Overweight, obesity, and food consumption in Galapagos, Ecuador: a window on the world

Overweight and obesity represent a critical global public health problem; worldwide, the rate of obesity has tripled since 1975 [1]. As is the case in most countries, Ecuador is currently faced with the overweight and obesity pandemic, which affects all age groups beginning in early childhood [2]. Located 600 miles west of mainland Ecuador’s Pacific coast, Galapagos is best known for its unique natural environment, but it is currently home to 25,244 residents [3]. This figure contrasts with 1,350 residents in 1950; 9,785 in 1990; and 18,640 in 2001. Population growth was mainly a product of national migration, which is now regulated. On the other hand, while around 2,000 visitors toured the islands in the 1960s (mostly on boats), 224,745 registered tourists visited in 2015, many staying in hotels [4‐6]. The challenges of balancing the benefits and pressures of tourism and conserving this World Heritage Site’s land and marine environment are daunting; moreover, local and national authorities must also attend to the health and nutrition of the islands’ residents [7]. While tourism is the major economic activity associated with the province, public administration and privately sector services are also important sources of employment. Recent regulations on the use of plastic reflects the importance of envorimental conservation and of the residents’ wellbeing [8]. Among Ecuador’s provinces, Galapagos has the highest rate of overweight and obesity in all age groups, including 12.7% among children under 5 and 75.9% among adults from 20 to 60. In comparision, the national average for adults is 65% and Latin American countries with the highest rates of adult overweight and obesity are Argentina (68%), Chile (65%), and Mexico (70%) [9, 10].

Galapagos may be viewed as different but not unique with respect to access, cost, and consumption of food, so an understanding of how those factors affect overweight and obesity can shed light on patterns observed in communities elsewhere in Ecuador and in other countries. In that sense, Galapagos represents a case study of the relationships between an emerging industrialized food regime and an increasingly prevalent local, regional, and global health problem [11‐13]. For example, among nation states in the Pacific region, high rates of overweight and obesity have been shown to be related to consumption of imported, processed, and energy-dense foods instead of traditional diets, reflecting the emergence of complex, globalized commodity chains, urbanization, changes in occupational structures, and sedentary life styles, which characterize all countries to one degree or another [14‐16]. Research on the nutritional transition shows that beginning in the 1970s, most countries experienced dietary shifts (especially, increased consumption of processed foods with high levels of fat, sugar, and salt and increases in away-from-home meals), and reduced physical activity. Consequently, rates of overweight and obesity and associated chronic diseases such as diabetes have increased worldwide. representing an emerging epidemic [17, 18]. This holds for Latin America, where obesity and overweight among children is of particular concern [19, 20].

The present study was designed to analyze overweight and obesity in Galapagos in the context of household food expenditures as well as perceptions and practices related to diet.

The authors declare no conflicts of interest. This study was approved by the IRB of the Universidad San Francisco de Quito. It combined quantitative and qualitative research techniques in order to take advantage of the complementary strengths of each approach [21]. The quantitative component was based on the Ecuadorian Survey of Living Conditions (ECV, Encuesta de Condiciones de Vida), which included 1,183 and 553 Galapagos households in 2009 and 2014, respectively, and which collected data on expenditures for foods, which we classified using the NOVA system [22, 23] based on a list of foods and beverages consumed in Ecuador [24]. ECV food expenditure data were matched with the Ecuadorian food composition tables [25], yielding a list of foods, categorized according to the NOVA system. The caloric content and the cost per calorie of each item were then calculated.

The NOVA system divides foods into four mutually-exclusive groups according to the level of processing. Unprocessed or minimally processed foods are unmodified or altered simply by separating edible from nonedible parts to preserve natural foods, enhance storability, or make foods safe to consume. Processed culinary ingredients contain oils, fat, sugar, or salt and are usually added to foods in the other groups. Processed foods are industrially transformed to increase the durability of unprocessed foods or to modify or enhance their sensory qualities. Examples include canned vegetables and fruits, cheese, and breads prepared by adding salt, oil, or sugar. Ultra-processed foods are manufactured products that include sweetened beverages, packaged snacks and desserts, reconstituted foods, meat products such as ham and sausages, and frozen or freeze-dried meals. These products include added sugar, fats, or salt as well as additional chemical or artificial ingredients, including colors or flavor enhancers [23].

Poisson multivariable regression was used to evaluate the marginal effect of socioeconomic variables on the contribution of ultra-processed items to the food basket for each survey [26]. In order to compare both surveys, estimations were calculated for combined data with the year as a dummy variable. This step was possible because the sampling designs were similar for both surveys. Three different regression models were applied using data from: (i) 2009 and 2014 combined (Model A), (ii) 2009 (model B), and (iii) 2014 (model C). Statistical estimations of variance were calculated with Taylor series approximations, survey weights, and complex survey design using the R survey package [27].

Since households are not homogeneous, the statistical analysis began by normalizing expenditures and caloric content data in the four NOVA categories in order to compare average proportions in each household. This was accomplished by calculating the proportion of expenditures and calories in each category for each household and the average of proportions of expenditures and caloric content in each category. This information was disaggregated by urban or rural residence, age group, level of formal education, and sex. A T test was applied in order to establish differences between 2009 and 2014, disaggregated according to the different categories.

The study’s qualitative component was designed to understand perceptions and practices that shape patterns of food purchase and consumption among different segments of the Galapagos population [21, 28‐30]. This component consisted of nine focus group discussions (FGD), 10 key informant interviews (KII), and structured observations (SO). FGD were conducted in the cities of Puerto Ayora (on the island of Santa Cruz) and Puerto Baquerizo (the provincial capital on the island of San Cristobal). In each city, four focus groups were conducted among adult women (≥ 20 years), adult men (≥ 20 years), unmarried male and female adolescents (12-19 years), and male and female children (8-11 years). An additional FGD was conducted with rural women on the island of San Cristobal. 38 (61.3%) of the participants were females and 24 (38.7%) were males. Perceptions of younger people were important to the study because of their influence in family food purchase and consumption, so 30 participants (48%) were between 8 and 11 years of age and 14 (11%) were between 12 and 17. All adult participants had attended at least six years of primary school; over a third attended or graduated from universities and an additional half were high school graduates.

KII were conducted with public health professionals, educators, and long-time residents of Galapagos in order to obtain information from persons with professional or personal knowledge about local dietary practices. SO were carried out in neighborhood shops, restaurants, municipal markets, and weekly farmers´ markets in order to assess food availability, quality, and cost of unprocessed or minimally processed, culinary, processed, and ultra-processed foods.

Focusing on how individuals perceive and navigate their social world, the qualitative component employed a theoretical sampling strategy to optimize validity by employing two operational principles. First, through triangulation, information was obtained from a variety of sources using a variety of techniques. Second, the principle of saturation was implemented: data collection continued until no additional information was obtained [31]. Verbatim transcriptions of FGDs and notes taken during KIIs and SO were analyzed in Spanish using a systematic three-stage coding process. First, open coding identified basic concepts enunciated by the participants in their own words. Second, axial coding provided for the development of underlying categories and properties in order to detect patterns of perceptions discussed by FGD participants. Third, selective coding integrated and refined the principal themes and interrelations among them to allow for the identification and analyisis of key dimensions [31].

The prevalence of obesity and overweight in Galapagos is higher than elsewhere in Ecuador [2], affecting residents in all age groups. Rates are also high compared to other countries, and as elsewhere, increasing consumption of processed and ultra-processed foods influences dramatic and troubling trends in the health and nutrition profile in Galapagos [32]. Galapagos residents face substantial barriers to the purchase and consumption of healthy foods (especially fresh fruit and vegetables). At the same time, they spend increasingly less on unprocessed and minimally processed foods and more on processed and ultra-processed foods and proportionally more on calories associated with the latter as compared to the former. A pattern of disparity with regard to the selection of unhealthy foods is observed, in particular, when males purchase food, among less educated persons, and among urban residents. While issues of cost clearly are in the forefront in this regard, this pattern also suggests that programs of promotion and prevention could be oriented toward specific groups in schools, shops, restaurants, health centers, and in mass media.

The qualitative component of this study suggests that prices for fresh produce are considered to be prohibitively high, availability is irregular, quality is often poor, and access to locally produced food is limited. This component confirms that expenditures are increasingly dedicated to the purchase of processed and ultra-processed foods, thereby resulting in a shift in food consumption patterns. While this trend characterizes all families to some degree, expenditures for processed and ultra-processed foods are greatest in urban households where males are responsible for purchasing food and when educational levels are higher.

Overweight and obesity respresent a challenge to public health in Galapagos, while food expenditures and consumption patterns reflect cost advantages of processed and ultra-processed foods and more broadly, the globalization of an increasingly industrialized food chain [33, 34]. Broad socioeconomic transformations that affect Galapagos (notably, urbanization and sedentary occupations and lifestyles) are important factors. Measures that should be taken in Galapagos may be valid elsewhere, although implementation strategies will necessarily vary. First, the availability and quality of fresh foods should be improved and local production of fruit and vegetables should be incentivized in order to improve dietary quality and reduce dependence on imported foods [35]. Second, a multi-faceted nutritional education program should include easily-understood information provided to parents and children. Third, policy options could include maintaining the current nutritional label and regulating or taxing sweetened beverages. Third, family, community, and school gardens should be promoted by the Ministries of Education and Agriculture, and incentives provided to local small-scale farmers. Agricultural production and urban residence represent only 3% of total land area in Galapagos [36], but the need for policies that are consistent with conservation is clear. Such a program should be established within the paraters set by the Galapagos National Park, which sets guidelines for all non-urban land use, and the Galapagos Biosecurity Agency, which regulates the control of insects and prohibit most pesticide use. It would concentrate on sustainable use of existing agricultural land and urban gardens, efficient use of water, organic production and pest control techniques, and enhanced linkages between Galapagos producers and consumers. This approach would be consistent with conserving the unique natural resources of the Galapagos.

Finally, mass media and other communication channels should provide information about healthy diets, and restaurants should receive incentives for providing nutritional information and for serving healthy foods.

While the residents of Galapagos face specific constraints to healthy dietary practices, these constaints are not unique but are, rather, accentuated due to the islands’ characteristics—especially their relative isolation and vulnerability. Access to healthy diets are limited to one degree or another in communities and countries worldwide, while at the same time, globalized and industrialized processed and ultra-processed foods increasingly contribute to the worldwide pandemic of overweight and obesity [37]. Local food consumption is shaped by both the tourist industry (because of the competing demands for high-quality fresh food and produce) and regulations on land use, but all local populations face limitations and opportunities for healthy consumption, and in this sense, Galapagos is, indeed, a window on the world.

This study benefitted from the intersection of quantitative methods, which allowed for analyzing statistical differences in food expenditures, and qualitative methods, which in themselves are not necessarily generalizable, but which are contextualize quantitavie findings in terms of the perceptions and practice of Galapagos residents. Qualitative methods alone do not allow for extrapolation, but they are invaluable in elucidating relationships established using quantitative techniques [28‐30, 34]. The NOVA classification system [22, 23] provides a useful way to analyze patterns and changes in food purchase and consumption among households with different demographic characteristics.