Silvia de Ponce’s research while affiliated with University of San Carlos of Guatemala 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.

Objectives To determine the long-term impact of a micronutrient fortified supplement on stunting rates and micronutrient status in young children living in rural Guatemala, which has the highest stunting prevalence in Latin America. Methods A parallel, open label randomised control trial in rural children aged 6–72 months (Registration NCT01643187). After growth screening, all children < 1SD for either weight for height (WHZ), height for age (HAZ), or weight for age (WAZ) were randomly allocated using 7:3 ratio, stratified by locality and age to receive either the test drink, Chispuditos®, a corn/soy beverage fortified with 21 vitamins or de-lactosed milk (control). Both drinks were isoproteic (4g/drink) and had similar energy content (test drink 147 kcal, milk 117 kcal) but the tst drink had higher micronutrient content (e.g., 9 mg zinc, 12.5 mg iron vs 1.5 mg zinc, 1.9 mg iron in control). They were supplied for 18 months and monthly visits were conducted to test for adherence. Results A total of 1238 children were screened, 971 met the criteria and 681 were allocated to test drink and 290 to control. At baseline, malnutrition prevalence of stunting (HAZ < -2SD), for test vs control was 48.4% vs 47.9%, 5.5% vs 6.7% for wasting (WHZ < -2SD) and 19.9% vs 18.7% for underweight (WAZ < -2SD). 73% of children reported to consume at least half of allocated drinks/day. After 18 months of intervention, the prevalence and relative risks [RR (95% CI)] for stunting in the test: control were 40.6:40.7% [RR 0.99 (0.84, 1.19)]; similarly, no differences were seen in WAZ, WHZ nor micronutrient status. Conclusions In this trial in rural Guatemalan children, long term supplementation with a micronutrient enriched drink had no impact on either stunting or micronutrient status. These results differ form long-term studies in urban Guatemalan nurseries. The present study suggest that fortified foods alone are not enough to reduce stunting rates in this setting when fed during an 18 month period. Funding Sources The Mathile Institute for the Advancement of Human Nutrition funded this study.

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.

Objectives: To assess the relationship between maternal employment and children's dietary diversity in rural Guatemala. Methods: A mixed-method design was used to compare quantitative findings on children's dietary diversity collected from Food Frequency Questionnaires (FFQs) (n = 802), with qualitative data from in-depth interviews (IDIs) with a sub-sample of participants (n = 20). Mothers reported the number of times per week their child consumed select food items from seven food groups (grains, legumes, vitamin A-rich fruits & vegetables, other fruits & vegetables, eggs, dairy and meat). The total for each food item was then divided by seven to find the number of times the child consumed each food per day. Then, the daily consumption of all food items within a category was totaled for each food group. If the total for the food group was at least one, the child was given one point for daily consumption, with a maximum dietary diversity score (DDS) of seven. Using multivariate linear regression, we compared the DDS of children of employed mothers to the DDS of children of unemployed mothers. We used separate multivariate logistic regression models to estimate the association between maternal employment and consumption of each food group. Models were adjusted for maternal (age, education, marital status, parity), child (age, sex), and household (size) characteristics. IDIs explored the mechanisms by which food purchasing and preparation, as well as child-feeding behavior differed for employed and unemployed women. Results: Maternal employment (versus unemployment) was associated with higher dietary diversity scores for children (β = 0.3; 95% CI: 0.06,0.54). The odds of consuming each food group did not differ significantly between children of employed and unemployed women, except for dairy (OR: 1.9, 95% CI: 1.0, 2.6), but the general trend suggested children of employed women were more likely to consume six of the seven food groups. Qualitative data indicates that employed women purchase higher quality and greater quantities of food. Conclusions: Maternal employment is associated with higher children's dietary diversity scores in rural Guatemala. Quantitative and qualitative data suggests that maternal employment is related to food purchasing behavior. Funding sources: Mathile Institute & Global Obesity Prevention Center at Johns Hopkins Bloomberg School of Public Health.

The double burden of malnutrition, defined by the coexistence of undernutrition and overweight, is well documented in low- and middle-income countries. However, the mechanisms by which employment may be related to maternal and child weight status in low- and middle-income countries are not well understood. We conducted in-depth interviews among 20 mothers who participated in Project MIEL, a contemporary trial which evaluated the effects of an integrated micronutrient supplement and parenting intervention in rural Guatemala. We utilized semi-structured interviews to explore the pathways by which maternal employment might influence bodyweight. Interviews were structured to explore the factors that mothers considered when deciding whether or not to participate in the labor force and how mothers perceived the influence of employment on determinants of their own bodyweight and that of their children. Themes were used to develop a conceptual framework. Mothers described four pathways through which employment could lead to changes in weight status: changes in food purchasing; improved household well-being; changes in time allocation; and psychological effects. Mothers described purchasing increased quantities and more varied types of food, as well as the purchase of energy-dense foods. Less time to devote to food preparation resulted in mothers preparing quicker meals and relying on substitute childcare. Mothers also expressed feelings of worry and neglect in relation to being employed, and perceived that these feelings would affect weight. A better understanding of these mechanisms is important for developing policies and programs to support women in the workplace and also reducing maternal and child overweight in Guatemala.

The main objective of this study was to evaluate the impact of a community‐based nutrition intervention using a fortified corn and soy premix on the reduction of anemia and improvement in hemoglobin concentrations in 6 to 76 month old children that live in Santa Cruz Muluá, a rural community in Retalhuleu, Guatemala. The children were provided a daily serving of an atole, Chispuditos®, fortified with 21 vitamins and minerals containing 12 mg iron via iron glycinate, 0.5 mg pyridoxine, 160 mg folic acid, 0.9 mcg vitamin B12, and 40 mg vitamin C. Children were screened and invited to participate in the nutrition program if they had height‐for‐age Z score (HAZ) <‐1SD and if parents agreed to participate and signed an informed consent. A total of 588 children were identified and received a daily portion of 18.75g of dry product that was mixed with either milk or water and consumed as a beverage. Hemoglobin concentrations were determined prior to and after 6 months of receiving the nutritional intervention. At baseline, close to half of the children suffered from anemia (43.3%), and after 6 months the prevalence of anemia decreased to 36.7%, p<0.001. Furthermore, mean hemoglobin concentrations significantly improved from 10.8 g/dL to 11.4g/dL, p<0.001. A mild but non‐significant improvement was observed in mean HAZ (−2.38 to −2.31SD, p=0.293) and mean weight‐for‐height Z scores (−0.10 to −0.07, p=0.680). Chispuditos, a well‐accepted and culturally appropriate method of providing micronutrients to children at risk of developing micronutrient deficiencies in this community in Retalhuleu, Guatemala, has proven effective in reducing anemia and improving hemoglobin concentrations in this population within 6 months. Support or Funding Information This project is sponsored by The Mathile Institute for the Advancement of Human Nutrition

A community‐based feeding study was undertaken in Retalhuleu among 939 malnourished 6‐72 mo old children (HAZ <‐1). Children resided in 18 villages in an impoverished region of southwest Guatemala. Children were randomly assigned to two groups to compare effects of two nutritional interventions on growth and micronutrient status. Group A (n=667) children received 18.75 g of Chispuditos®, a corn/soy atole fortified with 21 vitamins and minerals (delivering 12.5 mg of iron and 9 mg of zinc per day). Group B (n=272) children received an equivalent portion by weight of lactose free milk (diets were isocaloric and isonitrogenous). At the conclusion of 12 mo, the average HAZ score of Group A children increased 12.0% from ‐2.76 to ‐2.43 (p<.01) and by 7.3%, from ‐2.87 to ‐2.66 (p<0.01) in Group B. Children from both dietary groups exhibited improvements in linear growth, with Group A having a greater increase in HAZ than Group B (p=0.01). Formative research conducted with the micronutrient‐fortified corn/soy atole revealed the product was well accepted by both primary caretakers and children. During the study time period Chispuditos was one‐third the cost of lactose free milk and provided a greater linear growth benefit. In conclusion, Chispuditos® is a culturally accepted, fortified atole that improves the health and nutritional status of children from 6‐72 mo of age in a more cost‐efficient manner compared to milk powder. Grant Funding Source : The Mathile Institute for the Advancement of Human Nutrition®

Feeding pattern and dietary diversity was evaluated in 339 stunted children (HAZ < ‐1) 6‐36 mo of age from Retalhuleu using a food frequency questionnaire (Food and Nutrition Technical Assistance protocol). Dietary assessment was utilized to determine the frequency of food consumption for 7 consecutive days and was considered adequate if the food was included a minimum of 3x/wk in 75% of the population. Results indicated breast milk consumption was not adequate; 73% of children 0‐6 mo were breastfed at least 3x/wk and consumption decreased to 61% in children 19‐24 mo. The primary source of vitamin A was fortified sugar resulting in 88‐96% of the age groups having adequate vitamin A consumption patterns; vegetables rich in vitamin A were not consumed (0%). Meat and poultry had adequate consumption in the 25‐30 mo age group (80%), while younger children had intakes less than 75%. Consumption of cereals and grains increased with age and adequate consumption averaged 84% for infants and 86% for children 25‐36 mo. Hen eggs were the most frequently consumed food item (97%) as were instant soups, bean broths and other liquids (84%). In conclusion, diet diversity is poor in infants and young children from Retalhuleu, Guatemala. Fortified sugar and hen eggs were the only items consumed adequately across all age groups. Opportunities exist to increase breast feeding and improve complimentary feeding practices.