CHP Obesity 2005

8/2/2019 CHP Obesity 2005

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Tackling Obesity:

Its Causes, the Plight and Preven

Central Health Education Unit


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Obesity is a major public health problem worldwide.

Its rising trend is evident in both developed and

developing countries. There is also a significant

increasing trend among the younger age groups to

become obese.

Hong Kong is also affected by the global epidemic

of obesity. Local data suggest that 20.1% of men

and 15.9% of women are overweight, and 22.3% of

men and 20.0% of women are obese.i

Obesity threatens our health and creates an

enormous burden to our society. It results in ill

health, reduced quality of life, premature deaths,

increased health care costs and reduced productivity.

Urgent actions are required to address the obesity

epidemic.

The Department of Health of the HKSAR

Government is committed to reducing theprevalence of obesity in Hong Kong. However, to

effectively manage the obesity epidemic, everyone

in the community must take responsibility and

action. The synergy generated from our

2. encourage health pr

based initiatives in t

overweight in the p

3. facilitate planning an

for managing ob

population.

The contents of this do

1. an overview of th

overweight, and thei

and globally;

2. a brief introduction

conducted locally a

3. a summary of the e

obesity initiatives.

There are a number of w

range from preventive m

weight and prevent weig

such as dietary modifibehavioural therapy,

therapy and surger y.

document, however, is

prevent obesity/overwe


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Tackling Obesity: Its Causes, the Plight and Preventive Actions


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Foreword

List of Tables

List of Charts

List of Diagrams

Abbreviations

CHAPTER 1 HOW DO WE MEASURE OBESITY?

Adulthood Obesity

Childhood Obesity

CHAPTER 2 WHY SHOULD WE BE CONCERNED ABOUT O

Physical Problems

Psychosocial Problems

Deaths

Childhood and Adolescence Obesity

Economic Costs

CHAPTER 3 HOW COMMON IS OBESITY?Global Situation

Obesity in Hong Kong

Obesity Related Diseases in Hong Kong

Dietary Habits and Physical Activity of Hong Kong Peo

CHAPTER 4 WHO ARE AT RISK?

Biological Factors

NutritionPhysical Activity

Environmental Factors

Micro-environments

Macro-environments


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List of TablesList of Charts

List of Tables

1.1 Classification of BMI and risk of co-morbidities

1.2 Co-morbidities risk associated with different levels of BMI and ranges of wais

in adult Asians in 2000

1.3 Recommended sex-specific cut-off points of waist circumference by WHO an

2.1 Relative risk of health problems associated with obesity

3.1 Prevalence of obesity by gender in Hong Kong, 1995-1996

3.2 Prevalence of obesity by gender in Hong Kong, 2003 (self-reported data)

3.3 Prevalence of obesity by gender in Hong Kong, 2003/2004 (provisional data)

5.1 Ten steps to successful breastfeeding

5.2 Summary of the International Code of Marketing of Breastmilk Substitutes

5.3 Definition of one serving size of fruit and vegetable

5.4 Items for sale at tuckshops (extract of guidelines on meal arrangements in scho

5.5 Lunch box ingredients (extract of guidelines on meal arrangements in schools)

List of Charts1.1 Median BMI by age and gender in six nationally representative datasets

2.1 Relationship between BMI and relative risk of mortality

3.1 Prevalence of overweight and obesity (BMI 23) by age group and sex in Hong K


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List oAb

List of Diagrams

1.1 Measuring tape position for waist circumference in adults

5.1 An advertisement of promoting breastfeeding in MTR station in 2003

5.2 Promoting breastfeeding - Baby Expo 2003

5.3 Healthy Eating Movement for kindergartens and nurseries in 1999

5.4 An example of exercise prescription prescribed by doctors

5.5 Posters and stickers of point-of-decision prompts in public housing estate

5.6 Consultation paper on labelling scheme on nutrition information, issued

Welfare and Food Bureau in November 2003

Abbreviations

The following abbreviations are used in this report:

AIDS Acquired Immune Deficiency Syndrome

BFHI Baby-friendly Hospital Initiative

BMI Body Mass Index

DH Department of Health

EMB Education and Manpower Bureau

IASO International Association for the Study of Obesity

IOTF International Obesity Task Force


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1.1 Overweight refers to an abnormally high body

weight which may come from bone, lean

muscle, fat tissue and water. Obesity is a

condition in which the body stores an excessive

amount of fat to such an extent that health may

be adversely affected.1-3

1.2 A certain amount of fat is necessary for normal

body functions such as energy storage, heat

insulation, protection of vital organs and carrier

for fat-soluble vitamins, etc.

1.3 Our body can normally regulate overall energy

intake with overall energy expenditure without

a persistent change in body weight. It is only

when energy intake exceeds energy used for a

considerable period of time that obesity is likely

to develop.

1.4 Overweight and obesity can be measured byassessing weight and height as well as the

amount and distribution of body fat .

Computerised tomography (CT), dual-energy

X-ray absorptiometry (DEXA) and magnetic

simple and inexp

assessment. Refere

up for the purpose

identifying associat

however, be noted t

and should not b

determine whether

or obese.

Adulthood Obesit

Body mass index

1.6Body mass index (

recognised measure

based on weight an

dividing a persons

square of his/her

weight in kg/ (heig

1.7BMI is the most co

obesity classi f icresearchers and he

countries. It is econ

because height an

obtained without de

How do we measu


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How do we measure obesity?

1.8 As the risk of co-morbidities in relation to

BMI differs among different ethnic groups,

different cut-off values have been proposed to

classify overweight and obesity for different

populations. In 2000, a joint expert panel of

the Regional Office for the Western Pacific

(WPRO) of the WHO, the International

Obesi ty Task Force ( IOTF) and the

International Association for the Study ofObesity (IASO) recommended a lower BMI

Table 1.2 Co-morbidities risk associated with different levels of BMI and ranges of w

adult Asians in 20004

Table 1.1 Classification of BMI and risk of co-morbidities2

Classification BMI (kg/m2) Risk of co-morbidities

Underweight < 18.50 Low (with increased risk of clin

related to underweight)

Normal range 18.50-24.99 Average

Overweight 25.00

Pre-obese 25.00-29.99 IncreasedObese class I 30.00-34.99 Moderate

Obese class II 35.00-39.99 Severe

Obese class III 40.00 Very severe

cut-off point for the Asian

recommendations were

suggesting that obesity-

occurred at lower BM

populations (including H

which were prone to g

obesity.4 Table 1.2 sh

reference ranges for

circumferences and tmorbidities r isk in adult A


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How

the elderly) may b

when they are ov

Waist circumference and wa

1.11 The health risk

determined not

excessive fat being

where it is stored

(central obesity)

developing disease

can be identifi

circumference or c

1.12 Waist circumfere

BMI6 and is a roug

of abdominal fat7

body holds. It is

between the lowe

the iliac crest (Di

1.9 Although the WHO experts did not

recommend re-defining BMI cut-off points for

different populations after reviewing the

proposal, they suggested Asian countries define

obesity-related health risks for their populations

based on national data and considerations. A

few Asian countries such as mainland China

and Japan have developed their own BMI cut-

off points for obesity classifications.

1.10 Despite its wide acceptance, BMI has its

limitations. BMI is neither age-nor sex-

specifi c. It does not provide a direct

estimation of body fat accumulation. Thus it

may not be suitable for certain population

groups. For example, athletes and individuals

with large body frame and muscle bulk may

wrongly fall into the obese group, while those

who have reduced lean muscle mass (such as

Diagram 1.1 Measuring tape position for waist circumference in adults


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How do we measure obesity?

1.13 People of different sexes and ethnic origins

differ in the level of risk associated with a

part icular waist circumference. Table 1.3

shows the international recommendations

made by WHO and the recommendations for

adult Asians by WHO WPRO.

1.14 The waist-hip ratio (WHR) is another

measure of abdominal obesity. It correlates

closely with waist circumference.9 WHR is

calculated by dividing the waist measurement

(taken at its narrowest point) by the hip

measurement (taken at its widest point). For

example, a woman with a 76 cm waist and

94 cm hip would have a WHR of 0.81 (76

divided by 94 = 0.81). A WHR value greater

h 1 0 i 0 85 i i di

Table 1.3 Recommended sex-specific cut-off points of waist circumference by WHO and

Gender WHO recommendations WHO Western Pacific R

(1998) recommendations for adu

Men < 94 cm < 90 cm

Women < 80 cm < 80 cm

Growth charts

1.16 Reference charts for grow

for-age and height-f

produced in different c

the charts only compar

with that of other child

They do not take into a

in growth among these

an index of weight adju

id b


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How

Chart 1.1 Median BMI by age and gender in six nationally representative datase

Netherlands, Singapore, the UK and the US) from an international gro

> median weight for height x 120%. For

example, if the height of a child is 140 cm,

the corresponding median weight-for-height

is 35kg. If his/her weight is greater than 42kg

(35kg x 120%), then he/she is defined as

obese.

BMI-for-age reference curves

1.18 As for adults, BMI provides a useful measure

of fatness in children. However, BMI in

children varies substantially with age. It rises

steeply in infancy, falls during the pre-

school years and r i ses again during

adolescence. Therefore, BMI in childrenneeds to be assessed using age-related

reference curves.2

1.19 An international B

for defining ov

children 2 to 1

developed jointly

for Health Stati

Control and Pre

2000 (see Appe

population was

nationally repre

growth surveys

Netherlands, B

Singapore. Thes

subjects each and

males and 94,851years of age (Ch

provide internatio

rates of overweigh

Males Females

Brazil Great Britain Hong Kong Netherlands Singpore

22

23

22

23

dex(kg/m2)


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2.1 Obesity poses a growing threat to public health

all over the world. It is prevalent in both

developed and developing countries, and

affects men as well as women, children as well

as adults. Gradually replacing the more

traditional public health concerns such as

under-nutrition and infectious diseases, obesity

has become one of the most significant

contributors to ill health.

Obesity brings about health consequences that

range from physical to psychosocial problems

and results in conditions that vary from non-

fatal conditions affecting the quality of life to

premature death.

Physical Problems

2.2 Health problems associated with obesity have

been studied in various industrialised countries.

There is strong and consistent evidence on the

relationship between obesity and risk of ill

health. Alarmingly, the association begins at a

not very high level of BMI.2

2.5 Obesity is associate

musculoskeletal pro

major weight-bearin

lower back may be c

is also more common

2.6 In women, obes

reproductive disorgeneral menstrual di

outcome.

2.7Sleep apnoea is a sl

many obese people

the throat collapses during his/her sle

sleepiness, pulmo

failure and even sud

Why should we be

abo


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Why should we be concerned about obesity?

2.8 Table 2.1 summarises the increase in risk of

health problems associated with obesity.

2.9 The WHO estimates that globally approximately

58% of diabetes mellitus, 21% of ischaemic heart

disease and 8 to 42% of certain cancers are

attributable to BMI greater than 21 kg/m2.1

Psychosocial Problems

2.10 Obesity is associated with a number ofpsychosocial problems including body shape

dissatisfaction and eating disorders. People

with obesity are often confronted with social

bias prejudice and discrimination 14

Table 2.1 Relative risk of health problems associated with obesity2

Greatly increased by Moderately increased by Slightly increas

more than three-fold two- to three-fold one- to two-fol

Diabetes mellitus Coronary heart diseases Certain forms o

Gall bladder diseases Hypertension cancer in postm

Abnormal lipid or Osteoarthritis women and col

cholesterol levels Gout Reproductive h

Sleep apnoea abnormalities

Low back pain

Impaired fertilit

p sychosoc ia l funct

consistently showed an

between body weight a

esteem and body image

Overweight in adoles

associated with soci

problems in adulthood.

Deaths

2.13 The death rate increaseof overweight, as meas

increase in death rate

steeper for both men an

age of 50 Moreover th


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Why should we be

diseases such as raised blood pressure,

dyslipidaemia, insulin resistance and elevated

fasting glucose; all these factors can continue

into adulthood.21-22 In particular, childhood

obesity is associated with early development

of type II diabetes mellitus.

2.15 Childhood obesity can lead to orthopaedic

complications due to excessive weight bearing

upon joints.2 The most serious conditions

include slipped capital femoral epiphyses in

Economic Costs2.17 Overweight and

associated health

economic impact

bringing about bo

Direct costs refe

preventive, diagnrelated to overweig

doctor consultation

home care). Indir

wages for people

Chart 2.1 Relationship between BMI and relative risk of mortality 20

Relativerisk

BMI

Average risk Moderate risk High risk

0.5

1.0

1.5

2.0

2.5

20 25 30 35


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Global Situation

3.1 The WHO estimated that more than one billion

adults are overweight and at least 300 million

of them are clinically obese which is defined

by BMI greater than or equal to 30. Moreover,

childhood obesity is already epidemic in some

areas and on the rise in others. Around 22

million children under five are estimated to be

overweight worldwide.23

3.2 The prevalence of obesity is rising rapidly in

developed countries. In the US, the UK and

Japan, the prevalence of adult obesity has nearly

doubled or even more since the 1980s.2;24-26

Asimilar trend is also seen in adolescents.27-28

3.3 In general, obesity is more prevalent in urban

than in rural areas. In developing countries,

obesity is more common in people of higher

socioeconomic status and in those living inurban areas. In developed countries, it is

common in people, especially in women, of

lower socioeconomic status, and among people

living in rural areas.2

How common

Obesity in Hong K

3.4 The severity of the p

Kong has not yet r

countries such as th

percentage of overw

Kong from a local s

1996.29 The preva

obesity was also fou

women. Nearly 50%

were overweight an

obese. For men, h

overweight and o

different age group

3.5 A telephone surv

Department of Hea

early 2003 to assess t

and obesity, as well a

Among 1,700 subje

men and 13.8% of while 23.4% of men

obese (Table 3.2).3

overweight and obe

the study described


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How common is obesity?

be noted that the study conducted in 1995-

1996 was based on actual measurements. The

survey conducted in 2003 collected self-

reported values for height and weight. The cut-

off points for defining weight status differed

between the two studies as well.

3.6The Population Health Survey 2003/2004

commissioned by the Department of Health

(DH) estimated that 17.8% of the population

aged 15 and above were overweight and 21.1%

were obese (Table 3.3). Overall, overweight

was more common among males than females

(20.1% vs.15.9%). Similar trend was found for

Table 3.2 Prevalence of obesity by sex in Hong Kong, 2003 (self-reported data)30

Classification BMI (kg/m2) Male Female

Underweight < 18.5 8.2% 15.8%

Normal 18.5 - 22.9 48.7% 57.7%

Overweight 23.0 - 24.9 19.7% 13.8%

Obese Above 25.0 23.4% 12.7%

the obesity prevalence (B

sexes (males 22.3%, femal

3.7The same study showed th

overweight and obesity gener

(Chart 3.1). In males, the prob

among those aged 55-64 (55.

aged 45-54 (52.7%) and 35-4

the prevalence was highest am

(53.9%). The prevalence de

and females who are aged 75 a

mentioned in section 1.10, th

mass in elderly may lead to u

degree of overweight.31


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Chart 3.2 Prevalence of childhood obesity in primary schools by gender and school year

0%

5%

10%

15%

20%

25%

97/98 98/99 99/00 00/01

Year

Prevalenceofchildhoodobesity

Male

Female

Total

Chart 3.1 Prevalence of overweight and obesity (BMI23) by age group and sex i

0%

10%

20%

30%

40%

50%

60%

15-24 25-34 35-44 45-54 55-64

Age (Years)

Prevalenceofobesity(%)

Female

Male

Total


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How common is obesity?

3.8 The Student Health Service of the DH found

that the prevalence of obesity among local

primary and secondary school students

increased gradually from 12.1% in 1997/1998

to 14.1% in 2000/2001, and dropped slightly

afterwards using the definition of obesity as

having a weight > median weight for height x

120%. The problem was more serious in

primary school students than in secondary

school students. The prevalence remained

higher among boys with the difference

between boys and girls widening slightly over

the years (Charts 3.2 and 3.3).32-33

Obesity Related Diseases in Hong Kong

3.9 The majority of obesity-related diseases are

multi-factorial. Given the strong association

between increasing BMI and type II diabetes

mellitus, cardiovascular and cerebrovascular

diseases, it is reasonable to attribute a significantproportion of these diseases to obesity.

3.10 Heart diseases (coronary heart disease being the

major component) and cerebrovasular diseases

of males and 9.8% of f

mellitus (either already

treat diabetes or ha

11.1mmol/L after a

tolerance test); another

17.1% of females had

tolerance which was

diabetes mellitus (plasmhours after the 75g g

range 7.8-11.0mmol/L

Dietary Habits and Ph

of Hong Kong People

Dietary habits3.12 Healthy Living Survey 2

21% of adult respondents

at least twice a day and

vegetables at least twic

quantity of daily fru

consumption for thosvegetable at least once a

1.2 bowls. Only 3% of re

high-fat food at least onc

all visible fat in their foo


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increased with age, from 15.2% for those aged

18-24 to 38.2% for those aged 55-64. In males,

the proportions were the lowest in the 35-44

age group and the highest for those aged 55-64

(11.2% and 17.3% respectively).36

Low intake of fruits and vegetables is estimated

to cause about 19% of gastrointestinal cancers,

31% of ischaemic heart disease and 11% of stroke

worldwide. The WHO recommends 400 g daily

intake of fruits and vegetables for adults per day

for the prevention of chronic diseases such as heart

diseases, cancer, diabetes and obesity.37

Physical activity

3.14 In Hong Kong, sedentary lifestyle is prevalent

among the local population and television

viewing is a very popular pastime. A survey

found that more than 80% of children

watched TV at leisure time, while only 33%chose to exercise.38 Moreover, nearly half of

the children (45%) watched TV for over 3

hours per day. In 2001, Hong Kong people

on average spent 2 4 hours daily on watching

3.16 The Population H

commissioned b

33.3% of the Ho

15-64 (33.0% f

female s ) were

Comparatively, th

mostly sedentary a

by the 35-44 a

occupation, the m

was clerks (42.8%

The recommendation fo

at least 30 minutes of m

activity on most days iscardiovascular diseases a

amount needed to preve

is uncertain. Recommen

during two internation

about 45 to 60 minut

physical activity is needay to prevent unhealth


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4.1 Obesity results from an imbalance between

energy intake and energy expenditure. Energy

derived from food is used to sustain body mass,

to fuel metabolic functions and to perform

physical activity. When we take in more dietary

energy than we can consume, the excess is

stored in the body as fat.

Biological Factors

Age

4.2 In general, obesity in both sexes becomes more

prevalent as age increases up to at least 50 to 60

years old.41 The older population has a higher

tendency of being overweight or obese becauseof the decreased lean muscle mass, metabolic

rate and physical activity that occur along with

the ageing process.

Sex

4.3 Women generally have higher rates of obesity

while men have higher rates of overweight.2 It

is widely recognised that women usually have a

higher percentage of body fat and a lower resting

metabolic rate than men, which may predispose

Who

members of the sam

diet and similar life

obesity.

Ethnic origin

4.5 Certain ethnic gro

to the developm

complications, aapparent when th

to a more affluent

thi s problem se

combination of

change from a trad

and sedentary lifestdietary pattern.2

Biological factors may h

occurs in certain indiv

These irreversible fa

important than the nutrition and physical

promotion point of vie


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Who are at risk?

replaced by high-fat, energy-dense fast foods

and soft drinks.

4.8People choose energy-dense, nutrient-

poor fast foods because they are cheap,

t a s ty , wide ly promoted and read i ly

available. Energy-dense foods tend to be

high in fat (such as butter, oil and fried

natura

syrupincrea

of die

much

result

of tot

the ecomm

WHO

Agric

(FAO

guidel

populgoals f

diet-re

such as cardiovascular disea

and obesity. One recom

consumption of free sugar

10% of total energy intake

4.10 Eating habit has a bearing

of obesity. Skipping br

over-consumption later i


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Tackling Obesity: Its Causes, the Pli

devices both at home and at work, and more

sedentary leisure pursuits such as TV viewing.50 The global estimate for the prevalence of

physical inactivity among adults is 17%.

Estimates for prevalence of some, but

insufficient physical activity (


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Who are at risk?

School environment

4.16 Schools are the key setting for influencingchildrens behaviour. Hence, tackling obesity-

promoting elements in schools is important to

prevent childhood obesity. For example, soft

drink vending machines are increasingly

available in schools. A study has shown that

excessive consumption of high-sugar softdrinks is associated with obesity in children.58

Fast food restaurants

4.17 Fast food outlets which provide high-fat,

energy-dense foods and soft drinks are

increasingly popular throughout the world.

An average fast food restaurant meal provides

1,000-2,000 kilocalories, i.e., up to 100% of

the recommended daily intake for adults, and

the portion size is also increasing.59 Their

popularity is further enhanced by mass

advertising and low price.

TV advertisement

4.18 Fast food restaurants and en

drinks are among the mo

on television. Thes

commercials are often

targeted at children.

Moreover , the

amount of TVv i e w i n g w a s

associated with

childrens demand for

the highly advertised

foods.60

Macro-environments

Socio-economic environment

4.19 Obesity is more prevalen

high socio-economi

developing countries th

low SES in develop

developed countries,

people from becomi

individuals are better e

less obesity-promoting


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Tackling Obesity: Its Causes, the Pli

is allocated to cooking. All these have

profound effects on the dietary habit and

physical activity level of the population.

Cultural environment

4.21 Throughout most of human history,

increased weight has been viewed as a sign

of health and wealth. This is still the case inmany cultures, especially where conditions

make it hard to gain weight or where

thinness in babies is associated with increased

risk of infectious diseases.2

4.22On the other hand, in many industrialisedcountries, there has been a marked change

in the expectation of body shape and weight

in the last three

women has come

success, control

while obesity r

indulgence and a

values are reinforc

magazines62-63 th

unhealthy weighinappropriate d

results in weight c

failure to achieve

not generally reco

obese as a problem

concern becauseabdominal fat acc

ignore it.2


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5.1 This section will discuss the initiatives which

aim at preventing overweight and obesity mainlythrough l i festyle measures, changing

environment and sett ing policy. Literature

review was conducted by means of EBSCO

research database. Initiatives quoted in several

obesity prevention review papers are also

included in this section. Both initiatives eitherwith or without BMI/body weight change as

the outcome measurements are covered. For

example, studies aiming at increasing intake of

fruits and vegetables and decreasing sedentary

activities are also included. However, specific

treatments for obesity (e.g., drug treatment,surgical treatment) are excluded. A life-course

approach is adopted to summarise the initiatives

to prevent overweight and obesity.

Infancy

5.2 Infancy is an important stage of growth and

development. During infancy, nutrition is the

most important factor that affects growth of

infants. Therefore, this stage plays a key role

in controlling obesity. The level of physical

Initiatives

overweight a

growth and develo

recommended texclusively breastfe

life to achieve opti

and health.68

5.5 There is growing

breastfeeding can proverweight and that

gives greater protect

mechanism of this

Besides, breastfeedin

to mothers and c

protection, prombreastfeeding remain

5.6The US Governmen

as a key objective

agenda - Healthy

aims to attain a br

75% during early po

months and 25% at

5.7Three types of initi


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Initiatives to prevent overweight and obesity

5.8 The WHO and the United Nations Childrens

Fund (UNICEF) launched the Baby-FriendlyHospital Initiative (BFHI) in 1991 as a key

strategy for promoting breastfeeding.75 Under

the BFHI, hospitals and maternity facilities can

be designatedbaby-friendlywhen they do not

accept free or low-cost breastmilk substitutes,

feeding bottles or teats, and have implementedthe Ten Steps to Successful Breastfeeding

(Table 5.1).76 Moreover, the WHO and the

UNICEF have jointly developed the

International Code of Marketing of Breastmilk

Substitutes to guide appropriate marketing

practices and to protect breastfeeding

(Table 5.2).77

5.9 Breastfeeding rate in Hong

low but a rising trend h1991.78 A local study foun

1997, the breastfeeding ini

by 6.7% (from 26.8% to 3

the rate of breastfeeding for

increased from 3.9% in 198

Annual breastfeeding surveDH reveal that both the

duration of breastfeeding

increased since 1997. The

ever breastfed increased fr

62% in 2000.78

Table 5.1 Ten steps to successful breastfeeding76

Every facility providing maternity services and care for newborn infants

1. Have a written breastfeeding policy that is routinely communicated to all hea

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeed

4. Help mothers initiate breastfeeding within half an hour of birth.

5. Show mothers how to breastfeed, and how to maintain lactation even if they s

from their infants


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Initiatives to preve

5.10 Various efforts have been made to promote

breastfeeding in Hong Kong. Since the early

1980s, a designated team has been set up by

the former Medical and Health Department

to promote breastfeeding. Promoting work

includes running antenatal classes at Maternal

7th of August), th

campaign to ra

breastfeeding in 2

and 5.2).

Diagram 5.1 An a

Table 5.2 Summary of the International Code of Marketing of Breastmilk Substi

The Code includes these 10 important provisions:

1. No advertising of all breastmilk substitutes* to the public.

2. No free samples to mothers.

3. No promotion of products in health care facilities, including no free or

4. No company representatives to contact mothers.

5. No gifts or personal samples to health workers. Health workers should

mothers.

6. No words or pictures idealizing artificial feeding, including pictures of

7. Information to health workers must be scientific and factual.

8. All information on artificial infant feeding must explain the benefits and su

and the costs and hazards associated with artificial feeding.

9. Unsuitable products, such as sweetened condensed milk should not be

10. Manufacturers and distributors should comply with the Codes provisionot acted to implement the Code.

* Breastmilk substitutes include: infant formula, follow-up formula, feeding bottles, teats, baby food and beverages et


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Diagram 5.2 Promoting breastfeeding - Baby Expo 2003

Childhood and Adolescence5.11 Childhood and adolescence are the stages of

maximal physical development. Both

nutrition and physical activity are crucial for

normal development, as well as the prevention

of overweight and obesity in children and

adolescents. Unlike infants, the nutritional

intake of children and adolescents is only

partially controlled by their parents. Many

of them purchase snacks and lunch

themselves. Thus, health education is

during childhood an

associated with obesit

A study reported that

have a r isk as high as

adult obesity (BMI > 2

years old. 84

5.13 School-based prograprevention are attractiv

including the large amo

with school children; t

ex i s t ing organ i sa t i

communication structu

to reach a large percenthe population at a low

been controversies abo

of unhealthy food and

However, increasing the

healthy food and d

especially at lower p

alternative.86

5.14 Many school-based o

programmes do not


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5.15 Although obesity is common among school

children, it is not considered to be a topprior ity in the school agenda. The issue of

obesity has to compete with many other

health issues, such as anti-smoking,

sexuality and other non-health topics

including environmental protection, fire

safety, etc.101

5.16 The concept of health-promoting school is

an extension of the Ottawa Charter for Health

Promotion initiated by the WHO in 1986.

In a health-promoting school, students are

encouraged to enjoy healthy school life,

promote healthy living in their families and

communities, and protect their own health.102

Different health education and promotional

activities on various health topics, including

healthy lifestyles, are organised by the school

to create a healthy school environment that

facilitates the healthy development of students.

For example, a large-scale health promotion

campaign called The Biggest Healthy

Breakfast Day was organised in 2002 to

three mechanis

expenditure duephysical activi

increased energy

viewing or cons

after watching fo

decreased restin

viewing.105

5.18 Two school-bas

reducing the am

sedentary behavio

sizable decrease

children. One of

a significant dec

BMI, skinfold thi

and waist-to-hip

showed a 24% re

of obesity among

boys. 10 7 These

instructions in b

techniques or

monitoring of vi

access to TV and


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School-based programmes on physical education (PE)

5.19 School-based PE programmes promote physicalactivity by modifying curricula or policies in

schools. These programmes increase the amount

of time students spent on moderate and/or

vigorous activities. This can be done in a variety

of ways, including having more PE classes,

lengthening existing PE classes, or increasingthe intensity level of physical activity of students

during PE classes without necessarily

lengthening class time.108 Some schools

encourage extracurricular activities such as sports

days and outings to increase physical activity time

and levels among students.

5.20 There is strong evidence that school-based

PE is effective in increasing levels of physical

activity and improving physical fitness among

students. However, BMI measurements

most ly show smal l decreases or no

change.109-115 The varied results may be due

to limited efforts being put on dietary

education.115 However, increasing physical

activity levels can bring about many benefits,

project, rope skipping, et

promoted physical activthrough the use of kid son

showed that over 60% of

exercise 20 minutes each

after the programme.116

School-based programmes on dieta5.22 Many school-based pro

healthy eating as a m

obesity. Increasing the

vegetables, and decreasin

intake have been the m

programmes. The WHO

the consumption of fru

increased for both adults

and children should co

servings of fruits and veg

the definition of one serv

vegetable, see Table 5.

adoption of the recomm

the American children

been unsuccessful. A

among American childre


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5.23 Educational programmes on nutrition have

been implemented worldwide and aresuccessful in increasing the knowledge of

healthy eating among students. Changes in

attitude and behaviour are noted.120-122

5.24 School-based programmes aimed at educating

students to reduce intake of carbonated drinkswere shown to be effective. A cluster

randomised controlled trial conducted in the

UK found that consumption of soft drinks

was reduced among the students by an

educational programme to discourage them

from consuming carbonated drinks.

Moreover, the percentage of overweight and

obese children decreased in the intervention

group, compared with an increase in control

group.123

5.25 Similar programmes have been tried out in

Hong Kong. Three movements, namely,

Hea l t hy E a t i n g Movemen t f o r

kindergartens/nurseries (Diagram 5.3),

Healthy Tuckshop Movement in primary

schools and

Competition inconducted by the

eating among stu

aimed at increasin

eating among teac

tuckshop operat

availability of healtof the three mov

with non-governm

and academic insti

promoted throug

pamphlets, poster

etc. Parents, teac

were involved. A

for each healthy ea

sustainability of the

Similar programm

kindergartens and n

birthday parties.

programmes had f

in improving the

they did not show

the eating habits o


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5.26 The EMB has incorporated teaching of

healthy eating into the school curriculum.In primary schools, knowledge and correct

attitudes towards healthy eating are taught in

the General Studies curriculum. The teaching

becomes more advanced in secondary schools.

In addition to learning the importance of a

balanced diet in the classes of biology, socialeducation and home economics, students also

explore the issue of obesity in their science

and technology subjects.

Adulthood

5.27 Adulthood is a stage in which growth has been

stabilised and degeneration gradually sets in,

especially in late adulthood. Caloric intake

needs to be reduced as metabolic rate

decreases. In Hong Kong, adults are often

occupied with work and lack time for regular

exercise. According to the 2001 Healthy

Living Survey, around 45% of the respondents

had not exercised for at least 30 minutes in

the month before the study took place.35 This

lifestyle predisposed them to obesity.

verbal advice, written m

etc.) concluded that the It was suggested in the

facet initiatives targeted t

care to address physical

not achieve signific

programmes had to be

multi-faceted, communibecome effective. How

elaborate on details of

not included.

Exercise prescription (Diagra

advice on physical activity prto patients, like medication

clearly indicates the type, freq

of exercises that the patient n

Diagram 5.4 An example of

prescribed by do


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5.29 A randomised controlled trial on exercise

prescription was conducted in 2003 by theDH. General practitioners were recruited

from government and private clinics to

participate in the study. The results showed

that exercise prescription brought about

significant changes in stage progression in

Prochaska s Stages of Change Model.However, concomitant changes in physical

activity levels were not noted. This

indicates that the intervention could have

an impact to motivate sedentary patients

to exercise but the intensity is not strong

enough to bring about a change in physical

activity level. Developing methods to

reinforce the programme used in this study

is a future challenge. Reinforcement can

be provided by a conducive environment

for the patients to exercise or following up

the exercise prescription recommendations

by doctor s in subsequent medica l

consultations.

Tailor-made physical activity programmes

Workplace initiatives o

dietary modification5.31 Workplaces are id

implement heal

They offer not o

large proportion o

spend over half of

use of existing ordelivering these i

5.32 Workplaces init i

activity are gene

access to facilitie

people can do e

provide training

participants.136-14

effective in gettin

Other worksi

comprehensive h

to target behaviou

level of physical a

The programm

workshops, edu

groups, exhib


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support include making a contract with

other participants to achieve specified levelsof physical activity or setting up walking

groups to provide companionship and

suppor t. Project staff will also phone

participants to monitor progress and

encourage continuation of activities.108

5.34 Most social support initiatives are effective in

getting people to become more physically

active.141-145 The programmes enhance

participants fitness levels, knowledge about

exercise and confidence in exercising. These

initiatives are effective in various settings and

among adults of different sexes, ages and

interests to exercise.108

Commercial services or products for weight control

5.35 There are many commercial companies in

Hong Kong providing a range of services and

products for slimming and maintaining

fitness. Slimming has become a popular

trend in recent years . Many slimming or

beauty centres have been established in Hong

adults. Despite this, man

active and enjoy a good

5.37 The 2001 Healthy Livin

compared to younger

people had exercised in

the study.35 Older peopl

rate of 63.5%, which wapeople aged 40 to 49 at

5.38 Older people usually

vigorous exercise. M

stretching exercise or m

such as morning walks

exercises provide an op

gatherings as well as ben

To prevent obesity in eld

plays an equally importa

Nutritional education classes

5.39 Group nutritional ed

commonly held in diffe

elderly centres, clinics, etc.

nutritional knowledge th


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5.40 The Elderly Health Services of the DH often

organise health talks and support groups forthe elderly. Some of these activities are

organised in collaboration with other

community service units. The objectives of

the health talks are to motivate elderly to

adopt healthy lifestyles and to increase their

health knowledge on common health

problems such as weight control. Support

groups for weight reduction and healthy

eating are also organised.

Physical activity groups (m

5.41Morning walkEvery morning, th

large groups of

gathering to do

organised by gov

NGOs, or initiat

themselves. The t

mostly stretching e

intensity (e.g., Tai

overseas example

physical activity le

among the elderly

as walking train

reinforcement by

h d b


44/78


Diagram 5.5 Posters and stickers of point-of-decision prompts in public housing estates

General (all age)

Point-of-decision prompts to promote physical activity5.42 Point-of-decision prompts are signs placed

near escalators and elevators to encourage

people to use stairs for health benefits or

weight loss. This programme is shown to be

effective in various settings including subways,

train and bus stations, shopping malls,

university libraries, and among various

population subgroups including men and

women, both obese and not obese.150-154

Studies showed that point-of-decision

prompts were effective in increasing the level

of physical activity, as measured by an increase

in the percentage of people choosing to use

the stairs. More people would use the stairs

when these signs were posted. Tailor-made

prompts to describe specific benefits or to

appeal to population subgroups may increase

the initiatives effectiveness. For example, one

study found that obese people used the stairs

more if the signs linked stair use to weight

loss rather than to health

the effects were mainlpercentage of people u

when the prompts were

5.43 In 2003, the DH lau

decision prompts pil

promote stair use in sele

estates (Diagram 5.5). T

selected for the study

assigned as the interven

remaining 3 as the contr

showed that the sta

intervention group incr

the baseline level to 3.5

implementation of th

increment was significa

to that of the control g

survey found that both

personal factors were

enabling and disablin

respondents to use the

I i i i


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Community-wide campaigns to reduce risk factors of non-

communicable diseases (NCD)

5.44 Over the last 20 years, several large-scale,

community-wide and multi-component

programmes aiming at reducing the risk

factors for NCD like cardiovascular diseases

were conducted in many developed countries

including the US, Denmark, Finland, and so

on.156-162 The initiatives used in these

programmes adopted a multidisciplinary

approach and required multisectoral

collaboration. Campaign messages were

disseminated through mass media including

TV, radio, newspaper, mails , billboards and

advertisement to reach the target population.

Results showed that these campaigns were

successful in increasing the level of physical

activity of participants and changing their diet

towards healthy eating.

5.45 Community-wide educational campaigns

may produce additional benefits of increasing

social networking in the community. These

campaigns, however, require careful planning

Campaign in 2

exercise to the

comprised both h

media publicity p

5.47 In 2001, 55% o

Healthy Living

exercised in the

This figure is sign

found in 1999 (4

the increase is rela

be ascertained.

5.48 The DH has also

activity campaign

special commun

Exercise with Y

The short-term r

the proportion o

found in the cam

Environment and

5.49 Environmental an

years have impro



46/78


Reducing prices or increasing availability of healthy food

choices in vending machines or cafeterias

5.50 In todays schools, students can purchase

food from the tuckshops, vending machines

and canteens. Several studies were

obesity. These drinks

large amounts of calori

schools in the US have t

students access to unhe

in San Francisco has b

soft drinks and gradually

with healthy food cho

cafe.169 Preliminary dat

actions did not bring f

school or complaints to

the School Board of

conducted to see whether changes in the

cafeterias and vending machines at schools

and workplaces, including reducing the

price or increasing the availability of healthy

food, would increase healthy eating.86;165-168

It was found that increasing availability of



47/78


(Table 5.4).171 The guidelines recommended

school tuckshops to reduce the sale ofunhealthy foods such as potato chips, candies

and soft drinks. Instead, mineral water, low-

fat milk and healthy snacks such as fresh or

dried fruit and breakfast cereal are encouraged

to be sold to students.

Regulation on food advertisement for children

5.53 It has been estimated that an average American

child sees 10,000 food advertisements on TV

each year, and more than 90% of these

advertisements are about sugared cereals, fast

food, soft drinks and candies.172 There is

evidence that their content aimed at

promoting unhe

exposure affecteregulation on foo

to tackle the pr

alternative is allo

to promoting nu

Tax on unhealthy food

5.54 A study in the US

unhealthy snacks

of the taxes whi

acceptable to con

general revenue.

collected are earm

although not for n

Table 5.4 Items for sale at tuckshops (extract of guidelines on meal arrangements i

Items for Sale at Tuckshops

Schools should be careful in the choice of food items available for sale at the

influence pupils eating habits. Schools should therefore consider the nutrit

sold and advise staff and tuckshop operators to:

i reduce selling junk food such as potato chips and candies which are



48/78


example, one US state uses its soft dr ink tax

revenue to support its medical, dental andnursing schools.173

5.55 It is still unclear whether sales taxes have a

significant effect on the sale and consumption of

unhealthy food. The soft drink and snack

industries oppose this suggestion and have

organised campaigns against special taxes on their

products. As a result, some states, cities or

counties, have reduced or repealed their snack

taxes in recent years. One problem with taxing

unhealthy food is how to define unhealthy

food.173 Moreover, it is still not known how

high the taxes must be to affect consumption.101

Nutrition labelling

5.56 Nutrition labelling on pre-packaged food

provides information about the nutrition

composition, such as energy, protein,

carbohydrate, fat, and so on.174 Nowadays,

consumers are more concerned about

nutritional content of the food they purchased.

A local survey found that 65% of the

items on pre-packaged foo

the UK manufacturers aronly 4 to 5 items on the

5.58 In Hong Kong, the Foo

Hygiene Department ex

of nutrition labelling in

recommended that Ho

labelling scheme on nut

The labelling system

implemented in two stage

of voluntary complia

compulsory adoption will

was carried out in Decem

comments and views fro

and the trade on the prop

Diagram 5.6 Consultation pa

on nutrition in

Health, Welfare

November 2003



49/78


Working with the food industry

5.59The co-operation of the food industry isessential in modifying eating behaviours in the

society. However, choices of healthy food

available in restaurants and markets are limited.

There is an increasing interest to involve food

companies in promoting healthy products.

5.60 Many half-day primary schools in Hong

Kong have changed to whole-day schools.

Table 5.5 Lunch box ingredients (extract of guidelines on meal arrangements in sch

Lunch Box Ingredients

The quality of lunch boxes depends very much on the choice of ingredients a

used. The following are some simple rules for choosing lunch boxes:

(1) The lunch boxes should be able to meet pupils nutritional and energy

(2) Lean meat and poultry without skin should be used. Leafy vegetables a

included.

(3) Grilled, steamed, boiled or baked food or stir-fried with less oil can low

(4) Fatty or highly processed food (e.g. deep fried food, sausages, canned lu

avoided.

Students have to

lunch and many through their s

choosing health

developed and dis

the EMB (Table

5.61 A summary of

initiatives to prev

can be found in A


50/78


51/78

6.1 It is beyond doubt that obesity and overweight

are associated with ill health. Many places areworking hard to address this issue. As

highlighted in previous chapters, obesity and

overweight are the result of energy imbalance

with energy intake exceeding energy output.

On the individual level, the logical and healthy

approach to prevent and control the obesity

problem is to attain nutritional balance, that is,

to limit energy intake from food consumption

and increase energy expenditure through

physical activity promotion or sedentary lifestyle

reduction. At the societal level, however,

obesity is no longer an issue requiring medical

solutions per se. It is a public health problem

requiring solutions beyond the health sector.

It is an issue best addressed through formulation

of healthy public policies, creation of supportive

environments, enhancement of community

support, reorientation of health services, and

not least, development of personal skills.

Furthermore, as risk factors for overweight

prevail, anti-obesity action must start early,

starting from infancy, through children and

Recomm

Infancy

6.2Breastfeeding promohealth pr iority. Exc

first six months of

promoted and supp

Childhood and Ad

6.3 School-based pr

prevention should

because of the pro

students in the scho

of the existing o

communication str

the educational

proportion of child

low cost. That said,

out as a prominent p

based programme.

6.4 Healthy eating s

integrated part of

primary and second

6.5 Outside the schoo

Recommendations


52/78

6.7Educational programmes on nutrition,

including those teaching students to cut downon intake of carbonated drinks, should be

implemented, as they are shown to be effective

in improving the knowledge, attitude and

behaviour of healthy eating among students.

6.8 Game-based experiential learning should be

considered for producing favourable short term

results on knowledge gain. Their effectiveness

is optimised when coupled with other health

promotion actions.

Adulthood

6.9 Most adults are preoccupied with work. They

are prone to develop a sedentary lifestyle marked

by an unbalanced diet e.g. overeating, lack of

fruits and vegetables, and high fat content from

processed food. Hence, measures that

acknowledge special circumstances of

individuals and make use of their social

infrastructure should be considered for use.

6.10 Doctors working in primary care settings have

6.12 Workplace initiatives that

health education, partienvironmental modif

implemented to bring ab

in lifestyles habits of em

6.13 Social support initiativ

peer groups, contract-m

reminders are useful an

encourage continuation

Old Age

6.14 Group education comm

social or welfare setti

combined with physical

as walking, Tai Chi or st

support should be promo

Policy and Environmen

6.15 Environmental modifica

to peoples choosing a he

part in regular physical

has a part to play in cre

environment. Large-s


53/78


54/78


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1. World Health Organization. The world health report 2002: reducing risks, pro

WHO; 2002.

2. World Health Organization. Obesity: preventing and managing the global e

consultation on obesity. Geneva: WHO; 2000.

3. Garrow JS. Obesity and related diseases. London: Churchill Livingstone; 19

4. World Health Organization. The Asia-Pacific perspective: redefining obesity and

Communications Australia Pty Limited; 2000.

5. McKeigue PM. Metabolic consequences of obesity and body fat patt

studies. In: Shetty P.S., McPherson K., editors. The origins and conseque

John Wiley & Sons; 1996.

6. Lean ME, Han TS, Morrison CE. Waist circumference as a measure for i

management. BMJ1995; 311(6998):158-61.

7. Pouliot MC, Despres JP, Lemieux S, Moorjani S, Bouchard C, Tremblay A

and abdominal sagittal diameter: best simple anthropometric indexes of abdo

accumulation and related cardiovascular risk in men and women.Am J Car

8. Ross R, Leger L, Morris D, de Guise J, Guardo R. Quantification of adipose

with anthropometric variables.J Appl Physiol1992; 72(2):787-95.

9. Lean ME, Han TS, Deurenberg P. Predicting body composition by

anthropometric measurements.Am J Clin Nutr1996; 63(1):4-14.

10

References


56/78

15. French SA, Story M, Perry CL. Self-esteem and obesity in children and adol

review. Obes Res 1995; 3(5):479-90.

16. Lindsted K, Tonstad S, Kuzma JW. Body mass index and patterns of mortality

Adventist men. Int J Obes 1991; 15(6):397-406.

17. Sidney S, Friedman GD, Siegelaub AB. Thinness and mortality.Am J Public Health

18. Gordon T, Doyle JT. Weight and mortality in men: the Albany Study.Int J Epidemi

19.Jung RT. Obesity as a disease. Br Med Bull1997; 53(2):307-21.

20. Manson JE, Willett WC, Stampfer MJ, Colditz GA, Hunter DJ, Hankinson SE et

mortality among women.N Engl J Med1995; 333(11):677-85.

21. Guo SS, Roche AF, Chumlea WC, Gardner JD, Siervogel RM. The predictive

body mass index values for overweight at age 35 y.Am J Clin Nutr1994; 59(4):8

22. Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidi

overweight adolescents. A follow-up of the Harvard Growth Study of 1922 to

1992; 327(19):1350-5.

23. World Health Organization. Global strategy on diet, physical activity and health. O

Facts. Available at: http://www.who.int/dietphysicalactivity/publications/facts/o

15 March, 2005.

24. Nutritional and Physical Activity Task Forces.Obesity: reversing the increasing problem

London: Department of Health; 1995.


57/78

28. Kotani K, Nishida M, Yamashita S, Funahashi T, Fujioka S, Tokunaga K e

medical examinations in Japanese obese children: do obese children grow i

Relat Metab Disord1997; 21(10):912-21.

29.Janus ED, Cockram C, Fielding R, Hedley A, Ho P, Lam K et al. Hong K

prevalence study 1995-1996. Hong Kong: University of Hong Kong; 1997

30. Kwok P, Tse LY. Overweight and obesity in Hong Kong - What do w

Epidemiology Bulletin 2004; 13(4):53-60.

31. Department of Health.Population Health Survey 2003/2004 (provisional data

of Health; 2005.

32. Department of Health. Prevalence of childhood obesity in primary schools,

Department of Health.

33. Department of Health. Prevalence of childhood obesity in secondary schools,Department of Health.

34. Department of Health.Annual Report 2003/2004. Hong Kong: Departm

35. Lam TH, Chan B, Ho SY.A report on the Healthy Living follow-up survey 2

36. Department of Health. Behavioral risk factor survey 2004. Hong Kong: Dep

37. World Health Organization/ FAO consultation. Diet, nutrition and the p

Geneva: WHO; 2003.

38. The Boys & Girls Clubs Association of Hong Kong. Taipei, Hong Kong a

References


58/78

42. Allison DB, Faith MS, Nathan JS. Rischs lambda values for human obesity. In

Disord1996; 20(11):990-9.

43. The unfinished agenda: perspectives on overcoming hunger, poverty, and environmental deg

(DC): International Food Policy Research Institute; 2001.

44. Holt S, Brand J, Soveny C, Hansky J. Relationship of satiety to postprandial gl

cholecystokinin responses.Appetite1992; 18(2):129-41.

45. Binkley JK, Eales J, Jekanowski M. The relation between dietary change and risObes Relat Metab Disord2000; 24(8):1032-9.

46. Davies PS, Gregory J, White A. Physical activity and body fatness in pre-school

Relat Metab Disord1995; 19(1):6-10.

47. Rising R, Harper IT, Fontvielle AM, Ferraro RT, Spraul M, Ravussin E. Determ

energy expenditure: variability in physical activity.Am J Clin Nutr1994; 59(4):8

48. Schulz LO, Schoeller DA. A compilation of total daily energy expenditures a

healthy adults.Am J Clin Nutr1994; 60(5):676-81.

49. Westerterp KR, Goran MI. Relationship between physical activity related ene

body composition: a gender difference. Int J Obes Relat Metab Disord1997; 21(3

50. Ferro-Luzzi A, Martino L. Obesity and physical activity. In: Chadwick DJ, Card

origins and consequences of obesity. Chichester: Wiley; 1996. 207-27.

51. World Health Organization.Global Strategy on Diet, Physical Activity and Health. Chr


59/78

55. Gibson EL, Wardle J, Watts CJ. Fruit and vegetable consumption, nutrition

mothers and children.Appetite1998; 31(2):205-28.

56. Hearn MD, Baranowski T, Baranowski J. Environmental influences on

children: availability and accessibility of fruits and vegetables enable consum

29(1):26-32.

57. Skinner J, Carruth BR, Moran J, Houck K, Schmidhammer J, Reed A et al.

concordance with family members preferences.J Nutr Educ1998; 30:17-

58. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption

and childhood obesity: a prospective, observational analysis. Lancet2001;

59.Jacobsen MF, Nestle M. Halting the obesity epidemic: a public health app

2000; 115: 12-21.

60.Taras HL, Sallis JF, Patterson TL, Nader PR, Nelson JA. Televisions influephysical activity.J Dev Behav Pediatr1989; 10(4):176-80.

61. Subramania SV, Kawachi I, Kennedy BP. Does the state you live in ma

analysis of self-rated health in the US. Soc Sci Med2001; 53(1):9-19.

62. Nemeroff CJ, Stein RI, Diehl NS, Smilack KM. From the Cleavers to the

body orientation as reflected in magazine article content. Int J Eat Disord

63. Silverstein B, et al. The role of the mass media in promoting a thin standard

women. Sex roles 1986; 14:519-32.

64

References


60/78

68. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochran

2002; (1):CD003517.

69. Armstrong J, Reilly JJ. Breastfeeding and lowering the risk of childhood obesi

(9322):2003-4.

70. von Kries R, Koletzko B, Sauerwald T, von Mutius E, Barnert D, Grunert V et a

obesity: cross sectional study. BMJ1999; 319(7203):147-50.

71. Gillman MW, Rifas-Shiman SL, Camargo CA, Jr., Berkey CS, Frazier AL, Rockeoverweight among adolescents who were breastfed as infants.JAMA 2001; 285(

72. Dietz WH. Breastfeeding may help prevent childhood overweight.JAMA 2001

73. U.S. Department of Health and Human Services. Healthy people 2010 online do

Available at: http://www.healthypeople.gov/document/. Accessed 15 March, 2

74. Fairbank L, OMeara S, Renfrew MJ, Woolridge M, Sowden AJ, Lister-Sharp D.

to evaluate the effectiveness of interventions to promote the initiation of breastfe

Assess 2000; 4(25):1-171.

75. United Nations Childrens Fund. The baby-friendly hospital initiative. 2004. Availa

unicef.org/programme/breastfeeding/baby.htm. Accessed 15 March, 2005.

76. World Health Organization. Evidence for the ten steps to successful breastfeeding. Gen

77. World Health Organization. International code of marketing of breast-milk substitu

2004.


61/78

83. Stark O, Atkins E, Wolff OH, Douglas JW. Longitudinal study of obesity

Health and Development. Br Med J (Clin Res Ed) 1981; 283(6283):13-7.

84. Guo SS, Chumlea WC. Tracking of body mass index in children in relation

Am J Clin Nutr1999; 70(1):145S-8S.

85. Schmitz MK, Jeffery RW. Public health interventions for the prevention

Med Clin North Am 2000; 84(2):491-512.

86.Jeffery RW, French SA, Raether C, Baxter JE. An environmental intervesalad purchases in a cafeteria. Prev Med1994; 23(6):788-92.

87. Bush PJ, Zuckerman AE, Theiss PK, Taggart VS, Horowitz C, Sheridan M

factor prevention in black schoolchildren: two-year results of the Know Y

Epidemiol1989; 129(3):466-82.

88.Coates TJ, Jeffery RW, Slinkard LA. Heart healthy eating and exercise: inchanges in health behaviors.Am J Public Health 1981; 71(1):15-23.

89. Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH, Cade J. Randomised

school based intervention to reduce risk factors for obesity.BMJ2001; 32

90. Muller MJ, Asbeck I, Mast M, Langnase K, Grund A. Prevention of obesity

Concept and first results of the Kiel Obesity Prevention Study (KOPS). In

2001; 25 Suppl 1:S66-74.

91. Simonetti DA, Tarsitani G, Cairella M, Siani V, De Filippis S, Mancinelli S

in elementary and nursery school children. Public Health 1986; 100(3):166

References


62/78

95. Petchers MK, Hirsch EZ, Bloch BA. A longitudinal study of the impact of a

curriculum.J Community Health 1988; 13(2):85-94.

96. Puska P, Vartiainen E, Pallonen U, Salonen JT, Poyhia P, Koskela K et al. The N

project: evaluation of two years of intervention on health behavior and CVD ri

to 15-year old children. Prev Med1982; 11(5):550-70.

97. Killen JD, Robinson TN, Telch MJ, Saylor KE, Maron DJ, Rich T et al. The

Heart Health Program. Health Educ Q1989; 16(2):263-83.

98. Prevention of obesity in American Indian children: the Pathways study.Am J C

Suppl):745S-824S.

99. Homel PJ, Daniels P, Reid TR, Lawson JS. Results of an experimental

development programme in Australia. Int J Health Educ1981; 24(4):263-70.

100.Neumark-Sztainer D, Story M, Hannan PJ, Rex J. New Moves: a school-baseprogram for adolescent girls. Prev Med2003; 37(1):41-51.

101. Wadden TA, Brownell KD, Foster GD. Obesity: responding to the global epid

Psychol2002; 70(3):510-25.

102. Health promoting school & school curriculum. Hong Kong: Education and

2004.

103. Lee A, Tsang C, Tso C, Ho M, Ng P, Yue S et al. Healthy breakfast campaign

Primary Care & Health Promotion 2004; 1(1):10-6.

104


63/78

109. Dale D, Corbin CB. Physical activity participation of high school gradu

conceptual or traditional physical education. Res Q Exerc Sport2000; 71

110. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Hovell MF, Nader PR.

physical education on adiposity in children.Ann N Y Acad Sci1993; 699

111. Mo-suwan L, Pongprapai S, Junjana C, Puetpaiboon A. Effects of a contr

exercise program on the obesity indexes of preschool children.Am J Clin

112. Ewart CK, Young DR, Hagberg JM. Effects of school-based aerobic exadolescent girls at risk for hypertension.Am J Public Health 1998; 88(6)

113. Flores R. Dance for health: improving fitness in African American and H

Health Rep 1995; 110(2):189-93.

114. Duncan B, Boyce WT, Itami R, Puffenbarger N. A controlled trial of a

fifth grade students.J Sch Health 1983; 53(8):467-71.

115. Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Hovell MF, Nader PR.

physical education on adiposity in children.Ann N Y Acad Sci1993; 699

116. Lee PM. Exercise kid songs program: promote regular physical activit

Health Promotion Workforce Capacity Building Project 2001-2002. Hong Ko

2002.

117. Department of Health and Human Services.Nutrition and your health: di

Fourth edition. Washington, DC: Department of Agriculture; 2000.

118

References


64/78

122. Manios Y, Moschandreas J, Hatzis C, Kafatos A. Evaluation of a health and

program in primary school children of Crete over a three-year period. Pr

149-59.

123. James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reduc

carbonated drinks: cluster randomised controlled trial. BMJ2004; 328(7450):

124. Department of Health. Report on the healthy tuckshop movement for primary schoo

Kong: Department of Health; 2003.

125. Department of Health.Report on the healthy eating movement for kindergartens and

2001. Hong Kong: Department of Health; 2004.

126. Department of Health. Healthy birthday party. Hong Kong: KLW/KLC/

Committee DoH; 2000.

127.Smith BJ, Merom D, Harris P, Bauman A. Do primary care interventions to prowork? A systematic review of the literature. Sydney: NSW Centre for Physical A

2002.

128. Blair SN, Smith M, Collingwood TR, Reynolds R, Prentice MC, Sterling CL

for educators: impact on absenteeism. Prev Med1986; 15(2):166-75.

129. Cardinal BJ, Sachs ML. Prospective analysis of stage-of-exercise movement follo

self-instructional exercise packets.Am J Health Promot1995; 9(6):430-2.

130. Chen AH, Sallis JF, Castro CM, Lee RE, Hickmann SA, William C et al. A hom

intervention to promote walking in sedentary ethnic minority women: proj


65/78

135. King AC, Carl F, Birkel L, Haskell WL. Increasing exercise among b

tailoring of worksite programs to meet specific needs.Prev Med1988; 1

136. Bertera RL. Behavioral risk factor and illness day changes with workpla

year results.Am J Health Promot1993; 7(5):365-73.

137. Barratt A, Reznik R, Irwig L, Cuff A, Simpson JM, Oldenburg B e

screening and dietary intervention: the Staff Healthy Heart Project. S

Public Health 1994; 84(5):779-82.

138. Cook C, Simmons G, Swinburn B, Stewart J. Changing risk behaviou

disease in New Zealand working men-is workplace intervention effec

(1130):175-8.

139. Gomel M, Oldenburg B, Simpson JM, Owen N. Work-site cardio

randomized trial of health risk assessment, education, counseling, and in

1993; 83(9):1231-8.

140. Sorensen G, Thompson B, Glanz K, Feng Z, Kinne S, DiClemente C et

prevention: primary results from the Working Well Trial.Am J Public He

141. King AC, Frederiksen LW. Low-cost strategies for increasing exercise be

training and social support.Behavior Modification 1984; 8(1):3-21.

142. Simmons D, Fleming C, Voyle J, Fou F, Feo S, Gatland B. A pilot urban

to reduce risk factors for diabetes among Western Samoans in New Z

15(2):136-42.

References


66/78

147. Lalonde B, Hooyman N, Blumhagen J. Long-term outcome effectiveness of

program for the elderly: The Wallingford Wellness Project.J Gerontological S

(1/2):95-112.

148. Kriska AM, Bayles C, Cauley JA, LaPorte RE, Sandler RB, Pambianco G. A

trial in older women: increased activity over two years and the factors associat

Med Sci Sports Exerc1986; 18(5):557-62.

149. Jarvis KL, Friedman RH, Heeren T, Cullinane PM. Older women and physic

telephone to walk. Womens Health Issues 1997; 7(1):24-9.

150. Andersen RE, Franckowiak SC, Snyder J, Bartlett SJ, Fontaine KR. Can inexpe

the use of stairs? Results from a community intervention.Ann Intern Med199

151. Blamey A, Mutrie N, Aitchison T. Health promotion by encouraged use of s

(7000):289-90.

152. Brownell KD, Stunkard AJ, Albaum JM. Evaluation and modification of exe

natural environment.Am J Psychiatry 1980; 137(12):1540-5.

153. Kerr J, Eves F, Carroll D. Posters can prompt less active people to use the stairs.J

Health 2000; 54(12):942.

154. Russell WD, Dzewaltowski DA, Ryan GJ. The effectiveness of a point-of-decision

sedentary behavior.Am J Health Promot1999; 13(5):257-9, ii.

155. Department of Health. Guidebook on organizing stair climbing campaign. Hong K

Health; 2004.


67/78

159. Tudor-Smith C, Nutbeam D, Moore L, Catford J. Effects of the Heartb

five years on behavioural r isks for cardiovascular disease: quasi-experim

from Wales and a matched reference area. BMJ1998; 316(7134):818-22

160. Osler M, Jespersen NB. The effect of a community-based cardiovascula

in a Danish municipality. Dan Med Bull1993; 40(4):485-9.

161. Goodman RM, Wheeler FC, Lee PR. Evaluation of the Heart To He

community-based chronic disease prevention project.Am J Health Prom

162. Taylor CB, Fortmann SP, Flora J, Kayman S, Barrett DC, Jatulis D

community health education on body mass index. The Stanford Five-C

1991; 134(3):235-49.

163. Ho CL. To study the effects of a structured community-based intervent

activity of adult women in a public housing estate in Hong Kong.Health

Building Project 2001-2002. Hong Kong: Department of Health; 2002.

164. 15 popular fast food. Choices 2003; 323:22-7.

165. Perlmutter CA, Canter DD, Gregoire MB. Profitability and acceptability

hot entrees in a worksite cafeteria.J Am Diet Assoc1997; 97(4):391-5.

166. French SA, Story M, Jeffery RW, Snyder P, Eisenberg M, Sidebottom

promote fruit and vegetable purchase in high school cafeterias.J Am Diet

167. French SA, Jeffery RW, Story M, Hannan P, Snyder MP. A pricing st

snack choices through vending machines.Am J Public Health 1997; 87(5

References


68/78

171. Education and Manpower Bureau. Meal arrangements in schools. Hong Ko

Manpower Bureau. Available at http://www.emb.gov.hk/FileManager/E

guidelinemealarrangement_e.pdf. Accessed 15 March, 2005.

172. Horgen KB, Choate M, Brownell KD. Handbook of children and the media. T

Publications; 2001

173. Jacobson MF, Brownell KD. Small taxes on soft drinks and snack foods to pr

Public Health 2000; 90(6):854-7.

174. Irwin T. Nutrition labelling-the DAA perspective. Nutr Diet2002; 59:48-51.

175. Democratic Party. Nutrition labelling survey. Hong Kong: Democratic Party.

www.dphk.org/2003/images/thumbphoto/envir030315.doc. Accessed 15 M

176. Consumer Council.Competition policy study. Submission from the Consumer Counci

Panel on food safety and environmental hygiene on nutrition labelling and the regulation

food. Hong Kong; 2003.

177. Health, Welfare and Food Bureau. Consultation paper on labelling scheme on nutriti

Kong: Health, Welfare and Food Bureau; 2003.


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Appendix 1

Weight-for-height reference chart for boys and girls.

Obesity defined as weight > median weight-for-height x 120%.

Wasting defined as weight < median weight-for-height x 80%.11

Weight

Weight for Height (Boys)

40

50

60

70

80

90

100

kg

Appendices


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Weight

Weight for Height (Girls)

30

40

50

60

70

80

kg


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BMI 25 kg/m2 B

Age (years) Male Female Male2 18.4 18.0 20.1

2.5 18.1 17.8 19.8

3 17.9 17.6 19.6

3.5 17.7 17.4 19.4

4 17.6 17.3 19.3

4.5 17.5 17.2 19.3

5 17.4 17.1 19.3

5.5 17.5 17.2 19.56 17.6 17.3 19.8

6.5 17.7 17.5 20.2

7 17.9 17.8 20.6

7.5 18.2 18.0 21.1

8 18.4 18.3 21.6

8.5 18.8 18.7 22.2

9 19.1 19.1 22.89.5 19.5 19.5 23.4

10 19.8 19.9 24.0

10.5 20.2 20.3 24.6

11 20.6 20.7 25.1

Appendix 2

International cut-off points for BMI for overweight and obesity by sex

of age, defined to pass through BMI of 25 and 30 kg/m2 at age 18, ob

from Brazil, Hong Kong, the Netherlands, Singapore, the UK and th

Appendices


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Appendix 3Summary of evidence on preventing obesity interventions

Stage Intervention Evidence

Infancy Breastfeeding Breastfeeding has been shown t

effect against obesity as well as

to mothers and infants. The co

protection, promotion and sup

breastfeeding remain a major

Childhood/ School-based programmes to Some initiatives to reduce sed

Adolescence reduce sedentary activities resulted in decreases in report

time.

School-based programmes on There was strong evidence in

physical education physical activity levels and imp

fitness among students.

School-based programmes on Initiatives increased health kno

dietary modification consumption of fruit and vege

students.

Adulthood Promoting physical activity in As a sole initiative, it was not s

primary care settings to increase physical activity le

be incorporated within multi-

community-wide strategies.

Tailor-made physical activity with Initiatives proved generally eff

behavioural components increasing physical activity lev


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Old Age Nutritional education classes Effect of nutrition pro

is still controversial.

Physical activity groups They were effective in

activity levels among t

General Point-of-decision prompts to They were effective in

promote physical activity physical activity.

Community-wide campaigns to Campaigns were succe

reduce risk factors of levels of physical activ

non-communicable diseases diet towards healthier

Environment Reducing price or increasing the Increasing the availabi

and Policy availability of healthy food choices associated with an inc

in vending machines or cafeterias

Restricting sale of soft drinks and Further research will b

unhealthy snacks in school tuckshops effects of this initiative

Regulating food advertisements Further research will b

for children effects of this initiative

Tax on unhealthy foods Further research will b

effects of this initiative

Nutrition labelling Further research will b

effects of this initiative

W ki ith th f d i d t F th h ill b

Resources Link


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Central Health Education Unit,

Department of Health, HKSAR

http://www.cheu.gov.hk/eng/resources/exercise2_boards.htm

Childhood Obesity,

NSW Health

http://www.health.nsw.gov.au/obesity/

Food and Nutrition Information Center,

National Agricultural Library/USDA

http://www.nal.usda.gov/

International Association for the Study of Obesity

http://www.iaso.org/

International Obesity Task Force

http://www.iotf.org/

Resource Guide for Nutrition and Physical Activity Interventions to Prevent Obesity and

National Centre for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/nccdphp/dnpa/obesityprevention.htm

World Health Organization (WHO)

http://www.who.int/health topics/obesity/en/


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Adiposity:The state of being fat.

Cardiovascular diseases (CVD): Any abnormal condition characterised by d

blood vessels.

Cerebrovascular disease: Damage to blood vessels in the brain. Vessels can burst a

with fatty deposits. When blood flow is interrupted, brain cells die or are damaged

Cholesterol: A lipid unique to animal cells that is used in the construction o

building block for some hormones.

Coronary heart disease: A condition in which the coronary arteries narrow

plaque (atherosclerosis) and cause a decrease in blood flow.

Cross-sectional study: In a cross-sectional study, a defined population is ob

absence of an outcome of interest and possible risk factors at a single point in

Diabetes mellitus:A disorder that prevents the body from converting digested f

for daily activities due to a deficiency of insulin. It is characterised by excess sug

Fasting glucose test: A method for learning how much glucose (sugar) there

after an overnight fast. The fasting blood glucose test is commonly used in

mellitus.

Gallbladder: A small pear-shaped organ situated directly under the liver in t

the abdomen. Its main function is to collect and concentrate the bile that the

Gout: Condition characterised by abnormally elevated levels of uric acid in the

joint inflammation (arthritis), deposits of hard lumps of uric acid in and aroun

kidney function and kidney stones.

Glossary


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Mortality:A measure of the frequency of occurrence of death in a defined populatio

interval of time.

Musculoskeletal system: The soft tissue and bones in the body. The parts of the m

are bones, muscles, tendons, ligaments, cartilage, nerves and blood vessels.

Osteoarthritis:A joint disease that is characterised by a breakdown of the cartilage a

the fluid in a joint. Symptoms of osteoarthritis include pain and stiffness.

Postpartum: The period immediately after a woman gives birth.

Prevalence: The number or proportion of cases or events or conditions in a given p

Prochaskas Stages of Changes Model: It is a model of intentional changes w

decision making of the individual. Six stages of change are included in this model, name

contemplation, preparation or determination, action, maintenance, and termination

Prospective study:A study in which participants are initially enrolled, examined or t

and then followed up at subsequent time(s) to determine their status with respect to the

of interest.

Randomised controlled trial: Experiments in which individuals are randomly a

called study and control groups. The study group receives the initiative while the con

receive the initiative.

Stroke:The sudden disruption of blood flow to the brain.

Systematic review: A review of studies in which evidence has been systematically s

assessed, and summarised according to predetermined criteria. It often uses meta-an

results of comparable studies.


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Documents

CHP Obesity 2005