Excessive consumption of sugar-sweetened beverages (SSBs) increases risk of obesity. Similar data are lacking in Chinese populations with rapid nutritional transition. We aimed to examine the association between SSB intake, lifestyle factors and obesity in Hong Kong Chinese.
This is a cross-sectional survey on SSB intake with 2295 (49.6%) men and 2334 (50.4%) women (age: median 43.0 years, range 18–81 years). They were recruited from a territory-wide health promotion campaign in Hong Kong. All subjects completed a questionnaire and underwent simple health tests. Their SSB intake was based on a 1-week recall (1 unit of SSB=250 ml, frequent SSB consumption=daily intake⩾2 units).
Men were more likely than women to smoke, drink alcohol, frequently consumed SSB (20.5 vs 9.5%) and ate more meat portions (2.32±0.57 vs 2.15±0.44) but were physically more active (no exercise: 31.2 vs 39.2%) (P-values: all <0.001). After adjusting for confounding factors, frequent SSB intake remained independently associated with obesity in women (odds ratio (95% confidence interval): 1.86 (1.36–2.55)) while physical inactivity (1.84 (1.41–2.39) for none vs regular), smoking (1.29 (1.05–1.58)) and high daily meat intake (2.15 (1.36, 3.42)) predicted obesity in men.
In Chinese of working age, SSB consumption in women and physical inactivity, smoking and high meat intake in men were associated with obesity.
Obesity is a global health threat especially in countries undergoing rapid nutritional transition such as China (Chan et al., 2009). According to the China National Nutrition and Health Survey 2002, >280 million people in mainland China were overweight or obese using the Chinese criteria (body mass index (BMI) ⩾24 and 28 kg/m2, respectively) (Wu, 2006). The rising trends of obesity were observed in both adults and children. In school children aged 7–18 years, the prevalence of obesity has increased from <1% in 1985 to 4% and 8% respectively in girls and boys in 2000 (Wu et al., 2002).
Over-nutrition and physical inactivity are major culprits in this obesity epidemic (CDC, 2003). One important dietary risk factor is the increasing consumption of sugar-sweetened beverages (SSB) worldwide. In the United States, consumption of caloric sweeteners has increased by 22% between 1977 and 1996. During the same period, energy intake accounted by these sweeteners increased from 13.1 to 16.0% (Popkin and Nielsen, 2003). According to the US National Health and Nutrition Examination Survey, from 1988–1994 to 1999–2004, per capital consumption of SSB increased by 46 kcal/day and daily SSB consumption among drinkers increased by 6 oz (Bleich et al., 2009). Sugar-sweetened soft drink is now the largest source (47%) of added sugars. It is the top single food source of calories and accounts for 7% of total energy intake in the American diet (Nielsen and Popkin, 2004). Although studies from Caucasians suggested a link between SSB consumption and risk of obesity (Malik et al., 2006; Olsen and Heitmann, 2009), there is a paucity of data in Asia, where most of the data came from children and adolescents (Misra and Khurana, 2008; Olsen and Heitmann, 2009). Importantly, the modifying effects of lifestyle factors such as exercise remain unclear.
In this community-based health survey of 4629 Southern Chinese adults working in Hong Kong, a cosmopolitan city of 7 million people, we examined the risk associations of obesity with lifestyle factors including intake of SSB, physical activity, smoking and alcohol intake. Given the proven beneficial effects of lifestyle modification on cardio-metabolic risk (Wadden et al., 2009), this epidemiological information will be useful for public education and policy decision to reduce the burden of obesity in developing countries such as China.
Materials and methods
The Health InfoWorld is the health promotion department of the Hong Kong Hospital Authority, which governs all public hospitals and clinics in Hong Kong. In April 2000, a territory-wide health promotion campaign named ‘Better Health for a Better Hong Kong’ (BHBHK, the campaign) was launched to increase societal awareness of the importance of healthy diet, increased physical activity and mental wellness, targeting at work force. Details of the study design and methods of the campaign have been published (Ko et al., 2007). In short, we invited the two largest unions in Hong Kong (Hong Kong Confederation of Trade Union and Hong Kong Federation of Trade Union) to recruit participants from its 236 sub-unions consisting of 450 000 members. Subjects were randomly selected using computer-generated codes according to the distribution of occupational groups as recorded in the Hong Kong Population by Census Report. Respondents were invited to undergo a health check-up free of charge and without financial incentive. A total of 11 965 invitations were sent and 4841 subjects (40.5%) responded. Of these 4841 subjects, 212 had missing information on dietary intake and/or anthropometric indexes. Hence, 4629 subjects were included in this analysis. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Ethics Committee, Hospital Authority, Hong Kong. Written informed consent was obtained from all subjects.
On the day of assessment, subjects completed a questionnaire and underwent simple health tests in the labor union offices. The questionnaire included a dietary assessment, past medical history, smoking status and alcohol intake. The dietary assessment was based on a 1-week recall (that is, habitual dietary consumption pattern during the past 1 week) including major food items with 2–4 choices as answers. SSB was defined as beverages with added sugar, such as soft drinks or sweet soups, which are popular Chinese desserts. One unit of SSB was defined as 250 ml equivalent to the volume of a normal-sized glass or a paper pack of popular commercial beverages.
Frequent intake of SSB was defined as daily intake of two units or more. High meat intake (including fish) was defined as eight portions of meat per day. One portion of meat was defined as 1 tael of raw meat or 1 oz of cooked meat (roughly the size of a ping-pong ball, or an egg, or a piece of mah-jong cube, which approximates to a size of 3 cm × 3 cm × 2 cm). Number of meals per day including main meals and snacks was also documented. Physical activity was assessed by levels of regular exercise on a weekly basis. The level of exercise was classified as regular (at least three sessions per week with moderate-to-vigorous exercise for ⩾20 min at each session), infrequent (1–2 sessions per week of moderate exercise for ⩾20 min at each session) and no exercise (Hui et al., 1999). Ever use (current or ex-) of tobacco and current alcohol drinking was also recorded.
The simple health check included measurements of blood pressure, body weight, height, waist and hip circumferences. Blood pressure was measured in the right arm after at least 5 min of rest using a Dinamapp machine. Body weight, height and waist circumference were measured in subjects wearing light clothing and without shoes for calculation of BMI and waist–hip ratio. Waist circumference was defined as the minimum waist measurement between xiphisternum and umbilicus. Hip circumference was taken as the maximum measurement around the buttock. A team consisting of three trained nurses conducted all these health checks using the same set of equipments including weighing scale, tape measures and desktop machines. Obesity was defined as BMI ⩾27.5 kg/m2 (general obesity) and waist circumference ⩾80 cm for women and ⩾90 cm for men (central obesity) (WHO, 2004).
Statistical analysis was performed using the SPSS (version 15.0, SPSS Inc, Chicago, IL, USA) software on an IBM-compatible computer. All results are expressed as mean±s.d. or n (%) as appropriate. The Student's t-test, χ2 test and one-way analysis of variance were used for between-group comparisons. Fisher's exact test replaced χ2 test when a 2 × 2 comparison had at least one expected cell count <5. Multiple regression analyses were performed with obesity parameters as dependent variables; Independent variables included age, gender (men=1, women=0), ever-smoking status (yes=1, no=0), alcohol intake (yes=1, no=0), physical activity (frequent=1; occasional=2; none=3), frequent SSB intake (daily intake ⩾2 units=1, daily intake 1 unit or less=0), high daily meat intake (daily intake ⩾8 portions=1, <8 portions=0) and frequency of meals (from 1 to ⩾7). Linear regression was used for continuous variables (BMI, waist, hip, waist–hip ratio), whereas binary logistic regression was used for dichotomous variable (presence of obesity). A P-value <0.05 (two-tailed) was considered to be significant.
Of the 4629 subjects, 2295 (49.6%) were men and 2334 (50.4%) were women. The mean age was 42.3±8.9 years (median 43.0 years, range 18–81 years). In both men and women, waist, waist–hip ratio and percentage of obese subjects increased with age. Overall, 30–40% of the subjects had general or central obesity. One-third of subjects were physically inactive with 20% of men and 10% of women consuming ⩾2 units of SSB daily. Level of physical activity (regular or occasional exercise) declined with age in women but not in men. Compared with women, men were more obese, had higher blood pressure and were more likely to smoke, drink alcohol, ate more meat, less likely to be physically inactive and had less frequent meals (Table 1).
Table 2 summarizes the clinical and lifestyle factors stratified by daily intake of SSB. There were only 15 men and 6 women who consumed ⩾4 units of SSB. Hence, we stratified the subjects by SSB intake ⩾2 units and gender. Increased SSB consumption was associated with young age. Women who had frequent intake of SSB (⩾2 units daily) had higher BMI, waist and hip circumference and were more likely to smoke than those who took <2 units. Similar trend was not found in men.
Using multiple regression analyses with obesity indexes (BMI, waist, hip and waist–hip ratio as continuous variables; and BMI ⩾27.5 kg/m2 and/or waist ⩾90 cm in men or ⩾80 cm in women as dichotomous variables) as dependent variables, age and all lifestyle factors as independent variables, age was an independent predictor for obesity in both men and women. In women, SSB consumption was also a risk factor while smoking, high daily meat intake and physical inactivity were predictors for obesity in men (Table 3).
In this Chinese workforce, we observed multiple correlations among age, sex, anthropometric indexes and lifestyle factors including tobacco and alcohol intake as well as consumption of meat and SSB. Women who consumed ⩾2 units of SSB had 8% higher rate of central obesity (35.6 vs 27.5%) and 1.5 cm larger waist circumference (76.3 vs 74.8 cm) than infrequent SSB consumers after adjustment. Men were more likely than women to take SSB frequently (20 vs 10%) and ate more meat (2.30 vs 2.14 portions) but they were less likely to be physically inactive (31 vs 39%). Although older people were generally more obese, young people were more likely to consume SSB. After adjusting for other confounders, physical inactivity, high daily meat intake, smoking in men and SSB consumption in women were independents predictor of obesity. Taken together, our findings highlight the need to take age, gender and other lifestyle factors into consideration when giving health advice to our community.
To date, most of the Asian data on risk association between SSB and obesity came from cross-sectional studies in children and adolescents (Ariza et al., 2004; Berkey et al., 2004; Olsen and Heitmann, 2009). Although the risk association of SSB and health risks remains contentious with positive (Phillips et al., 2004; Welsh et al., 2005) and negative reports (Blum et al., 2005; Kvaavik et al., 2005), this is likely to be due to differences in study population and methodology. In agreement with our findings, other researchers have also reported the risk association between SSB and obesity (Schulze et al., 2004; Bes-Rastrollo et al., 2006), especially in women (Schulze et al., 2004). Apart from its high caloric content (Malik et al., 2006; Olsen and Heitmann, 2009), SSB is a major source of foods with high glycemic index, which is an independent risk factor for diabetes and obesity (Murakami et al., 2006; Villegas et al., 2007). As a liquid form of energy source, some studies suggested SSB did not trigger the physiological satiety mechanism, which could lead to overeating with obesity (Bawa, 2005; Bachman et al., 2006). However, other papers reported SSB might still be satiating (Drewnowski and Bellisle, 2007). Hence, the data in this area remain inconclusive.
There are many confounding factors for obesity including total energy intake and physical activity. However, in studies in which total energy intake was adjusted, SSB intake often remained a significant risk factor for obesity (Schulze et al., 2004; Bes-Rastrollo et al., 2006). Although we did not perform detailed dietary assessments, after adjusting for meat intake and number of meals per day, the association between SSB consumption and obesity remained statistically significant in women. Although men had higher intake of SSB and meat than women, they were physically more active than women. Even then, only 20% of men in this workforce had regular exercise. Compared with the latter, men with infrequent or no regular exercise had 30–80% increased odds of being obese. Interesting, the recent PREMIER trial reported that a reduction in SSB daily intake of one serving was associated with a weight loss of 0.49 kg at 6 months and of 0.65 kg at 18 months, which highlighted the importance of limiting SSB intake among adults (Chen et al., 2009).
Furthermore, we observed that smokers were 30% more likely to be obese than non-smokers. Although many studies suggested an inverse relationship between obesity and smoking, especially when the definition of smoking included ex-smoking, the present finding is in accord to our previous study with 3718 Chinese (Ko et al., 2001) that female smokers had higher BMI than non-smokers (women: 25.8 vs 24.7 kg/m2, P<0.05; men: 25.4 vs 25.0 kg/m2, P: NS). In this regard, several studies have shown that smoking increased risk of diabetes by 30% in a dose-dependent manner (Chen et al., 2008). In a prospective community-based survey in Korea involving 4000 men, the investigators reported a stepwise increase in risk association of diabetes with number of cigarettes, especially in those with high insulin resistance and low beta cell function using Homeostatic Model Assessment models. At baseline, smokers (current and ex-) had higher BMI and waist than non-smokers and similarly, in heavy smokers (>20 cigarettes per day) compared with those who smoked fewer cigarettes (Cho et al., 2009). We believe smokers are more likely to be associated with other unhealthy lifestyle such as physical inactivity and poor dietary pattern. A more comprehensive coverage of related risk factors in the analysis is needed for a clearer understanding on the relationship between smoking and obesity.
In our survey, 30% of men and <5% of women were ex- or current smokers although it is noteworthy that women who frequently consumed SSB were also more likely to smoke. These smoking rates are considerably lower than that in mainland China, which is now the largest producer and consumer of tobacco in the world (Chan et al., 2009). For the definition of obesity, common consensus is still lacking. In mainland China, the cut-off value for obesity was suggested to be ⩾28 kg/m2 in 2002 (Zhou, 2002). However, World Health Organization in 2004 proposed using ⩾27.5 kg/m2 in Asia as BMI cut-off point for public health action on obesity (WHO, 2004). We adopted the latter cut-off value for easier comparison with other international studies.
There are several limitations in our study. This was not a population-based survey but a health promotion survey with potential bias because of volunteer effects. The non-random and cross-sectional nature of our study may underestimate the risk association because obese people may be more motivated to modify their lifestyle and abstain or reduce SSB intake. Despite these limitations, we found positive and independent associations between frequent SSB intake and obesity indexes especially in Chinese women. On the other hand, the fact that younger people were more likely to consume SSB and that physical inactivity, high daily meat intake and smoking were predictors for obesity in men highlight the importance of taking age, gender and other modifiable lifestyle factors into consideration in designing health awareness and promotion programs in developing countries such as China undergoing rapid nutritional transition.
In summary, frequent SSB consumption in women, physical inactivity, smoking and high daily meat intake were risk factors for obesity in Chinese. Given the high rates of obesity and unhealthy lifestyle factors averaging 10–30% in these working populations, there is an urgent need to institute public health measures to increase awareness and create an environment conducive to promoting healthy lifestyle in developing areas such as China.
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We thank all participating labor unions and their members in making this study possible. The study was funded by the Hong Kong Hospital Authority with partial support from the Li Ka Shing Foundation. Members of the Research Committee of the BHBHK Campaign include Professor Cecilia LW Chan, Professor Juliana CN Chan, Dr Gary TC Ko, Professor Stanley SC Hui, Professor CY Chiu, Rosalie SY Kwong, Selina Khor, CY Wong, Spencer DY Tong, Amy WY Chan, Ruby LP Kwok, Ferrie Chow and Patrick TS Wong.
The authors declare no conflict of interest.
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Ko, G., So, W., Chow, C. et al. Risk associations of obesity with sugar-sweetened beverages and lifestyle factors in Chinese: the ‘Better Health for Better Hong Kong’ health promotion campaign. Eur J Clin Nutr 64, 1386–1392 (2010) doi:10.1038/ejcn.2010.181
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