Children and Adolescents Obesity

Risk Factors and Primary Prevention Strategies in China

Yeling Zhao, B Pharm, MPH Department of Public Health, University of Sydney yeling.zhao@gmail.com

Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China

Background An increasingly sedentary lifestyle and rapidly changing dietary practices have brought about a dramatic increase in prevalence of obesity, which has been recognized as an important public health problem all over the world [1-4]. According to World Health Organization (WHO), in 2010, approximately 40 million children were overweight globally. Nearly 35 million of them are living in developing countries, because they are more vulnerable to energy imbalanced diet and low levels of physical activity [5]. During the period from 1985 to 2005, it was estimated that the prevalence of overweight and obesity in China, among 7 to 18 years old children, has increased from 0.93% and 1.62% to 14.9% and 8.9%, for boys and girls, respectively [6]. Obesity has significant consequences for morbidity, disability and quality of life. It has been presented as an important risk factor for some non-communicable diseases, such as cardiovascular diseases (mainly heart disease and stroke), diabetes and some cancers (endometrial, breast and colon) [5, 7]. Obesity in childhood could result in a higher chance of obesity, disability and premature death in adulthood. Moreover, childhood obesity could increase the risks of breathing difficulties, fractures, hypertension, as well as early markers of cardiovascular disease, insulin resistance [5]. Furthermore, childhood obesity also has psychological consequences obese children are more predispose to have higher levels of anxiety, depression, and low self-esteem as well [8, 9]. Risk Factors for Childhood Obesity A number of risk factors contribute to the high prevalence of overweight and obesity among children and adolescents in China, ranging from behavioral to socio-economical, as well as cultural and political determinants. Behavioral Risk Factors Lots of research [2, 5, 7, 10, 11] has shown that behavioral factors, such as insufficient physical activity, a sedentary lifestyle, eating behaviors and inadequate sleep time etc., are associated with overweight and obesity. Table 1 [12] illustrates the prevalence of some major behavioral risk factors among school age children (6 - 18) in Beijing, the capital city of China, in 2010. Although it is recommended that students should do moderate or vigorous physical activity for at least one hour every day, approximately 80% of those school age children cannot meet the recommendation. Sedentary lifestyles are another serious issue and related to overweight and obesity in Chinese students. More than 44% school age children spent at least two hours per day to use computer, play video games or watch TV. In terms of eating behaviors, frequent consumption of western fast food and snacks could the
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Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China

contributing factors for weight gain as well. The prevalence of eating behaviors for consumption of snack and western fast food are 32.0% and 3.7%, respectively. Finally, lack of sleep in childhood could increase the long-term risk in overweight and obesity [10, 11]. Based on the US National Sleep Foundation recommendation [13], school age children (5 -12 years old) need 10-11 hours of sleep, those aged 13-18 need at least 8.5 hours. However, only one quarter of students have the sufficient hours of sleep. Socio-economical Risk Factors In contrast to most developed countries, whose socioeconomic status (SES) varies inversely with overweight and obesity [14], children and adolescents in high SES level have higher prevalence of overweight and obesity than those who are in lower SES level [15, 16]. China, as the biggest developing country in the world, has the same situation [17]. Table 2 [17] provides gender-specific information about the prevalence of overweight and obesity among children aged 7-18, according to local school area SES and urban versus rural residency in China in 2005. The risk of child and adolescent obesity is much greater in high SES areas compared with those in low and intermediate SES areas. In addition, urban residency comprises a doubled share of overweight and obesity compared with rural residency. Thus, it appears that those people living in urban areas with a high socioeconomic status are at greater risk of overweight and obesity than those in poorer, rural areas. Cultural and Political Risk Factors In the traditional cultural, Chinese people hold the beliefs that fatness is a sign of happiness and prosperity [18]. Moreover, the cultural basis for son preference also could result in the overweight and obesity for boys, since they are likely to enjoy more of the familys resources. This can be testified from the data of Table 2 no matter in which category, the prevalence of overweight and obesity is much higher for boys than those in girls. However, these traditional beliefs have not kept pace with the development of socioeconomic, which have contributed to a more food demand and the potential for over consumption and energy imbalance [18]. In addition, due to the one child policy in China, a single child, especially a boy, is likely to be spoiled by both parents and grandparents, which could lead to the overfeeding of children [19]. Primary Prevention Strategies Childhood and adolescent overweight and obesity have been recognized as an increasing health problem worldwide. Primary prevention plays a significant role in
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Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China

our effort to address obesity, and needs to be of high priority [20]. This is not only because the short-term and long-term effects of both medical and psychological, but also because: Children are the population group most vulnerable to the environment and gain most from intervention efforts [20]. Obesity, once established, is difficult to reverse and treat [7, 21]. The author of this paper separate the prevention program in terms of school-based and community-based, details as followed: School-Based Prevention Most school-based interventions focus on changing unhealthy behaviors for school aged children, including [22-25]: increase physical activity through structured physical fitness classes, decrease sedentary behavior and increase sleep time through pamphlets and lectures, deliver nutritional education, modification of food being provided by school canteens, change in diet (such as reducing the intake of high caloric food ). According to the review conducted by Consuelo et al. [26], the duration of school-based prevention program is in direct proportion to its effectiveness. Thus, long-running strategies for preventing and managing childhood and adolescents overweight and obesity should be taken into consideration by school principals and policymakers. A successful example of school-based prevention in China is a 3-year obesity intervention conducted by Capital Institute of Pediatrics in Beijing [27], where students and their parents were involved in a program of nutrition education and physical activity to increase awareness and change their unhealthy lifestyle. An unsuccessful example of this intervention is a nutrition-based comprehensive intervention study on childhood obesity in China [28]. It was conducted in six schools located in six cities from the beginning of 2009. However, due to the outbreak of H1N1 in the second half year of 2009, many schools refused the researchers of the study to enter schools; therefore, the intervention implementation had to be suspended. Hence, the appreciation and cooperation from school staff are of crucial importance in this situation. However, due to the limitation of educational resources and a large population in China, the competition in study is relatively high. As a result, an increasing pressure on students to preform in academic has caused a decreased emphasis on physical activity in school; therefore, a further decline in physical activity and increase in sedentary behavior [2]. Based on this situation, more amendment and cooperation in Chinese education system are need, which could contribute to improving either childrens health or overall well-being [12].

Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China

Community-Based Prevention Most community-based interventions are aimed either at reducing the behavioral determinants, or at reducing the socioeconomic and cultural-political risk factors. The target population of this intervention, therefore, is children and adolescents, as well as their parents and grandparents, especially those in high SES areas and urban areas. A national media campaign and educational program, which aimed at providing useful information to reduce the incidence of childhood obesity, could be one of the most cost-effective interventions. The information offered from those campaigns should cover not only the modification of unhealthy lifestyle, but also: fatness is not a sign of happiness and prosperity do not spoil children, even he or she is the only child in the family. This campaign could include pamphlets and brochures available at maternity hospital, poster, TV programs, websites, and guidelines from health professionals. Cooperation between health sectors, community and government service could contribute to this campaign. In return, this campaign would benefit the modification of unhealthy lifestyle among children and adolescents. Unfortunately, few studies or reviews about socio-economical or cultural-political interventions were found in China. This is probably because the relations between SES risk factors and childhood obesity are complex and not fully understood [30]; and the one child policy is still a sensitive political topic, hence few study is focused on this part of intervention. Summary This paper explores the prevalence and consequences of childhood and adolescent overweight and obesity. Then, lists the social determinants related to gaining weight in school age children. Based on those risk factors, primary prevention strategies, which aimed at reducing the rate of obesity in young people, are provided. Success of the interventions requires appreciation and cooperation not only from each stakeholders, but also from the Chinese education system. In addition, without the combination and cooperation of the school-based and community-based programs, hardly could we reduce the incidence of obesity of Chinese children and adolescences.

Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China

Annex
Table 1[12]. Prevalence (%) of those factors among school age children (618 years) in Beijing Behavior risk factors Physical Inactivity (< 1 hr/d) Sedentary Behavior (screen time >= 2 hrs/d) Snack Consumption (>= 3 times/wk) Western Fast Food (>= 3 times/wk) Short Sleep Time

All 79.5 44.4 32.0 3.7 78.6

Boy 77.9 48.1 30.2 3.9 77.7

Girl 81.1 40.7 33.8 3.5 79.5

Daily sleep time < 10 hours for children aged 6-12 years old, and <8.5 hours for children aged 13-18 years old Table 2 [17]. Gender-specific prevalence (%) of overweight and obesity according to local school SES and urban versus rural residency amongst Chinese children aged from 7 to 18 Overweight All SES Level of local school area High Intermediate Low Urban Rural 9.0 7.4 7.2 10.3 5.4 11.2 9.1 8.5 13.1 6.2 6.7 5.7 5.7 7.5 4.7 4.6 3.4 3.3 5.4 2.3 6.1 4.4 4.4 7.2 2.8 3.1 2.4 2.3 3.6 1.7 Boy Girl All Obesity Boy Girl

Urban/rural area of residence

SES = Socioeconomic Status

Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China

References 1. de Onis, M., M. Blssner, and E. Borghi, Global prevalence and trends of overweight and obesity among preschool children. The American journal of clinical nutrition, 2010. 92(5): p. 1257-1264. Gupta, N., et al., Childhood Obesity in Developing Countries: Epidemiology, Determinants, and Prevention. Endocrine Reviews, 2012. 33(1): p. 48-70. Consultation, W., Obesity: preventing and managing the global epidemic. World Health Organization technical report series, 2000(894). Swinburn, B., T. Gill, and S. Kumanyika, Obesity prevention: a proposed framework for translating evidence into action. Obesity reviews, 2005. 6(1): p. 23-33. WHO. Overweight and Obesity Fact Sheets. 2011 [cited 2012 6th April]; Available from: http://www.searo.who.int/linkfiles/non_communicable_diseases_obesity -fs.pdf. Ji, C.Y. and T.O. Cheng, Epidemic increase in overweight and obesity in Chinese children from 1985 to 2005. International journal of cardiology, 2009. 132(1): p. 1-10. Branca, F., H. Nikogosian, and T. Lobstein, The challenge of obesity in the WHO European Region and the strategies for response: summary2007: World Health Organization. Brownell, K.D., et al., The need for bold action to prevent adolescent obesity. Journal of Adolescent Health, 2009. 45(3): p. S8-S17. Ebbeling, C.B., D.B. Pawlak, and D.S. Ludwig, Childhood obesity: public-health crisis, common sense cure. The lancet, 2002. 360(9331): p. 473-482. Chen, X., M.A. Beydoun, and Y. Wang, Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Sleep, 2008. 14: p. 15. Landhuis, C.E., et al., Childhood sleep time and long-term risk for obesity: a 32-year prospective birth cohort study. Pediatrics, 2008. 122(5): p. 955-960. Shan, X.Y., et al., Prevalence and behavioral risk factors of overweight and obesity among children aged 2-18 in Beijing, China. International Journal of Pediatric Obesity, 2010. 5(5): p. 383-389. USNSF. Children and Sleep. 2011 [cited 2012 1st April]; Available from: http://www.sleepfoundation.org/article/sleep-topics/children-and-sleep . Gortmaker, S.L., et al., Social and economic consequences of overweight in adolescence and young adulthood. New England journal of medicine, 1993. 329(14): p. 1008-1012. Sharma, A., K. Sharma, and K. Mathur, Growth pattern and prevalence of obesity in affluent schoolchildren of Delhi. Public health nutrition, 2007.
6

2. 3. 4.

5.

6.

7.

8. 9.

10.

11.

12.

13.

14.

15.

Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China

16.

17.

18.

19.

20.

21. 22.

23.

24.

25.

26.

27. 28.

29. 30.

10(05): p. 485-491. Goyal, R.K., et al., Prevalence of overweight and obesity in Indian adolescent school going children: Its relationship with socioeconomic status and associated lifestyle factors. Journal of Association of Physicians of India, 2010. 58(MAR): p. 151-158. Chen, T.J., et al., Regional, socioeconomic and urban - rural disparities in child and adolescent obesity in China: a multilevel analysis. Acta Paediatrica, 2011. Cui, Z., et al., Temporal trends in overweight and obesity of children and adolescents from nine Provinces in China from 19912006. International Journal of Pediatric Obesity, 2010. 5(5): p. 365-374. Wang, Y., C. Monteiro, and B.M. Popkin, Trends of obesity and underweight in older children and adolescents in the United States, Brazil, China, and Russia. The American journal of clinical nutrition, 2002. 75(6): p. 971-977. Bell, A.C., et al., Preventing childhood obesity: the sentinel site for obesity prevention in Victoria, Australia. Health promotion international, 2008. 23(4): p. 328-336. Must, A., Does overweight in childhood have an impact on adult health? Nutrition reviews, 2003. 61(4): p. 139-142. Donnelly, J., et al., Nutrition and physical activity program to attenuate obesity and promote physical and metabolic fitness in elementary school children. Obesity Research, 1996. 4(3): p. 229. Mo-suwan, L., et al., Effects of a controlled trial of a school-based exercise program on the obesity indexes of preschool children. The American journal of clinical nutrition, 1998. 68(5): p. 1006-1011. Gortmaker, S.L., et al., Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Archives of Pediatrics and Adolescent Medicine, 1999. 153(4): p. 409. Gupta, N.K., et al., Is obesity associated with poor sleep quality in adolescents? American Journal of Human Biology, 2002. 14(6): p. 762-768. Gonzalez-Suarez, C., et al., School-Based Interventions on Childhood Obesity:: A Meta-Analysis. American journal of preventive medicine, 2009. 37(5): p. 418-427. Jiang, J., et al., The effects of a 3-year obesity intervention in schoolchildren in Beijing. Child: care, health and development, 2007. 33(5): p. 641-646. Li, Y., et al., The nutrition-based comprehensive intervention study on childhood obesity in China (NISCOC): a randomised cluster controlled trial. BMC public health, 2010. 10(1): p. 229. Lamb, M.M., et al., Early-life predictors of higher body mass index in healthy children. Annals of Nutrition and Metabolism, 2010. 56(1): p. 16-22. Magnusson, M.B., et al., Childhood obesity and prevention in different socio-economic contexts. Preventive Medicine, 2011.
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Children and Adolescents Obesity: Risk Factors and Primary Prevention Strategies in China