The World Is Fat: New Dynamics Shifts in Patterns of The Nutrition Transition - PowerPoint Presentation

The World Is Fat: New Dynamics Shifts in Patterns of The Nutrition Transition Barry Popkin W. R. Kenan, Jr. Distinguished University Professor Department of Nutrition Gillings School of Global Public Health School of Medicine Department of Economics The University of North Carolina at Chapel Hill

Outline: New Dynamics Global Dynamics: The US is no longer be the nation with the highest BMI and overweight levelsTotal Caloric Change: Eating Frequency(snacking), Caloric Beverages and Portion Sizing The World is Flat and Fat: globalization has occurred for centuries How do we proceed

Figure 1. Stages of the Nutrition Transition Urbanization, economic growth, technological changes for work, leisure, & food processing, mass media growth Source: Popkin 2002 revised 2006. Pattern 1 Paleolithic man/ Hunter-gathers Wild plants & animalswaterLabor intensive Pattern 3 Industrialization/Receding Famine Starchy, low variety, low fat, high fiberwaterLabor-intensive work job/home Increased fat, sugar, processed foodscaloric beveragesShift in technology of work and leisure Pattern 4Noncommunicable Disease Reduced fat, increased fruit, veg, CHO, fiberIncrease water, Reduce caloric beverage intakeReplace sedentarianism w/ purposeful activity Pattern 5Behavioral Change Cereals dominate waterLabor-intensive Pattern 2Settlements begin/Monoculture period/Famine emerges Low fertility, Low life expectancy Lean & robust, high disease rate Slow mortality decline MCH deficiencies, weaning disease, stunting Accelerated life expectancy, shift to increased DR-NCD,increased disability period Obesity emerges, bone density problems Extended health aging, reduced DR-NCD Reduced body fatness, improved bone health High fertility, high MCH mortality, low life expectancy Nutritional deficiencies emerge, stature declines

High Income vs. Transitional and Low Income CountriesTrend toward a higher BMI in higher income countries reaches back a century but major increase seen in the 1980’s to the present In contrast, minimal obesity in most of developing and transitional world until the late 1980’s. It is again rapid changes in the past 20 yearsNow at a point where across the globe in most countries obesity far exceeds undernutrition and the dynamics of energy balance changes are shifting upwards this gap rapidly

Mismatch: Our Biology Clashes with Modern TechnologyBiology Technology Sweet preferences cheap caloric sweeteners, food processing benefits Thirst and hunger/satiety mechanisms not linked Caloric beverage revolution Fatty food preference Edible oil revolution-high yield oilseeds, cheap removal of oils Desire to eliminate exertionTechnology in all phases of movement/exertion

Patterns Of Overweight & Obesity Globally For Nationally Representative Samples (Percentage overweight + Obese) South Atlantic Ocean South Pacific Ocean Indian Ocean Arctic Ocean Arctic Ocean North Pacific Ocean <10% 10-20% 21-30% 31-40% 41-50% > 51%

BMI (Kg/m 2 ) 0 .02 .04 .06 .08 .1 Kdensity BMI 10 15 20 25 30 35 40 45 50 55 60 65 1988 1999 2006 From Juan Rivera BMI Distribution Shifts among Mexican women 18-49 y (National Surveys 1988, 1999 y 2006)

Annual Absolute Change in the Prevalence of Overweight and Obesity in 9 Countries from 1985/1995 to 1995/2006 (BMI≥25.0 for adults; IOTF equivalent for children) Annual percentage change Popkin (2007) nature reviews, cancer 7:61

The Shift in BMI levels at the 95th Centile for Females Aged 30 BMI United States Australia United Kingdom China 2.7 increase 5.4 increase 3.5 increase Popkin, AJCN in process-not for distribution/use

The Shift in BMI Levels at the 95th Centile for Children Aged 6 BMI United States Australia United Kingdom NA China 5 increase Popkin, AJCN in process-not for distribution/use

Australian Youth Gain Fat, Shift Body Shape Based on the research of Olds (2009) EJCN 1-13.

The consequences vary by race-ethnicity: Body fat composition in the East vs the West (Yajnik & Yudkin 2004)

The burden of disease is shifting rapidly towards the poor.By burden, we refer to the greater prevalence of poor diets, sedentarianism, obesity, NR-NCD’s among the poor Brazil is the only country where a significant obesity reduction among the rich and increase among the poor is seen (only for adult females). Studies on the shifts in diet among various income groups in China point towards a similar shift occurring there in 10-15 yearsMonteiro and Popkin series of cross-sectional studies to show similar patterns acrsoss the globe of greater obesity emerging among the poor.

Sources of Major Global Dietary ShiftsAcross the globe: large increases in consumption of caloric beverages and increasing snacking Lower income countries: increased edible oil, animal source foods are another source of kcal increase Globally, we find an increased intake of ultra processed foods, refined carbohydratesGlobally, we find a reduced intake of fruits and vegetables and legumesGlobally, we find a reduced preparation time, increased use of precooked foods

From Traditional to Modern Meals

From Traditional to Modern Snacking

From Traditional to Modern..... Marketing of Food

Many think that we have inborn biological wisdom but how and why and what role this plays in our food preferences has not achieved consensus.  Because sweet foods are naturally good and are safe sources of energy and nutrients, adaptive evolutionary development has resulted in a preference for them. Of the five most widely acknowledged tastes, three generally signal acceptance (sweet, salty, and umami*), while two generally signal avoidance(sour and bitter). These early responses are modified by life experiences,producing adult tastes preferences. Sweetness

Sweetness Preference was Essential to Survive: Huge Shift in Amounts, Energy Density

Expose infants to sweetness and find several years later desire exists for sweet foodsStudies on mice, primates replicate thisVirtually no long-term studies on exposure to sweetness and sweet foods and how it effects our needs and eating patterns subsequently . Sweetness and Effects on Eating Preferences

Q1 Q2 Q3 Q4 Q5 Total 1965 60 161 262396701 316197732 114195299 5602401989-91 29113 206324616258 1999-0062193 321491 9594062001-02 59176300 464882376 2003-0456 172295646 896377 Increases in total calories from added sugar are greatest among top 20% of population -8.3% +27.7% Duffey & Popkin(2008) AJCN 88(suppl):1722S

Hunger – FeedingSensations that promoteattainment of minimal food energy needs Energy ExcessStoredEnergy Deficit: Die in 1-2 monthsThirst – DrinkingSensations that promote attainment of minimal hydration needs Water Excess ExcretedWater Deficit : Die in 2-4 days What are the implications of eating food and drinking water on energy balance ? General Properties

Biology vs Technology: Shift from Water to Caloric Beverages with No Food Calorie Compensation

Mourao, .. (2007). "Effects of food form ..." IJO: 31 (11): 1688-95.

Remarkably Short History for Caloric Beverages: Might the Absence of Compensation Relate to This Historical Evolution? AD BCE 10000 BCE 200000 BCE Beginning of Time 100000 BCE 200000 BCE Homo Sapiens Pre-Homo Sapiens 200,000BCE - 10,000 BCE Origin of Humans Modern Beverage Era 10,000 BCE - present 0 Earliest possible date Definite date Water, Breast Milk 2000 BCE Milk (9000 BCE) Beer (4000 BCE) Wine (5400 BCE) Wine, Beer, Juice (8000 BCE) (206 AD) Tea (500 BCE) Brandy Distilled (1000-1500) Coffee (1300-1500) Lemonade (1500-1600) Liquor (1700-1800) Carbonation (1760-70) Pasteurization (1860-64) Coca Cola (1886) US Milk Intake 45 gal/capita (1945) Juice Concentrates (1945) US Coffee Intake 46 gal/capita (1946) US Soda Intake 52/gal/capita (2004)

Global TrendsMinimal published dataMexico-see below.

Children aged 1-4 Children aged 5-11 165 297 190 343 Note: Sweetened juice drinks include 100% fruit juice with sugar added and agua fresca (water, juice, sugar). Sodas include carbonated and noncarbonated sugar bottled beverages. Source: Barquera et al (2008)J Nutr 138: 2454-61. Daily Beverage Consumption Trends of Mexican Children, 1999-2006

Beverage Consumption Trends of Mexican Adolescents and Adult Women, 1999 and 2006 154 349 145 366 Kcal per day Note High sugar is composed of mainly soft drinks, sweetened juices, agua frescas and alcohol. High calorie and low benefit is mainly whole milk. Low calories are slightly sweetened coffee and skim milk Source: Barquera et al (2008)J Nutr 138: 2454-61. 12-18 years of age 19-49 years of age

United States: a large shift toward caloric beveragesMilk-long-term decline since 1945Major increases in sugar-sweetened beverages since the 1980’s, some leveling off in last 4 yearsJuice intake, alcohol show important increases

Long Steady Decline of Total Milk Intake

Sugar-sweetened beverage Consumption Trends (Soda/Fruit Drinks) (kcal/day), Nationally Representative

JuicesSeveral studies from Australia, the US and Spain show a comparable effect of juices on energy intake, weight gain and CVD

Juice Consumption Trends (Kcal/Day), Nationally Representative

Alcohol Consumption Trends(kcal/day), Nationally Representative

Water Water: 60% of our body, essential for lifeWater consumption measurement is fairly crude with minimal effort on this critical nutrientWater research: very limited. Review: adding water to the diet alone or to replace sugar-sweetened beverages, juice, milk and diet beveragesOngoing random controlled trials in the US and Mexico on possible benefits of water

Difference in Total Energy Intake when Juice or Milk Displace Water Almiron Roig (2003) adults DellaValle (2005) women Almiron Roig (2003) menAlmiron Roig (2003) womenDellaValle (2005) womenHagg (1998) kids 4-7Weighted Average (Juice & Milk) Change (%) in Energy Intake with Added Water †P<0.05 Popkin,et al, under review; Daniels and Popkin, under review;

Differences in Total Energy Intake when HFCS or Sucrose Sweetened Beverages Displace Water (6 kids not shown; only sig adults shown out of 19 total) Almiron Roig (2003) (b) DellaValle(2005) (w) Flood (2006) (w) Flood (2006) (w) Mattes (1996) (L)Rolls (1990) (w)Rolls (1990) (b)Van Wymelbeke (2004) (L) Weighted Average (kids)Weighted Average (adults) Change (%) in Energy Intake †P<0.05(b) preload before meal(w) preload with meal (L) long study (2+meals) Popkin,et al, under review; Daniels and Popkin, under review;

Differences in Total Energy Intake When Diet Beverages Displace Water (6 kids; 19 adult comparisons; sig shown) Birch (1989) ( b) Lavin (1997) (L) Birch (1989) ( b) Weighted Average (kids)Weighted Average (adults) Change (%) in Energy Intake †P<0.05(b) preload before meal(w) preload with meal(L) long study (2+meals) Popkin,et al, under review; Daniels and Popkin, under review;

Total Caloric Intake is a Combination of Three Components Total caloric intake = f(Portion Size x Eating Frequency x energy density of the portion)Portion sizes ↑: US, UK, Germany, other countriesEating Frequency ↑↑: large increase documented in few countries, seeing new global increases. Snacks are significantly greater energy densityEnergy density ↑↓ : small increases in food energy density, declines in meal and snack energy density are significant when correctly combine food intake with all beverages consumed

Portion sizesPortion size increased for hamburgers, cheeseburgers (for kids only), pizza and Mexican dishesThe pizza increase in kcal portion size was particularly large (176 kcal for kids, 216 for adults). Snack foods: portion size down as frequency went up in last decadeDesserts, drinks, french fries down slightly

Trends in Overall Portion Sizes in the United States, Nationally Representative Adults Aged 19 and older

Trends in The Energy Density of Food And Beverages from Food plus Beverages at Meals and Snacking Occasions In the United States (kcal/gram) Kcal/gram Source : Piernas and Popkin, unpublished data

SnackingSignificant increases in 1990’s and again in the new Millenium in the United StatesChina—tripling in 2004-6 period. Expect great changes in the next several years.Few small studies across the globe

Income Education Source: CHNS 1991,2004 and 2006; Adjusted for income, education, urban, gender and age (2-18,19-59,60+) Zhihong Wang et al (2008) Asia Pac J Clin Nutr 17:123 The Likelihood of Snacking Across All Individuals Aged 2 and Older, China 1991-2006

The Percentage of Total Energy Intake from Snacks, Chinese 1991-2006

Does the physiological basis for eating exist any more? Continuous caloric intake is becoming the norm.

Percentiles of US Individuals Consuming Meals Plus Snacks Source : Popkin and Duffey, unpublished data

Fat Preference Key for Survival: Technology, Marketing have Utilized this Preference for Fatty Food

Fatty FoodsFatty foods: smoother, affects taste in many waysElsewhere I have written about and documented the very large increases in vegetable oil (edible oil) consumption across Asia, Africa, the Middle East and parts of Latin America.

Edible Oil Consumption Still Rising in China(grams per day per capita)Year 1989 1997 2006 Poorest (lowest income tertile) 11.8 26.5 30.8 Middle income tertile 1529.7 30.9Richest (highest income tertile) 17.431.330.9 Average for total adult population14.828.9 30.9% of all calories per capita from edible oil 4.911.2 12.4 Source: China Health and Nutrition Survey for adults aged 20-45

The Predicted Probability of Consuming Excessive Fried Foods in Chinese Urban Residents, 1991 and 2004 Probability Source: CHNS 1991 and 2004; Adjusted for socio-demographic factors Wang et al (2008) Asia Pac J Clin Nutr 17: 123 Note: excessive fried foods represents more than 20% of kcal from fried foods. Income Education

Major Global Dietary ShiftsIncreased animal source foods

Price Policies Are a Great Option: Price Elasticities of Demand Urban China 2000 All China 1990 S. Korea 1985 S. Korea 1962-92 Morocco 1969-85Beef -.90-1.04Livestock -.68-.49-1.63 Pork-.21-.98 -.57NA Poultry-.75-.53 -1.07-1.26Fish -.37-.81NA -.34-.17 AIDS Demand Models Various Sources cited in Delgado & Courbois 1998; urban China 2000 figures from Yen, et al. 2004; S. Korea 1985 figures from Cranfield et al, 1998

Real World Prices, 1990 US$ 100 kg Poultry 100 kg Beef 80-82 70-72 1 MT Maize 94-96 2020 90-92 100 200 300 400 500 AIDS Demand Models Various Sources Cited in Delgado & Courbois 1998

Fast Food ConsumptionNo studies address several key issuesFirst–is it the behavior of the consumer who selects fast food or the foods per se at the Fast Food restaurant?Second, no random controlled trials or studies of what people consume at fast food places or studies that somehow separate the characteristics and potential selectivity of fast food vs sit down restaurants on behavior.Third, enormous heterogeneity in consumption changes related to away-from-home eating.

The Struggle Over the Millenia to Eliminate Arduous Effort Could Not Foresee Modern Technology

From Traditional to Modern Household Production

From Traditional to Modern Economic Work at Home

From Traditional to Modern Leisure

Shift In MET Hours per Week by Activity Among Chinese Women (18-55 Years Old) 0 Source: Ng ,Norton, Popkin (2009) SSM 68: 1305-14.

The World is Flat and Fat: Globalization has Occurred for CenturiesNaïve idea that globalization is a phenomena of the past few decadesConsider how Columbus et al introduced from the Americas to the cuisines of the world: Chili peppers in Asia, Potatoes in Europe, and tomatoes in Italy are examples. Or noodles from Asia to ItalyRecent rapid acceleration in areas such as communications technology, transportation systems, distribution technologies affect how we eat, move, drink. Think of Red Bull’s impact globally in 5 years vs coke in 70 years

How do we proceed?Clearly action needed at all levels; however I believe the only way to produce concerted change is to look to the models of tobacco use, seat belt, other major public health changesRegulations, taxation, mass education are key components Examples: Mexico Beverage campaign, US Farm Bill, Brazil and Singapore schoolsCurrent global economic crisis has slowed down many changes

Mexico Initiative on BeveragesRemove all whole milk, shifted now to 1.5% and later to skim milk all gov’t programsSchools: working to ban all sugar sweetened beverages, provide safe water, allow water, low fat milk to be soldTaxation being considered: tax added sugars in beverages per gram, fat in milkNational media effort–began Feb 25 with launch of Mex. Beverage GuidelinesSource:Rivera et al, Salud Publica Mex 2008;50:173-195

Soda Soda Whole milk Whole milk Overall Poor Rich Effects of Price Changes on Soda and Whole milk Consumption 10% increase in the price of soda 10% increase in the price of whole milk Source: Barquera et al, (2008) J Nutr 138: 2454-61.

Price changes and dietary intake in the USCARDIA: in-depth 20-year cohortDetailed dietary data linked by UNC team with food prices for each community over the same time period Focus on prices of beverages and fast foods here

Methods: Price Elasticity of DemandElasticity= % change in demand % change in priceOwn-price elasticityCross-price elasticity $ kcals % % Δ Δ $ % % kcals Δ Δ Negative Negative or positive

Combined 10% Change in Price Results in Greater Percent Change in Outcomes: 20 year longitudinal analysis of price and CARDIA cohort Percent Change in outcome Source: Duffey et al, manuscript 2009 not for distribution/use

Program and policy effectiveness: Are we ready for preventive action? Major research gaps exist.Targets: sugary beverages is very clear as is the Media. Other foods are not as clear. Macroeconomic options: price changes matter, governments subsidize wrong foods nowRegulations: TV advertising, other advertising, edible oil contents, school meals, school PE, etcReprints (pdf files) and citations can be found on www.nutrans.org. New book The World Is Fat (Penguin Press) published end of Dec 2008

“The most serious epidemic ever is insidiously engulfing the world. Barry Popkin draws upon his decades of research and experience to describe its origins – and a set of potential solutions. Those interested in the future of mankind should read this book.” Walter Willett, author of Eat, Drink, and Be Healthy, and chair, Department of Nutrition, Harvard University THE BOOK

Acknowledgements to My Many Key Collaborators:University of North Carolina faculty co-investigators in various or many studies:Linda Adair, Penny Gordon-Larsen, John Akin, Peggy Bentley, John Briscoe, Jane Brown, Barbara Entwisle, Kelly Evenson, Pam Haines, Gail Henderson, David Guilkey, Tom Mroz, Shu Wen Ng, Daniel Rodriquez, Anna Maria Siega-Riz, Yan Song, June Stevens, Deb Tate,Dick Udry, Namvar ZohooriBrazil: Carlos Monteiro Philippines: Wilhelm Fleiger, Florentino S. Solon, Others in the US: Suchi Ayala, Robert Black, George Bray, Ben Caballero, Walt Willett, China: Zhai Fengying, Du Shufa, Ge Keyou, Chen Chunming, Chen XiaoshuMexico: Simon Barquera, Juan Rivera, Sonia HernandezRussia: Polina Kozyreva, Mikhail Kosolopov, late Michael Swafford, Alexander BaturinStudents and postdocs:Past: Linda Adair, Colin Bell, Colleen Doak, Kiyah Duffey, Elena Glinskaya, Penny Gordon-Larsen, Xuguang Guo, Ningqi Hou, Lisa Jahns, Soowon Kim, Ying Liu, Mikhail Lokshin, Bing Lu, Kathleen Mctigue, Michelle Mendez, Keri Monda, Shu Wen Ng, Tuan Nguyen, Samara Nielsen, Sahasporn Paeratakul, Ruth Patterson, Kathleen Reidy, Marie Richards, Jodi Stookey, Nguyen Thang, Carrie Waller, Youfa Wang, Monica Yamamoto, Claire ZizzaCurrent: Jessie Jones-Smith, Tracy Dearth-Wesley, Huijun Wang, Zhihong Wang, Daisy Zamora My right arms: Frances Dancy, Tom Swasey My FamilyAnd many coauthors of a range of papers important in my career