Links between child and adult chronic diseases: Lessons from Guatemala

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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.

Since 2013, I have had the great joy of working in rural Guatemala for the non-governmental organization Wuqu’ Kawoq | Maya Health Alliance—first during medical school at Harvard Medical School, and, since 2015, while as a resident physician at the University of Minnesota.

The bulk of my role with the organization has been to support a diabetes management program serving about 200 indigenous Maya diabetes patients. Although it may be difficult to believe given the tremendous burden of diabetes all around the globe, our comprehensive clinical diabetes program is one of the largest in any rural setting worldwide with comparable rates of poverty for which programmatic information is available.

In addition to my diabetes work, I have been involved with the organization’s child malnutrition programs. Like diabetes, malnutrition in Guatemala is a critical problem that dramatically affects indigenous communities. The type of malnutrition most common in Guatemala is chronic malnutrition, or stunting. Many readers of this site will be very familiar with this variety of malnutrition, which is distinct from the popular conception of an acutely malnourished child with a big belly and thin limbs. In contrast, chronically malnourished children are short but otherwise look quite normal, or may even appear plump. In fact, it can be difficult even for experienced clinicians to make the diagnosis without charting a child’s height and weight on standard growth curves.

Height may not seem like such a big deal, but, as I have previously discussed in posts on this site, stunting confers significant short-term and long-term risks. In the short-term, chronically malnourished kids are more likely to face illness or die in childhood. In the long term, they tend to have decreased school performance, worse economic prospects, and face some increased reproductive risks in the case of adult women.

My own programmatic nutrition role has consisted of managing an innovative home-based management program for chronic malnutrition in children under two years of age. My colleagues and I have made hundreds of home visits as we track down kids who have been identified by their local health centers as malnourished. During home visits, we screen for medical conditions that can cause growth delay, teach about the types and quantity of foods that are best at each age, give practical strategies to make better use of scarce family resources, deliver supplementary vitamins and food, and offer mothers family planning methods. These visits are conducted in the families’ preferred language, which, in most cases, is a Mayan language instead of Spanish, the dominant language of the government and health system.

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Photo from Watsi.org.

We carry out these activities with the full knowledge that rural Maya mothers lack many options and resources. In these communities, around 50% of families live on $3 per day or less, and many families simply cannot afford to offer their children the type and quantity of food that would meet all dietary needs. For example, in one study, our organization found that less than 3% of children received a “minimal acceptable diet,” according to WHO criteria. The most recent national-level data from Guatemala show that 61% of indigenous children are stunted, and, in the most marginalized communities, this figure reaches 80-90%.

In our pilot home-visit malnutrition program, we enrolled sixty children who had been diagnosed with severe chronic malnutrition (height-for-age Z-scores ≤-3). Our initial data suggested that we may have been successful in improving diets and recuperating a very modest height improvement in these children. Going forward, with a large grant from Grand Challenges Canada and in collaboration with Guatemalan researchers at the Universidad del Valle and the pioneering crowdfunding platform Watsi, our organization is scaling a similar program and rigorously testing its effects on physical growth and child developmental outcomes.

One individual success story is the case of Adam, a young boy we enrolled in our program in late November 2013 when he was 20 months old. Adam is from an indigenous, very poor family in an isolated rural community. He is the youngest of seven children. When our team first evaluated Adam, we observed that he was about 12 centimeters shorter than the average height for a child his age. We also learned that he’d been having chronic diarrhea, and was eating a diet of primarily liquid porridges and virtually no solid food.

Over the next six months, our nutrition team and I visited with Adam every two weeks. We treated him for his diarrhea, gave his mom frequent tips about good feeding practices and food-purchasing strategies, and provided the family with food for Adam and his siblings. Since he entered the program, Adam’s height-for-age has progressively improved. Whereas most children like Adam in Guatemala and around the world continue to have growth faltering until about three years of age, you can see below how Adam’s growth accelerated beginning at 20 months of age:

Photo from Wuqu' Kawoq | Maya Health Alliance.

Although not all of the cases are as successful as Adam’s, our organization’s ultimate goal is to show that it is meaningful to invest in treatment programs for children who are chronically malnourished. Currently, preventative child-centric policies dominate the nutrition agenda in Guatemala and around the world. Although prevention is crucial, we also don’t want to give up on children like Adam who have already arrived at a stage of severe chronic malnutrition.

Spending so much time caring for Maya adults with diabetes and children who are malnourished has made me reflect on the profound similarities between these two conditions. Both are chronic diseases that require primary care infrastructure for their adequate management. Both have complex, multifactorial etiologies greatly influenced by social factors like poverty, discrimination, and lack of access to health resources. Both necessitate culturally and linguistically sensitive behavior-change strategies for care to be effective.

Moreover, I have been very interested in emerging research findings suggesting that children who are chronically malnourished may have higher risks of obesity and even diabetes as adults. Using the idea of “mismatch” between the fetal and childhood environment compared with the adult environment, some researchers have found it useful to think of the link between malnutrition and obesity within the “developmental origins of health and disease” paradigm. The concept is that in a setting of nutritional scarcity, fetuses or young children undergo “early life programming” that permanently alters how their bodies regulate and store nutrients; however, as adults, these physiologic alterations may predispose the person to have diabetes or obesity.

In summary, coordinating diabetes and infant malnutrition programs in Guatemala has shown me how child and adult health are intricately connected. It also has reminded me how programs involving behavior change and education are essential at all ages–and that designing such programs thoughtfully is difficult yet critical. These lessons are important when I’m working in a U.S. academic medical center or a Guatemalan rural health center.