4. Possibilities and Suggested Future Directions
Knowing the consequences of obesity and its impact on morbidity and mortality, Nepal must take stronger steps towards prevention. Initiating this action and slowing the rise of NCDs, including obesity, requires a cross-disciplinary approach [53
]. Such an approach across different sections of a community, integrated management of the risk factors, and provision of essential public health services [54
] should provide an excellent starting point that can be implemented in the context of Nepal.
4.1. Prioritize Health Education
Health literacy, capacity building, and empowerment can all increase community awareness of the challenges posed by obesity and NCDs. Further, education of medical professionals and the creation of supportive environments for obese individuals may encourage healthy living. Health education is an important cornerstone of this approach. Indeed, health is best promoted by increasing individual health literacy. Unless individuals become literate about health, we cannot expect changes in individual behaviour. Literacy is even more important regarding NCDs because the risk factors are usually behaviour-related.
Although particularly challenging in rural areas, it is evident that the improvement of health literacy should be a priority. Several low- and middle-income countries have successfully controlled malaria through community health education, requiring only minor local adaptations of the training material [55
]. This approach could be useful as Nepal strives to improve health literacy about NCDs and obesity.
Since television and radio are popular among the Nepalese people, these media could be harnessed to provide general health education and information. Special public campaigns could complement general health education with simple messages directed at average citizens, thus circumventing literacy issues.
School curricula should include heart health-related topics that teach children the causality and consequences of obesity. To counteract the increasing trend of Nepalese adolescents and children remaining indoors, physical activity must be encouraged both at school and at home. Moreover, reversing the already entrenched habit of consuming junk food will require an integrated and massive effort across all levels of society.
Educating workers and employees about healthy lifestyles and providing opportunities for such education is another area that has not received attention to date. In a situation where even basic occupational safety has been neglected, a culture that promotes health activities appears to be a long distant dream.
There is also a need to re-direct health workers towards the risk approach for NCDs. Because the primary health care system does not currently address NCDs, little is done at the grass roots level. Thus, although the disease has already progressed into clinical complications, most health management is performed by a handful of specialists at the central level and in tertiary centres.
4.2. Modify the Increasingly Obesogenic Environment
Approaches to obesity prevention should be based on helping people change their lifestyles and modifying the obesogenic environment. Countries like the US, UK, and Australia have developed several strategies (e.g., modifying building design to encourage the use of stairs, making neighbourhoods more walkable, promoting active transport by an integrated network of footpaths and bicycle lanes, improving food labelling to help consumers make informed choices, and increasing healthy foods in schools and work cafeterias) [56
]. Some of these strategies could inspire similar implementation in Nepal.
Another efficient approach could involve banning advertisements for unhealthy junk food and increasing taxes on these foods and beverages. The WHO has asked its member states to establish strategies that promote responsible marketing of food and beverages to children [59
]. Several European countries have established legal and self-regulatory activities that address the ban on advertisements that encourage unhealthy dietary practices in children. In 2006, the Australian Democrats sought a complete ban on food and drink advertising during children’s television programmes [59
]. Some estimates suggest that a one penny-per-ounce excise tax on sugared beverages might reduce consumption by 13% [60
]. In Nepal, however, such bans or tax exercises appear to be a distant possibility.
We view as positive that Nepal has recently drafted a health policy for NCDs. The draft encompasses different preventive, curative, and administrative aspects of NCD control. It stresses the importance of establishing a surveillance system for NCD risk factors, capacity building, and strengthening the existing health system to incorporate NCDs. Strategies to counteract obesity include taxing junk food and adding health-related educational materials to the school curricula. However encouraging; it is still a long way from policy to practical reality.
4.3. Improve Health Management
Because information technology significantly shortens the time lag in transporting health information and health consultation [61
], the current poverty of information presents a serious obstacle for health professionals in the developing world. Networking health resources in low-income communities is certainly more time- and cost-effective in the short term than attempting to build hospitals or health clinics in each locality. Low-cost telecommunication networks enable doctors to “visit” patients in remote locations, thereby strengthening preventive health care [61
Several countries that already apply Internet- and telephone-based medical provisions show promising results. A prospective study of Internet-based remote counseling, which included participants from Europe, North America, and Australia, showed that both rural and urban areas benefit from combining such infrastructure with conventional practice [62
]. This is promising for countries like Nepal, where a large part of the population resides in rural areas. Telemedical care and monitoring efficiently manages type 1 diabetes in children and adolescents [63
] as well as NCDs [64
]. The feasibility of applying Internet and tele-technology to control NCDs and their risk factors, including obesity, in a low-income country like Nepal requires further exploration.
4.4. Increase Access to Drugs and Health Care
High acquisition costs for drugs to treat NCDs keep them beyond the reach of many people in low-income countries like Nepal. Non-affordability is one reason that patients in Nepal choose self-treatment over drugs prescribed by a health professional [65
]. One high-potential area in Nepal involves the application of traditional medicines such as Ayurveda. Research on widely popular alternative therapies such as herbs and meditation techniques such as yoga can open gateways for their scientific use alongside western medicine.
Nepal should also develop a concrete negotiating strategy within the World Trade Organization and collaborate with other low-income countries. It must work towards fully capitalizing the flexibilities offered by the agreement on Trade Related Aspects of Intellectual Property Rights and produce less expensive drugs [66
]. A national focus on research and development in the pharmaceutical sector would strengthen the capacity of domestic pharmaceutical companies to manufacture new and more effective drugs and also effectively capitalize on the vast amounts of medicinal plants that grow naturally in Nepal [66
Socioeconomic conditions in Nepal, a rural, agricultural economy with low human development and endemic poverty, make the health sector a priority for sustained economic development [50
]. Besides offering greater social protection to the poor and other vulnerable groups against high cost of ill health, health insurance provides an important mechanism for bridging the health-financing gap in Nepal [66
4.5. Preventive Measures beyond the Already Affected
The WHO’s global projections on obesity represent a substantial challenge for preventive measures. It is important to not limit efforts solely to children and adults whose BMI is already high, but also develop strategies aimed at preventive public health measures that affect the entire society. In this context, Nepal could adopt the goals of Healthy People 2010 [67
], which include increasing the quality and length of healthy life and eliminating health disparities. Other focus areas (e.g., nutrition and overweight, physical activity and fitness, educational and community-based programs, and public health infrastructure) may be important players in tackling the growing obesity epidemic.
The American Heart Association issued a scientific statement that details the essential features needed to address one goal of “Healthy People 2010” (i.e., reducing heart disease, stroke, and their risk factors by 25% by 2010). Similar to the WHO STEPwise approach, a key element involves standardizing data. Nepal could use this statement as a guideline for establishing a surveillance system to manage obesity and CVD. Similarly, many of the suggested public health responses for promoting cardiovascular health in low- and middle-income countries should provide efficient means of blunting the obesity epidemic.
4.6. Establish Health Demographic Surveillance Sites
Another strategy would establish health demographic surveillance sites (HDSS) that provide regular monitoring and health surveillance of every individual in a selected area. HDSS data can profile disease burden by systematically and longitudinally collecting information from well-defined populations [68
]. The validity of data is crucial, and the resulting information must be useful. The WHO STEPwise approach provides an option for risk factor surveillance [69
]. Designed as a three-step manual for NCD surveillance, STEPwise uses standardized instruments and protocols to collect information that can be compared over time and across locations. In low- and middle-income countries, HDSS sites could provide information on a range of health-related outcomes (e.g., cause of death; health systems coverage, particularly regarding vaccination rates, and health service utilization); and, in some cases, growth and nutrition. Such population-level data are especially important when: (i) the quality and accessibility of health services are poor, (ii) record-keeping systems are underdeveloped, (iii) deaths occur outside of the health system and go unrecorded, or (iv) cultural interpretations of disease in more traditional societies present communities with a competing array of alternative providers [56
]. Therefore, it is important that we develop such HDSS systems in Nepal to aim for better community health.
4.8. Increase Awareness of Research Funding Bodies
High-income countries have conducted extensive research on risk factors including obesity, CVD, and diabetes for more than 50 years. Longitudinal studies generate the most useful results. However, the applicability of such results in other geographical, social, and economic contexts has not been widely investigated. It is likely that there are substantial limitations in their transferability.
Unfortunately, most research and funding efforts in low- and middle-income settings are limited to communicable diseases, ignoring not only the imminent threat of obesity and NCDs but also the double-disease burden experienced by such countries. It is crucial that funding bodies recognize the global responsibility of directing supporting research to vulnerable populations in low- and medium-income settings, and focus on what lies ahead—a rapid increase in obesity and its related complications in a region that contains a large percentage of the world’s population.
The long onset of obesity and its clinical complications creates many preventive opportunities in low- and middle-income countries, which could benefit from the experience of other parts of the world. Factors that contribute to obesity are well known [75
]. While fighting the menace of communicable diseases, Nepal has largely neglected the problem of NCDs such as CVDs and cardiovascular risk factors such as obesity. To date, only two population-based national studies have focused on these issues. Lacking proper surveillance systems and appropriate policies, the burden of NCDs and their risk factors has silently foundered in the background even while they rapidly emerge as important public health problems.
Low-income settings like Nepal must overcome many obstacles. The largest hurdle likely involves redirecting already scarce health resources, both financial and human, towards the growing trend of obesity. In Nepal, many competing interests are related to infectious diseases and maternal/perinatal health. In addition, Nepal’s low literacy rate impedes health literacy and awareness of ongoing trends in the general population. The most efficient strategy would likely combine collaboration between governmental representatives, medical doctors, health workers, and communities.
We must not limit ourselves to cataloguing the ongoing epidemic with increasing precision but rather focus our efforts on active intervention. The major challenges in Nepal are the absence of a substantive public health infrastructure to address the emerging need for NCD prevention and control, and overemphasis on curative care rather than prevention.