Analysis of nutrition of children aged 13-36 months in Poland - a nation-wide study.
Analiza sposobu żywienia dzieci w wieku 13-36 miesięcy - badania ogólnopolskie
Halina Weker1, Marta Barańska2, Hanna Dyląg1, Agnieszka Riahi1, Małgorzata Więch1, Małgorzata Strucińska1, Patrycja Kurpińska1, Grażyna Rowicka1, Witold Klemarczyk1
1Department of Nutrition Head of Department: prof. nadzw. dr hab. n. med. H. Weker
2Early Psychological Intervention Department
Head of Department: dr G. Kmita
Institute of Mother and Child in Warsaw
Director: S. Janus
Aim: The aim of the study was to analyse the diets of children aged 13-36 months in Poland compared to nutritional recommendations. Material and methods: The questionnaire study was conducted between June and September 2010 on a representative, nation-wide sample of children aged 13-36 months. The study concerned 400 children from across Poland. They were selected by means of drawing their PESEL (personal identity) number. The nutritional status of children was assessed using anthropometric data, i.e. their current weight and height. The relative body mass index BMI (kg/m2) and the BMI z-score were calculated for each child and compared with the WHO child growth standards. The diets of children were assessed using an original questionnaire with 3-day diet records. Nutritional value was calculated using Dieta 4.0 computer programme. Results: The study demonstrated that 45.5% of children were in the normal BMI z-score range (from -1.0 to +1.0). Underweight children accounted for 12.5% (BMI z-score between -2.0 and -1.0) and severely underweight for 14.5% (BMI z-score < -2.0) of the studied group. The share of overweight and obese children was 14.5% and 13.0%, respectively. Large individual variation in food intake was observed in diets of the children. The intake of cereal products, meat, poultry and cold meats in daily diets was twice higher than recommended. The children ate significantly less vegetables and fruits and drank less milk and fermented milk beverages than recommended in model food rations. Energy and nutritional value of an average daily food ration diered considerably from the standards for majority of nutrients. The intake of proteins was three times higher than the current norms. Conclusions: The diets of children aged 13-36 months diered from current recommendations but the nutritional status evaluated based on BMI was normal in 45.5% of children from the analysed group. The content of majority of macronutrients, in particular protein, in average daily food rations was incompliant with nutritional norms, which in long term may increase the risk of diet-related diseases. Current nutritional recommendations concerning the diets of children in the post-infancy period need to be verified and disseminated.
Key words: nutrition, nutritional status, toddlers
Cel pracy: Celem pracy była analiza sposobu zywienia dzieci w wieku 13-36 miesiecy w Polsce w odniesieniu do zalecen zywieniowych. Materiał i metody: Badania przeprowadzono w okresie od czerwca do wrzesnia 2010 roku na reprezentatywnej ogólnopolskiej próbie dzieci w wieku 13-36 miesiecy, metoda ankietowa. Badaniami objeto 400 dzieci z terenu Polski. W doborze dzieci do grupy badanej posłuzono sie metoda losowania z numerów PESEL. Do oceny stanu odzywienia dzieci wykorzystano dane antropometryczne – aktualna mase i wysokość ciała oraz obliczony na ich podstawie wskaznik wzglednej masy ciała – BMI (kg/m2) i znormalizowany wskaznik masy ciała BMI z-score, które odniesiono do siatek centylowych WHO. Sposób zywienia dzieci oceniono na podstawie autorskiego kwestionariusza ankietowego z właczonym 3-dniowym zapisem jadłospisów. Do obliczen wartosci odzywczej diety wykorzystano program komputerowy Dieta 4.0. Wyniki: Posługujac sie niezaleznym od wieku i płci znormalizowanym wskaznikiem masy ciała BMI z-score wykazano, ze stan odzywienia 45,5% dzieci był prawidłowy i miescił sie w granicach normy dla BMI z-score od -1,0 do +1,0. Niedobór masy ciała wykazano u 12,5% dzieci (BMI z-score pomiedzy -2,0 a -1,0), a znaczny niedobór u 14,5% (BMI z-score<-2,0). Nadwage i otyłosc stwierdzono odpowiednio u 14,5% i 13,0% dzieci. Sposób zywienia dzieci był zróznicowany. W odniesieniu do zalecanych ilosci produktów w całodziennej diecie dzieci, podaz produktów zbozowych, miesa i drobiu oraz wedlin była wyzsza. Dzieci spozywały mniej warzyw i owoców, mleka i mlecznych napojów fermentowanych w odniesieniu do modelowych racji pokarmowych. Wartosc energetyczna i odzywcza sredniej całodziennej racji pokarmowej była zblizona do wczesniejszych zalecen i zdecydowanie odbiegała od aktualnych norm dla wiekszosci składników odzywczych. Ilosc białka w sredniej całodziennej racji pokarmowej, w odniesieniu do aktualnych norm spozycia była 3-krotnie wyzsza. Wnioski: Sposób zywienia dzieci w przedziale wiekowym 13-36 miesiecy był zróznicowany w odniesieniu do aktualnych zalecen zywieniowych, nie mniej jednak u 45,5% stan odzywienia oceniany za pomoca BMI nie budził zastrzezen. W srednich całodziennych racjach pokarmowych badanych dzieci udział istotnych składników odzywczych, zwłaszcza białka był nieprawidłowy w stosunku do norm zywieniowych co w perspektywie długofalowej moze skutkowac ryzykiem wystapienia chorób dietozaleznych. Istnieje potrzeba weryfikacji aktualnych zalecen zywieniowych w odniesieniu do postepowania zywieniowego u dzieci w wieku poniemowlecym i ich upowszechnienia.
Słowa kluczowe: zywienie, stan odzywienia, dzieci w wieku 13-36 miesiecy
In 2007, the principles of nutrition for children aged 13-36 months were developed in Poland and were published in 2008 as a medical standard (1).
The recommendations were to highlight the importance of appropriate nutrition in small children in obesity and undernutrition prevention.
That year also saw the change in the previously binding nutritional standards (from 2001) for the Polish population (2, 3). The changes to nutritional standards were introduced due to the results of research in the field of nutrition sciences and concerned the energy and nutrient requirements. It has been demonstrated that the observance of nutritional standards by following the balanced diet combined with appropriate physical activity is linked to the reduced risk of diet-related diseases, including obesity (4, 5, 6, 7, 8, 9). Numerous studies have shown that the appropriate diet of children impacts their physical health and intellectual development (10, 11, 12, 13).
Until now, in Poland there has been no study involving comprehensive evaluation of the diets of children aged 1-3 years and performed on the representative sample. The results of isolated studies carried out in various centres on small groups do not allow to formulate any conclusions concerning the nutrition for children at this age (14, 15, 16, 17). The study carried out attempts at assessing the practical functioning of current recommendations for the diet of healthy children aged 13-36 months.
The objective of the study was to analyse the diets of children aged 13-36 months in Poland as compared to nutritional recommendations.
MATERIAL AND METHODS
The questionnaire survey was conducted between June and September 2010 on a representative nation-wide sample of children aged 13-36 months1. Thee study concerned 400 children from across Poland. The children were selected for the studied group by means of drawing the PESEL (personal identity) number. The inclusion criterion for the studied group was the age of children and the exclusion criterion were diseases requiring the modification of the diet. The nutritional status of children was measured using anthropometric data, i.e. their current weight (in kg) and their height (in cm) (from measurements made in an outpatient clinic, entered into the child medical record book), as well as the relative body mass index BMI (kg/m2) and the BMI z-score index (calculated on their basis, which were compared to the WHO child growth standards) (8, 18, 19). The diets of children were assessed using an original authors’ questionnaire with the records on their 3-day diets. The questionnaires were filled in by mothers of selected children according to detailed instructions, with the assistance of professionally prepared pollsters. According to the adopted methodology of nutritional studies, the records of the diets of children for subsequent three days, including one holiday, were used for calculating the average daily food ration (2, 20). The nutritional value was calculated using the Dieta 4.0 computer programme.
1 Preliminary results - the final analysis is being prepared for the report of the study "Complex assessment of diets in children aged 13-36 months in Poland". Nutricia Foundation (No OPK 549-25-01).
The studied group of children (n=400) consisted of 222 boys and 178 girls aged 1336 months. The average age of children was 1.96±0.57 years. From among the studied group, 79% of children lived in towns/cities, and 21% in the country. The children came from families where 34% of mothers had completed secondary education and 49% higher education, while the others (17%) had completed primary and vocational education. In the case of fathers, 34% of them had completed secondary education and 37% higher education, while the others (29%) had completed primary and vocational education. The percentage of mothers with completed secondary and higher education was higher than the percentage of fathers. Mothers of the studied children were better educated than fathers. Table I presents the characteristics of the studied group of children.
Anthropometric data such as current body mass and height of each child were used for calculating the body mass index (BMI) and compared with the standards (8, 18, 19). Table II presents the number of studied children in percentile ranges of the body mass index. The percentage of children with the BMI between the 25th and the 75th percentile was 33.2% and between the 15th and the 85th percentile – 47.0%. The percentage of children below the 15th percentile was 26.0% and above the 85th percentile – 27.0%. The nutritional status of children was assessed using the normalised BMI z-score calculated for each child. The study demonstrated that 45.5% of children were within the wide standard adopted for BMI from -1.0 to +1.0. The underweight children accounted for 12.5% of the studied group (BMI z-score between -2.0 and -1.0), and severely underweight for 14.5% (BMI z-score<- 2.0). Overweight and obese children accounted for 14.5% and 13.0%, respectively (fig. 1). The above data show that the nutritional status of 54.5% of the studied children was inappropriate, which requires a thorough analysis of the reasons for such irregularities, also in relation to the nutritional factor. The diets of the children assessed from the records of their 3-day diets, including the intake of various product groups, varied significantly, as demonstrated by large deviations from average values. After estimating 1200 diet records of the studied children (3-day diet records of 400 children) according to the adopted principles, the average daily food ration and its nutritional value were calculated (tab. III and IV). The intake of cereal products, meat, poultry and cured meats in daily diets of children was twice higher than recommended. e children ate significantly less vegetables and fruits, milk and fermented milk beverages than recommended in model food rations (tab. III) (21, 22, 23). Energy and nutritional value of an average daily food ration differed considerably from the standards for majority of nutrients (tab. IV). The intake of proteins was three times higher than the current norms. Similarly, the intake of vitamins A, B2, B6, B12, PP, C and intake of phosphorus, magnesium, zinc and copper in average daily food rations was two to three times higher than recommended. The protein intake provided 14.1±2.5% of total energy, fat – 28.9±5.2%, whereas carbohydrates accounted for 57.0±6.1% of total energy intake. Such a large share of protein and sucrose (14.3 vs the recommended 10%) in average daily food rations may be a risk factor for excessive body weight in children. Figure 2 shows a comparison of energy and nutritional value of the children’s daily diets with the current and previous nutritional recommendations. It demonstrates that the nutritional value and nutrient content in average daily food rations significantly exceed the current standards (from 2008) and are similar to the previous dietary standards (2001). Summing up, the study showed that the nutritional status of children aged 13-36 months, assessed based on selected characteristics and anthropometric indicators (body mass, height, BMI, BMI z-score), was appropriate in 45.5% of children, whereas 27% of children were underweight and 27.5% overweight or obese. The diets of children aged 13-36 months varied in terms of their qualitative and quantitative composition. They were characterised by an excessive amount of high protein products and sucrose.
The results of research conducted by different authors confirm significant correlations between the children’s diets and their nutritional status (5, 9, 15, 24, 25, 26, 27, 28, 29, 30). There are publications indicating that eating behaviour develops in early childhood (31). Therefore, the appropriate diet not only promotes the optimal child development, but may also be one of the major factors reducing the risk of diet-related diseases in later life. e results of isolated studies on the nutritional status and diet of children in the rst year of age, diet of children aged 1-18 years and a group of children aged 4 years, as well as the results of studies evaluating nutrition for infants and small children, are known in Poland (14, 16, 17, 32). The authors of the above studies have demonstrated adverse trends and practical dificulties in diversifying the children’s diets, inappropriate choice of products in their diets, lack of balanced nutritional value of the diets, as well as the impact of the diet on nutritional status of children, including their overweight or underweight.
The studies conducted show that energy and nutritional value of the diets of children aged 13-36 months varied and was different than the current nutritional standards (developed in 2008), in particular for energy and protein, as well as vitamin A and vitamins from the B group. e same results compared with the nutritional standards of 2001 clearly show that the diets of children in this age group were more balanced. The 2008 studies evaluating the diets of children (n=1692) attending Warsaw day care centres gave comparable results as at present, with regard to the earlier and the current nutritional standards (33).
The question is how to assess the obtained data, since the nutritional status of 45.5% of children shows that their diets are appropriate. The attempt of an answer to that question may be the verication of nutritional standards, in particular those concerning the amount of protein in the children’s diets. The results concerning the intake of protein by children aged 13-36 months, obtained in the study on a representative, nation-wide group, may raise concerns, in particular when linked to the obesity prevention.
1. The diets of children aged 13-36 months differed from the current recommendations. However their nutritional status evaluated based on BMI raised no objections in 45.5% of children from the analysed group. 2. The content of the majority of macronutrients, in particular protein, in average daily food rations of the studied children was incompliant with nutritional standards, which in long term may cause the risk of diet-related diseases. 3. Current nutritional recommendations concerning the diets of children in the post-infancy period need to be verified and disseminated.
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Adres do korespondencji / Address for correspondence:
Department of Nutrition
Institute of Mother and Child in Warsaw
ul. Kasprzaka 17a, 01-211 Warsaw