Friday, 6 July 2012

FOCUS: Poor and fat

Fresh vegetables at a public market in Metro Manila ... mostly unaffordable to many people that they are forced to eat just instant noodles with rice.

Picture of children in Biafra, Nigeria
 POVERTY has always been associated with undernutrition - that is why it is easy to spot a child
coming from a poor family: thin, stunted (short), brownish hair, big belly.

Remember the iconic picture of a child in Biafra during the famine there in the early 70’s? That is the extreme of undernutrition-starvation.

In the Philippines, while we have not experienced starvation of such great proportions, we still have a sizeable proportion of children 0-5 who are underweight - still one-fourth, or 25% of this age group (1 in 4!), although figures have decreased since 1998 (down from 32%).

Likewise the proportion of underweight children 6-10 years old has decreased from previous, but still high and unpardonable.

However, though it may seem counter-intuitive given the large number of low income people, there is also cause for concern with the increasing number of children of all ages - from 0-19
 years who are becoming overweight and obese. 

Most especially among adolescents 11-19 years old when in 2005, the proportion of overweight and obese stood at 8% .   This is a national figure, from a random sample of subjects from all over the Philippines.

But studies focusing on certain areas, specifically, the urban areas tell a more disastrous tale.

In a study among school children in Metro Manila - both in public (surrogate measure for low
income) and private (measure for non-low income), nearly 9% were found obese and nearly 19% were overweight!

While figures were not stratified according to income, since this is a random sample, we assume that both income levels were proportionately represented, and therefore the same figure applies to both low and non-low income groups

The public burden of malnutrition - both under-nutrition and over-nutrition -- can overwhelm the public health system of a developing country. Under-nutrition puts a child at risk for infectious diseases, micronutrient deficiency and its consequence of low mental ability. Over-nutrition puts a child at risk for early development of chronic diseases such as diabetes mellitus, heart and kidney problems.

In our country where nearly half of the population is below the poverty line, obesity and poverty are inevitably linked. A perennially hungry stomach would want to gorge on high-density food because it assuages hunger longer.  
Instant noodles - too much of this could speed up obesity among adults and children.

In rice-eating Philippines, rice is the main food that could assuage hunger - as many mothers would say – “kahit walang ulam basta may kanin”. 

Nowadays, because of the high cost of vegetables and fruits and fish and meat products, many families content themselves with mixing instant noodles, to put some flavour, with rice.

Thus it has been reported recently that the Filipinos’ consumption of rice has increased to nearly 300 grams per person per day.

This high-calorie, low-nutrient diet drives obesity figures up, and makes for poorer health. For schoolchildren, busy mothers with no time to prepare “baon”, may just buy burger from Jollibee which is about Php20. Adolescent school children, save up to eat burger accompanied with the ubiquitous, sugar laden soda. 

Energy dense diet is only one of the drivers of obesity. Sedentariness is another. 

The advent of  the internet (Php5 per hour in the computer shop - I saw streetchildren doing Facebook in a computer shop!), lack of  recreational space in poor communities (the streets are “eskinitas” or just narrow alleys), and hours of TV viewing (what to do in a small, cramped barong-barong?;  even shanties under the LRT have TV!) all add up to long hours on one’s butt. 

Schools in urban areas are accessible by jeep or tricycle, unlike those in some of the provinces where there are not enough public transportation and children walk kilometers to go to school.

Adult obesity figures are much worse actually. Nearly 28% of women mostly in their middle age have been found to be overweight or obese. 

Worse, they have android obesity, or obesity in the middle (high waist –hip ratio), which implies worse health consequences.  

These women surveyed were mostly housewives  and were of low-income.  

Picture of obese young woman
It is also  important to note that in Asian adults, the health complications associated with overweight and obesity start at a lower BMI than seen in the US and Europe.

So many of these estimates of obesity prevalence  among Asians likely underestimate the true public health burden of obesity  (that means that if you are heavier than what you are supposed to weigh, but your BMI is lower than the cut off for overweight or obesity, you may be already at risk for certain  diseases). 

Addressing the over-nutrition problem of the country, in women who are at high risk, and especially among children, would need not only solutions aimed at correct food labeling, diet behavior modification, regulating advertisements of fast food aimed at children, health education to instil the value of eating the right food, or advising exercise.  

All these are commendable actions, but more important, in my mind is to address the predisposing factor, and that means   confronting the problem of poverty. 

The problem of increasing obesity , for the majority, is economic.  

Filipinos eat more and more rice, and more and more processed flour, energy dense, salt-laden instant noodles, doughnuts, etc because nutritious foods like vegetables, fruits, good and lean meat products are expensive!

Children eat burgers, spaghetti at Jollibee or Mcdo because- they are, well, cheap! The lack of exercise or sedentariness is also, to a large extent, affected by poor housing and community environments in many poor communities.  

A hamburger may be cheap but it could lead to improper nutrition, which could either be over-nutrition or under-nutrition.

In other words, the poor have no choice.

Therefore, what is primarily needed to address the double burden of under-nutrition and obesity, is a steadfast and unwavering action towards improving the lot of the poor.   Couple this with addressing the various specific factors that contribute to these problems, and we will be able to help our people  stave off or prevent the consequences of these twin  problems.   

That is the” matuwid na daan” to take, as the administration of P-Noy would say.   

Let us all take that long road ahead.   

(Dr Emma P Valencia is a physician and a health policy analyst and researcher. She also writes essays and poems when she is not busy with her work on health. She lives with her 85-year-old aunt and seven dogs.)

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