There's an App for That: Development of an Application to Operationalize the Global Diet Quality Score.

BACKGROUND: The global diet quality score (GDQS) is a simple, standardized metric appropriate for population-based measurement of diet quality globally. OBJECTIVES: We aimed to operationalize data collection by modifying the quantity of consumption cutoffs originally developed for the GDQS food groups and to statistically evaluate the performance of the operationalized GDQS relative to the original GDQS against nutrient adequacy and noncommunicable disease (NCD)-related outcomes. METHODS: The GDQS application uses a 24-h open-recall to collect a full list of all foods consumed during the previous day or night, and automatically classifies them into corresponding GDQS food group. Respondents use a set of 10 cubes in a range of predetermined sizes to determine if the quantity consumed per GDQS food group was below, or equal to or above food group-specific cutoffs established in grams. Because there is only a total of 10 cubes but as many as 54 cutoffs for the GDQS food groups, the operationalized cutoffs differ slightly from the original GDQS cutoffs. RESULTS: A secondary analysis using 5 cross-sectional datasets comparing the GDQS with the original and operationalized cutoffs showed that the operationalized GDQS remained strongly correlated with nutrient adequacy and was equally sensitive to anthropometric and other clinical measures of NCD risk. In a secondary analysis of a longitudinal cohort study of Mexican teachers, there were no differences between the 2 modalities with the beta coefficients per 1 SD change in the original and operationalized GDQS scores being nearly identical for weight gain (-0.37 and -0.36, respectively, P < 0.001 for linear trend for both models) and of the same clinical order of magnitude for waist circumference (-0.52 and -0.44, respectively, P < 0.001 for linear trend for both models). CONCLUSION: The operationalized GDQS cutoffs did not change the performance of the GDQS and therefore are recommended for use to collect GDQS data in the future.

Mixed methods evaluation explains bypassing of vouchers in micronutrient powder trial in Mozambique.

Micronutrient powders (MNP) are recommended by the World Health Organization as an effective intervention to address anaemia in children. A formative process evaluation was conducted to assess the viability of a model using free vouchers in two districts of Mozambique to deliver MNP and motivate adherence to recommendations regarding its use. The evaluation consisted of (a) an examination of programme outcomes using a cross-sectional survey among caregivers of children 6-23 months (n = 1,028) and (b) an ethnographic study to investigate delivery experiences and MNP use from caregiver perspectives (n = 59), programme managers (n = 17), and programme implementers (n = 168). Using a mixed methods approach allowed exploration of unexpected programme outcomes and triangulation of findings. The survey revealed that receiving a voucher was the main implementation bottleneck. Although few caregivers received vouchers (11.5%, CI [9.7, 13.6]), one-fourth received MNP by bypassing the voucher system (26.3%, CI [23.6, 29.0]). Caregivers' narratives indicated that caregivers were motivated to redeem vouchers but encountered obstacles, including not knowing where or how to redeem them or finding MNP were not available at the shop. Observing these challenges, many programme implementers redeemed vouchers and distributed MNP to caregivers. Virtually, all caregivers who received MNP reported ever feeding it to their child. This study's findings are consistent with other studies across a range of contexts suggesting that although programmes are generally effective in motivating initial use, more attention is required to improve access to MNP and support continued use.

Context-specific complementary feeding recommendations developed using Optifood could improve the diets of breast-fed infants and young children from diverse livelihood groups in northern Kenya.

OBJECTIVE: To formulate age- and context-specific complementary feeding recommendations (CFR) for infants and young children (IYC) and to compare the potential of filling population-level nutrient gaps using common sets of CFR across age groups. DESIGN: Linear programming was used to develop CFR using locally available and acceptable foods based on livelihood- and age-group-specific dietary patterns observed through 24 h dietary recalls. Within each livelihood group, the nutrient potential of age-group-specific v. consolidated CFR across the three age groups was tested. SETTING: Three food-insecure counties in northern Kenya; namely, settled communities from Isiolo (n 300), pastoralist communities from Marsabit (n 283) and agro-pastoralist communities from Turkana (n 299). SUBJECTS: Breast-fed IYC aged 6-23 months (n 882). RESULTS: Age-specific CFR could achieve adequacy for seven to nine of eleven modelled micronutrients, except among 12-23-month-old children in agro-pastoralist communities. Contribution of Fe, Zn and niacin remained low for most groups, and thiamin, vitamin B6 and folate for some groups. Age-group-consolidated CFR could not reach the same level of nutrient adequacy as age-specific sets among the settled and pastoralist communities. CONCLUSIONS: Context- and age-specific CFR could ensure adequate levels of more modelled nutrients among settled and pastoralist IYC than among agro-pastoralist communities where use of nutrient-dense foods was limited. Adequacy of all eleven modelled micronutrients was not achievable and additional approaches to ensure adequate diets are required. Consolidated messages should be easier to implement as part of a behaviour change strategy; however, they would likely not achieve the same improvements in population-level dietary adequacy as age-specific CFR.

Experiences and lessons learned for programme improvement of micronutrient powders interventions.

Continual course correction during implementation of nutrition programmes is critical to address factors that might limit coverage and potential for impact. Programme improvement requires rigorous scientific inquiry to identify and address implementation pathways and the factors that affect them. Under the auspices of "The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance," 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powder (MNP) interventions for young children. This paper focuses on how MNP interventions undertook key elements of programme improvement, specifically, the use of programme theory, monitoring, process evaluation, and supportive supervision. Methods included a review of published and grey literature, interviews with key informants, and deliberations throughout the consultation process. We found that although much has been written and published about the use of monitoring and process evaluation to inform MNP interventions at small scale, there has been little formal documentation of lessons for the transition from pilot to scaled implementation. Supervision processes and experiences are not documented, and to our knowledge, there is no evidence of whether they have been effective to improve implementation. Improving the efficiency and effectiveness of interventions requires identification of critical indicators for detecting implementation challenges and drivers of impact, integration with existing programmes and systems, strengthened technical capacity, and financing for implementation of effective monitoring systems. Our understanding of programme improvement for MNP interventions is still incomplete, especially outside of the pilot stage, and we propose a set of implementation research questions that require further investigation.

The stunted child with an overweight mother as a growing public health concern in resource-poor environments: a case study from Guatemala.

BACKGROUND: Overweight and obesity are emerging at alarming rates in low income women in many countries. Guatemala has the additional burden of a high prevalence of chronic under-nutrition (stunting) in children. AIM: The purpose of this paper is to explore the dual burden of infant and child (5-23 months) under-nutrition and maternal over-weight and obesity in the Western Highlands of Guatemala. SUBJECTS AND METHODS: Anthropometric measures were collected in 446 mother-infant dyads in a metropolitan population of mixed indigenous (Maya) and non-indigenous descent in the Western Highlands of Guatemala. Children were identified as stunted based on a height for age <-2 below the WHO reference median and maternal overweight/obesity defined as a BMI ≥25. Stunted children with an overweight/obese mother were compared to other children who were not stunted and/or who did not have an overweight/obese mother. RESULTS: The prevalences of stunting (38%) and maternal overweight/obesity (45%) were high, but just 17% of the mother and child pairs were dual burden. The socio-demographic characteristics of stunted children were not influenced by maternal overweight or obesity. CONCLUSION: Policies are needed to address under-nutrition as well as preventing obesity and obesity-related chronic disease risks of stunted children and their mothers.

Stunting at birth: recognition of early-life linear growth failure in the western highlands of Guatemala.

OBJECTIVE: Measurements of length at birth, or in the neonatal period, are challenging to obtain and often discounted for lack of validity. Hence, classical 'under-5' stunting rates have been derived from surveys on children from 6 to 59 months of age. Guatemala has a high prevalence of stunting (49.8%), but the age of onset of growth failure is not clearly defined. The objective of the study was to assess length-for-age within the first 1.5 months of life among Guatemalan infants. DESIGN: As part of a cross-sectional observational study, supine length was measured in young infants. Mothers' height was measured. Length-for-age Z-scores (HAZ) were generated and stunting was defined as HAZ <-2 using WHO growth standards. SETTING: Eight rural, indigenous Mam-Mayan villages (n 200, 100% of Mayan indigenous origin) and an urban clinic of Quetzaltenango (n 106, 27% of Mayan indigenous origin), Guatemala. SUBJECTS: Three hundred and six newborns with a median age of 19 d. RESULTS: The median rural HAZ was -1.56 and prevalence of stunting was 38%; the respective urban values were -1.41 and 25%. Linear regression revealed no relationship between infant age and HAZ (r = 0.101, r(2) = 0.010, P = 0.077). Maternal height explained 3% of the variability in HAZ (r = 0.171, r(2) = 0.029, P = 0.003). CONCLUSIONS: Stunting must be carried over from in utero growth retardation in short-stature Guatemalan mothers. As linear growth failure in this setting begins in utero, its prevention must be linked to maternal care strategies during gestation, or even before. A focus on maternal nutrition and health in an intergenerational dimension is needed to reduce its prevalence.

Energy contribution from non-breastmilk items in low-income Guatemalan infants in their sixth month of life.

OBJECTIVE: To examine the nature and energy contribution of complementary feeding in breastfed infants in their sixth month of life, and the prevalence of the use of bottles as a delivery method. MATERIALS AND METHODS: We recruited 156 breastfeeding infants at a health clinic in metropolitan Quetzaltenango, Guatemala. A previous-day recall was performed. RESULTS: Sixty nine mothers (44%) reported offering items other than breastmilk. The median contribution of energy from complementary foods among infants with mixed feeding (n=66) was 197 kcal/day (interquartile range [IQR] 49-353). The median energy contribution of formula or cow's milk among consumers (n=39) was 212 kcal/day (IQR 84-394). Bottles were used on the previous day by 55 (80%) of the 69 mothers not offering exclusive breastfeeding. CONCLUSIONS: Premature introduction of non-breastmilk items is commonly practiced in feeding Guatemalan infants. Adherence to the internationally recognized guidelines for early infant feeding should be an intervention priority for this population.

The Nutritional Contribution of Foods and Beverages Provided by Government-Sponsored Day Care Centers in Guatemala.

BACKGROUND: Meals served at government-run day care centers must be nutritionally adequate to ensure good health and proper development of preschool-aged children. They can provide a controlled opportunity to complement the daily diet of children in vulnerable populations. OBJECTIVE: To determine the nutrient adequacy and leading food sources of nutrients provided by the diet served in government-sponsored day care centers. METHODS: Estimated daily energy and nutrient intakes of a theoretical 40-day day care center menu were calculated, and the nutrient adequacy was assessed. Nutrient densities and critical nutrient densities of the menu were computed to identify nutrient inadequacies. Furthermore, main sources of nutrients were identified, and energy and nutrient distributions were examined by meal time. RESULTS: The menu provides approximately 90% of daily energy requirement and more than 100% of Recommended Nutrient Intakes (RNIs), with the exception of vitamin D and calcium. Sugar was the first leading source of energy, whereas milk was the first leading contributor of vitamin D. CONCLUSION: Within an environment of budgetary constraints, the Guatemalan government developed and advocated an exemplary menu offering for children in the vulnerable preschool period. We have demonstrated that, if prepared and served as planned, the items from the official, standard menu would supply most of the nutrients needed. High vitamin A intake related to the mandated national fortification program is a potential problem. From the analysis, it was found that vitamin D emerges as the most prominent candidate for a problem nutrient of deficient intake.

Quantitative Methodologies Reveal a Diversity of Nutrition, Infection/Illness, and Psychosocial Stressors During Pregnancy and Lactation in Rural Mam-Mayan Mother-Infant Dyads From the Western Highlands of Guatemala.

BACKGROUND: The nature and severity of 3 categories of maternal stressors (nutritional, infectious, and psychosocial) that may impact maternal health and early infant growth are not often considered together. OBJECTIVES: To describe quantitative methodologies; assess construct validity of questionnaires; report variability in sociodemographic, obstetric, nutritional, infectious, and psychosocial characteristics; and compare characteristics between pregnancy and lactation and between study cohorts of Mam-Mayan mother-infant dyads. METHODS: Grounded in participatory action research and a socioecological framework, this observational study enrolled a longitudinal cohort of 155 women, followed during pregnancy (6-9 months), early (0-6 weeks), and later (4-6 months) postpartum, and 2 cross-sectional cohorts (60 early and 56 later postpartum). Household and social factors; obstetric history; nutritional, infectious, and psychosocial stressors; and infant characteristics were explored. RESULTS: Diet diversity (3.4 ± 1.3) and adult food security (38%) were low. Urinary and gastrointestinal infections were rare (<5%), whereas experience of local idioms of distress was frequent (20%-50%). Participants reported low maternal autonomy (81%), high paternal support (70%), small social support networks (2.7 ± 1.3 individuals), and high trust in family (88%) and community-based institutions (61%-65%) but low trust in government services (6%). Domestic violence was commonly reported (22%). Infant stunting was common (36% early postpartum and 43% later postpartum) despite frequent antenatal care visits (7.5 ± 3.8). Participant engagement with the research team did not influence study outcomes based on comparisons between longitudinal and cross-sectional cohorts. CONCLUSIONS: The variability in sociodemographic, nutritional, and psychosocial variables, will allow exploration of factors that promote resilience or increase vulnerability of the mother-infant dyad.

Challenges in the elaboration of a field interview instrument to capture information for the evaluation of adherence to the WHO/PAHO Guiding Principles for Complementary Feeding of the Breastfed Child.

BACKGROUND: In 2003, the World Health Organization (WHO) and the Pan American Health Organization (PAHO) published "Guiding principles for complementary feeding of the breastfed child," which includes a series of 10 recommendations. OBJECTIVE: To illustrate the challenges in creating operative criteria for the evaluation of concordance with the tenets of the WHO/PAHO Guiding Principles recommendations. METHODS: We set out to define operative criteria for the evaluation of adherence to the tenets of the WHO/PAHO Guiding Principles. The 10 Guiding Principles were divided into subcomponents and examined carefully. Our indicators were based on evaluation variables collected by means of our prospectively designed data collection tool. The 2008 WHO-validated infant and young child feeding (IYCF) indicators were taken as a reference for evaluation. RESULTS: After careful examination of the 10 WHO/PAHO Guiding Principles, we were able to identify 28 specific subcomponents for evaluation. With our prospectively designed data collection tool, we were able to set evaluations for 17 of these 28 subcomponents. CONCLUSIONS: The considerations for devising the criteria involved in evaluation instruments must be transparently available to clarify the interpretations and conclusions derived from their application. Evaluation criteria can be set for most, but not all, IYCF practices of the WHO/PAHO Guiding Principles. Indicators that focus on selected, food-related dimensions of childfeeding can be measured in large surveys, whereas other dimensions of optimal feeding, such as hygienic food handling and adequate texture of food, are likely to require more complex measurement and evaluation approaches.

Human milk microbiome: associations with maternal diet and infant growth.

Introduction: Ingestion of human milk (HM) is identified as a significant factor associated with early infant gut microbial colonization, which has been associated with infant health and development. Maternal diet has been associated with the HM microbiome (HMM). However, a few studies have explored the associations among maternal diet, HMM, and infant growth during the first 6 months of lactation. Methods: For this cross-sectional study, Mam-Mayan mother-infant dyads (n = 64) were recruited from 8 rural communities in the Western Highlands of Guatemala at two stages of lactation: early (6-46 days postpartum, n = 29) or late (109-184 days postpartum, n = 35). Recruited mothers had vaginally delivered singleton births, had no subclinical mastitis or antibiotic treatments, and breastfed their infants. Data collected at both stages of lactation included two 24-h recalls, milk samples, and infant growth status indicators: head-circumference-for-age-z-score (HCAZ), length-for-age-z-score (LAZ), and weight-for-age-z-score (WAZ). Infants were divided into subgroups: normal weight (WAZ ≥ -1SD) and mildly underweight (WAZ < -1SD), non-stunted (LAZ ≥ -1.5SD) and mildly stunted (LAZ < -1.5SD), and normal head-circumference (HCAZ ≥ -1SD) and smaller head-circumference (HCAZ < -1SD). HMM was identified using 16S rRNA gene sequencing; amplicon analysis was performed with the high-resolution ANCHOR pipeline, and DESeq2 identified the differentially abundant (DA) HMM at the species-level between infant growth groups (FDR < 0.05) in both early and late lactation. Results: Using both cluster and univariate analyses, we identified (a) positive correlations between infant growth clusters and maternal dietary clusters, (b) both positive and negative associations among maternal macronutrient and micronutrient intakes with the HMM at the species level and (c) distinct correlations between HMM DA taxa with maternal nutrient intakes and infant z-scores that differed between breast-fed infants experiencing growth faltering and normal growth in early and late lactation. Conclusion: Collectively, these findings provide important evidence of the potential influence of maternal diet on the early-life growth of breastfed infants via modulation of the HMM.

Estimates of exclusive breastfeeding rates among mother-infant dyads in Quetzaltenango, Guatemala, vary according to interview method and time frame.

BACKGROUND: The World Health Organization (WHO) recommends exclusive breastfeeding, defined as receiving only breastmilk, through the first 6 months of life to optimize survival, health, and development. OBJECTIVE: To assess exclusive and predominant breastfeeding rates, as defined by WHO, in a sample of Guatemalan infants using three dietary assessment methods. METHODS: Mothers of 156 infants (78 boys and 78 girls) in the 6th month of life, attending a public health center in Quetzaltenango, an urban area located in the Highlands of Guatemala, were recruited. A single face-to-face interview was performed to assess infant dietary intake using three methods: previous day dietary recall (as suggested by WHO), current feeding practices, and recall of feeding practices since birth. RESULTS: Based on the previous day dietary recall method, exclusive breastfeeding was reported by 87 (56%) of the mothers. Exclusive breastfeeding rates were much lower when estimated by current feeding practices questions (20%) and even lower when based on recall of feeding practices since birth (9%). The sum of exclusive and predominant breastfeeding (full breastfeeding) rates was 58%, 49%, and 31% based on previous day dietary recall, current feeding practices, and recall of feeding practices since birth, respectively. CONCLUSIONS: The WHO method of dietary assessment, based solely on the previous day dietary recall, overestimates the exclusive breastfeeding rate compared with recall of feeding practices since birth. In our population sample, adherence to the WHO guidelines for feeding in the first semester of infancy was less than ideal and in need of strengthening.

A Nutrition Behavior Change Program Moderately Improves Minimum Diet Diversity and Handwashing Behaviors Among Tea Workers in Assam and Tamil Nadu, India.

Many workers in global supply chains remain nutritionally vulnerable despite the income they earn. The Seeds of Prosperity (SOP) program was implemented in Tamil Nadu and Assam, India, for tea supply chain workers (estate workers, small holder farmers, and farm workers). The aim was to enhance demand for diverse and nutritious foods and improve practices related to handwashing. The program used a behavior change communication approach wherein participants received weekly 1-hour group sessions with messaging on dietary diversity for 5 weeks and handwashing for 4 weeks. An impact evaluation was conducted to estimate changes in reported dietary and hygiene knowledge and behaviors among women. The study used a longitudinal quasi-experimental design in a subsample of program participants at baseline and post-intervention among both intervention and comparison. There was a small but significant increase in mean dietary diversity (DD) for all 4 worker groups (ranging from DD score changes of 0.3 to 0.7; P < .05) and in the proportion of women meeting the minimum dietary diversity in 2 of the 4 groups. Similarly, a significant increase in the mean number of handwashing moments was observed in 2 of the worker groups. An increase in home garden use was observed in 1 of the 4 worker groups. While the SOP program resulted in improvements in dietary diversity, most tea farming women still do not achieve minimum dietary diversity. Nutritious food access may be an important constraint to further improvement.

Food variety, dietary diversity, and food characteristics among convenience samples of Guatemalan women.

OBJECTIVE: To compare variety and diversity patterns and dietary characteristics in Guatemalan women. MATERIAL AND METHODS: Two non-consecutive 24-h recalls were conducted in convenience samples of 20 rural Mayan women and 20 urban students. Diversity scores were computed using three food-group systems.Variety and diversity scores and dietary origin and characteristics were compared between settings using independent t-test or Mann-Whitney-U-test. RESULTS: Dietary variety and diversity were generally greater in the urban sample when compared to the rural sample, depending on the number of days and food-group system used for evaluation.The diet was predominantly plant-based and composed of non-fortified food items in both areas.The rural diet was predominantly composed of traditional,non-processed foods. The urban diet was mostly based on non-traditional and processed items. CONCLUSION: Considerations of intervention strategies for dietary improvement and health protection for the Guatemalan countryside should still rely on promotion and preservation of traditional food selection.

Nutrient Density as a Dimension of Dietary Quality: Findings of the Nutrient Density Approach in a Multi-Center Evaluation.

The nutrient adequacy of a diet is typically assessed by comparing estimated nutrient intakes with established average nutrient requirements; this approach does not consider total energy consumed. In this multinational survey investigation in Indonesia, Mexico, and South Africa, we explore the applications of the "critical nutrient-density approach"-which brings energy requirements into the equation-in the context of public health epidemiology. We conducted 24 h dietary recalls in convenience samples of normal-weight (BMI 18.5-25 kg/m2) or obese (BMI > 30 kg/m2), low-income women in three settings (n = 290). Dietary adequacy was assessed both in absolute terms and using the nutrient density approach. No significant differences in energy and nutrient intakes were observed between normal-weight and obese women within any of the three samples (p > 0.05). Both the cut-point method (% of EAR) and critical nutrient density approach revealed a high probability of inadequate intakes for several micronutrients but with poor concordance between the two methods. We conclude that it may often require some approximate estimate of the habitual energy intake from an empirical source to apply a true critical nutrient density reference for a population or subgroup. This will logically signify that there would be more "problem nutrients" in the diets examined with this nutrient density approach, and efforts toward improved food selection or food- or biofortification will frequently be indicated.

Dietary intakes and food sources of fat and fatty acids in Guatemalan schoolchildren: a cross-sectional study.

BACKGROUND: Consumption of healthy diets that contribute with adequate amounts of fat and fatty acids is needed for children. Among Guatemalan children, there is little information about fat intakes. Therefore, the present study sought to assess intakes of dietary fats and examine food sources of those fats in Guatemalan children. METHODS: The study subjects consisted of a convenience sample of 449 third- and fourth-grade schoolchildren (8-10 y), attending public or private schools in Quetzaltenango City, Guatemala. Dietary data was obtained by means of a single pictorial 24-h record. RESULTS: The percentages of total energy (%E) from total fat, saturated fat (SFA) and monounsaturated fat (MUFA) reached 29%E for total fat and 10%E for each SFA and MUFA, without gender differences. %E from fats in high vs. low-socio economic status (SES) children were significantly higher for boys, but not for girls, for total fat (p = 0.002) and SFA (p < 0.001). Large proportions of the children had low levels of intakes of some fatty acids (FA), particularly for n-3 FA, with >97% of all groups consuming less than 1%E from this fats. Fried eggs, sweet rolls, whole milk and cheese were main sources of total fat and, SFA. Whole milk and sweet bread were important sources of n-3 FA for high- and low-SES boys and girls, respectively. Fried plantain was the main source of n-3 FA for girls in the high-SES group. Fried fish, seafood soup, and shrimp, consumed only by boys in low amounts, were sources of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, which may explain the low intakes of these nutrients. CONCLUSIONS: alpha-linolenic acid, EPA and DHA were the most limiting fatty acids in diets of Guatemalan schoolchildren, which could be partially explained by the low consumption of sources of these nutrients, particularly fish and seafood (for EPA and DHA). This population will benefit from a higher consumption of culturally acceptable foods that are rich in these limiting nutrients.

Concordance with selected population recommendations for cancer prevention among third- and fourth-grade schoolchildren in Quetzaltenango, Guatemala.

BACKGROUND: The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) 1997 recommendations for cancer prevention were meant to apply to children as well as adults. OBJECTIVE: To assess the concordance of behaviors and body composition of urban Guatemalan schoolchildren with the tenets of the WCRF/AICR 1997 recommendations. METHODS: A survey was conducted involving determination of 24-hour consumption of foods and beverages by a pictorial registry and height and weight measurements in 355 third- and fourth-grade schoolchildren in the western highland city of Quetzaltenango, Guatemala. Based on a previous, exhaustive parsing of the population goal recommendations of the WCRF/AICR 1997 report, 25 subcomponents were identified. Eleven could be evaluated with the survey data collected. Adult population criteria could be applied in seven, whereas four components had unique criteria adapted to this juvenile survey setting. RESULTS: The study sample was concordant on seven components-nutrient adequacy, total variety of foods consumed, plant-based diets, body mass index, vegetable and fruit intake, limitation of red meat consumption, and limitation of total fat consumption, and nonconcordant on four-variety of fruits and vegetables consumed, variety of starchy foods consumed, total intake of starchy foods, and limitation of sugar consumption. CONCLUSIONS: Educational and public health actions need to be conceived and implemented to further improve the rate of concordance of these 11 components with the WCRF/AICR 1997 recommendations for cancer prevention.

Contribution of beverages to energy, macronutrient and micronutrient intake of third- and fourth-grade schoolchildren in Quetzaltenango, Guatemala.

Beverages are selected based on availability, culture, taste preference, health, safety and social context. Beverages may be important to energy and to the macronutrient and micronutrient quality of overall intake. The aim of this study was to determine the contribution of beverages to the dietary energy and estimated macro- and micronutrient intake to the diet of young schoolchildren. We analyzed data from third- and fourth-grade urban Guatemalan school-children aged predominantly 8-10 years old. One-day pictorial registries of all beverages, foods and snacks consumed over a 24-h period were collected from children from private (n = 219) and public (n = 230) schools. Food composition nutrient values were assigned to the items consumed. Eleven main categories of beverages were identified. The contribution of each of the 11 beverage categories to energy, macro- and micronutrients was evaluated. The estimated intake of beverages was 475,300 mL, as reported by the 449 children. As a group, the beverage consumed in the greatest quantity was coffee (126,500 mL), followed by plain water (62,000 mL). Beverages represented a mean energy contribution of 418 +/- 26 kcal (21.5% of total dietary energy). The beverages varied in energy density from 0 (water) to 1.5 kcal mL(-1) (thin gruels). Beverages contributed one-third of the dietary carbohydrate. Through the contribution of fortified drinks, beverages were important sources of vitamin A (55%), vitamin C (38%), zinc (21%) and calcium (19%). Milk was an important source for vitamin D (10%). These results show the importance of drinks to nutrition and the balance of concerns of overweight/obesity with micronutrient quality.

The positive deviance approach can be used to create culturally appropriate eating guides compatible with reduced cancer risk.

The 1997 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) Report provides 14 individual guidelines to reduce global cancer risk. The positive deviance approach could be appropriate for creating class-appropriate, healthy eating menu guides for consuming a diet to minimize cancer risk in Guatemala. Guatemalan adult participants (n = 873) were enrolled in the Concordance Project from 3 socioeconomic strata: rural area (n = 301), lower urban (n = 298), and higher urban (n = 274). Participants with intakes below recommended nutrient intakes and current smokers were excluded from the analysis. Concordance with 14 selected WCRF/AICR individual guideline components was evaluated. We selected participants for making a set of 14 rotating menus for a cancer prevention healthy eating guide. A priority sorting through the 873 participants of the survey identified a total of 23 and 21 model participants, respectively, from the rural and urban poor groups (concordant with 12 of 14 recommendation components) and 15 from the urban middle class (concordant with 11 of 14 recommendation components), with the highest degree of concordance with the WCRF/AICR guidelines. The most commonly violated recommendation was sugar consumption, followed by maintaining weight stability. The FFQ for 14 individuals from each class were transformed into a day menu to create a rotating diet guide derived from members of each social group. A potentially useful personal guide for eating compatibly with adequate nutrient intake and reduced cancer risk, appropriate to the culture and economic means of distinct social classes in Guatemala, is approaching the stage for application.