Abstract
Background: Little information is available on the trends in severe pediatric obesity in China. Therefore, we aimed to examine the trends in overweight, obesity, and severe obesity in Chinese children from 1991 to 2015.
Methods: Overall, 17,004 children aged 6–17 years were included in this study, which was based on the China Health and Nutrition Survey 1991–2015. We defined overweight [BMI ≥85th percentile], obesity (BMI ≥95th percentile), and severe obesity (BMI ≥120% of the 95th percentile, or 35 kg/m2) according to the U.S. Centers for Disease Control and Prevention Growth Charts. Controlling for age, sex, and region, we performed multivariate analyses to assess secular trends in the prevalence of overweight, obesity, and severe obesity in the pediatric population.
Results: During 1991–2015, the prevalence of overweight increased from 4.6% to 21.1%, of obesity from 1.4% to 10.1%, and of severe obesity from 0.2% to 4.0% (relative increases of 358.7%, 621.4% and 1900.0% in overweight, obesity, and severe obesity, respectively). We observed a significant positive trend in the prevalence of overweight, obesity, and severe obesity in the pediatric population [odds ratios (95% confidence intervals): 1.23 (1.21, 1.26), 1.30 (1.26, 1.34), and 1.52 (1.41, 1.63), respectively; all ps < 0.001]. These results did not differ significantly between subgroups of sex, age, and region, or when Chinese national reference standards were used.
Conclusion: The prevalence of childhood overweight, obesity, and particularly severe obesity in China increased significantly from 1991 to 2015.
Keywords: children, China, obesity, severe obesity, trend
Introduction
Excess body weight in children is a major public health concern worldwide,1 and this condition is becoming more prevalent.2 Excess body weight in childhood is associated with serious immediate and long-term poor cardiovascular and metabolic effects and other health consequences. The effects of excess body weight on cardiometabolic risk factors, including elevated blood pressure, adverse lipid profiles, and increased glycated hemoglobin levels, have been well documented.3 Longitudinal cohort studies have reported that the persistence of excess body weight from childhood to adulthood increased the consequent risks of adult cardiovascular, metabolic, hepatic, and renal diseases, as well as chronic disability due to cardiovascular diseases.4–8
Excess body weight can be classified as overweight, obesity, or severe obesity based on the degree of adiposity. Evidence suggests that the prevalence of pediatric severe obesity is increasing.9–11 Notably, the number and severity of cardiometabolic risk factors also increase with the degree of adiposity in childhood.12 Children with severe obesity are at an increased risk of premature death.13,14 These children may require more intensive treatment approaches, comprising lifestyle modification, pharmacotherapy, and weight-loss surgery, as current treatments have shown limited efficacy.13,15,16
The prevalence of excess body weight in children is also increasing in China, where large absolute numbers of children are reported to have this condition.17 However, little is known about the trend of pediatric severe obesity in China. More information is needed to understand the effects of pediatric obesity on health and encourage decision makers to prioritize actions to address it. Therefore, the objective of this study was to investigate trends in severe obesity over time in Chinese children, using data from the China Health and Nutrition Surveys (CHNS) 1991–2015.
Methods
Study Population
Chinese citizens have experienced significant lifestyle changes during the last two decades as a consequence of China's rapid economic development. The CHNS encompasses 10 waves of longitudinal data collected at 2- to 4-year intervals.18,19 Thus, CHNS data provide a promising opportunity to assess secular trends in severe pediatric obesity across China.
The CHNS is an ongoing nationwide longitudinal survey that began in 1989, and its details have been presented elsewhere.18,19 The CHNS was implemented to identify variations in the health status and nutritional status of the Chinese population during China's social and economic transformation since 1989. The CHNS was administered in 1989, 1991, 1993, 1997, 2000, 2004, 2006, 2009, 2011, and 2015. The study population was drawn from 15 provinces and municipal cities according to a multistage random-clustering process. The protocols for the CHNS were approved by the Institutional Review Board of the University of North Carolina at Chapel Hill and the National Institute for Nutrition and Food Safety, China Center for Disease Control and Prevention. Signed informed consent was obtained from all the participants or their guardians. As the CHNS 1989 included only 196 participants aged 6–17 years, the current study was restricted to the CHNS 1991–2015, which included 17,004 participants aged 6–17 years with complete and available data on sex, age, region, height, and weight.
General Examinations
Well-trained staff used standardized procedures to measure the height of each subject to the nearest 0.2 cm in the absence of shoes, along with the weight of each subject to the nearest 0.1 kg, while wearing lightweight clothing. Each subject's BMI was calculated as the weight in kilograms divided by the square of the height in meters. A questionnaire survey was performed to collect demographic data.
Definitions
BMI can be used as an index of adiposity in children.20 We used the U.S. Center for Disease Control and Prevention criteria and American Heart Association recommendations to define overweight (BMI ≥85th percentile), obesity (BMI ≥95th percentile), and severe obesity (BMI ≥120% of the 95th percentile or 35 kg/m2).13,21
Statistical Analysis
The data are expressed as means (standard deviation) and numbers (percentages), as appropriate. Relative changes in the prevalence of overweight, obesity, and severe obesity during 1991–2015 were calculated. In addition, differences in the prevalence of overweight, obesity, and severe obesity between the 1991 and 2015 cycles were compared using the χ2 test. To evaluate the trends across the 25-year period, the CHNS survey waves were regressed to an ordinal variable. Furthermore, a multiple linear regression analysis was used to examine the trends in BMI over time, and a logistical regression analysis was performed to evaluate the trends in the prevalence of overweight, obesity, and severe obesity after adjustment for sex, age, and region.
Sensitivity analysis was performed to examine the robustness of the results. First, linear trend analyses were repeated in subgroup analyses by age (6–11 vs. 12–17 years), sex, and region (urban vs. rural). Second, overweight and obesity were defined using the sex- and age-specific cutoffs recommended by the National Health Commission of the People's Republic of China.22 As the Chinese national reference standards do not include a definition of severe obesity,22 a similar method (BMI ≥120% of the obesity-specific cutoffs recommended by Chinese national reference standards, or 35 kg/m2) was used to define severe obesity.13,22 We then repeated the linear trend analyses using these definitions.
All data analyses were performed using SAS version 9.4 (SAS Ins, Cary, NC) and SPSS version 19.0 (SPSS, Inc., Chicago, IL). Statistical significance was set at a two-tailed p value of <0.05.
Results
Table 1 summarizes the demographic characteristics of the participants. A total of 17,004 Chinese children aged 6–17 years who had participated in the CHNS 1991–2015 were included in the study (52.7% male; mean age, 11.3 years; mean BMI, 17.5 kg/m2). When all years were pooled, the prevalence of overweight, obesity, and severe obesity was 9.2%, 3.5%, and 0.9%, respectively.
Table 1.
Characteristics of the Participants Aged 6 to 17 Years, 1991 to 2015
| All participants | Excess body weight |
|||
|---|---|---|---|---|
| Overweight | Obesity | Severe obesity | ||
| No. | 17,004 | 1560 | 591 | 156 |
| Survey year, n (%) | ||||
| 1991 | 2705 (15.9) | 124 (7.9) | 37 (6.3) | 6 (3.8) |
| 1993 | 2583 (15.2) | 136 (8.7) | 37 (6.3) | 2 (1.3) |
| 1997 | 2501 (14.7) | 157 (10.1) | 55 (9.3) | 10 (6.4) |
| 2000 | 2361 (13.9) | 161 (10.3) | 54 (9.1) | 7 (4.5) |
| 2004 | 1546 (9.1) | 147 (9.4) | 44 (7.4) | 8 (5.1) |
| 2006 | 1222 (7.2) | 121 (7.8) | 46 (7.8) | 13 (8.3) |
| 2009 | 1114 (6.6) | 143 (9.2) | 54 (9.1) | 15 (9.6) |
| 2011 | 1572 (9.2) | 275 (17.6) | 122 (20.6) | 39 (25.0) |
| 2015 | 1400 (8.2) | 296 (19.0) | 142 (24.0) | 56 (35.9) |
| Male, n (%) | 8956 (52.7) | 959 (61.5) | 396 (67.0) | 100 (64.1) |
| Age, y | 11.3 (3.3) | 10.0 (3.0) | 9.2 (2.9) | 8.9 (3.1) |
| Urban, n (%) | 4867 (28.6) | 571 (36.6) | 204 (34.5) | 48 (30.8) |
| BMI, kg/m2 | 17.5 (3.4) | 23.3 (5.4) | 25.8 (7.4) | 31.2 (11.7) |
| WHtR | 0.43 (0.05) | 0.49 (0.08) | 0.51 (0.10) | 0.51 (0.14) |
Data are presented as n (%) or means (standard deviations) as appropriate.
WHtR, waist circumference-to-height ratio.
Table 2 presents the unstandardized and standardized regression coefficients (β and β', respectively) of survey year for BMI after adjusting for sex, age, and region. The regression analyses were conducted in four separate models. Varying trends over time were noted in different populations (β' for all participants vs. participants with overweight, obesity, and severe obesity: 0.147 vs. 0.165, 0.181, and 0.191, respectively).
Table 2.
Linear Regression Coefficients of Survey Year for BMI
| β (95% CI)a | β'a | pb | R2, % | |
|---|---|---|---|---|
| Model 1 | 0.195 (0.177, 0.213) | 0.147 | <0.001 | 22.6 |
| Model 2 | 0.330 (0.241, 0.420) | 0.165 | <0.001 | 19.7 |
| Model 3 | 0.506 (0.301, 0.711) | 0.181 | <0.001 | 19.7 |
| Model 4 | 0.988 (0.202, 1.774) | 0.191 | 0.014 | 16.1 |
β (95% CI), unstandardized regression coefficients (95% CI); β', standardized regression coefficients; R2, variance of BMI explained by the independent variable.
Model 1 included all participants; Model 2 included participants with overweight; Model 3 included participants with obesity; Model 4 included participants with severe obesity.
Adjusted for sex, age, and region.
p value for β.
CI, confidence interval.
Figure 1 displays the trends in the prevalence of overweight, obesity, and severe obesity. During 1991–2015, the prevalence of overweight increased from 4.6% to 21.1%, of obesity from 1.4% to 10.1%, and of severe obesity from 0.2% to 4.0% (relative increases of 358.7%, 621.4%, and 1900.0% in overweight, obesity, and severe obesity, respectively). Significant differences were observed in the prevalence of overweight, obesity, and severe obesity between 1991 and 2015 (all ps < 0.001).
Figure 1.
Trends in prevalence of overweight, obesity, and severe obesity in Chinese children from 1991 to 2015.
Table 3 shows the results of prevalence trends from 1991 to 2015 after controlling for sex, age, and region. The linear trend analysis across the CHNS survey waves demonstrated the significant positive trend in the prevalence of overweight, obesity, and severe obesity [odds ratios (95% confidence intervals [CIs]): 1.23 (1.21, 1.26), 1.30 (1.26, 1.34), and 1.52 (1.41, 1.63), respectively; all ps < 0.001]. Notably, the nonoverlapping 95% CIs of the odds ratios indicated a more rapid increase over time in the prevalence of severe obesity compared with the prevalence of overweight or obesity. In addition, the prevalence of overweight, obesity, and severe obesity in the most recent survey year (2015) was significantly greater than that in both the first survey year (1991; all ps < 0.001) and the previous survey year (2011; all ps < 0.05) after adjustment for sex, age, and region.
Table 3.
Multivariate Analysis of Overweight, Obesity, and Severe Obesity Trends
| Survey year | Overweight |
Obesity |
Severe obesity |
|||
|---|---|---|---|---|---|---|
| OR (95% CI)a | p | OR (95% CI)a | p | OR (95% CI)a | p | |
| 1991 | 1 [reference] | 1 [reference] | 1 [reference] | |||
| 1993 | 1.09 (0.85, 1.40) | 0.497 | 0.95 (0.60, 1.51) | 0.826 | 0.31 (0.06, 1.56) | 0.157 |
| 1997 | 1.34 (1.05, 1.71) | 0.018 | 1.57 (1.03, 2.39) | 0.037 | 1.76 (0.64, 4.86) | 0.275 |
| 2000 | 1.60 (1.26, 2.05) | <0.001 | 1.87 (1.23, 2.87) | 0.004 | 1.50 (0.50, 4.47) | 0.468 |
| 2004 | 2.31 (1.80, 2.97) | <0.001 | 2.31 (1.48, 3.60) | <0.001 | 2.55 (0.88, 7.38) | 0.084 |
| 2006 | 2.26 (1.74, 2.94) | <0.001 | 2.78 (1.79, 4.33) | <0.001 | 4.75 (1.80, 12.54) | 0.002 |
| 2009 | 2.93 (2.28, 3.78) | <0.001 | 3.44 (2.24, 5.27) | <0.001 | 5.70 (2.20, 14.75) | <0.001 |
| 2011 | 4.04 (3.22, 5.05) | <0.001 | 5.43 (3.73, 7.92) | <0.001 | 10.12 (4.27, 24.01) | <0.001 |
| 2015 | 5.09 (4.07, 6.37) | <0.001 | 7.13 (4.92, 10.34) | <0.001 | 15.96 (6.85, 37.19) | <0.001 |
| Continuous (trend)b | 1.23 (1.21, 1.26) | <0.001 | 1.30 (1.26, 1.34) | <0.001 | 1.52 (1.41, 1.63) | <0.001 |
Controlling for sex, age, and region.
Survey waves of CHNS were regressed to an ordinal variable.
OR, odds ratio; CHNS, China Health and Nutrition Survey.
We repeated the linear trend analyses in subgroups of sex, age, and region, and obtained similar results (Supplementary Table S1). The subgroup analysis results confirmed the markedly upward trends in the prevalence of and current relatively high prevalence of severe obesity among older, male, and rural children. Of note, the number of children with severe obesity in very specific subgroups was small (e.g., 33 children with severe obesity in the age subgroup of 12–17 years). In addition, we obtained similar results when using the Chinese national reference standards to define overweight, obesity, and severe obesity (Supplementary Fig. S1, Supplementary Tables S2 and S3).22
Discussion
This study demonstrated that the prevalence of pediatric overweight, obesity, and (particularly) severe obesity in China increased significantly from 1991 to 2015. Moreover, our findings did not differ significantly between the demographic subgroups of sex, age, and region, or when Chinese national reference standards were used.
Our findings are consistent with accumulating evidence suggesting that the prevalence of pediatric overweight and obesity in China has increased dramatically over time. For instance, a recent study revealed that the prevalence of overweight, defined as per the International Obesity Task Force definition, increased from 4.3% in 1995 to 18.4% in 2014.23 Our present and previous results confirm an increasing epidemic of pediatric overweight and obesity in both sexes and across all age groups and geographic areas in China.17 This increasing trend is largely attributable to preferences for high-fat and high-energy diets, a decrease in physical activity, an increase in sedentary activity, lack of knowledge about health, and the adoption of unhealthy attitudes and false health beliefs.24
Given the recent increase in the epidemic of pediatric overweight and obesity, interest in the trends in severe obesity has also increased. Our data clearly indicate that the prevalence of severe obesity has increased more rapidly than that of overweight and obesity. In recent years, a similar upward trend in severe obesity and a plateauing trend in the prevalence of pediatric overweight and obesity have been reported in U.S. children.9–11 In contrast, the prevalence of all forms of excess body weight increased in Chinese children at an alarming rate during 1991–2015. Given the current lifestyle and eating habits of the Chinese population,24 the upward trends in pediatric overweight, obesity, and severe obesity are likely to continue in the future.
The results of the recent U.S. National Health and Nutrition Examination Survey suggest that the prevalence of severe obesity among U.S. children was ∼6% during 2011–2014.10,11 In our study, we observed a corresponding prevalence of ∼4% among Chinese children in 2015. Another recent study reported a prevalence of severe obesity of 1.4% in Shandong, China in 2014.25 Although these prevalence rates are relatively low, China's large population suggests that a high absolute number of Chinese children are affected by severe obesity.
Our subgroup analysis results suggest that older, male, and rural children are more likely to have severe obesity. First, the marked upward trends in the prevalence of severe obesity and the current high prevalence of this condition among Chinese children aged 12–17 years were particularly notable. However, the reasons for these results remain unclear and need to be clarified in future studies. Second, the prevalence of severe obesity among boys, compared with girls, increased more rapidly over time, and boys showed a higher current prevalence of this condition. This finding is partly attributable to the traditional societal preference for sons, who are then privileged to enjoy more of a family's resources.17,25 Finally, our study confirms the urban–rural difference in the current prevalence of severe obesity and indicates that the rural prevalence of severe obesity has increased markedly. This observation can be attributed to the lack of food variety, public health services, and health education in rural areas and is consistent with the findings of two recent studies that observed a strong trend of increasing BMI in rural children and adults.26,27
Our results underscore the importance of the early identification of children with severe obesity in China. Unfortunately, the Chinese national reference standards do not include a definition of severe obesity.22 Further studies are needed to fill this gap. Notably, children with overweight/obesity are predisposed to develop severe obesity.13 Therefore, these at-risk children should be targeted as the recipients of severe obesity prevention strategies. Physical activity is critical to prevent further weight gain in individuals with overweight/obesity.28 However, it is difficult for adults to change their habits. Therefore, childhood is a crucial time for the establishment and maintenance of a healthy lifestyle. The development of healthy habits in childhood should be considered a top priority in the prevention of overweight, obesity, severe obesity, and associated diseases across the life span.
Our results are convincing due to the large nationwide sample size and rigorous quality control (well-trained examiners, calibrated instruments, and standardized procedures).29 However, our study had several limitations. First, we did not consider covariates that might have affected the trend in severe obesity because of a lack of relevant data. Second, we did not have the adequate sample size to examine trends in severe obesity among very specific subgroups. Those results should be interpreted with caution. Third, because the Chinese national reference standards do not include a definition of severe obesity,22 we used the U.S. Center for Disease Control and Prevention criteria and American Heart Association recommendations to define severe obesity.13 This might have introduced bias to our results. However, we used a similar method (BMI ≥120% of the obesity-specific cutoffs from Chinese national reference standards, or 35 kg/m2) to define severe obesity and obtained similar results in the sensitivity analysis (Supplementary Tables S2 and S3).13,22 Fourth, the sample size varied between survey years (Table 1), which may have affected our results.
In summary, our results indicate that the prevalence of severe obesity in children increased significantly during 1991–2015 in China. Given this upward trend, pediatric severe obesity warrants further attention and intensive interventions.
Supplementary Material
Acknowledgments
We thank the National Institute for Nutrition and Health, China Center for Disease Control and Prevention, Carolina Population Center (P2C HD050924, T32 HD007168), the University of North Carolina at Chapel Hill, the NIH (R01-HD30880, DK056350, R24 HD050924, and R01-HD38700) and the NIH Fogarty International Center (D43 TW009077, D43 TW007709) for financial support for the CHNS data collection and analysis files from 1989 to 2015.
Authors' Contributions
Drs. H.F. and X.Z. conceptualized and designed the study; Dr. H.F. carried out the initial analyses, drafted the initial article and reviewed and revised the article; Dr. X.Z. critically reviewed and revised the article; and all authors approved the final article as submitted.
Funding Information
This study was supported by the PhD Funding Program of North Sichuan Medical College (CBY18-QD02) and the Key Subject Development Program of North Sichuan Medical College (NSMC-M-18-19).
Author Disclosure Statement
No competing financial interests exist.
Supplementary Material
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