Juan

A Rivera,

Jean-Pierre

ABSTRACT wasting (< 90% old children assigned

Habichi,

Three-month weight-for-length)

in four

Guatemalan

villages

that

a moderate

(Atole)

or low

10% ofthe

(RDI)

from intake

than

daily

the supplement (including

a comparable

was

portion for.

to the

KEY WORDS

group

increased

energy

and whose

10.5%

ofthe

with

low

group ofthis

confounding 199 1;54:62-8.

recovery trial

from

Subjects

were

wasting (range

large mo

(1). For and

example,

in 1980

5 y in a national

as moderately of the National

controlled

Therefore, mentary

quate analysis effect

that

of Guatemala

in children

cannot

feeding

to

ages

6

classified

weighed < 90% (NCHS)-World

to malnourished

of supplementary

attending

Beaton

trials,

children, and

feeding

3). However, control groups.

used

has

programs

on “anthropometric

in a supplementation

ofwasting

and

recovery

that

and

public

health

pro-

in nutrition

research

design

for this analysis

tween

1969

trial

and

area

1977.

were

randomly

were

collected

during

in rural

Guatemala

conducted

Detailed

selected

allocated (63

g/L)

villages

were

assigned

protein amounts

supplement of vitamins

descriptions

for

centers

and

drink

of

each

session

available community aged 0-7

to the

nearest

times

study. Atole.

The

a low-energy

Fresco. minerals

a conbe-

the

sample,

of the

villages

(3.77

MJ/L),

remaining

two

(1 .38 MJ/L)

non-

Both supplements had similar (Table 1). A preventive and

offered centrally daily,

in all four villages in supplementary on

at two y were 10 mL.

the energy

Two

a high-energy

called

to receive called and

were

members of the takes of children

the

to receive

curative health program was supplements were distributed

a voluntary

(7). The feeding

basis,

to all

3-h sessions. Individual measured and recorded The

is almost

three

children plement

in the Atole villages consumed than did children in the Fresco

I

and

given

Butz

in ade-

a positive

effect

(5) in their

meta-

concluded

that

improvement

metaanalysis

Am

From

the Instituto

CAP), Guatemala,

to supple-

Habicht when

Ghassemi

as

of this on the

content

energy

content

ofFresco. larger villages.

inat

of Atole

Furthermore, volumes of supAs a result, the

nutrition-re(2,

solely

feeding,

surprisingly small.” Much of their to seek reasons for this small effect.

62

were

be attributed

supplementary

In contrast,

ofsupplementation

referred

between

and

supplementation

graphical

sup-

of children their height is

of children

from 40% to 80% centers had adequate

ofsupplementary

amounts

on growth.

range in these

Rrs reported feeding.

In a review

often

wasted because they for Health Statistics

(PEM)

centers studies

(4) concluded

are

programs

objective feeding

methods, and quality control were published elsewhere (6). A brief description follows: Four rural Guatemalan villages that were similar in population, ethnicity, development, and geo-

(WHO) references for weight-for-height observations, 1980). rates (Rrs) from mild to moderate protein-

malnutrition

habilitation none ofthe

25%

sample

to severely Center

Health Organization (INCAP, unpublished Reported recovery energy

children

the

methods

trolled

were

wasted

wasting

indicators

employed

and

The data

pro-

recovery,

feeding programs. The proportion as evidenced by low weight given

to moderate using

Study population

supplemental

trial

to severely

feeding

grams.

Introduction Moderately

mild

commonly

high-protein

supplementary who are wasted

of supplementary

higher

This

malnutrition,

importance

in Guatemala,

are

total

RDI

whose recovery

variables

the

of energy

supplementation.

Protein-calorie field

randomly

intake

group)

was

in the high-Atole recovered. Much

rose after potential Am J Clin Nutr

plementation

diet)

high-Fresco

due

been (Fresco)

dietary

(high-Atole home

had

Given

strategies for the control of undernutrition, study was to quantify the effect ofsupplementary

(Rr) in the Atole villages was villages (P < 0.05). This effect in the Atole villages who con-

recommended

energy intake. All those was due to malnutrition 29-52%)

S Robson

rates from moderate compared in 6-24-mo-

supplement. The recovery rate 12% higher than in the Fresco was above all due to the children

energy

Douglas

recovery were

to receive

sumed

and

from mild

the was

de Nutnci#{243}nde Centro

and the Division

America

of Nutritional

y Panama

Sciences

(IN-

and Bio-

metrics Unit, Cornell University, Ithaca, NY. 2 Supported in part by grant RD1-HD-20029 from the National Institute of Child Health and Human Development to the Rand Corporation and by the Instituto de Nutrici#{243}nde Centro America y Panama (INCAP), Guatemala. Financial support for J R’s doctoral studies was received from the Consejo Nacional de Ciencia y TecnologIa, Mexico, and from the Kellogg Company. 3 Address reprint requests to J Rivera, INCAP, P0 Box 1 188, Guatemala, Guatemala City, CA ReceivedJune 1, 1990. Accepted for publication November 14, 1990.

then

went

on

J C/in

Nutr

l99l;54:62-8.

Printed

in USA.

© 1991 American

Society

for Clinical

Nutrition

Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/62/4691088 by East Carolina University user on 13 January 2019

Effect of supplementary feeding on recovery to moderate wasting in preschool children13

SUPPLEMENTARY TABLE

1

AND score,

Ingredients

and nutrient

content

of Atole

and Fresco1 Frescot

Ingredients (g/0. 18 L) Incaparina Dry skim milk Sugar

Contents

per cup; cup volume

benefit.

-

were

90%

-

>

-

was

15.3 4.0

wasted

-

the

1.1

of the

as the

and

The

whose

-

than

in the Fresco

plement daily

intake group

aged

6-24 group.

The

sample

based

18-21,

risk

was

Measures ofsiblings

were

over,

some

thus

contributing

Therefore, holds

Rrs were Rrs)

used

as the

obtained

Fresco

of energy the

Fresco

can

(RDI)

considered

aged

6-24

show

1988).

a nonsupple-

of children supplementary

Fresco

from

the

village-level two

household

children

21-24

mo.

intervals:

Because

participated

was conducted

tional

Institutes

6-9,

the study

in more

study

than

according

mo.

one

The

analyses

tailed

9- 12, 12- 15, 15-18, was longitudinal, child-age

to ethical

interval.

guidelines

The

of the Na-

of Health.

formation vantage were

24-h

take.

method

was collected

every

3 mo for children

as the unit

of the example

tion,

during

signs

of other

The groups used were those children

economic

last

and

of which

height ofboth in the house,

parents, number

breast-feeding.

Three

about

the

the mothers:

house

of signs including

demographic

well as characteristics collected,

2 wk,

the

about

house

the

and ofthe

following

were

scores

were

vocabulary

generated and

infection and

used:

mother’s parity, number of persons per room,

characteristics

a maternal

diarrhea

data

ofthe

of respiratory

fever.

child’s

parents, years

and Socio-

family,

as

were also of school,

The mean

ofpersons living and duration of

from

the information

from

interviews

and

score,

a maternal

tests

modernity

group

were

children ance

of

intake

to as high-Fresco

household subtracted

is the sum high-Fresco

was

mean villages

tested

for one-

of variance

by using

an arc sine

treatment,

about

in the

the

Atole

trans-

of the

will

effects

individual

by taking

children

iningested

in the Atole in the high-Atole

with the percentile

a

benefit

supplement

6-24-mo-old

Fresco

and Atole

villages. groups.

high-Atole groups ofthe distribution

villages.

These

are

referred

groups.

Rrs ofwasted from

in the high-Atole

In addition, the

two

receiving

RDI from the supplement are referred to as being

of supplement

children

from

the

Atole

between

by using

Atole

for comparison above the 55th

to

(1 1). This analysis takes adstudy in which two villages

children

ofthe

villages

Rrs ofwasted

receiving Fresco. was to study household

45%

10% of the These children

infections,

the

information

aged 18-24 mo. Morbidity data were collected every 2 wk during home visits. Mothers were asked about the presence and durathe

to the

that

(mean compared

Fresco

compared

difference and

children

were

subtracted

the variances design ofthe

more than the children The second approach For

This

follow.

of RDI

occurred.

by an analysis

assigned

household that

households

and

from

ofanalysis

to stabilize ofthe original expectation

advantage

AB.

significance

household

of wasted

had

were

children

overall

randomly

priori

The data relevant to this paper were collected as follows: weight and length were obtained every 3 mo for the first 2 y of age. Home dietary intake (excluding breast-feeding) obtained by a dietary-recall

the

(mean

diet

household

villages

house-

rates

Atole

Rrs were

mean

sample.

within

averages

feeding

of wasted

statistical

the village

some

Fresco

Rrs

to compute included

The

the

effects,

The

within

ofthese

effects.

villages.

as the

in the

More-

the percentages

averaged

means

true

Overall and

The

in

for the calculations

as well were

Rrs

a number of wasting,

cluster

ofthese

used

ofthe

children.

observation

supplementation,

These

attributable

episodes

of analysis.

were

groups that

ofwasted

these

Rr

(10).

because

repeated

the means

supplement

% RDI).

between

(8) for the in children

observations,

be

sup-

1 1% of the

group

unpublished

group

daily

was

the

obtained.

the

oth-

in the estimation

one

unit

actual

initially

from

to the

not independent

than

and

Rr

were

exposure

consideration

variances

who

is analogous

in the group

more

experienced interval was

by subtracting

experienced into

and their

household

were

to take

were

This

included

children

to have of the

the Rr of a nonsupplemented,

Observations

intervals

of

was 90% at the end of 3 or the effect attributable to

(AB),

by a pernicious

ofeffects.

beginning

expected weight, reference stan-

of weight-for-length.

obtained

group. caused

child-age

at the

of children

group

comparable to a disease

from

in the Atole

the mean

children

intake 1% for

on six child-age

and

children

only

is higher

example,

wasted

(J Rivera,

the

mented

For

dietary

and

mo

Therefore,

were

villages.

in moderately

recommended

Atole

the supplement

obser-

rates, and attributable

end

references

benefit

supplementation,

erwise

1.5 18.5 1.2 5.0 0.2

considered at the

weight-for-length

of the supplemented

were from

as wasted

proportion

attributable

(8) from intake

unpublished

ifthey weighed < 90% ofthe according to the NCHS-WHO

To determine

energy

recovery

NCHS-WHO

defined

mo.

t Both preparations were distributed daily from January 1, 1969, to February 28, 1977. Vitamins and minerals were added to the Fresco on October 1, 1971. Institute of Nutrition ofCentral America and Panama, Guatemala City.

average

recovery, classified

dard (9). A wasted child was recovery if its weight-for-length

247

0.18 L.

=

ofwasting,

Children

the 3-mo intervals given their length,

13.3 2.1

682 11.5 0.7 27.8 4.0 0.4 1. 1 0.3 1.5 18.5 1.2 5.4 0.2

(J Rivera,

Analytic approach

-

-

score

the

ofthe mean groups

the group

two

variances compared.

in the high-Fresco

household

to obtain

household was

children

mean

ofthe Rr

Rrs

the AB. Rrs being

of the The

of wasted

The

high-Atole difference

AB vari-

subtracted. and between

of

Downloaded from https://academic.oup.com/ajcn/article-abstract/54/1/62/4691088 by East Carolina University user on 13 January 2019

Flavoring agent Nutrients (per 0.18 L) Energy (U) Protein(g) Fats(g) Carbohydrates (g) Ascorbic acid (mg) Calcium (g) Phosphorus (g) Thiamine (mg) Riboflavin (mg) Niacin(mg) Vitamin A (mg) Iron(mg) fluoride (mg)

a house-quality 1988).

Definition

13.5 21.6 9.0

63

RECOVERY

and

vations,

Atole

S

FEEDING

64

RIVERA

the

means

was

was tested To show

parison old

converted

how

were

the 55th

the

ABs

used,

in the

high-Fresco

nificances

were

Controlfor high-Fresco

computed

the

that

antee

equal

among

ofall

and

Logistic-regression

and

and

for the

which

statistical

groups,

sig-

in terms

groups that

of

were

on recovery

from

confounding

and

other

variables

that

identified

after

Rrs for the well-supplemented (high-Fresco)

(12).

independent

gistic-regression

(high-Atole)

groups

coefficients.

were

The

de-

causes

For this

and

estimated

poorly

by using

estimation

of

supthe lo-

logistic-regression the

clustering

the

regression

coefficient. effect

the

model

used

coefficient.

on the difference and

was

household’s

mean

described standard

above, errors

Therefore,

a correction

to multiply

the

The

between

effects of the

correction

predicted

(CF)

for

errors

of

is based

Rr for the household

Rr values

from

in time

I

(n(MRr x*(1x) H-K

-

J

will

high-Atole

group

ofregression

rates

of the

period,

as a result

from

by

100.

normal

ofthe

weight-for-length

not due This

frequency

areas

the curve

were

values

was estimated

in this

the

available set but

the

requisites

weight-for-length

(B) is the binomial expected variance

data

distributed

in this

ofthe

measured

variance

(16).

values

for the weight-for-height

the

2-wk

reliabilities

Fieller’s

formula

from

the

for

the

for this study in et al (17). These (18)

weight

to calculate

and

height

2brSS(RR)

-

re-

observed

in reference

+ b2SRJ/i2S

weight, (17),

R is the

S2 is the

reliability

variance,

calculated b is the

weight-for-length, r is the correlation coefficient observed weights and weights from standard given lengths, and i is the mean weight from standard given length (9).

mean

between observed observed

Results Household the

Atole

Fresco if

cumu-

as follows:

y is the

from

for reliability

the

the distribution

proportion ofthe

the curve 0 to Z, both

from

were normally

from

data

obtained

weight and length measurements are available a publication (15) that used data from Martorell meet

mea-

(ZsqR), towards

from

(1 1) because

variability

is not directly

measurement

other

in the

the area under

under

distribution

to week-to-week

reliability

on

and

was also obtained due to regression

by subtracting the area

These

lative

respectively,

ofimprecision

of unreliability

was estimated

0 to ZsqR

where

where ;r indicates summation over households, n is the number of observations per household, H is the total number of households, K is the number of parameters in the logistic-regression model, MRr is the mean Rr for each household, and is the mean ofthe predicted probability ofrecovery for all observations within a household from the logistic-regression model. The numerator (A) is the squared difference between the observed and the predicted (from the logistic model) rate of recovery of the (the cluster). The denominator for the household, which is the

(14),

at one

overestimation of this fraction. This peras follows: 1) the standard normal deviate 90% in the distribution ofpercent weightobtained for each age interval in the highgroups, 2) the product of the standard and the square root of the measurement

the mean from

or lower,

is because

of weight-for-length (sqR) the proportion of recovery

[SR

H-K

to be higher This

reliability 3) finally,

the

I

tend

the mean

or overestimated

percent

household variance

in

Rr

towards

that is under-

surement, is a slight centage was obtained (Z) corresponding to for-length values was Atole and high-Fresco normal deviate (Z)

(

i)2\

the effect

measurement.

liabilities H

In the

weight-for-length

next

data

the logistic

as follows:

CF=

Rr includes

because

population. Reliability

which of the

factor

standard

factor

the observed

ofthe

group.

multiplied

the independent

variables were held constant at their mean values. The estimated Rrs from the model were employed to obtain adjusted AB values after the potential confounding variables were controlled for. The child-intervals used as units of analysis for the logisticregression models have the cluster may result in an underestimate

form.

on the recovery

includes the AB. The part ofthe Rr that is not attributable to supplementation corresponds to the Ri ofthe high-Fresco group. This component the high-atole

ginning

the effect controlling

recovery.

plemented

antilog

lo-

components of unreliability reported for these children elsewhere (15). The fraction of Rr that results from regression towards the mean can be estimated. The percentage ofchildren in the highAtole and the high-Fresco groups who were misclassified as falling below the 90% weight-for-length of the standards (9), at the be-

variables

were

to the the mean

The

corrected for the odds

variables

were

pendent variable was a dichotomous variable indicating a child’s recovery within an interval from wasting as defined above. The independent variables were an indicator variable for treatment groups (high Atole and high Fresco), the potential confounding variables,

transformed toward

(13).

the corresponding confidence limits

point

to assess

wasting

then

by

the

wasting.

employed

were

ofregression

divided

of a cluster effect, both will be 1. The 95% confi-

by an approximation

coefficients and were used to obtain

is therefore

effect,

not guar-

to be or are suspected

from

a cluster

In the absence and the ratio

obtained

factor

correction

the procedure

were those variables with valbetween the high-Atole and

are known

was

The includes

does

confounding

variables

interval

that

which

variance. identical,

gistic-regression standard error ratios

clustering.

variance,

Effect

ABs.

However,

of recovery

potential

of

dence

low-Fresco,

their

similar

The

models

measured

at or

variables. The use of the with the high-Atole group

variables different

causes

of supplementation

were Atole)

the potential

groups.

groups

to be independent

who from

ofcomparison

as potential confounding ues that were significantly

for the

obtained

is no household actual

the binomial variances are

intake

low-Atole,

led to self-selection.

distribution

com-

the Rrs of 6-24-mo-

ofthe

of having

the comparison

high-Fresco

Rrs

as described

for the selection

if other

55th percentile of supplement differences between the Rrs

confounding comparison

likelihood

characteristics employed

the

were

potential group for

maximizes

the The

with

groups

been

of RDI

ofsupplement

there the

have

10%

AL

level

Rrs villages

villages effect

at the were

end 0.49

of 3-mo and

were 0.42 and 0.35 (

ofsupplementary

feeding

supplement

0.52

(

=

intervals

0.50)

0.38). The was 0. 12 (P =