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Anthropometric and nutritional assessment of the community of San Luis, Monteverde

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Title:
Anthropometric and nutritional assessment of the community of San Luis, Monteverde
Translated Title:
Valoración antropométrica y nutricional de la comunidad de San Luis, Monteverde ( )
Physical Description:
Book
Language:
English
Creator:
Bretnall, Ann
Publication Date:
Frequency:
normalized irregular

Subjects

Subjects / Keywords:
Nutrition--Costa Rica--Puntarenas--Monteverde--San Luis
Obesity in women--Costa Rica--Puntarenas--Monteverde--San Luis
Nutrition surveys--Costa Rica--Puntarenas--San Luis
Community Health 2001
Body measurement assessments
Genre:
Books/Reports/Directories
Books/Reports/Directories

Notes

Summary:
Findings and recommendations resulting from an anthropometric and nutritional study in San Luis, Monteverde, Puntarenas.
Summary:
Datos y recomendaciones del resultado de un estudio antropométrico y nutricional en San Luis, Monteverde, Puntarenas.
Abstract:
The Anthropometric and Nutritional Assessment aimed to collect and analyze anthropometric, nutrition, and hemoglobin levels, and to conduct a general clinical exam. This study was done at the San Luis Clinic on July 9, 2001. A 24 hour dietary recall survey of the mother and one child less than five years of age, who has been weaned, were conducted on July 10th and 11th, 2001, at the homes of people living in the San Luis area. Qualitative food frequency data and quantitative data were collected. The anthropometric data was analyzed in the computer programs Epi Info 2000, SPSS 10.0 for Windows, and Microsoft Excel. Food frequency data obtained from the dietary recall surveys was analyzed in Microsoft Excel. We found that malnutrition does not appear to be a problem in the sample studied, and that between 5% and 10% of boys and girls below the age of 12 are at risk for stunting. Young girls are more at risk for being overweight than boys, and women are much more likely to be obese than men. The results of the hemoglobin test indicate that anemia does not appear to be a problem in the community studied, although results are unclear for children under 3 years of age and pregnant women. The clinical exams detected low levels of goiter in women and children. The food frequency analysis indicated that the most common foods eaten were rice, beans, and café con leche. Oil and sugar were frequently used in the population studied. This analysis indicated that children are not getting enough of good quality protein, such as animal protein from red meat, milk and eggs, and that people’s diets tend to be low in vitamins A and C. Recommendations regarding healthy eating habits were made, as well asmore detailed recommendations for future research.
Abstract:
La valoración nutricional y antropométrica pretende recoger y analizar, los niveles antropológicos de nutrición, hemoglobina y realizar un examen clínico general. Este estudio fue hecho en el Centro de salud de San Luis, el 9 de julio del 2001. Una medición de 24 horas entre madres e hijos menores de 5 años, los cuales habían sido destetados, se realizó entre el 10 y el 11 de julio, en las casas de las familias de San Luis. Los datos de la frecuencia cualitativa y cuantitativa de los alimentos fueron recolectados. Los datos antropométricos fueron analizados en los siguientes programas computarizados Epi Info 2000, SPSS 10.0 for Windows, and Microsoft Excel. La frecuencia de los alimentos obtenidos de las dietas estudiadas fue analizada en Microsoft Excel. Encontramos que la desnutrición no parece ser un problema en las muestras estudiadas y que entre un 5 y un 10% de los niños y niñas menores a 12 años, están en riesgo de tener un crecimiento apropiado. Las niñassufren un mayor riesgo de volverse obesas que los niños, al igual que las mujeres en comparación con los hombres. Los resultados de las pruebas de hemoglobina indican que la anemia no parece ser un problema en la comunidad estudiada, a pesar de que los resultados no son muy claros para los niños menores a 3 años y las mujeres embarazadas. Los exámenes clínicos detectaron bajos niveles de ‘Bocio” en mujeres y niños. El análisis de los alimentos ingeridos con más frecuencia, señala que los más comunes son: arroz, frijoles, y café con leche. También el aceite y el azúcar fueron consumidos frecuentemente en la población estudiada. Este análisis indica que los niños no están consumiendo suficientes alimentos proteínicos de buena calidad, como lo son las carnes rojas, la leche, los huevos, y tampoco reciben suficiente vitaminas A y C. Se hicieron recomendaciones acerca de los hábitos alimenticios más saludables, tanto como otros detalles para futuras investigaciones.
Language:
EN

Record Information

Source Institution:
University of South Florida Library
Holding Location:
University of South Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
usfldc doi - M38-00002
usfldc handle - m38.2
System ID:
SFS0000196:00001


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The Anthropometric and Nutritional Assessment aimed to collect and analyze anthropometric, nutrition, and hemoglobin levels, and to conduct a general clinical exam. This study was done at the San Luis Clinic on July 9, 2001. A 24 hour dietary recall survey of the mother and one child less than five years of age, who has been weaned, were conducted on July 10th and 11th, 2001, at the homes of people living in the San Luis area. Qualitative food frequency data and quantitative data were collected. The anthropometric data was analyzed in the computer programs Epi Info 2000, SPSS 10.0 for Windows, and Microsoft Excel. Food frequency data obtained from the dietary recall surveys was analyzed in Microsoft Excel. We found that malnutrition does not appear to be a problem in the sample studied, and that between 5% and 10% of boys and girls below the age of 12 are at risk for stunting. Young girls are more at risk for being overweight than boys, and women are much more likely to be obese than men. The results of the hemoglobin test indicate that anemia does not appear to be a problem in the community studied, although results are unclear for children under 3 years of age and pregnant women. The clinical exams detected low levels of goiter in women and children. The food frequency analysis indicated that the most common foods eaten were rice, beans, and caf con leche. Oil and sugar were frequently used in the population studied. This analysis indicated that children are not getting enough of good quality protein, such as animal protein from red meat, milk and eggs, and that peoples diets tend to be low in vitamins A and C. Recommendations regarding healthy eating habits were made, as well asmore detailed recommendations for future research.
La valoracin nutricional y antropomtrica pretende recoger y analizar, los niveles antropolgicos de nutricin, hemoglobina y realizar un examen clnico general. Este estudio fue hecho en el Centro de salud de San Luis, el 9 de julio del 2001. Una medicin de 24 horas entre madres e hijos menores de 5 aos, los cuales haban sido destetados, se realiz entre el 10 y el 11 de julio, en las casas de las familias de San Luis. Los datos de la frecuencia cualitativa y cuantitativa de los alimentos fueron recolectados. Los datos antropomtricos fueron analizados en los siguientes programas computarizados Epi Info 2000, SPSS 10.0 for Windows, and Microsoft Excel. La frecuencia de los alimentos obtenidos de las dietas estudiadas fue analizada en Microsoft Excel. Encontramos que la desnutricin no parece ser un problema en las muestras estudiadas y que entre un 5 y un 10% de los nios y nias menores a 12 aos, estn en riesgo de tener un crecimiento apropiado. Las niassufren un mayor riesgo de volverse obesas que los nios, al igual que las mujeres en comparacin con los hombres. Los resultados de las pruebas de hemoglobina indican que la anemia no parece ser un problema en la comunidad estudiada, a pesar de que los resultados no son muy claros para los nios menores a 3 aos y las mujeres embarazadas. Los exmenes clnicos detectaron bajos niveles de Bocio en mujeres y nios. El anlisis de los alimentos ingeridos con ms frecuencia, seala que los ms comunes son: arroz, frijoles, y caf con leche. Tambin el aceite y el azcar fueron consumidos frecuentemente en la poblacin estudiada. Este anlisis indica que los nios no estn consumiendo suficientes alimentos protenicos de buena calidad, como lo son las carnes rojas, la leche, los huevos, y tampoco reciben suficiente vitaminas A y C. Se hicieron recomendaciones acerca de los hbitos alimenticios ms saludables, tanto como otros detalles para futuras investigaciones.
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Obesity in women--Costa Rica--Puntarenas--Monteverde--San Luis
Nutrition surveys--Costa Rica--Puntarenas--San Luis
Community Health 2001
Body measurement assessments
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Anthropometric and Nutritional Assessment of the Community of San Luis, Monteverde By Ann Bretnall Scarlett Hutchison Lourdes Rodriguez Claudia Sanchez Castillo Ann Smyntek Globalization, Nutrition, and Health Monteverde Institute June 24th to July 21st, 2001

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Abstract The Anthropometric and Nutritional Assessment aimed to collect and analyze anthropometric, nutrition, and hemoglobin levels, and to conduct a general clinical exam. This study was done at the San Luis Clinic on July 9, 2001. A 24 hour dietary recall survey of the mother and one child less than five years of age, who has been weaned, were conducted on July 10th and 11th, 2001, at the homes of people living in the San Luis area. Qualitative food frequency data and quantitative data were collected. The anthropometric data was analyzed in the computer programs Epi Info 2000, SPSS 10.0 for Windows, and Microsoft Excel. Food frequency data obtained from the dietary recall surveys was analyzed in Microsoft Excel. We found that malnutrition does not appear to be a problem in the sample studied, and that between 5% and 10% of boys and girls below the age of 12 are at risk for stunting. Young girls are more at risk for being overweight than boys, and women are much more likely to be obese than men. The results of the hemoglobin test indicate that anemia does not appear to be a problem in the community studied, although results are unclear for children under 3 years of age and pregnant women. The clinical exams detected low levels of goiter in women and children. The food frequency analysis indicated that the most common foods eaten were rice, beans, and caf con leche. Oil and sugar were frequently used in the population studied. This analysis indicated that children are not getting enough of good quality protein, such as animal protein from red meat, milk and eggs, and that people’s diets tend to be low in vitamins A and C. Recommendations regarding healthy eating habits were made, as well as more detailed recommendations for future research. Introduction The interdisciplinary research team for the Nutritional Assessment and Analysis project analyzed and reported on anthropometry and nutrition of the San Luis community. The teams were comprised of five individuals, who were further subdivided into two specific groups: Anthropometric Analysis and Nutritional Analysis. The Anthropometry Analysis team consisted of Ann Bretnall, an anthropology student from the University of South Florida, Ann Smyntek, a Public Health student from the Ohio State University, and Claudia Sanchez Castillo, a medical doctor and nutritional researcher from the National University of Mexico. The Nutritional Analysis group consisted of Scarlett Hutchison, a registered nurse and graduate anthropology student at the University of Alaska Fairbanks and Lourdes Rodriguez, a medical doctor and Pharmacological researcher at the Universidad de Morelos in Cuernavaca, Mexico. Both teams worked collaboratively throughout the project, sharing results and combining recommendations. This team undertook this research topic because of the opportunity to learn how to collect and analyze anthropometric and nutritional data. The group had the opportunity to provide tangible preliminary conclusions and recommendations to the community of the Monteverde Zone. The goals of this research project are twofold. First, we aim to raise awareness regarding people’s health and nutritional status. Secondly, we will attempt to provide education and motivation to change negative nutritional and health habits by offering simple and realizable recommendations to improve health and nutritional status, while encouraging healthy nutritional and health behaviors.

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Anthropometric Assessment of Nutritional Status in the Monteverde Zone Background of Nutrition in Costa Rica The health transition that Costa Rica underwent in the 1970s is almost unprecedented anywhere else in the world. Two measures which serve as indicators that a country is undergoing an epidemiological transition are infant mortality rate and life expectancy. In one decade – from 1970 to 1980 – the infant mortality rate declined by more than three fold, from 62 to 19 infant deaths per 1,000 live births. At the same time life expectancy has increased by 10 years, from 67 years in 1970 to 77 years in 1997. In addition, the incidence of children under five years of age suffering from under nutrition decreased by 11% in just four years, from 45% in 1978 to 34% in 1982 (United Nations University Press, 2000). The nutrition programs in existence in Costa Rica today have their roots in the complimentary food programs of the 1950s and 1960s. In 1966, a national nutritional survey was conducted in Costa Rica. The main nutritional deficiencies detected included deficiencies in vitamin A, protein, calories, iodine, and foliate. According to weight for age reference data, 57% of children had some degree of malnutrition. In addition, 18% of school children had endemic goiter (Muoz and Scrimshaw, 1995). In the early 1970s, Nutrition and Education Centers (CEN) were founded, in collaboration between CARE and local communities. The Family Allotment Fund was established in 1975, and as a result the Integrated Centers for Child Health Care (CINAI) were founded, with its primary function to ensure the nutrition of children aged 2 to 6 years. Since their respective inceptions, CEN and CINAI have been involved in numerous outreach and educational activities in the communities, including home visits, educational talks, and dissemination of nutritional information in both printed and broadcast media (Muoz and Scrimshaw, 1995). During the 1970s, the national and international push to fortify salt with iodine finally came to fruition when the Jose Figueres government came to power. In addition, in 1975, sugar was fortified with Vitamin A. By the end of the 1970s, these two successful food fortification initiatives had decreased the incidence of vitamin A and iodine deficiencies so greatly that they were no longer considered a public health problem (Muoz and Scrimshaw, 1995; United Nations University Press, 2000). Nutrition in the Monteverde Zone The Health Ministry and the National Health System known as the Caja appointed a doctor and part time nurse to the Monteverde Clinic in 1983. The clinic and its related services were improved throughout the years, and in 1995 the Monteverde Zone was established as a Health Sector, which allowed for the formation of the Equipo Bsico de Atencin Integral de Salud – Basic Team for Integral Health Attention (EBAIS) Monteverde. In 1997, the EBAIS Guacimal/San Luis was established, which allowed for the addition of a second doctor to the region. The Monteverde Clinic and its related EBAIS, along with the CEN and local health and nutrition committees, are the front line entities responsible for supplying nutritional information in the Monteverde Zone (Anlisis de Situacin de Salud, 2000).

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Description of the Community of San Luis San Luis is a community which is part of the Monteverde Zone with an approximate population of 3, 258 inhabitants. It is located in a very mountainous region, which is 1,450 meters above sea level at its highest point. It is about 7 km downhill from the town of Monteverde and the Monteverde Institute. The climate of the Monteverde Zone is humid and tropical, with average temperatures ranging between 15 and 25 degrees Celsius. The average yearly humidity is 79%, however the humidity reaches 100% during the rainy season (Anlisis de la Situacin de Salud de Monteverde, 2000). San Luis is located in the milk shed of the Monteverde Zone, which gives the local residents relatively ready access to milk products. Coffee is the major cash crop. Many men work in agriculture, while most women work in the home and/or are agricultural assistants. Research Methods This study incorporated anthropometric methods, a hematological study of anemia, clinical assessment of a number of nutritional deficiencies, including iodine deficiency, and a dietary recall survey. Anthropometry The term “nutritional anthropometry” has been defined as: “measurements of variations of the physical dimensions and the gross composition of the human body at different age levels and degrees of nutrition” (Gibson, 1990: 155). Today anthropometric measurements are widely used in the assessment of nutritional status, particularly when a chronic imbalance between intake of protein and energy occurs. Such disturbances modify the patterns of physical growth and the relative proportions of body tissues such as fat, muscle and total body water. Anthropometric measurements are of two types: growth and body, and composition measurements. The later can be further subdivided into measurements of body fat and fat free mass, the two major components of total body mass. Anthropometric indices can be derived directly from a single raw measurement (e.g. weight for age, height for age, etc.), or from a combination of raw measurements, such as weight and height, skinfold thickness at various sites, and/or limb circumferences. Some combinations (triceps skinfold and mid upper arm circumference) are used to derive prediction equations to estimate mid upper arm muscle area and mid upper arm fat area. The latter give an indication of the muscle mass and total fat content of the body, respectively. Anthropometric indices have advantages and limitations but can be used to monitor periodic changes in growth and/or body composition in individuals and in population groups. The most widely used anthropometric measurements of growth are those of stature (height or length) and body weight (Gibson, 1990). In population studies, the distribution of the anthropometric indices can be compared using percentiles and/or standard deviation scores derived from appropriate reference data. Percentiles are recommended for evaluating anthropometric indices of persons from industrialized countries. Standard deviation scores are preferred for less developed countries because the study population often has indices below the extreme percentiles of the international reference data population (US NCHS). As well, the proportion of individuals with indices below predetermined reference limits can also be determined.

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Standardized methods of evaluating anthropometric indices are essential for assessing the nutritional status of population groups and identifying malnourished individuals. The methods selected will depend on the objectives of the study and the facilities available for data handling. In population studies involving surveillance, or in cross sectional nutritional surveys, the data should be presented as frequency distributions of the anthropometric indices. The World Health Organization (WHO, 1983) recommends comparison of these distributions with the corresponding NCHS reference data. In addition, the proportion of individuals in the sample with indices below or above predetermined reference limits drawn from the appropriate reference data can be determined. To identify and classify malnourished individuals, the anthropometric indices can be compared with either predetermined reference limits or cutoff points which can classify an individual into one or more ‘risk’ categories indicative of the severity of malnutrition and/or mortality risk. Classification systems may also indicate the type of malnutrition. Hence, to evaluate anthropometric indices at both the individual and population level, appropriate reference data for each index are generally required. In population studies, the distribution of each anthropometric index can be compared using percentiles and/or standard deviation scores derived from the reference data. In either case, the distribution of the index for the study population can then be tabulated or presented graphically. Such an approach highlights critical features of the distribution of the study population. Only in cases where the sample size drawn from the target population is very small, should the mean or median value of the index by age and sex be compared with the corresponding mean or median value for the reference data. Standard Deviation Scores The use of standard deviation scores is recommended for evaluating anthropometric data from less industrialized countries. The method measures the deviation of the anthropometric measurements from the reference median in terms of standard deviations or Z scores. Standard deviation scores can be defined beyond the limits of the original reference data. Consequently, individuals with indices below the extreme percentiles of the reference data be classified accurately. The SD score, which is calculated for each subject within the sample, is a measure of an individual’s value with respect to the distribution of the reference population. The score is calculated using the following formula: SD score = Individual’s value median value of reference population Standard population value of reference population The reference limits used with SD scores vary; often scores of below 2 SD are designated as indicating risk of severe protein energy malnutrition, whereas scores above +2.0 are taken to indicate risk of obesity. Reference limits are comparable across al indices and at all ages, when based on the same standard deviation score values (e.g. 2.0 SD) (Waterlow, et al; 1977). Percentiles Percentiles can also be used for classifying individuals. The percentile for a subject of known age and sex can be calculated exactly, if the numerical percentile values are available for the reference data.

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Alternatively the percentile range within which the measurement of an individual falls can be read from graphs of the reference data. Depending on the reference data used, reference limits commonly used for designating individuals as ‘at risk’ to malnutrition are either below the 3rd or 5th percentiles or above the 97th or 95th percentiles (Gibson, 1990). Mid upper Arm Circumference Mid upper arm circumference for age is used in screening for protein energy malnutrition when weight and stature measurements are impossible and the precise age of the child is unknown. Arm circumference is relatively independent of age for children between one and five years and easy to measure. Both mid upper arm circumference by itself and in relation to age are used to assess wasting, a condition resulting from acute malnutrition and amenable to nutrition intervention. The mid upper arm cutoff points used to distinguish between normal and malnourished children vary. Sometimes a single cutoff point is chosen (e.g. 13.5 cm) for children aged one to five years. Alternatively, a series of cut off points, applicable to children aged from one to five years, can be used to classify degrees of malnutrition: Mid Upper Arm Circumference (cm) Category >13.5 Normal 12.5 – 13.5 Possibly mildly malnourished < 12.5 Malnourished When the index mid upper arm circumference for age is used instead of arm circumference alone, 85% or 80% of the reference median is commonly used as a reference limit. The Polish mid upper arm circumference reference data have been used (Wolanski, 1974). Single Skinfold Measurements to Assess Body Fat Skinfold thickness measurements are said to provide an estimate of the size of the subcutaneous fat depot, which in turn provides an estimate of the total body fat (Durnin and Rahaman, 1967). In general the triceps skinfold thickness (triceps SKF) has been the site most frequently selected for a single, indirect measure of body fat. This site, however, appears to be suitable for the assessment of percentage body fat in women and children only. Dietary Methodology Measures for studying community nutrition and health include dietary surveys and clinical exams. These measures may be used to assess the nutritional health of the individual, the family, and the community. These measures also aid nutritionists in making recommendations to improve health and clinical status within a community. Dietary surveys allow a more holistic assessment of an individual’s or family’s nutritional status,

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and its correlation to clinical manifestations, such as chronic and/or acute diseases, obesity, anemia, etc. Twenty four hour dietary recall is a method to assess nutritional intake and, optimally, should be repeated three times to provide an accurate representation of food intake. Dietary surveys are relatively inexpensive, easy to perform, and do not require specialized personnel. It is important to look for foods not recorded and to know the names and composition of local foods. Knowledge of the local language is crucial in understanding food intake. Both qualitative and quantitative data may be obtained through specific nutritional assessment questionnaires designed for an individual and/or family. Quantitative dietary surveys report the type and amount of food an individual or family consumes within a specific period of time. This type of survey requires the individual to report household measurements for each food consumed. These measures are then converted to grams and milliliters for analysis and comparison to food tables. Quantitative dietary surveys allow researchers to make more specific recommendations about the nutritional status of an individual or family. Qualitative dietary surveys are designed to determine what foods are consumed at each meal, as well as any snacks consumed between each meal. The data collected is then utilized to calculate food frequencies, and are compared with standard food groups and recommended guidelines. Once the food frequency analysis is completed and analyzed, appropriate recommendations can be made. Materials and Methods Anthropometry Anthropometric measurements were taken at the local health post facilities of the San Luis community, referred to as the San Luis Clinic. These measurements were collected by the Globalization, Nutrition, and Health class members studying at the Monteverde Institute. Skinfold thickness, mid upper arm circumference, weights, and heights were taken in adults. Body weight (Wt) was recorded in all subjects, who were asked to remove their shoes before weighing. Children under 2 years of age were held by their mother, and both were weighed together with a balance scale. Then the mother was re weighed without the child, her weight was recorded, and the difference between the 2 previous weights was recorded as the child’s weight. In adults and children over 2 years of age, the same balance scale was used to measure weight to the nearest 100g (Lohman et al, 1988). Height (Ht) was measured in meters (m), and subjects were asked to remove their shoes before measuring. In adults and children over 2 years of age, height was measured using a portable stadiometer attached to a platform with a graduation of 0.1m. In children less than 2 years of age, recumbent length (crown heel length) was measured with a wooden measuring length board (Infantmetro). Mid upper arm circumference (MUAC) was measured for all subjects, using a flexible plastic tape approximately 0.6 cm wide. Triceps skinfold was measured in all subjects as described by Durnin and Womersley (1974) with a Holtain skinfold caliper (CMS Weighing equipment LTD, 18 Camden High Street London NW1 OJH, UK). The triceps skinfold measurement was taken at the midpoint of the upper left arm, between the acromion process and the tip of the olecranon, with the arm hanging relaxed. To mark the midpoint, the left arm is bent 90 at the elbow and the forearm is placed palm down across the body. Then the tip of the acromion process of the shoulder blade at the outermost edge of the shoulder and the tip of the olecranon process of the ulna are located and marked. The distance between these two points is measured using a nonstretchable tape, and the

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midpoint is marked directly in line with the midpoint of the elbow and acromium process. The triceps skinfold measurement is made with the left arm extended so that it is hanging loosely by the side. Then the examiner grasps a vertical fold of skin plus the underlying fat, 1 cm above the marked midpoint, in line with the tip of the olecranon process, using the thumb and forefinger. The skinfold is gently pulled away from the underlying muscle tissue and then the caliper jaws applied at right angles, exactly at the marked midpoint. Several indices were used to classify malnutrition and over nutrition. In children of less than 18 years of age the weight for height (Wt Ht), weight for age (Wt Age) and height for age (Ht Age) indices were calculated from the CDC anthropometric reference standards (Jordan, 1986). These anthropometric indices were evaluated using the latest classification advocated by WHO, i.e. by the use of Z scores (WHO, 1983; 1995). The Z score scheme was then used to assess malnutrition in line with the concept advocated by Waterlow (1972). The reference limits of two standard deviations above and below the median of the NCHS reference data were taken (WHO, 1983). In adults 18 years of age and older, the Body Mass Index (BMI) was calculated as Wt (kg)/Ht2 (m2). BMI was used to assess overweight and obesity, as proposed by WHO (1995, 1997). Hematology Anemia is a problem mostly in tropical regions. It is associated with deficiencies in the physical and mental capacity of a population in general. For this reason its assessment was considered a priority in this field study. Trained individuals pricked a subject’s finger, and a curette was used to extract a small amount of capillary blood from both the adult and child population participating in the Monteverde Zone. The curette was then placed in the Hemocue system machine and the hemoglobin level was immediately available. Clinical Exam The clinical exam was performed by two medical doctors, who were primarily looking for functional signs of malnutrition, as well as any other chronic or acute infirmities. The doctors examined each subject’s hair, eyes, skin, fingernails, and the throat for goiters. Any abnormal findings were noted on the individual’s clinical report sheet. Nutritional Assessment For the purposes of this field work, mainly qualitative data was obtained on selected women and children in the Monteverde Zone. A 24 hour dietary recall survey was the tool selected for an initial assessment and analysis of food frequency patterns in women and children. The Globalization, Nutrition, and Health course members conducted a nutritional assessment of the mother and one child from 12 selected households in the San Luis area. The child surveyed should be less than 5 years of age and the second to the last child who has

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been weaned. The surveys were conducted during home visits to residents of the San Luis community during the mornings of July 10th and 11th, 2001. Twenty individuals were selected for the study which included 12 women between the ages of 19 and 71 years of age, and 8 children between the ages of 1 and 6 years of age. Dietary recall for the food consumed during the previous 24 hour period was collected about the female head of household and one of her children. Quantitative analysis was completed on two subjects, one adult woman and one child. Qualitative analysis was completed on all 12 adults and 8 children. The qualitative data was organized into a food pyramid and compared with the Traditional Healthy Latin American Diet Pyramid to determine deficiencies and/or excesses in the diet. In addition, a risk assessment was conducted with the food frequency data collected from the 12 adult women. Statistical Analysis The Statistical Package for Social Sciences, SPSS 10.0 for Windows (SPSS Inc. Chicago III) was the primary computer program used to conduct the analyses. In addition, Epi Info 2000, a statistical program developed by the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and Microsoft Excel were used to conduct statistical analyses. Findings Subjects The study included a total of 122 people, 36 women, 20 men, 40 girls and 26 boys, all between the ages of 8 months to 88 years. This was not a random sample but a self selected sample as the community was invited for their participation in our study. Demographic Information A total of 41 households were surveyed at the San Luis Clinic. The families came from three sectors of the San Luis community: San Luis Altos, including Finca la Bella and the Cataratas region, Invu, and San Luis Abajo. An analysis of the demographic data reported by the heads of households found that 60% of the men worked in agriculture, while 80% of the women worked in the home. Ninety five percent of the households surveyed consisted of married couples. Ninety eight percent of the households had running water, while 80% had toilets, and the other 20% had letrines. Mode of transportation, number of rooms in the house, and possession of a radio and/or television served as proxies for socioeconomic status. Half of the households surveyed had some sort of transportation, with the most common being a moto (63% of those who have some sort of transportation). The average number of rooms per household was 3.3, with the range between 2 and 8. Eighty five percent of households had a radio, and 72% had a television.

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Anthropometric Results The data collected from each of the sectors of the San Luis community were combined for statistical analyses. Tables 1 to 4 show the observed and derived values (mean + SD) of several anthropometric variables of both the adults and children. There were differences between males and females in most of the anthropometric indices, including height (Ht), weight (Wt), mid upper arm circumference (MUAC), skinfold, hemoglobin levels, and derived body mass index (BMI). In the measurements of the adults, men were, as expected, taller and heavier than women but when BMI was estimated, the women’s BMIs were substantially higher than the men’s. Excess adiposity was confirmed in the girls and women that had greater triceps values than the boys and men, the differences being greater in the adult group. Table 1: Frequencies of Adult Males (=>18) Height Weight MUAC Triceps SKF HGB BMI Age 2(y) N Valid 20 19 20 20 17 19 20 Missing 0 1 0 0 3 1 0 Mean 166.735 68.121 29.780 10.495 15.212 24.7732 44.588 Median 165.900 67.900 29.500 10.200 15.100 24.7000 38.958 Std. Deviation 7.967 12.277 2.680 4.007 1.061 2.9497 17.488 Minimum 153.3 50.5 24.7 4.6 13.6 20.00 20.0 Maximum 182.5 89.6 35.5 18.0 16.6 29.90 83.0 BMI: Body Mass Index; MUAC: mid upper arm circumference Table 2: Frequencies of Adult Females (=>18) Height Weight MUAC Triceps SKF HGB BMI Age 2(y) N Valid 34 32 34 34 34 32 34 Missing 0 2 0 0 0 2 0 Mean 155.671 66.194 34.221 21.862 14.059 27.1556 38.990 Std. Deviation 6.127 13.442 21.170 7.031 1.106 5.0928 12.586 Minimum 145.0 43.5 21.5 10.4 11.0 19.40 18.0 Maximum 168.2 90.3 150.8 35.0 16.4 36.10 66.3 BMI: Body Mass Index; MUAC: mid upper arm circumference Table 3: Boys Under 18 Years Height Weight MUAC Triceps SKF HGB Age(m) BMI N Valid 24 21 23 22 25 25 17 Missing 1 4 2 3 0 0 8 Mean 116.079 23.862 18.861 9.514 12.732 78.76 17.2741 Median 112.700 17.100 18.200 9.200 12.700 63.00 16.4000 Std. Deviation 27.521 15.905 3.483 2.337 1.305 49.59 2.7718 Minimum 68.5 7.1 14.4 5.0 10.3 8 14.60 Maximum 167.2 73.1 28.5 16.0 15.3 184 26.20 BMI: Body Mass Index; MUAC: mid upper arm circumference

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Table 4: Girls under 18 years Height Weight MUAC Triceps SKF HGB Age(m) BMI N Valid 40 40 38 32 40 41 35 Missing 1 1 3 9 1 0 6 Mean 121.895 28.363 19.908 11.769 12.913 95.44 18.1000 Median 121.100 22.400 19.100 11.300 12.700 91.00 16.6000 Mode 76.5 43.3 21.0 8.0 12.5 85 16.60 SD 22.785 15.074 4.054 3.606 1.104 50.52 4.0845 Minimum 76.5 10.3 13.9 7.2 11.0 18 13.80 Maximum 163.8 65.0 29.6 21.8 15.6 207 29.90 A Multiple modes exist. The smallest value is shown BMI: Body Mass Index; MUAC: mid upper arm circumference When the height and age for males and females of all ages were plotted, there is an indication of a trend, in which younger adult men and women are taller than older men and women, aged 50 and older (Figures 1 and 2). In the adult group 9 men (47%) and 5 women (16%) were overweight with BMIs of 25.0 29.9. There were 11 (36%) women defined as obese, with BMIs of 30 and above (Figure 3). The prevalence of obesity in women was particularly high in those 50 years of age and above (Figure 4).

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Figure 3: Percentage of Men and Women in each BMI Category Figure 4: Average BMI for Men and Women, by age and sex Our analysis and results, which included those of 27 girls and 19 boys aged 11 years and younger, showed that stunting, defined as a height for age Z score below 2, affected 3 girls (11%) and 1 boy (5.3%). In terms of the weight for height Z score, which can indicate the presence of wasting (an indication of under nutrition), only 2 girls (7.4%) and 1 boy (5.3%) had Z scores below 2 Z scores of the NCHS reference values. Only 1 boy, but no girls, classified in terms of their weight for age had weights below the 2 Z score, thus this was the expected proportion for a normal population (Figures 5 to 10).

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Hematological Assessment of Iron Status in San Luis, Monteverde Standard hemoglobin ranges in adult males are between 13 and 18 g/dl. In the population of men studied, their hemoglobin values ranged between 13.5 and 16.5 g/dl. The normal hemoglobin range in adult women is wider than that for men, between 11 and 16g/dl, and the range of hemoglobin among women studied was between 11 and 16.5 g/dl. Only one of 17 women studied had a hemoglobin value of 11 g/dl. All other women had hemoglobin levels of 13 g/dl or higher. Hemoglobin values in infants are lower than those in adults, ranging from 10 to 14 g/dl, and these values gradually increase to those of adults, as the child grows. The hemoglobin range of girls, age 11 and younger, was between 11 and 15.5 g/dl, and the range of boys in the same age group was between 10.5 to 15.5 g/dl (Figures 11 14).

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Clinical Assessment As noted previously, a clinical assessment was undertaken in the studied population. It is noteworthy to indicate that some cases of goiter were found in children under 5 years of age, in adolescents, and preteens. Some cases were also found in women, especially in those aged 50 or older. Dietary Findings Food frequency analysis of the 12 adult women demonstrates that white rice, beans, oil, and sugar are the foods most frequently consumed within a 24 hour period. White rice is consumed 29% of the time and beans are consumed 18% the time. Oil and sugar are used frequently in the preparation of various foods consumed (i.e. desserts, cookies, etc.). High protein foods, such as eggs and chicken, are consumed less frequently. Eggs are consumed only 8% of the time and chicken 5% of the time on a daily basis. In a comparison with the recommended daily food pyramid, the diet of these women may lack sufficient amounts of protein, fruits, and vegetables.

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Analysis of the daily beverage consumption of adult women shows frequent consumption of coffee (22%), fresco (22%), and Tang (18%). Milk (11%), high in protein, and fruit juice (7%), high in vitamins and micronutrients, are consumed less frequently than recommended by The Traditional Healthy Latin American Diet Pyramid (THLADP). Food frequency analysis of 8 children, aged 1 & to 6 years, similarly demonstrates frequent consumption of white rice (27%), beans (18%), sugar (17%), and oil (12%). The consumption of animal protein, eggs (8%), and chicken (<4%), is considerably less frequent than the recommended daily requirement. The consumption of fruits and vegetables are also less frequent than the recommended daily requirement. The daily beverage consumption of the children demonstrates frequent consumption of coffee (33%), milk (29%), and tang (13%). No consumption of fruit juice was recorded during the surveys. The children studied consumed proportionally more coffee than milk. Milk, a high protein food, should be consumed more frequently and in larger quantities by children according to the recommended Diet Pyramid. The Traditional Healthy Latin American Diet Pyramid provides guidelines for a nutritious, healthy diet by recommending the consumption frequency of different food groups. Food frequencies of the population studied were organized and placed in different levels on a diet pyramid for comparison with the Traditional Healthy Latin American Diet Pyramid. When the food frequencies of the population studied were compared with (THLAD), the findings suggest an inverse in food frequency consumption of many foods. Fruits and vegetables are consumed less frequently and placed at the top of the food pyramid instead of being consumed more frequently and placed on the bottom as recommended. Oil, sugar, and eggs are on the bottom of the food pyramid and are thus, consumed more frequently than recommended. Animal proteins are consumed less frequently than recommended. Quantitative Dietary Analysis Quantitative analysis of two 24 hour dietary surveys, 1 adult and 1 child, was done to determine the nutritional composition of the most frequently consumed foods. The amount of protein, carbohydrates, and fats, as well as the total amount of calories was calculated. Standardized tables were used to determine the dietary composition of frequently consumed foods. Quantitative analysis of the dietary intake for the adult woman shows protein intake was 34 grams and the total amount of calories consumed was 1, 033 Kcal. When compared with the recommended dietary allowances, protein and caloric intakes were below these recommendations. Protein consumption was only 66% of the daily requirements. Total caloric intake was only 53% of recommended daily requirements. Quantitative analysis of the dietary intake for the child shows protein intake was 62.25 grams and the total amount of calories consumed was 1467.2 Kcal. When compared with the dietary recommended allowances, protein consumption was 250% above the RDA. Caloric intake was below the RDA. Total caloric intake was only 83% of the RDA. A dietary risk questionnaire for chronic diseases was applied to 12 dietary surveys of adult women. Foods with protective properties and food with risky properties were included in the questionnaire to determine whether each woman consumed a risky diet or a protective diet. Analysis shows 62% of the women consumed a protective diet and 58% of the women consumed a risky diet.

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Discussion This investigation found that the sample studied was quite healthy overall. As we were unable to obtain any baseline data on the health status of the community of San Luis, we were not sure what to expect, but overall, were surprised and impressed about the positive health results obtained. The anthropometric and dietary data collected indicate that this community is undergoing an epidemiological transition, from a less developed to more developed region. From a nutritional standpoint, the relatively high incidence of obesity in women is one of the negative consequences of this epidemiological transition. Chronic diseases were not studied in this investigation, but we infer that the population will begin to suffer from more chronic diseases, in accord with the relatively high prevalence of obesity in women. Malnutrition, as measured by weight for age, does not appear to be a problem in the sample of children studied. There was only a limited amount of stunning detected in boys and girls less than 12 years of age. From the weight for age and weight for height information, it appears that girls have a greater tendency towards being overweight than boys. Women are much more likely to be obese than men, and older women tend to have higher BMIs than younger women, in part as a result of the onset of menopause. Although iron deficiencies, as measured by hemoglobin level, were not found in the studied group, there was a suggestion that there might be a risk of iron deficiency among children under 3 years of age in the area. A larger study is needed in women at reproductive age. We therefore suggest the intake of weekly iron supplement for mother and children. The discovery of some goiter in women and children during the clinical exam shows that iodine deficiency exists in the local ecology (i.e. soil, water, plants). Therefore, people should obtain their iodine requirements from other foods. It is well known that iodine deficiency, even a moderate one, affects the mental capacity of children. We therefore suggest that a local program of iodine supplementation be established in addition to the existing one of iodination of salt. This could be achieved by taking weekly iodine drop supplements. The food frequency data tend to support the anthropometric reports of obesity in women. Sugars and oils are frequently consumed, and fruits and vegetables are not being eaten as often as recommended by the Tradition Healthy Latin American Diet Pyramid. In addition, young children are not getting as much animal protein and vitamins A and C as recommended. Recommendations Recommendations for the Community Anthropometry Weight and health checks should be done every 2 months, between birth and 4 years of age. Control overweight and obesity with the doctor. Increased physical activity is important in regulating appetite and weight. Increase exercise, especially in women.

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Nutrition The traditional diet based on rice and beans could be considered good, but it is high in carbohydrates and moderate in protein. It is recommended to add some pasta, tortillas, and bananas to your diet, but not all of them at the same time, as there could be an excess of flours and starches. Eat less salt and sugar and more fruits and vegetables. Nutrition in infants and young children Start mixed feeding (breast milk and weaning foods – be sure to include fruit, vegetables, milk, and eggs) between 3 and 4 months of age. This will prevent the deficient infant growth. Before 4 years of age give the child milk at least twice a day. It would be good to regularly add animal products, such as meat, eggs, milk, and cheese, especially to children’s diets. At these ages give fruit and vegetables, especially green leaves every day. Anemia and Iodine Deficiencies Give every week, on Sundays, to women from the beginning of, or before, pregnancy and children from 8 months onward: 1 tablet of iron sulphate 5 drops of iodine solution (lugol) or other products with iodine. Recommendations for Future Research Rationale for the Need for Further Research The topic of nutritional status among members of the San Luis community, and its relationship to body composition and chronic disease ought to be explored more extensively and in more depth in future years. The present study was a pilot study, incorporating a small self selected sample of the San Luis community. In future years, more expansive anthropometric and nutritional studies ought to be conducted, in order to assure that the conclusions drawn, and consequent recommendations offered, are representative of the entire community of San Luis. The Ideal Composition of a Future Research Team Those who continue to work on this health topic in San Luis ought to work closely with the local health committee, and the people who work and/or volunteer at the San Luis Clinic. We recommend that an interdisciplinary team continue to work on this project. People in the fields of Public Health Anthropometry, and the applied health professions, including nursing and medicine, would be especially beneficial members of this research team. The research would be greatly enhanced if experts in the fields of anthropometry and

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nutrition were members of the research team, or if such individuals served as consultants and advisors to this research project. Benefits to the community The conclusions and recommendations stemming from this research project aim to directly benefit the community, by providing them with information regarding their current health status, as well as recommendations on how they can improve their health status through nutrition and exercise. This research team believes that one of the first steps to combating a health problem is to know that it exists, and that is what the anthropometric data and dietary recall surveys provide. The second step, is working to correct existing health problems, and we hope to begin this process by offering simple and realizable recommendations for improving health and nutritional status in families. The Need for Additional Data In order to provide a more thorough and complete nutritional and health analysis, a larger sample of the San Luis community needs to be studied, and this sample needs to be randomly selected, instead of a self selected sample of convenience. In addition, more information about body composition should be obtained from the skinfold and arm circumference measures. It is also important to incorporate more infants and young children into the study, especially children between 18 and 36 months, as this is the weaning period, and the period in which malnutrition can be best detected. Future Research Topics The possibilities of research topics in the areas of health and nutrition are almost endless. Before conducting further anthropometric and/or nutritional studies, the first step would be to conduct a thorough census of the San Luis area, and to obtain baseline demographic data. Once a census is completed, the primary topics of research that this group has identified are concentrated in the areas of obesity, particularly in women and girls, and chronic diseases. Another topic of study would be the prevalence of goiter, and related iodine deficiency in the community. In addition, a more involved dietary recall study, with more quantitative analysis would help more thoroughly assess the nutritional status of the San Luis community. Such a quantitative survey would also allow investigators to make individualized recommendations about eating a balanced diet.

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Reference Anlisis de Situacin de Salud, 2000. EBAIS No. 9, Monteverde. rea de Salud 3, Regin Pacifico Central. Caja Costarricense de Seguro Social. Durnin, J.V.G.A. & Rahaman, M.M., 1967. “The Assessment of the Amount of Fat in the Human Body from Measures of Skinfold Thickness”, British Journal of Nutrition, 21: 681 689. Gibson, R.S., 1990. Principles of Nutritional Assessment. Oxford University Press; Oxford, England. Jordan M.D., 1986. The CDC Anthropometric Software Package, Version 3.0. The Centers for Disease Control, Atlanta, Georgia 30333. Lohman T.G., Roche A.F. & Martorell R., eds., 1988. Anthropometrics Standardization Reference Manual. Human Kinetics Books, Champaign III. Muoz, C. & Scrimshaw, N.S., eds., 1995. The Nutrition and Health Transition of Democratic Costa Rica. International Foundation for Developing Countries, Boston, MA United Nations University Press, 2000. Food and Nutrition Bulletin. Supplement: Ending Malnutrition by 2020: An Agenda for Change in the Millennium, 21(3): 15 16. Waterlow J.C., 1972. “Classification and Definition of Protein Calorie Malnutrition”, British Medical Journal. 3: 566 569. Waterlow, J.C., Buzina, R., Keller, W., Lane, J.M., Nichaman, M.Z., & Tanner, J.M., 1977. “The Presentation and Use of Height and Weight Data for Comparing the Nutritional Status of Groups of Children Under the Age of 10 Years”, Bulletin of the World Health Organization. 55: 489 498. Wolanski, N.L., 1974. “Biological Reference Systems in the Assessment of Nutritional Status”, in Roche, A. F. & Falkner, F., eds. Nutrition and Malnutrition. Plenum Press, New York, pp. 231 269. World Health Organization, 1983. “Measuring Change in Nutritional Status”, Guidelines for Assessing the Nutritional Impact of Supplementary Feeding Programmes for Vulnerable Groups. World Health Organization, Geneva. World Health Organization, 1995. Physical Status: The Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. Geneva, World Health Organization, (WHO Technical Report Series, No. 854). World Health Organization, 1997. Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity. World Health Organization, Geneva.