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Benjamin Caballero, M.D., Ph.D. Center for Johns Hopkins Bloomberg School of Annual increase in rates in selected countries (women)

3

2.5

ar 2 e y 1.5

% per 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 10203040506070 Prevalence of stunting, %

SCC/SCN, UNICEF, 2004 World poverty, 1981-2001 % of people living with

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

, % 1.5 e t a

r 1.0 h t w o

r 0.5 G 0.0

-0.5 1500 1600 1700 1800 1900 2000 2100 Year Age shifts in world population

3.5 3.0

% 2.5 ,

te 2.0 0-14 a

r 1.5 15-59 th 1.0 60+ ow r 0.5 G 0.0 -0.5

0 990 1950 1960 1970 1980 1 200 2010 2020 2030 2040 2050 Year

Zlotnik, UN Population Div. Population over 59 years

Relative increase, 1950 =100

1200

1000

800

600

400

200

0 Europe N. Amer. Asia Latin Am. Africa

1950 1985 2025 Urban growth Annual increase, 1990-2000

5

4

3 crease n 2 % i

1

0 Africa Asia L.A. Europe N.A. Projected population growth in the developing world, 2000 - 2025

2000 2025 4 3.73 3.5 3.09 2.92 ) 3 2.5 1.99 illions

b 2

p. ( 1.5 o

P 1 0.5 0 Rural Urban

United Nations, 1998 and

Asia-Rural Asia-Urban Latin America 40

30

% 20

10

0 15 20 25 30 35 40 BMI INCLEN, 1996 GROWTH OF VENEZUELAN CHILDREN Weight/age

Percentiles Rural (%) Urban (%) < 10th 27.69 17.99

10th > <90th 67.21 72.93

> 90th 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 29 30 % 20 12 10

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 73 70 58 60 50 % 40 29 30 20 10 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 China: dietary trends Consumption of edible oils

55 50 45 40 35 30 1989 g/day 25 1997 20 15 10 5 0 Low Middle High Income level 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

90 80

nt 70 e

m 60 Service oy 50

pl Manufacturing

m 40 Agriculture e 30 of 20 % 10 0 1965 1975 1985 1995 Year Popkin et al, 1998 The nutrition transition in China: Prevalence of sedentary occupational activity

Men Women

90 83 80 72 70 60 50 % 40 30

20 13 8 10 0 Urban Rural 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 % 3 10 2 5 BMI tertile 1 0 123 Birthweight tertile

Valdez et al, Diabetologia, 1994 China: trends in obesity Population with BMI > 25

20

16

12 % 8 1989 1997 4

0 Low Middle High Income level

Du et al, SSM 2004 Trends in diabetes in China Adults

1994 2000 10 9 8

ce 7

en 6 5 eval

r 4 p 3 % 2 1 0 35-44 45-54 55-64 Age, years

China National Survey, InterAsia Study China NTP: and BMI (urban and rural)

Men Wome n 25 25 *

* 20 20

* 15 15 *

* 10 10 Odds ratio

*

5 5

0 0 5

5 .5 4.4 0.4 8. 2 26.4 22.4 26.4 24.4 2 20.4 22.4 <1 <18.5 >=26. >=26 22.5- 24.5- 20.5- 24.5- 22.5- 18.5- 18.5- 20.5-

* Significantly higher than 1, p<0.05 Age-adjusted urban-rural differences in lifestyle factors: Energy intake

Men Women 3000 2600 2500 2500 2001 2059 2000 ay d / 1500

kcal 1000

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

1989 1997 8

% 6

ce, 4 en 2 eval r

p 0 n -2 ce i

ren -4 e f f -6 Di -8 Undernutrition Obesity

Monteiro, AJPH 2004 Disease burden in the developing world

1990 2020

Acc 14% Inj. 11% CD 17% Non-CD 47% Non-CD CD 69% 42%

Murray & Lopez, 1996 The big picture BMI: 19 25 1.95

1.85 , m 1.75 ight He

1.65

1.55 40 50 60 70 80 90 100 110 Weight, kg BMI: 19 25 1.95

1.85 , m 1.75 ight 1975 ● He

1870 ● 1.65 1785 ● 1705 ●

1.55 40 50 60 70 80 90 100 110 Weight, kg Mean BMI in 27 yr-old U.S. males

25

24 I 23 BM

22

21 1864 1894 1944 1961 1991

Costa & Fogel, 1997 Trends in BMI in China Modeling from regional and national data

1960 → 1990

Upper SES

Lower 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 Improve maternal poverty and hunger health Achieve universal Combat HIV/AIDS, primary education malaria, and other Promote gender diseases equality and empower Ensure environmental women sustainability Reduce child mortality Develop a global partnership for development