A Southeast Asian epidemic

Malnutrition is leaving Southeast Asia’s children predisposed to obesity and fatal diseases. With the rise of processed foods and less active lifestyles, these health impacts are only going to get worse unless children become the focal point of change

Janelle Retka
May 15, 2018
A Southeast Asian epidemic

The stomachs of Southeast Asia have become enlarged in recent years. Unfortunately, the consequence is not well-nourished populations but an increased likelihood of non-communicable diseases from diabetes to heart disease, which are often fatal.

“It’s really spreading. It’s not just an urban wealthy problem. Now it’s a problem for everyone,” Jessica Blankenship, Unicef’s East Asia and Pacific nutrition specialist, says of dramatic weight gain across the region. Previously thought to be quite lean, Southeast Asia has been transformed by one of the world’s most rapid increases in over-nutrition in recent years. Moving forward, “the components are in place to increase obesity in the region”, according to Blankenship.

Sedentary lifestyles, increased screen time, more women moving into the workplace – thus depleting the prominence of healthy, home-cooked meals – and growing consumption of processed goods as international food chains enter the local market are all contributing factors to increasing obesity rates. Both rural and urban populations are seeing the impact of traditional grains, fruits and vegetables being pushed off the kitchen table to make way for convenient, high-sugar, high-calorie processed foods. The results are staggering.

According to World Health Organisation (WHO) statistics, at the turn of the century 7% of Malaysia’s adult population and 3.7% of Thailand’s were considered obese; those rates have since more than doubled in each country, with 15.6% of Malaysia’s adults classified as obese as of 2016. At the same time, the incidence of overweight and obese children across Southeast Asia has increased by 150%, resulting in a total of 4.2 million overweight or obese kids under the age of five in the region.

A group in a shopping mall in Bangkok. Increased screen time and sedentary lifestyles are key contributors to rising obesity levels Photo: ROPI

Across the population as a whole, WHO estimated that by 2016, 8.5 million Southeast Asians were dying each year from non-communicable diseases such as heart disease and diabetes. An unhealthy diet and lack of physical activity are leading causes, alongside tobacco use and alcohol abuse.

Experts say the uptick in the overweight population is likely to continue as Southeast Asia makes its way through a ‘nutrition transition’ that is propelled by urban and economic development and moves its population away from traditional home-cooking. “It’s pretty clear. We’ve had a rise [in obesity], and unless there’s a major intervention, there’s no reason why it would change,” Blankenship says.

The region’s malnutrition issue, however, does stand out from others globally due to its ‘double burden’ of undernutrition and excess weight that could aggravate the problem, experts say.

“There is a complex interplay between early undernutrition (in mothers before and during pregnancy, and in early childhood) and later over-nutrition that exacerbates the risk of non-communicable diseases (NCDs), the prevalence of which is rising rapidly in low- and middle-income countries,” write nutrition specialists Pattanee Winichagoon and Barrie Margetts in a report on the double burden published last year by the International Agency for Research on Cancer.

Governments are well aware of obesity, but I think that there’s usually less focus on children. There’s a lot of progress that needs to be made

The exact link between undernutrition and obesity later in life has yet to be determined, but as new factors come into play, such as low-quality foods entering the market, a likely cause has become clear.

“What we think is happening is that the process of being undernourished at a very young age… causes physiological and metabolic changes in the child, and it leaves them at higher risk of obesity later on in adulthood and also for NCDs,” says Blankenship.

Indonesia, Malaysia, the Philippines and Vietnam are all considered to have “public health concerns” caused by both undernutrition and excess weight, according to Unicef. In Indonesia, 12% of children under five years of age – 2.89 million of them – are overweight.

In countries such as Cambodia, excess weight and obesity have not yet become prominent, with only 3.9% of the adult population considered obese in 2016. Nutrition experts say the groundwork has been laid for the future, though.

“[In Cambodia], one in four children under [the age of ] five is underweight, one in ten is wasted and one in three is stunted, irreversibly damaging their long-term cognitive and physical development, and contributing to low wages and lost productivity as adults,” according to the 2017 Global Nutrition Report, which compiles data from global organisations including the WHO.

Foods with poor nutrient levels are being successfully marketed to young Cambodian children and their mothers, says Alissa Pries, a technical advisor for Helen Keller International’s Assessment and Research on Child Feeding (Arch) Project, which studies infant feeding habits in Phnom Penh and other developing cities.

Walking into an infant and baby supply store in Cambodia’s capital city, this becomes especially evident. Alongside nappies, wet wipes and baby shampoo sit Choco-Pie treats, Kinder eggs and potato chips with a smiling potato-man cartoon on their packaging. Baby cereal boxes list nutritional information in Indonesian – an uncommon language in this nearby country, making it a challenge for mothers to know what they are buying for their growing children.

“The taste preferences that children develop start from a very young age,” says Pries. “If kids are being exposed to and eating things that are high in sugar or high in salt, that can really steer the direction of their diet later into childhood and even into adolescence and adulthood.”

Southeast Asia suffers from a ‘double burden’ of undernutrition and excess weight Photo: Nicolas Asfouri / AFP

The Arch Project in Phnom Penh shows that where infant food products are marketed, mothers are biting. Among 222 mothers surveyed, 55% had fed their children aged under 23 months commercial packaged foods, such as those found in the infant store, the day prior to speaking with researchers; roughly 80% had done so in the week prior. Similarly high rates were recorded in other developing cities surveyed globally, according to Pries, making it a likely issue throughout Southeast Asia.

“For this young age group, they have very tiny stomachs, so whatever goes in needs to be very nutrient dense, packed full of good things,” Pries said. “If you’re consuming a lot of things that are low in micronutrients, vitamins and minerals but high in energy [and] calories, it could potentially displace consumption of other nutritious foods, so it could contribute not only to higher rates of overweight and obesity, but also undernutrition… So, for this age group there’s sort of a dual concern.”

According to Blankenship, governments throughout the region are making efforts to educate their populations on nutritious eating and regulate the marketing of food. However, she says that much of this is focused on adult diet alterations, which often end up being temporary changes.

The reality begs for attention to be shifted to infants and young children who can build healthy habits from the start, she says, pointing to a lack of school cafeteria regulations in the region – with the exception of the Philippines. Fruits, vegetables, animal products and items low in salt and sugar should be promoted in these settings to create healthy habits for the long-term.

“Governments are well aware of obesity and NCD reduction, [but] I think that there’s usually less focus on children,” Blankenship says. “There’s a lot of progress that needs to be made.”

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