E X P A N D I N G W A I S T L I N E S A "Nutrition Transition" in China KITSY S M I T H AS C H I N A ' S COFFERS HAVE SWELLED OVER T H E PAST THREE DECADES, ITS C I T I Z E N S ' W A I S T L I N E S HAVE ALSO E X P A N D E D . WESTERN G O O D S A N D LIFESTYLE H A B I T S ARE C O N S I S T E N T L Y B E I N G I M P O R T E D I N T O T H E A S I A N G I A N T , I N C L U D I N G T H E OBESITY E P I D E M I C . C H I N E S E C H I L D R E N ARE PARTICULARLY SUSCEPTIBLE A N D FUTURE G E N E R A T I O N S FACE T R E M E N D O U S H E A L T H RISKS DESPITE M E D I C A L A D V A N C E S . STATES A N D I N T E R N A T I O N A L B O D I E S S U C H AS T H E W O R L D H E A L T H O R G A N I Z A T I O N ARE A L A R M E D AT T H E D A M A G E OBESITY IS ALREADY P R O D U C I N G . T H E PRICE TAG TO TREAT T H E H E A L T H P R O B L E M S A S S O C I A T E D W I T H OBESITY A N D T H E R E S U L T I N G LOSS I N E C O N O M I C P R O D U C T I V I T Y IS S T A G G E R I N G . W H I L E T H I S ESSAY USES C H I N A AS A CASE STUDY TO E X A M I N E T H E CAUSES OF OBESITY A N D ITS C O N S E Q U E N C E S , S O C I A L A N D E C O N O M I C H E A L T H , T H E G R I M REALITY IS T H A T T H I S PATTERN IS O C C U R R I N G W O R L D W I D E AS C O U N T R I E S DEVELOP A N D T H E I R PEOPLE A D O P T WESTERN " N U T R I T I O N A L " N O R M S . China's remarkable economic growth over the past thirty years has been nothing short of a miracle. This advance- ment, however, comes with a price. Increased prosperity has brought a cultural and social desire for modern and western lifestyles, including western eating habits. "Nutrition transition," the spread of excessively-caloric meals and declining activity, is now saturating Asia. Though nowhere near the levels of obesity which the United States currently faces, China is headed in that dire direction unless action is taken by the government, food companies, and individuals. A concerted effort is required to avert the damaging public-health and economic costs of obesity. Since children are particularly vulnerable to this phenomenon, an unhealthy and less-productive future generation awaits China. This paper proposes to look specifically at China in relation to the "nutrition transition." Although it is a worldwide phenomenon, China has a unique cultural and historic qualities which could facilitate the rise of obesity. These in- clude both the fastest-growing economy and population in the world, a one-child policy, urban explosion, and cultural attitudes toward eating and fat. As China and the develop- ing world in general rise to the economic and social status enjoyed by the West, caution and care must be taken to pre- vent the negative and harmful consequences which accom- pany this transition, particularly with regard to eating habits. H E A L T H COSTS OF OBESITY Though relatively new to China, obesity is a familiar phe- nomenon in the West. According to Dr. Joseph Gigante, a pediatrician and professor at Vanderbilt University, "obe- sity is defined simply as too much body fat." Your body is made up of water, fat, protein, carbohydrates and various vi- tamins and minerals. Body fat is measured by body mass index (BMI) to determine obesity. I f you have a BMI of thirty or higher, your extra weight is putting your health in danger. I f you are Asian, your health may be at risk with a BMI of 27.5 or higher. The risks of obesity are numerous, and include "high blood pressure, high blood cholesterol, "The collision of newly affluent consumers with food companies eager to tap this emerging market has created the optimal conditions for a health crisis." diabetes, heart disease and stroke." Aptly described as "'globesity'... the W H O [World Health Organization] esti- mates there to be at least three hundred mil l ion obese peo- ple worldwide" sixty mil l ion of which are United States ci- izens. 1 The costs of obesity to the individual and society are stag- gering; Gigante warns that these include "decreased pro- ductivity, restricted activity, absenteeism, and bed days" from work as well as premature death. In fact, individuals who are 4 0 percent heavier than the recommended healthy weight level are "twice as likely to die prematurely as is an average-weight person."" Additionally, "medical expenses accounted for 9.1 percent of total U.S. medical expendi- tures in 1998 and may have reached as high as $78.5 billion ($92.6 billion adjusted for inflation in 2 0 0 2 ) . " Although China currently spends only 5 percent of its gross national product (GNP) on obesity-related costs, "it's only a matter of time before . . . spending catches up to that of the United States, which spends 17-20 percent of its GNP on related costs," warns expert Barry Popkin. 1 1 1 The money spent on medicine and care for an unhealthy population as well as the social and economic productivity losses caused by obe- sity could severely damage the awakening giant. Rather than face these losses and incur these costs, the Chinese government would be better serving its citizens and itself E L E M E N T S S P R I N G 10 by taking measures now to prevent and solve the causes be- fore dealing with the inevitable consequences of this real crisis. Medical costs and productivity loss for the "more than 169 mil l ion overweight adults, and [the] additional 26 mil l ion [who are] obese" wi l l take their toll on this eco- nomic powerhouse, i f they have not already.1V R I S I N G I N C O M E LEVELS F U E L U N H E A L T H Y E A T I N G H A B I T S Obesity is a serious problem which, rather than being ad- dressed and halted, is spreading eastward. It has been ob- served by the W H O that "as incomes rise and populations become more urban, diets rich in complex car- bohydrates give way to more var- ied diets with a higher propor- tion of fats, satu- rated fats and sugars. At the same time, shifts towards less physically demanding work have been observed."v The Chinese today enjoy greater economic prosperity and are experiencing urban expansion and growth. The introduction of will ing consumers to dicre- tionary income and foreign food companies' eagerness to tap the potential of this emerging market has ceated the op- timal conditions for a health crisis. Since joining the WTO organization in 2001 , China has lowered protectionism and opened itself to foreign investors and businesses. The first Kentucky Fried Chicken Franchise opened in 1987, and McDonalds quickly followed, opening its first restau- rant in Beijing in 1992. The increase and spread of SINCE THE 1980S, FAST FOOD C O M P A N I VAST OPPORTUNITIES OF McDonalds restaurants eastward is a perfect example of the "Nutrition Transition" phenomenon, and is modeled in Figure 1. Given that "every month, around a mil l ion or more 'Chinese enter the hallowed ranks of the middle class,'" the rapid purchasing power of consumers has set off the "shift from eat-to-live to live-to eat," and testifies to the cultural ex- perience of food as a "mode" and status rather than a sur- vival necessity/1 The prevalence of "a predominantly com- mercially-driven environment that encourages consumers to eat and eat more, [along with the] vast array of restau- rants [which] have opened in cities since the last decade," have resulted in an increase in "the share of household food expenditures spent on food away from home." v n China's "transi- tion from planned econ- omy to market economy has brought about great political and cultural changes, which naturally lead to changes in value system . . . when people begin to interact with each other in the market economy system, value consciousness becomes re-oriented [from ethics and politics] towards ma- terial benefits." v 1 1 1 The expansion and importance of the Chinese economy today has brought with it challenges and issues for the government and people it assists. The problem remains, however, that the Chinese are con- suming high fat, low nutrition foods such as meats, oils ES HAVE BEEN C A P I T A L I Z I N G O N THE THE CHINESE MARKET. E X P A N D I N G W A I S T L I N E S FIGURE 1: INTERNATIONAL EXPANSION OF MCDONALD'S FRANCHISE AS OF 2004. SOURCE: ATILIER DE CARTOCRAPHIE DE SCIENCES PO, 2007 E X P A N S I O N O F T H E MCDONALD'S F R A N C H I S E (1999-2004) CALCULATED BY NESTED AVERAGE; NUM- BER MULTIPLIED BY FACTROR BELOW FIGURE 2: GLOBAL CALORIE CONSUMPTION AS OF 2002. SOURCE: ATILIER DE CARTOCRAPHIE DE SCIENCES PO, 2007 and sugar in greater quantities, and these daily caloric in- take levels, i f unused, store as fat in the body, as noted in Figure 2. Experts at the 10th International Conference on Obesity pointed out that "overweight and obese people out- number the undernourished in the world and childhood obesity is now on such a scale that for the first time in his- tory, the human race is facing the possibility of millions of parents outliving their children." 1 5 4 Nutrition transition ex- pert Barry Popkin points out the bleak fact that " i n a decade, the energy density of food consumed by Chinese adults aged twenty to forty-five increased by over 13 percent. " x Increased consumption of cheaper and more readily avail- able high fat, high calorie food and ingredients in China (and worldwide) have contributed to this alarmingly rapid rise in obesity. C H A N G E TO U R B A N LIFESTYLE E A T I N G Urbanization is another factor contributing to this transi- tion, since, "compared to rural dwellers, urban residents continue to consume higher levels of fats and animal foods, along with lower intakes of vegetables. " X 1 Principle among the causes of this trend is the fact that the urban environ- ment is one in which "a variety of Western style foods are supplied and promoted, and these consumers are both more inclined and better able to purchase these products."X 1 1 Delphine Zhu, a Sciences Po student from Shanghai, explained the enormous inequality between the city and country in China due to wages and available work. She described the emphasis on family in the country versus the individual in the city (which could promote the desire for status based on where and what is consumed). City pop- ulations are rising due to the lifting of restrictions on urban-rural migration, and the "rural labor force [response] to economic incentives by seeking employment i n urban areas." x m These migrants are known as "Mingong," which means peasant workers, according to Delphine. Urban residents are increasingly drawn "to such relative in- tangible criteria as novelty, brand labels or other emotion- ally pleasing features of foods (feel goods)."X 1 V Delphine Zhu noted that there are "more choices and variety, more snacking, and more families going to restaurants" than in the past. Eating and socializing go hand in hand, not just in China but worldwide, and "as their rich and varied cui- sine reflects, the Chinese love to eat . . . China's rise in liv- ing standards is apparent at meal times. City residents, to whom even pork was once special, now regularly consume beef, fish, and shrimp." x v Popular western foods include "pizza, pasta, burgers and sandwiches," Delphine added. The younger generation seems to be buying into western habits more readily than their parents. She pointed out that "older people generally don't like using knives or forks so they find difficult to eat western food. They are loyal to Chinese cooking. I think it is mostly younger people and kids who like it. My mother hates cheese and she never un- derstands my way of combining milk and cereals for break- fast!" She also noted that young people eat out more and tend to buy more pre-packaged lunches in their busy days. Modern grocery stores and twenty-four hour convenience stores are also appearing in cities, selling pre-packaged foods like those found in the West. China's recent food- safety scares and the "SARS crisis of 2003 proved to be a boon for modern grocery formats, especially hypermarkets and convenience store chains, which have a strong reputa- tion for cleanliness and quality control." X V 1 It is ironic that a health scare such as SARS has to some degree helped the image and popularity of "healthy" western-style grocery and convenience stores which sell and promote unhealthy foods. Urban sprawl has also cut into farm land to build homes and offices, and this real estate expansion not only in China but worldwide limits the amount of land available for farming and thus increases the price of healthier foods. L IFESTYLE C H A N G E S A D D TO T H E P R O B L E M The rate of obesity has grown the fastest in urban areas, with the childhood obesity rate doubling in the past ten years. x v n This alarming development wil l compound the problem i f left unaddressed, since "tastes and preferences begin to be established in early l i f e . " x v m Urban residents tend to adhere to the one-child-per-family policy in China due to the very limited living space available for families in E X P A N D I N G W A I S T L I N E S STARVING C H I L D R E N OF 1950s C H I N A ARE INCREASINGLY REARING OBES E CHI LD REN A N D G R A N D C H I L D R E N . cities, whereas the i r r u r a l counterparts are less i n c l i n e d to fo l low these mandates given the i r m o r e t rad i t iona l views along w i t h the practical desire for m a n y sons to he lp o n the f a r m . W i t h only one c h i l d per fami ly for m o s t o f the f ami - lies i n cities, and, consequently, the " m a n y hopes r i d i n g o n t h e m . . . c h i l d r e n w i t h no sibl ings are usual ly spoiled by d o t i n g parents a n d even by grandparents [and are] dubbed ' l i t t le e m p e r o r s . " ' x i x I t is n o t h a r d to i m a g i n e , therefore, the wi l l ingness o f parents to give c h i l d r e n large amounts o f western foods. Advertisers target "kids i n C h i n a [who] n o w have pocket money, a n d they spend a sizable p o r t i o n o f i t o n j u n k food . . . Certa in foods, such as new candies or fast food, have cachet . M x x The new and enthusiastic fore ign food companies i n China take great, strategic efforts to w i n over y o u n g consumers and do "whatever they can to en- courage even the youngest c h i l d r e n to ask for advertised products i n the hope o f ent i c ing y o u n g people to become l i f e t ime c o n s u m e r s . " ™ W h e n asked whether she observes m o r e obese c h i l d r e n i n Shanghai t h a n previously, De lph ine said " n o t really i n m y everyday l i fe , b u t the m e d i a says yes." She added that the prevalence o f v e n d i n g ma- chines has increased " i n b i g cities, yes, i n transports , schools and other publ ic places [but] I hardly used t h e m u n - less I was very hungry . " Once obesity is acquired i n c h i l d h o o d , i t is very d i f f i cu l t to u n l e a r n a n d u n d o the d a m a g i n g eating and l i v i n g lifestyle. Gigante explained that l o o k i n g at the l o n g - t e r m conse- quences, "overweight adolescents have a 70 percent chance o f b e c o m i n g overweight or obese adults, w h i c h increases to 8 0 percent i f one or m o r e parent is overweight or obese." Address ing these problems early is cr i t ica l to heading o f f the o n c o m i n g hea l th crisis o f China's next generat ion. "The Chinese Center for Disease Contro l and Prevent ion (CDC) released a guide to healthy eating for Chinese ch i l - d r e n and the i r parents i n a direct a t tempt to slow r i s i n g c h i l d h o o d obesity l e v e l s . " ™ 1 P o p k i n agrees that "schools may provide an i m p o r t a n t opportunis t i c venue t h r o u g h E L E M E N T S S P R I N G 10 which preferences for more healthy options can be encour- aged. Another cultural promotion of obesity is the attitude to- wards fat in China. The fact that "there is still a widespread belief that excess body fat represents health and prosperity, . . . perhaps a consequence of China's recent history, where famine and chronic malnutrition caused the deaths of mi l - lions of people in the 1950s," compounds the likelihood that some individuals wi l l recognize the serious dangers of obesity. x x , v Such beliefs may actually increase the number of obesity cases among children and their parents and need to be addressed and dispelled by the government and healthcare professionals through increased education and public awareness of what is happening and, worse, what wi l l eventually happen i f left unaddressed and unresolved. Luxury items which decrease activity levels are becoming more common in Chinese cities as well. For example, be- tween 1989 and 1997, the number of households who owned cars increased by 14 percent. x x v Owning a car in- creases the likelihood of being obese by " 8 0 percent . . . compared to those [households] who did not own a vehi- cle." Television ownership has also escalated, increasing inactivity during leisure periods x x v i A study of attitudes and values concluded that "the most popular ways of spending leisure time include watching tv, surfing the in- ternet, listening to music and reading [with] no significant differences in preferences due to age, education level, or in- come." x x v u A l l these new luxuries and attitudes toward leisure time reduce the amount of movement and general activity which burn excessive caloric intake and could pre- vent weight gain. City planning and layout in China should address the need for recreation areas as well to promote recreation. Currently, "the lack of consideration towards constructing environments in inner cities that promote physical activity has meant that it has become increasingly difficult to find safe places in residential areas to exercise or even walk," a deficiency which adds to the decrease in phys- ical activity necessary to maintain appropriate body weight and overall h e a l t h . ^ 1 1 1 This presents another opportunity for the government and private individuals to change the current movement to head off the oncoming trend. Although the number of obese people in China do not yet rival that in the United States, the country with the largest population on Earth is headed for a major disaster. The group currently leading the obesity trend in China includes the "newly affluent and western-adapters . . . who broke most with the traditional food culture . . . [they are] to a large extent richer, more educated, and urban adults, as well as young adults." Indeed, the traditional Chinese diet, a pri- maraly vegetarian diet based on rice and vegetables, with moderate amounts of poultry, pork and seafood, creates a lower BMI over a l l . X X 1 X The only explanation then for this ex- plosion of obesity i n China is the diet shifts from the tradi- tional,healthy habits to the detrimental, western ones. INCREASING OBESITY IN C H I N A IS A GRAVE MEDICAL CORCERN. ^^^^ ft i f E X P A N D I N G W A I S T L I N E S G O V E R N M E N T A C T I O N C O U L D S T O P T H E T R E N D The future for China depends on action and prevention taken today by the government and individuals. The conse- quences of economic growth and a more open-door policy in this case show there are both positives and negatives to globalization and economic expansion. It is encouraging to note that the Chinese government has apparently realized this reality given its recent "rejection [of the] 'go-for-growth' policy and turning to a more balanced and sustainable ap- proach. ' , x x x I n a "people first" policy for a "well-off society" which uses economic growth to improve people's overall quality of life, we may yet see the crisis averted. Those who wil l be hit first with its consequences (the rich, young, and urban consumers) may be the pioneers in changing their western diet habits and reaffirming the "Chinese cultural value [of] extending and preserving life." Chinese culinary tradition reaching back several centuries has always appre- Gigante stressed again the critical roles of governments, in- ternational partners, civil society and nongovernmental or- ganizations and the private sector in shaping healthy envi- ronments and making healthier diet options affordable and easily accessible. Society's most vulnerable, the poor and children, must also be protected given they have limited choices about the food they eat and the environments in which they live. He further emphasized the responsibility of initiatives by the food industry itself to reduce the fat, sugar and salt content of processed foods as well as to in- crease employment of innovative, healthy, and nutritious choices, and to review current marketing practices could accelerate health gains worldwide. The "nutrition transition" i n China demonstrates the ef- fects of globalization even on basic and culturally-rich tra- ditions like the approach to and appreciation of food. China and other developing countries are beginning to experience the toll of their recently achieved economic and social sta- "Society's most vulnerable, the poor and children, must also be protected given they have limited choices about the food they eat and the environments in which they live." ciated the rapport between food and health. 5 0™ Gigante rec- ommends individuals l imit energy intake from total fats and shift fat consumption away from saturated fats to un- saturated fats, increase consumption of fruit and vegeta- bles, as well as legumes, whole grains and nuts, l imit the in- take of sugars, and increase physical activity to at least thirty minutes of moderate-intensity activity on most days. More activity may be required for weight control. Such ac- tion by the government and individuals could prevent fu- ture cases of obesity in China and reverse others already in existence. Nonetheless, other measures can be taken in this concerted effort to halt current and prevent future cases of obesity. tus. The economic boom has not protected them from the obesity trap posed by western-style eating habits and leisure activities. By contrast, the trend has shown that in higher-income households, eggs and meat are purchased more often and given more nutritional importance than grains. x x x " Obesity is no longer any single country's prob- lem, but a truly worldwide health crisis. Western experi- ences with obesity should serve as a warning and model of what has proven ineffective in addressing the crisis. The Communist state could potentially take action where west- ern, democratic governments have been unwilling or un- able to due to intense and effective lobbying by the food in- dustry; a more hands on regulation of unhealthier foods and the simultaneous education about a more nutritional E L E M E N T S S P R I N G 10 and holistic approach to diet and exercise. Banning junk food in schools, requiring clear and open labeling of the nu- trition facts on all good products, taxing food products which are known to be unhealthy, promoting physical activ- ity in schools and encouraging doctors to make recommen- dations during patient visits, and compelling restaurants to post the calories of each meal and highlight low-calorie op- tions are all concrete ways in which this catastrophe can be avoided. While these solutions are universal, China in par- ticular could work to counter the cultural myths surround- ing fat, educate the one-child parenting population on obe- sity's damaging effects and work to reduce the urban-rural inequalities which drive an exodus from the countryside to the cities where obesity is more rampant due to fatty food availability and a more sedentary work and leisure-filled lifestyle. Obesity is largely preventable and it costs far less to stay healthy than to regain one's health (or, in China's case, twenty-six mil l ion citizens' health). The social, economic, and human damages due to this global epidemic are truly horrific and far too high. Chinese citizens wi l l suffer, but such losses wil l hurt the international community as well given the interdependent world in which we live. Taking action now against the causes is far better than dealing with the more difficult consequences down the road. Food is a basic need for every individual and thus this crisis is one i n which all people can empathize. It is time for China and the world to seriously address this pressing disaster through several methods—education, awareness, regula- tions, and increased recreational areas in city-planning. The future of China's public health has a great weight in the global disaster. China is rapidly learning that "westerniza- tion" under globalization brings benefits and downsides. As Delphine reflected, "On the one hand, in terms of ma- teriel consumption, China is 'westernizing', especially in some big cities like Beijing, Shanghai, and Guangzhou, [where] people are more and more materialist. On the other hand, Chinese people exclude a lot western cultures while maintaining a Chinese authenticity . . . We are still isolated to certain extent from the world. The 'westerniz- ing' or 'modernizing' is superficial." This selective exclu- sion, this balance between westernizing and maintaining Chinese authenticity, in combination with collaborative, preventative action taken at different levels of society may be China's saving grace. E N D N O T E S i . Zhang 2008 i i . "Weight Loss: Health Risks Associated wi th Obesity" i i i . Markey 2006 iv. Ibid. v. "Global Strategy on Diet, Physical Activity Health" vi . Zhang 2008 vi i . Ibid. v i i i . Lu 2004 ix. 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