The Children of Sticky Rice: Building Clinical Dietetics Capacity to Address Malnutrition in the Lao People’s Democratic Republic

2017 Wimpfheimer-Guggenheim Essay Competition Winner

Written and Submitted By: Joanna Cummings, MS, RD, LD, and Diane Stadler, PhD, RD, LD


To make duck soup, I set I pot of water on the fire and then go to the pond where the ducks are eating. I pick the best duck and put it under my arm and bring it back to the fire. Now the water in the pot is boiling and I add lemon grass, tamarind leaves, bamboo shoots and whatever vegetables I picked from the garden and put into the pot, I chop up the duck and add it to the pot and then soup is ready to eat, with sticky rice. We eat until sticky rice is gone.” This is the response I received from a young Hmong woman as we sat with her family on bamboo stools barely four inches from the dirt floor, hunched over steaming bowls of soup and rolling sticky rice into small balls in the palms of our hands. A juxtaposition of plenty amidst poverty, and ease amidst great difficulties.

The Lao People’s Democratic Republic (PDR) has immense diversity and complexity of food practices, an overwhelming reliance upon the land for resources, and a daily necessity of searching for food or tending to a crop that involves all members of the household. There is richness in this country that cannot be described in statistical terms. Most families have a small plot of land to grow sticky rice, providing them with the staple food that supplies the bulk of their energy needs. Other plants and animals may be raised or collected from nearby rivers, streams, forests and fields. In the very poor rural villages, food caught or collected from the wild, especially edible plants (shoots, mushrooms, nuts, berries) and small animals (frog, fish, lizards, insects, birds, squirrels, wild boar) make up 50% of their diet. There is a Lao saying “we will eat anything with wings except airplanes and anything with legs except tables and chairs, and everything else in between.” The lack of food prohibitions and inhibitions allows for limitless options; being constrained by only what people cannot grow, catch or gather and by their seasonal availability.

The Lao consume more sticky rice per capita than anywhere else in the world. Sticky rice is used as a utensil at each meal, provides sustenance and plays an important role in cementing social relations and linking the Lao with the spirit world. However, under certain conditions (crop loss, extreme poverty or flooding during the rainy season) and at certain times (late pregnancy and the early postpartum period) sticky rice may be the only food available or permitted due to long standing traditions and food taboos. Although unintentional, this dependence on sticky rice is associated with severe acute malnutrition, perpetuation of chronic malnutrition, and risk of overt vitamin and mineral deficiencies. The short and long-term consequences of malnutrition that result from poor dietary diversity and food insecurity is especially concerning for high risk groups such as infants and young children, women during pregnancy, and the elderly. Deficiency in vitamins and minerals, such as thiamine, is deadly in infants, young children and new mothers. As in western countries, malnutrition in Lao PDR also manifests in older children and adults who are overweight, less physically active, and who are at higher risk of chronic diseases due to malnutrition experienced prenatally or as a young child. This “double burden” of malnutrition is especially compromising for the country and those now living in urban areas with increased availability of western foods and higher consumption of fat, sugar and salt. Chronic disease is on the rise in Lao PDR while malnutrition remains endemic.

Nearly half of the population in Lao PDR, mainly ethnic minority and other vulnerable groups, remain at risk for food insecurity, malnutrition, nutrition-related diseases and higher rates of morbidity and early mortality. Despite improvements over recent years, overall rates of stunting and wasting in Lao PDR are 35.6% and 9.6%, respectively, for children under the age of five years.1 The provinces of Oudomxay and Phongsaly currently experience the highest rates of stunting at 54.6% and 51.3%, respectively. Whereas the provinces of Saravan and Savannakhet have the highest rates of childhood wasting at 16.5% and 14.9%, respectively.1

Lao PDR has been forward thinking and progressive in their approach to ending malnutrition; together with the United States government and Oregon Health & Science University, a collaborative effort has established the Lao-American Nutrition Institute (LANI) aiming to create a “new normal” for the country, void of malnutrition. On September 5, 2016, one day before President Obama’s historic first visit to Laos by a U.S. President, the signing of two Memorandum of Understanding contracts initiated the establishment of the LANI. The first agreement between the Lao government and United States government initiated the construction of the LANI campus. The second agreement between the Lao PDR Ministry of Health and Oregon Health & Science University (OHSU) launched the development of educational tracks at the LANI to teach the first dietitians in the country. The official ground breaking ceremony was held on November 2, 2016 and, once complete, the LANI campus will offer: 1) outpatient and inpatient clinical facilities, 2) a dedicated teaching building complete with a demonstration kitchen, test kitchen, simulation labs, and library, 3) a research building with a focus on conducting clinical nutrition research, 4) six dormitories for students and staff housing, 5) an agricultural garden demonstrating best practices and growing techniques 6) insect farming, 7) aquaculture pond and 8) landscaping with native berry bushes and citrus trees. The development of the LANI and the implementation of its educational tracks are critical and exciting opportunities, yet somewhat daunting endeavors, as there are currently no formal nutrition/dietetics degree programs in Lao PDR and no formally trained Laotian clinical dietitians.

As we know, nutrition education used to increase knowledge of healthy dietary choices does not always result in anticipated behavior change no matter the circumstance. Rather, comprehensive, substantial change often requires individuals of influence – from villager chiefs to national policy makers – to make a meaningful difference to improve the nutritional status and the health and well-being of the country. The mission and goals of the LANI are aligned to empower Lao educators, health care providers, and health administrators to make a meaningful difference, to sustainably build their country’s capacity to address malnutrition by educating aspiring health care professionals to become the “nutrition experts” as clinical dietitians and community nutrition program managers.

The role of OHSU in this partnership, specifically the advanced clinical dietitians and graduate nutrition faculty, is to serve as technical advisors, guiding our Lao colleagues in the development of a priority-driven nutrition and dietetics curriculum and to achieve and maintain the highest level of excellence in nutrition education. The curriculum centers on the 2016-2020 National Nutrition Plan for Lao PDR which has established 22 nutrition-sensitive 1st priority health interventions: 4 agricultural, 4 educational, 10 health and hand washing, and 4 multi-sectoral priority interventions; all focused on achieving the goal of eliminating chronic undernutrition (stunting).1 The mission of the LANI aligns with the Lao PDR National Nutrition Plan though its mandate to become the Nutrition Education Center of Excellence to build training capacity and to initiate innovative approaches to educate Lao dietitians and to improve the state of nutrition for all citizens. After a year of planning, February 6, 2017 marks the first day of coursework for the first cohort of Lao clinical nutrition and dietetics students and future nutrition champions into a six-month intensive graduate certificate program. Additional cohorts will enter the program every six months with a five-year goal of having two dietitians working in each of the country’s five national and eighteen provincial hospitals and eventually having one dietitian working in each of the 148 district hospitals.

To inform our curriculum development we conducted a needs assessment among Lao health care providers to identify the most commonly treated pediatric and adult medical conditions, their ability to address nutrition-related issues, and community resources available for follow-up. Among adult patients, diabetes mellitus, hypertension, heart disease, bone disease and asthma/respiratory illness were the most common diseases. Among pediatric patients, chronic diarrhea, asthma/respiratory disease, anemia/iron deficiency, thalassemia, and prematurity/small for gestational age, and moderate-to-severe malnutrition were the most common diseases. Respondents identified knowledge of dietary components, treatment/prevention plans for stunting, wasting, malnutrition, and other chronic conditions, and changing nutritional needs throughout the lifecycle, as important, however fewer than 20% reported that their hospital staff had or were able to apply this knowledge to improve patient health (unpublished data).

As part of our student recruitment and selection process applicants completed a 50-item multiple choice examination with questions taken from seven existing educational modules used in Lao encompassing: behavior change counseling, nutrition across the lifespan, food security, principles of nutrition, malnutrition, prevention and treatment of malnutrition, and nutrition assessment and one question from the ASPEN Nutrition Support Curriculum. The average score on the entrance exam was 46% with a range between 38 and 60%. The highest scores were achieved in the nutrition across the lifespan content (average score of 68% correct) and the lowest scores were in malnutrition and treatment of malnutrition (average score of 27% correct). Based on these results and interviews with the applicants we modified our approach to Team-Based Learning, where pairs of learners from participating hospitals will work and learn together. We also revised the curriculum by increasing focal topics on malnutrition, fundamentals of nutrition, pediatric nutrition and adapting the medical nutrition therapy courses to more closely align with resources and diseases treated in Lao PDR. Additionally, each candidate underwent an English proficiency interview that assessed reading, writing and verbal communication. Based on the results of these interviews we established English language classes, in addition to nutrition coursework, for the students. Field-work was then conducted in various provinces, villages and hospitals to further elucidate the common disease states of patients and the access to resources within these rural areas.

The Clinical Nutrition and Dietetics curriculum was developed through a series of meetings with the LANI Curriculum Development Working Group, key stakeholders at the Ministry of Health, Department of Training and Research, and Lao National Nutrition Center. Core nutrition courses were identified and culturally appropriate content was included within each of these courses (Table 1).

Table 1. Core and Specialty Coursework for Lao-American Nutrition Institute (LANI) Clinical Nutrition & Dietetics Track

Core Courses Credit Instruction Hours
Fundamentals of Nutrition 2 30
Nutrition throughout the Lifecycle 2 30
Nutrition in Health & Disease 1 15
Nutrition Assessment 1 15
Food Safety, Sanitation & Security 1 15
Routine to Research 1 15
Nutrition Behavior Change Counseling 1 15
Specialty/Elective Courses Credit Instruction Hours
Clinical Experience 1 15
Pediatric Nutrition 1 15
Maternal & Infant Nutrition 1 15
Medical Nutrition Therapy I 1 15
Medical Nutrition Therapy II 1 15
Total 14 270

Curricular mapping and instructor interviews were conducted to establish or identify: student learning outcomes for each course, activities occurring in and out of class to reinforce learning objectives and prepare students for assessments, how student knowledge will be assessed in alignment with program-level outcomes, and opportunities for indirect assessment of student competency through student self-reflection upon and report of their perceived gains in knowledge and skills.

The educational model and curricular mapping that established the structure in which to train the first dietetics and clinical nutrition professionals in Lao People’s Democratic Republic can be readily adapted for use on an international level as the foundation of knowledge for dietitians is consistent regardless of geographic location and practice. Modifications would need to be made to address unique country or population-specific components of medical nutrition therapy, educational and public health resources, specific cultural beliefs, customs and dietary practices. Modifications would also need to be made to address the specific health priorities of the country, which may, like in Lao, prioritize maternal and infant malnutrition.

There is an underlying current of transition and innovation evolving at a rapid pace in Lao. We are privileged to support this movement by training the first dietitians to embrace evidenced based practice, while appreciating the cultural practices unique to Lao, and humbly recognizing how the future is built on the past as illustrated in this story. “As a little girl I watched my mother cook chicken. She would pluck it and then chop its head off and put it in the pot. Now that I am an adult and have my own home, I invited her over for dinner one evening. She watched as I prepared chicken for dinner. I plucked it and chopped its head off and put it in the pot. My mother said, ‘Why did you cut the head off the chicken?’ I responded, ‘because this is the way you taught me mother’ and my mother cackled in laughter. She said ‘I only cut the head off the chicken because it would not fit in the pot. You have different pots and larger pots, you can do things differently.

References

  1. Lao National Nutrition Strategy to 2025 and Plan of Action 2016-2020, Lao People’s Democratic Republic, December 2015.

Acknowledgements

The authors thank Dr. Chandavone Phoxay, Deputy Director of the Department of Hygiene and Health, and Dr. Sengchanh Kounnavone, Deputy Director of the National Institute of Public Health in Vientiane, Lao PDR for their support and review of this essay.