Traffic Lights, School Lunch and Cultural Perceptions of Health: Pediatric Obesity in Ecuador

Childhood obesity is one of the greatest health crises of the 21st century. According to a 2015 report by the World Health Organization (WHO), 42 million children under the age of 5 were either overweight or obese. Historically only considered a problem in western countries, this recent report noted that countries in Africa and Asia have rates that are now surpassing those of the United States. These children are at greater risk of developing metabolic syndrome with long-term health impacts such as diabetes and cardiovascular disease – which remain some of the most pervasive illnesses and some of the greatest drain on economic resources globally.

Nadia Al-Lami
Nadia Al-Lami

Across the world, more people are now obese than underweight. The plethora of calorie-dense, nutrient-poor foods being marketed and serviced globally have generated a new type of malnutrition, one in which a growing number of people are both overweight and undernourished. A recent New York Times article demonstrated that packaged food sales grew by 25 percent worldwide between 2011 and 2016, compared to a 10 percent growth in the United States. Sales of carbonated soft drinks have doubled in Latin America since 2000 and surpassed sales in North America in 2013. The influx of all this processed food into the global market has led to a phenomenon called the “nutrition transition” in many middle and lower income countries where the traditional, predominately plant-based low-calorie diets are replaced with high-calorie diets rich in fat, sugar, refined grains and animal-based sources.

As a global health fellow, I had the opportunity to witness first-hand the impacts of the nutrition transition in Ecuador. Having lived there for a year in 2008 and returning this past summer, I saw how the food environment has changed over the past decade. The city streets are now overrun with billboards advertising sugar-sweetened soft drinks, processed snacks and fast food restaurants. Local bodegas that used to carry staples such as rice, beans and vegetables now stock the latest sugar-laden processed snacks targeted directly to youth and children. Fresh fruit stands and choclo (large fresh corn snacks) vendors on the street have been replaced by vending machines selling processed snacks and sodas.

I visited urban and rural community health clinics and hospitals to observe how providers are addressing the global burden of pediatric obesity, but the truth is, most providers weren’t concerned about obesity. At my clinical visits, I saw illnesses I’d never seen in the United States: marasmus, kwashiorkor and stunting, the result of famine and malnourishment that have historically affected communities across Ecuador. Food access is still a major problem in many parts of the country, particularly rural communities where these hunger-related conditions continue to be a problem.

Problems of malnutrition have guided medical and nursing practices and government healthcare spending throughout modern history and it remains the same today. As a result, childhood obesity is a low priority for many practicing nurses and doctors. In fact, being overweight is considered a sign of health in many communities. “Un niño gordo es un niño sano” (an overweight child is a healthy child), is a comment I frequently heard from pediatric providers when discussing overweight patients. Just like in the United States, pediatricians in Ecuador track patients’ Body Mass Index (BMI) at almost every visit. But providers only seemed alarmed when patients were on the lower end of the BMI chart. Even when a child’s BMI exceeded the 99th percentile on the Body Mass Index Chart (placing them in the highest risk category for their weight), providers were not concerned. Should they be?

Over the past decade, Ecuador has experienced a higher burden of non-communicable diseases, and diabetes, hypertension, stroke, and ischemic heart disease are now the leading causes of death, according to the Instituto Nacional de Estadísticas y Censos, 2013. Ecuador’s 2013 National Nutrition and Health Survey demonstrated that excess body weight and obesity are widely prevalent across all age groups: 8.6% of children under five years old; 29.9% of school-age children; 26% of adolescents; and 62.8% of adults. Country experts are calling for the government to shift the focus of medical training to consider both underweight and overweight pediatric patients

Though the medical community may not yet be responding to the rise in pediatric obesity, the government has taken steps to improve the health of the population overall. Since 2014 they have instituted progressive policies (that we would do well to emulate here in the US) with the goal of improving the food environment and reducing health risks.

  • A “traffic light” food label mandate to help guide consumers in making healthier purchases. The law requires that packaged processed foods carry “traffic light” labels with horizontal red, yellow and green bars placed in that order from top to bottom. A 2016 study found that Ecuadorian consumers prefer food options with yellow and green labels, which led the food industry to change their products to make them more desirable. Many beverage companies voluntarily made their drinks sugar-free so their labels would be in the yellow or green zones.
  • School Lunches: In 2014 The Ecuadorian Ministry of Health’s regulatory committee published an agreement that prohibits the sale of products with high sugar, fat or salt (no red-light products based on their traffic light labeling system), energy drinks and products containing artificial sweeteners or caffeine in all Ecuadorian schools. In addition, school lunch programs in Ecuador are obliged to sell fruits and vegetables and offer free water. Something notable about this policy change is that the Ministry of Health banned food industry representatives from being on the regulatory committees in order to prevent any conflict of interest during the development of their regulations.

My experience in Ecuador opened my eyes to the benefits of being exposed to foreign health practices and political systems. There is a lot we can learn from the Ecuadorean government’s swift interventions to improve the food environment and support a healthier population. To solve our patient’s healthcare problems, we cannot just focus on medical treatment and what happens in our exam rooms. We must look upstream and consider how policy decisions are impacting the everyday health of our communities. We should get involved in changing our own food labeling laws (for updates and campaigns, sign up for The Center for Science in the Public Interest). We should advocate for healthier lunches in our public schools (to learn more, click here), and we should consider our patients’ cultural backgrounds and how that might shape their perceptions of health and risk.

In the Bay Area, we see a wide range of patients including immigrants from all over the world. Some are coming from countries, like Ecuador, that have experienced famine and may be happy to be in a place where calorie dense foods are available on every corner. Many patients and families may not be alarmed by a child’s high BMI or future risks. They may remember what their healthcare providers once said to them, “Un niño gordo es un niño sano.

Nadia Al-Lami is a second-year pediatric nurse practitioner student in the UCSF School of Nursing.