chp obesity 2005
TRANSCRIPT
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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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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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Initiatives to prevent overweight and obesity
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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Initiatives to prevent overweight and obesity
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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Initiatives to preve
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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Initiatives to prevent overweight and obesity
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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Initiatives to preve
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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Initiatives to prevent overweight and obesity
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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Initiatives to preve
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
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Initiatives to prevent overweight and obesity
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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Initiatives to preve
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
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Initiatives to prevent overweight and obesity
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
Initiatives to preve
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Initiatives to preve
(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
Initiatives to prevent overweight and obesity
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Initiatives to prevent overweight and obesity
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
Initiatives to preve
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Initiatives to preve
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
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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
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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
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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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