1. 33 rd Session of the SCN Working Group on Household Food Security Obesity and poverty in nutrition transition: the case of South-East Asia Geok Lin Khor Universiti Putra Malaysia March 12-17 2006, Geneva

2. From Ancient to Modern..... Diets The Nutrition Transition Program, The University of North Carolina at Chapel Hill

3. From Ancient to Modern..… Work The Nutrition Transition Program, The University of North Carolina at Chapel Hill

4. From Ancient to Modern..... Transport The Nutrition Transition Program, The University of North Carolina at Chapel Hill

5. Demographic and economic indicators Population (million) GDP /capita (USD) Life expectancy M F Malaysia24.4925370 75 Thailand62.8724867 73 Philippines80.0523165 71 Indonesia220.0339065 68 Vietnam81.4284768 74 (WHO, 2002)

6. Selected health indicators

7. Leading causes of mortality

8. Co-existence of obesity and poverty The prevalence of overweight adults appears to increase as the nutrition transition advances – an expected association?

9. Prevalence of overweight adults (aged 15 years and above) in Southeast Asia % (WHO Global InfoBase Online 2002) (BMI ≥ 25 kg/m 2 )

10. Trends in availability of total calories and calories from animal products in Southeast Asia, 1965-2003 (per capita per day) (FAO Food balance sheets) Total calories Calories from animal source products

11. Dietary changes associated with nutrition transition in SEA As household income becomes less the primary constraint to procuring food: home-cooked food increasingly replaced by ready- to-cook and ready-to-eat foods that are high in fat/oil, sugar and salt. proportion of animal source products consumed (meat, milk, egg) rises fast foods & soft drinks easily available and relatively affordable

12. Co-existence of obesity and poverty 1.The prevalence of overweight adults appears to increase as the nutrition transition advances – an expected association? 2.Increasing prevalence of overweight and obesity in low income/food insecure households – a paradoxical association?

13. Obesity and socioeconomic status - a complex relation. Stunkard AJ & Sorensen TIA, N Engl J Med, 1993 Does hunger cause obesity? Dietz WH, Pediatrics 1995 Economic determinants and dietary consequences of food insecurity in the United States. Rose D, J Nutr 1999 Food insecurity is positively related to overweight women. Townsend MS et al., J Nutr 2001 Food insecurity is associated with increased risk of obesity in California women. Adams EJ et al., J Nutr 2003 Obesity and household food insecurity: evidence from a sample or rural households in Malaysia Zalilah MS & Khor GL, Eur J Clin Nutr 2005 Not a new phenomenon

14. Underweight and obesity among female in urban slums areas, Indonesia (NSS-HKI data sets) (Atmarita, MOH, 2005)

15. 44% Nat Nutr Survey 1998 % women WHR > 0.85 39% 34% 41% poorer regions

16. Plausible explanations for the paradoxical association Dependent on low cost foods that are flour/tuber- based and tend to be high in refined sugar, fats/oils Limited variety of food consumed relying on a few “stomach-filling” high energy foods Seasonal or cyclic acquisition of food with periods of plentiful (binge eating) and involuntary food restriction Overweight housewives associated with more leisure time, mostly spent on sedentary activities

17. Co-existence of obesity and poverty 1.The prevalence of overweight adults appears to increase as the nutrition transition advances – an expected association? 2.Increasing prevalence of overweight and obesity in low income/food insecure households – a paradoxical association? 3.Evidence of overweight mother / underweight or stunted child in the same household among the poor - a challenging association?

18. Prevalence of underweight child/overweight mother pair in same household in SEA Multi-centre Study sponsored by Japan (2000-02) Child <6 yrs & mother 20-45 yrs pairs UW child & OW mother pairs % IndonesiaUrban11855.7 PhilippinesUrban3768.2 ThailandUrban19918.5 MalaysiaPeri- urban 14026.0

19. Main findings of UW/OW Study Indonesia: UW/OW pairs higher in larger households, both parents with low education; Indonesia & Malaysia: No significant difference in food intake between OW and NW mothers (under -reporting/under-estimation?) Philippines: significantly higher intake of calories, preference for meat and fried foods, under-estimation of body size

20. Obesity in adults across income levels Nutrition transition OBESITY Obesity prevalence reduces, driven more by individual than environmental factors ? ? Obesity prevalence rises, driven mainly by environmental factors at global and national levels: trade, media, food industry, etc

21. WE NEED TO………….  get the measure right (BMI vs WHR vs waist circumference vs fat mass; cut-off points for overweight & obesity)  get the message right (public health interventions need to distinguish between population, household and individual factors affecting malnutrition)  get the medium right (a broad coalition of people, professionals and policymakers)  get the method right (evidence based, context specific, gender & age sensitive interventions) (adapted from KS Reddy, 2003)

23. Dual forms of malnutrition in the same households in Malaysia - a case study among Malay rural households. GL Khor & Zalilah MS. Asia Pacific J Clin Nutr 2003 A case study on dual forms of malnutrition among selected households in District 1, Tondo, Manila. I Angele-Agdeppa I, Lana RD & Barba CVC. APJCN 2003. Factors associated with the dual forms of malnutrition in Nakhon Pathom Province and Bangkok, Thailand. Yamborisut et al., APJCN 2006

24. Obesity in adults in nutrition transition OBESITY Levels of development Higher income in less developed region Lower income in more developed region Poverty amidst affluence

25. Poverty and obesity % Population below income poverty line (US$2/day/person) % obesity 15 years & above male/female Malaysia9.31.6/8.2 Thailand32.52.5/8.4 Philippines46.41.1/3.7 Indonesia52.40.2/2.6 Vietnam63.70.01/0.32

26. Selected health indicators