Publications by authors named "Patricia de Carvalho Padilha"

29 Publications

  • Page 1 of 1

Analysis of clinical outcomes of oropharyngeal colostrum administration in very low-birth-weight preterm newborns.

Nutrition 2021 Apr 28;90:111292. Epub 2021 Apr 28.

Nutrition Institute Josué de Castro, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil. Electronic address:

Objectives: Colostrum is the first secretion produced by the mammary glands and is present through the seventh day after birth. Colostrum has important immunomodulatory components and protective factors that contribute to the protection and development of newborns. The oropharyngeal administration of colostrum (OAC) has been proposed as a potential nutritional option for very low-birth-weight (VLBW) newborns (<1500 g). This study aimed to analyze the clinical outcomes of VLBW infants receiving OAC.

Methods: This is a retrospective longitudinal study with nonprobability sampling of VLBW infants on the OAC protocol. VLBW infants for whom no OAC data were available, who received no dose, or who died within the first 7 d of life were excluded. The Mann-Whitney test was used to compare quantitative variables and the Wilcoxon test to assess the evolution of anthropometric values with a significance level of 5% (P < 0.05).

Results: Enteral nutritional therapy was commenced after 1 d (median: 1 d; interquartile range [IQR], 1-1 d). Full enteral feeding was achieved after 11 d (median: 11.0 d; IQR, 9.0-16.0 d). Birth weight was recovered after 11 d (median: 11 d; IQR, 7.0-14.0 d). OAC was commenced at 3 d of life, and 32.5 doses (IQR, 21.0-44.0 d) were given in total. There were significant differences in the evolution of anthropometric characteristics during hospitalization, with a tendency to recover birth weight more quickly the higher the number of doses administered (P = 0.07). Time to full enteral feeding was significantly longer and time to recovery of birth weight significantly shorter when OAC was commenced ≤3 d after birth (P = 0.023).

Conclusions: OAC was associated with a shorter time to recover birth weight and time to full enteral feeding.
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http://dx.doi.org/10.1016/j.nut.2021.111292DOI Listing
April 2021

Enteral and parenteral nutrition therapy for neonates at a neonatal unit: a longitudinal retrospective study.

J Matern Fetal Neonatal Med 2020 Nov 19:1-7. Epub 2020 Nov 19.

Instituto de Nutrição Josué de Castro (INJC), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.

Background: The goals of nutrition therapy include providing adequate growth and development, avoiding a negative energy and nitrogen balance, and preventing complications.

Objective: To evaluate the nutrition therapy received by newborns at the neonatal intensive care unit (NICU) of a public maternity hospital in Rio de Janeiro, Brazil.

Methods: Retrospective longitudinal observational study in which data were collected on newborns admitted to NICU, in Rio de Janeiro, in 2016. The time that elapsed before commencement of parenteral and trophic enteral nutritional, time to reach full enteral nutrition, type of diet at the beginning of trophic enteral nutrition and at discharge from the NICU, and the relationship between birth weight and nutritional therapy were evaluated.

Results: Trophic enteral nutrition began after 24.42 (SD +20.23) hours, on average, and the mean time to reach full enteral nutrition was 10.0 (SD +5.51) days. Newborns with a birth weight below 1500 g had a longer hospital stay ( = .002), longer oxygen therapy ( = .009), a longer time before commencement of enteral feeding ( = .005), and took longer to reach full enteral feeding ( = .010).

Conclusions: The institutional nutritional therapy practices were consistent with those proposed in the literature, but more support is needed for breastfeeding in this group.
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http://dx.doi.org/10.1080/14767058.2020.1818212DOI Listing
November 2020

Changes of Physical Activity and Ultra-Processed Food Consumption in Adolescents from Different Countries during Covid-19 Pandemic: An Observational Study.

Nutrients 2020 Jul 30;12(8). Epub 2020 Jul 30.

Laboratory of Epigenetics of Lipid Metabolism, Madrid Institute for Advanced Studies (IMDEA)-Food, CEI UAM + CSIC, 28049 Madrid, Spain.

Aim: to describe physical activity and ultra-processed foods consumption, their changes and sociodemographic predictors among adolescents from countries in Europe (Italy and Spain) and Latin America (Brazil, Chile, and Colombia) during the SARS-CoV-2-pandemic period.

Methods: Cross-sectional study via web survey. International Physical Activity Questionnaire (IPAQ) and weekly ultra-processed food consumption data were used. To compare the frequencies of physical activity status with sociodemographic variables, a multinomial logistic and a multiple logistic regression for habitual ultra-processed foods was performed. In final models, < 0.05 was considered significant.

Results: Sample of 726 adolescents, mostly females (59.6%) aged 16-19 years old (54.3%). Adolescents from Latin America presented odds ratio (OR) 2.98 (CI 95% 1.80-4.94) of being inactive and those whose mothers had higher level of education were less active during lockdown [OR 0.40 (CI 95% 0.20-0.84)]. The habitual ultra-processed consumption was also high during this period in all countries, and more prevalent in Latin America.

Conclusion: A higher prevalence of inactivity was observed in this population, but reductions of physical activity and habitual ultra-processed consumption during the pandemic were more pronounced in Latin America. Our findings reinforce the importance of promoting a healthy lifestyle, i.e., exercise and diet, during periods of social isolation.
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http://dx.doi.org/10.3390/nu12082289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468997PMC
July 2020

Covid-19 Confinement and Changes of Adolescent's Dietary Trends in Italy, Spain, Chile, Colombia and Brazil.

Nutrients 2020 Jun 17;12(6). Epub 2020 Jun 17.

Laboratory of Epigenetics of Lipid Metabolism, Madrid Institute for Advanced Studies (IMDEA)-Food, CEI UAM + CSIC, 28049 Madrid, Spain.

Confinement due to the COVID-19 pandemic can influence dietary profiles, especially those of adolescents, who are highly susceptible to acquiring bad eating habits. Adolescents' poor dietary habits increase their subsequent risk of degenerative diseases such as obesity, diabetes, cardiovascular pathologies, etc. Our aim was to study nutritional modifications during COVID-19 confinement in adolescents aged 10 to 19 years, compare them with their usual diet and dietary guidelines, and identify variables that may have influenced changes. Data were collected by an anonymous online questionnaire on food intake among 820 adolescents from Spain, Italy, Brazil, Colombia, and Chile. The results show that COVID-19 confinement did influence their dietary habits. In particular, we recorded modified consumption of fried food, sweet food, legumes, vegetables, and fruits. Moreover, gender, family members at home, watching TV during mealtime, country of residence, and maternal education were diversely correlated with adequate nutrition during COVID-19 confinement. Understanding the adolescents' nutrition behavior during COVID-19 lockdown will help public health authorities reshape future policies on their nutritional recommendations, in preparation for future pandemics.
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http://dx.doi.org/10.3390/nu12061807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7353171PMC
June 2020

Total metal content and chemical speciation analysis of iron, copper, zinc and iodine in human breast milk using high-performance liquid chromatography separation and inductively coupled plasma mass spectrometry detection.

Food Chem 2020 Oct 6;326:126978. Epub 2020 May 6.

Physical and Analytical Chemistry Department, Faculty of Chemistry, University of Oviedo, Oviedo, Spain.

The aim of this research was to quantify essential trace elements (iron, copper, zinc and iodine) and establish their speciation in human milk. Both the element and the species are important in new-born nutrition. Colostrum, and transitional and mature milks (25) were collected from 18 mothers of pre-term or full-term infants. Concentrations of the target elements were determined using ICP-MS. For speciation, HPLC coupled to ICP-MS was employed. Total contents of the micronutrients varied in mothers of pre-term (Fe = 0.997, Cu = 0.506, Zn = 4.15 and I = 0.458 mg L) and mothers of full-term (Fe = 0.733, Cu = 0.234, Zn = 2.91 and I = 0.255 mg L) infants. Fe, Cu and Zn were associated with biomolecules with high molecular mass compounds, such as immunoglobulins, albumin and lactoferrin whilst iodine was only found as iodide.
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http://dx.doi.org/10.1016/j.foodchem.2020.126978DOI Listing
October 2020

Gestational weight gain and adverse maternal outcomes in Brazilian women according to body mass index categories: An analysis of data from the Birth in Brazil survey.

Clin Nutr ESPEN 2020 06 10;37:114-120. Epub 2020 Apr 10.

Instituto de Nutrição Josué de Castro, Universidade Federal do Rio de Janeiro, UFRJ/RJ, Avenida Carlos Chagas Filho 373, Bloco J, 2º Andar, Rio de Janeiro, RJ, 21941-902, Brazil.

Background & Aims: Monitoring gestational weight gain (GWG) is relevant for perinatal outcomes, especially in the context of increasing obesity and overweight in the female population. This study analyses the association between GWG in Brazilian women, according to different body mass index (BMI) categories, and different outcomes, including hypertensive disorders of pregnancy (HDP), gestational diabetes (GD) and caesarean section.

Methods: Data on women from all the major regions of Brazil with a single pregnancy of a gestational age of 28 weeks or more and information available for anthropometric evaluation were included in the Birth in Brazil survey. Adequacy of GWG was assessed according to the percentile distribution of GWG of women with favourable neonatal outcomes, with the median of the distribution referred to as 100% adequacy in the GWG evaluation.

Results: The study consisted of 18,953 women, 58.3% of whom were normal weight and 35.1% were overweight. The adequacy of GWG was better amongst the normal weight women (91.1%) and worse amongst those with class III obesity (46.0% with excessive GWG), with the latter showing the highest occurrence of adverse outcomes. Results of the multivariate logistic regression analysis revealed that weight gain above 200% of the median in the normal weight, overweight and obese women was positively associated with HDP and caesarean section, but not with GD.

Conclusions: The proposed ranges of appropriate GWG associated with favourable neonatal outcomes based on the data from the Birth in Brazil survey proved good predictors of HDP and caesarean section amongst the women included in the study.
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http://dx.doi.org/10.1016/j.clnesp.2020.03.009DOI Listing
June 2020

Pregestational excess weight and adverse maternal outcomes: a systematic review of previous studies in Brazil.

Nutr Hosp 2020 Apr;37(2):384-395

Department of Nutrition and Dietetics. Instituto de Nutrição Josué de Castro.

Introduction: Introduction: obesity is increasing among women at reproductive age in Brazil. Excess body weight during pregnancy negatively impacts women's health. Objetives: to identify and analyze the publications that showed the effects of pregestational excess weight on pregnancy, delivery, and post-delivery in Brazilian women. Methods: this systematic review was performed including studies that involve Brazilian pregnant women with adverse outcomes caused by pregestational excess weight. Search, selection, and reporting were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study was conducted by manually searching and screening the databases LILACS, PubMed, Scopus, Cochrane, and Periodicos CAPES. The selected articles were evaluated according to the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE), and categorized as studies with high (A), moderate (B), low (C), or extremely low (D) evidence quality. Results: a total of 1,582 studies were found, of which 39 were included for final reading and evaluation. Among these, 12.8%, 69.2%, and 18.0% were classified as A, B, and C or D for evidence quality, respectively. Hypertensive disorders of pregnancy, caesarean section, excessive weight gain, and gestational diabetes mellitus were commonly associated with pregestational excess weight in Brazilian women. Conclusions: the negative effects of excess body weight during pregnancy reflect the need for effective public policies that can address the problem, focusing on interventions that promote the health of women at reproductive age.
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http://dx.doi.org/10.20960/nh.02851DOI Listing
April 2020

Impact of energy deficit during hospitalization and biomarkers at admission on clinical outcomes in critically ill children: A longitudinal study.

Clin Nutr ESPEN 2019 08 16;32:70-75. Epub 2019 May 16.

Universidade Federal do Rio de Janeiro, Instituto de Nutrição Josué de Castro, Programa de Pós-graduação em Nutrição, Programa de Pós-graduação em Nutrição Clínica, Brazil.

Background & Aims: To evaluate the impact of energy deficit during hospitalization and the biomarkers albumin and C-reactive protein (CRP) on the clinical outcomes length of stay (LOS) and duration of mechanical ventilation (DMV) in children and adolescents admitted to the pediatric intensive care unit (PICU) of a private hospital in Rio de Janeiro.

Methods: A longitudinal, retrospective study was conducted of the medical records of patients admitted to the PICU from May 2016 to June 2017 who received enteral nutrition (EN) for 72 h or longer. The cut-off points for serum albumin and CRP were set at ≥3.5 and <2.0, respectively. The energy balance was calculated as the difference between the energy prescribed and the energy received by the patient. The comparison of continuous variables related to LOS and DMV was assessed using Student's t-test and the Mann-Whitney test. The significance value was set at p < 0.05.

Results: Ninety-three patients were selected, with a median age of 32 (±39.49) months. The mean serum albumin and CRP levels were 4.04 (±0.59) and 4.67 (±7.40), respectively. In linear regression models adjusted for length of stay, reduced albumin, increased CRP, and negative energy balance were positively associated. In the models adjusted to DMV, the values for reduced albumin and increased CRP were significant.

Conclusion: A significant association was found between serum albumin and CRP at admission and the outcomes under investigation, LOS and DMV. Energy deficit was also associated with LOS.
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http://dx.doi.org/10.1016/j.clnesp.2019.04.011DOI Listing
August 2019

Predictive factors of non-HDL cholesterol in children and adolescents with type 1 diabetes mellitius: A cross-sectional study.

Diabetes Res Clin Pract 2019 Aug 17;154:9-16. Epub 2019 Jun 17.

Universidade Federal do Rio de Janeiro, Centro de Ciências da Saúde, Instituto de Nutrição Josué de Castro, Av. Carlos Chagas Filho, 373 - bloco J, Cidade Universitária, Rio de Janeiro, RJ, Brazil; Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Rua Bruno Lobo, 50, Cidade Universitária, Rio de Janeiro, RJ, Brazil. Electronic address:

Aims: To assess predictors of non-HDL cholesterol in children and adolescents with T1DM.

Methods: A cross-sectional study of 120 children and adolescents aged 7-16 with T1DM, but without any other chronic morbidities, at a referral outpatient clinic for the treatment of diabetes in Rio de Janeiro, Brazil. Socio-demographic, anthropometric, dietary, and clinical factors were assessed, which included measurements of serum lipids and glycated hemoglobin (HbA1c). Food intake was assessed by 24-h dietary recall. Multiple linear regression was adopted in the analysis.

Results: The mean age of of the subjects was 11.74 ± 2.88 years, 53.3% were female, and the mean duration of T1DM was 6.68 ± 3.33 years. The mean energy intake from carbohydrates, proteins, and lipids was 51.98% (±9.20), 21.43% (±6.13), and 26.57% (±9.98), respectively. The energy intake from processed and ultra-processed foods represented 40.79% of total energy intake. The predictors of non-HDL cholesterol were: HbA1c (%) (p = 0.000, β = 8.5, CI: 4.8-12.1), duration of T1DM (p = 0.000, β = 2.8, CI: 1.3-4.3), and sex (p = 0.032, β = 10.1, CI: 0.9-19.4).

Conclusion: Glycemic control was the major modifiable predictor of non-HDL cholesterol concentrations, a significant indicator of cardiovascular risk.
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http://dx.doi.org/10.1016/j.diabres.2019.06.005DOI Listing
August 2019

Predictor factors of glycemic control in children and adolescents with type 1 diabetes mellitus treated at a referral service in Rio de Janeiro, Brazil.

Diabetes Res Clin Pract 2019 Aug 28;154:138-145. Epub 2019 May 28.

Universidade Federal do Rio de Janeiro, Centro de Ciências da Saúde, Instituto de Nutrição Josué de Castro, Av. Carlos Chagas Filho, 373 - bloco J, Cidade Universitária, Rio de Janeiro, RJ, Brazil. Electronic address:

Aim: To evaluate the predictive factors of glycemic control in children and adolescents with type 1 diabetes mellitus (T1DM).

Methods: Cross-sectional study at a referral service in Rio de Janeiro, Brazil. Sociodemographic, anthropometric, clinical, and dietary factors were evaluated. Food consumption was evaluated by 24 h dietary recall and the NOVA system was adopted for classifying the foods according to the extent and purpose of industrial processing. The predictive factors were evaluated by multivariate linear regression, adopting p < 0.05.

Results: One hundred and twenty children and adolescents participated, with a mean age of 11.74 years (±2.88) and HbA1c of 8.13% (±1.26). The mean diabetes duration was 6.68 years (±3.33) and the insulin used was 1.05 units per kilogram of ideal weight (IU/kg of ideal weight; ±0.46) About 80% (n = 96) used carbohydrate counting and it was verified that 24.27% (±17.89) of the participants' total calories came from ultraprocessed foods. For each year of diagnosis with T1DM and for each IU/kg of weight used, HbA1c increased by 0.087% (β = 0.087, p = 0.007) and 0.651%, respectively (β = 0.651; p = <0.001). Use of carbohydrate counting was associated with a 1.058% reduction in HbA1c (β = -1.058; p = 0.001).

Conclusion: Disease duration and insulin dose were directly reflected in HbA1c concentrations, while carbohydrate counting showed an inverse association.
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http://dx.doi.org/10.1016/j.diabres.2019.05.027DOI Listing
August 2019

Patient-generated subjective global assessment predicts cachexia and death in patients with head, neck and abdominal cancer: A retrospective longitudinal study.

Clin Nutr ESPEN 2019 06 5;31:17-22. Epub 2019 Apr 5.

Departamento de Nutrição e Dietética, Instituto de Nutrição Josué de Castro, Universidade Federal do Rio de Janeiro, Av. Carlos Chagas Filho, 373, CCS, Bloco J, 2º andar, Cidade Universitária, 21941-902, Rio de Janeiro, Brazil. Electronic address:

Background & Aims: Cancer is a complex disease, with poor prognosis when associated with malnutrition. This condition can lead to Cancer Cachexia (CC), a syndrome characterized by loss of muscle mass with or without fat loss, often associated with higher risk of death. Although there are recommended screening tools to assess nutritional status in cancer patients, such as Patient-Generated Subjective Global Assessment (PG-SGA), little is known about CC prediction. The aim was to investigate the association between nutritional status of patients with head, neck and abdominal cancer, assessed by PG-SGA at the day of hospitalization, with CC, hospitalization time and death.

Methods: This is a retrospective longitudinal study, where we collected data of 97 patients about PG-SGA nutritional classification, anthropometry, gender, age, cachexia diagnosis and death.

Results: PG-SGA classification was strongly associated with all the anthropometric measures (p < 0.0001). According to PG-SGA classification, 30.61% (n = 15) of patients in group A developed pre-cachexia; 38.24% in group B developed CC (n = 13); and 60% (n = 9) in group C developed refractory cachexia (p < 0.0001). Death rate was 24.49% (n = 12), 54.55% (n = 18) and 80% (n = 12) in groups A, B and C, respectively (p < 0.0001). PG-SGA had good sensibility (89.5%) and accuracy (72%) for CC, and also good specificity (75.51%) and accuracy (69%) for death.

Conclusions: PG-SGA demonstrated a significative association with the variables measured and was able to predict CC and death. This, in addition to its simple applicability, suggests that PG-SGA can be a useful tool to screen cancer patients for CC establishment and death risk.
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http://dx.doi.org/10.1016/j.clnesp.2019.03.013DOI Listing
June 2019

Adaptation of DASH diet (Dietary Approach to Stop Hypertension) for postpartum nutritional care at primary healthcare.

Rev Bras Epidemiol 2019 25;22:e190035. Epub 2019 Apr 25.

Grupo de Pesquisa em Saúde Materna e Infantil - Rio de Janeiro (RJ), Brasil.

Introduction: Postpartum weight retention has been found to predict obesity. However, in Brazil, there's no national strategy for nutritional care of postpartum woman.

Objective: This study aimed to adapt DASH diet (Dietary Approaches to Stop Hypertension) for nutritional counseling of postpartum woman, at primary healthcare.

Method: Methodological study, carried out in 2016, at low-income urban neighborhood in the city of Rio de Janeiro. It was developed in four steps: translation, food and food groups adaptation, identification of geographic and economic access to food and viability evaluation.

Results: The food groups of original diet were structured to Brazilian dietary pattern. After viability analysis, it was observed that the geographical access of food should be accounted to enable greater adherence. A qualitative and illustrated meal plan was elaborated for nutritional counseling.

Conclusion: The adapted DASH diet for nutritional care of postpartum woman seems to be according to the Brazilian dietary pattern, maintaining nutritional characteristics that provide the health benefits previously demonstrated. Currently, it's being used in interventional study in two primary healthcare unities at the city of Rio de Janeiro.
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http://dx.doi.org/10.1590/1980-549720190035DOI Listing
June 2019

Food intake of women with gestational diabetes mellitus, in accordance with two methods of dietary guidance: a randomised controlled clinical trial.

Br J Nutr 2019 01 5;121(1):82-92. Epub 2018 Nov 5.

1Programa de Pós-graduação Mestrado Acadêmico em Nutrição Humana,Instituto de Nutrição Josué de Castro,Universidade Federal do Rio de Janeiro (UFRJ),Rio de Janeiro,RJ,21941-902,Brazil.

The aim of the study was to evaluate the food intake of pregnant women with gestational diabetes mellitus (GDM) according to two methods of dietary guidance. A randomised controlled clinical trial was conducted by appointment with a nutritionist and by using data from hospital records (2011-2014). The study population comprised adult women diagnosed with GDM treated in a public maternity hospital in Rio de Janeiro, Brazil. The control group (CG) received nutritional advice by the traditional method and the intervention group (IG) were instructed on carbohydrate counting. The analysis of food intake and the consumption of processed foods (PF) and ultra-processed foods (UPF) were evaluated in the second and third trimester. A total of 286 pregnant women were initially assessed (145 in the CG and 141 in the IG). It was observed that 89/120 (74·2 %) and 183/229 (79·9 %) consumed PF daily in the second and third trimesters, respectively, whereas 117/120 (97·5 %) and 225/231 (97·4 %) consumed UPF daily in the second and third trimesters, respectively. When analysing the intake of macronutrients (%) by quartiles, women who had fat intake in the third quartile had the highest average postprandial blood glucose compared with those who consumed fat in the second quartile (P=0·02). The consumption of PF and UPF was high and dietary intake was similar in both groups, regardless of dietary guidance method deployed, suggesting that both methods tested in the study can be used for monitoring the nutritional status of pregnant women with GDM.
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http://dx.doi.org/10.1017/S0007114518001484DOI Listing
January 2019

Predictive factors for birth weight of newborns of mothers with gestational diabetes mellitus.

Diabetes Res Clin Pract 2018 Apr 2;138:262-270. Epub 2018 Feb 2.

Mestrado Profissional em Nutrição Clínica do, Instituto de Nutrição Josué de Castro, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro (UFRJ), Av. Carlos Chagas Filho, 373, bl. J 2°, andar, sala 26, Cidade Universitária, CEP 21941.590 Rio de Janeiro, RJ, Brazil; Maternidade Escola da, Universidade Federal do Rio de Janeiro (UFRJ), Rua das Laranjeiras, 180, Laranjeiras, CEP 22240-003 Rio de Janeiro, RJ, Brazil. Electronic address:

Aims: To evaluate the predictive factors of birth weight (BW) of newborns of women with gestational diabetes mellitus (GDM).

Methods: A cross-sectional study was performed among pregnant women with GDM treated in a public maternity unit, Brazil. We selected 283 pregnant women, with nutritional follow-up initiated till the 28th gestational week, singleton pregnancy, without chronic diseases and with birth weight information of the newborns. The predictive factors of BW were identified by multivariate linear regression.

Results: Mean maternal age was 31.2 ± 5.8 years; 64.4% were non-white; 70.1% were pre-gestational overweight or obese. Mean BW was 3234.3 ± 478.8 g. An increase of 1 kg of weight in the first and third trimesters increased BW by 21 g (p = 0.01) and 27 g (p = 0.03), respectively. Similarly, the other predictive factors of BW were pre-gestational body mass index (β = 17.16, p = 0.02) and postprandial plasma glucose in the third trimester (β = 4.14, p = 0.008), in the model adjusted by gestational age at delivery (β = 194.68, p < 0.001).

Conclusions: The best predictors of BW were gestational age at birth, and maternal pre-gestational and gestational anthropometric characteristics. Maternal glycaemic levels may also influence BW. The results may contribute to a review of prenatal routines for pregnant women with GDM.
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http://dx.doi.org/10.1016/j.diabres.2018.01.032DOI Listing
April 2018

Phase angle assessment in critically ill cancer patients: Relationship with the nutritional status, prognostic factors and death.

J Crit Care 2018 04 10;44:430-435. Epub 2018 Jan 10.

Instituto de Nutrição Josué de Castro, Centro de Ciências da Saúde, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil. Electronic address:

Purpose: To evaluate the relationship between phase angle (PA) and nutritional status and the prognostic significance of PA in critically ill cancer patients.

Methods: 31 patients that had been admitted to the intensive care unit (ICU) of a center on oncology were evaluated. Their PA was obtained from their bioelectrical impedance within 48 h of the ICU admission. The logistic regression analysis of Cox was used in order to identify the independent predictors of the outcomes.

Results: Negative and significant correlations were observed between the PA and the following variables: the length of hospital ward stay, the length of ICU stay, the total time of hospital stay, the mechanical ventilation time, and the acute physiology and chronic health evaluation II (APACHE II) scores. A positive correlation was ascertained between the PA and albumin. PA was significantly associated with death. Patients with a PA ≤3.8° presented a significantly shorter survival time than those with a PA >3.8°.

Conclusion: PA was a prognostic marker in this population, independently of previously established prognostic factors. PA can represent a clinically feasible approach for the initial identification of critically ill cancer patients who require an early and specialized nutritional intervention.
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http://dx.doi.org/10.1016/j.jcrc.2018.01.006DOI Listing
April 2018

Hypertensive disorders of pregnancy in women with gestational diabetes mellitus from Rio de Janeiro, Brazil.

Pregnancy Hypertens 2017 Oct 30;10:196-201. Epub 2017 Aug 30.

Professional Masters Program in Perinatal Health of Maternidade Escola da Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil. Electronic address:

Pregnant women with Gestational Diabetes Mellitus (GDM) have a greater chance of developing Hypertensive Disorders of Pregnancy (HDP) by the effect of insulin resistance in nitric oxide action.This study aims to describe factors associated with the development of HDP in pregnant women with GDM, assisted in a public maternity hospital in Rio de Janeiro, Brazil. This is a cross-sectional study including 292 pregnant adult women with GDM assisted at Maternidade Escola of the Universidade Federal do Rio de Janeiro. The women were examined during pregnancy and postpartum. Data were collected between 2011 and 2014 from medical records and through in-person interviews. The Student t-test and the chi-square test were applied; additionally, the magnitude of the association between independents variables and HDP was estimated by logistic regression models. The occurrence of HDP was observed in 19.5% (n=57) of the evaluated women: 9.2% had pregnancy hypertension and 10.3% had preeclampsia. The chance of HDP was higher among women with GDM in a previous pregnancy (Odds Ratio-OR=3.8; Confidence Interval of 95%-95% CI: 1.1; 12.8) and among those who were 35 years old or older (OR 3.3; 95% CI: 1.2; 8.7) after controlling the effects of pre-gestational weight and dietary ingestion of calcium, riboflavin, thiamine, vitamin A and protein. Women that had any alteration in blood pressure in a previous pregnancy and those over 35 years old were under higher risk of HDP. The findings may help in the design of interventions aiming to prevent HDP in adult women.
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http://dx.doi.org/10.1016/j.preghy.2017.08.006DOI Listing
October 2017

Performance of Patient-Generated Subjective Global Assessment (PG-SGA) in Patients With Advanced Cancer in Palliative Care.

Nutr Clin Pract 2017 Oct 29;32(5):675-681. Epub 2017 Aug 29.

2 Department of Nutrition and Dietetics, Institute of Nutrition Josué de Castro, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Background: The purpose of this study was to evaluate the prognostic significance of the Patient-Generated Subjective Global Assessment (PG-SGA) in patients receiving palliative care for advanced cancer.

Methods: The PG-SGA was used to assess nutrition status of 120 patients admitted to the Palliative Care Unit at the National Cancer Institute in Brazil.

Results: According to the PG-SGA, 94.2% (n = 113) of the patients were evaluated as malnourished. The PG-SGA evaluated that xerostomia was the only symptom associated with a short survival (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.2-5.38; P = .014). Survival was found to be significantly higher in well-nourished (PG-SGA A) than malnourished (PG-SGA B [ P = .021] or C [ P = .013]) patients. Total PG-SGA score (hazard ratio [HR], 1.06; 95% CI, 1.001-1.09; P = .045) and Karnofsky Performance Status of 20%-30% (HR, 15.4; 95% CI, 1.63-92.9; P = .001) and 40%-50% (HR, 10.0; 95% CI, 1.22-64.9; P = .031) were found to be independent prognostic survival factors.

Conclusion: The scored PG-SGA is an independent prognostic factor of survival and thus can be a useful tool for nutrition evaluation in palliative care.
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http://dx.doi.org/10.1177/0884533617725071DOI Listing
October 2017

Carbohydrate Counting during Pregnancy in Women with Type 1 Diabetes: Are There Predictable Changes That We Should Know?

Ann Nutr Metab 2017 8;70(2):140-146. Epub 2017 Apr 8.

Federal University of Rio de Janeiro, Maternity-School of the Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

Background/aims: Carbohydrate counting (CC) is a helpful strategy for the treatment of type 1 diabetes mellitus (T1DM) and the main parameters used in this method are the insulin to carbohydrate ratio (ICR) and the sensitivity factor (SF). Throughout pregnancy, a state of insulin resistance develops. Therefore, we hypothesized that ICR and SF change and our aim was to describe the pattern of modification of these parameters in pregnant women with T1DM on CC.

Methods: This study followed 21 women with T1DM throughout pregnancy. Starting ICR was 1:15 and SF was calculated using the formula: 1,500/total daily insulin dose (TDID; for regular insulin) or 1,800/TDID (for ultra-rapid analogs). ICR was adjusted every 1-2 weeks according to self-monitoring of blood glucose. SF was recalculated every 1-2 weeks.

Results: Throughout gestation there was a mean decrease in the ICR in breakfast, lunch and dinner of 8.2 (p < 0.0001), 7.7 (p = 0.003) and 7 (p = 0.005) grams per international units (g/IU), respectively. Mean SF reduction from first to third trimester was 10 mg/dL per IU (mg/dL/IU; p < 0.0001).

Conclusions: Women with T1DM in CC during pregnancy evolve with a progressive reduction in the ICR at every meal (mean of 8.2 g/IU for breakfast, 7.7 g/IU for lunch and 7 g/IU for dinner) and also in the SF (10 mg/dL/IU).
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http://dx.doi.org/10.1159/000471859DOI Listing
March 2018

Overweight among children and adolescent with type I diabetes mellitus: prevalence and associated factors.

Diabetol Metab Syndr 2016 16;8:39. Epub 2016 Jul 16.

Department of Nutrition and Dietetics, Instituto de Nutrição Josué de Castro (INJC/UFRJ), Rio de Janeiro-RJ, Brazil ; Hepatology Sector of the Hospital Universitário Clementino Fraga Filho (HUCFF)/UFRJ, Rio de Janeiro-RJ, Brazil.

Objectives: Describe the overweight frequency (overweight and obesity) and identify the factors associated with this in children and adolescents with type 1 diabetes mellitus (T1DM) treated at a University Children's Hospital in Rio de Janeiro.

Methods: This is an analytical cross-sectional study, which included patients diagnosed with T1DM who had complete anthropometric data (weight and height) and excluded those using drugs with effect on weight gain, genetic syndromes, celiac disease, hypothyroidism, renal failure and other chronic diseases, and pregnant women. The data collection was referring to the last consultation, and with respect to laboratory tests, the most recent data was collected. The dependent variable was the overweight, defined as Z score ≥1. The independent variables were gender, age, insulin dose, duration of disease, lipid profile, glycated hemoglobin, type of prescribed food planning, and place of residence. A logistic regression model was built for each outcome studied, considering significant associations those with p < 0.05.

Results: The study included 195 patients with a mean age of 10.6 (±3.8) years, and 49.7 % (n = 97) aged less than 10 years. The overweight frequency was 40 % (n = 78). The age ≥10 years (OR 0.41; 95 % CI 0.20-0.86; p = 0.019) and the dose of insulin/kg ideal weight (OR 3.38; 95 % CI 1:55-7:39; p = 0.002) were considered the variables associated with overweight.

Conclusions: There was a high prevalence of overweight, which explains strategies for promoting healthy eating habits and changing lifestyle with a focus on children and adolescents with diabetes.
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http://dx.doi.org/10.1186/s13098-016-0154-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947366PMC
July 2016

EVALUATION OF EFFICACY AND EFFECTIVENESS OF PRENATAL NUTRITIONAL CARE ON PERINATAL OUTCOME OF PREGNANT WOMEN; RIO DE JANEIRO, BRAZIL.

Nutr Hosp 2015 Aug 1;32(2):845-54. Epub 2015 Aug 1.

Professor of the Departament of Nutrition and Dietetics from Instituto de Nutrição Josué de Castro (INJC)- Universidade Federal do Rio de Janeiro (UFRJ- Federal University of Rio de Janeiro). 2Grupo de Pesquisa em Saúde Materna e Infantil (GPSMI - Research group in Maternal and Infant Health). Maternidade Escola da UFRJ (UFRJ Maternity Hospital), Brazil..

Aim: to evaluate the impact of a prenatal nutritional assistance proposal (PNA) for adult pregnant women.

Methods: a study of the impact of an applied nutritional intervention throughout the prenatal on perinatal outcomes - adequacy of total gestational weight gain, gestational anemia frequency and pregnancy complications in a public maternity hospital in Rio de Janeiro. The data represent three groups of adult pregnant women, during 10 years: GI (1999-2001, n = 225), GII (2005-2006, n = 208) and GIII (2007-2008, n = 394).

Results: in GII (reference group) it was included a detailed nutritional assessment, an individualized eating plan and an attendance of at least four scheduled appointments with a nutritionist. PNA coverage occurred in only 20.4% of GI, 100% of GII and 42.1% in GIII (p < 0.001). Women in GI had a higher proportion of inadequate total weight gain (OR 1.82, 95% CI: 1.20 -2.75), anemia (OR 2.18, 95% CI: 1.35 - 3.55) and pregnancy complications (OR 1.57, 95% CI: 1.04 - 2.36), as well as those who joined GIII, - OR 1.68 (95% CI: 1.16 - 2.44), OR 2.45 (95% CI: 1.56 - 3.84), OR 2.07 (95% CI: 1.42 - 3.00) - when compared to women in GII.

Conclusions: the model tested in GII PNA demonstrated to be effective in the outcomes studied.
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http://dx.doi.org/10.3305/nh.2015.32.2.9045DOI Listing
August 2015

Determinants of gestational night blindness in pregnant women from Rio de Janeiro, Brazil.

Public Health Nutr 2016 Apr 9;19(5):851-60. Epub 2015 Jun 9.

4Departamento de Epidemiologia e Métodos Quantitativos em Saúde,Escola Nacional de Saúde Pública da Fundação Oswaldo Cruz (ENSP/FIOCRUZ),Rio de Janeiro,RJ,Brasil.

Objective: To describe the prevalence and determinants of gestational night blindness in pregnant women receiving care in a hospital in Rio de Janeiro, Brazil.

Design: Cross-sectional study of pregnant and postpartum women receiving care in a public hospital in Rio de Janeiro from 1999 to 2001 (group I; n 225) or from 2005 to 2008 (group II; n 381). Night blindness was identified through a standardized and validated interview (WHO, 1996). The determinants of gestational night blindness were identified through a hierarchical logistic regression model.

Setting: Public maternity hospital in Rio de Janeiro, RJ, Brazil.

Subjects: Adult pregnant and postpartum women (n 606), aged ≥20 years.

Results: The prevalence of gestational night blindness was 9·9 %. The final model revealed that not living in the South Zone of Rio de Janeiro (distal level: adjusted OR=1·846; 95 % CI 1·002, 3·401), belonging to group I (intermediate level: adjusted OR=2·183; 95 % CI 1·066, 4·471) and for the proximal level, having a history of abortion (adjusted OR=2·840; 95 % CI 1·134, 7·115) and having anaemia during the first and second trimesters of pregnancy (adjusted OR=3·776; 95 % CI 1·579, 9·029) were determinants of gestational night blindness.

Conclusion: Gestational night blindness should be assessed for during the prenatal care of all pregnant women, especially those living in deprived areas of the city and/or who have a history of abortion or anaemia. Nutritional monitoring is recommended during pregnancy to control gestational night blindness.
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http://dx.doi.org/10.1017/S1368980015001846DOI Listing
April 2016

Association between maternal glucose levels during pregnancy and gestational diabetes mellitus: an analytical cross-sectional study.

Diabetol Metab Syndr 2015 12;7:17. Epub 2015 Mar 12.

Universidade Federal do Rio de Janeiro (UFRJ) - Centro de Ciências da Saúde, Instituto de Nutrição Josué de Castro, Cidade Universitária, Av. Carlos Chagas Filho, 373, bl. J, 2°. andar, Rio de Janeiro, CEP. 21941.590 RJ Brasil.

Background: To evaluate the association between fasting glucose levels in women throughout pregnancy and the occurrence of gestational diabetes mellitus (GDM) and other pregnancy complications, macrosomia, and cesarean delivery.

Methods: An analytical cross-sectional study with 829 healthy pregnant women receiving health care at a public maternity unit in Rio de Janeiro between 1999 and 2008. The dependent variables assessed in the study were: GDM (was confirmed when two or more values were above the glucose curve using 100 g glucose), complications, mode of delivery and birth weight. Macrosomia was defined as a birth weight of >4000 g. The independent variables assessed were: maternal fasting glucose per trimester as a continuous variable, divided into three categories, socio-demographic data on the mothers. The level of statistical significance was set at 5%.

Results: The mean fasting glucose levels of the women who had GDM were higher in the second trimester than for those who had no pregnancy complications (90.5 mg/dL vs. 78.5 mg/dL, p = 0.000). Higher mean fasting glucose levels were also found in the third trimester for women who developed GDM than for those with no pregnancy complications (90 mg/dL vs. 77.8 mg/dL, p = 0.016). Women who had a cesarean delivery had higher fasting glucose levels in the second (80.4 mg/dL vs. 78 mg/dL, post hoc = 0.034) and third (80.4 mg/dL and 77.1 mg/dL; post hoc = 0.005) trimesters than women who had a normal delivery. Also, higher fasting glucose levels were found in the second semester for women whose infants had macrosomia than for women whose newborns were normal weight (86.2 mg/dL and 78.8 mg/dL; post hoc = 0.003). The chance of develop GDM was higher for the women with glucose levels in the 90-94 mg/dL range in the second trimester (OR = 7.2; 95% CI = 2.33-22.24) than for the women whose glucose levels were in the <80 mg/dL and 80-90 mg/dL ranges.

Conclusion: Second and third trimester fasting glucose levels below the cut-off values for the diagnosis of GDM are associated with an increased risk of pregnancy complications. The dependent variables assessed in the study were: GDM (present/absent), complications, mode of delivery (normal, forceps, cesarean), and birth weight.
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http://dx.doi.org/10.1186/s13098-015-0013-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4358904PMC
March 2015

The role of prenatal nutrition assistance on the prevalence of night blindness in pregnant adults.

Nutr Hosp 2014 May 1;29(5):1132-40. Epub 2014 May 1.

Federal University of Rio de Janeiro. Josué de Castro Institute of Nutrition (UFRJ/INJC). Center of Research for Micronutrients (NPqM-UFRJ/INJC). Brazil..

Introduction: In developing countries, night blindness is a very common public health problem among pregnant women.

Objective: Evaluate the effect of the changes occurred on prenatal care concerning prenatal nutritional care on the occurrence of night blindness (XN) in adult pregnant women in public maternity hospital in Rio de Janeiro between 1999-2001 and between 2007-2008.

Methods: Two cross-sectional studies were conducted, been the first one conducted between 1999-2001 and the second one between 2007-2008. Were studied 402 puerperal women, 225 between 1999-2001 (GI) and 177 between 2007-2008 (GII). The gestational XN was investigated during the immediate puerperium (GI) and during the prenatal/puerperium (GII), diagnosed by the World Health Organization. The study collected sociodemographic, clinical, obstetric, anthropometric and prenatal care information.

Results: It verified significant reduce of prevalence of gestational XN (GI = 18.7% e GII = 0.6%, p < 0.001). The occurrence of gestational XN was associated to sanitary conditions, education level, more than six prenatal consultations, miscarriage at last pregnancy, higher average number of deliveries, average number of prenatal care consultations and prenatal nutritional (p < 0.05). There was no association between gestational XN and marital status, skin color, pre-gestational nutritional status, adequacy of gain of total gestational weight, gestational anaemia and average number of pregnancies (p > 0.05).

Conclusion: The inclusion of nutritional care in routine prenatal care may have contributed to the reduction of gestational XN. Studies to assess the nutritional intervention in the prevention and treatment of gestational XN at regions at greatest risk are suggested.
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http://dx.doi.org/10.3305/nh.2014.29.5.7241DOI Listing
May 2014

Effect of the use of probiotics in the treatment of children with atopic dermatitis; a literature review.

Nutr Hosp 2013 Jan-Feb;28(1):16-26

Nutricionist. Specialist in Clinical Nutrition, Instituto de Nutrição Josué de Castro, Universidade Federal do Rio de Janeiro, UFRJ-Federal University of Rio de Janeiro.

Introduction: Atopic dermatitis (AD) is a disease that mainly affects the pediatric population involving chronic and repetitive inflammatory skin manifestations. Its evolution is known as atopic march, which is characterized by the occurrence of respiratory and food allergies.

Aim: To carry out a classical review of the state-of-theart scientific literature regarding the effect of probiotics on the treatment of children with AD.

Methods: Searches were conducted in Medline and Lilacs through the portals PubMed (http://www.ncbi.nlm. nih.gov/pubmed/) and SciELO (http://www.scielo.br). There was a selection of the available publications in the period from 2001 to 2011, using the keywords atopic dermatitis and probiotics (in English and in Portuguese).

Results: After applying the inclusion and exclusion criterias, we selected 12 case-control studies which were conducted in four European countries and Australia. The methodological quality of the studies was assessed according to the STROBE recommendations. Assessment of agreement among researches in classifying the quality of the articles showed excellent agreement (k = 1.00, 95%) with a total of 9 papers at B level. The majority of the studies (75%) indicated a beneficial biological effect of probiotics on AD, including protection against infections, enhancement of the immune response, inflammation reduction and changes in gut the flora. The remaining studies showed no beneficial effects according to the outcomes of interest.

Conclusion: The majority of the studies in the scientific literature in this review showed improvements in some inflammatory parameters and in intestinal microbiota and not exactly, changes in clinical parameters. However, the biological effects observed in most of them suggest the possibility of benefits of the use of probiotics as an adjuvant in the treatment of AD.
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http://dx.doi.org/10.3305/nh.2013.28.1.6207DOI Listing
March 2014

[Pregestational overweight and obesity: prevalence and outcome associated with pregnancy].

Rev Bras Ginecol Obstet 2011 Nov;33(11):348-53

Mestranda do Instituto de Nutrição Josué de Castro – INJC – da Universidade Federal do Rio de Janeiro – UFRJ. Mestranda Pesquisadora do Grupo de Pesquisa em Saúde Materna e Infantil do Núcleo de Pesquisa em Micronutrientes – GPSMI/NPqM – do Instituto de Nutrição Josué de Castro – INJC – da Universidade Federal do Rio de Janeiro – UFRJ – Rio de Janeiro (RJ), Brasil.

Purpose: To describe the obstetric outcome of women with overweight/obesity treated at the prenatal care clinic of a public maternity hospital in Rio de Janeiro.

Methods: A descriptive cross-sectional study which investigated 433 women (≥20 years-old, without any chronic diseases) and their newborns treated at public hospitals in Rio de Janeiro. Information was collected from medical records and through interviews. The characteristics of mothers and newborns evaluated were divided into maternal (social habits, anthropometric measurements and clinical, obstetric, and prenatal care) and newborn groups (birth conditions). Data regarding the categories of nutritional status were analyzed using the odds ratio (OR) and 95% confidence interval (CI).

Results: The prevalence of overweight/obesity in this sample was 24.5% (n=106). There was an association between inadequate weight gain and the prevalence of overweight/obesity (OR 2.7, 95%CI 1.5-4.9, p<0.05). Overweight/obese women had an increased risk for preeclampsia (OR 3.3, 95%CI 1.1--9.9, p=0.03). Regarding birth conditions, mean birth weight was 3291.3 g (±455.2), with rates of low birth weight of 4.7% (n=5) and rates of macrosomia of 2.8% (n=3).

Conclusions: There was an alarming prevalence of inadequate nutritional status before and during pregnancy, which may be associated with increased risk of perinatal morbidity and mortality. This suggests the need for nutritional monitoring of these pregnant women.
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November 2011

[Pica: epidemiology and association with pregnancy complications].

Rev Bras Ginecol Obstet 2009 Sep;31(9):440-6

Departamento de Nutrição e Dietética, Instituto de Nutrição Josué de Castro, Universidade Federal do Rio de Janeiro.

Purpose: to verify the occurrence ratio of pica in pregnant women and its impact on the mother and newborn health.

Methods: prospective study with 227 adult pregnant women and their newborns treated at the Maternity School of Universidade Federal do Rio de Janeiro, between 2005 and 2006. Pica has been considered as the ingestion of inedible substances or atypical food combinations. The data was collected was done by medical chart review and interview.

Results: Pica was referred to by 14.4% of the women, 42.1% of whom practiced it daily. The onset occurred in the second gestational trimester in 46.7% of the cases, and, in the third trimester, in 30% of them. Among the alleged reasons, 65% of the women were unable to give them, 15% declared relief of nausea and heartburn and 10% reported reduced stress and anxiety. The practice in the previous gestation/puerperium was referred to by 15% of the women. Pica was not associated with the maternal anthropometric condition, the skin color, the marital status, the maternal schooling and the presence of parasitosis. There was no difference between the average of the total family income and the number of gestations for the women who did or did not have pica. Pica was associated with gestational anemia (p<0.009) and gestational intercurrences (OR=3.5; CI95%=1.6-7.9). As for the baby, pica did not interfere in the health parameters at birth: weight, gestational age and intercurrences.

Conclusions: pica must be investigated at prenatal assistance and recognized as a risk factor for the mother's health.
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http://dx.doi.org/10.1590/s0100-72032009000900004DOI Listing
September 2009

[Factors associated to alcohol and smoking use in pregnancy].

Rev Bras Ginecol Obstet 2009 Jul;31(7):335-41

Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.

Purpose: to describe alcohol and tobacco use in adult pregnant women and determine its association with the obstetric outcome.

Methods: analytical transversal study, in which 433 adult pregnant women and their newborns have been included, attended at a public maternity hospital in Rio de Janeiro, from 1999 to 2006. Information on the mother and the newborn was collected at the moment of delivery and during puerperium through an interview and inspection of the medical records. 'Use of alcohol during gestation' and 'use of cigarette during gestation' have been considered when detected at any gestational age and written down on the medical record.

Results: it was observed that 5.5 and 7.7% of the pregnant women reported cigarette and alcohol use during gestation, respectively. Maternal features related to tobacco use during pregnancy were marital status (p=0.005), age (p=0.01) and pre-natal nutritional guidance (p=0.003). Tobacco use during pregnancy has been strongly associated with alcohol use, 31.3% of the women reporting concomitant use of both substances (p<0.05). No association between alcohol or tobacco use during gestation and obstetric outcome (gestational age, newborn weight at birth and newborn medical conditions; p>0.05) has been detected.

Conclusions: these results suggest that tobacco and alcohol use should be investigated during pre-natal care among all women, particularly single women, over 35 years old, with history of miscarriage, and with unwanted pregnancy. Nutritional guidance had a protective effect against tobacco use during gestation, and thus pregnant women should be informed as to the harmful effects of substance use to ensure better obstetric outcome.
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July 2009

Anthropometric assessment of nutritional status in Brazilian pregnant women.

Rev Panam Salud Publica 2009 Feb;25(2):171-8

Pediatric Institute, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

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http://dx.doi.org/10.1590/s1020-49892009000200011DOI Listing
February 2009
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