What should aid focus on, poor people or poor countries?

October 7, 2010

Why Facebook and Twitter won’t be leading the revolution

October 7, 2010

Is Obesity a Development Issue?

October 7, 2010
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innocent nkataAt a recent meeting of Oxfam’s country directors, I asked if they thought Oxfam should treat obesity as a development issue, just another form of ‘mal-nutrition’. The reaction was pretty negative. Innocent Nkata, from South Africa (left), summed it up by saying that whereas hunger was an issue of rights, obesity is a ‘question of morality’ i.e. is it right or wrong that some people should be overeating while others are starving? He sees it as a complex debate with potential to be very subjective and relative. I was happy to drop the issue, in part because even writing about it made me feel uncomfortable and judgemental (regular readers of this blog may be surprised to hear it, but that bothers me). But it’s been niggling away at me ever since, so here are some thoughts about how we might frame obesity as a development issue.

First, and most obviously, it’s a health issue: the World Health Organization reckons that worldwide, approximately 1.6 billion adults (age 15+) were overweight and at least 400 million adults were obese in 2005. The WHO further projects that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese. (The WHO defines “overweight” as a body mass index (BMI) over 25, and “obesity” as a BMI over 30.) 

Because of urbanization, sedentary lifestyles, changing diets and increased incomes, an increasing proportion of those people live in obesity ratesdeveloping countries – Mexico is fast overtaking the US in the obesity stakes (see chart). The WHO confirms that many low- and middle-income countries are now facing a “double burden” of disease:

· While they continue to deal with the problems of infectious disease and under-nutrition, at the same time they are experiencing a rapid upsurge in chronic disease risk factors such as obesity and overweight, particularly in urban settings. That is leading to rapidly increasing rates of diabetes, heart disease and strokes.
· It is not uncommon to find under-nutrition and obesity existing side-by-side within the same country, the same community and even within the same household.
· This double burden is caused by inadequate pre-natal, infant and young child nutrition followed by exposure to high-fat, energy-dense, micronutrient-poor foods and lack of physical activity.

But body size and image are about much more than physical health. I think Innocent’s remark also reflects the fact that traditionally, Africans have often been much less judgemental about body image (’body fascism’) than Europeans, and sometimes even see large size as a sign of success (a British friend of mine working in Mozambique found it hard to look pleased when she came back from holiday and was told ‘you’re looking fat’!). On the other hand Latin American countries such as Brazil and Argentina have alarming levels of anorexia and bulimia, especially among young women. Attitudes to body size are definitely culturally specific.

The link between obesity and income is also complex. In poor countries, unsurprisingly, obesity is generally confined to the wealthier parts of the population. In the rich countries, it is often seen as linked to poverty. According to a new (gated) paper in the Development Policy Review journal, the tipping point between the two occurs at a GDP of about $2,500 per capita, albeit with lots of variation based on diet and culture.

Of course it’s not just about quantity but quality – part of the reason for the surge in obesity in developing countries is the spread of Western diets, including fast food and sugary soft drinks, often driven by transnational corporations. And policies, as we know from our own countries, can make a difference. South Korea has vigorously promoted local foods rather than a high fat Western diet, and has lower rates of obesity than comparable economies.

So if all this is true, and obesity rates are rising, why does no aid agency ever talk about it?

Firstly, we feel more comfortable talking about what poor people need more of (schools, medicines, clean water, food, cash). Self denial is strictly for the rich. But a lot of obese people in developing countries aren’t particularly rich. So our simplistic divisions break down.

Secondly, as with population and family planning, talk of ‘public education’ makes us anxious in case it comes across as patronising and ‘blaming the poor’. But we’re comfortable with it in our own countries, so why not in development?

Thirdly there’s our institutional identity and culture. After all, Oxfam was originally called the ‘Oxford Committee for Famine Relief’. How can it start talking about over-nutrition?

On a global scale, the ‘well-nourished’ constitute only about half of the world’s 6 billion people, with legions of the mal-nourished at either end of the BMI spectrum – roughly a billion hungry and two billion overweight. The number of overweight people in developing countries is bound to continue rising, along with urbanization and rising incomes. So is it time to redefine mal-nourishment as eating too much, or the wrong stuff, as well as too little? To talk about the two billion (over-large) bottoms as well as the Bottom Billion?

If so, what sort of policies or institutions might be worth lobbying for? Controls (whether regulatory, soft law or voluntary) on food and drink companies? Investment in public education on nutrition? Any other ideas?


  1. This is a fascinating question and we’re answering it (or at least, giving a couple of perspectives on it) in the forthcoming issue of the international journal Gender and Development (www.genderanddevelopment.org). In an article on the so-called ‘nutrition transition’ in middle income communities in developing countries, Frances Hansford argues very much that it’s a development issue – it’s about lack of education, a desire for status symbols like high-fat US style food, and it takes place in families alongside other family members suffering deprivation – and guess what? There are gender issues in here!!! The other article in the G&D issue that’s relevant is one from Botswana, where issues of body image, what makes women attractive traditionally (i.e. curves mean fertility) is now also associated with HIV negative status. On the other hand, ‘modern’ ideas of attractiveness being a slender body are also associated with AIDS. And government strategies to cut and treat HIV are affected by these cultural pressures and beliefs. It’s fascinating and important stuff. The Food issue containing these articles will be out at the end of November though, so sorry – you’re ahead of the curve doing this blog now!!

    Duncan: thanks for the heads-up Caroline. What I haven’t seen is gender disaggregated stats on any of these issues – you seen anything?

  2. I’ll send you the Frances Hansford article, which has a lot of good references – and explains the whys and wherefores of the particular issues inherent in collecting gender disaggregated data relating to this. Among adults there are biological and gender (i.e. social) factors affecting differences in women’s and men’s health issues, and of course age and other issues cross-cut sex/gender differences. Interestingly Frances points out that there is a debate raging out there about how best to go about gender disaggregating data relating to children and adolescents in particular, which shows that it is very much a live issue for the agencies involved in health and food:

    ‘Gender patterns in childhood overweight and obesity are less clear because research data on children under 10 years are usually not disaggregated by gender (6). Gender-disaggregated data for adolescents are more readily available, but anthropometric assessment is particularly complex in adolescents, due to the many factors involved in individual processes of sexual maturation (IBGE 2006), and several different criteria for the assessment of adolescent weight status are currently in use. So, for instance, among adolescents aged between 10 and 19 years old in Brazil, overweight and obesity were higher among girls than boys in 2002/03 (8.4 percent of girls versus 4.1 per cent of boys) when assessed against World Health Organisation (WHO, 1995) recommended criteria, but about the same (8.9 per cent versus 8.5 per cent), if more recently-proposed criteria are used (IBGE, 2006) (6). Clearly, more work needs to be done on the appropriate approach to identify overweight and obesity among adolescents; it has received less attention than the assessment of excess weight in adults because it is still less of a problem’ (Hansford forthcoming, Gender & Development 18:2 November 2010)

  3. Fascinating topic, and I resonate with your mixed feelings around this topic. It is certainly not an easy issue, but my instinct is that yes, obesity is a form of mal-nutrition, and it is worth bringing in to discussions of nutrition and public health in the context of development. Obesity is linked to food insecuirty in some contexts as well, so that may be a useful link capturing people at both ends of the weight spectrum and raising broader issues of how nutrition is distributed in society. Interestingly, the OECD just came out with a major study on obesity: http://www.oecd.org/document/31/0,3343,en_2649_33929_45999775_1_1_1_37407,00.html

  4. While obesity is a serious issue, I don’t seeing it fitting the remit of Development Organisations. For me this is summed up in the chart you gave us of which countries are most affected. OK – this is a list of selected countries, but for once China and India are bottom of a list where coming last is a good thing.

    I think charities would have a hard time explaining why they are focussing on a problem that affects only the richest people in poor countries along with poorer people in richer countries.

    Is this something that can be left to the countries themselves as well as organisations such as WHO? As the problem is growing in richer countries they will be doing research and until obesity rates start falling here I doubt we even have very much to offer.

  5. Not easy to negotiate but spot on – your comment about ‘framing obesity as a development issue’ resonates with my work. I do various research across UK govt on behaviour change, so have written on obesity for DH, as well as writing for DFID and the development NGO sector on engaging the UK public in global poverty.
    First, the nutrition transition (as described well here, and going back to Popkin 2004) is clearly a development phenomenon. Largely it can be explained as the opening up of ‘new markets’, and the driving out of local (shorter) supply chains in favour of global (longer) ones – your S Korean comment is interesting in this light. If eg. disposable sanpro is a development issue, fizzy drinks certainly are. We might also like to argue about supply and demand; are those in developing countries demanding these products, or are they being supplied with them? In a further parallel, we find commentators asking in the environment sector whether developing nations need to follow the same (intensive) steps to industrialisation that we have. All this – health, climate change, energy – for me is development.
    But as well as reframing obesity we might also wish to reframe development. I’m currently working on a project for Oxfam UK (campaigns team – but spreading like wildfire) looking at the potential for using lessons from various bodies of theory (psychology, cognitive science, linguistics) which highlight values and frames as means by which we might re-engage the public in global poverty. This is rich fare (and material it would be good to open up to readers here – when I finish writing this month!) but in the context of the current thread, if ‘development’ is framed as economic progress, ie. a course of industrialisation which follows the established Western consumer-based model, then the ‘nutrition transition’ is likely to be let to accelerate, with obesity trends proceeding as observed. If development is about something else, such as wellbeing for instance, then alternative models can be adopted, which may be more reflective of local cultures (including food cultures) and are likely to slow down the rate of increase of overweight in populations in developing countries. Obesity and development are in correspondence, and it may be that obesity is just a symptom of the dominant model of development which we are following.

  6. Mass obesity is a wasting disease.

    You read that right.

    A wasting disease is when you can eat all you want of your regular diet (e.g. white rice) and still not fill a nutritional deficiency (e.g. Vitamin B) so you come down with, say, beri-beri.

    Now it’s true, a person might become obese in a well-nourished population through overindulgence and sloth.

    But where obesity is endemic, you will find that the population has multiple, chronic nutritional but “sub-lethal” nutrient deficiencies. It exists on low-quality staple foods, usually US-dumped. When you have nutrient deficiencies, your body may be ‘starving’ slowly even as you eat more and more low-quality food.

    American Indians have some of the worst rates of obesity in the US. In many tribes the staple food is frybread – government suplus flour fried in government surplus corn oil. Fillers like that mean no one will ever die of a caloric deficiency. And enriched flour will keep the classical wasting diseases away.

    But if that’s not a kind of malnutrition, I’ll be damned.

    People eat badly because they are poor.

  7. It is confusing to understand how the idea of promoting “local” food exists when developed & developing nations both need to import food items mainly for human consumption.

    Obesity is one of the the main health concerns people have talked about so much, so why did they hide the truth about the notions of so-called “local” food culture to be imposed upon those who differently need food for various dietary reasons?

    Can the obese people need special kinds of diet & exercise as attempts to avoid the stigma behind the notion? I think it is unfair to talk about it while trying to understand about how different kinds of food to make up a balanced diet on a daily basis.

    Do not forget what the doctors need to let the “obese” people do the exercise, especially under special supervision to lessen the chances of being discriminated upon by those who aren’t fat at all. The negative sentiments would arouse misunderstanding on various issues affecting people’s health.

    I shall find out more later on the signs of growth skepticism in both food and health.

  8. Thank you very much, Duncan, for raising this issue.
    It seems difficult to accept that overweight and obesity are a development issue, but they are. As you perfectly well described in your blog, for some countries, especially emerging ones, like Mexico and Brazil, it is becoming a drama. It is already considered epidemic. In Brazil, for instance, half of the population is overweighed; and more: something like 30% of children between 5 and 9 are overweighed and mostly within poor families – not very promising for the future adults.
    This reflects the complexity of poverty and it challenges us to revisit our traditional schemes of understanding food insecurity and poverty.
    People are getting fatter because they are having access to inadequate food (the cheapest food is fat and rich in sugar, carbohydrates etc) and because the urbanization process led to a dangerous sedentary life. This is not a matter of beauty. The diseases that results from overweighed and obesity, like diabetes, hart diseases and cancers, are very expensive to treat – representing new and additional costs to the health systems and to the economy in general, since people are more likely to get hill. That is why when we talk about the “right to adequate food”, “adequate” means quantity but also quality in terms of good balance of macro and micro nutrients and, also, safety (free from pesticides, hormones etc).
    To tackle the problem it is necessary to have a multidimensional approach. It is necessary to changes practices and beliefs but also to give the financial conditions for people living in poverty to have access to an adequate diet. As it is a new phenomenon in developing countries, it is still not clear what to do at national level. In Brazil the Food and Nutrition Security Policy seeks to coordinate policies like:
    – hard regulation on food market, specially food for children (like is was done for cigarettes, since inadequate food harms health) – Ministry of Health and Parliament. The role of private sector is crucial;
    – public education on nutrition through education and health systems and a national communication policy;
    – adequate food programmes offering balanced diets, including school feeding programmes, workers feeding programmes and popular restaurants (R$ 1 real meal for poor people) – Ministries of Education, Work, Social Communication, Health and Social Development;
    – public policies to stimulate people to do exercise, specially children – Ministries of Education, Health, Sports, Culture;
    – public policies to strengthen small scale farmers to produce, following agroecological practices, vegetables and fruits – Ministries of Health, Agrarian Development, Social Development;
    – stimulate urban agriculture;
    – stimulate exclusive breastfeeding until 6 month;
    – value traditional diets (indigenous people, peasants, regional cultures etc) that were nutritionally adequate in the past – Ministries of Social Development, Agrarian Development, Culture;
    – stimulate, financially, the consumption of a balanced diet;
    – increasing incomes etc…

    Duncan: Fascinating Nathalie, thanks. Your policy list is intriguing – half of it (public education, lifestyles etc) could apply to the UK government, but not the other half (small farmers, urban agriculture). And Brazil has to deal with this new problem as the same time as reducing its remaining levels of poverty.

  9. I think there is a real concern about that kind of growth skepticism it has on health issues. I suspect it is going to spook unsuspecting public into thinking that obesity is a problem (sort of).

    It is better to look more closely at various signs of growth skepticism whether it is real or not.

    Those who believe in or advocate both social change & economic growth should proceed with caution because obesity or any other health factor is a tricky subject that may mean a sign that growth skepticism does exists in (some) people’s minds.

    It is time to take action on this.

  10. I believe problems of overweight and obesity have to get our attention in a systemic perspective on development. Overweight and obesity are not confined to ‘middle income’ communities or wealthy sectors in developing countries, nor are they urban problems; they are rampant, and growing at fast rates, in some of the poorest sectors of ‘middle income’ (as defined by the World Bank) developing countries, including rural populations. I wrote the article to which Caroline referred above (Hansford in Gender and Development 18:3), based on my doctoral research. I collected data in a low-income rural community of sugar-cane cutters in NE Brazil, many of whom face months of seasonal unemployment during the growing season. Almost 20% of men and almost 39% of women were overweight; 5% of men and 13% of women were obese (sample of 72 adults). These figures are very similar to survey data for rural NE Brazil collected by the National Statistics Office (IBGE). The average household per capita income in the sample was US$47/mth; 75% of households had monthly per capita incomes below the poverty line (less than US$55/mth), and almost 19% below the extreme poverty line (less than US$28/mth) in the non-harvest period; 31% fell below the poverty line during the harvest season. Some of the overweight/obese individuals were in households which had faced food insecurity during the year preceding the survey.

    The rapid rise in excess weight among adults is largely due to changes in diet, with the spread of the so-called energy-dense, nutrient-poor ‘Western’ diet, as well as reductions in physical activity. There may also be a third factor involved in low-income populations. Young children (foetal or infants) subject to undernutrition may undergo permanent metabolic changes which leave them at higher risk of excess weight in the face of relativity higher energy intake in later life (this is known as the ‘early origin’ hypothesis). This can be triggered by a relatively small increase in calories; it can occur due to relatively small increases in incomes, or even no increase at all as energy-dense foods become the cheapest sources of dietary energy. The hypothesis provides a plausible explanation for high levels of adult overweight in low-income communities and households in which there are also undernourished individuals. In my sample, one fifth of girls and almost a quarter of boys were stunted and/or thin, and almost 19% of households contained under- and over-nourished individuals. In other words there may be a direct link from undernutrition in early life to later obesity, and excess weight will continue to increase as long as undernutrition persists among young children due to the poor health and nutrition of pregnant women, early termination of exclusive breastfeeding, poor weaning practices, lack of clean drinking water and adequate sanitation, high loads of intestinal parasites and infectious disease, and so on.

    The repercussions for developing countries are huge. Excess weight leads to chronic disease. I’ve referred to overweight as well as obesity because the risk of chronic disease starts to rise at BMIs of 25 (the definition of overweight, not obesity), or even lower. The dual burden of chronic and infectious disease creates huge costs for health systems, and new policy responses must be found to deal with undernutrition and overnutrition simultaneously in the same communities, and sometimes the same households.

    Who should act, and in what way is up for debate: in some respects, many middle income countries have the financial resources and the technical expertise to tackle these problems – Brazil has pioneered a number of innovative programmes and policies. But I strongly believe that the development community can’t afford to ignore the approaching pandemic of excess weight; it is a symptom of a broken, pro-growth development model and a perverse food system which is about profit not health and well-being – a food system in which agriculture, food production, marketing and distribution are controlled by a few large corporations, in which governments subsidise the production of commodities for industrial use and export rather than the production of food for domestic markets, in which markets for industrialised food products are created by aggressive advertising, and those same products distributed via the massive spread of ‘the supermarket’. Despite being rural, the population in my sample is almost 100% dependent on purchased foodstuffs; domestic food production has been wiped out as the sugar mills take over every last bit of land to plant their crop. The situation is common to many areas in which land ownership is concentrated in the hands of a few corporations.

  11. This is something that I am extremely interested in and would love to do more research on. Can anyone recommend any articles on Poverty, Obesity and Development?

    They would be very gratefully received,

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