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Copyright 2006, The Johns Hopkins University and Benjamin Caballero. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed. 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
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 Urbanization and body mass index 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: metabolic syndrome 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