Barry M. Popkin

Global nutrition transition and the pandemic of obesity in developing countries.

Decades ago, discussion of an impending global pandemic of obesity was thought of as heresy. But in the 1970s, diets began to shift towards increased reliance upon processed foods, increased away-from-home food intake, and increased use of edible oils and sugar-sweetened beverages. Reductions in physical activity and increases in sedentary behavior began to be seen as well. The negative effects of these changes began to be recognized in the early 1990s, primarily in low- and middle-income populations, but they did not become clearly acknowledged until diabetes, hypertension, and obesity began to dominate the globe. Now, rapid increases in the rates of obesity and overweight are widely documented, from urban and rural areas in the poorest countries of sub-Saharan Africa and South Asia to populations in countries with higher income levels. Concurrent rapid shifts in diet and activity are well documented as well. An array of large-scale programmatic and policy measures are being explored in a few countries; however, few countries are engaged in serious efforts to prevent the serious dietary challenges being faced.

Inequality in the built environment underlies key health disparities in physical activity and obesity.

CONTEXT. Environmental factors are suggested to play a major role in physical activity (PA) and other obesity-related behaviors, yet there is no national research on the relationship between disparity in access to recreational facilities and additional impact on PA and overweight patterns in US adolescents. OBJECTIVE. In a nationally representative cohort, we sought to assess the geographic and social distribution of PA facilities and how disparity in access might underlie population-level PA and overweight patterns. DESIGN, SETTING, AND PARTICIPANTS. Residential locations of US adolescents in wave I (1994–1995) of the National Longitudinal Study of Adolescent Health (N = 20745) were geocoded, and a 8.05-km buffer around each residence was drawn (N = 42857 census-block groups [19% of US block groups]). PA facilities, measured by national databases and satellite data, were linked with Geographic Information Systems technology to each respondent. Logistic-regression analyses tested the relationship of PA-related facilities with block-group socioeconomic status (SES) (at the community level) and the subsequent association of facilities with overweight and PA (at the individual level), controlling for population density. MAIN OUTCOME MEASURES. Outcome measures were overweight (BMI ≥ 95th percentile of the Centers for Disease Control and Prevention/National Center for Health Statistics growth curves) and achievement of ≥5 bouts per week of moderate-vigorous PA. RESULTS. Higher-SES block groups had a significantly greater relative odds of having 1 or more facilities. Low-SES and high-minority block groups were less likely to have facilities. Relative to zero facilities per block group, an increasing number of facilities was associated with decreased overweight and increased relative odds of achieving ≥5 bouts per week of moderate-vigorous PA. CONCLUSIONS. Lower-SES and high-minority block groups had reduced access to facilities, which in turn was associated with decreased PA and increased overweight. Inequality in availability of PA facilities may contribute to ethnic and SES disparities in PA and overweight patterns.

Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes: A meta-analysis

OBJECTIVE Consumption of sugar-sweetened beverages (SSBs), which include soft drinks, fruit drinks, iced tea, and energy and vitamin water drinks has risen across the globe. Regular consumption of SSBs has been associated with weight gain and risk of overweight and obesity, but the role of SSBs in the development of related chronic metabolic diseases, such as metabolic syndrome and type 2 diabetes, has not been quantitatively reviewed. RESEARCH DESIGN AND METHODS We searched the MEDLINE database up to May 2010 for prospective cohort studies of SSB intake and risk of metabolic syndrome and type 2 diabetes. We identified 11 studies (three for metabolic syndrome and eight for type 2 diabetes) for inclusion in a random-effects meta-analysis comparing SSB intake in the highest to lowest quantiles in relation to risk of metabolic syndrome and type 2 diabetes. RESULTS Based on data from these studies, including 310,819 participants and 15,043 cases of type 2 diabetes, individuals in the highest quantile of SSB intake (most often 1–2 servings/day) had a 26% greater risk of developing type 2 diabetes than those in the lowest quantile (none or <1 serving/month) (relative risk [RR] 1.26 [95% CI 1.12–1.41]). Among studies evaluating metabolic syndrome, including 19,431 participants and 5,803 cases, the pooled RR was 1.20 [1.02–1.42]. CONCLUSIONS In addition to weight gain, higher consumption of SSBs is associated with development of metabolic syndrome and type 2 diabetes. These data provide empirical evidence that intake of SSBs should be limited to reduce obesity-related risk of chronic metabolic diseases.

The nutrition transition: worldwide obesity dynamics and their determinants

OBJECTIVE: This paper explores the major changes in diet and physical activity patterns around the world and focuses on shifts in obesity.DESIGN: Review of results focusing on large-scale surveys and nationally representative studies of diet, activity, and obesity among adults and children.SUBJECTS: Youth and adults from a range of countries around the world.MEASUREMENTS: The International Obesity Task Force guidelines for defining overweight and obesity are used for youth and the body mass index ≥25 kg/m2 and 30 cutoffs are used, respectively, for adults.RESULTS: The nutrition transition patterns are examined from the time period termed the receding famine pattern to one dominated by nutrition-related noncommunicable diseases (NR-NCDs). The speed of dietary and activity pattern shifts is great, particularly in the developing world, resulting in major shifts in obesity on a worldwide basis. Data limitations force us to examine data on obesity trends in adults to provide a broader sense of changes in obesity over time, and then to examine the relatively fewer studies on youth. Specifically, this work provides a sense of change both in the United States, Europe, and the lower- and middle-income countries of Asia, Africa, the Middle East, and Latin America.CONCLUSION: The paper shows that changes are occurring at great speed and at earlier stages of the economic and social development of each country. The burden of obesity is shifting towards the poor.

Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases

Global energy imbalances and related obesity levels are rapidly increasing. The world is rapidly shifting from a dietary period in which the higher-income countries are dominated by patterns of degenerative diseases (whereas the lower- and middle-income countries are dominated by receding famine) to one in which the world is increasingly being dominated by degenerative diseases. This article documents the high levels of overweight and obesity found across higher- and lower-income countries and the global shift of this burden toward the poor and toward urban and rural populations. Dietary changes appear to be shifting universally toward a diet dominated by higher intakes of animal and partially hydrogenated fats and lower intakes of fiber. Activity patterns at work, at leisure, during travel, and in the home are equally shifting rapidly toward reduced energy expenditure. Large-scale decreases in food prices (eg, beef prices) have increased access to supermarkets, and the urbanization of both urban and rural areas is a key underlying factor. Limited documentation of the extent of the increased effects of the fast food and bottled soft drink industries on this nutrition shift is available, but some examples of the heterogeneity of the underlying changes are presented. The challenge to global health is clear.

Socioeconomic status and obesity in adult populations of developing countries: a review

A landmark review of studies published prior to 1989 on socioeconomic status (SES) and obesity supported the view that obesity in the developing world would be essentially a disease of the socioeconomic elite. The present review, on studies conducted in adult populations from developing countries, published between 1989 and 2003, shows a different scenario for the relationship between SES and obesity. Although more studies are necessary to clarify the exact nature of this relationship, particularly among men, three main conclusions emerge from the studies reviewed: 1. Obesity in the developing world can no longer be considered solely a disease of groups with higher SES. 2. The burden of obesity in each developing country tends to shift towards the groups with lower SES as the countrys gross national product (GNP) increases. 3. The shift of obesity towards women with low SES apparently occurs at an earlier stage of economic development than it does for men. The crossover to higher rates of obesity among women of low SES is found at a GNP per capita of about US

Sugar-Sweetened Beverages, Obesity, Type 2 Diabetes Mellitus, and Cardiovascular Disease Risk

2500, the mid-point value for lower-middle-income economies. The results of this review reinforce the urgent need to: include obesity prevention as a relevant topic on the public health agenda in developing countries; improve the access of all social classes in these countries to reliable information on the determinants and consequences of obesity; and design and implement consistent public actions on the physical, economic, and sociocultural environment that make healthier choices concerning diet and physical activity feasible for all. A significant step in this direction was taken with the approval of the Global Strategy on Diet, Physical Activity and Health by the World Health Assembly in May 2004.

The nutrition transition and its health implications in lower-income countries.

Obesity has recently emerged as a major global health problem. According to World Health Organization estimates, ≈1.6 billion adults worldwide were overweight (body mass index [BMI] ≥25 kg/m2) and at least 400 million were obese (BMI ≥30 kg/m2) in 2005, numbers that are expected to reach 2.3 billion and 700 million, respectively, by 2015. In the United States, the percentage of overweight and obese adults increased markedly from 47% and 15% in 1976 to 1980 to >66% and 33% in 2005 to 2006, with the greatest proportion of increase seen among non-Hispanic black and Mexican American women.1,2 The implications of excess body weight are far-reaching. Epidemiological studies indicate that overweight and obesity are important risk factors for type 2 diabetes mellitus (T2DM), cardiovascular disease, cancer, and premature death.3 In the United States, healthcare expenditures attributable to overweight and obesity are estimated to be

The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages

147 billion or 9.1% of total healthcare costs per year.4 Such excess costs could have serious repercussions for resource-poor countries, which must manage the dual burdens of chronic and infectious disease. In the setting of a pandemic of obesity and related chronic diseases, the American Heart Association recently released a scientific statement recommending reductions in added-sugar intake to no more than 100 to 150 kcal/d for most Americans.5 The statement identified sugar-sweetened beverages (SSBs) as the primary source of added sugars in the American diet.6 Although it has long been suspected that SSBs contribute at least in part to the obesity epidemic, only in recent years have large epidemiological studies been able to substantiate the relationship between SSB consumption and long-term weight gain, T2DM, and cardiovascular risk. It is thought that SSBs contribute to weight gain because of their high added-sugar content, low satiety, and potential incomplete compensation for total …

Acculturation and overweight-related behaviors among Hispanic immigrants to the US: The National Longitudinal Study of Adolescent Health

OBJECTIVE This article reviews information on the rapid changes in diet, activity and body composition that lower- and middle-income countries are undergoing and then examines some of the potential health implications of this transition. DESIGN AND SETTING Data came from numerous countries and also from national food balance (FAOSTAT) and World Bank sources. Nationally representative and nationwide surveys are used. The nationally representative Russian Longitudinal Monitoring Surveys from 1992-96 and the nationwide China Health and Nutrition Survey from 1989-93 are examined in detail. RESULTS Rapid changes in the structure of diet, in particular associated with urbanization, are documented. In addition, large changes in occupation types are documented. These are linked with rapid increases in adult obesity in Latin America and Asia. Some of the potential implications for adult health are noted. CONCLUSIONS The rapid changes in diet, activity and obesity that are facing billions of residents of lower- and middle-income countries are cause for great concern. Linked with these changes will be a rapid increase in chronic diseases. Little to date has been done at the national level to address these problems.