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1. Forum on Food Systems and Obesity in Latin America and The Caribbean (LAC) Meeting Report San Jose, Costa Rica 27-28 June 2018 Eugenio Díaz-Bonilla, Ricardo Rapallo, Joao Intini, Florencia Paz and Yenory Hernández

2. Contents BACKGROUND ........................................................................................................................................... 2 THE INTIAL MEETING ................................................................................................................................ 3 TOPICS OF DISCUSSION AND ANALYSIS .................................................................................................... 5 Presentations ........................................................................................................................................ 5 The need to consider the whole food system from production to consumption ................................ 5 The roles of the government and the private sector: regulations, labelling and taxes. ....................... 8 Consumer behavior: affordability, convenience, tastiness/palatability, and related topics .............. 11 Strengthening supply-side actions toward better nutrition ............................................................... 13 The impact on poor and vulnerable consumers, and on other fragile groups in the food system .... 15 FINAL COMMENTS .................................................................................................................................. 18 ................................................................................................................................................................ 20 BIBLIOGRAPHY ........................................................................................................................................ 21 1

3. BACKGROUND FAO and IFPRI have decided to launch a program of research and public policy advice on food systems, overweight and obesity in Latin America and the Caribbean. The rationale for this joint work program is that Latin America and the Caribbean (LAC) faces the triple burden of malnutrition, still suffering from undernutrition (first burden, mainly as prevalence of stunting) and micronutrient deficiencies (second burden), together with rising rates of overweight and obesity (third burden) across the region. Under current nutritional conditions and trends the region will not attain the related Sustainable Development Goals (SDGs) by 2030, specially Goal 2, with its targets to end hunger and all forms of malnutrition. In particular, overweight and obesity are major risk factors for chronic non-communicable diseases (NCDs), such as diabetes, hypertension and cancer, which are among the leading causes of death in countries of the region. Both directly through their impact on physical and mental capabilities, and indirectly through the associated NCDs, overweight and obesity represent a high social and economic burden, including the decline in days of healthy lives, and the costs they impose on public health-care systems (Box 1). Box 1: LAC’s Alarming Overweight and Obesity Statistics. •Overweight and obesity in LAC already affect 360 and 140 million adults, respectively, placing more than half the adult population in the region at a high risk of developing NCDs. •The medium-term prospects are by no means positive: 3.9 million children under five years of age (7%) are overweight, which is above the global average •Total costs of overweight and obesity have been estimated to reach as much as 0.56 – 1.73% of the GDP in Mexico and Ecuador respectively (Fernández, Martínez, Carrasco, & Palma, 2017); calculations for Chile put total burden of obesity at between 0.22-0.5% of the GDP (Vargas B., 2016); in Brazil, health costs alone have been estimated in US$5.8 billion in 2010 (Rtveladze et al., 2013). The increasing levels of overweight and obesity are caused by imbalances between energy intake and energy use, for given metabolic and genetic conditions. Table 1 mentions some of the environmental, behavioral and lifestyle factors that affect both ends of the imbalances. LAC has undergone a rapid transformation of food patterns in the last 30 years, characterized by the increased consumption of products high in sugar, fat and salt, to the detriment of legumes, fruits and vegetables rich in fiber, vitamins and other micronutrients. Within this context and in line with international frameworks and goals for better nutrition and sustainable development, it has become imperative to consider the potential of food system-based policies and interventions to improve nutrition. Table 1: Examples of environmental and behavioral factors contributing to energy imbalance Factors contributing to lower energy use Factors contributing to dietary changes and higher energy intake 2

4. •Urbanization •Changes in labor markets and the workplace •More sedentary habits •Decline in the costs of food items, particularly calories •Consumer preferences for convenience, when reflected in buying processed products with unhealthy characteristics •Expansion of food and beverage processing corporations and supermarkets, when it leads to increases in sales of processed products with unhealthy characteristics •International trade in processed products with unhealthy characteristics large chains of Yet, understanding the relation between food systems, food patterns and the rapid growth of overweight and obesity levels in Latin America and the Caribbean is a complex task (see for example: Allen, de Brauw, & Gelli, 2016; FAO - PAHO, 2016; Gelli et al., 2015; HLPE, 2017; IPES - FOOD, 2016; Panel Mundial sobre Agricultura y Sistemas Alimentarios para la Nutrición, 2016; Townsend, Jaffee, Hoberg, & Htenas, 2016). Among other things, research has shown that obesity and overweight interacts also with the other two burdens of malnutrition in complicated ways: children that have suffered undernutrition during gestation and early ages, appear more likely to be obese when adults; also, people overweight and obese tend to suffer from different types of nutrient deficiency. Therefore, it is essential to understand these relationships in order to develop comprehensive policies that contribute to stopping the problem the region is experiencing. In particular, considering the mandates of FAO and IFPRI, the analysis should also take into account other aspects such as: a) the implications for production, incomes, and employment, in the primary sector, as well as in the rest of the value chain; b) the impacts on environmental sustainability; and c) the effects on lower-income groups and on those more vulnerable (women, children, older adults, rural and indigenous people). THE INTIAL MEETING As a start for the joint work program, FAO and IFPRI organized a meeting of experts and stakeholders to discuss the structure and linkages between the current operation of food systems and their impact on overweight and obesity levels in the population of Latin America and the Caribbean. The main objective of the joint work program is to help LAC countries develop and implement efficient and equitable policy options and interventions that can turn around current trends towards increases in obesity and overweight of their population. A particular focus of the program will be to look at the causes that hinder the access to healthy foods of the poorest and most vulnerable sectors of the population, either due to the lack of physical availability of such foods, their high prices, or the inherent cultural or social conditions of the most vulnerable population groups, which make them live in unhealthy food 3

5. environments or choose unhealthy food patterns. It will also consider the production, employment, income and poverty implications of the potential changes in food systems needed to end hunger and all forms of malnutrition by 2030. A general objective of public policies in this regard is the construction of food systems that help with the achievement of different Sustainable Development Goals (SDGs): for example, that, among other things, they contribute to reduce poverty (SDG 1), eliminate malnutrition and improve agricultural productivity (SDG 2), lead to better health (SDG 3), facilitate gender equality (SDG 5), reduce inequality in general (SDG 10), promote sustainable production and consumption systems (SDG 12), help with the mitigation of climate change (SDG 13), ensure the sustainability of fisheries (SDG 14), and manage forests in a sustainable manner, combat desertification and degradation of the earth and protect biodiversity (SDG 15). Thus, the variety of objectives that an ideal food system should satisfy requires considering an array of public policies, institutions, governance, technologies, and financing and investment mechanisms throughout the system. The discussion at the meeting in Costa Rica focused basically on one of these aspects, which is the relationship between the functioning of food systems and the increase in overweight and obesity in the population of LAC. However, in this analysis, it was also necessary to consider the interrelationships with other relevant public policy objectives, represented in the SDGs mentioned above. In summary, the meeting, although focusing on overweight/obesity, considered not only the nutrition/health perspective, but also included the implications for the entire food system in terms of production, employment, environment, and other related SDGs, with a primary focus on the poor and vulnerable (system-wide). The participants were asked to think about potential issues/questions to consider in relation to their respective countries or the region as a whole. For example, •What are the main problems that you see in the links between food systems and overweight/obesity in your country or in the region? •What adequate studies do you know in your countries or in the region about the dimensions of the problems identified and their possible causes? •What studies exist on possible interventions (from producers to consumers) to improve the functioning of food systems? Are there appropriate evaluations of these interventions? •What are the public policy questions that in your opinion are not resolved? What databases exist that can be used to answer those questions? What additional data would be required, in particular to be able to better assess the situation by socio-economic groups and vulnerable sectors? •What are the main policies that can have an impact on the most vulnerable or excluded population groups? •How would production and employment be restructured in the transition to healthier diets? Are there studies on the costs of investment and other actions necessary for this restructuring and the implications for employment, income distribution, and poverty? •From the point of view of the consumer and what is called the "food environment" (see below in Figure 1 and Figure 2), where are the main challenges: in rural areas, in small and medium-sized cities, or large cities and metropolitan regions? What would those challenges be and what policies 4

6. are being used? What approaches, data, and studies do you know that can help answer those questions? It was recognized that many of those topics were very controversial with significant discrepancies between different groups of public policy analysts, the variety of actors of the private sector involved (starting with the primary producers and continuing with the whole chain of food processing and commercialization), and consumer groups. Therefore, it was stressed that the meeting was just an opportunity to develop a conversation in a neutral and participatory space for reflection, to exchange information and raise the relevant research and public-policy questions that need to be answered on this subject, with a diversity of visions and transparency, and without implying that the participants would take common positions. TOPICS OF DISCUSSION AND ANALYSIS Presentations In order to initiate the debate and analysis each section started with a presentation, as follows: •Trends on the nutritional transition in LAC and its causes (Barry Popkin); •Framework of analysis for food systems and nutrition utilized by the HLPE of FAO’s Committee on Food Security (Elisabetta Recine); •Transformations in the region related to the operation of processors, retailers, and food services (Tom Reardon); •Food systems, diets, overweight and obesity data and their implications for low-income and vulnerable populations (Eugenio Díaz-Bonilla); •Potential public policies for the transformation of the food system, from production to consumption (Ricardo Rapallo); •Case studies of food system-based interventions for better nutrition: the Brazilian experience (Patricia Gentil and Michele Lessa), and the experience with school lunches in the Caribbean (Carlisle Pemberton); •Work program of the UN Decade of Action on Nutrition (Trudy Wijnhoven). In what follows, a summary of the conversation is presented, organized by topics. The need to consider the whole food system from production to consumption In general, all participants considered that it was very important to take an integrated view of food systems. Independent publications on nutrition and food systems by -the High Level of Experts on Food Security and Nutrition (HLPE, 2017) and the Global Panel on Nutrition and Food Systems for Nutrition (Global Panel on Agriculture and Food Systems for Nutrition, 2016)- provide compatible frameworks to characterize the 5

7. whole food system and were utilized in different ways to guide the meeting discussions. These different frameworks are presented in Figure 1 and Figure 2 respectively. The HLPE considers more drivers and elements, but both frameworks include three components: the food supply chains from producers to consumers; the food environment (i.e. the conditioning factors under which consumers make decisions); and the consumer attitudes and behaviors. The three aspects interact to determine the quality of the diet actually consumed, which is the link to the nutrition and health problems, with other socioeconomic impacts. Figure 1: HLPE - Conceptual framework of food systems for diets and nutrition Figure 1 Conceptual framework of food systems for diets and nutrition Innovation, technology and infrastructure drivers Biophysical and environmental drivers Political and economic drivers Socio-cultural drivers Demographic drivers Leadership Population growth Changing age distribution Urbanization Migration& forced displacement Culture Globalization and trade Conflicts and humanitarian crises Food prices and volatility Land tenure Religions & rituals Social traditions Women’s empowerment Natural resource capital Ecosystem services Climate change Innovation Technology Infrastructure Food Food supply chains environments Food availability and physical access (proximity) Economic access (affordability) Promotion, advertising and information Food quality and safety Farmers, indigenous peoples, agribusiness, land and plantation owners, fisheries, financial entities Production systems Nutrition and health outcomes Consumer behaviour Diets Storage and distribution Transporters, agribusiness, distributors Quantity Quality Diversity Choosing where and what food to acquire, prepare, cook, store and eat Packing plants, food and beverage industry, small and medium enterprises Processing and packaging Impacts Safety Retail and markets Retailers, vendors, food outlet owners, traders, resauranters, wholesealers Social Economic Environmental Political, programme and institutional actions Sustainable Development Goals AVAILABILITY ACCESS UTILIZATION 26 Source: HLPE, 2017. 6

8. Figure 2: Glopan – Conceptual framework for the links between diet quality and food systems Source: Global Panel on Agriculture and Food Systems for Nutrition, 2016. Participants with a nutrition and health background felt that public policy interventions were more developed and advanced on the demand side (targeting consumers to achieve better nutrition), but that there was less work on adequate interventions towards the supply-side (in the conceptual diagrams presented above, supply-side policies would refer to the boxes in “Food Supply chains” and “Food Environment” of Figure 1, and to the outer circle of Figure 2, called “Food supply system”, particularly the “Agricultural production subsystem”and the “Food transformation subsystem”). Because policies tend to have a different perspective on Food Systems when targeted to producers or consumers, several participants pointed that, generally in their respective countries, there is little dialogue (o none) between the Ministries of Agriculture and those focusing on agro-industries, on one hand, and Ministries of Health and related institutions, on the other. The case of Brazil was highlighted as an example of a focused effort at fostering cross sectoral dialogue. The country has a comprehensive approach to food security and nutrition, that incorporates the definition of healthy eating as a human right, support to family farming, governmental procurement of food from small producers, the reduction of losses and waste, the promotion of public fairs, a regulatory agenda that includes food composition, food advertising and other aspects, comprehensive food guidelines, and the integration of nutrition in safety nets. Yet, the participants from that country highlighted the difficulties of working across Ministries and with States and local governments. Participants also mentioned a lack of analyses and monitoring mechanisms that use an integral view of the food systems when dealing with nutrition issues such as overweight and obesity. As a consequence, it was pointed out the importance of conducting more evidence-based studies in this field with adequate indicators, that could allow the development of better public policies and actions in this area. 7

9. The participants suggested that FAO and IFPRI could lead the work in the area of food supply chains, where currently there is a wide room for innovation and more nutrition-sensitive transformations. It was suggested that FAO and IFPRI help organize, in those countries interested, a process of dialogue and interaction between the different Ministries (particularly Health and Agriculture, but also others, such as Education, Social Development, Infrastructure, Economy and Finance) that have authority on different aspects of the food system and of the linkages to malnutrition (including obesity) and the health implications. These dialogues would lead to comprehensive analyses of food systems and malnutrition/obesity in several LAC countries as contemplated in the work program FAO/IFPRI (see below). The roles of the government and the private sector: regulations, labelling and taxes. This was a controversial topic, with the discussion revolving, in general, around the externalities from production and consumption.1 The food system may generate different types of externalities, positive and negative, including aspects related to the environment and health. In particular, the costs of bad nutrition in terms of private and public health expenditures and the overall reduction of economic productivity are non-trivial negative externalities for societies. Therefore, it has been argued that governments must intervene. To define adequate policies and interventions several questions need to be answered. The first one is who generates the externality. •The food industry, although also mentioning other factors, has tended to note the behavior of consumers (who do not exercise enough and who eat too much of everything) or the government (which does not provide the infrastructure, public space, and programs to facilitate physical exercise, or education about adequate nutrition). •On the other hand, as discussed in greater detail below, several of the participants of the Forum considered that the source of the externality is the private sector, which produces and promotes (through intense publicity campaigns and marketing strategies) unhealthy products. 1In welfare economics the governments may intervene because of market failures that lead to economic inefficiencies, or because of equity reasons (separate from efficiency considerations). A well-known market failure is the presence of externalities from production or consumption decisions by some individuals or firms, which generate effects (positive or negative) on others, but which are not internalized by those generating them. In the case of negative externalities there will be an excess of them (conversely, in the case of positive externalities there will be less than what would be socially desirable). The usual policy recommendation in the case of negative externalities is to use price-based policy instruments (such as taxes) or quantity-based instruments (such as prohibitions and regulations) so that these externalities are reduced or eliminated. In the case of positive externalities, the instruments may be subsidies or other policies that expand them. 8

10. A second level of analysis regarding the externalities focuses on the diet. In general, the food industry has argued that the analysis should consider the totality of the diet, and not some specific products (such as sugar-sweetened beverages, SSB, or fast food items) or individual ingredients (such as sugar or salt). In certain cases, although not during the debate in Costa Rica, the food industry has also challenged the scientific foundation of at least some nutritional recommendations and has argued that all “food is food” and “everything has a place in a balanced diet.” Many nutrition and health specialists also consider that consumers should indeed exercise more and the government should support those activities and provide better nutritional information. But, differing from the view from the private sector, they consider that the key variable is still the diet; that the scientific basis for the nutrition recommendations is by and large settled; and that the firms in the processing, retail and food-service segments are largely responsible for the inadequately large size of portions (through advertising and promotion that creates and expand demand) and for the unhealthy nutritional composition of current diets (by designing products that are of high palatability, even addictive, with an excess of sugar, salt, and inadequate fat, and that are aggressively marketed). Therefore, the nutrition and health specialists preferred government interventions focus on the private sector’s behavior and key products in diets, through regulations and taxes. Participants from the private sector highlighted the need of dialogue and consultation. They emphasized the relevance of the voluntary guidelines followed by the industry, and argued against what they called “punitive” labelling and taxes. They pointed out that the private sector is the one that creates employment and should not viewed as the “evil ones” of the story, nor “a cash cow” that has to be milked, but rather should be considered part of the solution. The response of the health and nutrition experts was that dietary guidelines and nutrition information are important but insufficient, given the aggressive advertising of the food industry and their promotion of ultra-processed products (which in the view of some health/nutrition analysts should not be called foods) under the disguise of nutrition education. Because nutrition and health-based regulations are the sole responsibility of governments, those experts consider that such regulations cannot be defined in dialogue with the private sector, as human metabolism is defined by science, not by industry. Furthermore, the health and nutrition specialists expressed that the calls for dialogue and voluntary guidelines from the private sector may only delay the process, while health continues to deteriorate. Finally, those specialists noted that the experience worldwide is that the industry has reformulated products only when faced with strict regulations that banned ingredients (such as trans fats), limited the use of others (such as salt), or were forced to provide clear information to consumers (such as with the recent Chilean approach to labelling) about the negative health implications of consuming certain products. Regarding food labelling interventions, several participants argued that in Chile this policy is working, with consumers becoming more aware of the nutrition conditions of different products, changing buying habits, and, therefore, leading to reformulation of products by the private sector. In a related discussion, some also argued that “traffic-light information” approaches, such as the one applied in Ecuador, do not have the same positive impact as the Chilean system because the consumer seems to get confused when having to interpret combinations of different colors (e.g. what does it mean for buying or not a product that it has one red light, two yellows and one green?). It was also mentioned 9

11. that for graphic labelling to work, it has to be complemented with other interventions that help consumers in their physical and economic access to healthier food choices. Some of the health and nutrition specialists argued as well that health claims (such as the addition of vitamins and minerals, content of insoluble fiber, and so on) cannot be used as a trade-off against clearly negative characteristics of those products (e.g., the excess of calories, sugars, salt, or inadequate fats content). Furthermore, it was argued that the use of misleading labels and packaging, such as the display of natural fruits when the product contains mainly artificial flavors and little of fresh items, should be banned even if the latter is acknowledged on the text section of the package. Similarly, it was argued that the use of pictures of famous people, cartoon characters, and the like, should be banned from products with unhealthy nutritional composition, particularly when directed to children. Some participants also praised the Chilean approach of banning ads directed to children and other restrictions linked to availability of unhealthy food products and beverages in or close to schools. The debate about the proper role of the public versus the private sector also led some to argue whether the government should engage in the public distribution of nutritional foods under the assumption that the private sector would not provide healthy alternatives. On the other hand, it was mentioned the case of Asia, where several countries have had, or still have, public food distribution systems, and, as a result, have experienced the limitations of such schemes in terms of efficiency, availability, variety, and nutritional quality (given that many of them focus on a limited number of products with high caloric content but deficient in key nutrients). Therefore, in that region there seems to be growing support for private sector channels, with a clear trend in the expansion of supermarkets chains. At the same time, some participants stated that government interventions many times do not have scale and are not integrated across public agencies, which leads to a lack of adequate public services and inefficient policy implementation. Also, they noted that governments sometimes fail because they do not develop consensus in the society about the vision and policies required. It was also recognized that governments should do more studies of impact assessment to help redesign and properly articulate public policies. A related debate was linked to whether the example of the efforts by health agencies to reduce tobacco use would be comparable to the current situation with unhealthy food. Some felt that the tactics used by the food industry to battle regulations and taxes have been borrowed from the tobacco industry (sowing doubts about scientific findings; litigation against health advocates and regulations; fomenting delays; and so on). Therefore, it was argued that the public sector should also take the example of tobacco when trying to design public policies and interventions. However, while tobacco is a single product, thus easily addressed through taxes and regulations, food can be unhealthy because of a larger variety of ingredients and products, which usually have to be considered in combination rather than separately. This characteristic may complicate the understanding of the problem from a public policy perspective. In any case, as a participant suggested, a holistic approach to healthy eating may be a matter of proportions, such as, for instance, cutting in half the energy consumed through junk food, increasing by a meaningful percentage the consumption of fruits, vegetables and pulses, and shifting to whole grains instead of refined ones. 10

12. In terms of public-private collaboration, there was more support to the idea of the public sector working with the private sector on topics such as reformulation of some products towards a better nutritional content (for example, expanding whole grain bread instead of white one), and the promotion of frozen, pre-cut, pre-washed, and pre-cooked healthy products (such as fruits and vegetables) that increase convenience and reduce preparation time. Another area could be to support small family farmers in issues related to food safety and market integration. It was mentioned that there are examples of the private sector developing healthy products, agro-ecological, organic, or similar when there is demand for certified high-quality niche market products (however, they tend to be more expensive than other alternatives, and therefore beyond the purchasing possibilities of low income customers). It was noted that most of public agricultural research and development (R&D) focuses on primary products, when more could be done in food technology in the subsequent components of the value chain. In fact, it may be argued that it would be better for the private sector to ask for governmental support with credit and technology for the investments needed for product reformulation rather than battling necessary health regulations on product composition. Consumer behavior: affordability, convenience, tastiness/palatability, and related topics In general, it is accepted that food-related preferences, prices and incomes define the potential food demand by consumers (see Figure 2). Whether that potential demand can be made effective, depends on other aspects such as physical access and availability of food (part of what has been called the “food environment” (Figures 1 and 2). In terms of prices, many countries have been protecting and subsidizing staple crops based on their caloric content, but without considering other nutritional aspects. Also, agricultural R&D in the last several decades has largely focused on increasing yields of several important staple products (mainly cereals) and succeeded in reducing the unit price of calories in those products. To a smaller degree, that has also happened with the unit price of proteins from some animal products. Similar efforts have not been applied to other food products (such as fruits, vegetables, and pulses) that can provide other key nutrients. As a consequence, relative prices have moved against products like fruits, vegetables, pulses, and nuts that are crucial for a balanced diet. As another example, it was also mentioned that in some countries international producers of sugar sweetened beverages (SSB) benefit from import tax exemptions and other subsidies, which reduces their prices and increases consumption. Furthermore, that special treatment puts at a disadvantage other local producers that are not enjoying the same benefits. Growing income, urbanization, and work opportunities outside of the households (increasingly affecting female members), have changed the demand for food towards products that are more convenient, ready- to-prepare, and ready-to-eat (within the household), and/or towards eating out (from street vendors to a variety of food establishments and fast food chains). In this regard, it has been argued that what food processors, supermarkets, and food chains did was basically follow the changes in demand and only tried to satisfy them. Therefore, changes in the food system not only reduced prices for consumers, but ensured 11

13. access, variety, and convenience (including freeing time from food preparation which, it is argued, benefitted mostly women), mainly of processed products. Under this perspective, given incomes, urbanization, and the operation of labor markets, it would be difficult to change the current system of food processing and distribution. Alternative narratives discussed in Costa Rica argued that the preferences were not autonomous but that have been shaped by the advertisement campaigns of the food industry, which suggested that their products were more “modern” and in line with the lifestyles of more developed countries. In this line of thinking, such campaigns would have led to overconsumption of certain products of low nutritional quality (which were nonetheless consumed because of other attributes of alleged modernity and lifestyles that were built into consumer preferences by publicity), while displacing traditional food products considered to be fresher, more natural, and of better nutritional quality. In that sense, food was also linked to forms of cultural identity, which would have been undermined by adopting transnational lifestyles pushed by aggressive advertisement. But it was also noted that such internalization worked both ways, with more US-style fast food in Latin America but also more chains selling traditional Latin American dishes in the US and other developed countries (even though the economic and health dimensions of both effects may not be comparable). A related debate was whether to take as given the drivers of income, urbanization, changes in labor markets, and globalization (including internationalization of life-styles), as well as the perennial consumer’s search for affordability, convenience, and palatability in food. If these factors cannot be easily modified, then it was argued by some participants that health authorities should focus their efforts in guiding/compelling the food industry towards reformulation of products, within the constraints imposed by those drivers and basic conditions, but with better nutritional composition in terms of calories, sugars, salt and inadequate fats. A related issue is whether reformulated healthy products could follow a traditional commodity product cycle provided that there is adequate demand and therefore move from being niche or specialty products to becoming mass products, where big food industry players would continue to dominate those new markets. On the other hand, some thought that the development of the food industry based on the drivers and factors discussed before and showing the penetration of large players can be altered through a combination of taxes and regulations, nutrition education, and the pressure of social movements. In that regard, an alternative approach to the one based on product reformulation by the food industry, which was debated in Costa Rica, would be for governments to focus on helping consumers to go back to traditional diets with natural and fresh products, which were considered healthier (but see below). For example, it was mentioned that in Peru people can assist to nutrition education sessions, where they learn to modify existing dishes to become healthier ones using hands-on approaches and best recipes contests. However, the dishes based on processing fresh products from scratch would need more time to prepare. In turn, this may have implications for the gender balance of household chores, and for the poor, which in many cases may be more time constrained, at least considering the lengths and means of commuting between their dwellings and places of employment. A third, in between, option was also mentioned, which takes into account the desire for convenience and the time constraints of urban life: expand and make more accessible and affordable fresh products that 12

14. are pre-washed, pre-cut, and even partially pre-cooked, that can be prepared then at home in a few minutes. It was mentioned the case of local supermarkets in Perú that are preparing pre-processed cooking kits with fresh food ingredients every day that can then be taken home and prepared in a shorter time than in the traditional cooking from scratch. That can apply as well to frozen vegetables, some grains (such as whole-grain rice and quinoa), and similar products that can be prepared in a few minutes. Of course, some of these options are more applicable to middle and upper income groups, which are equipped with refrigerators and microwaves. The potential paths within the three options suggest that the expansion of the private sector would continue, increasing the diversity of their supply, and towards the inclusion of healthier products in response to the consumers demand. The demand from better informed consumers could lead to healthier and more inclusive food systems, with production models more sustainable and closer to the consumer. A related discussion was whether traditional diets are more, or less, healthier than their more modern counterparts. Some considered that traditional diets, developed in many cases in rural settings for lifestyles with higher uses of energies, may be excessively rich in calories, sugar and fats. Others called attention to the food safety problems that fresh products may pose to consumers when not adequately handled. In any case, the issue called for a better differentiation within traditional diets of healthy and unhealthy aspects, and a more focused approach to food safety issues. In this regard it was mentioned that in many countries controls on levels of pesticides and other contaminants in fruits, vegetables, meat, dairy and other products are strict for export products but that the same levels of controls are not applied in products for domestic consumption. It was also mentioned by a participant that in handling these types of products modern supermarkets appear to have health and food safety advantages over traditional wet markets. Other possible policy interventions were mentioned such as the development and implementation of national food-based dietary guidelines across different sectors/settings; the design effective nutrition and cooking education interventions in schools; and the revalorization of healthy traditional dishes and products to counter the internationalization of diets. Some participants mentioned the importance of countries to participate adequately prepared in the deliberations of CODEX (e.g. those related to food labelling, but other aspects as well), coordinated by FAO and WHO, through the adequate Ministries and agencies. In some countries the public agencies participating in CODEX are not necessarily those linked to health or agriculture but the ones in charge of general economic and financial issues. Strengthening supply-side actions toward better nutrition As mentioned above, several participants argued that policy interventions on the demand/consumer side were more developed than the ones affecting the supply/producer side. Still, several options linked to the latter were also discussed in Costa Rica. An overall question is whether governments, and Ministries of Agriculture in particular, have the policies instruments and the operational capabilities to influence the 13

15. production side, be that primary farming or the processing sector. Yet several policy options and interventions were discussed. An obvious first step would be the elimination of subsidies and support measures to products with unhealthy profiles. Sugar crops and palm oil were mentioned as productions that should not be promoted, at least from the point of view of human consumption (they may be used for biofuels, but that is a separate discussion about the extent of the postulated environmental benefits). Earlier in the discussion, it was mentioned that some processed products (such as SSB) would be receiving tax exemptions and subsidies, which, if true, seem inadequate from a public health perspective. It was also noted that agricultural research and development (and extension) has placed greater emphasis on staples with high caloric content and focused on productivity measures related to quantity indicators. While these approaches are important, it is also necessary to diversify R&D efforts to include other products such as fruits, vegetables, and pulses, and in the case of traditional staple crops, consider also productivity indicators that include the nutritional quality (such as the content of iron, zinc, and other minerals). Biofortification of cereals and tubers has been also tried with success in different countries. Investments in infrastructure and improved management practices for the reduction of waste and losses, which affect more fresh products such as fruits and vegetables, would also contribute to increase affordability and access to those products. Participants also mentioned the important role of wholesale markets for fruits and vegetables, and of farmers’ markets and fairs, and the need of governmental support for their establishment and expansion, as well as support to primary producers (especially in relation to good agricultural practices/food safety). According to the experience of the “Federación Latinoamericana de Mercados de Abastos” (FLAMA) all this requires political will from national authorities, but it is also very important the support of the municipal and local authorities. Participants argued that there is a strong need for adequate data and research to better understand consumer behavior regarding the composition of diets and their perceptions of food quality, health, and safety. Related to this, it was also mentioned that governments need to rigorously evaluate consumer- based food and nutrition interventions to understand the pathways that lead to behavioral change, in order to improve existing public policies and/or scale up successful initiatives. The role of institutional purchases of food by governments (for instance to supply schools, prisons, and other governmental agencies) was also discussed. Although this type of purchase programs is usually part of the efforts to support family farms, they could be used as an opportunity to improve diets. Some participants that have participated in programs that tried to link producers of fruits and vegetables with school lunches noted that, although this is a promising approach, the logistical problems of the approach should not be underestimated and that those programs require adequate planning given the different actors involved (government, producers and consumers). The Brazilian program that supports family farms to supply school lunches with a broad range of products (including but not only fruits and vegetables), was highlighted as an innovative intervention, which is been already replicated in other countries. Other approaches that link fruits and vegetables with young populations are programs of food production in school gardens and orchards. 14

16. In the meeting it was recognized that all these approaches seem promising, but that they also need better documentation of the operational and legal aspects, and more systematic comparisons and rigorous evaluations studies across countries, in order to successfully inform policies and program design and be scaled up. In a related topic it was mentioned the experience of some countries in linking tourism to the promotion of traditional dishes and products, with a territorial approach, including the case of a national agricultural research institute that has a program of food technology for the development of traditional meals. The impact on poor and vulnerable consumers, and on other fragile groups in the food system There were several debates on the differential impacts on poor and vulnerable groups, considering both the consumption and the production angles. On the consumption side, the issue was whether the link diet-obesity-health differed by types of socio-economic groups, particularly in the case of the poor and other vulnerable population. On the production side, the question was what would be the income, employment and poverty effects of staying with current food systems or of moving towards healthier diets. Starting with the demand/consumer side, there are several dimensions to be considered to categorize vulnerable groups. One is the life cycle, which considers the different nutritional needs of special groups such as unborn children and pregnant women, children under 5, school-aged children and adolescents, women in reproductive age, adult population, indigenous and other ethnics groups, and the elderly. The nutrition and health challenges of these distinct groups have been reasonably established by nutrition and health specialists, considering average conditions for each age/stage. Additional layers of analysis would be to consider whether the diet-nutrition-health links need to be differentiated by socio-economic status (SES) (measured by income, assets, education, or other indicators), gender, race/ethnicity, and rural/urban characteristics. In terms of SES, the traditional narrative has been that in developed countries higher SES (measured by income, wealth, or education), usually leads to better diets (and more physical exercise), and therefore better weight and health outcomes; while in developing countries, higher SES (particularly measured by income/assets), is normally associated with more obesity. However, different studies mentioned at the meeting have shown that obesity was growing among poor populations in developing countries, and that the links between SES and obesity and health appear to be more complex, including the possibility of non-linear associations, such as an inverted U (similar to a Kuznets curve), with lower incomes associated in some cases to lower obesity (probably because of lower intakes of food, even if the affordable diets may be unhealthy); obesity increasing in middle-income groups; and then declining again with higher incomes (which, among other things, facilitate access to better, and usually more expensive, diets). In general, with the limited data available, it seems that the problem of obesity in LAC is more urban than rural and affects more women than men. Then, in the case of rural populations in general and urban populations in lower-income countries, obesity appeared positively correlated with the different indicators of SES (irrespective of which one is used). For urban populations in middle and upper middle- 15

17. income countries, links between SES and obesity seem to be different in men and women (with the latter suffering more problems of excess weight, except at high levels of incomes and education), and when SES is measured in income/assets as compared to education. A related question was whether, even though there are differences in obesity at different levels of SES (including the possibility of a Kuznets curve that would suggest that obesity is a problem of the middle classes rather than the poor or the rich), such differences were relevant (or not) for the design and implementation of public policies. For example, data shown at the meeting for Mexico (2016) suggest that the prevalence of obesity in urban women is 36% for those of low incomes; increases to 46% for middle incomes; and drops to 39% in high income. Are those differences relevant enough to merit distinct approaches by SES groups, or an average-consumer approach would be enough? In the case of rural men in the same Mexican data, however, the differences are larger: the incidence of obesity is about 19% for low income groups, reaching some 39% for higher income ones. It was also mentioned during the discussion that the poor, even if the main problem is not overweight and obesity, may still suffer from deficiencies in several key nutrients (2nd burden). At the same time, it may be the case that diabetes, cardiovascular problems and other non-communicable diseases hit the poor at lower levels of body mass index (BMI), due to other stressors, vulnerabilities, and lack of public services. Similar uncertainties appear in the case of vulnerable groups because of ethnicity/race. In LAC indigenous populations and afro-descendants tend to be poorer and more rural, and therefore they seem to be more affected by undernutrition (1st burden) and lack of key nutrients (2nd burden), rather than overweight and obesity. But at the same time, it has been argued by some health studies that those groups seem to be affected by some NCDs at lower levels of BMI than white populations. Therefore, from the point of view of public health, low income groups and ethnic groups may require differentiated attention even if the indicators of overweight and obesity appear less concerning. In this regard, it was argued that public policies tend to be monocultural and overlook the food systems of indigenous peoples, and thus it was acknowledged that there is a need for increasing their visibility. There were several discussions around the role of women. First, obesity is more prevalent among women on average in LAC (although it varies by income, education, and the rural/urban divide). Also, the debate around whether obesity can be reduced by reformulation of products or by returning to more traditional ways of buying and cooking fresh/healthier products, has important gender implications for the balance of work inside and outside the house, and for time allocation within the household. Therefore, the challenge is how to promote healthy and fresh cooking at home, without regressing to the old imbalances and asymmetries of household roles. Other gender issues, are discussed below from the producer side. A separate topic was the possibility of calculating the cost of different consumption baskets and poverty lines, considering the standard ones and compare them with others based on healthy products. It was mentioned that some countries considered the possibility of building “healthy” poverty lines but desisted due to the possible increases it may generate in the poverty headcount and incidence. In any case, it was considered a worthwhile exercise to estimate both, a healthy consumption basket (for the calculation of the consumption price index) and a healthy poverty line (for the calculation of poverty incidence). 16

18. Overall, there is a clear need for more and better data to be able to determine levels and trends in diets (i.e. what people actually eat), overweight and obesity prevalence, and NCDs appropriately disaggregated by main vulnerable groups (SES, race/ethnicity, gender, age and other variables). With that information it would be possible to analyze the drivers and characteristics of food value chains and food environments that shape the diets consumed by main vulnerable groups, and then take corrective actions. An issue is how to characterize diets for data collection and what databases exist with that information. At the meeting some options were discussed, such as the Global Dietary Database (GDD), which although considered a valuable effort, had only average information, not by relevant groups; also, some participants voiced doubts about the quality of some of the data by pointing to unlikely estimates in specific countries in LAC and Africa. Also, there was a discussion of the more promising efforts by FAO/WHO to build a database on food consumption called “GIFT - Global Individual Food consumption data Tool” (FAO - WHO, 2016) based on the food classification system developed by the European Food Safety Agency (EFSA). But this effort is just taking shape and there is no information yet on LAC countries. It was recognized the need for a more homogenous approach to survey design and data gathering, considering a social-debt approach to human rights, and systematically collecting data on human development. In addition to the differentiation of consumers by SES and vulnerability (the demand side), in the meeting it was also debated whether public policies should consider impacts on other vulnerable groups in terms of employment and income opportunities with accompanying poverty implications (the supply side). What are the implications of moving towards healthier diets (composition and quantity) for the employment, wages, incomes of low income and vulnerable groups in the whole value chains? Do we need specific policies for those segments, separate from what can be done focusing on consumers/demand? Possible groups to be considered include small and family farmers, and rural workers that may be affected (or benefited) by the changes in demand towards healthier diets. The same was mentioned about small and medium enterprises, informal operators, and workers in transportation, agro-processing, and the commercialization sectors. It was noted the limited number of analyses and outright lack of data related to employment and incomes in those segments. Focusing on the activities linked to the direct provision of food, it was also noted the diversity of operators and workers in the food services sector, from formal restaurants and fast-food chains to informal street vendors. In particular, in several LAC countries street food vendors and processors tend to be mostly poor women with limited education. Those differences in economic, educational and gender status must be considered in any analysis of public policies. Therefore, there are gender issues to consider on the supply side in the analysis of food systems, diets, and obesity, including the analysis of the role of women 1) as small farmers (e.g. fruits, vegetables, pulses); 2) as traders of agricultural products; and 3) as street food vendors. In this regard, it is important to consider gender inclusiveness in any strategy for the transformation of food systems aiming at better nutrition, with solutions that are sensitive to the needs of both women and men as food system actors. 17

19. Again, there seems to be an important vacuum in relevant information on the different components of the food system, particularly street vendors. In the presentations it was noted that more detailed studies for this sector exist in other developing regions, mainly in Sub Saharan Africa, including some estimates of the daily energy intake from street foods. Several points of view emerged throughout the discussion of the previous issues. Although no one seemed to consider that employment considerations and the impact on smaller firms were irrelevant to the design of health interventions (in the sense that governments could pursue regulatory and tax policies considering health objectives only and ignoring other effects), there were different opinions regarding the importance of the problem and what to do about it. Some mentioned studies in Brazil that would suggest that health regulations did not lead to losses of employment. Others considered natural that small producers and small companies may need longer times, and more governmental support to comply with regulations, but that such special treatment should not detract from eventually having to observe them. In general, those trade-offs cannot be ignored and need to be acknowledged, estimated, and addressed. In public policy analysis, if there is more than one objective (for example, health and employment) then it is needed to apply more than one policy instrument. In the meeting, it was mentioned a simulation of a sugar tax in Guatemala (a health objective), which when implemented alone generated declines in overall employment, but that if it was accompanied by a specific program to support agricultural R&D to produce fruits and vegetables (using the proceeds of the tax), then employment recovered after the initial shock.2 This approach requires a combined effort between health authorities and those working on agro- industrial and other productive and commercialization sectors. FINAL COMMENTS As noted, the conference in Costa Rica has been the initiation of a broader FAO/IFPRI program that would include: *Preparation of a protocol or methodology for conducting a comprehensive analysis of food systems and the linkages to overweight and obesity in Latin America and the Caribbean, emphasizing the challenges faced by low-income and vulnerable segments of the population. *Preparation of a series of national studies, using the template mentioned above, and a public-policy agenda to help transform food systems, aimed at the reduction of overweight and obesity in Latin America and the Caribbean, in those countries interested in participating in the program. *Facilitation of national dialogues between the Ministries and public agencies working on the agricultural and health sectors. *Developing and implementing a research program covering a wide range of evidence-based policy options that facilitate the transformation of food systems, to help reduce overweight and obesity levels, 2 A more direct program in support of production and employment in fruits and vegetables (rather than the longer- timed effects through R&D), would have a faster impact 18

20. focusing on the challenges faced by the low-income segments of the population. Some topics for research are mentioned in Box 2. *Outlining a map of the actors and institutions that influence the agenda, discussion and actions, regarding the transformation of food systems to help reduce overweight and obesity in the region. *Implementing regional and national communication strategies to disseminate the work of the FAO/IFPRI program. *Setting up of an internet portal with information, documents, opinions, analyses and data on the topic of food systems and obesity in LAC, focusing not only on nutrition/health issues, but covering all the dimensions of food systems. BOX 2. Possible research Topics 19

21. General and cross-cutting issues • Economic, social and environmental implications of the promotion of policies for an agriculture more sensitive to nutrition (impacts on production, employment, instruments for reconversion of affected sectors, environmental consequences of the implementation of policies to facilitate access to more nutritious foods, etc.) • Food environments in schools and related aspects (gardens, education, kitchens and food preparation, water, etc.). Documentation and evaluation of experiences. • Gender aspects of food systems and obesity, recognizing that on the consumption side obesity affects women more than men; and on the production side, women are key actors as farmers, traders, street vendors, and as anchor of key household activities related to food preparation. • Indigenous peoples (and afro-descendant populations) and food systems • Equity in the access to natural resources, inputs and services for the inclusion of traditionally excluded producers, informal operators, and workers to the options for the development of a healthier food system. • Conflicts of interest and the political economy of the food system in LAC • Multi-actor partnerships. Consumption • Nutritional standards for foods included in public procurement mechanisms and in companies. Possibility of joining a pilot work that INCAP is developing based on the Brazilian experience • Regional analysis of studies of the costs of healthy consumption basket versus basic "traditional" baskets that are currently used to calculate consumer price indices (CPI) and poverty lines. The study may include analyzes on the quality of diets among low-income populations and policy proposals to cover the cost to reach the "thresholds" of healthy eating of poor populations. • Collecting data on actual diets and comparison to the ones promoted by health and nutrition guidelines as healthier. Quality of diets among low income and vulnerable populations. Identification of information limitations at the micro level, including the need to collect data on quantities of food items and not only monetary outlays. Production and access • - Diversification of primary agricultural supply • - Short circuits, food deserts • - Agrifood chains, inclusion of family farmers in healthier food chains. • - Technological innovations that facilitate access and convenience (less preparation time included) of healthy foods. • - Compilation and documentation of production-side policies followed in LAC (and other parts of the world) with health and nutrition components, and evaluation of their impacts and effects. Communication • Good practices of the private sector (reformulation, technology, inclusion of family farmers) • Identification, promotion, and revalorization of traditional products and diets • Efficient means for the communication of scientific results (platform for the integration of reports, data, etc.) 20

22. BIBLIOGRAPHY Allen, S. L., de Brauw, A., & Gelli, A. (2016). Nutrition and sustainability: Harnessing value chains to improve food systems. In Global Food Policy Report (pp. 48–55). Washington D.C.: International Food Policy Research Institute http://ebrary.ifpri.org/cdm/ref/collection/p15738coll2/id/130214 (IFPRI). Retrieved from FAO - PAHO. (2016). América Latina y el Caribe: Panorama de la seguridad alimentaria y nutricional. Sistemas alimentarios sostenibles para poner fin al hambre y la malnutrición, 2016. Santiago, Chile. Retrieved from http://iris.paho.org/xmlui/handle/123456789/33680 FAO - WHO. (2016). GIFT - Global Individual Food consumption data Tool. Retrieved from http://www.fao.org/gift-individual-food-consumption/en/ Fernández, A., Martínez, R., Carrasco, I., & Palma, A. (2017). Impacto social y económico de la doble carga de la malnutrición: modelo de análisis y estudio piloto en Chile, el Ecuador y México. Gelli, A., Hawkes, C., Donovan, J., Harris, J., Allen, S., De Brauw, A., … Ryckembusch, D. (2015). Value chains and nutrition: a framework to support the identification, design, and evaluation of interventions. Global Panel on Agriculture and Food Systems for Nutrition. (2016). Food systems and diets: Facing the challenges of the 21st century. http://glopan.org/sites/default/files/ForesightSummarySpanish.pdf London, U.K. Retrieved from HLPE. (2017). Nutrition and food systems. A report by the High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security. Rome. Retrieved from http://www.fao.org/3/a- i7846e.pdf IPES - FOOD. (2016). Too big to feed: Exploring the impacts of mega-mergers, concentration, concentration of power in the agri-food sector. food.org/images/Reports/Concentration_FullReport.pdf Retrieved from http://www.ipes- Rtveladze, K., Marsh, T., Webber, L., Kilpi, F., Levy, D., Conde, W., … Brown, M. (2013). Health and economic burden of obesity in Brazil. PloS One, 8(7), e68785. Townsend, R. F., Jaffee, S., Hoberg, Y. T., & Htenas, A. (2016). Future of Food : Shaping the Global Food System to Deliver Improved Nutrition and Health. Washington D.C. Retrieved from http://documents.worldbank.org/curated/en/474831468186561685/pdf/104757-WP-Future-of- Food-Nut-Health-Web-PUBLIC.pdf Vargas B., S. (2016, November 24). A 2030 se estiman 14.780 muertes a causa de sobrepeso y obesidad. Universidad de Chile. Retrieved from http://www.saludpublica.uchile.cl/noticias/128966/a-2030-se- estiman-14780-muertes-a-causa-de-sobrepeso-y-obesidad 21