The double burden of disease in developing countries - overweight vs. underweight, and communicable vs. NC diseases

In the United States, the obesity epidemic is claiming hundreds of thousands of lives each year and costs upwards of 9.4% of national health care expenditures (1). Despite efforts to contain the disease, obesity doesn’t seem to be any more under control today than it was in the nineties. In this day and age, as the world becomes more interconnected economically, environmentally, and culturally, unfortunately we also begin to share and transmit disease. In South Asia, for example, obesity had never been an issue of concern; with the rise of Westernization and subsequently, the introduction of a Western diet high in fats and refined sugars, nearly one-third of the population is now classified as obese (2). In Latin America, obesity is the leading risk factor associated with mortality due to non-communicable chronic diseases (3).

Obesity is of a serious concern because it gives rise to various other diseases such as diabetes, hypertension, stroke and heart disease. It is estimated that by 2020, about two-thirds of the world’s global burden of disease will be attributable to non-communicable diseases, and that most of those diseases will be attributable to diet (4). In developing nations, however, the rise of obesity stands in stark contrast with the prevalence of starvation and malnutrition—problems that are themselves yet unsolved. Here we observe an interesting paradox, a double burden of disease, if you will.

It is a myth that obesity only affects the affluent, or only developed nations. Alaimo et al have found that low family income and food insufficiency can lead to obesity. Households that don’t have money to buy enough food end up relying on cheaper foods which usually higher in calories—a practice which gets more calories per dollar, basically (5). But why, in countries undergoing a nutritional and lifestyle transition due to increasing globalization, do we often see families in which under- and overweight members coexist? This occurs more frequently in middle-income countries than poor countries, which have usually been insulated from obesity due to an extremely limited availability of food. While many children in middle-income countries start out malnourished, they are actually most at-risk for becoming overweight in adulthood (6).

The double burden comes about due to various factors. Progress to improve public health systems and to improve water and sanitation has moved slowly, and thus under-nutrition is still persistent (7). As the FAO (Food and Agriculture Organization of the United Nations) explains, changes in diet and lifestyle (occurring a bit later though still concurrently to malnutrition) due to urbanization (and thus a shift away from an agricultural society), the liberalization of markets, and demographic shifts have done well to add overweight and subsequent chronic non-communicable diseases to the mix. For the most part, malnutrition fails to be eradicated due to uneven prosperity distribution and inadequate consumer protection (8).

And so it comes to be that obesity and hunger coexist more closely than previously thought. On top of that, developing countries also have infectious (communicable) diseases to worry about: malaria, HIV/AIDS, tuberculosis, avian flu, cholera, typhoid, dengue…the list goes on and on. Add to that the obvious lack of funding and resources. Developing countries therefore face a double burden of disease in more ways than one: not only do they have obesity and malnutrition, but they also have a slew of communicable and non-communicable diseases to address. Going back to South Asia, infectious and parasitic diseases alone account for 20% of DALYs (2). Unfortunately, as most of the focus is on containing, preventing, and treating communicable diseases, non-communicable disease control is largely put on the backburner.

The issue is further compounded by the fact that most developing countries lack the public health infrastructure and resources to carry out prevention and education interventions within communities anyway. And even if they did have the means, they would still need the government and NGO’s to actively support, promote, and implement an environment that would facilitate better eating and healthier lifestyle changes—this includes proactive policy-making as well as strict regulation of the food industry and of trading in general. The WHO estimates that 36 million lives could be saved by 2015 by employing chronic disease prevention strategies (9), which is promising, but without a system to implement these strategies, it may end up that 36 million lives are not changed at all, let alone for the better.

While it may be possible to effectively implement an awareness campaign designed to teach individuals that health and lifestyle are related, and teach them what foods constitute a healthy diet, developing nations will probably need to take a unique approach towards tackling the food industry. Unlike the tobacco industry, whose products are deadly if consumed, the WHO Process for a Global Strategy on Diet, Physical Activity, and Health suggests that the food industry can be an important ally (10). The objective in such a partnership is to get food and advertising to improve their products and messages to be healthier and more informative, respectively.

Just as obesity and malnutrition are progressing together—malnutrition being a constant and obesity ever rapidly gaining ground—policies and programs targeted at minimizing the burden of either disease should address them simultaneously. As nutritional problems are typically treated only as diseases of deficiency, countries must realize that overconsumption occurs just as frequently among the poor and is just as debilitating. Through careful control of food quality and allocation, it might be possible to keep obesity at bay while delegating more food to the underweight. In addition, it would also be necessary to promote a less sedentary lifestyle, a change also made possible by industrialization and the introduction of technology. Developing nations would also need to put into place an effective surveillance system to evaluate how their programs are working. The International Obesity Task Force (IOTF) suggests that monitoring and evaluation be used in both intermediate- and long-term to identify sub-groups of the population with particularly high obesity prevalence, track program progress in accomplishing goals and objectives, and to look at food and activity patterns within populations (11). However, any of these suggested solutions requires extensive planning and regulation; should they undertake such a task, developing countries have more than enough work cut out for them in the face of these ever-rising health challenges.

References
1. Colditz, G. A. "Economic costs of obesity and inactivity." Medicine and Science in Sports and Exercise 31 (1999): S663-667.

2. Basnyat, Buddha, and Lalini C. Rajapaksa. "Cardiovascular and infectious diseases in South Asia: the double whammy." British Medical Journal 328 (2004): 781.


3. Kain, Juliana, Fernando Vito, and Cecilia Albala. "Obesity trends and determinant factors in Latin America." Cadernos de Saúde Pública 19 (2003): S77-86.

4. Chopra, Mickey, Sarah Galbraith, and Ian Darnton-Hill. "A global response to a global problem: the epidemic of overnutrition." Bulletin of the World Health Organization 80 (2002): 952-58.

5. Alaimo, Katherine, Christine M. Olson, and Edward A. Frongillo, Jr. "Low Family Income and Food Insufficiency in Relation to Overweight in US Children: Is There A Paradox?" Pediatrics and Adolescent Medicine 155 (2001): 1161-167.

6. Caballero, Benjamin. "A Nutrition Paradox - Underweight and Obesity in Developing Countries." The New England Journal of Medicine 352 (2005): 1514-517.

7. "Fighting hunger -- and obesity." Spotlight: The Double Burden of Malnutrition. Feb. 2006.
Food and Agriculture Organization of the United Nations. 31 Jan. 2009 .

8. Kosulwat, Vongsvat. "The nutrition and health transition in Thailand." Public Health Nutrition 5 (2002): 183-89.

9. Center for the Advancement of Health. Health Behavior News Service. "Looming Chronic Disease Creates Double Burden in Africa." Press release. 25 Apr. 2006. 31 Jan. 2009 .

10. World Health Organization. "Obesity and overweight." Fact sheet. Sept. 2006. 31 Jan. 2009 .

11. Obesity prevention: the case for action. Rep. Vol. 26. Public Health Approaches to the Prevention of Obesity (PHAPO) Working Group of the International Obesity Task Force (IOTF), 2002.