Namlo Rural Nutrition Survey: Nicaragua

A Short Glimpse at Namlo’s Nicaragua Nutrition Survey – 2015

Nicaraguan boy with Greenpepper from Garden

Nicaraguan boy with Greenpepper from Garden

Introduction

By

Keith Frausto

Executive Director, Namlo International

Namlo International, Inc., has been implementing projects in Nicaragua since 2006, initially concentrating on school construction and infrastructure improvement. With the goal of building sustainable communities, Namlo makes use of a broad approach that includes education, economic development, infrastructure improvement, women’s empowerment and leadership training. In partnership with the communities of El Quebracho, Los Pinares, Barrio Nuevo and El Salmeron, over the years Namlo built schools, latrines, and water systems.   Economic development project activities, which are crucial drivers for development especially in remote mountain communities, were less successful.  Various attempts were made at community-owned economic projects, with little success.

At the end of 2013, Namlo partnered with Al Campo International to start an economic development program to address the issues of nutrition and poverty.  Al Campo International is a service learning organization that had been disseminating greenhouses in community called Las Palmas for over ten years. Tim Gibb, the director of Al Campo International took the idea of reducing a commercially available greenhouse down to a size that would be manageable and affordable to a typical rural Nicaraguan family. As part of the “proof of concept” stage of product development, Tim and his students installed twenty greenhouses in Las Palmas over a period of ten years.

Encouraged by Al Campo’s success in Las Palmas, Namlo adopted the Al Campo greenhouses as part of its program approach and has been introducing the greenhouses to its partner communities, with the intent to expand to other communities in Nicaragua, and possibly throughout Central America. A necessary first step in implementing the project has been to get some understanding of baseline nutritional and economic conditions that exist in the Namlo communities, to be able to eventually measure the impact of the Greenhouse Program as it moves forward.

This survey project has been a significant challenge, given extremely limited funding constraints. We were lucky to find a Fulbright nutritionist in Nicaragua, Dan Fenyvesi, as well as very talented graduate student from the University of Nicaragua, Kenia Páramo. We also forged a partnership with the Nutrition Department of the National Autonomous University of Nicaragua (UNAN), and recruited the nutrition students Taimy Hernandez, Ariel Marin and Diego Castro to help implement the survey in Namlo’s remote communities. Dan, Kenia and the students traveled by bus, spent their nights eating and sleeping in the communities and working under challenging conditions.

The Survey Team from the University of Nicaragua

The Survey Team from the University of Nicaragua

The result of the team’s work gives us a glimpse into the lives of the people in the remote communities, their nutrition, diets, incomes, family composition, food security and education. Comparisons can be made between the community where the greenhouses have been adopted, and those in the Namlo communities where greenhouses have just recently been introduced. Dan Fenyvesi’s commentary also provides a great summary of the survey, along with program recommendations for the future. The work the nutrition team and this report provides us with framework against which we can measure our progress as we move forward with the greenhouse program.  Below is Dan’s Commentary on the nutrition survey, which will be posted in its entirety at a later date

Commentary on the NAMLO Report

by Dan Fenyvesi M.S., R.D.

Historical Context

The diets of people in the mountains north of Nicaragua began to undergo dramatic changes in the 1950s. Prior to the 1950s people had small farms where they cultivated and consumed a diet that was very common for thousands of years throughout Central America and Mexico: the “Three Sisters Diet” of corn, beans, and squash. These three staples were supplemented by wild game (most commonly deer, iguanas, rabbits), chicken/eggs, and handful of other common fruits and vegetables.

Beginning in the 1950s, modernization resulted in the consolidation of much of the local people’s lands – all the most fertile plots- into large scale plantations to cultivate cash crops for export: coffee, cotton, sugarcane, chocolate, tobacco, and cattle ranches. Around this time rice was also introduced into the mountains. The locals who lost their farms were given much smaller plots of less fertile land and the diet for the first time included oil (originally a byproduct of cotton production) and sugar. Oil and sugar usage began climbing in the later half of the 20th century. (In our study we found that most families bought at least 5 lb of sugar per week and at least 1 liter of oil.

In the 1990s processed foods such as snack foods (chips, crackers), sweetened beverages, sweets, pasta, and white bread started becoming more common. Chronic disease and obesity began to become more common (overweight & obese together accounted for approximately. 41% in 1998[1] and was 58% by 2008[2]) and cavities also became much more widespread; none of these issues were known before 1950. Those over 70 people interviewed in this study reported they were the first generation to get cavities, and their grandchildren the first to experience obesity. In addition to dietary changes, activity levels were considerably higher in past generations. The elderly in the communities reported that, in their youth, a lack of roads and buses meant that everyone walked long distances on a regular basis.

  1. Methodology – We used a four-page questionnaire to conduct interviews, the questions covered conditions in several areas: social, economic, anthropometric, and nutrition. One aspect of the study was the HDDS, the Household Dietary Diversity Score. HDDS guide provides an approach to measuring household dietary diversity as a proxy measure of household food access. To better reflect a quality diet, the number of different food groups consumed is calculated, rather than the number of different foods consumed.
  1. Las Palmas

Las Palmas, the wealthiest community, and also the community with the most organic gardens had the highest HDDS score (its HDDS averaged at 9.25, no other community was above 9) and it had no food insecurity. The organic gardens were a big influence on the diet and were most of the reason that the HDDS score was high. As the study shows the gardens help; for instance 62% in Las Palmas said it saved money and another 25% said it improved their diet. As the surveys indicated, very few people reported ever buying fruits and vegetables, or if they did it was a very small amount. People spend most of their grocery budget on rice, beans, oil, sugar, and coffee. The gardens provide a bounty of high quality nutrition that would otherwise be neglected. The fact that garden owners state that the gardens are saving money indicates that the fresh produce from the garden is displacing other foods, which are very unlikely to be as nutritious as what the garden is producing. In addition to the gardens most families farmed corn, beans, and rice.

Las Palmas also had the highest rates of education, with only 40% of the population having a primary education or less, and over 58% had at least some secondary education. The slightly wealthier families/communities are spending a significant portion of their “extra” money on calorie-dense foods, both nutrient rich (dairy, meat) and nutrient poor (sweets, processed foods, refined carbohydrates). A significant portion of discretionary funds, as if often the case with populations that are poorly educated (though there is a range, all the populations in this study have minimal education), are being spent in ways that will erode health. Processing any food increases its status and desirability; local/unprocessed foods are viewed as inferior to anything in a bag, bottle, can, or box. Animal products are also high status, because of their expense and their calorie density. In non-industrialized countries, the more calorie dense a food is, the higher the status.

One classic example of this mode of thinking comes from the Las Palmas family that processed their organic tomatoes into a sugary marmalade: they had surplus wealth (in the form of superb tomatoes) and they turned it into a net negative for health. What will they do with those profits? Probably purchase more high status food items: meat, cheese, processed foods, and drinks. This family also has a small store on their porch that stocks all these unhealthy treats. The waist to hip ratio (a predictor of chronic disease) was high in Las Palmas 10/18 scored “at risk.”

  1. Las Labranzas

78% didn’t have organic gardens, those that did reported it saved them money and improved their diet. Another effect of not having the gardens was a smaller variety of both crops farmed (they mostly grow corn and beans) and a lower HDDS score than Las Palmas (8.9 versus 9.25). The two biggest dietary expenses are rice and sugar, followed by corn, beans, and coffee. Education levels were also lower: 80% had a primary education or less.

  1. El Quebracho

No one had organic gardens. They grow mostly beans, potatoes, and corn and most of their grocery money goes to sugar, rice, and oil. Their HDDS score was the lowest of three communities from Esteli, 7.25. Education levels were almost identical to Las Labranzas.

  1. Los Pinares

Only 8% had an organic garden. The HDDS score was lower than any of the Estelli communities – 7.1. Education levels – 62% had primary school or less. Corn, beans, bananas, and mango were the most commonly grown crops. Most (over 60%) of their grocery money goes to sugar, rice, corn, beans, and oil. The only vegetable bought was tomato, a tiny percentage of the budget.

  1. Barrio Nuevo

Only 8% had an organic garden. The HDDS was 7.2. This is region dominated by coffee growing though these were also grown: beans, banana, malanga, lime, squash, and other vegetables. Education (p. 77) – 78% had primary school or less. Most (>70%) of their grocery money goes to sugar, rice, and oil. Vegetables were the smallest slice of the budget (less than 5%).

  1. Health Education Knowledge

Our survey included 20 questions to test the general knowledge about nutrition, it revealed a low understanding among the populations. People don’t understand what foods are healthy and what are not, nor do they understand the connection between a healthy diet and disease, well-being, energy level, etc… This is consistent with other research on Latin America, a fatalistic view of health dominates (que dios quiere): health is in the hands of God, what we eat or what lifestyles we live doesn’t matter. If the education level remains low there is no amount of organic gardens that will be sufficient because people don’t actual understand the value of a vegetables, and in fact they are often considered less valuable than a bag of potato chips or a handful of white rice.

Even when the understanding of health is sufficient people usually choose fried foods and heavily sweetened beverages. Like people anywhere, Nicaraguans prefer the taste of calorie dense foods and perhaps need/desire the stress-relieving effect that accompanies consumption.

  1. Adult BMI

In Las Palmas, 44% subjects were overweight or obese, 56% were at a healthy weight.

In La Labranza 37% were overweight or obese, and 63% were at a healthy weight (page 34)

In El Quebracho 1 person (out of 19) was underweight (first incidence in Estelli’s communities), 37% were normal, 57% were overweight or obese (p.48).

Los Pinares 3 people (out of 28) were underweight, 53% were normal, 36% were overweight or obese.

In Barrio Nuevo, 1 person was underweight, 60% were normal, 35% were overweight or obese.

The presence of adults underweight is a strong indicator of poverty and occasionally other social dysfunctions (alcoholism or mental health issues, though we didn’t have reason to suspect that, in these cases). Adult overweight and obese percentages historically have been an indicator of wealth, this began to change in the developed world in the 1950s-1970s, in Latin America this change started very recently (post war/1990 in Nicaragua). Excess weight in Nicaragua can be due to a mix of factors, both poor and rich suffer from it. However, a certain very intense level of poverty (approximately under $70-100/month per family and this is an educated guess) while highly problematic for diseases of insufficiency, can be protective for obesity/chronic disease. We see that with Los Pinares and Barrio Nuevo having far lower BMIs than the communities in Estelli, i.e. many people are so poor they can’t even afford enough “junk calories” (sugar, oil, processed food) to become obese. However, even just a slight increase in wealth (from the very poorest to just poor, for instance >$100/month) can mean there is enough money to fry almost every meal in oil and put a tablespoons of sugar in every beverage.

On average adult women had higher BMIs (incidences of overweight and obese) than adult men; this is clearly due to the more physical nature of most men’s agricultural jobs. Among infants and children (up to 13 years old), in the three Esteli communities there were only 2 “non-normals” out of 15 (both overweight) and in the 2 Madriz communities, there were 6 non-normals out of 41 (4 overweight, 2 underweight), about the same percentage of outliers in both (12.5% for Estelli, 14.6% for Madriz). Children, perhaps because of the government and non-profit group’s focus, do not seem to be at any higher risk than adults, though their nutrient deficiencies (shown in #10) do have long term impacts.

 

  1. Economics: income and food insecurity

Income in dollars/month per family

Community <$40 $40-120 $120-240 >$240 Approx. Food Insecurity
Las Palmas 37% 37% 25% none
La Labranza 78% 11% 11% 11%
Quebracho 75% 25% 50%
Los Pinares 25% 42% 17% 17% 50%
Barrio Nuevo 23% 61% 15% 25%

The wealthiest community was Las Palmas, followed by Quebracho and La Labranza (similar but Quebracho had more food insecurity), the poorest was Barrio Nuevo. Los Pinares was slightly wealthier than Barrio Nuevo. Food insecurity was an issue in every community but Las Palmas. The methods used to determine food insecurity were strictly hunger/quantity of food (we used an industry standard set of questions), however it is worth noting that new definitions of food security are being developed that focus on nutrition quality/variety (the HDDS is an early prototype/headed in that direction). In that light one has to also take a look at the nutrient analysis (an example is given on point #10), almost everyone in these communities has at least some degree of malnutrition. While it is know that large deficiencies can affect growth and development, even modest nutrient deficiencies (that coexist with excess calories/obesity) found in the USA can effect development as well, an interesting article on some of these issues can be found here: http://www.washingtonpost.com/local/education/new-brain-science-shows-poor-kids-have-smaller-brains-than-affluent-kids/2015/04/15/3b679858-e2bc-11e4-b510-962fcfabc310_story.html

  1. Nutrition analysis: In Figures 1 and 2 that follow I show the nutritional breakdown for a common array of micronutrients (Figure 1) and macronutrients (Figure 2). These graphs and the discussion that follows are based on an average diet for the five communities.

The macronutrients fat and carbohydrate are at reasonable levels though protein, at 35 grams/day, is borderline inadequate.[3] For all communities, the primary source is beans. Beans provide an excellent source of inexpensive protein when eaten in sufficient quantities but in many cases the quantity consumed is too low. We need to delve into our numbers in more depth to confirm, but it looks like at least a fair portion of the population consumes too little or borderline too little protein. This is an easy problem to solve, 1.5 cups of beans a day is sufficient (when one considers a bit more protein comes form other sources such as rice and corn). Ideally other inexpensive nutrient dense sources of protein would be added such as peanuts and flaxseed (common in much of Nicaragua). These also contain a lot of decent quality fat, which could replace the refined vegetable oil’s very low quality fat.

The most striking nutritional issue is that over 30% of the total calories are provided by only two specific foods: oil and sugar. This is a consistent finding among all five communities, and a major issue throughout the country. Sugar and oil (it is always a highly refined vegetable oil) are empty calories devoid of vitamins and minerals. Oil and sugar are attractive because they are cheap, filling, taste good and make foods taste better. These two foods, which now account for so much of the diet, were almost unheard of before 1950. Then, there was no oil at all, only occasionally animal fat and coconut oil (in regions with coconuts) and sugar was a rarity and only its unprocessed form, sugar cane or a crude molasses.

The diet is deficient in many micronutrients (vitamins and minerals): Vitamin A, B6, B12, Vitamin E, and all the minerals. A few areas that are sufficient in the diet are Vitamin C, fiber, and carbohydrates and fat. Vitamin C is high because of fresh fruit intake. While fruit intake is common in certain seasons and areas, it is not universal – there are a significant number of families that rarely consume fruit. Fiber is sufficient because of beans. Carbohydrates are sufficient but the quality is low, most of the carbohydrates come from white rice and sugar. Corn (often in the form of tortillas), potatoes, and beans (which are a mix of protein and carbohydrate) provide the higher quality carbohydrates.

Issues with vitamin deficiencies are long and complex but to summarize briefly they include: poor vision/eye development (Vitamin A), increased risk of heart disease and compromised mental functioning (B6), anemia and increased risk of neurological complications (B12), muscle weakness poor vision (Vitamin E). Likewise mineral deficiencies contribute to a long list of risks/symptoms, again a few examples: compromised bone and heart health (calcium, magnesium, potassium, copper), anemia (iron, copper), and weakened immune system, stunted growth (zinc).

Our study did record four of the most commonly visible symptoms of nutrient deficiency (that data is not ready yet) but most evidence of nutrient deficiency is not easily visibly detected without blood samples. Two good reference articles on the topic are available here: http://www.publichealthreviews.eu/show/f/28

http://www.hopkinsmedicine.org/news/media/releases/new_testing_strategy_detects_population_wide_vitamin_and_mineral_deficiencies

 

  Grams Calories %-Cals  
Calories 1,794
Fat 73.4 648 36 %
Saturated 10.4 92 5 %
Polyunsaturated 33.7 297 17 %
Monounsaturated 24.8 219 12 %
Carbohydrate 259.0 1,022 57 %
Dietary Fiber 25.9
Protein 35.4 121 7 %

 

      RDA % RDA
Vitamin A 125.7 mcg 700.0 18
Vitamin A 1,080.7 IU
Vitamin B6 0.87 mg 1.5 58
Vitamin B12 0.55 mcg 2.4 23
Vitamin C 143.9 mg 75.0 192
Vitamin D 0.43 mcg 10.0 4
Vitamin D 17.3 IU
Vitamin E 10.2 mg 15.0 68
Vitamin E 15.2 IU
      RDA % RDA
Calcium 440.0 mg 1,200.0 37
Cholesterol 209.6 mg
Copper 0.91 mg 0.9 101
Iron 9.9 mg 8.0 123
Magnesium 234.0 mg 320.0 73
Manganese 2.3 mg 1.8 128
Niacin 7.5 mg 14.0 54
      RDA % RDA
Pant. Acid 4.0 mg 5.0 81
Phosphorus 861.6 mg 700.0 123
Potassium 1,836.4 mg 4,700.0 39
Riboflav 0.99 mg 1.1 90
Selenium 31.4 mcg 55.0 57
Sodium 2,353.6 mg 1,300.0 181
Thiamin 1.0 mg 1.1 91
Water 1,256.5 g
Zinc 4.6 mg 8.0 58

Recommendations:

The organic garden project is a highly effective project, but it should be paired with education/public health campaign, or at least materials, on why diet matters. The superiority of fresh, homegrown food is something that is entirely misunderstood in Nicaragua. People assume the opposite; if it is processed it is superior. An education element could help broaden the scope of the gardens. It is about more than money, it is about growing a garden to care for your family’s,- even country’s- health and future. It could also take a local pride angle, eat local, be strong or religious “food without packaging, from the earth, is food from God.” There are quite a few other organizations in Nicaragua that are working on similar projects, perhaps it would add momentum to the project if people felt like they were part of nationwide movement; let people know who their allies and fellow organic gardeners are.

[1] http://www.fao.org/ag/AGN/nutrition/NIC_en.stm

[2] http://globalnutritionreport.org/files/2014/11/gnr14_cp_nicaragua.pdf

[3] The World Health Organization (WHO) sets protein requirements at 5% of daily calories, for a 2000-calorie diet this would be about 25 grams of protein. The American Heart Association and the National Institutes of Health recommend 50-60 grams of protein for most adults