aene project a medium city public students obesity study 2013
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Nutritional State Evaluation of Public School Students
in a metropolitan city near São Paulo
Abstract
Identifying undernutrition and obesity on students and propose public policies of health
are urgent issues. This paper presents a study with weight and stature from students
collected by physical education teachers (PEF) in schools of a city near São Paulo. The
PEF collected the data and they were inserted in a program especially developed for each
school Department (AENE Project). The datas were analyzed by software and evaluation
done based on a World Health Organization (WHO_2007) table, that develops health
programs worldwide. The results evaluations were used to raise the students and family,
teachers and responsibles for treatment search (when required). Children’s nutrition state
had achieved the following results: In 2009 26,08% of pupils with overweight, in 2010
27,11% , in 2011 27.95% and in 2012 32,35%. We noted an increase in annual percentage
of students who have problems with obesity and cases of severe obesity had a 24,61%
increase from 2009 to 2012’.
(KEYWORDS: undernutrition, obesity, public policies, WHO_2007).
1. INTRODUCTION
The health problems caused by inappropriate eating habits are now problems in
rich and poor countries in different degrees. Malnutrition and obesity are disorders that
must be studied and analyzed in a way to find a solution for a reduction in found
contents.
There is a school community and familiar neglect with obesity and malnutrition
problems and health systems have difficulty to identify and treat the high percentage of
children with this type of problem.
The early diagnosis and multidisciplinary treatment effectiveness in long-term
design AENE line in Municipal network that embraces the entirety of elementary school
children.
The physical education teachers in municipal network were enabled to process
biometric data and make obesity and malnutrition identification of among their students.
In parent-teacher meetings the main focus was to raise awareness of personal responsibility
of each other with health and nutrition and what preventive actions can be taken by
family. Forwarding students cases to specialized care when necessary, under a parent’s
authorization was the Project objective each year.
Health is the sector that demand large investments of all Governments in the
world. The Organisation for Economic Cooperation and Development (OECD) countries
members invest 8.9% GDP average of on health. Keeping this trend, Governments will
have to adopt some measures to sustain the financing: increase taxes, cut spending in other
areas or do people pay more of their own private health plans.
Families in Brazil spend 6.5% average of family income with health in the
metropolitan regions. Government and family spending with health have increased sharply
in the last forty years that induced public actions in order to increase the importance of
personal responsibility for preventing disease, encouraging the improvement of physical
fitness and healthy eating habits, modifying the lifestyle with the regular practice of physical
exercises (LIMONGE-FRANCE, 2004).
The health condition of a person can be identified, simplistically, by their
nutritional status that reflects regular intake of macro and micronutrients. If nutritional
status of a person is identified as eutrophic it means that nutrient intake is adequate to
supply metabolic needs. Energy and macronutrient intake higher than absolutely necessary,
held for prolonged period is reflected by nutritional status that can be “Over weight”,
"obesity" or "severe obesity”. The eutrophy does not mean absence of disease, but points
to a low probability of occurrence. (CHARLES, 2001) (CEZAR, 2001)
We can look Obesity as a disorder caused by several factors and can be classified as
exogenous or endogenous. Endogenous is one that appears due to genetic, metabolic or
endocrine components and the exogenous appears due to external causes such as nutrition,
physical inactivity and psychological factors. Obesity caused by exogenous causes account
for more than 95% of cases. The abundance of foods rich in fats, the sedentary lifestyle
and ingested growth has been the major exogenous causes of obesity (FISBERG, 1993;
VASILENKO; BERNSHTEIN, 2003).
The obese child has a great chance of becoming an obese adult, depending on the
age of obesity start and its severity. Teens with Overweight have twice risk for developing
cardiovascular and other diseases associated in comparison to Eutrophic ones, for this
reason there is a growing interest in obesity prevention and early treatment due to prospect
of increased frequency of adults with obesity in rich and poor nations. (DAMASUS, 2001;
DIETZ, 1994; FISBERG, 1993; ROWLAND, 1990; DESPRÉS et al., 1990).
In Sao Paulo, studies conducted by the Nutrition and Metabolism discipline of
Pediatrics Department at Federal University of São Paulo, showed that approximately 4 to
5% of children up to 12 years, who came to medical attention by health problems also were
overweight or obese. Relevant in this study is that the parents and guardians, who
accompanied them, had not identified the children’s overweight or obesity condition . This
study emphasizes that the difficulty to access health systems, problems of daily survival and
family neglect due to a non understanding of malnutrition and obesity problem do that
parents rarely seek specialized care to treat these serious nutritional disorders. (VITOLO et
al. 1993).
It is essential to perform regular and systematic supervision over adolescents health
care as a way to detect, prevent or treat nutritional disorders due to the adverse effects that
they provide in a long time. The absence of a structure in the health system encourages
potential bad consequences to future generations of adults. Many authors point out that
nutritional disorders are difficult to treat in later life, must be prevented in childhood and
adolescence at the primary care level (DAKO, 2001).
The massive propaganda has collaborated to confuse the population emphasizing
cultural concepts of beauty that focus on thinness in girls before adolescence and
potentializing the excessive consumption of processed foods. The WHO adopted a set of
principles for construction of a primary care health services base, known as Ljubljana
Letter, which points out that people, in addition to influencing health services, must take
responsibility for their own health (STARFIELD, 2002).
Children obesity rates have increased worldwide and need goverment and public
health-related institutions attention. In countries that are under development grows the
interest in understanding reasons for the prevalence of nutritional disorder, increasingly
widespread in the world. In Brazil, in 1989, there were 2.7 million obese children, with the
highest prevalence among girls, data from the Brazilian Institute of Geography and
Statistics (IBGE) to the national survey on health and nutrition (PNSN) in 1989. In 2009,
one in three children from 5 to 9 years were over the weight recommended by the World
Health Organization (WHO). Some studies have shown a growing trend of obesity in
Brazilian population and the comparison of results between epidemiological studies of
ENDEF (National Family Expenditure Survey-conducted between 1974 and 1975), PNSN
(in 1989), and the PPV (Living Standard’s Survey-carried out between 1996 and 1997),
indicates that there is a gradual positive trend of adolescent’s BMI in Brazil over the last 25
years.
There is a need for more researchs that provide information about nutrition
development and health policies for the teen population. The national information
available, which actually characterize the health of young people in Brazil are few and,
except for a meagre epidemiological studies, the rest are often grounded in guidelines that
focus on little significant variables in relation to health or with highly questionable sampling
plans.
The Latin American Consensus on Obesity (2002) proposes that to perform studies
on prevalence of obesity the sample must be random (by conglomerates), with
identification by city region, under categories and in accordance with the population
distribution. Points out also that the geographical distribution must be proportional to the
cities and use a 95%confidence level, with 10% of relative accuracy level. However, where
to find the largest number of children and teenagers to carry out epidemiological studies
and identify prevalence and incidence of nutritional disorders? Our work tried to cover all
children of elementary school in public network and was made with more than 90% of the
student population of this age group.
The school environment is the most suitable for developing health studies and
monitoring the children and adolescents nutritional status because, in addition to being a
privileged space it is best suited to inform, educate and disseminate health and preventive
measures to decrease the incidence of nutritional disorders such as obesity. The school is
regarded as the ideal vehicle to obesity prevention actions because most of the children
from 6 to 17 years is here registered and may be influenced by teachers that, if properly
trained, may obtain excellent results by changing the feeding behavior and encouraging
physical activities to reverse the sedentary lifestyle.
Among national studies to investigate and provide information on the nutritional
status of schoolchildren, as well as deploy a biometric analysis in a school we have de
Souza and Pires-Neto study, held in 1998, whichis essential for assessment of nutritional
status in school, since the results assist the student for both treatment and forwarding
obese and malnourished children. Feldman & Goodman (1988) emphasize that many of
the studies conducted in this direction become invalid due to generally small and
unrepresentative sampling, non-use of reliable measurement instruments and use of
experimental protocols that do not protect against bias.
The reference values of weight and height to calculate body mass index (BMI) are
needed for monitoring the growth of children and adolescents. Studies have used this index
with the purpose of identifying the prevalence and incidence of nutritional disorders in
child and juvenile population, as well as to update these data (Charles, 2001). Our work
uses the WHO_2007 table (World Health Organization) that classifies nutritional States
within percentiles, taking into account, in addition the stature, weight, sex and age of
children.
In Brazil several studies have been conducted with school, but with the intention of
identifying relevant aspects for the health condition of children and adolescents with
emphasis on growth, development and motor performance. However, the main limitation
of these studies refer to the difficulty of generalization of the results, by the size of the
sample and the various analysis methodologies used (BOLFARINE; BUSSAB, 2005;
PEREIRA, 2001).
Admittedly, another difficulty is that the interested for the results obtained by
studies like these are exclusively researchers and post graduate or graduate students. It is
necessary that the school population (teachers, students, and family members) receive
information that makes sense to their reality. Most studies is finished without giving to the
the students informations about their evaluation and their participation, nor the results
obtained with a practical explanation for life or routine of the participants (THOMAS;
NELSON, 1990; SILVA, 2001; GIVING IT the, 2001; SHIGUNOV 2002).
Our work has been developed continuously in order to provide to the student and
his family, our stakeholders, the results obtained and to encourage them to participate in
the program Project AENE which includes lectures, thematic classes, sports courses
dissemination, consultations and medical orientations for food and physical activity, aimed
at changing habits and daily practice of physical exercises.
Then there is the possibility of epidemiological studies at school with the
participation of the teachers of the institution itself. However, to relate the different
dimensions of the nutritional status of schoolchildren with Physical education, in addition
to the public policy implications of education and health, it is necessary to analyze the
specific theoretical framework about the problem.
The school nutrition state evaluation may be inserted in the annual education plan,
no matter the teacher’s pedagogical approach used in professional activity, because the
results can be discussed based on philosophy, anthropology, politics, sociology, and
biology.
There is a need to carry out a study to analyse the school nutrition state to identify
those in condition of malnutrition or obesity and it needs to be a viable, effective and
efficient project and must be deployed without high costs. The study to be viable needs to
be low cost and the search should provide information to the population evaluated, both
for eutrófica as for the one with nutritional disorder, in addition to offering immediate and
appropriate treatment.
2. PROJECT METHODOLOGY AND FEATURES
We use a non-experimental research where public schools children had their weight
and stature evaluated. The physical education teachers encouraged students for new
attitudes and practices seeking changes for a healthier life, with obesity and malnutrition
lower prevalence and eutrophic state higher proportion.
To ensure homogeneous data digital scales with anthropometric rule were used for
all elementary schools and a new software was added as module in each school computer
control system where the data is typed and processed automatically and then sent over to
the central computer that centralizes the entire database.
The software calculates the BMI (body mass index) of students based on the who
table WHO_2007. This index takes into account the age, height and sex of children. The
Table WHO_2007 distributes the students according to the BMI found and classifies as
"sharp thinness", "thinness", "eutrophy", "overweight", "obesity" and "severe obesity". See
in table 1 below:
Table 1-Classification within the percentiles
FRAMING CLASSIFICATION
Below P 0,1 Sharp thinness
[P 0,1; P 3[ Thinness
[P 3; P 85] Eutrophy
]P 85; P 97 ] Weight
] P 97 ; P 99,9] Obesity
Over P 99,9 Severe Obesity
The first assessment of students nutritional status was held in 2008 second half and
children evaluated belonged to classes from elementary school 1st to 8th grade and,
removed some incorrect data, there was 37,336 total students evalueted. The data were
analyzed in the first half of 2009 and the following results were obtained:
Table No. 01 - AENE Project 2009 Results
Nutritional State Amount %
Sharp thinness 206 0,55
Thinness 979 2,62
Eutrophy 26722 71,57
Over Weight 5476 14,67
Obesity 3483 9,33
Severe Obesity 470 1,26
Total 37336
With the initial AENE Project deployment came out the first nutritional status
reality of City School network, that was, 25.26% (twenty-five point twenty six per cent)
students above eutrophy and 3.17% (three point seventeen percent) students below
Eutrophy.
The great training phase challenge was help physical education teachers to identify
students nutritional status in na standard and scientific form and load the data obtained in
the project database. AENE Project deployment was made concurrently with the progress
of educational planning and accepted for all teachers that had a overload in their job but
worked for good results at the end of the task. Were developed the following stages:
awareness, measurements, data typing, results statistical treatment, results publicy at a
parents meeting with nutritionists and doctors participation and later and subsequent
forwarding of nutritional problems for medical monitoring.
The results refer to children population enrolled in the city school network,
excluding no public school children. The schedule for data collection has not been set,
getting each teacher the freedom to run it in normal time of your physical education class.
Students were encouraged to participate in the project and the teachers used, on
average, two classes for data collection. Constructive discussions and debates were held on
malnutrition and obesity subject, showing facts disclosed by the current media and on
body, health, beauty, food, physical exercise and sedentary lifestyle knowledge.
In 2009 the data was collected again in the second half and reviewed in the first half
of next year. We obtained the following results:
Table no. 02- AENE Project 2010 results
Nutritional State Amount %
Sharp thinness 171 0,41
Thinness 1126 2,72
Eutrophy 29176 70,60
Over Weight 6202 15,01
Obesity 4171 10,09
Severe Obesity 477 1,15
Total 41,323
It was highlighted, once again, the remarkable percentage of students with
nutritional problems. The percentage of students ranked above the eutrophy was 26.25%
(twenty-six point twenty-five percent) and the percentage of students below the eutrophy
was 3.13% (three point thirteen percent).
From data analysis held in 2010 first half, were selected students classified with
"severe obesity", that is, above P99.99 percentile for a interdisplinar team forwarding
especially formed to meet the group. This students group parents were warned of a special
meeting with AENE Project team at each school where they were asked for an
authorization to these students nutritional medical follow-up. This follow-up was
conducted from 2010 second half and this group of children would contain approximately
420 (four hundred and twenty) students.
Students classified as "overweight" and "obesity" began to compose a group in each
school with special monitoring of pedagogical staff and physical education teachers. A
special motivation for this group participation in their schools sports activities and the
incentive for registration in courses offered by Sports and Culture Department.
In 2010 the process was repeated and the following results were obtained:
Table No. 03- AENE Project 2011 Results
Nutritional State Amount %
Sharp thinness 183 0,42
Thinness 1171 2,69
Eutrophy 30346 69,81
Over Weight 6541 15,05
Obesity 4661 10,72
Severe Obesity 569 1,31
Total 43,471
The students above eutrophy were 27.08 (twenty-seven point zero eight percent),
that is, 3.16% (three point sixteen percent) increase on the previous value. There was an
increase in each year of over weight, obesity and severe obesity cases and a need for
project activities continuation seeking to bring to the eutrophy stage the students with
nutritional problems.
In the year 2012 we were able to collect the data in the first half, analyzes them and
develop joint actions in the second half of the same year. We obtained the data contained
in the table no. 04 and found a new increase in percentage of students above the eutrofica
line. The data indicate the need to accelerate the preventive actions in school units, acting
more tightly together to families to reinforce the need for healthy food and habits and
preventive health measures with multidisciplinary teams of health Secretariat to enable a
more frequent monitoring of students who exhibit severe obesity.
Table No. 04- AENE Project 2012 results
Nutritional State Amount %
Sharp thinness 129 0,31
Thinness 1206 2,92
Eutrophy 27944 67,64
Over Weight 6507 15,75
Obesity 4835 11,71
Severe Obesity 690 1,67
Total 41,311
We show below the graphs with the compared results of each nutritional status:
Chart nº 01 – evolution of nutritional status "Eutrophy"
% DE 2009 % DE 2010 % DE 2011 % DE 2012
Eutrofia 73,92 72,89 72,05 67,65
73,92
72,89 72,05
67,65
64,00
65,00
66,00
67,00
68,00
69,00
70,00
71,00
72,00
73,00
74,00
75,00
Chart 02-Evolution of nutritional status "Over weight"
Chart 03-Evolution of nutritional status "Obesity"
% DE 2009 % DE 2010 % DE 2011 % DE 2012
Sobre Peso 15,15 15,49 15,53 15,76
15,15
15,49 15,53
15,76
14,80
14,90
15,00
15,10
15,20
15,30
15,40
15,50
15,60
15,70
15,80
15,90
% DE 2009 % DE 2010 % DE 2011 % DE 2012
Obesidade 9,63 10,42 11,07 11,74
9,63
10,42
11,07 11,74
0,00
2,00
4,00
6,00
8,00
10,00
12,00
14,00
Chart 04-Evolution of nutritional status "Severe Obesity“
Chart nº 05 - Pizza Graph of nutritional States (2009)
% DE 2009 % DE 2010 % DE 2011 % DE 2012
Obesidade Grave 1,30 1,19 1,35 1,62
1,30
1,19
1,35
1,62
0,00
0,20
0,40
0,60
0,80
1,00
1,20
1,40
1,60
1,80
Eutrophy; 71,57
Thinness; 2,62
Sharp thinness; 0,55
Obesity; 9,33
Severy Obesity; 1,26
Over weight; 14,67 PIZZA GRAPH AENE 2008
Chart nº06 - Pizza Graph of nutritional States (2010)
Chart nº 07 – Pizza Graph of nutritional states (2011)
Eutrophy; 70,60
Thinness; 2,72
Sharp thinness; 0,41
Obesity; 10,09
Severe Obesity; 1,15
Over weight; 15,01 PIZZA GRAPH
AENE 2009
Eutrophy; 69,81
Thinness; 2,69
Sharp thinness; 0,42
Obesity 10,72
Severe Obesity; 1,31
Over weight; 15,05
PIZZA GRAPH AENE 2010
Chart nº 08 – Pizza Graph of nutritional states (2012)
Chart nº 09-Student’s weights comparison chart
Sharp thinness; 0,3123%
Thinness; 2,9193%
Eutrophy; 67,6430%
Over Weight; 15,7513%
Obesity; 11,7039%
Severe Obesity; 1,6703%
Sharp thinness
Thinness
Eutrophy
Over Weight
Obesity
Severe Obesity
0,00%
1,00%
2,00%
3,00%
4,00%
5,00%
6,00%
7,00%
8,00%
9,00%
10,00%
13 20 27 34 41 48 55 62 69 76 83 90 97 104
2009_%
2010_%
2011_%
2012_%
AENE PROJECT COMPARATIVE WEIGHT (Kg)
Chart nº 09 - Comparison chart of student’s weights
above 97.00 Kg
Continuous weight increasing
3. DISCUSSION OF DATA
The analysis of results leads us to the conclusion that school students are with high
levels above the eutrophy and, in meetings with students and their parents, it was detected
a large number of children with sedentary habits and with inappropriate eating habits. Most
parents said that their children, when they come from school, have a normal food (lunch or
dinner) and dedicate mainly to computer (internet) or TV. Few are those with eating
disorders who practice any type of sport routinely outside school. Another case was
exaggerated offer of processed foods in their homes with a high caloric value and high
0,00%
0,02%
0,04%
0,06%
0,08%
0,10%
0,12%
0,14%
97 99 101 103 105 143
2009_%
2010_%
2011_%
2012_%
levels of saturated fats, sodium and potassium as soft drinks, biscuits, popcorn and fried
foods. This habit, allied to the fact that school offer a complete meal that is added to the
lunch or dinner at home when they arrive, exacerbates the nutritional situation.
The AENE project seeks to develop a continuous nutritional status study of all
public elementary school students and make an integrated inter sectoral action covering
education, health, sports, culture and school sectors. The massive use of physical education
teachers brought many advantages by a continuous contact with their students. It was
possible for physical education teachers of each school collect the weight and height of
each student and the data could be accompanied by more than three years, generating a
rich and efficient database.
With the meetings promoted in schools with groups of students with severe obesity
and obesity was possible to give to parents and students the results and promote the
nutritional medical follow-up of those students whose parents authorized forwarding.
The Health Department of was a key partner and could form profissisonals teams
to promote the medical nutritional follow-up of each student with standard deviation of
nutritional status. School meals staff became aware of the increasing percentage of students
outside the eutrophy and obtained concrete data to plan the acquisition of adequate
nutrients to city education network and Sport and Culture Departments began to
encourage children enrolled to participate more actively of the courses offered in their
workshops and lecture cycles began in each school unit to promote the dissemination of
available courses.
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