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Abstract Background The HEARTS technical package was developed by the World Health Organization to address the implementation gap in cardiovascular disease prevention in low- and middle-income countries. Guatemala is a middle-income country that is currently implementing HEARTS. National authorities in Guatemala are interested in exploring how hypertension and diabetes management can be integrated in HEARTS implementation. The objective of this study is to conduct a feasibility and acceptability pilot trial of integrated hypertension and diabetes management based on HEARTS in the publicly funded primary care system in Guatemala. Methods A single-arm pilot trial for 6 months will be carried out in 11 Ministry of Health primary care facilities starting in September 2023. A planned sample of 100 adult patients diagnosed with diabetes (n = 45), hypertension (n = 45), or both (n = 10) will be enrolled. The intervention will consist of HEARTS-aligned components: Training health workers on healthy-lifestyle counseling and evidence-based treatment protocols, strengthening access to medications and diagnostics, training on risk-based cardiovascular disease management, team-based care and task sharing, and systems monitoring and feedback, including implementation of a facility-based electronic monitoring tool at the individual level. Co-primary outcomes of feasibility and acceptability will be assessed using an explanatory sequential mixed-methods design. Secondary outcomes include clinical effectiveness (treatment with medication, glycemic control, and blood pressure control), key implementation outcomes (adoption, fidelity, usability, and sustainability), and patient-reported outcome measures (diabetes distress, disability, and treatment burden). Using an implementation mapping approach, a Technical Advisory Committee will develop implementation strategies for subsequent scale-up planning. Discussion This trial will produce evidence on implementing HEARTS-aligned hypertension and diabetes care in the MOH primary care system in Guatemala. Results also will inform future HEARTS projects in Guatemala and other low- and middle-income countries. Trial registration ClinicalTrials.gov ID NCT06080451. The trial was prospectively registered on October 12, 2023.

La región latinoamericana ha sido pionera en la implementación del etiquetado frontal de advertencia nutricional (EFAN), mismo que ha demostrado su eficacia y efectividad para identificar correctamente cuando un producto contiene cantidades excesivas de nutrientes asociados a Enfermedades no transmisibles (ENT). Sin embargo, ningún país del Sistema de la Integración Centroamericana (SICA); que incluye a Belice, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panamá y República Dominicana, lo ha adoptado. Por esta razón, el Instituto de Nutrición de Centro América y Panamá, convocó a un grupo de expertos de la academia y la sociedad civil con el objetivo de establecer una postura técnica, basada en la mejor evidencia científica, en relación al etiquetado frontal para los nutrientes críticos de alimentos y bebidas pre- envasados en la región centroamericana. Se presenta evidencia específica de la región del SICA que demuestran la superioridad del EFAN frente a otros etiquetados como las Guías Diarias de Alimentación (GDA), el semáforo y el Nutriscore para seleccionar opciones más saludables. Dentro del marco de los derechos de la niñez y de los consumidores, se brindan argumentos y se hace un llamado a los gobiernos para la pronta adopción del EFAN como una política costo-efectiva para la prevención de ENT. Además, se proveen recomendaciones para su monitoreo y evaluación, así como recomendaciones de otras políticas costo-efectivas como la regulación de la publicidad de alimentos no saludables dirigido a la niñez y adolescencia, entre otros, para la prevención de las ENT y la creación de ambientes y sistemas alimentarios más saludables y sostenibles.

Abstract Background Front-of-package warning labels (FOPWL) have been adopted in many countries aiming at reducing the consumption of unhealthy food and drink products and have also been considered in Guatemala. The aim of the study is to evaluate the efficacy of FOPWL versus Guidelines for Daily Amount (GDA) on products’ healthfulness perception (HP), purchase intention (PI) and the objective understanding of the nutrient content (UNC) in Guatemala. Methods Participants (children and adults) (n = 356) were randomly assigned to evaluate either FOPWL or GDA during a crossover cluster randomized experiment in rural and urban areas across 3 phases of exposure. During phase 1, participants evaluated mock-up images of single products (single task) and compared pairs of products within the same food category (comparison task) without any label. In phase 2, participants evaluated labels only (without any product), and during phase 3, they evaluated the same products and questions from phase 1, now depicting the assigned front-of-package label. We generated indicators for single-task questions and scores for comparison tasks, one for each HP, PI and UNC questions. We used intention-to-treat, difference-in-difference regression analysis to test whether exposure to FOPWL was associated with HP, PI and UNC, compared to GDA. We also tested models for children and adults and by area (rural/urban) separately adjusting for sociodemographic variables. Results In single tasks, FOPWL significantly decreased the PI (β -18.1, 95%CI -23.3, -12.8; p

Objective We examined associations among serial measures of linear growth and relative weight with adult body composition.Design Secondary data analysis of prospective birth cohort studies.Settings Six birth cohorts from Brazil, Guatemala, India, the Philippines and South Africa.Participants 4173 individuals followed from birth to ages 22–46 years with complete and valid weight and height at birth, infancy, childhood and adolescence, and body composition in adult life.Exposures Birth weight and conditional size (standardised residuals of height representing linear growth and of relative weight representing weight increments independent of linear size) in infancy, childhood and adolescence.Primary outcome measures Body mass index, fat mass index (FMI), fat-free mass index (FFMI), fat mass/fat-free mass ratio (FM/FFM), and waist circumference in young and mid-adulthood.Results In pooled analyses, a higher birth weight and relative weight gains in infancy, childhood and adolescence were positively associated with all adult outcomes. Relative weight gains in childhood and adolescence were the strongest predictors of adult body composition (β (95% CI) among men: FMI (childhood: 0.41 (0.26 to 0.55); adolescence: 0.39 (0.27 to 0.50)), FFMI (childhood: 0.50 (0.34 to 0.66); adolescence: 0.43 (0.32 to 0.55)), FM/FFM (childhood: 0.31 (0.16 to 0.47); adolescence: 0.31 (0.19 to 0.43))). Among women, similar patterns were observed, but, effect sizes in adolescence were slightly stronger than in childhood. Conditional height in infancy was positively associated with FMI (men: 0.08 (0.03 to 0.14); women: 0.11 (0.07 to 0.16)). Conditional height in childhood was positively but weakly associated with women’s adiposity. Site-specific and sex-stratified analyses showed consistency in the direction of estimates, although there were differences in their magnitude.Conclusions Prenatal and postnatal relative weight gains were positive predictors of larger body size and increased adiposity in adulthood. A faster linear growth in infancy was a significant but weak predictor of higher adult adiposity.

Abstract Background Little is known about associations of psychological and mental well-being with cognitive and socioemotional factors in low and middle-income countries, particularly among vulnerable populations born in adverse environments that may restrict developmental potential. This study aimed to examine the cognitive and socioemotional correlates of psychological well-being and mental health in a cohort of Guatemalan adults born in contexts of poverty and malnutrition. Methods From Dec 2017 to Apr 2019, data were collected from 704 women and 564 men ages 40–57 years living in four rural villages in eastern Guatemala and Guatemala City. We measured latent domains of psychological well-being, spirituality and religion, emotional support, and executive function using Confirmatory Factor Analysis (CFA). Under a Structural Equation Modeling framework, we examined intercorrelations among latent domains and observed measures of intelligence and mental health. Results CFA supported the construct validity of factor structures in this population. Correlations of psychological well-being with spirituality and religion were moderate in women (r = 0.68, p

Abstract Background and Aims Metabolic conditions such as obesity, type 2 diabetes, metabolic syndrome, and nonalcoholic fatty liver disease (NAFLD) are highly prevalent in Guatemala and increase the risk for a number of disorders, including hepatocellular carcinoma (HCC). Aflatoxin B1 (AFB1) levels are also notably elevated in the population and are known to be associated with HCC risk. Whether AFB1 also contributes to the high prevalence of the metabolic disorders has not been previously examined. Therefore, the purpose of this study was to assess the association between AFB1 and the metabolic conditions. Methods Four‐hundred twenty‐three individuals were included in the study, in which AFB1‐albumin adduct levels were measured in sera. Metabolic conditions included diabetes, obesity, central obesity, metabolic syndrome, and NAFLD. Crude and adjusted prevalence odds ratios (PORs) and 95% confidence intervals (95% CI) were estimated for the associations between the metabolic conditions and AFB1‐albumin adduct levels categorized into quartiles. Results The study found a significant association between AFB1‐albumin adduct levels and diabetes (Q4 vs Q1 POR = 3.74, 95%CI: 1.71‐8.19; P‐trend .003). No associations were observed between AFB1‐albumin adduct levels and the other conditions. Conclusions As diabetes is the metabolic condition most consistently linked to HCC, the possible association between AFB1 exposure and diabetes may be of public health importance. Further studies are warranted to replicate the findings and examine potential mechanisms.

Summary: Background: Approximately 80% of the 463 million adults worldwide with diabetes live in low-income and middle-income countries (LMICs). A major obstacle to designing evidence-based policies to improve diabetes outcomes in LMICs is the scarce availability of nationally representative data on the current patterns of treatment coverage. The objectives of this study were to estimate the proportion of adults with diabetes in LMICs who receive coverage of recommended pharmacological and non-pharmacological diabetes treatment; and to describe country-level and individual-level characteristics that are associated with treatment. Methods: We did a cross-sectional analysis of pooled, individual data from 55 nationally representative surveys in LMICs. Our primary outcome of self-reported diabetes treatment coverage was based on population-level monitoring indicators recommended in the 2020 WHO Package of Essential Noncommunicable Disease Interventions. Surveys were included if they were done in 2008 or after in an LMIC, as classified by the World Bank in the year the survey was done; were nationally representative; had individual-level data; contained a diabetes biomarker (fasting glucose, random glucose, or glycated haemoglobin); and had data on one or more diabetes treatments. Our sample included non-pregnant individuals with an available diabetes biomarker who were at least 25 years of age. We assessed coverage of three pharmacological and three non-pharmacological treatments among people with diabetes. At the country level, we estimated the proportion of individuals reporting coverage by per-capita gross national income and geographical region. At the individual level, we used logistic regression models to assess coverage along several key individual characteristics including sex, age, body-mass index, wealth quintile, and educational attainment. In the primary analysis, we scaled sample weights such that countries were weighted equally. Findings: The final pooled sample from the 55 LMICs included 680 102 total individuals and 37 094 individuals with diabetes. Using equal weights for each country, diabetes prevalence was 9·0% (95% CI 8·7–9·4), with 43·9% (41·9–45·9) reporting a previous diabetes diagnosis. Overall, 4·6% (3·9–5·4) of individuals with diabetes self-reported meeting need for all treatments recommended for them. Coverage of glucose-lowering medication was 50·5% (48·6–52·5); antihypertensive medication was 41·3% (39·3–43·3); cholesterol-lowering medication was 6·3% (5·5–7·2); diet counselling was 32·2% (30·7–33·7); exercise counselling was 28·2% (26·6–29·8); and weight-loss counselling was 31·5% (29·3–33·7). Countries at higher-income levels tended to have greater coverage. Female sex and higher age, body-mass index, educational attainment, and household wealth were also associated with greater coverage. Interpretation: Fewer than one in ten people with diabetes in LMICs receive coverage of guideline-based comprehensive diabetes treatment. Scaling up the capacity of health systems to deliver treatment not only to lower glucose but also to address cardiovascular disease risk factors, such as hypertension and high cholesterol, are urgent global diabetes priorities. Funding: National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy & Innovation, National Institute of Diabetes and Digestive and Kidney Diseases, Harvard Catalyst, and National Center for Advancing Translational Sciences of the National Institutes of Health.

Objectives Few studies have used longitudinal data to study the development of cognition over the life course in low-income and middle-income countries. The objectives of this study were to assess predictors of cognitive development trajectories from 6 months through 7 years, and if these trajectories predicted adult cognitive function in a birth cohort from Guatemala.Design We analysed data from the INCAP Nutrition Supplementation Trial Longitudinal Study in Guatemala. Cognition was assessed at eight different time points between 6 months and 7 years. We derived childhood development trajectories using latent class growth analysis. We assessed predictors of the trajectories using ordinal logistic regression, and associations between childhood trajectories and adult non-verbal intelligence and literacy at age 18–52 years (mean±SD =42.7±6.4 years) using mixed models.Setting The study was conducted in four Guatemalan villages.Participants The study included 927 participants from Guatemala with repeated measurements of cognitive function during the first 7 years of life.Results We identified three trajectories of cognitive development (high: n=214, average: n=583, low: n=130). Participants whose mothers were taller (proportional log odds (PO)=0.03, 95% CI=0.01 to 0.06), had more years of schooling (PO=0.15, 95% CI=0.06 to 0.25), or lived in households with higher socioeconomic scores (PO=0.19, 95% CI=0.09 to 0.29) were more likely to follow higher trajectories. Childhood trajectories predicted adult non-verbal intelligence (high=18.4±0.3, average=14.6±0.53, low=11.4±0.9) and literacy (high=63.8±2.0, average=48.6±1.2, low=33.9± 2.6) scores.Conclusions In this sample from Guatemala, cognitive development trajectories from 6 months through 7 years were associated with adult non-verbal intelligence and literacy. These findings provide evidence of tracking of cognition over time in a transitioning low-income setting.

Aflatoxin B1 (AFB1) is a known human hepatocarcinogen and a recent study reported elevated AFB1 levels, measured by serum albumin biomarkers, among Guatemalan adults. While AFB1 can contaminate a variety of foodstuffs, including maize, Guatemala’s main dietary staple, the relationship of maize intake to serum AFB1-albumin adducts levels in Guatemala has not been previously examined. As a result, a cross-sectional study was conducted among 461 Guatemalan adults living in five geographically distinct departments of the country. Participants provided a serum sample and completed a semi-quantitative food frequency questionnaire and a sociodemographic questionnaire. Multiple linear regression analysis was used to estimate the least square means (LSQ) and 95% confidence intervals (95% CI) of log-transformed AFB1-albumin adducts by quintiles of maize consumption in crude and adjusted models. Additionally, analyses of tortilla consumption and levels of maize processing were conducted. The median maize intake was 344.3 g per day [Interquartile Range (IQR): 252.2, 500.8], and the median serum AFB1-albumin adduct level was 8.4 pg/mg albumin (IQR: 3.8, 22.3). In adjusted analyses, there was no association between overall maize consumption and serum AFB1-albumin levels. However, there was a statistically significant association between tortilla consumption and AFB1-albumin levels (ptrend = 0.01). The LSM of AFB1-albumin was higher in the highest quintile of tortilla consumption compared to the lowest quintile [LSM:9.03 95%CI: 7.03,11.70 vs 6.23, 95%CI: 4.95,8.17, respectively]. These findings indicate that tortilla may be an important source of AFB1 exposure in the Guatemalan population. Therefore, efforts to control or mitigate AFB1 levels in contaminated maize used for tortillas may reduce overall exposure in this population. Keywords: Aflatoxins, Maize, Tortilla, Consumption, Guatemala

Objective In Guatemala, cirrhosis is among the 10 leading causes of death, and mortality rates have increased lately. The reasons for this heavy burden of disease are not clear as the prevalence of prominent risk factors, such as hepatitis B virus, hepatitis C virus and heavy alcohol consumption, appears to be low. Aflatoxin B1 (AFB1) exposure, however, appears to be high, and thus could be associated with the high burden of cirrhosis. Whether AFB1 increases the risk of cirrhosis in the absence of viral infection, however, is not clear.Design Cirrhosis cases (n=100) from two major referral hospitals in Guatemala City were compared with controls (n=200) from a cross-sectional study. Logistic regression was used to estimate the ORs and 95% CIs of cirrhosis and quintiles of AFB1 in crude and adjusted models. A sex-stratified analysis was also conducted.Results The median AFB1 level was significantly higher among the cases (11.4 pg/mg) than controls (5.11 pg/mg). In logistic regression analyses, higher levels of AFB1 was associated with cirrhosis (quintile 5 vs quintile 1, OR: 11.55; 95% CI 4.05 to 32.89). No attenuation was observed with adjustment by sex, ethnicity, hepatitis B virus status, and heavy alcohol consumption. A significantly increasing trend in association was observed in both models (p trend

The assessment of aflatoxin B1 (AFB1) exposure using isotope-dilution liquid chromatography-mass spectrometry (LCMS) of AFB1-lysine adducts in human serum albumin (HSA) has proven to be a highly productive strategy for the biomonitoring of AFB1 exposure. To compare samples across different individuals and settings, the conventional practice has involved the normalization of raw AFB1-lysine adduct concentrations (e.g., pg/mL serum or plasma) to the total circulating HSA concentration (e.g., pg/mg HSA). It is hypothesized that this practice corrects for technical error, between-person variance in HSA synthesis or AFB1 metabolism, and other factors. However, the validity of this hypothesis has been largely unexamined by empirical analysis. The objective of this work was to test the concept that HSA normalization of AFB1-lysine adduct concentrations effectively adjusts for biological and technical variance and improves AFB1 internal dose estimates. Using data from AFB1-lysine and HSA measurements in 763 subjects, in combination with regression and Monte Carlo simulation techniques, we found that HSA accounts for essentially none of the between-person variance in HSA-normalized (R2 = 0.04) or raw AFB1-lysine measurements (R2 = 0.0001), and that HSA normalization of AFB1-lysine levels with empirical HSA values does not reduce measurement error any better than does the use of simulated data (n = 20,000). These findings were robust across diverse populations (Guatemala, China, Chile), AFB1 exposures (105 range), HSA assays (dye-binding and immunoassay), and disease states (healthy, gallstones, and gallbladder cancer). HSA normalization results in arithmetic transformation with the addition of technical error from the measurement of HSA. Combined with the added analysis time, cost, and sample consumption, these results suggest that it may be prudent to abandon the practice of normalizing adducts to HSA concentration when measuring any HSA adducts—not only AFB1-lys adducts—when using LCMS in serum/plasma.

There is solid evidence documenting relationships between the food and beverage industry and academia that show that industry sponsored research is likely to bias results in favor of industry. In Latin America, examples of these situations have been documented in Mexico, Brazil, Chile, Peru, Colombia, and Ecuador , among others. Due to the urgent need for studying and managing relationships between the food and beverage industry and the field of health and nutrition research, in 2017, the President of the Latin American Society of Nutrition (SLAN) appointed a Conflict of Interest Committee (CCI). The CCI was charged with the development of a proposal of a position for the management of conflict of interest (COI) for consideration by SLAN. This document details the work of CCI, and the position adopted by SLAN.

Abstract Background The COVID-19 pandemic necessitated rapid changes in healthcare delivery in Guatemala’s public primary care settings. A new hypertension program, implemented as part of a type 2 hybrid trial since 2019, exemplifies an implementation effort amidst a changing context in an under-resourced setting. We assessed the implementation of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care), raising implications for health equity and sustainability. We present innovative application of systems thinking visuals. Methods Conducting a convergent mixed methods analysis, we assessed implementation in response to contextual changes across five Ministry of Health (MoH) districts at the pandemic’s onset. Utilizing quantitative programmatic data and qualitative interviews with stakeholders (n=18; health providers, administrators, study staff), we evaluated dimensions of “Reach, Effectiveness, Adoption, Implementation and Maintenance,” RE-AIM (Reach, Implementation delivery + adaptations), and “Practical Robust Implementation and Sustainability Model,” PRISM (Organizational perspective on the EBI, Fit, Implementation and sustainability infrastructure) frameworks. We assessed representativeness by comparing participants to census data. To assess implementation delivery, we built behavior-over-time (BOT) graphs with quantitative programmatic data (July 2019–July 2021). To assess adaptations and contextual changes, we performed matrix-based thematic qualitative analysis. We converged quantitative implementation delivery data + qualitative adaptations data in joint displays. Finally, we analyzed qualitative and quantitative results across RE-AIM/PRISM and health districts to identify equity and sustainability considerations. Results Contextual factors that facilitated program delivery included the perception that the EBI was beneficial, program champions, and staff communication. Key barriers to implementation delivery included competition with other primary care activities and limited implementation infrastructure (e.g., equipment, medications). Contextual changes related to COVID-19 hindered implementation delivery, threatened sustainability, and may have exacerbated inequities. However, adaptations that were planned enhanced implementation delivery and may have supported improved equity and sustainability. Conclusions Recognition of an EBI’s benefits and program champions are important for supporting initial uptake. The ability to plan adaptations amid rapid contextual changes has potential advantages for sustainability and equitable delivery. Systems thinking tools and mixed methods approaches may shed light on the relations between context, adaptations, and equitable and sustainable implementation. Trial registration NCT03504124

Abstract Background Uncontrolled hypertension is a major public health burden and the most common preventable risk factor for cardiovascular diseases in Guatemala and other low- and middle-income countries. Prior to an initial trial that evaluated a hypertension intervention in rural Guatemala, we collected qualitative information on the needs and knowledge gaps of hypertension care within Guatemala’s public healthcare system. This analysis applied Kleinman’s Explanatory Models of Illness to capture how patients, family members, community-, district-, and provincial-level health care providers and administrators, and national-level health system stakeholders understand hypertension. Methods We conducted in-depth interviews with three types of participants: 1) national-level health system stakeholders (n = 17), 2) local health providers and administrators from district, and health post levels (25), and 3) patients and family members (19) in the departments of Sololá and Zacapa in Guatemala. All interviews were conducted in Spanish except for 6 Maya-Kaqchikel interviews. We also conducted focus group discussions with auxiliary nurses (3) and patients (3), one in Maya-Tz’utujil and the rest in Spanish. Through framework and matrix analysis, we compared understandings of hypertension by participant type using the Explanatory Model of Illness domains -etiology, symptoms, pathophysiology, course of illness, and treatment. Results Health providers and administrators, and patients described hypertension as an illness that spurs from emotional states like sadness, anger, and worry; is inherited and related to advanced age; and produces symptoms that include a weakened body, nerves, pain, and headaches. Patients expressed concerns about hypertension treatment’s long-term consequences, despite trying to comply with treatment. Patients stated that they combine biomedical treatment (when available) with natural remedies (teas and plants). Health providers and administrators and family members stated that once patients feel better, they often disengage from treatment. National-level health system stakeholders referred to lifestyle factors as important causes, considered patients to typically be non-compliant, and identified budget limitations as a key barrier to hypertension care. The three groups of participants identified structural barriers to limited hypertension care (e.g., limited access to healthy food and unaffordability of medications). Conclusion As understandings of hypertension vary between types of participants, it is important to describe their similarities and differences considering the role each has in the health system. Considering different perceptions of hypertension will enable better informed program planning and implementation efforts.

Abstract Background Benchmarking the implementation of healthy food environment public policies against international best practices may accelerate the government response to prevent obesity and non-communicable diseases (NCDs) in the countries. The aim of the study was to determine the extent of food environment policy implementation in Guatemala and to identify and prioritize actions for the government to accelerate their implementation. Methods The INFORMAS Healthy Food Environment Policy Index (Food-EPI from the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support) was used. Evidence of implementation for 50 good practice indicators within the seven food policies and six infrastructure support domains was compiled, and subsequently validated by Guatemalan government officials. A national civil society expert panel on public health and nutrition performed an online assessment of the implementation of healthy food environment policies against best international practices. The level of agreement among evaluators was measured using the Gwet second order agreement coefficient (AC2). The expert panel recommended actions for each indicator during on-site workshops and those actions were prioritized by importance and achievability. Results The expert panel rated implementation at zero for 26% of the indicators, very low for 28% of indicators, low for 42%, and medium for 4% of indicators (none were rated high). Indicators at medium implementation were related to the use of evidence for developing policies and ingredient list/nutrition information panels on packaged foods. Seventy-seven actions were recommended prioritizing the top 10 for immediate action. The Gwet AC2 was 0.73 (95% CI 0.67–0.80), indicating a good concordance among experts. Conclusions In the Food-EPI of Guatemala, almost all indicators of good practice had a low or less level of implementation. The expert panel proposed 12 priority actions to accelerate policy implementation to tackle obesity and NCDs in the country.

Cardiovascular diseases are the leading causes of morbidity and mortality worldwide, but implementation of evidence-based interventions for risk factors such as hypertension is lacking, particularly in low and middle income countries (LMICs). Building implementation research capacity in LMICs is required to overcome this gap. Members of the Global Research on Implementation and Translation Science (GRIT) Consortium have been collaborating in recent years to establish a research and training infrastructure in dissemination and implementation to improve hypertension care. GRIT includes projects in Ghana, Guatemala, India, Kenya, Malawi, Nepal, Rwanda, and Vietnam. We collected data from each site on capacity building activities using the Potter and Brough (2004) model, mapping formal and informal activities to develop (a) structures, systems and roles, (b) staff and infrastructure, (c) skills, and (d) tools. We captured information about sites' needs assessments and metrics plus program adaptations due to the COVID-19 pandemic. All sites reported capacity building activities in each layer of the Capacity Pyramid, with the largest number of activities in the Skills and Tools categories, the more technical and easier to implement categories. All sites included formal and informal training to build Skills. All sites included a baseline needs assessment to guide capacity building activities or assess context and inform intervention design. Sites implementing evidence-based hypertension interventions used common implementation science frameworks to evaluate implementation outcomes. Although the COVID-19 pandemic affected timelines and in-person events, all projects were able to pivot and carry out planned activities. Although variability in the activities and methods used existed, GRIT programs used needs assessments to guide locally appropriate design and implementation of capacity building activities. COVID-19 related changes were necessary, but strong collaborations and relationships with health ministries were maintained. The GRIT Consortium is a model for planning capacity building in LMICs.

Abstract Background Parity has been associated with both short- and long-term weight gain in women. However, it is not clear if timing of parity across the reproductive age has different associations with BMI. Methods To prospectively assess the association between age at childbirth and maternal change in BMI, we analyzed data from the ongoing INCAP Longitudinal Study, which started in 1969 in four villages in Guatemala. Cohort women (n=778) provided information on reproductive history and anthropometric measures were measured in 1988-89 (adolescence, 15 to 25y), 2002-04 (early adulthood, 26 to 36y) and 2015-17 (mid adulthood, 37 to 55y). We evaluated the associations of number of live births in the period preceding each study wave (1969-77 to 1988-89, 1988-89 to 2002-04 and 2002-04 to 2015-17) with BMI change in the same period using multivariable linear regression models. Results Number of live births between 1988 and 89 and 2002-04 was positively associated with increased BMI, while there was not an association between number of live births and BMI in the other intervals. Women who had one, two, or three or more children between 1988 and 89 and 2002-04 had 0.90 (kg/m2, 95% CI: -0.55, 2.35), 2.39 (kg/m2, 95% CI: 1.09, 3.70) and 2.54 (kg/m2, 95% CI: 1.26, 3.82) higher BMI, respectively, than women who did not give birth in the same period. Conclusions Our findings suggest that women who had three or more children during early adulthood gained more weight compared to women who had no children in the same period. In contrast, women who had children earlier or later in their reproductive lives did not gain additional weight compared to those who did not have children during that period. Childbirth may have different associations with BMI based on the mother’s age.

Abstract Background Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system. Methods We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala’s public system using the World Health Organization’s health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers. Results Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor. Conclusions This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala’s public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach.

Abstract Background Asset-based indices are widely-used proxy measures of wealth in low and middle-income countries (LMIC). The stability of these indices within households over time is not known. Methods We develop a harmonized household asset index using Principal Component Analysis for the participants (n = 2392) of INCAP Longitudinal Study, Guatemala using data from six waves of follow-up over the period of 1965–2018. We estimate its cross-sectional association with parental schooling (in 1967–75) and attained schooling (in 2015–18) of cohort members. We study how patterns of cross-sectional loadings change over time and between urban-rural settings. We assess its robustness to omission of assets or study waves and alternate specifications of factor extraction procedure (exploratory factor analysis, multiple correspondence analysis). Results The harmonized index constructed using 8 assets and 11 housing characteristics explained 32.4% of the variance. Most households increased in absolute wealth over time with median wealth (25th percentile, 75th percentile; households) increasing from − 3.74 (− 4.42, − 3.07; 547) in 1967 to 2.08 (1.41, 2.67; 1145) in 2017–18. Ownership of television, electricity, quality of flooring and sanitary installation explained the largest proportion of variance. The index is positively associated with measures of schooling (maternal: r = 0.16; paternal: r = 0.10; attained: r = 0.35, all p

Background: Subjective social status (SSS, perception of social position relative to a frame of reference) has been associated with physical, mental and socio-emotional wellbeing. However, these associations may be susceptible to unmeasured confounding by life course objective socio-economic position (SEP; such as wealth, education and employment) and life satisfaction. Purpose: To estimate the association of position on ladders of perceived community respect and perceived economic status with weight, distress and wellbeing, independent of objective SEP in cohorts from three low and middle-income countries. Methods: We used data from birth cohorts in Guatemala (n = 1258), Philippines (n = 1323) and South Africa (n = 1393). We estimated the association of perceived community respect and perceived economic status with body mass index (kg/m2), the World Health Organization's Self-Reported Questionnaire-20 (SRQ-20) for psychological distress, and Lyubomirsky's Subjective Happiness Scale. We estimated these associations using robust linear regression models adjusting for indicators of life course objective SEP, early life characteristics, adult covariates, and life satisfaction. Results: Participants in South Africa (age 27-28y) rated themselves higher on average for both the respect (7 vs 5 in Guatemala and 6 in Philippines) and economic (5 vs 3 in Guatemala and 4 in Philippines) ladder measures. Position on neither community respect nor economic ladders were associated with BMI or psychological distress. Higher position on community respect (Guatemala: 0.03, 95%CI: 0.01, 0.04; Philippines: 0.03, 95% CI: 0.02, 0.05; South Africa: 0.07, 95%CI: 0.04, 0.09) and economic (Guatemala: 0.02, 95%CI: 0, 0.04; Philippines: 0.04, 95%CI: 0.02, 0.07; South Africa: 0.07, 95%CI: 0.04, 0.10) ladders were associated with greater happiness. Conclusions: Subjective social status showed small but consistent associations with happiness in birth cohorts independent of life-course SEP.

Abstract Background Hypertension is a major risk factor for cardiovascular disease (CVD). Despite advances in hypertension prevention and treatment, the proportion of patients who are aware, treated and controlled is low, particularly in low-income and middle-income countries (LMICs). We will evaluate an adapted version of a multilevel and multicomponent hypertension control program in Guatemala, previously proven effective and feasible in Argentina. The program components are: protocol-based hypertension treatment using a standardized algorithm; team-based collaborative care; health provider education; health coaching sessions; home blood pressure monitoring; blood pressure audit; and feedback. Methods Using a hybrid type 2 effectiveness-implementation design, we will evaluate clinical and implementation outcomes of the multicomponent program in Guatemala over an 18-month period. Through a cluster randomized trial, we will randomly assign 18 health districts to the intervention arm and 18 to enhanced usual care across five departments, enrolling 44 participants per health district and 1584 participants in total. The clinical outcomes are (1) the difference in the proportion of patients with controlled hypertension (

Background: Temporally-harmonized asset-based measures of wealth can be used to study the association of life-course wealth exposures in the same scale with health outcomes in low- and middle-income countries (LMICs). The within-individual longitudinal stability of asset-based indices of wealth in LMICs is poorly understood. Methods: Using data from five birth cohorts from three continents, we developed temporally-harmonized asset indices over the life course through polychoric principal component analysis of a common set of assets collected consistently over time (18 years in Brazil to 50 years in Guatemala). For each cohort, we compared the harmonized index to cross-sectional indices created using more comprehensive asset measures using rank correlations. We evaluated the rank correlation of the harmonized index in early life and adulthood with maternal schooling and own attained schooling, respectively. Results: Temporally-harmonized asset indices developed from a consistently-collected set of assets (range: 10 in South Africa to 30 in Philippines) suggested that mean wealth improved over time for all birth cohorts. Cross-sectional indices created separately for each study wave were correlated with the harmonized index for all cohorts (Brazil: r = 0.78 to 0.96; Guatemala: r = 0.81 to 0.95; India: 0.75 to 0.93; Philippines: r = 0.92 to 0.99; South Africa: r = 0.84 to 0.96). Maternal schooling (r = 0.15 to 0.56) and attained schooling (r = 0.23 to 0.53) were positively correlated with the harmonized asset index in childhood and adulthood respectively. Conclusions: Temporally-harmonized asset indices displayed coherence with cross-sectional indices as well as construct validity with schooling.

Summary: Background: Little is known about the effect of changes in mobility at the subcity level on subsequent COVID-19 incidence, which is particularly relevant in Latin America, where substantial barriers prevent COVID-19 vaccine access and non-pharmaceutical interventions are essential to mitigation efforts. We aimed to examine the longitudinal associations between population mobility and COVID-19 incidence at the subcity level across a large number of Latin American cities. Methods: In this longitudinal ecological study, we compiled aggregated mobile phone location data, daily confirmed COVID-19 cases, and features of urban and social environments to analyse population mobility and COVID-19 incidence at the subcity level among cities with more than 100 000 inhabitants in Argentina, Brazil, Colombia, Guatemala, and Mexico, from March 2 to Aug 29, 2020. Spatially aggregated mobile phone data were provided by the UN Development Programme in Latin America and the Caribbean and Grandata; confirmed COVID-19 cases were from national government reports and population and socioeconomic factors were from the latest national census in each country. We used mixed-effects negative binomial regression for a time-series analysis, to examine longitudinal associations between weekly mobility changes from baseline (prepandemic week of March 2–9, 2020) and subsequent COVID-19 incidence (lagged by 1–6 weeks) at the subcity level, adjusting for urban environmental and socioeconomic factors (time-invariant educational attainment, residential overcrowding, population density [all at the subcity level], and country). Findings: We included 1031 subcity areas, representing 314 Latin American cities, in Argentina (107 subcity areas), Brazil (416), Colombia (82), Guatemala (20), and Mexico (406). In the main adjusted model, we observed an incidence rate ratio (IRR) of 2·35 (95% CI 2·12–2·60) for COVID-19 incidence per log unit increase in the mobility ratio (vs baseline) during the previous week. Thus, 10% lower weekly mobility was associated with 8·6% (95% CI 7·6–9·6) lower incidence of COVID-19 in the following week. This association gradually weakened as the lag between mobility and COVID-19 incidence increased and was not different from null at a 6-week lag. Interpretation: Reduced population movement within a subcity area is associated with a subsequent decrease in COVID-19 incidence among residents of that subcity area. Policies that reduce population mobility at the subcity level might be an effective COVID-19 mitigation strategy, although they should be combined with strategies that mitigate any adverse social and economic consequences of reduced mobility for the most vulnerable groups. Funding: Wellcome Trust. Translation: For the Spanish translation of the abstract see Supplementary Materials section.

Background: The COVID-19 pandemic presents a challenge to health care for patients with chronic diseases, especially hypertension, because of the important association and increased risk of these patients with a severe presentation of COVID-19 disease. The Guatemalan Ministry of Health has been implementing a multi-component program aimed at improving hypertension control in rural communities since 2019 as a part of an intervention research cluster randomized trial. When the first cases of COVID-19 were reported (March 13, 2020) in Guatemala, our study paused all study field activities, and began monitoring participants through phone calls. The objective of this paper is to describe the approach used to monitor study participants during the COVID-19 pandemic and compare data obtained during phone calls for intervention and control group participants. Methods: We developed a cross-sectional study within the HyTREC (Hypertension Outcomes for T4 Research within Lower Middle-Income Countries) project ‘Multicomponent Intervention to Improve Hypertension Control in Central America: Guatemala’ in which phone calls were made to participants from both intervention and control groups to monitor measures important to the study: delivery of antihypertensive medications in both groups, receipt of coaching sessions and use of a home blood pressure monitor by intervention group participants, as well as reasons that they were not implemented. Results: Regarding the delivery of antihypertensive drugs by the MoH to participants, those in the intervention group had a higher level of medication delivery (73%) than the control group (51%), p

Background: Wealth mobility, as both relative (positional) and absolute (material) wealth acquisition, may counteract negative consequences of early life adversities on adult health. Methods: We use longitudinal data (1967–2018) from the INCAP birth cohort, Guatemala (n = 1386). Using wealth as a measure of socio-economic position, we assess the association of life course relative mobility using latent class analysis and absolute material gains using conditional wealth measures. We estimate associations of wealth mobility with indicators of human capital, specifically height, weight status (BMI in kg/m2), psychological distress (WHO SRQ-20 score) and fluid intelligence (Ravens Progressive Matrices score; RPM) in middle adulthood. Results: We identified four latent classes of relative mobility – Stable Low (n = 498), Stable High (n = 223), Downwardly Mobile (n = 201) and Upwardly Mobile (n = 464). Attained schooling (years) was positively associated with membership in Upwardly Mobile (odds ratio; 1.50, 95%CI: 1.31, 1.71) vs Stable Low, and inversely with membership in Downwardly Mobile (0.65, 95%CI: 0.54, 0.79) vs Stable High. Being Upwardly Mobile (vs Stable Low) was positively associated with height (1.88 cm, 95%CI: 1.04, 2.72), relative weight (1.32 kg/m2, 95%CI: 0.57, 2.07), lower psychological distress (−0.82 units, 95%CI: 1.34, −0.29) and fluid intelligence (0.94 units, 95%CI: 0.28, 1.59). Being Downwardly Mobile (vs Stable High) was associated with lower fluid intelligence (−2.69 units, 95%CI: 3.69, −1.68), and higher psychological distress (1.15 units, 95%CI: 0.34, 1.95). Absolute wealth gains (z-scores) from early to middle adulthood were positively associated with relative weight (0.62 kg/m2, 95%CI: 0.28, 0.96), lower psychological distress (−0.37 units, 95%CI: 0.60, −0.14) and fluid intelligence (0.50 units, 95%CI: 0.21, 0.79). Conclusions: Higher attained schooling provided a pathway for upward relative mobility and higher absolute wealth gains as well as protection against downward relative mobility. Upward mobility was associated with lower psychological distress and higher fluid intelligence but also higher weight status.

Objective: We study how life course objective socioeconomic position (SEP) predicts subjective social status (SSS) and the extent to which SSS mediates the association of objective SEP with nutritional status and mental health outcomes. Methods: We use data from participants of the INCAP Longitudinal Study 1969–2018 (n = 1258) from Guatemala. We use the MacArthur ladder for two measures of SSS - perceived community respect and perceived economic status. We estimate the association of SSS with health outcomes after adjusting for early life characteristics and life course objective SEP (wealth, schooling, employment) using linear regression. We use path analysis to study the extent of mediation by SSS on the health outcomes of body mass index (BMI; kg/m2), psychological distress (using the WHO Self-Reported Questionnaire; SRQ-20) and happiness, using the Subjective Happiness Scale (SHS). Results: Median participant rating was 5 [IQR: 3–8] for the perceived community respect and 3 [IQR: 1–5] for the perceived economic status, with no differences by sex. Objective SEP in early life and adulthood were predictive of both measures of SSS in middle adulthood as well as health outcomes (BMI, SRQ-20 and SHS). Perceived community respect (z-scores; 1 z = 3.1 units) was positively associated with happiness (0.13, 95 % CI: 0.07, 0.19). Perceived economic status (z-scores; 1 z = 2.3 units) was inversely associated with psychological distress (−0.28, 95 % CI: −0.47, −0.09). Neither measure of SSS was associated with BMI. Neither perceived community respect nor perceived economic status attenuated associations of objective SEP with health outcomes on inclusion as a mediator. Conclusions: Subjective social status was independently associated with happiness and psychological distress in middle adulthood after adjusting for objective SEP. Moreover, association of objective SEP with health was not mediated by SSS, suggesting potentially independent pathways.

Abstract Background Indigenous Maya women in Guatemala show some of the worst maternal health indicators worldwide. Our objective was to test acceptability, feasibility and impact of a co-designed group psychosocial intervention (Women’s Circles) in a population with significant need but no access to mental health services. Methods A parallel group pilot randomised study was undertaken in five rural Mam and three periurban K’iche’ communities. Participants included 84 women (12 per community, in seven of the communities) randomly allocated to intervention and 71 to control groups; all were pregnant and/or within 2 years postpartum. The intervention consisted of 10 sessions co-designed with and facilitated by 16 circle leaders. Main outcome measures were: maternal psychosocial distress (HSCL-25), wellbeing (MHC-SF), self-efficacy and engagement in early infant stimulation activities. In-depth interviews also assessed acceptability and feasibility. Results The intervention proved feasible and well accepted by circle leaders and participating women. 1-month post-intervention, wellbeing scores (p-value 0.008) and self-care self-efficacy (0.049) scores were higher among intervention compared to control women. Those women who attended more sessions had higher wellbeing (0.007), self-care and infant-care self-efficacy (0.014 and 0.043, respectively), and early infant stimulation (0.019) scores. Conclusions The pilot demonstrated acceptability, feasibility and potential efficacy to justify a future definitive randomised controlled trial. Co-designed women’s groups provide a safe space where indigenous women can collectively improve their functioning and wellbeing. Trial registration ISRCTN13964819. Registered 26 June 2018, retrospectively registered.

Ultraprocessed products (UPPs), associated with obesity and non-communicable diseases (NCDs), are becoming predominant on the global market and a target for market-driven fortification initiatives. The aim of this article is to describe the implications of adding micronutrients to UPPs with excessive amounts of critical nutrients associated with NCDs and provide recommendations for legislation and policies. UPPs with added micronutrients such as breakfast cereals, sugar-sweetened beverages, powder beverages, fruit juices, sauces, and bouillon cubes, among others, are commonly available and heavily promoted in Latin American countries. Misleading advertising of UPPs with added micronutrients and with excessive content of sugar, fat, and salt might increase the consumption of such products, giving them a “health halo effect” that leads consumers to overestimate their nutritional quality and healthfulness. Although international collections of standards such as the Codex Alimentarius provide some guidelines on this matter, countries need to implement national legislations, through a food systems approach, to regulate the marketing and labeling of UPPs. Lastly, there is still the need to foster research to close knowledge gaps and help countries to guide the process of food fortification strategies from a regulatory standpoint.

Nutrition in pregnancy and early childhood affects later blood pressure and precursors of atherosclerosis, but its influence on arterial stiffness is unexplored. This study determines whether exposure to improved nutrition during early life influences Augmentation index (AI) and pulse wave velocity (PWV) in mid-adulthood. We included 1221 adults (37-54y) who participated in a cluster-randomized nutritional supplementation trial of a protein-energy beverage (Atole), conducted between 1969-1977 in Guatemala. The comparison group received Fresco, a low-calorie protein-free beverage. In 2015-17, we measured anthropometry (weight, height, and waist-to-height ratio); AI and PWV (using carotid-femoral tonometry); blood pressure; fasting plasma glucose and serum lipids; and sociodemographic characteristics. Based on patterns of exposure, we characterized participants as fully, partially or unexposed to the intervention from conception to their second birthday (the 'first 1000 days'). We fit pooled and sex-specific models using intention-to-treat, difference-in-difference regression analysis to test whether exposure to the supplement in the first 1000 days was associated with AI and PWV in adulthood adjusting for basal and current sociodemographic variables and current life-style and cardio-metabolic risk factors. Prevalence of obesity in men and women was 39.6% and 19.6%, and prevalence of hypertension was 44.0% and 36.0%, respectively. Women had higher AI (34.4±9.6%) compared to men (23.0± 9.8%), but had similar PWV (7.60±1.13 m/s and 7.60±1.31, respectively). AI did not differ significantly across intervention groups. PWV was lower in individuals with full exposure to the supplement during the first 1000 days (-0.39m/s, 95% CI -0.87, 0.09; p = 0.1) compared to unexposed individuals. This difference was similar after adjusting for cardio-metabolic risk factors (-0.45m/s; 95%C-0.93, 0.01; p = 0.06). Exposure to improved nutrition during the first 1000 days was marginally associated with lower PWV, but not with AI.

Little is known about body size over the life-course and non-communicable disease risk in low- and middle-income country populations. Our study explored the role of body mass index (BMI) trajectories from infancy through mid-adulthood on cardio-metabolic disease (CMD) risk factors in a prospective cohort of Guatemalan adults. Study participants were born in Guatemala from 1962-77 and have been followed prospectively since participating in a nutrition supplementation trial as children. Sex-specific BMI latent class trajectories were derived using latent class growth modeling from up to 22 possible BMI values from age 1 month to 42 years measured between 1969 and 2004. CMD risk factors were assessed in 2015-17 (at age 37-54 years) using anthropometry, blood glucose and lipids, and blood pressure. We used logistic regression to assess the role of BMI trajectory on CMD risk factors in 510 women and 346 men (N = 856). We identified two BMI latent classes for women (low [n = 287, 56.3%] and high [n = 223, 43.7%]) and three classes for men (low [n = 141, 40.8%], medium [n = 160, 46.2%], and high [n = 45, 13.0%]). Given the small percentage of men in the high BMI latent class, we collapsed the medium and high BMI latent classes for men (n = 205, 59.1%). Among the most prevalent CMD risk factors at ages 37-54 years were abdominal obesity defined by waist-height ratio (99.6% of women and 87.3% of men), obesity defined by percent body fat (96.6% of women and 75.9% of men), low HDL-c (87.5% of women and 74.5% of men), and elevated triglycerides (78.3% of women and 73.6% of men). Except for obesity defined by BMI, we found no associations between BMI latent class and CMD risk factors in women. Among men, BMI latent class was not associated with CMD risk factors after controlling for current BMI. For the CMD risk factors we analyzed, the role of early life BMI on adult CMD appeared to be mediated by adult BMI among men-highlighting the need to establish and maintain healthy body weight over the life course.

Abstract Background Latin America is facing an increasing burden of nutrition-related non-communicable disease. Little is known about dietary patterns in Guatemalan adults and how dietary patterns are associated with cardio-metabolic disease (CMD) risk. Methods This analysis is based on data from a 2002–04 follow-up study of the INCAP Nutrition Supplementation Trial Longitudinal Cohort. Diet data were collected using a validated, semi-quantitative food frequency questionnaire. We derived dietary patterns using principal components analysis. CMD risk was assessed by anthropometry (body mass index, waist circumference), biochemistry (fasting blood glucose and lipids), and clinical (blood pressure) measures. We used sex-stratified multivariable log binomial models to test associations between dietary pattern tertile and CMD risk factors. The sample included 1428 participants (681 men and 747 women) ages 25–43 years. Results We derived three dietary patterns (traditional, meat-based modern, and starch-based modern), collectively explaining 24.2% of variance in the diet. Dietary patterns were not associated with most CMD risk factors; however, higher starch-based modern tertiles were associated with increased prevalence of low highdensity lipoprotein cholesterol (HDL-c) in men (Prevalence Ratio (PR) 1.17, 95% Confidence Interval (CI) 1.01, 1.20 for tertile 2; PR 1.20, 95% CI 1.00, 1.44 for tertile 3; p trend 0.04). Higher traditional tertiles were associated with increased prevalence of abdominal obesity in women (PR 1.24, 95% CI 1.07, 1.43 for tertile 2; PR 1.19, 95% CI 1.02, 1.39 for tertile 3; p trend 0.02) but marginally significant reduced prevalence of low HDL-c in men (PR 0.88, 95% CI 0.76, 1.00 for tertile 2; PR 0.85, 95% CI 0.72, 1.00 for tertile 3; p trend 0.05). Conclusion Our findings suggest the presence of two ‘modern' dietary patterns in Guatemala – one of which was associated with increased prevalence of low HDL-c in men. The association between the traditional dietary pattern and some CMD risk factors may vary by sex.

Summary: Background: Low-income and middle-income countries with populations that are chronically undernourished in early life are undergoing a nutrition transition and are experiencing an epidemic of cardiometabolic disease. These dual burdens are thought to be causally related; therefore, the extent to which improvements in early-life nutrition can offset adult-onset disease is important. The aim of this study was to examine whether improvement of protein-energy nutrition from conception to age 2 years can attenuate the risk of cardiometabolic disease. Methods: We followed up a cohort of 2392 individuals born between Jan 1, 1962, and Feb 28, 1977, in four villages in Guatemala who had participated in a cluster-randomised protein-energy nutritional supplementation (Atole) trial. Of 1661 participants available for follow-up from Feb 26, 2015, to April 29, 2017, we studied 684 women and 455 men. We assessed cardiometabolic disease risk at ages 37–54 years using anthropometry, fasting and post-challenge glucose, fasting lipid concentrations, and blood pressure. We used generalised linear and logistic regression modelling to estimate the effect of Atole from conception to age 2 years (the first 1000 days) on cardiometabolic disease risk. Findings: Exposure to Atole from conception to age 2 years was associated with increased fatness (body-mass index [1·29 kg/m2, 95% CI 0·08 to 2·50], body fat [1·73%, 0·20 to 3·26], and obesity [odds ratio 1·94, 1·11 to 3·40]), diastolic blood pressure (1·59 mm Hg, −0·74 to 3·92), and blood lipids (total cholesterol [10·10 mg/dL, 0·80 to 19·40] and non-HDL cholesterol [10·41 mg/dL, 1·51 to 19·31]), reduced post-challenge glucose (–5·84 mg/dL, −12·51 to 0·83), and reduced odds of diabetes (odds ratio 0·46, 0·21 to 0·97). We found stratum heterogeneity by sex in pooled models for non-HDL cholesterol (4·34 mg/dL, 95% CI −6·86 to 15·55 for women vs 19·84 mg/dL, 5·86 to 33·82 for men) and post-challenge glucose (–0·19 mg/dL, −8·63 to 8·24 for women vs −13·10 mg/dL, −23·64 to −2·56 for men). p values for interaction of sex and exposure to Atole from conception to age 2 years were 0·09 and 0·04, respectively. Interpretation: Improved protein-energy nutrition from conception to the 2nd birthday reduced the odds of diabetes at ages 37–54 years; however, this protein-energy supplementation also increased the risk of obesity and several obesity-related conditions. Our findings suggest a mixed ability of protein-energy nutritional supplementation in early life to prevent adult cardiometabolic disease incidence in the context of high childhood stunting and high adult overweight and obesity. Funding: National Institutes of Health.

Objectives. To evaluate the acceptability and feasibility of an intervention based on mobile health, for the adoption of healthy lifestyles in prehypertensive people living in low-income urban areas in Argentina, Guatemala and Peru. Materials and methods. Prehypertensive people aged 30-60 years were recruited for a pilot study. The intervention included two counseling calls made by a nutritionist followed by a weekly customized text message. An internet-based platform offered support for the implementation of the intervention. Using semi-structured interviews, we evaluated the reach and acceptability of the intervention in the participants and ease of use for the nutritionists. Results. It was possible to contact 43 of the 45 participants (95%). The average number of calls to contact a subject was two, with a range of 1-9 calls. Two participants could not be reached on their cell phone; five did not receive complete exposure to the intervention. Based on semi-structured interviews, the results showed good acceptability for the intervention by the participants. Nutritionists perceived the platform as friendly and easy to use. Barriers to deliver this intervention were related to difficulties in obtaining an adequate cellular signal. Conclusions. Given the high penetration of mobile phones in developing countries, it is concluded that it is feasible and acceptable to offer a mobile health based intervention oriented towards lifestyle modification in people with prehypertension or high risk of chronic disease intervention.

Liver cancer is an emerging global health issue, with rising incidence in both the United States and the economically developing world. Although Guatemala experiences the highest rates of this disease in the Western hemisphere and a unique 1:1 distribution in men and women, few studies have focused on this population. Thus, we determined the prevalence and correlates of aflatoxin B1 (AFB1) exposure and hepatitis virus infection in Guatemalan adults. Healthy men and women aged ≥40 years (n = 461), residing in five departments of Guatemala, were enrolled in a cross-sectional study from May-October of 2016. Serum AFB1-albumin adducts were quantified using isotope dilution mass spectrometry. Multivariate linear regression was used to assess relationships between AFB1-albumin adduct levels and demographic factors. Biomarkers of hepatitis B virus and hepatitis C virus infection were assessed by immunoassay and analyzed by Fisher's exact test. AFB1-albumin adducts were detected in 100% of participants, with a median of 8.4 pg/mg albumin (range, 0.2-814.8). Exposure was significantly higher (p

To determine the relative validity of three food frequency questionnaires (FFQs) compared with results from 24-hour dietary recalls for measuring dietary intakes in Guatemalan schoolchildren.A cross-sectional study of primary caregivers (mothers or grandmothers) of 6-11 year-old children. Caregivers completed one of three constructed FFQs to measure the child's dietary consumption in the last week: FFQ1 did not incorporate portion sizes; FFQ2 provided portion sizes; and FFQ3 incorporated pictures of median portion sizes. During the same week, each caregiver also completed three 24-hour dietary recalls. Results from the FFQ were compared with corresponding results from the 24-hour dietary recalls.Santa Catarina Pinula, peri-urban Guatemala City.Caregivers (n = 145) of 6-11 year-old children: 46 completed FFQ1, 49 completed FFQ2, and 50 completed FFQ3.The mean values for all nutrients obtained from the 24-hour dietary recall were lower than for those obtained from the FFQs, excluding folic acid in FFQ3, cholesterol and zinc in FFQ2, and cholesterol, folic acid, magnesium, potassium, sodium, and zinc in FFQ1. Energy-adjusted Pearson correlation coefficients ranged from 0.07 (protein) to 0.54 (cholesterol) for FFQ1 and from 0.05 to 0.74 for FFQ2 and FFQ3. Agreement by both methods (FFQ and 24-hour dietary recalls) of classifying children into the same or adjacent quartiles of energy-adjusted nutrient consumption ranged from 62.0% for cholesterol to 95.9% for vitamin B12 across all three FFQs.Our FFQs had moderate to good relative validity in measuring energy and nutrient intakes for 6-11 year-old Guatemalan children. More evidence is needed to evaluate their reproducibility and applicability in similar populations.

Objetivos. Evaluar la aceptabilidad y factibilidad de una intervención basada en salud móvil, para la adopción de estilos de vida saludables en personas prehipertensas que viven en zonas urbanas de bajos recursos en Argentina, Guatemala y Perú. Materiales y métodos. Se reclutaron prehipertensos entre 30 a 60 años para un estudio piloto. La intervención incluyó dos llamadas de consejería realizadas por una nutricionista, seguidas de un mensaje de texto customizado semanal. Una plataforma basada en Internet ofreció el soporte para la implementación de la intervención. Utilizando entrevistas semiestructuradas se evaluó el alcance y la aceptabilidad de esta intervención en los participantes, y la facilidad de uso en las nutricionistas. Resultados. Se logró contactar a 43 de los 45 participantes (95%). El número promedio de llamadas para contactar a un sujeto fue de dos, con un rango de 1-9 llamadas. Dos participantes pudieron ser contactados en su teléfono celular y cinco no recibieron una exposición completa a la intervención. Basados en las entrevistas semiestructuradas, los resultados mostraron una buena aceptabilidad a la intervención en los participantes. Las nutricionistas percibieron a la plataforma como amigable y de fácil manejo. Las barreras para ofrecer esta intervención se relacionaron con dificultades para obtener una señal de telefonía celular adecuada. Conclusiones. Dada la alta penetración de la telefonía celular en países en desarrollo, se concluye que una intervención basada en salud móvil es factible y aceptable para ofrecer una intervención orientada a la modificación del estilo de vida en prehipertensos o personas de alto riesgo de enfermedades crónicas.

Objetivos. Evaluar la aceptabilidad y factibilidad de una intervención basada en salud móvil, para la adopción de estilos de vida saludables en personas prehipertensas que viven en zonas urbanas de bajos recursos en Argentina, Guatemala y Perú. Materiales y métodos. Se reclutaron prehipertensos entre 30 a 60 años para un estudio piloto. La intervención incluyó dos llamadas de consejería realizadas por una nutricionista, seguidas de un mensaje de texto customizado semanal. Una plataforma basada en Internet ofreció el soporte para la implementación de la intervención. Utilizando entrevistas semiestructuradas se evaluó el alcance y la aceptabilidad de esta intervención en los participantes, y la facilidad de uso en las nutricionistas. Resultados. Se logró contactar a 43 de los 45 participantes (95%). El número promedio de llamadas para contactar a un sujeto fue de dos, con un rango de 1-9 llamadas. Dos participantes pudieron ser contactados en su teléfono celular y cinco no recibieron una exposición completa a la intervención. Basados en las entrevistas semiestructuradas, los resultados mostraron una buena aceptabilidad a la intervención en los participantes. Las nutricionistas percibieron a la plataforma como amigable y de fácil manejo. Las barreras para ofrecer esta intervención se relacionaron con dificultades para obtener una señal de telefonía celular adecuada. Conclusiones. Dada la alta penetración de la telefonía celular en países en desarrollo, se concluye que una intervención basada en salud móvil es factible y aceptable para ofrecer una intervención orientada a la modificación del estilo de vida en prehipertensos o personas de alto riesgo de enfermedades crónicas.

Existe evidencia científica que sugiere que la lactancia materna (LM) tiene beneficios a largo plazo, incluyendo un efecto protector contra la aparición de las enfermedades crónicas no transmisibles (ECNT). Por lo tanto, el objetivo de esta revisión fue identificar la evidencia generada sobre la relación de la LM y el desarrollo de las ECNT en la vida adulta. Se realizó una búsqueda electrónica en PubMed de estudios que evaluaran los efectos a largo plazo de la LM sobre los principales factores de riesgo para las ECNT. Se revisaron artículos publicados hasta agosto de 2014. De 75 artículos revisados, 31 fueron incluidos, los cuales fueron publicados entre los años 2001 y 2014. Algunos de los estudios presentados en esta revisión sugieren que la LM podría tener un rol protector en el desarrollo de las ECNT en la edad adulta o sus factores de riesgo, al igual que los mecanismos biológicos plausibles por los que la leche materna podría actuar. La disminución del riesgo de sobrepeso y obesidad es la que dispone de más evidencia, aunque hay resultados contrarios, al igual que para los factores de riesgo de enfermedad cardiovascular. En el caso de la disminución del riesgo de desarrollar diabetes tipo 2 y estados de inflamación, la evidencia aún es muy escasa. A pesar de que la mayoría de resultados provienen de estudios observacionales, lo que limita establecer causalidad, estos resultados pueden utilizarse para dar apoyo a las políticas y programas de salud relacionados con la promoción de la LM.