Food price volatility and obesity – a new development challenge?

Continuing on the ‘new development threats’ theme of yesterday’s post on Big Tobacco, the latest issue of the World Bank’s Food Price Watch looks at the links between increasing food price volatility and obesity. A blog post by the Bank’s José Cuesta starts with a nice counter-intuitive quiz (below).

The correct answers, by the way are C, B and C.

Food Price Watch report explains:

‘Overweight and obesity constitute a global epidemic even in a world of high and volatile food prices. The prevalence and numbers of people affected by overweight and obesity have increased in the last three decades, during both periods of low and high international food prices. So as one malnutrition problem, undernourishment, is falling, others, overweight and obesity, are increasing rapidly (figure 2). In 2008, the number of overweight adults was 1.46 billion, of which 508 million were obese. Even conservative projections predict truly shocking numbers in the future if current trends are unabated: 2.16 billion adults might be overweight and 1.12 billion obese by 2030. And such increases should be expected across all regions and in countries like China and India (figure 3).

As food prices remain high and, arguably, increasingly volatile, unhealthy calories tend to be cheaper than healthy ones. This is the case of junk food in the developed world, but also of less nutritious food substitutes in poor households in developing countries coping with recurrent food (and other) crises. In fact, overweight is not an epidemic restricted to rich countries. Half of the world’s overweight people live in nine countries, including the United States and Germany, but also in China, India, Russia, Brazil, Mexico, Indonesia, and Turkey. Regions with the highest obesity prevalence — exceeding 25% of the adult population — include North Africa and the Middle East, Central and South America, and southern sub-Saharan Africa.

Policy responses so far have only partially addressed the epidemic. Responses have ranged from doing nothing to punishing overweight people by, for instance, imposing fines on employers when employees exceed certain waistline limits in Japan. Taxes, outright bans, or restrictive legislation on certain foods and ingredients along with clearer standards for food labels and awareness campaigns are attempts to veer consumers toward healthier foods. Yet, it is not evident that reducing obesity is among the top global policy priorities. Nonetheless, the current multilateral discussions on the post-2015 Millennium Development Goals (along with the UN high-level meeting on the prevention and control of noncommunicable diseases) offer an unprecedented opportunity for integrating global and national collective action to fight all forms of malnutrition, from stunting to obesity. This integrated and collective action has, nonetheless, a tall order: it must help prevent this double burden — triple, if micronutrient deficiencies are considered — from increasing as the world becomes more prosperous.’

Fascinating and important, but a nightmare in terms of communications for any organization wanting to work on it!

What causes bad nutrition – not enough power or not enough vitamins?

As a general rule, the further The Economist magazine’s subject matter departs from economics, the better it gets, as information and analysis replace the ideological drumbeat of its market fundamentalist ‘priors’. Thanks to its coverage, vital development issues such as gendercide or resource scarcity reach a global mass audience. This week’s issue has an excellent analysis of the rise of the Muslim Brotherhood on the back of the Arab Spring, but the piece that caught my eye was a two page overview on poverty and nutrition, one of those issues that seems to be rising rapidly up the development agenda (see last week’s Save the Children report). Some highlights:

“In the 1960s and 1970s, ending hunger and malnutrition seemed relatively simple: you grew more crops. If the harvest failed, rich countries sent food aid. But the Ethiopian famine of 1984 undermined this approach. Here was a disaster of biblical proportions in a country where food was available. It was a reminder of what an Indian economist, Amartya Sen, had long taught: what really matters with food is not the overall supply, but individual access.

So in the 1990s and early 2000s the emphasis switched to helping people obtain food. This meant reducing poverty and making agricultural markets more efficient. Between 1990 and 2005 the number of people living on less than $1 a day in poor countries (at 2005 purchasing-power parity) fell by a third to 879m, or from 24.9% of the total population to 18.6%.

Yet the food-price spike of 2007-08 showed that this approach also had limitations. Prices of many staple crops doubled in a year; millions went hungry. The world remains bad at fighting hunger. Experts argue about exactly how many people are affected, but the number has probably held flat at just below 1 billion since 1990.

Even where there is enough food, people do not seem healthier. On top of 1 billion without enough calories, another 1 billion are malnourished in the sense that they lack micro-nutrients (this is often called “hidden hunger”). And a further 1 billion are malnourished in the sense that they eat too much and are obese. It is a damning record: out of the world population of 7 billion, 3 billion eat too little, too unhealthily, or too much.

More than 160m children in developing countries suffer from a lack of vitamin A; 1m die because they have weak immune systems and 500,000 go blind each year. Iron deficiency causes anaemia, which affects almost half of poor-country children and over 500m women, killing more than 60,000 of them each year in pregnancy. Iodine deficiency—easily cured by adding the stuff to salt—causes 18m babies each year to be born with mental impairments.

Malnutrition is associated with over a third of children’s deaths and is the single most important risk factor in many diseases (see chart). A third of all children in the world are underweight or stunted (too short for their age), the classic symptoms of malnourishment.

The damage malnutrition does in the first 1,000 days of life is also irreversible. According to research published in TheLancet, a medical journal, malnourished children are less likely (all things being equal) to go to school, less likely to stay there, and more likely to struggle academically. They earn less than their better-fed peers over their lifetimes, marry poorer spouses and die earlier.

Paradoxically, malnutrition can also cause obesity later in life. In the womb and during the first couple of years, the body adjusts to a poor diet by squirrelling away whatever it can as fat (an energy reserve). It never loses its acquired metabolism. This explains the astronomical obesity rates in countries that have switched from poor to middle-income status. In Mexico, for instance, obesity was almost unknown in 1980. Now 30% of Mexican adults are clinically obese and 70% are overweight.

These are among the highest rates in the world, almost as bad as in America. India has an obesity epidemic in cities, as people eat more processed food and adopt more sedentary lifestyles. And with obesity will come new diseases such as diabetes and heart disease—as if India did not have enough diseases to worry about.

Nutrition is also attracting attention because of some puzzling failures. In a few big countries, notably India and Egypt, malnutrition is much higher than either economic growth or improvements in farming would suggest it should be. India’s income per head grew more than fourfold between 1990 and 2010; yet the proportion of underweight children fell by only around a quarter. By contrast, Bangladesh is half as rich as India and its income per head rose only threefold during the same period; yet its share of underweight children dropped by a third and is now below India’s. Egypt’s agricultural value-added per person rose more than 20% in 1990-2007. Yet both malnutrition and obesity rose—an extremely unusual combination.

The good news is that better nutrition can be a stunningly good investment. Fixing micro-nutrient deficiencies is cheap. Vitamin supplements cost next to nothing and bring lifelong benefits. Every dollar spent promoting breastfeeding in hospitals yields returns of between $5-67. And every dollar spent giving pregnant women extra iron generates between $6-14. Nothing else in development policy has such high returns on investment.

If malnutrition does so much damage and the actions against it are cheap and effective, why is the affliction only now being taken seriously? Some countries have successfully tackled it. Brazil cut the number of underweight people by 0.7% a year between 1986 and 1996 and reduced stunting by 1.9% a year. Bangladesh reduced both rates by 2% a year in 1994-2005.

But in many countries the problem of “hidden hunger” is hidden from victims themselves, so there is no pressure for change. If everyone in a village is undernourished, poor nutrition becomes the norm and everyone accepts it. This may also explain the reluctance of poor, ill-fed people to spend extra money on food, preferring instead to buy such things as televisions or a fancy wedding. When asked about his spending choices, an ill-fed Moroccan farmer told Abhijit Banerjee and Esther Duflo of the Poverty Action Laboratory, a think-tank: “Oh, but television is more important than food.”

Education can help change attitudes by persuading people they would benefit from a better (if more expensive) diet. But people in rich countries consume vast quantities of junk food knowing full well that it is bad for them. It is unrealistic to expect consumers in poor countries to behave differently. Hence the idea of doing good by stealth.

HarvestPlus, a research group, breeds staple crops with extra nutrients and distributes the “bio-fortified” seeds. It released a vitamin A-rich cassava in Nigeria in 2011. This year it will bring vitamin A-rich maize (corn) to Zambia and iron-rich beans and pearl millet to Rwanda and India. Companies do something similar with processed foods: Kraft’s Biskuat biscuits (sold in Indonesia) have nine vitamins and six minerals added.

But education or fortified foods alone will not overcome the most intractable barrier to better nutrition, which is the sheer complexity of the task. Some problems of development are relatively straightforward. You can improve education by building schools and paying teachers. Nutrition is not like that.

A successful effort to improve nutrition has to push all the buttons at once. Brazil’s Fome Zero has 90 separate programmes run by 19 ministries. It embraces everything from a conditional cash-transfer scheme, called Bolsa Família, to irrigation projects and help for smallholders. Such an effort is hard to organise and cannot work unless politicians support it.

Hence the importance of Mr Graziano, the FAO’s new boss. Interest in improving nutrition is growing; so is alarm at the failures of fighting malnutrition so far. He will not find it easy to cajole more countries into a large, broad-based effort. Governments are reluctant to change and want clear evidence. And just as the damage from malnutrition builds up over a lifetime, so better nutrition reveals its benefits only over many years, as well-fed mothers pass on good health to well-fed children.

At a recent FAO conference someone was heard to remark that “at the moment nutritionists are in a position similar to environmentalists in the 1990s.” That is depressing, because it means progress will be slow; but it is encouraging, because progress will come eventually.”

My immediate reaction to this analysis  is ‘where’s the politics?’ – it seems to discuss only apolitical problems (ignorance, bad policies) and proffer technical solutions. Politics, power and inequality help explain those ’surprising’ failures in India and Egypt. But maybe poor nutrition really is at least partly soluble with technical fixes – iodine in salt, vitamin supplements etc. What do you think? Does helping the one billion people who are wrongly- (rather than under- or over-) nourished particularly lend itself to technical solutions?

Is Obesity a Development Issue?

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?