Table 4.

Stages of the nutrition transition and challenges for mega-countries to address the burden of non-communicable chronic diseases^a

Country group	Characteristics	What could be expected in the next decades?	What priorities must be addressed to diminish the burden of NCDs?
Low-Middle HDI	Mostly rural/labor-intensive work low sedentarism	Increasing urbanization trend. Decrease in physical activity associated with shifts to lower labor-intensive occupations and active transportation.	Raise priority of NCDs in development of national policies
Pattern 3 of the nutrition transition (receding famine) Bangladesh, Ethiopia, Nigeria, Pakistan, India, Indonesia, Philippines, Vietnam	Epidemiologic panorama dominated by under nutrition, but even low prevalence of NCDs represent a significant burden	Decreasing prevalence of stunting. Increasing prevalence of NCDs associated to national growth, trade and shifts in the food systems with low priority and resources from the governments and health sector to respond.	Improve/develop surveillance and monitoring systems for NCDs
	Increasing prevalence trends of NCDs (obesity, high blood cholesterol, blood pressure and blood sugar)	Higher prevalence of CVD at lower BMI levels than in higher HDI megacountries	Implement policies to promote adequate urban planning focused on active communities, active transportation and public transportation
	Elevated population growth	Tobacco consumption becoming major public health problem in particular among males	Disincentives for use of cars. Promotion of physical activity to compensate for increasingly sedentary jobs
	Starchy, high fiber, hydration mostly with water	Increasing consumption of processed foods, sugar-sweetened beverages and fast food	Reinforcement/Implementation of taxes and strict regulation to disincentive tobacco consumption
	Increasing consumption of tobacco	Alcohol consumption not expected to increase in most of these countries due to Muslim religion practices	Promotion and incentives to reinforce/maintain adequate breast-feeding practices
			Policies and incentives to maintain and value traditional foods and diets as the key to adequate nutrition. Guidelines for healthy hydration and disincentives to the development of SSBs industry.
			Introducing/improving nutrition education with emphasis on the unhealthy effects of high added sugar, salt and saturated/trans fats intake
High HDI	Mostly urban/physical activity very low	Increasing urbanization, often without proper urban planning. Decrease in physical activity (due mostly to shifts in labor) and active transportation	Raise priority of NCDs in design of national policies with a multisectoral approach. Develop monitoring systems to evaluate progress in NCDs prevention and control at global, regional and national levels
Pattern 4 of the nutrition transition (rise of noncommunicable diseases) Brazil, China, Mexico, Russia	Epidemiologic panorama dominated by NCDs (obesity, high blood cholesterol, blood pressure and blood sugar)	Decreasing prevalence of stunting. NCDs recognized as the main public health problem, however lack of comprehensive policies to tackle the epidemic	Promote a strong focus on urban planning considering active transportation, walkability and active living. Disincentives such as taxes and regulation for the use of cars and incentives for use of public transportation
	High tobacco, SSBs, fast foods and processed foods consumption. Poor potable water availability	Tobacco consumption remains a major public health problem with increases in consumption by vulnerable groups (young adults, women, low-income, ethnic minorities)	Continuing/improving efforts to reduce tobacco, SSBs and alcohol consumption: taxation, marketing and labeling regulations. Avoid subsidies on unhealthy ingredients/avoid policies that increase availability of sugar, high fructose and other caloric sweeteners, salt and saturated fats
	Poor public transportation, inadequate/insufficient public parks	Increasing consumption of processed foods, sugar-sweetened beverages, fast food	Improve health care response to the rapid rise in NCDs: review and update health care curricula and training, massive education campaigns, early detection, and effective treatment and control
	Lack of adequate regulations to protect children from unhealthy food and beverage marketing	Imported low-cost solutions to control CVD risk factors such as statins, antihypertensive drugs and aspirin will become more available	Develop creative solutions to address de NCDs burden such as: national soda taxation programs, strong healthy lifestyles programs, labeling and marketing regulations, polypill interventions in populations with poor access to health care, etc. Import effective initiatives and technology
	Transnational food companies lobbing against health policy attempts to modify food environment	Trends on implementation of creative national policies to improve food environment (soda tax, ultra processed food marketing and labeling regulation, physical activity promotion)	Develop international trade agreements that include healthy lifestyle considerations
Very High HDI	Mostly urban/physical activity very low however increasing, particularly on higher socioeconomic segments	Urban planning improving, with emphasis on walkability, active living, sustainability and environment.	Strengthen national policies and plans for the prevention and control of NCDs
Pattern 5 of the Nutrition Transition (desired societal/ behavioral change) Japan, USA	Epidemiologic panorama dominated by obesity and NCDs, however, reductions in smoking, SSBs and other risk factors	Stabilization/ saturation equilibrium/ slow reduction of obesity and NCDs	Promote research for the prevention and control of NCDs at global and national levels
	Relatively good public transportation, public parks, and potable water availability. Trends toward the practice of active transportation	Vulnerable groups such as low socio economic sectors, women, adolescents and minorities with higher exposure to unhealthy lifestyles: tobacco consumption, ultra processed foods, SSBs, fast foods, inactive transportation, poor access to incentives for physical activity	Continued improvement of environments to promote healthy lifestyles with emphasis on vulnerable groups (such as low-income population, disadvantaged ethnic groups, women and adolescents), to reduce inequalities in health
	Increasing trend to local, traditional unprocessed foods and healthy hydration	Effective solutions to control some CVD risk factors such as statins, antihypertensive drugs and aspirin widely available at low cost to the vast majority of population	Import effective national policies implemented in High HDI countries such as soda tax, ultra processed front-of-pack labeling, cycling paths, nation wide physical fitness programs, etc.
		Decreasing trend in consumption of processed foods, sugar-sweetened beverages and fast food franchises in particular on higher socioeconomic segments of the population	Control of emerging risk factors must be emphasized (high cholesterol and glucose in Japan; high tobacco consumption and sugar-sweetened beverages consumption in USA).
		Unhealthy products migrating to emerging, less regulated markets in other countries	Priority to low-income population and other disadvantaged minorities and vulnerable groups
			Promote social responsibility and fair trade of companies attempting to sell unhealthy products overseas

CVD, cardiovascular disease; HDI, human development index; NCD, noncommunicable chronic disease; SSB, sugar-sweetened beverage.

^aPatterns of the nutrition transition according to Popkin (2015).