Improving Infant and Young Child Nutrition in a Highly Stunted Rural Community: A Practical Case Study from Guatemala

  • Boris Martinez
  • David Flood
  • Katia Cnop
  • Andrea Guzman
  • Peter RohloffEmail author
Living reference work entry


Stunting is a major public health concern because of its association with child mortality and morbidity and later adult economic and health. Despite Guatemala’s important contributions on child nutrition research, the indigenous Maya population in Guatemala has one of the highest stunting rates in the world. This chapter contextualizes the global problem of child stunting with a close look to Guatemala’s historical nutrition research and policy, followed by a description of a comprehensive nutrition programming model for highly stunted communities developed by the nongovernmental healthcare organization Wuqu’ Kawoq ∣ Maya Health Alliance and a single-community case study of the model implementation. The model includes both preventative and curative evidence-based interventions to target food security, environmental factors, access to health services, and caregiver education and empowerment. Frontline workers with cultural and linguistic competency deliver individualized education and nutrition assessments. Over a 2-year implementation of the approach in a Maya community, the overall prevalence of stunting under 5 declined 20% and the prevalence of severe stunting 35%. In this and other similar settings, holistic, primary care approaches to malnutrition can have significant impact on child health.


Stunting Diet quality Feeding practices Case study Guatemala Indigenous Food security Community-based nutrition Nongovernmental organization Primary care 

List of Abbreviations


Food and Nutrition Technical Assistance


Instituto Nacional de Estadística


Low- and Middle-Income Country


Wuqu’ Kawoq | Maya Health Alliance


Ministerio de Salud Pública y Asistencia Social


Nongovernmental Organization


Expansion of Coverage Program


Plan de Pacto Hambre Cero


United States Agency for International Development


World Health Organization


Zero Hunger Plan


  1. Adair LS, Fall CH, Osmond C, Stein AD, Martorell R, Ramirez-Zea M et al (2013) Associations of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: findings from five birth cohort studies. Lancet 382:525–534CrossRefPubMedPubMedCentralGoogle Scholar
  2. Anderson I, Robson B, Connolly M, Al-Yaman F, Bjertness E, King A et al (2016) Indigenous and tribal peoples’ health (the Lancet–Lowitja Institute Global Collaboration): a population study. Lancet 388:131–157CrossRefPubMedGoogle Scholar
  3. Ashworth A, Khanum S, Jackson A, Schofield C (2003) Guidelines for the inpatient treatment of severely malnourished children. World Health Organization, GenevaGoogle Scholar
  4. Avila C, Bright R, Gutierrez JC, Hoadley H, Manuel C, Romero N et al (2015) Guatemala health system assessment. Health Finance & Governance Project, Abt Associates Inc, BethesdaGoogle Scholar
  5. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E et al (2008) What works? Interventions for maternal and child undernutrition and survival. Lancet 371:417–440CrossRefPubMedGoogle Scholar
  6. Black RE (2017) Patterns of growth in early childhood and infectious disease and nutritional determinants. In: Complementary feeding: building the foundations for a healthy life. Karger Publishers, Basel, pp 63–72CrossRefGoogle Scholar
  7. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M et al (2013) Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 382:427–451CrossRefPubMedGoogle Scholar
  8. Brown K, Henretty N, Chary A, Webb MF, Wehr H, Moore J et al (2014) 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 12:262–277CrossRefPubMedGoogle Scholar
  9. Chary A, Rohloff P (eds) (2015) Privatization and the new medical pluralism: shifting healthcare landscapes in Maya Guatemala. Lexington Books, LanhamGoogle Scholar
  10. Chary A, Dasgupta S, Messmer S, Rohloff PJ (2011) Breastfeeding, subjugation, and empowerment in rural Guatemala. In: Walks M, McPherson N (eds) Mothering: anthropological perspectives. Demeter Press, BradfordGoogle Scholar
  11. Chary A, Messmer S, Sorenson E, Henretty N, Dasgupta S, Rohloff P (2013) The normalization of childhood disease: an ethnographic study of child malnutrition in rural Guatemala. Hum Organ 72:87–97CrossRefGoogle Scholar
  12. Ciliberto MA, Sandige H, Ndekha MJ, Ashorn P, Briend A, Ciliberto HM et al (2005) Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr 81:864–870PubMedGoogle Scholar
  13. De Onis M, Onyango AW, Borghi E, Garza C, Yang H (2006) Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes. Public Health Nutr 9:942–947PubMedGoogle Scholar
  14. DeBoer MD, Lima AA, Oría RB, Scharf RJ, Moore SR, Luna MA et al (2012) Early childhood growth failure and the developmental origins of adult disease: do enteric infections and malnutrition increase risk for the metabolic syndrome? Nutr Res 70:642–653Google Scholar
  15. Dewey K (2003) Guiding principles for complementary feeding of the breastfed child. World Health Organization, GenevaGoogle Scholar
  16. Dewey KG, Begum K (2011) Long-term consequences of stunting in early life. Matern Child Nutr 7:5–18CrossRefPubMedGoogle Scholar
  17. Espina C (2015) PDH califica crisis de salud como situación sin precedentes en el país. In: El Periódico. Accessed 20 Feb 2017
  18. Flood D (2015) Reflections on the INCAP Oriente Longitudinal Study of early life nutrition: an interview with Aryeh Stein. Global Health Hub. Accessed 11 Feb 2017
  19. Food and Nutrition Technical Assistance Project (FANTA) (2010) TRM-01: preventing malnutrition in children under 2 approach (PM2A): a food-assisted approach. Food and Nutrition Technical Assistance II Project, FHI 360, Washington, DCGoogle Scholar
  20. Galicia N (2016) Errores y corrupción hacen caer a Otto Pérez Molina. In: Prensa Libre. Accessed 25 Mar 2017
  21. Gracey M, King M (2009) Indigenous health part 1: determinants and disease patterns. Lancet 374:65–75CrossRefPubMedGoogle Scholar
  22. Hoddinott J, Maluccio JA, Behrman JR, Flores R, Martorell R (2008) Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet 371:411–416CrossRefPubMedGoogle Scholar
  23. Horton JC (1987) The Behrhorst Foundation at 25 years. A report from Chimaltenango, Guatemala. N Engl J Med 316:1666–1669CrossRefPubMedGoogle Scholar
  24. King N, Alvizures R, García P, Wessel A, Rohloff P (2016) Argininemia as a cause of severe chronic stunting in a low-resource developing country setting: a case report. BMC Pediatr 16(142):1–4Google Scholar
  25. Lassi ZS, Kumar R, Bhutta ZA (2016) Community-based care to improve maternal, newborn, and child health. In: Black RE, Laxminarayan R, Temmerman M et al (eds) Reproductive, maternal, newborn, and child health: disease control priorities. The International Bank for Reconstruction and Development/The World Bank, Washington, DC, pp 263–284Google Scholar
  26. Martorell R (2010) Physical growth and development of the malnourished child: contributions from 50 years of research at INCAP. Food Nutr Bull 31:68–82CrossRefPubMedGoogle Scholar
  27. Martorell R, Habicht JP, Rivera JA (1995) History and design of the INCAP Longitudinal Study (1969–77) and its follow-up. J Nutr 125(Suppl 4):1027–1041Google Scholar
  28. Mata LJ (1978) The children of Santa Maria Cauqué: a prospective field study of health and growth. The MIT Press, Cambridge, MAGoogle Scholar
  29. Maupin J (2015) Strategic alliances: the shifting motivations for NGO collaboration with government programs. In: Chary A, Rohloff P (eds) Privatization and the new medical pluralism: shifting healthcare landscapes in Maya Guatemala. Lexington Books, Lanham, pp 3–18Google Scholar
  30. Ministerio de Salud Publica y Asistencia Social (MSPAS) (2010) Normas de Atención en Salud Integral. MSPAS, GuatemalaGoogle Scholar
  31. 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, GuatemalaGoogle Scholar
  32. Newell KW (ed) (1975) Health by the people. World Health Organization, GenevaGoogle Scholar
  33. Nutrinet (2009) Historia de la alimentación escolar en Guatemala. Accessed 02 Mar 2017
  34. Oglesby E, Nelson DM (2016) Guatemala’s genocide trial and the nexus of racism and counterinsurgency. J Genocide Res 18:133–142CrossRefGoogle Scholar
  35. Plan de Pacto Hambre Cero (PPHO) (2012) Gobierno de Guatemala. Accessed 02 Mar 2017
  36. Prentice AM, Ward KA, Goldberg GR, Jarjou LM, Moore SE, Fulford AJ et al (2013) Critical windows for nutritional interventions against stunting. Am J Clin Nutr 97:911–918CrossRefPubMedPubMedCentralGoogle Scholar
  37. Reinhardt K, Fanzo J (2014) Addressing chronic malnutrition through multi-sectoral, sustainable approaches: a review of the causes and consequences. Front Nutr 1:1–11CrossRefGoogle Scholar
  38. Roberts JL, Stein AD (2017) The impact of nutritional interventions beyond the first 2 years of life on linear growth: a systematic review and meta-analysis. Adv Nutr 8:323–336CrossRefPubMedGoogle Scholar
  39. Ruel MT, Rivera J, Habicht JP (1995) Length screens better than weight in stunted populations. J Nutr 125:1222–1228PubMedGoogle Scholar
  40. Sawaya AL, Martins P, Hoffman D, Roberts SB (2003) The link between childhood undernutrition and risk of chronic diseases in adulthood: a case study of Brazil. Nutr Res 61:168–175Google Scholar
  41. Scrimshaw NS, Béhar M, Guzmán MA, Gordon JE (1969) Nutrition and infection field study in Guatemalan villages, 1959–1964: IX. An evaluation of medical, social, and public health benefits, with suggestions for future field study. Arch Environ Health 18:51–62CrossRefPubMedGoogle Scholar
  42. Stein A (2014) Early childhood nutrition and adult metabolomic and cardiometabolic profiles. Accessed 10 Mar 2017
  43. Stein AD, Melgar P, Hoddinott J, Martorell R (2008) Cohort profile: the Institute of Nutrition of Central America and Panama (INCAP) nutrition trial cohort study. Int J Epidemiol 37:716–720CrossRefPubMedPubMedCentralGoogle Scholar
  44. Stein AD, Wang M, Martorell R, Norris SA, Adair LS, Bas I et al (2010) Growth patterns in early childhood and final attained stature: data from five birth cohorts from low-and middle-income countries. Am J Hum Biol 22:353–359CrossRefPubMedGoogle Scholar
  45. Stevens GA, Finucane MM, Paciorek CJ (2016) Levels and trends in low height-for-age. In: Black RE, Laxminarayan R, Temmerman M et al (eds) Reproductive, maternal, newborn, and child health: disease control priorities. The International Bank for Reconstruction and Development/The World Bank, Washington, DC, pp 85–93Google Scholar
  46. Thousand Days (2014) 1,000 days. Accessed 10 Jan 2017
  47. UNICEF (2016) Joint child malnutrition estimates – 2016 edition. UNICEF DATA. Accessed 20 Dec 2016
  48. United States Agency for International Development (USAID) (2016) Guatemala: nutrition profile. Last updated 8 Feb 2016. Accessed 10 Dec 2016
  49. Webb MF, Chary AN, De Vries TT, Davis S, Dykstra M, Flood D et al (2016) Exploring mechanisms of food insecurity in indigenous agricultural communities in Guatemala: a mixed methods study. BMC Nutr 2(55):1–11Google Scholar
  50. World Health Organization (2008) Indicators for assessing infant and young child feeding practices: part 1: definitions: conclusions of a consensus meeting held 6–8 November 2007 in Washington, DCGoogle Scholar
  51. World Health Organization (2016) Joint child malnutrition estimates – levels and trends. Accessed 23 Jan 2017

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Boris Martinez
    • 1
  • David Flood
    • 1
  • Katia Cnop
    • 1
  • Andrea Guzman
    • 1
  • Peter Rohloff
    • 1
    • 2
    Email author
  1. 1.Wuqu’ KawoqSantiago SacatepéquezGuatemala
  2. 2.Division of Global Health EquityBrigham and Women’s HospitalBostonUSA

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