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1.  Dynamics of the Chinese Diet and the Role of Urbanicity, 1991–2011 
China’s food consumption patterns and eating and cooking behaviors changed dramatically between 1991 and 2011. Macronutrient composition has shifted toward fats, and protein and sodium intakes remain high and potassium intake low. The rapid decline in intake of coarse grains and, later, of refined grains and increases in intake of edible oils and animal-source foods accompanied by major eating and cooking behavior shifts are leading to what might be characterized as an unhealthy Western type of diet, often based on traditional recipes with major additions and changes. The most popular animal-source food is pork, and consumption of poultry and eggs is increasing. The changes in cooking and eating styles include a decrease in the proportion of food steamed, baked, or boiled and an increase in snacking and eating away from home. Prior to the last decade there was essentially no snacking in China except for hot water or green tea. Most recently the intake of foods high in added sugar has increased. The dietary shifts are affected great by the country’s urbanization. The future, as exemplified by the diet of the 3 mega cities, promises major growth in consumption of processed foods and beverages.
PMCID: PMC3868998  PMID: 24341755
China; diet; away-from-home eating; consumer packaged food; Urbanicity
2.  China in the period of transition from scarcity and extensive undernutrition to emerging nutrition-related noncommunicable diseases, 1949–1992 
This study uses unique official data to document nutritional changes in the 1949–1992 period. In 1949 widespread famine, high mortality, and low life expectancy dominated. Economic progress was uneven, however, the longer-term food supply changed greatly, and hunger was conquered. Diet composition shifted greatly over this period. Cereal consumption, already high, increased from 541.2 grams per day (70.0% coarse grains) in 1952 to 645.9 grams per day (15.9% coarse grains) in 1992. Consumption of animal-source foods, half of which were pork and pork products, tripled from 30.0 grams per day to 103.0 grams per day. The proportion of energy intake from fat tripled from 7.6% to 22.5%, and that from carbohydrates decreased from 83.0% to 65.8% over the same period. Physical activity was high in all domains, but shifts were beginning to occur (e.g., the initial mechanization of work and the expansion of biking). Nutritional improvement was uneven, including increased undernutrition in the 1959–1962 period and a remarkable rebound and continued improvement thereafter. Overweight emerged only after 1982. Shifts in diet, activity, and body composition in 1949–1992 set the stage for major shifts in nutrition in the subsequent decades.
PMCID: PMC3869002  PMID: 24341754
malnutrition; food insecurity; overweight; poverty; physical activity
3.  The China Health and Nutrition Survey, 1989–2011 
The China Health and Nutrition Survey (CHNS) began in 1989 with the goal of creating a multilevel method of data collection from individuals and households and their communities to understand how the wide-ranging social and economic changes in China affect a wide array of nutrition and health-related outcomes. Initiated with a partial sample in 1989, the full survey runs from 1991 to 2011, and this issue documents the CHNS history. The CHNS cohort includes new household formation and replacement communities and households; all household members are studied. Furthermore in-depth community data are collected. The sample began with eight provinces and added a ninth, Heilongjiang, in 1997 and three autonomous cities, Beijing, Shanghai, and Chongqing, in 2011. The in-depth community contextual measures have allowed us to create a unique measure of urbanicity that captures major dimensions of modernization across all 288 communities currently in the CHNS sample. The standardized, validated urbanicity measure captures the changes in 12 dimensions: population density; economic activity; traditional markets; modern markets; transportation infrastructure; sanitation; communications; housing; education; diversity; health infrastructure; and social services. Each is based on numerous measures applicable to each dimension. They are used jointly and separately in hundreds of studies.
PMCID: PMC3869031  PMID: 24341753
Longitudinal Survey; Urbanicity; China; Nutrition
4.  Joint Association of Dietary Pattern and Physical Activity Level with Cardiovascular Disease Risk Factors among Chinese Men: A Cross-Sectional Study 
PLoS ONE  2013;8(6):e66210.
The purpose of this cross-sectional study was to investigate the joint associations of physical activity level (PAL) and dietary patterns in relation to cardiovascular disease (CVD) risk factors among Chinese men. The study population consisted of 13 511 Chinese males aged 18–59 years from the 2002 China National Nutrition and Health Survey. Based on dietary data collected by a food frequency questionnaire, four dietary patterns were identified and labeled as “Green Water” (high consumption of rice, vegetables, seafood, pork, and poultry), “Yellow Earth” (high consumption of wheat flour products and starchy tubers), “New Affluent” (high consumption of animal sourced foods and soybean products), and “Western Adopter” (high consumption of animal sourced foods, cakes, and soft drinks). From the information collected by a 1-year physical activity questionnaire, PAL was calculated and classified into 4 categories: sedentary, low active, active, and very active. As compared with their counterparts from the New Affluent pattern, participants who followed the Green Water pattern had a lower likelihood of abdominal obesity (AO; 50.2%), hypertension (HT; 37.9%), hyperglycemia (HG; 41.5%), elevated triglyceride (ETG; 14.5%), low HDL (LHDL; 39.8%), and metabolic syndrome (MS; 51.9%). When compared to sedentary participants, the odds ratio of participants with very active PAL was 0.62 for AO, 0.85 for HT, 0.71 for HG, 0.76 for ETG, 0.74 for LHDL, and 0.58 for MS. Individuals who followed both very active PAL and the Green Water pattern had a lower likelihood of CVD risk factors (AO: 65.8%, HT: 39.1%, HG: 57.4%, ETG: 35.4%, LHDL: 56.1%, and MS: 75.0%), compared to their counterparts who followed both sedentary PAL and the New Affluent pattern. In addition, adherence to both healthy dietary pattern and very active PAL presented a remarkable potential for CVD risk factor prevention.
PMCID: PMC3686814  PMID: 23840426
5.  Trends in Chinese Snacking Behaviors and Patterns and the Social-Demographic Role between 1991 and 2009 
This study investigates the dynamic shifts in snacking behaviors and patterns in China. Using four waves (1991, 2004, 2006, and 2009) from the China Health and Nutrition Survey (CHNS) with full socioeconomic and demographic data and 3-day, 24-hour dietary recall data, 45,402 individuals age two and older were studied. Multiple logistic regressions were performed to examine the association of social-demographic factors on snacking behaviors. Results show that snacking prevalence, frequency of daily snacking occasions, and percentage of total daily energy intake (EI) from snacks increased significantly across all ages between 1991 and 2009, with a dramatic increase after 2004. Snacking was much more prevalent among children and higher-income, urban, and educated populations over time. Evening was the preferred snacking occasion, and the proportion of total daily EI from snacks varied between 4.1% and 12.3% for all snackers by age. Fruits, grains, and beverages were the most popular snacks and the highest contributors to snacking EI over all age groups. A marked transition from a tradition of two or three meals per day toward meals combined with snacks is underway. Further research is needed to develop a better understanding of the nutritional implications of Chinese snacking behaviors.
PMCID: PMC3335772  PMID: 22507613
Snacking behaviors; snacking patterns; Chinese; social-demographic factors; trend
6.  Dietary patterns and hypertension among Chinese adults: a nationally representative cross-sectional study 
BMC Public Health  2011;11:925.
Several healthful dietary patterns appear to be effective at lowering blood pressure and preventing hypertension. However, the relationship between dietary patterns and hypertension among a representative Chinese population sample is unclear.
A nationally representative sample of 23 671 participants aged 18-59 years were recruited by the 2002 China National Nutrition and Health Survey. All participants had their blood pressure measured with standardized mercury sphygmomanometers. Hypertension was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg. We conducted factor analysis using dietary information from a validated food frequency questionnaire to derive dietary patterns. Information of participants on physical activities, education level, annual household income, smoking status and family history of hypertension was collected by interviewer-administrated questionnaires.
Three major dietary patterns, defined as 'Western', 'traditional northern', and 'traditional southern', were identified. Participants with the highest quartile for the score of the Western pattern had significantly higher blood pressure comparing with counterparts in the lowest quartile. In contrast, participants in the top quartile for the score of the traditional southern pattern presented significantly lower blood pressure comparing with counterparts in the lowest quartile. In multivariate analyses the traditional northern pattern score was associated with an odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.11-1.53, P for trend = 0.0001) comparing with the lowest quartile. The OR for the top quartile of score for the traditional southern pattern was 0.73 (95% CI, 0.59-0.89, P for trend = 0.0040) compared with the lowest quartile of traditional southern pattern score. However, the significant association between the traditional northern pattern and prevalence of hypertension disappeared after further adjusting for body mass index (BMI) (P for trend = 0.3), whereas the association between the traditional southern pattern and prevalence of hypertension persisted after further adjusting for BMI (P for trend = 0.01).
We observed a positive relationship between the traditional northern pattern and hypertension that was mediated through differences in BMI. In addition, the traditional southern pattern was significantly associated with lower odds of presenting with hypertension.
PMCID: PMC3299712  PMID: 22168909
8.  TV Use and Snacking Behaviors Among Children and Adolescents in China 
Television (TV) use has been linked with poor eating behaviors and obesity in young people. This study examines the association between TV watching and paying attention to TV commercials with buying and requesting snacks seen on commercials, and eating snacks while watching TV among youth in China.
Data from 1,552 participants (ages 6–17.99) in the 2004 China Health and Nutrition Survey (CHNS) were analyzed cross-sectionally. The CHNS is conducted in nine Chinese provinces.
Most respondents (92.2%) reported watching TV; on average children (6–11.99 years old) and adolescents (12–17.99 years old) watched 9–10 hours per week. Nearly half (49.7%) of all the respondents said they “sometimes” or “often” paid attention to TV commercials. Respondents who reported paying attention to commercials had higher odds of requesting snacks (OR = 3.42; 95% CI = 2.55–4.60) and buying snacks (OR = 2.73; 95% CI = 2.17–3.43) seen on TV, and eating snacks while watching TV (OR = 1.60; 95% CI = 1.23–2.07) than those who did not pay attention. Frequency of watching TV was not significantly related to snacking, however.
Attention to TV commercials for snack foods may be one of the factors affecting the increase in obesity among children and adolescents in China.
PMCID: PMC2845301  PMID: 20307822
China; children; adolescents; television; TV; snacking; nutrition; commercials
9.  Dietary Patterns and Glucose Tolerance Abnormalities in Chinese Adults 
Diabetes Care  2009;32(11):1972-1976.
To investigate the association of the dietary pattern with the presence of newly diagnosed glucose tolerance abnormalities among Chinese adults.
A total of 20,210 adults aged 45–69 years from the 2002 China National Nutrition and Health Survey were included. Information on dietary intake was collected using a validated food frequency questionnaire. Factor analysis and cluster analysis were used to identify the food factors and dietary pattern clusters.
Four dietary pattern clusters were identified (“Green Water,” “Yellow Earth,” “Western Adopter,” and “New Affluence”). The prevalence of glucose tolerance abnormalities ranged from 3.9% in the Green Water to 8.0% in the New Affluence. After adjustment for area, age, sex, current smoking, and physical activity, subjects in the Yellow Earth cluster (prevalence ratio 1.22 [95% CI 1.04–1.43]) and New Affluence cluster (2.05 [1.76–2.37]) had significantly higher prevalence rates compared with those for the Green Water cluster. After further adjustment for BMI and waist-to-height ratio, the elevated risk in the New Affluence remained statistically significant.
Dietary patterns and food factors are associated with the presence of glucose tolerance abnormalities in China, even independent of obesity. A New Affluence diet is an important modifiable risk factor, which needs attention from the prevention point of view.
PMCID: PMC2768212  PMID: 19675202

Results 1-9 (9)