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The Nutrition Transition Benjamin Caballero, M.D., Ph.D. Center for Human Nutrition Johns Hopkins Bloomberg School of Public Health
Annual increase in obesity rates in selected countries (women) 3 2.5 % per year 2 1.5 1 0.5 0 US Mexico Brazil Morocco Thailand China Popkin and Gordon-Larsen, 2004
Under- and overweight, 0-5 yr/old children Underweight Overweight 30 25 20 15 10 5 5 10 15 20 %
Is the world shifting from undernutrition to overnutrition?
Prevalence of stunting in < 5 yr/old children 2002 1995 1980 S Asia SE Asia SS Africa Near E-N Africa S America 0 10 20 30 40 50 60 70 Prevalence of stunting, % SCC/SCN, UNICEF, 2004
World poverty, 1981-2001 % of people living with <US$2 per day 1981 1990 2001 South Asia 89.1 85.5 77.2 Sub-Saharan Africa 73.3 75.0 76.6 South E Asia & Oceania 84.8 69.9 47.4 Latin American & Caribbean 26.9 28.4 24.5 North Africa & Middle E 28.9 21.4 23.2 Europe & Central Asia 4.7 4.9 19.7 World Bank, 2004
The Nutrition Transition Demographic trends Food availability and cost Lifestyle
Demographic trends Urbanization Increase in life expectancy Reduction in infant mortality
World population growth, 1500-2100 2.5 2.0 Growth rate, % 1.5 1.0 0.5 0.0-0.5 1500 1600 1700 1800 1900 2000 2100 Year
Age shifts in world population 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0-0.5 0-14 15-59 60+ Growth rate, % 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Year Zlotnik, UN Population Div.
Population over 59 years 1200 1000 800 600 400 200 Relative increase, 1950 =100 0 Europe N. Amer. Asia Latin Am. Africa 1950 1985 2025
Urban growth Annual increase, 1990-2000 5 4 % increase 3 2 1 0 Africa Asia L.A. Europe N.A.
Projected population growth in the developing world, 2000-2025 2000 2025 4 3.73 Pop. (billions) 3.5 3 2.5 2 1.5 1 2.92 3.09 1.99 0.5 0 Rural Urban United Nations, 1998
Urbanization and body mass index 40 Asia-Rural Asia-Urban Latin America 30 % 20 10 0 15 20 25 30 35 40 BMI INCLEN, 1996
GROWTH OF VENEZUELAN CHILDREN Weight/age Percentiles Rural (%) Urban (%) < 10 th 27.69 17.99 10 th > <90 th 67.21 72.93 > 90 th 5.09 9.06 Lopez Blanco et al, 1992
Dietary changes Changes in food type, availability and cost Changes in eating behaviors
Food commodities Global trends FAOSTAT, 2002
Growth in processed food market by GNI 1996-2002 USDA ERS-Euromonitor, 2003 World Bank country classification
Food cost: household budget share 50 47 40 % 30 20 10 29 12 0 Low (32) Middle (41) High (26) Country income level L=<15%, M=15-50%, H=>50% of U.S. median USDA ERS WRS-01-1
Food cost: income elasticity % 80 70 60 50 40 30 20 10 0 73 58 29 Low (32) Middle (41) High (26) Country income level L=<15%, M=15-50%, H=>50% of U.S. median USDA ERS WRS-01-1
China: dietary trends Consumption of edible oils g/day 55 50 45 40 35 30 25 20 15 10 5 0 Low Middle High Income level 1989 1997
Lifestyle changes Reduction in energy demands at work Reduction in energy demands of daily survival activities Limited leisure physical activity Television
Trends in employment type in South Asian transitional countries % of employment 90 80 70 60 50 40 30 20 10 0 1965 1975 1985 1995 Year Service Manufacturing Agriculture Popkin et al, 1998
The nutrition transition in China: Prevalence of sedentary occupational activity Men Women % 90 80 70 60 50 40 30 20 10 0 72 Urban 83 8 Rural 13
The added risk of early undernutrition
Birth weight and risk of diabetes and Syndrome X IGT/NIDD Syndrome X 50 40 % 30 20 10 0 < 2.5 < 2.95 < 3.4 < 3.86 < 4.3 > 4.3 Birth weight (kg) Phipps et al, 1993
Effects of birthweight and adult BMI on prevalence of the insulin resistance syndrome The San Antonio Heart Study 25 20 % 15 10 5 0 1 2 3 1 2 3 BMI tertile Birthweight tertile Valdez et al, Diabetologia, 1994
China: trends in obesity Population with BMI > 25 20 16 % 12 8 4 1989 1997 0 Low Middle High Income level Du et al, SSM 2004
Trends in diabetes in China Adults 1994 2000 % prevalence 10 9 8 7 6 5 4 3 2 1 0 35-44 45-54 55-64 Age, years China National Survey, InterAsia Study
China NTP: metabolic syndrome and BMI (urban and rural) 25 Men Women * 25 20 * 20 15 10 * * * 15 10 * 5 0 <18.5 18.5-20.4 20.5-22.4 22.5-24.4 24.5-26.4 >=26.5 <18.5 18.5-20.4 20.5-22.4 22.5-24.4 24.5-26.4 >=26.5 Odds ratio 5 0 * Significantly higher than 1, p<0.05
Age-adjusted urban-rural differences in lifestyle factors: Energy intake Men Women kcal/day 3000 2500 2000 1500 1000 2500 2600 2001 2059 500 0 Urban Rural
Recent trends In intermediate-income countries, obesity is increasing more among the poor Obesity prevalence in rural populations is approaching the rates of urban areas
Difference in prevalence of underweight and obesity, low vs. high SES - Brazil 8 1989 1997 Difference in prevalence, % 6 4 2 0-2 -4-6 -8 Undernutrition Obesity Monteiro, AJPH 2004
Disease burden in the developing world 1990 2020 Non-CD 47% Inj. 11% CD 42% Non-CD 69% Acc 14% CD 17% Murray & Lopez, 1996
The big picture
1.95 BMI: 19 25 1.85 Height, m 1.75 1.65 1.55 40 50 60 70 80 90 100 110 Weight, kg
1.95 BMI: 19 25 1.85 Height, m 1.75 1975 1.65 1785 1705 1870 1.55 40 50 60 70 80 90 100 110 Weight, kg
Mean BMI in 27 yr-old U.S. males 25 24 BMI 23 22 21 1864 1894 1944 1961 1991 Costa & Fogel, 1997
Trends in BMI in China Modeling from regional and national data 1960 1990 Lower SES Upper SES 18 19 20 21 22 23 24 25 26 27
% of men not working on the previous month due to illness (excluding accidents) - Bangladesh 50 40 % 30 20 10 0 <16 16-17 17-18 18-19 19-20 >20 BMI Pryer, Eur J Clin Nutr, 1993
UN Millenium Development Goals Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria, and other diseases Ensure environmental sustainability Develop a global partnership for development