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Obesity in Developing Countries: People are Overweight But Still Not Well Nourished

(November 11, 2004) For as long as the world has known it, malnutrition has been associated with hunger, conjuring up images of gaunt and prematurely aged children and adults. In 2004, malnutrition is still very much with us, and it is taking on a new form as well.

To be sure, there are still far too many hungry and underfed people--1.1 billion at last count. But over one billion people are now overweight and obese.

Perhaps most surprisingly, these aren't all cheeseburger-eating Westerners. Most are Asians, Pacific islanders, and Latin Americans, in particular urban women, living in developing countries. Usually poor, they are succumbing in alarming numbers to the misleadingly named "diseases of affluence"--obesity, heart disease, cancer, and diabetes--that arise from changing diets, lifestyles, and economies.

Chronic non-communicable diseases now cause close to 60 percent of all deaths worldwide. Surprisingly, nearly 80 percent of these deaths occur in developing countries.

Overweightness and obesity, the most glaring outward sign of the changing face of malnutrition in developing countries, increase the chances of a person falling prey to the other non-communicable diseases. (Overweight here refers to a body mass index [BMI] of 25 or more and obese to a BMI of 30 or more. BMI is a weight–height relationship that indicates amount of body fat.)

According to the World Health Organization (WHO), obesity-related ailments afflict more than 115 million people in the developing world, up from essentially none two generations ago. By 2030, these diseases as a group are projected to be the No. 1 killer of poor people around the world.

"We really are seeing the spread of a different form of malnutrition in the developing world and the globalization of chronic diseases due to the adoption of energy-dense high-calorie diets, high in fat and sugars, and Western-style work and social infrastructures," says Neville Rigby, director of policy and public affairs at the International Obesity Taskforce, a London-based nongovernmental organization (NGO) that researches weight-related health issues.

While data on obesity in the developing world are limited, the highest rates appear to be in the South Pacific. In Nauru, 70 percent of the population is classified as clinically obese, up from only 15 percent in the mid 1960s.The problem cannot be defined regionally, though. Obesity affects 25 to 50 percent of the populations in countries as diverse as Kuwait, Colombia, the Philippines, and China.

"Even in the low-income, Sub-Saharan African countries with HIV and malnutrition dominating, there are still 10 to 15 percent of adults that are overweight," says Barry Popkin, professor at the Nutrition School of the University of North Carolina at Chapel Hill.

Age is also no longer a safeguard. In much of North Africa and Latin America, one in five children aged 4 to 10 are overweight. While bad diets and obesity are most damaging to adults (because they often lead to fatal illness), they have serious consequences for children as well.

Overweight children are more than twice as likely to have high blood pressure or heart disease as children of normal weight. Often linked to obesity, Type 2 diabetes, once known as adult-onset diabetes before it started afflicting so many children, puts kids at risk for a range of disorders, including blindness, nerve damage, kidney failure, and cardiovascular disease.

The Energy Equation

Nutritionists working in developing countries once thought that if people obtained enough energy in their diets, they would obtain enough minerals, vitamins, and other micronutrients. But that is clearly not the case. Malnutrition is not simply caused by a lack of food overall, but by a lack of high-quality foods such as whole grains, fiber, fruits, and vegetables. Diets can also be injurious to health if they contain an excess of components such as saturated fat, sodium, and added sugar.

"Sadly, it seems that we have somehow managed to bypass good health, moving from hunger to obesity in a single generation in many parts of the world," says Marie Ruel, interim director of IFPRI's Food Consumption and Nutrition Division.

Perhaps most worrying is that obesity and diet-related non-communicable diseases are reaching epidemic levels in countries that are still struggling to eliminate hunger and poverty, encumbering them with a double health burden.

In some cases, undernutrition and obesity can even be found under the same roof. The prevalence of households with both overweight and underweight members in Brazil, for example, stands at 11 percent. In Asia it ranges between 3 and 15 percent, with households typically containing an underweight child and an overweight, nonelderly adult.

This one-two health punch has the potential to cause an economic and human disaster in countries whose medical systems are woefully unprepared to deal with diseases requiring long-term care.

"What's clear is that the developing world in particular is going to bear the enormous brunt of the adverse health impact of the world's weight gain and they aren’t prepared for it," says Rigby.

The Nutrition Transition

So, how did we reach this point?

The reasons are manifold, starting with our genetic make-up and including global economic development, higher incomes, shifting diets, and a range of changes in the nature of work and leisure. Together it is what scientists refer to as the "nutrition transition," a process that is accelerating rapidly.

People living in urban areas throughout the developing world are much further along in the transition than their rural counterparts. Comparatively sedentary jobs demand less physical energy than rural labor. And as more and more women work away from home, traditional patterns of food preparation are changing. Cities also offer a greater range of aggressively marketed calorie-rich food choices. The fact that more people are moving to cities makes the problem more pervasive.

Down on the farm, toil is also not always what it used to be as increased mechanization curbs energy expenditures. Many farmers are also opting now to grow a single, high-yielding cash crop instead of the multiple crops that supported their former subsistence livelihoods and that often provided a fairly balanced diet.

Another element of the nutrition transition is the increasing role of foods associated with industrialized countries.

As a result of all of these factors, traditional diets that may have featured grains and vegetables are giving way to meals high in saturated fat and sugar.

To get an idea of how revolutionary this change is, consider the eating patterns in China. Less than two generations ago, dinner for most Chinese consisted of rationed rice or wheat and vegetables with a little bit of soy sauce—and often coarse grains instead of rice or wheat if they were poor. Today, most meals include excessive vegetable oils, some meat or fish, eggs, and rice or wheat. While variety is a good thing, it can result in increased intakes of saturated fats, sugars and other potentially unhealthy food constituents, which become more damaging when combined with reduced physical activity.

"In China, the amount of oil being consumed now is high and the energy density has gone way up," says Popkin, adding that it is usually the increased use of edible oils, not animal foods, that account for the first jump in a country's caloric and fat intakes.

Our own taste buds have played a big role in these dietary shifts. Humans prefer energy-dense foods, high in fat and sugar. From an evolutionary point of view, it's how we adapted to help us endure times of famine. But only recently have such foods become so cheap and widely available to most of the world's population, thanks to new technologies and liberalized international trade and investment.

And as food companies watch incomes rise in the developing world, they are setting their sights on new markets and heightening the desirability of energy-dense foods, not all of which may be healthy.

The Costs Of A Poor Diet

Thanks to the developed world's struggles with diseases related to food consumption behavior, the health consequences of diets high in fat and sugar are well documented, ranging from increased risk of premature death to serious chronic conditions such as hypertension, stroke, diabetes, cardiovascular diseases, and a host of other ailments.

Alongside these diseases' ability to reduce the overall quality of life, they can also exact a large economic price with the potential to weaken or even undo a nation's development gains by diminishing people's capacity to work and by diverting scarce resources to healthcare. For nations whose economic and social resources are already stretched to the limit, widespread epidemics of non-communicable diseases could be disastrous.

In China, the economic cost of diet-related chronic diseases has already surpassed that of undernutrition— a loss of more than 2 percent of GDP.

The economic costs of obesity have been estimated only for some Western countries. Although methodology varies, estimates place the cost of diagnosing and managing obesity at 2 to 8 percent of total expenditure on health care. The economic impact in developing countries is likely to be higher.

"If action is not taken, this group of diseases will swamp health services of poor countries at a time when they are still addressing infectious diseases, and reduce worker productivity that is so needed to lift people out of poverty," says Derek Yach, professor of public health and head of Yale University's Global Health Division and formerly WHO's executive director for non-communicable diseases and mental health.

In Hunger's Shadow

Despite all that is at stake, obesity and related diseases continue to be overlooked as serious health problems in developing countries. Most policymakers in Asian countries and Pacific island states are still focusing exclusively on the problems of undernutrition, even when the costs of obesity are overwhelming the health care system.

There also needs to be more research into the nutrition transition, specifically on understanding how diets are changing among households and individuals in developing countries.

Addressing Dangerous Misconceptions

Among some policymakers and health officials, the misconception that obesity is a problem afflicting only affluent countries and households may be holding back needed research in poorer countries.

"Overall it seems that there has been a serious neglect of the public health aspects of nutrition/obesity," says Yach, who calls for much greater investment in studies on causal relations between food intakes and disease and for large-scale community-based intervention studies to test "best-option" programs.

The lack of research to date has meant that policymakers don't have the kind of detailed local information they need to evaluate the threat of increasing obesity and the rise of related chronic diseases or adequate guideposts on what might work in reversing these trends.

China, for example, which is facing the prospect of soon becoming the world leader in cardiovascular disease, would need to devise prevention programs for its own particular conditions, says Professor Chen Chunming from the Chinese Center for Disease Control and Prevention. "We need a country-specific strategy for China based on the current situation of the food industry and the food market and of people's dietary patterns, which are different from elsewhere."

The outline of what is needed is in place. Given the early successes of countries such as South Korea, Singapore, and Sweden, it is apparent that an integrated approach is needed that incorporates national food, agricultural, industrial, and healthcare policies, as well as the family, civic institutions, and the community.

The Task Ahead is Huge

"Right now this is clearly an underestimated challenge. Since it is lifestyle based and relates to major shifts in technology and food prices and processing and distribution, it will be most difficult to manage," Popkin says.

As such, the key to managing the problem will involve making the right choices at the national, community, and individual levels. That will require, as always, relevant research, capacity building, and individual and political will.

 This article originally appeared as Chris Burslem, "The Changing Face of Malnutrition." IFPRI Forum, October 2004. International Food Policy Research Institute: Washington, D.C. Reprinted with permission from the International Food Policy Research Institute, www.ifpri.org. The article can be found online at: http://www.ifpri.org/pubs/newsletters/ifpriforum/if200410.htm

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