Epidemic Obesity in China

1. Epidemic Obesity in China Chwan-Li (Leslie) Shen, PhD Associate Professor Pathology, School of Medicine May 20, 2009

3. China is now the fattest country in the world, second only to the US.

4. China’s National Nutrition and Health Survey of 2002 • Compared to 1992 survey, body weights and heights of preschool children in urban and rural areas have significantly improved, the prevalence of malnutrition (underweight and stunting) has been significantly reduced.

5. China’s National Nutrition and Health Survey of 2002 (continued) • However, micronutrient deficiencies, including calcium, zinc, vitamin A, vitamins B1 and B2, are still common in preschool and school children.

6. Between 1992 and 2002, more than 60 million people became obese. • In 2007, • 215 million people were overweight; • 68.44 million people were obese. (Li et al. 2007 Obes Surg)

7. What is of greater concern still, is the vast and fast-growing number of Chinese children and youth that are obese.

8. One out of five Chinese children over the age of 7 is overweight, and nearly 10 percent are obese. • Although the rate of obesity is lower in China than in America or Europe, the overall number is huge (China has 1.3 billion population). • By 2020, more obese people in China than in US.

9. Body mass index (BMI) Gao et al. 2007. J Public Health

10. Overweight prevalence distribution Gao et al. 2007 J Public Health

11. Obesity-associated complications • Glucose intolerance, diabetes • Coronary artery disease • Hypertension • Hyperlipidemia • Metabolic syndrome • Depression

12. Obesity-associated complications (continued) • Reduced lifespan • Respiratory system complications (obesity-hypoventilation syndrome and sleep apnea syndrome) • Joint degeneration • Cancers (breast, rectal, prostate) • Hepatic steatosis (fatty liver) Related to both genetic and specific environmental factors.

13. Why is it so devastating that obesity rates have increased 30-fold in 15 years in China?

14. How did a country that struggled with starvation just half a century ago now find itself dealing with an obesity epidemic?

15. Causes of Obesity

16. Culture Excess body fat represents health and prosperity… a consequence of chronic malnutrition that caused millions of deaths in the past two centuries.

17. China's one-child policy • Food is a common reward… when started early, can be hard to unwind when a child becomes an adolescent.  • Money from generous parents.

18. Economic growth • Nutritional quality was often poor in the past. • China’s first nutrition and health survey (2002) revealed dramatic improvement in nutritional quality with modernization and economic growth. • Obesity occurs due to: • massive decrease in daily activity and caloric expenditure, • increase in food intake.

19. Changing dietary intake • Intake of energy from animal sources increased from 8 to 25% from 1982 to 2002. • Average intake of dietary fat increased from 25 to 35% of energy (>30% recommended). • Expansion of the processed food and soft drink sector.

20. Introducing high-fat fast food -- KFC, McDonald’s … • Sign of affluence: you have some extra money to splurge. • Calorie count ignored. • Instead of sharing food, which is the Chinese norm, when a child eats at a fast food restaurant, the pressure is to finish all the food, even if full.  

21. Changing portion size • In an agrarian economy, with a limited food supply, the Chinese people historically ate small portions and worked off those calories in the fields. • Calorie intake and portion sizes increase, while the society shifts to more sedentary lifestyles ---- perfect storm for the obesity crisis.

22. Changing lifestyle • More sedentary lifestyles … television, computer, and automobile. • Night life. • Less time for exercise due to academic stress. • Hormone imbalance.

23. Relationship between energy intake and energy expenditure in the emergence of obesity over the last century. (Levine 2007, Chinese Medical Journal)

24. How can obesity be halted in China?

25. Strategic planning to halt obesity in China (Levine 2007 Chinese Medical Journal)

26. Organization Need: • a system for resource sharing, • universally recognized evaluation tools, • to define the standard for “success”, • to allow obesity interventions (personal or population) to be evaluated and compared in a common scientific-language.

27. Organization (continued) Need partners for change: • food industry • clothing manufacturers • pharmaceutical industry • media industry • furniture companies • health insurers • architects

29. Define models of success • Not only invoke personal action but also population-wide environmental re-engineering to directly promote daily physical activity and healthy eating. • Economically viable.

30. Define models of success (continued) • Cost-effective for the government in the long-term. • Positive economic balance – Obesity was created by wealth, and a successful obesity solution should not destroy this wealth.

31. Implementation • Obesity can be reversed. • Need strong leadership focused on the health of people.

32. Psychological treatment • In Asia, people often hold a prejudice against overweight/obesity. • Intense pressure on overweight/obese individuals (more serious among children). • Psychological interventions to release pressure leading to weight loss.

33. Involvement of family • Encourage proper balanced meals at home. • Encourage exercise. • Discourage TV and video games. • Dietary intervention. • Health education.

34. School-based intervention • Current strategies: • improving level of knowledge, • increasing physical activity, • dietary intervention in overweight children and adolescents. • None of the trials demonstrated convincing evidence of the efficacy of any single intervention for the prevention of overweight and obesity in children and adolescents.

35. School-based intervention (continued) Future direction: • facilitate health and nutrition educational components incorporated into school curriculum; • promote modification of the school and community environments to improve and support healthy lifestyle behavioral patterns.

36. Agro-food industry growth • China is the largest food producer and consumer in the world. • Roles of government and agro-food industry in addressing childhood obesity.

37. Alternative and complementary treatment • Herbal medicine • Dietary supplements • Acupuncture: flexible point selection and various methods without toxic and side effects Still need more studies to confirm.

38. Bariatric Surgery • In Europe and USA: BMI  40 kg/m2 or BMI  35 kg/m2 with related comorbidities. • In China: BMI  37 kg/m2 or BMI  32 kg/m2 with related comorbidities. • Surgery for obesity is now in its primary stages in China. • Success should be determined by weight change and by the improvement of obesity-associated complications.

39. Bariatric Surgery (continued) • Appropriate training and supervision of the multidisciplinary team to assure good outcomes. • Medical diagnosis and management of complications specific to bariatric surgery • Dietary instruction • Exercise training • Nursing care • Psychological support

40. The prevention and treatment of obesity in China remain to be open problems.

41. Thank you.