The Nutrition Transition: Evidence from Nicaragua, Costa Rica, and Chile
BY LISA R. PAWLOSKI, JEAN B. MOORE, NIGEL WATERS AND XINIA FERNANDEZ ROJAS
INTRODUCTION
Obesity is increasingly becoming an epidemic in industrialized nations, particularly in the U.S., where one out of every three adults is obese. However, the U.S. is not alone with this emerging public health crisis. In Europe, rates of obesity among adults are as high as 25% in the U.K. and Germany, and 10% in Italy and France (“WHO/Europe – Obesity in Europe – Home,” 2007). In the developed world, more time watching television, increased portion sizes, and the proliferation of cheap fast food restaurants is blamed for growing obesity and a toxic food environment. However, as obesity has risen within high-income nations, a new trend of overweight is emerging in both low and middle-income countries. More significantly, this trend has been noted where significant economic shifts have occurred. The idea of this change has been designated as “the nutrition transition” by epidemiologists and is officially defined as “population shifts in dietary patterns considered to increase the risks of obesity and related chronic diseases”. The nutrition transition is thought to be driven by demographic changes, urbanization, and changes in food production and marketing (Benjamin Caballero & Popkin, 2002).
The global threat of obesity has become a reality in the past ten years. The World Health Organization now estimates that about 28% of the world’s population as well as 10% of the world’s children are overweight or obese. The nutrition transition was first noted within South and Central America. In 1999, the Pan American Health Organization PAHO published a book entitled Obesity and Poverty by Manuel Pena and Jorge Bacalloa (2000), which cited the recent rise of obesity throughout the PAHO region. What was discovered was the rise in obesity primarily occurred in women of low socioeconomic status and men of high socioeconomic status. This was initially identified in Venezuela and in Brazil where wealthy women tried to remain thin as a social status while being fat signified greater wealth among men. Poorer women on the other hand had little access to healthy nutrient dense foods while working indoors and so they often consumed primarily calorie dense, low micronutrient filled foods (Obesity and Poverty, 2000). However, while evidence of obesity has been clear concerning adult women of low socioeconomic status, few studies have looked specifically at what is going on with adolescent girls. This is a significant lack in the research literature as adolescence sets the stage for future adult eating patterns and in wealthier nations, it is during adolescence when obesity rates climb to their highest levels, particularly among girls.
Here we report findings concerning the nutritional status among adolescent girls from three studies conducted in the PAHO region, namely urban areas in Costa Rica, Chile, and Nicaragua. The purpose is to compare the prevalence of obesity among these three groups of adolescent girls to determine if the problem of obesity may be of equal concern in three countries with varying economies and stages of economic transition in the PAHO region.
OBESITY AND THE NUTRITION TRANSITION IN FOCUS COUNTRIES
Concerning economic indicators, Real Gross Domestic Product (RGDP)per capita numbers reveal the following: Chile has the highest RGDP at $21,548.43, Costa Rica is next at $12, 353.53, while Nicaragua is the lowest with RGDP of just $2305.80. These are income numbers that are comparable across the world and are adjusted for differences in price levels for each country (“Penn World Table, index,” 2009). Below we describe evidence concerning the nutrition transition situation in each country.
Chile
Chile was one of the first countries in the world in which the phenomenon of the nutrition transition was recognized and is one of the wealthiest countries in South America. In the 1960s Chile faced health and nutrition problems, which were comparable to other regions within Latin America, including high rates of infectious disease, poor drinking water, and undernutrition. Public investments in the health infrastructure were later initiated in the early 1990s and overall the health status of Chileans improved dramatically (Vio & Albala, 2000).
While the health and nutrition transition in Chile in the past 47 years has resulted in a decrease in infectious diseases, it marks a notable increase in chronic illnesses. Obesity has therefore become a growing problem in Chile among all age groups, but it is more prevalent in lower socioeconomic groups, children, and women. The nutrition transition is thought to be driven by urbanization, and the population has shifted to a greater urbanization in Chile which correlates with the rise of obesity and obesity related chronic diseases. It is noteworthy that some researchers have found that obese Chilean children were already obese at 36 months of age, much younger than other populations facing the nutrition transition (Kain, Vio, & Albala, 2003).
Costa Rica
Costa Rica, which boasts one of the highest rates of longevity in the world and at present has relatively low rates of chronic disease, has not been immune to the nutrition transition. It has experienced a recent increase in overweight and obesity especially in children and adolescents. The 1996 Costa Rican National Nutrition Survey showed 4.2% of preschool-age children and 14.9% of school-age children were overweight, with even higher rates in metropolitan San José (Ministry of Health, 1996). The 2002 National School Health Survey, in which more than 25,000 school-age children participated, found that 12.7% were overweight and an additional 7.9% were obese. Obesity rates were higher in urban areas. Other studies have raised similar concerns. A study of Costa Rican children ages 7 to 12 years found that 34% were overweight (Nunez-Rivas, Monge-Rojas, Leon, & Rosello, 2003). Costa Rican adolescents also have high saturated fat intake, low levels of activity, and elevated LDL (bad cholesterol) levels that will increase their risk of coronary heart disease as adults (Monge, Beita, 2000).
Nicaragua
Nicaragua is considered the poorest country in Central America. As with the above cases, it is also facing a nutrition transition, but primarily in urban regions and among adult women. Very few studies exist which report the nutrition situation throughout the country, but suggesting a forthcoming trend in increasing overweight and obesity, Pawloski et al (2004) revealed evidence of obesity and overweight among adolescent girls living in Managua (L. R. Pawloski, J. B. Moore, L. Lumbi, & C. P. Rodriguez, 2004).
METHODS
Participants
Costa Rica. A convenience sample of 57 girls were selected from one school in San Jose which had an ongoing relationship with the Faculty of Nutrition at the Universidad de Costa Rica in San Jose, Costa Rica. The school is a public school in a low to middle class neighborhood. Convenience samples, while not the most ideal method of recruitment, are typically used in global health research, as research permits typically require approval from specific locations rather than allowing for random sampling.
Chile. A convenience sample of 119 girls were selected from two schools located in two suburbs outside the city of Santiago, Chile. Both schools were involved in previous research collaborations with faculty from the Pontificia Universidad Católica de Chile. The schools included a private Montessori school situated on the south side of the city that enrolls students from preschool through secondary school and a public school on the north side of the city that enrolls elementary and middle school students. The Montessori school consists primarily of students of high socioeconomic status and as a private school is considered relatively expensive while the public school, being partially funded by the Catholic Church is free to all students.
Nicaragua. A convenience sample of 79 girls were selected from the Axom Villa Liberdad barrio in Managua, the capital of Nicaragua. This particular barrio was established approximately 12 years ago such that many of its inhabitants are displaced people who arrived in Managua from rural communities because of political instability, economic crisis, and natural disasters.
Anthropometry
Height measurements without shoes, using a field portable GPM anthropometer (most accurate field equipment for measuring height) and hip and waist circumferences, were measured using non-flexible measuring tape. Weight was measured without shoes using a standard balance beam scale. All anthropometric measurements were collected based on methods described by Lohman, Roche, and Martorell (Pelletier, 1992). Heights and weights were collected among girls aged 9 to 18 years in Costa Rica, Chile, and Nicaragua. Body mass index BMI values were computed by dividing weight in kilograms by the square of height in meters.
BMI-for-age percentiles were calculated using the participants’ BMI, height, weight, and reference data developed by the US Centers for Disease Control (CDC) (Kuczmarski et al., 2002 and Ogden et al., 2002). The percentiles were generated using the program Epi-Info (Dean, 1990). The CDC data were published in 2000 and established primarily from US databases including the US National Health Examination (NHES) and National Health and Nutrition Examination surveys (NHANES) data (Kuczmarski et al., 2002). These data were revised from earlier growth data established in 1977 by the National Center for Health Statistics (Ogden et al., 2002). Percentiles allow for comparisons with reference data and are calculated for BMI-for-age percentiles. To estimate prevalence of the underweight, overweight, and obese, BMI and BMI-for-age data are compared with CDC cut-off data, for which underweight equals less than the 5th percentile, and overweight and obesity equal greater than the 85th percentile (Dean, 1990). Comparison data are chosen to serve as a reference rather than a standard. These international reference data were used because no large reference sample is available from Costa Rica, Chile, or Nicaragua with which to make a comparison. Using PASWStatistics 18.0, descriptive statistics were conducted as well as One-way ANOVA to examine differences in BMI percentiles between the three study sites.
RESULTS
Means and standard deviations concerning BMI-for-age percentiles for each country are presented in Table 1 and one-way ANOVA analysis results are presented in Table 2. These data show mean BMI-for-age percentiles above the mean reference populations, with Chile having the highest mean, followed by Costa Rica, and Nicaragua being last. One-way ANOVA shows statistically significant differences between the three countries (p<.05). However, Bonferroni Post hoc analyses show significant differences only between Chile and Nicaragua. Concerning the percentages of obesity, Costa Rica revealed 1.8% underweight and 21.1% overweight or obese, Chile revealed 0% underweight and 27.7% overweight or obese, and Nicaragua revealed 2.5% underweight and 10.1% overweight or obese, again showing Chile to have the highest percentage of overweight and obesity, with Nicaragua’s percentage being the lowest.
DISCUSSION
The results support earlier evidence that the presence of overweight and obesity suggests a nutrition transition has taken place in Costa Rica, Chile, and Nicaragua. However, these results present data from adolescent girls, which have not to a great extent been reported in the literature. Throughout South and Central America, overweight and obesity is known to be a greater problem among women of low socioeconomic status, and thus these data suggest the problem begins earlier than adulthood. Furthermore, this problem also crosses economic boundaries, showing that overweight and obesity occur among adolescent girls not only in the wealthier countries in the region, but also in Nicaragua, the poorest country in South and Central America. Further statistical comparisons between the three countries show significantly greater overweight and obesity in Chile when compared to Costa Rica and Nicaragua. These findings are counter-intuitive as we might expect a significantly lower amount of overweight and obese girls in Nicaragua, due to the country’s ongoing significant undernutrition and stunting problems . However, in Nicaragua, reports of undernutrition and stunting appear to occur primarily in the north and within rural regions, suggesting that the problem of overweight and obesity in urban Nicaragua is similar to that in Costa Rica. Both areas are still significantly behind Chile.
Previously, two of the authors have received funding from the Center for Global Studies to study the nutritional status of children from two schools in Santiago, Chile. Thanks to the 2009 summer research grant from the Center, the researchers are currently analyzing geographic factors, which might influence obesity in Costa Rica, including access and availability to healthy foods. One key factor in preventing overweight and obesity in children is access to fruits and vegetables. Pawloski et al (2004) reported poor fruit and vegetable consumption among Nicaraguan adolescents is correlated with poor access and availability to nutritious foods due to longer distances to larger markets, poor transportation, and the expense of traveling to markets (L. R. Pawloski et al., 2004 and Jean Burley Moore, Lisa Pawloski, Claudia Rodriguez, Laura Lumbi, & Ailinger, 2009). In the United States, a study of grocery stores in urban Baltimore that captured each facility using a healthy food availability index determined that low-income neighborhoods had a lower availability of healthy foods than higher-income neighborhoods (Franco, Diezroux, Glass, Caballero, & Brancati, 2008). Another study used a Geographic Information System (GIS) to examine the relationships between grocery stores and fast food outlets and childhood obesity, and found that those children who lived closer to fast food outlets consumed fewer fruits and vegetables (Timperio, Ball, Salmon, Roberts, & Crawford, 2007). While similar problems concerning access may occur in both Costa Rica and Nicaragua, reasons for poor access may be quite different. In Nicaragua, the community in which the participants lived was created from displaced peoples who were forced to live near people they did not trust or know well. This situation created a fear of theft and other forms of crime, which confined individuals to their homes causing them to only shop at local venders who sold few nutrient dense items. Further, in Nicaragua roads and public transportation are much less developed than in Costa Rica, such that many of the roads are not paved and there are few sidewalks. Thus, the issue of overweight and obesity in Costa Rica may be caused by issues more common to Chile, namely the overabundance and high availability of unhealthy foods and snacks rather than poor availability of high nutrient dense foods. Improved transportation only makes it easier to access these snacks and also causes reduced energy expenditure as more children are using buses or are driven to school (Huang et al, 2009). Hence, the problems related to overweight and obesity throughout South and Central America are complex and require multidimensional analyses that focus on structural factors of the environment the concerned populations live in.
CONCLUSIONS
Thus the data suggest that overweight and obesity are present within the adolescent girl population from three countries of varying economic status in Latin America, and that therefore overweight and obesity are not specific to high-income nations within this region. However, these findings do suggest that within urban centers in these countries, obesity may be of greater concern within the adolescent girl population in Chile, which has one of the highest economies in the Latin American region. This study represents one of the few analyses which have specifically examined adolescent girls, who are at greater risk for weight gain due to the adolescent growth spurt and greater independence in food choices.
Lisa R. Pawloski is Associate Professor and Chair at the Department of Global and Community Health at George Mason University. Jean B. Moor is Professor at the School of Nursing at George Mason University. Nigel Waters is Professor at the Department of Geography and Geoinformation Science at George Mason University and Director of the GIS Center of Excellence. Xinia Fernandez Roja is Professor at the Universidad de Costa Rica in San Jose, Costa Rica.
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