What does our region need in order to strengthen public policies on sugar-sweetened beverages? decision-makers’ dialogue

ABSTRACT In order to prioritize public policies to reduce the consumption of sugar-sweetened beverages in Argentina, Brazil, El Salvador and Trinidad and Tobago and to identify information gaps related to the burden of disease attributable to their consumption, a policy dialogue was held with government members, civil society organizations, researchers and communicators from Latin American and Caribbean countries. Presentations and deliberative workshops were conducted using semi-structured data collection tools and group discussions. The prioritized interventions were tax increases, front labeling, restriction of advertising, promotion and sponsorship, and modifications regarding the school environment. The main perceived barrier was the interference from the food industry. This dialogue among decision-makers led to the identification of priority public policies to reduce the consumption of sugar-sweetened beverages in the region.


INTRODUCTION
Globally, noncommunicable diseases (NCDs) are the leading cause of mortality and most deaths occur in low-and middle-income countries (1) .In addition to the significant burden of disease, NCDs also place a significant economic burden on health systems and society, which can be a barrier to global development (2) .
The burden of disease and mortality due to noncommunicable diseases is closely linked to overweight and obesity, with poor diet and sedentary lifestyle being the main risk factors.Sugar-sweetened beverages (SSBs) are a major source of added sugars in the diet, with high caloric content and low nutritional value; their consumption is associated with weight gain and the risk of developing type 2 diabetes and other related conditions (3)(4)(5)(6) .Its consumption in Latin America is high when compared to other regions, with an average consumption of 370 ml https://doi.org/10.17843/rpmesp.2023.401.12394 per day compared to the world average of 140 ml (7) .For this reason, in recent years, different public policies have been developed aiming to reduce SSB consumption, such as fiscal policies, labeling, restrictions on advertising, promotion and sponsorship (8)(9)(10)(11) .
Identifying the best available evidence to support the creation of public health policies is becoming increasingly relevant in the international agenda with the aim of strengthening healthcare systems worldwide.However, there are significant barriers to address the gap between knowledge and its appropriate use for the benefit of society, which can lead to ineffective or even harmful public policies (12) .Policy dialogues are useful tools to guide the creation of public policies, allowing interaction between the most relevant actors (researchers, decision-makers, communicators and civil society), as well as the integration of explicit and tacit knowledge in an inclusive and transparent environment, providing the opportunity to reflect on the application of evidence in different contexts with implications for the final decision making (13) .
This article presents the results of a policy dialogue involving government members, civil society organizations, researchers and communicators from four countries in Latin America and the Caribbean (Argentina, Brazil, El Salvador and Trinidad and Tobago) on policies for the control of alcohol consumption.It was carried out within the framework of a project funded by Canada's International Development Research Centre (IDRC) entitled "Empowering health decision-makers to achieve regional objectives in sugar-sweetened beverage control policies in Latin America and the Caribbean: building a framework for assessing the burden of disease, the cost-effectiveness of available interventions and estimating the burden of disease in four countries".The aim of the project was to develop a simulation model to estimate the burden of disease attributable to SSB consumption in the four countries and to evaluate the cost-effectiveness of interventions for its control (14) .The policy dialogue described here was carried out to inform the development of key aspects of the model (such as the target population and the outcomes) and to gain a better understanding of the problem at the regional level.In turn, the decision-makers' dialogue aimed to identify the public policy interventions prioritized worldwide for the control of SSB consumption and the real or perceived barriers as well as the facilitators in order to implement new interventions or reinforce those already implemented; and to understand the information needs regarding the promotion and simplification of decision making.

METHODS
Quali-quantitative study describing the main findings of the policy dialogue conducted through two face-to-face workshops in Buenos Aires, Argentina on May 14 and 15, 2018.

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 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.

RESULTS
The main characteristics of the participants are presented in Table 1.
Our findings are described below for each dimension of the thematic analysis.

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 contri-  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 rience 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 https://doi.org/10.17843/rpmesp.2023.401.12394evaluation 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.

DISCUSSION
An important group of decision-makers, academics and members of civil society organizations, were able to identify interference in the implementation of policies aimed at the control of noncommunicable diseases in Latin America (15- 17) .Other barriers mentioned by the participants were the difficulty in the implementation, monitoring, evaluation and articulation of policies aimed at reducing the consumption of SSBs and the need for resources to carry out these activities.
The participants agreed on the relevance of having clear information on the burden of disease in both the health and economic aspects and on the impact of interventions aimed at reducing the consumption of SSBs.We found considerable heterogeneity regarding the availability of information in Brazil, Argentina, El Salvador and Trinidad and Tobago for modeling estimates of the burden of disease associated with the consumption of SSB and interventions to reduce its consumption, except for demographic information, which further increases the relevance of having reliable estimates.
One of the most important benefits of policy dialogue events is the sense of ownership of the issue by decision-makers.Moreover, dialogue, whether formal or informal, can increase trust between decision-makers, researchers, and civil society, enabling the development of constructive engagements for society as a whole, anticipating barriers and facilitators to implementation (18) .
These types of events are relevant for the formulation of policies aimed at combating noncommunicable diseases (19,20) .It is important to mention the experience regarding tobacco consumption in Latin America, where the existence of multiple policy dialogues over time allowed the identification and promotion of successful policies to reduce the prevalence of tobacco consumption in recent years (21) .
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.https://doi.org/10.17843/rpmesp.2023.401.12394 bution 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 su- and prioritize fiscal policies, graphic front-of-pack food labeling and the regulation and/or prohibition of advertising, promotion and sponsorship of SSBs as the main interventions to reduce its consumption.Educational actions and the modification of school environment were considered relevant interventions, but not prioritized due to the difficulty in their implementation.The main barrier for the implementation of measures aimed at reducing consumption of SSBs was the interference by the manufacturing companies through different strategies such as political lobbying, delaying or hindering the enactment of regulatory standards and the promotion of corporate social responsibility programs and self-regulation initiatives.This perception is aligned with multiple examples in the literature regarding food industry

Table 1 .
Characteristics of the participants.
a The denominator for all percentages is 25, except for the case of the ratio of women, which varies in each focus group, which is why the proportion of women is greater than 100%.https://doi.org/10.17843/rpmesp.2023.401.12394gar-sweetened beverages; d) educational actions and actions to modify the school environment (public and private).

Table 2
tified 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.

Table 3 .
Availability of information sources by country.