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The trends in obesity rates from the 1980s to 2008 were beautifully illustrated by Finucaneand others [16] in a comprehensive analysis of huge data sets from around the world, as shown in Figure 1.1. The data reveal marked differences in the prevalences of males and females. In males, it is clear that the more affluent a society in 1980 then the greater the likelihood of some obesity. Thus North America, Latin America, Australia, and Europe had overall prevalences of 10% obesity. In general, the greater the degree of regional affluence, the greater the increase in obesity rates in men over the subsequent 28 years. However, in the early 1980 data, the highest level of obesity among women was not found in North America but rather in emerging counties in Southern Africa, North Africa, the Middle East, and Central Latin America, with Asian women having the lowest levels. In the following three decades, the 1980 regional ranking in women was generally preserved with the fattest regions showing the most significant increases in obesity so that by 2008 several regions of the world were approaching a 40% prevalence of obesity in women.

Since these comprehensive analyses of obesity prevalences, there has been a series of updates both by the Ezzati and Murray groups [17] supported by the Gates Foundation and by the OECD [18] with updates [19] – as well as by a range of national expert groups [20,21]. These data stimulate the question as to why this epidemic had become so striking and seemingly resistant to change and, indeed, how might the problem be tackled? This resistance to change is evident, for example, from surveys conducted by Public Health England who showed that 40% or more of men and over 50% of women aged 25–74 years were trying to lose weight in 2016 [22] and yet the obesity rates remain high suggesting that under current circumstances individuals attempt to slim is very ineffective as a population strategy.

Using historical records, Jaacks and others [23] then examined the evolution of obesity and highlighted four phases in the chronological development of obesity:

 Stage 1. Obesity is more prevalent in women than in men and is evident in more affluent groups with low prevalence rates in children. This phase is still evident in many South Asian countries and sub‐Saharan Africa.

 Stage 2. In stage 2 of the transition, there has been a significant increase in the adult obesity rates with less of a gap between the sexes and in terms of socioeconomic differences. Many Latin American and Middle Eastern countries are at this stage.

 Stage 3. In this stage, a swing occurs with those of lower socioeconomic status now having a higher obesity prevalence, but the more affluent women and children do not show any further secular increase. These features are evident in Europe.

 Stage 4. This stage is where obesity prevalence actually declines but is a phenomenon we have yet to observe.

In within‐country analyses, higher rates of obesity are traditionally associated with urban environments, but Ezzati and colleagues have highlighted that more recently there has also been a marked increase in rural obesity [24]. This implies that the drivers of obesity were originally most evident in urban areas, but as the world has developed, the factors promoting obesity have penetrated the rural communities and/or the rural environment has lost some of the factors which limited the development of obesity.