Developing World

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I n the developing world, undernourishment in the form of famine has historically been a bigger public health concern than overnourishment. There are serious health consequences when a person does not have enough food to eat or does not have sufficient variety in the diet. Mal-nourishment can lead to lack of energy, early death, and social disorder. Specific conditions of undernourishment can also exist when there is not enough of a specific type of nutrient such as protein or a particular vitamin. The case of pellagra, a disease caused by niacin (vitamin B3) deficiency, is a prime historical example. Endemic in the American South after the Civil War, it was argued by contemporaries that it was an "infectious disease of the poor." In 1918 at least 10,000 deaths were attributed to pellagra. Indeed, it was a disease of the poor as they ate the "three M's": meat (pork fatback); molasses; and meal (cornmeal). Its cure, as Joseph Goldberger discovered in the 1920s, was either to change one's diet by adding "real" meat, fresh vegetables, and milk or to augment it with a small amount of "brewer's yeast." The social impact had been catastrophic, as pellagra had as its symptoms mental illness as well as a wide range of physical debility, often ending in death (Kraut 2003). Although traditionally such types of malnutrition are associated with the developing world, especially with areas suffering from famine, overnourishment in the form of obesity has also become a problem. Indeed, where in the early twentieth century, pellagra was seen as a problem of the "New South," today obesity is most common in precisely those areas long haunted by undernourishment (Lopez et al. 2006). Pellagra continues to be a problem in developing countries where there is significant malnutrition or where niacin-deficient foods such as corn and rice are the primary sources of nutrition. Yet, there too, overnutrition may result in the diseases associated with obesity.

The complex nature of malnutrition in the developing world means that dieting interventions need to be developed for the specific state of nutrition in the population being targeted. Famines are not due to lack of food worldwide. They arise as a result of civil unrest affecting specific people. Amartya Sen's 1981 Poverty and Famines: An Essay on Entitlement and Deprivation argued that famine occurs not from a lack of food, but from inequalities built into mechanisms for distributing food. War and violence often prevent global relief agencies from delivering food to the people who are in need. Agencies such as the World Health Organization must negotiate with the local governments to allow food shipments to people. The main goal for this type of intervention is just to get people fed.

Sometimes, dietary interventions are needed because a particular population is deficient in a specific nutrient such as protein, vitamin A, or iron. In these cases, even though enough food is available to maintain caloric requirements, interventions are still necessary, as was the case with pellagra. Seasonal variations in the food supply can lead to deficiencies in protein. The results are classic images of emaciation, which have become the icons of famine. Two types of physical images of starvation exist, often appearing together. Marasmus, which is caused by the lack of energy due to insufficient food, presents with a "little old man" appearance in children, with obvious signs of emaciation: Radical thinness, prominent appearance of the ribs and spine, often accompanied by an alert but irritable behavior. Kwashiorkor, caused by the development of inefficient pathways through the protein deficiency disease often found in famine areas, provides further variations on the classic images of stunted children with its signs and symptoms of edema, with protruding stomachs that can be taken for plumpness on first glance; skin lesions; thick, easily bruised skin; thin, dry hair; lethargy and apathetic behavior (Eddleston et al. 2005: 594-5). They are the result of their not being able to meet the daily protein requirements for growth. Lack of protein leads to a weakened immune system and a greater chance of death from infection (Kleinman 2003). Often in areas of famine, therapeutic milk products, such as F75 and HEM (high energy milk), are employed. Interventions to target famine will then often consist of making further protein sources such as beans, meat, or eggs available.

Micronutrient (such as iron, folate, iodine, or vitamin C) deficiencies can lead to a variety of health outcomes such as mental retardation, maternal death in childbirth, and growth retardation. When micronutrients are the main source of deficiency, interventions often focus on supplementation of diet or fortification of foods. Fortification involves putting micronutrients such as iron, iodine, or folate in foods, like flour or salt, commonly consumed by the people. Most micronutrient deficiencies are reversible conditions and can be fixed with proper supplementation.

Overnutrition, a condition common to the developed world, is now affecting the developing world. Overnutri-tion often manifests itself in the form of obesity. As the developing world moves from rural to urban, from farming communities to manufacturing communities, individuals undergo a "nutrition transition." The nutrition transition occurs when a society moves away farming and the raising of livestock as the main source for their own food. Moderately developed countries have about 30 percent of their population engaged in farm work; affluent societies have only about 5 percent. Instead, food is often obtained secondarily, from markets, and, given the global expansion of food production and distribution, even supermarkets. Rather than obtaining food from the source, as much as 75 percent of the food is often processed and packaged, leaving it devoid of vitamins and minerals (James 2002). In addition to the change in access to the food supply, the nutrition transition is usually accompanied by a more sedentary lifestyle as people pursue work in offices or hi-tech manufacturing facilities.

People in countries undergoing nutrition transition are experiencing the same problems with obesity that has been seen in the U.S.A. In Latin America and the Caribbean as of 1995, there were still 6 million children under the age of five with low weight for their ages, yet the general tendency is now toward obesity: "In peri-urban areas it is normal to find a family in which the father has high blood pressure, may be fat or not, is short, and has a problematic history of malnutrition; the mother is anemic, probably obese, and short; and the child suffer frequent infections and show stunting" (Peña and Bacallao 2000: 3). The obesity rates in women there have increased more rapidly than in men. In Guatemala in 1995, 26.2 percent of women were overweight; 8 percent were obese (Peña and Bacallao 2000). The Food and Agriculture Organization of the United Nations (FAO) estimates that the burden of obesity in the developing world is becoming greater than the burden of not having enough food (see <http://www.fao.org>). Interventions to target these people are very different to those targeting people who do not have adequate food. Culturally specific interventions focus on teaching people about the importance of daily physical activity as well as moderate and diverse food intake. People in such populations very rarely have the wide variety of dieting choices available to the developed world. Therefore, the message is usually one of limiting food intake while maintaining energy requirements.

The movement of peoples also impacts on weight and disease. An example is the "Hispanic Paradox." Highly acculturated Mexicans have a marked higher rate of obesity in the U.S.A. than their Mexican cousins. Thus, Mexican-born men and women in the U.S.A. had the smallest waist circumference. Mexicans who were American-born speakers of English had intermediate waist circumference, but U.S.-born Spanish speakers had the largest waist circumference. Gender plays a role, as men were always larger than women (Sundquist and Winkelby 2000).

Thus, in such cultures, the very manifestation of eating disorders in addition to obesity reflects local concern. In China, for example, while anorexia nervosa is present in all of its "Western" appearance, patients attribute food refusal to "stomach bloating, loss of appetite, no hunger" and other rationales not concerned with body image (Lee et al. 1998). For these patients, "medical"

symptoms such as "stomach bloating" are socially much more acceptable as a means for bodily self-control than anxiety about weight gain.

SLG/Suzanne Judd

See also China in the Twentieth Century; Emaciated Body Images in the Media

References and Further Reading Allen, L.H. (2006) "New Approaches for Designing and Evaluating Food Fortification Programs," Journal of Nutrition 136 (4): 1055-8. Crawford, E. Margaret (1981) "Indian Meal and Pellagra in Nineteenth-Century Ireland," in J.M. Goldstrom and L.A. Clarkson (eds), Irish Population, Economy, and Society: Essays in Honour of the late K.H Connell, Oxford: Clarendon Press, pp. 113-33. Drewnowski, Adam and Popkin, Barry M. (1997) "The Nutrition Transition: New Trends in the Global Diet," Nutrition Reviews 55 (2): 31-43. Eddleston, Michael, Davidson, Robert, Wilkinson, Robert, and Pierini, Stephen (2005) Oxford Handbook of Tropical Medicine, Oxford: Oxford University Press. Food and Agriculture Organization (FAO) (2001) "The Developing World's New Burden: Obesity." Available online at <http://www.fao.org/FOCUS7E/obesity/ obesi.htm> (accessed March 18, 2007). James, W. Philip T. (2002) "A World View of the Obesity Problem," in Christopher G. Fairburn and Kelly D. Brownell (eds), Eating Disorders and Obesity: A Comprehensive Handbook, 2nd edn, New York: Guilford Press, pp. 411-16. Kleinman, Ronald E. (2003) Pediatric Nutrition

Handbook, 5th edn, Elk Grove Village, Ill.: American Academy of Pediatrics.

Kraut, Alan M. (2003) Goldberger's War: The Life and Work of a Public Health Crusader, New York: Hill & Wang.

Lee, Sing, and Katzman, Melanie A. (2002) "Cross-Cultural Perspective on Eating Disorders," in Christopher G. Fairburn and Kelly D. Brownell (eds), Eating Disorders and Obesity: A Comprehensive Handbook, 2nd edn, New York: Guilford Press, pp. 260-4.

Lee, Sing, Lee, A., and Leung, T. (1998) "Cross-Cultural Validity of the Eating Disorder Inventory: A Study of Chinese Patients with Eating Disorder in Hong Kong," International Journal of Eating Disorders 23 (2): 177-88.

Lopez, A.D., Mathers, C.D., and Ezzati, M. (2006) Global Burden of Disease and Risk Factors, New York: Oxford University Press.

Peña, Manuel and Bacallao, Jorge (2000) "Obesity Among the Poor: An Emerging Problem in Latin America," in Obesity and Poverty: A New Public Health Challenge, Washington, DC: Pan American Health Orgainzation, pp. 3-10.

Popkin, Barry M. (2003) "The Nutrition Transition in the Developing World," Development Policy Review 21 (5-6): 581-97.

Sen, Amartya (1981) Poverty and Famines: An Essay on Entitlement and Deprivation, Oxford: Clarendon Press.

Sundquist J. and Winkelby, M. (2000) "Country of Birth, Acculturation Status and Abdominal Obesity in a National Sample of Mexican-American Women and Men," International Journal of Epidemiology 29 (3):

Wahlqvist, M.L. (2005) "The New Nutrition Science: Sustainability and Development," Public Health Nutrition 8 (6a): 766-72.

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