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April 1998: 106-114 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Specid Article zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
The Obesity Epidemic Is a Worldwide Phenomenon zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Bany Ms zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAPopkin, Ph.D., and Colleen M. Doak, M.A.
Obesity is not just a disease of developed nations. nore in places such as Brazil, Cuba, Egypt, South Africa,
Obesity levels in some lower-income and
Thailand, and There is extensive documenta-
transitional countries are as high as or higher than
tion of populations in these countries with high energy
those reported for the United States and other
and fat intakes and above-average levels of obesity among
developed countries, and those levels are
adults. There are equally important problems emerging
increasing rapidly. Shifts in diet and activity are
among children and adolescents in lower-income coun-
consistent with these changes, but little systematic
tries,I6 but the focus of this review is adults; insufficient
work has been done to understand all the factors
data on adolescents preclude their use in this article.
contributing to these high levels. The goal of this
It is important to gain an understanding of the factors
review is to provide an understanding of the
that are contributing to this worldwide trend. Because so
patterns and trends of obesity around the world
many populations in a wide range of environments have
and some of the major forces affecting these
witnessed a large increase in the proportion of obese chil-
trends. Several nationally representative and
dren and adults, some comprehension of the role of key
nationwide surveys are discussed. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
underlying behaviors is important. The major factors im-
plicated in the West have been the modem food supply
and ready availability of high-fat foods for at-home and
Introduction
away-from-home consumption, along with marked shifts
It is widely acknowledged that obesity has emerged as an in physical activity patterns at work and during recre-
epidemic in developed countries during the last quarter of ation. Large nationwide surveys provide some sense of
the 20th century. It continues to be an issue of great con- not only body composition patterns but also some of the
cern. In addition, we now face the emergence of obesity key underlying shifts in diet and physical activity pat-
as a worldwide phenomenon, affecting wealthy and middle- terns.
income people alike in middle-income countries, as well as
residents of countries previously considered to be poor. Study Methods
Obesity is excessive enough to cause many to define this
as an obesity epidemic.’ From a nutrition perspective, re-
Survey Designs and Samples
search and policy in countries such as China, Brazil, and
Data come from several sources. Analyses discussed in
many lower-income countries have focused on problems
this article that have not been published elsewhere are
of undernutrition, but we present information here to point
based on Chinese and Russian surveys. The China Health
to an emerging paradigm of either a dominant problem of
and Nutrition Survey (CHNS), an ongoing, longitudinal
obesity or an ever-increasing obesity problem. Elsewhere
survey of eight provinces in China, is reviewed in detail.
we have shown that for China this increasing trend in
A multistage, random, cluster sampling procedure was
adult obesity may coexist with an increase in chronic en-
used to draw a sample from each province. Additional
ergy deficiency among adults.2
detail on the research design of this survey is presented
Several case studies using smaller, focused samples
e1sewhere.l’ Other data sets are from the Russian Longi-
have elucidated the complications of obesity and associ-
tudinal Monitoring Survey (IUMS),18*19 the first nation-
ated chronic diseases, such as cardiovascular diseases,
ally representative sample of the Russian Federation. Data
in adults. These diseases represent far too great a burden
collection is identical with that for the China survey, ex-
for researchers, health experts, and policy makers to ig- zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
cept that in China doctors and nutritionists collected all
data, whereas in Russia trained nonmedical interview spe-
cialists collected the data.
Dr. Popkin and Ms. Doak are with the Department
of Nutrition, University of North Carolina at Chapel Additional data from published surveys conducted
Hill, Chapel Hill, NC 27516-3997, USA.
in all regions of the world are also discussed. The main
Nutrition Reviews, Vol. 56, No. 4
106
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focus is on larger and more representative samples of measures: the United States, Finland, England, Germany9
adults. Selection criteria for presenting data from other and Australia. Table 12’-29 summarizes data on the pat-
surveys were size, sampling design, and geographic area. terns and trends of adult obesity in these countries. The
If a study was representative of a region or country, it was United States, Germany, and Finland have the highest lev-
always used. If it came from a country with few studies els of grade I1 overweight. Italy appears to have the high-
and did not fit our criteria of national representativeness, est level of grade 10verweight.2~ Grade I overweight is not
we used it if the sample size was large and it seemed rea- presented for any other high-income countries. The level
sonably representative of the population being sampled. of obesity and the rate of change per year over a longer
Because there are few studies of trends in obesity, those period of time are highest in the United States and En-
that provide reasonably comparable measurement and gland. The U.S. trend reflects a major increase in obesity
sampling criteria were always selected. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAduring the last decade.21J2
Measures Lower- and Middle-Income Countries zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Body mass index (BMI, measured in kg/m2) is the standard Prevalence. Before trends in these countries are ex-
population-based measure of overweight and obesity sta- plored, some sense of current knowledge on the preva-
lence of obesity should be discussed. Data from nation-
tus. For adults, the cutoffs used to delineate obesity are: < zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
18.5 for thinness (chronic energy deficiency), 18.5-24.99 ally representative surveys from a range of middle- and
for normal, 25.0-29.99 for overweight grade I, 30.0-39.99 lower-income countries are available, as are large surveys
from selected population groups in other countries. Both
for overweight grade 11, and 2 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA40.0 for overweight grade
III.zo For the purposes of this review, grades I1 and I11 are sets of results appear in Table zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA2,4,6J293M5 in which three
combined. Ideally, we would follow these cutoffs univer- measures of obesity-grade I, grades I1 and above, and
sally, but unfortunately, many published results &e lower grades I and above-are shown. The highest levels of
cutoffs (e.g., many define a BMI of > 25 as grade I, whereas obesity (grade I1 and above) occur in the Middle East,
others use the National Center for Health Statistics per- Western Pacific, and Latin America.
centile cutoffs of 27.8 for males and 27.3 for females). The Latin America. When we focus on obesity measures
data sets are unavailable for revision. of grades I and I1 and above for Latin America, we find
that more than 10% of females are obese in Brazil and
Results Colombia, more than 50% of the population is overweight
(grade I) in Mexico, and more than 30% are overweight in
Higher-Income Countries Peru. The range is lower in other South American coun-
As background, it is useful to present trends for adult tries. Several of these South American examples come from
obesity in countries for which we have good comparable urban samples only. In all three countries, where we have
Table 1. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBATrends in Adult Obesity in High-Income Countries zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
BMI Cutoff
Reference Time Period Obesity Trend (%) (kg/m2) Characteristics
United States 21,22 1960-1994 27.8 Nationally representative sample
Men 23.0-33.3
Women 23.6-34.9 27.3
England 23,62 1980-1994 >30 Nationally representative sample
Men 6-1 5
Women 8-1 6
Sweden 24,25 1980/1-198819 Nationally representative sample
Men 4.P-5.3 >30
G-Y Women 26 1985-1990 8.7-9.1 >28.6 Nationally representative sample
Men 14.1-17.2 >30
Women 16.5-19.3
Finland 27 1972-1992 Regionally representative sample
Men 1 1-21 >30
Women 22-1 8
Australia 28 1980-1989 Random, six cities
Men 9.M 1.5 >30
Women 8.0-13.2
Italy 29 198S1994 Nationally representative sample
Men 41.246.1 m zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Women 28.P-3 1.3
Nutrition Reviews, Vol. 56, No. 4 107
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Table 2. Obesitv Patterns in Adults in Lower- and Middle-Income Countries: Studies with Larae Samde Sizes zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Obesity zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBAYO Obese zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Latin America
Bd'2 1989 >30 25-64 5.9 13.3 9.6
23,544
- -
Peru30 1975l76 3145 225 Adults 33.8
- -
1975R6 3145 >30 Adults 9.0
-
- zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Colombia3' 1988-89 1572 2273 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA1W 11.1
-
MexicdZ 1995 20420 225 Adults 50.0 58.0
-
1995 20420 230 Adults 11.0 23.0
Caribbean
Cuba4 1982 225 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA36.4
30,063 20-59 31.5 39.4
1982 >a5 20-59 36.0 41.8 39.7
20,539 (U) zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
1982 9513(R) 225 20-59 22.6 33.9 29.4
Asia
China33 1992 >25 >20 11.9 17.0 14.6
54,006
23.1
1992 18,472 0 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA>25 20.8 25.1
>20
1992 35,534 (R) >25 >20 7.4 12.7 10.2
-
Kyrgystan 1993 4053 230 18-59 42 10.7
-
1993 4053 25430 18-59 26.4 24.3
- -
India'O 198W90 21,361 225 Adults 3.5
- -
1988190 21,361 >30 Adults 0.5
- -
India34 1994 1832 >25 12-47 6.6
- -
199344 1319(U,slum) >25 12-47 11.6
ThailandI5 1985 3495 0 225 35-54 25.5 21.4 24.6
1985 3493 0 230 35-54 22 3.0 2.4
-
phi lip pine^^^ 1993 9585 >30 220 1.7 3.4
-
1993 9585 25-30 220 11.0 11.8
Malaysia36 1990 4747 >25-30 18-64 24.0 18.1 21.4
1990 4747 >30 18-64 4.7 7.9 6.1
West Pacific
79.4
Nauru37 1994 1344 >30 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA25-69 80.2 78.6
New Caled~nia~~ 199244 6503 (R) 30-59 44.6 71.4 59.0
225 m
227 (M)
199244 225 (F) 30-59 59.1 79.6 72.7
641 0
227 (M)
North Africahliddle East
Kuwait39 1993-94 3435 >30 218 32.3 40.6 36.4
199344 3435 >25-30 218 35.2 32.3 33.8
Saudi Arabia40 1996 13,177 >30 15-95 16.0 24.0 19.8
1996 13,177 25-30 15-95 29.0 27.0 28.0
- -
Egypt41 199-4 5812 2515 36.8
- -
199344 5812 >30 >15 35.1
1984-85 Nationala 230 >20 23 14.6 8.7
1984-85 Urbana 230 >20 2.9 19.7 11.9
1984-85 Rurala 230 >20 1.9 10.3 63
Tunisia30 1990 861 1 >30 Adults 2.4 83 5.3
1990 861 1 >a5 Adults 20.0 32.7 26.3
Sub-Saharan Africa
- -
Congo30 1986'87 2295 225 >18 152
- -
1986/87 2295 >30 >18 3.4
- -
Congo6 1991 >25 218 23.6
30040
- -
1992 >25 218 4.1
1344(R)
- -
Mali30 1991 4868 225 Adults 72
- -
1991 4868 >30 Adults 0.8
South 1979 7187 >30 1564 14.7 18.0 16.5
1979 7187 225-30 (M) 15-64 41.9 38.8 40.3
224-30 (F)
South Africa4 1990 986 (Bl) 230 15-64 7.9 44.4 28.0
1992 5111 >30 2574 5.3 15.1 10.6
1992 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA5111 422
>25 25-74 35.7 47.7
Note: U = urban, R = rural, F = female, M = male, B1 =black. Obesity (BMI 130.0) and overweight (BMI = 25.0-29.99) are based on
classifications of the National Center for Health Statistics.
a The sample sizes for Morocco are unclear. They are either 41,921 or 10,445,034.
108 Nutrition Reviews, Vol. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA56, No. 4
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gender-specific data, women have higher levels of over- Again, female obesity is higher in all countries for which
weight and obesity than men. Few data are available in data are available for both genders.
terms of large-scale surveys in the Caribbean; however, Sub-Saharan Africa. Aside from Mauritius, there are
other studies and the Cuban data presented here indicate no nationally representative surveys in sub-Saharan Af-
that the Caribbean nations have high levels of obesity."6 rica. The scattered data from South Africa, Mali, and the
The Caribbean countries for which there is information Congo indicate high levels of obesity in urban sub-Saharan
are split zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA50150 between high versus moderate obesity
Africa. There are few data for rural areas, but what infor-
prevalence. Cuba and Barbados have a higher prevalence mation does exist shows a minimal problem. South Africa
(>20%), but Jamaica and St. Lucia have only about 12- might be the exception: limited studies on Africans, par-
15% obesity. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
ticularly women, indicate the possibility of high levels of
Asia. There is very little grade I1 and above obesity in obesity in both urban and rural areas.'"
Asia, and most countries have levels in the 5-1 5% range
for grade I. The documented exceptions are urban China, Trends
urban Thailand, Malaysia, and the Central Asian coun- Data on trends in body composition are excellent for a
tries, such as Kyrgyzstan, that were members of the So- small number of lower- and middle-income countries. There
viet Union before 1992. There is no clear gender pattern to are nationally representative or large nationwide data sets
obesity levels in Asia. The prevalence of obesity in Ma- for Brazil (Latin America), China and India (Asia), Mauritius
laysia and urban Thailand may be related to a relatively (Africa), Nauru and Western Samoa (South Pacific), and
higher level of economic development. Russia. These provide some sense of trends in adult obe-
Western Pacific. The high rates of obesity and related sity (Table 312,32-34~37~39~45~4s50 and Figure 1). In Figure 1 , all
chronic diseases in the island nations of Samoa and Nauru, of the trends are converted into percentage-point increases
Fiji, and Melanesia (the latter two are not re$esented in during a 1 O-year period.
the tables) have been the subject of many studies. Nearly Brazil. The trends in Brazil are presented in detail
half the population in this region has grade I1 or above elsewhere.I* During a 15-year period, the proportion of
obesity. In most cases, female obesity is much more preva- grade I1 and above overweight adult males almgst doubled
lent. (5.7-9.6%). For females of reproductive age, there are data
Middle East. Although data are limited, it appears over a 2 1 -year The proportion of grade I1 obesity
that more than a third of the adult population in increased by 230%. Interestingly, the ratio between the
oil-exporting countries such as Kuwait and Saudi Arabia underweight and overweight prevalence-a measure of
are overweight or obese. In the North African countries, the relative importance of each problem in the popula-
the situation reflects an emerging problem, with consider- tion-changed dramatically between 1974 and 1989. In
able grade I overweight but with less grade I1 and above. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
the case of all adults, the ratio was even reversed in 1974,
30
I Male Urban
Rural
I zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA0 Female
19.2 l9.t
20 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
16.E zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
4-
C
a,
2
a,
a zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
11.1
10
5.8 5.3
&
i Brazil 4
I
m i' Kuwait
0
China India Mauritius Russia Nauru W. Samoa
1 974/5-89 1 982-92 1989-94 1 987-92 1992-96 197594 1978-91
1980-94
(BM1225) (BM1>25) zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
(BMI >25) (BM1>25) (BM1>25) (BM I > 30) (BM I >30) (BMI >30)
Figure 1. Obesity trends: the percentage-point increase in obesity prevalence per 1 O-year period. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Nutrition Reviews, Vol. 56, No. 4
109
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