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Prevalence and concordance in the prediction of excess body weight by two anthropometric criteria in adolescents of western Brazilian Amazon

Prevalência e concordância na predição de excesso de peso corporal por dois critérios antropométricos em adolescentes da Amazônia ocidental brasileira

Abstract

The aim of this study was to identify the prevalence and concordance of excess weight (BMI) and body fat (fat %) in adolescents of both sexes from cities of Rio Branco-AC and Porto Velho-RO. This study evaluated 4,310 adolescents, 2,167 from Rio Branco and 2,143 from Porto Velho. No difference (p=0.46) for excess weight between adolescents from Rio Branco (34.8%) and Porto Velho (33.8%) was observed. Fat percentage was significantly higher (p<0.01) in adolescents from Porto Velho (59.8%) compared to those from Rio Branco (44.3%). In intra-pubertal and pubertal stages, moderate concordance was identified (p<0.01) and in pre-pubertal stage, substantial concordance was observed (p<0.01). Thus, the findings of this study point out the adequacy of screening and diagnosis of obesity and overweight, which will enable earlier approach and treatment of adolescents.

Key words
Adolescents; Body fat; Body mass index; Overweight

Resumo

O objetivo deste estudo foi verificar a prevalência e a concordância de excesso de peso (IMC) e de gordura corporal (% gordura) em adolescentes de ambos os sexos das cidades de Rio Branco-AC e Porto Velho-RO. Participaram do estudo 4.310 adolescentes, sendo 2.167 de Rio Branco e 2.143 de Porto Velho. Não houve diferença (p=0,46) entre o excesso de peso nos adolescentes de Rio Branco (34.8%) e de Porto Velho (33.8%). O % gordura foi significativamente maior (p=<0,01) nos adolescentes de Porto Velho (59,8%) em relação aos de Rio Branco (44,3%). Nos estágios intra-púbere e púbere foram identificadas moderadas concordâncias (p=0,01) e no estádio pré-púbere foi observado substancial concordância (p=0,01). Assim, os achados do presente estudo apontam para a necessidade da adequação do rastreamento da obesidade e sobrepeso que possibilitará identificação mais precoce e tratamento dos adolescentes.

Palavras-chave
Adolescente; Gordura corporal; Índice de massa corporal; Sobrepeso

INTRODUCTION

Puberty represents a period in which changes in the mass distribution of adipose tissue orchestrated by sex hormones occur11 Cintra IP, Ferrari GL, Soares AC, Passos MA, Fisberg M, Vitalle MS. Body fat percentiles of Brazilian adolescents according to age and sexual maturation: a cross-sectional study. BMC Pediatr 2013;13:96.. Adolescents with excess body fat tend to become obese adults22 Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS. The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics 2005;115(1):22-7.. Thus, evaluating the nutritional status during the pubertal period has been recommended as a health indicator of the young population, allowing the identification of individuals at greater risk for the development of obesity.

National and international studies have revealed a high prevalence of both overweight and excess body fat in puberty33 Yuca SA, Yilmaz C, Cesur Y, Dogan M, Kaya A., Basaranoglu M. Prevalence of overweight and obesity in children and adolescents in eastern Turkey. J Clin Res Pediatr Endocrinol 2010;2(4):159-63.

4 Pinto ICS, Arruda IKG, Diniz AS, Cavalcanti AMTS. Prevalência de excesso de peso e obesidade abdominal, segundo parâmetros antropométricas, e associação commaturação sexual em adolescentes escolares. Cad Saude Publica 2010; 26(9): 1727-37.

5 Kotian MS, Kumar G, Kotian S. Prevalence and determinants of overweight and obesity among adolescent school children of south Karnataka, India. Assoc Community Med 2010;35(1):176-8.
-66 Durá-Travé T, Hualde-Olascoaga J, Garralda-Torres I. Overweight amongchildren in Navarra (Spain) and its impact on adolescence. Med Clin (Barc)2012;4;138(2):52-6.. Similar results have been reported in studies with children and adolescents in western Brazilian Amazon77 Farias ES, Santos AP, Farias-Júnior JC, Ferreira CRT, Carvalho WRG, Gonçalves EM, Guerra-Junior G. Excesso de peso e fatores associados em adolescentes. Rev Nutr 2012;25(2): 229-36.,88 Souza OF, Farias ES. Magreza e sobrepeso em escolares de Rio Branco, AC, Brasil. Rev Bras Crescimento Desenvolv Hum 2011;21(3):878-82..

Among anthropometric indicators, body composition has been widely used due to its objectivity. Equations for estimating body fat percentage (Fat%) through skinfolds have been validated for the diagnosis of nutritional status in children and adolescents99 Slaughter MH, Lohman TG, Boileau RA, Horswill CA, Stillman RJ, VanLoan MD, et al. Skinfold equations for estimation of body fatness in children and youth.Hum Biol 1988;60(5):709-23.. On the other hand, body mass index (BMI) is a widely used method for the diagnosis of overweight in populations due to its practicality and low cost. BMI is limited in the diagnosis of the main body components such as fat, bones, water and muscles1010 Lohman TG. Advances in body composition assessment. Champaign: Human Kinetics; 1992..

A study with adults has revealed discrepancy between overweight by BMI and overweight and excess fat by Fat% in adults1111 Rech CR, Petroski EL, Silva RCR, Silva JCN. Indicadores antropométricos de excesso de gordura corporal em mulheres. Rev Bras Med Esporte 2006;12(3): 119-24.. Similarly, moderate concordance between BMI indicators and fat percentage in the estimation of body adiposity was observed in children and adolescents1212 Al-Mohaimeed A, Ahmed S, Dandash K, Ismail MS, Saquib N. Concordance of obesity classification between body mass index and percent body fat among school children in Saudi Arabia. BMC Pediatr 2015;15:16.,1313 Antal M, Péter S, Biró L, Nagy K, Regöly-Mérei A, Arató G, Szabó C, Martos E. Prevalence of underweight, overweight and obesity on the basis of body mass index and body fat percentage in Hungarian schoolchildren: representative survey in metropolitan elementary schools. Ann Nutr Metab 2009;54(3):171-6..

Therefore, the aim of this study was to verify the prevalence and concordance of overweight by BMI and excess body fat by Fat% in adolescents of both sexes from the cities of Rio Branco (AC) and Porto Velho (RO).

METHODOLOGICAL PROCEDURES

This cross-sectional study was carried out with adolescents from the cities of Rio Branco (AC) and Porto Velho (RO) in the northern region of Brazil and located in southwestern Amazon. The study was approved by the Human Research Ethics Committee of the Federal University of Acre (UFAC) (CAAE: 23107.009169 / 2009-89) and Federal University of Rondônia (CAAE: 14190113.30000.5300).

The calculation to determine sample size was based on an estimated prevalence of 50% of overweight (overweight and obesity), a two-percentage-point sample error, 95% confidence level, and the representative sample of Rio Branco (AC) of 1,806 and Porto Velho (RO) of 1,786 high-school students in the age group of 14-18 years. Considering possible losses and refusals, 20% were added to this value, and the study was carried out with 2,167 and 2,143 students, respectively, with simple paired randomization between public and private schools, totaling 4,310 students.

The selection process of students took place in two stages: a stratified sampling proportional to the number of students in each school was initially carried out, and then a random sampling was carried out within each school, including all public and private schools of the cities of Rio Branco (AC) and Porto Velho (RO). This sampling process allowed each student to be equally likely to be drawn, with loss replacement of up to 20%.

The stage of sexual maturation was obtained by the self-evaluation method, using photographs and written description of the five stages of breast development stages for females (M1 - M5) and genitals for males (G1 - G5) according to Marshall and Tanner1414 Marshall WA, Tanner JM. Variation in the pattern of pubertal changes in boys. Arch Dis Child 1970; 45(239): 13-23.,1515 Marshall WA, Tanner JM. Variation in the pattern of pubertal changes in girls. Arch Dis Child 1969; 44(235): 291-303. and students were asked to chose the photograph that best reflects their stage of development. Girls were asked about the presence or absence of menarche. M1 and G1 = prepubertal; M2 and M3 without menarche and G2 and G3 = intra-pubertal; and M3 post-menarche or M4 and M5 and G4 or G5 = pubertal.

Based on weight and height measurements, BMI was determined by the following formula: [body mass (Kg)/height (m2)]. The classification of the nutritional status of adolescents was performed according to criteria proposed by the World Health Organization1616 Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Developmentof a WHO growth for school-aged children and adolescents. Bull World Health Organ 2007; 85(9):660-7.. The cutoff points used were: zBMI <1.0 (eutrophic) and zBMI> 1.0 (overweight = overweight + obese).

Fat% was calculated according to equations of Slaugther et al.99 Slaughter MH, Lohman TG, Boileau RA, Horswill CA, Stillman RJ, VanLoan MD, et al. Skinfold equations for estimation of body fatness in children and youth.Hum Biol 1988;60(5):709-23., which use triceps and subscapular skinfolds, considering sex, race (white and black) and sexual maturation. The cutoff points for excess fat were for males at ≥ 25 (with excess fat) and <25 (without excess fat); for females ≥ 30 (with excess fat) and <30 (without excess fat) 1010 Lohman TG. Advances in body composition assessment. Champaign: Human Kinetics; 1992..

Statistical analysis was performed using the SPSS 17.0® software. The chi-square test was used to compare the frequencies of groups with and without excess fat by zBMI and Fat% between cities, sex, type of school and sexual maturation. The Kappa index was used to verify the degree of concordance between zBMI and Fat% according to sexual maturation. Concordance values between 0 and 0.39 were considered weak, between 0.40 and 0.59, moderate, between 0.60 and 0.79, substantial, and above 0.80, excellent1717 Landis JR, Koch GG. The measurement of observer agreement for categorical. Biometrics 1977;33(1):159-74.. The significance level was 5%.

RESULTS

In this investigation, 4,310 adolescent students were evaluated. Of these, 2,167 were from the city of Rio Branco-AC and 2,143 from the city of Porto Velho-RO. The mean age was 15.65 ± 1.72 years, while the gender distribution was 46.7% for males and 53.3% for females.

The overall overweight prevalence was 34.3% (overweight 22.4% and obesity 11.8%). The overweight prevalence was 34.8% (overweight 22.7% and obesity 12.0%) in adolescents from the city of Rio Branco-AC and 33.8% (overweight 22.0% and obesity 11.7%) in adolescents from the city of Porto Velho-RO. On the other hand, the overall excess fat prevalence was 77.2%, being higher in the city of Porto Velho, 59.8% (Table 1).

Table 1
Excess weight (zBMI) and fat (Fat%) prevalence in students aged 14-18 years by city, sex, school type and pubertal stage of cities of Rio Branco (AC) 2010 and 2011 and Porto Old (RO) 2012 and 2013.

Table 1 shows the overweight and excess body fat prevalence among high school students aged 14-18 years by city, sex, school type and pubertal stage.

Adolescents had similar overweight prevalence between cities of Rio Branco and Porto Velho (p = 0.46).

Regarding excess body fat, adolescent students from Porto Velho showed prevalence almost 10% higher than students from Rio Branco. Between sexes, greater overweight prevalence was observed in males (p <0.01) and, on the contrary, higher excess fat in females. A gradual increase in excess weight and excess fat from the pre-pubertal to pubertal stage was also observed (p <0.01).

The degree of concordance between zBMI and Fat% according to sexual maturation at all stages was 0.42 (moderate), 0.67 (substantial) in the prepubertal group, 0.53 (moderate) in the intra-group and 0.41 (moderate) in the pubertal group (Table 2).

Table 2
Concordance between zBMI and Fat% in 4,310 students aged 14-18 years according to sexual maturation of the city of Rio Branco (AC) 2010 and 2011 and Porto Velho (RO) 2012 and 2013.

DISCUSSION

This research evidenced overweight prevalence of 34.3% and 33.8% of excess fat prevalence of 48.3% and 59.8% in students from the cities of Rio Branco (AC) and Porto Velho (RO). Excess weight and excess fat indicators presented moderate concordance in the intra-pubertal and pubertal stages, whereas in the pre-pubertal stage, substantial concordance was evidenced.

The high overweight and Fat% prevalence is consistent with results of investigations carried out in Brazil. In the city of Presidente Prudente (SP), Fernandes et al.1818 Fernandes RA, Codgno JS, Cardoso JR, Ronque ERV, Freitas Junior IF, Oliveira AR. Fatores associados ao excesso de peso entre adolescentes de diferentes redes deensino do município de Presidente Prudente, São Paulo. Rev Bras Saude Matern Infant 2009;9(4):443–9. identified high overweight prevalence of 32.6% in adolescents aged 11-17 years from private schools. Likewise, Brasil et al.1919 Brasil LMP, Fisberg M, Maranhão HS. Excesso de peso de escolares em região do Nordeste Brasileiro: contraste entre as redes de ensino pública e privada. Rev Bras Saude Mater Infant 2007;7(4):405-12. evaluated 1,927 students aged 6-11 years in the city of Natal (Brazil) and found overweight prevalence of 33.6%. In Rio Branco (AC), a study carried out with students from the initial grades of elementary school showed overweight prevalence of 22.5%2020 Melo ME, Miguéis GL, Almeida MS, Dalamaria t. Souza OF. Sobrepeso eobesidade em escolares das séries iniciais do ensino fundamental de rio branco, acre: uma comparação entre referenciais. Rev Bras Crescimento Desenvolv Hum 2016;26(3):341-4..

International studies have shown overweight prevalence similar to that of the present study. In southern India55 Kotian MS, Kumar G, Kotian S. Prevalence and determinants of overweight and obesity among adolescent school children of south Karnataka, India. Assoc Community Med 2010;35(1):176-8., adolescents showed overweight prevalence of 29.3%. Likewise, adolescents from Canada2121 Rao DP, Kropac E, Do MT, Roberts KC, Jayaraman GC. Childhood overweight and obesity trends in Canada. Health Promot Chronic Dis Prev Can 2016;36(9):194-8. (31.4%) and the United States2222 Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311(8):806-14. (34.9%) showed high overweight prevalence.

In this study, the overweight prevalence was higher in male adolescents and excess fat was higher in females. These differences can be explained by changes in body composition that occur differently between sexes. Loomba-Albrecht and Styne2323 Loomba-Albrecht LA, Styne DM. Effect of puberty on body composition. Curr Opin Endocrinol Diabetes Obes 2009;16(1):10-5. and Veldhuis et al.2424 Veldhuis JD, Roemmich JN, Richmond EJ, Rogol AD, Lovejoy JC, Sheffield-Moore M, et al. Endocrine Control of Body Composition in Infancy, Childhood, and Puberty. Endocr Rev 2005; 26(1):114-46. showed that women have a gradual increase in Fat% throughout adolescence, with evolution from 15% at 9 years to 25% after menarche, while male adolescents have a decrease in speed of body fat gain, reaching in the adult life with Fat% of approximately 13%. On the other hand, lean body mass in females shows a decrease in growth velocity at 12 years and becomes stable at 15-16 years. Males show gain of lean body mass until the age of approximately 17-19 years2323 Loomba-Albrecht LA, Styne DM. Effect of puberty on body composition. Curr Opin Endocrinol Diabetes Obes 2009;16(1):10-5..

In the present study, overweight was more prevalent in adolescents from private schools. Similarly, studies conducted in southern Brazil by Suñe et al.2525 Suñé FR, Dias-da-Costa JS, Olinto MT, Pattussi MP. Prevalence of overweight and obesity and associated factors among schoolchildren in a southern Brazilian city. Cad Saude Publica 2007; 23(6): 1361-71. and Vieira et al.2626 Vieira MF, Araújo CL, Hallal PC, Madruga SW, Neutzling MB, Matijasevich A, et al. Nutritional status of first to fourth-grade students of urban schools in Pelotas, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008;24(7):1667-74. showed higher overweight prevalence in students from private schools in contrast to students from public schools. Hobold and Arruda2727 Hobold E, Arruda M. Prevalência de sobrepeso e obesidade em estudantes: Relaçãoentre nível socioeconômico, sexo e idade. Rev Bras Cineantropom Desempenho Hum 2015, 17(2):156-64 found higher overweight and obesity prevalence in students who belonged to families with higher purchasing power. It is speculated that students in the private network are more exposed to factors that contribute to overweight, such as high sedentary behavior due to the use of electronic devices, little active commuting, greater consumption of industrialized foods, among others2525 Suñé FR, Dias-da-Costa JS, Olinto MT, Pattussi MP. Prevalence of overweight and obesity and associated factors among schoolchildren in a southern Brazilian city. Cad Saude Publica 2007; 23(6): 1361-71.,2626 Vieira MF, Araújo CL, Hallal PC, Madruga SW, Neutzling MB, Matijasevich A, et al. Nutritional status of first to fourth-grade students of urban schools in Pelotas, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008;24(7):1667-74..

The moderate concordance between BMI and Fat% indicators identified in the present study was also observed in children and adolescents from Saudi Arabia1212 Al-Mohaimeed A, Ahmed S, Dandash K, Ismail MS, Saquib N. Concordance of obesity classification between body mass index and percent body fat among school children in Saudi Arabia. BMC Pediatr 2015;15:16. and Hungary1313 Antal M, Péter S, Biró L, Nagy K, Regöly-Mérei A, Arató G, Szabó C, Martos E. Prevalence of underweight, overweight and obesity on the basis of body mass index and body fat percentage in Hungarian schoolchildren: representative survey in metropolitan elementary schools. Ann Nutr Metab 2009;54(3):171-6.. Since BMI reflects both body fat and lean body mass, it may have induced moderate concordance among the investigated indicators. In addition, the concordance variations observed between maturational stages can be explained by differences in fat gain in the puberty stages2323 Loomba-Albrecht LA, Styne DM. Effect of puberty on body composition. Curr Opin Endocrinol Diabetes Obes 2009;16(1):10-5..

This moderate association may also be related to the fact that BMI is less accurate as an indicator of adiposity2828 Demerath EW, Towne B, Chumlea WC, Sun SS, Czerwinski SA, Remsberg KE, et al. Recent Decline in Age at Menarche: The Fels Longitudinal Study. Am J Hum Bio 2004; 16(4): 453-7., especially in the puberty phase. Thus, in the pre-pubertal group, consisting of adolescents in stages M1 and G1, there was substantial concordance. At stages M1 and G1, body composition has not yet undergone the physiological modification of maturation of the hypothalamic-pituitary-gonadal axis.

Thus, during puberty in assessing body composition at individual level, BMI and Fat% should be used with caution as similar parameters in the diagnosis of overweight and excess body fat in adolescents aged 14-18 years, especially in groups that are above M2 and G2.

The use of a double indirect method in the diagnosis of body fat is a study limitation. Since the study involves a representative sample of the population of students from Rio Branco (AC) and Porto Velho (RO), it makes it possible to generalize the results to the population.

CONCLUSION

The high overweight and excess body fat prevalence evidenced in students from Rio Branco (AC) and Porto Velho (RO) is a serious public health problem. This study showed the need to adequately screen and diagnose excess weight (overweight and obesity) and excess body fat in adolescents. Thus, accuracy in screening will enable the earlier treatment of these adolescents, preventing the outcomes of pathologies associated with obesity in adult life.

REFERENCES

  • 1
    Cintra IP, Ferrari GL, Soares AC, Passos MA, Fisberg M, Vitalle MS. Body fat percentiles of Brazilian adolescents according to age and sexual maturation: a cross-sectional study. BMC Pediatr 2013;13:96.
  • 2
    Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS. The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics 2005;115(1):22-7.
  • 3
    Yuca SA, Yilmaz C, Cesur Y, Dogan M, Kaya A., Basaranoglu M. Prevalence of overweight and obesity in children and adolescents in eastern Turkey. J Clin Res Pediatr Endocrinol 2010;2(4):159-63.
  • 4
    Pinto ICS, Arruda IKG, Diniz AS, Cavalcanti AMTS. Prevalência de excesso de peso e obesidade abdominal, segundo parâmetros antropométricas, e associação commaturação sexual em adolescentes escolares. Cad Saude Publica 2010; 26(9): 1727-37.
  • 5
    Kotian MS, Kumar G, Kotian S. Prevalence and determinants of overweight and obesity among adolescent school children of south Karnataka, India. Assoc Community Med 2010;35(1):176-8.
  • 6
    Durá-Travé T, Hualde-Olascoaga J, Garralda-Torres I. Overweight amongchildren in Navarra (Spain) and its impact on adolescence. Med Clin (Barc)2012;4;138(2):52-6.
  • 7
    Farias ES, Santos AP, Farias-Júnior JC, Ferreira CRT, Carvalho WRG, Gonçalves EM, Guerra-Junior G. Excesso de peso e fatores associados em adolescentes. Rev Nutr 2012;25(2): 229-36.
  • 8
    Souza OF, Farias ES. Magreza e sobrepeso em escolares de Rio Branco, AC, Brasil. Rev Bras Crescimento Desenvolv Hum 2011;21(3):878-82.
  • 9
    Slaughter MH, Lohman TG, Boileau RA, Horswill CA, Stillman RJ, VanLoan MD, et al. Skinfold equations for estimation of body fatness in children and youth.Hum Biol 1988;60(5):709-23.
  • 10
    Lohman TG. Advances in body composition assessment. Champaign: Human Kinetics; 1992.
  • 11
    Rech CR, Petroski EL, Silva RCR, Silva JCN. Indicadores antropométricos de excesso de gordura corporal em mulheres. Rev Bras Med Esporte 2006;12(3): 119-24.
  • 12
    Al-Mohaimeed A, Ahmed S, Dandash K, Ismail MS, Saquib N. Concordance of obesity classification between body mass index and percent body fat among school children in Saudi Arabia. BMC Pediatr 2015;15:16.
  • 13
    Antal M, Péter S, Biró L, Nagy K, Regöly-Mérei A, Arató G, Szabó C, Martos E. Prevalence of underweight, overweight and obesity on the basis of body mass index and body fat percentage in Hungarian schoolchildren: representative survey in metropolitan elementary schools. Ann Nutr Metab 2009;54(3):171-6.
  • 14
    Marshall WA, Tanner JM. Variation in the pattern of pubertal changes in boys. Arch Dis Child 1970; 45(239): 13-23.
  • 15
    Marshall WA, Tanner JM. Variation in the pattern of pubertal changes in girls. Arch Dis Child 1969; 44(235): 291-303.
  • 16
    Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Developmentof a WHO growth for school-aged children and adolescents. Bull World Health Organ 2007; 85(9):660-7.
  • 17
    Landis JR, Koch GG. The measurement of observer agreement for categorical. Biometrics 1977;33(1):159-74.
  • 18
    Fernandes RA, Codgno JS, Cardoso JR, Ronque ERV, Freitas Junior IF, Oliveira AR. Fatores associados ao excesso de peso entre adolescentes de diferentes redes deensino do município de Presidente Prudente, São Paulo. Rev Bras Saude Matern Infant 2009;9(4):443–9.
  • 19
    Brasil LMP, Fisberg M, Maranhão HS. Excesso de peso de escolares em região do Nordeste Brasileiro: contraste entre as redes de ensino pública e privada. Rev Bras Saude Mater Infant 2007;7(4):405-12.
  • 20
    Melo ME, Miguéis GL, Almeida MS, Dalamaria t. Souza OF. Sobrepeso eobesidade em escolares das séries iniciais do ensino fundamental de rio branco, acre: uma comparação entre referenciais. Rev Bras Crescimento Desenvolv Hum 2016;26(3):341-4.
  • 21
    Rao DP, Kropac E, Do MT, Roberts KC, Jayaraman GC. Childhood overweight and obesity trends in Canada. Health Promot Chronic Dis Prev Can 2016;36(9):194-8.
  • 22
    Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA 2014; 311(8):806-14.
  • 23
    Loomba-Albrecht LA, Styne DM. Effect of puberty on body composition. Curr Opin Endocrinol Diabetes Obes 2009;16(1):10-5.
  • 24
    Veldhuis JD, Roemmich JN, Richmond EJ, Rogol AD, Lovejoy JC, Sheffield-Moore M, et al. Endocrine Control of Body Composition in Infancy, Childhood, and Puberty. Endocr Rev 2005; 26(1):114-46.
  • 25
    Suñé FR, Dias-da-Costa JS, Olinto MT, Pattussi MP. Prevalence of overweight and obesity and associated factors among schoolchildren in a southern Brazilian city. Cad Saude Publica 2007; 23(6): 1361-71.
  • 26
    Vieira MF, Araújo CL, Hallal PC, Madruga SW, Neutzling MB, Matijasevich A, et al. Nutritional status of first to fourth-grade students of urban schools in Pelotas, Rio Grande do Sul State, Brazil. Cad Saude Publica 2008;24(7):1667-74.
  • 27
    Hobold E, Arruda M. Prevalência de sobrepeso e obesidade em estudantes: Relaçãoentre nível socioeconômico, sexo e idade. Rev Bras Cineantropom Desempenho Hum 2015, 17(2):156-64
  • 28
    Demerath EW, Towne B, Chumlea WC, Sun SS, Czerwinski SA, Remsberg KE, et al. Recent Decline in Age at Menarche: The Fels Longitudinal Study. Am J Hum Bio 2004; 16(4): 453-7.
  • 29
    Baker JL, Farpour-Lambert NJ, Nowicka P, Pietrobelli A, Weiss R, Childhood Obesity Task Force of the European Association for the Study of Obesity. Evaluation of the Overweight/Obese Child – Practical Tips for the Primary Health Care Provider: Recommendations from the Childhood Obesity Task Force of the European Association for the Study of Obesit. Obes Facts 2010; 3(2):131-7.

Publication Dates

  • Publication in this collection
    May-Jun 2017

History

  • Received
    13 Feb 2017
  • Accepted
    04 June 2017
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