The growing epidemic of obesity and related Non-Communicable Diseases (NCDs) of diabetes and cardiac arrests have become a daily fare in OECD country media (e.g. here). Obesity and undernutrition now co-exist in a large number of countries (Figure 1). Indeed under business as usual obesity will outstrip undernourishment in numbers: 795 million are estimated to be hungry by FAO in 2014  , but more than 1.9 billion adults, 18 years and older were overweight according to WHO in 2014. Of those, 600 million were obese (11 percent of men and 15 percent of women are obese) and the numbers are growing . But these transitions in development have not received the attention they deserve in the UN agenda for eradicating extreme poverty and achieving sustainable shared prosperity.
Increased per capita incomes are more strongly correlated with the prevalence of obesity than they are with under-nutrition, (Figure 1). Development experts have traditionally focused on undernutrition. Sustainable Development Goals (SDGs), which cover both developed and developing countries, have tried to correct this imbalance. SDG 2 “End hunger, achieve food security and improved nutrition and promote sustainable agriculture”, unlike Millennium Development Goal (MDG) 1, separates poverty and hunger and takes a more holistic view of food and nutrition security. Nutrition and Non-Communicable Diseases also receive more attention in the SDGs than they did in the MDGs. Although obesity is not mentioned in the SDGs, one of the 169 proposed targets is to reduce premature deaths from NCDs by one third; another is to end malnutrition in all its forms.
Why should obesity and undernutrition receive equal attention? Developed countries offer numerous lessons for rapidly transforming countries on how to and how not to manage the nutrition transition. The percentage of obese children aged 6–11 years in the United States increased from 7 percent in 1980 to nearly 18 percent in 2012. The percentage of obese adolescents aged 12–19 years increased from 5 percent to nearly 21 percent over the same period . Europe, South America and Middle East are close behind. Outliers in a good sense are Japan, South Korea and Singapore. They have adhered to their traditional diets. Small Island States are outliers too, but in a bad sense. They have some of the highest rates of obesity with increased reliance on low income western style diets. However, recent papers stress the increasing incidence of western style foods and beverages in Egypt and even South Korea among young adolescents . For OECD Countries there is a significant negative relationship between average adult BMI, obesity prevalence and relative “Big Mac” price . For non-OECD countries, there is a significant positive relationship between the prevalence of overweight only (25 ≤ BMI ≤ 30) and relative Big Mac price. Could it be because non-OECD countries have not yet completed their nutrition transition?
The health epidemic is leading to greater health-consciousness and greater demand for wider array of weight management products, perhaps explaining the peak in the curve at higher per capita income levels in Figure 1. The total global weight loss market was worth US$586.3 billion by 2014 . The industry’s compound annual growth rate was 10.9 percent during 2009 to 2014. Food and beverages (F&B) are at the center of this drama. They are the largest segment of the weight loss/gain industry, and projected to reach $355.7 billion by 2014, it annual growth rate being higher than of the industry as a whole, growing by 12.2 percent U.S. is the largest segment of this market worth $310 billion by 2014, followed by Europe, with a growth rate of 10.9 percent and expected to reach $238 billion by 2014. The F & B market compares with the total net Official Development Assistance (ODA) of $135 billion.
But more serious is the fact that the fiscal costs of obesity related diseases are projected to run into trillions in the U.S.  and these costs are increasing in developing countries as obesity rates rise. A recent study notes the changing associations of metabolic risk factors with macroeconomic variables and indicates that there will be a global pandemic of hyperglycemia and diabetes mellitus, together with high blood pressure in low-income countries, unless effective lifestyle and pharmacological interventions are implemented .
Figure 1: Relationship of GDP Per Capita (constant 2005 US$) to Prevalence of Undernourishment and Obesity of population (18+ years)
Equally worrying, male and female obesity rates exhibit different trends (Figure 2). According to WHO data a larger share of female population is reported to be obese at a given income relative to male populations. Studies based on more granular Demographic and Household Survey Data find similar differences in male female rates of obesity although they vary substantially among countries and time periods .
Figure 2: Relationship of GDP Per Capita (constant 2005 US$) to Male and Female Obesity [% of defined population (18+ years)]
In OECD countries, economists argue increasing obesity rates are not a result of cheap food relative to incomes . Although the long term downward trend in cereal prices was quite striking, at least until mid-2000s, they argue elimination of agricultural subsidies would not make a dent on the obesity problem. (Figure 3). Besides the levels of agricultural support and protection have been falling in OECD countries (helped by high world market prices).
The practices of the food industry in supplying calorie dense, testy and cheap foods and beverages are at the heart of the obesity challenge. Lancet authors frequently note that the behavior of the food industry has not received the attention that it deserves . In developing countries equating cereal production and low cereal prices with food security can be traced to the food shortages in the post-World War II period. Those concerns propelled the establishment of FAO in 1944, and accelerated investments in R and D in the 1960s and '70s, leading to the Green Revolution in Asia. Increasing crop yields of three major cereals- rice, wheat and maize expanded and stabilized calorie availability and “saved” land for crop diversification to pulses, fruits and vegetables. But the 2007 price rise and volatility following US biofuel policies, poor harvests, low stocks, and export bans from major producers brought a return to cereal supply concerns in developing countries. Globalization and integration of all kinds of markets have increased the concerns about risk and uncertainty of globalized markets in large developing countries such as China, India and Indonesia. Moreover, climate models have reinforced supply concern, making a convincing case that the already slowed crop yields would be severely affected particularly in South Asia and Sub-Saharan Africa increasing import dependence. Thus “Black swans” seem to becoming less black and more frequent, harking back to the old ideas of cereal self-sufficiency. Agricultural support and protection of cereals in a number of emerging economies has been increasing (concurrently with the increase in world market prices) .
So what is and what will be the effect of these emerging country policies on food consumption habits and obesity? Price support to cereals has been production and trade distorting, reducing risks in cereal production relative to crops that are not so supported and where value chains are less well developed. This has slowed diversification of food production
Figure 3: Agricultural Commodity Price Index (1977-79 = 100) (1900-2014)
Source: Pfaffenzeller, S (2013). “Updating the Grilli and Yang Commodity Price Index – beyond 2003”; and data updated by Keith Fuglie.
Besides sustainable and predictable global food flows, the development focus has rightly shifted from calories to diet diversity, food access and body’s utilization of food by individuals in the poorest households, particularly women and children. The estimated annual cost of $10 billion to $15 billion in reaching women and children in high burden countries with targeted nutrition interventions is manageable, provided service delivery can effectively reach the intended beneficiaries .
The increased focus on targeted nutrition intervention reflects a paradigm shift and strong advocacy. An influential set of papers in Lancet in 2008 made a strong case for direct nutrition interventions, reinforced, in part, by another set of papers in Lancet in 2013, followed by papers on obesity in Lancet in 2015. Recent evidence asserts that neglect of quality nutrition starting with the conception of the fetus in the mother’s womb and in the critical 1000 days thereafter has a range of adverse impacts, from children’s brain development, stunting and wasting, learning in schools, susceptibility to diseases, later in low labor productivity and earnings, loss of GDP and huge fiscal costs of non-communicable diseases associated with later obesity, a consequence of early malnutrition . A team of Nobel Prize winning economists have endorsed this shift to nutrition from their previous endorsement of HIV AIDS and other communicable diseases . Adolescent girls’ and mother’s health and nutrition and her breastfeeding of infants is the key to difference in later development outcomes.
The reason why per capita income shows weaker relationship to undernourishment relative to obesity needs more social science research in traditional societies. Undernutrition indicators in South Asia are even worse than in Sub-Saharan Africa. Prices have a major impact on real income of households. A woman’s knowledge of nutrition, power in household decision making, competing demand on her time and sustained income matters as the forthcoming World Bank study of Bangladesh shows (World Bank Group [Forthcoming]. “Dynamics of Rural Growth in Bangladesh: Sustaining Poverty Reduction”. Agriculture Global Practice, South Asia).
Nutrition is a “wicked” challenge even more than food security. It is multi-level, multi-sectoral, and multi-cultural. To tackle it effectively in all sectors will need huge political will and cultural sensitivity. If the developing world is not to repeat the mistakes of the industrialized countries, their citizens should demand, and their leaders should deliver the following: strong political commitment to addressing malnutrition in all its forms, a scale up of high impact food and nutrition interventions, and an enabling environment that makes it much easier and cheaper for all households to make healthy choices.
(This research is part of Uma Lele’s forthcoming book, Food for All: International Institutions and the Transformation of Agriculture).