THE PEOPLE OF OAXACA

Jia Lu Fresno State Dietetic Intern FFN 220 Spring 2014 Dr. Dormedy

ABSTRACT Oaxaca is a state located in Southwest Mexico, where the landscape of rugged terrain and high mountains has helped to preserve its indigenous culture (1,2). Despite the mountainous landscape, there is agricultural industry in Oaxaca; major crops are cacao, maize (3). Foods that are distinctive Oaxacan cuisine are tlayudas, chocolate mole, black beans and chapuline (grasshopper). A Oaxacans continue to practice their cultural method of diagnosing called susto, and use traditional tonic water treatments for their ailments (4). However, as Oaxaca becomes more modernized, prevalence of new world chronic diseases, such as diabetes, has infiltrated Oaxacas old world culture. A study conducted by Margaret Everett revealed that many diabetic Oaxacan women attribute the disease from negative and unresolved emotions from the past; and the link between diabetes and diet is absent (5). Factors such as perinatal and early childhood malnutrition and urbanization have contributed to the rise in diabetes in Oaxaca. Among its impoverished population a syndemic is emerging, which describes the presence of multiple disease conditions. Therefore, diabetic patients in Oaxaca are also at risk for acquiring comorbid conditions such as cholera or dysentery. These conditions make nutrition counseling especially important for the Oaxacan population in Mexico as well as in the United States, where cultural sensitivity is key to reaching this indigenous population, which has been discriminated against in the past.

INTRODUCTION
The restaurant was bustling, with several full tables, a busy kitchen and waitresses hustling about. In the middle of the restaurant was Carmelita, a twentytwo year old Mixteco sat facing the front door and engaged in an energetic conversation with a friend. I arrived with my friend Esmit, I greeted Carmelita and sat down. Esmit introduced me to Carmelita a few years ago and I was excited to interview her. The restaurant called Oaxaca and it was fairly large with fifteen tables. The waitress served our table, and took our drink orders. I asked Carmelita to describe chapulines also known as grasshoppers, a staple in the Oaxacan diet. She assured it was delicious, it tasted like chili and lime and I would enjoy it. Once the waitress returned to the table with our drinks, Carmelita suggested I ordered chapulines on a sope with carne asada. The waitress raised a brow when I placed my order and Carmelita continued to assure me it will be tasty, and she would eat some of it with me. Twenty minutes later the waitress brought the food. Esmit ordered enchiladas with coloradito mole. Oaxacan cuisine is known for the extensive mole and chapulines. I tasted the coloradito, which was a deep amber color. It was sweet, rich and dense, and it complemented the enchiladas nicely. Anxiously, I awaited my food; I was concerned of offending people if I did not enjoy it. I continued to interview Carmelita who shared stories that her mother would tell her about Oaxaca. In mid conversation the waitress slender arms came between Carmelita and me; in her hand was a hot carne asada sope topped with chopped iceberg

lettuce, fresco queso, diced tomatoes and chapulines. Carmelita began explaining that in Oaxaca, people would harvest chapulines using glass Coke bottles and boxes. The grass hoppers where brought back home where it was prepared by frying and cooked with oil, chili powder and lime juice. Chapulines was one of Carmelitas favorite cuisines. Carmelita urged me to try it. I drove my fork into the chapulines and examined the food. Without thinking too much it, I brought the fork to my mouth and began to chew; the texture was crunchy like a potato chip. In the article Chapulines and Food Choices in Rural Oaxaca by Cohen et al he described the grasshoppers to be tasty, however his only complaint was feel of the legs in his mouth. Cohen shared a tostada topped with chapulines with a local Oaxaqueo, who suggested for Cohen to remove the legs before eating. Adopting Cohens adverse to the legs, I anticipated the experience and discovered it I didnt mind it. I enjoyed the dish with Carmelita who continued to proudly share the food and cultural practices of Oaxaca.

THE STATE OF OAXACA

The state of Oaxaca surrounded by rugged Mountain terrain, which helped isolate indigenous population of from the modern world (1). The isolation from the modern world preserved much of the unique indigenous culture and lifestyle of the people in Oaxaca. Oaxaca City is the capitol of the state and was founded in 1529, it is located at 5,000 feet elevation and has year old mild climate. The history is rich because the people of Oaxacan maintained the identify with their indigenous heritage. Oaxaca is known as the Capitol of the Seven Moles (2). The word Oaxaca

is derived from the Nahuatl word, spelled Huayaca which is translated to The Place of the Seed because early citizens harvested corn, beans, chocolate, tomatoes, chili, squash, pumpkin, and gourds (1). There are sixteen different ethnicities identified in Oaxaca, the two largest groups are the Zapotecs and the Mixtecs (1). Due to the isolation, there is a history of civil unrest as neighboring indigenous groups fight to gain territory (3) Unlike the Northern states who has a large industry of exporting high demand fruits and vegetables, Oaxacas agricultural industry is impacted by rain and declining farming has led to large scale emigration to other states as well the United States (We Eat Meat). Crops that are harvested in Oaxaca are corn, beans, chocolate, tomatoes, chili, squash, pumpkin, gourds, fish, turkey, deer, armadillo, iguana, jabali and tepezunitle (1).

FOOD
Capital of the Seven Moles Oaxaca is most known for thick, rich sauces known as moles. Mole is a fusion food which appeared in the 1600 that combined spices from the Old World and chile and chocolate from the New World (4) There are seven different kinds of mole: negro, verde, amarillo, coloradito, rojo, chichillo, and mancha manteles. Although Oaxaca is referred to as the capital of seven moles, there are more moles. Each mole is unique and complements different dishes. Making the mole is labor intensive; it requires the preparer to grind the spices using a flat stone grinder and rolling pin. The infamous black or negro mole is very rich and contains over twenty different

ingredients in the sauce (5) . Mole is used to as a sauce and is served with various meats, poultry, tamale or enchiladas. Mole is a fusion sauce which Carmelita explained you could purchase dry mole spice, if you do not have time to grind the spices. Grinding the spices as you can imagine is a very time consuming process. At Oaxaca, the restaurant Carmelita picked up a small plastic bag filled with dried spices. The secret ingredient, she shared was to use chicken broken when instead of water when making the mole. Chapulines Grasshopper is unique food of Oaxaca. People all over Mexico eat insects, however grasshopper consumption is more prevalent in Oaxaca (6). Grasshoppers are found in grass green areas, however more specifically the ones for consumption are taken from milpas, and because the grasshoppers live on farms planted by human beings the insects are considered to be semi-domesticated (6). Harvesting season for grass hoppers usually occur during the beginning of the rainy season in spring and into early winter (6). There are degrees in the quality of the chapulines; newly hatched grasshoppers known as nymph are sweeter because of the alfalfa the insects have been eating therefore nymphs are the most expensive (6). As the grasshoppers begin to mature, they will migrate from eating alfalfa to eating maize, which leads to a bitter taste in the chapulines. Chapulines are harvested early in the morning when the grasshopper has not full awake yet, during that time insects move slowly and typically collected by young boys or men with nets, bottles or boxes (6). If a harvester attempted to collect

grasshoppers during the middle of the day, it is harder to catch them; early in the moving one can almost grab them by hand (6). Once the chapulines are captured, the harvest is cleaned and sorted and left in the box for three days without food in order to allow for the grasshoppers to void any waste. Smaller chapulines farmers take care in producing high quality grasshoppers, and often criticize large productions of the staple food because the factories do not allow for the chapulines to rest and void waste and attempt to mask the taste with overuse of chilies. After the chapulines have rested, women cook them by cooking it in boiling water flavored with garlic and lime. The chapulines are cooked on a clay-cooking surface in small batches season lightly with salt and lime juice. Chapulines offers a low-cost source of protein and it is a crucial part of the diet for rural families in Oaxaca. The diet in rural Oaxaca does not vary much beyond the tortillas, salsa, chicken, eggs, and low-grade meats (6).

THE CULTURE
The Patriarch The culture is Oaxaca is a patriarch driven; men take great pride in their manliness and their ability to provide for the family (3). In times they may not allow care providers to speak to the women in the family directly, the men are in charge of making al the decisions in the household. The men are the providers and the women adhered to maintaining the household, rearing children and selling food in local markets. Oaxacan men have a social fraternity that women cannot take part of, the fraternity provides socializing for men only.

Family orientated Due to the discrimination faced by many Oaxaqueos experienced, they tend to keep to themselves and they are extremely hard workers and prideful people. Family is has the utmost importance to Oaxaqueos and is often evident and celebrated during major holidays such as Dias de los Muertos (7). During such celebration the women and capable young girls spend the morning preparing for the big feast. Cultural Practices in Health In rural Oaxaca many people are become ill seldom visit the doctor or go to the hospital because the city or village may be far from the nearest hospital. In instances when people become sick often they seek medical treatment from practitioners known as curanderos and brujos. In America, Oaxaqueos are also likely to seek medical treatment from folk healers rather than visiting a doctor due to the history of discrimination and lack of familiarity (3). Oaxaqueos may have a mistrust or fear of working with American doctors; Oaxaqueos may have the doubt that conventional medication to treat illness will have overwhelmingly adverse number of side effects in comparison to traditional teas and tonics prescribed by curanderos. More over, in Fresno County 30% of the population is estimated to be uninsured and 20% are deterred from visiting a doctor due to costs (8). Traditional folk healers are more accessible, familiar and affordable for Oaxaqueos in the valley. Curandero and Curanderas Curanderos (male) and Curanderas (female) are traditional folk healers who are characterized by using herbs to create teas and tonics for healing. In a clinic in

Mexico, some doctors will treat patients with diabetes with a combination of both conventional medication and tonics prescribed by curanderos. Curanderos are not expected to cure their clients major problems but rather they are sought after to provide physical, spiritual and psychosocial problems, which are treated with massage, herbal remedies and spiritually focused cures (9). In rural Latino communities there is mistrust in White health care professionals when seeking medical treatment, will refer to the curanderos. About one third of Latinos who are treated in public hospitals has visited a Curandero sometime in their life; moreover Latinos with less than a 5-year residency and Spanish speaking preference are more likely to seek curanderos (9). About 39 % of Latino parents believe that licensed medical practitioners methods of treatment was more effective, and 31% believed that curanderos was a better choice when compared with conventional medicine (11-13). Curanderos are sought after by adults, they are able to treat children as well. Statistically, Latino children under the age of five have a higher prevalence of obesity compared to other ethnic groups. Low-income Latino preschoolers are 19% overweight, Black are 13% and White are 11.5% (11-13). Curanderos intervention may be the same as what is recommended by Registered Dietitians. Curanderos understand that the Westernized diets such as moving from corn tortillas to flour, deep fried foods, fatty meats, excessive use to cheese and increased consumption of soft drinks leads to childhood obesity (9). Moreover, in the Latino culture, there is what is known as the mijito syndrome. The syndrome is used to describe the action of overly nurturing children with behavioral problems is treated

by comforting through food such as sweets rather than correcting the behavior (9). Curanderos will help with correcting such behaviors by working with the families to correct areas that need improvement. Brujos and Bruja Brujeria is Spanish for witchcraft and is practiced by brujos and brujas (14). However, it is often viewed as a negative or a bad choice in healing because it is often associated with the works of the devil. Carmelita explains it: Brujos used things like animal sacrifices, chantings, they might call on the saints. People think its really bad if you see a brujos because it is believed they get their powers from the devil. But, still people do go see them. Brujos and brujas often use an egg to help cure and diagnose people they are feeling ill. Patty from WIC described a story of her sister-in-law attempted to use an egg to diagnose susto in her daughter: My sister-in-law asked me to get an egg one day for my little girl who was sick. I was against it, saying that she cant be using the devils magic on my daughter! She kept bugging me, and until finally I gave her an egg. She rolled the over all over my daughters body and then asked me to bring a glass of water. Apparently, after you roll the egg over the sick persons body, you have to crack it open and put it in a glass of water. If the egg looks like its cooked, its related to susto and the person needs to be treated immediately. If its uncooked its fine. So my sister-in-law cracked the egg and she told me it was cooked! It just looked like an egg in water, I got upset that she wasted my egg. Brujos will engage in activities to remove sustos, mal de ojo, nervios from the individual; essentially brujos will attempt to remove the evil curse when treating people. Brujos will also engage in animal sacrifices and praying to the saints as an attempt to cure the issue.

Prevalence of Disease The highest prevalence of disease in Oaxaca is type II diabetes; it has shown a significant increase in the past two decades due to the genetic make up of the indigenous population (15). According to Neels thrifty Gene Hypothesis in 1962, it suggested that the fetus would respond to life in the outside world through genetic coding to ensure survival. During times of starvation, the lack of calories from mother to fetus will determine the unborn childs susceptibility to disease. Neel argues that diabetes has a role in quick insulin triggers, which changed in the hunter-gatherer ancestors to respond to periods of feast and famine (15). Type 2 Diabetes has become a costly and major concern in Mexico, the prevalence has increased and it has become the 3rd cause of death in Oaxaca (15). The reason for the mortality rate is due to the lack of adequate care and the coexistence of other health issues such as hypertension, hyperlipidemia and abdominal obesity (16). Moreover, as Oaxaca becomes more modernized the sedentary lifestyles, westernized diets and genetic susceptibility contribute to the risk factors of developing diabetes. The study conducted by Margaret Everett revealed interesting health beliefs and behaviors in Oaxaca. The patients were interviewed and ask about how the found about diabetes, what they thought affected them, were other family members diabetic, what worried them the most, describe the impact of diabetes in their daily lives and if diabetes is openly discussed in their household. The majority of the responses were influences by strong emotional connections and upsetting events as to why the patients were diabetic such as susto rather than behavior issues. Some

women shared that their diabetes as originated from having bad tempers and frequent anger rather than one single event, because it stirs up the blood (16). During the interview there were no concerns that showed up, although some patients were very upset that they were the victims of the disease. Often during the doctor visits other family members will be present with them. Additionally, diabetes is a not a disease they are ashamed of because it is considered to be a normal thing, it is a natural disease and not a contagious disease. The study also interviewed health care providers and their perspective on the disease. The health care providers related the prevalence of diabetes to changes in diet, activity, alcohol use and genetics (16). Doctors have speculated that older generations developed diabetes because they did not have a method of diagnosing diabetes. Most doctors do agree that the common denominator for disease is the large consumption of soft drinks, a shift towards processed and convenience foods and consumption of high fat, high sugar traditional foods. The most common health problems in Oaxaca are intestinal and respiratory infections in children, low birth weight, underweight children, diabetes and high blood pressure in adults (16). The doctors understand that Oaxaqueos seek medical treatment from curanderos and will prescribe tonic with their medication. The patients have a difficult time changing their dietary lifestyle to adhere to the recommendations prescribed by the doctors and often will rely on the medications for treatment (16). Patients respond to the doctors recommendation to eating more fruits and vegetables as being expensive and instead will eat beans and tortillas (16).

During an interview, a doctor shared a obesity case. He would have a family come see him for diabetes, both the mother and father are obese while the young children are underweight. When the children become adolescents they become overweight and by the time the have reach adulthood they are obese. In Oaxaca child under nutrition is a concern. Low birthday weight and growth stunting are risks for chronic disease in adulthood (16). A study done in 2007 by Barquera revealed that maternal abdominal obesity lead to child stunting (17). In addition to chronic diseases, there has is a syndemics of chronic and communicable diseases in Oaxaca. There are high disease rates of HIV/AIDS, cholera, malaria, and dengue. Social inequality, poor housing, racism, hepatitis C suboptimal health care contribute to the increase of disease in the inner-city minority populations (16). Amongst the impoverished population, the regular deprivation of good nutrition has serious health consequences (16)

INTERVIEW WITH CARMELITA

Carmelita Mendoza is a 22-year-old Fresno native whose mother and father emigrated from Mixteco, Oaxaca. The gender roles in the Oaxacan culture parallel other patriarchal societies where women often maintained the homestead and men were providers. Women tended to all the tasks and duties in the household, which included cooking, sewing, rearing children and are often submissive to their husbands. Generally, men have a strong sense of machismo, which greatly influences counseling. Oaxacans are private people and often they will not seek medical attention until symptoms are severe. Mendozas father and uncle were

diagnosed with type 2 diabetes and they refuse to talk about diabetes, they are private about it...its like they are in denial of the disease. Mendoza shared family bonding is very important in the Oaxacan culture, during major celebrations families gather and prepare food together. The women would make homemade tortillas, which are thicker than the typical Mexican tortillas. Mendoza reported the typical foods in the Oaxacan culture consist of mole, home made tortillas, cilantro, tomatoes, onions, and cactus. The method of preparing the food often requires frying and cooking with a fat, preferably lard. Such cooking method leads to developing chronic diseases such as type 11 diabetes, high cholesterol and hypertension as reported by Mendoza. When interviewed about the matter if discrimination, Mendoza shared that in high school people gossiped that Oaxaqueos were short, dark and dumb people. It couldnt be more untrue, as a Oaxaqueo we are very hard working people. We have a lot of pride and we are resourceful. I felt bad that they would say that, but Im not either of those things. Carmelita Carmelita was born in America, both her mother and father emigrated from Oaxaca. Other second generation Oaxaqueos share the same sentiment as Mendoza. As described by Cruz-Manjarrezs paper, her interviewees struggle with their identy, are they Mesoindians or are they American? Many second generation Oaxaqueos in Los Angeles are pushed to participate in their cultural activities and their groups.

COUNSELING
Counseling Oaxaqueos you must be sensitive to their cultural practices, they end to be very proud people. During an interview with Bibiana, a team leader at Women Infants and Children (WIC) in Parlier reported that Oaxaqueos are more likely to engage in traditional cultural practices such as seeking medical attention from curanderos. You must be very open to them, make them laugh and make them feel welcomed when you are counseling them. There may be some Oaxacans who are not fluent in Spanish and counseling may be difficult. Thomas Brand, a Registered Dietitian shared that dietary compliance is largely based on the overall familys desire to change. Most of his participants, Oaxaqueos included are appreciative of the information but it may take several sessions for the recommendations to become common practice within the family. Through his experience Oaxacans share common disorders from other Hispanic populations with an emphasis on overweight/obesity and type II diabetes. Thomas shares his experience: Sometimes the very obese children can be difficult to counsel. Deep down part of me knows that some of these kids will never recover from the excessive weight theyve gained and will always carry it with them, as well as the poor dietary habits that caused it. It is a sad truth, but some of the children I see will wind up pre-diabetic by the time they are in high school. Thomas In Parlier, Bibiana sees and interacts with Oaxaquenos more and she understands their struggles and recognizes their resourceful skills derived from having to survive.

Oaxaqueos are very resourceful. They are the only ones who make panecitos using baby cerealno other Latinas know how to make it! [Non-Oaxacans] ask me, but I honestly dont know how they make it. Bibiana

CONCLUSION
The Oaxacan culture is rich and diverse. Recognition that Oaxacans are a different from Latinos from other states is important when providing health care. Oaxaqueos have a history of suffering and discrimination so during counseling; all health care providers have to be sensitive to their cultural practices such as seeking medical treatment from curanderos. The end of the research journey I realized that Oaxaqueos are a very unique group in the Central Valley, and having to befriend, collaborate with and research their culture is an enriching experience.

References: 1. John P. Schmal. OaxacaL A Land of Diversity. Available at: http://www.houstonculture.org/mexico/oaxaca.html Accessed on: 3/13/14 2. Visit Mexico Website. Available at: http://www.visitmexico.com/en/oaxaca. Accessed on: 4/12/14 3. J. Mendoza Interview. Recorded on April 22nd, 2014. 4. Cooks Info.Com. Mole. Available at: http://www.cooksinfo.com/mole Accessed on: 4/22/14 5. Rick Baylesss Oaxacan Black Mole from Mexico State Dinner. Huffington Post. Available at: http://www.huffingtonpost.com/2010/05/20/baylessblack-mole-recipe_n_583397.html Accessed on: 4/22/14 6. Cohen, J. S., N., Montiel-ishino, F. . (2009). Chapulines and Food Choices in Rural Oaxaca. Gastronomica: The Journal of Food and Culture, 9(1), 61-65. 7. Carmelia Mendoza Interview. Recorded on April 15th, 20114. 8. University of Wisconsin Population Health Institute. County Health Rankings 2013. Available at: http://www.countyhealthrankings.org/sites/default/files/states/CHR2013_ CA_0.pdf Accessed on: 4/13/2014 9. Clark, L., Bunik, M., & Johnson, S. L. (2010). Research opportunities with curanderos to address childhood overweight in Latino families. Qual Health Res, 20(1), 4-14. doi: 10.1177/1049732309355285 10. Risser, A. L., & Mazur, L. J. (1995). Use of folk remedies in a Hispanic population. Archives of Pediatrics and Adolescent Medicine, 149(9), 978-981. 11. Mei, Z., Scanlon, K. S., Grummer-Strawn, L. M., Freedman, D. S., Yip, R., & Trowbridge, F. L. (1998). Increasing preva- lence of overweight among U.S. low-income preschool chil- dren: Centers for Disease Control and Prevention pediatric nutrition surveillance, 1983 to 1995. Pediatrics, 101, E12. 12. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of over- weight and obesity in the United States, 1999-2004. JAMA, 295, 1549-1555. 13. Sherry, B., Mei, Z., Scanlon, K. S., Mokdad, A. H., & Grummer- Strawn, L. M. (2004). Trends in state specific prevalence of overweight and underweight in 2- through 4-year-old children from low-income families from 1989 through 2000. Archives of Pediatrics & Adolescent Medicine, 158, 1116-1124. 14. Anthony Polanco. University of Arizona. Brujeria and Self-Identity: How My Past Influenced My Research. Available at:http://eapolanco.com/brujeriaand-self-identity-how-my-past-influenced-my-research/ Accessed on 4/23/14.

15. Everett, M. (2011). They say it runs in the family: diabetes and inheritance in Oaxaca, Mexico. Soc Sci Med, 72(11), 1776-1783. doi: 10.1016/j.socscimed.2011.02.021 16. Everett, M., & Wieland, J. N. (2012). Diabetes among Oaxaca's Transnational Population: An Emerging Syndemic. Annals of Anthropological Practice, 36(2), 295-311. 17. Barquera, Simo n, aren . Peterson, Aviva Must, Beatrice . Rogers, Mario Flores, Robert Houser, Eric Monterrubio, and Juan A. Rivera-Dommarco 2007 Coexistence of Maternal Central Adiposity and Child Stunting in Mexico. International Journal of Obesity 31:601607 18. Cruz-Manjarrez, A. (2013). Children of Oaxacan Zapotec. Estudios sobre las Culturals Contemporneas, 19(1), 51-73. 19. Bibiana Gonzales Interview. Recorded on April 16th, 2014 20. Thomas Brand Interview. Recorded on Feburary 14, 2014.