Childhood obesity levels are still low, but growing fast.
Nine-year old Yanto was brought to a paediatric endocrinologist because of his small penis. His parents had taken him to the traditional healer for his ritual circumcision, and panicked when the man had difficulty reaching his ‘invisible’ penis. On examination, his penis length was normal, but it was buried deep in the layers of lower belly fat. Yanto dislikes sport, and no one asks him to join their games because he is too slow. He spends his leisure time playing computer games.
Dewi is a nice 14-year old girl, weighing 75 kilograms. She has low self-esteem because her school friends tease her for being fat. Her mother says she was a big baby. Her wealthy family sends her everywhere she needs to go with a driver, because it is too far or dangerous to walk or bike. She too is teased for being poor at sports.
Being born rich does not guarantee a healthier life. The risk of obesity for children in wealthy families is at least five times higher than for children born in less prosperous conditions. A 1999 study by myself and a group of colleagues in Yogyakarta showed that the prevalence of obesity in children aged six to eight years living in well-off urban households was 6.7 per cent, while among those living in urban slums and in rural areas it was 0.7 per cent and 1.2 per cent respectively. Five years later their situation had changed little: 85 per cent of the children overweight in 1999 remained overweight.
Childhood obesity is not yet as bad as in most developed countries, but it is growing much faster. The most shocking discovery of our follow-up study was that obesity had almost doubled in five years, from 6.7 per cent in 1999 to 12.3 per cent in 2004.
Boys suffer more than girls. Along with their greater privileges, typical of Asian culture, comes a risk of obesity that is 50 per cent higher than that for girls. National survey data from 2007 shows an overall prevalence of 9.5 per cent among boys and 6.4 per cent among girls aged 6 to 14 years. (Oddly, the same dataset showed that the risk of being underweight was also higher among boys: 13.3 per cent vs 10.9 per cent for girls).
While people in developed countries are already fighting the childhood obesity epidemic, most Indonesian parents, even the best educated ones, are unaware of the problem. Most parents still worry more about raising a malnourished child than they do about the threat at the other end of the scale.
While the fashion industry has successfully made adult obesity undesirable, parents still want their children to be fashionably plump. The prototype desirable child has light skin (from not being out in the sun) and chubby cheeks. Parents are proud of them, and so are grandparents. People associate fat children with wealth and a better standard of living, while underweight children are disagreeably associated with poverty. Indeed, our epidemiological survey data confirms that the association is real.
Indonesians are beginning to recognise that adult obesity can lead to problems like diabetes mellitus and cardiovascular disease. But not many people see the association between childhood obesity and adverse health outcomes. On the other hand, the association between malnutrition and developmental delay is so well known that doctors and paediatricians are asked about it almost every day by parents whose children have feeding difficulties or whose weight is just below the age average. When the doctor does not want to be bothered to explain the danger of obesity or the merits of a balanced diet, it is all too easy to prescribe vitamins, appetite stimulants or high energy formula milk. Parents are happy to take the short cut to make their children eat more, even if it means paying for expensive high calorie food supplements.
The ‘mistake’ starts early in a child’s life. While the government has long been trying hard to promote the breast as best for infants, the formula milk industry is promoting its products even harder. Using the best advertising agencies money can buy, they have succeeded in making parents think their children are not getting the best until they drink this or that brand of formula milk. Few parents realise how strong the link is between bottle-feeding and increased risk of malnutrition in less prosperous families (who often mix in too much water), and of obesity in more well-to-do families (who give their kids too much).
Parents still want their children to be fashionably plump. The prototype desirable child has light skin (from not being out in the sun) and chubby cheeks
Five-year old Sinta was brought to a paediatrician because she sometimes stopped breathing at night. She has always been big, and now weighed 35 kilograms, much too heavy for her age. Her upper middle class mother worried she did not eat enough, but she still drinks about five quarter-litre bottles of milk each day, particularly before bedtime.
The industry ethical code only allows breastfeeding substitutes to be marketed as a follow-on formula, i.e. for infants over six months. But some parents start them on it much sooner, for ridiculous reasons such as that the child will refuse to drink formula if it is not introduced early enough. Even worse, some parents think formula is an acceptable substitute for a balanced diet because they are busy. A hectic mother knows very well it takes less time to give a child a bottle than to feed it with a spoon.
Traditionally, Indonesians were farmers or fishers. Those living inland mostly ate roots, grains, vegetables and fruits, while in coastal areas they added fish. Meat, poultry and dairy products were not readily available. Thus most Indonesians got their energy mainly from carbohydrates, and little from fats.
Not eating enough meat, poultry or dairy products has been blamed as the cause of child malnutrition in Indonesia. Studies have indeed shown that malnourished children do not eat enough animal-derived protein. Modern parents try their best to provide their children with enough of these products. Nowadays, most families can afford them, and some even eat them in every meal. This trend has significantly increased the proportion of energy derived from fat in the Indonesian diet.
Studies show that, on average, children now get more than 30 per cent of their energy from fat. The need to provide enough animal-derived protein has thus shaped the concept of ‘healthy food’ for children. The common view is that children should eat meat, poultry or dairy products, the more the better. Meanwhile the importance of eating more fibre or drinking plain water is not known, especially for children. Pediatricians do not usually promote the traditional soy-based tahu and tempe as healthy foods.
The affordability of cooking oil has also changed the way the food is prepared. Traditionally it was boiled, steamed or grilled, but today deep-frying is considered more palatable. Cooking oil is now considered essential to a decent menu. If for some reason its price goes up mothers everywhere are concerned.
As in many developed countries, fast food also causes obesity in Indonesian children. Eating out and delivery services are an easy solution for busy mothers. But in Indonesia dining out in an international fast-food restaurant will cost at least twice what it costs in a traditional restaurant. Our study showed that children in car-owning families were four times more likely to eat out in a fast-food restaurant. We do not know to what extent fast food now replaces home cooking.
A sedentary lifestyle is another problem for children from wealthier families. Living in a busy city, they usually have busy parents who have little time for sport and who lead sedentary lives themselves. Since the family has a car, and most probably more than one, they are driven to school instead of walking or biking. This is because most of the time they go to the best possible school, known as a ‘favourite’ or elite school, some distance away. Favourite schools exist in all big cities. Parents are prepared to pay much more to send their children to one. Such schools teach more foreign languages, mathematics and other advanced subjects, and give more homework, thus keeping the children longer at school. Busy parents like this too, because they do not have to worry about what their children are doing after school.
Indonesian school curricula put little emphasis on sport. Around two to four hours a week are compulsory. Children who like sport can double that with extracurricular activities. But overweight or obese children try to avoid these activities. Joining a sport club outside school is not popular.
After school, rich children will mostly stay at home, doing their homework, watching television or playing computer games. Gone are the times when they played football or flew kites with the neighbourhood kids. Safety-conscious parents now want to know where their children are and who they are with. Some parents, even educated ones, worry that children who play outside will become too tired to study.
Overweight and obese children like Yanto and Dewi are a problem for the rich, while the poor still battle malnutrition. Rich parents can afford to provide their children with the best facilities. Ironically, Yanto’s computer games and Dewi’s driver have made them unhealthy. When they grow, up their health problems will only increase.
Madarina Julia (email@example.com) is a pediatric endocrinologist at the Department of Child Health, Faculty of Medicine, Gadjah Mada University and at Sardjito General Hospital, Yogyakarta. She completed her PhD at the Free University Amsterdam. She is researching childhood and adolescent obesity and metabolic syndrome.
This article is part of The Rich in Indonesia feature edition.