Hostname: page-component-7c8c6479df-r7xzm Total loading time: 0 Render date: 2024-03-28T13:25:27.086Z Has data issue: false hasContentIssue false

Contemporary nutritional transition: determinants of diet and its impact on body composition

Published online by Cambridge University Press:  22 November 2010

Barry M. Popkin*
Affiliation:
Nutrition Department, Carolina Population Center, University of North Carolina, Chapel Hill, 123 W. Franklin St, Chapel Hill, NC 27516-3997, USA
*
Corresponding author: Professor Barry M. Popkin, fax +1 919 966 9159, email popkin@unc.edu
Rights & Permissions [Opens in a new window]

Abstract

The world has experienced a marked shift in the global BMI distribution towards reduced undernutrition and increased obesity. The collision between human biology, shaped over the millennia and modern technology, globalization, government policies and food industry practices have worked to create far-reaching energy imbalance across the globe. A prime example is the clash between our drinking habits and our biology. The shift from water and breast milk as the only beverages available, to a vast array of caloric beverages was very rapid, shaped both by our tastes and aggressive marketing of the beverage industry. Our biology, shaped over millennia by daily consumption of water and seasonal availability of food, was not ready to compensate for the liquid energies. Other dietary changes were similarly significant, particularly the shift towards increased frequency of eating and larger portions. The roles of the food and beverage production, distribution and marketing sectors in not only shaping our diet but also accelerating these changes must be understood. Apart from the role of beverages, there is much less consensus about the role of various components of our diet in energy imbalance. Understanding the determinants of change in the key components of our diet through an array of research provides insights into some of the options we face in attempting to attain a great balance between energy intake and expenditures while creating an overall healthier dietary pattern. A few countries are systematically addressing the causes of poor dietary and physical activity patterns and high energy imbalance.

Type
Conference on ‘Nutrition and health: cell to community’
Copyright
Copyright © The Author 2010

Abbreviations:
TV

television

The shifts in global dietary patterns in terms of food sources, modes of processing and distribution over the past several decades have led to a world dominated by highly processed foods and drink. The concomitant shifts in the frequency of eating, the preparation of food and beverages and overall energy imbalance are being explored by scholars. The disappearance of water and milk from the diets of children and its replacement with an array of sugar-sweetened beverages are just one example of these shifts.

These changes, which decades ago began to emerge in higher-income countries, today reach billions of individuals across the globe. There are a few countries where major shifts towards increased overweight among adults are not documented, while undernutrition is slowly being reduced in many countries.

Although many shifts towards great energy imbalance were partially linked with reduced activity in physical activity in all phases of work (e.g. the effects of reduced activity in home production, transport, market activity and leisure have all been documented for China(Reference Monda, Adair and Zhai1Reference Ng, Norton and Popkin4)), the greatest potential for reducing the current energy imbalances will be found in increased physical activity.

A few countries have begun to systematically search for ways to enhance our understanding and use of more basic food stuffs. This is why the UK has instituted cooking classes for all youth(Reference King5Reference McPherson, Marsh and Brown7). This is why there is a greater push towards increasing incentives for low-income consumers to consume fruits and vegetables purchased in local farmers markets in the USA(8). However, the majority of individuals in many countries have moved to a point where food preparation requires less than 30 min per day and processed foods represent the bulk of consumption(9).

The levels of overweight have increased across the globe, diets are changing at a most rapid pace and apart from major actions by a few governments nothing is standing between these changes and a globe where increasing proportions of the population are overweight. With it has come a large increase in nutrition-related noncommunicable diseases(Reference Monteiro, Gomes and Cannon10Reference Monteiro14).

Dietary changes

In the last 20–30 years, the world has reduced its water intake, shifted towards sugar-sweetened beverages, increased its proportion of food that is sweetened and ultra processed and reduced its intake of many health components of our diet, including legumes, fruits and vegetables(Reference Monteiro, Gomes and Cannon10, Reference Monteiro14Reference Popkin17). The speed of change is astounding.

The clash of biology, shaped over tens of thousands of years, with modern marketing is personified in the beverage area(Reference Wolf, Bray and Popkin18).

We are what we drink

The field of nutrition does not fully understand the reasons why when we drink a beverage based on fat, carbohydrates or protein, we do not compensate by reducing food intake; however, when we eat that same food (e.g. watermelon, coconut and cheese), we reduce our intake of other food(Reference Mourao, Bressan and Campbell19). Beginning with the research by Mattes and his colleagues(Reference Mattes20Reference Mattes22) and followed by extensive work by scholars across the globe, it is apparent that we do not compensate for beverage energies(Reference DiMeglio and Mattes21Reference Flood, Roe and Rolls32). These studies argue that any type of sweetener with energies in liquid beverages may not suppress intake of solid foods to help maintain energy balance. This may occur week to week as in the 6-week DellaValle et al. study of meal to meal or day to day(Reference DellaValle, Roe and Rolls30). The reduced compensation occurs in both men and women(Reference Flood, Roe and Rolls32). The quantity of calorically sweetened beverages also increases as the portion size increases(Reference Flood, Roe and Rolls32). Many other studies demonstrate this lack of compensation(Reference De Castro24Reference Poppitt, Eckhardt and McGonagle29). See also the review by Mattes(Reference Mattes33).

Based on this, we looked at the evolution of beverage consumption patterns(Reference Wolf, Bray and Popkin18). A consideration of our evolutionary history may help us to explain our poor compensatory response to energies from fluids. We reviewed the history of eight important beverages: milk, beer, wine, tea, coffee, distilled alcoholic beverages, juice and soft drinks. We arrived at two hypotheses. First, human subjects may lack a physiological basis for processing carbohydrate or alcoholic energies in beverage because only breast milk and water were available for the vast majority of our evolutionary history. Alternatives to those two beverages appeared in the human diet no more than 11 000 years ago, but Homo sapiens evolved between 100 000 and 200 000 years ago. Second, carbohydrate and alcohol-containing beverages may produce an incomplete satiation sequence that prevents us from becoming satiated on these beverages(Reference Wolf, Bray and Popkin18). However, for alcohol-containing beverages, the picture is far more complex than that for other beverages(Reference Yeomans34).

A large number of meta-analyses seem to confirm in free-living human subjects that adding sugar-sweetened beverages to the diet, increasing the amount consumed or replacing water or other non-energetic beverages with these beverages increases energy intake and weight(Reference Vartanian, Schwartz and Brownell35Reference Malik, Popkin and Bray38). There are differences when these beverage studies have been funded by the beverage or sugar industries(Reference Vartanian, Schwartz and Brownell35, Reference Lesser, Ebbeling and Goozner39); however, a consensus has emerged that we do not compensate when we consume any caloric beverage and reducing the intake of these beverages via regulations and taxation has become a major public policy focus(Reference Brownell, Farley and Willett40).

The reasons for concern with beverages with energy: the consumption perspective

The shift away from water and milk to an array of energetically sweetened, often caffeinated, drinks has occurred on a global level. We drink juices that are essentially water combined with one of many concentrates of fructose and some fruit flavorings. In Mexico, the USA, the UK and many major countries, energy from sugar-sweetened beverages and other energetic beverages increased to about 17–25% of total energy intake in all age groups(Reference Popkin, Ng, Mhurchu and Jebb41Reference Muckelbauer, Libuda and Clausen45). This is a transformation that has occurred over the last 2–3 decades and for some countries over just a few years. Consider some of the results of the changes underway:

  1. 1. Mexicans aged 2 years and older appear to have doubled their energy intake from beverages between 1999 and 2006 according to two national representative surveys that used somewhat different dietary intake methods(Reference Rivera, Rosas-Peralta, Aguilar-Salinas, Popkin and Willett43, Reference Barquera, Campirano and Bonvecchio46, Reference Barquera, Hernandez-Barrera and Tolentino47).

  2. 2. Between 1989 and 2002 all US adults increased their intake of fluids by 21 ounces (612 ml). One hundred percent of these changes were in the form of sugar-sweetened beverages(Reference Duffey and Popkin48). Did they become more active and more dehydrated over this time or did marketing get them to just drink more?

  3. 3. School children in many countries across the globe in the period between 1990 and the present day have had water fountains removed from their schools and replaced by vending machines(Reference Popkin13).

  4. 4. Results from national dietary intake surveys in the UK shows that all age groups consume over 17% if their energy intake from beverages and juices, alcohol and sugar-sweetened beverages represent key components of the diet of these individuals(Reference Popkin, Ng, Mhurchu and Jebb41).

Sweetening of our food supply. Apart from sugar-sweetened beverages, there is surprisingly little documentation of the large proportion of processed foods that contain added sugar(Reference Popkin and Nielsen16). Partly this is the result of our ability to keep up with the nutrient contents of the modern food supply. For example, there are over 1·3 million unique Universal Product Codes for food. In the US food composition table, we measure about 20–30 000 foods. For measurement of added sugar, the number is much less. We have very poor measures often of what is added sugar and total sugar. The US food composition table, despite being developed and updated to measure key shifts in composition of many basic foods, is just unable to measure or even systematically collect data on all these new foods(Reference Slining and Popkin49). I have provided elsewhere with colleagues some rather indirect documentation of the increasing sugar use across the globe(Reference Popkin and Nielsen16). The array of caloric sweeteners is in itself quite startling, but even more so is this subtle long-term shift in the content of our processed foods.

Animal source foods are subsidized to replace other components of our diet. Most of the increases in animal source food intake come from the low- and middle-income countries in this new millennia(Reference Delgado50, Reference Delgado, Rosegrant and Meijer51). However, over the post World War II period, the USA and the European Economic Union provided billions of dollars and euros of subsidy to reduce the costs of animal source foods (see section ‘Underlying major economic, marketing and social changes’)(Reference Popkin13, Reference Gardner52, Reference Starmer, Witteman and Wise53). From 1970 to 1994, on a global letter Delgado and other scholars from the International Food Policy Research Institute showed that global prices for 100 kg of beef declined from over $500 to under $200. Beef, pork and other animal source foods have very high price elasticities such that consumers are quite sensitive to price declines and increase significantly their purchases of these products(Reference Delgado50, Reference Guo, Popkin and Mroz54). In addition, as income increases in low- and middle-income countries, a disproportionate increase in animal food consumption occurs(Reference Guo, Mroz and Popkin55, Reference Du, Mroz and Zhai56).

Salt in our food supply abounds! The issue of salt and its role in the global food supply is only recently coming under greater scrutiny(Reference Elliott and Brown5760). There are actually two camps of thought. There is one that states we need a certain amount of salt and if there is reduced salt in our food supply we might eat more food to obtain the same level of salt intake(Reference Geerling and Loewy61). The other side of the question is to assume that salt enhances appetite. There are dozens of home remedies and cookbooks based on the need to enhance appetite and use selected salts to assist. However, the science behind these assertions is lacking.

It is unclear how salt affects total food consumption and if it has a role in energy imbalance(60, Reference Mattes62Reference Sakai68). A few scholars have speculated on a salt–soft drink linkage(Reference Gibson69, Reference He, Marrero and MacGregor70), an MSG-obesity linkage (MSG is a sodium salt of the non-essential amino acid glutamic acid)(Reference He, Zhao and Daviglus71) and related a role of MSG in stimulating appetite and energy intake(Reference Cox, Perry and Moore72Reference Bellisle, Monneuse and Chabert74), and others but this is indeed a very understudied topic. One interesting study from the 1980s examined how a low-salt diet accompanied by an ad libitum salt shaker use would affect the total salt compensation but not overall food intake. This study found that there was no compensation(Reference Beauchamp, Bertino and Engelman75). In a personal note, this same author argued it appears that salt consumption was remarkably stable across thousands of years but I do not know the basis for this assertion (Beauchamp, personal communication).

The major concern was the role of salt in hypertension and not obesity. Because of the role of salt in so many energy dense foods that are increasingly consumed as snacks, this is an important understudied topic(Reference Piernas and Popkin76, Reference Piernas and Popkin77).

Increasing frying of food and use of vegetable oils. The total fat intake is another area where our biology seems to clash with modern technology. The ability to taste fat could hold evolutionary advantages in the ability to absorb essential fatty acids from food(Reference Caputo and Mattes78Reference Mattes81). An argument was made that preferences for dietary fats are also either innate or learned in infancy of childhood(Reference Drewnowski82). References to the desirable qualities of milk and honey (i.e. fat and sugar), cream, butter and animal fats are found throughout recorded history. All societies, irrespective of their income, price foods containing fat. Scientists have come to believe that physiological mechanisms that regulate fat intake are so imprecise that fat consumption is largely determined by the amount of fat available in the food supply(Reference Drewnowski, Kurth and Rahaim83, Reference Drewnowski, Krahn and Demitrack84). Another way to view the trend towards higher fat is the desire for a more diverse diet. Diets that incorporate meat and dairy products in addition to vegetables and grains tend to be higher in sugar and fat.

There was a large increase in the consumption of an array of vegetable-based oils and fats(Reference Popkin and Drewnowski85, Reference Drewnowski and Popkin86). Modern food technology provided the basis for cheap removal of corn, soyabean, cottonseed, rapeseed and dozens of other oils from their oilseed products. This was followed by plant breeding efforts to increase the oil content of all these plants and a revolution half a century ago in higher-income countries related to the use of vegetable oils. Across the globe, transfats were one component of this much larger shift, but in general what these reduced prices for vegetable oils has done is to have made it much cheaper for low-income households and poor countries to increase markedly their fat and oils intake. In Asia and the Middle East, the shifts were remarkable in terms of the consumption levels of vegetable oil of 1250–2100 kJ per individual. Frying of food is replacing baking, steaming and boiling in some countries(Reference Popkin, Lu and Zhai87Reference Wang, Zhai and Du89).

Losing many healthful components: fibre, legumes, fruits and vegetables and coarse grains

There is much weaker documentation across the globe of the adverse changes in other components of the human diet. For selected countries, it was shown that legume, coarse grain and whole grain products, in general, were reduced in absolute and relative terms(Reference Popkin, Keyou and Zhai90Reference Popkin, Horton and Kim94). The impact of these changes on health are clear; however, what they mean for obesity and energy imbalance is less understood and there is less consensus on that topic(12, Reference Montonen, Knekt and Jarvinen95Reference Jacobs and Gallaher101).

Cooking and eating behaviours: snacking up, eating events increased

We do not know a great deal about the effect of increased meal frequency on the total energy intake, weight dynamics, insulin resistance and lipid profile. The epidemiological literature is conflicting and often based on less than ideal study design(Reference Bellisle and Le Magnen102Reference Ma, Bertone and Stanek108). There is related literature on fasting and energy restriction suggesting potentially important benefits in terms of health and longevity(Reference Farshchi, Taylor and Macdonald109, Reference Heilbronn, Smith and Martin110), and a few studies suggest that frequent nibbling (defined as five or more times per day) has some health benefits, but this literature is small, conducted in diverse populations and lacks consensus(Reference Farshchi, Taylor and Macdonald109Reference Jenkins, Wolever and Vuksan112). With respect to diabetes, there is an unofficial consensus in clinical care that consuming on evenly spaced eating occasions throughout the day is better than major binging episodes, but little formal research to back these recommendations.

A series of new papers of my group shows a major shift upwards in snacking and the total eating event behaviour in each of the last two decades(Reference Piernas and Popkin76, Reference Piernas and Popkin77, Reference Popkin and Duffey113Reference Wansink115). Other work in China has found a similar shift upwards in snacking(Reference Wang, Zhai and Du116, Reference Wang, Zhai and Shufa117).

In fact snacking and meal consumption are beginning to meld together and we might need to just discuss eating occasions in the future(Reference Popkin and Duffey113). The amount of eating has increased over the past 30 years among all ages in the USA to an average of over five for all those aged 2 years and older. The change from 1977 to 2006 was greatest for those in the 75th and 90th percentiles for both groups, although the mean number increased across all percentiles(Reference Popkin and Duffey113). Energy intake, particularly from snacking, increased for both children and adults at all percentiles of the distribution. Over this period, the time between the start of each eating occasion decreased by an hour for both children and adults (to 3·0 for children and 3·5 h for adults in 2003–6). Overwhelmingly, meals consisted of both foods and beverages, but the percent of snacking occasions in which only beverages were consumed increased considerably among children(Reference Piernas and Popkin76).

Underlying major economic, marketing and social changes

Economic changes, infrastructure, pricing and farm policies. Elsewhere I have written about the ways that farm policies, economic changes, shifts in transportation and other infrastructures and overall food price structures have affected dietary intake(Reference Popkin13, Reference Guo, Mroz and Popkin55, Reference Du, Mroz and Zhai56, Reference Popkin118, Reference Popkin, Otsuka and Kalirajan119). We have created a food price structure that favours relatively animal source foods, sweets and fats. Furthermore, our infrastructure was designed in general around these same concerns.

Food distribution: supermarkets. Probably the most massive shift across the globe in terms of food supply in the last decade or two was the rise of supermarkets in all countries of the globe. Reardon and other economists have been documenting these shifts(Reference Minten and Reardon120Reference Reardon and Berdegué126). Essentially they have shown that across all of Latin America, over 80% of all expenditures on food in cash and kind goes today for food purchased in supermarkets, that these changes have increased exponentially now across urban areas in Africa, all of the Middle East and most of Asia and the Caribbean and the Pacific.

There are many benefits: a safer food supply solving the cold chain for dairy and all meats, poultry, fish/seafood and produce. The costs are cheaper and the access to a ready to purchase food supply is much better. But there are costs: oils, highly processed, salty, sweet and fatty foods are cheaper and more plentiful. We do not understand yet the implications of these shifts as little has been done and the literature is anecdotal except for one cross-sectional paper(Reference Asfaw127).

Marketing, media. One of the least discussed and least understood areas of change affecting dietary and physical activity patterns is the role of the modern mass media in the low- and middle-income world(128). Throughout the developing world, there was a profound increase in the ownership of television (TV) sets, cell phones, computers and the penetration of modern media into the lives of all individuals. This was accompanied by a proliferation of modern magazines and ready access to DVDs of Western movies. Apart from higher-income countries, there is little documentation of the health effects of these changes. Examples from China are used to illustrate this set of changes. Many scholars accuse TV viewing as being directly responsible for child obesity, due both to its effect on energy expenditure as well as to the direct marketing of food on the TV and increased snacking(Reference Jackson, Djafarian and Stewart129, Reference Robinson130). This remains to be studied in most developing countries in a rigorous causal manner. Similar increases in television ownership and viewership are noted throughout the developing world.

TV set ownership and modern TV programming are recent phenomena in China. In China, less than two-thirds (63%) of households owned a TV in 1989, and most (49%) owned a black and white set. By 2006, more than 99% of Chinese households owned a TV, with most (85%) owning a colour set.

Programming and advertisements were rapidly shifting towards more modern and Western content. For instance, the first TV advertisements began with one advertisement in 1979 on a Shanghai TV station and only began in earnest with a large increase in the 1990s. Today, China is considered the world's fastest-growing advertising market(Reference Weber131).

Speed of change. We do not fully understand the role of each of these broad changes on the transformation of eating and movement. However, what is clear is the dietary changes that have occurred in a few countries like China in just a few years match earlier changes that occurred in Japan or South Korea in a decade or more(Reference Popkin, Lu and Zhai87). It took coca cola more than a century to achieve worldwide penetration of its products, whereas Red Bull did the same in 5 years. Today similar newly introduced products reach global markets much faster(Reference Popkin13).

Body composition dynamics

Prevalence of overweight and obesity

There are over twenty larger countries with half of the adults overweight and obese and a large number of smaller islands that also fit in this category. At the upper level of overweight and obesity are the UK, Australia and the USA among high-income countries and Mexico, Egypt and South Africa among lower- and middle-income countries. Elsewhere I have provided detailed maps and data on overall patterns of overweight across the globe based on nationally representative samples(Reference Popkin13, Reference Popkin132Reference Ng, Jones-Smith and Popkin136).

In the past, it has always been shown that the USA had the largest proportion of adults at the very high end with BMI above 40. This is changing. In a recent paper, I have shown that both Australian and UK women are shifting upwards the 95th centile mean BMI such that soon they will equal the USA(Reference Popkin132). In Figs. 1 and 2, we present the basic data for the UK and then the differences between the USA, Australia and the UK.

Fig. 1. Trends in the BMI level at the 95th centile in the UK.

Fig. 2. The shift in BMI levels at the 95th centile for females aged 30.

Fig. 1 provides the three nationally representative surveys used for adults and the two available for children that had weight, height and demographic data. The National Heights and Weight Survey, 1980; The Dietary and Nutritional Survey of British, 1986–1987; The Health Survey for England, 1995 and 2003; The National Diet and Nutrition Survey: Adults aged 19–64 years, 2000–2001 were utilized. All the surveys were national representative, with multi-stage stratified random samples. In the survey of 1995 and 2003, data of children were available(Reference Stamatakis, Primatesta and Chinn137). The quantile regressions used to create at the 95th centile these age patterns are described in detail elsewhere (Reference Popkin132). What we have found in the 1995–2003 period is a much greater increase in BMI for younger adult women than older ones in the UK.

In Fig. 2, we compare for the age of 30 the BMI across four countries. Among adults women display higher BMI levels for the 95th centile. Although the US women show much higher levels, the increase in the 1988–2006 18-year period in the 95th centile BMI level was only 2·7 BMI units for women aged 30. In contrast, the increases over much shorter periods in Australia of 1989–2000 11-year period (32·3–37·7) and the UK of 1995–2003 8-year period (34·0–37·5) were greater. Men in the UK did not display major increases in the 95th centile BMI.

Trends

It is very hard to create a clear picture of trends in child and adult overweight. A few countries have repeated nationally representative samples of all individuals aged 2 years and older where weight, height, age and date of birth are collected. The largest concentration of such surveys are for women of child-bearing age in the Demographic and Health Surveys of Demographic and Health Survey-Measure(Reference Mendez, Monteiro and Popkin133). We have also obtained for a number of lower- and higher-income countries nationally representative surveys of weight and height(Reference Popkin, Conde and Hou134). We have two papers under review on this topic(Reference Jones-Smith, Gordon-Larsen and Siddiqi135, Reference Ng, Jones-Smith and Popkin136):

  1. 1. Across the low- and middle-income world adult overweight prevalence is growing by about 0·9–1·4 percentage points per year.

  2. 2. Across higher-income countries, the rate of growth for adults in overweight and obesity population prevalence points is about 0·8–1·0.

  3. 3. Across all countries, the rate of increase for child overweight and obesity using International Obesity Task Force standards is about 0·4–0·7 percentage points per year.

This means that we are seeing an increase in absolute numbers of a minimum of 67 million individuals each year right now. This is based on about 2·47 billion children and 5·4 billion adults in the world.

Shifts by social class

The general thinking for many years was that the burden of obesity and all other chronic diseases in higher-income countries was greater for low-income and low-education individuals, whereas for developing countries, it was the opposite, the rich bore the brunt of obesity(Reference Sobal and Stunkard138). For low- and middle-income countries, this assertion was based on very little data. In the past decade, with many nationally representative cross-sectional surveys available for women and a few for men, more systematic research has taken place among both higher- and lower-income countries. The pattern for lower-income countries is becoming clearer with the burden shifting for women to the lower socio-economic status groups but not for men(Reference Monteiro, Conde and Lu139Reference Monteiro, Conde and Popkin141). At the same time, in higher-income countries, in some cases the gap between rich and poor has widened and in others narrowed. Furthermore, these patterns do not hold for children and adolescents.

How do we proceed?

There are two global models for countries to take on the global obesity burden. One focuses on societal changes and the other on individual changes. I believe the UK is a global leader in the former approach and compare and contrast that with the US approach.

The UK and its Sociological Perspective. Although in the UK obesity prevention programmes of a large array have existed for a long time, the Foresight Obesity Project represented a milestone in national systematic efforts to produce a sustainable response to obesity(Reference King5Reference McPherson, Marsh and Brown7). This systematic government effort began with quantitative modelling of the growth of obesity, the economic effect of this and the effect on the national health system(142). It then created a fairly complex systems-map of the causes of energy imbalance which laid out societal as well as individual causes of food consumption and activity. Out of this came a broad examination of all potential leverage points with weighting of the causal linkages. Of course, the new UK government might undo some of the initiatives underway with the previous government and move to a less confrontational more cooperative approach to the food and beverage industry.

Similar efforts were undertaken by the Institute of Medicine and others. The major difference was that the Foresight project was a government initiative and led directly to a vast dialogue with all the major stakeholders and policy-makers in the UK. A strong case was made for environmental changes necessary to support individual change. They created a goal of being the first major nation to reverse the rising tide of obesity. They also focused attention and action on the environmental causes.

While there is extensive decentralization in the UK and some efforts have only taken place in England, there were also systematic efforts underway across the entire UK. Actions taken provide some sense of the process and, significantly, funding that went with all activities and actions:

  1. 1. Vending machines banned in schools and drinking water promoted; schools record annual assessments of all activities and changes.

  2. 2. Advertisers banned from advertising to children and banned from advertising unhealthy foods in media.

  3. 3. Children aged 6 to 8 years are required to receive weekly cooking classes to learn about food, its preparation and handling.

  4. 4. Government accountability created across all agencies.

  5. 5. Set of initiatives and coalitions created, focused on Change4Life, Coalition for Better Health and the Healthy Food Code (e.g. traffic light system).

  6. 6. Power to restrict fast-food restaurants near schools and parks.

  7. 7. Project to provide fresh fruits and vegetables to small stores in deprived areas.

  8. 8. Putting in systematic surveillance and monitoring.

There were just so many more actions related to children. These began with midwife and nursery training, school workforce and nurse training, parent support advisers, training of school caterers, an array of people linked to supporting youth activity in and out of the schools, and many private sector activities. They continue to study causes and solutions and remain most active in addressing obesity across the life cycle. They did not see this as one action but a long series of actions, evaluations, studies and new actions.

United States and its Psychological Perspective. The Institute of Medicine and many others have discussed similar causal networks. Members of Congress have discussed the needs to regulate beverages and vending in the schools, and many other issues have been discussed. However, there has been no systematic approach that involves any environmental changes on any major levels. To date, here are some of the US actions:

  1. 1. Dozens of states have mandated more physical education classes, but only a few have provided funding (e.g. the state of Illinois has created fully funded mandates).

  2. 2. Neither state nor federal government has banned vending and promoted water.

  3. 3. No national or other media bans or controls exist as they relate to children.

  4. 4. Minimal federal funding has been linked with improved school nutrition.

  5. 5. A number of state and local governments have implemented subsidies to provide supermarkets to food deserts (namely communities with limited access to affordable, healthy food); however, the research backing these activities is limited.

  6. 6. One or two municipalities have supported providing education and improved facilities and food supplies to food stores in poor areas.

  7. 7. Sustainable agriculture, promoted by upper-class intellectuals, has led to major funding for an unproven area of fresh open farmers markets for the poor; the government has jumped into this also.

Many US actions were based on politics without proven success, others were taken and done with minimal funding, and there is no systematic attack on any age group or across the life cycle. On the other hand, the media has repeatedly reported on a few issues such as sugar-sweetened beverages and the beverage industry has shifted to marketing ‘healthy function sugar-sweetened waters, etc.,’ as well as juices to counter this. Again unlike the systematic banning of vending in schools in the UK, even the US Institute of Medicine reports and analyses focus on allowing some sugary beverages but just limiting them.

Finally, the environment in the USA has not changed amid a decade of discussion about child obesity; only rather small, unsystematic efforts have been established. This campaign is unlike decades of work which got the USA to see seat belt regulations, fluoridation and tobacco prevention solutions as societal issues that require regulations, taxes and very systematic efforts(Reference Brownell and Warner143). Michelle Obama is leading an effort to place greater emphasis on prevention of child obesity; however, all efforts are based on a model of cooperation with minimal focus on legislative and other larger-scale regulatory options. The author feels if history taught us any lessons from some of these successful public health campaigns, a combination of taxation, regulation and norm changes are needed to successfully address the issue of obesity prevention in the modern world.

Acknowledgements

This work was supported by the National Institute of Child Health and Human Development at the National Institutes of Health (R01-HD30880, DK056350 and R01-HD38700). The author thanks Frances Dancy for administrative support. The author declares no conflicts of interest.

References

1.Monda, KL, Adair, LS & Zhai, F (2007) Longitudinal relationships between occupational and domestic physical activity patterns and body weight in China. Eur J Clin Nutr 62, 13181325.CrossRefGoogle ScholarPubMed
2.Bell, AC, Ge, K & Popkin, BM (2001) Weight gain and its predictors in Chinese adults. Int J Obes Relat Metab Disord 25, 10791086.CrossRefGoogle ScholarPubMed
3.Bell, AC, Ge, K & Popkin, BM (2002) The road to obesity or the path to prevention: motorized transportation and obesity in China. Obes Res 10, 277283.CrossRefGoogle ScholarPubMed
4.Ng, SW, Norton, EC & Popkin, BM (2009) Why have physical activity levels declined among Chinese adults? Findings from the 1991–2006 China health and nutrition surveys. Soc Sci Med 68, 13051314.CrossRefGoogle ScholarPubMed
5.King, D (2007) Foresight report on obesity. Lancet 370, 1754; author reply 1754.CrossRefGoogle ScholarPubMed
6.Kopelman, P (2009) Symposium 1: Overnutrition: consequences and solutions Foresight Report: the obesity challenge ahead. Proc Nutr Soc 69(1), 8085.CrossRefGoogle ScholarPubMed
7.McPherson, K, Marsh, T & Brown, M (2007) Foresight report on obesity. Lancet 370, 1755; author reply 1755.CrossRefGoogle ScholarPubMed
8.Institute of Medicine, National Research Council (2009) The Public Health Effects of Food Deserts: Workshop Summary. Washington, DC: Institute of Medicine, National Research Council.Google Scholar
9.American Time Use Survey (2008). Percent of the Population Engaging in Selected Activities by Time of Day. Washington DC: Bureau of Labor Statistics.Google Scholar
10.Monteiro, CA, Gomes, FS & Cannon, G (2010) The snack attack. Am J Public Health 100, 975981.CrossRefGoogle ScholarPubMed
11.Kearney, PM, Whelton, M & Reynolds, K (2005) Global burden of hypertension: analysis of worldwide data. Lancet 365, 217223.CrossRefGoogle ScholarPubMed
12.WCRF/AICR (2007) Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington, DC: World Cancer Research Fund/American Institute for Cancer Research.Google Scholar
13.Popkin, BM (2008) The World Is Fat – The Fads, Trends, Policies, and Products That Are Fattening the Human Race. New York: Avery-Penguin Group.Google Scholar
14.Monteiro, CA (2009) Nutrition and Health. The issue is not food, nor nutrients, so much as processing. Public Health Nutr 12, 729731.CrossRefGoogle Scholar
15.Popkin, BM, D'Anci, KE & Rosenberg, IH (2010) Water, hydration and health. Nutr Rev 68, 439458.CrossRefGoogle ScholarPubMed
16.Popkin, BM & Nielsen, SJ (2003) The sweetening of the world's diet. Obes Res 11, 13251332.CrossRefGoogle ScholarPubMed
17.Popkin, BM (2006) Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. Am J Clin Nutr 84, 289298.CrossRefGoogle Scholar
18.Wolf, A, Bray, GA & Popkin, BM (2008) A short history of beverages and how our body treats them. Obes Rev 9, 151164.CrossRefGoogle Scholar
19.Mourao, D, Bressan, J & Campbell, W (2007) Effects of food form on appetite and energy intake in lean and obese young adults. Int J Obes (Lond) 31, 16881695.CrossRefGoogle ScholarPubMed
20.Mattes, R (2006) Fluid calories and energy balance: the good, the bad, and the uncertain. Physiol Behav 89, 6670.CrossRefGoogle ScholarPubMed
21.DiMeglio, DP & Mattes, RD (2000) Liquid versus solid carbohydrate: effects on food intake and body weight. Int J Obes Relat Metab Disord 24, 794800.CrossRefGoogle ScholarPubMed
22.Mattes, R (1996) Dietary compensation by humans for supplemental energy provided as ethanol or carbohydrate in fluids. Physiol Behav 59, 179187.CrossRefGoogle ScholarPubMed
23.Raben, A, Vasilaras, TH & Moller, AC (2002) Sucrose compared with artificial sweeteners: different effects on ad libitum food intake and body weight after 10 wk of supplementation in overweight subjects. Am J Clin Nutr 76, 721729.CrossRefGoogle ScholarPubMed
24.De Castro, J (1993) The effects of the spontaneous ingestion of particular foods or beverages on the meal pattern and overall nutrient intake of humans. Physiol Behav 53, 11331144.CrossRefGoogle ScholarPubMed
25.Van Wymelbeke, V, Beridot-Therond, ME & de La Gueronniere, V (2004) Influence of repeated consumption of beverages containing sucrose or intense sweeteners on food intake. Eur J Clin Nutr 58, 154161.CrossRefGoogle ScholarPubMed
26.Lavin, JH, French, SJ & Ruxton, CH (2002) An investigation of the role of oro-sensory stimulation in sugar satiety? Int J Obes Relat Metab Disord 26, 384388.CrossRefGoogle ScholarPubMed
27.Hagg, A, Jacobson, T & Nordlund, G (1998) Effects of milk or water on lunch intake in preschool children. Appetite 31, 8392.CrossRefGoogle ScholarPubMed
28.Beridot-Therond, ME, Arts, I & Fantino, M (1998) Short-term effects of the flavour of drinks on ingestive behaviours in man. Appetite 31, 6781.CrossRefGoogle ScholarPubMed
29.Poppitt, SD, Eckhardt, JW & McGonagle, J (1996) Short-term effects of alcohol consumption on appetite and energy intake. Physiol Behav 60, 10631070.CrossRefGoogle ScholarPubMed
30.DellaValle, DM, Roe, LS & Rolls, BJ (2005) Does the consumption of caloric and non-caloric beverages with a meal affect energy intake? Appetite 44, 187193.CrossRefGoogle ScholarPubMed
31.Tordoff, MG & Alleva, AM (1990) Effect of drinking soda sweetened with aspartame or high-fructose corn syrup on food intake and body weight. Am J Clin Nutr 51, 963969.CrossRefGoogle ScholarPubMed
32.Flood, J, Roe, L & Rolls, B (2006) The effect of increased beverage portion size on energy intake at a meal. J Am Diet Assoc 106, 19841990.CrossRefGoogle ScholarPubMed
33.Mattes, RD (2006) Fluid energy-where's the problem? J Am Diet Assoc 106, 19561961.CrossRefGoogle ScholarPubMed
34.Yeomans, MR (2010) Alcohol, appetite and energy balance: is alcohol intake a risk factor for obesity? Physiol Behav 100, 8289.CrossRefGoogle ScholarPubMed
35.Vartanian, L, Schwartz, M & Brownell, K (2007) Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. Am J Public Health 97, 667675.CrossRefGoogle ScholarPubMed
36.Ebbeling, CB, Feldman, HA & Osganian, SK (2006) Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatric 117, 673680.CrossRefGoogle ScholarPubMed
37.Malik, VS, Schulze, MB & Hu, FB (2006) Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 84, 274288.CrossRefGoogle ScholarPubMed
38.Malik, VS, Popkin, BM, Bray, GA et al. ( 2010) Sugar sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care (In the Press).CrossRefGoogle ScholarPubMed
39.Lesser, LI, Ebbeling, CB & Goozner, M (2007) Relationship between funding source and conclusion among nutrition-related scientific articles. PLoS Med 4, e5.CrossRefGoogle ScholarPubMed
40.Brownell, K, Farley, T & Willett, W (2009) The public health and revenue generating benefits of taxing sugar sweetened beverages. New Engl J Med 360, 18051808.CrossRefGoogle Scholar
41.Popkin, BM, Ng, SW, Mhurchu, CN & Jebb, S (2010) Beverage Patterns and Trends in the United Kingdom. Chapel Hill, NC: University of North Carolina.Google Scholar
42.Barquera, S, Hernández, L & Tolentino, ML (2008) Energy from beverages is on the rise among Mexican adolescents and adults. J Nutr 138, 24542461.CrossRefGoogle ScholarPubMed
43.Rivera, JA M-HO, Rosas-Peralta, M, Aguilar-Salinas, CA, Popkin, BM & Willett, WC (2008) Consumo de bebidas y prevención de la obesidad. Salud Publica Mex 50, 173195.CrossRefGoogle Scholar
44.Sanigorski, AM, Bell, AC & Swinburn, BA (2007) Association of key foods and beverages with obesity in Australian schoolchildren. Public Health Nutr 10, 152157.CrossRefGoogle ScholarPubMed
45.Muckelbauer, R, Libuda, L & Clausen, K (2009) Promotion and provision of drinking water in schools for overweight prevention: randomized, controlled cluster trial. Pediatric 123, e661e667.CrossRefGoogle ScholarPubMed
46Barquera, S, Campirano, F & Bonvecchio, A et al. ( 2010) Caloric beverage consumption patterns in Mexican children. J Nutr (In the Press).CrossRefGoogle ScholarPubMed
47.Barquera, S, Hernandez-Barrera, L & Tolentino, ML (2008) Energy intake from beverages is increasing among Mexican adolescents and adults. J Nutr 138, 24542461.CrossRefGoogle ScholarPubMed
48.Duffey, K & Popkin, BM (2007) Shifts in patterns and consumption of beverages between 1965 and 2002. Obesity 15, 27392747.CrossRefGoogle ScholarPubMed
49.Slining, M & Popkin, BM (2010) How do we determine and measure junk foods (Foods with minimal nutritional value)? Carolina Population Center, University of North Carolina, unpublished manuscript.Google Scholar
50.Delgado, CL (2003) Rising consumption of meat and milk in developing countries has created a new food revolution. J Nutr 133, 3907S3910S.CrossRefGoogle ScholarPubMed
51.Delgado, CL, Rosegrant, MW & Meijer, S (2001) Livestock to 2020: the revolution continues. Paper presented at the Annual Meetings of the International Agricultural Trade Research Consortium (IATRC), 18–19 January 2001, Auckland, New Zealand.Google Scholar
52.Gardner, BL (2002) American Agriculture in the Twentieth Century: How it Flourished and What it Cost. Cambridge, MA: Harvard University Press.Google Scholar
53.Starmer, E, Witteman, A & Wise, TA (2006) Feeding the Factory Farm: Implicit Subsidies to the Broiler Chicken Industry. GDAE Working Paper 2006 [cited 12 March 2007]. Available from: http://ideas.repec.org/p/dae/daepap/06-03.htmlGoogle Scholar
54.Guo, X, Popkin, BM & Mroz, TA (1999) Food price policy can favorably alter macronutrient intake in China. J Nutr 129, 994–1001.CrossRefGoogle ScholarPubMed
55.Guo, XG, Mroz, TA & Popkin, BM (2000) Structural change in the impact of income on food consumption in China, 1989–1993. Econ Dev Cult Change 48, 737760.CrossRefGoogle Scholar
56.Du, S, Mroz, TA & Zhai, F (2004) Rapid income growth adversely affects diet quality in China–particularly for the poor! Soc Sci Med 59, 15051515.CrossRefGoogle ScholarPubMed
57.Elliott, P & Brown, I (2006) Sodium intakes around the world: background. Document prepared for the Forum and Technical Meeting on Reducing Salt Intake in Populations, Paris.Google Scholar
58.He, FJ & MacGregor, GA (2009) A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 23, 363384.CrossRefGoogle ScholarPubMed
59.Bibbins-Domingo, K, Chertow, GM & Coxson, PG (2010) Projected effect of dietary salt reductions on future cardiovascular disease. N Engl J Med 362, 590599.CrossRefGoogle ScholarPubMed
60.Institute of Medicine Food and Nutrition Board (2010) Strategies to Reduce Sodium Intake in the United States. Washington, DC: National Academy Press.Google Scholar
61.Geerling, JC & Loewy, AD (2008) Central regulation of sodium appetite. Exp Physiol 93, 177209.CrossRefGoogle ScholarPubMed
62.Mattes, RD (1997) The taste for salt in humans. Am J Clin Nutr 65, 692S697S.CrossRefGoogle ScholarPubMed
63.The China Salt Substitute Study Collaborative Group (2007) Salt substitution: a low-cost strategy for blood pressure control among rural Chinese. A randomized, controlled trial. J Hypertens 25, 20112018.CrossRefGoogle Scholar
64.Meneton, P, Jeunemaitre, X & de Wardener, HE (2005) Links between dietary salt intake, renal salt handling, blood pressure, and cardiovascular diseases. Physiol Rev 85, 679715.CrossRefGoogle ScholarPubMed
65.Beauchamp, GK & Moran, M (1984) Acceptance of sweet and salty tastes in 2-year-old children. Appetite 5, 291305.CrossRefGoogle ScholarPubMed
66.Desor, JGL & Maller, O (1975) Preferences for sweet and salty in 9- to 15-year-old and adult humans. Science 190, 686687.CrossRefGoogle ScholarPubMed
67.Contreras, RJ (1983) Salt appetite. Science 219, 1419.CrossRefGoogle ScholarPubMed
68.Sakai, RR (2004) The future of research on thirst and salt appetite. Appetite 42, 1519.CrossRefGoogle ScholarPubMed
69.Gibson, S (2008) Salt intake is related to soft drink consumption in children and adolescents: a link to obesity? Hypertension 51, e54; author reply e55.CrossRefGoogle ScholarPubMed
70.He, FJ, Marrero, NM & MacGregor, GA (2008) Salt intake is related to soft drink consumption in children and adolescents: a link to obesity? Hypertension 51, 629634.CrossRefGoogle ScholarPubMed
71.He, K, Zhao, L & Daviglus, ML (2008) Association of monosodium glutamate intake with overweight in Chinese adults: the INTERMAP Study. Obesity (Silver Spring) 16, 18751880.CrossRefGoogle ScholarPubMed
72.Cox, DN, Perry, L & Moore, PB (1999) Sensory and hedonic associations with macronutrient and energy intakes of lean and obese consumers. Int J Obes Relat Metab Disord 23, 403410.CrossRefGoogle ScholarPubMed
73.Maffeis, C, Grezzani, A & Perrone, L (2008) Could the savory taste of snacks be a further risk factor for overweight in children? J Pediatr Gastroenterol Nutr 46, 429437.CrossRefGoogle ScholarPubMed
74.Bellisle, F, Monneuse, MO & Chabert, M (1991) Monosodium glutamate as a palatability enhancer in the European diet. Physiol Behav 49, 869873.CrossRefGoogle ScholarPubMed
75.Beauchamp, GK, Bertino, M & Engelman, K (1987) Failure to compensate decreased dietary sodium with increased table salt usage. JAMA 258, 32753278.CrossRefGoogle ScholarPubMed
76.Piernas, C & Popkin, BM (2010) Trends in snacking among U.S. children. Health Affairs 29, 398404.CrossRefGoogle ScholarPubMed
77.Piernas, C & Popkin, BM (2010) Snacking increased among U.S. adults between 1977 and 2006. J Nutr 140, 325332.CrossRefGoogle ScholarPubMed
78.Caputo, FA & Mattes, RD (1993) Human dietary responses to perceived manipulation of fat content in a midday meal. Int J Obes Relat Metab Disord 17, 237240.Google Scholar
79.Mattes, RD (2005) Fat taste and lipid metabolism in humans. Physiol Behav 86, 691697.CrossRefGoogle ScholarPubMed
80.Lermer, CM & Mattes, RD (1999) Perception of dietary fat: ingestive and metabolic implications. Prog Lipid Res 38, 117128.CrossRefGoogle ScholarPubMed
81.Mattes, RD (1996) Oral fat exposure alters postprandial lipid metabolism in humans. Am J Clin Nutr 63, 911917.Google ScholarPubMed
82.Drewnowski, A (1989) Sensory preferences for fat and sugar in adolescence and adult life. Ann NY Acad Sci 561, 243250.CrossRefGoogle ScholarPubMed
83.Drewnowski, A, Kurth, CL & Rahaim, JE (1991) Taste preferences in human obesity: environmental and familial factors. Am J Clin Nutr 54, 635641.CrossRefGoogle ScholarPubMed
84.Drewnowski, A, Krahn, D & Demitrack, M (1992) Taste responses and preferences for sweet high-fat foods: evidence for opioid involvement. Physiol Behav 51, 371379.CrossRefGoogle ScholarPubMed
85.Popkin, B & Drewnowski, A (1997) Dietary fats and the nutrition transition: new trends in the global diet. Nutr Rev 55, 3143.Google Scholar
86.Drewnowski, A & Popkin, BM (1997) The nutrition transition: new trends in the global diet. Nutr Rev 55, 3143.CrossRefGoogle ScholarPubMed
87.Popkin, BM, Lu, B & Zhai, F (2002) Understanding the nutrition transition: measuring rapid dietary changes in transitional countries. Public Health Nutr 5, 947953.CrossRefGoogle ScholarPubMed
88.Popkin, BM (2009) Global changes in diet and activity patterns as drivers of the nutrition transition. Nestle Nutr Workshop Ser Pediatr Program 63, 110; discussion 10–14, 259–268.CrossRefGoogle ScholarPubMed
89.Wang, Z, Zhai, F & Du, S (2008) Dynamic shifts in Chinese eating behaviors. Asia Pac J Clin Nutr 17, 123130.Google ScholarPubMed
90.Popkin, BM, Keyou, G & Zhai, F (1993) The nutrition transition in China: a cross-sectional analysis. Eur J Clin Nutr 47, 333346.Google Scholar
91.Du, S, Lu, B & Zhai, F (2002) A new stage of the nutrition transition in China. Public Health Nutr 5, 169174.CrossRefGoogle ScholarPubMed
92.Du, S, Lu, B & Zhai, F (2002) The nutrition transition in China: a new stage of the Chinese diet. In The Nutrition Transition: Diet and Disease in the Developing World, pp. 205222 [Caballero, B and Popkin, B, editors]. London: Academic Press.CrossRefGoogle Scholar
93.Popkin, BM, Horton, S & Kim, S (2001) The nutrition transition and prevention of diet-related chronic diseases in Asia and the Pacific. Food Nutr Bull 22, 158.Google Scholar
94.Popkin, BM, Horton, S & Kim, S (2001) Trends in diet, nutritional status, and diet-related noncommunicable diseases in China and India: the economic costs of the nutrition transition. Nutr Rev 59, 379390.CrossRefGoogle Scholar
95.Montonen, J, Knekt, P & Jarvinen, R (2003) Whole-grain and fiber intake and the incidence of type 2 diabetes. Am J Clin Nutr 77, 622629.CrossRefGoogle ScholarPubMed
96.Holmes, MD, Liu, S & Hankinson, SE (2004) Dietary carbohydrates, fiber, and breast cancer risk. Am J Epidemiol 159, 732739.CrossRefGoogle ScholarPubMed
97.Pereira, MA, O'Reilly, E & Augustsson, K (2004) Dietary fiber and risk of coronary heart disease: a pooled analysis of cohort studies. Arch Intern Med 164, 370376.CrossRefGoogle ScholarPubMed
98.Schulze, MB, Liu, S & Rimm, EB (2004) Glycemic index, glycemic load, and dietary fiber intake and incidence of type 2 diabetes in younger and middle-aged women. Am J Clin Nutr 80, 348356.CrossRefGoogle ScholarPubMed
99.Burkitt, DP (1973) Some diseases characteristic of modern Western civilization. Br Med J 1, 274278.CrossRefGoogle ScholarPubMed
100.Liu, S, Manson, JE & Stampfer, MJ (2000) Whole grain consumption and risk of ischemic stroke in women: A prospective study. JAMA 284, 15341540.CrossRefGoogle ScholarPubMed
101.Jacobs, DR Jr & Gallaher, DD (2004) Whole grain intake and cardiovascular disease: a review. Curr Atheroscler Rep 6, 415423.CrossRefGoogle ScholarPubMed
102.Bellisle, F & Le Magnen, J (1981) The structure of meals in humans: eating and drinking patterns in lean and obese subjects. Physiol Behav 27, 649658.CrossRefGoogle ScholarPubMed
103.Bellisle, F, McDevitt, R & Prentice, AM (1997) Meal frequency and energy balance. Br J Nutr 77 Suppl 1, S57–70.CrossRefGoogle ScholarPubMed
104.Carlson, O, Martin, B & Stote, KS (2007) Impact of reduced meal frequency without caloric restriction on glucose regulation in healthy, normal-weight middle-aged men and women. Metabolism 56, 17291734.CrossRefGoogle ScholarPubMed
105.Solomon, T, Chambers, E & Jeukendrup, A (2008) The effect of feeding frequency on insulin and ghrelin responses in human subjects. Br J Nutr 100, 810819.CrossRefGoogle ScholarPubMed
106.Kerver, JM, Yang, EJ & Obayashi, S (2006) Meal and snack patterns are associated with dietary intake of energy and nutrients in US adults. J Am Diet Assoc 106, 4653.CrossRefGoogle ScholarPubMed
107.Kant, AK, Schatzkin, A & Graubard, BI (1995) Frequency of eating occasions and weight change in the NHANES I epidemiologic follow-up study. Int J Obes Relat Metab Disord 19, 468474.Google ScholarPubMed
108.Ma, Y, Bertone, ER & Stanek, EJ III (2003) Association between eating patterns and obesity in a free-living US adult population. Am J Epidemiol 158, 8592.CrossRefGoogle Scholar
109.Farshchi, HR, Taylor, MA & Macdonald, IA (2005) Beneficial metabolic effects of regular meal frequency on dietary thermogenesis, insulin sensitivity, and fasting lipid profiles in healthy obese women. Am J Clin Nutr 81, 1624.CrossRefGoogle ScholarPubMed
110.Heilbronn, LK, Smith, SR & Martin, CK (2005) Alternate-day fasting in nonobese subjects: effects on body weight, body composition, and energy metabolism. Am J Clin Nutr 81, 6973.CrossRefGoogle ScholarPubMed
111.Jenkins, DJ, Ocana, A & Jenkins, AL (1992) Metabolic advantages of spreading the nutrient load: effects of increased meal frequency in non-insulin-dependent diabetes. Am J Clin Nutr 55, 461467.CrossRefGoogle ScholarPubMed
112.Jenkins, DJ, Wolever, TM & Vuksan, V (1989) Nibbling versus gorging: metabolic advantages of increased meal frequency. N Engl J Med 321, 929934.CrossRefGoogle ScholarPubMed
113.Popkin, BM & Duffey, KJ (2010) Does hunger and satiety drive eating anymore? Increasing eating occasions and decreasing time between eating occasions in the United States. Am J Clin Nutr 91, 13421347.CrossRefGoogle ScholarPubMed
114.Wansink, B (2006) Mindless Eating – Why We Eat More Than We Think. New York: Bantam-Dell.Google Scholar
115.Wansink, B (2007) Snack attack? Don't be tricked by low fat labels It's easy to overeat when you think treats are ‘good’ for you [cited 9 March]. Available from: http://www.msnbc.msn.com/id/17469445/Google Scholar
116.Wang, Z, Zhai, F & Du, S (2010) Snacking trends in China (In the Press).Google Scholar
117.Wang, Z, Zhai, F & Shufa, D (2008) Dynamic shifts in Chinese eating behaviors. Asia Pac J Clin Nutr 17, 123130.Google ScholarPubMed
118.Popkin, BM (2006) Technology, transport, globalization and the nutrition transition. Food Policy 31, 554569.CrossRefGoogle Scholar
119.Popkin, BM & Ng SW (2008) The nutrition transition in high and low-income countries: what are the policy lessons? In Contributions of Agricultural Economics to Critical Policy Issues, pp. 199212 [Otsuka, K and Kalirajan, K, editors]. Malden, MA and Oxford, UK: Blackwell Synergy.Google Scholar
120.Minten, B & Reardon, T (2008) Food prices, quality, and quality's pricing in supermarkets versus traditional markets in developing countries. Appl Econ Perspect Policy 30, 480490.Google Scholar
121.Stunkard, AJ, Allison, KC & O'Reardon, JP (2005) The night eating syndrome: a progress report. Appetite 45, 182186.CrossRefGoogle ScholarPubMed
122.Reardon, T, Timmer, P & Berdegue, J (2004) The rapid rise of supermarkets in developing countries: induced organizational, institutional, and technological change in agrifood systems. Electron J Agr Dev Econ 1, 168183.Google Scholar
123.Hu, D, Reardon, T & Rozelle, S (2004) The emergence of supermarkets with Chinese characteristics: challenges and opportunities for China's agricultural development. Dev Policy Rev 22, 557586.CrossRefGoogle Scholar
124.Reardon, T, Timmer, CP & Barrett, CB (2003) The rise of supermarkets in Africa, Asia, and Latin America. Am J Agr Econ 85, 11401146.CrossRefGoogle Scholar
125.Balsevich, F, Berdegue, JA & Flores, L (2003) Supermarkets and produce quality and safety standards in Latin America. Am J Agr Econ 85, 11471154.CrossRefGoogle Scholar
126.Reardon, T & Berdegué, J (2002) The rapid rise of supermarkets in Latin America: challenges and opportunities for development. Dev Policy Rev 20, 371388.CrossRefGoogle Scholar
127.Asfaw, A (2007) Supermarket Expansion and the Dietary Practices of Households: Some Empirical Evidence from Guatemala. Washington, DC: International Food Policy Research Institute.Google Scholar
128.International Broadcasting Audience Research (2004) World Radio and Television Receivers International Broadcasting Audience Research Library. London: BBC World Service.Google Scholar
129.Jackson, DM, Djafarian, K & Stewart, J (2009) Increased television viewing is associated with elevated body fatness but not with lower total energy expenditure in children. Am J Clin Nutr 89, 10311036.CrossRefGoogle Scholar
130.Robinson, TN (2001) Television viewing and childhood obesity. Pediatr Clin North Am 48, 10171025.CrossRefGoogle ScholarPubMed
131.Weber, IG (2000) Challenges facing China's television advertising industry in the age of spiritual civilization: an industry analysis. Int J Advert, 259281.CrossRefGoogle Scholar
132.Popkin, BM (2010) Recent dynamics suggest selected countries catching up to US obesity. Am J Clin Nutr 91, 284S288S.CrossRefGoogle ScholarPubMed
133.Mendez, MA, Monteiro, CA & Popkin, BM (2005) Overweight exceeds underweight among women in most developing countries. Am J Clin Nutr 81, 714721.CrossRefGoogle ScholarPubMed
134.Popkin, BM, Conde, W & Hou, N (2006) Is there a lag globally in overweight trends for children compared with adults? Obesity (Silver Spring) 14, 18461853.CrossRefGoogle Scholar
135.Jones-Smith, J, Gordon-Larsen, P & Siddiqi, A (2010) Is the burden of overweight shifting to the poor across the globe? Time trends among women in 41 low- and middle-income countries (1991–2007). Carolina Population Center, University of North Carolina, unpublished manuscript.Google Scholar
136.Ng, SW, Jones-Smith, J & Popkin, BM (2010) Rising global obesity is reaching the rural areas quickly: a 43-country time trends study. Carolina Population Center, University of North Carolina, unpublished manuscript.Google Scholar
137.Stamatakis, E, Primatesta, P & Chinn, S (2005) Overweight and obesity trends from 1974 to 2003 in English children: what is the role of socioeconomic factors? Arch Dis Childhood 90, 999–1004.CrossRefGoogle ScholarPubMed
138.Sobal, J & Stunkard, AJ (1989) Socioeconomic status and obesity: a review of the literature. Psychol Bull 105, 260275.CrossRefGoogle ScholarPubMed
139.Monteiro, CA, Conde, WL & Lu, B (2004) Obesity and inequities in health in the developing world. Int J Obes Relat Metabol Disord 28, 11811186.CrossRefGoogle ScholarPubMed
140.Monteiro, CA, Moura, EC & Conde, WL (2004) Socioeconomic status and obesity in adult populations of developing countries: a review. Bull World Health Org 82, 940946.Google ScholarPubMed
141.Monteiro, CA, Conde, WL & Popkin, BM (2007) Income-specific trends in obesity in Brazil: 1975–2003. Am J Public Health 97, 18081812.CrossRefGoogle ScholarPubMed
142.Foresight (2007) Tackling Obesities: Future Choices-Project Report, 2nd ed. UK Government Office for Science.Google Scholar
143.Brownell, KD & Warner, KE (2009) The perils of ignoring history: big tobacco played dirty and millions died. How similar is big food? Milbank Q 87, 259294.CrossRefGoogle ScholarPubMed
Figure 0

Fig. 1. Trends in the BMI level at the 95th centile in the UK.

Figure 1

Fig. 2. The shift in BMI levels at the 95th centile for females aged 30.