Global energy imbalance and related obesity levels are rapidly increasing. The world is rapidly shifting from a dietary period in which the higherincome countries were dominated by patterns of degenerative diseases (while the lower and middle income countries were dominated by receding famine) to one in which the world is increasingly being dominated by degenerative diseases. Globally very high levels of overweight are found equally in high and lower income countries, in urban and rural areas. Dietary changes appear to be shifting universally toward a more energy-dense and sweeter diet with reduced complex carbohydrate intake. Large-scale declines in food prices (e.g., beef prices) increased access to supermarkets, and urbanization of urban and rural areas are key underlying factors. The challenge to global health is clear.

What is the nutrition transition ?

The concept of the nutrition transition focuses on large shifts in diet and activity patterns, especially their structure and overall composition. These changes are reflected in nutritional outcomes, such as changes in average stature and body composition. Further, dietary and activity pattern changes are paralleled by major changes in health status, as well as by major demographic and socioeconomic changes.

Why the concern ?

The rates of change in non-communicable diseases are great. Obesity prevalence and trends. Rates and levels of change in obesity across the globe are very high. Over 60% of the populations of Mexico, Egypt, the United States and South Africa (black women) are overweight and obese.
What is potentially far more important are the rates of change in the prevalence of overweight and obesity across the globe. Changes of 0.5 to 1.5% of the adult population in these countries becoming overweight is common. Obesity is universally found in urban and rural areas ! Universally obesity levels are higher in urban areas but studies conducted across the globe shows that except in a few countries, among adult women more overweight exists than underweight in most urban and rural areas in all but 4-5 countries.

What are the key dietary dimensions ?

Globally, our diet is becoming increasingly energy-dense and sweeter. At the same time, higher fiber foods are being replaced by processed versions.
There is enormous variability in eating patterns globally but the broad themes seem to be retained in most countries. Edible oil intake is increasing, particularly among lower income countries. Animal source food changes are equally dramatic, particularly in selected countries. Concurrent shifts are occurring in the use of caloric sweeteners. Fiber intake as well as that of coarse grains is down significantly. Similarly, studies on fruit and vegetable intake indicate declines in many countries and regions of the world, but again have not been systematically studied. There are also selected countries where fruit and vegetable intake remain very high (e.g., Spain, Greece and South Korea).

What are the major underlying global forces ?

Globalization, with its focus on freer movement of capital, technology, goods, and services has had profound effects on lifestyles that are linked with diet, activity, and subsequent imbalances that have led to the obesity epidemic. While many researchers have placed the global food production, marketing, and distribution sectors (including soft drink, fast food, and other multinational food companies) at the center of blame for these changes, there are other profound and equally responsible factors that must be understood to enact effective public policy to address them. These other factors include: (a) the worldwide shifts in trade of technology innovations that affect energy expenditures during leisure, transportation, and work; (b) globalization of modern food processing, marketing, and distribution techniques (most frequently linked with westernization of the world’s diet); (c) vast expansion of the global mass media; and (d) other changes that constitute the rubric of impacts resulting from an increased opening of our world economy.
One of the central shifts has occurred in the global food system related to the marketing and sales of food. The fresh (wet or open public) market is disappearing as the major source of supply for food in the developing world. These markets are being replaced by multinational, regional, and local large supermarkets which are usually part of larger chains or in other countries such as South African and China by local domestic chains patterned to function and look like these global chains. Increasingly, we are finding hypermarkets (very large megastores) as the major force driving shifts in food expenditures in a country or region. For example, in Latin America, supermarkets’ share of all retail food sales increased from 15% in 1990 to 60% by 2000. This same process is also occurring at varying rates and different stages in Asia, Eastern Europe, and Africa.

Global agricultural policies Global agricultural policies have a built-in longterm focus on creating cheaper grains and animal source foods. One clear outcome has been a dramatic decline in the real price of beef and related products.

Global mass media Global mass media access has shifted in an equally impressive manner.

The economic costs of this transition are huge

In the United States and other higher-income countries, there have been a large number of analyses of the health costs and other effects of this shift toward higher obesity. There has been a controversy in the United States about the impact of obesity on mortality. Essentially, Flegal and colleagues have shown that earlier work—done by the Center for Disease Control and Prevention (CDC) that showed a very high mortality linked with obesity—was in error and smoking killed more persons than obesity. More recently, following a more behavioral approach, there is a study that shows that the health care costs of obesity far outweigh those of smoking, particularly for those with a BMI greater than 30.

In developing countries, far less has been done to study this issue. In one set of studies on the economic costs in India and China it has been shown that these costs are rapidly increasing and represent a serious component of their GNP. In fact, it is quite possible that these economic effects of the shift toward the degenerative disease stage of the nutrition transition will overwhelm the health system of China and slow its economic growth.

Do we have any positive models at the national or regional level ?

See my website (www.nutrans.org) for examples from Brazil, Finland, and South Korea.

So where do we go from here ?

The challenge for us is to devise ways to improve the lives of our citizens to (a) give people the more varied and tasteful diets they want; (b) give people less burdensome work; (c) prevent obesity, type 2 diabetes, all other aspects of the metabolic syndrome, and (d) prevent a vast array of cancers linked with these dietary, activity and obesity patterns. The fruit and vegetable sector, a relatively untapped and neglected component of the agricultural sector, is one area that deserves major attention.