Obesity, Underweight and the Unacceptable Dual Burden

by Avik Chatterjee, MD

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Recently, I was speaking with a student about income and weight in the United States, and he described the difference he saw between his hometown in rural California, where many people appeared obese, and Cambridge (and especially Harvard), where seeing someone with overweight or obesity was a rarity. While it’s true that in the United States, socioeconomic status and rates of obesity tend to be inversely related – with lower-income groups tending to have higher obesity rates, and vice versa – other, rapidly developing countries are wrestling with high rates of both underweight and obesity, also known as the dual burden.

Some people attribute this pattern income and obesity in higher-income countries to the 5-stage “nutrition transition”; as societies develop and gain wealth, most people shift from lives requiring lots of physical activity to more sedentary ones, and foods high in calories, fat and sugar become more easily available. The final transition, at least for people with the highest incomes, is accompanied by a shift to a diet with less fat and more fruit/vegetables and more leisure time for exercise, and leads to an overall lower rate of overweight/obesity in this income group.

In contrast, in lower-income countries, where most people are in early stages of the nutrition transition (more energy expenditure necessary for daily living and more limited access to calories), lower-income people tend to be underweight (defined as BMI<18.5 in adults and <5% for age in children), while higher-income people are more likely to have overweight or obesity. Thus, in this traditional model, countries should face one burden or another—high rates of underweight when the country is lower-income, and high rates of overweight/obesity when the country becomes more developed.

Globally, as many countries are developing, they are transitioning from a high burden of underweight to the dual burden. But in my clinical work, I see a vulnerable population that suffers from the dual burden right here in the United States. Family homelessness is a large and growing problem in Massachusetts. Half of the homeless families in Massachusetts are given emergency shelter in motel rooms—motel rooms with only a mini-fridge and microwave. Of the over 213 homeless children Boston Health Care for the Homeless Program saw at two of our motel shelter sites in 2014, 44% had overweight or obesity (compared to 33% of children nationwide). Sadly, another 8% of the children we saw were underweight, compared to 3.5% nationally. I believe that the food environment in the family shelters, where the average stay is 11 months, exacerbates both sides of this dual burden. And as family homelessness grows, both problems will likely only get worse.

In the coming months, some of my students and I hope to work with families in motel shelters in Boston to better understand what they eat and how it affects their health. We also hope to talk with families who are eating healthful foods to learn how they manage to do so.  Finally, we hope that our conversations with these families will help us work with community partners to design an intervention providing healthy prepared food to homeless families in motels, both to improve their nutrition and their nutrition-related health measures. Because while it’s academically interesting that we see the dual burden of obesity and underweight in a sub-population in the wealthiest country on earth, it’s not ethically acceptable.