33rd Session of the SCNWorking Group on Household Food

Security

Obesity and poverty in nutrition transition: the case of South-East

Asia

Geok Lin KhorUniversiti Putra Malaysia

March 12-17 2006, Geneva

From Ancient to Modern .....Diets

The Nutrition Transition Program, The University of North Carolina at Chapel Hill

From Ancient to Modern ..…Work

The Nutrition Transition Program, The University of North Carolina at Chapel Hill

From Ancient to Modern .....Transport

The Nutrition Transition Program, The University of North Carolina at Chapel Hill

Demographic and economic indicators

Population (million)

GDP /capita (USD)

Life expectancy M F

Malaysia 24.4 9253 70 75

Thailand 62.8 7248 67 73

Philippines 80.0 5231 65 71

Indonesia 220.0 3390 65 68

Vietnam 81.4 2847 68 74

(WHO, 2002)

Selected health indicators Infant

mortality rate (per 1000 live

births)

Under five mortality rate (per 1000 live

births)

Maternal mortality rate (per 100,000 live births)

Malaysia 8 7 20

Thailand 7 21 21

Philippines 29 40 90

Indonesia 35 46 150

Vietnam 18 24 165

(SEAMIC, 2002; DHS 2002-03)

Leading causes of mortalityMalaysia Thailand Philippines Indonesia Vietnam Heart diseases 19.5%

Cancers 18.6%

Heart diseases 14.9%

Perinatal conditions 15.7%

Cerebro-vascular disease 13.5%

Cancers 10.9%

Heart Diseases 8.1%

Influenza & pneumonia 10.2%

Cerebro-vascular disease 11.8%

Perinatal conditions 10.5%

Cerebro-vascular disease 8.2%

Transport accidents 5.7%

Cancers 10.4%

Heart Diseases 6.9%

Heart Diseases 9.6%

Septicemia 7.1%

Cerebro-vascular disease 4.9%

Tuberculosis 8.4%

Intestinal infectious diseases 4.9%

Transport accidents 8.0%

Transport accidents 6.4%

Septicemia 4.8%

Hypertensive diseases 8.9%

Influenza & pneumonia 3.7%

Influenza & pneumonia 6.7%

pnu

SEAMIC Health Statistics 2002

Co-existence of obesity and poverty

• The prevalence of overweight adults appears to increase as the nutrition transition advances – an expected association?

Prevalence of overweight adults (aged 15 years and above) in Southeast Asia

0

5

10

15

20

25

30

35

Male Female

Malaysia

Thailand

Philippines

Indonesia

Vietnam

%

(WHO Global InfoBase Online 2002)

(BMI ≥ 25 kg/m2)

Trends in availability of total calories and calories from animal products in Southeast Asia, 1965-2003

(per capita per day)

0

500

1000

1500

2000

2500

3000

3500

1965 1975 1985 1995 2003

Malaysia

Thailand

Philippines

Indonesia

Vietnam

(FAO Food balance sheets)

Total calories

Calories from animal source products

Dietary changes associated with nutrition transition in SEA

As household income becomes less the primary constraint to procuring food:

• home-cooked food increasingly replaced by ready-to-cook and ready-to-eat foods that are high in fat/oil, sugar and salt.

• proportion of animal source products consumed (meat, milk, egg) rises

• fast foods & soft drinks easily available and relatively affordable

Co-existence of obesity and poverty

1. The prevalence of overweight adults appears to increase as the nutrition transition advances – an expected association?

2. Increasing prevalence of overweight and obesity in low income/food insecure households – a paradoxical association?

• Obesity and socioeconomic status - a complex relation. Stunkard AJ & Sorensen TIA, N Engl J Med, 1993

• Does hunger cause obesity? Dietz WH, Pediatrics 1995

• Economic determinants and dietary consequences of food insecurity in the United States. Rose D, J Nutr 1999

• Food insecurity is positively related to overweight women. Townsend MS et al., J Nutr 2001

• Food insecurity is associated with increased risk of obesity in California women. Adams EJ et al., J Nutr 2003

• Obesity and household food insecurity: evidence from a sample or rural households in Malaysia Zalilah MS & Khor GL, Eur J Clin Nutr 2005

Not a new phenomenon

Underweight and obesity among female in urban

slums areas, Indonesia (NSS-HKI data sets)

0

5

10

15

20

25

15-19 20-24 25-29 30-34 35-39 40-44

BMI <18.5

BMI >=30

(Atmarita, MOH, 2005)

44%

Nat Nutr Survey 1998

% womenWHR > 0.85

39%

34%

41%

poorer regions

Plausible explanations for the paradoxical association

• Dependent on low cost foods that are flour/tuber-based and tend to be high in refined sugar, fats/oils

• Limited variety of food consumed relying on a few “stomach-filling” high energy foods

• Seasonal or cyclic acquisition of food with periods of plentiful (binge eating) and involuntary food restriction

• Overweight housewives associated with more leisure time, mostly spent on sedentary activities

Co-existence of obesity and poverty

1. The prevalence of overweight adults appears to increase as the nutrition transition advances – an expected association?

2. Increasing prevalence of overweight and obesity in low income/food insecure households – a paradoxical association?

3. Evidence of overweight mother / underweight or stunted child in the same household among the poor - a challenging association?

Prevalence of underweight child/overweight mother pair in same household in SEA

Multi-centre Study sponsored by Japan

(2000-02)

Child <6 yrs & mother 20-45 yrs

pairs

UW child & OW mother

pairs

%

Indonesia Urban 1185 5.7

Philippines Urban 376 8.2

Thailand Urban 199 18.5

Malaysia Peri-urban

140 26.0

Main findings of UW/OW Study

• Indonesia: UW/OW pairs higher in larger households, both parents with low education;

• Indonesia & Malaysia: No significant difference in food intake between OW and NW mothers (under -reporting/under-estimation?)

• Philippines: significantly higher intake of calories, preference for meat and fried foods, under-estimation of body size

Obesity in adults across income levels

Nutrition transition

OBESITY

Obesity prevalence reduces, driven more byindividual thanenvironmental

factors

?

?Obesity prevalence rises, driven mainly by environmental factorsat global and national levels: trade, media, food industry, etc

WE NEED TO………….

get the measure right (BMI vs WHR vs waist circumference vs fat mass; cut-off points for overweight & obesity)

get the message right(public health interventions need to distinguish

between population, household and individual factors affecting malnutrition)

get the medium right(a broad coalition of people, professionals and

policymakers)

get the method right(evidence based, context specific, gender & age sensitive interventions)

(adapted from KS Reddy, 2003)

• Dual forms of malnutrition in the same households in Malaysia - a case study among Malay rural households. GL Khor & Zalilah MS. Asia Pacific J Clin Nutr 2003

• A case study on dual forms of malnutrition among selected households in District 1, Tondo, Manila. I Angele-Agdeppa I, Lana RD & Barba CVC. APJCN 2003.

• Factors associated with the dual forms of malnutrition in Nakhon Pathom Province and Bangkok, Thailand. Yamborisut et al., APJCN 2006

Obesity in adults in nutrition transition

OBESITY

Levels of development

Higher incomein lessdevelopedregion

Lower income inmore developedregion

Poverty amidst affluence

Poverty and obesity

% Population below income poverty line

(US$2/day/person)

% obesity

15 years & above

male/female

Malaysia 9.3 1.6/8.2

Thailand 32.5 2.5/8.4

Philippines 46.4 1.1/3.7

Indonesia 52.4 0.2/2.6

Vietnam 63.7 0.01/0.32

Selected health indicators Life

expectancy at birth (m + f) (years)

Infant mortality rate (per 1000 live births)

Under five mortality rate (per 1000 live births)

Maternal mortality rate (per 100,000

live births)

Malaysia 72 8 7 20

Thailand 70 7 21 21

Philippines 70 29 40 90

Indonesia 67 35 46 150

Vietnam 71 18 24 165

The World Health Report, 2005; SEAMIC, 2002; DHS 2002-03