China's economy has boomed, but a potentially disastrous side effect - along with pollution and a growing income gap between urban and rural regions - is the effects obesity will have on the country's fragile healthcare system. Today's overweight in China can look to a mixed future of bright economic hopes for their country, and poor and deteriorating health for themselves. From a situation 20 years ago when diets were limited by food availability, and famine was still a recent memory, China's urban centres have seen alarmingly rising rates of obesity. Throughout the country an estimated 200 million people out of a total population of around 1.3 billion were overweight (over 15%).
Why is this issue so important? Taking into account that the recent period of stable world economic growth has in large part been driven by the availability of cheap labour in China, which produces much of the goods that keep the retail tills ringing elsewhere in the world, the issue of China's rising obesity is an issue of potentially global economic significance. Consider a scenario just a few years down the line, where there are so many overweight urban Chinese, suffering from obesity-related illness, that the government, in order to pay for increased healthcare treatments, has to raise the levels of income and other tax to pay for this huge and continual expense.
About the Author
Paul French is a founder and the Chief China Representative of Access Asia based in Shanghai. Access Asia specializes in providing information on China's economy and consumer/retail markets. He is the author of a number of books on China's history, development and current society.
As co-founder of Access Asia, Matthew Crabbe has been analysing the consumer economy of China for almost two decades. He has specialist knowledge about the development of China's consumer lifestyles, and the repercussions that such fast change has for Chinese people and society.
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How Expanding Waistlines are Changing a Nation
By Paul French, Matthew Crabbe
Wimbledon Publishing CompanyCopyright © 2010 Paul French and Matthew Crabbe
All rights reserved.
CHINA GETS ON THE SCALES
Quantifying the Size of the Problem
Quantifying the potential size of China's obesity problem naturally requires measuring the growing size of the Chinese waistline. So first a technical note: Firstly, this book differentiates between being overweight and being obese. Literally, obesity means a condition characterized by excessive body fat. The body cannot store protein or carbohydrates, so the excess is converted to fat and stored. One pound of fat represents approximately 3,500 excess calories. Being overweight is nothing new and certainly not in any way specific to China — about 25 per cent of the world's population is overweight — that's over 1.2 billion people, according to the World Health Organization's (WHO) classification system, and 300 million of them are clinically obese. More alarmingly perhaps, the WHO estimates that worldwide, 22 million children under five are overweight.
Secondly, being obese is different from being overweight. An individual is considered obese when their weight is 20 per cent (25 per cent for women) or more over the maximum desirable for their height. When the excess weight begins to interfere with vital functions such as breathing, it is considered morbid obesity. Again, China is far from alone in seeing rising rates of obesity; indeed, in many ways the country severely lags the obesity rates of North America and Western Europe. Globally, approximately 5 — 10 per cent of children are obese; between 13 per cent and 23 per cent of all adolescents are obese. However, child obesity is an indication of longer-term trends — surveys have found that around 80 per cent of obese teenagers are likely to grow into obese adults.
Thirdly, most definitions of overweight and obesity rely on the Body Mass Index (BMI) calculation. There are problems with this as discussed below, but it is an internationally used measure of obesity, with some adaptations. The BMI formula was developed by the Belgium statistician Adolphe Quetelet (1796 — 1874), and was previously known as the Quetelet Index. BMI is also referred to as 'body mass indicator'.
However, it should, once again, be noted that the BMI is controversial for a number of reasons including that it is designed primarily for people aged between 25 and 65; it does not take into account muscle mass or overall body type ('apple' vs. 'pear' body types); and, perhaps most controversially of all, until recently it was generally considered a measure applicable to all racial types, while some in the fashion industry (who talk of 'silhouettes' rather than 'shapes') have called for variable BMIs for men and women and for age, too.
There are several alternative measures of weight that are occasionally used to determine obesity. Waist-to-hip ratios can provide an indication of whether an individual has too much body fat. Generally, the waist-to-hip ratio should not exceed about 0.9 for men and 0.8 for women. Higher ratios indicate an increased risk of stroke, diabetes and heart attack. There are also skinfold tests and Bioelectrical Impedance Analysis (BIA) that measures the total amount of body weight from fat. This method is considered far more accurate by some, though BMI remains the major, most widely used and popular global calculator of weight.
Weighing the Nation
At the start of Deng Xiaoping's 'Reform and Opening Up' movement in 1979 there was no data on weight in China available. In 1980 Charlotte Ikels, a regular visitor to Guangzhou, reported that hardly anyone appeared overweight, but this was about to change and by the end of the decade, obesity would be declared a national health issue in China's large cities.
The question of China seriously gaining weight first came to light in a series of partially comprehensive surveys on diet and nutrition that were conducted in the 1980s and early 1990s. However, none of these reports really focussed specifically on the prevalence of weight gain and obesity, but rather concentrated on how the more pressing issue, at the time, of China's successful reduction of the incidence of malnutrition across the country was progressing.
As a side effect of these studies, some findings relating to weight were published; figures compiled in 1982 reported that the number of overweight people in China accounted for approximately 7 per cent of the population (by way of contrast, in 1980 it was claimed that 26 per cent of American adults were obese). A decade later, a 1992 survey suggested that 15 per cent of Chinese were overweight and approximately thirty million were clinically obese. In other words, the number of overweight Chinese had doubled in percentage terms in a decade. Even compared to a slightly later survey conducted in 1996, the massed ranks of overweight Chinese had grown by 23 per cent. A trend was beginning to appear, but needed closer scrutiny. What was immediately becoming evident was that China was sharply divided between urban and rural on the question of weight, just as it was in terms of income, living standards, material well-being, lifestyle and access to services such as healthcare. In short, the cities were becoming richer and life for urbanites was dramatically improving compared to those residing in the countryside; one side effect of this was urban weight gain. The weight profile of the typical urbanite and the typical rural dweller was starting to significantly diverge.
China officially got on the scales as a nation and weighed itself in June 2002 when the country's State-associated China Academy of Medical Science (CAMS) issued its first-ever Obesity Index for Chinese Adults as part of CAMS' Fourth Nutrition and Health Survey. The Index was based on various data that had been gathered in the 1990s and Professor Zhou Beifan published the key findings in the journal Popular Medicine. The survey used the WHO standard index references of BMI — body weight divided by body height squared, as outlined above.
Since this was launched, there have been arguments about how applicable the traditional measurement of BMI is to Asians, being worked out largely on the basis of more wide-ranging and thorough studies conducted in the West on Europeans. In the West, a BMI of 25 to 29.9 is considered overweight; while 30 and above is categorized as clinically obese, indicating an abnormally high proportion of body fat. There is also the category of morbid obesity, a severe form of obesity in which a person is 100 or more pounds overweight. However, research in the US had suggested that the BMI normal threshold for Asians should be lowered to 23 or 24, with 25 or over being defined as obese. Asian researchers largely agreed with the American findings and China started revising its definitions of BMI in line with these calculations in 2001. Since then most researchers have used them, with some arguing that a BMI of as low as 20 should be considered overweight for Asians, while other researchers have suggested still lower thresholds. This naturally had inflationary ramifications for China's fat statistics.
The Beijing Chenbao, a daily newspaper in the Chinese capital, claimed that 50 per cent of the population in China would be classified as overweight under the new Asian weight index compiled by the WHO. Even under less stringent criteria, the Beijing Chenbao estimated that 40 per cent of the Chinese people would still be classified as overweight, and one-eighth of the overweight would be classified as obese. When Singapore's Health Ministry conducted a survey of the island state's population, they found that 60 per cent of Singaporean adults could be classified as overweight using the revised Asian BMI calculation. These findings and recalculations radically changed the discussion of obesity in China and other majority ethnic-Chinese nations such as Singapore and Taiwan. All agreed that this revealed a problem that had been partially hidden by the former European-standard BMI calculations, which had given false indications.
Despite this, according to these BMI standards, individuals were deemed overweight when their BMI surpassed or equalled 24, and obese when the index surpassed or equalled 28. Further, a male gets abdominally obese when his waistline reaches or surpasses 85 cm, and females, 80 cm. Waistline is considered an important measurement for abdominal obesity, because it reflects a person's abdominal adiposity (defined clinically as central obesity, or more commonly perhaps as 'belly fat') which has a lot to do with the onset of a series of metabolic disorders.
BMI also gives some indication of the potential future strains a country's healthcare service may have to suffer — when the BMI increases by two, the risks of coronary heart disease and stroke increases by 15.4 per cent and 6.1 per cent respectively, according to CAMS. When an individual reaches 24 on the index, then their likelihood of suffering high blood pressure, diabetes (which the WHO categorizes as a chronic non-communicable disease) and hyperlipidemia (excess levels of fats in the blood) at the same time exceeds 90 per cent. The key is abdominal fat, where the alarming-sounding 'red-line' is a level of 100 cm2 for males in the visceral fat area — the amount of fat inside the peritoneal cavity, packed in between the internal organs in the abdomen. With a high level of abdominal fat, patients are at risk of developing diseases such as hypertension (defined as a blood pressure of over 140/90 mmHg in adults) and diabetes. Indeed, those with elevated levels of visceral fat are three times more likely to suffer from diabetes (which can also be inherited) and have twice the risk of hypertension, stroke and heart attack. Since 2001 most Chinese research studies have used the designation of a BMI of 25 as indicating obesity.
It took another 18 months, though, before China's first comprehensive national survey on diet, nutrition and disease was released. China's then Vice Minister of Health Wang Longde announced the disturbing findings at a Beijing press conference. The survey had discovered that 22.8 per cent of Chinese adults were overweight and that 7.1 per cent were clinically obese (amounting to 60 million people). Twenty years after the first published surveys, there were now as many people defined as clinically obese in China as had been previously designated as simply overweight in 1982. Over the intervening two decades, the number of overweight people across the country had risen to an estimated 200 million out of a total population of around 1.3 billion, according to Vice Minister Wang. These were significant advances over Professor Zhou's earlier surveys, which had concentrated more on nutritional intake and the incidence of malnutrition than excess weight problems. However, Vice Minister Wang was forthright in the conclusions that had been drawn concerning the nation's growing obesity problem commenting, 'Compared with the nutrition survey results of 1992, the prevalence of being overweight has increased 39 per cent and the prevalence of obesity has increased by 97 per cent.'
In light of these findings, if the earlier surveys from the 1980s are looked at again the contrast becomes stark — by 2005 the official Xinhua news agency was reporting that 70 to 90 million Chinese were clinically obese. Though this number appears high, and is not substantiated scientifically, it would mean that China, due in part to its highly populous nature, could account for nearly one-third of the total number of obese people worldwide, which is rising, given the WHO's estimate in 2000 that obesity affected 300 million people globally and that approximately 1.2 billion people were overweight. Even if Xinhua's number was a little high, others didn't radically disagree; Pan Beilei, deputy director of the government-affiliated State Food and Nutrition Consultant Committee (SFNCC), estimated that 60 million Chinese were obese in 2006, while Chen Chaogang, a university doctor in southern China's Guangdong province who was studying obesity rates across China, predicted that as many as 200 million Chinese people would be dangerously overweight by 2015.
Vice Minister Wang continued to be quite frank and publicly warned that the problem was only going to get worse in China, his open comments on the subject indicating that the ruling Communist Party was now aware of a growing urban obesity problem and the long-term impact this could have on the nation's healthcare system. The rising obesity figures had immediately alerted the central government that chronic non-infectious disease rates were likely to start rising steeply. Lifestyle diseases had arrived in China's cities and the problem had already got noticeably worse. The 2002 survey had taken some time to be published — approximately two years — as it was far larger than any previous study on the nation's diet; 270,000 people were surveyed across a wide range of municipalities, cities, towns and counties nationwide. By the time it was released, there were already a lot more obese people around.
The adverse effects on health in China were already starting to show: 260 million individuals were considered either overweight or obese; hypertension rates among adults had reached 18.8 per cent, increasing by 31 per cent, or 70 million cases, since 1991; 160 million people, or 18.6 per cent of the population, were suffering from high blood pressure (which can be caused by a high salt intake, common in many traditional Chinese dishes) and abnormal blood lipid levels (hyperlipidemia), while a further 160 million were suffering from arteriosclerosis (hardening of the arteries); over 20 million Chinese were diagnosed with diabetes, fully 2.6 per cent of the total population, while a further 20 million Chinese had poor blood sugar levels, according to China's Ministry of Health. But it was diabetes that most worried health professionals. Compared with the data collected in the 1996 survey, the prevalence of diabetes among adults over the age of 20 in China's major cities had increased from 4.6 per cent to 6.4 per cent and in small- and medium-sized cities the rate had risen from 3.4 per cent to 3.9 per cent.
By mid-decade things were looking increasingly worrying. A survey jointly conducted by Ministry of Health and the National Bureau of Statistics (NBS), China's primary statistical gathering and dissemination organization, indicated that 30 per cent of the total population in China's big cities were overweight, compared with 21 per cent in 1992. Fully 12.3 per cent were considered to be obese, approximately double the 6.2 per cent recorded in 1992. The China Preventive Medicine Association (CPMA) issued a press release arguing that the number of overweight people in China's cities had reached the 100 million mark. Again, it seemed clear that as the urban economy was growing, so were 'prosperity induced' waistlines.
Back in the 1990s the figures had indicated that obesity was becoming a worrying factor, but only in China's largest and most advanced cities — the tertiary cities of Shanghai and Beijing in particular. But as wealth and changing lifestyles rippled out across the country, so did weight-related problems, as reported by tier-two and tier-three cities. In 2007 the 'Report on Sichuan Residents' Nutrition and Health' released by the Sichuan Provincial Disease Control and Prevention Centre (part of the fourth national nutrition and health investigation sponsored by the Ministry of Health, the Ministry of Science and Technology and the National Bureau of Statistics) disclosed that about 10 million of Sichuan's 87 million population, predominantly in the increasingly prosperous city of Chengdu, were suffering from hypertension as salt intake rose and fruit and vegetable intake fell. The report noted that the average Sichuan resident's salt intake had risen to 10 g a day, 4 g more than the recommended amount by nutritionists and dieticians. The report also noted that diabetes was becoming a more worrying problem and that approximately 2.5 million people in Sichuan Province were diagnosed as diabetic. Deng Ying, a leading official at the Sichuan Provincial Disease Control and Prevention Centre, explained the problem succinctly: 'The higher a family's income, the higher the incidence of diabetes.' Similar reports were starting to come in from other tier-two and tier-three cities in China — for instance, a study in the city of Wuhan, the capital of Hubei province, found that 8.9 per cent of 10 — 12-year-olds could now be classified as obese.
Excerpted from Fat China by Paul French, Matthew Crabbe. Copyright © 2010 Paul French and Matthew Crabbe. Excerpted by permission of Wimbledon Publishing Company.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
Introduction; Chapter 1 - China Gets on the Scales; Chapter 2 - China's Fat Class; Chapter 3 - Fat City – Obesity and Urbanisation; Chapter 4 - Mega-Wok – China's Diet From Cabbage to Cuisine; Chapter 5 - Shelves of Fat - Food Retailing in China; Chapter 6 - Fast Fat: The Impact of Fast-Food in China; Chapter 7 - Selling Fat - Promoting Fat in China; Chapter 8 - Little Fat Emperors - Obesity Among China's Children; Chapter 9: The Fat and the Thin - China's Body Image; Chapter 10: China's Fat Clinic – The Impact of Obesity on China’s Healthcare System; Conclusion: The Future of Fat China - Victims of Their Own Success?; Notes; Acknowledgments; Index
What People are Saying About This
'When Deng Xiaoping said 'To get rich is glorious', he probably didn't realize that getting wealthy would make many Chinese fat... In an informative and entertaining style, French and Crabbe reveal the dark side of China's growing middle-class: a fast increase in obesity-related illnesses such as diabetes. A great read on an important topic.' —Andy Rothman, China economist, CLSA Asia-Pacific Markets, Shanghai
'In this remarkably well researched and thought-provoking book, French and Crabbe expose a darker side of globalisation in China… Western multinationalists have submerged the Chinese consumer in a sea of chocolate and ice cream. The consequences for public health are incalculable.' —Tim Clissold, China investment specialist and author of ‘Mr China’
'While some people around the world agonize about the rapid spread of China’s global influence, others within China are more worried about the spread of the country’s waistlines – or at least they should be, according to this fascinating and exhaustively researched study by Paul French and Matthew Crabbe. By turns colourful, witty and alarming, this book provides fascinating insights into China’s fast-changing society.' —Duncan Hewitt, Shanghai correspondent for ‘Newsweek’ and author of ‘Getting Rich First: Life in a Changing China’