Latin American Study of Nutrition and Health (ELANS): rationale and study design.

BACKGROUND: Obesity is growing at an alarming rate in Latin America. Lifestyle behaviours such as physical activity and dietary intake have been largely associated with obesity in many countries; however studies that combine nutrition and physical activity assessment in representative samples of Latin American countries are lacking. The aim of this study is to present the design rationale of the Latin American Study of Nutrition and Health/Estudio Latinoamericano de Nutrición y Salud (ELANS) with a particular focus on its quality control procedures and recruitment processes. METHODS/DESIGN: The ELANS is a multicenter cross-sectional nutrition and health surveillance study of a nationally representative sample of urban populations from eight Latin American countries (Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Perú and Venezuela). A standard study protocol was designed to evaluate the nutritional intakes, physical activity levels, and anthropometric measurements of 9000 enrolled participants. The study was based on a complex, multistage sample design and the sample was stratified by gender, age (15 to 65 years old) and socioeconomic level. A small-scale pilot study was performed in each country to test the procedures and tools. DISCUSSION: This study will provide valuable information and a unique dataset regarding Latin America that will enable cross-country comparisons of nutritional statuses that focus on energy and macro- and micronutrient intakes, food patterns, and energy expenditure. TRIAL REGISTRATION: Clinical Trials NCT02226627.

The influence of breakfast and dairy products on dietary calcium and vitamin D intake in postpubertal adolescents and young adults.

BACKGROUND: Given the importance of both calcium and vitamin D for bone health and the high prevalence of vitamin D from around the world, the present study aimed to evaluate calcium and vitamin D intake in a group of healthy Brazilian adolescents and young adults and to examine the influence of breakfast and dairy products in the total intake of these nutrients. METHODS: One hundred and sixty adolescents and young adults, aged 16-20 years old, from a public school, participated in the present study. Three-day dietary records were used to assess calcium and vitamin D intakes. Serum 25(OH)D levels were measured using a radioimmunoassay kit. The results were expressed as the mean (SD). RESULTS: Only 3.8% of the subjects met the daily adequate intake recommendation for calcium, and none for vitamin D [682.2 (132.2)mg day(-1) and 124.0 (28.0)IU day(-1) , respectively]. 25(OH)D serum levels were insufficient in 51.5% and deficient in 9.7% of the individuals [72.5 (22.3) nmol L(-1) ]. There was a significant positive correlation between dairy product intake with both calcium and vitamin D (r=0.597 and r =0.561, respectively; P=0.000). Adolescents who ate breakfast had a significant higher mean calcium, vitamin D and dairy product intake than adolescents who did not report this meal. CONCLUSIONS: The majority of adolescents and young adults did not consume recommended intakes of calcium and vitamin D and also presented 25(OH)D insufficiency. The results indicate that a regular breakfast and the consumption of dairy products represent important strategies in improving calcium and vitamin D intake in the diet.

Calcium intake and its relationship with adiposity and insulin resistance in post-pubertal adolescents.

BACKGROUND: Dietary calcium intake has been described as being a negative contributor to adiposity. In adolescents, this relationship is not well established. The objectives of the present study were to compare the calcium intake of normal-weight and obese adolescents and to evaluate its relationship with adiposity and insulin resistance. METHODS: A cross-sectional analysis of 96 post-pubertal adolescents; 47 normal weight and 49 obese, mean age 16.6 (SD +/- 1.3) years. Body composition was assessed by dual-energy X-ray absorptiometry. Dietary intake was evaluated using a 3-day dietary record. The biochemical evaluation comprised the measurements of serum lipids, lipoproteins, glucose and insulin. Insulin resistance was calculated using the Homeostasis Model Assessment of Insulin resistance (HOMA-IR). RESULTS: The mean calcium intake, adjusted for energy, was lower in obese adolescents, 585.2 (+/-249.9) mg, than in normal weight adolescents, 692.1 (+/-199.5) mg. Only 4% of adolescents had an adequate intake of calcium. Calcium intake was inversely associated with body trunk fat, insulin and HOMA-IR in the obese group. The quartile analysis of calcium intake provided evidence that girls in the highest quartile had decreased adiposity and insulin resistance. CONCLUSIONS: This study showed a negative relationship between calcium intake and body fat and insulin resistance, mainly in obese girls, and demonstrates the importance of an increased dietary calcium intake.

Tetanus and diphtheria immunity in adolescents from São Paulo, Brazil.

Tetanus and diphtheria vaccines are of special concern in adolescents because boosters are necessary for adequate maintenance of protection and are often omitted. We assessed serum levels of tetanus and diphtheria antibodies in adolescents and their association with vaccination status. From May to October 2001, we evaluated the vaccination records of 208 adolescents aged 10 to 20 years in São Paulo, Brazil. Antibodies to tetanus and diphtheria were detected using double-antigen ELISA and vaccination records were analyzed according to the guidelines of the Brazilian National Immunization Program. All adolescents had received complete primary vaccinations against tetanus and diphtheria, but 23.1% of them had not received a booster dose in the last 10 years. All adolescents were immune to tetanus and 88.9% were fully protected (antibodies (3)0.1 IU/mL). One individual (0.5%) was non-immune to diphtheria and 86% were fully protected against the disease. Adolescents with up-to-date vaccination records had higher antibody levels than those with not up-to-date records for tetanus (0.763 vs 0.239 IU/mL, t-test: P < 0.0001) and diphtheria (0.366 vs 0.233 IU/mL, t-test: P = 0.014). Full immunity against tetanus (antibodies (3)0.1 IU/mL) was higher among individuals with up-to-date vaccination (93.1%) when compared to those with not up-to-date records (75%, Fisher's exact test: P = 0.001). All adolescents had received basic immunization in childhood and were protected against tetanus and diphtheria. However, these data indicate that more emphasis should be placed on the tetanus-diphtheria booster in order to avoid a decay in antibody levels.

Effects of type of physical exercise and leisure activities on the depression scores of obese Brazilian adolescent girls.

Several studies have indicated that depressive states may lead to hypokinesia with diminished metabolic rate and energy use. Hypokinesia associated with certain eating behaviors may lead to an unfavorable energy balance that can contribute to the emergence and prevalence of obesity among children and adults. The purpose of the present study was to examine the possibility of reducing depression inventory scores in female adolescents with third-degree obesity while testing the effectiveness of different exercise programs in reducing anxiety and depression scores. The sample consisted of 40 female subjects (mean age 16 +/- 1.56 years) divided into 4 groups (aerobic training, anaerobic training, leisure activities, and control). Subjects had a body mass index of 95% or more in relation to the 50th percentile. The aerobic program consisted of three ergometric bicycle sessions per week over a 3-month period (12 weeks) and the activities were prescribed after determining the anaerobic ventilatory threshold (VO2 threshold). Anaerobic training was based on the Wingate anaerobic power test. The leisure program consisted of a varied range of activities (games, exercises, etc.). A nutritionist interviewed the members of these two groups and the control group every week in order to adapt them to the nutritional guidelines proposed for the study. The study showed that all three programs (aerobic exercise, anaerobic exercise and leisure activities) were effective in reducing body mass. However, we found a significant reduction when analyzing the depression scores only for aerobic exercise (18.9 +/- 9.33 to 10.6 +/- 9.56 or 43.9%) but no significant alterations for anaerobic exercise (11.36 +/- 5.23 to 9.63 +/- 4.78 or 15.22%) and leisure (17.28 +/- 7.55 to 15.07 +/- 7.54 or 12.78%), thus indicating that in principle this type of activity could be included to improve emotional well-being of obese adolescent girls.

Controlled trial of zinc supplementation during recovery from malnutrition: effects on growth and immune function.

To evaluate the effect of zinc on growth and immune function, 32 marasmic infants were selected on admission to the nutrition recovery center; 16 received 2 mg/kg daily of elemental zinc supplement as acetate and the remaining received a placebo. Immunity was assessed by skin-test response, T-cell blastic proliferation immunoglobulins, and infectious morbidity. Weight-for-length gain for initial 60 days in Zn-supplemented group was 9% of standard vs 3% for placebo (p less than 0.05). Energy intake was similar in both groups. Incidence of infections, especially pyoderma, was significantly higher in placebo group: 10 of 16 vs 3 of 16 in the supplemented group (p less than 0.025). Plasma Zn was correlated with number of febrile days in the prospective month (r = -0.66, p less than 0.05). The percent anergic infants decreased and serum IgA increased significantly only in Zn-supplemented group. Zinc supplementation has significant effects on weight gain and host defense mechanisms despite normal plasma levels. Zinc supplementation is recommended for optimal recovery from marasmus.

Controlled trial of copper supplementation during the recovery from marasmus.

To evaluate copper nutritional status and the effect of a Cu supplement during recuperation, 27 marasmic infants were selected on admission to the nutrition recovery center at the Instituto de Nutrición y Tecnología de los Alimentos. Thirteen infants received 80 micrograms/kg/day of copper supplement as sulphate and the remaining a placebo. They were paired by birth weight, age, and sex. Anthropometric indices, complete blood count, ceruloplasmin, and Cu were measured on admission and at monthly intervals. Superoxide dismutase activity was measured in hypocupremic infants and was found to be low. The mean +/- SE Cu levels on admission were 127 +/- 10 micrograms/dl for the supplemented group and 137 +/- 10 micrograms/dl for the control. We found an increase in plasma Cu to 159 and 162 micrograms/dl on days 30 and 60 in the supplement group, and a significant decrease after day 30 in the placebo group. The ceruloplasmin levels followed this trend. Hypocupremia was found in 30% of the placebo group and none in the supplement group. The placebo group had a significantly higher prevalence of severe lower respiratory infections. It is concluded that a significant proportion of marasmic infants fed a milk-based diet present, during recovery, biochemical evidence of Cu deficiency. Supplementation with Cu is suggested.

Plasma zinc, copper, and erythrocyte superoxide dismutase in children with phenylketonuria.

Children with phenylketonuria (PKU) are treated with semisynthetic diets restricted in phenylalanine (PHE). The formulae must supply those trace elements and vitamins that are usually supplied by whole protein foods. We studied the effects of phenylalaline restricted diets in 42 children with PKU (P) and 31 normal (N) children, aged 1-12 y, divided into two groups (below and above 7 y). Plasma zinc and copper were analyzed by means of atomic spectrophotometry, and superoxide dismutase (CuZnSOD) activity was measured in erythrocytes, through NBT inhibition and its profile, as determined by isoelectric focalization. Plasma zinc of PKU children > or = 7 years old was significantly lower than that in the control group (17 mumol/L versus 20 mumol/L) but still within the normal range; in children < 7 years no substantial differences were found between the two groups. Plasma copper was not statistically different between PKU and normal children. Qualitative activity of CuZnSOD presented the same electrophoretic profile in both normal and PKU. Quantitative activity was not different in both P (1210 U/g Hb < 7 versus 1328 U/g hemoglobin (Hb) > or = 7) and N (1675 U/g Hb < 7 versus 1367 U/g Hb > or = 7). We concluded that children with PKU presented normal mean levels of zinc and copper, with preserved function, measured by enzyme activity.

Bone mineral density in juvenile systemic lupus erythematosus.

We evaluated spine bone mineral density (BMD) in Brazilian children with juvenile systemic lupus erythematosus (JSLE) in order to detect potential predictors of reduction in bone mass. A cross-sectional study of BMD at the lumbar spine level (L2-L4) was conducted on 16 female JSLE patients aged 6-17 years. Thirty-two age-matched healthy girls were used as control. BMD at the lumbar spine was measured by dual-energy X-ray absorptiometry. Weight, height and pubertal Tanner stage were determined in patients and controls. Disease duration, mean daily steroid doses, mean cumulative steroid doses and JSLE activity measured by the systemic lupus erythematosus disease activity index (SLEDAI) were determined for all JSLE patients based on their medical charts. All parameters were used as potential determinant factors for bone loss. Lumbar BMD tended to be lower in the JSLE patients, however, this difference was not statistically significant (P = 0.10). No significant correlation was observed in JSLE girls between BMD and age, height, Tanner stage, disease duration, corticosteroid use or disease activity. We found a weak correlation between BMD and weight (r = 0.672). In the JSLE group we found no significant parameters to correlate with reduced bone mass. Disease activity and mean cumulative steroid doses were not related to BMD values. We did not observe reduced bone mass in female JSLE.

[Intelligent quotient of obese children and adolescents by the Weschler scale]. / Quociente de inteligência de crianças e adolescentes obesos através da escala Wechsler.

The intellectual characteristics of 65 obese children and adolescents (weight for height > or = 140%), aged 8 to 13 years and 11 months, were compared to those of 35 eutrophic children and adolescents (weight for height between 90 and 110%; and stature for age > 95%) of the same age group, utilizing the Wechsler Intelligence Scale for Children--WISC. Children and adolescents of the two groups were paired according to age groups, schooling level and socioeconomic condition. The obese group was composed of new patients assisted at the Department of Pediatrics of the Federal University of S. Paulo (Escola Paulista de Medicina), Brazil. The control group was made up of children from public primary schools, from the same geographical area as those studied. The eutrophic group presented significantly better performance in the intelligence test (Intelligence Quotient--IQ) than the obese group (average IQ--91 x 85; p < 0.05). Eutrophic children and adolescents revealed a wider range of interests, better capacity for social adaptability as well as greater speed and dexterity. Although weak, there was a positive correlation between income level, weight/stature relation (W/S) and IQ. There was no correlation between IQ and level of schooling. The eutrophic boys from higher income levels showed better perceptual and spacial organizing ability and a wider range of interests than those from the lower income groups. In spite of the fact that all the average IQ results presented consistently favored the eutrophic in relation to the obese, it is not possible to confirm one group's superiority over the other, due to the wide range of intervenient factors involved in the intelligence process.

Nutritional assessment and serum zinc and copper concentration in leukemic children.

CONTEXT: Malnutrition in childhood cancer is commonly a serious problem. Changes in blood zinc and copper have also been found in malignant diseases. OBJECTIVE: To describe the protein-energy nutritional status and serum zinc and copper of children with newly diagnosed leukemia. DESIGN: Cross-sectional study. SETTING: University referral center. PARTICIPANTS: 23 children with newly diagnosed acute lymphocytic leukemia (ALL) or acute non-lymphocytic leukemia (ANLL) between the ages of 1 and 10 years. The control subjects were 31 healthy school children of similar age from local schools. MAIN MEASURES: Anthropometric measurements of height/age and weight/height, food intake and serum levels of zinc and copper. RESULTS: Almost the entire group of children were eutrophic. Zinc and copper intake were below the recommended values. Serum zinc levels were significantly lower and serum copper levels were significantly higher in the leukemic group when compared to normal children. CONCLUSION: At the time of diagnosis the children suffering from leukemia were not overtly malnourished but blood analysis showed alterations in concentrations of the trace elements zinc and copper.

Nutritional and metabolic assessment of critically ill children.

In a prospective study, with the objective of determining the metabolic profile, response to nutrient supply, and role of nutritional and metabolic assessment parameters in children admitted to a pediatric ICU, 11 patients in the age group 2-12 were studied. The assessment was carried out during the first 72 hours of admission, and again seven days later, and included the following parameters; caloric supply; nitrogen supply; prealbumin serum level; urinary urea nitrogen; nitrogen balance and creatinine-height index. The evolution of the parameters in the two stages of the study showed the following results: The urinary urea nitrogen median value at admission was 7.5 g/m2 of corporeal surface, and did not present significant changes seven days later. There was a significant increase in caloric supply from 42.9 to 70.3 kcal/kg, and in nitrogen supply, from 4.7 to 10.2 g/m2 of corporeal surface p 0.01. The level of nitrogen balance rose from -5.6 to 2.5 g/24 h (p < 0.03), and that of prealbumin, from 16.7 to 26.3 mg/dl (p < 0.03). There was a significant reduction in the creatinine-height index, from 86.2 percent to 55.0 percent p 0.01. The magnitude of urinary urea nitrogen excretion at admission varied 2.5-13.8 g/m2 of corporeal surface. Based on this parameter, it was not possible to establish a characteristic metabolic profile for the conditions studied. Notwithstanding an increase in the protein and caloric supply, prealbumin level and nitrogen balance observed in the second stage of the study, the patients lost muscle mass and entered into a malnutrition process, probably due to intense protein catabolism and the poor response to nutrition supply that occurs in metabolic stress.

Nutritional assessment and surgical risk markers in children submitted to cardiac surgery.

In order to assess the nutritional status of children with heart diseases and to evaluate nutritional parameters for predicting postoperative complications, 50 children undergoing to cardiac surgery and classified in high and low surgical risk prospectively evaluated. Assessment parameters included anthropometry and plasma proteins albumin, transferrin and prealbumin. The nutritional classification according to Waterlow's modified criteria showed a high prevalence of malnutrition in the population studied (78%). The measures of arm circumference when located below the 5th percentile showed a significant association with general postoperative complications in the high risk group (arm circumference, p = 0.0019; arm muscle circumference, p = 0.0419). The percentage of weight per height, serum albumin and transferrin has not played a prognostic role concerning postoperative morbidity. The mean value of prealbumin was significantly lower in high risk group patients developing postoperative infections (p < 0.01) compared to those who did not. The sensitivity-specificity analysis of prealbumin as risk indicator for postoperative infection was 87.5% and 59% respectively. The nutritional risk classification seems to be a good way to identify the subgroups of children with additional postoperative surgical risk. However, more specific and sensitive tests are desirable to provide an individual identification of these children.

Nutritional evaluation of children with phenylketonuria.

CONTEXT: Dietary phenylalanine (PA) restriction is the most effective form for reducing its excess in the blood and is the only efficient method for treating phenylketonuria. The diet is complex and should be adapted to combine the patients' eating habits, growth and development. It depends basically on the use of industrialized products as substitutes free of PA for proteins that are not fully supplied. OBJECTIVE: To evaluate the nutritional status of children with phenylketonuria (PKU) by anthropometric measurements and food intake. DESIGN: Cross-sectional study. SETTING: Children with PKU attending the Association of Parents and Friends of Handicapped Children (Associação de Pais e Amigos dos Excepcionais - APAE) and normal children attending at municipal day care centers in São Paulo. PARTICIPANTS: 42 children with PKU and 31 normal children aged 1 to 12 of both sexes were assessed in two groups, under and over 7 years of age. MAIN MEASUREMENTS: Weight and height measurements. RESULTS: Children with PKU ingested calories, calcium, iron, zinc, and copper below the recommended values, whereas the protein intake was within the normal range. Food intake in the group of normal children was within normality rates. The height/weight Z-score means for children with PKU were 0.47 for those under 7 years and 1.86 for 7 year-olds and over; in normal children the means were 0.97 <7 years and 1.54 >/=7 years, with no statistically significant difference. The height/age Z-score means were significantly lower in the PKU children <7 years (-1.23) than in the normal controls (0.91). CONCLUSIONS: The data presented demonstrate the importance of nutritional surveillance in patients with PKU so as to support adequacy of nutrient intake and to guarantee growth within the relevant standards.

[Nutritional status of children with congenital heart disease and left-to-right shunt. The importance of the presence of pulmonary hypertension]. / O estado nutricional de crianças portadoras de cardiopatia congênita com shunt esquerda-direita. Importância da presença de hipertensão pulmonar.

PURPOSE: To assess the nutritional status of children with congenital heart disease with left-to-right shunt and the nutritional disturbances related to the presence of pulmonary hypertension (PH). METHODS: In a prospective study, the nutritional status of 30 children with left-to-right shunt (16 with and 14 without PH) was determined by anthropometric parameters and plasma proteins albumin, transferrin and prealbumin. Frequency and extent of nutritional disturbances were analysed in relation to the presence of PH. A control group of 20 well-nourished children was formed, aiming to compare the values of the serum proteins. RESULTS: The nutritional classification according to Waterlow's criteria showed an overall prevalence of malnutrition of 83.3%, which was higher in those with PH (p = 0.0140). This patient's group was more wasted than the group without PH (median z score of weight for height -1.65 vs -0.78). There was a high occurrence of measurements of arm fat area below the 5th percentile, which were similar in both groups. Serum levels of albumin and prealbumin were significantly lower in children with congenital heart disease than in the control group and transferrin values were similar in both. CONCLUSION: The prevalence of malnutrition was high. The presence of PH was associated with higher nutritional disturbance. The nutritional assessment may be a good way to identify diagnostic groups at particular risk of failure to thrive. This can be useful in planning a management which ensures these patients to achieve adequate nutritional supplementation in early life.

Risk factors for atherosclerosis in students of a private university in São Paulo-Brazil.

OBJECTIVE: To characterize the risk profile for atherosclerosis (AS) in adolescents and young adults of a private university in São Paulo. METHODS: Clinical, nutritional, and laboratory parameters were evaluated in 209 students of both genders aged 17 to 25 years. In addition to determination of the lipid profile, the association of its abnormal values with other risk factors for AS was also investigated. RESULTS: Increased levels of total cholesterol, LDL-C and triglycerides (TG) were observed in 9.1%, 7.6% and 16.3% of the students, respectively, and decreased levels of HDL-C in 8.6% of them. Prevalence of the remaining risk factors analyzed was elevated: sedentary life style (78.9%); high intake of total fat (77.5%); high cholesterol intake (35.9%); smoking, hypertension (15.8%) and obesity (7.2%). There was an association between elevated LDL-C and TG levels and sedentary life style and body mass index. CONCLUSION: The high prevalence of risk factors for AS in young individuals draws attention to the need for adopting preventive plans.

The use of sugar fortified with iron tris-glycinate chelate in the prevention of iron deficiency anemia in preschool children.

In the present work, the effectiveness of consumption for 6 months of iron fortified sugar in the prevention or control of iron deficiency anemia was evaluated in 93 children (10-48 months old) attending a day care center in São Paulo, Brazil. Each child consumed 20 g of fortified sugar per day for 5 days a week in orange juice during breakfast. Two levels of fortification were tested using iron tris-glycinate chelate as the source of iron. Level one sugar contained 10 mg of iron/kg of sugar, and level 2, 100 mg of iron/kg. The children were assigned to either of the two groups. The first group (n = 42) received level 1 sugar, and those of group two (n = 52) received level 2 sugar. The daily iron intake corresponded to 2 and 20% of the RDA. At the end of the 6 months trial period, significant increases in weight/height ratio was observed in both groups. In the group consuming level 1 fortified sugar the mean change in hemoglobin concentration was 0.4 g/dL (from 11.3 grams to 11.7 g/dL), and in the group consuming level two fortified sugar the mean hemoglobin increase was also 0.4 g/dL (from 11.6 to 12.0 g/dL). Both changes were highly significant (p < 0.001). When only the anemic children were considered (32/93), the increment of hemoglobin was 1.4 g/dL. In anemic children there was a significant increase in the levels of serum ferritin. The increase was more notorious in group 2 children. We verified that the acceptability of the iron-fortified sugar was excellent. There were no detectable changes in the organoleptic characteristics of the fortified sugar as compared with unfortified sugar. No differences in response were observed between the two groups indicating that probably the lower level of iron was absorbed more efficiently that the higher level. The iron tris-glycinate chelate was very well tolerated with no side effects registered. It was concluded that even with low iron levels, the consumption of iron fortified sugar is an effective, low cost intervention for the control and prevention of iron deficiency anemia in preschool children.

Zinc, copper and iron and their interrelations in the growth of sickle cell patients.

In this study we evaluated the nutritional status of 34 children with sickle cell disease (SS). Results were compared to 9 siblings with sickle cell trait (AS) and 35 eutrophic children who presented normal hemoglobin and normal hemoglobin electrophoresis (AA). All of then came from low socioeconomic level. Analysis of the growth velocity curves revealed in SS group, tendency to increase deficit in weight and height with age. There was no relation between weight/height (W/H) and height/age (H/A) percentile and hemoglobin levels. There was no significant relation between nutritional status and severity of the disease. SS group showed significant skeletal maturation delay, the same did not occur with the siblings (AS group). Plasma zinc levels were significantly lower in SS group than in AS and AA groups. In SS group there was some association between lower plasma zinc levels and H/A percentile lower or equal to 10. Plasma copper levels were significantly greater in SS group than in AS and AA ones, and there was no relation between plasma copper levels and serum ferritin levels. In conclusion, our patients with sickle cell disease showed indexes of malnutrition, iron deficiency, hypercupremia and low plasma zinc levels related to low stature.

[Plasma zinc and copper in infants with protein-calorie malnutrition]. / Zinc y cobre plasmáticos en lactantes con desnutrición proteínico-energética.

Forty-five marasmic infants were studied for plasma zinc and copper levels. They were selected from those children admitted to a nutritional recovery center. The mean plasma zinc level was 92.4 +/- 24 micrograms/dl (mean +/- SD); 7% of the infants had low zinc values as defined by zinc less than 70 micrograms/dl. Median copper was 90 micrograms/dl (range 27-172) and 49% of the children had copper levels below 90 micrograms/dl (established as our normal limit). Birth weight, breast feeding and prior hospitalization for acute diarrhea with dehydration were studied as antecedents related to low Cu and Zn. Children with prior diagnosis of acute diarrhea and hospitalization had lower copper levels than those sent from primary care centers. Breast feeding was associated with higher Cu levels. No relationship was found between zinc levels and those antecedents, but differences were found in regard to the degree of malnutrition, season of the year and Zn status. In this investigation no Zn deficiency was found in marasmus cases. Hypocupremia, however, is a very significant problem in marasmic infants, especially when associated with early weaning and the presence of previous hospitalization for acute diarrhea.

The use of sweet rolls fortified with iron bis-glycinate chelate in the prevention of iron deficiency anemia in preschool children.

The effectiveness of bread fortified with iron bis-glycinate chelate for the control of iron deficiency and iron deficiency anemia was evaluated in 89 preschool children from families of low socioeconomic level attending 2 day nurseries of the Sao Paulo City Council. During the intervention's time of 6 months the children received besides their usual center's diet, a daily supplement of two sweet rolls fortified with 2 mg each of iron from the chelate for a total daily iron intake of 4 mg. After six months of intervention there was a significant decrease in the prevalence of iron deficiency anemia from 62 to 22%. There was a mean hemoglobin improvement of 1.1 g/dL, and in children with initial hemoglobin levels < 11 g/dL the mean increase in hemoglobin was 1.42 g/dL. The total mean plasma ferritin values increased from 11.34 to 20.2 micrograms/L, and in those children originally iron depleted the ferritin values normalized. A significant increase in the "z" score for weight/height was also observed. We concluded that the use of sweet rolls fortified with 2 mg of iron from the bis-glycinate chelate is highly effective for the control of iron deficiency and iron deficiency anemia in young children.