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This decline in total energy expenditure, if not accompanied by a reduction in energy intake, may result in weight gain and potential obesity.

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Changes in both dietary habits and physical activity create an environment in which a person predisposed to weight gain may become obese. Such predispositions include either a genetic factor, as seen in the Pima Indians in Arizona United States , or undernutrition early in life. The Pima Indians living in the United States are morbidly obese and suffer from high rates of diabetes and hypertension Ravussin and Swinburn, This is in sharp contrast with their genetic counterparts living in Mexico where body weight and chronic disease prevalence are normal Esparza et al.

It has been suggested that the Pima Indians possess a "thrifty gene" that predisposes them to weight gain when environmental conditions such as sufficient food supply, high-fat diets or decreased physical activity are favourable Ravussin and Swinburn, In addition, recent work has shown a correlation between nutritional stunting growth retardation attributed to undernutrition during childhood and later obesity in developing countries Sawaya et al.

The general concept that early life stimuli may have permanent effects on metabolism and development was first conclusively demonstrated by Wiesel and Hubel In their experiments with newborn kittens, only one eye was allowed to receive visual stimulus following birth for a period of three months. It was found that the covered eye lacked significant and proper ocular development compared with the uncovered eye. In humans, it has been reported that children deprived of proper nutrition through formula feeding had lower cognitive scores on standard examinations compared with children who were breastfed.

In Sawaya et al. Nutritional stunting has been associated with obesity later in life in several transitional countries, such as China, South Africa, the Russian Federation and Brazil Popkin, Richards and Monteiro, Finally, Schroeder, Martorell and Flores recently published a report suggesting that adolescents who were stunted were more likely to be overweight compared with their peers who were not stunted. Physiological reasons for these observations vary from improper muscle development that affects substrate oxidation and physical activity to poor development of food intake and satiety controls during critical periods.

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Finally, stunting has been found to be associated with both metabolic and psychological risk factors for obesity. A cross-sectional study in Brazil found that stunted children oxidized a lower percentage of energy as fat compared with healthy children Hoffman et al. Thus, the developing world appears to be faced with a potentially grave nutritional situation as more countries experience rapid economic and social development. It seems plausible that those countries that have had traditionally high prevalences of undernutrition and stunting may be faced with a double burden of under- and overnutrition.

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More important, these countries, already poorly equipped to handle acute and chronic diseases, will face the increased economic burden of supporting an overweight or obese population, together with the associated, costly chronic diseases that accompany a high fat mass. This final point deserves particular attention from both health and economic agencies overseeing and promoting the development of transitional countries.

The double burden of underand overnutrition presents a potentially grave situation which deserves attention from both health and economic agencies promoting development. Many countries that historically sought and used national and international funds to combat micronutrient deficiencies and undernutrition are now facing the coexistence of under- and overweight people among the lower-income sectors of society. This enigma appears more dire when the social and economic implications are considered. These effects are created by the medical implications associated and precipitated by excess adiposity and weight.

Thus, the importance of studying how and why obesity is becoming more prevalent in developing countries becomes more urgent. In addition, it is becoming even more important to study the effect of a large population of obese people on developing economies and health care systems. Economic development is undoubtedly related to a country's ability to maintain and stimulate economic growth, decrease external debt and foster productivity. Nutrition and poverty are intimately linked by the relationship between nutrition and work capacity, such that poor nutrition is not only a result of, but perhaps a cause of poverty as well Ray, Poverty is influenced by poor nutrition in that a poor person has a reduced ability to purchase nutritious foods and in turn has a lower work capacity that perpetuates a low income.

While this vicious circle clearly illustrates the poverty cycle that is perpetuated in relation to nutritional status, obesity and weight gain are somewhat particular. In many transitional countries, the poorest populations, in terms of energy intake and wages, often reside in rural areas. Among the urban poor, energy intake and wages may have improved with regard to their rural counterparts, but the quality of energy consumed is of utmost importance.

That is, while the urban poor may earn and consume more, the quality of the food they eat may lead towards weight gains that will eventually limit their work capacity and return them to a state of lower income. This idea has not been explored extensively in transitional countries for many reasons.

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Studies from Europe and the United States demonstrate quite unequivocally that obesity is negatively associated with a person's productivity and work performance. An increased fat mass has been reported to inhibit spontaneous movement, result in poor health that reduces overall activity and inhibit various movements Seidell, Several studies have reported a strong relationship between body mass index, decreased physical functioning and a reduction in overall productivity Rissanen, ; Seidell, Moreover, obesity exerts its effects on productivity not only by an increase in mortality, but also through an increase in morbidity.

Increased morbidity removes individuals from the workforce but leaves them in society where they are still able to place demands in terms of food and health care needs. An obese person reportedly experiences a 50 percent increase in lost productivity and visits a doctor 88 percent more than a healthy person during a six-year period in the United States Wolf and Colditz, This creates a situation in which the chronically ill person not only contributes less to the economy, but also essentially requires more, creating a drain on economic resources.

The more sick a person is the greater his or her degree of absence from the workplace; chronic diseases related to adiposity and obesity increase absenteeism.

Narbro et al. In both cases, obesity contributes to absenteeism and directly reduces the productivity of a population.

In Europe and the United States, it has been shown that obesity reduces a person's overall activity. It affects productivity and increases morbidity and mortality. An example of such an economic drain is the influence that an increased prevalence of obesity has on the health care systems of developing countries. Historically, health care systems in developing countries have been designed to treat and manage only acute diseases, such as diarrhoea or minor infections FAO, The ability to treat large populations with relatively little money has been accomplished primarily through the use of satellite clinics staffed by nurses and health aides.

Although these efforts have been successful in minimizing health care expenditures, it is not certain whether or not the burden of obesity-related diseases could be accommodated by the present system. Essentially there will be an increased need for health care targeting chronic diseases that may not always be met by an increase in the necessary appropriate expenditures.

Moreover, as the World Bank recently reported Figure 4 , public health care expenditures are directly related to the relative wealth of a country World Bank, This implies that poor countries can do little to meet the double burden of infectious and chronic diseases as the prevalence of obesity increases. Percent of public expenditures allocated to health, by country income, from Little research on the economic impact of obesity in developing countries has been undertaken, making it difficult to assess the impact accurately.

At the same time, however, speculation as to the economic impact of obesity in the developing countries can be made using data from developed countries. In terms of real costs, the combined effects of decreased productivity and increased absenteeism are quite significant. In terms of disability, there is a higher number of disability pensions among the obese compared with lean people in the Netherlands Seidell, It would not be implausible to suggest that similar impacts will be seen in developing and transitional societies as the prevalence of overweight and obesity increases.

An important distinction is that these economic forces will be combined with an unstable economic infrastructure, especially in terms of health care costs and infrastructures. Tremendous strides in reducing the prevalence of communicable diseases, undernutrition and infant mortality have been made.

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These efforts may provide models to impede the trend towards obesity. The ability or willingness of a country to increase health care expenditures is influenced primarily by the amount of public monies available. Many developing countries simply do not have the flexibility of large economic surpluses or gross domestic products GDPs from which monies may be drawn. In fact, most transitional countries spend a large percentage of their GDPs on external debt repayment World Bank, The overall economic effects of obesity and higher health care expenditures will ultimately be coupled with other factors associated with obesity that could contribute to a slowing of both economic growth and development.

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Based on these observations it may be concluded that an increase in the number of obese people in developing countries could slow economic growth. Given that the GDPs of developing countries are reliant less on technical and service oriented work and more on industrial and labour-intensive work, a loss of this workforce will contribute to a slowing of overall growth and a reduction in GDP.

Parallel with the economic effects will be a greater need for public monies for health care expenditures. This demand may impede the repayment of external debts, essentially creating a need for continued external borrowing and a slowing of the development process. Nevertheless, tremendous strides have been made in recent years in reducing the prevalence of communicable diseases, improving the infant mortality rate and reducing the prevalence of undernutrition Table 5 in developing countries.

These objectives have been pursued vigorously by both non-governmental organizations and government agencies alike and may provide a model by which transitional countries can impede or reverse the trend of an increasing population of overweight and obese people. TABLE 5. Percentage of malnourished children in developing countries: and , various scenarios. Serious attention still needs to be given to the increasing prevalence of obesity in developing countries and some form of preventive intervention is best undertaken sooner rather than later.

One example could be to increase the surveillance of mildly overweight people in poor populations. People living in impoverished areas are generally cared for by health care teams at community health centres where implementation of minimal education can take place. Another example could be through educational programmes designed to increase awareness of the health risks associated with obesity.

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School programmes that educate children on health, especially in communities where public assistance through food aid is provided, are other ways in which increased education could be implemented. Finally, overall awareness of the long-term risks of obesity can guide social attitudes towards the benefits and risks of either maintaining or attaining health weights and body sizes.

At the macro level, development efforts need to consider the eventual impact of increasing economic development without corresponding improvement of health care systems. It is highly unlikely that a transitional economy would be able to host an obese population without sacrificing some segment of its public expenditures, such as education or infrastructure. Furthermore, programmes designed to strengthen the infrastructure and increase economic growth must be designed in conjunction with groups monitoring health and health outcomes.

For example, the introduction of cattle production in countries with poor health care or high external debt could easily result in short-term economic success and long-term negative health consequences related to the increasing consumption of meat with a high fat content. Programmes such as these, while neither actively encouraged or discouraged, should be accompanied by studies and surveillance of weight and chronic disease related to overnutrition.