Wednesday, July 25, 2012

The idea that obesity is plaguing the majority of children in developed countries has been well documented. However, what about the rest of the world?

Obesity is a major health issue in developed countries.  One issue that seems to have scarce coverage is the increasing prevalence of obesity in children living in developing countries (DC) (Gupta, Goel, Shah, & Misra, 2012).  I will investigate the global impact of obesity on childhood populations in DC and explore the possible implications of childhood obesity on early childhood development (ECD) in DC.
DC are classified as countries with low to middle levels of gross national product (low or middle-income) (World Bank, 2004).   In addition, this classification also includes several countries with “transition economies”, based on low to middle levels of per-capita income, but they are also grouped with developed countries based on their high industrialization (World Bank, 2004).  Developed or high-income countries are industrialized, have high standard of living, and a large stock of physical capital (World Bank, 2004).  Therefore, in this paper, DC will be include low to middle-income countries, and transition economies (ex. China & India). 
NCDs are the leading cause of death in the world, and DC are now facing a greater burden of these diseases due to the consequences of globalization (WHO, 2010a).  NCDs have been affecting the health of individuals in DC differently than developed regions for various reasons: NCDs are increasing at greater rate in DC, in contrast to developed nations (Boutayeb, 2006).  Furthermore, NCDs are affecting individuals at a younger age than in developed countries, which is increasing the disability adjusted life years in the nation (DAILY; defined as the productivity years lost to premature death plus years lost to disability) (Boutayeb, 2006).  In addition, NCDs place a greater burden on the family of individuals in DC as they often have a low sociological economic status (SES) and face costly, prolonged care with greater disability due to complications from  NCDs (Boutayeb, 2006).   Finally, NCDs have not displaced communicable diseases in DC; in contrast, these nations have a polarized burden of disease (Yach, Hawkes, Gould, & Hofman, 2004).  For example, India has increasing rates of NCDs like diabetes and cardiovascular disease, and communicable disease (CD) like malaria, tuberculosis and diarrhea, which cause mortality in children (Uauy, Kain, Mericq, Rojas, & Corvalán, 2008).  Consequently, this “double” burden of disease puts an increased strain on a health care system, that is presently not prepared to handle chronic illness management (Yach et al., 2004)
It is important to note that many NCDs share a common physiological risk factor, obesity. Obesity prevalence has been increasing globally (Finucane et al., 2011).  In 2008, it was reported that the worldwide, age-standardized prevalence of obesity in men was 205 million, and in women 297 million (Finucane et al., 2011).  This is significant as these values are almost double the prevalence from 1980 (Finucane et al., 2011).  The global prevalence typically has not been distributed equally between developing and developed countries as obesity is higher in developed countries in comparison to  DC; 35.2% vs. 19.6% (overweight) and 20.3% vs. 6.7% (obese), respectively (Kelly, Yang, Chen, Reynolds, & He, 2008).  However, even though the prevalence is lower in DC, they have a greater number of people and thus the absolute numbers of people who are obese or overweight are higher in comparison (Kelly et al., 2008).  Furthermore, DC are projected to have a greater proportional increase in the numbers of obese and overweight individuals between 2005 and 2030 (Kelly et al., 2008).  In addition, in high-income countries, the prevalence of obesity tends to be higher among low SES groups, yet in middle or low-income countries, it initially is an issue for groups of higher SES, but with economic growth, the risk shifts towards groups of lower SES (Hawkes, 2006)
Corresponding with the increasing trends of obesity in adult populations is the increasing prevalence of overweight and obesity influencing children globally.  The WHO has categorized children based on deviations from growth standards (weight-for-height median), which were based on breastfed infants and young children from geographically distinct sites (Brazil, Ghana, India, Norway, Oman, United States) (Gupta et al., 2012).   Overweight and obesity were defined as the proportion of preschool children with values of standard deviation (SD) > 2 and SD>3, respectively (de Onis, Blössner, & Borghi, 2010).   In children 5-19 years, > 1+ SD are classified overweight and obese as >2+SD (Gupta et al., 2012).   Internationally, childhood overweight and obesity prevalence has increased from 4.2% in 1990 to 6.6% in 2010 and is expected to reach 9.1% by 2020(de Onis et al., 2010).  Similarly to adult populations, the prevalence rates of overweight and obesity in developed regions are currently higher than in DC (11.7% vs. 6.7%, respectively).  However, both the absolute number of children in DC and the relative increase that is occurring in overweight and obesity, is higher in DC, and thus, there is a greater burden of childhood overweight and obesity in DC (de Onis et al., 2010).  
Social determinants of health (SDOH) are factors that characterize the environments that individuals interact with and can influence long-term development and health outcomes (Maggi, Irwin, Siddiqi, & Hertzman, 2010).  Some important social determinants that influence ECD are the relationships between individuals, social and physical environments, interpersonal relations with family, living conditions, socio-demographics of family, learning environment in school, access to recreational space, neighbourhoods and socio-political context (Maggi et al., 2010).  The process of early childhood ECD, has also been considered a social determinant of health, and is influenced by the child’s health status and the interactions they develop with the caregivers in their environment (WHO, 2007).   During ECD rapid growth of the brain occurs as a child is sensitive to the influence of their external environment (WHO, 2007).  Healthy development is possible at this stage with proper nutrition and adequate environmental interactions (such as play), which can be essential in providing a foundation to achieve economic, social and physical wellbeing (WHO, 2007).  However, the negative health implications from obesity in childhood populations in DC are harmful to ECD.  As discussed previously, many DC are undergoing a “double burden” of both CD and non-CD.  Another way of framing a “double burden” of disease in DC is the experience of children experiencing both over-nutrition (obesity) and under-nutrition (malnutrition).  Both growth stunting and overweight have been reported to co-exist in children at both a community and family level in DC (Uauy et al., 2008; Jafar et. al, 2008).  It has also been reported that over and under-nutrition can possibly exist within the individual, for example, in South Africa, it was found that 19% of 3 year olds were both overweight and stunted, due to an environment that provides an abundance of energy-dense foods of little nutritional value (Poskitt, 2009).  Moreover, the reality of both over and under-nutrition is difficult as early malnutrition may cause obesity later in life (Uauy et al., 2008).  Thus, obesity has the potential to harm ECD in children in DC.
Many DC have experienced changes to their environments influenced by globalization, that have had a negative impact on the SDOH of ECD, such as urbanization, increased technological and food availability (Gupta et al., 2012; Popkin, 2006).  Globalization has had negative impact on ECD by promoting childhood obesity in DC:  Firstly, by decreasing physical activity opportunities by altering the amount of open space or safe areas for children to play, and increasing time spent with indoor sedentary activities like watching television (Gupta et al., 2012).   Secondly, increasing childhood caloric intake beyond healthy levels due to excess availability of energy-dense and nutrient poor foods (Gupta et al., 2012).  These changes in physical activity and caloric consumption promotes childhood obesity, which negatively affects ECD in children that reside in DC due to the negative health complications associated with obesity and increased risk of NCDs.  For example, a study investigating possible negative health outcomes of obesity in children (6-11 years) in urban India found that their participants had cardiovascular and endocrine dysregulation; insulin resistance, elevated blood pressure, and dyslipedimia (Saha, Sarkar, & Chatterjee, 2011).  Furthermore, childhood obesity has also the potential to carry over into adulthood and increase the risk of adult hypertension (Sabo, Lu, Daniels, & Sun, 2012), or metabolic syndrome (Sun et al., 2008).  These issues will be particularly troubling in DC due to the unpreparedness of health care systems to manage NCD, in addition to the existing burden of CD. Maggie et al (2010) discussed how a past focus in DC solely on efforts related to child mortality are  insufficient, and  should also focus on early childhood language/cognitive and social/emotional development.
Three levels of relationships that influence healthy ECD in children are with their family, community and the societal influence (Maggi et al., 2010).  Parental/caregiver interaction is the principal driving force of childhood development, as strong nurturing relationships can lead to healthy ECD (WHO, 2007).  These relationships often develop in the family environment as family members or primary caregivers provide the initial interactions with children and control their exposure to their environment (WHO, 2007).   These relationships are necessary for healthy ECD, as they create an environment where a child feels a secure attachment to a trusted caregiver, with consistent caring, support and affection (WHO, 2007; Maggi et al., 2010).  The environment that is created by the parents/caregivers for their children’s ECD are influenced by  the resources parents’ are able to devote to child raising, which is related to available their income and by their level of education; both being SDOH (Maggi et al., 2010).  This is relevant to childhood obesity, as families in DC, who may at one time have experienced times of malnutrition, are now increasingly provided with greater purchasing power and ample availability of refined and energy-dense food at a cheaper cost (Gupta et al., 2012).  Thus by having more economic resources and availability of cheap food, families in DC are facilitating obesity promoting environments for children.
Globalization has enhanced the interconnectedness of the world in terms of trade of goods, technology services and spread of modern mass media (Popkin, 2006). The global environment is able to influence ECD, at the societal level, through its control of the policies in nations where children live (WHO, 2007).  The association of globalization on ECD relates to the creation of power imbalances between various countries, where developed countries are able to influence policy in DC, which may not be in their best interest (WHO, 2007).  Thus, DC may be limited on the creation of policies that promote ECD, since increased privatization and decreased governmental influence are often associated with globalization, and the primary focus is on increasing economic growth (WHO, 2007).  Globalization has influenced the global burden of childhood obesity by promoting cheap energy-dense foods in three ways; production and trade of agricultural goods through liberalizing the agricultural market, increased food trade across borders, and finally, higher foreign investment and enlarging transnational companies (TNC) (Hawkes, 2006).  This enables TNC to control the entire process of producing, distributing and selling of food in an economical way (Hawkes, 2006).  Secondly, foreign-direct investment (FDI) across borders enables TNC from one nation to purchase and invest in companies from other nations (Hawkes, 2006).  This enables companies to achieve high efficiencies in marketing and distribution by gaining market power and cutting costs, for example, Mexico’s food production involved processed foods due to FDI from America and Canada (Hawkes, 2006).  FDI also increased growth of multi-national retailers such as Walmart, where companies could sell and store processed foods more efficiently, which increases availability and decreases cost of purchasing energy-dense processed foods (Hawkes, 2006).  Furthermore, these forces of globalization have increased the proportion of energy in DC that is consumed, such as animal sources, hydrogenated vegetable oils and refined carbohydrates, all of which are high energy, but low nutrient quality sources (Popkin, 2006).  Thirdly, the global communication of information has increased due to the expansion of new technologies such as increased TV, internet and phone use (Hawkes, 2006).  Global marketing speeds up product turnover, creates demand and encourages consumption, and have been possible due to these new technologies that improve access (Hawkes, 2006).  This is relevant to childhood obesity, as some fast food companies have been targeting children to buy their products, due to them being easier targets, as they are not attached to culturally specific food (Witkowski, 2007). Globalization has enabled DC to grow their economies, however there is a positive and linear relationship between gross domestic product and BMI to a GDP up to $5000US per person, per year, so as GDP increases initially in DC, so does the level of obesity (Swinburn et al., 2011).  The overall impact of globalization is the combination of technological changes that create an environment that promotes cheaper, more available, energy-dense food and economic forces that drive consumption (Swinburn et al., 2011).  However, there currently is little recognition of how globalization is causing obesity burden to grow in DC, in addition to the burden of malnutrition and CD, which may threaten future national and ECD (Swinburn et al., 2011).  
 Public health nurses (PHN) take an active role in promoting, restoring and maintaining health through active partnerships with individuals, families, communities and populations (CHNC, 2010).  PHNs must also consider the influence that the determinants of health have within the political, cultural and environmental context of health (CHNC, 2011).  Community Health Nursing Competencies (CHNC) focus on promoting, protecting and preserving the health of populations (CHNC, 2011).  Considering these competencies, and our role in Canada as healthcare providers, we should also be able to advocate for populations we feel are in need globally. The issue of childhood obesity is relevant to nursing practice at every population level in Canada.  The RNAO best practice guidelines for childhood obesity prevention recommends that nurses advocate for healthy public policy that includes monitoring and surveillance data at a population level, regarding measures of central adiposity (RNAO, 2005).  This recommendation could also be relevant for raising awareness about the increasing prevalence of childhood obesity in DC.  When investigating a global issue like childhood obesity in DC, the CHNC standards are available to guide our practice.  CHNC standard 6, access and equity, would be relevant for this issue as it describes the role of the PHN to facilitate access and equity by working to make sure resources and services are equitably distributed among populations and reach those in need.  This is pertinent when advocating for childhood obesity internationally, as globalization has created power imbalances in DC that have altered equitable disruption of health services and resources conducive to health, which create an environment that promotes childhood obesity and negatively influences ECD.  Therefore, as a PHN I would need to identify the influence globalization is having on SDOH, specifically ECD, and opportunities for health for individuals, groups, community and populations living in DC.  My initial focus would be at the population level, due to the scale of this issue.  In DC, there are inequities that interfere with individuals’ ability to access health care.  Do to the pressures of globalization, governments in these countries focus on economic growth, which diverts resources and services from healthcare (WHO, 2007).  Thus, I would use this standard to analyze the impact of SDOH on childhood obesity and opportunities for health for child populations in DC.  Secondly, I would advocate for equitable access and resource allocation of health and other services in DC, to address obesity in ECD.
In summary, the growing burden of childhood obesity in DC are related to the negative pressures from globalization on the SDOH that shape ECD.  Thus, childhood obesity in DC is an intersectoral issue, as many different  stakeholders are influencing obesity in these regions, such as the governments of the DC, multinational companies/private sector that, communities, healthcare sector, educators, families and children.  Intersectoral action (IA) is thought to be necessary when multiple sectors share control over an issue, like childhood obesity, or when one sector wishes to influence an area which it has less control (WHO & Public Health Agency Canada (PHAC), 2008).  Therefore, a PHC approach in this case would promote IC that includes commitments of all sectors, in order to have a meaningful action on childhood obesity in DC (Canadian Nursing Association, 2002).  
In conclusion, some DC are undergoing rapid industrialization, due to the forces of globalization.  This is creating an obesity-prone environment and, in addition, the DC are beginning to experience an increase in prevalence of over-nutrition and concurrent child populations who are malnourished, or burdened with CD.  Thus, my political action tool was an attempt at raising national awareness of this issue through various approaches.  The secondary goal would involve a stakeholder meeting to discuss strategies to manage this growing obesity threat internationally through IA.  This dilemma will be difficult for DC to navigate through as they need economic growth, yet cannot afford the resources to manage an increasing NCD burden, if these globalization practices continue unabated.

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