Bolivia’s

Nutritional Status By:

Camila Borda

April 2013

Photo: Stephan Gamillscheg

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INDEX

I. Introduction ........................................................................................................................................................... 3

II. Anthropometric Indicators .................................................................................................................................... 4

1. Indicators ........................................................................................................................................................ 4

2. Anthropometric measurements in Bolivia .................................................................................................... 5

3. Anthropometric studies in Bolivian Adolescents – An overall estimate of the nutritional status in

Bolivian youth ..................................................................................................................................................... 7

4. Anthropometric study and nutritional status in adolescents of the rural locality of Calama – Comparing

rural and urban results ....................................................................................................................................... 7

III. The Double Burden of Disease & The Double Burden of Malnutrition .............................................................. 8

IV. Nutritional status ................................................................................................................................................... 9

1. Youth ............................................................................................................................................................... 9

2. Women .......................................................................................................................................................... 11

3. Newborn ....................................................................................................................................................... 13

4. Food traditions / Eating habits .................................................................................................................... 13

5. Import of food products ............................................................................................................................... 14

6. Prevalence of Diabetes Mellitus in Bolivia .................................................................................................. 14

7. Madskolen’s students .................................................................................................................................. 15

V. The case of Denmark ........................................................................................................................................... 15

VI. Previous studies ................................................................................................................................................... 16

VII. Discussion...................................................................................................................................................... 17

1. Ethics ............................................................................................................................................................. 17

2. Previous and ongoing projects..................................................................................................................... 17

3. Public School Breakfast ‘Desayuno Escolar’ ................................................................................................ 18

4. Quinoa ........................................................................................................................................................... 18

5. Maternity: Crucial stage ............................................................................................................................... 18

VIII. References .................................................................................................................................................... 19

IX. Interviews and contacts ...................................................................................................................................... 20

X. Appendix 1 ........................................................................................................................................................... 21

XI. Appendix 2 ........................................................................................................................................................... 22

XII. Appendix 3 .................................................................................................................................................... 23

XIII. Appendix 4 .................................................................................................................................................... 24

XIV. Appendix 5 .................................................................................................................................................... 25

XV. Appendix 6 .................................................................................................................................................... 26

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I. Introduction

“En relación al estado nutricional se reveló que los principales problemas de magnitud nacional que aquejan a Bolivia son: la desnutrición crónica, las anemias nutricionales, la hipovitaminosis

"A", desórdenes por deficiencia de yodo, enfermedades crónicas en adultos (obesidad, diabetes e hipertensión).” – A. M. Aguilar Liendo, Memoria del taller nacional de alimentación y nutrición, 2003.

“Regarding the nutritional status it has been showed that the main problems of national impact in Bolivia are: chronic malnutrition, nutritional anemias, hipovitaminosis “A”, iodine deficiency, chronic diseases in adults (obesity, diabetes

and hypertension).” – A. M. Aguilar Liendo, National Workshop on food and nutrition, 2003.

Bolivia is going through a nutritional transition, due mostly to globalization. This transition consists on a change in the population’s diet from a traditional diet generally based on local products, to a rather ‘occidental’ diet, rich in high-density foods, food products not providing any nutrients (sodas, sweets, etc.) and especially fast food. This transition is enhanced by the decrease of physical activity due to advances in technology. This is leading to an increase on the country’s overweight and obesity levels. IBIS with its current project of the ‘Food School’ aims to reincorporate local products (such as quinoa) in the local diet, by making them more appealing to the people. This can help stop this food transition and prevent overweight and obesity in the Bolivian population. Furthermore, this is an ideal way to assure food safety and keep our culinary traditions. This report is the result of a work of investigation of the Bolivian nutritional status. It analyzes the links and differences of it according to region, urban and rural areas, socio-economical status, age and educational background. It presents some probable causes and analyzes the possible solutions.

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II. Anthropometric Indicators

“Anthropometric parameters and indicators are frequently used by physicians and health workers as a valuable instrument to determine health levels and disease, to define nutritional status, to assess growth and development, to determine differences in body proportion between populations as well as to optimize diagnosis and treatment. […] Decisions for policy making and planning in public health nutrition must be based on anthropometric accurate information about the population for which it is intended to be used.” (A. Baya Botti, F. J. A. Pérez-Cueto, P. A. Vasquez Monllor and P. W. Kolsteren, 2009)

1. Indicators

Height/Length, weight and birth-weight (Low birth-weight defines all children with a weight lower than 2,500 grams at birth).

Height-for- age z-score (HAZ) Weight-for-age z-score (WAZ) Weight-for-height z-score (WHZ) These three indicators compare a child’s weight and height with the median values of a well-nourished reference population (same age, weight or height and sex). The z-score measures the standard deviation (SD) above or below the normal (according to the reference population). Low HAZ is a sign of chronic malnutrition, while low WHZ defines an acute malnutrition that can be counteracted quite quickly. Low WAZ is affected by both HAZ and WHZ.

Source: R. Vera, M. Moore, G. Varela, R. López, V. Cossío, J. Rivera, A. Aliaga – Estado Nutricional de la población Boliviana, 1981

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Stunting, underweight & wasting:

o Stunting: reduced growth due to a long termed malnutrition in early childhood or during fetal development, also referred as ‘chronic malnutrition’ (measured by a low HAZ)

o Underweight: weight and BMI under the normal, considered too low to be healthy, can be a sign of both stunting and wasting (measured by a low WAZ)

o Wasting: loss of fat and muscle mass due to a short duration malnutrition, also referred as ‘acute malnutrition’ (measured by a low WHZ)

(The World Bank, 2010- based on WHO, 1995)

2. Anthropometric measurements in Bolivia

Source: WHO, Nutrition Landscape Information System – Country Profile – Bolivia, 2008

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Source: Instituto Nacional de Estadística de Bolivia INE - M. Gutiérrez Sardán, L. H. Ochoa, W. Castillo Guerra, Encuesta Nacional de Demografía y Salud ENDSA, 2003

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3. Anthropometric studies in Bolivian Adolescents – An overall estimate of the nutritional status in Bolivian youth

An anthropometric study of Bolivian adolescents from the Andean highlands, valleys and tropics presents an approximate estimate of the nutritional levels in Bolivian youth. The sample includes adolescents from rural, semi-urban and urban settings. Data was collected on 3,445 adolescents, 1,551 boys and 1,894 girls, from rural (34.8%) and urban areas (65.2%), and from public (76.4%) and private (23.6%) schools. “The aim of this cross sectional study was to provide age and sex specific centile values and charts of Body Mass Index, height, weight, arm, wrist and abdominal circumference from Bolivian Adolescents.”

Source: Baya Botti, Pérez-Cueto, Vasquez Monllor and Kolsteren, 2009 BMI values increase with age for both boys and girls. These values do not necessarily represent overweight, since BMI is calculated with both fat and muscle mass weight. However, if we take in consideration the overall of the investigation, most of these adolescent are very likely to have a high BMI due to fat weight and not so much muscle mass. The cause for these numbers is very likely to be malnutrition in childhood, causing low height and then overweight later in life. According to these results both genders’ BMIs are within the normal, even though girls have a tendency of higher BMI levels than boys. The problem is what happens if this development continues later in life. Then when they reach 30 their BMIs will no longer be within the normal. That is what we have to prevent.

4. Anthropometric study and nutritional status in adolescents of the rural locality of Calama – Comparing rural and urban results

F. J. A. Pérez-Cueto led an investigation of the Nutritional Status and Diet Characteristics of a Group od Adolescents from the Rural Locality Calama (Subtropic). According to the report of study,

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in 2003, “nine percent was the global prevalence of overweight, although it was more present in girls.” This prevalence has increased in only 6 years, to the moment of the investigation. This study provides evidence of the fact that Bolivia has, so far, been in an epidemiological picture, in which malnutrition has been the only problem, a more complex picture is coming up, in which overweight and stunting coexist in the same population (F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009). “Furthermore, the anthropometric measures of boys were compared with their urban counterparts, where the differences were only significant with students in private schools.” Both rural and urban areas are going through this nutritional transition. Only a minority is not or is less affected by it, but this is due to socio-economical background and thereby educational levels (F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009).

III. The Double Burden of Disease & The Double Burden of Malnutrition

The Burden of Disease is the impact of a health problem measured by different indicators: financial cost, morbidity and mortality, among other (WHO, 2010). Basically, the Double Burden of Disease (DBD) is when you have both ‘centuries-old’ or traditional communicable disease problems like for example infectious diarrhea, as well as the modern NCD’s (Non-Communicable Diseases) problems like CVD’s (Cardiovascular Diseases) and smoking. CVD’s are mostly lifestyle diseases. The DBD is especially present in developing countries. The Double Burden of Malnutrition (DBM) and the DBD are linked. Even though the DBM is very present in developed countries, developing countries are still the most vulnerable because of food availability, educational levels and the socio-economical development: developing countries want to imitate developed countries as it is the consumption of fast foods. The DBD main characteristic is the increase on the risk of NCD’s and CVD’s. The most preoccupying fact of both DBM and DBD is the health consequences it has. According to studies made by UNICEF about the ‘Prevalence of overweight in children under five (2000–2006)’, Bolivia is among the 20 developing countries with a prevalence of overweight in children higher than 5 per cent (6 % to be precise).

“Overweight is an increasingly important issue all over the world: 20 developing countries have rates above 5 per cent. Childhood undernutrition and overweight co-exist in many countries, leading to a double burden of malnutrition” (UNICEF, 2007).

It has been proven that Bolivia is facing a nutritional transition. A country that has had alarming rates of undernutrition and underweight is now affected by overweight and obesity. Though this doesn’t mean the part of the population affected by overweight is fully covered in nutritional matters (too high intake of non-nutritious foods): the DBM is the main affecting factor. Malnutrition was before in the form of undernutrition, but now malnutrition is in the form a coexistence of undernutrition and overweight.

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“The country (Bolivia) faces nutritional transition and adolescents are among the most vulnerable group to its impact: an increase in numbers of overweight and obese adolescents has been recently described” (Baya Botti, Pérez-Cueto, Vasquez Monllor and Kolsteren, 2009).

IV. Nutritional status

Globalization and development have enhanced a global nutritional transition, taking mostly place in developing countries, like Bolivia, since they are more vulnerable to these changes. The traditional diet is being replaced by a more occidental one rich in high-density foods, ‘empty’ calories (foods not providing any nutrients e.g. candy, soda, etc.), and fast foods. This transition is enhanced by the diminution of physical activity due overall technological developments (F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009). This nutritional transition enhances the DBM (Double Burden of Malnutrition) and thereby the DBD (Double Burden of Diseases), and therefore leads to an increase on the risks of NCDs (Non Communicable Diseases), CVDs (Cardiovascular Diseases) such as diabetes II, coronary diseases and cancer, among others. Bolivia is not the only country going through this process, all developing countries are. But Latin American countries have evolved more drastically than the rest of the world. In every Latin-American country the levels of obesity in women is over 30 % (up to 70 % in Paraguay). The case of children is not less shocking: in most South-American countries childhood obesity is over 6 % (F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009).

1. Youth

Source: F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto and M. E. Eulert, Nutritional Status and Diet Characteristics of a Group of Adolescents from the Rural Locality Calama, Bolivia, 2009 According to a study made to adolescents in the rural locality of Calama in the department of La Paz, there are no longer cases of extreme underweight; something that was a huge problem some years ago. It seems that the problem in future will no longer consist on fighting hunger, but

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fighting overweight and obesity. The results of this study show that the prevalence of overweight is 9 %, especially in girls. These results match another study made in the rural area of Beni (F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009). Regarding the anthropometric differences between adolescents in urban and rural areas there are significant differences. Kids in urban areas attending to public schools are approx. 4 cm taller and around 3 kg heavier. Kids from private schools have though anthropometric characteristics similar to kids from developed countries (F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009). “Secondary analysis of Bolivian Demographic and Health Surveys (‘Encuestas de Demografía y Salud’ - ENDSA) 1994, 1998 and 2003 revealed adolescents' cross-sectional data suggesting that overweight and obesity are mainly found in urban areas. Applying the Bolivian body mass index-for-age reference, obesity reached 5% in adolescents, while overweight affects 14% of adolescents. This overview highlights the importance of including the prevention of weight gain among the public health nutrition policies in Bolivia” (F. J. A. Pérez-Cueto, A. Bayá Botti, W. Verbeke, 2009).

Source: F. J. A. Pérez-Cueto, M. E. Eulert, Estado nutricional de un grupo de estudiantes universitarios de La Paz, Bolivia, 2009 Regarding university students’ nutritional status (in La Paz), we can see that men have healthier nutritional status tan women: 70,5 % of men have a healthy weight while only 63,4 % of women are in the healthy range. It is also important to highlight that underweight levels are much lower than overweight and even obesity. For men, the rates of overweight are 10 times bigger than those of underweight; while for women this relation is 32 times bigger. If we take in consideration the prevalence of obesity, for every two underweight students there are three obese. In the case of women, for every girl suffering from underweight there are 8 suffering from obesity (F. J. A. Pérez-Cueto, M. E. Eulert, Estado nutricional de un grupo de estudiantes universitarios de La Paz, Bolivia, 2009). According to previous results, the most vulnerable are those with low-income and low education. This results show a very alarming picture for university students. This can be a proof that, no matter what the socio-economical background is, the nutritional transition is little by little affecting all parts of the population. Since there are no recent studies of the nutritional status for

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lower socio-economic backgrounds, we can only imagine that the picture would be even more preoccupying.

Source: F. J. A. Pérez-Cueto, M. Almanza and P. W. Kolsteren, Female gender and wealth are associated to overweight among adolescents in La Paz, Bolivia, 2004 Girls have a tendency to have heavier weights than boys. Nonetheless the prevalence of obesity is higher for boys than for girls (3,4 against 1,4 respectively). On the other hand, there is a tendency of being thin in private schools, compared to public ones. However, the prevalence of obesity is a little higher for those who attend private schools and the rates of obesity are exactly the same for both private and public schools.

2. Women (See Appendix 1) According to a study on the changes, in the nutritional status on women from 1994 to 1998, using age ranges, demographic (high lands, low lands and valleys) and social (educational levels) predictors, underweight prevalence has decreased to a minimum in all geographic areas. There has though been an increase on the rates of undernutrition for women having a higher educational background. Nonetheless there has been decrease on the prevalence of normal BMIs. An increase on the levels of overweight and obesity (not taking in consideration the high lands) is the explanation of this. In 1994, Bolivia’s low lands were the most affected by undernutrition. Today, this region is by far the most affected by obesity. Considering educational backgrounds, both low or non-exiting and high educational backgrounds have low rates of obesity. Causes are obviously different. All in all, it is very clear to see that in only 4 years, from 1994 to 1998, overweight and especially obesity rates have increased a lot, together with the fact that underweight has decreased drastically (F.J.A. Pérez-Cueto and P.W.V.J. Kolsteren, 2004). “These findings suggest that overweight is a period effect, even after adjusting for other factors like educational level, age, total number of children, region and locality. Bolivian women were 1.6 times more likely to be overweight in 1998 than in 1994. […] Spanish and Aymara at home are positively associated with overweight in Bolivian women, while speaking Quechua at home decreases the odds of being overweight by 19%. Each child born to a woman adds her a 1.08 likelihood of becoming overweight. In 1998, women were 65% less likely

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to be considered as undernourished than in 1994. This suggests a dramatic improvement in nutritional status. The protective role of the number of children corresponds with the previous statement for overweight. Each child lowers the odds of being underweight by 17%. […] Despite the overall and sustained economic growth, the data presented in this paper suggest that Bolivia is undergoing the early stages of a nutritional transition, where the prevalence of overweight is increasing, while underweight is almost disappearing among women of reproductive age” (F.J.A. Pérez-Cueto and P.W.V.J. Kolsteren, 2004). An analysis of the Bolivian Demographic and Health Surveys (‘Encuestas de Demografía y Salud’ - ENDSA) of 1994, 1998 and 2003 revealed a steady raising trend in levels of overweight and obesity among women in childbearing age (20-45 years), reaching 30% (F. J. A. Pérez-Cueto, A. Bayá Botti, W. Verbeke, 2009).

Source: WHO, Nutrition Landscape Information System – Country Profile – Bolivia, 2008

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3. Newborn

(See Appendix 2) According to the Institute of Statistics in Bolivia (INE) and the Ministry of Health and Sports the prevalence of low birth weight has increased in almost every city in Bolivia from 1997 to 2010. It is remarkable that in the low lands, this increase is more dramatic than in the high lands: Beni, Pando and especially Santa Cruz are the most affected. Low birth weight is mainly due to mothers’ bad lifestyle: smoking, bad diet, little exercise, underweight, overweight and obesity, etc. It is important to follow up that low birth weight is one of the main causes for malnutrition in the first years in life and sometimes even death for the baby. Low birth weight may lead to stunting kids if not treated immediately after birth. Bad nutrition and low weight in early life leads to an increase of the risks of CVD’s and NCD’s later in life. Appendix 3 (Instituto Nacional de Estadística de Bolivia INE - M. Gutiérrez Sardán, L. H. Ochoa, W. Castillo Guerra, Encuesta Nacional de Demografía y Salud ENDSA, 2003) is a table stating the different food sources Bolivian infants got to eat the day previous to the interview. The information was taken through a 24-hour food recall to the mothers. There can therefore be some inaccuracies due mostly to memory.

4. Food traditions / Eating habits “The Bolivian diet is characterized by higher availability of foods of plant origin (cereals, fruits, potatoes and vegetables). Meat, milk and their products follow in the dietary preferences of Bolivians. Disparities in food availability within the country were also observed. Rural households systematically recorded lower amounts of food available, in comparison with the urban ones. Households of higher social status recorded higher availability values for all food groups, except for potatoes and cereals. Findings suggest that Bolivian households of lower socio-economic status prefer energy-dense and cheaper food sources” (F. J. A. Pérez-Cueto, 2011). According to a study of the Nutritional Status and Diet Characteristics of a Group od Adolescents from the Rural Locality Calama, “the energy intake is distributed in the five usual eating times as follows: 22% breakfast, 20% break time at school, 24% lunch, 12% tea time and 22% dinner“(F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009). It is remarkable that breakfast represents a big meal, and that all breakfast, morning-break ‘snack’, lunch and dinner consist of almost the same amount of energy. The study shows that in general breakfast is a warm meal with soup (with pasta, potatoes, rice, vegetables and some meat), or a meat plate with chili sauce, potatoes and rice or pasta. A smaller group consumes only bread and coffee. As for lunch and dinner, meals are very energy dense: a soup and a main dish with meat a several sources of carbohydrates. Even though we are in the country side 44 % of the energy intake is consumed outside the home. This is a clear proof of a food transition also present in rural areas, despite the little contact with civilization.

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Most of the interviewees considered there was variety in their diets, though only 14 % reported an intake of milk of other dairy products. The good side of most of the rural areas in Bolivia (specially the one in the subtropical area, as Calama) is the variety of local fruits and vegetables. (F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto y M. E. Eulert, 2009) “Agricultural production is different in each region: the highlands basically produce Andean cereals, potatoes and pulses; the valleys produce cattle, milk, fruits, vegetables and cereals; while the lowlands, that experienced the most rapid economic development in the past 30 years, are mostly devoted to cattle and meat and tropical fruit production” (F.J. A. Pérez-Cueto, A. Naska, J. Monterrey, M. Almanza-Lopez, A. Trichopoulou and P. Kolsteren, 2006). It is very interesting how food traditions have been imposed in the country. There are many traditions that haven’t really a reason to be: e.g. ‘salteñas’ only in the morning and ‘anticuchos’ only in the evening. The chef Pablo Grossman is writing a book on these traditions in La Paz, and complementing each one of them with a historical explanation. Madskole and GUSTU’s work is very important within the Bolivian eating habits since they aim to reintegrate traditional food products in the population’s diets through a national gastronomical movement.

5. Import of food products “In Bolivia, the food production covers only 60 % of the population. […] We have to take in consideration, not only the hunger of the poorest, but also the undernutrition that, in the case of the country’s kids, that reaches 48 %. Plus that currently, the cost of basic goods, many families are cutting back on food consumption and choosing because of the prices the lower quality ones.” (Página Siete, 2013) (See Appendix 4) The rates of food import in Bolivia and their development during the last years is a clear proof of the ‘internationalized’ food transition the country is going trough. Within the last decade, the import of most food products has increase enormously. Only dairy products, eggs, seeds and nuts’ import has had a decrease. The most preoccupying fact here is the huge increase on the import of beverages, including sodas and other sweet beverages. “Soy is the only transgenic food product produce in Bolivia, yet. In 2010 the area of transgenic soy produced in Santa Cruz reached 780 thousand hectares, representing 88 % of the whole soy production” (Alicia Tejada, Monsanto amplió sus negocios hacia Bolivia, 2011). The need to feed our population for cheap prices is leading us to choices against our health.

6. Prevalence of Diabetes Mellitus in Bolivia A population-based survey measured the prevalence of diabetes mellitus (DM), hypertension, obesity, and related risk factors in major cities in Bolivia: La Paz, El Alto, Santa Cruz, and

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Cochabamba. The total sample size was of 2,948 persons. Diabetes Mellitus (DM) was diagnosed through an oral glucose tolerance test 2 hours after an overload of 75 grams of glucose, using World Health Organization criteria. The overall prevalence of DM in the four urban areas combined was 7.2% and of impaired glucose tolerance (IGT) was 7.8%. A total of 73.1% of those previously diagnosed with DM and 73.7% of newly diagnosed cases were overweight, according to measurements of body mass index. Hypertension was found in 36.5% of known diabetics and in 36.6% of newly diagnosed cases, compared to only 15.9% among people without DM. “Diabetes was most common among older persons and those with little education. The disease is a genuine public health problem in Bolivia. Further, the high prevalence of IGT that was found suggests that diabetes’ prevalence will increase in the near future in the country unless prevention strategies are implemented” ( Barceló A, Daroca MC, Ribera R, Duarte E, Zapata A, Vohra M., 2001).

7. Food School’s students During the nutrition workshop I did with the students of Melting Pot, I used the opportunity not only to teach them about nutrition and the importance of a healthy lifestyle, but I used them as a target group for my own little investigation. I made them do a 24-hours food recall to investigate their eating habits. Even though they are all working with food and know how to prepare it (or at least they are learning to do it) their diets are quite monotone: they don’t vary in, for instance, lunch and dinner, besides the fact that almost 50 % of the food is consumed outside the home. Furthermore, they high intakes of sweets (ice cream, chocolate, candy…) and fast foods (deep-fried foods, snacks, french fries…) was very shocking. They also calculated their energy expenditure to see if the energy balance (relation between energy intake and energy expenditure) was positive, negative or, more or less neutral. Some students have a very active lifestyle: they train sports and walk a lot. So the high energy intakes are balanced with the energy expenditure, resulting on a more or less neutral energy balance. But for the most part, sports are not a part of their every day. The most preoccupying is that those who eat the most and have bad eating habits are those who exercise the less. For most of the students, the energy balance was neutral, even though the intake of ‘empty-calories’ was quite high. This may result in the deficiency of certain nutrients. If most of the energy you get is from ‘empty-calories’ you may not be meeting nutrient needs and recommendations.

V. The case of Denmark “There must be drastic solutions, if the so-called obesity epidemic must be stopped. […] In Denmark, the proportion of obese people onto a few decades increased from just over 5 % to just over 11 % of the population. The World Health Organization (WHO) estimates that 1.6 billion adults will be overweight by 2015. It is, therefore, the unflattering term "obesity epidemic" has

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gained ground in the debate. So far, neither informational campaigns, nor personal sense of responsibility are able to get people to eat healthier and exercise more. […] TrygFonden wrote a topical discussion-paper about a ‘minor revolution’ in the way we think about health and prevention. Instead of looking fat and unhealthy citizens as victims of a certain lifestyle, they are talking now about civilization diseases.” (DR - Steffen Klint, 2007) “In Denmark, obesity epidemic affects increasingly the most innocent - namely children. The number of overweight children is increasing steadily in the last years. That is what the vast majority of the municipalities assess in the newest study. Experts are very concerned about these developments that lead to unhappy and lonely children who have significantly higher risk for severe diseases as grown-ups. Nearly 9 out of 10 municipalities have special initiatives on how to help overweight children. In 63 percent of the municipalities, health nurses, local physicians and health consultants experience that there are more overweight children than in the past. Only three percent feel that there are fewer overweight children in their municipality” (Søren Kudahl, Flere og flere børn bliver tykke, 2009). Overweight and obesity are not only a ‘developing country’ problem; developed countries have the same problem, even at higher scales. The difference is the economic means they have to fight it. This explains that culture is not the only factor to take in consideration in order to change Bolivians’ eating habits.

VI. Previous studies

(See Appendix 3) According to the National Survey of Demography and Health (ENSDA, 2003), 10 years ago the main nutritional deficiencies were iron, folic acid, B-complex, iodine, and vitamin A. The national products were already fortified with these deficient nutrients. Regarding vitamin A and iron, besides the food fortification, a big strategy was the supply of these two nutrients via pharmacological supplements twice every year for the most vulnerable groups: children between 6 months and 5 years old and for women post delivery. The main problem was the undernutrition, especially in the rural areas (37%). In La Paz, Cochabamba, Oruro and the rural and the periurban areas the intake of iron in pregnant women is very low (19% or less). Furthermore, the percentage of women who took supplements of for example vitamin A after delivery is notoriously higher in the women belonging to the higher classes (37%) than those in the lower ones (24%) (Instituto Nacional de Estadística de Bolivia INE - M. Gutiérrez Sardán, L. H. Ochoa, W. Castillo Guerra, 2003). The main nutritional focus of the survey was on lactation and maternity. It is so that most of the stunting and undernutrition problems start during gestation and lactation. There have therefore been several campaigns to promote lactation and to teach the mothers how to incorporate ‘real’ food on their diets and what types of food are important. Appendix 3 shows what the newborn’s diets consists of. (See Appendix 6)

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The latest complete study of Bolivia’s nutritional status from 1981 focuses exclusively on underweight. Appendix 6 shows two graphs of height values in different areas of the country as a measure of anthropometry (R. Vera, M. Moore, G. Varela, R. López, V. Cossío, J. Rivera, A. Aliaga, 1981).

Things have changed drastically since the last complete investigation of Bolivia’s nutritional status was made. The focus today has changed from one extreme to the other. Nonetheless, the methods used to fight undernutrition and starvation can still be a guide to make new ones to fight the ongoing Double Burden of Malnutrition.

VII. Discussion

1. Ethics It is important to take in consideration the limits of health promotion and remember all the way long the concepts of intercultural communication while trying to change eating habits in the population. We need to raise awareness and give Bolivians the tools to change their lifestyles without imposing anything to them. It is also important to consider the fact that there is often a margin of error due to the hypothesis wanted to be proved. This can affect the results so that the investigation is more focused in what is relevant to prove the thesis and thereby the overall result.

2. Previous and ongoing projects There are already some organizations that are aware of the nutritional problem in Bolivia. The Government has implemented a program to fight undernutrition with a project called ‘Programa Desnutrición Cero’ (BID - N. Morales, E. Pando, J. Jogannsen, 2010). There also an insurance scheme for children under 5 (‘Seguro Universal Materno Infantil SUMI) were there is more focus on the prevention of nutritional problems for young children. This insurance offers the mothers food grants and gives them once periodically a mixture of healthy products. Unfortunately this campaign is not followed with an educational one. Many of the women receiving this help don’t know how to use the products, or simply don’t valuate them: they would rather sell them than use them. The main problem of the ongoing projects is though, the lack of nutrition professionals as a part of the whole project and not only on the planning (BID - N. Morales, E. Pando, J. Jogannsen, 2010). BID has started a pilot project in El Alto on how to change eating habits on this target group. Most of the project focused on an investigation on these eating habits and on the target group. Final papers with the results have not been published yet. It would though be very interesting to analyze them and see if the project succeeded, in order to create further similar projects in the rest of the country.

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3. Public School Breakfast ‘Desayuno Escolar’

The Scholar breakfast implemented by the Government is a very good way to fight malnutrition and especially undernutrition in children, mostly those coming from poor families. Evo Morales is now implementing quinoa in this Scholar breakfast, which is promoting a more balanced meal. Furthermore, there is fruit (bananas) and milk products that are part of this breakfast assuring kids’ intake of important nutrients (calcium, potassium and magnesium, among other). School is definitely a good place to start a health promotion reaching the most vulnerable: kids coming from families who have bad eating habits are most likely to assimilate these habits later in life.

4. Quinoa

“Quinoa (Chenopodium quinoa) is considered a pseudocereal or pseudograin, and has been recognized as a complete food due to its protein quality. It has remarkable nutritional properties; not only from its protein content (15%) but also from its great amino acid balance. It is an important source of minerals and vitamins, and has also been found to contain compounds like polyphenols, phytosterols, and flavonoids with possible nutraceutical benefits. It has some functional (technological) properties like solubility, water-holding capacity (WHC), gelation, emulsifying, and foaming that allow diversified uses. Besides, it has been considered an oil crop, with an interesting proportion of omega-6 and notable vitamin E content. Quinoa starch has physicochemical properties (such as viscosity, freeze stability) which give it functional properties with novel uses. Quinoa has a high nutritional value and has recently been used as a novel functional food because of all these properties” (Lilian E. Abugoch James, 2009).

During the event where the UN and Evo Morales inaugurated Quinoa’s year, the general director of the FAO (UN’s organization for Food and Agriculture), José Graziano da Silva, said that “quinoa is a new ally in the fight against hunger and food safety” (La Razón Digital - Carlos Corz, 2013).

Quinoa can help prevent the development of this ‘obesity epidemic’ in Bolivia. The only problem, that the Government is trying to solve now, is the rise on the prices. Before exporting the product abroad, we could promote its consumption inside the country as a part of a health promotion.

5. Maternity: Crucial stage

“Secondary analysis of Bolivian Demographic and Health Surveys (‘Encuestas de Demografía y Salud’ - ENDSA) 1994, 1998 and 2003 revealed a steady raising trend in levels of overweight and obesity among women in childbearing age (20-45 years), reaching 30% and 15% respectively in 2003 (F. J. A. Pérez-Cueto, A. Bayá Botti, W. Verbeke, 2009). Bad habits during maternity and breast-feeding are crucial to the kid’s good health later in life. Stunting is the typical result of malnutrition of the mother before pregnancy and birth. A good nutrition in this stage can prevent a lot of different diseases later in life. Therefore, it is important to reach mothers and future mothers as an important target group during health promotion.

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VIII. References

A. Baya Botti, F. J. A. Pérez-Cueto, P. A. Vasquez Monllor and P. W. Kolsteren, Anthropometry of height, weight, arm, wrist, abdominal circumference and body mass index, for Bolivian Adolescents 12 to 18 years – Bolivian adolescent percentile values from the MESA study, 2009

Alicia Tejada, Monsanto amplió sus negocios hacia Bolivia, 2011

Barceló A, Daroca MC, Ribera R, Duarte E, Zapata A, Vohra M., Diabetes in Bolivia from Pan American Health Organization, Program on Non-Communicable Diseases, 525 Twenty-third Street, N.W., Washington, D.C. 20037-2895, USA, 2001

BID - N. Morales, E. Pando, J. Johannsen, Comprendiendo el Programa de Desnutrición Cero en Bolivia: Un Análisis de Redes y Actores, 2010

DR - Steffen Klint, Hvordan slipper vi af med de fede?, 2007

F. J. A. Pérez-Cueto, A. Bayá Botti, W. Verbeke, Prevalence of overweight in Bolivia: data on women and adolescents, 2009

F.J. A. Pérez-Cueto, A. Naska, J. Monterrey, M. Almanza-Lopez, A. Trichopoulou and P. Kolsteren, Monitoring food and nutrient availability in a nationally representative sample of Bolivian households, 2006

F. J. A. Pérez-Cueto, M. Almanza and P. W. Kolsteren, Female gender and wealth are associated to overweight among adolescents in La Paz, Bolivia, 2004

F. J. A. Pérez-Cueto, M. E. Eulert, Estado nutricional de un grupo de estudiantes universitarios de La Paz, Bolivia, 2009

F. J. A. Pérez-Cueto, M. J. Almanza-López, J. D. Pérez-Cueto and M. E. Eulert, Nutritional Status and Diet Characteristics of a Group of Adolescents from the Rural Locality Calama, Bolivia, 2009

F. J. A. Pérez-Cueto, Monitoring food availability using Household Surveys data: The Bolivian experience, 2011

F.J.A. Pérez-Cueto and P.W.V.J. Kolsteren, Changes in the nutritional status of Bolivian women 1994–1998: demographic and social predictors, 2004

Instituto Nacional de Estadística de Bolivia INE - M. Gutiérrez Sardán, L. H. Ochoa, W. Castillo Guerra, Encuesta Nacional de Demografía y Salud ENDSA, 2003

Instituto Nacional de Estadística de Bolivia INE – R. Coa & L. H. Ochoa, Encuesta Nacional de Demografía y Salud ENDSA, 2008

La Razón Digital - Carlos Corz, Morales aboga en la ONU por alentar la producción de la quinua para

luchar contra el hambre, 2013

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Lilian E. Abugoch James, Quinoa (Chenopodium quinoa Willd.): Composition, Chemistry, Nutritional, and Functional Properties, 2009

P. B. Ngigi, W. Verbeke and F. J. A. Pérez-Cueto, Assessment of actual food portions sizes in the sample of adolescents from Cochabamaba (Bolivia), 2011

Página Siete, REFLEXIONES sobre la problemática de la subalimentación, a propósito del Año Internacional de la Quinua, 22/02/2013

R. Vera, M. Moore, G. Varela, R. López, V. Cossío, J. Rivera, A. Aliaga – Estado Nutricional de la población Boliviana, 1981

Sociedad Boliviana de Pediatría - A. M. Aguilar Liendo, Memoria del taller nacional de alimentación y nutrición, 2003

Statens Institut for Folkesundhed, Folkesundhedsrapporten, Danmark, 2007

Søren Kudahl, Flere og flere børn bliver tykke, 2009

The World Bank, What Can We Learn from Nutrition Impact Evaluations? : Lessons from a Review of Interventions to Reduce Child Malnutrition in Developing Countries, 2010

UNICEF, Progress for children: A world fit for children statistical review - MDG 1: Eradicate extreme poverty and hunger - Stunting, wasting and overweight, 2007. Available at: http://www.unicef.org/progressforchildren/2007n6/index_41505.htm

WHO - Department of Public Health and Environment, Quantification of the disease burden attributable to environmental risk factors - Programme on quantifying environmental health impacts, 2010

WHO, Nutrition Landscape Information System – Country Profile – Bolivia, 2008

IX. Interviews and contacts

F. J. Armando Pérez-Cueto – Postdoctoral researcher – Associate Professor of Public Health Nutrition at Aalborg University

Pablo Grossman – Professional Chef

Patricia Morales – Physician – ‘Asociación Civil Ayni’

Tatiana Bueno – BID

Jhoselyn Mendez Ferrufino – Nutrition expert

Roberto Calzadilla – Bolivian Ambassador in Holland (expert in the area of quinua)

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X. Appendix 1

22

XI. Appendix 2

Source: MINISTERIO DE SALUD Y DEPORTES & INSTITUTO NACIONAL DE ESTADÍSTICA

BOLIVIA: BAJO PESO AL NACER, SEGÚN DEPARTAMENTO

DESCRIPCION 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 200

9 2010(p)

BOLIVIA

Nacidos (1) 5.73

7 7.35

5 7.71

2 8.57

8 7.38

4 7.78

0 7.77

2 8.32

6 8.20

9 8.17

5 7.61

3 8.30

9 8.54

0 10.518

Porcentaje 4,8 5,59 5,26 5,42 5,03 4,67 4,64 5,52 5,2 4,96 4,66 4,98 4,93 5,78

Chuquisaca

Nacidos 616 613 684 756 825 555 623 583 599 578 559 613 608 747

Porcentaje 5,57 5,14 5,49 5,63 6,22 4,17 4,73 6,09 6,03 5,84 5,77 6,26 5,95 6,79

La Paz

Nacidos 1.69

3 2.46

9 2.19

5 2.48

7 2.12

4 2.34

5 2.27

5 2.47

7 2.37

5 2.61

5 2.43

0 2.52

8 2.60

0 2.736

Porcentaje 6,34 8,36 6,92 7,24 5,95 6,31 5,97 7,19 6,73 7,03 6,48 6,55 6,35 6,56

Cochabamba

Nacidos 806 966 1.00

1 1.19

6 1.79

6 1.29

7 1.28

1 1.30

0 1.53

2 1.51

7 1.58

0 1.67

5 1.67

7 1.832

Porcentaje 5,1 5,73 4,57 4,32 6,25 4,47 4,33 4,87 5,33 5,04 5,28 5,42 5,13 5,39

Oruro

Nacidos 352 381 394 377 328 347 312 465 418 448 470 534 493 524

Porcentaje 5,99 6,5 6,23 5,05 4,26 4,18 4,55 7,15 5,97 6,11 6,07 6,56 5,71 5,76

Potosí

Nacidos 510 507 567 594 651 602 576 568 631 644 722 588 782 828

Porcentaje 5 4,41 4,52 4,42 4,52 3,98 3,87 6,56 6,8 6,74 7,69 6,48 8,01 7,88

Tarija

Nacidos con 465 363 408 359 390 488 369 343 383 351 409 389 390 445

Porcentaje 6,16 4,79 4,96 4,3 4,85 6,26 4,81 4,76 5,17 4,57 5,09 4,78 4,49 4,61

Santa Cruz

Nacidos 913 1.68

2 2.03

5 2.36

1 885 1.79

1 1.97

1 2.20

6 1.91

0 1.51

3 973 1.53

5 1.42

4 2.551

Porcentaje 2,64 4,14 4,59 5,33 3 3,85 4,13 4,52 3,81 2,92 1,96 3,06 2,81 4,76

Beni

Nacidos 343 337 355 328 340 291 315 323 292 430 382 373 486 739

Porcentaje 4,86 4,91 4,43 4,08 4,13 3,55 3,79 4,1 3,34 4,47 3,91 3,61 4,84 6,97

Pando

Nacidos 39 37 73 120 45 64 50 61 69 79 88 74 80 116

Porcentaje 5,94 4,08 6,3 9,85 3,78 5,62 4,23 5,92 5,72 5,58 5,72 4,58 4,65 6,08

(1) Bajo peso al nacer comprende todos los recién nacidos vivos y muertos con peso menor a 2.500 gramos.

(p): Preliminar

23

XII. Appendix 3

Source: Instituto Nacional de Estadística de Bolivia INE - M. Gutiérrez Sardán, L. H. Ochoa, W. Castillo Guerra, Encuesta Nacional de Demografía y Salud ENDSA, 2003

24

XIII. Appendix 4

Source: Instituto Nacional de Estadística de Bolivia INE - M. Gutiérrez Sardán, L. H. Ochoa, W. Castillo Guerra, Encuesta Nacional de Demografía y Salud ENDSA, 2003

25

XIV. Appendix 5

Valor CIF Frontera en miles de dólares estadounidenses

DESCRIPCION 2002 2004 2006 2008 2010(p)

TOTAL 1.831.969 1.920.428 2.925.769 5.100.167 5.393.281

Animales Vivos y Productos Alimenticios 166.706 165.804 198.525 402.158 369.379

Animales vivos 2.065 2.079 2.600 4.303 4.770

Carne y preparados de carne 1.178 724 1.187 1.405 1.686

Productos lácteos y huevos de ave 15.210 11.677 12.574 11.792 13.653

Pescado (No incluidos los mamíferos marinos), crustáceos, moluscos e

invertebrados acuáticos y sus preparados 5.424 2.659 4.876 10.044 10.565

Cereales y preparados de cereales 89.369 87.218 88.951 226.350 165.755

Legumbres y frutas 10.243 11.780 13.148 23.370 26.269

Azúcares, preparados de azúcar y miel 10.017 10.638 16.756 21.514 23.194

Café, té, cacao, especias y sus preparados 7.986 9.505 14.621 27.826 29.403

Torta de soya, torta de girasol y cereales 3.278 3.822 5.354 9.706 13.567

Productos y preparados comestibles diversos

21.934 25.703 38.459 65.848 80.517

Bebidas 6.887 7.156 11.256 21.004 33.254

Tabaco y sus productos 2.208 3.845 4.739 7.211 8.687

Semillas y frutos oleaginosos 55.485 39.494 45.387 29.568 7.621

Productos animales y vegetales en bruto 2.065 2.085 2.695 8.108 11.749

Aceites, Grasas de Origen Animal y Vegetal 2.209 1.656 3.406 8.027 4.425

Aceites y grasas de origen animal y vegetal 636 754 1.696 2.402 1.145

Aceites y grasas fijos de origen vegetal, en bruto, refinados o fraccionados

677 426 1.120 2.076 1.857

Aceites y grasas de origen animal y vegetal, elaborados

896 477 590 3.549 1.423

Aceites esenciales 46.296 51.204 69.401 113.963 138.268

(p): Preliminar

Source: INSTITUTO NACIONAL DE ESTADÍSTICA (INE)

26

XV. Appendix 6

Source: R. Vera, M. Moore, G. Varela, R. López, V. Cossío, J. Rivera, A. Aliaga – Estado Nutricional de la población Boliviana, 1981