Dietary Changes Shift in the Overall Structure over Time

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The diets of the developing world are shifting equally rapidly. There are no good data for most countries on total energy intake, but there are reasonable data to examine shifts in the structure of the diet. Food balance data were used to examine the shift over time in the proportion of energy from fat.

The dramatic changes in the aggregate income-fat relationship from 1962 to 1990 are displayed in Figure 7 by the estimated regression lines based on cubic polynomial regressions. Most significantly, even the poor nations had access to a relatively high-fat diet by 1990, when a diet deriving 20% of energy (kcal) from fat was associated with countries having a GNP of only $750 per capita,

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Germany 1985-90

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Figure 3 Obesity trends among adults in the United States and Europe (the annual percentage point increase in prevalence). BMI, body mass index; F, female; M, male. (Popkin BM (2002) The shift in stages of the nutrition transition in the developing world differs from past experiences! Public Health Nutrition 5(1A): 205-214.)

whereas in 1962 the same energy diet (20% from fat) was associated with countries having a GNP of $1475 (both GNP values in 1993 dollars). This dramatic change arose from a major increase (1013%) in the consumption of vegetable fats by poor and rich nations; similar increases (3-6%) also occurred in mid- and high-income nations.

At the same time, there were decreases in the consumption of fat from animal sources for all except the low-income countries. The availability of animal fats continued to be linked to income, though less strongly in 1990 than in 1962. These decreases, combined with the increase in vegetable fat intake for all income countries, resulted in an overall decrease in fat intake for moderate-income countries of approximately 3% but an increase of approximately 4 or 5% for low- and high-income countries. Figure 7 shows these substantial shifts in the relationships between GNP and the composition of diets over time.

Vegetable fats in 1990 accounted for a greater proportion of dietary energy than animal fats for

Cuba Mexico Brazil

1982-98 1988-99 1974-96

GNP 3840 GNP 4630

Figure 4 Obesity trends among adults in Latin America (the annual percentage point increase in prevalence). BMI, body mass index; F, female; GNP, gross national product; M, male. (Data from Rodriguez-Ojea A, Jimenez, Berdasco A and Esquivel M. (2002) The nutrition transition in Cuba in the nineties: an overview. Public Health Nutrition 5(1A): 129-33. Rivera (2002) Reference: Rivera JA, Barquera S, Campirano F, Campos I, Safdie M and Tovar V. (2002) Epidemiological and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity. Public Health Nutrition 5(1A): 113-22.)

Cuba Mexico Brazil

1982-98 1988-99 1974-96

GNP 3840 GNP 4630

Figure 4 Obesity trends among adults in Latin America (the annual percentage point increase in prevalence). BMI, body mass index; F, female; GNP, gross national product; M, male. (Data from Rodriguez-Ojea A, Jimenez, Berdasco A and Esquivel M. (2002) The nutrition transition in Cuba in the nineties: an overview. Public Health Nutrition 5(1A): 129-33. Rivera (2002) Reference: Rivera JA, Barquera S, Campirano F, Campos I, Safdie M and Tovar V. (2002) Epidemiological and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity. Public Health Nutrition 5(1A): 113-22.)

Mauritius Morocco Kuwait

1987-92 1985-99 1980-93

GNP 3730 GNP 1240

Figure 5 Obesity trends among adults in North Africa/Middle East (the annual percentage point increase in prevalence). BMI, body mass index; F, female; GNP, gross national product; M, male. (Data from Benjelloun S. (2002) Nutrition transition in Morocco. Publlic Health Nutrition 5(1A): 135-40. Hodge (1996) Reference: Hodge AM, Dowse GK, Gareeboo H, Tuomilehto J, Alberti KG, Zimmet PZ. (1996) Incidence, increasing prevalence, and predictors of change in obesity and fat distribution over 5 years in the rapidly developing population of Mauritius. International Journal of Obesity 20: 137-46. Al-Isa (1995,1997) References: 1-Isa AN. (1995) Prevalance of obesity among adult Kuwaitis: a cross-sectional study. International Journal of Obesity and Related Metabolic Disorders. 19(6):431-3. A1-Isa AN. (1997) Changes in bidy mass index (BMI) and prevalance of obesity among Kuwaitis 1980-1994. International Journal of Obesity 21: 1093-9.)

countries in the lowest 75% of countries (all of which have incomes less than $5800 per capita) of the per capita income distribution. The absolute level of vegetable fat consumption increased, but there remained at most a weak association between GNP and vegetable fat intake in these aggregate data. The change in edible vegetable fat prices, supply, and consumption is unique because it equally affected rich and poor countries, but the net impact is relatively much greater on low-

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China Thailand Korea

1989-97 1991-96 1995-98

GNP 750 GNP 2160 GNP 8600

Figure 6 Obesity trends among adults in Asia (the annual percentage point increase in prevalence). BMI, body mass index; F, female; GNP, gross national product; M, male. (Data from Kosulwat V. (2002) The nutrition and health transition in Thailand. Public Health Nutrition 5(1A): 183-89. Du (2002) Reference: Du S,Lu B, Zhai F and Popkin BM. (2002) A new stage of the nutrition in China. Public Health Nutrition 5(1A): 169-74. Lee (2002) Reference: Lee M-J, Popkin BM and Kim S. (2002) The unique aspects of the nutritioin transition in South Korea: the retention of healthful elements in their traditional diet. Public Health Nutrition 5(1A): 197-203.)

GNP per capita (in constant 1993 US $'s)

Figure 7 Relationship between the percentage of energy from fat and gross national product (GNP) per capita, 1962 and 1990. (Source: Nonparametric regressions run with food balance data from FAOUN and GNP data from the World Bank for 134 countries; Guo X, Mroz TA, Popkin BM and Zhai F (2000) Structural changes in the impact of income on food consumption in China, 1989-93. Econoomic Development and Cultural Change 48: 737-60.)

GNP per capita (in constant 1993 US $'s)

Figure 7 Relationship between the percentage of energy from fat and gross national product (GNP) per capita, 1962 and 1990. (Source: Nonparametric regressions run with food balance data from FAOUN and GNP data from the World Bank for 134 countries; Guo X, Mroz TA, Popkin BM and Zhai F (2000) Structural changes in the impact of income on food consumption in China, 1989-93. Econoomic Development and Cultural Change 48: 737-60.)

income countries. Recent analysis in China shows that the pace of change for increased energy density and animal source foods in the diet has accelerated.

There is also an equally large and important shift in the proportion of energy from added caloric sweeteners in the diets of lower income countries. In fact, an additional 100-200 kcal per day was available for daily consumption from added caloric sweeteners in the diet in 2000 compared to 1962 in the developing world. In the United States, this added caloric sweetener increase derives mainly from soft drinks and fruit drinks, but in many other countries the source of this increase is other foods, even basic processed foods that have sweeteners added to them. Increasingly, high-fructose corn syrup is used as the sweetener of choice. This is unfortunate because there are mechanisms by which glucose may limit intake, but not fructose.

When we specifically examine the combined effect of these various shifts in the structure of rural and urban Chinese diets, we find an upward shift in the energy density of the foods consumed. In this study, the kilocalories of energy intake from foods and alcohol per 100 grams of food in both urban and rural Chinese adult diets increased by more than 10% (to 2.42) between 1989 and 1997. These are very rapid shifts in energy density. It is important to note that the value of 2.42 is not comparable with the normal measure of energy density of the diet. The normal method includes full measures of all beverages, whereas the Chinese Food Composition Table, from which this data was extracted, measures only a few beverages (milk, coconut juice, sugarcane juice, spirits, beer, wine, champagne, and brandy) and excludes many beverages, particularly tea and coffee. A number of clinical investigations have varied the energy density of the diet in ad libitum studies. Each study shows that increases in energy density, often as small as from 1 to 1.3kcal/g, can increase total energy intake. For these reasons, energy density changes in China, and most likely in other developing countries, are critical components of dietary change to be monitored.

Rapid Social Change Is Important: Urbanization, Rapid Demographic Change, and Other Behavioral Changes Are Occurring Simultaneously

Diets have shifted in urban areas in a far more dramatic fashion than in rural areas. We do not focus on many of the complex issues related to the type of urban change that has occurred. Nevertheless, critical sociodemographic issues include the following:

• Rapid reductions in fertility have enhanced the shift in the age distribution.

• Urbanization continues unabated in Asia and Africa. More poor will reside in urban than rural areas in future decades.

• Economic changes, particularly increased income and income inequality, appear to define changes in many regions of the developing world.

• Globalization of mass media is occurring at an earlier stage of economic development than occurred in higher income countries in the past.

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