The double burden of malnutrition: aetiological pathways and consequences for health.

Malnutrition has historically been researched and addressed within two distinct silos, focusing either on undernutrition, food insecurity, and micronutrient deficiencies, or on overweight, obesity, and dietary excess. However, through rapid global nutrition transition, an increasing proportion of individuals are exposed to different forms of malnutrition during the life course and have the double burden of malnutrition (DBM) directly. Long-lasting effects of malnutrition in early life can be attributed to interconnected biological pathways, involving imbalance of the gut microbiome, inflammation, metabolic dysregulation, and impaired insulin signalling. Life-course exposure to early undernutrition followed by later overweight increases the risk of non-communicable disease, by imposing a high metabolic load on a depleted capacity for homoeostasis, and in women increases the risk of childbirth complications. These life-course trajectories are shaped both by societal driving factors-ie, rapidly changing diets, norms of eating, and physical activity patterns-and by broader ecological factors such as pathogen burden and extrinsic mortality risk. Mitigation of the DBM will require major societal shifts regarding nutrition and public health, to implement comprehensive change that is sustained over decades, and scaled up into the entire global food system.

The impact of food addiction behaviours on the treatment of overweight students.

The present study evaluated the association of food addiction (FA), the change of the BMI/age z-score and the consumption of ultra-processed foods in overweight students undergoing a 16-month, multicomponent intervention in the school environment. FA was investigated using the Yale Food Addiction Scale for Children, and the dietary assessment was estimated using the semi-quantitative FFQ in overweight 9-11-year-old students (BMI/age z-score ≥ 1) of both sexes at their baseline and after the intervention (n 120). Among the schoolchildren, 33·4 % had FA in at least one of the two assessments. The analysis of mixed-effects models to assess the effect of the intervention and the change of the BMI/age z-score between evaluations showed that the occurrence of FA influenced the maintenance of weight (time#FA, ß = 0·30, 95 % CI 0·05, 0·54, P = 0·016). Weight loss was observed only in individuals who did not present FA (BMI/age z-score = -0·3). When evaluating the effect of the intervention and the dietary variables, we verified a reduction in the consumption of sugary milk-based drinks -71·13 kJ (-17 kcal), P = 0·04 only in non-FA students at the end of the study. FA has been identified as an underlying factor with therapeutic relevance, and an enhanced understanding of FA can open new paths for the prevention and management of obesity.

Food addiction symptoms and metabolic changes in children and adolescents with the double burden of malnutrition.

The double burden of malnutrition (DBM) has been described in many low-/middle-income countries. We investigated food addiction, thyroid hormones, leptin, the lipid/glucose profile and body composition in DBM children/adolescents. Subjects were allocated into groups according to nutritional status: control (C, n 28), weight excess (WE, n 23) and DBM (WE plus mild stunting, n 22). Both the DBM and WE groups showed higher mean insulin concentrations than the control (DBM = 57·95 (95 % CI 47·88, 70·14) pmol/l, WE = 74·41 (95 % CI 61·72, 89·80) pmol/l, C = 40·03 (95 % CI 34·04, 47·83) pmol/l, P < 0·001). WE and DBM showed more food addiction symptoms than the control (3·11 (95 % CI 2·33, 3·89), 3·41 (95 % CI 2·61, 4·20) and 1·66 (95 % CI 0·95, 2·37)). In DBM individuals, addiction symptoms were correlated with higher body fat and higher insulin and leptin levels. These data provide preliminary evidence consistent with the suggestion that DBM individuals have a persistent desire to eat, but further studies are required to confirm these results in a larger study. These hormonal changes and high body fat contribute to the development of diabetes in long term.

Exploring the consumption of ultra-processed foods and its association with food addiction in overweight children.

The present study explored the consumption of ultra-processed foods and its association with food addiction in overweight children. The prevalence of food addiction was investigated using the Yale Food Addiction Scale for Children in overweight 9-11 year-old children (BMI/age ≥1 Z score) of both sexes from two schools (n = 139). Food intake was estimated by a food frequency questionnaire and the food items were classified into 4 categories: minimally processed, culinary ingredients, processed foods and ultra-processed foods (UPF), based on their degree of processing. Among the children, 95% showed at least one of the seven symptoms of food addiction and 24% presented with a diagnosis of food addiction. In analysis of covariance adjusted for age and sex, a tendency of higher consumption of added sugar (refined sugar, honey, corn syrup) and UPF was found among those diagnosed with food addiction. Multiple logistic regression adjusted for sugar, sodium and fat ingestion showed that consumption of cookies/biscuits (OR = 4.19, p = 0.015) and sausages (OR = 11.77, p = 0.029) were independently associated with food addiction. The identification of foods that may be associated with addictive behavior is very important for correctly treating and preventing childhood obesity, which continues to be one of the greatest health problems in the world.

Effectiveness of a 16-month multi-component and environmental school-based intervention for recovery of poor income overweight/obese children and adolescents: study protocol of the health multipliers program.

BACKGROUND: Excess of weight is a serious public health concern in almost all countries, afflicting people of different ages and socioeconomic backgrounds. Studies have indicated the need for developing treatment strategies that intervene directly in the obesogenic environment. This study aims to evaluate the effectiveness of a multi-component and environmental school-based intervention, lasting 16 months, on the recovery of the nutritional status of low-income children and adolescents with overweight/ obesity. METHODS/STUDY DESIGN: The study was conducted by the Center for Recovery and Nutritional Education (CREN) in São Paulo, Brazil. Two schools located in poor neighborhoods were selected for the intervention, between March 2016 and June 2017. The participants were all students aged 8 to 12 years from the two participating schools. At the beginning of the intervention, anthropometric measurements were carried out to assess the nutritional status of the students. For convenience, students from one of the schools were considered as the control group, while those from the other school formed the experimental group. The intervention in the experimental group (n = 438) consists of the following weekly activities at school: psychological counseling in groups, theoretical/practical nutrition workshops, and supervised physical education classes. In addition, theoretical and practical educational activities are held regularly for parents, teachers, and cooks. Students with excess of weight (≥1 body mass index [BMI] -for-age Z score, n = 138) received clinical and nutritional care periodically at the outpatient care at CREN. Students enrolled in the control group (n = 353) participated in psychological counseling groups and theoretical/practical nutrition workshops for 6 months held in the school environment to provide motivation to entire classrooms. In the following 10 months, students with excess of weight from the control group (n = 125) were invited to attend the routine outpatient care at CREN. DISCUSSION: This study is the first to assess the effectiveness of a multi-component and environmental school-based intervention for the recovery of low-income, overweight/obese children and adolescents. If positive, the results demonstrate the feasibility for the recovery of excess of weight in populations of similar conditions and age. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials - ReBEC Primary Id Number RBR-9t2jr8 . Registration Date: Nov. 30, 2016. Retrospectively registered. Protocol version: 3.

Child undernutrition in Brazil: the wound that never healed.

OBJECTIVE: To describe the scenario of child undernutrition in Brazil and its determinants. DATA SOURCE: Narrative review of the literature with inclusion of data from population surveys, surveillance and monitoring systems, and active search in favelas and underserved communities carried out by CREN. DATA SYNTHESIS: Household surveys carried out from 1974 to 2019 indicate that undernutrition (<5 years) decreased until 2006. Underweight (W/A ≤-2 Z) and stunting (H/A ≤-2 Z) showed a decrease of 17% to 3% and 37% to 7%, respectively. After 2006, there was an increase in underweight of 53% and 76% for wasting (BMI/A ≤-2 Z), with the prevalence of stunting being stagnant at around 7%. Active search data in favelas and underserved communities show that the prevalence of stunting is 11% in those <5 years. In 2021, 30% of the population lived in poverty, 73% of which were black or brown. Stunting in black and brown children <5 years old is, respectively, 9% and 12% higher when compared to white children. Poverty decreased between 2012 and 2015 (27 to 25%), but increased again (2016=26% to 2021=30%), in parallel with food insecurity, which decreased between 2004 and 2013 (12% to 6%), but reached its worst level in the historical series (2022:15%). CONCLUSION: Despite advances, Brazil's social protection system was not able to reduce inequalities and the reversal of the trend towards decreasing child undernutrition could be observed from 2006 onwards.

High glycemia and resistin normalized in children with double burden of malnutrition: a cross-sectional study.

The coexistence of stunting and excess weight in the same individual is defined as a double burden of malnutrition (DBM) and is associated with noncommunicable diseases. In this study, we evaluated the impact of DBM on adipokine concentrations and metabolic profiles in children compared with weight excess alone. Children were allocated to the weight excess group (n = 23) (height-for-age (HAZ) > 0.0 and < 2.0 Z-score and body mass index-for-age (BMI/A) > 1.0 Z-score) or DBM (n = 22) group (HAZ < -1.0 Z-score (including mild stunting) and BMI/A > 1.0 Z-score). Lipid, glycemic profile, resistin, plasminogen activator inhibitor-1, leptin, and adiponectin concentrations were analyzed. Glycemia was significantly higher in the DBM group compared to the weight excess group (5.05 (4.76-5.31) mmol/L vs. 4.57 (4.35-4.81) mmol/L), although no differences were found in insulin and homeostasis model assessment of insulin resistance (HOMA-IR). Adipokine concentrations did not differ between the groups. However, the DBM group showed higher resistin concentrations normalized by body fat mass than those of the weight excess group (1.44 (0.98-1.93) ng/mL vs. 0.76 (0.55-1.45) ng/mL). Insulin and HOMA-IR showed a negative correlation with adiponectin (r = -0.590 and -0.624, respectively, both p < 0.01). DBM was associated with increased glucose and resistin concentrations adjusted by fat mass compared to that associated with excess weight alone. Therefore, this association between mild stunting and weight excess has deleterious potential for long-term metabolic function, highlighting an additional precaution against weight gain in children, especially in those with stunting.

Estimating total body fat using a skinfold prediction equation in Brazilian children.

BACKGROUND: The double burden of obesity and underweight is increasing in developing countries and simple methods for the assessment of fat mass in children are needed. AIM: To develop and validate a new anthropometric predication equation for assessment of fat mass in children. SUBJECTS AND METHODS: Body composition was assessed in 145 children aged 9.8 ± 1.3 (SD) years from São Paulo, Brazil using dual energy X-ray absorptiometry (DEXA) and skinfold measurements. The study sample was divided into development and validation sub-sets to develop a new prediction equation for FM (PE). RESULTS: Using multiple linear regression analyses, the best equation for predicting FM (R(2) = 0.77) included body weight, triceps skinfold, height, gender and age as independent variables. When cross-validated, the new PE was valid in this sample (R(2) = 0.80), while previously published equations were not. CONCLUSION: The PE was more valid for Brazilian children that existing equations, but further studies are needed to assess the validity of this PE in other populations.

Thyroid axis hormones and anthropometric recovery of children/adolescents with overweight/obesity: A scoping review.

Introduction: Thyroid hormones exert multiple physiological effects essential to the maintenance of basal metabolic rate (BMR), adaptive thermogenesis, fat metabolism, growth, and appetite. The links between obesity and the hormones of the thyroid axis, i.e., triiodothyronine (T3), thyroxine (T4), and thyrotropin (TSH), are still controversial, especially when considering children and adolescents. This population has high rates of overweight and obesity and several treatment approaches, including nutritional, psychological, and physical exercise interventions have been used. Understanding the importance of the hormones of the thyroid axis in the recovery from overweight and obesity may help directing measures to the maintenance of a healthy body composition. The present scoping review was carried out to analyze studies evaluating these hormonal levels throughout interventions directed at treating overweight and obesity in children and adolescents. The main purpose was to ascertain whether the hormones levels vary during weight loss. Methods: We selected for analysis 19 studies published between 1999 and 2022. Results: Most of the studies showed that changes in different anthropometric indicators, in response to the multidisciplinary interventions, correlated positively with free T3 (fT3), total T3 (TT3), and TSH. With respect to free T4 (fT4) and total T4 (TT4). Discussion: The most common finding was of unchanged levels and, hence, no significant association with weight loss. Moreover, thyroxine supplementation has failed to affect the response to the interventions. Further studies are necessary to elucidate the relevance of the variations in hormone levels to the establishment of overweight/obesity and to the recovery from these conditions in children/adolescents. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020203359.

Height and weight gains in a nutrition rehabilitation day-care service.

OBJECTIVE: To evaluate nutritional recovery patterns in 106 undernourished children assisted by the Center of Nutritional Recovery and Education (CREN, in Portuguese) between January 1995 and December 1999. DESIGN: CREN assists undernourished children aged 0 to 72 months living in the southern regions of Sao Paulo, in an outpatient setting. Nutritional status was assessed by Z-scores of weight-for-age, height-for-age and weight-for-height. Nutritional recovery evaluation considered Z-score gains in weight-for-age and height-for-age, grouping into four categories (Z-score increment of 0.50 between groups). Children with birth weight less than 2500 g were classified as low birth weight (LBW), while those born at term and with LBW were classified as small for gestational age. SETTING: CREN (Center of Nutritional Recovery and Education in Portuguese), Sao Paulo, Brazil. SUBJECTS: One hundred and six children from CREN. RESULTS: Among the 106 evaluated children, ninety-eight (92.5 %) recovered their weight or height and seventy-two (67.9 %) recovered both. Nearly half of studied children presented a nutritional recovery (increase in Z-score) of more than 0.50 in height-for-age (46.2 %) and about 40 % in weight-for-age (38.7 %). Multivariate analysis showed that treatment duration and initial weight-for-age contributed to weight-for-age Z-score increment, explaining 25 % of the variation; and treatment duration, initial height-for-age and weight-for-age Z-score increment contributed to height-for-age Z-score increment, explaining 62 % of the variation. CONCLUSIONS: Our findings show that nutritional recovery among children who attended CREN was influenced primarily by the degree of nutritional deficit at admission. It has also been shown that biological variables are more important than socio-economic status in determining the rate of nutritional recovery.

Child undernutrition in Brazil: the wound that never healed

Abstract Objective To describe the scenario of child undernutrition in Brazil and its determinants. Data source Narrative review of the literature with inclusion of data from population surveys, surveillance and monitoring systems, and active search in favelas and underserved communities carried out by CREN. Data synthesis Household surveys carried out from 1974 to 2019 indicate that undernutrition (<5 years) decreased until 2006. Underweight (W/A ≤-2 Z) and stunting (H/A ≤-2 Z) showed a decrease of 17% to 3% and 37% to 7%, respectively. After 2006, there was an increase in underweight of 53% and 76% for wasting (BMI/A ≤-2 Z), with the prevalence of stunting being stagnant at around 7%. Active search data in favelas and underserved communities show that the prevalence of stunting is 11% in those <5 years. In 2021, 30% of the population lived in poverty, 73% of which were black or brown. Stunting in black and brown children <5 years old is, respectively, 9% and 12% higher when compared to white children. Poverty decreased between 2012 and 2015 (27 to 25%), but increased again (2016=26% to 2021=30%), in parallel with food insecurity, which decreased between 2004 and 2013 (12% to 6%), but reached its worst level in the historical series (2022:15%). Conclusion Despite advances, Brazil's social protection system was not able to reduce inequalities and the reversal of the trend towards decreasing child undernutrition could be observed from 2006 onwards.

Short stature and food habits as determining factors for the low productivity of sugarcane labourers in the State of Alagoas, north-eastern Brazil.

Undernutrition, especially in the prenatal period and/or until 5 years of age, can cause stunting. Adults with short stature resultant from this process show a series of functional deficits, amongst which is a reduced capacity to do physical work. The aim of this investigation was to evaluate the dietary pattern, nutritional status and stature of sugarcane cutters, and to determine possible associations with worker productivity. Sixty-two male sugarcane cutters (18-50 y) were selected randomly from a population of 600 workers from a plantation in Alagoas (Brazil), and classified as underweight, normal weight or overweight according to BMI (BMI = 21.5, 21.5 to = 25 and >25 kg/m2, respectively). Body fat composition (%) was estimated by electrical bioimpedance and dietary intake by the direct weighing of food consumed. Whilst the average productivity was 8.13 ton/day, labourers with normal BMI values were more productive (9.12 ton/dia) and ingested significantly (p<0.05) greater amounts of energy (16506.4 kJ/dia) than their underweight (7.48 +/- 1.5; 12380.7 +/- 4184.1) or overweight (9.12 +/- 1.5; 16506.4 +/- 6360.0) counterparts, respectively. There were associations (p<0.05) between productivity, stature, energy intake and age. The tallest individuals (= 170 cm) had higher productivity and tended to have a higher energy intake, whilst those with the shortest stature (= 160 cm), had a significantly lower productivity, however ingested a similar quantity of energy, and tended to have a large accumulation of body fat. Multiple regression analysis identified stature as the parameter most associated with productivity, independent of age and body fat percentage. Productivity of the tallest individuals was 1.87 ton/day higher than that of the shortest individuals. The results emphasise the importance of good nutritional status throughout life for full development of working productivity.

MULTIDISCIPLINARY AND MOTIVATIONAL INTERVENTION FOR THE TREATMENT OF LOW INCOME BRAZILIAN OBESE ADOLESCENTS: PILOT STUDY. / INTERVENÇÃO MULTIDISCIPLINAR E MOTIVACIONAL PARA TRATAMENTO DE ADOLESCENTES OBESOS BRASILEIROS DE BAIXA RENDA: ESTUDO PILOTO.

OBJECTIVE: To test a multidisciplinary and motivational intervention for the treatment of Brazilian obese and low-income adolescents (Z score>2 BMI-for-age) that used nutritional counseling without dietary control. METHODS: An intervention protocol was developed including periodical nutritional education workshops, individual nutritional counseling guided by the stages of eating behavior of the Trans Theoretical Model of Behavior Change, physical exercise, psychological counseling, recreational activities, and clinical follow-up for 13 months in a sample of 21 adolescents (11-17 years old). RESULTS: The rate of treatment withdrawal (9.5%) was lower than that seen in dietary control studies (30-60%). Initially, 70% of the sample was in the pre-contemplation behavior stage and, in the end, 100% of the remaining adolescents were in the stages of action or maintenance. There was a mean reduction in BMI-for-age (p=0.038) and visceral fat (M±SD=3.67±1.19 and 2.78±0.78 cm, p=0.02, initial and final, respectively). The percentage of fat mass decreased and that of lean mass increased (42±5 and 38±8, p=0.04, 58±6 and 61±8%, p=0.03, respectively). CONCLUSIONS: The intervention seems to be effective in generating a lifestyle change, accompanied by anthropometric profile and body composition improvement. The intervention protocol may offer easy adaptation and low-cost methodology for health services, with high adherence and low abandonment rates.

OBJETIVO: Testar uma intervenção multidisciplinar e motivacional para o tratamento de adolescentes obesos brasileiros e de baixa renda (escore Z>2 IMC-para-idade) que utilizou o aconselhamento nutricional sem controle dietético. MÉTODOS: Desenvolveu-se um protocolo de intervenção que incluiu a realização periódica de oficinas de educação nutricional, aconselhamento nutricional individual com auxílio do modelo transteórico de mudança do comportamento, prática de exercícios físicos, aconselhamento psicológico, atividades recreativas e acompanhamento clínico, durante 13 meses, em uma amostra de 21 adolescentes (11-17 anos). RESULTADOS: A taxa de desistência do tratamento (9,5%) foi menor do que a verificada em estudos de controle dietético (30-60%). No início, 70% da amostra se encontrava no estágio de comportamento denominado pré-contemplação (sem intenção de mudança) e, ao final, 100% dos adolescentes que permaneceram passaram aos estágios de ação ou manutenção (mudaram o comportamento ou mantiveram a mudança por mais de seis meses). Observou-se diminuição média de IMC-para-idade (15%, p=0,038) e de gordura visceral (gordura inicial de 3,67±1,19 e final de 2,78±0,78 cm, p=0,02). O percentual de massa gorda diminuiu e o de massa magra aumentou, quando comparados os valores médios iniciais e finais (42±5% e 38±8%, p=0,04; 58±6% e 61±8%, p=0,03, respectivamente). CONCLUSÕES: A intervenção parece eficaz para gerar mudança de estilo de vida, acompanhada de melhoria do perfil antropométrico e de composição corporal. O protocolo de intervenção pode oferecer metodologia de fácil adaptação e baixo custo para serviços de saúde, com alta adesão e baixa taxa de abandono.

Body fat distribution in stunted compared with normal-height children from the shantytowns of São Paulo, Brazil.

OBJECTIVE: The objective of this study was to determine whether central fat distribution varies between children who were growth retarded as young children and normal-height children from the same impoverished communities of São Paulo, Brazil. METHODS: A prospective study of 50 stunted and normal-height children in São Paulo, Brazil was conducted in which children were measured for changes in fat mass (FM) and fat distribution (using dual-energy X-ray absorptiometry and anthropometry) and Tanner stage over a 4-y period. Statistical analyses included multiple linear regression to control for confounding factors and Student's t test was used to estimate group differences. RESULTS: At follow-up, stunted children were shorter, weighed less, and had less total FM compared with control children. There were no differences between the two groups with respect to percent FM or percent truncal FM (%TrFM). Linear regression analyses were used to determine that stunted children had 1) increased TrFM (independent of FM); 2) increased %TrFM (independent of FM, gender, and Tanner stage), and 3) a borderline significantly greater change in TrFM (independent of FM, gender, and Tanner stage). CONCLUSION: Stunted children are more likely to deposit fat centrally when entering puberty, a significant risk factor for chronic diseases. Our results may explain part of the association between early growth retardation and later risk for metabolic diseases.

Higher central fat and poor self-body image in short-stature overweight/obese women living in Brazilian shantytowns.

BACKGROUND: Short stature in adult life, a possible consequence of poor perinatal conditions, is associated with higher risk of mortality and social disabilities. We aimed to determine whether low-income, overweight/obese, short-stature (SS) women show alterations in body composition, self-body-image perception, and biochemical profile compared to their non-short (NS) counterparts. METHODS: A cross-sectional study was conducted with women living in shantytowns and mother or relatives to undernourished children treated in a center for recuperation and nutritional education. Inclusion criteria were: (1) age, 19-45 years; (2) stature < 152.3 cm or > 158.7 cm; and (3) body mass index > 25 kg/m2. Socioeconomic, anthropometric, biochemical, and body image data were collected. We analyzed 56 SS and 57 NS women. RESULTS: The SS group showed a higher waist-to-height ratio (WHtR) (mean: 0.63; standard deviation: 0.06 for SS and mean: 0.60; standard deviation: 0.07 for the NS group; p = 0.02), and, in the adjusted analysis, showed lower fat-free mass (Estimated Marginal Mean for the SS group: 45.7 kg 95% confidence intervals (CI) (45.2-46.2) and for the NS group: 46.9 kg 95% CI (46.4-47.4); p < 0.01) and higher fat mass (Estimated Marginal Mean for the SS group: 32.5 95% CI (31.9-33.0) and for the NS group: 31.4 kg 95% CI (30.9-31.9); p < 0.01). Body mass index was a better predictor of current self-body-image perception for NS women. The SS coefficient values were ß = 0.141, SE = 0.059, and R2-Nagelkerke = 0.107, and the NS coefficients values were ß = 0.307, SE = 0.058, and R2-Nagelkerke = 0.491 (Z = 2.006; p < 0.05). Considering the obese subgroup, six out of 32 (18.8%) SS women and 14 out of 33 (42.4%) NS women perceived themselves as obese (χ2 = 4.27; p = 0.03). This difference remained significant even after adjustment by age, schooling, and number of children (p = 0.04). Only the total thyroxin showed significant differences between groups, lower in SS women (p = 0.04). DISCUSSION: Overweight/obese, low-income SS women have more central adiposity and impaired self-body image perception, and the body mass index is a weaker predictor of it, compared to NS women. Misperception about body size may be linked with an overestimation of health and underestimation of risk, which may lead to a lower utilization of the health care system and inadequate physician counseling. These features may account, at least partially, for the higher mortality risk seen in SS adults.

Energy Intake in Socially Vulnerable Women Living in Brazil: Assessment of the Accuracy of Two Methods of Dietary Intake Recording Using Doubly Labeled Water.

BACKGROUND: Diet is related to the prevention of chronic diseases, but assessing dietary intake is a complex task, especially in socially vulnerable populations. OBJECTIVES: To assess the accuracy of the 24-hour food recall (24HFR) and the food frequency questionnaire (FFQ) methods in socially vulnerable women in Brazil and compare these methods against doubly labeled water (DLW). DESIGN: Cross-sectional study. Energy intake (EI) was measured using 3 24HFRs and 1 FFQ. Total energy expenditure (TEE) was measured using DLW. Cutoff points were calculated to assess underreporting and overreporting using both the difference and the ratio between the EI and TEE. PARTICIPANTS/SETTING: Sixty-seven socially vulnerable, nondieting adult women with stable body weight and mothers of malnourished children. MAIN OUTCOME MEASURES: EI, in kilocalories, derived from 24HFR and FFQ. STATISTICAL ANALYSES: Repeated measures analysis of variance was used to compare EI and TEE and Bland-Altman graphs were plotted to assess the agreement between these variables. Spearman correlation coefficient between the ratio of EI to TEE and socioeconomic or anthropometric variables was calculated. RESULTS: Mean TEE was 2,186 kcal (95% CI 2,063 to 2,309 kcal). EI obtained through 24HFR (mean=1,848.6 kcal [95% CI 1,737.5 to 1,959.7 kcal]) was significantly lower than TEE (P=0.01), and significantly lower than the EI obtained through FFQ (mean=2,084.5 [95% CI 1,929.0 to 2,240.0 kcal]; P<0.01). There were no statistically significant differences between the EI values of FFQ and TEE (P=0.89). The distribution of underreporters, nonunderreporters, and overreporters were more homogenous in the FFQ method. There was a positive correlation between body fat percentage and underreporting in the FFQ method (r=0.245; P=0.046). CONCLUSIONS: The methods of assessing dietary intake in our study showed poor agreement with TEE obtained by DLW. These may, therefore, not be the most suitable methods for assessing EI in this population.

Association between Adult Stature and Energy Expenditure in Low-Income Women from Northeastern Brazil.

BACKGROUND: Perinatal undernutrition may lead to important metabolic adaptations in adult life, short stature being the most visible. The present study aimed to evaluate the association between stature and total energy expenditure of low-income women. METHOD: Women aged 19-45 years from low-income communities in Maceió-AL were recruited. A sample of 67 volunteers was selected and divided into either short stature (≤ 152.4 cm; n = 34) or non-short stature (≥ 158.7 cm; n = 33) group. Data on socioeconomic status, anthropometric variables, and hormonal profiles was collected. Total energy expenditure and body composition were assessed by the doubly labeled water technique with multiple points over 14 days. In addition, physical activity levels were measured with triaxial accelerometers and dietary intake data were collected using three 24-hour food records. RESULTS: The mean subject age was 30.94 years. Women of short stature had lower body weight and lean body mass compared to non-short women, but there were no differences in thyroid hormone concentrations or daily energy intake between the two groups. Short-stature women showed lower total energy expenditure (P = 0.01) and a significantly higher physical activity level (P = 0.01) compared to non-short women. However, the difference in total energy expenditure was no longer significant after statistical adjustment for age, lean body mass, and triiodothyronine concentrations. CONCLUSION: Women with short stature present the same energy intake, but lower total energy expenditure than non-short women, even with a higher physical activity level, which suggests that they are more prone to weight gain.

Long-term effects of early malnutrition on body weight regulation.

Malnutrition is still highly prevalent in developing countries. Studies have shown an increase in the number of obese individuals in very poor urban communities. This review shows a co-existence between malnutrition and obesity in households of slums in Brazil and a higher prevalence of stunted/overweight or obese individuals (30%) in comparison with stunted/underweight (16%). These conditions are associated with important metabolic changes. Results from stunted children showed higher susceptibility to the effects of higher fats diets, lower fat oxidation, higher central fat, and higher body fat gain. A model to explain how early malnutrition alters energy balance in adults is outlined. In the presence of a relative food intake insufficiency, a higher cortisol:insulin ratio, associated with lower levels of IGF-1 will lead to lower muscle gain and linear growth, impaired lypolysis and fat oxidation. When these hormonal changes are combined with a higher fat/carbohydrate and/or marked decreased in physical activity, obesity with short stature will occur.

Stunting and future risk of obesity: principal physiological mechanisms.

There is a fair amount of epidemiological evidence showing that nutritional stunting causes increased risks of obesity. Obesity is increasing dramatically not only in developed countries but also in developing countries, such as Brazil, especially among the poorer. The mere coexistence of undernutrition and obesity among poor people has a great impact, as the burden in the social, economic, and health care systems is remarkable. In addition, an increasing number of studies have shown that nutritional stunting causes a series of important long-lasting changes such as lower energy expenditure, higher susceptibility to the effects of high-fat diets, lower fat oxidation, and impaired regulation of food intake. These findings suggest that a broader and more detailed understanding of the long-lasting effects of early undernutrition, direct cause of nutritional stunting, is needed. Within this context, we present data of some physiological mechanisms that substantiate the association between previous undernutrition and future obesity.

Lower waist circumference in mildly-stunted adolescents is associated with elevated insulin concentration.

OBJECTIVE: Augmented waist circumference (WC) is associated with non-communicable diseases and could represent a valuable marker in screening for metabolic dysfunctions in subjects with insufficient linear growth. The objective of the present study was to determine whether biochemical and hemodynamic parameters and waist circumference vary between mildly-stunted and non-stunted adolescents from impoverished communities of São Paulo, Brazil. METHODS: The cross-sectional study involved 206 subjects, aged between 9 and 19 years and living in impoverished areas of São Paulo, Brazil. The sample population was divided according to height-for-age Z-score (HAZ) into stunted (-1 > HAZ ≥ -2) and non-stunted (HAZ ≥ -1) groups, and was sub-divided according to gender. Logistic regression analysis was employed to compare individuals with elevated (> 75th percentile) insulin concentrations. The receiver operating characteristic curves were constructed to determine WC cut-off points that could be used to identify stunted and non-stunted individuals with elevated insulin concentrations. RESULTS: WC cut-off points of 58.25cm and 67.2cm allowed for correct classification of 90.7% of stunted and 88.7% of non-stunted individuals in the studied population. While the sensitivity of the model was high for stunted and non-stunted subjects (98.8% and 97.2%, respectively), the specificity was modest (57.1% and 41.2%, respectively). CONCLUSION: The results presented herein suggest that an increase in plasma insulin is one of the primary metabolic modifications in stunted individuals, and that this alteration could be identified at a lower WC cut-off point than in non-stunted counterparts.