As an emerging economy, Chile has greatly increased its GDP while making significant improvements in their Human Development Index, including reduced infant mortality and reduced malnutrition. Obesity and other dietary risk factors have replaced these traditional health issues and become the number one health concern in Chile. This phenomenon is known as the “nutrition transition,” and is a problem that often accompanies economic growth and trade liberalization due to shifts in the food market. It is essential that both the Chilean government and international organizations address both the structural economic causes, as well as the health issues. Specifically, this paper calls for strengthening the broad national health initiative; promoting better nutrition among school-age children; improving consumer information and restricting food marketing via government regulation; and increasing economic incentives to invest in health foods and programs.
Section I: A national epidemic
Accompanying substantial economic growth and significant progress in many health indicators, obesity has risen at an alarming rate in Chile. This “nutrition transition” results in an increasing incidence of diet-related diseases such as heart disease and Type II diabetes, which have become top health concerns in the country. These issues require a two-tiered approach of addressing economic incentives on the macro-level, as well as a revamping of ground-level health initiatives to influence consumer behavior.
Section II: The nutrition transition and increasing obesity
This section provides a brief overview of the “nutrition transition” and illustrates how it has evolved in Chile in the expansion of transnational food companies, changing food consumption patterns, and an increase in obesity and nutrition-related diseases. The nutrition transition is a global phenomenon associated with economic liberalization and expansion. An increased intake in fats and sweeteners, decreased intake of grains, and an inadequate consumption of fruits and vegetables characterize this trend. Various factors of globalization affect consumption patterns, including liberalization of international food trade, liberalization of foreign direct investment (FDI), global food advertising and promotion, emergence of global agribusiness and transnational food companies, and retail restructuring, especially an increase in the presence of transnational supermarkets.[1]
In addition to the general effects described above, two terms describe converse effects of such dietary changes. Dietary convergence is an “increased reliance on a narrow base of staple grains, increased consumption of meat and meat products, dairy products, edible oil, salt and sugar, and lower intake of dietary fiber” (Bruinsma 2003). In fact, the Food and Agriculture Organization of the United Nations (FAO) finds that economies more integrated into the world economy tend to have similar consumption patterns. Convergence is driven by income and price, occurring as certain foods are more readily available and at a lower cost. Convergence disproportionately affects people of a lower socio-economic status, as cheaper, heavily-processed foods begin to replace a more traditional diet based on whole foods.
The second notable effect of the transition is dietary adaptation, which G. Kennedy defines as an “increased consumption of brand-name processed and store-bought food, an increased number of meals eaten outside of the home, and consumer behaviors driven by the appeal of new food available” (Kennedy et al. 2004, 2). Adaptation is driven by increased demands on time, ubiquitous exposure to advertising, accessibility of new foods, and the appearance of food retail stores. It occurs more frequently with high-income consumers, as they are exposed to new, possibly more convenient, food options and are able to afford them. Expanding markets and the possibility of boosting profits are encouraging increased product differentiation. For example, the biotech food company Monsanto has created “Vistive,” a new type of soybean with low linolenic acid content. As compared to other beans and seeds used to produce oil, “Vistive” needs no hydrogenation and therefore contains little to no trans fat. High costs of the new product will eventually get passed down to the consumer. Wealthy, health-conscious consumers will pay the extra money to have no trans fat and no hydrogenated oil. This increase in product differentiation will benefit the wealthy consumer who has the means to pay for these new, healthier products. This could have a positive overall effect on the health situation. However, until increased FDI in this area leads to more companies which produce these goods—which in turn will lead to lower prices—the positive effects will be unilateral; it will benefit those of a higher socio-economic status, while excluding the low-income consumer. In this way, the effects of dietary convergence and dietary adaption often create more pronounced inequality in terms of health between high-income and low-income consumers.
Three processes of globalization directly contribute to the dietary changes that characterize the nutrition transition: food production and trade, foreign investment, and communication. Liberalizing economies has led to more open trade, which results in more food choices and higher FDI. This process encourages an increase in transnational food companies (TNCs) and a focus on food processing. Similarly, the spread of technology and communication has contributed to the effects of the nutrition transition. Better access to televisions and the internet regularly exposes consumers to advertising. At the same time, marketing techniques have become more sophisticated. This is problematic because advertising for energy-dense, processed foods is directed at young people, aiming to capture young consumers’ preferences early and continue on into adulthood. In Western countries, studies have shown that this advertising has influenced dietary patterns among young people (Hawkes 2007).
The liberalization of trade expands the imports and exports of agricultural products and processed food, which increases the options of the foods that are available and may lead to a decrease in their price. Consumers are exposed to new products and, in some cases, are able to buy more than they could before. Transnational food companies (TNCs) are multinational entities that work in the production, processing, distribution, or marketing of food.[2] Trade liberalization affords the TNCs a broader consumer base. This, in combination with increased FDI in the food sector, has allowed for unprecedented growth in the transnational food industry (Hawkes 2007). The expansion of the multinational food industry, along with increased exposure to advertising, technology changes have allowed global food marketing to become a driving force in the nutrition transition, as it raises awareness of the different products available, as well as increasing their desirability (Ibid 2007). Expansion of TNCs also leads to retail restructuring and an increase in the amount of supermarkets.
The nutrition transition manifested itself in Chile with the expansion of transnational food companies, changes in the food market and consumption patterns, and specific health indicators. The traditional food economy of Chile was based on locally grown foods sold in outdoor street markets, ferias, or neighborhood vendors selling produce and homemade bread out of their houses or garages.[3] While these methods still comprise much of the market, there is a growing presence of retail food outlets. For example, in 2009 Walmart bought Chile’s leading food retailer Distribución y Servício D&S. Retail stores as of September 30, 2012 totaled 327, including 70 Líder Hipers—which is the equivalent of a Super Walmart—59 Líder Express, which is a regular grocery store, and 139 Ekono discount stores (Walmart Chile Stores).[4] These stores carry many products typical in any Walmart, including their own Great Value brand, as well as other international or U.S. based brands.
The nutrition transition also manifests itself in the changing consumption patterns in Chile and the alarming increase in incidences of diseases such as heart disease and Type II diabetes—both associated with the rise in obesity rates. Mortality rates from cancer and diabetes have also risen sharply. Many health indicators in Chile have made significant gains, such as improved maternal and infant health, as well as an increased life expectancy. The infant mortality rate decreased from rates comparable to the rest of Latin America in the 1960s to 8 in 1000 live births in 2010 (World Health Organization 2013)—compared to 35.7 in the rest of Latin America. However, non-communicable, diet-related diseases as a cause of death rose from 54 to 75 percent in 1998 (Pan-American Health Organization [PAO] 2001). Such diseases are also the leading cause of disability-adjusted life years (DALYs) of life lost in Chile. In 2010 sedentary lifestyles and dietary risk factors caused the largest disease burden worldwide. This is a significant shift from previous years. In 1990 the top three factors were childhood underweight, household air pollution, and tobacco smoking. Of the dietary risk factors, high body mass index (BMI) is the leading risk in Southern Latin America, causing 10% of the overall disease burden in the region (Stephen S. Lim, et al. 2012).[5] In Chile in 2008, total expenditure on health was 8% of their total GDP. This is significant because the monetary and societal costs of treating diseases is quite high and can slow improvements in human capital and economic development. Disease prevention is more cost-effective.
Dietary issues are contributing factors to these main causes of death in Chile. As income increases, so does consumption of food and fats, most notably saturated fats. Consumption of fat per person rose from 13.9 kg in 1975 to 16.7 kg in 1995 in Chile, with total meat consumption rising 135 percent from 1985 to 1998 (Albala et al. 2001). Low consumption of fruits and vegetables and an increasingly sedentary lifestyle also contribute to increasing dietary risk factors (Stephen S. Lim, et al. 2012).
The increasing rate of obesity is especially detrimental because it concerns not only the current population, but it also affects future generations. Using WHO standards, rates of overweight Chilean children increased from 15% in 1987 to 20% for boys and from 17.2% to 21.8% for girls (Kain et al. 2002). A young population already experiencing high prevalence of dietary risk factors and excess weight will become an adult population with increased rates of disease, increased healthcare costs, and lower human capital. Obesity develops from exposure to the obesogenic niche, which includes a variety of factors predisposing humans to weight gain and obesity. Habits and consumption in very early life stages are extremely influential in determining a child’s predisposition to weight gain throughout their entire life. It determines not just consumption and lifestyle, but also alters metabolic and biological processes which make the child—both in early life stages and as an adult—more susceptible to obesity (Wells 2012, 261-276). These environmental factors of the obesogenic niche are becoming more and more common in Chile, and may have a permanent effect on the health of future generations. General trends of declining health in a population are costly in terms of health expenditures as well as a decline in human capital and productivity.
Section III: A multi-level approach to address the nutrition transition
Chilean policy makers and international health agencies must proactively tackle the rise in obesity and the associated increase in diet-related diseases. Apart from the gravity of rising mortality rates and the obesity epidemic, Jonathon C.K. Wells points to an underlying concern; humans adapt to their environment, and chronic under-nutrition or over-nutrition over generations changes the phenotype of people across generations (Ibid 2008). Therefore, it is imperative that policy makers and officials act quickly to address both the underlying economic structures, such as the immense growth of the TNCs and increased investment in processed foods. Policy makers should attempt to influence the preferences and behavior of the citizens towards healthier alternatives through health initiatives, increased education and awareness of issues, and improved consumer information, through better food labeling policies, for instance. The importance of a strong economy is unquestionable; increasing GDP is associated with longer life expectancy. Not wishing to stifle economic growth or discourage trade and investment with restrictive government regulation, the following policy recommendations focus on increasing regulation only on targeted aspects of the food industry: namely, food labeling and marketing practices. They also incorporate economic incentives through other policies such as eliciting more investment into new, healthier products, as well as community health campaigns in order to influence consumer knowledge and preferences.
The policy recommendations include limited regulations designed to encourage better consumer information and limit marketing practices, especially when related to children. It is essential to target the younger generations because Wells demonstrated that early exposure to the obesogenic niche is a determining factor of behavior and preferences in later life, and is a major risk factor in being overweight as an adult (Wells 2012). The obesogenic niche is the combination of environmental factors which makes individuals more susceptible to gaining weight (Wells 2008). Furthermore, many marketing campaigns for highly-processed, calorie-dense foods already target youth in an attempt to secure their preferences early in their lives (Hawkes 2007).
Bolstering health campaigns directed not only at school age children, but the general population as well, will encourage consumers to make healthier choices. The following policy recommendations lay out a multi-faceted approach in order to addresses both consumer behavior and the underlying economic structural issues.
Section IV: Policy Recommendations
The Chilean government should focus their efforts into the following four categories: a comprehensive health initiative directed at the general population, targeting youth, government regulation, and economic incentives.
i. Strengthen health initiatives targeted at the general population
Recognizing the importance of this issue is necessary though not sufficient to make improvements in national health. The Chilean Ministry of Health should continue and strengthen its national health campaign “Choose to Live Healthy.” Obesity and excess weight is still a pressing issue in the United States; however, the burden of disease caused by high blood pressure and total cholesterol has decreased significantly in North America and Western Europe (Lim et al. 2012). This indicates that efforts to improve national health have at least been partly effective.
ii. Target youth in multi-faceted health campaigns.
a) Introduce the MEND program (Mind Exercise Nutrition Do it!) in Chile. MEND is community based program that works with children and their families to help them develop healthier habits. It addresses improving nutrition, increasing physical activity and positive behavior change. Program staff work with parents to help them to improve the health habits of their children and become helpful role models (MEND Foundation 2013). Twelve months after completing the program participants had sustained decreases in BMI and waist circumference and continued increases in physical activity (Paul M. Sacher, et al. 2012). The United Kingdom, the United States and several other countries already utilize MEND. Chile has the infrastructure to successfully implement this program. Improving national health is already part of the political agenda. Chilean First Lady Cecilia Morel Montes heads the health initiative Choose to Live Healthy. The Ministry could incorporate the MEND program into this campaign. Funding will not be a restricting factor. MEND partners with private companies such as General Mills who help provide funding. MEND is run free of charge because of these private partnerships, along with other components of its organizational design.
b) The MEND program should be expanded beyond the core program of targeting overweight children between the ages of 7 and 13 to normal or overweight children ages 2 and older. Interventions aimed at younger children are more effective (Story 1999). Working to establish healthy eating patterns and lifestyles is more effective than treating excess weight problems and correcting negative health behaviors. In small communities which may lack the necessary resources, the Ministry could incorporate MEND into the already existing health education programs present in schools.
c) Changing the content of school meals to meet higher nutritional standards has been effective in improving students’ dietary intakes in certain programs in the United States and Europe (Jaime and Lock 2009). Many schools in Chile already provide free or reduced meals for breakfast and lunch to students. Schools should make these more nutritious. Instead of white bread and cheese sandwiches for breakfast and white rice with processed chicken for lunch, schools should provide healthier versions, such as whole grain bread or plain oatmeal for breakfast and brown rice with less processed chicken for lunch. These products are already common in Chile and are healthier alternatives than what schools currently serve.
iii. Increase government regulation through improved access to product information and restrict advertising of certain foods.
a) Require the labeling of trans fat on products that contain any amount of hydrogenated oils. Current regulations, even in the United States are misleading because food labels may indicate zero grams of trans fat if there is a fraction of a gram of trans fat. However, producers manipulate that loophole by decreasing the portion size so that legally, they may claim there are zero grams trans fat. When consumers eat more than the given serving size, or frequently consume such foods, trans fat will still build up in the coronary system and can cause health problems. Changes in labeling such as listing the single serving nutrition content alongside a second column listing nutrition content for the entire package may help consumers make healthier choices (Lando and Lo, 2013).
b) Place restrictions on advertising and marketing, for example:
b1) Children are more influenced by marketing and are develop preferences that will largely determine their choices and behaviors later in life. For this reason, the Chilean government should prohibit marketing of high-energy, low-nutritional value foods in and nearby schools.
b2) Advertisements should be balanced between those that encourage health and those that promote non-nutritious foods. The Chilean government should work with TNCs to sponsor advertisements that promote healthy foods or behaviors, such as, endorsing either a non- or little-processed food like plain oatmeal or milk, or encouraging a healthy lifestyle, such as exercising, getting involved in school sports, or eating fruits and vegetables. There should be one health-promoting advertisement for every ad for a processed food product that contains a certain amount of sugar and fat. The clearest example of this type of regulation in public policy is the Master Settlement Agreement between the tobacco industry and state attorneys general in the United States of America. This agreement involved similar measures, including prohibiting outdoor cigarette advertising within a 1,000 foot radius from schools or public playgrounds, and requiring industry giants to finance an anti-smoking campaign. These restrictions on advertisements were largely successful (Derthick 2012, 191 & 239).
iv. Provide economic incentives to private investors and multinational companies.
a) The Ministry of Health should elicit the assistance of the FAO to find more private funders to invest in the discovery and growth of alternative seeds and oils like the soybean seeds “Vistive.” The Ministry and FAO could use the Advanced Market Commitment (AMC) model currently utilized in the pharmaceutical industry. This strategy creates incentives for innovation through guaranteeing a market for a new product which meet certain criteria. This incentive structure may be more effective than a traditional subsidy for research and development (Kremer 2006). Increased investment in this area will eventually lead to better products and lower prices for the consumer. Therefore, even though such products will originally be marketed and sold to consumers of a higher socio-economic status, these healthier versions will eventually be a viable option for all.
b) The “Choose to Live Healthy” initiative already partners with major companies like Jumbo and Quaker on community health campaigns. The Ministry should reinforce these partnerships by offering tax breaks to domestic and transnational food companies that sponsor health programs in schools or in communities, such as community sports leagues or nutrition programs. An example of an already existing program in the United States is Wal-mart’s Healthier Food initiative, which includes working with their suppliers—name brand as well as their own Great Value brand—to reduce sugar and sodium in their products, keeping produce prices low, and drawing consumer attention to healthier products by featuring a “Great for You” icon (Wal-Mart Corporation).
Section V: Conclusion
Increasing obesity rates and rising incidences of diet-related diseases are a major health concern in Chile, and are spreading globally in their scope—no longer affecting only the richest nations, but developing countries and emerging economies as well. If policy makers and international health organizations take a multi-faceted approach, which addresses the underlying economic structural issues in conjunction with improving consumer health choices, these alarming health trends can be reversed. It is also essential to work with transnational food companies in order to encourage economic growth and to utilize the immense potential the private sector has to offer.
[1] For a concise table of these factors of globalization which contribute to the nutrition transition, see Appendix, Table 1.
[2] The Danone Group, Kraft, the H.J. Heinz Company, and General Mills are some examples.
[3] See Appendix, figures 1-2.
[4] See Appendix, figure 3.
[5] For a graph comparing incidence of dietary risk factors between Chile and South America, see Appendix, Figure 4.
Appendix
La fería in La Serena
La fería 2, La Serena
Líder Hiper in Antofogasta (Obtained 13 November 2012 from http://www.flickr.com/groups/antofagasta/pool/?view=lg)
Table 1: Globalization processes linked with the nutrition transition
|
Globalization process |
Nutritional implication following the conceptual framework |
|
Growth of transnational food companies (TFCs) |
Increases availability of processed foods (fast foods, snacks, soft drinks) through growth of fast food outlets, supermarkets and food advertising/promotion; driven by trade and FDI |
|
Liberalization of international food trade |
Imports change availability of foods and/or their price |
|
Global food advertising and promotion |
Shapes food preferences by affecting desirability of different foods |
|
Development of supermarkets |
Growth of transnational supermarkets changes food availability (increases diversity of available products), accessibility, price, and way food is marketed |
|
Cultural influences |
Migration, TNCs, and tourism introduce and popularize new foods (changes food availability and desirability) |
|
Liberalization of foreign direct investment (FDI) |
Changes type of foods available, their price and the way they are sold and marketed |
|
Technological developments |
Affects ability to transport, store and process foods, which affects their availability, accessibility and price |
|
Liberalization and commercialization of domestic agricultural markets |
Changes way food is produced, type of foods available, their price and the way they are sold and marketed |
Hawkes, Corinna. WHO Commission on Social Determinants of Health. Globalization, Food and Nutrition Transitions. p 26. 23 August 2007. http://www.who.int/social_determinants/resources/gkn_hawkes.pdf.
Adult risk factors for disease in Chile, 2008
World Health Organization, “Chile: health profile,” accessed February 13, 2013 from http://www.who.int/gho/countries/chl.pdf.
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