Generation XXL

“We obviously have an epidemic, but it is also obvious it is already too late,” she says bluntly. “If we can save the next generation, then it will be a success.”

To the uninitiated, this statement may seem premature when the cure for childhood obesity is so blindingly simple. More physical activity and selfrestraint is advocated, implying that a gluttonous, lazy youth has shaped its own downfall. But for Al Dossary, the obesity problem is so endemic in developed societies it won’t be fixed by jogging and sugar-free juice alone: “It is not simply a matter of changing the lifestyle, we are beyond that, I think the problems we have now will mostly be treated surgically.”

The fats don’t lie

Al Dossary isn’t alone in her beliefs. The results of the largest ever UK study into obesity, released last month, concluded that obesity was an inevitable consequence of modern society. The government-funded research found that excess weight was a logical result of an “obesogenic” society, in which cheap, energy-dense foods, motorised transport and sedentary work were rife. The authors also admitted that any evidence that current anti-obesity strategies worked was “scant”.

Al Dossary has recently conducted a study of the children in Al-Khobar, the eastern province of Saudi Arabia. Her results show that a whopping 22% are clinically obese. Accurate statistics for paediatric obesity are notoriously difficult to come by in the region, as nations are reluctant to compete for the mantle of unhealthiest children in the Gulf. Al-Dossary’s figures, however, are roughly mirrored by studies carried out in the UAE by Professor Abduelmula R Abduelkarem, chair of the clinical pharmacy department, Ajman University of Science and Technology. “Between 20 and 25% of our children are suffering from being overweight”, he concurs. “Obesity is now an epidemic disease.”

Perhaps the clearest sign that children are being irreparably damaged by modern lifestyles is the startlingly early appearance of the formerly ‘adult’ diseases, of type 2 diabetes, hypertension and atherosclerosis. In the space of a decade, type 2 diabetes is more than twice as prevalent as the congenital type 1, according to Al Dossary’s statistics. “It used to be that 1.7 children per 1,000 had type 1 diabetes and now it is 4 per 1,000,” she notes. “It was unheard of before and now we have more than double the rate of congenital diabetes. It’s really shocking.”

Life in the fat lane

Despite regional reticence about the extent of the problem, it is undeniable that the Gulf is facing an obesity crisis. The popularity of fast food with young people is nothing new, but nutritionists argue that it has now supplanted traditional fare as a primary food source. What used to be a guilty treat, or an occasional quick fix, is now considered an appropiate meal. Part of the problem, argues Valerie Houghton, a US trained dietician based in Abu Dhabi, is that children in the GCC are given too much opportunity to self-regulate their diet.

“Children here are given disposable income to freely spend on food outside of the home,” she explains. “They are not given any guidance on what to choose, what selections are okay, and, importantly, what constitutes a meal versus a snack.”
It is the last point that Houghton feels is most vital. The younger generation has simply lost sight of what is an acceptable daily amount to eat: “They will go after school for a snack and have a burger with 4/5oz of meat on it, two slices of cheese, a large fries and a large coke. That’s not a snack – it’s a full meal with a tremendous amount of calories.”

The most dangerous aspect of fast food, however, counters Al-Dossary, is not the cholesterol, it is the convenience; a problem compounded by the move away from traditional eating habits in the home. With the cost of living rising in the GCC countries, many families are required to have dual income. As a result, home-cooked food is becoming more of a rarity. “Women are more and more going into the work force and a lot of times the child is home before the mother,” she notes. “There is not normally enough time to sit down and prepare a proper meal and it is easier for the parent to pick up KFC or McDonalds on the way home.”

The takeaway trend is not helped by the reality that eating healthily is now seen as the expensive option for many families. “It’s cheaper to buy non-nutritious food than it is to buy proper meat and vegetables,” observes Al Dossary.

Parents juggling a career and home life are also less likely to keep tabs on their child’s diet. Dr Alya Ahmad, a specialist in paediatric care at the American Primary Care Clinic, Dubai, notes that she often has to ask to see the family nanny or maid, when treating an overweight child. “I often have to bring [them] in, because they are the ones feeding the child.”

Fatfare

If dietary problems begin at home, then they are enforced at school. The lack of nutritional education provided by the government in the UAE is so glaring, according to Professor Abduelkarem, he can only see the situation deteriorating: “Schools are one of the most important targets. If the Ministry of Health continues to show a lack of concern and does not bring this education to the school, then I am sure the obesity figures will go up. They have to think about changing the syllabus to include some lectures on health.”

The sedentary nature of school life in the Middle East is also a huge driver of obesity. Educational facilities in the region struggle to incorporate physical education into the school day due to the extreme weather conditions that persist for a large part of the year. Yet even when the climate is more moderate, misconceptions exist that outdoor exercise can actually harm a child’s health. Professor Abduelkarem recalls a case where parents have gone out of their way to prevent a child from exercising. “I have heard of children who will have a note that their parents got from their doctor, which says the child does not have to play outside. They believe it is healthier for the child to always be indoors and under air conditioning.”

Al Dossary has approached schools directly to urge the introduction of a minimum one-hour of activity daily, to the syllabus. “Lots of schools don’t even have recess any more, because of the demands of the curriculum,” she says. “I have been speaking to schools over here and they accept the idea, but have not implemented it yet.”

Abduelkarem is also an advocate of canteen-based crusades, accusing schools of simply serving repackaged junk food. “If you look at the food that is prepared for them at the school canteen it is really just junk. But when you ask schools about it they say they have to feed children that or they will not eat anything,” he explains. But adjusting the menu inevitably means adjusting the school budget and Al Dossary believes governments in the Gulf need to be proactive in reallocating funds for healthy food. “Schools get part of their income from the food they serve in the cafeteria and the vending machines – so if they get rid of it, then that is a budget problem. We need to target these things and make sure there is enough money to enable schools to get rid of the soda machines.”

In the US, former president Bill Clinton has been at the forefront of a campaign to overhaul the contents of school vending machines. The deal, struck with major food and beverage companies, promises to replace high-calorie snacks and drinks with healthier alternatives, such as sugar-free juice and water. Dr Ahmad is convinced that such tactics could translate successfully into regional schools. “I’m more optimistic about how the schools here could develop policies on this,” she says, pointing to the fragmented educational system in the US. “You wouldn’t be able to implement something as strongly in the States as you could here.”
Obesity begins at home

For physicians on the front line, the rise in paediatric obesity has required an adjustment to their traditional skills set. Many struggle with flatly diagnosing children as overweight, cowed by the expected guilt and embarrassment of the patient and parent. According to a 2005 study in the journal Pediatrics, doctors diagnosed obesity less than 1% of the time among 2-to-18-year-olds – a figure far below the one-third of young Americans struggling with weight.

When Ahmad started encountering clinically obese children as a physician in Houston, Texas, she found the experience so difficult she decided to seek further training in bariatrics. Families typically treat obesity as a guilty secret, she notes, recalling one heavily obese adolescent, brought in by his aunt for persistent enuresis. “The aunt couldn’t bring herself to tell me what the problems were, so she had just written them all down. She didn’t want to discuss anything in front of him.”

Despite specialist training, she concedes, treating childhood obesity can be like treading on eggshells. “When you ask a child or the family about obesity you quickly realise that they become very defensive about the condition – almost in a state of denial.”

Dealing with the patient’s family requires a great deal of tact, as more often than not the child’s problems are reflected in the actions of the parents. “There is a lot of guilt associated with the child’s obesity for the parent and a lot of times when you see an overweight child you see an overweight parent, if not two,” Ahmad notes.

It is important for a physician to remain non-judgmental, but it also crucial that the severity of the situation is made apparent to the patient. There is no point being polite if it masks the extent of the problem. Obesity carries cultural connotations in every country, but Ahmad reasons that it is the role of physicians to be detached and treat it as the serious medical condition it is: “If you can take away the stigma, you can start treating the disease.”

Bent out of shape

Much has been made of a scenario where this generation of parent’s will be burying their children but, putting emotive scenes aside, the greatest impact of childhood obesity will be on government coffers. Individuals who are obese as children are more likely to go onto develop serious, expensive complications early in their adult life, and are less likely to become productive community members. Governments might not enjoy investing heavily in prevention, but in this case they cannot afford not to.

Yet perhaps the most worrying aspect of childhood obesity worldwide is that it looks like it is going to get worse before it gets better. Valerie Houghton draws a disturbing analogy with smoking cessation campaigns. “When they finally began to recognise they needed to stop smoking it was an educational process. The way that smoking was first on the incline and then on a decline was like a bell curve. Right now, if you take paediatric obesity and put it on that curve we are still climbing.”

Houghton believes it may be as long as 15-20 years before efforts currently being made in the US start bearing fruit. In the GCC, these measures have not even begun to be implemented.

“Everyone recognises that there is a problem, but they must be willing to pay into it,” Al Dossary stresses. “Governments must buy into this and start investing if we are to prevent the future generation going the same way.”