‘All Poor Everything’ – The Food System, Poverty and the Double Burden of Disease

Based on the fact that the term ‘malnutrition’ has been redefined to include undernutrition AND overnutrition, it’s safe to say that malnutrition is now a global problem. However, even though it’s no longer just about starving children in Asia and Africa, it is about obese children in Europe and America…AND Asia and Africa. Yes indeed, thanks to globalisation and the nutrition transition, poor people in poor countries with poor diets and poor healthcare are now dealing with potential obesity epidemics and all the trimmings that come with it; including the chronic diseases once associated with the more affluent parts of the world such as cancers and heart disease and hypertension. So, all of this new burden is being piled on top of an existing burden of infectious diseases associated with undernutrition, which has actually gotten worse (See A Broken Food System…). So yes, poor people in poor countries with poor diets and poor healthcare (which I will now refer to as P to the 4th power or P4, or ‘All Poor Everything’) now have to battle against a double the burden of disease with the same malfunctioning, mediocre healthcare system they’ve always had – which is apparently seventy-six doctors for every one hundred thousand people; not to mention poor infrastructure, poor sanitation, poor road systems and poor electricity supplies (Pearson and Jordan, 2010) – talk about reverse progress.

So in addition to the 800 million people suffering from what is called ‘chronic hunger’ – “not consuming enough energy to lead a normal life”; another 600 million people are consuming too much energy to lead a normal life, suffering from what is called ‘obesity’. On top of this, another two billion people are deficient in essential micronutrients. In fact, here’s a not-so-fun trivia question: What do children’s diets in India, Kenya, Senegal and Guatemala all have in common? Answer: They are all deficient in micronutrients (vitamin A, Iodine and Iron) that are oh-so important for their optimum growth.

I think that everyone can now agree (at least I hope so) that this state of nutrition chaos is all down to an incredibly messed up food system – from the policies to the production to the processing to the marketing to the purchasing to the preparing to the consumption to the wasting. Yet the link between the human food system and human health is a relatively recent one and a difficult one to make at that, as audacious as that might sound – (like which other species relies on their food system to keep them healthy?) Worse yet are the links between agriculture, nutrition and health: the food you grow becomes the food you eat, which provides the nutrients you need to keep you in good health – sounds like a no-brainer right? Well apparently it’s more complicated than that; so complicated that some of the highest incidences of chronic hunger and childhood stunting are found in agricultural regions and in the households of small-scale farmers – people that grow food for a living. Let that one sink in…

To explain this complication, I find it fitting to use a quote made by Uncle Ryan from ‘Everybody Hates Chris’ – “you can get it good and cheap but not fast; fast and cheap but not good; or good and fast but not cheap.” Indeed he was referring to passport photos for a fake ID, but it can apply to the global food system as well. For many P4 people, food is either not available or not accessible, of really bad quality, or simply way too expensive. Not only that, but in those cases where food IS available AND affordable AND of good quality; some people apparently either don’t have the knowledge of how important this food is for their health, or have neither the time nor resources to prepare it, for whatever reason; be it too busy working in a fast-paced urban environment, or limited water to wash and cook with in a rural setting.

So change is needed – and not just any change, but quick and drastic change; something radical… like a food revolution; a total reshaping of the food system. So how do we go about achieving this? Some experts recommend that this should begin with governments improving national food policies to make them more sensitive to the nutrition needs of their population. Given that undernutrition during infancy and childhood can lead to poor cognitive development, permanent IQ loss and a decreased potential for lifelong learning; perhaps the emphasis should be placed on the economic impact of poor nutrition instead – after all, everyone talks, but money usually has the first say. So it may be momentarily heart-breaking to hear that three million children die every year because of undernutrition; but the fact that that undernourished children go on to earn 20% less when they become adults compared to those that were well nourished; and that Africa and Asia stand to lose eleven percent of their Gross National Product every year due to poor nutrition; and (one more) that chronic diseases can cost the global economy $35 trillion US dollars by 2030 might motivate more of a response.

Part 2: More expert recommendations – coming soon

Source: Healthy Food for a Healthy World: Leveraging Agriculture and Food to improve Global Nutrition. Sponsored by the Chicago Council on Global Affairs


References available on request


A Broken Food System and its Link to Disease Burden

The increasing burden of chronic noncommunicable diseases: 2002 - 2030.

Source: US Department of State and the Department of Health and Human Services

The stark reality that close to one billion people in the world are undernourished, while on the opposite spectrum over 1.9 billion people in the world are either overweight or obese (WHO, 2015; FAO, 2014); is by any scale a clear reflection of a broken food system. The long-term/indirect consequence of such a defunct system is a high disease burden of both communicable and non-communicable diseases (NCDs); given that research has long indicated that undernutrition has a hand in communicable disease susceptibility, while obesity increases the risk of developing NCDs (Black et al., 2013).  In fact, many low income countries are now facing a double burden of both communicable and NCDs (Black et al., 2013). For instance in 2010, over two million deaths in Sub-Saharan Africa were attributed to NCDs; a 46% increase since 2000. During the same period, deaths related to communicable diseases increased by 17% (Naghavi and Forouzanfar, 2013). This is an important public health concern that undoubtedly requires urgent government responses via policy actions.

Scientific evidence suggests that the promotion of healthier diets such as increased consumption of fruits, vegetables and wholegrains; and a decreased consumption of animal fats, and sodium through effective policies can be a crucial prevention strategy for minimising the global disease burden (Hawkes, 2012). These sentiments were reflective of  points raised in a recent public lecture given by Dr Corinna Hawkes, a research fellow at City University in London; some of which will be shared in this post.

Dr Corinna Hawkes

At the Food Thinkers seminar organised by the Food Research Collaboration at City University on April 22nd 2015, Dr Corinna Hawkes presented her research and thoughts on the links between the foods we consume, the wider environment and its relation to the food system, and the need for a collective approach to solution-oriented thinking. With well over 15 years of experience in research and analysis of the global food system, Dr Hawkes highlighted the importance of identifying the clear but often understated relationship between food systems and NCDs.

While indicating that there is no clear or single solution, Dr Hawkes mentioned that food and health researchers can benefit from working backwards: from the picture of an ideal food system that consists of an optimum food environment with adequate individual dietary habits, backwards to the problems of the current broken system.

“It is okay to get lost”- Dr Corinna Hawkes

In her talk Hawkes mentioned an argument regularly presented by the food industry that individuals themselves are responsible for their food preferences and choices. However, she also highlighted the interconnections between personal food preferences and the impact of the food industry; given that food preferences are learnt during the course of a person’s life and are influenced by a range of environmental factors that are underpinned by the food system. Hawkes also urged for policy makers and policy protagonists to remain patient, as changes in food preferences among the general population should not be expected to occur overnight.

Dr Hawkes spoke of her experiences in Cape Town, South Africa where she observed a poor food environment in some of the poorest communities. Within such communities, Hawkes observed high levels of obesity among women and high levels of stunting among children. This is in conjunction with findings of the South African National Health and Nutrition Examination Survey (SANHANES-1), which indicated that 11.9% of girls at birth to 14 years of age were overweight and 4.8% were obese, whereas 24.9% of women 15 years and older were overweight and 39.3% were obese (Shisana et al., 2013). South Africa actually has the highest prevalence of female overweight (69.3%) and obesity (42%) in Sub-Saharan Africa, which even surpasses the United States (Ng et al., 2014).

Hawkes noted the high consumption of cheap, fatty foods such as polony: a paste-like meat product produced from mechanically deboned meat (MDM) under high pressure. Polony is a popular food in South Africa, particularly in low income areas. Approximately 122,391 metric tons of polony was imported into South Africa in 2011, 90% of which came from Brazil. In addition to its high saturated fat content, the high-pressure conditions under which it is produced exposes the end product to the risk of microbial growth (EFSA). Despite its poor health profile, polony remains a cheap source of protein that is mostly affordable to the poorest of South Africa’s population. It is also an important commodity for the local food processing industry. Therefore, with regards to seeking policy solutions for healthy eating, Hawkes suggests that it cannot be as simple as calling for a ban on polony or other unhealthy foods; but rather for other ways that governments can support the availability of healthy food such as improving the capacity of production and promotion; which in this instance would be whole chicken production and other healthier sources of protein.

In line with the theme of the food system impacting on the food environment, which in turn influences food preferences; Hawkes gave the example of the marketing of unhealthy foods to children. Of particular mention was Coca-Cola, whom according to Hawkes has grand ambitions of increasing their point-of-sale presence to the point where you will be able to purchase a Coke within a 100 metre radius of every person on the planet.  Indeed such companies specifically target younger people via mass media advertisements (Stupar et al., 2012). To stress this point, Hawkes included quotes from executives at PepsiCo India and KFC respectively.

“We are focused on working our way into the skin of younger people” PepsiCo, India

“The philosophy is, if you get them in grade school, you’ll have them until they’re ninety” – KFC executive, Hungary.

Hence schools are a main target for the food and beverage industry. In fact, as a result of their huge advertising budgets, companies such as Coca-Cola are able to infiltrate millions of schools. Hawkes highlighted that as there is little consolidation among schools, many are not in a position to negotiate or bargain for better terms or healthier products.

Reiterating the point that there is no single solution to fixing the food system, Hawkes closed her talk by mentioning that there are elements of truth in every proposed solution. She encouraged researchers to have the courage to strategize and make judgments on how best to create change, as well as to try to understand the experience of others.

According to Hawkes’ most recent article published in the Lancet (2015), in order for food policies to have its desired effect on improving this food system, it must cater to the “preference, behavioural, socioeconomic, and demographic characteristics of the people they seek to support, are designed to work through the mechanisms through which they have greatest effect, and are implemented as part of a combination of mutually reinforcing actions”. The article went on to suggest that developing healthy food preferences for infants, children and disadvantaged populations should be an utmost priority for policy development and implementation. Therefore, the connection between the individual food preference and the wider food system should be made in order to identify specific problems and develop and implement effective policy actions.

Email for reference list: keiron.audain@gmail.com