1
Behavioral medicine and prevention of non-communicable diseases in China: Current
challenges and future directions
Ding Ding,
1*
Xuefeng Zhong,
2,5
Joseph Tak-Fai Lau,
3
Brian Oldenburg
4,5
1
Prevention Research Collaboration, Sydney Medical School & School of Public Health,
University of Sydney, 94 Parramatta Rd, Camperdown, New South Wales, Australia.
*Corresponding author: melody.ding@sydney.edu.au
Tel +61 2 9036 3332 | Fax +61 2 9036 3184
2
Institute of Health Education, Anhui Provincial Center for Disease Control and Prevention,
Hefei, Anhui, China
3
The Jockey Club School of Public Health and Primary Care, the Chinese University of Hong
Kong
4
Academic Centre for Health Equity, Melbourne School of Population & Global Health,
University of Melbourne, Victoria, Australia
5
Global Health and Society Unit, School of Public Health & Preventive Medicine, Monash
University, Melbourne, Victoria, Australia
2
Abstract
Purpose: We describe the emergence of recent public health challenges in China, particularly
those related to lifestyle-related non-communicable diseases (NCDs). We also summarize some
recent examples of behavioral medicine research and practice in relation to the prevention and
control of NCDs in China. Finally, we describe recent changes in the public health system in
China and how behavioral medicine research and practice can be incorporated into this system to
address these public health challenges.
Methods: We consider research and policy literature from both China and Western countries in
order to evaluate the relevance of the field of behavioral medicine for addressing the rising
NCDs in China.
Results: Rapid economic development and related social and environmental changes have
brought about increasing wealth and lifestyle changes in China, along with new public health
challenges related to the prevention and control of NCDs. The field of behavioral medicine has
much to offer China in addressing these public health challenges. Although the field of
behavioral medicine in public health is in its infancy in China, there are encouraging signs of its
development, particularly resulting from international collaborations with researchers from
Western countries. The next stage of this field’s development in China will involve increased
integration of behavioral medicine into public health education, training and the health system.
However, this process of integration will need to build on China’s traditional approaches to
public health training, research and practice.
Conclusions: Although the field of behavioral medicine in public health is still in its infancy in
China, we argue that the practice and principles of behavioral medicine are important for
successfully addressing the very substantial burden of NCDs now and in the future.
Keywords: Public health, non-communicable diseases, behavioral medicine, China, prevention
3
With a population of more than 1.3 billion people, China is the world’s most populous country
and it is now the second largest economy in the world. Its rapid economic progress
notwithstanding, China’s vast population also contributes significantly to the global burden of
disease and the health of many citizens still lags behind its rapid economic growth [1]. In this
article, we first discuss the recent emergence of public health challenges in China, particularly
those related to non-communicable diseases (NCDs) such as cardiovascular disease and diabetes.
We then summarize current behavioral medicine research and practice regarding NCD
prevention in western countries and in China and how behavioral medicine could help improve
this situation in China. We further describe the public health system in China and discuss the
challenges and opportunities involved in advancing the field of behavioral medicine in China.
Economic Growth, Lifestyle Changes and NCDs in China
Since economic reform commenced in the late 1970s, China has experienced rapid economic
growth and urbanization. Since then, China’s economy has been growing at a rate of around 10%
per year [2] and the percentage of the population living in urban areas has more than doubled
from under 20% in 1978 to almost 50% in 2010 [3]. The economic growth and urbanization have
contributed to significant improvements in many health indicators in China. For example,
between 1970 and 2010, life expectancy rose from 60 to almost 73 years for men and from 63 to
79 years for women, and the under-5 mortality rate declined from 101 to 13 per 1000 [4].
Meanwhile, the total fertility rate has declined from 4.8 to 1.6 children per woman from 1970 to
2010 [5]. In 2010, more than 13% of the population were aged 60 years and above, compared
with only 10% in 2000 [6] and this trend will continue to increase rapidly for years. The recently
4
published Global Burden of Disease, Injuries, and Risk Factors Study revealed a striking
transition in disease burden in China from 1990 till 2010. The disease burden (as measured by
disability-adjusted life-years) from communicable, maternal, neonatal, and nutritional disorders
declined by 67%, while that from NCDs increased by 12%. Indeed, seven of the ten leading
causes of years of life lost in China were NCDs in 2010, with these being stroke, ischemic heart
disease, chronic obstructive pulmonary disease (COPD), lung cancer, liver cancer, stomach
cancer, and esophageal cancer [4]. According to national data, NCDs accounted for an estimated
80% of deaths and 70% of the total disease burden in China in 2005 [7,8]. The number of NCD
cases among Chinese people over the age of 40 is expected to more than double over the next
two decades and the burden of the four leading NCDs (myocardial infarction, stroke, diabetes,
and COPD) is expected to increase by almost 50 percent between 2010 and 2030 [9]. China has
about one third of the world’s diabetes cases and the national prevalence of diabetes and pre-
diabetes among adults in 2010 was 11.6% and 50.1%, respectively [10].
Evidence from a variety of sources demonstrates that some of the most important contributors to
the recent rise of NCDs, particularly cardio-metabolic conditions, are changes in lifestyle
behaviors [7,11]. In 2010 the leading behavioral risk factors in China were nutrition and dietary
behaviors, smoking, high alcohol use and physical inactivity [4]. Between 1989 and 2004, the
proportion of fat in the total dietary energy intake increased from 19% to 28% [12]. Meanwhile,
most Chinese adults have experienced a significant reduction in physical activity, as the energy
expenditure from occupational and domestic sources declined by 23% and 54% from 1991 to
2000 [13]. Modes of transportation have also become increasingly inactive as car ownership
increased by an average of 20% per year between the 1990s and 2005 [14]. Television ownership
5
and the use of many other screen-based devices have also proliferated in Chinese households, so
that leisure-time pursuits have become increasingly sedentary. For example, a recent study found
that the proportion of Shanghai elderly who identified TV viewing as the most common leisure-
time activity increased from 66% in 1998 to 78% in 2008 [15]. As a result of changes in diet,
physical activity, and sedentary behavior, the prevalence of overweight and obesity among
Chinese adults increased from 23% and 7% in 2002 to 31% and 12% in 2010 [16].
To address the new public health challenge of lifestyle-related NCDs, it is important for China’s
health care and public health systems to emphasize on lifestyle changes among China’s vast
population. To be successful, this will require changes at all levels of society, particularly the
living and working environments that facilitate healthy lifestyles. The field of behavioral
medicine has much to offer in this regard, from understanding the multi-level influences on
behaviors, to developing and evaluating interventions and strategies, and finally, to the
translation of interventions to more ‘real world’ community settings [17].
Behavioral Medicine and the Prevention and Control of NCDs in China
The International Society of Behavioral Medicine’s definition of behavioral medicine
emphasizes its interdisciplinary nature: “[it is the] the interdisciplinary field concerned with the
development and integration of socio-cultural, psychosocial, behavioral, and biomedical
knowledge relevant to health and illness and the application of this knowledge to disease
prevention, health promotion, etiology, diagnosis, treatment, and rehabilitation” [18]. This
interdisciplinary approach is important for not only informing an understanding of the