PHN20: Nutrition transition: poverty alleviation, food consumption

Transcription

1 PHN20: Nutrition transition: poverty alleviation, food consumption Objective This chapter aims to discuss The changes in the dietary patters due to nutrition transition and the health risks as a consequence The role of poverty and nutrition transition and The Indian scenario Introduction 1. Food consumption pattern Human history has witnessed a transition in the patterns of food consumption. However, these transitions have been spread out over time for different countries and regions in the world. There was a shift from hunting and gathering to agriculture in the thousands of years. The transitions occurring within the developing and developed countries have occurred within a few decades. Three decades ago obesity which was rare in developing countries is now on the rise with serious health impact. In the developing countries the issue has advanced manifold. A characteristic of these successive transitions is their frequent occurrences. As a result of this nutrition transition, undernutrition and micronutrient deficiencies are coexisting with overnutrition simultaneously. Promoting healthy diets and lifestyles to reduce the global burden of non- communicable diseases requires a multi-sectoral approach. The agriculture sector figures prominently in this enterprise. Food strategies must not only be directed at ensuring food security for all, but must also achieve the consumption of adequate quantities of safe and good quality foods. Any recommendation to that effect will have implications for all components in the food chain. Economic development is usually accompanied by improvements in a country s food supply and the gradual elimination of dietary deficiencies, thus improving the overall nutritional status of the country s population. It also brings about qualitative changes in the production, processing, distribution and marketing of food. Both quantitative and qualitative changes in the diet characterize the nutrition transition. The adverse dietary changes include shifts in the structure of the diet towards a higher energy density diet, with an increasing trend in the intake of fat and added sugars in foods, reduced intakes of complex carbohydrates and dietary fiber, greater saturated fat intake (mostly from animal sources), and reduced fruit and vegetable intake. At the same time, however, poor countries continue to face food shortages and nutrient inadequacies [1,2]. Table 1 shows the nutrition transition profile and pattern. 1

2 Table 1: Nutrition transition profile and pattern TRANSITION PROFILE 1 NUTRITION PROFILE Diet Nutritional status 2 FOOD PROCESSING Pattern 1 Collecting food Plants, lowfat wild animals; varied diet Robust, lean, few nutritional deficiencies Non existent Pattern 2 Famine Cereals predomina nt; diet less varied Children, women suffer most from low fat intake; nutritional deficiency diseases emerge; stature declines Food storage begins Pattern 3 Receding Famine Fewer starchy staples, more fruits, vegetables, animal protein; low variety continues Continued MCH nutrition problems, many deficiencies disappear, weaning diseases emerge; stature grows Storage process, canning and processing technologies; increased food refining and milling Pattern 4 Degenerative Disease More fat[ especially from animal products], sugar and processed foods; less fiber Obesity, problems for elderly [bone health, etc.] Numerous food transforming technologies Pattern 5 Behavioral change Less fat and processing; increased carbohydrates, fruits and vegetables Reduced body fats levels and obesity; improved bone health Technologies create foods and food constituent substitutes 2. Dietary diversity Dietary diversity is a measure of the number of individual foods or food groups consumed in a given time period. It can reflect the household access to a variety of foods and can also act as a proxy for individual nutrient adequacy. Dietary diversity typically does not indicate the quantity of food consumed. In the developing world the average calorie availability has increased from about 1950 to 2680 kcals/person/day, while protein availability nearly doubled from about 40 to 70 g/person/day in comparison with

3 The rapid decline in real food prices has allowed consumers in developing countries to adopt food consumption patterns that were followed by the consumers in industrialized countries having a much higher gross domestic product (GDP) levels. Today, a consumer in a developing country can purchase more calories than ever before and more than consumers in industrialized countries ever could at comparable income levels. In China, for instance, consumers today have about 3000 kcals/day and 50 kg of meat per year [3] at their disposal, at less than US$1000 nominal income per year [4]. 2.1 Factors affecting food consumption Diets evolve over time, being influenced by many factors and complex interactions. The food consumption pattern is affected by the falling real prices of food, rapid urbanization and would continue to do so. Urbanization leads to A new and improved marketing and distribution infrastructure. Upsurge of supermarkets, their sophisticated food handling systems (cold chains, etc.) Makes for better roads and ports, thus improving the access to foreign suppliers and the importance of imports in the overall food supply; and above all, will promote a globalization of food consumption patterns. Most important from a nutrition perspective, these changes include not only a shift towards higher food energy supplies but also a shift towards more fats and oils and more animal-based foodstuffs, and thus higher intakes of animal protein and fats. 2.2 Evolution of the drivers of nutrition transition to 2030 Acceleration in urbanization Urbanization is also likely to heighten the burden of non-communicable diseases regardless of the shifts towards an urban diet and a more sedentary lifestyle. It is predicted that there will be a major shift in the urban-rural balance. Urbanization would also mean higher female participation in the work force and with that a shift away from traditional time-intensive food preparations towards precooked, convenience food at home or fast food and snacks for outside meals. For the urban poor, the shift towards convenience foods may also imply a shift away from fresh fruits and vegetables, pulses, potatoes and other roots and tubers towards a much more sugary, salty, and fatty diet. Inclusive of a shift from a diet rich in fiber, minerals and vitamins, towards one rich in energy, saturated fats and cholesterol. It provides the international suppliers advantages of the high proximity to locally concentrated masses of consumers. The globalization of the food distribution system and the emergence of supermarkets in developing countries The role of the food processing and the fast food industry: The growing trend of processing of foodstuffs has an increasing influence on food consumption patterns. For instance, vegetable oils, are important sources of essential fatty acids, but are as such not readily useable as ingredients for many 3

4 sophisticated food products. The process of hydrogenation makes possible the conversion of fluid oils into spreadable margarine. The same process turns valuable unsaturated fatty acids into nonessential fats and into potentially harmful trans-fatty acids. Since the 1950s, bread made of refined white wheat flour, the dominant staple of European diets for millennia, has made major inroads in all parts of the world. The spread of bread, together with expanding sales of a large variety of other baked goods, has been a key ingredient to the adaptation of a Western diet. Likewise, the universal shift to refined grain flour has a direct impact on the nutrient intake particularly where wheat and maize are staple foods. Modern milling techniques produce refined flour which has better digestibility but destroys its texture, structure and valuable dietary fiber. Urbanization also means frequent eating outside of the home, often under time constraints and sometimes also under budgetary constraints. The fast food industry has catered for these constraints by providing fast access to cheap meals, take away services, or alternatively, home delivery services [5,6]. Mushrooming of transnational food companies Growth of transnational food companies (TFCs) has been of immense importance in nutrition transition. TFCs increasingly organize food production, distribution and marketing on a global scale. With globalization the market power of TFCs throughout the whole food supply chain has grown considerably. Agricultural commodities, ranging from bananas to sugar to coffee, are in hands of a few who own the entire process of producing, distributing and selling a particular food under its control by buying and contracting other companies and services worldwide. This reduces the transaction costs associated with having different suppliers and creates economies of scale. Global sourcing :When a company searches for inputs, production sites and outputs where costs are lower, the political and social regimes has to be favorable. This would enable the TFCs to cut costs and helps safeguarding against the uncertainty of commodity production and product sales. Four particularly critical ways in which TFCs have altered the food supply, thereby affecting consumption are: more processed foods more fast food outlets more large supermarkets more food advertising and promotion The increasing number of fast food outlets along the years are an evidence of change. While the number of McDonald s increased rapidly, the proportion of outlets outside the US increased at an even faster rate. Advertising and promotion, large serving sizes, price inducements, aggressive entry into markets in developing countries, and by what is termed as substitution as has been mentioned above, the consumer consumption patterns are influenced [5,6]. Rapid income growth globally, but with considerable regional differences Over the next 30 years, average global per capita income is projected to rise at a rate of more than 2% per annum. The growing and increasingly urbanized populations of developing countries are expected to become increasingly affluent. Developing countries, which are at the lowest are expected to grow faster than the average. At nearly 4% annual growth per capita, their economies are expected to expand at twice the speed as those in the developed world. 4

5 The shift in population structure will be a crucial contributor to high growth. This rapid transition from high to low population growth means that a large share of their future population will be economically active, with only a small share of very old and very young people. Also, within the developing world, regional differences carry more importance than the overall averages. Sub-Saharan Africa is at the lower end of the scale with a GDP growth per capita which reaches approximately 2%. Now the low per capita incomes combined with rapid rural-to-urban migration is likely to result in premature urbanization in many countries of the region, with slums, urban poverty and HIV/AIDS rising at a high rate thus contributing to the urbanization of poverty (UN Habitat, 2003). Whereas, at the upper end of the scale is East Asia, likely to experience both robust income growth and rapid urbanization. Over the next 30 years, China s urban population is expected to nearly double from 456 million to 883 million, while its rural population is expected to shrink from 819 million to 601 million people (UN, 2003). Combined with the prospect for high income growth and increasing international trade integration, food consumption is likely to change as well. Ageing populations and little emperors For the developing world as a whole, the proportion of people above 60 years of age is projected to rise from about 7% in 2000 to 20% in People below 15 years of age is projected to decline from 33% to 21%.These shifts in the population structure are likely to have a direct impact on income growth and thus food consumption. What can affect the developing world at large in the future is already visible in urban China. The 20 years of a strict one-child policy and a booming economy have created a situation where rising incomes are often spent on the family's only child. Concentrating on feeding the only child well is often seen as a first investment in the younger generation. The situation is often explained as the 4:2:1 problem, where 4 grandparents and 2 parents are focusing much of their attention on the family s only child. The result is a sharp rise in the prevalence of overweight and obesity for a whole generation of little emperors [6,7]. 3. The global nutrition transition: from 1960 to 2030 The transition spanned across the years can throw light on where and in what form these drivers of change have already contributed to changes in food consumption patterns. Based on this, it will then sketch-out how this transition is expected to continue over the next 30 years. In many advanced developing countries, the rapid shift towards higher income levels and increases in animal food consumption has already been associated with a rapidly rising prevalence of overweight, obesity and non-communicable diseases. Further, the longer-term outlook suggests that the number of affected countries is likely to rise rapidly over the next 30 years. The speed of nutrition transition and thus the incidence of overweight and obesity may even gather pace. A faster nutrition transition could be caused by high income growth, more sedentary lifestyles, rapid urbanization, changes in the population structure (ageing) as well as changes in the food systems (marketing, processing and distribution systems) of developing countries (e.g. changes in food retailing and the emergence of supermarkets). Over the next 30 years, a growing number of countries will move into per capita energy supply levels of 2700 kcals and more. On average, consumers in developing countries will have nearly 3000 kcals per day at their disposal. These averages mask, however, substantial differences both within and across countries. Where the income disparities remain high, hunger and over-nutrition are likely to co-exist within the same country. The overall result would be that the double burden of malnutrition will remain unresolved and add to the health and consequent economic burdens of many developing countries. Changes in the composition of the diet towards a more energy dense one rich in saturated fats and cholesterol could further aggravate the burden of high and rising energy supplies and thus add to the prevalence of NCDs [8]. 5

6 3.1 Changes in the composition of the diet The rapid increase in food energy supply has been accompanied by a shift in the dietary composition. The principal steps of change seem to follow a common pattern: The first step expansion effect: At low income levels, the main thrust of change is one towards higher energy supplies whereby the additional calories come largely from cheaper foodstuffs of vegetable origin. This has been seen as an almost universal development and seems to take place regardless of agricultural production patterns, cultural, religious factors The second step substitution effect: reflects a shift from carbohydrate rich staples (cereals, roots and tubers) to vegetable oils, sugar and foodstuffs of animal sources -- largely at the same overall energy supply. It is more country-specific and often influenced by cultural or religious food traditions. These factors determine both the extent to which animal products substitute for vegetable products as well as the composition of animal products that enter the diet [9]. The increasing importance of deriving calories from animal products globally underlines the rapid expansion of consumption of animal products across different regions. Growth was particularly predominant in East Asia. East Asia was dominated by soaring (pig) meat consumption in China. The rising consumption of animal products in both China and India are projected to last for the next 30 years, but at a slower pace. The growth in South Asia was mainly driven by White Revolution (rapidly rising milk consumption over the past three decades). The expansion in the Near East/North Africa region will be driven by increased milk, eggs and poultry consumption, while higher beef and poultry consumption will be seen in Latin America. Within limits, this shift towards higher meat and milk consumption points towards a desirable nutritional goal, this means an increase in both the quantity and quality of protein and access to essential vitamins and minerals. It would be of benefit to infants and children as it would promote steady growth in the first years of life. It is advantageous to women who are at risk of anemia, as it improves the dietary availability of micronutrients in general and of iron in particular. On the contrary, high intakes are associated with detrimental health effects. Increased consumption of red meat contributes to the risk of some cancers, increased intakes of saturated fat and cholesterol from eggs, meat and dairy products increases the risk of cardiovascular diseases [10]. The adverse impacts of the rapid nutrition transition are likely to be reinforced by a number of other factors that are specific to developing countries. This means that the nutrition transition proceeds faster in developing countries and also its adverse impacts are felt more strongly there. These additional factors are: a) the speed of the transition itself, b) a phenotypic or genetic predisposition c) the fact that many developing countries lack adequate health promotion and healthcare systems that would help prevent and cope with the adverse impacts. Fig 1 shows the calories from major commodities in the developing countries 6

7 Fig 1: Calories from major commodities in the developing countries Across the countries the share of dietary energy supplied by cereals appears to have remained relatively stable, representing about 50% of dietary energy supply. Recently, however, subtle changes appear to be taking place. A closer analysis of the dietary energy intake in developing countries shows a decrease, where the share of energy derived from cereals has fallen from 60% to 54% in a span of 10 years. Much of this downward trend is attributable to cereals, particularly wheat and rice, becoming less preferred foods in middle-income countries such as Brazil and China, a pattern likely to continue over the next 30 years or longer. Fig 2 shows the share of dietary energy derived from cereals [11]. Fig 2: The share of dietary energy derived from cereals 7

8 3.2 Availability and consumption of fruits and vegetables Fruits and vegetables are an important component of a diversified and nutritious diet. Low consumption of fruits and vegetables in many regions of the developing world is, a persistent phenomenon, confirmed by the findings of food consumption surveys. At present, only a negligible minority of the world s population consume the recommended high average intake of fruits and vegetables. In 1998, 6 of the 14 WHO regions had an availability of fruits and vegetables equal to or greater than the earlier recommended intake of 400 g per capita per day. The situation in 1998 appears to have evolved from a markedly less favorable position in previous years, as evidenced by the great increase in vegetable availability recorded between 1990 and 1998 for most of the regions. In contrast, in most regions of the world the availability of fruit generally decreased between 1990 and Nationally representative surveys in India, indicate a steady level of consumption of only g per capita per day, with about another 100 g per capita coming from roots and tubers, and some 40 g per capita from pulses. This may not be true for urban populations in India, who have rising incomes and greater access to a diverse diet. Whereas in China, which is undergoing rapid economic growth and transition - the amount of fruits and vegetables consumed has increased to 369 g per capita per day by Increase in urbanization is another global challenge. Increasing urbanization will distance people from primary food production, and in turn have a negative impact on availability of a varied and nutritious diet with enough fruits and vegetables, and the access of the urban poor to such a diet. Nevertheless, those who can afford it can have better access to a diverse and varied diet. Also investment in periurban horticulture may provide an opportunity to increase the availability and consumption of a healthy diet. Global trends in the production and supply of vegetables indicate that the current production and consumption vary widely among regions. The global annual average per capita vegetable supply (in 2000), was 102 kg, with the highest level in Asia (116 kg), and the lowest levels in South America (48 kg) and Africa (52 kg) [12,13]. 3.3 Ethnic differences in food consumption/disease risk As compared to the native residents or indigenous populations the population specific risk of chronic non-communicable diseases is often manifested as ethnic variations in disease risk seen in migrant populations. This emphasizes the importance of environmental factors in chronic disease risk. The best examples of this are exhibited in the second generation Japanese immigrants to Hawaii and to California who have similar rates of mortality from colon cancer to the native Caucasians but have much lower rates of mortality from stomach cancer than the Japanese resident in Japan. Studies among the South Asian community so far studied in UK have neither demonstrated levels of plasma cholesterol higher than the national average in the UK nor have they shown any remarkable differences in dietary intakes of total saturated fat intake. However, they do show a 3-4 fold increased risk of coronary heart disease (CHD) and non-insulin-dependent diabetes mellitus (NIDDM) among migrants as compared to the native populations. Probably the present dietary intakes and lifestyles differ from their pre-migration diets, lifestyles and levels of physical activity may have altered and these changes may have unmasked a predisposition to these diseases. 8

9 Rural-urban differences in NIDDM and CHD within a region or a country as in India show similar variations in disease risk, suggesting that urbanization, internal migration, and exposure to modern diet and life-styles increase risk of chronic disease. Given the enormous movement of populations in developing countries into urbanized environments (practically their entire population growth will be urban over the next 30 years) and the diet and lifestyle changes that follow it reiterate that this aspect of nutrition transition cannot be exaggerated [14,15]. 4. Poverty alleviation The single biggest bane of the developing world today is widespread poverty, resulting in chronic and persistent hunger. The physical expression of this tragedy is the condition of under-nutrition which manifests itself among large sections of the poor, particularly amongst the women and children. Undernutrition results from inadequate intake of food or more essential nutrient(s) manifesting as a deterioration of physical growth and health. The inadequacy is relative to the nutrients and food needed to maintain good health, provide for growth and allow a choice of physical activity levels, including work levels that are socially necessary. This condition of undernutrition, enhances mortality and morbidity amongst children and reduces work capacity and productivity amongst adults. Such reduced productivity translates into reduced earning capacity, leading to further poverty, and the vicious cycle goes on [16]. Low earning capacity Project Impaired productivity Low intake of food and nutrients Small body size of adults Stunted growth of children and Growth faltering Undernutrition Repeated insults from nutrition related diseases and infections 9

10 At the time of Independence both acute and chronic undernutrition were problems of major concern. There was a recurrent threat of famine, resultant acute starvation due to low agricultural production and the lack of an appropriate public food distribution system. During the fifties, poverty was the major factor responsible for undernutrition in India. The country recognized that the association between income poverty and undernutrition was mediated through several pathways. Poverty might result in food insecurity and low dietary intake due to poor purchasing capacity and poor access to food stuffs poor environmental hygiene resulting in repeated infections duration and severity of infections was not reduced because of lack of public sector health care for effective treatment of infections low literacy impeding the access to available services [17] 4.1 Definition of poverty India was the first country in the world to define poverty as the total per capita expenditure of the lowest expenditure class, which consumed 2400 kcal /day in rural and 2100 kcal/day in urban areas and attempt to provide comprehensive package of essential goods and services to people below the poverty line. The poverty lines, defined as the basket of goods and services, have not been changed subsequently in order to preserve inter-temporal comparability, but the rupee value of the lines is regularly updated using the large sample consumer expenditure survey of the NSSO in order to reflect price increases that have taken place over the years [18]. 10

11 The last five decades have witnessed some major achievements. There has been a slow yet steady economic growth, which is accompanied by reduction in poverty. The Green Revolution ensured that the increase in food grain production stayed ahead of the increase in population. Successive Five Year Plans laid down the policies and multi-sectoral strategies to combat nutrition related public health problems and improve nutritional and health status of the population. The country has moved in phases from chronic shortages to self-sufficiency and later surplus and export of food grains. In spite of adequate food availability the poorest of the poor still do not get two square meals a day and there are regions where severe under nutrition takes its toll even today. Low birth weight is associated not only with higher infant mortality and low growth trajectory but also has long-term health consequences such as increased risk of non-communicable diseases. While the country is yet to overcome poverty, undernutrition and communicable diseases, it has started facing problems related to affluence due to industrialization, urbanization and economic improvement. In some segments of urban affluent population excessive energy intake, consume diets rich in saturated fats, decreased physical activity, addiction to tobacco and alcohol, and increase in psychosocial stress are common. There has been substantial reduction in physical activity in all segments of the population while energy intake has remained unaltered; as a result overnutrition, heart disease and diabetes are emerging as newer public health problems of concern. Henceforth, the country will have to gear itself up to prevent and contain the dual burden of undernutrition and overnutrition and associated health problems. There are substantial variances in the economic, social, nutrition and health profiles between states. Different states in the country are in different phases of socio-economic, demographic, nutrition and health transition [17]. 4.2 Economic growth, dietary intake and nutritional status The interrelationship between per capita income, dietary intake and nutritional status in India is multidimensional. The steady rise in per capita income till the nineties was accompanied by a slow reduction in energy intake. The last five years witnessed a sharp increase in per capita income; contrary to expectations. As food grain costs still remain low, the decline appears to be mainly related to changes in life style and consequent reduction in energy requirement. Some states like Himachal Pradesh, Punjab and Haryana have high per capita income and high energy intake. At the other end, are states like Goa, Delhi and Chandigarh, where per capita income is very high but energy intake is comparatively low. In some states like Assam, per capita income is low but energy intake is relatively high. Thus it would appear that, at present when food grains are available at low cost especially for the poor, life style and energy requirement rather than per capita income is the major determinant of energy intake in different states. States such as Orissa, Bihar, Uttar Pradesh, Assam, Madhya Pradesh, and Rajasthan have low per capita income and high undernutrition rates in women and children since three years. States like Delhi have high per capita income and low rates of undernutrition. However, Maharashtra and Gujarat with high per capita income have higher undernutrition rates perhaps because of inter-regional differences with in the states; example poverty and undernutrition rates are high in Vidharbha in Maharastra and Sourashtra in Gujarat [17,18]. 4.3 Preventing food prices from creating poverty and malnutrition: The challenge The current surge in food prices is causing acute economic hardship and social unrest across the world. The poor, have to spend large share of their income on food. Since rising food prices command a larger share of a limited budget, the poor are forced to shift their expenditures to cheaper diets which is constituted of less proteins and micronutrients. This is in exchange of reduction in their expenditures on 11

12 investment goods like education and health care, and a compromise on buying insurance against unemployment or on saving for retirement. As a result, soaring food prices threaten to reverse much of the progress made by developing countries in fighting chronic malnutrition and persistent poverty over the past decade, especially among the urban poor. At the same time, higher food prices are boosting the incomes of the food manufacturers, providing a unique opportunity for promoting agricultural and rural development in many low-income countries. 4.4 Why developing countries are likely to bear the major burden of the nutrition transition? According to the Barker hypothesis hunger and undernutrition during certain stages of pregnancy resulting in intra-uterine growth retardation (IUGR) programmes the fetal tissues such that food energy in adult life is more efficiently utilized. As a result, low birth weight babies are more likely to become obese and are also at increased risk of NCDs in adult life. The consequences of this link in the context of the accelerating nutrition transition over the next 30 years could be significant, with respect to mid-income developing countries. Rapid income growth and falling real prices for food, raise the dietary energy supplies for large parts of a population in a rapid and massive manner, therefore today s hunger problems could be a trigger for tomorrow s obesity and chronic disease epidemic. The developing countries with a high prevalence of low birth weights (LBW) today and high projected growth in dietary energy supply over the next 30 years could suffer an obesity and NCD epidemic in future. While consumers will no longer be food-poor, they are still too poor to afford the access to medical care ( health poor ), they may suffer from NIDDM, CHD and obesity without having access to the healthcare that would make these diseases unmanageable [18]. 5. The situation in India Implications of nutrition transition on health India is home to 214 million food insecure people and a third of all undernourished children in the developing world (FAO 2003). It is under double burden of nutrition and disease. It is predicted that the number of people with diabetes in India are projected to increase to 60 million by 2025, which will impose a huge health and economic burden on its resources. South Asian populations (which include India, Pakistan, Bangladesh and Sri Lanka) are experiencing rapidly escalating epidemics of cardiovascular and disease diabetes. Many unbranded producers of highly processed, ready-made foods have entered the Indian market, aiming at higher income groups mainly in urban areas. The changes in consumption are more among urban, higher income, more educated groups showing that the economic changes have affected a relatively small group in society who experienced substantial increases in income. The middle class professionals and skilled workers have helped to fuel increases in market demand for high caloric value foods such as processed foods and edible oils, increased availability of which is driven by imports and investment in TFCs. As a result, the Indian upper middle class is now more at risk of diet related chronic diseases than ever before. 12

13 The prevalence of NIDDM in urban Indian adults has shown an increase from <3% in the 1970s to >12% in The prevalence of CHD has increased from < 2% to 10%. It is estimated that CHD will be the leading cause of death in adults by This means that three out of four diabetics will be from developing countries and one in five diabetic patients in the world will be Indian. Vitamins and related antioxidant substances are normally (with the exception of vegans) provided by a balanced diet, but are in short supply in many developing countries. Elevated blood levels of homocysteine have been linked to increased risk of premature coronary artery disease (CAD), venous blood clots and stroke even among people with normal cholesterol levels. In developing countries issues such as the presence of parasitic infestations of the intestines which further compounds the vitamin and mineral deficiencies in the diet, complicate the problem. In principle, providing these vitamins can help prevent this problem, which in developed societies is often possible due to fortification of common foods for instance fortification of bread with folate. The two examples of recent demonstration of homocysteine as a culprit in CHD risk and the relationship between folic acid and pyridoxine status with homocysteine, show how marginal nutrient deficiencies in populations in developing countries may contribute to the increasing risk of noncommunicable diseases. Deficiency in folate affects a majority of women and many men in all countries [19,20]. Summary Most of the developing countries are currently undergoing a rapid nutrition transition. Falling real prices for food enable consumers to move swiftly towards higher calorie intake levels and allow them to embark on consumption patterns that had been reserved for consumers in developed countries at a much higher level of (nominal) income. In addition to falling real prices of food, rapid urbanization has and will continue to affect both consumption patterns and energy expenditure of the masses. Essentially the entire population growth over the next 30 years will be urban. Urbanization attracts supermarkets, creates a new and improved marketing and distribution infrastructure and their sophisticated food handling systems (cold chains, etc.), better roads and ports, thus improves the access of foreign suppliers and the importance of imports in overall food supply and, all in all, will promote globalization of dietary patterns. Most importantly from a nutrition perspective, these changes include not only a shift towards higher food energy supplies but also a shift towards more fats and oils and more animal-based foodstuffs, which indicates higher intakes of saturated fat. Urbanization is also often associated with a mechanization of production, less physical labour and the convenience of piped water or mechanized transportation leading to a more sedentary lifestyle with calorie expenditures that are 10-15% below rural averages. In many developed countries, the shift in consumption patterns and lifestyles has already resulted in a rapid increase in the prevalence of overweight, obesity and related NCDs. Many developing countries are following the footsteps of developed countries and undergoing a similar transition in nutrition and lifestyles, the health impacts of this transition could be more severe and the capacities to deal with adverse health impacts are more limited. The combination of rapid nutrition transition with rapidly declining share of expenditure on food as percent of total expenditure/income, urbanization, shift in diet towards more animal products, and the phenotypic and genotypic predisposition towards a more efficient metabolism and NCDs could spark a rapid increase in the prevalence of obesity and NCDs over the next 30 years. 13

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