Nutrition in Chile: Global Challenges, local solutions

A report from the Economist Intelligence Unit
Sponsoredby
Nutrition in Chile
Global challenges,
local solutions

© The Economist Intelligence Unit Limited 20131
Nutrition in Chile Global challenges, local solutions
About this research 2
Nutrition in Chile: Global challenges, local solutions 3
Obesity in Chile: The challenge 3
Obesity in Chile: The response 6
Global challenges and responses 7
The path forward in Chile: An integrated approach to local solutions 8
Contents

The Nutrition in Chile: Global Challenges, Local
Solutions is a white paper written by the Economist
Intelligence Unit and sponsored by DuPont. The
findings and views expressed in this briefing paper
do not necessarily reflect the views of DuPont,
which has sponsored this publication in the
interest of promoting informed debate. Lucy Hurst,
associate director of custom research for the
Americas, was the research director for the project.
Jamie Morgan, analyst, was the project manager
and editor. Leo Abruzzese, global forecasting
director and executive editor for the Americas,
served as senior advisor. Jill Mead served as a
contributing author and nutrition expert for the
project.
Aboutthis
research

Nutrition in Chile:
Global challenges, local solutions
Each year, US$53.5trn in social and economic costs
is lost to malnutrition—the equivalent of US$500
for every person on the planet. Although the
challenges of malnutrition were once confined to
undernourished and underweight populations,
today they include the overweight and the obese as
well. Indeed, global obesity rates have doubled in
the last 30 years, and obesity today is the
underlying cause of 2.8m adult deaths annually
worldwide.1
Whereas obesity was once considered a
problem of the rich world, it is now emerging in
low- and middle-income countries, even among
those that still struggle with underweight and
undernourished populations.2,3
According to the
World Health Organisation (WHO), obesity and
excess weight is now the fifth-leading risk to global
health. The condition is linked to more deaths
globally than underweight maladies.4
The increase in obesity is alarming public-health
agencies worldwide. Excess weight is linked to
higher risk of heart disease, stroke, breast cancer,
colon cancer and many other health problems,
including premature death.5,6
As a result, the
economic burden of obesity is staggering, with
treatment costs running into the hundreds of
billions of dollars in the United States alone. As
obesity rates rise in other countries, so, too, do
costs.7
1 World Health Organization (WHO), 2013.
2 Ibid.
3 Ibid.
4 Ibid.
5 Oxford Journals, The medical complications of obesity, August 2006.
6 Haslam, D. W., & James, W. P. (2005), “Obesity”. Lancet, 366, 1197-1209.
7 “Economic Costs,” The Obesity Prevention Source, Harvard School of Public Health,
website, accessed June 2013.
Several trends that transcend national
boundaries explain the dramatic increase in
obesity worldwide. Widespread industrialisation
has increased the availability of processed foods
high in fat, carbohydrates and sugar, and has
reduced the need for manual labour in farming and
industrial production. At the same time,
urbanisation has led to a relative increase in
sedentary occupations, and the rising standard of
living has improved access to motorised
transportation and other labour-saving devices.8
The result is that people are consuming greater
amounts of energy-dense foods while expending
fewer calories in their day-to-day lives, leading to a
global increase in body mass.
Obesity in Chile: The challenge
Fighting obesity has become a national struggle in
Chile. Indeed, Chile in many ways epitomises the
classic nutritional and health transition scholars
describe in emerging markets. In the 1970s,
malnutrition and infectious diseases were the
primary national food-security and health
challenges, particularly among the rural poor.9
The
rapid modernisation and urbanisation, of the
1980s and 1990s changed the lifestyles of many
Chileans and thus the country’s health profile. By
the end of the 1980s, undernutrition had virtually
vanished, but obesity was on the rise.10
Today,
obesity is considered one of the nation’s top health
8 “What is the Nutrition Transition?,” University of North Carolina, website, accessed
June 2013.
9 Vio del Rio, F., The Nutrition Transition in Chile, 2007.
10 Albala et al., Nutrition in Chile: Determinants and consequences, 2002.

*Or nearest year. Sources: OECD Health Data 2011; national sources for non-OECD countries.
Obesity globally: prevalence among select countries
% of population, 2009*
India
Indonesia
China
Korea
Japan
Switzerland
Norway
Italy
Sweden
France
Netherlands
Austria
Poland
Denmark
Israel
Belgium
Brazil
Germany
Turkey
Portugal
Spain
Slovenia
OECD
Slovak Republic
Czech Republic
Estonia
South Africa
Greece
Hungary
Russian Fed.
Iceland
Finland
Luxembourg
Ireland
United Kingdom
Canada
Australia
Chile
New Zealand
Mexico
United States
2.8
1.3
3.6
1.1
3.4
2.4
4.1
3.6
3.5
4.3
7.7
8.6
8.0
11.0
9.3
11.3
10.7
11.7
11.5
10.9
12.4
11.2
12.7
12.0
12.5
12.6
13.1
13.7
14.4
13.2
14.4
13.1
14.0
13.7
13.8
15.7
18.5
12.3
16.1
14.6
14.7
17.3
15.8
17.0
17.2
16.6
16.7
17.1
17.0
18.0
18.3
17.5
27.4
8.8
18.5
17.7
18.3
20.8
11.8
16.0
21.3
18.9
21.1
19.3
19.0
24.5
24.0
22.0
23.9
22.1
23.2
25.2
23.6
25.5
30.7
19.2
27.0
26.0
34.5
24.2
35.5
32.2
2.1
2.4
2.9
3.8
3.9
8.1
10.0
10.3
11.2
11.2
11.8
12.4
12.5
13.4
13.8
13.8
13.9
14.7
15.2
15.4
16.0
16.4
16.9
16.9
17.0
18.0
18.1
18.1
19.5
20.1
20.1
20.2
22.1
23.0
23.0
24.2
24.6
25.1
26.5
30.0
33.8
Self-reported data
Measured data
Females
Males

challenges. Results of the 2010 National Health
Survey found that 25.1% of Chileans are
overweight, an increase of 3.2 percentage points
from the last survey in 2003. Although data on
current obesity levels in the country is poor, the
NGO Fundación Chile this year estimated that
healthcare costs associated with obesity and excess
weight cost Chile nearly US$1bn a year—about 5%
of total annual healthcare costs.11,12
The prevalence of obesity varies by region in
Chile. The lowest level of obesity is in the densely
populated central region of Valparaíso; the highest
is in the nearby rural province of Libertador
General Bernardo O’Higgins.13
However, more than
geography determines obesity. More than 35% of
Chileans living below the poverty line are obese,
compared with 24.7% of middle class Chileans and
18.5% of those in the upper class.14
High-income
Chileans face greater pressure to conform to fitness
and weight standards, but they also have greater
access to the healthy foods, knowledge and fitness
facilities that help them do so. Gender also plays
an important role: 30.7% of women are considered
obese, compared with only 19.7% of men, a trend
that is common worldwide.15,16
Finally, obesity in
11 Fundacion Chile, website, accessed July 2013.
12 Fundación Chile, Chile Saludable, 2012.
13 Encuesta Nacional de Salud ENS Chile, 2009-2010.
14 Marianela Jarroud, Obesidad e hipertensión son un factor de desigualdad en Chile,
Noticias, 25 Mar 2013.
16 R. Kanter & B. Caballero, “Global gender disparities in obesity: a review”, Advances
in Nutrition, July 2012.
Chile has a strong inter-generational component.
One study found that the greatest risk factor for
developing obesity in childhood is having one or
more obese parents, suggesting the importance of
the home environment in the development of
healthy eating and physical-activity patterns.17
Chile’s rates of childhood obesity are
particularly alarming. Chile ranked sixth in a survey
of infant and child obesity in OECD countries, and it
has one of the highest rates of infant and child
obesity in Latin America, outside of Mexico.18
As
with national obesity, childhood obesity has
become a significant problem in the past 20 years:
since 1987, the number of overweight first graders
has more than tripled.19
The rise in childhood
obesity portends an on-going struggle with obesity
for at least the next several decades. Research
shows that obese children are at greater risk of
becoming obese adults than their peers. They are
also at risk of developing the same conditions in
childhood that obese adults can develop, such as
high blood pressure, high cholesterol or the high
blood-glucose levels that can lead to diabetes.20
Researchers who study obesity in Chile point to
changes in diet and increases in sedentary
behaviour as the most likely explanations for
Chile’s rapid weight gain. Incomes doubled in Chile
over 1987–97, increasing quality of life but also
providing people with more disposable income to
purchase processed foods, televisions, appliances,
cars and computers.21
As with many other countries
that experience this nutrition transition, the
industrialisation of food production decreased the
relative cost of food over time, and the cost of
foods high in fat, sugar and salt decreased to a
greater degree than the cost of healthier foods.22
Over time, Chileans have consumed less minimally
processed foods, such as legumes and fruits, and
more processed foods high in saturated fat and
sugar and low in micronutrients and dietary
18 Ibid, page 10.
19 Ibid.
20 Centers for Disease Control and Prevention (CDC), Childhood Obesity Facts,
website, accessed June 2013.
Note: Regional groupings defined by the WHO
Source: World Health Organisation
Obesity rate by region
% of population with Body Mass Index (BMI) ≥30 kg/m2
, 2008
Africa
Americas
Europe
Eastern Mediterranean
East Asia
Western Pacific
8
25
21
24
5
27

fibre.23,24
Fat consumption rose by more than 50%
over 1988–97.25
Daniela Montecinos Godoy, who grew up in the
southern region of Los Lagos, explained the ways
in which eating habits have changed: “Before,
mothers used to pack simple foods for their
children’s school lunches, things like a sandwich
and a piece of fruit. Today, students are sent to
school with supermarket-bought foods, like a
package of crackers and a juice box, nothing that
would be considered ‘natural’.” Even though Chile
exports fruits, vegetables and salmon to external
markets,26
only half of Chileans consume the
recommended amount of fruits and vegetables and
only 17% consume the recommended amount of
fish.27
Obesity in Chile: The response
Compared with other countries, Chile’s nutritional
transition has been particularly rapid.28
Having
dedicated resources to the underweight and the
undernourished for so many years, the Chilean
government was faced with a sudden need to
switch strategies. Although obesity began to
increase nationally in the 1980s, it was not until
1998 that the national food policy was changed to
address obesity rather than undernutrition.
The 1998 shift marked the start of an aggressive
effort to combat obesity—a process that has,
nonetheless, proved challenging. In 1998, the
newly-created National Board for Health Promotion
(VIDA Chile) introduced a calorie-reduction policy
in Chilean schools. The board co-ordinated with
schools and the Ministry of Education to reduce the
amount of calories in the school food programme,
cutting fat, sugar and salt while incorporating
greater amounts of fruits, vegetables, fish and
legumes.29
In spite of the strength of the early VIDA
Chile policies and other governmental efforts, it
was clear by 2005 that the country was not making
23 Chilean National Institute of Statistics, National Household Budget Survey, Nov
2006 – Oct 2007.
25 Mendoza et al., Evolucion de la situacion alimentaria en Chile, Revista chilena de
nutricion, Mar 2007.
28 Albala et al., Nutrition in Chile: Determinants and consequences, 2002.
sufficient progress in reducing obesity rates.30
The
Ministry of Health launched additional initiatives in
2005 and in 2010 to reduce the prevalence of
obesity, including the Global Strategy Against
Obesity (EGO Chile)31
and Elige Vivir Sano (Choose to
Live Healthily), a national programme to encourage
healthy eating and physical activity. Elige Vivir
Sano increased physical-activity requirements in
schools from two to four hours a week, “active
plazas” were created through the installation of
exercise equipment, and media campaigns
encouraged exercise at home using household
items like a kilo of rice.32
Although it is too early to
know the full effects of these programmes, the
government considers them a success.
Policymakers also enacted the Sistema Elige Vivir
Sano law, which further institutionalised the
programme at the national level and guarantees
funding for future efforts.33
Partnerships between the private sector and
non-governmental organisations (NGOs) have also
offered promising results in recent years. The
international programme 5 al Día (5 a Day) is an
example of a partnership between university
researchers, the private sector, the national
government and international health organisations
such as the United Nations. The programme, which
began in 2004, brings together the government
and food producers to create policies aimed at
increasing fruit and vegetable production and
quality. These include multimedia educational and
marketing campaigns to encourage Chileans to eat
five servings of fruits and vegetables a day. As a
result of the campaign, Chileans in the target
group consumed more fruit and vegetables.34
Despite 15 years of concerted efforts, obesity in
Chile continues to grow. In 2007, Dr Fernando Vio
del Rio, an academic who has been studying
nutrition in Chile for more than 20 years, noted
that although governmental efforts have increased
Chilean’s knowledge about nutritional eating, they
30 Ibid.
31 Chilean Ministry of Health, Global strategy against obesity (EGO-Chile), accessed
online June 2013.
32 Marianela Jarroud, Inter Press Service Noticias, 25 Mar 2013.
33 Elige viver sano, website, accessed June 2013.
34 Corinna Hawkes on behalf of the FAO, Promoting healthy diets through nutrition
education and changes in the food environment, 2013.

have been insufficient to change Chilean’s habits.
“The population knows both what healthy eating
means and the benefits of engaging in physical
activity, but many people persist in eating foods
that are high in sugar, fat and salt, and in leading
inactive lives,” Dr Vio del Rio said.35,36
Global challenges and responses
Chile is not alone in its challenge with obesity. A
variety of approaches are being tried in other
countries, and although many of them are
relatively new, several promising strategies have
emerged. Broadly, health research suggests that
the most effective programmes combine strategies
that change not only individual behaviours that
lead to obesity but also the broader social,
institutional and policy environment in which
those behaviours occur. In environments where
making a healthy choice is easier than making an
unhealthy choice, individuals find it easier to
35 Dr. Fernando Vio del Rio, publications available through Instituto de Nutricion y
Tecnologia de los Alimentos.
maintain healthier lifestyles. The transformation of
the social, institutional and political environment
of a country can be a slow and challenging
undertaking; therefore, governments are focused
on incremental changes and successes.
Because of the global emphasis on reducing and
preventing childhood obesity, many governments
have made schools their first point of attack in the
fight against obesity. Mexico and Peru have been
particularly active in this area. In Mexico, where
26.2% of school-aged children are obese,37
a 2010
law prohibits the sale or advertisement of “junk
food” in primary and secondary schools. The law
also requires 30 minutes of physical activity per day
and requires healthier foods in school cafeterias.
Peru implemented a similar law in 2012.38
Although
both laws are new and it is too early to judge the
results, other research suggests that this approach
has promise. A 2012 study conducted in the United
States found that students living in states with
37 Barquera et al., Obesity and central adiposity in Mexican adults: results from the
Mexican National Health and Nutrition Survey 2006, Salud publica de Mexico. 2009.
38 Chilean Ministry of Health, Ministerial resolution, 2012.
Note: The data measure obesity among children entering first grade
Source: Chilean National Board of Student Aid and Scholarships (Junta Nacional de Auxilio Escolar y Becas)
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Estimate
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Childhood obesity in Chile
Rate of obesity among Chilean students entering first grade, %

laws regulating the nutritional value of food in
schools showed a smaller body-mass index (BMI)
than students living in states with weak or non-
existent laws.39
Outside of schools, governments have also tried
different strategies to limit the availability and
consumption of high-calorie foods. In Denmark
and the US, governmental policies have targeted
the sale of high-calorie foods by restaurants and
vendors. In 2004, Denmark became the first and
only country to ban the use of trans fats in all
products.40
In 2007, New York city officials banned
restaurants from using trans fats. A subsequent
study found that New York’s policy significantly
reduced trans-fat consumption.41
In another approach, governments have tried to
manipulate the cost of healthy and unhealthy
foods. Denmark, France and Norway used taxes,
subsidies and other methods to alter the prices
consumers pay for foods.42
Perhaps the most-
widely-reported recent effort was Denmark’s 2011
implementation of a “fat tax” on foods composed
of more than 2.3% saturated fats. Although the tax
was rescinded after only a year, because of political
pressure, one study found a 10–20% drop in the
sales of margarine, butter and oil, suggesting that
the new, higher price may indeed have led to a
healthy shift in consumer behaviour.43
Other
countries, including France and Norway, tax
products containing excessive sugar. Evidence
from France suggests that consumption of soft
drinks has decreased as a result.44
Although taxes
on sugar-sweetened beverages have affected
consumption patterns, little if any evidence exists
on the long-term effectiveness of these policies in
reducing obesity.45,46
To complement efforts to modify the food
39 Taber et al., Weight status among adolescents in states that govern competitive
food nutrition content, Pediatrics, Sep 2012.
40 Caroline Scott-Thomas, Trans fat reducation policies are working to reduce
consumption, says WHO, Food navigator, 09 Apr 2013.
41 Angel et al., Change in Trans Fatty Acid Content of Fast-Food Purchases Associated
with New York City Restaurant Regulation: A Pre-Post Study, 2012.
42 OECD, Obesity update 2012.
43 “Denmark’s food taxes: A fat chance”, The Economist, 17 Nov 2012.
44 Ben Bouckley, Soft drinks stall in France as consumers trade down: Canadean,
Beverage daily, 24 Apr 2013.
45 Chriqui et al., “A typology of beverage consumption,” Journal of Public Health
Policy, May 2013.
46 Fletcher et al., Substitution patterns can limit the effects of sugar-sweetened
beverage taxes on obesity, Preventing Chronic Disease, 2013.
environment, a number of countries have
introduced programmes and policies to encourage
healthy eating and exercise. In 2008, the Mexican
government launched a national campaign, Vamos
Por un Millón de Kilos (Let’s Go For a Million Kilos)
to encourage people to exercise. The programme,
which provided Mexicans with access to
personalised weight-loss and physical-activity
guidance from doctors,47,48
generated considerable
excitement: more than a million people
participated, and they lost a collective 2.5m
pounds (over 1m kilos). The US launched a similar
campaign with Let’s Move!, and the UK with
Change4Life. National programmes such as these
emphasise the enjoyable aspects of a healthy
lifestyle and, in so doing, try to shift attitudes and
norms about healthy behaviour. These efforts also
provide citizens with information about healthy
eating and exercise. Although such programmes try
to support millions of citizens in the effort to lose
weight or prevent weight gain, it may be years
before their effect on large-scale obesity reduction
is known.
The path forward in Chile:
An integrated approach to local
solutions
The experiences of the past decade in the global
fight against obesity have made it clear to
governments and food and health professionals
alike that an integrated approach is needed for
meaningful results. Indeed, Fundación Chile’s Chile
Saludable (Healthy Chile) report calls for
“integrated intervention from multiple actors at
multiple levels”, combining changes in individual
behaviour with environmental changes in schools,
homes and workplaces, along with system-wide
changes in food production, transportation
networks, the educational system, and urban
planning.49
Perhaps the best evidence to support an
47 Jaime A. Zea, “Campaign calls for Mexicans to lose 2 million pounds,” USA Today,
28 Sep 2008.
48 Mileno, Finaliza con éxito campana nacional ‘Vamos por un million de kilos’,”
28 July 2008.

integrated approach comes from a study
undertaken in Finland in the 1970s. The North
Karelia Project tried to reduce mortality from heart
disease in Finland by curbing the intake of
saturated fat, increasing the consumption of fruits
and vegetables, and encouraging physical activity.
The project team partnered with a trusted
community organisation to create healthier
versions of traditional dishes, and it successfully
urged legislators to create policies to reduce the
fat content of school lunches. The team also
lobbied the government to reduce subsidies for the
producers of high fat foods and worked with other
food producers to create lower-fat versions of
foods such as sausages to meet the emerging
market demand for healthy food. At the same time,
the project team worked with local governments to
increase infrastructure that enables physical
activity, such as walking paths and bike lanes.50
By
altering the availability, attractiveness and
affordability of healthier options, the North Karelia
Project reduced deaths from premature heart
disease in men by 75% and contributed to lower
levels of obesity that continued into the 1990s.
Although Finns have become more obese in the last
decade,51,52
the programme still offers important
lessons for communities trying to implement
obesity-reduction policies. The success of the
programme hinged on three factors: the co-
operation of the national food industry, the
political will to implement the project team’s
recommendations and a focus on the entire
population, as opposed to solely those at risk of
heart disease.53
50 Joyce Hendley and Rachael Moeller Gorman, How the people of Finland took a
healthy message to heart, Eating Well, website, accessed June 2013.
51 OECD, Finland country page, website, accessed June 2013.
52 OECD, Health at a glance 2011.
53 Karen Allen, Fighting fat the Finnish way, BBC, 5 Feb 2004.
Food-security experts in Chile and other
countries face a new challenge today: develop
complementary strategies to ensure that people
get enough to eat while not eating too much of the
unhealthy foods that lead to obesity. Although the
problem of obesity is global, each country needs to
develop strategies and solutions appropriate to its
local context. Nonetheless, the most effective
strategies share a common blueprint: they focus on
understanding and changing the broader
environment in which individual behaviours occur.
They also target multiple settings, such as the
school, home and workplace. Finally, they enjoy
co-operation and collaboration among a wide
group of stakeholders, both public and private. A
single policy, however well-intentioned, cannot
reduce a country’s obesity rates; multiple,
complementary policies, however, can often create
healthier environments and, by default, healthier
individuals.
There is reason for optimism in Chile. Although
obesity continues to rise, the rate of its ascent is
slowing.54,55
A recent consumer survey in Chile
showed increased interest in healthy food, opening
the door for private companies to develop and
market healthy, tasty products.56
Companies that
do so will be helped by a new law that takes effect
in July 2013, the ﬁrst in the world to mandate
warning labels on foods with high sugar, fat or salt
content. With each new policy, Chile moves towards
a critical mass of successful programmes that can
collectively slow, and eventually reverse, the
obesity epidemic.
54 “Chile esta entre los 10 paises con mas sobrepeso del mundo” La Tercera, April 2nd
2013.
55 OECD, Obesity update 2012.

Whilst every effort has been taken to verify the accuracy of this
information, neither The Economist Intelligence Unit Ltd. nor the
sponsor of this report can accept any responsibility or liability
for reliance by any person on this white paper or any of the
information, opinions or conclusions set out in the white paper.
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