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Dietary changes and their health implications in the Philippines


M.R.A. Pedro and R.C. Benavides, Food and Nutrition Research Institute, and C.V.C. Barba, Institute of Human Nutrition and Food, University of the Philippines Los Baños

Introduction

In recent years, social, economic and demographic developments within the Southeast Asian region have accelerated to varying degrees. Nutritional status has improved widely in many countries, with some experiencing a transition in nutrition or the double burden of undernutrition and overnutrition. This report examines evidence of the dietary changes and whether or not the Philippines, in common with some of its neighbours in the region, is facing the double burden of under- and overnutrition.

The population of the Philippines was estimated at 85.5 million people in 2005, compared with 76.5 million in 2000. Growing at an annual 2.11 percent, the population is expected to reach 102.8 million in 2015. The Philippine economy has grown in recent years, with gross national product (GNP) expanding at an average of 5.05 percent and gross domestic product (GDP) at an average of 4.52 percent from 2001 to 2004 (NEDA, 2005). However, there has been a boom-bust pattern of growth over the 30 years from 1970 to 2000 (Figure 1). The sharp fall in growth of the economy from 1982 to 1984 coincided with political and economic crises. The dip from 1988 to 1990 reflected the impact of successive political shocks (i.e., coup attempts) and several natural disasters, as well as an economic slowdown that affected not only the Philippines but also the rest of the world; the Philippines was not spared the effects of the Asian crisis in 1997 (Templo, 2003).

FIGURE 1
Real GNP/GDP growth, 1970 to 2000

Source: Templo, 2003.

The Philippines has made remarkable progress in improving life expectancy and reducing infant mortality. Life expectancy has increased from 58 to about 70 years over the past 30 years, and infant mortality has decreased from 60 to 29 deaths per 1 000 live births (UNDP, 2004). In addition to improvements in health care services, high levels of literacy (94 percent simple literacy rate), high primary school enrolment rates (90 percent elementary participation rate) and access to safe water (80 percent) have contributed to these remarkable reductions in infant mortality and increased life expectancy.

TABLE 1
Key development indicators

Indicator

Value

Year

Estimated total population

85.5 million

2005

Population growth rate

2.11%

2000-2005

Human development index (HDI), HDI rank

0.753, 83rd

2002

Gender development index (GDI), GDI rank

0.751, 66th

2002

GDP per capita (US$)

1 026

2004

Social sector expenditure (as % of total expenditure)

42.81%

2003

Share of poorest quintile in income or consumption

4.7%

2003

Share of richest quintile in income or consumption

53.3%

2003

Male life expectancy: (at birth in years)

67.2

2003

Female life expectancy: (at birth in years)

72.5

2003

Unemployment rate

10.9%

2004

Underemployment rate

16.9%

2004

Poverty headcount ratio (% of families below national poverty line) (Preliminary)

24.7%

2003

Population with access to safe water supply

80%

2002

Simple literacy rate

94%

2003

Elementary school participation rate

90%

2002

Under-five mortality rate (per 1 000 children)

40

2003

Maternal mortality rate (per 100 000 live births)

172

1998

Sources: NEDA; UNDP, 2004; Family Income Expediture Survey (FIES), 2003

The age structure of the population is also shifting. The dependency ratio (defined as the ratio of people aged 0 to 14 years or over 64 years per 100 people aged 15 to 64 years) has decreased from 88 to 64 over the past 30 years. This decrease is due more to changes in the proportion of children, rather than elderly people. The child dependency ratio dropped from 88 to 64, while the elderly dependency ratio has remained constant at 6 (UN Population Division, 2004).

The last 30 years witnessed rapid urbanization in the Philippines, with the urban proportion of the population rising from 32 percent in 1970 to 54 percent in 1995. In 2001, 59 percent of the population lived in urban areas, and the urban growth rate was 5.14 percent (Table 2). The proportion of urban population is expected to increase to 68 percent in 2015.

TABLE 2
Trends in urban and rural growth rates, 1960 to 2001

Indicators

1960

1970

1975

1980

1990

1995

2001

Percentage urban

29.8

31.8

33.3

37.2

48.6

54.1

59.1

Urban growth (%)

2.7

4.0

3.0

4.9

5.0

5.0

5.14

Rural growth (%)

2.5

2.6

2.6

1.5

0.3

0.3

-

Source: Population Commission, 2002.

A new methodology for estimating poverty was adopted in 1997. Figure 2 illustrates the trends in prevalence of poverty among Philippine families over the last 17 years, and compares the estimates made with the earlier official methodology, which applied a constant Engel’s coefficient (i.e., the proportion of food expenditure to total expenditure), with estimates from the new methodology, which employs a changing Engel’s coefficient (i.e., depending on the year). Poverty decreased between 1991 and 1997, while GNP and GDP were increasing (Figure 1), and then increased slightly or remained unchanged (depending on the method used to estimate poverty) during a short period of growth slump brought on by the Asian economic crisis. The estimates indicate that in 2003, 24.7 percent of Philippine families were considered poor (measured as income below the poverty threshold of 12 267 Philippine pesos [p]), compared with 28.4 percent in 2000.

FIGURE 2
Trends in prevalence of poverty among Philippine families, 1988 to 2000

Source: Reyes, 2003.

While poverty has decreased in urban areas, it persists essentially as a rural phenomenon. Three out of four poor people reside in rural areas. In 2000, 13 percent of urban and 36 percent of rural families were considered poor, or had income below the poverty threshold of 12 267 p per year (Reyes, 2003). Disparities in poverty are also seen across different regions of the country, with the autonomous region of Muslim Mindanao, the Caraga region and the Zamboanga Peninsula - all in Mindanao or Southern Philippines - being the poorest (NEDA, 2005).

Income distribution in the Philippines has remained largely unequal as measured by the GINI ratio, which assigns values ranging from 0 to 1 - the closer to 1 the more unequal. Compared with its Asian neighbours, the Philippines has wider disparity in terms of income distribution. Between 1998 and 2000, the Philippine GINI ratio worsened from 0.4446 to 0.4822, but then improved slightly to reach 0.4660 in 2003.

Data sources used in the case study

The major sources of data used in this case study are the surveys of the Food and Nutrition Research Institute, Department of Science and Technology (FNRI-DOST). These are periodic National Nutrition Surveys (NNS), and regional updating of the nutritional status of Philippine children. The dietary data reported here were obtained from the 1978, 1982, 1987, 1993 and 2003 NNS, while the data on nutritional status of various population groups and nutrition-related risk factors for non-communicable diseases (NCDs) among adults come from Regional Updating of the Nutritional Status of Children and the 1993, 1998 and 2003 NNS. Data on mortality trends are from the Field Health Service Information System (FHSIS) of the Department of Health. These are components of the Philippine Statistical System, and provide vital inputs to the country’s nutrition, health and development programmes.

National Nutrition Surveys

FNRI-DOST conducts NNS every five years to obtain information on the nutritional status of the Philippine population through recording food consumption in households and using 24-hour recall for children and pregnant and lactating women. Surveys were carried out in 1978, 1982, 1987, 1993, 1998 and 2003, each of which included anthropometric, biochemical and clinical assessment of nutritional status. A food consumption survey component was carried out in all the surveys except for that of 1998.

Nutritional status is assessed by anthropometric measurements of all age groups, biochemical indicators (serum retinol and haemoglobin) in children aged 0 to five years and pregnant and lactating women, and urinary iodine excretion of children aged six to 12 years and pregnant and lactating women. Anthropometric measurements include weight and height for children and adults, and recumbent length for children under two years of age. Nutritional status of children 0 to ten years of age is assessed using the World Health Organization/National Center for Health Statistics (WHO/NCHS) growth curves (WHO, 1995); for pre-adolescents and adolescents aged 11 to 19 years body mass index (BMI)-for-age is used (Must, Dallal and Dietz, 1991), and for adults aged 20 years and over WHO’s recommendations for BMI are used (WHO, 1995). The nutritional status of pregnant women is based on a Philippine reference population (Magbitang et al., 1988).

The fifth (1998) and sixth (2003) NNS also included measurements of blood pressure, fasting blood glucose and blood lipids (triglyceride, cholesterol, HDL and LDL) for individuals aged 20 years and over in order to assess hypertension, diabetes and dyslipidaemia as nutritional factors associated with chronic degenerative diseases among adults.

Household food consumption data are collected through one-day household food weighing, which involves weighing all foods in "as-purchased" (AP) form before they are cooked. Food is weighed before breakfast, lunch and dinner. Food waste (i.e., edible and inedible food parts that are thrown away, given to pets, etc.) and plate waste are weighed after meals. Beginning and end inventories of all non-perishable food items such as coffee, sugar, salt and other condiments are taken, and food recall by all household members for foods eaten outside the home is recorded. The information generated is the aggregated measure of the foods eaten and the energy and nutrient intakes of all household members, which are divided by the number of people in the household during the reference period in order to derive per capita intakes. Energy and nutrient intakes from the foods consumed are based on the Philippines Food Composition Table (FCT); nutrient values of fortified foods, particularly of vitamin A, iron and iodine, are from food labels. The nutrient values in the latest Philippine FCT (1997) were revised using results from interlaboratory food composition analyses. The revision included new iron values for about 30 food items, many of which were fresh and processed fish.

Per capita percentage adequacies of energy and nutrient intakes were estimated for each household, after computing for the mean recommended dietary allowances (RDAs) or recommended energy and nutrient intakes (RENI), by summing the RDAs of each household member and dividing by the number of household members. There have been two revisions to the original 1976 RDAs for the Philippines, one in 1989 and the other in 2002. The original 1976 RDAs were used in the 1978, 1982 and 1987 NNS, the 1989 revision was used to determine energy and nutrient adequacy in the 1993 survey, and the 2002 revision was used in 2003. (For more details see Annexes 1, 2 and 3.)

Assessment of the dietary intake of children aged 0 to five years and of pregnant and lactating women was included in the 1987, 1993 and 2003 NNS. Information on the food intake of these groups is obtained through 24-hour food recall. Mothers are asked to recall all the foods and beverages consumed by their children in the previous 24 hours. Aids to assist the estimation of portion sizes include using standard household measures, such as cups and spoons, and an album of standard food portion sizes, which the mother can look at to estimate the amount consumed by the child.

Sampling design of NNS

All the NNS employed a multi-stage stratified sampling design, and covered all regions of the country. In the 1978, 1982, 1987 and 1993 NNS, the number of sample provinces or cluster areas for each of the regions and Metro Manila was selected based on probability proportional to the number of households. From each sample province, an equal allocation of urban and rural barangays[10] (i.e., four urban and four rural barangays) were selected at random. In the case of Metro Manila, eight barangays - all urban - were selected per cluster. A systematic sample of ten households per barangay, with replacements, were then selected in the final stage of sampling. In the 1998 and 2003 surveys, all provinces were covered and the number of barangays or enumeration areas was based on probability proportional to the number of households. The 2003 NNS adopted the Master Sample developed by the Philippine Statistical System for the 2003 Family Income and Expenditure Survey (FIES) and other national surveys.

For the 1978, 1982, 1987, 1993 and 2003 NNS, the final sampling unit was the household, and all the members of each household were included. In the 1998 NNS (when there was no household food consumption survey), the final sampling unit was the individual - i.e., subjects or respondents aged 0 to five years, six to 12 years, 13 to 19 years and 20 years and over were sampled within sample barangays.

Regional Updating of the Nutritional Status of Children

The nutritional status of children aged 0 to ten years is updated two to three years after each NNS, using anthropometry. The first updating survey was carried out in 1989/1990. The sampling design of the regional updating surveys is similar to that of the 1998 NNS, in which the barangay was the primary sampling unit and children aged 0 to ten years were the secondary sampling units. The update surveys generate national- and regional-level estimates.

TABLE 3
Sampling design of NNS and the Regional Updating of the Nutritional Status of Children, 1978 to 2003


19781

19821

19871

1989/19902

19931

19962

19981

20012

20031

Sampling design

Stratified 3-stage

Stratified 3-stage

Stratified 3-stage

Stratified 2-stage

Stratified 3-stage

Stratified 2-stage

Stratified 2-stage

Stratified 2-stage

Stratified 2-stage

Stratification

Region

Region

Region

Region

Region

Region

Region

Region

Region


Urban/rural

Urban/rural

Urban/rural

Province

Province

Province

Province

Province

Province





Urban/rural

Urban/rural

Urban/rural

Urban/rural

Urban/rural


Sampling units

Province

Province

Province

Barangay

Barangay

Barangay

Barangay

Barangay

Barangay


Barangay

Barangay

Barangay

Individual

Household

Individual

Individual

Individual

Household


Household

Household

Household







Sample size

Households

2 800

2 280

3 200


4 050


-


5 514

0-5 years




6 932

4 977

10 385

28 698

10 634

4 111

6-10 years




5 382

3 223

15 530

3 040

1 791

3 436

11-19 years





4 111


6 079


4 856

³ 20 years





8 480


9 299


11 685

Pregnant women





850


2 880


593

Lactating mothers





1 105


2 990


1 201

1 NNS: there was no food consumption survey component in NNS 1998.
2 Regional Updating of the Nutritional Status of Children included anthropometry among Philippine children only.

The Field Health Service Information System and Philippine Health Statistics

FHSIS is a nationwide compilation of health indicators collected by city and provincial health offices from health facilities such as district hospitals, rural health units (RHUs) and barangay health stations (BHS). The indicators collected reflect the state of health programmes: Maternal and Child Health, Family Planning, the Expanded Programme on Immunization, Nutrition, Dental, Communicable and Non-Communicable Disease Prevention and Control, and Environmental Health. Philippine Health Statistics (PHS) provides summary statistical data of births and deaths registered and reported in a given year, as well as the notified diseases reported in FHSIS.


[10] A barangay is the smallest local government unit in the Philippines, and is similar to a village.

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