Policy Recommendations for Rising Levels of Obesity in Urban China

BY ALICE YEN

Abstract:
Changing lifestyle patterns have led to increasing levels of obesity in China, particularly given great economic gains in urban regions. As a result, dietary choices have shifted toward heavy protein-based foods and trends toward energy-dense Western fast foods. Technological advancements have also enabled this drastically growing economy to resort to sedentary activities for entertainment. Without policy interventions, the Chinese government could be accountable for high levels of diet-related, non-communicable diseases in their population, where the WHO estimates the Chinese will lose $588 billion between 2005 and 2015 due to mortality and morbidity rates arising from weight-related health concerns. Though the Chinese government has sought out potential solutions, there is still opportunity for further development.

Background
The obesity epidemic is a major threat to China as a rising economic power. Historically, China has primarily focused on solving problems of undernutrition and malnutrition. However, the infiltration of dietary trends from the West has led to overabundance and thus massive increases in overall calorie intake as well as meat and sugar consumption, particularly in urban regions. While China’s overall obesity rates for adults stand below 5%, many cities in China are reaching levels of approximately 20% (WHO). As such, over 200 million Chinese citizens are overweight or obese (Levine). There are still many areas in China where hunger remains a large problem, but rising levels of obese citizens is a concern the Chinese government must address to prevent disastrous consequences.

Changing diets and patterns of physical activity have resulted in considerable increases in the levels of obesity in China. China’s first nutrition and health survey was finished in 2002, revealing that over 60 million Chinese citizens had become obese between 1992 and 2000 (Levine). Since then, rates have only increased. With the influence of globalization, urbanization, and technology, China’s economy has flourished, reaching an annual GDP growth of over 9% for the past several years (BBC News). As a result Chinese lifestyles have shifted, giving rise to the degenerative disease stage of the nutrition transition, where growing incomes have led to increased spending on unhealthy foods (Popkin). Urban areas are of particular interest, as on average 8% of Chinese children in cities are obese compared to the 3.1% of children in rural regions (Sean). Drastic weight increases in both children and adults brings attention to the obesity epidemic aimed at urban China.

With shifting trends in diet and exercise, obesity levels in China have been on the rise. Although China’s categorical weight cutoff points are lower than the World Health Organization’s norms, racial differences must be accounted for. In China, BMI over 24 is overweight and over 28 obese compared to the WHO’s 25 and 30, respectively (Wu). These distinctions are accounted for by the impact greater weight gain has on the health status for those of Asian descent compared to other racial groups. Between 1985 and 2000, the frequency of overweight or obese children increased 28 times in children ages 7-18 (Wu). Based on current trends, China could potentially reach the extreme levels of obesity seen in the United States by 2025 (Popkin et al.).

Influencing Factors and Determinants
Before the 1970s, the Chinese diet was primarily composed of cereals and starches with low levels of meat, sweets, fruits, and vegetables. In the 1980s, however, China made vast economic advancements, and as a result their dietary patterns changed. Beginning in 1988, the Chinese government no longer rationed meals (Du, Mroz, Zhai, and Popkin). The end of rationing, which had enabled the government to control the dietary habits of its people, allowed Chinese citizens to eat more freely and according to their own preferences. With options shifting toward more western-oriented products, Chinese consumers responded by demanding more energy-dense foods. As certain portions of China’s population grew richer, Chinese diets became more westernized. As a result, people consumed fewer grains though they remained a substantial portion of the diet. On average, vegetable intake has actually decreased even further (Du, Lu, Zhai, and Popkin). Patterns of animal products, sweets, and fruit consumption, however, have increased substantially. The average Chinese person ate nine times as many eggs and over six times as much fish in 2003 as in 1961. Sweet intake from sugars and sweetened beverages almost quadrupled (IIASA).

The livestock sector has expanded in China such that the nation produces the second-highest amount of poultry in the world. Prices of these commodities have fallen with higher levels of production, allowing for greater accessibility to meat by even the lowest tiers of China’s socioeconomic classes (Delgado, 1999). As incomes have increased, more people have eaten chicken, beef, and mutton, with the latter two meats showing the most significant increases (Du, Mroz, Zhai, and Popkin). Meat and milk consumed per capita doubled between 1983 and 1993 (Delgado). Because consumption of meat is signified with richness, easy access to these products
encourages overeating within the Chinese population. The distribution of energy from carbohydrates, proteins, and fats shifted from primarily carbohydrates in the 1960s to significant increases in fats by the 2000s (Du, Lu, Zhai, and Popkin). In addition to modifications within the Chinese diet, the levels of calories consumed increased over time as well, particularly given changes in rationing policies by the Chinese government. As China lifted restrictions and opened trade with the world, it soon became inundated with Western influence as businesses rushed to capitalize on this large untapped market. Globalization brought in new products and ideas. McDonald’s and Kentucky Fried Chicken, among many other Western fast food chains, have been upheld in China as a new standard, positioning themselves as high-class establishments in the eyes of the growing population. Although more energy-dense foods are being consumed, fewer calories are being expended, as many moved to urban areas and previous blue collar occupations were replaced by stationary desk jobs requiring little if any physical exertion (Du, Lu, Zhai, and Popkin). Technology advancements in transportation and leisure in addition to the effects of globalization have contributed to these changes in energy intake and expenditure as well. The quantity of cars and motorbikes in China has increased substantially over the past few decades as the country has flourished with economic success. Televisions, computers, and the internet have encouraged sedentary entertainment activities, further promoting an inactive way of living. With urbanization and Western influences spreading throughout China, rising trends of obesity appear inevitable unless intentional action is taken.

Potential Consequences
Without taking action, the Chinese government is threatened by chronic health care costs in its population arising from its heavier citizens. Diet-related, non-communicable diseases (DR-NCD), including cardiovascular diseases and diabetes, are likely to result from these changes, costing the Chinese in human capital and needed health care (Du, Lu, Zhai, and Popkin). Stroke mortality due to obesity has also increased, and 92.4 million Chinese adults currently have Type 2 diabetes (McDermid; Gale). The health costs of inaction are not limited to lost lives but also societal costs of lost productivity and monetary expenditures. In 2003 alone, the total medical cost of overweight and obese Chinese citizens was $2.74 billion (Zhao, Zhai, Hu, Wang, and Yang). The WHO estimates the Chinese will lose $588 billion between 2005 and 2015 due to deaths related to excessive weight gain if they do not take preventive measures. Given such extreme  circumstances, action must be taken.

Policy Solutions Undertaken
    In the past, the Chinese government has been primarily concerned with the undernourished and those who did have access to food. With such a large population, the objective for decades was to make sure the hungry were fed. Little attention was paid to what it was they were eating. Grain production was therefore encouraged in agricultural planning and unbalanced diets, skewed toward certain food products but not others, surfaced as a result. Previously, few governmental investments were pursued on the nutrition front, though some
action was taken by research institutes on the ground.
    The Chinese government has recognized that obesity threatens the health of its people and has taken action to address the issue with the hopes of preventing greater levels of obesity. The National Plan of Action for Nutrition was set-up in 1997 to address these concerns from the health level. In 1998, its implementation was under the responsibility of the Department of Disease Control (WHO). In 2001, a national day was also established to recognize the importance of nutrition (WHO). Developments on the supply-side of the market have also been pursued by seeking to provide incentives for the farmers of healthy crops. The Chinese government has laid down a foundation to address current cases of obesity and aims at prevention through the promotion of healthy lifestyles.
    While the Chinese government has taken action, there are great possibilities for expansion. The Chinese Nutrition Society and the Institute of Nutrition and Food Hygiene at the Chinese Academy of Preventive Medicine created dietary guidelines in 1997, including eight key values and a Pagoda (Appendix: Figure 3) similar to the United States’ food guide pyramid (Zhai, Fu, Du, and Chen).

    The eight principles, as written in the official handbook for Chinese citizens are: 1. Eat a variety of foods, with cereals as the staple; 2. Consume plenty of vegetables, fruits and, tubers; 3. Consume milk, beans, or dairy or bean products daily; 4. Consume appropriate amounts of fish, poultry, eggs, and lean meat. Reduce fatty meat and animal fat in the diet; 5. Balance food intake with physical activity to maintain a healthy body weight; 6. Choose a light diet that is also low in salt; 7. Drink alcoholic beverages in limited amounts, if at all; 8.
Avoid unsanitary and spoiled foods (Zhai, Fu, Du, Ge, and Chen).

    Although standards have been created, access and distribution of this material to the general public has not been initiated on a large scale. In addition to creating dietary guidelines, the Chinese government has also attempted to change cultural norms. Societal pressures have tended to promote academic achievement, encouraging many schoolchildren to sit and study rather than spend time doing  heavy-duty tasks that are often associated with labor workers (Cheng). The government has responded, however, by shortening the length
of national exams to lessen academic pressures. All of these initiatives, however, have room for growth.

Intervention Program to Address the Threat of Obesity
    Citizens living in urban areas of China are at particular risk for obesity, as their way of living provides easy access to eating out and requires little physical exertion due to advancements in technology and transportation. Given previous circumstances where  undernutrition was widespread and plumpness signified wealth, cultural norms encourage the Chinese to finish what is on their plates, often lending to habits of overeating. China’s notorious one-child policy, which is particularly enforced in cities, also leads to parents often spoiling their single child. As a result, many of these children are heavier than those with siblings, though confounding factors in this study may be debated (D’Arcy).

    Given that the one-child policy is more stringently enforced in urban areas, cities tend to have higher rates of obesity. When an individual lives in an urban area, they are likely to consume an average of 5.8-9.3 more kilograms of animal products per capita (Huang and Bouis). The reasoning behind this finding is debatable, ranging from changes in food prices to rising incomes. As such, in large cities such
as Beijing or Shanghai, on average 8% of 10- to 12-year-olds are obese and another 15% overweight (MacLeod). The intervention program developed will therefore focus on urban cities in China, particularly concentrating on prevention and weight loss to slow and hopefully lower current rates of obesity.

Nutrition Education in Schools and the General Community
Public awareness campaigns have been used to promote the Dietary Guidelines for Chinese Residents and the Balanced Diet Pagoda, created by the Chinese Nutrition Society. Similar to the United States’ food guide pyramid, these recommendations promote balanced eating habits (Zhai, Fu, Du, Ge, and Chen). The obesity rate of children in China as a whole is currently at 10%, an increase of 47%
compared to 2000 (Wei). Nutrition education, however, does not currently have an effective infrastructure to ensure broad reach. Thus, by using schools as a means, the Chinese government can inform and educate its citizens about obesity and general healthy eating.

Fast food restaurants such as McDonald’sTM and Kentucky Fried ChickenTM have a strong presence in the cities of China, and raising awareness about the health consequences these diets hold is necessary to promote changes in lifestyle norms (MacLeod). While it has been found China currently has low levels of fast food intake, these comparisons are made relative to countries such as the United
States (Popkin). The trends moving toward such circumstances must be prevented. Media campaigns both in the schools and local communities must be coordinated to push for greater awareness of leading healthy standards of living, encouraging family involvement to account for the times of day children are not in school (The George Institute for International Health). Whether it is flyers or television
announcements, these methods will target schoolchildren and the greater community. In urban China, children do not typically bring lunch from home. Instead, the school typically provides already-made lunches, consisting of traditional Chinese fare. Because these meals are regulated through the school, nutritional content can be controlled for and may be used as a means to introducing nutrition education.

Urban Planning and Investments to Promote Physical Activity
    In China, cultural norms currently encourage some forms of physical activity, since school schedules often allot time for daily morning exercises. China has already moved toward a program requiring daily physical activity in schools countrywide called Sunny Sports China that is currently in its pilot stage (Indiana University Newsroom). Schools in urban areas of China should also invest in sports equipment to
promote activity for schoolchildren. Initiatives to place slightly less emphasis on academics have been taken in favor of more time for physical exercise.

    Urban planning must also encourage greater levels of exercise by allowing areas for open green spaces. In 2000, there were only 6 million cars being driven in China, but by 2006 this number had increased to 20 million (NaturalNews). Pedestrian friendly city planning to promote walking or biking from one place to another rather than driving an automobile could also advance such goals as increased reliance on easier and accessible modes of transportation has been correlated with trends of obesity (Bell, Ge, and Popkin).

Regulations to Encourage Consumer Choice
The Chinese government should institute regulations on restaurants and food industry companies. Food labeling policies for chain restaurants and processed foods must also be initiated and enforced, encouraging visibility and increased knowledge for purchasing consumers. Doing so may also lead these companies toward offering healthier options. Food advertising has increased substantially with the influx of new technologies in the past few decades. As such, the number of television users in China has increased threefold, and the content being watched has been skewed more greatly toward marketing (Popkin). Marketing campaigns should be prohibited from
directing their advertisements toward children, who are most susceptible to these tactics, and the nutritional content of certain foods should be regulated to ensure healthy options are available. In conjunction with public awareness campaigns, increasing the amount of readily available information to consumers is pivotal to successfully influence dietary choices.

Increasing Accessibility to Healthy Foods Using Taxes and Subsidies
        Certain food prices must be controlled to encourage healthy eating habits. Lu and Goldman (2010) found when the price of cooking oil decreased, Chinese citizens’ intake increased. Because Chinese values often promote stinginess and savings, price sensitivity is a key  characteristic that must be capitalized upon. Currently, local goods such as vegetables typically used in Chinese dishes are cheaper than  Western options (Gao, Griffiths, Chan, 2008). Societal norms, however, must shift to ensure the latter are not held up as a standard of quality.

    Caution must also be taken when attempting to decrease the levels of fatty foods for the rich through the use of taxes and subsidies to ensure the poor are still able to access sources of protein, which may also be high in fat (Guo, Popkin, Mroz, and Zhai). Agricultural policies should also promote dietary goals (IIASA). Currently, the government uses subsidies to promote vegetables and the soybean industry rather than fatty animal products (Zhai, Fu, Du, Ge, and Chen). Such methods must be utilized across the board to ensure effective
results.

Suggestions for the Future
    Although the Chinese government has attempted to take action, there are various measures they have yet to pursue that could potentially prove advantageous to their cause. Nutrition programs and infrastructural modifications to encourage such curriculum are pivotal. Prevention programs are also of importance to slow down or even stop the drastic increases of overweight and obese Chinese children and adults while rates are still relatively low. Urban planning and investments to encourage physical activity must be used in conjunction with encouraging healthy eating.

    The population distribution in China presents various challenges that must be addressed with appropriate caution. While obesity is on the rise, undernutrition and micronutrient deficiencies are still prevalent, particularly due to the large income divides between the very  rich and the very poor. These divides were especially common in urban areas (Doak, Adair, Bentley, Zhai, and Popkin). Policymakers with the intent of addressing rising levels of obesity in China must be wary of indirectly influencing other segments of the population.
Instead, by taking a wide view of the people as a whole, Chinese policymakers can address the nutritional extremes in both circumstances to reach a middle ground.

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