Childhood obesity is an international problem in the 21st century. In Hong Kong, it is easy for us to find the increasing trend of child obesity rate from the media. Why does the problem happen in Hong Kong? Are there any solutions to reduce the childhood obesity? In this paper, I will firstly to talk about the seriousness of childhood obesity in Hong Kong. Then, I will explore the childhood obesity from the social determinants. Then, I will talk about the solutions of this health problem by using health promotion strategies.

The current situation of childhood obesity in Hong Kong

Childhood obesity as an international health problem

Childhood obesity is now becoming a worldwide problem nowadays. Obesity means a people who accumulates too much body fat and he or she will face on health problems in the future (Haslam & James, 2005). According to World Health Organization (2012a), obesity is one of the serious health problems in the 21st century and now there are 170 million overweight children who are under 18 years old. Also, more than 40 million children in the world under the age of five were overweight in 2010 (World Health Organization, 2012b).In every year, there are at least 2.6 million people die because of overweight or obese (World health organization, 2012c).

The negative effects from childhood obesity

Childhood obesity causes different problems in children’s development and health. LeBow (1986) had come out three potential dangers of not treating the fat child, including persistent obesity, barriers in the life and potential health threats. He thinks that obese children are stigmatized from peers, parents and society in the children’s development. This will leads them to enter into vicious circle that they have low self-esteem and become fatter and fatter. Many obese children think that they will still obese and it continues after they grow (Peckham et al., 1985; Stunkard & Burt, 1967). Yung (2009) has illustrated what diseases may lead by childhood obesity (See Figure 1). He also mentioned that if government fails to curb childhood obesity, there will be a lot of youngsters suffering from the diseases in the future.

Figure 1: Classification of medical and psychosocial consequences of childhood obesity (Yung, 2009).

The numbers and phenomenon of childhood obesity in Hong Kong

In Hong Kong, there is an increasing trend on the overall childhood obesity rate. Appendix 1 shows the latest data on childhood obesity in Hong Kong. According to the “[email protected]” Campaign (2012a), the overall obesity rate increases from 16.4% to 20.9% in the past 15 years. The numbers also show out that boys are easily to become obese than girls with around 5-10% of disparity on the obesity in different gender.

Besides the data from the government, more information reflects that the potential crisis on suffering from other diseases related to childhood obesity. A cross-sectional study from CUHK shows out that about 13% of boys and 11% of girls were obese in examining around 2 600 children aged 6-13 (Sung, 2007). It also mentioned that about 10% and 3% of the children were detected on having three or more and four or more of the six cardiovascular risk factors respectively, including high systolic blood pressure or diastolic blood pressure, high blood triglyceride, low blood high-density lipoprotein, high blood low-density lipoprotein, high blood glucose and high blood insulin (Sung, 2007). Also, patients are getting younger and younger to suffer from diabetes or cardiovascular diseases because of childhood obesity (Wan jiu xue tong, 2007).

Therefore, childhood obesity has become a major health care issue in Hong Kong from the facts in both statistics and news reports. In the next part, I will talk about the social determinants of childhood obesity.

The social determinants of the childhood obesity

The framework of social determinants in analyzing the childhood obesity

According to World Health Organization (2012d), social determinants of health include life, development and health system afforded by the distribution of power and resource. It also shows out the phenomenon as health inequity which affects people’s health status. World Health Organization – Western Pacific & South-East Asia (2008) had set up some index to evaluate the public health in Asia Pacific. In this time, I will borrow the framework to analysis childhood obesity in Hong Kong with adjusting the index and adding related factors (See Figure 2). The reason of adopting this framework is to show out how our social settings make childhood obesity instead of attributing to self-responsibility from individual. I also add the item “main stakeholders” because they are the main media to lead the things happening in society.

Factors

Main stakeholders

Original meanings

Adjusted meanings

Income and poverty

Family

Overall economic situation

Overall economic situation

Economic status of the grassroots

Lifestyle

Family

Eating habits

Physical activities

Eating habits

Physical activities

Personal growth

Education

School

Literacy rate

School setting

Culture and knowledge

Society

Not including

Traditions,

views and knowledge of food

Figure 2: The framework to analysis the childhood obesity in Hong Kong

Family

Family is one important sector in enforcing the childhood obesity because they have the most responsibility to take care their children. From our born to independence, it is not only fulfill children’s basic life but also learning the foundation of knowledge and skills. Therefore, they have an important responsibility in forming the childhood obesity.

Income and poverty

Economic status affects people’s health in their life. World Health Organization – Western Pacific & South-East Asia (2008) mentioned that poor people are hard to maintain their health because they lack of resource to access health service and take actions to prevent diseases. It also mentioned that Hong Kong is regarded as a high-income country from the World Bank in 2008. It also has a better medical system comparing to other developed countries. At the same time, there is a big disparity between the rich and the poor with high gini index around 53.3% (Central Intelligence Agency, 2007). So, the overall economic situation and economic status of the grassroots should be attended on analyzing the health problem in different class.

Meals with more meat and less vegetables are common after the improvement of economy. Every Hong Kong people consume 150KG meats in 2011 which is more than the US (Gang ren shi rou, 2012). Many parents regard children should eat more meat in their meals because of their physical development. Some parents even do not limit the amount of meat to their children because they think they should provide the best to their children if they can. In hence, children may bring up an unbalance diet. Parents will become more difficult to improve children into correct diet. When the children eat too much meat unconsciously, it will cause child obesity if the children lacks of enough exercise at the same time.

To the grassroots, fast-food is easily to lead childhood obesity. It is because poor children in Hong Kong usually follow their mothers, who are usually the new immigrants, to the fast food shops. According to Chan, Deave and Greenhalgh (2010), fast-food shops are good places for them to meet other parents and friends. They also think it is a more safety places than playgrounds. Additionally, Hong Kong style fast food is unhealthy. For example, 2 pieces of Western Toast (西多士) have 356 kcal, 19g fat, 116mg cholesterol, 513mg sodium and 8g saturated fat (Xiao xue sheng san, 2004). It is easy for children to overtake nutrition and harmful substances as Trans fats.

Except the grassroots, having too much fast food is also common for normal families. According to Chan, Deave and Greenhalgh (2010), long-hours culture is always happened on adults. To save time, some parents may buy fast-food or pre-prepared food as dinner to their children. Some children may provide “holding meal” in the evening and it always leads them not to eat dinner very late at night. Children eat too much fast food chronically and it will easily to become child obesity.

Lifestyle

Lifestyle is the way a person lives. From the World Health Organization – Western Pacific & South-East Asia (2008), diet and physical activity are the ways to promote and maintain good health in a country. Obesity means the unbalance state in high diet and low physical activities. Family should make sure their children to have enough nutrition but not overdose.

Unhealthy meals are one of the main factors to cause childhood obesity. Except having fast food or meals with more meat and less vegetables, another source of unhealthy meal is from bad cooking habits both from Chinese and Western. One of the examples is that Chinese prefer to use more oil and animal fat to cook the meal so the children have higher Cholesterol levels than foreign children (Fu mu tai qian, 1999). Another example is that Western meals may have high calories but low fiber as Baked Pork Chop with Rice containing over 1,200 calories (Yuan li zhu pai fan, 2003). If parents do not count nutrition intake, children will eat too much and it will become obese very easily.

Another factor for childhood obesity is lacking exercise. Doing exercise is a way to consume extra nutrition and maintain personal health. According to the Community Sports Committee of the Sports Commission (2012), about 80% tested children thinks that they have enough exercise but only 9% fulfill the US standard of physical fitness. Lacking exercise of Hong Kong children has lasted over 10 years.

There are few reasons to explain the phenomenon. The first reason is the school setting and I will explain later. The two one is the sense from parents. If parents are active in doing exercise, their children will also have more sense to do the exercise. Unfortunately, there are around 35% of parents with no participation in sports and more than 60% of families cannot arrange family sports time during each weekend (Community Sports Committee of the Sports Commission, 2012). The third one is the children spend too much time on different electronic screen. According to the Community Sports Committee of the Sports Commission (2012), about 40% of Hong Kong children aged 7-12 spend more than 5 hours on sedentary activities like studying and recreation. If children spend more time on the screen, they will have less time to do the exercise.

School

Schools are another important stakeholder in solving the childhood obesity. It is because children spend 1/3 of the whole day in schools for learning. If a school can convey enough health information through lessons and activities to the students, they can sustain their health on their lifetime and produce less health problems when they grow up.

Education

Public concerns on education are largely on formal education issues in a school setting. World Health Organization – Western Pacific & South-East Asia. (2008) evaluates the public health in different countries by assessing the literacy rate and enrollment rate. In Hong Kong, compulsory education is provided to the children for leading high literacy rate and enrollment rate, which are 94% and 74% respectively (World Health Organization – Western Pacific & South-East Asia, 2008). So, it seems the childhood obesity may not relate to insufficient knowledge. According to the Community Sports Committee of the Sports Commission (2012), the tested children reflect that too much school work is the barriers for doing exercise. Therefore, school setting may be a good way to observe childhood obesity.

Unhealthy food provided by the tuck shops and lunch supplies lead childhood obesity. Although Education Bureau and Department of Health create different guidelines to encourage schools for providing healthy food, there are still a lot of schools providing unhealthy food through tuck shops and meals. According to Chen (2008), 90% of primary schools still sell unhealthy snacks in their tuck shops. Maintaining revenue and student tastes are the reasons for the tuck shops continuing to provide unhealthy food. Also, guidelines cannot limit the schools to provide unhealthy food. Over 40% of primary schools still provide unqualified meals without enough vegetables and fruits (Si cheng xiao xue, 2009). 80% of kindergartens provide unqualified meals with over intake of fat, salt and health food products (Du & Cai, 2011). If children eat too much unhealthy food without enough exercise, it is not difficult for them to become obese.

Indifference on Physical Education and play areas is another reason to lead childhood obesity. Normally, students in primary schools have 2-3 Physical Education lessons with 35 minutes per lesson in each week. Only 22 minutes are doing exercise and even 4 minutes for moderate to vigorous exercise can be done in each Physical Education lesson (Chen, 2006). For kindergarten students, there are only 20 minutes for physical activities (Chan, Deave and Greenhalgh, 2010). Many schools also do not allow students to run during the recess because of not enough space and safety to everyone. It is a backward concept criticized by Dr. Patrick Lau who is a professor of the Department of Physical Education at Hong Kong Baptist University (Jia Xiao jin pao, 2005). Students can only conduct static activities which leads them have no chances to do the exercises. This will let students cannot release the extra nutrition which will cause obesity.

Over-emphasizing on academic subjects is also the problem for childhood obesity. Starting from Primary 4, students are forced to put more efforts on academic subjects because of a good path for a better secondary school and university. Sometimes, Physical Education lessons are sacrificed for academic subject lessons or classroom guidance. Also, tutorial classes after school is very common in Hong Kong.. Whether primary school or secondary school students, they will always spend some time after school to attend those lessons. This will reduce the student’s chance to do enough exercise to prevent child obesity in their leisure time.

Society

Society is the third stakeholder in solving the childhood obesity. It is because society has a force to integrate and coordinate different people and organizations for solving the problem. Also, it has the most influence on promoting healthy lifestyle.

Culture and knowledge

Culture is the values, beliefs, behavior and material objects that together form a people’s way of life (Macionis, 2006). Knowledge is someone who familiarizes somebody or something on facts, information, descriptions, or skills from experience or education. Culture and knowledge are directly affecting people’s mind and behavior.

Some Chinese tradition proverbs do not encourage children to do the exercise in their daily life. One is called “Fat equals to blessing” (肥是福氣). It means if a person is fatter, it also equals to a stable life. This is more popular to old generation because they have lower education level comparing to the young couples. Another one is called “diligent makes contribution and games are no use” (勤有功¼Œæˆ²ç„¡ç›Š). These concepts are widely in our society so that exercise is not preferred. For example, some grandparents may think that English is important than games because of low walkability and limited opportunities (Chan, Deave and Greenhalgh, 2010).

Fast food culture is also common in Hong Kong. It is not difficult for us to find a fast food shop in urban areas. They always promote their food or promotion on different media as TV or websites. The culture is very fit in Hong Kong because fast food strengths on efficiency which matches long working hours. On the other side, children loves to eat fast food too because it fits their taste.

The information of nutrition is not very clear to Hong Kong people. Although Hong Kong has nutrition labels since 2010, there are still around 40% people not or seldom attending the labels (Janice, Mingo & Sharon, 2011). Public are always late to know some of the products which is not as health as they imagine. According to Huang and Xin (2006), the content of sugar, salt and fat are over the normal standard in many corn chips.

Because of the social determinants in childhood obesity, the obesity rate for overall primary school students raises from around 16 % to around 21% in the past 10 decade. In the next part, I will introduce the health promotion strategies to reduce the problems of child obesity.

The health promotion strategies to tackle the childhood obesity

Health promotion means a process to lead people for improving their health with increasing the sense and applying the behavior. The responsibility of health promotion is not only at the health sector, but also to reach healthy lifestyles (World Health Organization, 1986). To solve the childhood obesity, I regard five approaches to health promotion by Naidoo and Wills (2000) and social marketing should be used to solve childhood obesity in Hong Kong. It is because it can easily to assess what strategies Hong Kong has done and anything should be improved during the promotion. In the next part, I will talk about what stakeholders would be needed to conduct the health promotion. Then I will focus on the five approaches with related measures to solve the problem, introducing current measures and new measures.

Stakeholders for health promotion

In the social promotion, there will be two stakeholders to conduct the health promotion. One is the government and another one is the Non-Government Organizations.

Government

Government is very important in the health promotion. It will have different cooperation between hospitals, clinics, District Council, sport facilities, schools and families.

Non-Government Organizations.

Non-Government Organizations are always the forerunner to sense the problems in society. They are also strength on the flexibility when they promote in small organizations.

It is because there are so many plans conducting to reduce childhood obesity, I can only use some famous examples to talk about how the strategies apply in our daily life. First, figure 3 shows the effects of the six approaches to health promotion in child obese.

The medical approach

Prevention and treatment

Behavior change

Encouraging somebody to adopt health behaviors

The educational approach

Providing knowledge and skills for personal choice in applying health behavior

Empowerment

Powering up somebody to concern and help in the issue

Social change

Creating choices with suitable cost, availability or accessibility

Social marketing and media

Increasing public awareness on particular concepts or behavior and stimulate public’s mind for the response

Figure 3: The effects of the six approaches to health promotion in child obese

Source: Naidoo and Wills (2000)

Promotions from government

Medical system in stopping childhood obesity

This system will focus on the prevention and treatment of childhood obesity in the media way. This is using the medical approach because of prevention and treatment in childhood obesity. Nowadays, Hong Kong had created the family health service and student health service for the children to check their health status from their born to 18 years old. It also connects with Specialist for the referral to treat the obese children. Maternal and Child Health Centres and Student Health Service Centre are distributed in different areas for children to do body check. Different Student Health Service Centre has the connection with hospitals in the same network. For example, the centre in South Kwai Chung can refer the children to Pediatrics and Adolescent Medicine at Princess Margaret Hospital.

The government can use the centres for scanning out the obese children from the checking on BMI, blood pressure and urine. Overweight or obese children will refer to assessment centres or Pediatrics and Adolescent Medicine in hospitals. They will do more body checking as exsanguinate to confirm their body status and give suitable treatment to them as Nutritionist for health meal suggestions. This approach is to find out the obese children and reduce the deterioration of them.

Social marketing

Social marketing and media is common used by local government. The promotion is using a simple and clear way to focus on single concept or behavior, The usage is to raise public awareness on particular concepts or behavior and stimulate public’s mind for the response. For example, the government had promoted the concept of “Two Plus three Every Day” through the TV advertisements. The aim of this advertisement is to explain the importance of enough amounts of vegetables and fruits in daily life. It also presents the examples on how do we count on eating enough vegetables and fruits.

Campaign cooperating with schools

[email protected] is one of the campaigns to promote healthy lifestyle in eating. It uses educational approaches to do the promotion because the plan provides teaching materials for school to spread the knowledge to parents and students for choosing health meals in daily life. Except teaching, the scheme wants schools to provide more healthy food to the students by giving them some guidelines. For example, there are over 20 documents to help schools for choosing suitable food supplies for tuck shop and lunch (“[email protected]” Campaign, 2012b). Through this approach, government prefers schools and students can choose the more healthy meals by themselves.

Promotions from Non-government Organizations

Smart Kids Fitness project

This project was created by Centre for Health Education and Health Promotion from the Chinese University of Hong Kong. There is cooperation between the professionals, schools and parents. This plan includes teacher training and support, needs assessment and progress monitoring, parent training and supports, tailor-made weight-management plan for individual students, 12-week weight management intervention programme and school-based health promotion programme (Centre for Health Education and Health Promotion, 2008). Figure 4 shows the concepts of the project.

Figure 4: A Health Promoting Schools’ Approach in Addressing the Problem of Childhood Obesity (Source: Centre for Health Education and Health Promotion, 2008)

It contains different approaches for its promotion. Firstly, Education approach is used to teachers, parents and students with related knowledge. The project strengths at using behavioral approach and empowerment approach. Through the tailor-made weight-management plan and 12-week weight management intervention programme, students had created the sense to supervise their own health and try to improve their health with changing their habits with their parents. This can also power up their confidence to manage their health. Last but not least, the organization thinks that it is success because they can create sustainability on the participators (Centre for Health Education and Health Promotion, 2008).

Recommendations for reducing childhood obesity

To me, different strategies applied by the government and non-government organizations are needed in reducing childhood obesity. From my observation, I regard many strategies focus on creating health lifestyle but little on food choices and easy exercise which can do it everything. So I will suggest two directions for increasing the approach of behavior change and social change.

Firstly, the government can cooperate to Green Monday, which is a non-government organization for promoting vegetarian food on each Monday for health and environment. For example, Cafe De Coral is one of the restaurants to join Green Monday. It will provide 2 dishes of vegetarian food on the Green Monday. The government can encourage food suppliers to join by adding the conditions in the tenders of tuck shop and lunch suppliers. Specific details need to be discussed but I may suggest some conditions to explain the idea. For example, tuck shops and lunch suppliers need to provide at least 50% of healthy food and drinks on Green Monday. If the bidders can meet the conditions, he or she will have the advantages in bidding the contracts or having subsides in operating the business. The reasons of promoting the day are to respond some of the tuck shops or lunch suppliers still providing too much unhealthy food to the students for many years and create a sense to students that they can choose for eating healthier meals.

Secondly, the government can promote easy exercises for urban people. One of the social determinants is parents and children have no sense to do the exercise. Climbing stairs activities and fitness walking are two examples for the promotion. Both exercise are easy to learn and do it in the surrounding areas as park or blocks. They are also suitable to whole family members. These exercises may increase the incentives to people for doing exercise.

Conclusion

To conclude, Hong Kong is an international city who also has childhood obesity as other countries in the 21st century. Everyone knows that obesity is harmful to adults and child but it is different to change personal lifestyle because society contains different elements which are not benefit to our health. Although our government and non-government organizations try their best to change the situation, there are still a lot of children who are living in unhealthy life. But I think we should have confidence to face on the childhood obesity because social atmosphere of healthy lifestyle will be informed gradually if we insist for healthy lifestyle.