Formative Assessment of and Young 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 Díaz, Wake Forest University and Wuqu’ Kawoq | Maya Health Alliance Nicole Henretty, Edesia Inc. Peter Rohloff, Brigham and Women’s Hospital, Children’s Hospital Boston, and Wuqu’ Kawoq | Maya Health Alliance Table of Contents

Introduction 4

Research Objectives 5

Study Design 5

Institutional Context and Ethics 6

General Demographics, Poverty, and 6

Family Structure, Roles, and Decision-making 7

Child Care and Feeding Practices 8

Foods and Feeding Patterns 11

Child Health and Illness Prevention 14

Child 15

Malnutrition in Pregnant Women 16

Health and Nutrition Information and Education 17

Summary and Conclusions 18

Study Implications 21

Study Limitations 22

Acknowledgements 22

Financial Disclosures and Conflict of Interest Statement 22

Appendix A: Acronyms, Abbreviations, Definitions 23

Appendix B: Fortified Food List 24

Appendix C: General Food List 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, Totonicapán, Huehuetenango, y El Quiché) 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, (16%), acute malnutrition (0.3%), and (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 K’ichee’- speaking communities in the Central highlands and Bocacosta region of Guatemala. Wuqu’ Kawoq’s 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 (K’exel) in the Bocacosta region of the Department of Suchitepéquez 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 K’exel was 71% in 20083 and in Xejuyu’ it was 57% in 20114.

4 Research Objectives time period of feeding patterns, specifically to look at foods that may not be given every day. The FFQ was This formative research will help build an evidence base for food group based, and included prompts about local developing and implementing solutions to child malnutrition in foods in each category and the number of times the indigenous communities in Guatemala by providing insight into food was consumed during the week. Quantification what motivates current feeding and care behaviors or inhibits of portion sizes of foods was not collected due to ideal behaviors5, and uncovering strategies to facilitate new or limits on the amount of time participants could improved practices. As a global public health recommendation, contribute to the surveys. should be exclusively breastfed for the first six months 2. Ten (10) focus groups (five in each community), targeted of life to achieve optimal growth, development, and health; at the primary caregivers of children ages 6 to 36 months thereafter, infants should receive safe and nutritionally adequate (men and women) and pregnant women. In each community, complementary foods, while continues for up to one focus group was held with male caregivers; three focus two years of age or beyond.6 groups were held with female caregivers; and one focus The main objectives of the study are as follows: group was held with pregnant women. Focus group sizes ranged from four to ten participants, who were recruited by 1. To understand current feeding and care behaviors of community health promoters, community leaders, and local infants and young children in two distinct regions of field staff. Question guides covered the following thematic Guatemala, including how knowledge, perceptions, areas: knowledge and perceptions of malnutrition and illness beliefs, culture, economics, social organization, family in young children and pregnant women; knowledge and roles, and food expenditures may factor into attitudes perceptions of prevention and preventive health behaviors; and behaviors. sources of health information; feeding patterns, practices, 2. To understand current knowledge and perceptions behaviors, perceptions and attitudes; knowledge of and regarding the treatment and prevention of child attitudes toward fortified foods, vitamins, and junk foods; food malnutrition and illness, including an understanding of security and purchasing behaviors. local perspectives regarding how vitamins (fortification), a) Xejuyu’: 10 male caregivers, 20 female caregivers, food choices, hygiene practices, and behaviors factor into and 4 pregnant women (total n=34). raising a healthy, well-nourished child. b) K’exel: 5 male caregivers, 18 female caregivers, and 5 3. To understand dietary intake and patterns in children pregnant women (total n=28). ages 6 to 36 months in these communities, including the 3. Twenty three (23) semi-structured, key-informant interviews role of snacks, packaged, fortified, convenience, specially- (KII) were conducted with community leaders as well marketed foods, and other commercial foods; and to as with local field staff of Wuqu’ Kawoq and with staff of collect information on the branding and marketing of other NGOs working on nutrition programming in the products for children. communities. Question guides covered the following thematic 4. To understand where current health and nutrition areas: perceived extent and causes of child malnutrition knowledge originates in order to formulate strategies for at community-level; opinions about ideal roles of various more effective information dissemination and behavior actors in improving child nutrition; perceived challenges in change. nutrition programming; effective strategies for information dissemination and behavior change. a) K’exel: 8 community leaders (3 males, 5 females): men Study Design were council members, elected town officials, and In order to build a satisfactory level of information from the pastor from the local evangelical church; women multiple sources, a mixed-methods approach was used. The study were representatives of the local organization that design included the following components: coordinates development projects, from the local school’s ’ association, from the board of a women’s cooperative group, and a local healer 1. One hundred and two (102) structured household-level (curandera). 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 b). K’exel: 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 K’exel), 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 Most residents work as seasonal agricultural day laborers or different categories of foods; average amount that children in construction; only 28% of households own land. Frequent and adults spend on snacks. All markets, stalls, stores and underemployment is common, with 28% of households living on shops open during interviewing hours were selected within less than $2 USD per day.3 Wuqu’ Kawoq has collaborated with the community; a random sample of locations were taken in this community for approximately six years in developing child- the larger towns outside of the two communities. nutrition programming, reproductive health services, a primary care clinic, and potable water initiatives. Data from the caregiver survey and the market survey was The community in the Central Highlands, Xejuyu’, is made coded and entered into Excel, checked for accuracy, and imported up of approximately 250 families. Virtually all members of the into STATA (version 11). Descriptive statistics were generated and community speak Kaqchikel in daily civic and domestic transactions, multiple responses to survey items were analyzed using the MRTAB although many, especially males, do have some proficiency in function. Statistical comparison of the two study communities were Spanish. Many households own and cultivate their own land (68% conducted using the Student’s t-test (for parametric continuous compared to 28% in K’exel, p=0.000a), and 45% of households live variables), Wilcoxon rank-sum test (for nonparametric continuous on less than $2 USD per day.4 Wuqu’ Kawoq has collaborated with variables), and either the chi-square or Fischer’s exact test (for this community for approximately two years in the formation of categorical variables). Throughout the report, the statistical tests various development projects, including clean water infrastructure, used are noted as super-scripts: a (Chi-square), b (Student’s t-test), disaster relief, and child-nutrition programming. c (Fisher’s exact test), and d (Rank-sum test).Transcripts from the During focus groups, participants in both communities focus groups and key informant interviews were reviewed to reported struggles with periods of food insecurity, i.e. inadequate create a preliminary codebook, which underwent five rounds of availability and access to enough healthy, safe, and nutritious foods modification. Data was coded thematically using Coding Analysis to feed their families. They reported the frequent need to make Toolkit (CAT), an online qualitative coding software. Surveys, focus decisions on which necessity (food, schooling, clothing, healthcare, group guides, and codebooks are available upon request. etc.) to spend their limited resources. In focus groups conducted in K’exel, men reported that the need to pay for other expenses Institutional Context and Ethics affected the amount of money spent on food. These other expenses included firewood, corn, electricity, cable, primary school The study was approved by the Institutional Review Board expenses, medicine, and lodging/travel expenses to and from their of Wuqu’ Kawoq and the elected local leadership in each of the job sites. Men reported selling tools or working extra hours when two communities. Verbal informed consent was obtained from there was not enough money to cover all household expenses. all participants. During the informed-consent process, study The majority of the men interviewed reported not having participants were notified that the decision not to participate adequate land. However, some men reported having enough land would not affect clinical care or services received from Wuqu’ to cultivate both coffee for sale as well as corn and beans for home Kawoq. Surveys were not linked in any way to respondents’ consumption. Less than 30% of families (of those interviewed in identifiable data. 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 General Demographics, Poverty and participants added that they often supplemented family income Food Security in times of scarcity by engaging in small-scale retail activities. One woman said that in times of economic need, she would borrow The community in the Bocacosta region, K’exel, is made up money from neighbors and/or family. of approximately 100 families. The community is of Maya descent, In the Highlands, findings of focus groups in Xejuyu’ differed but speaks mostly Spanish, although most heads of households in that the issue of food insecurity was much more prevalent in still retain conversational ability in either Kaqchikel or K’ichee’. discussions than it was in the Bocacosta. Among the cited factors

6 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 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 and mothers-in-law (child’s 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 K’exel, 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 Makes Household Purchasing Decisionsa Highlands Bocacosta Highlands Bocacosta Mother of the child 59% 70% Mother of the child 71% 62% Paternal grandmother 30% 13% Paternal grandmother 22% 15% Father of the child 10% 5% Father of the child 2% 12% Maternal grandmother 5% 7% Maternal grandmother 3% 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 Bocacosta P-valuea Large supermarket 33% 42% 0.37 Small stores 87% 64% 0.01 Street vendors/ market stalls 15% 54% 0.00

7 Cultural beliefs and traditions a large part in family earners, men often exert control over the amount of household structure and roles of individual family members. Indigenous funds spent on food, although they were not usually involved in Guatemala has a tradition of interdependent gendered divisions of specific decisions about food purchases. Despite less involvement labor. Under such traditions men occupy public spaces and women in day-to-day food decisions, many male focus group participants occupy domestic spaces. This public/private dichotomy translates nevertheless took their role as bread-winner quite seriously and to cultural expectations for the behavior of men and women.7 were aware of the implications of their income on the health and Several focus group participants said that parents needed to set wellness of their children. One participant stated, “As the father positive examples for their children. These positive examples it is my responsibility to not leave the children hungry.” Female of “correct” familial roles for mothers and fathers were nearly participants corroborated this sentiment: “If fathers don’t provide identical as reported by men and women from both communities. for their children, that is when they fall into malnutrition.” 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 and Feeding Practices whole family and to school their children. In both the structured survey and the focus groups, food purchasing and decision-making Roles and Respondsibilities for Child Care surrounding food and meals were reported as as being roles for women in the household. In both communities, around one-third of children had Although the dominant woman of the household was usually another important day-to-day caregiver other than the mother. the mother of the child in question, in a significant proportion Most commonly, this caregiver was the child’s paternal or of households (19% in the structured interviews), the mother- maternal grandmother or older sister. Fathers were seen mainly in-law (child’s paternal grandmother) played a dominant role. as providers, although the importance of fathers playing with their Some mothers reporting that their husbands gave the money children and encouraging their schooling was mentioned. In the for household expenses to the mother-in-law rather than to male focus groups, participants offered incisive and reflective them; in several other instances women stated, “My mother-in- commentary on the causes, prevention, and treatment of problems law is the one who is in charge of going shopping. My husband related to child health, nutrition, and physical and psychosocial gives money to his mother.” The prevalence of mothers-in-law development. However, in female focus groups, participants often as additional caregivers is not surprising given Mayan patterns of commented that men were only peripherally involved in the day- patrilocal residence following marriage.7 As the primary wage- to-day decisions regarding child welfare.

8 pregnant results in the child becoming ill (with vomiting/) Breastfeeding Frequency and Duration was a common theme. Although we did not specifically ask in focus Highlands Bocacosta P-valuea groups if becoming pregnant was a reason for a child, this practice was mentioned in several side conversations with Frequency 0.97 the researchers. Studies in similar settings9-10 have also shown that 1-2x/day 5% 5% becoming pregnant is often a cause for weaning. Another belief 3-6x/day 22% 18% mentioned in the focus groups was that weaning a child before the child is ready can cause illness or difficulties, such as rejection 6-10x/day 27% 26% of complementary food, psychological distress, or gastrointestinal >10x/day 46% 51% upset. Use of was very uncommon, with only five Duration 0.00 caregivers reporting its use in the preceding week. <5 min 3% 44% 5-10 min 24% 33% 10-30 min 53% 21% > 30 min 16% 2%

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 Complementary Feeding Practices impacts on income earning potential, physical work capacity, and attainment of education in adolescents and adulthood. The When breast milk is no longer enough to meet the nutritional current WHO recommendations6 support exclusive (only breast needs of the infant, complementary foods should be added to the milk from birth), “on demand” (as often as the child wants day and diet of the child. This is a very vulnerable period as it is the time night) breastfeeding for the first 6 months of life with the addition when malnutrition starts in many infants. In order to protect of appropriate complementary feeding (the introduction of solid against malnutrition, WHO provides guidance on ‘best practices’ foods and gradual replacement of breast milk as the primary for complementary foods. First, complementary feeding should source of nutrition) starting at six months. Additionally, WHO be timely, meaning that all infants should start receiving foods in recommends continuing breastfeeding until 24 months to ensure addition to breast milk from six months onwards. Next, it should a child’s growing nutritional requirements are met. The benefits of be adequate, meaning that the complementary foods should be following these recommendations are well established, particularly given in appropriate amount, frequency, consistency and variety to in resource-poor environments where early introduction to liquids cover the nutritional needs of the growing child while maintaining and food often leads to exposure to contaminants and inadequate breastfeeding. Foods should be prepared and given in a safe breastmilk intake, and where late introduction or introduction manner, meaning that measures are taken to minimize the risk of inappropriate complementary foods provide nutritionally of contamination with pathogens. Finally, they should be given in inadequate diets. To assess the relationship between WHO a way that is appropriate, meaning that foods are of appropriate infant feeding guidelines and practices in the study communities, texture for the age of the child and caregivers use responsive information on breastfeeding, complementary feeding, and dietary feeding techniques.6 recall information were collected through structured surveys. Only three caregivers of the 102 interviewed in the Adherence to continued breastfeeding and appropriate structured survey observed that their children were not yet timing of complementary food introduction were relatively high in taking complementary foods. The average age of introduction of both communities. Seventy nine percent (79%) of all the children solid foods was 7.3 ± 2.0 months (range 3 to 14 months) with 73% surveyed in both communities were currently breastfeeding; this of children starting complementary feeding between six and eight number rose to 90% for children under 24 months. Mothers in months; this did not differ between communities.b The percentage both communities tended to breastfeed six or more times per day, of caretakers that reported not initiating complementary foods with the majority of women breastfeeding more than ten times per or liquids until age six months or older was 98% in the Highlands, day. The communities differed on breastfeeding duration: women compared to 90% in the Bocacosta (p=0.08a). The first foods in the Highlands tended to breastfeed longer (10+ minutes), while commonly given to infants included bean or potato purees, women in the Bocoacosta tended to breastfeed for less than four rice, noodles, soup, and Gerber baby foods. The average age of minutes. introduction of first liquids (other than breastmilk) was 6.0± Multiple constructs surrounding breastfeeding emerged from 3.0 months (range 0 to17 months), with no statistical difference the focus group data. The idea that breastfeeding a child while between the two communities.b First liquids included Incaparina

9 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 nutrient- poor 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 Bocacosta P-valuea Honduras Minimum Dietary Diversity 12.5% 35% 0.07 65% Minimum Meal Frequency 6% 37.5% 0.001 77% Minimum Acceptable Diet 2.5% 20.6% 0.01 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) Highlands Bocacosta P-value Cereals & tubers* 19.7 ± 1 21.2 ± 1.4 0.37b Vegetables* 14.2 ± 1.1 12.8 ± 1.4 0.45b Fruits* 3.6 ± 0.4 6.0 ± 0.7 0.003b Vitamin A rich foods* 2.9 ± 0.3 3.8 ± 0.5 0.44d Animal foods (including eggs)* 3.0 ± 0.4 4.2 ± 0.4 0.034b Legumes & nuts* 1.8 ± 0.3 2.0 ± 0.2 0.43d Dairy* 0.6 ± 0.1 4.4 ± 0.4 0.000b Children’s fortified foods 4.5 ± 0.5 4.5 ± 0.4 0.93b Commercial/packaged foods 2.6 ± 0.3 3.0 ± 0.6 0.84d Added fat 4.6 ± 0.4 4.5 ± 0.5 0.86b Junk foods 0.7 ± 0.2 5.7 ± 0.5 0.000d Refined (added) sugar 12.4 ± 0.9 19.9 ± 0.8 0.000d Soda and store-bought juice 1.6 ± 0.4 1.6 ± 0.2 0.33d All high sugar beverages 4.2 ± 0.6 6.1 ± 0.6 0.043d (home-made tea, coffee, and juice drinks; store-bought soda and juice) Atoles 5.8 ± 0.4 3.3 ± 0.5 0.001d Broth 3.4 ± 0.4 2.6 ± 0.4 0.12b

10 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 , 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 24- hour food recall.

Top 10 most-mentioned foods from 24-hour food recall Highlands Bocacosta Food Total mentions Food Total mentions Tortillas 113 Tortilla 85 Atol 98 Coffee 59 Coffee 39 Eggs 28 Broth 31 Oil 27 Rice 28 Bread 25 Beans 25 Noodles 22 Oil 17 Rice 19 Eggs 16 Beans 18 Banana 16 Atol 13 Noodles 14 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. There’s not a part for the baby that’s spent separate from our expenses for food. Everything is together. Whatever food it is that you eat, that’s 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.

11 Caretakers in the structured surveys were asked if their Trigo, Quaker products, Gerber products, and powdered milk. A child consumes commercial or prepackaged foods, how often, and complete list of fortified foods sold in surveyed markets can be which foods. On average, 75% of caretakers in both communities found in Appendix B. A popular marketing strategy for fortified said their child consumed these foods approximately three times products targeted at young children among vendors was to per week. The types of foods that were most often mentioned in declare their vitamin content and health/nutritional benefits to each community included instant soups/broth packets, oatmeal, potential customers. They were usually aided in these declarations soda, juice boxes, and canned refried beans. Of note, some of the by slogans and informational blurbs printed directly on individual commercial foods mentioned included certain brands of juice products or marketing materials provided to them by distributors. boxes and powdered drink mixes that are also fortified (typically As examples, the printed slogans of three popular products are with vitamin C). reproduced below: Caretakers were also queried on their knowledge and purchasing and consumption habits regarding “fortified foods Kerns Fruit Juice Juniors “With vitamin C, for children.” For most caretakers, the term “fortified food” was calcium and zinc – especially for growth” synonymous with the popular corn-soy product Incaparina that Nestlé Nestum Cereal Infantil “Helps strengthen is frequently prepared as a thin gruel beverage. The term was not natural defenses of your baby - Immunonutrients: well understood generally, as many focus group participants also iron, zinc, vitamins A & C - 13 vitamins” thought that a number of unfortified foods were fortified, especially Quaker Avena Mosh Nutremás “Iron, calcium, canned black beans, soup mixes, and meats. Taken all together, zinc, vitamins – prevents anemia, strengthens commercial fortified foods for young children were consumed by bones, helps growth” 60% of children on at least a weekly basis. However, Incaparina made up the majority of these reported foods (46 mentions), with In each vendor establishment, vendors estimated the Nestle Nido (11), Quaker Mosh (9), Gerber products (6), Anchor amount spent by caretakers per individual food item. Prices for powdered milk (4), Nestle Nan (4), and Corazon de Trigo (3) also the common fortified children’s foods ranged between 4Q and being mentioned. 9Q (quetzals, $1 USD = approximately 8Q; $0.50-$1.13) with To complement the surveys of caregiver purchasing single-servings costing on the lower side; there was no statistical behaviors, survey of vendors in and around both communities difference between the communities.a Although on first pass, were conducted, as described above under Methodology. Eighty these prices seem fairly nominal, the problem of limited financial percent (80%) of the vendors surveyed currently sell or have sold resources and the high cost of these food items was one of the commercially fortified foods; the most common foods (mentioned most frequently cited reasons in focus groups for why they were more than 10% of the time) included Incaparina, Corazon de not purchased more often. As one female focus group participant

12 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 month’s supply. Importantly, participants did not identify health centers or other distribution programs as an important source of vitamin supplements for children. This focus group’s consensus mirrors findings from other recent studies of micronutrient consumption. For example, in the 2012 SIVIM report2, some 600 caregivers reported their children’s 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 (Corazón 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 children’s 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 what’s 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: Unhealthy 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 Household: cage-raised chicken and rice based); starches (yucca, potatoes, noodles, rice, bread, crackers, oats); peanuts; juice. Prepared: Tamales; Chuchitos; fried chicken Prepared: canned foods, instant soups Packaged: sweets, candy, cookies, crackers, ice cream, packaged Packaged: Incaparina; Protemás; Corazón de Trigo; Corn Flakes chips, soda, everything that is sold in small shops (tiendas)

13 Snacking Behaviors and the Role of Junk Foods junk food during recesses at primary school, and that parents feel bad denying their children the fifty cents or one quetzal because Several caregivers had heard during consultations with the they do not want their children to feel left out when other peers local health center staff that it is important for children to snack buy snacks. twice a day. These parents remarked that when they do have a In order to collect data on junk food purchasing using few extra quetzales (local currency, 1 USD = approximately 8Q), an approach aside from direct questioning of caregivers, the they like to buy snacks for their children that are not shared with market survey component of this study also incorporated this other household members, such as atoles (corn gruels, Incaparina), theme. Vendors were asked who (i.e., children, parents, other bananas, bread, cookies, juice, milk, fruit (apples, bananas, papaya, family members) most often purchased junk foods for children; watermelon, and peach), oatmeal (mosh), and potable water. interestingly, vendors reported that children themselves, rather Parents in focus groups in both communities typically did not than their caregivers, were the purchasers a full 50% of the time. mention buying junk foods as snacks for their own children, and Indeed, more than 95% of store owners reported routinely selling they generally labeled these foods as unhealthy. In fact, several junk foods directly to children, and they estimated that the average participants specifically criticized their neighbors’ junk food buying age at which children began to purchase snacks was around five behaviors. In the 7-day food recalls, children in both communities to six years of age, with no statistical difference between the consumed junk food weekly at ages 6 to 23 months; this ranged two communities.b Vendors estimated the average per-purchase from about one serving per week in the Highlands to almost 6 amount spent on junk foods at 4Q ($0.50 USD) in the Highlands servings per week in the Bocacosta (p=0.000d). Occasionally, focus and 5.5Q ($0.70 USD) in the Bocacosta (p=0.06b). group participants would remark that providing a child with junk food as a snack is often easier, more convenient, and less time- consuming than cooking and using up firewood to prepare snacks Child Health and Illness Prevention for children while simultaneously attempting to perform other daily household chores. In all focus groups, participants were asked what illnesses were This study found that children themselves often buy their common among children and how best to prevent them. During own junk food snacks, although this behavior tends to involve each group, these questions were asked in a variety of ways in children older than those in the age range that are the focus of this Spanish or Kaqchikel because caregivers typically responded study. Nevertheless, older siblings’ purchase of junk foods snacks to initial questioning about disease prevention with what the often sets expectations or models of consumption behaviors for researchers considered curative behaviors. Caregivers were asked younger siblings; older siblings may also be purchasing snacks for how to ensure that illnesses did not affect their children (e.g., their younger siblings as well. For example, one female caregiver para que no les peguen las enfermedades, Sp.; achike modo yeito’ remarked that she often leaves fifty-cent pieces sitting on the chwäch jun yab’il, Kaq.); how to avoid illnesses among their children countertop for errands she plans to run, but that her young (evitar, Sp.; richin man nuya’ ta chi ke jun yab’il, Kaq.); and how to children take the money and buy themselves treats at a local prevent illnesses among their children (prevenir, Sp.; -köl, Kaq.). tienda. Other mothers reported that their young children buy 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, ); 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 one’s 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 not participating in usual play activities) and, for older children, cognitive function (child does not perform well in school, does not Focus group participants were queried about their follow instructions, has poor memory). When asked to describe understanding of child malnutrition. In general, participants the feeding behaviors of a malnourished child, participants most of all focus groups referred to child malnutrition as an illness/ commonly observed or rejection of specific foods. Of disease (enfermedad, Sp.; yab’il, Kaq.) caused by lack of (quality) note, caregivers in the focus groups felt that their children or food and closely and unanimously associated with limited children they knew, exhibited some, but not all, of the characteristics economic resources. Other identified factors which were thought discussed, and were unsure how to determine whether a child is to contribute to child malnutrition included lack of caregiver malnourished or not. Some focus group participants characterized knowledge about recognizing and understanding malnutrition; child malnutrition as a serious problem both in severity and poor knowledge and behaviors around feeding (inappropriate frequency in the community, but some believed it was mainly a breastfeeding duration, meal frequency, and meal quantity, and problem in other areas of Guatemala, characterized by the very provision of junk foods or low-nutrient foods); poor care and skinny children that are seen in the newspaper. It should be noted hygiene behaviors (lack of hand washing, allowing children to crawl that in each community, Wuqu’ Kawoq’s nutrition programming in dirt, lack of attention to child’s nutrition and health status); involvement includes measuring of height and weight and regular common illnesses and infections (and associated poor appetite, discussions with caregivers (in their primary language, whether diarrhea, and vomiting); and inadequate family-planning and birth Spanish or Maya) about malnutrition and specifically stunting (low spacing-related responses. In the Highlands, particularly, women height-for-age). Historically, health workers in the communities expressed desires to use birth control, especially after having have detected very few cases of acute malnutrition. Therefore, at five or more children, but reported being unable to do so if their first pass, it is notable that participants first and most commonly husbands did not agree. Notably, however, men in the Highlands identify features of acute malnutrition. However, at the same time, directly linked frequent births and breastfeeding among women cases of acute malnutrition are commonly represented (often to children’s malnutrition and suggested a great need for family graphically) in newspapers and other media outlets, which might planning initiatives in the region. partially explain the salience of these features. Furthermore, as When asked to describe the physical characteristics of a described previously3, chronic malnutrition/stunting, although malnourished child, respondents often first provided descriptors highly prevalent in Guatemala, has not until very recently of acute malnutrition (thin, can see ribs, swollen stomach, weak, captured the attention of a broad public/private consensus, lacks bodily defenses). However, some participants did identify which further explains why community participants still struggle features more typical of chronic malnutrition/stunting (short to articulate its features. Finally, since chronic malnutrition rates for age, looks younger than age) or micronutrient deficiency in both these communities have historically been very high, it is states such as anemia (pale/pallid skin). When asked to describe also not surprising that recognizing this form of malnutrition is the psychomotor characteristics of a malnourished child, difficult. When most children are stunted, becomes participants most often observed effects on basic developmental “normalized” and does not stand out as abnormal.3 In the milestones (delayed walking or talking), energy level (fatigued, structured survey, one question asked whether the respondent

15 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 ye’ito chwäch ri ya’bil desnutrición, Kaq.); how to avoid malnutrition among children (evitar, Sp.; richin man nuya’ ta chi ke ri yab’il desnutrición, Kaq.); and how to prevent malnutrition among their children (prevenir, Sp.; -köl, 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 thought their own child (6 to 36 months) was malnourished. new foods). In the Highlands, 38% responded “yes” and 17% were “unsure”; Since limited awareness of malnutrition prevention was a “yes” and “unsure” responses in the Bocacosta were 28% and major feature of the community focus groups, this was explored in 20%, respectively. There was no statistical difference between the a greater detail with the staff of various NGOs (including our Wuqu’ communities for these responses. Kawoq field staff) working on child malnutrition in the region. Focus group participants were also queried regarding Most staff members corroborated that the concept of prevention their perceptions of potential solutions to child malnutrition. barely existed for most community members. They felt that most Responses in both communities were fairly similar; the most individuals addressed health and nutrition problems only after commonly offered solutions included providing supplemental they were already present. Some staff generalized that a lack of foods and vitamins, as well as medical care to children. Caregivers preventive health behavior is a feature of the entire Guatemalan in both communities felt that it was often necessary to provide population. Furthermore, one health educator hypothesized that, malnourished children with larger quantities of food; foods with until reliable and effective cures for common illnesses are available higher vitamin content; or specific recuperative foods such as milk, consistently throughout Guatemala, preventive health will remain grain products, fruits, and vegetables. However, on further query, a low priority for rural populations. these strategies were closely linked in participants’ minds almost exclusively to cases of acute malnutrition. Most focus group participants strongly emphasized the role Malnutrition in Pregnant Women of food or micronutrient supplementation in the care of the malnourished child. Micronutrient supplements or supplemental A common tangential theme present in most focus groups foods were thought to help prevent and cure malnutrition; was the link between health, nutrition status, and behaviors of a prevent anemia; help a child gain weight; and restore appetite. A pregnant woman and her baby’s health and nutrition status. While frequent caveat given was that supplements were not helpful alone malnutrition in pregnant women was perceived and reported as if an underlying concurrent medical illness was not simultaneously being uncommon in their communities, focus group participants in addressed. Among focus group participants who had been the both communities reported that lack of appetite, lack of vitamins, beneficiaries of supplement distribution programming, products , and anemia were not uncommon. Participants felt reflecting the history of Wuqu’ Kawoq and other organizations’ that the most common signs of malnutrition in pregnant women involvement in the communities, such as Incaparina, Vitacereal, included poor fetal growth, poor appetite, vomiting, poor weight Bienestarina, Chispitas, and Plumpy’Doz™ were mentioned; gain, fatigue or weakness, changes in vision, faintness, pale skin, and these products were thought to have been effective in helping brittle hair. Interestingly, anemia and sleepiness were often seen malnourished children recuperate. as causes, rather than signs, of malnutrition. Solutions important

16 for preventing or curing malnutrition in pregnant women included (e.g., midwives), commercial outlets (stores, pharmacies), and finding ways to cope with nausea (so that food intake would remain media (radio, newspapers) were all negligible sources of health adequate); eating nutritious and diverse foods such as atoles, fruits, information. A large proportion of caregivers (Highlands 42% vs. and vegetables; taking prenatal vitamins; staying active and not Bocacosta 26%, p=0.08a) reported that, with regard to child health sleeping too much; and going to prenatal checkups with physicians. and nutrition, they were simply “self-taught.” Some participants In both communities, atoles and soups/broths were repeatedly responded that they preferred not to ask other community mentioned as foods that give pregnant women strength. Atol, members for health advice. particularly, was believed to increase a woman’s weight gain during When queried, 95% of caretakers in both communities pregnancy. Importantly, infant malnutrition was correctly perceived affirmed that they would appreciate more access to health and to begin during pregnancy. Women reported that it was important nutrition information. In the Highlands, group educational sessions to satisfy all of their food cravings, or else their baby might be born and radio were popular options selected for additional health malnourished. Men felt that they were responsible for providing programming, while in the Bocacosta region, caregivers preferred resources to buy extra food for their pregnant wives. 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 Health and Nutrition Information included general education about child nutrition (malnutrition, and Education anemia, requirements for children and pregnant women, effects of inappropriate feeding practices), as well as more specific During structured surveys, researchers elicited caregivers’ education about individual foods and vitamin/micronutrient common sources of health and nutrition information. In both supplements (characteristics of healthy and unhealthy foods, communities, family members were a common source of health explanation of fortified foods and their use, nutritional value of information, although there were some differences. For example, packaged foods). in the Highlands, 29% of caretakers received health information These themes were also explored in key informant interviews from family members, whereas this number rose to 70% in the with NGO staff, who commonly stressed the difficulty of behavior Bocacosta (p=0.001a). In both communities, the family members change work around improving child nutrition. Several staff that commonly provided this information were the primary female reiterated that behavior change takes place over long periods of caregiver’s mother and her mother-in-law. time and that constant reminders and repeated review of new The only other commonly cited source of health information health information are crucial to effecting behavior changes. for caregivers was health projects/health posts (Highlands 38% One interviewee hypothesized that people who have completed vs. Bocacosta 30%, p=0.37a). Notably, lay health practioners primary school and/or secondary school are more likely to

17 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. accept health messages than those with lower levels of education. This observation corroborates anecdotal findings from health Another observed that for caregivers with many children, workers’ programmatic interactions with caregivers over the changing well-established household feeding and hygiene patterns years, where breastfeeding is often used primarily as a behavior and distributions of food was difficult and disruptive. This staff tool (to calm crying infants). Short duration of each breastfeeding member also asserted that, due to household gender inequalities, session can potentially have nutritional implications if the duration even if women accept messages learned from health educational does not provide adequate caloric support to the infant. opportunities, since men authorize all decision-making they may Although not discussed extensively in this paper, adequate prevent their wives from adopting new practices. Two educational birth-control options and birth spacing were notable themes in strategies that were widely agreed upon were native language breastfeeding behaviors. Most women felt that the use of birth use and collaborative community efforts. Several interviewees control was the decision of their husbands. If their husbands would remarked that speaking the language of the people (i.e. Kaqchikel) not allow for use of contraception, this would lead to multiple, in consultations, classes, and meetings allows people to ask successive births requiring early weaning. questions and clarify doubts. If instruction is given in Spanish, When more details were solicited about the quantity, people pretend to understand to avoid embarrassment, even if frequency, and quality of complementary foods being offered to they are mainly monolingual Kaqchikel speakers, and they leave children, several important features emerged. First, the average the sessions and consultations without learning anything. Many meal frequency in both communities was less than the four meals/ NGO staff members also stressed that when health messages snacks per day recommended for this age group. The average come from health promoters, community elders, and midwives, number of food groups consumed was also lower than the four in addition to NGO programs, people are more accepting of new groups per day that is recommended. Children in the Highlands information. Other suggestions from key informants for improving were found to have significantly worse indicators of dietary health education delivery included making healthier food options diversity and meal frequency than their counterparts in the for children available in local stores; using a positive deviance Bocacosta, although both areas showed deficiencies. Factors which model to disseminate information; performing individualized might explain the poorer adherence to ideal feeding behaviors needs assessments for families; and providing joint education to in the Highland community include its greater distance from the men and women. 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, Summary and Conclusions the most common first complementary food was bean puree; Objective 1 of this study was to better understand feeding when researchers asked to see examples of this food, it was and care behaviors of infants and young children taking noted to be extremely thin (only liquid from cooked beans), not into account all of the factors that play a role in shaping in keeping with the WHO recommendation that complementary knowledge, attitudes, beliefs, and practices of caregivers. foods should be of a thick enough consistency that they do not “fall off” a serving spoon. Similarly, in the Bocacosta, the most This study found that some optimal feeding practices were common first complementary food was soup/broth, again a food well understood and practiced by the communities, while others preparation with poor nutrient density. Along these lines, it is also were not. Seventy-eight percent (78%) of mothers reported significant that, in both communities, beverages (atol, coffee, water, exclusively breastfeeding their child with only 22% reporting any + sugar) were introduced earlier than foods. Even fortified atoles kind of pre-lacteal feeding. Most (90%) of children under two (Incaparina, Bienestarina), potentially appropriate complementary years were still being breastfed by their mothers. For comparison, food choices, are consistently prepared as a thin gruel beverage;

18 this is despite many unsuccessful attempts by community health Objective 2 of this study was to better understand workers to encourage more appropriate (thick) preparations. knowledge and perceptions around the treatment and The two factors influencing young child feeding practices that prevention of illness and malnutrition and how feeding came up repeatedly in the focus groups were economic scarcity and hygiene practices factor into raising a healthy child. and a lack of information and knowledge about what behaviors and practices are associated with healthier, well-nourished Participants easily identified the common child illnesses children. Parents reported that their financial situation often led of public health importance, such as upper respiratory tract to food insecurity and a lack of food expenditures and that this infections and gastrointestinal infections. Furthermore, participants also affected the youngest in the household, particularly because also readily discussed a number of best practices in preventative the whole family eats together and eats the same foods. childcare, such as appropriate practices related to hygiene and Caregivers were also eager for more specific information , food safety, food choices (i.e. junk foods were unhealthy), and recommendations on better young child feeding practices. and feeding practices. However, the concept of illness prevention Additionally, where specific “optimal” feeding behaviors (such as in children was very difficult to elicit in all of the focus groups, continued breastfeeding, appropriately timed food introduction, and most caregivers would only provide examples of curative types of complementary foods, etc.) were identified by caregivers, health behaviors, such as taking their child to the doctor when these were not often perceived as closely linked to child sick. Nevertheless, the fact that many households were practicing, malnutrition. In both the focus groups and the structured surveys, or at least knew of, appropriate preventative behaviors (especially it was noted that primary female caregivers’ mothers-in-law had related to hygiene and caring practices) should be highlighted and significant control over food purchases and feeding practices built upon to help strengthen the understanding between certain in some households and that fathers had power over spending practices and nutritional outcomes in their children. allocations. This highlights the need for integrative education for During discussions about illnesses, malnutrition was commonly whole households. perceived to be an important child health problem. However, in Some of the broader challenges to feeding and raising almost all cases, acute malnutrition was the salient disease for healthy children that came up during focus groups and through participants and caregivers, even though this condition is nearly interviews included: language and literacy barriers (especially absent in both communities. Awareness of the features of chronic among women) that leave them unable to learn about health and malnutrition/stunting was more difficult to elicit, and in the end, nutrition; the lack of resources and inequality in decision making recognize. This observation is further reinforced by the finding from that may affect whether a female caregiver changes her behavior, the structured survey that, even though stunting is highly prevalent even if she has the desire to do so; the many competing needs in both communities, a large proportion of caregivers were of households in these communities (water, sanitation, healthcare, “unsure” if their child suffered from this condition. This knowledge education, food security, etc.); and the small, remote locations of gap may emerge from a combination of factors, including both the these communities (and others) with high prevalences of chronic predominance of imagery of acute malnutrition in popular media malnutrition that may be difficult to identify. outlets as well as the very fact that chronic malnutrition is so

19 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 Consistently in all focus groups and key informant interviews, explored in this study. First, some foods available at the household commercial atol preparations, like Incaparina, were highly regarded, level may not in fact be made available to young children, despite known to be fortified with high concentrations of vitamins and the assertion in focus groups that most food preparation is “for thought to be a healthy food for both children and pregnant the entire family.” Whether this is because preferential provision women. These perceptions were reinforced by messaging about of higher-quality foods (beans, meat, and vegetables from soups, for the healthful benefits of these products, both in product packaging example) to those in the household that are income providers, or and promotional materials, as well as in interactions with vendors because habitual and traditional feeding knowledge and behaviors in local markets. However, few caretakers mentioned seeing or encourage provision of nutrient-poor family foods (broth only) remembering advertisements, branding, or health statements to children remains to be understood. Second, since households on widely available fortified foods, like Incaparina, on their own in the community with a greater proportion of land owners and without being prompted by facilitators. It may be that Incaparina, food producers in fact had worse dietary diversity among the which has been popular in Guatemala for decades, has become youngest children, it may be that the bulk of the food produced, part of the national identity so much so that its healthfulness is especially the high quality food, is in fact sold in local markets or common knowledge. diverted to the export economy. Vitamins were perceived as being needed to prevent Similar to the financial issues raised by caregivers regarding malnutrition and illness; important for development, growth, and the purchase of basic food items, many also reported that, health; and necessary for mental capacity. Caretakers had a good although they recognized the value of fortified foods as well as understanding of both sources and functions of vitamins more vitamins/micronutrient supplements for children, their ability to generally, although perhaps not specifically for each vitamin, purchase these items was limited. Nevertheless, consumption nor what foods provide which vitamins, as these were topics of fortified and commercial foods for children was high in both where community members reported their desire for additional communities with an average of 60% of children consuming them knowledge. Seven-day food recalls also provided some evidence weekly (mostly Incaparina, but also Nestle, Quaker, and Gerber that on average, the only foods consumed daily (i.e. ≥ 7 servings/ products). The number of servings of atol products per week week) by children 6 to 23 months were high starch and sugar (either home-prepared corn or rice flour drinks with sugar or foods, and vegetables, indicating that the importance of dietary equivalent commercial products such as Incaparina or Quaker diversity to provide a wide variety of vitamins and minerals is cereal products) also was high, with children in the Highland not well understood. These topics all provide good opportunities consuming more weekly servings than in the Bocacosta (5.76 for educational initiatives that are also of interest to the vs 3.29, p=0.001d). It should also be noted that atoles are family communities. foods, and that other family members in the households are likely It was common among caregivers to confuse foods perceived consuming these when they are available. as healthful in general with foods specifically fortified with

20 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 children’s 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 NGO- sponsored 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 3. Chary A, Messmer S, Sorenson E, Henretty N, Dasgupta S, Rohloff Study Limitations P. (2013). The normalization of childhood disease: An ethnographic The main weakness of this study is the low external validity, study of child malnutrition in rural Guatemala. Human Organization (in press). meaning the low ability to take the very detailed information we learned about these two communities and generalize this 4. Wuqu’ Kawoq | Maya Health Alliance. (2011). Baseline needs information to other communities in Guatemala or elsewhere assessment of Xejuyu’. Unpublished data. with great confidence. Because beliefs, knowledge, and behaviors can be so specific to cultures, ethnic groups, communities, or even 5. Guiding principles for complementary feeding of the breastfed child families, it is difficult to determine how similar other communities Pan American Health Organization, Washington, DC 2003 will be in relation to the findings presented here. Some of the 6. WHO. (2003). Global strategy for infant and young very salient similarities between the two indigenous communities child feeding. Retrieved from http://whqlibdoc.who.int/ may be generalizable; formative work in new areas would help to publications/2003/9241562218.pdf inform if these similarities are found elsewhere. 7. Carey, D. Jr. (2006). Engendering Mayan History: Kaqchikel Women as Agents and Conduits of the Past, 1875-1970. New York: Acknowledgements Routledge; Ehlers, TB (2002). Silent Looms: Women and Production in a Guatemalan Town. Austin: University of Texas Press. The study was co-conceived by Wuqu’ Kawoq | Maya Health Alliance and Edesia, Inc. Wuqu’ Kawoq is a nongovernmental 8. Hoddinott, J. M.-Z. (March 2011). The consequences of early childhood growth failure over the life course. International Food organization which assists in the development of culturally and Policy Research Institute Paper. linguistically excellent health programs in indigenous communities in Guatemala. Edesia, Inc. is a nonprofit manufacturer and 9. Merchant, K. (1990). Maternal and fetal responses to the stresses distributor of ready-to-use foods (RUFs) for use in the prevention of lactation concurrent with pregnancy and short recuperative and treatment of child malnutrition. Wuqu’ Kawoq’s staff and intervals. Am J Clin Nutr, 52: 280-8. volunteers were in charge of all data collection and in analyzing 10. Oliveros, C., et.al. (1999). Maternal lactation: A Qual. analysis of the qualitative data; Wuqu’ Kawoq and Edesia were jointly responsible breastfeeding habits and beliefs of pregnant women living in Lima, for analyzing quantitative data and writing this report. The study Peru. International Quarterly of Community Health Education, was funded in full by Nutriset, a leading manufacturer of ready- 18(4). 415-434. to-use foods in France. Collaborators: Yolanda Xuya, Glenda Gomez, Florencio Calí, Community of Xejuyu’, and Community 11. WHO. (2010). Indicators for assessing iycf practices Part 3: of K’exel. Country Profiles. Retrieved from http://www.who.int/maternal_ child_adolescent/documents/9789241599757/en/

12. Enneman, A., Hernandez, L., Campos, R., Vossenaar, M., Solomons, Financial Disclosures and Conflict of N.W. (2009). Dietary characteristics of complementary foods offered to Guatemalan infants vary between urban and rural Interest Statement settings. Nutrition Research, 29: 470-479.

All study authors are affiliated as staff, volunteers, or advisors 13. UNICEF. (2010). At a glance : Guatemala. Retrieved from http:// of either Wuqu’ Kawoq | Maya Health Alliance or Edesia, Inc. www.unicef.org/infobycountry/guatemala_statistics.html The study was funded in part by a research grant from Nutriset. Wuqu’ Kawoq | Maya Health Alliance uses some Edesia’s products in its child nutrition programming. Edesia, Inc. is a nonprofit manufacturer and distributor of Nutriset-licensed products.

Sources 1. Ministerio de Salud Pública yAsistencia 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 Children’s 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 Pública y Asistencia Social.

2. Sistema de Vigilancia de la Malnutrición en Guatemala (SIVIM). (Mayo, 2012). Fase I: Prueba del prototipo en cinco departamentos de la región del altiplano occidental de Guatemala: Resumen. INCAP, USAID/HCI, CDC.

22 Appendix A: Acronyms, Abbreviations, Definitions

General: Bocacosta Study site located along the Pacific coast; K’exel Highlands Study site located in the central highlands; Xejuyu’ Indigenous Self-identifying as Maya; often, speaking a Mayan language, or wearing traditional Maya clothing Kaqchikel, K’iche’ Mayan languages spoken in the study area Ladino(a) 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, Milpa agriculture especially beans, on small plots of land Subsistence agriculture Lifestyle in which the bulk of one’s work efforts are used to grow food for one’s own consumption Foods: Atol(es) Thin gruel that is served hot and is usually made from corn flour, rice flour, or a commercial mix Café de tortilla Drink made from soaking toasted tortillas in hot water, served with sugar Caldos Broths- chicken, beef, pork, vegetables, greens; liquid from cooked beans Comida chatarra(s) Junk foods Commercial foods Foods packaged and labeled commercially Corazón de trigo Processed wheat cereal product that is reconstituted into a gruel Fortified foods Commercial foods with added vitamins and/or minerals Galleta Packaged cookie or cracker Gaseosa, refrescos Soda, sweetened beverages Golosinas Sweets, candy Hierba(s) 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 Incaparina combined with vitamins and minerals Mosh/Avena 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 Plumpy’Doz™ months; provided through some Wuqu’Kawoq programs Tienda Small shop that sell groceries, junk foods, and other small household items Program: Capacitaciones Formal educational classes Pláticas 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 Positive deviance model to a problem than their peers, despite facing similar challenges and having no extra resources or knowledge than their peers. Feeding related: 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; Appropriate minimal dietary diversity 6-23 dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry and liver/organ meats); eggs; months (%) (WHO indicator) vitamin-A rich fruits and vegetables; and other fruits and vegetables; minimum number of food groups consumed for this age group is ≥ 4. Appropriate minimal meal frequency 6-23 Number of meals and snacks fed in 24 hour period; breastfed children 6-23 months of age who had months (%) (WHO indicator) 4 or more meals Appropriate minimal acceptable diet 6-23 Composite indicator; breastfed children 6-23 months of age who had at least the minimum dietary months (%) (WHO composite indicator) diversity and the minimum meal frequency during the previous day Infant and young child feeding (IYCF) Feeding practices of infants and young children between birth and age 3 years Infant and young child nutrition (IYCN) Specific nutritional needs of infants and young children between birth and age 3 years Complementary feeding Initiation of solid foods at 6 months of age to complement breastfeeding Continued breastfeeding Continuation of breastfeeding from 6 months to 2 years, in addition to appropriate foods Exclusive breastfeeding Infant receives only breast milk, vitamins, and some medicines for the first 6 months of life Pre-lacteal feeds Food/liquid given to the infant before initiating breastfeeding for the first time after birth

23 Appendix B: Fortified Food List

Product Sizes Cost Package labeling (Spanish) Package labeling (English)

Enriquecida con vitaminas; Fortificada Enriched with vitamins; fortified with Anchor Leche Entera en Polvo 26g; 120g; 3 Q; 10 Q; con hierro, ácido fólico, vitaminas A & D, iron, folic acid, vitamins A & D, zinc, (dry milk) 360g 29 Q zinc, calcio, vitaminas C, E, and A, biotina calcium, vitamins C, E, and A, biotin Azucar La Montana (iron, - - Fortificada con vitamina A Fortified with vitamin A vitamin A) Campo Rico Avena 66.92g 2.5 Q Calcio, hierro, vitaminas Calcium, iron, vitamins Chocolisto (dry beverage) 200g 8 Q Vitaminas y minerales Vitamins and minerals Corazon de Trigo 400g 7.25 Q Fortificada con vitaminas y hierro Fortified with vitamins and iron Cosecha Pura Naraja (juice box) 500 ml 3 Q Enriquecida con vitamina C Enriched with vitamin C Ducal Fruit Nectar (canned 220 ml 2.5 Q Con vitamin C With vitamin C juice) Gerber Frutas Mixtas (baby Fortificado con vitamina C, ácido fólico, Fortified with vitamin C, folic acid, and 100g 5-6 Q food jar) y hierro iron Gerber Manzana, Banano (baby Fortificado con vitamina C, ácido fólico, Fortified with vitamin C, folic acid, and 100g 5.5 Q food jar) y hierro iron Buena fuente de proteína; Nutrición Good source of protein; proven healthy comprobada, sana y natural; Mezcla and natural nutrition; mix of fortified 2 -2.5 Q; Incaparina 75g; 450g vegetal fortificada para hacer atol; vegetables to make atol (corn-based 7.5-9.5 Q Excelente fuente de hierro y zinc, más 5 gruel); Excellent source of iron and zinc, vitaminas and 5 other vitamins Kambú Fortified Drink (milk box) 1 each 3.5 Q Deliciosa, saludable, nutritiva Delicious, healthy, nutritious Kerns Fruit Juice 330 ml 3.5 Q Con vitamina C With vitamin C Kerns Vegetable Juice 330 ml 3.5 Q Con vitamina C With vitamin C Con vitamina C, calcio, y zinc - With vitamin C, calcium, and zinc - Kerns Junior; Nectar Melocoton 330 ml 3.5 Q escenciales para crecer especially for growth 2-2.5 Q; Maizena 47g; 190g Atol fortificada Fortified atol 7 Q (no health or nutrition claims on (no health or nutrition claims on Nestlé Kinder Nido 800g 65 Q package) package) NAN 1 (for 0-6 months): Formula NAN 1 (for 0-6 months): Initial milk láctea de inicio en polvo con hierro y formula in powder with iron and probióticos para lactantes; Gentle start, probiotics for infants; Gentle start, L-comfortis: DHA, ARA, OPTI-Pro. NAN L-comfortis: DHA, ARA, OPTI-Pro. NAN 2: Formula láctea de continuación en Nestlé NAN 1 & 2 350g 60 Q 2: Continuing milk formula in powder polvo con hierro y probióticos para with iron and probiotics for infants; lactantes; Gentle plus, L-comfortis: DHA, Gentle plus, L-comfortis: DHA, OPTI- OPTI-Pro. Aviso importante: La leche Pro. Important: Breast milk is the best materna es el mejor alimento para el nutritional source for infants lactante Nestlé Nesquik 200g 3.5 Q Fuente de hierro y vitamina C Source of iron and vitamin C

Helps to strengthen your baby’s natural Ayuda a fortalecer las defensas naturals Nestlé Nestum Cereal Infantil; 5, defenses- nutrients for the immune 360g 22 Q de tú bebe - Immunonutrientes: hierro, 8, arroz, trigo y miel system: iron, zinc, vitamins A & C, 13 zinc, vitaminas A & C -13 vitaminas vitamins

24 Appendix B: Fortified Food List (continued)

Nueve fórmula con probióticos; Doble New formula with probiotics; Double acción: Lactobacillus protectus, 11 action: Lactobacillus protectus, 11 vitaminas y 3 minerales. Es el primer vitamins and minerals. This is the first paso del sistema de nutrición NIDO step for the NIDO nutrition system, especializada para cada fase del specially designed for each phase of desarrollo de tus hijos; El alimento a base development of your children; This food de leche NIDO aporta vitamina A, la cual based in NIDO milk contains vitamin Nestlé Nido Crecimiento 360g 35 Q es esencial para el buen funcionamiento A, which is essential for the immune Protección (formula) del sistema immunológico- la vitamina system to function well - vitamin A A ayuda a mejorar la resistencia helps to improve the body’s resistance del organismo contra infecciones to gastrointestinal and respiratory gastrointestinales y respiratorias; No es infections; This is not a substitute sustituto de la leche materna sino un for breast milk, but rather it is an alimento lácteo adecuado especialmente appropriate milk-based food for children para niños desde 1 año y adelante aged 1 year and older Nestlé Nido Fortificada 840g 60 Q Hierro, zinc, vit C, vit D Iron, zinc, vit C, vit D Nestlé Nido Leche Entera en Fortificada: hierro, vitamina A, vitamina C, Fortified: iron, vitamin A, vitamin C, 360g 30 Q Polvo vitamina D, zinc Vitamin D, zinc Nestlé Nido Nutri-Rindes 480g 30 Q Hierro y ácido fólico Iron and folic acid Salud y mas nutricion en sus comidas Health and more nutrition in your food - proteina de soya texturada - con - textured soy protein - with iron and Protemás 120g 6.5 Q hierro y acido fólico - ayuda a reducar el folic acid - helps to reduce cholesterol colesterol por su naturaleza naturally. Suero Oral (Na, K, Cl, 500 ml 21 Q Ahora con zinc Now with zinc Zn and citrate added) Hierro, calcio, zinc, vitaminas - previene Iron, calcium, zinc, vitamins - prevents Quaker Avena Mosh Nutremás 80g; 400g 2 Q; 10 Q la anemia, foralece los huesos, ayuda el anemia, strengthens bones, helps with crecimiento, mejora el disempeno growth, improves performance Shaka Laka Shakes 200 ml 3.5 Q Extra minerales y vitaminas Extra minerals and vitamins Yus de Toki 35g 2-2.5 Q Contiene vitaminas A & C Contains vitamins A & C

Appendix C: General Food List

Product Sizes Cost

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

25