Anemia and Nutritional Status of Preschool Children: Comparison between Two Childhood Education Centers in Botucatu City, Brazil

The institutional care for children in Brazil and in the world has throughout its history conceptions quite different concerning its social purpose. This fact has influenced even today the opinions of parents, teachers and other citizens about the meaning of work from these educational child care providers [1].

Nutritional deficiencies, especially protein-energy malnutrition, overweight and obesity, are infant health problems. Nutritional status influences the growth and child development, therefore, nutritional assessment of this population is of utmost importance in order to identify risk groups and promote appropriate interventions.

Many child health problems are related to these nutritional changes as a result of inadequate nutrition, which can get worse by several other factors [2].

Childhood education centers are appropriate institutions to monitor development and growth of children, and by means of appropriate interventions to promote health [3]. Thus, the challenge to integrate health and education of preschool children has required the development of proposals involving different professionals.

Anemia is defined as the condition in which the hemoglobin content in the blood is below normal, as a result of the lack of one or more essential nutrients especially iron. It is an important nutritional disorder and a major problem of child health. Hemoglobin is responsible for transporting oxygen in the blood, and its reduction brings serious repercussions on growth and development of children [4].

Recent studies have shown a significant reduction in child malnutrition, and increase in overweight and obesity in children, called "nutritional epidemiological transition" due to increased consumption of foods high in fat and sugar [5]. The intake of precooked meals, like "fast foods" or snacks and processed foods is partly attributed to this change, in which the rush of everyday life and the search for practicality took the place of healthy and proper meals.

There are differences between urban and rural areas concerning eating habits and specific customs from each region, which are linked to demographic and socioeconomic changes.

According to Brazilian research based on population data, people from urban areas consume more processed foods, while people from rural areas consume fresh foods [6]. Besides food, activities and games for children also influence their maintenance energy and consequently the nutritional status.

Physical activities such as running and jumping rope were disregarded amid computers, television and video games, generating a great physical inactivity in children in the world today, also motivated by high rates of violence and insecurity on the streets of cities in Brazil [7].

Therefore, proper assessment of the nutritional status and level of anemia in children, followed by relevant counseling on lifestyle habits, including diet and physical activities aimed at children and their families are of great importance to reduce current health problems mainly related to the cardiovascular system and promote overall health of children.

Evaluate prevalence of anemia, overweight and obesity in preschool children and compare two Childhood Education Centers (CEC) located in urban and countryside areas in Botucatu city, São Paulo state, Brazil.

As a secondary aim the authors would like to make changes in the lifestyle of the families and children, introduce an adequate diet in calories and iron sources, and promote regular physical activities.

A cross-sectional study was performed in two Childhood Education Centers from 2014 to 2015, in Botucatu city, São Paulo state, Brazil. All children registered in the urban and countryside (fishing village) CEC were evaluated after the person responsible for them had signed the Written Informed Consent form to participate in this study.

Following the ethical principles established in the Helsinki Declaration, this study was evaluated and approved by the Research Ethics Committee of the Botucatu Medical School/UNESP.

Anthropometric measurements were performed and nutritional status evaluated according to sex and age using the Body Mass Index (BMI). These values were plotted in the new curves proposed by WHO and the 2006 BMI and BMI z-score determined by the WHO or WHO [8] AnthroPlus software. The nutritional status based on the results was: thin, normal weight, overweight, at risk of overweight or obese.

Children with BMI greater than +1 SD were considered overweight, and at risk of overweight depending on the child are less than or more than 60 months; and BMI greater than +2 SD were defined as obesity. Thinness was defined as BMI below -2 SD according to age and sex. Short stature: child height below -2 DP [8].

The diagnosis of anemia was performed by evaluating fingerstick hemoglobin level using the B-hemoglobinometer device (HemoCue^®), which is recommended for population research (Figure 1).

Figure 1: Method for evaluating fingerstick hemoglobin level using the Bhemoglobinometer device (HemoCue^®).

It requires small blood volume (20 μl) and allows achievement of immediate results. The cutoff point was 11.0 g/dl for the age group from 4 to 72 months. Less than 9.0 g/dl hemoglobin level was considered moderate/severe anemia [9]. Procedure gloves, lancets and microcuvettes, all disposable and of single use were used for collection of biological material.

Database was performed in Excel and analyzed by the Statistical Analysis System (SAS), nonparametric Chi-square test, and Fisher exact test and Mann-Whitney test [10].

A total of 151 in the urban and 31 children in the countryside CEC were evaluated. These numbers represent all children who attended the CEC and whose parents\guardians authorized blood exams and anthropometric assessment.

The urban CEC is bigger than the other one. They had a total of 160 and 45 children registered, respectively, in the study period.

The fact that researchers have been acting to promote health education activities at the urban ECC for five years , and just started them at the countryside CEC in the year of 2015, was the important reason, we believe, for the lower number of authorizations to evaluations when both centers are compared (94.4% versus 69.0%), pointing out that the link between education and health sectors is an important factor for adherence to studies and interdisciplinary projects

Table 1 shows the results of nutritional and hemoglobin assessments of each CEC and differences according to sex. A significant association was found between CEC and nutritional status and anemia, with higher prevalence of overweight children and with anemia in the urban CEC (p=0.002) (Table 1).

Table 1: Nutritional status and diagnosis of anemia for each Childhood Education Center.

Malnourished children (thinness) are currently considered a punctual issue, and overweight and obesity are a major concern as they have been reported at early ages. Brazil, like other developing countries, is currently experiencing a nutritional transition which is often determined by poor eating habits. Therefore, there is a tendency of reducing malnutrition associated with an increase in overweight at different stages of life [11].

In the urban CEC, the frequency of thinness (1%) may be due to children with chronic malnutrition, or any health problems that limited their growth, requiring better individual analysis of each case, which is the reason to refer these children to the pediatrics outpatient follow-up.

The prevalence of anemia in the urban CEC was considered high. Despite lack of comprehensive national studies, regional data have shown a substantial increase in the prevalence of anemia in Brazil. The increase is observed in children from all ages and socioeconomic levels.

Iron deficiency and anemia are caused by negative iron balance in the body. In contrast to the low global prevalence of anemia in childhood, it was found that the prevalence of anemia in children living in the suburbs of major North American cities is similar to the prevalence observed in developing countries [12], such as that found in this study.

Therefore, it is necessary to promote referrals to specific treatment for diagnoses of nutritional changes, and drug treatment of children diagnosed with anemia together with the activities of health education.

Monitoring the nutritional profile helps to foster an attitude of surveillance and guidance in health promotion actions, individually and collectively. Nutritional counseling to caregivers and family is very important to reduce complications and promote overall health of children. We believe that changes in eating habits of those who live in urban areas, associated with inadequate physical activity have contributed to changes in health diagnoses, while in rural areas or fishing villages, people still maintain a nutritionally adequate diet.

Urbanization and greater access to ready or pre-made food with low nutritional value can explain the higher prevalence of disorders found in our study in urban areas, while ancient practices of adequate feeding , such as eating more grains and vegetables have been still maintained in rural areas.

The extension project must have social responsibility and search the relationship between research and teaching, promoting dialogue between academic knowledge and social practice. In light of these considerations, the authors have reached this goal in this project and study.

This study was developed with the support of the Dean’s Office for Extension Projects (PROEX, the Portuguese language acronym) and the Dean’s Office for Research Projects (PROPE, the Portuguese language acronym) of UNESP-Paulista State University. We are grateful for this very important support.

Competing interests: The authors declare that they have no competing interests.

All authors have made substantial contributions to the study and endorsed data and conclusions. CRBF identified the research question, conducted the analyses and wrote the article. BLM, LRA, MMC and FNM contributed to data collection and literature review. All authors have read and approved the final manuscript.