Greetings,
Our March newsletter, authored by leadership and staff of the World Obesity Federation, made me realize how US-centric our focus has been. While we have been consumed with the inexorable rise in the prevalence of obesity in our country and the excitement about the effectiveness of the GLP-1s, the prevalence of global obesity has been quietly rising. As the authors’ table indicates, the number of men and women with obesity in the US constitutes only 6% of global obesity. Furthermore, obesity rates are disproportionately highest in low and middle income countries, and increases in the double burden of obesity and undernutrition are being driven by increases in obesity and decreases in undernutrition. A critical question that these data raise is what drivers of world obesity are we exporting, and do these drivers contribute to the global inequities that the World Obesity Federation has identified?
No-Longer the “Invisible Minority:” A Billion People with Obesity, Vast Majority in Low- and Middle-Income Countries
Ogweno Stephen was born in Nairobi, Kenya. As a child, he was admired and praised for his heavier weight but as he grew into young adulthood, the praise turned to scorn for having what we know are the early stages of obesity. More concerning, there was no acknowledgement in the health system of either the health issues associated with obesity or the role that bias and stigma might have been playing. Thankfully, with support from his family, university and a trusted teacher, he was able to access help and he has been healthy for a number of years. “In Kenya, no one has thought that obesity is a problem, let alone a disease,” he notes. “And in many African countries, it has only been recently that the soaring obesity rates and lack of resources to address them have been acknowledged. This World Obesity Day, it is time to change the narrative.”
In 2017, the Lancet published a study by the NCD Risc Factor Collaboration (NCD-RisC) reporting the number of people with obesity worldwide. At the time, the number was estimated to be 795 million children, adolescents and adults, already a deeply concerning figure. Most surprisingly, the majority were living in less developed countries, with limited resources to address the challenge. A series of measures was designed, offered, and discussed including recommitting to the WHO target set in 2013 of a zero increase in obesity prevalence by 2025 and a more intensive focus on regulations to address unhealthy foods and other elements of an obesogenic environment. Discussions around obesity in health systems remained modest outside of high-income countries where efforts to recognise obesity as a disease were having some success.
So, how are we doing? For World Obesity Day 2024, an update to the NCD-RisC study was released stating that there are now an estimated 1 billion people living with obesity. The projections from the World Obesity Federation suggest that instead of remaining flat, by 2025 prevalence would actually double. Most striking, the 2024 World Obesity Atlas reports that by 2035, between 70-85% of adults and children with obesity will be living in Low- and Middle-Income Countries (LMICs). (nb: the World Bank defines LMICs as those with a GNI per capita of up to $13,845, which includes some of the largest economies in the world like China and India).
Not only do obesity rates continue to rise around the world, at a rate and magnitude far greater than the policies and tools available to manage obesity, but the countries with the highest number of people living with obesity, the highest prevalence of people with obesity, and the most rapidly increasing rates are almost all LMICs.
This observation emphasises that no area of the world is immune from the effects of obesity, and the poorest suffer the most, often at ever younger ages. The table below shows projections for the number of women and men who will be living with overweight or obesity in 2035 globally. Notably, the United States is the only high income country featured in the top 10.
Table 1: Projected numbers of men and women living with overweight or obesity in 2035, global and top 10 countries
The Atlas also provides compelling evidence of how the lack of obesity care in health systems is driving major NCDs, including cancer and type 2 diabetes. Contrary to public perception, lower-income countries are increasingly leading the way in terms of disability and early death due to obesity and the diseases it is driving. An alarming indication of how much obesity is occurring at younger ages, and in parts of the world where health systems are even less equipped to address it, can be seen in the number of cases of high blood pressure, hyperglycaemia and low HDL cholesterol – all conditions that were historically limited to adults – being found among children and adolescents due to overweight or obesity. In 2020 alone, there were an estimated 41 million cases of low HDL cholesterol, 34 million cases of high blood pressure, and 15 million cases of hyperglycaemia attributable to overweight or obesity among children and adolescents “
It has been fairly well understood that the highest prevalences of obesity are in Small Island Developing States (SIDS) in the Pacific and Caribbean, such as Tonga and the Bahamas where the impacts of colonialism and trade combined with westernisation and the general loss of sovereign diets have all contributed to rising prevalence. South Africa is describing obesity as the “new HIV” in terms of being an untreated disease and the role stigma has played in ignoring it, while countries in the Gulf including the UAE, Saudi Arabia and Iraq are struggling with the health impact of soaring rates.
Most concerningly, there is little philanthropic or financing support for addressing obesity as an urgent global health issue. Even within non-communicable diseases (NCDs), which have struggled to gain attention and financial support, obesity is either rarely mentioned, or categorised solely as a nutrition issue. In June 2024, the World Health Organization and the World Bank will host a high-level global dialogue on financing for NCDs and at present there is scant reference to obesity on the agenda. This is unacceptable and must change.
The alarming rise in obesity rates demands immediate attention - with concerted action from governments and communities worldwide, and healthcare providers and professionals - and private sector accountability.