Obesity and the chronic diseases often connected with being overweight, such as diabetes, used to be thought of as problems for high-income countries. In fact, they’ve become global issues, with 2.1 billion people – nearly 30 percent of the world’s population – considered either obese or overweight. And according to the International Diabetes Federation, four out of every five people with diabetes now live in developing countries.
The familiar images of malnutrition in the developing world – emaciated children in Africa or food shortages in India – tell only half the story. Another form of malnutrition is overnutrition, when someone’s diet contains an excess or imbalance of energy, protein and micronutrients, and that can lead to obesity.
Both undernutrition and overnutrition can be devastating to a nation’s overall health and productivity. And many developing countries now suffer from both problems at the same time. The dramatic rise in childhood overweight and obesity is happening 30 percent faster in the developing countries than in richer nations.
Experts call this the “dual burden of malnutrition.” And the need to address both issues simultaneously, with little political support and almost no money, poses unique challenges to public health officials in the developing world.
The impact of obesity on health is well documented: Being overweight makes people susceptible to an array of noncommunicable or chronic illnesses, including cardiovascular disease, type 2 diabetes and even some cancers. The total number of people with diabetes has increased nearly fourfold, from 108 million worldwide in 1980 to 422 million adults in 2014. In 2010, studies estimated that overweight and obesity caused 3.4 million deaths.
Overnutrition is leading middle- and low-income countries to join more affluent nations in what medical professionals are calling a “pandemic of obesity.” In Qatar and Kuwait, 20 percent of the population has diabetes, while in Bangladesh it’s 10 percent.
But many people in developing countries can’t access or afford treatment for chronic diseases, and the costs to a nation’s physical and economic health are potentially disastrous. “Obesity damages productivity,” says Katharine Kreis, director of strategic initiatives at PATH (Program for Appropriate Technology in Health). “Obese people move slower and are sick from work more often because of complications of diabetes and other noncommunicable diseases.”
Tackling the rise in overweight and obesity in developing countries means understanding that overnutrition isn’t necessarily about eating too much food, but about eating the wrong kinds of food. Increasing economic development and urbanization have led to changes in lifestyles around the world, including more sedentary work and a reliance on processed foods or meals cooked outside the home. Food systems have brought about an increase in the consumption of packaged and processed foods, many of which are calorie dense and nutrition deficient, as well as being high in fat, salt and sugar.
“Overnutrition is not about income,” says Agnes Guyon, director of the JSI Research & Training Institute’s Maternal, Neonatal and Child Health Center. “In the 1960s, we encouraged monoculture (cultivating a single crop) in agriculture, to focus on cash crops. So now these countries import processed foods that trigger insulin responses.”
The problem promises only to get worse. Globally, in 2014, 41 million children under the age of 5 were overweight or obese. According to WHO, the number of overweight or obese adolescents is also increasing everywhere. The impact on adolescent girls, as well as older women of reproductive age, can include a greater risk of gestational diabetes and later development of type II diabetes, preeclampsia, pregnancy-induced hypertension and larger babies, which in turn increases the chance of induced labor, cesarean sections, stillbirths and preterm births.
At the same time, undernutrition continues to affect the lives of hundreds of millions of children. In 2014, 159 million under-5s were affected by stunting (low height-for-age ratio), which results from chronic undernutrition, and 50 million children were affected by wasting (low weight-for-height ratio) from acute undernutrition.
Obesity and undernutrition aren’t simply two issues that developing countries have to address in parallel – they are linked in a way that has massive ramifications for the futures of those countries. Perhaps counterintuitively, children who start out life suffering from undernutrition often end up suffering from overnutrition and its effects.
According to WHO, “Reflected in the epidemiology and supported by evidence, undernutrition early in life – and even in utero – may predispose to overweight and noncommunicable diseases such as diabetes and heart disease later in life.” One possible reason for this, according to experts, is that undernutrition actually changes a person’s physiology in ways that increase the likelihood of becoming overweight or obese later.
“It’s the elephant in the room,” says Guyon, referring to overnutrition and its consequences in people in the developing world. “There is attention, but no funding.”
PATH’s Kreis says that addressing the two-pronged problem requires political will and action. “There is no foreign funding for noncommunicable diseases in low-income settings,” she says. “Industry is interested in diagnostics and treatment, but prevention through lifestyle choices does not receive interest or funding.”
At the same time, she notes, the international community faces “an unfinished agenda of undernutrition.” In low- and middle-income countries, poor nutrition is the cause of almost half of deaths in children under 5 every year.
There also needs to be a global shift in how and what we eat, Kreis adds. She points to developments in improving access to fruits and vegetables and animal-source proteins while leaving a small environmental footprint. That includes promoting the consumption of chicken and eggs, and even rodents and insects where it’s culturally acceptable.
“Innovation in nutrition is needed,” she says. “We need more creativity in how food systems can provide higher-quality products.” For example, she noted that PATH has developed a heat-stable dispersible tablet against Newcastle disease in chickens, one of the most infectious poultry diseases out there.
Kreis would also like to see governments play a bigger role in educating the public about the dangers of malnutrition and overnutrition. “Some regulation against advertising might be part of that, modeled on the taxes on cigarettes,” she says. After a decade of debate on the potential effectiveness of a tax on soda, Mexico in 2013 implemented a national tax that has led to a decline in consumption, particularly among the poorest of the population. It’s too soon to see the impact on obesity rates and public-health outcomes, but many observers are optimistic.
At its core, any solution to the issues of malnutrition in both of its debilitating forms will require massive and consistent funding. “We need more money because this is in reality a long-term issue,” says Kreis. “As an international community, we should help people to live healthier lives.”