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SUMMARY The goal of the present study was to document the neonatal behavior and the psychophysiological development in infancy of a group of 157 Guatemalan infants drawn from a long-term prospective study of the effects of chronic malnutrition during pregnancy. Behavior in the neonatal period which reflected neuro-motor adequacy as well as social interaction were related significantly to gestational age, birthweight and age of testing. Maternal variables such as unexpectedly prolonged intervals between pregnancies, maternal height and socio–economic group, also related to neonatal performance in the offspring. These findings seem to point to inherited, non-genetic variables which can affect intrauterine conditions unfavourably and perpetuate the depleting effects of poverty from one generation to another. RESUME Comportement de nouveaux-nŕs guatŕmaltŕgues apres agression nutritionelle Le but de la prŕsente ŕtude a ŕtŕ de prŕciser le comportement nŕonatal et le dŕveloppement psycho-physiologique durant la premiere enfance dun groupe de 150 nourrissons guatŕmalteques tirŕs dune ŕtude prospective a long terme sur les effets de la malnutrition chronique durant les grossesses. Les comportements de la pŕriode nŕonatale indiquant 'intŕgritŕ neuromotrice aussi bien que 'interaction sociale ŕtaient reliŕs significativement a 'âge de gestation, au poids de naissance et a 'âge des examens. Les variables maternelles, telles que des intervalles prolongŕs inattendus entre les grossesses, la taille et le groupe socio-ŕconomique ŕtaient ŕgalement reliŕsaux performances nŕonatales des descendants. Ces faits semblent souligner 'existence de variables innŕes, non gŕnŕtiques pouvant affecter dŕfavorablement les conditions intra-utŕrines et perpŕtuer les effets nŕgatifs de la pauvretŕ dune gŕnŕration a 'autre. ZUSAMMENFASSUNG Das Verhalten von unterernahrten Neugeborenen in Guatemala Das Ziel dieser Arbeit bestand darin, Neugeborenenverhalten und psycho-physiologische Entwicklung im Kindesalter an einer Gruppe von 157 Kindern aus Guatemala darzustellen, die aus einer Langzeitstudie uber die Auswirkungen chronischer Unterernahrung wahrend der Schwangerschaft herausgenommen wurden. Verhaltensmuster in der Neonatalperiode, die fur die neuro-motorische Entwicklung sowie fur die soziale Interaktion zu werten waren, waren signifikant zum Gestationsalter, zum Geburtsgewicht und zum Testalter korreliert. Mutterliche Faktoren wie unerwartet lange Intervalle zwischen den Schwangerschaften, Grose der Mutter und sozio-okonomischer Status zeigten ebenfalls eine Relation zu dem Neonatalverhalten des Kindes. Diese Befunde scheinen auf vererbte nicht genetische Faktoren zu deuten, die intrauterine Bedingungen ungunstig beeinflussen und die die korperliche Erschopfung durch die Armut von einer Generation zur anderen weitertragen konnen. RESUMEN El comportamiento de reciŕn nacidos Guatemaltecos con un stress nutritivo La finalidad del presente estudio era documentar el comportamiento neonatal y el desarrollo psico-fisiologico en la lactancia de un grupo de 157 ninos de Guatemala entresacados de un estudio prospectivo a largo plazo sobre los efectos de la manutencion cronica durante la gestacibn. Los comportamientos del period0 neonatal que reflejan una adecuacion neuromotora, asi como una interaccion social estaban relacionados significativamente con la edad estacional, el peso del nacimiento y la edad en que se hizo la observacion. Las variables maternas tales como unos periodos inesperadamente prolongados entre las gestaciones, la estatura materna y el grupo socieconomico, tambiŕn estaban en relacion con la realizacion neonatal en el reciŕn nacido vivo. Estos hallazgos parecen apuntar hacia unas variables heredadas, no genŕticas que pueden afectar las condiciones intrauterinas de forma desfavorable y perpetuar los efectos de deplecion de la pobreza de una generacion a otra.

The present study reports 5,029 length and weight measurements as well as percentile distributions for a mixed longitudinal series of 1,119 rural Guatemalan Ladino children. The study sample, birth through seven years, is representative of children in clinically good health, but of suboptimal nutrition. Boys are longer and heavier than girls over the age range. Guatemalan children of both sexes are smaller than American white children from Denver. Differences are least at birth, and increase through two years of age. Between two and five years, differences between the rural Guatemalan Ladino and Denver samples are rather stable, but then increase through seven years. Despite these differences there is a linear weight for length relationship which is the same across all preschool ages, both sexes, and for both the Guatemalan and Denver populations. This implies that age, sex, ethnic differences between the two groups compared, and mild-to-moderate protein-calorie malnutrition do not affect the relationship between weight and length in preschool children.

This study ia aimed to develop indicators of low birth weight in the newborn for use in communities where babies are usually delivered at home and where scales to weigh newborns are not available. For this purpose head arm chest thigh and calf circumferences triceps and subscapular skinfolds weight and length were determined in 1000 newborns during the 1st 24 hours after delivery in 2 hospitals in Guatemala. Except for triceps and subscapular skinfolds all anthropometric variables were highly associated with birth weight. From the analysis performed the following limits may be useful to define newborns at risk of having low birth weight (=or< 2.5 kg): arm circumference =or< 9.0 cm; 2) head circumference =or< 32.0 cm; 3) calf circumference =or< 10.0 cm; 4) thigh circumference =or< 14.5 cm; 5) chest circumference =or< 30.0 cm; and 6) lenght =or< 48.0 cm. Newborns falling within these categories may be considered at high risk of low birth weight and thus be eligible for immediate nutritional as well as medical attention aimed to increase their chances for survival and optimal development. (authors modified)

Variability in stature among young children is often ascribed to health and nutrition differences in malnourished populations and to genetic differences in well-nourished populations. Hence, it was hypothesized that parent-child correlations in malnourished Guatemalan populations would be markedly lower than those reported for European samples. Instead, it was found that parent-child and sibling correlations were similar in both kinds of populations. The simplest interpretation of these results is that variability in stature among malnourished children is as much a reflection of genetic differences as in developed nations. However, explanations can also be advanced which would attribute the higher than expected correlations to the environment. For instance, it could be that socioeconomic and nutritional status is correlated across generations. In other words, parents who had relatively better conditions as children are more likely to provide a better environment for their children. Consequently, the relative contribution of genetics and environment to variability in height is still unsettled. Nonetheless, it appears that variability in body size in malnourished populations, regardless of the relative importance of its causes, is a useful indicator of health and nutrition.

Growth patterns in head and chest circumferences are reported for a mixed-longitudinal sample of rural Guatemalan Ladino children from birth to 7 years of age. The sample is representative of a population with suboptimal nutrition. Both circumferences show similar rapid growth from birth through 9 months, after which chest circumference continues to increase more rapidly, while head circumference increases at a slower rate. Chest circumference provides nutritional information apparently not contained in length and weight. Compared to a sample of well-nourished children from Denver, the head circumferences of Guatemalan children are consistently smaller. Differences are relatively small at birth, are well established by 6 months, and become progressively greater through 24 months. After 2 years the mean smaller head circumference of the Guatemalan children also reflects stunted growth during the first 2 years of life. Similarly, among 5-year-old Guatemalan children of similar stature, head circumference at 5 years of age indicates which of these children were more stunted in stature at 2 years of age.

The relationship between diarrheal diseases and growth increments in total body length and weight was investigated in 716 rural Ladino Gautemalan children. Data on diarrheal diseases were provided by the mothers through retrospective surveys carried out at 14-day intervals. Increments in length and weight, semestral from near birth at four years and yearly thence to seven, were related to days ill with diarrheal diseases during the same time interval. Because the data here reported were collected over a two year period, a child may have had information for more than one period. In total, 1,343 child periods were investigated. Days ill with diarrheal diseases were found to be significantly associated with reduced growth in length and weight. It was assumed that the average differences in growth by seven years of age between children in the present sample and children from well-to-do societies, are mainly a function of environmental differences and consequently, a measure of the extent of growth retardation. By expressing the growth retardation specifically associated with diarrheal diseases as a fraction of the above differences it was then estimated that around 10% of this growth retardation was associated with diarrheal diseases.

Total energy expenditures and intakes were simultaneously assessed in 18 free-ranging lactating women (10 months postpartum) and compared to six similarly-sized, nonlactating, nonpregnant but multiparous women living in the same rural villages in the Guatemalan highlands. Energy intakes were estimated by the 24-hr recall method for each of 4 consecutive days. Energy expenditures were determined for 2 days by monitoring heart rate throughout the day and relating heart rate to oxygen consumption by individually-determined regression lines. The mean energy intake for the 4 consecutive days was estimated to be 1929 +/- 360 kcal/day (39.2 kcal/kg per day) for the lactating group; and 1876 +/- 404 kcal/day (38.3 kcal/kg per day) for the nonlactating group. The 2-day mean energy expenditures were estimated to be 2007 +/- 292 kcal/day for the lactating women (41.8 kcal/kg per day) and 1966 +/- 382 kcal/day for the lactating women (40.1 kcal/kg per day). The way of life of both groups was judged "moderately active" by 1973 FAO/WHO classifications. Most of the lactating women had been losing weight progressively during the past 6 months. Over the 10-week period prior to our measurnth) (P less than 0.01) than in the nonlactating group (-35 g/month) (ns). The high correlation (r = 0.87) between weight loss and the reduction in the sum of the three skinfolds suggested adipose tissue loss. There were no significant differences between the two groups in terms of daily energy intake, daily energy expenditure, the energy cost of specific activities throughout the day. The slope of the heart rate/oxygen consumption regressions suggest adequate cardiorespiratory fitness. This study suggests that the energy cost of lactation was met to a greater extent by fat loss than by either increased energy intake, reduced energy expenditure, or both.Total energy expenditures and intakes were simultaneously assessed in 18 lactating women (10 months postpartum) and compared to 6 similarly-sized nonlactating, nonpregnant but multiparious women living in the same rural villag in the Guatemalan highlands. Energy intakes were estimated by the 24-hour recal method for each of 4 consecutive days. Energy expenditures were determined for 2 days by monitoring heart rate throughout the day and relating heart rate to oxygen consumption by individually-determined regression lines. The mean energy intake for the 4 consecutive days was estimated to be 1929 + or 360 kcal/day (39.2 kcal/kg/day) for the lactating group and 1876 + or - 404 kcal/day (38.3 kcal/kg/day) for the nonlactating group. The 2-day mean energy expenditures were estimated to be 2007 + or - 292 kcal/day for the lactating women (41.8 kcal/kg/day) and 1966 + or - 382 kcal/day for the nonlactating women (40.1 kcal/kg/day). The way of life of both groups was judged as moderately active by 1973 FAO/WHO classifications. Most of the lactating women had been losing weight progressively during the past 6 months. Over the 10-week period prior to our measurements, the mean weight loss was more than 10 times greater in the lactating group (-369 g/month) (P 0.01) than in the nonlactating group (-35 g/month) (ns). The high correlation (r=0.87) between weight loss and the reduction in the sum of 3 skinfolds suggested adipose tissue loss. There were n significant differences between the 2 groups in terms of daily energy intake; daily energy expenditure; energy cost of specific activities; or in the pattern of activites during the day. The slope of the heart rate/oxygen consumption regressions suggest adequate cardiorespiratory fitness. This study indicates that the energy cost of lactation was met to a greater extent by fat loss than by either increased energy intake, reduced expenditure, or both.

This paper describes SINAPS, a program of primary health care in Guatemala, planned by the Ministry of Public Health (MOH), Pan American Health Organization (PAHO), and the Institute of Nutrition of Central America and Panama (INCAP). The objective was to design, implement, and evaluate a program of primary health care in Guatemala based on service delivery by non-professional personnel. These personnel consist of Auxiliary Nurses (AN), Rural Health Technicians (RHT), Rural Health Promoters (RHP), and Traditional Birth Attendants (TBA). SINAPS activities are focused on immunizations, food supplementation, oral rehydration of children suffering from dehydration, family planning, perinatal surveillance, and promotion of health and environmental sanitation, with the participation of the community. This limited set of interventions is aimed at controlling the most important causes of death and disability in mothers and children in a cost-effective way.

The growth in arm muscle area and arm fat area of preschool children from rural Guatemala is compared to that of a standard from the U.S.A. It was found that although the Guatemalan children have reduced arm muscle and fat areas, the relative reduction in arm fat area was greater than in arm muscle area. Further, the upper arm cross-sectional area of Guatemalan children had proportionately more muscle than fat when compared to that of U.S.A. children. Lastly, for the same body weight, Guatemalan children had a similar arm muscle area but a clearly smaller arm fat area than North American children. It is concluded that these findings suggest that energy rather than protein is the main nutritional problem in these Guatemalan children.

The results of two studies of the influence of moderate maternal malnutrition on the weight and chemical characteristics of the placenta are discussed. In the first study, two groups of pregnant women of high and low socioeconomic status from Guatemala City were studied. Socioeconomic status was defined by family income, educational level of the mother, and environmental sanitary conditions. Both groups were very similar with respect to age, parity, gestational age, and absence of severe disease during pregnancy. The average placental weight in the low socioeconomic group was 15 per cent below that of the high socioeconomic group and there was a consistent association between the postpartum maternal weight and placental weight. There were no differences between the two groups regarding placental concentration of fat, protein, water, ash, hemoglobin, and DNA; hydroxyproline and fat concentration were significantly lower in the low socioeconomic group. The hypothesis that the difference in placental weight observed between the two groups was primarily due to maternal nutritional status was tested in the second study by means of nutritional intervention in four rural villages in Guatemala. Two of the villages received a protein-calorie preparation while the other two received a calorie supplement. Placental weight was higher among women with high levels of supplemented calories during pregnancy, independently of the type of food supplement ingested. On the average, the groups with low caloric supplementation (smaller than 20,000 calories) had placental weight 11 per cent below those with high caloric supplementation (larger than or equal to 20,000 calories), In contrast to placental weight, the concentration of placental chemical components studied was not associated with caloric supplementation. It was concluded that moderate protein-calorie malnutrition during pregnancy leads to lower placental weight without significantly changing the concentration of the biochemical components studied. The reduction of placental weight may be the mechanism by which maternal malnutrition is associated with high prevalence of low-birth-weight babies in these populations.The results of 2 studies carried out at the Institute of Nutrition of Central American and Panama are described. The 1st study was of an urban population and the other in rural villages. The influences of mode rate maternal malnutrition on the weight of the placenta and its chemical characteristics were particularly studied. Placentas were homogenized and then divided into 3 equal parts which were lyphilized. In the urban study, women of high and of low socioeconomic status were compared. The low socioeconomic group was considered to suffer from calorie deficiency, and particularly protein malnutrition at the time of the study. The values of the tricipital skinfold tests were lower in this group, and the weight for height ratio was low (p less than .01). The average placental weight in the low socioeconomic group was 15% below th at of the high socioeconomic group. Placental concentrations of protein, water, ash, hemoglobin, and DNA were the same in the 2 groups, while hydroxyproline and fat levels were less in the low socioeconomic group, and peripheral villi areas of the placenta were shown to be less in this group (p less than .001). These changes were attributed to moderate maternal malnutrition. In the rural study the female populations of 4 villages were investigated. Mean weight gains during pregnancy were only 60% of normal. Diet consisted mostly of corn and beans with little animal protein. In 2 villages, a dietary supplement containing protein was distributed and in the 2 other villages another supplement without protein and of lower caloric value was given. Placental weights were 11% less in those with the lower caloric and no protein supplement. An association between maternal malnutrition, placental weight, and birth weights of infants was shown. Low placental weight was considered to be the most important measurable factor in reducing birth weights.

The high prevalence of low-birtheight ( (≤ 2,500 gm) babies in many poor communities is a major public health problem. Studies in humans in situations of acute starvation suggest an effect of maternal nutrition on birth-weight, but less clear results appear under situations of moderate maternal malnutrition. We studied the effects of food supplementation during pregnancy on birthweight in four rural villages of Guatemala, in which two types of supplements were distributed: protein-caloric and caloric. The caloric supplementation increased the total caloric intake during pregnancy. In both supplements, the amount of calories supplemented during pregnancy showed a consistent nt association with birthweight. In the combined sample the proportion of low-birthweight babies in the high-supplement group (G ≥ 20,000 supplemented calories during pregnancy) was 9% compared with 19% in the low-supplement ent gro≤ (< 20,000 supplemented calories during pregnancy). The relationship between caloric supplementation and birthweight (29 gm of birthweight per 10,000 supplemented ented calories) was basically unchanged after controlling for the maternal home diet, height, head circumference, parity, gestational age, duration of disease during pregnancy, socioeconomic status, and different rates of missing data. Moreover, a similar association was found in consecutive pregnancies of the same mother. We concluded that caloric supplementation during pregnancy produced the observed increase in birthweight.

The number of deciduous teeth in a sample of rural Ladino Guatemalan children was counted every 3 months through 24 months of age, and at 6-month intervals from 24 to 36 months. Nutritional status at birth, whether expressed as full-term birth weight or as maternal caloric supplementation during pregnancy, influences the timing of deciduous tooth eruption. Furthermore, the timing of deciduous tooth eruption seems more closely associated with postnatal weight than with birth weight. Although indices of nutritional deficiencies are associated with retarded tooth eruption, the use of mean number of deciduous teeth erupted as an estimate of mean chronological age in populations living under conditions of mild-to- moderate malnutrition is relatively accurate because errors of age estimation based on mean values for the present sample only vary between I and 2 months. Am. J. Clin. Nutr. 28: 2 16-224, 1975. Marginal nutritional status during infancy and early childhood affects adversely various aspects of growth and development. Although malnutrition might be expected to delay dental

This paper discusses some conditions necessary to detect an effect of maternal nutrition on birth weight and the relative contribution of calories and protein to such an effect. The expected dose- and time-response relationships for nutritional interventions aimed at the improvement of birth weight are also discussed. There appears to be a minimal level of nutrients which must be available in order to obtain adequate birth weight. However, above this minimum level, pregnant women can adapt themselves to a wide variety of food intake, both in quantity and quality, without affecting birth weight. The relative contribution of calories and protein to an increase in birth weight depends on the limiting nutrients of the home diet in the population under study. Other factors like physical activity, prevalence of disease and magnitude of the maternal nutritional stores before pregnancy are also important determinants of the relative contribution of calories and protein to birth weight. The anticipated input of a nutritional intervention on birth weight should range between 25 and 84 g of birth weight/10,000 kcal ingested during pregnancy. This estimate was computed from analyses based on four sources of published data: weight gain during pregnancy, prepregnant weight, fetomaternal body composition, and food intake during pregnancy. The expected reduction in proportion of low birth weight (LBW less than 2.5 kg) babies following a nutritional intervention will depend not only on the estimated range of fetal weight increase but also on the total amount of supplemented calories ingested during pregnancy as well as on the existent proportion of low birth weight babies prior to the intervention. The offspring of women who have low prepregnant weight, poor diet, low level of replacement of the home diet by the supplement, low physical activity during pregnancy and good health status will show larger increase in birth weight per unit of supplemented calories. Finally, nutritional interventions during pregnancy as opposed to earlier in the life of the mother, should have the higher impact on birth weight. In consequence, interventions as of pregnancy are recommended.This paper discusses some conditions necessary to detect an effect of maternal nutrition on birthweight and the relative contribution of calories and protein to such an effect. The expected dose- and time-response relationships for nutritional interventions aimed at the improvement of birthweight are also discussed. There appears to be a minimal level of nutrients which must be available in order to obtain adequate birthweight. However, above this minimum level, pregnant women can adapt themselves to a wide variety of food intake, both in quantity and quality, without affecting birthweight. The relative contribution of calories and protein to an increase in birthweight depends on limiting nutrients of the home diet in the population under study. Other factors like physical activity, prevalence of disease, and magnitude of the maternal nutritional stores prior to pregnancy are also important determinants of the relative contribution of calories and protein to birthweight. The anticipated input of a nutritional intervention on birthweight should range between 25-84 g of birthweight/10,000 kcal ingested during pregnancy. This estimate was computed from analyses based on 4 sources of published data: weight gain during pregnancy, prepregnant weight, fetomaternal body composition, and food intake during pregnancy. The expected reduction in proportion of low birthweight (LBW or= 2.5 kg) babies following a nutritional intervention will depend not only on the estimated range of fetal weight increase but also on the total amount of supplemented calories ingested during pregnancy as well as on the existent proportion of low birthweight babies prior to the intervention. The offspring of women who have low prepregnant weight, poor diet, low level of replacement of home diet by the supplement, low physical activity during pregnancy, and good health status will show larger increase in birthweight/unit of supplemented calories. Finally, nutritional interventions during pregnancy as opposed to earlier in the life of the mother, should have the highest impact on birthweight. Consequently, interventions as of pregnancy are recommended.

The relationship between food supplementation during pregnancy maternal nutrition - as estimated by anthropometrical measurements - and birth weight in a chronically malnourished population was examined in 4 rural villages of Guatemala. The data were drawn from a long-term prospective study dealing with the effects of chronic malnutrition on physical growth and mental development. The findings showed that calorie supplementation was positively associated with maternal monthly weight gain during pregnancy after controlling for maternal home diet height head circumference gestational age parity birth interval morbidity socioeconomic status and type of supplement (protein-caloric and caloric). The proportion of mothers with a monthly weight gain equal to or less than 0.5 kg was 15% in the low-supplemental group and 2.4% in the high supplemented group. Direct associations between birth weight and all maternal measurements of mass and length (weight at 1st 2nd and 3rd trimester weight gain during pregnancy height and sitting height) with all the perimeters (head arm leg thigh and chest) and the 2 osseous diameters measured (biestyloid and bicondylar) were also observed. Associations between birth weight and skinfolds (subscapular bicipital tricipital midaxilar lateral and anterior thigh and leg) were less consistent. The results support the hypothesis that food supplementation improves both birth weight and maternal nutritional status.

The results of a food supplementation study conducted in four chronically malnourished rural villages in Guatemala were analyzed to determine possible effects on the study children's early mental and physical development. One of two food supplements, atole and fresco, were given to pregnant and lactating mothers and the infants born to them up to three years of age. The level of supplement received was noted and the subsequent course of the children's development observed. Food supplementation of pregnant mothers was found to correlate with higher weights of their babies at birth. No other major maternal variables--home diet, body height and/or weight, morbidity, obstetric characteristics, or socioeconomic status--could account for this association. At 36 months of age the children who had received a large amount of food supplementation showed a far lower prevalence of growth retardation than did those who received smaller quantities. Again, this correlation could not be attributed to any other major maternal variables. In regard to mental development, food supplementation was found to correlate with better performance in psychological tests beginning at six months of age. At 36 months the correlations were significant in five different tests. The results of this analysis have wide-ranging implications for public health. Given the recognized association between low birthweight and infant mortality, they point especially to the importance of maternal nutrition during pregnancy in programs aimed at reducing this serious problem.

The present study investigated the relationship between a number of anthropometric indices and behavioral development during the first 2 years of life in rural Guatemala. Length and weight were the indices most strongly correlated with behavioral development. If the effect of the infant's length and weight was statistically controlled for, none of the other anthropometric variables explained a significant proportion of the variance in behavioral development. Controlling the length (or weight) assessed at the same age as the behavioral assessment, length (or weight) for younger ages was not significantly correlated with behavioral development. Changes in length or weight over time correlated with changes in behavioral performance. We were unable to explain the association between physical growth and behavioral development by a number of variables including gestational age, nutrient intake, prevalence of disease, and familial characteristics.This study investigates the relationship between a number of anthropometric indices and behavioral development during the first 2 years of life in rural Guatemala. Length and weight are the indices most strongly correlated with behavioral development. If the effect on the infant's length and weight are statistically controlled for, none of the other anthropometric variables explain a significant proportion of the variance in behavioral development. Controlling for length (or weight) assessed at the same age as the behavioral assessment, length (or weight) for younger ages is not significantly correlated with behavioral development. Changes in length or weight over time are correlated with changes in behavioral performance. The authors are unable to explain the association between physical growth and behavioral developemnt by a number of variables including gestational age, nutrient intake, prevalence of disease, an familial characterisitcs.

This paper reviews the usefulness of the 1-day recall method for assessing calorie and protein intake. To this end, it discusses the basic assumptions in determining nutrient intake of either populations or individuals. It is concluded that the 1-day recall survey is valid and reliable to estimate mean dietary calorie and protein intake in population groups. Its reliability to estimate individual intake is, however, low, and similar to that of other more complicated dietary survey techniques. In consequence, frequent surveys per person are required to reliably estimate usual individual intake. Basic assumptions necessary to infer nutritional status as well as main limiting nutrients from dietary surveys are discussed. It is concluded that as long as basic objectives and assumptions are clear, the 1-day recall survey is a useful and practical tool estimate calorie and protein intake of population groups. In addition, a simplified one-day recall survey may be a suitable means for assessing calorie and protein individual intake provided that enough number of surveys per subject are performed.

• The relationship between morbidity and physical growth increments was investigated in 716 Guatemalan children ranging in age from 15 days to 7 years. The growth variables investigated were semestral and yearly increments in total body length and weight. The number of days ill with diarrhea, fever, and respiratory illnesses per semester or year was used as an indicator of morbidity. The morbidity data were collected through biweekly retrospective interviews of mothers. Children less ill with diarrhea had substantially larger increments in length and weight than children who were ill with diarrhea a greater percentage of the time. In contrast, fever and respiratory illnesses did not affect growth rates. These findings highlight the fact that diarrhea is a major public health problem in developing nations. ( Am J Dis Child 129:1296-1301, 1975)

This paper summarizes the initial phase of an effort to develop semiquantitative methods for nutrition and health planning. The general approach is to utilize the methods of systems analysis and operations research where appropriate, but the emphasis is on developing a simplified, approximate analysis that government planning groups could conveniently apply in evaluating various potential programs for attaining specific nutrition and health objectives, while satisfying certain constraints (e.g., budget, facilities, personnel). An essential element of the analysis is a model that provides an approximate description of malnutrition (inadequate growth, as indicated by weight for age) and mortality in terms of those variables that can be affected by intervention programs. We have concentrated initially on using the results of two INCAP longitudinal studies to develop models relating the incidence of malnutrition (second and third degree on the Gomez scale) to age and previous growth, including birth weight. The two studies cover rural Guatemalan communities with considerable variability in ethnic, socioeconomic, and ecological conditions. Because they are tentative, the resulting models are discussed only qualitatively and not quantitatively. The models may serve as baselines to estimate the consequences of potential programs aimed at different target groups, such as pregnant women and children whose weights at birth or thereafter fall below prescribed levels. The possible benefits of using models of this nature in nutrition and health planning are discussed.

The relationship between days ill with diarrhea and growth velocities in height and weight was investigated in 716 children from rural Guatemala, ranging in age from 0 to 7 years. Information regarding diarrheal diseases was obtained through biweekly interviews of mothers. Increments studies were semestral from 0 to 48 months and annual from 48 to 84 months of age. The results, based on two years of date collection, show that the greater the percent of time ill with diarrhea, the smaller the increments in height and weight. It was estimated that diarrheal diseases explain around 10% of the growth retardation observed in this population.

Women and children from four Guatemalan villages participated in a voluntary food supplementation program for seven years. In two of the villages, they received a vitamin and mineral fortified, high-protein calorie supplement. In the other two villages, the vitamin-mineral fortified supplement contained no protein and a relatively small number of calories. Cognitive tests were administered regularly to children ages three to seven, and anthropometric measures obtained. In addition, measures of families' social milieu were collected at several points in time. Using multiple regression analysis, we find that both nutritional and social environmental measures are related to various dimensions of cognitive competence. The results suggest that nutritional intake, independent of social factors, affects cognitive development. There is also some evidence that the children who receive the high-protein calorie supplement (and whose mothers received it during pregnancy and lactation) are more likely to score high in cognitive performance. Our results, while not diminishing social environmental explanations of differences in cognitive function, suggest benefits from nutrition intervention programs in rural areas of lesser-developed countries.

Developing societies share several common characteristics, including low gross national product per capita, heavy dependency on the export of raw materials, inefficient systems of land tenure, and deficient technology. Malnutrition and infectious disease are highly prevalent, especially during the first five to seven years of life. Such societies moreover are characterized by sharp differences between upper and lower socioeconomic status groups in terms of income and living conditions. Figure 1 summarizes results of several studies comparing height of adult women from high and low socioeconomic groups. Women from low socioeconomic groups in rural and urban populations are shorter; those from the high socioeconomic group resemble the white urban population in the United States. With regard to height or prepregnancy weight, similar facts obtain. In developing societies, socioeconomic status is also associated with other maternal characteristics. Dietary intake of proteins and calories7-13and weight gain during pregnancy4,14-17(L. J.

A longitudinal study of the social and biological determinants of physical growth and mental development in rural Guatemala was started in 1969. A program was launched involving supplementation of pregnant mothers with a protein and calorie supplement ("atole") in 2 villages and another calorie supplement ("fresco") in 2 other villages. This paper presents an integrated quantitative approach to the analysis of data collected in the maternal supplementation program using 2 examples. The first example compares the effects of maternal height and weight at conception, and maternal caloric supplementation during pregnancy on birthweight. It was found that maternal childhood nutrition is as important a determinant of birthweight as is caloric supplementation during pregnancy. Similarly, the nutritional status of the mother during conception is as powerful a determinant of birthweight as is caloric supplementation during pregnancy. Past obstetrical history and maternal age do not affect these interrelationships among birthweight and maternal height, weight at conception, and maternal supplementation. The second example involves a consideration of postnatal function of the child, as well as several prenatal factors which affect infant mortality. Infant mortality in the study villages was found to be 4 times greater for babies with birthweight of 2.5 kg or less at term ("small for dates" babies; infant mortality rate, 121/1,000) than for heavier babies (infant mortality rate, 30/1000) (p0.05). By increasing maternal calorie supplementation during pregnancy, the number of babies weighing 2.5 kg or less was reduced from 20% among babies born to mothers ingesting less than 5000 calories during pregnancy to 5% among babies born to mothers who consume more than 20,000 calories during pregnancy. The findings suggest that village infant mortality can be lowered, and the birth of "small for dates" babies prevented by ensuring adequate levels of maternal nutrition during pregnancy. Efforts to improve maternal nutrition should start in childhood for optimum infant survival.

The proportion of low birth weight (LBW) babies born in developing countries that are actually cases of intrauterine growth retardation due to malnutrition may be much higher than those that are LBW because they are preterm (born before 37 weeks of amenorrhea). In developed countries about 7% of infants are LBW of which 70% are preterm. In populations with a 40% incidence of LBW babies 17% of these are preterm. This suggests that the majority of LBW newborns in poor communities are cases of intrauterine growth retardation and that the total incidence of preterm babies is about the same as it is in affluent societies. The implication is that interventions to prevent LBW in poor communities should be nutritional supplementation and health care for mothers rather than prevention of premature births. 93% of the 21.9 million LBW infants born in 1975 were born in developing countries.

Previous studies suggest that low birth weight ( 1,2 Although potentially confounding factors are often ignored, consideration of other variables does not deny an association between low birth weight and poor mental performance. 3-9 The problem of whether low birth weight is associated with deficits in mental performance in a developing country must be considered. It is difficult to draw inferences from one population to another since cause of low birth weight may not be the same in the two populations. Different types of low birth weight appear associated with different functional outcomes, such as different morbidity, mortality, and prevalence and type of behavioral abnormalities. Some low-birth-weight newborns may be relatively more impaired mentally than others. Harper and Wiener 10 reported slightly lower intelligence quotients in low-birth-weight twins and triplets than in low-birth-weight singletons. Most studies reporting a relationship