Editorial

China's little emperors: Medical consequences of China's one-child policy

Tsung O. Cheng Department of Medicine, The George Washington University Medical Center, 2150 Pennsylvania Avenue, N.W., Washington, DC 20037, United States

a r t i c l e i n f o

Article history:Received 23 August 2013Accepted 23 August 2013Available online 30 August 2013

Keywords:China's one child policyChina's little emperorsChildhood obesity in China

1. Introduction

any uncertainty about the fact that China's one-child policy con-tributes to the rising prevalence of childhood obesity in China withits multiple undesirable sequelae [816]. The one-child policy inChina has produced a generation of little emperors who are obese(Fig. 1).

2. History of China's one-child policy

When the People's Republic of China was founded in 1949, itinherited world's most populous country with half of a billion people,which was triple the population of the United States. Mao Zedongproclaimed having lots of people was a very good thing; it meantmore workers and more soldiers and was a matter of national pride

International Journal of Cardiology 168 (2013) 51215125

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j ourna l homepage: www.e lsev ie r .com/ locate / i j ca rd Corresponding author at: Tel.: +1 202 741 2426; faxE-mail address: tcheng@mfa.gwu.edu.

Fig. 1. A chubby Little Emperor smili

0167-5273/$ see front matter 2013 Elsevier Ireland Lhttp://dx.doi.org/10.1016/j.ijcard.2013.08.074Although the debates continue with regard to the behavioral im-pacts of China's one-child policy [17], there does not appear to be: +1 202 741 2324.

ng in front of Mao Zedong's portrait

td. All rights reserved.[17]. When the U.S. Secretary of State Dean Acheson thought thatChina would not be able to feed the population, an angry Mao redback at the naysayers [17].at the Tiananmen Square in Beijing, China. Credit: AFP/Getty Images.

Then in 1979, Deng Xiaoping embarked on a most ambitious pro-gramofmarket reform following the economic stagnation of the Cultur-al Revolution. He introduced China's one-child policy upon the advice ofSong Jian, a leadingmissile scientist and a specialist in cybernetics, withwhom this author has been well acquainted for many years (Fig. 2).Song is a rm believer in eugenicsquality instead of quantity, as canbe deduced from his foreword written for my book Genetics in Cardio-vascular Disease (Fig. 3).

It might be of some historical interest to recapitulate how Songconceived China's one-child policy [18], as was described in details inGreenhalgh's book Just One Child: Science and Policy in Deng's China[19]. It was in 1975, when Song joined a Chinese delegation toEurope. At the University of Twente in Enschede, the Netherlands, hemet Geert Jan Olsder, a specialist in differential game theory. Overbeers at a pub, Olsder told Song about a series of equations he had de-veloped to control population on a ctional island. The key variable, cal-culated per time unit, was number of births. He immediately became

enthusiastic, recalls Olsder, who says his equations were theoretical.Olsder gave Song a paper explaining the equations, Population Planning:a Distributed Time Optimal Control Problem. Song put the methods ofOlsder and other European mathematicians to use. By 2080, they pre-dicted, China's population would top 4 billiona projection resting onunreliable data, says Greenhalgh. But it wowed Chinese leaders, propel-ling them toward another of the team's prognoses: that the only way toavert catastrophewas to reduce fertility to one child by 1985 andmain-tain that level for 20 to 40 years [18]. Thus was born China's one-child

Fig. 3. My book, entitled Genetics in Cardiovascular Disease (A), to which Song Jiangwrote a Foreword (B).

5122 EditorialFig. 2. Autographed photograph of Song Jiang (right) with this author (left). policy three and a half decades ago (Fig. 4).

5123Editorial3. China's one-child policy and male-heavy sex ratio

One unexpected consequence of the one-child policy in China is themale-heavy sex ratio (Fig. 5). This skewed sex ratio at birth reects theChinese traditional preference for boys to girls because boys will carrytheir family names through the generations in contrast to girls whowill take on the last names of their husbands. Furthermore, a boy willgrow up to work and support not only himself but also his two parentsand four grandparents as they get too old to work themselves. Chinese

Fig. 4. Cover of Beijing Review, February 4, 1980 praising China's one-child policy.

Fig. 5. Progressive increase in the ratio of boys to girls born after 1982.customs contribute to the portrayal of female children as a burden.The old proverb saying, raising a girl is like watering your neighbor'sgarden, remains a common belief among Chinese parents [20]. Ofcourse, if this trend continues, China would not have enough girls togrow up to reproduce anymore. What a naturalway to control popu-lation in China! [21].

4. China's one-child policy as the leading cause of child obesityepidemic in China

China's one-child policy is conducive to childhood obesity in twoways [22]. First, China is strict in allowing only one child per family.There is a saying in China: 2-4-8 (, pronounced as er, si' andba', respectively), you get fat. With only one child in the family, thedoting parents (2 in number), grandparents (4 in number) and greatgrandparents (8 in number) pamper their only child by overfeedingthe little emperor [23]. Furthermore, food that used to be distributedamong his siblings is now devoured by just one person. This phenome-non has also been euphemistically called the six-pocket syndrome bytheWesterners [24, pp. 143146]. Second, two decades of China's strictfamily planning, which allows only one child per family, has madeChina's labor force in such high demand that most of the labor workersnow demand a less strenuous job and thus no longer derive the healthbenets of physical exertion [25]. Thus, childhood obesity ensues andhas reached an epidemic proportion in China [16]. Fat Chinese childrengrow up to be fat Chinese adults [26], and fat Chinese adults developcoronary artery disease [27].

5. Medical consequences of China's childhood obesity epidemic

Among the manymedical complications of childhood obesity, includ-ing dyslipidemia, hypertension, Pickwickian syndrome, nonalcoholic fattyliver disease, etc. [16], diabetes is themost serious. According to the 2000World Health Organization report, the number of Chinese diabetics rankssecond in the world, and the increasing prevalence of diabetes in youngchildren doubled in the recent 5 years is particularly disconcerting[28]. The incidence of abnormal glucose metabolism in obese childrenhas reached 28.26% [28]. The prevalence of childhood diabetes is higherin economically developed regions than that in less developed regionsin China [12,13]. Economic developmentmay be associatedwith changesin lifestyle that often lead to physical inactivity, unhealthy diet, and obesi-ty, all of which are contributing factors for the development of diabetesepidemic in China [29].

Diabetes is not merely an endocrine disease. As a matter of fact, theAmericanHeart Association considers diabetes as a cardiovascular disease[30]. Furthermore, in the recently publishedHoorn Study of a population-based cohort, nearly half of patientswith diabetes and a rst cardiovascu-lar event had a recurrence after a median 4.1 years [31].

6. Socioeconomic implications of China's childhood obesity epidemic

Childhood obesity is the leading cause of childhood diabetes in China[32]. I sounded an alarm about diabetes epidemic in China as early as in2003 [33]. It is now careening on the brink of a national crisis [34].China's healthcare costs attributable to diabetes will far exceed 13% ofthe total in the very near future [29]. In another word, one of everyeight dollars spent on health care in China will be attributable to diabe-tes, which is obesity related.

As Dr. Chen Zhu, the immediate past Minister of Health of China,said, diabetes and other chronic diseases are threatening to sap thelabor force and slow the pace of economic growth in China [35]. In2012, the total healthcare cost in China reached 2.89 trillion yuan($473.5 billion), an 18.8% rise compared to the previous year, accordingto a statistics bulletin released on June 18, 2013, by the National Health

and Family Planning Commission [36].

ior t

5124 EditorialIn the United States, according to the Centers for Disease Control andPrevention, the cost of treating medical problems related to obesityreached an estimated $147 billion in 2008, and chronic health problemssuch as obesity and obesity-related diseases such as diabetes, coronarydisease and kidney disease account for more than 75% of the nation's$2.7 trillion in annual spending for medical care [37].

7. Time to reconsider the one-child policy to curtail childhood obesity

The one-child policy has undoubtedly curtailed the rapid populationgrowth in China (Figs. 6 and 7). The original purpose of China's one-child policy was to cut down the cost of feeding too many mouths in apoor developing country, which China was in the 1950s, 1960s and1970s. Now China is the second largest economy in the world, andsuch drastic policy is no longer needed. Furthermore, the one-child pol-icy has also given rise to many unintended medical problems, the mostserious of which is childhood obesity. Therefore, it is time to reconsiderthe wisdom of continuing this policy before the situation deteriorates

Fig. 6. Projected Chinese population prfurther.In June of 2013, the American Medical Association for the rst time

in its history has declared obesity as a disease [38]. This new labelingis a step toward trying to reduce other illnesses, including diabetesand coronary heart disease. An obese child grows up to be an obese

Fig. 7.China's population from 1952 to 2007, showing the plateauing after 200020 yearsafter the introduction of its one-child policy.adult [26]. To conquer obesity in adults is to prevent childhood obesity.The best way to treat a disease is to prevent it from happening in therst place. As the Chinese Yellow Emperor Huang Di said thousandsof years ago, the superior doctor prevents diseases; the mediocre doc-tor attends to impending diseases; the inferior doctor treats full-blowndiseases [22].

Therefore, the way to prevent child obesity epidemic in China is torelax or modify the one-child policy as soon as possible. The ChineseDream proposed by Chinese president Xi Jinping should include tacklingthis serious problem without delay. The recent merging of the NationalPopulation and Family Planning Commission with the Ministry of Health[39] is a step in the right direction.

8. Conclusion

Although the Chinese government should be applauded for adoptingthe one-child policy in controlling thebaby boom in the last century, it istime to reconsider the advisability of continuing this unpopular policy

o the introduction of one-child policy.with its unexpected dire medical, especially cardiovascular [40], and so-cioeconomic consequences now that the curtailment of population explo-sion has been successfully accomplished. I sincerely hope that the newlyelected, reform-minded Chinese president Xi Jinping will expedite thischange in the very near future to fulll his Chinese dreams [41].

Acknowledgment

I acknowledge the many helpful suggestions and advices of SusanGreenhalgh throughout the preparation of this manuscript.

I certify that I comply with the Principles of Ethical Publishing in theInternational Journal of Cardiology.

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5125Editorial

China's little emperors: Medical consequences of China's one-child policy1. Introduction2. History of China's one-child policy3. China's one-child policy and male-heavy sex ratio4. China's one-child policy as the leading cause of child obesity epidemic in China5. Medical consequences of China's childhood obesity epidemic6. Socioeconomic implications of China's childhood obesity epidemic7. Time to reconsider the one-child policy to curtail childhood obesity8. ConclusionAcknowledgmentReferences