1. The World Is Fat: New Dynamics Shifts in Patterns of The Nutrition Transition
Barry Popkin
Department of Nutrition, School of Public Health and Medicine, Department of Economics The University of North Carolina at Chapel Hill

2. Outline: New Dynamics
Global Dynamics: The US is no longer be the nation with the highest BMI and overweight levels
Total 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

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

4. High Income vs. Transitional and Low Income Countries
Trend 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 years
Now 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

5. Mismatch: Our Biology Clashes with Modern 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 exertion
Technology in all phases of movement/exertion

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

8. BMI Distribution Shifts among Mexican women 18-49 y
(National Surveys 1988, 1999 y 2006)
BMI (Kg/m2)
.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

9. 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

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

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

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

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

14. 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 years
Monteiro and Popkin series of cross-sectional studies to show similar patterns acrsoss the globe of greater obesity emerging among the poor.

15. Sources of Major Global Dietary Shifts
Across 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 carbohydrates
Globally, we find a reduced intake of fruits and vegetables and legumes
Globally, we find a reduced preparation time, increased use of precooked foods

16. From Traditional to Modern Meals

17. From Traditional to Modern Snacking

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

19. Sweetness
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.

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

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

22. Increases in total calories from added sugar are greatest among top 20% of populationQ1 Q2 Q3 Q4 Q5
Total
1965 60
161
262
396
701
316
1977 32
114
195
299
560
240 29
113
206
324
616
258 62
193
321
491
959
406 59
176
300
464
882
376 56
172
295
646
896
377
-8.3%
+27.7%
Duffey & Popkin(2008) AJCN 88(suppl):1722S

23. What are the implications of eating food and drinking water on energy balance?
General Properties
Hunger – Feeding Sensations that promote attainment of minimal food energy needs
Energy Excess Stored
Energy Deficit: Die in 1-2 months
Thirst – Drinking Sensations that promote attainment of minimal hydration needs
Water Excess Excreted
Water Deficit : Die in 2-4 days

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

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

26. 200,000BCE - 10,000 BCE Origin of Humans
Remarkably Short History for Caloric Beverages: Might the Absence of Compensation Relate to This Historical Evolution?
Earliest possible date
Definite date
US Soda Intake 52/gal/capita
(2004)
US Coffee Intake 46 gal/capita
(1946)
Juice Concentrates (1945)
US Milk Intake 45 gal/capita
(1945)
Pre-Homo Sapiens
200,000BCE - 10,000 BCE Origin of Humans
Modern Beverage Era
10,000 BCE - present
Coca Cola (1886)
Pasteurization ( )
Carbonation ( )
Liquor ( )
Lemonade ( )
Coffee ( )
Brandy Distilled ( )
(206 AD)
Tea (500 BCE)
Wine, Beer, Juice
Wine (5400 BCE)
(8000 BCE)
Beer (4000 BCE)
Water, Breast Milk
Milk (9000 BCE)
2000 BCE
BCE Homo Sapiens
BCE
Beginning of Time
BCE
10000 BCE
BCE AD

27. Global Trends
Minimal published data
Mexico-see below.

28. Daily Beverage Consumption Trends of Mexican Children, 1999-2006
343
297
190
165
Children aged 1-4
Children aged 5-11
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:

29. Beverage Consumption Trends of Mexican Adolescents and Adult Women, 1999 and 2006
366
349
Kcal per day
154
145
12-18 years of age
19-49 years of age
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:

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

31. Long Steady Decline of Total Milk Intake

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

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

34. Juice Consumption Trends (Kcal/Day), Nationally Representative

35. Alcohol Consumption Trends(kcal/day), Nationally Representative

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

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

38. 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)
Mattes (1996) (L)
Rolls (1990) (w)
Rolls (1990) (b)
Van Wymelbeke (2004) (L)
Weighted Average (kids)
Weighted Average (adults)
†P<0.05
(b) preload before meal
(w) preload with meal
(L) long study (2+meals)
Change (%) in Energy Intake
Popkin,et al, under review; Daniels and Popkin, under review;

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

40. 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 countries
Eating Frequency ↑↑: large increase documented in few countries, seeing new global increases. Snacks are significantly greater energy density
Energy 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

41. Portion sizes
Portion size increased for hamburgers, cheeseburgers (for kids only), pizza and Mexican dishes
The 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 decade
Desserts, drinks, french fries down slightly

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

43. at Meals and Snacking Occasions In the United States (kcal/gram)
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

44. Snacking
Significant increases in 1990’s and again in the new Millenium in the United States
China—tripling in period. Expect great changes in the next several years.
Few small studies across the globe

45. The Likelihood of Snacking Across All Individuals Aged 2 and Older, China 1991-2006
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

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

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

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

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

50. Fatty Foods Fatty foods: smoother, affects taste in many ways
Elsewhere 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.

51. 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 15
29.7
30.9
Richest (highest income tertile)
17.4
31.3
Average for total adult population
14.8
28.9
% of all calories per capita from edible oil
4.9
11.2
12.4
Source: China Health and Nutrition Survey for adults aged 20-45

52. The Predicted Probability of Consuming Excessive Fried Foods in Chinese Urban Residents, 1991 and 2004
Probability
Income
Education
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.

53. Major Global Dietary Shifts
Increased animal source foods

54. Price Policies Are a Great Option: Price Elasticities of Demand
Urban China 2000
All China 1990
S. Korea 1985
S. Korea
Morocco
Beef
-.90
-1.04
Livestock
-.68
-.49
-1.63
Pork
-.21
-.98
-.57 NA
Poultry
-.75
-.53
-1.07
-1.26
Fish
-.37
-.81
-.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

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

56. Fast Food Consumption No studies address several key issues
First–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.

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

58. From Traditional to Modern Household Production

59. From Traditional to Modern Economic Work at Home

60. From Traditional to Modern Leisure

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

62. The World is Flat and Fat: Globalization has Occurred for Centuries
Naïve idea that globalization is a phenomena of the past few decades
Consider 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 Italy
Recent 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

63. 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 changes
Regulations, taxation, mass education are key components
Examples: Mexico Beverage campaign, US Farm Bill, Brazil and Singapore schools
Current global economic crisis has slowed down many changes

64. Mexico Initiative on Beverages
Remove all whole milk, shifted now to 1.5% and later to skim milk all gov’t programs
Schools: working to ban all sugar sweetened beverages, provide safe water, allow water, low fat milk to be sold
Taxation being considered: tax added sugars in beverages per gram, fat in milk
National media effort–began Feb 25 with launch of Mex. Beverage Guidelines
Source:Rivera et al, Salud Publica Mex 2008;50:

65. 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
Overall Poor Rich
Soda
Whole milk
Soda
Whole milk
Source: Barquera et al, (2008) J Nutr138:

66. Price changes and dietary intake in the US
CARDIA: in-depth 20-year cohort
Detailed 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

67. Methods: Price Elasticity of Demand
Elasticity= % change in demand
% change in price
Own-price elasticity
Cross-price elasticity $
kcals % Δ
Negative $ %
kcals Δ
Negative or positive

68. 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

69. Program and policy effectiveness: Are we ready for preventive action
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 now
Regulations: TV advertising, other advertising, edible oil contents, school meals, school PE, etc
Reprints (pdf files) and citations can be found on New book The World Is Fat (Penguin Press) published end of Dec 2008

70. THE BOOK
“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

71. 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 Zohoori
Brazil: 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 Xiaoshu
Mexico: Simon Barquera, Juan Rivera, Sonia Hernandez
Russia: Polina Kozyreva, Mikhail Kosolopov, late Michael Swafford, Alexander Baturin
Students 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 Zizza
Current: Jessie Jones-Smith, Tracy Dearth-Wesley, Huijun Wang, Zhihong Wang, Daisy Zamora
My right arms: Frances Dancy, Tom Swasey My Family
And many coauthors of a range of papers important in my career