Food consumption and nutritional status in China
Consommation alimentaire et état nutritionnel en Chine
Consumo alimentario y estado nutricional en China
Achievements, problems and policy implications1
1 This is the first of two articles on food consumption and nutritional status in China. The second will appear in the next issue of Food, Nutrition and Agriculture.
K. Ge, C. Chen and T. Shen
Dr Chunming Chen is President of the Chinese Academy of Preventive Medicine (29 Nan Wei Road, Beijing, China 100050), where Dr Keyou Ge is Director of the Institute of Nutrition and Food Hygiene and Dr Tiefu Shen is a researcher.
Over the past two decades, China has made remarkable progress in boosting national economic development and agricultural production. Grain output reached 407.55 million tonnes in 1989, representing an increase of 70 percent over the level in 1970. There has been a great increase in the production of other major food items as well. The total production of meat, fruits and aquatic products was almost four times greater in 1989 than 20 years earlier. (State Statistical Bureau of the PRC, 1991).
The advances in food production were particularly notable after 1978 when the open policy was adopted (i.e. a policy of fostering international exchange and cooperation in economics and technology) and economic reform was initiated,2 More than half of these increases occurred between 1978 and 1989 (State Statistical Bureau of the PRC, 1991). Along with changes in food production during the period 1978-1989, real per caput incomes rose more than 100 percent in rural areas and about 90 percent in urban areas (State Statistical Bureau of the PRC, 1991; Pinstrup-Andersen et al., 1991).
2 The three chief aspects of the economic reforms are: permitting private contracts for use of land in exchange for producing a quota of farm products for purchase by the government; development of collective and individual ownership and gradual transfer to a multifaceted ownership system; and increased production and management decision-making by enterprises, allowing them to guide the development of commodities (Jiang et al., 1988).
In spite of the increased grain production, per caput grain availability has been levelling off since 1984 because of the steadily growing population, the shrinking amount of arable land and perhaps the diminishing economic return of food production. It has been projected that grain availability will remain at approximately 400 kg per caput until the year 2000 (Liu, 1991).
The preferences for high quality foods (e.g. meat and poultry) among high-income consumers will generate increasing demand for grains because of the high feed conversion ratios for animal food. Consequently, there will be pressure to raise the prices of staple foods. Usually the poor are harmed disproportionately by these price increases since their food budgets are more constrained and their nutritional status is more vulnerable to reduced consumption. Furthermore, the high-income groups may not be better off as a result of changing diets because of the problems associated with overnutrition.
China is a country with 1.1 billion people. To feed more than one-fifth of the world's population successfully using only one-seventh of the world's arable land, an appropriate and comprehensive food and nutrition policy is essential. The formulation of this policy should be a joint effort of many concerned agencies under the leadership of the State Council. The policy should address food production, food processing, marketing, food distribution, exports and imports, poverty alleviation and nutrition education. All government sectors involved should integrate better nutrition into the goals of their sectoral plans and programmes of development. Together with family planning, policies for fostering healthy and efficient food consumption patterns are regarded as basic measures in the Chinese Government's efforts to meet the challenge of feeding the country's population (Central Committee of the Chinese Communist Party, 1988).
China is at a crossroads: food and nutrition policy decisions made today will have an important impact on the nutritional well-being of millions of people tomorrow. The elaboration of these policies requires an assessment and an understanding of the general food and nutrition situation in the country. This article reviews China's achievements and problems in improving food consumption and nutritional status over the past ten to 15 years. It is hoped that by examining the nutritional outcomes of today's policies, some insight can be gained to help policy-makers design better policies for tomorrow.
Nutrition situation in the 1980s
In 1982, the second national dietary survey found that the average energy intake per caput was 2 485 kcal (Chen, 1986). Therefore, the Chinese Recommended Dietary Allowance (RDA) of 2 400 kcal, established by the Chinese Nutrition Society in 1988, has been reached (Jin, 1990). Average protein intake was 67 g, representing 97 percent of the RDA. Estimates of average nutrient adequacy have been substantiated by time series data from the State Statistical Bureau's household budget surveys.
When the survey data was stratified into urban and rural groups, it was found that energy and protein intakes were in the range of the RDA or very close to it within both strata (Chen, 1986). The surveys indicated that from 1981 to 1989, annual per caput grain consumption in urban households remained roughly 140 kg, while in rural households it was constant at the level of 260 kg (Table 1).
In both rural and urban households, per caput pork and red meat consumption increased until 1985 and then stabilized. Rural consumption of poultry, eggs and edible oil increased considerably over the years of the survey. While urban appetites for eggs and edible oil seemed to be saturated, there was still an upward trend of poultry consumption in cities. The apparent increases in consumption of animal foods associated with constant or decreasing consumption of grain indicate an improvement in quality and increase in cost of the diet. No clear trend over time was found for the consumption of vegetables in rural and urban areas.
These food consumption data have been transformed into estimates of nutrient intakes (Table 2). Daily protein consumption was consistently above 60 g over the decade and relatively equal across rural and urban populations. Fat consumption increased more rapidly in rural areas than in urban areas. However, in 1988 the urban population still consumed as much as 40 percent more fat than the rural residents.
TABLE 2
Dietary intake of protein, fat and energy in China, 1978-1989
Apport alimentaire en énergie, protéines et matières grasses en Chine
Ingesta dietética de energía, proteínas y grasas en China
Year | Protein | Fat | Energy | |||
Urban | Rural | Urban | Rural | Urban | Rural | |
(g/caput/day) | (kcal/caput/day) | |||||
1978 | 60 | 28 | 2304 | |||
1979 | - | 63 | - | 30 | - | 2400 |
1980 | - | 62 | - | 32 | - | 2396 |
1981 | 60 | 62 | 61 | 35 | 2088 | 2418 |
1982 | 61 | 63 | 64 | 37 | 2117 | 2461 |
1983 | 63 | 64 | 70 | 39 | 2192 | 2496 |
1984 | 62 | 66 | 70 | 41 | 2186 | 2587 |
1985 | 61 | 64 | 65 | 42 | 2072 | 2526 |
1986 | 64 | 65 | 71 | 43 | 2176 | 2567 |
1987 | 62 | 65 | 72 | 45 | 2146 | 2589 |
1988 | 63 | 65 | 71 | 43 | 2166 | 2581 |
1989 | - | 67 | - | 44 | - | 2603 |
Source: State Statistical Bureau of the PRC, 1991; Pinstrup-Andersen et al., 1991; Zhu, Xian and Pinstrup-Andersen, 1991, Yang, Yang and Pinstrup-Andersen, 1991.
Energy consumption was constant at about 2 580 kcal in rural areas and 2 160 kcal in urban areas. The higher energy consumption in rural areas could be attributed to larger energy expenditure by rural people. It is puzzling that the urban energy consumption was lower than 2 400 kcal, the level thought to be appropriate according to the RDA. Since it is very unlikely that serious energy deficiencies existed among urban people, we speculate that the RDA level was too high, Alternatively, urban energy consumption may have been underestimated, probably because foods eaten away from home were not fully counted. In either case, on an average basis, food security has been achieved since the early 1980s.
TABLE 3
Some characteristics of diet quality in rural and urban areas of China, 1981-1989
Quelques caractéristiques du régime alimentaire dans les zones rurales et urbaines en Chine
Algunas características específicas de la calidad de la dieta en las zonas rurales y urbanas de China
Year | Energy share from animal sources | Protein share from animal sources | Energy | |||
Urban | Rural | Urban | Rural | Urban | Rural | |
1981 | 0.14 | 0.06 | 0.10 | 0.06 | 0.26 | 0.13 |
1982 | 0.15 | 0.06 | 0.10 | 0.06 | 0.27 | 0.14 |
1983 | 0.15 | 0.07 | 0.11 | 0.07 | 0.29 | 0.14 |
1984 | 0.15 | 0.07 | 0.12 | 0.07 | 0.29 | 0.14 |
1985 | 0.16 | 0.08 | 0.11 | 0.07 | 0.28 | 0.15 |
1986 | 0.16 | 0.08 | 0.12 | 0.08 | 0.29 | 0.15 |
1987 | 0.16 | 0.08 | 0.12 | 0.08 | 0.30 | 0.16 |
1988 | 0.15 | 0.08 | 0.11 | 0.08 | 0.30 | 0.15 |
1989 | - | 0.08 | - | 0.08 | - | 0.15 |
Source: State Statistical Bureau of the PRC, 1991; Pinstrup-Andersen et al., 1991; Zhu, Xian and Pinstrup-Andersen, 1991; Yang, Yang and Pinstrup-Andersen, 1991.
Comparison of heights of young Chinese males, 1982 - Taille des enfants chinois de sexe masculin, 1982 - Altura por edad de los niños/adolescentes chinos, 1982
Comparison of weights of young Chinese males, 1982 - Poids des enfants chinois de sexe masculin, 1982 - Peso por edad de los niños/adolescentes chinos, 1982
Changes in health and nutritional status are evidence of the impact of socio-economic development and the improvement in food consumption. By 1989, the total mortality rate of the Chinese people had been reduced to seven per thousand, infant mortality had been lowered to 46 per thousand live births and life expectancy had reached 69 years (Departments of Health and Epidemic Prevention, Health Inspection and Supervision and Office of Overseas Loans, 1990). Furthermore, a recent survey found that the rate of low birth weight was 9 percent (Office of Sampling Survey on Children in China and Department of Social Statistics of the State Statistical Bureau, 1988).
Comparison of heights of young Chinese females, 1982 - Taille des enfants chinois de sexe féminin, 1982 - Altura por edad de las niñas/adolescentes chinas, 1982
Comparison of weights of young Chinese females, 1982 - Poids des enfants chinois de sexe féminin, 1982 - Peso por edad de las niñas/adolescentes chinas, 1982
Regional differences
Geographically, China is divided into north and south by the Yangzi River. The northern part of the country produces more wheat, while rice cultivation predominates in the south. The energy and protein intake is higher in the north than in the south. In the northern provinces, the average daily per caput consumption of rice, wheat and other cereals was 25 g, 340 g and 215 g, respectively. In contrast, consumption of these staples was 401 g, 72 g and 42 g, respectively, in some southern provinces (Institute of Health, Center of Preventive Medicine, China, 1985).
A large-scale survey in 1987 found that the percentage of wasted preschool children (weight for height below third percentile of the WHO reference) ranged from 1.4 to 4, 4 in urban areas and from 1.5 to 4.2 in rural areas in the north. In the south, 3, 1 to 9.2 percent of the preschool children were wasted in urban areas, while 3.4 to 8, 5 percent of rural preschool children were wasted (Ge et al., 1991).
Current food and nutrition problems
In rural areas, where nearly 80 percent of China's people live, the food and nutrition problems are primarily related to inadequacies rooted in poverty. According to the 1989 household budget survey, 42 percent of rural households had yearly per caput incomes below 500 yuan (US$95) and 5 percent of the household incomes were below 200 yuan (US$38) (Xian, 1989). Throughout the past two decades, per caput income in rural areas has been only half that in urban areas (State Statistical Bureau of the PRC, 1991; Pinstrup-Andersen et al., 1991). As might be expected, the disparity in incomes is reflected in the differences in rural and urban diets indicated by the proportion of energy and protein from animal sources and energy from fat (Table 3).
Although the average level of consumption seems to be adequate in rural areas, the mean may conceal variations and mask the inadequacy of diets consumed by the poor. For instance, in 1989 the grand mean of per caput energy consumption by rural people was 2 603 kcal; however, disaggregated analysis revealed that 7, 1 percent of rural households had per caput energy consumption of less than 1 680 kcal, which is 70 percent of the RDA (Xian, 1989).
Growth patterns of children
When the growth patterns of Chinese children are compared with the international standards, it is evident that the growth potential of children has yet to be met in spite of recent improvements (WHO, 1983); rural children are far more likely than urban children to have growth patterns below the international standard (Figs 1-4, based on BCIP, 1989).
The disparity in the growth of rural and urban children is of concern. A growth survey conducted in nine provinces in 1987 showed that the average prevalence of stunting (height for age below third percentile of the WHO reference) among preschool children, aged zero to six years, was 17 percent in urban areas and 40 percent in rural areas (Ge et al., 1991).
The growth of children in some indigent rural areas could be much poorer than these averages. For. example, the prevalence of stunting in some "comparatively poor" rural areas of Guizhou, Jiangxi and Hubei provinces (defined by regional average of yearly per caput income between 200 and 500 yuan (US$38 to 95)) was as high as 60 to 80 percent and the prevalence of wasting was close to 7 percent. More worrisome was the fact that there appeared to be little reduction of these high prevalences over the last four to five years (Child Nutrition Surveillance Working Team, 1991).
Apart from protein-energy malnutrition, other specific nutritional deficiencies still exist and even prevail in certain poor rural and remote sites. It has been estimated that the current prevalence of rickets in children under three years of age is 30 to 50 percent while the prevalence of iron-deficiency anaemia among under-fives is 30 percent (Departments of Health and Epidemic Prevention, Health Inspection and Supervision and Office of Overseas Loans, 1990). About 7.5 million people suffer from endemic goitre and 38 million are at risk of iodine deficiency. Most of the people with these nutritional deficiencies live in the so-called lao-shao-bian-qiong (revolutionary base, ethnic, border and poor) areas.
At present, the diseases of poverty and the diseases of affluence co-exist in China. Nutritional deficiencies are still dominant while the problem of overnutrition is beginning to emerge.
In contrast to the developing areas, most urban and some developed rural areas are experiencing an increase in nutrition-related chronic degenerative diseases, or diseases of affluence. A recent health survey in Beijing found that 50 percent of women aged 45 to 60 were overweight (body mass index (BMI) > 25). Studies reported that among the population aged 15 years or older, prevalences of hypertension, coronary heart disease, stroke and diabetes were 13.5, 4.0, 1.2 and 1.2 percent, respectively. The government's recent estimate on the overall prevalence of chronic degenerative diseases, including cardiovascular and cerebrovascular diseases, diabetes, obesity and certain cancers, was 25,1 percent in urban areas and 9 percent in rural areas (Departments of Health and Epidemic Prevention, Health Inspection and Supervision and Office of Overseas Loans, 1990). In 1985 the proportion of deaths due to cardio- and cerebrovascular problems was four times greater than in 1957. These diseases now rank as the top causes of death along with malignant neoplasm. At present, chronic and degenerative disease deaths account for 70 percent of total deaths in the country (Study Group on the Formulation of China's Strategic Goals of Preventive Medicine and Health Protection by the Year 2000, 1991).
Although the causes are not completely known, there is sufficient epidemiological evidence to suggest that high intakes of fat and energy are associated with these chronic degenerative diseases. As shown above, the consumption of meat and other animal foods in rural and urban areas increased dramatically during the past decade. The mean proportion of energy derived from fat in the diet of urban residents reached 30 percent in recent years (Table 3). Certainly, many individuals in urban areas are eating far more fat than the mean. Since the consumption of animal foods by urban residents was consistently twice that of rural inhabitants, high fat intake may explain why chronic diseases are far more common in urban areas.
Policy implications
China has succeeded in increasing the average level of food consumption and maintaining food security over the past 10 to 15 years. The food problem is no longer one of overall insufficient production. However, the limited potential of agricultural production and the growing population place constraints upon further improvements in per caput food consumption.
The present policy issues are threefold. First, national food security should be maintained, primarily through domestic production. A country as vast as China cannot rely heavily on imported foods to solve food problems (Xu, 1991). Second, adequate levels of food consumption among the poor need to be guaranteed as the current macro-adjustment of the economy advances. Finally, the problem of overnutrition in the urban population needs to be addressed. All three issues should be considered in future food and nutrition policies.
Malnutrition is still a major problem among the poor; the growth of preschool children keenly reflects its adverse impact. Although there remains a need to improve the growth of Chinese children in general, it is far more practical and justifiable to act now to improve the growth of children in some poor rural environments such as lao-shao-bian-qiong areas. The poor growth of these children is obviously a result of their low socio-economic status (Habicht et al., 1974). A recent study has shown that per caput income and the educational levels of mothers were closely associated with the growth performance of children in these households (Ge et al., 1991). Policy measures that will increase the energy content of diets in these households will certainly benefit the malnourished as well.
In contrast, urban diets with too much fat from pork and red meat are clearly undesirable. These habits should be discouraged not only for the sake of the consumers' health but because the demand for these foods can raise prices. This increase affects the nutritional well-being of the poor, who face the same food prices as high-income consumers. However, the national average of consumption of animal foods is quite low and increased consumption of these foods, particularly among the rural population, is necessary. The consumption of poultry could be encouraged because producing poultry is economically more viable than producing pork in terms of feed conversion efficiency (Liu, 1991). Furthermore, poultry fat contains more linoleic acid and less cholesterol than mammal fat (Institute of Nutrition and Food Hygiene, 1991). Therefore, poultry consumption may not be as strongly associated with cardiovascular diseases as consumption of mammal meat. Fostering healthy and efficient food consumption among the population will also help to achieve food security, since resources could be transferred and used more efficiently across population groups of different income levels. Indeed, this is a basic motivation for the current review of food and nutrition policy by the Chinese government.
REFERENCES
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Consommation alimentaire et état nutritionnel en Chine
Les progrès accomplis sur le plan du développement économique national et de la production agricole ont entraîné une hausse de 70 pour cent de la production céréalière et la multiplication par quatre de la production totale de viande, de fruits et de produits aquatiques. Plus de la moitié de ces progrès ont été enregistrés après 1978, date à laquelle ont été prises les premières mesures d'ouverture politique et économique. Pendant la période 1978-1989, le revenu par habitant a augmenté de plus de 100 pour cent dans les zones rurales et de près de 90 pour cent dans les zones urbaines.
Au début des années 80, la consommation alimentaire, moyenne par habitant atteignait le niveau recommandé de 2 400 kcal, tandis que l'apport protéique moyen était de 67 g, soit 97 pour cent de la ration recommandée.
Dans les zones rurales, où vivent près de 80 pour cent de la population chinoise, les problèmes nutritionnels liés au sous-développement et à la faiblesse des revenus subsistent. Bien que le niveau moyen de consommation semble correspondre aux normes, l'analyse détaillée révèle que 7, 1 pour cent des ménages ruraux ont une ration énergétique inférieure à 1 680 kcal (70 pour cent seulement de la ration recommandée).
Les enfants chinois ne réalisent pas encore tout leur potentiel de croissance, malgré quelques progrès récents. Outre la malnutrition protéo-calorique, d'autres carences nutritionnelles spécifiques comme le rachitisme, le goitre et l'anémie existent encore, voire prévalent, dans certains villages pauvres et reculés. Bien que les carences nutritionnelles soient encore le problème numéro un, les problèmes dus à la surnutrition commencent à apparaître. La plupart des zones urbaines et quelques zones rurales développées enregistrent une augmentation des maladies nutritionnelles caractéristiques de la société d'abondance. On évaluait récemment la prévalence générale des maladies chroniques comme les maladies cardio-cérébro-vasculaires, le diabète, l'obésité et certains cancers à 25,1 pour cent dans les zones urbaines et 9 pour cent dans les zones rurales. Les décès dus à des maladies chroniques et dégénératives représentent 70 pour cent des décès.
Les politiques actuelles en matière de nutrition visent trois objectifs; tout d'abord, il s'agit de garantir la sécurité alimentaire nationale essentiellement grâce à la production intérieure. Deuxièmement, il convient d'assurer aux pauvres des niveaux suffisants de consommation alimentaire en même temps que progresse le macro-ajustement actuel de l'économie. La priorité doit être donnée à l'amélioration des revenus, de l'éducation et de l'état nutritionnel des ménages des zones rurales pauvres. Enfin, le problème de la suralimentation de la population urbaine doit être traité. Ces trois questions devront être étudiées lorsque la Chine formulera ses futures politiques en matière d'alimentation et de nutrition. Promouvoir une consommation alimentaire saine et efficace contribuera à réaliser l'objectif de la sécurité alimentaire, puisque les ressources disponibles pourraient être transférées d'un groupe de population à l'autre pour être utilisées plus efficacement selon les niveaux de revenus. En vérité, il s'agit là d'une considération fondamentale qui est à l'origine de l'étude rétrospective sur la politique alimentaire et nutritionnelle à laquelle procède actuellement le Gouvernement chinois.
Consumo alimentario y estado nutricional en China
Los progresos realizados en el desarrollo económico de China y en la producción agraria han hecho que la producción de cereales aumente en un 70 por ciento y que la producción total de carne, frutas y productos acuáticos se cuadruplique. Más de la mitad de estos adelantos se produjeron después de 1978, fecha en que iniciaron las reformas de la economía y la apertura de la política económica. Entre 1978 y 1989 los ingresos reales por habitante aumentaron en más del 100 por ciento en las zonas rurales y aproximadamente en un 90 por ciento en las urbanas.
A principios del decenio de 1980, se alcanzó en China el aporte dietético recomendado (ADR) de 2 400 kcal diarias, y la ingesta media de proteínas era de 67 gramos, que representa el 97 por ciento del ADR.
En las zonas rurales, donde vive casi el 80 por ciento de la población china, siguen existiendo problemas de nutrición relacionados con el subdesarrollo y la carencia de medios. Aunque el nivel medio de consumo parece ser el adecuado, un análisis desglosado revela que en el 7, 1 por ciento de las familias rurales el consumo energético por habitante era de menos de 1 680 kcal (o sea el 70 por ciento del ADR).
A pesar de los últimos avances, todavía tiene que alcanzarse el potencial de crecimiento de los niños chinos. Además de la malnutrición proteíno-energética, siguen existiendo todavía otras enfermedades específicas de la deficiencia nutricional como el raquitismo, el bocio y la anemia provocada por deficiencia de hierro, que incluso son prevalentes en algunos lugares remotos y donde predomina la pobreza rural. Mientras siguen prevaleciendo las deficiencias nutricionales, está comenzando a surgir el problema de la hipernutrición y en algunas zonas rurales desarrolladas se está produciendo un aumento de las «enfermedades de la abundancia» relacionadas con la nutrición. Las últimas estimaciones de la prevalencia general de las enfermedades crónicas degenerativas, incluidas las enfermedades cerebro-cardiovasculares, la diabetes, la obesidad y algunos cánceres, fueron de un 25,1 por ciento en las zonas urbanas y de un 9 por ciento en las zonas rurales. Las muertes provocadas por enfermedades crónicas y degenerativas representan el 70 por ciento de las defunciones que se producen en el país.
Las actuales cuestiones normativas se refieren a tres aspectos del problema: en primer lugar, deberá mantenerse la seguridad alimentaria nacional, sobre todo a través de la producción propia. En segundo lugar, hay que garantizar unos niveles suficientes de consumo de alimentos entre los pobres a medida que avanzan los actuales ajustes macroeconómicos. Deberá tener prioridad el aumento de los ingresos y el nivel de educación y mejorar el estado nutricional de las familias de las zonas rurales pobres. Por último, hay que abordar el problema de la hipernutrición entre la población urbana. En el futuro, cuando en China se formulen políticas alimentarias y nutricionales habrá que tener en cuenta estos tres aspectos. Fomentar un consumo saludable y eficaz de alimentos contribuirá a alcanzar el objetivo de la seguridad alimentaria, ya que podrían transferirse recursos que se utilizarán de modo más eficaz entre los grupos de población de distintos niveles de ingreso. Es ésta una consideración fundamental que motiva el actual estudio retrospectico de las políticas sobre alimentación y nutrición del Gobierno de China.
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