Lisa Villanueva’s research while affiliated with Georgia Southern University and other places

Undernutrition and a lack of learning opportunities can jeopardize long-term growth and development among infants in low- and middle-income countries. We conducted a 6-month 2 × 2 cluster-randomized trial to assess the effects of multiple micronutrient-fortified beverages and responsive caregiving interventions among infants 6–18 months in 72 community sectors in southwest Guatemala. We administered baseline and endline assessments of childhood development (Bayley Scales of Infant and Toddler Development) and socioemotional development (Brief Infant Toddler Socio-Emotional Assessment) and measured ferritin and hemoglobin on a subsample. The trial was analyzed using linear mixed models. At the baseline, the mean age (SD) was 13.0 (4.6) months, including 49% males, 32% who were stunted, 55% who were anemic, and 58% who were iron deficient. At the endline (n = 328/386, 85% retention), there was no synergistic effect on the fortified beverage and responsive caregiving intervention. Compared to the non-fortified beverage group, socioemotional development improved in the fortified beverage group. There were no intervention effects on other measures of child development, hemoglobin, or ferritin. In a setting with high rates of anemia and iron deficiency, a multiple micronutrient-fortified beverage improved infants’ socioemotional development.

Background: About 47% of children < 5 years of age are stunted in Guatemala. In this study, the investigators aimed to compare growth and cognitive outcomes between children in second grade that attended five Guatemala City Municipal Nurseries (GCMN) vs. same sex, grade, and age-matched children. Methods: A cross-sectional design nested in a retrospective cohort was implemented between 2015 and 2019. Children that attended the GCMN and matched controls completed a math test and validated receptive language and fluid intelligence tests. The primary caregivers completed a sociodemographic survey. General and generalized linear mixed effect models were used to compare children that attended the GCMN vs. controls. The models were adjusted by maternal education, sex, asset score, and other relevant covariates. Results: Children that attended the GCMN exhibited greater math and fluid intelligence scores relative to the controls in the adjusted models (ß = 6.48; 95% CI (2.35-10.61)) and (ß = 1.20; 95% CI (0.12-2.29)), respectively. Lower odds of stunting were significant for children who went to any early childcare institution (AOR = 0.28; 95% CI (0.09-0.89)). Conclusions: The importance of integrating nutrition and high-quality early childhood education interventions in cognitive and growth outcomes is highlighted in this study. The GCMN model may be a scalable model in similar low-resource settings.

One in four children younger than age five in Guatemala experiences anaemia (haemoglobin <11.0 g/dl). This study characterized the factors and micronutrient deficiencies associated with anaemia in a baseline cross-sectional sample of 182 Guatemalan infants/toddlers and 207 preschoolers, using generalized linear mixed models. Associations between anaemia and maternal, child and household variables, and biomarkers (soluble transferrin receptor, ferritin, zinc, folate, vitamin B12, C-reactive protein, and α1-acid glycoprotein) were explored. Rates of anaemia were 56% among infants/toddlers and 12.1% among preschoolers. In children with anaemia, rates of iron deficiency (low ferritin based on inflammation status, and/or high soluble transferrin receptor, ≥1.97 mg/L) and zinc deficiency (serum zinc <65 μg/dl) were 81.1% and 53.7%, respectively. Folate deficiency (either plasma folate <3 ng/ml or erythrocyte folate <100 ng/ml) was 3.3%. Vitamin B12 deficiency (plasma vitamin B12 <148 pmol/L) was 7.5%. For infants and toddlers (<24 months), the odds ratio of anaemia was lower when higher number of adults lived in the household (OR = 0.69; 95% CI [0.53, 0.90]), and higher when children were zinc deficient (OR = 3.40; 95% CI [1.54, 7.47]). For preschoolers (36-60 months), the odds ratio of anaemia was lower for every additional month of age (OR = 0.90; 95% CI [0.81, 1.00]). Findings suggest that micronutrient deficiencies coexist in Guatemalan rural children, and zinc deficiency is associated with anaemia in children <24 months, highlighting the need of continued multidisciplinary interventions with multiple micronutrients. Further research examining how household composition, feeding practices, and accessibility to micronutrient supplements and to animal source foods is needed to incorporate strategies to improve the nutritional status of Guatemalan children.

Objectives: Anemia is a major public health problem among young children. In addition to iron deficiency, other micronutrient deficiencies have been associated with anemia. The purpose of this study was to identify biomarkers associated with anemia in children <5 years from rural Guatemala. Methods: A total of 182 infants (6-24 m) and 207 preschoolers (36-60 m) were recruited from community surveillance to participate in a randomized controlled trial of nutrition and child development. Methods included measured weight, length/height and venous blood draws. Inclusion criteria were length/height-for-age z-score <-1.0 and Hb >7.0 g/dL. Cross-sectional analyses using generalized linear mixed models of baseline data examined associations between anemia (Hb <11.0 g/dL) and micronutrient deficiencies, adjusting for maternal, child and sociodemographic variables. Iron deficiency was defined as low ferritin based on inflammation status, and/or high soluble transferrin receptor, ≥1.97 mg/L. Deficiencies for other parameters were designated as: zinc <65 µg/dL; vitamin B12 < 200 pg/mL; and plasma folate <3 ng/mL or erythrocyte folate <100 ng/mL. Results: Prevalence of anemia was 56% in infants and 12% in preschoolers. Among anemic infants/preschoolers, rates of iron, zinc, folate and vitamin B12 deficiencies were 83/75%; 63/18%; 3/4%; and 9/0%, respectively. For infants, the odds of anemia were higher when children were zinc deficient [OR = 3.59;95%CI (1.64-7.85)], after adjusting for community cluster, sex, age, maternal education and household size. No biomarkers were associated with anemia in preschoolers. Conclusions: Iron and zinc are common micronutrient deficiencies in children from low- and middle-income countries. These findings suggest that micronutrient deficiencies coexist among children in Guatemala, and that zinc should be considered as part of the prevention strategies to reduce anemia. In preschoolers, no biomarkers were associated with anemia, suggesting that other biological and psychosocial factors could be influencing anemia in this age group. Funding sources: The Mathile Institute for the Advancement of Human Nutrition, Sackler Institute for Nutrition Science of the New York Academy of Sciences.

The objective of this study was to test a novel and low‐cost distribution method to provide a 21 micronutrient‐fortified beverage (Chispuditos ® ) to improve the nutritional status of children with a Length/Height‐for‐age Z‐score (HAZ) ≤−1, in rural southwest Guatemala. Community woman leaders from 9 villages were identified and trained to provide coached guidance on nutrition, caregiving, parenting and early learning opportunities. The distribution mechanism consisted of groups of ~30 mothers organized by the community leader that met on a monthly basis at a point of convenience. The woman leader guided discussion and practice of the topics mentioned above among the peer group. Duration of meetings was approximately 30 minutes, and mother‐child dyads received a 24‐day supply of Chispuditos and instructions on how to prepare. Participants provided 1 Guatamalan Quetzal ($0.13 USD) to cover the complete cost of the community leader service. A total of 290 children from 6–72 months of age completed 21 months of receiving the fortified atole. A cross‐sectional analysis showed a significant improvement in mean HAZ scores: from −2.34 (0.89SD) to −1.95 (1.09SD), (p<0.01) and a significant reduction in the prevalence of stunting (from 58.3% to 46.0%, p<0.001). In conclusion, this community‐based low‐cost distribution model along with the nutrition intervention appears to be effective in improving linear growth in stunted children from rural southwest Guatemala. Support or Funding Information The Mathile Institute for the Advancement of Human Nutrition

A corn and soy atole fortified with 21 vitamins and minerals, including higher levels of iron and zinc than other locally available options, has been provided to children from 6–84 months of age attending 6 Sociedad Protectora del Niño day care centers in Guatemala since August of 2013. Trained staff prepared and fed the children one serving consisting of 18.75g (~one tablespoon) of dry product mixed with 8 oz of water, brought to a boil and served as a warm beverage 5 days per week throughout the year. The objectives of this study were to assess the changes in mean height for age Z‐scores (HAZ) and hemoglobin (Hb) after 21 months of intervention, and to quantify the amount of atole consumed by the children on two different non‐consecutive days. Children were followed‐up for anthropometry and Hb every 6 months. To evaluate the amount of atole that children consumed, a waste study was performed in 3 randomly selected nurseries, on two non‐consecutive days, using graduated cylinders and food scales to measure the amount of atole prepared and not consumed. Multivariate mixed model analyses were performed to evaluate changes over time in Z‐scores and Hb. Mean Hb improved on average of 0.5g/dL throughout the intervention (t=11.43, df=1761.15, p<0.001). Mean HAZ improved significantly in those children with HAZ<‐2 SD at baseline, showing an average monthly increase of ~0.03 SD, (t=6.15, df=1324, p<0.001) over the course of the intervention. The waste study indicated that children consumed 98.5% of the served beverage/day. This micronutrient intervention is effective in improving Hb concentrations and a significant effect in the improvement in HAZ among stunted children was also noted. The product is highly acceptable to children, making this fortified atole a good alternative to address chronic undernutrition in similar institutions in Guatemala and other Central American countries where atole consumption is a common habit and practice. Support or Funding Information This program was sponsored by The Mathile Institute for the Advancement of Human Nutrition

Since 2010, six Guatemala City Municipal Nurseries were provided a 21 micronutrient fortified corn and soy beverage that contains chelated forms of zinc (9mg) and iron (12mg) to address micronutrient deficiencies among children ages 6 to 84 months that attend the daycare centers for 5 days/week. The main objective of this study was to carry out a four‐year longitudinal analysis of the nutritional status of stunted children that have attended the nurseries. A total of 491 children with stunting (height‐for‐age Z scores (HAZ) <‐2SD) at enrollment were identified. Height and weight measurements were collected at the beginning and before the end of every school year. Hemoglobin (Hb) was assessed in a subsample of individuals at the beginning and before the end of the school year for the first year, and in subsequent years only at the end of the school year; concentrations were adjusted for an elevation of 1500m. A multivariate mixed model analysis was performed to evaluate the relationship between time of intervention and HAZ, and Hb concentrations. To assess prevalence of stunting and anemia across time, a multivariate generalized linear mixed model was performed. We observed that mean HAZ score (baseline HAZ=−2.54SD) improved over time by 0.02 SD per month (F=609.56, df=1, 1159.16 p<0.001) after controlling for sex; and on average, the odds of having stunting decreased by ~11% for every month the child received the nutrition intervention, OR=0.89 95% CI (0.88–0.91), p<0.001, controlling for sex. For those stunted children with anemia at baseline, the odds of having anemia decreased on average by 11% for every month of receiving the nutritional intervention, OR: 0.89, 95% CI (0.85–0.93), p<0.001. We also observed a significant increase in mean Hb concentrations (F=81.59, df=1, 102.00, p<0.001) in anemic children at baseline (mean Hb=10.45g/dL) and the next measurement after ten months (12.30g/dL). The Hb concentrations were maintained within normal ranges (≥11.60g/dL) in all subsequent measurements. This analysis demonstrates that the nutrition program at the Guatemala City Municipal nurseries is effective in reducing the prevalence of stunting and anemia, and in improving mean HAZ and Hb concentrations in stunted children from 6 to 84 months of age. Support or Funding Information This research was sponsored in part by the Mathile Institute for the Advancement of Human Nutrition.

Chispuditos® is a corn/soy atole fortified with 21 vitamins and minerals designed to reduce micronutrient deficiency of Central American children. A portion of atole (18.75g) was provided for 5 days/week to 6‐72 month‐old children. Seven hundred and forty seven children completed 1 year of the nutritional intervention. Hemoglobin, anthropometry and incidence of respiratory tract infections and diarrhea were analyzed at baseline, six months and one year. Repeated measures ANOVA indicated an increase in hemoglobin from baseline=11.76±1.17g/dL to endline=12.39±1.05 g/dL, p<0.001. HAZ scores increased from ‐1.25±1.02 to ‐1.07±0.96, p<0.001 over the time course of the intervention. Furthermore, there was a 57.1% reduction in respiratory tract infections, p<0.001 after 12 months. No changes in the incidence of diarrhea from baseline to one year were observed. Overall, children in this study had an improvement in HAZ scores, hemoglobin concentrations and respiratory tract infections after 12 months of intervention, while previous studies in comparable settings took approximately 24 months for HAZ scores to improve. Funded by The Mathile Institute for the Advancement of Human Nutrition.