176 (2019) 21e28

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Themed Paper e Original Research ‘Desculturizacion,’ , and transition among urban Kichwas Indigenous communities residing in the Andes highlands of Ecuador

* V.A. Chee a, , E. Teran b, I. Hernandez b,c, L. Wright a, R. Izurieta a, M. Reina-Ortiz a, M. Flores b, S. Bejarano a, L.U. Dao a, J. Baldwin d, D. Martinez-Tyson a a University of South Florida, College of Public Health, Tampa, FL, USA b Universidad San Francisco de Quito, Colegio de Ciencias de la Salud, Quito, Ecuador c Pontificia Universidad Catolica del Ecuador, Facultad de Enfermerı´a, Quito, Ecuador d Northern Arizona University, Center for Health Equity Research, Flagstaff, AZ, USA article info abstract

Article history: Background: The nutrition transition continues to affect populations throughout the world. Received 11 February 2018 The added impact of market integration and urbanization exacerbates the impact of the Received in revised form nutrition transition upon Indigenous populations worldwide. 25 March 2019 Objectives: This study aims to explore the nutritional concerns of the urban Kichwas Accepted 17 July 2019 community residing in the Andes highlands of Ecuador. Available online 1 November 2019 Study design: This is a qualitative study. Methods: Eight focus groups were conducted with Kichwas men and women in November Keywords: 2015 in the Imbabura province of the Andes in Ecuador. Nutrition transition Data analysis: Applied thematic analysis was used to analyze findings regarding nutrition. Desculturizacion Results: The participants shared concerns regarding increased intake of fast food, poor meal Urbanization timing, and a shift in the child's food preferences that rejects traditional foods. They Market Integration among attributed these concerns to urbanization resulting from an increase in dual-income Indigenous households and a loss of cultural identity. Syndemic theory Conclusions: Synergistic cultural factors are related to nutritional concerns voiced by the Kichwas urban Kichwas community. Indigenous communities Public health implications: Syndemic theory is a useful interpretive lens regarding nutritional Andes highlands trends within the Kichwas communities as they relate to the increased risk of chronic disease. © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. E-mail address: [email protected] (V.A. Chee). https://doi.org/10.1016/j.puhe.2019.07.015 0033-3506/© 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. 22 public health 176 (2019) 21e28

Indigenous peoples in Latin America.7 According to the In- Background ternational Working Group on Indigenous Affairs, more than half of the Ecuador's Kichwas people reside in the Central The nutrition transition refers to the epidemiologic shift from North Mountains of the Andes. This study took place in the infectious to chronic diseases that has accompanied global Imbabura province, one of the northern Andean provinces. dietary westernization. It unfolds in five stages: (1) food gath- The authors wish to acknowledge that the Kichwas people are ering; (2) famine; (3) receding famine; (4) degenerative diseases; also referred to as Quechua, who are generally Peruvian. The and (5) behavioral change to incorporate a healthy balanced use of the word Kichwas in this article reflects that the study diet, with the majority of populations being in the stage of either participants self-identify themselves as Kichwas, which is 1 receding famine or degenerative diseases. Several factors written in this manner because of the transition from the might contribute to this phenomenon, including the rise in Spanish to English alphabet, which includes the ‘Kich’ and sweet preferences; the availability of cheap caloric sweeteners; ‘was’ in place of the Spanish ‘Quech’ and ‘ua.’ This nominal imbalances between thirst, hunger, and their respective satiety difference is a linguistic distinction rather than a cultural one. mechanisms; the preferences for and inundative availability of This study was part of a larger cross-cultural study that nutrient-poor fatty foods; and a general aversion to physical examined the syndemics8,9 of HIV, nutrition, domestic 2 exertion. These changes are accompanied by several technol- violence, and substance abuse among the Mayan, Ngabe-€ ogy advances that herald the advent of our current era, in which Bugle and Kichwas peoples of Belize, Panama, and Ecuador the widespread availability of highly processed foods with respectively. In designing the focus group (FG) guide, re- chemical additives present an unprecedented threat to popu- searchers were careful to ask broad, open-ended questions lation longevity, health and well-being. Recent technological that probed for general community concerns in these topic advances of concern include the production of high-calorie, areas. As such, emergent findings regarding the nuances of sweetened beverages and the edible oil revolution - in the latter general nutritional concerns were not deeply probed. case, edible oils are made from high-yield oil seeds that facilitate easy and cost-effective extraction, which in turn in- Sampling and recruitment creases the industrial popularity of trans-fat oils in processed 2 foods. In this qualitative ethnographic study, eight focus groups In this global context of dietary westernization, the nutri- (FGs) were conducted among two Indigenous communities in tional consequences of urbanization upon Indigenous peoples is Ecuador. The researchers (E.T. and I.H.) who lead the team ' a growing area of research. For example, Gwich in tribe children practice of community medicine have a well-established his- of Alaska bypass traditional ancestral foods in favor of western tory and rapport with the community. Participants (n ¼ 59) 3 treats, primarily in the form of sweets and fatty foods. Similarly, were recruited through established community-based part- Aymara communities of the Bolivian Andes grapple with an nerships connected to various local Indigenous organizations. obesogenic urban environment in which unhealthy ‘junk foods’ The participants were told that they would be meeting with and ‘chemicals’ have supplanted healthy, ‘natural’, ‘Indigenous’ researchers who were interested in understanding commu- 4 foods from the countryside. As many of their Indigenous nity health concerns. This trust of the community was crucial counterparts around the world, urbanization has affected the to successful participant recruitment, in collaboration with traditional diet of the Kichwas people. Although little is docu- the Social Economic Kichwas organization that governs the mented regarding the Kichwas people and their health status, provinces and serves as a vital platform of community researchers have indicated that diabetes is a pressing concern in communication among elders, the wider community, and 5 Ecuador among rural and urban populations. parties such as the research team of this study. While the nutrition transition has been studied in several countries, little is known about how the nutrition transition Data collection and analysis phenomenon is affecting the Kichwas people of Ecuador. The purpose of this study was therefore to explore general nutri- Focus group facilitators were of the same sex as the focus tional concerns among the Indigenous Kichwas communities group participants. FGs were stratified by age and gender. This who reside in the Andes highlands of Ecuador. decision expressed respect for Indigenous cultural customs and gender roles in which women may defer to men’s voices and opinions even if they do not share the same perspective. Methods Similarly, younger generations are obligated to defer to the voice of their elders. For this reason, the participants were Research setting stratified by these characteristics of age and gender. The in- clusion criteria required that participants should be older than Ecuador is located in northwest South America and straddles 18 years, identify themselves as Kichwas, and reside within both the line of the Equator and the Andes Mountains. The one of the Indigenous communities in the Andes highlands of country is divided into three continental (the east, the coast, Ecuador. and the mountains) regions and one insular region (the Gal- Each group met once, for an average of four hours with apagos Islands). The Andes crosses the country from the north lunch provided at the two hour mark. The groups discussed to south and divides it into the three continental regions. the following topics: HIV, nutrition, domestic violence, and There are 14 Indigenous nationalities in Ecuador, totaling to substance abuse. Open-ended questions were used to 1.1 million,6 which represents 7% of the estimated number of encourage participation and to demonstrate that researchers public health 176 (2019) 21e28 23

were there to learn from the community as neutral outsiders chatarra’ (‘junk food’). The participants were specifically con- interested in the topic of nutrition. The participants were cerned about chronic diseases such as diabetes in conjunction given an incentive for their willingness to participate in the with the shift of household diets from traditional foods toward focus groups at the beginning of each focus group session. fried fatty foods that are easily available. In sharing their con- Prior to focus group data collection, a community advisory cerns about nutrition, the participants highlighted three main board was recruited from among the leaders and elders of the drivers that they associated with this dietary change within Kichwas Social Economic Organization. This board played a their communities. These main drivers are the three main pivotal role in the success of this project. The community themes that emerged from the data: la ‘desculturizacion’ advisory board received training on focus group methodology (which refers to the cultural shift away from traditional cus- (led by VAC) and provided feedback on the proposed focus toms in favor of modern lifestyles); urbanization; and house- group methodology and guides. The focus groups were con- hold dietary pattern shifts throughout Indigenous Kichwas ducted in Spanish by research team members from Uni- communities. versidad San Francisco de Quito and the University of South Florida. The comoderators included a trained Spanish- ‘Desculturizacion’ dloss of cultural identity speaking notetaker and a bilingual (Kichwas/Spanish) speaker who was there to assist in the event that participants The participants expressed concern over the loss of traditional preferred to express themselves as Kichwas rather than customs, as evidenced by men cutting their hair, shame Spanish. The study was explained using a standard script that (‘verguenza’) associated with speaking the Indigenous lan- was read out to all the participants. Their verbal consent was guage of Kichwas in a racist Spanish education system, and then obtained prior to beginning each focus group data children's aversion to eating packed lunches (consisting of collection session. traditional dishes such as rice and beans) in favor of school Data were transcribed verbatim, analyzed, and coded using lunches that comprise of western and fried fatty foods. The applied thematic analysis (ATA). ATA took into account emer- following quote illustrates this cultural loss of identity: gent codes and a priori codes. Debriefing sessions among the research team members (i.e., peer debriefings) were also con- “Our previous generations cared about maintaining customs and ducted. In keeping with the tenets of ATA, peer debriefings were traditions, but we focus on reality in a way that excludes those regularly conducted during the process of data collection. Peer customs because no one forces us to maintain them” (Focus group debriefings took place in the afternoon, at the conclusion of with younger women). each focus group session. In these meetings, facilitators from both the men's and women's groups would share insights The participants went on to explain that they are gradually gained that day with the team. A summative discussion was losing food as a means of maintaining their traditional also held after all data had been collected. A priori codes ancestral heritage. They further explained that the symbolic regarding nutrition included general nutrition concerns. After value of corn as a link that ties them to their ancestors is debriefing sessions, it was noted that the participants focused slowly giving way to dietary westernization, mainly through largely on the connection between urbanization and the nutri- the popularity of fast foods and processed foods. tion transition. Emergent codes pertained mainly to the nutri- tion transition and included the following: the nutrition “Because we do not eat well, because we eat almost a lot ... most transition; household dietary patterns; children'sfoodprefer- of the community eats noodles, and more rice, they eat very early, ences; dietary westernization mothers do not cook; changes in and they do not eat vegetables anymore…and the mothers household diet; poor adult meal timing; fast food; and as an themselves are responsible for ...Sausages (“salchipapas”)… we integral aspect of Kichwas cultural identity. have to eat the vegetables and food that is good nutrition. It is because now here we are not left with the food of before. ….we have stopped eating traditional foods…Now we are eating less of Results that because sometimes we do not grow it…the land does not produce any longer, in our grandparents’ days it produced pretty It was first noted during peer debriefings that there appeared to pumpkin, zambo white squash, beans, corn, now it does not be a synergistic relationship among the factors of urbanization, produce as before; Before these foods were in our lunch, our westernization, and , which when combined breakfast was corn tortilla (One participant says zambo squash) accelerated the likelihood of obesogenic lifestyles within and made corn bread, now these days [that daily traditional diet] households. This emergent finding led to the application of has been lost, we no longer make corn tortilla, we do not make syndemic theory to qualitative focus group findings, given that bread nor anymore corn, we do not do it anymore…” the synergistic factors together appeared to have a syndemic effect on the health outcomes associated with the nutrition This idea of identity loss (through dietary westernization transition, primarily the risk of diabetes that resulted from and urbanization) repeatedly came up in FGs. During the obesogenic lifestyles associated with nutrition transition. The debriefing meetings, the researchers named this theme following section presents our research findings that center on desculturizacion, which refers to the process and outcome desculturizacion, urbanization, and shifts in dietary behavior. of the loss of Indigenous identity, which in FGs surfaced as Every focus group mentioned nutrition as a serious community references to the transition from traditional lifestyles with concern. The participants were particularly concerned about homemaker wives who cooked all family meals to long, the increased consumption of fast foods known as ‘comida hectic urban schedules among a steadily increasing number 24 public health 176 (2019) 21e28

of dual-income households. The impact of urbanization was The participants went on to explain the consequences of evident in the arena of nutrition, primarily through chil- this shift in childcare, particularly regarding intergenerational dren's rejection of traditional food in favor of processed differences between children and grandparents as it relates to foods and secondly through poor meal timing among adults, food preferences, a topic that will be discussed in the who no longer had the time to eat regular homemade meals following section. as their forbears did. In this sense, desculturizacion is the underpinning theme that connects urbanization, nutrition, Household dietary patterns and Indigenous Kichwas identity in the global context of the nutrition transition. For the metropolitan Kichwas who participated in our study, the greatest change to households was the practice of women Urbanization working outside of the homedmothers in urban families now rise early to go to work, which caused a variety of conse- Urbanization among the Kichwas was linked to the loss of quences, which include children's preference for western traditions and customs because many households appeared to foods and poor meal timing for adults. value money (‘la plata’) and increased income/wealth as part of their new modern lifestyle that consists primarily of a strong Child's food preferences and feeding practices work ethic in a dual-income household. The consequent lack of time to do anything but commute to the city for work Child-feeding practices and the children's food preferences thereby affected the following aspects: (1) child rearing, as formed the primary nutrition concern among study partici- children were left with grandparents, with neighbors, or alone; pants, who repeatedly shared that children and adolescents left (2) meal preparation, as mothers had no time to cook and, thus, in the care of their grandparents complain that they have no often sent children to school without proper breakfasts; and (3) appetite and that they do not wish to eatdthey prefer to eat meal timing, as most adults did not eat regularly timed meals, sweets, candy, and miscellaneous junk food. eating lunch as late as two or three o'clock as opposed to noon. Children left in the care of elders often rejected home-cooked, The children even go so far as to make comments such as “Why traditional meals they were offered, instead preferring to eat did you cook this? Can't you cook anything else?” [This suggests sweets and assorted fast foods. Thus, many caretakers com- that children and adolescents reject traditional foods in favor of plained that children have no appetitedthey either do not eat fast food] (focus group with older women). or do not wish to eat what is prepared for them. Focus group participants indicated that most urban They also do not want to eat [traditional foods] they want foods Kichwas households are now dual-income. Adults rise as that make them fat. earlyasfourorfiveo'clock in the morning to commute to work, far away in the city. Men work in construction; What makes it wrong and sometimes teens are worse because women work in flower houses, as domestics, or in various they still choose fast food even if grandparents cook in the house roles at local social projects. The importance of this work traditional foods the teens say, “Why did you cook this, was there ethic has affected the family structure and childcare nothing else to cook?”…it seems that young people are not practicesdchildren are left in the care of grandparents, interested in [traditional] food. neighbors, or alone. This new norm of dual-income households has increased the level of household dispos- Our environment may have the healthy foods but the fact that able income available to children and adolescents, who can parents have to go out to work to other places outside the parish now access pocket money to purchase western snacks, means that they send children to school without breakfast and I processed foods and fried street food. For example, “sal- think that will influence a lot in the development of the child. chipapas” - sausages and potatoes- is a popular dish among children. Women also shared their concern that mothers rise so early and are so focused on work that they no longer cook or “Men have left agriculture to work in construction in the city. prepare breakfasts for childrendinstead, they rely on school They earn money and return home…they emigrate to large cit- breakfasts, sending their children to school without proper ies…equally, women do domestic work there” (FG with younger nutrition. Mothers do not cook and often give children money women). for food, or they feed them a quick breakfast (egg, coffee, fruits) as opposed to the lavish traditional meals that were The participants also shared that women rise early in the once prepared. morning to work at flower houses in the city. Their long hours have deeply affected household dietary patterns because “I believe that mothers are teaching children bad lessons about these women have less time to cook nutrient-rich, traditional food. Mothers give children something with an egg, coffee, fruits, meals. In addition, as a result of urbanization and the de- whatever….” (FG with older women). mands of long hours within dual-income households, chil- dren are left in the care of grandparents. “…my son comes from school…goes to his grandmother’s where he does not want to eat...instead he already has sweets in his “In general, they will be with grandparents in the case of those pocket …” (FG with older women). who live close to them” (Focus group with older women). public health 176 (2019) 21e28 25

“Mothers now are lazy (“carishinas”), they do not like to cook or times for such meals. This concern, closely connected to prepare breakfast as they should…they want to sleep a lot…we urbanization, reiterates the idea that demanding jobs in were not like this before” (FG with older women). dual-income households prohibited healthy dietary behavior among many adults within the Andean Kichwas The demands of work, caused by urbanization, have Indigenous communities of Ecuador. The participants thus fundamentally shifted the ways in which mothers described this issue using the following words: feed their children. It should be noted here that the use of the word ‘carishinas’ to describe lazy mothers is culturally “We do not eat well, because we eat a lot [of food] … almost loaded because the word does not merely mean lazy but everyone eats noodles, more rice, from a very early age we do not instead refers specifically to a woman who refuses to eat vegetables…and moms have themselves to blame for … fast fulfill the traditional roles assigned to women in the food” (Focus group with younger women). Kichwas culturedcooking, cleaning, laundry, and child- care. This view was voiced by older women and consti- “Adults have no fixed hours to eat…they get so wrapped up in tutes one of the most striking distinctions between the daily activities that they forget to eat well” (Focus group with findings generated by focus groups with older versus younger women). younger women. Men did not voice any opinions regarding the changing role of women or the laziness commented on by the older women. Thus, parents, hard-pressed for time due to long Discussion working hours and strenuous commutes, additionally opt to give their children lunch money to purchase food out of Our findings suggest that urbanization within the Kichwas the home in place of packing food that was prepared at community from Ecuador has led to changes in lifestyle and home. Foods purchased at school are also much more diet. Lifestyle changes such as adults' hectic schedules and likely to be westernized and processed, whereas foods poor meal timing as part of dual-income households and the prepared at home are more likely to be made using westernization of children's food preferences have together traditional grains such as corn (referred to as ‘cho- given way to a loss of Indigenous Kichwas identity due to the clo’dcorn consumed in this region being very different nutrition transition. from US versions of the crop, with full yellow kernels, The World Bank indicates that low access to nutrient-rich triangular and bursting with juices), various forms of le- food, poor infant-feeding practices, and high disease burden gumes, and meat such as chicken. The participants shared coalesce to simultaneously create worrisome rates of child- their concern that the food which children and adoles- hood nutritional deficiencies nationally, along with rising cents generally prefer to eat is predominantly fast foods. levels of adult .10 Overnutrition due to consumption of In this way, urbanization and westernization has had carbohydrates and fast foods is high in Ecuador, as is the na- several ripple effects (1) on family structures (because tional rate of childhood stunting, estimated at roughly 25% of children are raised by grandparents and neighbors) and (2) children younger than five years. This is of particular concern on household income and thereby on household dietary among the highland areas, which are prone to nutritional patternsdincreased income signifies a shift from tradi- disparities on account of the difficulty in growing crops at tional foods such as corns and beans to western, pro- such cold high-altitude regions. cessed, or fried foods such as rice, bread, and fried Strikingly, the highlands are home to 63% of Ecuador's potatoes with fried sausage (‘salchipapas’). moderately and severely stunted children, and the majority Researchers followed the lead of the participants, who (40e50%) of this severely stunted population is rural.10 These mainly focused on their concern over children's prefer- data corroborate the findings of this study - that while child ences for western foods over the traditional diet. Thus, obesity may become a concern in urban areas due to dietary the substantive focus of this article is reflective of the westernization, in the rural highlands, stunting and child community's main concerns. Similarly, although the re- remain prevalent threats to child well-being. searchers acknowledge that food advertisements are a Freire et al11 thus summarize Ecuador's nutritional landscape known factor that affects children's food preferences, as a dialectic between overnutrition and undernutrition, char- none of the participants indicated that this trend is a acterized by overweight and obesity prevalence across age- concern that applies to the Kichwas community. This is groups alongside malnutrition that manifests as stunting, ane- notable, given that many of the sample'surbanKichwas mia, and zinc deficiency. Chee12 illustrates that adult obesity in people, particularly the younger generations, had access the country is estimated to be 18.7%, and adult overweight is to television, the internet, and smartphones. estimated at 54%. Furthermore, 25% of the population identifies itself as physically inactive. Micronutrient availability has a Poor meal timing Global Index score of 25.3 of 100,12 which suggests that fruit and vegetable availability is a national concern that Long working hours and a demanding work schedule pro- underpins Ecuador's double burden of diseases. hibited many adults from eating regularly scheduled meals, The nutritional patterns and concerns described by focus the result being that lunch and dinner were often group participants suggest that the Kichwas communities consumed two to three hours later than the traditional are undergoing the nutrition transition as described,2 26 public health 176 (2019) 21e28

although further research is needed to properly assess the extent to which such a concerning phenomenon is affecting this underserved and marginalized population. Scholars have begun to explore the finding that for Indigenous com- munities, stunting, overweight, and food insecurity are entwined with transitions related to irrigation, a loss of agricultural practices, gradual westernization of the tradi- tional Indigenous diet.13 Thus, loss of Indigenous identity is an all-encompassing phenomenon that Andean commu- nities experience across a broad spectrum of their interper- sonal and ecological systems.13 Most notably, ‘desculturizacion’ da loss of cultural identity, is not unique to the Kichwas Indigenous people. The Inganos of the western Colombian region of the Amazon face a similar dilemma, with a loss of cultural pride and exposure to western influences corresponding to increased intake of packaged, processed foods in place of traditional foods that symbolize their ancestral heritage.14 The Ainu of northern Japan also face similar challenges on westernized account of cultural assimilation that has been enforced through their governmentdthe extent of this assimilation has become so widespread that traditional foods have all dis- e appeared from their diet, a matter which researchers and Figure 1 The syndemics of nutrition transition among community leaders are working to resolve.15 Kichwas-speaking Indigenous communities of the Andes A worthy discussion point is regarding the nuances of highlands in Ecuador. nutritional concerns among the Kichwas community. The highlands and lowlands of the Sierra Mountains where the Andean Kichwas of this study reside are affected by uniquely are experiencing an advanced stage of nutrition transition; distinct nutritional concerns. People of the high-altitude high- researchers report adult health problems that include high lands are more geographically isolated and suffer inaccessi- prevalence rates of overweight or obesity, as well as diabetes bility of health services, poorer crop outputs, lower intake of and vitamin A and C deficiencies among nearly all adult age- 19 animal foods, and a lack of access to micronutrient-rich such as groups. Among the Pohnpei, child health concerns include 19 citrus.10,16 By contrast, people of the lowland areas, such as the stunting, vitamin A deficiency, and oral dental decay. Cotacachi and Iluman residents of this study, are far more Before surveying the differences between the urban Kich- subject to the impact of market integration. Anthropologists was and other Indigenous groups, it is important to under- define market integration as the exchange of goods and services stand that, given the diversity of geographical regions in between Indigenous peoples and outsiders through trade.17 which Indigenous groups throughout the world reside, their 20 Market integration in this study refers to economic aspects of diet and lifestyle also vary considerably. Correspondingly, urbanization in which Indigenous economies that were pri- shifts that result from the nutrition transition apply to each marily agricultural integrate their markets with western goods. Indigenous community in fairly unique ways. Most notably, The result is increased access to western foods and commod- hunter societies such as the Inuit in Alaska and Nuxalk in ities, a precursor to dietary westernization among urbanized British Columbia have experienced shifts regarding the Kichwas populations. Researchers summarize this distinction availability of their traditional meats, whereas gatherers and as a clear ‘nutritional disparity’10,18 that distinguishes highland farmers such as the Kichwas of this study have experienced Indigenous peoples from their lowland counterparts. Thus, changes in their traditional lifestyle that typically involves while previous work has focused on the nutritional risks that cooking grains for several hours, to quicker, modern meals predispose people of the highlands to poor nutrition,18 this that are less nutrient dense, such as eggs, coffee, and fruit for study focuses on the obesogenic risks faced by the urban low- breakfast. Additionally, among the Inuit in Canada, carbon- land Indigenous people. In so doing, this study contributes to ated beverage consumption served as one of the most striking scholarship regarding the nuances of nutrition that distinguish markers that indicated the influence of the nutrition transi- 21 urban lowland dwellers from their rural highland peers. While tion, whereas among the Nuxalk of British Columbia, intake the highlanders face malnutrition on account of poor micro- of processed packaged foods amongst young people is the 22 nutrient access and crop production, lowlanders, such as those most pressing concern. who participated in this study, are more deeply impacted by The strengths of this study include the composition of our market integration and urbanized lifestyles. Together, these sample, which contributes a balanced view of concerns factors predispose their children to prefer western foods while regarding nutrition within the community. In addition, this adults eat poorly timed meals in an effort to maintain hectic city research would not have been possible without the support of schedules that involve long commutes to and from work. local community leaders within the Kichwas Social and Eco- Unlike the urban Kichwas, who are at the beginning stages nomic Organization. Limitations we identified were the small of the nutrition transition, the Pohnpei people of Micronesia sample size of the study among the urban Kichwas and that public health 176 (2019) 21e28 27

nutrition was one of several broad topics covered by the focus 2. Popkin B, Adair L, Ng S. Global nutrition transition and the group sessions. pandemic of obesity in developing countries. Nutr Rev 70 e Our data suggest that the participants are experiencing 2012; :3 21. 3. Kuhnlein H, McDonald M, Spigelski D, Vittrekwa E, household dietary shifts that are indicative of the nutrition Erasmus B. Chapter 3: Gwich'in traditional food for health: transition. These shifts appear to be driven by three co- phase 1. In: Kuhnlein HV, Erasmus B, Spigelski D, editors. occurring phenomena. Thus, less constrained food supplies, Indigenous Peoples' Food Systems: the many dimensions of culture, increased disposable income urbanization, and sedentary diversity and environment for nutrition and health. Rome: Food lifestyles combined with nutrient-poor diets align naturally and Agriculture Organization of the United Nations Centre for ' with the tenets of syndemic theory,8,9 which posits that health Indigenous Peoples Nutrition and Environment; 2009. e outcomes, in this case ‘desculturizacion,’ urbanization, and p. 45 58. 4. Lipus A, Leon J, Calle S, Andes K. “It is not natural household dietary changes, have been impacted by family anymore”: nutrition, urbanization, and Indigenous identity dynamics (Figure 1). on Bolivia's Andean plateau. Qual Health Res In conclusion, this study addresses existing gaps in the 2018;28:1802e12. literature, which pertain mainly to the nuances of the nutri- 5. Dirocco A, Cuvi N. An ethnographic approach to the nutrition tion transition within the Kichwas people of the Andes in transition in Ecuador. J Global Health 2014;4:6e10. Ecuador. Although this study has provided helpful insight into 6. International Work Group for Indigenous Affairs (IWGIA). Indigenous peoples in Ecuador. 2017. https://www.iwgia.org/en/ the nutrition transition from a qualitative standpoint, it has ecuador. also highlighted the need to quantitatively assess and mea- 7. Economic Commission for Latin America and the Caribbean sure the nutrition transition through instrumentation specif- (ECLAC). Guaranteeing Indigenous people's rights in Latin America: ically designed to evaluate this phenomenon. An additional progress in the past decade and remaining challenges. Summary; future implication of this study is the need for in-depth 2014. https://repositorio.cepal.org/bitstream/handle/11362/ ethnographic exploration of the nutrition transition among 37051/4/S1420782_en.pdf. the Kichwas of Ecuador. Such ethnographic work can enrich 8. Singer M. Introduction to syndemics: a critical systems approach to public and . John Wiley & Sons; 2009. our understanding of the ways in which this population is 9. Singer M, Clair S. Syndemics and public health: experiencing and coping with the worrisome phenomenon of reconceptualizing disease in bio-social context. Med Anthropol dietary westernization among their Indigenous communities. Q 2003;17:423e41. 10. Stone L. You are what you eat: malnutrition & its determinants in Ecuador. Boston College University Libraries; 2017. https://dlib. Author statements bc.edu/islandora/object/bc-ir:107353/datastream/PDF/view. 11. Freire W, Waters W, Rivas-Marino~ G, Belmont P. The double burden of chronic malnutrition and overweight and obesity in Acknowledgments Ecuadorian mothers and children 1986e2012. Nutr Health 2018;24:163e70. The study team wishes to acknowledge and thank all Kichwas 12. Chee VA. The nutrition transition among the Andean Kichwas of community leaders who facilitated data collection and Ecuador. Graduate Theses and Dissertations. University of recruitment. The authors also wish to thank Nelson Yamberla, South Florida; 2018. https://scholarcommons.usf.edu/etd/ who proved invaluable during their fieldwork. 7273. 13. Walrod J, Seccareccia E, Sarmiento I, Pimentel JP, Misra S, Morales J, Doucet A, Andersson N. Community factors Ethical approval associated with stunting, overweight and food insecurity: a community-based mixed-method study in four Andean This study was approved by the ‘Comite de Etica en Inves- Indigenous communities in Ecuador. BMJ Open tigacion en Seres Humanos’ (Ethics Committee on Human 2018;8:e020760. Research) of the Universidad San Francisco de Quito, Ecuador 14. Correal C, Zuluaga G, Madrigal L, Caicedo S, Plotkin M. (ID: 2015-122IN). This study was also approved by the University Chapter 5: ingano traditional food and health: phase 1, e of South Florida's Institutional Review Board (ID: Pro00020635). 2004 2005. In: Kuhnlein HV, Erasmus B, Spigelski D, editors. Indigenous Peoples' Food Systems: the many dimensions of culture, diversity and environment for nutrition and health. Rome: Food Funding and Agriculture Organization of the United Nations Centre for Indigenous Peoples' Nutrition and Environment; 2009. This study was supported by the University of South Florida p. 83e108. College of Public Health Interdisciplinary Team Award. 15. Iwasaki-Goodman M, Ishii S, Kaizawa T. Traditional food systems of Indigenous peoples: the Ainu in the Saru river Competing interests region, Japan. In: Kuhnlein HV, Erasmus B, Spigelski D, editors. Indigenous Peoples' Food Systems: the many dimensions of culture, diversity and environment for nutrition and health. Rome: There are no conflicts of interest or other financial disclosures. Food and Agriculture Organization of the United Nations Centre for Indigenous Peoples' Nutrition and Environment; e references 2009. p. 139 57. 16. Walker I, Marini A, Lucchetti L, Waters W, Lastra A, Levinson J, Bassett L. Nutritional failure in Ecuador: causes, consequences, and solutions. World Bank country study. 1. Ervin D, Lopez-Carr D, Lopez-Carr A. The nutrition transition. Washington, DC: World Bank; 2007. http://documents. Oxford Bibliographies in Geography; 2013. 28 public health 176 (2019) 21e28

worldbank.org/curated/en/823021468026950397/Nutritional- and environment for nutrition and health. Rome: Food and failure-in-Ecuador-causes-consequences-and-solutions. Agriculture Organization of the United Nations Centre 17. Gross D, George E, Flowers N, Leoi F, Lattman Ritter M, for Indigenous Peoples' Nutrition and Environment; 2009. Werner D. Ecology and acculturation among native peoples of p. 1e8. Central Brazil. Science 1979;206:1043e50. 21. Egeland G, Charbonneau-Roberts G, Kuluguqtuq J, Kilabuk J, 18. Katuli S, Natto Z, Beeson L, Cordero-Macintyre Z. Nutritional Okalik L, Soueida R, Kuhnlein HV. Back to the future: using status of highland and lowland children in Ecuador. J Trop traditional food and knowledge to promote a healthy future Pediatr 2012;59:3e9. among Inuit. In: Kuhnlein HV, Erasmus B, Spigelski D, editors. 19. Englberger L, Lorens A, Levendusky A, Pedrus P, Albert K, Indigenous Peoples' Food Systems: the many dimensions of culture, Hagilmai W, Paul Y, Nelber D, Moses P, Shaeffer S, Gallen M. diversity and environment for nutrition and health. Rome: Food and Chapter 6: documentation of the traditional food system of Agriculture Organization of the United Nations Centre for Pohnpei. In: Kuhnlein HV, Erasmus B, Spigelski D, editors. Indigenous Peoples' Nutrition and Environment; 2009. p. 9e22. Indigenous Peoples' Food Systems: the many dimensions of culture, 22. Turner N, Harvey T, Burgess S, Kuhnlein H. The Nuxalk food diversity and environment for nutrition and health. Rome: Food and nutrition program, coastal British Columbia, Canada: and Agriculture Organization of the United Nations Centre for 1981e2006. In: Kuhnlein HV, Erasmus B, Spigelski D, editors. Indigenous Peoples' Nutrition and Environment; 2009. Indigenous Peoples' Food Systems: the many dimensions of culture, p. 109e38. diversity and environment for nutrition and health. Rome: Food 20. Kuhnlein HV. Why are Indigenous Peoples' food systems and Agriculture Organization of the United Nations Centre for important and why do they need documentation? In: Indigenous Peoples' Nutrition and Environment; 2009. Kuhnlein HV, Erasmus B, Spigelski D, editors. Indigenous p. 23e44. Peoples' Food Systems: the many dimensions of culture, diversity