aene project a medium city public students obesity study 2013

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



Thinness 1126 2,72



Obesity 4171 10,09


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



Thinness 1171 2,69



Obesity 4661 10,72


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



Thinness 1206 2,92



Obesity 4835 11,71


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


Obesity; 10,09

Severe Obesity; 1,15

Over weight; 15,01 PIZZA GRAPH

AENE 2009

Eutrophy; 69,81

Thinness; 2,69


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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