Etiquetado frontal de advertencia nutricional de alimentos y bebidas pre-envasados. Postura intersectorial de expertos en Centro América y República Dominicana / Front-of-package warning labelling system for pre-packaged foods and beverages: an intersectoral position of expertsin Central American and Dominican Republic

La región latinoamericana ha sido pionera en la implementación del etiquetado frontal de advertencia nutricional (EFAN), mismo que ha demostrado su eficacia y efectividad para identificar correctamente cuando un producto contiene cantidades excesivas de nutrientes asociados a Enfermedades no transmisibles (ENT). Sin embargo, ningún país del Sistema de la Integración Centroamericana (SICA); que incluye a Belice, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panamá y República Dominicana, lo ha adoptado. Por esta razón, el Instituto de Nutrición de Centro América y Panamá, convocó a un grupo de expertos de la academia y la sociedad civil con el objetivo de establecer una postura técnica, basada en la mejor evidencia científica, en relación al etiquetado frontal para los nutrientes críticos de alimentos y bebidas pre- envasados en la región centroamericana. Se presenta evidencia específica de la región del SICA que demuestran la superioridad del EFAN frente a otros etiquetados como las Guías Diarias de Alimentación (GDA), el semáforo y el Nutriscore para seleccionar opciones más saludables. Dentro del marco de los derechos de la niñez y de los consumidores, se brindan argumentos y se hace un llamado a los gobiernos para la pronta adopción del EFAN como una política costo-efectiva para la prevención de ENT. Además, se proveen recomendaciones para su monitoreo y evaluación, así como recomendaciones de otras políticas costo-efectivas como la regulación de la publicidad de alimentos no saludables dirigido a la niñez y adolescencia, entre otros, para la prevención de las ENT y la creación de ambientes y sistemas alimentarios más saludables y sostenibles(AU)

The Latin American region has been a pioneer in the implementation of a front- of-pack warning labeling system (FOPWL), which has demonstrated its efficacy and effectiveness in correctly identifying when a product contains excessive amounts of nutrients associated with Non-Communicable Diseases (NCDs). However, countries of the Central American Integration System (SICA); which includes Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the Dominican Republic, have no adopted it. For this reason, the Institute of Nutrition of Central America and Panama convened a group of experts from academia and civil society with the aim of establishing an evidence-based technical position, in relation to front-of-pack labelling for critical nutrients of pre-packaged foods and beverages in the Central American region. Specific evidence from the SICA region demonstrating the superiority of FOPWL over other labels such as the Guideline Daily Amount (GDA), the traffic light and Nutriscore to select healthier choices is presented. Within the framework of children's and consumer rights, arguments are provided, and a call is made to governments for the prompt adoption of FOPWL as a cost-effective policy for the prevention of NCDs. In addition, recommendations for its monitoring and evaluation are provided, as well as recommendations for other cost-effective policies such as the regulation of unhealthy food advertising aimed at children and adolescents, among others, for the prevention of NCDs and the creation ofhealthier and more sustainable environments and food systems(AU)

Ultraprocessed Products as Food Fortification Alternatives: A Critical Appraisal from Latin America.

Ultraprocessed products (UPPs), associated with obesity and non-communicable diseases (NCDs), are becoming predominant on the global market and a target for market-driven fortification initiatives. The aim of this article is to describe the implications of adding micronutrients to UPPs with excessive amounts of critical nutrients associated with NCDs and provide recommendations for legislation and policies. UPPs with added micronutrients such as breakfast cereals, sugar-sweetened beverages, powder beverages, fruit juices, sauces, and bouillon cubes, among others, are commonly available and heavily promoted in Latin American countries. Misleading advertising of UPPs with added micronutrients and with excessive content of sugar, fat, and salt might increase the consumption of such products, giving them a "health halo effect" that leads consumers to overestimate their nutritional quality and healthfulness. Although international collections of standards such as the Codex Alimentarius provide some guidelines on this matter, countries need to implement national legislations, through a food systems approach, to regulate the marketing and labeling of UPPs. Lastly, there is still the need to foster research to close knowledge gaps and help countries to guide the process of food fortification strategies from a regulatory standpoint.

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.

Cognitive and socio-emotional correlates of psychological well-being and mental health in Guatemalan adults.

BACKGROUND: Little is known about associations of psychological and mental well-being with cognitive and socioemotional factors in low and middle-income countries, particularly among vulnerable populations born in adverse environments that may restrict developmental potential. This study aimed to examine the cognitive and socioemotional correlates of psychological well-being and mental health in a cohort of Guatemalan adults born in contexts of poverty and malnutrition. METHODS: From Dec 2017 to Apr 2019, data were collected from 704 women and 564 men ages 40-57 years living in four rural villages in eastern Guatemala and Guatemala City. We measured latent domains of psychological well-being, spirituality and religion, emotional support, and executive function using Confirmatory Factor Analysis (CFA). Under a Structural Equation Modeling framework, we examined intercorrelations among latent domains and observed measures of intelligence and mental health. RESULTS: CFA supported the construct validity of factor structures in this population. Correlations of psychological well-being with spirituality and religion were moderate in women (r = 0.68, p < 0.001) and men (r = 0.70, p < 0.001). Executive function was weakly correlated with psychological well-being in men (r = 0.23, p < 0.001) and showed no association in women. Correlations of psychological well-being with emotional support and IQ were weak in women (r = 0.34, and r = 0.15, respectively; p < 0.001 for both) and men (r = 0.35, and r = 0.25, respectively; p < 0.001 for both). Mental health and IQ were weakly correlated in men (r = 0.09, p < 0.05) and showed no association in women. Mental health showed weak correlations with emotional support (r = 0.18, p < 0.001 in women; r = 0.09, p < 0.05 in men), psychological well-being (r = 0.32 and r = 0.35, in women and men respectively; p < 0.001 for both) and showed no association with executive function in both sexes. CONCLUSIONS: Of all examined factors, spirituality and religion made the greatest contribution to psychological well-being. These findings support the notion that in populations experiencing difficult circumstances, religion can perhaps make a greater contribution to well-being and aid coping. More research is needed to examine mediators of this association.

Influence of enhanced nutrition and psychosocial stimulation in early childhood on cognitive functioning and psychological well-being in Guatemalan adults.

RATIONALE: Early-life nutrition interventions in low and middle-income countries have demonstrated long-term benefits on cognitive skills, however, their influence on socioemotional outcomes has not been fully explored. Moreover, the mediating processes through which nutrition intervention effects operate and are maintained over time are understudied. METHODS: We followed-up a cohort of Guatemalan adults who participated as children in a community randomized food-supplementation trial. We examined associations of exposure to nutritional supplementation from conception to age 2 years with executive function (measured using three sub-tests of the NIH Toolbox Cognition Battery) and psychological well-being (measured using two sub-scales of the NIH Toolbox Emotion Battery) at ages 40-57 years (n = 1268). We used structural equation modeling to investigate the mediating role of psychosocial stimulation (measured in childhood using parent reports and ratings of home environments), cognitive ability (measured at ages 26-42 years using standardized tests), and executive function on the association of early-life exposure to nutritional supplementation with adult psychological well-being (n = 1640). RESULTS: We found positive but inconsistent associations of nutritional supplementation in childhood with executive function and psychological well-being in adulthood. Psychosocial stimulation, cognitive ability, and executive function did not mediate the association of early-life nutritional supplementation with adult psychological well-being. We found strong and positive associations of psychosocial stimulation in childhood with cognitive ability, executive function, and psychological well-being in adulthood. Moreover, we observed no interaction of exposure to nutritional supplementation and psychosocial stimulation in childhood with cognitive and psychological well-being outcomes in adulthood. CONCLUSION: Our findings suggest that childhood nutrition interventions have long-lasting effects on cognitive ability and psychological well-being outcomes.

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.

Improved nutrition in early life and pulse wave velocity and augmentation index in mid-adulthood: Follow-up of the INCAP Nutrition Supplementation Trial Longitudinal Study.

Nutrition in pregnancy and early childhood affects later blood pressure and precursors of atherosclerosis, but its influence on arterial stiffness is unexplored. This study determines whether exposure to improved nutrition during early life influences Augmentation index (AI) and pulse wave velocity (PWV) in mid-adulthood. We included 1221 adults (37-54y) who participated in a cluster-randomized nutritional supplementation trial of a protein-energy beverage (Atole), conducted between 1969-1977 in Guatemala. The comparison group received Fresco, a low-calorie protein-free beverage. In 2015-17, we measured anthropometry (weight, height, and waist-to-height ratio); AI and PWV (using carotid-femoral tonometry); blood pressure; fasting plasma glucose and serum lipids; and sociodemographic characteristics. Based on patterns of exposure, we characterized participants as fully, partially or unexposed to the intervention from conception to their second birthday (the 'first 1000 days'). We fit pooled and sex-specific models using intention-to-treat, difference-in-difference regression analysis to test whether exposure to the supplement in the first 1000 days was associated with AI and PWV in adulthood adjusting for basal and current sociodemographic variables and current life-style and cardio-metabolic risk factors. Prevalence of obesity in men and women was 39.6% and 19.6%, and prevalence of hypertension was 44.0% and 36.0%, respectively. Women had higher AI (34.4±9.6%) compared to men (23.0± 9.8%), but had similar PWV (7.60±1.13 m/s and 7.60±1.31, respectively). AI did not differ significantly across intervention groups. PWV was lower in individuals with full exposure to the supplement during the first 1000 days (-0.39m/s, 95% CI -0.87, 0.09; p = 0.1) compared to unexposed individuals. This difference was similar after adjusting for cardio-metabolic risk factors (-0.45m/s; 95%C-0.93, 0.01; p = 0.06). Exposure to improved nutrition during the first 1000 days was marginally associated with lower PWV, but not with AI.

Leptin partially mediates the association between early-life nutritional supplementation and long-term glycemic status among women in a Guatemalan longitudinal cohort.

BACKGROUND: Early-life exposure to improved nutrition is associated with decreased risk of diabetes but increased risk of obesity. Leptin positively correlates with adiposity and has glucose-lowering effects, thus it may mediate the association of early-life nutrition and long-term glycemic status. OBJECTIVES: We aimed to investigate the role of leptin in the differential association between early-life nutrition and the risks of obesity and diabetes. METHODS: We analyzed data from a Guatemalan cohort who were randomly assigned at the village level to receive nutritional supplements as children. We conducted mediation analysis to examine the role of leptin in the associations of early-life nutrition and adult cardiometabolic outcomes. RESULTS: Among 1112 study participants aged (mean ± SD) 44.1 ± 4.2 y, 60.6% were women. Cardiometabolic conditions were common: 40.2% of women and 19.4% of men were obese, and 53.1% of women and 41.0% of men were hyperglycemic or diabetic. Median (IQR) leptin concentration was 15.2 ng/mL (10.2-17.3 ng/mL) in women and 2.7 ng/mL (1.3-5.3 ng/mL) in men. Leptin was positively correlated with BMI (Spearman's ρ was 0.6 in women, 0.7 in men). Women exposed to improved nutrition in early life had 2.8-ng/mL (95% CI: 0.3, 5.3 ng/mL) higher leptin and tended to have lower fasting glucose (-0.8 mmol/L; -1.8, 0.2 mmol/L, nonsignificant) than unexposed women. There were no significant differences in leptin (-0.7 ng/mL; -2.1, 0.8 ng/mL) or fasting glucose (0.2 mmol/L; -0.5, 0.9 mmol/L) in men exposed to improved nutrition in early life compared with unexposed men. Leptin mediated 34.9% of the pathway between early-life nutrition and fasting glucose in women. The mediation in women was driven by improved pancreatic ß-cell function. We did not observe the mediation effect in men. CONCLUSIONS: Leptin mediated the glucose-lowering effect of early-life nutrition in women but not in men.

Sociodemographic, Anthropometric, and Dietary Predictors of Polyunsaturated Fatty Acids in Adipose Tissue Among Mesoamerican Children and Their Parents.

BACKGROUND: Polyunsaturated fatty acid (PUFA) intake is low throughout Latin America. Improving PUFA status could be an effective intervention against chronic disease, but information on sociodemographic and dietary patterning of PUFA status in the region is limited. OBJECTIVE: To characterize sociodemographic, anthropometric, and dietary predictors of PUFA status biomarkers in adipose tissue among children and their parents from Mesoamerica. METHODS: This was a cross-sectional study of 220 children aged 7 to 12 years and 471 parents from capital cities of Guatemala, El Salvador, the Dominican Republic, Honduras, Nicaragua, Panama, Costa Rica, and Belize, as well as Tuxtla Gutiérrez in Mexico. The PUFA from gluteal adipose tissue was quantified using gas chromatography. Participants reported sociodemographic information and the type of vegetable oil used for cooking. We estimated percent mean differences in linoleic acid (LA), total long-chain n-6 PUFA (n-6 LCPUFA), α-linolenic acid (ALA), and total long-chain n-3 PUFA (n-3 LCPUFA) between levels of predictors using multivariable-adjusted linear regression models. RESULTS: Country was the strongest predictor of any PUFA, whereas body mass index was positively associated with n-6 LCPUFA in children and adults. Cooking primarily with soybean oil was positively associated with LA in children and adults and ALA in adults. Cooking with canola oil was positively related to n-6 LCPUFA in adults and n-3 LCPUFA in children and adults. Cooking with palm oil was associated with low adipose tissue levels of all n-6 and n-3 PUFA. CONCLUSIONS: Adipose tissue PUFA status in Mesoamerica is associated with country of origin and the type of oil used for cooking.

Exposure to improved nutrition from conception to age 2 years and adult cardiometabolic disease risk: a modelling study.

BACKGROUND: Low-income and middle-income countries with populations that are chronically undernourished in early life are undergoing a nutrition transition and are experiencing an epidemic of cardiometabolic disease. These dual burdens are thought to be causally related; therefore, the extent to which improvements in early-life nutrition can offset adult-onset disease is important. The aim of this study was to examine whether improvement of protein-energy nutrition from conception to age 2 years can attenuate the risk of cardiometabolic disease. METHODS: We followed up a cohort of 2392 individuals born between Jan 1, 1962, and Feb 28, 1977, in four villages in Guatemala who had participated in a cluster-randomised protein-energy nutritional supplementation (Atole) trial. Of 1661 participants available for follow-up from Feb 26, 2015, to April 29, 2017, we studied 684 women and 455 men. We assessed cardiometabolic disease risk at ages 37-54 years using anthropometry, fasting and post-challenge glucose, fasting lipid concentrations, and blood pressure. We used generalised linear and logistic regression modelling to estimate the effect of Atole from conception to age 2 years (the first 1000 days) on cardiometabolic disease risk. FINDINGS: Exposure to Atole from conception to age 2 years was associated with increased fatness (body-mass index [1·29 kg/m2, 95% CI 0·08 to 2·50], body fat [1·73%, 0·20 to 3·26], and obesity [odds ratio 1·94, 1·11 to 3·40]), diastolic blood pressure (1·59 mm Hg, -0·74 to 3·92), and blood lipids (total cholesterol [10·10 mg/dL, 0·80 to 19·40] and non-HDL cholesterol [10·41 mg/dL, 1·51 to 19·31]), reduced post-challenge glucose (-5·84 mg/dL, -12·51 to 0·83), and reduced odds of diabetes (odds ratio 0·46, 0·21 to 0·97). We found stratum heterogeneity by sex in pooled models for non-HDL cholesterol (4·34 mg/dL, 95% CI -6·86 to 15·55 for women vs 19·84 mg/dL, 5·86 to 33·82 for men) and post-challenge glucose (-0·19 mg/dL, -8·63 to 8·24 for women vs -13·10 mg/dL, -23·64 to -2·56 for men). p values for interaction of sex and exposure to Atole from conception to age 2 years were 0·09 and 0·04, respectively. INTERPRETATION: Improved protein-energy nutrition from conception to the 2nd birthday reduced the odds of diabetes at ages 37-54 years; however, this protein-energy supplementation also increased the risk of obesity and several obesity-related conditions. Our findings suggest a mixed ability of protein-energy nutritional supplementation in early life to prevent adult cardiometabolic disease incidence in the context of high childhood stunting and high adult overweight and obesity. FUNDING: National Institutes of Health.

Life-Course Body Mass Index Trajectories Are Predicted by Childhood Socioeconomic Status but Not Exposure to Improved Nutrition during the First 1000 Days after Conception in Guatemalan Adults.

BACKGROUND: Latin America has experienced increases in obesity. Little is known about the role of early life factors on body mass index (BMI) gain over the life course. OBJECTIVE: The objective of this research was to examine the role of early life factors [specifically, nutrition supplementation during the first 1000 d (from conception to 2 y of age) and childhood household socioeconomic status (SES)] on the pattern of BMI gain from birth or early childhood through midadulthood by using latent class growth analysis. METHODS: Study participants (711 women, 742 men) who were born in 4 villages in Guatemala (1962-1977) were followed prospectively since participating in a randomized nutrition supplementation trial as children. Sex-specific BMI latent class trajectories were derived from 22 possible measures of height and weight from 1969 to 2004. To characterize early life determinants of BMI latent class membership, we used logistic regression modeling and estimated the difference-in-difference (DD) effect of nutrition supplementation during the first 1000 d. RESULTS: We identified 2 BMI latent classes in women [low (57%) and high (43%)] and 3 classes in men [low (38%), medium (47%), and high (15%)]. Nutrition supplementation during the first 1000 d after conception was not associated with BMI latent class membership (DD test: P > 0.15 for men and women), whereas higher SES was associated with increased odds of high BMI latent class membership in both men (OR: 1.98; 95% CI: 1.09, 3.61) and women (OR: 1.62; 95% CI: 1.07, 2.45) for the highest relative to the lowest tertile. CONCLUSIONS: In a cohort of Guatemalan men and women, nutrition supplementation provided during the first 1000 d was not significantly associated with higher BMI trajectory. Higher childhood household SES was associated with increased odds of high BMI latent class membership relative to the poorest households. The pathways through which this operates still need to be explored.

Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities.

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.

Associations among dietary zinc intakes and biomarkers of zinc status before and after a zinc supplementation program in Guatemalan schoolchildren.

BACKGROUND: The associations among dietary zinc intakes and biomarkers of zinc status are unknown in apparently healthy children at high risk for zinc deficiency. OBJECTIVE: To assess associations among zinc-related parameters in a sample of Guatemalan school-aged children. METHODS: We assessed total dietary intakes and biomarkers of zinc status before and after receiving 6 months of zinc supplementation or placebo in 691 Guatemalan schoolchildren aged 6 to 11 years. Most of the children also received zinc-fortified milk from a government program that started shortly after the trial began. We assessed associations between zinc intakes and serum zinc, alkaline phosphatase (ALP), and albumin. RESULTS: At baseline, the prevalence of serum zinc < 65 microg/dL and dietary zinc intake below Estimated Average Requirements (EAR) (< 4 and < 7 mg/day for children < 9 and > or = 9 years, respectively) were 21.6% and 39.4%, respectively. Pearson correlations between serum zinc concentration and dietary zinc intake, serum ALP, and serum albumin were r = 0.07, 0.15, and 0.07, respectively. At the 6-month follow-up, low serum zinc and low total (diet plus fortified milk) zinc intakes were observed in 1.2% and 0.0% of children in the zinc-supplemented group and 4.0% and 34.1% in the placebo group, respectively. Pearson correlations between serum zinc concentration and total zinc intake, serum ALP, and serum albumin were 0.10, 0.06, and -0.11 in the zinc-supplemented group and -0.04, 0.05, and 0.01 in the placebo group, respectively. CONCLUSIONS: Zinc intake was inconsistently associated with markers of serum zinc concentration. Zinc fortification or supplementation attenuated the associations.

Breast milk vitamin B-12 concentrations in Guatemalan women are correlated with maternal but not infant vitamin B-12 status at 12 months postpartum.

In our previous studies, one-third of lactating Guatemalan women, infants, and children had deficient or marginal serum vitamin B-12 concentrations. Relationships among maternal and infant status and breast milk vitamin B-12, however, have not, to our knowledge, been investigated in such populations. Our purpose was to measure breast milk vitamin B-12 in Guatemalan women with a range of serum vitamin B-12 concentrations and explore associations between milk vitamin B-12 concentrations and maternal and infant vitamin B-12 intake and status. Participants were 183 mother-infant pairs breastfeeding at 12 mo postpartum. Exclusion criteria included mother <17 y, infant <11.5 or >12.5 mo, multiple birth, reported health problems in mother or infant, and mother pregnant >3 mo. Data collected on mothers and infants included anthropometry, serum and breast milk vitamin B-12, and dietary vitamin B-12. Serum vitamin B-12 concentrations indicated deficiency (<150 pmol/L) in 35% of mothers and 27% of infants and marginal status (150-220 pmol/L) in 35% of mothers and 17% of infants. In a multiple regression analysis, breast milk vitamin B-12 concentration was associated (P < 0.05) with both maternal vitamin B-12 intake (r = 0.26) and maternal serum vitamin B-12 (r = 0.30). Controlling for the number of breastfeeds per day and vitamin B-12 intake from complementary foods, infant serum vitamin B-12 was associated with maternal serum vitamin B-12 (r = 0.31; P < 0.001) but not breast milk vitamin B-12, implicating a long-term effect of pregnancy status on infant vitamin B-12 status at 12 mo postpartum.

Randomized trial of the effect of zinc supplementation on the mental health of school-age children in Guatemala.

BACKGROUND: Rates of mental illness in children are increasing throughout the world. Observational studies of depression, anxiety, and attention-deficit hyperactivity disorder suggest that zinc is an alternative treatment. OBJECTIVE: We examined the effect of zinc supplementation on the mental health of school-age children in Guatemala. DESIGN: From January to October 2006, we conducted a 6-mo randomized, double-blind, controlled trial comparing zinc supplementation (10 mg ZnO/d for 5 d/wk) with a placebo (10 mg glucose) in 674 Guatemalan children in grades 1-4. Outcome measures included internalizing (ie, depression and anxiety) and externalizing (ie, hyperactivity and conduct disorder) problem behaviors, positive behaviors (ie, socialization and leadership), and serum zinc concentrations. RESULTS: Zinc and placebo groups did not differ significantly in any behavioral measures at baseline or at follow-up. At baseline, 21.4% of children had serum zinc concentrations <65 µg/dL. At follow-up, both groups improved significantly, and zinc concentrations were higher in the zinc group. Increases in serum zinc concentrations were inversely associated with decreases in depressive symptoms (estimate: -0.01 points per µg Zn/dL; P = 0.01), anxiety (estimate: -0.012 points per µg Zn/dL; P = 0.02), internalizing symptoms (estimate: -0.021 points per µg Zn/dL; P = 0.02), and social skills (estimate: -0.019 points per µg Zn/dL; P = 0.01) in adjusted models that were controlled for child age, sex, socioeconomic status, household, and treatment group. CONCLUSIONS: Six months of zinc supplementation did not induce differences in mental health outcomes between zinc and placebo groups. However, increases in serum zinc concentrations were associated with decreases in internalizing symptoms (ie, depression and anxiety) in a community-based sample of children at risk of zinc deficiency. This trial was registered at clinicaltrials.gov as NCT00283660.

INCAP Oriente longitudinal study: 40 years of history and legacy.

Our purpose in this article is to describe the objectives, design, overall coverage, and main domains of data collection of the Institute of Nutrition of Central America and Panama Oriente Longitudinal Study and subsequent follow-up studies. This supplementary feeding trial targeted to pregnant and lactating women and children from birth to 7 y of age, conducted in 4 rural Guatemalan villages (1969-77) with a series of follow-up studies (1988-2007), is one of the richest sources of information on the effects of nutrition, growth, development, and human capital in the developing world, with outstanding data from gestation to adult age and 40 y of follow-up. Its results have influenced nutrition knowledge and policy with over 300 scientific publications. We present brief descriptions of preliminary studies that were critical for the success of the trial and the design and methods used during the trial and in the follow-up studies, in chronological order.

Nutritional supplementation in early childhood, schooling, and intellectual functioning in adulthood: a prospective study in Guatemala.

OBJECTIVE: To estimate the association of improved nutrition in early life with adult intellectual functioning, controlling for years of schooling. DESIGN: Prospective cohort study. SETTING: Four villages in Guatemala, as well as locations within Guatemala to which cohort members migrated. PARTICIPANTS: Individuals who had participated as children in a nutrition supplementation intervention trial from March 1, 1969, through February 28, 1977 (N = 2392). From May 1, 2002, through April 30, 2004, adequate information for analysis was obtained from 1448 of 2118 individuals (68.4%) not known to have died. INTERVENTIONS: Individuals exposed to atole (a protein-rich enhanced nutrition supplement) at birth through age 24 months were compared with those exposed to the supplement at other ages or to fresco, a sugar-sweetened beverage. We measured years of schooling by interview. MAIN OUTCOME MEASURES: Scores on the Serie Interamericana (InterAmerican Series) tests of reading comprehension and the Raven Progressive Matrices, obtained from May 1, 2002, through April 30, 2004. RESULTS: In models controlling for years of schooling and other predictors of intellectual functioning, exposure to atole at birth to age 24 months was associated with an increase of 3.46 points (95% confidence interval, -1.26 to 8.18) and 1.74 points (95% confidence interval, 0.53-2.95) on the InterAmerican Series and Raven Progressive Matrices tests, respectively. There was no statistical interaction between exposure to atole at birth to age 24 months and years of schooling on either outcome (P = .24 and P = .60, respectively). CONCLUSION: Improved early-life nutrition is associated with increased intellectual functioning in adulthood after taking into account the effect of schooling.

Prevalent vitamin B-12 deficiency in twelve-month-old Guatemalan infants is predicted by maternal B-12 deficiency and infant diet.

Approximately one-third of low-income women and children studied in Guatemala are reported to have deficient (<148 pmol/L) or marginal (148-220 pmol/L) plasma vitamin B-12 concentrations. Because vitamin B-12 deficiency can adversely affect infant development and cognitive function, the present study examined predictors of deficient plasma vitamin B-12 concentrations at the age of 12 mo. Analyses were performed on baseline data from a randomized clinical trial in 304 Guatemalan infants, 80% of whom were partially breast-fed, and their mothers. Exclusion criteria for infants included twins, severe stunting or moderate wasting, reported major health problems, severe developmental delay, hemoglobin <95 g/L, maternal age <17 y, and maternal pregnancy >3 mo. Data collected included socio-economic status, infant anthropometry, vitamin B-12 intake from complementary foods, and breast-feeding frequency reported by mothers. A complete blood count and plasma vitamin B-12, folate, ferritin, and C-reactive protein were measured. Deficient or marginal plasma vitamin B-12 concentrations were found in 49% of infants and 68% of mothers. The mean intake of maternal vitamin B-12 was 3.1 microg/d, and infants consumed 2.2 microg/d from complementary foods. In linear regression analysis, infant plasma B-12 concentration was strongly and positively associated with maternal plasma vitamin B-12 and B-12 intake from complementary foods (predominantly powdered cow's milk), and inversely associated with frequency of breast-feeding and larger household size (P < 0.0001). Vitamin B-12 supplementation of lactating women, food fortification, and education to improve infant's vitamin B-12 status are potential interventions that can improve the vitamin B-12 status of mothers and infants in this population.