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2011 Bentham Science Publishers Ltd. Obesity in China: What are the Causes? Karen M. von Deneen1,3 , Qin Wei1 , Jie Tian1,2 and Yijun Liu3, *

1 Life Sciences Research Center, School of Life Sciences and Technology, Xidian University,

2 Medical Image Processing Group, Insti- tute of Automation, Chinese Academy of Sciences,

3 Departments of Psychiatry and Neuroscience, McKnight Brain Institute University of Florida,

100 Newell Dr. L4-100K, Gainesville, FL 32610, USA Abstract: To address the causes for obesity in all of China is not feasible in a single article. There are hundreds of ethnic groups over a vast number of provinces. The diet and lifestyle of each is different based upon cultural/ethnic traditions and the environment. Several studies mentioned in this review have been done in particular areas and/or on specific population groups with regards to obesity and health risks associated with being overweight. Obesity is a multifactorial disease that is associated with genetic, physiological, environ- mental, and cultural/traditional perspectives in order to provide a broadened view on this epidemic in China. In this review, we will as- sess specific obesity gene and environment interactions, childhood obesity etiology, metabolic syndrome, and dietary and behavioral causes. We attempt to discuss obesity issues particularly in the Han Chinese population ranging from children, adolescents, adults to geriatrics. Keywords: Obesity, overweight, China, insulin resistance, hypertension, type

2 diabetes mellitus, metabolic syndrome, dyslipidemia. INTRODUCTION Obesity in China is becoming a pandemic disease resulting from a shift in energy balance caused by altered genes, a sedentary lifestyle, and neurohormonal imbalances. It is spreading to low- income and middle-income countries, such as China, as a result of novel dietary habits, promoting chronic diseases and premature mortality [1]. Work-related activities declined recently in industrial- ized countries, whereas leisure time is dominated by televi- sion/computer programs and other physically inactive pursuits [2,3]. In China, overweight rates doubled between

1991 and 2006, and the number of obese individuals tripled [4]. The prevalence of obesity in men was 10.5% in mainland China [5], and 16.3% in the Hong Kong population [6]. The prevalence of diabetes in China parallels that in the United States, with more than

92 million cases [7]. More importantly, related health care costs are also substantial [8]. The vicious obesity cycle begins with excess adipose leading to chronic low grade inflammation that results in insulin resistance (IR) along with hypertension, atherosclerosis, dyslipidemia and type

2 diabetes mellitus (T2DM), which are consistent findings of metabolic syndrome (MetS) [9]. In the past, obesity has been de- fined by the body mass index (BMI) [10]. BMI is the result (kg/m2 ) of dividing the weight (kg) by the height squared (meters). The accepted range for BMI

30 is obese. Obesity consists of three other categories including Class I: BMI 30.0 - 34.9, class II: BMI 35.0 - 39.9, and class III: BMI 40.0. Morbid obesity is considered to be >

35 [11]. However, as seen by a few of our pilot studies, BMI is not the best method for measuring obesity in China as well as other populations such as body-builders and geriatrics [12]. There- fore, to obtain a better picture of the weight status of an individual, BMI should be measured along with waist circumference (WC) and waist-hip ratio (WHR). WC of >