874 | Nature | Vol 615 | 30 March 2023

Article

Diminishing benefits of urban living for 
children and adolescents’ growth and 
development

NCD Risk Factor Collaboration (NCD-RisC)*

Optimal growth and development in childhood and adolescence is crucial for lifelong 
health and well-being1–6. Here we used data from 2,325 population-based studies, with 
measurements of height and weight from 71 million participants, to report the height 
and body-mass index (BMI) of children and adolescents aged 5–19 years on the basis 
of rural and urban place of residence in 200 countries and territories from 1990 to 
2020. In 1990, children and adolescents residing in cities were taller than their rural 
counterparts in all but a few high-income countries. By 2020, the urban height 
advantage became smaller in most countries, and in many high-income western 
countries it reversed into a small urban-based disadvantage. The exception was  
for boys in most countries in sub-Saharan Africa and in some countries in Oceania,  
south Asia and the region of central Asia, Middle East and north Africa. In these 
countries, successive cohorts of boys from rural places either did not gain height  
or possibly became shorter, and hence fell further behind their urban peers. The 
difference between the age-standardized mean BMI of children in urban and rural 
areas was <1.1 kg m–2 in the vast majority of countries. Within this small range, BMI 
increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan 
Africa and some countries in central and eastern Europe. Our results show that in 
much of the world, the growth and developmental advantages of living in cities have 
diminished in the twenty-first century, whereas in much of sub-Saharan Africa they 
have amplified.

The growth and development of school-aged children and adolescents 
(ages 5–19 years) are influenced by their nutrition and environment at 
home, in the community and at school. Healthy growth and develop-
ment at these ages help consolidate gains and mitigate inadequacies 
from early childhood and vice versa1, with lifelong implications for 
health and well-being2–6. Until recently, the growth and development 
of older children and adolescents received substantially less atten-
tion than in early childhood and adulthood7. Increasing attention 
on the importance of health and nutrition during school years has 
been accompanied by a presumption that differences in nutrition and 
the environment lead to distinct, and generally less healthy, patterns 
of growth and development at these ages in cities compared to rural 
areas8–17. This presumption is despite some empirical studies showing 
that food quality and nutrition are better in cities18,19.

Data on growth and developmental outcomes during school ages 
are needed, alongside data on the efficacy of specific interventions and 
policies, to select and prioritize policies and programmes that promote 
health and health equity, both for the increasing urban population and 
for children who continue to grow up in rural areas. Consistent and com-
parable global data also help benchmark across countries and territories 
and draw lessons on good practice. Yet, globally, there are fewer data on 
growth trajectories in rural and urban areas in these formative ages than 

for children under 5 years of age20 or for adults21. The available studies 
have been in one country, at one point in time and/or in one sex and nar-
row age groups. The few studies that covered more than one country22–24 
mostly focused on older girls and used at most a few dozen data sources 
and hence could not systematically measure long-term trends. Conse-
quently, many policies and programmes that aim to enhance healthy 
growth and development in school ages focus narrowly and generically 
on specific features of nutrition or the environment in either cities or 
rural areas10,13,25–28. Little attention has been paid to the similarities and 
differences between relevant outcomes in these settings or to the het-
erogeneity of the urban–rural differences across countries.

Here we report on the mean height and BMI of school-aged chil-
dren and adolescents residing in rural and urban areas of 200 coun-
tries and territories (referred to as countries hereafter) from 1990 to 
2020. Height and BMI are anthropometric measures of growth and 
development that are influenced by the quality of nutrition and healthi-
ness of the living environment and are highly predictive of health and 
well-being throughout life in observational and Mendelian randomiza-
tion studies2–6. These studies have shown that having low height and 
excessively low BMI increases the risk of morbidity and mortality, and 
low height impairs cognitive development and reduces educational 
performance and work productivity in later life2–4. A high BMI in these 

https://doi.org/10.1038/s41586-023-05772-8

Received: 27 May 2022

Accepted: 30 January 2023

Published online: 29 March 2023

Open access

 Check for updates

*A list of authors and their affiliations appears online.

https://doi.org/10.1038/s41586-023-05772-8


Nature | Vol 615 | 30 March 2023 | 875

ages increases the lifelong risk of overweight and obesity and several 
non-communicable diseases, and might contribute to poor educational 
outcomes5,6.

We used 2,325 population-based studies that measured height and 
weight in 71 million participants in 194 countries (Extended Data Fig. 1 
and Supplementary Table 2). We used these data in a Bayesian hier-
archical meta-regression model to estimate mean height and BMI of 
children and adolescents aged 5–19 years by rural and urban place of 
residence, year and age for 200 countries. Details of data sources and 
statistical methods are provided in the Methods. Our results repre-
sent the height and BMI for children and adolescents of the same age 
over time (that is, successive cohorts) in rural and urban areas of each 
country, and the difference between the two. For presentation, we 
summarize the 15 age-specific estimates, for single years of age from 
5 to 19, through age standardization, which puts each country-year’s 
child and adolescent population on the same age distribution and 
enables comparisons to be made over time and across countries. We 
also show results, graphically and numerically, for index ages of 5, 10, 
15 and 19 years in the Supplementary Information.

In 1990, school-aged boys and girls who lived in cities had a height 
advantage (that is, were taller) compared with their rural counterparts. 
The exception was in high-income countries, where the urban height 
advantage was either negligible (<1.2 cm for age-standardized mean 
height; posterior probability (PP) for children living in urban areas being 
taller ranging from 0.51 to >0.99) or there was a small rural advantage 
(for example, Belgium, the Netherlands and the United Kingdom) (PP 
for children in rural areas being taller ranging from 0.53 to >0.95 where 
there was a rural height advantage) (Fig. 1 and Extended Data Fig. 2). The 

largest height differences between children and adolescents in cities 
and rural areas in 1990 occurred in some countries in Latin America (for 
example, Mexico, Guatemala, Panama and Peru), east and southeast Asia 
(China, Indonesia and Vietnam), central and eastern Europe (Bulgaria, 
Hungary and Romania) and sub-Saharan Africa (Democratic Republic 
of Congo (DR Congo) and Rwanda). The urban height advantage in boys 
and girls in the named countries ranged from 2.4 to 5.0 cm, and the 
PP of children living in urban areas being taller than children living in 
rural areas was >0.99 (see Supplementary Table 3 for country-specific 
numerical values of height in children living in rural versus urban areas, 
their difference and the corresponding credible intervals (CrIs)).

The urban–rural height gap in the late twentieth century among 
low-income and middle-income countries was determined by how 
much children and adolescents in cities and rural areas had approached 
as opposed to fallen behind their peers in high-income countries, where 
there was little difference between urban and rural height. In countries 
such as Bulgaria, Hungary and Romania, the height of children and 
adolescents living in urban areas approached that of high-income coun-
tries, whereas children and adolescents in rural areas lagged behind, 
leading to a relatively large gap. In much of sub-Saharan Africa and 
south Asia, the height of children and adolescents lagged behind their 
peers in high-income countries regardless of where they lived, such that 
the urban–rural gap was relatively small. In a third group of low-income 
or middle-income countries that included Indonesia, Vietnam, Panama, 
Peru, DR Congo and Rwanda, children living in urban areas remained 
shorter than in high-income countries, but children from rural areas 
lagged even further behind, such that the urban–rural gap became 
large.

High-income Asia Paci�c

High-income western

East and southeast Asia

Central and eastern Europe

Sub-Saharan Africa

Oceania

Latin America and Caribbean

South Asia

Oceania

Latin America and Caribbean

South Asia

Age-standardized mean rural height (cm)

U
rb

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140 150 140 150 140 150

Age-standardized mean rural height (cm)

140 150 140 150 140 150

−1

0

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Fig. 1 | Change in the urban–rural height difference from 1990 to 2020.  
a,b, Change in the urban–rural difference in age-standardized mean height in 
relation to the change in age-standardized mean rural height in girls (a) and 
boys (b). Each solid arrow in lighter shade shows one country beginning in 1990 
and ending in 2020. The dashed arrows in darker shade show the regional 
averages, calculated as the unweighted arithmetic mean of the values for all 
countries in each region along the horizontal and vertical axes. For the urban–
rural difference, a positive number shows a higher urban mean height and a 

negative number shows higher rural mean height. See Extended Data Fig. 2 for 
urban–rural differences in age-standardized mean height and their change 
over time shown as maps, together with uncertainties in the estimates. See 
Supplementary Fig. 4a for results at ages 5, 10, 15 and 19 years. We did not 
estimate the difference between rural and urban height for countries classified 
as entirely urban (Bermuda, Kuwait, Nauru and Singapore) or entirely rural 
(Tokelau).



876 | Nature | Vol 615 | 30 March 2023

Article

By 2020, the urban height advantage in school ages became smaller 
in much of the world. In many high-income western countries and 
some central European countries, it disappeared or reversed into a 
small (typically <1 cm) urban disadvantage (Fig. 1 and Extended Data 
Figs. 2 and 8). Countries with substantial convergence over these three  
decades were in central and eastern Europe (for example, Croatia), Latin 
America and the Caribbean (for example, Argentina, Brazil, Chile and 
Paraguay), east and southeast Asia (for example, Taiwan) and for girls 
in central Asia (for example, Kazakhstan and Uzbekistan). The urban 
height advantage in the named countries declined by around 1–2.5 cm 
from 1990 to 2020 (the PP of urban–rural height difference having 
declined ≥0.90 for the named countries). In many other middle-income 
countries (for example, China, Romania and Vietnam), the urban–
rural height gaps declined, but children and adolescents living in cit-
ies remained taller than their rural counterparts (by 1.7–2.5 cm in the 
named countries for boys and girls; the PP of children in cities being 
taller than children in rural areas in 2020 >0.99). The exception to this 

convergence was for boys in most countries in sub-Saharan Africa and 
some countries in Oceania, south Asia and the region of central Asia, 
Middle East and north Africa, where the urban height advantage slightly 
increased over these three decades. The largest increase in the urban 
height advantage for boys occurred in countries in east Africa such as 
Ethiopia (0.9 cm larger height gap in 2020 than 1990; 95% CrI −0.9 to 
2.9, and PP of an increase of 0.86), Rwanda (1.0 cm larger gap, 95% CrI 
−0.7 to 3.0, and PP 0.88) and Uganda (1.1 cm larger gap, 95% CrI of −0.6 
to 3.1, and PP 0.89). For girls, the urban–rural gap remained largely 
unchanged in many countries in sub-Saharan Africa and south Asia.

In middle-income countries  and emerging economies (newly 
high-income and industrialized countries) where the height of children 
and adolescents residing in rural areas converged to those in cities, 
successive cohorts of children and adolescents living in rural areas 
outpaced their urban counterparts in becoming taller and attained 
heights that urban children in the same countries had done decades 
earlier: growing to heights closer to those seen in high-income countries  

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Fig. 2 | See next page for caption.



Nature | Vol 615 | 30 March 2023 | 877

(Figs. 2 and 3). Successive cohorts of children and adolescents residing 
in rural areas in sub-Saharan Africa did not experience the accelerated 
height gain seen in cohorts in rural areas of middle-income countries. 
Notably, in the case of boys living in sub-Saharan Africa, there was no gain,  
or possibly a decrease, in height, which in turn led to a persistence or 
even widening of the urban–rural gap. As a result of these global trends, 
by 2020, the largest urban–rural gaps in height were seen in Andean and 
central Latin America (for example, Bolivia, Panama and Peru, by up 
to 4.7 cm (95% CrI 4.0–5.5 cm) for boys and 3.8 cm (95% CrI 3.3–4.3 cm) 
for girls) and, especially for boys, in sub-Saharan Africa (for example,  
DR Congo, Ethiopia, Mozambique and Rwanda, by up to 4.2 cm  
(95% CrI 2.7–5.7 cm)).

The urban–rural BMI difference was relatively small throughout these 
three decades, <1.4 kg m–2 in all countries and years and <1.1 kg m–2 in all 
but nine countries, for age-standardized mean BMI (Fig. 4 and Extended 
Data Figs. 3 and 9). In 1990, the urban–rural BMI gap was largest in 
sub-Saharan Africa (for example, Ethiopia, Kenya, Malawi, South Africa 
and Zimbabwe) and south Asia (for example, Bangladesh and India), 
followed by parts of Latin America (for example, Mexico and Peru). The 
urban–rural BMI gap in the two sexes in the named countries ranged 
from 0.4 to 1.2 kg m–2, and the PP of children and adolescents living in 
urban areas having a higher BMI than those in rural areas was ≥0.89. 
At that time, girls and/or boys in rural areas of some of these countries 
had mean BMI levels that were close to, and in some ages below, the 
thresholds of being underweight (>1 s.d. below the median of the World 
Health Organization (WHO) reference population).

From 1990 to 2020, the BMI of successive cohorts of children and 
adolescents in both urban and rural areas increased in all but a few 
mostly high-income countries (for example, Denmark, Italy and 
Spain) (Figs. 5 and 6). There was heterogeneity in low-income and 
middle-income countries in how much the BMI increased in cities com-
pared with rural areas. In the majority of countries in sub-Saharan Africa 

and south Asia, the BMI of successive cohorts of children and adoles-
cents increased more in rural areas than in cities, leading to a closing 
of the urban–rural difference. The urban–rural BMI gap declined by up 
to 0.65 kg m–2 for both girls and boys, and the PP that the urban–rural 
BMI difference declined from 1990 to 2020 ranged from 0.52 to 0.95. In 
both sub-Saharan Africa and south Asia, these changes shifted the mean 
BMI of boys and girls in rural areas out of the range for being under-
weight. Moreover, in many countries in sub-Saharan Africa, this shift 
continued beyond the median of the WHO reference population and 
in some cases approached the threshold for being overweight (>1 s.d. 
above the median of the WHO reference population). The opposite, a 
larger increase in urban BMI, happened in most other low-income and 
middle-income countries, leading to a slightly larger urban BMI excess 
in 2020 than in 1990. High-income countries and those in central and 
eastern Europe experienced a mix of increasing and decreasing urban 
BMI excess, but remained within a small range (−0.3 to 0.6 kg m–2 for 
almost all countries) over the entire period of analysis. At the regional 
level, the urban–rural BMI difference changed by <0.25 kg m–2 in these 
regions.

The urban height advantage was larger in boys than girls in most 
countries (Supplementary Fig. 3). Urban excess BMI was larger in boys 
than girls in only about one-half of the countries. For the other half, 
mostly in high-income western countries and those in sub-Saharan 
Africa, urban excess BMI was larger in girls than boys. The urban height 
advantage was slightly larger at 5 years of age than at 19 years of age 
in most low-income and middle-income countries, especially for girls, 
but there was little difference across ages in high-income regions and 
in central and eastern Europe (Supplementary Fig. 4).

Since the introduction of modern sanitation in the nineteenth cen-
tury, cities provided substantial nutritional and health advantages in 
high-income and subsequently low-income and middle-income coun-
tries19. Our results show that in the twenty-first century, during school 

Fig. 2 | Urban and rural height in 2020 and the change from 1990 to 2020  
for girls. a, Age-standardized mean height in 2020 by urban and rural place  
of residence for girls. The density plots show the distribution of estimates 
across countries. b, Age-standardized change in mean height from 1990 to 
2020 by urban and rural place of residence for girls. The density plots show  
the distribution of estimates across countries. c, Change in mean height from 
1990 to 2020 in relation to the uncertainty of the change measured by posterior 
standard deviation. Each point in the scatter plots shows one country. Shaded 
areas approximately show the PP of an estimated change being a true increase 
or decrease. The PP of a decrease is one minus that of an increase. If an increase 
in mean height is statistically indistinguishable from a decrease, the PP of an 
increase and a decrease is 0.50. PPs closer to 0.50 indicate more uncertainty, 
whereas those towards 1 indicate more certainty of change. d, Age- 
standardized mean height in 2020 for all countries. The height of each column 
is the posterior mean estimate shown together with its 95% CrI. Countries are 
ordered by region and super-region. See Extended Data Fig. 4 for a map of PP of 
the estimated change. See Supplementary Fig. 5 for results at ages 5, 10, 15 and 
19 years. See Supplementary Table 3 for numerical results, including Crls, as 
age-standardized and at ages 5, 10, 15 and 19 years. We did not estimate mean 
rural height in countries classified as entirely urban (Bermuda, Kuwait, Nauru 
and Singapore), mean urban height in countries classified as entirely rural 
(Tokelau) or their change over time in these countries, as indicated in grey. 
Countries are labelled using their International Organization for 
Standardization (ISO) 3166-1 alpha-3 codes. Afghanistan, AFG; Albania, ALB; 
Algeria, DZA; American Samoa, ASM; Andorra, AND; Angola, AGO; Antigua and 
Barbuda, ATG; Argentina, ARG; Armenia, ARM; Australia, AUS; Austria, AUT; 
Azerbaijan, AZE; Bahamas, BHS; Bahrain, BHR; Bangladesh, BGD; Barbados, 
BRB; Belarus, BLR; Belgium, BEL; Belize, BLZ; Benin, BEN; Bermuda, BMU; Bhutan, 
BTN; Bolivia, BOL; Bosnia and Herzegovina, BIH; Botswana, BWA; Brazil, BRA; 
Brunei Darussalam, BRN; Bulgaria, BGR; Burkina Faso, BFA; Burundi, BDI; Cabo 
Verde, CPV; Cambodia, KHM; Cameroon, CMR; Canada, CAN; Central African 
Republic, CAF; Chad, TCD; Chile, CHL; China, CHN; Colombia, COL; Comoros, 
COM; Congo, COG; Cook Islands, COK; Costa Rica, CRI; Cote d'Ivoire, CIV; 

Croatia, HRV; Cuba, CUB; Cyprus, CYP; Czechia, CZE; Denmark, DNK; Djibouti, 
DJI; Dominica, DMA; Dominican Republic, DOM; DR Congo, COD; Ecuador, ECU; 
Egypt, EGY; El Salvador, SLV; Equatorial Guinea, GNQ; Eritrea, ERI; Estonia, EST; 
Eswatini, SWZ; Ethiopia, ETH; Fiji, FJI; Finland, FIN; France, FRA; French Polynesia, 
PYF; Gabon, GAB; Gambia, GMB; Georgia, GEO; Germany, DEU; Ghana, GHA; 
Greece, GRC; Greenland, GRL; Grenada, GRD; Guatemala, GTM; Guinea Bissau, 
GNB; Guinea, GIN; Guyana, GUY; Haiti, HTI; Honduras, HND; Hungary, HUN; 
Iceland, ISL; India, IND; Indonesia, IDN; Iran, IRN; Iraq, IRQ; Ireland, IRL; Israel, 
ISR; Italy, ITA; Jamaica, JAM; Japan, JPN; Jordan, JOR; Kazakhstan, KAZ; Kenya, 
KEN; Kiribati, KIR; Kuwait, KWT; Kyrgyzstan, KGZ; Lao PDR, LAO; Latvia, LVA; 
Lebanon, LBN; Lesotho, LSO; Liberia, LBR; Libya, LBY; Lithuania, LTU; 
Luxembourg, LUX; Madagascar, MDG; Malawi, MWI; Malaysia, MYS; Maldives, 
MDV; Mali, MLI; Malta, MLT; Marshall Islands, MHL; Mauritania, MRT; Mauritius, 
MUS; Mexico, MEX; Micronesia (Federated States of), FSM; Moldova, MDA; 
Mongolia, MNG; Montenegro, MNE; Morocco, MAR; Mozambique, MOZ; 
Myanmar, MMR; Namibia, NAM; Nauru, NRU; Nepal, NPL; Netherlands, NLD; 
New Zealand, NZL; Nicaragua, NIC; Niger, NER; Nigeria, NGA; Niue, NIU; North 
Korea, PRK; North Macedonia, MKD; Norway, NOR; Occupied Palestinian 
Territory, PSE; Oman, OMN; Pakistan, PAK; Palau, PLW; Panama, PAN; Papua 
New Guinea, PNG; Paraguay, PRY; Peru, PER; Philippines, PHL; Poland, POL; 
Portugal, PRT; Puerto Rico, PRI; Qatar, QAT; Romania, ROU; Russian Federation, 
RUS; Rwanda, RWA; Saint Kitts and Nevis, KNA; Saint Lucia, LCA; Samoa, WSM; 
Sao Tome and Principe, STP; Saudi Arabia, SAU; Senegal, SEN; Serbia, SRB; 
Seychelles, SYC; Sierra Leone, SLE; Singapore, SGP; Slovakia, SVK; Slovenia, 
SVN; Solomon Islands, SLB; Somalia, SOM; South Africa, ZAF; South Korea, 
KOR; South Sudan, SSD; Spain, ESP; Sri Lanka, LKA; Saint Vincent and the 
Grenadines, VCT; Sudan, SDN; Suriname, SUR; Sweden, SWE; Switzerland,  
CHE; Syrian Arab Republic, SYR; Taiwan, TWN; Tajikistan, TJK; Tanzania, TZA; 
Thailand, THA; Timor-Leste, TLS; Togo, TGO; Tokelau, TKL; Tonga, TON; Trinidad 
and Tobago, TTO; Tunisia, TUN; Turkey, TUR; Turkmenistan, TKM; Tuvalu, TUV; 
Uganda, UGA; Ukraine, UKR; United Arab Emirates, ARE; United Kingdom, GBR; 
United States of America, USA; Uruguay, URY; Uzbekistan, UZB; Vanuatu, VUT; 
Venezuela, VEN; Vietnam, VNM; Yemen, YEM; Zambia, ZMB.



878 | Nature | Vol 615 | 30 March 2023

Article

ages, these advantages have disappeared in high-income countries and 
diminished in middle-income countries and emerging economies in Asia, 
Latin America and the Caribbean, and parts of Middle East and north 
Africa. Specifically, in these settings, successive cohorts of school-aged 
children and adolescents living in cities were outpaced by those in rural 
areas in terms of height gain but gained slightly more weight by 2020, 
typically in the unhealthy range (Fig. 7). This contrasted with the poorest 
region in the world: sub-Saharan Africa. In this region, the urban height 
advantage persisted or even expanded, whereas rural mean BMI went 
beyond remedying underweight and surpassed the median of the WHO 
reference population in 2020, hence consolidating the urban advantage. 
South Asia had a mixed pattern of urban versus rural trends from 1990 
to 2020, with children and adolescents in rural areas gaining both more 
height and more weight for their height than those in cities. Notably, our 

results also show that differences in height and BMI between urban and 
rural populations within most countries are smaller than the differences 
across countries, even those in the same region.

We also found that the urban–rural BMI gap, although dynamic, 
changed much less than the BMI of either subgroup of the popula-
tion and less than commonly assumed when discussing the role of 
cities in the obesity epidemic8,10,12,13,15,16. Urban–rural BMI differences 
were especially small in high-income countries, which is consistent 
with evidence from a few countries that show diets and behaviours 
are affected more by household socioeconomic status than whether 
children and adolescents live in cities or rural areas29,30. Urban BMI 
excess increased slightly more in middle-income countries in east and 
southeast Asia, Latin America and the Caribbean, and Middle East and 
north Africa, a trend that was the opposite of the convergence in BMI of 

a
13

5
14

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135
140
145
150
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cm

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b

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Change in age-standardized mean

urban height (cm)

U
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Central and eastern Europe
Central Asia, Middle East and north Africa
East and southeast Asia
High-income Asia Paci�c
High-income western
Latin America and Caribbean
Oceania
South Asia
Sub-Saharan Africa

PP >0.99

0.975< PP ≤0.99

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Change in age-standardized mean

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130

135

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160Urban

M
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AFG

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130

135

140

145

150

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160Rural

Fig. 3 | Urban and rural height in 2020 and change from 1990 to 2020 for 
boys. a–d, See the caption for Fig. 2 for descriptions of the contents of the 
figure and for definitions. We did not estimate mean rural height in countries 

classified as entirely urban (Bermuda, Kuwait, Nauru and Singapore), mean 
urban height in countries classified as entirely rural (Tokelau) or their change 
over time, as indicated in grey.



Nature | Vol 615 | 30 March 2023 | 879

adults in these same regions21. Additional analyses of data collected by 
the NCD Risk Factor Collaboration (NCD-RisC) for young adults (20–29 
and 30–39 years) showed that the shift from a small divergent trend to 
convergence of BMI between urban and rural areas happens in young 
adulthood (Extended Data Figs. 6 and  7), a period during which there is 
substantial, but variable, weight gain among population subgroups31. 
These shifts in trends from adolescence to young adulthood might be 
a result of changes in diet and energy expenditure that accompany 
changes in household structure, social and economic roles and the 
living environment32–34.

Long-term follow-up studies have shown that children and adoles-
cents do not achieve their height potential if they do not consume suf-
ficient and diverse nutritious foods or if they are exposed to repeated 
or persistent infections, which result in loss of nutrients2. Studies that 
use data on household socioeconomic and environmental factors have 
indicated that these physiological determinants of height are them-
selves affected by income, education, quality of the living environment 
and access to healthcare in rural as well as urban areas35. This evidence 
indicates that the relatively small urban–rural height differentials in 
high-income countries may be because of a greater abundance of 
nutritious foods, including some fortified foods, better education 
and healthcare and greater ability to finance programmes that promote 
healthy growth in countries with greater per-capita income and better 
infrastructure. Variations across these countries in the urban–rural 
height gap within this small range may be due to the extent of socioeco-
nomic inequalities and poverty, differences in the availability and cost 
of nutritious foods between cities and rural areas and whether there 
are specific programmes (for example, food assistance or school food 
programmes) that improve nutrition in disadvantaged groups30,36,37. The 
more marked changes in height in urban versus rural areas took place 
in middle-income countries and emerging economies. Case studies in 

some countries where the heights of children and adolescents living in 
rural and urban areas converged show that the convergence was partly 
due to using the growth in national income towards programmes and 
services that helped close gaps in nutrition, sanitation and healthcare 
between different areas and social groups38–40. In countries in central 
and eastern Europe, transition to a market economy and increases in 
trade may have reduced the disparity in access to, and seasonality of, 
healthy foods between urban and rural areas41, and partly underlie the 
convergence of height seen in our results. By contrast, case studies in 
some countries have shown that where economic growth was accom-
panied by large inequalities in income, nutrition and/or services, the 
urban advantage persisted42–44.

The notable exception in the global trends was sub-Saharan Africa, 
where a stagnation or reversal of height gain in rural areas led to the 
persistence or widening of urban–rural height differences, whereas the 
opposite happened for BMI (Fig. 7). Case studies of specific countries 
have indicated that unfavourable trends in nutrition in rural Africa, 
where the majority of the poorest people in the world live, started from 
macroeconomic shocks in the late twentieth century45 and subsequent 
agriculture, trade and development policies that limited improvements 
in income and services, and emphasized agricultural exports over local 
food security and diversity45. These macroeconomic factors in turn 
led to less diverse diets, with higher caloric intake rather than a shift 
to protein-rich and nutrient-rich foods (for example, animal products, 
seafood, fruits and vegetables)46–48. Moreover, the slow expansion of 
infrastructure and services in rural areas restricted improvements in 
other determinants of healthy growth, such as clean water, sanitation 
and health care49.

Several other factors may have had a secondary role in the observed 
trends in height and BMI and their difference in rural and urban areas. 
First, weight gain during childhood may reduce the age of puberty 

High-income Asia Paci�c

High-income western

Central Asia, Middle East
and north Africa 

East and southeast Asia

Central and eastern Europe

Sub-Saharan Africa

Oceania

Latin America and Caribbean

South Asia

High-income Asia Paci�c

High-income western

Central Asia, Middle East
and north Africa 

East and southeast Asia

Central and eastern Europe

Sub-Saharan Africa

Oceania

Latin America and Caribbean

South Asia

Age-standardized mean rural BMI (kg m–2)

U
rb

an
–r

ur
al

 d
iff

er
en

ce
 in

 a
ge

-s
ta

nd
ar

d
iz

ed
 m

ea
n 

B
M

I (
kg

 m
–2

)

U
rb

an
–r

ur
al

 d
iff

er
en

ce
 in

 a
ge

-s
ta

nd
ar

d
iz

ed
 m

ea
n 

B
M

I (
kg

 m
–2

)

a b

Age-standardized mean rural BMI (kg m–2)

15 16 17 18 19 20 21 22 23 24 25 15 16 17 18 19 20 21 22 23 24 25 15 16 17 18 19 20 21 22 23 24 25 15 16 17 18 19 20 21 22 23 24 25 15 16 17 18 19 20 21 22 23 24 25 15 16 17 18 19 20 21 22 23 24 25

0

0.5

1.0

0

0.5

1.0

0

0.5

1.0

0

0.5

1.0

0

0.5

1.0

0

0.5

1.0

Fig. 4 | Change in the urban–rural BMI difference from 1990 to 2020.  
a,b, Change in urban–rural difference in age-standardized mean BMI for girls 
(a) and boys (b) in relation to change in age-standardized mean rural BMI. See 
the caption for Fig. 1 for a description of the contents of this figure. See Extended 
Data Fig. 3 for urban–rural differences in age-standardized mean BMI and their 

change over time shown as maps, together with uncertainties in the estimates. 
See Supplementary Fig. 4b for results at ages 5, 10, 15 and 19 years. We did not 
estimate the difference between rural and urban BMI for countries classified as 
entirely urban (Bermuda, Kuwait, Nauru and Singapore) or entirely rural 
(Tokelau).



880 | Nature | Vol 615 | 30 March 2023

Article

onset, which in turn may limit height gain during adolescence50,51. No 
comparable global data currently exist on age at menarche and timing 
of pubertal growth, even at the national level. Second, rural-to-urban 
migration and reclassification of previously rural areas to urban as 
they grow and industrialize may account for some of the observed 
population-level trends. However, migration tends to be less common 
in childhood and adolescence than in adulthood in most countries. 
Finally, improvements in survival among children aged under 5 years 
in rural areas, particularly low-birthweight children, may have influ-
enced the height and weight of those who survive beyond 5 years of 
age. However, current data on changes in child survival in rural and 
urban areas in sub-Saharan Africa are limited and inconclusive in terms 
of whether mortality declined faster in rural or urban areas52,53.

As attention in global health turns to children and adolescents, there 
is a need to consider and evaluate how growth and development in 
these formative ages may be affected both by social and economic 
policies that influence household income and poverty and by pro-
grammes that affect nutrition, health services, infrastructure and 
living environments in rural and urban areas. The need to identify, 
implement and evaluate policies and programmes that improve 
growth and development outcomes is particularly relevant as the 
increase in poverty and the cost of food, especially of nutrient-rich 
foods, as a result of the macroeconomic changes resulting from 
the COVID-19 pandemic and the war in Ukraine, may hinder further 
gains or even set back healthy growth and development in children and  
adolescents.

a

16 18 20 22 24

16 18 20 22 24

16
18
20
22
24

kg m–2

ASM
BHR
BMU
BRN

CPV
COM
COK
FJI

PYF
KIR
MDV
MHL

MUS
FSM
MNE
NRU

NIU
PLW
WSM
STP

SYC
SLB
TKL
TON

TUV
VUT

16
18
20
22
24

kg m–2

Rural

ASM
BHR
BMU
BRN

CPV
COM
COK
FJI

PYF
KIR
MDV
MHL

MUS
FSM
MNE
NRU

NIU
PLW
WSM
STP

SYC
SLB
TKL
TON

TUV
VUT

b

0 1 2 3

0 1 2 3

0
1
2
3

kg m–2

ASM
BHR
BMU
BRN

CPV
COM
COK
FJI

PYF
KIR
MDV
MHL

MUS
FSM
MNE
NRU

NIU
PLW
WSM
STP

SYC
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TKL
TON

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VUT

0
1
2
3

kg m–2

Rural

ASM
BHR
BMU
BRN

CPV
COM
COK
FJI

PYF
KIR
MDV
MHL

MUS
FSM
MNE
NRU

NIU
PLW
WSM
STP

SYC
SLB
TKL
TON

TUV
VUT

c
0

0.25

0.50

0.75

1.00

–2 0 2

–2 0 2

Change in age-standardized mean
urban BMI (kg m–2)

U
nc

er
ta

in
ty

 (p
os

te
rio

r 
s.

d
.)

of
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st
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(k
g 

m
–2

)

Central and eastern Europe
Central Asia, Middle East and north Africa
East and southeast Asia
High-income Asia Paci�c
High-income western
Latin America and Caribbean
Oceania
South Asia
Sub-Saharan Africa

PP >0.99

0.975< PP ≤0.99

0.95< PP ≤0.975

0.75< PP ≤0.95

PP ≤0.75

0

0.25

0.50

0.75

1.00

Change in age-standardized mean
rural BMI (kg m–2)

U
nc

er
ta

in
ty

 (p
os

te
rio

r 
s.

d
.)

of
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st
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(k
g 

m
–2

)

d

H
U

N
S

V
N

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R

B
M

K
D

H
R

V
A

LB
B

G
R

M
N

E
S

V
K

P
O

L
R

O
U

B
IH

C
ZE

ES
T

LV
A

LT
U

B
LR

RU
S

M
DA

UKR
UZB

GEO
ARM

AZE

M
NG

TKM

KAZ

KGZ

TJK
EGY

ARE
BHR
KWT

IRQ
QAT
DZA
PSE
SAU
LBN
SYR
LBY
JOR
OMN
TUR
TUN
IRN
MAR
YEM
CHN
TWN
PRK
BRN
MYS
THA
IDN
MDVMMRPHLLAOKHMVNMTLSKORSGPJPNUSANZLAUSGBRIRLCANGRLFINBELSW

EISLLUXDEUAUT

NO
R

C
H

E

N
LD
D

N
K

M
LT

G
R

C
ESP
A

N
D

C
Y

P
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ITAP

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T

FR
A

P
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B

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A
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B
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24

26
Rural

Urban Urban

Fig. 5 | Urban and rural BMI in 2020 and change from 1990 to 2020 for girls. 
a–d, See the caption for Fig. 2 for descriptions of the contents of the figure and 
for definitions. See Extended Data Fig. 5 for a map of PP of the estimated 
change. See Supplementary Fig. 6 for results at ages 5, 10, 15 and 19 years. See 
Supplementary Table 4 for numerical results, including CrIs, as age-standardized 

and at ages 5, 10, 15 and 19 years. We did not estimate mean rural BMI in countries 
classified as entirely urban (Singapore, Bermuda and Nauru), mean urban BMI 
in areas classified as entirely countries (Tokelau) or their change over time, as 
indicated in grey.



Nature | Vol 615 | 30 March 2023 | 881

Online content
Any methods, additional references, Nature Portfolio reporting sum-
maries, extended data, supplementary information, acknowledge-
ments, peer review information; details of author contributions and 
competing interests; and statements of data and code availability are 
available at https://doi.org/10.1038/s41586-023-05772-8.

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a

16 18 20 22 24

16 18 20 22 24

16
18
20
22
24

kg m–2

Urban

ASM
BHR
BMU
BRN

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16
18
20
22
24

kg m–2

Rural

ASM
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b

0 1 2 3

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kg m–2

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c
0

0.25

0.50

0.75

1.00

Change in age-standardized mean
urban BMI (kg m–2)

U
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ty

 (p
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.)

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 t

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Central and eastern Europe
Central Asia, Middle East and north Africa
East and southeast Asia
High-income Asia Paci�c
High-income western
Latin America and Caribbean
Oceania
South Asia
Sub-Saharan Africa

PP >0.99

0.975< PP ≤0.99

0.95< PP ≤0.975

0.75< PP ≤0.95

PP ≤0.75

0

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–2 20

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.)

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(k
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–2

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RL

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14

16

18

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26Urban

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B

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H

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EDEUISLDNKBELCHE

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14

16

18

20

22

24

26Rural

Fig. 6 | Urban and rural BMI in 2020 and change from 1990 to 2020 for boys. 
a–d, See the caption for Fig. 2 for descriptions of the contents of the figure and 
for definitions. We did not estimate mean rural BMI in countries classified as 

entirely urban (Singapore, Bermuda and Nauru), mean urban BMI in countries 
classified as entirely rural (Tokelau) or their change over time, as indicated  
in grey.

https://doi.org/10.1038/s41586-023-05772-8


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High-income Asia Paci�c

High-income western

Central Asia, Middle East
and north Africa 

East and southeast Asia

Central and eastern Europe

Sub-Saharan Africa

Oceania

Latin America and Caribbean

South Asia

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South Asia

Urban−rural difference in age-standardized mean height (cm)

U
rb

an
−

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ra

l d
iff

er
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ce
 in

 a
ge

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ta

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ar

d
iz

ed
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B
M

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kg

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)

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ru
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 a
ge

-s
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B
M

I (
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–2

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a b

Urban−rural difference in age-standardized mean height (cm)

−1 0 1 2 3 4 5 −1 0 1 2 3 4 5 −1 0 1 2 3 4 5

0

0.5

1.0

0

0.5

1.0

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0.5

1.0

0

0.5

1.0

0

0.5

1.0

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−1 0 1 2 3 4 5 −1 0 1 2 3 4 5 −1 0 1 2 3 4 5

Shorter
in cities

Taller in
cities

Higher BMI in cities

Lower BMI in cities

Central and eastern Europe

Fig. 7 | Change in the urban–rural height and BMI difference from 1990 to 
2020. a,b, Change in the urban–rural difference in age-standardized mean 
height and the urban–rural difference in age-standardized mean BMI in girls  
(a) and boys (b). See the caption for Fig. 1 for a description of the contents of 

this figure. See Supplementary Fig. 4c for results at ages 5, 10, 15 and 19 years. 
We did not estimate the difference between rural and urban height and BMI for 
countries classified as entirely urban (Bermuda, Kuwait, Nauru and Singapore) 
or entirely rural (Tokelau).



Nature | Vol 615 | 30 March 2023 | 883

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Article
NCD Risk Factor Collaboration (NCD-RisC)

Anu Mishra1,776, Bin Zhou1,776, Andrea Rodriguez-Martinez1,776, Honor Bixby2,3,776, 
Rosie K. Singleton1, Rodrigo M. Carrillo-Larco1, Kate E. Sheffer1, Christopher J. Paciorek4, 
James E. Bennett1, Victor Lhoste1, Maria L. C. Iurilli1, Mariachiara Di Cesare3, 
James Bentham5, Nowell H. Phelps1, Marisa K. Sophiea1, Gretchen A. Stevens6, 
Goodarz Danaei7, Melanie J. Cowan6, Stefan Savin6, Leanne M. Riley6, Edward W. Gregg1, 
Wichai Aekplakorn8, Noor Ani Ahmad9, Jennifer L. Baker10, Adela Chirita-Emandi11, 
Farshad Farzadfar12, Günther Fink13,14, Mirjam Heinen15, Nayu Ikeda16, Andre P. Kengne17, 
Young-Ho Khang18, Tiina Laatikainen19,20, Avula Laxmaiah21, Jun Ma22, 
Michele Monroy-Valle23, Malay K. Mridha24, Cristina P. Padez25, Andrew Reynolds26, 
Maroje Sorić27,28, Gregor Starc28, James P. Wirth29, Leandra Abarca-Gómez30, 
Ziad A. Abdeen31, Shynar Abdrakhmanova32, Suhaila Abdul Ghaffar9, Hanan F. Abdul 
Rahim33, Zulfiya Abdurrahmonova34, Niveen M. Abu-Rmeileh35, Jamila Abubakar Garba36, 
Benjamin Acosta-Cazares37, Ishag Adam38, Marzena Adamczyk39, Robert J. Adams40, 
Seth Adu-Afarwuah41, Kaosar Afsana24, Shoaib Afzal42,43, Valirie N. Agbor44, 
Imelda A. Agdeppa45, Javad Aghazadeh-Attari46, Hassan Aguenaou47, 
Carlos A. Aguilar-Salinas48, Charles Agyemang49, Mohamad Hasnan Ahmad9, Ali Ahmadi50, 
Naser Ahmadi12, Nastaran Ahmadi51, Imran Ahmed52, Soheir H. Ahmed53, Wolfgang Ahrens54, 
Gulmira Aitmurzaeva55, Kamel Ajlouni56, Hazzaa M. Al-Hazzaa57, Badreya Al-Lahou58, 
Rajaa Al-Raddadi59, Huda M. Al Hourani60, Nawal M. Al Qaoud61, Monira Alarouj62, 
Fadia AlBuhairan63, Shahla AlDhukair64, Maryam A. Aldwairji61, Sylvia Alexius65, 
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Kristine Allin10, Mar Alvarez-Pedrerol67, Eman Aly68, Deepak N. Amarapurkar69, 
Pilar Amiano Etxezarreta70, John Amoah71, Norbert Amougou72, Philippe Amouyel73,74, 
Lars Bo Andersen75, Sigmund A. Anderssen76, Odysseas Androutsos77, Lars Ängquist42, 
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Hajer Aounallah-Skhiri81, Joana Araújo82, Inger Ariansen83, Tahir Aris9, Raphael E. Arku84, 
Nimmathota Arlappa21, Krishna K. Aryal85, Nega Aseffa86, Thor Aspelund87, Felix K. Assah88, 
Batyrbek Assembekov89, Maria Cecília F. Assunção90, May Soe Aung91, Juha Auvinen92,93, 
Mária Avdičová94, Shina Avi95,96, Ana Azevedo97, Mohsen Azimi-Nezhad98, Fereidoun Azizi99, 
Mehrdad Azmin12, Bontha V. Babu100, Maja Bæksgaard Jørgensen101, Azli Baharudin9, 
Suhad Bahijri59, Marta Bakacs102, Nagalla Balakrishna21, Yulia Balanova103, 
Mohamed Bamoshmoosh104, Maciej Banach105, José R. Banegas106, Joanna Baran107, 
Rafał Baran107, Carlo M. Barbagallo108, Valter Barbosa Filho109, Alberto Barceló110, 
Maja Baretić111, Amina Barkat112, Joaquin Barnoya113, Lena Barrera114, Marta Barreto115,116, 
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Romdhane129, Judith Benedics130, Mikhail Benet131, Gilda Estela Benitez Rolandi132, 
Elling Bere133, Ingunn Holden Bergh83, Yemane Berhane134, Salim Berkinbayev135, 
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Mukharram M. Bikbov149, Bihungum Bista150, Dusko J. Bjelica151, Anne A. Bjerregaard10, 
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Mai J. M. Chinapaw219, Anne Chinnock220, Arnaud Chiolero221, Shu-Ti Chiou222, 
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Massimo Cirillo231, Frank Claessens167, Janine Clarke232, Els Clays172, Emmanuel Cohen72, 
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Ewelina Czenczek-Lewandowska107, Graziella D’Arrigo245, Eleonora d’Orsi119, 
Liliana Dacica246, Jean Dallongeville237, Albertino Damasceno247, Camilla T. Damsgaard42, 
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David De Ridder250, Karin De Ridder251, Susanne R. de Rooij252,49, Delphine De Smedt172, 
Mohan Deepa78, Alexander D. Deev253, Vincent DeGennaro Jr254, Hélène Delisle255, 

Francis Delpeuch256, Stefaan Demarest251, Elaine Dennison235, Katarzyna Dereń107, 
Valérie Deschamps257, Meghnath Dhimal150, Augusto Di Castelnuovo258, 
Juvenal Soares Dias-da-Costa259, María Elena Díaz-Sánchez260, Alejandro Diaz261, 
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Kouamelan Doua274, Nico Dragano275, Wojciech Drygas276,105, Jia Li Duan277, 
Charmaine A. Duante45, Priscilla Duboz278, Vesselka L. Duleva218, Virginija Dulskiene137, 
Samuel C. Dumith205, Anar Dushpanova279,280, Azhar Dyussupova281, Vilnis Dzerve282, 
Elzbieta Dziankowska-Zaborszczyk105, Guadalupe Echeverría138, Ricky Eddie283, 
Ebrahim Eftekhar284, Eruke E. Egbagbe285, Robert Eggertsen153, Sareh Eghtesad273, 
Gabriele Eiben286, Ulf Ekelund76, Mohammad El-Khateeb56, Laila El Ammari287, Jalila El Ati288, 
Denise Eldemire-Shearer289, Marie Eliasen10, Paul Elliott1, Ronit Endevelt156,290, 
Reina Engle-Stone291, Rajiv T. Erasmus292, Raimund Erbel293, Cihangir Erem294, Gul Ergor295, 
Louise Eriksen152, Johan G. Eriksson296, Jorge Escobedo-de la Peña37, Saeid Eslami297, 
Ali Esmaeili298, Alun Evans299, David Faeh166, Ildar Fakhradiyev135, Albina A. Fakhretdinova149, 
Caroline H. Fall235, Elnaz Faramarzi300, Mojtaba Farjam301, Victoria Farrugia Sant’Angelo230, 
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Francisco J. Felix-Redondo304, Trevor S. Ferguson289, Romulo A. Fernandes226, 
Daniel Fernández-Bergés305, Daniel Ferrante306, Thomas Ferrao232, Gerson Ferrari307, 
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Eldridge Ferrer45, Jean Ferrieres165, Thamara Hubler Figueiró119, Anna Fijalkowska310, 
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Anelise Reis Gaya319, Andrea Gazzinelli332, Ulrike Gehring333, Harald Geiger234, 
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Jonathan Giovannelli73,74, Glen Gironella45, Aleksander Giwercman338, 
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Justyna Godos328, Sibel Gogen203, Marcel Goldberg342,343, David Goltzman2, 
Georgina Gómez220, Jesús Humberto Gómez Gómez344, Luis F. Gomez236, 
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Geetha R. Menon208, Gert B. M. Mensink556, Maria Teresa Menzano327, Indrapal I. Meshram21, 
Diane T. Meto557, Jie Mi211, Kim F. Michaelsen42, Nathalie Michels172, Kairit Mikkel312, 
Karolina Miłkowska326, Jody C. Miller26, Olga Milushkina558, Cláudia S. Minderico559, 
G. K. Mini560, Juan Francisco Miquel138, J. Jaime Miranda136, Mohammad Reza Mirjalili51, 
Daphne Mirkopoulou561, Erkin Mirrakhimov458, Marjeta Mišigoj-Duraković27, 
Antonio Mistretta328, Veronica Mocanu562, Pietro A. Modesti563, Sahar Saeedi Moghaddam12, 
Bahram Mohajer12, Mostafa K. Mohamed564, Shukri F. Mohamed491, Kazem Mohammad273, 
Mohammad Reza Mohammadi273, Zahra Mohammadi273, Noushin Mohammadifard565, 
Reza Mohammadpourhodki297, Viswanathan Mohan78, Salim Mohanna136, 
Muhammad Fadhli Mohd Yusoff9, Iraj Mohebbi46, Farnam Mohebi4, Marie Moitry147,566, 
Line T. Møllehave10, Niels C. Møller225, Dénes Molnár389, Amirabbas Momenan399, 
Charles K. Mondo567, Roger A. Montenegro Mendoza568, Eric Monterrubio-Flores352, 
Kotsedi Daniel K. Monyeki569, Jin Soo Moon224, Mahmood Moosazadeh462, 
Hermine T. Mopa88, Farhad Moradpour336, Leila B. Moreira319, Alain Morejon570, 
Luis A. Moreno201,239, Francis Morey571, Karen Morgan572, Suzanne N. Morin2, 
Erik Lykke Mortensen42, George Moschonis573, Alireza Moslem574, Malgorzata Mossakowska575, 
Aya Mostafa564, Seyed-Ali Mostafavi273, Anabela Mota-Pinto25, Jorge Mota200, 
Mohammad Esmaeel Motlagh216, Jorge Motta568, Marcos André Moura-dos-Santos117, 
Yeva Movsesyan554, Kelias P. Msyamboza576, Thet Thet Mu577, Magdalena Muc25, 
Florian Muca578, Boban Mugoša487, Maria L. Muiesan579, Martina Müller-Nurasyid140, 
Thomas Münzel140, Jaakko Mursu19, Elaine M. Murtagh580, Kamarul Imran Musa313, 
Sanja Musić Milanović481,27, Vera Musil27, Geofrey Musinguzi581, Muel Telo M. C. Muyer582, 
Iraj Nabipour583, Shohreh Naderimagham12, Gabriele Nagel584, Farid Najafi379, 
Harunobu Nakamura476, Hanna Nalecz310, Jana Námešná94, Ei Ei K. Nang214,501, 
Vinay B. Nangia585, Martin Nankap586, Sameer Narake370, Paola Nardone269, Take Naseri587, 
Matthias Nauck530, William A. Neal507, Azim Nejatizadeh284, Chandini Nekkantti434, 
Keiu Nelis340, Ilona Nenko326, Martin Neovius588, Flavio Nervi138, Tze Pin Ng214, 
Chung T. Nguyen589, Nguyen D. Nguyen590, Quang Ngoc Nguyen591, Michael Y. Ni395, 
Rodica Nicolescu242, Peng Nie592, Ramfis E. Nieto-Martínez593, Yury P. Nikitin526, 
Guang Ning145, Toshiharu Ninomiya384, Nobuo Nishi16, Sania Nishtar594, Marianna Noale522, 
Oscar A. Noboa146, Helena Nogueira25, Maria Nordendahl314, Børge G. Nordestgaard43,42, 

Davide Noto108, Natalia Nowak-Szczepanska347, Mohannad Al Nsour595, Irfan Nuhoğlu294, 
Baltazar Nunes115,116, Eha Nurk340, Fred Nuwaha581, Moffat Nyirenda550, Terence W. O’Neill596, 
Dermot O’Reilly299, Galina Obreja597, Caleb Ochimana7, Angélica M. Ochoa-Avilés271, 
Eiji Oda598, Augustine N. Odili599, Kyungwon Oh600, Kumiko Ohara476, Claes Ohlsson153,469, 
Ryutaro Ohtsuka601, Örn Olafsson363, Maria Teresa A. Olinto319, Isabel O. Oliveira90, 
Mohd Azahadi Omar9, Saeed M. Omar602, Altan Onat603,777, Sok King Ong604, 
N. Charlotte Onland-Moret333, Lariane M. Ono398, Pedro Ordunez189, Rui Ornelas605, 
Ana P. Ortiz606, Pedro J. Ortiz136, Merete Osler10, Clive Osmond235, Sergej M. Ostojic265, 
Afshin Ostovar607, Johanna A. Otero608, Kim Overvad450, Ellis Owusu-Dabo609, 
Fred Michel Paccaud169, Ioannis Pagkalos383, Elena Pahomova282, Karina Mary de Paiva119, 
Andrzej Pająk326, Alberto Palloni610, Luigi Palmieri269, Wen-Harn Pan210, 
Songhomitra Panda-Jonas611, Arvind Pandey208, Francesco Panza612, Mariela Paoli179, 
Sousana K. Papadopoulou383, Dimitrios Papandreou613, Rossina G. Pareja268, 
Soon-Woo Park614, Suyeon Park600, Winsome R. Parnell26, Mahboubeh Parsaeian273, 
Ionela M. Pascanu615, Patrick Pasquet72, Nikhil D. Patel616, Marcos Pattussi259, 
Halyna Pavlyshyn323, Raimund Pechlaner464, Ivan Pećin111, Mangesh S. Pednekar370, 
João M. Pedro617, Nasheeta Peer618, Sergio Viana Peixoto508, Markku Peltonen20, 
Alexandre C. Pereira139, Marco A. Peres619, Cynthia M. Pérez606, Valentina Peterkova162, 
Annette Peters272, Astrid Petersmann530, Janina Petkeviciene137, Ausra Petrauskiene137, 
Olga Petrovna Kovtun80, Emanuela Pettenuzzo620, Niloofar Peykari264, Norbert Pfeiffer140, 
Modou Cheyassin Phall423, Son Thai Pham621, Rafael N. Pichardo622, Daniela Pierannunzio269, 
Iris Pigeot54, Hynek Pikhart159, Aida Pilav623, Lorenza Pilotto624, Francesco Pistelli625, 
Freda Pitakaka626, Aleksandra Piwonska276, Andreia N. Pizarro200, Pedro Plans-Rubió627, 
Alina G. Platonova628, Bee Koon Poh629, Hermann Pohlabeln54, Nadija S. Polka628, 
Raluca M. Pop615, Stevo R. Popovic151, Miquel Porta538, Georg Posch234, Anil Poudyal150, 
Dimitrios Poulimeneas383, Hamed Pouraram273, Farhad Pourfarzi630, Akram Pourshams273, 
Hossein Poustchi273, Rajendra Pradeepa78, Alison J. Price550, Jacqueline F. Price551, 
Antonio Prista631, Rui Providencia159, Jardena J. Puder534, Iveta Pudule632, Maria Puiu11, 
Margus Punab475, Muhammed S. Qadir633, Radwan F. Qasrawi31, Mostafa Qorbani634, 
Hedley K. Quintana568, Pedro J. Quiroga-Padilla555, Tran Quoc Bao635, Stefan Rach54, 
Ivana Radic265, Ricardas Radisauskas137, Salar Rahimikazerooni302, Mahfuzar Rahman636, 
Mahmudur Rahman637, Olli Raitakari638, Manu Raj488, Tamerlan Rajabov639, 
Sherali Rakhmatulloev34, Ivo Rakovac15, Sudha Ramachandra Rao453, 
Ambady Ramachandran206, Otim P. C. Ramadan640, Virgílio V. Ramires641, 
Jacqueline Ramke126, Elisabete Ramos97, Rafel Ramos642, Lekhraj Rampal643, 
Sanjay Rampal644, Lalka S. Rangelova218, Vayia Rarra645, Ramon A. Rascon-Pacheco37, 
Cassiano Ricardo Rech119, Josep Redon412, Paul Ferdinand M. Reganit646, 
Valéria Regecová647, Jane D. P. Renner648, Judit A. Repasy389, Cézane P. Reuter648, 
Luis Revilla515, Abbas Rezaianzadeh302, Yeunsook Rho374, Lourdes Ribas-Barba649, 
Robespierre Ribeiro650,777, Elio Riboli1, Adrian Richter530, Fernando Rigo651, Attilio Rigotti138, 
Natascia Rinaldo361, Tobias F. Rinke de Wit652, Ana I. Rito115, Raphael M. Ritti-Dias653, 
Juan A. Rivera352, Reina G. Roa654, Louise Robinson470, Cynthia Robitaille655, 
Romana Roccaldo204, Daniela Rodrigues25, Fernando Rodríguez-Artalejo106, María del Cristo 
Rodriguez-Perez262, Laura A. Rodríguez-Villamizar656, Andrea Y. Rodríguez657, 
Ulla Roggenbuck293, Peter Rohloff658, Fabian Rohner659, Rosalba Rojas-Martinez352, 
Nipa Rojroongwasinkul8, Dora Romaguera239, Elisabetta L. Romeo660, Rafaela V. Rosario661, 
Annika Rosengren153,469, Ian Rouse662, Vanessa Rouzier663, Joel G. R. Roy232, 
Maira H. Ruano664, Adolfo Rubinstein373, Frank J. Rühli166, Jean-Bernard Ruidavets165, 
Blanca Sandra Ruiz-Betancourt37, Maria Ruiz-Castell66, Emma Ruiz Moreno665, 
Iuliia A. Rusakova149, Kenisha Russell Jonsson425, Paola Russo666, Petra Rust474, 
Marcin Rutkowski667, Marge Saamel340, Charumathi Sabanayagam209, Hamideh Sabbaghi399, 
Elena Sacchini362, Harshpal S. Sachdev668, Alireza Sadjadi273, Ali Reza Safarpour302, 
Sare Safi399, Saeid Safiri300, Mohammad Hossien Saghi574, Olfa Saidi129, Nader Saki216, 
Sanja Šalaj27, Benoit Salanave257, Eduardo Salazar Martinez352, Calogero Saleva542, 
Diego Salmerón223, Veikko Salomaa20, Jukka T. Salonen296, Massimo Salvetti579, 
Margarita Samoutian669, Jose Sánchez-Abanto670, Inés Sánchez Rodríguez344, Sandjaja671, 
Susana Sans672, Loreto Santa Marina673, Ethel Santacruz132, Diana A. Santos559, 
Ina S. Santos90, Lèlita C. Santos520, Maria Paula Santos200, Osvaldo Santos674, Rute Santos200, 
Tamara R. Santos675, Jouko L. Saramies676, Luis B. Sardinha559, Nizal Sarrafzadegan565, 
Thirunavukkarasu Sathish418, Kai-Uwe Saum177, Savvas Savva376, Mathilde Savy256, 
Norie Sawada677, Mariana Sbaraini319, Marcia Scazufca678, Beatriz D. Schaan319, 
Angelika Schaffrath Rosario556, Herman Schargrodsky679, Anja Schienkiewitz556, 
Karin Schindler680, Sabine Schipf530, Carsten O. Schmidt530, Ida Maria Schmidt681, 
Andrea Schneider272, Peter Schnohr43, Ben Schöttker177, Sara Schramm293, 
Stine Schramm225, Helmut Schröder223, Constance Schultsz682, Matthias B. Schulze683, 
Aletta E. Schutte434,684, Sylvain Sebert93, Moslem Sedaghattalab382, Rusidah Selamat9, 
Vedrana Sember28, Abhijit Sen685, Idowu O. Senbanjo686, Sadaf G. Sepanlou273, 
Guillermo Sequera132, Luis Serra-Majem687, Jennifer Servais232, Ľudmila Ševčíková688, 
Svetlana Shalnova103, Teresa Shamah-Levy352, Seyed Morteza Shamshirgaran98, 
Coimbatore Subramaniam Shanthirani78, Maryam Sharafkhah273, Sanjib K. Sharma473, 
Jonathan E. Shaw523, Amaneh Shayanrad273, Ali Akbar Shayesteh216, Lela Shengelia441, 
Zumin Shi33, Kenji Shibuya366, Hana Shimizu-Furusawa689, Tal Shimony456, Rahman Shiri690, 
Namuna Shrestha85, Khairil Si-Ramlee604, Alfonso Siani666, Rosalynn Siantar209, 
Abla M. Sibai409, Labros S. Sidossis691, Natalia Silitrari692, Antonio M. Silva123, 
Caroline Ramos de Moura Silva117, Diego Augusto Santos Silva119, Kelly S. Silva119, 
Xueling Sim214,501, Mary Simon206, Judith Simons693, Leon A. Simons434, Agneta Sjöberg153, 
Michael Sjöström588,777, Natalia A. Skoblina558, Gry Skodje694, Tatyana Slazhnyova32, 
Jolanta Slowikowska-Hilczer105, Przemysław Slusarczyk575, Liam Smeeth550, 
Hung-Kwan So395, Fernanda Cunha Soares117, Grzegorz Sobek107, Eugène Sobngwi88, 
Morten Sodemann225, Stefan Söderberg314, Moesijanti Y. E. Soekatri695, 
Agustinus Soemantri696,777, Reecha Sofat159, Vincenzo Solfrizzi697, 
Mohammad Hossein Somi300, Emily Sonestedt338, Yi Song22, Sajid Soofi52, 
Thorkild I. A. Sørensen42, Elin P. Sørgjerd426, Charles Sossa Jérome698, 
Victoria E. Soto-Rojas364, Aïcha Soumaré699, Alfonso Sousa-Poza700, Slavica Sovic27, 
Bente Sparboe-Nilsen701, Karen Sparrenberger319, Phoebe R. Spencer397, Angela Spinelli269, 
Igor Spiroski702,703, Jan A. Staessen167, Hanspeter Stamm704, Kaspar Staub166, Bill Stavreski429, 
Jostein Steene-Johannessen76, Peter Stehle705, Aryeh D. Stein418, George S. Stergiou447, 



Article
Jochanan Stessman421, Ranko Stevanović481, Jutta Stieber272,777, Doris Stöckl272, 
Jakub Stokwiszewski706, Ekaterina Stoyanova707, Gareth Stratton182, Karien Stronks49, 
Maria Wany Strufaldi315, Lela Sturua441, Ramón Suárez-Medina260, Machi Suka708, 
Chien-An Sun709, Liang Sun509, Johan Sundström510, Yn-Tz Sung396, Jordi Sunyer67, 
Paibul Suriyawongpaisal8, Nabil William G. Sweis710, Boyd A. Swinburn126, Rody G. Sy646, 
René Charles Sylva711, Moyses Szklo451, Lucjan Szponar706, Lorraine Tabone230, 
E. Shyong Tai214,501, Konstantinos D. Tambalis447, Mari-Liis Tammesoo312, 
Abdonas Tamosiunas137, Eng Joo Tan712, Xun Tang22, Maya Tanrygulyyeva713, Frank Tanser714, 
Yong Tao22, Mohammed Rasoul Tarawneh715, Jakob Tarp450, Carolina B. Tarqui-Mamani670, 
Radka Taxová Braunerová489, Anne Taylor337, Julie Taylor159, Félicité Tchibindat716,  
Saskia Te Velde717, William R. Tebar226, Grethe S. Tell385, Tania Tello136, Yih Chung Tham209, 
K. R. Thankappan341, Holger Theobald198, Xenophon Theodoridis339, Nihal Thomas128, 
Barbara Thorand272, Betina H. Thuesen10, Ľubica Tichá688, Erik J. Timmermans718, 
Dwi H. Tjandrarini719, Anne Tjonneland377, Hanna K. Tolonen20, Janne S. Tolstrup152, 
Murat Topbas294, Roman Topór-Mądry326, Liv Elin Torheim701, María José Tormo720, 
Michael J. Tornaritis376, Maties Torrent721, Laura Torres-Collado223, Stefania Toselli722, 
Giota Touloumi447, Pierre Traissac256, Thi Tuyet-Hanh Tran492, Mark S. Tremblay723, 
Areti Triantafyllou339, Dimitrios Trichopoulos7,777, Antonia Trichopoulou724, 
Oanh T. H. Trinh590, Atul Trivedi725, Yu-Hsiang Tsao726, Lechaba Tshepo727, Maria Tsigga383, 
Panagiotis Tsintavis383, Shoichiro Tsugane677, John Tuitele728,729, Azaliia M. Tuliakova149, 
Marshall K. Tulloch-Reid289, Fikru Tullu730, Tomi-Pekka Tuomainen19, Jaakko Tuomilehto20, 
Maria L. Turley731, Gilad Twig217,732, Per Tynelius588, Evangelia Tzala1, Themistoklis Tzotzas445, 
Christophe Tzourio699, Peter Ueda588, Eunice Ugel733, Flora A. M. Ukoli734, Hanno Ulmer464, 
Belgin Unal295, Zhamyila Usupova55, Hannu M. T. Uusitalo735, Nalan Uysal736, 
Justina Vaitkeviciute137, Gonzalo Valdivia138, Susana Vale737, Damaskini Valvi738,  
Rob M. van Dam739, Bert-Jan van den Born49, Johan Van der Heyden251,  
Yvonne T. van der Schouw333, Koen Van Herck172, Wendy Van Lippevelde172,  
Hoang Van Minh492, Natasja M. Van Schoor408, Irene G. M. van Valkengoed49, 
Dirk Vanderschueren167, Diego Vanuzzo624, Anette Varbo43,42, Gregorio Varela-Moreiras740, 
Luz Nayibe Vargas236, Patricia Varona-Pérez260, Senthil K. Vasan235, Daniel G. Vasques319, 
Tomas Vega516, Toomas Veidebaum340, Gustavo Velasquez-Melendez332, Biruta Velika632, 
Maïté Verloigne172, Giovanni Veronesi308, W. M. Monique Verschuren155, Cesar G. Victora90, 
Giovanni Viegi741, Lucie Viet155, Frøydis N. Vik133, Monica Vilar742, Salvador Villalpando352, 
Jesus Vioque743, Jyrki K. Virtanen19, Sophie Visvikis-Siest744, Bharathi Viswanathan168, 
Mihaela Vladulescu745, Tiina Vlasoff746, Dorja Vocanec27, Peter Vollenweider534,535, 
Henry Völzke530, Ari Voutilainen19, Martine Vrijheid67, Tanja G. M. Vrijkotte252,49, 
Alisha N. Wade747, Thomas Waldhör680, Janette Walton185, Elvis O. A. Wambiya491, 
Wan Mohamad Wan Bebakar313, Wan Nazaimoon Wan Mohamud748, Rildo de Souza 
Wanderley Júnior117, Ming-Dong Wang655, Ningli Wang369, Qian Wang749, Xiangjun Wang750, 
Ya Xing Wang368, Ying-Wei Wang751, S. Goya Wannamethee159, Nicholas Wareham461, 
Adelheid Weber130, Karen Webster-Kerr752, Niels Wedderkopp225, Daniel Weghuber541, 
Wenbin Wei368, Aneta Weres107, Bo Werner753, Leo D. Westbury235, Peter H. Whincup754, 
Kremlin Wickramasinghe15, Kurt Widhalm680, Indah S. Widyahening755, Andrzej Więcek227, 
Philipp S. Wild140, Rainford J. Wilks289, Johann Willeit464, Peter Willeit464, Julianne Williams15, 
Tom Wilsgaard545, Rusek Wojciech756, Bogdan Wojtyniak706, Kathrin Wolf272, 
Roy A. Wong-McClure30, Andrew Wong159, Emily B. Wong380, Jyh Eiin Wong629, 
Tien Yin Wong207, Jean Woo396, Mark Woodward1,434, Frederick C. Wu596, Hon-Yen Wu757, 
Jianfeng Wu144, Li Juan Wu368, Shouling Wu213, Justyna Wyszyńska107, Haiquan Xu758, 
Liang Xu759, Nor Azwany Yaacob313, Uruwan Yamborisut8, Weili Yan760, Ling Yang44, 
Xiaoguang Yang388, Yang Yang750, Nazan Yardim203, Tabara Yasuharu322, 
Martha Yépez García742, Panayiotis K. Yiallouros761, Agneta Yngve510, Moein Yoosefi12, 
Akihiro Yoshihara762, Qi Sheng You368, San-Lin You709, Novie O. Younger-Coleman289, 
Yu-Ling Yu167, Yunjiang Yu763, Safiah Md Yusof764, Ahmad Faudzi Yusoff9, Luciana Zaccagni361, 
Vassilis Zafiropulos765, Ahmad A. Zainuddin9, Seyed Rasoul Zakavi297, Farhad Zamani766, 
Sabina Zambon529, Antonis Zampelas524, Hana Zamrazilová489, Maria Elisa Zapata199, 
Abdul Hamid Zargar767, Ko Ko Zaw499, Ayman A. Zayed710, Tomasz Zdrojewski667, 
Magdalena Żegleń768, Kristyna Zejglicova195, Tajana Zeljkovic Vrkic111, Yi Zeng22,769, 
Luxia Zhang770, Zhen-Yu Zhang167, Dong Zhao511, Ming-Hui Zhao770, Wenhua Zhao388, 
Yanitsa V. Zhecheva419, Shiqi Zhen771, Wei Zheng188, Yingfeng Zheng270, Bekbolat Zholdin772, 
Maigeng Zhou388, Dan Zhu773, Marie Zins342,343, Emanuel Zitt234, Yanina Zocalo146, 
Nada Zoghlami81, Julio Zuñiga Cisneros568, Monika Zuziak774, Zulfiqar A. Bhutta416,52, 
Robert E. Black775 & Majid Ezzati1,41 ✉

1Imperial College London, London, UK. 2McGill University, Montreal, Québec, Canada. 
3University of Essex, Colchester, UK. 4University of California Berkeley, Berkeley, CA, USA. 
5University of Kent, Canterbury, UK. 6World Health Organization, Geneva, Switzerland. 
7Harvard T. H. Chan School of Public Health, Boston, MA, USA. 8Mahidol University, Nakhon 
Pathom, Thailand. 9Ministry of Health, Kuala Lumpur, Malaysia. 10Bispebjerg and Frederiksberg 
Hospital, Copenhagen, Denmark. 11Victor Babes University of Medicine and Pharmacy, 
Timisoara, Romania. 12Non-Communicable Diseases Research Center, Tehran, Iran. 13Swiss 
Tropical and Public Health Institute, Basel, Switzerland. 14University of Basel, Basel, 
Switzerland. 15World Health Organization Regional Office for Europe, Copenhagen, Denmark. 
16National Institutes of Biomedical Innovation, Health and Nutrition, Tokyo, Japan. 17South 
African Medical Research Council, Cape Town, South Africa. 18Seoul National University 
College of Medicine, Seoul, Republic of Korea. 19University of Eastern Finland, Kuopio, 
Finland. 20Finnish Institute for Health and Welfare, Helsinki, Finland. 21ICMR–National Institute 
of Nutrition, Hyderabad, India. 22Peking University, Beijing, China. 23Universidad de San Carlos, 
Guatemala City, Guatemala. 24BRAC James P. Grant School of Public Health, Dhaka, 
Bangladesh. 25University of Coimbra, Coimbra, Portugal. 26University of Otago, Dunedin, New 
Zealand. 27University of Zagreb, Zagreb, Croatia. 28University of Ljubljana, Ljubljana, Slovenia. 
29GroundWork, Geneva, Switzerland. 30Caja Costarricense de Seguro Social, San José, Costa 
Rica. 31Al-Quds University, East Jerusalem, State of Palestine. 32National Center of Public 
Health, Astana, Kazakhstan. 33Qatar University, Doha, Qatar. 34Ministry of Health and Social 
Protection, Dushanbe, Tajikistan. 35Birzeit University, Birzeit, State of Palestine. 36Usmanu 
Danfodiyo University Teaching Hospital, Sokoto, Nigeria. 37Instituto Mexicano del Seguro 
Social, Mexico City, Mexico. 38Qassim University, Unaizah, Saudi Arabia. 39RehaKlinika, 

Rzeszów, Poland. 40Flinders University, Adelaide, South Australia, Australia. 41University of 
Ghana, Accra, Ghana. 42University of Copenhagen, Copenhagen, Denmark. 43Copenhagen 
University Hospital, Copenhagen, Denmark. 44University of Oxford, Oxford, UK. 45Food and 
Nutrition Research Institute, Taguig, The Philippines. 46Urmia University of Medical Sciences, 
Urmia, Iran. 47Ibn Tofail University, Kénitra, Morocco. 48Instituto Nacional de Ciencias Médicas 
y Nutrición, Mexico City, Mexico. 49University of Amsterdam, Amsterdam, The Netherlands. 
50Modeling in Health Research Center, Shahrekord, Iran. 51Shahid Sadoughi University of 
Medical Sciences, Yazd, Iran. 52The Aga Khan University, Karachi, Pakistan. 53University of 
Oslo, Oslo, Norway. 54Leibniz Institute for Prevention Research and Epidemiology–BIPS, 
Bremen, Germany. 55Republican Center for Health Promotion, Bishkek, Kyrgyzstan. 56National 
Center for Diabetes, Endocrinology and Genetics, Amman, Jordan. 57Princess Nourah bint 
Abdulrahman University, Riyadh, Saudi Arabia. 58Kuwait Institute for Scientific Research, 
Kuwait City, Kuwait. 59King Abdulaziz University, Jeddah, Saudi Arabia. 60The Hashemite 
University, Zarqa, Jordan. 61Ministry of Health, Kuwait City, Kuwait. 62Dasman Diabetes 
Institute, Kuwait City, Kuwait. 63Aldara Hospital and Medical Center, Riyadh, Saudi Arabia. 
64King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. 65Universidade 
Federal da Integração Latino-Americana, Foz do Iguaçu, Brazil. 66Luxembourg Institute of 
Health, Strassen, Luxembourg. 67Barcelona Institute for Global Health CIBERESP, Barcelona, 
Spain. 68World Health Organization Regional Office for the Eastern Mediterranean, Cairo, 
Egypt. 69Bombay Hospital and Medical Research Centre, Mumbai, India. 70Departamento de 
Salud del Gobierno Vasco, San Sebastián, Spain. 71Ghana Health Service, Kintampo, Ghana. 
72UMR CNRS-MNHN 7206, Paris, France. 73University of Lille, Lille, France. 74Lille University 
Hospital, Lille, France. 75Western Norway University of Applied Sciences, Sogndal, Norway. 
76Norwegian School of Sport Sciences, Oslo, Norway. 77University of Thessaly, Trikala, Greece. 
78Madras Diabetes Research Foundation, Chennai, India. 79Zahedan University of Medical 
Sciences, Zahedan, Iran. 80Yekaterinburg State Medical Academy, Yekaterinburg, Russia. 
81National Institute of Public Health, Tunis, Tunisia. 82Institute of Public Health of the University 
of Porto, Porto, Portugal. 83Norwegian Institute of Public Health, Oslo, Norway. 84University of 
Massachusetts Amherst, Amherst, MA, USA. 85Public Health Promotion and Development 
Organization, Kathmandu, Nepal. 86Haramaya University, Dire Dawa, Ethiopia. 87University of 
Iceland, Reykjavik, Iceland. 88University of Yaoundé 1, Yaoundé, Cameroon. 89Asfendiyarov 
Kazakh National Medical University, Almaty, Kazakhstan. 90Federal University of Pelotas, 
Pelotas, Brazil. 91University of Medicine 1, Yangon, Myanmar. 92Oulu University Hospital, Oulu, 
Finland. 93University of Oulu, Oulu, Finland. 94Regional Authority of Public Health, Banska 
Bystrica, Slovakia. 95Tel Aviv University, Tel Aviv, Israel. 96Hebrew University of Jerusalem, 
Jerusalem, Israel. 97University of Porto Medical School, Porto, Portugal. 98Neyshabur 
University of Medical Sciences, Neyshabur, Iran. 99Research Institute for Endocrine Sciences, 
Tehran, Iran. 100Indian Council of Medical Research, New Delhi, India. 101National Institute of 
Public Health, Copenhagen, Denmark. 102National Institute of Pharmacy and Nutrition, 
Budapest, Hungary. 103National Medical Research Centre for Therapy and Preventive 
Medicine, Moscow, Russia. 104University of Science and Technology, Sana’a, Yemen. 105Medical 
University of Lodz, Lodz, Poland. 106Universidad Autónoma de Madrid CIBERESP, Madrid, 
Spain. 107University of Rzeszów, Rzeszów, Poland. 108University of Palermo, Palermo, Italy. 
109Federal Institute of Education, Science and Technology of Ceara, Ceara, Brazil. 110University 
of Miami, Miami, FL, USA. 111University Hospital Center Zagr