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
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. 
