How come we are both?: The paradox between obesity and poverty

A seemingly contradictory phenomenon of the simultaneous prevalence of obesity and poverty in our population has taken hold across the world. Statistically, 2017 was reported to be the first year in a decade to record an alarming rise in the number of hungry people, according to the United Nations¹. Along with the rise in hunger, there has also been a continued aggressive rise in obesity². On the surface, this seems to be a highly unusual global phenomenon – an increase in global hunger with a simultaneous increase in global obesity. However, what is remarkable and counterintuitive is that the contradictory concepts between obesity and poverty can actually coexist within the same individual, family, or community; and practically a reality that is difficult to disentangle. Thus, it begs the question: how come we are both?

Food insecurity, hunger and urbanization as essential dimensions to this paradox

In 1990, the Life Sciences Research Office established the standard definition of food insecurity and hunger which according to them, food insecurity is defined as “existing whenever the availability of nutritionally adequate and safe foods is limited or uncertain. Hunger, in its meaning of the uneasy or painful sensation caused by a lack of food, is in this definition a potential, although not necessary, consequence of food insecurity³.” Our planet produces more than enough food to feed everyone and has for a number of years thanks to industrialization. However, food is unequally distributed and far too much is wasted. Some have access to too much, while others not enough. The increased production of low-cost, mass-produced food has made food more accessible to individuals on the unfortunate end of the economic spectrum, however, it has also led to these people consuming the wrong types of food. This kind of structure has a powerful effect on the food choices and dietary patterns, especially to low-income families⁴, because it ultimately creates a loss of diversity and nutrient adequacy in the diet which is one of the greatest factors contributing to the calorie and micronutrient malnutrition seen globally⁵. These foods are often very low in dietary fibers and higher in salt, sugar and saturated fats, with little to no nutritive value at all⁶. However, the attractiveness of these foods is actually understandable for both consumer and producer. For the consumer, especially for those people in the marginalized sectors of the society, these processed foods are so cheap and accessible, that sometimes these are just the only options that they have. Most of these families are deprived of their basic right to have access to healthier options, so they live with a diet that is inherently unhealthy. Meanwhile, mass producers are able to create large quantities of these products at minimal cost to themselves, which increases overall profits exponentially. So, while in some places this phenomenon, coupled with globalization, has resulted in a beneficial decrease in the numbers of hungry or undernourished people, it has also contributed to an equitable jump in the number of overweight and obese children⁷. And this trend has been significant and fast.

Simultaneously, aside from the result of changes in the global food system that make less nutritious food cheaper and more accessible, increased urbanization and the decrease in physical activities due to major technological shifts in the workplace, home, and transportation has resulted in less active forms of work and play. In south Asian and sub-Saharan African countries, for example, the risk of overweight and obesity has been seen to be greater among the urban areas⁷. These increasingly sedentary lifestyles, together with significant cultural shifts in consumption patterns – from locally grown, seasonal produce to highly processed, long-life products – has had profound and far-reaching effects in today’s nutritional landscape.

Other factors related to the poverty–obesity paradox

Our genes and the environment have also profound influence in determining obesity risk. Factors other than diet and lifestyle also link early undernutrition with overweight in adulthood. Supported by a number of observational epidemiologic studies, the hypothesis of “fetal origins of disease,” postulates that early (in-utero or early postnatal) undernutrition causes an irreversible differentiation of metabolic systems, which may, in turn, increase the predisposition to risks of certain chronic diseases in adulthood^8,9. For example, a fetus of an undernourished mother will adapt to a decrease in energy supply by activating genes that optimize energy conservation. This survival strategy imprints a permanent differentiation of the metabolic regulatory systems, and later in life when the adult is exposed to an unrestricted dietary energy supply, this results in an excess accumulation of energy (and consequently of body fat). Because in-utero growth retardation and low birth weight are common in developing countries⁴, this mechanism may result in the propagation of a population in which many adults are particularly susceptible to becoming obese.

Additionally, depression symptomatology has also been associated with the paradox^10,11,12,13, and may be more pronounced in women than men^14,15, and in mothers specifically¹⁶. The ‘sacrifice theory’ is a proposed mechanism suggesting that mothers adopt undesirable coping methods for the benefit of their children to protect them from hunger, such as sacrificing their own caloric intake and nutritional health¹⁷. Furthermore, women may also skip meals and then consume low-variety diets that are calorically dense but nutritionally deficient, mostly those high in fat and sugars, just to feed their families on a limited budget¹⁸. This somewhat ‘selfless’ act consequently increases their risk of gaining considerable weight, and if we can only offer band-aid solutions in reducing the vulnerability of mothers to the adverse consequences of poverty, we will continue to find malnourished children in the arms of overweight mothers.

Image credit: The Lancet Regional Health - Southeast Asia

The new nutrition reality and future perspectives

The global health community has been slow to acknowledge the challenge of the large proportion of low- and middle-income countries facing the burden of simultaneous, exponential poverty and obesity incidences⁷. This new nutrition reality is particularly important to acknowledge, because poverty, food insecurity, and hunger cannot be entirely divorced from obesity. Obesity is not only a medical issue but a socio-anthropological one, too. We often think of it as the polar opposite of malnutrition, but this is actually a common misconception. Malnutrition in all of its forms: undernutrition, micronutrient deficiencies and overweight/obesity, are closely interrelated. And economics perhaps pull much of the strings in influencing not only what food a family can afford to buy, but also where they can afford to live, greatly affecting their access to food stores, social services, public health services, and nutrition assistance programs.

So, how come we are both? Many things.

Although it is true that there is an endogenous programming deep within our biology, genetics and epigenetics that predisposes us to manifest certain metabolic phenotypes. However, the prevailing social injustices and unequitable access to healthier yet affordable food choices still present to be a major roadblock in addressing this paradox. As a society, changes need to be carried out from the household level to the production level and involve all of the supply chains in between to establish a robust food system that caters to everyone regardless of economic status. This requires that governments re-evaluate and restructure their food systems holistically. Laws around food marketing, consumer education, responsible nutrition labelling, and ethical food supply chains, are just a few of the areas that must become active advocates in the food discussion. The road to fitness is not one bicycle ride away. And until we close these gaps, we will continue to bear the double burden of malnutrition, and our prospect of building a sustainable, equitable, and healthy food future for everyone will always remain just a dream.

Finally, on a more personal note, I wish to touch more on the cultural influences of obesity such as the increasing preference to ready-to-eat foods like canned goods, instant noodles, instant 3-in-1 coffees, processed meats, microwave-ready meals, and carbonated drinks. Filipinos, in particular, are massively drawn to these so-called “ultra-processed food revolution” due to its inherent cheapness and convenience. Its increasing penetration to our family tables has completely changed on how we perceive the traditional, fresh, slow-cooked meals, especially among children and adolescents. Hence, this encourages a diet that normalizes consumption of preservative-laden, high caloric foods in place of fresh and organic ingredients, that are most often than not just within the reach of our own backyards. Thus, it goes without saying that a household that can recognize the factors that underlie obesity and make healthy eating choices is one step closer to avoiding the double burden of malnutrition and ending the vicious cycle of this paradox.

(Q.C., 05/2022)