Worldwide Obesity: Changing the Trend

| August 10, 2014

by Wendy Scinta, MD, MS

Dr. Scinta is Medical Director, Medical Weight Loss of NY, BOUNCE Program for Childhood Obesity, Fayetteville, New York; Clinical Assistant Professor of Family Medicine, Upstate Medical University, Syracuse, New York. Dr. Scinta is also Chief Medical Officer of 3 Pound Health, LLC.

Bariatric Times. 2014;11(8):12–14.

There is no question that obesity has become a major global health threat. We have now reached a point where nearly 30 percent of the world’s population is overweight or obese..[1] If current trends continue, it is expected that the world obesity rate will top one billion by the year 2030, surpassing malnourishment as a global issue.[2]

In the 1970s and 1980s, obesity affected mostly higher income countries. Since then, most middle income and lower income countries have joined the ranks. In fact, no country has successfully managed the transition to rid hunger without it shifting to obesity very rapidly. How does this happen?

Consider the many factors that influence diet: the cost of food, individual preferences (taking into account culture and religion), information and advertising, social changes in work patterns and gender roles (such as women joining the work force), public policy, and globalization and its influences through trade and investment. Although each of these factors play a role, there is no denying that globalization and the adoption of the Western diet is the major contributor to the global obesity epidemic.

The Western diet (in general) consists of larger portion sizes, more calorically dense and nutritionally deficient foods, increased processed foods, increased fat (specifically trans fat), and increased sugar (specifically fructose). As a country moves to improve its economy, trade policies are changed, creating a more liberalized global market. Soon, roads are built and channels are created to move goods and services into and out of that country. As the gross domestic product (GDP) improves, so too does technology, increasing motorization, mechanization, and urbanization. Soon after, the food and beverage companies and fast food restaurants make their appearance, and the shift occurs from traditional, whole foods to processed, energy-dense foods leading to an obesity crisis so rapid that the country has little time to respond.

But that is not all. Shortly thereafter, a second shift occurs from acute, infectious diseases as the prevailing health problem to noncommunicable chronic diseases. The country that was fighting so hard for economic independence now finds itself throwing its newly earned money into healthcare in an attempt to tackle the economic burden of diabetes, heart disease, cancer, sleep apnea, and other obesity related chronic diseases. It is caught off-guard, and it is resource deficient.
Once this shift has occurred, it is very difficult to reverse. The food and beverage industry is a well-funded lobbying force. In addition, consumers love the sugar-laden, energy-dense, hyperpalatable foods. There is plenty of data existing now to support the addictive nature of these foods, and countries that try to limit choices are heavily scrutinized.

Worldwide Obesity
Every country is unique. Here, I discuss a few countries with specific issues, and why policies to date have been largely ineffective.

India. In the last 20 years, there has been a four- to five-fold increase in obesity in India. Currently, there are one-half billion malnourished people in India, yet noninfectious disease and type 2 diabetes mellitus (T2DM) are the primary causes of death.[3] The increased obesity rates are blamed on the globalization of food, and the import of American brands, such as Kraft and Kellogg’s. Whereas meals in India used to be home cooked, most food now is eaten outside the home, with an increased tendency toward processed, energy-dense “fast” or “junk” food. India is seeing an increase in diabetes at much lower weights, and at much younger ages than any other country in the world.[4]

China. China has had one of the fastest growing obesity rates on the planet. In 1990, there were few overweight people in China. In 2010, one-half of the population was overweight.[5] As with many countries, fast food restaurants have propelled the epidemic in China to epic proportions. Kentucky Fried Chicken and McDonald’s have placed restaurants at nearly every street corner, making snacking in- between meals (something they had not done previously) more accessible. Vegetable oil has increased from 20 calories/day per person in 1990 to 400 calories/day in 2010. Diabetes emerged quickly in the young, and is now higher in China than in the United States.[6]

Brazil. More than 50 percent of Brazilian adults are obese, costing the Brazilian healthcare system 2.1 billion United States dollars per year.[7] As with other countries, farmer’s markets with healthy, whole foods have been replaced by supermarkets that carry unhealthy processed foods—most exported from the United States. One major food company in particular has fought to have a presence. With immediate growth in mind, this company designed a boat with 100m2 of supermarket space that travels regularly to 18 small cities and 800,000 potential consumers on the Amazon River. Simultaneously, workers with small refrigerator carts journey from home to home with samples of 300 different goods including chocolate, yogurt, ice cream, and juices. This project has introduced these foods into the Brazilian diet.

Mexico. Mexico has the highest rate of obesity in the world, recently passing the United States. Currently, two-thirds of Mexicans are overweight or obese. Paramount to the obesity epidemic in Mexico is the intake of soft drinks. Mexicans consume more soft drinks per person than anywhere in the world, with the average Mexican consuming half of a liter of soda per day.[8] In some poorer communities, there is limited or no drinking water in schools, but Coca-Cola has a significant presence. It comes as no surprise then, that diabetes is the primary cause of death in Mexico.

Policy Failures
According to a recent article published in Lancet, no nation has successfully reduced its obesity rate in thirty-three years.[2] There are several reasons for this. As discussed earlier, the food industry is a powerful lobbying force, and the public tends to view food choices as a matter of personal freedom. Fearful of backlash from public for meddling with diets and alienating the farming and food industry, politicians tend to skirt the main issues, and public policies are timid, having limited or no impact. Examples can be found in all of the countries described above.

In September 1990, the Department of Health and Human Services released Healthy People 2000: National Health Promotion and Disease Prevention Objectives, a strategy for improving the health of Americans by the end of the century.[9] Healthy People 2000,[9] 2010,[10] and 2020[11] has seen a steady increase in adult and childhood obesity rates, despite the millions of dollars poured into these campaigns. More recently the Let’s Move! campaign, although altruistic, has done little more. (If only the predominant issue was movement and not food.) Although recent National Health and Nutrition Examination Survey (NHANES) numbers were touted as showing obesity rates dropping in preschoolers,[12] a good look at the data shows that childhood obesity rates are holding steady at about 17 percent, despite tremendous attempts at intervention.[13,14]

A shift in our thinking
We can continue to attempt to tackle these issue from a supply standpoint, but unless we can work with the food and beverage industry to develop a solution, we will not be successful. There are efforts underway to remove all sugar-sweetened beverages (SSB) worldwide through taxation and other restrictive public policies. Although this will help countries like Mexico that has a definitive SSB issue, it will only mildly affect China whose main issue is trans fats. Still, pressure can be applied to the food and beverage industry to offer healthier options, and certainly food labeling can be improved to include sugar content on labels.

What about the demand side? Have we given up on the idea that individuals are still teachable when it comes to these issues? What parent wants to give their children poison? How can we possibly look at the Western diet as anything else but that? In my practice in Central New York, I am amazed at the lack of concrete knowledge on basic nutritional concepts, but what do we expect? Messaging from food companies, politicians, and diet gurus have clouded the picture for even the most astute caregivers.

Across the world, there has been some success for small programs that have honed in on the idea that it is about behaviors, and by offering education and incentives, public policies have a far better chance of affecting change. In Mexico, the Opportunidades program offers conditional cash transfers to low-income families as long as children 18 and under attend school regularly, and mothers with infants attend health education classes and have regular check-ups.[15] In South Korea, programs focusing on the preservation of healthy elements of the traditional Korean diet, including large-scale training of Korean women in preparation and cooking of traditional meals, has been very successful. Using a combination of publicity, education, and social marketing, fruit and vegetable consumption in Korean adults and children is on the rise, and trans fat intake has decreased.[16,17] In the United States, the Supplemental Nutrition Assistance Program (SNAP) program was not successful in its attempt to restrict fizzy drinks; however, the current pilot program, HIP (Health Incentive Pilot), which offers incentives for purchasing fruits and vegetables, looks promising.

There are many people, governments, health professionals, and corporations with a vested interested in the obesity epidemic worldwide. I urge readers to not only focus on big policy to tackle this issue, but consider treating it from the ground up. With appropriate knowledge, one household can make the changes and encourage other friends and family members to do the same. Efforts can be made to work through the community to improve access to healthier foods in the schools, and safe access to exercise and play. Together, in our respective nations, we must decrease our demand for unhealthy processed foods, and increase our demand for healthier options. If we do introduce policy, it must be accompanied by education for the public and incentives that encourage us to make healthy choices. Only then will we succeed at tackling this massive global issue.

References
1.    Kelly T, Yang W, Chen CS, Reynolds K, He J. Global burden of obesity in 2005 and projections to 2030. Int J Obes (Lond). 2008;32(9):1431–1437.
2.    Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014 May 28. [Epub ahead of print]
3.    The International Diabetes Federation. IDF Diabetes Atlas, Fifth Edition. Brussels, Belgium: International Diabetes Federation, 2011.
4.    Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res. 2007;125(3):217–230.
5.    2009-2010 World Health Survey.
6.    Xu Y, Wang L, He J, et al Prevalence and control of diabetes in Chinese adults. JAMA. 2013;310(9):948–959.
7.    World Health Organization. World Health Statistics 2013. http://www.who.int/gho/publications/world_health_statistics/2013/en / Accessed July 29, 2014.
8.    Mallén PR. Mexico, with world’s top obesity rate, raises prices on soft drinks to fight it. International Business Times. September 23 2013.
9.    Centers for Disease Control and Prevention. National Center for Health Statistics. Healthy People 2000. Accessed July 29, 2014 .http://www.cdc.gov/nchs/healthy_people/hp2000.htm. Accessed July 29, 2014.
10.    Centers for Disease Control and Prevention. National Center for Health Statistics. Healthy People 2010. http://www.cdc.gov/nchs/healthy_people/hp2010.htm. Accessed July 29, 2014.
11.    Centers for Disease Control and Prevention. National Center for Health Statistics. Healthy People 2020. http://www.cdc.gov/nchs/healthy_people/hp2020.htm. Accessed July 29, 2014.
12.    Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–814.
13.    Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303(3):235–241.
14.    Ogden CL , Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999–2010. JAMA. 2012;307(5):483–490.
15.    Keats S, Wiggins S. Overseas Development Institute. Future diets: Implications for agricultlre and food prices. January 2014. http://www.odi.org/sites/odi.org.uk/files/odi-assets/publicationsopinion-files/8776.pdf. Accessed July 29, 2014.
16.    Kim S, Moon S, Popkin BM. The nutrition transition in South Korea. Am J Clin Nutr. 2000;71(1):44–53.
17.    Lee MJ, Popkin BM, Kim S. The unique aspects of the nutrition transition in South Korea: The retention of healthful elements in their traditional diet. Public Health Nutr. 2002;5(1A):197–203.
18.    Swinburn BA, Sacks G, Hall KD, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011;378(9793):804–814.

funding: No funding was provided.

disclosures: The auhtor reports no conflicts of interest relevant to the content of this article.

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