Childhood obesity in China could heavily impact on its development. What is being done about it?
When China's healthcare researchers first uncovered a significant expansion in the nation's waistline they were looking to investigate something else entirely. In 1982 China's ministry of health had decided to undertake a massive survey of the country's diet looking to pinpoint sites of malnutrition and understand where best to target basic food resources. But in the course of their research they discovered that the number of overweight people in China accounted for approximately 7% of the population (by way of contrast, in 1980 it was claimed that 26% of American adults were obese).
Just over a decade later, a 1992 survey suggested that 15% of Chinese people were overweight and approximately 30 million were clinically obese. In other words, the number of overweight Chinese had doubled in a decade. Excessive weight and obesity were now items to be added to China's ever lengthening healthcare agenda. The 90s saw the government launch the first campaigns around smoking, excessive alcohol intake and tentatively consider the - still politically sensitive - adverse effects of pollution on the nation's health.
As China has become richer, so there have been what are known as "wealth deficits" - a rising awareness of depression as well as Alzheimers and other conditions associated with improved longevity. Obesity has fallen into this group as decades of food scarcity have receded into an era of availability. TV programmes and radio shows discuss the adverse effects of obesity on everything from marriage prospects to students' exam performance to getting a job. "Fat camps" for kids, bogus slimming pills, the massive uptake of liposuction, the explosion of gyms and all manner of quack diets are all the subject of debate and tabloid speculation. Weight and body image are not seen as sensitive subjects by the media censors and so a repressed tabloid media has taken to discussing obesity with a vengeance.
In the west there has been a tendency to equate the "obesity epidemic" with a single identifiable evil in the diet - a prime suspect if you like - trans-fats, junk food and fizzy drinks. But, in China, it is the cumulative change across the national diet that has made the difference.
The fact is that, particularly for China's urban middle class, diet has changed radically and seemingly definitely in terms of both volume and variety. Access to food has greatly improved - supermarkets, hypermarkets, convenience stores. At the same time the range of food products has grown, though mostly this has been pre-packaged and processed foods high in fat salt and sugar (HFSS). For instance, the total volume sales of the processed foods and beverages with high quantities of HFSS food products have grown at more than twice the rate of fresh fruit and vegetables sales over the last 15 years. The diet has changed, and urban malnutrition is now virtually extinct, but not necessarily for the better.
As new data revealed China's growing waistline so the policy of targeting the poor and underfed also became a quest to understand why some people were putting their health at risk by overeating. "From famine to gluttony in a generation," is how one dietician in Guangzhou phrased to me. Another described it as a "wealth benefit" in the new China and that, just as more people owning cars was leading to sky-rocketing accident rates, so the greater availability of, access to, and affordability of food was seeing some Chinese overindulge and gain weight to degrees that were injurious to their health. By 2012 China's Ministry of Health estimated that as many as 300 million Chinese people are obese in a population of 1.2 billion. This total makes China the second most obese nation after the USA in numbers of overweight citizens.
This rise in obesity translates into a major healthcare policy problem. Recent surveys of obesity and diabetes to date have found that the prevalence of diabetes and pre-diabetes is nearly 10% and 16%, respectively, across China, accounting for 92.4 million adults with diabetes and 148.2 million adults with pre-diabetes. Underdiagnosis is a major concern for healthcare policy planners in China. Diabetes, both type 1 and 2, are believed to be significantly underdiagnosed, while according to the ministry of health, only 30.2% of China's population is aware of hypertension as a clinical condition (and to many, this seems a high estimate). Due to underdiagnosis, China could potentially be home to many more diabetics, unaware of their condition or unable to access treatment. Their number could be being added to by 1.5 million to 2 million new sufferers per year.
Chinese healthcare planners are now far more aware of obesity, and the medical problems associated with it, than they were even just five years ago when Ji Chengye, of the Child and Adolescent Health Section of the China Preventive Medicine Association, declared that "China has entered the era of obesity". It is now a subject of many studies, media speculation and greater educational awareness. In large part the government has blamed inactivity and sedentary lifestyles as the major culprit. Tian Ye, director of the China Institute of Sports Science, has said the issue of weight and physical decline can be attributed partially to the lack of sports activities among young people but funding for more mass-participation programmes was never forthcoming.
Across the board - from exercise to diet - specific funding for obesity awareness programmes remains low to non-existent. In China's system of rigid central planning of budgetary allocations awareness of a problem can grow, but funding and new approaches are far slower to emerge, due to five year planning cycles. In 2009, as part of China's $586bn (£384bn) fiscal stimulus package, the central government budgeted for billions more to go into the healthcare system, in the countryside and cities. However, none of this went to obesity prevention. While the number of researchers in the field has increased ground level activity remains small. According to China's National Institute of Nutrition and Food Hygiene in Beijing, the country has just over 10,000 qualified nutritionists nationwide, but needs at least four million, based on international standards of one nutritionist for every 300 people.
China still remains legislation-lite when it comes to obesity. In 2007 when new obesity stats made headline news some initiatives were launched - the central government ordered the building of more playgrounds and passed a law requiring students to exercise or play sports for an hour a day at school. While more playgrounds were built they were often not well thought out and did not encourage more active play, while many schools have disregarded the exercise regulations (often due to parental criticisms of wasted time away from academic studies) or circumvented them by using the time for drilling or simple mass playground exercises.
Similarly, a government initiative to institute mass exercises in workplaces was largely ignored by employers as inappropriate when staff have customers to deal with. At the same time the Chinese Nutrition Society launched a campaign - Eat Smart at School - aimed at cultivating healthy eating practices in schools. This emphasis on school meals followed research in Hong Kong where staple lunchtime dishes such as fried rice and noodles were found to be high in fat, cholesterol and sodium. In 2006 Hong Kong launched a campaign entitled EatSmart@school.hk to promote territory-wide healthy eating. The campaign included issuing new nutritional guidelines on school lunch for primary school students to guide caterers to provide balanced diets to 300,000 students in some 600 whole-day primary schools. China followed suit, though only schools in wealthier urban areas have realistically been able to afford the new lunches.
However, despite debate, there has been no adoption of any formal legislation regarding TV advertising of fast food or requirements to introduce additional warning labeling to products in the HFSS category.
More recently there appears to have been a rethink on the approach to obesity by the Chinese government. As with other healthcare issues of growing concern - care of the increasing elderly population for instance - localised community-based interventions appear to be where resources will be targeted in future. China is currently experimenting with community-based interventions through the National Plan of Action for Nutrition in China. This programme is a mixture of the education and promotion of better diets and lifestyles while also providing incentives to food growers to both produce healthier foods and improve production and hygiene after China's decade long rash of food scares.
Still, at present, obesity rates - particularly among children - are continuing to grow and associated medical conditions, most notably type-2 diabetes, is continuing to add additional strains to an already overstretched national healthcare system. Today's overweight and obese in China can look forward to a mixed future of bright economic hopes for their country, but all too often, poor and deteriorating health for themselves. Many of China's young obese are about to hit healthcare problems associated with being overweight in middle age.
According to a 2012 survey undertaken by the Children's Hospital of Shanghai's Fudan University, the number of Chinese children under 14 suffering from diabetes is growing fast and has almost tripled over the past 25 years representing a significant rise in Maturity Onset Diabetes of the Young (MODY). MODY leads to more type 2 diabetes, caused by the wearing out of insulin-producing cells normally associated with the natural ageing process, in younger and younger patients. As well as more incidences of type 2 diabetes in the young, it also means that more cases of heart disease, strokes and kidney failure - problems caused by diabetes - will develop in ever younger people. Put quite simply, what was once a chronic disease of midlife in China is now a paediatric problem occurring in children as young as ten. All this will impact significantly on China's heathcare budget in the future.
A conservative estimate - comparing US and UK costs per obese patient to China, with cost factored in to reflect some lower prices of treatment - the annual additional cost to China created its overweight and obese population reaches $155 bn. In the next decade China's healthcare planner will have to dig deep to fight obesity.
Paul French is the author of Fat China: How Expanding Waistline will Change a Nation. Follow @chinarhyming on Twitter.
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Access to food, as well as the range of products available, has changed dramatically in China over the last 15 years. Photograph: Nikhil Patel/Guardian
