“Yesterday he only ate tortillas, it was the only food I could afford for him,” Marta told me in her native Maya Kaqchikel language. She is a young woman and mother of an eight-month-old boy enrolled in our chronic childhood malnutrition recovery program. Chronic malnutrition, also known as stunting, results from a complex interplay of several factors and commonly manifests as being shorter than normal for age. Marta lives in a remote rural community in the central Guatemalan highlands. In this community, poverty rates are almost twofold higher than the average rate for Guatemala, and stunting affects almost 80% of all children under five years of age. For Marta’s family and for the majority of the Maya people in Guatemala, maize is the most important component of the diet. In this and other Maya communities, agriculture is the main economic activity. However, their inhabitants usually eat monotonous diets with limited nutritious composition to promote normal growth. As Marta explained to me, there are some families who have land and crops where they grow produce such as cauliflower, lettuce, chard, green beans, onions, or tomatoes. However, the majority of the food being produced is destined for sale and not for their own consumption, due to “the critical need for >economic income”.
Unfortunately, this reality exists commonplace in rural Guatemala and has resulted in the highest rate of stunting in the Western Hemisphere. In Guatemala, 46.5% of all children under 5 years-old are stunted.[1] In the poorest areas of Guatemala, mostly rural and indigenous, stunting rates are even higher.[2,3] In fact, some analysis have shown that the Maya people from Guatemala are one of the most stunted populations in the world.[4] In Guatemala, several approaches had been successful in reducing the stunting rates in the last two decades. However these interventions have had more limited impact in the Maya population.[5-7] In this country, such as in other low- and middle-income countries, integrated-comprehensive interventions to fight stunting are urgently needed so that interventions can impact not only by improving health outcomes but also by improving accessibility and availability of nutritious foods in quality and quantity. But how do we address this problem and design these interventions? Collaboration is a great place to start!
Maya Health Alliance (MHA)
The Maya Health Alliance (MHA) is a global health organization providing primary care for indigenous populations in rural Guatemala. Since 2007, MHA has combated stunting in the Maya population. The MHA nutrition program model combines both preventative and curative evidence-based interventions to target child growth and health, diet diversity, and caregiver education and empowerment (See Figure 1). Over the years, MHA has carried out several nutrition research studies to better understand the dynamics and factors surrounding stunting in these populations including a proof-of-concept of its model in a recently concluded randomized controlled trial. All interventions are delivered at home-visits by nutrition technicians who provide individualized growth and diet assessments using the caregiver’s preferred language (Spanish or Maya). All child caregivers are invited to attend a five week- long nutritional curriculum where education on how to improve children’s diet and growth are provided. A two-year implementation of this model in a rural Maya community decreased the stunting prevalence in 20% and of severe stunting prevalence in 35% for children under 5-years-old. (For more information about the MHA nutrition model, curriculum of nutrition classes, and educational material, email andrea@wuqukawoq.org).
Despite great successes decreasing stunting rates in Maya communities, we acknowledge that there is more to do in the fight of stunting. At MHA we strongly believe that there is an urgency to design and develop sustainable interventions that can impact food access, availability, and diversity of nutritious foods in the long term. Since MHA does not have previous experiences conducting agricultural
Interventions, we sought help through members of the Academy of Nutrition and Dietetics (AND) (www.eatright.org). They referred us to great partners who are already collaborating with us to integrate agriculture within our nutrition program model through the development of our Nutritious Garden Project.
MHA´s Nutritious Garden Project
The vision behind our Nutritious Garden Project is that integrated agricultural interventions within our nutrition program model will lead to greater improvements in maternal and child’s dietary adequacy and overall household food insecurity, thereby resulting in greater-improved linear child growth. The key agricultural intervention will be nutritious family gardens containing culturally and locally accepted produce, and the provision of technical assistance and training to participating families (see Figure 1, upper right box).
Organizations Collaborating with MHA
Gardens for Health International (GHI)
Gardens for Health International (GHI) is a non-governmental organization based in Rwanda with several projects integrating agriculture into the clinical care of children with malnutrition. As GHI experience has shown, nutrition-focused home gardens are a key strategy for addressing stunting, especially among the most vulnerable families. Their innovative approach also includes partnering with local health centers, advocating for policies involving agriculture in the prevention and treatment of malnutrition, and training partners interested in adapting their model and methodology into their communities around the world.
GHI is advising MHA’s Nutritious Garden Project in the development of an agricultural curriculum, methodologies for agricultural trainings directed to children’s caregivers, and agricultural educational materials for families and MHA nutrition technicians. Great steps in the development of these materials had been already achieved through regular meetings with AND´s fellows working in GHI Rwanda. In fact, one of them recently visited MHA in Guatemala. (For more information about the work GHI is doing visit www.gardensforhealth.org.)
ECHO
ECHO is an information hub for development practitioners around the world. ECHO specializes in gathering solutions that contribute to solving hunger problems and disseminating them in their network. These solutions promote sustainable farming techniques, nutritional plants, and appropriate technologies.
ECHO and its practitioners collaborate with farmers around the world teaching them more effective ways to produce enough food to meet the needs of their families and their communities.
ECHO is currently collaborating on site with MHA through an agriculture consultant who is involved in the planning of the Nutritious Garden Project (interventions, logistics, and methodology) as well as advising in the creation of the agriculture curriculum and selection of agriculture indicators. (For more information visit www.echonet.org, or email kwilson@echonet.org)
The Academy of Nutrition and Dietetics
The Academy of Nutrition and Dietetics (Academy) is the world’s largest organization of food and nutrition professionals. The Academy is committed to improve health and advancing the profession of dietetics through research, education, and advocacy. The MHA is collaborating with the Academy’s Dietetics Practice-Based Research Network (DPBRN), which has provided assessment for the Nutritious Garden Project in terms of intervention design, monitoring and evaluation tools, and selection of outcomes. MHA was chosen by the Academy and its Foundation as an experienced site in strategic planning to provide feedback about the Hunger Free Communities Facilitation Guide and Tools, and the new phase of the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) which enables registered dietitian nutritionists to track nutrition care outcomes at the community-level and to advance evidence-based nutrition practice research. (For more information visit: www.eatright.org)
Nutritious Garden Project Collaborative Initiative – Early Reflections
Sharing philosophies, materials, and experiences, and having the ability to reach international resources has allowed us to maximize local existing resources, learn from similar previous experiences, minimize duplication efforts, and work together towards the common goal of improving children’s health in our communities. We hope that our experience in reaching out and bringing together
different international organizations will encourage other organizations to develop similar partnerships, and that the lessons learned from our experiences can light the path of initiatives alike around the world.
References
- Ministerio de Salud Pública y Asistencia Social (MSPAS), Instituto Nacional de Estadística (INE), ICF International (2017) Encuesta Nacional de Salud Materno Infantil 2014–2015. MSPAS/ INE/ICF, Guatemala, 2017.
- Chary A, Messmer S, Sorenson E, et al. The normalization of childhood disease: an ethnographic study of child malnutrition in rural Guatemala. Human Organization 2013;72:87–97.
- Martinez B, Flood D, Cnop K, et al. Improving Infant and Young Child Nutrition in a Highly Stunted Rural Community: A Practical Case Study from Guatemala. In: Preedy V, Patel V, eds. Handbook of Famine, Starvation, and Nutrient Deprivation. Cham, ZG: Springer. Published Online First: 27 June 2017. doi: 10.1007/978-3-319-40007-5_52-1
- Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low- income and middle-income countries. Lancet 2013;382:427–51.
- Food and Nutritional Assistance III Project. Summary report: Development of Evidence-based Dietary Recommendations for Children, Pregnant Women, and Lactating Women Living in the Western Highlands in Guatemala. Washington, DC: Food and Nutritional Assistance III Project 2013.
- Brown K, Henretty N, Chary A, et al. Mixed-methods study identifies key strategies for improving infant and young child feeding practices in a highly stunted rural indigenous population in Guatemala. Matern Child Nutr 2014;12:262–77.
- Webb MF, Chary AN, De Vries TT, et al. Exploring mechanisms of food insecurity in indigenous agricultural communities in Guatemala: a mixed methods study. BMC Nutr 2016;2:55.
Acknowledgements:
I am grateful to Dr. Boris Martinez, a Maya Health Alliance researcher, for his support and thoughtful revision of this essay.
Addendum: June 2018
Since the writing of this essay, the collaboration with Gardens for Health International (GHI) has changed to a more passive role. GHI is no longer advising MHA’s Nutritious Garden Project in methodologies and on development of agriculture curriculum. Rather, GHI has shared their agriculture education materials and have allowed us adapt them to Guatemalan agricultural context. In fact, the Academy Foundation`s fellow, Stephen Alajajian, who was working with GHI, is now currently working with MHA in Guatemala to help evaluate the implementation of the Nutritious Garden Project and help develop the agriculture curriculum. (For more information about the Academy Foundation`s fellow activities at MHA, email stephen@wuqukawoq.org).