Turkish Culture and Obesity among Children in Amsterdam: An Exploration towards the Causes and Solutions

“Göbeksiz erkek balkonsuz ev gibidir”

A man without a belly is like a house with no balcony

In February of this year, a family residing in Utrecht was put under supervision by an official parenting expert because they overfed their children (NRC, 8th of June). This family had Turkish backgrounds. Although many native Dutch children also show higher rates of obesity, the numbers among children with a Turkish background are significantly higher. “44% of all 10-year old children with a Turkish background in Amsterdam are overweight or obese” as reported by Maarten Poorter, councilor for the Amsterdam labor party ‘PvdA.’
 
The media pays much attention to extreme cases of obesity which can lead to severe law enforcements. Judges believe that in some cases parents ‘abuse’ their children because obesity puts the child's health is at risk. The number of children with obesity is rising in the Netherlands. A report from the GGD Amsterdam (Health Organization) reports that in 2011, twenty percent of Dutch children at age of five are overweight or obese, while in 2007 only fifteen percent fell into this category. Additionally, twenty-seven percent of the ten-year old children were defined overweight or obese in 2011. These are shockingly high numbers, and it is therefore not surprising that the GGD spoke in 2006 about obseity as a ‘pandemic’. Obesity in children can lead to many problems such as diabetes, heart diseases and colon cancer, and also social isolation and exclusion. Hans Budde, a Dutch doctor from the Slotervaart Hospital in Amsterdam whose clinic mainly focuses on obesity, says that diabetes and the other physical problems currently begin around age seventy or eighty in patients. He states, however; in the future these diseases will most likely occur in patients around age of forty or fifty. This will lead to an increase in the need for health care, which in turn will result in increased costs to the government. American research even shows that for the first time in decades children are not expected to grow to be older than their parents, they will instead have shorter life expectancies.
 
These are alarming facts, and their truth is reflected at elementary schools in Amsterdam. In the Netherlands there have been interesting developments among native Dutch children in contrast to Dutch children of foreign backgrounds. Native Dutch children tend to be less overweight than children from different backgrounds, for example, children with Turkish, Moroccan or the Dutch Antilles backgrounds. Dutch children with a Turkish background, particularly, are discernably more overweight than native Dutch children. Again, according to the report by the GGD in 2011, 33 percent of the five-year old Turkish children and 44 percent of ten-year old Turkish children in Amsterdam are overweight or obese. The rates for Moroccan children are slightly lower. 37 Percent of the Moroccan children at the age of ten are overweight or have obesity, but there is a bigger difference with the native Dutch children. Twelve percent of the native Dutch children at the age of five are overweight or have obesity. This is quite a difference in comparison to the Turkish children. This remarkable distinction between Dutch children with a Turkish background and native Dutch children requires an elaboration. By cruising many sites and talking to people in Amsterdam, we tried to shed a light on this topic.
 
Baklava and hospitality
 
One of the reasons for the high rates of overweight and obesity among Turkish children is the Turkish culture. The Turkish culture is known for its hospitality. According to Ufuk, a 24-year-old Dutch student with a Turkish background, visiting a Turkish friend or family will probably result in an evening with lots of food and drinks. Hospitality in Turkish culture is without doubt connected to food and it is impolite to refuse the food offered. This is a great tradition that many native Dutch people should use as an example. On the other hand, the coin of hospitality has another side. It can easily lead to overeating. Besides, the Turkish culture is not only known for its hospitality, but also for its baklava, pastry and other delicious, but mostly food full of sugar.
 
We met Azra, a Turkish woman of 39 years old in the community center in Amsterdam-East, where we talked about Turkish food habits. She has three children, two daughters of ten and fifteen years old and a son of seventeen years old. After having the interview, we all wanted to have dinner at her place. She told us some examples of the things she makes for dinner like lentils soup, chicken breast in the oven, rice with a lot of ingredients. This sounds much better than the Dutch “stamppot”, which she never makes of course. After dinner they always drink tea, that’s where the problems starts. Tea is not just tea, but tea with pastry such as baklava. The same food habit was told to us by Sahra, the 23-year old daughter of a family that runs the best Döner-Kebab place in Amsterdam. The stall is located at the Dappermarkt, one of the most vibrant and diverse markets, located in Amsterdam-East. She also referred to the tradition of drinking tea and eating pastry every single day. They do it in the afternoon, and sometimes even after dinner as well. Imagine yourself eating baklava and other sweets twice a day. It sounds really delicious, but it also means a lot of sugar. Another remarkable thing Sahra said and a fact we did not know actually, was that a lot of Turkish food is baked in butter. This is not a healthy way of cooking food, but she replied that it is the way they make Turkish food. We also asked her about fruit, which they only eat on occasional basis.
 
However, both women are quite aware of the necessity to eat healthy food and repeat this many times. At breakfast Azra serves the children a sandwich with cheese, but she uses brown bread, because “that is much healthier, although white bread is more tasteful”. This is something Sahra told us as well. Azra dresses the sandwiches with salad, cucumber and tomatoes. This she puts on the crackers they sometimes eat for lunch as well. Her children learned to eat fruit and Azra does not want them to drink sodas because that contains too much sugar. At Sahra’s home they also try not to drink sodas, but juices instead. This all sounds very good, but we got the feeling that both women did not have enough knowledge about what is healthy and what not. Azra does not use enough variety in her meals and does not exactly know how to feed her children in a healthier and balanced way. When we asked her about vegetables, she only spoke about salad, cucumber and tomatoes, which do not contain enough vitamins. Sahra’s family did use more variety in their meals though. They also eat cauliflower, sprouts and broccoli, but because they use a lot of butter, the food is still not that healthy and contains a lot of fat. In both families it is not a matter of eating unhealthy on purpose. A lack of knowledge about the necessity of eating diverse and healthy are partially causing these negative eating habits. Furthermore Turkish dishes contain lots of sugar and butter.
 
One of our experts is Suzanne Dölle, a psychologist specialized in cultural food habits among Turkish families and obesity among ethnic minorities. She believes that the role of the mother is of the essence in order to understand obesity among children with a Turkish background. In Turkish families, the mother represents the head of home and is in charge of the meals. Although the majority of the Turkish mothers have knowledge about healthy food, they rarely implement this nutritional knowhow in real life. A lot of different factors prevent implementation of this knowledge. One of them is the culture of overfeeding. In Dutch culture, when one eats its meal the rule goes, ”never finish your meal if your stomach is full”. However in Turkish culture you must not leave anything behind on your plate. Moreover, mothers want to be ‘good moms’ for their children and they have a hard time refusing their children’s need for unhealthy snacks. They want that their children to be happy in society. Hence Turkish moms believe that if their children eat more, they will be perform better in school and have more friends.
 
Maarten Poorter, member of the parliament in Amsterdam for the labor party ‘PvdA’, ‘blames’ the Turkish sweet food habits and the great hospitality partially as well. He started focusing on high obesity rates among children in January this year. In parliament he stated that he also could lose 10 kilos in order to set the good example. His suggestion was well received by the other members and he succeeded in doing so. Nevertheless there are many children in Amsterdam who do not succeed in their ambition to lose weight. We chat with Poorter on a sunny terrace next to the city hall of Amsterdam. One of the interesting things Poorter mentions about the Turkish culture is the habit of parents and grandparents of earlier generations who have lived in Turkey. These individuals stemming from previous generations believe one should always eat excessively whenever possible. Since one can face a situation in which food is scarce. However in the Netherlands these scarce occasions do not occur, but the mentality remains manifest in their eating habit. In association with the fact that the Turkish community in the Netherlands are also relatively wealthier in comparison to their family residing in Turkey, this may cause overweight.
 
Dölle agrees, the extended family still engages strongly in classical Turkish cultural behavior. They ‘carry’ the sociological motive of “overweight children = healthy children” which stems from the tough working ethic in (rural) Turkey. If you eat a lot you will work a lot. This pressure from extended family to the mother is one of the important cultural reasons for obesity among children with a Turkish background, according to Dölle. Also Ingrid Haaijen who is a social project coordinator of the elementary school ‘Einsteinschool’, a primary school in the West of Amsterdam, “Turkish people have a different cultural vision on food. According to them, being overweight as a child is a sign of being wealthy and rich. It is common to provide your children with meals full of sugar and fat.” For those people, being skinny is a sign of poorness or malnutrition. Specifically, Turkish culture is more focused on taking care of the child whereas in Moroccan culture children are more inclined to do it on their own. Although this difference is small, according to Poorter this can be the reason why children with a Turkish background score highest in rates of obesity and overweight.
 

“Did you ever see a Turkish child on Tennis?”
 

Besides cultural factors, there are many different and equally important social factors that can influence on unhealthy weight gain. Poorter even believes the high rates of obesity among Turkish children is mostly due to the low socioeconomic status of these ethnic minorities. The Turkish people in the Netherlands are often low-educated and many older people speak the Dutch language not well. This lead to segregation. Some of them do not integrate that well into the Dutch society, whereby it is difficult  to get in contact with this group. Schools and doctors have a hard time reaching the Turkish parents and making them aware of the consequences of overweight and obesity.
 
Another reason for overweight among children with a Turkish background could be the migration from the parents or themselves from their native country to the Netherlands. This means not only a change of environment, but also a change of food. Products that are very common in their home country might be very expensive in the Netherlands or not available at all. Therefore, food habits have to change and the people have to adapt to the Dutch food culture. No knowledge about Western products like ready-eat meals and junk food can lead to overeating and overweight. Besides, sweets and snacks are more often cheaper than healthy food like vegetables and fruit. As Haaijen says: “They are lower in socioeconomic status, and have less money. So they go the ‘Lidl’ to buy cheap food, unaware of the fact that there are lots of additives inside”. Many children have to buy lunch themselves or their parents give them chips and cake for lunch. This is a consequence of raising the children with too much laxity.
 
“Did you ever see a Turkish child on Tennis?” Ufuk asked us when we addressed these issues. Indeed, the rates among children with a Dutch background who do sports is much higher than among children with a Turkish background. Lack of exercise is also an important issue that causes overweight and even obesity. This is not only a problem under Turkish children, but for all Dutch children. While twenty years ago the majority of children spend their leisure time playing outside, now they mostly sit in front of the television or behind the computer. This is even more valid among Turkish children. The limited access to sport facilities in their neighborhoods seems an important factor. Thereby according to Poorter, the high costs of becoming a member of a sport club is a financial problem for most families. They often cannot afford the annual high contributions. Although the local government tries to alleviate this issue by subsidizing sport memberships among residents with a low socioeconomic status. Amsterdam-West for example provides free trials for children in sports clubs for a few months. Somehow the ‘Amsterdammers’ with a Turkish or Moroccan background still engage less in sporting activities than the native Dutch population. According to Dölle this is the result of the Turkish culture where they feel ashamed of making use of the help provided by organizations and the government. Ufuk says it is the result of the inaccessible character of Dutch sport organizations. It is very hard finding an entry, especially for Turkish or Moroccan girls. Besides the lack of exercise and playing outside, Dölle states that parents are afraid to let their children out on the streets on their own. They are worried that someone will harm them.
 

Overcoming underage obesity
 
The problem is well-known by the national government and they do have a policy to solve this problem. Marjolein Schut (reporter from Nieuwsuur, a Dutch daily report show) asked the minister of Education, Culture and Science, Marja van Bijsterveldt to respond on their policy but she refused to talk about it. Then Van Bijsterveldt sent the reporters to Edith Schippers, the minister of Health, Wellness and Sport. Schippers told Schut that her ministry pays attention to overweight and obesity, but only as a part of a bigger project about health and exercise for children. It is therefore not completely clear which ministry focuses on obesity and overweight of children.
 
The issue of child obesity is rather prevalent within the local parliament. Only on Wednesday the 20th of June, there were four proposals in the local parliament (of different political parties). All addressing the obesity issue and coming up with several interventions. These proposals are not selected and focused on specific minorities. However they all address the less privileged group in society. “Today I arranged to get 1 million out of the sporting fund to make sure that four thousand children are able to become a member of a sporting club” responded Poorter proudly.

Nowadays there is an overarching program running in Amsterdam. The first one called “Youth on a Healthy Weight” (JOGG in Dutch) which is being deployed on a national scale. It just started and focuses on the entire scope of children from the age of 0 till 19. Program coordinator of “Amsterdammers on a healthy weight” Karen den Hertog elaborates: “It is now only deployed in a neighborhood in the western district of Amsterdam, hopefully next year we’ll arrange it in another neighborhood”. The ‘JOGG’ program entails education on several aspects such as schools, healthcare, nutrition, exercise. “We try to engage as many partners as possible in order to make a change, if the entire social environment changes one has a bigger chance to lose weight” according to Den Hertog. 
 
A part of this is the program “Topscore” and is deployed at 70 elementary schools in Amsterdam and reaches 22.000 children. They are being weighed, measured and get lessons on how to live healthier. Furthermore parents are being educated on healthy nutrition. This project aims to get the youth familiar with several kinds of sports in order for them to subscribe more easily. However Poorter believes that this project is less fruitful: “We should really look at children of a younger age if we want to be effective in our policy. Younger children are more likely to change their habits. If we want to spend our money wisely, we should focus on children within the age of 5 to 10. 
 
Lunch on Schools
 
Although these programs sound rather sophisticated, it is unsure whether they remain working on the long run. A pilot which seemed very fruitful is now in its final stage, ‘Lunch on Schools’.
 
In order to get more info about this pilot, we visited the Einstein school. One of the elementary schools participating in this project situated in a western neighborhood of Amsterdam called ‘Slotervaart’. Although this area is infamous for its social problems in which ethnic minorities play a key role, construction seems to have improved the neighborhood. The only 2-year-old school entails many different functions through which children are also being ‘educated’ after class. The area seems rather peaceful and not threatening at all. Here we meet Ingrid Haaijen, who is the social project coordinator of the school.
 
The project at the Einstein school tries to shift unhealthy food habits for the better by organizing projects to increase children’s exercise and become more aware of their weight and health. Furthermore information is given to the parents via interactive theater in which parents can jump in whenever they like it, partially organized by the GGD. Moreover the GGD subsidized the “Lunch on schools” project by providing €26.000 to the Einstein school and to eight other elementary schools throughout Amsterdam. These schools were all situated in socially deprived neighborhoods. The ‘Lunch on Schools’ project started in the first semester of 2010/2011 and provides twice a week healthy lunches for children of the seventh and eighth grade, and for the students who remain during the lunch break. The healthy meal is prepared by a group of mothers who are trained in food preparation, hygiene and pedagogy. In liaison by the local greengrocer, a restaurant style lunch is prepared. The seventh and eighth graders were also assisting and learned how to prepare a healthy meal. By doing so they learned where their meals came from and how you can make a healthy meal yourself. There was for example a girl from the eighth grade who only wanted to eat ready-eat meals and nothing fresh. By learning her how to cook, the teacher hoped to improve her food habits. Hence the children learned to: appreciate water just as much as sweet drinks, eat slowly and gently, and enjoy vegetables. “Hopefully this brings about a change in their eating habits” Haaijen states expectantly. The social pressure in the classroom was a positive aspect in this project. The children saw their friends eating food they never ate before and felt therefore motivated to try new things. 
 
On the other hand there were some downsides. A significant problem was the fact that parents were not always willing to pay 75 cents a week for two meals. They found it too expensive and could not afford it. Moreover, some children came home reporting that they didn’t enjoy their lunch while in school they seemed very enthusiastic. Hence parents were afraid their children ate too little and still provided them with lots of food. Haaijen: “So we didn’t see any decrease in weight due to this project, however the students’ concentration in class after lunch increased drastically”. There were nevertheless also positive responses by some parents. They supported the initiative, because it stimulated the children to eat more different things and created a feeling of togetherness. They learned that the FEBO, a fast food restaurant, was not the only option to go to when they were hungry, but that there are also other healthier options. The mother of a daughter who took part in the project said that her daughter was now more aware that healthy food can be delicious as well. She definitely saw an improvement in the food habits of her daughter who was willing to eat more fruit now. What could not resolved by this project is the awareness in the whole family. The children were educated, but they do not make the food and are because of that more prone to a rapid change of thinking and behavior.  
 
Unfortunately these months will be the final ones of this charming project due to a lack of funding. Haaijen thinks it is “very regrettable...”. It seems that the local government is unable to plan on the long term and alleviate the problem substantially”. Did you ever see an initiative lasting for ten years? Only then you can get some decent results. They are fond of projects, but when it becomes effective they put an end to it”. The school dietician was let go due to cuts as well: “now overweight children immediately go to the GGD or obesity clinic which, in most of the times, they only visit once and costs a lot of money as well” as reported by Haaijen.
If this project at the Einstein school will continue somehow in another format, remains to be seen. In any case it will be without Haaijen, as her function disappears as well after this summer. Poorter is less critical on the termination of the ‘Lunch on Schools’ project:  “it was a pilot project, and inherently to a pilot project is the fact that it shut’s down after a while”. Furthermore they evaluated the program extensively and concluded that it was too costly, parents would pay €2,50 if the program was to be executed throughout all the elementary schools in Amsterdam.
 
Sharing responsibility 
 
These conflicts tap into the question of responsibility. Who should feel responsible and address and change the issue of overweight among children. The role of the school to alleviate this problem is limited according to Haaijen: “It is hard to change what’s coming in via the lunchboxes”. The parents put chocolate croissants in their box and think they do good because the other parents also give away croissants. Unaware of the fact that this tasty French pastry is full of sugar and rather unhealthy. It seems that parents remain responsible. Also, according to Poorter: “Of course everyone is responsible for their own lives or their children’s lives, however when the issues get more severe on a large scale, there is also a role for the government to take action”. Moreover, Poorter makes other organizations responsible. He believes that also schools, clubs and clinics should address these issues and intervene and communicate with families who have overweight children. Every structure and organization within society should think about this issue with less laxity.
 
Although many families work along with the projects, Poorter mentions that there are some families who don’t cooperate: “this has to do with the fact that there are more issues going on in these families except for overweight”. In these cases Poorter believes that other public organizations engaged in family education should intervene. Besides the sophisticated projects, a long term intervention is adopted. At infant clinics, children between the age of 0 and 3 are being weighed and measured. Cases in which the child is obese lead to nutrition and exercise advice. In extreme cases they are redirected to the obesity clinic at a hospital. Poorter thinks this is rather important since in these cases a little bit of dieting is not effective anymore. Small steps are being taken at the clinic since extreme diets can also harm the child’s health.  Furthermore the obtained fats before the age of 18 are hard to get rid of. In these alarming cases an obesity clinic is very helpful. However half of the children who are redirected to the obesity clinic do not show up, “this is something which should definitely be changed” states Poorter. Although the clinics seem very helpful they do not solve the problem, prevention is vital.
 
 
“A Drop in the Ocean”

“Everything you spend as a government on decreasing obesity will be a drop in the ocean”, states Poorter cynically. As a government you’re simply not able to solve social problems completely. Still there is lots of attention nowadays for this issue, consequently it is important to make a move right now. How in the upcoming future initiatives should overcome the overweight problem among children remains to be seen. “We’re contemplating about these issues. Many elements should be discussed at the same time. If we want to let children ride their bike more often, we should take a look at safe cycling lanes, the availability of affordable bikes, as well as entrepreneurs who can set up a bike shop in the neighborhood”, according to Den Hertog.
 
How to make this move remains questionable. Especially to have a long lasting impact and reduce obesity rates among children and children with a Turkish background in specific. Although projects with these fancy names such as “Topscore” will remain for a while. It is unsure for how long and if (since the recent implementation) they prove to be beneficial. Therefore Poorter believes that we also need to look at the large multinationals that have major impact on one’s nutrition and eating habit.
 
More specifically, in order to address the Turkish minorities in Amsterdam, it is very important to alter their habits via local Turkish networks. “Raising children is a sensitive topic, therefore it is better to address and alter these behaviors when families are approached from someone within their own community”, according to Poorter. Also Dölle believes that in order to solve the problem we should not constantly try to change eating behavior of individual families, this is not sustainable and realistic. Turkish families don’t like it when someone puts a finger on them and say what they must do for the sake of their children. Following to that she thinks that the best solution for changing their behavior is through indirect social pressure. That indirect pressure must come from authorities for which Turkish families show lots of respect such as the school staff, said Dölle. Moreover it is important to consider the Turkish minority culture when we try to implement initiatives. Take the water issue for example, many people within Turkish culture believe that drinking water is a sign of poverty according to Den Hertog. We should consider these attitudes if we want to make the children drink more water instead of soda. Interventions should target those in need and also try to tease them instead of obliging them.
 
Taking everything into consideration it becomes obvious that overweight and obesity problems became an important issue in the Dutch society. Especially the high rates among children with a non-Dutch cultural background are alarming, because it can cause a lot of problems at an older age. There is awareness on this matter by the parents, the schools and the government, but there is yet no suitable solution to resolve the issue on the long-term. It is necessary that society and the government make a serious step forward by considering the cultural background of obese families and come up with long lasting structural interventions.
 

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HIA Program:

Netherlands Netherlands 2012

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