**2. Global nutrition in transition**

**1. Introduction**

world population's quality of life.

190 Adiposity - Epidemiology and Treatment Modalities

and health statuses of population.

tain selected nutrients on food package.

education.

many countries.

Currently, nutrition in transition can be found globally even in most developing countries. Declining under-nutrition is occurring in parallel with increases in over-nutrition, obesity and non-communicable diseases (NCDs). A double burden of malnutrition is now affecting the

For decades, nutrition education has been recognized as a preventive strategy for the sustainable reduction of both under- and over-nutrition. International organizations have developed guidelines for healthy eating that countries have adopted for preparing more practical foodbased dietary guidelines (FBDGs). More simplified FBDGs were later developed in different graphical designs according to national cultures and eating contexts. These FBDGs have been modified periodically by including additional factors other than foods that affect the nutrition

Industrially-produced foods are the other important sources of nutrients for people especially in more developed countries. An attempt in using industrial food products as an education tool for populations exists in terms of nutrition labelling, which indicates the amounts of cer-

The traditional nutrition labelling panel, which contains amounts of nutrients that reduce risks of under- and over-nutrition, has been mandated in many countries. Data on these traditional nutrition labelling panels are normally tabulated and located on the back of food package or so called 'Back of Pack, BOP' nutrition labelling panel. After several years of implementation, the traditional BOP nutrition labelling panels were found to be inefficient tools for educating consumers, due to such causes as their hidden location on shelves, complicated information and unattractive design. Consumers generally did not use the panel, and it did not attract industries to reformulate their recipes towards healthier nutrient profiles. A more effective nutrition educational tool is now needed as the problems of overweight, obesity and non-communicable diseases have become serious nutrition issues worldwide, especially among the people of low socio-economic classes and with less

A simplified nutrition label in graphic format was introduced in the 1960s intentionally to conquer over-nutrition, and later more designs and types were widely developed. Among these differences, the common agreement was on the nutrients used for criteria development, which were basically related to non-communicable diseases, for example fat, sodium and sugar. In addition, this simplified nutrition labelling panel was located on the front of food package or so called 'Front-of-Pack, FOP' nutrition labelling panel. These panels of different types and different degrees of informativeness have been recognized differently by different groups of stakeholders within the food system. Most FOP nutrition labelling panels are still implemented on a voluntary basis. In this chapter, the logic behind the development of traditional and simplified nutrition labelling panels are discussed as well as their uses in For decades in many parts of the world, protein energy malnutrition (PEM) and micro-nutrient deficiencies have been significant health burdens. Consequently, tremendous investments have been made in programs to alleviate these under-nutrition issues. However, most malnutrition scenarios arise not just from a lack of sufficient, adequately nutritious and safe food. A host of other interacting processes also play a role, for example healthcare, education, sanitation and hygiene, agriculture, trade, access to resources, women empowerment and more [1]. Consequently, a multidisciplinary approach involving different stakeholders, such as public health, agriculture, education and local authorities, must be implemented with the involvement of communities. The applied knowledge of these stakeholders as well as strong contributions and the cooperation of communities are important requirements for the production and consumption of nutritious and safe foods. For example, improvements in human quality of life, via efficient sanitation and nutrition programs, can successfully reduce morbidity and mortality due to nutrient deficiencies and communicable diseases. Over the past four decades, this multidisciplinary approach has been tested and implemented on a large scale in several developing countries. Thailand is one such success story where PEM among under-5 year old children was drastically reduced after 20 years of implementing this approach (**Figure 1**).

**Figure 1.** The World Food Summit Goal in reducing underweight problem in school children, the current situation of most countries and the Thailand's experience. *Source*: Ending malnutrition by 2020: an agenda for change in the millennium. Final Report to the ACC/SCN by the Commission on the nutrition challenges of the twenty-first century.

Among many supporting factors, food and nutrition education is one of the keys to success. As information is modified and simplified to fit community contexts, understandable messages and practical guidance can be passed to consumers. In the case of Thailand, the messengers were village health volunteers—at a ratio of 1 volunteer per 10 households—who distributed important nutrition information all over the country. Effective communication proved to be a powerful tool for altering consumer behaviours in the food system.

It must be recognized, however, that economic development is also a significant factor for success in solving a country's under-nutrition challenges. It can allow a country to invest more in nutrition and increase people's access to nutritious and safe foods. Under-nutrition problems in many countries have shown improvement as national economies have grown in strength (**Figure 2**). As a consequence of economic development, potentially more nutritious, safe and energy-rich foods can be available, affordable and accessible by people of varying socio-economic statuses. Economic development and industrialization provide more food choices in marketplaces, which have changed food environments in many countries.

The roles of food industries nowadays have also become more significant in the daily diets of the world's populations, and not always for the better. Globalization and modernization have drastically changed people's lifestyles in developing countries that formerly had a more balanced way of living. Traditional and imported energy-rich foods can be easily accessed in fresh markets, convenience stores, supermarkets, food vendors, local restaurants and multinational franchise restaurants due to better logistics, more modern and economical agricultural and

**Figure 2.** World situation on protein energy malnutrition (PEM) problem. *Source*: http://www.fao.org/hunger/ key-messages/en/.

industrial production technologies and free trade agreements. Unfortunately, though, messages from food businesses can, in part, be based on fact, but they can also contain misleading information. Deceptive food advertisements and sales promotions can create an unhealthy food environment for consumers by promoting the excessive consumption of energy-, sugar-, saturated fat- and sodium-rich foods. In such an environment, physically easy or sedentary lifestyles, which result in low physical activity and less energy expenditure in everyday life, promote unbalanced nutrition. A mentally stressful lifestyle, furthermore, can cause a negative impact on non-communicable diseases.

Among many supporting factors, food and nutrition education is one of the keys to success. As information is modified and simplified to fit community contexts, understandable messages and practical guidance can be passed to consumers. In the case of Thailand, the messengers were village health volunteers—at a ratio of 1 volunteer per 10 households—who distributed important nutrition information all over the country. Effective communication

It must be recognized, however, that economic development is also a significant factor for success in solving a country's under-nutrition challenges. It can allow a country to invest more in nutrition and increase people's access to nutritious and safe foods. Under-nutrition problems in many countries have shown improvement as national economies have grown in strength (**Figure 2**). As a consequence of economic development, potentially more nutritious, safe and energy-rich foods can be available, affordable and accessible by people of varying socio-economic statuses. Economic development and industrialization provide more food choices in

The roles of food industries nowadays have also become more significant in the daily diets of the world's populations, and not always for the better. Globalization and modernization have drastically changed people's lifestyles in developing countries that formerly had a more balanced way of living. Traditional and imported energy-rich foods can be easily accessed in fresh markets, convenience stores, supermarkets, food vendors, local restaurants and multinational franchise restaurants due to better logistics, more modern and economical agricultural and

**Figure 2.** World situation on protein energy malnutrition (PEM) problem. *Source*: http://www.fao.org/hunger/

key-messages/en/.

proved to be a powerful tool for altering consumer behaviours in the food system.

192 Adiposity - Epidemiology and Treatment Modalities

marketplaces, which have changed food environments in many countries.

Allied, often well-meaning, government health programs can also affect a population's nutritional status. For example, successful family planning programs have led to very low population fertility rates in many countries (lower than 2.1). Due to lower birth rates as well as better public health care, these countries have steadily seen a decline in working age people and a growing elderly population (**Figure 3**). As the ratio of elderly people increases, these countries are faced with an ageing society with the expectation that a longer life will also be a healthy life. However, non-communicable diseases often come to the forefront, since they are found more often in older age population groups who are physiologically prone to the diseases, especially among overweight and obese individuals. Changes in food availability, lifestyle and population profiles, therefore, can exacerbate expanding problems of NCDs. The increase in NCDs in developing countries—where under-nutrition used to be the main nutrition problem but has improved—can partly be explained by using Barker's theory, as well. Some persons found within a population affected by NCDs were born malnourished and were low-birth-weight newborns. Their bodies adapted to an environment that was chronically short of food. In adulthood and living in a more affluent environment, they become more prone to metabolic disorders, such as obesity and type II diabetes [2].

**Figure 3.** The trend of the ratio (%) of the population aged 65 and over to the working-age population (aged 15–64) through the year 2050. *Source*: http://www.asiapathways-adbi.org/2015/02/why-do-we-need-financial-education-in-asia/.

While under-nutrition in the form of PEM and micro-nutrient deficiencies remains unsolved in many developing countries, unfortunately the challenge of over-nutrition has also rapidly emerged, thus presenting the world with a double-burden in terms of malnutrition. Incidences of overweight, obesity and diet-related NCDs, which were mainly found in more affluent developed countries, are now growing in many developing countries at an alarming rate. The worldwide prevalence of obesity more than doubled between 1980 and 2014. Globally, NCDs are now the leading causes of death. Cardiovascular diseases, diabetes, cancer and chronic respiratory diseases caused up to 68% of deaths in 2012 [3]. Almost three-quarters of all NCD deaths occur in low- and middle-income countries [4]. Four major risk factors have been primarily responsible for the rise in NCDs are tobacco use, physical inactivity, alcohol use and unhealthy diets [5]. The rapid rise in NCDs is predicted to impede poverty reduction in low-income countries, particularly by increasing household costs associated with health care. Vulnerable and socially disadvantaged people become ill and die sooner than people of higher socio-economic status, since they are at higher risk of being exposed to harmful products, such as tobacco or unhealthy food, and have limited access to health services. To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote interventions to prevent and control them. A global action plan for the prevention and control of NCDs 2013–2020 was initiated by WHO and member states. This plan aims to reduce the number of premature deaths from NCDs by 25% by 2025 [6].

Malnutrition, in every form, presents significant threats to human health. Today the world faces a double burden of malnutrition that includes both under-nutrition and over-nutrition, especially in developing countries (**Table 1**). Hunger and inadequate nutrition contribute to early deaths among mothers, infants and young children, and impaired physical and brain development in young children. Meanwhile, growing rates of overweight and obesity are linked to a rise in life-threatening chronic diseases (e.g. hypertension, stroke, cardiovascular disease, diabetes, cancer) that are difficult to treat in places with limited resources and already overburdened health systems. Nutrition problems that emerge in either direction impair individual productivity, which slow down national growth. The cost of malnutrition is approximately 3.5 trillion USD per year [7].
