Futuros Colectivos has wrapped up! Thanks to all to attended.
Sustaining donors are being sought! See our blog or Facebook.
No doubt many of you are aware of the “end of the world” craze that surrounds a specific date in the Mayan Calendar that will occur in December of this year.
Our colleague at Kaqchikel Cholchi’, Lolmay Pedro Garcia, has written a great informational article (in Spanish) about the “truth” surrounding this event from a Maya perspective. We thought some of you might like to read it and so, with Lolmay’s permission, we have provided a link here to the article hosted on our website.
Our staff in the Bocacosta have been giving classes (in our new clinical space!) to mothers and other beneficiaries about complementary foods and other themes in early child health. Here are a few pictures!
Wuqu’ Kawoq | Maya Health Alliance has a new program to link donor’s health goals to our patient’s health. Steps to Health! Are you looking to get in shape or achieve a new personal best? Organized races such as 5Ks, 10Ks, marathons and half-marathons provide great opportunities to get involved with your community, get in shape, and now support a great a cause!
Through Steps to Health, race runners can choose their race, their fundraising goal, and get healthy while helping provide much needed health and human services to Guatemalans in need.
This past Saturday, April 28th, our first Steps to Health runners ran the Illinois Half-Marathon in Champaign-Urbana, IL. Each step of these 13.1 miles means life-saving care for those in need.
Want to run a race for Wuqu’ Kawoq | Maya Health Alliance, it’s easy! Sign up your race at Steps to Health Sign-Up. Each runner will get a personalized Steps to Health t-shirt that includes the race, date, and customized Maya glyph for the full count of the date of the race. You can also support our other runners and view our upcoming races at Steps to Health, here you can see if there’s a race near you that already has a runner you can train with!
On Tuesday, March 6, Dr. Melinda Dabrowski with Wuqu’ Kawoq women’s health program developer Claire Melvin presented the topic of women’s health in rural Guatemala to University of Illinois Medical Students. Dr. Dabrowski has been volunteering with Wuqu’ Kawoq for over 4 years and has made a major impact on the work that WK has been able to do to improve women’s health services.
Dr. Dabrowski described the healthcare conditions for the women living in rural Guatemala. Whether it be due to lack of education, poverty, language barriers, or access to resources, Guatemalan women experience one of the highest rates of maternal death per year in the western hemisphere. WK attempts to combat this by collaborating with Guatemalan midwives, the first and sometimes only access women have to healthcare, to provide them with better education and resources.
WK has also implemented a women’s health education program to provide Guatemalan women with information on their own sexual and reproductive health beyond pregnancy. This program provides classes as well as clinical services in Kaqchikel to rural women, many of whom have never had the opportunity to discuss their own health, family planning, or preventative care before!
Dear Friends,
I am writing you again from Guatemala, where I have spent the last several days visiting our projects. This is just a short update, whose purpose is mostly to post a few pictures of our staff hard at work!
In most of the updates we have made to this project so far we have talked about the needs of the children we are serving and about the nutritional product, Plumpydoz, that we are using. However, I wanted to take a moment to celebrate the hard work of our staff, whose compassion, commitment, and dedication make our programs a success.
Community based nutritional programs like ours require multiple levels of staff in order to run smoothly. At the most local level, we work with women’s cooperatives, who coordinate most of the program logistics, such as distributing nutritional products and medications, measuring children’s heights and weights, and noting down data in medical records. These women’s groups are closely supported by our nursing staff, who help with triaging patients and who also lead educational sessions about nutrition and other health topics.
In the first picture, you can see Cristalina, one of our community leaders hard at work; she has just finished weighing and measuring children and she is recording their data for the medical team to review. In the second picture, you can see Herlinda, one of our nurses, together with Carolina, another community leader; they are just about to take off to make some house calls on some of our most malnourished children.
Finally, all children in our programs receive medical attention directly from our physician staff. This is done collaboratively with our nursing staff and with the community leaders, who always know the child’s individual situation very well and provide expert advice on how to achieve our nutritional goals for each child. In the final picture, you can see our nurse Herlinda together with Dr. Cesar and myself carefully reviewing the growth of a particularly complicated case, trying to figure out how best to help the child out.
Thanks for listening!
The team has been busy around Lake Atitlán distributing Nutributter. Click on the photo below to see a full gallery.
Lately, I’ve been giving a lot of talks about child malnutrition. In large part, this is because we have been working on a project to deliver Nutributter, a lipid based nutrient supplement, to children less than two years of age across a good-sized geographic chunk of Guatemala. Simultaneously, we’ve been using Plumpy’doz, another lipid based nutrient supplement, in more intensive community-based nutrition venues. In short, we have been doing a lot of talking up these new products, as well as continuing to raise awareness about chronic child malnutrition in general to other development and policy groups. When I give these talks, there are two questions that almost always come up, and so I’d like to take a few minutes to address them here in this forum.
The first question goes something like this: “Although nutrition programming and supplementation is important, isn’t the real problem in indigenous communities that they all have access to junk food now?” “Isn’t processed food displacing traditional dietary substances, resulting in diets that are less healthy and predisposing to more malnutrition?”
The short answer to this question is, “No” – or, at least “No, probably not.”
First, although it is common to assert that traditional diets in rural Guatemala are changing rapidly, there is remarkably little solid evidence, other than anecdotal evidence, that quantifies this. I am not saying that such dietary changes are not occurring. Rather, I am saying that measuring dietary change employs relatively standardized scientific instruments—things like food recalls and food frequency surveys—and that, generally speaking, these instruments have not been widely or rigorously used in rural Guatemala. Therefore, we cannot say with any authority at all, what the magnitude of dietary change in rural communities is –and, until we can, we should not be pointing to anecdotes of children walking down the street with bags of potato chips in hand to guide policy. This research badly needs to be done!
Similarly, putting dietary changes towards processed food and the Guatemalan child malnutrition endemic together conceptually takes a very short-term view of the problem, and disregards a lot of what we do know about it. For example, we know from forensic and biological anthropological studies that the bones of pre-Columbian Maya were substantially longer than those of modern-day Maya (1). In more recent memory, we have the elegant population-based studies of the INCAP investigators and others from the 1940s-1980s, who clearly delineated the widespread endemicity of chronic malnutrition and regular intercurrent acute infections in indigenous children (2-3). In other words, child malnutrition is a long-standing social problem in Guatemala, potentially dating all the way back to the arrival of the Spanish plunderers, and certainly farther back than any of the dietary changes of the recent decades.
Interestingly, early in our work with Wuqu’ Kawoq we tried to make some correlations between dietary change and child stunting. Although our study communities were small, meaning that our findings were very underpowered, we couldn’t find data to support any correlation. For example, several of our most remarkably malnourished communities were also communities with very low rates of junk food consumption. Our working position in recent years, therefore, has been that although eating junk food is not a good idea for any growing child anywhere in the world, we also do not have any data which specifically relate the problem of child malnutrition to stunting in any other than the most peripheral of ways.
The second question goes like this: “Although your nutritional supplementation programs are good, haven’t you heard about this herb (our vegetable, or tree nut, etc) “X”? It was widely cultivated in pre-Columbian times but has since been forgotten. It is so high in Nutrient “Y” that, if only it could be reintroduced into the diet, it would revolutionize the treatment of malnutrition!” This question is getting at concern about the lack of dietary diversity among the Maya (“they mostly eat salt and tortillas”); if dietary diversity could only be increased, malnutrition would no longer be a problem.
As you might imagine, my answer to the second question is basically the same as my answer to the first. Specifically, it turns out that we don’t actually have much good evidence that the Maya diet lacks diversity! Certainly, we have plenty of anecdotes (like the one above about, “eating nothing but salt and tortillas.” However, on the contrary, when dietary diversity is formally measured using validated research tools, it turns out to be, in most cases, better than expected. For example Noel Solomon’s research group CeSSIAM, based out of Guatemala City, has recently published a whole series of papers on dietary diversity in rural Guatemala backing up this point (4-6). Similarly, in our work with Wuqu’ Kawoq we routinely employ the World Food Program’s food security score, which generally has demonstrated a decent level of dietary diversity in most communities where we have surveyed.
In short, malnutrition in Guatemala is not primarily the result of a lack of dietary diversity. In most of rural Guatemala, despite junk food, the diet remains surprisingly high in a diverse range of fresh plants and other local foods. In other words, dietary diversity and overwhelming endemic malnutrition coexist in Guatemala, and adding another “plant” to the mix, no matter how nutritious and novel, is simply not going to be a game changer.
In closing, I’d like to reflect on some underlying assumptions that both questions make, because I think they are important to recognize and guard against.
First, both make the error of assuming that malnutrition is a relatively simple issue, with a handful of easily identifiable causes and solutions. It is “junk food” or it is “lack of plants in the diet.” But, in reality, malnutrition in childhood is the integral of a complex multifactorial function: unremitting periodic diarrheal and upper respiratory infections; lack of access to birth control and rapid pregnancy sequencing; lack of access to primary health care services for children; food insecurity and inadequate family land holdings; and so on. Malnutrition is all of these things and developing adequate nutrition policy requires a long view and a good dose of realism and humility.
Second, both questions make the error of substituting anecdotal evidence for quantitative data in ways that lead in very much the wrong direction. I think this should underscore for us the fact that the dimensions of child malnutrition are often not immediately apparent. If we rely on intuition, we will get it wrong much of the time.
Third, and more theoretically, both questions succumb to a “neoliberal” error by largely ignoring global political and economic systems that perpetuate poor health and injustice. Rather, they succumb to an empty concept of individualism that demands that vulnerable and marginalized populations “take charge” without empowering them to do so. If only mothers were “better educated” they could take better care of their children. At all costs, we need to resist shifting the blame for complex social problems onto their victims. In the final analysis, if bottled soft drinks are cheaper and more readily available in rural Guatemala than, say, clean water, I hardly think that the blame for that lies with parents.
References:
1. Rios L. (2009). Guatemala: Una revisión de las fuentes antropométricas disponibles. Historia Agraria 47:217-238.
2. Mata LJ. (1978). The children of Santa Maria Cauque. Cambridge: MIT Press
3. Early, JD. (1982). The demographic structure and evolution of a peasant system: The Guatemalan population. Boca Raton: University Presses of Florida.
4. Campos R. et al. (2010). Contribution of complementary food nutrients to estimated total nutrient intakes for rural Guatemalan infants in the second semester of life. Asia Pac J Clin Nutr 19:481-490
5. Soto-Mendez MJ. et al. (2011). Food variety, dietary diversity,
and food characteristics among convenience samples of Guatemalan women. Salud Publica Mex 53:288-298.
6. Enneman A. et al. (2009). Dietary characteristics of complementary foods offered to Guatemalan infants vary between urban and rural settings. Nutr Res 29:470–479
As you may remember, WK participated in this online dialogue earlier in the year. Now, if you go to the link, New Tactics staff have prepared a summary statement of that dialogue, which could practically read as a position paper on getting underrepresented languages into the internet. Highly recommended reading.
Dear friends,
Over the last few months since I last wrote a project update for our diabetes program, a lot of great things have happened!
As you know, for a number of years now we have focused on educational initiatives for our diabetic patients, coupled with intensive glucose-lowering strategies. One of the most rewarding parts of this initiative has been using glycosylated hemoglobin testing (“A1C” testing) to give us a better sense of how are patients are doing and how their medications should be adjusted. Using A1C as a target for treatment, about 50% of our patients now achieve a level of glucose control that we think is “excellent”, with another 25% achieving acceptable control (of course, with the other 25% still needing some work!
Now, in the last few months, we have been working to identify other areas where we can improve care for our diabetic patients. For example, since people with diabetes have a higher-than-average risk of heart disease, blood pressure control is very important. Although we have always treated high blood pressure in our diabetics, we are now being more aggressive in treating patients with more borderline high blood pressure readings, to reduce their risk of complications even further. This has been very successful, with more than 75% of our diabetics now reaching our goal for blood pressure control.
Finally, we have begun monitoring kidney function in our patients more aggressively. Long standing diabetes does permanent damage to the kidneys, and kidney disease in diabetes is a major cause of death and complications. Knowing whether a patient has kidney disease is tricky, because it means taking blood samples often in very rural settings, and transporting them to a central laboratory for analysis. However, thanks to several highly motivated staff members, we have been able to begin offering this service to our patients! Fortunately, only 10% of our patients have significant kidney disease; knowing this information, however, allows us to tailor our treatment for them in ways that better help to protect their kidneys.
Well, those are the updates for now! Thanks so much for your continued support!
Lipid based nutrient supplements (LNS) are perhaps one of the most exciting, and potentially transformative emerging technologies for the treatment of chronic malnutrition. LNS preparations are called ‘lipid-based’ because, unlike older nutritional formulations, they derive a much larger percentage of their calories from fats (typically from peanuts, milk, and vegetable oils). They also generally contain a full complement of vitamins and micronutrients. Because they are fat-based, these micronutrients may be more easily absorbed by the body (they are not bound up by plant phytates which are abundant in grain-based nutritional supplements). They also provide essential fatty acids, whose importance for promoting healthy growth and brain development is more and more appreciated today.
Most people have heard of at least one type of LNS product, Plumpydoz®, which has revolutionized the treatment of severe acute malnutrition in many countries throughout the world. Plumpydoz® is classified as a therapeutic food, meaning that it is extremely dense in calories and is essentially meant to be used in a situation where aggressive ‘refeeding’ is necessary. Since the product has a long shelf life, does not require mixing or cooking, and is tasty, it has produced a paradigm shift in the treatment of severe malnutrition. Previously, most cases of severe malnutrition needed to be hospitalized, often simply because the mixing and preparation of refeeding solutions was complex and required special tools and training. Plumpydoz® uncomplicates this process, which means that refeeding can happen in the home and in rural communities.
What many people do not know, however, is that new research has led to the development of a range of other LNS products, which are lower in calories while still providing a full complement of micronutrients. These products include some which provide a medium amount of calories (Plumpydoz® is one example) and some that provide a small amount of calories (Nutributter® is an example). These are very welcome developments, because they could potentially be used in development settings where chronic malnutrition, rather than acute malnutrition, is the norm. Chronic malnutrition, is generally a smoldering illness which affects a child over months to years and, until now, we haven’t really had any very effective tools for dealing with it. Using Plumpynut® for treating chronic malnutrition would be sort of like using a fire hose to put out a candle.
This isn’t to say that the ‘candle’ of chronic malnutrition is something to sniff at. There are many more children in the world with chronic malnutrition than with acute malnutrition. Whereas acute malnutrition puts a child at immediate and obvious risk of death, chronic malnutrition consumes their biological and social potential in a slow, insidious way. Chronically malnourished children are shorter than their peers. They have more frequent episodes of diarrhea and respiratory illness. They have slower intellectual development and lower IQs. They are less likely to complete school. As adults, and are more likely to be unemployed or to have low paying jobs. Perhaps most horrifying of all, chronic malnutrition as a child greatly increases the risk of obesity, hypertension, and diabetes in adulthood – directly contributing to the rising epidemic of these disease in the developing world.
Exactly how to combat chronic malnutrition with LNS formulations is not entirely worked out yet. There are some positive studies; for example, this study showed that the rates of severe chronic malnutrition could be reduced by supplementation with a Nutributter® like product in children in Malawi. However, the factors which influence and maintain chronic stunting vary significantly from environment to environment. For example, in Malawi chronic malnutrition is greatly influenced by seasonal food insecurity and cyclical droughts; in this type of setting, it is common for there also to be a lot of acute malnutrition. On the other hand, in Guatemala (which has the highest rates of chronic malnutrition in the Western hemisphere), there is no seasonality to malnutrition patterns; here, malnutrition is clearly related more to endemic racism and lack of access to basic medical care and only more obliquely to food production patterns and food insecurity. In short, what might work in one context to treat (or prevent) chronic malnutrition might not work somewhere else.
Clearly, there is exciting and important work to be done. In Guatemala, we have been working at Wuqu’ Kawoq with both medium calorie and low calorie LNS products. For example, we have been using Plumpydoz® in 5 different communities for about 12 months now. In these communities, the Plumpydoz® seems generally well accepted with decent uptake and utilization (we have just completed formal data collection to prove this point, although the numbers will have to wait for now as analysis is ongoing). In the cohort of the most severely stunted children, height recovery also seems to be progressing nicely. Most mothers also report reductions in rates of acute illness in their children. We are conducting a prospective analysis of the growth data in these communities over the next several years, which we hope will bear out these more anecdotal observations. Potentially the great advantage of a medium calorie preparation is that it could provide some nutritional boost to children who are already malnourished at the start of a program, and this is the hypothesis we are exploring – that Plumpydoz®, or another product like it, can provide both prevention of malnutrition onset in the youngest children but also some recuperation in older, already-malnourished children.
This contrasts with Nutributter®, a low calorie LNS preparation, which provides only about 100 daily calories (with, of course, a full complement of micronutrients). Nutributter® is unlikely to be as effective in the treatment of chronic malnutrition, but the hypothesis is that it could prevent malnutrition in the youngest of children. For this reason, it is typically used only in children under 24 months of age (who are at least somewhat less likely to be malnourished). Obviously, this hypothesis has some immediate problems, at least in Guatemala, where in our experience the onset of malnutrition is sometimes before 12 months of age. Nevertheless, because of its convenience and portability, Nutributter® is probably the best-suited product we have right now to blanket scale-up. For this reason, we are right now running a scale-up intervention using Nutributter® is 5,000 children under 2 years of age, with funding from USAID. We are collecting data prospectively on acceptability of the product, but also on growth, achievement of development milestones, and frequency of acute illness to try to better delineate the benefits of Nutributter® in this rural Guatemalan population.
One of the most exciting aspects of the low-intensity scale up initiative is that it has put us into contact with some 75 new rural communities and over a dozen collaborating organizations. Over the last 2 months, we have been visiting each of these communities to train their volunteers who will collect the growth data and administer the program locally in their respective communities. These trips and interactions have been very exciting, especially to see how quickly and eagerly community leaders apprehend the key concepts (What is chronic malnutrition? What causes it? What is the role of breastfeeding and complementary foods? What does an LNS product have to add?). In many of these communities, chronic malnutrition rates top 80%. LNS products here can serve as a unifying symbol which helps to mobilize and motivate in our collective fight against this endemic, devastating childhood disease.
