Nutrition Transition: An Unwelcome Byproduct of Globalization and Urbanization that is Bringing Obesity and Diabetes to the Developing World

Daniel Henryk Rasolt

Nutrition Transition

Being overweight has long been associated with various medical conditions, lethargy, leisure and lifestyle choices, but for most of history it was considered a condition of the affluent. After the industrial revolution, being overweight and obese also started to be seen as a condition of the middle classes, and eventually obesity became prevalent in low income brackets of society, but only in wealthy and industrialized countries. In fact, many chronic diseases directly linked to obesity are still labeled “Diseases of Affluence” in some circles.

This connection to wealth is no longer the case though, as “Western” dietary and lifestyle trends have spread around the world over the past few decades, piggybacking on the the rise of globalization and urbanization in developing countries. The replacing of traditional diets and more active lifestyles, and the inevitable associated diseases, like type 2 diabetes, stroke and coronary heart disease (CHD), have diligently followed this trend, and are threatening to become global health, economic and sociocultural crisis in the very near future.

This is not an attack on globalization; as with many complex topics, there are substantial pros and cons associated with the phenomena. The rise of obesity in particular is not just a byproduct of non-nutritious and energy-rich processed and refined foods along with less active and more stressful lifestyles. It is also a result of higher incomes and lower fertility rates in the developing world that often accompany an empowerment of women. These themselves are very positive trends for the individual countries and an increasingly strained planet, and are often referred to as the “Demographic Transition.” Infectious diseases, such as Aids, Cholera, Diarrhea, Malaria and Tuberculosis, which had previously accounted for the majority of deaths due to disease in the developing world, become less prevalent as fertility rates drop and incomes rise. The shift from these infectious diseases to noncommunicable diseases like Diabetes, Coronary Heart Disease (CHD) and Cancer, itself is referred to as the “Epidemiological Transition.” Famine and starvation have also generally become less prevalent in societies where obesity is now taking hold, which is an unquestionable necessary step out of poverty, starvation being associated with “extreme” poverty and food insecurity for a nation.  But due to industrial practices and shifting dietary, economic, technological and agricultural trends, obesity is not only a condition of the wealthy, and many overweight people in the world today are actually malnourished. It is possible to be fat without being well-fed.

That point about obesity not being just a condition of the rich is obviously not groundbreaking news for developed countries, where many low income populations have suffered from obesity and associated diseases like diabetes for decades. Despite this societal awareness, the trend of diabetes prevalence continues upwards in the United States and most other developed countries, across all societal demographics. According to the Centers for Disease Control (CDC), From 1995 to 2015, diagnosed cases of diabetes in the United States increased from 8.66 million to 23.35 million. It is going to take radical cultural, economic and policy shifts in the United States to move the majority of the population away from the causes (namely diets based on the high consumption of industrial and processed animal products and processed, refined and sugary foods and beverages, along with sedentary lifestyles) of the “Western Diseases” of diabetes, CHD, stroke and various forms of cancer, such as colon cancer.

The prevalence of obesity in low-income sectors of society is a new phenomena in many developing countries, however. These countries may become overwhelmed in the near future by the costs of obesity-related diseases. The death rates from diabetes, CHD and cancer are significantly higher in countries with less development and healthcare infrastructure. In fact, now non-communicable diseases like type 2 diabetes, cancer and CHD, the same diseases that have been the most prevalent causes of death in industrialized countries for more than a century, account for nearly two-thirds of all deaths in the developing world (approximately 23 million annually). This trend is set to increase with the rising impact of the “Nutrition Transition,” described in more detail below, along with other factors related to urbanization such as pollution, smoking, and more sedentary lifestyles, that in addition to obesity can cause various forms of cancer and chronic respiratory diseases.

For those in developing countries that do have the initiative, knowledge and access to healthcare services with the equipment and personnel to treat chronic diseases, the economic burden can be tremendous for individual families. These long-term costs have the potential to either keep them in, or force them back into, poverty. The economic burden can also be tremendous for the country as a whole, due to lost productivity and premature deaths, and also medical costs, depending on the national policies on public healthcare treatment for their citizens.

On the tenuous bright side, many of these countries that are being affected by the Nutrition Transition are still in relatively early stages of these shifts, and hold on to strong enough traditions of diet and active lifestyles. Therefore the prevention of obesity and associated diseases through awareness and education, could potentially have profound positive impacts on the actions of their citizens.

The shifts resulting from the importation of energy-rich diets to an increasingly urbanized, industrialized and sedentary developing world, and the subsequent replacement of their traditional diets that were most often, but not exclusively, rich in fruits and vegetables and other whole foods and lean animal sources of protein, and low in derived and industrialized animal products and refined carbohydrates and sugars, is known as the “Nutrition Transition.” This trend was first explicitly defined by Barry Popkin of the University of North Carolina in 1993, and has been neatly categorized into five steps, or patterns. While this might be a bit oversimplified since we are talking about a species, humans, who over the course of our evolutionary development have proved extremely adaptable and capable of surviving and thriving in a wide range of ecosystems and environmental conditions, and the natural diets that accompany them. From fish and meat based diets, to plant, nut and berry gatherers, and everything in-between, including and especially since the advent of agriculture, humans have nourished themselves.

Also, the Nutrition Transition is often interpreted as a chronological progression of human advancement, while in reality there still exist many traditional cultures, indigenous people for example, who fight to maintain traditional lifestyles and diets based on some combination of hunting and gathering and subsistence agriculture within their natural territories. When those rights and desires are protected, especially with beneficial modern infusions into their societies such as access to education and healthcare, they can exhibit the ability to live happy, healthy and sustainable lives free of the “Western” diseases and also free of infectious diseases and famine. A very interesting recent study that garnered some international press, of the Tsimane people of the Bolivian Amazon, who combine an active lifestyle with hunting and gathering and subsistence agriculture, found that they indeed had extremely healthy hearts and glucose levels and no incidence of, or risk for developing, CHD or diabetes or other obesity-related chronic diseases. The Tsimane are still susceptible to infectious diseases due to lack of awareness within the community and access to medications to help prevent the spread of communicable diseases, but many do live healthily into old age with no degenerative diseases. The point to take is that there are many ways in which humans are capable of living healthy and productive lives that don’t necessarily fit cleanly into generalized post-industrial revolution global trends. Nonetheless, the Nutrition Transition model helps to illustrate what is happening in a globalized world that is quickly becoming predominantly urban, and dietarily homogenized.

As Popkin describes it, there are five distinct patterns of the Nutrition Transition. The first pattern is illustrated by the Hunter-Gatherer, seen by many as a relic of the pre-agricultural revolution that will disappear by the end of this century. Individuals hunt typically lean wild animals high in protein, forage for plants high in fiber, and live very active lifestyles. In Hunter-Gatherer societies, which only exist in modern times in small groups of indigenous tribes in Australia, the Amazon, the African plains, some Arctic regions and a few other isolated territories and islands, obesity and noncommunicable diseases like diabetes and CHD were and are essentially nonexistent. Infectious diseases, however, and vulnerability to the natural elements, such as predators and weather, are thought to have greatly limited life expectancy in Hunter-Gatherer societies, though in historical context this last point is often debated.

The second pattern in the Nutrition Transition is defined by early or primitive agriculture, and famine. Much of the “underdeveloped” and even developing world, until recently, still lived under the conditions of this pattern, characterized by malnutrition, stunted growth, infectious diseases and sometimes starvation. There are still many millions of people suffering under these conditions of “extreme poverty” associated with pattern two, and there is some fear that these numbers will grow in the near future. With increased droughts, sea level rise, extreme weather events and a growing number of “climate refugees” (those people that must migrate due to their land becoming uninhabitable, or due to conflict over increasingly limited resources), associated with climate change, many more millions of individuals could face conditions of  food insecurity and famine.

But generally the trend over the past several decades in the developing world has been a transition out of this pattern of famine and into pattern three of the Nutrition Transition, where income rises, nutrition improves and famine recedes. As mentioned before, many positive trends accompany the transition into pattern three, such as longer life expectancy and stronger, healthier and more productive people that are less susceptible to infectious diseases. In addition to this, social and demographic trends such as increased access to education, for both boys and girls, and lower fertility rates, also tend to accompany this transition.

With technological and agricultural “advances” over the past 20-30 years taking hold in developing nations, and with incomes continuing to rise in those countries, small scale diversified farming characteristic of pattern three has been replaced in large part by industrial agricultural and the monocropping of cash crops and livestock, and populations have shifted from rural to urban centers. Lifestyles become much more sedentary (and stressful), industrial farming practices that incorporate more “efficient” techniques like machine harvesting and feeding animals energy dense diets of refined grains to make them grow faster, result in much lower food prices. Further industrial practices of refining and processing foods makes them less perishable and more easily transportable over large distances. With most consumers now living in urban centers, the supermarket becomes a staple of easy, cheap and “diverse” food and beverage choices, increasingly of the energy-dense foods and beverages derived from processed and refined grains, sugars and animal products, all of these purchases done with minimal personal energy expenditure. The result is pattern four of the Nutrition Transition, characterized by the overeating of high-calorie and low nutrition diets, the onset of obesity, and the rise of obesity-related chronic diseases such as type 2 diabetes and CHD.  

There are many factors at play that exacerbate this trend in pattern four. Some examples include: Global food advertising campaigns and large investments in the developing world by the fast a processed food and soft drink industries, international “Free Trade” agreements, and the lack of education and awareness as to the risks associated with these dietary and lifestyle shifts. Quoting the Food and Agriculture Organization of the United Nations, “As food companies watch incomes rise in the developing world, they are setting their sights on new markets. From Mexico to Morocco, the same foods that jeopardize health in wealthy countries are now tempting poor ones…In a number of countries, globalization has changed the face of obesity.”

The main focus of this analysis is on the transition from pattern three to four, and the need to quickly move towards some variety of pattern five, both in the developed and developing world. Pattern five is described as “behavioral change,” where communities, individuals, foundations and policy makers take action to change behaviors associated with the negative impacts of the previous transition patterns and reverse the trends of obesity and obesity related diseases.

Recent trends in global incidence of diabetes help to illustrate the impact of the Nutrition Transition. For example:

  • In Africa, from 1980 to 2014 diabetes prevalence increased from 3.1% of the adult population to 7.1%, or four million to 25 million people with diabetes.
  • The Eastern Mediterranean region over that same period, following the fall of the Soviet Union, has increased its prevalence from 5.9% to 13.7% (six to 43 million people),
  • The Americas from 5% to 8.3% (18 to 62 million adult individuals, which is including the rising trends in both developed countries like the United States and Canada, and developing countries in Central and South America)
  • South-East Asia Countries from 4.1% to 8.6% prevalence (17 to 96 million people).

However, as with many global issues like energy and resource consumption, pollution and climate change, it is the world’s two most populous countries that have become increasingly urbanized and industrialized, China and India, that have the most dramatic rising prevalence of diabetes. 8% of India’s population is now estimated to have diabetes, amounting to 61.3 million people, and China now has over 9% of their population living with diabetes (approximately 90 million people), to go along with more than 35% of the population that is now considered to be overweight or obese (India at 21%, and the United States at nearly 70% with a 9% diabetes prevalence, for comparison). In 1980, approximately 1% of the Chinese adult population is estimated to have suffered from diabetes. Overall, from 1980 to 2014, the global prevalence of diabetes has increased from 4.7% to 8.5%, or 108 million people to 422 million people, and rising! These statistics are all care of the World Health Organization, and their 2016 “Global Report on Diabetes.”

According to the report, “Diabetes caused 1.5 million deaths in 2012. Higher-than-optimal blood glucose was responsible for an additional 2.2 million deaths as a result of increased risks of cardiovascular and other diseases, for a total of 3.7 million deaths related to blood glucose levels in 2012. Many of these deaths (43%) occur under the age of 70. In 2014, 422 million people in the world had diabetes – a prevalence of 8.5% among the adult population. The prevalence of diabetes has been steadily increasing for the past 3 decades and is growing most rapidly in low- and middle-income countries. Associated risk factors such as being overweight or obese are increasing. Diabetes is an important cause of blindness, kidney failure, lower limb amputation and other long-term consequences that impact significantly on quality of life.”

Similar statistical trends exist for obesity, CHD, metabolic syndrome, and a whole range of other conditions described by pattern four of the Nutrition Transition and linked to globalization, urbanization and industrialization. When looking at the statistics more closely, those living in urban centers in the developing world have even higher prevalence of chronic disease than stated above (it has been estimated, for example, that diabetes prevalence in urban centers of Southern India have reached an incredible 20% of the population). The Food and Agricultural Organization of the United Nations estimates a doubling of obesity-related diabetes onset between 1998-2025 (to a total of 300 million people), “with three-quarters of that growth projected in the developing world. For nations whose economic and social resources are already stretched to the limit, the result could be disastrous.”

In many industrialized countries, and especially the United States, the population and culture as a whole is firmly entrenched into pattern four of the Nutrition Transition, with entire industries and ideologies devoted to staying there. Entire other industries and ideologies are devoted to finding the best way to shift the cultural mentality and the majority of the population into pattern five and to address these deeply entrenched and growing problems. It is actually very complex in a modern industrial country like the United States to address the issues associated with the last three patterns of the Nutrition Transition. This is because we are a country built in so many ways around efficiency and production, and have little in the way of a national and cultural identity when it comes to a traditional diet.  The United States is a relatively young country of immigrants from all over the world, and maintaining traditional diets in the face of so much diversity and cheap products that multi-billion dollar marketing campaigns helped glorify, never really had a chance (this in fact is another example of the Nutrition Transition, immigrants arriving to a new and industrialized country and abandoning their traditional diets and lifestyles from their home country, and developing chronic diseases as a result). In the developing world, in contrast, emphasis can still be placed on the benefits of preserving more healthful traditions, something that still is either very present in the country or culture, or a not too-distant memory. If action is not taken to combat these trends in both the developed and developing world, we will be looking at a world population that is increasingly dominated by chronic degenerative diseases.

References

“Global Report on Diabetes.” World Health Organization. 2016.

Kaplan, Hillard. Thomas, Gregory, et al..Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study. Lancet. March 2017.

Lomborg, Bjorn. “The spread of western disease: ‘The poor are dying more and more like the rich’.” The Guardian. March 2015.

“Long Term Trends in Diabetes,” CDC’s Division of Diabetes Tranlation, Center for Disease Control. April 2017.

Murray, Christopher. Ezzati, Majid, et al..“Rethinking the ‘‘Diseases of Affluence’’ Paradigm: Global Patterns of Nutritional Risks in Relation to Economic Development.” Harvard School of Public Health. PLOS Medicine. May 2005.

Popkin, BM. Gordon-Larson, P. “The nutrition transition: worldwide obesity dynamics and their determinants.” The International Journal of Obesity. 2004.

Popkin, BM. “Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases.” The American Journal of Clinical Nutrition. 2006.

“Rethinking Diseases of Affluence: The Economic Impact of Chronic Diseases.” World Health Organization. 2016.

“The Nutrition Transition and Obesity.” Food and Agriculture Organization of the United Nations.

Mattei, J. Malik, V. Hu, F. et al..”Reducing the global burden of type 2 diabetes by improving the quality of staple foods: The Global Nutrition and Epidemiologic Transition Initiative.” Globilization and Health. 2015.

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