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Podcast February 11, 2020

Already Confronting Undernutrition, Many Developing Countries Face a New Threat: Obesity

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For decades, developing countries have faced the threats of undernutrition, stunting and starvation. While those problems haven’t gone away, incredible progress has been made. Now, a new threat looms: Obesity and excess weight.  

In the latest episode of The Development Podcast, we hear from researchers at the forefront of new analysis into this “double-burden” of undernutrition and obesity. 

First up, we get the view from Mexico City, where pediatrician Dr. Salvador Villalpando talks through the economic and cultural factors that are driving alarming obesity trends among his patients – especially young children.  

From there, we get the global picture with the World Bank’s Nutrition Lead, Dr. Meera Shekar, and the University of North Carolina’s Distinguished Professor of Nutrition, Dr. Barry Popkin.  They globe-spanning research paints an alarming picture – but we’ll go beyond the headline figures and look at some of the solutions that are being tried around the world.  What’s working? What’s not?

It all comes to you from the World Bank Headquarters in Washington, DC. Listen, rate, review, and subscribe!



Raka Banerjee: Hello and welcome to the Development Podcast from the World Bank Group. I'm Raka Banerjee.

Paul Blake: I'm Paul Blake and today's episode is all about the issue of obesity.

Raka Banerjee: It's a problem that some may think only affects rich countries. But as we'll find out during this program, it's actually an urgent problem in low and middle income countries as well. Countries that are fighting at the same time issues of malnutrition.

Paul Blake: It's a super interesting topic, one that has so many different angles; science, culture, lifestyle, cuisine. So stay with us. We've got some great interviews lined up for you this episode. But before those, Raka, take us through the data.

Raka Banerjee: So, I've been digging into the numbers on obesity for this episode. And just as a guess, what do you think the top eight countries with the highest rates of obesity all have in common?

Paul Blake: I don't think I could list them off, but I think I could say what they probably have in common. I'm guessing it's high income countries, where there's easy cheap access to unhealthy foods.

Raka Banerjee: So, that's pretty much right in general. There's definitely a correlation between obesity prevalence on the one hand and GDP per capita levels. But talking just specifically about the top eight, they're all island countries.

Paul Blake: Really?

Raka Banerjee: Yeah. So, It's the Pacific Island states. Nauru is the top of the list, then Palau, the Marshall Islands, Tuvalu.

Paul Blake: So is it an island country problem, or a rich country problem, or-

Raka Banerjee: Honestly, it's a problem for all of us. So as of 2016, 44% of the global population was overweight or obese. So, that's more than 2 billion people. And while obesity rates are higher in higher income countries overall, more than 70% of people who are struggling with obesity as of 2016 were actually living in lower middle income countries.

Paul Blake: I'm slightly – I’m still stuck on the idea that the countries, struggling with this problem the most are all island countries. Just kind of my head. But moving on before I get on a tangent, let's back up for a second. How is obesity actually defined in sort of economic, I guess research terms?

Raka Banerjee: Great question. If you care about data, we always have to get into definitions. So, it's the percentage of adults that are age 18 and over, whose Body Mass Index, BMI, is 30 or above.

Paul Blake: If I'm remembering correctly, that's looks, it's a fraction of your weight over your height. I think I remember something from when I was in school, getting that calculated in health class.

Raka Banerjee: Yeah, exactly. And you can also go online, there's lots of BMI calculators. It's a person's weight in kilograms divided by the square of their height in meters. A BMI of 25 or above is considered overweight, and then 30 or above is considered obese.

Paul Blake: Okay, I think I've got it. There's a little bit of math going on there. But looking at the research, how have obesity trends changed over time? Over the past few years, the past few decades, I would assume it's getting worse?

Raka Banerjee: It's getting a lot worse. So, actually, since 1975, it has almost tripled. So, right now it's one of the major causes of deaths. Globally, it's responsible for more than 4 million deaths every year. Yeah, so that's actually... Just to put it in context, that's actually four times more than road accidents and five times more than HIV/AIDS.

Paul Blake: I mean, that's incredible. I feel like when I think of car crashes and AIDS, I think of them as these huge killers, not obesity. Is that the case kind of generally around the world, or are we talking about specific countries?

Raka Banerjee: No, it's true globally. So actually, diseases related to obesity are among the top three killers in every region of the world with the exception of Sub-Saharan Africa.

Paul Blake: What about the lowest rates of obesity? What countries, what economies aren't struggling with this?

Raka Banerjee: Yeah, great question. So the country with the lowest rates of obesity prevalence for both men and women is Vietnam. Right, so the gender breakdown is different in countries, but in Vietnam, it's 1.6% for men and 2.6% for women. But after that, there's a pretty big difference between men and women. When you break down the data, what's interesting is that in lower income countries, especially in Sub-Saharan Africa, obesity rates are actually much higher among women than men.

Paul Blake: So women in lower income countries, especially as you say, in Sub-Saharan Africa. It's more of an issue for women than for men.

Raka Banerjee: That's right.

Paul Blake: I would assume then that as you go up the income scale, higher income countries have a similar gender dynamic?

Raka Banerjee: Really, that's where it starts to flip. So we see it particularly in Western Europe where men around five percentage points more likely to be obese than women.

Paul Blake: I feel like we could talk about this all day. There's all sorts of like endlessly complex cultural dynamics playing out behind this data. But before we go too, too deep into the data, I want to switch gears a little bit and focus on one country in particular, and that's Mexico.

So, with each episode of the Development Podcast, we like to get the on the ground view and today we're looking at Mexico.

Raka Banerjee: It's the second biggest economy in Latin America and it's home to around 130 million people. It's also a country that like many countries around the world, has struggled with fairly high rates of obesity. But one that has worked really hard to enact measures that combat it.

Paul Blake: Well, to learn more about Mexico's experience and what lessons we can learn, we're joined by Dr. Salvador Villalpando on the line from Mexico City.

Raka Banerjee: Dr. Villalpando, you're a gastroenterologist in Mexico. Can you tell us a little bit about the current situation there when it comes to obesity and being overweight? Just how widespread is the problem?

Salvador Villalpando: Well, thank you for asking the question and yes, there is a huge, huge problem that's not getting any better in the last 20 plus years. We've had some real data coming from our national survey. And yes, I'm a gastroenterologist, but I'm a pediatrician for it. So I get to see mainly children and obese children. The numbers are quite demonstrating for how large and progressive the problem is. Mexican kids around five and 11 years of age are already obese. Either overweight or obese in the range around 30%. So one out of three kids. And then when we go into teenage years, from 12 to 19, it gets all the way to 38%, okay.

Paul Blake: And is this across sort of all aspects of Mexican society or is there a demographic group? Is it kind of rich or poor, is it younger or old, male or female?

Salvador Villalpando: 72% of the total population are actually overweight or obese here.

Raka Banerjee: Basically three out of four people.

Salvador Villalpando: That is correct. Three out of four people, [inaudible 00:07:02] adults mostly are either overweight or obese. Which is a huge, I mean really, really appalling number. I do want to mention that there is some relieving data on the younger kids here in Mexico, kids under five years of age. These kids are doing a little bit better. I mean, it's the only age range that will have an improvement condition.

Raka Banerjee: And when you're working with your patients, what factors do you see driving these high rates in all the other age ranges?

Salvador Villalpando: You know it's very, very complex. We always think of obese, there's a nutrition problem, right? And it's not that simple. They have to do with a lot of other stuff and has to do with availability of high calorie sweetened beverages that are coming in to the different diets, as the earliest six months of age.

Paul Blake: [inaudible 00:07:54] Infants drinking high calorie drinks.

Salvador Villalpando: That is correct. Yes. It's like eight out of 10 kids under the age of 24 months are consuming three tons beverages in a daily base.

Paul Blake: Is that because in maybe some parts of Mexico access to clean drinking water is either expensive or hard to come by? Or is it because there's some other factor about taste preferences?

Salvador Villalpando: Our national public health Institute has made a lot of research on that area and there is a lot of availability of drinking water. I mean, it's not like other parts of developing countries. We do have a lot of very well sanitized water accessibility. But the cultural part of having sweetened beverages that are very available and are perceived as outstanding for a poor community to be able to afford.

Paul Blake: I think what you're saying, is it's sort of like, it's a status symbol to be able to give your child.

Salvador Villalpando: That is correct.

Raka Banerjee: So, there's some element of like prestige basically that I can-

Paul Blake: You're successful, if you can-

Raka Banerjee: Yeah, I can give my kids soda. I can give them juice and-

Salvador Villalpando: Yes.

Raka Banerjee: But it's affecting their overweight.

Paul Blake: I wanted to ask. You're in the clinic working with, with children and their mothers and their fathers. Do you have any stories of any kids who've come in, where you've had to tell the mom or the father you need to do something about this or your child's going to end up with type two diabetes or another, another illness?

Salvador Villalpando: Let me tell you a story about this kid that had been overweight all his life. He came into the clinic and after a six month period, he lost almost 12 pounds. I mean, it wasn't that huge amount of overweight he lost, but his mom came in like sobbing very emotional. Because she had never seen his son get rid of a pair of shoes that were like totally wasted because the kid was running, actually running outside of that.

Raka Banerjee: Dr. Villalpando thank you so much for being with us. I mean, this is really fascinating and thank you so much for the great work that you're doing for kids in Mexico and honestly all around the world.

Salvador Villalpando: Oh, thank you very much for having me. Have a good one.

Raka Banerjee: That was the view on the ground. But now let's get into the big global picture and dig into the research.

Paul Blake: That's right. Joining us here in the studio is Meera Shekar. She's the global lead for nutrition at the World Bank. And down the line from the University of North Carolina, we have Barry Popkin. He's a PhD in economics and a distinguished professor of nutrition.

Raka Banerjee: Both have been studying global obesity for years and have authored a new World Bank report on the matter. So Meera, the report says that since 1975, obesity has tripled around the world. Can you just let us know, just sort of explain what's going on and how big is the problem?

Meera Shekar: Obesity rates have tripled across the world. And today, believe it or not, at least 44% of the adults are either overweight or obese across the world.

Raka Banerjee: Wow.

Meera Shekar: That's almost half.

Raka Banerjee: 40% of the world population?

Meera Shekar: 44, [crosstalk 00:11:08] even more than 40%. Yeah. And the other sort of surprising thing is most of use to think that, obesity is a problem among the rich or rich countries and rich people. But in fact-

Raka Banerjee: Fast food and so on.

Meera Shekar: Exactly. But what we are seeing is that if you look at who is overweight or obese, 70% of the overweight or obese people, actually more than 70%, live in either low or middle income countries.

Paul Blake: Putting a name on it, what sort of regions of the world are we talking about here?

Meera Shekar: So we're talking, certainly the developed world, but also Latin America and the Caribbean. There's been a rapid increase there. But very surprisingly, also rapid increases in East Asia, rapid also increases happening in many countries in Africa, as well as in South Asia as well.

Paul Blake: And Barry coming down the line from University of North Carolina, what has changed? Why are we all kind of getting fatter in particular, what's causing this in low and middle income countries.

Barry Popkin: So what's happened is the way we move has changed very drastically as well as to what we eat and what we drink. In terms of how we move, we've added technology to all aspects of our life. From the way we work in factories and office buildings, to the way we move around and turn to transportation, to what we do at home, home cookers, refrigerators, pumped in water. So we've reduced activity. And all of these things have cut our activity in very healthy good ways, because we cut out the most backbreaking work. At the same time, what we drink has shifted from water, tea and coffee, to all sorts of caloric sugary beverages. And it's exploded both in terms of fast food and away from home eating, as well as just food you can buy anywhere. And so the poorest village in the world now has a little stand, if not a store that sells only unhealthy junk food and beverages.

Raka Banerjee: So partially it's... What I'm hearing you say is it's being much more sedentary. And then the other is what we're consuming.

Barry Popkin: Yes.

Meera Shekar: If I can add to that, actually I was in Nepal two months ago. And was shocked to see a new study done by Helen Keller International that showed that, if you look at kids ages one to two, these are really young kids. 25% of their calories are coming from junk foods.

Raka Banerjee: 25% per one to two. That's not even, [crosstalk 00:13:42] basically.

Meera Shekar: Exactly. Really shocking this thing. And you think junk foods is a problem in the developed world, but now it's all over the developing world as well. So as Barry was saying, this change in what we referred to as food systems has really impacted obesity.

Paul Blake: When I think of nutrition in low and middle income countries. I think of stunting, malnutrition, kids not going to school because they're hungry, that sort of thing. But what you're finding is actually obesity is also a big concern in these countries. Can you explain that sort of dichotomy?

Meera Shekar: Yes. There are many countries that are seeing both stunting and obesity. And the reason is that, well stunting rates is something that we in the developed, among the developing partners have been working with client countries for a very long time to address that. And we seeing some declines in stunting rates. But countries started at 60%, 40% stunting rates, and so while those stunting rates are going down, they're going down relative at relatively modest rates. And at the same time obesity rates are going up. So we refer to... They're many countries that have high stunting and high obesity as well. And we refer to them as the countries with a double burden of malnutrition, both under nutrition and overweight obesity. And there're so many countries that are suffering for both of those.

Barry Popkin: Let me just add to that, what Meera said. What's very shocking to the world is if you go to every Sub-Saharan African country, every one of them has at least 20% of adults overweight and obese. And the same in most of Asia. So that you're talking about countries that we think of where they have a lot of under nutrition, have the overweight already. And adding to what Meera said, you'll go to most Sub-Saharan African, South Asian countries, not just what she said in Nepal. But you'll have infants, a third of the days, at least third of the kids, infants getting junk food and beverages. It's just like the kids are being fed them instead of healthier breath milk instead of healthier weaning foods-

Paul Blake: But why is that? Why are parents feeding their kids this?

Barry Popkin: The food is on the present. It's very cheap and the marketing is pervasive. They make it seem like sexy, wonderful food that you ought to have for your child.

Paul Blake: Just shifting a little bit more to the big picture here. I think we all sort of know the effects on individuals of poor nutrition, increased risks for various diseases. But I think a lot of what your report looks at, is also what it means for economies and for countries development. Can you sort of explain that? What are the burdens that are placed on economies and on global development by populations that are overweight or obese?

Meera Shekar: So just from a big picture perspective, higher obesity means lower productivity, means higher noncommunicable diseases like cardiovascular diseases, cancers, so on and so forth. That means increased healthcare costs. It means a higher absenteeism from work. It means basically lower productivity and higher cost. And that multiplies into an impact on national economies as well. And there are lots of estimates that have been done in terms of the billions and trillions that are lost in terms of productivity. But the challenge is there isn't a number that I can give you, reason being that there are many ways of estimating these costs. These are estimates of how increase healthcare costs, mostly estimates around increased healthcare costs. What has not been done accurately is losses of productivity as yet. Once we add those, it will become much, much greater than that. In China, they've estimated somewhere between 3.5 to 8.7 of GNP lost to overweight obesity alone. So every country it's a little bit different, but I know Barry can add a lot more on that.

Barry Popkin: Right. So let me put on my PhD in economics hat, and talk about what this means for China, one country where I've produced some of those numbers that Meera mentioned. That what we're finding in the office places is significant reduced productivity. About 25% for workers in factories, in office places, once they're overweight and obesity. Part of that is they're just not as active at work. And then on top of that, there are the miss days and there are the reduced time in work, and earlier retirement. So there's lots of things that go into this. But the individual... Actually, when we look at factories in the U.S or in China, or we look at the office place, people that are overweight and obese actually are producing much less in both of those situations. And the average figure that's used is about 25% reduced productivity, which is quite shocking when you think of the number of people across the globe that are overweight and obese.

And so the economic costs up till now have... Other than the China study, where we looked at the productivity loss directly using studies of individuals, and we looked at the disability and other costs, they've all been based on healthcare costs. And that's like a fifth of the cost. The main costs are really the reduced productivity, disability and early retirement.

Paul Blake: I wanted to pick up here and ask you. We've sort of established now the problems here, it's big, it's multifaceted. What can we do to address it? What are some of the solutions you guys have been looking at?

Meera Shekar: So before we go there, I just wanted to say that the evidence base is not as strong as we would like it to be. But there are some promising areas where we want to be investing in. So some of the areas that are promising, one is around fiscal policies.

Paul Blake: So what do you mean by that, is that taxing? Taxing bad food?

Meera Shekar: Taxing unhealthy foods, sugar sweetened beverages-

Paul Blake: Some people call it sin tax.

Meera Shekar: Sin taxes, yes. That's one of those. But also to consider subsidies for healthier foods. Those are things that need to be invested in.

Paul Blake: Barry, I think you've done quite a bit of research on the effects of sin taxes on unhealthy foods in Mexico. Can you explain that a little bit? How effective have they been down there?

Barry Popkin: They saw a significant reduction in sugary beverages. But equally important, it impacted low-income Mexicans the most. But that's the group that has the most untreated diabetes and poorly treated diabetes, so, and the highest prevalent. So that essentially it's a progressive health tax, because that group is consuming less of the sugary beverages. Mexico also instituted a junk food tax, an 8% tax and that also reduced junk food consumption. And as an in the case of the sugary beverage tax, water purchases went up, not sugar or diet sweeteners, not juices, not other things. So it's a very healthy substitute for water. So that's what we're finding increasingly in all the countries with the taxes so far, we haven't fallen in the loop of people changing the soft drinks for beer or changing it for other things that would maybe not be very healthy.

So that to date the sugary beverage taxes that have been evaluated in Latin America, in the U.S and very soon, we'll see studies come out in the UK that show very strong effects. So they're working in all the countries that have had them evaluated so far. We don't have a single place where the taxes haven't impacted, consumption and reduced consumption of unhealthy beverages.

Paul Blake: But slow down one second. I mean, even in rich countries, some people are... I mean, even here just outside of Washington, there's what people call food deserts. [crosstalk 00:22:11] And there isn't access to organic nice fresh food, fruit, and veg. Isn't it sort of controversial to be penalizing the poor like this?

Meera Shekar: So I'm not sure where penalizing the poor. It's actually sounds regressive, but it is actually a progressive strategy, because ultimately it has a health benefit for the poor. So are there food deserts in various parts of the developed world? Absolutely. They are so. And that's part of the menu of options that we have in terms of addressing this issue. Taxes is just one of those.

Raka Banerjee: So another question I was thinking about is what's the role of knowledge, or the lack of knowledge in this case about the impact of this food, right. So what I'm thinking about is labeling. Some studies in the U.S have shown that calorie labels have actually not had the effect of reducing total calories ordered. What are you guys finding in terms of the evidence on that?

Meera Shekar: Well, I think Barry can speak to the evidence, particularly from Chile. Lots of countries are experimenting with that, and you're right. The U.S evidence seems to suggest that, there hasn't been that much of an impact. But it's really a question of what is provided, what information is on the label and how it's provided as well. And Chile has done an incredible job of labeling unhealthy foods with a big stop sign that anyone can see and it's.

Raka Banerjee: Surgeon General warning.

Meera Shekar: It's very similar to learning from the tobacco experience. Exactly that if this food is really high in sugar, would you really want to give it to your child? That sort of thing, but Barry, you might want to add to that.

Barry Popkin: Yeah. So Chile has had the warning label. If it's each for a warning label, if it's high in sugar. Another warning sign, if it's high in saturated fat. Another one, if it's high in sodium. As a result, you cover a lot of the highly processed, unhealthy junk foods and beverages. And for example, in the first year of these warning labels, and they get progressively more strict and increase the number of labels. They had a 25% reduction in purchases of sugary beverages. And when the warning label law began, Chile was the highest consumer in per capita terms of sugary beverages in the world. So a major decline, and as a result, the warning labels have been adopted by Israel. Mexico just passed the law to adopt them a month ago and the regulations are being reviewed right now and will go into effect in the spring.

And we have Peru, Uruguay. We have several other countries in Africa looking at them and already going through studies to prepare for them. And the whole set of Caribbean nations doing the same thing. So this is one approach that's effective. We're learning. This is, as Meera said, we're very early in this world of... It took tobacco 40 years to get to the point where they have tobacco taxes and warning labels in all the countries. And, in just five or seven years sent to Mexico, sugary beverage tax and all the studies on it. We have 44 countries already with sugary beverage taxes. So we... This is an area where countries are desperate to find things that work. And despite the food industry, many countries really know they must do something.

Raka Banerjee: Dr. Barry Popkin on the line from University of North Carolina and Meera Shekar in the studio. Thanks so much.

Meera Shekar: Thank you.

Barry Popkin: Bye bye.

Raka Banerjee: Well, that's it for this edition of the Development Podcast. We hope you enjoyed it and hopefully even learn something

Paul Blake: I certainly did well as researching this episode. I'm super keen to learn though, what people think. If you have any feedback for us, please drop us a line using the

Raka Banerjee: And if you're up for it, please tell a friend about us and leave us a rating on iTunes or wherever you get your podcasts. It helps us get discovered by new people and makes all of the effort we put into each episode worth it.

Paul Blake: Our guests today were Dr. Salvador Villalpando in Mexico city, Meera Shekar in Washington, DC, and Barry Popkin in Chapel Hill, North Carolina, until next time, goodbye.

Raka Banerjee: Bye.


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