Fernanda Luisa Ceragioli Oliveira

Obesidade e fatores de risco cardiovascular em adolescentes de escolas públicas

BACKGROUND: Overweight in adolescence is a risk factor for the development of cardiovascular diseases in adulthood. OBJECTIVE: To study the association of cardiovascular risk factors (CRF) in overweight and normal-weight adolescents of both genders aged from 14 to 19 years, attending public schools. METHODS: Case-control study including 163 overweight and 151 normal-weight adolescents. Multiple logistic regression analysis was used to evaluate the associations between overweight and CRF (lipid profile, blood pressure and baseline insulin level). A set of CRF was defined for each individual, ranging from 0 (no risk factors) to 6 (all risk factors present). RESULTS: Overweight adolescents (body mass index > 85th percentile) presented a higher frequency of CRF in comparison to the normal- weight group. The CRF associated with overweight were HDLc 150 mg/dl (OR = 3.04; CI: 1.01-9.13), abnormal baseline insulin levels > 15 µU/ml (OR = 8.65; CI: 4.03-18.56) and abnormal blood pressure (OR = 3.69; CI: 1.76-7.72). Among overweight adolescents, 22.09% had more than three risk factors, whereas this percentage dropped to 6.12% among normal-weight adolescents. CONCLUSION: Overweight adolescents presented risk factors for cardiovascular diseases. The need for programs and policies targeted at the diagnosis and treatment of this condition is pointed out in order to reduce the risks of morbidity and mortality in adulthood.

Atherosclerosis prevention and treatment in children and adolescents.

The atherosclerotic process starts in childhood and studies show its development in fetuses. Clinical manifestation often occurs only in the sixth decade of life. Adolescence is a critical period in the development of atherosclerosis, because fatty streaks may change to transition plaque owing to genetic and environment factors. Healthcare by professionals plays a crucial role in the prevention and treatment of atherosclerosis, identifying poor lifestyle, positive family history of early cardiovascular disease, or other diseases such as dyslipidemia, obesity, arterial hypertension and diabetes. Dyslipidemia in childhood and adolescence should be treating by dietary therapy and change in lifestyle. Children with high-risk lipid abnormalities should be considered for drug treatment.

Interdisciplinary approach improves nutritional status of children with heart diseases.

OBJECTIVES We evaluated the role of an interdisciplinary team in improving the nutrient intake and nutritional status of children with heart diseases. METHODS Thirty-five children 10.0 +/- 7.5 mo old were studied over a 6-mo period with regard to anthropometric measurements and dietary intake. RESULTS On admission, malnutrition prevalence was 57% and vitamin and mineral intakes were below estimated average requirement levels (dietary reference intakes) in the majority of patients. Stunting and wasting were more frequent among patients with pulmonary hypertension and/or uncompensated congestive heart failure. Follow-up analyses showed increased Z scores of weight for height (-1.17 +/- 1.03 versus -0.32 +/- 1.08, P < 0.01) and height for age (-1.09 +/- 0.96 versus -0.51 +/- 1.36, P < 0.01). In patients with pulmonary hypertension or uncompensated congestive heart failure, the height-for-age index remained unchanged. Energy intake did not differ (112.0 +/- 20.4 and 119.0 +/- 18.0 kcal.kg(-1).d(-1)) and significant increases were seen in intakes of micronutrients and minerals over the study period. CONCLUSION Intervention by an interdisciplinary team improved the nutrient intake and nutritional status of patients overall but was insufficient to improve growth in the subgroup with pulmonary hypertension or uncompensated congestive heart failure. Nutritional support should be made routine in the treatment of children with heart disease.

Evolução nutricional de crianças hospitalizadas e sob acompanhamento nutricional

OBJECTIVE: This study aimed at evaluating the nutritional evolution of hospitalized children with infectious diseases, who were put under nutritional orientation. METHODS: Evaluate the effect of therapeutic nutritional orientation on 125 children between 6 and 36 months of age, who were admitted at the Pediatric Infectology Ward of the Hospital Sao Paulo, Sao Paulo, Brazil, between March 2001 and December 2002. The evaluations of nutritional status and energetic intake were based on data obtained from inquiry-forms on feeding-patterns and anthropometric measurements. RESULTS: Of the children being evaluated, 53,6% (67) were male. The mean age was 17 months, and the average period spent in the hospital was 10 days. At admission, 24,8% (31) of the children were undernourished and 10,0% (23) were overweight or obese. The diagnosis of acute diseases affected 69,6% (87) of the children. Nutritional support was provided for 21.6% (27) of the children, out of which, 81.5% (22) received nutritional support orally. The undernourished group presented a significant improvement of the Z-score of Weight over Height - Z W/H (p=0.001); the eutrophic group had no significant change of the Z-score Weight over Height (p=0.651), and the group overweight/obese showed a significant reduction of the Z-score Weight over Height (p=0.026). No significant associations were found between nutritional support therapy and improvement of the nutritional status (p=0.37). The children who had an energy intake higher than the one recommended for their age, had a significant improvement of the Z-score Weight over Height (p<0.001). CONCLUSION: The children followed up in this study had their nutritional condition significantly improved, making it evident that nutritional orientation, or diet therapy, can improve the treatment of hospitalized children.

Estado nutricional de crianças e adolescentes hospitalizados em enfermaria de cirurgia pediátrica

Objective: To evaluate the nutritional status, duration of hospital stay and clinical specialties of patients hospitalized in the Pediatric Surgery Unit of Sao Paulo Hospital, Unifesp-EPM. Methods: This cross-sectional retrospective study enrolled 749 children and adolescents of both genders admitted to the Pediatric Surgery Unit during the period of August 2007 to July 2008. The following data were collected: anthropometric variables, duration of hospital stay and surgical procedures. For nutritional status classification, the Z score for body mass index (Z BMI) and height-for-age (Z H/A) were used according to the World Health Organization growth chart (WHO, 2007). The 5Pediatra Nutrologa; Doutora em Pediatria e chefe do Setor de Suporte Nutricional da Disciplina de Nutrologia do Departamento de Pediatria da Unifesp-EPM, Sao Paulo, SP, Brasil Endereco para correspondencia: Fernanda Luisa C. Oliveira Rua Loefgreen, 1.647 – Vila Clementino CEP 04040-032 – Sao Paulo/SP E-mail: fernandalco.dped@epm.br Conflito de interesse: nada a declarar Recebido em: 17/3/2009 Aceito em: 30/6/2009 Rev Paul Pediatr 2010;28(1):41-7. Artigo OriginalObjective: To evaluate the nutritional status, duration of hospital stay and clinical specialties of patients hospitalized in the Pediatric Surgery Unit of Sao Paulo Hospital, Unifesp-EPM. Methods: This cross-sectional retrospective study enrolled 749 children and adolescents of both genders admitted to the Pediatric Surgery Unit during the period of August 2007 to July 2008. The following data were collected: anthropometric variables, duration of hospital stay and surgical procedures. For nutritional status classification, the Z score for body mass index (Z BMI) and height-for-age (Z H/A) were used according to the World Health Organization growth chart (WHO, 2007). The

Hepatic steatosis in a school population of overweight and obese adolescents

OBJECTIVE To assess hepatic steatosis by ultrasound method as a concomitant risk factor among overweight adolescents. METHODS A case-control study including 83 cases (47 overweight and 36 obese) and 89 controls (normal weight), frequency matched by gender, year of birth, pubertal stage (Tanner 4/5), and income. Cases and controls were selected from 1,420 students enrolled in a Vila Mariana public high school, in São Paulo, Brazil. Must et al. criteria were used for nutritional status classification. Nonalcoholic fatty liver disease was diagnosed through hepatic ultrasonography performed and analyzed by one radiologist. Hepatic enzymatic activities (alanine and aspartate transaminases, alkaline phosphatase, gamma-glutamyl transpeptidase) and direct bilirubin were measured. Eight covariables were fitted into logistic regression models; criterion for inclusion of variables was the association with overweight in the bivariate analyses (p < 0.20). A value of p < 0.05 was set as the criterion for inclusion into the final logistic regression models. RESULTS Prevalence of hepatic steatosis diagnosed through ultrasonography was 27.7% in overweight/obese students and 3.4% in normal weight students. Adjusted odds ratios (95%CI) for images compatible with nonalcoholic fatty liver disease and gamma-glutamyl transpeptidase > 24 U/L were 10.77 (2.45-47.22) and 4.18 (1.46-11.94), respectively. CONCLUSIONS This is the first population-based study showing that hepatic steatosis is strongly associated with overweight/obesity among adolescents attending a Brazilian public school. The diagnostic tool used in this investigation is a non-invasive method that might be applied to monitor overweight and obese adolescents and to propose actions for preventing more severe hepatic diseases in adulthood.

Body composition and lipodystrophy in prepubertal HIV-infected children

OBJECTIVE To identify lipodystrophy in prepubertal HIV-infected children using anthropometric parameters and body composition assessment. METHODS Cross-sectional study including 40 prepubertal HIV-infected children of both genders seen at the Care Center of the Division of Pediatric Infectious Diseases - Universidade Federal de São Paulo, São Paulo city, Brazil, was carried out from August to December 2008. Age, clinical and immunological status, prophylaxis, transmission and highly active antiretroviral therapy were recorded. Body mass index z-score and height-for-age z-score were calculated to characterize the nutritional status. Circumferences were measured with flexible tape and skinfolds were assessed by an adipometry. Fat mass and lean mass were determined by dual-energy X-ray absorptiometry. Presence of clinical signs of lipodystrophy was assessed by a trained clinician. Data were analyzed using SPSS 12.0 software. RESULTS The mean age and standard deviation were 9.8 (1.2) years, 50% were girls and 82.5% children from B and C categories. Clinical lipodystrophy and dislypidemia were present in 27.5% and 70%, respectively. The trunk to arm ratio and the limb to trunk ratio had positive association with lipodystrophy. Patients with lipodystrophy had short stature, higher triglycerides values and lower HDL-cholesterol. CONCLUSION The ratios obtained by skinfolds and dual-energy X-ray absorptiometry measurements can be considered as indicators of preclinical lipodystrophy. The cutoff points have not been determined yet; however, continuous assessment may be useful to identify early body composition changes.

Prevention of atherosclerosis and drug treatment of high-risk lipid abnormalities in children and adolescents

OBJECTIVE To discuss risk factors of atherosclerosis in pediatrics, dietary and physical activity guidelines, and, mainly, drug treatment of high-risk lipid abnormalities. SOURCES Data were obtained from articles indexed in MEDLINE, published over the last 5 years. SUMMARY OF THE FINDINGS Children with severe dyslipidemia or additional risk factors such as family history of early cardiovascular disease or other signs of metabolic syndrome may need treatment with hypolipidemic drugs. New recommendations from the U.S. guidelines indicate drug treatment before the age of 10 years according to the magnitude of the additional risk factors for cardiovascular disease. Pediatricians should know when to diagnose dyslipidemia, when to indicate drug treatment and which medication can be used in children and adolescents with the least risk or harm to their development. CONCLUSIONS The first-line treatment of dyslipidemia consists of lifestyle changes, focusing on prevention. Children with high-risk lipid abnormalities should be considered for drug treatment. Decisions to be made together with the parents must be evaluated taking into consideration risks and benefits of the medication to the patient.

Intrauterine energetic malnutrition in rats: skeletal muscle changes in the 1st and 2nd generations

OBJECTIVE: To study by histochemical analysis the skeletal muscle in malnourished newborn rats submitted to intrauterine malnutrition. METHODS: 90 days old female, Wistar EPM-1 rats, with 200 -/+ 20g body weight, malnourished during the gestation period were studied. At the 21th day of gestation, muscular biopsy was performed in the biceps bracchi of the newborns, obtained by cesarean (1st generation). One group of newborn intrauterine malnourished rats had nutritional recovery after birth by staying six/lactating rat and by free feeding up to the 90th day of life, when the females became pregnant and their offspring formed the 2nd generation. RESULTS: Weight gain during gestation and body weight of the newborn were significantly different when each malnourished group was compared to its respective control. The muscular biopsies of the malnourished newborns presented tissue involvement, characterized by loss of predominance of type II fibres, low oxidative activity, lessening of muscular fiber diameter, proliferation of intersticial tissue, and edema. In the 2nd generation, the newborns presented adequate body weight, but maintained muscular tissue involvement, with lessening of predominance of type II fibers, reduction of muscular fiber diameter, low oxidative activity, increase of intersticial space, necrosis, but without edema. CONCLUSION: The energetic malnutrition affects the skeletal muscle at birth, when it occurs during miogenesis, in both 1st and 2nd generation, maintaining permanent or temporary lesions in the muscular tissue.

Nutritional status of children and adolescents at diagnosis of hematological and solid malignancies

Objective To assess the nutritional status of child and adolescent patients with cancer at diagnosis. Methods A total of 1154 patients were included and divided into two groups: solid and hematological malignancies. The parameters used for nutritional assessment were weight, height, triceps skinfold thickness, mid-upper arm circumference, arm muscle circumference, body mass index and percentage weight loss. Results At diagnosis, below adequate body mass index was observed by anthropometric analysis in 10.85% of the patients – 12.2% in the solid tumor group and 9.52% in the hematologic group. The average weight loss adjusted for a period of 7 days was −2.82% in the hematologic group and −2.9% in the solid tumor group. Conclusions The prevalence of malnutrition is higher among patients with malignancies than in the general population, even though no difference was observed between the two groups.