Obesity and malnutrition can occur together due to economic and social factors. In low-income communities, obesogenic foods that are high in calories but low in nutrients are often most affordable and available. This can lead to weight gain while still being malnourished. Additionally, periods of food insecurity may cause people to overeat when food is available to store calories against future uncertainty. Overall, complex social and economic drivers can result in both obesity and malnutrition within the same family or community.

1. Obesity and malnutrition
An international perspective of the paradox
Gianluca Tognon
Sahlgrenska Academy
www.gianlucatognon.com

2. The undernutrition and
obesity paradox
• Obesity runs highest among the lowest income groups
• Undernutrition and obesity often occur together within the same
community, the same family, and sometimes within the same
person
• Obesity in people with very low food security becomes
understandable in the context of the food supply
• A person can easily gain weight and lose nutrient status when the
most affordable and available foods provide abundant calories but
few nutrients, such as refined grains, sweets, inexpensive
meats, oils and fast foods, which provide too many calories with too
few nutrients
• People who have gone hungry in the past and whose future meals
are uncertain may overeat when food or money becomes available

5. Hunger?
Malnutrition?
Undernutrition?
Undernourishment?
Food security?
Food insecurity?
ACTIVITY 1

6. • Hunger: A condition in which people lack the required nutrients for fully
productive, active and healthy lives. It can be short-term/acute or longer-
term/chronic, and has a range of mild to severe effects. It can also result from
insufficient nutrient intake or from people’s bodies failing to absorb the required
nutrients (hidden hunger). It can also result from poor food and childcare practices.
• Malnutrition: A physical condition in which people experience either nutrition
deficiencies (undernutrition) or an excess of certain nutrients (overnutrition).
• Undernutrition: The physical manifestation of hunger that results from serious
deficiencies in one or several macro- and micronutrients. These deficiencies impair
body processes, such as growth, pregnancy, lactation, physical work, cognitive
function, and disease resistance and recovery. It can be measured as weight for age
(underweight), height for age (stunting) and height for weight (wasting).
• Undernourishment: The condition of people whose dietary energy consumption is
continuously below the minimum required for fully productive, active and healthy
lives.
• Food security: A condition that exists when all people at all times are free from
hunger. It has four parts, which provide insights into the causes of hunger (FAO): 1.
availability: the supply of food in an area; 2. access: a household’s ability to obtain
that food; 3. utilization: a person’s ability to select, take in and absorb the nutrients
in food; 4. stability.
• Food insecurity, or the absence of food security, implies either hunger resulting
from problems with availability, access and use, or vulnerability to hunger in the
future.

8. The world food supply
• By all accounts, today’s total world food
supply can abundantly feed the entire current
population
• Wheat and corn, staple foods of many
nations, are abundant
• Adequate supply alone, however, does not
ensure that all people will receive adequate
food
• The political will to do so is also required

9. Threatens to world food
production and distribution
• Hunger, poverty and population growth
• Loss of food-producing lands
• Accelerating fossil fuel use
• Atmosphere and global climate
changes, droughts and floods
• Ozone loss from the outer atmosphere
• Water shortage
• Ocean pollution

10. The millennium development goals
• The Millennium Development Goals are eight international
development goals officially established following the
Millennium Summit of the United Nations in 2000
• The goals are:
– Eradicating extreme poverty and hunger
– Achieving universal primary education
– Promoting gender equality and empowering women
– Reducing child mortality rates
– Improving maternal health
– Combating HIV/AIDS, malaria, and other diseases
– Ensuring environmental sustainability
– Developing a global partnership for development

13. The importance
of proteins
• Foods of animal origin are the best protein sources, but they
tend to be expensive, not always available, or prohibited by
religious practices
• Staple vegetable foods can be complemented with other
vegetable foods such as legumes
• Corn and black bean combination (three parts of dry corn and
one part of dry beans) provides proteins in a proportion of
about 6:4 and have an excellent aminoacid composition which
allows adequate growth and function
• Energy density can be increased adding sugar and oil or other
fats

14. Food prices
• After declining in real terms throughout the 1980s and
1990s, international food prices began rising in 2002 in
an apparent reversal of this long-term trend
• By 2011, the FAO Food Price Index reached more than
double its level during 2000-02
• Sugar, oils and cereals showed the sharpest increases
in 2010 and early 2011
• Meat prices have risen least and have shown less
marked fluctuations
• Dairy prices have been below the FPI average since late
2010 and have fallen markedly in recent months

16. Reasons for food price increase
• Population growth
• Higher per capita incomes
• Urban migration and associated changing
diets in developing countries
• Weather-related production shocks
• Rising demand for biofuel feedstocks
• The role of speculative trading as a factor
underlying price volatility has also been
debated
Will global agriculture to keep pace with growth in demand?

19. Undernutrition
• A major health problem, especially in developing
countries
• Adequate water supply, sanitation and
hygiene, are important for preventing infections
and diarrhea
• Repeated or persistent diarrhea on nutrition-
related poverty and the effect of undernutrition
on susceptibility to infectious diarrhea are
reinforcing elements of the same vicious
circle, especially amongst children in developing
countries

20. Underweight in children < 5 yrs

21. Biologic and
environmental causes
• Maternal malnutrition before and/or during
pregnancy (underweight newborn)
• Infectious diseases (diarrheal
disease, measles, AIDS, tuberculosis and others)
• Overcrowded and/or unsanitary living conditions
(which increase the likelihood of infections)
• Agricultural patterns, droughts, floods, wars and
forced migrations

22. Social and economic causes
• Poverty
• Ignorance
• Inadequate weaning practices (withdrawal of
breastmilk or inadequate nutrient composition)
• Social problems (child abuse, maternal
deprivation, abandonment of the
elderly, alcoholism, drug addiction)
• Cultural and social practices (food taboos, food
and diet fads)

24. Differences between
countries
• Undernutrition is far more debilitating in some
places than in others
• In the industrialized countries, hungry people lack
130 kcal per day on average, while in the poorest
countries, the daily food deficit is more than
three times that, i.e. 450 kcal/day
• Most of the countries with the most extreme
depth of hunger (> 300 kcal/person/day) are
located in Africa and many of these face
extraordinary obstacles such as conflicts or
recurrent natural disasters

25. Consequences of
chronic hunger
• Tens of thousand people die of undernutrition every day.
Most do not starve to death, they die because their health
has been compromised by dehydration from infections that
cause diarrhea
• Undernutrition reduces mental and physical development in
children and makes people susceptible to potentially fatal
infections
• Consequences of unrelieved hunger include stunted
growth, poor learning, extreme weakness, clinical signs of
protein-energy malnutrition (PEM), increased susceptibility
to disease, loss of the ability to stand or walk, premature
death

26. Policies for malnutrition prevention, focus on:
- Governments/International agencies
- Private sectors
- Civil society
- Health professionals
ACTIVITY 2

27. Interventions for
malnutrition prevention
• Improved water supply, sanitation and
hygiene.
• Health education for a healthy diet
• Improved access, by the poor, to adequate
amounts of healthy food
• Ensuring that industrial and agricultural
development do not result in increased
malnutrition

28. Education
• Girls and women should be specially targeted in
educational and developmental programs
• Education programs must also be devised for
community leaders, civic action groups, and the
community as a whole
• Such programs should emphasize:
– promotion of breast-feeding
– appropriate use of weaning foods
– nutritional alternatives using traditional foods
– personal and environmental hygiene
– early treatment of diarrhea and other diseases

29. Focus on women
• Many societies around the world undervalue
females, depriving girls of nutritious foods and giving them
less education and fewer opportunities than are given to
boys
• Malnourished girls become malnourished women in
poverty who bear sickly infants who cannot fend off the
diseases of poverty
• Many such infants succumb within the first years of life
• Seven out of ten of the world’s hungry people are women
and girls, yet they receive only about half of the available
food aid and must use it to feed their children as well as
themselves

30. Women and hunger:
10 facts (WFP)
1. Women make up a little over half the world’s population but in many parts of the
world, especially in Asia and South America, they are more likely to go hungry than men
2. Following natural disasters, women and girls suffer more from shortages of food
3. Research confirms that putting more income in the hands of women yields beneficial
results for health, education and child nutrition
4. Closing the gender gap in agriculture by giving women farmers more resources could bring
the number of hungry people in the world down by 100-150 million people
5. Surveys in a wide range of countries have shown that women provide 85-90 % of the time
spent on household food preparation
6. Women in Africa work an average of 50% longer each day than men
7. Worldwide, for every 100 boys out of school there are 122 girls. But in some countries the
gender gap is much wider. For every 100 boys out of school in Benin there are 257 girls, in
Yemen 270, in Iraq 316, and in India 426
8. Educated mothers have healthier families. Their children are better nourished, are less
likely to die in infancy and more likely to attend school
9. Around half of all pregnant women in developing countries are anaemic. Iron deficiency
causes around 110,000 deaths during childbirth each year
10. Malnourished mothers often give birth to underweight babies who are 20% more likely to
die before the age of five. Up to 17 million children are born underweight every year

31. Hunger in developed
countries
• In developed countries (including the USA), the
primary cause of hunger is food poverty
• People go without nourishing meals because they
lack sufficient money to pay for food and other
necessities, including medicines
• Food poverty likelyhood increases with problems
such as abuse of alcohol and other drugs, mental or
physical illness, depression, lack of awareness of or
access to available food programs, and reluctance of
people to accept what is perceived as charity

32. Consequences
• Adults may skip meals or cut their portions
• They may be forced to break social rules, stealing
from markets, consuming pet foods, or even
harvesting dead animals from roadsides or
scavenging through garbage cans
• Such foods may be spoiled or contaminated and
inflict dangerous foodborne illnesses on people
already bordering on malnutrition
• Children in such families sometimes go hungry for
an entire day until the adults can obtain food

34. Supplemental Nutrition Assistance
Program (SNAP) in the US
• Administered by the USDA, it provides assistance to
more than 20 million people half of which are children
• Eligible households receive coupons or debet cards
similar to credit cards through state social services or
welfare agencies
• Recipients can use the coupons or cards like cash to
purchase food and food-bearing plants and seeds, but
not to buy tobacco or other non-food items
• Although this program helps millions, many millions
more are thought to be eligible to receive them

35. Second Harvest
• Each year, enough food to feed 49 million people is wasted
• Food recovery programs collect and distribute good food that
would otherwise go to waste and the donators qualify for tax
deductions for their donations
• Concerned citizens in many communities work through local
agencies and churches to help deliver food to hungry people
• National food recovery programs have made a dramatic difference
• In the US, Second Harvest, provides more than 1 billion pounds of
food to 45,000 local agencies that feed over 25 million people a
year
• Many food-insecure people rely on these sources of food for
survival

36. Protein-Energy malnutrition
• It results when the body’s needs for protein and energy
fuels are not satisfied by diet
• It can be primary (inadequate food intake), or secondary
to other diseases that lead to low food
ingestion, inadequate nutrient absorption or
utilization, increased nutritional requirements, and/or
increased nutrient losses
• It is the most important nutritional disease in developing
countries because of its high prevalence and relationship
with child mortality rates, impaired physical growth and
inadequate social and economic development

37. Classification of protein-energy
malnutrition based on BMI
Body Mass Index Protein-Energy
malnutrition
≥ 18.5 Normal
17.0 – 18.4 Mild
16.0 – 16.9 Moderate
< 16.0 Severe

38. Prevention and control
• Rates of malnutrition have declined rapidly in countries
that have reduced poverty and have invested in
health, nutrition, education and the social sector
• The strategies for prevention must follow a
multisectorial approach involving all levels of food
security, preventive medicine, education, social
development and economic improvement
• Effective control and prevention can be achieved only
through sustained long-term political commitments
and actions aimed at eradicating the underlying causes
of malnutrition
• Physicians, nutritionists, health personnel, social
workers and educators can and must play an active role

40. Background
• Obesity is caused by a chronic energy imbalance involving both
dietary intake and physical activity patterns
• A change in diet towards highly refined foods and meat as well
as dairy products containing high levels of saturated fats has
been occurring globally since the middle of the 20th century
• The shift from individual to mass preparation lowered the time
price of food consumption and produced more highly
processed food (with added sugar, fats, salt and flavour
enhancers) and marketed them with increeasingly effective
techniques

41. What’s obesity?
• Obesity if defined as having a BMI ≥ 30 kg/m2
• BMI is a good, but not perfect, surrogate for body fatness
• People with an ”obese” BMI may have a normal amount of body
fat and a large muscle mass, whereas others with a ”normal”
BMI may have excess adiposity and reduced muscle mass
• Measuring the circumference of the waist can provide an
additional check (cut-offs: 88 cm in women, 102 cm in men)
• Waist circumference is highly correlated with the amount of
intraabdominal or visceral fat, which is an independent
predictor of increased risk for
diabetes, hypertension, dyslipidemia and ischemic heart disease
• The combination of waist circumference and BMI can be useful
in assessing health risk

42. Health consequencies
• The prevalence has been increasing worldwide
over the past 30 yrs in both rich and poor
countries
• By 2050, 60% of men and 50% of women could
be clinically obese
• The risks of developing type 2 diabetes, heart
disease and cancer all increase as BMI will
increases
• Mortality increases gradually above a BMI of 25
kg/m2 with a sharper increase above a BMI of 30
kg/m2

44. Environmental factors
connected with weight gain
• Smoking cessation
• Maternal smoking and diabetes
• Breast-feeding
• Toxics exposure (endocrine
disruption)

45. The Heredity of Obesity
• It is estimated that up to 40% of variation in BMI is explained
by genetic factors
• BMI is highly correlated among first-degree family
members, with an increased relative risk for the development
of obesity for a first-degree relative of an obese person
• Single-gene defects have been identified (e.g. in the
MC4R, PPAR or leptin genes) although very few individuals
with these defects have been identified
• It is likely that obesity is a highly polygenic and complex
disorder, resulting from the input of multiple genes, with
additional interactions between genes and environment and
genes and behavior

46. The Genetic hypothesis
• Genes involved in the regulation of body weight are
estimated to have evolved 200,000 to 1 million years
ago, at a time when environmental factors controlling
habitual physical activity and food acquisition were
dramatically different
• The marked increase in the prevalence of obesity since
the mid-1980s cannot be attributed to changes in the
gene pool (which require longer period of time) and
must be largely a result of alterations in environmental
factors
• However, factors others than DNA could be implicated
(possible heredity of RNA subtypes, like microRNA)

47. • Family studies demonstrate that obese parents produce
the highest proportion of obese children
• Adoption studies provide another approach for
estimating heritability based on the similarity of adoptive
childrens’ body weight to that of both their adoptive and
biologic parents These studies suggest a stronger role for
genetics than for the environment
• Twin studies have been an integral part of the research
into the genetics of obesity and they provide stronger
support for the effect of genetic factors on BMI, which
has been shown to be similar between twins, with the
strongest correlation in monozygotic twin pairs. The
observation holds true whether twins were raised
separately of apart

48. Policies for obesity prevention, focus on:
- Governments/International agencies
- Private sectors
- Civil society
- Health professionals
ACTIVITY 3

49. Obesity policies
• Obesity threatens to have a great impact on
public health worldwide but the mechanisms of
its increase in prevalence and its consequences
are far less well understood in policy terms
• This lack of knowledge presents a serious
challenge to public health policy
• Curbing the global obesity epidemic requires a
population-based multisectoral, multi-
disciplinary, and culturally relevant approach
• Focus on the built environment and people
behaviour is also important

50. Obesity vs Tobacco control
• The associated adverse behaviour is more readily identified for
smoking than for obesity
• The major successes of tobacco control have been linkedin to
the application and implementation of a broad range of policies
• Obesity control policy is in many ways more complex
• The changes needed to reverse the obesity epidemic are likely to
require many sustained interventions at several levels: individual
behaviour change, interventions in schools, homes and
workplaces as well as sector changes within agriculture, food
services, education, transportation and urban planning
• For obesity however, no clear consensus on effective policy or
programmatic strategies has been reached
• Successful strategies to rapidly lower obesity rates need to
target all age groups and take a life-course approach

51. An unequal weight
• Obesity is a global problem, unequally distributed
between and within countries
• In affluent societies excess weight is more
common among socially disadvantaged
groups, but the inverse is true in low income
countries
• Focusing only on direct action to make people eat
more healthily and be more physically active
misses the heart of the problem: the underlying
unequal distribution of factors that support the
opportunity to be a healthy weight

52. THANKS FOR YOUR ATTENTION!
Gianluca Tognon
gianluca.tognon@gu.se
@gianlucatognon