Conceptualizing the effects of COVID-19 on eating and physical activity in people with type 2 diabetes and hypertension in Ecuador using the social ecological model | Journal of Public Health

Abstract

Introduction

Authors have referred to the syndemic nature of the COVID-19 pandemic,¹ where viral infection and non-communicable diseases (NCDs) rooted in social inequalities interact. This issue is highly relevant in the Latin American region where NCDs have become the leading cause of mortality in the last decade,² causing 81% of all deaths.³ Data obtained from the STEPS Survey in Ecuador conducted in 2018 showed that ~20% of the population had arterial hypertension (HTA) (23.8% in men and 16.0% in women), and 7.1% (7.6% in men and 6.7% in women) had type 2 diabetes mellitus (T2DM). Among the population aged 45–69 years, more than 1 in 3 individuals had HTA and 1 in 8 had T2DM.⁴ The inequalities in the burden of these diseases are largely attributable to social determinants such as poverty, education, gender, urbanization and ethnicity and/or race. These factors condition the population’s options for access to a healthy diet and physical activity, both of which are of major importance in the management of HTA and T2DM.^5–8

Pandemic control measures, particularly in the first months, had a major impact on the population. Social isolation, in combination with physical distancing, produced changes in the daily routines of citizens (e.g. physical activity levels, eating habits).^9,10 However, the effects were uneven across countries and settings, with some studies showing positive changes such as an increase in vegetable and fruit consumption, while others showed negative changes such as an increase in the consumption of sugary products and snacks, together with a significant reduction in physical exercise. However, most studies to date have been conducted in Western and high-income countries such as the USA, the Netherlands and Spain, among others.^11,12

The lack of economic resources and job opportunities plunged the economy into one of the worst recessions the country has ever faced. In addition, the public health emergency challenged the ability of the healthcare systems to meet the essential needs of the population.¹³ Here, our aim is to explore changes in diet and physical activity in patients diagnosed with T2DM and/or HTA, and to provide information on patients’ perceptions of why these changes occurred broadening the view from the individual to the context.

Methods

Study design and context

A qualitative, exploratory study using semi-structured telephone interviews was conducted during August and September 2020 in two settings in Ecuador: the low-income districts of south Quito and a rural area of the province of Esmeraldas (which accounts for ~70% of the Afro-Ecuadorian population in the country and is characterized by extreme poverty and limited infrastructure).

Study population and data collection

Recruitment strategy was purposive sampling to include a group of people with T2DM and/or HTA that was heterogeneous in terms of gender, age and socioeconomic status. In Quito, we recruited participants with the help of the diabetes patients’ clubs at different public primary care facilities, and in Esmeraldas, we recruited them with the help of community health promoters through the Centre for Community Epidemiology and Tropical Medicine (CECOMET). We increased the number of participants until we reached saturation, and no new information was obtained.

The interviews were conducted by telephone because they took place during the mobility restrictions implemented during the COVID-19 pandemic.¹⁴ The duration of the interviews ranged from 16 to 53 min. Details on data collection can be found in previous publications.

Data analysis

The interviews were recorded and transcribed verbatim for analysis. They were then uploaded to Atlas.ti 8 for content analysis to organize the key findings into key themes. For the publication of this article, the verbatims have been translated into English (the Spanish version and its translation can be found in the supplementary material).

The research group of seven researchers (one man and six women) agreed to use a basic set of codes, organized according to the objectives of the project, for the analysis. Each interview was coded by two researchers (I.B.D., E.C.R.) from different disciplines, both of whom had experience in qualitative data analysis. Then, a comparison of the codes was made between each pair and possible discrepancies were discussed.

We identified categories by cross-referencing the coded information and classifying it according to the social ecological model which is a framework for analysing the multiple levels of a social system and the interactions between individuals and the environment surrounding the individual or group of individuals (Supplementary file, Fig. 1).¹⁵

Results

Table 1 shows the sociodemographic data of the 19 participants (9 women). Interviewees reported changes in healthy habits related with diabetes and hypertension control because of the COVID-19 pandemic, which are described below organized by the different levels of determinants of health according to the socio-ecological model.

At the macro and public policy level, there was a generalized discourse that expressed a lack of public policies to address the worsening food situation. Participants reported lack of access to food due to mobility restrictions throughout the country, with a particular hardening in the capital, together with the loss of employment and income due to the pandemic. In this regard, people expressed the need for social policies including food voucher programmes, which are an important resource for low-income populations and can help reduce food insecurity. This lack of resources was more pronounced among migrants and people at higher risk of social exclusion in the country (Table 2, Quote a).

Due to the lockdown and curfew imposed by the Ecuadorian Government (which at times lasted from 2 pm to 5 am), people were barely able to leave their homes. For some interviewees, this meant a significant reduction in routine physical activity (Table 2, Quote b). In the rural setting, this limitation of movement was eased by the fact that interviewees’ properties had land, which allowed for walking and other activities (Table 2, Quote c).

Community factors

At the community level, limited movement and work environment changes had an impact on the uptake of physical activity. Particularly, for work activities that had to be suspended, such as street vending (Table 3, Quote a). Also linked to the precariousness of working conditions, some people associated their hours of activity to the working hours at their workplaces (Table 3, Quote b).

In addition, the work environment of some people before the pandemic was negatively related to their diet because of the presence of street food outlets selling ready-made meals and fast food rich in fat and sugar. In some cases, interviewees reported positive changes in their diet due to changes in working conditions, such as less time outside their home, which allowed them to pay more attention to diet and made them less reliant on food that was not home cooked (Table 3, Quote c).

Mobility and transport constraints had a major impact on food availability. The cost of transport was an added factor that made mobility difficult, and shops also lacked supplies to sell to people, particularly in Esmeraldas as it is an area that is difficult to access. Thus, in some rural areas dietary variety was limited as people were unable to travel to obtain certain foods and were limited to consuming what they could produce in their gardens (Table 3, Quote d). In the rural setting, the limitation of movement during the full lockdown also prevented activities such as fishing, which is an important source of food for these populations (Table 3, Quote e).

However, people living in Esmeraldas described a lower impact on physical activity in terms of outdoor mobility restrictions related to the neighbourhoods and type of housing they had with land to farm or walk. This situation would be comparable to that of people living in condominios in Quito. Condominios are large residential structures divided into apartments that share common spaces (corridors, gardens, sports areas…) (Table 3, Quote f). On the other hand, people with less space in their homes reported that they had to stop physical activity, which they perceived as having a negative impact on their disease control (Table 3, Quote g).

Intrapersonal factors

Social support from family members was crucial to overcome the economic shortfalls and the unavailability of food, which allowed for better control of diet and eating habits. Social support from the family in the purchase of food and financial support provided by them due to loss of employment and income during the pandemic, as explained above, fostered greater social cohesion between children and parents and families in general. (Table 4, Quote a). Support was also seen among neighbours by sharing knowledge and information related to food. However, relatives of chronically ill people feared catching an infection on the street, therefore limiting their outdoor physical activity. Instead, they adapted exercises to the home environment (Table 4, Quotes b and c).

Mobility restrictions also had a negative impact on people’s diets, particularly for those engaged in informal work (such as street vending) who lost their sources of income. The socioeconomic situation due to the discontinuance of economic activities led to a limited access to food, in some cases causing people without food for whole days (Table 4, Quote d).

In terms of health status and perception of care, some of the interviewees had difficulties accessing health services and medication to manage their disease and improved their eating habits as the only means available to them to maintain good control of their diabetes. This led to moderation of carbohydrate intake and sugar consumption, increased consumption of vegetables and fruit, and a decrease in unhealthy cooking techniques such as frying (Table 4, Quote e). People mentioned a greater commitment to reading nutrition labels due to increased time availability during the pandemic, which influenced decision-making when purchasing food (Table 4, Quote f).

Despite recognizing overeating as detrimental to disease management, people reported increased desire to binge eat due to emotional distress and anxiety resulting from lockdown measures, which were further exacerbated by media reports of the pandemic (Table 4, Quote g). One’s emotional state and perceptions of fear were frequently reported as reasons not to go out, as they identified themselves as a high-risk group for COVID-19 and preferred not to expose themselves. This, in turn, led to a decrease in their physical activity (Table 4, Quote h).

Original quotations in Spanish and their translation in English can be found in S1.

Discussion

Main finding of this study

This study explored the perceptions of patients with hypertension and T2DM regarding the self-management of their conditions with exercise and diet during the first months of the COVID-19 pandemic. Most of the people interviewed reported negative changes in their diet and physical activity that were exacerbated by loss of employment and income due to the lockdown and mobility restrictions. The findings are important because they coincide with severe restrictions in healthcare access and problems with medication stock in public health facilities and private pharmacies.¹⁴ The ability to self-care one’s health with diet and physical activity becomes even more important when access to health services and treatment is challenged. Here, we show that the difficulty in accessing products applied as much to food, as medication. Furthermore, participants had little opportunity to carry out physical activity, which prior to the pandemic had been covered in their jobs. Anxiety and fear also impacted negatively on people’s diets and daily activities. The family emerged as a source of emotional and economic support in the absence of public social policies.

What is already known on this topic

The analysis of the policy response to the COVID-19 pandemic in low-resource countries has highlighted the lack of policies against poverty and nutrition insecurity, further intensifying the social inequalities present even before the onset of the pandemic, especially in the most vulnerable populations, women and migrants.^16,17 In this context, the presence of chronic diseases and previous infections may have increased food insecurity¹⁸ as disruptions in the production and distribution of perishable and nutritious foods during crises limit dietary variety.¹⁹ More nutritious and costly food groups such as pulses, nuts and animal protein are replaced by relatively nutrient-poor and cheaper staples.^{20, 21}

The COVID-19 pandemic and the associated social distancing measures exacerbated pre-existing rural vulnerabilities to a greater degree in low-income countries compared to high-income ones²² and increased hunger through inaccessibility to food.^23–25 Given the lack of institutional support, the fragmentation of health services and the inaccessibility of medication, some participants reported that controlling their diet was the only means available to them to manage their illness. However, this was in turn difficult because of the loss of income that limited their access to food and medication, so the most vulnerable people reflected that they were struggling both with the pandemic and with hunger. In this sense, in the absence of institutional responsibility, individuals became responsible for their own care and disease management during the pandemic. A study in Chile, a country with a precarious health system, described how the care of chronic diseases in people in lower socioeconomic strata was completely neglected.²⁶

The lockdown related to the COVID-19 pandemic was associated with emotional problems including anxiety, depression and sleep disturbances that led to more frequent binge eating.^27,28 Our interviewees described negative emotions such as anxiety and fear, exacerbated by the vulnerability of their chronic conditions, as stimuli to increases in portion intake, especially of carbohydrates and unhealthy foods. During the COVID-19 pandemic, in the face of loss of income, isolation and the absence of social policies, greater family cohesion, neighbourhood solidarity and organization of community networks appear as a form of resilience to cope with the increased vulnerability generated. This may play a protective role against adverse health outcomes and buffer the negative impact of the pandemic. Other studies have highlighted the importance of social capital as an important resource with the capacity to organize help and support during the COVID pandemic19.²⁹

Lockdown limited the practice of physical exercise in public spaces. It should be remembered that in the poorer population, physical activity is frequently associated with work, rather than leisure-time physical activity, which is often inaccessible due to the economic cost involved.^23–25 Therefore, the loss of employment or the inability to engage in informal employment activities such as street vending was related to the cessation of physical activity in most cases.

What this study adds

People interviewed in our study, especially those living in rural and hard-to-reach areas, mentioned the difficulty purchasing and accessing food, which required long journeys and additional costs. Some of them limited themselves to consuming only what they grew on their own property. In urban and rural settings, informal sector workers had to isolate during the pandemic and were unable to earn a living, a problem that was exacerbated by their lack of sufficient resources and social protections.

Our results showed the relationship between purchasing power and people’s socioeconomic and housing conditions. Residing in rural areas or in condominiums with green spaces helped to stay active because rurality offers ample natural green spaces surrounded by rivers, allowing access to other activities such as swimming, canoeing (rowing or motorized) and entering family growing plots to walk and/or work, which can compensate for smaller housing sizes. However, people living in small houses, especially in urban areas, found it more difficult to exercise during confinement, but also tried to create imaginative ways of exercising through family activities, such as walking up and down stairs or dance therapy. In this sense, socioeconomic conditions related to neighbourhoods and living environments are relevant, as they are shown to be related to physical activity in our study. In addition, there are often fewer green spaces in low-income areas compared to higher-income areas, and these are often smaller and poorly maintained.³⁰

This study highlighted the limitations and difficulties in the self-management of chronic non-communicable diseases during the COVID-19 pandemic in Ecuador. Increased food insecurity and limited physical activity were marked among the most vulnerable people such as migrants and women and were coupled with the loss of income in a context of labour informality and difficulties in accessing health services and pharmacological treatment. The lack of social policies reflected the lack of social protection for people with chronic diseases who had to fight against the pandemic and hunger and placed the responsibility for care in the hands of the sick. People reported a worsening emotional state and social and family support emerged as a source of resilience and adaptation. The COVID-19 pandemic had led to a series of social crisis including health inequities in the globe, in particular low- and middle-income countries. In Ecuador, COVID-19 further intensified the social inequalities present before the pandemic by limiting access to physical activity and nutrition, key aspects in the management and control of chronic non-communicable diseases, but also in coping with emergency infectious diseases.³¹

There is a need to monitor the emerging consequences of this neglect and difficulty in chronic disease management, considering social and environmental factors and the role of resilience in this syndemic, by addressing appropriate policies that consider people from the most disadvantaged backgrounds to reduce the health inequality gap.

Limitations of this study

Our study has several limitations that must be considered when interpreting the results. On the one hand, the interviews were conducted by telephone due to the pandemic situation, which made it difficult to collect information related to non-verbal language. To counteract this, interviewers took notes on relevant information such as voice and intonation, the interviewee’s mood and the context in which the interview took place. The evidence shows that telephone interviews are an effective means of collecting information and in our study allowed us to conduct interviews in hard-to-reach areas of Esmeraldas and not only in the capital of the country.³² Even so, we had problems reaching rural communities due to a lack of resources. This meant that people in Esmeraldas were in higher education, technical jobs and with a basic monthly salary >400$. The interviews were conducted in Spanish, which may have resulted in the loss of information on how the pandemic has affected the indigenous population in Ecuador.

Acknowledgements

We would like to thank the participants for taking part in the interviews and sharing their experiences. Furthermore, we acknowledge the work of the interviewers who collected the data and the help of the diabetes clubs and CECOMET for recruiting the participants of the study.

Conflict interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript or in the decision to publish the results.

Funding

This research was funded by a H2020 European Research Council 2018 Starting Grant, grant number 804761—CEAD.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of the Hospital Universitario Sant Joan and Human Research Ethics Committee of Pontifical Catholic University of Ecuador. Informed consent was obtained from all participants, ensuring confidentiality and the use of information exclusively for research purposes. At the beginning of the interview, the informed consent form was read, and the participant verbally agreed to participate. Both the verbal informed consent and the interview were recorded to facilitate later analysis. Participation in the study was voluntary and there were no material incentives.

I. Benazizi-Dahbi, Researcher at the Global Health Research Group. Universidad Miguel Hernández de Elche AL.

A.L. Torres-Castillo, Director of the Public Health Institute of the Pontificia Universidad Católica del Ecuador.

C. Caicedo-Montaño, Director of CECOMET

M. Puig-García, researcher at the Global Health Research Group. Universidad Miguel Hernández de Elche

A. Peralta-Chiriboga, Lecturer and Researcher in Public Health. Insitute of Public Health (PUCE).

M. Hernández-Enríquez, Zonal administrator of Quitumbe (Quito).

M.F. Rivadeneira Guerrero, Lecturer and Researcher in Public Health in Public Health. Insitute of Public Health (PUCE).

M. Márquez-Figueroa,

L.A. Parker, Lecturer and Researcher in Public Health. Universidad Miguel Hernández de Elche.

E. Chilet-Rosell, Lecturer and Researcher in Public Health. Universidad Miguel Hernández de Elche.

References

© The Author(s) 2025. Published by Oxford University Press on behalf of Faculty of Public Health.