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Wednesday, 24 September 2008

A Diet Succumbs (Η Μεσογειακή διατροφή υποκύπτει)

Here's an article two friends passed onto me just today, from the New York Times (reprinted here for convenience; do take a look at the original article here and here to see the photos). The bold paragraphs are my responses to the article.

Fast Food Hits Mediterranean; a Diet Succumbs By ELISABETH ROSENTHAL September 24, 2008
KASTELI, Hania, Crete, Greece Dr. Michalis Stagourakis has seen a transformation of his pediatric practice here over the past three years. The usual sniffles and stomachaches of childhood are now interspersed with far more serious conditions: diabetes, high blood pressure, high cholesterol. A changing diet, he says, has produced an epidemic of obesity and related maladies.

Greek people have a tendency to be fat, but obesity is a clinical term. It is easy to call someone fat, but it is also subjective. Saying that, I also feel myself that there is a preponderance of fat-looking children and adults in the town, as this photo indicates. We probably also suffer from illnesses that were not so common in the past, but this is probably not only due only to diet.

Small towns like this one in western Crete, considered the birthplace of the famously healthful Mediterranean diet emphasizing olive oil, fresh produce and fish are now overflowing with chocolate shops, pizza places, ice cream parlors, soda machines and fast-food joints.

They certainly are. Even without tourism, the globalised nature of these kinds of leisure stores means that they would have eventually become a part of the landscape. It doesn't necessarily mean that you have to eat there on a regular basis, however...

The fact is that the Mediterranean diet, which has been associated with longer life spans and lower rates of heart disease an cancer, is in retreat in its home region. Today it is more likely to be found in the upscale restaurants of London and New York than among the young generation in places like Greece, where two-thirds of children are now overweight and the health effects are mounting, health officials say.

Again, 'overweight' is a clinical term, while appearance is a subjective factor. In my opinion, the primary school my children attend has children who look 'slim', 'healthy', 'slender', 'thin', 'active'; there are only a few children of the 120 who look 'fat', 'chubby', or 'obese'.

“This is a place where you’d see people who lived to 100, where people were all fit and trim,” Dr. Stagourakis said. “Now you see kids whose longevity is less than their parents’. That’s really scaring people.” (So it should!) That concern has been echoed by the Food and Agriculture Organization of the UN, which said in a report this summer that the region’s diet had “decayed into a moribund state.” “It is almost a perfect diet, but when we looked at what people were eating we noticed that much of the highly praised diet didn’t exist any more,” said the report’s author, Josef Schmidhuber, a senior economist at the food organization. “It has become just a notion.” Greece, Italy, Spain and Morocco have even asked Unesco to designate the diet as an “intangible piece of cultural heritage,” a testament to its essential value as well as its potential extinction.

An intangible piece of cultural heritage is going a bit far, as Crete is not the only island to claim the Mediterranean diet as part of their culture; Sicilians and Tunisians were also considered to follow the same kind of diet patterns. Longevity can still be reached in Crete, but the Japanese live far longer than anyone in the world, and their diet is completely different to the traditional Cretan one. Again, it is not just diet that accounts for longevity; medical care (relatively inadequate in Greece, extremely high in Japan) also plays a role.

The most serious effects of its steady disappearance are on people’s health and waistlines. Alarmed by the trends, the Greek government has been swooping into schools in villages like Kasteli annually for the past few years to weigh children and lecture them on nutrition. The lessons include a food pyramid focused on the Mediterranean diet. It is an uphill battle, though. This spring, a majority of children who were tested at the elementary school of this sleepy port town of 3,000, also known as Kissamos, were found to have high cholesterol. “It was the talk of the school,” said Stella Kazazakou, 44. “Instead of grades, the moms were comparing cholesterol levels.”

It's not that people haven't noticed what children are eating at school. It's worse seeing what they're not eating: when both parents are working, some children do not even bring lunch to school. This embarrassing fact was revealed at a parent-teacher meeting held recently at my children's primary school, when some parents discussed the problem of a communal dining area, as the school does not have a separate dining room, so that the children are eating off the desks that they end up doing their school work on. The headmaster also gave a stern warning to parents, boldly telling them that a chocolate-filled puff pastry for morning break followed by another chocolate-filled puff pastry for lunch would only lead their children to an early death. Sadly, not everyone heeds his words. Thankfully, there is no school canteen at this school, so parents have the responsibility to prepare their children's school meals.

In Greece, three-quarters of the adult population is overweight or obese, the worst rate in Europe “by far,” according to the United Nations. The rates of overweight 12-year-old boys rose more than 200 percent from 1982 to 2002 and have been rising even faster since. Italy and Spain are not far behind, with more than 50 percent of adults overweight. That compares with about 45 percent in France and the Netherlands. In the United States, 66 percent of adults older than 20 were overweight in 2004, and 31.9 percent of children 2 through 19 were overweight in 2006, although childhood statistics are compiled somewhat differently in different countries.

In my reading, I have often come across this statement (that Greeks are the fattest Europeans), but I have also read that Great Britain has the fattest Europeans. In Crete, people do have a tendency to look fat, as stated above, but it's difficult to compare levels of obesity if different methods of measuring it are used in each country. But I've also read that Greeks (with a record rate of smokers) are also some of the Europeans with the longest lifespan. Obesity clearly isn't the only factor involved in longevity, and neither should food and diet be the main factor involved in rising obesity. A typical Greek child spends about five-six hours a day at school, most of the time sitting at a desk. (Take my children as an example: they have two 40-minute Phys.Ed. classes a week on their schedule; what are they doing in all the other classes?) After school, there is homework to be written, English classes to go to, as well as (in the case of most children) other school-related lessons at private institutes. There is a general lack of physical activity, in some cases coupled with bad diet (aside from sedentary hobbies imported from the globalised universe, such as television, DVD and computer usage).

In Greece, the increase in the number of fat children has been particularly striking, parents and doctors say. “Their diet is totally different than ours was,” said Soula Sfakianakis, 40, recalling breakfasts of goat milk, bread and honey. Her son, Vassilis, a husky 9-year-old who had a chocolate mustache from a recently conquered ice cream cone, said he preferred cornflakes in the morning and steak or macaroni and cheese for dinner.

OK, Vassilis, are you allowed to eat what you like whenever you like, or do your parents also prefer steak and cheesy macaroni on a daily basis? It all depends on who cooks, what cooking habits they follow, and whether there is a conscious effort made on the part of the main food provider in a household as to what a child will eat on a daily basis.

Dr. Antonia Trichopoulou, a professor of epidemiology at the University of Athens Medical School, said the problem had grown acute with the spread of supermarkets and, especially, convenience foods. “In the last five years it’s become really bad,” she said. “The children are all quite heavy. The market is pushing a lot, and parents and schools seem unable to resist.” Advertising geared toward children has invaded Greece full force, stretching into the countryside. On television there are commercials for chips; at supermarkets there are stands of candy. Last year, Coca-Cola sponsored a play about healthful eating. But facing both aggressive convenience food marketing and obesity for the first time, many rural residents here have little resistance to or knowledge of the dangers.

Fast food has invaded all parts of the world, but Cretan rural residents have plenty of knowledge on what is good or not good to eat. People make food choices that they talk about in public; you often hear parents claiming that they don't keep soft drinks or crisps in the house, for instance. But it is also true that cheap mass-produced hi-fat hi-carb snacks have invaded the supermarkets, and they are an easy long-life shelf-storable solution for convenience food. Some people could do with a few lessons in food and time management. A little more organisation and more conscious food-buying decisions are probably all it takes to make a significant change in the way one copes with feeding their family.

Dr. Trichopoulou said that some older people might have been tolerant of childhood chubbiness because Greece had for so long been a poor nation where hunger was a recurrent problem. Outside one of Kasteli’s several ice cream parlors, Argyro Koromylla said, “You don’t want your child complaining or feeling left out, so you give him what he wants.” Her son Manolis, 12, was finishing a cone, a large T-shirt draped over his stocky frame.

Hunger was not exactly a problem in the sense that people sourced their own food in more natural ways. It was simply harder to store it for long periods of time, and it was necessary to continually source food in order to have it. The more members in a family (as in the past), the less food that was available to share out, not because it wasn't available, but because it wasn't easy to harvest as much as was needed. The bounty of nature was always used as the primary source of food in Crete, which is not necessarily the case anymore since the invention and widespread use of refrigerators and supermarkets, but a lot of good-quality Cretan food still comes from nature itself. It's just that it is easier to get access to it, hence less physical activity is needed to source food, hence people are fatter.

Dimitris Loukakis, 44, said he was so concerned about changing eating habits that he had bought a farm to grow traditional crops himself.

There's no doubt about the health benefits of maintaining a garden and growing your own produce. Most people where I live do in fact grow their own everything and are very proud of it. But you can't grow your own ice-cream and puff pastry, so it's just a case of being food-wise and health-conscious if you want your children to be healthy.

Sitting at an outdoor cafe by the beach, he and his wife drank iced coffee while their chunky 9-year-old daughter, Maria, nibbled on spinach pie and glumly drank water. “I’m on a diet; I have to eat less,” Maria piped up, noting that the local school had recently started to teach students about nutrition.

Should we be feeling sorry for Maria nibbling on spinach pie and glumly drinking water? Some children gulp both down ravenously: we continually tell ours how good these are for them, and they now believe us, even catching on to news items that contain food words we have discussed round the kitchen table. They know the food pyramid off by heart - I've had it stuck on the kitchen wall for over a year...

“Some diet,” interjected her father. “We’re trying to keep her off sugar now. If we continue like this, we’re going to become like Americans, and no one wants that.

This is what we hear on the news all the time, that Americans are fat and eat junk food all the time. We should look at ourselves before we make such claims. But if we 'know' what makes us fat ('junk food', 'American food'), why do we still eat it? Greeks are very image-conscious: it's important to be seen in the right places, doing the right things, wearing the right clothes, sporting the right accessories, eating the right food. We eat badly as part of the show to impress, to show off, to support local businesses, to be 'in', to feel good - and junk food has a tendency to make us feel really really good in many ways...

The traditional diet, low in saturated fats and high in nutrients like flavonoids, was based on vegetables, fruit, unrefined grains, olive oil for cooking and for flavoring, and a bit of wine all consumed on a daily basis.

And it still can be if you want it to be. It isn't hard to be seasonally inclined in one's food habits in Crete.

Fish, nuts, poultry, eggs, cheese and sweets were weekly additions. Red meat, refined sugar or flour, butter and other oils or fats were consumed rarely, if at all. Research on the diet took off in the 1990s, as scientists noted that people in Mediterranean countries lived longer and had low rates of serious disease despite a penchant for patently unhealthy habits like smoking and drinking. But that protection is now seen as rapidly eroding.

Nothing lasts forever, but we can make changes to our diet and physical activity patterns; it's in our own interest.

A generation ago, the typical diet in all Mediterranean countries complied with nutritional recommendations by the WHO that less than 10 percent of calories come from saturated fats and that less than 300 milligrams of cholesterol be consumed per day. Today, the typical diet in all of the countries exceeds those limits significantly, Dr. Schmidhuber said. In Greece, average daily cholesterol consumption has risen to 400 milligrams from 190 in 1963. Germany’s is similar. In Portugal, consumption went to 460 milligrams from 155. In 2002, a British study found that 31 percent to 34 percent of 12-year-olds in Greece were overweight a 212 percent increase since 1982 and “it has gotten worse, much worse, since then,” Dr. Stagourakis said. One-quarter of all children on Crete have cholesterol problems, he said, and seeing children with diabetes and high blood pressure is no longer uncommon. Unlike in the United States, where obesity is more pronounced in adults than in children, in the Mediterranean region the rise in weight problems has been more common among the young. Parents’ taste buds still tend to hew to a more traditional diet.

So it's clearly up to the parents to make conscious food choices in the household, which was stated above.

A survey by the World Health Organization last year of statistics from various countries found that among children in the first half of primary school, 35.2 percent in Spain were overweight the worst rate and 31.5 percent in Portugal. The lowest rates were in Slovakia (15.2 percent), France (18.1 percent) and Switzerland (18.3 percent). Greece was not included. Being overweight, particularly being obese, is associated with a wide variety of medical problems, like diabetes and liver disease. While heavy children may not suffer immediate health effects, they are statistically far more likely to grow into obese adults than their trimmer classmates. And in adulthood the conditions can be lethal.

I've also noticed another trend, based on my contact with children and young people in private language schools. Children tend to look fit and healthy, especially when parents make conscious food decisions. Young people tend to look slim, but they have developed a podgy stomach, evident from the way they sit at a desk. These children are clearly not getting enuch exercise, and are probably spending too much time sitting on a chair behind a desk, doing something else Greek parents just love seeing their kids do: studying for school. It's no wonder that the young will have a problem as they get older.

On traditional Crete, there was no need for calorie counting or food pyramids. People were poorer then, so their food was mostly homegrown, and producing it required more physical activity. “We ate what we grew and what we could make from it,” said Eleni Klouvidaki, 46, who lives in Kalidonia, a mountain village outside Kasteli, and describes her preferred diet as “whatever’s green.” On a recent day she prepared a meal of her staple mix of zucchini, tomatoes and other vegetables, and tossed it all in homemade olive oil. Now and again, she augments this dish with beans, or meat from her chickens or rabbits.

Believe it or not, a lot of people still eat like this, but they may still be overweight. The typical image of the 1960s Greek grandmother was a matronly figure dressed in black. She was probably standing by the stove, constantly wearing an apron. That was considered a normal image. Why are the rounded curvy bodies now looked down on? Probably something to do with fashion desingers and thier models. It isn't just the food that is changing people's health for the worse; physical activity, stress levels, the growing demands of modern society, pollution, occupational changes, they all have a part to play.

But she said that as more women worked and shops had moved in, the food culture had changed. “We’ve entered an era of convenience,” she said. “Even in this rural village, the diet is very different than it used to be.” She, too, occasionally grabs dinner in town, and four nights a week her son, who works in a car repair shop, drives to a fast-food restaurant. “They don’t deliver here yet,” she explained.

I know why her son can't limit his fast-food intake: in Crete, the going-out culture all has to do with eating out at the local grillhouse (taverna). Back in the good old days, people were unlikely to own a car; now, most households have at least two parked in their driveways. In time, that young man will realise that he shouldn't be eating so much junk; most young people do eventually learn not to eat so much junk food - it's never too late.

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