www.jped.com.br
ORIGINAL
ARTICLE
Calcium
intake
by
adolescents:
a
population-based
health
survey
夽
Daniela
de
Assumpc
¸ão
a,
Marcia
Regina
Messaggi
Gomes
Dias
b,
Marilisa
Berti
de
Azevedo
Barros
a,
Regina
Mara
Fisberg
c,
Antonio
de
Azevedo
Barros
Filho
b,∗aDepartmentofCollectiveHealth,FaculdadedeCiênciasMédicas,UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,
Brazil
bDepartmentofPediatrics,FaculdadedeCiênciasMédicas,UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil cDepartmentofNutrition,FaculdadedeSaúdePública,UniversidadedeSãoPaulo(USP),SãoPaulo,SP,Brazil
Received17April2015;accepted22September2015 Availableonline28December2015
KEYWORDS Adolescent; Calciumdietary; Foodconsumption; Healthsurveys
Abstract
Objective: Toanalyzecalciumintakeinadolescentsaccordingtosociodemographicvariables, health-relatedbehaviors,morbidities,andbodymassindex.
Methods: Thiswasacross-sectionalpopulation-basedstudy,withatwo-stageclustersampling thatuseddatafromasurveyconductedinCampinas,SãoPaulo,Brazil,between2008and2009. Food intakewasassessedusinga24-hourdietaryrecall.Thestudy included913adolescents aged10---19years.
Results: Averagenutrientintakewassignificantlylowerinthesegmentwithlowereducation oftheheadofthefamilyandlowerpercapitafamilyincome,inindividualsfromothercitiesor states,thosewhoconsumedfruitlessthanfourtimesaweek,thosewhodidnotdrinkmilkdaily, thosewhoweresmokers,andthosewhoreportedtheoccurrenceofheadachesanddizziness. Highermeancalciumintakewasfoundinindividualsthatsleptlessthansevenhoursaday.The prevalenceofcalciumintakebelowtherecommendationwas88.6%(95%CI:85.4---91.2). Conclusion: Theresultsalert toaninsufficient calciumintakeandsuggestthatcertain sub-groupsofadolescentsneedspecificstrategiestoincreasetheintakeofthisnutrient.
©2015SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
夽
Pleasecitethisarticleas:deAssumpc¸ãoD,DiasMR,deAzevedoBarrosMB,FisbergRM,deAzevedoBarrosFilhoA.Calciumintakeby adolescents:apopulation-basedhealthsurvey.JPediatr(RioJ).2016;92:251---9.
∗Correspondingauthor.
E-mail:[email protected](A.deAzevedoBarrosFilho). http://dx.doi.org/10.1016/j.jped.2015.09.004
PALAVRAS-CHAVE Adolescente; Cálcionadieta; Consumode alimentos; Inquéritodesaúde
Ingestãodecálcioporadolescentes:inquéritodesaúdedebasepopulacional
Resumo
Objetivos: Analisaraingestãodecálcioemadolescentessegundovariáveissociodemográficas, decomportamentosrelacionadosàsaúde,morbidadeseíndicedemassacorporal.
Métodos: Trata-sedeestudotransversaldebasepopulacional,comamostraporconglomerados, tomadaemdoisestágiosequeutilizoudadosdeinquéritorealizadoemCampinas,SãoPaulo, Brasil,em2008/09.OconsumoalimentarfoiestimadopeloRecordatóriode24horas.Foram analisados913adolescentesde10a19anos.
Resultados: Médiassignificativamenteinferioresdeingestãodonutrienteforamverificadasnos segmentosdemenorescolaridadedochefedafamília,demenorrendafamiliarpercapita,nos naturaisdeoutrosmunicípiosouEstados,nosqueconsomemfrutasmenosquequatrovezes nasemana,nosquenãobebemleitediariamente,nosfumantesenosquereferirampresenc¸a dedordecabec¸aetontura.Médiasuperiordeingestãodecálciofoiencontradanosindivíduos que dormemmenos de sete horaspor dia.A prevalênciade ingestãode cálcio inferior ao recomendadofoide88,6%(IC95%:85,4-91,2).
Conclusões: Osresultadosdesteestudoalertamparaoconsumoinsuficientedecálcioesugerem quedeterminadossubgruposdeadolescentesnecessitamdeestratégiasmaisespecíficaspara aumentaraingestãodestenutriente.
©2015SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
Calciumisanessentialnutrientformaintainingbonehealth, asit contributestobone mineralization and rigidity, thus preventingproblems suchasosteoporosis andfracturesin adulthoodandoldage.1,2Italsoparticipatesinfibrin
forma-tionduringthebloodcoagulationprocessandregulationof musclecontraction,sincetheproteintroponin,aregulator ofactinandmyosincontractility,dependsoncalcium.3
Adequatecalciumintakeisessentialforthedevelopment andmaintenanceofbonemasspeakduringadolescence.1,2
Frombirthtoadulthood,bonemassincreases40times,and thepeakisreachedattheendoftheseconddecadeoflife.2
Between40%and60%ofbonemassincreaseoccursduring adolescence.2
The nutritional recommendation of calcium intake for childrenandadolescentsaged9---18yearsisof1100mg/day, according to the estimated average requirements (EAR), whichshouldnotexceedthetolerableupperintakelevelof 3000mg/day.4 Accordingtothe2008---2009Household
Bud-getSurvey(PesquisadeOrc¸amentosFamiliares[POF]),the highestmeanvaluesofcalciumintakewere565.7mginboys aged14---18yearsand521.7mgingirlsaged10---13years.5
Dairyproducts,darkgreenvegetables,certaintypesof fish,andnutsareimportantdietarysourcesofthismineral.6
Brazilian researchhas shown that the dietary patternsof adolescentsischaracterizedbylowconsumptionofcertain foods,suchasmilkandotherdairyproducts,fruit,and veg-etables,andbytheincreasedintakeofhigh-caloriefoods, saturatedfats,sugars,and sodium,suchassugary drinks, sweets,andcookies.7---10 Thisdietarypatternmaybe
harm-ingtheconsumptionofcalcium-richfoods.
Considering the importance of the nutrient intake for good health and the results of studies that evidence a severely inadequate calcium intake by adolescents, this
studyaimedtoevaluatetheepidemiologicalprofileof cal-cium intakein adolescents inthe city of Campinas, state of São Paulo, Brazil, and to identify which segments are moresusceptibletocalciumintakedeficiency,accordingto demographic and socioeconomic variables, health-related behaviors,morbidities,andbodymassindex(BMI).
Methods
This was a cross-sectional population-based study that included 929non-institutionalizedadolescentsaged10---19 years,livingintheurbanareaofthecityofCampinas.The studydatawereobtainedfromtheCampinasHealthSurvey (InquéritodeSaúde nomunicípio deCampinas--- ISACamp 2008/09),carriedoutbetweenFebruaryof2008andMarch of2009.
Thestudysamplewasdeterminedbyprobabilistic samp-lingproceduresbyclusters,andintwostages:censussectors andhouseholds. Inthefirst stage,50censussectorswere selected by drawinglots,with probabilityproportionalto size(numberofhouseholds).Inthesecondstage,the house-holdswereselectedbydrawinglots.
Thesamplesizewascalculatedconsideringtheestimated prevalenceof50%(correspondingtothemaximum variabil-ity),withaconfidencelevelof95%,samplingerrorbetween 4%and5%,andaseconddesign effect,totaling1000 ado-lescents(10---19years).Expecting20%ofnon-response,the samplesizewascorrectedto1250.Toachievethisnumber ofindividuals,2150householdswererandomlyselectedfor interviewswiththeadolescents.
Duringthefieldwork,thecontentof24HRwascheckedto identifyandresolvetheincorrectfillingoutofforms.
A 24HR quantification was performed to convert the amountsof foods or preparationsmentioned in household measures into grams or milliliters. For this purpose, the authors used information available in household measure tables,11,12 food labels, and customer care services. The
intakeinformationwasinsertedintotheNutritionData Sys-temforResearchsoftwaredatabase (NDS-R,version2007, UniversityofMinnesota,USA).The analysesexcluded ado-lescents with caloric intake lower than 600kcal/day and greaterthan6000kcal/day.13
Study
variables
Dependentvariable:meancalciumintake(mg/day)
Theprevalenceofinadequatenutrientintakewasestimated using the EAR as the cutoff point, which corresponds to 1100mgand800mgforadolescentsaged10---18yearsand 19years,respectively.4
The following sets of independent variables were selected:
• Demographic and socioeconomic information: gender, age(years),ethnicity/skincolor(self-reported),number ofhouseholdmembers,placeofbirth,educationallevel of the headof thefamily(years),employment, private health insurance,school attendanceby the adolescent, number of appliancesin the household,and per capita
familyincome(inBrazilianminimumwages).
• Health-relatedbehaviors:smoking,frequencyofweekly
consumption ofalcohol, fruit,rawvegetables,andmilk obtained by the foodfrequency questionnaire; physical activity inthecontextof leisure,categorizedas: active (adolescentswhopracticedatleast150minutesaweek, distributed in at least three days),insufficiently active (those who practiced less than 150minutes a week or more,butinfewerthanthreedaysaweek)andsedentary (those who did not practice any kind of leisure physi-cal activity onany day of the week)14; and number of
hours/dayintendedforsleepandcomputeruse.
• Morbidities and BMI: presence of headache/migraine, dizziness, number of chronic diseases, and number of health complaints among those included in the check-list. BMI was calculated from the self-reported weight and height information. The cutoffs recommended for adolescents15 were used, with the following
classifi-cations: underweight, normal weight, overweight, and obese.
For the study analyses, the mean calcium intake was calculated according to the categories of the indepen-dent variables. The means and 95% confidence intervals were estimated usingsingle andmultiple generalized lin-earregressionmodels(GLM).Theselectionofvariablesfor themodeladjustmentwasperformedintwostages.Inthe first stage, the demographic and socioeconomic variables thatshowedasignificancelevel<0.20inthebivariate anal-ysiswereentered,andthosewithp<0.05remainedinthe model.Inthesecondstage,thehealth-relatedbehaviorand
morbidityvariablesthathadp<0.20inthebivariate anal-ysiswereaddedtothemodel andthosethatremainedat the5%significancelevel weremaintained.The modelwas adjustedfortotalcaloricintake,asrecommendedbyWillett etal.16
TheGLMallowsfortheassumptionofdistributionsother than the normal for the response variable, and provides greater flexibility for the functional association between themean of the response variableand the linear predic-tor.DistributionsmodeledbyGLMbelongtotheexponential family,includingdistributionsforbothcontinuousandmild responsevariables.17 Thegraphical analysisandstatistical
hypothesistesting demonstratedthatthegamma distribu-tionwasappropriatetomodelthecalciumintake.
Theinterviewswereenteredintothedatabasedeveloped usingEpidata3.1(EpidataAssoc.,Odense,Denmark)andthe statisticalanalyseswereperformedusingStata11.0(Stata Corp.,CollegeStation,USA),svymodule,whichtakesinto accounttheweightsandthestudysamplingdesign.
ThepresentstudywasapprovedbytheResearchEthics Committee of Universidade Estadual de Campinas and theNational Research Ethics Committee,under CAAENo. 37303414.4.0000.5404. For adolescents younger than 18 years, the consent form was signed by their parents or guardians.
Results
Ofthetotal of929 interviews, fivewereexcluded due to refusal in filling out the 24HR and 11 for having a daily caloricintake<600kcalor>6000kcal.Therefore,913 ado-lescentswereassessed,withameanageof14.1years(95% CI:13.8---14.4).
Calcium intakewas significantly lowerin girls, in ado-lescentsbelongingtothe lowerper capitaincomestrata, andin thosewhose head of the family had lower educa-tional level, those without private health insurance, and thosewhohadfewerhouseholdappliancesintheresidence. Comparedtoadolescentsfromprivateschools, thosewho didnotattendschool orwhoattendedpublic schoolshad lowermeancalciumintake(Table1).
Table2 shows thatindividuals whoconsumedfruitand milklessthanfourtimesaweekhadalowerintakeofthe nutrient,whichwasalsosignificantlyloweramongthosewho didnotconsumerawvegetablesdaily,insmokers,thosewho consumed alcohol two or more times a week, those who reportednineormorehoursofsleep,andthosewhodidnot useacomputer.
Table1 Meancalciumintake(mg)inadolescentsaged10---19years,accordingtosociodemographicvariables.CampinasHealth Survey(InquéritodeSaúdedeCampinas[ISACamp]),2008/09.
Variablesandcategories n Mean(95%CI) p-Valuea
Gender
Maleb 462 692.3(636.9---747.7)
Female 451 540.7(436.4---645.0) 0.000
Total 913 618.2(570.8---665.5)
Agerange(inyears)
10---14b 504 620.3(567.0---673.5)
15---19 409 615.5(496.0---735.0) 0.886
Ethnicity
Whiteb 587 639.7(595.6---683.8)
Non-white 323 579.0(461.7---696.4) 0.102
Numberofpeopleinhousehold
1---3b 220 646.0(574.7---717.4)
4---6 579 627.3(489.6---764.9) 0.572
7ormore 114 515.6(290.6---740.5) 0.094
Origin
Campinasb 692 633.8(580.9---686.6)
Anothermunicipalityorstate 221 569.5(445.6---693.3) 0.075
Headoffamilyeducationallevel(inyears)
0---7 382 528.6(379.8---677.4) 0.000
8---11 310 625.9(476.2---775.5) 0.003
12ormoreb 210 759.8(695.5---824.1)
Percapitaincome(inminimumwages)
<1 578 564.6(399.4---729.9) 0.000
≥1to≤2 193 646.7(450.5---842.9) 0.021
>2b 142 785.1(705.5---864.8)
Occupationalactivity
Worksb 148 655.5(557.8---753.2)
Doesnotwork 754 610.4(418.5---802.3) 0.341
Hashealthcareinsurance
Yesb 307 712.8(654.6---771.0)
No 601 566.7(440.7---692.6) 0.000
Attendsschool
No 143 596.4(412.9---779.8) 0.019
Yes,public 607 589.7(437.5---741.8) 0.001
Yes,privateb 162 735.0(666.4---803.5)
Numberofappliancesinhousehold
0---10 420 538.6(373.1---704.2) 0.000
11---15 231 643.2(486.6---799.8) 0.090
16ormoreb 261 718.7(649.5---787.8)
n,numberofindividualsintheunweightedsample.
aInbold,pvalue<0.05.
b Referencecategoryusedforcomparison.
Theprevalenceofinadequatecalciumintakewas88.6% forthetotalpopulation(95%CI:85.4---91.2),reaching85.1% in boys (95% CI: 80.6---88.7) and 92.2% in girls (95% CI: 89.1---94.5). In the segment withhigher educational level of the head of the family (12 yearsor more), the values correspondedto79.8%inthegroupofadolescents(95%CI: 71.1---86.0),75.9%inmales(95%CI:65.0---84.4)and84.5%in females(95%CI:76.0---90.4)(datanotshown).
Discussion
Table 2 Meancalcium intake(mg) inadolescents aged 10---19 years, according to variables of health-related behaviors. CampinasHealthSurvey(InquéritodeSaúdedeCampinas[ISACamp]),2008/09.
Variablesandcategories n Mean(95%CI) p-Valuea
Fruitconsumption
7timesaweekb 246 675.6(602.5---748.7)
4---6timesaweek 189 671.0(499.0---842.9) 0.927
≤3timesaweek 478 567.4(413.7---721.1) 0.010
Rawvegetableconsumption
7timesaweekb 295 658.0(597.5---718.6)
4---6timesaweek 214 581.2(443.0---719.3) 0.052
≤3timesaweek 404 608.2(480.9---735.5) 0.140
Milkconsumption
7timesaweekb 552 711.5(663.8---759.2)
4---6timesaweek 94 649.0(502.5---795.4) 0.209
≤3timesaweek 267 413.6(316.8---510.4) 0.000
Softdrinkconsumption
7timesaweek 207 625.4(491.1---759.6) 0.581
4---6timesaweek 145 668.7(518.3---819.2) 0.186
≤3timesaweekb 561 602.4(551.1---653.8)
Smokingstatus
Nonsmokerb 873 624.3(577.0---671.5)
Ex-smoker 18 591.9(344.9---838.8) 0.746
Smoker 22 396.1(255.0---537.2) 0.000
Alcoholconsumption
Doesnotdrinkalcoholb 764 616.4(564.5---668.3)
1---4timesaweek 118 669.2(525.6---812.7) 0.253
2ormoretimesaweek 26 476.7(333.5---620.0) 0.004
Physicalactivityatleisure
Sedentary 278 566.9(428.4---705.5) 0.013
Insufficientlyactive 305 610.0(474.5---745.6) 0.132
Activeb 330 667.7(607.7---727.7)
Sleep(hours/day)
<7 60 615.3(443.0---787.5) 0.445
7---8b 450 657.9(597.0---718.8)
9ormore 393 572.9(446.6---699.2) 0.012
Computeruse(hours/day)
0b 437 563.8(499.5---628.1)
1---2 298 657.5(522.0---792.8) 0.011
3ormore 172 688.3(527.2---849.4) 0.013
n,numberofindividualsintheunweightedsample.
a Inbold,p-value<0.05.
b Referencecategoryusedforcomparison.
daily,insmokers,andinthosewhoreportedthepresence ofheadacheanddizziness.
The limitations of thisstudy includethe applicationof onlyone24HR,which does notreflecttheusual intakeof adolescents, as it does not detect consumption variabil-ity.However,the24HRisconsideredanappropriatetoolto assessthemeanintakeoffoodsandnutrientswhenapplied in population-based samplesand on differentdays of the weekandmonthsoftheyear,asintheISACamp2008/09.18
Moreover, the possibility of reverse causality in a cross-sectionalstudypreventsinterpretingtheresultsasofcause andeffect.
TheDietaryGuidelinefortheBrazilianPopulation, pub-lished in 2014, proposed a comprehensive assessment of diet and its association with health, setting its guide-linesbasedonnutrients,foods,combinationsoffoods,and preparations.19Thefocusofthisstudywastoassesscalcium
intake,asitisanessentialnutrientforthedevelopmentand maintenanceofbonemassthroughoutlife,aswellasforthe preventionofosteoporosisduringchildhoodandadulthood, andfractureresultingfromthiscondition.2
Amongtheadolescents,evidenceonthelowconsumption ofcalcium-richfoods10,20andonthehighintakeofsodium20
Table3 Meancalciumintake(mg)inadolescentsaged 10---19years,according tomorbiditiesand bodymassindex(BMI). CampinasHealthSurveyofCampinas(InquéritodeSaúdedeCampinas[ISACamp]),2008/09.
Variablesandcategories n Mean(95%CI) p-valuea
Headache/migraine
Yes 227 543.4(431.8---655.0) 0.003
Nob 686 642.7(594.3---691.1)
Dizziness
Yes 55 490.8(349.5---632.2) 0.005
Nob 858 626.2(578.2---674.2)
Numberofchronicdiseases
0b 739 613.7(561.5---665.9)
1ormore 170 620.5(500.6---740.4) 0.840
Numberofhealthcomplaints
0b 344 638.0(572.9---703.2)
1 295 627.0(494.5---759.4) 0.742
2ormore 274 583.9(443.7---723.9) 0.153
BMI(kg/m2)
Lowweight 30 468.2(260.0---676.4) 0.055
Normalweightb 565 619.8(566.6---673.0)
Overweight 133 668.5(521.3---815.6) 0.303
Obesity 81 626.7(438.3---815.2) 0.918
n,numberofindividualsintheunweightedsample.
aInbold,pvalue<0.05.
b Referencecategoryusedforcomparison.
portiondoesnotmeettherecommendedlevelsofphysical activity,21reinforcetheneedforperformingepidemiological
researchoncalciumintake.
Inthis study,the meancalciumintakewas692.3mgin boys and 540.7mg in girls, higher than the values found in the 2008---2009 POF, which were 565.7mg in boys and 521.7mgingirlsaged10---18years.5However,itwaslower
thanthemean obtainedin astudy of 507students inthe city ofOuro Preto,state of Minas Gerais,which observed aconsumptionof730.6mgand679.4mgin boysandgirls, respectively.22
CalciumintakebelowtheEARwasobservedin88.6%of theadolescentsinthecityofCampinas.Analyzingdatafrom theNationalFoodSurvey(InquéritoNacionaldeAlimentac¸ão [INA])2008---2009,Veigaetal.20foundaninadequacy
preva-lence>95.0%inindividualsagedbetween10and18years. This result was attributed toa low consumption of dairy products,whicharethemainfoodsourcesofthenutrient, aswell asitsreplacementby softdrinksandother sugary beverages.5,23
Inthebivariateanalysis,femalegender wasassociated withlowercalciumconsumption, butit didnot remainin thefinalmodel,duetotheadjustmentbycaloric consump-tion (kcal). The caloric intake was significantly lower in girls,being,respectively, in boyswas2715.2kcal (95% CI: 2522.8---2907.6)and2277.1(95%CI:1977.0---2577.1)ingirls. Nonetheless,the authors decidedto maintain the gender variabletoadjustthemodel.
When compared with adolescents born in Campinas, those from other municipalities or states had lower cal-cium intake.Regarding individuals aged10---18 years,the 2008---2009 POF showed changes in mean calcium intake
among the major regions of Brazil: the Northeast region presentedthelowestvaluesandtheSoutheast,thehighest.5
Thefindingsofthisstudy showasignificantincrease in calcium intake with the improvement in the educational leveloftheheadofthefamily.Datafromthe2009National Schoolchildren’sHealthSurvey(PesquisaNacionaldeSaúde do Escolar [PeNSE]) demonstrated a positive association betweenregularconsumption ofmilk(fivedaysaweekor more)withmaternaleducationallevel.24 Studiesthat
ana-lyzedthequalityofdietinadolescentsfoundahigherintake of dairyproductsandvegetablesin thestratawithhigher educationalleveloftheheadofthefamily.25,26
Lowercalcium intake wasobserved in individuals who lived in households with a monthly per capita income of less thanBrazilian one minimumwage. The PeNSE results showedalowproportionofregularmilkconsumptionin indi-viduals fromlower socioeconomicclasses.24 Basedon the
2008---2009 POF,Levy etal.27 identifiedan increasein the
participation of milk anddairy products in the diet asso-ciated with an increase in household income. In Pelotas, researchersassessed2209adolescentsandobserveda sig-nificantreductioninthefrequencyofdailyconsumptionof milkwithworseninginthesocioeconomiclevel.7
Fruitconsumptionlessthanfourtimesaweekwas asso-ciatedwithlowercalciumintake.Apopulation-basedstudy carriedoutinSãoPaulofoundthat,ofthe812interviewed adolescents,only6.5%mettheminimumdaily recommen-dationof400goffruitandvegetables.9 Accordingtodata
Table4 Two-stepgeneralizedlinearmodel.CampinasHealthSurvey(InquéritodeSaúdedeCampinas[ISACamp]),2008/09.
Variablesandcategories Firststepa(95%CI) p-Valueb Secondstepc(95%CI) p-Valueb
Gender
Maled 328.6(213.2---443.8) 408.3(281.3---535.3)
Female 297.5(148.7---446.5) 0.068 399.8(229.6---570.0) 0.694
Origin
Campinasd 328.6(213.2---443.8) 408.3(281.3---535.3)
Anothermunicipalityorstate 279.7(123.6---435.8) 0.020 372.4(216.1---528.7) 0.017
Educationalleveloftheheadofthefamily(inyears)
0---7 173.4(9.25---337.6) 0.000 300.3(125.6---475.0) 0.000
8---11 245.7(68.2---423.2) 0.010 344.3(158.3---530.2) 0.034
12ormored 328.6(213.2---443.8) 408.3(281.3---535.3)
Percapitaincome(inminimumwages)
<1 241.2(52.0---430.5) 0.022 321.7(117.5---526.0) 0.029
≥1to≤2 240.3(44.7---435.8) 0.032 355.6(145.5---565.8) 0.209 >2d 328.6(213.2---443.8) 408.3(281.3---535.3)
Fruitconsumption
7timesaweekd 408.3(281.3---535.3)
4---6timesaweek 392.8(210.7---575.0) 0.576
≤3timesaweek 355.9(183.4---527.4) 0.025
Milkconsumption
7timesaweekd 408.3(281.3---535.3)
4---6timesaweek 328.6(155.3---502.1) 0.001
≤3timesaweek 215.4(51.0---379.9) 0.000
Smokingstatus
Nonsmokerd 408.3(281.3---535.3)
Ex-smoker 453.4(211.4---695.3) 0.434
Smoker 336.1(151.2---521.0) 0.016
Sleep(hours/day)
<7 506.7(297.2---716.2) 0.020
7---8d 408.3(281.3---535.3)
9ormore 413.6(255.7---571.5) 0.732
Headache/migraine
Yes 371.5(218.0---525.0) 0.007
Nod 408.3(281.3---535.3)
Dizziness
Yes 332.3(153.0---511.6) 0.005
Nod 408.3(281.3---535.3)
a Adjustedforcaloriesandfordemographicandsocioeconomicvariables. b Inbold,p-value<0.05.
c Adjustedforcaloriesandforallthevariablesofthetable. d Referencecategoryusedforcomparison.
andvegetablesisoneofthenationaltargetsintendedtohalt theincreaseofnon-communicablechronicdiseases,which involves actionsaimedat promotinghealthyeatingin the SchoolFeeding Program, lowerprices, andgreater supply andproductionofthesefoods.28
Individuals whoreporteddrinkingmilkdailyhadhigher mean levels of the nutrient. Among the participants of PeNSE,53.6%reportedconsumingmilkfiveormoredaysper week.24 Ofthe20foodsmostoftenmentionedbythe
ado-lescentsincluded in the2008---2009 POF, theitem‘‘juices andartificialjuices’’wasinthesixthposition(43.5%),while wholemilk wasin the18th(12.9%).29 National data show
that, between 1974 and 2003, the household availability
ofdairy products increased by 36% andof soft drinks, by 400%.23 Across-sectional study conducted in Canada with
610children aged8---10 years observed adecrease in the consumptionofsugarydrinkswiththeincreased consump-tionofdairyproducts,aswellasasignificantreductionin systolicbloodpressureinthesegmentthathadtwoormore dailyservingsofdairyproducts.30
When compared with non-smokers, smokers hadlower calciumintake.Ina population-based surveywith adoles-centsaged12---19 years,Bigio etal.9 found a decreasein
quality,reflectedbyalowerconsumptionoffruitanddairy products,andhigherconsumptionofmeatandsodium.By observingtheassociationwithdiet,tobaccocontrolcan con-tributetotheeffectivenessofstrategiesaimedatpromoting healthybehaviors,includingeatinghabits.
Adolescents who reported having headaches/migraine anddizzinessshowedsignificantlylowercalciumintake.To thebestoftheauthors’knowledge,nostudyintheliterature hasanalyzedtheassociationbetweencalciumintakeandthe occurrenceofheadacheordizziness.Usingthesamesample assessedinthisresearch,Braz etal.32 found aprevalence
of health problems in 61.5% of the sample, and frequent headache/migraine wasreported by 24.8% of the adoles-cents.
Ahighercalciumintakewasobservedinindividualsthat mentionedsleepinglessthansevenhoursaday.Lealetal.10
foundthat21.0%ofadolescentsdidnothavebreakfastand 22.0%didnoteatamid-afternoonsnack,mealsthatusually consistofmilkotherdairyproducts.Therefore,thefactthat adolescentshadlongersleepdurationmayhavecontributed totheskippingofbreakfastand,consequently,toalower intakeoffoodswithhighcalciumcontent.
A calcium-poor diet was observed concurrently with otherunhealthybehaviors,suchassmokingandlower fre-quency of fruit consumption. This result highlights the importanceofactionsaimedatthegroupofbehaviorsthat influencetheadolescents’overallhealth,includingthe pro-motionofahealthydiet.
Thepresentstudyprovidedpopulation-levelinformation oncalciumintakeinindividualsaged10---19yearslivingin thecityofCampinas.Itwasobservedthatthereis a defi-ciencyintheintakeofthisnutrientinallassessedsegments, demonstratingthatthoseinthelowersocioeconomicstatus strata andthose withother inappropriate behaviorsshow evenmoreunfavorableresults.Thesefindingssuggestthat strategiespromotinghealthyeatinghabitsshouldtakeinto accountthespecificitiesofeachpopulationsubgroup.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
The authors would like to thank Conselho Nacional de DesenvolvimentoCientíficoeTecnológico(CNPq,processn. 409747/2006-8)forfundingthisresearchandforthe produc-tivitygrants giventoM.B.A. Barrosand R.M. Fisberg;the Municipal Health Secretariat of Campinas and the Health SurveillanceSecretariat of theMinistry of Health,for the financialsupporttoperformthefieldresearchofISACAMP 2008;andCAPES,forthePh.D. scholarshipreceivedbyD. Assumpc¸ão.
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![Table 4 Two-step generalized linear model. Campinas Health Survey (Inquérito de Saúde de Campinas [ISACamp]), 2008/09.](https://thumb-eu.123doks.com/thumbv2/123dok_br/14994406.513183/7.918.71.839.103.823/generalized-campinas-health-survey-inquérito-saúde-campinas-isacamp.webp)
