Published On: Thu, Feb 5th, 2015

How middle-income countries became fat – podcast transcript

Mexico has overtaken the US as the country with the biggest weight problem in the world, according to the UN’s Food and Agriculture Organisation.

SB: Sarah Boseley

MdeS: Moira de Swardt

SR: Sandeep Ruder

JKS: Jomo Kwame Sundaram

TL: Tim Lobstein

NC: Norma Castillo

SV: Dr Salvador Villalpando

ELD: Eva Lilia Delgado

AC: Alejandro Calvillo

CG: Cristina Gutierrez

[Jingle: The Guardian]

SB: Moira de Swardt works for the St John Ambulance service as an administrator.

MdeS I’m vastly obese, what they call morbidly obese. And I’m really battling now with mobility issues. I don’t actually know what my weight is because I’m over the 150kg that the scale picks up. So I have no real idea of how much I weigh exactly.

SB Moira has lived in Johannesburg, South Africa, all her life.

MdeS I’m on the Tim Noakes diet. This is low carbohydrates and then high fat.

SB Most people think obesity is a problem for countries like the USA and the UK. But the diet and lifestyles that caused the obesity epidemics in affluent nations are being exported all over the world. Middle-income countries like South Africa and Mexico now have a massive problem and it is only a matter of time before the poorest are in the same plight.

Sandeep Ruder is an endocrinologist at Charlotte Maxeke Johannesburg Academic Hospital.

SR South Africa is a melting pot of various cultures and even economic dynamics. So the reasons would be the traditional reasons that you see in the first world, first of all, and that would relate to urbanisation, change in diet, high caloric content foods, sedentary lifestyles. And you’ve seen that with urbanisation. So people moving into cities, more office jobs, access to high calorie foods and becoming sedentary really.

There’s also a bit of a perception issue. So, within a South African black culture, being overweight, or just being larger in size, is associated with a perception of health, being rich and well off.

MdeS I think South Africans eat a lot of meat, really. And I don’t know that I eat more meat than other South Africans. So I think the biggest culprits are the sugars and the carbs.

SR When you look at the figures, 56% of females are overweight to obese. And in that category, predominantly it’s the black females that have the highest prevalence of being overweight and obese. Whereas in the male category, it’s the other way around; so white males are the most overweight and obese of the 25% that are overweight to obese. And black males fall last into the category; whereas mixed race and others in between. So I think it’s quite a mixed dynamic.

I think with the middle class in South Africa they are more aware of body weight, they do perceive overweight and obesity at an earlier stage, and studies have shown this, whereas in black patients that perception is not there; it’s underestimated.

MdeS Statistically, I think we were about number four in the world, so yes, obesity is a problem in South Africa. It’s part of the fact that South Africans don’t tend to exercise in the normal course and scope of their daily life. We hop into our cars and we drive to places that in other parts of the country we would walk to.

In our particular lifestyle, I think food is ubiquitous and we are very proud as South Africans of our hospitality which comes with some of the lovely traditional cakes and foods that we make in South Africa.

JKS We have well over 800 million people who are hungry, who are chronically hungry. We have well over two billion people who suffer from at least one micronutrient deficiency.

SB This is Jomo Kwame Sundaram. He is assistant director-general for economic and society development at the Food and Agriculture Organisation of the UN.

JKS In the past there was simplistic assumption that overweightness and obesity have to do with what was rather callously referred to as overnutrition or overnourishment. And it was presumed that it had to do with wealth. Now we understand, and in fact, in the richer countries of the world, the ones who are more likely to be overweight and obese are likely to be those from the lower income groups. And in fact it is in the middle-income countries where the problems of obesity and related non-communicable diseases are growing fastest.

SB Tim Lobstein is the director of policy and head of research programmes at the World Obesity Federation in London.

TL I think unless there’s a critical famine going on, then yes, you’ll find these patterns now in Bangladesh, you’ll find them in Zimbabwe, in Zambia and so on. You’ll find these problems of undernourishment in some impoverished areas, and then excessive fats and sugars intake, particularly in urban areas and amongst those that can afford access to these processed foods. So it’s a transition from inadequate supplies, or perhaps adequate but not commercialised, to rapidly commercialised supplies. And the commercial products coming in for lower-income countries tend to be these soft drinks, fortified noodles; various products which may have some nutrients in them, but they don’t have the full range of fruits, vegetables, lean meats and so on that we’re all recommended to eat.

America is no longer number one on the obesity charts. According to a study released last month by the United Nations Food and Agricultural Organisation Mexico just inches past – pun intended – the United States as the fattest nation …

SB You could argue that this might be the price of development, that as people become more affluent, their diets change. That’s certainly the case in America and the European Union. And following in their footsteps are middle-income countries like South Africa and Mexico.

SB I went to Mexico a year ago to find out how it had come to have the highest levels of childhood obesity in the world, and the remarkable campaign that was fought to do something about it.

In today’s programme, we hear from some of the people I spoke to for my book, The Shape We’re In. We’ll hear from those affected by obesity, the clinicians trying to help them and the campaigners trying to turn back the tide of processed food and drink in Mexican society.

I’m Sarah Boseley. That’s all to come on this global development podcast from The Guardian.

Norma Castillo first took her daughter to a hospital when she was eight. It was to look at marks on her skin, so she went to a dermatological ward, but they were quickly referred to a clinic that specialises in obese children. At the time, the eight-year-old Maite was 20 kilos overweight.

NC [Translated] I remember that she was always robust when she was little. Well she was a little, let’s not say fat, she was filled out. I didn’t see any problem with it. But when we came here and they told me that she was 20 kilos overweight, the truth is that I got worried. I never thought it was that much.

SB This is her daughter, the now 16-year-old, Maite.

Maite [Translated] I feel like food is a refuge where I can forget my problems. I like sweets a lot, they lift my spirits.

SB The obesity clinic Maite found herself in was run by Dr Salvador Villalpando.

SV We started out probably in 1999 when we feared that there was 24% of kids between five and 11 years of age overweight or obese. And then it started trending higher in the national survey in 2006 – it was around 32%; and now we’re around 34% which is very, very worrying. We thought there would be small changes that should be done, but they didn’t work and now it’s getting a lot more complicated.

Safety in the streets, you know, kids won’t go outside to play because there’s no security. Food-size portions, you know, we have very Americanised food-sized portions.

SB Eva Lilia Delgado lives with her son in Ecatepec on the outskirts of Mexico City. A place that is currently badly affected by violence.

ELD [Translated] You can’t let them go and play, or go to the park, because there is lots of violence and insecurity and they steal children. And I don’t have the money to buy a stationary bike, which is what I would like to do so that he gets some exercise.

SV What we do here at the hospital infantile is that we try to design interventions that work for our community. You can find in medical literature that there are many designs for trials to make kids lose weight, but they don’t have that big an impact. So what we say here is that when we get to obesity we’re too late. When we have to treat obesity we’re too late.

SB The results of treatment have not been encouraging.

SV We’re doing as well as probably any other clinic that has to deal with kids with obesity. So we can take 18% of the obese kids down to overweight. The big problem is that when they stay at home, they’re not coming back to the clinic, we see them after six months and we only keep like 6% of the total amount of kids without obesity of that same group. That means we have 94% of failure, 94% of failure after one year of treatment. It’s a lot of failure.

SB Tim Lobstein.

TL We haven’t seen very successful treatment for children. We’ve seen some successful treatment for seriously obese adults, through surgery. There are some drug trials that are proving fairly successful, but this isn’t really the way to go for preventing obesity; it is a way to go if all you’re going to do is treat it. But that’s an expensive solution, particularly if you go down the surgical route, that’s hugely expensive, and not really the way we would like to see the world develop. We don’t want to see people get obese, get seriously ill and then have surgery. That isn’t the ideal situation.

But there are treatment plans available to help children. They’re not necessarily very successful because children, once you’ve got their weight down, then, if you like, throw them back into a highly obesogenic environment where they’re being encouraged to overconsume again; the ads are on television – the soft drinks and fatty foods and sugary cereals are all very cheap and highly promoted and they want them. So you end up putting children back into a situation where they’re going to put weight on again.

SV Yes it’s very discouraging. But still, you see, there’s a huge problem and somebody’s got to do something about it. Kids will still be coming into the clinic and we’ll have to show some interest in their achievements. You have to set your mind on that.

SB David is 13. He’s about one metre fifty tall and weighs 57 kilos. He should probably weigh around 44 kilos.

David [Translated] I think everyone’s exaggerating. I think it is normal. I think it is fine really. There’s nothing wrong with being a little fat.

SB So can Mexico kick its addiction? Dr Villalpando.

SV How do we do it? It’s a secret! No, it’s no secret. We lower the … recommended for their age. Sometimes just stopping soda, quitting out soda makes a huge difference. I can tell you about two kilos loss in one month just because of stopping soda.

SB Can sugary drinks really be the cause of Mexico’s troubles? Alejandro Calvillo is a leading consumer activist from the campaign group El Poder del Consumidor.

AC We have the highest consumption of soda in all the world. We have an average 153 litres per person on soda a year. This is 30% above the United States’ consumption. That is the second country in soda consumption.

SB Johan is 10 years old. He was taken to the hospital with a pain in his gall bladder. His grandmother, Cristina Gutierrez, looks after him.

CG [Translated] Before we drank two bottles of soda a day in the house. Bottle are three litres.

SB There are lots of reasons why Mexico has such a love of soda. In rural areas where there wasn’t clean drinking water, Coke’s phenomenal distribution system ensured there was always a bottle of Coke on the table. And even in the cities, where there is clean water, people rely on soda. Dr Villalpando.

SV There was some sort of issue back in 1985 in Mexico City right after the earthquake, when water pipes were broken and polluted and they started consuming bottled water. We just lost the tradition of drinking water out of the faucet. And I think it has to do with that. And in some instances there is more availability of soda all over. Back in 2009, there was a law that forbid sodas inside schools. I know it works inside the schools, but outside of school there is no limitation on that.

SB Alejandro Calvillo again.

AC Coke promotion is everywhere – hospitals, the schools. Now we have regulation in schools and we are trying to implement this regulation. And also a problem is that the government not do anything in campaigns and not give a guarantee of bottled water, not for schools, not for houses. We have a problem of access to bottled water. But also we don’t have any kind of programme to promote filters in houses. And at the same time that we are the highest consumer of soda, we are the highest consumer of bottled water.

SB Added to this was a government seduced by big business and afraid of losing industrial growth.

JKS It was a sort of a standing joke in many nutrition communities in discussing Mexico that you could not expect otherwise – a former president of a leading popular beverage company became the president of the country. One should not be too surprised to find that there are these kinds of changes.

SB Jomo is talking about Vicente Fox. He was the former head of Coca-Cola in Mexico and became the country’s president in 2000. He was there for six years.

SV The previous government had a very particular trend of protecting work sources and big industries like that, like Coca-Cola. I don’t know if Coca-Cola are really big, but there has been some sort of protection for these kind of industries. And you can see that happening in junk food and soda legislation for schools. There was a lot of scientists and medical societies were against having any sort of the food inside the schools. And the last call was made by the economy ministry which was very interested in not losing a large market of foods. I don’t know the food bill was around something around $4bn a year in all the schools. So they weren’t willing to lose that market. The whole act softened because of the economy ministry.

AC If you look at the economy minister in Mexico and they are not fighting, they are very close to industry. The soda tax came from the minister of finance. And the other regulations, this regulation inside the schools came from a long battle from the National Institute of Public Health and the National Institute of Nutrition. And the regulation marketing also came from the battle of many years. It’s something that I think that also I never listen to the health minister talking about that we need to have more strict regulation on marketing or better labelling. They support the level in development by the industries.

SB This advert, campaigning for a soda tax, has been the result of years of campaigning. The three main broadcasters in Mexico refused to show it, but cable channels and the internet got the message across.

[Mexican advert]

AC The soda tax began the 1st January of 2014 and the taxes are around 10% of the price and it’s in sodas or any drink that have sugars added.

SB What might be surprising is the way in which the campaign came about. Tim Lobstein again.

TL We’ve seen a fascinating example in Mexico where the government was fairly reluctant to take any initiatives, it was under the thrall of food companies, largely. And then in came a $10m donation from Bloomberg philanthropists to local non-governmental organisations to campaigns and advocacy groups, who campaigned vigorously on having a soft drinks tax, on having limitations on advertising of junk food on television. And thanks to that impetus, they’ve seen those changes. Whether we’ll get a change in child obesity I don’t know, but the soft drinks tax has certainly reduced the consumption of soft drinks in that country. And we’re hoping the junk food advertising bans will also have an impact there.

So that’s an interesting example, because that isn’t your usual use of philanthropic money. Normally you will see it go to places like rural schools for health education development or something for young mothers or something like this. Here, it went directly to campaigning organisations campaigning on government policy issues. And I think that’s a fascinating change and an interesting development in world policies.

SB But Calvillo doesn’t think the tax in Mexico goes far enough.

AC We asked for a 20% tax that all the international literature and the recommendation was to have an important reduction in soda consumption you need to improve a tax of 20%.

The government we asked to put this money that came from the tax for health promotion and also to introduce drinking fountains inside all the schools. But the finance minister and the government, federal government, they denied to give … to the resources for a special tax because they say that if it happens one time, this will happen all the time. And they say they are putting more money for health issues and for prevention than the money that they are having now through the tax.

SB It’s not just about Big Soda. Ten companies control most of the packaged food that is exported around the world and processed food – or as one expert I spoke to calls it, “ultra-processed” food – is causing a lot of the harm.

And that’s not just in Mexico – it’s everywhere. People have stopped cooking traditional meals from fresh produce, or even if they do, they supplement it with snacks, so calories have gone up massively.

And there’s precious little that can be done for those who are already obese. Cristina Gutierrez is listening to Dr Villalpando’s advice, hoping her grandson, Johan, can be one of the 6% able to keep the weight off.

CG [Translated] We don’t drink soda anymore. We have changed the kind of soups, the carbohydrates, we have changed the biscuits. We used to buy two boxes of biscuits a day. We eat less dairy too.

SB In the face of such odds, all the real change has to come from government. And regulation of the food and drinks industries is getting the attention of health ministers in other middle-income countries.

TL There are foundations and there are movements to support these sorts of approaches. I think we may see something developing in India. We may see some actions in southern Africa, particularly South Africa, where there are moves to strengthen government policies on restricting advertising to children. And across the world there are now increasing concerns about not only breast-milk formula feeding, but also complementary foods that are being sold in place of traditional weaning foods. And there is the fear that these commercialised complementary foods transfer children not from a milk-based diet to family foods, but from a milk-based diet to a taste for highly processed foods. So that’s another area that both the World Health Organisation and our organisation are concerned about.

SB Is very much happening in South Africa at the moment?

TL South Africa, as far as I can recall now, they have got some legislation in process to restrict advertising to children and to improve the labelling of foods. I don’t know what sort of political opposition that is meeting, because often enough a government health department will want to promote these sorts of actions, but the ministries of economics or treasury or trade start to resist them because they see there are some economic downsides to these sorts of controls on a market.

SB It is sometimes difficult to pass legislation, isn’t it; soda tax legislation or any other sort because you run up against the economic arguments, particularly in developing countries.

TL Well, you certainly run up against the interested industries and they put forward economic arguments saying that there will pull out and they’ll be large unemployment or whatever. But actually, if you start doing the sums about the costs in terms of lost productivity due to diabetes and obesity, or the costs to the health services, if it’s a socialised health service in any way, then there’s a social cost to high levels of ill health. Then you start setting that against the lost economic benefits, then perhaps you see a different people. And it’s well worth doing those sums because generally you come out thinking that actually doing nothing is not an option: the health crisis will cost far too much.

SB In some ways, it would be a successful solution for everybody if people went back to a traditional diet, and the farmers locally could buy the food they need which has the right sort of nutrients.

JKS Yes I think this has been done not only in China to some extent, you see some encouragement of local farmers for school-feeding programmes. But these are all considered to be subsidies. And there has been in recent decades a big push against the elimination of subsidies. So it’s only countries like Brazil and China, who are big enough, who have the means to do so, who have defied international pressures to eliminate such subsidies. But elsewhere in the world, you have very little support for such schemes, so as a consequence this exacerbates the problem.

But to be quite realistic with the high levels of urbanisation in the world, with the big push for farmers to produce cash crops rather than food crops, it is very difficult to see this as the solution. And in other words, we really need a solution which recognises that many of these changes which have taken place in the world are almost irreversible.

SB Well that’s a really terrible thing to say, isn’t it. If these changes are irreversible then we will progress to become a much more obese planet entirely, will we not?

JKS Well just to give you one instance of success. I think mid last year there was a report which suggested that in the previous decade, childhood obesity in the US had gone down by 43%. Now, that is a very impressive reduction, but it began of course with very high levels of childhood obesity. So it is reversible. And I think we should be looking towards these kinds of gains rather than in trying to reverse-organisation which is unlikely to take place, or to try to force farmers to produce food crops which might actually result in much lower incomes for them. So we need to begin to find other ways. We have health warnings on smoking, there’s absolutely no reason why we cannot have health warnings on certain types of foods, if not to prohibit such foods.

AC We need to have a more strong regulation on marketing to children, not only some hours, some programmes on TV, we need to cover all TV and we need to cover internet, we need to cover point of sale. These products now in the supermarkets it’s the signs on the box of the cereals and all of these things we need to improve this regulation.

TL The World Health Organisation has moved its agenda significantly from the focus on under nutrition to a dual focus now on ensuring adequate nutrition, but also preventing the development of non-communicable diseases, particularly heart disease, cancers, diabetes and so on, that are largely a result of this excess consumption of processed foods.

SR And I think we’re sitting on a ticking time bomb here, because it’s a very silent epidemic and you see the consequences much later. We’re now starting to see the consequences of childhood obesity later in life. So if you’ve got a large proportion of your population that are overweight at a young age, you’re going to see the consequences of that 20/30 years down the line.

TL I think obesity is here to stay as a huge issue because it’s the cause of so many other health problems, be it heart disease or diabetes or some cancers and orthopaedic problems and so on. You get a whole range of issues that are a result of obesity and which cause people to feel unwell, to get back ache, to not do their jobs so well, to lose their incomes. And these are problems for individuals, problems for families in lost income. And particularly in developing economies, you just can’t afford to have an ill labour force. And if people are moving from undernourishment to excess obesity, you’re not helping that country to grow its economy and be a healthy, thriving country.

SB Losing weight long term is incredibly hard, as anyone who has ever tried to diet will know. What we need to do is prevent people becoming obese and suffering serious health problems in the first place.

There is a lot to do, but top of the agenda, we have to tackle the availability of junk food and drink in every country.

Thank you for listening to the Guardian Global development podcast and to all our speakers. The interviews you’ve heard today were by David Smith in Johannesburg and Joe Tuckman in Mexico City – thanks to them.

You can hear more episodes of issues facing the developing world, from the environment to women’s rights, by subscribing to our podcast feed. Just head to theguardian.com/global-development.

My name is Sarah Boseley. The producer was Matt Hill. Thanks for listening and goodbye.

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