Child malnutrition, growth, and development in global health – An interview with Dr. Barry Bogin

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David Flood
David Flood, MD, MSc, is a physician with the Guatemalan NGO Wuqu' Kawoq | Maya Health Alliance and resident in Medicine-Pediatrics at the University of Minnesota. He received his medical degree from Harvard Medical School and an MSc in international health policy from the London School of Economics.
Photo by Rob Tinworth.

Photo by Rob Tinworth

Barry Bogin is a professor of biological anthropology at Loughborough University, U.K. He also is an investigator for The Maya Project, a blend of art and academic research portraying the biosocial realities of the Maya in Mesoamerica. Dr. Bogin is an expert on how nutritional, social, economic, and political conditions contribute to human growth and development. Since the 1970s, his research has focused on the growth of Maya populations in Guatemala, Mexico, and the U.S. I recently had the opportunity to talk with him about his work.

Can you start by talking about your background? How did you become interested in a socially-oriented view of growth and nutrition in Maya communities?

I originally went to Guatemala in the 1970s as a PhD student to do my dissertation research on the esoteric problem of seasonal variation in child growth. I wanted to find a population of kids who were healthy and well nourished. I didn’t know much about the politics and history of Guatemala until I got there. I especially learned what was going on when one day a woman I worked with didn’t show up, and all of my Guatemala co-workers were crying. I asked what was going on and was told that this woman’s brother had been murdered. A motorcycle drove by his house, and somebody shot him.

I asked, “Why would somebody shoot him?” And then I began to learn about the politics of Guatemala. This young man was a member of an opposition political party that was against the military dictatorship. He had been assassinated. Then I began to hear about more assassinations and learned that, although it wasn’t publicized, the civil war that had started in 1960 was ongoing. The government pretended like everything was under control, but it was not. They were killing lots of people in rural areas and in Guatemala City. That began to sensitize me to other issues.

You mentioned that you were seeking a population of children who were healthy and well nourished. How did this relate to the Maya?

My seasonal growth study required healthy children, unaffected by malnutrition or disease. So, I chose a group of children attending an expensive private school in Guatemala City. In the 1970s, there were multiple growth studies going on in Guatemala, but none of them studied the Maya. I was associated with a longitudinal study of Guatemala City school children organized by the Universidad del Valle de Guatemala. This study measured only Ladino and European school children. Ladinos are the politically and economically dominate ethnic group in Guatemala. Even the Institute of Nutrition of Central America (INCAP) in its famous Oriente Longitudinal Study only investigated Ladino villages in eastern Guatemala. It was politically sensitive to study the Maya at this time.

INCAP had done some important studies in the late 1950s and 1960s in Maya villages, which showed that 50% of the newborns died before the age of 5 from infectious disease and malnutrition. But from their perspective, they couldn’t do a longitudinal study if 50% of their newborn sample were going to die before age 5. They had to move to a somewhat better-off, non-Maya area. Although INCAP’s work was always seen as the “longitudinal study going on in Guatemala,” in fact there were no Maya in the cohort. In general, if any Guatemalan growth cohorts had included the Maya, the investigators would have had to explain to the world why the Maya were so poorly off.

In the end, although no Maya were included, the INCAP Longitudinal Study was incredibly important and found out that it was the calories that mattered. Children just needed more food; if they got more food, they got more of all the other important nutrients too. The results were clear by the early 1970s that more food led to children who were bigger, smarter, and would stay in school longer. But my view has always been that what children need is not only more food but also medical care, clean drinking water, better schools, lack of civil war, all of those things. And that’s what happened when, by accident, I found out about Maya in the United States.

Photo by Rob Tinworth.

Photo by Rob Tinworth

Yes, this research has been very profound. Tell us more about the Maya communities you studied in the U.S. and what you learned.

In 1979, the Universidad del Valle de Guatemala began to measure Maya children in San Pedro Sacatepéquez. I thought that this community was so close to Guatemala City, Maya children there were bound to be better off than in more isolated rural areas. But they turned out to be the shortest of all the kids we measured, and the most likely not to stay in school.

So I decided to try to find affluent Maya families. Maybe not rich Maya families, but perhaps middle-class families. I started looking in Guatemala City. But what happens in Guatemala is that in order to rise to the middle class, you have to stop being Maya. The parents stop wearing Maya clothing, they shift away from speaking Mayan languages, and eventually their kids grow up not even knowing they’re Maya. They assimilate. We couldn’t really find affluent Maya in Guatemala City.

So, I’m minding my own business in 1991 when I learned about a news story in the New York Times about seven Maya men dying in a car accident in Florida. It was a human-interest story. But I thought to myself, “What are Maya doing in Central Florida?” The story talked about this community of 5,000 Maya who had fled the civil war in Guatemala, landed in central Florida, and were working picking citrus fruits. A place called Indiantown, Florida. Not named after the Maya, but after Seminole Indians whose land had been taken by European invaders centuries ago.

I contacted Maya community leaders in Indiantown. I explained that I was trying to find a group of Maya who were not living under the oppression in Guatemala, so I could show that Maya can be healthier, taller, and smarter than they had been portrayed in Central America. I got permission, and in 1992 I went to Florida and measured all the kids in Indiantown. This data showed that U.S. Maya children 6-12 years of age were about 7 centimeters taller on average than the Guatemalan Maya.

In 1999-2000, I updated the data with measurements of 700 Maya kids in Indiantown and Los Angeles. In this data set, the U.S. Maya were 11 centimeters taller—in less than one generation! I also found that the longer Maya children were in the U.S., the taller they grew. Not only were they taller, they also had relatively longer legs.

This is the notion of body proportions?

The Maya were always considered short with short legs. It was seen as a sign of being an inferior “race.” But the Japanese were short and short-legged before 1960. After 1960, when Japan began to industrialize, modernize, and democratize, the Japanese became much taller and longer-legged in the subsequent 15 years. In other words, although some believed that the Japanese were a short-legged “race” like the Maya, this view was false. The whole concept that people come in certain racial types such as “short-legged” turns out to be rubbish. It’s all about diet and health. Proportions are not genetically determined; we say they are very “plastic.”

Your research has shown remarkable increases in the growth of Maya children in the U.S. in just one generation. Can you talk about how height is influenced over the course of multiple generations?

I think we have explained something that anthropologists have been writing about for a long time, the “secular trend in growth.” This refers to the idea that successive generations of people in a given group grow taller. For example, my maternal grandparents were born in what is present-day Ukraine. My grandfather was about 5 foot 6 inches, and my grandmother was quite short. My mother was 5 feet 8 inches. I’m 6 feet 1.5 inches. Each generation got taller.

How can we explain these kinds of trends? They’re partially an epigenetic process, although we don’t know the exact mechanisms. It takes about five or six generations to overcome a history of malnutrition, infectious disease, warfare, and emotional stress. Each one of those problems reduces height and takes years off healthy life. Together they have synergistic effects that are more than additive. It takes five or six generations to recuperate normal birth weights and growth after just one generation of insult! This has been well demonstrated in experiments in non-human primates.

Do you have any plans to update some of your U.S. Maya data?

Photo by Rob Tinworth

Photo by Rob Tinworth

I would like to go back and try to find some of the kids we measured in 2000 and see how tall they get as adults. But that would be tough as Florida was hit hard by the economic crisis in the mid-late 2000s, and many Maya moved after losing their jobs in construction, landscaping, or agriculture. We may try to extend our studies in other Maya communities with whom we have some contacts. It was our dream to have separate cohorts of Maya children in Guatemala, Mexico, and the U.S., but we didn’t get the money for that.

You have also written on the history of Maya height that can be inferred from archaeologic and skeletal data. Can you summarize some of your findings?

Economic historians latched on to height as a sensitive indicator of population health in the 1970s. One of these economic historians asked me to write a paper on changes in height in Latin America, going back as far in time as possible. With a student of mine, we consulted with the archaeologists, who have ways to estimate height. With a whole skeleton it’s very easy, but they can also estimate height from just a femur or tibia.

We put all this height data together and drew a line through it. And the line showed that hunter-gatherers 8000 years ago in Latin America were as tall as healthy populations today. As the empires developed—Inca, Aztecs, Maya, and other state societies—stratifications emerged between the few very rich people and the many poor people. At this point, you start to see average heights decline, but Maya royalty were still very tall. Then the Spanish arrive, and everything went down. The Spanish brought diseases, and a conservative estimate is that the Maya experienced a 90% population decline in the 100 years after the Conquest. Then you have slavery and oppression as the Europeans took over. Height has stayed very low in American indigenous groups up to the present day.

The Maya are short relative to other native people. Does this suggest that, even compared with other oppressed American indigenous groups, the Maya have faced exceptional levels of suffering?

I think that’s accurate. The Maya are the shortest people in the world other than the pygmy people whose short stature has endocrine and/or genetic underpinnings. The tallest people in the world today on a statistical basis are the Dutch who are a few millimeters taller than, say, the Swedes. We’re talking about very small statistical differences. The Maya are the shortest in the world on the same basis. The native people in Peru living in the mountainous areas are also very short—a few millimeters taller than the Maya. So a lot of people in Latin American have suffered, not just the Maya. The Maya may have  just suffered a bit more.

Your recent research has focused on the notion of the nutritional dual burden. Can you talk about how it’s possible to have high rates of stunting and high rates of obesity in the same population?

It’s relatively rare for a single child to be stunted and overweight. More commonly with the Maya, you have children who are stunted, and adults who are both stunted and overweight. For example, only about 2% of the kids we measure are stunted and overweight, but 70-80% of the families with stunted kids also have short, overweight adults. As these kids get older, they will also be at great risk of obesity. In adults, we worry less about height and more about weight as this confers the burden for metabolic diseases like diabetes. There is this tremendous dual burden—very short people and very overweight people. This is a terrible combination for risk of diabetes, heart disease, and some cancers.

Stunting is a multifactorial issue, but, in terms of nutrition, what key messages should we be thinking about?

In the region where the Maya live in southern Mexico, people are generally getting enough calories. But nutrients like vitamin A, calcium, iron, vitamin B12, and folate—those are missing from the diet. These are essential nutrients, which means that your body cannot make them from simpler compounds. Every essential nutrient, if in short supply, inhibits growth. It’s not just bone growth but also muscle growth and brain growth; everything is slowed down. That’s the way the body compensates. People used to call that an adaptation—you’re “small but healthy.” We threw out that idea 20 years ago. On a population level, stunted people are not healthy.

Does this mean that that dietary diversity should to be emphasized more in nutrition programs where child stunting is highly prevalent?

Dietary diversity is very important. Interestingly, we know that the traditional Maya diet was not deficient in any nutrient. The ancient Maya grew hundreds of different kind of foods, and they had a complete diet that did not lack essential nutrients. That’s why Maya priest-kings were as tall as average U.S. Americans today. This is where the post-Conquest history of oppression, poverty, and land theft comes into play.

One of our next projects is fostering home gardens in a Maya community in Mexico. We believe that gardens can be important not only to diversify diets with additional fruits and vegetables, but also as a way to reinvigorate the Maya agricultural tradition. But in the end, until we have better equity in the distribution of food and access to education and medical care in this world, we are going to have people who are stunted.

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  • By A new post on the Hub | Our Life In Comalapa on Aug. 06, 2014 at 03:54

    […] I have a new post at the Global Health Hub. It’s an interview with an expert on the relationship between malnutrition and height. It’s here. […]