Carla Danusa da Luz Santos

Long-Lasting Effects of Undernutrition

Undernutrition is one of the most important public health problems, affecting more than 900 million individuals around the World. It is responsible for the highest mortality rate in children and has long-lasting physiologic effects, including an increased susceptibility to fat accumulation mostly in the central region of the body, lower fat oxidation, lower resting and postprandial energy expenditure, insulin resistance in adulthood, hypertension, dyslipidaemia and a reduced capacity for manual work, among other impairments. Marked changes in the function of the autonomic nervous system have been described in undernourished experimental animals. Some of these effects seem to be epigenetic, passing on to the next generation. Undernutrition in children has been linked to poor mental development and school achievement as well as behavioural abnormalities. However, there is still a debate in the literature regarding whether some of these effects are permanent or reversible. Stunted children who had experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted. Children treated before 6 years of age in day-hospitals and who recovered in weight and height have normal body compositions, bone mineral densities and insulin production and sensitivity.

A baixa estatura leve está associada a índices mais elevados de gordura corporal: estudo de uma população de baixa renda

OBJECTIVE: To determine the impact of transferring a pediatric population to mechanical ventilator dependency units (MVDUs) or to home mechanical ventilation (HMV) on bed availability in the pediatric intensive care unit (ICU). METHODS: This is a longitudinal, retrospective study of hospitalized children who required prolonged mechanical ventilation at the MVDU located at the Hospital Auxiliar de Suzano, a secondary public hospital in Sao Paulo, Brazil. We calculated the number of days patients spent at MVDU and on HMV, and analyzed their survival rates with Kaplan-Meier estimator. RESULTS: Forty-one patients were admitted to the MVDU in 7.3 years. Median length of stay in this unit was 239 days (interquartile range = 102-479). Of these patients, 22 came from the ICU, where their transfer made available 8,643 bed-days (a mean of 14 new patients per month). HMV of eight patients made 4,022 bed-days available in the hospital in 4 years (a mean of 12 new patients per month in the ICU). Survival rates of patients at home were not significantly different from those observed in hospitalized patients. CONCLUSION: A hospital unit for mechanical ventilator-dependent patients and HMV can improve bed availability in ICUs. Survival rates of patients who receive HMV are not significantly different from those of patients who remain hospitalized.

Adolescents with Mild Stunting Show Alterations in Glucose and Insulin Metabolism

Purpose. To evaluate glucose and insulin profiles in adolescents with mild stunting and overweight in order to assess the possibility of increased predisposition to diabetes. Subjects and Methods. The study population consisted of 66 pubertal adolescents classified as mildly stunted (height-for-age z scores ≥−2 and <−1) or of normal stature, as well as overweight (body mass index ≥85th percentile) or normal weight. Beta-cell function and insulin resistance were evaluated according to the homeostasis model assessment (HOMA). Results. In the group with mild stunting, glucose, insulin, and HOMA-IR levels were significantly higher in overweight adolescents compared with those of normal weight, whereas HOMA-B levels were significantly lower. Adolescents with mild stunting showed significantly higher accumulations of body and abdominal fat than their normal stature counterparts. Conclusions. The presence of mild stunting was associated with higher levels of glucose and insulin, diminished function of beta cells, and increased insulin resistance. These results reinforce the need for intervention in adolescents with mild stunting.

Mild stunting is associated with higher body fat: study of a low-income population

OBJECTIVE To test if individuals having height-for-age z scores between -2 and -1 present higher body fat percentage and, therefore, should not be categorized as having normal nutritional status. METHODS The study involved 96 individuals (52 boys and 44 girls); 57% of whom had already attained puberty. Body composition was analyzed by dual energy X-ray absorptiometry. RESULTS The percentage of abdominal body fat in pre-pubertal stunted girls was higher (27.4%; p = 0.01) in comparison with their non-stunted counterparts (20.6%). Similar differences in abdominal fat content (%) were observed for pubertal stunted and non-stunted girls and boys (37.6 and 29.8%, respectively, p = 0.01; 24.6 and 15.7%, p = 0.01, respectively). The percentages of total body fat percent in pre-pubertal stunted girls and pubertal stunted boys (29.9 and 24.5%, p = 0.03; 26.3 and 18.1%, p = 0.01, respectively) were higher than those of their non-stunted counterparts. Non-stunted groups showed lower waist circumferences. CONCLUSION Adolescents with mild stunting exhibit alterations in body composition indicating increased risk of metabolic diseases.

Mild stunting is associated with higher blood pressure in overweight adolescents

BACKGROUND Studies have shown that pre/postnatal undernutrition leads to higher risk of non communicable diseases such as diabetes, hypertension and obesity in adulthood. OBJECTIVE To determine whether overweight adolescents with mild stunting [height-for-age Z scores (HAZ) in the range <-1 to ≥ -2] have higher blood pressure than overweight individuals with normal stature (HAZ ≥ -1). METHODS Participants were classified as mildly stunted or of normal stature, and further stratified according to body mass index-for-age percentiles as overweight, normal or underweight. Systolic (SBP) and diastolic (DPB) blood pressures were determined according to guidelines, and abdominal fat was analyzed by dual energy X-ray absorptiometry. RESULTS Mild stunted overweight individuals showed higher DBP values (p=0.001) than their underweight counterparts (69.75 ± 12.03 and 54.46 ± 11.24 mmHg, respectively), but similar to those of normal BMI. No differences were found in DBP values of normal, overweight and underweight individuals among the normal stature groups. An increase in SBP (p=0.01) among mild stunted individuals was found when those with overweight were compared to their underweight and normal BMI counterparts (114.70 ± 15.46, 97.38 ± 10.87 and 104.72 ± 12.24 mmHg, respectively). Although no differences were observed in the means of SBP between mild stunting and normal stature groups, a significant intercept was found (p=0.01), revealing higher SBP among stunted individuals. There was a correlation between SBP and abdominal fat (r=0.42, ρ=0.02) in the stunted group. CONCLUSION Stunted individuals with overweight showed higher SBP than those of normal stature and overweight. These findings confirm that mild stunting increase the risk of future hypertension and alterations are evident at early age.BACKGROUND: Studies have shown that pre/postnatal undernutrition leads to higher risk of non communicable diseases such as diabetes, hypertension and obesity in adulthood. OBJECTIVE: To determine whether overweight adolescents with mild stunting [height-for-age Z scores (HAZ) in the range -2] have higher blood pressure than overweight individuals with normal stature (HAZ >-1). MEHTODS: Participants were classified as mildly stunted or of normal stature, and further stratified according to body mass index-for-age percentiles as overweight, normal or underweight. Systolic (SBP) and diastolic (DPB) blood pressures were determined according to guidelines, and abdominal fat was analyzed by dual energy X-ray absorptiometry. RESULTS: Mild stunted overweight individuals showed higher DBP values (p=0.001) than their underweight counterparts (69.75 ± 12.03 and 54.46±11.24 mmHg, respectively), but similar to those of normal BMI. No differences were found in DBP values of normal, overweight and underweight individuals among the normal stature groups. An increase in SBP (p=0.01) among mild stunted individuals was found when those with overweight were compared to their underweight and normal BMI counterparts (114.70 ± 15.46, 97.38 ± 10.87 and 104.72 ± 12.24 mmHg, respectively). Although no differences were observed in the means of SBP between mild stunting and normal stature groups, a significant intercept was found (p=0.01), revealing higher SBP among stunted individuals. There was a correlation between SBP and abdominal fat (r=0.42, ρ=0.02) in the stunted group. CONCLUSION: Stunted individuals with overweight showed higher SBP than those of normal stature and overweight. These findings confirm that mild stunting increase the risk of future hypertension and alterations are evident at early age.

Índice de massa corporal de adolescentes: comparação entre diferentes referências

Objective: To compare the performance of the references (National Health and Nutrition Examination Survey I, National Center for Health Statistics/2000, International Obesity Task Force and Pesquisa Nacional sobre Saude e Nutricao) to assess the nutritional status of children and adolescents with the new reference of body mass index values proposed by the World Health Organization in 2007. Methods: Cross-sectional study that enrolled a nonprobabilistic sample of 5,122 children and adolescents of low socioeconomic status. In the matrix study, sample size was calculated in order to identify the association between blood pressure changes and stunting in different nutritional status. This interim report relates to the comparison among different references for assessment of nutritional status. Cochran’s Q, McNemar, chi-square and Kappa statistics were used to compare the proportion of underweight and overweight by different references and the agreement among them. Endereco para correspondencia: Ana Paula G. Clemente Rua Botucatu, 862, 2o andar CEP 04023-060 – Sao Paulo/SP E-mail: ana.clemente@unifesp.br Fonte financiadora: Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (Fapesp), processo 06/56218-0 Conflito de interesse: nada a declarar Recebido em: 18/3/2010 Aprovado em: 8/9/2010OBJETIVO: Comparar el desempeno de las referencias (NHA-NES I, NCHS/2000, IOTF y PNSN) para la evaluacion del estado nutricional de ninos y adolescentes con la nueva curva de valores del IMC, propuesta por la OMS en 2007. METODOS: Se trata de un estudio transversal cuya pobla-cion fue constituida por una muestra no probabilistica, con 5.122 ninos y adolescentes de bajos ingresos. Se realizo el calculo del tamano de la muestra visando a identificar la asociacion entre alteracion en la presion arterial y la baja estatura en los distintos estados nutricionales mediante la estadistica Odds Ratio. En el presente estudio, se compararon las distintas referencias para evaluacion del estado nutricio-nal. Se aplicaron las pruebas Q de Cochran, McNemar, chi cuadrado e indice Kappa para comparar las proporciones y la concordancia de la clasificacion de bajo peso y exceso de peso en las distintas referencias. RESULTADOS: Las cinco referencias utilizadas en el presente estudio presentaron diferencias entre si. Tanto para los ninos como para las ninas, las prevalencias estimadas de bajo peso por la referencia del PNSN son bastante menores que las otras referencias. Respecto a las prevalencias de exceso de peso para los ninos, se observo la prevalencia mayor por la referencia PNSN. Cuando se utilizo la prueba de Kappa, se encontro la concordancia excelente (k>0.75) entre la mayoria de las clasificaciones para exceso de peso analizadas. Sin embargo, la concordancia entre las clasificaciones para bajo peso se presentodebil (k<0.40), sobre todo en el sexo masculino cuando se realizo la siguiente comparacion: PNSN x OMS/2007. CONCLUSIONES: Los datos de este estudio indican que la nueva referencia OMS/2007 se muestra adecuada para la clasificacion de los disturbios nutricionales en los adoles-centes brasilenos.

Body mass index of adolescents: comparison among different references

Objective: To compare the performance of the references (National Health and Nutrition Examination Survey I, National Center for Health Statistics/2000, International Obesity Task Force and Pesquisa Nacional sobre Saude e Nutricao) to assess the nutritional status of children and adolescents with the new reference of body mass index values proposed by the World Health Organization in 2007. Methods: Cross-sectional study that enrolled a nonprobabilistic sample of 5,122 children and adolescents of low socioeconomic status. In the matrix study, sample size was calculated in order to identify the association between blood pressure changes and stunting in different nutritional status. This interim report relates to the comparison among different references for assessment of nutritional status. Cochran’s Q, McNemar, chi-square and Kappa statistics were used to compare the proportion of underweight and overweight by different references and the agreement among them. Endereco para correspondencia: Ana Paula G. Clemente Rua Botucatu, 862, 2o andar CEP 04023-060 – Sao Paulo/SP E-mail: ana.clemente@unifesp.br Fonte financiadora: Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (Fapesp), processo 06/56218-0 Conflito de interesse: nada a declarar Recebido em: 18/3/2010 Aprovado em: 8/9/2010OBJETIVO: Comparar el desempeno de las referencias (NHA-NES I, NCHS/2000, IOTF y PNSN) para la evaluacion del estado nutricional de ninos y adolescentes con la nueva curva de valores del IMC, propuesta por la OMS en 2007. METODOS: Se trata de un estudio transversal cuya pobla-cion fue constituida por una muestra no probabilistica, con 5.122 ninos y adolescentes de bajos ingresos. Se realizo el calculo del tamano de la muestra visando a identificar la asociacion entre alteracion en la presion arterial y la baja estatura en los distintos estados nutricionales mediante la estadistica Odds Ratio. En el presente estudio, se compararon las distintas referencias para evaluacion del estado nutricio-nal. Se aplicaron las pruebas Q de Cochran, McNemar, chi cuadrado e indice Kappa para comparar las proporciones y la concordancia de la clasificacion de bajo peso y exceso de peso en las distintas referencias. RESULTADOS: Las cinco referencias utilizadas en el presente estudio presentaron diferencias entre si. Tanto para los ninos como para las ninas, las prevalencias estimadas de bajo peso por la referencia del PNSN son bastante menores que las otras referencias. Respecto a las prevalencias de exceso de peso para los ninos, se observo la prevalencia mayor por la referencia PNSN. Cuando se utilizo la prueba de Kappa, se encontro la concordancia excelente (k>0.75) entre la mayoria de las clasificaciones para exceso de peso analizadas. Sin embargo, la concordancia entre las clasificaciones para bajo peso se presentodebil (k<0.40), sobre todo en el sexo masculino cuando se realizo la siguiente comparacion: PNSN x OMS/2007. CONCLUSIONES: Los datos de este estudio indican que la nueva referencia OMS/2007 se muestra adecuada para la clasificacion de los disturbios nutricionales en los adoles-centes brasilenos.

Influência do déficit de estatura nos desvios nutricionais em adolescentes e pré-adolescentes

OBJECTIVE: The objective of this study was to evaluate the influence of stunting on nutrition disorders in low-income preadolescents and adolescents. METHODS: Body mass index was calculated from the weight and height of 4 to 8th grade students from public schools. The tables from the National Center for Health Statistics of 2000 for children and adolescents were used as reference guides. Individuals were considered overweight when Body Mass Index-for-age >P85 and underweight when Body Mass Index-for-age <P5. Individuals were considered stunted when height-for-age was below one standard deviation. Overweight and underweight rates were compared between the non-stunted and stunted groups according to gender and age. RESULTS: A total of 3766 individuals were studied, 50.4% being females. Mean age was 12.8 years, with a standard deviation of 2.0 years and no significant difference between the groups. In the stunted group, overweight was more common among the older children. In the non-stunted group, the distribution by age was similar for all three Body Mass Index-for-age classifications. Distribution by gender shows that overweight in the stunted group prevailed among females (76.1%) while in the non-stunted group the difference was minimal between the genders (4.4%). CONCLUSION: In the stunted group, overweight was more common among those older than 12 years and among females. Non-stunted boys were overweight more often than stunted boys.

Lower waist circumference in mildly-stunted adolescents is associated with elevated insulin concentration

OBJECTIVE Augmented waist circumference (WC) is associated with non-communicable diseases and could represent a valuable marker in screening for metabolic dysfunctions in subjects with insufficient linear growth. The objective of the present study was to determine whether biochemical and hemodynamic parameters and waist circumference vary between mildly-stunted and non-stunted adolescents from impoverished communities of São Paulo, Brazil. METHODS The cross-sectional study involved 206 subjects, aged between 9 and 19 years and living in impoverished areas of São Paulo, Brazil. The sample population was divided according to height-for-age Z-score (HAZ) into stunted (-1 > HAZ ≥ -2) and non-stunted (HAZ ≥ -1) groups, and was sub-divided according to gender. Logistic regression analysis was employed to compare individuals with elevated (> 75th percentile) insulin concentrations. The receiver operating characteristic curves were constructed to determine WC cut-off points that could be used to identify stunted and non-stunted individuals with elevated insulin concentrations. RESULTS WC cut-off points of 58.25cm and 67.2cm allowed for correct classification of 90.7% of stunted and 88.7% of non-stunted individuals in the studied population. While the sensitivity of the model was high for stunted and non-stunted subjects (98.8% and 97.2%, respectively), the specificity was modest (57.1% and 41.2%, respectively). CONCLUSION The results presented herein suggest that an increase in plasma insulin is one of the primary metabolic modifications in stunted individuals, and that this alteration could be identified at a lower WC cut-off point than in non-stunted counterparts.

A baixa estatura leve está associada ao aumento da pressão arterial em adolescentes com sobrepeso

BACKGROUND Studies have shown that pre/postnatal undernutrition leads to higher risk of non communicable diseases such as diabetes, hypertension and obesity in adulthood. OBJECTIVE To determine whether overweight adolescents with mild stunting [height-for-age Z scores (HAZ) in the range <-1 to ≥ -2] have higher blood pressure than overweight individuals with normal stature (HAZ ≥ -1). METHODS Participants were classified as mildly stunted or of normal stature, and further stratified according to body mass index-for-age percentiles as overweight, normal or underweight. Systolic (SBP) and diastolic (DPB) blood pressures were determined according to guidelines, and abdominal fat was analyzed by dual energy X-ray absorptiometry. RESULTS Mild stunted overweight individuals showed higher DBP values (p=0.001) than their underweight counterparts (69.75 ± 12.03 and 54.46 ± 11.24 mmHg, respectively), but similar to those of normal BMI. No differences were found in DBP values of normal, overweight and underweight individuals among the normal stature groups. An increase in SBP (p=0.01) among mild stunted individuals was found when those with overweight were compared to their underweight and normal BMI counterparts (114.70 ± 15.46, 97.38 ± 10.87 and 104.72 ± 12.24 mmHg, respectively). Although no differences were observed in the means of SBP between mild stunting and normal stature groups, a significant intercept was found (p=0.01), revealing higher SBP among stunted individuals. There was a correlation between SBP and abdominal fat (r=0.42, ρ=0.02) in the stunted group. CONCLUSION Stunted individuals with overweight showed higher SBP than those of normal stature and overweight. These findings confirm that mild stunting increase the risk of future hypertension and alterations are evident at early age.BACKGROUND: Studies have shown that pre/postnatal undernutrition leads to higher risk of non communicable diseases such as diabetes, hypertension and obesity in adulthood. OBJECTIVE: To determine whether overweight adolescents with mild stunting [height-for-age Z scores (HAZ) in the range -2] have higher blood pressure than overweight individuals with normal stature (HAZ >-1). MEHTODS: Participants were classified as mildly stunted or of normal stature, and further stratified according to body mass index-for-age percentiles as overweight, normal or underweight. Systolic (SBP) and diastolic (DPB) blood pressures were determined according to guidelines, and abdominal fat was analyzed by dual energy X-ray absorptiometry. RESULTS: Mild stunted overweight individuals showed higher DBP values (p=0.001) than their underweight counterparts (69.75 ± 12.03 and 54.46±11.24 mmHg, respectively), but similar to those of normal BMI. No differences were found in DBP values of normal, overweight and underweight individuals among the normal stature groups. An increase in SBP (p=0.01) among mild stunted individuals was found when those with overweight were compared to their underweight and normal BMI counterparts (114.70 ± 15.46, 97.38 ± 10.87 and 104.72 ± 12.24 mmHg, respectively). Although no differences were observed in the means of SBP between mild stunting and normal stature groups, a significant intercept was found (p=0.01), revealing higher SBP among stunted individuals. There was a correlation between SBP and abdominal fat (r=0.42, ρ=0.02) in the stunted group. CONCLUSION: Stunted individuals with overweight showed higher SBP than those of normal stature and overweight. These findings confirm that mild stunting increase the risk of future hypertension and alterations are evident at early age.