Series
Obesity in China 3
Lancet Diabetes Endocrinol
2021; 9: 446–61
Published Online
June 4, 2021
https://doi.org/10.1016/
S2213-8587(21)00118-2
This is the third in a Series of
three papers about obesity in
China
For the Chinese translation of the
paper see Online for appendix 1
*Contributed equally
Global Health Institute, School
of Public Health, Xi’an Jiaotong
University, Xi’an, China
(Prof Y Wang PhD, L Gao MS);
Department of Health Policy
and Management, West China
School of Public Health and
West China Fourth Hospital,
Sichuan University, Chengdu,
China (L Zhao PhD);
Department of Epidemiology
and Biostatistics, School of
Public Health, Tongji Medical
College, Huazhong University
of Science and Technology,
Wuhan, China (Prof A Pan PhD);
Department of Health
Administration and Policy,
College of Health and Human
Services, George Mason
University, Fairfax, VA, USA
(H Xue PhD)
Correspondence to:
Prof Youfa Wang, Global Health
Institute, Xi’an Jiaotong
University, Xi’an 710061, China
youfawang@gmail.com
446 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021
Health policy and public health implications of obesity in
China
Youfa Wang*, Li Zhao, Liwang Gao, An Pan, Hong Xue*
China has experienced many drastic social and economic changes and shifts in people’s lifestyles since the 1990s, in
parallel with the fast rising prevalence of obesity. About half of adults and a fifth of children have overweight or obesity
according to the Chinese criteria, making China the country with the highest number of people with overweight or
obesity in the world. Assuming that observed time trends would continue in the future, we projected the prevalence of
and the number of people affected by overweight and obesity by 2030, and the associated medical costs. The rising
incidence of obesity and number of people affected, as well as the related health and economic consequences, place a
huge burden on China’s health-care system. China has made many efforts to tackle obesity, including the
implementation of relevant national policies and programmes. However, these measures are inadequate for controlling
the obesity epidemic. In the past decade, China has attached great importance to public health, and the Healthy
China 2030 national strategy initiated in 2016 provides a historical opportunity to establish comprehensive national
strategies for tackling obesity. China is well positioned to explore an effective model to overcome the obesity epidemic;
however, strong commitment and leadership from central and local governments are needed, as well as active
participation of all related society sectors and individual citizens.
Introduction been rising steadily in China since the 1990s. Nowadays,
China has experienced many drastic social and China has the highest number of people with
economic changes in the past four decades, including, overweight and obesity.2,3 People’s eating and physical
but not limited to, rapid economic growth, urbanisation, activity behaviours are shaped by complex factors and
living and working environment, built environment, their interactions in the expanding obesogenic
food environment, dietary pattern, and lifestyles.1 In environment.
parallel, the prevalence of overweight and obesity has Obesity has substantial health, economic, and social
consequences. China has made many efforts to tackle
obesity, including the implementation of national
Key messages policies and programmes to promote healthy lifestyles
• The prevalence of overweight and obesity and their and to prevent non-communicable diseases (NCDs).4,5
associated medical costs have increased substantially in However, these efforts are clearly inadequate for
China over the past four decades, and will continue to controlling the rapid growth in incidence of overweight
and obesity in China. During 2015–19, we developed a
increase without effective prevention and control
strategies in place comprehensive report, the China Blue Paper on Obesity
• Some policies and programmes for obesity prevention have Prevention and Control, in collaboration with the
been implemented in China, but are inadequate; Chinese Nutrition Society and other leading domestic
such efforts need to address the multilevel and multifaceted and international experts.6,7 The Blue Paper aimed to
encourage policy makers, professionals, researchers, and
policy, environmental, economic, social, and behavioural
drivers of obesity other stakeholders in society to take more vigorous
• A coordinated and supportive policy system, including efforts in overcoming the obesity epidemic. More
laws and regulations, is pivotal in creating a regulatory awareness of the obesity problem is required to combat
environment that empowers the general population to the epidemic in China.
make healthier lifestyle choices In the first paper in this Series, we discussed
• All stakeholders, including governments, public health obesity prevalence, dynamics, trends, population-level
practitioners, health-care service providers, health deter­minants, and individual-level risk factors for
insurers, industries, communities, schools, families, overweight and obesity in China.8 In the second paper
and individuals, should work together to improve the in this Series, we summarised the latest progress in the
obesogenic environment and to promote healthy lifestyles clinical manage­ment and treatment.9 In this third Series
• More research is urgently needed in China to evaluate the paper, we provide an overview of the public health
effectiveness and cost-effectiveness of obesity-related implications of the obesity epidemic in China, in terms
policies and to facilitate development of effective and of morbidity and mortality and its burden on the health-
sustainable solutions, which could also help other countries care system; examine policy implications; and propose
policy recommendations on the basis of empirical
 Series

evidence and expert opinions. In addition, we modelled

Overweight Obesity Overweight and
the future prevalence of overweight and obesity and the obesity
medical expenditures attributable to these conditions in
Adults (aged ≥18 years)
China.
Year 2012 2030 2012 2030 2012 2030
All 32 440·4 51 578·0 12 825·3 27 417·2 45 265·7 78 995·2
Public health implications of obesity in China
Men 16 736·2 28 020·6 6683·5 15 696·7 23 419·7 43 657·1
Obesity and NCDs
Women 15 709·6 23 551·0 6147·2 11 881·6 21 856·8 35 415·5
We have comprehensively searched the literature and
Urban 18 357·0 24 580·7 7478·8 14 031·6 25 835·8 38 618·6
summarised the evidence about obesity and risk of NCDs
Rural 14 300·7 25 005·1 5401·3 12 527·5 197 02·0 37 476·4
and mortality, particularly that from prospective cohort
studies (appendix 2 pp 4–12).10–44 Few publications were School-aged children (aged 7–17 years)

available before 2000, which could be because few cohort Year ·· ·· ·· ·· 2014 2030

studies were established at that time in Chinese All ·· ·· ·· ·· 1783·2 5891·7

populations and because obesity was not as common and Urban ·· ·· ·· ·· 2096·9 3486·9
did not receive enough attention. Cohort studies started to Rural ·· ·· ·· ·· 1417·7 2484·9
emerge after 2000 and most publications were published Preschool-aged children (aged ≤6 years)
in the past decade. In general, these cohort studies in Year 2012 2030 2012 2030 2012 2030
Chinese populations have substantiated that overweight All 895·1 1374·8 330·3 444·3 1225·4 1819·1
and obesity were prospectively associated with higher Boys 513·3 785·7 196·6 279·0 709·9 1064·7
risks of hypertension,10–12 type 2 diabetes,13–19 cardiovascular Girls 374·0 581·8 129·9 172·4 503·9 754·2
disease,20–28 and particular cancers, such as breast,29 color­ Urban 470·5 590·7 184·9 267·8 655·4 858·5
ectal,29,30 endometrial,31 liver,31,32 ovarian,31 and pancreatic.33 Rural 427·2 756·1 147·5 181·0 574·7 937·1
A number of large cohort studies in Chinese populations Different BMI cutoff points based on national or international BMI references were
have reported that BMI associated with the lowest used to define obesity and overweight for different age groups: weight-for-height
mortality risk was in the range of 23·0–27·0 kg/m².34–44 greater than 2 (for overweight) and greater than 3 (for obesity) SDs above WHO’s
2006 Growth Standards median for children younger than 5 years49; BMI-for-age
Examples of selected studies are described in greater than 1 (for overweight) and greater than 2 (for obesity) SDs above WHO’s
appendix 2 (pp 1–2). 2007 Growth Reference median for children aged 5–6 years50; and Chinese sex-age-
Nevertheless, future studies are still needed to fill some specific BMI cutoff points for individuals aged 7–17 years (corresponding to BMI
24·0 kg/m² for overweight and 28·0 kg/m² for obesity at age 18 years) and for
important knowledge gaps. First, most of the studies in adults aged 18 years and older (24·0–28·0 kg/m² for overweight and ≥28·0 kg/m²
Chinese populations used BMI or waist circumference for obesity). Our projection analyses were done on the basis of published
measurements at one single timepoint and were done in prevalence estimates, which were based on different national survey data for the
middle-aged and older populations (aged ≥30 years). different age groups. The number estimates for 2012 or 2014 were based on actual
prevalence and those for 2030 on projected prevalence. Some results for school-
However, people’s weights change over the lifecourse,45 aged children are not provided because only the national estimates on the
and some studies in the USA indicated that obesity status combined prevalence of overweight and obesity were published, rather than
and weight change in early life period (eg, young adults) separate prevalences, and we did not have access to the original national survey
data to calculate missing prevalence data.
could have a profound effect on the risk of NCDs and
mortality in later life.46–48 Second, few studies have Table: Projected number (×10 000) of adults and children with
investigated how fat distribution and body composition overweight and obesity in China in 2030
affect the risk of NCDs in Chinese populations. Third, the
joint impacts of BMI and waist circumference or fat
distribution on the risk of NCDs are less studied in prevalence rates for school-aged children and adolescents
Chinese populations than in populations of high-income (aged 7–17 years) were from the Chinese National Survey
countries. Finally, studies on weight loss interventions on Students’ Constitution and Health (1995, 2000, 2005,
among people with overweight or obesity and their effect 2010, and 2014).53 The prevalence rates for preschool-
on risk of NCDs are scarce in Chinese populations. aged children (aged ≤6 years) were from the Chinese
National Nutrition Surveys (2002 and 2010–12).52 Details
Predictions of future obesity prevalence of the national surveys are described in the first paper of
Using results from large national surveys done this Series.8 Linear models of the prevalence of
between 1992 and 2018 among nationally representative overweight and obesity predicted by survey years were
samples, we projected the prevalence of and the number fitted for the three age groups, separately. The models
of people who would be affected by overweight and fitted the data points well (R² 0·97–0·99). We projected
obesity by 2030 in China, separately for adults (aged that, by 2030, the prevalence of overweight
≥18 years) and children (table). The prevalence rates of (BMI 24·0–28·0 kg/m²) and obesity (BMI ≥28·0 kg/m²)
overweight and obesity in adults used in our analysis might reach 65·3% in adults, 31·8% in school-aged
were from the Chinese National Nutrition Surveys (1992, children and adolescents (the Chinese sex-age-specific
2002, 2010–12, and 2015–19) and from the China Chronic BMI cutoff points), and 15·6% in preschool-aged
Disease and Risk Factor Surveillance (2013–14).51,52 The children (WHO standards), while the number of people

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with overweight and obesity might reach 789·95 million, not accounted for. In addition, more research is needed
58·92 million, and 18·19 million, respectively (table; to understand the indirect costs associated with
figure 1; appendix 2 p 3). This scenario is alarming overweight and obesity (including, but not limited to,
considering the potential burden on China’s health-care presenteeism, absenteeism, early retirement, and
system and the overall impact on the health of the disability), and to include them in the total economic
Chinese population. costs.

Medical costs of obesity in China Policy implications for tackling the obesity
Research on the medical costs of obesity in China epidemic in China
remains scarce. We identified six studies that estimated The obesity epidemic has become a public health
the costs attributable to overweight, obesity, or both, in emergency in China, which also provides unprecedented
China using nationwide survey data (appendix 2 p 3).54–59 opportunities to improve the country’s policies and health
With the assumption that the trends in the prevalence sectors to overcome the epidemic. We analysed and
and costs of overweight and obesity observed in the assessed China’s existing policies, and consulted national
China Health and Nutrition Survey56 would continue and international leading experts to seek their recommen­
into the future, we fitted linear regression models to dations for future obesity policies in China.
project the medical costs that would be attributed to
overweight and obesity in China by 2030. Our projection Current state of obesity-related national policies and
analysis suggested a medical cost of ¥418 billion programmes
(approximately US$61 billion), accounting for about We systematically identified 70 obesity-related national
See Online for appendix 2 22% of total national medical costs (figure 1; appendix 2 policies and programmes implemented in China since
p 3). It is worth noting that our projection might be 1949. These programmes can be categorised into three
conservative because we used the historical estimates at groups: (1) nutrition and school-based actions (eg,
the lower end of published cost estimates, and the Chinese Student Nutrition Day), and school-based
increases in health-care service costs over time were nutri­tion support programmes (eg, National Nutrition

450 Historial estimates of attributable medical costs 70

(% estimate of total medical costs)
Linear predictions of attributable medical costs 65·3
(% estimate of total medical costs)
400 Quadratic predictions of attributable medical costs
(% estimate of total medical costs) 60
Linear predictions of prevalence

350
Medical costs attributable to obesity and overweight, Yuan billions

417·8 (21·5%)
50
50·7
300

Prevalence of obesity and overweight, %

46·5

42·0 40
250 202·7
(15·0%)

200
30
29·9

150
64·3 (8·4%) 170·6 (8·8%)
20
20·0
100
29·4
(5·9%) 113·5 (8·4%)
19·1 10
50 (5·0%) 56·5 (7·3%)
2·6
(1·2%) 55·0
(7·3%)
0 0
1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035
Time, year

Figure 1: Projections of overweight and obesity prevalence in Chinese adults (aged ≥18 years) and the attributable medical costs for 2030

448 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021

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Available prevention resources

MACRO

MESO
Intervention programmes
Individual

Family
Prevention policies MICRO

Dynamic energy balance,

School nutrient, microbiome,
Social culture
organ, tissue, cells,
and norms
gene, etc
Community
Legal and regulation systems

Health-care

Global trade Health-care policies

National and provincial food policies

Figure 2: A conceptual framework informed by a systems approach for obesity prevention and control in China
Modified from Wang and colleagues.65 In this new framework, community, school, and health-care influences are added at the meso level to guide the specific
prevention actions at this level; energy-balance dynamics at the micro level are also reflected.

Campus Program, Early 1000 Days of Life Nutrition and
Health Action, Student Nutrition Improvement Action,
and Healthy Children Action Plan [2018–20]); (2) actions
pro­mot­ing exercise (eg, Happy 10 Minutes, Sunshine
Sports Activity, and walking action for professional
people); and (3) comprehensive actions (eg, National
Healthy Life­style Action [2017–2025] and the so-called
three reduc­ tions and three health-promoting actions
[ie, salt reduction, sugar reduction, oil reduction,
healthy weight, healthy oral cavity, and healthy bones]).
Our findings indicate that existing policies primarily
address people’s diet and physical activity, with a focus
on children (appendix 2 pp 14–16).
In recent years, China has introduced new policies to
promote public health. Although these policies are not
specifically aimed at obesity prevention and control, many
of them include strategies and action goals related to
obesity. In 2016, China announced the Healthy China
national development strategy,60 which required integra­
tion of health into all policies and provided a historical
opportunity to establish a compre­hensive policy system
for obesity prevention and control. In October, 2020,
China announced the strategical plan for obesity control
and prevention in children and adolescents.61 The plan
specifies the national aim of reducing the annual growth
rate of childhood overweight and obesity during 2020–30
by 70% of that seen during 2002–17, and emphasises the
importance of healthy diet and physical activity, as well as
the responsibilities of parents, schools, health-care
organisations, and governments in over­ coming the
epidemic.61
In general, substantial progress needs to be made to
advance obesity-related policies in China to promote
multilevel systematic changes, from the socioecological
and behavioural levels to downstream health services
and medical interventions.
A systems approach-guided framework for obesity
policy implications and recommendations
Obesity presents a complex systems challenge.62 As the
first paper in this Series reported, obesity in China has
been driven by multilevel and multifaceted policy, environ­
mental, economic, social, and behavioural factors.8
­
Despite the debate surrounding the drivers behind the
global obesity epidemic, it is widely accepted that obesity
prevention and control should target all aspects of the

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 Series
obesity problem;63 therefore, a systems approach could
effectively accelerate obesity prevention.64 Thus, we used a
systems approach-guided framework and proposed
multilevel and multifaceted policy recommendations to
address the multiple dimensions of the obesity epidemic
in China.62 Figure 2 depicts our proposed obesity
prevention and control framework informed by a systems
science approach, which recognises the complexity,
context, and dynamic nature of the obesity epidemic.
In the Chinese context, systems that contribute to the
obesity epidemic include multilevel sectors and actors.
First, systems contribute at the macro level, such as
general institutional and policy systems; fiscal systems
that influence energy balance behaviours through taxation
and subsidies; food systems, from production to
processing and distribution; and social environment
Panel 1: Recommendations for future national policies and efforts to combat obesity in China
Establish a comprehensive legal and regulation system for
obesity prevention and control
• Develop and implement evidence-based laws and
regulations to improve the legal system to support obesity
prevention and control—eg, health promotion and
education, restrictions in unhealthy food production,
and marketing
• Develop and implement national standards and
guidelines to support obesity screening, diagnosis,
prevention, and treatment at the population level and
clinical level
Improve governmental responsibility and accountability,
enhance cross-sector collaboration, and take comprehensive
measures to implement obesity prevention and control
• Governments should provide leadership to develop,
implement, and enforce regulatory policies
• Governments should coordinate cross-sector or public–private
collaborations
• Governments should advocate for needed funding for obesity
prevention and control
Improve the obesogenic environment
• Effectively monitor and regulate the food system, including
food and beverage production and marketing, to ensure a
supply of healthy foods and beverages
• Enforce a compulsory nutrition labelling system for the
catering and food industry
• Restrict the production, sale, and advertisement of
prepackaged food products high in energy density,
saturated fat, trans fatty acids, and added sugar or salt
• Improve the built environment to promote physical
activities (including footpaths, bicycle lanes, and public
sports venues and facilities) through urban planning, city
zoning, and community parks at the municipal level
• Encourage and facilitate the use of public transportation
systems through subsidy programmes and public awareness
initiatives
450 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021
systems that govern cultural and social norms, as well as
health-care systems, with governments and industries as
the major actors. Second, systems contribute at the meso
level, such as food and built environment systems at the
local level with communities, workplaces, and schools, as
well as the interaction and influence of individuals on
each other. Third, cells, tissues, and organisms, and their
emergent properties have important roles in the complex
obesity system at the micro level (figure 2).
Recommendations for improving China’s policy system
and efforts for obesity prevention and control
Under a systems approach-guided framework and on the
basis of current scientific evidence from various countries
and populations, experts’ opinions, and obesity prevention
strategies advocated by international organisa­ tions
Establish fiscal policies for obesity prevention and control
• Impose taxes on unhealthy foods and beverages
• Provide subsidies to promote healthy eating and healthy
lifestyles
Foster healthy families, communities, hospitals, workplaces,
and schools
Healthy families
• Encourage families to prepare healthy family meals,
including an adequate intake of fruits and vegetables,
with less added sugar, salt, and fat
• Encourage family members to live a healthy life, with a
healthy diet and adequate physical activity, following related
guidelines
• Encourage family members to have regular physical
examinations
Healthy communities
• Establish activity centres, footpaths, small parks, indoor
and outdoor fitness venues, and self-service testing points
for health management, with equipment for measuring
height, weight, and blood pressure
Healthy hospitals
• Employ qualified clinical nutritionists
• Offer meals that meet standard guidelines to patients
• Provide health education for patients during the various
contact times and venues
Healthy workplaces
• Provide employees with annual physical examinations
• Provide annual workshops to promote exercise and
healthy eating
Healthy schools
• Provide mandatory health, nutrition, and physical
education
• Prohibit the sale of unhealthy snacks and sugar-sweetened
beverages on site
(Continues on next page)

(Continued from previous page)
• Provide appropriate gym and playground facilities
• Recruit adequately qualified physical education teachers
• Provide health clinics with adequately qualified health
workers
• Provide students with access to health-care services,
including annual measurements of weight and height and
assessments of weight status
Improve the health service system for obesity prevention
and control
• Implement systematic training for obesity prevention and
management among medical students and medical
personnel, and incorporate such training in their
continuing education
• Establish community health service centres to provide
weight management services
• Incorporate obesity assessments and interventions into
the contracted services of family doctors and service
programmes offered by the local Centers for Disease
Control and Prevention system
including WHO, World Bank, UNICEF, Asian Develop­
ment Bank Institute, we propose a set of policy recom­
mendations (panel 1). Multiple sectors and relevant parties
within society could work together to help people to
develop healthy eating habits and to maintain a healthy
bodyweight (panel 2). It should be noted that these recom­
mendations are not intended to provide a comprehensive
list of specific obesity policies; rather, they are meant to
provide high-level guidance and an overview of the key
areas that should be targeted for effective obesity preven­
tion and control in China. The order of these recom­
mendations reflects the policy options, from the macro
level to meso level and micro level. Governments, related
agencies and public health practitioners at different levels
(ie, central, provincial, municipal, and local), and other
stakeholders could prioritise policy options on the basis of
their specific settings, goals, resources, and target
populations.
Develop China’s policy system for obesity
prevention and control through laws and
regulations
Existing obesity-related policies in China are fragmented.
A coordinated and supportive policy system is pivotal in
creating a regulatory environment that promotes systems
changes to tackle the obesity epidemic.
Evidence available for the importance of regulatory
policies in obesity prevention and control
As proposed by international organisations, such as the
World Bank and UNICEF, regulatory policies are central
in obesity prevention through limiting unhealthy dietary
intake and promoting healthy diet and lifestyles.66,67 On the
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• Encourage hospitals to begin clinically practising weight
management and to standardise nutrition, exercise,
and medicinal operations
• Include obesity treatment in health insurance coverage and
associate medical reimbursement with weight-management
outcomes in people with obesity
• Require community, district, and regional hospitals, and
medical centres at different levels to build special
programmes and to recruit appropriate personnel to
provide a weight-management service
Reduce inequalities in obesity
• Tackle increasing disposable income, nationwide
urbanisation, cultural differences, and unequal economic
development across different regions, which are major drivers
of inequalities
• Ensure that obesity prevention policies and strategies fully
take into account these inequalities and are tailored to target
populations at high risk to address, narrow, and prevent
future gaps in obesity prevalence among subpopulations,
ensuring health equity
basis of the chronic disease prevention model and data
from six low-income and middle-income countries,
including China, Cecchini and colleagues68 suggested that
establishing food advertisement regulations could help to
reduce BMI by 0·03–0·78 kg/m² in children aged
2–18 years, and that food labelling might lead to a BMI
reduction of around 0·02 kg/m² among consumers.
Promoting reductions of ultra-processed food and
beverage consumption through laws and regulations
should be one of the most urgent actions to be taken in
China. Ultra-processed foods and beverages, such as
packaged foods and snacks, cookies, carbonated soft
drinks, and many other pre-prepared and ready-to-eat
products, are formulations with additives and most of
the ingredients result from a series of industrial
processes.69 Based on data collected between 2013
and 2018, a study done by the George Institute for
Global Health (Sydney, NSW, Australia) found that
Chinese packaged foods and beverages had the highest
median saturated fat content (3·4 g/100 g) and the
highest median total sugar content (8·3 g/100 g)
compared with several other countries, such as
Australia, Canada, Chile, the UK, and the USA.70 In a
randomised crossover trial, Hall and colleagues71 found
a causal role of ultra-processed foods in excess energy
intake. Findings from a systematic review and meta-
analysis of 43 observational studies suggested that
higher consumption of ultra-processed food (ranging
from >23·0% to 30·8% of total calories from
ultra-processed food) was associated with a higher odds
of overweight (OR 1·36, 95% CI 1·23–1·51; p<0·001)
and obesity (1·51, 1·34–1·70; p<0·001) than was lower
consumption (ranging from <11·0% to <17·8% of total
 Series
Panel 2: Suggested intervention approaches and policies to promote healthy dietary habits in children
Maternity and childcare hospitals
• Strengthen mothers’ health knowledge, including
knowledge and skills to promote healthy lifestyles and
weight management
• Help parents to cultivate children’s healthy dietary behaviours,
and develop healthy dietary habits throughout their lives
• Prevent abnormal birthweight due to suboptimal maternal
nutrition
• Educate women on weight management and help them to
develop healthy eating behaviours and habits during prenatal
inspections and post-partum visits
• Provide education on and encourage breastfeeding and
feeding of adequate supplemental food during the postnatal
visit
• Provide annual check-ups for children aged younger than
7 years, measure their height and weight, evaluate growth
and whether or not they have overweight or obesity, and
inform parents
Family
• Help children to develop healthy eating habits
• Encourage family members to serve as good role models
for children regarding dietary intake
• Pay attention to food prepared at home and the balance
between food intake and exercise
• Measure bodyweight at least once weekly for children
with excessive weight
Childcare centres
• Provide children with healthy food and beverage choices,
and nutrition education
calories from ultra-processed food). Additionally, higher
consumption of ultra-processed food (ranging from
>29·0% to 76·2% of total calories from ultra-processed
food) was associated with a higher odds of abdominal
obesity (1·49, 1·34–1·66; p<0·0001) than was lower
consumption (ranging from <16·0% to <36·5% of total
calories from ultra-processed food).72
In 2016, Chile implemented the Law of Food Labeling
and Advertising, which included national, mandatory
front-of-package (FOP) warning labels for sugar-
sweetened beverages (SSBs) and energy-dense,
non-essential foods, as well as comprehensive restric­
tions on child-directed marketing to children aged
younger than 14 years and on the promotion and sales of
these products in schools.73 The purchases of beverages
containing a high content of nutrients of concern
(ie, sugars, sodium, saturated fat, or energy) decreased
by 23·7% following implementation of the law.74 It was
also found that after Chile’s restrictions on food
marketing were implemented in 2016, there was a sharp
decrease in television advertisement for foods high in
energy, saturated fats, sugars, or sodium (from 41·9%
452 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021
• Measure height and bodyweight semi-annually, evaluate
growth and weight status, and inform parents the results
Schools
• Incorporate health and nutrition education into the required
school curriculum teaching plan, and cultivate healthy eating
habits
• Establish a healthy school food environment, prohibit sale of
sugar-sweetened beverages in primary and secondary schools,
and avoid sale of high-salt, high-sugar, and high-fat foods
• Strengthen and implement weight-management guidance
and services for students with overweight and obesity
Communities
• Create a supportive, non-stigmatising community culture for
obesity prevention
• Regulate and manage the food environment near schools
• Prohibit advertisement of unhealthy food and beverages to
children
• Provide free and safe drinking water in public places
• Encourage communities to establish vegetable gardens
Hospitals
• Include diet therapy and exercise therapy within the family
doctor’s contracted services to promote self-management of
bodyweight
• Educate parents on promotion of healthy dietary behaviours
• Assign relevant departments to measure height and weight of
children, evaluate their obesity status, and inform the parents
to 14·8%).75 Additionally, advertising for these foods with
child-directed appeals decreased substantially (by
35% for preschool-aged children and by 52% for
adolescents).76
Peru, in 2019, and Uruguay and Mexico, in 2020, also
implemented FOP warning labels. China, among other
countries, could learn from the experiences of these
countries. However, whether or not FOP labels can help to
decrease consumption of SSBs and energy-dense, non-
essential foods in other countries would depend on many
country-specific factors. A systematic review that examined
randomised controlled trials, pre-post studies, and case-
control studies in several high-income countries (eg,
Australia, the UK, and the USA) suggested mixed and
inconsistent findings regarding the efficacy of FOP
labelling in prompting healthy purchases.77 What works in
other countries might not necessarily work in China, and
China-specific research is needed to evaluate the potential
of these policy options, taking into account the policy
environ­ments and popula­tion characteristics. For example,
in China, preparing and encouraging consumers to use
nutrition labels to guide purchasing and consumption

Panel 3: Recommendations to improve the obesogenic environment
Improving the food environment
Improving the food environment includes developing related
policies, ranging from food production to marketing, food
labelling, and nutrition education; establishing and improving
regulations and policies on food storage, and surveillance and
management of restaurants and food wholesale; and
encouraging healthy food supply and choices in the workplace.
Responsibilities of government agencies
• Regularly evaluate China’s food systems
• Take comprehensive measures, including fiscal policy
approaches, to promote healthy eating and to control the
intakes of salt, sugar, and cooking oil
• Limit the production, sale, and advertising of
sugar-sweetened beverages, saturated fats, trans fatty acids,
and prepackaged foods with added sugar or salt
• Support the food industry to produce healthy food products
• Implement a mandatory nutrition labelling system for the
catering and food industry
• Strengthen the supervision and management of nutrition
labels for prepackaged food
• Implement mandatory front-of-package (FOP) warning
labels of energy, sugars, and other nutrients
(eg, saturated fat and sodium)
• Actively promote the use of FOP information to help
consumers choose food products quickly
• Develop guidelines for preparing for group meals (eg, in
schools) to promote healthy eating
decisions could be essential for the success of FOP labels.
Existing studies in China suggest that the majority of
consumers rarely or never used nutrition labels when
shopping for food.78,79 Furthermore, institutional and legal
infra­structures that enforce the food industry’s compliance
and that implement penalty of violations should be
studied, designed, and established to ensure that the
intended goals of FOP labelling regulations are
accomplished.
Aligned with the Healthy China 2030 plan, China’s
National Food Safety Standard for Nutrition Labeling of
Prepackaged Foods is under revision. For the first time, a
voluntary FOP nutrition labelling scheme was proposed
in the new draft released on Aug 31, 2020,80 which was a
milestone in FOP labelling in China. However, research
is still needed on voluntary versus mandatory FOP
labelling, and the effects of different FOP label systems,
to support more effective policies in China for reducing
consumption of ultra-processed foods.
Furthermore, empirical research in high-income
countries suggests that food and beverage marketing
targeting children has been contributing to the childhood
obesity epidemic.81 Food and beverage promotions through
TV advertisements, free gifts, and packaging might
adversely influence children’s knowledge and percep­tions
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• Prohibit the supply of high-sugar and high-fat foods in
particular settings
• Improve the packaging standards for oil, salt, and sugar
products with related recommendations for consumption
• Regulate junk food advertising that affects children’s dietary
choices and risks of obesity
Establishing a healthy built environment
• Improve the built environment to promote physical
activities, including footpaths, bicycle lanes, and public
sport venues and facilities
• Improve urban planning, city zoning, and community parks
at the municipal level
• Encourage and facilitate the use of public transportation
systems through subsidy programmes and public awareness
initiatives
Establishing a supportive social information environment
• Change social norms and culture regarding healthy weight
and energy balance behaviours through social marketing,
traditional mass media, and new social media
• Increase the public’s awareness of the health risks of obesity
and empower people to make desirable behaviour choices
and to maintain a healthy bodyweight in non-stigmatising
ways
• Provide strong support for public health education and take
advantage of social media (such as WeChat, which has
become very popular in China)
of nutrition, food preferences, food purchase and purchase-
related behaviours, and diet-related health status.81
Therefore, regulating food and beverage marketing should
also be an important policy component.
China’s future policies for obesity prevention and
control should be implemented under the Healthy China
national strategy, which will guide cooperation of
government agencies and institutions at various levels.
China needs to establish a policy system that includes
relevant laws and regulations to cover many issues and
social sectors, such as food environment, built environ­
ment, social environment, schools, and health sectors.
China also needs to gradually implement new laws
including, but not limited to, Health Promotion Law and
Nutrition Education Law.
Improve governmental responsibility and
accountability, enhance cross-sector
collaboration, and take comprehensive
measures to implement obesity prevention and
control policies
Governments at the central and subnational levels are key
stakeholders and should be responsible for providing
leader­ship; developing, implementing, and enforcing regu­
la­tory policies; coordinating cross-sector and public–private
 Series
collaborations; and advocating for and providing needed
funding for obesity prevention and control.
Empirical evidence of the importance of government
engagement in obesity prevention and control is not
readily available due to the difficulty of doing experi­mental
or quasi-experimental research to assess and quantify the
effects of governmental actions. However, as the WHO
Stakeholder Involvement report pointed out, governments
at all levels are key stakeholders in developing agriculture,
trade, food, and public health policy, recognising the
importance of diet and physical activity, disseminating
good practices, and acting as a mediator between
potentially conflicting interests.82
We suggest that obesity prevention in China requires
high-level government support and leadership to integrate
obesity prevention and control into government mandates
and the day-to-day work of relevant government agencies
and other sectors of society. Comprehensive national
preven­tion strategies are urgently needed, an approach
that has already been adopted by several countries such as
the USA, Mexico, Brazil, Chile, South Africa, Poland,
Turkey, Thailand, and Sri Lanka.66 National programmes
promoting obesity-related education, health literacy, and
behaviour targeted at children, adolescents, and popula­
tions at high risk should be implemented.66,67,83,84 It is also
important that China improves its health-care service
system for obesity prevention, control, and treatment, as
discussed in the second paper of this Series.9
Improve the obesogenic environment
Improving the obesogenic environment includes
improving the food environment, built environment, and
social and cultural norms for obesity prevention and
control, as suggested by WHO, the World Bank, UNICEF,
and the Asian Development Bank Institute (panel 3).
Evidence available for the importance of changing the
obesogenic environment
The food environment includes physical, social, and
person-centred environments that influence food availa­
bility, accessibility, and affordability.85 Unhealthy food
environ­ments, which supply processed foods high in fat,
salt, sugar, and flavour additives at a relatively low cost due
to an increasingly industrialised modern food system,
have been a major driver behind the obesity epidemic.86 A
systematic review of 71 studies suggested an inverse asso­
ciation between supermarket availability and obesity, as
well as a positive association between fast food availa­bility
and obesity; however, there is incon­sistency across these
studies due to methodological differences.87 Several syste­
matic reviews also suggested that density of and proximity
to convenience stores might be positively associated with
unhealthy eating behaviours in children.88 Nevertheless,
evidence for the association between access to super­
markets and childhood obesity remains incon­sistent.89
Involving the food and beverage industry is key to
improving the food environment. This involvement
454 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021
could include government-mandated regulations and
guidelines, and voluntary industry actions to improve
the supply of healthy foods and beverages from the
initial point of production to the endpoint of marketing
and retail. These measures could include reduction of
empty calories, clear nutrition labelling, and regulating
the expansion of the fast food industry.
Built environments are often associated with physical
activity.90 Two systematic reviews found that different land
uses, connectivity and population density, and overall
neighbourhood design were important determinants of
physical activity,91 and that a higher accessibility to built
environment and new infrastructure for walking, cycling,
and public transportation were associated with increased
both overall and transportation-related physical activity.92
Whether or not promoting physical activity is key in
reducing obesity in populations has been debated for
years.93 A meta-analysis of 18 randomised controlled trials
published between 1966 and 2008 reported that diet-plus-
exercise interventions resulted in greater weight loss than
did diet-only interventions, and that pooled weight loss
was 1·14 kg (95% CI 0·21–2·07) or 0·50 kg/m² (0·21–0·79)
greater for the diet-plus-exercise group than for the
diet-only group.94 These findings were substantiated in
another systematic review that included studies published
between 2000 and 2015.95 Therefore, improving the built
environment, together with food environment, might
help to promote healthy eating and active living for obesity
prevention and control.
Social environment refers to the relationships, norms,
rules, and social processes between individuals that are
associated with lifestyle and that indirectly affect risk of
obesity.96 Studies have shown that a supportive social
environment might promote physical activity and a
healthy diet.97,98 It is well known that obesity spreads in
social networks,99 that is, when an individual gains weight,
it increases the chances that individuals from their social
networks will also gain weight. A simulation study
suggested that traditional weight management inter­
ventions were less efficacious if the surrounding social
environment was not taken into account.100 Therefore,
promoting a supporting and positive social environment
should be an integral part of the obesity effort to prevent
unintended adverse effects and social stigma for people
with obesity.
Establish fiscal policies for obesity prevention
and control
Obesity can be viewed as a result of market failure due to
negative externalities. Thus, fiscal policy is a useful
instrument to address the obesity problem, as recom­
mended by WHO.101
Evidence for fiscal policies to prevent obesity
Fiscal policy tools, such as imposing an excise tax on
SSBs and unhealthy foods, subsidising healthy diet
choices (eg, fruits and vegetables), and providing tax

credits for healthy food and beverage retailing and
distribution, have been gaining increasing popularity in
obesity prevention.
Some countries have imposed taxes on unhealthy
foods and beverages in recent years, such as the fat tax
in Demark in 2012102 and the local-level soda taxes in
Mexico and the USA in 2014.103,104 Soda tax in several
countries and regions have shown some effects. For
example, it was estimated that an excise tax of 1 peso
per L on SSBs imposed in 2013 led to an average 6%
(–12 mL/capita per day) reduction in the consumption
level of SSBs in Mexico in 2014.105 In Berkeley, CA, USA,
an excise tax of 1 cent per oz (29·6 mL) imposed on
SSBs was estimated to decrease SSB sales by 9·6%
(p<0·001), compared with a rise in SSB sales of 6·9%
(p<0·001) in comparison city neighbourhoods.106 In the
UK, it was estimated that a 20% tax on SSBs could
reduce the number of adults with obesity by 1·3% on
the basis of the 2010 prevalence estimate.107 Based on
meta-analysis estimates from 15 studies done in high-
income countries and high-middle-income countries
such as the USA, France, Finland, Chile, and Mexico, a
systematic review suggested that a 10% increase in SSB
tax could be associated with a 10% decrease in beverage
purchases and consumptions.108 Existing studies also
suggested that baseline levels of consumption and tax
structure are important factors to consider in SSB tax
designs.109 Although the effectiveness of taxes on
unhealthy foods and beverages is understudied in
China, considering emerging evidence from other
countries and related WHO recommen­ dations, we
suggest that taxation as a fiscal policy means of tackling
the obesity epidemic should be adequately explored in
China.110
Providing subsidies to help reduce price is another
fiscal policy approach that could promote healthy eating
for obesity prevention.101 Studies in the USA have
suggested that the price of fruits and vegetables was
associated with weight outcomes in children. For
example, a price increase of fruits and vegetables by
one SD was associated with a 0·11 kg/m² increase in
BMI from kindergarten to the third grade (aged
5–8 years).111
Taxation could also be used to promote physical activity.
For example, as the Sleep, Leisure, Occupation, Trans­
portation, and Home (also known as SLOTH) model
recommended, taxes on computers and game equipment
could potentially reduce sedentary behaviours and incen­
tivise physical activity.112 However, although this proposal
might be theoretically justified, empirical evidence is still
needed to provide quantitative estimates of the
magnitude of effect (eg, price elasticity estimates) to
guide practical development of tax policy in China.
Govern­ments could offer tax credits for sporting goods
and services, as Canada has practised.113 Subsidy and
education programmes could be funded by revenue
generated by these taxes, which could result in a feedback
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Panel 4: Action options for fostering healthy families,
schools, communities, and workplaces
Families
• Incorporate weight management in contracted services of
family doctors
• Require maternity and childcare hospitals to provide
education for women and their children for weight
management during the entire lifecycle
• Encourage all family members to have adequate physical
activity and healthy diets
Schools
• Mandate schools to include education related to health,
nutrition, and physical activity in the curriculum
• Prohibit unhealthy food or snack stalls within 50 m of the
school
• Prohibit sale of snacks and sugar-sweetened beverages on
campus
• Ensure protected time for adequate physical activity
• Equip school clinics with space, facilities, and health
professionals
• Carry out annual health examinations and set up health
records for faculty, staff, and students
• Address and prevent obesity-related stigma
Communities
• Set up community centres equipped with health
education and self-service facilities, including pedestrian
streets, small parks, and exercise facilities
Workplaces
• Encourage employers to provide employees with regular
health examinations, heath consultations, nutrition
canteens, and fitness facilities; employers could receive
taxation breaks for offering such services
loop and provide sustainable funding sources to support
the obesity prevention effort.
Foster healthy families, schools, communities,
and workplaces
Families, individuals, and communities need to be
empowered to make desirable behavioural choices to
maintain a healthy bodyweight. Examples of action
options for fostering these healthy environments are
provided in panel 4.
Evidence available for interventions based in family,
school, community, and workplace environments
Family-based interventions are especially important for
childhood obesity prevention and control. Through
education on lifestyle and parenting style, role modelling,
and child behaviour management, family-based inter­
ventions can have a direct impact on the risk of obesity
through­out childhood and adulthood. An umbrella
systematic review suggested that family-based
 Series
interventions were efficacious in weight-related behaviour
manage­ment in children.114 However, further research is
required to identify the comparative efficacy of parent-
only and parent–child interventions.
Promoting a healthy diet and physical activity in
schools should be a focus in childhood obesity
prevention and control.115,116 A systematic review and
meta-analysis that included 100 published school-based
intervention studies (quasi-experimental design and
randomised controlled trials) until January, 2020,
suggested that reducing unhealthy food and SSB intake,
and promoting fruit and vegetable consumption, were
common strategies in changing the food environment
in school, through introduction of new or modified
dietary guidelines, regulation of vending machines and
kiosks or food stores, and provision of snack bars and
fruit and vegetable buffets.117 The study reported that the
standard mean difference in Z score between the
intervention and control groups for BMI was reduced
by 0·12 (95% CI –0·15 to –0·10) and that of fruit
consumption (portions per day) increased by 0·19
(0·16 to 0·22).117 However, the majority of existing
intervention studies were done in high-income
countries, such as the USA and UK.
Research of school-based interventions in China
remains scarce, but is increasing. Between May, 2009, and
May, 2010, a multicentre randomised controlled trial was
done among 9867 urban children aged 6–13 years in
38 primary schools across Shanghai, Chongqing,
Guangzhou, Jinan, Harbin, and Beijing.118 In Beijing,
selected schools were divided into a nutrition education
only group, a physical activity only group, and a control
group. In each other city, schools were assigned to a
comprehensive intervention group, including nutrition
education and physical activity, and a control group. The
prevalence of overweight and obesity increased by 1·5%
(from 22·7% to 24·2%) in the control group and by 0·2%
(from 23·6% to 23·8%) in the comprehensive inter­
vention group after 1 year in the Beijing site (between-
group comparison p=0·061).118 However, no significant
differences were observed between groups in the other
five sites for the nutrition education intervention (from
14·3% to 19·8%), physical activity intervention
(from 16·1% to 21·9%), and the control group (from 11·1%
to 17·6%; between-group comparison p=0·572 and 0·637,
respectively).118 Another cluster randomised controlled
trial done between October, 2013, and September, 2014,
among 1889 children in 12 primary schools in Beijing
implemented a multicomponent intervention, including
health education, physical activity promotion, and school
lunch improvement.119 Although the study did not find
significant effects on BMI (between-group difference
0·07 kg/m², 95% CI –0·16 to 0·31; p=0·54) and BMI
Z score (0·02, –0·08 to 0·11; p=0·73) at 12 months,
improvements were observed regarding obesity-related
knowledge, frequency of moderate-to-vigorous physical
activity, and percentage of children consuming SSBs.119
456 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021
The Youth Olympic Health Heritage Project and the
CHIRPY DRAGON intervention study were another
two large-scale, school-based randomised controlled
trials done in China showing that school-based
multicomponent interventions could improve eating,
duration of moderate-to-vigourous physical activity, and
BMI among students (aged 6–12 years).120,121 The Youth
Olympic Health Heritage Project was a school-based
randomised controlled trial promoting physical activity
among 10 091 students from 32 primary schools and
16 junior high schools in Nanjing from September, 2013,
to June, 2014. Findings from the project suggested that
participants receiving education on physical activity
and health had a higher odds of increasing the duration
of time spent doing physical activity of moderate-to-
vigorous intensity (OR 1·15, 95% CI 1·06 to 1·25) and a
smaller increase in mean BMI (0·22 kg/m² vs
0·46 kg/m²) and BMI Z score (0·07 vs 0·16) than did
the control group by the end of the intervention
(p=0·01).120 The CHIRPY DRAGON intervention study
was a cluster randomised controlled trial done among
1641 students from 40 primary schools in Guangzhou,
which included four school-based and family-based
components aiming to promote physical activity and
healthy eating in children both within and outside of
school. The 12-month intervention programme was
delivered between March, 2016 and March, 2017. This
study found that students who received the intervention
programme had a smaller mean BMI Z score after the
12-month intervention than did the control group, who
did not receive the programme (mean difference −0·13,
95% CI −0·26 to 0·00; p=0·048).121
However, future research is needed to carefully
evaluate whether such programmes can be scaled up or
whether nationwide, large-scale interventions can be
designed and implemented on the basis of these existing
studies. Linking school-based interventions with other
strategies and national policies for obesity prevention is
a must for the interventions to have a real impact. In
addition, our systematic review, funded by the US
Agency for Healthcare Research and Quality, found that
childhood obesity interventions in a school-based setting
with home or community components were more
successful in preventing childhood obesity than were
school-based interventions without family or community
components.122
Community-based interventions are usually imple­
mented across multiple levels (eg, individual, family,
community) and multiple sectors (eg, school, worksite,
neighbourhood), and are promising strategies for obesity
prevention in both children and adults.123,124 An umbrella
review of systematic reviews suggested that community-
based interventions with multiple com­ponents to promote
healthy diet and physical activity might be a promising
way to reduce BMI, as indicated by a pooled mean change
in BMI of −0·40 (95% CI −0·58 to −0·22) in adults and a
pooled mean change of BMI Z score of −0·08

(−0·14 to −0·02) in children and adolescents in the inter­
vention groups compared with the control groups.125 The
Communities Putting Prevention to Work programme
launched in 2010 by the US Centers for Disease Control
and Prevention is a good example of large-scale,
community-based interventions for the prevention and
reduction of obesity and smoking.126 A simulation study
suggested that the sustained programme might have led
to US$2·4 billion in discounted direct medical costs
averted, and to $9·5 billion in discounted lifetime and
annual productivity losses averted, from 2010 to 2020.127
Although evidence of the efficacy of the multilevel and
multisector interventions is mixed due to difficulties in
establishing strategy-specific effects at the population
level and in reaching enough people in a community
setting,128 community-based interventions are promising
strategies for obesity prevention.
The workplace environment has become a new target
for obesity prevention. Workplace-based interventions
could include educational components to increase
employees’ nutrition literacy, health insurance benefits
or cash incentives for weight management and healthy
lifestyle, and environmental changes that make a healthy
diet and physical activity an easier choice. A review found
that nutrition and physical activity programmes in the
workplace could lead to a pooled estimate weight
reduction of 1·3 kg (95% CI 0·5–2·1), based on nine
randomised controlled trials, and a decrease in BMI of
0·5 unit (0·2–0·8), based on six randomised controlled
trials.129 However, a 2018 review indicated that most of the
studies were not of high quality and that more research is
needed to assess the long-term efficacy of worksite
interventions.130
Reduce inequalities in obesity
The incidence and prevalence of overweight and obesity
vary depending on sex, socioeconomic status, and
geographic region, and lead to related disparities in
morbidity and mortality, as reported in the first paper in
this Series.8 Increasing disposable income, nationwide
urbanisation, cultural differences, and unequal
economic development across different regions are the
major drivers behind the inequalities. The proposed
policies and strategies for obesity prevention should
fully take into account these differences and be tailored
to target populations at high risk to address, narrow, and
prevent future gaps in obesity prevalence among
subpopulations, and to ensure health equity.
Limitations and knowledge gaps about obesity-
related policy studies in China
Evidence from empirical research in Chinese popula­tions
supporting the development and implemen­ tation of
policies for obesity prevention and control is scarce.
International experiences are the primary evidence base
for many policy proposals and recom­ mendations in
China. For example, empirical evidence of the efficacy of
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Search strategy and selection criteria
We systematically searched Baidu (the dominant search
engine in China), official websites of national-level
government departments and agencies (eg, State Council,
National Health Commission of the People’s Republic of
China, and related departments), Chinese academic research
databases (China National Knowledge Infrastructure and
Wanfang), PubMed, Google Scholar, and Google for original
articles and reviews published in English and Chinese
between Jan 1, 1949, and March 31, 2021, using the
following search terms in various combinations: “overweight,
“obesity”, “weight”, “BMI”, “abdominal obesity”, “body fat”,
“regulation” , “policy”, “law”, “strategy”, “intervention”,
“prevention”, “control”, “diet”, “physical exercise”,
and “environment”. We selected relevant literature and
reports by reviewing their title, abstract, and full text. We also
manually searched the reference lists of relevant literature.
We included the publications and other data sources that we
judged to be important and timely contributions to the topic.
fiscal policies, laws, and regulations comes from
high-income countries (eg, the USA, the UK, and Chile)
and some low-income and middle-income countries
(eg, Brazil, Mexico, and other Latin American countries).
It is possible that some of the strategies used in other
countries might not work in China or might only have a
small effect. Thus, country-specific research is urgently
needed to provide scientific evidence to support the design
and implementation of future policies and interventions
in China. Despite the many years of policy efforts in China
from central to local governments, rigorous evaluative
research on the effectiveness of these existing policies is
scarce. Furthermore, large-scale, longitudinal obesity
research at the community, workplace, household, and
individual level, by use of nationally representative
cohorts, is largely missing in China. These challenges
limited the depth and scope of this Series paper.
Nevertheless, the research gaps revealed by this Series
paper also point out the future directions and urgent
needs of obesity-related policy research in China.
Conclusions
China has the highest number of people with overweight
and obesity globally, and obesity has become a serious
public health problem. Existing policies in China are
inade­quate for controlling the epidemic. The policy
recommendations highlighted in this Series paper for
China’s future efforts align with related international
guide­lines. Strong central and local government
commit­ment, leadership, and support are needed, and
it is important that all related society sectors and
individual citizens actively participate in the campaign.
Enhancing food policies and regulations to limit and
reduce the supply and consump­tion of ultra-processed
foods and to promote healthy food intake should be a
 Series
focus in China’s strategies for obesity prevention and
control. Rigorous research evaluating the potential
effectiveness of policies and strategies is urgently
needed in China. China is well positioned to explore an
effective model to overcome the obesity epidemic, and
might also provide other countries with useful insights
for obesity prevention and control policy design and
implementation.
Contributors
All authors contributed to the literature search and collection and
interpretation of data. YW, HX, LZ, and LG drafted the report. YW, HX,
and AP critically revised the report. All authors approved the authorship
and final manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
The study is funded in part by research grants from the UN Children’s
Fund (UNICEF 2018-Nutrition-2.1.2.3), Chinese National Key Research
and Development Program (grant number 2017YFC0907200 &
2017YFC0907201), China Medical Board (grant number 16–262),
Chinese Nutrition Society, and the US National Institute of Health
(U54 HD070725). The collaboration institutions have contributed
additional resources. The content of the paper is solely the responsibility
of the authors and does not necessarily represent the official views of the
funders. We thank the following experts from China and other countries
who have contributed to the study, and provided recommendations for
future obesity interventions in China, information about the practice in
their countries, or both: Gengsheng He and Weidong Qu from Fudan
University (Shanghai, China), Zhaoping Li from the University of
California, (Berkeley, CA, USA), Luis Alberto Moreno from The
Nutrition Society of Spain (Madrid, Spain), Harry Rutter from the
University of Bath (Bath, UK), Changhao Sun from Harbin University
(Harbin, China), Mingxiao Sun from Qide Hospital (Wuhan, China),
Boyd Swinburn from the University of Auckland (Auckland,
New Zealand), Limin Wang and Jing Wu from the National Center for
Chronic and Non-Communicable Disease Control and Prevention,
Chinese Center for Disease Control and Prevention (Beijing, China),
Shaw Watanabe from the Asia Pacific Clinical Nutrition Society,
Life Science Promoting Association (Tokyo, Japan), Bao Xin from
Shaanxi University of Chinese Medicine (Xianyang, China), Fei Xu from
Nanjing Center for Disease Control and Prevention (Nanjing, China),
Yuexin Yang from The Chinese Nutrition Society (Beijing, China),
and Qian Zhang from the National Institute for Nutrition and Health,
Chinese Center for Disease Control and Prevention (Beijing, China).
We want to give special thanks to Lu Ma and Guorui Ruan from the
Xi’an Jiaotong University Global Health Institute (Xi’an, China) for their
valuable assistance in collecting some related information and
documents and in formatting parts of the manuscript.
References
 1 Wu Y, Xue H, Wang H, Su C, Du S, Wang Y. The impact of
urbanization on the community food environment in China.
Asia Pac J Clin Nutr 2017; 26: 504–13.
2 Wang Y, Wang L, Qu W. New national data show alarming increase
in obesity and noncommunicable chronic diseases in China.
Eur J Clin Nutr 2017; 71: 149–50.
3 Ng M, Fleming T, Robinson M, et al. Global, regional, and national
prevalence of overweight and obesity in children and adults during
1980–2013: a systematic analysis for the Global Burden of Disease
Study 2013. Lancet 2014; 384: 766–81.
4 Wang H, Zhai F. Programme and policy options for preventing
obesity in China. Obes Rev 2013; 14 (suppl 2): 134–40.
5 State Council of the People’s Republic of China. National nutrition
plan 2017–2030. https://extranet.who.int/nutrition/gina/en/
node/24710 (accessed Oct 26, 2020).
6 Wang Y, Sun M, Yang Y. Blue paper on obesity prevention and
control in China. Beijing: Peking University Medical Press, 2019.
7 Wang Y, Xue H, Sun M, Zhu X, Zhao L, Yang Y. Prevention and
control of obesity in China. Lancet Glob Health 2019; 7: e1166–67.
458 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021
8 Pan XF, Wang L, Pan A. Epidemiology and determinants of obesity
in China. Lancet Diabetes Endocrinol 2020; 9: 373–92.
9 Zeng Q, Li N, Pan XF, et al. Clinical management and treatment of
obesity in China. Lancet Diabetes Endocrinol 2020; 9: 393–405.
10 Hwang LC, Bai CH, Sun CA, Chen CJ. Prevalence of metabolically
healthy obesity and its impacts on incidences of hypertension,
diabetes and the metabolic syndrome in Taiwan.
Asia Pac J Clin Nutr 2012; 21: 227–33.
11 Ding WQ, Yan YK, Zhang MX, et al. Hypertension outcomes in
metabolically unhealthy normal-weight and metabolically healthy
obese children and adolescents. J Hum Hypertens 2015; 29: 548–54.
12 Zhao Y, Qin P, Sun H, et al. Metabolically healthy general and
abdominal obesity are associated with increased risk of
hypertension. Br J Nutr 2020; 123: 583–91.
13 Xu F, Wang YF, Lu L, et al. Comparison of anthropometric indices
of obesity in predicting subsequent risk of hyperglycemia among
Chinese men and women in Mainland China. Asia Pac J Clin Nutr
2010; 19: 586–93.
14 Liang Y, Hou D, Zhao X, et al. Childhood obesity affects adult
metabolic syndrome and diabetes. Endocrine 2015; 50: 87–92.
15 Bragg F, Tang K, Guo Y, et al. Associations of general and central
adiposity with incident diabetes in Chinese men and women.
Diabetes Care 2018; 41: 494–502.
16 Wang B, Zhang M, Wang S, et al. Dynamic status of metabolically
healthy overweight/obesity and metabolically unhealthy and
normal weight and the risk of type 2 diabetes mellitus: a cohort
study of a rural adult Chinese population. Obes Res Clin Pract
2018; 12: 61–71.
17 Fan Y, Li W, Liu H, et al. Effects of obesity and a history of
gestational diabetes on the risk of postpartum diabetes and
hyperglycemia in Chinese women: obesity, GDM and diabetes risk.
Diabetes Res Clin Pract 2019; 156: 107828.
18 Wei Y, Wang J, Han X, et al. Metabolically healthy obesity increased
diabetes incidence in a middle-aged and elderly Chinese population.
Diabetes Metab Res Rev 2020; 36: e3202.
19 Feng S, Gong X, Liu H, et al. The diabetes risk and determinants of
transition from metabolically healthy to unhealthy phenotypes in
49,702 older adults: 4-year cohort study. Obesity (Silver Spring) 2020;
28: 1141–48.
20 Zhang X, Shu XO, Gao YT, et al. Anthropometric predictors of
coronary heart disease in Chinese women.
Int J Obes Relat Metab Disord 2004; 28: 734–40.
21 Zhang X, Shu XO, Gao YT, Yang G, Li H, Zheng W. General and
abdominal adiposity and risk of stroke in Chinese women. Stroke
2009; 40: 1098–104.
22 Tian Y, Yang SC, Yu CQ, et al. [Association between central
obesity and risk for heart disease in adults in China: a prospective
study]. Zhonghua Liu Xing Bing Xue Za Zhi 2018; 39: 1172–78
(in Chinese).
23 Chen Z, Iona A, Parish S, et al. Adiposity and risk of ischaemic
and haemorrhagic stroke in 0·5 million Chinese men and
women: a prospective cohort study. Lancet Glob Health 2018;
6: e630–40.
24 Li L, Chen K, Wang AP, et al. Cardiovascular disease outcomes in
metabolically healthy obesity in communities of Beijing cohort
study. Int J Clin Pract 2018; published online Sept 30. https://doi.
org/10.1111/ijcp.13279.
25 Xu Y, Li H, Wang A, et al. Association between the metabolically
healthy obese phenotype and the risk of myocardial infarction:
results from the Kailuan study. Eur J Endocrinol 2018; 179: 343–52.
26 Li JC, Lyu J, Gao M, et al. [Association of body mass index and waist
circumference with major chronic diseases in Chinese adults].
Zhonghua Liu Xing Bing Xue Za Zhi 2019; 40: 1541–47 (in Chinese).
27 Li H, He D, Zheng D, et al. Metabolically healthy obese phenotype
and risk of cardiovascular disease: results from the China Health
and Retirement Longitudinal Study. Arch Gerontol Geriatr 2019;
82: 1–7.
28 Guo X, Li Z, Zhou Y, et al. The effects of transitions in metabolic
health and obesity status on incident cardiovascular disease:
insights from a general Chinese population. Eur J Prev Cardiol
2020; published online July 1. https://doi.
org/10.1177/2047487320935550.

29 Guo L, Li N, Wang G, et al. [Body mass index and cancer
incidence:a prospective cohort study in northern China].
Zhonghua Liu Xing Bing Xue Za Zhi 2014; 35: 231–36 (in Chinese).
30 Pang Y, Kartsonaki C, Guo Y, et al. Adiposity and risks of colorectal
and small intestine cancer in Chinese adults: a prospective study of
0.5 million people. Br J Cancer 2018; 119: 248–50.
31 Liu Y, Warren Andersen S, Wen W, et al. Prospective cohort study of
general and central obesity, weight change trajectory and risk of
major cancers among Chinese women. Int J Cancer 2016;
139: 1461–70.
32 Pang Y, Kartsonaki C, Guo Y, et al. Central adiposity in relation to
risk of liver cancer in Chinese adults: A prospective study of
0.5 million people. Int J Cancer 2019; 145: 1245–53.
33 Pang Y, Holmes MV, Kartsonaki C, et al. Young adulthood and
adulthood adiposity in relation to incidence of pancreatic cancer:
a prospective study of 0.5 million Chinese adults and a meta-
analysis. J Epidemiol Community Health 2017; 71: 1059–67.
34 Yuan JM, Ross RK, Gao YT, Yu MC. Body weight and mortality:
a prospective evaluation in a cohort of middle-aged men in
Shanghai, China. Int J Epidemiol 1998; 27: 824–32.
35 Zhou BF. Effect of body mass index on all-cause mortality and
incidence of cardiovascular diseases--report for meta-analysis of
prospective studies open optimal cut-off points of body mass index
in Chinese adults. Biomed Environ Sci 2002; 15: 245–52.
36 Schooling CM, Lam TH, Li ZB, et al. Obesity, physical activity, and
mortality in a prospective chinese elderly cohort. Arch Intern Med
2006; 166: 1498–504.
37 Gu D, He J, Duan X, et al. Body weight and mortality among men
and women in China. JAMA 2006; 295: 776–83.
38 Zhang X, Shu XO, Yang G, et al. Abdominal adiposity and mortality
in Chinese women. Arch Intern Med 2007; 167: 886–92.
39 Zheng W, McLerran DF, Rolland B, et al. Association between body-
mass index and risk of death in more than 1 million Asians.
N Engl J Med 2011; 364: 719–29.
40 Lin WY, Tsai SL, Albu JB, et al. Body mass index and all-cause
mortality in a large Chinese cohort. CMAJ 2011; 183: e329–36.
41 Warren Andersen S, Shu XO, Gao YT, et al. Prospective cohort
study of central adiposity and risk of death in middle aged and
elderly Chinese. PLoS One 2015; 10: e0138429.
42 Sun H, Ren X, Chen Z, et al. Association between body mass index
and mortality in a prospective cohort of Chinese adults.
Medicine (Baltimore) 2016; 95: e4327.
43 Jia G, Shu XO, Liu Y, et al. Association of adult weight gain with
major health outcomes among middle-aged Chinese persons with
low body weight in early adulthood. JAMA Netw Open 2019;
2: e1917371.
44 Liu L, Gao B, Wang J, et al. Joint association of body mass index and
central obesity with cardiovascular events and all-cause mortality in
prediabetic population: a prospective cohort study. Obes Res Clin Pract
2019; 13: 453–61.
45 Sheehan TJ, DuBrava S, DeChello LM, Fang Z. Rates of weight
change for black and white Americans over a twenty year period.
Int J Obes Relat Metab Disord 2003; 27: 498–504.
46 Stokes A, Collins JM, Grant BF, et al. Obesity progression between
young adulthood and midlife and incident diabetes: a retrospective
cohort study of U.S. adults. Diabetes Care 2018; 41: 1025–31.
47 Chen C, Ye Y, Zhang Y, Pan XF, Pan A. Weight change across
adulthood in relation to all cause and cause specific mortality:
prospective cohort study. BMJ 2019; 367: l5584.
48 Zheng Y, Manson JE, Yuan C, et al. Associations of weight gain
from early to middle adulthood with major health outcomes later in
life. JAMA 2017; 318: 255–69.
49 WHO. Child growth standards. https://www.who.int/toolkits/child-
growth-standards/standards (accessed May 27, 2020).
50 WHO. Growth reference data for 5-19 years. http://www.who.int/
growthref/en (accessed May 27, 2020).
51 Chinese Center for Disease Control and Prevention. National
chronic disease and risk factor surveillance. Beijing: People’s
Medical Publishing House, 2013.
52 Disease Prevention and Control Bureau of National Health and
Family Planning Commission. Report on the status of nutrition
and chronic diseases of Chinese residents. Beijing: People’s
Medical Publishing House, 2015.
www.thelancet.com/diabetes-endocrinology Vol 9 July 2021 459
Series
53 Dong Y, Jan C, Ma Y, et al. Economic development and the
nutritional status of Chinese school-aged children and adolescents
from 1995 to 2014: an analysis of five successive national surveys.
Lancet Diabetes Endocrinol 2019; 7: 288–99.
54 Popkin BM, Kim S, Rusev ER, Du S, Zizza C. Measuring the full
economic costs of diet, physical activity and obesity-related chronic
diseases. Obes Rev 2006; 7: 271–93.
55 Zhao W, Zhai Y, Hu J, et al. Economic burden of obesity-related
chronic diseases in Mainland China. Obes Rev 2008;
9 (suppl 1): 62–67.
56 Qin X, Pan J. The medical cost attributable to obesity and
overweight in China: estimation based on longitudinal surveys.
Health Econ 2016; 25: 1291–311.
57 Zhang J, Shi XM, Liang XF. [Economic costs of both overweight
and obesity among Chinese urban and rural residents, in 2010].
Zhonghua Liu Xing Bing Xue Za Zhi 2013; 34: 598–600
(in Chinese).
58 Yan X, Shi J, Cheng W, et al. Out-of-pocket care expenditures due to
excess of body weight in the Chinese population aged 45 and older.
Chin J Heal Stat 2019; 36: 22–27.
59 Shi J, Wang Y, Cheng W, Shao H, Shi L. Direct health care costs
associated with obesity in Chinese population in 2011.
J Diabetes Complications 2017; 31: 523–28.
60 National Health Commission of the People’s Republic of China.
Healthy China: start a new journey of happiness. March 9, 2015.
http://www.nhc.gov.cn/xcs/wzbd/201503/
bcd5272e72824491812b004eb1aa0bf6.shtml (accessed Jan 8, 2020).
61 National Health Commission of the People’s Republic of China.
The National Health Commission held a press conference to
introduce my country’s elderly care work and the results of Chinese
residents’ health literacy monitoring results (2018). Aug 27, 2019.
http://www.gov.cn/xinwen/2019-08/27/content_5424988.htm
(accessed Jan 8, 2020).
62 Wang Y, Xue H, Esposito L, Joyner MJ, Bar-Yam Y, Huang TT.
Applications of complex systems science in obesity and
noncommunicable chronic disease research. Adv Nutr 2014;
5: 574–77.
63 Institute of Medicine. Bridging the evidence gap in obesity
prevention: a framework to inform decision making. Washington,
DC: The National Academies Press, 2010.
64 Committee on Accelerating Progress in Obesity Prevention.
Accelerating progress in obesity prevention: solving the weight of
the nation. Washington, DC: The National Academies Press, 2010.
65 Wang Y, Xue H, Liu S. Applications of systems science in
biomedical research regarding obesity and noncommunicable
chronic diseases: opportunities, promise, and challenges. Adv Nutr
2015; 6: 88–95.
66 Shekar M, Popkin B. Obesity: health and economic consequences of
an impending global challenge. https://openknowledge.worldbank.
org/bitstream/handle/10986/32383/9781464814914.pdf (accessed
June 15, 2020).
67 UNICEF. Programme guidance for early life prevention of non-
communicable diseases. August 2019. https://www.unicef.org/
media/61431/file (accessed June 15, 2020).
68 Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V,
Chisholm D. Tackling of unhealthy diets, physical inactivity,
and obesity: health effects and cost-effectiveness. Lancet 2010;
376: 1775–84.
69 Monteiro CA, Cannon G, Moubarac J-C, Levy RB, Louzada MLC,
Jaime PC. The UN Decade of Nutrition, the NOVA food
classification and the trouble with ultra-processing.
Public Health Nutr 2018; 21: 5–17.
70 Dunford EK, Ni Mhurchu C, Huang L, et al. A comparison of the
healthiness of packaged foods and beverages from 12 countries
using the Health Star Rating nutrient profiling system, 2013–2018.
Obes Rev 2019; 20: 107–15.
71 Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause
excess calorie intake and weight gain: an inpatient randomized
controlled trial of ad libitum food intake. Cell Metab 2019;
30: 67–77.
72 Lane MM, Davis JA, Beattie S, et al. Ultraprocessed food and
chronic noncommunicable diseases: a systematic review and
meta-analysis of 43 observational studies. Obes Rev 2021;
22: e13146.
 Series
73 Corvalán C, Reyes M, Garmendia ML, Uauy R. Structural responses
to the obesity and non-communicable diseases epidemic:
the Chilean Law of Food Labeling and Advertising. Obes Rev 2013;
14 (suppl 2): 79–87.
74 Taillie LS, Reyes M, Colchero MA, Popkin B, Corvalán C.
An evaluation of Chile’s Law of Food Labeling and Advertising on
sugar-sweetened beverage purchases from 2015 to 2017: a before-
and-after study. PLoS Med 2020; 17: e1003015.
75 Correa T, Reyes M, Taillie LS, Corvalán C, Dillman Carpentier FR.
Food advertising on television before and after a national unhealthy
food marketing regulation in Chile, 2016-2017. Am J Public Health
2020; 110: 1054–59.
76 Dillman Carpentier FR, Correa T, Reyes M, Taillie LS. Evaluating
the impact of Chile’s marketing regulation of unhealthy foods and
beverages: pre-school and adolescent children’s changes in
exposure to food advertising on television. Public Health Nutr 2020;
23: 747–55.
77 An R, Shi Y, Shen J, et al. Effect of front-of-package nutrition
labeling on food purchases: a systematic review. Public Health 2021;
191: 59–67.
78 Zhang J, Zhai L, Osewe M, Liu A. Analysis of factors influencing
food nutritional labels use in Nanjing, China. Foods 2020; 9: 1796.
79 Ma J, Zhu Z, Chen X, et al. A cross-sectional survey of nutrition
labelling use and its associated factors on parents of school students
in Shanghai, China. Public Health Nutr 2018; 21: 1418–25.
80 Chinese National Health Commission. Standard on nutrition
labelling of prepackaged foods. Aug 31, 2020. https://members.wto.
org/crnattachments/2020/TBT/CHN/20_5665_00_x.pdf (accessed
April 9, 2021).
81 Cairns G, Angus K, Hastings G, Caraher M. Systematic reviews of
the evidence on the nature, extent and effects of food marketing to
children. A retrospective summary. Appetite 2013; 62: 209–15.
82 Griffiths J, Maggs H, George E. Stakeholder involvement.
Background paper prepared for the WHO/WEF Joint Event on
Preventing Noncommunicable Diseases in the Workplace (Dalian/
China, September 2007). Geneva: World Health Organization,
2007.
83 WHO. Taking action on childhood obesity. Geneva: World Health
Organization, 2018.
84 Thavorncharoensap M. Effectiveness of obesity prevention and
control. January 2017. https://www.adb.org/publications/
effectiveness-obesity-prevention-and-control (accessed June 7, 2020).
85 Lytle L, Myers A. Measures registry user guide: food environment.
Washington, DC: National Collaborative on Childhood Obesity
Research, 2017.
86 Hall KD. Did the food environment cause the obesity epidemic?
Obesity (Silver Spring) 2018; 26: 11–13.
87 Pineda E, Mindell J. Association of the food environment with
obesity: a systematic review of geographical and statistical methods.
Lancet 2016; 388: S89.
88 Xin J, Zhao L, Wu T, et al. Association between access to
convenience stores and childhood obesity: a systematic review.
Obes Rev 2021; 22 (suppl 1): e12908.
89 Zhou Q, Zhao L, Zhang L, et al. Neighborhood supermarket access
and childhood obesity: a systematic review. Obes Rev 2021;
22 (suppl 1): e12937.
90 Townshend T, Lake A. Obesogenic environments: current evidence
of the built and food environments. Perspect Public Health 2017;
137: 38–44.
91 McCormack GR, Shiell A. In search of causality: a systematic review
of the relationship between the built environment and physical
activity among adults. Int J Behav Nutr Phys Act 2011; 8: 125.
92 Kärmeniemi M, Lankila T, Ikäheimo T, Koivumaa-Honkanen H,
Korpelainen R. The built environment as a determinant of physical
activity: a systematic review of longitudinal studies and natural
experiments. Ann Behav Med 2018; 52: 239–51.
93 Medicine Io. Physical activity: moving toward obesity solutions.
Washington, DC: The National Academies Press, 2015.
94 Wu T, Gao X, Chen M, van Dam RM. Long-term effectiveness of
diet-plus-exercise interventions vs. diet-only interventions for
weight loss: a meta-analysis. Obes Rev 2009; 10: 313–23.
95 Chin S-H, Kahathuduwa CN, Binks M. Physical activity and obesity:
what we know and what we need to know. Obes Rev 2016; 17: 1226–44.
460 www.thelancet.com/diabetes-endocrinology Vol 9 July 2021
96 Suglia SF, Shelton RC, Hsiao A, Wang YC, Rundle A, Link BG.
Why the neighborhood social environment is critical in obesity
prevention. J Urban Health 2016; 93: 206–12.
97 Ding D, Sallis JF, Kerr J, Lee S, Rosenberg DE. Neighborhood
environment and physical activity among youth a review.
Am J Prev Med 2011; 41: 442–55.
98 Patrick H, Nicklas TA. A review of family and social determinants
of children’s eating patterns and diet quality. J Am Coll Nutr 2005;
24: 83–92.
99 Christakis NA, Fowler JH. The spread of obesity in a large social
network over 32 years. N Engl J Med 2007; 357: 370–79.
100 Bahr DB, Browning RC, Wyatt HR, Hill JO. Exploiting social
networks to mitigate the obesity epidemic. Obesity (Silver Spring)
2009; 17: 723–28.
101 WHO. 2008–2013 action plan for the global strategy for the
prevention and control of noncommunicable diseases. Geneva:
World Health Organization, 2009.
102 Smed S. Financial penalties on foods: the fat tax in Denmark.
Nutr Bull 2012; 37: 142–47.
103 Cawley J, Frisvold D. The pass-through of taxes on sugar-sweetened
beverages to retail prices: the case of Berkeley, California.
J Policy Anal Manage 2017; 36: 303–26.
104 Grogger J. Soda taxes and the prices of sodas and other drinks:
evidence from Mexico. Am J Agric Econ 2017; 99: 481–98.
105 Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases
from stores in Mexico under the excise tax on sugar sweetened
beverages: observational study. BMJ 2016; 352: h6704.
106 Silver LD, Ng SW, Ryan-Ibarra S, et al. Changes in prices, sales,
consumer spending, and beverage consumption one year after a tax
on sugar-sweetened beverages in Berkeley, California, US:
a before-and-after study. PLoS Med 2017; 14: e1002283.
107 Briggs AD, Mytton OT, Kehlbacher A, Tiffin R, Rayner M,
Scarborough P. Overall and income specific effect on prevalence of
overweight and obesity of 20% sugar sweetened drink tax in UK:
econometric and comparative risk assessment modelling study.
BMJ 2013; 347: f6189.
108 Teng AM, Jones AC, Mizdrak A, Signal L, Genç M, Wilson N.
Impact of sugar-sweetened beverage taxes on purchases and dietary
intake: Systematic review and meta-analysis. Obes Rev 2019;
20: 1187–204.
109 Popkin BM, Ng SW. Sugar-sweetened beverage taxes: lessons to
date and the future of taxation. PLoS Med 2021; 18: e1003412.
110 Ma G. Report on sugar sweetened beverage consumption in
Chinese children. Beijing: Peking University Medical Press, 2018.
111 Powell LM, Chaloupka FJ. Food prices and obesity: evidence and
policy implications for taxes and subsidies. Milbank Q 2009;
87: 229–57.
112 Pratt M, Macera CA, Sallis JF, O’Donnell M, Frank LD. Economic
interventions to promote physical activity: application of the
SLOTH model. Am J Prev Med 2004; 27 (suppl): 136–45.
113 von Tigerstrom B, Larre T, Sauder J. Using the tax system to
promote physical activity: critical analysis of Canadian initiatives.
Am J Public Health 2011; 101: e10–16.
114 Chai LK, Collins C, May C, Brain K, Wong See D, Burrows T.
Effectiveness of family-based weight management interventions for
children with overweight and obesity: an umbrella review.
JBI Database Syst Rev Implement Reports 2019; 17: 1341–427.
115 Story M, Nanney MS, Schwartz MB. Schools and obesity
prevention: creating school environments and policies to promote
healthy eating and physical activity. Milbank Q 2009; 87: 71–100.
116 UNICEF. Prevention of overweight and obesity in children and
adolescents: UNICEF advocacy strategy guidance. New York, NY:
United Nations International Children’s Emergency Fund, 2020.
117 Pineda E, Bascunan J, Sassi F. Improving the school food
environment for the prevention of childhood obesity: what works
and what doesn’t. Obes Rev 2021; 22: e13176.
118 Xu H, Li Y, Zhang Q, et al. Comprehensive school-based
intervention to control overweight and obesity in China: a cluster
randomized controlled trial. Asia Pac J Clin Nutr 2017;
26: 1139–51.
119 Liu Z, Li Q, Maddison R, et al. A school-based comprehensive
intervention for childhood obesity in China: a cluster randomized
controlled trial. Child Obes 2019; 15: 105–15.

120 Wang Z, Xu F, Ye Q, et al. Childhood obesity prevention through a
community-based cluster randomized controlled physical activity
intervention among schools in china: the health legacy project of
the 2nd world summer youth olympic Games (YOG-Obesity study).
Int J Obes 2018; 42: 625–33.
121 Li B, Pallan M, Liu WJ, et al. The CHIRPY DRAGON intervention
in preventing obesity in Chinese primary-school--aged children:
a cluster-randomised controlled trial. PLoS Med 2019; 16: e1002971.
122 Wang Y, Wu Y, Wilson RF, et al. Childhood obesity prevention
programs: comparative effectiveness review and meta-analysis.
Rockville, MD: Agency for Healthcare Research and Quality, 2013.
123 Ewart-Pierce E, Mejía Ruiz MJ, Gittelsohn J. “Whole-of-
Community” obesity prevention: a review of challenges and
opportunities in multilevel, multicomponent interventions.
Curr Obes Rep 2016; 5: 361–74.
124 Brand T, Pischke CR, Steenbock B, et al. What works in
community-based interventions promoting physical activity and
healthy eating? A review of reviews. Int J Environ Res Public Health
2014; 11: 5866–88.
125 Roberts S, Pilard L, Chen J, Hirst J, Rutter H, Greenhalgh T.
Efficacy of population-wide diabetes and obesity prevention
programs: an overview of systematic reviews on proximal,
intermediate, and distal outcomes and a meta-analysis of impact on
BMI. Obes Rev 2019; 20: 947–63.
www.thelancet.com/diabetes-endocrinology Vol 9 July 2021 461
Series
126 Bunnell R, O’Neil D, Soler R, et al. Fifty communities putting
prevention to work: accelerating chronic disease prevention through
policy, systems and environmental change. J Community Health
2012; 37: 1081–90.
127 Soler R, Orenstein D, Honeycutt A, et al. Community-based
interventions to decrease obesity and tobacco exposure and reduce
health care costs: outcome estimates from Communities Putting
Prevention to Work for 2010–2020. Prev Chronic Dis 2016;
13: 150272.
128 Baker PR, Francis DP, Soares J, Weightman AL, Foster C.
Community wide interventions for increasing physical activity.
Cochrane Database Syst Rev 2015; 1: CD008366.
129 Anderson LM, Quinn TA, Glanz K, et al. The effectiveness of
worksite nutrition and physical activity interventions for controlling
employee overweight and obesity: a systematic review.
Am J Prev Med 2009; 37: 340–57.
130 Tam G, Yeung MPS. A systematic review of the long-term
effectiveness of work-based lifestyle interventions to tackle
overweight and obesity. Prev Med 2018; 107: 54–60.
© 2021 Elsevier Ltd. All rights reserved.