BY EMMA RYAN
Over the past decade, rates of diet-related illnesses such as diabetes and hypertension have risen noticeably in coastal Ecuador.1 In this region, essentially every meal consists of a plate that is half filled with rice and half filled with fried fish, with maybe a few slices of cucumber and tomato on the side. Half a plate of rice, multiplied by three meals a day, adds up quickly. As this illustrates, dietary diversity and food insecurity are a challenge for many households in coastal Ecuador. This brings one to question the true root of this problem, is it a lack of knowledge about what constitutes a balanced diet, or lack of access to the necessary food?
This past summer, I worked as part of a student-research team that examined the links between dietary diversity, food insecurity, and Body Mass Index (BMI) in coastal towns in the province of Santa Elena, Ecuador. We collaborated with the Futuro Valdivia clinic to conduct research in the hope that the information we collected would prove useful to the clinic’s team. Our research indicated that an average six-person household in the area has a monthly income of $466, a generous estimate given the sporadic nature of employment in the region. The average BMI of the study population was 25.9, which falls in the category of “overweight,” with a large percentage of the population falling in the “obese” category. Diabetes was the principal cause of mortality in Ecuador in 2008, causing more deaths than either cerebrovascular disease or hypertensive heart disease, and the Santa Elena province has the highest diabetes-related mortality per 100,000 people in the entire country.2,3
What is causing this rise in diabetes and other diet-related illnesses? Over the course of our study, we found that lack of information and nutritional knowledge certainly plays a role in the rise of diet-related illnesses. For example, one woman we spoke with told us that putting lemon on fried food reduced the amount of fat in the cooking. Beliefs such as this one suggest that certain knowledge barriers should be addressed. For the most part, however, the population had a fairly accurate idea of what constituted an ideal balanced diet. According to many people with whom we spoke, the problem lies principally in the dearth of available, steady employment, rather than a lack of knowledge about a healthy diet. The lack of resources to buy enough fruits and vegetables to maintain a balanced diet constituted the main obstacle to healthy eating, hence the enormous quantities of rice that characterize most Ecuadorean plates.
It makes intuitive sense that food insecurity and job insecurity go hand in hand, a relationship that has been demonstrated in studies worldwide.4 After all, in the simplest terms, people need money in order to buy food, unless they are among the small minority who can exist entirely upon subsistence farming. In the coastal region of the Santa Elena province of Ecuador, subsistence farming is a rarity. Most people do contract work on construction projects or work as part-time agricultural laborers. Almost no one in coastal Santa Elena has a steady source of income. According to the World Health Organization, 35.5% of the rural Ecuadorian population lives below the national poverty line.1 Given the almost uniform lack of job security in coastal Ecuador, the high prevalence of food insecurity is unsurprising.
We surveyed approximately 250 people to gather information on household dietary diversity scores (HDDS) and food insecurity among the study population. We asked people questions about how often they worried about not having enough food in the house, and if they had to reduce the quantities of food in meals due to lack of money. Our survey found that only 5% of the households were food secure, whereas 32% were mildly food insecure, 31% were moderately food insecure, and 31% were severely food insecure. The level of food insecurity in this region is substantially worse than the overall food insecurity levels in Ecuador, where 33% of households are reported to be food secure, 21% mildly food insecure, 25% moderately food insecure, and 21% of households severely food insecure.5
Unsurprisingly, people with higher levels of food insecurity also tended to have lower dietary diversity. Overall, approximately 35% of people had dietary diversity scores in the lowest category, but that number climbed closer to 55% for people who were severely food insecure. Conversely, 13% of all participants had dietary diversity scores in the highest category, while only around 6% of severely food insecure people had high dietary diversity scores. These numbers highlight the fact that a lack of money inhibits both the quantity and diversity of food that people are able to buy.
|All participants||Food Secure||Mildly food insecure||Moderately food insecure||Severely food insecure|
|n = 254||13 (5%)||80 (32%)||78 (31%)||80 (31%)|
|HDDS, n (%)|
|1 (lowest)||90 (35.4%)||3 (23.1%)||19 (23.8%)||22 (28.2%)||43 (55.1%)|
|2||131 (51.6%)||7 (53.9%)||49 (61.3%)||43 (55.1%)||30 (38.5%)|
|3||33 (13.0%)||3 (23.1%)||12 (15.0%)||13 (16.7%)||3 (6.4%)|
|BMI, n (%)|
|Underweight||6 (2.37%)||1 (7.7%)||1 (1.3%)||2 (2.6%)||2 (2.6%)|
|Normal||104 (41.1 %)||7 (53.9%)||32 (40%)||35 (44.9%)||27 (34.6%)|
|Overweight||107 (42.3%)||3 (23.1%)||38 (47.5%)||25 (32.1%)||40 (51.3%)|
|Obese||36 (14.2%)||2 (15.4%)||9 (11.3%)||16 (20.5%)||9 (11.5%)|
Data courtesy of Etna Tiburcio, Yale School of Public Health MPH 2017 Candidate
We also conducted multiple focus groups and in each one, participants linked the lack of steady employment with unbalanced diets and their related illnesses. They mentioned the rising price of food, citing the fact that chicken used to cost $1.25 and now sells for $2.00. As a result, people tend to eat large quantities of fish and rice, because “la pobreza no da para comprar otra clase de comida,” (poverty doesn’t allow for buying other types of food). Many focus group participants stressed the difficulty of allocating income to food and other necessities such as clean water and school supplies. They told us that, when faced with long lists of school books to buy for their children, they were often forced to reduce both the quantity and diversity of food that they bought. Parents will often forgo a meal or eat a very small quantity so their children can have something a bit more substantial to eat.
In addition to the focus groups and surveys we performed in the coastal towns, we spent two days in the town of Casas Viejas collecting socio-demographic data at the request of Futuro Valdivia. Casas Viejas is a small town in the mountains near the coast that is very challenging to access. The road to get there crosses the river at least 20 times, which meant that the pickup truck we rode in drove down a couple of precariously steep riverbanks and jolted along the rocky riverbed multiple times. We asked people what they considered to be the most pressing issues facing their community, and 79% stated that a lack of steady employment was the largest problem because it made buying food and medicine difficult and stressful. The second most mentioned problem was the lack of an easily accessible health clinic – the closest one is a three-hour walk away in the town of Jipijapa. These remarks echoed those made by people we spoke with in the coastal focus groups, highlighting again the link between employment and health issues related to poor nutrition.
It is tempting to assume that a lack of education drives diet-related illnesses, in part because increasing access to education has proven to be a somewhat concrete and manageable goal. The reality, however, is much more complicated. The people with whom we spoke often knew that diabetes resulted from a poor diet, but the constant job insecurity made it impossible for them to eat a diet healthy enough to prevent the onset of diabetes and other diet-related illnesses. As much as we would like to believe the contrary, even when we enter Ecuador with the best of intentions to educate people about the importance of a balanced diet, we will unfortunately have a limited impact unless a substantial overhaul of the local economy occurs that enables people to maintain a steady income.
1) Diabetes Programme. (2014). World Health Organization Retrieved from http://www.who.int/diabetes/en/.
2) Ecuador. (2015). The World Bank. Retrieved from http://data.worldbank.org/country/ecuador.
3) Neira-Mosquera et al. (2013). Study on the mortality in Ecuador related to dietary factors. Nutricion Hospitalaria, 28(5), 1732 – 1740. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24160240.
4) Thorne-Lyman, A., Valpiani, N., Sun, K., Semba, R., Klotz, C., Kruaemer, K., . . . Bloem, M. (2009). Household Dietary Diversity and Food Expenditures Are Closely Linked in Rural Bangladesh, Increasing the Risk of Malnutrition Due to the Financial Crisis. Journal of Nutrition 140(1). Retrieved from http://jn.nutrition.org/content/140/1/182S.full.pdf html.
5) Food and Agriculture Organization of the United Nations. (2010, March 1). ELCSA Aplicada en la Encuesta de Empleo. Retrieved from http://coin.fao.org/coin-static/cms/media/9/13116978926430/ecuador_-_elcsa_aplicada_en_la_encuesta_de_empleo.pdf.
Additional Sources Consulted:
Seligman, H., Laraia, B., & Kushel, M. (2009). Food Insecurity Is Associated with Chronic Disease among Low-Income NHANES Participants. Journal of Nutrition, 304-310. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806885/.
Food Security in the U.S.: Key Statistics & Graphics. (2015, September 8). United States Department of Agriculture: Economic Research Service. Retrieved from http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us.aspx.
Vozoris, N., & Tarasuk, V. (2003). Household Food Insufficiency Is Associated with Poorer Health. Journal of Nutrition 133(1), 120-126. Retrieved from http://jn.nutrition.org/content/133/1/120.full.
Rome Declaration on World Food Security and World Food Summit Plan of Action. (1996). World Food Summit. Retrieved from http://www.fao.org/docrep/003/w3613e/w3613e00.HTM.