Discussion and Dialog at the University of Puerto Rico Graduate Medical Sciences

(By: Phoebe Ryland Gauthier)

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Today we visited the University of Puerto Rico Graduate Medical Sciences campus to hear from several key speakers as well as engage in discussion with graduate nutrition students. The Dean of the School of Public Health welcomed us and provided a brief overview of the Puerto Rican health system which contextualized the presentations we would hear from professors and students. Previously, Puerto Rico operated a pyramid system with over 80 regional Diagnostic and Treatment Centers across the island. These multi-disciplinary centers provided numerous clinical services–such as primary care, nutrition, and health education– to the surrounding community regardless of ability to pay. The system operated this way until 1994 when it switched to managed care, which the Dean stated, “we are still trying to recover from.”

Graduate nutrition students presented on the social, cultural and political influences on the Puerto Rican food system. Puerto Rican cuisine is greatly influenced by African culture and native Taino indians. Traditional cuisine includes fried street food such as fritters (frequently enjoyed at the beach with pinacooladas), rice and beans, and mofongo. These meals are strongly tied to Puerto Rican identity, holidays, and cultural celebrations. Transitioning to the health of the population, the students highlighted that obesity is a leading cause of death in Puerto Rico. In 2014, 69.9% of men and 62.7% of women were considered to be overweight or obese. Additionally, of the six leading causes of death in Puerto Rico, five of them can be attributed to dietary habits and lifestyle. Being overweight serves as a risk factor for diabetes and other chronic diseases, and risk further increases when combined with other behaviors such as lack of physical exercise, tobacco use, and frequent alcohol consumption. 

In response to the burgeoning obesity epidemic in Puerto Rico, several bills have been put forth to control the issue. The Healthy Children Program (Law no. 246-2011)–not yet passed– states that parents who pose any risk or harm to their child’s physical health, or emotional well-being are punishable by law. In this context, harm includes enabling a child to become overweight either through modeling poor eating habits or not providing the child with enough fresh fruits and vegetables to allow them to maintain a healthy weight.  This bill aims to promote healthy eating habits, however, it is also incredibly stigmatizing. I believe that Puerto Rico needs to distance itself from initiatives that penalize poor decisions and instead focus on encouraging healthy behaviors. One initiative that embodies this perspective is Playing for Your Health, a program operated jointly by the Puerto Rico Department of Health and Department of Sports and Recreation. This program combines team sports and competitions with nutrition education (Palacios & Anglero 2013). This program encourages children to be physically active in a recreational environment where they do not feel penalized or stigmatized for their weight. 

Winna Rivera-Soto, professor at the UPR-Graduate Medical Sciences, was consulted on the Healthy Children Program bill, and shared her thoughts on the bill with us. Dr. Rivera-Soto opposed the legislation, stating that individual families cannot be blamed for the obesity epidemic in Puerto Rico and that the root of the issue rests in the system as a whole. The current food system in Puerto Rico is not one of producers, Rivera-Soto continues, but rather one of consumers. The population is bombarded with advertisements and commercials promoting food products, however, families do not yet have the skills necessary to make healthy food choices. Rivera states that this is where the government needs to step in and provide guidance to the population. It is Rivera-Soto’s hope that instead of policing parents and penalizing them for poor choices, parents can be educated and empowered to lead healthy lifestyles and to share those lifestyle choices with their children. Additionally, I’d like to add that Rivera-Soto’s own research (Rivera-Soto & Rodrigues-Figueroa 2012), found that socioeconomic status (SES) was related to a parent’s ability to identify their children as overweight or obese. This study found that parents with higher education had more accurate perceptions of their child’s weight status than those parents with lower education. This research shows that the legislation put forth to penalize parents with obese children may unfairly target lower SES families, since it is more likely that these parents may underestimate their child’s weight status. Since food purchases are frequently linked to cost, penalizing these families with fines may push them farther away from being able to provide their children with fresh food and produce.  

Aside from the systemic issues with the legislation, I do not believe that coercion is the best method of inducing behavior change. As a mental health counselor, I have studied how individuals engage in health behavior modification and understand how challenging it can be to encourage someone to alter deeply ingrained habits. Puerto Rico faces additional barriers in that foods which are deeply rooted in the culture may also be contributing to the population’s weight gain. Looking towards the future, I echo Dr. Rivera-Soto’s sentiments and hope to see more system-level change that encourages health education and fosters a culture in which parents have the knowledge and means to make healthy food choices for their families. 

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