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Obesity in the developing world

Hannily Harvey and Janneke Patterson explain why the starving stereotype is not always accurate

Imagine a hot day in rural India. A slow moving queue forms at the local hospital as people wait for their outpatient appointments. You might assume the people queuing are gaunt, hollow eyed women and stick thin infants.

This is not the case. Although a large proportion of people in the developing world are still critically underweight, many will have a body mass index over 25.¹ The World Health Organization estimates that there are around 300 million clinically obese people worldwide and that the incidence in developing countries has trebled to 115 million in the past few decades.² However, the general notion in the West is that people living in developing countries are malnourished and underweight, a misconception perpetuated by high profile media images focused on famine and catastrophic diseases such as HIV/AIDS.

Non-communicable diseases such as obesity were estimated to have contributed to 43% of the global burden of disease in 1999, a figure set to increase to 60% by the year 2020. Within 30 years communicable disease is expected to decrease by around 25%, whereas the incidence of non-communicable disease is set to increase by 22%.³ Crucially, existing healthcare services cannot accommodate this rise as they have focused largely on the threat of infectious disease and malnutrition, and little or no provision is made for follow-up of chronic disease. This raises justifiable alarm as the clinically obese population rapidly increases.

A salient point when considering the importance of obesity compared with communicable diseases is that while tuberculosis (a potentially fatal infective disease) can be effectively cured within six months, diabetes mellitus requires lifelong treatment, a difference that has important economic implications.

Big city boom

It is a well documented fact that obesity is rising in urban populations throughout the developing world. In China and Indonesia adult obesity is twice as prevalent in urban areas as it is in rural areas; in Congo it is almost six times as prevalent.⁴ To understand the reasons behind this phenomenon, one must consider the differences between developed and developing worlds. Firstly, the factors associated with obesity in the West, such as cheap fast food chains, fatty school dinners, passive leisure pursuits, and the decline of the family unit, do not exist to such a degree in the developing world. Although obesity has previously been associated with a high income and an indulgent lifestyle, lower socioeconomic groups in Western countries also have a rapidly increasing incidence, a reflection seen in the developing world.⁵

The migration of rural populations to urban areas is correlated with the increase in these so called “diseases of affluence.”⁶ So what is it about urban culture that promotes such an unhealthy lifestyle?

A spreading problem

The spread of obesity to rural communities can result in extremes of proportion across the developing world, where equally poor people in different areas may be severely malnourished or obese. This disparity cannot be explained by an influx of Western culture but may correlate with the associated economic growth (see box for summary).

In recent years, the choice of crops in rural communities has changed from a small variety of different produce enabling self sufficiency to a single mass produced high yield product to maximise profit. This leads to a restricted diet comprising high calorie, starch based produce with large amounts of milk and animal products, along with fats and oils.⁵ This type of diet, combined with minimal physical activity, results in increased calorie intake with decreased calorie expenditure and, thus, obesity.

Individuals are likely to be deficient in vitamins and minerals because of the restricted diet, an occurrence often masked by obesity. An added concern is the lack of fresh fruit and vegetables in the daily diet despite a local abundance. However, this is more understandable when the cost of such produce is considered in relation to the average wage. In India, for example, on a reasonable monthly salary of 1500 rupees (£20; €24; $30), the cost of eating one apple a day (7 rupees) would be a massive 14% of monthly income. Contributing to this financial problem is the skewed health belief held by many villagers that taking vitamins in tablet form is better than consumption of the natural sources.

Cultural factors

Problems associated with obesity are well known in the West, and awareness of the importance of a healthy diet and an active lifestyle is high (even if this advice is not acted on). However, in developing countries, health education regarding basic food groups is not widely available.

The consequences of incorrect health beliefs can be harmful, particularly regarding the disabling health risks associated with obesity. An anecdotal example of this is the group of elderly men in rural India claiming to have diabetes. Despite confidently informing the doctor of their diagnosis, there was little evidence of where this originated from. It was eventually discovered that the men had been observing their early morning urine stream for a period of time. After careful observation they noticed a colony of ants persistently making its way to the site. They concluded that the ants were attracted to the sweetness in the urine. To them, a sure fire sign of diabetes. Incorrect health beliefs can be particularly harmful in developing countries because many drugs can be purchased without prescription, and such beliefs could lead to dangerous and unnecessary self medication without proper education.

Chronic disease management is still not widely available in developing countries. Patient centred medicine does not feature within many curriculums, yet the development of these relations is crucial for patient agreement. This is exemplified by the management of diabetes mellitus, where insufficient emphasis on the incurable, progressive nature of the disease leads to poor patient compliance and thus poor disease control, manifested by serious complications which threaten mortality. Diabetic patients are two to four times more likely to develop heart disease and strokes, and three times more likely to die from influenza or pneumonia. Other complications include damage to vessels and nerves resulting in limb loss and blindness.⁹

The confusing provision of health care in many developing countries is a complex issue and contributing factor to poor disease management. Different regions may be supplied by a variety of government, non-governmental, alternative, and private doctors (not all of which are fully licensed). This often results in a lack of continuity in health care as patients may register at many localities and visit any indiscriminately. This problem is compounded by the fact that there is often no effective means of contacting patients informing them of test results or appointment times.

Cost of more obesity

The consequences of obesity are serious. About 80% of obese adults have at least one, and 40% have two, or more associated diseases such as diabetes, hypertension, cardiovascular disease, gallbladder disease, and cancers.¹⁰

The increase in obesity related complications will be most noticeable in developing countries, where the number of people with diabetes is expected to increase from 84 million to 228 million.¹ Although the United States is widely considered the land of the obese, it is India that has the largest number of diabetic patients, estimated to reach 75 million by 2026.¹¹ Hypertension is also set to increase from 1 billion to 1.56 billion people worldwide by 2025,¹² evidence indicating that once again, the brunt of the problem will be borne by the developing world.¹³ Increased susceptibility to weight gain within these population groups compared with their Western counterparts will also result in exaggerated and earlier effects of obesity.

Inevitably, a reallocation in government healthcare spending will be required if any progress is to be made in halting the progression of this phenomenon. Unfortunately, in countries where economic and social resources are minimal, diverting monetary focus could lead to abandonment of the ongoing campaign against infectious disease.

Is it just the responsibility of local governments to tackle this concern or should the international community share the burden? At present, “rich countries and donor agencies do not donate resources on the grounds, they argue, that poorer nations do not identify chronic disease as a priority. At the same time, developing nations do not ask for funding because they think they have a better chance of securing money for research and treatment of infectious diseases.”¹⁴ This is an undesirable scenario. When finite funds are available, it is imperative that allocations are prioritised appropriately. Failure to do so may cost the international community the chance to improve standards of health in the developing world.

As well as the impact on health, an important consideration is the number of work days lost to obesity related illness. In China, the economic cost of diet related chronic diseases has already surpassed that of undernutrition—a loss of more than 2% of gross domestic product.¹⁵ A nation’s developmental gains could even be undone by a large reduction in the people’s capacity to work.

What can be done?

The “stepwise surveillance” approach recommended by WHO is a realistic framework which encourages the collection of small amounts of useful information to monitor within country trends and enable comparisons across countries.¹⁶ Using this approach and with support from the World Bank, India has developed an integrated national programme for the prevention and control of diabetes mellitus and cardiovascular disease.¹⁷ However, it is estimated that India will be spending only 2-3% of its gross national product on health care by the year 2010,¹⁸ which is still below the WHO recommendation of 5%.¹⁹

Finding a solution to the problem will require concerted efforts from international policy makers regarding the license of food marketing and perhaps a restriction on imported calorie dense products. This may lead to government enforced restrictions on advertising, food labelling, and the establishment of Western chains.⁸

Education has a major role in the fight against the spreading endemic of obesity. WHO estimates that 80% of cases of coronary heart disease, 90% of cases of type 2 diabetes, and one third of cancers can be prevented by maintaining a healthy diet, increasing exercise, and stopping smoking.²⁰ Revising undergraduate medical curriculums to emphasise the importance of protocol based treatment will encourage an improved standard of care overall, as targets will have to be met. Increased public awareness can be achieved with the help of local non-governmental organisations, with the most effective strategy perhaps public teaching and advertising campaigns within all healthcare systems. Additional recommendations include, “making cities pedestrian-friendly, reducing salt and switching to unsaturated fats in food manufacturing, and banning advertising to children of sugared food and drinks.”²¹

Conclusion

Such changes will be difficult to implement and will necessitate government led initiatives to reprioritise their healthcare funding, as well as the commitment of healthcare professionals to support and empower a healthy lifestyle within the community. It is essential, however, that action is taken sooner rather than later, as the scale of the problem will soon increase to uncontrollable proportions, rendering such solutions even more difficult to implement.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Hannily Harvey final year medical student
hannilyh@gmail.com
Janneke Patterson final year medical student Peninsula Medical School
Student BMJ 2009;17:001-036-ISSN 0966-6494 | January 2009

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