China.” Public Health Nutrition 5 (1A): 215–21. Doak, C. M., L. S. Adair, M. Bentley, C. Monteiro, and B. M. Popkin. 2005. “The Dual Burden Household and the Nutrition Transition Paradox.” International Journal of Obesity 29 (1): 129–36. Doak, C. M., L. S. Adair, C. Monteiro, and B. M. Popkin. 2000. “Overweight and Underweight Coexist within Households in Brazil, China and Russia.” Journal of Nutrition 130 (12): 2965–71. Esser, N., S. Legrand-Poels, J. Piette, A. J. Scheen, and N. Paquot. 2014. “Inflammation as a Link between Obesity, Metabolic Syndrome and Type 2 Diabetes.” Diabetes Research and Clinical Practice 105 (2): 141–50. Prevalence and Trends | 65 Felson, D. T., J. J. Anderson, A. Naimark, A. M. Walker, and R. F. Meenan. 1988. “Obesity and Knee Osteoarthritis: The Framingham Study.” Annals of Internal Medicine 109 (1): 18–24. Garrett, J., and M. Ruel. 2005. “Stunted Child–Overweight Mother Pairs: Prevalence and Association with Economic Development and Urbanization.” Food and Nutrition Bulletin 26 (2): 209–21. GBD 2015 Obesity Collaborators. 2017. “Health Effects of Overweight and Obesity in 195 Countries over 25 Years.” New England Journal of Medicine 377 (1): 13–27. Hardy, L. L., S. Mihrshahi, J. Gale, B. A. Drayton, A. Bauman, and J. Mitchell. 2017. “30-Year Trends in Overweight, Obesity and Waist-to-Height Ratio by Socioeconomic Status in Australian Children, 1985 to 2015.” International Journal of Obesity 41 (1): 76. Jaacks, L. M., M. M. Slining, and B. M. Popkin. 2015. “Recent Underweight and Overweight Trends by Rural-Urban Residence among Women in Low- and Middle-Income Countries.” Journal of Nutrition 145: 352–57. Jones-Smith, J. C., P. Gordon-Larsen, A. Siddiqi, and B. M. Popkin. 2011. “Cross- National Comparisons of Time Trends in Overweight Inequality by Socioeconomic Status among Women Using Repeated Cross-Sectional Surveys from 37 Developing Countries, 1989–2007.” American Journal of Epidemiology 173 (6): 667–75. ———. 2012a. “Emerging Disparities in Overweight by Educational Attainment in Chinese Adults (1989–2006).” International Journal of Obesity 36 (6): 866–75. ———. 2012b. “Is the Burden of Overweight Shifting to the Poor across the Globe? Time Trends among Women in 39 Low- and Middle-Income Countries (1991–2008).” International Journal of Obesity 36 (8): 1114–20. Joshi, P., S. Islam, P. Pais, S. Reddy, P. Dorairaj, K. Kazmi, M. R. Pandey, S. Haque, S. Mendis, and S. Rangarajan. 2007. “Risk Factors for Early Myocardial Infarction in South Asians Compared with Individuals in Other Countries.” JAMA 297 (3): 286–94. Knai, C., T. Lobstein, N. Darmon, H. Rutter, and M. McKee. 2012. “Socioeconomic Patterning of Childhood Overweight Status in Europe.” International Journal of Environmental Research and Public Health 9 (4): 1472–89. Kuzawa, C. W., P. C. Hallal, L. Adair, S. K. Bhargava, C. H. Fall, N. Lee, S. A. Norris, C. Osmond, M. Ramirez-Zea, and H. S. Sachdev. 2012. “Birth Weight, Postnatal Weight Gain, and Adult Body Composition in Five Low and Middle Income Countries.” American Journal of Human Biology 24 (1): 5–13. Mendez, M. A., C. A. Monteiro, and B. M. Popkin. 2005. “Overweight Exceeds Underweight among Women in Most Developing Countries.” American Journal of Clinical Nutrition 81 (3): 714–21. Misra, A. 2015. “Ethnic-Specific Criteria for Classification of Body Mass Index: A Perspective for Asian Indians and American Diabetes Association Position Statement.” Diabetes Technology and Therapeutics 17 (9): 667–71. Monteiro, C. A., W. L. Conde, and B. M. Popkin. 2001. “Independent Effects of Income and Education on the Risk of Obesity in the Brazilian Adult Population.” Journal of Nutrition 131 (3): 881S–6S. ———. 2007. “Income-Specific Trends in Obesity in Brazil: 1975–2003.” American Journal of Public Health 97 (10): 1808–12. 66 | Obesity Monteiro, C. A., M. H. D’A Benicio, W. L. Conde, and B. M. Popkin. 2000. “Shifting Obesity Trends in Brazil.” European Journal of Clinical Nutrition 54 (4): 342–46. Nair, M., and D. Prabhakaran. 2012. “Why Do South Asians Have High Risk for CAD?” Global Heart 7 (4): 307–14. NCD-RisC (NCD Risk Factor Collaboration). 2016. “Trends in Adult Body-Mass Index in 200 Countries from 1975 to 2014: A Pooled Analysis of 1698 Population-Based Measurement Studies with 128.9 Million Participants.” The Lancet 387 (10026): 1377–96. ———. 2019. “Rising Rural Body-Mass Index Is the Main Driver of the Global Obesity Epidemic in Adults.” Nature 569 (7755): 260–64. Ng, S. W., and B. M. Popkin. 2012. “Time Use and Physical Activity: A Shift Away from Movement across the Globe.” Obesity Reviews 13 (8): 659–80. Patel, S. R., and F. B. Hu. 2008. “Short Sleep Duration and Weight Gain: A Systematic Review.” Obesity 16 (3): 643–53. Popkin, B. M. 2004. “The Nutrition Transition: An Overview of World Patterns of Change.” Nutrition Reviews 62 (7 Pt 2): S140–43. Popkin, B. M., C. Corvalan, and L. Grummer-Strawn. 2019. “Dynamics of the Double Burden of Malnutrition and the Changing Nutrition Reality.” The Lancet. https://doi.org/10.1016/S0140-6736(19)32497-3. Pries, A. M., A. M. Rehman, S. Filteau, N. Sharma, A. Upadhyay, and E. L. Ferguson. 2019. “Unhealthy Snack Food and Beverage Consumption Is Associated with Lower Dietary Adequacy and Length-for-Age z-Scores among 12–23-Month- Olds in Kathmandu Valley, Nepal.” The Journal of Nutrition. https://doi.org​ /10.1093/jn/nxz140. Shrimpton, R., and C. Rokx. 2012. “The Double Burden of Malnutrition: A Review of Global Evidence.” Health, Nutrition, and Population Discussion Paper, World Bank, Washington, DC. Stein, A. D., M. Wang, R. Martorell, S. A. Norris, L. S. Adair, I. Bas, H. S. Sachdev, S. K. Bhargava, C. H. Fall, D. P. Gigante, and C. G. Victora. 2010. “Growth Patterns in Early Childhood and Final Attained Stature: Data from Five Birth Cohorts from Low- and Middle-Income Countries.” American Journal of Human Biology 22 (3): 353–59. UNICEF, WHO, and World Bank (United Nations Children’s Fund, World Health Organization, and World Bank). 2016. Joint Child Malnutrition Estimates. Global Database on Child Growth and Malnutrition. https://www.who.int​ /nutgrowthdb/estimates2016/en/ (accessed July 2017). Victora, C. G., L. Adair, C. Fall, P. C. Hallal, R. Martorell, L. Richter, and H. S. Sachdev. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” The Lancet 371 (9609): 340–57. Watts, A.W., S. M. Mason, K. Loth, N. Larson, and D. Neumark-Sztainer. 2016. “Socioeconomic Differences in Overweight and Weight-Related Behaviors across Adolescence and Young Adulthood: 10-Year Longitudinal Findings from Project EAT.” Preventive Medicine 87: 194–99. WCRF and AICR (World Cancer Research Fund and American Institute for Cancer Research). 2018. Diet, Nutrition, Physical Activity and Cancer: A Global Perspective (A Summary of the Third Expert Report). Continuous Update Project Expert Report Prevalence and Trends | 67 2018. London: WCRF. https://www.wcrf.org/sites/default/files/Summary-third​ -expert-report.pdf. Wells, J. C., E. Pomeroy, S. R. Walimbe, B. M. Popkin, and C. S. Yajnik. 2016. “The Elevated Susceptibility to Diabetes in India: An Evolutionary Perspective.” Frontiers in Public Health 4: 145. Wells, J. C., A L. Sawaya, R. Wibeak, M. Mwangome, M. S. Poullas, R. Yajnik, and A. Demaio. Forthcoming. “Emerging Biological Pathways in the Double Burden of Malnutrition.” The Lancet. Wells, J. C., R. Wibaek, and M. Poullas. 2018. “The Dual Burden of Malnutrition Increases the Risk of Cesarean Delivery: Evidence From India.” Frontiers in Public Health 6. WHO (World Health Organization). 2011. “Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity.” WHO, Geneva. https:// apps.who.int/iris/handle/10665/85839. ———. 2012. “WHO BMI Classification.” http://apps.who.int/bmi/index.jsp​ ?introPage=intro_3.html. ———. 2017. “The Double Burden of Malnutrition.” Policy brief. WHO, Geneva. https://www.who.int/nutrition/publications/doubleburdenmalnutrition​ -policybrief/en/. WHO Expert Consultation. 2004. “Appropriate Body-Mass Index for Asian Populations and Its Implications for Policy and Intervention Strategies.” The Lancet 363 (9403): 157–63. WHO Multicentre Growth Reference Study Group. 2006. WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for- Height and Body Mass Index-for-Age: Methods and Development. Geneva: WHO. https://www.who.int/childgrowth/standards/Technical_report.pdf?ua=1. Ziraba, A. K., J. C. Fotso, and R. Ochako. 2009. “Overweight and Obesity in Urban Africa: A Problem of the Rich or the Poor?” BMC Public Health 9 (1): 465. 3 Health and Economic Impacts of Overweight/Obesity Pia Schneider, Barry Popkin, Meera Shekar, Julia Dayton Eberwein, Charlotte Block, and Kyoko Shibata Okamura Key Messages ­ orbidity • Being overweight/obese puts an individual at higher risk of m and mortality from non-communicable diseases (NCDs): the heavier the person and the longer the person has carried excess weight, the higher the risks. • Overweight/obesity-related NCDs are among the top-three killers in every region of the world except Sub-Saharan Africa. Childhood ­ overweight/obesity is particularly damaging. It puts the child at high risk of developing debilitating NCDs and living with them longer, denying the child her or his full health and economic potential. • Low- and middle-income country contexts, which include weak health care systems already burdened with high prevalence of infec- tious disease, create additional challenges to preventing and treating the health consequences of overweight and obesity. • Overweight/obesity reduces productivity and increases ­absenteeism, disability rates, and the risk of earlier retirement. • The estimated economic costs of overweight/obesity vary consider- ably since studies use different methodologies to estimate direct and indirect costs. 69 70 | Obesity overweight/ • The shift in diets and activity patterns linked to increased ­ obesity are also linked to important water and carbon ­ emissions con- cerns, thus perpetuating what is termed by the Lancet ­Commission on Obesity (LCO) as the syndemic of undernutrition, obesity, and climate change. That report also highlights potential double- and triple-duty actions that will provide climate co-benefits in addition to ­ addressing overweight/obesity and undernutrition. The Lancet EAT Commission report also advocates a shift toward more sustain- able plant-based diets to address both overweight/obesity and ­climate change. • Whatever estimates of costs one might subscribe to, the big picture message is that growing health care costs linked to increasing ­ overweight/obesity rates are a trend across both the developed and developing world. And there are climate co-benefits to changing food systems to promote healthier diets. Prevention of overweight/ obesity therefore makes sense from a public finance perspective. Governments have a key role to play in this effort, including by ensur- consumers are informed about their health and the conse- ing that ­ quences of their dietary and lifestyle choices. The Health Impact: Why Overweight/Obesity Matters Overweight/obesity by itself puts an individual at greater risk for mortality, but it is also part of a progressive disease state that starts with carrying exces- sive weight and leads to the development of NCDs such as type 2 ­ diabetes, cardiovascular disease, and cancers (figure 3.1, box 3.1). An extensive description of all the cancers linked to overweight/obesity is found else- where (WCRF and AICR 2018). Overweight/obesity is increasingly seen as a major preventable cause for cancers, diabetes, and other NCDs. Table 3.1 presents the overweight/obesity-related risk of developing NCDs. In general, the heavier a person is and the longer he or she is over- weight/obese, the higher the risk of developing and dying from NCDs (Abdullah 2015; Martin-Rodriguez et al. 2015; WCRF and AICR 2018). For example, an overweight man is over twice as likely as a man with a healthy weight to develop diabetes; an overweight woman has an almost four times greater risk. The risk increases greatly if the individual is obese: obese men are almost seven times more likely and women over 12 times more likely to have diabetes than normal-weight adults. Excess weight confers a much greater risk for women than men of developing some NCDs, including kidney cancer, hypertension, and coronary artery dis- ease. Men are at higher risk for pancreatic cancer and osteoarthritis (Guh et al. 2009). Health and Economic Impacts of Overweight/Obesity | 71 Figure 3.1 Health Impacts of Overweight/Obesity DIABETES CARDIOVASCULAR Stroke, kidney disease, DISEASE gestational diabetes, Stroke, aneurysm, amputation, heart attack, vision loss kidney disease, preeclampsia HEALTH IMPACTS OF OBESITY CANCER OTHER Uterine, esophageal, Liver disease, liver, kidney, infection, asthma, pancreatic, colorectal pain, depression BOX 3.1 Obesity: Both a Disease and a Risk Factor Obesity is a complex condition. It has long been considered a risk fac- tor for other diseases, especially non-communicable diseases (NCDs, as described in this chapter). Debate has centered on whether all cases of obesity should be categorized in the same way, because obesity can exist with and without comorbidities and therefore treatment require- ments vary. Within the past several decades, more and more medical and health entities—such as the World Health Organization, the Asia Oceania Association for the Study of Obesity, and the American Medi- cal Association—have declared obesity to be a disease state. Obese individuals without comorbidities are still at risk for developing the dis- ease of obesity—a condition by which obesity is accompanied by addi- tional comorbidities such as high blood pressure, high blood glucose, or high cholesterol. Obesity by itself increases risk of mortality, and obesity disease, with obesity-related NCDs, puts an obese individual at greater risk for morbidity and mortality (Bray et al. 2017; Kyle, Dhurandhar, and Allison 2016; Lobstein et al. 2017). ­ Table 3.1 Body Fatness and Risk of Cancer Incidence: Evidence from the WCRF/AICR Third Expert Report 72 Cancer site Exposure and increment Risk estimates (relative risk) (measure of body fatness) number of studies; number of cases Overall Men Women WCRF/AICR conclusion: Convincing: Increases risk a Oesophagus BMI per 5 kg/m2 1.48 (1.35–1.62) 1.56 (1.39–1.74) 1.48 (1.29–1.71) (adenocarcinoma) studies = 9; cases =1,725 studies = 3; cases = NR studies = 3; cases = NR Pancreas BMI per 5 kg/m 2 1.10 (1.07–1.14) 1.13 (1.04–1.22) 1.10 (1.04–1.16) studies = 23; cases = 9,504 studies = NR; cases = NR studies = NR; cases = NR Liver BMI per 5 kg/m 2 1.30 (1.16–1.46) 1.21 (1.02–1.44) 1.21 (1.10–1.33) studies = 12; cases = 14,311 studies = 8; cases = NR studies = 4; cases = NR Colorectum BMI per 5 kg/m 2 1.05 (1.03–1.07) 1.08 (1.04–1.11) 1.05 (1.02–1.08) studies = 38; cases = 71,089 studies = 20; cases = NR studies = 24; cases = NR Breast BMI per 5 kg/m 2 n.a. n.a. 1.12 (1.09–1.15) (postmenopause) studies = 56; cases = 80,404 Endometrium BMI per 5 kg/m 2 n.a. n.a. 1.50 (1.42–1.59) studies = 26; cases = 18,717 Kidney BMI per 5 kg/m 2 1.30 (1.25–1.35) 1.29 (1.23–1.36) 1.28 (1.24–1.32) studies = 23; cases = 15,575 studies = NR; cases = NR studies = NR; cases = NR continued next page Table 3.1 (continued) Cancer site Exposure and increment Risk estimates (relative risk) (measure of body fatness) number of studies; number of cases Overall Men Women WCRF/AICR conclusion: a Probable: Increases risk Mouth, pharynx, BMI per 5 kg/m2 1.15 (1.06–1.24) * * and larynx studies = 20; cases = 796 Stomach (cardia) BMI per 5 kg/m2 1.23 (1.07–1.40) 1.13 (0.98–1.30) * studies = 7; cases = 2,050 studies = 3; cases = 360 Gallbladder BMI per 5 kg/m2 1.25 (1.15–1.37) studies = 8; cases = 6,004 Ovary BMI per 5 kg/m 2 n.a. Prostate (advanced) BMI per 5 kg/m 2 n.a. WCRF/AICR conclusion:a Limited – suggestive: Increases risk Cervixb BMI per 5 kg/m2 n.a. n.a. 1.02 (0.97–1.07) studies = 9; cases = 5,144 Source: WCRF and AICR 2018. Available at dietandcancerreport.org. Reproduced with permission. Note: This table is based on a Cochrane style meta-analysis conducted by a global panel of scholars with WCRF staff assisting. BMI = body mass index; n.a. = not applicable; NR = not reported; WCRF/AICR = World Cancer Research Fund/American Institute for Cancer Research. a. For a full description of the definitions of, and the criteria for, the terminology of convincing, probable, and limited – suggestive please see J udging the Evidence (WCRF and AICR 2018), available at wcrf.org/dietandcancer/judging-the-evidence. ­ b. There is no evidence of effect modification by menopausal status for body fatness and the risk of endrometrial, ovarian, or cervical cancer so the evidence of all women (irrespective of menopausal status) is presented together. * Not possible to conduct analysis stratified by sex. 73 74 | Obesity It is important to note that these relative risks and the related disability- adjusted life years (DALYs) are based on epidemiological studies and assumptions that mainly include non-Hispanic white populations from the United States, the United Kingdom, and other high-income countries (Albrecht, Mayer-Davis, and Popkin 2017; Bell, Adair, and Popkin 2002; WHO Expert Consultation 2004; WHO Western Pacific Region 2000).1 These risks ignore to a great extent the increased risk of hypertension, dia- betes, heart disease, and cancers that can be linked to body-mass index (BMI) levels below 25 in low- and middle-income countries (WHO Expert Consultation 2004), as noted in chapter 2. Because these estimates are based on limited population groups, the real costs in terms of DALYs lost will be much greater. The Global Burden of Disease study estimates that overweight/obesity- related disease causes about 4 million deaths a year, or about 7 percent of deaths from all causes (GBD 2015 Obesity Collaborators 2017). Overweight/ obesity also contributes approximately 120 million DALYs, or about 5 per- cent of DALYs from all causes. Among many other overweight/obesity- related illnesses, cardiovascular disease is the first major contributor of deaths and DALYs, followed by type 2 diabetes (second contributor of deaths) and chronic kidney disease (second contributor of DALYs). Large increases in attributable DALYs between 1990 and 2016 have been seen among the 20 illnesses for which there is evidence of association with high BMI. Type 2 diabetes and osteoarthritis have had the largest increase in DALYs, doubling their impact over the last decades (GBD 2015 Obesity Collaborators 2017). Multiple factors influence the health impact of overweight/obesity. First is the relatively unknown area of genetics, which is not amenable to action. Second is the long-term impact of stunting and malnutrition during the first 1,000 days of life; this may also be the reason why the influence of lower BMI levels is larger on many low- and middle-income-country popu- lations than in non-Hispanic white populations. Stunting in the first 1,000 days appears to affect visceral fat (central adiposity) more than overall overweight/obesity and also the health consequences of visceral fat. The third are dietary causes. The second of these factors may be less obvious. Major shifts in the prev- alence of stunting have occurred over the past four decades in low- and middle-income countries. However, it is important to note that there is a considerable lag between stunting during the preschool period and the sub- sequent increased risk of becoming overweight/obese with all its related complications (Wells, Wibaek, and Poullas 2018). This proposition of the links between low birthweights and adult chronic diseases was first pro- posed as the Barker Hypothesis (Barker 1990; Law et al. 1992); subsequent research has refined this understanding, so now the focus is on fetal and Health and Economic Impacts of Overweight/Obesity | 75 infant development that is linked to reduced height (stunting) as the major measurable pathway. The literature suggests that stunting is more closely associated with increased risks of an array of NCDs and some increased risks of overweight/obesity, particularly in the most critical visceral fat mea- sures (Adair et al. 2013; Kuzawa et al. 2011). The levels of stunting seen in the 1990s, for example, will be reflected now, in 2019, only by those in the 20-to-30-year-old age group. This lag indicates that many low- and middle- income countries will see future rises in overweight/obesity linked both to the high stunting rates and to the reduced energy expenditure and chang- ing food patterns discussed in the next chapter (Adair et al. 2013; Stein et al. 2010; Victora et al. 2008). The Economic Costs of Overweight/Obesity Overweight/obesity creates a need for health care to treat higher incidence of chronic diseases such as diabetes and heart disease. It can lead to ­ disability and earlier retirement, and can also lower productivity. Chronic diseases require medical treatment that contributes to higher health expenditures. Several studies have attempted to estimate the economic costs of ­ overweight/obesity. However, each study uses different methodologies and differing definitions of direct and indirect costs of overweight/obesity, mak- ing comparison difficult. An unpublished systematic review of published studies conducted for this report (by Ana Perez Exposito) identified 34 studies between 2007 and 2017 that estimated the national costs of overweight, obesity, or both. These 34 studies cover 13 countries, 3 of which are middle-income coun- tries (Brazil, China, and Thailand) and 10 are high-income countries. No lower-income countries were included in these studies. The results suggest an estimated cost range (share of GDP lost) of 0.01 percent in Brazil to 2.08 percent in the United States for both obesity and overweight (18 studies), and 0.00 percent (Brazil) to 4.78 percent in the United States for obesity only. In the United States these costs are estimated to be between US$300 and more than US$3,000 per capita (between US$89 billion and US$212 billion in total costs); estimates in other high-income countries are much lower. Another estimate from the United States suggests that overweight/ obesity costs the government, employers, and individuals about US$147 billion per year; however, this cost will rise significantly as medical treat- ment for chronic diseases becomes more sophisticated. One estimate from Indonesia (Kosen 2018) suggests losses of about 3 percent of GDP, equivalent to about US$28.4 billion; another global estimate suggests losses of 2.8 percent of GDP, equal to about US$2.0 trillion (Dobbs et al. 2014). 76 | Obesity A recently published systematic review (Tremmel et al. 2017) lays out the methodological challenges of comparing the results from these studies. Table 3.2 summarizes some of the recent estimates, which demonstrate a variety of definitions applied for “direct” and “indirect” costs. Within these categories, different types of costs are measured—for example, the health care costs incurred by a person that stem from overweight/obesity as well as the obesity-related treatment costs incurred by the health system. These differences are relevant to projections about possible savings if the prevalence of obesity were to be reduced. ­ A summary of estimated costs of overweight/obesity from various countries (Qin and Pan 2016) is presented in table 3.3. ­ These estimates also reiterate a wide range of costs associated with overweight/obesity—between US$300 to more than US$3,000 per capita ­ in the United States (between US$89 billion and US$212 billion in total costs), versus much lower estimates in other high-income countries. Combined with the fact that overweight/obesity rates in the United States are on the rise and life expectancy is declining (especially as compared with countries such as France, Germany, Japan, and the United Kingdom), this should be a cause for major concern among policy makers. In Germany, the direct costs were estimated at €8,647 million, corresponding to 3.27 ­ percent of total German health care expenditures in 2008, with additional indirect costs of €8,150 million, of which two-thirds were costs of workdays lost. In China, the estimates of health care costs associated with overweight/ obesity rose from 3.13 percent of China’s annual national health care expenditure in 2009 to 0.56 percent in 2000. In Brazil, overweight/obesity- related health care costs are expected to double from US$5.8 billion in 2010 to US$10.1 billion in 2050. All of this shows that increasing health care costs linked to increasing overweight/obesity rates are a trend across the world. The Economic Factors That Affect Overweight/Obesity Two major sets of theories relate to the economic causes of overweight/ obesity. One connects it to the major shifts in technology and hence reduced activity; the other relates to the relative price of food—the price of healthy and unhealthy foods and the way these prices focus consumption on lower- priced ultra-processed foods, refined starchy staples, and a high-calorie diet relative to energy expenditure (Cutler, Glaeser, and Shapiro 2003; Finkelstein et al. 2008; Finkelstein and Strombotne 2010). Most of the ­ literature focuses on high-income countries. Few longitudinal rigorous ­ analyses from lower-income countries exist, but one long-term study has shown that declining physical activity played a major role—which in turn Table 3.2 The Economic Costs of Overweight/Obesity Country/region and year Characteristics Study Methodology Estimated costs International Estimated indirect Goettler, Indirect costs defined as the losses from Because of the methodological (Australia, costs Grosse, reduced work productivity due to short- heterogeneity, no aggregated/comparative Canada, Finland, International and term and long-term inability to work, figures were proposed. Germany, comparison Sonntag including “temporary work loss” such as Republic of 2017 sick leave (“absenteeism”) and reduced Korea, Not a meta-analysis productivity while being present at work Netherlands, New (graphical (“presenteeism”), permanent work loss Zealand, Sweden, comparison) such as disability pension and premature and the United death. States) 2017 United States Estimated direct and Waters Direct costs calculated from the Medical In 2016, the cost of chronic diseases 2018 indirect costs and Graf Expenditure Panel Survey (including attributable to the prevalence of obesity and 2018 household survey and insurance data), overweight resulted in a US$1.72 trillion price using the concept of the treated prevalence tag, equivalent to 9.3% of US GDP of health conditions that are associated (US$480.7 billion in direct health care costs with obesity in overweight/obese adults, and US$1.24 trillion in indirect costs due to compared to normal weight individuals. lost economic productivity). This makes up Methodology/definition of indirect costs is 47.1% of the total cost of chronic diseases not mentioned. nationwide. Republic of Estimated direct and Dee et al. Included direct costs as health care Republic of Ireland: Ireland; indirect costs 2015 utilization costs and drug costs and indirect In 2009 €437 million in direct costs (health Northern Ireland costs as work absenteeism and premature care costs) and €865 million in indirect costs mortality. (productivity loss due to overweight/obesity). 2015 Northern Ireland: In 2009, €127.41 million in direct costs (health care costs) and €362 million in 77 indirect costs (productivity loss). continued next page Table 3.2 (continued ) 78 Country/region and year Characteristics Study Methodology Estimated costs Germany Estimated direct and Lehnert Direct costs estimated for inpatient/ Total costs attributable to excess weight 2015 indirect costs et al. 2015 outpatient treatment, rehabilitation, and (BMI > 25kg/m2) in Germany in 2008 Estimated the other direct costs (including health amounted to €16,797 million (up 70% increase in the costs protection, ambulance, administration, compared to 2002). between two time research and evaluation, investments, and Direct costs were €8,647 million, points (2002 and other facilities). corresponding to 3.27% of total German 2008) by updating Indirect costs calculated as loss of heath care expenditures in 2008. the 2002 research productivity from paid and unpaid work Indirect costs were €8,150 million in 2008 due to sickness absence, early retirement, (up 62% compared to 2002), of which two- and mortality, applying the human capital thirds (€5,276 million) were costs of unpaid approach. work (up 75% compared to 2002). China Estimated direct costs Qin and Direct costs based on medical expenditures The per capita medical cost attributable to 2016 Per capita and share Pan 2016 calculated using the China Health and obesity and overweight in a single medical of national health care Nutrition Survey (2002, 2004, 2006, event is estimated to be 6.18 yuan, or 5.29% expenditure 2009), which includes self-medication of the total personal medical expenditure. expenses (for example, over-the-counter This translates to 24.35 billion yuan annual Uses longitudinal data drugs) and formal health costs (impatient, from 2000–2009 cost on the national scale, accounting for outpatient, preventive services) including 2.46% of China’s national health care China Health and both insurance providers’ and out-of- Nutrition Surveys expenditure. pocket payments. The subsample analyses also show that costs are higher for urban dwellers, women, and for the better educated, and it increases over time. continued next page Table 3.2 (continued ) Country/region and year Characteristics Study Methodology Estimated costs Republic of Korea Estimated direct costs Song et al. Direct costs were calculated using the Obese individuals with BMI ≥ 30 had 2018 Estimated the cost 2018 National Health Insurance Service-Health medical expenditures of 1.21–1.40 times over 11 years, using Screening Cohort data that includes those of normal weight individuals over the longitudinal insurance eligibility, medical treatments, approximately 11 years (after being adjusted database medical care institutions, and general for age, sex, income level, and examinations. comorbidities) Overweight (BMI 23–24.99) and obesity I (25–29.99), II (30–34.99), and III (35– 59.99) were defined by Asian BMI criteria. Brazil Estimated direct costs Rtveladze The study projects an increase in health Health care costs will double from 2010 2013 et al. 2013 care costs of obesity-related diseases (US$5.8 billion) in 2050 alone (US$10.1 between two time points (2010 and 2050), billion). Over 40 years costs will reach but the estimates are not derived from US$330 billion, based on the model that comparison between overweight/obese projects an increase in the overweight/ and normal-weight counterparts. obesity prevalence in Brazilian male population from 57% in 2010 to 95% by 2050. Source: Original compilation (see the References section of the chapter for full study information). Note: BMI = body mass index. 79 80 | Obesity Table 3.3 Summary of Estimated Costs of Overweight/Obesity in Selected Countries Percentage Per capita Cost of national cost Country Study (2010 US$, millions) medical costs (2010 US$) Australia Access Economics 675.30 1.3 32.41 2006 Canada Katzmarzyk and 1,577.90 2.2 48.54 Janssen 2004 France Emery et al. 2007 2,368.00–7,126.00 1.5–4.6 90.25 Germany Konnopka, Bödemann, 5,579.00 2.1 67.82 and König 2011 Korea, Kang et al. 2011 1,787.00 3.7 36.56 Rep. Spain Vazquez-Sanchez and 1,001.00 1.7 22.25 Lam 2002 Sweden Swedish Council on 182.62–365.34 1.0–2.0 30.00 Technology Assessment in Health Care 2002 United House of Commons 1,790.00–2,000.00 2.3–2.6 32.22 Kingdom Health Select Committee 2004 United Finkelstein, Fiebelkorn, 89,415.10 5.7 302.35 States and Wang 2003 United Finkelstein et al. 2009 148,902.80 10.0 503.50 States United Cawley and 212,462.00 20.6 3,059.00 States Meyerhoefer 2012 Source: Based on Qin and Pan 2016. links to the technology issue (Ng et al. 2012). More recently, economists point to the relatively higher costs of healthy food globally. As noted in chapter 2, it is this balance between energy expenditure and the metabolic effects of various types of food that jointly affects weight gain. Economic theory assumes that perfectly informed consumers will maxi- mize their utility by consuming various goods depending on their relative prices as well as on the consumers’ income and preferences. This means that changes in prices and income influence how much of different goods rational consumers will buy, as will their preferences for different products. Health and Economic Impacts of Overweight/Obesity | 81 Relative Price The price of a good is inversely related to the demand for it. According to consumer theory, if prices decrease, demand will go up. Over the past decades, prices for food and beverages have increased globally—but not all prices have increased equally. Some products saw a higher price increase than others, which resulted in a change in the relative price across products. For example, U.S. data point to substantial differences in price increases across products in the past 35 years. Prices for fresh fruits and vegetables rose by 190 percent, compared with a 66 percent increase for sweets and sugar. Low-income households are particularly wary about food prices because food makes up a large share of their household con- sumption basket (Drewnowski and Specter 2004). They are therefore most likely to adjust their consumption and shift from higher-priced items to cheaper products even though these substitutes may be less healthy and higher in calories and sugar, which contributes to weight gains (Epstein et al. 2012). In general, across the developing world, it is the relative reduced price of unhealthy ultra-processed food along with their ingredients—such as refined flours, sugars, and edible oils—that have fueled a major shift in global food intake toward less healthy foods. In addition to the shift in global rela- tive and absolute prices for these highly processed foods and beverages com- pared with prices for healthier legumes, vegetables, and fruits, among other items, there has been a long-term global decline in the price of animal-source foods, particularly beef (Popkin 2011). The change in beef prices led the International Food Policy Research Institute (IFPRI) and others to speak about a “beef revolution” (discussed as a major increase in global beef con- sumption as the driver of animal-source food consumption trends) (Delgado 2003; Delgado et al. 1999). However, from more recent trends, this appears to have shifted to the current “poultry revolution” whereby much of the more recent increase in animal-source food consumption has come from poultry globally (see Zhai et al. [2014] for an example from China). But again, as a vast array of research on price elasticity, food taxation, and related topics has shown, it is the relative price of various healthy versus unhealthy foods and beverages that m ­ atters (Deaton and Muellbauer 1980; Timmer and Alderman 1979). Lower prices for s ­ ugary beverages and ultra-processed foods is one of the arguments for governments to tax unhealthy products. Income and Preferences A combination of increased income, increased marketing of ultra-processed foods and beverages, and the growth of global media has led to major shifts in food preferences toward much less healthful ultra-processed foods in general and animal-source foods in low- and middle-income c ­ountries 82 | Obesity (Chaudri and Timmer 1986; Monteiro et al. 2013; Popkin 2008, 2014; Popkin and Reardon 2018). Concurrent rapid penetration by modern ­ retailers has also been linked to these shifts, particularly in low-income areas where retailers selling fresh products are not readily available (Popkin and Reardon 2018). The result of these combined factors has been a marked increase in the demand for both ultra-processed foods and animal-source foods. Worldwide, the demand for food and beverages has increased, as shown by higher total calorie intake per capita. The World Health Organization (WHO) estimates that average daily per capita food consumption in the developing world has increased by 400 kilocalories: from 2,405 kilocalories per capita per day in 1985 to 2,850 in 2015.2 To some extent, higher demand is driven by more income as well as by the retail revolution, increased food marketing, and reduced prices for ultra-processed foods (Reardon et al. 2003; Tschirley et al. 2015). In addition, food consumption patterns tend to change as per capita incomes rise (see chapter 2). Low-income households are more susceptible to price changes and will consume fewer fruits and vegetables ­ and less fiber, but more fat and sugar-sweetened beverages than the better- off (Drewnowski and Specter 2004). Preferences have changed too, as more diverse products become avail- able. Much of the increase in calories in consumption is caused by the increased availability of high-caloric ready-to-eat and ready-to-heat snack food and beverages as well as energy-dense and nutrient-poor food pre- pared by the formal and informal retail and food service sectors. Critical regional patterns to these changes as well as unique factors in each country exist; nevertheless, snacking on convenience foods (an activity that in the nineteenth century did not exist) has been a major part of the increased caloric intake in both high-income countries and low- and middle-income countries in the past 40 years. How to differentiate the impact of modern marketing and affluence on these snacking behaviors is unclear. Countries as diverse as Brazil, Mexico, and the United States are among those where over a fifth of kilocalories are coming from snacks, and there is evidence of an explosion in snacking in China (Duffey, Pereira, and Popkin 2013; Duffey, Rivera, and Popkin 2014; Dunford and Popkin 2017; Erlanson- Albertsson and Zetterstrom 2005; Huffman et al. 2014; Popkin 2008; Roester 2017; Seabrook 2011; Wang et al. 2012) as well as most recently in Nepal (Pries et al. 2019). Modern Technologies, Energy Expenditure, and Lifestyle Changes A combination of globalization, trade agreements, and the push to find cheaper labor markets along with most development initiatives has led to Health and Economic Impacts of Overweight/Obesity | 83 the introduction of an array of modern technologies that affect energy expenditure at work and lifestyles in both urban and rural areas example, the introduction of computers, small gas-driven cheap plows, (for ­ modern irrigation pumps, and electricity in rural areas; see Herrin 1979). Moreover, this push has affected home-based work (with refrigeration, rice cookers, water piped into houses and villages, and propane stoves), trans- portation (with motorized vehicles of all sorts), and leisure (with the arrival of television and smart phones), and how much time people spend “­ moving.” These effects demonstrate that many technologies have led to enormous declines in energy expenditure in the past four decades in l ­ow- and middle-income countries (Ng, Norton, and Popkin 2009; Ng and Pop- kin 2012). It is important to note that they come at a time when, based on the WHO data cited above, caloric intake appears to be increasing. As a result, lifestyles have become much more sedentary and people now expend fewer calories since they are working in jobs that require less physical activity. This means that people will also need fewer calories than they expend. Individuals with higher incomes will have more opportuni- ties to offset increased calorie consumption through physical activity, for example, by joining a gym. However, for lower-income households, this may not be an option as they may not be able to afford high membership fees; they may reside in densely populated urban areas where walking or jogging is difficult and personal safety is often a great concern. They may also incur opportunity costs for their time if they have to work longer hours to make ends meet (Drewnowski and Specter 2004). Expectation of Health Effect In addition to consumption theory, economic theory also uses expected utility theory to explain how uncertainty affects individuals’ decisions and behavior. Using expected utility theory, it can be argued that individuals make choices between an uncertain “health loss” due to obesity that may likely occur in the future and a certain financial loss caused by paying a higher price for fruits and vegetables today to prevent obesity. This uncertainty about an expected future outcome affects their behavior today. Expected utility theory assumes that people are risk averse. They make choices about what risk to take as it has implications for their overall wealth, which includes their health status. If indi- viduals are rational, they will go for certainty and pay a higher price today for healthy products to prevent a future loss (illness related to overweight). How- ever, through modern medicine, people can level out different risks over time, and this affects their choices about how to behave. They will pay less today for unhealthy food knowing they are taking a health risk (weight gain). But this risk and its consequences become less risky through modern medicine and medical coverage. 84 | Obesity Access to modern medicine therefore alleviates the health conse- quences of being overweight or obese for individuals. This is especially the case where government and health insurance pay for care and indi- vidual out-of-pocket payment is low. It could therefore be argued that individuals are less inclined to pay a higher price for healthy food today to prevent obesity, because they do not think about future health prob- lems as much as current costs or they know they will have access to rela- tively inexpensive health care in case they need it in the future. As a result, they will care less about their growing waistline and obesity pre- vention although they are aware of the possible negative effect on their health status. The resulting impact on government health expenditures is a main argument for governments to invest in prevention and inform people about the negative health consequences of obesity. While such health care is available in Latin America and selected other low- and ­ middle-income countries, it is available in the majority of high-income countries. The Role of Government From an economic perspective, obesity becomes a public policy concern if it leads to higher health care costs and market failure and if it threatens equity objectives. These concerns would be reason for government to ­intervene. Health Expenditures As shown in the previous sections, overweight/obesity affects health status and it creates a need for medical care to treat related health ­ ­ consequences. It has been associated with higher incidence of chronic diseases, such as diabetes and heart disease; earlier risk of disability and retirement; and lower life expectancy for some population groups. Chronic diseases require medical treatment that contribute to higher health expenditures. It could be expected that if obesity leads to shorter lifespans, then total health expenditures may be lower for the obese than the non-obese—as, for example, is the case for tobacco consumption. However, findings from the United States suggest that obesity costs the government, employers, and individuals about US$147 billion per year as medical treatment for chronic diseases becomes more sophisticated. Another estimate suggests costs between US$89 billion and US$212 bil- lion in the United States. In China, one estimate that looked at the total costs of overweight and obesity, including the indirect costs of overweight/ obesity and related dietary and physical activity patterns, ranged between Health and Economic Impacts of Overweight/Obesity | 85 3.58 percent and 8.73 percent of gross national product in 2000 and 2025, respectively (Popkin et al. 2006). The estimates of health care costs associ- ated with overweight and obesity rose from 3.13 percent of China’s annual national health care expenditure in 2009 to 0.56 percent in 2000 (Qin and Pan 2016). In Brazil, obesity-related health care costs are expected to double from US$5.8 billion in 2010 to US$10.1 billion in 2050 (Rtveladze et al. 2013). Government interventions to prevent over- weight/obesity and its health consequences therefore make sense from a public finance perspective, which aims for efficient allocations of funds. Market Failure From an economic perspective, overweight/obesity becomes a concern if it leads to market failure; this would be another reason for government to intervene (Begg, Fischer, and Dornbusch 2000). Market failure means that resource allocation through the private sector is not efficient. Market fail- ure can be triggered by (1) externalities, (2) asymmetric information, (3) market power, and (4) public goods characteristics (Finkelstein and Strombotne 2010). Externality is a reason for government to intervene, but overweight/obe- sity does not create externalities or negative side-effects on others in the way smoking does on nonsmokers. Although some “quasi-externalities” on individual behavior exist when people live and work in an environment with a higher prevalence of overweight/obese individuals, which may have a self-enforcing effect on unhealthy eating behavior for the group, this increased prevalence does not create any negative impact on others. In addition, excessive medical care costs for treating overweight/obesity may increase insurance costs for normal weight individuals. Asymmetric or imperfect information is a problem in food consumption because producers know more about the nutrient-content than consumers do and use marketing that is often deceptive to incorrectly inform consum- ers. To improve information, governments have launched awareness cam- paigns about what makes up a healthy diet and requested producers to label food packages to inform consumers about content and nutrient value; however, the costs and successes of such campaigns are limited because of extensive marketing of ultra-processed foods and beverages. Market power means that a single firm or a few firms dominate the mar- ket. Because of their market power, firms can dictate the price at which a ­ product is offered, which leads to price increases. Government antitrust agencies are tasked with preventing firms from dictating prices. Price increases are problematic for overweight/obesity because unhealthy food tends to be cheaper, which has led governments to introduce diet-related taxes on these products. 86 | Obesity Finally, public goods are goods that would not be produced by the private sector—for example, certain health services such as emergency care. However, it would be difficult to argue that overweight/obesity rates are triggered by a shortage of public goods such as health care. From an economic perspective, therefore, government’s role is to inter- vene and correct for market failure in the private sector. Governments can ensure that consumers are informed about the health consequences of their dietary choices and governments can correct for large differences in relative prices between healthy and unhealthy products and work to limit marketing that increases sales of ultra-processed foods. Equity in Health In addition to their role in preventing overweight/obesity to manage health expenditures and correct for asymmetric information, governments inter- vene to meet equity objectives. Governments may argue for targeted pre- vention programs for lower-income groups if they and other disadvantaged individuals are more affected by overweight/obesity and do not have the same access to medical treatment for related diseases. Brazil, for example, has issued guidelines to improve equity in access to healthy food, particu- larly in low-income areas and in schools. In this case, government inter- ventions help ensure that disadvantaged groups are not excluded from good health. Adequate diagnosis and treatment are major issues for the poor in most countries of the world (Gordon-Larsen et al. 2017). Equity issues represent a major argument for the use of government interventions to prevent obesity. It is often argued that most sin or ultra- processed food and beverage taxes are regressive because the poor spend a higher proportion of their income on goods subject to these taxes than the rich. However, while such indirect taxes reduce the redistribution effect from the rich to the poor, they may still have a pro-poor effect if tax reve- nues are used by government to finance pro-poor public services such as health care in the public sector that is predominantly used by the poor (Begg, Fischer, and Dornbusch 2000) or if the impact of these taxes improves significantly the health of the poor and prevents overweight/obesity and many NCDs that would otherwise be undiagnosed or poorly treated. Some population groups, such as children, will need additional protec- tion as they are too young to fully understand the health consequences of consuming unhealthy food and beverages, including alcohol. This has caused governments to focus even more strongly on child health and pre- vention. In South Africa, the Advertising Standards Authority (ASA) pro- hibits misleading food marketing and advertising tactics via any form of media, including enticing children with toys and using celebrities and cartoon characters to advertise unhealthy food products to children. ­ Health and Economic Impacts of Overweight/Obesity | 87 Children’s rights are written into constitutions in many low- and middle- income countries. These constitutional rights are used for legal and govern- ment challenges to the marketing of ultra-processed foods. This discussion shows that, from an economic perspective, o ­ verweight/ obesity is affected by market factors such as relative prices, income, preferences, and technological advances at work and in medicine. ­ Government interventions should therefore focus on overweight/­ obesity prevention by facilitating information and access and by reduc- ing the relative cost for healthy diets and physical activity, particularly for low-income groups. This would require a comprehensive approach to policy formulation including in agriculture, environment, transport, taxation, and health care. The Cost of Overweight/Obesity for Climate Co-Benefits and Water Use Costs of overweight/obesity are linked not only with the outcomes noted above but also with the food and activity dynamics that are linked to global weight increases. The latter ones also have significant impacts on climate with all the related costs (Springmann et al. 2018). The underlying causes of obesity are very much linked to increased water use and carbon emis- sions. This is true for both the reduced energy expenditures for home and market production and transportation as well as for shifts in dietary pat- terns. For the food sector, much of the attention has centered on the growing global demand for animal-source food, in particular ruminant ani- ­ mals, whereas the huge growth in the packaged processed food sector has been generally ignored except for a few very focused studies. Both sets of causes are deeply linked to an increased use of energy, increased carbon emissions, and, for food, increased water use. The current literature suggests that just a shift in global diets to reduced animal-source foods use would not only reduce overweight/obesity but also address much of the global climate problem (EAT Lancet Commission 2019; Godfray et al. 2018; Springmann et al. 2018). A major reduction in the pro- duction of animal-source foods is one central element that could significantly reduce greenhouse gases. Much of this reduction would come from the reduction in methane emissions from ruminant animals (cows and lambs, in particular). The Food and Agriculture Organization of the United Nations, for example, states that one-third of total emissions from global livestock are related to these animals (FAO 2007). The Lancet EAT Commission group showed that their proposed dietary shifts away from ruminant animal-based diets (that is, diets based on beef and lamb) would meet the Paris Accord climate goals (EAT Lancet Commission 2019; Springmann et al. 2018). 88 | Obesity A healthy diet with fewer sweetened, sugary beverages would also reduce water use because crops that provide the sugar require a great deal of water (Springmann et al. 2018). There is a small literature on water use and sugary beverage intake, but to date no major studies have been published on other aspects of any dimension of climate change related to the production and distribution of the least healthy ultra-­ processed foods and beverages. This represents a critical gap because there are also major environmental (particularly water and carbon emis- sions) costs associated with the production of sugary drinks. For a half liter (500 milliliters or 17 ounces) of a regular soft drink, the total water life cycle costs range from 168 liters when the sweetener is derived from sugar beets to 309 liters for sugarcane in India (Ercin, Aldaya, and Hoekstra 2011; Hoekstra 2013; Hoekstra and Chapagain 2007). A major knowledge gap is found in the water and carbon emissions footprint for all other unhealthy ultra-processed foods, which institutions such as the World Bank could help fill in. Notes 1. DALYs are calculated by summing years of life lost and years of life lived with disability due to each illness. 2. These data are available at the World Health Organization’s “Global and Regional Food Consumption Patterns and Trends” at https://www.who.int​ /­nutrition/topics/3_foodconsumption/en/. References Abdullah, A. 2015. “The Double Burden of Undernutrition and Overnutrition in Developing Countries: An Update.” Current Obesity Reports 4 (3): 337–49. Access Economics. 2006. “The Economic Costs of Obesity: A Report Prepared for Diabetes Australia.” http://www.accesseconomics.com.au. Adair, L. S., C. H. Fall, C. Osmond, A. D. Stein, R. Martorell, M. Ramirez-Zea, H. S. Sachdev, D. L. Dahly, I. Bas, S. A. Norris, L. Micklesfield, P. Hallal, and C. G. Victora. 2013. “Associations of Linear Growth and Relative Weight Gain during Early Life with Adult Health and Human Capital in Countries of Low and Middle Income: Findings from Five Birth Cohort Studies.” The Lancet 382 (9891): 525–34. Albrecht, S. S., E. Mayer-Davis, and B. M. Popkin. 2017. “Secular and Race/Ethnic Trends in Glycemic Outcomes by BMI in US Adults: The Role of Waist Circumference.” Diabetes/Metabolism Research and Reviews 33:e2889. Barker, D. J. 1990. “The Fetal and Infant Origins of Adult Disease.” BMJ 301 (6761): 1111. Begg, D., S. Fischer, and R. Dornbusch. 2000. Economics. London: McGraw-Hill Companies. Health and Economic Impacts of Overweight/Obesity | 89 Bell, C. A., L. S. Adair, and B. M. Popkin. 2002. “Ethnic Differences in the Association between Body Mass Index and Hypertension.” American Journal of Epidemiology 155 (4): 346–53. Bray, G., K. Kim, J. Wilding, and World Obesity Federation. 2017. “Obesity: A Chronic Relapsing Progressive Disease Process. A Position Statement of the World Obesity Federation.” Obesity Reviews 18 (7): 715–23. Cawley, J., and C. Meyerhoefer. 2012. “The Medical Care Costs of Obesity: An Instrumental Variables Approach.” Journal of Health Economics 31 (1): 219–30. Chaudri, R., and C. P. Timmer. 1986. “The Impact of Changing Affluence on Diet and Demand Patterns for Agricultural Commodities.” Staff Working Paper 785, World Bank, Washington, DC. Cutler, D. M., E. L. Glaeser, and J. M. Shapiro. 2003. “Why Have Americans Become More Obese?” Journal of Economic Perspectives 17 (3): 93–118. Deaton, A., and J. Muellbauer. 1980. “An Almost Ideal Demand System.” American Economic Review 70 (3): 312. Dee, A., A. Callinan, E. Doherty, C. O’Neill, T. McVeigh, M. R. Sweeney, A. Staines, K. Kearns, S. Fitzgerald, L. Sharp, F. Kee, J. Hughes, K. Balanda, and I. J. Perry. 2015. “Overweight and Obesity on the Island of Ireland: An Estimation of Costs.” BMJ Open 5:e006189. Delgado, C. L. 2003. “Rising Consumption of Meat and Milk in Developing Countries Has Created a New Food Revolution.” Journal of Nutrition 133 (11 Suppl 2): 3907S–3910S. Delgado, C., M. Rosegrant, H. Steinfield, S. Ehui, and C. Courbois. 1999. “Livestock to 2020: The Next Food Revolution.” Food, Agriculture, and the Environment Discussion Paper 28, International Food Policy Research Institute, Washington, DC. Dobbs, R., C. Sawers, F. Thompson, J. Manyika, J. Woetzel, P. Child, S. McKenna, and A. Spatharou. 2014. “Overcoming Obesity: An Initial Economic Analysis.” McKinsey Global Institute Discussion Paper. https://www.mckinsey.com​ /~/media/McKinsey/Business%20Functions/Economic%20Studies%20TEMP​ /­Our%20Insights/How%20the%20world%20could%20better%20fight%20 obesity/MGI_Overcoming_obesity_Full_report.ashx. Drewnowski, A., and S. E. Specter. 2004. “Poverty and Obesity: The Role of Energy Density and Energy Cost.” American Journal of Clinical Nutrition 79: 6–16. Duffey, K. J., R. A. Pereira, and B. M. Popkin. 2013. “Prevalence and Energy Intake from Snacking in Brazil: Analysis of the First Nationwide Individual Survey.” European Journal of Clinical Nutrition 67 (8): 868–74. Duffey, K. J., J. A. Rivera, and B. M. Popkin. 2014. “Snacking Is Prevalent in Mexico.” Journal of Nutrition 144 (11): 1843–49. Dunford, E. K., and B. M. Popkin. 2017. “37 Year Snacking Trends for US Children 1977-2014.” Pediatric Obesity 13 (4): 247–55. EAT Lancet Commission. 2019. Willett, W., J. Rockström, B. Loken, M. Springmann, T. Lang, S. Vermeulen, T. Garnett, D. Tilman, F. DeClerck, A. Wood, M. Jonell, M. Clark, L. J. Gordon, J. Fanzo, C. Hawkes, R. Zurayk, J. A. Rivera, W. De Vries, L. Majele Sibanda, A. Afshin, A. Chaudhary, M. Herrero, R. Agustina, F. Branca, A. Lartey, S. Fan, B. Crona, E. Fox, V. Bignet, M. Troell, T. Lindahl, S. Singh, S. E. Cornell, K. Srinath Reddy, S. Narain, S. Nishtar, and C. J. L. Murray. “Food in the Anthropocene: The EAT–Lancet Commission on Healthy 90 | Obesity Diets from Sustainable Food Systems.” The Lancet 393 (10170): 447–92. https:// www.thelancet.com/commissions/EAT. Emery, C., J. Dinet, A. Lafuma, C. Sermet, B. Khoshnood, and F. Fagnani. 2007. “Cost of Obesity in France.” La Presse Médicale 36 (6 Pt 1): 832–40. Epstein, L. H., N. Jankowiak, C. Nederkoom, H. A. Raynor, S. A. French, and E. Finkelstein. 2012. “Experimental Research on the Relation between Food Price Changes and Food-Purchasing Patterns: A Targeted Review.” American Journal of Clinical Nutrition 95 (4):789–809. Ercin, A. E., M. M. Aldaya, and A. Y. Hoekstra. 2011. “Corporate Water Footprint Accounting and Impact Assessment: The Case of the Water Footprint of a Sugar- Containing Carbonated Beverage.” Water Resources Management 25 (2): 721–41. Erlanson-Albertsson, C., and R. Zetterstrom. 2005. “The Global Obesity Epidemic: Snacking and Obesity May Start with Free Meals during Infant Feeding.” Acta Paediatrica 94 (11): 1523–31. FAO (Food and Agriculture Organization of the United Nations). 2007. Livestock’s Long Shadow: Environmental Issues and Options. Rome: FAO. Finkelstein, E. A., D. S. Brown, D. R. Brown, and D. M. Buchner. 2008. “A Randomized Study of Financial Incentives to Increase Physical Activity among Sedentary Older Adults.” Preventive Medicine 47 (2): 182–87. Finkelstein, E. A., I. C. Fiebelkorn, and G. Wang. 2003. “National Medical Spending Attributable to Overweight and Obesity: How Much, and Who’s Paying?” Health Affairs (Millwood) 22 (3): 219–26. Finkelstein, E. A., and K. L. Strombotne. 2010. “The Economics of Obesity.” American Journal of Clinical Nutrition 91 (5): 1520S–1524S. Finkelstein, E. A., J. G. Trogdon, J. W. Cohen, and W. Dietz. 2009. “Annual Medical Spending Attributable to Obesity: Payer- and Service-Specific Estimates.” Health Affairs 28 (5): 822–31. GBD 2015 Obesity Collaborators. 2017. “Health Effects of Overweight and Obesity in 195 Countries over 25 Years.” New England Journal of Medicine 377 (1): 13–27. Godfray, H. C. J., P. Aveyard, T. Garnett, J. W. Hall, T. J. Key, J. Lorimer, R. T. Pierrehumbert, P. Scarborough, M. Springmann, and S. A. Jebb. 2018. “Meat Consumption, Health, and the Environment.” Science 361 (6399). Goettler, A., A. Grosse, and D. Sonntag. 2017. “Productivity Loss Due to Overweight and Obesity: A Systematic Review of Indirect Costs.” BMJ Open 2017; 7:e014632. Gordon-Larsen, P., S. M. Attard, A. G. Howard, B. M. Popkin, B. Zhang, S. Du, and D. K. Guilkey. 2017. “Accounting for Selectivity Bias and Correlation across the Sequence from Elevated Blood Pressure to Hypertension Diagnosis and Treatment.” American Journal of Hypertension 31 (1): 63–71. Guh, D. P., W. Zhang, N. Bansback, Z. Amarsi, C. L. Birmingham, and A. H. Anis. 2009. “The Incidence of Co-Morbidities Related to Obesity and Overweight: A Systematic Review and Meta-Analysis.” BMC Public Health 9 (1): 88. Herrin, A. N. 1979. “Rural Electrification and Fertility Change in the Southern Philippines.” Population and Development Review 5: 61–86. Hoekstra, A. Y. 2013. The Water Footprint of Modern Consumer Society. Oxon, UK, and New York: Routledge. Hoekstra, A. Y. and A. K. Chapagain. 2007. “Water Footprints of Nations: Water Use by People as a Function of Their Consumption Pattern.” Water Resources Management 21: 35–48. Health and Economic Impacts of Overweight/Obesity | 91 House of Commons Health Select Committee. 2004. Obesity: Third Report of Session 2003/2004. The Stationery Office: London. http://www.sbu.se/upload/Publikationer​ /Content0/1/obesity_2002/obsesityslut.pdf. Huffman, S. L., E. G. Piwoz, S. A. Vosti, and K. G. Dewey. 2014. “Babies, Soft Drinks and Snacks: A Concern in Low- and Middle-Income Countries?” Maternal and Child Nutrition 10 (4): 562–74. Kang, J. H., B. G. Jeong, Y. G. Cho, H. R. Song, and K. A. Kim. 2011. “Socioeconomic Costs of Overweight and Obesity in Korean Adults.” Journal of Korean Medical Science 26 (12): 1533–40. Katzmarzyk, P. T., and I. Janssen. 2004. “The Economic Costs Associated with Physical Inactivity and Obesity in Canada: An Update.” Canadian Journal of Applied Physiology 29: 90–115. Konnopka, A., M. Bödemann, and H. H. König. 2011. “Health Burden and Costs of Obesity and Overweight in Germany.” European Journal of Health Economics 12 (4): 345–52. Kosen, S. 2018. “The Economic Burden of Overweight and Obesity Reaches 3% of GDP in Indonesia.” Asia Pathways blog post, February 2. https://www​ .­asiapathways-adbi.org/2018/02/the-economic-burden-of-overweight-and​ -obesity​-in-indonesia/. Kuzawa, C., P. C. Hallal, L. Adair, S. K. Bhargava, C. H. Fall, N. Lee, S. A. Norris, C. Osmond, P. M. Ramirez-Zea, H. S. Sachdev, A. D. Stein, and C. G. Victora, and COHORTS Group. 2011. “Birth Weight, Postnatal Weight Gain and Adult Body Composition in Five Low and Middle Income Countries.” American Journal of Human Biology 24 (1): 5–13. Kyle, T. K., E. J. Dhurandhar, and D. B. Allison. 2016. “Regarding Obesity as a Disease: Evolving Policies and Their Implications.” Endocrinology and Metabolism Clinics of North America 45 (3): 511–20. Law, C. M., D. J. Barker, C. Osmond, C. H. Fall, and S. J. Simmonds. 1992. “Early Growth and Abdominal Fatness in Adult Life.” Journal of Epidemiology and Community Health 46 (3): 184–86. LCO (Lancet Commission on Obesity). 2019. Swinburn, B. A., V. I. Kraak, S. Allender, V. J Atkins, P. I. Baker, J. R. Bogard, H. Brinsden, A. Calvillo, O. De Schutter, R. Devarajan, M. Ezzati, S. Friel, S. Goenka, R. A. Hammond, G. Hastings, C. Hawkes, M. Herrero, P. S. Hovmand, M. Howden, L. M. Jaacks, A. B. Kapetanaki, M. Kasman, H. V. Kuhnlein, S. K. Kumanyika, B. Larijani, T. Lobstein, M. W. Long, V. K. R. Matsudo, S. D. H. Mills, G. Morgan, A. Morshed, P. M. Nece, A. Pan, D. W. Patterson, G. Sacks, M. Shekar, G. L. Simmons, W. Smit, A. Tootee, S. Vandevijvere, W. E. Waterlander, L. Wolfenden, and W. H. Dietz. 2019. “The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission Report.” The Lancet 393 (10173): 791–846. https://www.thelancet.com/commissions​ /­global-syndemic. Lehnert, T., P. Streltchenia, A. Konnopka, S. G. Riedel-Heller, and H.-H. Konig. 2015. “Health Burden and Costs of Obesity and Overweight in Germany: An Update.” European Journal of Health Economics 16: 957–67. Lobstein, T., H. Brinsden, T. Gill, S. Kumanyika, and B. Swinburn. 2017. “Comment: Obesity as a Disease – Some Implications for the World Obesity Federation’s Advocacy and Public Health Activities.” Obesity Reviews 18 (7): 724–26. 92 | Obesity Martin-Rodriguez, E., F. Guillen-Grima, A. Martí, and A. Brugos-Larumbe. 2015. “Comorbidity Associated with Obesity in a Large Population: The APNA Study.” Obesity Research and Clinical Practice 9 (5): 435–47. Monteiro, C. A., J. C. Moubarac, G. Cannon, S. W. Ng, and B. Popkin. 2013. “Ultra- Processed Products Are Becoming Dominant in the Global Food System.” Obesity Reviews 14 (S2): 21–28. Ng, S. W., E. C. Norton, D. K. Guilkey, and B. M. Popkin. 2012. “Estimation of a Dynamic Model of Weight.” Empirical Economics 42 (2): 413–43. Ng, S. W., E. C. Norton, and B. M. Popkin. 2009. “Why Have Physical Activity Levels Declined among Chinese Adults? Findings from the 1991–2006 China Health and Nutrition Surveys.” Social Science and Medicine 68 (7): 1305–14. Ng, S. W., and B. M. Popkin. 2012. “Time Use and Physical Activity: A Shift Away from Movement across the Globe.” Obesity Reviews 13 (8): 659–80. Popkin, B. M. 2008. The World Is Fat: The Fads, Trends, Policies, and Products That Are Fattening the Human Race. New York: Avery-Penguin Group. ———. 2011. “Agricultural Policies, Food and Public Health.” EMBO Reports 12 (1): 11–18. ———. 2014. “Nutrition, Agriculture and the Global Food System in Low and Middle Income Countries.” Food Policy 47: 91–96. Popkin, B. M., S. Kim, E. R. Rusev, S. Du, and C. Zizza. 2006. “Measuring the Full Economic Costs of Diet, Physical Activity and Obesity-Related Chronic Diseases.” Obesity Reviews 7: 271–93. Popkin, B. M., and T. Reardon. 2018. “Obesity and the Food System Transformation in Latin America.” Obesity Reviews 19 (8): 1028–64. Pries, A. M., A. M. Rehman, S. Filteau, N. Sharma, A. Upadhyay, and E. L. Ferguson. 2019. “Unhealthy Snack Food and Beverage Consumption Is Associated with Lower Dietary Adequacy and Length-for-Age z-Scores among 12–23-Month- Olds in Kathmandu Valley, Nepal.” Journal of Nutrition 149 (10): 1843–51. Qin, X., and J. Pan. 2016. “The Medical Cost Attributable to Obesity and Overweight in China: Estimation Based on Longitudinal Surveys.” Health Economics 25 (10): 1291–311. Reardon, T., C. P. Timmer, C. B. Barrett, and J. A. Berdegue. 2003. “The Rise of Supermarkets in Africa, Asia, and Latin America.” American Journal of Agricultural Economics 85: 1140–46. Roester, N. 2017. “Global Savory Snack Market Ripe for Growth.” Food Business News, April 7. https://www.foodbusinessnews.net/articles/9167-global-savory​ -snack-market-ripe-for-growth. Rtveladze, K., T. Marsh, L. Webber, F. Kilpi, D. Levy, W. Conde, K. McPherson, and M. Brown. 2013. “Health and Economic Burden of Obesity in Brazil.” PLOS ONE 8 (7): e68785. Seabrook, J. 2011. “Snacks for a Fat Planet: PepsiCo Takes Stock of the Obesity Epidemic.” The New Yorker. May 16. Song, H. J., J. Hwang, S. Pi, S. Ahn, Y. Heo, S. Park, and J.-W. Kwon. 2018. “The Impact of Obesity and Overweight on Medical Expenditures and Disease Incidence in Korea from 2002 to 2013.” PLOS ONE 13 (5): e0197057. Springmann, M., M. Clark, D. Mason-D’Croz, K. Wiebe, B. L. Bodirsky, L. Lassaletta, W. de Vries, S. J. Vermeulen, M. Herrero, K. M. Carlson, M. Jonell, M. Troell, F. DeClerck, L. J. Gordon, R. Zurayk, P. Scarborough, M. Rayner, B. Loken, Health and Economic Impacts of Overweight/Obesity | 93 J. Fanzo, H. C. J. Godfray, D. Tilman, J. Rockström, and W. Willett. 2018. “Options for Keeping the Food System within Environmental Limits.” Nature 562 (7728): 519–25. Stein, A. D., M. Wang, R. Martorell, S. A. Norris, L. S. Adair, I. Bas, H. S. Sachdev, S. K. Bhargava, C. H. Fall, D. P. Gigante, and C. G. Victora. 2010. “Growth Patterns in Early Childhood and Final Attained Stature: Data from Five Birth Cohorts from Low- and Middle-Income Countries.” American Journal of Human Biology 22 (3): 353–59. Swedish Council on Technology Assessment in Health Care. 2002. “Obesity – Problems and Interventions: A Systematic Review.” http://www.sbu.se/upload​ /Publikationer/Content0/1/obesity_2002/obsesityslut.pdf. Timmer, C. P., and H. Alderman. 1979. “Estimating Consumption Parameters for Food Policy Analysis.” American Journal of Agricultural Economics 61 (5): 982–87. Tremmel, M., U. G. Gerdthan, P. M. Nilsson, and S. Saha. 2017. “Economic Burden of Obesity: A Systematic Literature Review.” International Journal of Environmental Research and Public Health 14 (4): 435. Tschirley, D., T. Reardon, M. Dolislager, and J. Snyder. 2015. “The Rise of a Middle Class in East and Southern Africa: Implications for Food System Transformation.” Journal of International Development 27 (5): 628–46. Vazquez-Sanchez, R., and J., Lam. 2002. “Obesity Costs Reach 7% of Total Health Care Expenses.” Revista Española de Salud Pública 1 (3): 40–42. Victora, C. G., L. Adair, C. Fall, P. C. Hallal, R. Martorell, L. Richter, and H. S. Sachdev. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” The Lancet 371 (9609): 340–57. Wang, Z., F. Zhai, B. Zhang, and B. M. Popkin. 2012. “Trends in Chinese Snacking Behaviors and Patterns and the Social-Demographic Role between 1991 and 2009.” Asia Pacific Journal of Clinical Nutrition 21 (2): 253–62. Waters, H., and M. Graf. 2018. America’s Obesity Crisis: The Health and Economic Costs of Excess Weight. Santa Monica, CA: Milken Institute. https://assets1c​ .­milkeninstitute.org/assets​/­Publication/ResearchReport/PDF/Mi-Americas​ -Obesity-Crisis-WEB.pdf. WCRF and AICR (World Cancer Research Fund and American Institute for Cancer Research). 2018. Diet, Nutrition, Physical Activity and Cancer: A Global Perspective (A Summary of the Third Expert Report). Continuous Update Project Expert Report 2018. London: WCRF. https://www.wcrf.org/sites/default/files/Summary​ -third-expert-report.pdf. Wells, J. C. K., R. Wibaek, and M. Poullas. 2018. “The Dual Burden of Malnutrition Increases the Risk of Cesarean Delivery: Evidence From India.” Frontiers in Public Health 6: 292. WHO (World Health Organization) Expert Consultation. 2004. “Appropriate Body- Mass Index for Asian Populations and Its Implications for Policy and Intervention Strategies.” The Lancet 363 (9403): 157–63. WHO Western Pacific Region. 2000. The Asian-Pacific Perspective: Redefining Obesity and Its Treatment. Caulfield, Victoria: International Diabetes Institute. Zhai, F. Y., S. F. Du, Z. H. Wang, J. G. Zhang, W. W. Du, and B. M. Popkin. 2014. “Dynamics of the Chinese Diet and the Role of Urbanicity, 1991–2011.” Obesity Reviews 15: 16–26. 4 Factors Affecting Overweight/Obesity Prevalence Barry Popkin, Julia Dayton Eberwein, and Kyoko Shibata Okamura Key Messages • Three sets of factors can affect overweight/obesity: (1) early life undernutrition and reduced linear growth, (2) reduced energy expen- diture through changes in technology and lifestyles in all phases of life, and (3) a set of factors linked to changing food systems and the resultant shifts in food consumption and eating behaviors. • Urbanization has been a major global factor affecting overweight/ obesity because of the confluence of changes wrought by urban liv- ing that affect both diet and activity ­ patterns. • Globalization—particularly the free trade of services such as modern marketing trade in food products as well as methods of production and retailing—has been another global factor in speeding the growth of ­­overweight/obesity. • Country wealth, as seen in increased national income as well as increased household income, has been linked to higher rates of overweight/obesity. Similarly, greater female labor force participa- ­ tion has played a critical role in the shift toward greater consumption of convenient, time-saving, ultra-processed ­ food. 95 96 | Obesity • Modern food retail and food service systems are growing rapidly in low- and middle-income ­ countries. Around the world, more television ads are placed for unhealthy foods and drinks than for healthy ones, especially during children’s peak viewing times. ­ Further, marketers now have much more tools, such as mobile, viral, and social media, to target young audiences. With these modern systems and aggressive marketing come rapid increases in consumption of ultra-processed foods, shown to be highly ­ obesogenic. Increased consumption of ultra-processed foods may be one of the major global factors affect- ing overweight/obesity ­ today. • At the individual level, lifestyle changes and modern energy-saving technologies—in the home, in the workplace, in the use of personal cars and motorcycles as a mode of transportation, and through modern urban design—have significantly reduced physical ­ activity. Reduced physical activity and increased sedentary behavior likely represent the most important causes of the rapid overweight/obe- sity increases that occurred between 1990 and 2010 in most low- and middle-income ­countries. Figure 4.1 Factors Affecting Overweight/Obesity: A Conceptual Framework COUNTRY WEALTH INDIRECT FACTORS URBANIZATION FOOD SYSTEMS DIET PHYSICAL ACTIVITY DIRECT FACTORS BUILT ENVIRONMENT TRADE LIBERALIZATION EARLY LIFE NUTRITION AND GENETICS SOCIAL AND CULTURAL NORMS TECHNOLOGY The key factors affecting overweight/obesity as laid out in the conceptual chapter. framework (figure 4.1) are discussed in depth in this ­ Factors Affecting Overweight/Obesity Prevalence | 97 Global Factors Associated with Increased Overweight/Obesity An array of studies and reviews has repeatedly found that overweight and obesity are linked closely to urbanization and the globalization of access to goods and services and modern ­ technologies. One of the first major docu- ments concerned with the global situation was a World Health Organization (WHO) report addressing the obesity epidemic in 2000, followed by the sec- ond report in 2002 (WHO 2000; Joint WHO/FAO Expert Consultation 2002). These represent the beginning of global recognition of this rapid increase in overweight/obesity in all c ­ ountries. Most of the increase in over- weight/obesity in low- and ­ middle-income countries’ occurred in urban areas, so this was a major focus of research and policy discussions (Popkin 1999). The literature on urbanization is vast, with documentation of major shifts in activity patterns, access to modern food supply, and new lifestyles (Jones-Smith and Popkin 2010; Monda ­ et al. 2007; Popkin 1999; Popkin and Reardon 2018). Globalization was a second major factor, and included open access to modern technologies affecting both activity and dietary pat- terns (Clark ­et al. 2012; Hawkes and Thow 2008; Thow and Hawkes 2009).­ Urbanization. The urbanization literature shows that a confluence of components that define urbanization—modern transportation, more ser- vice sector jobs, access to modern technology in factories, modern commu- nications, water and public infrastructure, housing, higher wages, increased food services, and modern food retailing—has created an environment conducive to ­overweight/obesity. Extensive research has shown that urban areas have had and continue to have higher overweight/obesity levels, among both adults and children (Neuman e ­ t al. 2013). This is predicted to shift in the future according to the recent report by the NCD Risk Factor Collaboration showing that faster rates of increase in adult BMI have been seen in rural areas than in urban ones in all regions except in Sub-Saharan Africa (NCD-RisC 2019). Globalization. The globalization and trade literature is much less focused (Bogin ­ et al. 2014; Fox, Feng, and Asal 2019; Popkin 2006; Reardon, Stamoulis, and Pingali 2007; Snowdon and Thow 2013; Thow 2009; Thow and Hawkes 2009; Wilkinson 2004). Globalization is very much repre- sented by the increased flow of goods (for example, food retailers selling ultra-processed food), services, and technology, all of which are discussed ­ below. In some ways, the impact of urbanization showed the initial effects of globalization on ­ overweight/obesity. The other effects of globalization are covered by many of the factors noted b ­ elow, ranging from the popula- tion’s access to the modern food sector to technology affecting all aspects of 98 | Obesity activity and modern food marketing as well as media penetration in every low- and middle-income ­country. Country ­wealth. Many studies using a variety of data have shown how country wealth is related to higher body mass index and overweight/­ obesity (Masood and Reidpath 2017). At the same time, an array of stud- ies show that, as country wealth increases, there are more rural poor than urban poor and the likelihood that overweight prevalence is greater among the poor than the rich increases (Jaacks, Slining, and Popkin 2015; Jones-Smith e ­ t al. 2011, 2012a, 2012b; NCD-RisC 2019; Popkin and Slining 2013). Modern food retail ­ sector. A substantial factor affecting overweight/­ obesity has been a major shift in the type of food and beverages sold by retailers including ready-to-eat, ready-to-heat, processed and packaged et al. 2015). The past 60 years have seen a revolution in food sci- food (Poti ­ ence and in the manufacturing of highly processed foods, increasingly labeled ultra-­processed foods in the ­ literature. The proportion of calories obtained from these foods—which are full of additives that enhance flavors and scents and are high in added saturated fat, added sugar, and added salt—has shown explosive growth first in the 1970 to 2000 period in high- income countries, then in Latin America in the 1990s with modern retail- ing, and now across all remaining low- and middle-income countries (Monteiro ­ et al. 2013; Monteiro ­ et al. 2017; Popkin and Reardon 2018). Over the past 25 years, the availability and sales of these same ultra-­ processed foods have exploded across all low- and middle-income countries and all regions of the world; a growing set of studies is measuring this ­ shift. More profoundly, there is now a solid and growing link between the shift from real foods to these ultra-processed foods and their effects on over- weight/obesity as well as on many diet-related N ­ CDs. A recent randomized controlled trial by a team of U.S. National Institutes of Health researchers, with a cross-over design where each person was his/her own control, showed that normal-weight adults fed a real food diet and then a diet com- posed of ultra-­processed foods lost 0.9 kilograms in two weeks when fed the real food but gained 2.1 kilograms when fed the ultra-­ processed ­diet. Each group started with one diet regimen and then shifted to the other (Hall 2019). This work was further amplified by several papers in the British Medical Journal that looked at two large European cohorts and showed a strong positive relation between ultra-­ processed foods and cardiovascular disease and all-cause mortality (Lawrence and Baker 2019; Rico-Campà et al. 2019; Srour ­ ­ et al. 2019). There are now studies documenting the rapid growth of these ultra-processed foods in all continents among almost all low- and middle-income ­ countries. It is the rapid growth of the sales of Factors Affecting Overweight/Obesity Prevalence | 99 these foods in low- and middle-income countries that greatly threatens to increase overweight/obesity as well as undernutrition because infants are products. We are beginning to see the emer- increasingly being fed these ­ gence of studies that associate these same ultra-processed foods with reduced length-for-age (Pries ­ et al. 2019). Lifestyle ­changes. A series of changes in technology and transportation infrastructure affect individual physical activity patterns and have led to massive declines in physical activity as noted ­ below. At the same time, shifts in female labor force participation and modern food sector market- ing have all combined to shift diets toward ready-to-eat or ready-to-heat convenient ultra-processed f ­oods. The following sections provide back- ground on these lifestyle changes and their i ­mpact. Together all these fac- tors have profoundly affected social and cultural norms, including food norms, globally. Technological ­change. The literature on the economic factors linked to overweight/obesity touches briefly on the role that technology plays in affecting its prevalence, but technology as an economic driver has been so depth. critical a causal factor that it is important to explore it in greater ­ Most of the weight changes over the past three decades in low- and ­ middle-income countries were driven first by reductions in physical activity. Technology has reduced occupation-related energy expenditure, ­ has caused an increase in ready-to-eat food, has reduced cooking and food preparation time (for example, with rice cookers, kerosene stoves), and has reduced the need for physical activity in the home (for example, tech- nology has provided piped-in water, refrigerators, washing machines) (Monda ­ et al. 2008; Monda and Popkin 2005). For instance, the risk of overweight/obesity in China has more than doubled in relation to the decline in energy expenditure in each occupation; similarly, overall declines in market work–related physical activity have also been docu- mented to be very significant not only in China but also in Brazil (Bell, Ge, and Popkin 2001; Ng ­ et al. 2012). Transportation infrastructure and d ­ esign. Equally important has been a global shift in transportation-related physical activity as a result of mod- ern technology: individuals have shifted from walking and biking toward using modes of motorized ­ transportation. For example, the addition of personal cars and motorcycles to an economy (as in China) is associated with two times the overweight risk (Bell, Ge, and Popkin 2001). There has also been an increase in sedentary time, personified, again in China, by the child who spends much of his or her time watching television, studying, or playing computer games, and who experiences minimal physical activity 100 | Obesity (Dearth-Wesley e ­ t al. 2017). Technology-driven changes to occupation- and transportation-based physical activity, as well as increased sedentary time, have led to a remarkable decline that represents over half of the energy expenditure in many low- and middle-income countries (Dearth- Wesley ­ et al. 2017; Ng and Popkin 2012). Income and female labor force p ­ articipation. Two other major fac- tors are increased income and greater female market labor force participation. The former is very much linked to the shift from higher ­ overweight/obesity among higher socioeconomic status subpopulations to those with lower socioeconomic status (Jones-Smith e ­t al. 2011, 2012­b). These income effects are documented in earlier sections, includ- ing how economic growth has been linked to both rapid increases in access to labor-saving technologies in all domains of life and to modern, time-saving processed packaged f ­oods. Female labor force participation has always been high in low- and middle-income countries, but it has increasingly seen improved wages and shifts to modern formal employ- ment ­ sectors. Rural nonfarm income earned by women and overall income earnings have greatly shifted the rise in women’s opportunity costs of time, both in rural areas and in urban ones (Popkin and Reardon 2018). That means the demand for convenience foods, such as processed foods, has grown in rural areas just as it has in c ­ ities. The proximity of most rural households to urban areas means that packaged, processed foods are accessible and penetrate rural a ­ reas. This in turn has meant reduced time for food preparation and shopping and increased con- sumption of time-saving packaged processed food, much of which may obesogenic ultra-processed ­ be ­ food. Marketing of ultra-processed ­ food. The WHO and other major health organizations worldwide point to children’s exposure to pervasive, unhealthy food marketing as a significant risk factor for childhood over- weight/obesity (Cairns ­ et al. 2013; CDC 2015; Ebbeling, Pawlak, and Ludwig 2002; Gearhardt ­ et al. 2012; Lobstein ­ et al. 2015; McGinnis, Gootman, and Kraak 2006; Montgomery and Chester 2009; PAHO 2011; Pries et al. 2019; Swinburn e ­ t al. 2011). Foods and drinks are promoted to children more than any other product type and in far greater proportion than to adults (Singh ­et al. 2008). Children are exposed every day to food marketing where they live, learn, and play—on television, at school and sports practice, in stores, at the movies, on mobile devices, and online (Federal Trade Commission 2012; Harris ­ et al. 2009; McGinnis, Gootman, and Kraak 2006; Palmer and Carpenter 2006). In the United States, children ages 2–11 view roughly 13 ads a day for foods, beverages, and ­ restaurants on television, and 12- to 17-year-old adolescents see 16.5 (Dembek, Harris, and Schwartz 2014). A 2019 study of television Factors Affecting Overweight/Obesity Prevalence | 101 advertising in 22 countries around the world found, on average, four times more ads for unhealthy foods and drinks than for healthy ones dur- ing all television viewing times, and 35 percent more unhealthy food ads during children’s peak viewing times (Kelly e ­ t al. 2019). While television has historically been the medium of choice to reach children, marketing via newer online, mobile, viral, and social media has exploded in recent years, offering marketers more tools to target young audiences (Cheyne et al. 2013; Common Sense Media 2014; McGinnis, Gootman, and Kraak ­ 2006; Montgomery and Chester 2009). The majority of promoted food products are calorie dense and nutrient poor, with added sugar, saturated fat, and sodium well above recommended levels (for example, sugary breakfast cereals, soft drinks, candy, salty snacks, and fast foods) (American Heart Association 2016; Cairns e ­ t al. 2013; Federal Trade Commission 2012; Harris ­ et al. 2009; Kelly ­et al. 2010; Matthews 2008; McGinnis, Gootman, and Kraak 2006; Palmer and Carpenter 2006; WHO 2010, 2016). Children are repeatedly exposed to marketing that portrays eating unhealthy foods in unlimited quantities as fun, cool, and exciting, and ultimately having only positive outcomes (Harris, Brownell, and Bargh 2009; Harris ­ et al. 2009). Food, beverage, and restaurant industries spend billions of dollars every year to reach children with targeted marketing, and they spend millions lobbying against laws that might prevent them from doing so, demonstrating the value they see in the child market (Federal Trade Commission 2012; Hawkes 2004, 2007; Matthews 2008; Simon 2006; Wilson and Roberts 2012). Factors Linked to Weight Gain and Overweight/Obesity at the Individual and Community Levels The above analysis lays out the country-level factors that are associated with overweight/obesity across low- and middle-income countries over time. This section draws on prior cohort and longitudinal studies from low- ­ and middle-income countries to detail the causes of overweight and obesity for individuals within ­populations. Evidence shows that three sets of factors can affect overweight/obesity: (1) early life undernutrition and reduced lin- ear growth (see the discussion in chapter 2), (2) reduced energy expendi- ture through changes in technology and lifestyles in all phases of life, and (3) a set of factors linked to changing food systems and the resultant shifts in food consumption and eating b ­ ehaviors. The literature on urbanization, access to modern technology affecting all aspects of energy expenditure, increased income, and greater female labor force participation has been reviewed ­ above. The only area deserving of special attention is the new driver of most weight gain globally, namely the food system ­ dynamics. 102 | Obesity The Role of Changing Diets and Food Systems To summarize where the globe is right now we need to understand that much of the impact of globalization and technology changes in reducing activity has taken place in most countries aside from a select few, mainly in Sub-Saharan Africa and South Asia, while the food system and its effects on diet have become a major global factor linked with increased overweight and obesity in all c­ ountries. While dietary changes—relative to declines in physical activity—may not have explained increases in overweight/obesity in the past (for example, in 1990–2010), the increased availability and consumption of ultra-processed foods and sugar-sweetened beverages, ­ especially ready-to-eat snack foods, explain much of the recent overweight/ obesity increases (2010–present) (Monteiro ­ et al. 2011; Monteiro ­ et al. 2013; Popkin and Hawkes 2015; Popkin and Reardon 2018). It is not only these unhealthy foods and beverages but also the large upsurge in edible oil intake in low- and middle-income countries that represents an additional element of dietary change that has uniquely impacted overweight/obesity prevalence in these contexts (Drewnowski and Popkin 1997). More recently (2000–present), the consumption of vegetable oils in low- and middle-income countries has been linked to the reduced cost of palm oil (Fitzherbert ­et al. 2008). At the same time, shifts away from traditional diets, which are largely composed of staple foods, have impacted over- weight/obesity prevalence in low- and middle-income ­ countries. These dietary issues deserve consideration when identifying and designing future interventions to reduce weight gain because implementing food policies to help people change their dietary choices is much more feasible than mov- ing backward in order to reduce the use of technologies linked to labor, home, and ­ transportation. Two recent World Bank studies laid out many of these challenges to the food system (Htenas, Tanimichi-Hoberg, and Brown 2017; Townsend ­ et al. 2016). Examples at the individual level of the impact of improved access to modern technology for market and home production and transportation globalization. Equally significant represent critical aspects of the effects of ­ has been the spread of modern global and regional food retailers into most low- and middle-income countries and the ways these food retail systems have become a major part of the global transformation of food systems and subsequently ­ diets. Reardon and others have documented across Asia, Africa, and Latin America the ways the World Trade Organization (WTO) and earlier global trade agreements allowed for free movement of food companies and retailers, resulting in the increasingly rapid transformation of global food systems (Hu ­ et al. 2004; Popkin and Reardon 2018; Reardon ­ et al. 2015; Reardon and Berdegué 2002; Reardon, Timmer, and Minten 2012). Factors Affecting Overweight/Obesity Prevalence | 103 Impetus for Action Overall the literature shows that there are three sets of factors affecting overweight/obesity: early life undernutrition and reduced linear growth, reduced energy expenditure due to technological development and lifestyle changes, and shifts in food consumption and eating behaviors driven by changing food systems. Modern shifts in access to labor-saving technology and the resulting decreases in energy expenditure, along with increased food consumption and the consumption, in particular, of ultra-processed foods, have been major forces in the growth of overweight/obesity preva- lence across the ­globe. Although changes in physical ­ activity mostly drove the upsurge in overweight/obesity prevalence in low- and middle-income countries in the earlier periods of the endemic (1990–2010), more recently (2010–present) modern food and retail services, which are the major pur- veyors of ultra-processed foods and beverages, have become critical deter- minants of increased ­overweight/obesity. These shifts in energy expenditure and diet stem from greater country wealth and greater u ­rbanization. Underlying these changes have been rapid increases in urban residency as well as a major shift in the quality of urbanization in terms of access to modern ultra-processed foods and many labor-saving technologies, global movement of goods and services, and economic growth as exemplified by real gross national product per capita, as well as large shifts in female labor force participation and female wages and thus their time ­ costs. As noted above, these economic and social changes were experienced by adults and adolescents much earlier than they were by younger c ­ hildren. In a similar way, changes in energy expenditure, along with the introduc- tion of modern food systems, occurred first in urban ­ areas. Together, these results point out many critical roles that different sectors can play to help prevent the rise of overweight/obesity in future ­generations. Improved physical activity and reduced sedentary behavior are important for health in general as well as important to reducing overweight/obesity; however, most countries must also focus on reducing or stopping the rapid growth of consumption of ultra-processed foods. References American Heart A ­ ssociation. 2016. “Children Should Eat Less than 25 Grams of Added Sugars D ­ aily.” American Heart Association Scientific Statement News Release, August 22. ­ https://newsroom.heart.org/news/children-should-eat​ -less-than​-25­-grams-of-added-sugars-daily. A. ­ Bell, ­ K. Ge, and B C., ­ M. ­ ­. ­ Popkin. 2001. “Weight Gain and Its Predictors in Chinese ­Adults.” International Journal of Obesity and Related Metabolic Disorders 25 (7): 1079–86­ . 104 | Obesity ———. 2002. “The Road to Obesity or the Path to Prevention: Motorized Transportation and Obesity in ­ China.” Obesity Research 10 (4): 277–83. Bogin, ­ B., ­H. Azcorra, ­ H. ­J. Wilson, ­ A. Vázquez-Vázquez, ­ M. ­L. Avila-Escalante, M. T. Castillo-Burguete, I ­ ­. Varela-Silva, and F Dickinson. 2014. “Globalization ­. ­ and Children’s Diets: The Case of Maya of Mexico and Central A ­ merica.” Anthropological Review 77 (1): 11–32. Cairns, ­G., ­K. Angus, G ­ . Hastings, and M ­ .­Caraher. 2013. “Systematic Reviews of the Evidence on the Nature, Extent and Effects of Food Marketing to Children: A Retrospective ­ Summary.” Appetite 62: 209–15. CDC (Centers for Disease Control and P ­ revention). 2015. “Childhood Obesity Causes & ­Consequences.” ­https://www.cdc.gov/obesity/childhood/causes.html. Cheyne, ­ A. ­D., ­L. Dorfman, ­ E. Bukofzer, and ­ L. ­ J. ­ Harris. 2013. “Marketing Sugary Cereals to Children in the Digital Age: A Content Analysis of 17 Child-Targeted ­Websites.” Journal of Health Communication 18 (5): 563–82. Clark, ­ E., ­ S. ­ C. Hawkes, ­ S. ­ M. Murphy, ­ A. Hansen-Kuhn, and ­ K. ­ Wallinga. 2012. D. ­ “Exporting Obesity: US Farm and Trade Policy and the Transformation of the Mexican Consumer Food ­ Environment.” International Journal of Occupational and Environmental Health 18 (1): 53–64.  Common Sense ­ Media. 2014. “Advertising to Children and Teens: Current Practices.” A Common Sense Media Research B ­ ­ rief, Common Sense Media, San Francisco. h ­ttps://www.commonsensemedia.org/research/advertising-to​ -children-and-teens-current-practices. Dearth-Wesley, ­ T., ­ G. Howard, ­ A. ­ H. Wang, ­ B. Zhang, and ­ M. ­ B. ­ Popkin. 2017. “Trends in Domain-Specific Physical Activity and Sedentary Behaviors among Chinese School Children, 2004–2011.” International Journal of Behavioral Nutrition and Physical Activity 14 (1): 141. Dembek, ­ C., ­ L. Harris, and ­ J. ­ M. ­B. ­Schwartz. 2014. “Trends in Television Food Advertising to Young People: 2013 U ­ pdate.” Yale Rudd Center for Food Policy and ­Obesity. ­http://www.uconnruddcenter.org/resources/upload/docs/what​ /­reports/RuddReport_TVFoodAdvertising_6.14.pdf. Drewnowski, ­ A., and ­ M. ­ B. ­ Popkin. 1997. “The Nutrition Transition: New Trends in the Global ­ Diet.” Nutrition Reviews 55 (2): 31–43. Ebbeling, ­ B., ­ C. ­ D. ­B. Pawlak, and ­ S. ­ D. ­ Ludwig. 2002. “Childhood Obesity: Public- Health Crisis, Common Sense ­ Cure.” The Lancet 360 (9331): 473–82. Federal Trade C ­ ommission. 2012. A Review of Food Marketing to Children and Adolescents: Follow-Up ­Report. Washington, DC: Federal Trade ­ Commission. ­ https://www.ftc​ .gov/sites/default/files/documents/reports/review-food-marketing-children​ -and-adolescents-follow-report/121221­foodmarketingreport.pdf. Fitzherbert, ­ E. ­ M. ­ B., ­ J. Struebig, ­ A. Morel, ­ F. Danielsen, ­ A. Brühl, ­ C. ­ F. Donald, P. ­ and ­ B. ­Halan. 2008. “How Will Oil Palm Expansion Affect Biodiversity?” Trends in Ecology and Evolution 23 (10): 538–45. Fox, ­ A., ­W. Feng, and ­ V. ­Asal. 2019. “What Is Driving Global Obesity Trends? Globalization or ‘Modernization’?” Globalization and Health 15 (1): 32. Gearhardt, ­ A. ­ N., ­ M. ­A. Bragg, R ­. ­ L. Pearl, N ­. ­ A. Schvey, C A. Roberto, and ­. ­ K. D. Brownell. 2012. “Obesity and Public P ­ ­ olicy.” Annual Review of Clinical Psychology 8: 405–30. Factors Affecting Overweight/Obesity Prevalence | 105 Hall, K ­.­ D. 2019. “Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: A One-Month Inpatient Randomized Controlled Trial of Ad Libitum Food ­ Intake.” NutriXiv ­ Preprints. Febrary 11. ­ https://osf.io/preprints/nutrixiv​ /­w3zh2. Harris, ­ L., ­ J. ­ K. ­ D. Brownell, and ­ A. ­ J. ­ Bargh. 2009. “The Food Marketing Defense Model: Integrating Psychological Research to Protect Youth and Inform Public ­Policy.” Social Issues and Policy Review 3 (1): 211–71. Harris, ­ J. ­L., ­ J. ­ L. Pomeranz, ­ T. Lobstein, and ­ D. ­ K. ­ Brownell. 2009. “A Crisis in the Marketplace: How Food Marketing Contributes to Childhood Obesity and What Can Be ­ Done.” Annual Review of Public Health 30: 211–25. Hawkes, ­ C. 2004. “Marketing Food to C ­ hildren.” The Regulatory F ­ramework. World Health Organization, Geneva. ———. 2007. “Regulating and Litigating in the Public Interest: Regulating Food Marketing to Young People Worldwide: Trends and Policy D ­ rivers.” American Journal of Public Health 97 (11): 1962–73. Hawkes, ­ C. and A ­.­Thow. 2008. “Implications of the Central America-Dominican Republic-Free Trade Agreement for the Nutrition Transition in Central ­America.” Revista Panamericana de Salud Pública 24 (5): 345–60. Htenas, ­ A. ­ M., ­Y. Tanimichi-Hoberg, and L ­. ­Brown. 2017. An Overview of Links between Obesity and Food Systems: Implications for the Agriculture GP A ­ genda. Washington, DC: World Bank ­ Group. Hu, ­D., ­ T. Reardon, ­ P. Timmer, and ­ S. Rozelle, ­ Wang. 2004. “The Emergence of H. ­ Supermarkets with Chinese Characteristics: Challenges and Opportunities for China’s Agricultural ­ Development.” Development Policy Review 22: 557–86. Jaacks, ­ L. ­M., ­M. ­M. Slining, and ­ B. ­M. ­Popkin. 2015. “Recent Underweight and Overweight Trends by Rural-Urban Residence among Women in Low- and Middle-Income ­Countries.” Journal of Nutrition 145 (2): 352–57. Joint WHO/FAO Expert ­ Consultation. 2002. Diet, Nutrition and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert ­ Consultation. Geneva: ­WHO. Jones-Smith, ­ C., ­ J. ­ P. Gordon-Larsen, ­ A. Siddiqi, and B ­.­ Popkin. 2011. “Cross- M. ­ National Comparisons of Time Trends in Overweight Inequality by Socioeconomic Status among Women Using Repeated Cross-Sectional Surveys from 37 Developing Countries, 1989–2007.” American Journal of Epidemiology 173 (6): 667–75­ . ———. 2012­ a. “Emerging Disparities in Overweight by Educational Attainment in Chinese Adults (1989–2006).” International Journal of Obesity 36 (6): 866–75­ .  ———. 2012­ b. “Is the Burden of Overweight Shifting to the Poor across the Globe? Time Trends among Women in 39 Low- and Middle-Income Countries (1991–2008).” International Journal of Obesity 36 (8): 1114–20. Jones-Smith, ­ C., and ­ J. ­ M. ­ B. ­ Popkin. 2010. “Understanding Community Context and Adult Health Changes in China: Development of an Urbanicity ­ Scale.” Social Science and Medicine 71 (8): 1436–46. Kelly, ­ B., ­ C. Halford, ­ J. ­ E. ­ J. Boyland, ­ K. Chapman, ­ I. Bautista-Castaño, ­C. Berg, M. Caroli, ­ ­ B. Cook, ­ G. Coutinho, and T J. ­ ­. ­Effertz. 2010. “Television Food Advertising to Children: A Global P ­ erspective.” American Journal of Public Health 100 (9): 1730–36. 106 | Obesity Kelly, B S. Vandevijvere, ­ ­ ., ­ S. Ng, ­ J. Adams, ­ L. Allemandi, ­ L. Bahena-Espina, S. Barquera, ­ ­ E. Boyland, ­ P. Calleja, and ­ C. ­ I. ­ Carmona-Garcés. 2019. “Global Benchmarking of Children’s Exposure to Television Advertising of Unhealthy Foods and Beverages across 22 ­ Countries.” Obesity ­Reviews. ­https://doi​ .org/10.1111­/obr.12840. Lawrence, ­ M. ­ A., and ­ I. ­ P. ­ Baker. 2019. “Ultra-Processed Food and Adverse Health ­Outcomes.” BMJ 365: l2289. Lobstein, ­ R. Jackson-Leach, ­ T., ­ M. ­L. Moodie, ­ K. ­ D. Hall, ­ S. ­L. Gortmaker, ­ A. B. ­ Swinburn, ­ W. ­ T. James, ­ P. ­ Y. Wang, and ­ K. ­McPherson. 2015. “Child and Adolescent Obesity: Part of a Bigger ­ Picture.” The Lancet 385 (9986): 2510–20. Masood, ­ M., and ­ D. ­ D. ­Reidpath. 2017. “Effect of National Wealth on BMI: An Analysis of 206,266 Individuals in 70 Low-, Middle- and High-Income ­Countries.” PLOS ONE 12 (6): e0178928-e0178928. Matthews, ­ A. ­E. 2008. “Children and Obesity: A Pan-European Project Examining the Role of Food ­ Marketing.” European Journal of Public Health 18 (1): 7–11. McGinnis, ­ M., ­ J. ­ A. Gootman, and ­ J. ­ I. ­ V. ­ Kraak. 2006. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: National Academies ­ Press. Monda, ­ K. ­ L., ­ L. ­ S. Adair, F ­. Zhai, and B ­. ­ M. ­ Popkin. 2008. “Longitudinal Relationships between Occupational and Domestic Physical Activity Patterns and Body Weight in ­ China.” European Journal of Clinical Nutrition 62: 1318–25. Monda, ­ K. ­L., ­P. Gordon-Larsen, ­ J. Stevens, and ­ M. ­ B. ­ Popkin. 2007. “China’s Transition: The Effect of Rapid Urbanization on Adult Occupational Physical ­Activity.” Social Science and Medicine 64 (4): 858–70. Monda, ­ K. ­L., and ­ B. ­M. ­Popkin. 2005. “Cluster Analysis Methods Help to Clarify the Activity-BMI Relationship of Chinese ­ Youth.” Obesity Research 13 (6): 1042–51. Monteiro, ­ C. ­ A., ­R. ­ B. Levy, ­ R. ­ M. Claro, ­ R. de Castro, and ­ I. ­ G. ­ Cannon. 2011. “Increasing Consumption of Ultra-Processed Foods and Likely Impact on Human Health: Evidence from ­ Brazil.” Public Health Nutrition 14 (1): 5–13. Monteiro, ­ C. ­A., ­ C. Moubarac, G J. ­ ­ . Cannon, S ­.­W. Ng, and B Popkin. 2013. “Ultra- ­ .­ Processed Products Are Becoming Dominant in the Global Food S ­ystem.” Obesity Reviews 14 (S2): 21–28. Monteiro, ­ C. ­A., ­J.-C. Moubarac, ­ B. Levy, ­ R. ­ D. ­ S. Canella, ­M. ­ d. ­ L. ­ C. Louzada, and ­ G. ­ Cannon. 2017. “Household Availability of Ultra-Processed Foods and Obesity in Nineteen European ­ Countries.” Public Health Nutrition 21 (1): 18–26. Montgomery, ­ K. ­C., and J ­.­Chester. 2009. “Interactive Food and Beverage Marketing: Targeting Adolescents in the Digital A ­ ge.” Journal of Adolescent Health 45 (3 Suppl): S18–29. NCD-RisC (NCD Risk Factor ­ Collaboration). 2019. “Rising Rural Body-Mass Index Is the Main Driver of the Global Obesity Epidemic in ­ Adults.” Nature 569 (7755): 260–64.  Neuman, ­ M., ­ I. Kawachi, S ­ . Gortmaker, and S ­. ­V. ­Subramanian. 2013. “Urban- Rural Differences in BMI in Low- and Middle-Income Countries: The Role of Socioeconomic ­Status.” American Journal of Clinical Nutrition 97 (2): 428–36.  S. ­ Ng, ­ W., ­E. ­ C. Norton, ­ D. ­K. Guilkey, and ­ B. ­M. ­ Popkin. 2012. “Estimation of a Dynamic Model of ­ Weight.” Empirical Economics 42 (2): 413–43. S. ­ Ng, ­ W., and ­ M. ­ B. ­ Popkin. 2012. “Time Use and Physical Activity: A Shift Away from Movement across the ­ Globe.” Obesity Reviews 13 (8): 659–80. Factors Affecting Overweight/Obesity Prevalence | 107 PAHO (Pan American Health ­ Organization). 2011. Recommendations from a Pan American Health Organization Expert Consultation on the Marketing of Food and Non- Alcoholic Beverages to Children in the ­ Americas. Washington, DC: ­ PAHO. Palmer, ­ E., and ­ Carpenter. 2006. “Food and Beverage Marketing to Children and C. ­ Youth: Trends and ­ Issues.” Media Psychology 8 (2): 165–90. Popkin, ­ M. 1999. “Urbanization, Lifestyle Changes and the Nutrition ­ B. ­ Transition.” World Development 27: 1905–16­ . ———. 2006. “Technology, Transport, Globalization and the Nutrition ­ Transition.” Food Policy 31 (6): 554–69. Popkin, ­ B. ­M., and ­ C. ­Hawkes. 2015. “Sweetening of the Global Diet, Particularly Beverages: Patterns, Trends, and Policy R ­ esponses.” The Lancet Diabetes and Endocrinology 4 (2): 174–86. Popkin, ­ M., and ­ B. ­ Reardon. 2018. “Obesity and the Food System Transformation T. ­ in Latin ­ America.” Obesity Reviews 19 (8): 1028–64. Popkin, ­ B. ­M., and ­ M. ­ Slining. 2013. “New Dynamics in Global Obesity Facing M. ­ Low- and Middle-Income ­ Countries.” Obesity Reviews 14 (Suppl 2): 11–20. J. ­ Poti, ­ M., ­ M. ­ A. Mendez, ­ S. ­ W. Ng, and ­ B. ­M. ­Popkin. 2015. “Is the Degree of Food Processing and Convenience Linked with the Nutritional Quality of Foods Purchased by US Households?” American Journal of Clinical Nutrition 99 (1): 162–71.  Pries, ­ M., ­ A. ­ M. Rehman, ­ A. ­ S. Filteau, ­ N. Sharma, ­ A. Upadhyay, and ­ L. ­ E. ­ Ferguson. 2019. “Unhealthy Snack Food and Beverage Consumption Is Associated with Lower Dietary Adequacy and Length-for-Age z-Scores among 12–23-Month- Olds in Kathmandu Valley, ­ Nepal.” Journal of N ­ utrition. ­https://doi.org/10.1093​ /jn/nxz140. Reardon, ­ T., and ­ J. ­ Berdegué. 2002. “The Rapid Rise of Supermarkets in Latin America: Challenges and Opportunities for ­ Development.” Development Policy Review 20 (4): 317–34. Reardon, ­ T., ­ K. Stamoulis, and ­ Pingali. 2007. “Rural Nonfarm Employment in P. ­ Developing Countries in an Era of ­ Globalization.” Agricultural Economics 37 (s1): 173–83. Reardon, ­ T., ­ C. Timmer, and ­ B. ­Minten. 2012. “The Supermarket Revolution in Asia and Emerging Development Strategies to Include Small F ­armers.” Proceedings of the National Academy of Sciences of the United States of America 109 (31): 12332–37. Reardon, ­ D. Tschirley, ­ T., ­ B. Minten, ­ S. Haggblade, ­ S. Liverpool-Tasie, ­ M. Dolislager, and ­ C. ­Ijumba. 2015. “Transformation of African Agrifood Systems in the New Era of Rapid Urbanization and the Emergence of a Middle ­ Class.” In Beyond a Middle Income Africa: Transforming African Economies for Sustained Growth with Rising Employment and Incomes, edited by ­O. Badiane and ­T. ­Makombe. Chapter 4. ReSAKSS Annual Trends and Outlook Report 2014. Washington, ­ DC: International Food Policy Research Institute ( ­IFPRI). ­ http://ebrary.ifpri.org​ /­cdm/ref/collection/p15738coll2/id/130005. Rico-Campà, ­A., ­M. ­A. Martínez-González, I ­ . Alvarez-Alvarez, R ­ . de Deus Mendonça, ­ C. de la Fuente-Arrillaga, ­ C. Gómez-Donoso, and ­ M. ­ Bes-Rastrollo. 2019. “Association between Consumption of Ultra-Processed Foods and All Cause Mortality: SUN Prospective Cohort ­ Study.” British Medical Journal 365: l1949. 108 | Obesity Simon, M ­ . 2006. “Can Food Companies Be Trusted to Self-Regulate: An Analysis of Corporate Lobbying and Deception to Undermine Children’s H ­ ealth.” Loyola of Los Angeles Law Review 39: 169. Singh, ­ A. ­ C. Mulder, ­ S., ­ J. ­ W. Twisk, ­W. van Mechelen, and M ­ .­ Chinapaw. 2008. J. ­ “Tracking of Childhood Overweight into Adulthood: A Systematic Review of the ­Literature.” Obesity Reviews 9 (5): 474–88. Snowdon, ­ W., and ­ M. ­ A. ­ Thow. 2013. “Trade Policy and Obesity Prevention: Challenges and Innovation in the Pacific ­ Islands.” Obesity Reviews 14: 150–58. Srour, ­ B., ­ K. Fezeu, ­ L. ­ E. Kesse-Guyot, ­ C. Méjean, ­ B. Allès, ­ R. ­M. Andrianasolo, E. Chazelas, ­ ­ M. Deschasaux, ­ S. Hercberg, and ­ Galan. 2019. “Ultra-Processed P. ­ Food Intake and Risk of Cardiovascular Disease: Prospective Cohort Study ­(NutriNet-Santé).” British Medical Journal 365: l1451. Swinburn, ­ B. ­ G. Sacks, K A., ­ ­ .­ D. Hall, K­ . McPherson, D ­ .­T. Finegood, M ­ .­L. Moodie, and ­ L. ­ S. ­ Gortmaker. 2011. “The Global Obesity Pandemic: Shaped by Global Drivers and Local ­ Environments.” The Lancet 378 (9793): 804–14. Thow, ­ A. ­M. 2009. “Trade Liberalisation and the Nutrition Transition: Mapping the Pathways for Public Health N ­ utritionists.” Public Health Nutrition 12 (11): 2150–58. Thow, ­ A. ­M. and ­ C. ­Hawkes. 2009. “The Implications of Trade Liberalization for Diet and Health: A Case Study from Central ­ America.” Global Health 5: 5. Townsend, ­ S. ­ R., ­ M. Jaffee, Y. Hoberg-Tanimichi, ­ A. ­M. Htenas, ­ M. Shekar, ­ Z. Hyder, M. Gautam, H ­ A. Kray, ­ ­ .­ L. Ronchi, ­ S. Hussain, L ­.­ K. Elder, and E. ­Moses. 2016. The Future of Food: Shaping the Global Food System to Deliver Improved Nutrition and ­Health. Washington, DC: World ­ Bank. WHO (World Health ­ Organization). 2000. Obesity: Preventing and Managing the Global Epidemic. Report of a WHO ­ ­ Consultation. Geneva: ­ WHO.  ———. 2010. Set of Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to ­ Children. Geneva: ­ WHO. ———. 2016. Consideration of the Evidence on Childhood Obesity for the Commission on Ending Childhood Obesity: Report of the Ad Hoc Working Group on Science and Evidence for Ending Childhood ­ Obesity. Geneva: ­ WHO. Wilkinson, ­ J. 2004. “The Food Processing Industry, Globalization and Developing ­Countries.” Electronic Journal of Agricultural and Development Economics 1(2): 184–201. Wilson, ­ D., and ­ J. ­Roberts. 2012. “Special Report: How Washington Went Soft on Childhood ­ Obesity.” Reuters Special Reports, April 27, 2012. h ­ ttps://www​ .reuters.com/article/us-usa-foodlobby/special-report-how-washington-went​ -soft-on-childhood-obesity-idUSBRE83Q0ED20120427. 5 Addressing Overweight/ Obesity: Lessons for Future Actions Barry Popkin, Pia Schneider, and Meera Shekar Key Messages • Fiscal policies linked mainly to sugar-sweetened beverage (SSB) taxes but also, in selected countries, ultra-processed foods have been seen as key areas for intervention. Major efforts are starting in a number of countries around food marketing at the media, retail, and product level (via front-of-package food labeling and p­ rofiling). • Front-of-package labeling and related nutrition profiling models with warning labels show great promise for helping to shift con- sumption away from ultra-processed foods and ­ beverages. • There is now extensive global experience in designing taxation on SSBs, albeit taxation on other unhealthy foods such as ultra-­ processed foods has yet to become ­ mainstream. • Diet-related taxes remain a promising approach, although they will challenges. The main challenges to the successful implementa- face ­ tion of these taxes are a tax system’s administrative capacity, 1 This chapter draws on lessons learned from nine case studies, conducted by the World Bank Health, Nutrition and Population teams, of country-level experiences with strategies to reduce overweight/obesity, supplemented with a review of the global ­literature. 109 110 | Obesity substitution effects, tax evasion, and opposition from the food industry. These challenges need to be considered when designing ­ effective tax ­ policies. • Countries with strong tax administrations generally design excise taxes based on nutrient ­ content. Alternatively, taxes on product vol- umes may be easier to implement in countries where tax administra- tion is not so s ­ trong. Tiered tax systems based on sugar consump- tion appear to be another promising ­ approach. And experience suggests that a regional approach to taxation will reduce cross-­ border purchases and prevent tax ­ evasion. • No countries have considered tying diet-based taxes to subsidies for legumes, vegetables, fruits, and other healthful, less obesogenic foods. This might have potential, although the challenges of ear- ­ marking sin taxes for public programs bring even more ­ challenges. One key thrust in many countries is removing SSBs from schools and promoting only healthy beverages to be sold or provided in school feeding ­programs. • To date, no countries have tackled the rapidly growing food ser- vice ­ sector. Nor is there much experience with subsidies for healthier foods or marketing regulation for unhealthy foods, except perhaps what has been learned from the marketing of infant ­formulas. • Experience with physical activity improvements for obesity preven- tion is limited to a handful of countries, mostly in the global north; while these are promising strategies, future efforts need to build in evaluation of large-scale urban or national programs to document their ­impacts. No evaluations equivalent to the Mexican or Chilean rigorous evaluations of their food-related fiscal and regulatory poli- cies yet exist in the physical activity ­ domain. • Concurrent important shifts in urban planning and design are being undertaken. All forms of design that increase physical activity—from ­ building design that makes stairs an attractive option to active transport and urban design to incentivize and enable biking and walking—are ­ important. Aside from climate co-benefits, there is a need to continue to build the case for this sector’s impact on overall ­activity. • The most neglected area is food systems, including sectoral work related to farms, agribusinesses, food retailers, and food service chains as well as street ­ vendors. While there has been much discus- sion on this in  the recent literature, few actionable agendas have been ­ identified. The evidence for programmatic and policy impact remains ­unclear. Addressing Overweight/Obesity: Lessons for Future Actions | 111 Typology of Actions to Prevent Overweight/Obesity The evidence base for preventing overweight/obesity is still emerging; table 5.1 summarizes promising interventions/policies that have the potential to prevent ­ overweight/obesity. These include a range of (1) fis- cal policies such as taxation and subsidies; (2) regulatory policies on mar- keting and advertising; (3) food systems approaches including through food service; (4) education sector policies such as school cafeterias and physical activity in schools; (5) transport and urban design interventions such as mass transit and city and building design; and (6) early childhood nutrition programs that focus on improving breastfeeding rates and reducing stunting among c ­hildren. Unlike many other public health interventions, very few of these policies or interventions have been rigor- ously evaluated (except for early childhood nutrition programs), and they have not been and cannot be tested through randomized controlled trials, and few have undergone systematic reviews because their effectiveness has not yet been demonstrated or carefully ­ documented. Nonetheless, initial assessments, a limited number of systematic reviews, and lessons from several countries suggest that the following policies/interventions are promising, not just for their potential impacts on preventing over- weight/obesity, but also for potential climate c ­ o-benefits. In addition, a series of interventions have been shown to impact undernutrition, such as breastfeeding promotion, that are also triple-duty actions in terms of their impact on undernutrition, overweight, and climate ­ change. Table 5.1 summarizes the suitability of various intervention types (see also table 5.4) in different country ­contexts. Approaches to Reducing Overweight/Obesity It is clear that the reasons for the rapid increases in overweight/obesity across low- and middle-income countries include a combination of major shifts toward reduced physical activity and increased sedentariness as well as shifts in food consumption ­patterns. Reducing excessive weight gain and ultimately reducing future overweight/obesity will require a multisectoral approach. Achieving these goals are critical for achieving the United ­ Nations’ Sustainable Development Goals ­ (SDGs). To date, much of the focus in countries with active overweight/obesity prevention programs has been exclusively on the food sector, in particular on three major spheres of activity: (1) fiscal policies mainly linked to taxa- tion of SSBs, ultra-processed foods, and selected other unhealthy foods and beverages; (2) marketing work focused on two areas: front-of-package food labeling systems and marketing controls both for media that market directly 112 | Obesity Table 5.1 Typology of Interventions Suitable for Low- Middle- High- Intervention income income income type countries countries countries Notes/comments Fiscal policies X X X These policies show the most evidence of impact to ­date. Regulatory X X X These policies show policies growing evidence of impact ­potential. Agriculture/food X X X Limited or no impact systems evaluations on agriculture systems. and food ­ Education sector Marketing controls are policies needed first before education programs can be ­effective. Transport/urban X X Limited or no impact design evaluations on transport shifts and their impact on physical ­activity. Early childhood X These programs have the nutrition strongest evaluation base to programs date but are focused more on the impact on undernutrition—not ­overweight/obesity. and solely to children and, more recently, for broader marketing approaches such as character branding and coverage that is wider than just child-ori- ented media; and (3) programs focused both on school feeding and the marketing and selling of ultra-processed foods in schools and areas around ­schools. Concurrent important shifts in urban planning and design are occurring. All forms of design that increase physical activity—from build- ­ ing design that makes stairs an attractive option to urban design of walk- able city areas; from approaches to incentivize and enable biking and walking to instigating weekend days when driving is banned in major urban areas; and from designing public transport and mass transit systems that provide an alternative to driving to plans that enhance walking and cycling to bus or subway systems—are ­ important, albeit the impact of these strategies has not been studied. Addressing Overweight/Obesity: Lessons for Future Actions | 113 This section reviews the lessons learned from countries that have experi- mented with these ­ approaches. First the focus is on fiscal policies: the area that has seen the most atten- tion ­globally. Fiscal policies are highlighted as being among the most prom- ising tools for governments to create incentives to encourage healthy lifestyles, promote the consumption of healthy products, and provide disin- centives for the consumption of unhealthy ­ products. Fiscal policies include taxes to increase the price of taxed products and subsidies to decrease the price of healthier food for consumers (see table 5.2 for an overview of taxation ­ options). The expectation is that consumers will Table 5.2 Diet-Related Taxes in Five Case Study Areas Country (effective date) Mexico Thailand (2014) Chile Kerala, India (2017) South Africa Excise and (2014) (2016–17) Excise and (2018) Tax type ad valorem Ad valorem Ad valorem ad valorem Excise Tax rates Mexican Raised from Fat tax of Baht 0.1–1.0 Rand 2.1 cents on peso 1 per 13% to 18% 14.5% on per liter per gram for products liter on any for SSBs unhealthy beverage SSB with >4 non- with food sold in with grams of sugar alcoholic >15 grams restaurants >6 grams of per 100 ml drink with of sugar per with brand sugar per (legislation to added sugar 240 ml name or 100 ml increase the (rate inflated trademark 14% of retail tax is currently only after registered price on SSB under 10% inflation consideration) mark hit) After 6 years, rate 8% of price increases to of energy- 5 baht per dense foods liter for with >275 drinks with calories per >10 grams of 100 gramsa sugar per 100 ml beginning in 2023 Price ≈10% ≈3% Unclear Unclear ≈10% pass- preliminary through 6 months’ analysis Sources: Vilar-Compte 2018 (Mexico); Azar 2018 (Chile); Nair and Suresh (Kerala, India, forthcoming); for Thailand and South Africa, case study reports are being prepared by the World ­B ank. Note: ml = milliliters; SSB = Sugar-sweetened ­ beverages. a. Energy-dense foods include snacks, confectionary products, chocolate, puddings, flans, ice cream, candies, and peanut butter. 114 | Obesity react to price changes set by taxes and s ­ubsidies. Both aim to influence consumer behaviors at the point of purchase by encouraging consumers to purchase lower-priced foods and reduce consumption of higher-priced products. It has been estimated that a 10 ­ ­ percent price increase on sugary drinks through a tax would reduce consumption by about 10 ­ percent and lead to a reduction of 20 kilocalories per day (Härkänen et ­ al. 2014). To date, over 40 countries have added diet-related taxes on SSBs and several have also taxed unhealthy foods, with a large number of other countries considering similar ­proposals. The maps of countries with such taxes to date provide some sense of the range and variety of taxes (see maps 5.1–5.4). Few of these taxation approaches have been rigorously evaluated for their impact on prices, food purchases, or dietary intake. Only a select number of these taxes in low- and middle-income countries and high-income coun- tries are being carefully ­ evaluated. Similarly, a government subsidy or a tax exemption policy decreases the price for consumers and can lead to increased consumption and conse- quently increased production to meet higher consumer ­ demand. Subsidized food products often include rice and wheat or foods high in protein, such as pulses. Governments also exempt specific products from value added taxes ­ (VAT) that are levied on goods and s ­ ervices. Not all goods are taxed: medi- cines, milk, bread, and other basic staples are among the goods that tend to Map 5.1 Sugar-Sweetened Beverage Taxes around the World IBRD 44264 | DECEMBER 2019 EUROPE Belgium WESTERN PACIFIC Estonia Brunei Darussalam Finland Cook Islands France Fiji Hungary French Polynesia AMERICAS Ireland Kiribati Barbados Latvia Nauru Bermuda Morocco Palau Chile AFRICA, EASTERN Norway MEDITERRANEAN, Philippines Colombia Portugal AND SOUTHEAST ASIA Samoa Dominica Spain (Catalonia) Bahrain Tonga Mexico St. Helena India Vanuatu Peru U.S. (8 local) United Kingdom Malaysia Maldives Mauritius Saudi Arabia South Africa Sri Lanka Thailand Implemented United Arab Emirates Passed Source: Global Food Research Program, University of North Carolina, ­ http://globalfood​ -researchprogram.web.unc.edu/multi-country-initiative/resources/. Note: The map was created based on the dataset available as of March 2019. Map 5.2 Sugar-Sweetened Beverage Taxes: The Americas IBRD 44267 | DECEMBER 2019 SEATTLE, WA: 1.75 cents per ounce on sugary drinks; exempts diet sodas, milk-based products, and fruit juice. BOULDER, CO: 2 cents per ounce on beverages with Implemented January 2018 added sugars or sweeteners. Implemented July 2017 SAN FRANCISCO, CA: 1 cent per ounce on drinks with added PHILADELPHIA, PA: 1.5 cents per ounce on sugar- and sugar and >25 kcal per 12 oz; applies to syrup and powder artificially-sweetened drinks, including diet soda. concentrates; exempts 100% juice, artificially sweetened Implemented January 2017 beverages, infant formula, milk products, medical drinks, and alcoholic beverages. Implemented January 2018 NAVAJO NATION: 2% junk food tax on “minimal-to-no nutritional value food items,” including SSBs. ALBANY, CA: 1 cent per ounce on drinks with added Implemented April 2015 caloric sweetener; exempts 100% juice, artificially sweetened beverages, infant formula, milk products, medical drinks, and alcoholic beverages. Implemented April 2017 BERKELEY, CA: 1 cent per ounce on sweetened drinks; BERMUDA: 50% import tax on sugar, sugary drinks, candies and exempts meal-replacement and dairy drinks, diet sodas, dilutables; exempts diet sodas, 100% juice, and diet iced teas. 100% fruit juice, and alcohol. Implemented March 2015 Implemented October 2018 OAKLAND, CA: 1 cent per ounce on drinks with added Increases to 75% import tax sugars; exempts 100% juice, artificially sweetened beverages, Implemented April 2019 infant formula, milk products, medical drinks, and alcoholic BARBADOS: 10% excise tax on sugary drinks, including carbonated beverages. Implemented July 2017 soft drinks, juice drinks, and sports drinks; exempts 100% juice, coconut water, and plain milk. Implemented August 2015 MEXICO: 1 peso per liter ($0.05) on all drinks with added sugar, DOMINICA: 10% excise tax on food and drinks with high sugar excluding milks or yogurts. Implemented January 2014 content, including soft drinks and energy drinks. COLOMBIA: VAT on soft drinks now applied as multiphase tax Implemented September 2015 at production, distribution, and commercialization phases of supply chain (previously VAT only applied to production phase). Implemented January 1, 2019 CHILE: 18% ad valorem tax on sugary drinks containing >6.25 g sugar per 100 ml includes all non-alcoholic drinks with added sweeteners; exempts 100% fruit juice PERU: 25% tax (increase from 17%) on non-alcoholic beverages and dairy-based beverages; 10% ad valorem tax on drinks with with ≥6 g sugar per 100 ml; drinks with <6 g sugar per 100 ml, <6.25 g sugar per 100 ml. Implemented October 2014 including bottled waters, remain at 17% tax rate. Implemented May 2018 Implemented Passed Source: Global Food Research Program, University of North Carolina, ­ http://globalfoodresearchprogram.web.unc.edu/multi-country-initiative​ /­resources/. 115 Note: The map was created based on the dataset available as of March 2019. g = gram; ml = milliliter; VAT = value added tax. 116 Map 5.3 Sugar-Sweetened Beverage Taxes: Europe and Northern Africa IBRD 44266 | DECEMBER 2019 BELGIUM: €0.068 per L (US$0.077) excise on soft drinks with added sweeteners; €0.41 per L (liquids) (US$0.48) and €0.68 per 100 kg (US$0.79) (powders) excise on concentrates. Implemented January 2016 NORWAY: 3.34 NKr per L (US$0.39) on drinks containing added sugar or sweeteners; 20.32 NKr per L (US$2.36) on UNITED KINGDOM: £0.18 per L (US$0.23) on drinks with >5 g syrup concentrates. Implemented 1981 total sugar per 100 ml; £0.24 per L (US$0.31) on drinks FINLAND: €0.22 per L (US$0.25) on sugar-containing soft with >8 g total sugar per 100 ml. Implemented April 2018 drinks; €0.11 per L (US$0.13) on sugar-free soft drinks, IRELAND: €0.20 per L (US$0.23) on drinks with >5 g total mineral waters. Implemented 1940, updated 2011 sugar per 100 ml; €0.30 per L (US$0.34) on drinks with >8 g ESTONIA: €0.10 per L (US$0.11) on drinks with 5–8 g total sugar per 100 ml. Implemented May 2018 sugar per 100 ml or only artificial sweeteners; €0.20 per L (US$0.23) for artificial sweeteners and 5–8 g sugar per 100 ml; FRANCE: €0.11 per 1.5 L (US$0.12) on drinks with added €0.30 per L (US$0.34) if >8 g sugar per 100 ml. Implemented sugars or artificial sweeteners. Implemented January 2012. January 2018 2018 UPDATE: Sliding scale tax, up to €20 per hl LATVIA: €0.074 per L (US$0.084) excise on drinks with (US$0.23 per L) if >11 g sugar per 100 ml added sugar, sweetener, or other flavoring; excludes fruit/ CATALONIA, SPAIN: €0.12 per L (US$0.14) levy for drinks vegetable juices with <10% added sugar and flavored/ with added sugars and >8 g sugar per 100 ml, or €0.08 per L functional waters without added sugars, sweeteners, or (US$0.09) for 5–8 g sugar per 100 ml. Implemented May 2017 flavorings. Implemented May 2004; increased tax rate 2016. PORTUGAL: €0.08 per L (US$0.09) on drinks with a sugar HUNGARY: 7 Ft per L (US$0.025) on soft drinks; content of <80 g per L or €0.16 per L (US$0.18) on drinks 200 Ft per L (US$0.71) on syrup concentrates. with >80 g per L sugar. Implemented February 2017 Implemented 2011 ST. HELENA: £0.75 per L (US$0.97) excise duty on carbonated drinks with ≥15 g sugar per L. Implemented May 2014 MOROCCO: 0.7 DH per L (US$0.074) VAT on soft and noncarbonated drinks with ≥5 g sugar per 100 ml; 0.6 DH per L (US$0.063) on energy drinks (20% increase); 0.15 DH per L (US$0.016) on nectars (50% increase); and tax on soft drink manufacturers will increase 50% Implemented to 0.45 DH per L (US$0.047). Implemented January 2019 Source: Global Food Research Program, University of North Carolina, ­ http://globalfoodresearchprogram.web.unc.edu/multi-country​ -­initiative/resources/. Note: The map was created based on the dataset available as of March 2019. g = gram; hl = hectoliter; kg = kilogram; L = liter; ml= milliliter. Map 5.4 Sugar-Sweetened Beverage Taxes: Sub-Saharan Africa, Asia, and the Pacific MALAYSIA: 40 sen per L (US$0.097) tax on carbonated, flavored, and other IBRD 44265 | DECEMBER 2019 non-alcoholic drinks with >5 g sugar per 100 ml or on fruit or vegetable juices SAMOA: 0.40 SAT per L (US$0.15) on with >12 g sugar per 100 ml. Implementation April 1, 2019 carbonated beverages. Implemented 1984 THAILAND: 3-tiered ad valorem and excise on all drinks with >6 g sugar per 100 ml FRENCH POLYNESIA: 40 CFP per L local Ad valorem rate will decrease over time as excise increases. Drinks with >6g sugar per (US$0.38); 60 CFP per L import tax (US$0.57) 100 ml will face higher tax rates, up to 5 baht per L (US$0.16) for drinks with on sweetened drinks. Implemented 2002 >10g sugar per 100 ml from 2023 onwards. Implemented September 2017 PALAU: US$0.28175 per L import tax on carbonated soft drinks. Implemented 2003 INDIA: 12% GST on all processed packaged beverages and foods; additional 28% GST FIJI: 0.35 F$ per L local (US$0.16); 15% import on aerated beverages and lemonades. duty on sweetened drinks. Updated 2016. Implemented July 2017 10% import duty on concentrates. Implemented 2007, updated 2017 SAUDI ARABIA: 100% excise on energy drinks, 50% tax on carbonated drinks. Implemented June 2017 NAURU: 30% import duty on all products with added sugars (+ removal of bottled water BAHRAIN: 100% excise tax on energy drinks, 50% excise tax BRUNEI DARUSSALAM: B$4.00 per levy). Implemented 2007 on aerated soft drinks. Implemented December 2017 10 L (US$0.25 per L) excise on all drinks with >6 g sugar per 100 ml. Implemented April 2017 COOK ISLANDS: 15% import duty UNITED ARAB EMIRATES: 100% excise tax on energy drinks; (with 2% rise per year) on sweetened drinks. 50% tax on all carbonated drinks except sparkling water. PHILIPPINES: 6 per L (US$0.11) on drinks Implemented 2013 Implemented October 2017 using sugar and artificial sweeteners; 12 per L (US$0.23) on drinks using HFCS; exempts TONGA: 1 Pa’anga per L (US$0.44) on MAURITIUS: MUR 0.03 per g sugar dairy drinks, sweetened instant co ee, drinks carbonated beverages. Implemented 2013 (US$0.00088) on sodas, syrups, and sweetened using coco sugar or stevia, and KIRIBATI: 40% excise tax on drinks containing fruity drinks with added sugar. 100% juices. Implemented January 2018 added sugar and fruit concentrates; exempts Implemented January 2013, 100% juices. Implemented 2014 updated October 2016 MALDIVES: Rf 33.64 per L (US$2.17) import tari on all energy drinks; Rf 4.60 per L VANUATU: 50 vatu per L excise (US$0.44) on SOUTH AFRICA: R 0.021 per g sugar (US$0.30) tari on soft drinks (including carbonated beverages containing added sugar (US$0.0015) on sugary drinks and sweetened and unsweetened carbonated or other sweeteners. Implemented February 2015 concentrates (4 g per 100 ml exempt). If sodas, sports drinks) Implemented March 2017 sugar not labeled, default tax based on 20 g sugar per 100 ml; exempts dairy SRI LANKA: SL Rs' 0.50 per g sugar (US$0.003) Implemented drinks and fruit, vegetable juices. on sweetened drinks, or SL Rs' 12 per L (US$0.066), Passed Implemented April 2018 whichever is higher. Implemented November 2017 Source: Global Food Research Program, University of North Carolina, ­ http://globalfoodresearchprogram.web.unc.edu/multi-country-initiative​ /­resources/. Note: The map was created based on the dataset available as of March 2019. g = gram; GST = goods and services tax; HFCS = high-fructose corn 117 syrup; L = liter; ml = milliliter. 118 | Obesity be exempt from VAT to prevent hardship on low-income ­ households. Subsidies and tax exemptions mainly benefit households with high con- sumption of the targeted product and the poor who are more sensitive to price changes; thus, policy to reduce prices mainly works as an income transfer policy and, to a lesser extent, as a nutritional intervention (Chakrabarti, Kishore, and Roy 2018; de Walque 2018). Diet-related taxes are mainly levied on SSBs and foods high in added saturated fat, sodium, or sugar—often termed junk foods, nonessential foods, or ultra-processed ­ foods. The advantages of taxing SSBs are linked both to the impact of sugar on health and to the inability of the body to compensate for the calories from a beverage by reducing food intake (DiMeglio and Mattes 2000; Mourao et ­ al. 2007; WCRFI 2015; WHO 2014). Taxation for Sugar-Sweetened Beverages: Design, Impact, and Challenges Taxing SSBs successfully requires careful consideration of the design of the tax in the context of the specific country involved and an understanding of both its expected impact including substitution patterns and the challenges inherent in such a ­policy. Design of SSB Taxes The design of a diet-related tax needs to consider the objectives set by a government and economic realities related to the market structures of unhealthy ­ products. Design issues include whether diet-related taxes are structured as a specific excise tax based on the “unhealthy” content in a product or as an ad valorem tax based on a ­ percentage of the ­ price. A spe- cific excise tax is a per unit tax—for example, a tax based on the sugar or fat content of a product or the product volume, such as one pound of sugar. These excise taxes can be tiered, as with the ­ ­ U.K. and South African systems where low sugar content is untaxed and the rates change with the amount of sugar used in the ­ product. Excise taxes on content can have a greater impact on consumers who switch to healthier alternatives than those who do not, as well as on producers who have an incentive to reduce unhealthy content such as sugar (Briggs et ­ al. 2017). These taxes are also better targeted, because the product price increases with a greater unhealthy ­ content. Because a tax on content is independent from the product price, it will prevent consumers from switching from more expen- sive to lower-priced ­ products. Still, some countries combine their excise tax with an ad valorem tax as a ­ ­ roduct. percentage of the retail price of the p Addressing Overweight/Obesity: Lessons for Future Actions | 119 More recently governments have begun to consider taxes that would affect supply and demand, with reformulation of the content to create healthier beverages and foods being the prime supply ­goal. Two ­countries— South Africa and the United Kingdom—were the first, in 2018, to initiate such ­ taxes. In April 2018, South Africa introduced a health promotion levy that left untaxed items with less than 4 grams of sugar per 100 milli- liters and then taxed the grams of sugar in p ­ roducts. The tax is 2.1 cents per gram for beverages with a sugar content exceeding 4 grams per 100 milliliters, which translates into about 11 ­ percent of the retail price (National Treasury 2016).1 A slightly more complex version of this tax is the tax the United Kingdom introduced with its Soft Drink Industry Levy in August 2018, which directly targets producers and importers of sugary drinks. The goal of the levy is to encourage manufacturers to produce soft ­ healthier products, remove added sugar, reduce portion sizes, and pro- mote diet ­ beverages. Soft drink companies are charged on beverages with added sugar and total sugar content of 4 grams or more per 100 milliliters, or about 4 ­ percent sugar c­ ontent. The levy is higher for beverages contain- ing 8 grams or more per 100 m ­ illiliters, in which case the sugar levy is 18 pence a liter or 24 pence a liter if the sugar content is over 8 grams per 100 ­milliliters. The question that remains unresolved as it relates to these tiered and nutrient-related taxes is whether promoting reformulation, which typically involves a rapid increase in diet sweeteners—primarily in high-income countries—is ­ healthful. At this point, the global consensus has been to sup- port reformulation but several countries are considering labeling foods and beverages containing diet sweeteners with that information on the front- of-package label (for example, “contains diet ­ sweeteners”). Fiscal Policy and SSB Taxes: The Evidence of Impact to Date Taxation policy often spurs debate on equity and efficiency ­ objectives. Efficient taxation curbs unhealthy consumption without negatively affecting individual welfare as a result of higher prices (Härkänen et ­ al. 2014). It has been argued that diet-related taxes levied on unhealthy products can increase efficiency because they aim to influence unhealthy consumption and subsequently curb the incidence of costly ­ diseases. Taxes on consumption—including diet-related taxes—are considered inequitable if the poor spend a higher proportion of their income than the rich on taxed ­goods. On the other hand, taxes have a pro-poor welfare effect if the poor are more sensitive to price changes and subsequently reduce their intake of unhealthy ­ products. As a result, the poor would benefit disproportionately more than the rich from the health benefits of adjusted ­ consumption. 120 | Obesity This is the subpopulation most likely to have undiagnosed, untreated, or poorly treated non-communicable diseases linked to excessive SSB intakes. It can therefore be argued that a diet-related tax is expected to increase the overall welfare of consumers since it will reduce unhealthy consumption, particularly for low-income groups, and curb related societal c ­ osts. The tax also becomes pro-poor if it is used to finance public services such as health care predominantly used by the poor (Begg, Fischer, and Dornbusch 2000), as discussed in an earlier ­chapter. Over 42 countries have instituted SSB ­ taxes. Many are smaller Pacific or Caribbean Island countries with high overweight/obesity rates, but a number of large countries have also introduced SSB ­ taxes. To date, most of the taxes have been based on the volume of drinks consumed and tax at the distributor/manufacturer level, not on the sugar content of the product—this is the case in the United Kingdom and South Africa, dis- cussed ­earlier. Sin taxes on tobacco and alcohol have a long history; the World Health Organization (WHO) and the broader health community anticipated that SSB taxes would work equally well, but the particular substitutions that would take place had to be studied to understand the net effect (Brownell et ­ al. 2009; WHO Commission on Ending Childhood Obesity 2016). One critical question for any caloric beverage- or food-related tax is its impact and the potential for ­ substitution. Most evaluations use food pur- chase data sets that are usually representative of the urban segment of each ­country. Mexico’s SSB tax, its price pass-through, and its impact are discussed in box 5.1. In that case, water was found to be the major substitute. Taxes based on volume have generally followed a pattern simi- ­ lar to the experience in ­ Mexico. Volume-based taxes in Barbados, Chile, France, and in Berkeley, California and Philadelphia, Pennsylvania in the United States for example, have reduced SSB purchase slightly less than a higher tax rate would ­ suggest. Chile increased the tax on most SSBs from 13 ­percent to 18 ­ percent while reducing the tax rate from 13 ­ percent to 10 ­percent on diet beverages and concentrates (a key SSB substitute for the ­poor). Price increases in the 3.1–3.5 ­ percent range were found by two studies using identical data; however, one found purchases declined slightly, which seemed appropriate for this small price increase (a volume reduction of 3.4 ­ percent in SSBs, an increase in low-taxed items of 10.7 ­percent, and a total calorie decrease of 4.0 ­percent; Caro et ­al. 2018). A different study with the same data found the unbelievable result of a 21.6 ­percent decline in the volume of higher taxed SSBs purchased, with no effect on the lower tax category in Chile (Nakamura et ­ al. 2018). These two studies are indicative of the complexity of studying the impact of these complex taxes using different econometric approaches and classifying products into various tax ­ categories. Addressing Overweight/Obesity: Lessons for Future Actions | 121 BOX 5.1 The Impact of Taxes on Sugar-Sweetened Beverages and Nonessential Foods in Mexico Mexico’s prevalence of overweight/obesity and diabetes is one of the highest in the ­ world. This burden falls disproportionately on lower- income Mexicans, who also are most likely to have undiagnosed or poorly treated ­ diabetes. To address these issues, the Mexican govern- ment implemented a peso-per-liter tax on sugar-sweetened bever- ages (SSBs) and an 8 ­ percent tax on nonessential foods with energy density ≥ 275 kilocalories per 100 ­ grams. These were the first taxes in either category to be rigorously evaluated with representative food purchase ­data. Price pass-through results in the first year showed that the SSB tax was passed through at greater than its approximate pretax 10 ­ percent level on small sizes of beverages and in urban areas relative to larger- sized containers and poorer rural areas (Colchero, Salgado, Unar- Munguía, Molina, et ­ al. 2017). al. 2015; Colchero, Zavala et ­ The impact of this tax in the first year was an approximate 6 ­ percent overall decline in purchases followed by an additional 4  ­ percent decline in the second year (Colchero et  ­ al. 2016; Colchero, Rivera- Dommarco et ­ al. 2017). To estimate these effects, the researchers esti- mated changes in household purchases of beverages in 2014 com- pared with 2012 and 2013 (see figure B5.1.1). Longitudinal fixed effects models that examined the difference in trends before and after the tax (difference-in-differences model) were to account for a preexisting decline in SSB purchases over the two-year period prior to the t ­ax. Household socioeconomic status and composition along with contex- tual controls for changing economic conditions (city-level unemploy- ment and salary levels) were ­ used. In the first year, the tax had the greatest impact among lower socio- economic households, with a 9 ­ percent average decline in purchases of sugary drinks over 2014 and a 17 ­ percent decline by December 2014 (see figure B5.1.2). The top socioeconomic status tertile did not signifi- cantly reduce SSB ­ purchases. Furthermore, the purchase of untaxed beverages increased by 4  ­ percent overall, primarily driven by an increase in bottled water p ­ urchases. This meant about 12.8 liters of additional water ­ purchased. Figure B5.1.3 highlights the additional impact of the tax in the second year. Additional research found that the largest consumers reduced their intake the ­ most. Groups that typi- cally had high purchases of the taxed beverages saw the largest continued next page 122 | Obesity Box 5.1 (continued ) Impact of Sugar-Sweetened Beverage Taxes in Figure B5.1.1  Mexico in Year 1 a. Taxed Beverages 250 Duan back-transformed taxed 225 beverages, ml/capita/day 200 175 In total over 2014, the 150 average urban Mexican purchased 125 4,241 ml (4.2 liter) less taxed beverages 100 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14Apr-14 Jul-14 Oct-14 b. Untaxed Beverages 1200 Duan back-transformed untaxed 1100 beverages, ml/capita/day 1000 900 800 In total over 2014, the average urban Mexican purchased 12,827 ml 700 (12.8 liter) more untaxed beverages 600 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Pre-tax adjusted Post-tax adjusted Post-tax counterfactual (based on pre-tax) Source: Analyses and calculations based on data from Nielsen through its Mexico Consumer Panel Service (CPS) for the food and beverage categories for ­ January 2012–December 2014. Copyright © 2015, The Nielsen Company. Nielsen is not responsible for and had no role in preparing the results reported herein. Note: Predictions do not adjust for quarter in order to show seasonal trends in bev- erage purchases. Total 2014 changes calculated using only months with significant differences by taking the summation of product of difference for month and the number of days in month. ml = milliliter; SSB = sugar-sweetened beverage. continued next page Addressing Overweight/Obesity: Lessons for Future Actions | 123 Box 5.1 (continued ) Impact of Sugar-Sweetened Beverage Tax in Figure B5.1.2  Mexico in Year 1 by Socioeconomic Status (SES) a. Low SES households Duan back-transformed taxed 250 beverages, ml/capita/day 225 200 175 **Feb–Dec 2014 150 12 14 -12 -12 Se 2 No 12 Ja 2 13 M 13 -13 Se 3 No 13 Ja 3 M 4 -14 -14 Se 4 No 14 l-1 1 l-1 1 1 l-1 n- p- v- n- - p- v- n- p- v- ar ay ar ay ar ay Ju Ju Ju Ja M M M M b. Middle SES households Duan back-transformed taxed 250 beverages, ml/capita/day 225 200 175 **March–Dec 2014 150 12 -12 Se 2 No 12 Ja 2 13 M 13 -13 Se 3 No 13 Ja 3 M 4 -14 -14 Se 4 No 14 14 M 12 l-1 1 l-1 1 1 l-1 n- - p- v- n- - p- v- n- p- v- ar ay ar ay ar ay Ju Ju Ju Ja M M M c. High SES households 275 Duan back-transformed taxed beverages, ml/capita/day 250 225 200 175 **Jan–Dec 2014 150 12 M 12 -12 Se 2 No 12 Ja 2 13 M 13 -13 Se 3 No 13 Ja 3 M 4 -14 -14 Se 4 No 14 14 l-1 1 l-1 1 1 l-1 n- - p- v- n- - p- v- n- p- v- ar ay ar ay ar ay Ju Ju Ju Ja M M M Pre-tax adjusted Post-tax adjusted Post-tax counterfactual Source: Analyses and calculations based on data from Nielsen through its Mexico Consumer Panel Service (CPS) for the food and beverage categories for ­ January 2012–December 2014. Copyright © 2015, The Nielsen Company. Nielsen is not responsible for and had no role in preparing the results reported herein. Note: Predictions do not adjust for quarter in order to show seasonal trends in beverage purchases. ml = milliliter. continued next page 124 | Obesity Box 5.1 (continued ) Two-Year Impact of Sugar-Sweetened Beverage Figure B5.1.3  Tax in Mexico 300 Per capita purchases of taxed beverages, ml/day Average 2-year post-tax di erence (relative to counterfactual) = –7.6% Average for 2014: –5.5% Average for 2015: –9.7% 200 100 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2014 2015 Counterfactual 2014 Counterfactual 2015 Estimated post-tax 2014 Estimated post-tax 2015 Source: Colchero, Rivera-Dommarco et al. 2017. Note: ml = milliliter; SSB = sugar-sweetened beverage. reduction (−18  percent) in those purchases, as well as the largest increase (+12 percent) in purchases of untaxed beverages by 2015, the second year of the tax (Ng et ­ al. 2018). The nonessential food tax followed the same methodology as the al. 2016; Taillie et ­ SSB tax (Batis et ­ al. 2017). The post-tax declines in continued next page Addressing Overweight/Obesity: Lessons for Future Actions | 125 Box 5.1 (continued ) percentage of taxed food purchases increased from 4.8 ­ the ­ percent in percent in the second year, yielding a two-year the first year to 7.4  ­ mean decline of 6.0 ­percent beyond the counterfactual (p<0.01). Post- tax change in the ­ percentage of taxed food purchases varied by pre- tax purchasing ­level. Most importantly, the major change was found in those who were unhealthy food purchasers before the ­ tax. The posi- tive effect of Mexico’s junk food tax continued in the second year, and households with greater earlier preferences for taxed foods showed a larger decline in taxed food ­purchases. Employment research found that there were no reductions in the number of employees either in the SSB or energy-dense food manu- facturing industries or in the Mexican commercial establishments after the taxes were implemented (Guerrero-López, Molina, and Colchero 2017). Barbados introduced a 10 ­ percent ad valorem tax on SSBs but omitted taxing powdered drinks (a major ­ substitute). Using point-of-sale data from the major chain on the island, the authors found sales of SSBs decreased by 4.3 ­percent. Sales of non-SSBs increased by 5.2 ­ percent, with water sales increasing an average of 7.5 ­ percent (Alvarado et ­ al. 2019). The government of France introduced an SSB tax of €0.072 per liter (more recently increased, albeit without an evaluation, to a higher tax with a sliding scale tax of up to €20 per hectoliter [US$0.23 per liter] if there are more than 11 grams of sugar per 100 m ­ illiliters). Based on a study of about a half million price records for non-alcoholic beverages, the tax was shifted to cover all carbonated beverages and partially to fruit drinks (Berardi et ­al. 2016). An alternate study in France compared con- sumer purchase data from two French regions and two neighboring Italian regions with longitudinal fixed effects models and found differen- tial price increases linked to the tax by drink category with an average of €0.07–€0.08 (Capacci et ­ al. 2016). They also found a statistically signifi- cant but small reduction in purchases of carbonated SSBs (0.08 liters per week) and fruit drinks (0.4 liters per week) and an overall decline in taxed drinks (of 0.09 ­ liters per week). A variety of U­ .S. cities have instituted t­ axes. The most important set of evaluations to date are for Philadelphia, a large city with a large poor ­ population, which put in place a tax of 1.5 cents per U.S. 126 | Obesity ounce (approximately 15 percent). Preliminary results have been pub- lished online by several groups (Cawley et al. 2018; Seiler, Tuchman, and Yao 2019). Enormous variance in methods and results have occurred, but generally most studies find purchases dropped signifi- cantly, reducing the frequency of SSB consumption by over 10 times per month (Cawley et al. 2018). Price pass-through varied greatly by type of retailer, with a net reduction of sales estimated at 38 ­ percent after recon- sidering leakage to other areas and sales trends (Roberto et ­ al. 2019). The only other publications to date relate to the small city of Berkeley where initial consumption was very low; nevertheless, the tax affected prices and reduced SSB ­ purchases. An array of publications using sales data (Silver et ­ al. 2017) or consumer intercept data (Falbe et ­ al. 2015; Falbe et ­ al. 2016) have found the tax impact on prices to be fairly com- plex, with price changes equal to the tax in major retail outlets but no increases in small convenience stores; nevertheless, SSB purchases declined ­ overall. Overall, the higher decline found in Philadelphia could reflect the higher tax, much greater initial consumption, or a poorer population. All of these issues are ­ ­ impactful. SSBs have been the major taxation target for two clear ­ reasons. First, consuming a beverage does not impact food i ­ntake. Second, sugar has unique adverse health ­ effects. A systematic review of 30 ­publications from 1996 to 2005 found a positive association between greater intakes of SSBs (particularly soda) and weight gain and over- weight/obesity in both children and adults (Malik and Hu 2015). Another meta-analysis considering 88 studies found clear associations of soft drink intake with increased energy intake and body ­ weight. SSB consumption was also linked to lower intakes of milk as well as calcium and other nutrients and to an increased risk of several health problems, including diabetes (Vartanian, Schwartz, and Brownell 2007). A sophisticated set of studies on the health impacts of the Mexican SSB tax estimated that it would result in about 189,300 fewer incident type 2 diabetes cases, 20,400 fewer incident strokes and myo- cardial infarctions, and 18,900 fewer deaths occurring from 2013 to 2022 (Sánchez-Romero et ­ a l. 2016); a second estimated that by 2030, the tax would reduce obesity by 2.5 ­ percent (Barrientos-Gutierrez et ­a l. 2017). The major issues about tax design remain unsettled until more evalua- tions are put in place, including evaluations of the two nutrient-based ­ taxes. These are the three-tiered ­ U.K. tax rate system based on grams of sugar levied at the manufacturer level and the South African per gram of sugar tax ­ system. Very high tax rates—such as the 50 ­ percent SSB taxes in Saudi Arabia and the United Arab Emirates—have also not been evaluated as ­yet. Addressing Overweight/Obesity: Lessons for Future Actions | 127 Challenges Any diet-related tax will face c ­hallenges. The main challenges to their successful implementation are a tax system’s administrative capacity, ­ ­ substitution effects, tax evasion, and opposition from the food i ­ndustry. These challenges need to be considered when designing effective tax policies. A useful guide to many of the issues to consider was published by ­ the World Cancer Research Fund (WCRFI 2015). Successful implementation of any tax will depend on, among other things, the effectiveness of tax a ­ dministration. Countries with strong tax administrations generally design excise taxes based on nutrient ­ content. Alternatively, taxes on product volumes may be easier to implement in countries where tax administration is not so ­ strong. It is generally easier for tax administrators to collect and enforce taxes if they are levied on the pro- ducer or wholesalers, as there are fewer producers and wholesalers than retailers that would have to comply with the tax (IMF 2016). For taxes based on nutrient levels such as grams of sugar, countries have employed defaults to the highest tax level when the product lacked adequate nutri- tion facts front-of-package labeling data; this is a very effective method of getting nutrition facts front-of-package labeling data ­ added. The substitution effect posits that consumers will switch to lower-priced ­ products. It limits the impact of a sugar tax on total sugar consumption if consumers who like sugar find a substitute for sugary beverages and will drink, for example, more fruit juices (Fletcher 2011). The Mexican and Chilean experiences did not find t ­ his. Instead, in Mexico consumers substi- tuted bottled water for SSBs after the SSB tax went into effect; and in Chile there were no signs of increasing purchase of additional kilocalories of other beverages (Caro et ­ al. 2018; Colchero et ­ al. 2016). The experience from the United States with soda taxes shows that consumers—children and teenagers especially—may switch to other high-calorie drinks that are relatively inexpensive, meaning there is little or no effect on excess weight and obesity (Fletcher, Frisvold, and Tefft 2013). If individuals switch from sugary drinks to foods that are even higher in calories or high in fat and sodium, then the calorie intake could even increase and diminish any health gains that may be achieved through reduced sugar ­ intake. However, findings from the United States suggest that substitution to other beverages mainly involved fruit juices, and there was no evidence of substitution with sugary foods and no effect on total sodium purchased (Finkelstein et ­ al. 2013). To date, most countries planning such sin taxes in the food area have first used demand systems to study food and beverage substitutes and found most substitutes to be healthful (Caro, Ng, Bonilla et ­ al. 2017; Caro, al. 2017; Colchero, Salgado, Unar-Munguía, Hernández-Ávila, Ng, Taillie et ­ and Rivera-Dommarco 2015; Colchero, Salgado, Unar-Munguía, Molina al. 2015; Stacey, Tugendhaft, and Hofman 2017). et ­ 128 | Obesity Another challenge is that consumers may try to avoid paying diet- related taxes through cross-border ­ purchases. The short-lived saturated fat tax in Denmark, for example, led Danes to purchase non-taxed prod- ucts across the border in Germany or Sweden (Smed et ­ al. 2016). Similarly, it is estimated that about 10 ­ percent of the alcohol market in the United Kingdom and 20 ­ percent of the cigarette market in France take place across the ­ border. Such cross-border purchases can limit the effectiveness of ­taxes. Setting tax rates therefore requires an understand- ing of the purchasing behavior of consumers, of tax rates in neighboring markets, and of the effectiveness of the tax authority to enforce compliance. A regional approach to taxation can reduce the evasion ­ effect. At the same time, leakage into purchases from other countries is ­ less likely for a product as bulky as SSBs but much more likely for ciga- rettes and ultra-processed ­ foods. The highly concentrated food and beverage industry constantly chal- lenges diet-related ­ taxes. The beverage and food markets consist of few manufacturers sharing a large share of total p ­ roduction. In France, for example, the top two soft drink manufacturers share 89 ­ percent of total production (Bonnet and Réquillart 2013). Because of this concentrated market situation, the food and beverage industry will challenge diet- related taxes through aggressive marketing campaigns for sugary drinks and highly processed f ­oods. In 2014, the beverage industry in California spent more than US$10 million on advertising campaigns to fight sugar taxes on beverages (WHO Expert Committee 2016). In Philadelphia, the soft drink industry pledged to donate US$10 million to the Children’s Hospital of Philadelphia if the city council voted down the sugar ­ tax.2 In 2018, the American beverage industry had its appeal to the Pennsylvania Supreme Court granted; it unsuccessfully challenged the legality of Philadelphia’s sugar tax (Du et ­ al. 2018). These examples show that indus- try interests are powerful and could influence the lifespan of a t ­ax. The New York Times documented similar efforts in Colombia, Mexico, and a number of other countries in which not only did the food industry engage in counter-marketing activities but it also used much more personal attacks against advocacy leaders and scholars supporting taxes and other regula- tions; additionally, it utilized trade negotiations and other legal approaches (Jacobs and Richtel 2017a, 2017­ b). Despite these industry attacks, for fis- cal and health reasons an increasing number of countries (as shown in maps 5.2, 5.3, and 5.4) are introducing SSB ­ taxes. The following section presents experiences from selected countries, including how they have designed and implemented diet-related taxes and the challenges they have f ­aced. Thereafter, the final section presents lessons and recommendations for countries interested in diet-related ­taxes. Addressing Overweight/Obesity: Lessons for Future Actions | 129 Diet-Related Taxation Diet-related taxes have been introduced in Finland, France, and Hungary in 2011; followed by Chile, Mexico, and Mauritius in 2014; and, most recently, in the Gulf Cooperation Council countries, South Africa, and Thailand. The highest diet-related taxes are levied in Saudi Arabia and the ­ United Arab Emirates, where they amount to 50 ­ percent of the price of soda and 100 ­ drinks. It is important to note percent of the price of energy ­ that none of these taxes have focused directly on ultra-processed foods, but recent studies of the health impact of these foods suggest that this is a criti- cal future direction to consider (Hall 2019; Rico-Campà et ­ al. 2019; Srour al. 2019). et ­ Design of Diet-Related Taxes To examine countries’ experience with taxes, the World Bank conducted nine case studies on dietary policies in Brazil, Chile, Mexico, Poland, South Africa, Sri Lanka, Thailand, Turkey, and the state of Kerala in I ­ ndia. Chile has the highest consumption of sugary beverages in the world (Popkin and Hawkes 2015), a very high junk food intake, and high overweight/obesity prevalence (Cediel et ­ al. 2017; Corvalán et ­ al. 2018; Popkin and Reardon 2018). High levels of SSB consumption, combined with high overweight/ obesity rates and increasing prevalence of related diseases, have prompted the introduction of diet-related taxes in five of the nine cases studied (table 5.2 presents an ­ overview). Governments argued that taxes would lead to higher prices and, combined with other public health measures, would cause con- sumers to reduce their sugar intake, which would help reduce their weight and improve their health ­ status. The five case study areas that introduced diet-related taxes were focused on taxing beverages with high sugar c ­ ontent. Of this group, only Mexico also taxes unhealthy foods (Batis et ­ al. 2016). Kerala’s fat tax on unhealthy food was abolished after one ­ year. When designing a diet-related tax, governments make decisions about which products to tax based on content or volume or price, and whether the tax will be a specific excise or an ad valorem tax on the ­ price. As noted earlier, the first product considered for taxation linked to public health has been ­SSBs. In September 2014, Chile increased the tax rate from 13 ­ percent to 18 ­percent for SSBs that have a sugar content higher than 15 grams per 240 milliliters or equivalent p ­ ortion. The rate was reduced to 10 ­ percent for other beverages (Caro et ­ al. 2018). In 2018, South Africa introduced a sugar levy of 2.1 cents per gram for beverages with a sugar content exceed- ing 4 grams per 100 milliliters, which translates into about 11 ­ percent of the price. This is the first low- or middle-income country that has used a retail ­ nutrient-based tax for ­ SSBs. 130 | Obesity In Thailand, beverage retailers are also taxed based on the amount of sugar in their SSBs (table 5.2). The new excise tax rates in the country are not expected to lead to a significant increase in the prices of sugar-­ sweetened carbonated drinks, whereas the SSB tax will lead to higher prices for sugar-sweetened tea, coffee, and fruit and vegetable drinks with excess ­ sugar. Prices are likely to increase: for example, a 500 ­ milliliter bottle of tea that contains 54.5 grams of sugar will be taxed at 10 ­ percent per value and 0.5 baht (US$0.015) per ­ liter. This tax is quite complex and its rate increases over time, with the government’s goal being to encour- age ­ reformulation. The sugar tax increases every two years; by 2023 onward the tax will be approximately 1 baht (US$0.03) per liter for drinks containing 6–8 grams, 3 baht (around US$0.095) for drinks containing from 8 to 10 grams, and 5 baht (around US$0.15) per liter for drinks with over 10 ­ grams. Mexico taxes unhealthy food and beverages, whereas other countries mainly tax beverages high in sugar ­ content. Kerala also had a fat tax on unhealthy foods, but it was in effect for only a y ­ ear. The fat tax in Kerala was an ad valorem tax of 14.5 ­ percent of the price levied on burgers, pizzas, tacos, doughnuts, sandwiches, pasta, and bread fillings sold by restaurants with an international brand name or trade mark ­ registration. This made international restaurant chains such as Kentucky Fried Chicken, Pizza Hut, Dominos, Chic King, French Fried Chicken, Southern Fried Chicken, and McDonald’s the primary targets of the ­ tax. As such, the fat tax was based on the type of food business operator and not the content of unhealthy product. The Kerala government planned to start with branded products ­ and slowly expand the fat tax to unhealthy food items sold by bakeries and other local e­ ateries. From the start this tax addressed only international fast food chains and missed the bulk of unhealthy fast food consumption from local stalls and ­chains. An excise tax based on volume is more practical to implement than an ad valorem ­ tax. Mexico and Thailand introduced a combination of excise and ad valorem t ­ axes. A specific excise per gram of sugar content instead of liter or kilogram will result in higher taxes for products higher in sugar content. However, sugar excise taxes in Mexico are per liter of beverage, ­ which results in a lower tax per gram of sugar content for more sugary drinks (Colchero et ­al. 2016; Colchero, Salgado, Unar-Munguía, Hernández- Ávila, and Rivera-Dommarco 2015). Diet-related taxes have often been implemented as part of a broader health promotion strategy, but in many low- and middle-income countries they also emerged as easy ways to raise r ­evenues. The support of health professionals and civil society has been critical to ensure the appropriate implementation of taxes and to counteract undue pressure from the food and beverage ­ industry. Addressing Overweight/Obesity: Lessons for Future Actions | 131 The introduction of diet-related taxes will have to be coordinated and sequenced with other tax reforms such as VAT on goods and s ­ ervices. The Gulf Cooperation Council countries first introduced the VAT and then successfully added diet-related t ­ ­axes. In Kerala the sequencing was the other way around, and the fat tax ended in 2017. Chile’s tax was part of a tax reform package; it was not explicitly designed as a health tax and some selected SSBs actually experienced reduced taxes (Caro et ­al. 2018). Mexico, in contrast, included the SSB tax as a health-related tax, but the nonessen- tial food tax was added by the Ministry of Finance to raise r ­ evenues and it was designed very rapidly with many gaps in the definition of nonessential ­foods. Impact of Diet-Related Taxes Evidence from countries with diet-related taxes shows that taxes have an impact on the consumption of unhealthy ­ products. Studies have mainly shown the effect of diet-related taxes on the products’ price and consump- tion, and on the population’s health ­ status. In January 2012, France intro- duced a tax of €7.16 per hectoliter of non-alcoholic beverages with added sugar or sweeteners, including sodas, fruit drinks, and flavored w ­ aters. Capacci et ­ al. (2016) examined to what extent the tax was passed on to consumers through a price increase on the taxed ­ beverages. Findings sug- gest that within six months soda prices increased fully by the SSB tax amount of about 11 cents for 1.5 liter of s ­ oda. However, the tax was not fully passed on to prices for fruit drinks and flavored waters, and different price increases were applied across vendors and beverages (Berardi et ­ al. 2016). Denmark introduced a tax as a ­ percentage of the price of soft drinks in 1998 and 2001 (Jensen and Smed 2013; Smed et ­ al. 2016). Bergman and Hansen (2016) analyzed a micro price data set and found that both tax increases were over-shifted on to consumers—that is, the price increase for consumers was higher than the nominal value of the tax. A tax must be high enough to trigger a c ­ hange. Studies of the expected consumption effect suggest that a sales tax of around 5 ­ percent on soft drinks tends to be too small to affect consumption (Brownell et ­ al. 2009; Caro et ­ al. 2018). The WHO has recommended a diet-related tax equiva- lent of 20 ­ percent of the retail price to effectively change ­consumption. Tax simulations from Chile indicate that an 18 ­ percent tax on ultra-­ processed junk foods and beverages (those high in fats, salt, sugars) is associated with the highest reduction in intake of calories, sodium, satu- rated fats, and added sugar, compared with alternative policies (Caro, Ng, Taillie et ­ al. 2017). Another study from Chile found a drop of 21.6 ­ percent in the monthly purchased volume of higher-taxed sugary soft drinks (Nakamura et ­ al. 2018), but an alternate study using the same data set 132 | Obesity found, for the same 3.1 ­percent price increase, only a comparable 3 ­percent reduction in purchases (Caro et ­ al. 2018). Both studies found the same small price increase but the Nakamura one found a much larger, almost unbelievable, purchase reduction from this small price i ­ ncrease. In Mexico, the National Public Health Institute predicted that a 10 ­ percent increase in the price of SSBs would reduce consumption by around 10 ­ percent, which would translate into a 12 ­ percent reduction in new cases of ­ diabetes. However, the first year of the tax decreased consumption by about 6 ­percent; the second year, purchases decreased an additional 4 ­ percent approximately (Colchero et ­ al. 2016; Colchero, Rivera-Dommarco et ­ al. 2017). Similar reductions in soda consumption have been observed in the city of Berkeley, California, in response to a soda tax introduced in November 2014 (Silver et ­ al. 2017). Most importantly, the Mexican SSB tax was associated with a much higher decline in purchases among heavy consumers—those for whom the health impact of the tax would be poten- tially most effective (Ng et ­ al. 2018). The recently introduced SSB tax in Thailand may not be high enough (the WHO recommends 20 ­ percent) and may thus have less effect on consumer ­ behavior. The tax will increase the final retail price by approxi- mately 2.00 baht (US$0.06) or 10.6 ­ percent, which is below the WHO recommended 20 ­ percent. As noted above, the Thai Ministry of Finance plans a phased approach to increase the SSB tax rate every two years until 2023. Colchero et ­ al. (2016) examined pre- and post-tax purchase trends in Mexico from January 2012 to December 2014 to compare the predicted volumes of taxed and untaxed beverages purchased in 2014 with the esti- mated volumes that would have been purchased without the ­ tax. Following the introduction of a tax of 1 Mexican peso per liter on any non-alcoholic beverage with added sugar in 2014, sales of sugary beverages fell on aver- age by 6 ­ percent. All socioeconomic groups reduced their consumption; low-income groups reported the highest reductions: they cut their sugary drink intake by 9 ­ percent during 2014. Purchases of untaxed beverages— mainly bottled plain water—increased and were 4 ­ percent higher than the counterfactual (Colchero et ­ al. 2016). Similarly, studies from Hungary report reduced consumption of unhealthy products after the excise on soft and energy drinks was introduced in 2011, and most people maintained this lower consumption level over time (WHO Regional Office for Europe 2015­b). In Kerala, the government expected that the fat tax would lead to reduced consumption of unhealthy f ­ ood. However, the tax was levied only on multinational chains and branded trademark owners, which comprise percent of the food business in ­ less than 10 ­ Kerala. Much of the unhealthy food consumed by the population of Kerala is produced by local businesses Addressing Overweight/Obesity: Lessons for Future Actions | 133 such as bakeries, food stalls, and home-grown fast food chains, but they were exempt from the fat ­ tax. It is not clear whether the one-year fat tax has influenced food consumption and health ­ outcomes. Research from the European Union concludes that an excise tax based on the sugar content is the most effective way to limit consumption of SSBs (Bonnet and Réquillart 2013). Longer-term data and surveys will be needed to evaluate the impact of reduced consumption of unhealthy products on obesity and diabetes in these ­ countries. Diet-related taxes generate a public discourse on healthy ­ diets. The experience with strong opposition to sin taxes from the United States shows that the campaign to pass the tax—even if unsuccessful—helps to inform consumers about unhealthy products, encourages producers to reformu- late the nutrition content of products, and reduces consumption of unhealthy drinks and ­ foods. The one-year introduction of the fat tax in Kerala has generated a public discussion in the national media about obe- sity and unhealthy food, although the tax has been abolished because of the introduction of the goods and services tax ( ­GST). Following Kerala’s experience, the Food Standard and Safety Authority in India set up a national committee that recommended introducing diet-related taxes on processed food with high salt and fat ­ content. Other ideas under consider- ation are Chile-style front-of-package labels with negative ­ warnings, described later in this chapter. Because of the relatively recent experience with diet-related taxes, it is too early to identify a definitive impact on health ­ status. Therefore, most studies report on their expected health ­ effect. Studies from the United States suggest that a 20 ­percent price increase through a tax on SSBs would result in a daily reduction of 24.3 kilocalories intake per individual (Finkelstein et ­ al. 2013). In Mexico, addi­ tional revenues from diet-related taxes were initially proposed for use in providing potable drinking water fountains in low-income schools, but this has not been implemented. Two studies have used the diet effects of the SSB tax in Mexico to project the impact over 10 and 20 years on mor­ tality and NCDs and have found quite significant effects (Barrientos-Gutierrez et al. 2017; Sánchez-Romero et al. 2016). The first study found that the 10 percent tax on SSBs in Mexico is expected to reduce obesity by 2.5 percent by 2024 and prevent 86,000 to 134,000 new cases of diabetes by 2030; the second study, with an assump- tion of a larger impact, found 189,300 fewer cases of type 2 diabetes, 20,400 fewer cases of strokes and myocardial infarctions, and 18,900 fewer deaths occurring from 2013 to 2022. See box 5.1 for a summary of the impact of Mexico’s diet-related taxes. Data and surveys over a longer time will be needed to confirm the taxation effect on population ­ health. The fiscal impact of diet-related taxes has been estimated in the United States. A tax of 1 cent per 30 milliliters of SSBs would increase the price ­ 134 | Obesity of a 250 milliliter soda by about 8 cents and raise about US$14.9 billion in tax revenues in the first year (Brownell et ­ al. 2009). The government of Kerala anticipated additional tax revenues per year from its fat tax of around 100 million Indian rupees (≈US$1,520,253).3 Challenges One of the main lessons from countries with diet-related taxes is that industry opposition can substantially delay the SSB taxation ­ process. In Thailand, the process took over a ­ decade. In 2008, the Sweet Enough Network (SEN) partnered with nongovernmental organizations (NGOs) and academia, including the International Health Policy Foundation (IHPF), to develop SSB taxation ideas and held a full-day international seminar coordinated by the IHPF, with guest economist Barry Popkin and speakers from the Ministry of Finance, Mahidol University, and the Ministry of Public ­ Health. Because of strong industry opposition argu- ments that taxes would not affect consumption but instead lead to job losses and negatively affect the poor, the Thai Ministry of Public Health withdrew the taxation proposal in 2011. However, by 2012, SSB-tax advocates regrouped and argued based on the successful introduction of SSB taxation in other countries, including Hungary and Mexico, and by citing increasing evidence of the effectiveness of SSB taxation on con- sumer ­ behavior. In early 2016, after it had been endorsed by the National Reform Steering Assembly (NRSA), the Thai government reviewed the SSB taxation proposal ­ again. The proposal recommended the SSB tax be limited to beverages containing sugar above 6 grams per 100 milliliters at a rate that could result in an after-tax increase of at least 20 ­percent on the retail ­price. However, the beverage and sugar industries again opposed the ­proposal. But this time the SSB taxation team countered the industry with research findings and media support, and with support of NGOs as well as the ­ WHO. Ultimately, the National Reform Council (NRC) and the NRSA voted in favor of SSB taxation in 2016. In January 2017, the Thai government announced the implementation of SSB taxes in September 2017. This was not the only Thai focus for creating healthier d ­ iets. The Thai government, led by their Food and Drug Administration and scholars from Mahidol University, met a number of times to create a front-of-package labeling ­ system. They opted for working regionally with Singapore, Malaysia, and China in a series of meetings that ultimately led to the devel- opment in each country of positive logo choices-style front-of-package sys- tems (Roodenburg, Popkin, and Seidell 2011). After several years of meetings, in August 2016, the voluntary Healthier Choices logo—a front- of-package labeling scheme to help consumers identify healthier food Addressing Overweight/Obesity: Lessons for Future Actions | 135 choices—was launched in ­ Thailand.4 The logo was developed in a collabo- ration between the National Food Commission, the Ministry of Public Health’s Food and Drug Administration, the Health Promotion Foundation, and Mahidol ­ University. The Healthier Choices logo is owned by the Thai Food and Drug Administration, and its use is managed by the Nutrition Promotion Foundation of Mahidol U ­ niversity. Industry opposition again led to this becoming voluntary rather than legally ­ required. In Kerala the tax was introduced ­ swiftly. The food industry associations were not consulted about the diet-related food t ­ax. Rather, they learned about the fat tax when the budget was ­ announced. Still, most industry associations supported the tax as a positive step toward controlling overweight/obesity. It could also be that industry representatives may have ­ anticipated that the fat tax would be short-lived, since the national govern- ment was preparing for the GST nationwide, which would exempt obeso- genic products from ­ taxation. Some governments—including those of Demark, Finland, and Kerala— had to abolish their diet-related taxes for different reasons, which provide useful lessons for future consideration: • Denmark introduced an excise tax of €2.15 per kilogram of saturated fat, plus an additional 25 ­ percent ad valorem ­ tax. Although the tax was efficient in reducing the intake of saturated fat, opponents of the tax— mainly the food industry—successfully initiated European Union (EU) it. The tax was abolished on the grounds of jurisdictional action against ­ design weaknesses, insufficient support from public health groups, and lack of evidence that it would improve health ­ outcomes. • Finland abolished the tax on sweets in 2015 in response to pressure from the food industry, which argued that a tax on specific products is unfairly discriminatory against specific manufacturers and therefore dis- torting ­competition. • Kerala abolished its fat tax after one year, in 2017, when the national government of India introduced the G ­ ST. However, the GST does not tax unhealthy food but it did place an additional sin tax on carbonated bev- erages of 28 ­ percent and on processed packaged foods of an additional 12 ­percent ­GST. Unofficially no price increases have been seen in SSBs after the national government tax reforms were ­ instituted. These challenges highlight the need for a well-planned public awareness campaign, involving a broad coalition of health and community leaders, that can help inform the public about the potential harm caused by the taxed unhealthy products and overcome opposition to diet-related t ­axes. Diet-related taxes should be implemented as part of a broader health pro- motion strategy with the support of health professionals and civil society to ensure appropriate implementation and counteract undue pressure from 136 | Obesity the food and beverage ­industry. This strategy can include warning labels on taxed products to inform the public about health impacts as well as limit the marketing of taxed products to ­ children. In addition, evidence of the effects of taxes on food purchases, consumption, population health, and revenues will help inform policy adjustments and the launch of diet-related taxes in other ­ countries. Lessons from Countries with Diet-Related Taxes Countries with diet-related taxes provide important lessons for other coun- tries that plan similar fiscal policies (Jou and Techakehakij 2012): • First, taxes on SSBs and unhealthy foods should be developed and implemented in coordination with VAT reforms and tobacco taxes when ­ possible. The revenue collection authority unit at the ministry of finance would be responsible for implementing diet-related taxes, and the same requirements would apply for the administration of all taxes. A realistic timeline for designing and implementing a tax will ­ be essential to manage the process and should be aligned with ongo- ing tax ­reforms. • The introduction of a diet-related tax would have to be sequenced appropriately to prevent overloading the tax ­ system. Governments may consider identifying a steering committee to supervise and guide the implementation process or task the VAT steering committee with super- vising the ­process. Legislation and regulations would have to be passed to implement a diet-related tax, and this legislation should be aligned with legislation on VAT and on tobacco ­ taxes. • Governments would need to consider defining the major policy issues to be addressed with diet-related taxes to develop a strategy that will serve dialogue. The policy issues include whether the tax as the basis for public ­ will be a specific excise tax based on product volume such as liter or kilogram or nutrient content, or an ad valorem ­ tax. Policy decisions would have to be made on the criteria to be used in nutrition profiling to decide which beverages and foods would be taxed and whether the tax should be levied on the consumer or on the producer, as is the case in the United K ­ ingdom. The WHO nutrient profiling model can serve to identify the foods and beverages to be taxed, or a similar system could be adapted as various WHO regional offices have done (PAHO 2016). Chile created its nutrient profiling model earlier; this is highly impactful and has been adapted by Israel, Peru, and Uruguay (Colchero et ­ al. 2016; Colchero, Rivera-Dommarco et ­ al. 2017; Corvalán et ­ al. 2013, 2018). This model is based on grams and milliliters of food (versus the PAHO use of milligrams of salt per 1,000 kilocalories), limited its warning labels Addressing Overweight/Obesity: Lessons for Future Actions | 137 to four components to allow an adequate size for each logo, and did not use the labels for controversial issues (for example, diet sweeteners and total fat content) as some other profile systems have ­ done. This approach allowed Chile and Israel to withstand many legal challenges from the industry and the ­ World Trade Organization. • International experience suggests that a diet-related tax should be defined as a specific excise tax based on volume and levied on either the producer or the w ­ holesaler. As in Finland, France, Hungary, and Mexico, for example, governments may decide to charge a specific tax amount per liter of beverage with added sugar on all such beverages or per kilo- gram of energy-dense foods (such as candies, pastries, ice cream, choco- late, pudding, peanut butter, vegetable and palm oil products, and so on). Alternatively, the government could levy the tax per gram of sugar ­ and fat in drinks and foods, as has been done in South Africa, leading to higher taxes on products high in sugar or fat ­ content. Or the govern- ment can reinforce other policies and use a nutrient profiling system such as that of Chile, which identifies the most unhealthy, ultra-­ processed foods for ­ taxation. • A diet-related tax should be implemented as part of a broader strategy for healthy ­ diets. To examine possible market reactions from the indus- try, a market analysis of the beverage and food industry would shed light on how they will likely react to a possible diet-related ­ tax. Such an anal- ysis might help gain the public support of health professionals for a tax and counteract undue pressure from the i ­ndustry. In addition, a public information and education campaign involving health professionals and civil society could help inform the public about the negative health effect of sugary drinks and energy-dense foods and help prevent opposition to the ­tax. A public awareness campaign could also encourage healthy behavior through healthier food consumption and physical activities, particularly for children and a ­dolescents. Food regulations through front-of-package nutrition labels would inform consumers about the nutrient content of f ­ood. As in Chile, governments could consider pass- ing a law on food labeling that requires food labels similar to a traffic stop sign to identify products high in sugars, trans-fats, sodium, and calories (Corvalán et ­ al. 2018). Governments would need to set up a monitoring and evaluation framework to examine the effect of taxation on pur- chase, consumption, revenues, and population ­ health. Similarly, as in Mexico, population surveys could be conducted before and after the launch of the tax to evaluate possible consumption changes following the price i­ncrease. To estimate changes in consumption levels, informa- tion would have to be collected across different population groups on the consumption frequency and amount of the taxed goods and substi- tution ­goods. 138 | Obesity • Finally, countries may want to consider developing and implementing countries. A regional diet-related taxes in coordination with neighboring ­ approach to taxation would reduce cross-border purchases and prevent evasion. resulting tax ­ There are major gaps in the current sets of fiscal ­ policies. Few countries have used the revenue for health ­purposes. None have considered tying the taxes to subsidies for healthier legumes, vegetables and fruits, and other healthful, less obesogenic ­ foods. None have gone further and created tar- geted subsidies for healthier foods or to use subsidies to ensure increased purchases of foods such as legumes and vegetables, albeit the challenges of earmarking sin taxes for public programs brings even more ­ challenges. Country Experience with Other Diet-Related Programs and Policies While fiscal policies linked mainly to SSB taxes have dominated in the response to overweight/obesity, many other regulatory options are being used by countries to achieve improved diet quality and prevent o ­ verweight/ obesity. One of the newer initiatives, which was led by innovative policies in Chile, is to create a nutrient profiling model that can be linked not only to fiscal policies but also to food marketing, front-of-package food warning labels, school food bans on regulated food, and marketing controls (Corvalán et ­al. 2013; Corvalán et ­ al. 2018). A series of evaluations and historical descriptions of the first 18 months of the Chilean experience will be pub- lished in the near future, possibly in 2020; it will show remarkably large impacts (Correa et ­ al. 2019). This Chilean approach, as well as a more recently adopted recommendation by the Pan-American Health Organization (PAHO), focuses on unhealthy ultra-processed foods and bev- erages and attempts to shift eating norms away from these foods (PAHO 2016). Doing so may well shift food norms away from the least healthful components of ultra-processed packaged foods and beverages, but it will not necessarily push consumers to pick the least obesogenic ­ diet. Israel plans to combine a negative warning label designed to mirror Chile’s label with a positive logo on the healthiest foods and beverages such as whole grain breads, water, unsweetened dairy products, legumes, and produce (Endevelt et ­ al. 2017). Important experimentation is expected over the next decade in an attempt to learn best ­ practices. Policies in this area are really in their infancy and to date no country—be it a low- or middle-income country or a high-income country—has reduced overweight/obesity, so the programs and policies that are initiated need rigorous evaluations to allow us to ultimately understand which Addressing Overweight/Obesity: Lessons for Future Actions | 139 combination of policies can create the desired food norms and ultimately create a truly healthy diet that adequately reduces the risks of being ­overweight/obese. Front-of-Package Labeling At this time a small number of countries have national regulations requir- ing front-of-package label ­ profiling. A much larger number of countries across the globe have voluntary systems, as shown in map 5.5. The few countries with statutory programs are Thailand, with a positive healthier choices label (Roodenburg, Popkin, and Seidell 2011); and Chile, Israel, Peru, and Uruguay (and soon Canada), with negative warning labels (Corvalán et ­ al. 2019). Four to six other countries are moving to utilize negative warning l ­abels. India has already had hearings on such a negative warning label system and now is in the final phases of considering it. Israel will use both negative and positive labels in an effort to address the large proportion of foods that are not deemed very unhealthy but might not be as good for preventing overweight/obesity (for example, identifying whole grain bread versus refined carbohydrate-based ­ breads). There are approximately 20 to 25 other countries with some sort of vol- untary front-of-package label, which vary from those promoting healthy food choices (Choices International and Scandinavian Keyhole) to traffic light systems with red, yellow, and green signals for various nutrients and those providing grading systems, such as the French Nutri-Score approach (Frølich, Åman, and Tetens 2013; Julia and Hercberg 2017; Roodenburg, Popkin, and Seidell 2011).5 Published evaluations to date are ­ rare. Only the Chilean approach is being thoroughly evaluated, but this multipronged approach in Chile will not tell us whether a policy focused only on front-of-package warning effective. An evaluation of the front-of-package law is under- labels will be ­ way in Peru; this may provide further ­ information. Maps 5.5 and 5.6 give a sense of the array of front-of-package labeling options that exist but, aside from Chile, none have been shown to impact purchasing behavior system- atically (Crockett et ­al. 2018). The countries with mandatory interpretive labels are much fewer than those with voluntary ones, as shown in map 5.6. Of these, the negative warning label is the one that several regional WHO groups (such as PAHO and the WHO regional offices in Latin America and Europe) are p ­ romoting. Nutrient Profiling Models Behind all of the front-of-package labeling approaches is some type of nutrient profiling system (Rayner, Scarborough, and Kaur 2013). Many of 140 Map 5.5 Countries with Mandatory or Voluntary Front-of-Package Labels Denmark IBRD 44261 | DECEMBER 2019 Iceland Lithuania Norway Sweden Finland Denmark United Kingdom kingdom Belgium Czech Republic Netherlands Poland Islamic Republic of Iran Mexico Thailand Slovenia Croatia France Philippines United Arab Emirates Ecuador Israel Nigeria Darussalam Brunei darussalam Peru Sri Lanka Sri lanka Malaysia Mayalsia Singapore Argentina Australia Chile Uruguay New Zealand zealand Mandatory Voluntary Mandatory/voluntary To be implemented Source: Global Food Research Program, University of North Carolina, 2019, ­ http://globalfoodresearchprogram.web.unc.edu/multi-country​ ­-initiative/resources/. Note: The map was created based on the dataset available as of March 2019. Map 5.6 Countries with Mandatory Front-of-Package Labels FINLAND IBRD 44262 | DECEMBER 2019 Since 1993, all packaged food categories that contribute significantly to salt intake (for example, bread, MEXICO cheese, deli meats) must carry a “high salt content” Since 2014, most prepackaged foods and non-alcoholic warning label. This law was updated in 2016 to apply beverages sold and distributed in Mexico must to unpackaged products sold at retail outlets, as well. carry a Guideline Daily Amount (GDA) label listing saturated fat, other fats, total sugars, sodium, and ISLAMIC REPUBLIC OF IRAN energy energy—perper serving, serving, per per pack, pack, or or both both— Since 2015, all industrial foods manufactured expressed both as kcal amounts (or mg for sodium) in or imported into the Islamic Republic of Iran must and percentages of recommended daily amounts. carry a tra c light label with information on levels fat, of fat, sugar, salt, trans fats, and energy content relative to set thresholds. THAILAND Since 2007, five categories of snack ISRAEL (implementation 2020) foods are required to carry a GDA Beginning in January 2020 (implementing in two stages), ECUADOR label listing calorie, sugar, fat, and a red emblem will be required to appear on solid foods Since August 2014, packaged sodium content as well as percent with >500 mg sodium, >12 g sugar, or >5 g saturated foods must carry a color-coded of recommended daily intake. Also fat per 100 g of product, as well as on liquids with “tra c light” label with levels required to bear a warning, >500 mg sodium, >5 g sugar, or >3 g saturated of fats, sugar, and salt. “Should consume in small amounts fat per 100 g. and exercise for better health.” PERU (Not shown.) (implementation 2019) URUGUAY SRI LANKA (implementation guidelines and dates to be determined) Since May 2016, drinks must have a red sugar/100mL) (>11 g sugar per 100 ml) amber (2–11 g sugar per 100 ml) CHILE or green (<2 g per 100 ml) color label. Since June 2016, packaged foods that exceed Mandatory set nutrient thresholds for calories, saturated fat, Voluntary sugar, or sodium are considered “high in” foods Mandatory/voluntary or beverages and must carry black-and-white To be implemented warning labels on the front of pack. Source: Global Food Research Program, University of North Carolina, 2019, ­ http://globalfoodresearchprogram.web.unc.edu/multi-country​ -­initiative/resources/. Note: The map was created based on the dataset available as of March 2019. g = grams; GDA = Guideline Daily Amount; mg = milligrams; 141 ml = milliliter. 142 | Obesity the early systems were focused on creating nutrition profiles for foods that would be banned in child-focused marketing ­ regulations. Several regional WHO offices have created their own nutrient profiling models, including WHO Europe (WHO Regional Office for Europe 2015a), PAHO (PAHO 2016), and other regional WHO ­ offices. The Chilean government created their approach earlier (Corvalán et ­ al. 2018) and is the al. 2013; Corvalán et ­ only nutrient profiling approach adoped as law in other countries (for example, Israel, Peru, U ­ ruguay). In each case, these models focus on removing nonessential or unhealthy ultra-processed foods and b ­ everages. Many other models have been prepared based on an array of criteria, but in general they focus around one of three themes: identifying ultra-pro- cessed foods and beverages, identifying very healthy foods and beverages, and some type of grading system overall or for various nutrient ­components. Another useful guide for implementing a front-of-package label in a coun- try comes from a World Cancer Research Fund document (WCRFI 2019). The Chilean case is highly cited and used as it utilizes its nutrient profil- ing model not only to create a negative warning label on packaged foods but also to ban foods and beverages with the warning label from schools and to use it for a series of marketing ­ laws. This experience has led to three countries that used the exact Chilean approach and cutoffs and a number of others that are considering front-of-package labeling laws similar to Chile’s (for example, Brazil, Colombia, and ­ Mexico). It is increasingly felt by all involved in the areas of promoting healthier eating that such systems are essential for the design of front-of-package labeling, marketing controls, school food services and vendors selling in schools or around schools, and taxation on unhealthy f ­oods. However, aside from Chile—where a half dozen publications to come out possibly in 2020 will identify many aspects of the impact of the Chilean approach— little will be known about the actual impact of such systems on food pur- chasing and overall ­ diets. To date these comprehensive nutrient profiling models have not been utilized for fiscal policies, but at least one country is considering ­this. School Food Services and Food Available at and around Schools A large number of countries have begun to consider or already have poli- cies banning unhealthier foods and beverages and promoting healthier patterns. One of the more innovative is the Brazilian approach, eating ­ which puts a premium on both promoting the use of fresh foods and on employment. The Brazilian approach (Coitinho, Monteiro, small farmer ­ and Popkin 2002), which has become a model emulated by some other countries in both Sub-Saharan Africa and Latin America, requires Addressing Overweight/Obesity: Lessons for Future Actions | 143 30 ­percent of all food to be purchased from local small farmers and another 40 ­ percent to come from real f ­oods. No evaluations have been performed of either the employment impact or the nutritional impact of this program on food consumed at school or overall for children involved in these ­ programs. One key thrust in many countries is removing SSBs from schools and promoting only healthy foods and beverages to be sold or provided in school-based ­ programs. Another relates to vendors either coming into the schools or selling near the s ­ chools. Again, a major gap is in evaluation of such efforts, although several evaluations have been initiated in new pro- grams at the Caribbean Institute for Health Research, University of the West ­Indies. Marketing Controls: Child Oriented and Overall Only a few countries have instituted mandatory regulatory bans on mar- keting oriented toward ­ children. Many are focused on child-oriented tele- vision in a selected time period or other very limited ways (the Republic of Korea, Mexico, Thailand, and ­ Uruguay). The most comprehensive ban occurred in Chile, where the ban does the following: • Applies to all foods and beverages • Uses uniform nutrition criteria across categories • Restricts all characters on packages for foods deemed unhealthy • Adds warning logos to packaged foods high in sugar, saturated fat, sodium, or calories marketed to other audiences • Bans advertising of unhealthy foods when 20 ­ percent or more of the audience is younger than 14 years of age (and, starting June 2018, insti- tuted a regulated foods marketing ban from 6am to 10pm) This law has shifted marketing away from children’s programs toward other ­programs. The overall exposure of children to media, which will be published in 2019 (see Carpentier et ­ al. 2018), has been reduced some- what, as have the child-oriented food and beverage advertisements, but the non–child-oriented advertisements have ­ increased. The Chilean law was modified in June 2018, and now a total ban is in effect on regulated foods and beverages (those with warning labels) from 6am to 10pm; out- side those hours, any marketing must include a clear warning message about the food or beverage under regulation. A future evaluation will be able to describe the added impact of this total marketing b­ an. One impor- tant Chilean study that is currently under review will show no impact on either employment in each food sector or overall and also no impact on wages. Clearly the large companies that make ultra-processed foods real ­ have wide-ranging portfolios of food products to ­ sell. 144 | Obesity There are few countries with mandatory or statutory marketing l ­aws. The Chilean approach is unique in first testing its impact on child-focused marketing and now in addressing total marketing of ultra-processed foods (map 5.7). An additional 30 to 45 countries have voluntary marketing codes worked out by the food and beverage ­ industries. In all evaluations to date, these have proven ineffectual (Théodore et ­ al. 2017). Again, the big gaps lie in the impact of such marketing laws on knowl- edge, attitudes, and, ultimately, b ­ehavior. A second major question is whether it is more important to jointly institute a set of policies as Chile did or to impose separate ones, and to determine what impact a truly effective marketing law would ­ have. It is clear, however, that without control over the marketing of unhealthy food and beverages, which represents a large proportion of ads seen by households in all low- and middle-income countries, it is very difficult—if not impossible—to have effective nutrition education campaigns that focus on healthier ­ eating. Other than Chile, no country has a comprehensive marketing law at this point, but several are currently working on such a l ­aw. In contrast, dozens of countries have ineffectual voluntary industry self-regulation ­ standards. Countries with Any Statutory Regulations on Marketing Food Map 5.7  to Children IBRD 44259 | MARCH 2019 National or regional statutory regulation Source: Global Food Research Program, University of North Carolina, 2019, ­http://­globalfoodresearchprogram.web.unc.edu/multi-country-initiative/resources/. Note: The map was created based on the dataset available as of March 2019. Addressing Overweight/Obesity: Lessons for Future Actions | 145 Retail Sector Clearly it is the increase in the retail sector that has been responsible for opening up both households and small vendors to cheaper, quicker access to ultra-processed food (Popkin and Reardon 2018; Reardon and Berdegué 2002; Reardon et ­ al. 2003). At the same time, improved sanitation and well-managed cold chains for handling most perishable products have resulted, and prices are often lowered—both in financial terms and in terms of time ­expended. There is a growing literature of small experiments in high-income countries in working with retailers to shift consumers toward healthier purchasing ­ patterns. These experiments include shifts in the food available at checkout counters, aisle placement, provision of cold storage options to smaller stores, and in-store marketing s ­hifts. Recently, in the United Kingdom scholars have been working with some large chains to reduce processed meat consumption, which can have both climate and health ­benefits. No country-level efforts have existed to date and these efforts are all very small s­ cale. But this is a promising sector that deserves attention in low- and middle-income countries especially because retailers actually may have higher profit margins from produce and other healthier ­foods. The Broader Food System While there are many studies about the need to shift our food systems toward the promotion of healthier foods and beverages, and although the Consultative Group on International Agricultural Research (CGIAR) investment in legume and produce has increased, this sector has done relatively little to truly invest in studies on the array of credit, price, subsidy, and other policies that might be used to incentivize the entire ­ everages. food chain toward shifts in relative costs of healthier foods and b The World Bank, the Food and Agriculture Organization of the United Nations (FAO), and many others speak about the food system and the need to promote healthier options at cheaper prices, but there are few actual impact evaluations or even process studies to show for this and no set of programs to promote ­ globally. The World Bank’s Agriculture Global Practice has expended considerable time in considering options for improving the food system (Htenas, Tanimichi-Hoberg, and Brown 2017; Townsend et ­ al. 2016), where growing evidence shows that the entire food chain is increasingly being controlled directly by agribusi- nesses, food manufacturers, large retailers, and the food service sector (Popkin and Reardon 2018; Reardon, Timmer, and Minten 2012; Reardon et ­ al. 2015). 146 | Obesity Cross-Cutting Multisectoral Healthy Eating–Related Initiatives In 2007 the United Kingdom produced a Foresight Report on overweight/ obesity that began with a terribly complex model of all the causes of ­ overweight/obesity. Out of this report, the government initiated across most sectors focused activities all related to promoting long-term changes in both diet and physical activity (Foresight 2007; McPherson, Marsh, and Brown 2007). Programs and policies were initiated in dozens of ­ areas. However, a shift in governments and the cutting of funding for most of the off. This is a remarkable program occurred before this effort could truly take ­ example, however, of how systems analysis, when linked to actual funding and program initiation in dozens of sectors, can focus on overweight/obe- sity ­prevention. Physical Activity, Building Design, and Transportation- Related Policies The major global push on physical activity has been to find ways to reduce sedentary behavior and increase movement and activity through urban planning, the design of the built environment, and the provision/promo- tion of public transport and active mobility options (box 5.2). These can range from land-use and transportation policies to integrated regional and local land-use policies and building and street d­ esign. But it is very clear we cannot remove many of the technologies that have significantly reduced activity in the economic and home sectors and in ­ transportation. There is a much better-established literature on how various aspects of design and construction in the physical activity domain can impact movement. While there are several reviews and broader documents on city design and physical activity (Reis et ­ al. 2016; al. 2016; Sallis, Bull et ­ Sallis, Cerin et ­al. 2016; WHO 2018), few large-scale evaluations in low- and middle-income countries show major effects on a ­ctivity. Rather the literature focuses on studies of cities and areas in cities from high-income countries to document potentially important low- and middle-income country i ­nterventions. The four most important options that have the potential to be impactful are listed ­below. Clearly transportation and urban design as well as the education sectors are fertile areas for major ­ impacts. • Integrating regional and local land-use and transportation interventions can address increasing urban density, design, destination accessibility, dis- tance to public transport, and desirability of movement in ­ neighborhoods. Addressing Overweight/Obesity: Lessons for Future Actions | 147 BOX 5.2 Links between Active Transport and Overweight/ Obesity Walking and bicycling, also known as active transport or nonmotor- ized transport, are very important modes for people to access jobs, schools, and services, especially in the cities of the developing w ­ orld. Active transport has also been suggested as an option to promote physical activity and to fight both sedentarism and overweight/obe- sity levels, although there is very limited research to date to establish a causal ­ link. A cross-sectional study by Evi Dons and collaborators (Dons et  ­ al. 2018) used data from seven European cities and found statistical evidence to suggest that car users have a higher body mass index (BMI) than bicycle ­ users. One of the fundamental reasons that active transport has been promoted as an option to reduce overweight/obesity is the low cost of the interventions (such as sidewalks and bikeways) and the possi- bility of targeting large user ­ populations. In a scoping review pre- sented by Brown et ­ al. (2017), the authors mention that active trans- port can have very small impacts on BMI, but they also clarify that “active transport interventions that are low cost and targeted to those most amenable to modal switch are the most likely to be effec- tive and cost-effective from an obesity prevention p ­erspective.” Promoting active transport in cities may therefore be a cost-effective way of controlling ­ BMI. Since the evidence seems to point toward relatively small effects on body weight, the effectiveness of the mea- sures will greatly depend on the size of the population being served by the ­ interventions. It is important to mention that promoting active modes of trans- port has a plethora of co-benefits that help cities achieve other health and environmental objectives beyond overweight/obesity levels. The health benefits of physical activity go beyond weight loss, ­ with conclusive literature showing the benefits of active transport associated with mental health (Avila-Palencia et  ­ al. 2018; Mueller et ­al. 2015) and significant levels of reduction in all-cause mortality (Mueller et  ­ al. 2018). When an increase in bicycling and walking is promoted as modal shift from personal motorized transport, these changes also imply reductions in both greenhouse gas and local pollutant emissions (Xia et  ­ ­ al. 2013). Despite some evidence high- lighting the negative effects that higher exposures and inhaled doses of air pollutants can have on active travelers, the most recent continued next page 148 | Obesity Box 5.2 (continued ) evidence suggests that health benefits outweigh the possible negative outcomes (Tainio et ­ ­ al. 2016). Promoting active transport in a safe and appropriate built environ- ment may therefore help cities not only control the rise of overweight/​ obesity levels but may do so in a cost-effective way with additional co-benefits that address several Sustainable Development ­ Goals. Few other interventions in cities can have such strong impacts across ­multiple development ­agendas. Some of the major experiments and larger-scale studies have come from high-income countries (for example, Perth’s Residential Environment work to create walkable areas and then add other facets of urban design to al. 2013; Knuiman et ­ increase physical activity; see Giles-Corti et ­ al. 2014). Few have been rigorously evaluated, but some lessons can be learned from these ­ efforts. • Promoting walking, cycling, and the use of public transport over per- sonal motor vehicles such as cars and motorcycles is an important area of intervention with a great deal of p ­otential. An array of cities—­ including many higher-income ones such as London and Stockholm— have done this; other lower-income cities such as Bogotá have also attempted ­ this. However, none have been evaluated for ­ impact. • Building design that increases stair climbing by making stairs more attractive and central and escalators and elevators less attractive is another area with ­ potential. • Involving schools and other government facilities in these efforts can have decisive ­ results. Schools, in particular, which have discounted the important value of activity on learning and cognitive ability as well as on health, need to rethink their curricula and experiment with wide ranges of ways to increase movement as well as provide skills in activities that ­ifetime. In the past 20 years across the globe there has been a can last a l marked reduction in physical activity in schools as well as in facilities and equipment for physical activity, as the push to enhance learning has led to a short-sighted focus on cutting out physical activity, particularly vigorous ­activities. It is important to note that in the area of physical activity improvements and overweight/obesity prevention there is a need for evaluation of Addressing Overweight/Obesity: Lessons for Future Actions | 149 large-scale urban or national programs to document their impacts on pop- ulation-level activity patterns, which can in turn be linked to ­ overweight/ obesity. No evaluations equivalent to the Chilean or Mexican rigorous eval- uations of their food-related fiscal and regulatory policies exist as yet in the physical activity ­ domain. Lessons for Overweight/Obesity Prevention Strategies from Nine Country Case Studies The nine country case studies included for this review were developed as background papers for these ­ analyses. They present different strategies and processes that have been implemented by governments to prevent and manage obesity among children and a ­ verview. ­ dults. Table 5.3 presents an o Most countries have some national strategy or plan to manage NCDs or overweight/obesity. School-based prevention programs are common, as ­ childhood overweight/obesity is a growing concern globally and a predictor for overweight/obesity in ­ adulthood. National strategies or p ­ rograms. Several governments have man- dated expert groups to develop national strategies to curb ­ overweight/obe- sity. Some countries, albeit not all, include overweight/obesity management as part of their broader NCD ­ strategies. Only one country (Brazil) has focused on access to healthy, nonprocessed foods, and two of the nine (Poland and Thailand) include a focus on playgrounds for promoting physi- cal ­activity. • The Mexican government in 2010 adopted the National Agreement for Healthy Nutrition: Strategy against Overweight and Obesity ( ­ANSA). The food and beverage industry, academia, and NGOs are all co-­ signatories of ANSA together with the ­ government. ANSA established three pillars of action: (1) public health, including epidemiological sur- veillance, health promotion, and prevention actions; (2) medical atten- tion, comprising quality and effective access to primary health care services; and (3) ­ regulatory and fiscal policies in areas such as labeling, regulation of marketing strategies, and fiscal instruments to promote healthier ­lifestyles. The Mexican ANSA strategy includes recommenda- tions for physical activity, safe drinking water, moderate consumption of sugars and fats in drinks, daily intake of fiber, food labeling to inform decision-making, exclusive breastfeeding, appropriate portion sizes, as well as reduced intakes of saturated fats, sodium, and added caloric sweeteners. In Mexico, the development of the national ANSA strategy has helped generate a national dialogue on overweight/obesity and put the topic on the government’s ­ agenda. 150 | Obesity Table 5.3 Overview of Strategies and Processes to Prevent and Manage Overweight/Obesity Kerala South Sri Strategy/Policy Mexico Brazil Chile (India) Poland Thailand Africa Lanka Turkey National strategy/program X X Food NCD NCD X X NCD X law strategy strategy strategy Initiatives for government entities X X X X X School-based prevention X X X X X X X Regulations on marketing and X X X X advertisement of unhealthy food and beverages Mass media to inform about healthy diet X X X X Food labeling X X X X X X X Nutritional education in primary school X X X curriculum Access to healthy, nonprocessed food X markets Physical activity (playgrounds) X X School health survey screening for X X X X X X overweight Note: NCD = non-communicable ­ disease. Addressing Overweight/Obesity: Lessons for Future Actions | 151 • Brazil takes a multisectoral approach to improve nutritional outcomes through the Intersectoral Strategy to Prevent and Control Obesity, the National Pact for Healthy Eating, and policies to ensure access to healthy ­food. • Chile has perhaps the most aggressive multisectoral program to address overweight/obesity, as highlighted in the sections ­ above. • Kerala addresses overweight/obesity as part of its National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), which focuses on early diagnosis, treatment, and behavior change in family health ­ centers. • Poland introduced in 2006 the first National Program for the Prevention of Overweight and Obesity and Chronic Non-Communicable Diseases through Improved Nutrition and Physical Activity 2007–2011. In 2012, the program was extended as the National Program for the Prevention of Non-Communicable Diseases 2012–2014. Both programs highlight the role for central and local governments in health policies and prevention of ­NCDs. • The Thailand Healthy Lifestyle Strategic Plan promotes healthy food consumption and physical ­ activity. • South Africa has the National Strategy for the Prevention and Control of Obesity (2015–2020). • Sri Lanka developed and adopted the Multisectoral Action Plan for the Prevention and Control of Non-Communicable Diseases 2016–2020, which aims to reduce the preventable and avoidable burden of morbid- ity, mortality, and disability due to ­ NCDs. • Turkey developed the Healthy Nutrition and Active Life (HNAL) Program in 2010 to control ­overweight/obesity. The program aims to (1) improve equitable access to basic healthy foods for a balanced and healthy diet; (2) allocate resources to fight overweight/obesity in all sectors and to include fighting overweight/obesity in sector plans; (3) conduct an anal- ysis of the overweight/obesity situation in Turkey for different popula- tion groups; and (4) establish a monitoring and evaluation system to regularly track overweight/obesity ­ progression. Countries such as Chile that have put in place multipronged strategies are starting to show results (figure 5.1). Initiatives. In line with national strategies and agreements, govern- ments have established various initiatives for government agencies to regu- late unhealthy dietary i­ntake. Initiatives include policies and actions to be implemented across different government ­ entities. For example, the Fatless Belly Thais policy in Thailand includes various initiatives for different gov- ernment agencies to implement, and Sri Lanka has set up the Nutrition Coordination Division within its Ministry of H ­ ealth. Mexico’s Health 152 | Obesity Figure 5.1 Chile’s Multipronged Obesity Prevention Program HIGH ENERGY, [SATURATED] FRONT-OF-PACKAGE WARNING LABELS FAT, SALT, OR SUGAR Regulated foods are required to carry a warning label for each nutrient/ (HEFSS) FOODS AND ingredient exceeding set thresholds. BEVERAGES ARE SUBJECT TO: MARKETING RESTRICTIONS 1. RESTRICTED ADVERTISING NUTRIENT PROFILING (added June 2016) HEFSS products may not advertise in any of the following: IDENTIFIES FOODS HIGH IN - On dedicated children’s TV channels or websites - During programs/movies or on websites targeting children • Added sugar - When child audience share >20%. • Added sodium ADDED JUNE 2018 • Added saturated fat - Advertising ban from 6:00 am to 10:00 pm (in TV and cinema) • Energy density (if also contains added - Warning messages required on advertising outside this time frame. sugar or saturated fat) 2. RESTRICTED TECHNIQUES TO APPEAL TO CHILDREN HEFSS may not use the following in any marketing: Thresholds as of June 27, 2019 - Characters, child figures, animations, or cartoons (including brand - 275 kcal per 100 g (beverages 70 kcal per 100 ml) equity characters) or people, animals that capture children’s interest - Children’s music - 400 mg sodium per 100 g (100 mg per 100 ml) - Premiums, toys, accessories, or stickers - 10 g total sugar per 100 g (5 g per 100 ml) - Statements or fantastic arguments about the products or its effects - 4 g saturated fat per 100 g (3 g per 100 ml) - Situations that represent children’s daily life, expressions, language - Interactive applications, games, contests - Applies to all products (that is, no food or - “Hooks” not related to the products itself. beverage groups are exempt) and criteria are SCHOOL-BASED RESTRICTIONS uniform across categories. HEFSS products cannot be sold or advertised inside preschool, elementary, or secondary schools. FUTURE TAXATION There are plans to add a large tax on foods identified as HEFSS (in addition to existing sugar-sweetened beverage tax). Source: Institute of Nutrition and Food Technology, University of Chile and Global Food Research Program, University of North Carolina. Note: g = grams; HEFSS = high energy, saturated fat, salt, or sugar; kcal = kilocalorie; mg = milligrams; ml = milliliter. Secretariat launched a National Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes signed by the president and all cabinet al. 2016). Brazil used a wide-ranging consul- secretaries (Bonilla-Chacín et ­ tative process to establish several initiatives, the most far-reaching being the school feeding initiative to enhance fresh food use in school meals (Coitinho, Monteiro, and Popkin 2002). In 2011, Turkey created a Healthy Nutrition and Active Life ­Program. School-based prevention p ­ rograms. To manage overweight/obe- sity early on, governments have introduced school-based childhood overweight/obesity prevention programs that can include policies for healthy food and food service practices, restricted access to unhealthy food, physical education, student health services, and staff health and ­nutrition. • In Mexico, the Ministry of Education has issued school guidelines to regulate the sale and distribution of foods and drinks in schools and pro- mote healthy ­ eating. • The School Meal Program Law in Brazil requires healthy ingredients in meals and 30 ­ percent of the school meal budget to be spent on healthy Addressing Overweight/Obesity: Lessons for Future Actions | 153 fresh food produced by local ­ farmers. SSBs are not allowed as part of school meals in ­Brazil. • Chile’s Food Law restricts the type of food that can be sold and distrib- uted within ­schools. • Poland regulates school food including the type of food sold in school shops. cafeterias and ­ • SSBs. Thailand has a soda ban policy in schools for ­ • In Sri Lanka, the School Canteen Program aims to prevent and control overweight/obesity by providing healthy food to ­ children. • Turkey has two school-based interventions that were initiated by the Ministry of Health: restrictions on the type of food and beverages sold in school canteens and a Physical Fitness Scorecard for Health to encourage physical activity among children in secondary and high schools through personalized fitness ­schemes. School-based programs have not been evaluated in these c ­ountries. However, studies from the United States find encouraging results for school-based programs that combine diet and physical activity (Hung et ­ al. 2015; Wang et ­ al. 2015). A meta-analysis of 27 programs found that school-based interventions have not been effective for improving body mass index or curbing childhood overweight/obesity; however, programs that focused on physical activity or nutrition have shown promising results (Hung et ­ al. 2015). Another meta-analysis of 115 school-based studies from the United States came to similar conclusions, with stronger evi- dence when physical activity–only interventions were delivered in schools with home involvement or diet and physical activity interventions were combined and delivered in schools with both home and community com- ponents (Wang et ­ al. 2015). Laws and regulations on marketing and a ­ dvertisement. Regulations aim to restrict food and beverage advertisements on tele- vision during family program times and in movie ­ theaters. In Mexico, only products meeting nutritional standards can be advertised during screen time appropriate for children, including on television and in movie theaters. Brazil mandated warning messages of health risks to accompany ­ advertisements for unhealthy foods and beverages; however, this regula- tion was challenged in court by the food industry and had to be ­ abolished. Chile also initially prohibited unhealthy food advertisement directed at children under 14 years, which has been modified as a total marketing ban on regulated foods through any media form from 6:00 am to 10:00 pm daily. Unhealthy food cannot be sold or distributed in nurseries, ele- ­ mentary schools, or high schools and it is forbidden to give it for free to children. In South Africa, the Advertising Standards Authority (ASA) reg- ­ ulates the advertisement and marketing of unhealthy food and beverages. 154 | Obesity The ASA prohibits misleading food marketing and advertisement tactics via any form of media, including enticing children with toys and using celebrities and cartoon characters to advertise unhealthy food products children. Some lessons from the ­ to ­ marketing of infant formula may also apply ­here. Food ­labeling. Regulations on food labels require that food products provide information about their ­ content. In Chile, the Food Law requires front-of-package labeling with nutrition information clearly identifying products high in sugar, saturated fat, sodium, or calories (Corvalán et ­ al. 2019). Foods high in sugar have more than 10 grams of sugar per 100 grams of food; foods high in saturated fat have more than 4 grams of satu- rated fat per 100 grams of food; those high in sodium have more than 400 milligrams of sodium per 100 grams of food, and foods are considered high in calories if 100 grams of food exceeds 275 k ­ ilocalories. For liquids, the thresholds are per 100 milliliters: 5 grams for sugar, 3 grams for saturated fat, 100 milligrams for sodium, and 70 kilocalories for energy d ­ rinks. In Sri Lanka, the food labeling and advertising regulations require that packaged food have the required food l ­abeling. The Food Based Dietary Guidelines for Sri Lankans 2011 recommends an intake of no more than 25 grams of sugar per day per ­ person. The Food Color Coding Regulation was enacted in 2016. Traffic light colors—green, amber (yellow), and red—are now used on the label to indicate low, medium, and high levels, respectively, of sugar. Implementation of the regulations is monitored by Public Health Inspectors and Food and Drug I ­nspectors. Thailand instituted a Healthy Choice–type voluntary front-of-package labeling program in 2016 pat- terned after the Choices International Program and the Smart Choice pro- gram used in Singapore (Foo et ­ al. 2013; Roodenburg, Popkin, and Seidell 2011). Peru, in 2019, started a program identical to the Chilean warning label system; Israel will follow in 2020 (Endevelt et ­ al. 2017). Both start with the Chilean second phase’s more stringent lower added sodium, added saturated fat, and added sugar ­ cutoffs. Information through mass ­ media. Governments and social health insurers have used mass media such as television and radio to inform the population about prevention of o ­verweight/obesity. Mexico has added information sessions for people who visit employment centers and health care ­facilities. The Fatless Belly Thais policy creates public awareness about diet and physical activity through mass media and through cross-sectoral collaboration. Visual versions of dietary guidelines help ensure easy under- ­ standing across socioeconomic ­ groups. Nutritional ­education. Nutritional guidelines in school curricula have been issued by ministries of health and have become part of the curriculum in primary schools in Mexico, Brazil, and ­ Chile. Both foods and beverages are ­included. Addressing Overweight/Obesity: Lessons for Future Actions | 155 Access to healthy, nonprocessed ­ food. Access to healthy food influ- ences dietary ­behavior. Brazil has issued guidelines to improve equity in access to healthy food, particularly in low-income areas and in s ­chools. Guidelines promote family farming, sustainable farming methods, and agri- culture marketing, and they facilitate access to food markets in low-income ­areas. Physical ­activity. The Ministry of Sports in Poland has introduced a national initiative to increase opportunities for physical activity in all communities, including the construction of playgrounds for children, soccer and basketball fields, and so o ­ n. Thailand promotes regular physical activity through national policy including public and private ­ sector platforms to promote exercise and physical activity close to home, workplace, and c ­ ommunity. The focus is on public parks, the mass transport system, and urban development to encourage exercise and ­activity. School health s ­urveys. Countries conduct regular national school health surveys to monitor children’s health ­ status. • The 2008 school health survey in Mexico identified a high prevalence of overweight in children, which led to the development of the national strategy ­ANSA. • The school health survey in Brazil is mandated by law and helps policy makers monitor students’ nutrition status and health behavior and inform school health policies. • The Polish Gdan ’ sk region introduced overweight screening and intense case management for children in elementary and middle schools. Children with a BMI above the 85th ­ percentile receive one year of case management, including four visits with health care pro- viders (pediatrician, dietician, psychologist, and physical activity trainer) and workshops on nutrition and physical activity for children and their families. • Turkey conducted the Childhood Obesity Initiative survey in 2013, which found an increase in childhood overweight/obesity among all age ­groups. Key Interventions with Potential for Impact Policies that restrict unhealthy foods and beverages tend to be challenged by the food and beverage industry and by stakeholders when they face dif- ficulties finding consensus on the types of foods and beverages to be restricted. As there are no internationally recommended threshold levels ­ for sugar intake, the process for establishing parameters for products with low, medium, or high sugar content can become ­ challenging. 156 | Obesity The implementation of strategies and guidelines requires budgets, imple- mentation support, and monitoring and evaluation to ensure they achieve ­ djustments. For example, insufficient budgetary their objective and allow a resources, poor collaboration, and inadequate monitoring and evaluation have contributed to less effective guidelines in M ­ exico. In Poland, the lack of human and financial resources has limited program implementation, and the school meal guidelines were too technical and restrictive and were not accurately ­communicated. Moreover, local food vendors were not ade- quately informed so they could adjust their supplies in t ­ime. As a result, children reacted by bringing their own foods and beverages to s ­chool. Guidelines were adjusted to be less restrictive on ingredients such as sugar and salt ­ content. The soda ban policy in schools in Thailand does not ban unhealthy foods, and it does not apply to vendors near ­ schools. Table 5.4 provides a summary of an actionable policy agenda based on the evidence and experience of the countries discussed in this ­ chapter. Based on our current knowledge of each item, we assess its potential impact as well as the population that can be reached by each ­ policy. Table 5.4 Key Interventions with Potential for Impact Policy Effectiveness Potential impact and scope of Intervention type Goal demonstrated impact on target population Fiscal policies  Taxes/subsidies Reduce Chile, Mexico, • Impact depends on the size/ consumption of United design of the tax ultra-processed Kingdom, and • Nutrient-based taxes such as foods and South Africa tiered taxes and taxes based beverages, [papers on number of grams of primary focus to forthcoming]; sugar promote reformulation date on sugar- U.S. cities • Impactful in reducing sweetened consumption among beverage high-volume consumers, reduction with potential for prevention of overweight/obesity among children/adolescents Regulatory policies on marketing and advertising Front-of-   Reduce Chile • Very impactful when package consumption of [unpublished combined with other linked warning labels ultra-processed series of policies foods and papers • Universal targeting beverages; change forthcoming] eating norms continued next page Addressing Overweight/Obesity: Lessons for Future Actions | 157 Table 5.4 (continued) Policy Effectiveness Potential impact and scope of Intervention type Goal demonstrated impact on target population  Marketing Reduce Chile, many • Potential for impact when controls on consumption of others linked to other policies foods for ultra-processed • Can reduce child exposure; children foods and total family exposure does beverages; change not change eating norms  Regulations on Reduce Chile • Potential for changing norms total consumption of • Reaches all children; more marketing and ultra-processed impactful on younger sales of foods and children unhealthy beverages; change foods eating norms  Retailer Reduce United States, • Potential for high impact interventions consumption of United • Potential for important food ultra-processed Kingdom purchase changes foods and beverages Agriculture/food systems approaches  Agriculture Incentivize CGIAR • Potential for high impact research research on • Potential to shift relative underserved foods prices (legumes, fruits, vegetables) Ensure agriculture CGIAR, • Potential high in general; research has a country only initial stages of efforts nutrition focus, programs globally not just a yield • Potential huge for shifting focus relative food prices  Agriculture Eliminate subsidies Yet to be • Potential impact unclear for subsidies for unhealthy implemented shifting relative prices; but ingredients (for could provide fiscal benefits example, sugar, for countries corn, palm oil)  Food Build awareness of Yet to be • Potential impact unclear processing unhealthy implemented ingredients used in food processing continued next page 158 | Obesity Table 5.4 (continued) Policy Effectiveness Potential impact and scope of Intervention type Goal demonstrated impact on target population  Formal food Reduce None • Potentially impactful service sector consumption of • As income increases, the ultra-processed proportion of meals eaten foods and outside the home increases beverages rapidly, so the potential impact rises • Dependent on laws impacting pricing policies, labeling, sizing  Informal food Reduce Singapore • Great potential but requires service sector consumption of experimentation (existing ultra-processed experience shows limited foods and impact as focus is on beverages sanitation, healthy oils; no pricing/portion controls used) Education sector approaches  School food Reduce CGIAR, • Potential high; only initial service quality consumption of country stages of efforts globally and school ultra-processed programs • Potential huge for shifting premises sales foods and relative food prices regulations beverages; change eating norms for children Active transport and building/city design Mass transit   Increase None • Minimal potential for impact system movement, energy on overweight/obesity but expenditure important for health and climate • Mostly affects low- and middle-income populations  City design: Increase Colombia, • Potential for impact among parks, cycling movement, energy Netherlands, users lanes expenditure United Kingdom  Building Increase Europe, • Minimal impact on design to movement, energy United States, overweight/obesity but enhance expenditure Australia important for health walking • Potential for increasing physical activity continued next page Addressing Overweight/Obesity: Lessons for Future Actions | 159 Table 5.4 (continued) Policy Effectiveness Potential impact and scope of Intervention type Goal demonstrated impact on target population Early childhood nutrition programs  Breastfeeding Improve Many • Impact global as promotion breastfeeding countries documented across many rates low-, middle-, and high- income countries  Prevention of Well-documented Many • Relevant mostly for early childhood package of countries low-income countries and stunting interventions some middle-income across sectors countries Note: CGIAR = Consultative Group on International Agricultural Research. Applying the right combinations of policies and interventions in the right country context seems to be key to s ­uccess. Furthermore, building national capacity to design, monitor, and implement these interventions, as well as documenting their experiences and impacts, is critical to continue to build the evidence base of what works under different ­contexts. Notes 1. Further information about the Health Promotion Levy on Sugary Beverages in South Africa is available at ­ http://www.sars.gov.za/ClientSegments​ /­Customs-Excise/Excise/Pages/Health%20Promotion%20Levy%20on%20 Sugary%20­Beverages.aspx. 2. Details about the Philadelphia beverage tax can be found at h ­ ttps://www​ .phila.gov/services/payments-assistance-taxes/business-taxes/philadelphia​ -beverage-tax/. 3. Per the exchange rate of April 19, 2018, US$1 equals 65.68 Indian ­rupees. 4. Details about the Choices Programme can be found at h ­ttps://www​ .­choicesprogramme.org/. 5. The French Nutri-Score is a system that gives all foods a grade from A to E based on a complex diet quality scoring system (Julia and Herchberg 2017). References M., ­ Alvarado, ­ N. Unwin, S ­.­J. Sharp, I ­. Hambleton, ­M. ­M. Murphy, T A. Samuels, ­. ­ M. Suhrcke, and ­ ­ Adams. 2019. “Assessing the Impact of the Barbados Sugar- J. ­ Sweetened Beverage Tax on Beverage Sales: An Observational S ­tudy.” . International Journal of Behavioral Nutrition and Physical Activity 16 (1): 13­ 160 | Obesity Avila-Palencia,I., ­ L. ­I. Panis, ­E. Dons, ­ M. Gaupp-Berghausen, ­ E. Raser, ­T. Götschi, R. Gerike, ­ ­ C. Brand, ­ A. de Nazelle, ­ J. ­P. Orjuela, ­ E. Anaya-Boig, E ­ . Stigell, S. Kahlmeier, ­ ­ F. Iacorossi, and ­ M. ­ J. ­Nieuwenhuijsen. 2018. “The Effects of Transport Mode Use on Self-Perceived Health, Mental Health, and Social Contact Measures: A Cross-Sectional and Longitudinal ­ Study.” Environment International 120 (2018): 199–206. Azar, ­ A. 2018. Development and Implementation Processes of the Food Labeling and Advertising Law in ­ Chile. Global Delivery I ­nitiative. Washington, DC: World ­Bank. Barrientos-Gutierrez, ­ R. Zepeda-Tello, ­ T., ­ E. ­R. Rodrigues, ­ A. Colchero-Aragonés, R. Rojas-Martínez, ­ ­ E. Lazcano-Ponce, ­ M. Hernández-Ávila, ­ J. Rivera- Dommarco, and ­ R. ­Meza. 2017. “Expected Population Weight and Diabetes Impact of the 1-Peso-Per-Litre Tax to Sugar Sweetened Beverages in M ­ exico.” PLOS ONE 12 (5): e0176336. Batis, ­ J. ­ C., ­ A. Rivera, ­ B. ­M. Popkin, and ­ S. ­ L. ­ Taillie. 2016. “First-Year Evaluation of Mexico’s Tax on Nonessential Energy-Dense Foods: An Observational S ­ tudy.” PLOS Medicine 13 (7): e1002057. Begg, ­ D., ­ S. Fischer, and ­ Dornbusch. 2000. Economics (6th ­ R. ­ ed). New York: ­McGraw-Hill. Berardi, ­ N., ­ P. Sevestre, ­ M. Tepaut, and ­ Vigneron. 2016. “The Impact of a ‘Soda A. ­ Tax’ on Prices: Evidence from French Micro D ­ ata.” Applied Economics 48 (41): 3976–94. Bergman, ­ U., and N ­ . Lynggård ­ Hansen. 2016. “Are Excise Taxes on Beverages Fully Passed through to Prices? The Danish E ­ vidence.” ­ FinanzArchiv 10.1628/fa​ -2019-0010. Bonilla-Chacín, ­ M. ­ E., ­R. Iglesias, ­ A. Suaya, C ­ . Trezza, and ­ C. ­Macías. 2016. “Learning from the Mexican Experience with Taxes on Sugar-Sweetened Beverages and Energy-Dense Foods of Low Nutritional Value: Poverty and Social Impact ­ Analysis.” Health, Nutrition and Population Discussion P ­ aper. World Bank, Washington, ­ DC. Bonnet, ­ C., and ­ Réquillart. 2013. “Tax Incidence with Strategic Firms in the Soft V. ­ Drink ­Market.” Journal of Public Economics 106: 77–88. Briggs, ­ A. ­ D. ­ M., ­O. ­T. Mytton, ­ A. Kehlbacher, ­ R. Tiffin, ­ A. Elhussein, ­M. Rayner, ­ S. ­A. Jebb, ­ T. Blakely, and ­ Scarborough. 2017. “Health Impact Assessment of P. ­ the UK Soft Drinks Industry Levy: A Comparative Risk Assessment Modelling ­Study.” The Lancet Public Health 2 (1): e15–e22. Brown, ­ V., ­M. Moodie, ­ A. ­M. Mantilla Herrera, J L. Veerman, and R ­. ­ ­ .­ Carter. 2017. “Active Transport and Obesity Prevention: A Transportation Sector Obesity Impact Scoping Review and Assessment for Melbourne, ­ Australia.” Preventive Medicine 96: 49–66. Brownell, ­ D., ­ K. ­ T. Farley, ­W. ­C. Willett, ­ B. ­ M. Popkin, ­ J. Chaloupka, ­ F. ­ W. Thompson, J. ­ and ­ D. ­S. ­Ludwig. 2009. “The Public Health and Economic Benefits of Taxing Sugar- Sweetened ­Beverages.” New England Journal of Medicine 361 (16): 1599–605. Capacci, ­ S., ­O. Allais, ­C. Bonnet, and ­ M. ­ Mazzocchi. 2016. “The Impact of the French Soda Tax on Prices and Purchases: An Ex Post E ­ valuation.” Preliminary ­ paper. ­https://www.aeaweb.org/conference/2019/preliminary/paper/Ni9­ZDaQD. Addressing Overweight/Obesity: Lessons for Future Actions | 161 Caro, ­ J. ­C., ­C. Corvalán, M ­ . Reyes, A ­ . Silva, B ­ . Popkin, and L S. ­ ­. ­ Taillie. 2018. “Chile’s 2014 Sugar-Sweetened Beverage Tax and Changes in Prices and Purchases of Sugar-Sweetened Beverages: An Observational Study in an Urban ­Environment.” PLOS Medicine 15 (7): e1002597. Caro, ­ J. ­C., ­S. ­W. Ng, ­ R. Bonilla, ­ J. Tovar, and ­ B. ­M. ­Popkin. 2017. “Sugary Drinks Taxation, Projected Consumption and Fiscal Revenues in Colombia: Evidence from a QUAIDS ­ Model.” PLOS One, December 20. ­ https://doi.org/10.1371​ ­/­journal.pone.0189026. Caro, ­ J. ­C., ­ S. ­W. Ng, ­ L. ­S. Taillie, and ­ B. ­M. ­ Popkin. 2017. “Designing a Tax to Discourage Unhealthy Food and Beverage Purchases: The Case of ­ Chile.” Food Policy 71: 86–100. Carpentier, ­ T. Correa, M F., ­ ­ . Reyes, and L ­.­Taillie. 2018. “Preschool and Adolescent Children’s Changes in Exposure to Food Advertising on Television: Evaluating the Impact of Chile’s Marketing Regulation of Unhealthy Foods and ­Beverages.” Presentation at the Latin American Nutrition Society Congress (SLAN), Guadalajara, November 11–15. Cawley, ­ D. Frisvold, A J., ­ ­ . Hill, and D ­.­ Jones. 2018. “The Impact of the Philadelphia Beverage Tax on Purchases and Consumption by Adults and ­ Children.” NBER Working Paper 25052. National Bureau of Economic ­ Research, Cambridge, MA. ­https://www​.nber.org/papers/w25052. Cediel, ­ G., ­M. Reyes, ­ M. ­L. da Costa Louzada, ­ E. Martinez Steele, ­ A. Monteiro, C. ­ ­ C. Corvalán, and ­ Uauy. 2017. “Ultra-Processed Foods and Added Sugars in R. ­ the Chilean Diet (2010).” Public Health Nutrition 21 (1): 125–33. Chakrabarti, ­ A. Kishore, and ­ S., ­ D. ­Roy. 2018. “Effectiveness of Food Subsidies in Raising Healthy Food Consumption: Public Distribution of Pulses In I ­ndia.” American Journal of Agricultural Economics 100 (5): 1427–49. Coitinho, ­ D., ­ C. ­A. Monteiro, and ­ B. ­M. ­Popkin. 2002. “What Brazil Is Doing to Promote Healthy Diets and Active ­ Lifestyles.” Public Health Nutrition 5 (1A): 263–67. Colchero, ­ M. ­ B. ­ A., ­ M. Popkin, J ­.­A. Rivera, and S W. ­ ­ .­ Ng. 2016. “Beverage Purchases from Stores in Mexico under the Excise Tax on Sugar Sweetened Beverages: Observational ­Study.” BMJ 352: h6704. Colchero, ­ M. ­ J. Rivera-Dommarco, B A., ­ ­ .­ M. Popkin, and S W. ­ ­ .­ Ng. 2017. “In Mexico, Evidence of Sustained Consumer Response Two Years after Implementing a Sugar-Sweetened Beverage ­ Tax.” Health Affairs 36 (3): 564–71. Colchero, ­ M. ­ A., ­ C. Salgado, ­ J. ­ M. Unar-Munguía, ­ M. Hernández-Ávila, and J. ­ ­ A. ­Rivera-Dommarco. 2015. “Price Elasticity of the Demand for Sugar Sweetened Beverages and Soft Drinks in ­ Mexico.” Economics and Human Biology 19: 129–37. Colchero, ­ M. ­ A., ­ J. ­C. Salgado, M ­ . Unar-Munguía, ­ M. Molina, S ­. Ng, and ­ J. ­ A. ­Rivera-Dommarco. 2015. “Changes in Prices After an Excise Tax to Sweetened Sugar Beverages Was Implemented in Mexico: Evidence from Urban ­Areas.” PLOS ONE 10 (12): e0144408. Colchero, ­ M. ­ J. ­ A., ­ A. Zavala, ­ C. Batis, ­ T. Shamah-Levy, and ­ A. ­ J. ­ Rivera-Dommarco. 2017. “Changes in Prices of Taxed Sugar-Sweetened Beverages and Nonessential Energy Dense Food in Rural and Semi-Rural Areas in ­ Mexico.” Salud Pública de México 59 (2): 137–46. 162 | Obesity Correa, ­ T., ­C. Fierro, ­ M. Reyes, ­ F. ­ R. Dillman Carpentier, ­ S. Taillie, and ­ L. ­ Corvalan. C. ­ 2019. “Responses to the Chilean Law of Food Labeling and Advertising: Exploring Knowledge, Perceptions and Behaviors of Mothers of Young ­ Children.” International Journal of Behavioral Nutrition and Physical Activity 16 (1): 21. Corvalán, ­ C., ­M. Reyes, ­ M. ­L. Garmendia, and R ­ .­Uauy. 2013. “Structural Responses to the Obesity and Non-Communicable Diseases Epidemic: The Chilean Law of Food Labeling and ­ Advertising.” Obesity Reviews 14: 79–87­ . ———. 2018. “Structural Responses to the Obesity and Non-Communicable Diseases Epidemic: Update on the Chilean Law of Food Labelling and ­Advertising.” Obesity Reviews 20 (3): 367–74. Crockett, ­ A., ­ R. ­ E. King, T S. ­ ­.­M. Marteau, A ­ .­T. Prevost, G ­ . Bignardi, N ­ .­W. Roberts, B. Stubbs, ­ ­ G. ­ J. Hollands, and ­ S. ­ A. ­ Jebb. 2018. “Nutritional Labelling for Healthier Food or Non-Alcoholic Drink Purchasing and ­ Consumption.” The Cochrane ­ Library. de Walque, ­ D. 2018. “The Use of Financial Incentives to Prevent Undesirable ­ Behaviors.” Policy Research Working Paper 8424, Washington, DC, World ­ Bank. DiMeglio, ­ D. ­ P., and ­ D. ­ R. ­ Mattes. 2000. “Liquid Versus Solid Carbohydrate: Effects on Food Intake and Body W ­ eight.” International Journal of Obesity and Related Metabolic Disorders 24 (6): 794–800. Dons, ­E., ­D. Rojas-Rueda, E ­ . Anaya-Boig, I ­ . Avila-Palencia, C ­ . Brand, ­T. ­Cole-Hunter, A. de Nazelle, ­ ­ U. Eriksson, ­ M. Gaupp-Berghausen, ­ R. Gerike, ­ S. Kahlmeier, M. Laeremans, ­ ­ N. Mueller, ­ T. Nawrot, ­ M. ­ J. Nieuwenhuijsen, ­ P. Orjuela, J. ­ ­ F. Racioppi, ­ E. Raser, A ­ . Standaert, L ­.­ I. Panis, and T Götschi. 2018. “Transport ­. ­ Mode Choice and Body Mass Index: Cross-Sectional and Longitudinal Evidence from a European-Wide ­ Study.” Environment International 119 (October): 109–16. Du, ­M., ­ A. Tugendhaft, ­ A. Erzse, and ­ K. ­ Hofman. 2018. “Focus: Nutrition and J. ­ Food Science: Sugar-Sweetened Beverage Taxes: Industry Response and ­Tactics.”Yale Journal of Biology and Medicine 91 (2): 185. Endevelt, ­ R., ­I. Grotto, R ­ . Sheffer, R ­ . Goldsmith, M ­ . Golan, J ­. Mendlovic, and ­ M. ­ Bar-Siman-Tov. 2017. “Policy and Practice: Regulatory Measures to Improve the Built Nutrition Environment for Prevention of Obesity and Related Morbidity in ­ Israel.” Public Health Panorama 3 (4): 567–75. Falbe, ­ N. Rojas, ­ J., ­ A. ­H. Grummon, and ­ K. ­ Madsen. 2015. “Higher Retail Prices of A. ­ Sugar-Sweetened Beverages 3 Months after Implementation of an Excise Tax in Berkeley, ­California.” American Journal of Public Health 105 (11): 2194–201. Falbe, ­ H. ­ J., ­ R. Thompson, ­ C. ­M. Becker, N ­ . Rojas, C E. McCulloch, and ­ ­ .­ K. ­A. ­Madsen. 2016. “Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage ­Consumption.” American Journal of Public Health 106 (10): 1865–71. Finkelstein, ­E. ­A., ­C. Zhen, ­M. Bilger, ­J. Nonnemaker, ­A. ­M. Farooqui, and ­J. ­E. ­Todd. 2013. “Implications of a Sugar-Sweetened Beverage (SSB) Tax When Substitutions to Non-Beverage Items Are ­ Considered.” Journal of Health Economics 32 (1): 219–39. Fletcher, ­ J. 2011. “Soda Taxes and Substitution Effects: Will Obesity Be Affected?” Choices 26 (3): 1–4. Fletcher, ­ D. Frisvold, and ­ J., ­ N. ­Tefft. 2013. “Substitution Patterns Can Limit the Effects of Sugar-Sweetened Beverage Taxes on ­ Obesity.” Preventing Chronic Disease 10. Addressing Overweight/Obesity: Lessons for Future Actions | 163 Foo, L­. ­L., ­K. Vijaya, ­ A. Sloan, and ­ R. ­ A. ­Ling. 2013. “Obesity Prevention and Management: Singapore’s ­ Experience.” Obesity Reviews 14: 106–13­ . Foresight. 2007. Tackling Obesities: Future Choices-Project ­ Report. Government Office for ­Science. Frølich, ­ W., ­ P. Åman, and ­ I. ­Tetens. 2013. “Whole Grain Foods and Health: A Scandinavian ­ Perspective.” Food and Nutrition Research 57 (1): 18503. Giles-Corti, ­ B., ­F. Bull, ­M. Knuiman, ­ G. McCormack, ­ K. Van Niel, ­ A. Timperio, ­ H. Christian, ­ S. Foster, ­ M. Divitini, ­ N. Middleton, and ­ B. ­Boruff. 2013. “The Influence of Urban Design on Neighbourhood Walking Following Residential Relocation: Longitudinal Results from the RESIDE ­ Study.” Social Science and Medicine 77 (January): 20–30. Guerrero-López, ­ M., ­ C. ­ M. Molina, and ­ M. ­A. ­ Colchero. 2017. “Employment Changes Associated with the Introduction of Taxes on Sugar-Sweetened Beverages and Nonessential Energy-Dense Food in M ­ exico.” Preventive Medicine 105: S43–S49. Hall, ­ D. 2019. “Ultra-Processed Diets Cause Excess Calorie Intake and Weight K. ­ Gain: A One-Month Inpatient Randomized Controlled Trial of Ad Libitum Food ­Intake.” Cell Metabolism 30: 1–10. Härkänen, ­ K. Kotakorpi, ­ T., ­ P. Pietinen, ­ H. Reinivuo, and ­ J. Pirttilä, ­ Suoniemi. I. ­ 2014. “The Welfare Effects of Health-Based Food Tax P ­olicy.” Food Policy 49: 196–206. Htenas, ­ A. ­ M., ­ Y. Tanimichi-Hoberg, and L Brown. 2017. An Overview of Links ­. ­ between Obesity and Food Systems: Implications for the Agriculture GP A ­ genda. Washington, DC: World Bank ­ Group. Hung, ­ D. ­ L.-S., ­ K. Tidwell, ­M. ­ E. Hall, ­ M. ­L. Lee, ­C. ­A. Briley, and ­ P. ­ B. ­ Hunt. 2015. “A Meta-Analysis of School-Based Obesity Prevention Programs Demonstrates Limited Efficacy of Decreasing Childhood O ­ besity.” Nutrition ­Research. 35 (3): 229–40. IMF (International Monetary ­ Fund). 2016. “Fiscal Policy: How to Design and Enforce Tobacco Excises?” How-To N ­otes. Fiscal Affairs Department, International Monetary ­ Fund, Washington, DC. Jacobs, ­ A., and ­ M. ­Richtel. 2017­ a. “A Nasty, NAFTA-Related Surprise: Mexico’s Soaring ­Obesity.” The New York Times, December 11. ­ https://www.nytimes​ .com/2017/12/11­/health/obesity-mexico-nafta.html. ———. 2017­ b. “She Took on Colombia’s Soda I ­ndustry. Then She Was S ­ ilenced.” The New York Times, November 13. ­ https://www.nytimes.com/2017/11/13​ /­health/colombia-soda-tax-obesity.html. Jensen, ­ D., and S J. ­ ­. ­Smed. 2013. “The Danish Tax on Saturated Fat: Short Run Effects on Consumption, Substitution Patterns and Consumer Prices of ­ Fats.” Food Policy 42 (October): 18–31. J., and ­ Jou, ­ W. ­Techakehakij. 2012. “International Application of Sugar-Sweetened Beverage (SSB) Taxation in Obesity Reduction: Factors that May Influence Policy Effectiveness in Country-Specific ­ Contexts.” Health Policy 107 (1): 83–90. C., and S Julia, ­ Hercberg. 2017. “Development of a New Front-of-Pack Nutrition ­. ­ Label in France: The Five-Colour ­ Nutri-Score.” Public Health Panorama 3(4): 712–25. Knuiman, ­ M. ­ W., ­H. ­E. Christian, M­ . ­ L. Divitini, S A. Foster, F ­. ­ C. Bull, H ­. ­ M. ­. ­ Badland, and ­ Giles-Corti. 2014. “A Longitudinal Analysis of the Influence of B. ­ 164 | Obesity the Neighborhood Built Environment on Walking for Transportation: The RESIDE ­Study.” American Journal of Epidemiology 180 (5): 453–61. Malik, ­ S., and ­ V. ­ B. ­ F. ­ Hu. 2015. “Fructose and Cardiometabolic Health: What the Evidence from Sugar-Sweetened Beverages Tells U ­ s.” Journal of the American College of Cardiology 66 (14): 1615–24. McPherson, ­ K., ­T. Marsh, and ­ Brown. 2007. “Foresight Report on O M. ­ ­ besity.” The Lancet 370 (9601): 1755; author reply 1755. Mourao, ­ D., ­J. Bressan, ­ W. Campbell, and ­ Mattes. 2007. “Effects of Food Form on R. ­ Appetite and Energy Intake in Lean and Obese Young A ­ dults.” International Journal of Obesity 31 (11): 1688–95. Mueller, ­ N., ­ D. Rojas-Rueda, T ­ . Cole-Hunter, A ­ . de Nazelle, E ­ . Dons, R ­ . Gerike, ­ T. Götschi, ­ L. ­I. Panis, ­ S. Kahlmeier, and ­ M. ­Nieuwenhuijsen. 2015. “Health Impact Assessment of Active Transportation: A Systematic ­ Review.” Preventive Medicine 76 (2015): 103–14. Mueller, ­ N., ­ D. Rojas-Rueda, ­ M. Salmona, ­ D. Martineza, ­ A. Ambrosa, ­ C. Brand, ­A. de Nazelle, E ­ . Dons, ­M. Gaupp-Berghausen, ­R. Gerike, ­T. Götschi, ­F. Iacorossi, ­ L. ­I. Panis, ­ S. Kahlmeier, ­ E. Raser, and ­ M. Nieuwenhuijsen on behalf of the PASTA ­ consortium. 2018. “Health Impact Assessment of Cycling Network Expansions in European ­ Cities.” Preventive Medicine 109 (2018): 62–70. Nair, ­ A.B., and ­ M. ­K. ­Suresh. ­ Forthcoming. The “Fat Tax” in Kerala State, India: A Case ­Study. Nakamura, ­ R., ­ A. Mirelman, ­ C. Cuadrado, ­ N. Silva, ­ J. Dunstan, and ­ M. ­ Suhrcke. E. ­ 2018. “Evaluating the 2014 Sugar-Sweetened Beverage Tax in Chile: An Observational Study in Urban ­ Areas.” PLOS ­Medicine. ­https://doi.org/10.1371​ /­journal.pmed.1002596. National Treasury, ­ R. ­ S. ­ o. ­ A. 2016. Taxation of Sugar Sweetened Beverages, ­R. ­o. ­S. ­A. National Treasury, Economics Tax Analysis Chief Directorate Pretoria, National Department of ­ Treasury. S. ­ Ng, ­ W., ­ J. ­A. Rivera, ­ B. ­ M. Popkin, and ­ M. ­ Colchero. 2018. “Did High Sugar- A. ­ Sweetened Beverage Purchasers Respond Differently to the Excise Tax on Sugar-Sweetened Beverages in Mexico?” Public Health Nutrition 1–7. PAHO (Pan American Health O ­ rganization). 2016. Nutrient Profile M ­ odel. Washington, DC: PAHO. Popkin, ­ B. ­ M., and ­ C. ­Hawkes. 2015. “Sweetening of the Global Diet, Particularly Beverages: Patterns, Trends, and Policy ­ Responses.” Lancet Diabetes and Endocrinology 4 (2): 174–86. Popkin, ­ B. ­M., and ­ Reardon. 2018. “Obesity and the Food System Transformation T. ­ in Latin ­ America.” Obesity Reviews 19 (8): 1028–64. Rayner, ­ M., ­ P. Scarborough, and ­ A. ­ Kaur. 2013. “Nutrient Profiling and the Regulation of Marketing to Children: Possibilities and P ­itfalls.” Appetite 62 (March): 232–35. Reardon, ­ T., and ­ J. ­Berdegué. 2002. “The Rapid Rise of Supermarkets in Latin America: Challenges and Opportunities for ­ Development.” Development Policy Review 20 (4): 317–34.  Reardon, ­ C. Timmer, ­ T., ­ C. Barrett and ­ Berdegué. 2003. “The Rise of Supermarkets J. ­ in Africa, Asia, and Latin ­ America.” American Journal of Agricultural Economics 85 (5): 1140–46. Addressing Overweight/Obesity: Lessons for Future Actions | 165 Reardon, ­ T., ­C. Timmer, and ­ B. ­Minten. 2012. “The Supermarket Revolution in Asia and Emerging Development Strategies to Include Small F ­ armers.” Proceedings of the National Academy of Sciences of the United States of America 109 (31): 12332–37. Reardon, ­ D. Tschirley, ­ T., ­ B. Minten, ­ S. Haggblade, ­ S. Liverpool-Tasie, ­ M. Dolislager, and ­ C. ­Ijumba. 2015. “Transformation of African Agrifood Systems in the New Era of Rapid Urbanization and the Emergence of a Middle C ­ lass.” In Beyond a Middle Income Africa: Transforming African Economies for Sustained Growth with Rising Employment and Incomes, edited by O ­ . Badiane and T ­ .­Makombe. ReSAKSS Annual trends and outlook report 2014. Washington, DC: International Food Policy Research Institute ­(IFPRI). ­http://ebrary.ifpri.org​/­cdm/ref/collection​ /­p15738coll2/id/130005. Reis, ­ R. ­S., ­D. Salvo, ­ D. Ogilvie, ­ E. ­ V. Lambert, ­ S. Goenka, ­ C. Brownson, and R. ­ ­ L. ­P. ­A. ­ E. ­ S. ­ Committee. 2016. “Scaling Up Physical Activity Interventions Worldwide: Stepping Up to Larger and Smarter Approaches to Get People ­Moving.” The Lancet 388 (10051): 1337–48. Rico-Campà, ­ A., ­ M. ­ A. Martínez-González, ­ I. Alvarez-Alvarez, ­ R. de Deus Mendonça, ­ C. de la Fuente-Arrillaga, ­ C. Gómez-Donoso, and ­ M. ­Bes-Rastrollo. 2019. “Association between Consumption of Ultra-Processed Foods and All Cause Mortality: SUN Prospective Cohort ­ Study.” BMJ 365: l1949. Roberto, ­ C. ­ A., ­H. ­G. Lawman, ­ M. ­ T. LeVasseur, ­ N. Mitra, ­ A. Peterhans, ­ B. Herring, and ­ S. ­ N. ­ Bleich. 2019. “Association of a Beverage Tax on Sugar-Sweetened and Artificially Sweetened Beverages with Changes in Beverage Prices and Sales at Chain Retailers in a Large Urban ­ Setting.” JAMA 321 (18): 1799–810.  Roodenburg, ­ B. Popkin, and ­ A., ­ J. ­Seidell. 2011. “Development of International Criteria for a Front of Package Nutrient Profiling System: International Choices ­Programme.” European Journal of Clinical Nutrition 65: 1190. Sallis, ­ J. ­F., ­ F. Bull, ­ R. Burdett, ­ L. ­ D. Frank, ­ P. Griffiths, ­ B. Giles-Corti, and M. ­ ­ Stevenson. 2016. “Use of Science to Guide City Planning Policy and Practice: How to Achieve Healthy and Sustainable Future ­Cities.” The Lancet 388 (10062): 2936–47. Sallis, ­ F., ­ J. ­ E. Cerin, T L. Conway, M ­. ­ ­ .­ A. Adams, L D. Frank, M ­. ­ ­ . Pratt, D­ . Salvo, J. Schipperijn, ­ ­ G. Smith, ­ K. ­L. Cain, ­ R. Davey, ­ P.-C. Lai, ­ J. Kerr, ­ J. Mitáš, ­R. Reis, O. ­ ­ L. Sarmiento, G ­ . Schofield, J ­ . Troelsen, ­ D. Van Dyck, I ­. De Bourdeaudhuij, and ­ N. ­ Owen. 2016. “Physical Activity in Relation to Urban Environments in 14 Cities Worldwide: A Cross-Sectional ­ Study.” The Lancet 387 (10034): 2007–17. Sánchez-Romero, ­ M., ­ L. ­ J. Penko, ­ P. ­G. Coxson, ­ A. Fernández, ­ A. Mason, ­ E. A. ­ Moran, ­ L. Ávila-Burgos, ­ M. Odden, ­ S. Barquera, and ­ K. ­Bibbins-Domingo. 2016. “Projected Impact of Mexico’s Sugar-Sweetened Beverage Tax Policy on Diabetes and Cardiovascular Disease: A Modeling ­ Study.” PLOS Medicine 13 (11): e1002158. Seiler, ­ S., ­A. Tuchman, and ­ Yao. 2019. “The Impact of Soda Taxes: Pass-Through, S. ­ Tax Avoidance, and Nutritional ­ Effects.” Working Paper 3752. Stanford Business ­School. ­https://www.gsb.stanford.edu/faculty-research/working​ -papers/impact-soda-taxes-pass-through-tax-avoidance-nutritional-effects. Silver, ­ D., ­ L. ­ S. ­W. Ng, ­ S. Ryan-Ibarra, ­ L. ­ S. Taillie, ­ M. Induni, ­ D. ­R. Miles, ­ M. Poti, J. ­ and ­ B. ­ M. ­ Popkin. 2017. “Changes in Prices, Sales, Consumer Spending, and 166 | Obesity Beverage Consumption One Year after a Tax on Sugar-Sweetened Beverages in Berkeley, California, US: A Before-and-After ­ Study.” PLOS Medicine 14 (4): e1002283. Smed, ­ S., ­P. Scarborough, M ­ . Rayner, and J ­. ­ Jensen. 2016. “The Effects of the D. ­ Danish Saturated Fat Tax on Food and Nutrient Intake and Modelled Health Outcomes: An Econometric and Comparative Risk Assessment E ­ valuation.” European Journal of Clinical Nutrition 70 (6): 681. Srour, ­ B., ­ K. Fezeu, ­ L. ­ E. Kesse-Guyot, ­ B. Allès, ­ C. Méjean, ­ M. Andrianasolo, R. ­ ­ E. Chazelas, ­ M. Deschasaux, ­ S. Hercberg, and ­ P. ­Galan. 2019. “Ultra-Processed Food Intake and Risk of Cardiovascular Disease: Prospective Cohort Study ­(NutriNet-Santé).” BMJ 365: l1451. Stacey, ­ N., ­ A. Tugendhaft, and K ­. ­Hofman. 2017. “Sugary Beverage Taxation in South Africa: Household Expenditure, Demand System Elasticities, and Policy ­Implications.” Preventive Medicine 105 (Supplement): S26–S31. Taillie, ­ L. ­ J. ­ S., ­ A. Rivera, B ­. ­M. Popkin, and C ­. ­Batis. 2017. “Do High v ­ s. Low Purchasers Respond Differently to a Nonessential Energy-Dense Food Tax? Two-Year Evaluation of Mexico’s 8% Nonessential Food ­ Tax.” Preventive Medicine 105 (Supplement): S37–S42. Tainio, ­ M. ­ A., ­ J. de Nazelle, ­ T. Götschi, ­ S. Kahlmeier, ­ D. Rojas-Rueda, ­ J. M. ­ Nieuwenhuijsen, ­ H. de Sá, ­ T. ­ P. Kelly, and ­ J. ­Woodcock. 2016. “Can Air Pollution Negate the Health Benefits of Cycling and Walking?” Preventive Medicine 87 (2016): 233–36. Théodore, ­ F. ­L., ­L. Tolentino-Mayo, ­ E. Hernández-Zenil, ­ L. Bahena, ­ A. Velasco, ­ B. Popkin, J A. Rivera, and S ­. ­ ­.­Barquera. 2017. “Pitfalls of the Self-Regulation of Advertisements Directed at Children on Mexican T ­ elevision.” Pediatric Obesity 12 (4): 312–19. Townsend, ­ S. ­ R., ­ M. Jaffee, ­Y. Hoberg-Tanimichi, ­ M. Htenas, ­ A. ­ M. Shekar, ­ Z. Hyder, M. Gautam, H ­ A. Kray, ­ ­ .­ L. Ronchi, ­ S. Hussain, L ­.­ K. Elder, and ­ Moses. 2016. E. ­ The Future of Food: Shaping the Global Food System to Deliver Improved Nutrition and ­Health. Washington, DC: World ­ Bank. Vartanian, ­ R., ­ L. ­ M. ­B. Schwartz, and K ­.­ Brownell. 2007. “Effects of Soft Drink D. ­ Consumption on Nutrition and Health: A Systematic Review and ­Meta-Analysis.” American Journal of Public Health 97 (4): 667–75. Vilar-Compte, ­ M. 2018. Using Sugar-Sweetened Beverage Taxes and Advertising Regulations to Combat Obesity in ­ Mexico. Global Delivery ­ Initiative. Washington, DC: World ­ Bank. Wang, ­ L. Cai, Y Y., ­ ­ . Wu, ­R. Wilson, C­ . Weston, O ­ . Fawole, S N. Bleich, L ­ .­ ­ .­J. Cheskin, ­ N. Showell, ­ N. ­ D. Lau, ­ B. ­ D. ­T. Chiu, ­A. Zhang, and ­ Segal. 2015. “What J. ­ Childhood Obesity Prevention Programmes Work? A Systematic Review and ­Meta-Analysis.” Obesity Reviews 16 (7): 547–65. WCRFI (World Cancer Research Fund ­ International). 2015. “Curbing Global Sugar Consumption: Effective Food Policy Actions to Help Promote Healthy Diets and Tackle ­Obesity.” ­Brief. ­https://www.wcrf.org/sites/default/files/Curbing​ -Global-Sugar-Consumption.pdf. ­ ———. 2019. Building Momentum: Lessons on Implementing a Robust Front-of-Pack Food ­Label. London: ­ WCRF.  Addressing Overweight/Obesity: Lessons for Future Actions | 167 WHO (World Health O ­ rganization). 2014. Draft Guidelines on Free Sugars Released For Public ­Consultation. Geneva: ­ WHO. ­ ———. 2018. ACTIVE: A Technical Package for Increasing Physical ­ Activity. Geneva: ­WHO. ­https://apps.who.int/iris/handle/10665/275415. WHO Commission on Ending Childhood ­ Obesity. 2016. Report of the WHO Commission on Ending Childhood ­ WHO. Obesity. Geneva: ­ WHO Expert ­Committee. 2016. Fiscal Policies for Diet and Prevention of Noncommunicable Diseases: Technical Meeting Report, 5–6 May 2015, Geneva, ­ Switzerland. WHO Technical ­ Report. Geneva: ­ WHO. WHO Regional Office for ­ Europe. 2015­ a. Nutrient Profile Model: 6. Copenhagen: WHO Regional Office for ­ Europe. ———. 2015­b. Using Price Policies to Promote Healthier D ­iets. Division of Noncommunicable Diseases and the ­ Lifecourse. Nutrition Physical Activity and Obesity ­ Programme. Brussels: WHO Regional ­ Office for Europe. Xia, ­ Y. Zhang, S T., ­ ­ . Crabb, and ­ Shah. 2013. “Cobenefits of Replacing Car Trips P. ­ with Alternative Transportation: A Review of Evidence and Methodological ­Issues.” Journal of Environmental and Public Health 2013: Article ID 797312. ­https://doi.org/10.1155/2013/797312. 6 Business Unusual: How Can Development Partners Support Countries to Fight Obesity? Meera Shekar and Anne Marie Provo This chapter builds on the previous chapters to provide guidance for exter- nal partners and World Bank teams working across multiple sectors on how to leverage the comparative advantage of the World Bank and other devel- opment partners to catalyze future action on this ­ agenda. It builds on chapters 1–5, which lay out the growing problem of overweight/obesity, ­ the rationale for public action, potential strategies/interventions to prevent overweight/obesity, and the lessons learned from these efforts to ­ date. It links these elements together to propose a framework for how client coun- tries and development partners such as the World Bank can use advocacy, policy, and analytical and financial tools to accelerate their contribution to the prevention of ­overweight/obesity. Key Messages • The global overweight/obesity epidemic presents a formidable chal- lenge to human capital acquisition, national wealth accumulation in ­ countries, and the World Bank’s twin goals of ending extreme poverty and boosting shared ­ prosperity. While investments in reducing under- nutrition are at an all-time high and reductions in undernutrition are being observed globally, overweight/obesity rates are rising r­ apidly. 169 170 | Obesity • Overweight/obesity has large impacts on national economies—both through reduced productivity and increased health care costs and because efforts to address overweight/obesity have substantial potential for climate ­ co-benefits. Efforts to control overweight/­ obesity are, therefore, efforts toward building a global public good, with a strong role for ­ governments. • Previous chapters make a strong case for the role of governments in preventing ­ overweight/obesity. While the role of governments remains central, development partners also have a key role, and there has been considerable discussion among partners on the rationale for preventing ­ obesity. However, most partners have not yet maxi- mized the opportunities to translate current knowledge into ­ action. • Continued economic growth among the world’s low- and middle- income countries will only intensify the magnitude of the devastat- ing impacts of overweight/obesity on health, well-being, and productivity. Furthermore, as economies grow, the burden of over- ­ weight/obesity will shift even more toward the poor, making it all the more imperative for institutions such as the World Bank to engage and to support governments in this ­ effort. • In its engagement with country governments, the World Bank and other development partners can highlight the issue of overweight/ obesity as one that requires corrective public action rather than one of individual ­ responsibility. And it can transform this advocacy into tangible investment ­ opportunities. The World Bank has at its disposal a repertoire of analytical, diagnostic, policy, technical assistance, and investment tools that it can deploy to address different aspects of the overweight/obesity ­ challenge. Other development partners have sim- ilar tools that can be ­deployed. • Given the renewed focus on human capital, its links to the over- weight/obesity epidemic, and the growing evidence base for dou- ble- and triple-duty actions, there is both an urgent need for action and a tremendous opportunity to prevent overweight/obesity to enhance Human Capital in countries. • The health sector needs to lead on diagnostics, but tackling this complex agenda will require both a whole-of-government and a whole-of–development partner approach, with the agriculture, transport, macroeconomics, trade and investment, and education sectors each having a major role to p ­ lay. Triple-duty actions that link to climate change offer yet another opportunity for advocacy and action at ­ scale. • Because the evidence base is still emerging, five key areas are iden- tified here for further research and analysis by countries and devel- opment partners: documenting the impact of fiscal and regulatory policies and active transport and building/city design solutions in Business Unusual | 171 countries where these are being applied; quantifying the climate co- benefits of investing in overweight/obesity prevention policies and programs; building the evidence base on food systems approaches to prevent overweight/obesity; engaging the private sector in each of the above areas; and quantifying the contribution of overweight/ obesity to Human Capital. • Overall, three strategic areas are identified for action: leveraging the range of policy, advocacy, and investment tools; scaling up promising interventions and policies; and continuing to build the evidence base. • Small tweaks to work programs and budgets will not be s ­ ufficient. A  transformative approach and additional financial and human resources need to be dedicated to this a ­ genda. Building capac- ity among development partners as well as capacity within ­ client countries to work across sectoral boundaries and with nontradi- tional partners will be ­ crucial. Experience from tobacco sug- gests that this is feasible, in consultation with like-minded global and national partners such as Bloomberg Philanthropies; UN partners such as the World Health Organization (WHO), the Food and Agriculture Organization of the UN (FAO), and the United Nations Children’s Fund (UNICEF); and academia and civil ­society. The Role of Development Partners in Supporting Countries to Prevent Overweight/Obesity Previous chapters have made a strong case for the role of governments in preventing ­ overweight/obesity. While the role of governments remains central, development partners also have a key r­ ole. The World Bank Group has a corporate commitment to human capital, and overweight/obesity is implicated therein, including in the construct of the Human Capital Index (HCI; see figure 1.1). The World Bank, along with many of its development partners—including the WHO, bilateral agencies, and civil society ­ organizations—are also fully committed to universal health coverage (UHC) and, within that commitment, the non-communicable disease (NCD) agenda. Primary prevention of overweight/obesity through fiscal policies ­ and addressing its social determinants by strengthening health systems for the early detection and management of overweight and diet-related NCDs commitments. Box 6.1 lays out the key milestones are implicit within these ­ in recent global dialogue on overweight/obesity ­ prevention. Many development partners have been engaged in overweight/obesity prevention. Table 6.1 lists some of the key partners. ­ 172 | Obesity BOX 6.1 Key Milestones for Scaling Up Global Efforts to Prevent Overweight/Obesity 1992 – World Declaration on Nutrition follows the FAO/WHO-­convened International Conference on Nutrition in R­ ome. The existence of popu- lations with excessive/unbalanced dietary intakes is acknowledged, yet “obesity” is not explicitly mentioned, and the declaration has a focus on hunger and ­undernutrition. 2000 – The WHO report Obesity: Preventing and Managing the Global Epidemic is ­published. Available at ­https://www.who.int​/­nutrition​ /­publications/obesity/WHO_TRS_894­/en/. 2004 – World Health Assembly endorses the Global Strategy on Diet, Health. Physical Activity and ­ 2010 – The Scaling Up Nutrition Movement (SUN) is initiated. The World Bank, in partnership with the Bill and Melinda Gates Foundation, USAID, and the governments of Japan and Canada, convened stake- holders at the World Bank Spring Meetings to commit to the SUN movement, a renewed effort to eliminate all forms of malnutrition, subsequently launched at the UN General ­ Assembly. The SUN move- ment has since garnered 60 countries as members, and nearly 3,000 civil society organizations across the globe ( .org). ­ scalingupnutrition​ It focuses on both undernutrition and ­ overweight/obesity. 2013 – The 2nd Lancet Series on Maternal and Child Nutrition f­ollows on the 2008 Lancet Series on Maternal and Child Undernutrition and includes an analysis of the burden of overweight/obesity but does not recommend key, evidence-based, and cost-­ effective interventions for scale ­up. May 2013 – The World Health Organization Global Action Plan for the Prevention and Control of Noncommunicable Diseases (2013–2020) is endorsed. This plan includes six objectives whose implementation at ­ the country level will support the attainment of the nine non-­ communicable disease (NCD) targets by 2025, as well as facilitate the achievement of Sustainable Development Goal (SDG) 3: Good Health and ­Well-Being. 2013 – The World Health Assembly endorses the Global Nutrition Targets for 2025 (WHO, n.d.), including Target 4: No increase in child- hood ­overweight. continued next page Business Unusual | 173 Box 6.1 (continued ) 2014 – The Rome Declaration on Nutrition, a key output from the Second International Conference on Nutrition, raises the importance of addressing malnutrition in all of its forms, including undernutrition, micronutrient deficiencies, and ­overweight/obesity. 2015 – The Sustainable Development Goals (SDGs) are l aunched. ­ These include SDG2: Zero Hunger (including an end to hunger and all forms of malnutrition) and SDG3: Good Health and Well-Being (ensuring healthy lives and promoting well-being for all at all ages with ­ a one-third reduction of premature NCD ­ mortality). See ­ https://www​ .un​.org/sustainabledevelopment/sustainable-development-goals/. 2016 – The United Nations Decade of Action on Nutrition 2016–2025 includes actions to reduce the consumption of sugars, sodium, and ­fats. See ­https://www.unscn.org/en/topics/un-decade-of-action​-on​ -nutrition. 2017 – The WHO issues “Best Buys” and updates the menu of options presented in the Global Action Plan for the Prevention and Control of NCDs 2013–2020 with a list of best buys and other recommended interventions to address NCDs based on new evidence of cost- effectiveness. 2018 – The Third UN High-Level Meeting on Non-Communicable Diseases takes place in New Y­ ork. Informed by previous meetings in 2011 and 2014 and the recommendations of the WHO Independent High-Level Commission on NCDs in Time to Deliver (WHO 2018), the meeting served to call on heads of state to commit to scaling up the fight against NCDs and to promote mental health and ­ well-being. 2019 – Lancet EAT Commission report (EAT Lancet Commission 2019) highlights the role of sustainable diets that affect both obesity as well as major climate and water use ­ effects. 2019 – Lancet Commission on Obesity report (LCO 2019) follows Lancet Obesity series of 2011 and 2015, highlights the global “syndemic” of obesity, undernutrition, and climate change and lists several dou- ble-duty and triple-duty actions to address the ­ syndemic. 174 | Obesity Table 6.1 Partners Engaged in Overweight/Obesity Prevention Client country Global stakeholders stakeholders Private sector Academics • Heads of state and • Food and beverage • Lancet Commission on relevant ministries companies Obesity • Advocacy groups • Public health/medical • Civil society providers and their Think tanks associations • World Obesity Federation organizations • Research groups • Media companies • World Cancer Research • Media outlets Institute • Parliaments/legislatures • Consumer groups • Social media Multilateral agencies • OECD • WHO • UNICEF • WBG Regional development banks • ADB • AfDB • IDB • AIIB Private financiers • EAT Foundation • Bloomberg Philanthropies Global partnerships • Scaling Up Nutrition Movement • UHC2030 Civil society organizations that have played a big role in tobacco/sugar-sweetened beverage taxes and so on Note: ADB = Asian Development Bank; AfDB = African Development Bank; AIIB = Asian Infrastructure Investment Bank; IDB = Inter-American Development Bank; OECD = Organisation for Economic Co-operation and Development; UHC = universal health coverage; UNICEF = United Nations Children’s Fund; WBG = World Bank Group; WHO = World Health ­ O rganization. Preventing Overweight/Obesity Will Boost Human Capital A healthy, well-educated population drives economic growth, poverty reduction, and future income generation (figure 6.1). Recent estimates indicate that human capital—the sum total of a population’s health, skills, knowledge, experience, and habits—accounts for over two-thirds of total global wealth (estimated at US$1,143 trillion in 2018). Human capital con- tributes to growth as it accumulates, as it affects innovation and adaptation, and in its ability to interact with other forms of digital and hard capital to Business Unusual | 175 drive skill-based technological change (see box 6.2). The contribution of human capital to country wealth increases as countries climb the income ladder, with human capital constituting about 70 percent of the wealth in high-income countries and only about 40 percent in low-income ­ ones. Unfortunately, human capital does not just appear; continued acquisition of wealth requires investments from both individuals and countries to ensure that the population has the skills and resources to be able to maxi- mize the use of limited natural and produced ­ capital. With its growing concentration in low- and middle-income countries, the overweight/obesity epidemic is a formidable threat to human capital acquisition and sustained economic growth in these c ­ ountries. Overweight/ obesity and diet-related NCDs will directly affect adult survival; this in turn impacts adult survival rates (ASRs) and labor force productivity (see figure B6.2.1). As highlighted in chapters 2–4, the overweight/obesity epi- demic will increasingly exacerbate health inequities in low- and middle- income countries, contributing to the growing divide in human capital assets between the rich and ­ poor. Supporting countries to prevent and control overweight/obesity—and focusing on low- and middle-income economies—can further drive progress toward the World Bank’s twin goals of ending extreme poverty and boosting shared ­ prosperity. Within this context, the World Bank has an opportunity to intervene with a unique value proposition to build human ­ capital. Overweight/obe- sity is a key contributor to ASRs (see figure 6.2). The convening power of the World Bank, the financial and technical support for developing country governments, and the multisectoral engagements across health, education, Figure 6.1 Benefits of Investing in Human Capital HUMAN CAPITAL MATTERS FOR INDIVIDUALS ECONOMIES SOCIETIES Investment in human capital Human capital is a key Education is associated is a dynamic process akin to ingredient for higher with more civic investment in physical income and growth participation, trust, and capital political awareness 176 | Obesity BOX 6.2 What Is Human Capital and How Are Countries Engaged? Human capital doesn’t materialize on its own; it must be nurtured by the ­state. — World Bank 2018 For over a decade, the World Bank has spearheaded global wealth accounting in an effort to capture the long-term health of an economy and complement gross domestic product (GDP) measures of “return on ­ wealth.” The publication The Changing Wealth of Nations 2018 (Lange, Wodon, and Carey 2018) was the first time that human capital was included as a main ingredient in such estimates of economic progress and sustainable ­ development. The three components of national wealth include produced capital (buildings, machinery, and infrastructure); nat- ural capital (agricultural land, forests, protected areas, minerals, and oil, coal, and gas reserves); and human capital (the sum total of a popula- tion’s health, skills, knowledge, experience, and ­habits). Recent studies indicate that human capital alone explains between 10 and 30 percent of differences in per capita income across ­ countries. Despite this evidence, governments typically favor investments in physical capital—roads, bridges, and other forms of infrastructure— over these “soft” investments in ­ people. The Human Capital Project (HCP) aims to highlight the individual, economic, and social value of investing in people and accelerate more and better investments in people g ­ lobally. The HCP is a program of advocacy and knowledge work aimed at increasing awareness of and demand for interventions to build human capital in client countries and consists of three main dimensions: 1. The Human Capital Index (HCI) is an advocacy tool measuring countries’ investments in the human capital of the next g ­ eneration. The HCI aims to demonstrate the joint effects of health and education on the future productivity of children born today, benchmarking coun- tries against complete education and full ­health. The HCI is built upon three main ingredients: survival, school, and health (figure B6.2.1). The last component has two subcomponents: child stunting and adult sur- rates. Evidence presented in this report and elsewhere shows vival ­ ­ ates. that overweight/obesity is closely linked to adult survival r continued next page Business Unusual | 177 Box 6.2 (continued ) Figure B6.2.1 Ingredients of the Human Capital Index SURVIVAL SCHOOL HEALTH HCI Children who Contribution of Contribution of Productivity of = don't survive quality-adjusted health (average a future worker don't grow up to years of school of adult survival (relative to become future to productivity of rate and stunting) benchmark of workers future workers to productivity of complete future workers education and full health) 2. Measurement is an ambitious program to improve measurement of human capital and its components and provide analysis to support formation. effective investments in human capital ­ 3. Country Engagement involves working with countries and using new approaches and tools to identify specific actions, policy mea- outcomes. sures, and investments to improve human capital ­ Figure 6.2 Human Capital Index and Its Links to Nutrition HUMAN CAPITAL INDEX INGREDIENTS LINKS TO NUTRITION SURVIVAL TO AGE FIVE UNDERNUTRITION Under-five mortality rate (U5MR) underlies 45% of U5MR QUALITY OF LEARNING STUNTED/ANEMIC CHILDREN LEARN LESS Expected years of school learning and are more likely to drop out of school; Iodine deficient kids lose up to 13 IQ points HEALTH Stunting rate: Fraction of kids under 5 STUNTING is a key marker of undernutrition more than 2 reference standard deviations below median height for age Adult survival rate (ASR): Fraction of RISING OVERWEIGHT/OBESITY RATES 15-year-olds who survive to age 60 contribute to non-communicable diseases and lower adult survival rates Source: Based on World Bank 2018. 178 | Obesity transport, urban development, and macro-fiscal sectors are unique among global health and development actors involved in overweight/obesity prevention. The World Bank also has the potential to play a strong role in ­ building global, regional, and country partnerships that bring overweight/ obesity to the attention of ministers of finance and heads of state; to strengthen diagnostics and evidence to increase the scope and fiscal and other impact of action; and to leverage its financial and analytical services and policy instruments across all these sectors to stimulate change well beyond ministries of ­health. Many of these instruments have been deployed successfully for the tobacco agenda, which offers useful lessons for over- weight/obesity ­prevention. Besides these high-level commitments at global and regional levels, there are at least six potential and very tangible instruments at the World Bank’s ­disposal. These range from technical support on specific issues or policies to investment lending across various sectors and to policy reforms agenda. These instruments are and design of fiscal policies to deliver on this ­ summarized in table 6.2. Is There Potential for Business Unusual? Development partners have a number of important opportunities to play a transformative role in the global response to obesity prevention and control with a focus on at least three strategic areas (figure 6.3): • Strategic Area 1: Leveraging the range of advocacy, policy, and invest- ment tools at the global, regional, and country levels • Strategic Area 2: Scaling up promising interventions and policies, and supporting reforms through multisectoral engagement, including in the private sector • Strategic Area 3: Building the evidence and knowledge base across sectors Working across these three strategic areas can build the investment and advisory pipeline with middle-income countries; support preemptive, pre- ventive public action in low-income countries; and offer potential for stron- ger reimbursable advisory services (RAS) with high-income ­ countries. Chapter 5 highlights the promising regulatory and fiscal policies and interventions for the primary prevention of overweight/obesity, including (1) taxing unhealthy foods and subsidizing healthy foods; (2) creating nutrient profiling models and using those models for front-of-package labels to reduce consumption of ultra-processed foods and beverages; (3) limiting access to and marketing of unhealthy ultra-processed foods to children and adolescents through an array of linked regulations and Table 6.2 An Overview of Relevant World Bank Products and Services to Support Countries Relevance for overweight/obesity Instrument Description Purpose prevention Systematic A diagnostic exercise that identifies the Informs the strategic dialogue between Signals the magnitude of the Country most important constraints a country has the World Bank Group and the client overweight/obesity challenge and Diagnostics and opportunities it can embrace to country on priority areas for the economic and poverty (SCD) accelerate progress toward the twin ­ goals engagement. Includes a thorough, ­ implications to clients and World of eliminating extreme poverty and systematic review of the country situation Bank Group teams/country boosting shared prosperity. Informed by that can guide World Bank Group ­management. analysis and multistakeholder c­ onsultation. analytical and operational support over a Sets the foundation for further three-year ­period. analytical engagement and operational investments in the ­country. Country The central tool guiding World Bank Group Aims to make the country-driven Provides the space for related Partnership engagement at the country l ­evel. Outlines engagement more systematic, evidence analytical work and lending as well Framework the key objectives and development focused. based, selective, and ­ as policy reforms on overweight/ (CPF) results that guide World Bank Group Defines the main development goals to obesity prevention for the next support for the member country’s be supported by the World Bank Group three-year ­period. development p ­ rogram. Informed by the and a selective program of World Bank ­SCD. Group–supported investments across all purpose. sectors for this ­ continued next page 179 Table 6.2 (continued) 180 Relevance for overweight/obesity Instrument Description Purpose prevention Development Provides IDA/IBRD funds as non- Support clients to design and implement Provides financial incentives for the Policy earmarked general budget financing that a program of policy and institutional approval of key policies that are Financing is subject to the client’s own reforms while providing financing to needed for preventing ­ overweight/ (DPF) implementation processes and systems reduce fiscal ­ deficit. obesity. contingent upon completing a set of Brings critical sectoral policy policy and institutional actions or bottlenecks to the attention of triggers—termed prior actions—before ministries of finance, planning, and ­ disbursement. Lending operations so on; can call attention to and employing this instrument are commonly accelerate the process of achieving referred to as Development Policy difficult policy reforms by providing Operations ­(DPOs). policy triggers, based on which development finance is released to client ­countries. Can be used to design and implement taxation, regulation, on. subsidy reforms, and so ­ Investment Provides financing through a loan, credit, IPF is used for specific projects with a Can finance the policy Project grant, or project-based guarantee for a set clearly defined set of discrete activities, development ­process. Financing of expenditures for a project, disbursing objectives, and ­ results. IPF can be used in Can invest in training of sectoral (IPF) against agreed eligible e ­ xpenditures. The all sectors, often to build physical and staff, public communication World Bank Group disburses funds to the social infrastructure and institutional campaigns, direct interventions client, who is then responsible for project ­ capacity. Examples include building a such as building playgrounds or implementation. This is the World Bank ­ road, establishing off-grid solar access, parks or bike lanes, and so ­on. Group’s oldest and most used financing enhancing rural clinics and training health ­instrument. care workers, and providing micro-loans Can invest in capacity development to support women’s entrepreneurship in for institutions needed to monitor a community or ­ region. Policy reform is and regulate the food and other not the primary objective of IPF, but a ­industries. project may include technical assistance to support ­ reform. continued next page Table 6.2 (continued) Relevance for overweight/obesity Instrument Description Purpose prevention Program for A form of results-based financing that Provides financial incentives for certain Can be designed to incentivize Results (P4R) moves from a project approach toward a results rather than ­ inputs. Provides capacity development to prevent and program a ­ pproach. Disbursements are greater flexibility, accountability, and obesity; or policy development, Investment triggered both by eligible expenditures ownership, as there is less World Bank reforms, regulations, or specific Project and by achievement of agreed-upon micromanagement of inputs and process outputs that trigger release of Financing outputs, outcomes, and institutional and greater client autonomy in problem ­financing. with strengthening actions defined as ­solving. Disbursement Disbursement Linked Indicators (DLIs), Linked which must be tangible, transparent, and Indicators ­ verifiable. When a DLI is achieved, the (IPF w/DLI) client informs the World Bank and provides evidence as agreed through a verification p­ rocess. Once the World Bank Group has verified the achievement of the results, funds are d­ isbursed. Reimbursable Non-lending activities with a clearly RASs support clients in designing or RASs can provide the opportunity Advisory defined development objective that implementing reforms, regulations, to engage with middle- and Services provide access to World Bank Group stronger policies, strengthening high-income countries to provide (RAS) and technical assistance for governments on a institutions, building capacity, informing technical assistance for policy Non-Lending full cost recovery basis (RAS), or as strategies or operations when World development and institutional Technical preparation for a new investments ­ (NLTA). Bank Group administrative budget or strengthening, such as for Assistance Can range from a rapid policy note to a donor funding is not ­ available. NLTA sugar-sweetened beverage ­ taxes. (NLTA) complex, multiyear program in design and provides similar support for countries NLTA is usually for low-income implementation of major r ­ eforms. where IDA/IBRD resources are ­ available. ­countries. Note: IBRD = International Bank for Reconstruction and Development; IDA = International Development Association; IPF = Investment Project Financing. 181 182 | Obesity Figure 6.3 Strategic Areas for Potential Development Partners Action STRATEGIC AREA 2 Scaling up promising interventions STRATEGIC AREAS and policies, and supporting reforms through multisectoral engagement, including through the private sector STRATEGIC AREA 1 Leveraging the range of tools at global/regional/ country levels OBESITY PREVENTION FOR POTENTIAL INVOLVEMENT OF DEVELOPMENT PARTNERS TO SUPPORT COUNTRIES STRATEGIC AREA 3 Building the evidence and knowledge base across sectors policies such as those exemplified by the Chilean model; (4) working with schools to enhance the nutritional quality of school food services and remove access to and sales of unhealthy foods and beverages in and near schools; (5) enhancing urban redesign and revitalization, including by pro- moting active transport and land and building designs that enhance physi- cal activity; (6) promoting healthy diet and physical activity for children and adolescents; (7) increasing the quality of the food system through pro- duction, transport, processing, food environment, and food retail; and (8) scaling up prenatal and early childhood nutrition ­ interventions. By lever- aging its comparative advantages and building on the lessons learned from tobacco control, development institutions such as the World Bank have the potential to promote the scale-up of these promising ­ approaches. However, maximized. as shown in table 6.3, this potential has yet to be ­ Business Unusual | 183 Table 6.3 Summary of World Bank Experience in Overweight/Obesity Policies and Interventions World Bank experience as identified through Policy/intervention area review of project documents Tax unhealthy foods and subsidize • Two Development Policy Operations healthy foods (Tonga and Samoa) • Prior actions for excise duties for unhealthy/ sugary and salty products to improve health and nutrition and to reduce NCDs • Reimbursable Advisory Services in Saudi Arabia on obesity prevention, including sugar- sweetened beverage taxation (ongoing) Implement front-of-package food • No identified experience labeling and related nutrient profile models to identify unhealthy foods and beverages Enhance school food quality in • Many school feeding programs exist, but these school feeding programs and in are focused primarily on hunger alleviation and kiosks in the schools and around the improved child growth rather than on schools preventing overweight/obesity or increasing physical activity Limit access to and marketing of • Nine education projects that work on school unhealthy foods to children and canteens adolescents • Consumer knowledge and awareness appear in some World Bank engagement, though infrequently, and not specifically targeted at children Redesign and revitalize urban areas, • Vast experience in building sidewalks, including promotion of active pedestrian facilities, bridges, walkways, transportation modes bikeways, and bicycle paths in both the transport and urban development sectors • Most projects are in East Asia and Pacific and in Latin America and the Caribbean; four of these projects are in China • However, urban design and transport projects are not currently designed with an overweight/ obesity lens Promote healthy diet and physical • School health interventions are among the most activity for children and adolescents common obesity prevention activities supported by World Bank ­ operations. However, limited documentation prevents clear assessment of the content and curricula used in these interventions and the extent to which they are evidence-based and address healthy eating and healthy lifestyles. continued next page 184 | Obesity Table 6.3 (continued) World Bank experience as identified through Policy/intervention area review of project documents • Financed interventions have not been evaluated from a health/nutrition perspective • Operations financing school health span regions and income groups, though concentrated in Sub-Saharan Africa, followed by Latin America and the Caribbean and South Asia • School health projects are equally divided between education (25) and health (25) sectors • No projects focus on a school nutrition curriculum, but Turkey finances “nutrition- friendly schools” Increase the quality of the food • Recent projects in Sub-Saharan Africa and East system through production, Asia and Pacific have focused on increasing transport, processing, food production and creating demand for nutrient- environment, and food retail of rich foods vegetables, fruits, and legumes • There is little experience of working on retail aspects of healthy food; projects mention supermarkets but have not had meaningful engagement with the sector • One health project (Kazakhstan) provides direct support for setting food quality standards Implement prenatal and early • Considerable experience focusing on childhood nutrition interventions breastfeeding and early life undernutrition • Operations span regions, though most are highly concentrated in Sub-Saharan Africa and South Asia • Often in the health sector but also incorporated in projects in the social protection, labor and jobs, and agriculture sectors Note: This table is based on a review of the World Bank’s lending portfolio and interviews informants. During the construction of the taxonomy, a decision was made to with key ­ exclude interventions focused on undernutrition, including breastfeeding and maternal gain. Therefore, projects supporting these interventions are not included in the weight ­ ­ hapter. NCD = non-communicable ­ summary of projects in this c disease. Strategic Area 1: Leveraging the Range of Tools to Scale Up Investments Chapter 5 described the range of country experience in supporting over- weight/obesity prevention and c­ ontrol. Strategic Area 1 further identifies how these tools for advocacy, data, and diagnostics; strategic engagement; and investment lending can be maximized for this ­ agenda. Each of these is presented ­below. Business Unusual | 185 Advocacy, Data, and Diagnostic Tools Institutions such as the World Bank have the convening power, along with the tools and expertise, needed to elevate the issue of overweight/obesity on the development agenda—not just with ministers of health but also with ministers of finance and heads of s ­ tate. At the global level, diagnostics such as the ones presented throughout this report can bring the issue to the attention of leaders and influencers in both the public and private sectors at country and global ­ levels. The Lancet Commission on Obesity (LCO 2019) and the EAT Lancet Commission (EAT Lancet Commission 2019) are a start- ing point in this ­process. Including overweight/obesity-related indicators in the Human Capital Index (HCI) is another such high-level advocacy ­ effort. Similar analyses and advocacy are warranted at regional levels, and a care- ful quantification of the links between overweight/obesity, adult survival rates, and the HCI will provide further valuable information for c ­ ountries. New, ongoing analytical pieces focused on urban food systems in Asia and on the processed food industry in Central America serve to fill some of these gaps, but such analyses will need to be further expanded and repli- cated in other ­ regions. At the country level, careful diagnostics can be a very powerful advocacy tool to stimulate ­ action. For example, as observed in the Pacific (box 6.3), World Bank–supported diagnostics highlighted the crippling economic impact of the unabated rise in overweight/obesity and diet-related NCDs, showing that the annual cost of glucose test strips alone exceeded the per capita public health expenditure, with overseas dialysis threatening to bankrupt the government of Samoa in just decades (Anderson 2013). These figures shocked Pacific Island countries into taking swift action and devis- ing a regional road map for a ­ ction. This road map then served as the basis for several subsequent investment ­ operations. Fully integrating overweight/obesity into NCD diagnostics will further help strengthen the rationale and urgency of action, as well as ensure that as World Bank Group investments in NCDs rise, these include not just treatment of the diseases themselves but also primary prevention strategies, including a strategy for the prevention of ­ overweight/obesity. These diag- nostics can then feed into the strategic engagement process, and the Systematic Country Diagnostics and Country Partnership Frameworks can be translated into additional investments in the ­ pipeline. While these diagnostics can draw attention and stimulate political will, deeper analytical work will be needed in each country context to under- stand the drivers of overweight/obesity and identify appropriate and con- text-specific policy and intervention ­ solutions. World Bank teams will need to work across sectoral boundaries to deepen their understanding of the structure of food systems, the role of food distributors and processors and retailers in driving the expansion of the processed foods subsectors, the role 186 | Obesity BOX 6.3 From Diagnostics to Dialogue to Development Finance: Building Momentum for Scaling Up Engagement on Overweight/Obesity and Non-Communicable Diseases in the Pacific In the Pacific, strong diagnostics, engaged country-level counterparts, and sustained management commitment have translated into growth of the lending portfolio targeting the prevention and control of over- weight/obesity and the burden of non-communicable diseases ­(NCDs). Diagnostics and Dialogue In 2013, the World Bank commissioned a study aiming to stimulate country-level discussion regarding the fiscal implications of the region’s NCD crisis (Anderson 2013). The diagnostics sounded the alarm of the time bomb of NCDs in the Pacific and captured the Community. Subsequently, attention of the Secretariat of the Pacific ­ the World Bank, together with the Quintilateral Group members (Australia, New Zealand, the Secretariat of the Pacific Community, the World Health Organization) developed the NCD Roadmap for the Pacific. The Pacific Joint Forum of Economic and Health Ministers ­ endorsed the Roadmap in 2014 as a tool to broaden and strengthen multisectoral NCD responses at the country level (SPC 2014). The UN General Assembly second high-level special session on NCDs further captured the attention of heads of ­ state. Along with the health and economic ministers, there was widespread recognition of the urgency of the problem and commitment to implement strong ­ actions. Management Attention The NCD dialogue between the World Bank and counterparts continued, and in 2016–17 the World Bank prepared Pacific Possible: a ­ ­ flagship program of research and dialogue focusing on long-term eco- nomic growth perspectives of Pacific Island ­ Countries. While the pro- gram highlighted five transformative economic opportunities for the region, it also identified NCDs as one of two major threats to Pacific ­ livelihoods. The Pacific Possible program engaged World Bank teams across disciplines and highlighted the importance of bending the NCD curve (World Bank 2017). Simultaneously, there was strong traction among management, as the East Asia Pacific Regional Vice Presidency had identified nutrition as a regional priority and endorsed the East continued next page Business Unusual | 187 Box 6.3 (continued ) Asia Pacific Multisectoral Strategy and Action Plan to address the dou- ble burden of ­ malnutrition. These diagnostics influenced the World Bank’s strategic engagement: the Pacific 8 Systematic Country Diagnostic included an in-depth analysis of the challenges of the over- weight/obesity and NCD ­ epidemics. Regional management further agreed to apply a “nutrition filter” on all lending in the Pacific that would aim to systematically screen and identify all proposed opera- sensitivity. With the launch of the Human Capital tions for nutrition ­ Project, there is sustained attention on the importance of improving diet to reduce early life undernutrition and increase healthy, produc- tive ­adulthood. Development Finance In the six years since the program of diagnostics was initiated, there has been a substantial increase in the portfolio addressing overweight/ obesity and diet-related NCDs in the Pacific r ­egion. Samoa’s agricul- ture project and additional financing have a focus on the production and demand for nutritious foods; a project is being prepared to sup- port the country’s NCD ­ program. Development policy operations in Tonga and Samoa have included policy triggers on taxation of unhealthy ­foods and beverages. In Tonga, quantitative and qualitative analyses are underway to demonstrate the impact of the taxation pol- icy on consumption and health and to identify opportunities for policy improvement. In countries without such lending operations, Non- ­ Lending Technical Assistance is aiming to support improvements in public financial management, service delivery, and supply chain in the health sector that can further increase the effectiveness of primary and secondary overweight/obesity prevention efforts and improve the efficiency of public resources to prevent and control ­ overweight/obe- sity. Although these operations are still in the early stages, they are a positive indication that tangible results in client engagement can be achieved through collaboration and sustained ­ momentum. of the growing formal and informal food service sector, and the influence of markets and food environments on food choice, particularly in develop- countries. Both nutrition-sensitive value chains and food environments ing ­ will need to be analyzed further for substantive entry points in a manner that can influence tangible actions and i ­nvestments. Furthermore, nutri- tion-sensitive public expenditure reviews in agriculture could also be explored more to encourage greater consideration of processed food 188 | Obesity value chains. Similar diagnostics will be needed for physical activity, regulatory processes, and other relevant ­ ­ areas. The experience with tobacco control has raised the promise of leveraging fiscal policies to reduce overweight/obesity-related risk factors, such as the consumption of unhealthy foods and beverages (box 6.4). Among develop- ment institutions, the World Bank is uniquely placed to provide the techni- cal guidance that can situate taxation reform in the overall macro-fiscal environment. To successfully advise governments on integrating taxation ­ efforts into public health and fiscal reforms, the World Bank can provide analytical and technical advice on design issues, implementation, and strat- egies to manage possible ­ challenges. BOX 6.4 Learning from Experience in Global Tobacco Control The World Bank Group has partnered with major global players in global health and non-communicable disease (NCD) control, such as Bloomberg Philanthropies, the Bill and Melinda Gates Foundation, the World Health Organization, and the Campaign for Tobacco-Free Kids, among others, to support global tobacco c ­ ontrol. The World Bank Group addresses tobacco control and taxation as a development issue. With multisectoral entry points, the World Bank Group—in close ­ partnership with ministries of finance and other related ministries—­ ­ provides support for agencies with the mandate for macroeconomic, fiscal, and regulatory policy making in c ­ ountries. The institution has established a strong track record of addressing tobacco control and taxation with governments and partner a ­ gencies. This box presents a summary of elements that have been instrumental to the program’s ­success. Resources The World Bank’s efforts on tobacco control are supported through a multidonor trust fund and World Bank budget, with a full-time dedi- team. The program has the ability to flexibly engage global, cated ­ regional, and country experts to support the program’s goals and ­ policy reform, and to convene knowledge sharing and learning sessions that have moved the agenda ­ ­ forward. continued next page Business Unusual | 189 Box 6.4 (continued ) Advocacy The World Bank Group Global Tobacco Control program has devel- oped diverse advocacy and awareness-raising tools with dedicated dialogue. These include op-eds resources for coordinating the policy ­ and commentaries to major mainstream and academic publications, conferences. blogs and reports, videos, infographics, panels, and ­ Analytics and Learning The World Bank Group Tobacco Control program has been prolific in its publications, with country-specific diagnostics spanning all World Bank Group regions and including countries as diverse as Armenia, Belarus, Botswana, Peru, the Philippines, Sierra Leone, Turkey, and Vietnam. The diagnostics assess various dimensions of tobacco pro- duction, consumption, and taxation; these dimensions range from estimating the long-term impact of taxation on use and revenues to better understanding the impacts of tobacco industries on employ- ment and the ­ economy. Global public goods such as peer-to-peer learning through the Joint Learning Network for Universal Health Coverage and the development of a joint World Bank Group/ International Monetary Fund Tobacco Taxation Module as part of the Tax Policy Assessment Framework have served to promote knowl- edge exchange across the ­ world. Azerbaijan, Belarus, Indonesia, Moldova, Nigeria, Senegal, Sierra Leone, Ukraine, and Uzbekistan received technical assistance and inputs from the World Bank Group for policy reforms that were eventually ­adopted. Investment The resources available for advocacy, awareness, and analytics have been leveraged in order to advance the tobacco control policy agenda across the ­world. In the period 2016–18, six countries (Armenia, Colombia, Gabon, Moldova, Mongolia, and Montenegro) have incorpo- rated tobacco taxation policy reforms as “prior actions” (triggers), finance. accounting for US$1,085 million in development policy ­ Source: World Bank 2019. However, for these ambitions to be realized, significantly more attention will be needed to strengthen in-house technical skills in this niche area, develop models of long-term health and economic impact at country level, support countries in designing effective taxation and regulatory policies, and address the implications for food production, processing, and ­ trade. The lessons learned in designing such policies and regulations (chapter 5) efforts. will be critical in ensuring the success of these ­ 190 | Obesity Strategic Engagement Tools Engaging upstream with country clients and World Bank Country Management Units (CMUs) will increase the likelihood that the evidence impact. The health sector can lead country and advocacy are translated into ­ teams in incorporating evidence on the epidemiology and the health and economic consequences of overweight/obesity and diet-related NCDs into human capital analyses within the systematic country diagnostic process (see the previous section on Advocacy, Data, and Diagnostic ­Tools). Working with country governments and the governance, macroeconomics, trade and investment sectors, the country teams can then identify opportunities to integrate meaningful activities, operations, and indicators into country ­engagements. Investment Lending Instruments Tools There is opportunity to enhance the impact of development partners in addressing overweight/obesity through tailored expansion of investments (both grants and lending) to achieve these ­ objectives. A historical review of World Bank experience in overweight/obesity prevention and control indicates that investment lending has been the near-exclusive tool used for financing interventions to address ­ overweight/obesity. Investment financing may best serve in low-income contexts and sectors where insti- tutions exist and are well-functioning, and where there is a discrete set of activities to be carried out (for example, school-based physical a ­ ctivity). Disbursement-linked indicators can be used to catalyze the development or strengthening of often weak institutions needed for regulating and monitoring the private sector, while results-based approaches such as the Program for Results may be an effective tool in contexts where NCD pre- vention and control policies and strategies are in ­ place. Given the impor- tance of the enabling fiscal policy environment for overweight/obesity, there are also opportunities to leverage Development Policy Financing instruments and technical assistance such as through Reimbursable Advisory Services for the operationalization of taxation and regulatory policy ­reform. Strategic Area 2: Scaling Up Promising Interventions and Policies Chapter 5 identifies promising policy and intervention areas for the pre- overweight/obesity. With greater attention and intention, invest- vention of ­ ment and policy instruments can be leveraged to scale up the most countries. promising of these approaches across client ­ Business Unusual | 191 Tax Unhealthy Foods and Subsidize Healthy Foods Fiscal policies are highlighted as being among the most promising tools for governments to create incentives to encourage healthy lifestyles, pro- mote the consumption of healthy products, and provide disincentives for the consumption of unhealthy ­ ones. Among development institutions, the World Bank is uniquely placed to provide the technical guidance that can situate taxation and regulatory reforms in the overall macro-fiscal environment. Moreover, development policy financing offers additional ­ financial incentives to countries to undertake reforms that might other- appealing. However, to successfully integrate taxa- wise be less politically ­ tion efforts into operations (particularly Development Policy Operations), the country teams will need to build upon the diagnostics listed in the sections above to understand the long-term impacts of such policies so that policy reforms can be appropriately designed and discussed with countries. The lessons learned in designing fiscal policies listed in chapter ­ 5 provide useful guidance in taking this opportunity f ­orward. Table 6.4 Table 6.4 Overview of Options to Tax Unhealthy Foods and Subsidize Healthy Foods Description of options Levy taxes on sugar- Challenges sweetened beverages • Strong and growing private • Moderate (but Levy taxes on foods high in sector opposition growing) evidence of specific nutrients/ impact (especially ingredients (salt, sugars, relative to tobacco) fats) or classified as Opportunities “unhealthy” ultra- processed foods • Growing political will and • High-income country consumer support, experience as Reduce taxes or implement especially in high-income precedent for low- subsidies to increase countries, and increased and middle-income consumption of fruits, advocacy efforts countries vegetables, and legumes Selected examples • Saudi Arabia Reimbursable • Tonga Development Advisory Services Policy Operation prior • Samoa Development Policy action to “strengthen Operation prior action to incentives to consume “Introduce excise duties for healthy foods’’ sugary and salty products to improve health and nutrition outcomes and reduce the incidence of non- communicable diseases” 192 | Obesity highlights how different sectoral groups, engaging with various ministries within government, can contribute toward this agenda, using a “whole- of-government ­approach.” Nutrient Profiling Models and Front-of-Package Labeling Systems The negative warning labeling system created in Chile has had a signifi- cant impact not only on food purchases and diets but potentially on long- term eating norms of children and their parents (Correa, Fierro et ­ al. 2019). As countries strive for more systematic ways of identifying unhealthy and healthy foods, such front-of-package labeling systems may be a useful way ­forward. These also lend themselves readily to creating systematic cross-cutting policies across marketing controls and fiscal actions across sectors, and to leveraging several policy and investment instruments, as highlighted in table 6.5. Table 6.5 Overview of Options for Food Labeling Description of options Regulate the promotion of Challenges unhealthy foods by • Often indirect links to • Limited World Bank identifying unhealthy traditional client Group expertise in ultra-processed foods and counterparts engaging the food beverages • Often limited in-country industry; potential technical expertise, yielding conflicts of interest • Front-of-package labeling weak or nonexistent • Regulatory agencies • Traffic light systems domestic institutions for often sit outside of the • Nutrient labeling at point regulation Ministry of Health and of sale, especially in • Strong opposition of the require inter- restaurants food and beverage industry ministerial transfers Opportunities • Use of a labeling system that enables across fiscal policies (taxation and subsidies), marketing and enforcement; and school health and nutrition policies Selected examples • Israeli food labeling program • Chile’s comprehensive • Uruguay food labeling ban on marketing program linked with front-of- • Peru food labeling program package warning labels and school bans on warning-labeled regulated foods and beverages Business Unusual | 193 Limit Access to and Marketing of Unhealthy Foods, Especially to Children and Adolescents Supporting food regulation and marketing is comparatively new for countries and development partners, including the World Bank, and there is relatively little institutional experience in this ­area. This is in part because these actions require engaging with food and drug admin- istrations that are less familiar than health or agriculture sector counter- parts, and very few partners or countries have extensive experience in engaging with the private ­ sector. However, with creative thinking, part- nerships, and new diagnostics, there are opportunities to ­ engage. In Argentina, for example, World Bank support was able to extend beyond policy development and strengthen the national agency involved in food regulatory ­ activities. The World Bank Group has also provided sim- ilar support for strengthening the capacity of such regulatory bodies in several other countries, including ­ in India. Investments in the education sector provide entry points to engage in school food environments, both by setting standards for healthy foods provided in schools and by regu- lating the availability of foods in canteens and kiosks in and around schools (making healthy foods more available and unhealthy foods less available). The results of the Chilean experience with marketing regula- ­ tions (see chapter 5) suggest the need to go beyond child-related mar- keting to a total ban during most hours of the day to be truly impactful (Correa, Reyes et ­ al. 2019). Table 6.6 lists some of the options in this space and potential ways to take this ­ forward. Urban Redesign and Revitalization, Including Promotion of Active Transport A strong and growing World Bank portfolio in urban areas—and particularly in nonmotorized transport—offers the opportunity to scale up World Bank engagement in urban environments to contribute to overweight/obesity prevention. As noted above, the transport portfolio has long been engaged ­ in improving access to infrastructure for walking and cycling, and there are work to link with obesity prevention. possibilities for further expanding this ­ Urbanization has changed the face of food systems and built environments, and is deeply intertwined with risk factors for o ­ verweight/obesity. There is both a need and an opportunity to consider health in community design and to ensure that building spaces and transport systems facilitate physical activ- ity and exercise and promote access to healthy foods (table 6.7). Moreover, local governments are often counterparts or key stakeholders for many transport operations, and there is growing evidence about the importance of engaging local and municipal authorities in multicomponent initiatives to address childhood overweight/obesity (Van Koperen et ­al. 2013). 194 | Obesity Table 6.6 Overview of Options for Regulating Access to Unhealthy Foods Description of options Regulate the promotion of Challenges unhealthy foods, including • Unclear links to client • Regulatory agencies by restricting advertising counterparts, weak or situated outside the and/or media coverage for nonexistent domestic Ministry Health and unhealthy foods, especially institutions for regulation require inter-ministerial in and around schools • Strong opposition of the transfers Promote healthy food food and beverage • School food kiosks serve choices in schools and early industry as income-generating childhood centers • Limited expertise in activities for women and engaging the food alternative products Have unhealthy foods industry, marketing, and would need to be identified by front-of- advertising; potential provided and promoted package labeling to conflicts of interest facilitate education of children and norm shifts Opportunities • Integrate school food • Engage parent-teacher environment regulations associations and school into operations administrations to push supporting school school food regulation feeding and health curricula Selected examples • Chile's comprehensive ban on marketing linked with front-of-package warning labels Thus, there are clear opportunities for the transport and health sectors to interest. engage together more closely to further stimulate countries’ ­ Promote a Healthy Diet and Physical Activity for Children and Adolescents Children have the greatest opportunity to learn and succeed when they are healthy and ­ well nourished. The education sector plays a significant role in shaping children’s preferences and beliefs, and can do so with ­ ctivity. From this perspective, there respect to health, diet, and physical a are a variety of options for scaling up childhood overweight/obesity pre- vention and control efforts through the education ­ sector. The global com- munity’s vast experience working on school health and school meals provides an entry point to engage in this space: to increase the nutritional Business Unusual | 195 Table 6.7 Role of the Transport Sector in Addressing Overweight/ Obesity Description of options Expand infrastructure for Challenges nonmotorized and active • Infrastructure will need to be accompanied by transport choices behavioral change communication or other incentives Encourage transit-friendly to be most impactful developments and compact Opportunities building design • Strong and growing portfolio • Harmonize transport Discourage driving by of nonmotorized transport master plans with having specific days and projects; development of overweight/obesity hours of limited traffic and tools to support planning of and NCD prevention implementing private low-stress nonmotorized strategies car-free zones transport networks Implement workplace and • Dialogue about health school-based interventions impacts of nonmotorized to discourage driving and transport can augment promote walking and sectoral rationale of time cycling efficiency and environmental sustainability Ensure that playgrounds Selected examples and spaces for walking, cycling, and physical • CicloRutas Master Plan in • Reimbursable activity are available and Colombia Advisory Services for accessible Bogotá and Lima on nonmotorized transport value of the meals provided, to limit marketing of and access to ultra-­ processed foods, to strengthen the inclusion of evidence-based revisions to school health and physical education curricula, to engage parents and parent-teacher associations to promote healthy behaviors at home, and to ­ create school environments that are conducive to play and physical ­activity. Table 6.8 highlights some options for what more could be done in the near ­future. Prenatal and Early Childhood Nutrition Interventions Healthy diet practices begin very early in ­life. Low birthweight babies are more prone to abdominal overweight/obesity in adulthood, and breast- feeding has a potential effect in reducing the risk of becoming overweight/ life. Furthermore, improving the overall young child feeding obese in later ­ profile and supporting improvements in sanitation and water quality can 196 | Obesity Table 6.8 Working through the Education Sector to Reduce Overweight/Obesity Description of options Provide healthy food in Challenges schools (healthy school • Very few projects support • Constraints in land breakfasts and lunches, curriculum reform, which availability for physical fresh fruit and is often a political task; activity in urban schools: vegetable programs) curriculum reform is trade-offs between Implement whole-of- narrowly focused on core classrooms and play space school programs that subjects (math, science, • Need to engage closely with include quality physical reading), and it is difficult kiosk vendors to provide education, availability to influence the periphery healthy alternatives and of adequate facilities, • Little expertise and minimize income losses, and programs to guidance are available for particularly for women- support physical design of school health owned small enterprises activity for all children and nutrition programs • Challenges exist in procurement and Implement curriculum implementation fidelity for standards and revisions monitoring the quality of on health, nutrition, food in school meal and physical education programs Implement after-school Opportunities or out-of-school programs promoting • School feeding programs • Most education operations physical activity and are often included in basic engage parent-teacher healthy diets with education operations and associations as key youth and adolescents provide "low-hanging stakeholders; school-based fruit" as an entry point to interventions are most Construct playgrounds modify training and effective when they engage and gymnasiums school nutrition guidelines these groups and other • Strong evidence of community partners, and are effectiveness of programs implemented in the long in increasing physical term activity especially when • Modify specifications for part of a multicomponent school construction to strategy include multifunction spaces • There is potential to • Early childhood development remove unhealthy food and “skills” components for from kiosks and vending unemployed youth and machines and from sales adolescents have promise around schools for delivering behavior change Selected examples • Norway subsidy for school • Guyana training to school vegetables fruit and ­ cooks on hygiene, nutritious • Haiti school lunch menu options nutrition guidelines Business Unusual | 197 lead to healthier growth, reduced stunting, and subsequent reductions in the risk of excessive visceral fat and NCDs (table 6.9). Reducing stunting in childhood is critical to reducing abdominal overweight/obesity in adult- hood and the associated risks of many ­ NCDs. Food Systems Interventions Perhaps the greatest challenge (and also the greatest opportunity) will be to trigger meaningful, transformative changes in the food system to deliver safe, diversified, and healthy diets, finding the right balance of food that is healthy for the planet and for people (Htenas, Tanimichi- Hoberg, and Brown 2017; Townsend et ­ al. 2016). Undernutrition and overnutrition share root causes in a food system that does not deliver nutritious diets in sufficient quantity or affordability relative to non- healthy ­options. Though food systems interventions are yet to show robust evidence of effectiveness of their impact, there is a clear need to continue to work toward improving the healthfulness of the food system and food environments (Poti et ­ al. 2015). This involves working across the entire food chain from farmer to retailer to consumer to ensure shifts Table 6.9 Prenatal and Early Childhood Nutrition Interventions Description of options Promote breastfeeding and Challenges support the implementation • Strong private sector • Restrictions of parental of the International Code of interests and weak leave policy to formal Marketing of Breastmilk regulatory bodies jobs despite limited Substitutes responsible for marketing formality of women’s jobs Promote optimal infant and breastmilk substitutes in low- and middle- young child feeding income countries practices in health facilities, Opportunities communities, and through mass media • Increasing focus on • Focus on human capital quality of primary health increases advocacy for care to include improving early breastfeeding counseling childhood nutrition and and promotion in quality breastfeeding standards Selected examples Alive & Thrive programs in Brazil communications and Bangladesh, Ethiopia, and maternity leave Vietnam 198 | Obesity in the relative prices of healthy versus unhealthy foods (including ultra- processed and junk foods) and beverages and to experiment with ways to focus subsidies on legumes, vegetables, and fruits as well as to control actions of this entire sector that is now inimical to a healthy diet (table 6.10). With increasing urbanization in low- and middle-income countries, greater involvement of the social protection and governance sectors may be necessary to support transformation in urban food s ­ ystems. Furthermore, the EAT Lancet Commission suggests five key strategies to ­ nvironment. enhance the agriculture system’s impact on nutrition and the e These strategies and their implications for sectors involved are listed in table 6.11. Table 6.10 Food Systems Interventions Description of options Encourage the production of Challenges fruits, vegetables, and pulses (for • Operational guidance • Food processing has example, through alignment of and expertise on job creation value, research, policies, subsidies, strengthening and this issue needs inputs, irrigation, and technical nutrition-sensitive to be addressed assistance and good agricultural value chains is not yet practices for these value chains) widely available Enhance demand creation, Opportunities marketing, and advertising for healthy foods • Healthier foods are • Countries with often higher value; multiple operational Regulate food formulation (for economic analysis of entry points have the example, salt/sugar/trans-fat the benefits can ability to support a content) and/or the portion size of contribute to shifting supply of nutritious processed and ultra-processed policy-maker foods and create foods perspectives and demand Encourage food processing farmer production • In net food importers, companies to voluntarily patterns high-value nutritious reformulate foods to contain less • Small shifts in the crops provide an added sugar, fat, and other allocation of irrigation opportunity for unhealthy ingredients and infrastructure can import substitution have significant Expand retail access to healthy impact foods (including through zoning Selected examples policies and incentives) • Cambodia Agriculture • Samoa agriculture Increase the affordability of Sector Diversification competitiveness healthy foods (through vouchers project prioritizes operation links to Eat and other social assistance support for nutrition- the Rainbow school programs, subsidies, and price sensitive value chains nutrition campaign promotion) operation Business Unusual | 199 Table 6.11 Five Key Strategies Suggested by the EAT Lancet Commission: Implications for Sectors Involved EAT Commission Implications for sectors and Strategy recommendations policy instruments involved Strategy 1 Seek international and national DPOs across several sectors could commitment to shift toward dietary support this shift targets for planetary health Strategy 2 Reorient agricultural priorities from Agriculture investment operations producing high quantities of food to will need to be designed differently producing healthy food to bring about this reorientation Strategy 3 Sustainably intensify food Implications for fertilizer subsidies production to increase high-quality and agriculture practices in country output operations Strategy 4 Strong and coordinated governance Implications for agriculture DPOs of land and oceans and the governance sector Strategy 5 At least halve food losses and waste, Implications for design of in line with the UN Sustainable agriculture operations and private Development Goals sector engagement Note: DPO = Development Policy ­ O peration. Strategic Area 3: Building the Evidence and Knowledge Base across Sectors Finally, each of the sectoral ministries has the potential and the responsi- ­ vidence base on “what works” in this emerging field as bility to build the e well as the knowledge base to document the “how to” of policy and pro- gram ­ implementation. While the evidence base of effective interventions for the prevention and control of overweight/obesity is growing, institu- tions such as the World Bank have both a great opportunity and a respon- base. sibility to support countries to grow this ­ This is particularly true in the food systems domains, where complex systems with many players including the private sector and long impact pathways make it difficult to quantify and attribute improvements in diets and health outcomes to policy or program ­ interventions. Similarly, few transport or urban design projects build in evaluations of their impact on physical activity, and the evidence base on the impact of taxation and regu- lation of unhealthy foods remains modest to date, with no published sys- tematic ­ reviews. Chapters 4 and 5 in this report, the recent Lancet Commission on Obesity, and the EAT Lancet reports as well as the nine country case studies produced as background documents for this report offer a growing compendium toward this goal of building a stronger 200 | Obesity knowledge base of not just what may work in different contexts, but also how these can best be implemented, and ­ why. The following five key areas are identified for further research and anal- ysis by countries and development partners: • Documenting the impact of fiscal and regulatory policies and cross-­ sectoral interventions in countries where these are being applied, includ- ing a focus on how these can be adapted and applied in different country contexts • Quantifying the climate co-benefits of investing in overweight/obesity- prevention policies and programs • Building the evidence base on food systems approaches to prevent over- weight/obesity • Engaging more strongly with the private sector • Quantifying the contribution of overweight/obesity to adult survival rates and the Human Capital Index Conclusions and Next Steps: The Opportunities and the Challenges Reducing overweight/obesity is a global public good and hence a key role for governments, with support from development partners as countries commit to accelerate progress toward universal health coverage ­ (UHC). Under this umbrella, partners such as the World Bank can step up efforts to address overweight/obesity and diet-related NCDs within health sys- tems, increase awareness of the importance of primary prevention, and promote a whole-of-government approach to ­ action. Action is needed across multiple sectors, including agriculture and food systems, education, social protection, transport, and macroeconomics and trade, to achieve goal. Since many of the effective interventions to prevent overweight/ this ­ obesity are multisectoral in nature, strong country buy-in is needed at the leadership level to create true multisectoral programs such as those seen in Chile. Other countries, such as Israel and Saudi Arabia, are starting to move in this ­ direction. Helping low- and middle-income countries focus more clearly and specifically on comprehensive cross-ministry actions will require significant commitment from development partners such as the World Bank across ­ sectors. To achieve this goal, challenges need to be o­ vercome. For example, the unintended consequences of a sustained focus on productivity-focused agricultural production—particularly in low- and lower-middle-income countries—have not been explicitly ­ recognized. Despite the ongoing dia- logue to address overweight/obesity through the food system, the primary incentives driving agricultural production in most developing countries aim Business Unusual | 201 to increase the incomes and productivity of agricultural households, improve production of staple crops, and advance agro-processing without due attention to the nutritional quality of the final ­outputs. Agriculture operations are increasingly focused on engaging small and medium enterprises, many of which are agro-­ processors engaged in the production of unhealthy, packaged, and processed ­ foods. Without clear guidance and alternatives, teams could continue to sup- port such operations with unmitigated nutritional ­ consequences. Food value chains have increasing impact on the nutrition sensitivity of food systems, with food manufacturers and retailers having a growing influence on overall diets (Popkin 2014; Popkin and Reardon 2018). Both rich and poor in low- and middle-income countries are all pur- chasing increasing amounts of processed and ultra-processed f ­oods. However, support from several development partners, including the World Bank, has yet to focus on unpacking the extremely rapid changes underway in low- and middle-income country value chains, the retail sector, and food systems overall, and linking these changes to nutri- tional impacts through analytics or i ­nvestments. Nutrition-sensitive value chains and the food environment sit at the nexus of agriculture and public health nutrition and there remains a vacuum of appropriate knowledge and skills to address these adequately. Moreover, translat- ing such diagnostics into operations would require further technical and institutional ­ support. The current skills mix of staff in most development institutions, including the World Bank—particularly ­ among operational staff—is not adequate to engage on these complex ­issues. Despite the dramatic increases in overweight/obesity over the last decades, and its potential impacts on human capital, this issue has not received significant attention from countries or from development partners such as the World Bank Group over the past two ­ decades. Historically, the most support for overweight/obesity reduction within the World Bank seems to have been through the transport sector, with some engagement in schools through the education ­ sector. The health sec- tor has provided little stewardship on this ­issue, even with the rising inter- est in addressing NCDs. The renewed focus on human capital and the growing evidence base for double- and triple-duty action highlight the urgent need for countries to take action to address o ­ verweight/obesity. The growing awareness and attention also present a tremendous o ­ pportunity. Triple-duty actions that link actions on undernutrition and overweight/obesity to climate co-­ benefits offer yet another opportunity for piggybacking on the climate agenda, advocacy, and action at ­ scale. Given the need for technically sound diagnostics, the health sector needs to take the lead on the initial diagnostics, starting with global and regional 202 | Obesity diagnostics, followed by country-level analyses incorporated into Systematic Country Diagnostics and Country Partnership F ­ rameworks. These analytics can then also feed into the wider health sectoral investments, including primary prevention of ­ NCDs. Delivering on this complex agenda, however, will require a cross-­ sectoral approach and a whole-of-government and whole-of–development partner effort. In addition to the health sector, which needs to provide overall stew- ­ ardship, the agriculture, transport, macroeconomics and trade, and educa- tion sectors have major roles to ­ play. Paralleling the dietary mantra of “everything in moderation,” develop- ment partners have not yet taken a firm stance on producers and proces- sors of ultra-processed foods and b­ everages. As a result, there are competing priorities in health and agriculture with respect to food systems ­investments. However, taking such a hard line against health-harming products is not unprecedented: in 1991 the World Bank adopted a mandatory operational policy not to lend, invest in, or guarantee investments or loans for tobacco production, processing, or ­ marketing. Many other partners followed ­ suit. A similar approach for a subset of particularly harmful foods and beverages could be ­ explored. Small tweaks to work programs and budgets will not be s ­ufficient. A transformative approach and additional financial and human resources need to be dedicated to this agenda, and building internal capacity as well as capacity within client countries to work across sectoral boundaries and with nontraditional partners will be c ­ rucial. The experience with tobacco suggests that this is feasible, in partnership with like-minded global and national partners such as Bloomberg Philanthropies, UN partners such as the WHO and UNICEF, and academia and civil ­ society. References Anderson, I ­. 2013. “The Economic Costs of Noncommunicable Diseases in the Pacific Islands: A Rapid Stocktake of the Situation in Samoa, Tonga, and Vanuatu.” Health, Nutrition, and Population (HNP) Discussion Paper, World ­ Bank, Washington, D https://openknowledge.worldbank.org/handle/10986​ ­ C. ­ /17851 License: CC BY 3.0 ­ IGO. Correa, ­ T., ­C. Fierro, ­M. Reyes, ­ F. ­ R. Dillman Carpentier, ­ L. Smith Taillie, and ­ C. ­Corvalan. 2019. “Responses to the Chilean Law of Food Labeling and Advertising: Exploring Knowledge, Perceptions and Behaviors of Mothers of Young ­Children.” International Journal of Behavioral Nutrition and Physical Activity 16 (1): 21. T., ­ Correa, ­ M. Reyes, ­ C. Corvalan, and ­ L. Smith Taillie, ­ R. Dillman ­ F. ­ Carpentier. 2019. “Changes in TV Advertising after the Implementation of the Chilean Law of Food Labeling and Advertising: Evidence from a Pre-Post S ­ tudy.” Unpublished. Santiago, Institute of Nutrition and Food Technology, University of ­ Chile. Business Unusual | 203 EAT Lancet ­ Commission. 2019. Willett, ­ W., ­J. Rockström, ­ B. Loken, ­ M. Springmann, T. Lang, ­ ­ S. Vermeulen, ­ T. Garnett, ­ D. Tilman, ­ F. DeClerck, ­ A. Wood, ­ M. Jonell, M. Clark, ­ ­ L. ­J. Gordon, ­ J. Fanzo, ­ C. Hawkes, ­ R. Zurayk, ­ J. ­A. Rivera, ­ W. De Vries, ­ L. Majele Sibanda, A ­ . Afshin, ­ A. Chaudhary, ­ M. Herrero, R ­ . Agustina, ­ F. Branca, ­ A. Lartey, ­ S. Fan, ­ B. Crona, ­ E. Fox, ­V. Bignet, ­ M. Troell, ­T. Lindahl, S. Singh, S ­ ­. ­E. Cornell, K ­ . Srinath Reddy, S ­ . Narain, S ­ . Nishtar, and C ­. ­ L. J. ­ ­ Murray. “Food in the Anthropocene: The EAT–Lancet Commission on Healthy Diets from Sustainable Food ­ Systems.” The Lancet 393 (10170): 447–92. ­ https:// www.thelancet.com/commissions/EAT. Htenas, ­ A. ­ M., ­ Y. Tanimichi-Hoberg, and L ­. ­Brown. 2017. An Overview of Links between Obesity and Food Systems: Implications for the Agriculture GP A ­ genda. Washington, DC: World Bank ­ Group. Lange, ­ G.-M., ­ Q. Wodon, and K ­.­ Carey. 2018. The Changing Wealth of Nations 2018: Building a Sustainable ­ Future. Washington, DC: World ­ Bank. LCO (Lancet Commission on ­ Obesity). 2019. Swinburn, B ­. ­A., ­ I. Kraak, S V. ­ ­. Allender, ­ V. J Atkins, ­ I. Baker, ­ P. ­ J. R. Bogard, ­ H. Brinsden, ­ A. Calvillo, ­O. De Schutter, ­ R. Devarajan, ­ M. Ezzati, ­ S. Friel, ­ S. Goenka, ­ R. ­A. Hammond, ­ G. Hastings, ­ C. Hawkes, ­ M. Herrero, ­ S. Hovmand, ­ P. ­ M. Howden, ­ L. ­M. Jaacks, A. ­ ­ B. Kapetanaki, ­ M. Kasman, ­ H. ­V. Kuhnlein, ­ K. Kumanyika, ­ S. ­ B. Larijani, ­T. Lobstein, ­M. ­W. Long, ­V. ­K. ­R. Matsudo, ­S. ­D. ­H. Mills, ­G. Morgan, ­A. Morshed, ­ P. ­ M. Nece, ­ A. Pan, ­ D. ­ W. Patterson, G ­ . Sacks, ­ M. Shekar, G L. Simmons, ­. ­ W. Smit, A ­ ­ . Tootee, ­ S. Vandevijvere, W ­ . ­E. Waterlander, L ­ . Wolfenden, and W. ­ ­ H. ­ Dietz. 2019. “The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission R ­ eport.” The ­Lancet 393 (10173): 791–846. ­https://www.thelancet.com/commissions/global-syndemic. Popkin, ­ M. 2014. “Nutrition, Agriculture and the Global Food System in Low and B. ­ Middle Income ­ Countries.” Food Policy 47: 91–96. Popkin, ­ M., and ­ B. ­ Reardon. 2018. “Obesity and the Food System Transformation T. ­ in Latin ­ America.” Obesity Reviews 19 (8): 1028–64. Poti, ­ M., ­ J. ­ M. ­ A. Mendez, ­ S. ­ W. Ng, and ­ B. ­M. ­Popkin. 2015. “Is the Degree of Food Processing and Convenience Linked with the Nutritional Quality of Foods Purchased by US Households?” American Journal of Clinical Nutrition 99 (1): 162–71.  SPC (Secretariat of the Pacific ­ Community). 2014. “Joint Forum Economic and Pacific Health Ministers Meeting Outcomes S ­tatement.” Honiara, Solomon ­Islands. Townsend, ­ S. ­ R., ­ M. Jaffee, ­ Y. Hoberg-Tanimichi, and ­ M. ­ A. ­ Htenas. 2016. The Future of Food: Shaping the Global Food System to Deliver Improved Nutrition and H ­ ealth. Washington, DC: World ­ Bank. Van Koperen, ­ T. ­M., ­ A. Jebb, ­ S. ­ C. ­ D. Summerbell, ­ T. ­ S. Visscher, ­ L. ­ M. Romon, J. ­ ­ M. Borys, and ­ C. ­ J. ­ Seidell. 2013. “Obesity Prevention: Characterizing the EPODE Logic Model: Unravelling the Past and Informing the F ­ uture.” Obesity Reviews 14: 162–70. WHO (World Health Organization). 2014. Global Nutrition Targets 2025: Policy Brief Series. Geneva: World Health Organization. https://www.who.int/nutrition​ /publications/globaltargets2025_policybrief_overview/en/. ———. 2018. Time to Deliver: Report of the WHO Independent High-Level Commission on Noncommunicable ­Diseases. Geneva: ­WHO. 204 | Obesity ­ ank. 2017. Pacific Possible: Long-Term Economic Opportunities and Challenges for World B Countries. Washington, DC: World ­ Pacific Island ­ Bank. ———. 2018. The Human Capital Project. World Bank, Washington, DC. https:// openknowledge.worldbank.org/handle/10986/30498. License: CC BY 3.0 IGO. ———. 2019. Global Tobacco Control Program: Selected Country Work: Tobacco Tax Policy Reforms, Analytical Reports, Videos, and B ­logs. Washington, DC: World ­ Bank. ­ http://documents.worldbank.org/curated​ /en/170101548686925502/Global-Tobacco-Control-Program-Selected-Country​ -Work-Tobacco-Tax-Policy-Reforms-Analytical-Reports-Videos-and-Blogs. ECO-AUDIT Environmental Benefits Statement The World Bank Group is committed to reducing its environmental footprint. In support of this commitment, we leverage electronic publishing options and print-on-demand technology, which is located in regional hubs world- wide. Together, these initiatives enable print runs to be lowered and shipping distances decreased, resulting in reduced paper consumption, chemical use, greenhouse gas emissions, and waste. We follow the recommended standards for paper use set by the Green Press Initiative. The majority of our books are printed on Forest Stewardship Council (FSC)–certified paper, with nearly all containing 50–100 percent recycled content. The recycled fiber in our book paper is either unbleached or bleached using totally chlorine-free (TCF), processed chlorine–free (PCF), or enhanced elemental chlorine–free (EECF) processes. More information about the Bank’s environmental philosophy can be found at http://www.worldbank.org/corporateresponsibility. This report, Obesity: Health and Economic Consequences of an Impending Global Challenge, is timely; it complements recent and forthcoming technical reports on this issue. It is also at the core of the World Bank’s Human Capital Project, which highlights the importance of investing in people to boost economic growth. The report reviews the changing epidemiology of overweight/obesity; current trends globally and by region, gender, and age; the health and economic costs, and the potential impacts of failure to address it, including on the climate; the potential effectiveness of policies and interventions; and country experiences and lessons learned, particularly with diet-related taxes and other preventive actions across several sectors. It puts forward a call to action for next steps in fighting this growing challenge. ISBN 978-1-4648-1491-4 90000 9 781464 814914 SKU 211491