The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable

Abstract

The Nutrition Transition model is presented with the nature and pace of change in key stages varying by location and subpopulations. At present, all high-income and many low- and middle-income countries are in a stage of the transition where nutrition-related noncommunicable diseases including obesity, type 2 diabetes, and hypertension are dominating adult morbidity and mortality and are very high or growing rapidly in prevalence. Some countries still have key subpopulations facing hunger and undernutrition defined by stunting or extreme thinness among adults. We call these double burden of malnutrition countries. All low- and middle-income countries face rapid growth in consumption of ultra-processed food and beverages, but it is not inevitable that these countries will reach the same high levels of consumption seen in high-income countries, with all the negative impacts of this diet on health. With great political and civil society commitment to adoption of policies shown in other countries to have improved dietary choices and social norms around foods, we can arrest and even reverse the rapid shift to diets dominated by a stage of high ultra-processed food intake and increasing prevalence of nutrition-related noncommunicable diseases.

Keywords: Nutrition Transition; double burden of malnutrition; front-of-package labeling; obesity; taxation; ultra-processed food.

FIGURE 1

Stages of the nutrition transition

FIGURE 2

The global double burden of malnutrition in low‐ and middle‐income countries. Based on 1990s and 2010s weight and height data* (using UNICEF, WHO, World Bank, and NCD‐RisC estimates, supplemented with selected DHS and other country direct measures). Source: Popkin et al., lancet, 2020: 395 (10217): 65–74. *double burden of malnutrition (DBM) = at least 1 child with stunting and 1 adult with overweight (at 20%, 30%, or 40% overweight prevalence)

FIGURE 3

Prevalence of overweight and obesity based on 1990s and late 2010s weight and height data (using UNICEF, WHO, World Bank, and NCD‐RisC estimates, supplemented with selected DHS and other country direct measures). Countries colored according to highest overweight/obesity prevalence for either men or women

FIGURE 4

Role of our history: Biology which evolved over millennia clashes with modern technology (Core biochemical and physiologic processes have been preserved from those who appeared in Africa between 100,000 and 50,000 years ago)

FIGURE 5

The shifting burden of overweight/obesity* from higher‐ to lower‐wealth populations in sample countries**. * positive difference indicates higher annualized growth in overweight/obesity prevalence for the lowest‐wealth quartile. ** countries presented here had earliest‐to‐latest‐year data spanning 10 or more years. The data presented is from years spanning 1988 to 2018, but exact years vary by country. The span of earliest‐to‐latest years collected ranges from 15 years to 27 years. All data are from the demographic and health surveys (DHS, https://dhsprogram.com/) with the exceptions of China (China health and nutrition survey), Indonesia (Indonesian family life survey), Mexico (Mexico National Survey of health and nutrition), Brazil (Brazil National Health Survey), and Vietnam (Vietnam living standards survey)

FIGURE 6

Trends in packaged soft drink sales by category (ml per capita per day, 2006–2020). Note that Euromonitor does not separate data by full‐sugar vs. “diet”/light or noncaloric brands, so these data slightly overestimate total SSB sales. Source: Euromonitor international limited 2021 © all rights reserved

FIGURE 7

Trends in packaged junk food sales by category (grams per capita per day, 2007–2019). Note that these data approximate actual trends but significantly underestimate total junk food sales. Confectionery includes chocolate and sugar confectioneries and gum; savory snacks include nuts, seeds, trail mixes, salty snacks (e.g., chips), savory biscuits, popcorn, pretzels, and other savory snacks; sweet snacks include fruit snacks, snack bars, sweet biscuits, chilled and shelf‐stable desserts (Chile, South Africa, and Saudi Arabia only), frozen desserts, and ice cream. Source: Euromonitor international limited 2021 © all rights reserved

FIGURE 8

Impact of Chilean policies: Key findings after year 1 (during phase 1: Least‐restrictive nutrient and energy thresholds). Graphics created using resources from Flaticon.com

FIGURE 9

Impact of Chilean policies after year 1: Child‐directed marketing on breakfast cereal packages. Graphics created using resources from Flaticon.com