“Over 1.3 billion people in the world are overweight” The World Is Fat: New Dynamics Shifts in Patterns of The Nutrition Transition Barry Popkin Department

“Over 1.3 billion people in the world are overweight”

The World Is Fat: New Dynamics Shifts in Patterns

of The Nutrition Transition

Barry PopkinDepartment of Nutrition, School of Public Health and Medicine,

Department of Economics The University of North Carolina at Chapel Hill


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

Figure 1. Stages of the Nutrition Transition

Urbanization, economic growth, technological changes for work, leisure, & food processing, mass media growth

Source: Popkin 2002 revised 2006.

Pattern 1Paleolithic

man/Hunter-gathers

• Wild plants & animals

• water• Labor intensive

Pattern 3Industrialization/Receding Famine

• 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

Pattern 4Noncommunicable

Disease

• Reduced fat, increased fruit, veg, CHO, fiber

• Increase water, Reduce caloric beverage intake• Replace sedentarianism

w/ purposeful activity

Pattern 5Behavioral Change

• Cereals dominate

• water• Labor-intensive

Pattern 2Settlements begin/

Monoculture period/Famine emerges

Low fertility,Low life expectancy

Lean & robust, high disease rate

Slow mortality decline

MCH deficiencies, weaning disease,stunting

Accelerated life expectancy, shift to increased DR-NCD,increased disability period

Obesity emerges,bone density problems

Extended health aging,reduced DR-NCD

Reduced body fatness,improved bone health

High fertility,high MCH mortality,low life expectancy

Nutritional deficiencies emerge, stature declines


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


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 preferenceEdible oil revolution-high yield oilseeds, cheap removal of oils

Desire to eliminate exertionTechnology in all phases of movement/exertion

Patterns Of Overweight & Obesity Globally For Nationally Representative Samples (Percentage overweight + Obese)

South Atlantic Ocean South Pacific Ocean

Indian Ocean

Arctic Ocean

Arctic Ocean

North Pacific Ocean

<10% 10-20%

21-30% 31-40% 41-50% >51%

BMI (Kg/m2)

0.0

2.0

4.0

6.0

8.1

Kd

ensi

ty B

MI

10 15 20 25 30 35 40 45 50 55 60 65

1988

1999

2006

From Juan Rivera

BMI Distribution Shifts among Mexican women 18-49 y (National Surveys 1988, 1999 y 2006)

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)

1.7

0.5

0.7

0.40.5

0.1 0.1

0.90.9

1.1

0.80.9

0.8

1.2

0.5

0.3

1.3

1.0 1.0

0.6

0.1

1.0 1.0

0.4

1.9

-0.02

-0.5

0.0

0.5

1.0

1.5

2.0

Australia U.K. U.S.A. Brazil Russia China Indonesia Vietnam Mexico

Children Adult Males Adult Females

An

nu

al p

erc

en

tag

e c

ha

ng

e

Popkin (2007) nature reviews, cancer 7:61

35.2

42.5

29.7

37.7

30.7

37.5

26.3 27.2 27.734

32.3

39.8

0

5

10

15

20

25

30

35

40

45

1971

-75

1988

-94

2003

-06

1980

1989

2000

1980

1995

2003

1991

1997

2006

The Shift in BMI levels at the 95th Centile for Females Aged 30B

MI

United States Australia United Kingdom China

2.7 increase

5.4 increase3.5 increase

Popkin, AJCN in process-not for distribution/use

The Shift in BMI Levels at the 95th Centile for Children Aged 6

18

21.6 22.2 21.620.1 19.8 20.1

18.819.8

24.8

0

5

10

15

20

25

30

1971-75 1988-94 2003-06 1985 1995 2007 1995 2003 1991 1997 2006

BM

I

United States Australia United Kingdom

NA

China

5 increase

Popkin, AJCN in process-not for distribution/use


Australian Youth Gain Fat, Shift Body Shape

Based on the research of Olds (2009) EJCN 1-13.

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.


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

From Traditional to Modern Meals

From Traditional to Modern Snacking

From Traditional to Modern.....Marketing of Food


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.

Sweetness


Sweetness Preference was Essential to Survive: Huge Shift in Amounts,

Energy Density


• 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 .

Sweetness and Effects on Eating Preferences


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

Increases in total calories from added sugar are greatest among top 20% of population

-8.3% +27.7%Duffey & Popkin(2008) AJCN 88(suppl):1722S


• Hunger – FeedingSensations that promoteattainment of minimal food energy needs

• Energy ExcessStored

• Energy Deficit: Die in 1-2 months

• Thirst – DrinkingSensations that promote attainment of minimal hydration needs

• Water Excess Excreted

• Water Deficit : Die in 2-4 days

What are the implications of eating food and drinking water on energy balance?

General Properties


Biology vs Technology: Shift from Water to Caloric Beverages with No

Food Calorie Compensation


0

5 0 0

1 0 0 0

1 5 0 0

2 0 0 0

2 5 0 0

3 0 0 0

3 5 0 0

4 0 0 0

Kc

alsEnergy Intake

(N=40)

L iq u id

So lid

L iq u id

So lid

L iq u id

So lid

Carbohydrate Fat Protein

**

*

(Watermel lon) (Coconut) (Dairy )

Mourao, .. (2007). "Effects of food form..." IJO:31(11): 1688-95.

Remarkably Short History for Caloric Beverages: Might the Absence of Compensation Relate to This Historical Evolution?

AD

BC

E

10

000

BC

E

20

000

0 B

CE

Beg

inn

ing

o

f T

ime

100000 BCE

200000 BCE Homo Sapiens

Pre

-Ho

mo

Sa

pie

ns

20

0,0

00

BC

E -

10

,000

BC

E O

rig

in o

f H

um

an

s

Mo

de

rn B

eve

rag

e E

ra1

0,0

00

BC

E -

pre

sen

t

0

Earliest possible date

Definite date

Water, Breast Milk2000 BCE

Milk (9000 BCE)

Beer (4000 BCE)

Wine (5400 BCE) Wine, Beer, Juice

(8000 BCE)

(206 AD) Tea (500 BCE)

Brandy Distilled (1000-1500)

Coffee (1300-1500)

Lemonade (1500-1600)

Liquor (1700-1800)

Carbonation (1760-70)

Pasteurization (1860-64)

Coca Cola (1886)

US Milk Intake 45 gal/capita(1945)

Juice Concentrates (1945)

US Coffee Intake 46 gal/capita (1946)

US Soda Intake 52/gal/capita (2004)


Global Trends

• Minimal published data

• Mexico-see below.

24 19 38 5537 17

86116

226

110

158

17

16

26

45

8

0

100

200

300

400

1999 2006 1999 2006

Ca

lori

es

pe

r ca

pita

(kc

al)

Sodas Sweetened Juice Drinks Whole Milk Other

Children aged 1-4 Children aged 5-11

165

297

190

343

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.

Daily Beverage Consumption Trends of Mexican Children, 1999-2006

Beverage Consumption Trends of Mexican Adolescents and Adult Women, 1999 and 2006

100

225

81

25047

120

52

109

7

4

12

7

0

50

100

150

200

250

300

350

400

1999 2006 1999 2006

Year

High sugar High calorie low benefit Low calories

154

349

145

366

Kca

l per

day

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.

12-18 years of age 19-49 years of age


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


Long Steady Decline of Total Milk Intake


Sugar-sweetened beverage Consumption Trends(Soda/Fruit Drinks) (kcal/day), Nationally Representative


Juices

• Several studies from Australia, the US and Spain show a comparable effect of juices on energy intake, weight gain and CVD


Juice Consumption Trends (Kcal/Day), Nationally Representative


Alcohol Consumption Trends(kcal/day), Nationally Representative


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


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;

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)

Change (%) in Energy Intake †P<0.05(b) preload before meal(w) preload with meal(L) long study (2+meals)



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)

Change (%) in Energy Intake†P<0.05(b) preload before meal(w) preload with meal(L) long study (2+meals)



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


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


Trends in Overall Portion Sizes in the United States, Nationally Representative Adults Aged 19 and older

Trends in The Energy Density of Food And Beverages from Food plus Beverages at Meals and Snacking Occasions In the United States (kcal/gram)

2.7

7

1.7

9

0.2

8

0.2

6

0.8

9 1.0

1

2.8

1

1.7

8

0.2

7

0.2

6

0.9

3

0.9

9

2.7

1

1.7

3

0.2

8

0.2

6

0.9

8

0.9

8

2.8

3

1.8

5

0.2

2

0.2

4

0.7

6 0.9

2

0

1

2

3

Snackingfood

Meals food Snackingbeverages

Mealsbeverages

Totalsnacking

Total meals

1977-78 1989-91 1994-98 2003-6

Kca

l/gra

m

Source : Piernas and Popkin, unpublished data


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

0.06 0.070.08

0.05

0.080.10

0.07

0.10

0.15

0.05

0.080.11

0.25

0.32

0.44

0.20

0.29

0.34

0

0.1

0.2

0.3

0.4

0.5

low Middle high Low Middle high

Pro

po

rtio

n s

na

ckin

g o

ver

3 d

ays

1991 2004 2006

Income 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

The Likelihood of Snacking Across All Individuals Aged 2 and Older, China 1991-2006

3.1

1.3

0.6 0.5 0.50.8

4.3

1.4 1.5

0.7 0.8 0.8

8.4

3.2

2.5

1.5 1.61.0

0

2

4

6

8

10

2-6 7-12 13-18 19-44 45+ Total

Age (years)

1991 2004 2006

The Percentage of Total Energy Intake from Snacks, Chinese 1991-2006

Does the physiological basis for eating exist any more? Continuous caloric

intake is becoming the norm.

0

5

10

15

20

25

30

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

.01

0.5

11

.01

1.5

12

.01

2.5

13

.01

3.5

14

.01

4.5

15

.01

5.5

16

.01

6.5

17

.01

7.5

18

.01

8.5

19

.01

9.5

20

.02

0.5

21

.02

1.5

22

.02

2.5

23

.0

Number of meals plus snacks averaged over two days

Pe

rce

nt

1977-78 1994-98 2003-2006

Percentiles of US Individuals Consuming Meals Plus Snacks

Source : Popkin and Duffey, unpublished data


Fat Preference Key for Survival: Technology, Marketing have Utilized

this Preference for Fatty Food


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.


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

Middle income tertile 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

Source: China Health and Nutrition Survey for adults aged 20-45

The Predicted Probability of Consuming Excessive Fried Foods in Chinese Urban Residents, 1991 and 2004

0.3

0.370.39

0.31 0.3

0.390.4

0.490.51

0.42 0.41

0.51

0

0.1

0.2

0.3

0.4

0.5

0.6

low Middle high Low Middle high

1991 2004

Pro

bab

ility

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.

Income Education


Major Global Dietary Shifts

• Increased animal source foods


Price Policies Are a Great Option: Price Elasticities of Demand

Urban China 2000

All China1990

S. Korea 1985

S. Korea1962-92

Morocco 1969-85

Beef -.90 -1.04

Livestock

-.68

-.49 -1.63

Pork -.21 -.98 -.57 NA

Poultry -.75 -.53 -1.07 -1.26

Fish -.37 -.81 NA -.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

Real World Prices, 1990 US$

100 kg Poultry

100 kg Beef

80-8270-72

1 MT Maize

94-96 202090-92

100

200

300

400

500

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.


The Struggle Over the Millenia to Eliminate Arduous Effort Could Not

Foresee Modern Technology

From Traditional to Modern Household Production

From Traditional to Modern Economic Work at Home

From Traditional to Modern Leisure

1991 1993 1997 1997 2000 2004 2006

Year

200

250

300

350

400

450

500

ME

T h

ou

rs p

er

we

ek

Leisure activityTravel activityDomestic activityOccupational activity

Shift In MET Hours per Week by Activity Among Chinese Women (18-55 Years Old)

0

Source: Ng ,Norton, Popkin (2009) SSM 68: 1305-14.


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


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


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

-50.

02

-53.

02 -46.

10

2.07

2.43

2.03

-70

-60

-50

-40

-30

-20

-10

0

10

1

Cha

nge

in c

onsu

mpt

ion

(mL/

day)

-11.

34

-10.

31

-11.

38

-1.2

0

-1.2

4

-0.8

8

-16

-14

-12

-10

-8

-6

-4

-2

0

2

1

Soda Soda

Whole milk

Whole milk

Overall Poor Rich

Effects of Price Changes on Soda and Whole milk Consumption

10% increase in the price of soda 10% increase in the price of whole milk

Source: Barquera et al, (2008) J Nutr138: 2454-61.


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


Methods: Price Elasticity of Demand

• Elasticity= % change in demand

% change in price

• Own-price elasticity

• Cross-price elasticity

$ kcals% %Δ Δ

$% % kcalsΔ Δ

Negative

Negative or positive

Combined 10% Change in Price Results in Greater Percent Change in Outcomes: 20 year longitudinal analysis

of price and CARDIA cohort

-1.1

-0.3

-1.9

-1.2-0.9

-2.3-2.3

-1.1

-4.2-4.5

-4

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

Total Energy Body Weight HOMA-IR

Soda Pizza Soda & Pizza

Per

cent

Cha

nge

in o

utco

me

Source: Duffey et al, manuscript 2009 not for distribution/use


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

“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

THE BOOK


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

Documents

“Over 1.3 billion people in the world are overweight” The World Is Fat: New Dynamics Shifts in Patterns of The Nutrition Transition Barry Popkin Department