Formative Assessment of

Infant and Young Child

Nutrition in Two Indigenous
Communities in Guatemala

MAY 2013

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

Table of Contents
Introduction

Research Objectives

Study Design

Institutional Context and Ethics

General Demographics, Poverty, and Food Security

Family Structure, Roles, and Decision-making

Child Care and Feeding Practices

Foods and Feeding Patterns

11

Child Health and Illness Prevention

14

Child Malnutrition

15

Malnutrition in Pregnant Women

16

Health and Nutrition Information and Education

17

Summary and Conclusions

18

Study Implications

21

Study Limitations

22

Acknowledgements

22

Financial Disclosures and Conflict of Interest Statement

22

Appendix A: Acronyms, Abbreviations, Definitions

23

Appendix B: Fortified Food List

24

Appendix C: General Food List

25

Introduction

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

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

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

time period of feeding patterns, specifically to look at

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

b). Kexel: 3 female Wuqu Kawoq program coordinators

and health educators with five years experience in
the community.
c). Xejuyu: 3 community leaders (1 male, 2 female):
Town officials and local midwife (comadrona).
d). Xejuyu: 9 NGO staff members (3 males, 6 females):
Wuqu Kawoq employees who have worked as
program coordinators and health educators (7); staff
at another NGO providing primary maternal-child
health services (2).
4. Eighty-two (82) market surveys (45 in Xejuyu, 37 in Kexel),
conducted with owners of small food shops (tiendas) and
pharmacies (farmacias) in and near each community. Surveys
covered the following thematic areas: store demographics;
foods sold specifically for children; snack/junk foods sold;
fortified foods sold; client preferences; average cost of
different categories of foods; average amount that children
and adults spend on snacks. All markets, stalls, stores and
shops open during interviewing hours were selected within
the community; a random sample of locations were taken in
the larger towns outside of the two communities.

Most residents work as seasonal agricultural day laborers or

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

Data from the caregiver survey and the market survey was
coded and entered into Excel, checked for accuracy, and imported
into STATA (version 11). Descriptive statistics were generated and
multiple responses to survey items were analyzed using the MRTAB
function. Statistical comparison of the two study communities were
conducted using the Students t-test (for parametric continuous
variables),Wilcoxon rank-sum test (for nonparametric continuous
variables), and either the chi-square or Fischers exact test (for
categorical variables). Throughout the report, the statistical tests
used are noted as super-scripts: a (Chi-square), b (Students t-test),
c (Fishers exact test), and d (Rank-sum test).Transcripts from the
focus groups and key informant interviews were reviewed to
create a preliminary codebook, which underwent five rounds of
modification. Data was coded thematically using Coding Analysis
Toolkit (CAT), an online qualitative coding software. Surveys, focus
group guides, and codebooks are available upon request.

Institutional Context and Ethics

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

General Demographics, Poverty and

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

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

Family Structure, Roles, and Decision-making

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

Makes Household Purchasing Decisionsa

Makes Household Food Purchasesa

Highlands

Bocacosta

Mother of the child

59%

70%

Paternal grandmother

30%

13%

Father of the child

10%

5%

5%

7%

Maternal grandmother

Highlands

Bocacosta

Mother of the child

71%

62%

Paternal grandmother

22%

15%

Father of the child

2%

12%

Maternal grandmother

3%

6%

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

Location of Purchases
Highlands

Bocacosta

P-valuea

Large supermarket

33%

42%

0.37

Small stores

87%

64%

0.01

Street vendors/ market stalls

15%

54%

0.00

Cultural beliefs and traditions play a large part in family

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

earners, men often exert control over the amount of household

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

Child Care and Feeding Practices

Roles and Respondsibilities for Child Care
In both communities, around one-third of children had
another important day-to-day caregiver other than the mother.
Most commonly, this caregiver was the childs paternal or
maternal grandmother or older sister. Fathers were seen mainly
as providers, although the importance of fathers playing with their
children and encouraging their schooling was mentioned. In the
male focus groups, participants offered incisive and reflective
commentary on the causes, prevention, and treatment of problems
related to child health, nutrition, and physical and psychosocial
development. However, in female focus groups, participants often
commented that men were only peripherally involved in the dayto-day decisions regarding child welfare.
8

pregnant results in the child becoming ill (with vomiting/diarrhea)

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

Breastfeeding Frequency and Duration

Highlands

Bocacosta

Frequency

P-valuea
0.97

5%

5%

22%

18%

27%

26%

46%

51%

Duration

0.00
3%

44%

24%

33%

53%

21%

Breastfeeding and Weaning Practices

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

Complementary Feeding Practices

When breast milk is no longer enough to meet the nutritional
needs of the infant, complementary foods should be added to the
diet of the child. This is a very vulnerable period as it is the time
when malnutrition starts in many infants. In order to protect
against malnutrition, WHO provides guidance on best practices
for complementary foods. First, complementary feeding should
be timely, meaning that all infants should start receiving foods in
addition to breast milk from six months onwards. Next, it should
be adequate, meaning that the complementary foods should be
given in appropriate amount, frequency, consistency and variety to
cover the nutritional needs of the growing child while maintaining
breastfeeding. Foods should be prepared and given in a safe
manner, meaning that measures are taken to minimize the risk
of contamination with pathogens. Finally, they should be given in
a way that is appropriate, meaning that foods are of appropriate
texture for the age of the child and caregivers use responsive
feeding techniques.6
Only three caregivers of the 102 interviewed in the
structured survey observed that their children were not yet
taking complementary foods. The average age of introduction of
solid foods was 7.3 2.0 months (range 3 to 14 months) with 73%
of children starting complementary feeding between six and eight
months; this did not differ between communities.b The percentage
of caretakers that reported not initiating complementary foods
or liquids until age six months or older was 98% in the Highlands,
compared to 90% in the Bocacosta (p=0.08a). The first foods
commonly given to infants included bean or potato purees,
rice, noodles, soup, and Gerber baby foods. The average age of
introduction of first liquids (other than breastmilk) was 6.0
3.0 months (range 0 to17 months), with no statistical difference
between the two communities.b First liquids included Incaparina
9

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

Bocacosta

P-valuea

Honduras

12.5%

35%

0.07

65%

Minimum Meal Frequency

6%

37.5%

0.001

77%

Minimum Acceptable Diet

2.5%

20.6%

0.01

52%

Minimum Dietary Diversity

Of note, children 6 to 23 months surveyed in the Bocacosta were slightly older on average by about one month (15.27 months
vs. 14.24 months on average), and in our structured survey age was found to be moderately correlated with both meal frequency and
dietary diversity (0.34, p=0.003; 0.40, p=0.0004, respectively). However, the difference in age between the two communities was not
statistically significant (p=0.35b).
Caretakers were also asked about the number of servings their child consumed of a list of varied foods (53 foods, 15 beverages,
and free response) in the past week, using a food frequency questionaire. As shown below, statistically significant differences between
consumption patterns for children 6 to 23 months existed. In the Bocacosta, children consumed significantly more servings of fruits,
animal foods, dairy, refined sugar, high sugar beverages, and junk foods; in the Highlands, children consumed more atol (Incaparina).
Although both study communities are rural, in the Bocacosta community, there has been more penetration of processed and prepared
foods. Therefore, these results are explicable, and they are qualitatively similar to studies that have compared the feeding practices of
infants in other rural Highlands communities to infants from urban Guatemala City.12
Seven-day food recall for children 6 to 23 months (servings/week) (*=WHO food groups)
Cereals & tubers*
Vegetables*
Fruits*
Vitamin A rich foods*
Animal foods (including eggs)*
Legumes & nuts*
Dairy*
Childrens fortified foods
Commercial/packaged foods
Added fat
Junk foods
Refined (added) sugar
Soda and store-bought juice
All high sugar beverages
(home-made tea, coffee, and juice drinks; store-bought soda and juice)
Atoles
Broth
10

Highlands
19.7 1
14.2 1.1
3.6 0.4
2.9 0.3
3.0 0.4
1.8 0.3

Bocacosta
21.2 1.4
12.8 1.4
6.0 0.7
3.8 0.5
4.2 0.4
2.0 0.2

P-value
0.37b
0.45b
0.003b
0.44d
0.034b
0.43d

0.6 0.1

4.4 0.4

0.000b

4.5 0.5
2.6 0.3
4.6 0.4
0.7 0.2
12.4 0.9
1.6 0.4

4.5 0.4
3.0 0.6
4.5 0.5
5.7 0.5
19.9 0.8
1.6 0.2

0.93b
0.84d
0.86b
0.000d
0.000d
0.33d

4.2 0.6

6.1 0.6

0.043d

5.8 0.4

3.3 0.5

0.001d

3.4 0.4

2.6 0.4

0.12b

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

Bocacosta
Food
Total mentions
Tortilla
85
Coffee
59
Eggs
28
Oil
27
Bread
25
Noodles
22
Rice
19
Beans
18
Atol
13
Cookies/crackers
10

Total mentions
113
98
39
31
28
25
17
16
16
14

Foods and Feeding Patterns

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

11

Caretakers in the structured surveys were asked if their

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

12

Trigo, Quaker products, Gerber products, and powdered milk. A

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

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

Vitamins and Micronutrient Supplements

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

Healthy and Unhealthy Food Beliefs

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

Unhealthy foods:

Household: cage-raised chicken

Prepared: canned foods, instant soups

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

Snacking Behaviors and the Role of Junk Foods

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

Several caregivers had heard during consultations with the

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

Child Health and Illness Prevention

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

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

not participating in usual play activities) and, for older children,

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

thought their own child (6 to 36 months) was malnourished.

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

In all focus groups, participants were asked how to prevent

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

Malnutrition in Pregnant Women

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

for preventing or curing malnutrition in pregnant women included

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

Health and Nutrition Information

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

17

(e.g., midwives), commercial outlets (stores, pharmacies), and

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

accept health messages than those with lower levels of education.

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

Summary and Conclusions

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

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

this is despite many unsuccessful attempts by community health

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

Objective 2 of this study was to better understand

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

highly prevalent (and therefore is not obvious when comparing

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

Consistently in all focus groups and key informant interviews,

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

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

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

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

3.

Chary A, Messmer S, Sorenson E, Henretty N, Dasgupta S, Rohloff

P. (2013). The normalization of childhood disease: An ethnographic
study of child malnutrition in rural Guatemala. Human Organization
(in press).

4.

Wuqu Kawoq | Maya Health Alliance. (2011). Baseline needs

assessment of Xejuyu. Unpublished data.

5.

Guiding principles for complementary feeding of the breastfed child

Pan American Health Organization, Washington, DC 2003

6.

WHO. (2003). Global strategy for infant and young

child feeding. Retrieved from http://whqlibdoc.who.int/
publications/2003/9241562218.pdf

7.

Carey, D. Jr. (2006). Engendering Mayan History: Kaqchikel Women

as Agents and Conduits of the Past, 1875-1970. New York:
Routledge; Ehlers, TB (2002). Silent Looms: Women and Production
in a Guatemalan Town. Austin: University of Texas Press.

8.

Hoddinott, J. M.-Z. (March 2011). The consequences of early

childhood growth failure over the life course. International Food
Policy Research Institute Paper.

9.

Merchant, K. (1990). Maternal and fetal responses to the stresses

of lactation concurrent with pregnancy and short recuperative
intervals. Am J Clin Nutr, 52: 280-8.

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

10. Oliveros, C., et.al. (1999). Maternal lactation: A Qual. analysis of the
breastfeeding habits and beliefs of pregnant women living in Lima,
Peru. International Quarterly of Community Health Education,
18(4). 415-434.
11. WHO. (2010). Indicators for assessing iycf practices Part 3:
Country Profiles. Retrieved from http://www.who.int/maternal_
child_adolescent/documents/9789241599757/en/

Financial Disclosures and Conflict of

Interest Statement

12. Enneman, A., Hernandez, L., Campos, R.,Vossenaar, M., Solomons,

N.W. (2009). Dietary characteristics of complementary foods
offered to Guatemalan infants vary between urban and rural
settings. Nutrition Research, 29: 470-479.

All study authors are affiliated as staff, volunteers, or advisors

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

Sources
1.

Ministerio de Salud Publica y Asistencia Social (MSPAS), Instituto

Nacional de Estadistica (INE), Universidad del Valle de Guatemala,
United States Agency for International Development (USAID),
Agencia Sueca de Cooperacion para el Desarollo Internacional
(ASDI), Centers for Disease Control and Prevention (CDC),
United Nations Childrens Fund (UNICEF), United Nations
Population Fund (UNFPA), Pan American Health Organization
(PAHO)/Calidad en Salud 2009 V Encuesta Nacional de Salud
Materno Infantil 2008-2009. Guatemala City: Ministerio de Salud
Publica y Asistencia Social.

2.

Sistema de Vigilancia de la Malnutricin en Guatemala (SIVIM).

(Mayo, 2012). Fase I: Prueba del prototipo en cinco departamentos
de la regin del altiplano occidental de Guatemala: Resumen.
INCAP, USAID/HCI, CDC.

22

13. UNICEF. (2010). At a glance : Guatemala. Retrieved from http://

www.unicef.org/infobycountry/guatemala_statistics.html

Appendix A: Acronyms, Abbreviations, Definitions

General:
Bocacosta

Study site located along the Pacific coast; Kexel

Highlands

Study site located in the central highlands; Xejuyu

Indigenous

Self-identifying as Maya; often, speaking a Mayan language, or wearing traditional Maya clothing

Kaqchikel, Kiche

Mayan languages spoken in the study area

Ladino(a)

Non-indigenous; generally of mixed Maya/European descent, but no longer self-identifying as Maya

Milpa agriculture

Traditional form of agriculture consisting of intercropping of corn and other staple commodities,
especially beans, on small plots of land

Subsistence agriculture

Lifestyle in which the bulk of ones work efforts are used to grow food for ones own consumption
Foods:

Atol(es)

Thin gruel that is served hot and is usually made from corn flour, rice flour, or a commercial mix

Caf de tortilla

Drink made from soaking toasted tortillas in hot water, served with sugar

Caldos

Broths- chicken, beef, pork, vegetables, greens; liquid from cooked beans

Comida chatarra(s)

Junk foods

Commercial foods

Foods packaged and labeled commercially

Corazn de trigo

Processed wheat cereal product that is reconstituted into a gruel

Fortified foods

Commercial foods with added vitamins and/or minerals

Galleta

Packaged cookie or cracker

Gaseosa, refrescos

Soda, sweetened beverages

Golosinas

Sweets, candy

Hierba(s)

Local greens, can be bought in the market or grown; includes some wild greens

Incaparina

Guatemalan commercially-made atol base made from a mixture of corn flour and soy flour
combined with vitamins and minerals

Mosh/Avena

Oatmeal, usually prepared as a thin drink with sugar and cinnamon

PlumpyDoz

Peanut based ready-to-use supplementary food fortified with vitamins and minerals for children 6-36
months; provided through some WuquKawoq programs

Tienda

Small shop that sell groceries, junk foods, and other small household items

Capacitaciones

Formal educational classes

Plticas

Informal discussions

Positive deviance model

Approach to behavioral and social change based on the observation that in any community, there are
people whose uncommon but successful behaviors or strategies enable them to find better solutions
to a problem than their peers, despite facing similar challenges and having no extra resources or
knowledge than their peers.

Program:

Feeding related:
Appropriate minimal dietary diversity 6-23
months (%) (WHO indicator)

Number of distinct food groups consumed in 24 hour period by breastfed children 6-23 months; the
7 foods groups used for tabulation of this indicator are grains, roots and tubers; legumes and nuts;
dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry and liver/organ meats); eggs;
vitamin-A rich fruits and vegetables; and other fruits and vegetables; minimum number of food groups
consumed for this age group is 4.

Appropriate minimal meal frequency 6-23

months (%) (WHO indicator)

Number of meals and snacks fed in 24 hour period; breastfed children 6-23 months of age who had
4 or more meals

Appropriate minimal acceptable diet 6-23

months (%) (WHO composite indicator)

Composite indicator; breastfed children 6-23 months of age who had at least the minimum dietary
diversity and the minimum meal frequency during the previous day

Infant and young child feeding (IYCF)

Feeding practices of infants and young children between birth and age 3 years

Infant and young child nutrition (IYCN)

Specific nutritional needs of infants and young children between birth and age 3 years

Complementary feeding

Initiation of solid foods at 6 months of age to complement breastfeeding

Continued breastfeeding

Continuation of breastfeeding from 6 months to 2 years, in addition to appropriate foods

Exclusive breastfeeding

Infant receives only breast milk, vitamins, and some medicines for the first 6 months of life

Pre-lacteal feeds

Food/liquid given to the infant before initiating breastfeeding for the first time after birth

23

Appendix B: Fortified Food List

Product

Sizes

Cost

Package labeling (Spanish)

Package labeling (English)

Anchor Leche Entera en Polvo

(dry milk)

26g; 120g;
360g

3 Q; 10 Q;
29 Q

Enriquecida con vitaminas; Fortificada

con hierro, cido flico, vitaminas A & D,
zinc, calcio, vitaminas C, E, and A, biotina

Enriched with vitamins; fortified with

iron, folic acid, vitamins A & D, zinc,
calcium, vitamins C, E, and A, biotin

Azucar La Montana (iron,

vitamin A)

Fortificada con vitamina A

Fortified with vitamin A

Campo Rico Avena

66.92g

2.5 Q

Calcio, hierro, vitaminas

Calcium, iron, vitamins

Chocolisto (dry beverage)

200g

8Q

Vitaminas y minerales

Vitamins and minerals

Corazon de Trigo

400g

7.25 Q

Fortificada con vitaminas y hierro

Fortified with vitamins and iron

Cosecha Pura Naraja (juice box) 500 ml

3Q

Enriquecida con vitamina C

Enriched with vitamin C

Ducal Fruit Nectar (canned

juice)

220 ml

2.5 Q

Con vitamin C

With vitamin C

Gerber Frutas Mixtas (baby

food jar)

100g

5-6 Q

Fortificado con vitamina C, cido flico,

y hierro

Fortified with vitamin C, folic acid, and

iron

Gerber Manzana, Banano (baby

food jar)

100g

5.5 Q

Fortificado con vitamina C, cido flico,

y hierro

Fortified with vitamin C, folic acid, and

iron
Good source of protein; proven healthy
and natural nutrition; mix of fortified
vegetables to make atol (corn-based
gruel); Excellent source of iron and zinc,
and 5 other vitamins
Delicious, healthy, nutritious

Incaparina

75g; 450g

2 -2.5 Q;
7.5-9.5 Q

Buena fuente de protena; Nutricin

comprobada, sana y natural; Mezcla
vegetal fortificada para hacer atol;
Excelente fuente de hierro y zinc, ms 5
vitaminas

Kamb Fortified Drink (milk box)

1 each

3.5 Q

Deliciosa, saludable, nutritiva

Kerns Fruit Juice

330 ml

3.5 Q

Con vitamina C

With vitamin C

Kerns Vegetable Juice

330 ml

3.5 Q

Con vitamina C

With vitamin C

Kerns Junior; Nectar Melocoton

330 ml

3.5 Q

Con vitamina C, calcio, y zinc escenciales para crecer

With vitamin C, calcium, and zinc especially for growth

Maizena

47g; 190g

2-2.5 Q;
7Q

Atol fortificada

Fortified atol

Nestl Kinder Nido

800g

65 Q

(no health or nutrition claims on

package)

(no health or nutrition claims on

package)
NAN 1 (for 0-6 months): Initial milk
formula in powder with iron and
probiotics for infants; Gentle start,
L-comfortis: DHA, ARA, OPTI-Pro. NAN
2: Continuing milk formula in powder
with iron and probiotics for infants;
Gentle plus, L-comfortis: DHA, OPTIPro. Important: Breast milk is the best
nutritional source for infants

Nestl NAN 1 & 2

350g

60 Q

NAN 1 (for 0-6 months): Formula

lctea de inicio en polvo con hierro y
probiticos para lactantes; Gentle start,
L-comfortis: DHA, ARA, OPTI-Pro. NAN
2: Formula lctea de continuacin en
polvo con hierro y probiticos para
lactantes; Gentle plus, L-comfortis: DHA,
OPTI-Pro. Aviso importante: La leche
materna es el mejor alimento para el
lactante

Nestl Nesquik

200g

3.5 Q

Fuente de hierro y vitamina C

Source of iron and vitamin C

22 Q

Ayuda a fortalecer las defensas naturals

de tu bebe - Immunonutrientes: hierro,
zinc, vitaminas A & C -13 vitaminas

Helps to strengthen your babys natural

defenses- nutrients for the immune
system: iron, zinc, vitamins A & C, 13
vitamins

Nestl Nestum Cereal Infantil; 5,

360g
8, arroz, trigo y miel

24

Appendix B: Fortified Food List (continued)

Nueve frmula con probiticos; Doble
accin: Lactobacillus protectus, 11
vitaminas y 3 minerales. Es el primer
paso del sistema de nutricin NIDO
especializada para cada fase del
desarrollo de tus hijos; El alimento a base
de leche NIDO aporta vitamina A, la cual
es esencial para el buen funcionamiento
del sistema immunolgico- la vitamina
A ayuda a mejorar la resistencia
del organismo contra infecciones
gastrointestinales y respiratorias; No es
sustituto de la leche materna sino un
alimento lcteo adecuado especialmente
para nios desde 1 ao y adelante

New formula with probiotics; Double

action: Lactobacillus protectus, 11
vitamins and minerals. This is the first
step for the NIDO nutrition system,
specially designed for each phase of
development of your children; This food
based in NIDO milk contains vitamin
A, which is essential for the immune
system to function well - vitamin A
helps to improve the bodys resistance
to gastrointestinal and respiratory
infections; This is not a substitute
for breast milk, but rather it is an
appropriate milk-based food for children
aged 1 year and older
Iron, zinc, vit C, vit D

Nestl Nido Crecimiento

Proteccin (formula)

360g

35 Q

Nestl Nido Fortificada

840g

60 Q

Hierro, zinc, vit C, vit D

Nestl Nido Leche Entera en

Polvo

360g

30 Q

Fortificada: hierro, vitamina A, vitamina C, Fortified: iron, vitamin A, vitamin C,

vitamina D, zinc
Vitamin D, zinc

Nestl Nido Nutri-Rindes

480g

30 Q

Hierro y cido flico

Iron and folic acid

Health and more nutrition in your food
- textured soy protein - with iron and
folic acid - helps to reduce cholesterol
naturally.

Protems

120g

6.5 Q

Salud y mas nutricion en sus comidas

- proteina de soya texturada - con
hierro y acido flico - ayuda a reducar el
colesterol por su naturaleza

Pedialyte Suero Oral (Na, K, Cl,

Zn and citrate added)

500 ml

21 Q

Ahora con zinc

Now with zinc

Quaker Avena Mosh Nutrems

80g; 400g

2 Q; 10 Q

Hierro, calcio, zinc, vitaminas - previene

la anemia, foralece los huesos, ayuda el
crecimiento, mejora el disempeno

Iron, calcium, zinc, vitamins - prevents

anemia, strengthens bones, helps with
growth, improves performance

Shaka Laka Shakes

200 ml

3.5 Q

Extra minerales y vitaminas

Extra minerals and vitamins

Yus de Toki

35g

2-2.5 Q

Contiene vitaminas A & C

Contains vitamins A & C

Appendix C: General Food List

Product

Sizes

Cost

Azucar La Montana

Black beans

1 lb

4.5-8 Q

Chocolate-covered bananas

1 each

1Q

Cup Noodles (dry soup)

1 cup (64g)

3-5 Q

Ducal Black Refried Beans

10.5 oz can

6-8 Q

Eggs

1 each

1Q

Issima La America Pasta

200g

3Q

Knorr Costilla de Res Soup (dry soup)

57 g

2.5 Q

Fresh cheese

1 each

7Q

White rice

1 lb

3.5-4 Q

Salchichas

1 each

0.75 Q

25