China is expected to overtake the U.S. in the coming years as the world’s biggest economy, and it is fast closing in on another first with the rising rate of obesity among its citizens. Chinese citizens’ waistlines are quickly expanding as they indulge in their growing affluence. Just 20 years ago, back when most Chinese city dwellers were still pedaling bicycles to work and few could afford lavish, fat- and sugar-laden meals, not many were seriously overweight. By 2010, though, about 38.5% of all Chinese 15 or older were either overweight or obese, up 54% from 2002.
For a country far too familiar with famine, the abundance of affordable food for most Chinese is an unimagined luxury. But it is a mixed blessing, for diabetes and other health problems associated with obesity pose a daunting challenge for the country’s Spartan health system. So far, there are few signs that neither the government nor the public has come to grips with the fast advancing epidemic of obesity or the changes in lifestyles needed to counter it.
Weight Watchers International, Inc., the world’s leading weight management service company, found this out the hard way. It made little headway after setting up a China joint venture in 2008 with Groupe Danone of France and began revamping its strategy in July 2011. While Chinese increasingly are emulating American lifestyles, their unique habits and attitudes make it a very different and difficult market. “We decided to review the strategy. It was a joint venture and it was not working as we had hoped,” says Bruce Rosengarten, Asia Pacific president for Weight Watchers International.
The market is potentially a huge one. China, with its 1.3 billion people, may well soon have more obese people than the U.S., with its population of 311 million. According to the World Health Organization, among Chinese over 15, 45% of males and 32% of females are overweight or obese. Combined, the nearly 40% of overweight Chinese add up to some 500 million people. Among Americans, about 78% are overweight or obese. “It is a growing, serious problem in China, but it is not as bad as in the U.S. or other Western countries. There are a lot of fit people as well as a lot of unfit people in China,” says Sheldon Dorenfest, CEO of the Dorenfest China Healthcare Group, a Chicago-headquartered health care investing and consulting company.
A Focus on the Figure
In tackling China, Weight Watchers faces two main problems: its own inadequate understanding of the Chinese market and the unexpectedly different attitudes among its clientele toward what a healthy weight loss program should entail. “Most people in China do not understand the importance of having a healthy diet or that weight loss is about health. People see weight loss only in terms of shaping their figures,” Rosengarten says.
He says Weight Watchers’ foray into the Chinese market so far has been something of a laboratory experiment in learning about how different the market is. “We have to understand how they eat and how much they eat; how they cook their food. We also have to understand how their lifestyles changed in term of snacking, increased wealth and the influence of western lifestyles. People no longer ride bicycles — the shift to a sedentary lifestyle has been quite significant.”
The usual doctor’s orders for a change of diet and more exercise tend to fall on deaf ears, says Paul French, chief China market strategist for the U.K.-based Mintel Group and co-author of a book titled, Fat China, How Expanding Waistlines Are Changing China. “The problem is that everyone in China wants to do things very quickly … so they would rather go have liposuction or use slimming pills than commit to six or 12 months of exercising. They don’t want to change their diet, but they want a miracle cure,” says French, who has lived in China more than 20 years.
Weight Watchers is still revamping its China strategy, and Rosengarten declined to provide annual revenues or other operation-related figures. The company has two shop-front operations in Shanghai, holding 45 meetings per week in that city, four or five meetings a week in Beijing and three in Nanjing. The company’s approach of promoting weight loss through healthful habits, eating smarter and getting more exercise has yet to take hold. So far, the 6,000 people who have participated in the program have lost a combined 40,000 kg ¬– an average of less than 7 kg apiece.
In a worldwide shift of strategy, Weight Watchers is recalibrating its programs to appeal to men as well as women — in the past, the approach was too “feminized,” Rosengarten says. He expects to see a dramatic change in attitudes toward health in the next few years, as those aged 45 and over begin to develop chronic diseases and those approaching middle-age learn from their example. “They will say that they do not want to be like the 45-plus group and will start taking action. That will open up a new, big opportunity for Weight Watchers,” Rosengarten says. “We want to appeal to a broad cross-section of women and men, and we want to spread the message that we are not just about shaping, but about helping people to be healthy.”
A Growing Awareness
While most Chinese are still enamored of their newly comfortable lifestyles, there is a growing recognition of the hazards of weight gain, both for the young and old, especially given that Chinese appear predisposed to suffer from diabetes more easily than some other populations. A study led by researchers at the University of North Carolina found in July this year that the rate of diabetes among Chinese teenagers was nearly four times higher than among those in the U.S. The risk factor for heart disease was 50% higher among Chinese teenagers than for their American peers. Barry Popkin, a professor of nutrition at UNC’s Gillings School of Global Public Health who led the study, said in a statement, “What is unprecedented is the change in diet, weight and cardiovascular risk for children aged seven or older.” While many older Chinese have also grown fatter, most still shun Western fast foods, favoring a more traditional diet, albeit one much heavier in fats and meats than a generation ago. But many children have grown accustomed to dining on Kentucky Fried Chicken, McDonalds and snack foods. “China’s health care system will face a huge burden if nothing changes,” said Popkin, “Already, 1.7 million Chinese children aged seven to 18 have diabetes and another 27.7 million are considered prediabetic. In addition, one-third of children under age 18 had high levels of at least one cardiometabolic risk factor.”
This giant-sized problem is partly one of the government’s own making. Urban renewal has pushed many urban families out of city centers, as ownership of automobiles and scooters or e-bikes — the most convenient modes of transport for long commutes from newly built suburbs — has soared. At the same time, the government’s obsession with Olympic gold medals has meant few resources go into providing sports facilities for the general public.
Most Chinese view athletic activities as something only worth pursuing for competitive purposes. “The idea of offsetting the richer food you are taking in with physical activities does not play well in China. There is a perception that if you are physically active, it is because you are doing a lot of manual labor, or if you are physically active in sports, you are doing something competitive at the international level,” says Benjamin Shorbert, managing director of Rubicon Strategy Group, a Seattle-based consulting firm, and a China health care specialist. “That is part of the reason the problem is so profound. It is not unique to China, but the lack of being physically active is uniquely Chinese.”
A look at public sports facilities in Shanghai — or the lack thereof — amply illustrates the problem. “If you are capable of wining medals, there are a lot of facilities, special schools and closed facilities which are not open to the public,” French says. “For example, Shanghai, with a population of 23 million people, has how many public swimming pools?” In schools, too, sports get short shrift. “Parents get angry over their kid having an hour of swimming. They would rather their children do an hour of math or an hour of English,” says French.
A Coming ‘Tsunami’ of Health Issues
Shorbert chalks this up to general attitudes toward quality of life. “This is a poor country aspiring to have a [significant] middle class. It is a pursuit that is single-minded and shows very little consideration for other factors like diet, lifestyle or the environment (such as air pollution). They are all part of the same problem,” he says. While a small number of Chinese can be seen running in the mornings and evenings and eating healthier foods, they are generally the people who already were focused on a healthy lifestyle, he believes. But China may be reaching a tipping point, as obesity and related illnesses skyrocket. He expects a “tsunami” of lifestyle diseases in the coming decade, led by problems with diabetes. “The present health care system in China is nowhere near ready to begin to absorb the kinds of demands and the cost curve that is going increase due to the obesity epidemic. You will definitely see the beginning of the cost curve get out of the control in the next 10 years,” Shorbert says. “We already have children and teenagers with diabetes, and many more will get it when they are in 20s. There will be an explosion among diseases related to excess weight such as cancer, heart disease and hypertension, but diabetes is the big one because you cannot cure diabetes; you can only manage it,” he said. The New England Journal of Medicine reported in 2010 that China already had 92 million diabetics and another 150 million pre-diabetics, compared with about 26 million diabetics in the U.S.
With these tidal waves of ill health and chronic disease looming, China’s health care spending is projected to soar from US$357 billion in 2011 to US$1 trillion in 2020, according to a McKinsey report titled, “Healthcare in China, Entering Uncharted Waters.” The report attributes the huge spending increase to continuing urbanization, increasing disease burdens and chronic conditions such as diabetes and hypertension as many more people move into cites and their lifestyles change. McKinsey projects that 61% of all Chinese will be urbanized by 2020, up from 52% in 2012, as 142 million people migrate from the countryside to cities. Many of these former farm families already are making the transition, living in ghetto-like villages in city outskirts, snacking on the vast array of biscuits, chips and instant noodles that crowd the shelves of nearby convenience and grocery stores. While many young migrant workers remain slender, especially if they are working in factories or on construction sites, family members who join them appear to be gaining weight on heavy diets of such cheap processed foods.
The looming hit to the financial system from rising health care costs could even pose a threat to social stability, given the overburdened and underfunded state of the medical industry, says French. Already, frustrations with the medical system have led to violent attacks on doctors and other hospital staff. But strangely enough, because they have intruded into virtually every area of people’s private lives, particularly their reproductive lives, China’s leaders are loathe to interfere with general health and lifestyle issues, he says. “They already control people lives in so many ways that they do not want to tell people what they should buy and what they should consume,” French says. “The government already is doing so many campaigns [such as] patriotic civilization campaigns [and] trying to improve peoples’ driving skills campaigns. If they launched yet another campaign, about being careful of what you eat, people would not follow it.”
Given these facts of life, convincing Chinese who already work long hours and endure lengthy commutes to add an hour’s exercise to their already busy schedules is a tough sell, especially given the lack of adequate public recreation facilities. China’s middle class, and those aspiring to join them, are still too focused on pursuing economic gains. “I am not sure if the solution that the Western health care model would like to propose, which is a lifestyle change, a combination of diet change and exercise, would have much attraction in China in the next five to 10 years. This would suggests that this problem would get much worse,” says Shorbert.
He believes it will take years for Chinese to begin stepping back and questioning their quality of life. “That sort of internal evaluation will be a half-generation away,” he says.