The world ‘is experiencing an accelerated epidemic of diet-related non-communicable diseases. Unbalanced and excessive food and nutrient intakes, often closely associated with other changes in lifestyle that include less physical activity, stress, tobacco smoking and excessive alcohol consumption, underlie a range of these diseases. These include coronary heart disease, hypertension and stroke, various cancers, non-insulin dependent diabetes mellitus, obesity, dental caries, gall bladder disease and osteoporosis1.
Obesity has emerged as a world wide epidemic not only prevalent in the affluent and developed countries, but is also appearing rapidly in less wealthy and developing countries. One of the explanations for obesity and other non-conimunicable diseases is the ‘Barker’s Hypothesis’, the basic concept of which is that factors affecting the fetus and the young have long lasting effects and are important causes of diseases later on in life2. Under-nutrition in utero and in infancy may cause ‘programming’ of the body in such a way that it may lead to a number of diseases in adulthood, including obesity. Popkin and other researchers have presented another hypothesis of the Developmental and Nutrition Transition. Various papers from the developing world describe the concept of the nutrition transition, which is a sequence of characteristic dietary and nutritional patterns resulting from large shifts in the overall structure of the diet, correlated with changing economic, social, demographic and health factors3. These changes are associated with a high prevalence of obesit , particularly childhood obesity4.
Pakistan is still in the early stages of the nutrition transition. High rates of intra—uterine growth retardation. low birth weight and subsequent malnutrition are seen. Most work done on children has concentrated on malnutrition, and obesity has not been studied adequately. However. the National Health Survey data set clearly shows the double burden of under—nutrition and over-weight in adolescents and adults. More adolescents are under weight than overweight, while the opposite is true for adults5. With the high prevalence of stunting in children and a shift in dietary and lifestyle patterns, countries like Pakistan may experience a larger burden of stunted-obese individuals in the next few decades.
There is a great need to coiiduct representative surveys of the population to study the changing trends in the dietary and life style pattern of Pakistani families and their consequences on the health of the population. It is essential to analyse whether obesity is more closely associated with stunted children in Pakistan: to see whether these trends follow into adulthood: to assess whether there is evidence to prove the hypotheses mentioned earlier. This paper is a review of the relevant literature. The main focus is on the developmental transition and its impact on the developing countries. A number of people have studied these changes in vanous countries. The present paper analyses the situation in Pakistan. in the light of the international literature and the limited local data that are available. The paper further assesses Pakistan’s stage of development and discusses the implications of this transition on health. Some recommendations are made especially in terms of directions for policy makers.
Obesity is becoming an increasingly important public health issue. It is not just restricted to affluent countries, but the prevalence is increasing in developing countries as well. In some of the Latin American and Asian countries, not only is adult obesity seen, but childhood obesity is also an emerging problem. Obesity is very closely related to a number of non-communicable and chronic diseases.Moderation in food, to maintain appropriate energy intake and body weight47.
Recognize energy needs decline with age and decreased activity17.
Avoid excessive intakes of fat, especially saturated fats and cholesterol48.
Increases the intake of complex carbohydrates and dietaiy fibre and limit the sugar intake to moderate levels48.
Combat the use oh alcohol and tobacco48.
Moderation in salt use47.
Eat plenty of fresh fruit and vegetables48.
Promotion of healthy lifestyles, such as physical activity48.
Improvement in the working conditions48.
‘The child is father to man’, is the principal on which this hypothesis is built. The concept is that factors affecting the foetus and the young have long lasting effects and are important causes of diseases later on in life. During growth associations have been tbund for glucose intolerance in spurts, which are periods of sensitive and critical growth in fetal life and infancy, the actual ‘programming’ of the body takes place2. The timing of these critical periods of development differs for different tissues6-8. As growth depends on nutrition, the foetus responds to a lack of nutrients by adapting a slow rate of cell division. Hence each brief period of under-nutrition may permanently reduce the number of cells in a particular organ. In this way under—nutrition in utero can have lasting memories on the body6. Barker’s group of researchers also showed that it is the disproportionately short, thin or small baby that is associated with diseases and risk factors, and not the proportionately small babies. These have a slow growth trajectory. an adaptation to continuous under—nutrition, which evenly reduces the demand for nutrients in fetal life6,9.
Coronary heart diseases and associated conditions such as hypertension, insulin response to glucose, cholesterol metabolism, blood coagulation and hormonal settings have been shown to he associated with foetal origins in England7,10 Sweden11 and South India12. Similar adults exposed to famine in Netherlands8. for ischaemic heart disease in Sweden11, for non-insulin diabetes and obesity14.
Animal studies show that rats that are malnourished in utero or in early childhood become overweight adults when put on unrestricted In humans, exposure to famine in early pregnancy and low birth weight have been associated with adult obesity and greater waist to hip ratio, respectively. Improvement in the socio-economic status and diet subsequent to childhood malnutrition are thought to strengthen these associations8,17.
Critique of Barker’s Hypothesis
Barker’s hypothesis is in line with the body of research of the past fifty years on the deferred effects of fetal exposure to underweight, famine, viral infections, atomic bombs, hormonal treatment during pregnancy and smoking18. None of the studies done actually measure the nutritional intake of the mother or the baby. Early malnutrition is inferred indirectly from fetal and infant growth18. The studies mostly use conveniently available cohorts, mostly from developed countries, where malnutrition is relatively less common. Little attention has been paid to issues like selection bias and confounding, inconsistencies in evidence, the fact that the hypothesis is not rigorously tested and is usually broadly stated18,19. Also the fact that twins who have restricted fetal growth, do not suffer from a greater risk of mortality than the general population18,20. It is not that the hypothesis has been rejected. but it requires more careful testing before it can form the basis for national policy18.
Development and Nutrition Transition
As opposed to the above work on the ‘programming hypothesis’. there is research that suggests that socioeconomic, epidem iological, demographic and nutritional factors may be responsible for the emergence of a considerable excess of obesity in the developing countries.
The prevalence of under-nutrition is very high in Pakistan and has not reduced mitch over the years. The prevalence of stunting in children under five years has reduced very slightly from 43 per cent in 197721, to 42 percent in 198622 arid 36 per cent in 19925. Whereas wasting in the under five year olds has remained almost static being 9 percent in 197721, 10.8 per cent in 198623 and 9 per cent in 19925. In spite of the fact that a large burden of malnutrition persists in the country, the problem of obesity has started to emerge5. Unfortunately, trends on obesity are not available.
Although the surveys done in the 70s and 80s21,22 were specifically nutrition surveys, they did not report on obesity. The main thrust of both the Micronutrient Survey of Pakistan 1976-77 and the National Nutrition Survey 1985-87 was on studying under-nutrition other aspects such as dietary pattern, infant and child feeding practices, etc. were also studied21,22. The later survey does look at overweight and obesity in pregnant and lactating women, but the indicator used is body mass index (BMI). which is riot useful i,i determining the hea lth status of the pregnant mothers. As pregnancy and lactation have been reported together, the prevalence of obesity cannot he determined for lactating mothers either. It is possible that these surveys did not aim to look at obesity, even though the problem was there. On the other hand it is more likely that during the 70s and 80s, obesity was not perceived as a public health issue and hence not studied. Even in other countries of the South Asian region, mostly under-nutrition has received attention and it is only recently that over-nutrition has been looked at23.
The National Health Survey 1990-94 (NHS), does report on obesity5. About I percent of the population was reported to be obese and 5 percent overweight in the 15-24 years age group. In the older age group i.e.. 25-44 years, the prevalence increased to 6 and 15 percent for obese and overweight, respectively5. Along with obesity, figures for other degenerative diseases are also high5. A comparison with two cross sectional surveys in Brazil supports the findings that underweight has decreased over 5 years in both children and adults, whereas obesity has increased in adults but not in children24. Pakistan like many other third world countries is experiencing a double burden of health problems. This double burden is typical for countries passing through the developmental transition, whereby poverty is slowly being eradicated and varying proportions of the populations ach iev ing affluence23.
The developmental transition encompasses a number of transitions within it. It involves demographic and epidemiological transitions as well as health and nutrition transitions, which occur simultaneously.
Figure presents these changes, which have long since been recognised in the developed world. The developing countries are now passing through the same process. However, the important difference is that the transition in the developing countries is much more rapid than in the developed countries and along with it the technological advancement is not as rapid. Therefore the developing countries are in for a greater impact, such, as China is already experiencing23. In China the nutritional problems have become bipolar—problems of deficit among the poor aiid problems of excess in the rich. Brazil. on the other hand is experiencing an increase in the problems of dietary excess, and because food security is not a problem, a decrease in under-nutrition25. The enormity of the task at hand is not yet fully recognised by most countries23.
The third world countries are at various stages of struggle to achieve soclo-econOrnic development. The demographic transition grows out of this struggle. It is characterised by a progressively aging population, which is a consequence of a fapid decline in fertility, a decline in mortality—whether modest or significant. China is a classic example of these changes. The under fifteen population has significantly decreased, whereas the 15-64 year old group has increased, It is projected that the over 65 years age group will increase in the next decade3. This rapid process in China has grown out of the adaptation and enforcement of a ‘one-child policy’, because of which the total fertility rate (TFR)------------
studied these changes in some South-East Asian countries and found that as the population moved up the socioeconomic scale, the dietary pattern changed. Coarse grains were substituted with prestigious cereals (wheat and rice), that result in a significant decrease in the amount of fibre intake. The consumption of green leafy vegetables remained low, but the fat intake increased, so did the animal food and sugar. Overall the energy consumption increased iii relation to the energy expenditure. The beneficial change that Gopalan found was an increase in the use of legumes, fruits and vegetables23,35.
Table shows a comparison of trends in the consumption of food in Pakistan and in China.
interestingly, the data from Pakistan over the decade from 1978 to 1988 shows a tremendous decrease in the consumption of sugar, fats and oils. in spite of this, the number of grams used per person per day is still very high. Similar is the case of milk products. These is. however, an increase in the consumption of meat, vegetables, roots and pulses. There is a dire need to conduct up to date surveys to assess the trends now. Health professionals need to probe further into the issue and assess the causes and the implications of these dietary changes. There is evidence suggesting that diet composition has an association with the development of obesity36-37. This would suggest that as a consequence of consuming large amounts of fats, oils and sugars, the population could suffer from obesity.
The Western industrialised nations are spending money on programs to convince their citizens to replace dietary fat with simpler diets based on grains, vegetables and fruits and at the same time the developing nations use their meagre income increases to replace their traditional diets, rich in fibre and grains, with `Western diets’ rich in fats and caloric sweeteners4. This is perhaps because the Western fat rich diet has always been regarded as a sign of prosperity. The Chinese diet was generally assumed to be low in fat, and was thought to be a reflection of poverty, rather than concerns for nutrition and health4. Hence as income becomes better, the diet diversifies and people consume more of foodstuff that was not previously accessible to them. Jointly, this dietary shift and lowered physical activity are a leading cause of increased obesity in many low-income countries and in sub-populations in others4,38.
Association of Stunting and Overweight
Researchers have found that there is an association between stunting and obesity. In Brazil, Sawaya et al found that in both younger children and adolescents, obesity associated with stunting was more common than obesity without stunting, in both sexes39. In Guatemalan children, born in deprived communities, poor linear growth or stunting in childhood was associated with increased abdominal fatness (increased waist to hip ratio)17. These findings are the same reported from the Netherlands in 1976 by Ravel I i8 Recent work further strengthens this association. It was observed that a slight improvement in food availability in a low—income population, with high prevalence of maIn utrition and stunting. might very easily lead to obesity39. In Brazil like Pakistan, stunting is the most frequently seen nutritional disorder. In their study Sichieri R. et al (1996)40 found that high weight-for height was mainly dependent on the low stature reached by children. But researchers have asked why the pattern of stunting and obesity did not exist in earlier periods, when rates of stunting were similarly higli?41 A possible explanation is that due to pool’ socio-economic conditions, obesity was not a physical possibility. A study in Chile correlates the level of poverty to prevalence of low height-for-age in children34. With the development and nutrition transitions now, the income of people is increasing. With this is the corresponding change in lifestyle and diet that makes the situation conducive for obesity i This would explain at least part of the increasing burden of obesity in developing nations. Migrant studies have shown that given the opportunity to grow to genetic potential, people from developing countries show the same pattern of chronic diseases, as people from developed countries. McKeigue (1997)42 concluded that migrant South Asian populations develop high rates of coronary heart diseases and diabetes in association with central obesity. These patterns of susceptibility probably result from past adaptation to survival under adverse conditions. The ability to deposit fat in visceral depositions. for instance, may he advantageous under conditions of unreliable food supply and physically demanding work. The experience of migrant populations provides a window to predict the pattern of morbidity and mortality that will emerge in the countries of migrant origin42.
The Transition Stages and Pa kista n’s Position
Popkin has presented his views on how the developmental transition progresses in five stages. It would be beneficial to see where Pakistan fits into it. A brief description of these stages is given below.
The first stage is ‘the food collection stage’. People move from one place to another to hunt for food. Their diets are varied, with large amounts of carbohydrates and fibre. Nutritional deficiencies are few and the fertility rate is low. The main killers are infectious diseases, because of which mortality is high and life expectancy is low25. Before Europeans colonised Australia in 1788. the Aborigines were hunter gatherers and had this kind of lifestyle.43
The second stage of transition, ‘famine’, is characterised by a less varied diet, with periods of famine.
Social stratification begins and people start taking tip occupations such as animal husbandry and agriculture. Nutritional deficiencies emerge. from which women and children stiffer most. Fertility is naturally high, life expectancy low due to starvation and epidemics and consequently mortality-both infant and maternal-is high. In general, most countries are beyond this stage, but in some African countries famine is still seen25. In Pakistan. there are pockets such as the Tharparkar desert area, where there is little to eat and generally the features are similar to this stage. But Pakistan mainly falls between the third and the fourth stages of this transition.
Stages three and four are the ‘receding famine’ and ‘degenerative diseases’ stages. With the limited data that are available, it can be assessed that Pakistan has some features of both the stages. Crop rotation and use of fertilisers has been in Pakistan for sometime now. Women have joined the labour force, although not in equal numbers and status as men. More recently mechan isat ion and technological revolution has started, which are features of stage four.
Similar is the case of diet. The country has characteristics of stage three and is adopting those of stage four. People use few starchy staple and more animal protein. Food variety continues to he low. In the high socioeconomic strata, changes towards more fat especially: from animal sources, more sugar, processed foods and consequently less fibre can he seen. These changes are along side a shift towards a sedentary life style25. The trends towards eating out, especially fast food in increasing at a tremendous rate. The available fast foods are most ly high in fat, mainly from animal sources. These changes are typical of stage four, but to be able to actually assess exact changes in the dietaiy pattern more information is required, but is presently not available.
Stage three is characterised by a decrease in mortality, static fertility at first and then a decline, with a cumulative population growth25. The trends in both infant and maternal mortality show that although the decline in death rates in not very significant yet, there is a reduction in mortality. In 1978 the infant mortality rate (IMR) was 120/1000 births and the maternal mortality rate (MM R) was 700/100,000 live births. This has declined to 95 and 500. respectively in 199727. The crude death rate has declined from 14 to 9. I in these years. The cumulative population growth rate is 2.6127. The TFR has been fluctuating between 6.0 and 6.9 in the 70s and 80s. In the 90s it has been reported to have reduced to 5,426, While Pakistan has not reached stage four as far as fertility is concerned, which is expected to be low and fluctuating in stage four, it has the life expectancy of this stage. Male life expectancy at birth has risen from 54 in 1978 to 61 in 1993 and that of females from 53 to 60 years27. Pakistan also shows the stage four feature of growth in income and in income disparities.
On the health side the third stage is characterised by infectious diseases, parasitic diseases, polio, growth retardation and diarrhoea, which first expand and then decline. For most of’ these. Pakistan has seen the increase but the decline is yet to come. For example, the number of wasted children tinder five years has remained static over a 15-year period and stunting has reduced only by 7 percent5. Anemia was reported in 45 percent of the pregnant and lactating women in 1986 22 and 42 percentfor all childbearing age women in 19925. The two figures are not comparable, but if anything it shows that the prevalence of anemia may have increased.
Pakistan has also started to show signs of stage four health changes. Chronic diseases such as heart diseases and cancers are manifesting themselves in substantial numbers. Cardio-vascular diseases effect about 18 percent of the population fifteen years and above. The prevalence of these diseases increases with age amid is more common in high socio-economic classes and in urban areas5. It is not possible to say much about trends in chronic diseases. because ofa lack of information. There are no regular health and dietary surveys to show how disease patterns are changing amid what the causes are. Using the emergence of obesity and other diet-related chronic diseases of affluence as a crude indicator, it can be suggested that the traditional Pakistani diet is giving way to the Western diet. Hence. although malnutrition and deficiency diseases are still prevalent in the low socio-economic strata, obesity is emerging at the other end of the spectrum.
Stage five ‘the behavioural change stage’ is recognised by high industrialised robotization and mechanisation, leisure exercise grows to offset sedentary jobs: less fat processing and increased use of carbohydrates. fruits and vegetables: reduces body fat and obesity and improves bone health. A life expectancy of 70 and 80 years. with an increase in disability free life is had. lmproved health promotion, both preventive and therapeutic, leads to a dccl inc in coronary heart disease, i m proven ent in age— specific cancer Irofi le anti consequently an increased proportion of elderly over 75 years26. The developed countries are at this stage. If the developing countries learn from the lessons of the developed world and enact policies in the right direction earlier on in the transition, it may be possible to reduce the damage that stages three and four can do to the health of the Popu at on.
Im plicatiotis of Developmental Transition: Future Directives
The Government of’ Pakistan rightfully recognises the importance of nutrition on the health of people27,44,46 Improving tile nutritional status of people has been an objective for planning in its own right. A whole range of policies and programs have been suggested27-45 and separate funds allocated to it46. Under the umbrella of nutrition importance is given to the prevention of malnutrition (underweight), low birth weight and deficiency diseases27,44.
The thrust of the discussion on developmental transition is that as nations undergo transition, the demographic make-up of the country changes. It is essential that countries recognise this change and cater for the new problems that emerge with the changing population47. Hence policy recommendations in this direction are imperative. At this stage the requirements would be of a preventive nature, while in the future the requirement would be for effective treatment programs23,47. Preventing obesity and chronic diseases would require much less money than that required for treatment programs3,23. Hence keeping in view Pakistan’s position in the transition pattern and the experience of other countries, obesity and other chronic diseases are problems in which failure to articulate primary prevention measures and health awareness programs now, will lead to a waste of precious monetary resources being allocated to its treatment later. Also that prevention is the only possible way out witil problems like obesity and chronic diseases. Treatment is only marginally effective and mostly leads to weight cycling (cycles of weight gain and loss). This is more harmful than the original problem.
In no way is this arguing against the importance of programs directed towards under-nutrition17. But the fact is that a major cause of under-nutrition in Pakistan is the maldistribution of food and is therefore preventable46. What is needed is a shift in tile resource allocation formula: to bring about a balance in the money spent on under-nutrition and over-nutrition3.
Experience from China3,25, Thailand25, India23, Latin America25 and African countries24 suggests that tile traditional focus of developing countries on poverty and deficiencies leads to resource allocation in this direction only. It is important not to magnify the problem of deficit or distort resource allocation, which might actually hurt the poor who then start to suffer from problems of dietary excess. The promotion of one unified, balanced diet is required, instead of special diets for the two groups25.
It is important to emphasize the relationship of nutrition to the development of chronic diseases and obesity. Chronic diseases related interventions must not be entirely focused on medical interventions but should also include food and nutrition guidelines and other educational interventions related to nutrition24. Yet no isolated nutrition program can effectively deal with this problem alone23, what is required is an integrated food and nutrition policy. This demands inter sectoral collaboration. Not just the heaitll sector policy, but all sectors need to be aware of tile impact policies have on the health of tile population. Health is a by-product of decisions that are being made in agriculture. politics, economics. public works and the like48. Hence all policies should be “healthy public policies”. Tile Government of Pakistan recognises this in the Ninth Five Year Plan45, but needs to take steps to implement it. Norway is one country that has effectively been able to develop an integrated policy49 and the effects on tile health of its people can be clearly seen4,25.
There is a lot to be done, before Pakistan can reach the goal of developing an effective nutrition and health policy. lnfornlation øn dietary trends and changes taking place over time need to be assessed. There is a dire need for a central data collection unit, which collects information on an on-going basis, analyses it and gives feedback to the Government and the people. Such information would form the basis of appropriate guidelines for the population. It must be remembered that great caution needs to be exercised when suggesting guidelines for the general population47. There need to he National goals, strategies and recommendations for children. adolescents, pregnant and lactating women48. To be effective, these strategies should be culturally sensitive, grounded in tradition and values that promote ilealth and well-being33.
In general the recomnlendations shoti Id include the fol lowing:
Educating the public is very essential. Educational programs should start very early in schools and be reemphasized through other programs such as community awareness campaigns. mass media and health professional45
. Children in schools can be reached through nutrition education curricula, fitness programs and modification of school meals to meet the suggested dietary guidelines27,45
Mass media is a good way to reach a large number of people. The recent campaigns for family planning and use of iodised salt have been fairly successful in raising awareness. Television, radio, cinema, press and other sources cover almost the whole population27,46
The lady health worket’s (LHW) program also has a great out reach. A lot can be achieved in terms of educating the public through lady health workers. As education is the only thing that works out and goes a long way, investing in it is the most efficient use of funds23,27
The role of Non-Governmental Organizations (NGO) and Community Based Organizations (CBO) cannot be emphasized enough. Such organizations work at the grass root level, with the people and know the actual limitations and problems of the people. They can effectively help develop workable guidelines. Developing partnerships between the public and private sectors, involving industries, shopkeepers association, consumer groups, health and medical associations in educating the public and providing healthy food stuff help build the spirit of good nutrition27
Monitoring and surveillance systems need to be strengthened at local, provincial and national levels33
. No program can succeed if monitoring, evaluation or feedback is inadequate. These systems must have links back into the community. otherwise the exercise is fruitless. The timeliness of the feedback and action is of the essence23
To develop a coherent policy, it is imperative that governments focus on the whole, and not part of the picture. Running supplementary feeding programs can oni work as a trigger for improving the health status of the people. as India has experienced23
. They are costly and cannot be sustained, The change has to be in income and food affordability, in production and availability of foodstuffs. arid in the social structure of our societies, in order to reinforce women’s health along with that of their families. Accessibility to good quality and appropriate health services and improved literacy and awareness of health issues, such as family planning must play central roles.
Developing countries like Pakistan are at a cross road, where the issues of deficit and the issues of excess exist together. It is time the third woi’ld realises that obesity, cardiovascular diseases, diabetes and other diseases of ‘affluence’ are not issues on the agenda for only the developed world, the are being plagued with them at an even faster rate. It is not enough to reduce mortality and increase life expectancy; it. is also essential to improve the quality of life of the people.
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