To identify the prevalence and predictors of malnutrition among 2-year old children in the Western Highlands of Guatemala.
Methods
Prospective cohort of 852 Guatemalan children in San Lucas Toliman, Guatemala followed from birth to age 2 from May 2008 to December 2013. Socio-demographic, anthropometric, and health data of children was collected at 2 month intervals.
Results
Among the 402 males and 450 females in the cohort, mean weight-for-age Z-score (WAZ) declined from -0.67 ± 1.01 at 1 year to -1.07 ± 0.87 at 2 years, while mean height-for-age Z-score (HAZ) declined from -1.88 ± 1.19 at 1 year to -2.37 ± 0.99 at 2 years. Using multiple linear regression modeling, number of children <5 years old, vomiting in the past week, fever in the past week, and WAZ at 1 year were significant predictors of WAZ at 2 years. Significant predictors of HAZ at 2 years included household size, number of children <5 years old, diarrhea in the past week, WAZ at 1 year, and HAZ at 1 year. Vomiting in the past week and WAZ at 1 year were significant predictors of weight-for-height z-score (WHZ) at 2 years.
Conclusions
Number of children <5 years old, symptoms such as vomiting or diarrhea in the previous week, and prior nutritional status were the most significant predictors of malnutrition in this cohort. Future research may focus on the application of models to develop predictive algorithms for mobile device technology, as well as the identification of other predictors of malnutrition that are not well characterized such as the interaction of environmental exposures with protein consumption and epigenetics.
“Vic-TOR-ia!” Fátima cried, a grin lighting up her face. The 5-year-old had become fast friends with Stanford medical student Tori Bawel almost instantly after Bawel arrived in San Lucas Tolimán. After giving piggy-back rides to Fátima, a career in global pediatrics changed from a distant wish to a developing reality for Bawel.
Bawel is one of a few lucky medical students to travel with Stanford pediatrician Paul Wise, MD, MPH, to San Lucas Tolimán, a town in the mountains of rural Guatemala that serves as a base for his work to improve nutrition for local children. Once she completes her medical training, Bawel plans to devote her life to improving health in underserved areas.
“As an elementary school student, I was really compelled by issues of social justice,” she said. “I hope that over the course of my lifetime, I’m able to make a difference like physicians have done here in Guatemala and around the world.”
Every summer, Wise, a professor of pediatrics and a Stanford Health Policy core faculty member, takes a handful of undergraduates to the communities around San Lucas to learn about the Rural Guatemala Child Health and Nutrition Program. A collaboration between Stanford and a group of local health promoters, the program uses nutritional supplements and health education to save the lives of children under five. The students follow the promoters on house visits, help them measure the weight and height of children and gain an understanding of how the program helps the rural communities.
“We feel it is part of our educational mission,” said Wise. “We want to grow people who will make a difference, and part of that is providing them opportunities to do so.”
Bawel’s experience reinforced her desire to engage in global health work: “It’s inspired me and motivated me to want to give my life, like Wise, to… serving in areas of the world with the greatest need.”
Meeting Guatemalan students who overcame economic difficulties to study medicine — like Flor Julajuj — was also deeply moving for Bawel. Very few in rural Guatemala have the opportunity to pursue higher education or good health care. But with some help from Wise, Julajuj was able to attend medical school; just this month, she graduated from the University of San Carlos in Guatemala City.
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“It’s been a great opportunity,” said Julajuj. “It’s changed my life.”
Most, though, are not so lucky; Bawel also encountered two young women who dream of becoming physicians but cannot afford medical school. Meeting the young, ambitious women “makes me want to empower them with the education and opportunities I have had,” said Bawel.
Wise, meanwhile, will continue to each Stanford students about ways to help these communities.
“They see the poverty, but they also begin to understand why being a great doctor or a great diplomat or a great economist will serve the interests of people down here if done well,” he said. “We want them to go back to whatever field they’re interested in, committed to gaining skills and then using them to serve the needs and the rights of people in places like San Lucas.”
Stanford pediatrician Paul Wise stooped below the black tarp roof of a cinderblock house in Guatemala to offer his condolences to a mother who had just lost her child.
“Doctor Pablo,” as he is known in the communities around San Lucas Tolimán, talked softly as he relayed his sympathies to the mother, whose 9-year-old son had been a patient of his.
Stanford’s Children in Crisis Initiative seeks to save the lives of children in areas of poor governance. In Guatemala, their efforts work toward eliminating death by malnutrition for children under 5.
The boy’s genetic disorder would have been terminal anywhere, but thanks to Wise and local health promoters, the boy’s family had years with him instead of months.
While Wise spoke to the heartbroken mother, his Stanford research assistant Alejandro Chavez helped the promoters set up inside a local community center to measure the weight and height of local kids to determine their nutrition level.
Chavez and the promoters had worked together for months to create an app for tablets that will make it easier to find malnourished children.
The app they designed will decrease training time for new health promoters and allow the program to expand. The goal is to distribute the app globally to help programs in other countries tackle malnutrition.
Children in crisis
As recently as 2005, about one of every 20 children in this rural area of Guatemala died before their 5th birthday. Almost half the deaths were associated with severe malnutrition.
“The death of any child is always a tragedy, but the death of any child from preventable causes is always unjust,” said Wise, a Stanford Health Policy core faculty member.
Along with other faculty from the Freeman Spogli Institute for International Studies (FSI) and the School of Medicine, Wise created the Children in Crisis Initiative to save the lives of children in areas of poor governance. The program brings together Stanford researchers and students across disciplines.
Nowhere are their efforts better illustrated than in the rural communities around San Lucas Tolimán, in the central mountains of Guatemala.
The program’s effectiveness rests on a deep respect for the local communities merged with innovation by Stanford researchers.
“It’s absolutely essential to any program that the people in need be part of the solution,” said Wise. Unlike many nongovernmental organizations and health programs, Wise believes the way to create a sustainable health system is for the locals to run it, so the health promoters manage the program’s day-to-day activities.
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This leaves the Stanford team free to focus on innovation – such as the new app. They believe the technology could change child health programs around the world. Wise’s team has partnered with Medic Mobile – a nonprofit that creates open-source software for health care workers – which plans to distribute the app to other areas suffering from malnutrition.
The six Android tablets purchased by Children in Crisis are enough to monitor the program’s 1,500 kids through the app.
Role of nutrition
When done well, nutrition surveillance is very effective at decreasing child mortality in poor countries.
“Nutrition contributes enormously to health and well-being,” Wise said as he walked through Tierra Santa, a small community near San Lucas, making house calls. “So the focus of our work turned to improving young child nutrition. It’s not an easy thing to do in a place that’s extremely poor.”
Wise and his colleagues – Stanford medical student Tori Bawel and Stanford professor of pediatrics Lisa Chamberlain – made their rounds during their visit in March. Evidence of poverty was everywhere.
Here, clean tap water is a dream and even the sturdier homes often lack four walls or paned windows, though the children were neatly dressed in T-shirts or colorful traje, traditional Mayan clothing.
It’s hard to provide proper nutrition when most families can’t find enough work to buy adequate food. But a little help can make a big difference.
Bawel, a first-year medical student who plans a career improving health in areas of poverty, was struck by the impact the promoter program has had on the community.
“There are children who need supplements and nutrition to stay alive,” she said. “Without this program, that infrastructure does not exist.”
With FSI’s assistance, the nutrition program distributes Incaparina, a supplement of cornmeal, soy and essential nutrients. The sweet, mealy drink helps the program’s most malnourished children get back on track.
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Every two months, the promoters gather each community’s children to measure their weight and height. Children and their mothers sit patiently, waiting for their turn. The children enjoy a cup of Incaparina, and their mothers eagerly listen to the promoters’ tips for keeping their children healthy.
“It’s very important to me,” said Elsira Rosibel Samayoa, who brought her 2-year-old to be measured. “There are mothers who don’t understand the importance of monitoring their children’s weight, but I do.”
Since its implementation in 2009, the Stanford program has slashed nutrition-based mortality in the participating communities by about 80 percent and decreased severe malnutrition by more than 60 percent – saving hundreds of children’s lives.
However, nutrition surveillance and intervention isn’t easy. Tracking nutrition takes training and expertise, and when the local population rarely exceeds a fourth-grade education, learning these skills is especially challenging. Detailed graphs on a standard growth chart are essential to identifying malnourished children.
“The community health workers are extremely capable and smart, but some have never seen a graph before,” said Wise. “Think about what it is to try to explain a graph to someone for the first time.”
It takes the health workers about three years to learn to graph and then interpret the results for intervention.
Wise said, “So we all got together and said, ‘How do we make this easier to do?’”
The app was the answer.
‘Let’s create an app’
Enter Alejandro Chavez, a recent Stanford computer science graduate and Stanford Health Policy research assistant. He developed the app to collect child health data, then determine the child’s degree of malnutrition and suggest intervention.
“The major goal was to lower training requirements and make programs like this simpler to start and maintain,” said Chavez, who now lives and works in Guatemala, where he gets daily feedback from the health promoters.
“I feel like they’ve been very honest with me about things I need to improve,” he said.
Cesia Lizeth Castro Chutá is a senior coordinator for the program who has worked with Chavez to ensure that the app meets the promoters’ needs.
“The tablet automatically generates the information we need to know,” she said. “It becomes easier to confirm that a child is malnourished and needs supplements.”
Looking forward
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With the app’s launch, it looks like training time for the promoters will be reduced from three years to less than six months. That means new communities can be incorporated into the program quickly, creating broader access to care.
Meanwhile, many health programs around the world are waiting to see how well the Stanford app works in Guatemala.
Josh Nesbit, a Stanford alumnus and Medic Mobile CEO, said, “As more health programs recognize the importance of nutrition and implement community-based interventions, screening and surveillance tools will be critical. We must learn from Dr. Wise’s success.”
The primary goal of the Guatemala Rural Child Health and Nutrition Program is to use the capacities of Stanford University to save young children’s lives in Guatemala and other areas of the world plagued by conflict and political instability. Part of the Children in Crisis Initiative, this Stanford effort in Guatemala has been focused on young child malnutrition, the central contributor to child mortality and life-long disability in these regions.
Katy Long's research focuses on migration, citizenship and refugee issues, especially responses to long term crisis and conflict -- both by the international humanitarian and political communities and by refugees and migrants themselves. Although her work looks at global policy implications, she has carried out detailed fieldwork in Guatemala, Rwanda and Uganda.
Katy has written extensively on these topics, and in 2013 The Point of No Return: Refugees, Rights and Repatriation -- a monograph based on her Ph.D research into "durable solutions" to refugee crises (Cambridge, 2009) -- was published by Oxford University Press. Prior to taking up posts at Oxford, the London School of Economics and Edinburgh University she worked for the United Nations High Commission for Refugees' (UNHCR) Policy Development and Evaluation Service in Geneva, writing on a number of issues including opening up labour migration routes for refugees, border closures and out-of-country voting. She is also co-editor of The Oxford Handbook of Refugee and Forced Migration Studies (OUP, 2014), the first comprehensive guide to refugee studies scholarship.
Katy also enjoys engaging in public discussions and debate on migration and humanitarian issues: she runs the website migrantsandcitizens.org and tweets as @mobilitymuse. Her work has also appeared at Open Democracy, The Conversation, Democracy in Africa, and Africa@LSE, as well as BBC World Service, ITV and Channel 4. She is also the author ofThe Huddled Masses: Immigration and Inequality, a short accessible ebook.
While at FSI Katy is also working on a new project that considers how the sale of citizenship for money -- on both the legal and black markets -- affects our understandings of political community and freedom of movement.
Zack Bonzell came to Stanford with a strong interest in human biology and political science. Last summer, the undergraduate had the chance to fuse his interests while doing field research with faculty at the university’s Freeman Spogli Institute for International Studies (FSI).
During a two-week internship, he travelled to Guatemala with FSI senior fellows Paul Wise, Beatriz Magaloni, Alberto Díaz-Cayeros and Scott Rozelle to learn about the country’s rural health care system by shadowing doctors and interviewing mothers in an impoverished area about the issues leading to the area’s high rates of child malnutrition.
“That experience was an ideal way to blend my interests and gave me a better idea of how to craft my course of study at Stanford,” said Bonzell, who is now a junior. “One of the things that really struck me was when Paul Wise said the health outcomes we were seeing are the result of extreme material deprivation. These people are sick because they are poor. That gave me more of an interest in political economy.”
Students conduct interviews about nutrition with REAP in China. Photo Credit: Matt Boswell
FSI is now expanding its educational opportunities for students, like Bonzell, who want to do research on global issues in Asia, Latin America, Europe and Africa.
The Stanford Global Student Fellows program (SGSF) is being funded in large part through a $1.25 million anonymous gift that will help grow existing programs and create new offerings for graduates and undergraduates.
“This program deepens FSI’s commitment to its mission of educating the next generation of leaders in international affairs,” said FSI Director Mariano-Florentino Cuéllar. “It also offers outstanding opportunities for Stanford students to work closely with the leading thinkers on global policy issues.”
The program, which is part of FSI’s efforts to expand student opportunities, will build on the institute’s undergraduate mentorship programs that allow students to work on faculty research projects each quarter. Those positions will now be available during the summer. Some of the positions will be connected to projects in FSI’s new International Policy Implementation Lab, an initiative that gives students a close-up view of how academics and policy influencers can address some of the world’s thorniest issues.
PoliSci 114S students work together in a UN conflict simulation. Photo Credit: Rod Searcey
Building on FSI’s experience placing students in research opportunities, the program will create and expand summer field research internships. The two- to six-week internships this summer will give undergraduates the opportunity to work with FSI senior fellows in China, Guatemala, India and Mexico who study global health, conflict resolution, governance and poverty reduction. In coming years, the program will likely include additional fieldwork projects in Rwanda, Tanzania and Brazil. The SGSF program covers all travel expenses for students and provides students with an opportunity to work closely with a faculty member and a team of other students on an ongoing research project addressing real-world problems in a specific region.
“What makes FSI such an incredible institution is that it attracts faculty who have very pragmatic interests,” Bonzell said. “It seeks to wed academic work with a more direct impact, and there’s a lot of potential for more students to think along similar lines.”
The Stanford Global Student Fellows will also allow FSI to work closely with its partners, including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students.
Mexican Ambassador Eduardo Medina Mora and Jorge Olarte, '13, speaking with students at the US-Mex FoCUS event. Photo Credit: Rod Searcey
One of the program’s new initiatives geared toward undergraduates is the Global Policy Summer Fellowships. The fellowships help secure placement and a $6,000 stipend for students interested in interning at international policy and international affairs organizations. This summer,The Europe Center at FSI is placing students at the Center for European Policy Studies and Bruegel, two Brussels-based think tanks. Future positions will be created with six offerings abroad and two based in the United States.including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students.
The Stanford Global Student Fellows program will also commit $400,000 to create a Mentored Global Research Fellowship that will provide research opportunities for students to conduct their own overseas research under the close mentorship of a faculty member. The program will award stipends of $6,000 for summer undergraduate projects and $9,000 for summer graduate projects, and $1,500 for smaller projects executed during the school year.
Thomas Hendee '13 chatting with children in rural Guatemala. Photo Credit: Maria Contreras
The faculty advisory committee overseeing the development and implementation of these new programs includes Scott Rozelle, the Helen F. Farnsworth Senior Fellow and the co-director of FSI’s Rural Education Action Program; Stephen Stedman, a senior fellow at FSI and the deputy director of CDDRL; and Lisa Blaydes, assistant professor of political science.
The application deadline for all summer programs is Feb. 28, 2015. The deadline to apply for academic quarterly programs is the end of the first week of each quarter, beginning in the fall of 2014.
Zack Bonzell came to Stanford with a strong interest in human biology and political science. Last summer, the undergraduate had the chance to fuse his interests while doing field research with faculty at the university’s Freeman Spogli Institute for International Studies (FSI).
During a two-week internship, he travelled to Guatemala with FSI senior fellows Paul Wise, Beatriz Magaloni, Alberto Díaz-Cayeros and Scott Rozelle to learn about the country’s rural health care system by shadowing doctors and interviewing mothers in an impoverished area about the issues leading to the area’s high rates of child malnutrition.
“That experience was an ideal way to blend my interests and gave me a better idea of how to craft my course of study at Stanford,” said Bonzell, who is now a junior. “One of the things that really struck me was when Paul Wise said the health outcomes we were seeing are the result of extreme material deprivation. These people are sick because they are poor. That gave me more of an interest in political economy.”
Students conduct interviews about nutrition with REAP in China. Photo Credit: Matt Boswell
FSI is now expanding its educational opportunities for students, like Bonzell, who want to do research on global issues in Asia, Latin America, Europe and Africa.
The Stanford Global Student Fellows program (SGSF) is being funded in large part through a $1.25 million anonymous gift that will help grow existing programs and create new offerings for graduates and undergraduates.
“This program deepens FSI’s commitment to its mission of educating the next generation of leaders in international affairs,” said FSI Director Mariano-Florentino Cuéllar. “It also offers outstanding opportunities for Stanford students to work closely with the leading thinkers on global policy issues.”
The program, which is part of FSI’s efforts to expand student opportunities, will build on the institute’s undergraduate mentorship programs that allow students to work on faculty research projects each quarter. Those positions will now be available during the summer. Some of the positions will be connected to projects in FSI’s new International Policy Implementation Lab, an initiative that gives students a close-up view of how academics and policy influencers can address some of the world’s thorniest issues.
PoliSci 114S students work together in a UN conflict simulation. Photo Credit: Rod Searcey
Building on FSI’s experience placing students in research opportunities, the program will create and expand summer field research internships. The two- to six-week internships this summer will give undergraduates the opportunity to work with FSI senior fellows in China, Guatemala, India and Mexico who study global health, conflict resolution, governance and poverty reduction. In coming years, the program will likely include additional fieldwork projects in Rwanda, Tanzania and Brazil. The SGSF program covers all travel expenses for students and provides students with an opportunity to work closely with a faculty member and a team of other students on an ongoing research project addressing real-world problems in a specific region.
“What makes FSI such an incredible institution is that it attracts faculty who have very pragmatic interests,” Bonzell said. “It seeks to wed academic work with a more direct impact, and there’s a lot of potential for more students to think along similar lines.”
The Stanford Global Student Fellows will also allow FSI to work closely with its partners, including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students.
Mexican Ambassador Eduardo Medina Mora and Jorge Olarte, '13, speaking with students at the US-Mex FoCUS event. Photo Credit: Rod Searcey
One of the program’s new initiatives geared toward undergraduates is the Global Policy Summer Fellowships. The fellowships help secure placement and a $6,000 stipend for students interested in interning at international policy and international affairs organizations. This summer, The Europe Center at FSI is placing students at the Center for European Policy Studies and Bruegel, two Brussels-based think tanks. Future positions will be created with six offerings abroad and two based in the United States.including the Program in International Relations, the Haas Center for Public Service, and Stanford in Government to provide opportunities for graduate and undergraduate students.
The Stanford Global Student Fellows program will also commit $400,000 to create a Mentored Global Research Fellowship that will provide research opportunities for students to conduct their own overseas research under the close mentorship of a faculty member. The program will award stipends of $6,000 for summer undergraduate projects and $9,000 for summer graduate projects, and $1,500 for smaller projects executed during the school year.
Thomas Hendee '13 chatting with children in rural Guatemala. Photo Credit: Maria Contreras
The faculty advisory committee overseeing the development and implementation of these new programs includes Scott Rozelle, the Helen F. Farnsworth Senior Fellow and the co-director of FSI’s Rural Education Action Program; Stephen Stedman, a senior fellow at FSI and the deputy director of CDDRL; and Lisa Blaydes, assistant professor of political science.
The application deadline for all summer programs is Feb. 28, 2015. The deadline to apply for academic quarterly programs is the end of the first week of each quarter, beginning in the fall of 2014.
