Chapter Four

The Obesity Crisis
51

Eileen Kennedy
Professor of Nutrition,
Former Dean of the Friedman School of Nutrition Science and Policy,
Tufts University, Boston, USA

“The rise of childhood obesity has placed the health of an entire
generation at risk.”
Tom Vilsack, United States Secretary of Agriculture52

Key messages•		The current increase in obesity in the
global population is unprecedented.
•		Worldwide, approximately 1.4 billion
adults are overweight, and 500 million
are obese.
•		As the most common cause of death,
infectious diseases have now been
overtaken by non-communicablediseases (NCDs).
•		In many low-income countries wealthy
and well-educated people are more likely
to be overweight than the poor.
•		In higher-income countries lower-income
populations tend to be more at risk ofobesity and its long-term consequences.
policy-makers in developing countries
need to pay greater attention to the obesity
crisis and its linkages to undernutrition.

The problem of obesity has assumed epidemic proportions in recent years
Source: Sight and Life

The world continues to experience malnutrition andundernutrition on an unprecedented scale. So huge andcomplex is this problem that it sometimes diverts attention
from another rapidly growing issue which has vast
ramifications and will have severe long-term consequences:
the rise of obesity.
According to the United Nations World HealthOrganization (WHO), 1.4 billion adults worldwide are
overweight, and of these, approximately 300 million
women and 200 million men are obese. Worldwide obesity
has doubled since 1980, in fact, and 65% of the world’s
population now lives in countries where overweight andobesity related diseases kill more people than undernutrition.
This is a dramatic reversal of the traditional paradigm
whereby poor diet is associated exclusively with
undernutrition. What makes it especially concerning is thefact that overweight and obesity can lead to healthproblems such as diabetes, hypertension, heart disease andcancer. The significant increase in the prevalence of these
non-communicable diseases (NCDs) in recent years isdirectly attributable to the rise in obesity in the world’s
population. The traditional focus of governments andNGOs on eliminating starvation and hunger, however, tends
to divert attention from this growing public health problem.
It is hard to imagine that a person can overeat their way tomalnutrition. But this is precisely what is happening.

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53

The nutrition transition
In poorer regions of the world and poorer sections ofsociety in general, the staple diet has traditionally been low
in fat, generally taking the form of cereals and pulses andbeing supplemented as and when possible by nutrient-richanimal protein. The past few decades have witnessed a‘nutrition transition’ to a more Western-influenced diet inmany parts of the globe, however. This diet offers morediversity, but contains considerably more saturated fats,
total fats, sugars, starches and animal proteins.
A striking example of this phenomenon is to be found in
Micronesia in the Pacific Ocean. According to the Bulletinof the World Health Organization (Volume 88, Number 7,
July 2010, 481–560), “Replacing traditional foods with
imported, processed food has contributed to the highprevalence of obesity and related health problems in the
Pacific Islands … Beyond the image of white sandy beaches
and carefree lifestyles, the Pacific Islands are facing serious
health problems, the prime culprit being imported foods. In
at least 10 Pacific Islands more than 50% (and in some, up
to 90%) of the population is overweight … Obesity
prevalence ranges from more than 30% in Fiji to a
staggering 80% among women in American Samoa, aterritory of the United States of America (USA). WHO
defines overweight as having a body mass index (BMI)
equal to or more than 25, and obesity as a BMI equal to or
more than 30. Diabetes prevalence among adults in the
Pacific region is among the highest in the world; 47% in
American Samoa compared with 13% in mainland USA,and it ranges from 14% to 44% elsewhere in the region.”

Stranger than paradise
Micronutrient deficiencies are common in the PacificIslands. In 15 of 16 countries surveyed, more than one fifthof children and pregnant women were anemic. In Fiji,
Papua New Guinea and Vanuatu, iodine deficiency andrelated goiter are endemic. Vitamin A deficiency is also asignificant public health risk in Kiribati, the MarshallIslands, the Federated States of Micronesia and Papua
New Guinea.
About 40% of the Pacific Island region’s population of
9.7 million has been diagnosed with a NCD, notably
cardiovascular disease, diabetes and hypertension. Thesediseases account for three quarters of all deaths across the
Pacific archipelago and 40–60% of total healthcare
expenditure, according to a meeting on obesity prevention
and control strategies in the Pacific held in Samoa in
September 2000.
Dr Temo K Waqanivalu, technical officer for nutrition andphysical activity at the Office of the WHO Representative
for the South Pacific in Suva, Fiji, partly blames poor dietfor the region’s health problems. “Promotion of traditional
foods has fallen by the wayside. They are unable tocompete with the glamour and flashiness of imported
foods,” he says.
People in the Pacific Islands may know what constitutes
healthy eating but, as in many parts of the world,
governments struggle to change people’s behavior. In eight
countries, less than 20% of people surveyed reported
eating the recommended five or more portions of fruit andvegetables a day. The often calorie-rich and nutrient-poor
imported foods have a stronger appeal.
Life expectancy data make clear the urgent need for action.
The average age at which people develop diabetes andcardiovascular disease is getting lower. In Fiji, only 16% of
the population is aged more than 55 years due to premature
deaths primarily caused by non-communicable diseases.

The double burden of malnutrition: parental obesity and child malnutrition
often exist side by side
Source: Sight and Life

Source: Bulletin of the World Health Organization (Volume 88, Number
7, July 2010, 481–560)

Chapter Four | The Obesity Crisis | Eileen Kennedy

The extremes witnessed among the populations of the
Pacific Islands are part of a trend that is leaving no cornerof the globe unaffected. Certain populations – inhabitantsof the Indian subcontinent, for instance, or the Pima Indiansin the United States – are especially susceptible to weightgain in the face of exposure to a Western diet rich in fats,sugars and starches. But the whole world is affected by thegeneral trend towards a more sedentary lifestyle. Whereas
before World War II, the majority of the world’s population
worked in agriculture, manufacturing or some other area
requiring physical effort, the proliferation of labor-saving
devices, automotive transportation and computerization has
vastly and rapidly reduced the need to expend physicaleffort during the course of a normal day. People are burning
off fewer calories during their day-to-day lives and at thesame time consuming more calories. This inevitably resultsin weight gain. The combination of a change in dietary
patterns plus a change in lifestyle has brought about thesimple formula for obesity: ‘energy in’ exceeds ‘energy out’.
According to the Morbidity and Mortality Report publishedin 2004 by the Centers for Disease Control and Prevention,in 1971, women in the US consumed an average of 1,542
calories per day compared with 1,877 in 2004. Men
consumed an average of 2,450 calories in 1971, but
consumed an average of 2,616 calories in 2004. So in a timeframe of just over 30 years, average calorie intake increased
by 22% for women, and 10% for men. It is not surprising
then, that obesity has become a major problem in the US.

Unless people compensate for increased calorie intake bymeans of increased energy expenditure, they will put on
unnecessary weight.
The United States and Western Europe were the first regionsof the world to go through the nutrition transition. In the
1920s and 1930s, during the Great Depression, theseregions contained many food-insecure people andhouseholds. By the 1950s and 1960s, greater affluence led
to richer diets, with an evening meal usually comprising
meat, potatoes and vegetables for even the poorer sectionsof society. This did not lead to obesity on a wide scale,
however, for the fast-food culture of today was still in its
infancy and lifestyles were still comparatively active for mostpeople. The situation has changed radically in recent years
in the US, however, with a knock-on effect that extends
beyond the shores of the United States and to the furthest
corners of the globe.
The poorest countries of the world are now going throughthe nutrition transition first charted by America, and they
too have seen an increase in the proportion of the
population that is overweight and obese. This increase has
been followed by a dramatic increase in non-communicablediseases, particularly type 2 diabetes. Recent statistics fromthe World Health Organization show that 44% of theworld diabetes burden, 23% of the ischemic heart disease
burden and between 7% and 41% of certain cancer
burdens are attributable to overweight and obesity.

Definitions of key terms

does not produce enough insulin.

Overweight for adults is a BMI between 25 and 29.99“Diabesity” is a term coined by Dr Francine Kaufman toindicate a combination of diabetes and obesity.

Obesity for adults is a BMI 30 to 39.99
Morbidly obese for adults is BMI 40 or greater
Note: BMI is weight (kg)/height squared (meters)
For children, overweight is 85th to 95th percentile on
child growth chart, and obesity is more than the 95%
Type 1 diabetes, also sometimes called juvenile-onset diabetes
or insulin-dependent diabetes is a chronic condition in which
the pancreas produces little or no insulin.
Type 2 diabetes, also sometimes called adult-onset or
non-insulin-dependent diabetes, is a chronic condition that
affects the way the body metabolizes sugars. With type 2
diabetes, the body either resists the effects of insulin or else

Non-communicable diseases (NCDs) – also known aschronic diseases – are not transmitted from person to person.
NCDs can progress slowly and persist in the body for
decades. The main types of NCDs include cardiovasculardisease, cancers, respiratory diseases and diabetes.
“Hidden hunger” is another name for micronutrient
malnutrition. This term is used since the specific deficiency is
typically not visible.
The “double burden of malnutrition” is defined as thecoexistence of undernutrition and overweight in the samecommunity or even the same household.

54

Chapter Four | The Obesity Crisis | Eileen Kennedy

55

Case study
The Pima Indians: A case study of therelationship between obesity and diabetes
The National Institute of Diabetes and Digestive andKidney Diseases (NIDDK)
Research conducted on the Pima Indians for the past 30
years has helped scientists prove that obesity is a majorrisk factor in the development of diabetes. One half ofadult Pima Indians have diabetes and 95% of those withdiabetes are overweight.
These studies, carried out with the help of the Pima
Indians, have shown that before gaining weight,
overweight people have a slower metabolic rate comparedto people of the same weight. This slower metabolic rate,
combined with a high-fat diet and a genetic tendency toretain fat may cause the epidemic overweight seen in thePima Indians, scientists believe.
Along with genetic make-up, diet is a key factor to healthy
lifestyle. The influence of traditional desert crops on themetabolism of the Pima Indians is being studied to determine
how to prevent the onset of diabetes and obesity.
Scientists use the “thrifty gene” theory proposed in 1962
by geneticist James Neel to help explain why many Pima
Indians are overweight. Neel’s theory is based on the factthat for thousands of years populations who relied on
farming, hunting and fishing for food, such as the Pima
Indians, experienced alternating periods of feast andfamine. Neel said that to adapt to these extreme changes
in caloric needs, these people developed a thrifty gene thatallowed them to store fat during times of plenty so thatthey would not starve during times of famine.
This gene was helpful as long as there were periods offamine. But once these populations adopted the typicalWestern lifestyle, with less physical activity, a high-fat diet,and access to a constant supply of calories, this gene began
to work against them, continuing to store calories in
preparation for famine. Scientists think that the thrifty genethat once protected people from starvation might also
contribute to their retaining unhealthy amounts of fat.
There are approximately 100,000 genes packed into 23
pairs of chromosomes in every cell of a person’s body.
Within a gene, chemicals form individual codes, likewords, which tell the cells of the body what to do. It is thecode within a gene that directs the body to grow skin, anddetermines whether the skin is brown, yellow, black orwhite; to form hair and bone; to circulate blood andhormones such as adrenalin and insulin; and to perform
every other biological process in the body.
Some diseases are caused by bacteria or viruses that infectthe body and make it sick. Others, such as diabetes, occur
because a gene’s code causes it to function differently
under some circumstances. For instance, if a person has agene that makes that person likely to get diabetes, eating a
lot of high-fat food over time may increase that person’s
chance of getting sick. On the other hand, eating lower fat
foods such as fruits and vegetables and exercising each
day may help to prevent the disease. A person can’t
choose his or her genes, but can choose what to eat andwhether or not to exercise.
Finding the gene or genes that may increase a person’s risk
for getting diabetes and obesity is the most effective way
scientists have to learn what’s wrong in a diabetic person.
With the help of the Pima Indians, National Institutes of
Health (NIH) scientists have already learned that diabetes
develops when a person’s body doesn’t use insulin
effectively. They know that other genes probably influencesome people’s bodies to burn energy at a slow rate, and/or
to want to eat more, making it more likely that they will
become overweight. Being overweight, in turn, puts aperson at even higher risk for diabetes. Because they havelearned this over 30 years of working with the Pima
Indians, NIH scientists now are able to test ways toprevent the disease with low-fat diets and regular exercise.
Source: http://diabetes.niddk.nih.gov/dm/pubs/pima/obesity/obesity.htm,
March 2013

Chapter Four | The Obesity Crisis | Eileen Kennedy

56

An inhabitant of Pohnpei in Micronesia, where diet-related obesity is a problem of epidemic proportions
Source: Sight and LifeThe critical first one thousand days

The time bomb of obesity

The Scaling Up Nutrition (SUN) Movement was launchedin September 2010. The SUN Movement stresses direct
nutrition interventions of known efficacy targeted topregnant women and children up to age two. The direct
nutrition interventions are complemented by nutritionsensitive policies and programs. SUN addresses
undernutrition; ironically, by improving nutritional status in
the first 1,000 days, health and nutrition in adulthood canbe enhanced. The developmental origins of health anddisease (DOHaD), also called the Barker Hypothesis,
uncovered a relationship between birth weight and chronic
disease. Infants born small have a higher risk of obesity,
hypertension, coronary heart disease and diabetes.
Environmental stresses, primarily in utero, alter structures oforgans and change regulatory gene expression, resulting in an
increased risk of chronic disease later in life. Thus, poormaternal diet has a double, negative effect of contributing to alower birth weight, an increased risk of developmental
disorders and higher risk of chronic disease later in life.
Effective nutrition interventions aimed at the 1,000 days have
immediate as well as long-term health consequences.

In the past few years, non-communicable diseases such asheart disease, diabetes and cancer have overtaken infectious
diseases as the major cause of death globally. However,health policy in developing countries still tends to focus on
combating undernutrition and infectious diseases only,
rather than tackling the obesity epidemic and its
consequences at the same time. There is a generalperception that if people are overweight, then they havemore than enough food and are not in need of help. The
time bomb of NCDs linked to obesity is all too frequently
overlooked. The Millennium Development Goals, forexample, do not include a goal related to NCDs.
According to WHO, 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 undernutrition, they are experiencing a rapid
upsurge in non-communicable disease risk factors such as
obesity and overweight, particularly in urban settings. It is
not uncommon to find undernutrition and obesity existingside by side within the same country, the same communityand even the same household.

Chapter Four | The Obesity Crisis | Eileen Kennedy

57

The double burden of malnutrition
Many developing countries now face the double burden of
malnutrition, defined as the coexistence of undernutritionand overweight in the same community or even in thesame household.
This study sought to estimate the prevalence of the double
burden of malnutrition and to identify associatedmaternal, child, and household characteristics in rural
Indonesia and Bangladesh.
A total of 247,126 rural households that participated in
the Indonesia Nutrition Surveillance System (2000–2003)
and 168,317 rural households in the Bangladesh
Nutritional Surveillance Project (2003–2006) were
included in the analysis. Maternal and child double
burden (MCDB) and its association with individual andhousehold characteristics were determined by using
logistic regression models.

MCDB was observed in 11% and 4% of the households
in rural Indonesia and Bangladesh, respectively. Maternal
short stature, and older age of mothers were strong
predictors of MCDB. Child characteristics such as older
age and being female were associated with an increased
risk of MCDB, whereas currently being breastfed wasprotective against MCDB. A large family size and higher
weekly per capita household expenditure was a strong
predictor of MCDB.
This study showed for the first time that even in
Bangladesh the double burden is not exclusive to urban
areas. Therefore, future policies and interventions should
address under- and overweight simultaneously in bothrural and urban developing country settings.
Source: Oddo VM, Rah JH, Semba RD, Sun K, Akhter N, Sari M, de Pee S,
Moench-Pfanner R, Bloem M, Kraemer K. Predictors of maternal and childdouble burden of malnutrition in rural Indonesia and Bangladesh. Am J
Clin Nutr. 2012; 95(4):951–8.

A healthy, balanced diet, accompanied by regular exercise, is the best way to avoid the risk of obesity
Source: Sight and Life

Chapter Four | The Obesity Crisis | Eileen Kennedy

Double Burden of Malnutrition: Time to Drop “Double”?
One of the things that is apparent from the recent Lancet
Nutrition Series is that it is becoming more and more difficult
to keep the under- and overnutrition agendas separate.

has not been much thinking in the past 10 years on how
to bring them together in the policy, program, training,communication and advocacy spaces.

It is really tempting to keep them separate.

Perhaps the time is only now right to do this.

First, dealing with undernutrition is difficult enoughwithout having to deal with overnutrition … And ofcourse, dealing with undernutrition is one great way tohelp prevent overnutrition later in life. In addition, dealing
with overnutrition means having to grapple with the foodindustry and a whole range of factors outside ofnutrition’s comfort zone: urban development, education,
trade, taxes and agriculture for example. Also, there aren’t
exactly a range of interventions and policies that havebeen shown to be effective to inspire us to ramp up action
on the overnutrition front. Finally, it is not easy to get
research funding to address the two in an integrated fashion.

A paper in the Lancet from December 2012 by Moodle etal. (“Profits and Pandemics”) draws the parallels between
the practices of the tobacco, alcohol and “ultra-processedfood and drink” industries. They conclude that “despite
the common reliance on industry self-regulation andpublic-private partnerships, there is no evidence of theireffectiveness or safety”. I think the evidence base uponwhich they draw is weak (not their fault), but theirconclusions are in accord with my own sense of thesituation and indeed I made the same parallels in a
Development Policy Review paper from 2003 where I go
through the various triggers for successful government
regulation of tobacco and see how they apply to obesity.

But I think the separation … is no longer sustainable.
First, overnutrition does not operate in a different space: it
is not just a later in life phenomenon – it is happening tounder fives; it is not just in urban areas and it is not just in
middle- and upper- income countries – it is everywhere.
Second, the undernutrition community can’t avoid
engaging with the private sector – not having to deal withthe private sector is no longer a reason for not getting
involved in overnutrition. Third, we now know that thefight against undernutrition has to go way beyond health,and into the wider development space. This is somethingeven more obvious in dealing with overnutriton.

I think policy-makers are about to get a wakeup call fromadvocacy groups, consumers, the health community, andeven some industry leaders, to do something.
The Double Burden is here to stay. Perhaps it is time todrop the Double (on the double).
Source: Lawrence Haddad, Institute of Development Studies (http://www.
developmenthorizons.com/2013/06/double-burden-of-malnutrition-time-to.html?
utm_source= feedburner&utm_medium=email&utm_ campaign=Feed %3A+
DevelopmentHorizons+%28Development+Horizons%29) 23 June 2013

All the reasons for separating the two are dissolving.
So, seemingly, something that is difficult (undernutrition
reduction) just got much harder (dealing with under- andovernutrition). But is that really so? Can an integrated
approach help us address both issues better? I think that
may be the case.
Making development more nutrition-sensitive and making
nutrition more politically aware surely brings the worldsof over- and undernutrition together, indeed, shows they
were never that far apart in the first place. They should nolonger be separated at birth.
In this context, a new review of Global Evidence on the
Double Burden of Malnutrition from the World Bank (byRoger Shrimpton and Claudia Rokx) is comprehensive
and well done, but depressing … It is depressing because itshows how divided the two camps are and how that is toeither’s advantage. Beyond the physiological linkages there

Snack bar in Micronesia with overweight manager
Source: Sight and Life58

Chapter Four | The Obesity Crisis | Eileen Kennedy

59Childhood obesity
Once considered a high-income country problem,
overweight and obesity are now on the rise in low- andmiddle-income countries, particularly in urban settings.
More than 30 million overweight children are living indeveloping countries and 10 million in developed countries.
Children in low- and middle-income countries are more
vulnerable to inadequate prenatal, infant and young childnutrition. At the same time, they are exposed to high-fat,high-sugar, high-salt, energy-dense, micronutrient-poor
foods, which tend to be lower in cost but also lower innutrient quantity and quality. These dietary patterns inconjunction with lower levels of physical activity, result in
sharp increases in childhood obesity while undernutrition
issues remain unsolved.
Childhood obesity is associated with a higher chance ofobesity, premature death and disability in adulthood. But
in addition to increased future risks, obese children
experience breathing difficulties, increased risk offractures, hypertension, early markers of cardiovasculardisease, insulin resistance and psychological effects.
Source: WHO Fact Sheet 311, March 2013

Protecting children from the negative impact of marketing on dietary behavior
The marketing of food and beverage products high in fat,sugar and salt to children is recognized in Europe as animportant element in the etiology of child obesity and in
the development of diet-related non-communicable diseases.
Overweight is one of the biggest public health challenges ofthe 21st century: all countries are affected to varying extents,
particularly in the lower socioeconomic groups.
The picture is not improving in most countries of the
WHO European Region. The figures for children from the
WHO Childhood Obesity Surveillance Initiative show
that, on average, one child in every three aged 6–9 years isoverweight or obese.
The WHO Regional Office for Europe has been working
in recent years with Member States to devise policy
options that could protect children better from thenegative impact of marketing on dietary behavior. This
process has been developed by working together in theimplementation of the set of recommendations endorsedat the Sixty-third World Health Assembly in 2010 on themarketing of food and non-alcoholic beverages tochildren, as well as within the context of the WHO
European Network on reducing food marketing pressure
on children.
The bases of policies to address unacceptable marketing
practices to children depend on appropriate intersectoral
action and dialogue, sound governance and accountability
mechanisms, as well as a focus on equity and a child’s
rights approach. These are all elements at the heart of the
new health policy framework for the WHO European

Region, Health 2020, which supports action acrossgovernment and society for health.
I strongly believe that the trends in childhood obesity canbe reversed. This report [Marketing of foods high in fat,salt and sugar to children: update 2012–2013],
although a small step in providing evidence on thetrends and policy processes in tackling one of thedeterminants of childhood obesity, illustrates theenormous progress that has been made in recent years.
At the same time, it highlights how collaboration
among Member States can trigger decisive action.
To be effective, the initiative to reduce the exposure ofchildren to the marketing of foods and non-alcoholic
beverages should be part of a broader package that needs
to include: scaling up and adopting the WHO Childhood
Obesity Surveillance Initiative; introducing appropriate
governance mechanisms with an intersectoral perspective
to streamline action and implement a best buys approachto tackling childhood obesity; and ensuring that childhood
obesity strategies and non-communicable disease policies
are connected and interact appropriately with strategies toreduce inequality.
Zsuzsanna Jakab
WHO Regional Director for Europe
Source: Marketing of foods high in fat, salt and sugar to children: update
2012–2013, http://www.euro.who.int/en/what-we-publish/ abstracts/
marketing-of-foods-high-in-fat,-salt-and-sugar-to-children-update-20122013

Chapter Four | The Obesity Crisis | Eileen Kennedy

		

Men

Women

Urban

49%

45%

Rural

25%

43%

60

BrazilIndia
Urban		 19.9%

Bangladesh
Urban

5.4%

5.4%

Rural

3.7%

3.6%

Russia

30.3%

50.3%

USA

61%*

Rates of overweight and obesity in selected networkcountries in men and women 30–59 years old
Source: Asia Pacific J Clin Nutr 2002;11:S738-S739

The world is getting wider
It is lunchtime at Eastside Elementary School in Clinton,
Mississippi, the fattest state in the fattest country in theWestern world. Uniformed lunch ladies stand at the ready.
Nine-year-olds line up dutifully, trays in hand. Yes tochocolate milk, yes to breaded chicken sandwiches, yes tobaked beans, yes to orange jelly, no to salad. Bowls of
iceberg lettuce and tomatoes sit rim to rim, rejected.
Regina Ducksworth, in charge of Clinton’s lunch menu,
sighs. “Broccoli is very popular,” she says, reassuringly.
Persuading children to eat vegetables is hardly a new
struggle, nor would it seem to rank high on the list of
global priorities. In an age of plenty, individuals have theluxury of eating what they like. Yet America, for all its
libertarian ethos, is now worrying about how its citizens
eat and how much exercise they take. It has become anissue of national concern.
Two thirds of American adults are overweight. This isdefined as having a body mass index (BMI, a common
measure of obesity) of 25 or more, which for a man
standing 175 cm (5 feet 9 inches) tall means a weight of
77 kg (170 pounds) or more. Alarmingly, 36% of adults
and 17% of children are not just overweight but obese,with a BMI of at least 30, meaning they weigh 92 kg or
more at the same height. If current trends continue, by
2030 nearly half of American adults could be obese.
Americans may be shocked by these numbers, but for the
rest of the world they fit a stereotype. Hamburgers, sodas

and sundaes are considered as American as the Stars andStripes. Food at state fairs is American cuisine at its mostexuberantly sickening. At the Mississippi fair, a deep-fried
Oreo biscuit’s crispy exterior gives way to soft dough,sweet cream and chocolate goo. It is irresistible.
The rest of the world should not scoff at Americans,because belts in many other places are stretched too, asshown by new data from Majid Ezzati of Imperial College,
London, and Gretchen Stevens of the World HealthOrganization (WHO). Some continental Europeans remain
relatively slender. Swiss women are the slimmest, and most
French women don’t get fat, as they like to brag (thoughnearly 15% do). But in Britain 25% of all women are obese,with men following close behind at 24%. Czech men takethe European biscuit: 30% are obese.
And it is not just the rich world that is too big for its own
good. The world’s two main hubs for blub are the PacificIslands and the Gulf region. Mexican adults are as fat astheir northern neighbors. In Brazil the tall and slender are
being superseded by the pudgy, with 53% of adults
overweight in 2008. Even in China, which has seen
devastating famine within living memory, one adult infour is overweight or obese, with higher rates amongcity-dwellers. In all, according to Dr Ezzati, in 2008 about
1.5 billion adults, or roughly one third of the world’s
adult population, were overweight or obese. Obesity rates
were nearly double those in 1980.

Chapter Four | The Obesity Crisis | Eileen Kennedy

61

Fat of the land
Not long ago the world’s main worry was that people had
too little to eat. Malnourishment remains a serious
concern in some regions: some 16% of the world’s
children, mainly in sub-Saharan Africa and South Asia,
were underweight in 2010. But 20 years earlier the figure
was 24%. In a study of 36 developing countries, based ondata from 1992 to 2000, Barry Popkin of the Universityof North Carolina found that most of them had more
overweight than underweight women.

availability of food have made the car the new dining
room. In the Middle East, Bedouin traditions of hosting
and feasting have combined with wealth to makeovereating a nightly habit. Any inclination to exercise is
discouraged by heat and cultural restrictions. In Beijing
teenagers and office workers cram the fast-food restaurants
along Wangfujing. Even home-cooked Chinese meals containmore meat and oil than they used to. Doting grandparents
shower edible treats on scarce grandchildren.

The clearest explanation of this extraordinary modern
phenomenon comes from a doctor who lived in the 5th
century BCE. “As a general rule,” Hippocrates wrote,“the constitutions and the habits of a people follow thenature of the land where they live.” Men and women of
all ages and many cultures did not choose gluttony andsloth over abstemiousness and hard work in the space ofjust a few decades. Rather, their surroundings changed
dramatically, and with them their behavior.

Together, these disparate changes have caused more andmore people to become fat. Many cultures used to view alarge girth with approval, as a sign of prosperity. But
obesity has costs. It lowers workers’ productivity and in
the longer term raises the risk of myriad ailments,
including diabetes, heart disease, strokes and somecancers; it also affects mental health. In America,
obesity-related illness accounted for one fifth of total
healthcare spending in 2005, according to one paper.

Much of the shift is due to economic growth. BMI rises inline with GDP up to $5,000 per person per year, then thecorrelation ends. Greater wealth means that bicycles areabandoned for motorbikes and cars, and work in thefields is swapped for sitting at a desk. In rich countries theshare of the population that gets insufficient exercise ismore than twice as high as in poor ones.

A new global health study, led by Christopher Murray of
the University of Washington, shows that since 1990
obesity has grown faster than any other cause of disease.
For women a high BMI is now the third-largest driver ofillness. At the same time childhood mortality has dropped
and the average age of the world’s population has risen
rapidly. In combination these trends may mark a shift inpublic-health priorities. Increasingly, early death is less ofa worry than decades spent alive and sick.

Very importantly, argues Boyd Swinburn of Deakin
University in Melbourne, diets change. Families can afford
to eat more food of all kinds, and particularly those highin fat and sugar. Mothers spend more time at work andless time cooking. Food companies push their products
harder. Richard Wrangham of Harvard University saysthat heavily processed food may have helped increaseobesity rates. Softer foods take less energy to break down
and finely milled grains can be digested more completely,
so the body absorbs more calories.
These global changes react with local factors to create
different problems in different regions. Counter-intuitively, insome countries malnutrition is leading to higher obesity
rates. Undernourished mothers produce babies who are
predisposed to gaining weight easily, which makes children
in fast-developing countries particularly prone to getting fat.
In Mexico unreliable tap water and savvy marketing havehelped make the country the world’s leading guzzler ofCoca-Cola: the average adult consumed 728 servings lastyear. In America junk-food calories are often cheaper thanhealthy ones. Suburban sprawl and the universal

It is plain that obesity has become a huge problem, thatthe factors influencing it are fiendishly hard to untangle
and that reversing it will involve difficult choices. Radical
moves such as banning junk food would infringe
individuals’ freedom to eat what they like. Instead, somegovernments are cautiously prodding their citizens to eat
less and exercise more, and food companies are offering atleast some healthier foods.
In a few places obesity rates seem to be leveling, but for
now waistlines in most countries continue to widen
unabated. Jiang He and his colleagues at Tulane
University have estimated that by 2030 the global numberof overweight and obese people may double to 3.3 billion.
That would have huge implications for individuals,
governments, employers, food companies and makersof pharmaceuticals.
Source: Charlotte Howard, Special Report: The world is getting wider,
www.theeconomist.com, December 2012

Chapter Four | The Obesity Crisis | Eileen Kennedy

Why lower-income households suffer the most
In many low-income countries, the populations affectedmost by the problem of obesity and NCDs are the wealthy
and well-educated people that have changed theirtraditional dietary patterns. One reason for this shift is theincreased capability that comes with rising incomes topurchase a more diverse diet, including more protein andfat, combined with changing tastes. In developed countries,
however another reason for the change in diet is that poor
households lack access to more nutritious foods, either
because they are not readily available (cf. the section onfood deserts in Chapter Three) or they cannot afford them.
The more inexpensive foods tend to be high in fats andsugars, so they may be energy-dense but are typicallynutrient-sparse.

62

It is not unusual to find households containing overweightpeople who are also anemic, or who have significant
deficiencies in zinc, vitamin A, and other micronutrients. It
can be difficult to acknowledge such dietary inadequacies,
as anemia is not immediately apparent to the eye. Calorierich but nutrient-poor fast food is one obvious culprit, butthere are other factors too. Snacking, for instance, isanother major problem and it has become, in developed
countries, the ‘fourth full meal’ of the day – a meal that is
surplus to requirements.

The long road to behavior change
In the United States and Europe, much attention was given
to the topic of nutrition at the end of World War II. Thiswas partly on account of the lessons learned about therelationship between nutrition and health in the extreme
conditions of wartime, and partly on account of a general
concern about how to feed a rapidly growing global
population during a time of general peace. In the UnitedStates, as elsewhere in the West, the people who had
experienced the war wanted a better life – less work, more
food, more leisure, more consumer goods. The creation andsatisfaction of consumer desire became a key driver of theeconomy in the boom years of post-war peace and plenty.
While cheap food was made readily available, however, thelong-term consequences of the new fast-food culture were
not understood. We now have a situation whereby theUnited States feeds itself too well – and at the same time notwell enough. In the United States, around two thirds ofadults are either overweight or obese. Non-Hispanic,
African-Americans and Mexican-Americans in the US tend
to have higher rates of obesity linked to low incomes. And

the rest of the world is following the American model, withalarming consequences: the UN reports a worldwide figureof $190 billion (US) worth of workdays lost and healthcare
costs as a direct result of obesity and its related noncommunicable diseases.
Treating people who are already obese is not easy, however.
Studies show that only 5–8% of people who go on weight
reduction diets keep the weight off long-term (defined as
5–10 years or more). There is a long-running study called the‘Weight Maintainers Study’ in the United States which sets
participants the goal of losing 50lb and keeping this weight off
for five years or more. The weight maintainers have succeededin keeping the weight off by following a combination ofclosely monitoring their food intake, routinely eating breakfast
and having, on average, one hour of exercise per day. This
specific set of behaviors is proven to work. Nevertheless, formany people, adoption of these behaviors is difficult due tomoney and time limitations. Thus gaining weight is easy but
alas losing it is a very different matter.

Further reading
World Health Organization. Obesity: Preventing andmanaging the global epidemic. Report of a WHO
consultation. WHO Tech Rep Ser 2000;894:1-252.
Geneva: WHO, 2000.
Birch LL, Parker L, Burns A (eds). Early Childhood
Obesity Prevention Policies. Washington, DC:
Institute of Medicine, 2011.

Chapter Four | The Obesity Crisis | Eileen Kennedy

63WHO’s recommendations
Overweight and obesity, as well as their related noncommunicable diseases, are largely preventable.
Supportive environments and communities arefundamental in shaping people’s choices, making healthierfoods and regular physical activity the easiest choice(accessible, available and affordable), and therefore
preventing obesity.
At the individual level, people can: limit energy intake
from total fats and sugars; increase consumption of fruitand vegetables, as well as legumes, whole grains and nuts;
engage in regular physical activity (60 minutes a day forchildren and 150 minutes per week for adults).
Individual responsibility can only have its full effect where

people have access to a healthy lifestyle. Therefore, at thesocietal level it is important to: support individuals in
following the recommendations above, through sustained
political commitment and the collaboration of many
public and private stakeholders; make regular physicalactivity and healthier dietary choices available, affordable
and easily accessible to all - especially the poorest individuals.
The food industry can play a significant role in promoting
healthy diets by: reducing the fat, sugar and salt content ofprocessed foods; ensuring that healthy and nutritious
choices are available and affordable to all consumers;
practicing responsible marketing especially those aimed atchildren and teenagers; ensuring the availability of healthy
food choices and supporting regular physical activity
practice in the workplace.

The WHO Global Strategy on Diet,
Physical Activity and HealthMy personal view

Adopted by the World Health Assembly in 2004, the
WHO Global Strategy on Diet, Physical Activity and
Health describes the actions needed to support healthy
diets and regular physical activity. The Strategy calls
upon all stakeholders to take action at global, regional
and local levels to improve diets and physical activity
patterns at the population level.

Professor of Nutrition, Former Dean of the Friedman
School of Nutrition Science and Policy, Tufts University,
Boston, USA

WHO has developed the 2008–2013 Action Plan for the
Global Strategy for the Prevention and Control of
Noncommunicable Diseases to help the millions who are
already affected cope with these lifelong illnesses andprevent secondary complications. This action plan aims
to build on the WHO Framework Convention on
Tobacco Control and the WHO Global Strategy on Diet,
Physical Activity and Health. The action plan provides aroadmap to establish and strengthen initiatives for thesurveillance, prevention and management of NCDs.
The Political Declaration of the High Level Meeting of
the United Nations General Assembly on the Prevention
and Control of Non-communicable Diseases of
September 2011 recognizes the critical importance of
reducing the level of exposure of individuals andpopulations to unhealthy diet and physical inactivity.
Source: WHO Fact Sheet 311, March 2013

Eileen Kennedy

Globally we are facing an obesity
epidemic of alarming proportions.
Diet-related chronic diseases now
account for more deaths thanundernutrition. This is seen in someof the poorest countries of the world.
In the past few decades traditional
grain-based diets have been replacedby diets higher in total fats, saturated fats and sugars.
The changing consumption patterns are occurring
simultaneously with lifestyles that include less physicalactivity. Yet, despite the magnitude of the problem, themessage has not reached policy-makers in many
low-income countries. The challenge is daunting. Theinternational community must aggressively implement
multi-pronged strategies to combat overweight andobesity, while at the same time tackling undernutrition.