MULT - uma nova referência internacional para avaliação nutricional de crianças e adolescentes / MULT - a new international growth reference to assess the nutritional status of children and adolescents

Introdução: A disponibilidade de várias curvas de crescimento propostas por diversas instituições e modeladas com diferentes populações dificulta a adoção de uma referência internacional. Objetivo: Elaborar uma nova referência internacional e comparar seu desempenho com o de outras curvas de referências já existentes. Métodos: Dados sociodemográficos, antropométricos e de composição corporal de participantes com idades entre zero e 23 anos foram coletados dos inquéritos populacionais: National Health and Nutrition Examination Survey (NHANES), Porto Alegre, Santos, Young Lives: an International Study of Childhood Poverty (YL), Millennium Cohort Study (MCS), Geração XXI (G21), Epidemiological Health Investigation of Teenagers in Porto (EPITeen) e Estudo Longitudinal de Avaliação Nutricional de Adolescentes (ELANA). A nova referência internacional denominada MULT apresentou curvas de altura, índice de massa corporal (IMC) e índice alométrico de massa corporal (IAMC) para a idade construídas por meio do método LMS e o Generalized Additive Models for Location, Scale, and Shape (GAMLSS). A eficiência da referência MULT foi comparada com as das referências internacionais da World Health Organization (WHO), International Task Force Obesity (IOTF) e Centers for Disease Control and Prevention (CDC). A precisão diagnóstica das curvas foi realizada por meio da análise de adiposidade corporal e o risco de sobrepeso na pré-adolescência foi estimado a partir da análise da canalização de crescimento de IMC (CC-IMC). Ademais, uma ferramenta para avaliação nutricional baseada nos valores de referência MULT foi elaborada no Microsoft Excel e disponibilizada online. Resultados: Em comparação com as curvas da WHO, IOTF e CDC, as curvas de altura da MULT mostraram meninos mais altos nos períodos de 61-174 e 196-240 meses, e meninas mais altas nos períodos de 61-147 e 181-240 meses, com relação as de IMC, a MULT apresentou os valores médios mais baixos para as idades de 102-240 meses para os meninos e de 114-220 meses para meninas. Já as de IAMC apresentaram as maiores diferenças nas idades de 138-150 meses para meninos e de 114-132 meses para meninas, coincidindo com a puberdade. As curvas de IAMC apresentaram as melhores performances para diagnosticar obesidade a partir da análise da composição corporal (meninos=0,95;IC95%:0,94- 0,95/meninas=0,92; IC95%:0,92-093) e a análise de risco relativo (RR) apontou que crianças eutróficas durante a infância que aumentaram seu CC-IMC em ≥0,67 e <0,86 apresentaram maior probabilidade de estarem com excesso do peso aos 9,5-13,5 anos [IOTFRR= 2,31;IC95%:1,82-2,93/MULT-RR=2,49;IC95%:2,00-3,09/WHO-RR=2,47; IC95%:1,96- 3,12], em comparação com aquelas que permaneceram dentro do seu canal. Conclusão: Para diagnóstico da obesidade, a referência MULT teve um desempenho melhor entre as referências de IMC, enquanto que as curvas de IAMC da MULT apresentaram o melhor desempenho entre todas, sendo a única capaz de detectar que as meninas apresentavam, proporcionalmente, mais massa de gordura do que os meninos para os mesmos valores de índice. Além disso, a análise da canalização apontou que um aumento no CC-IMC ≥0,67DP durante a infância foi associado a um risco de excesso de peso aos 9,5-13,5 anos. Esses resultados apontam que a referência MULT pode ser uma excelente opção para avaliação nutricional de crianças e adolescentes.

Introduction: The availability of several growth references proposed by different institutions and modeled with different populations complicates the adoption of an international growth reference. Objective: To develop a new international reference and compare its performance with other existing growth references. Methods: Sociodemographic, anthropometric, and body composition data from birth to 23 years old were collected from the population surveys: National Health and Nutrition Examination Survey (NHANES), Porto Alegre, Santos, Young Lives: an International Study of Childhood Poverty (YL), Millennium Cohort Study (MCS), Generation XXI (G21), Epidemiological Health Investigation of Teenagers in Porto (EPITeen), and Longitudinal Study of Nutritional Assessment of Adolescents (ELANA). A new international reference called MULT was developed, which included height, BMI, and allometric body mass index (ABMI) growth charts. These curves were constructed using the LMS method and the generalized additive models for location, scale, and shape (GAMLSS). The efficiency of this reference was compared with the international growth references of the World Health Organization (WHO), International Task Force Obesity (IOTF), and Centers for Disease Control and Prevention (CDC). The diagnostic accuracy of the growth references was assessed through the analysis of body adiposity, and the risk of overweight in pre-adolescence was estimated from the analysis of the BMI growth channeling (BMI-GC). In addition, a nutritional assessment tool based on MULT reference values was developed in Microsoft Excel and made available online. Results: In comparison to the WHO, IOTF, and CDC, the MULT height reference showed taller boys during the periods of 61-174 and 196-240 months, and taller girls during the periods of 61-147 and 181-240 months. Regarding the BMI, the MULT presented the lowest mean values for the ages of 102-240 months for boys and for the ages of 114-220 months for girls. The ABMI reference presented the largest differences at ages 138- 150 months for boys and 114-132 months for girls, coinciding with the pubertal stage. The ABMI reference demonstrated the best performance in diagnosing obesity based on body composition analysis (boys=0.95;95%CI:0.94-0.95/girls=0.92;95%CI:0.92-0.93). The analysis of relative risk (RR) indicated that normal weight children who increased their BMI-GC during childhood by ≥0.67 and <0.86 were more likely to be overweight at 9.5-13.5 years [IOTFRR= 2.31; 95% CI: 1.82-2.93/MULT-RR=2.49; 95% CI: 2.00-3.09/WHO-RR=2.47; 95% CI: 1.96-3.12] compared to those who remained within their channel. Conclusion: For diagnosing obesity, the MULT reference performed better among the BMI references, while the ABMI reference showed the best performance overall, being the only one capable of detecting that girls had proportionally higher fat mass (FM) than boys for the same index values. Moreover, the canalization analysis indicated that an increase in BMI-GC ≥0.67 during childhood was associated with a significantly higher risk of overweight at 9.5-13.5 years. These results suggest that the MULT reference can be an excellent option to assess the nutritional status of children and adolescents.

Accuracy of international growth charts to assess nutritional status in children and adolescents: a systematic review.

OBJECTIVE: To verify, through a systematic review, the accuracy of nutritional assessment in children and adolescents using the length/height-for-age and BMI-for-age growth charts of the Centers for Disease Control and Prevention (CDC) (2000), the World Health Organization (WHO) (2006/2007) and the International Obesity Task Force (IOTF) (2012). DATA SOURCE: We selected articles from the databases Medical Literature Analysis and Retrieval System Online (MEDLINE), through PubMed, National Library of Medicine and The National Institutes of Health (NIH), Scientific Electronic Library Online (SciELO) and Virtual Health Library (VHL). The following descriptors were used for the search: "Child", "Adolescent", "Nutritional Assessment", "Growth Chart", "Ethnic Groups", "Stature by age", "Body Mass Index", "Comparison", "CDC", "WHO", and "IOTF". The selected articles were assessed for quality through the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the NIH. DATA SYNTHESIS: Thirty-three studies published between 2007 and 2020 were selected and, of these, 20 presented good quality, 12 presented fair quality and one presented poor quality. For children under five years old, the WHO length/height-for-age growth charts were shown appropriate for children from Argentina, South Africa, Brazil, Gabon, Qatar, Pakistan and the United States. For those five years old and older, the WHO BMI-for-age growth charts were accurate for the Brazilian and Canadian populations, while the IOTF growth charts were accurate for the European populations. CONCLUSIONS: There are difficulties in obtaining international growth charts for children from 5 years old and older that go along with a long period of growth, and which include genetic, cultural and socioeconomic differences of multiethnic populations who have already overcome the secular trend in height.

Overweight and Risk of Noncommunicable Diseases in Adulthood: An Analysis of NHANES IV 2015-2016.

BACKGROUND: Worldwide, overweight is one of the main risk factors for Noncommunicable Diseases (NCDs). In this scenario, Body Mass Index (BMI) is the main tool to assess nutritional status of the adult population. AIM: To analyze the association between overweight and the risk of developing type 2 diabetes Mellitus (T2DM) and/or high blood pressure (HBP) during adulthood. SUBJECTS AND METHODS: We used data of subjects aged between 30-64 years old from the United States National Survey of Health and Nutrition Examination (2015-2016). We calculated the risk of developing T2DM and/or HBP in adulthood using a Log-Binomial Regression model. We included sampling weights in our analysis and we adjusted it for confounding factors. RESULTS: We evaluated a total of 2,666 individuals. Overweight affected around 38% of the sample when they were 25 years old and around 70% during the interview. We found 4 factors (overweight, smoking, sedentary lifestyle, and age) that were positively associated with the development of T2DM and/or HBP. Long-term overweight more than doubles the risk of developing these diseases [RR = 2.44; 95%CI: 1.92-3.09]. CONCLUSION: The incidence of T2DM and/or HBP were positively associated with the overweight in adulthood. These results suggest that the prevention of overweight could decrease NCDs prevalence into adulthood.

Concordância entre o Índice de Massa Corporal e a Mini Avaliação Nutricional em idosos / Agreement between the Body Mass Index and Mini Nutritional Assessment in elderly

Avaliar a concordância entre o Índice de Massa Corporal (IMC) e a Mini Avaliação Nutricional (MAN) para avaliação do estado nutricional de idosos. Estudo transversal, analítico descritivo, com idosos da Estratégia de Saúde da Família. Avaliou-se o estado nutricional pelo IMC e pela MAN, e foi descrito o perfil sociodemográfico, de comorbidades e estilo de vida. A correlação entre os indicadores foi calculada pelo teste de Spearman e a concordância avaliada através do estimador de Bland-Altman. Segundo o IMC, 29% dos idosos apresentaram baixo peso, enquanto a MAN demonstrou que 35% estavam desnutridos ou risco de desnutrição. A MAN apresentou diferença de média de -0,29 para o IMC e correlação positiva (rho = 0,35; p = 0,01). Houve concordância entre os métodos utilizados para avaliação do estado nutricional de idosos, sendo observada elevada prevalência de baixo peso, assim como de desnutrição e risco de desnutrição.

To evaluate the agreement between the Body Mass Index (BMI) and the Mini Nutritional Assessment (MNA) to assess the nutritional status of the elderly. Cross-sectional study with elderly in the Family Health Strategy program. Nutritional status was assessed using BMI and MNA, as well as the sociodemographic profile, comorbidities and lifestyle. The correlation between the indicators was calculated using the Spearman test and the agreement was assessed using the Bland-Altman estimator. According to the BMI, 29% of the elderly were underweight, while MNA demonstrated that 35% were malnourished or at risk of malnutrition. MNA showed a mean difference of -0.29 for BMI and a positive correlation (rho = 0.35; p = 0.01). There was agreement between the methods used to assess the nutritional status of the elderly, with a high prevalence of underweight, as well as malnutrition and risk of malnutrition.

BRAZIL'S PROGRESS IN PROTECTING, PROMOTING AND SUPPORTING BREASTFEEDING FROM THE PERSPECTIVE OF THE GLOBAL BREASTFEEDING COLLECTIVE.

OBJECTIVE: To identify and to discuss the progress of actions for the protection, promotion and support of breastfeeding in Brazil from the perspective of the indicators proposed by the Global Breastfeeding Collective. DATA SOURCE: A narrative review was conducted according to the methodological orientation of the implementation research and through a qualitative approach. Publications from the World Health Organization and the United Nations Children's Fund were selected, as well as publications from the Brazilian Ministry of Health were collected from the Virtual Health Library and from the libraries of the Department of Primary Care's portal and the Brazilian's Institute of Geography and Research. DATA SYNTHESIS: Brazil has shown promising results regarding the implementation of breastfeeding protection legislation, the participation of municipalities in community breastfeeding support programs, and the continued evaluation of these programs. However, reports of breastfeeding rates have not been produced every five years and the progress of these indicators is very far from the agreed targets for 2030. There is also a need to improve the number of births in child-friendly hospitals and financial donations for breastfeeding programs. CONCLUSIONS: It is necessary to strengthen systematic monitoring of breastfeeding and following up current strategies to more effectively impact the breastfeeding rates in the country. Furthermore, it is suggested that the practice of donations is a pathway to be explored to support breastfeeding programs.

Brazils progress in protecting, promoting and supporting breastfeeding from the perspective of the global breastfeeding collective / Progressos do brasil na proteção, promoção e apoio do aleitamento materno sob a perspectiva do global breastfeeding collective

ABSTRACT Objective: To identify and to discuss the progress of actions for the protection, promotion and support of breastfeeding in Brazil from the perspective of the indicators proposed by the Global Breastfeeding Collective. Data source: A narrative review was conducted according to the methodological orientation of the implementation research and through a qualitative approach. Publications from the World Health Organization and the United Nations Children's Fund were selected, as well as publications from the Brazilian Ministry of Health were collected from the Virtual Health Library and from the libraries of the Department of Primary Care's portal and the Brazilian's Institute of Geography and Research. Data synthesis: Brazil has shown promising results regarding the implementation of breastfeeding protection legislation, the participation of municipalities in community breastfeeding support programs, and the continued evaluation of these programs. However, reports of breastfeeding rates have not been produced every five years and the progress of these indicators is very far from the agreed targets for 2030. There is also a need to improve the number of births in child-friendly hospitals and financial donations for breastfeeding programs. Conclusions: It is necessary to strengthen systematic monitoring of breastfeeding and following up current strategies to more effectively impact the breastfeeding rates in the country. Furthermore, it is suggested that the practice of donations is a pathway to be explored to support breastfeeding programs.

RESUMO Objetivo: Identificar e discutir o progresso das ações para a proteção e a promoção do aleitamento materno no Brasil, bem como o apoio a ele, sob a perspectiva dos indicadores propostos pelo Global Breastfeeding Collective. Fontes de dados: Foi realizada uma revisão narrativa de acordo com a orientação metodológica da pesquisa de implementação e por meio de uma abordagem qualitativa. Foram selecionadas publicações da Organização Mundial da Saúde e do Fundo das Nações Unidas para a Infância e também publicações do Ministério da Saúde do Brasil coletadas na Biblioteca Virtual em Saúde e nas bibliotecas do portal do Departamento da Atenção Básica e do Instituto Brasileiro de Geografia e Estatística. Síntese dos dados: O Brasil tem apresentado resultados promissores com relação à implementação da legislação para proteção do aleitamento materno e à participação dos municípios nos programas comunitários de apoio ao aleitamento materno e na avaliação continuada desses programas, contudo os relatórios das taxas de aleitamento materno não têm sido produzidos a cada cinco anos, e o progresso desses indicadores está muito distante das metas pactuadas para 2030. Também há necessidade de melhoria no número de nascimentos em hospitais amigo da criança e das doações financeiras para os programas em prol da amamentação. Conclusões: É necessário o fortalecimento do monitoramento sistemático do aleitamento materno e do acompanhamento das estratégias atuais para que impactem de maneira mais efetiva nas taxas de amamentação no país. Ademais, sugere-se que a prática de doações é um caminho a ser explorado para o apoio dos programas de amamentação.