Clogged arteries and sedentary lifestyles have replaced germs as the world's leading killers. Where hunger once held much of the world in its grip, the 1.6 billion overweight and obese now outnumber the malnourished by nearly 2-to-1.
The United States clearly has a weight problem. The World Health Organization says a third of American adults were obese in 2008, and 69.4 percent were overweight. Two years later, WHO said 80 percent of American adult men were overweight, along with 77 percent of women. Obesity accounts for at least $150 billion a year in American health care spending.
But obesity is spreading more rapidly in other parts of the world. Saudi Arabia and other Arab states, along with many Pacific island nations, are fatter than the United States. (Most of the adult population of Samoa is obese; in 2008, 46.3 percent of Egyptian women were obese.) Mexican women are heavier than U.S. women, and once the latest data is sifted, Mexican men may eclipse U.S. men as well.
Much of the turnaround reflects advances in public health. In 1900, pneumonia, tuberculosis and childhood diarrhea were the leading killers of Americans. Those were replaced by noninfectious diseases such as heart attacks, strokes and cancer.
That transition has now occurred worldwide. The most recent WHO statistics show that in 2008, 63 percent of deaths around the world were caused by non-communicable diseases - and that 80 percent of them occurred in low- and middle-income countries. By itself, obesity kills 2.8 million people a year, and it is the fifth-leading risk factor for death worldwide. (The top four risk factors are high blood pressure, tobacco use, raised blood sugar and physical inactivity.)
Some health specialists call these diseases of affluence or civilization. But they place an enormous health care cost burden on society, and lead to many premature deaths as well, WHO officials say. Mexico, for instance, expects the cost to treat obesity-related illnesses like type-2 diabetes will nearly triple by 2017, to $73 billion.
"Yes, we've eradicated some of these diseases. Most nations are no longer starving. Nutrition is available for everyone," said Deborah Clegg, an associate professor of nutrition at the UT Southwestern Medical Center. "But good and healthy calories are not available to everyone."
Countries across the world are trying to come to grips with this major shift in public health. Japanese companies require employees to undergo annual physicals that include waistline measurements. Men over 33.5 inches and women over 35.4 inches count against the company. If too many fail the test, the firm has to increase its contributions to public health care for the elderly.
Several countries tax soft drinks and other sugared beverages. Mexican legislators introduced a bill last month that would add a 20 percent tax to the cost of such drinks. In 2011, the average Mexican adult consumed 728 servings of Coca-Cola, according to the company's statistics. (The average American consumed 403 servings.)
China's Health Ministry has asked Dr. Kenneth Cooper of Dallas, founder and chairman of Cooper Aerobics, to explore the introduction of FitnessGram testing among its schoolchildren. Cooper says Ross Perot kicked in $2 million to help pay for a computer system to aggregate the results.
"He told me, 'I believe what you are doing to improve the health of their children is the most beneficial thing we can do to improve relations with China,'" Cooper said of Perot.
"Ten years ago, they didn't have any obesity in China. None at all," Cooper said. "Now it's jumping fast. They're sharp enough to know they are seeing the handwriting on the wall."
The problem is as simple as it is difficult to solve, said Todd Whitthorne, president and CEO of Cooper Wellness in Dallas. Too many calories in, and too little physical exertion to burn them up.
"Our world has changed. We eat differently, we work differently and we don't move very much. We're not only eating more, but we're eating more that's inferior from a nutrition standpoint," he said. "Poor-quality food is what's ultimately causing this increase in obesity."
WHO estimates that 45 percent of Chinese men are overweight or obese, along with 32 percent of Chinese women.
The weight gains coincide with a change in Chinese lifestyles. A third of Chinese adults no longer get sufficient exercise (30 minutes of moderate activity five times a week, or 20 minutes of vigorous exercise three times a week).
And there is much more to eat. In 1989, 14.7 percent of Chinese got 30 percent or more of their calories from fat. By 2006, that had climbed to 44.7 percent, according to Barry Popkin, a professor of nutrition at the University of North Carolina and author of the book, "The World Is Fat."
In the same time period, fast-food restaurants have popped up all across China.
The slogan of Yum Brands, Inc., which includes Dallas-based Pizza Hut as well as KFC and Taco Bell restaurants, is "Serving the World." The company has 38,000 fast-food outlets globally, including 740 Pizza Huts and 4,043 KFCs in China.
Company chairman David Novak told investors last month that the company plans to add 600 restaurants a year in China, and more than 150 next year in India.
"We are literally everywhere, and we have tremendous opportunity going forward," he said.
Yum's chief nutritionist, Jonathan Blum, was not available to comment for this article. The company instead released a statement:
"We believe that all food can be part of a balanced diet if eaten in moderation and balanced with appropriate exercise. Yum Brands was the first company to eliminate trans fats, we led the effort to put calorie information on menu boards and we continue to reduce sodium levels in our products."
Popkin says restaurant and food companies have a greater responsibility.
"Our food industry has done a very good job of trying to convince everyone that this isn't a problem of their ads for fast food, or the vending machines in schools or that every movie and every TV show is selling the stuff upside and down, but that it's people's responsibility," he said. "We're about the only country that's gone in that direction. Most every other country says it's the environment that's changed."
Clegg of UT Southwestern sees a strong correlation between the rise of obesity and the westernization of foreign cultures - "Burger King, Starbucks and the like."
It's also affecting countries with a reputation for resisting the lure of fast food - like France.
"I just got back from Paris," Clegg said. "Parisians who would sit down and have a fabulous meal have now jumped on the McDonald's bandwagon. They're in and out of fast-food places. It's no longer the same type of cultural environment."
Clegg said she was "shocked" to see how many Starbucks outlets are in Paris, a city with a reputation for fine, small cups of coffee.
"I was really honestly shocked to see people going for a tankard of coffee with whipped cream ... and really, really high sugar content."
To combat this trend, governments around the world have tried a variety of strategies.
Two years ago, WHO published a list of 12 recommendations to protect children from the heavy marketing of foods high in fats, sugar and salt. The European Union warned companies to cut back or face regulation. Such ads are down 29 percent.
Colombia is building bicycle paths and banning all but bikes and pedestrians on certain roads on Sundays. Mauritius' government prodded cooking oil makers to switch from palm oil to soybean oil. (Total cholesterol concentrations fell significantly.)
In New Zealand, WHO reports 64 percent of adults are overweight or obese, while 48 percent don't get enough exercise. Primary care physicians include a discussion of the benefits of exercise with their patients and write up a "green prescription" of agreed goals for improvement. The prescription is faxed to the patient's local sports foundation, where exercise specialists call the patient at least three times to see how it's going.
WHO says New Zealand is getting results with this approach. Among patients followed by testers, the number of calories burned increased by more than 1,200 a week.
"There are really an enormous number of things going on by other countries, while the U.S. has hardly any," Popkin said. "We may have talked about it in nutrition circles, but our government has been unwilling to take on anything seriously."
It's no mystery why, Clegg said.
"People believe it's their right to have a piece of chocolate cake, independent of what the consequences are."