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Childhood obesity in China: trends, risk factors, policies and actions
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COMMENTARY Childhood obesity in China: trends, risk factors, policies and actions Na Zhang 1, 2, Guansheng Ma 1, 2* 1 Department of Nutrition and Food Hygiene, School of Public Health, Peking University, 38 Xue Yuan Road, Hai Dian District, Beijing 100191, China 2 Laboratory of Toxicological Research and Risk Assessment for Food Safety, Peking University, 38 Xue Yuan Road, Hai Dian District, Beijing 100191, China Abstract Childhood is the key stage for the development of physical and mental health in the life cycle. The nutritional and health status of childhood are not only related to adulthood health, but also have effects on the long-term development of the country. Along with the rapid transitions in dietary patterns and lifestyle, the prevalence of childhood obesity in China showed an astonishing growing trend in the past few decades. Obesity is a kind of disease, moreover, it is the risk factor for a variety of chronic diseases. Obesity is a serious threat to people’s health and brings huge social and economic burden. It is necessary to take effective measures to prevent and control childhood obesity. International organizations and many countries have formulated policies and launched projects to prevent and control obesity. In China, series of outline, guidance, blueprint, plans and projects has been developed and released, such as the Outline of the Programme for Food and Nutrition Development in China (2014–2020), Blueprint of Healthy China 2030, National Nutrition Plan (2017–2030), Healthy Lifestyle Campaign for All, and so on. Improving the obesogenic environment needs world cooperation: international economic agreements and policies should be formulated to prevent and control obesity; obesity prevention and control should be integrated into all policies to improve the obesogenic environment; mechanism with the lead of government, the cooperation of multisector and the engagement of public should be established; national childhood obesity surveillance system should be improved; actions to prevention and control of obesity should be initiated in early stage of life and impetrated in all life cycle; and three-tiered prevention for childhood obesity should be implemented. Keywords: obesity; childhood; prevalence; trend; policy
Introduction In the past thirty years, the prevalence of overweight and obesity has grown in an astonishing pace globally.
Along with the rapid development of economy, in both developed and developing countries, the prevalence of overweight and obesity among children and adolescents presents the trend of accelerating growth [1]. From 1975
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to 2016, the overweight and obesity rate among children and adolescents aged 5‒19 increased from 4% to over 18% [2]. The overweight and obesity rate of children in developing countries is lower than those in developed countries, but the increasing rate in the former in the recent thirty years is not necessarily slower than the latter. Obesity has become a serious public health problem globally [1, 3]. In China, with the rapid changes in dietary patterns and lifestyles, the nutritional and health status of children has gradually improved, the level of growth and development has enhanced, and the malnutrition rate has decreased. However, the problem of childhood obesity in China is becoming increasingly serious, and is in a status of rapid increase. The prevalence of overweight among children aged below seven years old was 8.4% in 2015 [4]. In 2014, the overweight and obesity rate in children aged 7 and over was 12.2% and 7.3%, respectively. The corresponding number of overweight and obesity increased to 34.96 million [5]. At present, although the overweight and obesity rate of children in China is lower than that of developed countries in Europe and America, but the absolute number of obese children is astonishing because of the large population base in China. Should no timely obesity interventions be taken, the obesity rate in developing countries will soon catch up with or even overtake the obesity rate in developed countries. The trend will further increase the burden on healthcare and socioeconomic systems in developing countries. We should seize this critical period to widely promote preventive measures against childhood obesity, curb the rising trend of childhood and adolescent obesity, prevent the rapid growth of obesity-related chronic diseases in China in the future, and lay a solid foundation for health in the early life.
Worldwide and national trends in childhood obesity According to a systematic analysis with 19,244 agesex-country year observations-based on both physical measurements and self-reports, in developed countries, the overweight and obesity rate for boys and girls starting at ages 2‒4 years increased from 16.9% and 16.2% in 1980 to 23.8% and 22.6% in 2013. In developing
countries, the overweight and obesity rate for boys and girls increased from 8.1% and 8.4% to 12.9% and 13.4% from 1980 to 2013 [1]. At all ages, overweight and obesity rate in developed countries was higher than that in developing countries [1]. In another pooled analysis of 2416 population-based measurement studies, global age-standardised prevalence of obesity for boys and girls starting at ages 5 years increased from 0.7% and 0.9% in 1975 to 5.6% and 7.8% in 2016 [6]. The number of obese boys and girls increased from 7 million and 5 million in 1975 to 74 million and 50 million in 2016 [6]. According to the report of World Health Organization (WHO), the overweight and obesity rate among children and adolescents aged 5‒19 increased from 4% in 1975 to over 18% in 2016 [2]. The number of overweight and obese children and adolescents aged 5‒19 were over 340 million in 2016 [2]. In China, for children below seven years old, according to the data of the Epidemiological Survey for Obesity among Children below Seven Years Old in Nine Cities in China, the detection rate of obesity was 0.91% in 1986, with 0.93% for boys and 0.90% for girls, which suggested a relatively low level [7]. However, over the next 20 years, the rate of obesity showed an increased trend. In 1996, the detection rate of obesity among children aged below 7 years old was 1.76%, with 2.12% for boys and 1.38% for girls. Compared with the prevalence of obesity in 1986, the prevalence in 1996 increased 93.4% [8]. The prevalence of obesity among children aged below 3 years old did not change significantly from 1986 to 1996, while the prevalence of obesity among children aged 4‒7 years old increased obviously, rising from 0.84% to 4.17% [8]. In 2006, the detection rate of overweight among children aged 0‒7 years old was 6.25%, with 6.59% for boys and 5.88% for girls; the detection rate of obesity was 3.19%, with 3.82% for boys and 2.48% for girls (Figure 1). The obesity prevalences in different age groups were different, 1.86% for infants aged 1 month to 1 year, then reduced among children aged 1 to 3 years, increased again among children aged above 3 years, and reached 7.02% among children aged 6‒7 years [9]. Compared with the obesity prevalence in 1986, it increased by 278% in 2006 [9].
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Figure 1 Changes of the obesity prevalence among children aged 0–7 years old from 1986 to 2006 [7-9]
According to the data of China National Nutrition Survey in 1992, the prevalence of overweight among children aged below six years old was 2.3%, with 2.4% for boys and 2.2% for girls; the prevalence of obesity was 1.6%, with 1.7% for boys and 1.6% for girls [10]. In 2002, the increasing rate of overweight and obesity was higher in girls aged below 6 years than boys, while among other age groups, the rate in boys was higher than girls [10]. According to the Report on Nutrition and Chronic Diseases of Chinese Residents (2015), the prevalence of overweight among children aged below seven years old was 8.4%, with 9.4% for boys and 7.2% for girls; the prevalence of obesity was 3.1%, with 3.6% for boys and 2.5% for girls in 2012 (Figure 2) [4].
In Hong Kong Special Administration Region (SAR), the prevalence of overweight and obesity for children aged 3‒6 year old was 13.5%, with overweight 9.3% and obesity 4.2% in 2011‒2012 [3,11,12]. For school-age children aged 7‒18 years old, according to the data of the Physical Fitness and Health Survey for Chinese Students, the detection rates of overweight and obesity for urban boys were 1.1% and 0.2%, with 1.4% and 0.2% for urban girls; 0.4% and 0.1% for rural boys; 1.5% and 0.1% for rural girls in 1985 [13], which suggested the problem of obesity was not serious. In 1995, the detection rates of overweight and obesity for urban boys were 6.4% and 2.2%, with 4.2% and 1.4% for urban girls; 2.1% and 0.6% for rural boys;
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Figure 2 Changes of the overweight (A) and obesity (B) prevalence among children aged below 7 years old from 1992 to 2012 [4,10] PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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2.5% and 0.4% for rural girls, which suggested that the trend of obesity prevalence has begun to increase [14]. In 2000, overweight and obesity prevalence has become a major health problem, and showed a fast increasing trend from then on. In 2014, the detection rates of overweight and obesity for urban boys were 17.1% and 11.1%, with 10.6% and 5.8% for urban girls; 12.6% and 7.7% for rural boys; 8.3% and 4.5% for rural girls [5], which demonstrated that childhood obesity had already gained national prevalence (Figure 3). The overweight and obesity rate in primary school students (aged 7‒12 years) was 22.5%, 17.3% in middle school students (aged 13‒15 years) and 15.4% in senior high school students (aged 16‒18 years) [5]. According to the data of China National Nutrition Survey, the prevalence of overweight among children
aged 6‒17 years old was 3.9%, with 4.3% for boys and 3.5% for girls; the prevalence of obesity was 1.8%, with 1.8% for boys and 1.9% for girls in 1992 [10]. Based on the Report on Nutrition and Chronic Diseases of Chinese Residents (2015), the prevalence of overweight among children aged below seven years old was 9.6%, with 10.9% for boys and 8.2% for girls; the prevalence of obesity was 6.4%, with 7.8% for boys and 4.8% for girls in 2012 (Figure 4) [4]. In Hong Kong SAR, the prevalence of overweight and obesity for children aged 7‒12 year old was 26.9%, with overweight 19.5% and obesity 7.4%; 14.0% for children aged 13‒19 year old, with overweight 10.3% and obesity 3.7% in 2011‒2012 [3,11]. According to the data from Students’ Health Service Centre under Department of Health in Hong Kong SAR, the overweight and obesity
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B Figure 3 Changes of the overweight (A) and obesity (B) prevalence among children aged 7–18 years old from 1985 to 2014 [5,13] PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Figure 4 Changes of the overweight (A) and obesity (B) prevalence among children aged 6–17 years old from 1992 to 2012 [4, 10]
rates for primary students was 17.6%, with 21.9% of boys and 12.9% girls in 2016‒2017 [11]. In Macao SAR, according to the report of physical fitness monitoring for Macao citizens, the proportion of overweight and obesity for boys aged 6‒22 years old was 19.1% to 40.8%, with 8.4% to 35.0% for girls [15]. In Taiwan, it was shown that the childhood overweight and obesity rate was 29% in boys and 21% in girls [16].
Characteristics of childhood obesity prevalence in China The prevalence of childhood overweight and obesity in China shows the following characteristics: (1) The prevalence of overweight and obesity is on the rise; (2) The prevalence of overweight is higher than that of obesity; (3) The prevalence of overweight and obesity in boys is higher than that of girls; (4) The prevalence of overweight and obesity in urban is higher than that in rural; (5) The prevalence of overweight and obesity among children with higher socioeconomic status is higher than those with lower socioeconomic status; (6) High prevalence of overweight and obesity is found in the stage of infancy and pre-school age, which is coincide with the period of fast develop and repolymerization of fat tissues; (7) The majority of the obese children of different sex at younger age are mildly obese [9]. However, the proportion of moderate and severe obesity increases with age. Severe obesity is mainly found among children
aged above three years old; in addition, the proportion of severe obesity in boys is more than that in girls; the rate of childhood obesity in rural has accelerated in recent years [9].
Prediction on the prevalence of childhood obesity in China From 1985 to 2005, the detection rate of obesity among children aged 0‒7 years old increased from 0.9% to 3.2% [7, 9]. From 1985 to 2014, the prevalence of overweight among school-age children aged above 7 years old increased from 2.1% to 12.2%; the prevalence of obesity among school-age children aged above 7 years old increased from 0.5% to 7.3% [5]. Should no effective interventions be adopted, with the method of trend extrapolation, it is estimated based on the above data that the prevalence of obesity among children aged 0‒7 years old will reach 4.8% in 2020 and 6.0% in 2030 [12]. The prevalence of overweight and obesity among children aged above 7 years old will reach 22.3% in 2020 and 28.0% in 2030 [12].
Determinants contribute to the prevalence of childhood obesity in China Multiple determinants contribute to the prevalence of obesity, such as genetic, environment and socio-cultural factors. Rapid development of genome technology has made that it was possible to investigate the link between PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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genetics and obesity. With more scientific evidences, it is generally believed that those who are seriously obese at a younger age are more likely to carry genetic mutation related to obesity. Susceptibility to obesity inheritance varies by age and difference exits between children and adults in terms of such susceptibility [17,18]. In the Developmental Origins of Health and Disease theory [19], it is suggested that the antenatal events and environmental factors affected the physiological functions of the fetuses and newborns, including causing permanent changes to the physical structure and functions of organs. This will further increase risks for the incidence of noncommunicable diseases (NCDs) such as obesity during childhood and adulthood. Obesogenic environment contribute to the increasing prevalence of obesity, including dietary determinants (irrational dietary pattern with over supply of fat, over consumption of food items with high energy density) [20], physical inactive and increased sedentary activities (decreased physical activity, increased time with the use of screens) [21], unhealthy dietary behaviors (skipping and eating breakfast with inadequate nutrition, increased consumption of soft drinks; more frequenting eating out) and so on [22, 23]. Some socioeconomic and cultural context also have contributed to the epidemics of obesity. In addition, the association between gut bacteria and obesity has become a popular research topic. Studies have shown that gut bacteria play a certain role in the incidence and development of obesity, for a possible important part the bacteria contribute to the nutrition, metabolism and immunity of the host [24, 25]. Despite a vital role played by genetic factors, genes do not mutate significantly in the short term, genetic factors exert its influence on the incidence of obesity only in an enabling environment. Therefore, the steep increases of childhood overweight and obesity in the recent years is not caused by mutant genes, but rather the fast-changing environmental and social factors. The control of childhood obesity should be focused on improving the obesogenic environment, behaviours and life styles.
The impacts of childhood obesity on health and economic Obesity is a disease and also a risk factor for multiple non-communicable diseases, such as cardiovascular, endocrinology, respiratory systems, liver, skeleton, psychological behaviors, cognitive and intelligence capacity [26-28]. In addition, childhood obesity may increases the risk for adulthood obesity and NCDs, which may bring serious economic burden. In 2002, the adult overweight and obesity rate at 29.9% directly cost 21.11 billion CNY [29]. Upon extrapolation, by 2030, the direct economic costs incurred by NCDs as a result of adult obesity will reach 49.05 billion CNY each year [12]. Analysis of the data from Nutrition and Health Survey for Chinese Residents in 2002 and the 3rd National Health Service Survey in 2003 showed that direct economic costs for hypertension, diabetes, coronary heart disease and stroke caused by overweight and obesity accounted for 3.2 and 3.7% of the total health expenditure and medial spending for China in 2003 [29]. It is estimated direct losses attributable to obesity in the U.S.A., Australia, France and the Netherlands take up 5.7%, 2.0%, 2.0% and 4.0% of the health expenditure for each country [3]. The share for NCDs spending caused by obesity against the total health expenditure for China is higher than that of Australia and France. Between 2000 and 2025, the indirect losses caused by obesity will account for 3.6%‒8.7% of Grooss National Product (GNP) [3].
Policies and actions to control childhood obesity Orienting towards treating with the problem of childhood obesity, WHO has released a series of reports, such as Obesity and Poverty: a New Public Health Challenge, Prevention and Control for the Global Prevalence of Obesity and Global Strategy on Diet, Physical Activity and Health, and so on [30-32]. These advocates are aimed to promoting a lifestyle of energy balance achieved through a healthy die and physical activities, promoting individual and community health, reducing the risks and morbidity of NCDs. The Commission on Ending Childhood Obesity
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was established by WHO in 2014, and then released the Report of the Commission on Ending Childhood Obesity in 2016, which proposed the scientific evidence-based recommendations to eliminate childhood obesity [33]. Experts from International Obesity Task Force advocated to ban the sales of junk food and soft drinks to the children below 16 years old through legislation (including an international law) in 2008 [34]. Only the foods in strict compliance of healthy diet principle are allowed to be sold to the children. The Taskforce proposed the Sydney Principles to prevent obesity and NCDs. The health ministers from 53 European countries ratified the first European Charter on Counteracting Obesity, which was the first joint charter to fight against obesity in 2006. This anti-obesity declaration was drafted by WHO specifically for Europe and was an attempt to require robust measure from the government to combat obesity [3, 35]. According to the Charter, signatories must put in place and improve measure within the specific timeframe to help people to eat healthy and exercise more. For instance, more lanes for bicycles and pedestrians should be built up in cities to reduce dependence on cars. The charter even includes provisions to restrict sales of high-calorie food to children and prohibit advertisements of unhealthy food for children. U.S. CDC worked with WHO for the Global Strategy on Diet, Physical Activity and Health and developed the Nutrition and Physical Activity Plan to Prevent Obesity and Other NCDs in 2007, funding was provided to 28 states of the U.S.A. for the obesity prevention and control activities among the entire people. The plan is aimed to reducing obesity rate through increasing physical activity, increased consumption of fruit and vegetable, increasing the breastfeeding coverage, extending the lactation, reducing the consumption of high-calorie food and sugary beverages and cutting the hours to watch TV. New Moves Research was launched by National Institutes of Health [36], which aimed to intervene with overweight puberty girls or at risks. Interventions includes three phases: promoting changes to dietary pattern and physical activities through interventions on the social/environmental factors and personal preferences; attending physical activity classes every day; having lunch meeting every week to discuss
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the experiences and questions during the intervention. New Moves Research achieved the intended results to improve healthy behaviours and the self-esteem. Let’s Move Campaign was promoted by Michel Obama, which advocated young Americans to exercise more and drink more water [37]. In 2009, the British government initiated Change4Life, a programme to advocate healthy lifestyle to the public [38]. Through the publicity of health concepts in media, the public are encouraged to adopt healthy diet, increase their physical activity, and change their unhealthy behaviours so as to improve the physical fitness of the entire population. In France, Together Let’s Prevent Childhood Obesity Project (EPODE) prevents and controls childhood obesity by changing the obesogenic environment in community, school and household [39], such as removing vending machines from schools, re-arranging the playground of schools, setting up various fitness equipment at communities, restricting consumption of unhealthy food and beverages among children, testing and labelling the nutrients in foods, and promoting sports activities organized by various organizations. The project showed that in the urban towns where the strategy was implemented, childhood obesity incidence significantly reduced compared with the control urban towns and national average level. In Netherlands, Healthy weight among the Youth Programme (JOGG) aimed at studying on how to promote the healthy lifestyle among the entire population through mothers. The programme effectively reduced the intake of sugary beverages through promoting water drinking [40]. Another programme Enjoying Being Fit targeted children age 6‒12 years old by promoting more physical activity opportunities and got better results [3]. Japan proposed objectives to prevent obesity in Health Japan 21 programme in order to reduce the NCDs incidence and mortality, decrease the deaths for middleaged people, extend healthy lifespan, improve living standards, and establish a dynamic society where all citizens have sound body and mind through changing the day-to-day habits [41]. The Health Japan 21 programme sets up 80 objectives in nine areas including nutrition PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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1.49%. The importance of breastfeeding was gradually recognized by the public. The prevalence of anemia has been reduced and was 4.79% among children under 5 years old. The health environment are getting better. But, childhood obesity has not got enough attention and been effectively curbed [51]. In 2014, Outline of the Programme for Food and Nutrition Development in China (2014‒2020) was released by the State Council, which specifies 21 indicators in five areas including food production, development of food processing industry, food consumption, nutrients intake, and control of nutritional diseases [52]. One of the vital objectives is to drastically bring down the increase rate of overweight, obesity and dyslipidaemia among residents. In 2016, the Blueprint of Healthy China 2030 was issued by the State Council [53]. It clearly suggested that “Health for All ” is the fundamental purpose of building a healthy China. Five aspects of strategic mission in this blueprint include the popularize of healthy life, the optimization of health service, the improvement and perfection of health security, the building of healthy environment, and the development of health industry. The blueprint highlights the developmental ideology of “One Health”, and proposes to integrate this ideology into the whole process of public policy formulation and implementation, in order to coordinate comprehensive health factors, and to maintain the health of the people in omni-direction and full life cycle. In 2017, National Nutrition Plan (2017‒2030) was issued by the State Council [54]. In this plan, one of the primary objectives is to control the rising trend of obesity rate among students effectively through the action of nutrition improvement among students. In order to prevent and control the overweight and obesity rate among students, several suggestions are proposed. Weight management and intervention strategies should be carried out aimed at sports and nutrition, such as conducting education on balanced diet and nutrition, enhancing students’ physical exercises, and so on. Targeted comprehensive intervention measures should be put forward by strengthening the monitoring and evaluation of overweight and obesity of students, and analyzing of influencing factors including family, school
and society. Comprehensive intervention program for children nutrition should be implemented and appropriate techniques for preventing and intervening obesity should also be studied and developed.
Recommendations of comprehensive policies and strategies, and future prospects Once obesity is developed, it is challenging to lose weight. Prevention should be the key guiding principle to control obesity at the population level. Efforts should be made at the early stage of life, starting from the pregnancy. With the leading of government and the engagement of public, a control and prevention network integrating schools, families and communities should be established.
Formulating international economic agreements and policies conducive to prevention and control obesity International economic agreements and policies are closely related to the health of population, through the effects on food production, processing, trade, marketing and retail globally. International institutions and governments should reach consensus on the importance and significance of the prevention and control of childhood obesity, establish and implement internationally recognized standards, develop scientific and effective guidelines and action plans, promote cooperation, capacity building and academic research, establish healthier economic agreements and policies, and facilitate effective prevention and control of childhood obesity throughout the world.
Integrating obesity prevention and control into all policies and improving the obesogenic environment As the Report of the Commission on Ending Childhood Obesity mentions, obesogenic environment includes many factors, such as political and commercial factors, the built environment, social norms and family environment [33]. In order to improve the complex obesogenic environment, it is necessary to integrate obesity prevention and control into all policies, prioritize health and pay close attention to childhood obesity when socioeconomic policies are developed. PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Establishing mechanism with the lead of government, the cooperation of multi-sector and the engagement of public The government should be fundamentally responsible for the childhood obesity related policy development, implementation and supervision. A working mechanism featuring government leadership, multi-sectoral cooperation, and public engagement should be established; definite and specific goals should be made, sound urban planning should be made, transport system should be well designed, enough sports facilities and sports venues in schools should be provided, development and management of food labels should be strengthened, standardized food label should be developed, and advertisement of unhealthy food and beverages should be better managed. Schools should be the main avenue to control childhood obesity. Healthy lifestyle such as adequate nutrition and regular physical activity should be incorporated into the school curriculum and subject content; health education should be developed systematically in schools; meals provided in school should meet related nutrition guidelines and standards, the provision or sale of unhealthy foods nearby school should be regulated and limited, and a sound inter-personal communication environment should be created. Parents should guide, support, supervise and encourage their children to form healthy lifestyle, provide health food, master health-related skills and knowledge. Community should create a supportive environment for childhood obesity control, provide safe venues for games and exercise, conduct various health education and promotion activities, improve the public awareness and skills on childhood obesity control, advocate healthy lifestyle and provide health counselling and services. The community-based primary health facilities should provide family-based and diversified weight management service. Corporations, media and academic institutions should play a positive role on the improvement of obesogenic environment. Guided by policies, food companies should try to ensure their product line and development can protect and promote health; the exaggerated or misleading food advertising should be changed, so that consumers will not be misled by the advertising on children’s food;
food industry should reinforce their social responsibility while seeking profit and government, scientific community, and all social sectors can work with the socially responsible food companies; media should tap their influence and provide positive guidance; academic institutions can address childhood obesity via researches on the biological, behavioural and environmental risk factors and determinants and they can work effectively with media to disseminate relevant messages in a more intelligible manner. Key research projects on childhood obesity should be established, so as to strengthen the basic and applied researches on childhood obesity, explore aetiology, determinants, economic burden, prevention and intervention strategy, treatment and rehabilitation for childhood obesity, exploring innovative techniques from the convergence of information, biology and medical technologies.
Improving national childhood obesity surveillance system The national childhood obesity surveillance system should be improved, by incorporating childhood obesity into the existing national surveillance systems. Specific population groups, surveillance sites, duration and indicators should be determined, and standard approaches should be employed to study and master the most updated prevalence, trends, characteristics of changes and determinants for childhood obesity.
Starting prevention and control of obesity in early stage of life and impetrating in all life cycle Prevention and control of obesity should be started in early stage of life, even in the stage of pregnancy. Pregnant women should strengthen pregnancy management, and gain appropriate weights during pregnancy and seek timely diagnosis and management for their high blood glucose and hypertension. The overweight and obesity rate and physiological characteristics in different stages of life cycles are various, thus, the emphasis on prevention and control of obesity at various stages is also different, and measures should be taken to prevent and control obesity pertinently in all life cycle. For example, the birth weight, the way of feeding, the time and way of adding
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food, and the dietary behaviors are all the factors that affect infant obesity.
be freely available to any scientist wishing to use them for non-commercial purposes.
Implementing three-tiered prevention for childhood obesity
Competing interests
A three-tiered prevention and control strategy should be employed, namely general prevention, targeted prevention for at-risk groups and integrated interventions for overweight and obese groups [12]. General prevention: health promotion theories and practices should be employed to target the entire population in order to help the children to foster healthy behaviours and lifestyle and prevent obesity among them. Measures include policy development, building a supportive physical and social environment, promoting community engagement, raising awareness, conducting capacity building and delivery of health services Targeted prevention: the children facing with higher risks of developing obesity in an obesogenic environment should be targeted with specific preventive measures, so as to prevent them from becoming overweight and obese. The interventions in the setting of families and schools should be incorporated into the daily life of such children prone to overweight and obesity. Integrated interventions for overweight and obese groups: it is necessary to maintain normal weight gains and avoid excessive gains for overweight and obese individuals. Schools and families should be both involved to implement the sustainable integrated prevention and control plans. Measures include modified diet, physical activity and behavioural therapy.
Additional files Acknowledgments Thanks for the support of United Nations International Children’s Emergency Fund.
Funding It was funded by United Nations International Children’s Emergency Fund.
Availability of data and materials We declare that materials described in the manuscript will
All authors have no competing interests.
Consent for publications All authors have been informed of consent for publication.
Ethics approval and consent to participate It is not applicable for this review paper.
References 1. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-81. 2. World Health Organization. Obesity and overweight. [updated 2018-02-16; cited 2018-03-20]. http://www.who.int/en/newsroom/fact-sheets/detail/obesity-and-overweight. 3. Ma GS. Report on childhood obesity in China. Beijing: People’s Medical Publishing House, 2017. (in Chinese) 4. National Health and Family Planning Commission of the People’s Republic of China. 2014 report on Chinese residents’ chronic disease and nutrition. [updated 2015-0615; cited 2018-03-20]. http://en.nhfpc.gov.cn/2015-06/15/ c_45788.htm. 5. Wang S, Dong YH, Wang ZH, Zhou ZY, Ma J. Trends in overweight and obesity among Chinese children of 7-18 years old during 1985-2014. Chin J Prev Med. 2017;51(4):300-5. (in Chinese) 6. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017;390(10113):2627-42. 7. Ding ZY, Zhang R, Huang Z. Epidemiological survey of simple obesity among children aged 0~7 years in urban areas of China. Acta Nutrimenta Sinica. 1989;(3):255-66. (in Chinese) 8. Li H, Zhang X, Yan GF. Prevalence and Trend of Obesity in Preschool Children in China 1986 to 1996. Chin J Child Health Care. 2002;10(5):316-8. (in Chinese) 9. Coordinating Group of Nine Cities Study on the Physical Growth and Development of Children, Capital Institute of Pediatrics, Li H. A national epidemiological survey on obesity of children under 7 years of age in nine cities of China. Chin J Pediatr. 2008;46(3):174-8. (in Chinese) 10. Ma GS, Li YP, Wu YF, Zhai FY, Cui ZH, Hu XQ, et al. The
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prevalence of body overweight and obesity and its changes among Chinese people during 1992 to 2002. Chin J Prev Med. 2005;39(5):311-5. (in Chinese) 11. Department of Health of the Government of the Hong Kong Special Administrative Region. Overweight and obesity rate of Hong Kong primary students. [cited 2018-03-20]. http:// school.eatsmart.gov.hk/files/pdf/Childhood_obesity_bi.pdf. (in Chinese) 12. Zhang N, Ma GS. Interpretation of Report on childhood obesity in China. Acta Nutrimenta Sinica. 2017;39(6):5304. (in Chinese) 13. Ma J, Cai CH, Wang HJ, Dong B, Song Y, Hu PJ, et al. The trend analysis of overweight and obesity in Chinese students during 1985-2010. Chin J Prev Med. 2012;46(9):77680. (in Chinese) 14. Liao WK. A survey of national students’ physical health in 1995. Chin J Prev Med. 1997;8(1):42-3. (in Chinese) 15. Lee A, Ho MM, Keung VM. Global epidemics of childhood obesity is hitting a ‘less industrialized’ corner in Asia: a case study in Macao. Int J Pediatr Obes. 2011:6(2-2): e252-6. 16. Bureau of Health Promotion Department. Taiwan Obesity Map. [cited 2018-03-20]. http://www.bhp.doh.gov.tw/BHPnet/Portal/Them.aspx?No=201108110001.2. (in Chinese) 17. Mei H, Chen W, Mills K, He J, Srinivasan SR, Schork N, et al. Influences of FTO gene on onset age of adult overweight. Hum Genet. 2012;131(12):1851-9. 18. Wang J, Mei H, Chen W, Jiang Y, Sun W, Li F, et al. Study of eight GWAS-identified common variants for association with obesity-related indices in Chinese children at puberty. Int J Obes. 2012;36(4):542-7. 19. Visser G.H.A. Developmental origins of health and disease (DOHaD). Early Hum Dev. 2006;82(8):iii-iv. 20. Su C, Wang HJ, Wang ZH, Zhang JG, Du WW, Zhang J, et al. Current status and trends of both dietary fat and cholesteral intake among Chinese children and adolescents aged 7 to 17 years old in 9 provinces of China, from 1991 to 2009. Chin J Epidemiol. 2012;33(12):1208-12. (in Chinese) 21. Liu AL, Li YP, Hu XQ. Sedentary activities during leisure time of children and adolescent in China. Chin J Sch Health. 2008;29(4):312-4. (in Chinese) 22. Zheng MQ, Liu H, Hong L, Cao XY, Zhang Z, Ma GS. Breakfast-eating behaviors among children in six cities of China. Chin J Sch Health. 2017;38(2):166-8. (in Chinese) 23. Li YH, Lv QJ, Wang HJ, Yu DM, Liu AD, Zhao LY, et al. Trend analysis of snacks consumption behavior among school aged children and adolescents in nine provinces of China. J Hygiene Res. 2008;37(5):621-2. (in Chinese) 24. Bäckhed F, Ding H, Wang T, Hooper LV, Koh GY, Nagy A, et al. The gut microbiota as an environmental factor that regulates fat storage. Proc Natl Acad Sci U S A. 2004;101(44):15718-23. 25. Tremaroli V, Bäckhed F. Functional interactions be-
tween the gut microbiota and host metabolism. Nature. 2012;489(7415):242-9. 26. Liang YJ, Xi B, Hu YH, Wang C, Liu JT, Yan YK, et al. Trends in blood pressure and hypertension among Chinese children and adolescents: China health and nutrition surveys 1991–2004. Blood Press. 2011;20(1):45-53. 27. Chen F, Wang Y, Shan X, Cheng H, Hou D, Zhao X, et al. Association between Childhood Obesity and Metabolic Syndrome: Evidence from a Large Sample of Chinese Children and Adolescents. PloS One. 2012;7(10):e47380. 28. Liang Y, Hou D, Zhao X, Wang L, Hu Y, Liu J, et al. Childhood obesity affects adult metabolic syndrome and diabetes. Endocrine. 2015;50(1):87-92. 29. Zhao WH, Zhai Y, Hu JP, Wang JS, Yang ZX, Kong LZ, et al. Economic burden of obesity related chronic diseases in China. Chin J Epidemiol. 2006;27(7):555-9. (in Chinese) 30. World Health Organization. Global Strategy on Diet, Physical Activity and Health. [cited 2018-03-20]. http://www. who.int/dietphysicalactivity/goals/en/. 31. Peña M, Bacallao J. Obesity and poverty: a new public health challenge. Geneva: WHO, 2000. 32. World Health Organization, UN Food and Agriculture Organization. Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. Geneva: WHO, 2003. 33. Commission on Ending Childhood Obesity. Report of the Commission on Ending Childhood Obesity. Geneva: WHO, 2016. 34. Swinburn B, Sacks G, Lobstein T, Rigby N, Baur LA, Brownell KD, et al. The “Sydney Principles” for reducing the commercial promotion of foods and beverages to children. Public Health Nutr. 2008;11(9):881-6. 35. Miu J. Inspiration from European and American governments’ intervention on obesity among adolescents. The 9th National Sports Science Conference, Shanghai, China, 2011. Shanghai: China Sport Science Society/ Shanghai University of Sport, 2011. (in Chinese) 36. Neumark-Sztainer D, Flattum CF, Story M, Feldman S, Petrich CA. Dietary approaches to healthy weight management for adolescents: the New Moves model. Adolesc Med State Art Rev. 2008;19(3):421-30, viii. 37. Grier P. Michelle Obama says ‘Let’s Move’ on obesity in American kids. [updated 2010-02-09; cited 2018-03-20]. https://www.csmonitor.com/USA/2010/0209/MichelleObama-says-Let-s-Move-on-obesity-in-American-kids. 38. Fletcher R. Change4life campaign. Lancet. 2009; 373 (9665):720-1. 39. Borys JM, Le Bodo Y, Jebb SA, Seidell JC, Summerbell C, Richard D, et al. EPODE approach for childhood obesity prevention: methods, progress and international development. Obes Rev. 2012;13(4):299-315. 40. Leenaars K, Jacobs-van der Bruggen M, Renders C. Determinants of successful public-private partnerships in the
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context of overweight prevention in Dutch youth. Prev Chronic Dis. 2013;10(10):E117. 41. HASEGAWA T. “Healthy Japan 21”[J]. Korean Journal of Health Education & Promotion, 2005, 22(3): 135-55. 42. Zheng HW, Lai TD. Firmly implementing the educational guideline of “Health First” and fully exerting the role of school physical education in quality education. Teach Phys Educ. 2000;20(1):14-5. (in Chinese) 43. The Ministry of Education of the People’s Republic of China. The Ministry of Education issued a notice to carry out ‘Sunny Sports Programme for nationwide hundreds of millions of students’. http://www.gov.cn/gzdt/2006-12/25/ content_477488.htm. (in Chinese) 44. The State Council of the People’s Republic of China. Opinions on increasing physical exercises of teenagers to strengthen the constitutions. Ethn Educ Chin. 2007; 28(6): 481-3. (in Chinese) 45. Chen CM. Guidelines on the prevention and control of obesity and overweight among school-aged children in China (for Trial). Beijing : People’s Medical Publishing House, 2008. (in Chinese) 46. Bureau of Disease Prevention and Control, National Health and Family Planning Commission of People’s Republic of China. National Dissemination Plan for Health Knowledge. [cited 2018-03-20]. http://www.jilijihua.com/%e5%85%b3 %e4%ba%8e%e6%88%91%e4%bb%ac/. (in Chinese) 47. Zhang J, Li Y, Shi XM, Liang XF. The progress of National Campaign on Healthy Lifestyle for All (2007-2012). Chin J
13 Prev Contr Chron Dis. 2013;21(6):739-40. (in Chinese) 48. Gao AY, Pan YP, Shi XY, Cui ZH. Effect of “Happy 10 minutes” for preventing childhood obesity. Chin J Sch Health. 2008;29(11):978-9. (in Chinese) 49. Chang G, Liu H, Yang Y, Ma J, Wang WJ, Jiang GH. Effects of “Take 10!” intervention on the related indexes of obese pupils. Chin J Prev Contr Chron Dis. 2009;17(5):5057. (in Chinese) 50. The State Council of People’s Republic of China. Notice of the State Council on issuing the Outline of Women Development and the Outline of Children Development in China. [updated 2011-07-30; cited 2017-03-20]. http://www.gov.cn/ gongbao/content/2011/content_1927200.htm. (in Chinese) 51. National Bureau of Statistics of People’s Republic of China. Report on the Statistical monitoring of Outline of children development in China (2011-2020) in 2016. http://www. stats.gov.cn/tjsj/zxfb/201710/t20171026_1546618.html. (in Chinese) 52. Ding SJ. Grasp features of the outline of the Program for Food and Nutrition Development in China (2014-2020) to make sure food safety. Agric Outlook. 2014;10(3):30-3. (in Chinese) 53. Tan X, Liu X, Shao H. Healthy China 2030: a vision for health care. Value Health Reg Issues. 2017;12:112-4. 54. General Office of the State Council of People’s Republic of China. National Nutrition Plan (2017-2030). [updated 2017-06-30; cited 2018-03-20]. http://www.gov.cn/zhengce/ content/2017-07/13/content_5210134.htm. (in Chinese)
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COMMENTARY Childhood obesity in China: trends, risk factors, policies and actions Na Zhang 1, 2, Guansheng Ma 1, 2* 1 Department of Nutrition and Food Hygiene, School of Public Health, Peking University, 38 Xue Yuan Road, Hai Dian District, Beijing 100191, China 2 Laboratory of Toxicological Research and Risk Assessment for Food Safety, Peking University, 38 Xue Yuan Road, Hai Dian District, Beijing 100191, China Abstract Childhood is the key stage for the development of physical and mental health in the life cycle. The nutritional and health status of childhood are not only related to adulthood health, but also have effects on the long-term development of the country. Along with the rapid transitions in dietary patterns and lifestyle, the prevalence of childhood obesity in China showed an astonishing growing trend in the past few decades. Obesity is a kind of disease, moreover, it is the risk factor for a variety of chronic diseases. Obesity is a serious threat to people’s health and brings huge social and economic burden. It is necessary to take effective measures to prevent and control childhood obesity. International organizations and many countries have formulated policies and launched projects to prevent and control obesity. In China, series of outline, guidance, blueprint, plans and projects has been developed and released, such as the Outline of the Programme for Food and Nutrition Development in China (2014–2020), Blueprint of Healthy China 2030, National Nutrition Plan (2017–2030), Healthy Lifestyle Campaign for All, and so on. Improving the obesogenic environment needs world cooperation: international economic agreements and policies should be formulated to prevent and control obesity; obesity prevention and control should be integrated into all policies to improve the obesogenic environment; mechanism with the lead of government, the cooperation of multisector and the engagement of public should be established; national childhood obesity surveillance system should be improved; actions to prevention and control of obesity should be initiated in early stage of life and impetrated in all life cycle; and three-tiered prevention for childhood obesity should be implemented. Keywords: obesity; childhood; prevalence; trend; policy
Introduction In the past thirty years, the prevalence of overweight and obesity has grown in an astonishing pace globally.
Along with the rapid development of economy, in both developed and developing countries, the prevalence of overweight and obesity among children and adolescents presents the trend of accelerating growth [1]. From 1975
*Correspondence: [email protected] PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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to 2016, the overweight and obesity rate among children and adolescents aged 5‒19 increased from 4% to over 18% [2]. The overweight and obesity rate of children in developing countries is lower than those in developed countries, but the increasing rate in the former in the recent thirty years is not necessarily slower than the latter. Obesity has become a serious public health problem globally [1, 3]. In China, with the rapid changes in dietary patterns and lifestyles, the nutritional and health status of children has gradually improved, the level of growth and development has enhanced, and the malnutrition rate has decreased. However, the problem of childhood obesity in China is becoming increasingly serious, and is in a status of rapid increase. The prevalence of overweight among children aged below seven years old was 8.4% in 2015 [4]. In 2014, the overweight and obesity rate in children aged 7 and over was 12.2% and 7.3%, respectively. The corresponding number of overweight and obesity increased to 34.96 million [5]. At present, although the overweight and obesity rate of children in China is lower than that of developed countries in Europe and America, but the absolute number of obese children is astonishing because of the large population base in China. Should no timely obesity interventions be taken, the obesity rate in developing countries will soon catch up with or even overtake the obesity rate in developed countries. The trend will further increase the burden on healthcare and socioeconomic systems in developing countries. We should seize this critical period to widely promote preventive measures against childhood obesity, curb the rising trend of childhood and adolescent obesity, prevent the rapid growth of obesity-related chronic diseases in China in the future, and lay a solid foundation for health in the early life.
Worldwide and national trends in childhood obesity According to a systematic analysis with 19,244 agesex-country year observations-based on both physical measurements and self-reports, in developed countries, the overweight and obesity rate for boys and girls starting at ages 2‒4 years increased from 16.9% and 16.2% in 1980 to 23.8% and 22.6% in 2013. In developing
countries, the overweight and obesity rate for boys and girls increased from 8.1% and 8.4% to 12.9% and 13.4% from 1980 to 2013 [1]. At all ages, overweight and obesity rate in developed countries was higher than that in developing countries [1]. In another pooled analysis of 2416 population-based measurement studies, global age-standardised prevalence of obesity for boys and girls starting at ages 5 years increased from 0.7% and 0.9% in 1975 to 5.6% and 7.8% in 2016 [6]. The number of obese boys and girls increased from 7 million and 5 million in 1975 to 74 million and 50 million in 2016 [6]. According to the report of World Health Organization (WHO), the overweight and obesity rate among children and adolescents aged 5‒19 increased from 4% in 1975 to over 18% in 2016 [2]. The number of overweight and obese children and adolescents aged 5‒19 were over 340 million in 2016 [2]. In China, for children below seven years old, according to the data of the Epidemiological Survey for Obesity among Children below Seven Years Old in Nine Cities in China, the detection rate of obesity was 0.91% in 1986, with 0.93% for boys and 0.90% for girls, which suggested a relatively low level [7]. However, over the next 20 years, the rate of obesity showed an increased trend. In 1996, the detection rate of obesity among children aged below 7 years old was 1.76%, with 2.12% for boys and 1.38% for girls. Compared with the prevalence of obesity in 1986, the prevalence in 1996 increased 93.4% [8]. The prevalence of obesity among children aged below 3 years old did not change significantly from 1986 to 1996, while the prevalence of obesity among children aged 4‒7 years old increased obviously, rising from 0.84% to 4.17% [8]. In 2006, the detection rate of overweight among children aged 0‒7 years old was 6.25%, with 6.59% for boys and 5.88% for girls; the detection rate of obesity was 3.19%, with 3.82% for boys and 2.48% for girls (Figure 1). The obesity prevalences in different age groups were different, 1.86% for infants aged 1 month to 1 year, then reduced among children aged 1 to 3 years, increased again among children aged above 3 years, and reached 7.02% among children aged 6‒7 years [9]. Compared with the obesity prevalence in 1986, it increased by 278% in 2006 [9].
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Figure 1 Changes of the obesity prevalence among children aged 0–7 years old from 1986 to 2006 [7-9]
According to the data of China National Nutrition Survey in 1992, the prevalence of overweight among children aged below six years old was 2.3%, with 2.4% for boys and 2.2% for girls; the prevalence of obesity was 1.6%, with 1.7% for boys and 1.6% for girls [10]. In 2002, the increasing rate of overweight and obesity was higher in girls aged below 6 years than boys, while among other age groups, the rate in boys was higher than girls [10]. According to the Report on Nutrition and Chronic Diseases of Chinese Residents (2015), the prevalence of overweight among children aged below seven years old was 8.4%, with 9.4% for boys and 7.2% for girls; the prevalence of obesity was 3.1%, with 3.6% for boys and 2.5% for girls in 2012 (Figure 2) [4].
In Hong Kong Special Administration Region (SAR), the prevalence of overweight and obesity for children aged 3‒6 year old was 13.5%, with overweight 9.3% and obesity 4.2% in 2011‒2012 [3,11,12]. For school-age children aged 7‒18 years old, according to the data of the Physical Fitness and Health Survey for Chinese Students, the detection rates of overweight and obesity for urban boys were 1.1% and 0.2%, with 1.4% and 0.2% for urban girls; 0.4% and 0.1% for rural boys; 1.5% and 0.1% for rural girls in 1985 [13], which suggested the problem of obesity was not serious. In 1995, the detection rates of overweight and obesity for urban boys were 6.4% and 2.2%, with 4.2% and 1.4% for urban girls; 2.1% and 0.6% for rural boys;
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Figure 2 Changes of the overweight (A) and obesity (B) prevalence among children aged below 7 years old from 1992 to 2012 [4,10] PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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2.5% and 0.4% for rural girls, which suggested that the trend of obesity prevalence has begun to increase [14]. In 2000, overweight and obesity prevalence has become a major health problem, and showed a fast increasing trend from then on. In 2014, the detection rates of overweight and obesity for urban boys were 17.1% and 11.1%, with 10.6% and 5.8% for urban girls; 12.6% and 7.7% for rural boys; 8.3% and 4.5% for rural girls [5], which demonstrated that childhood obesity had already gained national prevalence (Figure 3). The overweight and obesity rate in primary school students (aged 7‒12 years) was 22.5%, 17.3% in middle school students (aged 13‒15 years) and 15.4% in senior high school students (aged 16‒18 years) [5]. According to the data of China National Nutrition Survey, the prevalence of overweight among children
aged 6‒17 years old was 3.9%, with 4.3% for boys and 3.5% for girls; the prevalence of obesity was 1.8%, with 1.8% for boys and 1.9% for girls in 1992 [10]. Based on the Report on Nutrition and Chronic Diseases of Chinese Residents (2015), the prevalence of overweight among children aged below seven years old was 9.6%, with 10.9% for boys and 8.2% for girls; the prevalence of obesity was 6.4%, with 7.8% for boys and 4.8% for girls in 2012 (Figure 4) [4]. In Hong Kong SAR, the prevalence of overweight and obesity for children aged 7‒12 year old was 26.9%, with overweight 19.5% and obesity 7.4%; 14.0% for children aged 13‒19 year old, with overweight 10.3% and obesity 3.7% in 2011‒2012 [3,11]. According to the data from Students’ Health Service Centre under Department of Health in Hong Kong SAR, the overweight and obesity
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B Figure 3 Changes of the overweight (A) and obesity (B) prevalence among children aged 7–18 years old from 1985 to 2014 [5,13] PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Figure 4 Changes of the overweight (A) and obesity (B) prevalence among children aged 6–17 years old from 1992 to 2012 [4, 10]
rates for primary students was 17.6%, with 21.9% of boys and 12.9% girls in 2016‒2017 [11]. In Macao SAR, according to the report of physical fitness monitoring for Macao citizens, the proportion of overweight and obesity for boys aged 6‒22 years old was 19.1% to 40.8%, with 8.4% to 35.0% for girls [15]. In Taiwan, it was shown that the childhood overweight and obesity rate was 29% in boys and 21% in girls [16].
Characteristics of childhood obesity prevalence in China The prevalence of childhood overweight and obesity in China shows the following characteristics: (1) The prevalence of overweight and obesity is on the rise; (2) The prevalence of overweight is higher than that of obesity; (3) The prevalence of overweight and obesity in boys is higher than that of girls; (4) The prevalence of overweight and obesity in urban is higher than that in rural; (5) The prevalence of overweight and obesity among children with higher socioeconomic status is higher than those with lower socioeconomic status; (6) High prevalence of overweight and obesity is found in the stage of infancy and pre-school age, which is coincide with the period of fast develop and repolymerization of fat tissues; (7) The majority of the obese children of different sex at younger age are mildly obese [9]. However, the proportion of moderate and severe obesity increases with age. Severe obesity is mainly found among children
aged above three years old; in addition, the proportion of severe obesity in boys is more than that in girls; the rate of childhood obesity in rural has accelerated in recent years [9].
Prediction on the prevalence of childhood obesity in China From 1985 to 2005, the detection rate of obesity among children aged 0‒7 years old increased from 0.9% to 3.2% [7, 9]. From 1985 to 2014, the prevalence of overweight among school-age children aged above 7 years old increased from 2.1% to 12.2%; the prevalence of obesity among school-age children aged above 7 years old increased from 0.5% to 7.3% [5]. Should no effective interventions be adopted, with the method of trend extrapolation, it is estimated based on the above data that the prevalence of obesity among children aged 0‒7 years old will reach 4.8% in 2020 and 6.0% in 2030 [12]. The prevalence of overweight and obesity among children aged above 7 years old will reach 22.3% in 2020 and 28.0% in 2030 [12].
Determinants contribute to the prevalence of childhood obesity in China Multiple determinants contribute to the prevalence of obesity, such as genetic, environment and socio-cultural factors. Rapid development of genome technology has made that it was possible to investigate the link between PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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genetics and obesity. With more scientific evidences, it is generally believed that those who are seriously obese at a younger age are more likely to carry genetic mutation related to obesity. Susceptibility to obesity inheritance varies by age and difference exits between children and adults in terms of such susceptibility [17,18]. In the Developmental Origins of Health and Disease theory [19], it is suggested that the antenatal events and environmental factors affected the physiological functions of the fetuses and newborns, including causing permanent changes to the physical structure and functions of organs. This will further increase risks for the incidence of noncommunicable diseases (NCDs) such as obesity during childhood and adulthood. Obesogenic environment contribute to the increasing prevalence of obesity, including dietary determinants (irrational dietary pattern with over supply of fat, over consumption of food items with high energy density) [20], physical inactive and increased sedentary activities (decreased physical activity, increased time with the use of screens) [21], unhealthy dietary behaviors (skipping and eating breakfast with inadequate nutrition, increased consumption of soft drinks; more frequenting eating out) and so on [22, 23]. Some socioeconomic and cultural context also have contributed to the epidemics of obesity. In addition, the association between gut bacteria and obesity has become a popular research topic. Studies have shown that gut bacteria play a certain role in the incidence and development of obesity, for a possible important part the bacteria contribute to the nutrition, metabolism and immunity of the host [24, 25]. Despite a vital role played by genetic factors, genes do not mutate significantly in the short term, genetic factors exert its influence on the incidence of obesity only in an enabling environment. Therefore, the steep increases of childhood overweight and obesity in the recent years is not caused by mutant genes, but rather the fast-changing environmental and social factors. The control of childhood obesity should be focused on improving the obesogenic environment, behaviours and life styles.
The impacts of childhood obesity on health and economic Obesity is a disease and also a risk factor for multiple non-communicable diseases, such as cardiovascular, endocrinology, respiratory systems, liver, skeleton, psychological behaviors, cognitive and intelligence capacity [26-28]. In addition, childhood obesity may increases the risk for adulthood obesity and NCDs, which may bring serious economic burden. In 2002, the adult overweight and obesity rate at 29.9% directly cost 21.11 billion CNY [29]. Upon extrapolation, by 2030, the direct economic costs incurred by NCDs as a result of adult obesity will reach 49.05 billion CNY each year [12]. Analysis of the data from Nutrition and Health Survey for Chinese Residents in 2002 and the 3rd National Health Service Survey in 2003 showed that direct economic costs for hypertension, diabetes, coronary heart disease and stroke caused by overweight and obesity accounted for 3.2 and 3.7% of the total health expenditure and medial spending for China in 2003 [29]. It is estimated direct losses attributable to obesity in the U.S.A., Australia, France and the Netherlands take up 5.7%, 2.0%, 2.0% and 4.0% of the health expenditure for each country [3]. The share for NCDs spending caused by obesity against the total health expenditure for China is higher than that of Australia and France. Between 2000 and 2025, the indirect losses caused by obesity will account for 3.6%‒8.7% of Grooss National Product (GNP) [3].
Policies and actions to control childhood obesity Orienting towards treating with the problem of childhood obesity, WHO has released a series of reports, such as Obesity and Poverty: a New Public Health Challenge, Prevention and Control for the Global Prevalence of Obesity and Global Strategy on Diet, Physical Activity and Health, and so on [30-32]. These advocates are aimed to promoting a lifestyle of energy balance achieved through a healthy die and physical activities, promoting individual and community health, reducing the risks and morbidity of NCDs. The Commission on Ending Childhood Obesity
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was established by WHO in 2014, and then released the Report of the Commission on Ending Childhood Obesity in 2016, which proposed the scientific evidence-based recommendations to eliminate childhood obesity [33]. Experts from International Obesity Task Force advocated to ban the sales of junk food and soft drinks to the children below 16 years old through legislation (including an international law) in 2008 [34]. Only the foods in strict compliance of healthy diet principle are allowed to be sold to the children. The Taskforce proposed the Sydney Principles to prevent obesity and NCDs. The health ministers from 53 European countries ratified the first European Charter on Counteracting Obesity, which was the first joint charter to fight against obesity in 2006. This anti-obesity declaration was drafted by WHO specifically for Europe and was an attempt to require robust measure from the government to combat obesity [3, 35]. According to the Charter, signatories must put in place and improve measure within the specific timeframe to help people to eat healthy and exercise more. For instance, more lanes for bicycles and pedestrians should be built up in cities to reduce dependence on cars. The charter even includes provisions to restrict sales of high-calorie food to children and prohibit advertisements of unhealthy food for children. U.S. CDC worked with WHO for the Global Strategy on Diet, Physical Activity and Health and developed the Nutrition and Physical Activity Plan to Prevent Obesity and Other NCDs in 2007, funding was provided to 28 states of the U.S.A. for the obesity prevention and control activities among the entire people. The plan is aimed to reducing obesity rate through increasing physical activity, increased consumption of fruit and vegetable, increasing the breastfeeding coverage, extending the lactation, reducing the consumption of high-calorie food and sugary beverages and cutting the hours to watch TV. New Moves Research was launched by National Institutes of Health [36], which aimed to intervene with overweight puberty girls or at risks. Interventions includes three phases: promoting changes to dietary pattern and physical activities through interventions on the social/environmental factors and personal preferences; attending physical activity classes every day; having lunch meeting every week to discuss
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the experiences and questions during the intervention. New Moves Research achieved the intended results to improve healthy behaviours and the self-esteem. Let’s Move Campaign was promoted by Michel Obama, which advocated young Americans to exercise more and drink more water [37]. In 2009, the British government initiated Change4Life, a programme to advocate healthy lifestyle to the public [38]. Through the publicity of health concepts in media, the public are encouraged to adopt healthy diet, increase their physical activity, and change their unhealthy behaviours so as to improve the physical fitness of the entire population. In France, Together Let’s Prevent Childhood Obesity Project (EPODE) prevents and controls childhood obesity by changing the obesogenic environment in community, school and household [39], such as removing vending machines from schools, re-arranging the playground of schools, setting up various fitness equipment at communities, restricting consumption of unhealthy food and beverages among children, testing and labelling the nutrients in foods, and promoting sports activities organized by various organizations. The project showed that in the urban towns where the strategy was implemented, childhood obesity incidence significantly reduced compared with the control urban towns and national average level. In Netherlands, Healthy weight among the Youth Programme (JOGG) aimed at studying on how to promote the healthy lifestyle among the entire population through mothers. The programme effectively reduced the intake of sugary beverages through promoting water drinking [40]. Another programme Enjoying Being Fit targeted children age 6‒12 years old by promoting more physical activity opportunities and got better results [3]. Japan proposed objectives to prevent obesity in Health Japan 21 programme in order to reduce the NCDs incidence and mortality, decrease the deaths for middleaged people, extend healthy lifespan, improve living standards, and establish a dynamic society where all citizens have sound body and mind through changing the day-to-day habits [41]. The Health Japan 21 programme sets up 80 objectives in nine areas including nutrition PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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1.49%. The importance of breastfeeding was gradually recognized by the public. The prevalence of anemia has been reduced and was 4.79% among children under 5 years old. The health environment are getting better. But, childhood obesity has not got enough attention and been effectively curbed [51]. In 2014, Outline of the Programme for Food and Nutrition Development in China (2014‒2020) was released by the State Council, which specifies 21 indicators in five areas including food production, development of food processing industry, food consumption, nutrients intake, and control of nutritional diseases [52]. One of the vital objectives is to drastically bring down the increase rate of overweight, obesity and dyslipidaemia among residents. In 2016, the Blueprint of Healthy China 2030 was issued by the State Council [53]. It clearly suggested that “Health for All ” is the fundamental purpose of building a healthy China. Five aspects of strategic mission in this blueprint include the popularize of healthy life, the optimization of health service, the improvement and perfection of health security, the building of healthy environment, and the development of health industry. The blueprint highlights the developmental ideology of “One Health”, and proposes to integrate this ideology into the whole process of public policy formulation and implementation, in order to coordinate comprehensive health factors, and to maintain the health of the people in omni-direction and full life cycle. In 2017, National Nutrition Plan (2017‒2030) was issued by the State Council [54]. In this plan, one of the primary objectives is to control the rising trend of obesity rate among students effectively through the action of nutrition improvement among students. In order to prevent and control the overweight and obesity rate among students, several suggestions are proposed. Weight management and intervention strategies should be carried out aimed at sports and nutrition, such as conducting education on balanced diet and nutrition, enhancing students’ physical exercises, and so on. Targeted comprehensive intervention measures should be put forward by strengthening the monitoring and evaluation of overweight and obesity of students, and analyzing of influencing factors including family, school
and society. Comprehensive intervention program for children nutrition should be implemented and appropriate techniques for preventing and intervening obesity should also be studied and developed.
Recommendations of comprehensive policies and strategies, and future prospects Once obesity is developed, it is challenging to lose weight. Prevention should be the key guiding principle to control obesity at the population level. Efforts should be made at the early stage of life, starting from the pregnancy. With the leading of government and the engagement of public, a control and prevention network integrating schools, families and communities should be established.
Formulating international economic agreements and policies conducive to prevention and control obesity International economic agreements and policies are closely related to the health of population, through the effects on food production, processing, trade, marketing and retail globally. International institutions and governments should reach consensus on the importance and significance of the prevention and control of childhood obesity, establish and implement internationally recognized standards, develop scientific and effective guidelines and action plans, promote cooperation, capacity building and academic research, establish healthier economic agreements and policies, and facilitate effective prevention and control of childhood obesity throughout the world.
Integrating obesity prevention and control into all policies and improving the obesogenic environment As the Report of the Commission on Ending Childhood Obesity mentions, obesogenic environment includes many factors, such as political and commercial factors, the built environment, social norms and family environment [33]. In order to improve the complex obesogenic environment, it is necessary to integrate obesity prevention and control into all policies, prioritize health and pay close attention to childhood obesity when socioeconomic policies are developed. PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
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Establishing mechanism with the lead of government, the cooperation of multi-sector and the engagement of public The government should be fundamentally responsible for the childhood obesity related policy development, implementation and supervision. A working mechanism featuring government leadership, multi-sectoral cooperation, and public engagement should be established; definite and specific goals should be made, sound urban planning should be made, transport system should be well designed, enough sports facilities and sports venues in schools should be provided, development and management of food labels should be strengthened, standardized food label should be developed, and advertisement of unhealthy food and beverages should be better managed. Schools should be the main avenue to control childhood obesity. Healthy lifestyle such as adequate nutrition and regular physical activity should be incorporated into the school curriculum and subject content; health education should be developed systematically in schools; meals provided in school should meet related nutrition guidelines and standards, the provision or sale of unhealthy foods nearby school should be regulated and limited, and a sound inter-personal communication environment should be created. Parents should guide, support, supervise and encourage their children to form healthy lifestyle, provide health food, master health-related skills and knowledge. Community should create a supportive environment for childhood obesity control, provide safe venues for games and exercise, conduct various health education and promotion activities, improve the public awareness and skills on childhood obesity control, advocate healthy lifestyle and provide health counselling and services. The community-based primary health facilities should provide family-based and diversified weight management service. Corporations, media and academic institutions should play a positive role on the improvement of obesogenic environment. Guided by policies, food companies should try to ensure their product line and development can protect and promote health; the exaggerated or misleading food advertising should be changed, so that consumers will not be misled by the advertising on children’s food;
food industry should reinforce their social responsibility while seeking profit and government, scientific community, and all social sectors can work with the socially responsible food companies; media should tap their influence and provide positive guidance; academic institutions can address childhood obesity via researches on the biological, behavioural and environmental risk factors and determinants and they can work effectively with media to disseminate relevant messages in a more intelligible manner. Key research projects on childhood obesity should be established, so as to strengthen the basic and applied researches on childhood obesity, explore aetiology, determinants, economic burden, prevention and intervention strategy, treatment and rehabilitation for childhood obesity, exploring innovative techniques from the convergence of information, biology and medical technologies.
Improving national childhood obesity surveillance system The national childhood obesity surveillance system should be improved, by incorporating childhood obesity into the existing national surveillance systems. Specific population groups, surveillance sites, duration and indicators should be determined, and standard approaches should be employed to study and master the most updated prevalence, trends, characteristics of changes and determinants for childhood obesity.
Starting prevention and control of obesity in early stage of life and impetrating in all life cycle Prevention and control of obesity should be started in early stage of life, even in the stage of pregnancy. Pregnant women should strengthen pregnancy management, and gain appropriate weights during pregnancy and seek timely diagnosis and management for their high blood glucose and hypertension. The overweight and obesity rate and physiological characteristics in different stages of life cycles are various, thus, the emphasis on prevention and control of obesity at various stages is also different, and measures should be taken to prevent and control obesity pertinently in all life cycle. For example, the birth weight, the way of feeding, the time and way of adding
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food, and the dietary behaviors are all the factors that affect infant obesity.
be freely available to any scientist wishing to use them for non-commercial purposes.
Implementing three-tiered prevention for childhood obesity
Competing interests
A three-tiered prevention and control strategy should be employed, namely general prevention, targeted prevention for at-risk groups and integrated interventions for overweight and obese groups [12]. General prevention: health promotion theories and practices should be employed to target the entire population in order to help the children to foster healthy behaviours and lifestyle and prevent obesity among them. Measures include policy development, building a supportive physical and social environment, promoting community engagement, raising awareness, conducting capacity building and delivery of health services Targeted prevention: the children facing with higher risks of developing obesity in an obesogenic environment should be targeted with specific preventive measures, so as to prevent them from becoming overweight and obese. The interventions in the setting of families and schools should be incorporated into the daily life of such children prone to overweight and obesity. Integrated interventions for overweight and obese groups: it is necessary to maintain normal weight gains and avoid excessive gains for overweight and obese individuals. Schools and families should be both involved to implement the sustainable integrated prevention and control plans. Measures include modified diet, physical activity and behavioural therapy.
Additional files Acknowledgments Thanks for the support of United Nations International Children’s Emergency Fund.
Funding It was funded by United Nations International Children’s Emergency Fund.
Availability of data and materials We declare that materials described in the manuscript will
All authors have no competing interests.
Consent for publications All authors have been informed of consent for publication.
Ethics approval and consent to participate It is not applicable for this review paper.
References 1. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-81. 2. World Health Organization. Obesity and overweight. [updated 2018-02-16; cited 2018-03-20]. http://www.who.int/en/newsroom/fact-sheets/detail/obesity-and-overweight. 3. Ma GS. Report on childhood obesity in China. Beijing: People’s Medical Publishing House, 2017. (in Chinese) 4. National Health and Family Planning Commission of the People’s Republic of China. 2014 report on Chinese residents’ chronic disease and nutrition. [updated 2015-0615; cited 2018-03-20]. http://en.nhfpc.gov.cn/2015-06/15/ c_45788.htm. 5. Wang S, Dong YH, Wang ZH, Zhou ZY, Ma J. Trends in overweight and obesity among Chinese children of 7-18 years old during 1985-2014. Chin J Prev Med. 2017;51(4):300-5. (in Chinese) 6. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017;390(10113):2627-42. 7. Ding ZY, Zhang R, Huang Z. Epidemiological survey of simple obesity among children aged 0~7 years in urban areas of China. Acta Nutrimenta Sinica. 1989;(3):255-66. (in Chinese) 8. Li H, Zhang X, Yan GF. Prevalence and Trend of Obesity in Preschool Children in China 1986 to 1996. Chin J Child Health Care. 2002;10(5):316-8. (in Chinese) 9. Coordinating Group of Nine Cities Study on the Physical Growth and Development of Children, Capital Institute of Pediatrics, Li H. A national epidemiological survey on obesity of children under 7 years of age in nine cities of China. Chin J Pediatr. 2008;46(3):174-8. (in Chinese) 10. Ma GS, Li YP, Wu YF, Zhai FY, Cui ZH, Hu XQ, et al. The
PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
9-98S全球健康杂志（英文）.indd 11
2018/10/18 13:37:28
12
Global Health Journal / Volume 2, Issue 1, March 2018
prevalence of body overweight and obesity and its changes among Chinese people during 1992 to 2002. Chin J Prev Med. 2005;39(5):311-5. (in Chinese) 11. Department of Health of the Government of the Hong Kong Special Administrative Region. Overweight and obesity rate of Hong Kong primary students. [cited 2018-03-20]. http:// school.eatsmart.gov.hk/files/pdf/Childhood_obesity_bi.pdf. (in Chinese) 12. Zhang N, Ma GS. Interpretation of Report on childhood obesity in China. Acta Nutrimenta Sinica. 2017;39(6):5304. (in Chinese) 13. Ma J, Cai CH, Wang HJ, Dong B, Song Y, Hu PJ, et al. The trend analysis of overweight and obesity in Chinese students during 1985-2010. Chin J Prev Med. 2012;46(9):77680. (in Chinese) 14. Liao WK. A survey of national students’ physical health in 1995. Chin J Prev Med. 1997;8(1):42-3. (in Chinese) 15. Lee A, Ho MM, Keung VM. Global epidemics of childhood obesity is hitting a ‘less industrialized’ corner in Asia: a case study in Macao. Int J Pediatr Obes. 2011:6(2-2): e252-6. 16. Bureau of Health Promotion Department. Taiwan Obesity Map. [cited 2018-03-20]. http://www.bhp.doh.gov.tw/BHPnet/Portal/Them.aspx?No=201108110001.2. (in Chinese) 17. Mei H, Chen W, Mills K, He J, Srinivasan SR, Schork N, et al. Influences of FTO gene on onset age of adult overweight. Hum Genet. 2012;131(12):1851-9. 18. Wang J, Mei H, Chen W, Jiang Y, Sun W, Li F, et al. Study of eight GWAS-identified common variants for association with obesity-related indices in Chinese children at puberty. Int J Obes. 2012;36(4):542-7. 19. Visser G.H.A. Developmental origins of health and disease (DOHaD). Early Hum Dev. 2006;82(8):iii-iv. 20. Su C, Wang HJ, Wang ZH, Zhang JG, Du WW, Zhang J, et al. Current status and trends of both dietary fat and cholesteral intake among Chinese children and adolescents aged 7 to 17 years old in 9 provinces of China, from 1991 to 2009. Chin J Epidemiol. 2012;33(12):1208-12. (in Chinese) 21. Liu AL, Li YP, Hu XQ. Sedentary activities during leisure time of children and adolescent in China. Chin J Sch Health. 2008;29(4):312-4. (in Chinese) 22. Zheng MQ, Liu H, Hong L, Cao XY, Zhang Z, Ma GS. Breakfast-eating behaviors among children in six cities of China. Chin J Sch Health. 2017;38(2):166-8. (in Chinese) 23. Li YH, Lv QJ, Wang HJ, Yu DM, Liu AD, Zhao LY, et al. Trend analysis of snacks consumption behavior among school aged children and adolescents in nine provinces of China. J Hygiene Res. 2008;37(5):621-2. (in Chinese) 24. Bäckhed F, Ding H, Wang T, Hooper LV, Koh GY, Nagy A, et al. The gut microbiota as an environmental factor that regulates fat storage. Proc Natl Acad Sci U S A. 2004;101(44):15718-23. 25. Tremaroli V, Bäckhed F. Functional interactions be-
tween the gut microbiota and host metabolism. Nature. 2012;489(7415):242-9. 26. Liang YJ, Xi B, Hu YH, Wang C, Liu JT, Yan YK, et al. Trends in blood pressure and hypertension among Chinese children and adolescents: China health and nutrition surveys 1991–2004. Blood Press. 2011;20(1):45-53. 27. Chen F, Wang Y, Shan X, Cheng H, Hou D, Zhao X, et al. Association between Childhood Obesity and Metabolic Syndrome: Evidence from a Large Sample of Chinese Children and Adolescents. PloS One. 2012;7(10):e47380. 28. Liang Y, Hou D, Zhao X, Wang L, Hu Y, Liu J, et al. Childhood obesity affects adult metabolic syndrome and diabetes. Endocrine. 2015;50(1):87-92. 29. Zhao WH, Zhai Y, Hu JP, Wang JS, Yang ZX, Kong LZ, et al. Economic burden of obesity related chronic diseases in China. Chin J Epidemiol. 2006;27(7):555-9. (in Chinese) 30. World Health Organization. Global Strategy on Diet, Physical Activity and Health. [cited 2018-03-20]. http://www. who.int/dietphysicalactivity/goals/en/. 31. Peña M, Bacallao J. Obesity and poverty: a new public health challenge. Geneva: WHO, 2000. 32. World Health Organization, UN Food and Agriculture Organization. Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. Geneva: WHO, 2003. 33. Commission on Ending Childhood Obesity. Report of the Commission on Ending Childhood Obesity. Geneva: WHO, 2016. 34. Swinburn B, Sacks G, Lobstein T, Rigby N, Baur LA, Brownell KD, et al. The “Sydney Principles” for reducing the commercial promotion of foods and beverages to children. Public Health Nutr. 2008;11(9):881-6. 35. Miu J. Inspiration from European and American governments’ intervention on obesity among adolescents. The 9th National Sports Science Conference, Shanghai, China, 2011. Shanghai: China Sport Science Society/ Shanghai University of Sport, 2011. (in Chinese) 36. Neumark-Sztainer D, Flattum CF, Story M, Feldman S, Petrich CA. Dietary approaches to healthy weight management for adolescents: the New Moves model. Adolesc Med State Art Rev. 2008;19(3):421-30, viii. 37. Grier P. Michelle Obama says ‘Let’s Move’ on obesity in American kids. [updated 2010-02-09; cited 2018-03-20]. https://www.csmonitor.com/USA/2010/0209/MichelleObama-says-Let-s-Move-on-obesity-in-American-kids. 38. Fletcher R. Change4life campaign. Lancet. 2009; 373 (9665):720-1. 39. Borys JM, Le Bodo Y, Jebb SA, Seidell JC, Summerbell C, Richard D, et al. EPODE approach for childhood obesity prevention: methods, progress and international development. Obes Rev. 2012;13(4):299-315. 40. Leenaars K, Jacobs-van der Bruggen M, Renders C. Determinants of successful public-private partnerships in the
PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
9-98S全球健康杂志（英文）.indd 12
2018/10/18 13:37:29
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context of overweight prevention in Dutch youth. Prev Chronic Dis. 2013;10(10):E117. 41. HASEGAWA T. “Healthy Japan 21”[J]. Korean Journal of Health Education & Promotion, 2005, 22(3): 135-55. 42. Zheng HW, Lai TD. Firmly implementing the educational guideline of “Health First” and fully exerting the role of school physical education in quality education. Teach Phys Educ. 2000;20(1):14-5. (in Chinese) 43. The Ministry of Education of the People’s Republic of China. The Ministry of Education issued a notice to carry out ‘Sunny Sports Programme for nationwide hundreds of millions of students’. http://www.gov.cn/gzdt/2006-12/25/ content_477488.htm. (in Chinese) 44. The State Council of the People’s Republic of China. Opinions on increasing physical exercises of teenagers to strengthen the constitutions. Ethn Educ Chin. 2007; 28(6): 481-3. (in Chinese) 45. Chen CM. Guidelines on the prevention and control of obesity and overweight among school-aged children in China (for Trial). Beijing : People’s Medical Publishing House, 2008. (in Chinese) 46. Bureau of Disease Prevention and Control, National Health and Family Planning Commission of People’s Republic of China. National Dissemination Plan for Health Knowledge. [cited 2018-03-20]. http://www.jilijihua.com/%e5%85%b3 %e4%ba%8e%e6%88%91%e4%bb%ac/. (in Chinese) 47. Zhang J, Li Y, Shi XM, Liang XF. The progress of National Campaign on Healthy Lifestyle for All (2007-2012). Chin J
13 Prev Contr Chron Dis. 2013;21(6):739-40. (in Chinese) 48. Gao AY, Pan YP, Shi XY, Cui ZH. Effect of “Happy 10 minutes” for preventing childhood obesity. Chin J Sch Health. 2008;29(11):978-9. (in Chinese) 49. Chang G, Liu H, Yang Y, Ma J, Wang WJ, Jiang GH. Effects of “Take 10!” intervention on the related indexes of obese pupils. Chin J Prev Contr Chron Dis. 2009;17(5):5057. (in Chinese) 50. The State Council of People’s Republic of China. Notice of the State Council on issuing the Outline of Women Development and the Outline of Children Development in China. [updated 2011-07-30; cited 2017-03-20]. http://www.gov.cn/ gongbao/content/2011/content_1927200.htm. (in Chinese) 51. National Bureau of Statistics of People’s Republic of China. Report on the Statistical monitoring of Outline of children development in China (2011-2020) in 2016. http://www. stats.gov.cn/tjsj/zxfb/201710/t20171026_1546618.html. (in Chinese) 52. Ding SJ. Grasp features of the outline of the Program for Food and Nutrition Development in China (2014-2020) to make sure food safety. Agric Outlook. 2014;10(3):30-3. (in Chinese) 53. Tan X, Liu X, Shao H. Healthy China 2030: a vision for health care. Value Health Reg Issues. 2017;12:112-4. 54. General Office of the State Council of People’s Republic of China. National Nutrition Plan (2017-2030). [updated 2017-06-30; cited 2018-03-20]. http://www.gov.cn/zhengce/ content/2017-07/13/content_5210134.htm. (in Chinese)
PEOPLE’S MEDICAL PUBLISHING HOUSE Co., LTD.
9-98S全球健康杂志（英文）.indd 13
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