Height does matter, and in more ways than one

 (Published in ENRICH magazine, 2022)

IN THE PHILIPPINES, the phrase "stand tall" should be taken with a figurative, and not literal, meaning.

That's because Filipinos still retain the dubious honor of being one of the world's shortest people in average population height, average female height and average male height. On average, Filipino men and women are a mere 156.41 cm (5 feet 1.57 inches) tall, according to data released in 2019 by NCD Risk Factor Collaboration (NCD-RisC), a project linked to Imperial College London. This made Filipinos the fifth shortest people in the world based on NCD-RisC reckoning.

The same data also showed the average Filipino man with a height of 163.22 cm (5 feet 4.25 inches). That's as tall as Hollywood stars Michael J. Fox and Kevin Hart. The average Filipina is 149.60 cm (4 feet 10.89 inches) tall. Heightwise, that’s similar to former President Gloria Macapagal-Arroyo, superstar Nora Aunor and the late Hollywood legend Judy Garland.

Filipinos are only marginally taller than citizens of Timor-Leste, which topped the shortest stature list of NCD-RisC. The average height of both males and females from Timor-Leste was 155.47 cm (5 feet 1.28 inches). The average Timorese man stands 159.79 cm (5 feet 2.90 inches) tall while the average woman gets to 151.15 cm (4 feet 11.50 inches).

On the other hand, the average Timorese woman (151.15 cm) is taller than the average Filipina (149.60 cm). This makes Filipinas the second shortest in the world behind the women of Guatemala, who have an average height of 149.38 cm (4 feet 10.81 inches).

NCD-RisC is a global network of health scientists that provides timely data on major risk factors for non-communicable diseases for all countries.

The question now is why are we still of such short stature when this problem has been with us for generations? There are short and easy answers to this question.

Basically, it boils down mostly to genetics (or biological factors) coupled with the right food and adequate nutrition (or socioeconomic factors), especially in childhood.

Some scientists estimate that genetics accounts for more than 60% of a person's height. This being the case, a relatively well-to-do Filipino couple whose height is above average will likely sire taller than average children.  The reverse is also true.

The hereditary advantage conferred by tall parents who have enough money to regularly feed their children more protein (generally meat) than carbohydrates (rice) in their kids' growing years should see much taller children. Most Filipinos, however, are neither tall nor rich. The consequences of these realities are what we see daily on our streets: a sea of short and poor Filipinos.

Stunted, poor and malnourished

Height matters, and not only because of bragging rights. It turns out "height is a proxy indicator of how well the Philippines is doing as a society to reduce childhood poverty and improve access to nutrition," according to a report released in 2015 by Save the Children Philippines. It appears the Philippines is failing in this task.

"If the Philippines is to progress economically, we must not leave the poorest children behind," said the report with the title, "Sizing Up the Stunting and Malnutrition Problem in the Philippines".

World Atlas, an educational geography website online since 1996, publishes its own set of global stature statistics. In 2017, it estimated the average height of Filipinos at only 154.9 cm (5 feet 1.5 inches), a full 8.3 cm (3.3 inches) shorter than the estimate from NCD-RisC.

This made the Philippines the country with the third shortest population in the world. Instead of Timor-Leste, World Atlas said Bolivia had the world's shortest population. It placed the height of the average Bolivian at 151.1 cm (4 feet 11.5 inches).

What makes the estimate by World Atlas remarkable is that it attributed the short stature of Filipinos to "severe malnutrition problems ... especially prevalent in the event early age pregnancies, where the mother is not fully physically equipped for childbirth and childcare".

It noted the Department of Education (DepEd) admitting 1.8 million malnourished Filipino children are in danger from abnormalities such as stunting.

"The result is that the likelihood of this situation being repeated in the next generation is high. Although feeding programs have been launched, funds are not adequate enough," it reported.

It appears the DepEd estimate is off the mark. A report published by the Philippine Daily Inquirer in 2015 claimed 30% of all Filipino children under the age of five were stunted or short for their age. In numbers, this is an astonishing 3.6 million children, the ninth largest number of any country at the time.

"This is not a theoretical problem; this is a nutritional emergency," said the story.

At 63%, the Autonomous Region in Muslim Mindanao (ARMM) had the highest level of stunting among children in the entire country. Childhood stunting in Mindanao comes to 40%. This figure is equivalent to the average for all of sub-Saharan Africa consisting mostly of black African countries.

The report defined "stunted" as a child chronically malnourished during the first 1,000 days of its life, or from conception until the second birthday. This is the critical growth period for any child.

The World Health Organization (WHO) asserts stunting is the irreversible outcome of inadequate nutrition and repeated infections during the first 1,000 days of a child’s life.

The latest data about stunted Filipino children remains troubling and points to a neglect of the problem by both the national and local governments. The World Bank estimated 29% of Filipino children in 2019 age five and below were stunted.

It said the Philippines is still plagued by childhood stunting because of undernutrition, which it labeled "the silent pandemic". Stunting keeps most children in poverty for their entire lives while poverty creates the conditions leading to stunting.

In 2015, poverty meant 1.5 million Filipino children went through a day without a full meal. Some 2.7 million Filipino children missed a meal because their families don't have enough money for three meals a day. This situation has remained rampant.

In 2018, the Department of Health (DOH) estimated there were 4.2 million stunted Filipino children and more than 300,000 children under five years that are severely wasted, or thin for their height. Severely wasted children have at least nine to 12 times an increased risk of death.

The toll taken by malnutrition on Filipino children is gruesome and heartbreaking. UNICEF Philippines estimates 95 Filipino children die every day from malnutrition.

Another indignity: 27 out of 1,000 Filipino children do not live past their fifth birthday. And still another:  a third of Filipino children are stunted, and stunting after two years of age can be permanent, irreversible -- and even fatal. We must put a stop to this!

Bad for the brain

Malnutrition and poverty are also bad for the brain. A poor and stunted Filipino child will unlikely achieve his full cognitive and intellectual potential.

WHO and the United Nations Children's Fund (UNICEF) both agree stunting affects the cognitive development of children, which can be seen in their paltry academic results at school.

Nine out of 10 Filipino children at age 10 cannot read or understand a simple story by the age of 10. This translates into a record high "learning poverty" of 90.5%. The inability of Filipino children to read by 10 years-old will also mean they face huge obstacles to learning math, science and a host of other more difficult subjects.

 Learning poverty is defined by the World Bank as a child being unable to read and understand simple text by age 10. Also called "galloping illiteracy", learning poverty will later translate into economic poverty.

 It has gotten far worst over the past two years due to the cancellation of face-to-face classes in the aftermath of COVID-19. Before COVID-19 struck in early 2020, learning poverty in the Philippines was lower at 69.5%.

Malnourished Filipino children

First 1,000 days

During the presidential campaign 2016, candidates were asked to support the “First 1,000 Days Act,” a piece of legislation pending in Congress whose goal was to make reducing stunting and improving nutrition nationwide a presidential priority.

The man that won the presidential race, Rodrigo Duterte, did do something: he signed laws aiming to address the malnutrition problem. In the middle of his six-year long administration that bowed out on June 30, 2022, he signed Republic Act 11148 into law on November 29, 2018.

RA 11148, or the “Kalusugan at Nutrisyon ng Mag-Nanay Act," is more popularly known as the First 1,000 Days Law.  It seeks to boost national and local health and nutrition programs through an integrated strategy for maternal, neonatal, child health and nutrition in the first 1,000 days of a child's life.

"This law will complement the much-awaited Universal Health Care Law to further boost the country’s health status on our way to make Filipinos the healthiest in Southeast Asia by 2022 and in Asia in 2040,” boasted DOH Secretary Francisco Duque III.

Over three years later or in June 2022, the national government announced its intent to borrow $178.1 million from the World Bank to further support RA 11148.

It said the loan will “increase the utilization of a package of nutrition-specific and nutrition-sensitive interventions and improve key behaviors and practices known to reduce stunting in targeted local governments”. The project will be jointly implemented by the DOH and the Department of Social Welfare and Development (DSWD).

“It’s important that we focus on the health and nutrition of children starting in their mother's womb, especially because it has a big effect on their capacity to learn,” said Sen. Sherwin Gatchalian, who co-authored RA 11148.

“We should make sure that our communities have enough participation and capability, together with the local government, in order to ensure the good health of Filipino children”.

RA 11148 complements Republic Act No. 11037 (or the Masustansyang Pagkain Para sa Batang Pilipino Act) signed into law on June 2018. This is a law "Institutionalizing a National Feeding Program for Undernourished Children in Public Day Care, Kindergarten and Elementary Schools to Combat Hunger and Undernutrition among Filipino Children and Appropriating Funds Therefor".

Both laws are part of the national government's bid to eliminate hunger and reduce all forms of malnutrition. They also intend to secure healthy lives, promote the well-being of Filipinos, and end hunger and food insecurity.

Up and down

Up until his death in 2020, Junrey Balawing from Sindangan, Zamboanga del Norte was the shortest living man in the Philippines and the world. He stood tall at 56.0 cm (22.0 inches), as verified by Guinness World Records in 2012.

He became the world's shortest non-mobile person after the death of Chandra Bahadur Dangi from Nepal in September 2015. Chandra measured 54.6 cm (21.5 inches). Balawing was only 27 at the time of his death in the City of Dapitan.

On the opposite end of the scale, the tallest indigenous Pinoy on record is Raul Dillo standing at an eye-popping 221 cm (7 feet 3 inches), a height he hit when he was only 17 years-old. Now 30 years-old, this giant used to play basketball in college and in the defunct Metropolitan Basketball Association but never shone despite his height advantage.

Dillo later played bit roles in a number of Filipino movies where he was predictably typecast as a giant. Asked about the downside to being gigantic in 2012, he replied: “Sa transportation ang hirap. Kung bus, okay pa. Pero tulad ng tricycle, mahirap.”

The tallest home-grown Philippine Basketball Association (PBA) player is center Edward Joseph "E. J." Feihl, whose ceiling was 215.9 cm (7 feet 1 inch).  The second overall pick in the 1995 PBA draft, Feihl played for Ginebra San Miguel and six other teams until his retirement in 2007.

Feihl was born in Santa Barbara, Pangasinan to a Filipino mother and a German father. He’s 52 years-old.

The dearth of six-foot tall home-grown Filipino giants is a reason why the PBA is riddled with towering imports. In 2021, the PBA implemented a height limit of 198 cm (6 feet 6 inches) on imports to prevent the favorite Pinoy sport from being completely dominated by foreign skyscrapers.

 

Raul Dillo

Have you heard of this new disease called ageing?

 

(Published in ENRICH magazine, 2022)

A MOMENTOUS DEBATE raging in the global medical community will profoundly alter the way we perceive and treat the many diseases and infirmities that inevitably come with growing old.

At issue is the vexed question: "Is ageing a disease"?

It is a conundrum the informed Filipino layman will likely answer with, "Of course, not". In his world view, ageing is not a disease because he knows of no disease or medical condition called ageing. But he does realize chronic diseases like cancer, diabetes, stroke, arthritis, heart disease and Alzheimer's are prevalent among his old parents and even older grandparents.

The World Health Organization (WHO), however, no longer holds with certainty the view that ageing is not a disease. In January 2022, WHO effectively paved the way for defining ageing, specifically biological ageing or senescence, as a disease in the 11th revision of the International Classification of Diseases (ICD-11).

Its reasoning: old age gives rise to biological changes that make people more vulnerable to diseases that worsen with age like cancer and arthritis. Some experts contend ageing is the biggest risk factor for heart disease, cancer and dementia.

WHO, therefore, has apparently redefined ageing as a treatable condition that can be delayed and cured like a disease. It likely sees "ageing itself" as the principal cause of the myriad of illnesses linked to old age.

This redefinition of ageing as a disease should also lead doctors and scientists to address not only the effects of ageing but the underlying causes of the symptoms linked to ageing.

It's known that the processes underlying age-related diseases probably overlap. Therefore, if scientists can determine what biological processes make people more susceptible to age-related diseases such as heart disease and Alzheimer’s, a treatment might be found that can potentially treat multiple diseases at once instead of one at a time.

Age-related diseases are deadly. Of the 150,000 people that die every day across our planet, about two-thirds (close to 100,000) die from age-related causes. Even wars can't kill as many people. Some 27,000 people died daily in World War 2, the deadliest war in human history.

What exactly is ageing?

This festering dispute among the learned leads us to the question as to what ageing -- or the process of becoming older -- really is.

A medical definition describes chronological ageing as a time-dependent functional decline marked by a progressive loss of physiological integrity. This attenuation leads to the impairment of bodily functions and increases one's vulnerability to death. In other words, the older you get, the weaker and sicker you become. But is this due to the cumulative effects of individual age-related diseases, or to ageing as a disease? That is the question.

At the biological level, ageing is caused by the gradual accumulation of molecular and cellular damage over a person’s lifetime. These molecular level changes trigger a decline in mental and physical function and increase the risk of disease and death.

Then, there's the role cellular senescence plays in ageing. Ageing is also defined as the accumulation of senescent cells. Senescent cells cause many of the degenerative changes we perceive as ageing, as well as age-related diseases.

Cellular senescence is the process in which cells age and stop dividing permanently -- but don't die. Over time, massive numbers of old, or senescent, cells accumulate in our body tissues.

These "living-dead" cells or zombies release a range of inflammatory factors and enzymes that destroy the tissues in which they reside. As a result, our immune cells attack and kill senescent cells, thereby changing our tissues for better or worse.

In one fell swoop

ICD, the tool that ignited the ageing firestorm, is a globally used diagnostic tool published by WHO to help doctors and healthcare professionals identify diseases. It is a healthcare classification system providing diagnostic codes for classifying diseases.

The specific changes to ICD-11 about ageing involve general symptoms (code “MG2A”) and in the causality section of “XT9T”.  ICD-11 classifies "old age" as a specific disease in contrast to ICD-10 where old age is classified as a “general symptom”. Another contentious change was replacing the code for “senile debility” with the code MG2A, which originally stood for “old age”.

WHO also implemented an extension code (or a new category of codes) for "ageing related", or XT9T diseases. These are diseases “caused by pathological processes which persistently lead to the loss of organism’s adaptation and progress in older ages”. Extension codes provide additional information on a disease, injury or disorder.

The new code XT9T can be immediately applied to relevant conditions listed in ICD-11, as well as to future relevant medical conditions.

On the other hand, the implementation of the extension code XT9T in ICD-11 "is not tantamount to formal recognition of ageing as a disease," asserts an editorial in the peer-reviewed scientific journal, The Lancet. The advent of XT9T does, however, "signal acknowledgment by WHO of ageing as a major disease risk factor and of the considerable public health problem posed by ageing-related diseases".

The new proposals in ICD-11 intend to ensure ICD has a complete list of pathologies and disorders related to ageing. It also seeks to guarantee and account for the full spectrum of degenerative changes.

Accomplishing this means all ageing-related pathologies will have to be included in disease or disorder classifications, which wasn't the case previously. This omission meant an ageing diseases classified and assessed for the level of severity in one organ can be unclassified in another. It is a confusing situation at best.

More seriously, the absence of classifications and staging can result in less than ideal treatments since pathological ageing changes are not included in ICD.

The ageing-related changes to ICD-11 came from a joint proposal submitted to WHO’s ICD-11 Task Force by the Biogerontology Research Foundation, the International Longevity Alliance, and the Council for Public Health and the Problems of Demography.

Cellular senescence

Raging storm

The release of ICD-11 quickly ignited a storm of controversy, splitting medical professionals involved in gerontology, longevity science and other disciplines having to do with ageing into pro-disease and anti-disease factions.

Advocates for classifying ageing as a disease have long argued ageing is the biggest risk factor for chronic diseases, which are today treated individually as a matter of course. They contend ageing is not a deviation from the normal state as can be expected from a disease.

Treatments that focus on the underlying ageing process will “in one fell swoop, intervene in several or many chronic diseases of ageing,” claims Dr. Alexander Fleming, the founder of Kinexum (a company that develops drugs and biotech products).

Dr. David Sinclair, professor of genetics at Harvard Medical School and one of the better known longevity scientists, agrees that ageing is the main cause of all major diseases in society today.

"I'd argue that just because ageing happens to more than half of us, is no reason to not include it as a disease," he noted. "In fact, I would say it's even more important that we work on trying to combat it, because ageing is the main cause of all major diseases in society now.”

This line of thinking mirrors that made by Dr. Leonard Hayflick, professor of anatomy at the University of California San Francisco School of Medicine, back in 1962.

At the time, Dr. Hayflick argued that if old age is a risk factor for nearly all of the diseases likely to kill us, "why then are we not devoting significantly greater resources to understanding what … increase(s) vulnerability to all age-associated pathology?"

He said the lack of distinction between ageing and age-related diseases “is the most serious impediment to our understanding of the ageing process.”

Dr. Hayflick gained fame by discovering a limit to how many times human cells divide before they become senescent. His name is inextricably linked to the discovery of the key role telomeres play in the ageing process.

The declaration by WHO seems a belated acknowledgement of a landmark study about ageing published in February 1954 by Dr. Robert Perlman in which he described ageing as a “disease complex" while emphasizing the etiologic significance of both internal and external environmental stress.

Perlman's study, “The Ageing Syndrome”, published in the Journal of American Geriatrics Society has slowly gained adherents over the past half century.

In 2015, a team of international researchers published a study in the online biomedical and life sciences journal PubMed Central with the provocative title, “It is time to classify biological ageing as a disease.” It sees "the ageing process as the underlying cause for the chronic diseases affecting the elderly".

Alarm bells

The ageing-related revisions in ICD-11 were met with alarm by medical professionals holding the contrary but majority view. Current thinking contends ageing is a natural process and not a disease, and "should not be considered a disease in and of itself."

A paper published in The Lancet in October 2021 took WHO to task for supporting moves to classify ageing as a disease.

"We argue that simply equating old age as a disease in the ICD-11 is potentially detrimental and deleterious from clinical, research, and humanitarian points of view, and propose alternate productive solutions," wrote the study authors.

They argue chronological age has limited use in diagnosis, prognostication, and treatment guidance. In addition, “age by itself is of limited use for the assessment of population health, for the evaluation of initiatives designed to promote healthy ageing, and for health or social care planning. “

Instead on harping on ageing, the authors "propose that frailty should be included as a clinical disorder instead of old age." They ask WHO "develop the reporting of frailty in the ICD classification system" and argue that frailty "is a much more homogeneous and better-defined clinical entity" compared to old age.

They claim ICD-11 branding ageing as a disease will potentially magnify the socioenvironmental disadvantages in terms of equality in healthcare provision endured by the elderly.  Ageing as a disease will also reinforce commonly held ageistic beliefs in society and the medical community.  Validation of ageistic beliefs will also stand to worsen the societal marginalization and discrimination against the elderly.

The International Association of Gerontology and Geriatrics based in Belgium and comprising 84 national societies from 72 countries has also assailed the inclusion of old age as a pathological criterion in ICD-11. Others are urging WHO to revise the ICD-11 classification of old age.

What's at stake

Behind the fire and fury engulfing those for and against the proposition is a deep concern for the plight of the elderly. The implications of the WHO declaration that ageing is a disease -- which many medical professionals dispute or dismiss -- will massively affect the healthcare provided the elderly and the development of drugs needed to combat diseases of ageing.

The protagonists don't dispute ageing is a one-way street culminating in six feet of subterranean real estate. What they can't agree on is how to make this final journey more tolerable, which means an emphasis on healthy ageing or our healthspan.

Those that contend ageing should be classified as a disease want to goad governments and pharmaceutical firms into emphasizing the development of therapeutic interventions targeting ageing and ageing-related diseases.

They argue that new therapeutic interventions for ageing will lead to the acceptance of ageing as a disease. This acknowledgement will help ensure treatments are covered by health insurance providers, especially those in the West. It is also critical to boost funding from grant-awarding organizations for ageing research.

The poorest of Filipinos

The implications of this debate on ageing in the Philippines will be huge.

The country has an elderly population age 60 up of more than 12 million persons. This total comprises 11% of the total population of 110.8 million persons, estimated the Commission on Population and Development (PopCom).

In 2015, PopCom said the country’s population will begin to age by 2025 to 2030. It was because of this former PopCom executive director Juan Antonio Perez III said he was gravely concerned that “social protection systems have yet to catch up with social conditions”.

“People are living longer but in poorer health and socio-economic conditions," said Perez.  "They are only partially reaping the benefits of better health and social conditions."

He warned the government has only 10 years to craft programs for the elderly that address healthcare, rehabilitation, depression and daily activities, among others.

He emphasized senior citizens will need the government’s help as they will be “the poorest members of the population because usually their pensions are not enough for them”. Not much has occurred since 2015 to negate this warning.

In 2017, the Philippines was ranked 60th out of 191 countries in WHO’s Ranking of the World's Health System. The country with the world’s best healthcare was France; Singapore had Asia’s best healthcare system.