Technical Report Interim Report on Child Nutrition Program in Redacted (June 2011- May 2013; growth data through

February 2013) May 8, 2013 Wuqu Kawoq 2 Calle 5-43 Zona 1, Santiago Sacatepquez, Guatemala peter@wuqukawoq.org Peter Rohloff

Background In June 2011, the WK team conducted a baseline demographic survey of the community of Redacted. This formed the basis for a community-based nutrition program with the following elements: 1. Supplementation of all children 6-59 months of age. Initially this was with Plumpydoz, transitioned to Chispitas in October 2012 according to Ministry of Health Guidelines. 2. Supplementation of all pregnant women, as above. 3. Deworming every 6 months. 4. Anemia testing every 6 months. Program Size, Retention, Process Outcomes There are currently 94 children enrolled in the program. This means that the program is maintaining its size. Our baseline survey in June 2011 identified 102 children in the target age range. Our interim report in October 2012 identified 96 children. Obviously, there has been turnover, as children have aged in and aged out of the program over time. One problem we identified in the last progress report was suboptimal recruitment of children aging in to the program. In June 2011, there were 27 children 6-24 months of age and only 18 children 6-24 months of age in December 2011 that were regularly showing up. However, in October 2012, this has increased to 28 children and, in January 2013, 24 children. Therefore, we conclude that the program is now adequately capturing eligible children once again. Coverage is also adequate. There have been three data collection time points since the last report, and 76% of children have data available for at least two of those time points (83% in October 2012). At the last distribution points for supplements, 72% of eligible children received supplements from our staff (74% in October 2012). We believe the coverage is better than this because supplements are left with local staff to give out to those who do not show up to distribution points, but documenting distribution by the womens committee has been spotty. Growth Data Here we compare baseline community data from December 2011 with data from January 2013. 1. Mean population level weight for age Z score for all children 6-59 months increased from -0.89 to -0.70 (not statistically significant at p=0.19) 2. Mean population level height for age Z score increased from -2.17 to -1.80 (highly statistically significant at p=0.03)

3. Population % severely stunted decreased from 26% to 12.5% (highly statistically significant at p=0.04) a 52% reduction in severe stunting. 4. Population overall stunting decreased from 57% to 41% (p=0.05, highly statistically significant), a 28% decrease in overall stunting. 5. Population overall underweight decreased from 14% to 5% (p=0.06, modestly statistically significant), a 64% reduction in underweight. We are quite happy with these results, and will continue to follow them over time. We are especially happy that we are seeing a differential improvement in population stunting versus underweight, indicating that we are effectively targeting our key metric (heightfor-age) while also not causing unnecessary weight gain. Micronutrient deficiencies The mean population hemoglobin has been checked three times, once in fall 2011 and again in spring 2012 and again in winter 2013. In all three occasions, the population average hemoglobin has been excellent: 12.6 mg/dl, 12.1 mg/dl, and 12.1 mg/dl, respectively. These values are not completely easy to interpret, because many parents opt out of blood testing for their children, so in many cases we do not have repeat blood tests on the same child at successive dates. However, when we looked at clinical cure rates for anemia in the fall of 2011 for the 25 children identified as being anemic, the clinical cure rate was 53%, and the mean change in hemoglobin was +2.5 mg/dl. Similarly between Fall 2012 and Winter 2013, we identified 10 children with clinical anemia. Among these 10 children, the clinical cure rate was 70%, with a mean change in hemoglobin of + 1.9 mg/dl (highly statistically significant, p=0.02). Conclusions The nutrition program is successful at reducing rates of stunting and severe stunting in the community. It does this without causing unnecessary weight gain in children who are normally weighted. Clinical anemia is also efficiently identified and treated in the community. The statistical analysis we present here is a real world test of the programs efficacy, because we have employed an intention-to-treat analysis in this progress report, meaning that childrens data is not censored from the analysis simply for not showing up or participating in the program consistently. This coming year, we will continue to improve our monitoring of process measures and will continue to monitor anthropometric, clinical, and hemoglobin data as indicated.