(December 2008) On Dec. 10, Barry M. Popkin, professor of nutrition at the University of North Carolina at Chapel Hill and director of the UNC-CH's Interdisciplinary Center for Obesity, visited PRB to discuss rising obesity worldwide and his new book, The World is Fat, published by Avery in December 2008.

The global confluence of changing diets, increased food marketing, access to technology, and lifestyle changes has led to an upsurge in global obesity, especially in developing countries. According to Popkin, 1.3 billion people are overweight while 800 million are underweight. As people become more sedentary and gain access to cheaper food, including animal products, oils, and caloric beverages (which Popkin feels are especially problematic), the amount of calories people ingest far exceeds their energy expenditures. The social and economic costs of this rising public health problem will be immense and the burden of obesity-related diseases is shifting rapidly toward the poor. Although government action across the board is required, Popkin pointed out that it is much easier to garner political will and public support to address hunger than obesity. Obesity carries a social stigma and the public does not understand its negative social, economic, and health impacts.

Popkin took some time before his PRB policy seminar to answer a few questions on his research.

Seeing how your book is a play on Thomas Friedman's book, The World is Flat, how is the trend of rising obesity in the developing world tied to globalization?

It's a play, but it's a reality. Essentially, we've had in the high income world for over 100 years some obesity but everywhere in the world we've seen a marked shift from the late 1980s to the present, in particular in every country you think of as the Third World…That acceleration is very much related to huge shifts in the marketing and availability and pricing of food and beverages to huge changes in accessibility, and all sorts of modern technology…Take for example a village in Chiapas…a Mayan village. Five to seven years ago, there were no roads to it. People were living a very simple life, they made their tortillas, they grew their grain and so on. All of a sudden, the Pan-American highway comes in and goes near them, boom, all of a sudden you see Coke and Pepsi everywhere, you see electricity, you see a shift—the men are all heavy, the diet has shifted. They buy tortillas produced in other places, they have gas stoves…This is played over wherever you go in the world in a range of different ways. People are no longer walking or biking to work or carrying their produce to the village themselves and are using buses or tractors…the technology at work has cut [caloric] energy expenditures immensely. There's not a place in the world where you can't get access to TV…and home technology. When I started working in China in 1989, no one had refrigerators. Very few had stoves. Today, 70 percent have refrigerators in their homes. They have microwaves, rice cookers. All of these little changes change [caloric] energy expenditures and they change what people eat and buy. And so you go one step further and talk about the modern food sector. Essentially in 1990, 15 to 18 percent of pesos spent in all of South and Central America was spent in supermarkets, a decade later, 65 to 70 percent. Now, closer to 80 percent of all money spent on food in cash goes to supermarkets. These shifts—and it's not all Wal-Mart or Carrefour, it's local equivalents as well—this globalization of the food distribution system, globalization of technology, all of these things meld together.

You've previously said that this is largely a problem of the poor but is it also a problem of the cities? Is it tied to increased urbanization?

Initially, it affects the urban areas the most. The availability of modern technology and processed foods, the political wherewithal that gives them access to cheaper food than in rural areas, the penetration of modern supermarkets all reach urban areas first…The most rapid increases in obesity in recent years are in the rural areas of the globe. Rural Mexico is not different from urban Mexico today in the way they look. They may have started a little later but today 71 percent of women and 66 percent of men are overweight. In China, over 30 percent are overweight and obese. It's happening everywhere…I have a friend who came back from working in rural Haiti and told me that in their hospitals, they're seeing diabetes and obesity in the midst of all of this hunger and famine. It's this confluence of these forces, be it lower global food prices over the past 30 years, increased access to modern processed foods, the super penetration of caloric beverages, and the technologies, it's all going hand in hand.

Do you see a link with population growth?

In terms of quality of population, yes in terms of poverty and health. In terms of quantity, clearly the age pyramid is shifting in the world. Particularly in countries where the fertility has really gone down quickly like China, the age pyramid has shifted toward older and older. As that happens, people are living longer and these chronic diseases are going to debilitate them…obesity debilitates, it does not kill…smoking kills. Obesity will kill in the end, but you'll be sick for a long time.

So then you have wider social costs.

Yes, you have much wider social and economic costs than smoking in that sense. Over half of the 20 to 25 countries with half of the adults overweight are in the Third World. The poverty and burden of diabetes and obesity on the poor is just emerging. It's there in South America, it's there in China, it's there in the higher income places in Southeast Asia, it's there in the Middle East, but the rest of the world, it will be another decade. But by 2015, the world will be fat and the fat in the world will be poor. The rates of change are pointing that way. Even with the global food price changes, that just hurts a subset of the poor, it actually may shift people away from beef and pork but it won’t shift people away from oils or sugars.

The increasing demand for meat, global food transport, and packaging of foods have huge environmental impacts, don't they?

Right. You're getting a global tsunami occurring. On the one hand, you have water being depleted slowly…on the other hand, animal foods is the biggest user of water…it enhances environmental degradation over basic staples of fruits and vegetables. We got that side of the nutrition transition playing into environmental and water problems. Then you have the energy crisis which you would think would push back against this because it will increase the costs of all these energy-rich products, like beef, against ones that are less energy intensive—like grains and legumes. But the world has been shifting to more and more animal foods. It may slow down, but it's not going to change. India will keep buying more dairy, China's going to keep eating more pork and poultry…It will penetrate more urban areas in Africa. These problems of transition all play together to exacerbate problems that can only be dealt with by macroeconomic and major government decisions. Very few governments have the guts right now to even take on the animal food aspect of the problem.

How do you address the argument that people should be free to make their own decisions?

Clearly, there are enormous externalities on health costs and debilitation on society. Obesity and diabetes don't directly affect the health of your neighbor in the same way as smoking. There's no passive effect. But the social and economic costs of having people without feet and toes and who need insulin are huge. We're at a point where in some areas of the Middle East in 10 to 15 years, 20 percent of the adults will be debilitated…The economic costs become so huge that the public good becomes concerned with the health costs of debilitated people and countries therefore have the rationale to move forward as you do with any public good such as highways, clean water. And when 1.6 billion people in the world are obese and the rates are not slowing down, you've got to do something. Some countries like Mexico are desperate and are taking serious action. I'm working with their congress on taxation issues and essentially banning caloric beverages in some locations. The U.S. is way behind. Believe me, more countries will be moving on this in the next three to five years.

Is there a tension between the interests of private food companies and public oversight?

I don't think it's a tension with private processing per se…There are proactive policies in the food industry. In a number of countries, we're going to have this program called Choices where all food in grocery stores will be labeled…We're going to be moving toward that in a number of countries including the U.S. The food industry is willing to start moving but in the end, government action to create level playing fields is critical. If McDonald's says "we're going to cut portion sizes," but Burger King says "I'm not," unless the government says "Everyone has to do this," it's not going to work. In the case of the developing world, the global actors to some extent have a little bit more of an ethical side partly because they're being watched by their home countries and are more vulnerable to public opinion. The local equivalents and processors are actually much more unsanitary, much richer in calories and trans fats. So we need to create a level playing field not only between companies in a sector, but between global and local. It will happen eventually. How costly will it be before we get there, who knows?


Eric Zuehlke is an editor at the Population Reference Bureau.