The World Is Fat:
New Dynamics Shifts in Patterns
of The Nutrition Transition
Barry Popkin
Department of Nutrition, School of Public Health and Medicine,
Department of Economics
The University of North Carolina at Chapel Hill
“Over 1.3 billion people in the world are overweight”
Outline: New Dynamics
• Global Dynamics: The US is no longer be the
nation with the highest BMI and overweight levels
• Total Caloric Change: Eating Frequency(snacking),
Caloric Beverages and Portion Sizing
• The World is Flat and Fat: globalization has occurred
for centuries
• How do we proceed
“Over 1.6 billion people in the world are overweight”
Figure 1. Stages of the Nutrition Transition
Urbanization, economic growth, technological changes for work, leisure,
& food processing, mass media growth
Pattern 1
Paleolithic man/
Hunter-gathers
• Wild plants &
animals
• water
• Labor intensive
Lean & robust,
high disease
rate
Low fertility,
Low life expectancy
Pattern 2
Settlements begin/
Monoculture period/
Famine emerges
• Cereals
dominate
• water
• Labor-intensive
Nutritional
deficiencies
emerge, stature
declines
High fertility,
high MCH mortality,
low life expectancy
Source: Popkin 2002 revised 2006.
Pattern 3
Industrialization/
Receding Famine
Pattern 4
Noncommunicable
Disease
• Starchy, low variety,
low fat, high fiber
• water
• Labor-intensive
work job/home
• Increased fat, sugar,
processed foods
• caloric beverages
• Shift in technology
of work and leisure
• Reduced fat, increased
fruit, veg, CHO, fiber
• Increase water, Reduce
caloric beverage intake
• Replace sedentarianism
w/ purposeful activity
MCH deficiencies,
weaning disease,
stunting
Obesity emerges,
bone density problems
Reduced body fatness,
improved bone health
Accelerated life
expectancy, shift to
increased DR-NCD,
increased disability
period
Extended health aging,
reduced DR-NCD
Slow mortality decline
Pattern 5
Behavioral Change
High Income vs. Transitional
and Low Income Countries
• Trend toward a higher BMI in higher income countries
reaches back a century but major increase seen in the
1980’s to the present
• In contrast, minimal obesity in most of developing and
transitional world until the late 1980’s. It is again rapid
changes in the past 20 years
• Now at a point where across the globe in most countries
obesity far exceeds undernutrition and the dynamics of
energy balance changes are shifting upwards this gap
rapidly
“Over 1.6 billion people in the world are overweight”
Mismatch: Our Biology Clashes with Modern
Technology
Biology
Technology
Sweet preferences
cheap caloric sweeteners,
food processing benefits
Thirst and hunger/satiety
mechanisms not linked
Caloric beverage revolution
Fatty food preference
Edible oil revolution-high
yield oilseeds, cheap
removal of oils
Desire to eliminate exertion
Technology in all phases of
movement/exertion
“Over 1.6 billion people in the world are overweight”
Patterns Of Overweight & Obesity Globally For Nationally Representative Samples
(Percentage overweight + Obese)
<10%
10-20%
21-30%
31-40%
41-50%
>51%
Arctic Ocean
Arctic Ocean
North Pacific Ocean
Indian Ocean
South Pacific Ocean
South Atlantic Ocean
.1
BMI Distribution Shifts among Mexican women 18-49 y
(National Surveys 1988, 1999 y 2006)
1999
.04
.06
2006
0
.02
Kdensity BMI
.08
1988
10
15
20
25
30
35
40
BMI (Kg/m2)
From Juan Rivera
45
50
55
60
65
Annual Absolute Change in the Prevalence of Overweight
and Obesity in 9 Countries from 1985/1995 to 1995/2006
(BMI≥25.0 for adults; IOTF equivalent for children)
2.0
1.9
Annual percentage change
1.7
Children
Adult Males
Adult Females
1.5
1.3
1.2
1.1
1.0
1.0
1.0
0.9
1.0
1.0
0.9
0.8
0.7
0.9
0.8
0.6
0.5
0.5
0.5
0.5
0.4
0.4
0.3
0.1
0.1
0.1
0.0
-0.02
-0.5
Australia
U.K.
U.S.A.
Brazil
Russia
China
Indonesia
Vietnam
Mexico
Popkin (2007) nature reviews, cancer 7:61
The Shift in BMI levels at the 95th Centile for Females Aged 30
45
42.5
2.7 increase
37.7
39.8
35
3.5 increase
5.4 increase
30.7
29.7
34
32.3
26.3
27.2
27.7
25
20
15
10
5
United States
Australia
Popkin, AJCN in process-not for distribution/use
United Kingdom
1991
2003
1995
1980
2000
1989
1980
2003-06
1988-94
0
1971-75
BMI
30
37.5
2006
35.2
1997
40
China
The Shift in BMI Levels at the 95th Centile for Children Aged 6
30
24.8
25
21.6
22.2
21.6
20.1
BMI
20
19.8
20.1
1995
2003
18.8
18
5 increase
19.8
15
10
5
NA
0
1971-75 1988-94 2003-06
United States
1985
1995
Australia
Popkin, AJCN in process-not for distribution/use
2007
United Kingdom
1991
1997
China
2006
Australian Youth Gain Fat, Shift Body Shape
Based on the research of Olds (2009) EJCN 1-13.
“Over 1.6 billion people in the world are overweight”
The consequences vary by race-ethnicity: Body
fat composition in the East vs the West
(Yajnik & Yudkin 2004)
The burden of disease is shifting
rapidly towards the poor.
• By burden, we refer to the greater prevalence of poor diets,
sedentarianism, obesity, NR-NCD’s among the poor
• Brazil is the only country where a significant obesity reduction
among the rich and increase among the poor is seen (only for
adult females).
• Studies on the shifts in diet among various income groups in
China point towards a similar shift occurring there in 10-15
years
• Monteiro and Popkin series of cross-sectional studies to show
similar patterns acrsoss the globe of greater obesity emerging
among the poor.
“Over 1.6 billion people in the world are overweight”
Sources of Major Global Dietary Shifts
• Across the globe: large increases in consumption of
caloric beverages and increasing snacking
• Lower income countries: increased edible oil, animal
source foods are another source of kcal increase
• Globally, we find an increased intake of ultra processed
foods, refined carbohydrates
• Globally, we find a reduced intake of fruits and
vegetables and legumes
• Globally, we find a reduced preparation time, increased
use of precooked foods
“Over 1.6 billion people in the world are overweight”
From Traditional to Modern Meals
From Traditional to Modern Snacking
From Traditional to Modern.....
Marketing of Food
Sweetness
Many think that we have inborn biological wisdom but how and
why and what role this plays in our food preferences has not
achieved consensus. Because sweet foods are naturally good and
are safe sources of energy and nutrients, adaptive evolutionary
development has resulted in a preference for them. Of the five
most widely acknowledged tastes, three generally signal
acceptance (sweet, salty, and umami*), while two generally
signal avoidance(sour and bitter). These early responses are
modified by life experiences,producing adult tastes preferences.
“Over 1.6 billion people in the world are overweight”
Sweetness Preference was Essential
to Survive: Huge Shift in Amounts,
Energy Density
“Over 1.6 billion people in the world are overweight”
Sweetness and Effects on Eating Preferences
• Expose infants to sweetness and find several years later
desire exists for sweet foods
• Studies on mice, primates replicate this
• Virtually no long-term studies on exposure to sweetness
and sweet foods and how it effects our needs and eating
patterns subsequently .
“Over 1.6 billion people in the world are overweight”
Increases in total calories from added sugar
are greatest among top 20% of population
Q1
Q2
Q3
Q4
Q5
Total
1965
60
161
262
396
701
316
1977
32
114
195
299
560
240
1989-91
29
113
206
324
616
258
1999-00
62
193
321
491
959
406
2001-02
59
176
300
464
882
376
2003-04
56
172
295
646
896
377
-8.3%
Duffey & Popkin(2008) AJCN 88(suppl):1722S
“Over 1.6 billion people in the world are overweight”
+27.7%
What are the implications of eating food and
drinking water on energy balance?
General Properties
• Hunger – Feeding
Sensations that promote
attainment of minimal
food energy needs
• Thirst – Drinking
Sensations that
promote attainment of
minimal hydration
needs
• Energy Excess
Stored
• Water Excess
Excreted
• Energy Deficit: Die in
1-2 months
• Water Deficit : Die in
2-4 days
“Over 1.6 billion people in the world are overweight”
Biology vs Technology: Shift from
Water to Caloric Beverages with No
Food Calorie Compensation
“Over 1.6 billion people in the world are overweight”
Energy Intake
(N=40)
4000
Fat
Protein
(Coc onut)
(Dairy )
Carbohydrate
3500
(Waterm ellon)
3000
K cals
2500
2000
*
*
L iq u i
So lid
*
1500
1000
500
0
“Over 1.6 billion
people
the world
are overweight”
Mourao,
.. in
(2007).
"Effects
of food form..." IJO:31(11): 1688-95.
L iq u i
So lid
L iq u i
So lid
Remarkably Short History for Caloric Beverages:
Might the Absence of Compensation Relate to This Historical Evolution?
Earliest possible date
Definite date
US Soda Intake 52/gal/capita
(2004)
Modern Beverage Era
10,000 BCE - present
Pre-Homo Sapiens
200,000BCE - 10,000 BCE
Origin of Humans
US Coffee Intake 46 gal/capita
(1946)
Juice Concentrates (1945)
US Milk Intake 45 gal/capita
(1945)
Coca Cola (1886)
Pasteurization (1860-64)
Carbonation (1760-70)
Liquor (1700-1800)
Lemonade (1500-1600)
Coffee (1300-1500)
Brandy Distilled (1000-1500)
(206 AD)
Tea (500 BCE)
Wine, Beer, Juice
(8000 BCE)
Wine (5400 BCE)
Beer (4000 BCE)
Milk (9000 BCE)
2000 BCE
AD
0
BCE
100000 BCE
10000 BCE
200000 BCE
Homo Sapiens
200000 BCE
Beginning
of Time
Water, Breast Milk
Global Trends
• Minimal published data
• Mexico-see below.
“Over 1.6 billion people in the world are overweight”
Daily Beverage Consumption Trends of Mexican Children, 1999-2006
Sodas
Sweetened Juice Drinks
Whole Milk
Other
400
Calories per capita (kcal)
343
45
297
300
200
16
190
165
226
17
100
0
26
110
116
24
37
8
1999
19
2006
Children aged 1-4
158
86
17
38
55
1999
2006
Children aged 5-11
Note: Sweetened juice drinks include 100% fruit juice with sugar added and agua fresca (water, juice, sugar).
Sodas include carbonated and noncarbonated sugar bottled beverages.
Source: Barquera et al (2008)J Nutr 138: 2454-61.
Beverage Consumption Trends of Mexican Adolescents
and Adult Women, 1999 and 2006
High sugar
High calorie low benefit
400
366
349
Kcal per day
350
Low calories
7
4
109
300
120
250
200
150
154
145
7
12
47
225
100
50
250
52
100
81
0
1999
2006
1999
2006
Year
12-18 years of age
19-49 years of age
Note High sugar is composed of mainly soft drinks, sweetened juices, agua frescas and alcohol.
High calorie and low benefit is mainly whole milk. Low calories are slightly sweetened coffee and skim milk
Source: Barquera et al (2008)J Nutr 138: 2454-61.
United States: a large shift toward caloric
beverages
• Milk-long-term decline since 1945
• Major increases in sugar-sweetened beverages
since the 1980’s, some leveling off in last 4 years
• Juice intake, alcohol show important increases
“Over 1.6 billion people in the world are overweight”
Long Steady Decline of Total Milk Intake
“Over 1.6 billion people in the world are overweight”
Sugar-sweetened beverage Consumption Trends
(Soda/Fruit Drinks) (kcal/day), Nationally Representative
“Over 1.6 billion people in the world are overweight”
Juices
• Several studies from Australia, the US and Spain
show a comparable effect of juices on energy
intake, weight gain and CVD
“Over 1.6 billion people in the world are overweight”
Juice Consumption Trends (Kcal/Day), Nationally Representative
“Over 1.6 billion people in the world are overweight”
Alcohol Consumption Trends(kcal/day), Nationally Representative
“Over 1.6 billion people in the world are overweight”
Water
• Water: 60% of our body, essential for life
• Water consumption measurement is fairly crude with
minimal effort on this critical nutrient
• Water research: very limited.
• Review: adding water to the diet alone or to replace
sugar-sweetened beverages, juice, milk and diet
beverages
• Ongoing random controlled trials in the US and
Mexico on possible benefits of water
“Over 1.6 billion people in the world are overweight”
Difference in Total Energy Intake when Juice or Milk Displace Water
Almiron Roig (2003) adults
DellaValle (2005) women
Almiron Roig (2003) men
Almiron Roig (2003) women
DellaValle (2005) women
Hagg (1998) kids 4-7
Weighted Average (Juice & Milk)
Change (%) in Energy Intake with Added Water
†P<0.05
Popkin,et al, under review; Daniels and Popkin, under review;
“Over 1.6 billion people in the world are overweight”
Differences in Total Energy Intake when
HFCS or Sucrose Sweetened Beverages Displace Water
(6 kids not shown; only sig adults shown out of 19 total)
Almiron Roig (2003) (b)
DellaValle(2005) (w)
Flood (2006) (w)
Flood (2006) (w)
Mattes (1996) (L)
Rolls (1990) (w)
Rolls (1990) (b)
Van Wymelbeke (2004) (L)
Weighted Average (kids)
Weighted Average (adults)
†P<0.05
(b) preload before meal
(w) preload with meal
(L) long study (2+meals)
Change (%) in Energy Intake
Popkin,et al, under review; Daniels and
Popkin, under review;
Differences in Total Energy Intake
When Diet Beverages Displace Water
(6 kids; 19 adult comparisons; sig shown)
Birch (1989) (b)
Lavin (1997) (L)
Birch (1989) (b)
Weighted Average (kids)
Weighted Average (adults)
†P<0.05
(b) preload before meal
(w) preload with meal
(L) long study (2+meals)
Change (%) in Energy Intake
Popkin,et al, under review; Daniels and Popkin, under review;
“Over 1.6 billion people in the world are overweight”
Total Caloric Intake is a Combination of
Three Components
• Total caloric intake = f(Portion Size x Eating
Frequency x energy density of the portion)
• Portion 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 ↑↓ : small increases in food energy
density, declines in meal and snack energy density are
significant when correctly combine food intake with all
beverages consumed
“Over 1.6 billion people in the world are overweight”
Portion sizes
• Portion size increased for hamburgers,
cheeseburgers (for kids only), pizza and Mexican
dishes
• The pizza increase in kcal portion size was
particularly large (176 kcal for kids, 216 for adults).
• Snack foods: portion size down as frequency went
up in last decade
• Desserts, drinks, french fries down slightly
“Over 1.6 billion people in the world are overweight”
Trends in Overall Portion Sizes in the United States,
Nationally Representative Adults Aged 19 and older
“Over 1.6 billion people in the world are overweight”
Trends in The Energy Density of Food And Beverages from Food plus Beverages
at Meals and Snacking Occasions In the United States (kcal/gram)
1989-91
1994-98
2003-6
0.92
0.98
0.99
1.01
0.76
0.98
0.24
0.26
0.26
0.26
0.22
0.28
0.27
0.28
1
0.93
0.89
1.85
1.73
2
1.78
2.83
2.71
2.81
1.79
Kcal/gram
3
2.77
1977-78
0
Snacking
food
Meals food
Snacking
beverages
Source : Piernas and Popkin, unpublished data
Meals
beverages
Total
snacking
Total meals
Snacking
• Significant increases in 1990’s and again in the new
Millenium in the United States
• China—tripling in 2004-6 period. Expect great
changes in the next several years.
• Few small studies across the globe
“Over 1.6 billion people in the world are overweight”
The Likelihood of Snacking Across All Individuals
Aged 2 and Older, China 1991-2006
2004
1991
2006
0.5
Proportion snacking over 3 days
0.44
0.4
0.34
0.32
0.29
0.3
0.25
0.20
0.2
0.15
0.10
0.1
0.06 0.07
0.07
0.08 0.08
0.08
0.10 0.11
0.05 0.05
0
low
Middle
Income
high
Low
Middle
Education
Source: CHNS 1991,2004 and 2006; Adjusted for income, education, urban, gender and age
(2-18,19-59,60+) Zhihong Wang et al (2008) Asia Pac J Clin Nutr 17:123
high
The Percentage of Total Energy Intake from Snacks, Chinese
1991-2006
1991
2004
2006
10
8.4
8
6
4.3
4
3.2
3.1
2.5
2
1.5
1.3 1.4
0.5 0.7
0.6
1.6
1.5
0.5
0.8
1.0
0.8 0.8
45+
Total
0
2-6
7-12
13-18
19-44
Age (years)
Does the physiological basis for eating
exist any more? Continuous caloric
intake is becoming the norm.
Percentiles of US Individuals Consuming Meals Plus Snacks
1977-78
1994-98
2003-2006
30
25
15
10
5
0
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
9.5
10.0
10.5
11.0
11.5
12.0
12.5
13.0
13.5
14.0
14.5
15.0
15.5
16.0
16.5
17.0
17.5
18.0
18.5
19.0
19.5
20.0
20.5
21.0
21.5
22.0
22.5
23.0
Percent
20
Number of meals plus snacks averaged over two days
Source : Popkin and Duffey, unpublished data
Fat Preference Key for Survival:
Technology, Marketing have Utilized
this Preference for Fatty Food
“Over 1.6 billion people in the world are overweight”
Fatty Foods
• Fatty foods: smoother, affects taste in many ways
• Elsewhere I have written about and documented the very
large increases in vegetable oil (edible oil) consumption
across Asia, Africa, the Middle East and parts of Latin
America.
“Over 1.6 billion people in the world are overweight”
Edible Oil Consumption Still Rising in China
(grams per day per capita)
Year
1989
1997
2006
Poorest (lowest income tertile)
11.8
26.5
30.8
15
29.7
30.9
Richest (highest income tertile)
17.4
31.3
30.9
Average for total adult population
14.8
28.9
30.9
% of all calories per capita from edible oil
4.9
11.2
12.4
Middle income tertile
Source: China Health and Nutrition Survey for adults aged 20-45
“Over 1.6 billion people in the world are overweight”
The Predicted Probability of Consuming Excessive Fried Foods in
Chinese Urban Residents, 1991 and 2004
0.6
1991
2004
0.5
Probability
0.51
0.42
0.4
0.4
0.3
0.51
0.49
0.37
0.41
0.39
0.31
0.3
0.39
0.3
0.2
0.1
0
low
Middle
high
Low
Income
Source: CHNS 1991 and 2004; Adjusted for socio-demographic factors
Wang et al (2008) Asia Pac J Clin Nutr 17: 123
Note: excessive fried foods represents more than 20% of kcal from fried foods.
Middle
Education
high
Major Global Dietary Shifts
• Increased animal source foods
“Over 1.6 billion people in the world are overweight”
Price Policies Are a Great Option:
Price Elasticities of Demand
Beef
Urban
China
2000
All
China
1990
-.90
-1.04
Pork
-.21
-.98
Poultry
-.75
-.53
Fish
-.37
-.81
S. Korea
1985
Livestock
-.68
NA
S. Korea
1962-92
Morocco
1969-85
-.49
-1.63
-.57
NA
-1.07
-1.26
-.34
-.17
AIDS Demand Models Various Sources cited in Delgado & Courbois 1998; urban China 2000 figures from Yen, et al.
2004; S. Korea 1985 figures from Cranfield et al, 1998
“Over 1.6 billion people in the world are overweight”
Real World Prices, 1990 US$
500
100 kg Beef
400
300
1 MT Maize
200
100 kg Poultry
100
70-72
80-82
90-92
94-96
2020
AIDS Demand Models Various Sources Cited in Delgado & Courbois 1998
Fast Food Consumption
• No studies address several key issues
• First–is it the behavior of the consumer who selects fast
food or the foods per se at the Fast Food restaurant?
• Second, no random controlled trials or studies of what
people consume at fast food places or studies that
somehow separate the characteristics and potential
selectivity of fast food vs sit down restaurants on
behavior.
• Third, enormous heterogeneity in consumption changes
related to away-from-home eating.
“Over 1.6 billion people in the world are overweight”
The Struggle Over the Millenia to
Eliminate Arduous Effort Could Not
Foresee Modern Technology
“Over 1.6 billion people in the world are overweight”
From Traditional to
Modern Household Production
From Traditional to Modern
Economic Work at Home
From Traditional to Modern Leisure
Shift In MET Hours per Week by Activity
Among Chinese Women (18-55 Years Old)
500
Leisure activity
Travel activity
Domestic activity
Occupational activity
MET hours per week
450
400
350
300
250
200
0
1991
1993
1997
1997
Year
Source: Ng ,Norton, Popkin (2009) SSM 68: 1305-14.
2000
2004
2006
The World is Flat and Fat:
Globalization has Occurred for Centuries
• Naïve idea that globalization is a phenomena of the past
few decades
• Consider how Columbus et al introduced from the Americas to
the cuisines of the world: Chili peppers in Asia, Potatoes in
Europe, and tomatoes in Italy are examples. Or noodles from
Asia to Italy
• Recent rapid acceleration in areas such as communications
technology, transportation systems, distribution technologies
affect how we eat, move, drink. Think of Red Bull’s impact
globally in 5 years vs coke in 70 years
“Over 1.6 billion people in the world are overweight”
How do we proceed?
• Clearly action needed at all levels; however I believe the
only way to produce concerted change is to look to the
models of tobacco use, seat belt, other major public
health changes
• Regulations, taxation, mass education are key
components
• Examples: Mexico Beverage campaign, US Farm Bill,
Brazil and Singapore schools
• Current global economic crisis has slowed down many
changes
“Over 1.6 billion people in the world are overweight”
Mexico Initiative on Beverages
• Remove all whole milk, shifted now to 1.5% and later to skim
milk all gov’t programs
• Schools: working to ban all sugar sweetened beverages,
provide safe water, allow water, low fat milk to be sold
• Taxation being considered: tax added sugars in beverages per
gram, fat in milk
• National media effort–began Feb 25 with launch of Mex.
Beverage Guidelines
• Source:Rivera et al, Salud Publica Mex 2008;50:173-195
“Over 1.6 billion people in the world are overweight”
Effects of Price Changes on Soda and Whole milk Consumption
10% increase in the price of soda
2.03
2.43
Soda
0
Poor
2
Rich
Whole milk
Soda
0
1
-6
-30
-8
-40
-70
Source: Barquera et al, (2008) J Nutr138: 2454-61.
-16
-11.38
-14
-10.31
-12
-11.34
-60
-53.02
-50
-46.10
-10
-0.88
-4
-20
-1.24
-10
1
-2
-1.20
Whole milk
-50.02
Change in consumption (mL/day)
10
2.07
Overall
10% increase in the price of whole milk
Price changes and dietary intake in the US
• CARDIA: in-depth 20-year cohort
• Detailed dietary data linked by UNC team with food prices
for each community over the same time period
• Focus on prices of beverages and fast foods here
“Over 1.6 billion people in the world are overweight”
Methods: Price Elasticity of Demand
• Elasticity= % change in demand
% change in price
• Own-price elasticity
%Δ $
%Δ
kcals
%Δ
Negative or
kcals
positive
Negative
• Cross-price elasticity
%
Δ
$
“Over 1.6 billion people in the world are overweight”
Combined 10% Change in Price Results in
Greater Percent Change in Outcomes: 20 year longitudinal analysis
of price and CARDIA cohort
Soda
Pizza
Soda & Pizza
Percent Change in outcome
0
-0.5
-0.3
-1
-1.5
-0.9
-1.1 -1.2
-1.1
-2
-2.5
-1.9
-2.3
-2.3
-3
-3.5
-4
-4.2
-4.5
Total Energy
Body Weight
Source: Duffey et al, manuscript 2009 not for distribution/use
HOMA-IR
Program and policy effectiveness:
Are we ready for preventive action?
Major research gaps exist.
• Targets: sugary beverages is very clear as is the Media.
Other foods are not as clear.
• Macroeconomic options: price changes matter,
governments subsidize wrong foods now
• Regulations: TV advertising, other advertising, edible oil
contents, school meals, school PE, etc
• Reprints (pdf files) and citations can be found on
www.nutrans.org. New book The World Is Fat
(Penguin Press) published end of Dec 2008
“Over 1.6 billion people in the world are overweight”
THE BOOK
“The most serious epidemic ever
is insidiously engulfing the world.
Barry Popkin draws upon his
decades of research and
experience to describe its
origins–and a set of potential
solutions. Those interested in
the future of mankind should
read this book.”
Walter Willett, author of Eat,
Drink, and Be Healthy, and chair,
Department of Nutrition, Harvard
University
Acknowledgements to My Many Key Collaborators:
University of North Carolina faculty co-investigators in various or many studies:
Linda Adair, Penny Gordon-Larsen, John Akin, Peggy Bentley, John Briscoe, Jane
Brown, Barbara Entwisle, Kelly Evenson, Pam Haines, Gail Henderson, David Guilkey,
Tom Mroz, Shu Wen Ng, Daniel Rodriquez, Anna Maria Siega-Riz, Yan Song, June
Stevens, Deb Tate,Dick Udry, Namvar Zohoori
Brazil: Carlos Monteiro
Philippines: Wilhelm Fleiger, Florentino S. Solon,
Others in the US: Suchi Ayala, Robert Black, George Bray, Ben Caballero, Walt Willett,
China: Zhai Fengying, Du Shufa, Ge Keyou, Chen Chunming, Chen Xiaoshu
Mexico: Simon Barquera, Juan Rivera, Sonia Hernandez
Russia: Polina Kozyreva, Mikhail Kosolopov, late Michael Swafford, Alexander Baturin
Students and postdocs:
Past: Linda Adair, Colin Bell, Colleen Doak, Kiyah Duffey, Elena Glinskaya, Penny
Gordon-Larsen, Xuguang Guo, Ningqi Hou, Lisa Jahns, Soowon Kim, Ying Liu, Mikhail
Lokshin, Bing Lu, Kathleen Mctigue, Michelle Mendez, Keri Monda, Shu Wen Ng, Tuan
Nguyen, Samara Nielsen, Sahasporn Paeratakul, Ruth Patterson, Kathleen Reidy, Marie
Richards, Jodi Stookey, Nguyen Thang, Carrie Waller, Youfa Wang, Monica Yamamoto,
Claire Zizza
Current: Jessie Jones-Smith, Tracy Dearth-Wesley, Huijun Wang, Zhihong Wang, Daisy
Zamora
My right arms: Frances Dancy, Tom Swasey My Family
And many coauthors of a range of papers important in my career
“Over 1.3 billion people in the world are overweight”