China

China was estimated in 1991 to have a population of 1.16 billion, the largest in the world, with an annual growth rate between 1980 and 1991 of 1.5%. Over recent years China has had accelerated economic growth. Between 1986 and 1993 per caput GDP grew in real terms at an average rate of 6.4%.

Nutrition trends were previously reported in SCN's 1989 Update on the Nutrition Situation (ACC/SCN, p.112-115, 1989), and in the Second Report on the World Nutrition Situation (vol.I, p.30-33, 1992).

Recent Trends in Nutrition

With its large population, conclusions regarding trends must differentiate between urban and rural areas and between regions. Recent data based on surveys of the nutrition of children and adults in China have recently become available. Anthropometric data on children based on surveys in 1990 were recently reported, and are generally comparable to an earlier survey in 1987, the first ever to cover much of the country. More recent nutrition surveys were carried out in 1992, but results are not yet available. Anthropometric data for adults were also made available comparing results from 1989 and 1991 from nutrition surveys in 8 provinces.

Child Nutrition. The general conclusion from data for young children (0-71 months; see Figure 1) indicates improvements mainly in the growth of children in the urban areas, with the situation in rural areas remaining static. While the prevalence in underweight children (<-2 s.d. weight-for-age NCHS) in urban areas improved from 12.8% in 1987 to 7.1% in 1990, the proportions in the rural areas remained fairly constant at 23.9% in 1987 to 21.2% in 1990. In Guangdong, a coastal province where rapid economic growth in incomes was observed, improvements were seen in both urban and rural areas, but more dramatically in the urban areas (from 22.1 to 10.6%). The urban areas of Sichuan (largest province with 109 million population in 1990) likewise experienced dramatic improvements in the growth of children (19.8% to 10.4%), but stayed nearly the same in the rural areas (29.3 to 27.3%). In the urban areas of Heilongjiang, prevalence of underweight declined from 8.0% to 5.0%, but in rural areas there seemed to have been a slight deterioration from 14.0 to 17.4% between 1987 and 1990.

Figure 1. China: Prevalence of Underweight Children, (0-71 months), 1990, by Province

Source: Shen et al (1992).

Figure 2. China: Mean Weights of Urban and Rural Children, 1987 and 1990

Source: Shen et al (1992).

The second important trend is that the mean weights for urban children in 1990 is clearly higher than the mean weights of children in 1987, and this is true for practically all age groups. This indicates that improvements were more or less homogeneous and that the entire distribution in growth shifted to the right-which means that the majority of children were better off. The mean weights in the rural areas were similar at least for the younger children below 36 months, although the older children in the 1990 survey were slightly heavier. The analysis by Shen et. al. (1993) indicates that the urban children between ages 0 to 71 months were roughly 2.5 to 3.5 cm taller and 0.6 to 1.2 kg. heavier than rural children.

Third, the fact that the gap in the growth of children between urban and rural areas in China is widening is a notable development in the sense that the increasing gap in incomes, and probably access to public health services, are now being reflected in the nutritional outcomes. Moreover, although the mean child growth in rural areas remains static, the dispersion of distribution becomes wider, meaning increased inequity and heterogeneity in nutritional status in rural children according to recent analysis. In contrast, both the mean and dispersion of child growth improve in urban areas. Thus, when nutrition overall in a rural population group is bad, certain subgroups, presumably the poorest, are disproportionately worse off.

Overall, child malnutrition occurs mainly in rural China where about 70% of the population live (see "Notes" at the end of this section). Here, the major determinants of poor nutritional status have been shown to be infection, household food availability, female gender, and low birth weight. In urban areas, the first two are not related to nutrition, but gender and birthweight are. Infant mortality is also higher in rural than urban areas, which is related to government health care expenditures and literacy. Infant mortality is responsive to changes in these, more so in poor counties.

Nutrition Amongst The Adult Population. Data obtained from surveys in 1989 and 1991 showed for the first time an overview of the trends in the nutrition amongst adults in China. The China Health and Nutrition Surveys is a longitudinal survey that covers the provinces of Guangxi, Guizhou, Henan, Hubei, Hunan, Jiangsu, Liaoning, and Shandong. The panel data of adults aged 20-45 years, analyzed by Popkin et al (1994), showed some significant changes in adult nutrition over the two years. The study classified those who were underweight as those with BMI <18.5, and those groups who were overweight or obese as those with BMI >25.0. In 1991, the proportion of adults classified as overweight was estimated at 11.2% (15.2% in urban and 9.4% in rural), whereas those classified as underweight was about 8.2%.

The trend analysis done by Popkin et al (1994) indicates that the proportion of adults classified as underweight decreased by 0.4% and the proportion classified as overweight increased by 1.9%, between 1989 and 1991. The largest increase in the proportion of overweight (4%) was observed among urban males. In the rural areas, the increase in the proportion of overweight adults was the same for both sexes (1.8%). There was an increase in the proportion of underweight men (1.5%) and women (0.5%) in the lowest income tercile. The study also showed that, concurrently, there was an increase in the proportion of overweight in middle income (3.5%) and high income subjects (3%).

Factors Affecting Trends in Nutrition

Economic Growth. Per capita GNP in China in 1993 was estimated at U.S.$490. Real GDP per capita grew by rapidly between 1986 and 1993, by 6.4% per annum.

The nutritional changes occurring between 1987 and 1990 in China reflect the rapidly evolving patterns of development in the country as a whole. The cities and major urban areas were booming in late 1980s and early 1990s. Economic growth in the rural areas, particularly in inland provinces, has lagged behind urban areas. Rural areas suffered from large out-migration, and have remained isolated from new investments which have been concentrated in urban areas, mainly in the coastal provinces of the country.

Quite consistent with the patterns of child nutrition is the increasingly different trends in the patterns of economic development between coastal and inland regions, and between urban and rural areas. Such disparity is now reflected in the increasingly widened gap in the nutrition of urban and rural areas. The various paths in socio-economic transformation happening in China can be illustrated in the changes happening in the inland provinces. In Heilongjiang, there appears to be a rise in prevalence of underweight children, but not in its urban areas. This can be compared to the fairly rapid economic growth in the coastal province of Guangdong, where the prevalence improved in both urban and rural areas (35.9% to 27.0% between 1987 and 1990).

The economic performance and sources of economic growth between inland and coastal provinces have been changing. Using published reports from China's Statistical Yearbook on economic data by region, the gross value of social output (measure adopted by China to measure overall economic development by area) showed that between 1980 and 1990, the share of economic output in the coastal regions increased from 46% to 56%, whereas the share coming from the inland regions declined from 53% to 44%.

Food Security. The guarantee of food security in the pre-reform era in China has given way to a new system where access to food has become more of a household responsibility than that of the state. In the period between 1987 and 1990, the data on food consumption in China indicate continuing increases from around 2600 kcals per capita to 2700 per capita on average. These are much improved figures compared to early 1980s. Overall grain output increased from 403 million MT in 1987 to 446 million in 1990, and meat increased from 22 million MT to 28 million in the same period. Households without access to land for agricultural production now have better access to food since food can now be purchased with cash income from commercial production or off-farm activities. However, the average figures showing increases in energy intakes mask regional problems, particularly for the inland provinces.

Data on food energy consumption and supply balance by province indicate that 10 of the 24 provinces were net deficit areas. These areas included those provinces for which the nutritional status of children were very high, such as the province of Yunnan. But although the country produces most of the grain needed to feed the population, transportation and storage problems make it necessary to import grain from overseas to feed the urban population in the coastal areas in the eastern seaboard.

Health. An important factor responsible for the static or deteriorating nutrition situation in rural areas is the poor performance of the health sector in rural areas. One of the negative consequences of the economic reforms was the loss of "socialist" privileges from the state such as medical care. The rural health insurance has been ineffective or is diminishing, which leaves a good proportion of these populations without access to adequate health services. The famous barefoot doctors are now starting to disappear in many areas. Hence, health services in rural areas deteriorated for many of the poor.

CHINA

(Estimates in 1993)

Population	: 1.2 billion
Population Density	: 120 per sq. km.
Population Growth Rate	: 1.5% per annum
Urban Population	: 27%
IMR	: 35
GNP US$ (Per Capita) (WB Atlas Methodology)	: 490
PPP estimates of GDP ($ Per Capita, in 1991)	: 2946

CHILD GROWTH AND SURVIVAL

Underweight preschool children (Percent below -2 s.d. weight for age)

Infant mortality rate (Per 1,000 live births)

ECONOMICS

GDP per capita (1987 Mkt. prices, Yuan / capita)

Debt service ratio (Debt service/exports)

FOOD

Food production index (Per caput, 1979-81=100)

Dietary energy supply (Kcals/caput/day)

Consumer price index (1980=100)

FPI/CPI ratio (1980=100)

HEALTH

Immunization coverage (Percent)

Access to local health care (Percent)

PUBLIC EXPENDITURES

Education and health expenditures (US $ per capita)

Education and health expenditures (Percent of government expenditures)

Conclusions

In recent years, there have been general improvements in the nutrition of children and adults in the country as a whole. It appears from the nutrition trends that, although the reform and development strategies adopted by China have been very effective in raising incomes, faster development in the urban areas, and generally in the coastal provinces, has widened the gap in the nutritional well being between these areas. The static trends in nutrition of children in inland areas maybe a result of the poor performance of health sector in the rural areas.

Another important conclusion is that China is rapidly moving towards conquering the problem of food scarcity and has begun a rapid epidemiological and nutrition transition. Recent data showed that, while the proportions of underweight adults have been declining, there has been a concurrent increase in the proportion of adults classified as overweight or obese. Obesity is often associated with conditions such as hypertension, high serum cholesterol, and insulin resistance that are strong risk factors for other chronic diseases, particularly coronary heart diseases. These findings have considerable implications for the preventive health care policy for China.

Notes

The reported figure of 60% urban population in some Chinese statistical books is caused by a different definition of rural population around 1990. Until the late 1980s, the rural-urban classification was based on whether a population received government food subsidies. Starting in 1984, the Chinese government began to broaden the administrative boundaries of cities by incorporating nearby rural counties. Thus, a rural county with an essentially agricultural population and no food subsidy may have been labelled urban even though it received no food subsidy. Realizing the inconsistency, recent China Statistical Yearbooks have adopted the 28-30% figure again, for the urban population.