William F. Waters

Globalization and local response to epidemiological overlap in 21st century Ecuador

BackgroundThird World countries are confronted by a complex overlay of two sets of health problems. Traditional maladies, including communicable diseases, malnutrition, and environmental health hazards coexist with emerging health challenges, including cardiovascular disease, cancer, and increasing levels of obesity. Using Ecuador as an example, this paper proposes a conceptual framework for linking epidemiologic overlap to emerging social structures and processes at the national and global levels.DiscussionEpidemiologic trends can be seen as part of broader processes related to globalization, but this does not imply that globalization is a monolithic force that inevitably and uniformly affects nations, communities, and households in the same manner. Rather, characteristics and forms of social organization at the subnational level can shape the way that globalization takes place. Thus, globalization has affected Ecuador in specific ways and is, at the same time, intimately related to the form in which the epidemiologic transition has transpired in that country.SummaryEcuador is among neither the poorest nor the wealthiest countries and its situation may illuminate trends in other parts of the world.As in other countries, insertion into the global economy has not taken place in a vacuum; rather, Ecuador has experienced unprecedented social and demographic change in the past several decades, producing profound transformation in its social structure. Examples of local represent alternatives to centralized health systems that do not effectively address the complex overlay of traditional and emerging health problems.

Globalization, socioeconomic restructuring, and community health.

New trends in global public health have social, economic, and political underpinnings that can be found in three 20th century revolutions: globalization, a new epidemiological transition, and an historical shift in patterns of production and consumption throughout the world. Globalization is more than the internationalization of commerce and manufacture; it represents a new development paradigm that creates new links among corporations, international organizations, governments, communities, and families. Social and economic restructuring is reflected in the emerging health profile in underdeveloped countries, including those in Latin America. This emerging profile defies simple categorization, however; while the prevalence of cardiovascular disease and cancer has increased, the traditional diseases (infectious and respiratory disease) are still the leading cause of death. At the same time, industrialized countries are experiencing the re-emergence of those same traditional diseases. These apparent anomalies can be understood by examining class structures within and among countries and by linking health outcomes at the local level to new patterns of production and consumption in the global system.

The Road of Many Returns

The dramatic growth of the informal economy is one of the most notable tendencies in Ecuador and throughout much of Latin America. While the informal sector is also found in industrialized countries (Portes, Castells, and Benton, 1989), it is a particularly important component of dependent development, largely because it provides for the cheap reproduction of a highly flexible labor force. In general, it is regarded as an essentially urban phenomenon, and its analysis frequently invokes images of sprawling marketplaces, city thoroughfares choked by sidewalk kiosks, and ambulatory vendors offering thousands of different goods and services. Alternatively, the informal sector is said to be swelled by innumerable rural migrants, who have lost or abandoned their land and who are then transformed into permanent fixtures of urban society (Alarc6n, 1987). Both concepts are limited, however, because they fail to account for large numbers of people who continue to reside and work in rural areas but also participate in the urban economy. Complex patterns of agricultural restructuring, changing international trade, land ownership, and evolving class structures have forced rural households

Eggs in Early Complementary Feeding and Child Growth: A Randomized Controlled Trial

This rigorously conducted trial showed that when offered early in complementary feeding, the food-based intervention of eggs produced a large effect size on child growth. BACKGROUND: Eggs are a good source of nutrients for growth and development. We hypothesized that introducing eggs early during complementary feeding would improve child nutrition. METHODS: A randomized controlled trial was conducted in Cotopaxi Province, Ecuador, from March to December 2015. Children ages 6 to 9 months were randomly assigned to treatment (1 egg per day for 6 months [n = 83]) and control (no intervention [n = 80]) groups. Both arms received social marketing messages to encourage participation in the Lulun Project (lulun meaning “egg” in Kichwa). All households were visited once per week to monitor morbidity symptoms, distribute eggs, and monitor egg intakes (for egg group only). Baseline and end point outcome measures included anthropometry, dietary intake frequencies, and morbidity symptoms. RESULTS: Mothers or other caregivers reported no allergic reactions to the eggs. Generalized linear regression modeling showed the egg intervention increased length-for-age z score by 0.63 (95% confidence interval [CI], 0.38–0.88) and weight-for-age z score by 0.61 (95% CI, 0.45–0.77). Log-binomial models with robust Poisson indicated a reduced prevalence of stunting by 47% (prevalence ratio [PR], 0.53; 95% CI, 0.37–0.77) and underweight by 74% (PR, 0.26; 95% CI, 0.10–0.70). Children in the treatment group had higher dietary intakes of eggs (PR, 1.57; 95% CI, 1.28–1.92) and reduced intake of sugar-sweetened foods (PR, 0.71; 95% CI, 0.51–0.97) compared with control. CONCLUSIONS: The findings supported our hypothesis that early introduction of eggs significantly improved growth in young children. Generally accessible to vulnerable groups, eggs have the potential to contribute to global targets to reduce stunting.

A qualitative study of consumer perceptions and use of traffic light food labelling in Ecuador.

OBJECTIVE To analyse patterns of knowledge, comprehension, attitudes and practices regarding the traffic light label placed on processed food packages to inform Ecuadorian consumers about levels of added fat, sugar and salt. DESIGN Twenty-one focus group discussions organized by age group, sex and place of residence. Interviews with representatives of companies that manufacture or market processed foods. Analysis of regulations and structured observations of processed food labels. SETTING Cities and towns in Ecuadors coastal, highland and eastern lowland regions. SUBJECTS One hundred and seventy-eight participants in twenty-one focus group discussions and nine key informants. RESULTS Focus group participants knew about the traffic light label and understood the information it conveys, but not all changed their attitudes and practices related to the purchase and consumption of processed foods. Children, adolescents and adult males reported using the information infrequently; adolescents interested in health and adult women used the label the most to select products. Representatives of companies that manufacture or market processed foods generally opposed the policy, stating that the information is misleading. Nevertheless, some companies have reduced levels of added fat, sugar or salt in their products. CONCLUSIONS The traffic light label is an effective tool for conveying complex information. Its potential contribution to reduce consumption of products with high levels of fat, sugar and salt could be enhanced by promoting healthy diets among consumers who have not changed purchasing and consumption behaviour, by placing the label on front panels and by monitoring the production and marketing of processed foods.

Eggs early in complementary feeding increase choline pathway biomarkers and DHA: a randomized controlled trial in Ecuador

Background: Choline status has been associated with stunting among young children. Findings from this study showed that an egg intervention improved linear growth by a length-for-age z score of 0.63. Objective: We aimed to test the efficacy of eggs introduced early in complementary feeding on plasma concentrations of biomarkers in choline pathways, vitamins B-12 and A, and essential fatty acids. Design: A randomized controlled trial, the Lulun (“egg” in Kichwa) Project, was conducted in a rural indigenous population of Ecuador. Infants aged 6–9 mo were randomly assigned to treatment (1 egg/d for 6 mo; n = 80) and control (no intervention; n = 83) groups. Socioeconomic data, anthropometric measures, and blood samples were collected at baseline and endline. Household visits were made weekly for morbidity surveillance. We tested vitamin B-12 plasma concentrations by using chemiluminescent competitive immunoassay and plasma concentrations of choline, betaine, dimethylglycine, retinol, essential fatty acids, methionine, dimethylamine (DMA), trimethylamine, and trimethylamine-N-oxide (TMAO) with the use of liquid chromatography–tandem mass spectrometry. Results: Socioeconomic factors and biomarker concentrations were comparable at baseline. Of infants, 11.4% were vitamin B-12 deficient and 31.7% marginally deficient at baseline. In adjusted generalized linear regression modeling, the egg intervention increased plasma concentrations compared with control by the following effect sizes: choline, 0.35 (95% CI: 0.12, 0.57); betaine, 0.29 (95% CI: 0.01, 0.58); methionine, 0.31 (95% CI: 0.03, 0.60); docosahexaenoic acid, 0.43 (95% CI: 0.13, 0.73); DMA, 0.37 (95% CI: 0.37, 0.69); and TMAO, 0.33 (95% CI: 0.08, 0.58). No significant group differences were found for vitamin B-12, retinol, linoleic acid (LA), α-linolenic acid (ALA), or ratios of betaine to choline and LA to ALA. Conclusion: The findings supported our hypothesis that early introduction of eggs significantly improved choline and other markers in its methyl group metabolism pathway. This trial was registered at clinicaltrials.gov as NCT02446873.

Discourse versus practice: are traditional practices and beliefs in pregnancy and childbirth included or excluded in the Ecuadorian health care system?

Background Traditional beliefs, knowledge and practices are formally integrated into the Ecuadorian health system. We sought to understand whether they are integrated in practice. Methods Qualitative data were collected in two rural parishes in the central highlands of Ecuador through four focus group discussions (30 participants), eight key informant interviews, three participatory exercises (24 participants), structured observations of health facilities and analysis of official documents. Results We found different levels of integration, coexistence, tolerance, and intolerance of traditional health beliefs and practices in health facilities. One parish has undergone dramatic social and cultural transformation, and the role of traditional birth attendants is limited. In the other parish, traditional indigenous norms and values persist, and traditional birth attendants are sought during pregnancy and childbirth. The degree to which traditional birth attendants, indigenous women and their families are included or excluded from public health services depends largely on decisions taken by local health professionals. Conclusions Formal policies in Ecuador stipulate that health care should be intercultural, but the role of traditional birth attendants is not necessarily incorporated in practice. The integration of culturally-informed beliefs and practices is critical for providing appropriate health services to members of vulnerable populations.

Semáforo nutricional de alimentos procesados: estudio cualitativo sobre conocimientos, comprensión, actitudes y prácticas en el Ecuador

Objectives. To analyze awareness, understanding, attitudes, and practices related to the nutritional traffic light system (NTLS) on processed food packaging in Ecuador. Materials and methods. 21 discussions were held in focus groups (FG) in populations of various sizes in the coastal, mountainous, and eastern regions. Nine interviews were conducted with key informants (KI) representing large, medium, and small enterprises producing or selling processed foods. Results. There were 171 FG participants, the majority of whom recognized and understood the NTLS. There was a certain amount of discussion around awareness of the NTLS and purchasing attitudes, and other factors such as taste, brand, or accessibility were considered. Attitudes were different between age groups: while the group of five- to nine-year-olds knew little about the NTLS and preferred homemade foods, the group of 15- to 19-year-olds was indifferent to the NTLS information and placed more value on other features, such as taste. Practices related to the purchase and consumption of processed foods highlighted seven different strategies that ranged from replacing the product to ignoring the NTLS information. The KIs did not agree with the policy, but they acknowledged having amended the content of some products to reduce fat, sugar, and salt. Conclusions. The NTLS has had a positive effect on awareness and understanding of the content of processed products. Practices related to purchasing and consuming processed foods would be improved by promotion of the nutritional labeling policy, trade control, and the monitoring and surveillance of its implementation.

Aging, Health, and Identity in Ecuador’s Indigenous Communities

Middle-income countries like Ecuador are in the process of demographic and epidemiological transitions, and their populations are aging. The challenges associated with providing services to growing numbers of citizens who experience the inevitable deterioration associated with aging are mirrored by the manner in which aging is perceived in a culturally heterogeneous society. This paper presents the results of qualitative research conducted among older men and women in indigenous communities in the Ecuadorian highlands in order to investigate the perceptions regarding the ability of family and community networks to provide adequate and appropriate support for older persons in the context of their perceptions of health, health care, and aging. The principal findings are that: (i) perceptions of aging are shaped by chronic illness, fatigue, deteriorating sensory capacities, and vulnerability to accidents; (ii) barriers to health care are exacerbated among aging members of indigenous communities, although in some cases they can be addressed through traditional alternatives; (iii) the sense of identity shifts as aging people are increasingly unable to work the land and participate in community activities; and (iv) family and community support networks for older adults are not as strong as is generally thought. These findings represent the context within which issues related aging in a culturally heterogeneous society can be best understood and addressed.

The double burden of chronic malnutrition and overweight and obesity in Ecuadorian mothers and children, 1986–2012

Background: The simultaneous presence of undernutrition and over-nutrition represents a paradox in global public health and is of increasing concern in Ecuador, where chronic malnutrition and overweight and obesity occur in the context of demographic and epidemiologic transitions. Two overlapping trends are present in Ecuador; while levels of stunting have decreased slowly in the past three decades, increasing proportions of children <5 years and women of reproductive age suffer from overweight and obesity. Aim: To analyze stunting and overweight and obesity in children <5 and their mothers aged from 15 to 49 years in the context of demographic and household characteristics between 1986 and 2012. Methods: This study compares data from nationally-representative surveys conducted in Ecuador in 1986, 2004, and 2012, each of which collected information on children <5 and mothers aged 15–49 years. Results: The prevalence of chronic malnutrition in children <5 decreased at different rates among Ecuadorians who differ in terms of residence, socioeconomic status, and mothers’ level of education, while overweight and obesity increased dramatically in the same period. Conclusion: Chronic malnutrition in children <5 and overweight in children <5 and mothers 15–49 years represent a double burden of malnutrition in Ecuador. The phenomena differ in their effects, and, while the prevalence of stunting is declining in Ecuador as it is in many parts of the world, the problem of overweight and obesity has emerged in dramatic fashion, and currently represents an extraordinary challenge to public health.