And so the list goes—on and on and on.1
Much of the interest in obesity by the world press is prompted by surveys done by health ministries in various countries showing increased prevalence.2 Escalating problems are clear in China, Canada, and Cameroon; Samoa, Spain, and the Seychelles; Poland, Paraguay, and Palau, just to begin.
Dr. Stephan Roessner, a scientist from Sweden and President of the International Association for the Study of Obesity, said, “There is no country in the world where obesity is not increasing. Even in [developing] countries we thought were immune [such as Zimbabwe and Gambia], the epidemic is coming on very fast. The frightening thing is that so far nobody has succeeded to stop it.”3 The World Health Organization (WHO) has declared obesity a global epidemic.4
The first major WHO obesity report, which declared the global epidemic, was in 1998. Only four years later, the WHO presented a picture even more dire.5 More than 25 percent of Egyptian children are obese; the numbers are similar for Chile, Peru, Germany, and Mexico. Fifteen percent to 20 percent of four-year-olds are obese in Zambia and Morocco.
Obesity is increasing across all segments of society, adults and children, young and old, rich and poor, males and females. Rates are rising in Alaskan Eskimos, the Evenki (reindeer herders in Siberia), and the Walpiri (Australian Aborigines).6 Few pockets in the world are left untouched.
The simple answer is that people are eating more and exercising less. Why this occurs is more complex.
“Because they can” is a glib but probably correct answer. Economic factors, globalization, increasing urbanization, advances in energy-saving devices, and the glamorization of high-calorie, high-profit foods by the food industry, to name a few of the likely explanations, interact with biology to make overeating and sedentary behaviors very likely (see Chapter 2).
Physical inactivity joins eating as a central explanation for rising obesity. An article in the Wall Street Journal noted that:
• Swedish lumberjacks who may have burned 7,000 calories per day in heavy physical labor are being replaced by machines.
• Highway construction in Malaysia is being done with heavy machinery rather than picks and shovels.
• Bicycle sales in areas of China are declining and more people are buying motor scooters.7
Barry Popkin from the University of North Carolina has coined the term “nutrition transition” to explain global changes in diet.8 He has done the most thorough global examination of nutrition and activity changes, and defines five nutrition patterns that characterize different countries at different times:
• Pattern 1: Collecting Food. Food comes from hunting and gathering. The diet is high in carbohydrates and fiber and low in fat. Activity levels are high and there is little obesity.
• Pattern 2: Famine. Diet is less varied, scarcity occurs, and malnutrition is common. Obesity is rare.
• Pattern 3: Receding Famine. Consumption of fruit, vegetables, and animal protein increases as do inactivity and leisure time.
• Pattern 4: Nutrition-Related Noncommunicable Disease. The diet is high in fat, cholesterol, sugar, and other refined carbohydrates, and low in polyunsaturated fat and fiber. Sedentary behavior increases. Obesity increases as does chronic disease.
• Pattern 5: Behavioral Change. The desire to prevent disease leads to changes in diet and physical activity, sometimes self-driven by consumers and other times stimulated by government action.
Many countries are in pattern 3 or 4. In particular, many developing nations are making a rapid transition from receding famine to energy-dense diets and declining physical activity.
A good example is Popkin’s analysis of China, an important case study both because the population is so large and because the Chinese experience may portend what occurs in other countries. The percentage of calories from fat in the Chinese diet was 10 percent in the 1970s, but now one-third of families eat a diet with more than 30 percent of calories from fat. The number of televisions has risen dramatically, and the number of jobs requiring physical labor is decreasing. Popkin points out that as countries like China have advanced from food shortages to a healthier diet, the line is quickly crossed where eating too much and weight gain become key concerns:
Changes in diet and activity patterns are fueling the obesity epidemic. These rapid changes in the levels and composition of dietary and activity/inactivity patterns in transitional societies are related to a number of socioeconomic and demographic changes.9
Nation after nation is experiencing the same social, economic, and technological forces that have crafted America into an obese nation. High-calorie food is becoming more available around the globe. Technology’s steady march forward is removing physical activity in most countries. Diseases caused by poor diet and inactivity follow on the heels of the changing environments.
Many cultural changes can increase eating and diminish activity. For instance, the growth of urban centers increases distance between masses of people and those who grow food, exposes people to more prepared and fast foods, and makes physical labor less likely. As another example, more women entering the workplace means less time (and economic incentive) for meals to be prepared at home.
Many factors contribute to obesity in a nation. Some are probably not yet recognized. The balance of factors varies from culture to culture, so the entire blame cannot be placed at the feet of any one cause, any one food, any one company, any one institution, or any one national policy. To say, however, that all foods, companies, institutions, and policies bear no blame is also shortsighted.10
It would be convenient but wrong to blame the global epidemic only on the spread of American food. Other factors (like declining physical activity) are influential, but it is also the case that eating outside the home is rare in countries like India and China and that food patterns are determined much more by local factors than by outside influences.
The American experience is instructive to the extent that factors damaging diet and activity in the United States are occurring around the world. American food and lifestyles entering other countries may signal problems in the making.
Perhaps more than any American export, our food has powerful symbolic importance to the world’s inhabitants. Both revered and hated, our food represents affluence and innovation. People in China, Australia, Spain, or the Bahamas may buy a Big Mac or have Kentucky Fried Chicken not only because the food tastes good, but also because it represents the perception of a good life. They buy a dream.
American food also represents the bloated U.S. lifestyle and American domination of the world. It may portend, in the eyes of non-Americans, obesity, poor health, and disability, along with takeover of local culture and further enrichment of America. Fair or not, our food generates strong feelings.
The spread of American food involves many companies. Coca-Cola, for instance, is in 200 countries selling 230 brands.12 Frito-Lay, now part of PepsiCo, sells its snack foods around the globe. Mars Incorporated, makers of M&M’s, Twix, Milky Way, Snickers, Starburst, Skittles, and more, has an M&M’s website with messages in Danish, Spanish, Portuguese, and other languages.13 The most controversial piece of the food picture, however, is fast food. Being the leading purveyor, McDonald’s draws both admiration and ire, and it does so around the world.
Over half of McDonald’s sales come from outside the United States; Asian-Pacific sales alone accounted for almost 18 percent of that total in 2000.15 With its 30,000 restaurants in 118 countries, McDonald’s has a key global impact.16 McDonald’s opens a new restaurant every 17 hours17 and is the world’s largest user of beef.18 KFC has more restaurants outside than within the United States.19
McDonald’s modifies its selections to suit local needs, of course. Monthly, 3.2 million customers in India avoid taboo products such as beef and pork (Muslims are not to eat pork, and the Hindu religion holds cows sacred) and have a mutton burger called the Maharaja Mac. Respecting the many vegetarians in India, McDonald’s separates vegetable and meat products during cooking.20 McDonald’s and its partners are planning to invest about $75 million dollars in the Indian market to more than triple the number of restaurants.21
In China, McDonald’s has 350 restaurants and a workforce of 38,000. Workers make less than U.S. wages, but are paid more than many other employees in China, causing college graduates to line up for job opportunities.22 Japan has more than 3,000 McDonald’s franchises serving rice dishes and a fried chicken sandwich with soy sauce and ginger. Thai customers order Samurai Pork Burgers, a teriyaki-spiced sandwich that may have contributed to the chain’s 10 to 15 percent increase in expansion in 1999 alone. Hong Kong has 158 franchises, which is one restaurant for every 42,000 residents, not far from the U.S. number, which approaches one restaurant for every 30,000 Americans.23
McDonald’s is not the only fast-food company with a strong foreign presence. In New Delhi, India, seventeen McDonald’s are joined by twenty Domino’s Pizzas, eleven Pizza Huts, and nine Wimpy’s franchises.24 In 1989, Kentucky Fried Chicken was the first foreign fast-food franchise allowed to enter China. It has 490 outlets and a twenty-year goal of 5,000 franchises. A Nielsen poll ranked KFC the most recognized foreign brand in China, over Coke, Nestle, and Mickey Mouse. Chinese outlets have the most per-store sales worldwide.25
Pizza, considered by some the most representative of American fast foods, is a big seller abroad, creating fierce competition among chains such as Pizza Hut and Domino’s. The top seller for Domino’s in Japan is a pizza with mayonnaise, potatoes, and ham or bacon, while those in Hong Kong want Cajun spices and satay, according to Pizza Hut. The Thai request lemongrass and lime on their pizzas; people in England want tuna and sweet corn. Domino’s has 2,094 chains in sixty-one countries, while Pizza Hut maintains 4,000 outlets in ninety countries.
Foreign fast-food companies competing in their own countries against American chains have learned American tactics. Bangkok restaurants have begun delivery service, following in the footsteps of KFC. Almost half of KFC’s orders there are filled by delivery.26
What makes McDonald’s, KFC, Coca-Cola, Pizza Hut, and Dunkin’ Donuts thrive overseas? Certainly they are “pushed” into countries by American business interests, but there is pull as well. The foods taste good for the biological reasons discussed in Chapter 2. Technology inspires the economy, hence more people have more money and eating out is a treat. More demanding work makes convenience and “fast” food more attractive. Whether or not American food survives abroad, its presence reflects changing conditions.
Fierce debates occur over the place of fast food in foreign cultures. On one side are arguments that the companies simply respond to demand, so by definition their presence is accepted, even wanted. They provide local jobs, may purchase local supplies, and in some cases are owned by local businesspeople (who can cut their way through extensive red tape). One-quarter of McDonald’s foreign outlets are owned by local individuals.28 Some locals welcome the introduction of standards for cleanliness, foods they feel are safe, and even clean toilets.
Fast-food franchises are special in some cultures because of novelty and well-known advertising icons and because all things American are held in awe. Local people are known to save money to expose their children to “American culture” at fast-food chains, buying less expensive food for themselves later.
At the same time, there are worries that fast-food franchises threaten local customs and values and represent the worst of American influence. Complaints of homogenization of culture and standardization of cuisine are common, along with disapproval of local money going to U.S. companies.29
There have been protests in more than fifty countries at McDonald’s restaurants alone.30 Regular protests by anarchists occur in Paris and London.31 Restaurants in Prague and Cape Town have endured attacks such as bricks hurled through windows.32 Hindu activists have demanded that the Prime Minister shutter all McDonald’s in India, which they consider an affront to the culture (especially after revelations that McDonald’s used beef products to make its French fries).33 Protests in New Delhi caused police to increase security and surveillance around all fast-food outlets. During the American bombing of Afghanistan from Pakistani airspace, Pakistan’s Kentucky Fried Chicken outlets became targets for stoning and riots by virtue of their association with American culture.34 Mexico’s most famous living artist, Francisco Toledo, led a campaign to prevent the opening of a McDonald’s restaurant in the main square of Oaxaca, a colonial city famous for its food.35
KFC entering India has become a celebrated case study in resistance to globalization.36 The first KFC in India opened in 1995. Tens of thousands of people protested. Many stories emerged, including one in which local officials accused KFC of selling carcinogenic foods to farmers who protested anticipated changes in local agriculture. Farmers joined with antiglobalization demonstrators to pressure KFC in places such as Bangalore, and KFC has since abandoned business in India.
In Fast Food Nation, Schlosser notes: “The overseas critics of fast food are more diverse than America’s old Soviet bloc adversaries. Farmers, leftists, anarchists, nationalists, environmentalists, consumer advocates, educators, health officials, labor unions, and defenders of animal rights have found common ground in a campaign against the perceived Americanization of the world. Fast food has become a target because it is so ubiquitous and because it threatens a fundamental aspect of national identity: how, where, and what people choose to eat.”37
History provides foreign nations with an opportunity no longer available to the United States. America has grown wise to the negative effects of poor diet and obesity, but poor foods and the companies selling them are cemented into both the U.S. economy and the American psyche. The horse has left the barn.
Most countries are not this far down the road. If alert to early signs of change, early response may be possible. Among the signs are:
• diminishing activity as a part of work
• diminishing activity in day-to-day life (transportation)
• more time devoted to sedentary activities (television, etc.)
• more opportunities for eating (food in schools, vending machines, restaurants, etc.)
• more eating out and snacking and increasing portion sizes
• increasing availability and promotion of energy-dense foods
• economic forces that encourage unhealthy eating (less time to prepare meals, etc.)
The United States can change only by retrofitting an entrenched and toxic environment. Other countries may be able to create a better fit between modernization and healthy lifestyles. Preserving native cultures may be one leverage point, but preventing the ravages of poor diet and inactivity is sensible on economic and humanitarian grounds. Countries can seize this special opportunity by shaping policies to their needs. Regulating food advertising may be possible in some countries, as may keeping poor foods from schools, helping children walk or bike to school, instituting food labeling regulations, and so on. Regional or even worldwide efforts might be especially powerful.
A number of countries in the world are alert to the obesity crisis and are beginning to take action.38 Creative approaches are being tried, some with good results, but most programs are in the early stages of being evaluated. There is much countries can learn from one another.
In Mauritius, a small, developing nation in the Indian Ocean, people had very high levels of cardiovascular risk factors and diabetes. One problem was a universally used cooking oil called ration oil that is high in palm oil (high in saturated fat). A five-year program began in which the government reduced palm oil in cooking oil and launched a program that encouraged lifestyle changes. This effort produced impressive changes in diet and cholesterol.39
One of the earliest and most extensive lifestyle change programs occurred in Finland, centered originally in the district of North Karelia. In the early 1970s, Finnish men had the highest rates of heart disease in the world. To improve diet and other lifestyle factors, an ambitious program was launched that included education, TV announcements, and work with food and catering companies.
Over a period of twenty years, striking changes were made. The number of people using butter on bread went from 60 percent to 5 percent. Similarly, the number of people drinking fatty milk declined from about 40 percent to about 6 percent. Use of vegetable oil for cooking went from 2 percent of the population to 34 percent. These are only a few of the positive developments. From 1971 to 1995, the rate of ischemic heart disease dropped by 73 percent in North Karelia and 65 percent in all of Finland.40
Brazil has undertaken a variety of programs to improve diet. Labeling is now required for packaged foods, legislation has been enacted to improve school food programs, work sites have been targeted for educational programs, and major efforts have been used to educate the public about healthy eating. Results are not yet available, but the Brazilian effort has shown that consensus requiring the input of multiple parties (health professionals, government, businesses, schools, etc.) can be reached and that creative programs can be implemented.41
A National Plan for Nutrition in China, along with programs for smoking and physical activity, has been implemented in recent years. With pork and fat intakes increasing and soy intake decreasing, efforts are being aimed at increasing vegetable consumption in northern China by using price adjustments and subsidies and increasing the conception and production of soybean products. Limited results have been reported thus far, but China is one of the few places where policy changes such as altering the price of food have been tried.42
Many countries are following the regrettable path taken by the United States. Diets grow worse, physical activity declines, and obesity increases. The U.S. experience has shown the extraordinary cost of waiting too long to act.
Nations at the early stages of the problem are in an ideal position to anticipate what looms ahead and to inoculate their citizens. We suggest that nations be aware of the warning signs mentioned above, but in addition they need to:
• Be aware that programs to feed hungry nations can overshoot the mark. Providing calories at low cost is a priority when shortages are the issue, but when availability of poor foods becomes extreme, overnutrition can supersede malnutrition as the top priority.
• Track the prevalence of obesity in both children and adults. Increasing prevalence in children in particular should be considered an ominous warning.
• Resist the temptation to blame individuals for the problem and to rely solely on calls for personal responsibility. The environment will overwhelm any such efforts.
• Recognize the need to intervene early and to address the problem of prevention in children. Treatment is difficult, costly, and not very effective, so prevention is an obvious focus.
• Do not permit the negative influences of food companies to flourish without challenge. Brand loyalties and preferences for certain foods can be difficult to reverse once established. Regulation of advertising may be a necessary step. Children need to be protected from inducements to eat unhealthy food.
• Enlist institutions designed to protect children, such as schools, to avoid contributing to poor diet and inactivity. They should be engaged as agents for positive change.
• Develop and test strategies for intervening in local environments. Encouraging local creativity is likely to generate many new approaches that may be adapted for use elsewhere. An example is a system for setting local priorities developed by Boyd Swinburn and colleagues in New Zealand that is sensitive to local customs and takes advantage of local resources.43
• Establish a culture in which promoting unhealthy food is unpopular, much as the United States has done with tobacco. Public pressure on celebrities to endorse only healthy products and popular publications refusing to advertise some products are examples of changing a culture. Each such move helps mobilize public opinion.
Obesity, poor diet, and physical inactivity are problems around the world. Many factors are responsible, but some common economic, social, and cultural themes are clear. There are opportunities for the world to learn from America’s history, its mistakes, and its innovations. Many countries may have the opportunity to intervene before the environment grows so bad it can no longer be subdued.