The Global Media and the Obesity Epidemic

8/6/2019 The Global Media and the Obesity Epidemic

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The Global Media and the Global Obesity Epidemic

Michael S. Abrams

26 February 2009MALS

Skidmore College


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TABLE OF CONTENTS

Introduction

I. The Nutrition Transition

II. The Global Obesity Epidemic

III. The Role of the Global Media

Conclusion

References


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INTRODUCTION

In March, 1972, I had the privilege of visiting the former U.S.S.R. as part of a group of

students and faculty from Jericho High Schooltwo months before Nixons famous trip.

We toured three citiesMoscow, Leningrad and Kievand, in at least one setting, were

allowed to interact freely with our Russian peers. It was an eye-opening experience, one

that would have been unimaginable for many years for all of us on this side of the Iron

Curtain.

What stands out in memory most almost forty years later, however, was not the bitter

cold we felt standing in Red Square, or the tours of the behemoth Hermitage Museum.

What stands out is how little food was available there that was familiar to us. In

particular, Coca Colathat icon of Western civilization--was nowhere to found. For two

weeks, I would endure without access to my favorite beverage, only to be reunited when

we stopped to change planes at the airport in Amsterdam on our way back to the US.

Today, of course, such a situation would be unthinkable. Coca Cola is available in more

than 200 of the worlds nations. (For comparison, the United Nations boasts only 192

member states.) Other mainstays of the American fast food culture such as McDonalds,

Pepsi, Pizza Hut and Kentucky Fried Chicken have attained similar degrees of ubiquity.

In my own neighborhood in Sao Paulo, I find myself within walking distance of a

McDonalds, a Subways, a Pizza Hut, a T.G.I. Fridays, and a Burger King. (Though,

often, walking is not even a prerequisite. Almost anywhere in Brazil, one can place an

order on the McDonalds McEntrega website and it will be delivered to your home

within minutes.) All of the supermarkets and grocery stores stock a variety of familiar

soft drink brands, including numerous versions of Coca Cola and Pepsi.

It is axiomatic that the American fast food culture would not have achieved its dominance

in the US without access to, and adroit use of, the mass mediapreeminently, television.

It is only now possible for it to achieve a comparable global dominance in tandem with


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the globalization of the mass mediaagain, especially, television. To whatever degree

human health is impacted, it is no longer a question of impacting the 5% of the worlds

population that the US population represents, but rather the whole of the human family.

But so-called fast foods represent only the tip of the iceberg. It was not many years

ago that supermarketsand the diets based in processed foods that they make possible

were an emblematic feature of the industrialized world. Such is no longer the case, as

supermarkets and processed foods have made major inroads on every continent on the

planet. We might inquire as to what degree the messages of the global media help to

make our Western food lifestylebased in fast foods and processed foodsseem natural

and inevitable throughout the world and, especially, throughout the developing world.

But this is not to say that the effects are always the same. In Brazil, where even middle-

class domiciles invariably include a maids quarters, the preponderance of the meals that

are prepared at home are still made from raw ingredientseven if these are typically

purchased at supermarkets. When our doctor travels to the US for conferences, he is

amazed that he can gain 10 lbs. or more from only a few days of the American diet.

The world now finds itself in the midst of a global obesity epidemic, replicating in

developing nations a situation that had heretofore been confined to the developed world.

There can be little doubt that the globalization of the Western food culture is the driving

force. But precisely what role does globalization in generaland, in particular, the

globalization of the mass mediaplay in this phenomenon? It is to be hoped that this

paper can make a small contribution in helping to open these questions.

Michael S. Abrams

Sao Paulo, Brazil


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I. The Nutrition Transition

The last 200 years have seen a radical transformation of diet in industrialized countries.

First, the Industrial Revolution transformed every stage of the process by which human

sustenance is provided; i.e., foods production, processing, storage, and distribution.

Economic development together with recent technological innovations andmodern marketing techniques have modified dietary preferences, and,consequently, led to major changes in the composition of diet. There was a shifttowards high-fat, refined carbohydrate and low-fibre diet. (Uusitalo, Pietinen, &and Puska, 2002, p. 2)

The industrialized world was the first to experience this transition. In England, for

example, the per capita consumption of fats and refined carbohydrates increased five- toten-fold over 1800-2000; also, there was a significant decline in the consumption of

grains. It is only in recent decades that the longer term adverse health effects of a diet

rich in fat, especially saturated fat, but deficient in complex carbohydrate food have

become clear. (Uusitalo, Pietinen, & and Puska, 2002, p. 2)

The shift that took place within 100-200 years in the West occurs within a few

short decades in the developing world. Globalization is the critical factor in this

accelerationincluding, exposure to the global mass media. Concomitant factors

include the trend from labor-intensive occupations and leisure time activities toward

more capital-intensive, less strenuous work and leisure.

Globalization has been defined as a process whereby increasing economic,

political, and social interdependence and global integration take place in terms of capital,

traded goods, persons, concepts, images and ideas. Globalization can result in a

homogenization and Westernization of the worlds dietit can also result in a

diversification that could lead to heterogenization of the food and nutrition system.

(Uusitalo, Pietinen, & and Puska, 2002, p. 2-3)

Globalizations effect on diet is a double-edged sword:

Often overall nutrient intake improves with an increasing variety of foods, but themovement toward more fats, salt, sugars and refined food quickly moves beyondthis more optimal state to one in which diets contributes to rapidly escalating ratesof obesity and chronic diseases. Salt-sensitive hypertensive or fat-sensitive


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cardiovascular disorders [CVD] that may not have been expressed on a traditionaldiet become prevalent. The transition is accelerated by a high urbanization rate,which is usually accompanied by decreased physical activity level, and increasedoverweight and obesity. (Uusitalo, Pietinen, & and Puska, 2002, p. 3)

Scholars understand the changes in diet that have occurred over the last centuryor two in industrialized societiesand which are presently occurring much more rapidly

in the developing worldas the nutrition transition.

Modern societies seem to be converging on a diet high in saturated fats, sugar andrefined foods and low in fibreoften termed the Western dietand onlifestyles characterized by lower levels of activity. These changes are reflected innutritional outcomes, such as changes in average stature, body composition andmorbidity. (Popkin, 2003, p. 581)

The nutrition transition depends on two other historical transitions: a

demographic transition and an epidemiological transition. The demographic transition

can be described as the shift from a pattern of high fertility and mortality to one of low

fertility and mortality. The developed countries have all fully completed this transition.

The epidemiological transition is the shift from a pattern of high prevalence of

infectious disease, associated with malnutrition, periodic famine and poor environmental

sanitation, to one of high prevalence of chronic and degenerative disease, associated with

the urban industrial lifestyle. (Popkin, 2003, p. 581)

The nutrition transition has three broad stages:

Stage 1 sees famine recede as the economy modernizes and people have more

income. Stage 1 diets are starchy, and have little variety, but they are also characterized

as low in fat and high in fibre. Stage 1 lifestyles are typically labour intensive. The

result is immunodeficiencies, weaning disease and stunting. There is a slow decline in

mortality over time.

Stage 2 is characterized by the ascendance of degenerative disease. Stage 2 diets

are dominated by processed foods, and are high in fat and sugar. Stage 2 lifestyles are

relatively sedentary, the result of a shift in technology of work and leisure. It is in

Stage 2 that obesity becomes a public health problem; also, osteoporosis emerges.

Although there is an increase in life expectancy, this is accompanied by an increased


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disability period. Diet-related non-communicable diseases (NCD) become highly

significant factors both in mortality and morbidity.

With Stage 3, volitional behavioral change becomes an important factor. Stage

3 diets are deliberately high in fruits and vegetables and low in fatalso, they have high

levels of complex carbohydrates and fibre. Stage 3 lifestyles see sedenterianism replaced

by purposeful changes in recreation, such as exercise. The result is that obesity and

osteoporosis become less significant as public health issues. At this point, extended

healthy aging becomes the norm, and diet-related NCD are on the decline.

The nutrition transition is driven by a number of factors, including mass media

growth. Other factors include: urbanization, economic growth, and technological

changes for work, leisure and food processing. (Popkin, 2003, p. 581-82)

The diet in the developing world is currently undergoing rapid change. Three

factors stand out: fat, sweeteners, and animal source foods.

There is some general misunderstanding of exactly how this process unfolds:

In the popular mind, the Westernization of the global diet continues to beassociated with increased consumption of animal fats. Yet the nutrition transitionin developing countries typically begins with major increases in the domesticproduction of and imports of oilseeds and vegetable oils, rather than meats andmilk. (Popkin, 2003, p. 583)

Over 1991-1996/7, the world saw the production of vegetable fats and oils increase by

almost 20%, but the production of butter and tallow remained relatively constant. Over

1961-1990, the global production of each of four of the five primary vegetable oils

(soybean, sunflower, rapeseed, and palm oil) have tripled.

Among nations, fat intake increases with per capita income, but this profile has

changed in the last 40 years, and even poor countries had access to a relatively high-fat

diet by 1990. By then, countries with a per capita income of as little as US $750 (about

$2/day) attained an average diet where 20% of energy comes from fat; in 1962, this same

level of fat was associated with a much higher standard of living (a per capita GNP of

$1475). (Dollar amounts are given in constant 1993 dollars.) This dramatic change

arose principally from a major increase in the consumption of vegetable oils.


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Although the worlds main sweetener is sugar, caloric sweeteners include a

variety of other products. High fructose corn syrup is a prime example, as it is the

sweetener used in all US soft drinks. Globally, 306 kcal of sweetener were consumed

per person per day in 2000about a third more than the comparable figure for 1962.

Caloric sweeteners also accounted for a larger share of both total energy and total

carbohydrates consumed.

Predictably, all measures of caloric sweetener increase significantly as GNP per

capita and urbanization increase. But there is a surprising relationship in how

urbanization impacts the dependence of intake on income. For countries with an

urbanization level of 25% in 1990, energy derived from sweetener steadily increases

from about 5% to about 15% as per capita increases from $200 to $10,000. Contrast this

to countries that had an urbanization level of 75%. For these much more urbanized

countries, even a per capita GNP of $200 is associated with 16% of energy derived from

sweetener; as income increases to $10,000, this figure steadily drops to 12%.

Developing countries are experiencing a revolution in animal source foods; i.e.,

an increase in demand and production of meat, fish, and milk in low-income developing

countries. Developing countries are responsible for most of the worlds growth in

production and consumption of these foods. By 2020, developing countries will

produce most (63%) of the worlds meat, and half (50%) of the worlds milk. This is a

global phenomenon, which redirects grain production to serve as animal feed. It also

leads to resource degradation, rapid increase in feed grain imports, rapid concentration of

production and consumption and social change. (Popkin, 2003, p. 583-86)

Over 1989-1997, the changes in the Chinese diet as documented by the Chinese

Health and Nutrition Study (CHNS) follows a classic Westernization pattern:

1) There is an increase in cereal intakeboth coarse and refinedboth

for urban and rural residents, and for all income groups.

The shift away from coarse grain consumption such as millet, sorghum and corn,is a key component of this change. CHNS data showed a 38g [per capita per day]decrease in refined cereals between 1989 and 1997 [from 549 g to 511 g] but aneven larger decrease in coarse grain consumption of 89 g [from 135 g to 46 g].(Popkin, 2003, p. 587)


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2) Consumption of animal products increased, with the rich having greater

increases than the poor, and the urban having greater increases than the rural. In 1997,

consumption of animal products for urban residents was 180 g per capita per day,

compared to 117.9 g for rural residents. Over 1989-1997, urban residents saw an

increase of 48.5 g, compared to a 38.1 g increase for rural residents. Consumption of

animal products increases with income level (low income, medium income, and

high income) for both the 1989 and 1997 data, and there were increases at every

income level. But over 1989-1997, intake for the high income group was almost 3 times

that of the low income group (191.6 g per capita per day vs 77.1 g). Also, over 1989-

1997, the increase for the high income group was more than 3 times that of the low

income group (63.6 g vs. 18.2 g).

3) Partly as a consequence of changes in cereal and animal product intake, there

was a steady shift in the diet from carbohydrates to fat. For urban and rural residents,

and for each income group, the period of 1989-1997 saw a clear trend of increasing

percentages of energy from fat, and decreasing percentages of energy from

carbohydrates. The population as a whole got 8% more of its energy from fat in 1997

than it did in 1989 (27.3% vs. 19.3%), and 8.9% less of its energy from carbohydrates

(59.8% vs. 68.7%). (This is based on CHNS data for 1989, 1991, 1993, and 1997.)

4) The net result of all these changes is an upward shift in the energy density of

the foods consumed. The amount (in kcals) of energy intake from foods and alcohol per

100 grams of food in both urban and rural Chinese diets increased by 13% between 1989

and 1997. These are really very rapid shifts. [Italics mine.] (Popkin, 2003, p. 587-88)

Several changes are combining to alter physical activity profiles: (1) a shift from

occupations that involve significant levels of physical labor (especially, "farming, mining

and forestry") to service industries, (2) "reduced energy expenditures in the same

occupation, (3) changes in transportation, and (4) changes in leisure activities.

China exemplifies these shifts. Over 1989-1997, there were significant increases

for three of four groups employed in occupations with relatively light levels of physical

activity (urban males, urban females, and rural females). However, there were significant

decreases for only two of the groups employed in occupations with relatively vigorous

levels of physical activity (urban males and urban females.) "In rural areas . . . there has


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been a shift for some towards increased physical activity linked to holding multiple jobs

and more intensive effort."

There were important changes in transportation and leisure activities, as well. "In

China, 14% of households acquired a motorized vehicle between 1989 and 1997." (It has

been demonstrated that there is a statistically significant association between the

ownership of a motorized vehicle and the probability of being obese.) Also,"television

ownership has skyrocketed in China, leading to greater inactivity during leisure time"

(Popkin, 2003, pp. 588-89)

The immediate consequences of changes in diet and physical activity patterns are

an increase in the prevalence of overweight and obesity. This has been seen, in fact, in

countries as diverse as Mexico, Egypt and South Africa, where overweight levels

match or exceed that of the US.

Comparing obesity rates among a variety of less developed countries (LDCs)

e.g., Brazil, Mexico, Egypt, Morocco, South Africa, Thailand, and Chinaone striking

fact emerges: many . . . countries with quite high overweight levels are very low-

income. Moreover, it probably surprises many people that the levels of obesity of several

countriesall with much lower income than the USare so high.

Obesity emerged as a public health issue in some countries extremely quickly.

Contrast the rise of obesity in the US and Europe (about 0.25%/year) with that in Mexico

(for women, 2.4%/year), Brazil (1.0%/year for men, 0.7%/year for women), Morocco

(0.5%/year for men, 1.0%/year for women), Thailand (1.1%/year for men, 1.9%/year for

women), and China (1.1%/year for men, 0.6%/year for women). The rates of change are

very high in Asia, North Africa, and Latin Americatwo to five times greater than in the

US. (Popkin, 2003, pp. 589-90)

The most salient health-related concomitant of the nutrition transition is the

growth of NCD as a major factor in mortality and morbidity, globally. Diabetes is one

such NCD. There is a growing literature documenting rapid increases in diabetes in

many lower-income countries, caused mainly by diet and inactivity. Although the

relationship between diet and diabetes is not fully understood, obesity and inactivity are

well-established as two of its risk factors.


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As it is both debilitating and health-care intensive, diabetes saps both the vigor

of the individual and the society. There are nations in the developing world where the

prevalence of diabetes matches or exceeds that of the USnotably in Latin America,

North Africa, and the Middle East. Already, 4% of Chinese adults and 2% of Indian

adults are afflicted: together, there are more new cases each year in these two

countries than in the rest of the world combined. [Italics mine.] Not only do prevalence

rates in the developing world meet or exceed those in the developed world, but the age of

onset is typically lower. (Popkin, 2003, pp. 590)

There has been a remarkable decline in deaths related to infectious and parasitic

morbidity in Chinaone that is still underway in India. Simultaneously, China is

already showing increases in mortality from heart disease and cancer, due to the rapid

rise in nutrition-related NCDa development that will soon be replicated in India

(Popkin, 2003, pp. 591)

In the LDCs, the social costs of diet-related NCD (DR-NCD) have begun to rival

those of undernutrition. In China and India, for example, undernutrition is still a

significant factor. In China, undernutrition represents 0.5%-1.8% of lost GDP; in India,

0.7%-1.1%. But these estimates, if anything, underestimate the problem as the overall

cost of undernutrition, also including cognitive costs, is almost certainly higher.

Projections show these costs diminishing to 0.2% in China by 2025, but still at 0.4%-

0.7% in India.

In contrast, the costs of DR-NCD are already substantial and will grow very

rapidly. They represent a loss of 1.6% of GDP in China and 0.35% in Indiaand these

figures only take into account health care expenditures. Though currently at parity with

the costs of undernutrition in China, by 2025 the costs due to DR-NCD will far exceed

those of undernutrition. A similar trend is evident in India, where undernutrition costs

are more significant now, but projections show the two factors attaining parity by 2025

(Popkin, 2003, pp. 591)

Several causes have been cited for the nutrition transition in the developing world:


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1) The developments are entirely consistent with economic theorys

understanding of the rational actor. Obtaining a more varied and tasteful diet and a less

burdensome work pattern is an important choice desired by most individuals.

2) Rising incomes are changing consumption patterns, so that additional high-fat

foods are being purchased with additional income.

3) From the early 1970s to the early 1990s, there has been a significant

inflation-adjusted drop in food prices.

4) . . . The centralization of mass media and the generation of major pushes topromote selected dietary patterns directly or indirectly via these media. There isas yet little in the way of rigorous analysis to link shifts in mass media coverageto the consumption or work patterns in the developing world, but there is anemerging literature on increased television ownership and viewing. There is aprofound cultural side not only to the globalization of mass media, but also to the

related penetration of Western-style fast food outlets in the developing world.There is some evidence that these changes affect the entire culture of food

production and consumption. [Italics mine.] (Popkin, 2003, p. 592)

5) Advances in technology make possible lifestyles with less exertion. The effect

is ubiquitous, as the impact is felt in domestic work, in transportation, in farming, and in

the service industries. Urbanization is a critical factorresulting in lowered costs for the

production and distribution of food, and also of work-related technology. (Popkin,

2003, pp. 592-93)


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II. The Global Obesity Epidemic

Among the many things that globalization has globalized is obesity, and we are now in

the midst of a global obesity epidemic.

Globalization is a concept that very much relates to the focus on freer and morerapid movement of capital, technology, goods, and services. It captures theprofound effects on lifestyles that are linked with diet, activity, and subsequentimbalances that have led to the obesity epidemic. The freer movement of thesefactors is linked in quite complex ways, with very rapid shifts in dietary andactivity patterns seen on a global level. These globalization-related changes aretaking place particularly fast in the low-and middle-income countries of thedeveloping world. Adult obesity levels are increasing far more rapidly than in thehigher-income countries; overweight and obesity levels of some lower-income

developing countries match or exceed that of the United States. Currently, childobesity is still relatively less common in the lower- and middle-incomedeveloping countries. (Popkin, 2007, p. 227)

Surprisingly, rates of adult obesity can fail to vary dramatically between countries

of vastly differing living standards. In 1999, the US (with a per capita GNP of $35,686),

had an obesity rate of 67.0% for males and 62.0% for females. In 1998, Egypt (with a

per capita GNP of $1290) had an obesity rate of 48.4% for males and 70.0% for females.

[Obesity is defined as having a Body Mass Index (BMI) >= 25.] (Popkin, 2007, pp. 228-

29)

Even more than the rates of prevalence of obesity, the annual rates of increase in

obesity prevalence can fail to reflect standards of living. During 1999-2000, the increase

in obesity prevalence among females in the US (with a per capita GNP of $35.686) was

0.39%. The corresponding figure for Mexico in 1999 ($3840) was 2.40%; for Brazil in

1996-97($4630), 0.70%; for Morocco in 1985-1999 ($1240), 1.00%; for Thailand in

1991-1996 ($2160), 1.86%; and for China in 1989-1997 ($750), 0.60% (Popkin, 2007,

pp. 228-229). (Popkin, 2007, p. 228-29)Since 1950, there have been profound technological advances that have resulted

in a far more sedentary lifestyle for the population of developed countries--whether at

work or at home. The impact of these advances has been virtually universal, greatly

affecting how farmers and both blue- and white-collar do their work (Popkin, 2007, p.

230)


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Both middle- and lower-income countries are rapidly following the developed

countries towards a more sedentary lifestyle:

Even in 1980 most lower-income country farmers did all activities by hand,

people walked and biked everywhere, and all aspects of food preparation requiredextensive time and energy. In the new millennium, jobs in urban areas arecomparable often in use of technology to those in the United States, and somecities around the developing world are as modern as any in the United States (e.g.,Shanghai, China). Food in urban areas is processed as often as in Europe and theUnited States, walking is being limited, and television and computers abound. Inrural areas, mechanization of most farming activities from the spreading offertilizer and insecticides to plowing with tiny powered plows to the use oftractors and trucks has replaced most labor intensive activities (which also tend touse much higher level of energy expenditure per minute) " (Popkin, 2007, pp.230-31)

It might be conjectured that the prevalence of obesity (BMI >=25) in developing

countries was a predominantly urban affair. However, data for urban and rural women of

child-bearing age (20-49 y.o.) in 36 developing countries (with per capita GNI's ranging

from US$190 to $4440) paint a remarkably similar picture. Perhaps even more

surprisingly, and for both urban and rural regions, the prevalence of overweight generally

far overshadowed that of underweightexcept for the case of rural women from those

countries with a per capita GNI below US $500 (Popkin, 2007, pp. 230-31)

Statistics from country after country show increasing prevalence of obesity, with

extreme prevalence in some areas. In Kosrae, one of four districts in Micronesia, almost

9 in 10 adults (88%) are overweight, and more than half of the adult population (53%) is

obese. What accounts for such dire statistics?

. . . The recent development of a wage-based economy has upset traditionaleating habits and made them dependent on imported food from developedcountries. Whereas previously individuals relied heavily on local foods such as

fresh tuna, increasingly men and women use cash to buy nutrient poor packagedfood. (Quoted in Brownell, 2006)


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Among the important ways in which the global food system has changed are:

the rapid increase in consumption of low-cost edible vegetable oils and . . . the way

large supermarket chains have gained control of food distribution. (Popkin, 2007, pp.

232)

Until the 1950's, the preponderance of fats that humans could consume was

animal fats--i.e., "milk, butter and meat". But shortly thereafter,

a revolution in the production and processing of oilseed-based fats occurred.Principal vegetable oils include soybean, sunflower, rapeseed, palm, and peanutoil. Technological breakthroughs in the development of high-yield oilseeds andin the refining of high-quality vegetable oils greatly reduced the cost of bakingand frying fats, margarine, butter-like spreads, salad oils, and cooking oils inrelation to animal-based products. (Popkin, 2007, p. 232)

As a consequence, "lower-income countries can now consume fat levels equivalent to the

consumption in higher-income countries." (Popkin, 2007, p. 232)

During 1945-65 the production of vegetable oils in the US grew 400%, while the

corresponding figure for animal fats was only 11%. Two factors were responsible. First,

were the "health concerns regarding the consumption of animal fats and cholesterol."

Second, "a number of major economic and political initiatives led to the development of

oil crops, not only in Europe and the United States, but in South East Asia (palm oils), in

Brazil, and in Argentina (soybean oils)."

Now, the developing world is following our lead:

In developing nations, one of the earliest shifts toward a higher-fat diet beganwith major increases in the domestic production and imports of oilseeds andvegetable oils, rather than increased imports of meat and milk. With theexception of peanut oil, global availability of the vegetable oils . . . hasapproximately tripled from 1961 to 1990" (Popkin, 2007, p. 233).

A number of factors have contributed to the rapid proliferation of supermarkets as

the primary conduit of food sales in the developing world. First, "consumer demand for

processed and safer foods is on the rise in the developing countries." Second, as

countries modernize, women become part of the labor force, and the demand grows for

"time-saving, prepared foods." Third is the growing availability of motorized

transportation and refrigerators.


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In Latin America, the use of supermarkets has become almost universal,

spreading "across both large and small countries, from capital cities to rural villages, and

from upper- and middle-class families to the working class." The same phenomenon can

be observed throughout the developing world. (Popkin, 2007, p. 233)

Fresh markets are being replaced by supermarkets:

The fresh market (in the agricultural field these are termed 'wet markets', as noneof the food is processed or sealed and often even the animal portions are live) isdisappearing as the major source of supply for food in the developing world.Fresh food markets are being replaced by multinational, regional, and local largesupermarkets--supermarkets which are usually part of larger chains (e.g.,Carrefour or Wal-Mart) or, in other countries such as South Africa and China, bylocal domestic chains patterned to function and look like these global chains.Increasingly, large megastores are found" (Popkin, 2007, p. 233)

Within a single decade, 1990-2000, "the role of supermarkets in Latin America

has expanded equivalent to about half a century of expansion in the United States." The

proportion of all food sales in supermarkets in Latin America was only 15% in 1990; by

2000, it was 60%. The comparable figure for the US in 2000 was 80% (Popkin, 2007, p.

233)

However, the proliferation of supermarkets has not been an entirely negative

development:

Supermarkets are large providers of processed higher-fat, added-sugar, and salt-laden foods in developing countries, but they have also been the purveyors ofsome good. For example, supermarkets (a) were instrumental in the developmentof radioactively treated mil, giving it a long shelf life and providing a safe sourceof milk for all income groups and (b) were key players in establishing food safetystandards. Most importantly, they have solved the cold chain and in manyinstances have brought higher-quality produce to the urban consumer throughoutthe year. (Popkin, 2007, pp. 233-34)

Some researchers believe that "the US fast food sector and soft drink industry"

has resulted in "the declines of diets throughout the developing world." It is certainly

true that companies like Coca-Cola, McDonalds, Pizza Huts, and Kentucky Fried

Chicken now have a presence throughout the world. The important question is whether

such companies are having a significant impact on diets in the developing world. "Are


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they leading people away from their healthy traditional diets to higher-fat and added

sugar-laden away-from home prepared food products? Are they leading to increased

portion sizes worldwide, as they have in the United States?" (Popkin, 2007, p. 234)

Surprisingly, the impact of McDonalds has not been unqualifiedly negative.

In Hong Kong and China, for instance, McDonald's has actually contributed toimproving standards of bathroom cleanliness and table manners. Thetransformation has also affected McDonald's . . . McDonald's itself has beenforced to adapt to local culture and tastes and has undergone a complex process ofcultural accommodation, compromise, and change in its assimilation into Asiansocieties. (Popkin, 2007, p. 236)

NCD are a significant factor globally, and are projected to become even more

significant:

Non-communicable diseases are leading causes of death [both] in developing anddeveloped countries. Only in Africa do communicable diseases cause moredeaths than non-communicable diseases. . . . Non-communicable deathscontribute substantially to adult mortality with the highest rates being in centraland eastern European countries. They add to health inequalities within andbetween countries, mainly affecting poor populations largely because ofinequalities within and between countries, mainly affecting poor populationslargely because of inequalities in the distribution of major risk factors. The globalpatter of death will be dominated by non-communicable diseases; by 2020, CHD

[coronary heart disease] and stroke are expected to be the leading causes of deathand loss of disability-adjusted life years. (Beaglehole, 2003, p. 903)

Further, NCD are poised to be a significant factor in the developing world.

Consider the ten leading risk factors regarding to their contribution to the global burden

of disease. For developed countries,seven of these pertain to NCD (i.e., tobacco, blood

pressure, cholesterol, BMI, low fruit and vegetable intake, physical activity, and illicit

drugs). Compare this to developing countries with low mortality rates, where as many as

six of the ten leading risk factors pertain to NCD (alcohol, blood pressure, tobacco, BMI,

cholesterol, low fruit and vegetable intake). Only developing countries with high

mortality ratesby definition, these are countries which have yet to navigate the

epidemiological transitionshow a significant difference, in which only three of the ten

leading risk factors pertain to NCD (blood pressure, tobacco, and cholesterol.) In most

developing countries, non-communicable disease factor levels have increased during the


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past decade [1993-2003], portending an increase in the rate of non-communicable

diseases in the next two decades. (Beaglehole, 2003, p. 903)

Some argue that the extensive migration of people into cities is responsible for the

global obesity epidemic. People whose diets have a preponderance of fast food are

obviously more prone to obesity than those who subsist on more traditional fare. Mexico

City typifies this situation, where almost a third (30%) of primary school children and

almost half (45%) of secondary school children are overweight.

A rural Mexican diet is rich in corns, beans, fruits and vegetables, while the urbandiet increasingly includes imported fast foods and local junk foods. Whether richor poor, Mexicans are eating more fried fatty foods and meats, since the prices for

these products have gone down in price. The ability to eat these foods isassociated with status, and has become a cultural norm that is hard to break. (TheLevin Institute, 2005)

Both under- and over-nourishment increase susceptibility to disease and reduce

life expectancy, but there are important differences. The former typically has its worst

effect in childhood, while the latter gradually impacts the middle years. Further, the

effects of undernourishment, such as stunted growth and blindness, are often irreversible,

while illnesses from overeating can often be tamed through changes in diet and lifestyle.

The World Bank and Harvard University's Global Burden of Disease Studycaptured the broad impact of malnutrition on health. The study measured 'yearsof healthy life lost' because of death or disability resulting from various riskfactors. Hunger and micronutrient deficiencies are now regarded as the top twocauses for a year of healthy life: updated analysis by Dr. John Mason, whoworked on the original study, finds hunger to be responsible globally for 22percent of these losses, and micronutrient deficiencies for 18 percent. The studydid not measure the contribution of being overweight, but Dr. Alan Lopez, headof the Harvard study team, is confident that overeating is responsible for at leastas large a share of global illness as hunger. (Gardner & Halweil, 2000, pp. 34-35)

We may therefore conclude that "poor nutrition would easily count for more than half of

the global burden of disease." (Gardner & Halweil, 2000, pp. 35)

Economic development enables an epidemiological transition--from a mortality

profile dominated by infectious diseases, to one dominated by chronic diseases, such as

"heart disease, stroke and cancer." But it is also associated with a nutritional transition,


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"when diets, particularly in Western Europe, changed to overconsumption of energy-

dense fats and sugars, producing more obesity" (Wilkinson, 2003, p. 26).

Human health and wellbeing requires a good diet. An inadequate diet--whether

from an insufficient amount or insufficient variety of food intake--directly impacts health.

Traditionally, malnutrition was equated with an insufficient diet--but overconsumption is

also a form of malnutrition, with its own dire health consequences. Such include:

"cardiovascular diseases, diabetes, cancer, degenerative eye diseases, obesity and dental

carries." It is entirely possible for overnutrition to coexist with undernutrition in the same

country--or even the same community. (Wilkinson, 2003, p. 26)


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III. The Role of the Global Media

While the primary driver of the global obesity epidemic is the global food production,

marketing, and distribution sector (including soft drinks, fast food, and other

multinational food companies, there are several critical ancillary factors, including the

vast expansion of the global mass media. Other such factors include the globalization

of modern food processing, marketing and distribution techniques (most frequently

linked with the westernization of the Worlds diet). (Popkin, 2007, pp. 227-28)

Fully comprehending the role of the global mass media may represent an

important new frontier in research.

One of the least discussed and least understood areas of change affecting dietary

and physical activity patterns is the role of the modern mass media. Throughoutthe developing world, there has been a profound increase in the ownership oftelevision sets and the penetration of modern television programming . . . . Thishas been accompanied by a proliferation of modern magazines and ready accessto DVDs of Western movies. To date documentation of the health implications ofthis are limited. (Popkin, 2007, pp. 234)

However, there is no doubt that access to modern mass media [in the LDCs] has

grown very rapidly, particularly in the last decade [1992-2002]." For example, over

1989-1997, TV ownership in China rose significantly, and at every income level. For

low-income families, it grew from 46.5% to 78.0%; for medium income families, from

67.5% to 90.9%; for upper income families, from 80.1% to 95.6%. (Popkin, 2002, pp.

210-11)

But already there have been some significant efforts to understand the impact of

the global media on eating behaviors in LDCs. For example, a study of a sample of 214

young Tanzanian women showed significant positive correlation between exposure to the

global media (television, film, and Internet) and eating disorders. Tanzania is one of the

worlds least developed nations, with a GDP per capita of US$744 and a life expectancyof 51.0 years. (Eddy, Hennessey, & Thompson-Brenner, 2007)

Obesityonce an affliction largely confined to the developed nationsis now

becoming a global phenomenon. And not only adult obesity is being globalized, but

childhood obesity as well. Levels of obesity and overweight amongst children in a

number of LDCs are as high as in the U.S.


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As a health issue, obesity is a risk factor for several NCD, including adult-onset

diabetes, CVD, and cancer, and is highly associated with high cholesterolanother risk

factor for CVD. But obesity is not the only culprit; the incidence of NCD is also rising

amongst populations who are within the recommended weight levels. (Hawkes, 2002, p.

1)

In addition toand independently ofobesity, both diet and exercise are risk

factors for NCD. It has been suggested that the Westernization of diets has been an

important factor in this regard.

Sometimes termed the nutrition transition, Westernization occurs when thepopulations consume more fats and sugars and fewer wholegrains. Although thefindings remain controversial, a wide range of studies from all over the worldhave linked dietary fats and sugars with obesity and/or disease in populations both

rich and poor. (Hawkes, 2002, p. 1)

A major factor in the Westernization of diets globally is

the carbonated soft drinks and fast foods purveyed by U.S.-based corporations.These products are becoming more prevalent in the global diet, in large part dueto the global expansion of multinationals into the emerging markets of low- andmiddle-income countries. The attraction for these companies is clear: themajority of the worlds population, rising incomes and changing lifestyles. Inother words, they are markets that represent significant untapped sources ofvolume. (Hawkes, 2002, p. 1)

Over 1995-1999, soft drink consumption rose in every region in the world. This

has been driven by Coca-Cola and PepsiCo, the two largest soft drink companies in the

world. Coca-Cola has expanded its presence from 28 countries in 1930 to more than 200

countries, with the expansion during 1980-2000

particularly aggressive. The company aimed to double non-US sales in the 1990s,taking advantage of the end of the Cold War and the liberalization of tradepolicies. Today, 70 percent of Coca-Colas worldwide volume sales are outsideNorth America, Latin America being the major non-U.S. market, and on average[globally] a person now consumes 70 Coca-Cola drinks each year. (Hawkes,

2002, pp. 1)

Around the world, the per capita consumption varies greatlywith North America (398)

and Latin America (205) at the high end, Europe, Eurasia and the Middle East (72)

near the world average, and Africa (34) and the Asia-Pacific region (23) at the low end.

(Hawkes, 2002, pp. 1-2)


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As with soft drinks, fast foods are become a significant factor in the global diet.

And as with soft drinks, the two largest companies are driving the change--McDonald's

Corporation and Yum! Brands. (Yum! Brands owns Kentucky Fried Chicken and Pizza

Hut, and has a bigger total number of outlets than McDonald's.) "Growth of global fast

food companies was particularly rapid in the 1990s when the companies adopted policies

of aggressive international expansion." For example, over a single decade, 1991-2001,

McDonalds

more than doubled the number of countries of operation (from 59 to 121), morethan quadrupled its number of non-U.S. units (from 3,665 to 15,919), thusincreasing its proportion of non-U.S. outlets from 30 to 55 percent. 51 percent ofMcDonald's sales now come from outside the U.S." (Hawkes, 2002, p. 3)

Although the relationship between the global proliferation of fast food and the

global obesity epidemic may seem straightforward, it is not uncontroversial. Other

factors may, indeed, be more significant. These include immediate factors such as "the

increased availability of cheap vegetable oils and local processed-food brands," together

with distal factors, such as "rising incomes and urbanization." " . . . The precise impact

of Western fast foods and soft drinks relative to other drivers of the 'nutrition transition' is

not well-understood" (Hawkes, 2002, pp. 4-5).

However, marketing efforts by global fast food and soft drink companies amount

to a deliberate attempt to influence consumption habits. Thus, the impact of such efforts

on the global obesity epidemicand the associated rise in NCDis necessarily in a

different category than the impact of other, much more amorphous processes that

stimulate demand for western food products, such as urbanization and rising incomes.

(Hawkes, 2002, p. 5)

The critical factor that makes it important to understand the role of global fast

food companies in the nutrition transition is marketingwhich was cited as a cause for

concern by the World Health Organizations Director General.

There has been a general concern for some time that the marketing practices of

food companies encourage unhealthy eating patterns, and global companies especially

have the resources to employ effective marketing strategies. But the important issue is

whether food companies are trying to meet a demand or fulfill a demand. In established


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markets such as exist in most of the developed countries, companies fight for a share of

an established target market. But, in less developed markets, the

consumption of fast foods and soft drinks as categories is rising, and . . . this isdriven by the increasing presence of global brands (brands of non-local origins

tend to be viewed as more desirable by many consumers in LCDs). Thusalthough the nature of the competition varies between and within countries, globalcompanies are stimulating new demand and competition, and therefore furthergrowth of the soft drink and fast food sectors as a whole" (Hawkes, 2002, p. 5).

Although each market will demand its own mix of advertisingi.e., signage,

TV, print, and radioadvertising on television is critical.

As explained by McDonalds: Television commercials are used as soon and asfrequently as possible. However, in those markets where access to commercialtelevision is limited, we rely on other media, like the cinema, the radio, billboards,

newspapers, magazines and direct mail. (Hawkes, 2002, p. 16)

When McDonalds first arrived in China, advertising campaigns there focused on

newspapers and magazines more than television commercials, which were considered

ineffective. Even now, Coca Cola markets through signage in China much more than

television. But typically, TV commercials are the dominant form of marketing, in India,

for example, and southeast Asian countries. (Hawkes, 2002, p. 16)

Advertising often sells much more than just a product:

Advertising is often the most visible form of marketing by global fast food andsoft drinks companies. While advertising cannot expand availability or make aproduct affordable, it is crucial because it nurtures brand image and 'creates value'by attempting to convince consumers that they are getting more than just a drinkor some food. Rather, they are getting a lifestyle. As the Coke CEO put it, 'Yes,it's refreshing on a hot day, but we're not selling just that: we're selling an idea,and that is done through the imagery, the 100 years of advertising, thecommunication, the local community attitude and the supportive education.We've made it much more than just a product. (Hawkes, 2002, p. 16)

TV advertising by the big four (McDonalds, Yum! Brands, Coca-Cola, and Pe

PepsiCo) is often part of a global campaign, but, to varying degrees, adapted to local

markets. As it is for most companies, it can be divided into two broad categories:

promotional and reputational. While promotional ads extol the virtues of one

particular product and/or its price,


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reputational ads use an emotional bonding technique of associating the brandwith consumer desires and values. By encouraging people to believe thatconsuming the product is part of pursuing their desires and holding to their values,the companies aim to make the product acceptable to more people, and to instill asense of loyalty to the brand. (Hawkes, 2002, p.17)

Examples of the desires and values portrayed are:

1) Strong family values Virtually all of McDonalds advertising everywhere

portrays its restaurants as a special place for families. For example, a commercial run

in 2000 in India sought to

create warmth and beckoning the target to experience the warm and friendlyexperience of McDonalds. It depicted a five-year old child too scared to performhis role in a school function. But when his parents take him to McDonalds, he isable to perform. The implication: McDonalds is a friendly, relaxing

consumption environment. (Hawkes, 2002, p.17)

2) Enjoying friendship and good times Coca-Cola often employs this theme.

For example, a campaign in 2000 broadcast in 40 languages was designed to appeal to

people all over the world by persuading them that Coke adds a touch of magic to the

special moments in their lives. A 1998 campaign, rolled out in several Islamic

countries during Ramadan, used childhood friendship to emphasize love, charity and

forgiveness.

3) Importance of local traditions Here, Western consumption habits are

merged with a celebration of local traditions. Local celebrities are utilized in soft drink

ads, but specifically those who are suitable for the image of youth and modernity.

For example, Pepsis very first commercial in Vietnam featured Miss Vietnam (a

favorite role model) in traditional dress playing classical music in an opera house. These

[sic] scene then switches to a Westen-style bar where she is drinking Pepsi.

4) Rebellion and romance for teens In those markets in which the teen culture

embraces rebellion, romance, and individuality, celebrities are utilized who can

symbolize this.

5) Fun and excitement for children Cartoons are an effective way to reach

young children.

In 2000, Pizza Hut rolled out an animated ad for its international markets,including Mexico, Korea, and the Philipines. The ad, aimed at kids aged 8 to 12,


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featured children sitting in a Pizza Hut with their parents, with an animated PizzaPooch playing in the background. (Hawkes, 2002, p. 18)

Thus ads feature young children, animation, celebrities popular with children and

teens, and glamorous, good-looking youth and young adults. Also, the settings are

places and times that are not traditionally connected with soft drink and fast food

consumption, such as after school, after the opera, at a concert, at the Ramadan break

fast, or in the cooler seasons. (Hawkes, 2002, pp. 17-18)


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CONCLUSION

Popkins incisive remark about how global media as an important factor in

helping to facilitate the nutrition transition may be worth quoting again:

There is a profound cultural side not only to the globalization of mass media, butalso to the related penetration of Western-style fast food outlets in the developing

world. There is some evidence that these changes affect the entire culture of food

production and consumption. [Italics mine.] (Popkin, 2003, p. 592)

Of course, the globalization of the American food lifestyle operates in tandem

with the globalization of the consumer society:

" . . . [T]he desire to consume was systematically cultivated in the United Statesby a number of institutions, the advertising and marketing industries spearheadingthe process. Today, we see this process taking place in an accelerated fashion inevery corner of the globe. The cultivation of consumerism and attendant ways oflife and modes of consciousness are advancing steadily, as villagers in India arepersuaded by roving salesmen in vans and trucks that there is no life withouttoothpaste, and as localized versions of Elle and Cosmopolitan sprout in Poland,Russia, and scores of other countries." (Luthra, n.d.)

It was the great Italian political theorist Gramsci who has enabled us to appreciate

the critical role of hegemony in human affairs. The globalization of the mass media is an

important example of such hegemonyas it has helped to make the consumer society

and the Western lifestyle a goal and an expectation throughout the world. It is now our

responsibility to endeavor to more fully understand the role of the global media in

enhancing or limiting the quality of human life in that most fundamental of ways: the

physical health of human beings.


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Works Consulted

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Eddy, K. T., Hennessey, M., & Thompson-Brenner, H. (2007). "Eating pathology in EastAfrican women: The role of media exposure and globalization." The Journal ofNervous and Mental Disease, 195(3), 196-202.

Gardner, G., & Halweil, B. (2000, March). Overfed and underfed: The global epidemic

of malnutrition. Paper at Worldwatch Institute, Washington D.C. RetrievedFebruary 9, 2009, from http://www.worldwatch.org/

Hawkes, C. (2002). "Marketing activities of global soft drink and fast food companies inemerging markets: a review." In World Health Organization (Ed.), Globalization,diets and noncommunicable disease . Geneva, Switzerland: World HealthOrganization. Retrieved January 29, 2009, from http://www.who.int/en/

Huynen, M. M., Martens, P., & and Hilderink, H. B. (2005, August 3). "The healthimpacts of globalization: A conceptual framework." Globalization and health,1(14). Retrieved January 27, 2009, from

http://www.globalizationandhealth.com/articles/browse.asp?date=8-2005Lieberman, L. S. (2003). "Dietary, evolutionary, and modernizing influences on the

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Luthra, R. (n.d.). "JOURNALISM AND MASS COMMUNICATION: THE MAKING OFMEANING. Retrieved February 23, 2009, from the Encyclopedia of Life SupportSystems (EOLSS) Web site: http://www.eolss.net

Martens, P., & Hilderink, H. (2002). "Human health in transition: Towards more diseaseor sustained health?" In P. Martens & J. Rotmans (Eds.), Transitions in aglobalising world(pp. 61-84). Oxford: Taylor & Francis.

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Popkin, B. M. (2002). "The shift in stages of the nutrition transition in the developingworld differs from past experience!"Publich Health Nutrition, 5(1A), 205-14.

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