The big picture

LIKE MANY others in her generation, 11-year-old Clara Buenconsejo was bigger than her mother was at that age. In fact, she could no longer wear the clothes sold at the children’s section in department stores and her mother Malou had to scour shops selling surplus goods from the United States to find something that would fit her. But Clara’s size left Malou worried, not proud. The girl weighed 143 pounds, and by the time Malou brought her to a pediatric endocrinologist, Clara sported dark circles under her eyes and similar dark pigmentation on her nape, which the doctor would later point out as markers that a child is overweight.

Clara was diagnosed with borderline diabetes and put on medication for over a year to normalize her insulin level. A nutritionist also began seeing her for a weight management program, the first prescription of which was to remove all processed food from Clara’s diet — hotdogs, canned food, canned juices. After about four weeks Clara lost eight pounds. For three months she would visit the nutritionist once a week, discuss her food diary, be shown educational videos, and counseled about eating and living right. Malou would also be assisted in planning the family menu.

Two years later, Clara is now off that professional supervision. Both she and her mother are confident she no longer needs professional help to do those exercises and eat those veggies. Unfortunately, Clara’s story is becoming more common, and often, the tales of other overweight children do not have a similarly happy ending. Though still small in absolute numbers, the proportion of overweight children in the country has increased threefold between only 1998 and 2003, say experts. The World Health Organization (WHO) calls this increasing incidence an “epidemic,” which along with undernutrition in far bigger segments of the population make for a double burden that a country as poor as the Philippines is ill-equipped to handle.

More adults are also growing overweight, with the increasing trend being more pronounced among women. Government surveys show that the proportion of overweight adult women had increased from just over 39 percent in 1998 to 54.5 percent in 2003.

Doctors say that the danger in becoming overweight is that once it begins, it gets even more difficult to lose the excess weight, leading to what doctors call “overfatness.” The diseases associated with overfatness are so many that in itself, obesity is referred to as a disease. In turn, obesity is associated with health risks that run from head to toe, including stroke, cardiovascular disease, and diabetes.

It’s not hard to see why this phenomenon is taking place in the Philippines today, even as hundreds of thousands of families across the nation scrounge for food. Simply put, larger segments of the urban population now have diets where taste and convenience are considered primary, and health and nutrition only a luxury. Too often, they consume large amounts of processed food that are poor in nutrients and dense in energy. This makes them eat a lot without feeling full, which soon gets them hungry again and looking for more food.

Clara herself recounts how, up until three years ago, her family dined mostly on canned and processed food like hotdogs, corned beef, and tuna. “Para kaming refugee,” she recalls. Her mother admits,”“I was rather lazy to cook then.”

Clara could put away quite a few of those hotdogs, but her processed-food diet was not the only reason she was ballooning. Never very active as a child, she was rarely out playing in the streets. Instead, she was almost always indoors, either drawing or taking on her grandfather in a round of chess. By the time she was 11, Clara carried some 30 pounds more than what was ideal for her age and height.

HEALTH AND nutrition experts agree about the ingredients that make up what they call an “obesogenic environment,” one that makes people grow fat, fast: high-fat, high-salt, and high-sugar diets and lifestyles that involve little physical activity. There are also medical conditions that can lead to obesity such as those associated with having hormonal glands that do not function properly. Genetics could play a part as well — some people are predisposed to getting fat because of family lineage. But minding the balance of food that one takes in and energy that is taken out tempers such predisposition and allows the individual to escape growing overweight.

WHO estimates that more than one billion adults worldwide are overweight; of these, at least 300 million are obese. In countries such as the United States, the problem has grown so huge that one in every four children is, or is at risk of becoming, overweight or obese. Meanwhile, Asia in the past 20 years has become a focal point of international concern with rates of increasing incidence rivaling those observed in the First World half a century ago. In countries as diverse as India, New Zealand, China, and Vietnam, the WHO is noting a “disturbing” increase in the prevalence of overweight especially among children.

Here in the Philippines, pediatricians like Dr Sioksoan Chan-Cua have long been concerned about the increase in the number of obese children. Chan-Cua, who deals with illnesses related to growth and metabolism, says this is no recent trend, having noticed a growing number of obese children as early as a decade ago. Today she says, “In just one of my clinics, one whole drawer (of medical files) is for obese patients.”

Chan-Cua says many of these children are textbook cases of obesity: consuming a lot of fried and energy-dense food and drinks such as colas, and not having enough physical activity. One patient, she says, gained nine pounds in two months by spending the entire summer vacation watching TV and eating French fries. Another child drank his way to obesity by downing a liter of soda per day and doing little else other than eat, sleep, and go to school. Says Chan-Cua: “Children just don’t jump around as much as children used to.”

What is even more difficult, she says, is that most people carry the notion that plumpness in a child is good because it is “cute,” and it is a sign that the parents are not being remiss in their duty. “What these parents do not know,”says Chan-Cua, “is that it’s like a time bomb in the body.” And diffusing the time bomb becomes more difficult through time. In a recent report on diet and nutrition and their associated risks of chronic diseases, the WHO and Food and Agriculture Organization (FAO) warn about how overweight in childhood persists into adolescence and adulthood. “Overweight and obesity,” says the report, “are notoriously difficult to correct after becoming established.”

Yet even while they are young, overweight and obese children already face numerous health risks. “Children are aging prematurely,” laments nutritionist-dietician Virgith Buena, who says many of her young patients are developing illnesses that the medical community used to see only among much older people. Among her patients are two hypertensive boys; one of them is 11 years old while the other is only four — but already weighing more than 100 pounds. There is a 17-year-old boy who has just had a stroke. “Ang tindi (It’s all too much)!” says Buena, who, even as she sees one case after another, still cannot hide her grief.

A PARTICULAR concern is the increasing number of young children developing diabetes, of the type that — again — used to be seen only among adults. Diabetes is a life-threatening condition where the production of insulin by the pancreas is either deficient or ineffective, resulting in increased concentrations of glucose in the blood, which in turn damages many of the body’s systems, in particular the blood vessels and nerves. Diabetes accounts for some 3.2 million deaths worldwide every year. Two-thirds of all diabetes cases are directly caused by obesity. Dr Gauden Galea, WHO’s adviser on chronic diseases for Asia-Pacific, says, “The link is so intimate and is even stronger than the link between smoking and lung cancer.”

This increase in “diabesity,” is something Chan-Cua knows only too well. She says she has many adolescent patients who are obese and who have diabetes. “They’re around 12, 13, they do not even know that they have diabetes because they can get by,” she says. That is, until a simple wound festers and their parents start to worry and take them to seek medical help.

But seeing the doctor is only the first step in treating chronic diseases such as diabetes. At the minimum, says Chan-Cua, diabetic patients would need lifestyle changes including shifting to a healthy diet and keeping it and doing more regular physical exercise. Others might need to undergo medication upon diagnosis, and for some, for longer periods of time.

Chan-Cua says, though, that some patients eventually stop coming way before their treatment is completed because, she says, “they are limited by lack of time and money.” These are middle-income families she is speaking about. Given that access to medical attention is severely limited by financial resources, the problem may actually even be bigger than many of us are willing to believe.

By most accounts, the majority of those who consult specialists belong to the middle- and upper-income families. A poor family earning the minimum wage would be hard pressed coming up with the money for even just the weekly consultations. For those who would have to undergo a supervised weight management program, for instance, a minimum dozen weekly sessions with a professional nutritionist costs over P10,000. The total goes even higher once one adds the cost of medication.

But WHO warns that overweight and obesity may already be seeping into poorer families. “This is all hypothesis at this stage,” says Galea,”“but overweight is probably going deeper into the population where people do not have the funds to be able to buy foods that are healthier.” Thus, there have been accounts of what has been called “the bloating of the poor” in Asia, as ever-falling incomes lead poor families to buy more of mass-produced foods that are cheap and filling but very nutrient-poor, and less of low-energy dense foods such as fruits, vegetables and whole grain cereals that are more expensive. A recent study in the International Journal of Obesity also found that in developing countries, the burden of obesity shifts from the relatively well-off to the poor as per-capita income rises.

DESPITE THE numerous data from both government and the health industry, these have not been enough for anyone to map the prevalence of overweight and obesity in the country and, in turn, the associated health risks. The Food and Nutrition Research Institute (FNRI), for one, regularly churns out nutrition surveys that are regarded as a “beacon” by international experts such as WHO’s Galea, who says these “give us a valid and scientifically credible figure behind policy.” But for Dr Cecilia Florencio, nutrition scholar and University of the Philippines professor, too much remains unknown. “Which Filipinos are we talking about?” she asks, referring to figures pointing to increasing overweight. “We haven’t even mapped out where overweight is, where there is more of, less of, where it is rising faster, not rising so fast and so on.”

Knowing these characteristics, Florencio says, will allow the formulation of the appropriate response. Right now, the official response has been to trumpet the need for a healthy lifestyle, the main components of which are to stop smoking, do regular exercise, and have a healthy diet. From this perspective, the point of having a healthy diet is to consume enough of the nutrients needed by the body to function properly, including drinking a lot of water and eating more fruits and vegetables.

But Florencio warns that it would be naive to think that teaching nutritive values would make the problem of poor eating habits go away. After all, she says, food is not just about nutrients: “Food is a source of contentment, of pride, success, of regularity of one’s life.”

Dr. Catherine Castañeda agrees, noting that what makes people decide if they will eat a particular food is mainly whether it’s tasty and affordable. A nutrition anthropologist, she says, “We don’t go to the market to get food because it’s high in, say vitamin A.”

“People won’t even look at nutritive labels unless they’re at the age where they might get these lifestyle diseases then they start to look,” she says. Which, she adds, makes it even more important to start educating children at a young age.

Today’s Filipino children, however, are learning a rather different lesson, courtesy of aggressive marketing by the fast-food industry: that fast food is modern and hip. It’s a message that parents have heeded as well, although they also appreciate that fast food products are affordable, tasty, and convenient. Many parents thus often reward a child for having high grades with a trip to Jollibee. Florencio remarks,’“But how many would say, ‘pag mahusay ka igagawa kita ng suman (if you do well, I’m going to make you a sticky-rice roll)’?”

Fast-food goodies, however, are not always the prime suspects in the blimping of populations. WHO’s Galea cites the case of Vietnam, where traditional local cuisine still reigns. He says local dishes such as the popular chicken noodles served on the streets now contain more cholesterol: “It has more fat in it therefore more tasty, but also more dangerous.” In addition, more and more Vietnamese are now getting less exercise after abandoning their bicycles in favor of motorcycles. As a result, Vietnam is seeing increased obesity and its associated diseases such as diabetes, the rates of which have doubled between 1993 and 2003.

The Philippine food landscape, though, is clearly influenced by the fast-food industry. Dr. Chan-Cua’s own daughter also fell under the spell of Jollibee, chasing after the toys the local fast-food chain offered. But the doctor put her foot down and made sure her child would not get used to eating too much fast food. She also made her daughter eat vegetables,’“even just one piece,” the habit of which her daughter has grown into.

Experts say parents need to remain firm and teach their children to appreciate “proper” food. Still, getting a child to eat less junk and more nutritious food can be tricky. Jay Vincent Guevarra’s parents, for example, have just about given up trying to make him eat the family’s home-cooked meals. Instead, his father Jun brings home either Chickenjoy from Jollibee or spaghetti from McDonald’s for him almost every day. The 12-year-old says he likes these because they are’“delicious.”

TO WHO’s Galea, the food industry needs to take some responsibility, too. He says the industry needs to consider the impact of its food products on the health of consumers in deciding what they should offer. To help push the food industry in that direction, WHO in 2003 began a program with the Department of Health that would give recognition to exemplary food providers.

These food providers have to meet certain criteria in the health scale, including not allowing smoking, using healthier culinary methods, and providing healthy choices in the menu. Pasig City was the first city to participate in the program and attracted applications for recognition from 40 food establishments. Of these, two were recognized. Mandaluyong and Makati are next to be covered by the program.

For such a program to be relevant and make sense, however, consumers need to be armed with the right information about the nutritive values of the different kinds of food they are being offered. Many would also have to be reintroduced to the concept of exercise.

“The point is to balance,” says Buena. If you have to have those French fries, for instance, go easy on the salt, drink more water, and walk up the stairs instead of taking the lift. Regular physical activity — not just small chunks of time inserted in one’s routine whenever it is convenient — thus becomes currency for food.

Clara, now a trim 13-year-old, has become used to such trade-offs. If she wants a second helping of something — say, a brownie — her mother Malou would have her do the treadmill for more than the usual half-hour. Says Malou: “There’s a price tag in terms of exercise.”

It hasn’t been easy, says Clara, especially when it came to eating vegetables and doing the treadmill. “But I had my mom,” she says. Indeed, the mother who used to rely on canned goods has changed her ways as well and now supervises all the meals prepared at home and makes sure Clara has vegetables in her lunchbox. The 42-year-old magazine editor even experiments with vegetable dishes, hoping to stumble on something that would tickle her daughter’s palate. The results from her kitchen adventures aren’t always hits, but Malou has become a master of bargaining with Clara about doing extra rounds of jump rope in exchange for a second helping of desserts or other food that she really likes.

But since the physical exercise isn’t supposed to be punishment, Malou strives to make her daughter’s regimen fun. Because the treadmill bores Clara, there is the jump rope and aerobics at home. As often as they can, mother and daughter also head for the U.P. Diliman on Saturdays, doing three rounds of walking around the academic oval or playing soccer at the Sunken Garden.

On a recent Saturday morning, they make it to U.P., where Clara tries frisbee for the first time. She likes it, but says soccer still rules. Then she and Malou do their usual three rounds of walking, although the last round is interrupted by the ringing of a sorbetero’s bell. Clara has done well, and for that, her mother tells the ice-cream man to give her a scoop on an unsweetened cone.