Health and development from preconception to 20 years of age and human capital.

Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood.

Early life predictors of body composition trajectories from adolescence to mid-adulthood.

OBJECTIVES: Guatemala has experienced rapid increases in adult obesity. We characterized body composition trajectories from adolescence to mid-adulthood and determined the predictive role of parental characteristics, early life factors, and a nutrition intervention. METHODS: One thousand three hundred and sixty-four individuals who participated as children in a nutrition trial (1969-1977) were followed prospectively. Body composition characterized as body mass index (BMI), fat mass index (FMI), and fat-free mass indices (FFMI), was available at four ages between 10 and 55 years. We applied latent class growth analysis to derive sex-specific body composition trajectories. We estimated associations between parental (age, height, schooling) and self-characteristics (birth order, socioeconomic status, schooling, and exposure to a nutrition supplement) with body composition trajectories. RESULTS: In women, we identified two latent classes of FMI (low: 79.6%; high: 20.4%) and BMI (low: 73.0%; high: 27.0%), and three of FFMI (low: 20.2%; middle: 55.9%; high: 23.9%). In men, we identified two latent classes of FMI (low: 79.6%; high: 20.4%) and FFMI (low: 62.4%; high: 37.6%), and three of BMI (low: 43.1%; middle: 46.9%; high: 10.0%). Among women, self's schooling attainment inversely predicted FMI (OR [being in a high latent class]: 0.91, 95% CI: 0.85, 0.97), and maternal schooling positively predicted FFMI (OR: 1.16, 95% CI: 0.97, 1.39). Among men, maternal schooling, paternal age, and self's schooling attainment positively predicted FMI. Maternal schooling positively predicted FFMI, whereas maternal age and paternal schooling were inverse predictors. The nutrition intervention did not predict body composition class membership. CONCLUSIONS: Parents' age and schooling, and self's schooling attainment are small but significant predictors of adult body composition trajectories.

Unhealthy food advertising on Costa Rican and Guatemalan television: a comparative study.

This study aimed to exhaustively explore the characteristics of food advertising on TV in Guatemala and Costa Rica. The International Network for Food and Obesity Non-Communicable Diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) methodology was applied. In 2016, we recorded 1440 h of video among 10 TV channels. We used the Pan American Health Organization (PAHO) Nutrient Profile (NP) Model to identify 'critical nutrients', whose excessive consumption is associated with NCDs. We created a nutritional quality score (0 if the product did not exceed any critical nutrient, 1 if the product exceeded one and 2 if it exceeded ≥2). We classified food ads as permitted (score = 0) and not-permitted (score 1 or 2) for marketing. Persuasive marketing techniques were classified as promotional characters (e.g. Batman), premium offers (e.g. toys), brand benefit claims (e.g. tasty) and health-related claims (e.g. nutritious). In Guatemala, foods that exceeded one critical nutrient were more likely to use persuasive marketing techniques, and in Costa Rica were those with an excess of ≥2 critical nutrients, compared with foods without any excess in critical nutrients [Guatemala: promotional characters (odds ratio, OR = 16.6, 95% confidence interval, CI: 5.8, 47.3), premium offers (OR = 3.4, 95% CI: 1.4, 8.2) and health-related claims (OR = 3.5, 95% CI: 2.2, 5.7); Costa Rica: health-related claims (OR = 4.2, 95% CI: 2.0, 8.5)]. In conclusion, Guatemalan and Costa Rican children are exposed to an overabundance of not-permitted food ads on TV. This justifies implementing national policies to reduce exposure to not-permitted food for marketing, including on TV and other media.

This study aimed to exhaustively explore the characteristics of food advertising on TV in Guatemala and Costa Rica. In 2016, we recorded 1440 h of video among 10 TV channels. We used the PAHO Nutrient Profile Model to identify 'critical nutrients' (e.g. sodium) whose excessive consumption is associated with Non-Communicable Chronic Diseases (e.g. hypertension). We created a nutritional quality score (0 if the product did not exceed any critical nutrient, 1 if the product exceeded one and 2 if it exceeded ≥2). We classified food ads as permitted (score = 0) and not-permitted (score 1 or 2) for marketing. Persuasive marketing techniques were classified as promotional characters, premium offers, brand benefit claims and health-related claims. In Guatemala, foods that exceeded one critical nutrient had a high probability of using promotional characters, premium offers and health-related claims than foods without any excess in critical nutrients. However, in Costa Rica health-related claims had a high probability of appearing with foods that exceeded ≥2 critical nutrients. In conclusion, Guatemalan and Costa Rican children are exposed to an overabundance of not-permitted food ads on TV. This justifies implementing national policies to reduce exposure to not-permitted food for marketing.

Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala.

BACKGROUND: The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. OBJECTIVES: To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. METHODS: Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0-7 y; life course, outcome data from 2017-2018 follow-up, ages 40-57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self-Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. RESULTS: Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. CONCLUSIONS: Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status.

Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala.

BACKGROUND: The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. OBJECTIVES: To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. METHODS: Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0-7 y; life course, outcome data from 2017-2018 follow-up, ages 40-57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self-Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. RESULTS: Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. CONCLUSIONS: Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status.

Age at childbirth and change in BMI across the life-course: evidence from the INCAP Longitudinal Study.

BACKGROUND: Parity has been associated with both short- and long-term weight gain in women. However, it is not clear if timing of parity across the reproductive age has different associations with BMI. METHODS: To prospectively assess the association between age at childbirth and maternal change in BMI, we analyzed data from the ongoing INCAP Longitudinal Study, which started in 1969 in four villages in Guatemala. Cohort women (n=778) provided information on reproductive history and anthropometric measures were measured in 1988-89 (adolescence, 15 to 25y), 2002-04 (early adulthood, 26 to 36y) and 2015-17 (mid adulthood, 37 to 55y). We evaluated the associations of number of live births in the period preceding each study wave (1969-77 to 1988-89, 1988-89 to 2002-04 and 2002-04 to 2015-17) with BMI change in the same period using multivariable linear regression models. RESULTS: Number of live births between 1988 and 89 and 2002-04 was positively associated with increased BMI, while there was not an association between number of live births and BMI in the other intervals. Women who had one, two, or three or more children between 1988 and 89 and 2002-04 had 0.90 (kg/m2, 95% CI: -0.55, 2.35), 2.39 (kg/m2, 95% CI: 1.09, 3.70) and 2.54 (kg/m2, 95% CI: 1.26, 3.82) higher BMI, respectively, than women who did not give birth in the same period. CONCLUSIONS: Our findings suggest that women who had three or more children during early adulthood gained more weight compared to women who had no children in the same period. In contrast, women who had children earlier or later in their reproductive lives did not gain additional weight compared to those who did not have children during that period. Childbirth may have different associations with BMI based on the mother's age.

Leukocyte telomere length is inversely associated with a metabolic risk score in Mesoamerican children.

OBJECTIVE: Leukocyte telomere length (LTL) may be involved in the etiology of the metabolic syndrome (MetS). We examined the associations of LTL with MetS and its components among Mesoamerican children and their adult parents, in a region where MetS prevalence is high. METHODS: We conducted a cross-sectional study of 151 children aged 7-12 years and 346 parents from the capitals of Belize, Honduras, Nicaragua, Costa Rica, Panama, and Chiapas State, Mexico. We quantified LTL by qPCR on DNA extracted from whole blood. In children, we created an age- and sex-standardized metabolic risk score using waist circumference (WC), the homeostasis model of insulin resistance (HOMA-IR), blood pressure, serum high-density lipoprotein (HDL) cholesterol, and serum triglycerides. In adults, MetS was defined according to the National Cholesterol Education Program's Adult Treatment Panel III definition. We estimated mean differences in metabolic risk score and prevalence ratios of MetS across quartiles of LTL using multivariable-adjusted linear and Poisson regression models, respectively. RESULTS: In children, every 1 LTL z-score was related to an adjusted 0.05 units lower (95% CI: -0.09, -0.02, P = 0.005) MetS risk score, through WC, HOMA-IR, and HDL. Among adults, LTL was not associated with MetS prevalence; however, every 1 LTL z-score was associated with an adjusted 34% lower prevalence of high fasting glucose (95% CI: 3%, 55%, p = .03). CONCLUSIONS: Among Mesoamerican children, LTL is associated with an improved metabolic profile; among adults, LTL is inversely associated with the prevalence of high fasting glucose.

Two countries, similar practices: the political practices of the food industry influencing the adoption of key public health nutrition policies in Guatemala and Panama.

OBJECTIVE: To identify the corporate political activity (CPA) strategies used by food industry actors during the development of two public health nutrition policies in Central America: Law #570 (taxation of sugar-sweetened beverages) in Panama and Bill #5504 (labelling and food marketing regulations) in Guatemala. DESIGN: We triangulated data from publicly available information from 2018 to 2020, (e.g. industry and government materials; social media material) with semi-structured interviews with key stakeholders. SETTING: Guatemala and Panama. PARTICIPANTS: Government, academia and international organisations workers in health and nutrition. DESIGN: CPA strategies were categorised according to an existing internationally used taxonomy into action-based, instrumental strategies (coalition management, information management, direct involvement and influence in policy, legal action) and discursive strategies. RESULTS: Instrumental strategies included the establishment of relationships with policymakers and direct lobbying against the proposed public policies. Discursive strategies were mainly criticising on the unfounded ground that they lacked evidence of effectiveness and will imply negative impacts on the economy. The industry pointed at individuals for making their own food choices, in order to shift the focus away from the role of its products in contributing to ill health. CONCLUSION: We provide evidence of the political practices used by the food industry to interfere with the development and implementation of public health nutrition policies to improve diets in Central America. Policymakers, public health advocates and the public should be informed about those practices and develop counterstrategies and arguments to protect the public and policies from the vested interests of the food industry.

Explanatory models of hypertension in Guatemala: recognizing the perspectives of patients, family members, health care providers and administrators, and national-level health system stakeholders.

BACKGROUND: Uncontrolled hypertension is a major public health burden and the most common preventable risk factor for cardiovascular diseases in Guatemala and other low- and middle-income countries. Prior to an initial trial that evaluated a hypertension intervention in rural Guatemala, we collected qualitative information on the needs and knowledge gaps of hypertension care within Guatemala's public healthcare system. This analysis applied Kleinman's Explanatory Models of Illness to capture how patients, family members, community-, district-, and provincial-level health care providers and administrators, and national-level health system stakeholders understand hypertension.  METHODS: We conducted in-depth interviews with three types of participants: 1) national-level health system stakeholders (n = 17), 2) local health providers and administrators from district, and health post levels (25), and 3) patients and family members (19) in the departments of Sololá and Zacapa in Guatemala. All interviews were conducted in Spanish except for 6 Maya-Kaqchikel interviews. We also conducted focus group discussions with auxiliary nurses (3) and patients (3), one in Maya-Tz'utujil and the rest in Spanish. Through framework and matrix analysis, we compared understandings of hypertension by participant type using the Explanatory Model of Illness domains -etiology, symptoms, pathophysiology, course of illness, and treatment. RESULTS: Health providers and administrators, and patients described hypertension as an illness that spurs from emotional states like sadness, anger, and worry; is inherited and related to advanced age; and produces symptoms that include a weakened body, nerves, pain, and headaches. Patients expressed concerns about hypertension treatment's long-term consequences, despite trying to comply with treatment. Patients stated that they combine biomedical treatment (when available) with natural remedies (teas and plants). Health providers and administrators and family members stated that once patients feel better, they often disengage from treatment. National-level health system stakeholders referred to lifestyle factors as important causes, considered patients to typically be non-compliant, and identified budget limitations as a key barrier to hypertension care. The three groups of participants identified structural barriers to limited hypertension care (e.g., limited access to healthy food and unaffordability of medications). CONCLUSION: As understandings of hypertension vary between types of participants, it is important to describe their similarities and differences considering the role each has in the health system. Considering different perceptions of hypertension will enable better informed program planning and implementation efforts.

Early-Life Nutrition and Subsequent International Migration: A Prospective Study in Rural Guatemala.

BACKGROUND: It is generally accepted that migrants are favorably self-selected for labor market skills such as higher schooling and greater cognitive capacity, which are highly correlated with early-life nutrition. However, the influence of early-life nutrition on later-life migration is understudied. OBJECTIVE: The objective of this study was to examine prospectively the association between height-for-age z scores (HAZ) at 24 mo and subsequent international migration in a cohort of 2392 participants born between 1962 and 1977 in 4 rural villages in eastern Guatemala. METHODS: Information on nutritional status and covariates was collected between 1969 and 1977 and migration status was determined as of 2017 (at ages 40-57 y). We used proportional hazards and logistic regression models to assess whether HAZ was associated with international migration, adjusting for early-life and adult characteristics. RESULTS: Between 1978 and 2017 there were 297 international migrants (12.4% of the original cohort) during 99,212 person-y of follow-up. In pooled models that were adjusted for early-life characteristics, a 1-SD increase in HAZ was associated with a 19% increase in the risk of international migration (HR: 1.19; 95% CI: 1.02, 1.38). Further adjustment for village characteristics did not alter the estimate substantively (HR: 1.18; 95% CI: 1.02, 1.37), while additional adjustment for schooling attainment attenuated the estimate somewhat (HR: 1.14; 95% CI: 0.98, 1.33). In all models, effect sizes were stronger for men than for women. CONCLUSIONS: Our results indicate that early-life nutrition is positively associated with subsequent international migration.

Metabolomic Profiling Demonstrates Postprandial Changes in Fatty Acids and Glycerophospholipids Are Associated with Fasting Inflammation in Guatemalan Adults.

BACKGROUND: Metabolic flexibility is the responsiveness to heterogeneous physiological conditions, such as food ingestion. A key unresolved question is how inflammation affects metabolic flexibility. OBJECTIVES: Our study objective was to compare metabolic flexibility, specifically the metabolomic response to a standardized meal, by fasting inflammation status. METHODS: Participants in Guatemala (n = 302, median age 44 y, 43.7% men) received a standardized, mixed-macronutrient liquid meal. Plasma samples (fasting, 2 h postmeal) were assayed by dual-column LC [reverse phase (C18) and hydrophilic interaction LC (HILIC)] with ultra-high-resolution MS, for concentrations of 6 inflammation biomarkers: high-sensitivity C-reactive protein (hsCRP), leptin, resistin, IL-10, adiponectin, and soluble TNF receptor II (TNFsR). We summed the individual inflammation biomarker z-scores, after reverse-coding of anti-inflammation biomarkers. We identified features with peak areas that differed between fasting and postmeal (false discovery rate-adjusted q <0.05) and compared median log2 postprandial/fasting peak area ratios by inflammation indicators. RESULTS: We found 1397 C18 and 974 HILIC features with significant postprandial/fasting feature ratios (q <0.05). Overall inflammation z-score was directly associated with the postprandial/fasting feature ratios of arachidic acid, and inversely associated with the feature ratio of lysophosphatidic acid (LPA), adjusting for age and sex (all P < 0.05). The postprandial/fasting ratio of arachidic acid was negatively correlated with resistin, IL-10, adiponectin, and TNFsR concentrations (all P < 0.05). Feature ratios of several fatty acids-myristic acid [m/z 227.2018, retention time (RT) 229], heptadecanoic acid (m/z 269.2491, RT 276), linoleic acid (m/z 280.2358, RT 236)-were negatively correlated with fasting plasma concentrations of leptin (nanograms per milliliter) and adiponectin (micrograms per milliliter), respectively (all P < 0.05). The postprandial/fasting ratio of LPA was positively correlated with IL-10 and adiponectin (both P < 0.05); and the ratio of phosphatidylinositol was positively correlated with hsCRP (P < 0.05). CONCLUSIONS: Postprandial responses of fatty acids and glycerophospholipids are associated with fasting inflammation status in adults in Guatemala.

Linear Growth Trajectories in Early Childhood and Adult Cognitive and Socioemotional Functioning in a Guatemalan Cohort.

BACKGROUND: Growth faltering in early childhood is associated with poor human capital attainment, but associations of linear growth in childhood with executive and socioemotional functioning in adulthood are understudied. OBJECTIVES: In a Guatemalan cohort, we identified distinct trajectories of linear growth in early childhood, assessed their predictors, and examined associations between growth trajectories and neurodevelopmental outcomes in adulthood. We also assessed the mediating role of schooling on the association of growth trajectories with adult cognitive outcomes. METHODS: In 2017-2019, we prospectively followed 1499 Guatemalan adults who participated in a food supplementation trial in early childhood (1969-1977). We derived height-for-age sex-specific growth trajectories from birth to 84 mo using latent class growth analysis. RESULTS: We identified 3 growth trajectories (low, intermediate, high) with parallel slopes and intercepts already differentiated at birth in both sexes. Children of taller mothers were more likely to belong to the high and intermediate trajectories [relative risk ratio (RRR): 1.21; 95% CI: 1.15, 1.26, and RRR: 1.11; 95% CI: 1.07, 1.15, per 1-cm increase in height, respectively] compared with the low trajectory. Children in the wealthiest compared with the poorest socioeconomic tertile were more likely to belong to the high trajectory compared with the low trajectory (RRR: 2.24; 95% CI: 1.29, 3.88). In males, membership in the high compared with low trajectory was positively associated with nonverbal fluid intelligence, working memory, inhibitory control, and cognitive flexibility at ages 40-57 y. Sex-adjusted results showed that membership in the high compared with low trajectory was positively associated with meaning and purpose scores at ages 40-57 y. Associations of intermediate compared with low growth trajectories with study outcomes were also positive but of lesser magnitude. Schooling partially mediated the associations between high and intermediate growth trajectories and measures of cognitive ability in adulthood. CONCLUSIONS: Modifiable and nonmodifiable risk factors predicted growth throughout childhood. Membership in the high and intermediate growth trajectories was positively associated with adult cognitive and socioemotional functioning.

Excess Mortality During the COVID-19 Pandemic in Guatemala.

Objectives. To describe excess mortality during the COVID-19 pandemic in Guatemala during 2020 by week, age, sex, and place of death. Methods. We used mortality data from 2015 to 2020, gathered through the vital registration system of Guatemala. We calculated weekly mortality rates, overall and stratified by age, sex, and place of death. We fitted a generalized additive model to calculate excess deaths, adjusting for seasonality and secular trends and compared excess deaths to the official COVID-19 mortality count. Results. We found an initial decline of 26% in mortality rates during the first weeks of the pandemic in 2020, compared with 2015 to 2019. These declines were sustained through October 2020 for the population younger than 20 years and for deaths in public spaces and returned to normal from July onward in the population aged 20 to 39 years. We found a peak of 73% excess mortality in mid-July, especially in the population aged 40 years or older. We estimated a total of 8036 excess deaths (95% confidence interval = 7935, 8137) in 2020, 46% higher than the official COVID-19 mortality count. Conclusions. The extent of this health crisis is underestimated when COVID-19 confirmed death counts are used. (Am J Public Health. 2021;111(10): 1839-1846. https://doi.org/10.2105/AJPH.2021.306452).

Development of a temporally harmonized asset index: evidence from across 50 years of follow up of a birth cohort in Guatemala.

BACKGROUND: Asset-based indices are widely-used proxy measures of wealth in low and middle-income countries (LMIC). The stability of these indices within households over time is not known. METHODS: We develop a harmonized household asset index using Principal Component Analysis for the participants (n = 2392) of INCAP Longitudinal Study, Guatemala using data from six waves of follow-up over the period of 1965-2018. We estimate its cross-sectional association with parental schooling (in 1967-75) and attained schooling (in 2015-18) of cohort members. We study how patterns of cross-sectional loadings change over time and between urban-rural settings. We assess its robustness to omission of assets or study waves and alternate specifications of factor extraction procedure (exploratory factor analysis, multiple correspondence analysis). RESULTS: The harmonized index constructed using 8 assets and 11 housing characteristics explained 32.4% of the variance. Most households increased in absolute wealth over time with median wealth (25th percentile, 75th percentile; households) increasing from - 3.74 (- 4.42, - 3.07; 547) in 1967 to 2.08 (1.41, 2.67; 1145) in 2017-18. Ownership of television, electricity, quality of flooring and sanitary installation explained the largest proportion of variance. The index is positively associated with measures of schooling (maternal: r = 0.16; paternal: r = 0.10; attained: r = 0.35, all p < 0.001). In 2015-18, house ownership versus housing characteristics and ownership of electronic goods differentiate households in urban and rural areas respectively. The index is robust for omission of assets or study waves, indicator categorization and factor extraction method. CONCLUSION: A temporally harmonized asset index constructed from consistently administered surveys in a cohort setting over time may allow study of associations of life-course social mobility with human capital outcomes in LMIC contexts. The approach permits exploration of trends in household wealth of the sample over a follow-up period against repeated cross-sectional surveys which permit the estimation of only the mean trajectory.

Postprandial glycemic response differed by early life nutritional exposure in a longitudinal cohort: a single- and multi-biomarker approach.

PURPOSE: Populations malnourished in early life are at increased risk for cardiometabolic diseases. We assessed if improved nutrition predicts cardiometabolic function, as assessed by postprandial biomarker responses. METHODS: Participants had been randomized at the village level to receive one of two nutritional supplements as children. At mean age 44 y (range 37-53 years), we obtained plasma samples before and 2 h after a mixed-component meal challenge. We assayed biomarkers including lipids, glycemic measurements, and inflammatory cytokines. We compared postprandial biomarker responses among those who received the improved nutrition intervention from conception through to their second birthday (the first 1000 days) to those with other exposure status, including those who received the improved nutrition intervention at other ages, and those who received the less nutritious supplement. RESULTS: Among 1027 participants (59.4% female), 22.9% were exposed to improved nutrition in the first 1000 days. Insulin increased the most in response to the meal challenge (over twofold), and non-esterified fatty acids decreased the most (by half). Glucose increased postprandial by 11.4% in the exposed group, compared with 15.7% in the other exposure group (p < 0.05), which remained significant after adjusting for confounders (- 4.7%; 95% confidence interval: - 9.3%, - 0.01%). Responses to the prandial challenges for the other biomarkers did not differ by intervention group (all p > 0.05). CONCLUSION: Early life exposure to improved nutrition was associated with a more favorable postprandial glucose response in this population. We did not observe a difference in overall cardiometabolic responses between the exposure groups.

B-vitamins and metabolic syndrome in Mesoamerican children and their adult parents.

OBJECTIVE: To examine the associations between vitamins of the methionine-homocysteine (Hcys) cycle (B6, B12 and folate) and Hcys with metabolic syndrome (MetS) among Mesoamerican children and their adult parents. DESIGN: We conducted a cross-sectional study. Exposures were plasma vitamins B6 and B12 concentrations, erythrocyte folate and plasma Hcys. In children, the outcome was a continuous metabolic risk score calculated through sex- and age standardisation of waist circumference, the homoeostatic model assessment for insulin resistance, mean arterial pressure (MAP), serum HDL-cholesterol and serum TAG. In parents, the outcome was the prevalence of MetS according to the Adult Treatment Panel III Criteria. We estimated mean differences in the metabolic risk score and prevalence ratios of MetS between quartiles of the exposures using multivariable-adjusted linear and Poisson regression models, respectively. SETTING: Capital cities of Belize, Guatemala, El Salvador, the Dominican Republic, Honduras, Nicaragua, Panama, Costa Rica and Chiapas State in Mexico. PARTICIPANTS: In total, 237 school-aged children and 524 parents. RESULTS: Among children, vitamin B12 was inversely associated with the metabolic risk score (quartiles 4-1 adjusted difference = -0·13; 95 % CI: -0·21, -0·04; Ptrend = 0·008) through MAP, HDL-cholesterol and TAG. In contrast, folate was positively associated with the metabolic risk score (quartiles 4-1 adjusted difference = 0·11; 95 % CI: 0·01, 0·20; Ptrend = 0·02). In adults, vitamin B6 was inversely associated with MetS prevalence, whereas vitamin B12 and folate were positively related to this outcome. CONCLUSIONS: Vitamins of the methionine-Hcys cycle are associated with MetS in different directions. The associations differ between children and adults.

Educational inequalities in obesity: a multilevel analysis of survey data from cities in Latin America.

OBJECTIVE: Using newly harmonised individual-level data on health and socio-economic environments in Latin American cities (from the Salud Urbana en América Latina (SALURBAL) study), we assessed the association between obesity and education levels and explored potential effect modification of this association by city-level socio-economic development. DESIGN: This cross-sectional study used survey data collected between 2002 and 2017. Absolute and relative educational inequalities in obesity (BMI ≥ 30 kg/m2, derived from measured weight and height) were calculated first. Then, a two-level mixed-effects logistic regression was run to test for effect modification of the education-obesity association by city-level socio-economic development. All analyses were stratified by sex. SETTING: One hundred seventy-six Latin American cities within eight countries (Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico and Peru). PARTICIPANTS: 53 186 adults aged >18 years old. RESULTS: Among women, 25 % were living with obesity and obesity was negatively associated with educational level (higher education-lower obesity) and this pattern was consistent across city-level socio-economic development. Among men, 18 % were living with obesity and there was a positive association between education and obesity (higher education-higher obesity) for men living in cities with lower levels of development, whereas for those living in cities with higher levels of development, the pattern was inverted and university education was protective of obesity. CONCLUSIONS: Among women, education was protective of obesity regardless, whereas among men, it was only protective in cities with higher levels of development. These divergent results suggest the need for sex- and city-specific interventions to reduce obesity prevalence and inequalities.

Hypertension in Guatemala's Public Primary Care System: A Needs Assessment Using the Health System Building Blocks Framework.

BACKGROUND: Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system. METHODS: We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala's public system using the World Health Organization's health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers. RESULTS: Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor. CONCLUSIONS: This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala's public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach.

Macronutrient, Energy, and Bile Acid Metabolism Pathways Altered Following a Physiological Meal Challenge, Relative to Fasting, among Guatemalan Adults.

BACKGROUND: The healthy human metabolome, including its physiological responses after meal consumption, remains incompletely understood. One major research gap is the limited literature assessing how human metabolomic profiles differ between fasting and postprandial states after physiological challenges. OBJECTIVES: Our study objective was to evaluate alterations in high-resolution metabolomic profiles following a standardized meal challenge, relative to fasting, in Guatemalan adults. METHODS: We studied 123 Guatemalan adults without obesity, hypertension, diabetes, metabolic syndrome, or comorbidities. Every participant received a standardized meal challenge (520 kcal, 67.4 g carbohydrates, 24.3 g fat, 8.0 g protein) and provided blood samples while fasting and at 2 h postprandial. Plasma samples were assayed by high-resolution metabolomics with dual-column LC [C18 (negative electrospray ionization), hydrophilic interaction LC (HILIC, positive electrospray ionization)] coupled to ultra-high-resolution MS. Associations between metabolomic features and the meal challenge timepoint were assessed in feature-by-feature multivariable linear mixed regression models. Two algorithms (mummichog, gene set enrichment analysis) were used for pathway analysis, and P values were combined by the Fisher method. RESULTS: Among participants (62.6% male, median age 43.0 y), 1130 features (C18: 777; HILIC: 353) differed between fasting and postprandial states (all false discovery rate-adjusted q < 0.05). Based on differing C18 features, top pathways included: tricarboxylic acid cycle (TCA), primary bile acid biosynthesis, and linoleic acid metabolism (all Pcombined < 0.05). Mass spectral features included: taurine and cholic acid in primary bile acid biosynthesis; and fumaric acid, malic acid, and citric acid in the TCA. HILIC features that differed in the meal challenge reflected linoleic acid metabolism (Pcombined < 0.05). CONCLUSIONS: Energy, macronutrient, and bile acid metabolism pathways were responsive to a standardized meal challenge in adults without cardiometabolic diseases. Our findings reflect metabolic flexibility in disease-free individuals.

Associations between Helicobacter pylori with nonalcoholic fatty liver disease and other metabolic conditions in Guatemala.

BACKGROUND: Previous studies have suggested an association between Helicobacter pylori (H pylori) and nonalcoholic fatty liver disease (NAFLD). The aim of the current study was to examine the association in Guatemala, a region with elevated prevalences of both H pylori and NAFLD. Associations between H pylori and other metabolic conditions were also examined, as were associations between H hepaticus and H bilis and the metabolic conditions. MATERIALS & METHODS: The analysis included 424 participants from a cross-sectional study in Guatemala. H pylori seropositivity was defined as positivity for ≥ 4 antigens. Seropositivities for H bilis and H hepaticus were defined as positivity for ≥ 2 antigens. NAFLD was estimated using the Fatty Liver Index and the Hepatic Steatosis Index. Other conditions examined were obesity, central obesity, hypercholesterolemia, low HDL, diabetes and metabolic syndrome (MetSyn). Prevalence odds ratios (POR) and 95% confidence intervals (CIs) were estimated. RESULTS: No overall associations between H pylori,H hepaticus, or H bilis and NAFLD or related metabolic conditions were found. Seropositivity for H pylori antigens CagA and VacA and H hepaticus antigen HH0713 was each significantly associated with NAFLD, however. In addition, associations were observed between the H pylori antigens HyuA, HP1564, and UreA and specified metabolic conditions. CONCLUSIONS: While no overall associations between H pylori or Helicobacter species with NAFLD or related conditions were observed, some selected Helicobacter spp. antigens were associated with NAFLD. Further research is warranted to examine whether H. species are associated with any metabolic condition.