Conforme publicamos em 25 de janeiro de 2023, a OMS abriu Consulta Pública em relação às suas Recomendações sobre Políticas Fiscais para Promover uma Alimentação Saudável. Abaixo, as sugestões elaboradas e submetidas pelo FórumDCNTs e seus membros com interesse no tema.
Intersectoral Forum to Fight NCDs in Brazil - ForumDCNTs congratulates the World Health Organization (WHO) and contributes to the WHO draft guideline on fiscal policies to promote healthy diets
Since 2017, the ForumDCNTs unites organizations from the different sectors dedicated to policies and programs on NCDs prevention and care. It was planned from its conception to assist the country in achieving the SDG 3.4 through SDG 17. Nowadays, over a hundred and fifty organizations from the public, private and not-for-profit/civil society sectors join efforts in the key alliance for partnerships to fight NCDs that is the ForumDCNTs. It is worth mentioning that since 2019 PAHO and WHO have also joined the ForumDCNTs in several opportunities. Regarding the web-based consultation for Member States on the draft guidelines on fiscal policies to promote healthy diets, the ForumDCNTs and the institutions that comprise it - especially the ones co-signing below - share the following comments.
Obesity and overweight are growing epidemics in Brazil, where more than 20% of adults live with obesity and over 60% with overweight. According to the Global Obesity Observatory by 2060, the projected percentage of adults living with overweight and obesity in Brazil is 88% in women and 94% in men; in children, the projected percentage for 2060 is 70% in females and 84% in males. In Brazil, obesity is still not recognized as a chronic and multifactorial disease and is seen only as a modifiable risk factor. The ForumDCNTs has a Working Group exclusively dedicated to this theme.
Unhealthy dietary patterns are associated with increased risk of non-communicable diseases (NCD) and diet-related non-communicable diseases have been steadily increasing globally. This poses a pressing need on the society as a whole to implement evidence based-responses that can address the contributing factors. Among the evidence-based policy options to improve food environments is the implementation of taxes on sugar-sweetened beverages (SSBs). Recently, adding to several other publications as described on the draft guidelines, a study published in PLOS Global Public Health by the Public Health Institute's Prevention Policy Group points out that consumption of these beverages decreased by 34% in San Francisco in the first two years after the implementation of taxes on soda.
The WHO Draft Guideline is overall a very well designed document, presenting a clear line-up of relevant evidence, the WHO Recommendations, as well as considerations for implementation. We sum our voices with the recommendations of implementing fiscal policies to promote healthy diets. Our Working Groups on Obesity and Healthy Eating have been working in collaboration with all the other working groups of the ForumDCNTs to build strategic objectives linked to the prevention and promotion of healthy eating, a key factor for the prevention of NCDs; we have been working on the following actions that are in line with the WHO Recommendations on the draft guideline:
Implementation of proper taxation of sugar-sweetened (WHO Recommendation 1), highly-processed and other products inconsistent with a healthy diet (WHO Recommendation 2). Continuous advocacy actions for the taxation of unhealthy food, emphasizing the agenda “healthy food needs to be cheaper and ultra-processed food more expensive”. It is also important to consider, as mentioned in the draft guideline, that the acceptability of taxes on SSBs and other products that are inconsistent with a healthy diet is influenced by how the revenue raised by such taxes is used.
Implementation of tax measures that exempt food that contribute to a healthy diet, including tax incentives/subsidies which can be balanced from the SSBs taxes (WHO Recommendation 3).
We are additionally working on other actions/measures that we believe could be included in the draft guideline:
Implementation of proper taxation of alcoholic beverages and ultra-processed food;
Implementation of frontal food labeling and advertising control policies of ultra-processed, salty food and SSBs;
Regulation of the sale of food inconsistent with a healthy diet in school canteens/cafeterias and regulation of the school environment to promote healthy diets and subsequently improve nutrition and prevent obesity and diet-related NCDs;
Restriction of advertising and marketing of ultra-processed and unhealthy foods, especially aimed at children.
Policy modeling studies, including burden of disease and dietary risk factors, with assessment of tax, regulatory and fiscal measures, and their impact on price and access to healthy foods.
We consider that it can be interesting to mention the absence of specific international experiences of taxing ultra-processed products (UPP) and considering UPP as a great potential for tax policy, given the growth of evidence linking higher UPP consumption with a slew of poor health outcomes (references below). We also suggest that the guidance overall use more actionable information about best practice policies for each recommendation, and/or provide manuals for healthy food subsidies and taxes on ultra-processed foods such as for SSB taxes. Regarding the definition of SSBs, we recommend suppressing fruit and vegetable juices from the list of taxed products. There is no conclusive evidence on the health benefits of removing free sugars from fruit and vegetable juices, an important part of overall healthier diets. Furthermore, if the guide would include the NOVA classification, fruit and vegetable juices are not ultra-processed products, thus only ultra-processed fruit drinks with added sugar and/or other components would be included. We suggest including the arguments of other studies in the draft guideline, namely the publications Changes in sugar-sweetened beverage consumption in the first two years (2018 – 2020) of San Francisco’s tax and Premature Deaths Attributable to the Consumption of Ultra-processed Foods in Brazil.
We also suggest limiting the mentions that the recommendations or other aspects are "based on the very low certainty evidence from a limited number of real-world policy evaluations" as it may unconsciously cause a negative effect on decision-makers. It is possible to alternatively mention that, for example, “although there are no/little specific international experiences on [subject], it would be interesting to consider them as …”.
Among the draft guideline, we appreciated the reference to the importance of considering the wider political context, as well as the implementation considerations, including resource, technical and legal feasibility of adopting new measures. The ForumDCNTs reinforces that the inter and multisectoral discussion and collaboration and a strong multisectoral coalition of support are quintessential on the development and implementation of fiscal policies to promote healthy diets. We would like to reinforce and emphasize that single interventions don’t ensure that all aspects of the food environment support healthy diets, addressing the need for a comprehensive package of policy actions.
We cordially acknowledge WHO’s attention and the opportunity for this contribution, and put ourselves at its disposal to assist in global and regional recommendations, as well as to collaborate for their implementation in Brazil.
Mark Barone, PhD
Founder and General Manager
Intersectoral Forum to Fight NCDs in Brazil (ForumDCNTs)
ForumDCNTs@gmail.com
Bruno Helman
Founder and President
Institute Running for Diabetes (ICPD)
www.correndopelodiabetes.com
Elton Junio Sady Prates
CEO
Comitê Estudantil da Associação Brasileira de Enfermagem - Seção Minas Gerais (COEST ABEn-MG)
coestmg@gmail.com
https://abenmg.com.br/comite-estudantil/
Fadlo Fraige Filho, MD, PhD
President
Associação Nacional de Atenção ao Diabetes (ANAD)
Federação Nacional das Associações e Entidades de Diabetes (FENAD)
anad@anad.org.br
www.anad.org.br
www.fenad.org.br
Iseli Yoshimoto Reis CEO
Fleximedical iseli@fleximedical.com.br www.fleximedical.com.br
Karla Melo, MD, PhD
Coordinator, Department of Public Health
Brazilian Diabetes Society (SBD)
karlamelo@diabetes.org.br
www.diabetes.org.br
Lucas Leme Galastri
President
Ronaldo Pineda-Wieselberg, MD
Vice-president
ADJ Diabetes Brasil
adj@adj.org.br
www.adj.org.br
Patricia Vieira de Luca, MSc
CEO
Associação Brasileira de Hipercolesterolemia Familiar (AHF)
contato@ahfcolesterol.org
www.AHFcolesterol.org
Paula Johns
General Director
ACT Health Promotion
act@actbr.org.br
www.actbr.org.br
References·
Harb, A. A. et al (2022). Ultra-processed foods and the development of obesity in adults. European Journal of Clinical Nutrition, 1-9. https://www.nature.com/articles/s41430-022-01225-z
Mesas, A. E. et al. (2022). Increased Consumption of Ultra-Processed Food Is Associated with Poor Mental Health in a Nationally Representative Sample of Adolescent Students in Brazil. Nutrients, 14(24), 5207. https://doi.org/10.3390/nu14245207 Martini, D. et al. (2021). Ultra-Processed Foods and Nutritional Dietary Profile: A Meta-Analysis of Nationally Representative Samples. Nutrients, 13(10), 3390. https://doi.org/10.3390/nu13103390
Hall, K. D. et al. (2019). Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell metabolism, 30(1), 67–77.e3. https://doi.org/10.1016/j.cmet.2019.05.008