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The nutritional status and physical work performance of children of migrant agricultural workers in Southern.. Waddell, Charlotte 1981

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THE NUTRITIONAL STATUS AND PHYSICAL WORK PERFORMANCE OF CHILDREN OF MIGRANT AGRICULTURAL WORKERS  IN SOUTHERN B R A Z I L  by  CHARLOTTE WADDELL B.Sc,  University  A THESIS SUBMITTED  of B r i t i s h  Columbia,  1978  IN PARTIAL FULFILMENT OF  THE REQUIREMENTS  FOR THE DEGREE OF  MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES D i v i s i o n o f Human N u t r i t i o n School  We a c c e p t  o f Home E c o n o m i c s  this  thesis  to the r e q u i r e d  THE UNIVERSITY  conforming  standard  OF B R I T I S H COLUMBIA  April  ©  as  1981  CHARLOTTE WADDELL,  I98I  '  In p r e s e n t i n g  this  thesis  in partial  f u l f i l m e n t of the  r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e of B r i t i s h Columbia, I agree that it  freely  the L i b r a r y  a v a i l a b l e f o r r e f e r e n c e and s t u d y .  agree t h a t p e r m i s s i o n for  University  f o r extensive  s c h o l a r l y p u r p o s e s may  for  financial  shall  of  The U n i v e r s i t y o f B r i t i s h 2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  thesis  Columbia  my  It is thesis  n o t be a l l o w e d w i t h o u t my  permission.  Department  further  be g r a n t e d by t h e h e a d o f  copying or p u b l i c a t i o n of this  gain  I  make  copying of t h i s  d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . understood that  shall  written  i i  ABSTRACT  A s t u d y was c o n d u c t e d t o i n v e s t i g a t e a n d compare t h e n u t r i t i o n a l s t a t u s and p h y s i c a l agricultural The  workers w i t h  relationship  was a l s o  work p e r f o r m a n c e o f c h i l d r e n o f B r a z i l i a n  between  Brazilian children nutritional  status  and p h y s i c a l  backgrounds.  work  performance  investigated.  D i e t a r y a n a l y s i s was c o n d u c t e d u s i n g E v i d e n c e was f o u n d t h a t n i a c i n , and v i t a m i n children. rice,  from wel1-to-do  migrant  t h e 24-hour  intakes o f energy, calcium,  C may h a v e been  diet  recall  thiamin,  c o n s i d e r a b l y more v a r i e d w i t h  good  riboflavin,  i n a d e q u a t e among m i g r a n t w o r k e r  T h e i r d i e t was g e n e r a l l y m o n o t o n o u s a n d c o n s i s t e d  b e a n s , and c o f f e e w i t h s u g a r .  method.  mainly of  Diets of well-to-do children representation  from a l l  major  were food  groups. Anthropometric assessment values  f o r w e i g h t and t r i c e p s  to American muscle  standards.  skinfold  t h a t m i g r a n t w o r k e r c h i l d r e n had  thickness  meters  exceeded  t h a t were low compared  V a l u e s f o r h e i g h t , a r m c i r c u m f e r e n c e , a n d arm  c i r c u m f e r e n c e were a v e r a g e compared  to-do c h i l d r e n  American  t o American  standards.  Well-  standards f o r a l l anthropometric para-  measured.  Biochemical  i n v e s t i g a t i o n s o f p r o t e i n and i r o n  ducted.  Serum t o t a l  subjects  i n both groups.  values  indicated  protein  l e v e l s were adequate  l e v e l s were normal  con-  i n most  H o w e v e r , many m i g r a n t w o r k e r , c h i 1 d r e n had l o w  f o r h e m a t o c r i t , serum  well-to-do children  and a l b u m i n  s t a t u s were a l s o  i r o n , and t r a n s f e r r i n  had normal i n most  saturation.  values f o r these parameters.  subjects.  Most Hemoglobin  i ii  Physical children.  work performance was  E x e r c i s e heart rates and p o s t - e x e r c i s e blood l a c t i c a c i d  in response  to a s t a n d a r d i z e d b i c y c l e - e r g o m e t e r work t e s t were  cantly higher  c o r r e l a t i o n was found between a n t h r o p o m e t r i c  cators of n u t r i t i o n a l Finally,  s t a t u s and parameters o f p h y s i c a l  s o c i o - e c o n o m i c and e c o l o g i c a l  assessment  levels  signifi-  in migrant worker compared to w e l 1 - t o - d o c h i l d r e n .  tion, a significant  living  found to be impaired in migrant worker  In  addi-  indi-  work performance. i n d i c a t e d that  the  c o n d i t i o n s o f migrant worker c h i l d r e n were impoverished and un-  sanitary.  This  probably aggravated h e a l t h problems  that were found to o c c u r among these c h i l d r e n . not share  these  conditions.  such as  infections  Well-to-do c h i l d r e n did  iv  TABLE OF CONTENTS Page ABSTRACT  i i  L I S T OF TABLES  vi  L I S T OF FIGURES  v i i  ACKNOWLEDGEMENTS  viii  CHAPTER I  INTRODUCTION  1  II  REVIEW OF THE LITERATURE  6  1. 2. 3. k. 5-  Socio-economic Factors in M a l n u t r i t i o n Assessment o f N u t r i t i o n a l Status A s s e s s m e n t o f P h y s i c a l Work P e r f o r m a n c e A s s o c i a t i o n B e t w e e n N u t r i t i o n a l S t a t u s and P h y s i c a l Work P e r f o r m a n c e Nutrition in Brazil  6 7 15  a) b)  25 29  B r a z i l i a n Socio-economic S i t u a t i o n N u t r i t i o n a l Status o f B r a z i l i a n People i) ii)  III  •.  29 3k 38  1. 2. 3.  38 39 kO  k. 5-  P o p u l a t i o n and Sample Experimental Procedure Assessment o f N u t r i t i o n a l  Status  Socio-economic Factors Dietary Analysis Anthropometric Determinations Biochemical Tests.  hO kO 43 kk 51 53  A s s e s s m e n t o f P h y s i c a l Work P e r f o r m a n c e Statistical Analysis  RESULTS 1.  2. 3.  5k  Assessment o f N u t r i t i o n a l a) b) c) d)  V  National Studies S t u d i e s i n R i b e i r a o P r e t o , Sao P a u l o  METHODS AND MATERIALS  a) b) c) d)  IV  18 25  Status  Socio-economic Factors Dietary Analysis Anthropometric Determinations Biochemical Tests  A s s e s s m e n t o f P h y s i c a l Work P e r f o r m a n c e A s s o c i a t i o n B e t w e e n N u t r i t i o n a l S t a t u s and P h y s i c a l Work P e r f o r m a n c e  5k  .  5k 59 69 Ik 78 78  DISCUSSION  8k  1.  8k  Socio-economic Considerations  V  2.  Assessment a) b) c)  3k.  VI  of N u t r i t i o n a l  Dietary Analysis Anthropometric Determinations Biochemical Tests  Assessment of P h y s i c a l Work Performance A s s o c i a t i o n Between N u t r i t i o n a l Status and P h y s i c a l Work Performance  SUMMARY AND CONCLUSIONS  BIBLIOGRAPHY  Status  86 86 91 Sk 97 99 102 107  vi  LIST OF TABLES  Table  Page  11-1  Typical  d i e t of b o i a - f r i a migrant workers.  IV—1  Comparison of  indicators  of h e a l t h s t a t u s  . in  37 subjects  from b o i a - f r i a and w e l l - t o - d o f a m i l i e s IV-2  IV—3  IV-4  60  Comparison of d a i l y n u t r i e n t intake o f s u b j e c t s b o i a - f r i a and w e l l - t o - d o f a m i l i e s  from 61  D a i l y n u t r i e n t i n t a k e of s u b j e c t s from b o i a - f r i a and w e l l - t o - d o f a m i l i e s in comparison with WHO/FAO recommended d a i l y i n t a k e s . . . Number of s u b j e c t s with d a i l y 2/3 of  recommended d a i l y  nutrient  intake  less  than  intake  64  1V-5  C o n t r i b u t i o n of food groups to n u t r i e n t  IV-6  Sample d a i l y menus taken from d i e t from b o i a - f r i a s u b j e c t s  recalls collected  Sample d a i l y menus taken from d i e t from w e l l - t o - d o s u b j e c t s  recalls collected  IV-7  IV-8  IV-9  IV-10  IV-11  IV-12  1V — 13  IV-14  intake  64  67 68  Comparison of p h y s i c a l growth and development of from b o i a - f r i a and w e l l - t o - d o f a m i l i e s Comparison of blood b i o c h e m i s t r y in s u b j e c t s b o i a - f r i a and w e l l - t o - d o f a m i l i e s  subjects  biochemical  79  . . .  76  parameters  Comparison of change in heart r a t e in s u b j e c t s b o i a - f r i a and w e l l - t o - d o f a m i l i e s  77 from  Comparison o f blood l a c t i c a c i d l e v e l s b e f o r e and a f t e r e x e r c i s e in s u b j e c t s from b o i a - f r i a and well-to-do families Correlations  70  from  Blood b i o c h e m i s t r y in s u b j e c t s from bo i a - f r i a and w e l l - t o - d o f a m i l i e s in comparison with normal values Number of s u b j e c t s having below normal v a l u e  62  between s e l e c t e d p a i r s of v a r i a b l e s  80  81 83  vi i  LIST OF FIGURES Figure  Page  11-1  Stages of m a l n u t r i t i o n  I I-2  Map of Brazi 1 .  I I 1-1  Q u e s t i o n n a i r e used  IV-1  Typical  house  IV-2  Typical  street  IV—3  Typical  corner store  IV-4  Goods a v a i l a b l e  IV-5  T y p i c a l house  in Jardim R e c r e i o  58  IV-6  T y p i c a l house  in Jardim R e c r e i o  58  IV-7  Weight of s u b j e c t s from b o i a - f r i a and w e l l - t o - d o f a m i l i e s in comparison with standards  71  Height of s u b j e c t s from b o i a - f r i a and w e l l - t o - d o f a m i l i e s in comparison with standards  72  S k i n f o l d t h i c k n e s s , arm c i r c u m f e r e n c e , and arm muscle c i r c u m f e r e n c e of s u b j e c t s from b o i a - f r i a and w e l l - t o - d o f a m i l i e s in comparison with standards  73  Change in heart r a t e w i t h . t i m e w e l l - t o - d o subjects  79  IV-8  IV-9  IV-10  8 27  in 24-hour d i e t  in V i l a  recall  interviews  Recreio  in V i l a  55  Recreio  in V i l a  in t y p i c a l  k2  55  Recreio  store  in V i l a  57 Recreio  57  in b o i a - f r i a and  vi i i  ACKNOWLEDGEMENTS  To my r e s e a r c h d i r e c t o r , sincere  thanks  out, i t .  and  for facilitating  I a l s o wish  advisors,  Dr. l.D. D e s a i , this  t o express  I would  like  t o extend  p r o j e c t and f o r a s s i s t i n g  my a p p r e c i a t i o n t o my o t h e r  i n the preparation of this  t o thank  help  i n d e v e l o p i n g computer programs t o a n a l y s e the data like  w i t h o u t whom t h i s de O l i v e i r a ,  James a n d V i r g i n i a  to offer a special  Green f o r t h e i r  thanks  guidance  In a d d i t i o n , I  wish  I would  Lewis  thesis.  through-  research  Dr. M e l v i n Lee and Dr. B l a n c a M u r a t o r i o , f o r t h e i r  encouragement  me  my  most v a l u a b l e f o r this  t o t h e many B r a z i l i a n  p r o j e c t w o u l d n o t have been p o s s i b l e :  project. people  Dr. J.E. Dutra  D i r e c t o r o f t h e F a c u l t y o f M e d i c i n e , U n i v e r s i t y o f Sao  P a u l o , R i b e i r a o P r e t o ; E. D u a r t e  a n d M.L. R o b a z z i  from  t h e School o f  N u r s i n g , U n i v e r s i t y o f Sao P a u l o , R i b e i r a o P r e t o ; D r . L . S . C e v a l l o s Romero a n d D r . F . L . V i c h i  from  the Cardiology Unit, Hospital  das C l i n i c a s ,  U n i v e r s i t y o f S a o P a u l o , R i b e i r a o P r e t o ; C. B o s e r e t , D i r e c t o r , V i t a Pax Colegio; and  V.L. F a r i a  Director,  M. l o z z i , D i r e c t o r , O r g a n i z a c a o A special  both at  Fernandes,  thanks  the Hospital  i salso offered  To  i n conducting this  the Brazilian  I wish  t o M. D e s a i  and t o t h e s t a f f a t  i n Ribeirao Preto for their  thesis.  o b r i g a d a , from  cheerful  in this  s t u d y and from  the heart!  t o acknowledge t h e f r i e n d s ,  In p a r t i c u l a r ,  Medicine  research.  both Canadian and  B r a z i l i a n , a n d t h e f a m i l y members who g a v e me g r e a t s u p p o r t this  No. 3^6;  Nova.  c h i l d r e n who p a r t i c i p a t e d  whom I l e a r n e d s o much: Finally,  E d u c a t i o n a l SESI  das C l i n i c a s and t h e Department o f C l i n i c a l  t h e U n i v e r s i t y o f Sao P a u l o  assistance  Vida  Centro  I extend  a special  thanks  i n doing  to. D a v i d  Jiles,  ix  my p a r e n t s , and George Hermanson.  T h e i r warmth, p a t i e n c e , and  feedback enabled me to see t h i s work to c o m p l e t i o n .  informed  1  CHAPTER I INTRODUCTION  "The o p p r e s s e d , who have been shaped by the d e a t h a f f i r m i n g c l i m a t e o f o p p r e s s i o n , must f i n d through t h e i r s t r u g g l e the way to l i f e - a f f i r m i n g h u m a n i z a t i o n , which does not l i e s i mply in having more to eat (although i t does i n v o l v e having more to eat and cannot f a i l to i n clude this aspect). The oppressed have been destroyed p r e c i s e l y because t h e i r s i t u a t i o n has reduced them to things. In o r d e r to regain t h e i r humanity they must cease to be t h i n g s and f i g h t as men." (Paulo F r e i r e , Brazil  1970)  has been heralded by many to be an example of a development  m i r a c l e among t h i r d world n a t i o n s .  A country t r a d i t i o n a l l y  agricultura1-export  in the e a r l y  its  agricultural  growth of  this  economy, B r a z i l  and i n d u s t r i a l  bound to an  1970 s managed  to  1  output by an astounding  r a t e exceeded by few developed c o u n t r i e s .  10% a n n u a l l y , a  Yet c l o s e r  scrutiny  development m i r a c l e has y i e l d e d i n c r e a s i n g evidence t h a t  economic growth has o c c u r r e d at the expense o f the vast m a j o r i t y B r a z i l i a n people.  The a g r i c u l t u r a l  d o c u t i o n depended have r e a l i z e d very wealth.  in p o l i t i c a l  processes  and lack o f  have c o n t i n u e d to be a way o f  These are the oppressed about whom F r e i r e  are a l s o the s u b j e c t s Brazil  today  is  p o p u l a t i o n , and f i f t h  of  this  of  Brazilian  poverty, malnutrition,  inadequate h o u s i n g ,  national  labourers on whom p r o -  l i t t l e o f the burgeoning  For most workers and p e a s a n t s ,  inadequate medical c a r e ,  past.  and i n d u s t r i a l  increase  illiteracy,  participation  life,  as  in the  (1970) speaks.  These  study.  the w o r l d ' s  seventh  in terms o f s i z e ,  based on the e x p o r t of a g r i c u l t u r a l  largest its  products  country  economy  is  in terms still  such as c o f f e e ,  of  largely soybeans,  2  and  sugar,  recently The  however m a s s i v e e x p a n s i o n o f  i n the  north of  d r y and other  south  Brazil  is very  than s u b s i s t e n c e  motivating attracted  to the  been e q u i p p e d in h a s t i l y  medical  fishing crop  north  Specific  most  or  farming and  to the  lack access  among t h o s e  n u t r i t u r e , although  north o r on  urban c e n t e r s  s h a n t y - t o w n s on  major  south,  south  coffee have  Most m i g r a n t s the edges o f  who  has  or  rarely  must  live  cities for  been d o c u m e n t e d by  peasant farming migrate  south  identified  and  and  include  respect  to these  Nutrition  for National  et^ aj_. , 1976;  and  Desai  i r o n , and  sub-acute or e a r l y - s t a g e  Alves,  et^ a_l_. , 1980)  e n e r g y m a l n u t r i t i o n h a v e been  1977; .  nutrients  as  Patrick  Simmons, 1976;  A and  1956;  and  Martins  sub-acute p r o t e i n -  problems p a r t i c u l a r l y  Vergara,  has  (Interdepartmental  ICNND, 1965;  Vitamin  A,  calcium  J a n s e n e_t aj_. , 1977;  identified  c h i l d r e n ( W a t e r l o w and  S i g u l e m et_ a ] _ . , 1976;  Defense -  fave1 a s .  i n urban  inadequate vitamin  malnutrition with as  many  fishing families  dwell  C,  R o n c a d a , 1972;  1979).  industries  fertile  i n the  vitamin  S i m o e s , 1971;  ing B r a z i l i a n  the  is  developed.  to migrate  riboflavin,  identified  C o m m i t t e e on  climate  t o e v e n t h e most b a s i c f a c i l i t i e s  among t h e  p r o b l e m s t h a t h a v e been  been  Paulo.  education.  It occurs and  been  occurred  unemployment a r e  i n f l u x of migrants.  favelas or  south:  t h e c o a s t , and  chronic  i n the c i t i e s  s e c t o r has  s t a t e o f Sao  have not  from the  Unfortunately,  p r o t e i n , energy, thiamin,  Olson,  and  existence of m a l n u t r i t i o n in B r a z i l  researchers.  1974;  in comparison  failures,  hope o f j o b s  constructed  care  The  often  poor  to handle the  t o w n s , and  the  e s p e c i a l l y i n the  factors for Brazilians  sugar p l a n t a t i o n s .  of  industrial  i n h o s p i t a b l e t o a g r i c u l t u r e , e x c e p t on  Extreme p o v e r t y ,  and  of B r a z i l ,  the  ICCND, 1965;  R o n c a d a et^ aj_. , 1978;  affectGuitti, and  3  Insufficient  a t t e n t i o n has been paid  these n u t r i t i o n a l  problems o f  their malnutrition e a r l y stages  in the past to  ameliorating  the B r a z i l i a n poor, perhaps  is not acute or  late  in s t a g e .  because much o f  Malnutrition  is o f t e n undramatic and u n o b t r u s i v e even though  d a i l y erosion of health ing c o u n t r i e s malnutrition  such as in  in epidemic p r o p o r t i o n s  Brazil  (Berg,  1973)-  i t can cause  s i d e e f f e c t of  not been c l e a r l y c h a r a c t e r -  i z e d , e s p e c i a l l y among c h i l d r e n , may be the impairment o f p h y s i c a l performance  (Spurr et_ aj_. ,  The a s s o c i a t i o n interest  well-being,  including  for several  s t a t u s and p h y s i c a l  reasons.  loss of physical  by the i n d i v i d u a l who is  undernourished  First,  losses  if  Second, undernourished income  f i t n e s s , which may be e x p e r i e n c e d is o f unequivocal  labourers  Agriculture Organization-FAO, Third,  individuals  in net l o s s e s  It  has  been suggested t h a t  for national  s h o r t e r working  life  1962 and Berg,  1973)•  Indeed,  labour  increased c o s t s  product  countries  for production, is a d v e r s e l y a f f e c t e d can  result  decreased work o u t p u t , f o r medical  care  (FAO,  Correa and Cummins ( 1 9 7 0 ) e s t i m a t e d  i n c r e a s e d c a l o r i c consumption alone c o u l d account f o r 5% of in n a t i o n a l  (Food and  inadequate d i e t s  economies by causing  span, and  the case  for developing  work performance of many i n d i v i d u a l s  by m a l n u t r i t i o n .  is  1962).  t h e r e may be economic r a m i f i c a t i o n s  the p h y s i c a l  may e x p e r i e n c e economic  in c o u n t r i e s such as B r a z i l  such as B r a z i l , which depend h e a v i l y on manual if  importance and  can be e f f e c t i v e l y  is d i r e c t l y dependent on work o u t p u t , as  f o r many a g r i c u l t u r a l  work p e r f o r -  the loss of h e a l t h and  needs to be we 11-documented so t h a t p r e v e n t i v e measures conceived.  work  1978).  between n u t r i t i o n a l  mance i s o f  its  among people in d e v e l o p -  One p o s s i b l e  i t s e a r l i e r stages which has  in  the  that  growth  in nine L a t i n American c o u n t r i e s s t u d i e d between  4  1950 and 1962. planners  Economic arguments  to r e c o g n i z e and address  have f a i l e d  (Berg,  Few s t u d i e s  such as  these may sway government  m a l n u t r i t i o n where humanistic  1973)•  in the past have focussed on the p o s s i b l e  between u n d e r n u t r i t i o n and impairment o f p h y s i c a l Brazilian populations.  A l s o , while  work performance in a d u l t s , Conflicting  have been done in c h i l d r e n Satyanarayana  The r e l a t i o n s h i p mance in c h i l d r e n leave school  between n u t r i t i o n a l  is o f  interest  their physical  undernutrition will their a b i l i t y  is  group.  requirements f o r  agricultural  work p e r f o r -  because c h i l d r e n  kinds of manual  labour.  the case with a d u l t s .  from and  Undernutrition  because o f  addi-  growth. to o b t a i n  i n f o r m a t i o n on  work performance o f c h i l d r e n of  workers  residing  in urban f a v e l a s .  Children  s o c i o - e c o n o m i c groups were s e l e c t e d to s e r v e as a c o n t r o l  The primary o b j e c t i v e s o f  whether n u t r i t i o n a l  this  s t a t u s and p h y s i c a l  migrant w o r k e r s ' d i f f e r e d s i g n i f i c a n t l y cal  like. B r a z i l  impact on c h i l d r e n than a d u l t s  s t a t u s and p h y s i c a l  B r a z i l i a n migrant  1978;  work performance that could r e s u l t  Hence, the present study was designed the n u t r i t i o n a l  that  a d v e r s e l y a f f e c t both t h e i r sense o f w e l l - b e i n g  may have an even g r e a t e r  from higher  status,and.physreal  in c o u n t r i e s  to earn a l i v i n g , as  nutritional  relationship  et_ aj_. , 1979; and Desai et_ aj_., 1981).  at an e a r l y age to begin v a r i o u s  Any impairment o f  tional  have examined t h i s  e_t aj_. , 1969; Spurr et_ aj_. ,  e_t a_l_. , 1979; F e r r o - L u z z i  have  s t a t u s and p h y s i c a l  have been o b t a i n e d from s t u d i e s  (Areskog  in  r e s e a r c h e r s of o t h e r p o p u l a t i o n s  few s t u d i e s  results  association  work performance  examined and found a r e l a t i o n s h i p between n u t r i t i o n a l  in c h i l d r e n .  arguments  study were t w o f o l d :  to determine  work performance o f c h i l d r e n of from n u t r i t i o n a l  s t a t u s and p h y s i -  work performance o f c h i l d r e n from h i gherr> soc i o-economi c  groups;  5  and to a s c e r t a i n whether p h y s i c a l tional  status  in these 2 groups  work performance was  located  in the i n t e r i o r o f  1979 in the c i t y of  Ribeirao  the s t a t e o f Sao Paulo  B r a z i l , and which has a p o p u l a t i o n of approximately migrant workers are a t t r a c t e d to R i b e i r a o  study were e i t h e r c h i l d r e n of migrant  in  workers  300,000 p e o p l e .  Subjects  residing  residing  for  Many  availthis  in f a v e l a s  the p e r i p h e r y o f R i b e i r a o P r e t o , or c h i l d r e n o f w e l l - t o - d o or b u s i n e s s p e o p l e  Preto,  southern  Preto because j o b s are  a b l e on nearby sugar cane and c o f f e e p l a n t a t i o n s .  professionals  nutri-  of c h i l d r e n .  T h i s study was conducted d u r i n g which is  r e l a t e d to  on  Brazilian  in a f f l u e n t areas of  Ribeirao  Preto. Nutritional  status  was e v a l u a t e d u s i n g  socio-economic c o n s i d e r a t i o n s ;  the f o l l o w i n g  d i e t a r y assessment,  method; a n t h r o p o m e t r i c assessment,  including  using  criteria: the 24-hour  the measurement o f  h e i g h t , . m i d - u p p e r - a r m c i r c u m f e r e n c e , and t r i c e p s s k i n f o l d and biochemical assessment,  including  and a l b u m i n , and percentage of performance was assessed lactic acid  levels  o f 94 s u b j e c t s  transferrin saturation. in heart  between the ages of  Physical  work  r a t e and blood  o f Paulo  Freire  (1970)  of t h i s  would address  the problems of B r a z i l i a n migrant workers  expressed  i n t r o d u c t i o n , i t was not expected that t h i s  i t was merely hoped that the r e s u l t s  of t h i s  the r a m i f i c a t i o n s of m a l n u t r i t i o n  could serve as a b a s i s f o r  A total  11 and 14 were s t u d i e d .  the beginning  ing some of  thickness;  to a b i c y c l e - e r g o m e t e r work t e s t .  In keeping with the thoughts  Rather,  weight,  the d e t e r m i n a t i o n of serum p r o t e i n  by measuring changes  in response  recal1  at study  in t h e i r e n t i r e t y .  study,  by document-  in migrant workers'  children  informed a c t i o n to a m e l i o r a t e n u t r i t i o n a l  o t h e r problems among B r a z i l i a n migrant workers  and t h e i r  families.  and  6  CHAPTER  II  REVIEW OF THE LITERATURE  1.  Socio-economic  Factors  Human m a l n u t r i t i o n ecological Probably income  is widely acknowledged  no o t h e r f a c t o r has  (Mellor,  and L e v i n s o n ,  o f which  greater  1 9 7 3 ) , and numerous  1973)-  transport,  storage,  about n u t r i t i o n a l  has  parasitic  malnutrition  needs  is  growth  lack of medical (Sai,  1976).  1966).  and e d u c a t i o n a l  Finally, cultural  i n f l u e n c e what people e a t . express  social  status,  Infections services, habits  tional  services;  (Berg,  (Call  status  1973).  (Devadas,  income l e v e l ;  and c u l t u r a l  irriga-  Lack of  or  are themselves  social  of  exacerbated by  and by poor s a n i t a r y  are powerful  conditions  factors  significance,  that may  families,  or  1970).  influence nutritional  food a v a i l a b i l i t y ; l e v e l o f medical  habits.  cause  e f f e c t s on the development  (Devadas,  infections;  is  1970).  may be d i s t r i b u t e d u n e q u a l l y w i t h i n  needs; presence^of  educational  nutritional  Foods may have r e l i g i o u s  then, f a c t o r s which can  clude the f o l l o w i n g :  income spectrum  that b a c t e r i a l , v i r a l ,  may be r e j e c t e d due to unfami 1 i a r i t y In summary  signi-  another f a c t o r which can o f t e n  can e x e r t s y n e r g i s t i c  (Jelliffe,  than  i n f l u e n c e d i n t u r n by c l i m a t e , s o i l ,  been wel1-documented  infections  the  that a f f e c t s  m a l n u t r i t i o n even in the midst o f wealth It  status  have documented h i g h l y  across  and p o p u l a t i o n  and  is complex and m u l t i - f a c t o r i a l .  studies  Another f a c t o r is  to be a s o c i o - e c o n o m i c  impact on n u t r i t i o n a l  in food consumption  food a v a i l a b i l i t y , which  knowledge  Malnutrition  problem the e t i o l o g y  ficant differences  tion,  in  status  knowledge  of  innutri-  and  Because many f a c t o r s  influence  7  m a l n u t r i t i o n , any attempt malnutrition 1976).  to a s s e s s n u t r i t i o n a l  i n the community must take a m u l t i - f a c e t e d approach  Anyone attempting  a l s o be w i l l i n g  to g r a p p l e with the u n d e r l y i n g causes o f p o v e r t y ,  to m a l n u t r i t i o n  in much of the world  Malnutrition  has  been s a i d  It  and a c t i v i t i e s governments,  has been well  of m u l t i n a t i o n a l  in the world  and Col 1i ns , 1 9 7 7 ) .  documented r e c e n t l y that food and a g r i b u s i n e s s play a r o l e  (Frank,  the  Assessment of N u t r i t i o n a l  physiological Behar  1 9 6 9 ; George,  it  major  poverty  1 9 7 6 ; and Lappe  and.act i vi t ies cons t i (1978)  rigorously.  Status  This  is  stages commenc-  f o l l o w e d by d e p l e t i o n o f body  and b i o c h e m i c a l changes,  illness,  and f i n a l l y  stores,  death.  As  ( 1 9 7 6 ) p o i n t e d o u t , d i f f e r e n t methods of assessment must be used to  e v a l u a t e d i f f e r e n t stages of m a l n u t r i t i o n . Figure  interests  corporations,  The development o f m a l n u t r i t i o n proceeds through s e v e r a l inadequate d i e t .  the  of poverty and food s c a r c i t y which McLaren  has suggested should be examined more  ing with  may be  in p e r p e t u a t i n g  These e x p l o i t a t i ve i n t e r e s t s  t u t e the u n d e r l y i n g causes  2.  Yet the acknowledgement  in s o c i e t y gain from e x p l o i t i n g  and t h i r d world e l i t e s  and food s c a r c i t y  1978).  to be the consequence of a m a l f u n c t i o n i n g  long overdue t h a t c e r t a i n s e c t o r s poor.  food  s e r v i c e s which c o n t r i b u t e  (McLaren,  ( C r a v i o t o and L i c a r d i e , 1 9 7 3 ) .  world's  (Sai,  to understand o r a m e l i o r a t e m a l n u t r i t i o n must  s c a r c i t y , and l a c k o f medical and e d u c a t i o n a l  society  s t a t u s or to a m e l i o r a t e  I 1-1.  An important note  is  that  This  is  illustrated  in the i n t e r e s t s  is always p r e f e r a b l e to assess m a l n u t r i t i o n  in i t s  in  of p r e v e n t i o n ,  earliest  stages.  The e a r l i e s t s t a g e o f m a l n u t r i t i o n , an inadequate d i e t , can be d e t e c t e d using  e c o l o g i c a l , socio-economic,  d i e t a r y , and food balance  sur-  INADEQUATE DIET  DEPLETION OF  PHYSIOLOGICAL AND BIOCHEMICAL  PERMANENT  RESERVES  CHANGES  BODY DAMAGE  • biochemical s t u d i e s anthropometry  FIGURE 11-1 Stages o f m a l n u t r i t i o n ' Modified  from Behar, 1976.  DEATH  AND  BODY  e c o l o g i c a l s t u d i e s • b iochemi ca1 soc i o-economi c studies s tud i e s d i e t a r y surveys food balance sheets  a  ILLNESS  c l i n i cal exam. ination m o r b i d i t y data  m o r b i d i t y data morta1i ty data  9  veys.  The second stage o f m a l n u t r i t i o n , d e p l e t i o n o f body n u t r i e n t  can be d e t e c t e d using physiological  biochemical  t e s t s o f body t i s s u e s .  and b i o c h e m i c a l changes  nutrient stores  The ensuing  that follow d e p l e t i o n of  can be a s s e s s e d u s i n g b i o c h e m i c a l and c l i n i c a l  Advanced m a l n u t r i t i o n which m a n i f e s t s  itself  in i l l n e s s  body studies.  and permanent  body damage can be a s s e s s e d using c l i n i c a l examinations a l o n e . t i o n which has  stores,  Malnutri-  r e s u l t e d i n death can be s t u d i e d by examining m o r b i d i t y  and m o r t a 1 i t y d a t a . Because t h e r e are inherent l i m i t a t i o n s of m a l n u t r i t i o n at a l l  s t a t u s as p o s s i b l e  D i e t a r y assessment is  ( J e l l i f f e , 1966) .  This  status. the o n l y  tool  that allows the :researcher :  to e s t i m a t e what s u b j e c t s are a c t u a l l y e a t i n g . is e s s e n t i a l  in the i n t e r p r e t a t i o n o f  results  m e t r i c components o f a n u t r i t i o n survey usually  examine  cover a s p e c t s o f d i e t a r y , a n t h r o p o m e t r i c , and b i o c h e m i c a l  assessment o f n u t r i t i o n a l  is  f o r assessment  s t a g e s , most comprehensive n u t r i t i o n surveys  as many i n d i c e s o f n u t r i t i o n a l review w i l l  in methodologies  conducted in three phases:  This  knowledge  from biochemical and a n t h r o p -  (ICNND,  1963).  D i e t a r y assessment  c o l l e c t i o n of food intake d a t a ;  a n a l y s i s o f n u t r i t i v e v a l u e o f food;' and i n t e r p r e t a t i o n of data  (Jelliffe,  1966). There are t h r e e b a s i c methods that e x i s t intake data:  1970)-  Diet  diet  and d i e t  recalls  records are accounts o f food consumption kept by  tions,  f a m i l i e s , or  day to  k  weigh a l l  records, diet h i s t o r i e s ,  f o r the c o l l e c t i o n o f  weeks foods  .individuals  (Pekkarinen,  to be consumed.  (Pekkarinen, institu-  f o r p e r i o d s o r d i n a r i l y ranging  1970).  Subjects  Problems  keeping d i e t  food  from 1  records o f t e n  that have been noted with d i e t  10  records  i n c l u d e inaccuracy due to f a u l t y memory o r u n t r u t h f u l n e s s o f  j e c t s ; and unconscious changes being surveyed  in the usual  (Chalmers et_ a_l_. ,  The d i e t h i s t o r y  dietary habits of  is a t o o l which g i v e s an e s t i m a t e of an  v o l v e s c o n d u c t i n g a d e t a i l e d one-hour i n t e r v i e w which to e s t i m a t e both the usual  The d i e t It  usually  that  recall  involves  is  This usually includes  i t can be very  1947)-  The d i e t  questions food  time-consuming.  the method most f r e q u e n t l y used in n u t r i t i o n  interviewing  recall  in-  The major drawback  i n d i v i d u a l s or f a m i l i e s as  consumption d u r i n g the preceeding 24-hour o r 7~day p e r i o d 1970).  individual's  amounts and the f r e q u e n c i e s o f  intake over p e r i o d s o f a year o r more (Burke, to t h i s method is  individuals  1952).  average food i n t a k e p a t t e r n over a longer time p e r i o d .  designed  sub-  surveys.  to t h e i r food  (Pekkarinen,  method is q u i c k and i n e x p e n s i v e , and can be used  in non-modernized s o c i e t i e s where poverty and i l l i t e r a c y are widespread (Flores,  1962).  when s t u d y i n g  Also,  the 2 4 - h o u r r e c a l l  c h i l d r e n (Rasanen,  lacks a c c u r a c y f o r the f o l l o w i n g memory and w i l l i n g n e s s  to t e l l  intake  1979);  is  (Beaton et a 1 . ,  low and underestimates  1979). reasons:  the t r u t h ;  i s p r e f e r a b l e t o the d i e t However, the d i e t it  recall  is dependent on the  i t makes no e s t i m a t e of  i t overestimates  i t when consumption  history  method subject's usual  intake when consumption is high  (Linusson  et a l . ,  1974 and Madden et_ a_l_. , 1976) and i t cannot be used with any a c c u r a c y to assess  intake o f  i n d i v i d u a l s , o n l y of p o p u l a t i o n s  S t a p l e t o n and Abernathy, Once d i e t a r y  (Garn et a 1 . ,  1978 and  1980).  i n f o r m a t i o n is  food i n t a k e may be conducted.  c o l l e c t e d , a n a l y s i s of n u t r i e n t v a l u e of Actual  food samples may be c o l l e c t e d and  chemically analysed for n u t r i e n t composition  (ICNND, 1 9 6 3 ) , or foods may  11  be compared to food composition The f i n a l  stage  data o b t a i n e d .  Many authors  to judge  simply  However, as  Beaton  intakes  most of  the p o p u l a t i o n , and i n d i v i d u a l  are c a l c u l a t e d  suggested that d i e t a r y d a t a ,  most s u b j e c t s intake,  that n u t r i t i o n a l  (Beaton,  is  interpreting nutrient  intake  is  intake  intakes  of Beaton  be i n t e r p r e t e d in  inadequacy e x i s t s .  terms  For i n s t a n c e ,  if  below the recommended  inadequate  intakes  s i z e and body composition  d e f i c i e n c i e s cause growth d e c e l e r a t i o n  Anthropometric  indicators  non-nutritional disease,  factors  do e x i s t  for nutritional  to h e i g h t  long  term  because most 1966).  are not n u t r i e n t - s p e c i f i c however, and many  can  and s o c i a l  (Jelliffe,  i n f l u e n c e growth and s i z e ,  status  (Tanner,  1973).  including  anthropometry, e s p e c i a l l y  and weight  (Jelliffe,  mainly with n u t r i t i o n survey  genetics,  Complex methodology  1966).  This  anthropometry  as  is  the assessment of  growth and development o f c h i l d r e n , and the e s t i m a t i o n  itself  not  1975).  nutritional  relation  is  to meet the requirements  i n s t e a d , should  high that  e f f e c t s o f m a l n u t r i t i o n on growth,  available  it  to  deficient  Anthropometric assessment a l l o w s the r e s e a r c h e r to d e t e c t  sex,  dietary  requirements vary g r e a t l y .  in a p o p u l a t i o n have d i e t a r y  then the p r o b a b i l i t y  calculated.  (1975) pointed out,  from t h i s whether an observed  recommended  o f the p r o b a b i l i t y  involves  compare a c t u a l  because  (1975)  and n u t r i e n t content  in d i e t a r y assessment  recommended i n t a k e s . possible  tables  of body f a t review w i l l  it  relates  in concern  to the  assessment o f c h i l d r e n . According can be taken  to J e l l i f f e  (1966),  in n u t r i t i o n surveys  the f o l l o w i n g  principal  of c h i l d r e n :  weight;  measurements  height;  head  cumference; chest c i r c u m f e r e n c e ; upper-arm c i r c u m f e r e n c e ; and t r i c e p s  cirand/  12  or subscapular  skinfold  taken are w e i g h t , thickness. obtaining  thickness.  height,  Jelliffe  The f o u r measurements most commonly  upper-arm c i r c u m f e r e n c e , and t r i c e p s  (1966) o u t l i n e d standard  skinfold  recommended procedures  for  these f o u r measurements.  The r e l a t i v e m e r i t s o f the a n t h r o p o m e t r i c measurements commonly used in n u t r i t i o n surveys (1970)  have been assessed by s e v e r a l  found t h a t the r a t i o w e i g h t / h e i g h t  was a b e t t e r  2  index f o r p r e d i c t i n g p r o t e i n - e n e r g y m a l n u t r i t i o n anthropometric height  indices.  Similarly,  than were o t h e r a n t r o p o m e t r i c various  indices.  nutritional  and found that w e i g h t / h e i g h t  2  weight/  s t a t u s of c h i l d r e n  Keys and co-workers  ( 1 9 7 2 ) examined  (which g i v e s a measure  and t r i c e p s s k i n f o l d  ness were both w e l 1 - c o r r e 1ated to body d e n s i t y . finally,  age-independent  in c h i l d r e n than other  i n d i c a t o r s o f body shape and body d e n s i t y  of "fatness")  Rao and Singh  Dugdale ( 1 9 7 1 ) found that  was c o r r e l a t e d b e t t e r w i t h o v e r a l l  1 - 6  authors.  thick-  Upper-arm c i r c u m f e r e n c e ,  has been found to be a good i n d i c a t o r of d e c r e a s i n g body mass  in p r o t e i n - e n e r g y m a l n u t r i t i o n , e s p e c i a l l y (Loewenstein and P h i l l i p s , -  i f compared to  height  1973) -  The a p p r o p r i a t e e v a l u a t i o n o f a n t h r o p o m e t r i c measurements depends on c h o i c e of standards  used f o r comparative purposes,  a r e d i f f i c u l t to d e f i n e dards  (Jelliffe,  I966).  but community  In many c o u n t r i e s ,  standards  local  f o r growth and development have not been p r e p a r e d , so survey  are compared to North American s t a n d a r d s , o f North American growth standards questionable  (Garn,  1965).  anthropometric r e s u l t s standards.  results  even though the a p p l i c a b i l i t y  to d e v e l o p i n g c o u n t r i e s  Jelliffe  stan-  is  highly  (1966) recommended that where  should be compared to both l o c a l  and  Once a standard has been s e l e c t e d , s e v e r i t y o f  possible,  international malnutrition  13  in an i n d i v i d u a l standard  the  s u b j e c t may be graded a c c o r d i n g  individual  Biochemical  tests  to a s s e s s n u t r i t i o n a l d e f i c i e n c y at  subject achieves  p r o v i d e perhaps  stages.  would be f u r n i s h e d by analyses biochemical  u r i n e , and h a i r a n a l y s e s methods a r e a v a i l a b l e this  review s h a l l  No biochemical tory  in e v a l u a t i n g  the most o b j e c t i v e means by which  l i v e r , muscle, and bone t i s s u e ;  assessment u s u a l l y  (Jelliffe,  itself  1966) .  assessment  measurement  Numerous  acid  ratios;  exists  at present  that  sensitive  is h i g h l y  satisfac-  commonly used  means,  to diagnose  (Sauberlich  in p r o t e i n  status  urinary creatinine e x c r e t i o n ; urinary hydroxyproline excreratios.  Serum t o t a l  p r o t e i n appears  to have  and c o - a u t h o r s  in p r o t e i n - d e f i c i e n t c h i l d r e n not  s i g n s of m a l n u t r i t i o n .  (1974)  l i t t l e value alone as a  i n d i c a t o r o f p r o t e i n n u t r i t u r e , however serum albumin  tend to have As w e l l ,  assessment  serum l e v e l s o f p r o t e i n and albumin; serum amino  have been shown to decrease clinical  however,  than biochemical  The procedures have been reviewed by S a u b e r l i c h follows.  nutriture,  While severe forms of p r o t e i n m a l -  by c l i n i c a l  parameters  t i o n ; and u r i n a r y u r e a - c r e a t i n i n e  as  wel1-documented  p r i m a r i l y with the biochemical  protein nutriture.  Biochemical  include:  however,  must be r e s t r i c t e d to b l o d d ,  m i l d e r forms of p r o t e i n d e f i c i e n c y remain d i f f i c u l t 1974).  stores  status.  n u t r i t i o n can be b e t t e r diagnosed  et a l • ,  nutritional  More a c c u r a t e assessments o f body  to a s s e s s v i t a m i n and mineral  concern  o f p r o t e i n and i r o n  of  the  (Gomez et a l . , 1956).  s t a t u s because they permit d e t e c t i o n of  sub-clinical  in human surveys  to what percentage o f  levels  exhibiting  C h i l d r e n with p r o t e i n m a l n u t r i t i o n  reduced serum c o n c e n t r a t i o n s  of the e s s e n t i a l  amino  they tend to e x c r e t e l e s s c r e a t i n i n e as a f u n c t i o n of  body mass, and tend to e x c r e t e e l e v a t e d amounts  also  acids.  lower  of hydroxyproline,  which  14  is a by-product o f c o l l a g e n metabolism. ratios  Fasting  urinary.urea/creatinine  are o f t e n reduced in p r o t e i n m a l n u t r i t i o n , although  ratio  more r e f l e c t i v e o f  recent d i e t a r y  tion.  p r o t e i n and albumin a r e parameters most commonly  Serum t o t a l  intake than  this  assessed because of methodological  is  long-term p r o t e i n n u t r i -  simplicity  ( J e l l i f f e , 1 9 6 6 , and  ICNND,  1963).  The  b i o c h e m i c a l assessment o f  by Cook and Finch ( 1 9 7 9 ) .  iron s t a t u s has been r e c e n t l y reviewed  These authors  have noted that although  hemo-  g l o b i n and h e m a t o c r i t have been the parameters most commonly measured assess and  i r o n - d e f i c i e n c y , these methods are  indicate  available  i r o n - d e f i c i e n c y only  in recent y e a r s ,  is  t r a n s f e r r i n s a t u r a t i o n , which iron-binding  tion  is  thought  with body s t o r e s  in l a t e s t a g e s .  is  is an e a r l y  indicator of  iron.  specificity,  A p r e f e r r e d method,  d e r i v e d from the r a t i o o f serum i r o n to i n d i c a t o r of  iron status  to be serum f e r r i t i n , of  lack  the d e t e r m i n a t i o n o f the percentage of  c a p a c i t y , and which  An even more s e n s i t i v e  insensitive,  iron d e f i c i e n c y .  than t r a n s f e r r i n  l e v e l s of which c o r r e l a t e  Serum f e r r i t i n a f f o r d s Unfortunately,  a measure of  d e f i c i e n c y at  its e a r l i e s t stage.  determination  is as yet too c o m p l i c a t e d f o r e x t e n s i v e use  i r o n d e f i c i e n c y at d i f f e r e n t s t a g e s ,  transferrin saturation,  and hemoglobin.  saturahighly  iron-  the methodology in f i e l d  Cook and F i n c h ( 1 9 7 9 ) have recommended combining s e v e r a l assessing  only estimations  practicable  in large  nutrition  in  ferritin,  (1966)  surveys.  its  surveys.  methods  i n c l u d i n g serum  However, J e l l i f f e  for  has  p o i n t e d out t h a t f r e q u e n t l y hemoglobin and h e m a t o c r i t d e t e r m i n a t i o n s the  to  are  15  3.  Assessment o f P h y s i c a l Physical  fitness  o f both endurance  Work  Performance  f o r w o r k h a s been d e f i n e d a s t h e c a p a c i t y ,  and s t r e n g t h ,  t o enjoy moderate muscular  out d i s c o m f o r t (Jones e t a l . , 1975).  Concommitantly,  known t h a t c o n t i n u a n c e o f a g i v e n a c t i v i t y in performance  of fatigue  eventually  1971)-  (Simonson,  the s a l i e n t  physiological  may be m o n i t o r e d The  t h e human body 1971;  highly  simplified  is distilled  from  causes  work  Both  pumped t o t h e w o r k i n g m u s c l e .  energy-yielding  formed  through  oxygen  in glycolysis  t h e Kreb's  cycle  by i n c r e a s i n g  and  Lactic acid  diffuses  Fatigue develops  1977).  Activity f o r both  This increased  the cardiac  output.  i n prolonged a c t i v i t y  when  t h e t h e s e m e c h a n i s m s and when  become d e p l e t e d . is available  to the working muscle, p y r u v i c  i s n o r m a l l y m e t a b o l i z e d t o a c e t a t e and t h e n t o form adenosine  accumulates  into the blood.  a c i d and p y r u v i c a c i d  (Simonson,  i n c r e a s e s o t h a t more b l o o d i s  a n a e r o b i c c o n d i t i o n s , however, p y r u v i c a c i d stead.  they  to exercise in  authors  s u c h as g l y c o g e n .  be m a i n t a i n e d  substances  When s u f f i c i e n t acid  cannot  summarize  o f the c o n t r a c t i n g muscles  c a n be met p a r t i a l l y  h e a r t r a t e a n d s t r o k e v o l u m e may  oxygen s u f f i c i e n c y  impairment  performance.  and A s t r a n d and R o d a h l ,  an i n c r e a s e i n t h e r e q u i r e m e n t  requirement  leads to  account o f responses  o x y g e n and e n e r g y - y i e l d i n g s u b s t a n c e s oxygen  i t has l o n g been  review w i l l  t h e works o f s e v e r a l  1976;  Morehouse and M i l l e r ,  with-  c h a n g e s t h a t a c c o m p a n y f a t i g u e a n d how  to assess physical  following  activity  A v a s t l i t e r a t u r e e x i s t s on  t h e p h y s i o l o g y o f w o r k and e x e r c i s e , h o w e v e r , t h i s only  i n terms  t r i p h o s p h a t e (ATP). i s reduced  i n the muscle  Under  to l a c t i c  under a n a e r o b i c  conditions  The c o m b i n e d a c c u m u l a t i o n o f b o t h  can e v e n t u a l l y  result  acid i n -  lactic  in metabolic acidosis.  Con-  16  commitant to t h i s whole p r o c e s s , muscle glycogen  stores,  the s o l e  source f o r the anaerobica11y working muscle, become d e p l e t e d and  energy fatigue  becomes pronounced. Given these b a s i c activity,  physiological  t h e r e are s e v e r a l  may be a s s e s s e d :  responses  to prolonged  i n d i c e s by which the body's  increased r e s p i r a t o r y  rate;  muscular  response to work  i n c r e a s e d heart  r a t e ; accumu-  lation of  l a c t i c a c i d and p y r u v i c a c i d  in the muscle and b l o o d ;  acidosis;  and d e p l e t e d muscle glycogen  stores.  d i c e s , maximal to the l e v e l in e x e r c i s e  In a d d i t i o n  oxygen uptake can be measured.  Maximal  intensity  ing c h a r a c t e r i s t i c s  is  not accompanied by any  in response  l e v e l s of  a low degree o f m e t a b o l i c a c i d o s i s ;  high muscle glycogen  low p h y s i c a l  Most assessments o f p h y s i c a l  index of  f a t i g u e and the c h o i c e of considerations.  performance be measured  standardized exercise tests  physical  intake  such as  the t r e a d m i l l  that  increases  is w i d e l y  1976).  in heart  oxygen consumption  low  l e v e l s ; and high  fitness  However,  to be used o f t e n  As w e l l ,  it  is  pre-  to w e l l -  or bieye 1e-ergometer,  (Jones et a 1.,  when e x e r c i s e  1975).  i n d i c a t o r of is  prolonged  i t has a l s o been w e l l - e s t a b l i s h e d  r a t e and v e n t i l a t i o n  in e x e r c i s e of  indices  regarded to be the best  capacity or physical  (Morehouse and M i l l e r ,  rate;  performance employ  in response  where power output can be a c c u r a t e l y r e g u l a t e d oxygen  follow-  in comparison with the s u b j e c t who has a  depends on t e c h n i c a l and l o g i s t i c f e r a b l e that physical  the  uptake.  l a c t i c a c i d and p y r u v i c a c i d ;  This  more than one  exhibit  refers  increase  in oxygen  low r e s p i r a t o r y  maximal oxygen uptake. capacity.  is  in-  oxygen uptake  increase  capacity w i l l  to e x e r c i s e :  heart r a t e ; low blood and muscle  maximal  to these  o f oxygen uptake during e x e r c i s e beyond which f u r t h e r  The s u b j e c t who has a h i g h p h y s i c a l  Maximal  metabolic  increasing  r a t e para 11 el  increases  i n t e n s i t y , and that  in  maximum  17  oxygen uptake can in f a c t Miller,  1976).  be p r e d i c t e d from heart  rate  blood are regarded to be a meaningful  a n a e r o b i c metabolism is  taking place  T e s t s of muscle glycogen  i n v o l v e t a k i n g needle b i o p s i e s There are o t h e r t e s t s  (Simonson,  e f f i c i e n c y are a l l  logical  changes  results of these t e s t s  f a s h i o n than  actual  physical  those  load,  output produced at a  j o b , and s i m p l e o b s e r v a t i o n s about l e v e l  o f work  techniques that have been used to assess p h y s i c a l  These k i n d s of t e s t s  factors  fatigue,  r e p o r t e d in the l i t e r a t u r e that assess  l i k e hand-grip,  1975).  mentioned because  Endurance time to e x h a u s t i o n a t a g i v e n work  factory or agricultural  extraneous  (Jones et_ aj_. ,  1971).  work performance in a l e s s d i r e c t or p h y s i o l o g i c a l  s t r e n g t h at a s p e c i f i c task  that  1 9 7 6 ) , and  s t o r e s , w h i l e e x c e l l e n t i n d i c a t o r s of  are t e c h n i c a l l y more unwieldy than the o t h e r t e s t s  just discussed.  indicator  (Morehouse and M i l l e r ,  blood pH is a good i n d i c a t o r o f m e t a b o l i c a c i d o s i s  performance.  and  When blood samples can be t a k e n , e l e v a t e d l a c t i c a c i d  l e v e l s o f venous  they  (Morehouse  are more c o n s p i c u o u s l y  such as m o t i v a t i o n than t e s t s  in response to e x e r c i s e  these t e s t s  i n f l u e n c e d by  that measure  (Simonson,  1971).  physio-  T h i s makes  d i f f i c u l t to i n t e r p r e t , but at the same t i m e ,  may approximate r e a l i t y more c l o s e l y than o t h e r kinds of  R e s u l t s of t e s t s  work  tests.  o f p h y s i c a l work performance must always be i n t e r -  preted  in view of the f a c t  Durnin  (1976)  that many f a c t o r s  i n f l u e n c e performance.  reviewed sex d i f f e r e n c e s in energy requirements f o r work  and concluded t h a t females have l o w e r e n e r g y e x p e n d i t u r e and lower maximal p h y s i c a l work c a p a c i t y than males, metabolic r a t e .  Several  authors  independent of body s i z e o r  basal  (Dehn and Bruce, 1972 .and N y l i n d et a l . ,  18  1978)  have n o t e d  factors  s u c h as  that  physical  t e m p e r a t u r e , h u m i d i t y , and  influence  physical  performance  1978;  Buskirk  and  and  which s t r o n g l y  influences  (Dehn and  found  physical  skill,  p e r f o r m a n c e than maximal  of  found  that  supervision.-  physical  and  a l s o c a n n o t be  that motivation,  (1964)  physical  1972  Bruce,  economic f a c t o r s  (Sen  performance: capacity  p r o d u c t i v i t y on  on  capcity  exercise  also provide  t h a t may  be  and  when a s s e s s i n g  4.  fitness,  I t has t i o n s of  Factors  the  j o b was  Wyndham and  directly  related  o b s c u r e the  physiological  i s the  (1964)  on  job  Cook  to q u a l i t y effects  b e s t measure  responses to  lactic acid  s u c h as  sex,  age,  levels,  of  work  manifest  documented t h a t  themselves  p s y c h o m o t o r changes t h a t can  Indicators  include:  blood  pH,  be  and  heart muscle  conditions, considered  performance.  Between N u t r i t i o n a l S t a t u s  been w e l l  of  sub-maximal  environmental  and  Physical  under a c t u a l  food shortages of extended d u r a t i o n ,  deficiencies  and  socio-economic s i t u a t i o n should a l s o  physical  Association  Socio-  co-workers  a means t o a s s e s s w o r k p e r f o r m a n c e .  r e s p i r a t o r y rate, blood  habituation,  counter-  wages w e r e a l l more i n f l u e n t i a l  used t o a s s e s s sub-maximal work performance  glycogen stores.  people  work performance'.  physical  rate,  factor  sedentary  Wyndham and  work c a p a c i t y ;  to  Lane e t a 1 . ,  0'Donovan, 1977).  In summary, w h i 1 e m a x i m a l o x y g e n u p t a k e of  environmental  regularly active  Thus, s o c i o - e c o n o m i c f a c t o r s can  capacity  and  is another  than t h e i r  discounted:  physical  age,  a l t i t u d e h a v e been shown  Habituation  W a t s o n and  and  with  G u p t a et^ aj_. , 1977;  M e n d e z , 1967)-  d e m o n s t r a t e much g r e a t e r parts  fitness declines  the  and  Work  Performance  experimental  e f f e c t s of  nutritional  in p h y s i o l o g i c a l , psychological,  undermine p h y s i c a l  condi-  work p e r f o r m a n c e .  and A  vast  19  literature exists in t h i s  regard  on the e f f e c t s o f acute s t a r v a t i o n o r  (Shi Is,  to examine o n l y  1980), however,  it  is  s t a t u s on the p h y s i c a l  nutritional  status,  more s p e c i f i c a l l y ,  experienced for a l i f e t i m e The r e l a t i o n s h i p  (Berg,  Sub-optimal  r e f e r s to the e r o s i o n o f  health  d e f i c i e n c i e s that may be  1973)-  between n u t r i t i o n a l  formance has been e x t e n s i v e l y s t u d i e d i n c r e a s i n g a t t e n t i o n has  undernourishment  review  sub-optimal  work performance of humans.  caused by c h r o n i c but non-acute n u t r i t i o n a l  as  the purpose of t h i s  the l i t e r a t u r e t h a t d e a l s with the e f f e c t s of  nutritional  years,  semi-starvation  s t a t u s and p h y s i c a l  work p e r -  in humans o n l y w i t h i n the l a s t 20  been p a i d to the s i t u a t i o n of  in d e v e l o p i n g c o u n t r i e s .  The FAO (1962)  chronic  reviewed the  consequences of an inadequate d i e t f o r working people and found them to be f o u r f o l d :  lethargy;  high a c c i d e n t  rates.  work o u t p u t .  C o n v e r s e l y , when i n a d e q u a t e l y nourished workers have r e c e i v e d  supplemental output has  These f a c t o r s  rations,  improved.  low r e s i s t a n c e  as s t u d i e s  to d i s e a s e ;  high absenteeism;  are p o s t u l a t e d  to r e s u l t  c i t e d by the FAO (1962)  Numerous s t u d i e s  since this  Individual tional  s t a t u s and p h y s i c a l  tion exist i t has  variability  not without  work performance because wide  requirements  I96I and Widdowson,  (Durnin et^ aj_. , 1973)  in r e l a t i o n to e x p e n d i t u r e are  This  metabolic latter  varia-  1979), and  requirements vary w i d e l y  1962).  nutri-  ranges of  (Edmundson,  independent o f sex, a c t i v i t y , o r basal  led some authors  performance more  is a confounding f a c t o r when s t u d y i n g  long been accepted t h a t n u t r i e n t  (Rose and W i l l i a m s ,  i n d i c a t e , work  controversy.  in human m e t a b o l i c and work e f f i c i e n c y  individuals,  has  is  in decreased  review have examined the  r e l a t i o n between undernourishment and p h y s i c a l w o r k d i r e c t l y but the l i t e r a t u r e  and  between  rate  observation  to comment t h a t human energy indeed p o o r l y  understood.  20  Several  studies  have i n v e s t i g a t e d  energy e x p e n d i t u r e and  requirements  in manual  l a b o u r e r s and have found work performance to be u n a f f e c t e d by  seemingly  inadequate energy  Ramanamurthy  intakes  and Belavady,  These i n v e s t i g a t o r s  (Ramanamurthy  1966; Belavady,  assessed c a l o r i c  and Dakshayani,  1966; and Ashworth,  1968).  i n t a k e , and then e i t h e r measured  actual  h o u r l y work output or assessed work e f f i c i e n c y by simple  tion.  Actual  physiological  1962;  responses  observa-  to e x e r c i s e were not t e s t e d  in these  studies. Areskog and co-workers tional  (1969) examined s e v e r a l  s t a t u s and t e s t e d p h y s i c a l  in response  to i n c r e a s i n g  E t h i o p i a n boys.  that  work performance by measuring  b i e y e 1e-ergometric workload  Bieye 1e-ergometer t e s t s  c h i l d r e n had poorer maximal work c a p a c i t y  parameters of  showed that  status.  such as  prompted the s u g g e s t i o n that t h e r e may be a d a p t i o n such that p h y s i c a l etal.,  fitness  is  not  nourished  maximal  These authors  R e s u l t s of s t u d i e s  to  concluded  work p e r f o r -  these have  inadequate  impaired by undernourishment  diets  (Durnin  1973).  In a study o f work output o f c o a l - m i n e r s , 500 supplemental sub-optimal  diets  kcal  d a i l y while control  (Satyanarayana  et a 1.,  test  subjects 1972).  s u b j e c t s were  given  consumed t h e i r  usual  A f t e r 6 months,  mentation had no e f f e c t on work output or attendance on the j o b , supplemented s u b j e c t s improved s t a m i n a . factors  rate  undernourished  there was no demonstrable c o r r e l a t i o n between p h y s i c a l  mance and n u t r i t i o n a l  heart  in p o o r l y  work c a p a c i t y f o r age but g r e a t e r  f o r s i z e than d i d Swedish c o n t r o l s .  nutri-  gained a s i g n i f i c a n t  and reported various  i n f l u e n c i n g p r o d u c t i v i t y of Jamaican sugar cane c u t t e r s ,  includ-  height,  skinfold  (Heywood et_ a_l_. , 1974)  but  examined  ing weight,  Another study  amount o f weight  supple-  thickness,  arm c i r c u m f e r e n c e , hemoglobin,  21  hematocrit,  and f o o d  nutritional  status,  intake. were  Weight  found  and w e i g h t / h e i g h t ,  t o have  the strongest  assumed t o  reflect  correlation with  pro-  duct i v i t y . In a s t u d y  of  peasant  farmers  in East  no c o r r e l a t i o n b e t w e e n d a i l y e n e r g y energy  e x p e n d i t u r e , was  d a i l y energy records. of  Chronically  regards  s u b j e c t was  composition,  and a s  a t a t r e a d m i l l work found  to n u t r i e n t s  undernourished  complete assessment of  was  10 b a s i c  No c o r r e c t i o n was made f o r b a s a l  the d i e t w i t h  t e s t were e v a l u a t e d  variables,  (Angeleli,  1978)  t o submaximal mentation. reduced  examined  After several  in workers  in  albumin, suffering  India,  and c o - w o r k e r s as  and s o c i o - e c o n o m i c f r o m any o v e r t  data v a r i e d w i d e l y . high  weeks,  body w e i g h t .  et_ aj_. , 1979)  exercise  study  compared  by  the e f f e c t s of  supple-  controls.  d i d not  significantly  t h e same  response  of  hemoglobin,  d e f i c i e n c i e s , but  Brazil  significantly  work o u t p u t  indices,  Subjects  to  did  in  in  It mass,  Another  (1977) m e a s u r e d  nutritional  cell  state.  r a t e s were  time  1978).  endurance  anthropometric  A l a t e r study  and e n d u r a n c e e t a 1.,  a  body  however  heart  adequacy  d w e l l e r s were g i v e n  levels,  as  H i g h w o r k o u t p u t was  examined  rural  for  b e f o r e and a f t e r d i e t a r y  variables.  total  energy.  c o r r e l a t e d to muscle  r e c e i v i n g supplements  as w e l l  than  rate of a g r i c u l t u r a l workers  b i e y e 1 e - e r g o m e t r i c work  Satyanarayana workers  heart  or  c a l c u l a t e d from a c t i v i t y  (Barac-Nieto  and h e m o g l o b i n  t o be a f f e c t e d by n u t r i t i o n a l  Work o u t p u t ,  including estimation of  power was  not appear  found  a c t i v i t i e s , then  maximum o x y g e n c o n s u m p t i o n  t h a t maximum a e r o b i c  anthropometric  status  (1977)  m e t a b o l i c r a t e , nor  other  Colombian  nutritional  well,  Edmundson  i n t a k e and o u t p u t .  determined for  e x p e n d i t u r e o f each  Java,  appear  factory serum to  be  anthropometric correlated with  investigators  (Satyanarayana;  nutritional deprivation  in  early  22  c h i l d h o o d on body s i z e and heart of boys  in  India.  to c u r r e n t weight Desai 's  Maximal  rate response  physical  work c a p a c i t y was s t r o n g l y  and h e i g h t , and to l e v e l s o f h a b i t u a l  group  ( 1 9 8 1 ) a l s o found that  in agreement with a study of  However, t h i s  Italian children  rates  in response  activity.  r e l a t e d to result  was  ( F e r r o - L u z z i et a l . ,  1 9 7 9 ) , which found t h a t c h i l d r e n who were m a r g i n a l l y lower heart  correlated  physical  low body s i z e was  low work performance in B r a z i l i a n c h i l d r e n . not  to b i c y c l e - e r g o m e t r i c work  malnourished had  to e x e r c i s e , d e s p i t e growth  retardation,  than t h e i r we 1 1 - n o u r i s h e d c o u n t e r p a r t s . While the data f o r c h i l d r e n seems et^ aj_., 1 9 7 8 ) , physical workers  it  is  ( 1 9 7 9 ) presented r e s u l t s t r e a d m i l l work  p e r i o d of d i e t a r y including  of t h e i r studies  on heart  Increased  s e v e r i t y of  f o r h e i g h t was a s s o c i a t e d with  work t e s t s  may be u s e f u l  as a f u n c t i o n a l  affects  Spurr and c o rate  in malnourished Columbian a d u l t s  replenishment.  underweight  (Spurr e_t_ a_l_., 1 9 7 9 ) .  response to work to such a degree t h a t these authors maximal  (Spurr  becoming g e n e r a l l y accepted that m a l n u t r i t i o n  work performance in a d u l t s  to sub-maximal  to be more c o n t r o v e r s i a l  in  response  during a  malnutrition  i n c r e a s e d heart suggested that  assessment of  rate sub-  nutritional  status. While the s t u d i e s  just  discussed  have examined p h y s i c a l  work p e r f o r -  mance in r e l a t i o n to a wide range o f parameters of n u t r i t i o n a l  status,  there  primarily  is another body of  with the e f f e c t s o f and c o - a u t h o r s  l i t e r a t u r e which has concerned i t s e l f  i r o n - d e f i c i e n c y on p h y s i c a l  ( 1 9 7 3 ) assessed responses  in A f r i c a n  industrial  and severe  (Hemoglobin  s e v e r e l y anemic s u b j e c t s  Davies  to b i c y c l e - e r g o m e t r i c e x e r c i s e  workers with moderate less  work performance.  than 8 g/100 ml)  (hemoglobin anemia.  8 - 1 0 g/100 ml)  Both moderately and  e x h i b i t e d i n c r e a s e d e x e r c i s e heart  rates  compared  23  to  non-anemic  (hemoglobin g r e a t e r  anemic s u b j e c t s  than  13 g/100 m l ) c o n t r o l s .  also exhibited significantly  lower  Severely  maximum a e r o b i c  power  than c o n t r o l s . (1975)  Gardner and co-workers  studied  i t s e f f e c t on p h y s i c a l p e r f o r m a n c e blood step and  lactic  i n Venezuelan a d u l t s .  a c i d , and maximal oxygen c o n s u m p t i o n  Heart  received  iron  acid  initiation  l e v e l s were  t r e a t e d group than  unaffected  by i r o n  exercise heart  i n the untreated.  study  on i r o n - d e f i c i e n c y anemia  m o n i t o r e d as s u b j e c t s  performed  t r e a d m i l l t e s t s and b l o o d  l e v e l s were d e t e r m i n e d  before  r a t e a t a l l work  and p o s t - e x e r c i s e  loads  higher  and a f t e r e x e r c i s e . blood  When a n e m i c w o r k e r s  p l e m e n t s f o r o n e m o n t h , an i n c r e a s e  of everyday a c t i v i t y  subjects  a l s o appeared  r a t e was  lactic  acid  acid  levels  were  b e l o w 7 g / 1 0 0 ml  levels then  heart  received  iron  sup-  i n hemoglobin and a s i g n i f i c a n t i n -  i n amount o f t e a p i c k e d was o b s e r v e d placebo-treated  Heart  Both e x e r c i s e  lactic  i n subjects with hemoglobin  i n non-anemic c o n t r o l s .  compared w i t h  t o be  status.  ( G a r d n e r et_ aj_. , 1 9 7 7 ) -  crease  Eighty-  Muscle s t r e n g t h appeared  i n Ceylon  than  then  r a t e s and b l o o d  tea e s t a t e workers  significantly  status,  and maximal oxygen c o n s u m p t i o n h i g h e r i n  Gardener's group conducted a l a t e r in  standard  f o r hookworm i n f e s t a t i o n .  of treatment,  lower  iron  One g r o u p o f a n e m i c s u b j e c t s  i n j e c t i o n s and treatment  t h r e e days a f t e r lactic  measurements.  rate,  responses t o a  t e s t w e r e d e t e r m i n e d , as w e l l a s m u s c u l a r s t r e n g t h , anthropometric  the  i r o n - d e f i c i e n c y anemia and  f o r i r o n - t r e a t e d s u b j e c t s as  (Edgerton  e t a 1.,  1979).  to increase s i g n i f i c a n t l y  Levels  after  iron  treatment. The  same r e s e a r c h e r s ,  i n another study  ( O h i r a e t a l . , 1979)  t h a t h e m o g l o b i n and m a x i m a l w o r k e n d u r a n c e began t o i n c r e a s e  found  i n anemic  2k  Ceylonese Another  workers  as  recent study  I n d o n e s i a by B a s t a  s o o n as  four  d a y s a f t e r commencement  o f a n e m i a and w o r k  and c o - w o r k e r s  p r o d u c t i v i t y was  (1979)-  of  In m a l e w o r k e r s  l e v e l s were c o r r e l a t e d to s t e p  mance,  t o a c t u a l work o u t p u t ,  and t o m o r b i d i t y  meters  in comparison  showed  that c a l o r i c  formance o r work In a d d i t i o n formance, o t h e r mance. muscle has  i n t a k e was  specific nutrient  in nerve  since  et a l . , 1967).  ordination  extraneous  exhaustion  i f administered  (Consolazio  glycogen  found  muscle  and J o h n s o n , have  in that  per-  work  stores  1972;  tasks  severe  is  can  diets  (Astrand,  may exer-  1967  during  reduction  regarded  and B e r g s t r o m  an a f f e c t on e x e r c i s e  exercise testing  performance time  of  caloric  et_ a j _ . , 1 9 6 7 ) .  performance.  By  to  (Martin  t o be t h e p r e f e r r e d  following periods  co-  1977).  influence exercise  exercise  and  malnutrition,  et a l . ,  can p r o l o n g  perfor-  deficiency  This  significant  (Kumar  per-  influence  deposition.  to cause  factors  before or  carbohydrate  the working  i n t a k e can a l s o  test  i n c h i l d r e n , w h i c h may a f f e c t m u s c l e  Carbohydrate-rich  et_ a j _ . , 1978) , s i n c e  1980),  to  t e r m p r o t e i n and e n e r g y  dietary  ways.  for  by m u s c l e  velocity  in various  source  para-  assessment  a b i l i t y to perform prolonged  and a b i l i t y t o p e r f o r m w o r k  Finally,  infec-  i n f l u e n c e work  been f o u n d  in glycogen  muscle  Long  has  (Sundeen,  m y e l i n a t i o n , was  conduction  d e f i c i e n c i e s may  restriction  performance  impeding  Dietary  i r o n - d e f i c i e n c y on p h y s i c a l  in poultry  metabolism  i n f l u e n c e d markedly  through  perfor-  in these  c o r r e l a t e d to e i t h e r step  to the e f f e c t s of  been shown t o c a u s e  Bergstrom  improvements  Java  output.  carbohydrate  is  in s i g n i f i c a n t  not  test  f r o m d i a r r h e a and  with placebo-treated controls.  Vitamin A deficiency  a f f e c t work cise  resulted  in  on a West  p l a n t a t i o n , hemoglobin  Iron treatment  treatment.  c a r r i e d out  rubber  tions.  iron  energy  restriction Caffeine stimulating  25  f r e e f a t t y a c i d m o b i l i z a t i o n , an energy source f o r the a e r o b i c a l l y muscle, c a f f e i n e e x e r t s a s p a r i n g  e f f e c t on muscle g l y c o g e n ,  in prolonged endurance at heavy e x e r c i s e  5.  Nutri t i o n a)  colonial  Socio-economic  was f i r s t  society  in B r a z i l ' s  settled  Situation  in 1532 by the Portuguese, who o r g a n i z e d a  natural  resources.  founded on p l a n t a t i o n a g r i c u l t u r e , Indian s l a v e s  pendence from Portugal (Worcester,  ( C o s t i 11 et_ aj_., 1 9 7 8 ) .  in the n o r t h e a s t of the country to p r o t e c t t h e i r  abundant  o f Negro and  and  This e a r l y B r a z i l i a n  patriarchal  (Freyre, 1956).  life,  1822 B r a z i l  s o c i e t y was  and the gained  labour  inde-  in 1889 an independent R e p u b l i c was d e c l a r e d  history  and m i l i t a r y d i c t a t o r s h i p s elected populist  has been stormy s i n c e  have only o c c a s i o n a l l y  governments  recent change o f government,  (Rosenbaum and T y l e r ,  Brazil's  1889 -  Authoritarian  been i n t e r s p e r s e d with 1972).  The most  in 1 9 6 4 , r e s u l t e d from the f o r c i b l e o v e r -  throw of an e l e c t e d p a r t y by a m i l i t a r y coup  its  In  family  interest  1973).  Brazilian political  of  resulting  in Brazi 1  Brazilian  Brazil  working  (Frank,  1969)-  economic past was dominated by the e x p l o i t a t i o n and export  cash crops and m i n e r a l s , o f t e n to the e x c l u s i o n of p r o d u c t i o n o f  adequate  local  products  t h a t were exported at v a r i o u s  sugar, gold,  food s u p p l i e s  1969 and Worcester,  rubber, c a c a o , and c o f f e e  tained a p r i m a r i l y c o l o n i a l at which time dramatic automotive and s t e e l Brazil  (Frank,  is  (Margolis,  agricultural  industrial  industries  a large  times s i n c e  1973).  1600 have i n c l u d e d : 1973).  Brazil  export economy u n t i l  (Rosenbaum and T y l e r , of  main-  the  development began, e s p e c i a l l y  country which o c c u p i e s hl%  Major  1950's,  in the  1972). the geographic  area  26  o f South America Figure  11-2.  Brazil  and t r o p i c a l the South. Portuguese  (Government of B r a z i l ,  has a d i v e r s e c l i m a t e  forests Its  population  people  (Inter-American  growth  rate  is 2.8% annually  (United Nations  The B r a z i 1 i a n economy today, as  (UN, 1 9 8 0 ) .  c l u d e kidney beans,  rice,  the p o p u l a t i o n Although  cline  that  ]Q% in the e a r l y (UN, I 9 8 O ) .  exceeding e x p o r t s . consumer p r i c e s  The average  is 9 - 1 0 % (IADB, is s t i l l  Other p r i n c i p a l  products  annual  growth  1970's, t h i s  based  primarily  soya  beans,  f o r export i n (Govern-  o f the c o u n t r y , the p r o p o r t i o n o f 1975).  r a t e o f the i n d u s t r i a l  sector  soared  r a t e o f i n c r e a s e has s t a r t e d to d e -  balance o f trade  Inflation  f o r females  1979).  b e e f , c o c o a , t e a , t o b a c c o , and c o t t o n  Brazil's  is  The p o p u l a t i o n  f o r males and 6 1 . 0 years  r u r a l exceeds 50% (Shrimpton,  the small  language  - UN, 1 9 7 9 a ) .  in the p a s t ,  In most parts  is  temperate regions o f  l e a d i n g e x p o r t s are c o f f e e beans,  and u n r e f i n e d sugar  1976).  from the dry backlands  IADB, 1 9 7 9 ) .  1 9 7 9 a ) , w h i l e the i n f a n t m o r t a l i t y . r a t e  ment o f B r a z i l ,  in  i s c u r r e n t l y e s t i m a t e d to be 1 1 9 , 6 5 6 , 0 0 0  is 5 7 - 6 years  Brazil's  illustrated  1976).  Development Bank -  l i f e expectancy at b i r t h  over  ranging  is  is 90% C a t h o l i c and the n a t i o n a l  (Government o f B r a z i l ,  on a g r i c u l t u r e .  This  o f the north to the f e r t i l e ,  The p o p u l a t i o n o f B r a z i l  (UN,  1976).  is now n e g a t i v e with  imports  is a major problem; so much so that  in 1979  rose by over 50% (IADB,  1979).  A c c o r d i n g to Shrimpton  (1975), incomes in B r a z i l are unevenly d i s t r i b u t e d such that 10% o f the population  r e c e i v e s 48% o f the w e a l t h .  The wages o f the B r a z i l i a n  c l a s s have not kept pace with the severe country s i n c e  1950 ( A r r u d a ,  income is thought  inflation  working  that has plagued the  1 9 7 5 ) , and the present e s t i m a t e d per c a p i t a  to be approximately  US $ 1 , 3 8 4 per year  (UN, 1 9 7 9 a ) .  E39 State FIGURE I 1-2 Map o f Brazi1 .  a  a  From Government of B r a z i l ,  1976.  of  Sio Paulo  28  There e x i s t s  an o f f i c i a l  minimum s a l a r y ,  to pay t h i s wage to n o n - u n i o n i z e d workers. B r a z i l i a n people have no s o c i a l ment of B r a z i l ,  1976).  Unemployment has been e s t i m a t e d  mentioned, high unemployment  is  leave t h e i r homes and f a m i l i e s in w e a l t h i e r southern s t a t e s right  ment ( 1 9 7 6 ) , y e t of a l l  and  insurance to vary  1975)-  As  of B r a z i l  to e d u c a t i o n  (Govern-  between previously  force of migration.  Workers  (Margolis, is  1973).  r e c o g n i z e d by the B r a z i l i a n  B r a z i l i a n c h i l d r e n e n t e r i n g primary s c h o o l ,  is a n a t i o n a l  of  in the n o r t h hoping to secure employment  (Freire, 1970).  reach even the second grade  illiteracy  (Shrimpton,  the d r i v i n g  a f r a c t i o n ever reach u n i v e r s i t y rarely  In a d d i t i o n , the m a j o r i t y  s e c u r i t y or unemployment  15 and 30% o f the male a d u l t work f o r c e  The u n i v e r s a l  but employers are not f o r c e d  governonly  Most poor c h i l d r e n  (Government o f B r a z i l ,  1 9 7 6 ) , and  problem of c o n s i d e r a b l e p r o p o r t i o n  ( F r e i r e , 1970  1973). The B r a z i l i a n government  by the s t a t e analysis Brazil  (1976) asserts  in c h i l d b i r t h , i n f a n c y , and c h i l d h o o d , but  ( 1 9 7 5 ) o f the medical  system  had no d o c t o r , 85% o f a l l  in B r a z i l  1  disease,  endemic p u b l i c h e a l t h problems Brazil country:  still  high  insurance.  exhibits  rate;  large  rural  skewed  in favour of a small  townships  in  1979),  1973).  are  of  both of Schisto-  continuing  (Government o f B r a z i l ,  1976).  many o f the c h a r a c t e r i s t i c s of an underdeveloped  infant mortality;  growth  (UN,  (Berg,  and t u b e r c u l o s i s  in B r a z i l  for  The l e a d i n g causes  disease  associated with m a l n u t r i t i o n  s o m i a s i s , m a l a r i a , Chagas  paid  beds were p r i v a t e , and 60% o f  are e n t e r i t i s and d i a r r h e a l  which are d i s e a s e s  is  Shrimpton's  r e v e a l e d that k%% of  hospitals  the B r a z i l i a n p o p u l a t i o n had no h e a l t h death  that h e a l t h care  low l i f e e x p e c t a n c y ; high  population; d i s t r i b u t i o n of percentage o f  population  income h e a v i l y  the p o p u l a t i o n ;  widespread  29  illiteracy;  and a high  poor hygiene.  i n c i d e n c e of d i s e a s e s  Because so much of B r a z i l  is  r e l a t e d to m a l n u t r i t i o n and still  so underdeveloped,  has been suggested t h a t B r a z i l ' s  s o - c a l l e d development m i r a c l e ,  the r a p i d  growth s i n c e the 1 9 5 0 ' s , has  increase  in  industrial  b e n e f i t t e d o n l y a small 1975; Davis,  b)  1 9 7 7 ; and Souza,  Nutritional i)  This  (Frank,  namely  actually 1969; Forman,  1975).  Status o f B r a z i l i a n  National  Numerous people.  m i n o r i t y of B r a z i l i a n people  it  People  Studies  studies  have i n v e s t i g a t e d  review w i l l  the n u t r i t i o n a l  s t a t u s of  summarize r e s u l t s o f p e r t i n e n t s t u d i e s  Brazilian conducted  w i t h i n the l a s t 20 y e a r s . There have been two comprehensive surveys a n t h r o p o m e t r i c , b i o c h e m i c a l , and c l i n i c a l status of B r a z i l i a n over 5 , 5 0 0 standing  families.  individuals  findings  of  aspects  in 1963 of  (ICNND, 1 9 6 5 ) .  survey were that energy and p r o t e i n  were low among most of the sample p o p u l a t i o n ; c h i l d r e n were well  of the n u t r i t i o n a l  The ICNND conducted a survey  in n o r t h e a s t e r n B r a z i l  this  that examined d i e t a r y ,  below American s t a n d a r d s ;  o f m a l n u t r i t i o n were o b s e r v e d .  that h e i g h t s and that  The o u t intakes  and weights o f  few c l i n i c a l  T h i s survey a l s o found that 60% of  signs the  p o p u l a t i o n had e i t h e r low or d e f i c i e n t l e v e l s o f serum v i t a m i n A, which indicates  probable d e p l e t i o n of  serum t o t a l  body v i t a m i n A s t o r e s .  p r o t e i n , u r i n a r y t h i a m i n , and u r i n a r y  Examinations  riboflavin  indicated  that a p p r o x i m a t e l y 25% o f the p o p u l a t i o n appeared to be d e f i c i e n t these  of  in  nutrients. A more recent survey o f 500 Sao Paulo f a m i l i e s  found t h a t o f  the poorest  (Campino et a l . ,  20% of people s t u d i e d , 50% had c l i n i c a l  1975)  signs  30  m a l n u t r i t i o n , 25% were below American standards and most had p r o t e i n and energy subjects  intakes  f o r h e i g h t and  significantly  weight,  lower than w e a l t h i e r  studied.  D i e t a r y assessment o f the B r a z i l i a n p o p u l a t i o n has been the of many s t u d i e s .  As c i t e d by Shrimpton  consumption surveys  (1975),  in 1 9 6 1 - 1 9 6 3 ,  were conducted by the Vargas Foundation  Covering 9 , 0 0 0 f a m i l i e s , 48 c i t i e s , and r u r a l areas surveys people tion  p r o v i d e d the f o l l o w i n g e s t i m a t e s  urban p o p u l a t i o n areas,  in B r a z i l .  o f food consumption:  these  75% of  the r u r a l  popula-  nourished, while nearly half  in the south consumed energy d e f i c i e n t d i e t s ;  ( 1 9 6 4 ) noted that basal  s i s t e d of dry s a l t e d noted that although  diets  the  and in a l l  in the n o r t h e a s t o f B r a z i l  b e e f , f l o u r , beans, and sugar. food p r o d u c t i o n  between 1948 and 1 9 6 1 , B r a z i l L a t i n American c o u n t r i e s  Brazil  in B r a z i l  still  Siqueira  increased  con-  (1970)  dramatically  compared unfavourabley with o t h e r  in terms of  individuals'  food purchasing  power.  P a t r i c k and Simoes ( 1 9 7 1 ) found t h a t poor people in c e n t r a l spent  80% o f  their  income on food but most people f a i l e d to meet  recommended d i e t a r y allowances Jansen and co-workers  f o r any o f the n u t r i e n t s  ( 1 9 7 7 ) found that  c a l o r i e s and p r o t e i n was g r e a t l y urban B r a z i l i a n s  families,  total  considered.  availability  dependent on income, and that  of low-income  simply c o u l d not purchase an adequate q u a n t i t y o f  to meet t h e i r needs.  In another study  15% o f f a m i l i e s  (Alves,  1977) o f 2 , 3 8 0 Sao  food Paulo  consumed inadequate amounts of p r o t e i n and  e n e r g y , and the mean income of f a m i l i e s who d i d consume an adequate was  food  most people consumed adequate amounts of p r o t e i n .  Chaves  Indeed,  family  in 7 s t a t e s ,  in the n o r t h e a s t consumed e n e r g y - d e f i c i e n t d i e t s ;  in the south appeared to be well  subject  twice that o f f a m i l i e s who d i d  not.  diet  31  Martins and c o - a u t h o r s thiamin, levels  (1977)  r i b o f l a v i n , v i t a m i n C, and c a l c i u m were w e l l  in 337 Sao Paulo f a m i l i e s  studies,  reported that mean intakes o f v i t a m i n A,  Szarfarc  of  ( 1 9 7 9 ) found that  low-income.  below recommended  In o t h e r Sao  intakes o f high q u a l i t y  Paulo  protein  foods  such as meat, m i l k , and eggs had d e c l i n e d by over 20% between 1969 and 1975  in low-income f a m i l i e s ;  consumed l e s s  and Roncada  ( 1 9 7 2 ) found that most people  than k0% o f the recommended amounts o f v i t a m i n A in the d i e t .  Biochemical  and c l i n i c a l  i n d i c e s of n u t r i t i o n a l  B r a z i l i a n p o p u l a t i o n have been examined by s e v e r a l examined b i o c h e m i c a l and c l i n i c a l status  in Sao Paulo f a m i l i e s .  of s u b j e c t s  In t h i s  authors.  as d i e t a r y  study,  i t was  another s t u d y ,  k0% o f  study  families  (Szarfarc,  r e p o r t e d that  10-30%  clinical  1972) found t h a t k0% of  had low hemoglobin v a l u e s .  individuals  found to e x c r e t e sub-normal  people  As w e l l ,  in  from low-income Sao Paulo f a m i l i e s  levels of  riboflavin  in t h e i r u r i n e  were  (Wilson  1977).  Apart from s t u d i e s of B r a z i l i a n  infants  investigators.  o f the general  p o p u l a t i o n , the n u t r i t i o n a l  An e a r l y work by Waterlow and Vergara  towns in B r a z i l .  It  (1956)  outlined five  was found that many i n f a n t s were weaned e a r l y  that were inadequate  in most c a s e s ,  status  and c h i l d r e n has been o f p a r t i c u l a r concern to many  the r e s u l t s of a p r o t e i n m a l n u t r i t i o n survey made of c h i l d r e n in  diets  (1972)  A were found.  Another biochemical in Sao Paulo v i l l a g e  Roncada  indices of vitamin A  had low serum v i t a m i n A values and that s e v e r a l  signs of hypovitaminosis  et al_.,  as well  s t a t u s of the general  unsanitary  in most n u t r i e n t s conditions  d i a r r h e a and i n f e c t i o n s d u r i n g  i n c l u d i n g p r o t e i n and  into that  caused many c h i l d r e n to c o n t a c t  the f i r s t  year of  life.  These  factors  g r e a t l y aggravated e x i s t i n g m a l n u t r i t i o n and many o f these c h i l d r e n e i t h e r  32  died  or developed c l i n i c a l  signs  o f kwashiorkor  (Waterlow and V e r g a r a ,  1956). Puffer mortality  (1973)  and Serano  i n Pan-American c o u n t r i e s .  found t o have t h e f o u r t h studied. tious  Most  highest  i n f a n t s who d i e d  diseases.  Puffer  i n northeast  i n Recife  were r e p o r t e d  (1973)  B r a z i l , was  r a t e among 25  cities  to dieof infec-  also estimated  that  nutritional  i n c h i l d r e n under 5  c a u s e o f kd% o f d e a t h s  1975-  patterns  Breast feeding  among l o w - i n c o m e women. the  Recife,  i n t h e i r study o f infant  in Recife. Breast feeding  in  Brazil  infant mortality  and Serano  d e f i c i e n c y was an u n d e r l y i n g years  included  in Brazil  appeared  were reviewed  t o be d e c l i n i n g g e n e r a l l y ,  O v e r 70% o f women e m p l o y e d  t i m e t h e i r i n f a n t was 2 m o n t h s o l d .  breast  feeding,  reasons  More r e c e n t  studies  f o rthe rise  colleagues  especially  b o t t l e - f e e d i n g by  Ignorance about t h e b e n e f i t s o f  and t h e i n f l u e n c e o f i n f a n t f o r m u l a a d v e r t i s i n g  c i t e d a s two m a j o r 1975).  by S o u s a a n d  i n bottle-feeding  h a v e shown t h a t w h i l e  were  (Sousa e t a l . ,  many women b r e a t  feed  t h e i r c h i l d r e n f o r s i x t o t w e l v e months a f t e r b i r t h , w e a n i n g f o o d s  like  s u g a r w a t e r , c a s s a v a f l o u r , and r i c e weeks a f t e r b i r t h Dietary children  studies  in Brazil.  bread and c o f f e e Paulo school efficacy  could  et_ a_j_. , 1 9 8 0 , a n d Swann, 1 9 7 9 ) .  h a v e been c o n d u c t e d among s e v e r a l Rosenberg  with  a s e a r l y a s two  a little  (1977)  found  that  sugar and m i l k  groups o f o l d e r  breakfast  consisted of  f o rthe majority  o f Sao  c h i l d r e n , a l t h o u g h no comment was made a s t o t h e n u t r i t i o n a l  of this  value of a rice ditional  (Desai  f l o u r are introduced  breakfast. (Oriza  Santos'  sativa)  group  a n d bean  B r a z i l i a n f a r e , f o rpre-school  be a s a t i s f a c t o r y p r o t e i n  source  (1979)  studied  the nutritional  (Phaseolus v u l g a r i s ) d i e t ,  tra-  children.  diet  They f o u n d  this  i f a c c o m p a n i e d by a d e q u a t e  energy  33  i ntake. Many r e s e a r c h e r s h a v e l o o k e d a t a n t h r o p o m e t r i c status  in B r a z i l i a n  children.  M a r c o n d e s and  a cross-sectional anthropometric  a r e o f t e n used (Shrimpton, low  in Brazil  from h i g h e r (1974)  Guitti Brazil,  local  years.  The  standard  both  a l s o examined  of children  f o r age  under 5 years  standards American  f o r h e i g h t and  and  standards.  e_t a l _ . 1 9 7 8 ;  Hegg, 1978;  have e x p r e s s e d  similar  Clinical nutrition widespread nourished  i n 63%  tended  studies  school  children  incidence of c l i n i c a l among p r e - s c h o o l Biochemical  and  children  some c a s e s  in central  urinary riboflavin/creatinine  small  Another  study  children American fell  Desai  are  below Turini 1981)  e t al.. ,  s c h o o l age  and  younger.  Maldonada  reported  t h y r o i d among p o o r l y  Simmons A,  (1968)  (1976)  including  found  a  high  blindness  Brazil. children  poorer  ratios  and  e_t a]_. , 1977;  of enlarged  assessment of B r a z i l i a n  income s u b j e c t s h a v e s i g n i f i c a n t l y  in  c o n f i r m the e x i s t e n c e of  Brazil.  in northeast  children  showed t h a t  and  signs of hypovitaminosis  children  were  Brazilian  body w e i g h t  (Guitti  p r o b l e m s among l o w - i n c o m e g r o u p s . dental caries  weight  low-income c h i l d r e n  f o r c h i l d r e n who  studies of B r a z i l i a n  study  weight  for  of subjects.  Y u n e s e t aj_. , 1978;  results  this  t o meet o r e x c e e d  whereas,  later  Low  et_ aj_. , 1976)  families  Several  values  low-income school-age  were found  weight;  results of  Paulo  groups.  (S i gu 1 em  from high-income B r a z i l i a n  l o w - i n c o m e Sao  f o r h e i g h t and  American standards  socio-economic  published  f o r h e i g h t and  c o m p a r i n g them t o A m e r i c a n s t a n d a r d s .  head c i r c u m f e r e n c e  by  12  1975), even though v a l u e s o b t a i n e d  in comparison with  children  as a  9,000  nutritional  (1970  co-workers  study of over  b e t w e e n a g e s 3 months and  children  i n d i c e s of  has  riobflavin  than  shown t h a t s t a t u s , as  well-to-do children  lowindicated (Martins  e_t^ aj_. , 1 9 7 6 ) . Sao as low  Paulo,  In a n o t h e r b i o c h e m i c a l  low  hemoglobin  a whole, did occur  c h i l d r e n of children  with  greater  i n the  frequency  e x a m i n e d s e r u m v i t a m i n A and  s e r u m v i t a m i n A and  results of previous  B r a z i 1 i an  t o have m a r g i n a l  nutriture.  of  c a u s e s had  more, v i t a m i n A  reserves as  vitamin A  l i v e r vitamin A reserves b e t w e e n 3 w e e k s and  extremely  i n 50%  low  liver  in this  area  Studies  Relatively  nutrition  R i b e i r a o Preto area included  mortality.  incidence of The years  was  in that  Sao  Paulo  P r e t o was i t had  study,  lower  Dutra  state  found  status of 586  i n v e s t i g a t e d by  reserves.  indicating  had Further-  of  probable  Brazilian  Paulo  in B r a z i l .  a p r o j e c t area  i n f a n t deaths having  nutritional  o l d who  s t u d i e s h a v e been p r e v i o u s l y c o n d u c t e d  R i b e i r a o P r e t o as  Ribeirao  L a t i n America  of  that  1979)-  (Olson,  in Ribeirao Preto, Sio  few  socio-  d i e d under 4 years  widespread cause f o r concern about v i t a m i n A n u t r i t u r e of in this  and  found  2 years  vitamin A  o f c h i l d r e n who  inadequate  (1979),  of  carotene.  (Gomes e t a l . , 1 9 7 0 lower  i n h i s study  were c l a s s i f i e d  studies  showing t h a t c h i l d r e n from  of c h i l d r e n in c e n t r a l B r a z i l  (1973)  in  of both  died of various  the  carotene  values  economic groups tend  i i)  in children of  low o r d e f i c i e n t  1972)  children  population  They f o u n d t h a t o v e r 50%  Va r e 1 a et_ a]_. ,  in  1978).  (Sigulem,  (1978)  prevalent  Paulo.  the  age  significantly  i r o n - d e f i c i e n c y anemia  i n Sao  had  Olson,  not  of  national migrants  This confirmed  30%  levels, while  socio-economic status Roncada's group  study  de  t o be  P u f f e r and  in t h e i r  study  s u p e r i o r to other  i n f a n t m o r t a l i t y r a t e s and m a l n u t r i t i o n as  an  Serano  of  infant  areas a  associated  and  co-workers  in  lower cause.  R i b e i r a o P r e t o c h i l d r e n aged 2 t o Oliveira  in  in 1964.  10 All  35  subjects  in t h i s  study were found to have values  arm c i r c u m f e r e n c e w e l l this  for height, weight,  below American standard v a l u e s .  study were found to be low, and iron s t a t u s ,  globin  as  Energy  and  intakes  in  i n d i c a t e d by hemo-  l e v e l s , was found to be g e n e r a l l y adequate.  Angeleli agricultural eaters")  (1978)  of n u t r i t i o n a l  migrant workers, p o p u l a r l y known as b o i a - f r i a s  residing  male energy  examined general a s p e c t s  in the R i b e i r a o P r e t o a r e a .  intakes averaged 2 , 2 0 0  f o l l o w e d a s i m i l a r meal p a t t e r n :  kcal  It  (or " c o l d meal  was found that  per day and that most  no b r e a k f a s t ;  and r i c e and beans f o r supper o c c a s i o n a l l y tomatoes, o r s a u s a g e . . J8% of s u b j e c t s  s t a t u s of male  adult  individuals  r i c e and beans f o r  lunch;  supplemented with eggs, b e e f ,  showed e v i d e n c e of p a r a s i t i c  f e s t a t i o n , and hl% o f s u b j e c t s e x h i b i t e d a n t h r o p o m e t r i c i n d i c e s o f grade m a l n u t r i t i o n a c c o r d i n g to the Gomez ( 1 9 5 6 ) American standards Biochemical  first  using  f o r comparison.  t e s t s were a l s o conducted in A n g e l e l i ' s  Over 9 0 % o f s u b j e c t s  had normal values  8 7 % had normal v a l u e s hematocrit.  classification,  in-  study.  (1978)  f o r plasma v i t a m i n A and c a r o t e n e ;  f o r hemoglobin; and 5 7 % had norma.l values  P r o t e i n and albumin  in the serum were normal  A recent comprehensive n u t r i t i o n survey of  for  in most s u b j e c t s .  1 0 0boia-fria  migrant  worker f a m i l i e s was conducted in R i b e i r a o P r e t o by Desai and co-workers (I98O). following  A s o c i o - e c o n o m i c q u e s t i o n n a i r e used in t h i s information:  male f a m i l y members u s u a l l y worked as day  c u t t i n g sugar cane or p i c k i n g c o f f e e on large women and c h i l d r e n o f t e n worked as w e l l most f a m i l i e s  wage; and 40-60% o f a d u l t  boia-frias  had  land h o l d i n g s  labourers  near the c i t y ;  to supplement the f a m i l y  reported earning s u b s t a n t i a l l y  was no sewage system  study y i e l d e d the  l e s s than the legal  income; minimum  no e d u c a t i o n whatsoever.  in most homes and p a r a s i t i c  There  i n f e s t a t i o n was found  in  36  60% o f c h i l d r e n examined. The t y p i c a l d i e t o f b o i a - f r i a s , questionnaires,  is o u t l i n e d in T a b l e  as  r e v e a l e d from food frequency  11-1.  Quantitative analysis of  a d u l t b o i a - f r i a d i e t , based on 24-hour r e c a l l average d a i l y  (WHO/FAO) recommended d i e t a r y  Very low n u t r i e n t i n t a k e s were r e p o r t e d f o r c a l c i u m ,  t h i a m i n , n i a c i n , r i b o f l a v i n , and a s c o r b i c a c i d , and f o r only.  For a l l  were well  below American s t a n d a r d s ,  except f o r weight  showed low serum v i t a m i n A v a l u e s ,  25% o f  d i f f e r somewhat  due to the f a c t t h a t A n g e l e l i Desai and co-workers  the a d u l t p o p u l a t i o n examined  (1978).  T h i s c o u l d be  ( 1 9 7 8 ) s t u d i e d only male s u b j e c t s ;  whereas,  ( 1 9 8 0 ) s t u d i e d both males and f e m a l e s , and found than females  c a r o t e n e , and f o r hemoglobin and h e m a t o c r i t .  appeared to be  adults.  f o r hemoglobin and h e m a t o c r i t .  from A n g e l e l i ' s  t h a t males had higher mean values  and co-workers  in female  values  30% showed low or d e f i c i e n t serum  c a r o t e n e v a l u e s , and 25% showed low values These r e s u l t s  retinol,  i r o n among women  a n t h r o p o m e t r i c parameters measured, mean b o i a - f r i a  In terms o f b i o c h e m i c a l a n a l y s e s ,  Desai  the  intake o f most n u t r i e n t s was below the World Health O r g a n i z a -  t i o n / F o o d and A g r i c u l t u r e O r g a n i z a t i o n allowances.  i n t e r v i e w s , showed that  the  (1980a)  satisfactory.  f o r plasma v i t a m i n A and In a separate  report,  i n d i c a t e d t h a t v i t a m i n E s t a t u s of boi a - f r i as  37  TABLE Typical  Meal s  11-1  d i e t of b o i a - f r i a migrant w o r k e r s .  Foods Dai l y  and b e v e r a g e s Week 1y  3  consumed Somet i mes  Breakfast  Coffee & sugar, white bread  Hot mi l k & s u g a r '  Lunch  W h i t e rum, & beans  rice  Beer Egg-fried Salad-raw: -tomato -on i on  Beef o r c h i c k e n - f r i e d Salad-raw: - lettuce - wild chicory Vegetables-boiled: - potato - cassava  Di n n e r  W h i t e rum, & beans  rice  Beer Macaron i-soup White bread  Sausage-fried  Snacks  Coffee & sugar  Tea & s u g a r Soft d r i n k s  Limewater S sugar F r u i t s : banana, orange  Fats  Soybean o i l , pork l a r d  Cond i ments  Salt, onion, garlic  a  Modified  b  Consumed m a i n l y by  Red  f r o m D e s a i et_ aj_. , children.  pepper  1980.  b  3  Tomato  sauce  38  CHAPTER I I I METHODS AND  1.  Population A study  and  and  MATERIALS  Sample  was d e s i g n e d  to obtain  i n f o r m a t i o n on t h e n u t r i t i o n a l  p h y s i c a l work performance o f c h i l d r e n o f m i g r a n t a g r i c u l t u r a l  commonly  identified  as b o i a - f r i a s ,  purposes o f comparison,  living  in southern  i n f o r m a t i o n was a l s o o b t a i n e d  s t a t u s and p h y s i c a l w o r k p e r f o r m a n c e o f c h i 1 d r e n s o c i o - e c o n o m i c g r o u p s who the as  study,  these  controls.  had a c c e s s  l a t t e r c h i l d r e n were  their  well-to-do  Brazil.  workers,  For the  on t h e n u t r i t i o n a l  from  higher  t o a d e q u a t e d i e t s and h e a l t h c a r e . identified  The o b j e c t i v e s o f t h e s t u d y  children with and  status  a s " w e l l - t o - d o " and  In  served  were t o compare b o i a - f r i a  counterparts  i n terms o f n u t r i t i o n a l  status  p h y s i c a l w o r k p e r f o r m a n c e , and t o d e t e r m i n e w h e t h e r p a r a m e t e r s o f p h y s i -  c a l "work p e r f o r m a n c e w e r e r e l a t e d t o p a r a m e t e r s o f n u t r i t i o n a l study  was  conducted during  t h e months o f May  The s u b j e c t s o f t h e s t u d y Preto  w e r e b o y s a g e d 11-14  i n t h e s t a t e o f Sao P a u l o ,  agricultural Several First,  Brazil,  boia-fria  whose p a r e n t s  in s e l e c t i n g subjects  The  1979.  living  in Ribeirao  were e i t h e r m i g r a n t businesspeop1e. f o r the  study.  m a l e c h i l d r e n w e r e s t u d i e d due t o t i m e c o n s t r a i n t s .  S e c o n d , t h e a g e r a n g e o f 11-14 critical  years  w o r k e r s , o r w e l 1 - t o - d o p r o f e s s i o n a l s and  f a c t o r s were c o n s i d e r e d only  through August,  status.  years  g r o w t h p e r i o d when n u t r i t i o n a l chiIdren  while well-to-do  leave  school  c h i l d r e n remain  was  chosen because t h i s  needs a r e h i g h .  A l s o , many  by age 15 t o become a g r i c u l t u r a l in school.  i n a y o u n g e r age r a n g e who w e r e a l l s t i l l  I t was  i n school  is a  labourers,  thought that c h i l d r e n w o u l d be more  likely  39  than o l d e r c h i l d r e n Third,  the c i t y  t o be s i m i l a r  daily  activities.  o f R i b e i r a o P r e t o was c h o s e n t o be t h e l o c a t i o n  s t u d y b e c a u s e many m i g r a n t research  i n terms o f t h e i r  workers  lived  t h e r e and because  f o r the  excellent  f a c i 1 i t i e s w e r e a v a i l a b l e a t t h e U n i v e r s i t y o f Sao P a u l o  Finally, two g r o u p s  s u b j e c t s f o r t h e s t u d y had t o be s e l e c t e d  living  in Ribeirao Preto:  either  or c h i l d r e n of w e l l - t o - d o p r o f e s s i o n a l t o c h o o s e two s c h o o l s  in the c i t y  Hospital.  f r o m one o f  c h i l d r e n of migrant  and b u s i n e s s p e o p l e .  I t was  t h a t were p o p u l a t e d m a i n l y  o f t h e two g r o u p s t o be s t u d i e d , a n d t o s e l e c t  workers, decided  by one o r o t h e r  s u b j e c t s from  these s c h o o l s .  S c h o o l s w e r e s e l e c t e d on t h e b a s i s o f p r e v i o u s s t u d i e s ( D e s a i e t a 1. , 1980)  and w i t h t h e h e l p o f l o c a l  from a p u b l i c phery  school  in Vila  people.  Boia-fria  Recreio, a favela  o f R i b e i r a o P r e t o w h e r e most m i g r a n t  c h i l d r e n were  o r s l u m a r e a on t h e p e r i -  workers  lived.  Vila  was c h a r a c t e r i z e d  a s b e i n g one o f t h e p o o r e s t a r e a s o f t h e c i t y  of  h o u s i n g , and e d u c a t i o n  income l e v e l s ,  were s e l e c t e d  from a p r i v a t e school  of R i b e i r a o P r e t o which and  businesspeople.  affluent A total  2.  All  levels.  Well-to-do  Recreio i n terms  children  in Jardim Recreio, a residential  was p o p u l a t e d a l m o s t  exclusively  by  area  professionals  J a r d i m R e c r e i o was c o n s i d e r e d t o be one o f t h e most  areas of the c i t y  i n terms o f income, h o u s i n g , and e d u c a t i o n .  o f Sk s u b j e c t s w e r e t e s t e d ,  Experimental  selected  59 b o i a - f r i a  and 35 w e l l - t o - d o .  Procedure  tests except  biochemical bloodwork  were conducted  sity  o f Sao P a u l o H o s p i t a l  in Ribeirao Preto.  done  i n l a b o r a t o r i e s o f the Department o f C l i n i c a l  o f M e d i c i n e a t t h e U n i v e r s i t y o f Sao P a u l o  a t the Univer-  Biochemical bloodwork Medicine  was  i n the F a c u l t y  in Ribeirao Preto.  40  On the morning of t e s t i n g , 8 a.m.  They were f i r s t  gram by a p h y s i c i a n participation  given a p h y s i c a l  that might prevent  Subjects were then i n t e r v i e w e d to o b t a i n  their diet.  Following  the  taken.  The s u b j e c t  taken.  subjects  r e s t e d and were given  Anthropometric measurements were taken a f t e r the r e s t then returned to t h e i r s c h o o l s  approximately  3.  for a n a l y s i s .  refreshments.  period.  Subjects  and blood specimens were t r a n s p o r t e d  to  The e n t i r e procedure took each s u b j e c t  3 hours.  Assessment of N u t r i t i o n a l a)  sample  :  the work t e s t ,  the l a b o r a t o r y  blood  then performed a work t e s t on a b i c y c l e - e r g o m e t e r  and a second blood sample was After  in-  i n t e r v i e w , experimental e q u i p -  ment and procedures were e x p l a i n e d to the s u b j e c t and a f i r s t was  at  examination and an e l e c t r o c a r d i o -  to d e t e c t any medical c o n d i t i o n s  in the s t u d y .  formation about  s u b j e c t s were taken to the h o s p i t a l  Socio-economic  Socio-economic  Status  Factors  factors  that may have b e a r i n g on n u t r i t i o n a l  were assessed by c o n v e r s i n g with  local  people and by making v i s i t s  houses, markets, and shops to o b t a i n q u a l i t a t i v e c u l t u r e and home l i f e .  Information  status  about general  i n f o r m a t i o n about physical  to local  h e a l t h of  bo?a-  f r i a as compared to w e l l - t o - d o c h i l d r e n was o b t a i n e d from an examination conducted by a p h y s i c i a n on each s u b j e c t p r i o r to experimental It was expected that  this  interpreting  of more d i r e c t t e s t s  b)  results  Dietary  Information method.  i n f o r m a t i o n might p r o v i d e h e l p f u l of n u t r i t i o n a l  testing.  background  in  status.  Analysis on d i e t a r y  Each s u b j e c t  intake was o b t a i n e d using  in the study was  the 24-hour  interviewed in Portuguese  reca 1 1 by a  41  Brazilian  n u r s e who had been p r e v i o u s l y  Foods e a t e n w e r e r e c o r d e d by t h e in terms o f I I 1-1  local  measures.  t r a i n e d t o do 2 4 - h o u r d i e t  i n t e r v i e w e r and q u a n t i t i e s w e r e  Any s u p p l e m e n t s  i l l u s t r a t e s the q u e s t i o n n a i r e  used  analysis.  This  in the  interview.  used  All  Figure  foods  food group  developed  w i t h the a d d i t i o n of  35  foods. Information  on t h e c o m p o s i t i o n o f  t h e 35 f o o d s  t a b l e was o b t a i n e d f r o m Leung and F l o r e s  not  included  (1961) and W a t t and  in  f o o d was used.  listed  If  closely approximating  (1977).  i t was  cookbooks  and f r o m l o c a l  a p p r o p r i a t e and  ingredients  were a p p r o x i m a t e d . ingredient  For mixed d i s h e s ,  used,  tables  was  the c o m p o s i t i o n of .  a-tocopherol values  developed  women.  These  by  and q u a n t i t i e s o f  foods  then coded  used  for  Bauernfeind  r e c i p e s were averaged in mixed  in terms o f  from  where dishes  individual  foods. d e v e l o p e d by s t a t i s t i c i a n s a t  C o l u m b i a were used  for nutrient analysis.  centage c o n t r i b u t i o n of food groups to n u t r i e n t each s u b j e c t .  daily  a  B r a z i l i a n r e c i p e s were o b t a i n e d  The m i x e d d i s h was  C o m p u t e r programmes British  If  l o c a l l y a p p l i c a b l e source  in e i t h e r s o u r c e ,  were o b t a i n e d from c o m p o s i t i o n  and D e s a i local  t h e more  a f o o d c o u l d n o t be f o u n d  t h e f o o d most foods  in both sources,  Swann's  Merrill  (1963), and n u t r i e n t c o m p o s i t i o n was e x p r e s s e d p e r lOOg o f f o o d .  for  for  t a b l e f o r B r a z i l i a n foods  for nutrient analysis,  re-  number,  t r a n s c r i b e d onto computer cards  The m o d i f i e d f o o d c o m p o s i t i o n  by Swann (1979) was new  i n f o r m a t i o n was  expressed  consumed w e r e n o t e d .  c o r d e d f o r e a c h s u b j e c t w e r e t h e n c o d e d f o r f o o d number, and q u a n t i t y .  recalls.  intakes  Nutrient  (Passmore  Nutrient  i n t a k e and  of per-  i n t a k e were determined  i n t a k e s were compared  e t a l . , 1974).  the U n i v e r s i t y  t o WHO/FAO  recommended  42  QUANT IDADES DE COMIDAS E BEBIDAS CONSUMIDAS NO DIA ANTERIOR (ULTIMAS 24 HORAS)  NOME DA FAMILIA  DATA:  NOME DA CRIANCA  I DADE  VILA RECREIO  HORARIO  •  VITA ET PAX  ALIMENTOS  •  SEXO:  QUANT 1 DADE  Cafe da Manna  Entre  Cafe  e Almoco  ALMOqO  Entre Almoco e Jantar  JANTAR  Noi te  FIGURE Q u e s t i o n n a i r e used  I I 1-1  in 24-hour d i e t  recall  interviews.  OBSERVAQOES  43  c)  Anthropometric Deterrhi nat i ons  All  a n t h r o p o m e t r i c measurements were taken a c c o r d i n g  recommended procedures measured: triceps  weight,  skinfold  (Jelliffe,  standing  1966).  The f o l l o w i n g  to  standard  parameters were  h e i g h t , mid-upper-arm c i r c u m f e r e n c e , and  thickness.  In a d d i t i o n , mid-upper-arm muscle c i r c u m -  f e r e n c e was c a l c u l a t e d . To measure weight, weighed to the nearest minimum of  light  a p l a t f o r m beam balance was used. 1/10 kg b e f o r e meals, without shoes,  clothing.  height was measured using measuring  rod.  Subjects were and wearing a  No c o r r e c t i o n was made f o r c l o t h i n g .  Standing  a p l a t f o r m beam balance equipped with a v e r t i c a l  Subjects were measured to the nearest mm without  shoes.  Mid-upper-arm c i r c u m f e r e n c e was measured using a p l a s t i c i z e d f i b r e tape.  Measurements  l e f t arm.  were taken to the nearest mm on the f u l l y  Triceps skinfold  t h i c k n e s s was measured using  c a l i p e r s which e x e r t e d a uniform p r e s s u r e of taken to the n e a r e s t  1/10 mm on the f u l l y  10 g/mm . 2  Lange  skinfold  Measurements were  r e l a x e d l e f t arm.  muscle c i r c u m f e r e n c e was c a l c u l a t e d f o r each s u b j e c t using formula  relaxed  Mid-upper-arm the  following  ( J e l 1 i f f e , 1966) : xi  where:  =  x  2  =  TT(X ) 3  x^ = mid-upper-arm-muscle c i r c u m f e r e n c e (cm) X £ = mid-upper-arm c i r c u m f e r e n c e (cm) X3 = t r i c e p s s k i n f o l d  All standards dards  thickness  (cm)  a n t h r o p o m e t r i c measurements were compared to both (Nelson et^ aj_. , 1979 and F r i s a n c h o ,  (Marcondes  et a l . ,  1971) where  possible.  international  1974) and B r a z i l i a n  stan-  d)  Biochemical  Tests  S u b j e c t s were asked  t o give blood  10 ml o f v e n o u s b l o o d w e r e drawn u s i n g  Before e x e r c i s e , approximately sterilized Of  d i s p o s a b l e needles  t h e 10 m l , a p p r o x i m a t e l y  and r u b b e r - s t o p p e r e d  k ml w e r e drawn  anti-coagulant ethylene-diamine  no a n t i - c o a g u l a n t , f o r t e s t s  frigerated  total tion  iron,  p r o t e i n , and serum a l b u m i n . i n s e r u m was a l s o Total  (Crosby  serum  Blood  samples were r e total  of transferrin  and  Brij-35 for  solution,  15 m i n u t e s ,  and Houchin,  1957;  of E i l e r s  cyanide  sample absorbances Standards  (1967) a n d t o t a l  a calibration  i n 1,000  30 g/100 m l , a d d e d ) .  spectrophotometer.  satura-  u s i n g t h e cyanomethemog1obin Drabkin,  ml o f w a t e r After  hemoglobin  1967)•  Drabkin's  ferricyanide,  w i t h 0 . 5 ml o f  being mixed w e l l  w e r e r e a d a t 5^0  were p r e p a r e d  colori-  19^9; and E i l e r s ,  (100 p a r t s s o d i u m b i c a r b o n a t e , 20 p a r t s p o t a s s i u m  5 parts potassium  hemo-  calculated.  F o r e a c h s a m p l e , 20 y l o f w h o l e b l o o d w e r e a d d e d t o 5-0 ml o f solution  and s t a n d i n g  nm on a Beckman DU  according to the s p e c i f i c a t i o n s  i n each sample'was d e t e r m i n e d  from  curve.  Hematocrit  was d e t e r m i n e d  u s i n g t h e ICNND s t a n d a r d method  (1963)-  F o r e a c h s a m p l e , a s m a l l amount o f w h o l e b l o o d was i n t r o d u c e d i n t o a micro-capillary  h ml  i r o n - b i n d i n g c a p a c i t y , serum  The p e r c e n t a g e  h e m o g l o b i n was d e t e r m i n e d  m e t r i c method  A f t e r e x e r c i s e , another  c o n t a i n i n g EDTA.  total  requir-  i n t o a tube c o n t a i n i n g  2k-k8 h o u r s f o r t h e f o l l o w i n g :  and a n a l y s e d w i t h i n  g l o b i n , h e m a t o c r i t , serum  serum.  tubes  c o n t a i n i n g the  (EDTA), f o r t e s t  6 ml w e r e drawn  requiring  i n t o a tube  glass vacutainer  i n t o a tube  tetraacetic acid  i n g whole b l o o d , and a p p r o x i m a t e l y  o f b l o o d w e r e drawn  b e f o r e and a f t e r e x e r c i s e t e s t s .  tube, which  was t h e n  p u t t y , and c e n t r i f u g e d a t 3 , 0 0 0  s e a l e d a t one e n d w i t h  rpm f o r 5 m i n u t e s .  Critoseal  When t h e c e l l s  were  packed, using  the percentage o f volume that was red blood c e l l s was determined  a standard  micro-capillary  Serum i r o n and t o t a l  hematocrit  reader.  serum i r o n - b i n d i n g  f e r r o z i n e c o l o r i m e t r i c methods  (Carter,  c a p a c i t y were determined  1971 :and P e r s i j n et_ a_l_. , 1971)-  determine serum i r o n , 0.5 ml of serum was added t o 2.5 ml o f b u f f e r tion and  (hydroxylamine  hydrochloride  Then 0.05 ml o f f e r r o z i n e  1.5% w/v in a c e t a t e b u f f e r , pH 4.5),  (0.85% w/v in hydroxylamine  hydro-  chloride solution)  was added and the s o l u t i o n was incubated a t 3 7 ° f o r  10 minutes.  absorbance was then read a t 560 nm.  Final  prepared and the f o l l o w i n g  A standard was  formula was used t o c a l c u l a t e serum t o t a l  i ron: Serum t o t a l Final -=-:  Final  A t  —  Where:  e  7  s  t  ~  1  n  ' t '  a  1  iron A t e  (pg/lOOm) =  st  : — r — : — - — 7  A ^ , ,-Initial standard  A ^ , , standard  A^ ^ = absorbance test  i r o n , and i n i t i a l  3  o f 560 nm o f s t a n d a r d ,  serum i r o n - b i n d i n g  added t o 0.5 ml o f i r o n standard of  . , .(yg/lOO ml) standard  a t 560 nm o f t e s t ,  A ^ , , = absorbance standard  To determine t o t a l  x Concentration  capacity,  0.5 ml o f serum was  s o l u t i o n which c o n t a i n e d 500 yg/100 ml  absorbance was read a t 560 nm.  Then 0.05 ml o f  f e r r o z i n e was added and the s o l u t i o n was incubated a t 3 7 ° f o r 10 minutes Final  absorbance was read a t 560 nm.  following  A standard was prepared and the  formulae were used to c a l c u l a t e  total  iron-binding  To  solu-  absorbance was read a t 560 nm on a Beckman DU s p e c t r o p h o t o -  initial  meter.  using  capacity:  50  1.  Serum unsaturated  Concentration  iron-binding capacity =  , .(uq/lOO ml) s tandard 3  where:  Fi na I A test  -  Final A  standard  - i nt t i a I A test A . standard  = absorbance at 560 nm of  test  A ^ , . = absorbance at 560 nm of standard 2.  Serum t o t a l  x Concentration  , - Initial  iron-binding capacity  standard  .(tig/100 ml) 3  test standard  (yg/100 ml) =  Serum total iron (ug/100 ml) + Serum unsaturated iron-binding capacity (yg/100 ml)  Percentage of t r a n s f e r r i n s a t u r a t e d was c a l c u l a t e d using  the f o l l o w i n g  formula: L .. total .—: iron (yg/100 % ^ transferrin saturation =Serum 7 ' , . ml) r — , , x 100 Serum total iron-binding capacity (yg/100 ml) c  A  Serum t o t a l method ( G o r n a l l  p r o t e i n was determined using et_ a_l_., 1949).  For each sample, 0.1 ml df serum was  added to 5.0 ml of b i u r e t reagent sodium h y d r o x i d e ) . temperature f o r  in 3-0% w/v  15 minutes, then absorbance was read at 540 nm on a Beckman  was c a l c u l a t e d using  A standard was prepared and serum t o t a l  protein  the f o l l o w i n g f o r m u l a :  p r o t e i n (g/100 ml) =  Absorbance/ri, \ of n  -rr  (0.15% w/v copper s u l f a t e  The s o l u t i o n was mixed w e l l , allowed to stand at room  DU spectrophotometer.  Serum t o t a l  the b i u r e t c o l o r i m e t r i c  r  Absorbance(c^g)  ~E °'  test J — T * standard  Serum albumin was determined using method (Doumas and B i g g s ,  Concentration ^  , (g/100 ml)  standard the bromcresol green c o l o r i m e t r i c  1972 and Rodkey,  to 5.0 ml of bromcresol green s o l u t i o n  ,  19&5).  (0.01% w/v  20 y l of serum were added in b u f f e r , pH 4 . 0 ) ,  and  51  t h e s a m p l e was m i x e d w e l l . ture,  After  s t a n d i n g f o r 10 m i n u t e s a t room  t h e a b s o r b a n c e o f t h e s a m p l e was r e a d a t 630 nm o n a Beckman  spectrophotometer. lated  using  A standard  the following  Serum a l b u m i n  was p r e p a r e d  and serum a l b u m i n  was  temperaDU calcu-  formula:  (g/100 m l ) =  Absorbance, v -TT r Absorbance/ \ , , (630) s t a n d a r d 6 3 Q  For a l l b i o c h e m i c a l normal  k.  values  x  Concentration  d e t e r m i n a t i o n s , s u b j e c t s ' v a l u e s were compared t o  ( S a u b e r l i c h e t a 1.,  Assessment o f P h y s i c a l  1974).  Work P e r f o r m a n c e  Two t e s t s w e r e u s e d t o a s s e s s heart to  r a t e i n response  assess  procedure heart ject and  t o work, and change  t h e change  was u s e d .  rate monitor  i n heart  First,  i n blood  rate  i n response  lactic  change i n  acid  i n response  t o work, t h e f o l l o w i n g  e a c h s u b j e c t was c o n n e c t e d  u s i n g e l e c t r o d e s w h i c h were taped  t h e n was s e a t e d  on a b i e y e 1 e - e r g o m e t e r  to a  f o r 3 m i n u t e s w i t h a l o a d o f 25  (Brazilian-made  watts,  with  3 minute rest period.  pace h e l d c o n s t a n t Heart  minimum r e c o r d e d  P e d a l l i n g was t h u s  Subjects  T h i s was f o l l o w e d by continuous  f o r 9 mimutes  a t t h e end o f e a c h m i n u t e o f t e s t i n g ,  Change i n h e a r t heart  Funbec model)  a t 50 rpm.  r a t e was r e c o r d e d  rest periods.  The sub-  3 minutes w i t h a load o f  w a t t s , a n d 3 m i n u t e s w i t h a l o a d o f 75 w a t t s .  another  continuous  to h i s chest.  f o l l o w i n g a 3 m i n u t e r e s t p e r i o d , commenced p e d a l l i n g .  pedalled  ing  p h y s i c a l work p e r f o r m a n c e :  work. To  50  ^ , ,(g/100 m l ) standard  r a t e from  r a t e was c a l c u l a t e d  maximum  recorded  heart  includ-  by s u b t r a c t i n g rate.  I f a t any  52  9  time d u r i n g  testing a subject's  t e s t i n g was  stopped.  test  an  measured  idex of  in whole  previously  present  180  beats  throughout  per  minute,  the e n t i r e  described.  tate  blood proteins  Weil,  1967;  1944;  ml o f  The  a c i d by  Marbach  1,000  and W e i l ,  This  load  1967;  was  (Long,  and S e g a l  a d d e d t o 2.8  dinucleotide  (NAD); 2.0  ml o f  Marbach  mixed  was  read a t  (Long, sample, 10 mg  buffer, suspension,  m i x e d and  340  deter-  containing:  l a c t a t e dehydrogenase  Then a b s o r b a n c e  to  For each  ml o f g l y c i n e  The s o l u t i o n was  and  vigorously  e n z y m a t i c method  a solution  blood  to p r e c i p i -  then used  et^ a_l_. , 1 9 5 6 ) . ml o f  i n a manner  w/v)  1944;  was  was  ml o f w h o l e  (8%  s o l u t i o n was  l a c t a t e dehydrogenase  i n ammonium s u l f a t e .  3 7 ° f o r 30 m i n u t e s .  acid  c l e a r supernatant  ml o f w a t e r ; a n d 0.1  units/ml  t o work  ml o f c o l d p e r c h l o r i c a c i d  resulting  the  supernatant  4.0  response  a f t e r c o l l e c t i o n , 2.0  e t a 1. , 1 9 5 6 ) .  nicotinamide adenine  pH 9 - 2 ;  in  and s t a b i l i z e l a c t i c  and S e g a l  lactic  acid  Immediately  i n t o 4.0  and c e n t r i f u g e d . mine  lactic  b l o o d c o l l e c t e d b e f o r e and a f t e r e x e r c i s e  transferred  at  A c a r d i o l o g i s t was  fatigue,  were  of  r a t e exceeded  period. As  0.2  heart  nm on a  incubated Zeiss  spectrophotometer. Lactic acid Blood  lactic  i n t h e s a m p l e was acid  6.22 A  Where:  340  (mg/100 m l )  3.0 x 0.0667 x 1  c a l c u l a t e d using  x  90.0 =  10 maximum a b s o r b a n c e  3.0  reaction  6.22  millimolar  0.0667  volume o f  value  formula:  =  X  ^31+0  the f o l l o w i n g  of  A  3 1 F 0  sample at  X  65.1  340  nm  (ml)  e x t i n c t i o n c o e f f i c i e n t of b l o o d sample  in cuvet  (ml)  NADH a t 340  nm  53  Change  1  = 1 i ghtpath  90.0  = molecular weight  10  = conversion  in blood  (cm) of  factor  lactic acid  (g/mole)  1000 ml T ml.  l a c t i c a c i d was c a l c u l a t e d by s u b t r a c t i n g  e x e r c i s e from l a c t i c a c i d a f t e r e x e r c i s e .  l a t i c a c i d before  Percentage d i f f e r e n c e between  l a c t i c a c i d b e f o r e and a f t e r e x e r c i s e was a l s o c a l c u l a t e d .  Statistical  5.  All  Analysis  statistical  programmes  at  and w e l l - t o - d o  analyses  the U n i v e r s i t y  were conducted using of B r i t i s h  c h i l d r e n were f i r s t  compared as  S t u d e n t i s t - t e s t and the c h i - s q u a r e  cal  to determine the a s s o c i a t i o n  as one group.  were a l s o determined f o r the same v a r i a b l e s ately. those  two separate  between n u t r i t i o n a l  c o e f f i c i e n t s were determined f o r s e l e c t e d p a i r s subjects  data,  However, s i n c e these values  and  boia-fri a  groups. signi-  groups.  work performance, c o r r e l a t i o n a n a l y s i s was  b o i a - f r i a and w e l l - t o - d o  For a l l  t e s t were used to determine the  f i c a n c e o f d i f f e r e n c e s between the two Then,  Columbia.  computer f a c i l i t i e s  used.  s t a t u s , and phys i -..  Pearson's  of v a r i a b l e s , Correlation  treating  correlation treating  coefficients  the two groups  were not found to be d i f f e r e n t  f o r the two groups t r e a t e d as one, they are not  separthan  reported in the  study.  54  CHAPTER  IV  RESULTS  1.  Assessment of N u t r i t i o n a l a)  Socio-economic  Local  visits  Status  Factors  y i e l d e d the f o l l o w i n g  i n f o r m a t i o n about  living  conditions  in V i l a R e c r e i o and in Jardim Recreio.. Vila  R e c r e i o was  l o c a t e d approximately  from the c e n t e r o f R i b e i r a o P r e t o .  Living  generally  lived  very poor.  Most f a m i l i e s  that they c o n s t r u c t e d themselves or t i n ing.  roofs.  Figure  IV-1  is  conditions in two-or  with d i r t  in V i l a  R e c r e i o were  three-room houses  f l o o r s , wooden w a l l s and  tile  i l l u s t r a t i v e o f t y p i c a l migrant worker  These homes o f t e n had no e l e c t r i c a l  much of  10 km, or 45 minutes by bus,  the time cooking was done outdoors  not have running water, so f a m i l i e s  lighting  hous-  or v e n t i l a t i o n , and  on open f i r e s .  shared water taps  Many homes d i d  located  in p u b l i c  lots. There was no sewage system  in most V i l a  o t h e r waste water flowed i n t o the s t r e e t s . typical  R e c r e i o homes, Figure  IV-2  so sewage and  illustrates  s t r e e t scene in V i l a R e c r e i o where c h i l d r e n played b a r e f o o t  the e f f l u e n t , a p r a c t i c e probably a g g r a v a t i n g c h r o n i c problems with sitic  i n f e c t i o n that have been documented among bo i a - f r i as  1980).  Soil  in the area was dry and red ( t e r r a  coated c h i l d r e n and t h e i r c l o t h i n g . gardens or f r u i t  roxa)  Very few f a m i l i e s  t r e e s , but some kept domestic animals  Most b o i a - f r i a  families  d i d not possess  a in para-  (Desai et a 1.,  and red dust planted  often  vegetable  such as dogs or  t h e i r own cars o r horses  t r a n s p o r t a t i o n and depended on b i c y c l e s or the m u n i c i p a l  bus  to t r a v e l  cats. for to  Typical  FIGURE IV-2 s t r e e t in V i l a  Recreio.  56  the c i t y c e n t e r .  Bus t r a v e l was both time-consuming  and c o s t l y  a r e s u l t , most f a m i l i e s bought food l o c a l l y a t c o r n e r s t o r e s one i l l u s t r a t e d  in F i g u r e  with p r i c e s approximately center Vila  (Swann, 1979)-  IV—3-  These s t o r e s  15% h i g h e r than  Figure  Recreio corner s t o r e :  so that  such as  had l i m i t e d stock  in the l a r g e r s t o r e s  as  the  selection in the c i t y  WJ-k shows the type o f goods a v a i l a b l e  in a  l i q u o r , c i g a r e t t e s , white unenriched bread,  and sausages, as w e l l as white r i c e and d r i e d kidney beans.  Fresh produce  was seldom s o l d . Jardim R e c r e i o was a l s o o f R i b e i r a o P r e t o but those  l o c a t e d approximately  l i v i n g conditions  in V i l a R e c r e i o .  Most f a m i l i e s  in t h i s  10 km from the c e n t e r  suburb were s u p e r i o r  to  i n Jardim R e c r e i o l i v e d i n a t t r a c t i v e  t h r e e - or four-bedroom homes b u i l t o f wood and s t u c c o or b r i c k c o n s t r u c t i o n with t i l e f l o o r s  and r o o f s .  homes found i n Jardim R e c r e i o . water, and f l u s h  toilets.  as well as a p p l i c a n c e s  Figures All  had gas  such as washing machines,  illustrate  stoves  and  typical  refrigerators,  televisions,  and  were h i r e d to perform domestic  radios. duties  chores.  The s t r e e t s in Jardim R e c r e i o were a l l gardens where f r u i t , v e g e t a b l e s  t i o n o f foods a v a i l a b l e  paved and most homes had fenced  and f l o w e r s were grown.  owned cars and d i d t h e i r shopping  duce, meats, v a r i o u s  and IV-6  homes here had e l e c t r i c i t y , running  Most f a m i l i e s  In many o f these homes, b o i a - f r i a s and to do gardening  IV-5  Most  families  in downtown R i b e i r a o P r e t o .  The s e l e c -  in the c i t y markets was w i d e - r a n g i n g :  fresh pro-  baked goods, and imported c o n f e c t i o n s .  Jardim R e c r e i o a l s o frequented the many r e s t a u r a n t s  located  People from in  Ribeirao  Preto. It was e s t a b l i s h e d  from c o n v e r s a t i o n s w i t h  local  people that  average migrant worker earned approximately US$1,000 a n n u a l l y .  the  The average  FIGURE \\l-k Goods a v a i l a b l e in t y p i c a l s t o r e in V i l a R e c r e i o (Photo c o u r t e s y of Dr. l.D. Desai)  58  Typical  FIGURE IV-6 house in Jardim R e c r e i o .  59  working  personJs  income  US$10,000 a n n u a l l y . comes  earned  farms.  On t h e o t h e r  lawyers,  their  obtained  do  was e s t i m a t e d  t o be  living  h a n d , most p e o p l e  about the h e a l t h  in Jardim  Recreio  were  doctors,  executives. status of boia-fria i s summarized  and w e l l - t o - d o  i n Table  were a p p a r e n t l y  healthy,  as i n d i c a t e d by a n o r m a l  (ECG) a n d by t h e a b s e n c e o f b r o n c h i a l  infection.  than w e l l - t o - d o  subjects  had c a r d i a c  than w e l l - t o - d o  subjects  e x h i b i t e d symptoms o f i n f e c t i o n  cough, o r sore  Dietary  The  mean d a i l y  calcium,  IV-2.  well-to-do  s u c h as f e v e r ,  For a l l n u t r i e n t s except a-tocopherol,  were s t a t i s t i c a l l y iron,  and v i t a m i n  Table  boia-fria  n u t r i e n t i n t a k e o f boi a - f r i a and w e l l - t o - d o  vitamin  d a r d d e v i a t i o n was v e r y niacin,  More b o i a - f r i a  Analysis  nutrients, differences  to-do s u b j e c t s  electro-  a n d more  o f b o i a - f r i a s u b j e c t s was l o w e r t h a n t h a t o f w e l l - t o - d o following  well-do-  throat.  b)  i n Table  irregularities,  children,  I V - 1 . From  t a b l e i t c a n be s e e n t h a t p r o p o r t i o n a l l y f e w e r b o i a - f r i a t h a n  cardiogram  fat,  in Vila  p i c k i n g c o f f e e o r c u t t i n g s u g a r - c a n e on n e a r b y  from p h y s i c a l e x a m i n a t i o n s ,  subjects  shown  approximately  i n average i n -  As p r e v i o u s l y m e n t i o n e d , most p e o p l e  professors, o r business  Information  Recreio  T h u s , t h e r e was a t e n f o l d d i f f e r e n c e  i n t h e two a r e a s .  Recreio  this  in Jardim  high  i n mean  f o r mean  subjects.  For the  energy, p r o t e i n ,  riboflavin,  and v i t a m i n  intakes o f calcium,  and w e l l total  C.  vitamin  StanA,  C.  IV-3 shows t h e mean d a i l y subjects  the intake  i n t a k e between b o i a - f r i a  significant:  A, t h i a m i n ,  subjects i s  nutrient  i n c o m p a r i s o n w i t h WH0/FA0  ( P a s s m o r e et_ aj_. , 1 9 7 4 ) .  intake o f b o i a - f r i a recommended  The mean i n t a k e o f b o i a - f r i a  and "  intakes  subjects  was l e s s  TABLE  IV-1  Comparison o f i n d i c a t o r s o f h e a l t h s t a t u s in s u b j e c t s from b o i a - f r i a and w e l l - t o - d o f a m i l i e s .  Number of s u b j e c t s Boi a - f r i a Well-to-do (n = 34) (n = 58) 3  Health status  Apparently as  indicator  35 (60.3)  healthy:  30 (88.2) .  b  i n d i c a t e d by a b r i e f  physical  examination  and  an ECG.  Cardiac as  1  (2.9)  3  (8.8)  i n d i c a t e d by an  abnormal  Bronchial as  6 (10.3)  irregularities:  ECG.  17 (29.3)  infection:  b  i n d i c a t e d by presence  of f e v e r , . cough , sore t h r o a t , or chest  congestion  a  Figures  in parentheses  denote % of  total  in  b  Values f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s d i f f e r e n t (p < .001) using c h i - s q u a r e t e s t .  group. are  significantly  TABLE  IV-2  Comparison o f d a i l y n u t r i e n t intake of s u b j e c t s b o i a - f r i a and w e l l - p o - d o f a m i l i e s .  Daily Boia-fria  Nutrient  Energy  (kcal/kg) (g) (g/kg) Total  fat  (g)  Carbonhydrate Calcium Iron  (g)  (mg)  Thiamin  (RE)  (mg) (mg)  +  18 .2 27 .o  a  1 .49+  0 .79  60.9  +  21 • 9  182.7  +  66,.5  +  3.. l  + 253. , l  1863 .2  b  a  79..4 +  32.8  10. .0  d  0.65  42.1  +  4.3  1121. ,6 + 570.9  a  0.59 +  0.,24  0.78 +  0.,38  a  1. 85  Values f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s are d i f f e r e n t using Student's o n e - t a i l e d t - t e s t : a b c  15.6  206,• 7 + 67.6 681 .8 . + 359.0  d  4.65 +  37 • 7 +  81 .6 , +  b  a  (mg)^  + 604.0  1,.61 +  8.55 + 7.,14 + 42.,6 28.7  (mg)  ot-Tocopherol e q u i v a l e n t s  d  43.4  451.9  Vitamin C (mg)  a - c  485 . 9  7-9  Riboflavin Niacin  +  391 .1 + 264,,4  (mg)  Vi tami n A  U75.6 51 .0  (mean + SD) Well-to-do  (n = 32)  IrT^W  (kcal)  Protein  intake  from  0. 76 +  0.40  1 .27 +  0.46  12. 04 +  1 1.89  95. 0 + 85.8 4. 34 + 1 -99  significantly  p < .001 p < .01 p < .05  a-Tocopherol e q u i v a l e n t value o b t a i n e d by m u l t i p l y i n g mg a - t o c o p h e r o l x 1.2 to c o r r e c t f o r n o n - a t o c o p h e r o l s (Desai et a l . 1980a).  TABLE  IV-3  D a i l y n u t r i e n t i n t a k e o f s u b j e c t s f r o m b o i a - f r i a and w e l l - t o - d o f a m i l i e s i n c o m p a r i s o n w i t h WHO/FAO recommended d a i l y i n t a k e s .  WHO/FAO Recommended daily intake  Nutrient  Mean d a i l y i n t a k e e x p r e s s e d as % o f WHO/FAO recommended Boi a - f r i a Well-to-do  2600 k c a l  Energy  71 Protein  56.8  37 - 43 g  b  1.0-1.2 g / k g Ca 1 c i urn  600 - 700 mg  1 ron  r-  b  -7  5 - 7 mg 575 RE  V i tami n A  61 . l  kcal/kg  b  C  71.7  c  53.l  118.6  214.6  129.6  159.4  60.2  C  200.0  78.6  195.1  Th i ami n  1 .0 mg  59.0  Ri b o f 1 a v i n  1 .6 mg  48.8  C  17.2 mg  49.7  C  20 mg  143.5  Vi t a m i n C  e_t a j _ . ,  104.9  112.9  C  N i ac i n  c  76.0 79.4 70.0 475.0  a  Passmore  b  Lower v a l u e a p p l i e s t o d i e t r i c h i n a n i m a l s o u r c e f o o d s ( w e l l - t o do). H i g h e r v a l u e a p p l i e s t o m i x e d c e r e a 1 -1egume d i e t w i t h s m a l l amounts o f a n i m a l s o u r c e f o o d s ( b o i a - f r i a ) .  c  Values  are  less  1974.  t h a n 2/3  WHO/FAO recommended  values.  63  than 2/3  of  that  recommended f o r the f o l l o w i n g  thiamin,  r i b o f l a v i n , and n i a c i n .  do s u b j e c t s was g r e a t e r except energy  than 2/3  boi a - f r i a and w e l l - t o - d o  daily  IV-4  nutrient  WH0/FA0.  j e c t s had d a i l y  table  intakes  energy,  In g e n e r a l , intakes  intakes  energy,  the mean intake of  nutrients  the recommended i n t a k e f o r  both  subjects. number o f s u b j e c t s  that were below 2/3  of  in each group who had  the l e v e l s  illustrates,  between 60 and 80%  below 2/3  those  of  calcium, thiamin,  fewer w e l l - t o - d o  subjects  t h a t were below 2/3 of  the f o l l o w i n g  well-to-  The mean intakes of p r o t e i n ,  recommended by the of b o i a - f r i a  recommended f o r the  than b o i a - f r i a s u b j e c t s  the recommended l e v e l s .  nutrients:  energy, c a l c i u m , t h i a m i n ,  sub-  following  r i b o f l a v i n , n i a c i n , and v i t a m i n  C.  had n u t r i e n t  These d i f f e r e n c e s  between b o i a - f r i a and w e l l - t o - d o s u b j e c t s were s t a t i s t i c a l l y for  calcium,  the recommended i n t a k e f o r a l l  100% o f  shows the a c t u a l  As t h i s  nutrients:  of  i n t a k e per u n i t of body weight.  i r o n , and v i t a m i n C were over  Table  In c o n t r a s t ,  nutrients:  significant  riboflavin, niacin,  and vi tami n C. The percentage c o n t r i b u t i o n o f v a r i o u s is  illustrated  by c e r e a l s  in T a b l e  In b o i a - f r i a d i e t s ,  (40.0%) and legumes  s u p p l i e d by animal (15-4%)  IV-5.  from animal  sources  (24.4%).  p r o t e i n sources  in w e l l - t o - d o d i e t s . (34.0%),  food groups to n u t r i e n t  Comparatively,  (25.2%),  Protein legumes  cereals  of  In both groups,  the c a l c i u m  legumes  dairy  in the d i e t .  In  most energy  ( 1 8 . 9 % ) , and  in the b o i a - f r i a d i e t was (25.2%),  and c e r e a l s  in the w e l l - t o - d o d i e t , p r o t e i n was d e r i v e d mainly (57-8%).  most energy was  products  s u p p l i e d approximately  the b o i a - f r i a d i e t , 48.8% o f  and 18.2% from the animal  p r o t e i n s o u r c e s ; whereas,  supplied was  sweets derived  (23-8%);  from animal  intake  whereas,  sources one  half  i r o n came from in the w e l l - t o -  TABLE IV-4 Number o f s u b j e c t s w i t h d a i l y n u t r i e n t i n t a k e 2/3 o f recommended d a i l y i n t a k e .  Number o f Boia-fria  Nutrient  30 (71.4)  Energy Protei n  29  1 ron  (69.0)  2 ( 6.3)  Th i ami n  30 (71.4)  b  Ri b o f 1 a v i n  31 (73.8)  b  Niacin  34 (81.0)  C  Vitamin C  26 ( 6 l . 9 )  b  b c  p < .001 p < .05  1 ( 3.1)  % o f total  V a l u e s f o r b o i a-- f r i a a n d w e l l - t o - d o d i f f e r e n t us i ng c h i - s q u a r e t e s t :  -  8 (25.0)  b  10 (23.8)  denote  Wel1-to-do  0  8 (19.0)  Figures i n parentheses  3  15 (46.9)  b  Vi t a m i n A  b - c  subjects  7 (16.7)  Ca1c i urn  a  less  14 (43.8) 9 (28.1) 20 (62.5) 8 (25.0)  i n group.  s u b j e c t s a r e s i g n i fi c a n t l y  TABLE  IV-5  Contribution of food groups to n u t r i e n t  intake'  Food groups Nutrient  Dairy Products  o  t  e  i  n  . L  e  g  u  m  e  S  sources  "  V  e  9  e  t  a  b  l  «  F  r  u  ,  Cereal,  t  products  F  oils  Sugars, sweets  Miscellaneous foods  2,,2 3..It  1.9 5.8  ItO.,0  5..0 5..2  7..5  0.2  18, 9  15..It  0.8  12..9 16. 9  3<t..0  2,.0 19 ,  1.0 1.2  23.,8 9. 9  0..8 0..5  0..0 0..5  0.1  57.,8  25. 2 10. 5  b c  7..8  15.3 32..2  36. 3 16. 5  1. 3 2.,8  1.0 0.9  25..9  12 .It 13 .9  0 .0  0.0 0.0  b c  U. 9 9..7  0..1) 1.,0  17.1  3.. 1  33 12.5  55. 3 29..0  Prote i n  b c  Total  Calcium  r  2lt..It 12. 0  b c  Carbohydrate  p  12..6 25..2  Energy  fat  Animal  b c  6. 2  13.2  .1  Ii6. 6  SI. .5  It..8  9. 1  11, .9  2..6  0.7  0.. 1 0. 3  15 3 32.. 1  0^5  1..0  l.lt 0.2  12. 6 17..6  16..it  1.,6 2. 3  3-7 5.5  16.. 1  5. 9  7.,5  0..6 0..5  18..2 35..8  W..8  It. 3  5..7  it.O 12.8  lit..7 10,.0  0• 7 0..7  3.,0 - 1 .3 3• 9  1 .It  2.0 0.6  1 ron  b c  Vi tami n A  b c  20..it 32. 2  17..5 15.. 1  IU.  2 5. 3  lit..It 18..2  lit. 1  8.3  1,.2 3 .8  13 .7 6 .5  0. 5 It..8  0.0 0.0  Thiami n  b c  12..5  9..6  12..7 28..it  <!7..2 20. 1  5..8 8..0  5.7 13-6  16,.it 11. .it  0 .8 0..7  0..it It..7  1 .It 0.6  b c  32. 8 32.• 9  30. 3 kl. 3  18. 6  2. 9 3..8  2.7 it. 7  9,,0 it..8  1..1 0..5  0.• S It. 5  2.0 0.2  N i ac i n  b c  2. 5 3. 3  30. 1 53..7  18. 0 8..It  7.. 1  2.8  30..2 lit..0  0..9 0. 9  . 0..0 0. 7  8.3 2.9  Vi tami n C  b c  •21) .6 9 .2  0 .0 0..0  0 .0 0 .0  28.5 <t9-9  0 .0 2 .2  0 3 0 .6  It .8 10 .0  0. 7  b c  0. 3 7..2  8..7 19 .5  23..5  2.3 3.8  32 .It 17 .7  12 .5 21 .0  0 .0 1 .6  0.0 0.0  Ri b o f l a v i n  a-Tocopherol equ ivaIents  a b c'  5.• 9 8. 5  Values are percentage food group c o n t r i b u t e s Boia-fria diet, We I I - to-do d i e t .  22..0  6. 3  Itl., I  to n u t r i e n t  8. 9 33 .5 27 .2  2• 7 .5..6 intake,  7.2  1.2  66  do d i e t , 2 2 . 0 %  of  iron  came  from  legumes  and 3 5 . 8 %  from animal  protein  sources. Vitamin A in b o i a - f r i a d i e t s products  ( 2 0 . 4 % ) , and a n i m a l  was  products  protein  T h i a m i n was  and c e r e a l s (28.4%),  (16.4%)  legumes  Both animal  ( 2 0 . 1 % ) , and f r u i t  sources.  and a n i m a l  obtained  from vegetables  in b o i a - f r i a d i e t s ,  oils  (32.4%)  IV-6  and  from f r u i t  but  show r a n d o m l y  from  generally  q u i t e monotonous.  c o f f e e or m i l k , w h i l e  beans s u p p l e m e n t e d foods  were e a t e n  c r e a m , and s o f t greater  between m e a l s , drinks.  variety.  contrast,  For b r e a k f a s t ,  and c o f f e e .  Lunch  quently  but  beef  In  usually  sometimes  those  they  consisted  usually  chicken or  reported  diets  subjects  products  (41.4%)  (23-5%),  fats  diets.  of  vegetables.  bread rice Not  included bread,  had w h i t e b r e a d w i t h  green  plus  meat,  vegetables,  daily  was  of white  consisted  and  and  representative  r i c e and b e a n s  seafood,  (24.6%)  (27-2%)  of w e l l - t o - d o children  usually of  cereals  V i t a m i n C was  legumes  consisted  w i t h meat, eggs, or but  from  from  The b o i a - f r i a d i e t  usually  l u n c h and s u p p e r  occasionally  niacin  and  in w e l l - t o - d o  s e l e c t e d but  b o i a - f r i a and w e l l - t o - d o s u b j e c t s .  with  products  (53-7%).  legumes  (19-5%)  menus f o r  Breakfast  diets.  well-to-do  came f r o m  (47.2%)  sources  ( 4 9 - 9 % ) and v e g e t a b l e s  tocopherols  diets, animal  legumes  protein  ( 2 8 . 5 % ) , and d a i r y  p r o t e i n sources  IV-7  ( 1 8 . 2 % ) , and  in w e l l - t o - d o  obtained  dairy  In w e l l - t o - d o  by a n i m a l s  p r o t e i n sources fruit  (24.2%),  p r i m a r i l y by  (30.1%); whereas,  in b o i a - f r i a d i e t s ,  ( 2 1 . 0 % ) , and a n i m a l Tables  (33-5%),  Finally,  but  subjects  from animal  but mainly  in w e l l - t o - d o d i e t s . cereals  supplied  (13-6%)  p r o t e i n sources  n i a c i n mainly  (17-5%).  r i b o f l a v i n from d a i r y  Boia-fria  obtained  legumes  (32.2%), vegetables  in b o i a - f r i a d i e t s ,  g r o u p s o b t a i n e d most  protein  (30.2%)  (15.1%).  from  p r o t e i n sources  v i t a m i n A came f r o m d a i r y sources  derived  and many  ice showed milk fre-  and  fruit  TABLE  IV-6  S a m p l e d a i l y menus t a k e n f r o m d i e t recalls c o l l e c t e d from boi a - f r i a s u b j e c t s . 3  Breakfast  1 s l i c e white bread w i t h marga r i n e , 1 cup h o t m i l k w i t h sugar.  2 s l i c e s white bread with with margarine, 1 c u p c o f f e w i t h m i l k and sugar.  Lunch  1 c u p wh i t e r i c e , 3/4 c u p k i d n e y b e a n s , 2 f r i e d c h i c k e n wings.  3/4 3/4  Afternoon  a  2 s l i c e s white m a r g a r i ne.  snack  Supper  Quantities are  cup w h i t e r i c e , cup k i d n e y b e a n s .  1 cup w h i t e r i c e , 3/4 c u p k i d n e y b e a n s , 1 tangerine,  approximate.  bread  with  1 c u p wh i t e r i c e , 3/4 c u p k i d n e y b e a n s , .1/2 c u p f r i e d p o t a t o e s .  68  TABLE  IV-7  Sample d a i l y menus taken from d i e t from w e l l - t o - d o s u b j e c t s .  recalls  3  Breakfast  2 white r o l l s with b u t t e r , 3/4 cup c o f f e e with m i l k and sugar.  Morning  4 plain  snack  Lunch  Afternoon  snack  Supper  Evening  a  snack  3 s l i c e s white bread with butter, 1 cup c o f f e e with milk and suga r.  cookies.  1 cup wh i te r i c e , 3/4 cup kidney beans, 4 oz beef s t e a k , l e t t u c e s a l a d with tomatoes and oi1 dress i ng, 1 tangerine, 1 cup orange j u i c e with sugar.  1 cup white r i c e , 3/4 cup kidney beans, 6 oz beef s t e a k , l e t t u c e s a l a d with tomatoes and oi1 dress i ng, 1 cup f r i e d p o t a t o e s , 2 cups orange j u i c e .  1 apple, 1 tangerine.  2 s l i c e s white bread with butter.  1 cup white r i c e , 3/4 cup kidney beans, 1/2 cup f r i e d c a s s a v a , l e t t u c e s a l a d wi th tomatoes and o i l dressing.  1 ham and cheese sandwich on white bread with b u t t e r 1 cup c o f f e e with milk and sugar, 2 cups c o l a pop.  1 1/2 cups orange  1 cup hot milk with sugar.  Q u a n t i t i e s are approximate.  pop.  69  or j u i c e .  Supper was e i t h e r s i m i l a r  wiches arid c o f f e e . meals  to lunch or was a l i g h t e r meal o f  Many w e l l - t o - d o s u b j e c t s  r e p o r t e d e a t i n g foods  a day although  c)  b r e a k f a s t was seldom very  and w e l l - t o - d o f a m i l i e s  measured, boi a - f r i a do s u b j e c t s . values  reported e a t i n g t h r e e meals  large.  A n t h r o p o m e t r i c Determination  A comparison o f p h y s i c a l  growth and development of s u b j e c t s is  shown in Table  In a d d i t i o n , b o i a - f r i a s u b j e c t s  than w e l l - t o - d o s u b j e c t s  and height  for  IV-8.  s u b j e c t s had s i g n i f i c a n t l y  for several  mid-upper-arm muscle c i r c u m f e r e n c e , weight  For a l l  lower values  do s u b j e c t s  of  e t a 1., 1971) where p o s s i b l e . in comparison with standards  for height  standards standards  Weight of b o i a - f r i a and w e l l - t o is  shown in F i g u r e  Well-to-do subjects'  the American and B r a z i l i a n standards  IV-7 -  with s t a n d a r d s .  Boia-fria  Boi a 100.4%  mean weight exceeded  by 20.2% and 50.6% r e s p e c t i v e l y .  shows h e i g h t o f b o i a - f r i a and w e l l - t o - d o s u b j e c t s  s t a n d a r d , but  including  r a t i o s , and weight  mean weight was 82.7% of the Amercian s t a n d a r d , but  the B r a z i l i a n s t a n d a r d .  IV-8  lower  age.  subjects'  Figure  than w e l l - t o -  c a l c u l a t e d parameters  (Nelson e_t a_l_. , 1979, and F r i s a n c h o , 1974) and to B r a z i l i a n (Marcondes  from boi a -  parameters  had s i g n i f i c a n t l y  A n t h r o p o m e t r i c measurements were compared to American  fria  between  such as cake, c o o k i e s , f r u i t , s o f t d r i n k s , b r e a d , m i l k , or c a n d i e s .  Most s u b j e c t s , both w e l l - t o - d o and b o i a - f r i a ,  fria  sand-  in comparison  s u b j e c t s mean h e i g h t was 93-6% of the American  101.4% of the B r a z i l i a n s t a n d a r d .  Well-to-do subjects'  mean  height was 102.0% o f the American standard and 110.5% of the B r a z i l i a n standard. Figure  IV-9  shows t r i c e p s s k i n f o l d  t h i c k n e s s , arm c i r c u m f e r e n c e , and  70  IV-8  TABLE Comparison o f p h y s i c a l from b o i a - f r i a  g r o w t h and d e v e l o p m e n t o f s u b j e c t s and w e l l - t o - d o f a m i l i e s .  Mean + Parameter  Age  Wei 1 - t o - d o (n == 35)  (years)  12.1  ±  1 .0  Weight  (kg)  34.0  ±  5• 3  Height  (cm)  141.7  ±  7• 7  20.0  ±  2 .6  6.3  ±  1• 7  Arm  circumference  (cm)  Triceps skinfold thickness (mm)  c i r c u m f e r e n c e (cm) 17-9 ± 2 2 Weight/height (kg/cm ) 1.7(10" ) + Arm  SD  B o i a-- f r i a (n = 59)  muscle  3  Weight/height  (kg/cm)  .24  +  2 .6  3  a  a  a  a  .000 • 03  a  a  2.  12.4  +  0.9  49.4  +  10.8  154.5  +  8.7  23-9  +  3.1  11.1  +  4.0  20.5  +  2.6  Kio" ) 3  +  .000  .32  +  .06  Height/age  (cm/years)  11.8  ±  0 .8  a  12.5  +  0.7  Weight/age  (kg/years)  2.8  ±  0 .4  a  4.0  +  0.9  a  V a l u e s f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s a r e s i g n i f i c a n t l y d i f f e r e n t (p < .001) using Student's o n e - t a i l e d t - t e s t .  71  AMERICAN STANDARD  BRAZILIAN STANDARD  3  13  FIGURE IV-7 Weight  of subjects  from b o i a - f r i a and w e l l - t o - d o f a m i l i e s with standards.  a  N e l s o n e t . aj_. , 1979 .  ( 1 0 0 . 0 % = 41.1 k g ) ,  b  M a r c o n d e s e t . aj_. , 1971 ( 1 0 0 . 0 % = 32.8  kg.).  i n comparison  72  [  | Standard Boi a - f r i a  ZD  < >  Wel1-to-do  IkO ^  120J  90% o f s t a n d a r d  Q < Q  100J  < rt/5  UJ <  o  AMERICAN STANDARD  BRAZILIAN STANDARD^  £  FIGURE IV-8 Height  o f s u b j e c t s from b o i a - f r i a and w e l l - t o - d o in comparison with standards.  et_ a j _ . , 1979  a  Nelson  b  M a r c o n d e s et^ aj_. , 1971  (100.0% = 151 .h cm) . (100.0%=  139.8cm).  families  73  |  | Standard  TRICEPS SKINFOLD THICKNESS  ARM CIRCUMFERENCE  FIGURE Skinfold  0  ARM MUSCLE CIRCUMFERENCE  IV-9  t h i c k n e s s , arm c i r c u m f e r e n c e , a n d a r m m u s c l e c i r c u m f e r e n c e o f s u b j e c t s from b o i a - f r i a and w e l l - t o - d o f a m i l i e s in comparison with standard v a l u e s .  a  Frisancho,  197^.  b  100.0% = 1 1 . 0  c  100.0% = 21.6 cm.  d  100.0% = 18.1 cm.  mm.  74  arm muscle c i r c u m f e r e n c e in comparison with American s t a n d a r d s . subjects'  mean measured values were as f o l l o w s :  triceps skinfold  thickness;  98.9% of standard  92.6% of standard  by comparison, were as  triceps  thickness;  skinfold  113-3% o f standard  d)  f o r arm c i r c u m f e r e n c e ; and Well-to-do  follows:  110.6% of standard  subjects'  100.9% of standard  blood t e s t s  are shown in Table  IV-9.  o b t a i n e d f o r o t h e r biochemical  in comparison with normal  values  parameters measured were not  mean values  Table having  expresses  biochemical  IV-10  f o r biochemical  values  in a l l  paraAll  subjects,  in b o i a - f r i a s u b j e c t s , which was 96.8%  the a c t u a l  parameters  57-9% had h e m a t o c r i t v a l u e s  number of s u b j e c t s  below normal.  in each  Among b o i a - f r i a  p a r a t i v e l y , among w e l l - t o - d o s u b j e c t s ,  group  subjects,  below normal, 40.0% had serum iron  below normal, and 47.1% had t r a n s f e r r i n s a t u r a t i o n  respectively.  Table  standard  value.  IV-11  below normal  The  ( S a u b e r l i c h et^ aj_., 1974).  measured mean values exceeded 100.0% o f the normal with the e x c e p t i o n of hematocrit  in  protein.  d i f f e r e n t f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s .  shows b o i a - f r i a and w e l l - t o - d o s u b j e c t s '  o f the normal  There  d i f f e r e n c e s between b o i a - f r i a and w e l l - t o - d o s u b j e c t s  d e v i a t i o n was very high in values o b t a i n e d f o r serum i r o n .  meters  for  f o r arm c i r c u m f e r e n c e ; and  v a l u e s o b t a i n e d f o r h e m a t o c r i t , hemoglobin, and serum t o t a l  significantly  mean  Tests  R e s u l t s of biochemical  The values  for  f o r arm muscle c i r c u m f e r e n c e .  Biochemical  were s i g n i f i c a n t  57-3% of standard  f o r arm muscle c i r c u m f e r e n c e .  measured v a l u e s ,  Bo i a - f r i a  values  below normal.  32.3%, 30.0%, and 27.6% had  f o r h e m a t o c r i t , serum i r o n , and t r a n s f e r r i n  Comvalues  saturation,  D i f f e r e n c e s between b o i a - f r i a and w e l l - t o - d o s u b j e c t s were  75  TABLE I V - 9 Comparison o f blood b i o c h e m i s t r y i n s u b j e c t s bo i a -f r i a and w e l 1 - t o -•do f ami 1 i es ,  Mean ± S D  Parameter  {%)  39. • 3  Hemoglobin  (g/100 m l )  15. .3  ±  Serum i r o n  (yg/100 m l )  80..5  ±  313. . 1  ±  25.. 1  ±  TIBC  (yg/100 m l )  T r a n s f e r r i n s a t u r a t i o n (%) Serum t o t a l (g/100 m l )  protein  Serum a l b u m i n  (g/100 m 1)  7..57  ±  ±  4,.64 ±  i n parentheses denote  a  Wel 1 t o - d o  Boi a-• f r i a  Hematocrit  from  5.0(38)  b  42, .0  +  1.2(38)  b  2.9(30  16, .4  +  1.8(31)  56.4(35)  82, .8  +  33-7(30)  78.4(34)  314, .4  +  56.5(29)  26, .4  +  10.7(29)  13.0(34) 0.65(33)  b  0.46(34)  7,.12 +  0.53(30)  4,.42 +  0.67(30)  a  Figures  number o f s u b j e c t s .  b  Values f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s a r e s i g n i f i c a n t l y d i f f e r e n t (p < .01) u s i n g S t u d e n t ' s t w o - t a i l e d t - t e s t .  76  TABLE IV-10 Blood  b i o c h e m i s t r y i n s u b j e c t s f r o m b o i a - f r i a and w e l l - t o - d o f a m i l i e s i n c o m p a r i s o n w i t h normal v a l u e s .  Norma 1 Value a  Parameter  Hematocr i t  >  40.6%  Hemog1ob i n  >  13-9  Serum i r o n  > 60.0  Transferri n s a t u r a t i on  >  Serum t o t a l p r o t e i n  >  6.0  g/100  Serum a l b u m i n  >  3-5  g/100  a  S a u b e r l i c h e t aj_. ,  b  Figures  Mean e x p r e s s e d a s % n o r m a l v a l ue Boia-Fria W e l 1 - t o - •do  96.8 g/100 yg/100  (38)  b  103-4  (3D  110.1  (38)  118.0  (3D  134.2  (35)  138.0  (30)  125.5  (34)  132.0  (29)  ml  126.2  (33)  118.7  (30)  ml  132.6  (34)  126.3  (30)  ml ml  20%  1974.  i n p a r e n t h e s e s d e n o t e number o f s u b j e c t s .  TABLE  IV-11  Number of s u b j e c t s having b i o c h e m i c a l below normal v a l u e  parameters  Number of Boia-fri a  Parameter  subjects' Wel1-to-do  Hematocri t  22  (57-9)  Hemog1ob i n  5  (13.2)  3 ( 9-7)  Serum i ron  14  (40.0)  9  (30.0)  16  (47.1)'  8  (27.6)  Transferrin  saturation  Serum t o t a l  protein  Serum albumin  10  (32.3)  0  1 (  0  2 ( 6.7)  a  Figures  in parentheses denote % o f t o t a l  b  Values f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s are d i f f e r e n t (p < .01) using c h i - s q u a r e t e s t .  3-3)  in group. significantly  78  statistically  2.  significant  f o r h e m a t o c r i t and t r a n s f e r r i n s a t u r a t i o n .  Assessment o f P h y s i c a l Figure  IV-10  Work Performance  illustrates  the change  response to i n c r e a s i n g sub-maximal do s u b j e c t s . heart  work load  E x c l u d i n g the i n i t i a l  r a t e was s i g n i f i c a n t l y  in heart  maximum heart r a t e and the change higher  in boi a - f r ia than  Changes Table  IV—13-  greater fria  in blood Blood  l a c t i c acid  in b o i a - f r i a than  subjects  The mean v a l u e s IV-12  significantly  l e v e l s a f t e r e x e r c i s e were  showed g r e a t e r a c t u a l  the two groups were not s i g n i f i c a n t .  Association  However, although  and percentage i n c r e a s e s  i n hea r t r a t e wi th a l l  a c i d with a l l all  Table  Status and P h y s i c a l  maximum heart r a t e with a l l other v a r i a b l e s ;  Work Performance  actual  following  other  increase  variables; in  f o r which no s i g n i f i c a n t  at the 33% l e v e l  lactic  in l a c t i c a c i d with  IV-lA shows those p a i r s of v a r i a b l e s  Pearson c o r r e l a t i o n was s i g n i f i c a n t pairs  lactic  The standard d e v i a t i o n was very high  o t h e r v a r i a b l e s ; and percentage i n c r e a s e  other v a r i a b l e s .  in  boia-  these d i f f e r e n c e s between  Pearson c o r r e l a t i o n c o e f f i c i e n t s were o b t a i n e d f o r the  change  significantly  lactic acid.  Between N u t r i t i o n a l  combinations of v a r i a b l e s :  The  in response to e x e r c i s e are shown in  a c i d with e x e r c i s e than w e l l - t o - d o s u b j e c t s ,  3.  f o r both groups.  subjects.  in w e l l - t o - d o s u b j e c t s .  in values o b t a i n e d f o r blood  sub-  f o r maximum, minimum,  in heart r a t e are both  in we 11-to-do  l a c t i c acid  1 minute,  in b o i a - f r i a than in w e l l - t o - d o  r a t e are shown in Table  in  in both b o i a - f r i a and w e l l - d o -  3 minutes and the f i n a l  higher  j e c t s at every minute of t e s t i n g . and change  in heart r a t e with time and  or b e t t e r .  f o r which Variable  c o r r e l a t i o n was o b t a i n e d are not r e p o r t e d .  Maximum heart r a t e was s i g n i f i c a n t l y  c o r r e l a t e d with w e i g h t ,  height,  79  a b-d  Values are sample mean Values f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s are d i f f e r e n t using Student's o n e - t a i l e d t - t e s t : b p < .001 c p <. .01 d p < .05  significantly  80  TABLE  IV-12  Comparison of change in heart r a t e in s u b j e c t s from b o i a - f r i a and w e l l - t o - d o f a m i l i e s .  Mean ± SD Parameter  Boi a - f r i a (n = 3D  Maximum heart r a t e  (beats/min)  177.4  ±  15.9  Mi n i mum heart r a t e  (beats/min)  87.7  ±  13.0  89.6  ±  16.6  Change  a-b  in heart  rate  (beats/min )  We 1 1 - d o - d o (n = 3 0 )  a  b  161.4  ±  1 7 .. 1  84.5  ±  1 0 ..8  76.9  ±  1 4 .• 9  Values f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s are s igni f i c a n t l y d i f f e r e n t using S t u d e n t ' s o n e - t a i 1 e d t - t e s t : a b  p < p <  .001 .01  81  TABLE  IV-13  Comparison of blood l a c t i c a c i d l e v e l s b e f o r e and a f t e r e x e r c i s e from b o i a - f r i a and w e l l - t o - d o f a m i l i e s .  subjects  Mean + SD  Parameter  Boia-Fria  L a c t i c acid before e x e r c i s e (mg/100 ml)  1 1• .Ik  +  5. 19(32)  Lactic acid a f t e r (mg/100 ml)  18,.87  +  6.• 1 9 ( 3 0 )  6,.98  +  5. 54(30)  71.• 3  +  66. 7 (30)  Increase in l a c t i c (mg/100 ml) Increase  in  exercise  acid  in l a c t i c a c i d  (%)  in parentheses  denote number of  Wel1-to-do  b  10.• 35 +  4.37(30)  +  6.10(28)  +  4.51(28)  +  48.8 (28)  14..91  4.• 98 52..5  a  Figures  subjects.  b  Values f o r b o i a - f r i a and w e l l - t o - d o s u b j e c t s are s i g n i f i c a n t l y d i f f e r e n t (p < .01) using S t u d e n t ' s o n e - t a i l e d t - t e s t .  82  arm  circumference,  dietary and  v i t a m i n A,  dietary  arm  muscle circumference,  blood  riboflavin.  w i t h w e i g h t , h e i g h t , arm a  lesser extent, with  lactic  correlated.  to a  lesser extent, with  acid after exercise, dietary  Change i n h e a r t circumference,  s e r u m a l b u m i n and  o f d e t e r m i n a t i o n were r e l a t i v e l y  and,  low  r a t e was arm  to  v i t a m i n A.  .kl)  C,  significantly correlated  muscle circumference,  dietary  (.09  vitamin  and,  to  Coefficients  for a l l variables  TABLE Correlations  Associated  Maximum h e a r t  IV-14  between s e l e c t e d p a i r s o f v a r i a b l e s .  Pearson c o r r e 1 a t i on coefficient (r)  variables  rate  Coefficient of determination (r ) 2  with: .38  weight  -.6l7  b  height  -.645  b  arm c i r c u m f e r e n c e  -.563^  -32  arm m u s c l e  -.511°  -33  -.425  b  .18  +.338  C  .11  dietary  circumference  vitamin  post-exercise  A  blood  lactic  acid  .42  dietary  vitamin  C  -.309  -10  dietary  riboflavin  -.307°  .09  weight  -.564  .32  height  -.590  .35  arm c i r c u m f e r e n c e  -.523^  -27  arm m u s c l e c i r c u m f e r e n c e  -.553  -31  serum a l b u m i n  --365°  -13  -.302  .09  Change i n h e a r t  dietary  rate  vitamin  with:  A  a  B o i a - f r i a and w e l l - t o - d o s u b j e c t s  b  Statistically  significant  (p < .001).  c  Statistically  significant  (p < . 0 1 ) .  b  b  c  t r e a t e d as one group.  84  CHAPTER V DISCUSSION  1.  Socio-economic  Considerations  Visits  homes and markets y i e l d e d i n f o r m a t i o n that  to l o c a l  confirmed the f i n d i n g s  o f o t h e r r e c e n t l y p u b l i s h e d authors  1980) who r e p o r t e d g e n e r a l l y poor l i v i n g c o n d i t i o n s migrant workers. be poor in t h i s  largely  (Desai et a 1 . ,  among B r a z i l i a n  L i v i n g c o n d i t i o n s o f boi a - f r i a fami1i es were found to study as w e l l .  Housing was crowded and d i r t y , and  indoor  running water, e l e c t r i c i t y , and sewage f a c i l i t i e s were f r e q u e n t l y nonexi s t a n t . In c o n t r a s t , w e l l - t o - d o f a m i l i e s  l i v e d in homes that were  c l e a n , and f u l l y equipped with modern a m e n i t i e s . of bo i a - f r i a f a m i l i e s were estimated  in t h i s  lower than those o f w e l l - t o - d o f a m i l i e s .  study  This  i t has been documented that b o i a - f r i a f a m i 1 i e s food p r i c e s than w e l l - t o - d o f a m i l i e s Many p r e v i o u s s t u d i e s  in B r a z i l  a major f a c t o r which s e v e r e l y l i m i t s adequately  incomes o f b o i a - f r i a f a m i 1 i e s their a b i l i t y  animal  income  to be roughly  levels ten times  is d e s p i t e the f a c t f r e q u e n t l y paid  that  higher  1979)-  have reported that people's a b i l i t y  (Jansen e_t aj_. , 1 9 7 7 ; A l v e s ,  S i gu 1 em et^ aj_. , 1978; and S z a r f a r c ,  Stores  (Swann,  As w e l l ,  spacious,  low incomes are  to feed themselves  1977; G u i t t i e_t aj_., 1977;  1979).  It  is  l i k e l y that the low  in the present study were a l s o  limiting  to purchase an adequate d i e t .  in the f a v e l a areas o f f e r e d l i t t l e s e l e c t i o n of f r e s h produce,  p r o t e i n s o u r c e s , or d a i r y p r o d u c t s .  The time and expense of  t r a v e l l i n g to the c i t y c e n t e r where a g r e a t e r v a r i e t y o f good were a v a i l -  85  a b l e would probably preclude if  they were a f f o r d a b l e .  white  rice, The  general  Still,  than w e l l - t o - d o bronchial  previous  H e n c e , most p e o p l e  health of subjects  found between b o i a - f r i a  and  from p u r c h a s i n g  these  items  and w e l l - t o - d o  subjects  infections.  studies  many b o i a - f r i a  significant" differences subjects.  A great  i t was n o t t e s t e d  1978 a n d D e s a i  et_ a_l_.,  and c h i l d r e n a l s o s u f f e r e d  diet. assessed  were  anomalies  f o r in this  1980)  like  many more b o i a -  presented evidence o f cardiac  Although  (Angelel i ,  adults  i n t h e p r e s e n t s t u d y was o n l y  statistically  even  r e l i e d on cheap s t a p l e s  b e a n s , w h i t e b r e a d , c o f f e e , a n d s u g a r t o make up t h e i r  i n a l i m i t e d way.  fria  b o i a - f r i as  study,  h a v e shown  from p a r a s i t i c  that  infesta-  tion. The  existance  parasitic  of health  i n f e s t a t i o n was n o t s u r p r i s i n g g i v e n  conditions  these people  tion coupled with also probably  high  lived  To  children.  of bronchial  infestation are factors  that  impoverished  i n boia-fri a subjects  daily  lives.  well-to-do  that  boia-fria  f r i a children could  which  incidence of  as compared t o w e l l - t o -  further  study. yielded  low incomes, and t h e p r e s e n c e  c h i l d r e n had t o c o n t e n d w i t h i n synergistica11y  i n f l u e n c e d and  p r o b l e m s e x i s t i n g among t h e s e c h i l d r e n .  these f a c t o r s appeared subjects.  conditions,  These f a c t o r s p r o b a b l y  a g g r a v a t e d any n u t r i t i o n a l contrast,  living  infec-  deficiencies existing  The s i g n i f i c a n c e o f t h e h i g h e r  i s not c l e a r and p r o b a b l y w a r r a n t s  i n f e c t i o n s were f a c t o r s  their  incidence  unsanitary  summarize, b r i e f s o c i o - e c o n o m i c and e c o l o g i c a l assessment  evidence of  The h i g h  rates o f p a r a s i t i c  cardiac anomalies observed subjects  in.  i n f e c t i o n s and  t h e crowded and  g r e a t l y a g g r a v a t e any n u t r i t i o n a l  among b o i a - f r i a  do  problems such as b r o n c h i a l  t o be a b s e n t f r o m t h e l i v e s o f most  I t i s u n l i k e l y that be a m e l i o r a t e d  In  without  nutritional  problems o f b o i a -  simultaneously  ameliorating  86  these s o c i o - e c o n o m i c problems .  2.  Assessment o f N u t r i t i o n a l a)  Dietary  The d i e t  Analysis  recall  assessment has  Status  method which was used in t h i s  specific  limitations  study  f/or d i e t a r y  and inherent e r r o r s , namely:  subjects  may not remember food i n t a k e a c c u r a t e l y ; t h e r e is no e s t i m a t i o n o f intake;  i n t a k e may be o v e r e s t i m a t e d when low or underestimated when h i g h ;  and t h i s method cannot be used to a s s e s s populations  intake of  i n d i v i d u a l s , o n l y of  (Beaton et_ a_l_. , 1979; Linusson et_ a_j_. , 1974; Madden et al . ,  1976; Garn e_t aj_. , 1978; and S t a p l e t o n and Abernathy, limitations  in mind, the d i e t a r y f i n d i n g s  The mean d a i l y for a l l  i n t a k e of b o i a - f r i a s  was  less  study s h a l l  recommended intakes consumed l e s s  f o r the f o l l o w i n g  nutrients:  (Passmore et^ aj_. , 1974),  These  energy, p r o t e i n ,  i t was found that boi a - f r i as  than 2/3 o f the recommended intake f o r energy, c a l c i u m , On the o t h e r hand, w e l l - t o - d o  it  is  not p o s s i b l e  to a s s e r t  t h a t there is  nutrients considered.  truly exist,  some p r o b a b i l i t y of d e f i c i e n t  i f many s u b j e c t s consume s u b s t a n t i a l l y 1975)-  subjects  from simple comparison with the recommended  intake to d i s c e r n whether d e f i n c i e n t intakes  (Beaton,  subjects  intakes o f both groups were compared to WHO/FAO  r i b o f l a v i n , and n i i a c i n .  While  possible  these  be d i s c u s s e d .  than w e l l - t o - d o  consumed over 2/3 o f the recommended intake f o r a l l  daily  Keeping  i r o n , v i t a m i n A, t h i a m i n , r i b o f l a v i n , and v i t a m i n C.  When mean d a i l y  thiamin,  of t h i s  1930) .  n u t r i e n t s examined with the e x c e p t i o n of a - t o c o p h e r o l .  d i f f e r e n c e s were s i g n i f i c a n t calcium,  usual  less  For the purpose of t h i s  is  intakes  than the recommended intake  study,  recommended intake was chosen to be a rough  it  the f i g u r e 2/3 of  indicator of  the  low i n t a k e .  87  Further  i n s p e c t i o n o f the data showed t h a t f o r the f o l l o w i n g  nutrients,  60-80% o f bo i a - f r i a s u b j e c t s had intakes below 2/3 of the recommended intake:  energy, c a l c i u m , t h i a m i n , r i b o f l a v i n , n i a c i n , and v i t a m i n C.  C o m p a r a t i v e l y , the o n l y n u t r i e n t f o r which over 60% o f w e l l - t o - d o  subjects  consumed below 2/3 o f the recommended i n t a k e was n i a c i n . From the d i e t a r y data o b t a i n e d the p r o b a b i 1 i t y ' i s  g r e a t e r that b o i a - f r i a s  than that w e l l - t o - d o s u b j e c t s d i d . s u b j e c t s were at include these: C.  in t h i s  r i s k of having  study  i t appears  consumed low n u t r i e n t  It a l s o appears  that  if  boia-fria  are not j u s t i f i a b l e  intakes and o v e r a l l q u a n t i t i e s o f food consumed have  and Shrimpton,  fria  1975), e s p e c i a l l y those from the lowest  (Patrick intake,  subjects  and Simoes,  r e p o r t e d in t h i s  t e n t with p r e v i o u s s t u d i e s found bo i a - f r i a d i e t s  study suggests that o v e r a l l As w e l l , most energy  intakes.  quantities in the b o i a - f r i a  (Angelel i ,  is  consis-  1978 and Desai et^ a_l_. , 1980)  which  to be q u i t e monotonous. l i t t l e r i s k o f consuming  low  In the w e l l - t o - d o d i e t , most energy came from animal  p r o t e i n sources such as of energy  The low mean  beans, and b r e a d , a f i n d i n g which  W e l l - t o - d o s u b j e c t s appeared to be at energy  socio-economic  intake per u n i t of body weight, o f boi a -  o f food consumed may have been low. d i e t was d e r i v e d from r i c e ,  fre-  (ICNND, 1965  1971 and Jansen et_ aj_., 1977).  i n c l u d i n g energy  given  method.  q u e n t l y been r e p o r t e d to be low among B r a z i l i a n p o p u l a t i o n s  energy  intakes,  energy, c a l c i u m , t h i a m i n , r i b o f l a v i n , n i a c i n , and v i t a m i n  the l i m i t e d nature o f the d i e t a r y r e c a l l  classes  that  low intakes of any n u t r i e n t s , they would  Any c o n c l u s i o n s more d e f i n i t i v e than t h i s  Energy  then,  b e e f , c h i c k e n , o r eggs.  Significant  in the d i e t were a l s o c o n t r i b u t e d by r i c e ,  sweets, and d a i r y p r o d u c t s .  percentages  bread, sugar and  T h i s would seem to i n d i c a t e that there was  88  much g r e a t e r Mean appeared  variety i n the well-to-do  intakes o f protein t o be a d e q u a t e .  various 1975;  regions  of Brazil  results.  in various  F o u n d a t i o n as c i t e d e t a l . , 1980) A study found  that  regions  found p r o t e i n  of the country  Calcium Brazilian  this  holds  intakes  Brazilian  populations.  1980).  (Chaves,  Food  t o be g e n e r a l l y area  1978;  i t i s doubtful  that  (Vargas  and Desai  adequate.  by S a n t o s  1  r i c e and bean d i e t can in sufficient  i n t a k e s t u d i e s have  These s t u d i e s have r e p o r t e d  income f a m i l i e s f r e q u e n t l y but  et_ aj_. , 1977;  f o r c h i l d r e n i n the present  Arigeleli,  again  i n c l u d i n g Sao P a u l o  supply  quantities.  It  study. studied in consump-  including school-age  R o s e n b e r g , 1977;  and Desai  eta l . ,  t h a t school-age c h i l d r e n from low-  consumed a s much as one g l a s s o f m i l k  t h i s q u a n t i t y was s u f f i c i e n t  requirements o f a growing c h i l d  (1979)  group  indicated that  i s low among many B r a z i l i a n s ,  1964;  Campi no e t a l . ,  studies,  i s a n u t r i e n t w h i c h has n o t been f r e q u e n t l y  tion of dairy products children  true  conducted i n  (ICNND, 1965;  Martins  a d e q u a t e p r o t e i n f o r c h i l d r e n i f consumed appears that  intakes of B r a z i l i a n  studies  But r e s u l t s o f o t h e r  in the Ribeirao Preto  the t r a d i t i o n a l  subjects  found evidence o f d e f i c i e n t intakes  by S h r i m p t o n , 1975;  conducted  Several  i n c l u d i n g Sao P a u l o  among b o t h c h i l d r e n a n d a d u l t s .  diet.  and w e l l - t o - d o  s t u d i e s on p r o t e i n  a n d P a t r i c k a n d S i m o e s , 1971)  conducted  the b o i a - f r i a  i n both b o i a - f r i a  Previous  p e o p l e have y i e l d e d d i f f e r i n g  than  unless  other  a day,  t o meet t h e c a l c i u m  calcium  s o u r c e s were  also  i n s p e c t i o n o f bo i a - f r i a s '  diet recalls  showed  consumed. In t h e . p r e s e n t  study,  c o n s u m p t i o n o f d a i r y p r o d u c t s was v e r y few  ounces o f m i l k  taken  the  findings o f previous  limited, often  no more t h a n a  i n c o f f e e once o r t w i c e  a day.  Brazilian  above,  studies  cited  In k e e p i n g  with  i t i s probable  89  that calcium intakes being  deficient.  products  o f bo i a - f r i a s u b j e c t s  In c o n t r a s t ,  in B r a z i l i a n d i e t s  the main e x c e p t i o n t o t h i s reported for adult (Desai study  appeared  has  being  the very  to the  in previous intakes  1980).  However,  studies  for nutrients  (Martins  interviews  quantitative probably  sources  study  o f Sao  of  Preto  in the  like  to  Roncada,  1972;  Sao  v i t a m i n A where d a i l y (1980) p o i n t e d o u t ,  trend  and D e s a i  intakes  results  l i k e vitamin A unless  low  et al . ,  of  diet-recall  vary  greatly.  of such  studies  numerous  H e n c e , an  reported  diet  accurate  in t h i s  study  possible.  have  Paulo subjects  Desai  readily  reported very  interpret results  are conducted w i t h each s u b j e c t .  and n i a c i n  studies  present  boia-fria  to f o l l o w the  Paulo f a m i l i e s which  for nutrients  t h a n has a s s e s s m e n t o f several  study in the  The d i e t a r y a s s e s s m e n t o f B r a z i l i a n p e o p l e w i t h r e s p e c t riboflavin,  were  and may n o t h a v e been  i n t e r p r e t a t i o n of vitamin A intakes not  inadequate,  that  subjects  iron  d i d not appear  et_ a j _ . , 1977;  S t a p l e t o n and A b e r n a t h y  recall  iron for a l l  However,'75%  i t c a n be d i f f i c u l t  are seldom a c c u r a t e  is  in t h i s  studies  dietary  As  intakes  intake.  body.  Vitamin A intakes noted  low i r o n  of  dairy  t o t h e recommended  in a recent R i b e i r a o  Mean i n t a k e s o f  t o be a d e q u a t e .  close  risk  consumed  n o t o f t e n been r e p o r t e d t o be  d i e t came f r o m p l a n t o r non-heme available  intakes  b o i a - f r i a women  et_ aj_. , 1980).  s t u d y were a t  most w e l l - t o - d o s u b j e c t s  f r e q u e n t l y and had d a i l y  Iron  in t h i s  intakes  has  received  p r o t e i n , energy,  reported  (Martins  less  attention  to  in the  or vitamin A intakes,  low v i t a m i n B i n t a k e s  e t a l . , 1977; W i l s o n  among  thiamin, past  although  low-income  e t a l . , 1977;  and  et^ a_l_., 1980) . This  study  appears  to confirm these previous  findings  for  several  90  reasons.  F i r s t , 70-80% of b o i a - f r i a s u b j e c t s  the recommended d a i l y  Second, a l l  r i c e and bread  that t h e r e were low intakes of  bo i a - f r i a s u b j e c t s  in s u b s t a n t i a l  amounts  are not e n r i c h e d in B r a z i l a f t e r stantial of  amounts of B v i t a m i n s  r i c e and wheat f l o u r .  F l o u r and c e r e a l s  (Desai et_ aj_., 1980), and sub-  may be l o s t  d u r i n g the commercial  F i n a l l y , B vitamins  r i s k o f having  may a l s o be l o s t  C o n s i d e r i n g these f a c t s ,  low B v i t a m i n  intakes o f thiamin and r i b o f l a v i n , although  eggs, and d a i r y p r o d u c t s .  milling  through boia-frias  intakes.  W e l l - t o - d o s u b j e c t s presented a b e t t e r p i c t u r e :  Major sources of these t h r e e B v i t a m i n s  these  r e p o r t e d e a t i n g white r e f i n e d  in t h e i r d i e t s .  refining  prolonged cooking o f beans and r i c e . were probably at  than 2/3 of  intake f o r t h i a m i n , n i a c i n , and r i b o f l a v i n , s u g g e s t -  ing t h a t the p r o b a b i l i t y e x i s t s nutrients.  consumed l e s s  niacin  most had high  intakes were lower.  in the w e l l - t o - d o d i e t were meat,  Thus, w e l l - t o - d o s u b j e c t s were much l e s s  a f f e c t e d than boi a - f r i as by B v i t a m i n l o s s e s which o c c u r r e d through commercial  r e f i n i n g of  Dietary  r i c e and wheat  flour.  intakes o f v i t a m i n C have not been w i d e l y s t u d i e d among  B r a z i l i a n p e o p l e , although mean intakes as  low as 50% o f recommended  i n t a k e have been r e p o r t e d among poorer s o c i o - e c o n o m i c groups and Simoes,  1971; Martins et^ aj_. , 1977; and Desai et^ aj_. , 1980).  b o i a - f r i a mean intake of v i t a m i n C was n e a r l y i n t a k e , but t h i s consumed very intakes of  (Patrick  f i g u r e obscures the f a c t  150% o f the recommended  t h a t w h i l e a few  individuals  large amounts o f v i t a m i n C, over 60% of s u b j e c t s  less  that b o i a - f r i a s  than 2/3 of the recommended i n t a k e .  consumed  Considering,  consumed very l i m i t e d amounts of f r e s h f r u i t and  which are s u p e r i o r d i e t a r y sources o f v i t a m i n C, v i t a m i n C intakes  occurred.  The  it  is  too, vegetables,  l i k e l y that  low  91  The mean v i t a m i n C intake o f w e l l - t o - d o s u b j e c t s was n e a r l y 500% o f the recommended i n t a k e ! subjects  C o n s i d e r i n g as well  consumed over 2/3 of  that  is  u n l i k e l y that t h e i r v i t a m i n In summary,  sive  and animal  the higher  and  Most meals  Consumption of d a i r y  p r o t e i n sources  vegetables,  Inadequate.  the b o i a - f r i a d i e t was very monotonous.  f r u i t , vegetables,  was  fresh f r u i t s  C intakes were  s i s t e d mainly of b r e a d , r i c e , and beans.  Comparatively,  well-to-do  the recommended i n t a k e , and that most of  these c h i l d r e n r e p o r t e d f r e q u e n t consumption of it  75% of  products,  appeared to be very  socio-economic status of w e l l - t o - d o  con-  limited.  subjects  r e f l e c t e d in the g r e a t e r v a r i e t y and the preponderance o f more expenfoods  such as meat, s e a f o o d , and c o n f e c t i o n s  from the d i e t  r e c a l l s , b o i a - f r i a subjects  as w e l l as q u a l i t y , o f f o o d . suming  If  a l s o consumed a lower  b o i a - f r i a s u b j e c t s were at  low intakes of any n u t r i e n t s ,  clude:  energy, calcium, thiamin,  quantity,  risk of  r i b o f l a v i n , n i a c i n , and v i t a m i n  Anthropometric  All  a n t h r o p o m e t r i c parameters measured lower  Judging  those n u t r i e n t s would probably  b)  be s i g n i f i c a n t l y  in t h e i r d i e t .  conin-  C.  Determinations  in b o i a - f r i a  than  in t h i s  study were found to  in w e l l - t o - d o s u b j e c t s .  Large  d i f f e r e n c e s between b o i a - f r i a and w e l l - t o - d o s u b j e c t s were a l s o observed when a n t h r o p o m e t r i c parameters were compared to American and  Brazilian  standa r d s . In comparison  to American standards  o f most b o i a - f r i a s u b j e c t s f e l l first  (Nelson et a 1.,  below 90% o f  the s t a n d a r d ,  degree m a l n u t r i t i o n a c c o r d i n g to the Gomez (1956)  However, mean weight by 20%, p o s s i b l y  of well-to-do  subjects  i n d i c a t i n g overweight,  1979). weights indicating  classification.  exceeded the American  although  standard  the comment should be  92  made here that most w e l l - t o - d o s u b j e c t s appeared large obese. 10% o f  Mean h e i g h t s  f o r age but not  o f both b o i a - f r i a and w e l l - t o - d o s u b j e c t s  the American s t a n d a r d ,  fell  within  i n d i c a t i n g normal height a c c o r d i n g to the  Gomez (1956) c l a s s i f i c a t i o n . Boia-fria  subjects'  mean weight was very s i m i l a r  s t a n d a r d ; whereas, w e l l - t o - d o s u b j e c t s ' standard by 50%! within It  Mean h e i g h t s  10% of the B r a z i l i a n  mean weight exceeded the B r a z i l i a n  o f b o i a - f r i a and w e l l - t o - d o s u b j e c t s  should be noted t h a t the B r a z i l i a n standards  (Marcondes  used in B r a z i l  et_ a_l_. , 1971).  (Shrimpton,  fell  standard.  used here were d e r i v e d from a study o f c h i l d r e n o f status  to the B r a z i l i a n  f o r height and weight  low s o c i o - e c o n o m i c  These s o - c a l l e d standards  1975), even though J e l l i f f e  c a u t i o n e d that the use of such standards  are w i d e l y  (1966) has  in d e v e l o p i n g c o u n t r i e s  is  d e c e i v i n g because they p r o v i d e a p i c t u r e o f development a c h i e v e d by dren who are probably n u t r i t i o n a l l y compromised. that  local  standards  are o n l y meaningful  Jelliffe  chil-  (1966) suggested  i f prepared from growth  patterns  o f c h i l d r e n from upper s o c i o - e c o n o m i c s t r a t a who have had the o p p o r t u n i t y to consume adequate d i e t s . Thus, the r e s u l t s s u b j e c t s are comparable c h i l d r e n of optimal  of  the present study  in terms of height and weight  low s o c i o - e c o n o m i c s t a t u s .  growth was a c h i e v e d .  But t h i s  to o t h e r  hardly  Brazilian  indicates  that  suggest t h a t b o i a - f r i a s u b j e c t s were  a c t u a l l y underweight f o r age and f o r h e i g h t . local  boia-fria  Rather, comparisons with both w e l l - t o - d o  s u b j e c t s and American standards  acceptable  i n d i c a t e that  B r a z i l i a n standards  Thus  i t would appear  f o r h e i g h t and weight  have yet to  be found. Numerous s t u d i e s have  i n d i c a t e d height and weight  that  in B r a z i l i a n  93  children.  Early studies  et_ a]_. , 1964) and  conducted in R i b e i r a o Preto  in n o r t h e a s t  Brazil  and weights of c h i l d r e n to be well Brazilian  studies  confirmed t h i s  (ICNND, 1965)  (Dutra  de O l i v e i r a  found both  below American s t a n d a r d s .  finding  f o r c h i l d r e n from  heights More recent  low-income  f a m i l i e s , and found that c h i l d r e n from upper s o c i o - e c o n o m i c c l a s s e s to surpass American standards  f o r both h e i g h t and weight  1 9 7 5 ; Sigulem e_t a_l_. , 1 9 7 6 ; G u i t t i  tended  (Campino et a 1 . ,  et_ aj_., 1 9 7 7 ; T u r i n i e_t_ aj_. , 1 9 7 8 ; and  Desai e_t aj_., 1981) . Boia-fria  subjects  in t h i s  study were g e n e r a l l y  s h o r t and very  thin  in comparison with t h e i r w e l l - t o - d o c o u n t e r p a r t s .  that  they had normal  heights  However, the  compared to American standards  that u n d e r n u t r i t i o n in these c h i l d r e n was not so severe as  suggests to  stunt  growth.  Thus, u n d e r n u t r i t i o n may have been l e s s severe here than  children  researched  in p r e v i o u s  studies.  There is support  B r a z i l i a n standards ceps s k i n f o l d  thickness,  study American standards  do not e x i s t  adequate  f o r upper-arm c i r c u m f e r e n c e ,  1974) were used.  in  development. thickness  fell  within  10% o f standard v a l u e s ,  But b o i a - f r i a s u b j e c t s '  were very  low:  well-to-do subjects'  less  mean values  thickness  this for  and  indicating  for triceps  than 60% o f the s t a n d a r d .  mean s k i n f o l d  tri-  Mean values  arm c i r c u m f e r e n c e and arm-muscle c i r c u m f e r e n c e in both b o i a - f r i a well-to-do subjects  in  study.  or upper-arm-muscle c i r c u m f e r e n c e , so (Frisancho,  for  for this  t h a t d i e t a r y assessment . i n d i c a t e d p r o t e i n intakes were probably among b o i a - f r i a c h i l d r e n in the present  fact  adequate  skinfold  Comparatively,  approximated  100% of  the  thickness  Brazilian  standard. In a p r e v i o u s children  study on t r i c e p s  skinfold  in  (Hegg, 1978) values were c i t e d f o r s u b j e c t s who were 11 years  94  old,  one y e a r y o u n g e r  Nevertheless, here  these  t h e mean age o f  previous  values  for boia-fria subjects.  intermediate or high Preto for  than  (Desai  indicate fact  Children  groups.  low b o i a - f r i a v a l u e s  that these  fall  subjects  below standards  suggests  done  the o b s e r v a t i o n  triceps low f a t  study  skinfold  thickness  reserves.  The  these  was  not  severe  subjects severe  enough  to  for  triceps skinfold  values.  This  is  the a n t h r o p o m e t r i c f i n d i n g s  their well-to-do counterparts.  in agreement  t o be b i g - b o n e d  and had  of  lesser  Undernutrition  in b o i a - f r i a s  in s t u n t e d growth or muscle w a s t i n g .  much more m e a n i n g f u l l y  standards.  These  if appropriate  low f a t s t o r e s  results  local  it  fat stores  and a g e ,  w i t h American  and  study,  in  than  low body w e i g h t s  this  be m a n i f e s t e d m a i n l y rather  thickness with  and  well-  obese.  t h a t boi a - f r i a c h i l d r e n were s h o r t e r  c)  from  Ribeirao  that undernutrition, while  t h a t w e l l - t o - d o s u b j e c t appeared  To s u m m a r i z e  standards  came  to the present  circumference of  fat stores,  exceed standard  but not g e n e r a l l y  comparison  in  found  wasting.  d i d not g r e a t l y  muscled,  for  had v e r y  W e l l - t o - d o c h i l d r e n had mean v a l u e s that  similar  obtained  probably  enough t o p r e v e n t a c c u m u l a t i o n o f muscle  twice those  (1978) study  A study  study.  thickness.  t h a t arm c i r c u m f e r e n c e and a r m - m u s c l e  d i d not  cause  in Hegg's  et a l . , 1981) y i e l d e d results  The v e r y  in the present  were a p p r o x i m a t e l y  socio-economic  tricepts skinfold  subjects  c o u l d be  appears than  seemed for  This  to  height is  in  interpreted  B r a z i l i a n anthropometric  existed.  Biochemical  Tests  The b i o c h e m i c a l  tests  two n u t r i e n t s :  conducted  i r o n and p r o t e i n .  in t h i s  While  study  the t e s t s  assessed  the status  used t o a s s e s s  iron  of  95  status body  i n c l u d e d some that are g e n e r a l l y  iron stores  (Cook and F i n c h ,  s t a t u s have l i m i t a t i o n s be d i s c u s s e d w i t h t h i s  regarded to be good i n d i c a t o r s  1979),  in s e n s i t i v i t y  the t e s t s  of  used to assess p r o t e i n  ( S a u b e r l i c h et_ aj_. , 1974) and s h a l l  in mind.  B o i a - f r i a and w e l l - t o - d o groups were found to s i g n i f i c a n t l y  differ  from each o t h e r in values o b t a i n e d f o r h e m o t o c r i t , hemoglobin, and serum total  protein.  B o i a - f r i a v a l u e s were lower than w e l l - t o - d o f o r h e m a t o c r i t  and hemoglobin, but higher normal  values  f o r serum t o t a l  protein.  When compared to  ( S a u b e r l i c h et_ a\_. , 1 9 7 4 ) , mean values  for a l l  parameters  measured in both bo i a - f r i a and w e l l - t o - d o s u b j e c t s appeared to be adequate or to m a r g i n a l l y exceed normal v a l u e s . standard d e v i a t i o n  However, t h e r e was a very high  in values o b t a i n e d f o r both serum i r o n and t r a n s f e r r i n  s a t u r a t i o n , which makes mean values  d i f f i c u l t to i n t e r p r e t .  In  fact,  4 0 - 6 0 % o f b o i a - f r i a s u b j e c t s had h e m a t o c r i t , serum i r o n , and t r a n s f e r r i n s a t u r a t i o n v a l u e s below normal, s u g g e s t i n g some, cause f o r concern about i ron  status. Previous  biochemical  studies  of  iron s t a t u s o f B r a z i l i a n people have  u s u a l l y examined hemoglobin and h e m a t o c r i t , which are both indicators of  iron-deficiency.  many as k0% o f v i l l a g e  late-stage  Two p r e v i o u s Sao Paulo s t u d i e s  populations  had low hemoglobin  levels  found as (Szarfarc,  1972 and Sigulem et_ aj_. , 1 9 7 8 ) ; w h i l e two R i b e i r a o P r e t o s t u d i e s t h a t h e m a t o c r i t and hemoglobin income c h i l d r e n and a d u l t s 1978).  (Dutra de O l i v e i r a et a 1•,  had low hemoglobin v a l u e s .  may not a g r e e , but c o n s i d e r i n g or  l e v e l s were g e n e r a l l y adequate among  boia-frias  R e s u l t s of these  that they measured l a t e - s t a g e  i r o n d e f i c i e n c y , any evidence of  low v a l u e s  low-  1964 and A n g e l e l i ,  Most r e c e n t l y , a R i b e i r a o Preto survey o f a d u l t  that 25% of s u b j e c t s  found  found studies  indicators  is cause f o r c o n c e r n .  96  In the present s t u d y , a s u b s t a n t i a l presented of  low values  number o f b o i a - f r i a  f o r both t r a n s f e r r i n s a t u r a t i o n ,  i r o n - d e f i c i e n c y , and h e m a t o c r i t , a l a t e  c h i l d r e n have been shown to s u f f e r et al . , 1980)  which can cause  requirements.  indicator.  from p a r a s i t i c  regular  blood  these f a c t s , and warrants  further  i r o n s t a t u s measured.  mean i r o n  intakes  s o u r c e s , where  i r o n which, e s p e c i a l l y  iron  This  been d i s c u s s e d ,  acceptable  subjects  (Sauberlich  for a l l  in the s u b j e c t s  ment conducted in t h i s  have been  of  this  findings  p r o t e i n and albumin studied.  showed  l e v e l s were  Serum a l b u m i n , as  i n d i c a t o r of protein status levels  e_t^ aj_. ,  are  has than  become depressed much e a r l i e r  1974).  The g e n e r a l l y is  adequate probably  study. in agreement with the d i e t a r y  study which found mean p r o t e i n  probably adequate.  Few p r e v i o u s  p r o t e i n and albumin  in B r a z i l i a n p o p u l a t i o n s .  i n c i d e n c e of sub-normal  parameters  d i e t was d e r i v e d from animal  found here i n d i c a t e that p r o t e i n s t a t u s  These biochemical  a high  may well  In  available.  serum t o t a l  p r o t e i n because albumin  levels  in the  twice the recommended i n t a k e , and which  is a more meaningful  in p r o t e i n d e f i c i e n c y  boia-frias  r e l a t e s well with d i e t a r y data that  is more h i g h l y  g e n e r a l l y adequate among a l l  iron  in the body.  presented normal v a l u e s  in the w e l l - t o - d o  In the present s t u d y ,  serum albumin  (Desai  study.  to be almost  showed that most i r o n  serum t o t a l  Many b o i a - f r i a  infestation  iron s t a t u s o f boi a - f r i a s u b j e c t s  Most w e l l - t o - d o s u b j e c t s of  indicator  l o s s e s and i n c r e a s e d  absence o f v i t a m i n C, may not be r e a d i l y a v a i l a b l e  marginal  an e a r l y  In a d d i t i o n , d i e t a r y assessment showed that most  consumed mainly p l a n t source o r non-heme  view o f  subjects  studies  values  assess-  intakes were a l s o  have measured both serum t o t a l The ICNND  f o r serum t o t a l  (1965) reported  p r o t e i n in n o r t h -  97  east  Brazil  but thi.s  recently, Angeleli albumin  is  not a good  (1978)  indicator of protein d e f i c i e n c y .  found normal mean values  in a d u l t migrant workers  More  f o r serum p r o t e i n and  in R i b e i r a o P r e t o , but: no s t u d i e s were  done o f c h i 1 d r e n . In summary t h e n , b i o c h e m i c a l assessment status  may be marginal  in the present s t u d y .  y i e l d e d evidence that  iron  among b o i a - f r i a but not among w e l l - t o - d o c h i l d r e n Protein status  was found to be adequate  in both  groups of ch i 1 d r e n .  3.  Assessment  of Physical  Work Performance  In t h i s s t u d y , p h y s i c a l work performance was assessed change  in heart r a t e and change  in blood l a c t i c a c i d  s t a n d a r d i z e d b i c y c l e - e r g o m e t e r work Many f a c t o r s cluding:  t i o n to e x e r c i s e . in t h i s  study:  all  were males; and a l l  in response to a  test.  can confound r e s u l t s o f work t e s t s  age, sex,  by measuring  such as  these,  in-  c l i m a t e , food intake p r i o r to t e s t i n g , and h a b i t u a These f a c t o r s were c o n t r o l l e d in the f o l l o w i n g way s u b j e c t s were a p p r o x i m a t e l y the same age; a l l s u b j e c t s performed work t e s t s  subjects  at the same room  temperature and a l t i t u d e . Food intake p r i o r to e x e r c i s e was  l e s s w e l 1 - c o n t r o l 1ed because s u b -  j e c t s consumed c o f f e e , m i l k , s u g a r , and sometimes  bread or j u i c e in t h e i r  homes b e f o r e being t e s t e d .  It was not p o s s i b l e  to s t a n d a r d i z e t h i s  e x e r c i s e food consumption.  H a b i t u a t i o n to e x e r c i s e was c o n t r o l l e d f o r  in so f a r as s u b j e c t s were q u e s t i o n e d about t h e i r usual physical similar  activity.  levels  of  B o i a - f r i a and w e l l - t o - d o s u b j e c t s appeared to be  in terms of usual  levels of physical  a c t i v i t y , but  it  is  ledged t h a t the e v i d e n c e used to determine t h i s was e s s e n t i a l l y tive  in n a t u r e .  pre-  acknowqualita-  98  Mean heart  r a t e at every minute of e x e r c i s e t e s t i n g  p e r i o d s was s i g n i f i c a n t l y  greater  in b o i a - f r i a  Maximum heart r a t e and maximum change c a n t l y higher  in heart  for b o i a - f r i a subjects.  than  excluding  in w e l l - t o - d o  r a t e were a l s o  These h i g h e r heart  in w e l l - t o - d o This  finding  signifi-  subjects  is  in keeping with rates  the r e s u l t s  to be higher  of s e v e r a l  previous  in undernourished than  w e l 1 - n o u r i s h e d s u b j e c t s when both performed the same work task et_ a_l_. , 1981 ; Satyanarayana  adults  and c h i l d r e n .  in  (Desai  et_ a]_. , 1979; Davies et_ a_l_. , 1973; Gardner  1975; and Gardner e t a l . , Angeleli  1977).  and found s i g n i f i c a n t  These stud ies were o f  both  (1978) a l s o examined e x e r c i s e heart  b e f o r e and a f t e r d i e t a r y supplementation adults,  taken  subjects.  s t u d i e s which found heart  et a l . ,  subjects.  r a t e s are  to be evidence that work performance was poorer in b o i a - f r i a than  rest  reduction  in undernourished in e x e r c i s e heart  rates  Brazilian rates  after  supplementat i o n . Two p r e v i o u s above.  in a c c o r d with the r e s u l t s  (19^9) found evidence that  performed b e t t e r at work t e s t s  although  c i t y was dietary  are not  Areskog and co-workers  subjects parts,  studies  this  described  malnourished  than t h e i r w e l 1 - n o u r i s h e d  d i f f e r e n c e was o n l y pronounced when p h y s i c a l  r e l a t e d to body weight. requirements are set  a l s o found malnourished  These authors  too h i g h .  subjects  concluded that  Ferro-Luzzi  capa-  perhaps  and co-workers  performed b e t t e r at work t e s t s  counter-  (1979)  than  we 11-nourished c o n t r o l s , and suggested that t h e r e may have been a d a p t a t i o n to inadequate d i e t s  such that work performance was not  The present study would seem to add weight work performance can  impaired.  to the evidence  that  indeed be impaired in undernourished s u b j e c t s  compared to w e l 1 - n o u r i s h e d c o n t r o l s .  as  A d a p t a t i o n d i d not appear to be  a factor  in this  Mean b l o o d higher in  study. lactic  i n boi a - f r i a  blood  lactic  acid  acid  levels  a f t e r e x e r c i s e were  than w e l l - t o - d o s u b j e c t s .  Blood  lactic  acid  G a r d n e r ' s g r o u p (1975.and  blood  lactic  acid  levels  1977)  i n response  in  s t u d i e s were c o m p a r a b l e t o those the present  study,  performance as a s s e s s e d well-to-do subjects. lactic  acid  Blood  In  found  significantly  acid  levels  i n the present  reported study.  lactic  acid  levels  than  c o r r e l a t e d t o maximum h e a r t for this  r e l a t i o n s h i p was o n l y  t h a t t h e c o r r e l a t i o n was o f p r a c t i c a l  summary, c o n s i d e r i n g b o t h  heart  rate.  r a t e and b l o o d  lactic  significance. a c i d as  i n d i c a t o r s o f p h y s i c a l w o r k p e r f o r m a n c e , w o r k p e r f o r m a n c e was f o u n d be  impaired  in boia-fria  a s c o m p a r e d t o w e l l - t o - d o s u b j e c t s when  g r o u p s were c o n f r o n t e d w i t h  k.  t h e same work  A s s o c i a t i o n Between N u t r i t i o n a l  indicators of nutritional heart change  i n blood  lactic  acid.  both  Performance  s t a t u s and p h y s i c a l work p e r f o r -  correlation  coefficients  between v a r i o u s  s t a t u s and each o f t h e f o l l o w i n g :  r a t e ; change i n h e a r t  to  task.  S t a t u s a n d P h y s i c a l Work  The a s s o c i a t i o n b e t w e e n n u t r i t i o n a l mance was t e s t e d by d e t e r m i n i n g  work  groups o f s u b j e c t s , p o s t - e x e r c i s e blood  l e v e l s were s i g n i f i c a n t l y  so i t i s d o u b t f u l  studies  s u b j e c t s e x h i b i t e d poorer  by p o s t - e x e r c i s e b l o o d  However, t h e c o e f f i c i e n t o f d e t e r m i n a t i o n 11%,  lactic  found  then, b o i a - f r i a  For both  than  i n r e s e a r c h on u n d e r n u t r i -  t o e x e r c i s e were  in iron-deficient  In  i n bo i a - f r i a  i n two s e p a r a t e  elevated these  subjects.  f o r change  as a p a r a m e t e r o f p h y s i c a l work  p e r f o r m a n c e h a s o n l y o c c a s i o n a l l y been u s e d tion.  Maximum v a l u e s  w i t h e x e r c i s e were a l s o h i g h e r  well-to-do subjects.  significantly  rate; post-exercise blood  lactic  maximum a c i d ; and  100  , . Maximum heart weight;  height;  r a t e was s i g n i f i c a n t l y  negatively  correlated with:  upper-arm c i r c u m f e r e n c e ; arm-muscle c i r c u m f e r e n c e ; d i e t a r y  v i t a m i n A, d i e t a r y v i t a m i n C; and d i e t a r y r i b o f l a v i n . r a t e was s i g n i f i c a n t l y  negatively  correlated with:  Change  weight;  in heart  height;  upper-arm c i r c u m f e r e n c e ; arm-muscle c i r c u m f e r e n c e ; serum a l b u m i n ; and d i e t a r y v i t a m i n A.  Blood  l a c t i c acid  l e v e l s were not found to be c o r r e -  l a t e d w i t h any parameters o f n u t r i t i o n a l  status.  Although c o r r e l a t i o n s may be s t a t i s t i c a l l y little  practical  meaning  was the case f o r s e v e r a l including:  significant,  they have  i f c o e f f i c i e n t o f d e t e r m i n a t i o n is variables  small.  This  which were c o r r e l a t e d with heart  d i e t a r y v i t a m i n A; d i e t a r y v i t a m i n C; d i e t a r y  rates,  riboflavin;  and serum a l b u m i n . On the o t h e r hand, s e v e r a l more s t r o n g l y  a n t h r o p o m e t r i c v a r i a b l e s were  c o r r e l a t e d to heart  rates,  including:  weight;  considerably height;  arm  c i r c u m f e r e n c e ; and arm muscle c i r c u m f e r e n c e . The f i n d i n g  that a n t h r o p o m e t r i c v a r i a b l e s  work performance is  in accordance with s e v e r a l  were c o r r e l a t e d to previous  studies  found p r o d u c t i v i t y , maximum a e r o b i c power, and e x e r c i s e heart strongly  c o r r e l a t e d to a n t h r o p o m e t r i c v a r i a b l e s  B a r a c - N i e t o et_ aj_. , 1978; and Satyanarayana The n u t r i t i o n a l pometric v a r i a b l e s nutritional 1979)  status.  implications  are w i d e l y Indeed,  of this  has  which  rates  to be  (Heywood et_ aj_. , 1974;  et_ aj_. , 1977 and  1979).  r e l a t i o n s h i p are that  regarded to be i n d i c a t o r s o f it  physical  anthro-  long-term  r e c e n t l y been suggested  (Spurr et a l . ,  that because o f c o r r e l a t i o n s o b t a i n e d between a n t h r o p o m e t r i c  variables  and parameters o f work performance, sub-maximal  be u s e f u l  as  functional  However, the f a c t  assessments o f n u t r i t i o n a l that p h y s i c a l  work t e s t s  may  status.  work performance has been c o r r e l a t e d  101  to a n t h r o p o m e t r i c parameters of n u t r i t i o n a l causal  s t a t u s does not mean that a  r e l a t i o n s h i p has been demonstrated between u n d e r n u t r i t i o n and  physical  work performance.  previous studies studies  simply  show that a n t h r o p o m e t r i c  A f u r t h e r note e i t h e r p r o t e i n or studies  e x e r c i s e heart  is  of both t h i s  T h i s and  work performance appear to vary  that  i t does not appear from t h i s  had found  rates  and  previous  indicators of n u t r i t i o n a l  status  together.  study  i r o n s t a t u s was c o r r e l a t e d with p h y s i c a l  that  work performance.  i r o n - d e f i c i e n c y anemia to c o r r e l a t e with e l e v a t e d  (Davies e_t a_l_. , 1973; Gardner e_t aj_., 1975; and  Gardner et_ aj_. , 1977). chemical  the r e s u l t s  must be i n t e r p r e t e d c a u t i o u s l y .  and parameters o f p h y s i c a l  Previous  Consequently,  However,  in t h i s  study,  n e i t h e r d i e t a r y nor  assessment y i e l d e d evidence that severe p r o t e i n or  bio-  iron d e f i c -  i e n c i e s were wi despread . ., It  should be acknowledged  present study subjects  to p o p u l a t i o n s  that e x t r a p o l a t i o n of  in t h i s  of  the  o f B r a z i l i a n c h i l d r e n o t h e r than the a c t u a l  s t u d i e d can o n l y be made very c a u t i o u s l y .  f a c t o r s were operant  the r e s u l t s  This  is  because s e v e r a l  study which may have biased the  results.  Because s u b j e c t s were v o l u n t e e r s , people may have p a r t i c i p a t e d who wanted medical a t t e n t i o n o r who had d i f f e r e n t d i e t s C h i l d r e n who were i l l participate  in t h i s  than those who d i d  and c h i l d r e n who had dropped out of school  s t u d y , which probably added b i a s .  that sample s e l e c t i o n was not  Finally,  random probably added b i a s .  were unavoidable but n e v e r t h e l e s s ,  These  they r e q u i r e acknowledgement.  not. d i d not the  fact  factors  102  CHAPTER VI SUMMARY AND CONCLUSIONS  This  study was designed and conducted to e v a l u a t e  s t a t u s and p h y s i c a l workers  the n u t r i t i o n a l  work performance o f c h i l d r e n o f B r a z i l i a n  migrant  in comparison with c h i l d r e n from w e l l - t o - d o B r a z i l i a n  and to i n v e s t i g a t e  the r e l a t i o n s h i p  between n u t r i t i o n a l  families,  s t a t u s and p h y s i c a l  work performance in these two groups o f c h i l d r e n . Nutritional  s t a t u s was assessed by the f o l l o w i n g means:  economic and e c o l o g i c a l  observations  views were used to assess d i e t a r y i n c l u d i n g h e i g h t , weight,  were made; 24-hour d i e t  intake; anthropometric  sociorecall  inter-  measurements,  mid-uppei—arm c i r c u m f e r e n c e , and t r i c e p s  skin-  f o l d t h i c k n e s s were t a k e n ; and hemoglobin, h e m a t o c r i t , and serum t o t a l p r o t e i n , albumin, determined as Physical responses,  i r o n , and percentage of  biochemical  i n d i c a t o r s o f p r o t e i n and iron  work performance was assessed by measuring  namely heart  r a t e and blood  b i c y c l e - e r g o m e t e r work t e s t . for a l l  t r a n s f e r r i n s a t u r a t i o n were status. physiological  l a c t i c a c i d changes,  to a  The two groups of s u b j e c t s were compared  parameters of n u t r i t i o n a l  s t a t u s and p h y s i c a l  work performance.  Then, i c o r r e l a t i o n a n a l y s i s was used t o . d e t e r m i n e whether parameters physical  work performance were a s s o c i a t e d with parameters o f  status.  The b a s i c  findings  of  this  study were as  insufficient  intakes o f the f o l l o w i n g  thiamin,  r i b o f l a v i n , n i a c i n , and v i t a m i n C.  c h i l d r e n may have  nutrients:  The o v e r a l l  food consumed by these c h i l d r e n were low, j u d g i n g  nutritional  follows.  D i e t a r y assessment showed that migrant w o r k e r s ' consumed  of  energy, quantities  from c a l o r i c  calcium, of  intakes  103  and  from  inspection of diet recall  family diet apparently  consisted  appeared probable that  p r o t e i n and  r i c e , w e r e consumed  at  little  of  niacin.  protein  iron, derived  r i s k o f low i n t a k e Generally,  c h i l d r e n a l s o appeared  from a l l food  sources.  skinfold thickness.  l o w body f a t r e s e r v e s  that  subjects  as e v i d e n c e d  t h a t were  assessed.  Physical  values  Exercise  heart  e x e r c i s e was  and p o s t - e x e r c i s e  in boia-fria  than  low v a l u e s f o r  exceeded  American  i n both groups o f c h i l d r e n  that  some  boia-fria children  indicators of iron  f o u n d t o be i m p a i r e d  c h i l d r e n as compared t o w e l l - t o - d o  Physical  these  f o r age and f o r  The w e l l - t o - d o  f o r a l l biochemical  workers'  more e l e v a t e d  by  H o w e v e r , b o t h e a r l y - and  iron status.  w o r k p e r f o r m a n c e was  rates  exception  parameters measured.  deficiencies.  h a v e had m a r g i n a l  normal  t o be  deficiencies of  by e x t r e m e l y  subjects  assessment o f p r o t e i n s t a t u s  presented  consumed  i n l o w body w e i g h t s  i n d i c a t o r s o f iron d e f i c i e n c y suggested  may  pro-  appeared  the possible  nutritional  The w e l l - t o - d o  f o r a l l anthropometric  showed no e v i d e n c e o f o v e r t  subjects  ate a varied  including dairy  f o r any n u t r i e n t w i t h  were m a n i f e s t e d  triceps  late-stage  f r o m b e a n s and  apparently  groups  It  t o be a d e q u a t e .  and  Biochemical  worker  subjects.  t h e o v e r a l l q u a n t i t i e s o f food  height,  standards  mainly  The w e l l - t o - d o  A n t h r o p o m e t r i c a s s e s s m e n t showed boi a - f r i a s u b j e c t s  migrant  r i c e and k i d n e y beans.  children studied  good r e p r e s e n t a t i o n  d u c t s and a n i m a l  of white  The b a s a l  i n a d e q u a t e amounts by b o i a - f r i a  In c o n t r a s t , w e l l - t o - d o diet with  results.  children  blood  in well-to-do  lactic  i n migrant  in this acid  study.  l e v e l s were  both  subjects.  w o r k p e r f o r m a n c e a s i n d i c a t e d by c h a n g e i n h e a r t f o u n d t o be s i g n i f i c a n t l y  status  correlated with  rate  during  anthropometric  104  parameters o f n u t r i t i o n a l  status  in the s u b j e c t s  studied.  was not demonstrated f o r o t h e r parameters o f n u t r i t i o n a l  This c o r r e l a t i o n status.  Neither  was a c o r r e l a t i o n demonstrated between parameters o f n u t r i t i o n a l and p h y s i c a l work performance as  i n d i c a t e d by blood l a c t i c a c i d  status levels  during e x e r c i s e . The o v e r a l l  s i g n i f i c a n c e o f the f i n d i n g s  that u n d e r n u t r i t i o n d i d In c o n t r a s t , study.  of t h i s  study appears  indeed e x i s t among these migrant workers'  to be  children.  u n d e r n u t r i t i o n was not found .in w e l l - t o - d o c h i l d r e n in  In a d d i t i o n , f u n c t i o n a l assessment  the same work t a s k ,  boia-frias  this  showed that when c o n f r o n t e d with  performed more p o o r l y than w e l l - t o - d o  ch i I d r e n . A b r i e f summary of  the l i v i n g c o n d i t i o n s and h e a l t h s t a t u s  two groups was made as an adjunct to t h i s  study.  such as  in  workers  impoverished, crowded, and devoid of conveniences-  indoor running w a t e r , e l e c t r i c i t y , or sewage f a c i l i t i e s .  In c o n t r a s t ,  the w e l l - t o - d o c h i l d r e n l i v e d in an area where the  p i c t u r e was much more a p p e a l i n g . and gardens,  and f u l l  were the r u l e . stantially  bronchial  Spacious  homes, a t t r a c t i v e  streets  a m e n i t i e s such as e l e c t r i c i t y and indoor plumbing  Incomes o f w e l l - t o - d o f a m i l i e s were e s t i m a t e d to be sub-  h i g h e r than those o f migrant worker  Migrant w o r k e r s '  T h i s was  the  Living conditions  the f a y e l a or slum area o f R i b e i r a o P r e t o where most migrant l i v e d were g e n e r a l l y  of  children also  presented a much h i g h e r  i n f e c t i o n s and c a r d i a c anomalies in a d d i t i o n to the p a r a s i t i c  endemic among migrant workers and i n f e c t i o n e x i s t  families.  than d i d w e l l - t o - d o c h i l d r e n .  i n f e s t a t i o n that  in t h i s a r e a .  incidence of  Thus  is  known to be  i t appears  that  disease  s y n e r g i s t i c a 1 1 y with u n d e r n u t r i t i o n among bo i a - f r i as.  To extend s o c i o - e c o n o m i c a n a l y s i s  beyond the simple  observations  105  made in t h i s  study,  i t appears  that t h e r e are f a c t o r s  in the l i v e s  of  migrant worker f a m i l i e s  which deeply aggravate any n u t r i t i o n a l  problems  these people may have.  Indeed,  probably  the e x i s t e n c e of these f a c t o r s  p r e c l u d e s the s o l u t i o n o f n u t r i t i o n problems of  these f a c t o r s  tion;  jobs  is  long:  that o f f e r  impossibly  in  isolation.  The  litany  low wages that are ravaged by  l i t t l e hope of enjoyment or upward m o b i l i t y ;  quent unemployment without p r o v i s i o n s ease without a c c e s s i b l e medical  for social  fre-  s e c u r i t y ; endemic  c a r e ; i l l i t e r a c y ; and s q u a l i d  infla-  dis-  living  con-  d i t i ons. Another workers  important f a c t o r  see no way to  is  the m e n t a l i t y o f p o v e r t y .  improve the c o n d i t i o n s o f t h e i r  they have always been o b j e c t s , cogs  in the wheels of  economy.  their situation  of  Possiblities  t h e i r sense o f  they themselves  T h i s process  can  and h e a l t h care would play an important  add weight exist  of this  the r e l a t i o n s h i p  for  self-deter-  through e d u c a t i o n and sanitation,  transformational  worker f a m i 1 i e s  in B r a z i l .  It  their  thoughtful income education,  role.  study are p r o f f e r e d in the hope that  they w i l l problems  is a l s o hoped that  that was demonstrated here between u n d e r n u t r i t i o n and  impaired work performance may fuel  children.  in the awakening  to the a l r e a d y c o n s i d e r a b l e evidence that n u t r i t i o n  among migrant  nutritional  lie  Brazilian  could be a i d e d by the development o f  As w e l l , programs to improve h o u s i n g ,  The r e s u l t s  the  migrant  because  improve the c o n d i t i o n s of  programs to a l l e v i a t e n u t r i t i o n problems assistance.  lives  t h e i r own humanity and t h e i r a b i l i t i e s  m i n a t i o n such that lives.  f o r changing  These  conditions  economic j u s t i f i c a t i o n s  among B r a z i l i a n a g r i c u l t u r a l  To conclude on a sombre n o t e , enough  is  for  improving  labourers and t h e i r now known about  nutritional  problems o f people such as  The time f o r a c t i o n  is overdue.  these migrant worker  families.  107  BIBLIOGRAPHY  Alves  ELG. 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