Undervalued professionals: placement of nutritionist in the Ecuadorian health system

**Background:** Ecuador faces significant nutrition-related public health challenges, including 63.6% of adults with overweight/obesity, 19.8% with hypertension, 12.3% of older adults with type 2 diabetes, and 34.7% with high total cholesterol. Additionally, Ecuador has the second highest rates of chronic malnutrition in Latin America (23% of children under 5 years, 27.2% of children under 2 years). Despite these issues, the Ecuadorian public healthcare system does not include nutrition services at every level of care, and there is no public information regarding the job occupation and satisfaction of nutritionists in Ecuador. This study aimed to identify and analyze nutritionists' employment situation in Ecuador and areas of work covered, and determine if type of university (private vs. public) impacts work situation.

**Methods:** A cross-sectional study was conducted, approved by the ethics committee of Universidad San Francisco de Quito (COD 2019-003IN). The study included 442 nutritionists in Ecuador who graduated from 13 universities (5 private, 8 public) between 2008 and 2019. Participants were selected using stratified random sampling design, with type of university (public or private) as strata. An online survey with 38 items measured job satisfaction, job opportunity, and professional recognition. Data was collected from November 2019 to April 2020 via text message and phone calls using Open Data Kit (ODK) survey technology. The response rate was approximately 56%. Statistical analyses were performed using R version 4.0.3, with two-sided weighted chi-square tests to estimate differences between public and private university graduates at a 95% confidence level (p between 0.01 and 0.05 considered significant).

**Key Results:** Of the 442 participants, 84.2% were women and 74.9% were not married. Overall, 50.63% currently worked as nutritionists, 11.01% worked outside nutrition, and 38.36% were unemployed. There was a significant difference between university types: 68.28% of private university graduates (PR) were currently employed and 58.87% worked as nutritionists, compared to 56.86% of public university graduates (PU) currently working and 44.69% working in the field (p=0.027 and p=0.021 respectively). 76% of all participants reported being unemployed at some point in their careers, with 70% citing difficulty finding jobs as the main reason, 46% citing low salaries, and 12% citing non-convenient work schedules. 51.46% of PR vs. 40.97% of PU graduates perceived finding a job as the main reason for unemployment (p=0.033). Regarding time to first job after graduation, 44% of PR and 31% of PU graduates found a job immediately, while 42% of PU and 41% of PR graduates took 6-12 months. Most professionals had their own business (40.69%), while the least common field was community nutrition (3.64%). The main activity of PR graduates was clinical nutrition (23.3%) compared to 15.9% from PU (p<0.05). One third (28.6%) worked in a second economic activity, with more PR graduates having another activity (37.2% vs. 21.4% PU). The predominant monthly income was 800 USD for both PR (34.93%) and PU (56.71%) graduates (p<0.01). 54.39% of PR earned over 1000 USD compared to 30.92% from PU. No PU participants reported an income of 2500 USD. 64.34% of PU graduates had stable income compared to 43.1% from PR.

**Clinical Implications:** This study reveals a critical shortage of job opportunities for nutritionists in Ecuador despite high population-level nutritional needs. The finding that fewer than 4% of nutritionists work in community and public health nutrition is particularly alarming given Ecuador's high rates of malnutrition and non-communicable diseases. The current organization of the Ecuadorian public healthcare system does not include nutrition services at every level of care, with first-level care centers lacking nutritional care positions entirely. This not only reduces work opportunities but limits nutrition education received by patients. The study highlights the need for policy changes to integrate nutritionists into all levels of the healthcare system, particularly primary care, and to establish standardized staffing ratios for nutrition professionals in healthcare facilities. The salary disparity (800 USD/month median) compared to international standards (e.g., $63,000/year for registered dietitians in the US) may contribute to professional dropout and underutilization of nutrition expertise in addressing Ecuador's nutrition-related disease burden.