Abstracts
OBJECTIVE:
To perform a review of studies of food consumption and nutritional adaptation in Brazilian infants pointing the main findings and limitations of these studies.
DATA SOURCE:
The articles were selected from Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) (Latin-American and Caribbean Literature in Health Sciences), Scientific Electronic Library Online (SciELO) and Science Direct in Portuguese and in English. The descriptors were: ''food consumption'', ''nutritional requirements'', ''infant nutrition'' and ''child''. The articles selected were read by two evaluators that decided upon their inclusion. The following were excluded: studies about children with pathologies; studies that approached only food practices or those adaptation of the food groups or the food offert; and studies that did not utilize the Dietary Reference Intakes (DRI).
DATA SYNTHESIS:
Were selected 16 studies published between 2003 and 2013. In the evaluation of the energy consumption, four studies presented energetic consumption above the individual necessities. The prevalence of micronutrients inadequacy ranged from 0.4% to 65% for iron, from 20% to 59.5% for vitamin A, from 20% to 99.4% for zinc, from 12.6% to 48.9% for calcium and from 9.6% 96.6% for vitamin C.
CONCLUSIONS:
The food consumption of Brazilian infants is characterized by high frequencies of inadequacy of micronutrients consumption, mainly iron, vitamin A and zinc. These inadequacies do not exist only as deficiencies, but also as excesses, as noted for energetic consumption.
Food consumption; Nutritional requirements; Infant nutrition; Child nutrition
OBJETIVO:
Fazer uma revisão de estudos sobre o consumo alimentar e adequação nutricional em crianças brasileiras e apontar os principais resultados e as principais limitações desses estudos.
FONTES DE DADOS:
Os artigos foram selecionados nas bases de dados da Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs), Scientific Electronic Library Online (SciELO) e Science Direct. Os descritores usados foram: "consumo alimentar" (food consumption), "necessidades nutricionais" (nutritional requirements), "nutrição do lactente" (infant nutrition) e "criança" (child). Os artigos selecionados nas bases de dados foram lidos por dois avaliadores que decidiram sobre a inclusão. Excluíram-se estudos de crianças com patologias; que abordavam apenas práticas alimentares; que analisaram adequação somente de grupos alimentares ou da alimentação oferecida; e os que não usaram as Dietary Reference Intakes (DRI). Buscaram-se artigos em português ou inglês e não se delimitou o período de busca.
SÍNTESE DOS DADOS:
Selecionaram-se 16 estudos, publicados entre 2003 e 2013. Na avaliação do consumo de energia, quatro estudos mostraram consumo energético acima das necessidades individuais. A prevalência de inadequação de micronutrientes variou de 0,4% a 65% para o ferro, 20% a 59,5% para a vitamina A, 20% a 99,4% para o zinco, 12,6% a 48,9% para o cálcio e de 9,6% a 96,6% para a vitamina C.
CONCLUSÕES:
O consumo alimentar de crianças brasileiras é marcado por frequências elevadas de inadequação no consumo de micronutrientes, sobretudo ferro, vitamina A e zinco. Essas inadequações não se apresentam apenas sob o aspecto da deficiência, mas também por meio de excessos, como observado para o consumo energético.
Consumo alimentar; Necessidades nutricionais; Nutrição do lactente; Nutrição da criança
Introduction
Children represent a group of highly vulnerable individuals, due to their rapid growth, physiological and immunological immaturity.11 Lima DB, Fujimori E, Borges AL, Silva MM. Feeding in the two first years of life. Rev Esc Enferm USP. 2011;45:1705-9. , 22 Palmeira PA, Santos SM, Vianna RP. Feeding practice among children under 24 mouths in the semi-arid area of Paraíba, Brazil. Rev Nutr. 2011;24:553-63. Adequate nutrition in the early years of life is essential for healthy growth and development.33 Fidelis CM, Osório MM. Dietary intake of macro and micronutrients by children under five years of age in the State of Pernambuco, Brazil. Rev Bras Saude Mater Infant. 2007;7:63-74. Inadequate nutrient consumption can impair the nutritional status, leading to the development of nutritional deficiencies or excesses.44 Cavalcante AA, Tinôco AL, Cotta RM, Ribeiro RC, Pereira CA, Franceschini SC. Food consumption and nutritional profile of children seen in public health services of Viçosa, Minas Gerais, Brazil. Rev Nutr. 2006;19:321-30.
Deficiency diseases increase children's susceptibility to diarrhea and infection and can
compromise the maturation of the nervous, visual, mental and intellectual systems.55 Bernardi JR, Cezaro CD, Fisberg RM, Fisberg M, Rodrigues GP, Vitolo MR.
Dietary micronutrient intake of preschool children at home and in kindergartens of
the municipality of Caxias do Sul (RS), Brazil. Rev Nutr.
2011;24:253-61. In Brazil, iron and vitamin A deficiencies are the
most often observed micronutrient deficiencies, representing a public health
problem.66 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento
de Atenção Básica. In: Programa Nacional de Suplementação de Ferro: manual de
condutas gerais. Brasília: Ministério de Saúde; 2013.
,
77 Miglioli TC, Fonseca VM, Gomes Junior SC, Lira PI, Batista Filho M.
Vitamin A deficiency in mothers and children in the state of Pernambuco. Cienc Saude
Colet. 2013;18:1427-40. Data from the National Demographic and Health
Survey (PNDS), carried out in 2006, show a prevalence of anemia of 20.9% and inadequate
levels of vitamin A in 17.4% of children younger than five years.88 Brasil. Ministério da Saúde. Centro Brasileiro de Análise e
Planejamento. PNDS 2006: dimensões do processo reprodutivo e da saúde da criança
Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pndscriancamulher.pdf.
Acessado em 20 mar 2014.
http://bvsms.saude.gov.br/bvs/publicacoe...
With the nutritional transition, obesity and overweight, which reflect excessive energy
consumption and / or insufficient energy expenditure, have shown a high prevalence in
the Brazilian pediatric population. The Household Budget Survey (2008-2009) demonstrated
the evolution of anthropometric indicators of Brazilian children aged five to nine
years, showing an increase of overweight of 10.9% in 1974-1975 to 34.8% in 2008-2009 in
boys and from 8.6% to 32% in girls, in the same period.99 Brasil. Instituto Brasileiro de Geografia e Estatística. Pesquisa de
Orçamentos Familiares 2008-2009: antropometria e estado nutricional de crianças,
adolescentes e adultos no Brasil. Disponível em:
http://ibge.gov.br/home/estatistica/populacao/condicaodevida/pof/20082009encaa/pof20082009encaa.pdf.
Acessado em 10 mar 2014.
http://ibge.gov.br/home/estatistica/popu...
Infant feeding practices should be able to provide enough food, with nutritional and sanitary quality, to meet the nutritional needs of children and ensure the development of their full potential.1010 Nejar FF, Segall-Corrêa AM, Rea MF, Vianna RP, Panigassi G. Breastfeeding patterns and ernergy adequacy. Cad Saude Publica. 2004;20:64-71. Proper nutrition in childhood contributes to the establishment of healthy eating habits, which will have an impact not only in the short term, but also in adulthood.33 Fidelis CM, Osório MM. Dietary intake of macro and micronutrients by children under five years of age in the State of Pernambuco, Brazil. Rev Bras Saude Mater Infant. 2007;7:63-74. Children with inadequate food intake since childhood tend to the early development of overweight and obesity, as well as other associated chronic diseases.1111 Oliveira S, Filha E, Araújo JS, Barbosa JS, Gaujac DP, Santos CF, Silva DG. Consumption of food groups among children attending the public health system of Aracaju, Northeast Brazil, in Sergipe. Rev Paul Pediatr. 2012;30:529-36. On the other hand, children submitted to optimal feeding practices reach their normal development and become healthier adults, with greater intellectual and productive capacity.1212 Penn H. Primeira infância: a visão do banco mundial. Cad Pesq. 2002;115:7-24.
Considering the importance of adequate dietary intake in childhood to reach the nutritional needs, this article aims to perform a systematic review of studies on food consumption and nutritional adequacy in Brazilian children, pointing out the main findings and limitations of these studies.
Method
This is a systematic review of the literature based on the analysis of studies related to food consumption and nutritional adequacy of Brazilian children. Articles were selected by searching the Latin American and Caribbean Literature on Health Sciences (LILACS), Scientific Electronic Library Online (SciELO) and Science Direct databases in December 2013. The descriptors used in the search for articles were chosen after consulting the "Descriptors in Health Sciences (DeCS)". The following descriptors and their combinations in Portuguese and English were used: "Food Consumption" ("Consumo Alimentar"), "nutritional requirements", ("Necessidades nutricionais"), "Infant nutrition" ("Nutrição do lactente") and Child (Criança).
This review included articles published in Portuguese and English, carried out with Brazilian children aged 0 to 10 years that addressed the subject of food consumption in childhood and nutritional adequacy in quantitative terms. There was no limitation regarding the year of publication of the articles. Studies with children with any type of pathology; those that addressed inadequate feeding practices without quantitatively expressing the inadequacies in nutrient intake; the ones that assessed the adequacy of food groups only, but not of nutrients; the ones that analyzed the food offered to children without verifying consumption; and manuscripts that did not use the Dietary Reference Intakes (DRI) to verify nutritional adequacy were excluded.
A total of 3,234 studies were identified in the database search. Subsequently, we performed an analysis by title to exclude repeated articles or articles that did not meet the predefined criteria, which resulted in 62 articles. After this phase, summaries or full texts were read in their entirety to verify the inclusion and exclusion criteria. The selected articles were read by two examiners who decided on their inclusion based on the eligibility criteria. Each examiner independently decided by "inclusion" or "exclusion" and discrepant results were reassessed by the examiners.
A total of 16 studies were selected for this review: 14 cross-sectional and two longitudinal studies, published between 2003 and 2013, which quantitatively evaluated dietary intake of Brazilian children (Fig. 1).
Results
Table 1 shows the methodological aspects concerning the site and types of studies, the dietary survey used to assess dietary intake, sample group and objectives of the assessed studies.
When assessing energy consumption in children, the studies by Cavalcante et al.,44 Cavalcante AA, Tinôco AL, Cotta RM, Ribeiro RC, Pereira CA, Franceschini SC. Food consumption and nutritional profile of children seen in public health services of Viçosa, Minas Gerais, Brazil. Rev Nutr. 2006;19:321-30. Antunes, Sichieri and Salles-Costa,1313 Antunes MM, Sichieri R, Salles-Costa R. Food intake among children under three years of age in area with high food insecurity. Cad Saude Publica. 2010;26:1642-50. Costa et al.1414 Costa EC, Silva SP, Lucena JR, Batista Filho M, Lira PI, Ribeiro MA, et al. Food consumption of children from cities with a low human development index in the Brazilian Northeast. Rev Nutr. 2011;24:395-405. and Tavares et al.1515 Tavares BM, Veiga GV, Yuyama LK, Bueno MB, Fisberg RM, Fisberg M. Nutritional status and energy and nutrients intakes of children attending day-care centers in the city of Manaus, Amazonas, Brazil: are there differences between public and private day-care centers. Rev Paul Pediatr. 2012;30:42-50. were the ones that showed energy consumption above the individual needs calculated by the Estimated Energy Requirements (EER). The studies by Spinelli et al.,1616 Spinelli MG, Goulart RM, Santos AL, Gumiero LD, Farhud CC, Freitas EB, et al. Consumo alimentar de crianças de 6 a 18 meses em creches. Rev Nutr. 2003;16:409-14. Fidelis and Osório33 Fidelis CM, Osório MM. Dietary intake of macro and micronutrients by children under five years of age in the State of Pernambuco, Brazil. Rev Bras Saude Mater Infant. 2007;7:63-74. and Gomes et al.1717 Gomes RC, Costa TH, Schmitz BA. Dietary assessment of pre-school children from Federal District Brazil. ALAN. 2010;60:168-74. highlight the protein intake above the recommended levels among the assessed children.
When assessing micronutrient intake, we observe that most studies demonstrate the inadequacy of iron, vitamin A and zinc levels. The prevalence of inadequacy ranged from 0.4% to 65% for iron, from 20.0% to 59.5% for vitamin A, from 20.0% to 99.4% for zinc, from 12.6% to 48.9% for calcium and from 9.6% to 96.6% for vitamin C. Table 2 shows the results of assessed studies.
In this article, eight studies assessed the dietary intake of institutionalized children, especially in public and private day care centers. Six publications used only one 24-hour recall record. Among the eight studies that applied weighed food records, five did so on a single day.
The study by Barbosa et al.1818 Barbosa RM, Soares EA, Lanzillotti HS. Assessment of nutrients intake of children in a charity daycare center: application of dietary reference intake. Rev Bras Saude Mater Infant. 2007;7:159-66. performed the calculation of the apparent adequacy in the analysis of food intake in 35 children in Paqueta-RJ. Among the other assessed studies, 15 used the Estimated Average Requirements (EAR) as the cutoff and only one used RDA (Recommended Dietary Allowance). Among the studies that estimated the prevalence of inadequate nutrient consumption based on EAR, only five made the adjustment for intra-individual variability.55 Bernardi JR, Cezaro CD, Fisberg RM, Fisberg M, Rodrigues GP, Vitolo MR. Dietary micronutrient intake of preschool children at home and in kindergartens of the municipality of Caxias do Sul (RS), Brazil. Rev Nutr. 2011;24:253-61. , 1414 Costa EC, Silva SP, Lucena JR, Batista Filho M, Lira PI, Ribeiro MA, et al. Food consumption of children from cities with a low human development index in the Brazilian Northeast. Rev Nutr. 2011;24:395-405. , 1515 Tavares BM, Veiga GV, Yuyama LK, Bueno MB, Fisberg RM, Fisberg M. Nutritional status and energy and nutrients intakes of children attending day-care centers in the city of Manaus, Amazonas, Brazil: are there differences between public and private day-care centers. Rev Paul Pediatr. 2012;30:42-50. , 1717 Gomes RC, Costa TH, Schmitz BA. Dietary assessment of pre-school children from Federal District Brazil. ALAN. 2010;60:168-74. , 1919 Bueno MB, Fisberg RM, Maximino P, Rodrigues GP, Fisberg M. Nutritional risk among Brazilian children 2 to 6 years old: a multicenter study. Nutrition. 2013;29:405-10.
Discussion
Among the studies that assessed children's energy intake,33 Fidelis CM, Osório MM. Dietary intake of macro and micronutrients by
children under five years of age in the State of Pernambuco, Brazil. Rev Bras Saude
Mater Infant. 2007;7:63-74.
4 Cavalcante AA, Tinôco AL, Cotta RM, Ribeiro RC, Pereira CA, Franceschini
SC. Food consumption and nutritional profile of children seen in public health
services of Viçosa, Minas Gerais, Brazil. Rev Nutr. 2006;19:321-30.
-
55 Bernardi JR, Cezaro CD, Fisberg RM, Fisberg M, Rodrigues GP, Vitolo MR.
Dietary micronutrient intake of preschool children at home and in kindergartens of
the municipality of Caxias do Sul (RS), Brazil. Rev Nutr.
2011;24:253-61.
,
1414 Costa EC, Silva SP, Lucena JR, Batista Filho M, Lira PI, Ribeiro MA, et
al. Food consumption of children from cities with a low human development index in
the Brazilian Northeast. Rev Nutr. 2011;24:395-405.
15 Tavares BM, Veiga GV, Yuyama LK, Bueno MB, Fisberg RM, Fisberg M.
Nutritional status and energy and nutrients intakes of children attending day-care
centers in the city of Manaus, Amazonas, Brazil: are there differences between public
and private day-care centers. Rev Paul Pediatr. 2012;30:42-50.
16 Spinelli MG, Goulart RM, Santos AL, Gumiero LD, Farhud CC, Freitas EB,
et al. Consumo alimentar de crianças de 6 a 18 meses em creches. Rev Nutr.
2003;16:409-14.
17 Gomes RC, Costa TH, Schmitz BA. Dietary assessment of pre-school
children from Federal District Brazil. ALAN. 2010;60:168-74.
18 Barbosa RM, Soares EA, Lanzillotti HS. Assessment of nutrients intake of
children in a charity daycare center: application of dietary reference intake. Rev
Bras Saude Mater Infant. 2007;7:159-66.
19 Bueno MB, Fisberg RM, Maximino P, Rodrigues GP, Fisberg M. Nutritional
risk among Brazilian children 2 to 6 years old: a multicenter study. Nutrition.
2013;29:405-10.
20 Menezes RC, Osório MM. Energy and protein intake and nutritional status
of children under five years of age in Pernambuco state, Brazil. Rev Nutr.
2007;20:337-47.
21 Alves G, Colauto EV, Fernandes JK, Zabine L, Nienow RC. Anthropometric
and food intake assessment of preschoolers in day-care centers in Umuarama, Paraná.
Arq Cienc Saude Unipar. 2008;12:119-26.
22 Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary
feeding: inappropriate practices in infants. J Pediatr (Rio J).
2010;86:196-201.
23 Martino HS, Ferreira AC, Pereira CN, Silva RR. Anthropometric evaluation
and food intake of preschool children at municipal educational centers, in South of
Minas Gerais State, Brazil. Cienc Saude Colet. 2010;15:551-8.
-
2424 Silva JV, Timóteo AK, Santos CD, Fontes G, Rocha EM. Food consumption of
children and adolescents living in an area of invasion in Maceio, Alagoas, Brazil.
Rev Bras Epidemiol. 2010;13:83-93. four showed energy consumption above the
individual requirements44 Cavalcante AA, Tinôco AL, Cotta RM, Ribeiro RC, Pereira CA, Franceschini
SC. Food consumption and nutritional profile of children seen in public health
services of Viçosa, Minas Gerais, Brazil. Rev Nutr. 2006;19:321-30.
,
1414 Costa EC, Silva SP, Lucena JR, Batista Filho M, Lira PI, Ribeiro MA, et
al. Food consumption of children from cities with a low human development index in
the Brazilian Northeast. Rev Nutr. 2011;24:395-405.
,
1515 Tavares BM, Veiga GV, Yuyama LK, Bueno MB, Fisberg RM, Fisberg M.
Nutritional status and energy and nutrients intakes of children attending day-care
centers in the city of Manaus, Amazonas, Brazil: are there differences between public
and private day-care centers. Rev Paul Pediatr. 2012;30:42-50.
,
1919 Bueno MB, Fisberg RM, Maximino P, Rodrigues GP, Fisberg M. Nutritional
risk among Brazilian children 2 to 6 years old: a multicenter study. Nutrition.
2013;29:405-10. and three33 Fidelis CM, Osório MM. Dietary intake of macro and micronutrients by
children under five years of age in the State of Pernambuco, Brazil. Rev Bras Saude
Mater Infant. 2007;7:63-74.
,
1616 Spinelli MG, Goulart RM, Santos AL, Gumiero LD, Farhud CC, Freitas EB,
et al. Consumo alimentar de crianças de 6 a 18 meses em creches. Rev Nutr.
2003;16:409-14.
,
2323 Martino HS, Ferreira AC, Pereira CN, Silva RR. Anthropometric evaluation
and food intake of preschool children at municipal educational centers, in South of
Minas Gerais State, Brazil. Cienc Saude Colet. 2010;15:551-8. showed insufficient energy intake among the
assessed children.
Costa et al.1414 Costa EC, Silva SP, Lucena JR, Batista Filho M, Lira PI, Ribeiro MA, et al. Food consumption of children from cities with a low human development index in the Brazilian Northeast. Rev Nutr. 2011;24:395-405. observed mean energy and macronutrient consumption above the recommended amounts, with the exception of children aged 7-11 months, who had inadequate energy consumption. The diet of these children was characterized as dull, with high consumption of sugar and fat, and low in micronutrients. Tavares et al.1515 Tavares BM, Veiga GV, Yuyama LK, Bueno MB, Fisberg RM, Fisberg M. Nutritional status and energy and nutrients intakes of children attending day-care centers in the city of Manaus, Amazonas, Brazil: are there differences between public and private day-care centers. Rev Paul Pediatr. 2012;30:42-50. emphasize that the high percentage of children with excess weight can be explained by the high energy intake observed in more than 40% of the children. As an effect of high energy consumption, there is a higher frequency of overweight and obesity, as well as micronutrient deficiencies due to poor diet quality.2626 Leão AL, Santos LC. Micronutrient consumption and overweight: is there a relationship. Rev Bras Epidemiol. 2012;15:85-95. The high protein intake observed in some studies is a marker of the diet quality of these children, as it may be a protective factor against protein-energy malnutrition.2020 Menezes RC, Osório MM. Energy and protein intake and nutritional status of children under five years of age in Pernambuco state, Brazil. Rev Nutr. 2007;20:337-47. In situations of unbalanced consumption of other macronutrients, protein can have its function diverted and used to supply energy.1616 Spinelli MG, Goulart RM, Santos AL, Gumiero LD, Farhud CC, Freitas EB, et al. Consumo alimentar de crianças de 6 a 18 meses em creches. Rev Nutr. 2003;16:409-14.
This review showed that micronutrient levels most often found to be inadequate in children were iron, vitamin A and zinc. Iron deficiency is associated with an increase in frequency and duration of infections, changes in growth and development, cognitive acquisition and intellectual performance impairment.2727 Bortolini GA, Vitolo MR. The impact of systematic dietary counseling during the first year of life on prevalence rates of anemia and iron deficiency at 12-16 months. J Pediatr (Rio J). 2012;88:33-9. Children are particularly at risk for this deficiency, mainly due to inadequate dietary habits during childhood. Some of the main ones are: delayed introduction of iron-rich foods (meats, for instance), weaning and early introduction of cow's milk.2828 Braga JA, Vitalle MS. Iron deficiency in infants and children. Rev Bras Hematol Hemoter. 2010;32 Suppl 2:38-44.
The low prevalence of exclusive breastfeeding up to six months of age in Brazil has been
documented in the literature2929 Carrascoza KC, Possobon RF, Ambrosano GM, Costa Júnior AL, Moraes AB.
Determinants of the exclusive breastfeeding abandonment in children assisted by
interdisciplinary program on breast feeding promotion. Cien Saude Colet.
2011;16:4139-46.
,
3030 Kaufmann CC, Albernaz EP, Silveira RB, Silva MB, Mascarenhas ML. Feeding
during the first three months of life for infants of a cohort in Pelotas, Rio Grande
do Sul, Brazil. Rev Paul Pediatr. 2012;30:157-65. and represents an important risk factor for
inadequate iron consumption. Breast milk is often replaced by cow's milk, which has
lower iron bioavailability, in addition to causing intestinal microbleeds.2828 Braga JA, Vitalle MS. Iron deficiency in infants and children. Rev Bras
Hematol Hemoter. 2010;32 Suppl 2:38-44. In Brazil, the prevalence of iron deficiency is
high, especially in children aged 6-24 months due to the increased need for this
micronutrient in this phase.66 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento
de Atenção Básica. In: Programa Nacional de Suplementação de Ferro: manual de
condutas gerais. Brasília: Ministério de Saúde; 2013.
,
3131 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento
de Atenção Básica. Careˆncias de micronutrientes. Cadernos de Atenção Básica. 20.
Brasília. Ministério da Saúde. 2007. Disponível em:
http://189.28.128.100/nutricao/docs/geral/abcad20.pdf
http://189.28.128.100/nutricao/docs/gera...
In order to fight this deficiency, the
Brazilian government has created the National Iron Supplementation Program, which
proposes preventive supplementation of this nutrient for children aged 6 to 18 months in
the entire country. Although this supplementation has occurred since 2005, currently the
prevalence of iron deficiency is still high.66 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento
de Atenção Básica. In: Programa Nacional de Suplementação de Ferro: manual de
condutas gerais. Brasília: Ministério de Saúde; 2013.
,
3232 Castro TG, Silva-Nunes M, Conde WL, Muniz PT, Cardoso MA. Anemia and
iron deficiency among schoolchildren in the Western Brazilian Amazon: prevalence and
associated factors. Cad Saude Publica. 2011;27:131-42. This demonstrates the complexity of the
nutritional adequacy of this nutrient, which is not limited to supplementation, but
requires a network of actions ranging from the increase in the population's level of
schooling to the promotion of exclusive breastfeeding until six months of age.3333 Bortolini GA, Vitolo MR. Low compliance with supplementary iron to
infants attending public health services. Pediatria (São Paulo).
2007;29:176-82.
Vitamin A deficiency is the leading cause of preventable blindness worldwide and even in milder cases, it can lead to a compromised immune system and increased childhood morbidity and mortality.77 Miglioli TC, Fonseca VM, Gomes Junior SC, Lira PI, Batista Filho M. Vitamin A deficiency in mothers and children in the state of Pernambuco. Cienc Saude Colet. 2013;18:1427-40. The study by Caetano et al.2222 Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary feeding: inappropriate practices in infants. J Pediatr (Rio J). 2010;86:196-201. demonstrated inadequate feeding practices, such as the short duration of exclusive breastfeeding, use of whole cow's milk and the early introduction of processed foods rich in lipids, sugar and salt to children aged 4-12 months. As a consequence of this diet, we observed a high prevalence of inadequacy for several micronutrients, including vitamin A. Similarly to the strategy adopted for iron, Brazil also created the Vitamin A Supplementation Program to fight deficiency of this vitamin. However, the prevalence of vitamin A deficiency remains high in Brazil, indicating the need for further actions that encourage greater consumption of this nutrient by Brazilian children.55 Bernardi JR, Cezaro CD, Fisberg RM, Fisberg M, Rodrigues GP, Vitolo MR. Dietary micronutrient intake of preschool children at home and in kindergartens of the municipality of Caxias do Sul (RS), Brazil. Rev Nutr. 2011;24:253-61.
From the sixth month, approximately 70% of the infant's iron and zinc requirements must be met through adequate complementary feeding.2222 Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary feeding: inappropriate practices in infants. J Pediatr (Rio J). 2010;86:196-201. Imbalances in complementary feeding can cause damage to the adequacy of zinc in children. The study by Palmeira et al.22 Palmeira PA, Santos SM, Vianna RP. Feeding practice among children under 24 mouths in the semi-arid area of Paraíba, Brazil. Rev Nutr. 2011;24:553-63. observed a higher intake of dairy meals instead of other foods. This dietary practice may involve the lower consumption of meats and thus impair the consumption of zinc, as these are the main source of this nutrient in the child's diet.3434 Cruz JB, Soares HF. Uma revisão sobre o zinco. Ensaios e C. 2011;15:207-22.
Analysis of institutionalized children's food intake was assessed in seven studies of this review. Martino et al.,2323 Martino HS, Ferreira AC, Pereira CN, Silva RR. Anthropometric evaluation and food intake of preschool children at municipal educational centers, in South of Minas Gerais State, Brazil. Cienc Saude Colet. 2010;15:551-8. when assessing children attending Municipal Educational Centers (EMC), found that the food consumption covered more than 70% of energy requirement and the distribution of macronutrients was adequate, although the intake of calcium and iron was inadequate. However, this study only evaluated the dietary intake of these children at the institution and not at home, where the intake can be supplemented and contribute to the achievement of these recommendations.3535 Longo-Silva G, Toloni MH, Goulart RM, Taddei JA. Evaluation of food consumption at public day care centers in São Paulo, Brazil. Rev Paul Pediatr. 2012;30:35-41.
Tavares et al.1515 Tavares BM, Veiga GV, Yuyama LK, Bueno MB, Fisberg RM, Fisberg M. Nutritional status and energy and nutrients intakes of children attending day-care centers in the city of Manaus, Amazonas, Brazil: are there differences between public and private day-care centers. Rev Paul Pediatr. 2012;30:42-50. observed that food consumption did not differ between public and private day care centers. The authors of this study point out that the nutritional adequacy of children is more often related to the frequency of attendance at the daycare than to the type of day care (public or private). In the study by Bernardi et al.,55 Bernardi JR, Cezaro CD, Fisberg RM, Fisberg M, Rodrigues GP, Vitolo MR. Dietary micronutrient intake of preschool children at home and in kindergartens of the municipality of Caxias do Sul (RS), Brazil. Rev Nutr. 2011;24:253-61. although children attending private schools had better consumption than the ones in public schools, the latter showed no risk at the intake, as the recommendations were reached with the food received at home. Therefore, the analysis of total dietary intake of these children, considering the school and home, did not differ between the types of school.
The studies by Alves et al.2121 Alves G, Colauto EV, Fernandes JK, Zabine L, Nienow RC. Anthropometric
and food intake assessment of preschoolers in day-care centers in Umuarama, Paraná.
Arq Cienc Saude Unipar. 2008;12:119-26. and Gomes et
al.1717 Gomes RC, Costa TH, Schmitz BA. Dietary assessment of pre-school
children from Federal District Brazil. ALAN. 2010;60:168-74. demonstrated the need to adapt the diet
consumed by children in the institutions. This indicates the need for greater caution
regarding the proposed feeding recommendations at the institutional level. The National
School Feeding Program (PNAE) is the oldest social program of the federal government and
constitutes an important government strategy to ensure Food and Nutrition Security among
the population.3636 Villar BS, Schwartzman F, Januario BL, Ramos JF. Situation of the
municipalities of São Paulo state in relation to the purchase of products directly
from family farms for the National School Feeding Program (PNAE). Rev Bras Epidemiol.
2013;16:223-6. One aim of the program is to
meet the nutritional needs of public school students during the period they are at
school, in order to contribute to the adequate development and learning, as well as to
improve school performance.3737 Brasil. Ministério da Educação. Fundação Nacional de Desenvolvimento da
Educação. Coordenação Geral do Programa Nacional de Alimentação Escolar. Manual de
orientação para a alimentação escolar na educação infantil, ensino fundamental,
ensino médio e na educação de jovens e adultos. 2a ed. Brasília: Ministério da Saúde;
2012. Disponível em:
http://www.fnde.gov.br/arquivos/category/110-alimentacao-e-nutricao?download=7669:manual-de-orientacao-sobre-alimentacao-escolar-nas-diferentes-etapas-de-ensino
http://www.fnde.gov.br/arquivos/category...
In day care centers
where children stay full-time, all the meals offered must provide at least 70% of the
daily nutritional needs. It is supposed that the 30% complementation occurs at home,
which can lead both to nutritional adequacy and excess, if there is no qualitative and
quantitative balance.3535 Longo-Silva G, Toloni MH, Goulart RM, Taddei JA. Evaluation of food
consumption at public day care centers in São Paulo, Brazil. Rev Paul Pediatr.
2012;30:35-41.
Children aged 7 months to 5 years that stay only part-time in the institution, must
receive two meals that provide 30% of the daily nutritional needs. For schoolchildren
aged 6 to 10 years, who usually stay at school part-time, 20% of the nutritional needs
must be provided. The reach of these percentages in the meals offered in day-care
centers and schools is an important action to contribute to the nutritional adequacy of
Brazilian children attending the public education network.3737 Brasil. Ministério da Educação. Fundação Nacional de Desenvolvimento da
Educação. Coordenação Geral do Programa Nacional de Alimentação Escolar. Manual de
orientação para a alimentação escolar na educação infantil, ensino fundamental,
ensino médio e na educação de jovens e adultos. 2a ed. Brasília: Ministério da Saúde;
2012. Disponível em:
http://www.fnde.gov.br/arquivos/category/110-alimentacao-e-nutricao?download=7669:manual-de-orientacao-sobre-alimentacao-escolar-nas-diferentes-etapas-de-ensino
http://www.fnde.gov.br/arquivos/category...
Studies carried out in institutions show very different results of nutritional adequacy depending on the type of school, but they seem to indicate that children that receive their meals at school are more protected from inadequacies in their total consumption. And as observed in the study by Barbosa et al., 1818 Barbosa RM, Soares EA, Lanzillotti HS. Assessment of nutrients intake of children in a charity daycare center: application of dietary reference intake. Rev Bras Saude Mater Infant. 2007;7:159-66. attending day care seems to improve the children's dietary profile.
It is noteworthy that the different methods used to analyze food intake in several studies is a factor that may contribute to result variability. The most often used tools were the 24-hour recall and weighed food record. It is essential to choose the most adequate method to assess dietary intake for increased estimate reliability. As no method of assessing dietary intake is free of errors, the choice of the dietary survey should take into account the aims of the study, age, gender and the agreement of the methods regarding their application and accuracy.3838 Fisberg RM, Slater B, Marchioni DM, Martini LA. Inquéritos alimentares: métodos e bases científicos. São Paulo: Manole; 2005. In this review, six studies associated more than one type of food intake assessment method. A combination of methods is commonly used in studies with children when they want to evaluate daily consumption in daycare and also at home.
The number of days of survey application is an important aspect to consider, as by increasing the number of days one can minimize the effects of intra-individual variability.3939 Verly Junior E, Cesar CL, Fisberg RM, Marchioni DM. Within-person variance of the energy and nutrient intake in adolescents: data adjustment in epidemiological studies. Rev Bras Epidemiol. 2013;16:170-7. In population studies, the application of 24-hour recalls for two nonconsecutive days seems to have similar results to applications for more days. To obtain the mean consumption by direct weighing, the application for 3 non-consecutive days is recommended.4040 Falcão-Gomes RC, Coelho AA, Schmitz BA. Characterization of dietary intake assessment studies in pre-school children. Rev Nutr. 2006;19:713-27. In this article, only two studies applied the 24-hour recalls for more than a day. It is noteworthy that the application of a single 24-hour recall or food record does not reflect the individual's usual intake and the use of repeated measures (repeating the survey with part of the sample) with correction of intra-individual variability is necessary to prevent under or overestimation of the results. The study by Verly-Jr et al.4141 Verly-Jr E, Castro MA, Fisberg RM, Marchioni DM. Precision of usual food intake estimates according to the percentage of individuals with a second dietary measurement. J Acad Nutr Diet. 2012;112:1015-20. investigated the accuracy of estimates of usual intake using different replication rates in different sample sizes. It was observed that it was necessary to repeat the measurement at least in 40% of the sample, as the accuracy of usual intake estimates decreased when low replication rates used were.
The calculation of the apparent adequacy allows estimating the level of reliability at what the intake of a nutrient meets the individual's need, comparing the reported intake and that the EAR.4242 Marchioni DM, Verly Junior E, Cesar CL, Fisberg RM. Assessment of nutrient intake adequacy in clinical practice. Rev Nutr. 2011;24:825-32. Therefore, it is necessary to consider the intra-individual variability, as food consumption of the same individual varies from day to day, as well as the variability of needs, because even at the same stage of life, there are differences in the needs of each individual.3939 Verly Junior E, Cesar CL, Fisberg RM, Marchioni DM. Within-person variance of the energy and nutrient intake in adolescents: data adjustment in epidemiological studies. Rev Bras Epidemiol. 2013;16:170-7. Recently, Castro et al.4343 Castro MA, Verly-Jr E, Fisberg M, Fisberg RM. Children's nutrient intake variability is affected by age and body weight status according to results from a Brazilian multicenter study. Rev Nutr. 2014;34:74-84. estimated values of intraand interpersonal variance for children aged 1-6 years through multilevel analysis, in addition to calculating the rate of variation and the number of days of dietary assessment of energy and nutrients, according to age and body weight. However, there are no Brazilian studies for the other age groups of children that have evaluated the intra-and interpersonal variability and, therefore, American data are still used. It is worth mentioning that this type of analysis should only be used for the evaluation of individuals, being inadequate for population groups.
One study was found2222 Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary feeding: inappropriate practices in infants. J Pediatr (Rio J). 2010;86:196-201. that used RDA values as a cutoff to calculate the prevalence of inadequate dietary intake. This is an inadequate method to evaluate the prevalence of inadequacies, as the RDA values refer to consumption goals and not need estimates. Therefore, it is possible that the results of this study overestimated the prevalence of inadequacy.
EAR represents the value of a nutrient intake that meets the mean estimated needs
according to the phase of life and gender.4444 National Research Council. Dietary reference intakes: applications in
dietary assessment. Washington: The National Academy Press; 2000.
,
4545 Slater B, Marchioni DL, Fisberg RM. Estimating prevalence of inadequate
nutritent intake. Rev Saude Publica. 2004;38:599-605. EAR, as a cutoff, is a simplified method of
probabilistic approach, which allows the assessment of inadequate consumption of
population groups.4545 Slater B, Marchioni DL, Fisberg RM. Estimating prevalence of inadequate
nutritent intake. Rev Saude Publica. 2004;38:599-605. Among the studies that
comprised this review, most used EAR as a cutoff to calculate the prevalence of
micronutrient inadequacy. This is the correct approach for group analysis; however, it
is necessary to perform control by intra-individual variability to obtain a better
estimate. To calculate the prevalence of inadequate consumption, it is necessary to
obtain the intrapersonal and interpersonal variances through the analysis of variance
(ANOVA).3838 Fisberg RM, Slater B, Marchioni DM, Martini LA. Inquéritos alimentares:
métodos e bases científicos. São Paulo: Manole; 2005. For that purpose, we need at least
two independent measurements of each individual's diet, i.e., assessment of food
consumption for at least two days. To remove the intra-individual variability, the
methods most often used are those of the National Research Council / Institute of
Medicine, Iowa State University, Iowa State University Foods, Best-Power and National
Cancer Institute.
4646 Dodd KW, Guenther PM, Freedman LS, Subar AF, Kipnis V, Midthune D, et
al. Statistical methods for estimating usual intake of nutrients and foods: a review
of the theory. J Am Diet Assoc. 2006;106:1640-50.
,
4747 Tooze JA, Kipnis V, Buckman DW, Carroll RJ, Freedman LS, Guenther PM, et
al. A mixedeffects model approach for estimating the distribution of usual intake of
nutrients: the NCI method. Stat Med. 2010;30:2857-68. After applying these methods, the adjusted
distribution reflects only the interpersonal variability.4242 Marchioni DM, Verly Junior E, Cesar CL, Fisberg RM. Assessment of
nutrient intake adequacy in clinical practice. Rev Nutr.
2011;24:825-32. Most studies33 Fidelis CM, Osório MM. Dietary intake of macro and micronutrients by
children under five years of age in the State of Pernambuco, Brazil. Rev Bras Saude
Mater Infant. 2007;7:63-74.
,
44 Cavalcante AA, Tinôco AL, Cotta RM, Ribeiro RC, Pereira CA, Franceschini
SC. Food consumption and nutritional profile of children seen in public health
services of Viçosa, Minas Gerais, Brazil. Rev Nutr. 2006;19:321-30.
,
1313 Antunes MM, Sichieri R, Salles-Costa R. Food intake among children under
three years of age in area with high food insecurity. Cad Saude Publica.
2010;26:1642-50.
,
1616 Spinelli MG, Goulart RM, Santos AL, Gumiero LD, Farhud CC, Freitas EB,
et al. Consumo alimentar de crianças de 6 a 18 meses em creches. Rev Nutr.
2003;16:409-14.
,
1818 Barbosa RM, Soares EA, Lanzillotti HS. Assessment of nutrients intake of
children in a charity daycare center: application of dietary reference intake. Rev
Bras Saude Mater Infant. 2007;7:159-66.
,
2020 Menezes RC, Osório MM. Energy and protein intake and nutritional status
of children under five years of age in Pernambuco state, Brazil. Rev Nutr.
2007;20:337-47.
21 Alves G, Colauto EV, Fernandes JK, Zabine L, Nienow RC. Anthropometric
and food intake assessment of preschoolers in day-care centers in Umuarama, Paraná.
Arq Cienc Saude Unipar. 2008;12:119-26.
22 Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary
feeding: inappropriate practices in infants. J Pediatr (Rio J).
2010;86:196-201.
23 Martino HS, Ferreira AC, Pereira CN, Silva RR. Anthropometric evaluation
and food intake of preschool children at municipal educational centers, in South of
Minas Gerais State, Brazil. Cienc Saude Colet. 2010;15:551-8.
24 Silva JV, Timóteo AK, Santos CD, Fontes G, Rocha EM. Food consumption of
children and adolescents living in an area of invasion in Maceio, Alagoas, Brazil.
Rev Bras Epidemiol. 2010;13:83-93.
-
2525 Paiva-Bandeira GT, Rios-Asciutti LS, Riveira AA, RodriguesGonçalves C,
Pordeus-de-Lima RC, Marinho-Albuquerque T, et al. The relationship between income and
children's habitual consumption of ß-carotene, vitamin C and vitamin E in food. Rev
Salud Publica. 2011;13:386-97. did not perform the intra-individual
variability control and, therefore, their results should be viewed with caution, as the
prevalence of inadequacy may be overestimated. Statistical adjustments for food
consumption analysis must be used to obtain more reliable results about the individuals'
usual consumption. Failure to use these techniques is an important limitation of some of
the analyzed studies.
The results of the studies compiled in this review can be considered representative of
Brazilian children, as they include several age ranges, socioeconomic strata, regions of
the country and urban and rural areas. The PNDS, carried out with a representative
sample of children younger than five years in the five Brazilian macroregions, in urban
and rural areas, found a high prevalence of anemia and inadequate levels of vitamin A,
characterizing public health problems.88 Brasil. Ministério da Saúde. Centro Brasileiro de Análise e
Planejamento. PNDS 2006: dimensões do processo reprodutivo e da saúde da criança
Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/pndscriancamulher.pdf.
Acessado em 20 mar 2014.
http://bvsms.saude.gov.br/bvs/publicacoe...
The
results of this study agree with those shown in the studies of this review; however,
they did not cover all age ranges of childhood and evaluated only the micronutrients
iron and vitamin A.
Conclusion
The dietary intake of Brazilian children shows high prevalence of inadequate consumption of micronutrients, especially iron, vitamin A and zinc. This inadequate consumption is not due only to deficiency, but also to excess, as observed for energy consumption in some studies of this review. This profile discloses the children's poor quality of the diet, which despite showing energy intake that is even higher than the recommended amounts, have significant nutritional deficiencies in terms of micronutrients.
The observed inadequacies are probably due to incorrect dietary practices in infancy, mainly represented by the early cessation of breastfeeding, inadequate introduction of complementary foods, excessive consumption of industrialized products that are rich in sugars, fat and salt.
Institutionalization seems to have a protective effect on children regarding the best nutritional adequacy, as they complement the meals provided at home. However, analysis of the studies does not allow us to conclude whether the type of school or daycare influences the nutritional adequacy.
Finally, it is noteworthy the difficulties comparing the studies due to the methodological differences between them, both in relation to the methods used in assessing the diet, as well as the result analysis.
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22Caetano MC, Ortiz TT, Silva SG, Souza FI, Sarni RO. Complementary feeding: inappropriate practices in infants. J Pediatr (Rio J). 2010;86:196-201.
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23Martino HS, Ferreira AC, Pereira CN, Silva RR. Anthropometric evaluation and food intake of preschool children at municipal educational centers, in South of Minas Gerais State, Brazil. Cienc Saude Colet. 2010;15:551-8.
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24Silva JV, Timóteo AK, Santos CD, Fontes G, Rocha EM. Food consumption of children and adolescents living in an area of invasion in Maceio, Alagoas, Brazil. Rev Bras Epidemiol. 2010;13:83-93.
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25Paiva-Bandeira GT, Rios-Asciutti LS, Riveira AA, RodriguesGonçalves C, Pordeus-de-Lima RC, Marinho-Albuquerque T, et al. The relationship between income and children's habitual consumption of ß-carotene, vitamin C and vitamin E in food. Rev Salud Publica. 2011;13:386-97.
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35Longo-Silva G, Toloni MH, Goulart RM, Taddei JA. Evaluation of food consumption at public day care centers in São Paulo, Brazil. Rev Paul Pediatr. 2012;30:35-41.
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36Villar BS, Schwartzman F, Januario BL, Ramos JF. Situation of the municipalities of São Paulo state in relation to the purchase of products directly from family farms for the National School Feeding Program (PNAE). Rev Bras Epidemiol. 2013;16:223-6.
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37Brasil. Ministério da Educação. Fundação Nacional de Desenvolvimento da Educação. Coordenação Geral do Programa Nacional de Alimentação Escolar. Manual de orientação para a alimentação escolar na educação infantil, ensino fundamental, ensino médio e na educação de jovens e adultos. 2a ed. Brasília: Ministério da Saúde; 2012. Disponível em: http://www.fnde.gov.br/arquivos/category/110-alimentacao-e-nutricao?download=7669:manual-de-orientacao-sobre-alimentacao-escolar-nas-diferentes-etapas-de-ensino
» http://www.fnde.gov.br/arquivos/category/110-alimentacao-e-nutricao?download=7669:manual-de-orientacao-sobre-alimentacao-escolar-nas-diferentes-etapas-de-ensino -
38Fisberg RM, Slater B, Marchioni DM, Martini LA. Inquéritos alimentares: métodos e bases científicos. São Paulo: Manole; 2005.
-
39Verly Junior E, Cesar CL, Fisberg RM, Marchioni DM. Within-person variance of the energy and nutrient intake in adolescents: data adjustment in epidemiological studies. Rev Bras Epidemiol. 2013;16:170-7.
-
40Falcão-Gomes RC, Coelho AA, Schmitz BA. Characterization of dietary intake assessment studies in pre-school children. Rev Nutr. 2006;19:713-27.
-
41Verly-Jr E, Castro MA, Fisberg RM, Marchioni DM. Precision of usual food intake estimates according to the percentage of individuals with a second dietary measurement. J Acad Nutr Diet. 2012;112:1015-20.
-
42Marchioni DM, Verly Junior E, Cesar CL, Fisberg RM. Assessment of nutrient intake adequacy in clinical practice. Rev Nutr. 2011;24:825-32.
-
43Castro MA, Verly-Jr E, Fisberg M, Fisberg RM. Children's nutrient intake variability is affected by age and body weight status according to results from a Brazilian multicenter study. Rev Nutr. 2014;34:74-84.
-
44National Research Council. Dietary reference intakes: applications in dietary assessment. Washington: The National Academy Press; 2000.
-
45Slater B, Marchioni DL, Fisberg RM. Estimating prevalence of inadequate nutritent intake. Rev Saude Publica. 2004;38:599-605.
-
46Dodd KW, Guenther PM, Freedman LS, Subar AF, Kipnis V, Midthune D, et al. Statistical methods for estimating usual intake of nutrients and foods: a review of the theory. J Am Diet Assoc. 2006;106:1640-50.
-
47Tooze JA, Kipnis V, Buckman DW, Carroll RJ, Freedman LS, Guenther PM, et al. A mixedeffects model approach for estimating the distribution of usual intake of nutrients: the NCI method. Stat Med. 2010;30:2857-68.
-
Funding This study did not receive funding.
Publication Dates
-
Publication in this collection
Apr-Jun 2015
History
-
Received
09 Apr 2014 -
Accepted
18 July 2014