Life on the margins:
the inequality of food and nutrition security
PowerPoint presentation by
Médecins Sans Frontières / Doctors Without Borders
Schools Team: Mary Doherty and Severa von Wentzel
January 2014
Awareness ribbon for malnutrition
Image: Wikipedia
“With diseases related to malnutrition on the rise, the challenge
is not only to ensure food security, but also to address the
nutritional quality of the food being consumed and its impact on
health.” - Dr Frenck G20 2012,
Malnutrition terms
Adequate food is at the basis of an active and healthy life. Yet, in
spite of significant improvements, millions of people today are
Malnutrition: An abnormal physiological condition caused by
inadequate, unbalanced or excessive consumption of macronutrients
and/or micronutrients. Malnutrition includes undernutrition and
overnutrition as well as micronutrient deficiencies.
Minimum dietary energy requirement (MDER): amount of energy
needed for light activity and a minimum acceptable weight for attained
Body Mass Index (BMI) relates weight to height and is used to
evaluate thinness and obesity.
World bank, Scaling up Nutrition: What will it cost? 2010
Malnutrition terms
Protein-energy malnutrition: BMI and shortness are indicators. A
broad (older) term from the 1970s when protein deficiency was felt to
be the primary driver behind malnutrition. Replaced by the more
general term ‘acute malnutrition’ which includes macronutrient
imbalance/insuffiency as well as micronutrient deficiency.
Micronutrient deficiency: “hidden hunger”, a lack of one or more
essential vitamins and minerals, such as Vitamin A, iron, iodine or zinc.
Indicator iron-deficiency anaemia low haemoglobin in blood.
Micronutrient powders (MNP) are used to prevent micronutrient
deficiencies; for example, on a large-scale basis in Bangladesh.
Poor health, growth and development outcomes can result from hunger and poor
Under nutrition is “the outcome of undernourishment, and/or poor absorption and/or
poor biological use of nutrients consumed as a result of repeated infectious disease. It
includes being underweight for one’s age, too short for one’s age (stunted), dangerously
thin for one’s height (wasted) and deficient in vitamins and minerals (micronutrient
malnutrition).(FAO definition
Under nutrition includes being:
• Underweight: a child has low weight for age. Composite measure includes chronic
and acute malnutrition.
• Stunting: child short for their age as a result of chronic under nutrition during the
most critical periods of growth and development in early life.
• Wasting: child’s weight is too low for their height as a result of acute under nutrition,
can vary with the seasons. Reflects loss of muscle tissue and fat.
• Kwashiorkor: sudden onset swelling of the feet, hands and face. Cause unknown,
but occurs typically in children 2-3 years old once they are weaned from breast milk
and can be cured by feeding a specially fortified milk. Form of severe malnutrition.
Undernourishment or chronic hunger: A state, lasting for at
least one year, of inability to acquire enough food, defined as a
level of food intake insuffiecient to meet dietary energy
requirements. For the purposes of this presentation, hunger was
defined as being synonymous with chronic undernourishment.
Famine is the state in which significant proportion (at least 20%)
of a defined population lacks access to food in sufficient quantity
and quality, such that epidemics of infectious disease become
more frequent, acute malnutrition rates in children under 5 are
above 30% and death rates rise. In famine conditions, the most
vulnerable members of the population - the very young, the
elderly and those with chronic illness – are at higher risk of
Starvation occurs when the individual’ nutrient intake drops
below what is needed to maintain body mass and the body
begins to consume muscle and other lean tissues in order to
supply nutrients to maintain metabolic function.
In an otherwise well adult who continues to drink water but
ceases all nutrient intake, this process of starvation leads to
death in about 2 months.
The process of starvation affects all the body’s organ systems,
but the most visible signs are weakness, apathy and muscle
Hunger IQ and FAQs
Action for students:
1. With a partner test your Hunger IQ: and
read Hunger Frequently asked questions (FAQs) including the overview,
record what is hunger, who are the hungry, what causes hunger, what is
2. Extract the salient information from each of the documents and
individually record the information so you can readily refer to it.
3. Can you explain why solving hunger is regarded as a ‘best buy’ in
today's tough economy?
4. Use the data from Who are the hungry?
– Draw a bar chart showing how the 870 million hungry people in the world are
– Draw a pie chart which shows the proportion of hungry people living in rural areas.
– Draw another pie chart showing the proportion of hungry people from small holding
farming communities, those from landless families dependent on farming and the
proportion dependent on herding, fishing or forest resources.
case studies
“Every man, woman and child has the inalienable right to be free from hunger.”
- First World Food Conference Declaration, Rome, 1974
Action for students:
1.Look through Hunger in the news
2.Make brief notes on the current hunger crises and debates around the globe paying
particular attention to the case studies used in this unit:
- The Sahel (Sub-Saharan Africa )
- Bangladesh, India (South Asia)
- Kenya
- The UK
- The USA
3.What is in the news about these case studies, malnutrition and life on the margins? Add
helpful information to your notes.
World economic growth
and undernourishment
Agriculture plays an essential role in the world economy. Beyond food
production, it is as an engine of economic growth key to growth in rural settings
and poverty reduction in transition countries. It generally accounts for half of
GDP in developing countries; its share in the economy tends to decline with
development. Investments in agriculture have a poverty-reduction impact larger
than any other sector.
Source: Fairfood
Rise in
hungry people
Number of hungry people, 1969-2010
Since 1995-97 the number of
hungry people has risen.
Even at times of economic
growth and low food prices,
the number of hungry has not
fallen below around 800
million over the past 40
Source: FAO; Source:;
Factors in
rise of hungry people
1. Governments and international agencies have neglected agriculture
and the synergy between agriculture and social protection relevant
to very poor people; for every five people suffering from hunger, three
rely on farming. Women and small holder farmers most affected. Food
reserves have also shrunk.
2. Current worldwide economic crisis and financial, trade and policy
3. Energy and climate issues;
4. Devastating impact of food price hikes, a large upward movement in
price in a short time, on people existing on only a few dollars a day.
5. Speculation and concentration of agribusiness* and retail among
very few players.
* Agribusiness: the manufacture and distribution of farm supplies,; farm production operations, storage,
processing and distribution of farm commodities and products most often by corporations.
Source: FAO; Source:;
Global Hunger Index
International Food Policy Research Institute
Action for
students: Note the
three dimensions of
which the GHI is
composed in your
folder along with the
main trends per
Prevalence: proportion
of people in a population
with a particular disease
at a specified point in
time or over a specified
period of time – as
opposed to new cases
which is incidence
Rate “A measure of the
intensity of the
occurrence of an event.
For example, the
mortality rate equals the
who die in one year
divided by the number at
risk of dying. Rate—A
measure of the intensity
of the occurrence of
Hunger and
Further info:
Community voices
from Bangladesh:
How to measure
Weight and height must be compared to age or to each other and
therefore are turned into indices
Length or height
Middle upper arm circumference
Weight for age called ‘underweight’. Includes both wasting and stunting
Weight for length or body mass index, measure of ‘wasting’ and ‘obesity’
Height for age, measure of ‘stunting’
Other signs or measures
Oedema (water retention) of feet, hands, face
Blood test for anemia (iron deficiency in particular)
Blood test for certain micronutrients: Vitamin A or zinc
How malnutrition kills
The commonest form of malnutrition called marasmus results in an
affected child being severely wasted, with no fat and very little muscle
tissue left on his or her body. The internal organs, including the heart and
the blood, are also weakened. The child is left with no reserves to fight
infection, and any illness that comes along is likely to be fatal. The
commonest causes of death during a famine are in fact infectious diseases,
rather than starvation per se. Chief among these are pneumonia,
diarrhoea, and measles.
UNICEF on Marasmus
The other form of malnutrition, called kwashiorkor, in which the child's
body is swollen, likewise kills by lowering resistance to infection. However,
kwashiorkor can also be fatal in its own right, because of the disturbed
levels of salts and minerals (electrolyte imbalances) that accompany it.
In a therapeutic feeding centre, where only severely malnourished children
are cared for, many deaths tend to occur at night. This is because these
children are especially prone to low blood sugar (hypoglycaemia) and low
body temperature (hypothermia). (MSF US website)
Clip on Kwashiorkor
Determinants of
child nutrition and development
Immediate determinants include:
• Adequate food and nutrition intake
• Parenting, caretaking and feeding practices
• Low burden of infectious diseases
Underlying determinants include:
• Food and nutrition security
• Adequate resources at the community, household and maternal
(mother’s) level
• Access to health care provision
• Safe and hygienic environment
The wrong start
One out of six children -- roughly
100 million -- in developing countries
are underweight, but trend is down.
Source: Global health Observatory, WHO, 2011
Source: Unicef Nutrition Report 2013 and World bank
Wasting and stunting
When a population is short this points to nutritional deprivation or disease in
• has greater propensity for developing obesity and
chronic diseases as an adult, fuelling obesity epidemic in low
and medium income countries.
• has lower chances of survival and
less optimal health and growth.
• is more likely to have been born to a mother with poor nutrition
and health status, which perpetuates
vicious cycle of under nutrition and poverty.
International health organisations are starting to shift their focus from
underweight prevalence (inadequate weight for age) to prevention of
stunting (inadequate length / height for age).
Stunting prevalence by region
Globally, about 1 in 5 (26% in 2011) children are stunted of whom 80% live in 40
countries. Undernutrition affects poor children most, but rates are high enough to deserve
attention even among the better-off children in developing countries.
South Asia
Sub-Saharan Africa
Middle-East / North Africa
East Asia / Pacific
Latin America / Caribbean
Developing countries
Prevalence is the proportion of the population that has a condition of interest at a
specific point in time.
Source:; A Ergo et al “What difference do
the new WHO child growth standards make for the prevalence and socioeconomic distribution of undernutrition?” Food Nutrition Bulletin
Stunting in children and
income growth
Improvements in nutritional status lag behind economic
growth, but are boosted by income growth.
Silent emergency
of stunting
Action for students:
1. With a partner use the resources
below and others to research the
trends of malnutrition prevalence
since 1980.
Malnutrition prevalence, weight for age (% of
children under 5) Map from 1980 in 4 year
segments up to 2012.
“Improving Child Nutrition - The achievable goal
for Global Progress”
2. Explain the reasons why some
have shifted their focus from
underweight to stunting .
3. From your research explain the
title-The silent emergency of
4. Find out about and write a brief
paragraph on the Scaling Up
Nutrition (SUN) Movement.
“Break the cycle of stunting":
“The Life cycle of malnutrition”
Clip on Cycle in South Asia
Trendalyzer video / presentation on 1000-day
window, cycle and initiatives: and
“A Life Free from Hunger” on the life-long
consequences of stunting
Source: 1000 infographic What causes maternal and child malnutrition
What is at the root
of the problem?
Further info on where the poor live and are going to live? Free exchange: The geography of poverty”, The
Economist September 1st 2012,
Image: 1000 infographic What causes maternal and child
Childhood malnutrition:
causes, campaign and Sahel (1)
The mother’s status (is she disadvantaged?) is likely to affect
the child’s food intake and health status – both proximate determinants
of the child’s nutritional status.
Causes of malnutrition include:
• poverty,
• quality of environmental conditions (poor housing conditions,
inadequate water, hygiene practices and sanitation),
• illiteracy,
• unemployment,
• social problems
• poor awareness about mal/nutrition
• poor access or quality of health services.
Source: World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva,
Switzerland: WHO,1999: Accessed November
Childhood malnutrition:
causes, campaign and Sahel (2)
Action for students:
1. Make notes in your folder from the nutrition glossary:
2. Watch the “Rewrite the Story” clip on MSF’s campaign to make childhood
malnutrition more visible on the global agenda and in people’s minds. What
are the main arguments?
3. Time to prevent malnutrition in the Sahel (on Malaria and Malnutrition)
4. Report Malnutrition in the Sahel: One Million Children Treated – What’s
5. Sahel: Treating malnutrition.
Girls and women
• The distribution of malnutrition is highly gendered, girls and
women make up more than 70% of the world’s hungry (UN).
• Girls and women produce more than 55% of the world’s food
supply (UN). They endure lower salaries, fewer promotions, less
secure employment, unreasonably long hours whilst continuing
with traditional household responsibilities.
• They represent 41% of farmers around the world; own only 2% of
the land (Rural Poverty Portal)
• Women in Africa receive less than 10% of all credit going to small
farmers, and only 1% of the total credit going to the agricultural
sector (Rural Poverty Portal)
empowerment (1)
Women’s health and nutrition, equality
and empowerment are worthwhile ends in themselves.
In addition they have many benefits, including:
• Intergenerational benefits
• Poverty reduction
• Economic efficiency
In many settings, greater access to agricultural lands
and economic rights are needed for women to exploit
the synergy between agriculture and social protection.
empowerment (2)
“Gender-based inequalities at every point in the value-chain have traditionally
impeded the realization of food and nutritional security.....In most developing
countries women play a key role in the cultivation of food and cash crops as well as
the nutritional care of their children and are therefore critical to food and nutritional
security. Investment in women can lead to tremendous dividends.”
According to the Lancet, evidence supports that women and men allocate food
differently. There are:
• Positive associations between women’s empowerment and improved maternal
and child nutrition.
• Negative associations between disempowerment such as domestic violence and
child nutrition outcomes
• Positive impacts on women’s empowerment of agricultural programmes and
cash transfers
Source:; The lancet “Nutrition-sensitive Interventions and Programmes: How Can They Help Accelerate Progress in
Improving Maternal and Child Nutrition?”
Women’s inequality
drives the cycle
Gender “refers to the socially constructed roles behaviour, activities and
attributes that a particular society considers appropriate for men and
women.” Not inherently given by biology, these vary across cultures.
“The distinct roles and behaviour may give rise to gender inequalities, i.e.
differences between men and women that systematically favour one
group. In turn, such inequalities can lead to inequities between men and
women in both health status and access to health care.”
Gender equality “implies a society in which women and men enjoy the same
opportunities, outcomes, rights and obligations in all spheres of life.”
Gender equity Process of being fair to men and women alike that leads to
Gender empowerment: “A critical aspect of promoting gender equality is the
empowerment of women, with a focus on identifying and redressing power
imbalances and giving women more autonomy to manage their own lives.
Women's empowerment is vital to sustainable development and the
realization of human rights for all.”
Women’s inequality
and food and nutritional security
Image gender cycle:;
Feast or Famine
Action for students:
1. Watch the interactive slideshow on nutrition
emergencies and classification:
2. Discuss in pairs: what is the difference between
hunger, malnutrition, starvation and famine. Make
sure you have a clear definition of each of these
words recorded in your folder.
3. Explain why there is malnutrition in LEDCs.
4. What do you believe the phrase ‘Feast or Famine’
Bangladesh and India
Action for students:
1. Label the map with countries,
main cities, bodies of water.
2. Watch “Terrifying Normalcy” of
malnutrition in Bangladesh –
3. Record key data and
information for your case
study on Bangladesh and
4. What do you understand is
meant by the title of the
Why is it terrifying?
Malnutrition in
South Asia
“Among all regions, South Asia has the worst record on malnutrition... In
developing countries, on average, 29 per cent of children are underweight; In South
Asia it is 49 per cent. Thirty-three [of] children in developing countries are stunted; but
48 per cent in south Asia are. Ten per cent of children in the developing world are
wasted; the share is 17 per cent in south Asia ... [but] child survival rates in south Asia
[are] so much better than in SSA....the south Asian child usually has better access to
modern medical care, especially antibiotics”
– Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political, Weekly
March 11, 2006
profile (1)
In South Asia, Bangladesh urbanisation (highest rate in South Asia) is
largely driven by rural-urban migration, which gained in momentum
after the country’s independence in 1971. The capital Dhaka has most
dominant role.
Half of its population of 163,654,860 (July 2013 est., CIA World
Factbook) live in poverty and about one third in extreme poverty, so
third largest number after China and India. Poor access to food due to
Between 1990 and 2010 poverty rates declined substantially with per
capita GDP doubling and economic growth appearing to have reached
the poor; agricultural growth averaged 3.3% a year thanks to great gains
in rice yields (FAO 2012).
Source:* Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political
Weekly March 11, 2006;
CIA World factbook;
profile (2)
Most densely populated country in the world, 28.4% of total population
is urban (2011). Overcrowding, especially intense in urban areas, makes
environmental hygienic conditions worse, which leads to greater disease
affecting absorption of nutrients. The socio-economic status of rural-urban
migrants is moderately lower than their urban native counterparts.
Women in South Asia have the worst educational indicators relative to
men with lowest adult literacy rates for women as a percentage of men
Bangladesh has seen dramatic advances in child survival thanks to
– economic, economic and political empowerment of women; and
– higher participation of girls in formal education with literacy rates 38% in
1991 increasing to 77% in 2009
Source:* Santosh Mehrotra,“Child Malnutrition and Gender Discrimination in South Asia”; Economic and Political
Weekly March 11, 2006;
CIA World factbook;
Bangladesh health
“During pregnancy, they eat the same food. Whatever they are having now, they have the same then.
Who will give them extra food? That’s why their children are weak and suffer from malnutrition; for
which they do not do well in education like the children of the rich class. Who will get this fact?”
Female, Nilphamari District, Bangladesh, HANCI report
Share of government spending on health about double that of India and Pakistan, its large
Twenty-five million face hunger. Hunger distribution is highly gendered with nearly one third of
women undernourished (Ahmed, Mahfuz, Ireen et al 2012)
Second highest child malnutrition rates in the world with 48%, which is linked to low status
of women in Bangladeshi society (circumscribed autonomy/agency). Husband and boys can be
prioritised in food allocation. Mothers and daughters can have inadequate or low quality food and
work requirements, leading to low health status.
Malnutrition, it is estimated, costs US$ 1 billion a year in lost economic productivity.
An estimated 50% reduction in undernourishment has been achieved (SUN 2011) Consumption of
nutritious food appears to be on the increase.
Bangladesh indicators
Significant public
health concern:
prevalence beyond
15% emergency
Levels of
stunting 41% and
underweight 36%
(2011 figures,
according to UN
India case study:
country profile sources
Action for students: Using the previous slide on Bangladesh
as a template for a country profile, distil relevant facts
pertaining to the population’s well-being in general and
malnutrition in particular. Why do studies look at the level of the
mother’s education?
CIA World Factbook, Measure DHS (demographic and health surveys), World
Bank and BBC Country Profiles are good starting points
Nutritional status:
Bangladesh and India
Percentage of children under 5
underweight (this is a
nutritional indicator for the
whole community) among
highest in the world 2nd for
India and 4th for Bangladesh
(World Factbook); stunting
prevalence 41.3% in
Bangladesh in 2011 (Measure
Among lowest adult obesity
prevalence rate in the world
184th for India and 190th for
Bangladesh in the world, but
alarming rise in BMI over 25 for
women in Bangladesh from
12% in 2007 to 17% in 2011
• Childhood under nutrition has declined, but maternal
nutrition has not improved significantly in
Bangladesh (
Anaemia continues to be a major nutritional problem in
children and women in Bangladesh
Action for students:
1. Note some of the issues arising from the fact that
the latest data for India dates back to a 2005-2006
national family health survey
2. Record the relevant points for your folder from
“UNICEF Nutrition in India”
FAO Country India Nutrition profile
Source: CIA World factbook
“Malnutrition, both under and over, can no longer be
addressed without considering global food
insecurity, socioeconomic disparity, both globally
and nationally, and global cultural, social and
epidemiological transitions.”
- Darnton-Hill and ET Coyne “Feast and famine: socioeconomic disparities in global nutrition and health”
Double burden of
malnutrition (1)
Double burden of malnutrition: Persistence of under nutrition, especially
among children, along with rapidly increasing overweight, obesity and dietand life-style related chronic diseases especially among the poor. In
China, for example, there has been a significant rural-urban difference in
obesity prevalence which offset marked reductions in underweight
These forms of malnutrition usually result from uneven access to food and
unbalanced diets. Both under- and over-nutrition are problems of poverty
and are bound to become even more closely interwoven. Immediate and
root causes of malnutrition are multidimensional and complex.
Double burden of
malnutrition (2)
In countries where famine and under nutrition were traditionally the
main issue, the reverse now is the case: over nutrition is increasing,
especially in India and China, countries recently more affluent.
In developing countries, rapid urbanisation is linked to diets with
more fats, animal source foods and processed products and lower
activity levels resulting in higher levels of obesity.
Action for students: Write a few paragraphs for your folder explaining
what is meant by the phrase “the double burden of malnutrition.”
Nutritional adequacy
Energy – provided in the form of protein, carbohydrates and fats.
Sometimes referred to as macro-nutrients.
Micronutrients – vitamins and minerals essential to all metabolic
processes in the body. Fruits and vegetables are rich in micronutrients,
as are many animal sourced foods. Liver is an excellent source of iron,
B vitamins and Vitamin A.
Animal sourced food – meat, fish, eggs, dairy. These foods provide
complete protein and many micronutrients in addition. For example,
dairy foods provide complete protein, an excellent source of calcium,
zinc and essential fats.
Tubers and cereal – the least expensive source of energy,
predominately carbohydrates. Also provide some protein and often rich
in B vitamins. However, protein is usually not complete and these foods
must be paired with beans or lentils to provide all the essential aminoacids (protein-building blocks).
Hunger and obesity both forms of malnutrition
Action for students:
Watch the video Nutrition in 2 minutes and
Unicef slideshow lessons with quiz on nutrition
Childhood Malnutrition: What happens now
Discuss and write notes for your folder on ‘under
nutrition’ and the malnutrition cycle.
Record in your folder the arguments in favour of
preventing under nutrition?
Discuss in groups of four why hunger and obesity
are two sides of the same coin, bearing in mind
socio-economic, political and environmental factors.
Poorest are
most vulnerable to malnutrition
Triad: Poverty – Dietary Quality / Adequacy – Health
In MEDC, poverty can be associated with poorer health and
shortened life expectancy due to obesity because calories are cheap
and micronutrients are expensive.
In LEDC, it can manifest as wasted/stunted children who do not get
enough of the right kinds of foods at crucial moments in their life
when assailed by many infections. Adult obesity is one of the risks in
populations with many undernourished young children as well as
higher mortality rates at all phases of the life cycle.
Hunger and obesity
The number of hungry people and obese people are both growing, worldwide.
Source: FAO and WHO study
Hunger and obesity
afflict poorest populations most (1)
• Root cause of chronic hunger: poverty and lack
of income generation. These also can limit
access to basic health and sanitation services
and decent housing.
• Malnutrition and food insecurity are interrelated
with poverty.
• Social disparities drive both hunger and obesity.
• Tremendous issues around affordability of food,
percentage of income spent on food.
Hunger and obesity
afflict poorest populations most (2)
Further info: Gapminder Human development trends, 2005:interactive format
Source: Food aid or hidden dumping -
Silent killers:
hunger, malnutrition and obesity
Action for students: Why
should some attention shift
from infectious diseases that
you can catch from other
people (e.g., HIV/AIDS, TB) or
mosquitoes (e.g., malaria) to
the rising burden of illness
related to obesity?
People affected
0.9 billion
Children underweight
146 million
Children overweight
43 million
Micro-nutrient deficiency
More than 2 billion
Overweight to chronic
1.5 billion overweight
500 million obese
Source: Joachim von Braun, IFPRI, September 2007;; Source: Women in Agriculture: Closing the Gender Gap
for Development, FAO, 2011; Source: Levels and Trends in Child Mortality, UNICEF, 2011
Globalisation of
hunger and obesity
Globalisation and technical innovation have reduced global inequality, but
inequality within countries has widened. The twin forces expose the food system
to novel economic and political pressures.
Image:; Source: ; Economist October 13th 2012 “True Progressivism”
Globalisation of
hunger and obesity
Action for students:
1. Define globalisation and take special note of trends and their
relevance to obesity and hunger around the world
2. In pairs, watch the Ted Talk video and explain Why “Obesity +
Hunger = 1 Global Issue”. What does globalization of obesity and
hunger mean? How does obesity in the US relate to Africa?
2. Work with a partner and discuss and record the conclusions that can
be drawn from the TED talk.
of obesity
Action for students: Label the ‘obese’ countries. Discuss: What are the factors which
have contributed to the burden being so high in the various countries? Looking at the
following slide, what are the trends around the world? Record your agreed answers in
your folder
Source: Map not
dated in source, but website up to date (2013)
Public health
Obesity is an issue that is as complicated as undernutrition and it
is far more complex than personal lifestyle choices.
• Double burden countries. India is the best example. High
prevalence of low-birth weight and childhood undernutrition and
rapidly increasing prevalence of adult obesity
• Mexico: now the most obese country in the world. Excessive
consumption of sugar-sweetened beverages, in large part driven by
a long history of water-borne illness in the water supply (e.g., poor
sanitation, contaminated drinking water)
• Food policies: the US government with a forty-year history of
subsidising corn and soy bean farmers – resulting in a large source
of cheap calories , but lead to high calorie, cheap food that coerce
the poorer quintiles of the population into consuming less nutritious
food that promotes obesity.
Image fact food:
Physical factors
Apart from social disparities and being at the bottom of the
income distribution, physical factors cause obesity. These are
influenced by the food and physical activity environment in
which people live.
Further info on obesity causes and source:
Genes (a
Too much
Prenatal and
early life
Poor diet
Too little sleep,
too little exercise
of obesity
In many countries around the
world, being obese is now the
biggest driver of sickness,
because it raises the risk of,
for example, diabetes, heart
disease, stroke and some
cancers. It is also linked to
the increased incidence of
osteo-athritis of the hip and
knee (major cause of hip and
knee replacements)
Source:; The Economist December 15th 2012;
Impact of obesity
• Individuals bear the bulk of the burden, but in many countries the
state covers some or most of the associated and growing healthcare
• The prognosis of those who do fall ill depends on where they live
and whether they have access to health care. This can be a major
issue for the poor living in the US and India, for example, where
there is very high quality health care for those who can afford it.
• The social consequences go beyond increased health costs and
National security concerns. In the United States, where health care is privatised
for approximately half of the population, obesity is seen as a national security
issue because so many military recruits are unfit (overweight). Similarly in
China, childhood obesity is becoming a major concern, resulting from increased
wealth (better and higher caloric diets) at the intersection of the one-child policy.
– Economic concerns: lost work days due to illness ultimately impacts productivity.
Obesity and social
inequality in the UK
Obesity prevalence for adult women increases overall with greater levels of
deprivation regardless of indicator used, whereas only occupation-based and
qualification-based measures show differences in obesity rates by levels of
deprivation for adult men.
Highest level of educational attainment can be used as a measure of socioeconomic
status. Obesity prevalence goes down as levels of educational attainment go up for
both women and men.
Action for students: In
pairs, explain why
malnutrition and disease
work in a deadly cycle
and are driven by
inequality and note
down your agreed
answers in your folder.
Adult obesity prevalence by highest level of education
Health Survey for England 2006-2010
Adult (aged 16+) obesity: BMI ≥ 30kg/m2
Further info and source: Health Survey for England;
and Factsheet
epidemic (1)
Since 1980: significant increases in global obesity** rates, the rate has
nearly doubled
Rises in obesity-related chronic diseases poses threat to individuals,
health care systems and economies (e.g., cardiovascular disease diabetes
type 2, musculoskeletal disorders — especially osteoarthritis, some cancers
(endometrial, breast, and colon).
Since 1990: rise in childhood obesity.
Obesity has now reached epidemic*** proportions globally. Most prevalent
in high-income countries, the obesity epidemic is also spreading to low- and
middle-income countries as countries move up the income scale.
Sixty-five per cent of the world's population live in countries where
overweight and obesity kills more people than underweight.
Obesity: Body mass index (BMI) of 30 or higher. Body mass index is defined as the individual's body
mass divided by the square of their height
Overweight: 25 BMI or higher.
** Rate “A measure of the intensity of the occurrence of an event. For example, the mortality rate equals the
who die in one year divided by the number at risk of dying. Rate—A measure of the intensity of the
occurrence of
an event.“(
*** Definition of epidemic and pandemic:
epidemic (2)
Action for students:
Based on the article below, research and discuss
in a group of four:
1. What are the trends by regions?
2. What are the differences by gender?
3. What social disparities drive the globesity epidemic?
• Globalisation of obesity
• OECD 2012 Update:
• Articles on obesity trends by region:
Obese children
43 million overweight and obese pre-schoolers worldwide
35 million of whom live in developing countries.
Action for students:
1. Research latest data for obese children for the countries on the graphs and
add to the graph and chart on this and the following slide.
2. What conclusions can you draw about obesity in children in England
compared to the other countries on the graph?
Transition paradox;
• Developmental transition: better food and nutritional status;
urbanisation and globalisation as countries become more
developed. Urbanisation and meat consumption rising hand in hand
• Nutrition transition: shift to food with high energy density
especially fat “stone age appetites meeting capitalist abundance”
• Life style changes especially less physical activity
• Social disparities in obesity are unabated. Obesity shifting
disproportionately to poor.
• Paradox: persisting underweight along with rising obesity within the
same country, sometimes household.
images:; The Economist September 1st 2012 “More or less”
Busy bee or
couch potato?
There are worryingly high rates of inactivity. “Since the beginning of the industrial revolution,
technology and economic growth have conspired to create a world in which the flexing of muscles is
more of an option rather than a necessity”
– The Economist, July 21st 2012, p. 78
Convergence of diets and lifestyles globally:
More globalised food tastes such as westernised habits of meat eating, more dairy
which takes more energy to produce and drives future grain consumption.
– Media encourages the food transition from traditional diets of grains and
vegetables to often high protein and fats and sugars, westernised dietary habits and
lower physical activity levels. Globalisation can mean that there is a switch from
associating being obese with being rich to with being poor.
– With rising income rising middle classes in transition economies such as China are
changing their food habits (China more quickly than India for various reasons)
More choices and less active life style in urban areas
Mechanisation of farm activity, switch from subsistence farming to high yielding cash crop
also imports bad eating habits to rural areas. Food transition drives obesity and heart
disease health risks and changes in the social and physical environment of production
The shift to foods that are far more resource-intensive to produce such as meat puts
pressure on scarce resources.
Source:; Edexcel Student Guide Unit 4, Option 3;
Shifting consumption
Action for students: The issue is with what we eat
– too much meat! Watch the Mark Bittman Ted Talk
clip and Michael Pollan Oprah interview and write a
paragraph supporting or disagreeing with the
statement that we must reduce meat consumption
Image above Joachim von Braun Popkin, B., The World is Fat;
Image of McDonalds;
Consumption culture
Many consider obesity a personal decision or weakness, but
actually a culture of consumption with much broader forces
must be at work given the growing scale of the problem around
the world.
Many answers to deal with obesity have to do with culture and the
food system and are not medical or personal, but the chronic
health problems created in part by the food system tend to be
medicalised by healthcare systems (hooking us up to machines
and onto medicines).
Double pyramid
Environmental impact of food choices
Transition Paradox
and globesity (1)
Action for students:
1. Looking at the PowerPoint “World Is Fat: New Dynamics Shifts in
Patterns of The Nutrition Transition”
view note in your folder what is meant by transition paradox.
2. Using the information in the slides in this section write a report
explaining the Nutrition transition and the consequences it may have
for food supply, agriculture and health in non-western countries and
regions. OR Write a plan, an introductory paragraph and
methodology for a report: The nutrition transition is at the root of the
growing global obesity (globesity).
Transition Paradox
and globesity (2)
Cartogram: proportion of
underweight children by country
Action for students:
Label the countries with the biggest burden such as India, Pakistan, Nigeria, Bangladesh and the
Relate this worldmapper cartogram to earlier one on human development – is the proportion of
underweight children related to development?
Equal area cartogram*
Food availability and access
do not always mean a good diet
Availability and access to good
food alone do not suffice for
balanced, good nutrition, which is
necessary for optimal growth and
mental development.
In Bangladesh (see Figure 3),
for example:
• 65 % of women live in households
with food security, but 1 in 5 food
secure women are malnourished
• Still 26% of children in wealthiest
households are stunted!
Obesity prevalence
over time
Child obesity
on the rise
Converging diets
Rising food
Global meat production and consumption is projected to rise by 70% between 2000 and 2030
and by 120% between 2000 and 2050. This growth and land degradation drive an increase in
fertiliser use (IAASTD 2009)

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