Phytosterol-enriched milk lowers LDL-cholesterol levels in Brazilian children and adolescents: Double-blind, cross-over trial.

BACKGROUND AND AIMS: Despite evidence of the lipid-lowering effect of plant sterols among adults with hypercholesterolemia, data regarding phytosterol use in children are limited. In this paper, we examined the effects of daily consumption of a phytosterol-enriched milk compound on the lipid profiles of Brazilian children and adolescents with dyslipidemia. METHODS AND RESULTS: This was a randomized, double blind, crossover clinical trial. Twenty eight dyslipidemics outpatients (aged 6-9 years) from an University Hospital were randomly allocated to control or intervention group. The intervention group received milk enriched with 1.2 g/day of plant sterol and the control group received the equivalent amount of skim milk during the period of 8 weeks. Changes from baseline in the mean lipid profile, including total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), and triglyceride (TG) concentrations. Serum lipid profiles, glucose levels, dietary and anthropometric data were determined at weeks 0, 4, 8, 16, and 20. Details regarding the safety and tolerance of phytosterol were obtained, using an open-ended questionnaire. Intention-to-treat analysis were performed, using the proc mixed procedure in SAS. After 8 weeks, the mean concentrations of TC and LDL-C were significantly reduced in the intervention group as compared to the control group with reductions of 5.9% (p = 0.09) and 10.2% (p = 0.002), respectively. In addition, TG concentrations were reduced by 19.7% (p = 0.09). No serious side effects were reported during the study. CONCLUSION: Our results confirm that plant sterols are an effective and safe treatment of infantile dyslipidemia. TRIAL REGISTRATION: RBR-3h7f9k.

Adjusting diet-outcome associations for random error: comparison of associations based on observed and estimated usual intakes.

BACKGROUND/OBJECTIVES: To compare linear regression coefficients adjusted for random errors with true coefficients. SUBJECTS/METHODS: Three hundred and two individuals from the city of Rio de Janeiro, Brazil answered 20 non-consecutive 24-hr. Means of 20 24-hr were used as an approximation of the usual dietary intakes. It was simulated outcomes with pre-defined linear regression coefficient (ß=1.0, referred as 'true coefficient') for usual coffee and soft-drink intakes as explanatory variables controlled for sex and age. Regression calibration was applied in each 1000 random combinations of j days of intake (j=2, 4 and 6), and adjusted coefficients were compared with true one. RESULTS: Mean-adjusted coefficients were 1.06 to 1.03 (coffee) and 1.17 to 1.11 (soft drink). The association was not detected (95% CI included zero) in 33 to 23% (coffee) and 37 to 23% (soft drink) when using two and six collection days, respectively, compared with 20% when using observed usual intake. Frequency of consumption as covariate in the regression calibration model increased the precision of the adjusted coefficients. CONCLUSIONS: Adjustment for random errors de-attenuates the association but its precision depends mainly on the number of collection days and sample size.

Misreport of energy intake assessed with food records and 24-h recalls compared with total energy expenditure estimated with DLW.

BACKGROUND/OBJECTIVES: The accuracy of dietary assessment methods has rarely been validated using precise techniques. The objective of this work was to evaluate the validity of energy intake (EI) estimated with food records (FRs) and 24-h recalls (24hRs) against total energy expenditure (EE) estimated by the doubly labeled water (DLW) method. In addition, the magnitude of EI under-reporting was assessed along with its associated characteristics. SUBJECTS/METHODS: The studied group included 83 adults between 20 and 60 years of age who were recruited from a population-based sample. Within-person variation-adjusted means of EI estimated from two FRs and three 24hRs were compared with EE estimated using the DLW method multiple-point protocol. The Wilcoxon signed-rank test was used to assess the differences between EI and EE, whereas Bland-Altman and survival-agreement plots assessed the agreement between the estimates. RESULTS: The mean EE (2540 kcal) was greater than the mean reported EI for both dietary assessment methods (FR: 1774 kcal; 24hR: 1658 kcal, P<0.01). The frequency of under-reporting was lower (20%) for EI estimated with the 24hR than that estimated with the FR (32%). Men presented lower magnitude of under-reported EI than women did. For women, differences between EI and EE were lower with FR than with 24hR. Overall, FR and 24hR showed similar performance. The mean under-reported EI was ~30% for both methods. CONCLUSIONS: Irregular meal habits, smoking and low education were associated with the under-report of EI. Both FR and 24hR are subjected to bias suggesting the need of refining the procedures applied in dietary assessment methods.

Factors associated with the calibration of a food frequency questionnaire for the Bambuí Project, Brazil.

BACKGROUND: The present study aimed to calibrate a food frequency questionnaire (FFQ) using one 24-h recall (R24) associated with foodstuff replicas. METHODS: Calibration was performed by linear regression. Of a probability sample of 150 individuals (>18 years) of the town of Bambui, 98 completed the study. RESULTS: The mean age of the participants was 43.8 years and 63.3% were women. The calibration of the FFQ included sex for the estimation of iron, protein and zinc; and an interaction between sex and R24 was significant for vitamin A and cholesterol models. Age contributed to the vitamin C, polyunsaturated fatty acids, proteins and zinc models, and an interaction between age and R24 was significant for protein and zinc. CONCLUSIONS: Calibration coefficients and many interactions in linear regression models revealed important differences between dietary methods, indicating the complexity encountered when combining two methodologies for estimating food intake.

Rationale, design, and analysis of combined Brazilian household budget survey and food intake individual data.

BACKGROUND: Data on food intake at the individual level and its statistical distribution in population groups defined by age, gender, or geographic areas are important in planning public health and nutrition programs. However, individual-based surveys in representative population samples are expensive to perform. METHODS/DESIGN: In Brazil, an individual based survey is under consideration to be conducted alongside the household budget survey (HBS), which will be carried out in 2008-2009. This paper presents the methodological framework of dietary data collection and indicates the directions to combining both sources of data. The 2008-2009 Brazilian HBS sample will include 60,000 households. Of the selected HBS households, 30% will be randomly sampled to gather data on individual food intake. Therefore, individual dietary intake data is expected to be gathered for 70,000 individuals. Data collection procedures will comprise: completion of a diary with information regarding food purchases during a seven-day period; registration of all items consumed during two non-consecutive days for all 10 year-old or older members of the household. The sample will be large enough to capture the variation between individuals, and the two records will assure the estimation of the variation within individuals for food groups, energy and nutrients. Data on individual dietary intake and food family budget will be stratified by the five regions of the country and by rural or urban. A pilot study has been conducted in two states, and it indicated that combining individual and budgetary data in a survey is feasible. DISCUSSION: This kind of study will allow us to estimate correlations between individual intake and household purchases, overcoming the limitations of individual dietary surveys, and enhancing the HBS with information on eating out and intra-familiar distribution of food.

Trends in underweight, overweight and body mass index among elderly population of Brazil.

OBJECTIVE: To evaluate body mass index (BMI - kg/m2) trend of the elderly (superior 60 y) in the poorest (Northeast) and richest (Southeast) regions of Brazil. METHOD: Household surveys conducted in 1975, 1989 and 1997 measured weight and stature of a probabilistic sample of about 18,000 elderly people. Weighted prevalences were calculated and analysis took into account the sample design. RESULTS: In the entire period, the prevalence of overweight doubled reaching 37.4% for men and 50.6% for women in the most recent survey. Although there was an important reduction in the prevalence of underweight, these percentages were still high in the poorest region for both sexes in 1997 (13%). The increase in BMI in the period from 1975 to 1989 was significant for all subgroups, except for the men living in the rural area of the richest region, but this group was the only one that presented a significant increase in the BMI in the 1989--1997 period. CONCLUSIONS: Overweight has highly prevalent among the elderly. However there was no trend of increasing BMI in the last period, except for men living in the rural area of the richest region. Underweight is still an important nutritional problem in the poorest region.

n-6 and n-3 Long-chain polyunsaturated fatty acids in the erythrocyte membrane of Brazilian preterm and term neonates and their mothers at delivery.

Placental transfer of the long-chain polyunsaturated fatty acids (LCPUFA) arachidonic (AA) and docosahexaenoic (DHA) acids is selectively high to maintain accretion to fetal tissues, especially the brain. The objectives of the present study were to investigate the essential fatty acid (EFA) and LCPUFA status at birth of preterm and term Brazilian infants and their mothers, from a population of characteristically low intake of n-3 LCPUFA, and to evaluate the association between fetal and maternal status, by the determination of the fatty acid composition of the erythrocyte membrane. Blood samples from umbilical cord of preterm (26-36 weeks of gestation; n = 30) and term (37-42 weeks of gestation; n = 30) infants and the corresponding maternal venous blood were collected at delivery. The LCPUFA composition of the erythrocyte membrane and DHA status were similar for mothers of preterm and term infants. Neonatal AA was higher (P < 0.01) whereas its precursor 18:2n-6 was lower (P < 0.01) than maternal levels, as expected. There was no difference in LCPUFA erythrocyte composition between preterm and term infants, except for DHA. Term infants presented a worse DHA status than preterm infants (P < 0.01) and than their mothers (P < 0.01) at delivery. There was a negative correlation of neonatal DHA with maternal AA and a positive correlation between neonatal AA and maternal AA and 18:2n-6 only at term. These results suggest that the persistent low DHA maternal status, together with the comparatively better AA and 18:2n-6 status, might have affected maternal-fetal transfer of DHA when gestation was completed up to term, and possibly contributed to the worse DHA status of term neonates compared with the preterm neonates.

Waist circumference and waist-to-hip ratio as predictors of serum concentration of lipids in Brazilian men.

OBJECTIVE: It is unknown whether waist circumference can predict a lipid profile beyond that predicted by body fatness alone, after adjustment for important confounding variables such as smoking, alcohol intake, and physical activity. The purpose of this non-clinical, healthy-subject study was to test this hypothesis. METHODS: Data refer to 416 men, ages 20 to 58 y with a body mass index between 18.5 and 29.9 kg/m(2), who were blood donors living in a Brazilian city. Alcohol consumption, smoking, and physical activity were evaluated by interview; body fat was measured by electrical bioimpedance, and weight, height, and waist and hip circumferences were measured by trained anthropometrists. Multiple linear regression analysis was performed to quantify the association between measurements of fat distribution (waist circumference and waist-to-hip ratio) and the ratio of total cholesterol to high-density lipoprotein cholesterol and triacylglycerols independently of measurements of fatness and potentially confounding factors. RESULTS: Waist circumference was strongly correlated with percentage of body fat (r = 0.90), whereas waist-to-hip ratio was less correlated (r = 0.55). After adjustment for age, percentage of body fat, smoking, alcohol intake, and physical activity, waist circumference was not significantly related to the ratio of total cholesterol high-density lipoprotein cholesterol, whereas the waist-to-hip ratio was strongly associated among the youngest subjects (beta = 3.51, P = 0.005). CONCLUSION: Although several studies have analyzed the association between serum lipids with anthropometric markers, few, including the present one, support waist circumference as a good predictor of lipid profile.

Combined effect of short stature and socioeconomic status on body mass index and weight gain during reproductive age in Brazilian women

Short stature, a marker for undernutrition early in life, has been associated with obesity in Brazilian women, but not in men. We tested the hypothesis that weight gain during the reproductive years could explain this gender difference. A national two-stage household survey of mothers with one or more children under five years of age was conducted in Brazil in 1996. The subjects were women aged 20 to 45 years (N = 2297), with last delivery seven months or more prior to the interview. The regions of the country were divided into rural, North/Northeast (urban underdeveloped) and South/Southeast/Midwest (urban developed). The dependent variables were current body mass index (BMI) measured, BMI prior to childbearing (reported), and BMI change. Socioeconomic variables included mother's years of education and family purchasing power score. A secondary analysis was restricted to primiparous women. The prevalence of current overweight and overweight prior to childbearing (BMI > or = 25 kg/m²) was higher among shorter women (<1.50 m) compared to normal stature women only in the urban developed region (P < 0.05). After adjustment for socioeconomic variables, age, parity, BMI prior to childbearing, and age at first birth, current BMI was 2.39 units higher (P = 0.008) for short stature women living in the urban developed area compared with short stature women living in the urban underdeveloped area. For both multiparous and primiparous women, BMI gain compared to the value prior to childbearing was significantly higher among short stature women living in the urban developed region (P <= 0.04). These results provide clear evidence that short stature was associated with a higher BMI and with an increased risk of weight gain/retention with pregnancy in the developed areas of Brazil, but not in the underdeveloped ones

Combined effect of short stature and socioeconomic status on body mass index and weight gain during reproductive age in Brazilian women.

Short stature, a marker for undernutrition early in life, has been associated with obesity in Brazilian women, but not in men. We tested the hypothesis that weight gain during the reproductive years could explain this gender difference. A national two-stage household survey of mothers with one or more children under five years of age was conducted in Brazil in 1996. The subjects were women aged 20 to 45 years (N = 2297), with last delivery seven months or more prior to the interview. The regions of the country were divided into rural, North/Northeast (urban underdeveloped) and South/Southeast/Midwest (urban developed). The dependent variables were current body mass index (BMI) measured, BMI prior to childbearing (reported), and BMI change. Socioeconomic variables included mother's years of education and family purchasing power score. A secondary analysis was restricted to primiparous women. The prevalence of current overweight and overweight prior to childbearing (BMI > or = 25 kg/m2) was higher among shorter women (<1.50 m) compared to normal stature women only in the urban developed region (P < 0.05). After adjustment for socioeconomic variables, age, parity, BMI prior to childbearing, and age at first birth, current BMI was 2.39 units higher (P = 0.008) for short stature women living in the urban developed area compared with short stature women living in the urban underdeveloped area. For both multiparous and primiparous women, BMI gain compared to the value prior to childbearing was significantly higher among short stature women living in the urban developed region (P <= 0.04). These results provide clear evidence that short stature was associated with a higher BMI and with an increased risk of weight gain/retention with pregnancy in the developed areas of Brazil, but not in the underdeveloped ones.

Prospective assessment of exclusive breastfeeding in relation to weight change in women.

OBJECTIVE: To study prospectively the relation of parity, prepregnancy body mass index (BMI), and exclusive breastfeeding to weight gain. DESIGN: The cohort of the Nurse's Health Study II, with analysis restricted to women who were aged 24 to 40 y at baseline (1989), who had a history of no more than one past full-term pregnancy at baseline, gave birth to one child between 1990 and 1991, but had no other pregnancies during the follow-up. SUBJECTS: 1538 of the 33 082 nulliparous women and 2810 of the 20 261 primiparous, in 1989. MEASUREMENTS: Introduction of daily formula/milk was assumed to represent the end of exclusive breastfeeding period. Duration of exclusive breastfeeding was categorized into 0, 1-3, 4-7, 8-11, and 12 months or more. RESULTS: After adjusting for age, physical activity, and BMI in 1989, lactation was associated with a weight gain from 1989 to 1993 of approximately 1 kg (statistically significant only for women nulliparous in 1989 with a BMI <25 kg/m(2) (P=0.02) and for those women primiparous in 1989, with a BMI >/=25 kg/m(2) (P=0.04)) comparing women who breastfed with women who did not, and duration of lactation was unrelated to the magnitude of weight change (P>0.40 for all comparisons). CONCLUSIONS: Although promotion of breastfeeding has high priority because of its enormous advantages for a newborn child, the associated maternal weight reduction is minimal. Dietary guidelines for pregnant and breastfeeding women should include ways to prevent weight retention after parity.

Food consumption of adolescents. A simplified questionnaire for evaluating cardiovascular risk.

OBJECTIVE: To develop a simplified questionnaire for self-evaluation by adolescents of foods associated with the risk of coronary diseases. METHODS: Frequency questionnaires about 80 foods were answered by representative samples of 256 adolescents aged 12 to 19 from Rio de Janeiro as part of the Nutrition and Health Research project. The dependent variable was the serum cholesterol predicting equation as influenced by diet, and the independent variables were the foods. The variables were normalized and, using Pearson's correlation coefficient, those with r>0.10 were selected for the regression model. The model was analyzed for sex, age, random sample, and total calories. Those food products that explained 85% of the cholesterol variation equation were present in the caloric model, and contained trans fatty acids were selected for the questionnaire. RESULTS: Sixty-five food products had a statistically significant correlation (P<0.001) with the dependent variable. The simplified questionnaire included 9 food products present in all tested models: steak or broiled meat, hamburger, full-fat cheese, French fries or potato chips, whole milk, pies or cakes, cookies, sausages, butter or margarine. The limit of the added food points for self-evaluation was 100, and over 120 points was considered excessive. CONCLUSION: The scores given to the food products and the criteria for the evaluation of the consumption limits enabled the adolescents to get to know and to balance their intake.

High prevalence of hypertension among Black and Mulatto women in a Brazilian survey.

STUDY OBJECTIVES: Brazil has a high admixture of Blacks and Whites, making it possible to compare the prevalence of hypertension among Blacks, Whites, and Mulattos. DESIGN: A population-based health and nutrition survey was carried out in 1996 in the city of Rio de Janeiro, Brazil. Blood pressure, weight, height, food frequency information, and skin color were obtained from a sample of 2,802 private household residents aged 20 years or older. MAIN OUTCOME MEASURE: Hypertension was defined as systolic blood pressure >140 mm Hg and/or diastolic pressure >90 mm Hg or the use of antihypertensive medication. RESULTS: The prevalence of hypertension among men was 12.0% among Whites, 13.8% among Mulattos, and 14.4% for Blacks. For women, these prevalences were 12.0%, 16.4%, and 20.2%, respectively. After adjustment for age, calcium and salt intake, physical activity level, body mass index, and waist-hip ratio, we observed (among women only) a trend toward increasing prevalence of hypertension with increasing skin darkness. The adjusted odds ratio of hypertension was 1.52 for Mulatto women compared to Whites and 2.27 for Blacks compared to Whites (P<.05). With further adjustment for income, the odds ratios were reduced to 1.30 (95% CI 0.86-1.95) and 1.75 (95% CI 1.04-2.94). CONCLUSIONS: Black women showed increased risk of hypertension independent of socioeconomic factors or overweight status.

[Physical activity in a probabilistic sample in the city of Rio de Janeiro]. / Atividade física em uma amostra probabilística da população do Município do Rio de Janeiro.

This study evaluated physical activity in a probabilistic sample of 4,331 individuals 12 years of age and older residing in the city of Rio de Janeiro, who participated in a household survey in 1996. Occupation and leisure activity were grouped according to categories of energy expenditure. The study also evaluated number of hours watching TV, using the computer, or playing video-games. Only 3.6% of males and 0.3% of females reported heavy occupational work. A full 59.8% of males and 77.8% of females reported never performing recreational physical activity, and there was an increase in this prevalence with age, especially for men. Women's leisure activities involved less energy expenditure and had a lower median duration than those of men. Mean daily TV/video/computer time was greater for women than for men. The greater the level of schooling, the higher the frequency of physical activity for both sexes. Analyzed jointly, these data show the low energy expenditure through physical activity by the population of the city of Rio de Janeiro. Women, the middle-aged, the elderly, and low-income individuals were at greatest risk of not performing recreational physical activity.

Obesity and weight change related to parity and breast-feeding among parous women in Brazil.

OBJECTIVE: Studies on the independent role of parity in long-term body weight change in economically developing countries are scarce and inconclusive, and only a few studies have taken into account patterns of breast-feeding. This association was examined in a national cross-sectional survey representative of Brazilian parous women. DESIGN AND SETTING: The survey conducted in 1996 measured women's height and weight in the household and data on weight prior to the first pregnancy, parity and breast-feeding were recalled. SUBJECTS: A sample of 2338 parous women, 15 to 49 years of age, 29 months after last delivery on average, had current body mass index (BMI, in kg m(-2)) modelled through hierarchical multiple linear regression analysis. Explanatory variables included parity, days of predominant breast-feeding, BMI pre-pregnancy, socio-economic, geographic, demographic and other reproductive variables. RESULTS: Prevalences of overweight (BMI = 25.0-29.9 kg m(-2)) and obesity (BMI > or = 30.0 kg m(-2)) were 25.2% and 9.3%. The overall mean weight gain per year after the first pregnancy was 0.90 kg for an average time since first pregnancy of eight years. BMI pre-pregnancy modified the association between current BMI and parity. Therefore, weight change attributed to parity calculated for a woman of average height (1.56 m) was 0.60 kg greater for primiparous women with a BMI pre-pregnancy of 30 kg m(-2), compared with women with BMI pre-pregnancy of 25 kg m(-2). This greater weight retention among obese women was 1.21 kg for women with two children and 1.82 kg for women with three or more children. Parity reduced the effect of weight loss associated with lactation (1.75 kg for six months of lactation among primiparous women and 0.87 kg among women with three or more children). For the sub-sample of 793 primiparous women, a weight decrease of 300 g was associated with each month of predominant breast-feeding for all prior BMI levels. CONCLUSIONS: In this study, weight change associated to reproduction was highly dependent on BMI previous to pregnancy and the effects of parity and lactation were small.

Validation and calibration of mercury intake through self-referred fish consumption in riverine populations in Pantanal Mato-grossense, Brazil.

The objective of most epidemiological studies is to classify/rank people according to their relative quantity of consumption. In the specific case of quantifying fish consumption, in order to assess mercury intake rate, the method used must estimate the individual quantity consumed accurately, or from the self-referred quantity it must be possible to estimate the real consumption-termed calibration. Therefore, the objective of this study was to validate and calibrate the 24-h recall method for assessing the amount of fish consumed to estimate the mercury intake in riverine populations from Baixada Cuiabana, in Pantanal Mato-grossense, Brazil. The weighed dietary method was used as the reference standard, and the validity of the 24-h recall method was assessed using correlation coefficients (r), regression coefficients (beta), and the intraclass correlation coefficient (ICC). The results showed that the ICC, which assesses the agreement level between measures, was a more adequate measure than the correlation coefficient (r). Therefore, the calibration equation was calculated applying a multiple linear regression model using the consumption mean of the second and third days, which presented the highest ICC, stratified by sex and adjusted by age and season variables.

Height, weight, weight change and risk of breast cancer in Rio de Janeiro, Brazil.

CONTEXT: The relationship between body size and breast cancer still remains controversial in considering menopausal status. OBJECTIVE: To evaluate the association of height, weight and weight changes with breast cancer in the city of Rio de Janeiro, Brazil. DESIGN: Case-control study. SETTING: National Cancer Institute (INCA), Rio de Janeiro, Brazil, and State University of Rio de Janeiro (UERJ). SAMPLE: 177 incident cases of invasive breast cancer admitted to the main hospital of INCA between May 1995 and February 1996, and 377 controls recruited from among female visitors to the same hospital. MAIN MEASUREMENTS: Height and weight were measured and information on maximum weight, weight at ages 18 and 30 years, and potential risk factors were ascertained by interview at the hospital. RESULTS: Height was not related to risk of breast cancer among both pre and postmenopausal women. Nevertheless, women in this study were shorter than in studies that have found a positive association. Premenopausal women in the upper quartile of recent body mass index (BMI) and maximum BMI showed a reduced risk of breast cancer (P for trend < or = 0.03). Weight loss between ages 18 and 30 years and from 18 years to present was also associated with breast cancer among premenopausal women. CONCLUSIONS: These findings may merely indicate the known association between leanness and breast cancer. Further studies should explore the role of weight loss on breast cancer risk.

[Reliability of the WPPSI-R test in the evaluation of cognitive development in preschool children]. / Confiabilidade do Teste WPPSI-R na avaliação do desenvolvimento cognitivo de pré-escolares.

The WPPSI-R scale (Wechsler Preschool and Primary Scale of Intelligence - Revised) is a psychometric test chosen as the evaluation tool in a study on preschool-age cognitive development in a cohort of very low birth weight (VLBW) premature children from the Fernandes Figueira Institute (IFF), applied by four previously trained psychologists. The objective of this study was to verify inter-observer reliability in the test application. Two types of reliability study design were used: balanced incomplete blocks, to verify agreement in the application of the scale, and crossed design, to verify agreement in scoring of items. We studied 12 preschool children born at IFF (birthweight < 1,500g). The intraclass correlation coefficients (ICC) were: 0.82 (full-scale IQ), 0.89 (verbal IQ), and 0.91 (performance IQ), in the incomplete block design study, and 0.99, 0.98, and 0.99, respectively, in the crossed design study, indicating good reliability. Application of the WPPSI-R scale in the study of cognitive development of VLBW premature children at IFF proved adequate, as shown by these results.