Participants

Participant selection was carried out with the intention of including government members of the Ministries of Health and Finance/Economy, members of civil organizations dedicated to public health with a background in actions aimed at the control of SSB consumption, researchers or academics who had participated or were participating in or had published studies related to the control of SSB consumption in the four countries. We decided to include members of the Pan American Health Organization (PAHO) and the United Nations Children’s Emergency Fund (UNICEF) as regional organizations. The coordinating team based in Argentina included 11 researchers from the partner countries, with a project leader for Brazil, El Salvador and Trinidad and Tobago.

Researchers had experience in research on burden of disease, economic evaluations and/or public policy. The team consisted of physicians (n=6), social scientists (n=3), health economists (n=2) and research fellows (n=2). The project was designed with an active gender perspective to achieve representativeness of both sexes, all four countries and all parties involved.

Development, conduct and program of the event

In order to conduct the policy dialogue, the working team developed: (a) a detailed program, (b) a comprehensive list of public policy interventions for the control of sugar-sweetened beverages, (c) a list of relevant outcomes to be considered when assessing the burden of disease due to sugar-sweetened beverages or the impact of interventions, and (d) four semi-structured data collection instruments that inquired about interventions for the reduction of SSB consumption, their prioritization for the Latin American and Caribbean (LAC) region, population subgroups particularly those vulnerable or impacted by the consumption of SSB, barriers and facilitators, and the need and availability of information for the development of healthy eating policies in Latin America and the Caribbean.

Two deliberative workshops were held as part of the policy dialogue. The participants were initially divided into three groups (A, B and C), ensuring that in each group all the sectors and at least three of the four countries were represented. Afterwards, the work of each group was presented to all participants.

The first day began with a presentation of the objectives of the deliberative dialogue, then a regional expert gave a presentation on the status of SSB consumption in LAC, which was followed by presentations given by four experts on the respective statuses of Argentina, Brazil, El Salvador and Trinidad and Tobago. The three groups were then provided with a list of possible interventions to reduce SSB consumption, which they were asked to prioritize. Subsequently, the barriers and facilitators for the implementation and success of these interventions in each of the countries were assessed.

On the second day, the second deliberative workshop was held to inquire about the needs and availability of information regarding the promotion of policies to reduce SSB consumption. Subsequently, a country-specific activity was held to discuss the availability of epidemiological and economic information at the local level. All findings from the deliberative workshops and the country-specific activity were shared with the rest of the participants at the end of the day.

Data analysis

We developed an analysis matrix that included the dimensions outlined in the objectives of the policy dialogue and the data collection instruments. Two recorders were used to register the group sessions, and we used the transcripts for the analysis. These data were analyzed by two researchers and then organized in tables to facilitate their reading.

Ethics

Oral informed consent was obtained from all participants. Participants were informed that the audio recordings of the group sessions would be transcribed to complement the data collection.

Consumption situations in each country

Participants associated the use of SSB with festive events, noting that these events are very frequent, therefore, there are many moments to consume SSBs over the course of a year. Other participants identified frequent SSB consumption in adults and children as part of daily life, and highlighted the great accessibility that exists in environments such as school, clubs or home.

Prioritized interventions

Through an exhaustive review of the literature and the contribution made by the experts who participated in the deliberative workshops, 89 potentially implementable interventions were identified in Latin American and Caribbean countries. These interventions were classified into four groups: a) policies to modify the price of sugar-sweetened beverages (taxes) or consumption alternatives (subsidies for sugar-free beverages or water); b) graphic labeling in the front face of food packaging; c) regulation and/or prohibition of direct and indirect advertising, promotion and sponsorship of sugar-sweetened beverages; d) educational actions and actions to modify the school environment (public and private).

The implementation of policies to modify the price of SSB via taxes was prioritized in all three groups, with special emphasis on taxing the amount of sugar and the volume of SSB. Some of the important reasons for prioritizing these measures were the amount of evidence about their benefits and the potential use of these funds to address health problems derived from SSB consumption in the population.

Likewise, graphic front-of-package food labeling was also prioritized by the three groups, explicitly mentioning the need to have large, graphic warnings with direct and clear interpretation on the front of food packages. The participants highlighted the favorable local and regional socio-political context that encourages collaboration between countries for the implementation of this measure, the existence of ongoing regional experiences, and stressed the importance of this measure as the one that “will trigger the implementation of the rest of the interventions” by identifying which products should be included in the other interventions.

Restrictions on advertising and marketing of SSBs were also prioritized by the three groups, despite recognizing that the evidence is scarce regarding the effect of prohibition policies. The scope of potential regulatory and/or prohibition measures were an important concern for the three groups, suggesting that it should reach not only mass media, but also the Internet, mobile applications and social networks.

Finally, measures to modify the school environment were prioritized by only two of the groups, and educational measures by only one. Some of the reasons for prioritizing measures aimed at modifying the school environment were: short-term execution, the importance of the measure in responding to the Declaration of the Rights of the Child, and the fact that it had already been implemented in some countries in the region, such as Brazil, where only water and natural juices were allowed to be sold.

Barriers and facilitators for the implementation of public policies

The three groups considered that the barriers presented in Table 2 threatened the implementation of interventions to control SSB consumption. Four types of barriers were identified for general measures: political advocacy or “lobbying” by the industries producing SSB, potential social rejection of the measures, difficulty in political articulation, and difficulties in implementation and monitoring. The barriers related specific measures are also described.

Regarding facilitators, the successful implementation of all the prioritized interventions in countries of the region such as Chile (frontal labeling) and Mexico (taxes) was highlighted, as well as the fact that legislative projects in some countries are already being discussed aiming to work towards these interventions, the political declaration stating the fact that obesity is a global and local epidemiological emergency, and the importance that this topic has had in the global public policy agenda, the positive experience with some of these measures when they were implemented to reduce tobacco consumption, allowing the reuse of the circuits and processes that allowed the implementation of these measures, facilitating multisectoral articulation. In all cases, the role of civil organizations as social engines to promote these interventions was highlighted. The following were considered to be important actors: scientific societies, organizations that promote political advocacy on issues related to public health, consumer law organizations, journalists and social communicators.

Information needs of decision-makers to promote public policies

The three groups agreed on the need for evidence on the impact of these interventions in terms of: a) prevalence of obesity and overweight, diabetes, mortality and number of years of life lost prematurely; b) health impact of cancers associated with increased risk due to the consumption of AD and associated cardiovascular diseases; and c) cost to the health system. Regarding the population subgroups of interest, all groups agreed with the disaggregation of these outcomes by sex, age groups, and socioeconomic level. In the case of economic outcomes, participants mentioned that they would like to have information regarding the attributable costs by health subsystem and by health event. Some groups reported that the following outcomes were relevant: prevalence of caries, bullying, quality of life issues, health and gender inequities associated with obesity and overweight, unreimbursed health care expenditures, macroeconomic externalities, and use of health resources (hospitalizations, outpatient appointments, etc.).

Availability and quality of the information required for the economic models and the definition of policies

The availability of information for the design of the model of burden of disease due to consumption of SSBs and of the evaluation of interventions to reduce its consumption was identified by a group discussion of representatives from each country (Table 3). Overall, participants agreed on the availability of information on basic demographic parameters and consumption data, although they noted lower availability of information about the effectiveness of interventions to reduce consumption of SSBs.

Population groups vulnerable to the consumption of sugar-sweetened beverages

Throughout both days, participants highlighted the importance of considering children and adolescents as a particularly vulnerable group. One of the main reasons was that eating habits are created at those ages, which is why companies producing sugar-sweetened beverages target their marketing campaigns at them, violating their rights with repercussions for the rest of their lives. It was also noted that it is important to obtain data by socioeconomic level in order to make equity estimates.

It should be noted that the gender perspective was not spontaneously introduced by the participants as a dimension to be considered in the group dynamics or in the plenary sessions. In order not to induce socially expected and/or politically correct answers, we avoided asking explicitly by using this expression (“gender perspective” or “gender approach”), opting instead to inquire whether the interventions or the information should consider different population groups and, if so, which ones. In response to this inquiry, priority was mostly given to classification by age (particularly children) and by socioeconomic stratum, but not by gender. One of the groups mentioned that there are not too many differences in the consumption of SSBs between men and women, nor in cases of obesity, although perhaps in the latter, women show higher indicators because they are the ones who mostly seek medical attention. In response to other more direct questions regarding women (in view of the spontaneous non-response), the participants mentioned that they were not perceived as a differentially affected population group.