EDITOR'S NOTE - Obesity is now a global problem, spreading even to the developing world where it is contributing to new health threats. This is the first story in an occasional series on the subject by The Associated Press.
It's a bitter truth to swallow: About every fourth person on Earth is too fat. Obesity is fast becoming one of the world's leading reasons why people die.
In an astonishing testament to globalization, this outbreak of girth is occurring just as doctors are winning the fight against a number of vexing diseases.
Except in the poorest nations of Africa, new drugs and improved public health have corralled, if not cured, infectious diseases like smallpox, malaria and influenza that used to kill millions.
Now a new enemy is emerging in the 21st century - our appetite. Around the globe, about 1.7 billion people should lose weight, according to the International Obesity Task Force. Of those who are overweight, about 312 million are obese - at least 30 pounds over their top recommended weight.
Already, a third of all deaths globally are from ailments linked to weight, lack of exercise and smoking. And perhaps most worrisome is obesity's spread beyond wealthy western nations.
From the glaciers of Iceland to the palm-fringed beaches of the Philippines, there are now more fat people in the world than hungry people. And in extreme cases, people who are heavy since childhood could die as much as five to 10 years early.
"What's clear is that the developing world in particular is going to bear the enormous brunt of this weight gain," said Neville Rigby, policy director of the obesity task force.
"It's rapidly accelerating. We're even seeing obesity in adolescents in India now. It's universal. It has become a fully global epidemic - indeed, a pandemic."
U.S. nutrition scientist Barry Popkin agrees. He serves as a key adviser to the World Health Organization, which will propose the first global strategy on diet, physical activity and health next week at its annual meeting in Geneva, Switzerland.
"When you find nary a country that's being missed, nary a rural area that's being missed, let alone an urban area," Popkin said, "you've got to say it's more than an epidemic."
No country immune
Certainly the United States - home of the Whopper and the Super Big Gulp - remains a nation of scale-busters, with two of every three Americans overweight.
But there are a dozen places even worse:
South Pacific islands like Tonga, Kosrae and Nauru, where traditional meals of reef fish and taro are replaced by cheap instant noodles and deep-fried turkey tails.
Greece, birthplace of the Olympic Games, where the traditional Mediterranean diet is as much a relic as the Parthenon.
Oil-soaked Kuwait where Mercedes-driving mothers draped in black burqas feed french fries to their children while shopping for $375 giraffe-leather Italian loafers.
Soon China will be the world's biggest country in more ways than sheer population, experts predict. It's a stunning reversal from the Mao Zedong era when as many as 40 million people starved in the Great Leap Forward famine of 1958-61.
Pursuing a new doctrine of a "well-off society," Chinese cities represent the world's biggest growth market for restaurants that until recently were considered to be counterrevolutionary. Now a new KFC, Pizza Hut or Taco Bell opens almost every day. Virtually every mainland home now has a television blaring junk food ads.
When university student Li Guangxu was a baby, rice was rationed. Now he eats cookies for breakfast.
Shopping at a CarreFour supermarket in western Shanghai, the solidly built young man fills a shopping cart with cookies, potato chips, soda and beer. The bustling new store devotes 12 aisles to snacks, including the bulk bins and freezers stocked with crackers, candy, and ice cream.
"I like these things. They taste great," Li said. "I don't have time for anything else. Older folks don't eat this stuff, but we do. We like snacks."
Most scientists believe our bodies have retained a prehistoric tendency to store fuel for periods of deprivation. Modern foods are so plentiful and so packed with calories that getting fat might be biologically difficult to avoid.
But the problem is rooted in something deeper than nutrition math. Pleasure and emotional comfort are basic instincts, and eating tends to stimulate those circuits in the brain, not unlike addictive drugs.
A food fix always is within arm's reach.
Hardware emporiums host parking lot barbecues, and airports sell gooey, hot cinnamon rolls. Gas stations have morphed into grocery stores, and grocery stores have ballooned into warehouses. You can buy potato chips whether you are trekking in Nepal or paddling a chocolate-brown river in Borneo's tropical jungles.
Who can resist? Almost no one.
"I compare the propensity to eat as somewhere between the propensity to breathe and the propensity to have sex," said Stephen Bloom, chief of metabolic medicine at the University of London's Imperial College. "Just saying, 'Stop eating!' doesn't work. It's much worse than stopping smoking."
Weight's health effects
Simply being fat won't necessarily kill you outright. And it's not weight alone that determines your risk from several diseases. But being overweight carries severe consequences.
Diabetes, heart disease and some cancers have been linked to weight, and all are on the rise.
Type 2 Diabetes is the illness most directly linked to obesity. A condition that often leads to heart disease and kidney failure, it is blamed for more than 3 million deaths a year. It afflicts 154 million people - nearly four times the number who have HIV or AIDS - and the WHO forecasts more than twice as many people will develop diabetes in the next 25 years.
Obesity can triple the risk of heart disease. One-third of all deaths globally - about 17 million - are blamed on heart disease, stroke and related cardiovascular problems, WHO figures show.
Some scientists predict it will outstrip infectious killers by the end of the decade.
Countries with extensive health care have stalled the onset of heart disease into old age and saved lives. But in much of the world, the latest drugs and arterial scouring procedures are not widely available.
In those countries, fatal heart attacks and strokes are much more common among younger, working age adults.
Researchers from Columbia University's Earth Institute examined Brazil, China, India, South Africa and the Russian republic of Tartarstan. They found that the heart disease death rate for adults ages 30-59 was up to twice as high as the U.S. rate. Among Russians in the study, the rate was up to five times higher.
Obesity was cited as a primary factor, along with smoking, lack of exercise and untreated high blood pressure. The researchers described the influence of unhealthy diets as "surprising."
"Never before ... have so many people been at risk of premature death," they wrote.
In South Africa, 11 percent of the population has HIV. Yet cardiovascular disease there still accounts for a higher rate of death among men and women under age 45.
Over the next 30 years, the trend in those counties is projected to worsen.
In India, more than a quarter of the 5 million people who die from heart attacks and strokes every year are younger than 65. This exceeds U.S. rates in the 1950s before aggressive cardiac care and prevention, said study co-author Susan Raymond.
Obesity also plays a significant, if poorly understood, role in many cancers. WHO data shows cancer accounts for about 12.5 percent of the world's deaths, and that rate is expected to increase dramatically, mostly in developing countries.
The fact that obesity is on the rise in these countries as well is due to a confluence of factors that researchers say must be examined.
The global trend toward weight gain and its associated illnesses is not restricted to the well-off. High-fat, high-starch foods tend to be cheaper, so poor people eat more of them.
In Mexico, 40 percent of its 105 million people live in poverty. Yet two-thirds of men and women there are overweight or obese.
In the slums of Sao Paulo, Brazil, 30 percent of the schoolchildren in 500 poor families have stunted growth due to poor diet. Yet, reports the Pan American Health Organization, about 6 percent of the children and 9 percent of the adults were obese, too.
In southern Africa, Zambia, which experienced a food crisis in 2002, reports that 10 percent to 15 percent of urban schoolchildren are obese.
"It's a myth that you can't have poverty and obesity coexisting," said Tufts University nutritionist Bea Rogers.
How it happened
Many factors contribute to the widening of the world's waistline.
"For the last 150 years we've been getting fatter," said Bloom. But now, he says, "everything has kind of come together."
For starters, there is cheap, plentiful food. In developing countries, people still spend 40 percent of their income on food, as opposed to 15 percent by American families.
But even in poor nations, the relative cost of eating is declining as the world's farmers are able to grow huge quantities of grain that is quickly processed and shipped without spoilage.
According to U.N. figures, the consumption of oils and fats over the last 30 years has doubled and is forecast to keep growing.
"In the developing world, it happened overnight," said WHO adviser Popkin, who heads nutrition epidemiology at the University of North Carolina. "One year they had very expensive butter and the next year edible oil came on the scene. It was a tenth of a cost and all of a sudden for very little money you could make your food taste better."
Nutritionists say more and cheaper sugar is another factor, despite the industry's strenuous denials.
James E. Tillotson, director of Tufts University's Food Policy Institute, calculates the average American drinks the equivalent of a 55-gallon drum of soda every year, compared to 20 gallons of sweetened beverages a year in 1970.
Increases almost as dramatic have occurred in Europe, and soft drink factories are increasingly popping up in developing countries.
Tillotson, who developed fruit-based drinks for Ocean Spray in the 1980s, says the beverage industry did not consider the health ramifications of their now-ubiquitous products.
"We never thought people would abuse them," he said. "What everybody wanted and liked has become dangerous."
Slowly, the food industry is responding.
McDonald's has healthier menus and is phasing out super-sizing. Kraft Foods, whose products range from Oreos to Jell-O in 150 countries, has a scientific advisory panel. Among the company's initiatives: capping the portion size of single-serving packaging.
Much of Big Food's response comes after failed efforts by obese people to sue fast-food chains for damages.
"A lot of chief executives are really in a state of shock right now," said international nutrition expert Andrew Prentice of the London School of Hygiene and Tropical Medicine. "They've produced this stuff, cheaper and cheaper, feeding the world. All of a sudden, we're saying, 'Stop doing this!"'
Another factor is how food is promoted and distributed. Brightly packaged brands that remain safe for months have widely replaced fresh bulk foods sold in community markets.
In 1990, no more than 15 percent of food bought in Latin America came from supermarkets. Now, 60 percent is from six supermarket chains.
Experts say that because the changes occurred so rapidly and medical care is so lagging, the developing world's obesity problem - combined with more cigarette smoking - could be both public health and economic disasters in countries that were verging on prosperity.
There are demographic changes, too. In many nations, women joining the work force created a demand for convenience foods.
"We already are tired from working and we buy only packaged foods," said Bertha Rodriguez of Mexico City. The 61-year old great-grandmother is a widow who supports herself by frying quesadillas in a streetside stand. One health concession: She now uses vegetable oil instead of lard.
"Before, we were at home preparing something light and nutritious," she said.
People spend more time sitting in the car, at the computer and especially in front of the television - an average of 1,669 hours a year in the United States, a habit that is extending internationally.
With such low activity levels, as little as 100 extra calories a day translates into 10 pounds in a year.
"Physical activity is not on the front burner in many people's minds, said Stephen Blair, research director at the Cooper Institute of Aerobics Research in Dallas.
Technology is changing people's activity levels even in the poorest nations, where backbreaking work and hauling water from the community well was the norm.
In China's megacities, crowds once pedaled identical black bicycles to work. Now adults drive cars and ride trains and buses. In southeast Asia, farmers are replacing water buffalo plows with tiny tractors, and choosing crop chemicals over hand cultivation.
"It was done with the best of intentions," Bloom said. "Telephones, cars, computers all come from the freedom from hunger and fear. But it's had a bad side effect."
Governments in some developing nations are taking steps.
Singapore schools have added physical activities and replaced soft drinks with bottled water. Brazil is making school lunch programs serve fruits and vegetables.
Such efforts are among those the World Health Organization says will be necessary to prevent a worldwide crisis.
But it's a battle against human nature.
Experts say it's unreasonable to expect people with 21st century lifestyles and desires to return to a leaner, 1950s-era silhouette.
"It would be a huge public health achievement if we simply stopped the weight gain where it is now," Blair said.
"I think that's what we're stuck with."
Medical Writer Emma Ross reported from London and Science Writer Joseph Verrengia reported from Denver. Elaine Kurtenbach in Shanghai and Morgan Lee in Mexico City contributed to this report.