Trends in Micronutrient Interventions, Anemia, and Iron Deficiency among Women and Children in Guatemala, 2009-2019.

Background: Food fortification and micronutrient supplementation are public health strategies to improve micronutrient status in Guatemala; their population effectiveness has not been evaluated in recent years. Objective: We evaluated trends in food fortification, micronutrient supplementation, anemia, and iron deficiency among nonpregnant women aged 15-49 y [women of reproductive age (WRA)] and children 6-59 aged mo [preschool age children (PSC)]. Method: Nationally representative serial cross-sectional surveys were used to assess changes in hemoglobin, anemia, ferritin, iron deficiency, iron deficiency anemia, and self-reported consumption of fortifiable foods and micronutrient supplements during 2008/2009, 2013, 2015, 2016, 2017/2018, and 2018/2019. Predictors of hemoglobin and ferritin were assessed using generalized linear mixed models adjusted for survey year as random effects, and the consumption of fortifiable foods, supplements, and other potential confounders were fixed effects. Results: Multiple micronutrient powder consumption among PSC during the previous 3 mo was 53.3% (95% CI: 49.4, 57.2) in 2013 and 33.6% (28.8, 38.4) in 2018/2019. Anemia among PSC was 11.3% (8.0, 14.5) in 2008/2009 and 6.1% (3.6, 8.6) in 2018/2019. Anemia among WRA was 10.7% (7.2, 14.2) in 2008/2009 and 3.9% (2.7, 5.2) in 2018/2019. Iron deficiency among PSC was 15.5% (12.1, 19.0) in 2008/2009 and 10.9% (7.4, 14.5) in 2016 (lowest), but 17.1 (13.3, 21.0) in 2017/2018 (highest). Iron deficiency among WRA was 14.9% (11.6, 18.2) in 2008/2009, 13.8% (11.8, 15.8) in 2013 (lowest), and 18.9% (16.3, 21.6) in 2017/2018 (highest). Wheat flour/bread consumption was positively associated with hemoglobin among PSC, and sugar consumption was positively associated with hemoglobin among WRA. The reported consumption of fortifiable foods was not associated with ferritin among PSC or WRA. Conclusions: Guatemala has implemented multiple food fortification strategies, and anemia has declined. Increases in iron deficiency in 2017-2019 warrant further attention. Secular trends toward poverty alleviation, education, and development might be responsible for changes not explained by the micronutrient interventions evaluated.

Experiences and Lessons Learned in Developing and Implementing a Population-Based Nutrition and Health Surveillance System in Guatemala 2011-2021.

Background: Practice-based experiences documenting development and implementation of nutrition and health surveillance systems are needed. Objectives: To describe processes, methods, and lessons learned from developing and implementing a population-based household nutrition and health surveillance system in Guatemala. Methods: The phases and methods for the design and implementation of the surveillance system are described. Efforts to institutionalize the system in government institutions are described, and illustrative examples describing different data uses, and lessons learned are provided. Results: After initial assessments of data needs and consultations with officials in government institutions and partners in the country, a population-based nutrition surveillance system prototype with complex sampling was designed and tested in 5 Guatemalan Highland departments in 2011. After dissemination of the prototype, government and partners expanded the content, and multitopic nutrition and health surveillance cycles were collected in 2013, 2015, 2016, 2017/18, and 2018/19 providing nationally representative data for households, women of reproductive age (15-49 y), and children aged 0-59 mo. For each cycle, data were to be collected from 100 clusters, 30 households in each, and 1 woman and 1 child per household. Content covered ∼25 health and nutrition topics, including coverage of all large-scale nutrition-specific interventions; the micronutrient content of fortifiable sugar, salt, and bread samples; anthropometry; and biomarkers to assess annually, or at least once, ∼25 indicators of micronutrient status and chronic disease. Data were collected by 3-5 highly trained field teams. The design was flexible and revised each cycle allowing potential changes to questionnaires, population groups, biomarkers, survey design, or other changes. Data were used to change national guidelines for vitamin A and B-12 interventions, among others, and evaluate interventions. Barriers included frequent changes of high-level government officials and heavy dependence on US funding. Conclusions: This system provides high-quality data, fills critical data gaps, and can serve as a useful model for others.

Prevalence and Predictors of High Blood Pressure Among Women of Reproductive Age and Children Aged 10 to 14 Years in Guatemala.

INTRODUCTION: Data on the prevalence and predictors of high blood pressure among children and non-pregnant women of reproductive age are sparse in Guatemala. Our objective was to identify the prevalence and predictors of high blood pressure among women of reproductive age and children in Guatemala. METHODS: We analyzed data on blood pressure among 560 children aged 10 to 14 years and 1,182 non-pregnant women aged 15 to 49 from a cross-sectional, nationally representative household survey, SIVESNU (Sistema de Vigilancia Epidemiológica de Salud y Nutrición). We defined high blood pressure among children by using 2004 and 2017 US pediatric guidelines. We defined high blood pressure among women by using 1999 World Health Organization (WHO) and 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines. We used multivariable logistic regression to identify significant predictors of high blood pressure. A base model included key covariates (age, ethnicity, socioeconomic index, anthropometric indicators) and accounted for complex sampling. We used backward elimination to identify additional candidate predictor variables. RESULTS: High blood pressure was prevalent among 8.0% (95% confidence interval [CI], 5.4%-10.7%) and 14.0% (95% CI, 10.6%-17.5%) of children using 2004 and 2017 guidelines, respectively; and among 12.7% (95% CI, 10.7%-14.8%) and 41.1% (95% CI, 37.7%-44.4%) of women using 1999 WHO and 2017 ACC/AHA guidelines, respectively. Levels of awareness, treatment, and control of high blood pressure were low in women. Among children, significant predictors of high blood pressure were obesity, overweight, and indigenous ethnicity. Among women, significant predictors of high blood pressure included obesity, overweight, and diabetes. CONCLUSION: The prevalence of high blood pressure was high among Guatemalan women and children. Overweight and obesity were strong risk factors for high blood pressure. Increasing obesity prevention and control programs may help prevent high blood pressure, and expanding high blood pressure screening and treatment could increase awareness and control of high blood pressure in Guatemala.

An Integrated Infant and Young Child Feeding and Small-Quantity Lipid-based Nutrient Supplementation Program Is Associated with Improved Gross Motor and Communication Scores of Children 6-18 Months in the Democratic Republic of Congo.

OBJECTIVE: To evaluate the impact of an infant, young child feeding practices-small-quantity lipid nutrient supplements (SQ-LNS) intervention on child development scores in children aged 6-18 months in the Katanga Province, Democratic Republic of Congo (DRC). STUDY DESIGN: We analyzed data of 2595 children from 2 health zones in a quasi-experimental design with preimplementation and postimplementation surveys to evaluate program impact on child development scores. Standard care was received in the comparison health zone and the intervention health zone received standard care plus enhanced infant, young child feeding practices with a monthly supply of 28 SQ-LNS sachets for up to 1 year. Program exposure and communication and motor domains of the Ages and Stages questionnaire were collected to assess changes in child development scores. A quasi-intent-to-treat and adjusted difference-in-difference analyses were used to quantify impact of the enhanced compared with the standard package. RESULTS: In adjusted models contrasting endline with baseline, there was a greater relative increase in proportion of children with normal communication (difference-in-difference, +13.7% [95%CI, 7.9-19.6; P < .001] and gross motor scores, +7.4% [95% CI: 1.3-13.5; P < .001]) in the intervention vs comparison health zones. Further, in separate analyses among children of intervention health zone at endline, each additional SQ-LNS distribution was associated with +0.09 (95% CI, 0.03-0.16) z-score unit increase in gross motor scores (P < .01). CONCLUSIONS: The integrated infant, young child feeding practice-SQ-LNS intervention was positively associated with larger relative improvements in measures of child communication and motor development in the Katanga province of DRC.

Reexamination of hemoglobin adjustments to define anemia: altitude and smoking.

The correct interpretation of hemoglobin (Hb) to identify anemia requires adjusting for altitude and smoking. Current adjustments were derived using data collected before 1985, from low-income preschool-aged children (PSC) in the United States and indigenous men in Peru for altitude, and from White women of reproductive age (WRA) in the United States for smoking. Given the oldness and limited representativeness of these data, we reexamined associations between Hb and altitude and/or smoking using 13 population-based surveys and 1 cohort study each conducted after 2000. All WHO regions except South-East Asia were represented. The dataset included 68,193 observations among PSC (6-59 months) and nonpregnant WRA (15-49 years) with data on Hb and altitude (-28 to 4000 m), and 19,826 observations among WRA with data on Hb and smoking (status or daily cigarette quantity). Generalized linear models were used to assess the robustness of associations under varying conditions, including controlling for inflammation-corrected iron and vitamin A deficiency. Our study confirms that Hb should be adjusted for altitude and/or smoking; these adjustments are additive. However, recommendations for Hb adjustment likely need updating. Notably, current recommendations may underadjust Hb for light smokers and for those residing at lower altitudes and overadjust Hb for those residing at higher altitudes.

Association between anemia and household water source or sanitation in preschool children: the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project.

BACKGROUND: The associations between anemia and household water source and sanitation remain unclear. OBJECTIVES: We aimed to assess the associations between anemia and household water source or sanitation in preschool children (PSC; age 6-59 mo) using population-based surveys from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. METHODS: We analyzed national and subnational data from 21 surveys, representing 19 countries (n = 35,963). Observations with hemoglobin (Hb) and ≥1 variable reflecting household water source or sanitation were included. Anemia was defined as an altitude-adjusted Hb concentration <110 g/L. Household water source and sanitation variables were dichotomized as "improved" or "unimproved." Poisson regressions with robust variance estimates were conducted for each survey, adjusting for child sex, age, household socioeconomic status, maternal education, and type of residence. RESULTS: Access to an improved water source and improved sanitation ranged from 29.9% (Burkina Faso) to 98.4% (Bangladesh, 2012), and from 0.2% (Kenya, 2007) to 97.4% (Philippines), respectively. Prevalence of anemia ranged from 20.1% (Nicaragua) to 83.5% (Bangladesh, 2010). Seven surveys showed negative associations between anemia and improved sanitation. Three surveys showed association between anemia and improved water, with mixed directions. Meta-analyses suggested a protective association between improved household sanitation and anemia [adjusted prevalence ratio (aPR) = 0.88; 95% CI: 0.79, 0.98], and no association between improved household water and anemia (aPR = 1.00; 95% CI: 0.91, 1.10). There was heterogeneity across surveys for sanitation (P < 0.01; I2 = 66.3%) and water (P < 0.01; I2 = 55.8%). CONCLUSIONS: Although improved household sanitation was associated with reduced anemia prevalence in PSC in some surveys, this association was not consistent. Access to an improved water source in general had no association with anemia across surveys. Additional research could help clarify the heterogeneity between these conditions across countries to inform anemia reduction programs.

Effect of Adjusting for Tanner Stage Age on Prevalence of Short and Tall Stature of Youths in the United States.

OBJECTIVE: To evaluate the extent to which pubertal timing alters the classification of extremes of attained stature across race-ethnicity groups of youths in the US. STUDY DESIGN: We performed analyses of height and Tanner staging data of 3206 cross-sectional national sample of youths ages 8-18 years (53% male, n = 1606), 72% of whom were non-Hispanic white, 9% Mexican American, and 19% non-Hispanic black . Specialized growth models were used to derive Tanner-stage-age-adjusted z scores (TSAHAZ). The prevalence of shortness (<-1SD) and tallness (≥+1SD) status was quantified using TSAHAZ. RESULTS: Highly variable patterns of prevalence of shortness and tallness via chronologic age height z score (CAHAZ) were observed in results stratified by race-ethnicity and sex. Tallness CAHAZ prevalence was high among non-Hispanic white and non-Hispanic black male youths relative to Mexican American (40.0%-43.3% vs 20.5%) with a similar pattern in female youths. In both sexes, this pattern was eliminated with TSAHAZ, with Mexican American youth becoming statistically not different from their non-Hispanic white and non-Hispanic black peers. CONCLUSIONS: Differences in timing of puberty between race-ethnicity groups affects estimated prevalence of shortness and tallness of attained height that remains uncaptured with CAHAZ. Adjustment for pubertal development might help isolate crucial determinants of attained stature and other aspects of body composition that may be most responsive to intervention programs in populations. The curves developed by adjusting for pubertal status may help the clinician avoid misclassification of children with early and late pubertal development.

Determinants of Anemia among School-Aged Children in Mexico, the United States and Colombia.

Anemia affects approximately 25% of school-aged children (SAC-aged 5.00-14.99 years) globally. We determined in three countries the prevalence and determinants of anemia in SAC. Data on sociodemographics, inflammation and nutrition status were obtained from the 2006 Mexican National Nutrition Survey, the 2003-6 US National Health and Nutrition Examination Surveys, and the 2010 Encuesta Nacional de Nutrición Situación Colombia. In the US, vitamin A and iron deficiency (ID) were available only for girls aged 12.00-14.99 years to which our analysis was limited. Associations were evaluated by country using multivariable logistic regression adjusting for confounders and complex survey design. The prevalence of anemia and ID were: Mexico 12% (ID 18%), n = 3660; US 4% (ID 10%), n = 733; and Colombia 4% (ID 9%), n = 8573. The percentage of anemia associated with ID was 22.4% in Mexico, 38.9% in the US and 16.7% in Colombia. In Mexico, anemia was associated with ID (adjusted OR: 1.5, p = 0.02) and overweight (aOR 0.4, p = 0.007). In the US, anemia was associated with black race/ethnicity (aOR: 14.1, p < 0.0001) and ID (aOR: 8.0, p < 0.0001). In Colombia, anemia was associated with black race/ethnicity (aOR: 1.6, p = 0.005), lowest socio-economic status quintile (aOR: 1.8, p = 0.0005), ID (aOR: 2.7, p < 0.0001), and being stunted (aOR: 1.6, p = 0.02). While anemia was uniformly associated with iron deficiency in Mexico, Columbia, and the United States, other measured factors showed inconsistent associations with anemia. Additional data on anemia determinants in SAC are needed to guide interventions.

The relation of peripubertal and pubertal growth to final adult height in children with classic congenital adrenal hyperplasia.

OBJECTIVES: To determine the relationships between peripubertal and pubertal timing and growth, along with glucocorticoid exposure, to the reduced final adult height seen in patients with congenital adrenal hyperplasia (CAH). STUDY DESIGN: Chart review of 104 children with classic CAH (41 males: 28 salt-wasting, 13 simple-virilizing; 63 females: 38 salt-wasting, 25 simple-virilizing) were selected from a cohort from 3 medical institutions in Minnesota. Triple logistic modeling of longitudinal data was performed to determine patterns of peripubertal and pubertal growth. RESULTS: Hydrocortisone dose was similar between subtypes and during all growth periods. Simple-virilizing boys (P < .01) and girls (P < .01) were diagnosed later than their salt-wasting counterparts. Height at take-off SDS was reduced for patients with salt-wasting (boys: P < .01; girls: P < .01), and bone age at take-off SDS was more advanced for patients with simple-virilizing (boys: P < .01; girls: P = .05). Bone age at pubertal onset SDS was advanced for all patients, but more so for boys and girls with simple-virilizing. Although all patients had reduced final adult height SDS, this was more pronounced in patients with salt-wasting. CONCLUSION: Reduced final adult height SDS in patients with salt-wasting vs simple-virilizing may be attributable in part to a later age of diagnosis and resultant less prolonged exposure to hydrocortisone. This finding suggests that duration of hydrocortisone treatment in the peripubertal period, independent of the hydrocortisone dose, may affect final adult height in patients with CAH.

Effectiveness evaluation of the food fortification program of Costa Rica: impact on anemia prevalence and hemoglobin concentrations in women and children.

BACKGROUND: Food fortification is one approach for addressing anemia, but information on program effectiveness is limited. OBJECTIVE: We evaluated the impact of Costa Rica's fortification program on anemia in women aged 15-45 y and children aged 1-7 y. DESIGN: Reduced iron, an ineffective fortificant, was replaced by ferrous fumarate in wheat flour in 2002, and ferrous bisglycinate was added to maize flour in 1999 and to liquid and powdered milk in 2001. We used a one-group pretest-posttest design and national survey data from 1996 (baseline; 910 women, 965 children) and 2008-2009 (endline; 863 women, 403 children) to assess changes in iron deficiency (children only) and anemia. Data were also available for sentinel sites (1 urban, 1 rural) for 1999-2000 (405 women, 404 children) and 2008-2009 (474 women, 195 children), including 24-h recall data in children. Monitoring of fortification levels was routine. RESULTS: Foods were fortified as mandated. Fortification provided about one-half the estimated average requirement for iron in children, mostly and equally through wheat flour and milk. Anemia was reduced in children and women in national and sentinel site comparisons. At the national level, anemia declined in children from 19.3% (95% CI: 16.8%, 21.8%) to 4.0% (95% CI: 2.1%, 5.9%) and in women from 18.4% (95% CI: 15.8%, 20.9%) to 10.2% (95% CI: 8.2%, 12.2%). In children, iron deficiency declined from 26.9% (95% CI: 21.1%, 32.7%) to 6.8% (95% CI: 4.2%, 9.3%), and iron deficiency anemia, which was 6.2% (95% CI: 3.0%, 9.3%) at baseline, could no longer be detected at the endline. CONCLUSIONS: A plausible impact pathway suggests that fortification improved iron status and reduced anemia. Although unlikely in the Costa Rican context, other explanations cannot be excluded in a pre/post comparison.

Impact of hydrocortisone on adult height in congenital adrenal hyperplasia-the Minnesota cohort.

OBJECTIVE: To estimate the impact of the average daily dose of hydrocortisone (HC) on the amount of growth attained in children with congenital adrenal hyperplasia (CAH). The effect of glucocorticoid therapy on adult height (AH) in children with CAH has yet to be elucidated. STUDY DESIGN: Triple-logistic models estimating components of growth and maturation were fitted to longitudinal records of 104 patients with classic CAH from 3 pediatric medical centers in Minnesota between 1955 and 2012. A total of 3664 clinical encounters were examined. Random-effects longitudinal models with time-related covariates were used to estimate the effect of HC therapy on linear growth. RESULTS: The predicted AH z-score (-0.7) was similar between the sexes and among CAH subtypes. The mean growth period HC dose was 18.9 ± 5.6 mg/m(2)/day. In the final regression model, HC dose was negatively associated with predicted AH, with each mg/m(2)/day increase in average growth period HC dose predicting a 0.37-cm decrease in AH (P < .004). CONCLUSION: This study has quantified the fractional reduction in predicted final AH with an incremental increase in HC dose. These findings have important clinical implications in the decision making balance between HC replacement dose and adrenal androgen suppression in children with CAH.

Maternal height and child growth patterns.

OBJECTIVE: To examine associations between maternal height and child growth during 4 developmental periods: intrauterine, birth to age 2 years, age 2 years to mid-childhood (MC), and MC to adulthood. STUDY DESIGN: Pooled analysis of maternal height and offspring growth using 7630 mother-child pairs from 5 birth cohorts (Brazil, Guatemala, India, the Philippines, and South Africa). We used conditional height measures that control for collinearity in height across periods. We estimated associations between maternal height and offspring growth using multivariate regression models adjusted for household income, child sex, birth order, and study site. RESULTS: Maternal height was associated with birth weight and with both height and conditional height at each age examined. The strongest associations with conditional heights were for adulthood and 2 years of age. A 1-cm increase in maternal height predicted a 0.024 (95% CI: 0.021-0.028) SD increase in offspring birth weight, a 0.037 (95% CI: 0.033-0.040) SD increase in conditional height at 2 years, a 0.025 (95% CI: 0.021-0.029 SD increase in conditional height in MC, and a 0.044 (95% CI: 0.040-0.048) SD increase in conditional height in adulthood. Short mothers (<150.1 cm) were more likely to have a child who was stunted at 2 years (prevalence ratio = 3.20 (95% CI: 2.80-3.60) and as an adult (prevalence ratio = 4.74, (95% CI: 4.13-5.44). There was no evidence of heterogeneity by site or sex. CONCLUSION: Maternal height influences offspring linear growth over the growing period. These influences likely include genetic and non-genetic factors, including nutrition-related intergenerational influences on growth that prevent the attainment of genetic height potential in low- and middle-income countries.