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Journal of Public Health Advance Access originally published online on November 6, 2007
Journal of Public Health 2008 30(4):436-448; doi:10.1093/pubmed/fdm057
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© The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Community-based interventions to reduce overweight and obesity in China: a systematic review of the Chinese and English literature



Yang Gao, Postdoctoral Fellow

Sian Griffiths, Director

Emily Y. Y. Chan, Assistant Professor
School of Public Health, the Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China

Address correspondence to Yang Gao, E-mail: gaoyeung{at}cuhk.edu.hk

Background Overweight and obesity pose a challenge to public health in China. According to Chinese definition, 303 million Chinese are overweight (body mass index, BMI ≥ 24 kg m–2). Among them, 73 million are clinically obese (BMI ≥ 28 kg m–2). In line with the global trend, the rate of obesity in China continues to increase, with associated morbidity and mortality. This study was to identify interventions, which are effective in Mainland Chinese society.

Methods All non-drug-controlled interventions (≥3 months) in Mainland China, which used anthropometric outcome measures, were selected from three Chinese and nine international electronic databases (before May 2006) and included in this systematic review.

Results A total of 20 studies met the selection criteria and were included in the review. Among them only one was published in an international journal. Most studies combined at least physical activity, dietary intervention and health education. Seventeen studies (85%) reported significant effects in anthropometric measurement outcomes.

Conclusions Comprehensive interventions with at least physical activity, dietary intervention and health education may be effective in reducing obesity in Chinese children. The role of grandparents as carers in the one-child society is worth considering further. Current evidence of effective interventions for adults is limited. Publication bias in Chinese databases should be taken into account.

Keywords: obesity, overweight, prevention, systematic review


   Introduction
TOP
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Acknowledgements
 References
 
The rapid increase in overweight/obesity has become a global problem for public health, not only in developed countries but also in developing ones.1 According to the World Health Organization (WHO) classifications, defining overweight and obesity as a body mass index (BMI, kg m–2) ≥25 and 30, respectively, 1.6 billion adults (aged ≥15 years) worldwide are currently overweight and more than 400 million are obese.2 In China, the overweight and obese adults (aged ≥18 years) are 195 and 25 million, respectively.3 This identifies one out of eight overweight people and one out of 16 obese people in the world are Chinese. However, increasing evidence has shown that obesity in China might be underestimated by the WHO's classifications. The Asia-Pacific recommendations (BMIs of 23 and 25) are provisionally built on limited evidence from studies outside Mainland China.4 New Chinese classifications, with a BMI ≥ 24 for overweight and a BMI ≥ 28 for obesity, have been recommended based on the data of the Chinese national surveys.5 Using the Chinese definitions, the estimated number of overweight and obese Chinese in 2005 would reach 303 and 73 million, respectively (Table 1). The rise of overweight/obesity in China started in the late 1980s, mainly caused by increased energy intake and decreased physical activity.8,9 As elsewhere, it is widely believed that the rising trend will continue if effective intervention strategies are not undertaken to reduce it.


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  		Table 1 Prevalence and estimated population of overweight/obesity in China (2005)

 
Since the 1990s, a large number of intervention programmes in China, either focusing on reducing obesity as an aim, have been initiated or are ongoing. However, there has been no systematic review of the existing interventions published. Internationally, several systematic reviews have been undertaken to address this issue, but none of these included interventions in China due to challenges associated with the access and translation of Chinese written and published research. Language is also a major barrier to publishing Chinese studies in international English journals. As a result, the Chinese literature has mainly been excluded from international reviews.

Whilst The English-language-published literature highlights the potential for some community-based interventions to be effective in reducing obesity, cost-effective approaches to decrease or even reverse the rising trend of obesity through reducing risk levels are being developed.1,10 Commonly adopted interventions included healthier diets, promoting physical activity and reducing sedentary time (usually reducing TV viewing), health education, counselling, as well as changes in familial, social and cultural environments, which address the wider determinants of obesity.11

This review describes the existing literature in Chinese journals and identifies effective components from interventions with anthropometric measures as outcomes.


   Methods
TOP
 Introduction
 Methods
Results
 Discussion
 Conclusions
 Acknowledgements
 References
 
The search strategy was developed according to recommendations by the Cochrane Health Promotion and Public Health Field.12 The relevant studies published before June 2006 were searched in three Chinese and nine international electronic databases with a combination of subject headings and textwords. Search words (also their counterparts in Chinese) consisted of three main categories: weight-related (including obese, obesity, overweight, weight change, weight gain, weight loss, etc.), intervention-related (including diet, exercise, behaviour therapy, prevention, etc.) and subject-related (including adults, youth, children, etc.). The appendix showed the search strategy in details. The Chinese databases available since 1994 included: Chinese Medical Current Contents, Chinese Biomedical Literature Database and Chinese Journal Full-text Database. The international databases included: MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, as well as four EBM reviews (ACP Journal Club, Cochrane CCTR, Cochrane DSR and DARE).

Studies that evaluated public health programmes aiming to prevent, control or reduce either obesity or obesity-related risk factors (e.g. diet, physical activity, wider environmental factors) implemented in China were included. Community studies in which obesity prevention was not a primary aim but a potential outcome were also included in this review (e.g. interventions to reduce cardio-cerebral vascular diseases in the community in China). The further inclusion criteria were: (i) the intervention duration was not <3 months; (ii) a control group; (iii) anthropometric measures were used as outcomes (e.g. weight, BMI) and (iv) the full text was available. There were no further limits on study design. However, studies assessing clinic-based programmes focusing on the treatment of obesity were excluded from the review. References listed in the articles were also selected following the inclusion and exclusion criteria. ‘Effective’ interventions were defined as those with statistically significant benefits in outcomes in the intervention group compared to the control one (P < 0.05). The quality of studies was assessed from eight aspects based on the Quality Assessment Tool for Quantitative Studies and the appraisal criteria recommended by the Cochrane Effective Practice and Organization of Care Review Group.12–14


   Results
TOP
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Acknowledgements
 References
 
Search results
In total, 20 studies met the selection criteria and were included in this review, among which, only one was published in an international journal (Fig. 1).15–34 Figure 2 shows the location of the 20 studies and overweight (BMI ≥ 24) prevalence distribution in China in 2002.35 There were 14 studies evaluating programmes among children and adolescents in either school or family. The remaining six assessed interventions among adults and none of them were implemented in the workplace. Except for anthropometric outcomes, most studies also measured changes in knowledge, attitude, behaviour or any combinations of them and showed significant differences between the intervention and control groups.15–21,24–27,29–34 Table 2 summarizes the assessment of the studies. Tables 3 and 4 separately show the summaries of the included studies undertaken in children and adults. Meta-analysis was not performed because of heterogeneity in the age group of subjects, interventions, duration as well as outcome measurements among studies.


Figure 1
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  		Fig. 1 Diagram of literature search flow.

 


Figure 2
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  		Fig. 2 Overweight (BMI ≥ 24 kg m–2) prevalence distribution by province and location of 20 studies in China.

 


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  		Table 2 Summaries of study assessment

 


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  		Table 3 Summaries of 14 studies in childhood and adolescent overweight/obesity

 


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  		Table 4 Summaries of six studies on adulthood overweight/obesity

 
Interventions for overweight/obesity among children and adolescents
Six studies evaluated the integrated population-wide interventions, i.e. interventions that involved both the healthy weight and overweight/obese population groups.15–20 Except for one study undertaking only health education (among pre-school students),16 all others included at least physical activity, dietary intervention and health education. The duration of the interventions varied between 1 and 3 years. All studies reported results by changes in obesity prevalence before and right after interventions. One study observed a slight but insignificant increase in obesity prevalence in the intervention group from that in the control one (1.7 versus 0.7%);20 one found a significant net effect of 17.3% (changes in obesity prevalence in the intervention group minus that in the control one) for girls only;18 and the other four reported significant benefits for both genders, with overall net effects varied from 4.2 to 12.2%.15–17,19 There were three studies that evaluated the national Health Promoting Schools (HPS) project aiming to control obesity in the primary schools of three cities, but observed inconsistent outcomes (Table 3).17,18,20 Li et al.17 showed significant benefits in the intervention group for both genders after a 1-year intervention. Wang et al.18 indicated that the intervention was effective only in girls after a similar duration (10 months). Shi et al.20 indicated that the HPS project could not effectively prevent and treat obesity after a longer-term intervention (2 years). The HPS project was co-launched by both the Chinese government and the WHO, and participant schools are required to implement interventions through setting up leadership groups, establishing health-related school policies, closely working with the local community, establishing an inclusive ethos, training staff, improving school physical environment and promoting a sense of responsibility in individuals for their own actions, health-related behaviours and lifestyles.

The other eight studies focused on the overweight/obese population only.21–28 Six studies implemented comprehensive interventions adopted from ‘the routine for prevention and treatment of childhood simple obesity’,36 consisting of promoting physical activity, encouraging a healthy diet, education and behaviour modification at least for 1 or 2 years. Outcomes were measured by different indicators, including change in body weight, BMI and percentage of body weight over the Standard Weight-for-Height recommended by the WHO. All studies reported significant benefits: Yang22 observed a less weight gain of 2.34 kg; He et al.21 and Jiang et al.27 found a reduced BMI by 2.9 and 2.5 kg m–2, respectively; and the other three studies showed percentage of over the WHO Standard Weight-for-Height decreased by 7.7–10.6%.24–26 The remaining two undertook physical activity only for a relatively short duration: one conducted in a university setting, which observed 11.1% obese youth whose weight became normal after 3-month interventions,23 whereas the one in kindergarten failed to control weight gain through 4-month interventions.28

Interventions for adulthood overweight/obesity
All of the six studies in adults were implemented in the community.29–34 Two interventions focused on reducing obesity, and both of them undertook comprehensive approaches (physical activity, diet and education): one undertook interventions among the general population for 1 year and reported no significant difference in the means for body weight change between the intervention and control groups (–0.16 kg);34 the other one focused on overweight adults (BMI ≥24) only and found significant effect on decreasing BMI (–1.16 kg m–2) after 10-month interventions.29

The other four studies assessed programmes of prevention and control of cardio-cerebral-vascular diseases in the community, with an aim of reducing obesity. Two studies measured the effectiveness of 2-year individualized interventions in hypertensive subjects (urban residents) and those at risk of hypertension (rural residents), and both of them showed significant effects.30,31 In the study among urban hypertensives, 6.8% overweight/obese subjects in the intervention group lost their weight to be normal, whereas 5.1% more subjects in the control group became overweight;30 in the one among rural residents, the overweight rate decreased by 3.5% in the intervention group whereas that increased by 18% in the control one.31 The remaining two adopted quasi-experimental study design to evaluate long-term effectiveness of interventions. Different samples for each measurement were separately and randomly drawn from the whole community. One study assessed a series of health education and health promotion programmes in the three cities for three times (after 3, 5 and 8 years, respectively) and showed gradually and significantly preventive effects, with a net effect on decreased obesity prevalence of 4.8% after 8-year interventions.32 The other study measured the effectiveness of interventions in urban, suburban and rural residents after a duration of 5 years, and significant effect was only found in urban adults (decreased BMI of 1.03 kg m–2).33


   Discussion
TOP
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Acknowledgements
 References
 
Main finding of this study
Twenty studies in China met our selection criteria and were reviewed in this study: 14 were interventions for childhood and adolescent obesity, and six were in adults. Thirteen studies combined at least physical activity, dietary intervention and health education. Seventeen studies reported significant effects in anthropometric measurement outcomes.

What is already known on this topic
Overweight and obesity rates in Mainland China increased by 46.8 and 80.6%, respectively, in the decade between 1992 and 2002 and pose an increasing challenge to the population's health as the country becomes increasingly affluent.9 At present, two major features of the overweight/obesity distribution in China are: people living in the north are at higher risk than those in the south; rates among urban populations are higher than in rural ones.9 Evidence of effective interventions in the community in China was previously unknown. Internationally, there are numerous systematic or literature reviews addressing this public health issue published though none of them included the studies in China.37–45 Doak et al.37 showed that most prevention measures for overweight and obesity reviewed found significant benefits, with physical education in schools and reducing television viewing being more effective.37 Sharma38 reviewed 11 interventions in the UK and the USA and indicated that TV viewing may be the most modifiable, followed by physical activity and eating behaviours. However, Summerbell et al.39 concluded that evidence was not enough to support that the physical activity and/or healthier diet were effective to prevent childhood obesity; although comprehensive strategies combined both, together with psycho-social support and environmental change they might help.39 Connelly et al.40 indicated that the previous systematic reviews of controlled trials of interventions for childhood obesity had not applied practice-relevant guidance. Their systematic review found that the major factor distinguishing effective from ineffective studies was the provision of aerobic physical activity on a ‘compulsory’ rather than ‘voluntary’ basis. Gibson et al.42 concluded that there was little evidence in the effectiveness of dietary interventions (with a low-fat energy-restricted diet as a core component) for interventions of childhood obesity. As for adults, evidence showed that low-fat diets, not low- or very low-calorie diets, were associated with weight loss.43 Dietary interventions combined with exercise resulted in a greater weight reduction than each of them alone,43,44 whereas both of them plus psychological interventions (e.g. behavioural and cognitive-behavioural strategies) were most effective.45

What this study adds
This is the first systematic review of interventions for obesity in China published in both local Chinese journals and international English ones. All non-drug-controlled interventions in both children and adults were selected according to the systematic search strategy.

Interventions for children and adolescents
Comprehensive interventions in China to reduce childhood obesity may be effective, especially those focusing on obese populations. Physical activity, dietary interventions and health education are the effective components. Engaging children's interest is a key factor for effective physical activity, while involvement of parents is determinative to effective dietary interventions. In addition, effective components of dietary intervention include eating slowly and eating low-caloric foods first (e.g. soup, vegetable) during a meal, avoiding sugary drink, snack and western fast foods as well as no eating after supper. Health education encouraging physical activity, healthier eating and better knowledge of health is likely to be an effective component. The HPS project has strengthened links between schools and local communities. However, that was not shown to make a direct contribution to reduce obesity in children. It was not possible to comment on the sustainability of the impact because all included studies estimated interventions right after their implementation.

Traditional and political differences from other countries may make a difference when implementing interventions for childhood obesity in China. In the Chinese tradition and culture, fat people are thought to be happy, lucky, rich and have a high quality of life.35 This may lead to children being over-fed. Children are also likely to be over-protected, as the impact of the one-child policy has predominantly led to only one child in most urban families, where most studies took place.46 Promoting fatness as wellness may well be more likely to occur when grandparents live as part of the family. Within Chinese families, grandparents are very influential, reflecting the Chinese veneration of age and promotion of family values. Many older retired people have time to help with childcare and their thinking and behaviours may be more heavily influenced by Chinese tradition resulting in a preference to over-feed children and be over-protective towards them. As a result, living with grandparents may be a significant barrier to address when implementing interventions.16–21,24–26

Interventions for adults
From the literature reviewed, the current evidence is insufficient to draw a conclusion on the effectiveness of community-based interventions for adult obesity. First, the number of interventions focusing on adulthood obesity was limited (two studies). Moreover, community-based interventions for cardio-cerebral-vascular diseases (a target of reducing obesity) were initiated in 31 demonstrations during 1996–2003;47 among them, only four met our selection and exclusion criteria and were reviewed. As a result, it is not possible to make any conclusion in relation to their effectiveness.

Tang et al.33 implemented a programme in urban, suburban and rural residents, but it was found to be effective in urban residents only. One possibility may be that the development of obesity and its determinants are at different stages in urban and rural areas. The main drivers of obesity in an area are its economic growth and social development, such as the process of urbanization, modernization and globalization. However, there are large disparities between urban and rural areas: urban areas are relatively well developed and overweight/obesity has become a health threat to the public there, whereas rural areas are currently developing, and poverty and underweight are still prevalent. That might result in significant differences in the effectiveness of interventions. Taking the results from the national nutrition and health survey in 2002 as an example, the overall prevalence of obesity (BMI ≥28) in large cities (10.6%) was about quadruple of that in Class 4 rural areas (the poorest ones, 2.7%),48 whereas the prevalence of underweight of children <5 years old in urban areas (3.1%) was one-third of that in rural areas (9.3%).7 Thus, interventions need to be locally tailored.

Limitations of this study
We suspect that there is likely to be a publication bias in favour of the positive results observed. Some interventions were excluded from this review because of suboptimal study quality (e.g. no control group, limited description of interventions or unclear results in anthropometric measurements), whereas others were excluded as they had provided inadequate details about evaluations. We also searched studies on relevant governmental websites (e.g. national and local health sections and the Centre for Disease Control and Prevention, CDC) and published conference reports, but failed to find studies meeting our selection criteria. We further sought advice from experts in the national and several local CDCs. They indicated that assessments of intervention programmes were not paid enough attention in China until recent years, which resulted in the fact that some measured outcomes were not presented, especially for those without statistical significance or those unsupportive of their hypotheses. As a result, it is likely that the effectiveness of interventions may be over-estimated in our study. In addition, along with the ‘Guidelines to prevention and control of overweight/obesity for Chinese adults’ issued in 2003, new and well-planned community-based interventions have been launched and are still ongoing, but their evaluations are so far unavailable and therefore not included in this review.


   Conclusions
TOP
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Acknowledgements
 References
 
We conclude that comprehensive interventions with physical activity, dietary intervention and education may be effective in reducing childhood and adolescent obesity in China, whereas existing evidence is too limited to draw a conclusion of the effectiveness of community-based interventions in adults. The limitations of the study, e.g. publication bias and suboptimal study quality of primary studies, need to be taken into account. There is an urgent need for more interventions to reduce obesity in China, with high quality in study design, organization, management, implementation and assessment. Engaging the family can ensure the effectiveness of interventions, and since grandparents may be a barrier to the implementation of healthy policies to prevent obesity, future initiatives should include targeting them as well as promoting safe exercise environments,10 which may be helpful to increase children's physical activity levels. Unlike in developed countries (e.g. the US and the UK), costs of healthy traditional foods (e.g. vegetables) are still relatively lower in contemporary China, compared with those of westernized high-energy foods, and should be promoted. In addition, further community-based interventions need to be localized and tailored to address local circumstances of the huge and diverse Chinese population.

Appendix: search strategy for English literature in international electronic databases
Searching date: 01 July 2006.

Databases: CDSR, ACP Journal Club, DARE, CCTR, AMED, British Nursing Index, CINAHL, EMBASE, INSPEC BIOMEDICAL, IPAB, Ovid MEDLINE(R) In-Process, Other Non-Indexed Citations, Ovid MEDLINE(R), Ovid MEDLINE(R) Daily Update, PsycINFO.


No. Search history Results
1 Exp OBESITY/ 144 874
2 Exp Weight Gain/ 40 792
3 Exp Weight Loss/ 44 657
4 obes$.af. 210 037
5 (weight gain or weight loss).af. 131 574
6 (overweight or over weight or overeat$ or over eat$).af. 59 418
7 weight change$.af. 11 499
8 ((bmi or body mass index) adj2 (gain or loss or change)).af. 2968
9 or/1-8 352 500
10 Exp Behavior Therapy/ 65 633
11 Exp Social Support/ 72 189
12 Exp Family Therapy/ 24 118
13 Exp Psychotherapy, Group/ 28 567
14 ((psychological or behavio?r$) adj (therapy or modif$ or strateg$ or intervention$)).af. 186 229
15 (group therapy or family therapy or cognitive therapy).af. 116 183
16 ((lifestyle or life style) adj (chang$ or intervention$)).af. 11 535
17 counsel?ing.af. 215 138
18 social support.af. 108 652
19 (peer adj2 support).af. 5636
20 (children adj3 parent$ adj therapy).af. 4875
21 or/10-20 542 449
22 Exp OBESITY/dh [Diet Therapy] 4581
23 exp Diet, Fat-Restricted/ 4891
24 Exp Diet, Reducing/ 10 021
25 Exp Diet Therapy/ 104 094
26 exp FASTING/ 46 771
27 (diets or diet or dieting).af. 417 920
28 (diet$ adj (modif$ or therapy or intervention$ or strateg$)).af. 36 092
29 (low calorie or calorie control$ or healthy eating).af. 7078
30 (fasting or modified fast$).af. 94 953
31 Exp Dietary Fats/ 71 330
32 (fruit or vegetable$).af. 84 092
33 (high fat$ or low fat$ or fatty food$).af. 29 009
34 formula diet$.af. 1220
35 or/22-34 603 615
36 Exp EXERCISE/ 132 494
37 Exp Exercise Therapy/ 44 104
38 exercis$.af. 399 463
39 (aerobics or physical therapy or physical activity or physical inactivity).af. 185 065
40 (fitness adj (class$ or regime$ or program$)).af. 2296
41 (aerobics or physical therapy or physical training or physical education).af. 143 107
42 Dance therapy.af. 1165
43 Sedentary behavio?r.af. 924
44 or/36-43 548 802
45 exp Complementary Therapies/ 198 750
46 (alternative medicine or complementary therap$ or complementary medicine).af. 47 841
47 (hypnotism or hypnosis or hypnotherapy).af. 27 030
48 (acupuncture or homeopathy or homoeopathy).af. 50 893
49 (chinese medicine or indian medicine or herbal medicine or ayurvedic).af. 39 003
50 or/45-49 270 475
51 ((diet or dieting or slim$) adj (club$ or organi?ation)).af. 286
52 (weightwatcher$ or weight watcher$).af. 179
53 (correspondence adj (course$ or program$)).af. 463
54 (fat camp$ or diet$ camp$).af. 149
55 or/51-54 1050
56 Exp Health Promotion/ 81 895
57 Exp Health Education/ 217 405
58 (health promotion or health education).af. 252 321
59 (media intervention$ or community intervention$).af. 14 533
60 Health promoting school$.af. 1562
61 ((school or community) adj2 program$).af. 55 402
62 ((school or community) adj2 intervention$).af. 30 676
63 (family intervention$ or parent$ intervention).af. 19 998
64 (parent$ adj2 (behavio?r or involve$ or control$ or attitude$ or educat$)).af. 89 245
65 or/56-64 492 522
66 Exp Health Policy/ 132 871
67 Exp Nutrition Policy/ 46 526
68 (health polic$ or school polic$ or food polic$ or nutrition polic$).af. 116 442
69 or/66-68 197 109
70 Exp OBESITY/pc [Prevention & Control] 7922
71 Exp Primary Prevention/ 91 875
72 (primary prevention or secondary prevention).af. 53 282
73 (preventive measure$ or preventative measure$).af. 20 917
74 (preventive care or preventative care).af. 13 442
75 (obesity adj2 (prevent$ or treat$)).af. 20 981
76 or/70-75 184 912
77 Randomized controlled trial.pt. 436 318
78 Controlled clinical trial.pt. 143 017
79 Exp Controlled Clinical Trials/ 481 605
80 Exp Random Allocation/ 97 360
81 Exp Double-Blind Method/ 215 659
82 exp Single-Blind Method/ 22 314
83 exp Placebos/ 108 325
84 *Research Design/ 17 240
85 Exp Intervention studies/ 6 781 682
86 Exp Evaluation studies/ 685 207
87 exp Comparative Study/ 1 618 242
88 Exp Follow-Up Studies/ 589 708
89 Exp Prospective Studies/ 356 996
90 Exp Cross-over Studies/ 49 880
91 Clinical trial.tw. 101 958
92 Clinical trial.pt. 738 245
93 Latin square.tw. 4369
94 (time adj series).tw. 17 627
95 (before adj2 after adj3 (stud$ or trial$ or design$)).tw. 4 199 243
96 ((singl$ or doubl$ or trebl$ or tripl$) adj5 (blind$ or mask)).tw. 275 926
97 placebo$.tw. 310 156
98 random$.tw. 987 509
99 (matched communities or matched schools or matched populations).tw. 239
100 control$.tw. 3 104 233
101 (comparison group$ or control group$).tw. 362 634
102 matched pairs.tw. 5141
103 (outcome study or outcome studies).tw. 12 577
104 (quasiexperimental or quasi experimental or pseudo experimental).tw. 7872
105 (nonrandomi?ed or non randomi?ed or pseudo randomi?sed or quasi randomi?ed).tw. 20 872
106 prospectiv$.tw. 509 985
107 volunteer$.tw. 233 606
108 or/77-107 12 432 509
109 21 or 35 or 44 or 50 or 55 or 65 or 69 or 76 2 418 942
110 9 and 109 and 108 94 358
111 Animals/ 4 029 322
112 exp CHILD/ 1 736 608
113 exp ADOLESCENT/ 1 555 980
114 exp CHILD, PRESCHOOL/ or CHILD/ 1 574 976
115 exp INFANT/ 884 955
116 (child$ or adolescen$ or infant$).af. 4 007 066
117 (teenage$ or young people or young person or young adult$).af. 271 647
118 (schoolchildren or school children).af. 62 329
119 (pediatr$ or paediatr$).af. 1 053 085
120 (boys or girls or youth or youths).af. 231 349
121 or/112-120 4 324 185
122 110 not 111 86 178
123 122 and 121 25 799
124 China.mp. [mp = ti, ab, tx, kw, ct, ot, sh, hw, it, tn, dm, mf, id, rw, nm, tc] 72 846
125 Chinese.mp. [mp = ti, ab, tx, kw, ct, ot, sh, hw, it, tn, dm, mf, id, rw, nm, tc] 137 138
126 124 or 125 186 000
127 126 and 123 390
128 Remove duplicates from 127 336
129 128 336


   Acknowledgements
TOP
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgements
References
 
We acknowledge Prof. Elizabeth Waters, Chair of Public Health, School of Health and Social Development, Deakin University, Australia and Prof. TANG Jingling, Director of The Hong Kong Branch of the Chinese Cochrane Centre, School of Public Health, the Chinese University of Hong Kong for helping in revisions and providing valuable comments of the manuscript. We are also grateful to those experts who provided us valuable advice, especially Prof. WU Fan, Director of National Center for Chronic and Non-communicable Disease Control and Prevention, China CDC, Prof. XU Ruiheng, the former Deputy Director of Guangdong Provincial CDC, Prof. LIU Xiaoli, Director of Shenzhen Center for Chronic Disease Prevention and Treatment.


   References
TOP
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgements
 References
 

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