THE OBESITY EPIDEMIC 1

CONTENTS
1


Introduction
– The Worldwide Obesity Epidemic
1

2


Mexico´s 8
approach to controlling obesity and NCDs

3


Fiscal Policies in
Public Health
10

4


Fiscal Policies as an 14
Innovation in Public Health Interventions

5


Why we need
Good Governance
17

6
Conclusions and
Recommendations
20

7 References 22
ENES/LEÓNUNAM 2
 3 THE OBESITY EPIDEMIC

The obesity epidemic:

fiscal policies and Good
Governance -the key to
successful public health
interventions
Abstract

The continual increase in obesity constitutes one of the bi-

ggest public health challenges of the 21st Century. On a global

level, rates of obesity have almost doubled during the last thirty

years. One of the countries that face a serious public health

threat from obesity is Mexico and costs for the health care

sector are considered to rise by $1.2 billion by the year 2030.

The introduction of a sugar tax by the Mexican government has

constituted an important step towards the prevention of exces-

sive Sugar Sweetened Beverage consumption and in general it

seems, as fiscal policies for the fight against obesity tend to in-

crease in use. Yet, there are also concerns attached to the idea

of implementing fiscal policies for public health purposes. This

is why we need the concept of Good Governance as a guide to

make fiscal policies effective. The obesity epidemic presents

a big challenge for governments and health professionals but

fiscal policies present a valuable option if their implementation

is governed in an adequate manner.

Keywords: obesity, public policies, taxation, Good Gover-

nance, sugar consumption.

Discussions about the steady increase in obesity prevalen-

ce have offered many perspectives to the question: how to

stop the rise in obesity? In this paper I shall concentrate on four

specific issues, viz., (i) the worldwide obesity epidemic in gene-

ral, (ii) obesity in Mexico, (iii) the use of fiscal policies in public

health, and (iv) the issue of Good Governance. The beginning

of this paper should give the reader an introduction about the

pressing issue of obesity around the world and about its so-

cietal and economic consequences. Followed by this section,

I shall try to present how fiscal policies are increasingly beco-

ming an option for policy makers that try to find solutions to

tackle obesity and its connected health consequences. Even-

tually and at the heart of this paper, I shall try to argue that fiscal

policies in public health can become much more effective if the

concept of Good Governance is applied.

ENES/LEÓNUNAM 4

1. Introduction
– The Worldwide
Obesity Epidemic
The continual increase in obesity in many
countries constitutes one of the biggest
public health challenges of the 21st Cen-
tury (Finkelstein et al. 2012; Wang et al.
2011). Obesity is associated with a number
of important health conditions and has im-
pacts beyond public health and medicine
(Alwan, 2011; Gilbert & Slingerland, 2013;
Vucenik & Stains, 2012; Webber et al.,
2012). The rapid increase in the prevalence
of obesity in many low and middle income
countries (LMIC) illustrates the nutrition
transition (Drewnowski & Popkin, 1997;
Popkin, 2001).
On a global level, rates of obesity have
almost doubled during the last thirty years
(WHO, 2014). One of the main underlying
causes for the increase in obesity is a shift
in dietary patterns around the world (Drew-
nowski & Popkin, 1997; Popkin, 2001). The
“WHO Action Plan 2008-2013 for the Glo-
bal Strategy for the Prevention and Control
of NCDs” and the “WHO Global Action Plan
for the Prevention and Control of NCDs
2013-2020” identified increasing inactivity,
obesity and unhealthy diets as the major
contributors for the rise of NCDs, specifi-
cally in LMICs (WHO 2008, WHO 2013). (WHO, 2015). Furthermore, childhood obe-
A steady increase in the production and
consumption of energy dense foods, high
THE OBESITY EPIDEMIC 5
in fats and sugars, along with a decrease
in physical activity, is related to the increa-
sed prevalence of obesity (Popkin, 2001).
The shift in dietary patterns commenced
in high-income countries (HICs) and even-
tually diffused to low-and middle-income
countries, is partially due to the effects of
globalization. People have changed their
diets from culturally unique diets into a so-
called Western style diet (Popkin, 2001). As
a result, obesity has rapidly developed into
a global epidemic constituting one of the
major risk factors for non-communicable
diseases (NCDs) worldwide (Escober et
al., 2013; James, 2008).
Epidemiological patterns, which were
common for underdeveloped and develo-
ping countries (e.g. communicable disea-
ses, malnutrition), have changed in quite
dramatic ways uncovering an epidemiolo-
gical transition in LMICs en route to very
high incidence rates of obesity and NCDs
(Popkin, 1994; Drewnowski & Popkin,
1997; Popkin, 2001).
Despite the fact that obesity is a pre-
ventable condition, the WHO estimates
that 600 million adults are currently obese
sity has been on the rise and based on esti-
mations by the World Health Organization,
in 2013, 42 million children under the age
of five were overweight and at high risk of
obesity (WHO, 2015).
Numerous newly established epidemio-
logical patterns seem to be directly linked
to the process of globalization, not least
the pattern of obesity in LMICs (Labonté,
2001; Labonté & Spiegel, 2013). The so-
called “global production of diets” and its
interconnectedness with intercontinental
brands such as Coca Cola has changed the
food supply chain towards the unhealthy
(Chopra & Darnton-Hill, 2004; Labonté,
Mohindra & Schrecker, 2011). The shifting
burden of diseases from communicable
disease to NCDs such as cancer, cardio-
vascular diseases and type 2 diabetes is
a consequence of the impact of globaliza-
tion processes (Gushulak & MacPherson,
2004). Globalization has influenced the glo-
bal food chain and general global health,
particularly in LMICs (Swinburn & Boyd, et
al., 2011). Globalization is a “constellation
of processes by which nations, busines-
ses and people are becoming more con-
nected and interdependent via increased
economic integration and communication
exchange, cultural diffusion and travel” (La-
bonte & Torgerson, 2005).
THE PREVENTION AND
CONTROL OF NUTRITION-
RELATED DISEASES SUCH AS
OBESITY AND NCDS
The prevention and control of nutrition-
related diseases such as obesity and of
NCDs is of the utmost importance for the
global community. The fight against obe-
sity has been, and still is, a major challen-
ge for policy makers. Current approaches
to prevent obesity have not been effec-
tive (Escoberet al., 2013; James, 2008).
The shift in epidemiological patterns in
LMICs is taking on a more significant
dimension because it will place extra
ENES/LEÓNUNAM 6
burdens on already overburdened and
underfinanced health care systems in.
Increases in numbers of obese patients
and NCDs will have both, an economic
and societal impact on countries and, in
particular, on their health care systems
(Malik, Willet and Hu, 2013).
Politicians are reluctant to address the
looming increase in obesity and associa-
ted increases in the metabolic syndrome
of high blood pressure, CVD, and diabe-
tes because they do not recognize the
effects that they will have on costs to the
health services, productivity and quality
of life. One reason for this is that obe-
se patients do not immediately constitu-
te a significant challenge to the national
health care system because complica-
tions occur in later life. Second, the cau-
ses of obesity and NCDs are multifactorial
and require direct actions encompassing
regulatory actions towards the food and
beverage industry (Labonté, Mohindra &
Schrecker, 2011; adapted from Glasgow,
2005).
UPSTREAM APPROACHES
TO TACKLE THE PROBLEM OF
OBESITY AND NCDs
On a global and national level, important
decisions need to be taken to successfully
tackle the problem of obesity and NCDs.
Some solutions are available, but there is
a need to come up with new innovative
ways of prevention. One approach is fis-
cal policies; the taxation of nutrients such
as sugars and food products like sugars
sweetened beverages (SSBs) to reduce
the consumption of unhealthy foods and
drinks. As mentioned in the WHO World
Health Report, taxing unhealthy food does
not solely constitute a means to prevent
obesity and unhealthy diets, but furthermo-
re increases ways of augmenting financial
resources for the health care sector to treat
the NCDs (WHO, 2010).

The problem of obesity is increasing in
importance in Latin America, particularly in
Mexico where 32% of the population are
currently obese (Astudillo, 2014). Fiscal
policy reforms as a public health preven-
tion tool are primarily aimed at prevention
of obesity but their consequences can be
far reaching. Therefore, the key in imple-
menting fiscal policies for public health
matters lies within adequate implemen-
tation and good governance. Mexico is
therefore an example of fiscal policies for
public health purposes. The government of
THE OBESITY EPIDEMIC 7
Mexico implemented a fiscal reform packa-
ge, which includes a tax on junk food (8%
for products containing 275kcal and more
per 100g) and sugary beverages (one Mexi-
can peso per litre) (Astudillo, 2014).
In the subsequent sections of this pa-
per, the obesity situation in Mexico will
be discussed, before reviewing the issue
of fiscal policies in public health. That is
followed by the main part of this paper;
good governance in relation to fiscal poli-
cies in public health with a focus on obesi-
ty prevention.
2. Mexico’s
Approach to controlling
obesity and NCDs
Obesity in Mexico is a very serious public
health threat. It is costing the Mexican
health care system billions of Mexican pe-
sos and costs are considered to raise by
$1.2 billion in 2030 (Rtveladze et al., 2014).
Mortality rates attributable to NCDs have
increased with increases in the prevalence
of obesity (Rivera et al, 2002). The impact
of obesity and NCDs on health has been
considerable. About three quarters of all
deaths in Mexico are caused by NCDs (The
Burden of Disease Project, 2010). Almost
14% of all Mexican deaths were attributa-
ble to diabetes mellitus since the begin-
ning of the 21st Century (Rull et al., 2005)
and diabetes has become the dominant
NCD in Mexico. Between 1980 and 2000,
the number of deaths related to diabetes
mellitus has increased by almost 50%
(Barquera et al., 2003). Direct costs for the
Mexican health care system, as well as in-
direct costs for the Mexican economy, will
therefore constitute a significant problem
in the near future (Barquera et al., 2013).
Much of the increase in obesity and
NCDs has been attributed mainly to the
increased consumption of Sugar-Sweete-
ned Beverages (SSBs). There has been a
substantial increase in the consumption
of SSBs in Mexico during the last two de-
ENES/LEÓNUNAM 8
cades. The increase in SSBs consumption
has been accompanied by a reduction in
consumption of fruits and vegetables (Bar-
quera, Campos & Rivera 2013). The SSBs
yield extremely little nutritional value but
are advertised aggressively and are cheap,
and highly accessible (Caprio, 2012; Yn-
gve et al., 2012). Today, Mexicans drink
more SSBs than any other population (Bar-
quera et al., 2008; Barquera et al., 2010).
To combat obesity and NCDs, the Mexi-
can government has established a “Natio-
nal Strategy for the Prevention and Con-
trol of Overweight, Obesity and Diabetes”
(Pilares de la Estrategia Nacional para un
México sin Obesidad 2013). The strategy
encompasses three closely related pillars,
1. a focus on public health, 2. provision
of health care and 3. fiscal policies (Pre-
sidencia de la República Mexico, 2014).
The fiscal policies that the Mexican gover-
nment has recently introduced includes
a fiscal reform package which includes
a tax on junk food (8% for products con-
taining 275kcal and more per 100g) and
sugary beverages (one Mexican peso per
litre) (Astudillo, 2014). Introducing sugar
taxation constitutes an important step
towards the prevention of excessive SSB
consumption. President Pena Nieto an-

nounced that a significant amount of the
sugar tax revenues will be used for further
prevention programs as well as providing
schools with drinking water fountains (As-
tudillo, 2014).
The implementation of a fiscal policy
with the aim of tackling obesity can un-
doubtedly be regarded as a success for
public health. Nonetheless, to achieve
positive outcomes, it is of the utmost im-
portance to determine further actions that
could enhance and support fiscal policies
THE OBESITY EPIDEMIC 9
(Barquera, Campos and Rivera, 2013). As
Mexico has been regarded as the leading
SSB consumer worldwide, implementing a
tax on sugary beverages reflects an eviden-
ce-based policy. Yet, relying solely on the
fiscal policy will most probably not result
in worthwhile outcomes. The Mexican go-
vernment will need to use its full adminis-
trative capacities to win the fight against
obesity. This will ultimately come back to
the topic of Good Governance, which will
be discussed in subsequent sections.
3. Fiscal Policies
in Public Health
The use of fiscal policies targeting public
health issues becomes increasingly favou-
red by governments, as illustrated by the
latest example of sugary beverage taxation
in Mexico (Blakely, Wilson and Kaye-Blake,
2014; Sassi et al., 2014). Considering the
history of taxation and fiscal policies world-
wide, it seems as that most taxes, at least
in theory, have been imposed with the aim
of increasing the overall welfare of the pa-
yer. The United Nations (UN) High Level
Summit on NCDs in 2011 emphasized the
use of fiscal policies and food taxes for the
prevention and control of NCDs (United
Nations, 2011). In addition, as the special
international public health organization of
the UN, the WHO has advocated the use
of fiscal policies in order to “encourage
healthy eating” (WHO, 2009). A significant
number of public health professionals have
stressed the importance of governmental
actions to effectively tackle the obesity epi-
demic (WHO, 2012, Moodie et al., 2013).
When we talk about fiscal policies and
taxation for public health objectives, we
should emphasize the important differen-
ce between direct and indirect taxes. Di-
rect taxes are in general adjusted to the
capabilities of a person to pay, whereas
indirect taxes are non-person adjusted
ENES/LEÓNUNAM 10
and generally encompass taxation on pur-
chased goods and services. Furthermore,
the imposition of direct and indirect taxes
can have consequences of different natu-
re, namely being progressive or regressive.
Direct taxes typically foist an equal relati-
ve burden on each payer and are, hence,
of progressive nature. On the other hand,
indirect taxes are known to be regressive,
putting the same financial burden on each
taxpayer without considering their perso-
nal relative capabilities of paying (Britanni-
ca Encyclopaedia, 2014).
One possible way of changing the na-
ture of future anti-obesity policies includes
the application of multi-sectorial actions
by governments, including fiscal policies
(Gortmaker et al., 2011). An obvious rea-
son for the continuous increase in SSB
consumption has been the way the food
industry has marketed their products
(Woodward-Lopez, Kao & Ritchie, 2011;
Pomeranz, 2012). The marketing success
of the food industry consequently led to an
increased consumption of SSBs on a glo-
bal scale (Zenith International, 2013). As
a further consequence, the increased con-
sumption of SSBs had a serious negative
impact on the health of millions of people
worldwide (Lavin & Timpson, 2013). Fiscal

policies and the taxation of food products
are worthwhile options for governments
complementing the considerably lighter
option of health promotion to prevent
obesity and unhealthy food consumption.
Governments, which proactively decide to
implement fiscal policies, might not only
increase government revenues, but may
ultimately influence purchasing behaviours
of consumers (Moodie et al., 2013).
The literature on fiscal policies and food
taxation indicates that it is effective (Andre-
yeva, Long & Brownell, 2010). Modelling
studies, empirical evidence from countries,
which have already implemented fiscal
policies for the fight against obesity and
NCDs, as well as experimental studies, are
increasingly becoming available. The main
question is, in which way fiscal policies
influence the consumption of unhealthy
food products, especially SSBs, and how
governments justify their implementation?
Moreover, with an increase in ill health due
to SSB consumption, social costs are rising
concomitantly, thus supporting the argu-
ment of market failure, which reflects the
common consensus of public health pro-
fessionals, and even economists (Brownell
et al., 2009).
The cost of food is second to taste in re-
gard to decisions about which food to eat
but “little is known as to whether variations
in food prices account for differences in
diet quality or weight status” (Story et al.,
2008). The basic underlying idea of taxing
unhealthy foods and drinks is that the in-
creased price of a product leads to a de-
crease in the consumption of that product.
The economic term behind this idea is “pri-
ce elasticity”. In regard to the taxation of
unhealthy food, we need to consider two
kinds of price elasticity: “Own Price Elasti-
city” and “Cross Price Elasticity”. “Own pri-
ce elasticity” is solely concerned with one
specific product and the eventual change
in demand after a price change of this spe-
cific product has occurred. The ratio of the
THE OBESITY EPIDEMIC 11
percentage change of the demand and pri-
ce give an indication whether the demand
of the product is inelastic (demand decrea-
ses after price increase; ratio value < 1)
or elastic (demand does not decrease af-
ter price increase; ratio value > 1). “Cross
price elasticity” is concerned with the de-
mand change of one product after a price
change to another product has occurred
(Principles of Economics, 2011).
A meta-analysis by Escobar and collea-
gues referring to “evidence that a tax on
SSBs reduces the obesity rate” has conclu-
ded that “an increase in price of SSBs is as-
sociated with a decrease in consumption;
and the higher the price increase, the grea-
ter the reduction in consumption (Escobar
et al., 2013)”. Unfortunately, the number
of studies analysing “own price elasticity”
outweigh the number of studies encom-
passing “cross-price elasticity” analyses
(Moodie et al., 2013).
Data from observational studies indica-
te that a price change of a certain unhealthy
food does not relatively affect the demand
(Andreyeva, Long & Brownell, 2010). A
number of other studies, which assessed
the impact of fiscal policies on unhealthy
food consumption, concluded that the im-
pact would be moderate (Chouinard et al.,
2005; Kuchler, Abebayehu & Harris, 2005).
The results of a more recent systematic re-
view of “price, demand and body weight
outcomes”, however, demonstrate that the
demand is to a greater extent price sensiti-
ve as concluded by previous studies, espe-
cially for the consumption of SSBs (Powell
et al., 2013). Moreover, according to a re-
view concerning the “Acceptability of a Tax
on SSBs” by Lavin and Timpson, “research
unanimously agrees that the strongest evi-
dence is for a tax on SSBs (Lavin & Timp-
son, 2013). A modelling study in the United
States suggested that taxation of SSBs is
more likely to be effective if the excise tax
is large (20-25% increase in price) (Wang
et al., 2012). Wang’s study supports the
evidence of a previous study by Powell and
Chaloupka, which concluded that a little
increase in the price of an unhealthy food
product would only marginally affect body
weight (Powell & Chaloupka, 2009).
The effectiveness of fiscal policies in
regard to health outcomes is of utmost
importance. Yet, one should not forget the
significance of their cost effectiveness.
The question is not only whether fiscal in-
terventions result in positive public health
outcomes but also whether their health
outcomes justify the costs. Administratio-
nal costs can in theory both outweigh the
revenues of the taxation and the monetary
value of the health outcome. A study by
Moodie and colleagues assessed the “cost
effectiveness of fiscal policies to prevent
obesity”. The authors conclude “that defi-
nitive conclusions about the value for mo-
ney of fiscal policies for obesity prevention
cannot yet be drawn”, despite the fact that
“early indications are that population-level
fiscal policies are likely to be potentially
effective and cost-saving” (Moodie et al.,
2013).
Concerns attached to the idea of im-
plementing fiscal policies for public health
purposes There are a number of concerns
attached to the idea of implementing fis-
cal policies for public health purposes. The
increase in price of one unhealthy product
can lead to the increase in consumption
of another unhealthy product (“Cross-Pri-
ce Elasticity”). A number of studies have
emphasized the issue of compensatory
food consumption behaviour (Epstein, et
al., 2012; Powell et al., 2013) A further is-
sue arises in regard to the potential finan-
cial impact of fiscal policies on different
socio-economic classes within a society.
On the one hand, it is said that taxes on
food are of a regressive nature. Hence,
people from lower socio-economic classes
need to contribute a higher proportion of
their income as compared to people from
higher socio-economic classes (Mytton,
ENES/LEÓNUNAM 12
Clark & Rayner, 2012). In addition, the con-
sumption of SSBs seems to be particularly
higher in the lower socio-economic clas-
ses (Lavin & Timpson, 2013). On the other
hand, if SSB consumers from lower socio-
economic classes show a more significant
price sensitivity compared to SSB consu-
mers from higher socio-economic classes,
the consequent benefits of positive health
outcomes would be of progressive nature
and the gap of inequalities would eventua-
lly become smaller between different so-
cio-economic classes (Brownell & Frieden,
2009; Capewell & Graham, 2010; Powell et
al., 2013; Lavin & Timpson, 2013). Discus-
sions about the evidence of fiscal policies
and taxation strategies repeatedly empha-
size equality issues in regard to different
socio-economic classes (Craven, Marlow
and Shiers, 2012; Moodie et al., 2013).
The use of fiscal policies for public
health purposes is increasingly becoming
popular on a global level. Regulating SSB
consumption has risen up the agenda of
necessary public policy initiatives, as seen
in Mexico. The results of such fiscal poli-
cies are not solely aiming at the financial
aspects of the problem, but are equally
important as an educational tool, conside-
ring it as an educational tax. Altering the
food environment in a way that makes un-
healthy food more expensive will very likely
result in an enduring change of food con-
sumption behaviours and thus, decreasing
obesity rates and the prevalence of NCDs
(Osei-Assibey et al., 2012).
It will be important to understand that
implementing fiscal policies for one un-
healthy product or nutrient may conse-
quently lead to an overconsumption of
other unhealthy products or nutrients. A
study by Myrron, Clark and Rayner sugges-
ted an extensive application of taxes on
a number of distinct unhealthy nutrients.
Moreover, they advised that the minimum
level of the tax percentage should be twen-
ty percent (Mytton, Clark & Rayner, 2012).

Other studies have indicated that fiscal
policy reforms encompassing unhealthy
food taxation should preferably incorpora-
te some form of subsidy for healthier food
products (Fletcher, Frisvold & Tefft, 2013;
Lavin & Timpson, 2013).
In general, it is beneficial if govern-
ments would earmark their fiscal policies,
precisely indicating for what taxation reve-
nues will be used. Overall evidence on fis-
cal policies indicates that fiscal policies are
a potential tool for public health purposes.
A disadvantage is, that most studies vary
in methodology, which makes it difficult to
pool the different results. This is especia-
lly the case for cost-effectiveness studies
encompassing the topic of unhealthy food
taxation (Moodie et al., 2013). A further di-
sadvantage in regard to the quality of evi-
THE OBESITY EPIDEMIC 13
dence is that most studies are based on
modelling techniques. Thus, not being able
to produce real empirical evidence. Excise
taxes have yielded effective results in the
field of tobacco prevention, (Chaloupka,
Yurekli & Fong, 2012). This, however, does
not denote that strategies used for taxing
tobacco can be easily transferred to food
products. The consumption of food cons-
titutes a necessity for each individual and
is of high complexity, thus not directly
comparable with tobacco use. Govern-
ments will need to assess, which taxation
strategies will be most appropriate (health
outcome, cost-effectiveness, subsidization
of healthy products, equality) and need to
adequately govern this process in a way
that yields the greatest positive results for
the welfare of the society as a whole.
4. Fiscal policies as an
Innovation en Public Health
Interventions
The utilization of fiscal policies as a preven-
tion tool for public health might be consi-
dered as some sort of innovation. Before
it becomes necessary to explain why good
governance of innovations in public health
is of great importance, we need to elabo-
rate more on the question of why fiscal
policies for the prevention of obesity can
be considered as actual and genuine inno-
vations.
“Innovation is the process of making
changes to something established by in-
troducing something new that adds value”
(O´Sullivan, 2008). The first important
message, which can be drawn from the
definition by O´Sullivan, is that an inno-
vation does not merely describe the final
creation and end of something, but em-
bodies the whole process of making the
creation, thus its whole means to an end.
Second, an important connotation can be
given to the mentioning of “making chan-
ges” and “adds value”. If making changes
and adding value are the core criteria of
what constitutes an innovation, we need to
analyse if this is the case in regard to fiscal
policies for the prevention of obesity.
A number of different prevention
methods for obesity have been applied du-
ring the last decades. First and foremost,
ENES/LEÓNUNAM 14
health education is most commonly used.
Because of the realization of the relative
ineffectiveness of health education there
has been a noticeable change in the way
countries try to challenge food-related
public health problems such as obesity.
This challenge manifests itself in a chan-
ge of prevention techniques towards the
application of fiscal policies. Yet, the sole
change of prevention techniques does not
constitute an innovation per se. The ques-
tion of whether these changes add value
still remains to be tested. In regard to pre-
vious prevention methods, fiscal policies
seem to be a new approach, not so much
in alcohol and tobacco prevention, but cer-
tainly in the prevention of obesity, including
fat and SSB consumption. Considering the
latter, fiscal policies evidently add value in a
sense that they ought to be more efficient
in the prevention of SSB consumption and
thus, might prevent obesity and increase
the overall welfare of society. Notwithstan-
ding research results ascribing ineffective-
ness to fiscal policies for the prevention
of, e.g. SSB consumption and obesity, the
vast majority of recent studies indicates
that fiscal policies are effective (Escobar et
al., 2013; Lavin & Timpson, 2013; Powell
et al., 2013; Wang et al., 2012). Essentia-

lly, the added value of fiscal policies ,for
example the prevention of SSB consump-
tion and obesity, could be measured by re-
ductions in the prevalence of obesity and
accompanying NCDs, a reduction in health
care costs for correlated health complica-
tions, and in the decrease of sales of SSBs
as well as in an increase of the knowled-
ge base of consumers in regard to the un-
healthiness of the food product or nutrient
in question.
At this point, we conclude that fiscal
policies for prevention of obesity can be
called an innovation. Apart from the issue
of change, there are two further domains,
which accompany the nature of innovation,
namely: “Innovation and Knowledge, and
Innovation and Society” (O´Sullivan, 2008).
As an increasing number of countries turn
to implementation of fiscal policies for the
prevention of obesity, one can definitely see
a transformation in the way public health
prevention methods are applied. The con-
sequential outcomes of implementing fis-
cal policies for obesity prevention ought
to be of positive nature, yet, can also be of
negative nature. In order to qualify as an
innovation, the process must add value to
its means and ends. In practice, this is only
possible if positive outcomes outweigh ne-
gative outcomes. The important question
at this point is, whether the process of in-
novating allows for negative outcomes,
and to be outweighed, in respect to fiscal
policies? As mentioned before in this arti-
cle, the regressive nature of food taxation
may constitute a negative outcome from a
financial perspective, whereas from a health
perspective, people seem to consume less
amounts of the unhealthy food at stake. To
better answer this question, we need to fo-
cus on “Innovation and Knowledge”.
During the process of innovation, failu-
res and negative outcomes should be
allowed for two reasons. Primarily, making
failures are a consequence of suboptimal
knowledge. Detecting the failure, analysing
THE OBESITY EPIDEMIC 15
it, and eventually drawing conclusions from
the analysis is the only way of enhancing
and ameliorating this knowledge. Second,
failures can be a valuable source of infor-
mation, not just for the intrinsic process of
the innovation, but also for the institution
or organization as a whole. Institutions and
organizations, which aim at innovating their
modus operandi, should consider negative
outcomes as an excellent opportunity for
continuous learning.
In spite of the fact that failures carry
some positive connotation, we have a
pause at this point. It is important to ack-
nowledge the fact, that there is a differen-
ce between the consequences of failures
made by a private business company and
by a government. Since fiscal policies are
affecting roughly every person in the juris-
dictional area of the responsible govern-
ment, the opportunity of learning from mis-
takes does not mean that any well-meant
policy can be brought into being without
a rigorous policy analysis. The aim of a go-
vernment should always be to keep failu-
res and negative outcomes to a minimum
to safeguard the public. At the same time,
mechanisms of continuous surveillance
of fiscal policy outcomes have to be ins-
talled by the government. In the end, the
weighing of positive and negative conse-
quences of a specific fiscal policy depends
relatively exclusive on how good a govern-
ment governs their policy processes.
The last domain of consideration is “In-
novation and Society”. By definition and as
mentioned before, fiscal policies are imple-
mented with the underlying aim to even-
tually increase the overall welfare of the
society. If fiscal policies for the prevention
of obesity and accompanying NCDs ultima-
tely culminate in positive health outcomes,
the welfare of the society would undoub-
tedly increase. A decrease in obesity and
NCDs may result in a decrease of health
care costs. Furthermore, we could assume
that the productivity of a country would
rise with a healthier workforce, which may penditures for the government, but rather
eventually lead to an increase of the GDP. indicates an investment, based on the well-
This would effectively imply, that the pre- known saying “health is wealth” (European
vention of obesity does not only reflect ex- Commission, 2007).

ENES/LEÓNUNAM 16

5. Why we need
Good Governance
The concept of Governance is increasing in
importance. It has been a much-discussed
issue, mainly in the fields of political science
and global development. The notion of go-
vernance as an important element in public
health practice is also increasingly recogni-
sed in health related literature (Dodgson,
Lee & Drager, 2002; Kickbusch & Gleicher,
2012). Governance describes the very spe-
cific process of how macro-institutional as
well as micro-institutional activities are ad-
ministered and how these institutions exer-
cise their competences at one point in time
by encompassing time and space related
determinants. In other words, governance
explains the process in which administrative
procedures are determined and how they
are consequently exercised or not.
Considering the many actions taken by
governments, all could simply be descri-
bed with one word: governance. What we
want to find out in regard to fiscal policies
for the prevention of obesity is, however,
what “Good Governance” implies. Brand
described Good Governance as “a leading
concept in public administration” with the
intention of “bringing together administrati-
ve bodies and all relevant stakeholders (ci-
tizens, NGOs, industry, etc.) to implement
reforms improving the living conditions for
THE OBESITY EPIDEMIC 17
all people” (Brand, 2007). By describing
how “Good Governance” could be applied
in the context of Public Health, Brand makes
use of the “Good Governance” concept de-
veloped by the United Nations Economic
and Social Commission for Asia and the
Pacific (UNESCAP). The UNESCAP concept
of “Good Governance” has initially been
designed for the field of development but
has since found broader application. In a
nutshell, “Good Governance” according to
the UNESCAP concept encompasses eight
characteristics, namely: participation, rule
of law, transparency, responsiveness, con-
sensus oriented, equity and inclusiveness,
effectiveness and efficiency, and accounta-
bility (Figure 2) (United Nations, 2014).
Accountable
Consensus
oriented
Transparent
Participatory
Follows the rule
of law Responsive
Efective and Equitable and
efficient inclusive
Figure 2:
Characteristics of Good Governance. (UNESCEP 2014)

With respect to fiscal policies for the pre-
vention of obesity, the UNESCEP concept
of good governance constitutes a valuable
guide to make fiscal policies mostly effec-
tive. In the following, we will focus at the
eight UNESCEP concept characteristics
and examine what each characteristic en-
tails in regard to fiscal policies for the pre-
vention of obesity.
Participation implies that fiscal policies
for the prevention of obesity should not be
put into practice without actively including
the civil society into the analysis for and
of policies, which is informed and allowed
to freely assemble. Moreover, the poorest
segment of society and their viewpoints
should be adequately represented in order
to attain complete societal participation.
As mentioned earlier, the highest percen-
tage of obese people are in the lowest so-
cio-economic classes. We have a duty to
consider their circumstances and perspec-
tives, and only by doing so, will we be able
to create adequate policies.
The Rule of Law, the second characte-
ristic of the “Good Governance” concept,
focuses on human rights and fairness.
Article 25 of the Universal Declaration of
Human Rights emphasizes that “everyone
has the right to a standard of living adequa-
te for the health and well-being of himself
and of his family, including food” (United
Nations, 1948). If the food products, which
significantly foster the development of
obesity and infringe on the wellbeing of
individuals, are considered to be of inade-
quate standard in regard to Article 25, we
either need to ban them or give people
from lower socio-economic classes the
possibility of purchasing more adequate
food products by implementing the right
policies. The full legal, social and financial
protection of each and every citizen has to
be guaranteed. The implementation of fis-
cal policies can only be justified if it was
followed in lights of a fair legal framework.
ENES/LEÓNUNAM 18
Transparency is one of the most impor-
tant elements in respect to fiscal policies for
the prevention of obesity. It encompasses,
that all information concerning the policy
will be made freely available by the gover-
nment. This includes the application of sim-
ple terminology in order to create compre-
hension throughout all gradients of society.
Adequate coverage by the media, informing
people about the policy process is prefe-
rable. Furthermore, transparency plays an
immense role when it comes to the earmar-
king of fiscal policies. Information with res-
pect to how taxation revenues will be used
should be unconditionally transparent and
comprehensible by everyone.
Responsiveness and Accountability are
key components of a well-governed institu-
tion. Every stakeholder involved in the po-
licy process should be served by the same
means and on an equal basis. In this res-
pect, the food industry should be treated in
the same way as governmental institutions
or NGOs, in terms of timely responses as
well as complete disclosure of information.
Liability in terms of accountability is, howe-
ver, a two-way concept, which effectively
means that each involved stakeholder has
to be accountable for its action. The go-
vernment will have to be accountable for
its implemented fiscal policies. Moreover,
the food industry will have to be accounta-
ble to the government and to the public in
regard to its products and their presumed
health effects.
The more stakeholders are involved in
making policies, the more opinions will
flow into the decision-making process. A
well-governed institution should be able to
steer the mediation process into a direc-
tion, which eventually reaches a consen-
sus of highest value for the welfare of the
society as a whole. Especially in the case
of food consumption, obesity and NCDs,
it is very important to incorporate a long-
term perspective into the decision-making
process. An adequate consensus can only

be reached, if the elements of participation
and transparency are guaranteed. A valid
consensus is solely the result of incorpora-
ting all necessary information made availa-
ble through transparency.
The two last elements of the “Good Go-
vernance” concept are Equity and Inclusi-
veness. Both elements are strongly related
to participation and the rule of law. Never-
THE OBESITY EPIDEMIC 19
theless, they play important separate parts.
By inclusiveness, a well-governed institu-
tion should decide upon future policies by
including all distinct social segments and
members. The final public policy should be
one, which offers the greatest advantage
for the worst-off of the society. Only then
can we strive for a world in which equity
counts as the true prime principle.
6. Conclusions and
Recommendations
This paper sets out to show how public
health prevention techniques can change
over time. With regard to continuously in-
creasing prevalence of obesity, one may
assume that, at this point in time, global
and national public health is in a particu-
lar crisis. Public health practice has new
challenges to deal with. Challenges that
can be characterized as being of extreme
complexity. On the one hand, the rather
novel practice of implementing fiscal po-
licies for public health purposes might
constitute a valid option in how to best
challenge complex public health threats
such as obesity. On the other hand, it is
likely that even taxation of unhealthy food
products will not be the complete solution
to the obesity crisis. Professionals from a
number of different disciplines within the
field of public health have suggested what
to eat to stay healthy. Public health educa-
tion has tried unsuccessfully to counteract
the development of obesity by informing
citizens about healthy ways of eating and
living and numerous health promotion
campaigns have been implemented. Ne-
vertheless, they have been relatively ine-
ffective, as evidenced by the rising rates
of obesity. The question of why this has
been the case is worth asking.
ENES/LEÓNUNAM 20
The increasing prevalence of obesity in-
dicates that health education has not been
successful in changing dietary patterns
and physical activity. But moreover, there
are also reasons to question the implemen-
tation of fiscal policies. Why should the
increase in prices of unhealthy products
change consumer behaviour? As current
research indicates, and as described in this
paper, fiscal policies seem to be effective
in lowering SSB consumption. Whether
this will end the obesity epidemic, is a
question, which has not yet been answe-
red by research. This brings us to a subse-
quent question in which it is inevitable to
focus on the core problem of the issue, na-
mely under which conditions the concept
of health is truly established.
Determinants of health are of great im-
portance when it comes to public policy
making. To create and implement adequate
public policies requires consideration, not
just of what health professionals consider
as health, but also focusing on the com-
mon understandings and relevance of how
the general public considers and further-
more understands health.
Only by applying a holistic framework in
which the determinants of health are well
understood, will fiscal policies be more

effective. This, eventually, brings us to the
point of Good Governance – the key to a
successful public health endeavour. In a
democracy, the idea of inclusiveness of
citizens is an unconditional characteristic.
Including the general population and their
values and beliefs is of utmost importance
to follow the lines of Good Governance. If
fiscal policies are enacted, which do not
represent the characteristics, ideas, values
and ultimately, health determinants, of the
general population, Good Governance will
fail. This reflects an intrinsic problem bet-
ween science and evidence based public
health practice on the one hand, and de-
mocracy as well as citizen inclusiveness on
the other hand. Furthermore, it may also
indicate “the complicated relationship bet-
ween public health, science and democra-
cy” (Horstman, 2013).
Horstman has emphasized the problem
of people not following the advice given
by public health professionals: “In public
health, citizens are constructed more as
the object than the subject of policies and
interventions”; “the gap between policy
and practice”. It seems obvious that health
professionals are in possession of the ne-
cessary knowledge on how to preserve the
health of the people. However, and as we
see more and more people are becoming
obese, we start to recognize that a vast
number of people tend to ignore the advi-
ce. At issue here is why some people do
not follow public health advice. The answer
might lie in an argument by Horstman, na-
mely, that “It is naïve to assume – as many
public health policies and programmes do
– that experts driven interventions actually
result in behaviour change in everyday life
on short notice” (Horstman, 2013). The-
refore, in fiscal policies for the prevention
of SSB consumption, it will be pivotal to
make people understand why the taxation
was levied, and second, to create meaning
and a relationship of trust between the ge-
neral population and the people responsi-
THE OBESITY EPIDEMIC 21
ble for the policy (politicians, public health
professionals). This atmosphere of belief
and trust can only be created, if Good Go-
vernance is applied as governance encom-
passes the eight important characteristics:
participation, rule of law, transparency, res-
ponsiveness, consensus oriented, equity
and inclusiveness, effectiveness and effi-
ciency, and accountability.
In conclusion, the nature of public
health has to change and can be guided
by Good Governance. We need to make
public health congruent with democracy.
Until now, public health has predominately
focused on framing their problems as “te-
chnical problems which have to be solved
through scientific expertise” (Horstman,
2013). However, it is not only about pre-
senting evidence, giving advice and ma-
king interventions. It is also about creating
a consistent and fruitful dialogue between
citizens and the governing parties. Specifi-
cally, in the field of public health, this dia-
logue should be of great value. In addition,
qualitative research within the communi-
ties to create empirical evidence of how
different socio-economic classes think and
feel about implemented policies such as
the sugar taxation is badly needed.
The obesity epidemic presents a big
challenge for governments and health pro-
fessionals. Fiscal policies may help, if their
implementation and administrative proces-
ses are governed in an adequate manner,
taking into account all possible determi-
nants of the health problem. Since many of
the determinants of health are beyond the
scope of health professionals, the dialogue
with citizens will eventually influence more
than just the health of the people - and lead
to an overall increase in the welfare of the
society.
7.

References

• Alwan, A. (2011). Global status report on noncommunicable

diseases 2010. World Health Organization

• Andreyeva, T., Long, M. W., & Brownell, K. D. (2010). The

impact of food prices on consumption: a systematic review
of research on the price elasticity of demand for food. Ame-
rican journal of public health, 100(2), 216.

• Astudillo, O. (2014). Country in Focus: Mexico’s growing

obesity problem. The Lancet Diabetes & Endocrinology, 2(1),
15-16.

• Barquera, S., Campirano, F., Bonvecchio, A., Hernández-

Barrera, L., Rivera, J. A., & Popkin, B. M. (2010). Caloric be-
verage consumption patterns in Mexican children. Nutrition
journal, 9, 47-47.

• Barquera, S., Campos, I., & Rivera, J. A. (2013). Mexico at-

tempts to tackle obesity: the process, results, push backs
and future challenges. Obesity Reviews, 14(S2), 69-78.

• Barquera, S., Campos-Nonato, I., Aguilar-Salinas, C., Lopez-

Ridaura, R., Arredondo, A., & Rivera-Dommarco, J. (2013).
Diabetes in Mexico: cost and management of diabetes and
its complications and challenges for health policy. Glob
Heal, 9, 3.

ENES/LEÓNUNAM 22
 THE OBESITY EPIDEMIC 23
• Barquera, S., Hernandez-Barrera, L., Tolentino, M. L., Es-
pinosa, J., Ng, S. W., Rivera, J. A., & Popkin, B. M. (2008).
Energy intake from beverages is increasing among Mexican
adolescents and adults. The Journal of nutrition, 138(12),
2454-2461.

• Barquera, S., Tovar-Guzmán, V., Campos-Nonato, I., Gonzá-

lez-Villalpando, C., & Rivera-Dommarco, J. (2003). Geography
of diabetes mellitus mortality in Mexico: an epidemiologic
transition analysis. Archives of medical research, 34(5), 407-
414.

• Blakely, T., Wilson, N., & Kaye-Blake, B. (2014). Taxes on Su-

gar-Sweetened Beverages to Curb Future Obesity and Dia-
betes Epidemics. PLoS medicine, 11(1), e1001583.

• Brand H. (2007). Good governance for the public’s health.

European journal of public health, 17(6), 541.

• Britannica Online Encyclopedia, 2014 (retrieved on March,

8th http://www.britannica.com/EBchecked/topic/584578/
taxation )

• Brownell, K. D., Farley, T., Willett, W. C., Popkin, B. M., Cha-

loupka, F. J., Thompson, J. W., & Ludwig, D. S. (2009). The
public health and economic benefits of taxing sugar-swee-
tened beverages. New England journal of medicine, 361(16),
1599-1605.

• Brownell, K. D., & Frieden, T. R. (2009). Ounces of preven-

tion—the public policy case for taxes on sugared beverages.
New England Journal of Medicine, 360(18), 1805-1808.

• Capewell, S., & Graham, H. (2010). Will cardiovascular disea-

se prevention widen health inequalities. PLoS Med, 7(8).

• Caprio, S. (2012). Calories from soft drinks—do they matter.

N Engl J Med, 367(15), 1462-1463.

• Chaloupka, F. J., Yurekli, A., & Fong, G. T. (2012). Tobacco

taxes as a tobacco control strategy. Tobacco Control, 21(2),
172-180.

• Chopra, M., & Darnton-Hill, I. (2004). Tobacco and obesity

epidemics: not so different after all?. BMJ: British Medical
Journal, 328(7455), 1558.
• Chouinard, H. H., Davis, D. E., LaFrance, J. T., & Perloff, J. M.
(2005). The effects of a fat tax on dairy products.

• Craven, B. M., Marlow, M. L., & Shiers, A. F. (2012). Fat Taxes

and Other Interventions Won’t Cure Obesity. Economic
Affairs, 32(2), 36-40.

• Dodgson, R., Lee, K., & Drager, N. (2002). Global health go-
vernance. A Conceptual Review, London/Geneva.

• Drewnowski, A., & Popkin, B. M. (1997). The nutrition transi-

tion: new trends in the global diet. Nutrition reviews, 55(2),
31-43.

• Epstein, L. H., Jankowiak, N., Nederkoorn, C., Raynor, H. A.,

French, S. A., & Finkelstein, E. (2012). Experimental research
on the relation between food price changes and food-pur-
chasing patterns: a targeted review. The American journal
of clinical nutrition, 95(4), 789-809.

• Escobar, M. A. C., Veerman, J. L., Tollman, S. M., Bertram,

M. Y., & Hofman, K. J. (2013). Evidence that a tax on sugar
sweetened beverages reduces the obesity rate: a meta-
analysis. BMC public health, 13(1), 1072.

• European Commission (2007). White Paper. Together for

Health: A Strategic Approach fort he EU 2008-2013.

• Finkelstein, E. A., Khavjou, O. A., Thompson, H., Trogdon, J.

G., Pan, L., Sherry, B., & Dietz, W. (2012). Obesity and severe
obesity forecasts through 2030. American journal of preven-
tive medicine, 42(6), 563-570.

• Fletcher, J., Frisvold, D., & Tefft, N. (2013). Substitution pat-

terns can limit the effects of sugar-sweetened beverage
taxes on obesity. Preventing chronic disease, 10.

• Gilbert, C. A., & Slingerland, J. M. (2013). Cytokines, obesity,

and cancer: new insights on mechanisms linking obesity to
cancer risk and progression. Annual review of medicine, 64,
45-57.

• Glasgow SM. 2005. The private life of public health: mana-

ging chronic disease in an era of neoliberal governmentality.
PhD diss. Univ. Maryland

ENES/LEÓNUNAM 24
 THE OBESITY EPIDEMIC 25
• Gortmaker, S. L., Swinburn, B. A., Levy, D., Carter, R., Mabry,
P. L., Finegood, D. T., ... & Moodie, M. L. (2011). Changing the
future of obesity: science, policy, and action. The Lancet,
378(9793), 838-847.

• Gushulak, B. D., & MacPherson, D. W. (2004). Globalization

of infectious diseases: the impact of migration. Clinical in-
fectious diseases, 38(12), 1742-1748.

• Horstman K. (2013). Struggling with science and democra-

cy: Public health and citizenship in the Netherlands. In: F.
Huisman, H. Oosterhuis (Eds.) Health and citizenship. Politi-
cal cultures of health in modern Europe. London, Pickering
& Chatto, 2013.

• INEGI (2013). Encuesta Nactional de Ingresos y Gastos de

los Hogares 2012.

• James, W. P. T. (2008). WHO recognition of the global obesi-

ty epidemic. International Journal of Obesity, 32, S120-S126.

• Kickbusch, I., & Gleicher, D. (2012). Governance for health in

the 21st century. World Health Organization

• Kirk, D. (2006). The ‘obesity crisis’ and school physical edu-

cation. Sport, Education and Society, 11(2), 121-133.

• Kuchler, F., Tegene, A., & Harris, J. M. (2005). Taxing snack

foods: Manipulating diet quality or financing information
programs?. Applied Economic Perspectives and Policy,
27(1), 4-20.

• Labonte, R. (2001). Health, globalization and sustainable de-

velopment. Draft discussion paper prepared fort he World
Health Organization Meeting „Making Health Central to Sus-
tainable Development, Oslo, Norway, 29 November – 1 De-
cember 2001.

• Labonté, R., Mohindra, K., & Schrecker, T. (2011). The

growing impact of globalization for health and public health
practice. Public Health, 32(1), 263.

• Labonte, R., & Spiegel, J. (2003) Setting global health re-

search priorities. British Medical Journal, 326, 722-23.
• Labonte, R., & Torgerson, R. (2005). Interrogating globaliza-
tion, health and development: Towards a comprehensive
framework for research, policy and political action. Critical
Public Health, 15(2), 157-179.

• Lavin, R., Timpson, H. (2013). Exploring the acceptability of

a tax on sugar-sweetened beverages. Brief evidence review.
Centre for Public Health. Liverpool John Moores University.

• Malik, V. S., Willett, W. C., & Hu, F. B. (2013). Global obesity:

trends, risk factors and policy implications. Nature Reviews
Endocrinology, 9(1), 13-27.

• Moodie, M., Sheppard, L., Sacks, G., Keating, C., & Flego, A.
(2013). Cost-effectiveness of fiscal policies to prevent obe-
sity. Current obesity reports, 2(3), 211-224.

• Mytton, O. T., Clarke, D., & Rayner, M. (2012). Taxing un-

healthy food and drinks to improve health. BMJ, 344, e2931.

• Osei-Assibey, G., Dick, S., Macdiarmid, J., Semple, S., Reilly,

J. J., Ellaway, A., ... & McNeill, G. (2012). The influence of
the food environment on overweight and obesity in young
children: a systematic review. BMJ open, 2(6)
• O’Sullivan, D., & Dooley, L. (2008). Applying innovation. Sage.

• Oxford Dictionary 2014

• Pomeranz, J. L. (2012). Advanced policy options to regulate

sugar-sweetened beverages to support public health. Jour-
nal of public health policy, 33(1), 75-88.

• Popkin, B. M. (1994). The nutrition transition in low‐income

countries: an emerging crisis. Nutrition reviews, 52(9), 285-
298.

• Popkin, B. M. (2001). The nutrition transition and obesity in

the developing world. The Journal of nutrition, 131(3), 871S-
873S.

• Presidencia de la Republica Mexico. Tres pilares de la estra-

tegia nacional para un Mexico sin obesidad. 2014 (retrieved
March 25th 2014, http://www.presidencia.gob.mx/3-pilares-
de-la-estrategia-nacional-para-un-mexico-sin-obesidad/ )

• Principles of Eocnomics. N. Gregory Mankiw. 10. February

2011.

ENES/LEÓNUNAM 26
 THE OBESITY EPIDEMIC 27
• Rawlins, E. (2008). Citizenship, health education and the
obesity ‘crisis’. ACME: An International E-Journal for Critical
Geographies, 7(2), 135-151.

• Rivera, J. A., Barquera, S., Campirano, F., Campos, I., Safdie,

M., & Tovar, V. (2002). Epidemiological and nutritional transi-
tion in Mexico: rapid increase of non-communicable chronic
diseases and obesity. Public health nutrition, 5(1a), 113-122.

• Powell, L. M., & Chaloupka, F. J. (2009). Food prices and obe-

sity: evidence and policy implications for taxes and subsi-
dies. Milbank Quarterly, 87(1), 229-257.

• Powell, L. M., Chriqui, J. F., Khan, T., Wada, R., & Chaloupka,
F. J. (2013). Assessing the potential effectiveness of food
and beverage taxes and subsidies for improving public
health: a systematic review of prices, demand and body
weight outcomes. Obesity reviews, 14(2), 110-128.

• Rtveladze, K., Marsh, T., Barquera, S., Sanchez Romero, L.

M., Levy, D., Melendez, G., ... & Brown, M. (2014). Obesity
prevalence in Mexico: impact on health and economic bur-
den. Public health nutrition, 17(01), 233-239.

• Rull, J. A., Aguilar-Salinas, C. A., Rojas, R., Rios-Torres, J. M.,

Gómez-Pérez, F. J., & Olaiz, G. (2005). Epidemiology of type
2 diabetes in Mexico. Archives of medical research, 36(3),
188-196.

• Sassi, F., Belloni, A., Capobianco, C., & Alemanno, A. (2014).

Taxation and Economic Incentives on Health-Related Com-
modities: Alcohol, Tobacco and Food.

• Story, M., Kaphingst, K. M., Robinson-O’Brien, R., & Glanz, K.

(2008). Creating healthy food and eating environments: poli-
cy and environmental approaches. Annu. Rev. Public Health,
29, 253-272.

• Swinburn, B. A., Sacks, G., Hall, K. D., McPherson, K., Fine-

good, D. T., Moodie, M. L., & Gortmaker, S. L. (2011). The
global obesity pandemic: shaped by global drivers and local
environments. The Lancet, 378(9793), 804-814.

• The Burden of Disease Project, 2010. http://www.health-

metricsandevaluation.org/gbd/visualizations/gbd-arrow-dia-
gram (accessed March 2014).
• United Nations. Economic and Social Commission for Asia
and the Pacific. What is Good Governance? (retrieved March
17th, 2014. http://www.unescap.org/sites/default/files/
good-governance.pdf )

• United Nations. Prevention and control of non-communica-

ble diseases. A/66/83. United Nations, 2011

• United Nations (1948). The Universal Declaration of Human

Rights.

• Vucenik, I., & Stains, J. P. (2012). Obesity and cancer risk: evi-
dence, mechanisms, and recommendations. Annals of the
New York Academy of Sciences, 1271(1), 37-43.

• Wang, Y. C., Coxson, P., Shen, Y. M., Goldman, L., & Bib-
bins-Domingo, K. (2012). A penny-per-ounce tax on sugar-
sweetened beverages would cut health and cost burdens of
diabetes. Health Affairs, 31(1), 199-207.

• Wang, Y. C., McPherson, K., Marsh, T., Gortmaker, S. L., &

Brown, M. (2011). Health and economic burden of the pro-
jected obesity trends in the USA and the UK. The Lancet,
378(9793), 815-825.

• Webber, L., Kilpi, F., Marsh, T., Rtveladze, K., Brown, M., &
McPherson, K. (2012). High rates of obesity and non-com-
municable diseases predicted across Latin America. PloS
one, 7(8), e39589.

• Woodward-Lopez, G., Kao, J., & Ritchie, L. (2011). To what

extent have sweetened beverages contributed to the obesi-
ty epidemic?. Public Health Nutrition, 14(03), 499-509.

• World Health Organization. (2000). Obesity: preventing and

managing the global epidemic (No. 894). World Health Or-
ganization.

• World Health Organization. (2009). 2008-2013 Action plan

for the global strategy for the prevention and control of
noncommunicable diseases: prevent and control cardio-
vascular diseases, cancers, chronic respiratory diseases
and diabetes.

• World Health Organization (2010). World Health Report. Fi-

nancing for universal coverage. Chapter 2. More money for
health.

ENES/LEÓNUNAM 28
 THE OBESITY EPIDEMIC 29
• World Health Organization. (2012). A framework for imple-
menting the set of recommendations on the marketing of
foods and non-alcoholic beverages to children.

• World Health Organization. (2013). Global action plan for the

prevention and control of noncommunicable diseases 2013-
2020.

• World Health Organization. (2015) Media Centre Overview:

Obesity and Overweight, (retrieved 16.02.2015 http://www.
who.int/mediacentre/factsheets/fs311/en/ )

• Yngve, A., Haapala, I., Hodge, A., McNeill, G., & Tseng, M.
(2012). Making soft drinks the dietary version of the cigaret-
te. Public health nutrition, 15(08), 1329-1330.

• Zenith International (2013) Accessed 15/03/2014 from http://

 Universidad Nacional Autónoma de México
ENES LEÓN
The obesity epidemic: fiscal policies and Good Governance
-The key to successful public health interventions
Esta edición se terminó de imprimir en el mes de abril de 2015
en los talleres de Editores Buena Onda, S.A. de C.V.
Suiza 14, Col. Portales Oriente, México 03570, D.F.
Su composición se realizó con las familias tipográficas:
Zurich Bt 8, 11, 18, 24, 36, 46, 60
El tiraje consta de 000 ejemplares
El cuidado de la edición estuvo a cargo de

ENES/LEÓNUNAM 30