Diet, the global obesity epidemic, and prevention.

In 2008, 34% of adults (1.46 billion) globally were overweight and obese (body mass index [BMI] 25); of these, an equal proportion (502 million) were obese. This translates to a twofold increase over the last 30 years. Whereas the increase in mean BMI in high-income countries was highest in the United States, Nauru in the Oceania reported the greatest gain in BMI globally (1). China is expected to have the largest number of overweight and obese individuals in 2030 (2). Overweight and obesity are major risk factors for cardiovascular disease (CVD), type 2 diabetes mellitus, and certain forms of cancer (3,4), and account for approximately 10% of direct medical costs of countries globally (5). Furthermore, abdominal obesity and insulin resistance are the main underlying factors of the metabolic syndrome, a multiplex of cardiometabolic risk factors, generally considered to include abdominal obesity, elevated blood pressure, impaired fasting glucose, low highdensity lipoprotein (HDL) cholesterol, and elevated triglycerides (6-8). Metabolic syndrome is associated with a twofold risk for CVD and a fivefold risk for type 2 diabetes mellitus (6,9,10), and currently affects 20% to 30% of the global adult population (11). In Seychelles, a middleincome country with comprehensive data on CVD risk factors, the prevalence of metabolic syndrome increased by 16% over a 15-year period, from 20% in 1989 to 36% in 2004 (12), whereas South Korea, a high-income country, experienced an increase of 6% over 7 years from 1998 to 2005 (13,14). Medical costs for metabolic syndrome increase by approximately 24% for each additional metabolic syndrome trait present (15). The obesity epidemic and corresponding increase in metabolic syndrome prevalence are in part attributable to a global nutrition transition, with a shift from traditional plant-based foods to consumption of a more energy-