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Rev Med Hosp Gen Mex 2018;81:102-6 - DOI: 10.1016/j.hgmx.2017.02.004
Review Article
The freedom to choose, eat, add and gain weight
La libertad de elegir, comer, sumar y engordar
D.A. Cabrera-Gaytána,, , M.T. Cruz-Patiñob
a Coordinación de Vigilancia Epidemiológica, Instituto Mexicano del Seguro Social, Mexico City, Mexico
b Unidad Académica Profesional Nezahualcóyotl, Universidad Autónoma del Estado de México, Nezahualcóyotl, Mexico
Recibido 16 enero 2017, Aceptado 01 febrero 2017
Abstract

The Federal Commission for Protection Against Health Risks (COFEPRIS) launched a regulation for new front nutritional labelling for food and non-alcoholic beverages, recommending that consumers add up their consumptions throughout the day without exceeding a hundred percentage points. The campaign has therefore been called “Add up and do not exceed 100%”. The policy established by the Federal Government is based on assumptions that encourage consumption and will not solve the problem in depth. Following is a descriptive and critical argument against said policy.

Resumen

La Comisión Federal para la Protección Contra Riesgos Sanitarios (COFEPRIS), lanzó una regulación del nuevo etiquetado frontal nutrimental en los alimentos y bebidas no alcohólicas, con la recomendación al consumidor sumar a lo largo del día los consumos sin exceder de cien puntos porcentuales, por lo que a la campaña se le ha denominado “Suma y no te pases de 100%”. La política instaurada por el Gobierno Federal, se basa en supuestos que fomentan el consumo y no resolverán de fondo el problema, por lo que se hace una argumentación descriptiva y crítica de esa política.

Keywords
Obesity, Public policy, Consumption
Palabras clave
Obesidad, Política pública, Consumo
Introduction

It would seem that, in Mexico, “grams” have been invested to combat obesity and “kilograms” have been invested to encourage the problem through market regulation policies applicable to sugary beverages. According to figures published by the National Geography and Statistics Institute (INEGI), there has been an increase in the consumption of sugary beverages among the Mexican population.1,2 There has also been considerable growth in the number of convenience stores, where all the products on sale are packaged, and even classified as “junk food”. They also provide other services that “corner shops” do not, such as being open at night, tax payments, telephone charging, pharmacy, etc., creating a new market niche permitted and regulated by different State agencies.3 Our objective is to present counter arguments based on a linear reality to the campaign against obesity in Mexico, not with a view to categorically rejecting State policy, but to present assumptions that need to be considered when planning, developing and implementing health policies in the federal public administration based on critical and descriptive arguments. Ultimately, we propose a reflection on the reality of contradictory health policies in a globalised world.

Development

The Federal Commission for Protection against Health Risks (COFEPRIS) has launched a much-trumpeted advance of the new regulation for nutritional labelling on food and non-alcoholic beverages, according to which the content in each nutrient relative to the total has to be visible on the front of such products. The consumer is advised to add up consumption during the day and not exceed a hundred percentage points. The campaign has therefore been called “Add up and do not exceed 100%”.4–6 This regulatory policy is based on a number of different assumptions regarding an individual's ability to choose: (a) that all consumers are literate, (b) that all consumers know how to add figures, (c) that all consumers have the purchasing power required to buy these products every day, (d) that all consumers are able to visually distinguish the colours of the products, (e) that all consumers are conversant with and understand the conceptual function of each nutrient and (f) that all consumers base their diet solely on packaged food and beverages that can, all together, add up to one hundred points. Below is an analysis of each assumption.

(a) All consumers are literate

Although census data show that, from 1970 to 2010, the percentage of population aged 15 and over who were illiterate fell from 25.8% to 6.9%, the 2010 Population and Housing Census shows that 6 out of every 100 men and 8 out of every 100 women aged 15 and over are illiterate.7

(b) All consumers know how to add figures

Mexico is constitutionally committed to providing the entire population with basic education. However, nearly 32 million Mexicans (1 out of every 3) over 15 years of age did not complete secondary or primary school. According to PISA tests, 15-year old Mexican students have a poor performance in mathematics, reading and science.8

(c) All consumers have the purchasing power required to buy these products every day

According to the National Commission for the Protection and Defence of Financial Service Users (CONDUSEF), the average spending of Mexican children on sweets and junk food is over 20 billion pesos per year. The Commission reports that soft drink prices are not very high (12.50 Mexican pesos), but the cost of consumption per family could range from $2400 to $9600. Due to the above, the real average cost per litre of soft drinks is lower than that of other sugary beverages.9,10

(d) All consumers are visually able to distinguish the colours of products

According to the INEGI, the second type of limitation among the Mexican population is the use of glasses, 27.2%.11 43.24% of the population, 48,575,560 people, require optometric services in Mexico.12 Although these are isolated figures, there are other considerations to be made: the least educated do not fully understand nutritional information13 and, with ageing comes a reduction in visual capacity.14

(e) All consumers are conversant with and understand the conceptual function of each nutrient

This appears in the “nutritional information” section, which describes size per portion, energy content (the kilocalories provided by carbohydrates, proteins and fats), portions per container of pack, content in fats, proteins, carbohydrates, sodium and vitamins/minerals. This information is always provided when there is an assigned Daily Recommended Intake. This is important information, but which first and foremost is based on everyone being literate. Furthermore, they have to understand the different concepts and then make mathematical calculations based on portions per pack and energy content. In other words, there is a problem of definition and fact-related ambiguity. Unfortunately, the magnitude of this conceptualisation among the population is not precisely known. According to INEGI figures for 2010, 8.5% presented mental difficulties and 4.4% of the population presented attention deficits or learning disorders.11

In this respect, a study conducted in three countries on this continent revealed that people are familiar with the word “salt”, but not with “sodium” (the term included in nutritional information), that more salt and sodium are consumed than is reported and that there is no prospect of reduction.15 Similar results were found in Spain in 2010.16 In Mexico, a study conducted in six cities in the northern, central and southern regions showed that only 17% of people choose food based on nutritional labelling and that 49% do not understand the information contained on rear nutritional labels.13

(f) All consumers base their diet solely on packaged food and beverages that can, all together, add up to one hundred points

The consumption of sugary beverages among the Mexican population has been studied with controversial results. On the one hand, Colchero et al., revealed that purchases of taxed sugary beverages fell by an average of 6% in 2014 (−12ml/person/day), largely in low income households.17 On the other, consumption habits are of key importance, and ingesting soft drinks instead of food means that low-income Mexicans are the largest consumers on the market. According to the non-alcoholic beverage industry, Mexico is the country where most soft drinks are consumed per capita and year in the world. Up to 2012, every individual consumed an average of 176.2 litres per year, the equivalent of around 483ml per day, 85.9% greater than average consumption in the US (94.8 litres per year) and 694% greater than the world average (22.2l per year).3 The different methods and periods related to these studies suggest that more studies are required to obtain more evidence. The INEGI, for instance, revealed that fried snacks in Mexico generate a market valued at 62,758 million pesos, representing 22,558 tonnes produced by the 3,700 companies in the sector.18 Ultimately, this is a consumers’ world, with freedom of choice, what Bauman has referred to as Homo eligens.19 But this freedom of choice, though democratic, is exclusive by nature, pragmatic and incrementalist due to the concept of “only adding”. The definitions therefore need to be refined on the basis of the evidence and of the reality of the Mexican population.

All the above assumptions are reminiscent of what Margaret Thatcher said in 1970: “One of the reasons why we value individuals is not because they’re all the same but because they’re all different … Let our children grow tall and some taller than others, if they have the ability in them to do so. Because we have to build a society in which everyone can fully develop his potential, both in his own benefit and for the community at large”.19 In this respect, Bauman said that “Thatcher assumed that height can be manipulated and that individuals have different skills rather than different abilities to develop their potential because they live in different social conditions”.19

Although the State has applied fiscal measures to discourage the consumption of sugary beverages among the population, the evidence suggests that they did not have a positive impact in Mexico, as the reduction obtained was less than 0.5% of all calories consumed. The State's intervention has rather increased the divide between the population, as (1) it affected the total spending of Mexican households, especially low-income sectors18 and (2) consumers were able to buy 3% less of the basic food basket due to the price increase.20 In Chile and Ecuador visual measures have been implemented to control the consumption of high-fat, high-salt and high-sugar content foods, which are easy to identify by the consumer, as they use icons like traffic signals and traffic lights,3,21 which have proven to be effective tools for transmitting complex information that could potentially help to reduce the consumption of products with high fat, sugar and salt levels.21 In our country, labels adapted from the Daily Diet Guide system were used, and then changed to front labelling with the “Add up and do not exceed 100%” regulation.4–6

Consequently, it can be seen that “The state lives from the opposition between public and private, between general and specific interests”,22 and market regulation policies related to carbonated beverages implemented in Mexico (based on consumer markets) have generated economic growth, afforded women access to the work force, encouraged mass food production, imports, and the invention of industrial cooling and preservation of food (cans, vacuum packing, pasteurisation, etc.), reduced the prices of processed versus fresh food, economies of scale, transport and storage (convenience stores), where the State's role in the policy regulating the soft drink market is decisive, where Homo eligens has become Homo conditionatus, fostered by and through consumerism, which “has rapidly detected and exploited human needs (decadences)”, and the heterogeneity (underlined by the authors) of “processes induced by globalisation”, where the production and encouragement to consume these products reflects a fall to subhuman nature due to conditioned choice,23 not only owing to cost and affordability, but also brand loyalty; for instance, in a study of choice patterns for sugary beverage brands, consumers preferred leading brands, and it was found that 70% of those consumers who bought other brands also purchased the leading brand.24 However, from a social perspective, consumption is also by imitation, recommendation or related to phrases such as “it was on offer” or “someone recommended it”, which would seem to indicate a level of consumer awareness regarding their preferences.24

We therefore find a scenario where there is symbolism in human behaviour in perception (oppression, leading and acceptance) of oneself as obese, as it emulates a pattern or model determined by a social process, and therefore the individual's behaviour as part of a group. These symbolisms are perceived in values that come into conflict between the perception of I and the food that I need to ingest in a consumer-based society. Thus, the facts of this reality organise values, and not the other way around. Robbins and Beer,25 relate that judgements of others are more precise than judgements of themselves, as individuals tend to over-estimate their own values. If individuals perceive themselves as overweight or obese, and the prevalence of obesity is seven out of every ten Mexicans, self-perception is thus correlated to the setting, as described by Macías,26 becoming a sick society “owing to the mere fact of living in a society that has sacrificed everything for technological progress and unnatural well-being”.27 This reinforces the proposed idea of Homo eligens to Homo conditionatus. It may also be the case that consumers do not realise how they act and/or how they react to risk, as shown by a study in three Latin American countries, as people who ingest too much salt will have health risks, and they also failed to realise that processed food contains salt and sodium.15

A culture of consumption has been created; as a “culture is a set of suggested, recommended or imposed preferences according to correction, excellence or beauty”,28 so “health and lifestyle are cultural facts”.29 If only the State can suggest or impose such preferences, this creates a necessary market and the “Add up and do not exceed 100%” regulation4–6 aims to be palliative; or, in the worst case, it contributes to the problem, as it assumes that the Mexican diet is based on processed food and promotes its consumption to add up to a hundred points. Therefore, the campaign is flawed and will not benefit its followers. What is the goal? To foster consumption or combat obesity? The foregoing reinforces the vicious circle of consumption, where the State government must pay the cost of market failures, with collateral damage to its inhabitants, as according to a study conducted in 200 countries (including Mexico) it is estimated that, if the trend towards obesity continues, the world prevalence rate will be 18% in men and more than 21% in women by 2025.30 The National Health and Nutrition Survey of 2016 revealed important figures related to being overweight and obesity: (1) the prevalence of excess weight and obesity combined in adolescents aged 12–19 was 36.3%, 1.4% greater than in 2012 (34.9%), (2) in the population aged 20 and over, this prevalence rate rose from 71.2% in 2012 to 72.5% in 2016; (3) regarding the consumption of food and beverages that increase the risk of developing obesity or chronic diseases, 81.5% of the population of school age regularly consume sugary non-dairy beverages, 61.9% sweets and desserts and 53.4% sweet cereals, (4) 40.6% of the population read the nutritional labelling on packaged food and bottled beverages, and (5) 30.5% of the population reported that current nutritional labelling is fairly understandable, 28% not easy to understand and 16.6% difficult to understand.31

Although this information is now on the front of packaging and, to a certain extent, visible, legible and indelible. However, when one buys a product this shows that the extent to which this is followed is questionable. For example, it is difficult for consumers to read the label, specifically the list of ingredients and energy content, and even more difficult to understand it. The objective of such policies should be for consumers to be able to make informed, safe, healthy and sustainable decisions, providing significant, useful, clear, understandable, inclusive and legitimately expected information, in order to avoid misunderstandings and eliminate inconsistencies, without merely stating “this product is harmful for health”; for instance, the consumer should be informed of the maximum amount to be ingested in a given period (day, week or month) and that this product could lead to or be associated with a harmful event over a certain period of time. One model was the “traffic light” system of labelling food,21,32 which was used in Mexico.33 A study published in 2014 revealed that identifying the healthiest alternative is largely achieved by initial access to the pertinent information on food labels and familiarity with the architecture of choice; transparency in the quantities of trans fats had a clearly positive impact on options, specifying the healthiest one.34 In summary, the proposal is (1) to evaluate the impact of front labelling, (2) lobby for and evaluate the proposal to use “traffic light” labelling in Mexico, (3) replace some names used on labels, such as replacing “sodium” with “salt” (or include it in brackets), (4) provide nutritional information on the supplier's website, and in competent bodies in the governmental apparatus, and (5) specify on packaging the maximum amount to be consumed in a given period.

Finally, a point to be evaluated is not only the impact of this measure on consumption, household spending on sugary beverages and the incidence of selected conditions, but also the consumer's rational preference in regard to nutritional information and evaluation of the policy per se.

Ethical disclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that no patient data appear in this article.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Funding

This study was not funded.

Conflict of interest

There are no conflicts of interest among the authors.

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Corresponding author at: Coordinación de Vigilancia Epidemiológica, Instituto Mexicano del Seguro Social, Mier y Pesado N.° 120 1st floor, Colonia del Valle, Benito Juárez, C.P. 03100 Mexico City, Mexico. (D.A. Cabrera-Gaytán dcpreventiva@gmail.com)
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