NUTRITION EPIDEMIOLOGY

Transcription

1 NUTRITION EPIDEMIOLOGY IN CHINA AN OVERVIEW TO NUTRITION PROBLEMS IN CHINESE POPULATION AND HOW TO APPROACH THEM Freida Pan B.S., University of Nebraska-Lincoln Candice Tan B.S., University of Wisconsin-Madison

2 AGENDA General background of China Cohort studies conducted in Chinese population China Health and Nutrition Survey (CHNS) Trends and changes in dietary patterns related to urbanization (Zhai et al., 204) Shanghai Women s Health Study & Men s Health Study (SWHS & SMHS) Chinese Food Pagoda and Adherence (Yu et al., 204) Bridging the gap Q&A

3 GENERAL BACKGROUND OF CHINA

4 FACTS ABOUT CHINA Total population of China:.3 billion people in 23 provinces (States) Traditional eating pattern Four major dietary patterns Yellow Earth/ traditional northern pattern: high intakes of refined cereal products, potatoes, and salted vegetables Green water/ traditional southern pattern: high intakes of rice and vegetables and moderate intake in animal foods New affluent pattern: high intake of animal source and soybean products Western pattern: high intakes of beef, lamb, milk, cheese, yogurt, cakes, juices and nuts Wang, Dong et al Joint Association of Dietary Pattern and Physical Activity Level with Cardiovascular Disease Risk Factors among Chinese Men: A Cross-Sectional Study. PLoS ONE 8 (6): e6620.doi:0.37/journal.pone

5 COMMUNICABLE DISEASES (NRNCD) IN CHINA Table. The prevalence of chronic non-communicable disease (per 000) THE EMERGING NUTRITION-RELATED NON- Cerebralvascular disease Cardiovascular disease Diabetes Hypertension Ge et al, 20, 20 (3): The major data sources are obtained from annual statistical reports and sample survey from the Chinese Ministry of Health ( China Health Statistical Yearbook 200 )

6 THE EMERGING NUTRITION-RELATED NON- COMMUNICABLE DISEASES (NRNCD) IN CHINA Studies CHNS survey year Sample Adair et al (204) CHNS 2009 n> 9,000 nonpregnant individuals Age 7 years and above Outcomes Prevalence for CVD risk factors (BP, high TC, LDL and TG, low HDL, and high TG +low HDL) L.S. Adair et al, 204, 5 (Suppl. ):

7 L.S. Adair et al, 204, 5 (Suppl. ): P < 0.05 P > 0.05 Male Female

8 THE EMERGING NUTRITION-RELATED NON- COMMUNICABLE DISEASES (NRNCD) IN CHINA Studies CHNS survey year Sample Outcomes Liang et al (204) CHNS ( ) Five cohorts of adults ( 8 yrs) who were free of HTN at baseline Incidence of HTN Cohort : n=462 Cohort : n=976 Cohort : n=795 Cohort : n=479 Cohort : n= p trend = Incidence (per 00 person-years) of HTN (hypertension) (defined as BP 40/90 mmhg or currently using antihypertensive drugs) Liang et al, 204; 75: 96-0.

9 P trend < 0.05 P trend < 0.0 except for young adults 8-39 years Figure. SBP and DBP from 99 to 2004 in different age groups Figure 2. The proportion of selfreported antihypertensive treatment Liang et al, 204; 75: 96-0.

10 CHINA HEALTH AND NUTRITION SURVEY (CHNS) Cohort studies conducted in Chinese population

11 CHINA HEALTH AND NUTRITION SURVEY (CHNS) An ongoing open cohort, international collaborative project Examine the effects of the health, nutrition, and family planning policies and programs implemented by national and local governments Assess how the social and economic transformation of Chinese society is affecting the health and nutritional status of its population

12 DESIGN AND METHOD Drawn from nine provinces Diverse socioeconomic factors and other health factors Multi-stage, random cluster process Stratified by income and a weighted sampling scheme to randomly select 4 counties Survey every two years Sample size ~ 4,000 to 6,000 projects/china

13 DATA COLLECTION Household Survey Health and Nutrition Survey Dietary intake Three consecutive 24-hr recalls Household food consumption: changes in inventory from the beginning to the end day All processed foods (including edible oil and salt) remaining after the last meal before initiation of the survey have been weighed and recorded All purchases, home production and processed snack foods Food Composition Table for China to calculate nutrient values Body composition, blood pressure, health history, and health-related behaviors Physical Activity

14 EXAMPLE: KONG PAO CHICKEN Day : Household Inventory: Total amount of the ingredients used for this dish: x grams of chicken, y grams of red pepper, z grams of green onion, oil, salt and pepper Total nutrients for this dish Day : 24-hr food recall Subject : Consumed one cup of this dish Nutrients consumed by Subject

15 China Health and Nutrition Survey vs. National Human and Nutrition Examination Survey CHNS NHANES Year started 989 Early 960s Study population Nine provinces Fifty states Survey Design Sample Data Collection: Dietary Intake Multi-stage, random cluster process 5,648 individuals participate in 2000 Three 24-hr recalls Ø Household food consumption Ø Weighed and recorded leftovers Multistage complex, stratified, probability cluster sampling design 9,756 individuals participated in Two 24-hr recall (one inperson and one telephone follow-up) Food Composition Table for China was utilized to calculate nutrient value USDA Nutrient Database is used to calculate nutrient values

16 TRENDS AND CHANGES OF THE CHINESE DIET AND THE ROLE OF URBANICITY China Health and Nutrition Survey (CHNS)

17 TIMELINE OF URBANIZATION 949: Creation of the People s Republic of China (PRC) Widespread famine, high mortality and low life expectancy : Dramatic growth of agriculture, industry, trade and government revenue 979: economy & agricultural productivity changed greatly Major land, social and economic reforms have been implemented Du et al, 204, 5 (Suppl. ): 8-5.

18 URBANIZATION AND DIETARY SHIFTS The First Fast Food Stores Kentucky Fried Chicken in 987 McDonalds in China in 990 Pizza Hut in 990 Today McDonald s plans to double the number of its restaurants in China to 2,000 by 203 More than 4,600 KFCs in nearly,000 cities 2 Over,200 Pizza Hut restaurants in 37 cities in China 2 Validity and reproducibility of the food frequency questionnaire used in the Shanghai Women s Health Study

19 SHIFTS IN DIET OF CHINESE POPULATION Eating behaviors Snacking have emerged and continue to grow Away-from-home consumption has increased Convenience food consumption has increased Cooking methods Changed from predominantly steaming and boiling to frying Dietary Diversity 2 Consuming foods from more number of food groups Intake of vegetable, fruits, cakes, and milk and other animal products have increased, whereas that of cereals and tubers has decreased Zhai et al. obesity reviews (204) 5 (Suppl. ), Batis et al. British Journal of Nutrition (204),, doi:0.07/s

20 TREND ANALYSIS OF DIETARY PATTERN IN CHINESE ADULTS LESS WORDS Author, year CHNS Year Batis et 99 al, Sample Included all adults aged 8 65 years with complete dietary data for at least three waves (n=9253) Results é prevalence of overweight and in the proportion of subjects classified as medium- and high-income earners over the same period traditional southern and modern high-wheat dietary patterns increase in dietary diversity, remained fairly similar Batis et al. British Journal of Nutrition (204),, doi:0.07/s obesity reviews (204) 5 (Suppl. ), 6 26

21 BATIS ET AL: ENERGY INTAKE AND NUMBER OF FOOD GROUPS CONSUMED BY WAVE Mean energy (kcal/d) ,638,62,574,579,583,565,537 Mean number of food groups consumed Year Year Batis et al. British Journal of Nutrition (204),, doi:0.07/s

22 BATIS ET AL: PERCENTAGES OF CONSUMERS FOR SELECTED FOOD GROUPS BY WAVES 6% Percentage of consumers 4% 2% 0% 8% 6% 4% 2% Low-fat red meat High-fat red meat 0% Year Low-fat red meat = low-fat beef, lamb, donkey, rabbit High-fat red meat = high-fat beef, lamb Batis et al. British Journal of Nutrition (204),, doi:0.07/s

23 DYNAMICS OF THE CHINESE DIET AND THE ROLE OF URBANICITY, BY ZHAI ET AL. Zhai et al, 204 Study Design Sample Variables measured Trend analysis, Descriptive study, CHNS data (99-20) 99 3, , , , ,932 Age 2 and over. Dietary data 2. Eating behaviors: snacking, awayfrom-home consumption, cooking methods 3. Urbanicity measure: Using CHNS urbanicity index 3 mega cities: Beijing, Shanghai and Chongqing with approximately million residents (n=4,058) Zhai et al, 204, 5 (Supply. ): Zhang et al, 204, 5 (Suppl. ): 2-7

24 DIETARY ASSESSMENT 24-h recall for 3 consecutive days 3 consecutive days Dietary data All household members Daily inventory Food consumed at home + away from home Recorded/weighed: Food foods models in stock, and picture aids used purchased or produced, Type edible of food, oil, amount, type of meal and place condiments, food preparation Nutrient analysis: waste Chinese Food Composition Table 2002 Household food inventory F.Y. Zhai, 204, 5 (Supply. ): 6-26 Individual intake

25 MAJOR FINDINGS FROM ZHAI ET AL. Nutrient trend: ê % energy from carbohydrates; é % energy from fat; Na consumption levels are very high, potassium levels are low Food consumption trend: é Consumption of animal-source foods é % energy consumed from edible oils Eating behavior: Cooking methods shift from steaming, boiling and baking to stirfried and deep fried. é snacking during é % kcal prepared away from home The levels of changes are even more pronounced in the areas with high levels of urbanization F.Y. Zhai, 204, 5 (Supply. ): 6-26

26 MACRONUTRIENT AND MINERALS CONSUMPTION BY AGES 2 AND OVER FROM 99 TO 20 F.Y. Zhai, 204, 5 (Supply. ): 6-26.

27 SNACKING PATTERNS AND TRENDS BY AGES 2 AND OVER FROM 99 TO 20 What type of snacks? F.Y. Zhai, 204, 5 (Supply. ): 6-26

28 EATING BEHAVIOR CHANGES IN CHINA AGED 2 AND OLDER FROM 99 TO 20 STRATIFIED BY LEVEL OF URBANIZATION % kcal prepared away from home Low urbanization Middle urbanization High urbanization F.Y. Zhai, 204, 5 (Supply. ): Adapted from Table 3.

29 TOTAL ANIMAL SOURCE FOODS INTAKES IN ADULT AGED 9-59 BY URBANICITY LEVELS Total animal source foods intakes in adult aged 9-59 Total animal-source foodskcal d Low urbanization Middle urbanization High urbanization F.Y. Zhai, 204, 5 (Supply. ): Adapted from Table 2.

30 DAILY INTAKE OF ANIMAL SOURCE FOODS IN CHINA (G/DAY), Grams/day F.Y. Zhai, 204, 5 (Supply. ): 6-26

31 LIMITATION CHNS only covers 9 provinces, may not be representative to regions that were not covered Descriptive paper: limited quantitative analysis (health and policy implication?) Limited demographic information presented Chinese Food Composition Table (FCT) Include purchased foods and raw food items only No recipe included Limited processed foods F.Y. Zhai, 204, 5 (Supply. ): 6-26

32 WHAT DID WE LEARNED FROM ZHAI ET AL? How to improve the Chinese Food Composition Table Work with CHNS to collect adequate recipe to expand the current food library CHNS is an important monitoring system for understanding dietary shifts and epidemiology in health in China Future studies needed to fully understand the food revolution and its health implication Quantitative analysis F.Y. Zhai, 204, 5 (Supply. ): 6-26

33 ADHERENCE TO NATIONAL GUIDELINE IN TWO COHORT STUDIES Shanghai Women s Health Study & Men s Health Study (SWHS & SMHS)

34 CHINESE FOOD PAGODA (CHFP) g g g g g Keyou Ge, 20, 20 (3): Pictures from 2005 Encyclopaedia Britannica

35 ADHERENCE TO DIETARY GUIDELINES AND MORTALITY (YU ET AL, 204) -A REPORT FROM PROSPECTIVE COHORT STUDIES OF 34, 000 CHINESE ADULTS IN URBAN SHANGHAI 0- component Chinese Food Pagoda 2007 score Modified DASH score Total and cause-specific mortality Modified AHEI-200 score n=34, 455 Shanghai Men s Health Study; Shanghai Women s Health Study

36 PROSPECTIVE COHORT STUDY IN CHINA Shanghai Women s Health Study (SWHS) Time Period: December 996- May 2000 Shanghai Men s Health Study (SMHS) Time Period: April 2002-June n=200 Dietary intake has communities 8 communities - completed one been assess using n=95 74,942 participants quantitative Food 6,582 participants FFQ at baseline - one FFQ at (response rate of 92.7%) Identify Frequency dietary factors that (response rate of 74.%) and 24-h dietary baseline and 24-h increase Questionnaire or reduce risk of recalls twice/ cancer (FFQ): dietary recalls and other chronic month - diseases, baseline evaluate survey once/month and consecutively for 2 association - 2 year after between diet a second FFQ at months and recruitment chronic diseases,2 the end of the - every 2 year study ρ= afterwards ρ= Zheng, W et al. Am J Epidemiol 2005;62: Villegas, R et al. British Journal of Nutrition (2007), 97, Shu, XO et al. European Journal of Clinical Nutrition (2004) 58, 7 23

37 ADHERENCE TO THE CHINESE FOOD PAGODA Examine adherence to the Chinese Food Pagoda in association with total and cause-specific mortality Cardiovascular disease mortality Cancer mortality Diabetes mortality Prospective cohort study 6,239 men and 73,26 women (aged 40 to 74 years) from 2 population-based prospective study in Shanghai, China The average follow-up years: 6.5 and 2.0 y Adherence: assess by CHFP score ranged from 0 (lowest adherence) and 45 (highest adherence) Yu, Danxia et al. Am J Clin Nutr 204;00:

38 CHINESE FOOD PAGODA COMPONENTS AND SCORES Yu, Danxia et al. Am J Clin Nutr 204;00:

39 DEMOGRAPHIC CHARACTERISTICS ACCORDING TO QUARTILES OF THE CHFP SCORE Yu, Danxia et al. Am J Clin Nutr 204;00:

40 CONSUMPTION OF FOOD GROUPS ACCORDING TO QUARTILES OF THE CHFP SCORE IN MEN Food Group (g/d) Recommendation from Chinese Food Pagoda Men (SMHS, n = 6,239) Lowest quartile Fat and oils 25-30g 42±6 33± 6 Salt 6g 7 ± 2 6 ± Milk and Milk Products Bean and Bean Products Red Meat and Poultry Fish and Shrimps Highest quartile 300g 59±99 6 ± g 2±8 24 ± g 9±5 22±26 46 ± 2 3 ±6 50g 50±52 60 ±39 Eggs 25-50g 33±28 26 ± 6 Vegetable g 32 ± ± 66 Fruits g 92 ± 2 22 ± 2 Cereal g 367 ± ± 47 Yu, Danxia et al. Am J Clin Nutr 204;00: Adapted from Table

41 CONSUMPTION OF FOOD GROUPS ACCORDING TO QUARTILES OF THE CHFP SCORE IN WOMEN Food Group (g/d) Recommendation from Chinese Food Pagoda Women (SWHS, n = 73,26) Lowest quartile Highest quartile Fat and oils 25-30g 39±4 32±7 Salt 6g 8 ± 3 6 ± Milk and Milk Products Bean and Bean Products Meat Poultry 300g 65±0 40± g 20±7 23± g 83±47 24±27 43±2 4±2 Fish and Shrimps 50g 55±54 65±43 Eggs 25-50g 38±30 27±7 Vegetable g 302 ± ± 69 Fruits g 257 ± ± 9 Cereal g 344 ± ± 52 Yu, Danxia et al. Am J Clin Nutr 204;00: Adapted from Table

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43 Yu, Danxia et al. Am J Clin Nutr 204;00: Adapted from Table 3 Multivariable Hazard Ratio P<0.000 for men Figure. Hazard Ratio Cardiovascular Disease Mortality Multivariable Hazard Ratio P=0.02 for men Figure 2. Hazard Ratios for Cancer Mortality Multivariable Hazard Ratio P=0.02 for men Figure 3. Hazard Ratios for Diabetes Mortality Quartile of dietary recommendation adherence scores 0.73 Men Women

44 WHAT DID WE LEARN FROM THIS STUDY? Results from these 2 large population-based prospective cohort studies suggest Adherence to Chinese Food Pagoda guidelines is associated with lower mortality in Chinese men and women Decrease in all three specific-cause mortality is significantly associated with highest quartile range in men All three specific-cause mortality was not associated with high adherence score in women This may mean that we need different recommendations for women and men Yu, Danxia et al. Am J Clin Nutr 204;00:

45 WHAT DID WE LEARN SO FAR? Zhai et al (204) Trend analysis, descriptive paper CHNS data (9 provinces) and 3 megacities Yu et al (204) Prospective cohort study, quantitative analysis SWHS, SMHS (Shanghai) 3 days 24-hr-recall +household inventory Conclusion: undesirable dramatic dietary shifts increased over the years Validated FFQs Conclusion: Adherence to Chinese food pagoda shows decreased in mortality in men

46 PUTTING IT ALL TOGETHER With urbanization and increased incidence of non communicable chronic disease, there is a need for nutrition intervention. Chinese Food Pagoda is a great start; may need different guidelines for different sex or regions. However, currently China is not a member of ICDA, nor does it currently have uniform didactic educational curricula for dietetics and supervised training.

47 THE BURNING QUESTION What do you want to investigate before you make nutrition-related recommendations to the government? If you were a nutrition advocate in China, what would be the next steps to correct or slow down the progress of the non-communicable nutritionrelated diseases?

48 WHERE IS THE GAP AND HOW TO FIX THAT? Lack of Dietetic Education Programs and Career Paths Lack of Clear Scope of Work for Dietetic Professional Establish undergraduate program for dietetics; recognize license by other countries Pass Nutrition legislation that needs to clarify who can call themselves dietitians and scope of work Lack of Professional Practice Guideline Promulgate and publish regulations for practice standards Sun et al Pacific journal of clinical nutrition, 23(), 6-26.

49 QUESTIONS?

50 REFERNCES Zhai FY, Du SF, Wang ZH, Zhang JG, Du WW, Popkin BM. Dynamics of the Chinese diet and the role of urbanicity, Sun, L, & Dwyer, J. (204). Dietetics in china at the crossroads. Asia Pacific journal of clinical nutrition, 23(), Shu, X O, Yang, G, Jin, F, et al. (2004). Validity and reproducibility of the food frequency questionnaire used in the shanghai women. European journal of clinical nutrition, 58(), Villegas, R, Yang, G, Liu, D, et al. (2007). Validity and reproducibility of the food-frequency questionnaire used in the shanghai men. British journal of nutrition, 97(5), Du, S F, Wang, H J, Zhang, B, et al. (204). China in the period of transition from scarcity and extensive undernutrition to emerging nutrition-related non-communicable diseases, Obesity reviews, 5 Suppl, 8-5. Zheng, W, Chow, W, Yang, G, et al. (2005). The shanghai women. American journal of epidemiology, 62(), Zhang, B, Zhai, F Y, Du, S F, et al. (204). The china health and nutrition survey, Obesity reviews, 5 Suppl, 2-7. Adair, L S, Gordon Larsen, P, Du, S F, et al. (204). The emergence of cardiometabolic disease risk in chinese children and adults: Consequences of changes in diet, physical activity and obesity. Obesity reviews, 5 Suppl, Yu, D, Zhang, X, Xiang, Y, et al. (204). Adherence to dietary guidelines and mortality: A report from prospective cohort studies of 34,000 chinese adults in urban shanghai. The American journal of clinical nutrition, 00(2),