The Whole World ’Round

Posted on Jan. 15, 2016

Barry Popkin warned that other countries were following Americans into obesity. Now he’s helping world leaders decide how to fight back.

by Susan Hardy ’05

Barry Popkin was rushing to tie up loose ends before a trip to Kuala Lumpur, Malaysia. Thailand, Singapore and China, too. The world was catching up with America. Getting fat, in other words, and Popkin and a team of scholars were working on the details of how to counterattack — work that he’s pretty sure will never be finished.

“There’s not a village you can go to in Latin America or Asia where you won’t find a little junk-food store,” he said.

In the U.S., 17 percent of children are obese; adults, twice that rate. And the rest of the world seems to be rushing to catch up. Popkin, who holds two distinguished chairs in the study of nutrition, spent much of his 38-year career at Carolina warning about an obesity epidemic, only to watch it keep spreading around the world, into areas where the problem used to be just the opposite.

Humans have a predilection for sweets and a long, long history of mining sugar from the things they grow. They have applied their ingenuity to artificial sweeteners; nurtured snacking as a hobby; and, more and more, ceded control of eating to restaurants that are invested in fat-and-calorie satisfaction. All this is in sync with a labor-saving lifestyle that acts against opportunities to work it all off.

Popkin has made a name for himself as the go-to person on obesity; he’s routinely quoted in articles on the American diet and the growing health crisis as a new generation grows up overweight. Just over the course of his research, he has seen a dramatic shift in the way the world eats. He sees progress in what sometimes seems to be an intractable problem. The rate of obesity in the U.S. stabilized after 16 big U.S. companies made a commitment in 2010 to reduce calories in the foods they sell.

Now governments are calling on his team to help craft policies that can help people lose weight and reduce their risk of heart disease, diabetes and cancer.

“Far too many successful people sit on the sidelines,” said Barbara Rimer, dean of the UNC Gillings School of Global Public Health. “But Barry hasn’t stopped with observation. He’s one of the people who will have had among the greatest impact on public health in the nutrition field.”

From malnourished to overfed

Ironically, Popkin started out trying to get more food to disadvantaged people. Living in a squatter community in India during college in the 1960s heavily impressed on him the horror of malnutrition. “Hunger was the issue — both here and everywhere else. Hunger in America was real,” he said. “We had kids with severe malnutrition not so different than people from Biafra or elsewhere.”

At the University of Wisconsin, Popkin had begun to see the world outside his small-town upbringing. By his senior year he had earned a scholarship to study in India. His experience there cemented his decision to study the economics of nutrition. A political activist had been born, and he was all in — Vietnam war protests, Students for a Democratic Society and community organizing — from a Marxist and Maoist point of view.

He stayed at Wisconsin for a master’s in economics and paired that with a doctorate in agricultural economics from Cornell. He worked with the Rockefeller Foundation in Southeast Asia for three years before coming to UNC in 1977.

While working on a panel on child health in the administration of President Jimmy Carter in the 1970s, Popkin realized that nutrition programs in the U.S. had become more than successful. School breakfast and lunch programs and food stamps made sure that few kids were undernourished.

“But now the kids were overweight,” Popkin said. “And all our programs were focused on treating people like we were still in an age of hunger.”

While studying nutrition and health around the globe, Popkin saw that the trend wasn’t limited to the U.S. or even to wealthy countries. The developing world also was getting fat. “In China, I saw change even from 1989 to 1991,” he said. “What hit us in the ’70s and ’80s hit Latin America in the ’80s and ’90s. Then they and the Middle East started becoming really heavy. And it’s hit Asia and Africa in the last 15 years — snacks, soft drinks.”

Working with the Chinese Center for Disease Control and Prevention, he started the China Health and Nutrition Survey in the late 1980s to study the effects of government programs and policies — and dramatic social and economic change in the country — on health and nutrition.

Now that work has been expanded to all corners of the world.

In the ’90s, Popkin’s work sounded the alarm: Nutritional problems don’t end when food becomes plentiful and no one is underfed. After the bounty of industrialization, Popkin said, obesity always will follow unless deliberate steps are taken to stop it. A few countries — including Sweden, Denmark and France — got the drop on obesity before it really took off. Most of the rest of the world faces the double challenge of treating the health problems caused by obesity while trying to stop its youngest generations from growing up fat.

“Right now, we don’t know what works,” Popkin said. “We have ideas — say, putting a label on healthy or unhealthy foods. But what impact does that have on purchasing behavior?”

He and his team hope to find out at least part of that answer in Mexico, where the government has decided it wants prominent nutrition information — not just numbers, but easy-to-understand visuals of recommended daily allowances — on the front of food packages. UNC faculty are helping to design the labels. Popkin and his team will evaluate the results.

He also is paying close attention to junk food and sugary-beverage taxes that have started popping up around the world — in Thailand, Chile and France along with Berkeley, Calif. He advised the Mexican government on starting taxes of its own. Diabetes is as common today in Mexico as hunger used to be, Popkin said, and one of the big culprits is soda. Mexico started taxing sugary beverages at 10 percent in 2014. Popkin is helping several other low- and middle-income countries plan beverage and junk-food taxes as well, but those countries aren’t ready to go public with their plans.

Taxing works elsewhere

“The tax works,” Popkin said. He and an international group of researchers found that as Mexicans started to feel the impact of the tax, they started spending less on sugary beverages — 12 percent less by the end of 2014, the first year of the tax. The decrease in drink sales happened more among low-income Mexicans, who are most at risk for obesity and diabetes.

“Those findings have the potential to influence policy worldwide. Countries are looking for ways to combat obesity and reduce the harm of sugary beverages,” said Neena Prasad, a researcher at Bloomberg Philanthropies, former New York Mayor Michael Bloomberg’s charitable organization that is contributing millions of dollars to Mexico’s fight against obesity. Popkin bases his ideas about health policy on solid data, Prasad said.

Placing extra taxes on certain kinds of food may still sound strange in the U.S., but Popkin sees plenty of precedent for the idea — not just in other countries, but in American antismoking campaigns. What Prasad calls Popkin’s “contagious enthusiasm” for nutrition policy came out as he warmed to the subject. “The United States taxed cigarettes. It worked, so other countries started taxing it,” Popkin said. “We banned cigarette marketing, and so other countries are doing the same.”

In 1978, the Federal Trade Commission proposed banning TV ads for sugary foods directed at kids. Advertisers of sugary foods also would have had to pay for ads about nutrition and the dangers of eating too much sugar.

The idea of banning junk-food advertising to kids isn’t new even in the U.S., Popkin said. “We came very, very close 35 years ago.” In 1978, the Federal Trade Commission proposed banning TV ads for sugary foods directed at kids. Advertisers of sugary foods also would have had to pay for ads about nutrition and the dangers of eating too much sugar. First Amendment concerns were raised, and the changes never happened.

“But the FTC does have the right to ban certain things that aren’t healthy, just like the FDA does, even if it’s against the First Amendment,” Popkin pointed out.

He is certain that in years to come there will be more taxation of sugary drinks. “And I can see us first labeling foods as healthy and unhealthy, and even requiring that when you market something unhealthy, you have to give a certain amount of money for counter-advertising,” he said.

“That’s what we had with cigarettes long ago — for every dollar that went into cigarette advertising, a dollar had to go into another pot for anti-cigarette advertising. I can imagine that kind of thing happening here.” (It already is occurring in France.) Popkin also predicts that more U.S. cities and states will pass sugary-beverage and junk-food taxes. This year, Berkeley started taxing sugary beverages at 1 cent per ounce. Popkin’s group, with Bloomberg Philanthropies and local researchers, are evaluating how that goes.

Bringing the industry around

Tracking how a law or a policy changes ordinary people’s purchases takes a lot of work. For a decade, Popkin and researchers have been perfecting ways to track what foods people buy and what they eat. “In this country, people bought about 1.2 million different foods between 2000 and 2013. Then we have people scanning 60,000 to 80,000 households every day — everything they’ve purchased.

“We’ve been gaining skill in working with large commercial databases on food purchases and other things we can use in Berkeley. And within six months there might very well be a tax in Chicago on sugary beverages — we’re ready to evaluate that.”

But in the U.S. and around the world, Popkin and his team aren’t just studying people — diets, weight and health. They’re also studying industry. “We can say, ‘Let’s ban media advertising of junk food.’ But we don’t know what the ban will do. Coke and Pepsi can sell healthier food. They can sell water and healthier drinks. But they’re not going to do it unless you push them.”

After the 16 U.S. companies made their calorie-reduction commitment, they cut their total calories sold by an impressive-sounding 6.6 trillion calories in 2012 compared with 2007. Popkin led the team that evaluated the results. Though the U.S. obesity rate stabilized, it is still high.

“It’s not clear whether the change came from the companies or whether it was because the culture of eating and diet in America was already changing. In other words, we already had a trend going on, and they didn’t accelerate that trend,” Popkin said. To really make an impact, he says, companies would have to change the nutrients in foods, not just the calorie count. “Kids are still eating junk food. They’re just eating a little less of it.”

When it comes to improving our diets, Popkin’s rules are simple: more real food and less sugar. Popkin was one of the authors of a 2004 study that sparked controversy over high-fructose corn syrup, suggesting that the common additive might not be as good as other sugars at helping the body feel full, leading to overeating. But he no longer thinks that hypothesis is correct.

“It turns out all sugars are equally bad. So when the soft drink companies now say we have natural sugar, it’s irrelevant. Sugar’s sugar.” (Except for fruit, he added. “You eat an orange — it’s fine. You have a glass of orange juice — it’s six oranges. That’s not so fine.”)

Popkin has his own daily indulgences. Cases of Coke Zero are piled in his office. He’s fond of unsweetened tea — he likes caffeine.

“I try as much as I can to eat real food with a lot of vegetables. I pretty much have salads for lunch with some protein. On the other hand, I love sweets. I love going out to eat at nice restaurants. I love wine. But it’s all in moderation.” To offset these luxuries, Popkin bikes for half an hour every day, does strength training twice a week and practices yoga.

The obesity numbers may remain alarming, but he sees movement — at home and abroad — toward a commitment to make the difficult changes that could help bring them down.

“I’m 71, and I have no plans to stop, because now is when I’m finally seeing some fruit.” 

Susan Hardy ’05 is a freelance writer and editor based in Durham.