1999: Jennifer Shaw, MPH, RD
CHRONIC DISEASE: THE NEW FACE OF POVERTY IN CHILE
In developing societies, human, social and economic development is largely influenced by the nutritional condition of the population. Unemployment, lack of income, poor alimentation, adverse environmental conditions and lack of basic services continue to be a problem in Latin America. Chile is no exception. Over the last 25 years, Chile has experienced a large growth in its economy, and a shrinking rate of malnutrition, but not all have enjoyed its recent prosperity. The economic growth has resulted in a widening of the gap between the poor and the wealthy, preserving the rigid class structure that leaves a large segment of the population living an impoverished life of food and income insecurities. Though Chile has maintained growth rates of more than 7% annually, the wealthiest 10% in Chile have maintained 41% of the population's income while the poorest 10% have received between 1.4% and 1.7% of the total income earned in Chile between 1987 and 1996.(1) According to the National Population Census (CASEN), between the years of 1994 and 1996 the gap between the rich and the poor increased by a factors ranging between 13.12 and 13.83. In monetary terms, this income breach translates into household earnings of US $137.36 per year for the poorest 10% of the population and US $3,939.32 for the wealthiest 10% of the population, or an income gap between the poor and rich of a factor of 29. According to a UN report in 1997, "La Realisation des Droits Economiques, Sociaux et Culterels" these statistics place Chile in 50th place (out of 54 countries) regarding the difference between the highest and lowest income quintiles, or the gap between the rich and poor. In regards to overall poverty, the latest CASEN figures show that at the end of 1996, the poverty rate in Chile was approaching 3.3 million people or 23.2% of the total population. Statistics from the years between 1990 and 1996 show that women are more affected by poverty than men with poverty rates ranging between 23.5% and 39.3% of the population. These figures have decreased over the last 10 years, but reducing poverty levels has become more and more difficult.(1)
Whereas in recent history, the manifestations of poverty were malnutrition and infectious disease, the new faces of poverty are obesity and chronic disease. According to the Institute de Nutrición y Tecnologia de Alimentos (INTA), an institute for health and nutrition at the University of Chile:
"the major present and projected causes of death and disability in Chile are diet related non-communicable chronic disease (coronary heart disease, diabetes, obesity, hypertension, stroke and cancer). These can be ameliorated by a healthy diet throughout the lifecycle and by the availability of safe foods. The health challenge of foodborne disease has changed, new emerging pathogens have been described, changes of food production and processing have lead to new problems. Genetically modified organisms represent new concerns."(2)
Therefore, though Chile is still considered a developing country, diet related non-communicable chronic disease (coronary heart disease, diabetes, obesity, hypertension, stroke and cancer) has now surpassed communicable diseases as the main cause of death. In 1998, infections contributed to less than 3% of all deaths. At the same time, chronic disease rates in Chile are similar or higher than those in developed nations like the US and Canada. Statistics from Chile between 1986 and 1987 demonstrate that for every 100,000 deaths 186.1 were from cancer, 117.3 were attributed to coronary heart disease and 103.7 resulted from stroke. During the same year in the US, the mortality rates for these same diseases were 190.7, 200.65 and 58.8, respectively.(3)
In Chile, the prevalence of risk factors for chronic disease is high and steadily increasing. A study done by Berrios et al in 1988 and 1992 in adults in the Greater Metropolitan area of Santiago de Chile shows an increase in alcohol consumption (57.1% to 61.7%), sedentarism (55.4% to 57.8%), hypertension (19.7% to 35.5%), hypercholesterolemia (33.8% to 43.3%) and a decrease in smoking (47.1% to 43.6%) in men. These same risk factor rates were even more striking among women. During the same time period, alcohol consumption increased (19.2% to 29.8%), as did sedentarism (77.4% to 80.1%) smoking (40.3% to 44.7%), hypertension (16.7% to 33.4%) and hypercholesterolemia (34.0% to 45.85%).(4) Berrios et al., Vega et al. and Albala et al. found rising rates of elevated cholesterol levels among poorer populations.(5) In Vega's study, 49% of the subjects in the high socioeconomic level and 47.5% of the subjects in the lower socioeconomic group had elevated cholesterol levels indicating that along with the growing gap in income levels, there is a heightening of chronic disease risk factors among low socioeconomic levels.
Obesity is also on the rise, especially in low income populations and children. National health statistics show that in Chile in 1996, 17% of men and 27% of the women were obese. At the same time, the prevalence of obesity increased with age and was more common in lower socioeconomic levels.(5) The growing number of obese in lower economic levels is a great concern due to the poor access to medical services, food and job insecurity and high stress that low income individuals encounter.
Childhood obesity has also grown while childhood malnutrition rates are as low as 5% (down from 15.5% in 1975). According to The Sistema Nacional de Servicios de Salud (SNSS) obesity rates for children under six years of age have increased by 56% over the last 10 years with a prevalence of 7.2% in 1995. Between 1987 and 1996 the proportion of obesity in children between zero and six years has doubled in boys (6.5% to 13.1%) as well as girls (7.7% to 14.7%). As a result, Obesity has become the most important nutritional problem in the child population in the lower-middle and lower classes.(5)
Despite the substantial increase in chronic disease and obesity, Chile is still experiencing some malnutrition and transmissible diseases albeit few cases. This epidemiological transition has come about due to large demographic changes and rapid urbanization and industrialization. The quick growth of the economy and a large rate of migration to and expansion of the cities (mainly the capital city of Santiago) has increased the risk factors discussed previously — all of which are associated with an increased incidence of chronic illness, accidents, violence and mental disturbances.
Behind these alarming statistics of chronic disease lie fragmenting social relations brought about by a rapid industrialization process and the economic stress of the growing gap between the rich and the poor. The large migration to cities has torn apart the family safety net as individuals must leave their families to work in the larger cities because of lack of job opportunities in their home town. Moreover, with the entrance of greater numbers of women into the workforce and a greater rate of urbanization and mobilization, the number of people eating one or more meals outside of the home has increased, along with the number of fast food restaurants. Added to this is the industrialization of the food processing industry, flooding the market with processed foods high in fat and sugars, and genetically altered produce. In this manner, the traditional Chilean diet, once rich in cereals, plant foods and low in fat and animal protein, has changed to one characterized by fats, sugars and processed foods. This typical Western diet has lead to a higher lipid profile among Chilean people. High fat intake, economic and personal stress, a fragmenting social network, and the sedentary lifestyle which is also becoming more frequent in Chile, are undoubtedly related to the change in the population's health profile.
While the rates of chronic disease and obesity among the poor are growing, the health system is struggling. Geared towards preventing malnutrition and infectious diseases, chronic disease monitoring and prevention programs are not yet equipped to handle the large demand. Nor is the system apt to deal with the social factors that are related to this crisis. The few prevention and treatment measures that do exist are geared towards the upper socioeconomic levels and not towards the increasing number of people with scarce resources and limited education that are experiencing many of the same types of chronic diseases that are typically associated with wealth.
In addition to the preliminary measures that the political and health authorities have taken, the greater population has come up with some of their own answers to the social, economic, and health problems they are experiencing. One very important measure is Urban Agriculture. The production of organic produce and small scale animal husbandry in limited spaces and the creation of microenterprise and microcredit groups are viable and sustainable actions that can help individuals overcome poverty and poor health. The self-reliance which accompanies the implementation of Urban Agriculture is an(6) important aspect which is not always included in nutrition interventions and economic development programs.
However, with few resources and little political power, populations with limited resources need support to organize. In the beginning, their efforts must be coordinated with institutions that they can rely on for technical support, training, credit and other resources. Through a strategy of production technology based in agroecological principles it is possible to develop a road to overcoming poverty which strengthens the organization and management capacity of low income people, improving the city's environment and creating a chain of initiatives that are economically viable. This focus aims to create wealth (economic and social) and well-being while considering human resources and materials (social and institutional) in order to overcome poverty.(6)
The Centro de Educación and Tecnologia (Center for Education and Technology or CET) operates along these principles. As a Non Governmental Organization (NGO) in Chile, CET has enjoyed great success in implementing Urban Agriculture as a method of sustainable economic and social development in populations with limited resources. Starting in 1986 in response to a Cholera scare, high rates of malnutrition due to poor food access, and food contamination from pesticides, as well as the transformation of the food system into a highly processed and global one, it now recognizes the need for chronic disease and obesity prevention programs, in order to combat these new plagues in Chile. Among their programs geared towards increasing food security, environmental reclamation and income generation CET administers an urban garden training program where peer educators train neighborhood groups in urban gardening and microenterprise. During the process, the groups form their own microcredit lending groups in order to pay for materials like seeds and to finance their small businesses. The model of organic food production that increases the participant's access to quality organic fruits and vegetables, not available in stores, provides each family with approximately 821 kg of food including fruits, vegetables, chicken, rabbits and bread all free of pesticides and/or chemicals. In the process, the family is able to meet more than their vitamin C needs, raise their iron and calcium intake and consume lower calorie foods. CET is currently working with 10 municipalities to implement the sustainable development model that they have developed and implemented in Tomé (a peri-urban city of 49,000 inhabitants in the South of Chile) one of their five locations in Chile. In Chile, approximately 85% of the cities and 75% of the counties have the same population size as the city and county of Tomé,(7) and given that Chile's socioeconomic indicators tend to reflect the population size, CET's interventions are very applicable to a large portion of the population. In fact, the expansion of the programs into the 10 new municipalities will extend CET's reach to approximately 85,000 people.(8)
CET's programming currently addresses food security issues, but does not reach as far as disease control and prevention, nor adequate care issues, such as hygiene, and usage of health services and health information, all of which are very important given Chile's current health profile. In this manner, as a Nutritionist, I have been incorporated into CET Tomé's work team of a veterinarian, agronomists, an economist, a civil engineer, a social worker and peer educators to expand their food security program to encompass these nutritional themes in order to achieve nutrition security as well.
Together, we are working to reshape CET's Food Security program to face the growing problems of obesity and chronic disease affecting Chile's populations. In this manner, we are applying CET's three work areas to develop the new programming: the development of human resources through the transfer of feasible technology to poor populations, systematic data collection of impacts and processes of urban agriculture and sustainable development and the on-going improvement of CET's program areas using both of the above.
In the area of human resource development, we are in the midst of developing a nutrition curriculum focused on changing the food habits and nutrition knowledge of the program's participants — low-income residents in the town of Tomé. This curriculum is prevention-based by nature and focuses on using what the participants produce in their homes to improve their health and that of their families. The six encounters are activity-based and most of the discussion questions revolve around the participants own experiences with food preparation. Each class relates foods that the people typically eat with the appropriate nutritional concepts. For example, the fruit and vegetable class deals with vitamins and antioxidants and how to prepare the foods which contain these nutrients in a healthy and appealing manner. Other themes include food safety, cereals and energy, meat and fat consumption and activity and weight loss. The group meetings also serve as a time for sharing and drawing on the experiences of the other participants to solve common problems that they all face in the aspects of food preparation, health issues and social problems.
The curriculum is now in the testing phase. The social worker, a peer educator and I are field testing the classes and we are working with the Director on the theoretical and structural parts of the program. These experiences, the participants' evaluations of each course and peer educator inputs will be used to revise the curriculum and train the other peer educators to administer the courses to the neighborhood groups. We are also including an outcome evaluation, consisting of a pre and post test nutrition knowledge and practice questionnaire in order to document the nutrition program's effects. The participatory nature of these nutrition classes, as well as the involvement of the peer educators makes it a sustainable, comprehensive method of disease prevention. It is hoped that with the perfection of this model, other members of the CET network in Chile and Latin America will be able to adapt the curriculum to their needs, in order to improve the nutrition status of their populations.
By emphasizing low-cost methods of food preparation, this program supports the socio-economic development portion of CET's methodology. In this manner, healthy and inexpensive alternatives to commonly purchased foods which are often expensive, highly processed and high in fat, sugar and salt are prepared during the classes, such as home made low-fat granola instead of sugared corn-flakes, and whole wheat bread instead of white. In the future, there will be workshops on bread, fruit preserves and dried fruit production for the women who have interest in selling these products to raise income for their families. Between the monetary savings of home food preparation and the increased income of microenterprise, the economic development achieved through this program will play an important role in the overall quality of life and health of the 500 or so families that the program currently reaches and those in the II cities in the region that are currently implementing CET's model.
The final component of the human resource phase of the program is one of self-development which occurs on two levels. The first is the level of the participant who, through the active participation format of the program is better able to care for the health of her family through food preparation and the generation (and/or savings) of income. The second is the level of the peer educators (or Monitoras) who will be trained to give the nutrition courses. During the process of training and working as a Monitora, the women increase their own self worth and self-efficacy. Not only does the knowledge and experience they gain through training and teaching change their habits and self-perception, but their earnings also boost their importance in the family structure and their freedom to make their own decisions.
CET's model and experiences are an important lesson for the rest of the country and Latin America in terms of improving food security and economic self-sufficiency. However, without sound nutritional assessment data, it is difficult to convince others of the important impact that CET's methodology could have on improving the nutritional status and reducing the chronic disease rates in low income populations. The second component of the program consists of a nutritional assessment project to measure the impacts of the urban gardening program on the participants and to assess the general nutrition status in Tomé. In this study, 100 families will be interviewed by various members of the team to determine their daily nutrient intake and their overall nutrition status. The study is now in the development phase with the help of the other members of the CET team. The current plan is to administer a 24-hour recall using a food list developed through a preliminary diet study carried out in March. The assessment tool will be administered two times to obtain a representative sample of the subject's daily consumption. A trained team consisting of the social worker, the Monitoras and a few participants in CET's Ecoclub, an environmental club for students from the ages of 12 to 18, will administer the questionnaire to 100 low-income women in Tomé. The experimental group will be 50 participants in CET's neighborhood garden groups and 50 women who do not participate in CET's programming will form the control group. Part of the investigation process will be to validate this dietary assessment tool to be used in other parts of Chile where the CET programs are to be implemented. We are also planning to collect height and weight data to use the Body Mass Index measure to document obesity. The diet intake surveys will be analyzed using a computer program developed by the computer technician at CET using the Chilean food composition tables, also to be used in future studies. The expertise of a Professor of Nutrition at the University of Concepción will also be incorporated in the data collection and analysis process. The results from this study will be used for three purposes:
- To document the possible existence of a difference between the diets of people who have urban gardens and those who do not.
- To document the nutritional status of Tomé's low-income population.
- To reshape CET's current programming to meet the needs of its participants.
As stated above, the third portion of CET's methodology is the improvement of the current programming. The development and testing of the nutrition curriculum and the diet study will serve to improve CET's programs and make it more applicable and helpful to the low income populations. In the future, this model will be implemented in the 10 other cities in which CET is currently implementing its model.
The current health problems in Chile will not be solved solely through medical treatment of chronic disease. Preventative measures that not only focus on health and diet, but personal and economic development must also be implemented. Up until now, CET has been working on solving economic, environmental and food security problems using a participatory and sustainable methodology. Performing a scientific study of the nutritional status of the population and designing and evaluating a nutrition curriculum will give CET the power it needs to spread its effective programs to other populations in need. Only a prevention focused, participatory methodology will be able to lower the alarming rates of chronic disease in Chile and improve the social and economic conditions of Chile's population.
REFERENCES
- Instituto de Tercer Mundo. Social Watch. World Wide Web.
- Instituto de Nutrición y Tecnologia de los Alimentos, Universidad de Chile. World Wide Web. www.inta.uchile.cl/
- Albala C, Vio F, Yañez M. Epidemiological transition in Latin America. A comparison of four countries. Revista Médica de Chile. 1997;125:719-727.
- Berrios X. Tendencia temporal de los factores de riesgo de enfermedades crónicas: la antesala silenciosa de una epidemia que viene? Revista Médica de Chile. 1997;125:1405-07.
- Albala C, Vio F, Kain J. Obesity, an unresolved problem in Chile. Revista Médica de Chile. 1998;126:1001-1009.
- Montero A. Desarrollo local sustentable: Agricultura urbana, microempresas y manejo de residuos solidos. Agricultura y Desarrollo. 1997;Nov(11/12):89-98.
- Censo Nacional de la Población (CASEN). 1992.
- Letelier E. Economist. Personal communication. July 1999.