Vitamin A deficiency and associated risk factors in children aged 12-59 months living in poorest municipalities in the South Region of Brazil.

OBJECTIVE: To estimate the prevalence of vitamin A deficiency (VAD) in children and associated risk factors. DESIGN: Analysis of data from a cross-sectional multicentre study performed in the primary care units of the municipalities from January to June 2015. The children's legal guardians answered a socio-economic questionnaire, and the children's blood samples were obtained by venipuncture. Plasma retinol was determined by HPLC. Plasma retinol values of <0·70 µmol/l were considered VDA. Poisson multiple regression with robust variance was used. Values of P < 0·05 were considered significant. The data were analysed in the SPSS software, 21.0. SETTING: Forty-eight poorest municipalities in the South Region of Brazil. PARTICIPANTS: Children (n 1503) aged 12-59 months. RESULTS: The prevalence of VAD in the sample was 1·9 % (95 % CI (0·5, 6·8)). The following risk factors were associated with the outcome in the final explanatory model: family received Bolsa Familia program benefits (PR = 3·19; 95 % CI (1·69, 6·02)), child was not being breastfed (PR = 5·22; 95 % CI (1·68, 16·18)) and stunting (PR = 4·75; 95 % CI (2·10, 10·73)). CONCLUSIONS: VAD did not represent a public health problem for children living in socio-economically vulnerable municipalities in the South Region of Brazil, suggesting a new panorama of this nutritional deficiency even in regions of low socio-economic conditions in these three states. Thus, in view of the current nutritional transition scenario, it is necessary to continuously monitor and improve public policies related to vitamin A supplementation in the country.

Primary Dentition Caries Patterns as Predictors of Permanent Dentition Caries: A Prospective Cohort Study.

The aims of this study were to estimate the risk of caries in the permanent teeth at 12 years of age and to describe the diagnostic accuracy of caries patterns in the primary dentition at age 4 years to predict caries at age 12 years. A prospective cohort study followed children from birth to age 12 years in the city of São Leopoldo, Brazil. Sociodemographic variables were collected at birth, and dental caries was measured at 4 and 12 years of age (n = 204). At 4 years, children were classified according to the presence of caries (cavitated and non-cavitated lesions), number of lesions, affected segment (anterior or posterior), and affected surface (occlusal, smooth, or proximal). Prediction of permanent dentition caries occurrence (DMFT ≥1) (primary outcome) involved Poisson regression with robust variance and standard diagnostic accuracy measures. The prevalences of caries at age 4 years (including non-cavitated lesions) and 12 years were 61.8% and 42.2%, respectively. All caries patterns in the primary dentition were associated with caries in the permanent dentition. In multivariable analysis, the strongest associations were carious lesions on the primary posterior teeth (RR 2.2; 95% CI 1.5-3.2) and occlusal surfaces (RR 2.1; 95% CI 1.4-3.0). Among patterns evaluated, the presence of any tooth with caries (cavitated or non-cavitated) had the highest sensitivity (73%), but any tooth with cavitated decay had the highest accuracy (67%). In conclusion, any dental caries experience in early childhood is strongly predictive of dental caries experience in early adolescence. Primary dentition carious lesions on the posterior teeth or occlusal surfaces and the presence of cavitated lesions were stronger predictors.

Early-Life Patterns of Sugar Consumption and Dental Caries in the Permanent Teeth: A Birth Cohort Study.

Early-life family conditions may presage caries development in childhood. The aim of this study was to evaluate associations between patterns of sugar consumption in early childhood and permanent dentition caries at age 6 years. A cohort enrolled women accessing prenatal care at public health clinics in Porto Alegre, Brazil. Sociodemographic, anthropometric, and dietary data were collected during pregnancy and 6-month, 12-month, and 3-year follow-ups. Calibrated dental examinations occurred at ages 3 and 6 years. Multivariable logistic regression analysis was performed in series to quantify associations between early-life variables and permanent dentition caries. At age 6 years, 7.9% of children (21/266) had ≥1 caries lesion on permanent teeth (first molars). In unadjusted models, gestational weight gain, sweet food introduction (age 6 months), household sugar purchases (age 3 years), and caries (age 3 years) were positively associated with permanent dentition caries (age 6 years). In multivariable models, each 1-kg increase in gestational weight gain (odds ratio [OR]: 1.08; 95% confidence interval [CI]: 1.01, 1.16) and each 1-item increase in sweet food consumption at age 6 months (OR: 1.27; 95% CI: 1.02, 1.59) remained statistically significantly associated with permanent molar caries. Findings from this cohort study suggest family and child factors that long predate the permanent dentition, including sugar-related behaviors, predict future dental status, and may inform prevention strategies.

Exploring the risk factors for early-life sugar consumption: A birth cohort study.

BACKGROUND: Sugar consumption in early childhood is the primary cause of negative health outcomes, including early childhood caries. AIM: To investigate risk factors associated with early-life sugar consumption. DESIGN: Explanatory variables were collected at baseline of a birth cohort in Porto Alegre, Southern Brazil. At six months of age, data were collected on child feeding practices, including the number of foods and beverages containing sugar. Multivariate Poisson regression analysis with robust variance was performed. RESULTS: Virtually all children (98.3%) had consumed sugar by the age of 6 months. Multivariable analysis showed that the number of sweet items was significantly larger in children whose mothers were less than 20 years of age (MR = 1.19; 95% CI: 1.05-1.36), those from non-nuclear families (MR = 1.12; 95% CI: 1.04-1.20), those whose mothers had less than eight years of schooling (MR = 1.34; 95% CI: 1.20-1.50) and those whose mothers smoked (MR = 1.23; 95% CI: 1.13-1.35). Moreover, the number of sweet items was significantly lower among children who breastfed in the first hour of life (MR = 0.85; 95% CI: 0.76-0.95). CONCLUSION: Sugar consumption begins very early, especially in children with no access to breastfeeding in the first hours of life and those from younger, less educated, and smoking mothers.

Impact of maternal dietary counseling in the first year of life on DNA methylation in a cohort of children.

Epigenetic modifications established during prenatal and early life, including DNA methylation, have been suggested as potential mediators of the interaction between environmental exposures during the perinatal period and adult metabolic health adverse outcomes, especially cardiometabolic complications and overweight. The effect of a dietary intervention in the first year of life on global methylation levels in leukocyte samples from a cohort of children born between 2001 and 2002 in southern Brazil was examined. Overall methylation measurements were performed using enzyme-linked immunosorbent assays on DNA samples from 237 children at 4 years old. Mean methylation values were higher in the intervention group (mean: 2.20 ± 1.31%) than in the control group (mean: 1.65 ± 1.11%; P = 0.001). It was observed that nutritional counseling in the first year increased breastfeeding duration and stimulated the development of healthier eating habits. Therefore, these factors might have contributed to increase global DNA methylation. The findings of the present study reinforce the notion that performing nutritional interventions in the early stages of life is important and provide further evidence of the interaction between the environment and epigenetic traits.

Infant Feeding Practices and the Effect in Reducing Functional Constipation 6 Years Later: A Randomized Field Trial.

OBJECTIVE: The aim of this study is to assess the impact of health worker training on infant feeding practices on the prevalence of functional constipation (FC) among children at 6 years of age. METHODS: Cluster randomized field trial conducted in Porto Alegre, Brazil. Health centers were randomly allocated into intervention (n = 9) or control (n = 11) groups. In intervention sites, health workers joined training sessions on the "Ten Steps for Healthy Feeding for Children from Birth to Two Years of age". Pregnant women in the last trimester of both groups were identified, invited to participate and enrolled in the study as the potential mothers to receive the dietary counseling provided by the health workers. At 6 years of age, the prevalence of FC was evaluated based on Rome III, defined by 2 or more of the following: infrequent defecation, fecal incontinence, history of retentive posturing, or/and history of painful defecation. RESULTS: Among 387 mother-child pairs (206 intervention, 181 control) evaluated at 6 years of age, the prevalence of FC was lower in the intervention group compared with the control group (15.0% vs 23.9%, respectively). The probability of being constipated was 38% lower in the intervention group (PR = 0.62; 95% CI 0.44-0.87; P < 0.01). CONCLUSION: The health workers training to promote the "Ten Steps" was an effective way to reduce the prevalence of constipation among children at 6 years of age.

Family Health Strategy associated with increased dental visitation among preschool children in Brazil.

BACKGROUND: Early-life dental service utilization could improve child dental health. AIM: Identify contextual, socioeconomic, and child characteristics associated with dental visitation by age 3 years. DESIGN: Within a Brazilian birth cohort (N = 435), multivariable regression models were fitted to identify independent predictors of having made a dental visit at age 3 years. Contextual variables considered included health center type (Traditional vs. Family Health Strategy, which perform home visits) and composition of oral health teams at the heath center where mothers accessed prenatal care. RESULTS: Dental visitation was positively associated with Family Health Strategy health centers (36% vs. 23%) and with higher maternal education and family social class. Visitation was lowest among families served by a health center without a dentist, but number of dentists and oral health team composition were not associated with visitation among facilities with ≥1 dentists. Dental visitation was not statistically significantly associated with caries experience but was higher if parents reported worse oral health-related quality of life. The vast majority of dental decay remained untreated. CONCLUSIONS: Dental visits were underutilized, and socioeconomic inequalities were evident. Dental visitation was more common when mothers received prenatal care at Family Health Strategy health centers, suggesting a possible oral health benefit.

"What can I do when he/she doesn't want to eat?": Maternal strategies for ensure children's food consumption in early childhood.

This cross-sectional analysis aimed to analyze the strategies used by mothers of children aged 2-3 to ensure their food consumption as well as to investigate the maternal and family characteristics associated with using these strategies. Data of 463 mothers who use the public health care system in Porto Alegre, Brazil, were analyzed. Among these mothers, 58.5% (n = 271) used some type of strategy. However, 42.4% (n = 115) of mothers did not identify their behavior as a strategy to ensure their children's food consumption. In regard to the type of strategy used, 69% (n = 187) were classified as information strategies and 43.2% (n = 117) as trading strategies. Maternal age and educational level were inversely associated with the use of trading strategies (p < 0.05), indicating that the adolescent mothers and mothers with less schooling more often used strategies that have been shown by the literature not to be conducive to positive long-term results. In 46.9% (n = 123) of the cases, some types of food were involved in the mothers' strategies, generally ultra-processed foods (46.3% n = 57). We conclude that the use of strategies to promote children's food consumption considered appropriate by the mothers is a fairly common practice. Health care professionals should consider mothers' perceptions and attitudes about the subject in order to conseil them as to the best feeding practices for their children, as the use of these strategies can be detrimental to the formation of eating behaviors.

Relationship between overweight/obesity in the first year of age and traumatic dental injuries in early childhood: Findings from a birth cohort study.

BACKGROUND/AIM: The impact of traumatic dental injuries (TDI) in the primary dentition on oral health-related quality of life indicates the need for the planning of prevention strategies. The aim of this study was to assess whether anthropometric characteristics in early life are associated with TDI by preschool age. MATERIALS AND METHODS: A birth cohort was recruited from the public healthcare system in the city of Porto Alegre, Brazil. Socio-demographic variables, type of birth, head circumference, weight, and length were collected at birth (WHO standards). Head circumference, body mass index for age, and height for age were collected at 12 months. TDI (Andreasen criteria) at three years of age (n = 458) were recorded by two examiners who had undergone training and calibration exercises. Multivariable analysis was carried out with Poisson regression with robust variance. RESULTS: A total of 31.0% of the children (142/458) exhibited TDI at three years of age. In the final model, the risk of TDI was 47% higher among children with a smaller head circumference upon birth and nearly 60% higher among those who were overweight/obese at 12 months of age (RR: 1.58; 95% CI: 1.15-2.17). The risk of TDI was also significantly higher among boys (RR 1.50; 95% CI: 1.13-2.00), but the outcome was not significantly associated with socioeconomic variables or other anthropometric variables. CONCLUSION: Overweight/obesity in early life is a risk factor for TDI in preschool children.

Low prevalence of inadequate micronutrient intake in young children in the south of Brazil: a new perspective.

In Brazil, children's eating patterns have been characterised by an increased consumption of ultra-processed foods that are fortified. Our aims were to (1) estimate the prevalence of inadequate micronutrient intake among children from low-income families and (2) to assess micronutrient intake from fortified foods. We carried out a cross-sectional study from a randomised field trial conducted at healthcare centres in Porto Alegre, Brazil, with 446 mother-child pairs, with the children aged 2-3 years. Dietary data were assessed using two 24-h recalls. The prevalence of inadequacy for six micronutrients was estimated using the proportion of individuals with intakes below the estimated average requirement (EAR). Micronutrient intakes from fortified foods were evaluated using EAR and upper tolerable level (UL). Healthy foods consumption was below the recommendations, except for beans, and 88·1 % of the children consumed ultra-processed foods. A low prevalence of inadequate micronutrient intake was observed for Fe (1·2 %), vitamin C (4·7 %), vitamin A (5·2 %), Ca (11·4 %) and folate (15·2 %). None of the children had intakes less than the EAR for Zn. Fortified foods contributed between 11·3 and 38·3 % to micronutrient intakes, and 43·0 % of the children met the EAR for Fe, 13·9 % for vitamin C and 12·3 % for Zn using fortified foods only. In addition, 4·0 % of the children exceeded the UL for vitamin A, 3·1 % for Zn, 1·1 % for folic acid and 0·2 % for Fe. These results highlight a low prevalence of inadequate micronutrient intakes among children and suggest that such a group could be at risk of excessive micronutrient intakes provided by ultra-processed foods.

Healthy eating index measures diet quality of Brazilian children of low socioeconomic status.

OBJECTIVE: This study aimed to assess the adaptation of the Healthy Eating Index (HEI) to Brazilian dietary recommendations for children aged 3 to 4 years (n = 345) and 7 to 8 years (n = 307). METHODS: Dietary data were collected using two 24-hour recalls and diet quality was evaluated according to the adapted HEI. RESULTS: The mean HEI score was 65.7 ± 11.2 at 3 to 4 years and 65.0 ± 8.8 at 7 to 8 years. The HEI correlated positively with dietary variety and food groups (grains, vegetables, fruits, and meat/beans), except for milk at 3 to 4 years, and negatively with sodium, total fat, and saturated fat intake. HEI score was moderately to strongly associated with dietary fiber and several micronutrients. CONCLUSIONS: The HEI as adapted to Brazilian dietary guidelines can be used to determine diet quality in preschool- and school-aged children in Brazil.

Diet quality from pre-school to school age in Brazilian children: a 4-year follow-up in a randomised control study.

A previous study demonstrated that dietary counselling for mothers during the first year of life improved overall diet quality of children at pre-school age in a low-income population. Thus, the objective of the present study was to assess the long-term effect of this intervention on diet quality of children at school age and examine the tracking of dietary intake throughout childhood. The present study was a follow-up of a randomised controlled trial with children who were assessed at 3-4 years (n 345) and 7-8 years (n 307) of age. We collected two 24 h dietary recalls and assessed diet quality using the Healthy Eating Index (HEI). Analyses were performed by group using a paired t test and a Student's t test for independent samples. Diet quality did not differ between the intervention and control groups at 7-8 years of age (HEI score 65·2 (SD 9·5) v. 64·9 (SD 8·5)). Regarding changes in diet quality from pre-school to school age, we observed the tracking of diet quality in the control group and the loss of the intervention effect in the intervention group. In both groups, the score for fruit and milk intake decreased, while that for saturated fat and dietary variety intake increased. The score for the intakes of grains, meat and legumes, and total fat remained constant for all children. The present data provide evidence that diet quality tracks during childhood since the total HEI score did not differ over time in the control group. The decrease in score for some HEI components did not affect the overall diet quality due to the increase in score for other HEI components.

Socioeconomic, behavioral, and anthropometric risk factors for traumatic dental injuries in childhood: a cohort study.

AIM: To investigate risk factors for the occurrence of traumatic dental injuries (TDI) at 4 years of age. DESIGN: Prospective cohort study. METHODS: A birth cohort (n = 500) was recruited from the public healthcare system in São Leopoldo, Brazil. Demographic, socioeconomic, anthropometric, and behavioral variables were collected at 6 months, 1 year, and 4 years of age. Clinical examinations at 4 years of age were carried out by a single examiner using the Andreasen classification. Poisson regression was used to determine risk factors for the occurrence of TDI at 4 years of age. RESULTS: A total of 23.7% of the children (80/337) exhibited TDI at 4 years of age. The risk of TDI was 35% lower among children who had been breastfeed for ≥6 months relative risk (RR 0.65; 95% CI 0.43-0.97) and more than twofold higher among those who were bottle fed ≥ three times a day (RR 2.37; 95% CI 1.10-5.11) at 12 months of age. Higher household income in the first year of life and greater height at 4 years of age were significantly associated with the outcome. CONCLUSIONS: The identification of behavioral, socioeconomic, and anthropometric risk factors for TDI in early childhood can contribute to the elaboration of prevention strategies.

Ankyloglossia and Breastfeeding Duration: A Multicenter Birth Cohort Study.

Background and Objective: The prevalence of ankyloglossia and its impact on breastfeeding practices may be overestimated, leading to surgical overtreatment in newborns. The study was conducted to estimate the prevalence of ankyloglossia in the first year of life and investigate the association with exclusive and total breastfeeding duration in different regions of Brazil. Materials and Methods: This multicenter prospective cohort study involved the recruitment of mother-infant pairs soon after childbirth in public hospitals in three state capitals in Brazil. Interviews were held with the mothers after birth, at 6 and 12 months to collect sociodemographic variables and data on exclusive and total breastfeeding duration. At 12 months of age, the children were submitted to a dental examination for classification of the lingual frenulum using the Bristol Tongue Assessment Tool. Data analysis involved Poisson regression with robust variance, with the calculation of unadjusted and adjusted relative risk (RR). Results: The final sample was composed of 293 children. The prevalence of defined and suspected ankyloglossia was 1% and 4.8%, respectively, totaling 5.8% (confidence interval [95% CI]: 3.1-8.5). No significant difference was found in the prevalence of exclusive and total breastfeeding at 1, 4, and 6 months between children with defined/suspected ankyloglossia and those without ankyloglossia. The multivariable analysis showed that the probability of the child achieving 6 months of breastfeeding did not differ between groups (RR = 0.98; 95% CI: 0.79-1.23; p = 0.907). Conclusion: The prevalence of defined ankyloglossia was very low and defined/suspected ankyloglossia was not associated with exclusive or total breastfeeding duration. Clinical Trial Registration: Registered with clinicaltrials.gov (n° NCT03841123).

Association between a frequent variant of the FTO gene and anthropometric phenotypes in Brazilian children.

BACKGROUND: Our goal was to analyze the association of the fat mass and obesity- associated (FTO) gene rs9939609 variant (T/A) with the anthropometric and dietary intake phenotypes related to obesity in Brazilian children. METHODS: We analyzed the association of this single nucleotide polymorphism (SNP) with phenotypes related to the accumulation of body mass in a cohort of 348 children followed from the time of birth until 8 years old and then replicated the main findings in an independent schoolchildren sample (n = 615). RESULTS: At the age of 4, we observed a significant association between the A/A genotype and a higher mean BMI Z-score (P = 0.036). At the age of 8, the A/A individuals still presented with a higher BMI Z-score (P = 0.011) and with marginal differences in the volume of subcutaneous fat (P = 0.048). We replicated these findings in the schoolchildren sample, which showed that those with at least one copy of the A allele presented with a higher BMI Z-score (P = 0.029) and volume of subcutaneous fat (P = 0.016). CONCLUSION: Our results indicate that this FTO variant is associated with increased body mass and subcutaneous fat in Brazilian children beginning at the age of 4.

Risk factors for high blood pressure in low income children aged 3-4 years.

UNLABELLED: This study aimed to evaluate the effect of dietary sodium intake on blood pressure among low income children aged 3-4 years. Data were collected during a randomized trial conducted in São Leopoldo, Brazil, with 500 mother-child pairs recruited from the maternity ward of a local hospital. Breastfeeding data were obtained during the children's first year of life. At 3 to 4 years of age, children's anthropometric, dietary, and blood pressure assessments were obtained. Sodium intake was estimated from two multiple-pass 24-h dietary recalls. Systolic blood pressure > 90th percentile for age, sex, and height was classified as high systolic blood pressure, according to the population-based percentiles provided by the Task Force on Hypertension Control in Children and Adolescents. Blood pressure data were obtained from 331 children at 3 to 4 years. The mean value of systolic blood pressure was 91.31 mmHg (SD = 8.30 mmHg) and 5.2% (n = 17) presented high systolic blood pressure. The results of the multivariable analyses showed that children who consumed more than 1,200 mg of sodium/day and with waist-to-height ratio higher than 0.5 presented, respectively, 3.32 (95%CI 0.98-11.22) and 8.81 (95%CI 2.13-36.31) greater risk of having high systolic blood pressure. Exclusive breastfeeding, child overweight and change in body mass index z score during the first year of life were not associated with the outcome. CONCLUSIONS: The results of this study suggest that at preschool age sodium intake and high waist-to-height ratio are risk factors for high systolic blood pressure.

Breastfeeding Protects from Overjet in Adolescence by Reducing Pacifier Use: A Birth Cohort Study.

Increased dental overjet in adolescence is a clinically relevant outcome associated with the complexity and high cost of treatment, indicating the need for prevention strategies. We investigated the long-term impact of breastfeeding and pacifier use on increased overjet (IOVJ) in permanent dentition. A prospective cohort nested in a randomized controlled trial was conducted from birth to 12 years of age (n = 214). Breastfeeding and pacifier use were recorded monthly until 12 months. Overjet was assessed at age 12 years. We employed a causal mediation analysis using parametric regression models assuming no interaction between breastfeeding and pacifier usage. We found a total protective effect of breastfeeding on IOVJ (OR 0.49; 95% CI 0.28-0.96), where 63.1% were mediated by pacifier use (OR 0.61; 95% CI 0.44-0.87). Breastfeeding directly decreased the odds of IOVJ by 20%; however, the confidence interval included the null estimate (OR 0.81; 95% CI 0.41-1.60). In conclusion, breastfeeding protects by half of the IOVJ in adolescence through reducing pacifier use. Oral and general health professionals should collaborate to support WHO breastfeeding guidelines during individual patient counseling. Guidelines for practice, policy or public information require messages that include a common risk approach to oral and general health.

Risk factors for discontinuing breastfeeding in southern Brazil: a survival analysis.

To identify risk factors for discontinuing breastfeeding during an infant's first year of life. A cohort study recruited mothers in a hospital in São Leopoldo, Brazil, which mainly serves the low-income population. In order to obtain socioeconomic, environmental, and behavioral information, face-to-face interviews with mothers were conducted after birth, and when their infants were 6 and 12 months old. The duration of breastfeeding was investigated at 6 and 12 months, and recorded separately for each month. Depressive symptoms were assessed using the Beck Depression Inventory. The multivariate model for predicting the discontinuation of breastfeeding, adjusted Kaplan-Meier survival curves and Cox regression were used. Of the 360 participants, 201 (55.8%) discontinued breastfeeding within the first 12 months. A multivariate Cox regression model revealed that symptoms of maternal depression (low levels: RR = 1.59, 95% CI 1.02-2.47; moderate to severe: RR = 2.03, 95% CI 1.35-3.01), bottle feeding (RR = 2.07, 95% CI 1.31-3.28) and pacifier use in the first month of life (RR = 3.12, 95% CI 2.13-4.57) were independently associated with the outcomes after adjusting for confounders. Breastfeeding cessation rates were lower for children who did not use bottle feeding or a pacifier in the first month of life and for the children whose mothers presented with minimal depression. Early pacifier use and bottle feeding must be strongly discouraged to support long-term breastfeeding. In addition, screening maternal depression at a primary care service can be a step forward in promoting a longer duration of breastfeeding.

Waist-to-height ratio as a screening tool for children with risk factors for cardiovascular disease.

BACKGROUND: Waist-to-height ratio (WHtR) has been recommended as a tool for predicting cardiovascular risk in children. However, there is little evidence about the accuracy of using WHtR as a predictor of disease risk in pre-school children. AIMS: To assess the accuracy of waist-to-height ratio (WHtR), waist circumference (WC) and body mass index (BMI) as well as to determine the optimal cut-off values for each of these measures in order to identify pre-school children with cardiovascular risks. SUBJECTS AND METHODS: This study conducted a cross-sectional analysis of 315 children between 3-4 years of age. Multiple risk factors for cardiovascular disease (MRFCD) were defined as having two or more of the following conditions: HDL-c < 35 mg/dL, LDL-c ≥ 110 mg/dL, triglycerides ≥ 150 mg/dL and systolic and/or diastolic blood pressure ≥ 90(th) percentile. RESULTS: The accuracy of WHtR in identifying cardiovascular risk in pre-school children was not significantly different compared to BMI or WC, for both sexes. The optimal cut-off measures for predicting cardiovascular risk in boys and girls, respectively, were as follows: 0.51 and 0.49 for WHtR; 0.61 and 0.69 for BMI Z-score; and 51.2 cm and 50.2 cm for WC. CONCLUSIONS: The data support the use of a 0.5 cut-off value for WHtR to predict cardiovascular risk factors among pre-school children and suggest that using WHtR is comparable to both BMI and WC.