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