Obesity and Diabetes in the Developing World — A Growing Challenge

Globally, the prevalence of chronic, noncommunicable diseases is increasing at an alarming rate. About 18 million people die every year from cardiovascular disease, for which diabetes and hypertension are major predisposing factors. Propelling the upsurge in cases of diabetes and hypertension is the growing prevalence of overweight and obesity — which have, during the past decade, joined underweight, malnutrition, and infectious diseases as major health problems threatening the developing world.1 Today, more than 1.1 billion adults worldwide are overweight, and 312 million of them are obese. In addition, at least 155 million children worldwide are overweight or obese, according to the International Obesity Task Force. This task force and the World Health Organization (WHO) have revised the definition of obesity to adjust for ethnic differences, and this broader definition may reflect an even higher prevalence — with 1.7 billion people classified as overweight worldwide.1
In the past 20 years, the rates of obesity have tripled in developing countries that have been adopting a Western lifestyle involving decreased physical activity and overconsumption of cheap, energy-dense food. Such lifestyle changes are also affecting children in these countries; the prevalence of overweight among them ranges from 10 to 25%, and the prevalence of obesity ranges from 2 to 10%. The Middle East, Pacific Islands, Southeast Asia, and China face the greatest threat. The relationship between obesity and poverty is complex: being poor in one of the world's poorest countries (i.e., in countries with a per capita gross national product [GNP] of less than $800 per year) is associated with underweight and malnutrition, whereas being poor in a middle-income country (with a per capita GNP of about $3,000 per year) is associated with an increased risk of obesity. Some developing countries face the paradox of families in which the children are underweight and the adults are overweight. This combination has been attributed by some people to intrauterine growth retardation and resulting low birth weight, which apparently confer a predisposition to obesity later in life through the acquisition of a "thrifty" phenotype that, when accompanied by rapid childhood weight gain, is conducive to the development of insulin resistance and the metabolic syndrome.
The human and financial costs of obesity are also mounting: a higher body-mass index (the weight in kilograms divided by the square of height in meters) has been shown to account for up to 16% of the global burden of disease, expressed as a percentage of disability-adjusted life-years. In the developed world, 2 to 7% of total health care costs are attributable to obesity. In the United States alone, the combined direct and indirect costs of obesity were estimated to be $123 billion in 2001. In 2004 in the Pacific Islands, the economic consequences of noncommunicable diseases, mainly obesity and diabetes, amounted to $1.95 million — almost 60% of the health care budget of Tonga.2
The growing prevalence of type 2 diabetes, cardiovascular disease, and some cancers is tied to excess weight. The burden of these diseases is particularly high in the middle-income countries of Eastern Europe, Latin America, and Asia, where obesity is the fifth-most-common cause of the disease burden — ranking just below underweight. The high risk of both diabetes and cardiovascular disease associated with obesity in Asians may be due to a predisposition to abdominal obesity, which can lead to the metabolic syndrome and impaired glucose tolerance.