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American Journal of Public Health logoLink to American Journal of Public Health
. 2016 Dec;106(12):2103–2110. doi: 10.2105/AJPH.2016.303499

Prevalence of Underweight, Overweight, and Obesity Among Reproductive-Age Women and Adolescent Girls in Rural China

Yuan He 1, An Pan 1, Ying Yang 1, Yuanyuan Wang 1, Jihong Xu 1, Ya Zhang 1, Dujia Liu 1, Qiaomei Wang 1, Haiping Shen 1, Yiping Zhang 1, Donghai Yan 1, Zuoqi Peng 1, Frank B Hu 1, Xu Ma 1,✉
PMCID: PMC5105028  PMID: 27831775

Abstract

Objectives. To provide prevalence and trends of underweight, overweight, and obesity among reproductive-age women and adolescent girls in rural China.

Methods. We measured weight and height in 16 742 344 women aged 20 to 49 years and 178 556 girls aged 15 to 19 years from the National Free Preconception Health Examination Project between 2010 and 2014.

Results. Among women, the prevalence of underweight was 7.8% (95% confidence interval [CI] = 7.7%, 7.9%), and overweight or obesity was 16.5% (95% CI = 16.4%, 16.6%; World Health Organization criteria). Among adolescents, prevalence of underweight was 6.0% (95% CI = 5.7%, 6.2%; Centers for Disease Control and Prevention criteria) and overweight or obesity was 8.3% (95% CI = 7.9% to 8.8%; International Obesity Task Force criteria). According to Chinese criteria, overweight and obesity prevalence was 24.8% (95% CI = 24.7%, 24.9%) for women and 17.2% (95% CI = 16.6%, 17.8%) for adolescents, and underweight prevalence was 2.9% (95% CI = 2.8%, 3.1%) for adolescents. Considerable disparities existed in prevalence and trends within subpopulations (age groups, parity, region, education levels, and socioeconomic status).

Conclusions. Our results reveal coexisting underweight and overweight or obesity among rural women and adolescents of reproductive age, which requires public health attention.

The epidemic of overweight and obesity has become a global public health crisis.1 Evidence exists that overweight and obesity are prevalent among women of reproductive age, accounting for 40% to 60% in developed countries and 30% to 40% in developing countries.2 Obese women are at higher risks for infertility and gestational complications such as hypertensive disorders, gestational diabetes, hemorrhage, and caesarean delivery, and also have increased risks of fetal and infant death, neural tube defects, and newborn macrosomia.3,4 Furthermore, maternal obesity increases the risk of obesity in their children during childhood and early adulthood and raises the risks of diabetes and cardiovascular disease in later life.5

On the other hand, underweight is well established to be associated with reduced fertility and adverse pregnancy complications including low birth weight, preterm birth, small for gestational age, and neonatal death.6,7 Despite a continuous decline in underweight in most countries, it remains a major concern for women of reproductive age in low- and middle-income countries (LMICs)—for example, affecting more than 15% of women in Asia and Africa.2

Prepregnancy body mass index (BMI) is a major determinant of weight changes during and after pregnancy.8 In the United States, more than 50% of women were either overweight or obese before becoming pregnant and nearly 4% were underweight at prepregnancy.9 Few studies are available to specifically investigate the distribution of BMI among women of reproductive age before pregnancy in China, where dramatic changes in diet, lifestyles, and living environment are occurring.10,11 In this study, we aimed to provide the most recent national estimates of the prevalence of overweight or obesity and underweight among reproductive-age women and adolescent girls before pregnancy based on a national megasurvey between 2010 and 2014 in rural China.

METHODS

The National Free Preconception Health Examination Project (NFPHEP), administrated by the National Health and Family Planning Commission and Ministry of Finance, was carried out beginning in 2010 across China for rural reproductive-age couples planning pregnancies within 4 to 6 months. Rural couples were defined on the basis of either women or men having a rural household registration. The project provided preconception care including free health examinations, risk assessments, consultations, and 2 follow-ups for pregnancy outcomes, which aimed to reduce birth defects in China. The NFPHEP began with 100 rural counties in 2010, and extended to 220 rural counties in 2011, and further extended to 2790 counties of 31 provinces in 2013. Before 2013, the numbers of NFPHEP units were selected in proportion to the local population size and numbers of total counties in each province with a 2-stage stratified cluster sampling method. Because NFPHEP is a free health care program aiming to improve pregnancy outcomes and reduce birth defects, women voluntarily came to get the service. Detailed project design and data collection have been described elsewhere.12,13 This report is based on data from all NFPHEP units in China between 2010 and 2014.

Procedures

All enrolled women and adolescent girls completed medical examinations at the local centers of maternal and child health care and family planning service. During the physical examination, trained doctors measured weight (nearest 0.1 kilogram) and height (nearest 0.1 centimeter) with standardized techniques and protocols after the participants had removed their shoes and heavy clothes. We calculated the BMI as weight in kilograms divided by height in meters squared (kg/m2) and rounded it to 1 decimal place. We excluded from the study all participants with missing information on height or weight or extreme or implausible BMI values. Following the World Health Organization (WHO) recommendations, we defined underweight as a BMI less than 18.5 kg/m2, overweight as a BMI of from 25.0 to 29.9 kg/m2, and obesity as a BMI of 30.0 kg/m2 or higher. Among adolescents, we defined underweight as a BMI less than the 5th percentile of the sex-specific US Centers for Disease Control and Prevention’s (CDC’s) BMI-for-age growth charts.14 We defined overweight and obesity on the basis of the sex- and age-specific values of BMI cutoffs of the International Obesity Task Force (IOTF) reference.15

In addition, we also calculated the prevalence of underweight, overweight, and obesity with the Chinese definitions.16,17 For women, we defined overweight and obesity as BMI of 24.0 to 27.9 kg/m2, and of greater than or equal to 28.0 kg/m2, respectively. For adolescents, underweight, overweight, and obesity were defined by using BMI-for-age growth curves for Chinese children and adolescents for those aged 15 to 18 years, and using definitions for adults for those aged 19 years.

All participants also finished a standard questionnaire to collect data about demographic characteristics, reproductive history, health status, and other relevant information through a face-to-face interview by trained local health staff. We defined parity by the number of live births: no previous pregnancy or no live birth (nulliparous), 1 live birth (primiparous), 2 or more live births (multiparous). We classified the study locations as North (Beijing, Hebei, Inner Mongolia, Shanxi, Tianjin), Northeast (Heilongjiang, Jilin, Liaoning), East (Anhui, Fujian, Jiangsu, Jiangxi, Shandong, Shanghai, Zhejiang), Central (Henan, Hubei, Hunan), South (Guangdong, Guangxi, Hainan), Northwest (Gansu, Ningxia, Qinghai, Shaanxi, Sinkiang), and Southwest (Guizhou, Sichuan, Tibet, Yunnan, Chongqing) according to geographical regions. We categorized the education levels into 4 groups including primary school or below, junior high school, high school, and college degree or above. We evaluated economic development in the study areas by gross domestic product (GDP) per capital based on data from the subdistricts in 2013, and divided into tertiles with the ranges of 0.2 to 3.4, 3.5 to 4.3, and 4.4 to 10.0 (per CNY 10 000), respectively.

Statistical Analysis

The prevalence is shown as percentage (95% confidence interval). Because of the convenience sampling, we weighted all calculations to represent the overall Chinese women and adolescents aged 15 to 49 years by using poststratification sampling. We used data from the China Population Census in 2010 for calculation of weight coefficients, particularly for age-standardization for every 1 year and regional standardization. Standard errors were on the basis of the Taylor series linearization method. We examined prevalence of underweight, overweight, and obesity in the total population and in sociodemographic subpopulations for women and adolescents. We used the χ2 test to compare differences in prevalence between age groups, parity, regions, education, and GDP levels. We tested temporal trends over 2010–2012 to 2013–2014 by using t statistics and orthogonal contrast matrices. We reported P values for trends, along with the absolute changes in prevalence of underweight, overweight, and obesity. In addition, we fitted multivariable logistic regression models including age, parity, region, education, and GDP subgroups, for women and adolescents separately. We performed statistical analysis by using Stata software version 13.0 (StataCorp LP, College Station, TX). Statistical tests were 2-sided and we considered a P value less than .05 statistically significant.

RESULTS

This report is based on data from 16 742 344 women aged 20 to 49 years and 178 556 adolescents aged 15 to 19 years between 2010 and 2014. Detailed sample size and demographic characteristics are shown in Table 1.

TABLE 1—

Unweighted Sample Sizes and Weighted Proportions of Demographic Characteristics for Reproductive-Age Women and Adolescent Girls: Rural China, 2010–2014

Variable 2010 (n = 343 494) 2011 (n = 997 384) 2012 (n = 3 936 800) 2013 (n = 6 063 590) 2014 (n = 5 579 632) Total (n = 16 920 900)
Age groups, y, %
 15–19 5.0 9.0 8.6 11.0 9.9 9.8
 20–24 27.2 22.3 16.1 17.5 15.3 17.0
 25–29 12.3 11.9 9.1 12.8 12.7 11.7
 30–34 12.5 11.7 10.7 12.4 12.7 12.0
 35–39 16.3 16.1 16.1 15.0 16.4 15.8
 40–44 14.2 15.3 19.5 17.2 18.2 17.9
 45–49 12.5 13.7 19.9 14.1 14.8 15.8
Parity, %
 Nulliparous 50.7 44.1 34.3 39.6 35.1 37.5
 Primiparous 48.3 54.3 62.7 57.5 61.7 60.0
 Multiparous 1.0 1.6 3.0 2.9 3.2 2.5
Region, %
 North 6.9 19.9 9.0 11.1 12.1 11.4
 Northeast 4.0 10.2 16.7 15.6 17.1 15.7
 East 20.6 25.6 16.4 21.0 22.1 20.4
 Central 13.2 11.5 14.7 14.7 13.8 14.1
 South 14.9 5.8 6.9 10.0 8.1 8.4
 Northwest 17.1 12.2 9.5 10.2 9.2 10.0
 Southwest 23.3 14.8 26.8 17.4 17.6 20.0
Education, %
 Primary school or below 10.4 11.1 15.2 12.8 11.4 12.9
 Junior high school 69.1 68.6 66.8 65.7 64.2 65.8
 High school 14.5 13.1 11.9 12.8 13.4 12.8
 College or above 6.0 7.2 6.1 8.7 11.0 8.5
Gross domestic product, %
 Tertile 1 48.7 50.8 48.8 42.7 44.0 45.5
 Tertile 2 21.4 23.6 31.1 31.1 30.9 30.3
 Tertile 3 29.9 25.6 20.1 26.2 25.1 24.2
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Note. The data are shown as percentage of sample size in each year, and all proportion estimates are weighted with the 2010 China Population Census.

The overall age-adjusted prevalence of underweight among reproductive-age women was 7.8% (95% confidence interval [CI] = 7.7%, 7.9%; Table 2), and ranged from 3.5% (95% CI =  3.3%, 3.7%) in the age group of 45 to 49 years to 15.5% (95% CI = 15.4%, 15.6%) in those aged 20 to 24 years. The prevalence was significantly higher among nulliparous women (12.9%; 95% CI = 12.8%, 13.0%) compared with primiparous women (5.4%; 95% CI = 5.3%, 5.5%; P < .001) or multiparous women (4.1%; 95% CI = 3.7%, 4.4%; P < .001). The prevalence varied dramatically across regions, with the highest in the south region (14.0%; 95% CI = 13.9%, 14.1%) and lowest in the northeast region (3.5%; 95% CI = 3.4%, 3.7%). The prevalence was also higher among women who had higher education levels or who lived in the higher GDP region.

TABLE 2—

Prevalence of Underweight, Overweight, and Obesity for Reproductive-Age Women Aged 20–49 Years: Rural China, 2010–2014

WHO Criteria
 Chinese Criteria
Variable Underweight, % (95% CI) Overweight and Obesity, % (95% CI) Obesity, % (95% CI) Overweight and Obesity, % (95% CI) Obesity, % (95% CI)
Total 7.8 (7.7, 7.9) 16.5 (16.4, 16.6) 2.0 (1.9, 2.1) 24.8 (24.7, 24.9) 4.8 (4.7, 4.9)
Age groups, y
 20–24 15.5 (15.4, 15.6) 7.6 (7.5, 7.7) 1.1 (1.0, 1.2) 12.2 (12.1, 12.3) 2.3 (2.2, 2.4)
 25–29 13.1 (13.1, 13.2) 10.2 (10.1, 10.3) 1.5 (1.4, 1.6) 15.7 (15.6, 15.8) 3.2 (3.1, 3.3)
 30–34 7.8 (7.7, 7.9) 14.8 (14.7, 14.9) 2.1 (2.0, 2.2) 22.3 (22.2, 22.4) 4.6 (4.5, 4.7)
 35–39 5.0 (4.9, 5.1) 18.2 (18.1, 18.3) 2.2 (2.1, 2.3) 27.4 (27.3, 27.5) 5.3 (5.2, 5.4)
 40–44 3.8 (3.7, 3.9) 21.4 (21.2, 21.6) 2.4 (2.3, 2.5) 32.0 (31.8, 32.2) 6.0 (5.9, 6.2)
 45–49 3.5 (3.3, 3.7) 24.4 (23.9, 24.9) 2.5 (2.3, 2.7) 35.4 (34.8, 36.0) 6.8 (6.5, 7.1)
Parity
 Nulliparous 12.9 (12.8, 13.0) 9.9 (9.8, 10.0) 1.4 (1.3, 1.5) 15.3 (15.2, 15.4) 3.0 (2.9, 3.1)
 Primiparous 5.4 (5.3, 5.5) 19.5 (19.3, 19.6) 2.2 (2.1, 2.3) 29.1 (29.0, 29.2) 5.6 (5.5, 5.7)
 Multiparous 4.1 (3.7, 4.4) 24.7 (23.8, 25.6) 3.1 (2.8, 3.5) 34.8 (33.9, 35.8) 7.6 (7.0, 8.1)
Region
 North 5.4 (5.3, 5.6) 21.9 (21.6, 22.2) 3.1 (3.0, 3.2) 31.3 (30.9, 31.6) 7.0 (6.9, 7.2)
 Northeast 3.5 (3.4, 3.7) 23.3 (23.0, 23.7) 2.7 (2.6, 2.8) 33.9 (33.5, 34.3) 6.6 (6.4, 6.8)
 East 8.5 (8.4, 8.6) 17.1 (16.9, 17.3) 2.3 (2.2, 2.3) 25.2 (24.9, 25.4) 5.3 (5.2, 5.5)
 Central 9.7 (9.6, 9.8) 12.3 (12.2, 12.4) 1.4 (1.3, 1.5) 19.7 (19.6, 19.9) 3.3 (3.2, 3.4)
 South 14.0 (13.9, 14.1) 8.0 (7.9, 8.2) 1.0 (0.9, 1.1) 13.4 (13.2, 13.6) 2.2 (2.1, 2.3)
 Northwest 8.9 (8.7, 9.1) 10.5 (10.3, 10.7) 1.2 (1.1, 1.3) 16.3 (16.0, 16.5) 2.8 (2.7, 2.9)
 Southwest 7.5 (7.4, 7.6) 16.1 (15.9, 16.4) 1.7 (1.6, 1.8) 24.9 (24.7, 25.2) 4.4 (4.3, 4.6)
Education
 Primary school or below 5.9 (5.7, 6.0) 21.1 (20.7, 21.4) 2.7 (2.6, 2.8) 31.0 (30.5, 31.4) 6.5 (6.3, 6.7)
 Junior high school 6.7 (6.6, 6.8) 17.2 (17.1, 17.3) 2.0 (1.9, 2.1) 25.8 (25.7, 26.0) 5.0 (4.9, 5.1)
 High school 10.7 (10.6, 10.8) 12.6 (12.4, 12.8) 1.6 (1.5, 1.7) 19.6 (19.2, 19.7) 3.5 (3.4, 3.6)
 College or above 13.7 (13.6, 13.9) 10.4 (10.1, 10.6) 1.3 (1.2, 1.4) 16.2 (15.9, 16.5) 2.8 (2.8, 3.0)
Gross domestic product
 Tertile 1 7.1 (7.0, 7.2) 16.4 (16.2, 16.5) 1.9 (1.8, 2.0) 24.7 (24.5, 24.9) 4.7 (4.6, 4.8)
 Tertile 2 7.8 (7.7, 7.9) 17.7 (17.5, 17.9) 2.1 (2.0, 2.2) 26.4 (26.2, 26.7) 5.1 (5.0, 5.2)
 Tertile 3 9.2 (9.1, 9.3) 15.2 (15.0, 15.3) 2.0 (1.9, 2.1) 22.7 (22.5, 22.9) 4.6 (4.5, 4.7)
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Note. CI = confidence interval. Among women aged 20–49 years, underweight, overweight, and obesity were defined according to World Health Organization (WHO) criteria and Chinese criteria. All estimates are weighted with the 2010 China Population Census.

The overall age-adjusted prevalence of combined overweight and obesity, and obesity alone was 16.5% (95% CI = 16.4%, 16.6%) and 2.0% (95% CI = 1.9%, 2.1%) according to the WHO criteria, respectively (Table 2). We observed a significant increasing trend within subgroups of older age and more parity (P < .001). The proportions of overweight or obesity were highest in the northeast region, and lowest in the southwest region (P < .001). Women with higher education levels and those in the low and high GDP regions were more likely to have a lower prevalence of overweight or obesity (P < .001). When we used the Chinese criteria, the corresponding values of combined overweight and obesity, and obesity alone were 24.8% (95% CI = 24.7%, 24.9%) and 4.8% (95% CI = 4.7%, 4.9%), respectively. The overall and the sociodemographic profiles were similar to those based on the WHO criteria (Table 2).

According to the CDC criteria, the overall prevalence of underweight among adolescent girls was 6.0% (95% CI = 5.7%, 6.2%; Table 3). The prevalence was significantly higher among girls aged 19 years, and those in the south and lower GDP regions, compared with their counterparts (P < .001). The prevalence of overweight and obesity (combined) and obesity was 8.3% (95% CI = 7.9%, 8.8%) and 1.1% (95% CI = 0.9%, 1.3%), respectively, in the total sample, and significantly higher among adolescents aged 15 to 16 years according to the IOTF criteria (P < .001). Adolescents with 1 or more previous parities, lower education levels, and living in the higher GDP regions had a higher prevalence of overweight or obesity. The prevalence of overweight or obesity was highest in the northeast region, and lowest in the south region (P < .001). When we used the Chinese criteria, 17.2% (95% CI = 16.6%, 17.8%) of adolescents were classified as having overweight or obese, and 4.9% (95% CI = 4.5%, 5.3%) as obese. The patterns related to the sociodemographic factors were similar to that based on the CDC and IOTF criteria (Table 3).

TABLE 3—

Prevalence of Underweight, Overweight, and Obesity Among Adolescent Girls Aged 15–19 Years: Rural China, 2010–2014

US CDC or IOTF Criteria, % (95% CI)
 Chinese Criteria, % (95% CI)
Variable Underweight Overweight and Obesity Obesity Underweight Overweight and Obesity Obesity
Total 6.0 (5.7, 6.2) 8.3 (7.9, 8.8) 1.1 (0.9, 1.3) 2.9 (2.8, 3.1) 17.2 (16.6, 17.8) 4.9 (4.5, 5.3)
Age groups, y
 15–16 4.1 (3.6, 4.7) 10.1 (8.9, 11.4) 1.3 (0.9, 1.8) 1.1 (0.8, 1.5) 22.1 (20.5, 23.8) 7.0 (6.0, 8.1)
 17–18 5.4 (5.2, 5.6) 7.5 (7.2, 7.8) 1.0 (0.9, 1.1) 1.9 (1.7, 2.0) 16.1 (15.6, 16.5) 4.6 (4.4, 4.9)
 19 7.3 (7.1, 7.6) 7.4 (7.2, 7.7) 1.1 (1.0, 1.2) 5.6 (5.4, 5.8) 13.5 (13.1, 13.8) 3.2 (3.0, 3.4)
Parity
 Nulliparous 5.5 (5.2, 5.7) 7.9 (7.4, 8.4) 1.1 (0.9, 1.3) 2.5 (2.3, 2.7) 16.9 (16.2, 17.6) 4.9 (4.5, 5.3)
 Primiparous or multiparous 5.2 (4.7, 5.6) 10.2 (9.1, 11.3) 1.2 (0.9, 1.6) 2.5 (2.2, 2.7) 20.3 (18.7, 21.9) 5.8 (5.0, 6.8)
Region
 North 4.2 (3.5, 5.2) 12.8 (10.4, 15.7) 2.2 (1.4, 3.5) 2.4 (1.9, 3.0) 22.4 (19.0, 26.1) 7.2 (5.2, 9.7)
 Northeast 6.7 (5.8, 7.8) 16.1 (14.5, 18.0) 3.1 (2.3, 4.2) 3.7 (2.9, 4.7) 27.6 (25.6, 29.8) 10.9 (9.4, 12.6)
 East 5.9 (5.4, 6.4) 9.0 (7.9, 10.3) 1.2 (0.9, 1.5) 2.9 (2.6, 3.1) 18.2 (16.5, 20.1) 5.3 (4.2, 6.6)
 Central 6.0 (5.6, 6.4) 9.4 (8.7, 10.1) 1.2 (1.0, 1.5) 3.1 (2.8, 3.4) 18.1 (17.2, 19.1) 5.4 (4.9, 6.0)
 South 11.6 (9.1, 14.8) 5.4 (3.5, 8.3) 0.5 (0.3, 0.8) 5.6 (4.2, 7.4) 9.8 (7.3, 13.1) 3.2 (1.5, 6.5)
 Northwest 6.7 (6.3, 7.0) 5.1 (4.7, 5.5) 0.4 (0.3, 0.6) 3.2 (3.0, 3.4) 13.0 (12.3, 13.6) 2.6 (2.3, 3.0)
 Southwest 4.7 (4.3, 5.2) 7.4 (6.4, 8.5) 0.8 (0.5, 1.2) 2.1 (1.9, 2.4) 16.3 (14.9, 17.7) 4.3 (3.5, 5.2)
Education
 Primary school or below 4.9 (4.4, 5.5) 5.7 (4.8, 6.6) 0.6 (0.4, 0.9) 1.9 (1.6, 2.1) 14.7 (13.4, 16.2) 3.1 (2.6, 3.8)
 Junior high school 5.5 (5.3, 5.8) 9.1 (8.6, 9.7) 1.3 (1.1, 1.5) 2.6 (2.4, 2.8) 18.4 (17.7, 19.0) 5.6 (5.2, 6.1)
 High school or above 5.9 (5.3, 6.7) 7.3 (5.7, 9.2) 1.1 (0.5, 2.3) 3.4 (2.9, 4.0) 16.8 (13.7, 20.4) 4.0 (2.8, 5.7)
Gross domestic product
 Tertile 1 6.0 (5.8, 6.3) 7.9 (7.4, 8.4) 1.1 (0.9, 1.3) 2.9 (2.7, 3.1) 16.5 (15.9, 17.2) 4.7 (4.3, 5.1)
 Tertile 2 6.4 (5.8, 7.1) 12.1 (10.4, 14.0) 1.7 (1.3, 2.2) 3.6 (3.3, 4.0) 21.2 (19.1, 23.5) 6.8 (5.5, 8.3)
 Tertile 3 5.6 (5.1, 6.0) 8.7 (7.8, 9.8) 1.1 (0.9, 1.3) 2.8 (2.5, 3.1) 18.2 (16.7, 19.7) 5.0 (4.2, 6.0)
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Note. CI = confidence interval. Among adolescent girls aged 15–19 years, underweight was defined according to the sex-specific body mass index for age growth charts from the US Centers for Disease Control and Prevention (CDC) and Chinese criteria; overweight and obesity were defined according to the International Obesity Task Force (IOTF) criteria and Chinese criteria. All estimates are weighted with the 2010 China Population Census.

Information on the distribution of weight status among women and adolescents in 31 provinces, municipalities, and autonomous regions is shown in Figures A and B and Tables A and B, available as supplements to the online version of this article at http://www.ajph.org. In these analyses, 4 of the 31 regions had both an underweight and overweight or obesity prevalence greater than or equal to 10% in rural areas (Shanghai, Zhejiang, Hunan, and Hainan) in women according to WHO criteria, and 10 of those had coexisting high prevalence in Shanghai, Zhejiang, Fujian, Guangdong, Hubei, Hunan, Guangxi, Jiangxi, Hainan, and Gansu according to Chinese criteria. For adolescents, the rates were more than 10% in Zhejiang for underweight and overweight or obesity based on CDC or IOTF criteria.

We further evaluated the temporal trends between 2010–2012 and 2013–2014 in the study population. As shown in Table 4, in women, there were increased trends in the prevalence of underweight in the age groups of 20 to 24, 25 to 29, and 30 to 34 years, respectively. Increases in overweight and obesity were significant among women aged 20 to 39 years. In adolescents, there was a decreasing trend in underweight whereas there was an increasing trend in overweight or obesity among adolescents aged 19 years. We observed no significant changes for those aged 15 to 16 years for either underweight or overweight or obesity, whereas there was an increasing trend in overweight or obesity for those aged 17 to 18 years. Finally, we performed multivariable logistic regression models to explore the independent risk factors for underweight and overweight or obesity in women and adolescents (Table C, available as a supplement to the online version of this article at http://www.ajph.org). The characteristics of prevalence of underweight and overweight or obesity in different subgroups mostly remained in the multivariable analyses. For example, increasing age was associated with lower odds of underweight but higher odds of overweight or obesity in women, whereas in adolescents we observed the opposite pattern.

TABLE 4—

Temporal Trends in Prevalence of Underweight, Overweight, and Obesity Among Women Aged 20–49 Years and Adolescent Girls Aged 15–19 Years: Rural China, 2010–2012 to 2013–2014

Underweight
 Overweight and Obesity
 Obesity
Variable 2010–2012, % (95% CI) 2013–2014, % (95% CI) Percentage Point Change (95% CI) 2010–2012, % (95% CI) 2013–2014, % (95% CI) Percentage Point Change (95% CI) 2010–2012, % (95% CI) 2013–2014, % (95% CI) Percentage Point Change (95% CI)
Women
WHO criteria, age group, y
 20–24 14.8 (14.7, 14.9) 15.9 (15.8, 16.0) 1.1 (1.0, 1.2) 6.9 (6.8, 7.0) 8.0 (7.9, 8.1) 1.1 (1.0, 1.2) 0.9 (0.8, 1.0) 1.2 (1.1, 1.3) 0.3 (0.2, 0.3)
 25–29 12.4 (12.3, 12.5) 13.4 (13.3, 13.5) 1.0 (0.9, 1.1) 9.3 (9.2, 9.3) 10.6 (10.5, 10.7) 1.4 (1.3, 1.5) 1.3 (1.2, 1.4) 1.6 (1.5, 1.7) 0.3 (0.2, 0.4)
 30–34 7.5 (7.4, 7.6) 7.9 (7.8, 8.0) 0.4 (0.3, 0.5) 14.0 (13.9, 14.1) 15.2 (15.1, 15.3) 1.2 (1.0, 1.3) 1.9 (1.8, 2.0) 2.2 (2.1, 2.3) 0.3 (0.2, 0.4)
 35–39 5.0 (4.9, 5.1) 5.0 (4.9, 5.1) 0.0 (−0.1, 0.2) 17.5 (17.3, 17.7) 18.6 (18.4, 18.7) 1.1 (0.8, 1.3) 2.1 (2.0, 2.2) 2.3 (2.2, 2.4) 0.2 (0.1, 0.3)
 40–44 3.8 (3.7, 4.0) 3.8 (3.7, 3.9) 0.0 (−0.1, 0.1) 21.2 (20.9, 21.5) 21.5 (21.3, 21.7) 0.3 (−0.1, 0.7) 2.4 (2.2, 2.5) 2.5 (2.4, 2.6) 0.1 (−0.0, 0.2)
 45–49 3.6 (3.3, 4.0) 3.4 (3.1, 3.6) −0.2 (−0.1, −0.2) 24.5 (23.8, 25.3) 24.2 (23.6, 24.9) −0.3 (−1.3, 0.7) 2.5 (2.2, 2.7) 2.5 (2.3, 2.8) 0.1 (−0.3, 0.4)
Chinese criteria, age group, y
 20–24 11.5 (11.4, 11.6) 12.8 (12.7, 12.9) 1.3 (1.2, 1.4) 2.0 (1.9, 2.1) 2.5 (2.4, 2.6) 0.5 (0.4, 0.6)
 25–29 14.6 (14.5, 14.7) 16.2 (16.1, 16.3) 1.6 (1.5, 1.7) 2.8 (2.7, 2.9) 3.4 (3.3, 3.5) 0.6 (0.5, 0.7)
 30–34 21.4 (21.3, 21.6) 22.7 (22.6, 22.8) 1.2 (1.1, 1.4) 4.3 (4.2, 4.4) 4.8 (4.7, 4.9) 0.5 (0.4, 0.6)
 35–39 26.6 (26.4, 26.9) 27.9 (27.7, 28.1) 1.3 (1.0, 1.6) 5.1 (4.9, 5.2) 5.4 (5.3, 5.5) 0.4 (0.2, 0.5)
 40–44 31.8 (31.4, 32.1) 32.1 (31.8, 32.4) 0.3 (−0.1, 0.8) 6.0 (5.8, 6.1) 6.1 (6.0, 6.3) 0.2 (−0.1, 0.4)
 45–49 35.7 (34.8, 36.5) 35.2 (34.5, 36.0) −0.5 (−1.6, 0.6) 6.6 (6.2, 7.1) 6.9 (6.5, 7.3) 0.3 (−0.3, 0.9)
Adolescent girls
US CDC or IOTF criteria, age group, y
 15–16 4.2 (3.1, 5.6) 4.1 (3.5, 4.8) −0.1 (−1.4, 1.3) 11.2 (8.6, 14.4) 9.7 (8.5, 10.9) −1.5 (−4.6, 1.6) 1.7 (0.9, 3.2) 1.1 (0.8, 1.6) −0.6 (−1.8, 0.6)
 17–18 5.2 (4.7, 5.7) 5.5 (5.2, 5.8) 0.3 (−0.2, 0.8) 6.8 (6.3, 7.5) 7.8 (7.4, 8.2) 0.9 (0.2, 1.7) 0.8 (0.6, 1.0) 1.1 (1.0, 1.2) 0.3 (0.0, 0.6)
 19 8.2 (7.7, 8.7) 6.8 (6.6, 7.1) −1.4 (−1.9, −0.8) 6.9 (6.4, 7.4) 7.7 (7.4, 8.0) 0.7 (0.2, 1.4) 0.8 (0.7, 1.0) 1.2 (1.1, 1.4) 0.4 (0.1, 0.6)
Chinese criteria, age group, y
 15–16 1.2 (0.6, 2.5) 1.0 (0.7, 1.4) −0.2 (−1.2, 0.8) 21.8 (18.6, 25.4) 22.2 (20.5, 24.1) 0.4 (−3.4, 4.3) 8.5 (6.2, 11.5) 6.3 (5.4, 7.4) −2.2 (−5.0, 0.6)
 17–18 2.0 (1.7, 2.3) 1.8 (1.7, 1.9) −0.2 (−0.5, 0.1) 15.5 (14.7, 16.5) 16.3 (15.8, 16.8) 0.8 (−0.3, 1.8) 4.1 (3.7, 4.6) 4.8 (4.6, 5.1) 0.7 (0.2, 1.2)
 19 6.2 (5.8, 6.6) 5.3 (5.1, 5.5) −1.0 (−1.4, −0.5) 12.7 (12.0, 13.4) 13.9 (13.5, 14.5) 1.2 (0.4, 2.0) 2.4 (2.2, 2.8) 3.6 (3.4, 3.8) 1.1 (0.8, 1.5)
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Note. CI = confidence interval. Among women aged 20–49 years, underweight, overweight, and obesity were defined according to World Health Organization (WHO) criteria and Chinese criteria. Among adolescent girls aged 15–19 years, underweight was defined according to the sex-specific body mass index for age growth charts from the US Centers for Disease Control and Prevention (CDC) and Chinese criteria; overweight and obesity were defined according to the International Obesity Task Force (IOTF) criteria and Chinese criteria. All estimates are weighted with the 2010 China Population Census.

DISCUSSION

From our representative data from a rural population, we estimated that the most recent prevalence of overweight or obesity in rural China was 16.5% among women aged 20 to 49 years according to WHO criteria and 8.3% among adolescent girls aged 15 to 19 years according to IOTF criteria. Meanwhile, 7.8% of women and 6.0% of adolescents were classified as underweight. The prevalence of overweight or obesity was much higher when the Chinese criteria were used (24.8% in women and 17.2% in adolescents). Furthermore, we observed a small increasing trend for underweight and overweight or obesity in women between 2010 and 2014, and the prevalence of overweight or obesity showed an increasing trend across years in adolescents. In addition, considerable disparities existed in the prevalence of underweight and overweight or obesity across subpopulations of demographic, geographical, and socioeconomic variables. Our estimates indicate a coexisting situation of overweight or obesity and underweight among reproductive-age women and adolescents in China.

Global survey has suggested a rise in overweight and obesity among women of reproductive age worldwide.2 In the United States, about two thirds of reproductive-age women were overweight or obese in 2011 to 2012.18 Despite a relatively lower prevalence, the increasing trend has been observed in China. Data from China Health and Nutrition Surveys have shown that the prevalence of overweight and obesity (BMI ≥ 25.0 kg/m2) among women of childbearing age increased from 10.2% to 17.3% between 1993 and 2009.19 The China National Nutrition and Health Survey (CNNHS) has reported an increase from 19.9% to 27.9% in the prevalence of overweight or obesity (BMI ≥ 24.0 kg/m2) among women aged 18 to 44 years on the basis of representative Chinese samples between 1992 and 2002.20 Meanwhile, the prevalence was much higher among women in urban compared with rural areas (e.g., 29.2% vs 21.4% in 2002).20 From a recent government report of the CNNHS, the prevalence of overweight and obesity increased to 42% in 2012 among men and women aged 18 years and older.21 However, the exact prevalence in rural women of reproductive age (18–45 years) was unknown, and would be expected to be much lower because the CNNHS 2002 data showed that the prevalence sharply increased in women after they were aged 45 years.20 In another national survey in 2010, China Chronic Disease and Risk Factor Surveillance, the rate of overweight or obesity was 33.5% among rural women (aged 18–44 years), which is also higher than the rates in our study.22

When compared with data from other developing countries, a previous study in South Asian countries has showed the rising trend of overweight and obesity among reproductive-age women between 1996 and 2006, from 2.7% to 8.9% in Bangladesh, 1.6% to 10.1% in Nepal, and 10.6% to 14.8% in India.23 The rate of overweight (BMI ≥ 25.0 kg/m2) among women aged 19 to 49 years was substantially increasing in LMICs from the 1990s to the 2000s, especially in rural areas.24 Taken together, our results (16.5% with WHO criteria of BMI ≥ 25.0 kg/m2 and 24.8% with Chinese criteria of BMI ≥ 24.0 kg/m2 for combined overweight and obesity) in women from rural areas are consistent, though slightly lower than those in previous studies.19–21 The difference is possibly because the target population was all from rural China and many of them had intended pregnancies in a short period, which is different from general women of childbearing age (i.e., those who had not intended pregnancies in a short period).

Similar to the rising trend in adults, the proportions of overweight and obesity have increased dramatically since 1980 among children and adolescents globally.1,25 Available data indicated that approximately 33.8% of adolescent girls aged 12 to 19 years were overweight or obese and 20.7% were obese during 2011 and 2012 according to the CDC criteria in the United States.18 In China, the China Health and Nutrition Survey data showed that 8.0% of adolescent girls aged 15 to 18 years were overweight or obese in 2011, compared with the prevalence of 6.0% in 2004 with IOTF references.26 Data from 6 cross-sectional studies in China showed a similar increasing trend of overweight and obesity since the early 1990s among female adolescents based on Chinese National Surveys on Students’ Constitution and Health.27 Results on overweight and obesity in older children and adolescents are difficult to compare because of the different definitions, few survey data, and small sample sizes. We reported here that 8.4% of adolescents aged 15 to 19 years were overweight or obese in China according to IOTF criteria, and 17.6% according to Chinese criteria, which is significantly lower than that in Western countries, but was consistent with previous reports in China and East Asia.26,27 In addition, the proportion showed a small increasing trend between 2010 and 2014, which deserves special attention.

The burden of overweight is exceeding that of underweight in most countries; however, the prevalence of underweight among women of reproductive age remains high in Asia.2 Epidemiological studies have confirmed the adverse effects of maternal underweight on pregnancy complications.6 Among women aged 15 to 45 years, CNNHS showed the proportion of underweight was 8.3% in 2002 in Chinese rural areas, with an decreasing trend compared with that in 2012 (6.0%).21,28 Similarly, underweight in women with a similar age range has decreased from 9.3% to 5.5% between 1991 and 2004 according to data from the China Health and Nutrition Surveys.29 Among Chinese female adolescents, the prevalence of underweight was less consistent, ranging from 6% to 25% in different studies, which was probably attributable to the differences in definitions and selected populations.26,29,30 The trends in adolescents were all similar showing that the prevalence has been decreasing during the past decades.26,29 Studies from LMICs reported that the prevalence decreased between 1990s and early 2000s, but recently increased between early 2000s and late 2000s or early 2010s among women in rural China; underweight remains more prevalent among adolescent girls than overweight (rural areas: 23% vs 8%; urban areas: 20% vs 8%) in East Asia.24,26 In our study, underweight in women attempting to conceive (7.9%) was higher than that in earlier studies in the United States (4.5%)31 and United Kingdom (5.0%),32 and in data from CNNHS 2012.25 Meanwhile, underweight in adolescents (5.4%) remained a significant problem in China. We observed a slightly increased trend in underweight prevalence in women, and a declining trend in adolescents when we used Chinese criteria.

The shift toward coexisting conditions of overweight or obesity and underweight, particularly the epidemic of excess weight, is associated with remarkable changes in living environments, nutrition transition, and sedentary lifestyles owing to rapid economic growth and urbanization.10,11 Across vast geographic areas in China, substantial variations were present in the levels of economic growth and concomitant lifestyle changes, which could result in regional differences in the degree and trends of overweight and obesity. We found a higher prevalence of overweight and obesity in the north and northeast regions in our study.

It is well known that the effect of socioeconomic status on overweight and obesity varies in differently developed regions.33,34 Our analyses showed that the prevalence of overweight and obesity was higher in groups with higher levels of GDP from a macro perspective. Data from the Demographic and Health Surveys including 538 140 women aged 15 to 49 years in LMICs showed that the BMI increased as national income increased.31 Furthermore, in developing countries, the burden of obesity tends to shift from high- to low-socioeconomic-status groups in women when the country’s economic development achieves a certain point.34 At the individual level, women and adolescents with less education had a higher prevalence of overweight and obesity in our study. It is acknowledged that women of low socioeconomic status face multiple barriers to health care resources and, thus, may be susceptible to obesity and related health risks.32

Although the prevalence of overweight and obesity in China remained relatively low in our study, it is expected to increase precipitously in parallel with rapid economic growth in less-developed areas. In addition, along with the universal 2-child policy conducted in China, more women will have their second pregnancy at higher ages. When one considers these situations, little access to preconception health care systems for these populations, especially in rural areas, becomes an even greater challenge for China.

Childbearing years are an important stage of a woman’s life, and the weight status of a woman before pregnancy results in substantial influence on maternal and offspring health.4,6 Because China has the largest population in the world, a coexisting situation of overweight or obesity and underweight has an impact on the largest number of women and their offspring. These risks could be minimized by effective nutritional and lifestyle interventions toward weight loss and maintenance, as well as prevention of excess weight gain during women’s preconception period and during pregnancy. To date, limited evidence-based recommendations have been proposed for women of reproductive age regarding underweight and overweight or obesity in the world, particularly in China. Given the focus of the health of 2 generations, trends in weight status of reproductive-age women should be closely monitored. In addition, there is a need for more well-designed, comprehensive, population-based randomized controlled trials to evaluate the effects of weight management interventions for pregnancy outcomes.

Limitations

There are several limitations to this analysis. First, our findings were based on a nonrandom sampling method of rural areas of 31 provinces, municipalities, and autonomous regions; therefore, the results should be cautiously interpreted when one is generalizing to all reproductive-age women and adolescents in China. Previous studies have suggested that the prevalence of overweight and obesity was higher in urban than rural areas20,27; thus, we expect a higher prevalence across China when urban areas are included in the future.

Second, measurement errors in body weight and height were possible. However, all research personnel were well trained with standard protocol provided by the National Health and Family Planning Commission. The between-investigator measurement error was more likely to be random and less likely to materially change the results. Finally, we defined rural population in our study as people with rural household registration. However, if one considers the large proportion of such population who are working and living in urban areas, and the constant population mobility between rural and urban areas, this definition may have its own limitations.

Conclusions

There is an increasing trend of overweight and obesity among women and adolescents of reproductive age in rural China. Despite a declining trend, underweight remains prevalent in this population. These results bridge a crucial gap to understand the weight status and related health risk in women in the preconception period, which offered many opportunities to improve the health of 2 generations. Thus, interventions of weight management need to be longitudinally and contextually integrated into the preconception care system in China, and should include multiple strategies simultaneously to tackle the issue of coexisting overweight or obesity and underweight.

ACKNOWLEDGMENTS

This study was funded by “Five-Twelfth” National Science and Technology Support Program (grant 2013BAI12B01), Operating Funds for Basic Scientific Research of the Central Authorities (2015GJM09), and National Natural Science Foundation of China (81602854).

Note. The funding agencies had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the article; or the decision to submit the article for publication.

HUMAN PARTICIPANT PROTECTION

The study was approved by the institutional research review board at the National Health and Family Planning Commission and National Research Institute for Family Planning. Informed consents in Chinese were obtained from all participants or their legal representatives.

Footnotes

See also Yu, p. 2086.

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