THE W RLD IS FAT
The Nutrition Transition and Global Food System
Dynamics: The Accelerating Speed of Change and
Global Challenges We Face for Creating a
Healthier Global Diet
Barry Popkin W. R. Kenan, Jr. Distinguished University Professor
Department of Nutrition
Gilling's School of Global Public Health
School of Medicine
Department of Economics
The University of North Carolina at Chapel Hill
Outline: Why Do We Need Large-Scale
Changes to Improve Our Diets?
• Introduction: the nutrition transition and major mismatches: modern technology vs. inherited biological preferences
• Physical activity: a major concern but not the solution
• The modern food system and how it has shaped our diet
• Major dietary shifts of the past 2-3 decades
• Regulatory and tax options: global lessons from Chile and Mexico
• Chile may be the first country to reverse obesity and all the diet and obesity-related NCDs, but there are key gaps to fill.
Role of Our History
Core biochemical and
physiologic processes
have been preserved
from those who
appeared in Africa
between 100,000 and
50,000 years ago.
Biology Evolved Over
100,000 Years
Modern Technology has taken
advantage of this biology
Sweet preferences Cheap caloric sweeteners, food
processing create habituation to
sweetness
Thirst, hunger/satiety
mechanisms not linked
Caloric beverage revolution, sweetening
of beverages consumed
Fatty food preference Edible oil revolution — high yield oilseeds,
cheap removal of oils, modern processed
food/restaurant sector
Desire to eliminate
exertion
Technology in all phases of work and
movement reduce energy expenditure,
enhance sedentarianism
Mismatch: Biology which has evolved over the
millennia clashes with modern technology
Source: © (copyright) Barry M. Popkin, 2015
Stages of the Nutrition Transition
Pattern 4
Chronic Disease (NCD’s)
Reduced body fatness
& NR-NCD’s, improved
disease prevention
Obesity & NR-NCD
emerge, and medical
cures keep us alive
MCH deficiencies,
weaning disease,
stunting
Nutritional
deficiencies
emerge, stature
declines
Lean &
robust, tall,
high disease
rate
• Reduced refined carbs, sugar
• Unhealthy fats↓, increased
fruit, veg, whole grains,
legumes
• Drink water, low kcal bev.
• Replace sedentarianism
with purposeful increases
in activity
• Increased fat, sugar,
processed foods diet
• Drink sugary beverages, juices
• Shift in technology of work and leisure
• Sedentarianism high
• Starchy, low
variety, low fat,
high fiber diet
• Drink water
• Labor-intensive
work/leisure
• Monoculture ag.
• Cereals
dominate diet
• Drink water
• Labor-intensive
Pattern 2
Famine
High fertility, high
MCH mortality,
low life expectancy
Urbanization, economic growth, technological changes for work, leisure, & food processing, mass media growth
Pattern 1
Collecting Food
Low fertility,
low life expectancy
• Diverse wild plants
& animal food diet
• Drink water
• Labor-intensive
Pattern 3
Receding Famine
Slow mortality
decline
Accelerated life expectancy,
shift to increased NR-NCD,
increased % disability years
Pattern 5
Behavioral Change
Extended healthy aging,
reduced NR-NCD
The Struggle Over the Millennia to
Eliminate Arduous Effort Could
Not Foresee Modern Technology
Source: Ng S.W. & Popkin B.M. Time use and physical activity: A shift away from movement across the globe. Obesity Reviews 13 (8):659-80
0
5
10
15
20
25
30
35
40
45
0
50
100
150
200
250
1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030
Ave
rag
e h
ou
rs p
er
we
ek b
ein
g s
ed
en
tary
Ave
rag
e M
ET-h
ou
rs p
er
we
ek
Year
Active Leisure PA
Travel PA
Domestic PA
Occupational PA
Sedentary Time (hrs/wk)
1965: 235
MET-hr/wk
2009: 160
MET-hr/wk
by 2020: 142
MET-hr/wk
by 2030: 126
MET-hr/wk
US Adults MET-hours/Week of All Physical Activity,
and Hours/Week of Time in Sedentary Behavior:
Measured for 1965-2009 and Forecasted for 2010-2030
0
5
10
15
20
25
30
100
150
200
250
300
350
400
450
1991 1994 1997 2000 2003 2006 2009 2012 2015 2018 2021 2024 2027 2030
Ave
rag
e h
ou
rs p
er
we
ek b
rin
g s
ed
en
tary
Ave
rag
e M
ET-h
ou
rs p
er
we
ek
Year
Active Leisure PA
Travel PA
Domestic PA
Occupational PA
Sedentary Time (hrs/week)
by 2030: 188 MET-hr/week
2009: 213 MET-
hr/week
by 2020: 200
MET-hr/week
1991: 399
MET-hr/week
Source: Ng S.W. & Popkin B.M. Time use and physical activity: A shift away from movement across the globe Obesity Reviews 13 (8):659-80
Chinese Adults Met-hours/Week of Physical Activity &
Hours/Week of Time in Sedentary Behavior: Measured for
1991-2009 and Forecasted for 2010-2030
0
10
20
30
40
50
60
1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011 2016 2021 2026
Se
de
nta
ry T
ime
(h
rs/w
k)
India China Brazil UK US
Global TV Viewing Time of Adults
2030
Source: Ng S.W. & Popkin B.M. Time use and physical activity: A shift away from movement across the globe Obesity Reviews 13 (8):659-80
• Our work in China and elsewhere has convinced me
that a major component of global obesity increase is
linked with reduced physical activity at work, home, and
transport along with increased sedentarianism
• At the same time we cannot turn back the clock on
technology at work, home, transportation, leisure
• Thus the need is to create new activity—marginal gains
at work and home, but major increased activity must
come from purposeful recreational movement, energy
expenditure. Very hard to offset modern diets’ effects.
Physical Activity:
A Major Cause, Not a Solution
• Most dietary guidelines focus on increased produce, whole grains,
minimal red meat, healthy fats, more plant food.
• Michael Pollan: “Eat food. Not too much. Mostly plants.”
• Monteiro, PAHO guidelines, others pushing the same, possibly
could interpret PREDIMED results similarly as a push for minimally
or unprocessed food-based diet
• The reality: the enormous rapid shift in our food system discussed
next runs completely counter to these pushes.
• Unanswered question: Can we have any type of highly processed
foods as part of a healthy diet? Or does such a diet with excessive
highly processed food even exist?
• All this is being played out in nutrient profiling and FOP policies will
note later but seeing negative and positive logos as separate but
joint efforts emerging finally to address both sides of this issue—
remove junk food, promote truly healthy food.
Diet: Major Conflict among Diet People
What is driving our increased obesity globally
• The modern agricultural and entire food system
has changed remarkably not only in the US and
higher income countries but globally.
• Every village, location in the world now faces
many of the same packaged and processed
junk foods and beverages
Stage 1
1800’s mainly
scientific underpinnings
Stage 3 Post WWII massive investments
modern system
Stage 4
Systematically
transmitted globally (1955-2008)
Stage 5 Commercial sector shifts
major drivers of system
change (present)
Stage 2
1900-1944
Stage 6
Healthier food
supply
Reduced
noncommunicable
diseases, reduced
climate footprint,
achieve total
sustainability, fewer
animal source foods
consumed
Production linked to
the needs of food
manufacturers and
retailers, ignoring
climate, sustainability,
and health concerns
Green revolution,
irrigation, credit, farm
extension, and
agricultural institutions
mirror those of the
west; modernizing of
food processing
High income countries see
rapid mechanization;
development of new food
processing technologies (e.g.
extraction of edible
oils from oilseeds); and
investment in transportation/
irrigation/electrification/
modernization of agriculture
Farming systems
developed;
underpinnings post
WWII revolution
added modernization
of agricultural
production inputs
and machinery
Farming remains
the major source of
the food supply;
industrial/large-
scale monoculture
initiated
Investments in
infrastructure
and training
Food industry
farm links drive
production and
marketing
decisions,
incentives and
economic
drivers change
Investment training,
institutions, infrastructure,
CGIARC (Consortium
Global International
Agricultural Research)
Extensive funding for
major infrastructure,
systems, input and
enhanced seeds,
and major technology
development
Expansion of
science; develop
reaper; many
other technologies
Fossil energy,
modern genetics,
fertilizer, beginning
agricultural science
and experimental
work, & land
grant/agricultural
universities
Price incentives, taxation,
other regulatory controls
(e.g. marketing healthy
food only) and system
investments
Retailers, agricultural
input & processing,
businesses, and food
manufacturers
dominate farm-level
decision-making
Farm research,
extension systems,
and education mirror
those of the West
Create the modern
food system focused
on staples, animal
source foods, and
cash crops
Expansion
technologies;
science
Stages of Modern Global Agricultural and Food System’s
Development
Science and
institution building
Source: © (copyright) Barry M. Popkin, 2015
See Anand,Hawkes et al, J Am College Card (2015) 66; Popkin (2017) Nutr Reviews
Scientific and technological change, economic change, urbanization, globalization
Major Food System Changes Occurred Different Times, Similar Now
Four big players drive food
and agricultural systems in
LMICs and the US: (agricultural economists have documented)
Source: Popkin BM. Nutrition, Agriculture, global food systems in LMIC’s Food Policy (2014) 14;47:91-96; Zhou et al (2015).
The food retail revolution in China and its association with diet and health. Food Policy 55:92-100.
• Trend in disappearing fresh markets being replaced by small stalls,
convenience stores and supermarkets all selling ultra-processed foods
and beverages
• Mexico and China: packaged foods with bar codes based on nationally
representative 24-hour recalls surveys with questions probing this issue
– 58% of kcal Mexico in 2012 and 29% in China in 2011 (growing by
50%/year)
• Latin America/Gulf states: first major growth, now Asia and urban Africa;
high penetration into all African and Middle East communities now
• Major shifts in types of foods and integrated marketing strategies used by
food industry sectors across global regions with Latin America being
penetrated most completely and earlier than Africa and Asia
• Global agribusinesses
• Retailers
• Food manufacturers
• Large restaurant chains
• Walmart: completely post-WWII phenomena
with all growth from 1970 onwards
• Carrefour: 1960’s onward
• Ahold: (began as Albert Heijn) and expanded
in early 1900’s, as did Tesco with basic foods.
• Most major growth as chains occurred after WWII
• Our focus is not only on these global chains but all the domestic clones
across the globe in low and middle income countries
• Packaged processed food growth, especially highly or ultra-processed
food is mainly a recent phenomena of the last 30-50 years with modern
food science and related food manufacturer revolution.
Retail Sector and Processed Foods are a Post-WWII Phenomena:
The Mega Chains and Global Growth
Evolution of Human Experience with Food
• Old and accumulative process
• Increase penetration of the matter
• From domestic & artisanal to industrial
Butchering,
smoking &
drying
of meats
Pounding,
grinding,
roasting,
wetting,
boiling,
fermenting
of seeds
and acorns
Granaries,
agriculture,
husbandry,
pottery
Large
granaries
Mass
production
of oil, salt
& sugar
Pasteurization,
canning,
roller mills
Cooking
Ultra-processing
Industrial
ingredients,
biochemicals,
genetics
By Jean-Claude Moubarac
Paleolithic
2 mya
300 000 BC
Neolithic
12 000 - 2000 BC
First
States
Post-war/global
1950-2013
Industrial
1780
From Jean-Claude Moubarac
• Income
• Culture
• Market-Based Food Systems
• Income
• Modernity
• Convenience
Category Definition Examples
Unprocessed/
minimally processed
Single foods, no/very slight
modifications
Fresh or frozen produce, milk, eggs, fresh meat
Basic processed Single foods, processed – A) isolated food components or
B) modified by preservation methods
Sugar, oil, flour, pasta, white rice, unsweetened canned fruit, veggies canned without salt
Moderately
processed
Single foods with addition of flavor
additives
Salted nuts, fruit canned in syrup, veggies canned with added salt, whole-grain breads/cereals with no added sugar
Highly processed Multi-ingredient industrially
formulated mixtures
Refined-grain breads, cookies, sugar-sweetened beverages, salty snacks, candy, ready-to-eat cereal, ketchup, margarine, pre-prepared mixed dishes
Poti J, et al.
Am J Clin
Nutr 2015.
Degree of processing: Classification
Category Definition Examples
Requires cooking
and/or preparation
Not consumed as purchased, requires significant input of consumer’s time, culinary skill, energy, or attention to cook/prepare
Flour, dry pasta or rice, oil, eggs, fresh potatoes, uncooked meat, mixes for grain-based desserts or pancakes, some fresh veggies
Ready-to-heat
(RTH)
Not consumed as purchased, requires only a small amount of consumer’s time or effort during prep (e.g., by microwaving)
Frozen dinners or pizza, frozen waffles, canned soup, hot dogs, instant oatmeal, canned or frozen vegetables
Ready-to-eat (RTE) Can be consumed immediately with no preparation
Bread, salty snacks, milk, candy, pre-made cookies, most fresh fruit, canned fruit, baby carrots, sugar-sweetened beverages, ready-to-drink beverages
Poti J, et al. Am J Clin Nutr 2015.
SSB: sugar sweetened beverages
Convenience classification
Category Top contributors (per capita kcal/d)
Minimally
processed
Milk, eggs, fresh/frozen veggies, unsalted
nuts, fresh/dried fruit, whole-grain hot
cereal, dried beans
Basic
processed
Sugar, oil, flour, pasta,
unsweetened fruit juice, white rice
Moderately
processed
Salted nuts, peanut butter, potato chips,
cheese, butter, fruit canned in syrup,
sweetened juice, seasoned or cured meat
Highly
processed
Refined bread, grain-based desserts,
SSBs, salty snacks, candy, cereal, ice
cream, prepared meals, condiments,
sauces, margarine, processed meat
61.4% 62.0% 62.3% 61.0%
13.6% 15.3% 15.3% 15.9%
14.6% 12.9% 12.6% 12.6%
10.4% 9.9% 9.9% 10.5%
0
200
400
600
800
1000
1200
1400
2000 2004 2008 2012
Per
cap
ita
kcal
/day
*
*
Trends in CPG Food and Beverage Purchases
by Degree of Processing (1.4 million barcoded products)
Nationally representative weighted unadjusted mean kcal/d per person and % kcal/d of food and beverage
purchases from each category defined by degree of processing or convenience among US households.
Poti J, et al. Am J Clin Nutr 2015.
Category Top contributors (per capita kcal/d)
Requires
cooking
and/or
preparation
Oil, flour, pasta, eggs, grain-based
dessert mixes, some fresh veggies,
pancake/biscuit mixes, boxed mac-and-
cheese, rice, uncooked meat
Ready-to-
heat (RTH)
Frozen pizza, frozen meals, prepared
mixed dishes, frozen waffles or
pancakes, canned soup, hot dogs,
instant oatmeal
Ready-to-
eat (RTE)
Salty snacks, bread, RTE grain-based
desserts, milk, sugar, SSBs, candy,
butter, margarine, cereal, condiments,
nuts, peanut butter, ice cream, cheese,
juice, fruit, some veggies
70.9% 69.9% 68.6% 68.1%
13.1% 14.3% 15.3% 15.2%
15.9% 15.9% 16.2% 16.7%
0
200
400
600
800
1000
1200
1400
2000 2004 2008 2012
Per
cap
ita
kcal
/day
*
*
Nationally representative weighted unadjusted mean kcal/d per person and % kcal/d of food and beverage
purchases from each category defined by degree of processing or convenience among US households.
Poti J, et al. Am J Clin Nutr 2015.
Trends in CPG food and Beverage Purchases
by Level of Convenience (1.4 million barcoded products)
Global increases in:
• Use of added caloric sweeteners, especially
beverages but increasingly all packaged foods
consumed
• Refined carbohydrates, ultra-refined highly
processed foods.
• Animal source foods
• Convenience foods for snacking, away-from-home
eating, precooked/uncooked ready-to-heat food
• Large increase in edible oil used to fry foods
(unique to LMICs)
Global decreases in:
• Legumes, vegetables, fruits in most countries
• Food preparation time
Sources of Major Global Dietary Shifts
• Always loved sweetness and as fruit provided
unique source of nutrients.
• Mattes, Rolls others showed the way on what we
drink affects us differently than sugar in food.
• Amount of added sugar in our food supply is
surprising—not only for taste but also other
properties
First Major Global Shift:
Sweetness, Added Sugars
The Proportion of CPG Products with Unique Formulations
by Weight Containing Any Sweeteners in the United States (nationally representative sample of food purchases)
NS= Nutritive/Caloric Sweetener, NNS= Non-nutritive/non-caloric sweetener,
FJC= Fruit Juice Concentrate (excluding lemon/lime and when reconstituted)
Source: Popkin,Hawkes Lancet Diab: 2016
30 29 32 31 31 34 28 26 28
3 6 5
0 0 0
9 14 12
63 60 55 66 66 63 58 51
45
3 5 7 2 2 2 4
9 15
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
20
00 (
N=
40,5
62)
20
06 (
N=
76,9
71)
20
13 (
N=
129,5
27)
20
00 (
N=
35,8
96)
20
06 (
N=
67,6
00)
20
13 (
N=
11
3,0
15)
20
00 (
N=
4,6
66
)
20
06 (
N=
9,3
71
)
20
13 (
N=
16
,51
2)
All CPG Foods & Beverages Foods only Beverages only
% o
f u
niq
ue
fo
rmu
latio
ns c
on
tain
ing
sw
ee
ten
ers
by w
eig
ht Any FJC
Both NS and NNS
NS only
NNS only
No addedsweeteners
7 14 10 9 11
19
52
73
112
149
0
50
100
150
200
250
Rural Small Cities Large Cities Mega-Cities
Pe
r C
ap
ita
In
take
Kca
l/D
ay
1991
2000
2011
20 31
38
11 14
38
111
150
211 221
0
50
100
150
200
250
Rural Small Cities Large Cities Mega-Cities
Pe
r C
ap
ita
In
take
Kca
l /D
ay
11 9 17
9 6
27
68 79
112
155
0
50
100
150
200
250
Rural Small Cities Large Cities Mega-Cities
Pe
r C
ap
ita
In
take
Kca
l/D
ay
Second, Snacking: Chinese Snacking Is an Example of the Role
of Marketing, Modern Food Systems
a. Ages 2-18 b. Ages 19-59
c. Ages 60+
Fat Preference Key for Survival:
Technology, Marketing Have Utilized
This Preference for Fatty Food
• Fatty foods: smoother, affects taste in many ways
• Shifts largest in Africa, Middle East and Asia but also in
the Americas
• Oils have and will continue to face many challenges
regarding trans fat content (e.g. India’s Vanaspati;
possibly palm oil) and unhealthful fatty acid components
• Possibly the biggest early caloric driver in the developing
world, but rapidly being replaced by SSB’s, junk food
Third Major Shift: Fatty Foods and
Edible Oils in Particular, Unsure of
Weight and Health Effects
Vegetable Oils: The Third Leg Edible Oil Consumption Still Rising in China and the
Proportion of Fried Food Is Rapidly Rising
(Grams per Day per Capita)
Year 1989 1991 1997 2006 2011
Poorest (lowest income tertile) 11.8 19.4 26.5 30.8 37.9
Middle income tertile 15 22.4 29 35.4 39.2
Richest (highest income tertile) 17.4 26.9 32.2 33.9 41.1
Average for total adult population 14.8 22.9 29.2 33.4 39.6
% of all calories per capita from
edible oil 4.9 7.8 11.3 13.2 15.4
Oil added during cooking of rice can retrograde the
rice and significantly decrease the glycemic indexurvey for adults aged 20-45
1991
1993
1997
2000
2004
2006
2009
2011
me
ga
citie
s
seafood
fish
poultry
Beef, lamb, mutton,other red meat
All dairy
eggs
Pork & pork products
Fourth Major Shift: Daily Intake of
Animal Source Foods in China
(Grams/day),1991-2009*
0
25
50
75
100
125
150
175
200
225
1991
1993
1997
2000
2004
2006
2009
2011
me
ga
citie
s
Gra
ms/d
ay
*Adjusted for age and gender Megacities: Beijing, Shanghai, Chongqing
A. Children Aged 2-18 B. Adults Aged 19 and Older
Fengying Zhai et al Obesity Reviews. 2014; 15.
Fifth major shift: Eating Away from Home Is
Associated with Urbanization in China, Most
Other Low- and Middle-Income Countries
3
11
16
4
8
17 16
12
20
25
0
5
10
15
20
25
30
Low Urbanization Middle Urbanization High Urbanization 3 mega cities
Pe
rce
nta
ge
kca
l e
atin
g a
wa
y f
rom
ho
me
1991 2000 2011 3 mega cities 2011
Fengying Zhai et al Obesity Reviews. 2014; 15.
• Total caloric intake = f(Meal Size(G) x Eating
Frequency(#) x energy density of the meal (kcal/g))
• Meal 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 ↑↓ : biggest shift toward higher number
& size snacks of higher energy density and excessive
added sugar and refined carbs; caloric beverages
increased also in total volume with comparable results
for children
Total Caloric Intake Is a Combination
of Three Components
Duffey & Popkin (2011) Plos Medicine; Duffey & Popkin (2013) AJPM 44
• Use classic total derivative approach by creating partial
derivatives for each component and using them to
create total derivative
• Major finding was that the increases in energy intake in
the last century were driven more by increased eating
frequency than meal portion size (note we looked at
total meal portion size and not one dish).
Mathematical Decomposition of the
Change in Total Calorie Intake
Duffey & Popkin (2011) Plos Medicine
[VALUE] -11.3
-1.6 -3.7
14.8 11.7
-1.0
10.1
4.3
37.2
39.4 21.7
-20.0
-10.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
1977-78 to 1989-91 1989-91 to 1994-98 1994-98 to 2003-06 1977-78 to 2003-06
En
erg
y c
on
trib
utio
n to
an
nu
aliz
ed
ch
an
ge
in
tota
l d
aily
en
erg
y inta
ke
(kcal)
Energy Density Portion Size Eating Occasions
*Values represent the annualized energy (kcal) contribution of changes in the number of eating occasions, portion
size or energy density of each eating occasion to changes in total daily energy (kcal) intake.
Nationally representative data. Duffey & Popkin (2011) Plos Medicine
Annualized Energy Contribution of Portion Size,
Energy Density, and Eating Occasions to
Changes in Total Energy Intake*
Salt, 80.8
MSG, 0.9
Soy Sauce, 7.7
Regular
Food, 8.8
Processed
Food, 1.8
1991
Salt, 69.7 MSG, 3.4
Soy Sauce, 8.5
Processed
Food, 6.8
2009
Prepared
at Home
Regular
Food, 11.5
Prepared
at Home
Lee et al, J Hum Hyp (2013) S Korea 27 :298; Du (2014) China…AJCN 99: 334
China and many low and middle income countries: Sodium intake
from salt continues to dominate. The proportions of sodium from
processed food and MSG small in absolute terms, but increasing.
No solid data from Latin America and Africa.
Sodium Intake
1. Adult obesity precedes child obesity: conjecture
relates to the rapid decline in adult activity along with
the more recent food system shifts
2. Rightward shift in BMI at all ages—age-period-cohort
and other research suggests 8-10 kg increase over
past 10-20 years (e.g. Jaacks et al, IJE 42:828-837)
3. Waist circumference at each BMI level is increasing
4. Remember much higher body fat proportion, visceral
fat among many LMIC subpopulations. Also increased
NCD susceptibility at lower BMI’s
What Does All This Mean for Global
Obesity?
76.2
84.4
82.8*
86.4*
70
72
74
76
78
80
82
84
86
88
Mexican Mexican-American
WC
(cm
)
1999/1999-2002 2012/2007-2010
2.0 cm
Waist Circumferences Are Going up Globally at the Same
BMI, for most countries globally. Just one example for
Hispanic Women (mean WC over time for females aged 20
years and BMI=25 kg/m2)
6.6.cm
• *p<0.0001, comparing predicted WC in most recent survey year to predicted WC in earlier survey year for
Mexican women and Mexican-American women.
• All models adjusted for age, BMI, BMI-squared, and survey year in linear regression analyses.
• Age centered to age 20 years and BMI centered to BMI=25 kg/m2
Source:Albrecht et al EJCN 2015; 69: 1306-12.; Albrecht, et al AJHumBiol 26: 627–634
•
0
5
10
15
20
25
30
35
1988-1994 2007-2012 1988-1994 2007-2012 1988-1994 2007-2012 1988-1994 2007-2012
18.5-24.9 25.9-29.9 30-34.9 ≥35
Dia
be
tes p
reva
len
ce
(%
)
BMI (kg/m2)
Non-Hispanic whites Non-Hispanic blacks Mexican-Americans
* * *
* * * *
* * *
*
* *
*
*
*p<0.05, compares diabetes prevalence among non-Hispanic blacks and Mexican-Americans to
non-Hispanic white referent group within BMI categories and within survey years
Diabetes Prevalence Is Higher at Each BMI level for US Mexican
Americans and US Non-Hispanic Blacks, Despite Adjustment for
Socioeconomic and Demographic Factors
Source: Albrecht, Mayer-Davis and Popkin (2017) from nationally representative NHANES data
Regional Percent Underweight and Overweight in Most Recent Available
Survey among Women Aged 19-49 by Urban and
Rural Residence, Weighted by 2010 Population
Underweight Overweight Underweight Overweight
7
3
4
2
38
14
01020304050
28
50
50
64
9
14
0 20 40 60 80
9
3
3
1
22
9
01020304050
24
52
52
76
27
33
0 20 40 60 80
Sub-Saharan
Africa
South Asia
Middle East and
North Africa
Latin America and
the Caribbean
Eastern Europe and
Central Asia
East Asia
and Pacific
Sub-Saharan
Africa
South Asia
Middle East and
North Africa
Latin America and
the Caribbean
Eastern Europe and
Central Asia
East Asia
and Pacific
Sample size: 290,278 rural, 232,581 urban Percentage
Source: Jaacks and Popkin, J Nutr 2015
Rural Urban
Regional Annualized Change Absolute Change in Percent Underweight
and Overweight in the Most Recent Period in Percent Underweight and
Overweight among Women Aged 19-49 by Urban and Rural Residence,
Weighted by 2010 Population
Percentage
0.03
0.01
-0.30
0.00
-0.44
-0.09
-0.6 -0.4 -0.2 0.0 0.2 0.4
Underweight Overweight
Sub-Saharan
Africa
South Asia
Middle East and
North Africa
Latin America and
the Caribbean
Eastern Europe and
Central Asia
East Asia
and Pacific 0.95
1.18
1.12
0.81
0.51
0.31
0.0 0.5 1.0 1.5
Rural
0.03
-0.18
-0.29
0.00
-0.18
-0.12
-0.6 -0.4 -0.2 0.0 0.2 0.4
Underweight Overweight
Sub-Saharan
Africa
South Asia
Middle East and
North Africa
Latin America and
the Caribbean
Eastern Europe and
Central Asia
East Asia
and Pacific 0.13
0.77
1.14
0.39
0.53
0.60
0.0 0.5 1.0 1.5
Urban
Source: Jaacks and Popkin, J Nutr 2015
• Major Tools considered to date for obesity prevention at the macro/regulatory level:
– Economic tools: prices(taxation), subsidies?, trade controls?
– Labeling: FOP labeling approaches being used; considering claims restrictions-ideally linked with marketing controls
– Marketing controls and restrictions: kids only vs overall
– Restrict foods in selected institutions(e.g. schools, hospitals,etc) but really minimal evidence in any country of major impact of major feeding changes and their impact (especially LMIC’s)
• Other aspects of our food system not addressed to date:
– Retailer change only via changes noted above to date
– Neglect of restaurant/fast food/stall sector
– Other farm system/sector changes: no sense of potential impact .
– To date, know traditional nutrition education efforts small, not possible without major marketing controls, but no sense of modern mass media/social media efforts.
The Focus is on Food system And Dietary Change
Spectrum of approaches for changing behaviors Effe
ctiveness p
ote
ntial (a
t popula
tion level)
Gov’t
led
Indiv
driven
Fiscal
Measures
(e.g., tax)
Marketing/
advertising
controls/FOP
Industry’s
voluntary
efforts
Food service &
other regulations
Modify choice
architecture
Cultural/
societal norms
for healthy
eating
Individuals, communities, food manufacturers, retailers, food service,
policymakers, regulatory agencies all have roles to play but to date little evidence
industry will play a significant role without regulatory efforts
Labeling regs:
Menu,
Package
Our ultimate goal: How to use multiple approaches to change
BOTH supply and demand?
Behaviors
(measureable) as
proxies for norms
(non-measurable)
Social marketing/
nutrition education
From Shu Wen Ng
Mexico: History All Linked to National Institute of Pub
Health
• Mexican Beverage panel 2007-8: recommended taxing sugary
beverages; got all medical societies to sign on and publish document
• Series of meetings on ways to reduce added sugar, bad fats, sodium
• National Prevention Plan
• Front-of-the-package profiling: MOH, MinFinance, Mex FDA — I
chaired
• New elections, new President, Min of Health with strong industry ties
and Bloomberg involvement with major public campaign
• 2 taxes instituted, fought off attempts to cut, constant battles with
industry over SSB tax. Surprisingly little over junk food tax.
• Media strategy: Create public debate
through press conferences (1xweek),
public actions/performances (1xmonth)
and newspaper ads (2xweek in Oct.)
• Engagement with decision-makers and
lobbying:
- Actor mapping
- Identification of champion(s)
- Relationship building across parties,
ministries and Congressional committees
- Mini public campaign targeting Congress
- Tracking industry lobbying (responding
or exposing as necessary)
• International support: WHO
recommendations, PAHO, IASO/IOTF and
other allied INGO’s, health advocates in
the US
Campaign Strategy
OCT NOV DEC JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV
NEW PRESIDENT
TAKES OFFICES
“12 SPOONFULS
OF SUGAR”
CAMPAIGNS
“FIRST CAME OBESITY,
THEN DIABETES” “A HEALTHIER
MEXICO”
“SUGARY
DRINKS”
“WATER IS
LIFE”
EARNED MEDIA
COALITION BUILDING
SSB TAX BILL
INTRODUCED
IN SENATE –
“TABLED”
UNTIL FISCAL
REFORM
KEY DIALOGUE
WITH MINISTRY
OF FINANCE
COLLECT
SIGNATORIES
TO SSB TAX
BILL
INDUSTRY CAMPAIGNS
INTENSE
LOBBYING
ACADEMIA
LAUNCH OF
POLICY RECOM’S
PRINT AD BATTLE IN THE PRESS
EXPERT FORUMS
The Mexican SSB Tax Timeline
PEÑA NIETO
ANNOUNCES SODA
TAX IN FISCAL REFORM
SSB TAX
PASSED
CONGRESS IN SESSION CONGRESS IN SESSION CONGRESS IN SESSION
ALLIANCE
BORN
The Mexican tax: Leading the Way So Far and Used
to Build Basis for Taxes in Many Countries, Cities
• Passed Oct 31, 2013
• Sugar-sweetened beverages (SSB): All flavored waters
(including concentrates, powders or syrups used to prepare
flavored waters) that have added sugars will be subject to a tax
of $ one peso per liter.(≈10%)
• Junk food: All non-basic foods (chips and snacks; candies;
chocolate and cacao based products; puddings; fruit-made and
vegetable-made sweets; peanut and hazelnut butters; milk and
caramel-based sweets; cereal-based products; ice-cream and
ice-pops) with an energy density ≥275kcal/100g will be subject
to a tax of 8%.
• Evaluation of price, marketing, food purchase shifts underway
led by INSP with UNC major collaboration
• To date, price increases are being passed along.
• First year of taxes saw overall 6% decline, with 12% by month 12.
– Lowest SES group (most affected by diabetes that is untreated)
saw a 17% decline.
– Water purchases significantly increased.
• Year 2 Found an additional 4% decline
• Nonessential food taxes equally impactful in similar fashion with a
much larger year 2 decline (4.4% in first year, 16.6% in second year).
• Fought off repeated industry legal, political and extralegal efforts to
stop these efforts
The Mexican Tax: Leading the Way So Far
• Chile has the most comprehensive set of marketing
restrictions to date evaluating their impact will
be crucial for learning what is working to create
healthier eating patterns.
Chile’s Laws: Marketing to Children
Strengths: 2015-16 TV where kids 22% or more of audience
Applies to all foods and beverages and uses uniform nutrition criteria
across categories
Includes comprehensive in-school restrictions.
Restricts all characters on food packages deemed unhealthy based on a
very comprehensive set of guidelines
Strong negative logos on junk foods/beverages high in added sodium,
added sugar, added saturated fats, energy density(separate for each)
(junk food—about 50% of what retailers sell)
Strengths: new law 2017 and implementation guidelines ban 6am to
10pm
Builds on current law and adds total ban during those hours
Adds negative warning message to any media with ads for foods and
beverages with negative logos.
Chile Law Evaluation: UNC Working with
Strong University of Chile Collaborators
Planning: year later mega possibly 18% tax on all banned food-bev-
still unclear.
Chile Regulatory and Tax Evaluation:
INTA and GFRP UNC
Data sources
Household Food Purchases
SES, Media Exposure, and Diet
• GOCCs cohort of 12y-olds, n=767, additional diet and media
• New cohort of 4y-olds, n=965
• SES and diet • Knowledge
• Media • Attitudes
Content analysis of TV
Nutrition Facts Panel and FOP labels
Focus groups of Low SES mothers
Regulations
Front-of-package
warning labeling
July 1, 2016
Marketing
& Advertising
Restrictions
• children 0-14y
July 1, 2016
• all ages 6am to 10pm
July 1, 2017
5% Sugar-sweetened
beverages tax
Jan 1, 2015
Outcomes Analysis
Changes in attitude,
knowledge, and understanding
of regulations
Food Purchases Changes in regulated and
unregulated food and beverage
purchases; reformulation changes
Dietary Intake Changes in regulated and
unregulated dietary intake
Obesity & NCDs Changes in health outcomes
The Future: Large series of countries globally
instituted or seeking similar tax and other
regulatory changes
• SSB taxes: Pacific & Caribbean Islands, S Africa,
Thailand, Phil., others
• Except Chile and Mexico—no exploration of other taxes
• Will reducing junk food/beverages be enough? I doubt it
• Marketing/FOP: Chile the leader, others are following
• FOP: few countries combining negative Argentinean
with push for Keyhole/choices type real healthy food
• Ultimately we must figure a way to get to a healthy diet
to truly succeed.
Our Goal is to find a way to create effective public health nutrition efforts and policies in our
initiatives
Short-term outcomes Changes in food
purchases or diets (overall, by subpops)
Longer-term outcomes Changes in health
outcomes (overall, by subpops)
Focus on packaged food sector and need to expand ultimately
Spectrum of approaches
Research
From Shu Wen Ng
Spectrum of approaches for changing behaviors Effe
ctiveness p
ote
ntial (a
t popula
tion level)
Gov’t
led
Indiv
driven
Fiscal
Measures
(e.g., tax)
Marketing/
advertising
controls/FOP
Industry’s
voluntary
efforts
Food service &
other regulations
Modify choice
architecture
Cultural/
societal norms
for healthy
eating
Individuals, communities, food manufacturers, retailers, food
service, policymakers, regulatory agencies all have roles to play
but to date little evidence they will without regulatory efforts
Labeling regs:
Menu,
Package
Our ultimate goal: How to use multiple approaches to change
BOTH supply and demand?
Behaviors
(measureable) as
proxies for norms
(non-measurable)
Social marketing/
nutrition education
From Shu Wen
The Struggle Over the Millennia to
Eliminate Arduous Effort Could Not
Foresee Modern Technology