At a recent meeting of Oxfam’s country directors, I asked if they thought Oxfam should treat obesity as a development issue, just another form of ‘mal-nutrition’. The reaction was pretty negative. Innocent Nkata, from South Africa (left), summed it up by saying that whereas hunger was an issue of rights, obesity is a ‘question of morality’ i.e. is it right or wrong that some people should be overeating while others are starving? He sees it as a complex debate with potential to be very subjective and relative. I was happy to drop the issue, in part because even writing about it made me feel uncomfortable and judgemental (regular readers of this blog may be surprised to hear it, but that bothers me). But it’s been niggling away at me ever since, so here are some thoughts about how we might frame obesity as a development issue.
First, and most obviously, it’s a health issue: the World Health Organization reckons that worldwide, approximately 1.6 billion adults (age 15+) were overweight and at least 400 million adults were obese in 2005. The WHO further projects that by 2015, approximately 2.3 billion adults will be overweight and more than 700 million will be obese. (The WHO defines “overweight” as a body mass index (BMI) over 25, and “obesity” as a BMI over 30.)
Because of urbanization, sedentary lifestyles, changing diets and increased incomes, an increasing proportion of those people live in 
developing countries – Mexico is fast overtaking the US in the obesity stakes (see chart). The WHO confirms that 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 under-nutrition, at the same time they are experiencing a rapid upsurge in chronic disease risk factors such as obesity and overweight, particularly in urban settings. That is leading to rapidly increasing rates of diabetes, heart disease and strokes.
· It is not uncommon to find under-nutrition and obesity existing side-by-side within the same country, the same community and even within the same household.
· This double burden is caused by inadequate pre-natal, infant and young child nutrition followed by exposure to high-fat, energy-dense, micronutrient-poor foods and lack of physical activity.
But body size and image are about much more than physical health. I think Innocent’s remark also reflects the fact that traditionally, Africans have often been much less judgemental about body image (’body fascism’) than Europeans, and sometimes even see large size as a sign of success (a British friend of mine working in Mozambique found it hard to look pleased when she came back from holiday and was told ‘you’re looking fat’!). On the other hand Latin American countries such as Brazil and Argentina have alarming levels of anorexia and bulimia, especially among young women. Attitudes to body size are definitely culturally specific.
The link between obesity and income is also complex. In poor countries, unsurprisingly, obesity is generally confined to the wealthier parts of the population. In the rich countries, it is often seen as linked to poverty. According to a new (gated) paper in the Development Policy Review journal, the tipping point between the two occurs at a GDP of about $2,500 per capita, albeit with lots of variation based on diet and culture.
Of course it’s not just about quantity but quality – part of the reason for the surge in obesity in developing countries is the spread of Western diets, including fast food and sugary soft drinks, often driven by transnational corporations. And policies, as we know from our own countries, can make a difference. South Korea has vigorously promoted local foods rather than a high fat Western diet, and has lower rates of obesity than comparable economies.
So if all this is true, and obesity rates are rising, why does no aid agency ever talk about it?
Firstly, we feel more comfortable talking about what poor people need more of (schools, medicines, clean water, food, cash). Self denial is strictly for the rich. But a lot of obese people in developing countries aren’t particularly rich. So our simplistic divisions break down.
Secondly, as with population and family planning, talk of ‘public education’ makes us anxious in case it comes across as patronising and ‘blaming the poor’. But we’re comfortable with it in our own countries, so why not in development?
Thirdly there’s our institutional identity and culture. After all, Oxfam was originally called the ‘Oxford Committee for Famine Relief’. How can it start talking about over-nutrition?
On a global scale, the ‘well-nourished’ constitute only about half of the world’s 6 billion people, with legions of the mal-nourished at either end of the BMI spectrum – roughly a billion hungry and two billion overweight. The number of overweight people in developing countries is bound to continue rising, along with urbanization and rising incomes. So is it time to redefine mal-nourishment as eating too much, or the wrong stuff, as well as too little? To talk about the two billion (over-large) bottoms as well as the Bottom Billion?
If so, what sort of policies or institutions might be worth lobbying for? Controls (whether regulatory, soft law or voluntary) on food and drink companies? Investment in public education on nutrition? Any other ideas?