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T he fear of obesity has reappeared in China during the past decade in an age that remembers another moment of famine against which it defines itself. Mao Zedong's famine from 1958 to 1961, which resulted from the collectivization of the peasants killed millions in China and evoked the horrors of the famines of the 1940s during the war against the Japanese, the civil war, and the policies of the nationalist government (Becker 1996). For adults in today's China, "famine" evokes their own experiences under Mao and the tales of starvation during the war by their parents and grandparents.

What is fascinating is how recent studies of obesity in China have come to reverse the claim that such food-borne diseases invade from the primitive "Orient." These Chinese-based studies are often rooted in the view that obesity and its attendant symptoms are the result of the recent pathological "Occidentalization" of China and the Chinese. This obsession with the "contamination from the West" has come to be part of the imagined etiology of obesity in contemporary medicine in China (People's Republic of China, PRC) as well as in Western (U.S./U.K.) medicine dealing with the diaspora Chinese.

The obesity epidemic seems to be the next great fear of Chinese public health officers following smoking. Chronic diseases now account for an estimated 80 percent of deaths and 70 percent of disability-adjusted life-years lost in China. Cardiovascular diseases and cancer are the leading causes of both death and the burden of disease, and exposure to risk factors is high: More than 300 million men smoke cigarettes, and 160 million adults are hypertensive, most of whom are not being treated. Children in the twenty-first century are at risk of being in a poor state of health. The transition from smoking to obesity as the most important threat to public health clearly parallels the argument in Western sources, such as the World Health Organization, that had identified obesity as the next great danger—having "eliminated" smoking as a public health hazard (Reid 2006).

For China, with an exploding number of people now smoking, but where tobacco remains a major source of state revenue, obesity is the new danger. The fat child not the Marlboro Man is the source of anxiety (Chen and Dietz 2002). Indeed, smoking is popularly seen as a "positive" reflection of the process of modernization, while obesity has come to represent the corruption imported from the West. The official journal of "preventive medicine," Zhonghua Yu Fang Yi Xue Za Zhi, acknowledged in 2005 that the prevalence of overweight and obesity among people living in rural areas was lower than that of their urban counterparts, while the increment of overweight and obesity prevalence among rural people was greater than that of their urban counterparts. It was estimated that another 70 million overweight and 30 million obese Chinese people emerged in China from i992 to 2002. The prevalence of overweight and obesity of Chinese people was increased rapidly in the past decade, which had affected 260 million Chinese people. It would continue to increase in the near future if effective intervention measures have not been taken.

Chinese medical and epidemiological studies argue that "obesity has become a global epidemic" though there seems to be little knowledge of the state of affairs in China (meaning the PRC). Looking at "a group of 2776 randomly selected adults (20-94 years of age) living in the Huayang Community in Shanghai, China," a 2002 study argued that while "the prevalence of obesity [using Western standards] was lower in China than in the West," the "overall fat mass-related metabolic disorders were also common" (Jia at al. 2002). The Chinese, unlike the Japanese over the past fifty years, seem to be growing "fat" without developing greater height or frame size. Rather than the positive aspects of a change in diet being measured, only the pathological results of overweight preoccupy the medical scientists. The diseases of "modernity," such as diabetes, are often the proof of a decaying, decadent population, just as it was in the nineteenth century in studies of diabetes, then labeled the "Jewish" disease. Today, the argument is that diabetes is more than twice as frequent in the Chinese (urban) overweight population, even though this population was of a lower weight than the equivalent Western population. The visible pathology of obesity was immediately translated into the invisible disease of diabetes. But what is the cause?

Westernization and "economic success" in the new China or among diaspora Chinese is seen as the ultimate cause of the disease. "Americanization" is the cause of obesity rather than, as in the early twentieth century, the place from where "cure" may come. Tsung O. Cheng of George Washington University's medical school has made the claim concerning even the recent work on obesity in China that "the proportion of obesity among children under the age of 15 increased from 15% in 1982 to 27% today" because of "fast food and physical inactivity." "All of the children in China recognize the image of Ronald McDonald, even though they may not be able to read English" (Cheng 2004). Zumin Shi of the Jiangsu Provincial Center for Disease Control and Prevention looks at the expansion of obesity-related illnesses such as anemia among adolescents in the new China and correlates this to parental attention and "overnutrition" (Shi et al. 2005). J.X. Jiang at the National Center for Women's and Children's Health examines a similar problem in terms of family structure for etiology and intervention (Jiang et al. 2005). Bin Xie, a social worker who is based in California, looks at data from Wuhan to correlate mental state (depression) and obesity among the newly successful that now lack an adequate social network. The claim is that "the findings of this study may contribute to our understanding of the influences of psychological correlates in pediatric overweight in the Eastern cultural environment" (Xie et al. 2005: 1137). All imagine that obesity is a reflex of the altered status of individual, family, and society to the most recent changes in the economic system.

What happens when we leave (for a moment) China and move with the Chinese Diaspora to that land of McDonald's, America? Jyu-Lin Chen and Christine

Kennedy examine correlative material in an analysis of overweight Chinese-American children:

a more democratic parenting style contributes to a higher BMI in Chinese-American children. First, several studies have shown that an authoritarian parenting style in Chinese families may not necessarily reflect the strict parenting that was measured in Western society. Conversely, parents' involvement, care, supervision, and encouragement of academic achievement, all of which typically have been identified as components of an "authoritarian" parenting style in Western society, are, in fact, a reflection of caring and loving parenting in the Chinese culture.

(Chen and Kennedy 2005: 111)

American-type success breaks down the "parental control and warmth" that constitutes Chinese child-raising and leads to fat Chinese children who are a pathological sign of that success: "a democratic parenting style, and poor family communication contribute to higher BMI in Chinese-American children" (Chen and Kennedy 2005: 115). All obesity comes from the West. Chinese families, understood as a traditional society (certainly not in terms of the cultural revolution), simply don't produce fat kids. Only American children raised "Chinese" (not "Asian-American") children are at risk, unless, of course, you live in Shanghai.

There are, of course, large numbers of "Asian Americans" who fall below the poverty line. They are seen to be at risk for the obesity associated in contemporary medical argument with poverty. In this way, too, they mimic "typical" American dietary patterns. In one study, "Asian American ethnic groups," defined as the Chinese, Vietnamese, and Hmong in California, were the focus. In the study, the concept of good health [in these communities] included having a harmonious family, balance, and mental and emotional stability. All groups also expressed the general belief that specific foods have hot or cold properties and are part of the Yin/Yang belief system common to Asian cultures. The lure of fast food, children's adoption of American eating habits, and long work hours were identified as barriers to a healthy, more traditional lifestyle.

(Harrison et al. 2005: 2962)

Yet the results here are virtually identical with those whose belief systems were very different: The classification of the "poor" as those at risk for the pathologies of obesity. Indeed, one recent study has argued that children in China stunted by malnutrition are at substantially greater risk from obesity as they mature (McCarthy 1997).

"America" serves as more than the place where obesity has its origin. In many Chinese studies, the model of a multiethnic America, with different rates of risk, becomes the model for understanding different groups' responses to obesity. What was once a monolithic risk to the "Chinese" becomes a more differentiated risk, where ethnic subgroups are seen as being at greater risk because of their implied genetic or cultural difference. Looking at "ethnic" populations in Xinjiang, a recent study documented that more "obese" Kazak people developed hypertension, whereas more "obese" Uygur people developed diabetes. Implicitly, the different "genetic" background was suggested as the cause using the American studies of African-American and Mexican-American obesity and the resultant increase in cases of Type II diabetes in these communities. (The People's Republic of China includes fifty-six national minorities, but the "majority" Han is itself a composite category.) But it is also clear that the Uygur subjects were from rural south Xinjiang and the Kazak subjects from suburban north Xinjiang (Yan et al. 2005). Thus, the "Han" become the unspoken parallel to the labels in American majority culture: epidemiologi-cally rarely differentiated and labeled "white" or "Caucasian." This is just as constructed a "majority" category in opposition to the other minority and therefore "racial" ones, as is the Han (Dikotter 1992). The "rural versus urban" question of healthy versus unhealthy is here a muddy one as the studies reveal that for ethnic minorities, as in the U.S.A., ethnicity trumps geography.

There are numerous questions, which seem to go unanswered in these studies. Is "obesity" in "Asia" the same phenomenological category as in the "West"? Not only are there different histories of the "large" body and its meaning in "Asia," but are there different physiological measures which would be used for the definition of the obese body? I use the label "Asia" in this context rather than "Chinese," as, in 2002, the World Health Association called a meeting in Hong Kong to examine whether the obese body was to be defined differently among "Asians." This "led to the proposal that adult overweight could be specified in Asia when the body mass index exceeded 23.00 and that obesity should be specified when the BMI exceed 25.00" (James 2002). This is substantially (almost 10 points) lower than the American criteria, which should include that new category "Asian-Americans." It is clear that the Asian-American population is being measured by Western public health definitions of overweight and obesity. What are the boundaries of "Asia"? Do they now contain Taiwan, which sees itself in the context of the Pacific islands? Does it reach north into Mongolia and Siberia? To the Ainu? To the west to India? Or is it a composite that rests in an American fantasy of the "Asian"? Bodily changes among Japanese-Americans over three generations after immigration have been demonstrated. Yet, there seems to be no increase in obesity except over the past decade with the imposition of "Western" definitions of "obesity" (Tahara et al. 2003). Indeed, "Japanese Women Don't Get Old or Fat," the title of a recent book claiming that Japan has the lowest obesity rate in the developed world, the longest life expenditure and the lowest per-capita health care cost (Moriyama 2005). It postulates a "Japanese Paradox" (analogous to the "French paradox" and the claim of universal thinness in France): "How can the world's most food-obsessed nation have the lowest obesity rates in the industrialized world—and the best longevity on Earth?" The answer given is diet: "the Asian diet is probably the best on earth" (Moriyama 2005: 8). Yet, the take-out foods available are Western: "Italian, Chinese, French, and Indian, since food in Japan has been a global affair for many centuries" (Moriyama 2005: 25). No such claims are made about the low impact of Western foods on China. Indeed, a recent popular American study claims that the Chinese diet is the answer to Western obesity (Campbell and Campbell 2005: 69-110).

Westernization in both China and the Chinese diaspora may well play a role, but it is a secondary cause— the primary cause is the long-established one-child policy in China and the change in the status of urban children. This change is analogous to the attitudes of many firstgeneration immigrants in the American urban diaspora (not only the Chinese). There is a preoccupation with the diseases of obesity, specifically diabetes (Type II) found within this literature on China. In a paper from 200i, a study of adults in a population of northeastern China, specifically in Da Qing City, argued, increasing waist measurements predicted i0-fold increases in hypertension and a three-to-five times increased risk of diabetes. Suitable waist cut-off points were 85cm for men and 80cm for women, with statistical analysis showing waist as the more dominant predictor of risk than age, waist-to-hip ratios or BMIs. Hence, small increases in BMI, and particularly in waist circumference, predict a substantial increase in the risk of diabetes . . . in Chinese adults.

What is being seen is the shift in body size because of the accessibility of different foods and the so-called "thrifty genotype" hypothesis that had been suggested in 1964. Simply stated, it has been observed that when mice are transferred from a harsh to a benign environment, they gain weight and are hyperglycemic. When one thus measured first-generation groups of immigrants to the U.S.A. in the late nineteenth century, there was a substantially higher rate of diabetes. The initial groups showed an extremely low index of obesity and the resultant diabetes. This index, however, skyrocketed after just a short time of living in their new environment. Thus, diabetes and obesity seem to be an index of a failure to adapt rapidly to changed surroundings (Schmidt-Nielsen et al. 1964). It is the rapidity of change that lies at the heart of the matter.

In China today, rural children are suffering from malnutrition. The Beijing-based Institute of Nutrition and Food Safety found that more than 29 percent of children under five years old in China's poorest regions were growing at a slower than normal rate. This is quite different to the cities where too rich a diet has increased the level of obesity. In China's larger, wealthier cities, milk, formula milk powder, yogurt, and many other types of food are available which would prevent childhood malnutrition. Yet, of course, the availability of such foods seems also to be viewed as causal for the new Chinese "obesity epidemic." According to Chinese public-health sources, severe obesity now affects some 16-20 percent of urban youngsters. (Malnutrition hits 30 percent.) But, of course, "urban" itself is a highly problematic category for it includes the rural diaspora, living marginal lives in the large cities as well as cities which have had little share in the new boom economy.

Now, in a China with a growing urban middle class, obesity seems to have been uncoupled from the official demand under Mao Zedong in i979 that only one child per couple be allowed which radically reduced the average three to four children per family in rural areas and two to three in urban areas. China, unlike most societies in transformation that have a reduction in birth rate as a reflex of increasing economic status, saw the reduction in the number of children per family prior to the development of the new economic modernization begun under Deng Xiaoping. More food and more television are today indeed a means of pampering these children, often called the "Little Emperors" (xiao huangdi)—but the number of children and their status are independent of economic change. These "Little Emperors" are "used to getting plenty of candy, lavish praise from grownups, and pretty much anything else [they] want" (Chandler 2004: 138). And what they want is food, at least as imagined from the perspective of a Western observer writing for a Western audience accustomed to critiques of the "Fast Food Nation" (Schlosser 2002). They are imagined being "weaned on cheeseburgers from McDonald's, pizza from Pizza Hut, and fried chicken from KFC," (Chandler 2004: 138). Their growing obesity has become not only a public-health problem but also a source for a new "weight-loss business."

At the Aimin Fat Reduction Hospital in Tianjin, a former military institution that launched China's first weight clinic in 1992, doctors treat 200 patients, most of them under 25, with a daily regimen of acupuncture, exercise, and healthy food. Fifteen-year-old Liang Chen reports proudly that he has lost 33 pounds in less than a month at Aimin. But he can't stop reminiscing wistfully about his regular visits to KFC. (Indeed, his favorite T-shirt is a souvenir from China's largest KFC store.) "I used to be able to eat an entire family-size bucket all by myself," he recalls. "Just one?" snorts his roommate, 14-year-old Li Xiang. "That's nothing. I used to be able to eat four buckets—sometimes five, if I didn't eat the corncobs and bread."

(Chandler 2004: 140)

Childhood obesity is not the only curse of the "Little Emperors," as anorexia nervosa seems also to be present. In 1993, researchers reported 200 cases of radical underweight among children from 1988 to 1990 brought to an eating disorders clinic in the Fujien area. The gender balance was remarkable from Western criteria for anorexia nervosa, as 112 cases were boys and only eighty-eight were girls. It was not the case that these were the product of a starvation culture but rather of "non-fat phobic anorexia" caused, according to the researchers by the single-child policy as the children were spoiled by their parents and developed unhealthy eating habits which contributed to their underweight (Cheng 2004).

Here the problem is not "Western" food but the absence of moderation, an absence fostered by the "Little Emperor" syndrome. The number of children is a result of the "Old" Communist system and maybe exacerbated by the availability of "Western" fast foods. There are studies that minimize the shifts of diet in regard to a "Westernization" of the Chinese diet. One such study argues that while in the U.S.A. snacks contribute "more than one-third of their daily calories and a higher proportion of snack calories from foods prepared away from home," in

China . . . snacks provide only approximately 1% of energy. Fast food plays a much more dominant role in the American diet (approximately 20% of energy vs. 2% to 7% in the other countries), but as yet does not contribute substantially to children's diets in the other countries. Urban-rural differences were found to be important, but narrowing over time, for China . . . whereas they are widening for Russia.

(Adair and Popkin 2005: 1281)

What has changed in contemporary China? Moderation is what has been sacrificed—not traditional foods. The status of the child may be linked to the new status of what the child eats, but childhood obesity is not the result of the availability of alternative, Western foods but the perceived special status of the child. No such parallel state existed in Japan, where the reduction in the birthrate was concomitant to the increase of economic status. In Japan, American fast food has been omnipresent since the 1960s. If there is an increase of childhood obesity (and the argument is that this is then reflected in adult obesity), then it has occurred only over the past decade. In the National Survey of Primary and Middle Schools in Japan, between 1970 and 1997, obesity in nine-year-old children increased threefold, but the focus has been on the past decade, a decade of economic retrenchment (< 101 .cfm>).

Today in China, no one would imagine tying childhood obesity to anything but perceived economic improvement in the "New Economy" as part of "Jiang Zemin's legacy." This, of course, mimics the Western Super Size Me rationale that sees all obesity as a result of the global "epidemic" of "junk food." The introduction of Westernized forms of "traditional" Chinese medicine, such as "electroacupuncture" for the treatment of overweight has melded traditional views of obesity and the newest research on human metabolism including serum total cholesterol, triglyceride, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol (Cabioglu and Ergene 2005). What comes from the West can be cured now by that which (seems) indigenous to the East (but, of course, is not—just like obesity).

China, like America, is suffering from a new epidemic but one that documents its modernity—no model of Oriental, primitive infectious diseases here. Rather, a claim of the "invasion from the West," the negative aspects of the new economy which can be confronted through the importation of models of obesity from Western public health. Obesity and its treatment are both to be understood as part of a system of modernization with all of the pitfalls recognized and the "cure" in sight.

See also Developing World; Electrotherapy; Jews; Obesity Epidemic; Smoking

References and Further Reading Adair, L.S. and Popkin, B.M. (2005) "Are Child Eating Patterns Being Transformed Globally?" Obesity Research 13 (7): 1281-99. Becker, Jasper (1996) Hungry Ghosts: China's Secret

Famine, London: J. Murray. Cabioglu, M.T. and Ergene, N. (2005)

"Electroacupuncture Therapy for Weight Loss Reduces Serum Total Cholesterol, Triglycerides, and LDL Cholesterol Levels in Obese Women," The American Journal of Chinese Medicine 33 (4): 525-33.

Campbell, T. Colin and Campbell, Thomas M., II (2005) The China Study: The Most Comprehensive Study of Nutrition Ever Conducted and the Startling Implications for Diet, Weight Loss and Long-Term Health, Dallas, Tex.: Benbella Books. Chandler, Clay (2004) "Little Emperors: China's Only Children—More Than i00 Million of Them—Make

Up the Largest Me Generation Ever. And Their Appetites Are Big," Fortune October 4, pp. 138-42.

Chen, Chunming and Dietz, William H. (eds) (2002) Obesity in Childhood and Adolescence, Philadelphia, Pa.: Lippincott Williams & Wilkins.

Chen, D.G., Cheng, X.F. and Wang, L.L. (1993) "Clinical Analysis of 200 Cases of Child Anorexia," Chinese Mental Health Journal 7: 5-6. (In Chinese.)

Chen, Jyu-Lin and Kennedy, Christine (2005) "Factors Associated with Obesity in Chinese-American Children," Pediatric Nursing 31 (2): 110-15.

Cheng, Tsung O. (2004) "Obesity in Chinese Children," Journal of the Royal Society of Medicine 97 (5): 254.

Dikötter, Frank (1992) The Discourse of Race in

Modern China, Stanford, Calif.: Stanford University Press.

Harrison, G. G., Kagawa-Singer, M., Foerster, S.B., Lee, H., Pham Kim, L., Nguyen, T.U., Fernandez-Ami, A., Quinn V. and Bal, D.G. (2005) "Seizing the Moment: California's Opportunity to Prevent Nutrition-Related Health Disparities in Low-Income Asian American Population," Cancer 104 (suppl): 2962-8.

James, W.P.T. (2002) "Appropriate Asian Body Mass Indices," Obesity Reviews 3: 139.

Jia, W.P., Xiang, K., Chen, L., Xu, J. and Wu, Y. (2002) "Epidemiological Study on Obesity and Its Comorbidities in Urban Chinese Older Than 20 Years of Age in Shanghai, China," Obesity Reviews 3 (3): i57-65.

Jiang, J., Xia, X.X.L., Greiner, T., Lian, G.L., and Rosenqvist, U. (2005) "A Two Year Family Based Behaviour Treatment for Obese Children," Archives of Disease in Childhood 90 (12): 1235-8.

Li, G., Chen, X., Jang, Y., Wang, J., Xing, X., Yang, W. and Hu, Y. (2002) "Obesity, Coronary Heart Disease Risk Factors and Diabetes in Chinese: An Approach to the Criteria of Obesity in the Chinese Population," Obesity Reviews 3 (3): 167-72.

Ma, G.S., Li, Y.P., Wu, Y.F., Zhai, F.Y., Cui, Z.H., Hu, X.Q., Luan, D.C., Hu, Y.H. and Yang, X.G. (2005) "The Prevalence of Body Overweight and Obesity and

Its Changes Among Chinese People During 1992 to 2002," Journal of Preventive Medicine 39 (5): 31115.

-(2005) "Malnutrition Hits 30 Percent of China's

Poverty-Stricken Children," Agence France Presse. October 8.

McCarthy, Michael (1997) "Stunted Children Are at High Risk of Later Obesity," Lancet 349: 34.

Moriyama, Naomi (2005) Japanese Women Don't Get Old or Fat: Secrets of My Mother's Tokyo Kitchen, New York: Delacorte.

Reid, Roddey (2006) Globalizing Tobacco Control: Anti-Smoking Campaigns in California, France and Japan, Bloomington, Ind.: Indiana University Press.

Schlosser, Eric (2002) Fast Food Nation: The Dark Side of the All-American Meal, New York: Perennial.

Schmidt-Nielsen, K., Haines, H. and Hackel, D.B. (February 14, 1964) "Diabetes Mellitus in the Sand Rat Induced by Standard Laboratory Diets," Science 143:689.

Shi, Zumin, Lien, Nanna, Kumar, Bernadette Nirmal, Dalen, Ingvild, and Holmboe-Ottesen, Gerd (2005) "The Sociodemographic Correlates of Nutritional Status of School Adolescents in Jiangsu Province," Journal of Adolescent Health 37 (4): 313-22.

Tahara, Y.K., Moji, S., Muraki, S., Honda, S., and Aoyagi, K. (2003) "Comparison of Body Size and Composition Between Young Adult Japanese-Americans and Japanese Nationals in the 1980s," Annals of Human Biology 30 (4): 392-401.

Xie, B., Chou, C.P., Spruijt-Metz, D., Liu, C., Xia, J., Gong, J., Johnson, Y., and Li, C.A. (2005) "Effects of Perceived Peer Isolation and Social Support Availability on the Relationship Between Body Mass Index and Depressive Symptoms," International Journal of Obesity 29: 1137-43.

Yan, W., Yang, X., Zheng, Y., Ge, D., Zhang, Y., Shan, Z., Simu, H., Sukerobai, M. and Wang, R. (2005) "The Metabolic Syndrome in Uygur and Kazak Populations," Diabetes Care 28: 2554-5.

Chittenden, Russell Henry (1856-1943) Researcher and pioneer in area of daily protein requirements for humans

I n 1880, Chittenden received his Ph.D., and in 1882 he started his career as the Professor of Physiological Chemistry in the Sheffield Scientific School of Yale University. Chittenden's initial research dealt with the chemical nature of proteins. In collaboration with the German physiologist Wilhelm Friedrich Kühne (1837-1900), the two studied the enzymatic splitting of proteins, which has contributed to the understanding of the complexity of protein molecules. His initial studies sparked his interest in nutritional science and further led to his most important research, that on the protein requirements of humans.

The early nineteenth-century belief was that people needed an extensive amount of protein (118 grams) in their daily diet. After Chittenden encountered Horace Fletcher who maintained a low-calorie and low-protein diet, Chittenden's interest was sparked. He began a widespread study of low-protein diets, in which his subjects were Yale athletes and army volunteers. His volunteers consumed 2,600 calories a day and 50 grams of protein. In 1905, Chittenden enthusiastically published his results in his Physiological Economy in Nutrition.

While Chittenden passionately believed in a lower protein diet, there were many skeptics. He defended his findings through a study on dogs, which are primarily carnivorous animals. Unfortunately, the diet did not prove to be healthy for the dogs, as many began to suffer from ill health. Even so, Chittenden maintained enthusiasm for a low-protein diet, and once again defended his position in The Nutrition of Man, a course of eight lectures delivered before a general public at the Lowell institute of Boston in the early part of 1907. While nutritionists did eventually disregard the initial high protein requirements (118 grams), they continued to doubt Chittenden's findings. Throughout his career, Chittenden continued to be involved in nutritional studies and discussions and was regarded as an expert in nutritional sciences.

In 1918, he represented the U.S.A. on an Inter-Allied Scientific Food Commission, which met to discuss the nutritional needs of the allied forces in World War I. He was not able in his lifetime to prove his theories on protein requirements, though his research was continued by others.

See also Fletcher; Ornish

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