Background, Career, and Future

1. Background, Career, and Future Barry Popkin Department of Nutrition, School of Public Health and Medicine,Department of Economics The University of North Carolina at Chapel Hill

2. ASN Nutritional Epidemiology Research Interest Section Research Leader Webinar Series Purpose of the Series: Hear about personal education and research experiences of successful researchers in the field of nutritional epidemiology. Learn what they are doing to stay on the cutting edge of nutritional epidemiology research, and get an opportunity to seek advice to help your own research efforts.

3. Outline: Why is this occurring? Background: youth, maturation, nutrition entry to my life, activist decade Research career: first phase hunger in the world, MCH issues [USDA, Breast-feeding, Cebu] Second phase: larger SES forces on nutrition, the nutrition transition Third phase: continue second phase,deepening knowledge, add major policy push

4. Background: Upbringing • Book the world is fat provides some depth on how I ate, drank, moved, lived as a youth. Small midwestern town in northern Wisconsin, very provincial, very poor schooling, family very promotive of education • College: University of Wisconsin. Big break—brother told me about college year in India free funded program • India: awoke me to world of poverty, slums of India, villages of India. Also awoke me to global politics, Vietnam war

5. Return from India • Second senior year: interested in human welfare. Read and thought about health and just hit on some papers on nutrition. Decided to do senior thesis on the economics of nutrition • Civil Rights involvement, led group to North Carolina • Led to summer job with Off of Economic Opportunity, 400 of theses reprinted and sent all around, congressional interest, involvement in hunger in America, beginning of Headstart, more

6. Beyond Senior Year • Woodrow Wilson fellowship, focus on nutrition and went to Wharton economics. Increasing involvement • Returned to Madison, increasing involvement in politics, SDS, at least half time organizing in midwest, also MS economics. Congressional testimony and article on economic benefits of eliminating hunger for Senate, later published in journal • Left after 1 year for fulltime leftist organizing

7. Wandering Period • After organizing, repression led me ultimately to Boston and ABT associates after a year at UW with rural negative income tax project as research associate • Met someone I knew from my earlier nutrition economics work. Introduced me to leftist faculty in nutrition at Cornell. Welcomed me back to academia • 1972 fall went to Cornell, set up int’l nutrition degree, then Jan 73 joined agricultural economics doctoral program

8. Cornell Onwards to Nutr Economics Career • Focused thesis on RCT of vitamin A and child 1-11 health. Used baseline data for dissertation. Graduated summer 74. Took a job Rockefeller Foundation Asia in Quezon City. • 3 years in Phil. Started Laguna long, survey, began Bicol Multipurpose, began to involve economics with nutrition more systematically • Jobs: turned down, accepted and new career • UNC job 1977 to present

9. UNC Career Phase 1 • Attempt to get started. Wanted to merge nutrition with econ work. Convinced USDA to give grant. Evaluate FST,NLSP. Got small grant to do breast-feeding work. Involved other economists in breast-feeding and USDA work • Built small very productive team. MCH, US food programs. • Wanted Rolls Royce study to test all linkages of determinants and consequences of maternal and infant health related to infant feeding. Began Cebu project

10. Phase 2 • Learned in first phase to do NIH grants, got 4 or 5 on Cebu project. Then passed Cebu baton to Linda Adair • Felt scope of Cebu limiting, SES change could swamp nutrition change, needed larger area to understand how SES factors and nutrition interplay. Decided on China and took 2 years to explore all options in China. • China Health and Nutrition Survey part of first P01 for NICHD along with set of Cebu projects • China: first had done very cheap survey 1989 and led to 1991 and 1993

11. Nutrition Transition • First CHNS results: saw undernutrition small, emerging shifts in diet • Sat back and read about dietary change across the globe, demographic, SES, other nutrition-related factors and outcomes. Broadened CHNS to capture and began to write in-depth internal document on the nutrition transition that ultimately led to many papers on the topic

12. Figure 1. Stages of the Nutrition Transition Urbanization, economic growth, technological changes for work, leisure, & food processing, mass media growth Pattern 1 Paleolithic man/ Hunter-gathers Pattern 2 Settlements begin/ Monoculture period/ Famine emerges Pattern 3 Industrialization/ Receding Famine Pattern 4 Noncommunicable Disease Pattern 5 Desired societal/ Behavioral Change • Reduced fat, increased • fruit, veg, CHO, fiber • Increase water, Reduce • caloric beverage intake • Replace sedentarianism • w/ purposeful activity • Wild plants & animals • water • Labor intensive • Cereals dominate • water • Labor-intensive • Starchy, low variety, • low fat, high fiber • water • Labor-intensive • work job/home • Increased fat, sugar, • processed foods • caloric beverages • Shift in technology of work and leisure Lean & robust, high disease rate Nutritional deficiencies emerge, stature declines MCH deficiencies, weaning disease, stunting Obesity emerges, range of other NR-NCD’s Reduced body fatness, Reduced NR-NCD’s Low fertility, Low life expectancy High fertility, high MCH mortality,low life expectancy Slow mortality decline Accelerated life expectancy, shift to increased DR-NCD, increased disability period Extended health aging, reduced DR-NCD Source: Popkin 2002 revised 2006.

13. Current Phase • Continuing to deepen thinking, understanding of dynamics of diet, activity, body composition change across the globe • US and international longitudinal work: trends, dynamics key foci. All longitudinal when can • Two projects as examples of current work: CHNS and Cardia • Activist examples: beverages in obesity, NCD and push for more beverage panels, working on taxation, etc

14. Mismatch: Biology which has evolved over the millennia Clashes with Modern Technology

15. CHNS • 1991-2009: in-depth diet {note I focus in all work on foods more than nutrients and work hard to measure well}, detailed activity, body composition, SES • Always all work multilevel from Laguna, Bicol, Cebu. Measure at community, household, individual levels • Now CHNS adding fasting blood, full CVD biomarkers, stored buffy coat and GPS data • Now my focus building full model from community changes to HH to individual diet, activity, NS, NCD’s

16. Various levels of data & use • Community • Infrastructure • Access to eating and food shopping options • Prices • Health services • Household • Income & Assets • Relations • Individual • Health outcomes • Physical activity • Diet Associations Causality / Direction and strength of relationships Longitudinal changes Policy recommendations

17. Urbanization & Urbanicity • Urbanization: migration into cities; change in size, density and heterogeniety of places1 • Urbanicity: extent to which a place exhibits urban characteristics • Dichotomous Urban-Rural vs. Continuous Urbanicity scale • Heterogeneous variations in health missed by urban-rural categorization. • Economic, social & demographic change moves in a continuum. • Scale is useful for understanding impacts of both initial levels and changes in urbanicity as they related to health behaviors and outcomes New Urbanicity Scale (Jones-Smith & Popkin)

18. Supermarkets Bars Cafes Open air food & Fuel markets Health Services Modern Markets Modern & Traditional Markets Housing Newspaper Telephone Postal Service Cinema Color TV Computer Cell Phone Traditional Markets Communications Transportation Economy Communication Diversity Sanitation Social networks Population Size Education Population Density Social Services Urbanicity Scale Components Urbanicity Which features define and distinguish urban places? Galea and Vlahov 2005; Dahly 2007; National Research Council 2003;

19. Results: Heterogeneity in Urban Change for “Rural” Communities (Initial Score<50) Change in individual components by level of overall change in urban score for “Rural” Communities (1991-2006) Jones-Smith & Popkin (working paper)

20. e.g., Predicted Probability of Incident Overweight (1991-2004) by Change in Urban Score Over Follow-up for Varying Levels of Initial Urban Score Jones-Smith & Popkin (working paper)

21. New 2009-Geographic Information System (GIS) • Computerized map • Plots of resource layers onto a coordinate system • Spatially analyze the density and proximity of resources, environment factors, and population characteristics • locations can be geo-coded, or assigned a geographic reference, such as latitude and longitude • Link to national and other community level data on • Economics • Population size & density • Availability of facilities, markets and services • Integrate dimensions of the built environment to link with individual-level data to enable understanding of multiple levels of influence • individual family/home; school/peers; Community; culture/society

22. 8.05 km 8.05 km 8.05 km 8.05 km Using GIS to Create Measures of Environmental Context • Take advantage of GIS flexibility to define communities appropriately • Use GIS to calculate frequency/density/proximity of physical activity resources and constraints within the communities • Create rich set of measures associated with each respondent • Determine association with respondent physical activity, diet and overweight/obesity patterns

23. CARDIA • Reasonably good diet, good activity, body composition, biomarkers • Added contextual data via geographic coordinates. Began this measurement work to create systems to measure huge scale linkage to food, activity,etc 10 years ago. Now longitudinal files and many papers coming out. Penny Gordon-Larsen took over measurement and lead • Now papers coming out on price to diet to obesity to diabetes, more in future

24. More Precise Measurement of Food Prices Previously Commodities Taxes Food expenditure State-level food $ (general)

25. $ % % Δ Δ kcals $ % % Δ Δ kcals Methods: Price Elasticity of Demand • Elasticity= % change in demand % change in price • Own-price elasticity • Cross-price elasticity Negative Negative or positive

26. Combined 10% Change in Price Results in Greater Percent Change in Outcomes: 20 year longitudinal analysis of price and CARDIA cohort Percent Change in outcome Source: Duffey et al, Archives of Internal Medicine, in press not for distribution/use

27. Always Focused on Poverty, Equity, Understand How Affecting the Poor • Goes back to activism, USDA programs, SES of the poor overseas, time constraints, etc • Carlos Monteiro: global shift toward burden for the poor

28. Mentoring Young and Old • Favorite approach is one-on-one with faculty and students alike. This is my greatest pleasure.

29. My Unique Perspective • Keen observation: linkage from personal experiences to research and back. Use all literatures from social and biomedical sciences . Early on read anthropology, demographics, etc • How do I focus on dynamics when others can not. Unsure but critical to our future understanding. • Always trying to meld all approaches, go into dynamics and not looking just for the present

30. How to Prevent Obesity • Caloric beverages: only element I feel has now a clear justification for control. • Water research: 2 RCT’s, much focus in my writing as I attempt to understand how this basic element is important for us and how leaving it has affected us.wb m • Beverage guidelines and subsequent regs, taxes [first US, then Mexico, working with China, bunch of other countries] • Other economic changes: just not clear to me yet • Media regulations: for sure

31. Acknowledgements to My Many Key Collaborators: University of North Carolina faculty co-investigators in various or many studies:Linda Adair, Penny Gordon-Larsen, John Akin, Peggy Bentley, John Briscoe, Jane Brown, Barbara Entwisle, Kelly Evenson, Pam Haines, Gail Henderson, David Guilkey, Tom Mroz, Ron Rindfuss,Daniel Rodriquez, Anna Maria Siega-Riz, Yan Song, June Stevens, Deb Tate,DickUdry, NamvarZohoori Brazil:Carlos Monteiro Philippines:Wilhelm Fleiger, Florentino S. Solon, Others in the US: George Bray, Ben Caballero, Walt Willett, Suchi Ayala, Robert Black China: Zhai Fengying, Du Shufa, Ge Keyou, Chen Chunming, Chen Xiaoshu Mexico: Simon Barquera, Juan Rivera, Anabelle Bonvecchio Arenas, Sonia Rodriguez Russia: Polina Kozyreva, Mikhail Kosolopov, late Michael Swafford, Alexander Baturin Students and postdocs: Past:Linda Adair, Colin Bell, Colleen Doak, KiyahDuffey, Elena Glinskaya, Penny Gordon-Larsen, XuguangGuo, Lisa Jahns, Soowon Kim, Ying Liu, Mikhail Lokshin, Bing Lu, Kathleen Mctigue, Michelle Mendez, Keri Monda, Samara Nielsen, SahaspornPaeratakul, Ruth Patterson, Kathleen Reidy, Marie Richards, Jodi Stookey, Nguyen Thang, Tuan Nguyen, Carrie Waller, Youfa Wang, Monica Yamamoto, Claire Zizza Current:Tracy Dearth-Wesley, NingqiHou, Jessie Jones-Smith, ShuWen Ng, Carmen Piernas, Huijun Wang, Zhihong Wang, Daisy Zamora My right arms:Frances Dancy, Tom Swasey My Family And many coauthors of a range of papers important in my career

32. THE BOOK “The most serious epidemic ever is insidiously engulfing the world. Barry Popkin draws upon his decades of research and experience to describe its origins–and a set of potential solutions. Those interested in the future of mankind should read this book.” Walter Willett, author of Eat, Drink, and Be Healthy, and chair, Department of Nutrition, Harvard University

33. ASN Nutritional Epidemiology Research Interest Section Research Leader Webinar Series Other upcoming webinars: • December 2009 - Amy Subar, NIH/NCI • January 2010 - Keith West, Johns Hopkins Bloomberg School of Public Health • February 2010 - Michele Forman, The University of Texas • March 2010 - Katherine Tucker, Tufts University Contact Regan Bailey at baileyr@mail.nih.gov for details.