Formative Assessment of Infant and Young Child Nutrition in Two Indigenous Communities in Guatemala

MAY 2013

Authors/Researchers:
Anita Chary, Washington University in St. Louis and Wuqu Kawoq | Maya Health Alliance Kelley Brown, University of Illinois at Chicago Meghan Farley Webb, University of Kansas Heather Wehr, University of Kansas Jillian Moore, Wuqu Kawoq | Maya Health Alliance Caitlin Baird, University of Florida Anne Kraemer Daz, Wake Forest University and Wuqu Kawoq | Maya Health Alliance Nicole Henretty, Edesia Inc. Peter Rohloff, Brigham and Womens Hospital, Childrens Hospital Boston, and Wuqu Kawoq | Maya Health Alliance

Table of Contents
Introduction Research Objectives Study Design Institutional Context and Ethics General Demographics, Poverty, and Food Security Family Structure, Roles, and Decision-making Child Care and Feeding Practices Foods and Feeding Patterns Child Health and Illness Prevention Child Malnutrition Malnutrition in Pregnant Women Health and Nutrition Information and Education Summary and Conclusions Study Implications Study Limitations Acknowledgements Financial Disclosures and Conflict of Interest Statement Appendix A: Acronyms, Abbreviations, Definitions Appendix B: Fortified Food List Appendix C: General Food List 4 5 5 6 6 7 8 11 14 15 16 17 18 21 22 22 22 23 24 25

Introduction

Guatemala has the highest rate of chronic childhood malnutrition in Latin America, and one of the highest in the world. In a recent survey, 43% of a national sample of children under five years of age were found to be stunted.1 Furthermore, it is well known that stunting disproportionately affects rural, indigenous communities in Guatemala to an extent not well reflected in national summary statistics. For example, as part of a recently reconstituted national malnutrition surveillance system,2 children in five heavily indigenous departments of Western Guatemala (San Marcos, Quetzaltenango, Totonicapn, Huehuetenango, y El Quich) were surveyed. In this sample, 60% of surveyed children 3 to 59 months of age were stunted (3 to 5 months: 41.2%, 6 to 11 months: 47.5%, 12 to 23 months: 68%, 24 to 35 months: 69.4%). Furthermore, among children who were found to be stunted, 86% were from rural areas and 77.5% were from indigenous families. Micronutrient deficiencies were also found to be a concern, as 14% of children 6 to 59 months were anemic, with the highest prevalence of anemia being found in children 6 to 11 months (41%) and 12 to 23 months (23.3%). Consistent with the known dynamics of child malnutrition in Guatemala, underweight (16%), acute malnutrition (0.3%), and overweight (5%) were found to be much less critical public health concerns. Wuqu Kawoq | Maya Health Alliance is a non-governmental assistance organization with nonprofit status in the United States and in Guatemala. Since 2007, Wuqu Kawoq has been providing primary health care, chronic disease management, maternal-child and nutritional programming, and disaster relief services in Kaqchikel- and Kichee- speaking communities in the Central highlands and Bocacosta region of Guatemala. Wuqu Kawoqs programs are unique because special effort is directed toward providing culturally and linguistically sensitive programming for the rural Maya target populations. In 2012, Wuqu Kawoq and partners set out to conduct a formative, mixed-methods study on infant and young child feeding practices. Because the majority of chronic malnutrition burden in Guatemala resides within rural indigenous households, the two sites chosen for this study were small rural indigenous villages.The two communities, one (Kexel) in the Bocacosta region of the Department of Suchitepquez and the other (Xejuyu) in the Central Highlands of the Department of Chimaltenango, were chosen from a number of communities where Wuqu Kawoq has primary care and nutrition programs. These two communities have many demographic and socioeconomic similarities, including a high percentage of households living on less than $2 USD per day; a majority of residents of Maya descent, with indigenous language spoken to some degree; and high levels of chronic malnutrition. However, in order to have a broader understanding of beliefs, attitudes, and practices found in indigenous communities, these particular communities were also chosen because of some key differences, such as the percentage of day laborers vs. subsistence farmers; prevalence of land ownership; distance to a larger town; and encroachment on traditional food purchasing strategies by the presences of outlets selling processed foods. Both communities have historically high levels of malnutrition, based on baseline survey work Wuqu Kawoq has performed.The rate of stunting in children 6-59 months in Kexel was 71% in 20083 and in Xejuyu it was 57% in 20114. 4

Research Objectives
This formative research will help build an evidence base for developing and implementing solutions to child malnutrition in indigenous communities in Guatemala by providing insight into what motivates current feeding and care behaviors or inhibits ideal behaviors5, and uncovering strategies to facilitate new or improved practices. As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development, and health; thereafter, infants should receive safe and nutritionally adequate complementary foods, while breastfeeding continues for up to two years of age or beyond.6 The main objectives of the study are as follows: 1. To understand current feeding and care behaviors of infants and young children in two distinct regions of Guatemala, including how knowledge, perceptions, beliefs, culture, economics, social organization, family roles, and food expenditures may factor into attitudes and behaviors. 2. To understand current knowledge and perceptions regarding the treatment and prevention of child malnutrition and illness, including an understanding of local perspectives regarding how vitamins (fortification), food choices, hygiene practices, and behaviors factor into raising a healthy, well-nourished child. 3. To understand dietary intake and patterns in children ages 6 to 36 months in these communities, including the role of snacks, packaged, fortified, convenience, speciallymarketed foods, and other commercial foods; and to collect information on the branding and marketing of products for children. 4. To understand where current health and nutrition knowledge originates in order to formulate strategies for more effective information dissemination and behavior change.

Study Design
In order to build a satisfactory level of information from multiple sources, a mixed-methods approach was used. The study design included the following components: 1. One hundred and two (102) structured household-level surveys (51 in each community), targeted at the primary caregivers of children aged 6 to 36 months. Surveys covered the following thematic areas: demographic information; breastfeeding, complementary food introduction, and responsive feeding techniques; 24-hour and 1-week food recalls; power over decision making around infant feeding; knowledge about commercial infant foods and their availability and utilization; subsistence food production; and sources of available health information. a) 24-hour recalls were collected to determine World Health Organization (WHO) young child feeding practice indicators; 7-day recalls using a food-frequency questionnaire (FFQ) were collected to elicit a longer 5

time period of feeding patterns, specifically to look at foods that may not be given every day. The FFQ was food group based, and included prompts about local foods in each category and the number of times the food was consumed during the week. Quantification of portion sizes of foods was not collected due to limits on the amount of time participants could contribute to the surveys. 2. Ten (10) focus groups (five in each community), targeted at the primary caregivers of children ages 6 to 36 months (men and women) and pregnant women. In each community, one focus group was held with male caregivers; three focus groups were held with female caregivers; and one focus group was held with pregnant women. Focus group sizes ranged from four to ten participants, who were recruited by community health promoters, community leaders, and local field staff. Question guides covered the following thematic areas: knowledge and perceptions of malnutrition and illness in young children and pregnant women; knowledge and perceptions of prevention and preventive health behaviors; sources of health information; feeding patterns, practices, behaviors, perceptions and attitudes; knowledge of and attitudes toward fortified foods, vitamins, and junk foods; food security and purchasing behaviors. a) Xejuyu: 10 male caregivers, 20 female caregivers, and 4 pregnant women (total n=34). b) Kexel: 5 male caregivers, 18 female caregivers, and 5 pregnant women (total n=28). 3. Twenty three (23) semi-structured, key-informant interviews (KII) were conducted with community leaders as well as with local field staff of Wuqu Kawoq and with staff of other NGOs working on nutrition programming in the communities. Question guides covered the following thematic areas: perceived extent and causes of child malnutrition at community-level; opinions about ideal roles of various actors in improving child nutrition; perceived challenges in nutrition programming; effective strategies for information dissemination and behavior change. a) Kexel: 8 community leaders (3 males, 5 females): men were council members, elected town officials, and the pastor from the local evangelical church; women were representatives of the local organization that coordinates development projects, from the local schools parents association, from the board of a womens cooperative group, and a local healer (curandera).

b). Kexel: 3 female Wuqu Kawoq program coordinators and health educators with five years experience in the community. c). Xejuyu: 3 community leaders (1 male, 2 female): Town officials and local midwife (comadrona). d). Xejuyu: 9 NGO staff members (3 males, 6 females): Wuqu Kawoq employees who have worked as program coordinators and health educators (7); staff at another NGO providing primary maternal-child health services (2). 4. Eighty-two (82) market surveys (45 in Xejuyu, 37 in Kexel), conducted with owners of small food shops (tiendas) and pharmacies (farmacias) in and near each community. Surveys covered the following thematic areas: store demographics; foods sold specifically for children; snack/junk foods sold; fortified foods sold; client preferences; average cost of different categories of foods; average amount that children and adults spend on snacks. All markets, stalls, stores and shops open during interviewing hours were selected within the community; a random sample of locations were taken in the larger towns outside of the two communities. Data from the caregiver survey and the market survey was coded and entered into Excel, checked for accuracy, and imported into STATA (version 11). Descriptive statistics were generated and multiple responses to survey items were analyzed using the MRTAB function. Statistical comparison of the two study communities were conducted using the Students t-test (for parametric continuous variables),Wilcoxon rank-sum test (for nonparametric continuous variables), and either the chi-square or Fischers exact test (for categorical variables). Throughout the report, the statistical tests used are noted as super-scripts: a (Chi-square), b (Students t-test), c (Fishers exact test), and d (Rank-sum test).Transcripts from the focus groups and key informant interviews were reviewed to create a preliminary codebook, which underwent five rounds of modification. Data was coded thematically using Coding Analysis Toolkit (CAT), an online qualitative coding software. Surveys, focus group guides, and codebooks are available upon request.

Institutional Context and Ethics

The study was approved by the Institutional Review Board of Wuqu Kawoq and the elected local leadership in each of the two communities. Verbal informed consent was obtained from all participants. During the informed-consent process, study participants were notified that the decision not to participate would not affect clinical care or services received from Wuqu Kawoq. Surveys were not linked in any way to respondents identifiable data.

General Demographics, Poverty and Food Security

The community in the Bocacosta region, Kexel, is made up of approximately 100 families. The community is of Maya descent, but speaks mostly Spanish, although most heads of households still retain conversational ability in either Kaqchikel or Kichee. 6

Most residents work as seasonal agricultural day laborers or in construction; only 28% of households own land. Frequent underemployment is common, with 28% of households living on less than $2 USD per day.3 Wuqu Kawoq has collaborated with this community for approximately six years in developing childnutrition programming, reproductive health services, a primary care clinic, and potable water initiatives. The community in the Central Highlands, Xejuyu, is made up of approximately 250 families. Virtually all members of the community speak Kaqchikel in daily civic and domestic transactions, although many, especially males, do have some proficiency in Spanish. Many households own and cultivate their own land (68% compared to 28% in Kexel, p=0.000a), and 45% of households live on less than $2 USD per day.4 Wuqu Kawoq has collaborated with this community for approximately two years in the formation of various development projects, including clean water infrastructure, disaster relief, and child-nutrition programming. During focus groups, participants in both communities reported struggles with periods of food insecurity, i.e. inadequate availability and access to enough healthy, safe, and nutritious foods to feed their families. They reported the frequent need to make decisions on which necessity (food, schooling, clothing, healthcare, etc.) to spend their limited resources. In focus groups conducted in Kexel, men reported that the need to pay for other expenses affected the amount of money spent on food. These other expenses included firewood, corn, electricity, cable, primary school expenses, medicine, and lodging/travel expenses to and from their job sites. Men reported selling tools or working extra hours when there was not enough money to cover all household expenses. The majority of the men interviewed reported not having adequate land. However, some men reported having enough land to cultivate both coffee for sale as well as corn and beans for home consumption. Less than 30% of families (of those interviewed in the caregiver survey) in the Bocacosta owned land or consumed food grown on their land; almost none of the families had male heads-of-household who were subsistence farmers. Many female participants added that they often supplemented family income in times of scarcity by engaging in small-scale retail activities. One woman said that in times of economic need, she would borrow money from neighbors and/or family. In the Highlands, findings of focus groups in Xejuyu differed in that the issue of food insecurity was much more prevalent in discussions than it was in the Bocacosta. Among the cited factors

contributing to food insecurity were the high cost of food and other basic necessities. This finding was surprising, given the fact that significantly more families in the household survey reported owning land (69%), producing food for home consumption (67%), or engaging in subsistence agriculture (35%). As a result of the lack of economic resources, men reported often trying to find work outside the community or borrowing money to cover their household expenses, subsequently repaying the loan during harvest season. Men reported that food production was generally not sufficient to satisfy domestic consumption needs, and that it was often necessary to purchase additional food, causing considerable economic hardship. Likewise, women reported that they often restricted themselves to purchasing less expensive foods rather than more highly-desired foods, such as beans or meat. While women voiced their concern over food insecurity, they also acknowledged that some families were able to eat food what they grew; these included beans, corn, and broccoli. Men reported taking advantage of times of greater financial security, such as crop harvests, by buying extra food and other household needs such as clothing.

Family Structure, Roles, and Decision-making

In most households, the mother and father of the subject child were married (85%), with a small number of couples cohabitating (11%); the remaining women were single or separated. There was no statistically significant difference between the two communities in this regard.a Many of the families had both mothers and mothers-in-law (childs paternal grandmother) actively sharing tasks and responsibilities. There was an average of 6.97 people and 3.93 children per household, with no significant differences between communities.b In focus groups, men were most often identified as the primary income generators, along with older sons in some cases. Mothers taking part in the structured survey were on average 28 years olda; 54% were literatea with 3.5 years of educationb. There were no statistically significant difference between communities on these measures. Many males in the households (husbands, older sons) were able to read and write, so that at least one person per household was literate. In Xejuyu, men in the community are much more fluent in Spanish than the women, who are often monolingual; in Kexel, both men and women in the community speak Spanish, with some of the population retaining bilingual skills. In the structured surveys, caregivers were asked who was responsible for making food purchases, and who made food purchasing decisions; the most common answers are listed in the table below. No statistical difference was found between the two communities in responses to either question. These results show the importance of the mother and mother-in-law (paternal grandmother) when it comes to making decisions about and purchasing food for the household.

Makes Household Food Purchasesa Highlands Mother of the child Paternal grandmother Father of the child Maternal grandmother 59% 30% 10% 5% Bocacosta 70% 13% 5% 7%

Makes Household Purchasing Decisionsa Highlands Mother of the child Paternal grandmother Father of the child Maternal grandmother 71% 22% 2% 3% Bocacosta 62% 15% 12% 6%

Caretakers responding to the survey on average made 1.2 and 3.1 major shopping trips per week in the Highlands and Bocacosta, respectively (p = 0.00d). More than half of caretakers in both communities made additional minor trips to buy bread, fruit, chicken, soda, gelatin, juice, chips, instant soup, cake, and cheese. Caretakers surveyed bought their food from different locations, including supermarkets, street vendors/market stalls, and small stores (tiendas). The most common are listed in the table below. Note that in the Highlands, small stores were where most food purchases were made, while in the Bocacosta, street vendors were popular in addition to tiendas. Supermarkets were used only by one third of all households in both communities.

Location of Purchases Highlands Large supermarket Small stores Street vendors/ market stalls 33% 87% 15% Bocacosta 42% 64% 54% P-valuea 0.37 0.01 0.00

Cultural beliefs and traditions play a large part in family structure and roles of individual family members. Indigenous Guatemala has a tradition of interdependent gendered divisions of labor. Under such traditions men occupy public spaces and women occupy domestic spaces. This public/private dichotomy translates to cultural expectations for the behavior of men and women.7 Several focus group participants said that parents needed to set positive examples for their children. These positive examples of correct familial roles for mothers and fathers were nearly identical as reported by men and women from both communities. While female household members roles were mainly focused on shopping, feeding, and caring for children, male household members roles centered around providing the funds to feed the whole family and to school their children. In both the structured survey and the focus groups, food purchasing and decision-making surrounding food and meals were reported as as being roles for women in the household. Although the dominant woman of the household was usually the mother of the child in question, in a significant proportion of households (19% in the structured interviews), the motherin-law (childs paternal grandmother) played a dominant role. Some mothers reporting that their husbands gave the money for household expenses to the mother-in-law rather than to them; in several other instances women stated, My mother-inlaw is the one who is in charge of going shopping. My husband gives money to his mother. The prevalence of mothers-in-law as additional caregivers is not surprising given Mayan patterns of patrilocal residence following marriage.7 As the primary wage8

earners, men often exert control over the amount of household funds spent on food, although they were not usually involved in specific decisions about food purchases. Despite less involvement in day-to-day food decisions, many male focus group participants nevertheless took their role as bread-winner quite seriously and were aware of the implications of their income on the health and wellness of their children. One participant stated, As the father it is my responsibility to not leave the children hungry. Female participants corroborated this sentiment: If fathers dont provide for their children, that is when they fall into malnutrition.

Child Care and Feeding Practices

Roles and Respondsibilities for Child Care
In both communities, around one-third of children had another important day-to-day caregiver other than the mother. Most commonly, this caregiver was the childs paternal or maternal grandmother or older sister. Fathers were seen mainly as providers, although the importance of fathers playing with their children and encouraging their schooling was mentioned. In the male focus groups, participants offered incisive and reflective commentary on the causes, prevention, and treatment of problems related to child health, nutrition, and physical and psychosocial development. However, in female focus groups, participants often commented that men were only peripherally involved in the dayto-day decisions regarding child welfare.

Breastfeeding Frequency and Duration Highlands Frequency 1-2x/day 3-6x/day 6-10x/day >10x/day Duration <5 min 5-10 min 10-30 min > 30 min 3% 24% 53% 16% 44% 33% 21% 2% 5% 22% 27% 46% 5% 18% 26% 51% 0.00 Bocacosta P-valuea 0.97

pregnant results in the child becoming ill (with vomiting/diarrhea) was a common theme. Although we did not specifically ask in focus groups if becoming pregnant was a reason for weaning a child, this practice was mentioned in several side conversations with the researchers. Studies in similar settings9-10 have also shown that becoming pregnant is often a cause for weaning. Another belief mentioned in the focus groups was that weaning a child before the child is ready can cause illness or difficulties, such as rejection of complementary food, psychological distress, or gastrointestinal upset. Use of infant formula was very uncommon, with only five caregivers reporting its use in the preceding week.

Breastfeeding and Weaning Practices

Appropriate childcare and feeding practices and behaviors are critical for adequate growth and development, and as well as to avoid illness. Breastfeeding and weaning practices are important determinants of growth and development not only in infancy and childhood but also later in life.8 Poor infant-feeding practices can lead to stunted growth, delayed motor and mental development, a weak immune system, and increased risk of infectious diseases such as diarrhea.6 Early childhood nutrition status also has impacts on income earning potential, physical work capacity, and attainment of education in adolescents and adulthood. The current WHO recommendations6 support exclusive (only breast milk from birth), on demand (as often as the child wants day and night) breastfeeding for the first 6 months of life with the addition of appropriate complementary feeding (the introduction of solid foods and gradual replacement of breast milk as the primary source of nutrition) starting at six months. Additionally, WHO recommends continuing breastfeeding until 24 months to ensure a childs growing nutritional requirements are met. The benefits of following these recommendations are well established, particularly in resource-poor environments where early introduction to liquids and food often leads to exposure to contaminants and inadequate breastmilk intake, and where late introduction or introduction of inappropriate complementary foods provide nutritionally inadequate diets. To assess the relationship between WHO infant feeding guidelines and practices in the study communities, information on breastfeeding, complementary feeding, and dietary recall information were collected through structured surveys. Adherence to continued breastfeeding and appropriate timing of complementary food introduction were relatively high in both communities. Seventy nine percent (79%) of all the children surveyed in both communities were currently breastfeeding; this number rose to 90% for children under 24 months. Mothers in both communities tended to breastfeed six or more times per day, with the majority of women breastfeeding more than ten times per day. The communities differed on breastfeeding duration: women in the Highlands tended to breastfeed longer (10+ minutes), while women in the Bocoacosta tended to breastfeed for less than four minutes. Multiple constructs surrounding breastfeeding emerged from the focus group data. The idea that breastfeeding a child while 9

Complementary Feeding Practices

When breast milk is no longer enough to meet the nutritional needs of the infant, complementary foods should be added to the diet of the child. This is a very vulnerable period as it is the time when malnutrition starts in many infants. In order to protect against malnutrition, WHO provides guidance on best practices for complementary foods. First, complementary feeding should be timely, meaning that all infants should start receiving foods in addition to breast milk from six months onwards. Next, it should be adequate, meaning that the complementary foods should be given in appropriate amount, frequency, consistency and variety to cover the nutritional needs of the growing child while maintaining breastfeeding. Foods should be prepared and given in a safe manner, meaning that measures are taken to minimize the risk of contamination with pathogens. Finally, they should be given in a way that is appropriate, meaning that foods are of appropriate texture for the age of the child and caregivers use responsive feeding techniques.6 Only three caregivers of the 102 interviewed in the structured survey observed that their children were not yet taking complementary foods. The average age of introduction of solid foods was 7.3 2.0 months (range 3 to 14 months) with 73% of children starting complementary feeding between six and eight months; this did not differ between communities.b The percentage of caretakers that reported not initiating complementary foods or liquids until age six months or older was 98% in the Highlands, compared to 90% in the Bocacosta (p=0.08a). The first foods commonly given to infants included bean or potato purees, rice, noodles, soup, and Gerber baby foods. The average age of introduction of first liquids (other than breastmilk) was 6.0 3.0 months (range 0 to17 months), with no statistical difference between the two communities.b First liquids included Incaparina

and other atoles (thin beverages made of corn/soy flour or other flours, water, and sugar), boiled water (with and without sugar), and coffee (with sugar). The distribution of first liquid types provided did differ between communities (p=0.00)a; 80% of children in the Highlands received a type of atol (Incaparina) as their first liquid, whereas almost 50% of children in the Bocacosta received a nutrientpoor beverage (water or coffee, plus sugar). Seventy-three percent (73%) of children started complementary foods between the age of six and eight months of age and 85% of children had their own bowls. WHO Complementary feeding indicators were calculated for children 6 to 23 months of age using data from 24-hour recalls taken as part of the structured survey; minimum dietary diversity (food groups/day), appropriate meal frequency (meals/day), and minimum acceptable diet (composite indicator) were poor in both communities, and significantly worse in the Highlands. The mean number of food groups consumed per day by children 6 to 23 months of age in the Bocacosta was 2.97 0.17 and was 2.13 0.19 (p = 0.003b) in the Highlands. The mean meal frequency for children 6 to 23 months of age in the Bocacosta was 3.21 0.19 and in the Highlands was 2.74 0.14 (p=0.049b). WHO recommends children 6 to 23 months consume at least four of the seven food groups per day and four meals/snacks per day as these patterns have been associated with better quality diets. Although no country or regional level data is available for Guatemala, country-level data for neighboring Honduras is displayed below as a comparison.11 WHO Indicators for children 6 to 23 months of age Highlands Minimum Dietary Diversity Minimum Meal Frequency Minimum Acceptable Diet 12.5% 6% 2.5% Bocacosta 35% 37.5% 20.6% P-valuea 0.07 0.001 0.01 Honduras 65% 77% 52%

Of note, children 6 to 23 months surveyed in the Bocacosta were slightly older on average by about one month (15.27 months vs. 14.24 months on average), and in our structured survey age was found to be moderately correlated with both meal frequency and dietary diversity (0.34, p=0.003; 0.40, p=0.0004, respectively). However, the difference in age between the two communities was not statistically significant (p=0.35b). Caretakers were also asked about the number of servings their child consumed of a list of varied foods (53 foods, 15 beverages, and free response) in the past week, using a food frequency questionaire. As shown below, statistically significant differences between consumption patterns for children 6 to 23 months existed. In the Bocacosta, children consumed significantly more servings of fruits, animal foods, dairy, refined sugar, high sugar beverages, and junk foods; in the Highlands, children consumed more atol (Incaparina). Although both study communities are rural, in the Bocacosta community, there has been more penetration of processed and prepared foods. Therefore, these results are explicable, and they are qualitatively similar to studies that have compared the feeding practices of infants in other rural Highlands communities to infants from urban Guatemala City.12 Seven-day food recall for children 6 to 23 months (servings/week) (*=WHO food groups) Cereals & tubers* Vegetables* Fruits* Vitamin A rich foods* Animal foods (including eggs)* Legumes & nuts* Dairy* Childrens fortified foods Commercial/packaged foods Added fat Junk foods Refined (added) sugar Soda and store-bought juice All high sugar beverages (home-made tea, coffee, and juice drinks; store-bought soda and juice) Atoles Broth 10 Highlands 19.7 1 14.2 1.1 3.6 0.4 2.9 0.3 3.0 0.4 1.8 0.3 0.6 0.1 4.5 0.5 2.6 0.3 4.6 0.4 0.7 0.2 12.4 0.9 1.6 0.4 4.2 0.6 5.8 0.4 3.4 0.4 Bocacosta 21.2 1.4 12.8 1.4 6.0 0.7 3.8 0.5 4.2 0.4 2.0 0.2 4.4 0.4 4.5 0.4 3.0 0.6 4.5 0.5 5.7 0.5 19.9 0.8 1.6 0.2 6.1 0.6 3.3 0.5 2.6 0.4 P-value 0.37b 0.45b 0.003b 0.44d 0.034b 0.43d 0.000b 0.93b 0.84d 0.86b 0.000d 0.000d 0.33d 0.043d 0.001d 0.12b

A total of 57 different food items were mentioned during 24-hour recalls by the 102 caregivers of children 6 to 36 months in both regions.This represents the cumulative dietary variety at the sample level. Of the 57 food items, 15 were unique to the Bocacosta while only six were unique to the Highlands. Many of the food items unique to the Bocacosta were commercial foods, including infant formula, Gerber baby food, margarine, and yogurt. Junk foods such as chocolates, cake, and gelatin were also uniquely consumed by respondents in the Bocacosta. The Highlands were unique in a variety of traditional greens and vegetables. For both communities, however, none of the unique food items received a large number of mentions. Below is a table of the top 10 foods mentioned by caregivers in the 24hour food recall. Top 10 most-mentioned foods from 24-hour food recall Highlands Food Tortillas Atol Coffee Broth Rice Beans Oil Eggs Banana Noodles Total mentions 113 98 39 31 28 25 17 16 16 14 Bocacosta Food Total mentions Tortilla 85 Coffee 59 Eggs 28 Oil 27 Bread 25 Noodles 22 Rice 19 Beans 18 Atol 13 Cookies/crackers 10

Foods and Feeding Patterns

Both men and women in the focus groups reported that the whole family ate the same types of foods and that no special foods were bought for children. The foods that were mentioned as bought specifically for children included instant soup mixes, refried beans, noodles, milk, eggs, oats, Cornflakes (cereal), Gerber baby-food products, and Nestle baby cereal. One mother participating in a focus group summarized the prevailing philosophy, Almost everything is done together. Theres not a part for the baby thats spent separate from our expenses for food. Everything is together. Whatever food it is that you eat, thats what the child eats too. In the structured survey, caregivers were asked if they purchase foods specifically for children; only 8% and 16% of caretakers in the Highlands and Bocacosta respectively responded that they did (p=0.19a). Among the minority of female caregivers who did report buying special foods for their children, a common theme was experimenting one by one with individual food items (such as those described above), in order to determine which best suited their children and which did not. These caregivers also reported buying foods such as chow-mein packets (Chinese-style flavor and noodle mix) for family meals from time to time in order to provide children (and adults) with tastes of new foods, even when these could not be purchased regularly due to cost.

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Caretakers in the structured surveys were asked if their child consumes commercial or prepackaged foods, how often, and which foods. On average, 75% of caretakers in both communities said their child consumed these foods approximately three times per week. The types of foods that were most often mentioned in each community included instant soups/broth packets, oatmeal, soda, juice boxes, and canned refried beans. Of note, some of the commercial foods mentioned included certain brands of juice boxes and powdered drink mixes that are also fortified (typically with vitamin C). Caretakers were also queried on their knowledge and purchasing and consumption habits regarding fortified foods for children. For most caretakers, the term fortified food was synonymous with the popular corn-soy product Incaparina that is frequently prepared as a thin gruel beverage. The term was not well understood generally, as many focus group participants also thought that a number of unfortified foods were fortified, especially canned black beans, soup mixes, and meats. Taken all together, commercial fortified foods for young children were consumed by 60% of children on at least a weekly basis. However, Incaparina made up the majority of these reported foods (46 mentions), with Nestle Nido (11), Quaker Mosh (9), Gerber products (6), Anchor powdered milk (4), Nestle Nan (4), and Corazon de Trigo (3) also being mentioned. To complement the surveys of caregiver purchasing behaviors, survey of vendors in and around both communities were conducted, as described above under Methodology. Eighty percent (80%) of the vendors surveyed currently sell or have sold commercially fortified foods; the most common foods (mentioned more than 10% of the time) included Incaparina, Corazon de

Trigo, Quaker products, Gerber products, and powdered milk. A complete list of fortified foods sold in surveyed markets can be found in Appendix B. A popular marketing strategy for fortified products targeted at young children among vendors was to declare their vitamin content and health/nutritional benefits to potential customers. They were usually aided in these declarations by slogans and informational blurbs printed directly on individual products or marketing materials provided to them by distributors. As examples, the printed slogans of three popular products are reproduced below: Kerns Fruit Juice Juniors With vitamin C, calcium and zinc especially for growth Nestl Nestum Cereal Infantil Helps strengthen natural defenses of your baby - Immunonutrients: iron, zinc, vitamins A & C - 13 vitamins Quaker Avena Mosh Nutrems Iron, calcium, zinc, vitamins prevents anemia, strengthens bones, helps growth In each vendor establishment, vendors estimated the amount spent by caretakers per individual food item. Prices for the common fortified childrens foods ranged between 4Q and 9Q (quetzals, $1 USD = approximately 8Q; $0.50-$1.13) with single-servings costing on the lower side; there was no statistical difference between the communities.a Although on first pass, these prices seem fairly nominal, the problem of limited financial resources and the high cost of these food items was one of the most frequently cited reasons in focus groups for why they were not purchased more often. As one female focus group participant

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observed, If I buy a bag of Incaparina for my children, I am unable to buy corn to feed the rest of my family. This portion of the study was designed to examine the availability and purchasing behaviors surrounding specific commercial foods for children. As such, it did not examine the availability, purchasing or consumption of basic fortified-food staples, such as flour and sugar. However, numerous other studies have examined this issue. For example, in a recent SIVIM report2, 77% of children under five years of age were found to consume vitamin-A fortified sugar daily, while 48% consumed iodized salt daily, and 16% consumed iron-fortified bread daily. Eighty-seven percent (87%) of households had sugar that was fortified to adequate levels, while only 27% of households had adequately fortified salt. Of the 59 samples of bread that were tested in the study, all were found to be fortified to some degree with iron, however most were fortified less than is legally mandated.

Vitamins and Micronutrient Supplements

Focus groups explored participants understanding of the concept of vitamins (i.e. vitamins and minerals; minerals were not mentioned separately or specifically). Most focus group participants could correctly identify many of the general functions of vitamins and minerals. Commonly mentioned functions of vitamins included preventing and curing malnutrition and anemia; giving energy; strengthening and protecting the body; and helping growth (height, weight) and development. Participants also reported that the main source of vitamins for their children came from foods rather than from supplements. Some added that health centers sometimes provided vitamins in their communities, but usually only for pregnant women. Particularly in the Bocacosta, participants also added that this source of vitamin supplements was not reliable, since health centers often ran out of vitamins or did not give pregnant women a full months supply. Importantly, participants did not identify health centers or other distribution programs as an important source of vitamin supplements for children. This focus groups consensus mirrors findings from other recent studies of micronutrient consumption. For example, in the 2012 SIVIM report2, some 600 caregivers reported their childrens consumption of micronutrient supplements in the previous day. In this survey, 3.5% of children consumed iron sulfate, 1.5% consumed vitamin A, 1.3% consumed folic acid, 0.9% consumed zinc, 1.9% consumed micronutrient powders (Chispitas), and 5.1% consumed some other micronutrient. On the other hand, as also alluded to in the focus groups, micronutrient consumption during pregnancy was more common; of all the women surveyed in the SIVIM who had a pregnancy in the last five years, 66% and 63% reported receiving ferrous sulfate and folic acid, respectively, while 51% received prenatal multivitamins. In both communities, many caregivers mentioned that their families are too poor to buy micronutrient or vitamin supplements for their children. Therefore, they state that they rely on their diets to supply adequate vitamins. In the Bocacosta community, foods perceived to have a significant vitamin content included greens, atoles, orange juice, dried salted fish, beef broth, carrots, and free-range chicken; in the Highlands community, these foods included greens, V8 juice, eggs, free-range chicken, Incaparina, mosh (oatmeal), wheat cereal (Corazn de Trigo), cucumber, and citrus.

Healthy and Unhealthy Food Beliefs

Caregivers characterized healthy foods as those that contain vitamins and some fat. Most commonly, caregivers referred to natural foods as the healthiest foods. Participants in focus groups referred to natural foods as those that one can grow oneself, as well as those that contain no chemicals or preservatives. Most commonly cited as natural foods were black beans and greens (hierbas). The category of natural foods also encompassed free-range chicken, while participants expressed that cage-raised chickens are not natural foods. A few fortified foods and very few commercial or prepared foods were mentioned as healthy foods. Caregivers characterized unhealthy foods as those that have chemicals or preservatives, which are thought to destroy the vitamin content within; foods with artificial food coloring; those that lack vitamins; and those that cannot be digested by childrens intestines. Canned and packaged foods were also mentioned during discussions around unhealthy foods, as community members felt that these foods are full of preservatives and chemicals and that one never knows whats really in them as they might be manufactured in foreign countries. Additionally, focus group participants expressed concerns that packaged foods might sit around on shelves for years before purchase and could already be expired when bought. Junk foods (comida chatarra), such as sweets, soda, and chips were also repeatedly labeled as unhealthy; some of these foods were reportedly prohibited for young children as they were thought to provide excessive fat and sugar. Healthy foods: Household: vegetables (greens, beans, cucumber, plantains); fruits (bananas, citrus); dairy (cheese, cream, milk); eggs; animal foods (pork, chicken, sausage); broths; home-made atoles (corn and rice based); starches (yucca, potatoes, noodles, rice, bread, crackers, oats); peanuts; juice. Prepared: Tamales; Chuchitos; fried chicken Packaged: Incaparina; Protems; Corazn de Trigo; Corn Flakes Unhealthy foods:

Household: cage-raised chicken

Prepared: canned foods, instant soups Packaged: sweets, candy, cookies, crackers, ice cream, packaged chips, soda, everything that is sold in small shops (tiendas) 13

Snacking Behaviors and the Role of Junk Foods

Several caregivers had heard during consultations with the local health center staff that it is important for children to snack twice a day. These parents remarked that when they do have a few extra quetzales (local currency, 1 USD = approximately 8Q), they like to buy snacks for their children that are not shared with other household members, such as atoles (corn gruels, Incaparina), bananas, bread, cookies, juice, milk, fruit (apples, bananas, papaya, watermelon, and peach), oatmeal (mosh), and potable water. Parents in focus groups in both communities typically did not mention buying junk foods as snacks for their own children, and they generally labeled these foods as unhealthy. In fact, several participants specifically criticized their neighbors junk food buying behaviors. In the 7-day food recalls, children in both communities consumed junk food weekly at ages 6 to 23 months; this ranged from about one serving per week in the Highlands to almost 6 servings per week in the Bocacosta (p=0.000d). Occasionally, focus group participants would remark that providing a child with junk food as a snack is often easier, more convenient, and less timeconsuming than cooking and using up firewood to prepare snacks for children while simultaneously attempting to perform other daily household chores. This study found that children themselves often buy their own junk food snacks, although this behavior tends to involve children older than those in the age range that are the focus of this study. Nevertheless, older siblings purchase of junk foods snacks often sets expectations or models of consumption behaviors for younger siblings; older siblings may also be purchasing snacks for their younger siblings as well. For example, one female caregiver remarked that she often leaves fifty-cent pieces sitting on the countertop for errands she plans to run, but that her young children take the money and buy themselves treats at a local tienda. Other mothers reported that their young children buy

junk food during recesses at primary school, and that parents feel bad denying their children the fifty cents or one quetzal because they do not want their children to feel left out when other peers buy snacks. In order to collect data on junk food purchasing using an approach aside from direct questioning of caregivers, the market survey component of this study also incorporated this theme. Vendors were asked who (i.e., children, parents, other family members) most often purchased junk foods for children; interestingly, vendors reported that children themselves, rather than their caregivers, were the purchasers a full 50% of the time. Indeed, more than 95% of store owners reported routinely selling junk foods directly to children, and they estimated that the average age at which children began to purchase snacks was around five to six years of age, with no statistical difference between the two communities.b Vendors estimated the average per-purchase amount spent on junk foods at 4Q ($0.50 USD) in the Highlands and 5.5Q ($0.70 USD) in the Bocacosta (p=0.06b).

Child Health and Illness Prevention

In all focus groups, participants were asked what illnesses were common among children and how best to prevent them. During each group, these questions were asked in a variety of ways in Spanish or Kaqchikel because caregivers typically responded to initial questioning about disease prevention with what the researchers considered curative behaviors. Caregivers were asked how to ensure that illnesses did not affect their children (e.g., para que no les peguen las enfermedades, Sp.; achike modo yeito chwch jun yabil, Kaq.); how to avoid illnesses among their children (evitar, Sp.; richin man nuya ta chi ke jun yabil, Kaq.); and how to prevent illnesses among their children (prevenir, Sp.; -kl, Kaq.). A range of illnesses (including cold, diarrhea, ameobas, infections, etc.) were identified by focus group participants as having the following five main causes: transition from breastfeeding to solid foods; poor hygiene and food safety behaviors (covering food, cooking food well, hand washing); infection/body weakness; environmental factors (winter and rainy seasons); and local traditional beliefs (evil eye, breastfeeding while pregnant, not fulfilling pregnancy cravings, fright). Typically, community members stated that when a child is sick, they visit the health center; buy medicine in a pharmacy or a local shop per recommendation of the shopkeeper, family members, or other community members; visit the clinic of an NGO operating locally or within the region; or seek out a private physician for consultation. Other responses given less frequently included home and/or herbal remedies; praying to God; asking advice of ones husband, family members, or elders; and seeking care immediately with local healers or health promoters. Caregivers understood and practiced many preventative behaviors, despite the difficulty in eliciting the concept of prevention of illness in discussions. These included maintaining a clean house; bathing children; washing clothes often; washing hands; drinking only potable water and cooking food well; and feeding children natural food (and not junk food). Staff perceptions of community members understanding regarding the prevention of illness were mixed: they reported that culture, access to reliable medical care, and resources played into preventative beliefs and actions. 14

Child Malnutrition
Focus group participants were queried about their understanding of child malnutrition. In general, participants of all focus groups referred to child malnutrition as an illness/ disease (enfermedad, Sp.; yabil, Kaq.) caused by lack of (quality) food and closely and unanimously associated with limited economic resources.Other identified factors which were thought to contribute to child malnutrition included lack of caregiver knowledge about recognizing and understanding malnutrition; poor knowledge and behaviors around feeding (inappropriate breastfeeding duration, meal frequency, and meal quantity, and provision of junk foods or low-nutrient foods); poor care and hygiene behaviors (lack of hand washing, allowing children to crawl in dirt, lack of attention to childs nutrition and health status); common illnesses and infections (and associated poor appetite, diarrhea, and vomiting); and inadequate family-planning and birth spacing-related responses. In the Highlands, particularly, women expressed desires to use birth control, especially after having five or more children, but reported being unable to do so if their husbands did not agree. Notably, however, men in the Highlands directly linked frequent births and breastfeeding among women to childrens malnutrition and suggested a great need for family planning initiatives in the region. When asked to describe the physical characteristics of a malnourished child, respondents often first provided descriptors of acute malnutrition (thin, can see ribs, swollen stomach, weak, lacks bodily defenses). However, some participants did identify features more typical of chronic malnutrition/stunting (short for age, looks younger than age) or micronutrient deficiency states such as anemia (pale/pallid skin). When asked to describe the psychomotor characteristics of a malnourished child, participants most often observed effects on basic developmental milestones (delayed walking or talking), energy level (fatigued, 15

not participating in usual play activities) and, for older children, cognitive function (child does not perform well in school, does not follow instructions, has poor memory). When asked to describe the feeding behaviors of a malnourished child, participants most commonly observed anorexia or rejection of specific foods. Of note, caregivers in the focus groups felt that their children or children they knew, exhibited some, but not all, of the characteristics discussed, and were unsure how to determine whether a child is malnourished or not. Some focus group participants characterized child malnutrition as a serious problem both in severity and frequency in the community, but some believed it was mainly a problem in other areas of Guatemala, characterized by the very skinny children that are seen in the newspaper. It should be noted that in each community, Wuqu Kawoqs nutrition programming involvement includes measuring of height and weight and regular discussions with caregivers (in their primary language, whether Spanish or Maya) about malnutrition and specifically stunting (low height-for-age). Historically, health workers in the communities have detected very few cases of acute malnutrition. Therefore, at first pass, it is notable that participants first and most commonly identify features of acute malnutrition. However, at the same time, cases of acute malnutrition are commonly represented (often graphically) in newspapers and other media outlets, which might partially explain the salience of these features. Furthermore, as described previously3, chronic malnutrition/stunting, although highly prevalent in Guatemala, has not until very recently captured the attention of a broad public/private consensus, which further explains why community participants still struggle to articulate its features. Finally, since chronic malnutrition rates in both these communities have historically been very high, it is also not surprising that recognizing this form of malnutrition is difficult. When most children are stunted, short stature becomes normalized and does not stand out as abnormal.3 In the structured survey, one question asked whether the respondent

thought their own child (6 to 36 months) was malnourished. In the Highlands, 38% responded yes and 17% were unsure; yes and unsure responses in the Bocacosta were 28% and 20%, respectively. There was no statistical difference between the communities for these responses.a Focus group participants were also queried regarding their perceptions of potential solutions to child malnutrition. Responses in both communities were fairly similar; the most commonly offered solutions included providing supplemental foods and vitamins, as well as medical care to children. Caregivers in both communities felt that it was often necessary to provide malnourished children with larger quantities of food; foods with higher vitamin content; or specific recuperative foods such as milk, grain products, fruits, and vegetables. However, on further query, these strategies were closely linked in participants minds almost exclusively to cases of acute malnutrition. Most focus group participants strongly emphasized the role of food or micronutrient supplementation in the care of the malnourished child. Micronutrient supplements or supplemental foods were thought to help prevent and cure malnutrition; prevent anemia; help a child gain weight; and restore appetite. A frequent caveat given was that supplements were not helpful alone if an underlying concurrent medical illness was not simultaneously addressed. Among focus group participants who had been the beneficiaries of supplement distribution programming, products reflecting the history of Wuqu Kawoq and other organizations involvement in the communities, such as Incaparina, Vitacereal, Bienestarina, Chispitas, and PlumpyDoz were mentioned; these products were thought to have been effective in helping malnourished children recuperate. 16

In all focus groups, participants were asked how to prevent malnutrition among children. During each group, these questions were asked in a variety of ways, including how can caregivers ensure that malnutrition did not affect their children (para que no les pegue la desnutricion, Sp.; achike modo yeito chwch ri yabil desnutricin, Kaq.); how to avoid malnutrition among children (evitar, Sp.; richin man nuya ta chi ke ri yabil desnutricin, Kaq.); and how to prevent malnutrition among their children (prevenir, Sp.; -kl, Kaq.). Similar to the situation encountered when querying about preventing child illness, the concept of malnutrition prevention was elusive to direct questioning and often not well understood. However, occasional casual side conversations with investigators throughout the course of the study provided some insight into caregivers preventative practices. For example, some female caregivers felt that eating well and taking vitamins were crucial practices that could maintain child health. Notably, numerous best practices that are closely linked to the prevention of malnutrition were common and well-understood themes elaborated in all of the focus groups. These practices included proper hygiene (washing hands, bathing children); food safety (properly washing foods, cooking foods thoroughly, drinking only potable water, discarding spoiled foods); food choices (junk foods, fortified foods, fruits and vegetables); and deworming. However explicit linkages between these practices and the prevention of malnutrition were only rarely made by focus group participants. Other preventable behaviors were mentioned, but caretakers acknowledged more knowledge is needed to enact them. These included food preparation (ways to preserve vitamins) and appropriate feeding (amounts, types, times, and introduction of new foods). Since limited awareness of malnutrition prevention was a major feature of the community focus groups, this was explored in greater detail with the staff of various NGOs (including our Wuqu Kawoq field staff) working on child malnutrition in the region. Most staff members corroborated that the concept of prevention barely existed for most community members. They felt that most individuals addressed health and nutrition problems only after they were already present. Some staff generalized that a lack of preventive health behavior is a feature of the entire Guatemalan population. Furthermore, one health educator hypothesized that, until reliable and effective cures for common illnesses are available consistently throughout Guatemala, preventive health will remain a low priority for rural populations.

Malnutrition in Pregnant Women

A common tangential theme present in most focus groups was the link between health, nutrition status, and behaviors of a pregnant woman and her babys health and nutrition status. While malnutrition in pregnant women was perceived and reported as being uncommon in their communities, focus group participants in both communities reported that lack of appetite, lack of vitamins, weight loss, and anemia were not uncommon. Participants felt that the most common signs of malnutrition in pregnant women included poor fetal growth, poor appetite, vomiting, poor weight gain, fatigue or weakness, changes in vision, faintness, pale skin, and brittle hair. Interestingly, anemia and sleepiness were often seen as causes, rather than signs, of malnutrition. Solutions important

for preventing or curing malnutrition in pregnant women included finding ways to cope with nausea (so that food intake would remain adequate); eating nutritious and diverse foods such as atoles, fruits, and vegetables; taking prenatal vitamins; staying active and not sleeping too much; and going to prenatal checkups with physicians. In both communities, atoles and soups/broths were repeatedly mentioned as foods that give pregnant women strength. Atol, particularly, was believed to increase a womans weight gain during pregnancy. Importantly, infant malnutrition was correctly perceived to begin during pregnancy. Women reported that it was important to satisfy all of their food cravings, or else their baby might be born malnourished. Men felt that they were responsible for providing resources to buy extra food for their pregnant wives.

Health and Nutrition Information and Education

During structured surveys, researchers elicited caregivers common sources of health and nutrition information. In both communities, family members were a common source of health information, although there were some differences. For example, in the Highlands, 29% of caretakers received health information from family members, whereas this number rose to 70% in the Bocacosta (p=0.001a). In both communities, the family members that commonly provided this information were the primary female caregivers mother and her mother-in-law. The only other commonly cited source of health information for caregivers was health projects/health posts (Highlands 38% vs. Bocacosta 30%, p=0.37a). Notably, lay health practioners

(e.g., midwives), commercial outlets (stores, pharmacies), and media (radio, newspapers) were all negligible sources of health information. A large proportion of caregivers (Highlands 42% vs. Bocacosta 26%, p=0.08a) reported that, with regard to child health and nutrition, they were simply self-taught. Some participants responded that they preferred not to ask other community members for health advice. When queried, 95% of caretakers in both communities affirmed that they would appreciate more access to health and nutrition information. In the Highlands, group educational sessions and radio were popular options selected for additional health programming, while in the Bocacosta region, caregivers preferred to receive new health information either in group educational sessions or during individual clinical consultations. According to focus group participants, areas where health education was needed included general education about child nutrition (malnutrition, anemia, requirements for children and pregnant women, effects of inappropriate feeding practices), as well as more specific education about individual foods and vitamin/micronutrient supplements (characteristics of healthy and unhealthy foods, explanation of fortified foods and their use, nutritional value of packaged foods). These themes were also explored in key informant interviews with NGO staff, who commonly stressed the difficulty of behavior change work around improving child nutrition. Several staff reiterated that behavior change takes place over long periods of time and that constant reminders and repeated review of new health information are crucial to effecting behavior changes. One interviewee hypothesized that people who have completed primary school and/or secondary school are more likely to

17

accept health messages than those with lower levels of education. Another observed that for caregivers with many children, changing well-established household feeding and hygiene patterns and distributions of food was difficult and disruptive. This staff member also asserted that, due to household gender inequalities, even if women accept messages learned from health educational opportunities, since men authorize all decision-making they may prevent their wives from adopting new practices. Two educational strategies that were widely agreed upon were native language use and collaborative community efforts. Several interviewees remarked that speaking the language of the people (i.e. Kaqchikel) in consultations, classes, and meetings allows people to ask questions and clarify doubts. If instruction is given in Spanish, people pretend to understand to avoid embarrassment, even if they are mainly monolingual Kaqchikel speakers, and they leave the sessions and consultations without learning anything. Many NGO staff members also stressed that when health messages come from health promoters, community elders, and midwives, in addition to NGO programs, people are more accepting of new information. Other suggestions from key informants for improving health education delivery included making healthier food options for children available in local stores; using a positive deviance model to disseminate information; performing individualized needs assessments for families; and providing joint education to men and women.

Summary and Conclusions

Objective 1 of this study was to better understand feeding and care behaviors of infants and young children taking into account all of the factors that play a role in shaping knowledge, attitudes, beliefs, and practices of caregivers. This study found that some optimal feeding practices were well understood and practiced by the communities, while others were not. Seventy-eight percent (78%) of mothers reported exclusively breastfeeding their child with only 22% reporting any kind of pre-lacteal feeding. Most (90%) of children under two years were still being breastfed by their mothers. For comparison, 18

the national average for infants still breastfeeding at age two was 46%13 and exclusive breastfeeding was 56% in children under the age of six months.2 In the same report, some 600 caretakers in the occidental region of Guatemala participated in a survey that recorded feeding practices: 29.6% of children started complementary foods before the age six months; 56.6% started complementary foods between six to eight months; and 14% started after nine months of age. Although both this study and other studies do not show perfect adherence to ideal behaviors, they do indicate that there is a high level of awareness in the population as a whole about the need to engage in exclusive breastfeeding before six months and to introduce complementary foods beginning at or around six months. However, the strength of this study is that, rather than asking about feeding behaviors in a binary fashion alone, the structured surveys continued by probing for more nuanced details. Here, major deficiencies emerged. For example, a major feature of breastfeeding practices was insufficient duration of each breastfeeding episode. This was especially evident in the Bocacosta region, where a full 44% of women breastfed for less than five minutes per episode. This observation corroborates anecdotal findings from health workers programmatic interactions with caregivers over the years, where breastfeeding is often used primarily as a behavior tool (to calm crying infants). Short duration of each breastfeeding session can potentially have nutritional implications if the duration does not provide adequate caloric support to the infant. Although not discussed extensively in this paper, adequate birth-control options and birth spacing were notable themes in breastfeeding behaviors. Most women felt that the use of birth control was the decision of their husbands. If their husbands would not allow for use of contraception, this would lead to multiple, successive births requiring early weaning. When more details were solicited about the quantity, frequency, and quality of complementary foods being offered to children, several important features emerged. First, the average meal frequency in both communities was less than the four meals/ snacks per day recommended for this age group. The average number of food groups consumed was also lower than the four groups per day that is recommended. Children in the Highlands were found to have significantly worse indicators of dietary diversity and meal frequency than their counterparts in the Bocacosta, although both areas showed deficiencies. Factors which might explain the poorer adherence to ideal feeding behaviors in the Highland community include its greater distance from the nearest large town as well as higher household poverty rates. In both communities, the quality of first complementary foods was often nutritionally deficient. For example, in the Highlands, the most common first complementary food was bean puree; when researchers asked to see examples of this food, it was noted to be extremely thin (only liquid from cooked beans), not in keeping with the WHO recommendation that complementary foods should be of a thick enough consistency that they do not fall off a serving spoon. Similarly, in the Bocacosta, the most common first complementary food was soup/broth, again a food preparation with poor nutrient density. Along these lines, it is also significant that, in both communities, beverages (atol, coffee, water, + sugar) were introduced earlier than foods. Even fortified atoles (Incaparina, Bienestarina), potentially appropriate complementary food choices, are consistently prepared as a thin gruel beverage;

this is despite many unsuccessful attempts by community health workers to encourage more appropriate (thick) preparations. The two factors influencing young child feeding practices that came up repeatedly in the focus groups were economic scarcity and a lack of information and knowledge about what behaviors and practices are associated with healthier, well-nourished children. Parents reported that their financial situation often led to food insecurity and a lack of food expenditures and that this also affected the youngest in the household, particularly because the whole family eats together and eats the same foods. Caregivers were also eager for more specific information and recommendations on better young child feeding practices. Additionally, where specific optimal feeding behaviors (such as continued breastfeeding, appropriately timed food introduction, types of complementary foods, etc.) were identified by caregivers, these were not often perceived as closely linked to child malnutrition. In both the focus groups and the structured surveys, it was noted that primary female caregivers mothers-in-law had significant control over food purchases and feeding practices in some households and that fathers had power over spending allocations. This highlights the need for integrative education for whole households. Some of the broader challenges to feeding and raising healthy children that came up during focus groups and through interviews included: language and literacy barriers (especially among women) that leave them unable to learn about health and nutrition; the lack of resources and inequality in decision making that may affect whether a female caregiver changes her behavior, even if she has the desire to do so; the many competing needs of households in these communities (water, sanitation, healthcare, education, food security, etc.); and the small, remote locations of these communities (and others) with high prevalences of chronic malnutrition that may be difficult to identify. 19

Objective 2 of this study was to better understand knowledge and perceptions around the treatment and prevention of illness and malnutrition and how feeding and hygiene practices factor into raising a healthy child. Participants easily identified the common child illnesses of public health importance, such as upper respiratory tract infections and gastrointestinal infections. Furthermore, participants also readily discussed a number of best practices in preventative childcare, such as appropriate practices related to hygiene and sanitation, food safety, food choices (i.e. junk foods were unhealthy), and feeding practices. However, the concept of illness prevention in children was very difficult to elicit in all of the focus groups, and most caregivers would only provide examples of curative health behaviors, such as taking their child to the doctor when sick. Nevertheless, the fact that many households were practicing, or at least knew of, appropriate preventative behaviors (especially related to hygiene and caring practices) should be highlighted and built upon to help strengthen the understanding between certain practices and nutritional outcomes in their children. During discussions about illnesses, malnutrition was commonly perceived to be an important child health problem. However, in almost all cases, acute malnutrition was the salient disease for participants and caregivers, even though this condition is nearly absent in both communities. Awareness of the features of chronic malnutrition/stunting was more difficult to elicit, and in the end, recognize.This observation is further reinforced by the finding from the structured survey that, even though stunting is highly prevalent in both communities, a large proportion of caregivers were unsure if their child suffered from this condition.This knowledge gap may emerge from a combination of factors, including both the predominance of imagery of acute malnutrition in popular media outlets as well as the very fact that chronic malnutrition is so

highly prevalent (and therefore is not obvious when comparing children of the same age to other children in the community). Similarly to the case of child illness in general, participants and caregivers had difficulty making explicit linkages between certain positive health behaviors and practices and the prevention of malnutrition. For example, although many participants discussed important behaviors, such as hygiene, food safety, and food choices, they did not do so in connection to discussions of malnutrition. Similarly, although many participants have been the recipients of food or micronutrient supplements by Wuqu Kawoq or other NGO or governmental programs, these were generally thought of as recuperative rather than preventative products. Objective 3 of this study was to better understand dietary intake and patterns in young children, including especially the role of junk foods and packaged, commercial, and fortified foods. As described above under Objective 1, dietary diversity was low in both communities. Children in the Bocacosta region, on average, had more diverse diets, consuming more fruit, animal foods and dairy than children in the Highland. Community members considered naturally grown foods to be the healthiest for their children, in particular mentioning milk, eggs, beans, chicken, vegetables, and fruits. One interesting finding was that dietary diversity was more lacking in the community with a much higher proportion of land ownership and food production for household consumption. Two hypotheses evolved that might explain low-dietary diversity but these were not adequately explored in this study. First, some foods available at the household level may not in fact be made available to young children, despite the assertion in focus groups that most food preparation is for the entire family. Whether this is because preferential provision of higher-quality foods (beans, meat, and vegetables from soups, for example) to those in the household that are income providers, or because habitual and traditional feeding knowledge and behaviors encourage provision of nutrient-poor family foods (broth only) to children remains to be understood. Second, since households in the community with a greater proportion of land owners and food producers in fact had worse dietary diversity among the youngest children, it may be that the bulk of the food produced, especially the high quality food, is in fact sold in local markets or diverted to the export economy. Similar to the financial issues raised by caregivers regarding the purchase of basic food items, many also reported that, although they recognized the value of fortified foods as well as vitamins/micronutrient supplements for children, their ability to purchase these items was limited. Nevertheless, consumption of fortified and commercial foods for children was high in both communities with an average of 60% of children consuming them weekly (mostly Incaparina, but also Nestle, Quaker, and Gerber products). The number of servings of atol products per week (either home-prepared corn or rice flour drinks with sugar or equivalent commercial products such as Incaparina or Quaker cereal products) also was high, with children in the Highland consuming more weekly servings than in the Bocacosta (5.76 vs 3.29, p=0.001d). It should also be noted that atoles are family foods, and that other family members in the households are likely consuming these when they are available. 20

Consistently in all focus groups and key informant interviews, commercial atol preparations, like Incaparina, were highly regarded, known to be fortified with high concentrations of vitamins and thought to be a healthy food for both children and pregnant women. These perceptions were reinforced by messaging about the healthful benefits of these products, both in product packaging and promotional materials, as well as in interactions with vendors in local markets. However, few caretakers mentioned seeing or remembering advertisements, branding, or health statements on widely available fortified foods, like Incaparina, on their own without being prompted by facilitators. It may be that Incaparina, which has been popular in Guatemala for decades, has become part of the national identity so much so that its healthfulness is common knowledge. Vitamins were perceived as being needed to prevent malnutrition and illness; important for development, growth, and health; and necessary for mental capacity. Caretakers had a good understanding of both sources and functions of vitamins more generally, although perhaps not specifically for each vitamin, nor what foods provide which vitamins, as these were topics where community members reported their desire for additional knowledge. Seven-day food recalls also provided some evidence that on average, the only foods consumed daily (i.e. 7 servings/ week) by children 6 to 23 months were high starch and sugar foods, and vegetables, indicating that the importance of dietary diversity to provide a wide variety of vitamins and minerals is not well understood. These topics all provide good opportunities for educational initiatives that are also of interest to the communities. It was common among caregivers to confuse foods perceived as healthful in general with foods specifically fortified with

micronutrients. For example, many thought that meat, canned black beans, and soup were all fortified products. There was also some distrust around packaged foods, as participants felt they had added chemicals or that they could be old and expired. These discussions revealed that educational initiatives about fortified foods should address the differences between fortified, processed, and natural foods. Despite focus group discussions where caretakers clearly described junk foods as unhealthful for children, diets of young children surveyed were found to contain this element, especially in the Bocacosta. Consumption of refined sugar was high in both communities, and consumption of high-sugar beverages was also present. One very interesting feature of the market surveys was the finding that average per-purchase expenditures on junk foods were in the range 0.5-5.5Q ($0.06-0.69 USD). This range, although more imprecise, was similar to the range of reported prices for childrens fortified foods (4-9Q; $0.50-1.13 USD). From our 7-day recall results, the absolute number of junk food servings per week in the Highlands was low (0.72 0.21 per week) and much higher in the Bocacosta (5.71 0.47 per week). However, since in both communities expense was cited as a major factor prohibiting the purchase of fortified or healthy foods, this represents an excellent opportunity for education interventions designed at shifting purchasing behaviors from one type of food product to another (without increasing overall household expenditures). This intervention could be complemented by targeting other areas of specific food consumption patterns, such as the high rates of refined sugar consumption observed in both communities. Objective 4 of this study was to better understand where current health and nutrition knowledge originates from, in order to formulate strategies for more effective information dissemination and behavior change. The sources of health and nutrition information for most caregivers were either family members, health centers, or NGOsponsored health activities. Other avenues of health information, including local media, were of negligible reported impact. Most caregivers were interested in learning more, especially after interacting with study staff on themes related to nutrition, malnutrition, illness, and prevention. Participants in both communities were interested in receiving additional health information through group educational activities, as well as radio (in the Highlands) and clinical consultations (in the Bocacosta). Other potential strategies that may have success include the use of home visits, church sermons, movies, photos and handouts, food preparation classes, personal coaches, and positive deviance care groups. Key informant interviews highlighted the difficulty of achieving behavior change, but also pointed toward new potential strategies. These strategies included delivering all education in local Mayan languages as appropriate; working to diversify healthier food options for children available in local markets; using a positive deviance model to disseminate information; and providing education to all stakeholders, including both men and women as well as extended family members.

Study Implications
From the standpoint of intervention development, the findings of this study lend themselves to the following overall recommendations: 1. Teaching of exclusive breastfeeding adherence for the first six months of life is not a sufficient intervention. Additional effort must be directed toward encouraging adequate duration and quality of the breastfeeding interaction. 2. While many caregivers may be adherent to feeding behaviors that are associated with healthier children, such as appropriate timing of complementary food introduction, more attention should be directed to the quality (nutrient density, diversity) of first complementary foods. 3. Community education interventions must include efforts to explicitly link general knowledge about infant and young child health with preventative health measures. Additionally, work is needed to increase awareness about the prevalence of chronic child malnutrition (especially in comparison to low prevalence of acute malnutrition) as a community health problem. Interventions should also focus on the health, growth, and development implications of stunting and the 1000 day window of opportunity. 4. Interventions to increase awareness about the need for dietary diversity, especially as it relates to food purchasing behaviors and household allocation of food, should be developed. 5. Educational interventions to deconstruct household food expenditures in ways that shift economically constrained purchasing decisions towards more healthful food items and away from junk foods should be pursued. 6. Analysis of the quality, acceptability, and appropriateness of locally available fortified foods should be completed, including foods provided for free through government- and NGO-supported programs. 7. Nutrition education interventions must make greater efforts to engage all stakeholders, not just mothers, including fathers and female members of the extended family. A wide variety of nutrition education strategies should be used to engage caregivers. Additional avenues for education, including community radio stations, should also be explored. 21

Study Limitations
The main weakness of this study is the low external validity, meaning the low ability to take the very detailed information we learned about these two communities and generalize this information to other communities in Guatemala or elsewhere with great confidence. Because beliefs, knowledge, and behaviors can be so specific to cultures, ethnic groups, communities, or even families, it is difficult to determine how similar other communities will be in relation to the findings presented here. Some of the very salient similarities between the two indigenous communities may be generalizable; formative work in new areas would help to inform if these similarities are found elsewhere.

3.

Chary A, Messmer S, Sorenson E, Henretty N, Dasgupta S, Rohloff P. (2013). The normalization of childhood disease: An ethnographic study of child malnutrition in rural Guatemala. Human Organization (in press). Wuqu Kawoq | Maya Health Alliance. (2011). Baseline needs assessment of Xejuyu. Unpublished data. Guiding principles for complementary feeding of the breastfed child Pan American Health Organization, Washington, DC 2003 WHO. (2003). Global strategy for infant and young child feeding. Retrieved from http://whqlibdoc.who.int/ publications/2003/9241562218.pdf Carey, D. Jr. (2006). Engendering Mayan History: Kaqchikel Women as Agents and Conduits of the Past, 1875-1970. New York: Routledge; Ehlers, TB (2002). Silent Looms: Women and Production in a Guatemalan Town. Austin: University of Texas Press. Hoddinott, J. M.-Z. (March 2011). The consequences of early childhood growth failure over the life course. International Food Policy Research Institute Paper. Merchant, K. (1990). Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and short recuperative intervals. Am J Clin Nutr, 52: 280-8.

4. 5. 6.

7.

Acknowledgements
The study was co-conceived by Wuqu Kawoq | Maya Health Alliance and Edesia, Inc. Wuqu Kawoq is a nongovernmental organization which assists in the development of culturally and linguistically excellent health programs in indigenous communities in Guatemala. Edesia, Inc. is a nonprofit manufacturer and distributor of ready-to-use foods (RUFs) for use in the prevention and treatment of child malnutrition. Wuqu Kawoqs staff and volunteers were in charge of all data collection and in analyzing qualitative data; Wuqu Kawoq and Edesia were jointly responsible for analyzing quantitative data and writing this report. The study was funded in full by Nutriset, a leading manufacturer of readyto-use foods in France. Collaborators: Yolanda Xuya, Glenda Gomez, Florencio Cal, Community of Xejuyu, and Community of Kexel.
8.

9.

10. Oliveros, C., et.al. (1999). Maternal lactation: A Qual. analysis of the breastfeeding habits and beliefs of pregnant women living in Lima, Peru. International Quarterly of Community Health Education, 18(4). 415-434. 11. WHO. (2010). Indicators for assessing iycf practices Part 3: Country Profiles. Retrieved from http://www.who.int/maternal_ child_adolescent/documents/9789241599757/en/ 12. Enneman, A., Hernandez, L., Campos, R.,Vossenaar, M., Solomons, N.W. (2009). Dietary characteristics of complementary foods offered to Guatemalan infants vary between urban and rural settings. Nutrition Research, 29: 470-479. 13. UNICEF. (2010). At a glance : Guatemala. Retrieved from http:// www.unicef.org/infobycountry/guatemala_statistics.html

Financial Disclosures and Conflict of Interest Statement

All study authors are affiliated as staff, volunteers, or advisors of either Wuqu Kawoq | Maya Health Alliance or Edesia, Inc. The study was funded in part by a research grant from Nutriset. Wuqu Kawoq | Maya Health Alliance uses some Edesias products in its child nutrition programming. Edesia, Inc. is a nonprofit manufacturer and distributor of Nutriset-licensed products.

Sources
1. Ministerio de Salud Publica y Asistencia Social (MSPAS), Instituto Nacional de Estadistica (INE), Universidad del Valle de Guatemala, United States Agency for International Development (USAID), Agencia Sueca de Cooperacion para el Desarollo Internacional (ASDI), Centers for Disease Control and Prevention (CDC), United Nations Childrens Fund (UNICEF), United Nations Population Fund (UNFPA), Pan American Health Organization (PAHO)/Calidad en Salud 2009 V Encuesta Nacional de Salud Materno Infantil 2008-2009. Guatemala City: Ministerio de Salud Publica y Asistencia Social. Sistema de Vigilancia de la Malnutricin en Guatemala (SIVIM). (Mayo, 2012). Fase I: Prueba del prototipo en cinco departamentos de la regin del altiplano occidental de Guatemala: Resumen. INCAP, USAID/HCI, CDC.

2.

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Appendix A: Acronyms, Abbreviations, Definitions

General: Bocacosta Highlands Indigenous Kaqchikel, Kiche Ladino(a) Milpa agriculture Subsistence agriculture Atol(es) Caf de tortilla Caldos Comida chatarra(s) Commercial foods Corazn de trigo Fortified foods Galleta Gaseosa, refrescos Golosinas Hierba(s) Incaparina Mosh/Avena PlumpyDoz Tienda Capacitaciones Plticas Positive deviance model Study site located along the Pacific coast; Kexel Study site located in the central highlands; Xejuyu Self-identifying as Maya; often, speaking a Mayan language, or wearing traditional Maya clothing Mayan languages spoken in the study area Non-indigenous; generally of mixed Maya/European descent, but no longer self-identifying as Maya Traditional form of agriculture consisting of intercropping of corn and other staple commodities, especially beans, on small plots of land Lifestyle in which the bulk of ones work efforts are used to grow food for ones own consumption Foods: Thin gruel that is served hot and is usually made from corn flour, rice flour, or a commercial mix Drink made from soaking toasted tortillas in hot water, served with sugar Broths- chicken, beef, pork, vegetables, greens; liquid from cooked beans Junk foods Foods packaged and labeled commercially Processed wheat cereal product that is reconstituted into a gruel Commercial foods with added vitamins and/or minerals Packaged cookie or cracker Soda, sweetened beverages Sweets, candy Local greens, can be bought in the market or grown; includes some wild greens Guatemalan commercially-made atol base made from a mixture of corn flour and soy flour combined with vitamins and minerals Oatmeal, usually prepared as a thin drink with sugar and cinnamon Peanut based ready-to-use supplementary food fortified with vitamins and minerals for children 6-36 months; provided through some WuquKawoq programs Small shop that sell groceries, junk foods, and other small household items Program: Formal educational classes Informal discussions Approach to behavioral and social change based on the observation that in any community, there are people whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources or knowledge than their peers. Feeding related: Appropriate minimal dietary diversity 6-23 months (%) (WHO indicator) Appropriate minimal meal frequency 6-23 months (%) (WHO indicator) Appropriate minimal acceptable diet 6-23 months (%) (WHO composite indicator) Infant and young child feeding (IYCF) Infant and young child nutrition (IYCN) Complementary feeding Continued breastfeeding Exclusive breastfeeding Pre-lacteal feeds Number of distinct food groups consumed in 24 hour period by breastfed children 6-23 months; the 7 foods groups used for tabulation of this indicator are grains, roots and tubers; legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry and liver/organ meats); eggs; vitamin-A rich fruits and vegetables; and other fruits and vegetables; minimum number of food groups consumed for this age group is 4. Number of meals and snacks fed in 24 hour period; breastfed children 6-23 months of age who had 4 or more meals Composite indicator; breastfed children 6-23 months of age who had at least the minimum dietary diversity and the minimum meal frequency during the previous day Feeding practices of infants and young children between birth and age 3 years Specific nutritional needs of infants and young children between birth and age 3 years Initiation of solid foods at 6 months of age to complement breastfeeding Continuation of breastfeeding from 6 months to 2 years, in addition to appropriate foods Infant receives only breast milk, vitamins, and some medicines for the first 6 months of life Food/liquid given to the infant before initiating breastfeeding for the first time after birth

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Appendix B: Fortified Food List

Product Anchor Leche Entera en Polvo (dry milk) Azucar La Montana (iron, vitamin A) Campo Rico Avena Chocolisto (dry beverage) Corazon de Trigo Ducal Fruit Nectar (canned juice) Gerber Frutas Mixtas (baby food jar) Gerber Manzana, Banano (baby food jar) Sizes 26g; 120g; 360g 66.92g 200g 400g Cost 3 Q; 10 Q; 29 Q 2.5 Q 8Q 7.25 Q 3Q 2.5 Q 5-6 Q 5.5 Q Package labeling (Spanish) Enriquecida con vitaminas; Fortificada con hierro, cido flico, vitaminas A & D, zinc, calcio, vitaminas C, E, and A, biotina Fortificada con vitamina A Calcio, hierro, vitaminas Vitaminas y minerales Fortificada con vitaminas y hierro Enriquecida con vitamina C Con vitamin C Fortificado con vitamina C, cido flico, y hierro Fortificado con vitamina C, cido flico, y hierro Buena fuente de protena; Nutricin comprobada, sana y natural; Mezcla vegetal fortificada para hacer atol; Excelente fuente de hierro y zinc, ms 5 vitaminas Deliciosa, saludable, nutritiva Con vitamina C Con vitamina C Con vitamina C, calcio, y zinc escenciales para crecer Atol fortificada (no health or nutrition claims on package) NAN 1 (for 0-6 months): Formula lctea de inicio en polvo con hierro y probiticos para lactantes; Gentle start, L-comfortis: DHA, ARA, OPTI-Pro. NAN 2: Formula lctea de continuacin en polvo con hierro y probiticos para lactantes; Gentle plus, L-comfortis: DHA, OPTI-Pro. Aviso importante: La leche materna es el mejor alimento para el lactante Fuente de hierro y vitamina C Ayuda a fortalecer las defensas naturals de tu bebe - Immunonutrientes: hierro, zinc, vitaminas A & C -13 vitaminas Package labeling (English) Enriched with vitamins; fortified with iron, folic acid, vitamins A & D, zinc, calcium, vitamins C, E, and A, biotin Fortified with vitamin A Calcium, iron, vitamins Vitamins and minerals Fortified with vitamins and iron Enriched with vitamin C With vitamin C Fortified with vitamin C, folic acid, and iron Fortified with vitamin C, folic acid, and iron Good source of protein; proven healthy and natural nutrition; mix of fortified vegetables to make atol (corn-based gruel); Excellent source of iron and zinc, and 5 other vitamins Delicious, healthy, nutritious With vitamin C With vitamin C With vitamin C, calcium, and zinc especially for growth Fortified atol (no health or nutrition claims on package) NAN 1 (for 0-6 months): Initial milk formula in powder with iron and probiotics for infants; Gentle start, L-comfortis: DHA, ARA, OPTI-Pro. NAN 2: Continuing milk formula in powder with iron and probiotics for infants; Gentle plus, L-comfortis: DHA, OPTIPro. Important: Breast milk is the best nutritional source for infants Source of iron and vitamin C Helps to strengthen your babys natural defenses- nutrients for the immune system: iron, zinc, vitamins A & C, 13 vitamins

Cosecha Pura Naraja (juice box) 500 ml 220 ml 100g 100g

Incaparina

75g; 450g

2 -2.5 Q; 7.5-9.5 Q 3.5 Q 3.5 Q 3.5 Q 3.5 Q 2-2.5 Q; 7Q 65 Q

Kamb Fortified Drink (milk box) Kerns Fruit Juice Kerns Vegetable Juice Kerns Junior; Nectar Melocoton Maizena Nestl Kinder Nido

1 each 330 ml 330 ml 330 ml 47g; 190g 800g

Nestl NAN 1 & 2

350g

60 Q

Nestl Nesquik

200g

3.5 Q

Nestl Nestum Cereal Infantil; 5, 360g 8, arroz, trigo y miel

22 Q

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Appendix B: Fortified Food List (continued)

Nueve frmula con probiticos; Doble accin: Lactobacillus protectus, 11 vitaminas y 3 minerales. Es el primer paso del sistema de nutricin NIDO especializada para cada fase del desarrollo de tus hijos; El alimento a base de leche NIDO aporta vitamina A, la cual es esencial para el buen funcionamiento del sistema immunolgico- la vitamina A ayuda a mejorar la resistencia del organismo contra infecciones gastrointestinales y respiratorias; No es sustituto de la leche materna sino un alimento lcteo adecuado especialmente para nios desde 1 ao y adelante Hierro, zinc, vit C, vit D New formula with probiotics; Double action: Lactobacillus protectus, 11 vitamins and minerals. This is the first step for the NIDO nutrition system, specially designed for each phase of development of your children; This food based in NIDO milk contains vitamin A, which is essential for the immune system to function well - vitamin A helps to improve the bodys resistance to gastrointestinal and respiratory infections; This is not a substitute for breast milk, but rather it is an appropriate milk-based food for children aged 1 year and older Iron, zinc, vit C, vit D

Nestl Nido Crecimiento Proteccin (formula)

360g

35 Q

Nestl Nido Fortificada Nestl Nido Leche Entera en Polvo Nestl Nido Nutri-Rindes Protems Pedialyte Suero Oral (Na, K, Cl, Zn and citrate added) Quaker Avena Mosh Nutrems Shaka Laka Shakes Yus de Toki

840g 360g 480g 120g

60 Q 30 Q 30 Q 6.5 Q

Fortificada: hierro, vitamina A, vitamina C, Fortified: iron, vitamin A, vitamin C, vitamina D, zinc Vitamin D, zinc Hierro y cido flico Salud y mas nutricion en sus comidas - proteina de soya texturada - con hierro y acido flico - ayuda a reducar el colesterol por su naturaleza Ahora con zinc Hierro, calcio, zinc, vitaminas - previene la anemia, foralece los huesos, ayuda el crecimiento, mejora el disempeno Extra minerales y vitaminas Contiene vitaminas A & C Iron and folic acid Health and more nutrition in your food - textured soy protein - with iron and folic acid - helps to reduce cholesterol naturally. Now with zinc Iron, calcium, zinc, vitamins - prevents anemia, strengthens bones, helps with growth, improves performance Extra minerals and vitamins Contains vitamins A & C

500 ml 80g; 400g 200 ml 35g

21 Q 2 Q; 10 Q 3.5 Q 2-2.5 Q

Appendix C: General Food List

Product Azucar La Montana Black beans Chocolate-covered bananas Cup Noodles (dry soup) Ducal Black Refried Beans Eggs Issima La America Pasta Knorr Costilla de Res Soup (dry soup) Fresh cheese White rice Salchichas Sizes 1 lb 1 each 1 cup (64g) 10.5 oz can 1 each 200g 57 g 1 each 1 lb 1 each Cost 4.5-8 Q 1Q 3-5 Q 6-8 Q 1Q 3Q 2.5 Q 7Q 3.5-4 Q 0.75 Q

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