EDITORIAL

Defining the Filipino Family: Implications to Family Practice

The “family” has been defined in several ways. The Webster Dictionary defines a family as “the basic unit in society
traditionally consisting of two parents rearing their children or any of various social units differing from but regarded as
equivalent to the traditional family.”1 The Britannica defines a family as “a group of persons united by the ties of marriage,
blood, or adoption, constituting a single household and interacting with each other in their respective social positions,
usually those of spouses, parents, children, and siblings.”2 In terms of legal definition the, Title V, Chapter 1 of the Family
Code of the Philippines define a Filipino family as “being the foundation of the nation, is a basic social institution which
public policy cherishes and protects. Consequently, family relations are governed by law and no custom, practice or
agreement destructive of the family shall be recognized or given effect.”3 These are the traditional definitions. With the
social and cultural changes in the past decade on the other hand, the concept of ‘family’ has expanded to include single
parents, separated families, extended families, unrelated individuals living cooperatively, and same sex couples, among
others.
Capturing the evolving definition and conceptual beliefs of what constitute a family has been attempted by family
medicine practitioners. This is their response to provide a better role in the health care system. Family practitioners are
supposed to provide continuing, comprehensive health care for the individual and family, integrating both the clinical
and behavioral skills to provide better health care. In this issue we included a qualitative study by Silva and Laviña that
attempted to define the Filipino family. The article focused on the psychosocial as well as the health aspects of the definition.
In terms of the psychosocial dimension, the article emphasized that the relationship between the husband and wife is the
foundation of “wellness” in a family. Financial and physical health was also pointed out as equally important.
This definition is important if family physicians are serious in defining the specialty of family medicine and performing
their role in the Philippine health system. Illness in the family usually bring stress and may disturb the relationship
equilibrium. Such disturbance may affect the family’s capacity to cope with the illness and might actually contribute to
failure of treatment. To maintain the relationship equilibrium, family physicians must be adept in counseling and other
forms of behavioral intervention to strengthen family relationship. They should have extra time with their patients in the
provision of these counseling services as this usually needs extra time and effort from both the physician and family. This
will facilitate the family in coping with the illness.
Financial capacity was also revealed to be important in the article. The Philippine health system is a predominantly
fee for service system. Private fund sources account for roughly more than 65.8% of the total national health expenditure.4
Illness in the family will usually result to financial strain and will also contribute to the stress and disequilibrium in the
family. In this situation, family physicians must also develop equitable payment schemes for their patients.
Addressing the psychosocial family relationship and adapting to their financial capacity will lead to the last element
of the definition of a family wellness i.e. physical health. In this third element, family medicine training programs have
strongly been focused. We may have to adjust to find the balance and maintain the equilibrium when there is an illness
in the family.

Noel L. Espallardo, MD, MSc, FPAFP

References
1. Webster Dictionary. Available at https://www.merriam-webster.com/dictionary/family. Visited Sept 23, 2018.
2. Encyclopaedia Britannica. Available at https://www.britannica.com/topic/family-kinship. Visited Sept 23, 2018.
3. Official Gazette. Available at http://www.officialgazette.gov.ph/1987/07/06/executive-order-no-209-s-1987/. Visited Sept 23, 2018.
4. Philippine Statistics Authority. Available at https://psa.gov.ph/pnha-press-release. Visited Sept 23, 2018.

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 105

 ORIGINAL RESEARCH

Structured Education on Weight Loss of Overweight and

Obese Clients Seen at the Northern Mindanao
Medical Center Department of Family and Community Medicine
Clinic from July 2015 to July 2016

Jessica Cagadas, MD

Background and Objective: Overweight and obesity increase health risks. Despite recommended guidelines on its control
and management, there remains no consensus on the best treatment.10 Establishing the effectiveness of a structured
education on weight loss among overweight and obese clients seen at the Northern Mindanao Medical Center Department
of Family and Community Medicine Clinic was therefore aimed in this study.
Methods: This two-arm prospective, open-label, randomized controlled trial evaluated 23 participants who were divided
into two groups. The intervention group received the usual physician’s advice coupled with individualized nutrition and
exercise counselling. The control group received only the usual physician’s advice. Analysis was focused on estimating the
size of the difference in predefined outcomes between the intervention groups.
Results: The participants who received the structured education lost weight with a mean difference in body mass index
(BMI) from baseline to follow-up of 0.41 kg/m2 (p=0.12). The participants who received the physician advice alone lost
weight with a mean difference in BMI from baseline to follow-up of 1.12 kg/m2 (p=0.19). The difference in the mean
change in the BMI of both control and intervention group was not significant (p=0.19).
Conclusion: The results of this study did not provide a significant outcome on the effectiveness of structured education
on weight loss among overweight and obese clients seen at the Northern Mindanao Medical Center Department of Family
and Community Medicine Clinic.

Keywords: Obese, overweight, structured education, weight loss, body mass index

Introduction
According to the World Health Organization report
in March 2013, overweight and obesity has gone high in
epidemic proportions around the world.1 Among adults
20 years and older, 1.4 billion were overweight. This is
comprised of over 200 million obese men and about 300
million obese women.1 Sixty five percent of the world’s
population live in countries where overweight and obesity
kills more people than underweight.1 In the Philippines,
5.7 million Filipino adults are either overweight or obese
based on the Food and Nutrition Research Institute Survey in

106 THE FILIPINO FAMILY PHYSICIAN

1993.2 This was shown to have increased from 26.6 percent
in 2008 to 31.1 percent in 2013 as reflected in the 8th
National Nutrition Survey (NNS) conducted by the Food and
Nutrition Research Institute of the Department of Science
and Technology (FNRI-DOST).3 Co-morbidities tend to occur
at lower body mass indices among Asians, which is why
overweight and obesity are of much clinical importance.4
Overweight and obesity increase health risks as reflected by
the top ten leading causes of mortality of the Philippines
in 2009, namely diseases of the heart (109.4 per 100,000
population), vascular system (71.0), malignant neoplasm
(51.8), and diabetes mellitus (24.2).5 Recommendations
and guidelines have been made regarding the control
and management of obesity but most researches focus on
diabetes mellitus type 2 with weight loss as a secondary
outcome. In a study done by Jones N, et al. subjects
preferred being given information regarding diet, physical
activity, behavioural strategies and the risks of obesity.6
Physician based education and counselling is considered
generally positively associated with self-reported
behaviour change in patients.7,8,9 However, these were
deemed insufficient as to the extent by which it can help
obese patients reach their goals.9 Despite recommended
guidelines on its control and management, there remains
no consensus on the best treatment.10 Several weight loss
programs and fad diets have been recommended but mostly
are available only to the economically advantaged groups.
Randomized trials and systematic reviews rarely report
impact across socioeconomic strata, and are most often
done in rich countries.11 Establishing the effectiveness of a
structured education on weight loss among overweight and
obese clients seen at the Northern Mindanao Medical Center
Department of Family and Community Medicine Clinic was
therefore aimed in this study.
Objectives
This study aimed to determine the effectiveness of
structured education on weight loss among overweight
and obese patients at the Department of Family and
Community Medicine Clinic.
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 107
Specifically, the study aimed to:
1. Describe the baseline socio-demographic variables of
study subjects.
2. Compare the socio-demographic variables of study
subjects.
3. Determine the level of success in terms of weight
reduction using the body mass index (BMI in kg/m2) as
the outcome measure.
Research Question
Among individuals, 18 to 60 years old, who are
overweight or obese, consulting at the Department
of Family and Community Medicine Clinic of Northern
Mindanao Medical Center from July 2015 to July 2016, what
is the effectiveness of a structured education versus usual
physician advice on weight loss using BMI (kg/m2), in a
randomized controlled trial?
Research Hypothesis
Structured education is an effective approach in
educating patients to induce weight reduction among
overweight and obese patients as compared to physician
advice alone as the previous gives exact instructions as to
correct food choices and food portions as well as correct
exercise type, frequency, intensity and duration.
Operational Definition
Structured education - organized written instructions
comprised of individualized daily food plan and
individualized exercise prescription
Usual physician advice - the passive giving of instructions
without the exact measurement of a certain diet and
exercise
 Methods
Design
The study was a two-arm prospective, open-label,
randomized controlled trial. A computer-generated
randomization method was used. (Figure 2)
Setting
The study was done at the Northern Mindanao Medical
Center Family and Community Medicine Clinic. Recruitment
was started in July 2015. After which, subjects who signed
the informed consent were randomized in September 2015.
Subjects started the study at different dates. The last subject
finished the follow-up in July 2016.
Population
Forty two (42) adult subjects diagnosed as overweight,
obese class 1 and obese class 2 at the NMMC-Department of
Family and Community Medicine Clinic were recruited and
23 of them fulfilled the following:
Inclusion criteria
• Adult men and women age 18-70 y.o.
• Not currently taking weight loss drugs
• Not currently on a weight loss program/ fad diet
Exclusion criteria
• No informed consent
• Pregnant or lactating
• Having a psychiatric disorder
• Having speech and/or hearing difficulty
• Unstable co-morbidities
Control Group
The control group received the usual physician advice
being done in a routine consultation. Subjects were given
108 THE FILIPINO FAMILY PHYSICIAN
information about their ideal body weight and body mass
index. After which, goal setting was done. For the purpose
of uniformity, the following physician advices were given by
only one provider:
• Slowly reduce food portions from the usual diet
• Preferred daily exercise of 30 minutes to one hour
duration excluding the usual household chores
• Five key elements of a healthy lifestyle (0-5-10-30-
150) lifted from Rakel’s Textbook of Family Medicine
* 0: No smoking
* 5: Consuming 5 servings of fruits or vegetables
each day
* 10: Ten minutes of relaxation, silence, or
meditation daily for stress reduction
* 30: Maintaining BMI less than 30 kg/m2 and
working to bring it down toward 18.5 kg/m2
* 150: Exercising for at least 150 minutes a week
(about 20 minutes daily), equivalent to at least
brisk walking.
Intervention Group
The intervention group also received the usual
physician advice being done in a routine consultation
with the addition of a referral to the NMMC-Nutrition and
Dietetics Department for nutrition counselling. Their daily
total caloric requirements (TCR) were computed based
on their level of activity and desirable body weight by
Tannhauser’s method. The TCRs were computed with an
energy deficit of 500 kcal/day to achieve an initial goal
loss of 10%. Subjects were given a food exchange list
and food guide preparations computed to their individual
daily total caloric requirements. Exercise prescription was
individualized using the following parameters:
• Mode: walking, jogging, walk-jog, dancing (e.g.
zumba), or bicycling
• Frequency: At least five times a week
• Duration: 30 minutes to one hour
• Intensity: low, using a target heart rate of 60-80% of
the individual maximum heart rate

Both groups were then instructed to keep a food

diary as well as an exercise diary. They agreed to come
for follow-up for at least two weeks apart for monitoring.
Pre-intervention BMI (kg/m2) using the Asia-Pacific
Classification of Overweight and Obesity was taken. On the
6th visit, BMI (kg/m2) was again measured.

Data Analysis

Sample Size

To detect a difference of 1.8 kg/m2, a previous

systematic review by RA Millstein in 2014 was used in
computing for the sample size. If the true difference in the
experimental and control means is 1.8 kg/m2, the study
of eight experimental subjects and eight control subjects
was able to reject the null hypothesis that the population
means of the experiment and control groups are equal,
with probability (power) of 0.8. The type 1 error probability
associated with this null hypothesis is 0.05.
Figure 2. Study design
Statistical Analysis

Baseline characteristics of the two groups were

compared. Analysis was focused on estimating the size
of the difference in predefined outcomes between the
intervention groups. Data are presented as means and
standard deviation. Analyses were performed using MS
Excel 2010. To compare the differences between the mean
BMI (kg/m2) at baseline and mean BMI (kg/m2) after the
treatment, the t-test was used. Categorical variables were
analyzed using chi-square (x2). Continuous variables were
analyzed using the Mann-Whitney U test. The p values were
reported as one-sided with the level of significance set
at p< 0.05. Intention to treat analysis was done. The last
available BMI (kg/m2) of the subjects who were randomized
but were not able to complete the study were used.
Results
Over the study period which ran from July 2015 to
July 2016, a total of 42 subjects were invited to participate
in the study. Twenty three fulfilled the criteria and were
subsequently randomized. The demographic characteristics
of the study population (Table 1) show that both the control
(Physician advice alone) and intervention (Physician advice
plus referral to the Nutrition and Dietetics Department
plus exercise prescription) group were similar. The mean
age in the control group was 36.63 years old comprising
of one male and ten females while the intervention group
was comprised of two males and ten females, with a mean

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 109

age of 36.41 years old and a p value of 0.311. Majority of
the participants were at college level (control- 63.63%,
intervention- 66.66%). The rest of the participants were
at high school level. Almost half of the participants in the
control group were either employed or unemployed.
Fifty percent of the participants in the intervention
group were self-employed. Majority of the participants for
both groups had incomes more than Php 2,000 per month.
There was a change in the BMI (kg/m2) of subjects from
the baseline and upon follow- up. In the control group, the
baseline mean BMI was 32.37 kg/m2, which went down to
31.24 kg/m2 in the follow-up period. This was also the same
with the intervention group, wherein the baseline mean
BMI was 30.37 kg/m2 and lowered down to 29.97 kg/m2
during the follow-up.
Taking into consideration the difference in the mean
BMIs for both groups, the control had a difference of 1.12
kg/m2 in contrast to the intervention group which had a
difference of 0.41 kg/m2. This was however not significant
with a p value of 0.19.
Discussion
This study was designed to test the effectiveness of a
structured education in weight loss among overweight and

Table 1. Demographic variables of study subjects.

Characteristics Physician advice alone Physician advice plus P value

N= 11 Structured diet and exercise
N=12

Age in years (mean, SD) 36.63 (±5.72) 36.41 (±7.36) 0.311230328**

Sex 0.589962*
Male 1 (9.0%) 2 (16.66%)
Female 10 (91.0%) 10 (83.33%)

Education 0.878854*
Elementary 0 (0%) 0 (0%)
High school 4 (36.36%) 4 (33.33%)
College 7 (63.63%) 8 (66.66%)

Employment 0.103491791*
Employed 5 (45.45%) 3 (25%)
Unemployed 5 (45.45%) 3 (25%)
Self-employed 1 (9.09%) 6 (50%)

Monthly household income 0.327607*

Below 500 0 (0%) 0 (0%)
P500- <P1,000 0 (0%) 0 (0%)
P1,000- < P1,500 0 (0%) 1 (8.33%)
P1,500- < P2,000 0 (0%) 0 (0%)
≥ P 2,000 11 (100%) 11 (91.66%)

* Chi-square
** Mann-Whitney

110 THE FILIPINO FAMILY PHYSICIAN

 Table 2. Change in body mass index (kg/m2) in subjects from baseline and after follow-up.

Baseline Treatment Change

Physican Physican pvalue Physican Physican pvalue Physican Physican pvalue

advice advice advice advice advice advice
alone plus alone plus alone plus
(+SD) Structured Structured Structured
diet diet diet
and and and
exercise exercise exercise

Mean BMI 32.37 30.37 0.12* 31.24 29.97 0.19* 1.12 0.41 0.19*
(kg/m2) (+4.14) (±3.76) (±2.85) (±4.18) (±2.22) (±1.55)

obese patients versus physician advice alone in a primary
care provider setting. It showed that participants who
received the structured education lost weight with a mean
difference in body mass index (BMI) from baseline to follow-
up of 0.41 kg/m2. This however, was not significant, owing
to a p value of 0.12. Likewise, patients who received the
physician advice alone lost weight with a mean difference
in BMI from baseline to follow-up of 1.12 kg/m2, with a
p value of 0.19. This was also not a significant change. The
difference in the mean change in the BMI of both control
and intervention group was not significant (p=0.19). The
said results showed that both control and intervention
demonstrated a successful weight reduction although
insignificant, which means that it did not show a reduction
that is 10% of initial body weight as recommended by
the WHO.12 The results are incomparable to that of several
intervention studies such as the SLiM programme by
Brown, et al., which showed ≥5% (p=0.0001) weight loss
within 6 months and the Louisiana Obese Subjects Study- a
primary care practice program.13 Such study, in addition to
structured patient education, employed a self-management
group approach. The formation of a support group provided
an impact on the motivational and behavioural aspects of
weight loss, which were not done in this study. The setting
of the clinical trial may have a direct effect on the results of
weight loss programs. This study was done in a clinic with
primary preventive approach wherein the main educator
was a primary care physician. It has been shown that
success rates are more evident among community-based
weight management programs. According to Graffagnino,
et al. a community-based medical wellness center can
effectively address a structured weight management
program emphasizing a significant correlation between
percentage weight loss and number of weekly counselling
sessions. A social and behavioural approach could have also
been done in this study.14
Conclusion/Recommendation
The results of this study do not provide a significant
outcome on the effectiveness of structured education
on weight loss among overweight and obese clients
seen at the Northern Mindanao Medical Center
Department of Family and Community Medicine Clinic.
A weight management program employing the social,
motivational and behavioural approach would be an
important consideration that would most probably
optimize weight reduction. It would also be good to look
into the adherence of subjects to the follow-ups as well
as the employment of treatment partners or support
groups to improve outcomes.

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 111

 References
1. World Health Organization. Obesity and overweight. Fact sheet no
311. (Online) 2013. Available: http://www.who.int/mediacentre/
factsheets/fs311/en/.
2. Yee, Grace A. Medical Nutrition Division. Food and Nutrition Research
Institute Digest. (Online) 2013. Available: http://www.fnri.dost.gov.
ph/index.php?option=content&task=view&id=714.
3. Philippine Information Agency. Feature: More Filipinos are
Overweight, Obese. (Online) November 2012. Available: http://r13.
pia.gov.ph/index.php?article=1701352265237
4. Ko GTC, Chan JCN, Cockram CS, et al. Prediction of hypertension,
diabetes, dyslipidaemia or albuminuria using simple anthropometric
indexes in Hong Kong Chinese. Int J Obes 1999; 23: 1136–42.
5. Republic of the Philippines Department of Health. Leading Causes of
Mortality 2009. (Online) 2013. Available: http://www.doh.gov.ph/
node/198.html.
6. Jones N, Furlanetto DLC, Jackson JA, Kinn S. An investigation of obese
adults’ views of the outcomes of dietary treatment. J Hum Nutr Diet
2007; 20(5): 486-94.
7. Loureiro ML, Nayga RM Jr. Obesity, weight loss, and physician’s advice.
Soc Sci Med 2006; 62(10): 2458-68.
8. Huang J, Yu H, Marin E, Brock S, Carden D, Davis T. Physicians’ weight
loss counseling in two public hospital primary care clinics. Acad Med
2004; 79(2): 156-61.
112 THE FILIPINO FAMILY PHYSICIAN
9. Stafford RS, Farhat JH, Misra B, Schoenfeld DA. National patterns of
physician activities related to obesity management. Arch Fam Med
2000; 9(7): 631-8.
10. Jagielski AC, Brown A, Gouldstone A, et al. Comparison of baseline
characteristics and weight loss outcomes in patients with extreme
obesity attending a weight management focused structured
educational group or a specialist community weight management
service. Endocr Rev 34 (03_MeetingAbstracts): MON-705.
11. 10/90 Gap. The Global Forum. http://www.globalforumhealth.org/
about/1090-gap/
12. Bischoff SC, et al. Multicenter evaluation of an interdisciplinary 52-
week weight loss program for obesity with regard to body weight,
comorbidities and quality of life-a prospective study. Int J Obesity
2012; 36: 614-24.
13. Brown, et al. Description and preliminary results from a structured
specialist behavioural weight management group intervention:
Specialist Lifestyle Management (SLiM) programme. BMJ Open 2015;
5:e007217
14. Graffagnino, et al. Effect of a community-based weight management
program on weight loss and cardiovascular disease risk factors.
Obesity 2006; 14: 280-8.
 ORIGINAL RESEARCH

Prevalence of Low Back Pain Among Employees of Eastern

Visayas Regional Medical Center (EVRMC)
Tacloban City, Leyte*

Ma. Daphne Rachelle R. Delgado, MD and Mae Christine Agatha Bodo-Bernabe, MD, FPAFP

Introduction: Occupational low back pain has been prevalent in many work places everywhere. The authors have
encountered employees from all sorts of job coming in for a health consultation relative to low back pain, including those
who work at Eastern Visayas Regional Medical Center (EVRMC).
Objectives: This study aimed to assess the prevalence of low back pain among the employees of Eastern Visayas Regional
Medical Center (EVRMC). The study specifically aimed to determine the profile of the employees, their low back pain
experience, and the physical, psychological, and ergonomic factors which may be contributing to low back pain.
Methods: This was a cross-sectional study among employees of EVRMC. A questionnaire was distributed to 1002 employees,
from which 914 was returned, yielding a return rate of 91%. Eight hundred six (806) respondents were considered for the
study after excluding those who were pregnant and had history of trauma, and those whose questionnaires had missing
data. Under an alpha level of 0.05, associations between the employees’ profile and LBP were determined.
Results: Findings revealed that one hundred sixty seven out of the eight hundred six respondents (20.71%) had low
back pain. One hundred forty-seven (147) of them had moderate disability. Majority of the respondents were young
adults, aged 25-45 years old. Males and Females were affected equally. The most number of employees who were able to
participate in the study were from the administrative (n=288) and the nursing (n=262) divisions. Twenty-one percent
(21%) of the respondents had low back pain at the time of data gathering, and 51.49 % of them had ergonomic factors
mostly causing their back pain.
Conclusion: The most common factor causing low back pain among the employees was ergonomic in nature and it had
something to do with poor body mechanics. Awareness raising and giving of inputs through seminars and distribution
of educational materials and pamphlets on proper body mechanics was put forth as recommendation from the findings
of the study.

Keywords: low back pain, ergonomic factors, occupational, employee

_______________
* From the Department of Family and Community Medicine, Eastern Visayas Regional Medical Center, Tacloban City, Leyte

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 113

 Introduction
Low back pain (LBP) has been reported as the most
frequent cause of disability for individuals less than 45 years
old and the third leading cause of disability for those more
than 45 years old. This problem has a substantial impact
on individuals and their families, communities, health-
care systems and businesses. This includes pain, activity
limitations, participation restrictions, career burden, high
utilization of health-care resources and financial burden.
Worldwide, 37% of LBP are attributed to occupation.
Occupational exposures to ergonomic stressors represent
a substantial source of preventable back pain. Job
dissatisfaction, monotonous tasks, poor work relations,
lack of social support in the workplace, demands, stress
and perceived ability were associated with an increased
occurrence of low back pain. Job dissatisfaction has also
been shown to be associated with transition from acute to
chronic low back pain.1
The researcher has encountered employees from all
sorts of job coming in for a health consultation in relation to
low back pain, including those who work at Eastern Visayas
Regional Medical Center (EVRMC). This hospital is the
largest government hospital in Region VIII. It is a 450-bed,
level 3 hospital located in Tacloban City, Leyte. It provides
integrated and comprehensive multi-specialty health
care services for the people of Samar and Leyte, whose
population is at 4.5 million. The workload of the hospital
workers here can be enormous and overwhelming.
On this light, the researcher embarked on this study
to be able to primarily determine the number of cases
complaining of work-related low back pain and the factors
that trigger the pain. Results of this study may be able to
influence the employers and coordinators of EVRMC to help
reduce or modify the ergonomic factors at work that mostly
causes low back pain among the employees.
Objectives
This study aimed to determine the prevalence of
low back pain and disability among the employees
114 THE FILIPINO FAMILY PHYSICIAN
of Eastern Visayas Regional Medical Center, Tacloban
City.
Specifically, this study aimed to:
1. Identify the profile of the employees as to age, sex,
area of assignment and Body Mass Index (BMI).
2. Determine the prevalence of low back pain among
EVRMC employees.
3. Determine the physical, psychological and ergonomic
factors which contribute to low back pain among the
respondents.
4. Determine the number of employees who are at risk to
have low back disability.
Methods
Study Design
This study is a descriptive survey involving all the
EVRMC employees who were eligible to become part of
the study. The profile of the respondents as to age, sex,
weight, height, and body mass index and area of work was
determined alongside with the prevalence of low back pain
as an occupational problem with its severity as low back
disability scores were gathered. The researcher likewise
described the number of documented or reported cases of
low back pain among the EVRMC employees.
Subjects and Setting
The study involved a complete enumeration of the
1002 employees in the various work areas of Eastern
Visayas Regional Medical Center. Excluded in the study were
pregnant women employees and those who had a history of
trauma to the back.
Nine hundred fourteen (914) completed questionnaires
were returned, yielding a return rate of 91%. Eight hundred
six (806) respondents were considered for the study after
excluding those who were pregnant (10) and had history of
trauma (20), and those whose questionnaires had missing
data (78). Of the 806 respondents, 167 disclosed presence of
acute low back pain at the time of data gathering.
Two hundred eighty-eight (288) of the 806 were from
the Administrative Division, 134 were from the Allied
Services, 122 were from the Medical Division and 262 were
from the Nursing Division.
This study was conducted at Eastern Visayas Regional
Medical Center, Tacloban City, Leyte. The research was
conducted within 1 year.
Data Collection Tool
The study employed the use of a four-part
questionnaire. The first part of the questionnaire is designed
to collect the demographic data of the respondents as to
age, sex, weight, height (will be used for the computation
of the BMI) and area of assignment. The second part of
the questionnaire asked about the prevalence of low back
pain among the respondents, the duration of the pain and
its recurrence. This part is an Acute Low Back Pain Survey
Questionnaire by Linton and Halden (1996). The third part
of the questionnaire was the tool that extracted data as
to the physical, psychosocial and ergonomic factors in the
workplace present in the respondents’ life. This is based
on the the study of Feuerstein and his colleagues (2001)
on Working with Low Back Pain: Workplace and Individual
Psychosocial Determinants of Limited Duty and Lost Time
were included. The respondents were asked to note how
often the factors present in their life, with the use of
a four-point Likert Scale where 4 means always and 1,
never. Statements 1-3 pertain to the physical factors of
the respondents, 4-10 for psychosocial factors and 11-19
for ergonomic factors in the workplace that predispose the
respondent to develop low back pain.
The fourth part of the questionnaire were only filled
up by those who had disclosed a current history of low
back pain. This questionnaire is the standardized Revised
Oswestry Disability Index (also known as the Oswestry
Low Back Pain Disability Questionnaire). This test is
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 115
considered the gold standard of low back functional
outcome tools.
Outcome Measurement
The acute low back pain screening questionnaire were
scored according to the suggested scoring methods by the
author. Each question was scored differently, as follows:
1. For question 4, the number of pain sites were counted
and multiplied by 2
2. For questions 6, 7, 8, 9, 10, 12, 13, 14, 17, 18 and
19, the score was the number that has been ticked or
circled.
3. For questions 11, 15, 16, 20. 21, 22, 23 and 24 the
score was 10 minus the number that has been ticked or
circled.
4. Sum of all the scores were then computed.
If the computed sum is 105 or more, the respondent
is at risk for developing more persistent problems in the
future. When the respondent is at risk, he is prompted to
answer the next questionnaire in which the mean score
of the physical, psychological and ergonomic factors was
computed through item analysis. The answers pertaining
to the extent to which the factors were present were
aggregated by computing the mean. The obtained mean
scores were interpreted as being present to a certain extent,
as being present to a high extent if the obtained mean score
was more than the median score of 2.50 and present in a
low extent if the obtained mean score was below 2.49
The disability questionnaire was scored on a vertical
scale of 0-5. The total scores were added up and was
multiplied by 2. The sum was divided by the total number of
sections answered by the respondent. The quotient was then
finally multiplied by then which resulted to a percentage. A
score of 22% or more was considered significant activities
of daily living disability. Specifically, the answers were
categorized as follows:
 The obtained scores were interpreted as follows:
0-20% The patient can cope with most living activities.
minimal disability Usually no treatment is indicated apart from advice
on lifting, sitting and exercise.
21-40% The patient experiences more pain and difficulty with
moderate disability sitting, lifting and standing. Travel and social life are
more difficult and they may be disabled from work.
Personal care, sexual activity and sleeping are not
grossly affected and the patient can usually be managed
by conservative means.
41-60% Pain remains the main problem in this group but
severe disability activities of daily living are affected. These patients
require a detailed investigation.
61-80% Back pain impinges on all aspects of the patient’s life.
crippled Positive intervention is required.
81-100% These patients are either bed-bound or exaggerating
their symptoms.
Analysis
The research question on the profile (age, sex, BMI
and area of assignment), history of low back pain and
disability scores (minimal disability to crippled) were
presented in frequency and percentage distribution tables.
Mean scores for age and BMI were likewise computed. Data
pertaining to the contributing factors were subjected to an
item analysis for the 4-point Likert scale. Mean scores were
then determined and were ranked from the largest to the
smallest mean score.
This then reflected the factors that was present to
a high extent and a low extent among the employees.
The most common factors were also reflected using other
measures of central tendency like the mean.
Results
The Eastern Visayas Regional Medical Center (EVRMC)
has 1002 employees during the study period. Eight hundred
116 THE FILIPINO FAMILY PHYSICIAN
six of them were considered as respondents to this study.
Table 1 (last column) shows that 167 out of 806 (20.71%)
employees experienced low back pain at the time of data
gathering. Six hundred seventy of the respondents belong
to the young adult age group (<45 years old) and 55.09%
of them were female.
Only 36.10% of the respondents had a healthy body
mass index (BMI) while 14.64% were underweight and
18.86% and 15.39% were obese I and obese II, respectively.
Two hundred eighty-eight (35.73%) of the respondents
came from the administrative division while 32.51% were
nurses, 16.63% came from the allied services and 15.13%
were doctors.
Table 1 also shows that of the 167 respondents, LBP was
more prevalent among those who were less than 45 years
old (78.44%) and among females (51.49%). Low back pain
was also more prevalent among those with a healthy BMI
(40.12%) and among those working at the administrative
division (35.33%).
Table 2 reveals the possible factors causing low back
pain among the employees. Ergonomic factors were
identified to be present to a high extent among the
respondents. Four items under ergonomic exposure was
rated to be present to a high extent by a majority of the
respondents. Ergonomic factors included in the study are
lifting heavy materials, work that requires one to kneel or
squat, or seated most of the time, also repeated bending
of the back, carrying items with one hand and lifting
stuff quickly even if body is twisted. Most of the items
answered pertained to a low application of the principles
of body mechanics.
Table 3 shows that 147 out of the 167 with LBP at the
time of data gathering had moderate disability. Of the
147, there were 32 who scored high on developing a more
persistent disability in the future.
Discussion
The study revealed that 167 out of the 806 respondents
(20.71%) had low back pain. The problem was more
 Table 1. Socio-demographic profile and anthropometric measurement of employees at EVRMC with low back pain
(January 2017- December 2017)

With LBP Without LBP Grand Total

n=167, 20.71% n=639, 79.29%

Age in Years f % F % f %
<45 years old 131 78.44 539 84.35 670 83.12
45-54 old 31 18.56 91 14.24 122 15.13
>55 years old 5 3.00 9 1.41 14 1.75
Total 167 100.00 639 100.00 806 100.00

Gender
Male 81 48.51 281 77.63 362 44.91
Female 86 51.49 358 80.64 444 55.09
Total 167 100.00 639 79.3 806 100.00

BMI
Underweight 27 16.16 91 14.24 118 14.64
Healthy 67 40.12 224 35.05 291 36.10
At risk 29 17.37 92 14.40 121 15.01
Obese 1 23 13.77 129 20.19 152 18.86
Obese 2 21 12.58 103 16.12 124 15.39
Total 167 100.00 639 100.00 806 100.00

Area of Work
Administrative 59 35.33 229 35.84 288 35.73
Allied 33 19.76 101 15.81 134 16.63
Medical 39 23.35 83 12.98 122 15.13
Nursing 36 21.56 226 35.37 262 32.51
Total 167 100.00 639 100.00 806 100.00

Table 2. Factors that contribute to low back pain among EVRMC employees (January 2017 – December 2017).

High Extent Low Extent

Physical Factors N % n %
1 Not getting enough exercise 440 54.6 366 45.4
2 Cigarette smoking 113 14.0 693 86.0
3 Not feeling good about health status 186 23.1 620 76.9

Psychological Factors
4 Being bothered by feelings of depression in the past week 271 33.6 535 66.4
5 Feeling tense or anxious in the past week 314 39.0 492 61.0
6 Having worries interfere with your daily life 331 41.1 475 58.9
7 Feeling that work situation is putting the respondent under too much stress 354 43.9 452 56.1
8 Not having enough people available for support in bad moments or in illness 272 33.7 534 66.3
9 Not being satisfied with job in terms of work routines, management, salary,
promotion possibilities and workmates 128 15.9 678 84.1
10 Feeling that job is heavy or monotonous 434 53.8 372 46.2

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 117

 High Extent Low Extent

Ergonomic Factors
11 Lifting materials that weigh more than 25 pounds 369 45.8 437 54.2
12 Lifting or handling bulky items 330 40.9 476 59.1
13 Work requiring that employee kneel or squat 240 29.8 566 70.2
14 Repeatedly bending back (e.g., forward, backward, to the side or twist)
in the course of work 401 49.8 405 50.2
15 Twisting body whenever lifting something 333 41.3 473 58.7
16 Lifting and/or carrying items with one hand 440 54.6 366 45.4
17 Lifting or moving components at work require that the hands are lower
than the knees. 412 51.1 394 48.9
18 Continually leaning forward when working 476 59.1 330 40.9
19 Work requires that employee is seated 508 63.0 298 37.0

Table 3. Prevalence of low back pain among EVRMC employees from January 2017- December 2017(n = 806).

Frequency Percent

With current low back pain 167 20.71

(n=806)

Disability Score for Employees with Current

LBP
Minimal disability 20 11.97 (n= 167)
Moderate disability 147 88.2
(n=167)
Total 167

Employees at risk for developing disability from lower back pain (LBP) 32 19.16 (n=167)

prevalent among the younger age group, among females,
and those with a BMI within the normal limits. The findings
of the present study is similar to a study investigating
the prevalence and factors associated with low back pain
among adults in Taiwan (Chou et al) found that among the
24,435 adults, 25.7% had reported low back pain within the
past 3 months. One of the factors associated with low back
pain included female gender (odds ratio (OR) = 1.67, 95%
confidence interval (CI) = 1.43-1.95).7
Veras dos Santos, et al. posit that certain causes of
lower back pain have a tendency to occur more often
in younger individuals versus older adults: Younger
adults (30 to 60 year old) are more likely to experience
back pain from the disc space itself (e.g. lumbar disc
herniation or degenerative disc disease) or from a back
muscle strain. 6
Findings from the study likewise reflect that there
were more respondents who had ideal body mass index
who experience LBP. It was once assumed that extra body
weight would stress the low back and lead to pain, however,
researchers have reported inconsistencies association
between body weight and back pain.13 Several studies have,
however, clearly shown that people with high BMI are more
prone to LBP. A meta- analysis including 33 studies showed
that obesity was associated with increased prevalence of
LBP in the past 12 months.14

118 THE FILIPINO FAMILY PHYSICIAN

 The most common factor proven to be associated
with low back pain as identified by the respondents is
an ergonomic. Occupational exposures to ergonomic
represent a substantial source of preventable back pain.
Job dissatisfaction, monotonous tasks, poor work relations,
lack of social support in the workplace, demands, stress
and perceived ability were associated with an increased
occurrence of low back pain. Job dissatisfaction has also
been shown to be associated with transition from acute to
chronic low back pain.1
Conclusion and Recommendation
The prevalence of low back pain among the employees
of Eastern Visayas Regional Medical Center is at 20.71% with
18.23% of the respondents manifesting signs of moderate
disability. Ergonomic factors, mostly pertaining to poor
body mechanics on lifting, bending and twisting, was the
one factor identified by the respondents to be present to a
high extent. Low back pain has been found to be prevalent
among those who belong to the younger age group (<45
years old), among females and those who have normal BMI
and mostly from the Administrative Division (35.33%).
It is highly recommended that interactive seminars be
conducted on the Principles of Body Mechanics. Educational
materials on the principles and application of the proper
body mechanics at work may also be distributed. Employees
who had LBP must be checked and examined thoroughly
by the Occupational Safety and Health Officer (OSH) in
Industrial and Employee Clinic for evaluation and treatment
or for proper referral to the Rehabilitation Medicine to
prevent further injury and disability.
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 119
References
1. Punnett L, Ustün AP, Nelson DI, Fingerhut MA, Leigh J, Tak S, Phillips
S. Estimating the global burden of low back pain attributable to
combined occupational exposures. Am J Ind Med 2013.
2. University of Queensland, School of Population Health, Herston Rd,
Herston, QLD 4006, Australia. d.hoy@uq.edu.au
3. Waddell G, Burton AK. Occupational health guidelines for the
management of low back pain at work: Evidence review. Occup Med
2001; 51 (2): 124-35. Oxford University Press. Great Britain
4. National Institute of Neurological Disorders. (2014 December). Back
Pain Fact Sheet. NINDS Publication No 15 (5161).
5. Helfenstein Jr. M, Goldenfum MA & Siena C. Occupational low back
pain. Revista da Associacao Medica Brasileira 2010; 56 (5): 583-9.
6. Veras dos Santos J, Gomes Júnior VF, Souza AS, Farias NS, Marques SS,
da Costa JM. Socio-demographic and physical- functional profile of
low back pain patients 2015.
7. Chou YC, Shih CC, Lin JG, Chen TL, Liao CC. Low back pain is prevalent
among Taiwanese adults and is associated with osteoporosis. J Rehab
Med 2013; 45 (1): 76-80. DOI: 10.2340/16501977-1070
8. Shiri R, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The
association between smoking and low back pain: a meta-analysis. Am
J Med 2009; 123(1): 87. e7-35. doi: 10.1016/j.amjmed.2009.05.028.
9. Thompson D Jr. Chronic pain and smoking. Everyday Health Media,
LLC. 2016
10. Simmonds MJ, Kumar S, Lechelt E. Psychological factors in disabling
low back pain: causes or consequences? Disab Rehab 2000; 18(4):
161-8.
11. Feyer AM, Herbisona P, Williamsonb AM, de Silvac I, Mandrykd J,
Hendried L. Helye MCG. The role of physical and psychological factors
in occupational low back pain: a prospective cohort study. Occup
Environ Med 2000; 57 (2):116-20.
12. Deardorff, William W. (2016). Stress-Related Back Pain. Spine.
13. Seaman D. Chiropractic and manual therapies. BioMed Central 2013;
21 (15).
14. Duthey B. Low back pain. Priority medicines for Europe and the world
“A Public Health Approach to Innovation” Update on 2004 Background
Paper. 2013
 ORIGINAL RESEARCH

Prevalence of Comorbid Anxiety and Depression Among DM

Type II Patients of OMMC Department of Family and Community
Medicine Using the Hospital Anxiety and Depression Scale –P*

Jamie Lee J. Legaspi MD

Background: Over the past decades, diabetic patients have more than doubled globally making it a significant public
health challenge. Many studies and trials show that patients with chronic illness such as diabetes are vulnerable to develop
anxiety and depression hence identification and treatment of both comorbid conditions should be promptly addressed.
Objectives: This study aimed to determine the prevalence of anxiety and depression among DM patients of Ospital ng
Maynila Medical Center Department of Family and Community Medicine.
Methods: Survey used HADS-P questionnaire which is a 14-item self-administered rating scale. A cut off score of > 8
either on the subscale of depression or anxiety was used to determine their respective prevalence.
Results: Data obtained show prevalence of Anxiety and Depression was, 46% and 1% respectively. It is also important
to note that the prevalence for borderline symptoms of anxiety and depression are 33 and 36% respectively. Identifying
the individual patients and notifying the physician in charge may help promote general well-being of these patients.

Keywords: anxiety, depression, diabetes mellitus II

Introduction cause of mortality in 2030. Its prevalence is increased

Diabetes mellitus (DM) type II, which is commonly
associated with a higher risk of vascular complications1,2
is rapidly increasing with an estimated prevalence of
171 million to 366 million from the year 2000 to 2030
respectively3 and is projected to be the seventh leading
_______________
* From the Department of Family and Community Medicine, Ospital ng
Maynila Medical Center (OMMC)
even in middle and low income countries. Generally,
the comorbidity of the depression is doubled in patients
with DM type II.4-6 This comorbidity appears to be highly
frequent,7-11 exists years after initial diagnosis7 and is
commonly ignored and untreated.12 This makes recognition
and treatment of comorbid depression in diabetic patients
clinically relevant as previous studies link depression with
poor compliance in medication leading to progression of the
disease and its complications.13-15 Patients with depression
are observed with a persistent loss of interest and feeling of
sadness that negatively impact life quality.16

120 THE FILIPINO FAMILY PHYSICIAN

 Recent data show that this trend increases at an
alarming rate wherein 80% of the total population in low
and middle-income countries is affected. Notwithstanding
also is the co-occurrence of DM type II to other similar forms
of depression such as anxiety and distress which frequently
coexist with diabetes17,18 to which extensive studies are
greatly lacking. Partly, maybe due to the failure of a more
specific definition and measurement of depression which
usually is diagnosed only through symptoms.13 Underlying
mechanisms to fully elucidate or at least establish a
basic relationship of DM type II and depression is of great
interest19 not only due to its known economic impact on
patient’s health20 but also on possible grave implications
such as suicidal behavior.21
Taken together, depression and anxiety may have a high
impact on diabetic patients affecting their life quality due
to disease progression.22 A study done by Tan, et al.23 noted
the prevalence of anxiety and depression among Philippine
COPD patients however; studies on diabetic Filipino patients
in relation with depression is non-existent as of date. In this
paper, the authors looked on the prevalence of anxiety and
depression to diabetes in Ospital ng Maynila Medical Center
(Manila, PH) using the HADS-P Questionnaire.
Methods
Study Design, Selection & Criteria
Criteria included all outpatients from the DM clinic of the
Ospital of Maynila (Department of Family and Community
Medicine). Patients diagnosed with Diabetes type II with
FBS or HBA1c in the past three months were included while
patients who were pregnant, previously diagnosed to have
diabetes mellitus type I, anxiety or depression and had been
with any anti-anxiety or any anti- depressant medications
were excluded. Purposive sampling was done to identify
patients enrolled in this research.
The patients were asked to sign the informed consent
after full explanation of this study. The consent signing,
interview and giving of questionnaire were conducted by
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 121
the principal investigator or one of the study coordinators.
Patients who gave consent and those who have met all
of the inclusion criteria and none of the exclusion criteria
were given a questionnaire (English or Filipino, whichever is
preferred) to answer. Additionally, socio-demographic data
were obtained including the age, sex, civil and employment
status. The clinical profile of the respondents was also
obtained. The informed consent and the questionnaires
were read to patients with reading difficulty due to
ophthalmologic problems. All data obtained from Ospital
ng Maynila Medical Center Family Medicine outpatient
patients were treated with full and strict confidentiality
only for the purpose of this research.
Diagnosis of Diabetes Mellitus
Type 2 diabetes mellitus consists of an array of
dysfunctions characterized by hyperglycemia and resulting
from the combination of resistance to insulin action,
inadequate insulin secretion, and excessive or inappropriate
glucagon secretion. 24
The American Diabetes Association (ADA) criteria for
the diagnosis of diabetes are any of the following:
A hemoglobin A1c (HbA1c) level of 6.5% or higher; the test
should be performed in a laboratory using a method that is
certified by the National Glycohemoglobin Standardization
Program (NGSP) and standardized or traceable to the
Diabetes Control and Complications Trial (DCCT) reference
assay, or
A fasting plasma glucose (FPG) level of 126 mg/dL (7
mmol/L) or higher; fasting is defined as no caloric intake for
at least 8 hours, or
A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or
higher during a 75-g oral glucose tolerance test (OGTT), or
A random plasma glucose of 200 mg/dL (11.1 mmol/L) or
higher in a patient with classic symptoms of hyperglycemia
(ie, polyuria, polydipsia, polyphagia, weight loss) or
hyperglycemic crisis
Hospital Anxiety and Depression Scale (HADS)
The Hospital Anxiety and Depression Scale (HADS)
was developed by Zigmoid and Snaith in 1983 25 and was
used in this study. The English and Filipino translations
of HADS (HADS & HADS-P) were utilized in this study. In
1990, Pfizer Philippines carried out the HADS translation
into Filipino and was utilized with permission. The
HADS-P validation among Filipino patients was done by
de Guzman, wherein permission was likewise obtained.
According to her study, the optimal cut off score for the
HADS or HADS-P is a score of 11 with a sensitivity of 75%,
specificity of 70% and PPV of 75%. 35 HADS was developed
to identify probable anxiety disorders and depression
among patients in non-psychiatric acute care hospitals.
HADS is specially used to avoid false positives such as
from patients with somatic diseases 26,27 which was done
by excluding questions regarding headache, insomnia,
fatigue, eating disorders and unemployment. It measures
symptoms level from a 10-day duration.
HADS includes 14 items (sentence-questions) which
can be answered in four grades on a Likert scale. These 14
items are divided into two subscales; namely, anxiety and
depression. Each item scored on a 4-point scale of 0 to 3.
Total sum is 21 for each scale. A score below 8 indicates
absence of depression and anxiety symptoms; however, a
score beyond it indicates otherwise. Coordination with the
patients’ attending physicians was done with regards to
the results of the questionnaire and for proper referral to
a psychiatrist if anxiety and/or depression were noted. The
Hospital Anxiety and Depression Scale-Pilipino Translation
(HADS-P) is shown in the Appendix.
Statistical Analyses
Sample size was selected via the Raosoft.com online
sample size calculator tool <www.raosoft.com/samplesize.
122 THE FILIPINO FAMILY PHYSICIAN
html>. Confidence interval was set at 95% with 5% margin
of error. Recommended sample size was 98.
Results
Demographic Data
The study gathered 96 participants from the Diabetes
Clinic of the Department of Family Medicine Ospital ng
Maynila Medical Center. The computed mean age was 64
indicating that more than half of the sample size belongs
to the advanced age or geriatric group. A similar study by
Masmoudi, et al. shows a mean age of 66.8 years old.30
The ADA reported that rates of diabetes remain high in
the elderly population, impacting 25% of patients above
65 years old. International studies also show that onset of
diabetes increases as the age increases. According to the
CDC, from 1997 to 2011, the average age at which a person
was diagnosed with diabetes in the United States was
largely the same, at around 54 years old.32
Majority (72%) of the respondents were women and
more than half (62%) were married. In terms of employment
status of the respondents only 22% were employed. This
could probably be explained because more than half of the
respondents were from the geriatric group and there was
female predominance among the respondents. According to
the Labor Force Participation Rate in the Philippines, female
employment was lower estimated at 14.8 million compared
to 22.9 million males. Also,a portion of female subjects
were housewives.
The top 3 comorbid conditions identified are
Hypertension which was present in 65% of the respondents
followed by peripheral neuropathy (58%) and chronic kidney
disease (26%). One study shows that hypertension alone
shows evidence of insulin resistance and that up to 75%
of diabetic patients have hypertension. Both diseases are
commonly intertwined conditions with significant overlap
in underlying risk factors.28 In a population-based study,
22% of the diabetic patients had peripheral neuropathy
which is the most common diabetic neuropathy.29 In one
cross sectional study of patients, the prevalence of CKD in
patients with T2DM was 53%.31
The prevalence of Anxiety and Depression was, 46%
and 1% respectively. The average score of anxiety was 7.70
± 3.32. The average score of depression was 5.25 ± 2.76. It
is also important to note that the prevalence for borderline
symptoms of anxiety and depression was 33 and 36%
respectively.
Table 1. Sociodemographic profile of the study population.
Diabetic Patients
(n=96)
Age Mean (SD) 64.45+10.35
Sex
Female 69 (71.88)
Male 27 (28.12)
Civil Status and increased health-care utilization.34
Single 15 (15.63)
Married 53 (55.21)
Widowed/Separated 21 (21.88)
Employment Status
Employed 21 (21.88)
Unemployed 75 (78.13)
Hypertension 62 (64.58)
Cardiovascular Disease 20 (20.83)
Chronic Kidney Disease 25 (26.04)
Cancer 2 (2.08)
Peripheral Neuropathy 56 (58.33)
No comorbidities 16 (16.67)
Table 2. HADS- P Results of the study population.
Diabetic Patients
(n=96)
HADS-P for Anxiety among individuals with diabetes relative to those without.39
Normal (0-7) 44 (45.83)
Suggestive (8-10) 32 (33.33)
Probable(>11) 20 (20.83)
HADS-P for Depression symptoms of anxiety and depression was 33% and 36%
Normal (0-7) 70 (72.92)
Suggestive (8-10) 25 (26.04)
Probable (>11) 1 (1.04)
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 123
Discussion
The World Health Organization showed that the
prevalence rate of depression worldwide ranged from 2.6
percent to 29.5 percent. In another survey conducted by
Perlas, Tronco et al in the Philippines, about 5.3 percent of
the subjects were suffering from depression.33
A similar study conducted in the province of Rizal
using the Geriatric Depression Scale (Short Form) showed
a 6.6-percent rate of depression. It is considerable to
note that 26.5% of the population has scores suggestive
of depression. Borderline diagnosis of depression gives
physicians and health care workers a chance to have early
intervention and prevent further progression of the disease.
It is also very important to do prompt medical treatment
and psychosocial support to patients with both diabetes and
comorbid depression because both have been found to be
associated with poor disease prognosis, longer recuperation
According to the World Health Organization (WHO),
depression is associated with negative health outcomes
accounting for approximately 12% total years lived with
disability. In their studies in 2000, it was noted that
depressive disorders are higher in women than in men and
that globally, depressive disorders are the fourth leading
cause of disease burden in women and seventh leading
cause in men.37
In another recent study by the WHO, depression is
ranked as the single largest contributor to global disability
(7.5% of all years lived with disability in 2015) while
anxiety disorders are ranked 6th (3.4%). Depression is also
the major contributor to death from suicide approximately
800 000 per year.38 Other epidemiological studies correlate
that the risk of mood and anxiety disorders was higher
The data obtained in this study show the prevalence of
anxiety and depression was 46% and 1% respectively. It is
also important to note that the prevalence for borderline
respectively. Studies across the globe showed that the
geriatric and chronically-ill patients are vulnerable to
develop anxiety and depression that can greatly affect
their general health and well being. Identification of these
comorbid psychiatric symptoms or disorders should be part
of a holistic approach in disease management.
Conclusions and Recommendations
As with any self-administered questionnaire, caution
must be observed regarding the patient’s literacy and
ability to read. It should also be remembered that the
gold standard for a definitive diagnosis of any psychiatric
illness is still a structured clinical interview based on DSM
criteria.
The researcher suggests that prospective studies
be done to follow up patients overtime and determine
the association of anxiety and/or depression with
adverse disease outcomes. Identification of both overt
and subclinical anxiety and depression should prompt
psychiatric referral. Further analytical studies may compare
psychiatric and medical intervention outcomes in patients
identified with subclinical and overt depression.
Psychiatric comorbidities often receive less focus in
patients with chronic medical illnesses. Further psychiatric
and medical treatment should be offered to these patients
in order to achieve better health outcomes.
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23. Tan SK, Benedicto J and Santiaguel J. Determinants of anxiety
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7176.2011.00434.x.
29. Davies, et al. The prevalence, severity, and impact of painful diabetic
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 FAMILY AND COMMUNITY HEALTH

The Filipino Well Family: A Qualitative Study Among

Selected Families Residing in Mandaluyong City*

Alvin B. Silva, MD and Shiela Marie S. Laviña, MD, MsCM

Background: The Filipino family has always been described to have solid household, innate close family ties and high
regard to interpersonal relationships. However, there has been paucity of local studies regarding Filipino families and
how specifically do Filipinos see, define and perceive a family unit in general.
Objective: To explore Filipino family’s concepts and ideas of what qualities represent and define a well family.
Method: The study was qualitative in design with mixed data collection methods: 18 interviews, 10 Focus Group Discussions,
and a literature review.
Results: Caring parents, unconditional love, able to maintain a good relationship between family members, constant
presence for loved ones and capacity to forgive were reflected as important characteristics of a well Filipino family. Love
and respect are considered to be the foundations and faith in God as an important component of a family. However,
the wellness of the family begins with husband-wife relationship and that a strong and happy marital relationship will
provide mutual support, encouragement and understanding. Likewise, financial capability combined with a commitment
to provide for the family’s future was a quality believed to bind the family together. Physical well-being and the absence
of diseases were also part of family wellness.
Conclusion: The nine qualities of a well Filipino family include loving, affectionate, responsible family members; spiritually
healthy; has the capacity to provide; having strong husband-wife relationship; effective parents; has a system of open
communication within the family; united with flexible family structure; spends time together; and physically healthy
with good community life.

Keywords: Filipino, well family, qualities

Introduction
The Filipino family has always been described to be a
solid household because of its inherent ability to face up
_______________
* From the Department of Family Medicine, Philippine General Hospital,
University of the Philippines Manila
against various challenges. Known for its innate close family
ties, Filipino families are also renowned to cherish family
name, put high regard to interpersonal relationships and
religion. Families are part of the big definition of happiness
among Filipinos as the unit remain to be the main support
of each member in times of financial, personal or health
problems.
There has been paucity of local studies regarding
how Filipino families see, define and perceive a family

126 THE FILIPINO FAMILY PHYSICIAN

unit in general. Available literature from other countries
had used descriptive words such as strong, resilient
or successful to define the well-family as a unit. De
Frain, Stinnett and Olson have shown that regardless of
cultural variances, strong families would share six major
qualities: commitment to the family, appreciation/
affection for each other, positive communication
patterns, enjoyable time together, a sense of spiritual
wellbeing/connection, and the ability to manage stress
and crisis. 1 On the other hand, YooYoung–Ju described
nine factors of a strong family: respect, commitment,
appreciation/affection, positive communication, sharing
values and goals, role performance, ability to solve
problems, economic stability and connectedness with
social system. 2
Resiliency was used by Walsh in 2002 to describe
the ability of the family to withstand and recover from
disruptive life challenges. Key processes identified
for family resiliency included making sense of
adversity, positive outlook, spiritual nourishment,
flexibility, family connectedness, ability to mobilize
social-economic resources, open communication, and
collaborative problem-solving. 3 A successful family was
likewise described by the US Department of Health as
“adaptable and able to deal with crises in a constructive
manner” but “not necessarily families that are trouble-
free.” 8
In the context of biopsychosocial approach in the
field of family medicine, the term “well family” would
be more encompassing and appropriate to use when
compared to strong, resilient or successful families used
in other international studies. The concept of wellness
addresses good quality of life, healthy relationships
among family members and the community. Family
wellness therefore pertains to the total well-being of
the family in all aspects of living. But in what manner
does adult Filipinos define and perceived a “well
family”? Hence, this study explored the Filipino family’s
concepts of what qualities constitute and define a well
family.
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 127
Methods
Study Design
The study was qualitative in design with mixed data
collection methods including focus group discussions, semi-
structured interviews and systematic review of available
literature. The research proposal was approved by an
Institutional Review Board prior to implementation.
Study Sites
Study sites were four urban barangays namely
Plainview, Mauway, Barangka Drive and Addition Hills of
Mandaluyong City, Philippines. Barangay permission to
conduct the study was sought prior to actual recruitment
and implementation of the study.
Study Participants
Adult members of Filipino families aged 18 years
old and above who are residing in Mandaluyong City,
Philippines at the time of data collection were included.
Families with members who are mentally incapacitated/
impaired or with members who were living overseas were
excluded. Likewise, individuals belonging to families with
pre-determined sensitive issues and were unable to attend
FGDs were also excluded.
Data Collection Process
Focus Group Discussion and Semi-structured Interviews
Guide question for the focus group discussions (10)
and interviews (18) were developed based on the study
objective. Sessions were started with an open ended
question relating to the qualities of the well Filipino family.
A well family had been operationally defined based on
literature review as strong or resilient. Responses to the
open-ended query were then followed by probe questions
in order to clarify and review answers of participants.
 All interviews and focus group discussions were
facilitated by the investigator using the local language
(Pilipino). Sessions were documented thru digital
audiotapes and subsequently transcribed verbatim.
Systematic Review of the Literature
Literature review was done using systematic database
searches of MEDLINE, Embase, Herdin, and libraries of
Ateneo (http://rizal.lib.admu.edu.ph/), University of the
Philippines Diliman (http://www.mainlib.upd.edu.ph/),
Dela Salle University (http://www.dlsu.edu.ph/library/)
Philippine elib (http://www.elib.gov.ph/bsearch.php),
American Academy of Family Physician (http://www.aafp.
org/online/en/home.html), Philippine Academy of Family
Physician (http://www.thepafp.org/), Philippine Journal
Online (http://www.philjol.info/philjol/index.php),
Philippine E-Journal (http://ejournals.ph/), Australian
Institute of Family Studies (http://www.aifs.gov.au),
Family and Relationship Services Australia (http://frsa.org.
au) and various journals about family issues.
The following keywords were utilized in the database
search: Family, Filipino Family, Well, Qualities, Perception/s,
Definition/s, Strong, Resilient and Successful. Grey
literature searching among the various family institutions
was likewise done.
Data Analysis
Transcripts of the interviews and focus groups were
analyzed using content analysis. Three independent persons
were tasked to identify key concepts from the transcripts.
Related concepts were then grouped into specific categories
describing qualities of a well Filipino Family. Themes from
responses were summarized using traditional narrative
method as how the investigators analyzed and understood
the phrases and responses of the selected families.
There were no local articles identified from the
literature review. Articles from international publications
identified were reviewed to identify concepts used to
generate main themes.
128 THE FILIPINO FAMILY PHYSICIAN
Results
A Well Family is composed of Loving, Affectionate and
Responsible Family Members
Caring parents, unconditional love, able to maintain
a good relationship between family members, constant
presence for loved ones and capacity to forgive were
reflected as important characteristics. Love and respect
were considered to be the foundations of a well family
with support and presence in times of crisis as a way of
expressing love and affection.
A loving family helped strengthen emotional ties
between family members and the expressions of affections
include caring, display of concern, interest, and willingness
to do things for each other. Love, even when it demanded
sacrifice, should not be withheld or withdrawn. It also
meant assuring that all family members felt a sense of
belongingness and well-being. As such, the expression and
manifestation of these feelings will bind the family together.
Loving parents were signs of parental care as support
rendered to everyone in the family should be founded on
love, respect and affection. Children who were drawn into
illicit drug use and other vices were thought to grow up in
families where these foundations were lacking.
Family members must also be friends so each can
be comfortable to share problems, be understood and
accepted.
You are siblings . . . yet like friends . . .
- 39 years old/male
. . . so that you will be able to share all your problems
even sensitive ones to your parents and to your siblings. .
- 18 years old/female
. . . in my experience a well family rests on the wife/mother.
– 55years old /female
The role of the wife/mother was highlighted in
keeping the family intact specially in times of difficulties
and trials when other members were not doing as was
expected. Supportive families understood the need to
help each other and to look out for members thus further
promoting a setting of openness, support, encouragement
and reassurance. Many believed that strong families were
the ones who can freely call for help and also be able to
receive such needed help. Well families were described
as supportive, responsible, with a firm commitment to
family roles and had exercised fairness in distribution of
duties.
Likewise, respect for parents and older siblings was
equally important. Parents believed that children should
not be humiliated in front of friends. Often, this event was
believed to be linked to having rebellious children.
A Well Filipino Family Should be Spiritually Healthy
Faith in God was an important component of a well
family. Spirituality was described as a cohesive factor and
faith promote a stable family structure and function. A
prayerful family who entrusted difficulties to God conveyed
hope, strength and a sense of contentment in life. It was by
having a right relationship with God that all things about
the family life fall in its proper place.
My faith in the Lord is the only thing which sustained
our relationship all throughout our lives.
- 55 years old/female.
Having faith in God brought good character,
good character brought good relationship amongst us.
- 30 years old/ male.
Material possession is not the only factor which makes a
family strong.
Relationship with God is also included.
- 65 years old/ female.
Faith in God was given priority in family life because
Filipinos believe that the neglect of faith can lead into
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 129
serious consequences. It was faith that provide strength to
overcome weaknesses and obstacles towards having a well
family. Hence, faith in God was and must be the centrepiece
of every Filipino family.
Family should only be second priority in your life.
Faith in God should be put first. My faith in God is my first
priority.
I need to put God first before my family in order to
have a strong foundation and a strong relationship among
family members
. - 55 years old/female.
Members of the Filipino families interviewed had
described spiritual well-being as having a cohesive, a
kind faith or belief and a relationship of acceptance and
guidance from God. The connection with God was important
in preserving good ties within the family. For most,
spirituality started with the parents teaching the children
how to pray and fostering a common faith.
Not only material things, we also need to have a relationship
with God to make our family relationship well.
-51 years old/Male.
A Well Filipino Family has the Capacity to Provide
Financial capacity combined with a commitment to
provide for the family’s future was a quality believed to
clamp the family together. The responsibility had been
delegated to the paternal head of the family but some think
it was a shared responsibility. Parents were considered
responsible if both were working hard to find a steady
employment and secure financial stability.
The capability to provide adequate food, education and
other basic needs for members was part of being a well
family. It was thought of as a manner to prevent potential
problems and gave a sense of happiness-contentment
among family members. Education was considered
necessary and parents must do all they can to send children
to school.
. . . so as to feed the children well and be able
to send them to school . . ..
- 51years old/Male
Financial support by parents can continue to extend
to the children and their own families as long as nuclear
parents were still able to provide.
As long as the parents are able to provide their
(children) needs
. . . they will be together as a family.
– 40 years old/male
. . . the family is destroyed because they do not
have any means of living . . .
- 30 years old/male
A Well Filipino Family Displays a Strong Husband and Wife
Relationship
The wellness of the family had been described to
begin with the husband and wife relationship. A strong
and happy marital relationship was assumed to provide
mutual support, encouragement and understanding.
Some members had expressed that the quality of marital
relationship affected the kind of family they have because
the children saw how happy or dysfunctional their parents
were.
Some parents believed arguments in front of
the children should be avoided because with positive
associations, the children feel happy and inspired to live
well.
The kind of husband and wife relationship determines
what kind of family they will have.
Their relationship should be first and foremost that of a
happy one...
– 30 years old/male
130 THE FILIPINO FAMILY PHYSICIAN
Trust was mentioned as an important element in
husband-wife relationship because it kept the family
together and avert marital arguments. Minor disagreements
must be resolved without delay by exerting patience and
understanding. Other marital characteristics considered
to be essential include a give-and-take relationship,
faithfulness, fear of God, open communication and mutual
respect. With these qualities, families would learn to accept
and understand each other’s weaknesses and shortcomings.
. . . Trust is central in a husband and wife relationship.
Without trust, their relationship will not last despite
the love toward each other.
– 32 years old/female
Avoid entertaining negative thoughts . . .
For example you are far from each other,
think of what is positive about your partner,
do not think about things which can be stressful,
burdensome . . .
– 33 years old/female
A Well Filipino Family is Composed of Effective Parents
Parents were considered to be the major source
of strength in the family. Effective parenting meant
responsibility, provision of sound guidance and good
example as a way of life when children were growing
up. Parents should be able to show equal care, love and
attention to all children without any preference. It also
involved a concrete style of discipline, nurturing, adequate
attention and sensitivity on the behavior and unspoken
needs of the children.
. . . the children should be raised appropriately and proper
guidance provided to them, lest problems may arise.
– 66 years old/male
Provision of all-encompassing parental guidance was
perceived to be of greater importance than the ability to
provide financially. For the children, a good measure of
effective parenting was how the parents were able to raise
children.
Parents should set the examples to their children.
– 18 years old/male
Adolescents sought a friendly relationship with the
parents including the ability to share problems and to talk
freely about joys, concerns and plans. A reasonable sense of
freedom was a felt need that must be provided.
Don’t be too strict if they want to attend parties, allow them.
But always give them advice.
Give them words to ponder and guide them.
– 60 years old/female
A Well Filipino Family has a System of Open Communication
A well family should be able to provide a venue for
open communication to its members to promote a choice to
freely express feelings, dreams, aspirations and difficulties.
A family member’s worries were considered a concern of
the whole family and therefore was deemed a right of each
member to be informed. A family decision was and should
be a collective decision.
. . . You can open up your problems .You can tell what
you like and don’t like to your family . . . and also all your
plans in life.
- 35 years old/male
Open communication among family members was
believed to avert the feeling of aloneness in facing
difficulties and help strengthen efforts towards finding a
solution. Communication should be positive, honest and
involvement of every family member was vital. Avoidance
of unpleasant words that were meant to demean or ignore
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 131
were encouraged so each member can speak and express
feelings. Every member must be heard because an open
communication would increase family togetherness.
If you will not talk about it, it will lead to discord,
and you will end having chaotic family, then broken.
– 45 years old/male
Two-way communication between parents and children
was also believed to encourage sharing of problems, dreams
and love interests. Children felt that they should be asked
about preferences and if choices seem inappropriate or
risky, it can be discussed and explained. Involvement in
family matters and problem-solving was supposed to help
youth experience and learn.
. . .it is not appropriate and beneficial to keep on imposing
upon our children.
Growing up, they start to form their own world.
– 48 years old/female
A Well Family is United with a Flexible Family Structure
A unified family was described as having similar goals
and sharing comparable perspectives in life. When faced
with struggles and difficulties, Filipino families regarded it
as an opportunity for cohesiveness and togetherness. Being
united was regarded as an important coping mechanism
against family crises.
. . . being together as a family . . .
against difficulties . . . to strengthen the family.
– 66 years old/male
The young members of the family felt that it was
important to recognize their share and role in establishing a
well family. The need to be heard and allowed to participate
in family decision making and problem solving was clearly
stated. Flexibility was an essential part of family life.
 . . . Except when the problem is too heavy for us. . .
but it is ok to share it to us nevertheless. . .
- 18 years old/female
More than finances and other things,
the most important thing in a family is being together. . .
-51 years old /male
Even when life seems to be difficult, you stay together for
each other, finding time to talk about the problems. . .
still together, as one family ….
– 45 years old/male.
For most Filipinos, the well family was the family who
stayed united in the midst of trials and difficulties. This was
often viewed as an important coping mechanism during
difficult times and thus becomes an opportunity to pull in
together. The family was able to cope because they were
together.
A Well Family Spends Time Together
Family time and family bonding were the most common
descriptions given by the respondents of a family who were
spending time together. Filipinos appreciate presence as
expressed as being there for each other and being together.
Economic capabilities and family orientations influence the
way each family spends time together.
We usually go to the beach, to Luneta Park, to PICC.
I walked them there.
Yes, we were together (as a family),
we brought a lot of foods.
– 80 years old/male
Bonding or family time means going to church
together, eating out, mall shopping, doing household
chores or simply watching favorite television programs at
home. For other families, it meant participation in cultural
or religious activities and celebrations. Going out together
was described as a method to relieve stress and pressures.
132 THE FILIPINO FAMILY PHYSICIAN
Family bonding time was also seen as an opportunity
to share each one’s problems and steer children away
from vices. It provided a good venue for children to share
problems, plans and concerns. Likewise, it promoted
mutual love as family members feel important and loved.
What I see in a well family is a time to spend for their
children and time for her husband and for his wife.
– 51 years old/male
A Well Family is Physically Healthy with a Good Community
Life
Physical well-being and the absence of diseases were
also regarded as part of family wellness. It meant being
able to choose the right kind of foods with less risks for the
development of disease. Physical well-being was considered
part of having a good quality of life which was an important
quality of a well Filipino family.
. . . the family is well when they are healthy. . .
– 65 years old/female
Families believed how the community viewed the
household was similarly important. It was not adequate to
have economic or educational status because community
life was measured by the relationships with neighbors and
participation in community affairs.
Even to their neighbors, they are able to maintain a
good relationship in order to become a well family.
– 45 years old/male
Good community image was believed to be established
by interactions and civic relations by avoiding becoming
a burden. Gossiping should be averted as this was the
common source of conflict in the neighborhood. There was a
shared opinion that the family should likewise be free from
the suspicions of misconduct and delinquencies.
 A family who showed acts of goodness was thought of
as being involved with the community.
. . . Interactions with other people . . .other people will be
able to say that this family is well because
they’re good to get along with.
– 30 years old/male
Discussion
The results of the study revealed nine qualities of a
well Filipino family: loving, affectionate, responsible family
members; spiritually healthy; has the capacity to provide;
having strong husband-wife relationship; effective parents;
has a system of open communication within the family;
united with flexible family structure; spends time together;
and physically healthy with good community life.
These qualities are similar to the results of studies
conducted in other countries. The terminologies used
to describe the different qualities were different but
the concepts were essentially similar. Unfortunately,
the literature review part of the study did not reveal any
available local studies about Filipino families at the time
of data collection. Hence, the recurring themes were
compared with studies abroad and the qualities narrated in
the study were based solely on transcripts of responses of
selected families during the interviews and FGDs.
The concept of Family wellness which includes good
quality of life, healthy relationships among family members
and its community was well represented in the ideas and
themes described by the respondents in the study. Loving
and affectionate family members as qualities were evident
since “Filipinos are by nature affectionate people”.4 Love,
respect and care within the family were also considered
strong factors in order to overcome crises. Furthermore,
as the Filipino families are very devout people, religion
plays a significant role in shaping the values and norms of
the society.4 As such, attendance to church services and
praying together are considered to be essential factors that
keep the family close and well.
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 133
Some Filipino parents still consider children reasoning
or disagreements as disrespectful. However, results
showed that young adults and even most parents believe
that a system of open communication must be allowed in
the family as this will allow free expression of feelings,
problems and dreams. Young adults expressed their need
for freedom of expression.
Common qualities were noted between the results and
the study of De Frain.1 All six major qualities of strong family
which included commitment to the family, appreciation/
affection for members, positive communication patterns,
pleasing time together, a sense of spiritual wellbeing/
connection, and the ability to successfully manage
stress were consistent with the themes narrated in the
result section.1 In addition, four extra qualities of a well
family were described: strong husband-wife relationship,
effective parenting, capacity to provide for family and
good community life. The qualities relating to husband-
wife relationship and effective parenting are attributed to
the fact that Filipino parents are “very strong role models
for their children.”5 The Filipino family likewise puts high
regard on maintaining a good community life as Filipinos
are “accustomed to having a supportive network of family
and friends, especially during difficult situations.”5 On the
other hand, the capacity to provide is especially related to
the ability of the parents to send the children to school as
Filipinos place a high regard on education. Filipinos believe
“that a college diploma is a passport to a better life, not only
for the graduate, but for the whole family.”6
The concepts of what represent a well family for an
average Filipino family is crucial information for family
physicians. The importance of family strengths and what
concepts define it has also been highlighted in several
studies.7 It has been pursued by researchers from a variety
of disciplines, including psychiatry, sociology, psychology,
and family marriage counselling.8 Results from these
studies are being used to develop community resources to
help the family with problems. It had also been incorporated
into nursing care resulting in an enhanced intervention
that has helped the families define visions and hopes for
the future instead of looking at what factors contribute to
family problems.10 By learning the different qualities of a
well family from perceptions of an average Filipino family
will help Family Medicine specialist formulate strategies
that can help support and nurture families in crisis.
Limitations of the Study
The study was conducted among middle class, Catholic
families residing in one urban city in Metro Manila. The
scope limits the ideas, concepts of Filipinos about a well
family as such themes can be affected by urbanization,
financial capabilities, spiritual beliefs, life cycle stage
and educational attainment. However, the ideas and
perceptions presented can be representative of an average
middle class Family living in an urban setting.
Conclusion
The nine qualities of a well Filipino family include
loving, affectionate, responsible family members;
spiritually healthy; has the capacity to provide; having
strong husband-wife relationship; effective parents; has a
system of open communication within the family; united
with flexible family structure; spends time together; and
physically healthy with good community life.
134 THE FILIPINO FAMILY PHYSICIAN
References
1. Defrain J, Asay SM. Strong Families Around the World: An Introduction
to the Family Strength Perspective. (n.d.) page 4.
2. Young Ju, Yoo Qualities of Korean family strengths. Kyunghee
University, Seoul, Korea. President, Institute of Korean Family
Strengths. (n.d)
3. Walsh FA. Family Resilience Framework. Innovative Practice
Applications. Family Relations 2002; 51(2): 130.
4. Del Villar CP. Correlation between compliance-gaining strategies and
high-power distance cultural orientation of Filipinos: Validation and
re-validation. Human Communication A Publication of the Pacific and
Asian Communication (n.d.) 16(3): 133-52.
5. Cruz GT, Laguna EP, Raymundo CM. Family influences on the lifestyle
of Filipino youth. Population Series East West Center. October 2001.
No. 108 - 8.
6. De Torres S. Understanding persons of Philippine origin: A primer for
rehabilitation service providers. 2002. University of the Philippines
College of Education (Special Education)
7. Arshat Z, Baharudin R. Correlates of family strength in Malaysia. Eur
J Soc Sc 2009; 10(1).
8. Krysan M, Moore K. Zill, N Identifying successful families. An overview
of constructs and selected measures. May 1990. Child Trends Inc.,
U.S. Department of Health and Human Services Assistant Secretary
for Planning and Evaluation.
9. Sittner BJ, Hudson DB, De Frain J. Using the concept of family strengths
to enhance nursing care (November – December 2007). Am J Matern
Child Nurs 2007; 32 (6): 353-7.
10. Geggie J, DeFrain J. Hitchcock S. Family Strength Research Project.
2000. Family Action Centre, The University of Newcastle, Australia
 FAMILY AND COMMUNITY HEALTH

Common Geriatric Illnesses Seen at the Manila Doctors

Hospital–Department of Family and Community Medicine
(MDH-DFCM) Clinic at Barangay 662, Paco, Manila,
from June 2011 to December 2016*
Jayne May R. Nubla, MD and Roberto L. Ruiz, MD, FPAFP

The global trend of decreasing mortality and decreasing fertility, has brought about “Population Aging”. The steady increase
in the number of geriatric patients calls for the need to improve the holistic management of illnesses of this population.
Objective: The objective of the study is to identify the common illnesses of geriatric patients seen at the Manila Doctors’
Hospital - Department of Family and Community Medicine Clinic at Barangay 662, Paco, Manila, from June 2011 to
December 2016.
Methods: This a retrospective-descriptive study. Barangay 662, at Cristobal St., Paco, Manila, has been the adopted
community of the MDH-DFCM since June of 2011. All patients aged sixty (60) years old and above seen at the said clinic
were included in this study. Baseline demographics were obtained and patients’ charts were used as basis for this study.
Frequency of consults and demographic data were tallied at the time of consult. Qualitative variables and percentages
were analysed for this study.
Results: Over a span of 6 years, the most common illness of geriatric patients seen at the MDH-DFCM Clinic were osteoarthritis
(n=145), hypertensive cardiovascular disease (n=126) and hypertension stage 2 (n=124). There were more consults by
female patients (69% n=458). Purok 4 had the most number of consults (28% n=144). According to the ICD-10, reasons
for consult belonged to disease of the circulatory system (n=344).
Conclusion: This study concludes that the most common illnesses of geriatric patients seen at the MDH-DFCM Clinic at
Barangay 662, Paco, Manila, from June 2011 to December 2016 were non-communicable diseases.

Keywords: Geriatric population, common geriatric illnesses, barangay clinic

Introduction in their World Population Ageing report of 2015. Ageing

“Population Ageing” is said to be taking place in
majority of the countries as stated by the United Nations
_______________
* From the Department of Family Medicine, Manila Doctors Hospital
is a result of decreasing mortality and decreasing fertility
which results to a reduction in the proportion of children
and an increase in the older persons in the population.
The improvements in health and longevity aid in the
prolongation of life, thus promoting longer lifespan. As
stated in the World Population Ageing Report of 2015

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 135

by the United Nations, it was said that the number of
older persons aged 60 years and over living all over the
world is projected to grow by 56 percent between 2015
and 2030. It is expected that over the next 15 years, the
number of older persons in Asia is said to grow by a 66
percent increase in the population aged 60 years or over.
As of 2015, one in 8 people was aged over 60 years old. It
is expected by 2030, one out of 6 people will be over 60
years old.
The practice of Family Medicine is known to cater
to patients from “womb to tomb”. Much attention is
given to pediatric patients as can be seen by the multiple
pediatric clinics in the metro. Geriatric patients however go
unnoticed as the practice of Geriatric Medicine is quite new
to the country with only a handful of physicians practicing
Geriatric Medicine.
Geriatric patients are a growing number in the world
with the improvement of health through the development
of better medications, improved education on health
promotion and having better access to health care. Geriatric
patients in general have chronic diseases with a few acute
illnesses.
In the 2010 National Statistics Office report on
Population and Housing, it was said that senior citizens,
aged 60 years old and over, constitute 5.75 percent of
the household population in the National Capital Region.
Barangay 662, at Cristobal St., Paco, Manila, has been
the adopted community of the Manila Doctors’ Hospital
- Department of Family and Community Medicine since
June of 2011. Barangay 662 occupies approximately 0.917
hectares of land area and has a total population of 3,501
with 157 senior citizens as of 2017, comprising 4.48% of the
community’s population. Male geriatric residents comprised
35% (n=55) of the population, while the remaining 65%
(n=102) were female geriatric residents. According to age,
60% (n=94) of the said population were in the age range of
60-69 years old, 31% (n=48) were in the age range of 70-
79 years old and 9% (n=15) were in the age range of 80-89
years old. There was no resident older than 89 years old. For
place of residence, 16% (n=205) belonged to Purok 1, 11%
(n=18) were from Purok 2, 18% (n=28) were from Purok
136 THE FILIPINO FAMILY PHYSICIAN
3, 17% (n=26) were from Purok 4, 10% (n=16) were from
Purok 5, 9% (n=15) were from Purok 6, and the remaining
19% (n=29) were from Purok 7.
Manila Doctors Hospital - Department of Family and
Community Medicine has been holding regular clinic hours
at the said Barangay clinic since June of 2011 and has seen
numerous consults of geriatric patients. It is the aim of this
study to identify the common illnesses of geriatric patients
seen at the Manila Doctors Hospital - Department of Family
and Community Medicine clinic at Barangay 662, Paco
Manila so that primary healthcare providers will be able
to appropriately address the health needs of the growing
population of geriatric patients by providing preventive and
curative holistic management in terms of health programs,
medical consultations and health education.
Objectives
The study aimed to identify the common illnesses of
geriatric patients seen at the MDH-DFCM Clinic at Barangay
662, Paco, Manila, from June 2011 to December 2016.
Specifically, this study aimed to:
i. Describe the socio-demographic variables of the elderly
patients seen at the MDH-DFCM Clinic at Barangay 662,
Paco, Manila as to age, gender and purok
ii. Identify the top ten (10) reasons for consult of geriatric
patients seen at MDH-DFCM clinic at Barangay 662,
Paco, Manila, from June 2011 - December 2016
iii. Identify the top ten (10) common illnesses of geriatric
patients seen MDH-DFCM clinic at Barangay 662, Paco,
Manila, per year starting from 2011 to 2016
iv. Identify the proportion of male to female geriatric
patients seen at the MDH-DFCM clinic at Barangay 662,
Paco, Manila
v. Identify the frequency of consults of geriatric patients
seen at the MDH-DFCM clinic at Barangay 662, Paco,
Manila, as per Purok (location)
vi. Classify the common illnesses of geriatric patients seen
at the MDH-DFCM Clinic at Barangay 662, Paco Manila
as to the International Classification of Diseases-10
Methods
This study shows the demographic profile of geriatric
individuals residing in Barangay 662, Paco, Manila which is
the location of the Manila Doctors Hospital – Department
of Family & Community Medicine adopted community.
Patients who consulted at the Manila Doctors Hospital –
Department of Family & Community Medicine Clinic at
Barangay 662, Paco, Manila, from June 2011 to December
2016 with patient records were included in this study. Only
patients with ages of 60 years old and above, were included
in this study.
Records of patients with ages 59 years old and younger
at the time of consult were excluded in this study. Patients
who were enrolled in the home visit program, blood sugar
screening program and paps smear program were likewise
excluded from this study. A total of 157 geriatric patients
were recorded to have been residing in Barangay 662 at the
end of this study.
Charts were evaluated and the following were obtained:
gender, age, date of consult, purok to which the patient
resided in and final diagnosis at the time of consult. Data
were inputted into the data collection forms. Frequency of
consults, gender, age, puroks, illnesses and date of consult
were recorded and analyzed. International Classification of
Diseases – 10 (ICD-10) was used as basis for categorizing
the illnesses seen in geriatric patients of the said clinic.
Study Design
This study is a descriptive retrospective study.
Data Analysis
Data analysis was performed and qualitative variables
were tabulated as frequency and percentage. Different
distributions are graphically presented as bar graphs.
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 137
Results
Table 1 shows the socio-demographic profile of geriatric
patients who consulted at the MDH-DFCM clinic at Barangay
662 from June 2011 to December 2016. The 6- year duration
of this study included a total of 666 geriatric patient
consults seen at the Manila Doctors Hospital – Department
of Family & Community Medicine Clinic at Barangay 662,
Paco, Manila.
Table 1. Socio-demographic variables of geriatric patients w ho consulted
at the MDH- DFCM Clinic in Barangay 662, Paco, Manila from June 2011 to
December 2016.
Characteristics Number Percentage (%)
Gender (Total
N=666)
Male 208 31%
Female 458 69%
Age (Total N=666)
60-69 years old 420 63%
70-79 years old 233 35%
80-89 years old 13 2%
≥ 90 years old 0 0%
Figure 1 shows the top 10 reasons for consult at
the said clinic during the duration of this study. During
the 6-year period, osteoarthritis was the top reason for
consult of geriatric patients seen at the MDH-DFCM Clinic
at Barangay 662, Paco Manila with 145 recorded consults.
This was followed by the following diseases: hypertensive
cardiovascular disease (n=126), hypertension stage 2
(n=124), upper respiratory tract infection (n=85), diabetes
mellitus type 2 (n=70), pneumonia in the elderly (n=67),
pulmonary tuberculosis (n=53), urinary tract infection
(n=46), acid peptic disease (n=39), and bronchial asthma
(n=32).
 Table 2. Top 10 Reasons for Consult of geriatric patients seen at the MDH–DFCM
Clinic at Brgy 662, Manila per year from 2011 to 2016.

Year & Reason for Consult Number of consults

Rank per year
2011
1. Osteoarthritis 38
2. Hypertensive Cardiovascular Disease 36
3. Diabetes Mellitus Type 2 20
4. Upper Respiratory Tract infection 19
5. Hypertension Stage 2 17
6. Functional Constipation 10
7. Hypersensitivity Reaction 8
Figure 1. Top 10 Reasons for Consult of Geriatric Patients seen at the MDH–
8. Contact Dermatitis 6
DFCM Clinic at Brgy 662, Manila , from June 2011 to December 2016.
9. Chronic Kidney Disease 6
10. Pneumonia in the Elderly 6
2012
Table 2 illustrates the top 10 reasons for consult of 1. Osteoarthritis 34
geriatric patients at the said barangay during the year 2011 2. Hypertensive Cardiovascular Disease 24
to 2016. 3. Acid Peptic Disease 21
4. Hypertension Stage 2 19
Barangay 662 at Paco Manila is made up of 7 Puroks 5. Diabetes Mellitus Type 2 15
or localities. During the duration of this study, it was noted 6. Pulmonary Tuberculosis 15
that 12% (n=79) of consults were from Purok 1, 14% 7. Pneumonia in the Elderly 12
(n=90) were from Purok 2, 15% (n=98) were from Purok 8. Urinary Tract Infection 12
9. Bronchial Asthma 10
3, 22% (n=144) were from Purok 4, 10% (n=70) were from 10. Upper Respiratory Tract Infection 9
Purok 5, 15% (n=102) were from Purok 6 and12% (n=83)
2013
were from Purok 7. 1. Hypertensive Cardiovascular Disease 31
2. Upper Respiratory Tract Infection 25
3. Osteoarthritis 20
4. Diabetes Mellitus Type 2 19
5. Pneumonia in the Elderly 13
6. Urinary Tract Infection 12
7. Hypertension Stage 2 10
8. Musculoskeletal strain 10
9. Pulmonary Tuberculosis 8
10. Gouty Arthritis 7
2014
Figure 2. Frequency of Consults among Geriatric Patients seen at the MDH–DFCM 1. Hypertension Stage 2 28
Clinic at Brgy 662, Manila , From June 2011 to December 2016. 2. Osteoarthritis 26
3. Hypertensive Cardiovascular Disease 22
4. Diabetes Mellitus Type 2 15
5. Upper Respiratory Tract Infection 14
The global classification of diseases follows the 6. Pneumonia in the Elderly 13
7. Contact Dermatitis 11
International Classification of Diseases -10 (ICD-10). For this 8. Presbycusis 11
study, the most frequent causes for consults were caused 9. Benign Prostatic Hypertrophy 8
by diseases of the circulatory system (n=344), followed 10. Functional Constipation 7

138 THE FILIPINO FAMILY PHYSICIAN

Year & Reason for Consult Number of consults
Rank per year
2015
1. Hypertension Stage 2 35
2. Osteoarthritis 16
3. Pneumonia in the Elderly 14
4. Hypertensive Cardiovascular Disease 13
5. Diabetes Mellitus Type 2 12
6. Upper Respiratory Tract Infection 10
7. Pulmonary Tuberculosis 9
8. Bronchial Asthma 7
9. Urinary Tract Infection 6
10. Allergic Cough 6
2016
1. Hypertension Stage 2 18
2. Osteoarthritis 12
3. Pneumonia in the Elderly 9
4. Pulmonary Tuberculosis 8
5. Upper Respiratory Tract Infection 8
6. Diabetes Mellitus Type 2 7
7. Allergic Cough 7
8. Chronic Stable Angina Pectoris 6
9. Urinary tract infection 6
10. Musculoskeletal strain 6
by diseases of the respiratory system (n=271), followed
by diseases of the musculoskeletal system and connective
tissues (n=138). (Table 3)
Table 3. Top 10 diseases seen in geriatric patients at the Barangay 662 MDH-
DFCM Clinic from 2011-2016 according to ICD-10.
Rank Disease Classification Frequency
(N)
1. Diseases of the Circulatory System 344
2. Diseases of the Respiratory System 271
3. Diseases of the Musculoskeletal system and Connective
Tissue 138
4. Certain Infectious & Parasitic Diseases 90
5. Diseases of the Skin and Subuctaneous Tissue 53
6. Diseases of Genitourinary System 47
7. Diseases of the Digestive System 41
8. Diseases of the Ear and Mastoid Process 34
9. Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified 34
10. Endocrine, Nutritional and Metabolic Diseases 33
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 139
Discussion
The geriatric population residing in Barangay 662 at
the end of this study in 2017 was 157, which is 4.57% of the
total population of the barangay (3,501 individuals). This
is comparable to the 4.7% of older individuals according
to the Census of Population of the Philippines as of 2015.
Males made up 35% (n=55) of the geriatric population. It is
expected that beyond the age of 55 years old, females will
outnumber males.1,3
Majority of geriatric patients belonged to the
younger age group of 60-69. There was a decreasing
number of geriatric patients as their ages increased 3,
with no individuals aged 90 years old or older residing
in Barangay 662. The geriatric patients were well
distributed in the 7 puroks of the barangay. Purok 3
(n=28), Purok 4 (n=26) and Purok 1 (n=25). The total
number of geriatric consults at the MDH-DFCM clinic at
the said barangay totaled to 666 over a course of 6 years.
It was seen that majority of consults, with 69% (n=458)
were by female patients which could be attributed to
the overall geriatric population of the community, with
women comprising 65%. In terms of place of residence,
majority of consults were by individuals residing in
purok 4 (n=144) which is the closest purok near the
clinic. Reflecting the same pattern as that of the study of
Sharma, Mazta and Parashar in 2016, place of residence
emerged to be ansignificant factor for health seeking
behavior of geriatric patients in Himach Paradesh, North
India. Those living near healthcare facilities were seen
to have more frequent consults compared to those living
farther away. 5
The top 10 reasons for consult of geriatric patients seen
at the MDH-DFCM clinic at Barangay 662, Paco, Manila,
over a span of 6 years, was led by cases of osteoarthritis
of varying locations and lateralities. This was followed by
hypertensive cardiovascular disease and hypertension
stage 2 which both belong to circulatory diseases, which
ranked in the list as 2nd and 3rd, respectively. In the study
of Tiwari, et al. this pattern is comparable as osteoarthritis
ranked number 1 in the top health problems in their
study population followed by hypertension.6 In this study
the authors categorized the illnesses based on the final
diagnosis during consult. Osteoarthritis is also classified
under musculoskeletal disease. The study of Sharma,
Mazta and Parashar in 2016 noted that age related health
problems were among the top comorbidities seen in their
study population of geriatric patients.5 Their study in 2016
showed that musculoskeletal disease is the most common
morbidity seen in their study population as this is an age-
related health problem. This is comparable in the present
study spanning 6 years from 2011 to 2016. The top 5th most
common reason for consult at the MDH-DFCM Barangay
662 clinic from 2011 to 2016 is Diabetes Mellitus Type 2.
In the WHO Report on Global Health and Aging in 2016,
it was reflected that non-communicable diseases such as
hypertension, and diabetes were more common illnesses of
the elderly population compared to communicable diseases
such as infections.7 Thirty-five percent (35%) of the
overall illnesses seen at the MDH-DFCM Barangay 662 clinic
comprised of respiratory problems during the duration of
this study. These comprised of the top 4th which is upper
respiratory tract infection, top 6th which is pneumonia
in the elderly, followed by pulmonary tuberculosis in 7th
place and bronchial asthma in 10th place. In the 2007
study of Francisco, et al. declining immune response with
increasing age is a factor for increasing the susceptibility to
pulmonary infection.8 Bronchial asthma may present
exacerbations due to bacterial or viral infections. Vianzon,
et al. conducted a surveillance report on tuberculosis in the
Philippines in 2013 and it was seen that 8% of the total
population diagnosed with smear positive Acid-Fast Bacilli
sputum stain were from the geriatric population.10 These
respiratory illnesses which were mostly infectious in origin
can again be caused by the declining immune response seen
in elderly individuals.8 It was noted that smoking is a factor
that influences respiratory infection8, however smoking
history was not included in this study.
Urinary Tract Infection was 8th in the list of most
common reasons for consult of geriatric patients in this study.
Ageing entails many changes in the human body, including
the genitourinary tract.11 Elderly individuals are prone
140 THE FILIPINO FAMILY PHYSICIAN
to dehydration, hormonal changes, immunosuppression,
incontinence and neurogenic bladder which makes them
vulnerable to infection of the urinary tract.11 Acid Peptic
Disease was 9th in the list of top 10 reasons for consult
at the Barangay 662 clinic. Frequency of this illness in
geriatric patients was explained by Khaghan and Holt in
2000 as geriatric patients having physiologic changes in
their gastric system and increasing comorbidities leading to
taking in maintenance medications such as aspirin and non-
steroidal anti-inflammatory (NSAIDs).12 Given this scenario,
geriatric patients easily develop peptic disease as seen in
the study population. Comparing the results of this study
with the study of Nasrin, et al. diabetes and hypertension
were their top 2 most common diseases, with diabetes as
number one.13 Hypertension, which is also hypertensive
cardiovascular disease, also placed second in the current
list, but diabetes was only fifth and osteoarthritis being
the most common reason for consult. Nasrin, et al. noted
that variations in disease pattern between the developed
and developing countries may be due to socio-economic,
demographic and environmental factors.13
Comparing the data gathered per year in this study,
2011 had 4 diseases which were not present in the
overall top 10 most common reasons for consult at the
MDH-DFCM Barangay 662 clinic. These were functional
constipation(6th), hypersensitivity reaction(7th), chronic
kidney disease(9th) and contact dermatitis(10th). The
elderly population undergo multiply physiologic changes
including changes in the gut. Contributory factors to
constipation in the elderly are drug intake, such as NSAIDS,
opioid analgesics, NSAIDs, anticholinergic drugs, calcium-
channel blockers and calcium supplements, reduced
intestinal smooth- muscle contractility, poor fluid intake,
diets low in fiber, impaired mobility, and other comorbid
disorders such as neurological or cognitive disorders.14
In the study of Nasrin, et al. kidney disease and skin
disease were the 4th and 5th, respectively, diseases
noted in their study population of geriatric patients in
Bangladesh. Increasing prevalence of traditional risk
factors such as diabetes and cardiovascular disease as
well as new definitions of chronic kidney disease based
on glomerular filtration rate have contributed to the high
prevalence of chronic kidney disease in the elderly.16 Due to
physiologic changes in the aging skin, mainly by decreased
skin lipids thereby having an impaired permeability barrier
homeostasis, these changes bring about xerosis or excessive
drying of the skin which makes the elderly more sensitive to
irritants.15
The top 10 common reasons for consult in our
study population during the year 2012, 2015 and 2016
reflected the same diseases and as can be seen in the
current overall list. These included musculoskeletal,
cardiovascular and respiratory diseases. The list for 2013
now included musculoskeletal strain (7th) and gouty
arthritis (10th). Both these diseases are age-related
illnesses which are commonly seen in the geriatric
population. 5
The top 10 common reasons for consult during
the year 2014 included presbycusis (7th) and benign
prostatic hypertrophy (9th). Presbycusis is included in the
common syndromes seen in the elderly primarily due to
physiologic and anatomic changes. 4 Studies on prevalence
of presbycusis in the elderly do not have a significant
number as noted by Veras and Mattos in 2007. This is due
to lack of diagnostic tests and audiologic services not
being readily available to the elderly population. 17 Benign
prostatic hypertrophy is a disease with multi-factorial
etiologies but is seen in 50% of men over 50 years of age. 18
It is therefore an age-related disease which explains the
presence of this disease in the study population in 2014.
The study populations’ most common reasons for consult
were classified based on ICD-10. The top 3 categories
were diseases of the circulatory system (1st), respiratory
system (2nd) and musculoskeletal and connective tissue
system (3rd). Non-communicable diseases which include
hypertension were noted to be common illnesses of the
elderly population. 7 There is a declining immune response
with increasing age which is a factor for increasing the
susceptibility to pulmonary infections. 8 Common reasons
for consult in the geriatric population are brought about
by age-related physiologic changes. 5 These age-related
physiologic changes encompass all the organ systems
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 141
which result in the prevalence of certain diseases in the
elderly.
Conclusion
The common illnesses of geriatric patients seen in
the Manila Doctors Hospital – Department of Family &
Community Medicine clinic at Barangay 662 from June 2011
to December 2016 were musculoskeletal, cardiovascular
and pulmonary diseases. Majority of these concerns were
non- communicable and age-related illnesses.
In line with these findings, local health units should
prepare programs that will help educate individuals
in preventing the development of non-communicable
diseases and promoting wellness through healthy lifestyle
choices. Since majority of illnesses of geriatric patients are
non-communicable illnesses, another recommendation is
to do a study correlating diet preferences, social history and
levels of activities of patients with their lifestyle-related
or non-communicable comorbid conditions. Another
recommendation is to conduct a study among geriatric
patients to learn the basis for health seeking behaviors of
those in urban communities.
References
1. Word Population Ageing 2015. Department of Economic and Social
Affairs Population Division. United Nations, New York. 2013
2. World Population Aging Matters: A Global Perspective. National
Institute on Aging. National Institutes on Health. United States
Department of Health and Human Services. United States of America.
2007
3. 2015 Census of Population and Housing. National Statistics Office,
Republic of the Philippines. June 30, 2017
4. Kane R, et al. Common Syndromes in Older Adults Related to Primary
and Secondary Prevention. Minneapolis, Minnesota. 2011
5. Sharma D, Mazta SR, Parashar A. Morbidity pattern and health-
seeking behavior of aged population residing in Shimla Hills of North
India: A cross sectional study. J Fam Med Prim Care 2013; 188-93.
6. Tiwari, et al. Prevalence of health problems among the elderly: A
study in the rural population of Varanasi. Indian J Prev Med 2010; 41(3
& 4): 54-8.
 7. Global Health and Aging. National Institute on Aging. National
Institutes on Health. United States Department of Health and
Human Services. World Health Organization. 2016
8. Francisco, et al. Factors associated with eespiratory diseases among
the elderly. Rev Saude Publica 2007; 40: 43-51.
9. Rajagopalan S. Tuberculosis and Aging: A Global Health Problem. J
Aging Inf Dis CID 2001; 33: 20-4.
10. Vianzon, et al. The tuberculosis profile of the Philippines 2003-
2011: Advancing DOTS and beyond. Western Pacific Surveillance and
Response 2013; 4(2): 11-6.
11. Omieperisa BY. Urinary tract infection in the elderly. J Clin Nephrol
Res 2016; 3(6): 154-6.
12. Khaghan N, Holt P. Peptic disease in elderly patients. Can J
Gastroenterol 2000; 14(11): 923-8.
13. Nasrin N, et al. Common geriatric disorders and their management
in selected hospitals in Bangladesh. Int J Pharm Sci Res 2012; 13(2):
5-8.
142 THE FILIPINO FAMILY PHYSICIAN
14. Gallegas-Orozco J, et al. Constipation in the elderly. Am J Gastroenterol
2012; 107: 18-25.
15. Jafferany M, et al. Geriatric dermatoses: A clinical review of skin
disease in the aging population. Int J Dermatol 2012; 509-22.
16. Mallapallil M, et al. 2014. Chronic kidney disease in the elderly:
evaluation and management. J Clin Pract 2014; 525-34.
17. Veras R, Mattos L. Audiology and aging: Literature review and current
horizons. Brazilian J Otorhinolaryngol 2007; 122-8.
18. Clinical Practice Guidelines on Benign Prostatic Hypertrophy in
the Philippines. Philippines Urological Association, Inc. 2009.
Compendium of Philippine Medicine 11th Edition. Pp 17-24
 CLINICAL UPDATE

Ciguatera Fish Poisoning in the Philippines:

A Review of Epidemiologically-confirmed Outbreaks

Allan R. Dionisio, MD, FPAFP

Background: Ciguatera fish poisoning (CFP) is a disease caused by the ingestion of poisonous coral reef fish. To the
best of the author’s knowledge, no attempt has so far been made to consolidate available reports of outbreaks in order to
characterize the toxidrome of CFP in the Philippines.
Objective: To review and consolidate data from epidemiologically-documented CFP outbreaks in order to characterize
the toxidrome of CFP in the Philippines and identify the areas of high risk for outbreaks.
Methods: Epidemiologic reports of CFP outbreaks in the Philippines were reviewed. A compilation of symptoms of CFP
patients was done to describe the toxidrome. High risk areas in the Philippines were identified.
Results: Ten reports were retrieved related to 17 CFP outbreaks from 1988 to 2010. No epidemiologic reports were found
after 2010. Consolidation of reported symptoms showed a CFP toxidrome with prominent paresthesia, muscle weakness,
and myalgia with some gastrointestinal symptoms. Based on the reports, the high risk islands identified were Palawan,
Panay, Romblon, the islands in the Cuyo Pass, and Basilan. Cases of CFP continue to be encountered but are not reported
to public health epidemiologists.
Conclusion: When put together, the reports describe a CFP toxidrome where the neurologic symptoms predominate over
the gastrointestinal symptoms. Most of the cases occurred in the west central and southern portion of the archipelago
suggesting a higher risk for CFP in that area. Cases of what appear to be CFP continue to be diagnosed although they are
not reported to government epidemiology units. More systematic surveillance of CFP by government agencies is needed.

Keywords: Ciguatera fish poisoning, Philippines, Coral reef fish

Introduction are typically the larger carnivorous ones, reflecting the

Ciguatera fish poisoning (CFP) is a disease caused
by the ingestion of poisonous coral reef fish. CFP
occurs mainly in the Pacific Ocean, the Caribbean
basin and the Indian Ocean. 1,2,3 The poisonous fish
contain ciguatoxin congeners (CTX), synthesized by the
dinoflagellate Gambierdiscus toxicus. The poisonous fish
bioaccumulation of CTX as one goes up the food chain.
The toxidrome of CFP is gastroenteritis with
prominent neurologic manifestations such as
paresthesia, dysesthesia, pruritus, allodynia (hot-cold
sensory reversal), myalgia, arthralgia, and dizziness.
Bradycardia and hypotension may also occur although
are less frequent. 4

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 143

 Disturbances in the reef resulting in dead coral are
usually the first events leading to CFP outbreaks. The
Philippines has an extensive system of coral reefs but
destructive fishing practices, sedimentation and pollution
from land-based sources, and supertyphoons like Typhoon
Haiyan have led to the death of many corals,5,6,7 making the
Philippines fertile ground for CFP outbreaks. The risk may
be further aggravated by higher sea surface temperatures
which have risen from 1985 to 2006 by 0.3 and 0.2 degrees
Celsius per decade in the northern and southern part of the
Philippines, respectively.8 Such increases in sea surface
temperatures have been shown to cause coral death6,9,10 and
increased populations of Gambierdiscus species.11,12
The number of people who suffer from CFP annually
range from 25,000 to 50,000 worldwide but due to under-
reporting of cases, these probably represent only 10-20%
of actual CFP cases.4 In the Philippines, CFP is a largely
unknown entity among doctors and it is reasonable to
assume that the problem of under-reporting is also present
in the country. Although there are epidemiologic reports of
CFP outbreaks in the country, these reports have not been
consolidated so as to form a clearer picture of this disease
entity. Hence, the objective of this paper was to review
and consolidate the documented CFP outbreaks in order
to characterize the toxidrome of CFP, identify the areas of
high risk for outbreaks, and propose recommendations for
surveillance control in the high risk areas.
Methods
This was a descriptive study reviewing epidemiologic
reports of Philippine CFP outbreaks. Records of such reports
were gathered from the library of the National Epidemiology
Center of the Department of Health (DOH) Philippines using
their online public access catalogue.12
In addition, a search of Philippine online news reports
using Google was done using the search terms “fish
poisoning” and “ciguatera.” A search was also done for
journal articles that made mention of CFP outbreaks in the
Philippines using the Herdin NeoN database, the Philippine
144 THE FILIPINO FAMILY PHYSICIAN
Health Research Registry, Researchgate and MEDLINE.
Inquiries were also made to all Regional Epidemiology
and Surveillance Units (RESU) of the DOH to find out if
epidemiologic reports existed that documenting any CFP
outbreaks in their respective regions. Feedback was obtained
from all the regions except for Bicol (Region 5) which, as of
this writing, is still pending. Inquiries were also made from
the Bureau of Fisheries and Aquatic Resources (BFAR) for
any CFP-related data.
The lead persons of the following offices were also
interviewed for further data related to Philippine CFP
outbreaks: the Region 6 RESU, the Aquatic Toxicology
Laboratory of the BFAR, and the poison centers of the
Zamboanga City Medical Center, the Corazon Locsin
Montelibano Memorial Regional Hospital in Bacolod, and
the East Visayas Regional Medical Center in Tacloban. The
attending doctor of 18 patients in a possible CFP outbreak
in Zamboanga was also interviewed.
Only outbreaks that were confirmed by an epidemiologist
or by laboratory identification of CTX in the offending fish
or in biologic samples from the patients were included in
this review. In addition, only outbreaks that involved fish
caught in Philippine waters, and only outbreaks that were
associated with fish known to produce CFP were included.
From the collected reports, the circumstances surrounding
the outbreaks were collated narratively. The signs and
symptoms from the reports were collated numerically and,
when appropriate, proportions and frequencies where used
to summarize the data.
Results
A total of 10 documents detailing 17 confirmed
outbreaks were included in the review, the details of
which are in Table 1. One outbreak was in Basilan 13 , 1
in Navotas, Metro Manila, 14,15,16 11 in Sibuyan Island,
Romblon, 17 and 4 in the province of Iloilo. 3,18,19,20,21 It
should be mentioned that in the Sibuyan report, apart
from the 11 outbreaks mentioned above, there were two-
outbreaks one involving anchovies “dilis” and another
involving parrotfish that did not appear to be CFP.
Anchovies are not typically associated with CFP, hence the
non-inclusion of this outbreak. The two fatalities and 3
of the 5 hospitalizations recorded in the original report
were from the parrotfish outbreak, but while parrotfish
are associated with CFP, the manifestations of the patients
(board-like rigidity of the abdomen and tetanus-like
posturing) were more consistent with palytoxin rather
than ciguatoxin, hence its non-inclusion in this paper.
There was a report of a French tourist who contracted
CFP from the Philippines. His case was included in a review
of 18 French tourists who contracted CFP outside France

Table 1. Details of epidemiologically confirmed CFP outbreaks in the Philippines (1989 to 2018).

Confirmed Reference Number of Patients Age Range Hospitalized Fish Involved Origin of Fish
Outbreaks In Years Patients

Basilan, August Guerrero 198913 19 (11F, 8M) (4 4 to 61 (mean Hospitalizations Syphraena jello Caught “in the
1988 households) 26) occurred but vicinity of Basilan”
number not
reported.

Sibuyan Island, Castillo, et al. 25 (11 incidents 6 to 70 (median 2 Lethrinus sp caught in the
Romblon, 199817 involving different 28) Gymnocranius sp vicinity of Sibuyan
September 1, fish)(male/female Pagellus sp Island
1997 to February distribution not Lutjanus sp
12, 1998 available) (number
of households not
available)

Navotas, Metro Tante, et al. 38 (22F, 16M) (number 2 to 68 (median 3 Sphyraenidae sp. source of fish traced
Manila June 6, 2001a14 of households not 36) to Palawan
2001 Tante, et al. described)
2001b15
Tante-Apurillo,
et al. 200216

Oton, Iloilo, June Alonsabe and No data No data No data Lutjanus bohar. No data
2005 Gallardo 2006a18

Oton, Iloilo, June Alonsabe and 7 (4F, 3M) (1 10 to 51 (no 4 Lutjanus bohar. No data
7, 2006 Gallardo 2006a18 household) mean or median
reported)

Iloilo City, Alonsabe and 35 (25F, 10M) (8 2 to 65 (median 34 Sphyraenidae sp. Cuyo Pass, northern
August 6, 2006 Gallardo 2006b19 households) 32) Sulu Sea
Michille 200620

Mina, Iloilo, June Mendoza, et al. 22 (2 households) 1 to 50 (no 22 Lutjanus No data

21, 2010 20133 mean or median campechanus
Ponsaran- reported)
Rendon 201021

VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 145

and who consulted in a French poison center22 but no other
details about the case were given so this was not included. A
report was found about 5 Filipino seafarers who contracted
CFP after eating barracuda when they were docked in
the Caribbean.23 Since the barracuda did not come from
Philippine waters, this case series was not included. Finally,
an online news report was retrieved that describing how
18 construction workers in Zamboanga became ill after
eating barracuda.24 Although CFP was highly suspected by
the attending physician, no epidemiology report could be
found confirming the diagnosis and the outbreak was not
included.25
Description of the Outbreaks
1. Basilan Island, August 1988
The first ever recorded outbreak of CFP was in
August 1988 in Basilan Island involving 19 persons from
4 households, aged 4 to 61 years, after eating a single
barracuda (Syphraena jello).13 Some patients were
hospitalized but the report did not indicate how many. The
fish was caught in the vicinity of the island and CTX at levels
> 3ng/g (or >3 ppb) was detected in the cooked meat of
the fish using a stick enzyme immunoassay method. Mild
symptoms can already appear after eating fish containing
0.1ppb of Pacific CTX.26
2. Sibuyan Island, Romblon, September 1997 to
February 1998
Between September 1, 1997 to February 12, 1998. 11
incidents of CFP involving 25 persons, aged 6 to 70 years, took
place in Sibuyan Island, Romblon.17 Two were hospitalized.
The fish involved were Lethrinus sp (“manambuyao” or
“dugso”, English common name “emperor”) in 7 outbreaks,
Gymnocranius sp. (“dayang dayang”, English common name
“emperor”) in 2 outbreaks, Pagellus sp (“isdang bato”,
English common name “porgy”) in 1 outbreak, and Lutjanus
sp (“ahaan”, English common name “snapper”) in another.
All of the fish were at least 3kg in size. All the fish were
146 THE FILIPINO FAMILY PHYSICIAN
caught in the vicinity of the island. The presence of CTX,
however, was not documented and the diagnoses were
based on clinical features.
3. Navotas, Metro Manila, June 2001
A third report described the outbreak of CFP in Navotas,
Metro Manila on June 6, 200114,15 involving 38 patients
ranging from 2 to 68 years of age. Twenty-two sought
medical consultation and 3 were hospitalized. They all ate
from one batch of barracuda (Sphyraenidae sp.) purchased
from a single vendor. Samples of fish liver from the batch
were tested using a membrane immunobead assay method
and the samples showed CTX levels of of 2-3ppb.
In order to trace the origin of the fish, the BFAR
randomly sampled fish from different regional fish markets
and the results pointed to Palawan as the source. The report
stated that Gambierdiscus toxicus was subsequently found
in the fishing grounds, that fish samples from the area were
positive for CTX, and that harvesting of reef fish from waters
with ciguatoxic fish was subsequently prohibited. The
report, however, did not state what fishing grounds were
involved.16 While the original BFAR report on CTX in the fish
samples is not available, in an interview for this paper, the
head of BFAR’s Aquatic Toxicology Laboratory, who did the
testing of fish, confirmed that the Palawan specimens were
positive for CTX.27
The report also stated that after the Navotas outbreak,
CFP case surveillance resulted in the identification of 19
additional CFP cases “from various areas”, between June
2001 and June 200216 but these “areas” were not identified
and no further details about the cases were given, so these
cases were not included in this review.
4. Oton, Iloilo June 2005 and June 2006
Two outbreaks, one year apart, occurred in Oton, Iloilo
which is a coastal town 11 km west of Iloilo City. On June
7, 2006, there was an outbreak involving 7 patients, ages
ranging from 10 to 51 years old, who had ingested “maya-
maya”, also known as “bagangan” (English common name
“snapper”). All sought medical consultation and 4 were
hospitalized.18 Fish samples were sent to the BFAR for CTX
analysis. An inquiry with BFAR, however, revealed that the
records for that time period were unavailable.
The report went on to state that: “The RESU record
showed that ciguatera fish poisoning occurred in Oton
exactly a year ago. The fish was identified as Lutjanus bohar
or ‘red snapper’ …commonly known as ‘maya-maya’ or
‘bagangan’.” The 2005 report could not be found, but since
the outbreak had been investigated by the same authors of
the 2006 report, and because clear reference was made to
the report’s existence, the 2005 outbreak was considered as
a confirmed CFP outbreak.
5. Iloilo City, August 2006
An outbreak involving 35 patients from 8 households,
ages ranging from 2 to 65 years of age, took place in Iloilo
City on August 6, 2006, one month after the outbreak in
Oton. Of the 35 patients, 34 were hospitalized.19 The fish
involved was barracuda purchased from a single fish vendor
in the Villa Arevalo public market. Fish samples were sent
to the BFAR but the records of the tests were unavailable.
However, a news report about the outbreak quoted a BFAR
report which stated that “...barracuda fished from Cuyo
Pass and landed in Barangay Butuan, Anini-y, Antique were
found to be positive for ciguatoxin,” and the public was
warned not to eat barracuda caught in the Cuyo Pass.20 In
an interview for this paper, the head of the BFAR Aquatic
Toxicology Laboratory confirmed that he did the testing for
these specimens and that the test was positive.27
6. Mina, Iloilo, June 2010
Mina is a town about 30 km north of the port of Iloilo
City. There was a RESU report of the outbreak but it could
not be found. However, a news report21 and a journal article3
about the outbreak were available. On June 21, 2010, 22
individuals from 2 households, ages ranging from 1 to 50
years, were diagnosed to have CFP. All were hospitalized.
The fish involved was “maya-maya” (English common name
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 147
“snapper”) later on identified as Lutjanus campechanus.
CTX determination in the available remaining fish meat
was positive using an enzyme-linked immunosorbent assay
method. Blood samples from some of the patients revealed
the presence of CTX-1 and CTX-3B/3C.3
In summary, documents describing 17 confirmed CFP
outbreaks involving at least 146 patients were gathered,
11 in Sibuyan, 4 in Iloilo province, 1 in Basilan, and one in
Navotas Metro Manila. Except for Navotas, the locations of
the outbreaks described above were in the western central
and southern Philippines: the Cuyo Pass between Palawan
and Panay and the islands of Panay, Sibuyan, Palawan and
Basilan. Even the Navotas outbreak was traced to a fishing
ground in Palawan. The outbreaks were usually associated
with a family meal, and the usual trigger for reporting the
outbreaks to the authorities was hospitalization of several
family members after ingesting the poisonous fish.
Signs and Symptoms of CFP
In the outbreak reports of Basilan,13 Sibuyan,17
Navotas14,15,16 and Mina,3 symptoms were recorded and
frequencies obtained. The combined symptoms and their
frequencies are listed in Table 2. There was wide variability
in the manner the symptoms were listed in original reports,
so some aggregation of similar symptoms was done to
facilitate tabulation. Symptoms less than 15% were not
included in the table.
The most frequently encountered neurologic symptoms
were paresthesia of the distal extremities (66.3%),
weakness of extremities (52.9%), myalgia (26.9%),
and hot-cold sensory reversal (25%). Gastrointestinal
symptoms encountered were abdominal cramps (48.1%),
diarrhea (38.5%) and vomiting (30.8%). There was no
mention of bradycardia or hypotension in the reports.
Three reports (Basilan, Sibuyan, and Navotas) described
incubation periods albeit in different ways. The Basilan
report described the range as 1 to 12 hours with a mean of
6 hours and a standard deviation of 2.73. The report about
Sibuyan described the incubation period as a range (4 to 28
hours) and as intervals--5 cases had incubation periods of
Table 2. Frequency of symptoms in 4 outbreaks of CFP in the Philippines.

Basilan 198816 Sibuyan, Navotas, Metro Manila Mina, Iloilo Total Percentage
Romblon 200119,20,21 20103
199718

Number 19 25 38 22 104 100.0

Neurologic
Paresthesia of the distal extemities 14 17 36 2 69 66.3
Weakness of extremities 14 22 16 3 55 52.9
Myalgia 14 8 6 28 26.9
Hot cold sensory reversal 11 2 12 1 26 25.0
Perioral paresthesia 4 15 19 18.3
Ataxia 11 5 16 15.4
“stiffness of extremities and difficulty
in opening mouth” * 16 16 15.4

Gastrointestinal
Abdominal cramps 6 6 25 13 50 48.1
Diarrhea 1 11 22 6 40 38.5
Vomiting 2 5 15 10 32 30.8

Miscellaneous
Dry lips and/or buccal mucosa 21 21 20.2
Joint pains 14 3 17 16.3
*quoted from Guerrero 198913

less than 10 hours, for 10 cases the period was 10-20 hours,
and for 7 cases, the period was more than 20 hours. No data
was available for 3 cases. The Navotas report described a
range of 1-24 hours with a median of 6 hours.
Only the Sibuyan report had data regarding the duration
of the symptoms of the CFP patients post-ingestion. Nine
had symptoms for less than a week. Thirteen patients had
symptoms for 1 to 2 weeks. One had symptoms for 1 month
and another had symptoms that persisted for 4.5 months.
There was no data for one patient.
This paper’s objective is to describe the toxidrome of
CFP in the Philippines. In summary, based on the frequency
of symptoms, the emerging CFP toxidrome appears to
be one which is primarily neurologic and secondarily
gastrointestinal. Paresthesias and weakness of the
extremities (66.3% and 52.9% respectively) are a prominent
feature and are even more frequent than the gastrointestinal
manifestations of abdominal cramps (48.1%), diarrhea
(38.5%) and vomiting (30.8%). Hypotension and
bradycardia, were not among the symptoms listed in the
reports.
The other objective of the paper was to identify areas
with increased risk of CFP. It appears that west central and
southern Philippines, specifically Palawan, Panay, Sibuyan,
Basilan, and the Cuyo Pass are the areas of higher risk.
Discussion
1. Philippine CFP toxidrome compared to descriptions in
the international literature
The predominance of neurologic symptoms in
Philippine CFP is consistent with the observation that in
the Caribbean, gastrointestinal symptoms predominate
whereas in the Pacific, neurologic symptoms are more

148 THE FILIPINO FAMILY PHYSICIAN

prominent. This can be explained by the fact that Pacific
CTX congeners, cause more prolonged opening of voltage-
gated sodium channels and are 10-fold more toxic relative
to Caribbean CTX congeners.3,28
The wide range of incubation periods in this case series
is consistent with the observations in other countries that
gastrointestinal symptoms can occur within up to 12 hours
from the ingestion of toxic fish and neurologic symptoms
can appear up to 48 hours post-ingestion.4
Fifteen patients in the Sibuyan outbreak had prolonged
symptoms, one of them lasting for one month and the
other lasting for 4.5 months. This is consistent with the
observation in other countries that peripheral neurologic
and systemic symptoms may persist for weeks or months.3,29
Exposure to fish, caffeine, nuts, chicken, pork and physical
overexertion or dehydration can precipitate a recurrence of
the symptoms. The hypotheses that have been proposed for
these recurrences include cross-sensitization to CTX as well
as possible mobilization of CTX from fatty tissue.4
All of the fish involved in the reports were big
predatory fish. This is consistent with the phenomenon of
bioaccumulation that has been described in CFP where the
toxin load in the organism increases as one goes up the food
chain.4,29
In most of the reports in this review, the poisonings
took place in the setting of households sharing a meal of
toxic fish, which accounts for the wide range of ages of
patients affected, from children to the elderly.
The outbreaks in this review came to the attention
of public health authorities only when there were
hospitalizations. Based on international experience,
only 20% of cases are reported to health authorities. 1,4,32
It is conceivable that there are significantly more CFP
cases in the Philippines that similarly go unreported
because no hospitalization is needed. It is also probable
that the diagnosis of CFP can be missed by physicians in
the front line because of unfamiliarity with the disease
entity.
There were no deaths in this review of cases. The
absence of fatalities in this series is consistent with the
literature which states that CFP is rarely fatal.4
VOL. 56 NO. 3 JULY - SEPTEMBER, 2018 149
2. Temporal synchronicity of the outbreaks
Gambierdiscus spp. thrive in higher water
temperature.11,31 Furthermore, in French Polynesia, it was
demonstrated that there is a lag time of approximately
3 months between peak densities of Gambierdiscus
polynesiensis and CFP outbreaks.32 The hot dry season in
the Philippines is from March to May.33 The outbreaks in
Navotas, Oton in 2005, Oton in 2006 and Mina took place
in June while the Basilan and Iloilo City outbreaks occurred
in August, one month and 3 months respectively after
the end of the hot dry season. It is possible that blooms
of Gambierdiscus sp. occurred during the hot dry months
followed by outbreaks within 3 months from the blooms.
The Sibuyan data showing 11 outbreaks over 6 months
starting September does not follow the same pattern and
suggests a continuing presence of dinoflagellates and
ciguatoxic fish in the area independent of season.
3. Explanation for the absence of confirmed CFP outbreaks
since 2010.
It is notable that there have been no RESU reports of
confirmed CFP outbreaks from the high risk islands since
2010. Inquiries with the RESUs of Region 4B (covering
Mindoro, Masbate, Romblon, and Palawan), Region 6
(Western Visayas), Region 9 (Western Mindano), and Region
7 (Cebu) were done and no reports have been received over
the last 8 years. This is probably because, at the moment,
only passive surveillance of CFP is being done by the different
RESUs in the high risk areas. Active investigation takes place
only when there are hospitalizations. Except for the post-
Navotas outbreak surveillance, where an additional 19 CFP
cases were found, the reports in this review did not indicate
that continuing active surveillance was done post-outbreak.
As previously mentioned, world-wide, only 20% of CFP cases
are reported to public health authorities4 and the same
phenomenon is probably happening in the Philippines.
There is evidence, however, that CFP cases continue to
occur. Clinical toxicologists based in Bacolod, Zamboanga,
and Tacloban have informed the author that they have
handled a combined total of 9 cases of CFP since 2015.
The head of RESU 6 in Iloilo City also told the author that
he would hear about 1 or 2 cases of CFP every year that
would not be formally reported to the RESU (unpublished
data). In the previously mentioned 2014 Zamboanga
outbreak of fish poisoning involving 18 patients who had
eaten barracuda, the attending physician of the patients
said that her primary diagnosis was CFP but there was no
epidemiologic investigation that was done to confirm her
diagnosis.25
Limitations of the Study
True prevalence of CFP in the Philippines cannot
be determined from the reports in this paper. Only
outbreaks that were reported to the epidemiologists of
the affected regions were included, and in only one report
was active post-outbreak surveillance done though it was
not sustained. It is probable that many more cases go
unreported in the entire archipelago.
The data presented in this paper are also limited by
the variations between reports in the manner in which
symptoms were recorded. In addition, records of CTX testing
were not available for most of the outbreaks, although
many of the reports clearly stated that specimens had been
sent to BFAR for this purpose.
Conclusions and Recommendations
The toxidrome emerging from the consolidated
data of the outbreaks reviewed demonstrate a clinical
entity manifesting primarily with neurologic symptoms
(paresthesias and weakness of the extremities, myalgia,
and hot-cold sensory reversal) and secondarily with
gastrointestinal symptoms (abdominal pain, diarrhea, and
vomiting). The manifestations are consistent with that
described for Pacific CTX congeners. The pattern of outbreaks
suggests a high risk area in the islands of Palawan, the
Cuyo Pass, Sibuyan, Panay and Basilan in west central and
southern Philippines. There are continuing reports of fish
150 THE FILIPINO FAMILY PHYSICIAN
poisoning outbreaks compatible with the diagnosis of CFP,
and it is probable that most cases go unreported.
Given the already degraded condition of Philippine
coral reefs and the further degradation that could come as a
result of climate change, more cases of CFP can be expected.
More systematic case finding and surveillance should be
done by public health authorities. An effort needs to be
made to educate doctors, especially those in the coastal
areas, about CFP and to encourage them to report suspected
cases. Coordination with BFAR can identify the high risk
reefs so that reasonable control measures to protect the
public and the fishing industry can then be instituted.
Acknowledgements
The author would like to acknowledge the assistance
of the following individuals who greatly assisted in the
writing of this article: Dr. Marc Lawrence J. Romero,
section chief of the National Fisheries Laboratory Division,
BFAR; Dr. Jesse Glen L. Alonsabe, head of the Region
6 RESU, Dr. Eunice Sapaap, attending physician of the
Labuan District Hospital, Zamboanga City; Dr. Aeesha
Yahcob-Pingli, clinical toxicologist of the Zamboanga
City Medical Center; Dr. Cherie Grace Quingking, clinical
toxicologist of the Corazon Locsin Montelibano Memorial
Regional Hospital in Bacolod; Dr. Lourdes Agosto, clinical
toxicologist of the East Visayas Regional Medical Center in
Tacloban.
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