CHINA: FROM DISEASES OF POVERTY TO
DISEASES OF AFFLUENCE. POLICY
IMPLICATIONS OF THE EPIDEMIOLOGICAL
T. COLIN CAMPBELL, CHEN JUNSHI, THIERRY BRUN, BANOO PARPIA, QU YINSHENG,
CHEN CHUMMING, and CATHERINE GEISSLER
[ Intro I Methods I Results and Discussion I Policy Implications ]
[ References I Exclusive Interview With Colin Campbell ]
'Division of Nutritional Sciences, Cornell University, Ithaca
, Institute of Nutrition & Food Hygiene, Chinese Academy of Preventive Medicine,
Beijing, 'Institute Of Mediterranean Agriculture, Montpellier, 'Department
of Food and Nutritional Science, Kings College, University of London.
(Received 5th February, 1991; in final form November 5th, 1991)
One hundred and forty years ago John Hughes Bennett, Senior Professor of
Clinical Medicine at the University of Edinburgh, when writing about the
causes of cancer, said that nutritional conditions that favored the risk
of tuberculosis were opposite to those favoring the risk of cancer (Bennett,
1849). Just three years before, Walshe had published cancer mortality data
and proposed that cancer was a "disease of civilization" (Walshe,
1846) because death rates were higher amongst the upper income citizenry.
On many occasions since then, it has been observed that disease prevalence
changes radically after economic development (Pellett, 1989). The diseases
that were responsible for a vast majority of deaths in Europe and North
America in the nineteenth century are not the primary causes of death today.
Although the specific reasons for these changes in mortality rates are not
well understood, a few of the more general characteristics of these trends
are as follows. The decline in infectious and communicable diseases follows
an increase in, and more equitable distribution of, economic resources.
An extensive investigation of mortality rate trends in England and Wales
in the eighteenth, nineteenth and twentieth centuries (McKeown and Record,
1955; McKeown and Record, 1962; McKeown et aL, 1975) indicates that the
nineteenth century decline in mortality rates for the most prevalent infectious
diseases was wholly attributable to environ- mental control, not to intervention
with curative medicines and vaccines.
McKeown et al. (1975) suggest that a better diet, improved hygiene, and
a more favorable relationship between microorganisms and humans were major
contributors to these trends, with better nutrition accounting for about
three-fourths of the effect. Deliberate improvements in sanitation, however,
may have been somewhat more important than he supposed as suggested by Cairns
(1985) who added that the wider use of cotton, which did not shrink like
wool, allowed clothes to be washed and, in so doing, people also washed
themselves. In many developing nations there has been a rapid increase in
the incidence of cardiovascular disease, obesity, diabetes, lung cancer
and a host of other health disorders concomitant with a rise in economic
affluence (Pellett, 1989). In contrast with the communicable and infectious
diseases affecting the rural poor, the more economically privileged urban
sectors in these countries suffer from a rising preval- ence of chronic
degenerative diseases appropriately referred to as 'diseases of misdevelopment'
by Dumont (1989). Not only do these chronic diseases have a debilitating
effect on a productive segment of the active elite but also the costs of
treating these diseases tend to absorb a disproportionate share of the public
health resources in favor of an already privileged social group. It is therefore
of utmost importance to developing nations to avoid creating a new and costly
pathology soon after emerging from the scourge of infectious and nutritional
deficiency diseases (Pellett, 1989).
China, a vast and densely populated country in the process of rapid modern-
ization offers a unique setting to study the relationship between dietary,
environ- mental and economic changes and health indicators. Two recent surveys
(National Cancer Control Office, 1979; Chen et aL, 1990) in the People's
Republic of China have confirmed the emergence of a similar trend in certain
areas of this country: that is, an increase in chronic diseases and a decrease
in communicable diseases. This paper reports on an analysis of primary data
collected in an ecologic survey of dietary and lifestyle factors (Chen
et aL 1990) together with secondary data on disease-specific mortality rates
for the survey sites (National Cancer Control office, 1979). Two broad research
questions are addressed:
1) are there any discernible patterns or clusters
of disease distribution across China?
An analysis of these
Chinese data, which is the focus of this communication, provides evidence
to suggest that diseases such as cancers and coronary heart disease may
share a common nutritional etiology based on the enrichment of diets with
animal products. Policy implications of these findings for China and other
countries also are briefly discussed.
2) what effect, if any, do nutritional
factors or dietary patterns have on this distribution?
Data from a 1976 retrospective mortality survey ft)r 1973-75 causes of death
and a ecologic survey in 1983 84 were combined to study the relationship
between various mortality rates and several dietary, lifestyle and environmental
charac- teristics in 65 mostly rural counties in China (et al, 1990). Sampling
procedures and analytical methodology have been described in detail by Chen
et al ( 1990) and are only briefly noted below.
The mortality data were obtained from the same survey of causes of death
for 1973-75 that resulted in the publication of the Atlas of Cancer Mortality
in China (National Cancer Control Office, 1979). Cause of death was determined
using medical records from clinics and hospitals and by questioning relatives
and close friends of the deceased person in addition to area officials.
Diagnosis and classi- fication of the cause of death were standardized by
the Chinese Ministry of Public Health. The accuracy and reliability of these
mortality rates is more fully discussed in the Foreward to the Atlas (National
Cancer Control office, 1979) and further underscored by similar values obtained
in neighboring counties juxtaposed on opposite sides of provincial borders
and surveyed by different health survey teams (Le et aL, 1981). In addition
the wide range of values across survey counties for most causes of death
and the generally high correlation between values by sex, indicates a minimal
impact of diagnostic errors. Deliberate precautions were taken to distinguish
causes of death easily confused with one another such as liver cancer and
hepatocirrhosis, stomach cancer and gastric ulcer, lung cancer and pulmonary
TB, amongst others.
Disease-specific mortality rates for each county were calculated as cumulative
mortality rates per 1,000 persons by sex for all ages up to age 64, and
for all ages up to age 15. The cumulative mortality rate up to a particular
age is "n" times the sum of the annual crude death rates in all
age groups up to that age, where "n" is the number of single years
in an age group (WHO, 1976). Thus, the cumulative mortality rate for a particular
disease may be interpreted as approximately equivalent to the cumulative
risk of death by age 64 (or age 15, as the case might be), in the absence
of death from other causes. The question of competing risks is unlikely
to be of relevance in the context of this analysis primarily because mortality
data have been expressed as age-standardized rates. Furthermore, there is
no reason to believe that risk of chronic degenerative disease during middle
age is going to be different for individuals who otherwise would have died
from non-degenerative diseases earlier in life.
The ecologic survey was conducted in 65 rural counties dispersed throughout
the populated regions of China, selected to represent the full range of
mortality rates for seven of the most prevalent cancers. A three-stage random
cluster sampling procedure was used to select the smaller survey units of
communes (2 per county), production brigades (2 per commune) and production
teams (2 per production brigade). Within each of the 260 production teams,
25 households were randomly selected from an official registry of residences
yielding 100 households per county. A total of approximately 6500 adults
aged 35-64 were included in the survey, with 100 individuals per county,
half of each sex. The study design and remaining experimental details
are provided by Chen et al. (1990).
The information obtained from this survey included nutritional, metabolic,
hormonal, environmental, reproductive, demographic and socioeconomic characteristics. The combined data from the two surveys of 65 counties (130 communes)
consisted of 367 items of information including cumulative disease-specific
county mortality rates (from the 1973-1975 retrospective study) and a comprehensive
set of dietary, lifestyle and environmental characteristics. The analysis
assumes the stability of biochemical indicators and dietary patterns in
the population over time. The negligible migration in this population (an
average of 94% of the survey subjects were born in their county of residence),
food production and consumption patterns based on stable locally available
crops, and the remarkably constant trend in the national food intake data
(Piazza, 1986) underscore the validity of such an assumption.
Pearson product-moment correlation coefficients were used to relate every
variable with all other variables in the compiled data set. These correlation
co-efficients are cross-sectional measures of association between characteristics
and were used as such with the recognition that they do not establish a
causal link between the variables examined. Geographic clustering of disease
mortality rates was investigated by visual inspection of a table of correlation
coefficients for each disease with every other disease. Disease mortality
rates that were directly correlated (p 0.05) with each other were placed
in one group; inversely correlated (p 0.05) rates comprised the second group
(Table 2). Any disease mortality rate that did not show a consistent correlation
(when significant) with all diseases included in each of the two groups
was omitted from the set.
RESULTS AND DISCUSSION
Three features of these data make this epidemiologic investigation of mortality
in China particularly appropriate and informative. First, the ranges of
mortality rates across China as illustrated for a few diseases in Table
1, were far greater than those typically observed for countries that are
more industrialized (and less economically diverse). Such broad ranges may
facilitate the detection of otherwise unobserved relationships. Second,
mortality rates were distributed around China in clusters that formed unique
geographic patterns for each disease (National Cancer Control Office, 1979;
Chen et aL, 1990). The uniqueness of these patterns indicates the presence
of specific causes for each disease, perhaps related to routine consumption
of locally grown foods. And third, among these several dozen disease categories
Average age-.standardized county mortality rates per 100,000 and ranges
for selected diseases in The People's Republic of China, 1973 - 75*
Disease Males Females TABLE 11
CANCERS' Nasopharynx 8 (0-75)SS 4 (0-26)
Esophagus 120(1-435) 72(0 286) Stomach 9](6-386) 41 (2-141)
Liver 78(7-248) 26(3-67)
Colorectal 14(1-67) 10 (2-61)
Lung 23(3-59) 1O(O-26)
Leukemia 4 (0-9) 3 (0-7)
Pulmonary tuberculosis 113(31-270) 70(26 230)
Infectious diseases 31 (6 64) 23 (4-50)
Diabetes 4(0-9) 3(0-14)
Myocardial infarcation / coronary heart disease 12(0-52) IO(O-50)
Hypertensive heart disease 16(1-43) 15 (2-65)
Rheumatic heart disease 16(0-55) 27 (3-99)
Stroke 77 (20 197) 64 (21-251)
Pneumonia 14 (2-54) II(O-56)
Cirrhosis of the liver 51(6-155) 26(2-58)
Digestive disease other than ulcer 23(3-61) 18 (4 55)
Age truncated, 35-64 years; standardised to world population (WHO, 1976).
7Tht)se cancer @ites were used in the selection of the 1983 survey c,)unties.
They represent the full range of mortality rates for all 2392 counties
in China. The average annual age-standardized county mortality rates are
based t)n age-sex-specific deaths in each of the 65 counties (49 counties
for non- cancers) for the population aged 35-64 years.
Range of county mortality rate in the 65 (49 counties for non-cancers) counties,
Some were significantly correlated with each other, thus suggesting that
they might share a common underlying nutritional etiology. In addition to
providing important information on the chief correlates and possible causes
of geographic differences between these mortality rates, the data could
also be useful in the investigation of mortality rate trends over time.
At the turn of the century, for example, Reclus (1905) noted the similarities
between chronological and geographic trends of economic development and
concluded that ". . . geography is nothing but history into space and
similarly history is geography on a time scale." If so, the present
health profile of some economically developed counties in China might be
used to predict changes in more traditional counties. Such projections could
be useful in planning nutrition, health and agricultural strategies.
Diseases in group A (Table 11) are those generally associated with impoverished
conditions while most of those in group B tend to be characteristic of more
affluent societies. To investigate common causes underlying each disease
group, cumulative mortality rates for each disease group were calculated
for each survey county. The relationship between these group mortality rates
and the various characteristics measured in the 1983-1984 ecologic survey
were then analyzed (Chen et aL, 1990) and the correlations that were statistically
significant at p<O.OL are listed in
As expected, diseases of poverty are
associated more with agricultural than with industrial
activity. Areas where these diseases are common
are located further inland where mean elevation
is higher and overall economic activity, literacy
and population density are lower. In contrast, diseases
of affluence are found in the more densely populated
rural areas' nearer the seacoast where industrial
Self-clustered disease groups
Group A - Disease of Poverty Group B - Diseases of Affluence
Pneumonia (16) Stomach cancer
intestinal obstructions (I 2) liver cancer
Peptic ulcer (13) Col,in cancer
Other digestive disorders ( 17) lung cancer (16)
Nephritis ( 12) Breast cancer
Pulmonary tuberculosis ( 10) Leukemia (15)
Infectious diseases (other than tuberculosis) (17) Diabete@ (2)
Parasi(ic diseases (other than schisit)st)miasis) (I 0) Coronary heart
Eclampsia ( 1 3) Brain cancer (ages 0- 14) (13)
Rheumatic heart disease ( 13)
Metabolic and endocrine disease (other than diabetes) ( IO)
Diseases of pregnancy and birth (other than eclampsia ( 15)
*Each disease category, when significantly correlatted
(p<0.05) with any other disease category is positive for disease categories
in its own group and negative for disease categories in the second group.
'Numbers in parenthesis indicate the number of correlations which are statistically
significant at p<0.05 (from a total of 20 comparisons).
The major municipalities of Shanghai, Beijing and Tianjin were not included
in this survey.
and literacy rates are higher and more fish, eggs, soy sauce, beer
and processed starch and sugar products are consumed. However, such
univariate geographic correlations do not provide strong evidence of
causal relationships between dietary factors and these diseases, particularly
because relatively small amounts of several of these specific foods
are consumed. For example, mean egg consumption in China nationwide
is very low by Western practices, with mean daily intake being only
about 5-10% that for the united States; egg consumption averages less
than once per week in 78% of the 65 survey counties. Fish consumption
averages only about 15% of the median intake in the United States, except
for three counties in the Southeastern coastal provinces of Fujian,
Guangdong and Zhejiang. Beer and processed starch and sugar products
are also consumed in much lower quantities.
Therefore, consumption of these foods is probably more indicative
of general economic conditions and other local circumstances than
of biological relationships to disease. The correlation of diseases
of poverty with higher levels of arsenic contamination of food remains
Correlations of disease groups with various characteristics
Characteristics / Diseases of poverty / Diseases of affluence
Total cholesterol 0.48'
Urea nitrogen -0.47 0.40
Antibody to core HBV 0.44 -0.32
Cotinine 0.37 0.50
Ribonavin excess -O..41 0.45
RED BL00D CELLS
Total n3 fatty acids (RBC) 0.44
Height -0.59 0.51
Weight -0.45 0.41
Beer (per day) -0.32 0.59
Fgg (per year) -0.54' 0.31
Total pregnancies 0.53' -0.38
Stillborn 0.51 -0.34
Infant mortality 0.69 -0.47
Fish (g/day) 0.56
Processed starch and sugar 0.5 1
Mean elevation 0.43 -0.39
Mean longitude 0.48 0.40
Ciross value of industrial and agricultural output, 0.44
Population density' 0.45 0.41
Literacy ratel 0.51 0.39
Agricultural employment' 0.64' -0,58
Industrial employment' 0.63' 0.58
Further characteristics of the areas where diseases
of poverty are more common
include greater infant mortality and a greater number
of pregnancies per woman.
The average age of the women surveyed in 1983 was 48
years and so these characteristics of reproduction and childhood disease describe
childbearing practices of
the 1950s and 1960s, a period that included some severe
malnutrition and the great
famine of 1959-61. In contrast, contemporary characteristics
could be quite
In the China study, the analysis of blood samples
shows that plasma cotinine (a
nicotine metabolite from tobacco smoking) is inversely
associated with diseases of
affluence including lung cancer but directly associated
with diseases of poverty. At
first glance, this finding might appear anomalous,
since the smoking of manufactured cigarettes in China has been centered mostly
around major metropolitan
areas such as Shanghai where diseases of affluence
are more common. However,
high plasma cotinine levels in the rural areas where
diseases of poverty predominate, are strongly associated with the use of homemade
cigarettes which contain
high levels of nicotine (R. Peto, personal communication).
Thus the inverse association between plasma cotinine levels and diseases of
affluence may be explained by
the high consumption of homemade cigarettes in less
affluent areas and the lower
consumption of homemade cigarettes in more industrialized
and more literate
regions of the country.
Nutritional status may be assessed by several indicators
including body size,
biochemical factors in blood and urine, and dietary
intake. The mechanisms of
action of nutritional factors on disease are complex
and have not yet been fully
elucidated but it has been estimated in Europe that diseases
to which diet makes a
significant contribution are responsible for approximately
50 percent of premature
deaths in both men and women below the age of
65 (WHO, 1986). There is
increasing evidence that in China the most affluent segments
of the urban and rural
populations are adopting unsatisfactory dietary practices
that only can lead to
disease and their costly consequences similar to
those observed in industrial
countries. It is reasonable to assume that the frequent
occurrence of food restrictions and famines in China (Mellor and Gavian, 1987)
has favored the survival of
those with the ability to store fat in times of sufficient
food to better resist starvation. If this assumption is true, then a longlasting
period of food affluence may
bring about a high prevalence of obesity and associated
disorders such as hypertension, stroke, some cancers, and heart diseases. The
physical stature of adults
(both height and weight) is greater in areas where diseases
of affluence are more
common. Also, diseases of affluence are associated
with higher levels of plasma
cholesterol, plasma urea nitrogen and plasma albumin,
each of which indicates a
diet richer in fat and protein and lower in fiber and
other plant food constituents.
The proportion of a 5 mg experimental supplement of
riboflavin excreted in urine
within the following 4 hours is significantly greater in
areas where diseases of afflu-
ence predominate, indicating greater tissue repletion
with this vitamin. Riboflavin
intake is significantly positively correlated with the
consumption frequency of meat
and milk (Campbell, et aL, 1990).
Inclusion of liver and stomach cancers among "diseases of affluence"
was some-what surprising because these cancers are much more
common in economically underdeveloped countries. One interpretation
could be that, for each of these cancers, there may be a predisposing
associated factor which is:
First, it approaches being a prerequisite cause, as indicated by the extraordinary
risk observed in case control studies (Beaseley, Huang and Lin, 1981; Blumberg
and London, 1982); second, its mean prevalence is 13% in China but only
0.1-0.3% in the United States; and third, it is widely spread across all
65 survey counties (46 counties had 10-28% prevalence, while the remaining
19 counties had 1-9% prevalence). Moreover, liver cancer mortality was significantly
positively correlated with plasma total cholesterol to indicate a promoting
effect of nutritional enrichment (Campbell, et aL, 1990). In regards to
stomach cancer, a predisposing cause could be something associated with
the widespread use of non-refrigerated, non-canned foods. In Western countries,
stomach cancer markedly declined with the introduction of refrigeration
(Coggon and Acheson, 1984; Howson, et al., 1986; Coggon et al., 1989).
- a) a prerequisite for disease onset,
- b) much more common in China than in Western countries, and
- c) reasonably well distributed across all survey counties.
When these conditions are met, as in China, the effects of nutritional
influence then becomes apparent and can be readily observed. In the
case of liver cancer, persistent infection with hepatitis B virus meets
these criteria and could be this factor.
Presently in China, many foods are preserved either by salting or by fermentation,
leaving opportunities for widespread exposure to endogenous nitro- samine
formation and mold toxins, which could be a prerequisite cause upon which
nutritional enrichment has an effect in the same manner as with the other
diseases of affluence. For example, several investigators have reported
a protective effect upon stomach cancer of vegetable consumption (Hirayama,
1971; Hirayama, 1981; Correa, et aL, 1982) and in this study, stomach
cancer mortality was positively correlated with plasma albumin, plasma urea,
and body weight and height, any or all of which indicate a promoting effect
of nutritional enrichment. A model similar to that for liver and stomach
cancers also appears to exist for tung cancer. Smoking is the prerequisite
cause while nutritional enrichment of the same type as for stomach and liver
cancers enhances risk of tumor (Peto, et aL, 1981; Shekelle, et aL, 1981; Byers, et aL, 1987).
China is presently at a stage of development where public health measures
could be taken to avoid the mistakes of the West, a proposition similarly
made by Keck (1991). Appropriate action now could prevent a large increase
in the diseases of affluence. Lung can@er is one of the few cancers for
which the most important cause is well known and which is therefore amenable
to preventive action. There has been an alarming increase in cigarette smoking
in China. According to Richard Peto, a leading British epidemiologist and
one of the principal investigators of this study, the number of Chinese
deaths from tobacco are expected to increase from about 100,000 per year
at present to about 2 million per year by the year 2000 (R. Peto, personal
communication). Strong measures involving health education, cigarette import
restrictions and the curbing of domestic tobacco production are essential
to reverse the smoking trend and prevent an otherwise inevitable leap in
lung and other related cancer rates.
The results reported here have direct implications for public health policy.
The ideal future policy, of course, would be to reduce mortality from the
diseases of poverty without causing a large compensatory increase in the
diseases of affluence. Among the characteristics listed in Table Ill, the
number of characteristics that are correlated positively with one disease
group and inversely with the other suggests that there could be a trade-off
in disease mortality trends. There are, however, some characteristics that
are significantly correlated only with one disease group. For example, relatively
high levels of plasma cholesterol, plasma albumin and omega-3 erythrocyte
phosphatidylcholine fatty acids (directly correlated with fish consumption)
reflect increased mortality only from diseases of affluence without simultaneously
being associated with decreased mortality from diseases of poverty.
Diseases of poverty are correlated with increased urinary chloride and decreased
hemoglobin whereas diseases of affluence show no relationship to either.
If these do at least partially reflect causal relationships then a diet
low in protein, fat and salt, but sufficient to allow adequate synthesis
of hemoglobin may be associated with reasonably low mortality rates for
both disease groups.
China has developed a unique system of decentralized planning which has
recently incorporated private initiative in agriculture, industry, and trade.
From the early 1950s to the mid-1970s the Chinese government had strict
control over agricultural production and trade. It gave priority to staple
foods over preferred foods (legumes, meats, fruits) in order to ensure an
adequate supply of essential grain for all provinces. Until recently government
policy favored direct consump- tion of grain over consumption of animal
products requiring feedgrains (Jamison and Piazza, 1987). However, policy
has changed markedly in the last few years. With the consolidation of the
new 'production responsibility system' the govern- ment expects a rapid
growth in the livestock sector (World Bank, 1985). Cattle production will
be limited by the carrying capacity of China's grasslands, which are already
overgrazed. Poultry and pig production are more dependent on the avail-
ability of feed concentrates. Such production has been increasing for the
last ten years, and there is now a concern that it might be necessary to
monitor the consumption of high-animal-fat food to prevent deleterious effects
both economic and nutritional.
From an economic standpoint, increasing the share of consumption of animal
products from 6 percent to 16 percent of total food intake (the official
goal for the year 2000) presents technical difficulties and considerable
risks of dependency on feedgrain imports (World Bank, 1985). China also
might be tempted to take advan- tage of low grain prices on the world market
to establish its poultry and pig industry. But imported feedgrains would
present considerable social risks if, in the future, political and economic
obstacles were to lead to cutbacks in meat availability or a rise in meat
prices. Increasing food prices has often been the cause of social unrest
in many developing countries. According to World Bank estimates (1985),
even with a favorable feed conversion ratio, control of related factors,
and use of local feeds only, this target would require the dedication of
more than one third (35-40 percent) of China's cultivatable land to livestock
production. Given severely limited arable land per capita and already intensive
use of land resources this is neither desirable nor even possible.
From a food and nutritional standpoint, China has a choice to make between
various consumption patterns. In terms of total per capital energy supply
and the respective proportion of calories from carbc)hydrate, protein, and
fat, China could follow either the Japanese or the European model of consumption.
The Japanese dietary pattern seems more appropriate to China because it
is characterized by lower intakes of energy and animal products, and a higher
intake of fish products than the European pattern. Because Japan has the
highest average life span in the world its food pattern would appear to
be preferable. Riboflavin intake in China may not be as critically low as
previously suspected, a finding discussed in depth in a separate manuscript
(Campbell et al, 1990). An overestimated riboflavin allowance tends to foster
the technological development of foods and food industries designed to alleviate
the implied deficiency. For example, greater consumption of dairy products
and other foods of animal origin have been justified, in part, because their
assumed riboflavin richness would help alleviate the perceived problem.
Not only in this recommendation of greater consumption of animal products
highly questionable for China for very significant economic reasons (World
Bank, 1985), but also the assumption that dairy products are a particularly
useful riboflavin source is not entirely valid because it ignores the even
richer sources of riboflavin provided by certain plant foods such as green
The Chinese food system is unique in its ability to provide for more than
a billion individuals a reasonably nutritious diet that may be closer to
health promoting dietary guidelines than that of industrialized nations
(Wittwer, et at, 1987): for example, the average Chinese diet is substantially
lower in total fats, saturated fats, and sugar (soluble carbohydrate), and
higher in dietary fiber, 0-carotene and vitamin C (Table IV). Chinese food
policy planners are doing much better from a dietary point of view than
their Western counterparts, while avoiding problems associated with increased
obesity and higher incidence of cardiovascular disease (Sidet and Sidel,
1982), as well as a considerable waste of topsoil, water, fertilizers, pesticides,
and other agricultural resources. Dietary iron intake and iron absorption
in China are surprisingly high in a diet so low in animal products (Chen
et al, 1990).
Comparison of American diet with rural Chinese diet (mean daily intakes)
U. S. China
Total fat (% of kcal) 38-40 15
Dietary fiber (g/day) 10-12 33
Solul)le carbohydrate (g/day) 240 470
Calcium (mg/day) 1140 540
Protein (g/day, 70 kg mate) 90-95 64
Animal protein (% of total protein) 70 7
Iron (mg/day) 18 34
Thiamin (mg/day) 1.4 2.3
Retinol (RE/day) 990 30
Total carotenoids (RE/day) 429 836
Vitamin C (mg/day) 73 140
Riboflavin (mg/day) 1.9 0.8
Encrgy intake (kcal/day) 2360 2640
'Chen et al., ( 1 990).
This study, which in the next phase will include survey data from Taiwan,
provides an unprecedented opportunity for scientists and policy makers in
China, the US and other developed and developing countries to explore the
complex relationships between lifestyle and disease, thus helping to make
policy recommendations to influence agroindustrial production and consumer
behaviour. This also may help developed countries to find ways to curb their
excesses while encouraging developing countries to avoid the mistakes
of Western societies (Keck, 199 1). There is much to learn from China, a
country that is successfully feeding a billion people primarily on plant
derived food, and rapidly making the transition from an agrarian to an industrial
society, but so far avoiding much of the major diseases affecting Western
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