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There are no practical options to reduce breast cancer risk in American women that are without side-effects. Almost all preventive strategies are designed to diminish the role of estrogens in promoting breast cell proliferation. Brassica vegetables (e.g., broccoli) contain indole glucosinolates that can shift estrogen metabolism away from the highly estrogenic 16α-hydroxyestrone (16HE) and toward 2-hydroxyestrone (2HE), which has little estrogenic activity on breast cells. The relative strength of these two pathways is measured in urine as the ratio 2HE/16HE (2/16). In controlled trials that have enrolled premenopausal women or young men, large quantities of Brassica vegetables or indole glucosinolate derivatives decreased urinary 16HE levels relative to 2HE levels, possibly lowering breast cancer risk. However, in order to be an acceptable and effective preventative, Brassica vegetables must shift estrogen metabolism as Brassica consumption is practiced within free-living women. The goal of this research is to determine if Brassica should be further explored as a strategy to prevent breast cancer. In order to do so, it was determined that three issues must be addressed: (1) Brassica consumption must increase the 2/16 ratio among healthy free-living women, without serious side-affects, (2) the 2/16 ratio must be a valid indicator of breast cancer risk, and (3) a reliable and valid method to estimate Brassica consumption must be identified. As part of this research, thirty-seven healthy postmenopausal women participated in a dietary intervention designed to facilitate daily Brassica consumption. The diet, 2/16, and other information were measured before, during, and after the intervention. The 2/16 ratio significantly increased with greater Brassica intake. However, urinary 2/16 levels between participants were sensitive to dietary fat and fiber intake, and future studies evaluating the 2/16-breast cancer association should control for macronutrient intake. Dithiocarbamate excretion, a biomarker of Brassica consumption, inconsistently predicted self-reported Brassica intake and is sensitive to the types of vegetables consumed. However, DTC may be useful to rank-order participants in epidemiological studies. Overall, to the extent that lower 2/16 values are associated with increased breast cancer risk, Brassica vegetables may be an important component of any strategy to reduce breast cancer risk.

Thesis (PH.D.)--Syracuse University, 2003. / "Publication number AAT 3113236."

This thesis describes the development of the idea of an 'obesity epidemic' that figures prominently in contemporary public health discourse. It uses conceptual approaches from Science and Technology Studies and the history of medicine to analyse changing ideas about obesity, particularly as formulated and mobilised by British researchers from the 1960s onwards, to show how excess body weight became understood as a significant public health problem in this period. The thesis begins by describing the post-war refocusing of medical attention in developed countries from infectious diseases, the rates of which are falling, to chronic disease such as heart disease, diabetes, cancer and stroke. Heart disease, in particular, became seen as an 'epidemic'. After World War II, increase research funding by the American government made possible the development of a new research method - the long-term prospective epidemiological study - and a new way of understanding chronic diseases as caused by risk factors such as high blood pressure, cigarette smoking and high blood cholesterol. Excess body weight was includes in this list of risk factors, and so became an object in increased medical attention. The thesis then outlines how a new public health coalition was formed around obesity in the 1970s by British biomedical researchers working on topics in the fields of nutrition, diabetes and coronary heart disease. It describes the development of what I call the 'individual paradigm' of obesity which characterises the condition as an individual problem that leads to heart disease and mechanical complaints and is treatable by weight loss diets. It then describes two key features of British obesity science in the 1980s and 1990s. The first of these is the adoption of the Body Mass Index and the standard cut-off points that are used to define overweight and obesity, which together facilitate the collection and dissemination of data on changes in average body weights, The second is the energy balance model of weight regulation, which served to unify the diverse disciplinary approaches to biomedical research incorporated into this new knowledge, but which could not account for the high rates of failure acknowledged as occurring with conventional treatments such as weight loss diets, anorectic drugs and bariatric surgery. The thesis describes how researchers in the field of obesity science than extended their institutional research to participate in the production of a series of reports for the World Health Organization, including one on the global epidemic of obesity published in 2000. This new platform, combined with data produced by prospective studies, enabled them to disseminate a new understanding of obesity and overweight - what I call the 'environmental paradigm' - which characterises it as a global health problem associated with an increased risk of many diseases and caused by structural factors such as inappropriate diet and sedentary lifestyles. Despite refocusing attention of structural determinants of ill health, however, public health experts were constrained by considerations of political practicality and commercial interest when calling for preventive measures in the areas of diet and physical activity. The thesis concludes by considering the different ways in which scholars have theorised the epidemiological transition from infectious to chronic disease. Drawing on approaches from the health inequalities literature, it argues that the conventional framings of chronic disease epidemiology have tended systematically to obscure structural links between obesity and other forms of diet-related ill health on the one hand, and relative poverty on the other.

Doctor of Philosophy / Human Nutrition / Richard R. Rosenkranz / Child stunting refers to a condition where the child is relatively shorter in height, in comparison to their age group. Child stunting is a public health nutrition problem that hinders the development of future generations, not only physiologically but also potentially deprives their cognitive function and productivity. The demographic transition, conjoined with the epidemiological and nutrition transitions, has resulted in the coexistence of an over- and under-nutrition problem known as double burden of malnutrition, and child stunting has been a persistent part of the problem. In 2014, the World Health Organization (WHO) reported that one-fourth of the children in the developing countries have been suffering from child stunting. The objective of this research was to apply the behavioral epidemiology approach to tackle child stunting in households with double burden of malnutrition. It was hypothesized that unlike any other households with problem of child stunting, households with double burden of malnutrition possess some degree of capacity that, with proper support and direction, might enable them to help themselves reduce or prevent this nutrition-related debacle. Results from a secondary data analysis revealed that child stunting was associated with lower dietary diversity as an indication of poor food choice in the household, related to children’s nutrient requirements. Another cross-sectional study in this dissertation was conducted in an urban setting in Indonesia, and found that households with child stunting alone was associated with extreme food insecurity, while households with double burden of malnutrition ─ in the form of stunted child and overweight/obese mother (SCOWT) ─ was associated with even a mild degree of food insecurity. These results support our hypothesis that households with double burden of malnutrition lack the capacity to direct their resources properly to prevent child stunting. Most notably, we expected that the role of the mothers to manage healthy food choices through indirect measure of dietary diversity, availability and distribution within the household was lacking. In order to equip mothers with necessary components to be able to overcome these problems, we conducted a behaviorally based intervention that targeted mothers in the households experiencing the problem of double burden of malnutrition. The intervention provided the potential to achieve participant self-administered goal setting to improve diet, as well as child feeding behavior, by means of improved self-efficacy, nutrition literacy and dietary diversity. Maternal self-efficacy may be potentially enhanced by vicarious experience and active mastery experience gained during 6 sessions of behavioral intervention and verbal motivation by community health workers during 6 additional home visits. These studies, collectively comprising the present dissertation, present a message for policy makers in developing countries: nutrition literacy and behaviors for choosing healthy foods are lacking in mothers that affect both maternal and child food intake, but efforts such as improving vicarious and mastery experience on child feeding practices and healthy food choices can boost mother’s self-efficacy to engage in appropriate behaviors and improve their child’s nutrition.

Unhealthy food and beverage products marketed through diverse media platforms contribute to poor diet quality, obesity, and chronic diseases in the United States (US). Limited empirical research is available on the effectiveness of integrated marketing communications (IMC) and branded media campaigns used to positively influence Americans' diet-related cognitive, behavioral and health outcomes. The purpose of this research was to assess and inform the Partnership for a Healthier America's Fruits and Veggies (FNV) Campaign to increase fruit and vegetable purchases and intake among targeted teen and mom populations. This PhD research evaluated the use, outcomes, and perspectives on branded food marketing campaigns to inform the FNV Campaign through four studies. Study 1 used a mixed-methods research approach that included a scoping review; comprehensive review of peer-reviewed articles, gray literature and media sources; and key-informant interviews (n=11) to identify 13 national branded marketing campaigns that used health-branding strategies to encourage healthy dietary purchases and consumption in the US between 1990-2016. Study 2 explored views of diverse stakeholders (n=22) regarding the FNV Campaign using semi-structured interviews that were thematically analyzed using a conceptual framework with eight constructs (i.e., campaign design, reach, adoption, effectiveness, impact, expansion, scaling up and sustainability). Study 3 assessed FNV Campaign awareness, cognitions and behaviors for buying and eating fruits and vegetables through a survey of targeted teen and millennial mom audiences (n=1,604) in Hampton Roads, Virginia and Fresno, California where the FNV Campaign pilot was launched. Study 4 encompassed a mixed-methods evaluation using data from the second and third studies that assessed and explored congruence between FNV brand awareness and recall of IMC strategies among survey respondents with stakeholders' perspectives regarding IMC strategy contexts and potential. This body of research expands knowledge about the effectiveness of diet-related IMC and media campaigns and provides a foundation for future FNV Campaign evaluations. Taken together, findings across the four studies identified significant opportunities for large-scale IMC campaigns to improve evaluation designs and outcome reporting. These results can inform evidence-based strategies and policies to improve the design of the FNV Campaign and other IMC initiatives to improve dietary patterns and population health. / Doctor of Philosophy / Marketing promotions for unhealthy foods and beverages are widespread in the United States (US) and influence Americans' diet choices that lead to weight gain, obesity, and chronic diseases. There is little understanding of how marketing and media campaigns can be used to positively influence Americans' to consume high quality diets and improve their health outcomes. The purpose of this research was to assess and inform the Partnership for a Healthier America's Fruits and Veggies (FNV) Campaign to increase fruit and vegetable purchases and intake among target populations. This PhD research evaluated the use, outcomes, and perspectives on branded food marketing campaigns to inform the FNV Campaign through four studies. Study 1 used a mixed-methods research approach that included a scoping review of the academic and non-academic literature, and key-informant interviews to identify 13 national branded marketing campaigns that used branding strategies to encourage healthy diets in the US between 1990-2016. Study 2 used interviews to explore the views of 22 stakeholders experienced with the FNV Campaign or fruit and vegetable promotion. Interviews were thematically analyzed using a framework with eight constructs (i.e., campaign design, reach, adoption, effectiveness, impact, expansion, scaling up and sustainability) to understand diverse stakeholder perspectives. Study 3 assessed FNV Campaign awareness, cognitions and behaviors for buying and eating fruits and vegetables through a survey of targeted teen and millennial mom audiences (n = 1,604) in Hampton Roads, Virginia and Fresno, California where the was initially launched. Study 4 used data from the second and third studies that assessed similarities and differences between FNV brand awareness and recall of marketing strategies among survey respondents with stakeholders' perspectives regarding marketing strategy contexts and potential. This body of research expands knowledge about the effectiveness of diet-related marketing and media campaigns and provides a foundation for future FNV Campaign evaluations. Taken together, findings across the four studies identified opportunities for large-scale marketing campaigns to improve evaluation designs and outcome reporting. These results can inform future strategies and policies to improve the design of the FNV and other IMC campaigns to improve population diets and health.

<p>Dietary supplement (DS) use is highly prevalent in the U.S. and can contribute substantial amounts of micronutrients to the one-half of U.S. adults and nearly one-third of U.S. children who use them. Despite their pervasive use, the best practices for assessing the prevalence of use of and measuring nutrient intakes from supplemental sources remain largely unknown, and currently no metric designed to assess total micronutrient exposures from foods, beverages, and DS exists. Comprehensive and robust methods for assessing the prevalence of use of and nutrient intakes from DS are critical for population-level research and surveillance. </p> <p>Therefore, the overarching aims of the research presented in this dissertation were to 1) identify the most comprehensive method for assessing the prevalence of use of and estimating nutrient intakes from DS, 2) characterize DS use and examine trends in overall and micronutrient-containing DS use among the U.S. population using multiple modes of DS assessment, 3) develop the first micronutrient-based diet quality index designed to capture usual intakes from all sources of under-consumed micronutrients among the U.S. population (i.e., the Total Nutrient Index (TNI)) and 4) to determine if the TNI is a useful measure for assessing total micronutrient exposures among the U.S. adult population.</p> <p>National Health and Nutrition Examination Survey (NHANES) 2011-2014 data among U.S. adults were employed to evaluate four combinations of methods constructed from two data collection instruments (i.e., the 24-hour dietary recall (24HR) and the NHANES in-home inventory with a frequency-based DS prescription medicine questionnaire (DSMQ)) for measuring the prevalence of use of and amounts of selected nutrients from DS. The results from the analysis indicated that a higher prevalence of DS use is reported when using frequency-based methods, like the DSMQ, but higher nutrient amounts are reported on the 24HR. Thus, combining the DSMQ with at least one 24HR (i.e., DSMQ or ≥1 24HR) provides the most comprehensive approach for measuring DS use and estimating nutrient intakes from supplemental sources among U.S. adults.</p> <p>Differences in the estimated prevalence of use of DS on the DSMQ or ≥1 24HR as compared with the DSMQ only were also noted among a nationally representative sample of the U.S. population from the 2007-2018 NHANES. When characterizing DS use and examining trends in overall and micronutrient-containing DS use among the U.S. population using multiple modes of DS assessment, increases in both overall and micronutrient-containing DS use were observed over time, but the prevalence of use was lower on the DSMQ than the DSMQ or ≥1 24HR among the total population and across all population subgroups. Therefore, the findings from this study were congruent with our previous analysis and contributed to a growing body of literature that utilizes multiple methods of DS assessment to improve the comprehensiveness of DS exposure assessment. </p> <p>The insights garnered from identifying the most comprehensive method for approximating micronutrient intakes from supplemental sources were implemented in the development and initial application of the first micronutrient-based diet quality index designed to capture usual intakes from all sources of under-consumed micronutrients among the U.S. population, named the TNI. The TNI assesses U.S. adults’ total nutrient intakes relative to the Recommended Dietary Allowance or Adequate Intake for eight under-consumed micronutrients identified by the Dietary Guidelines for Americans: calcium, magnesium, potassium, choline, and vitamins A, C, D, E. In the initial application of the TNI, based on dietary data from the 2011-2014 NHANES, the mean TNI score of U.S. adults was 75.4 out of 100, whereas the mean score when ignoring contributions from DS was only 69.0 (t-test; p<0.001). Therefore, the results from this analysis suggested that the TNI extends existing measures of diet quality by including nutrient intakes from all sources.</p> <p>However, another analysis designed to examine the construct and criterion validity of the TNI was completed using data from a nationally representative sample of U.S. adults who participated in the 2011-2014 NHANES, as well as exemplary menus reflective of high-quality diets. The results showed that the TNI yielded high scores on exemplary menus (84.8-93.3 out of 100), was moderately correlated with the Healthy Eating Index-2015 (r=0.48) and was able to differentiate between groups with known differences in nutrient intake for DS users vs. non-DS users, non-smokers vs. smokers, and those who were food-secure vs. food insecure (all <em>p</em><0.001). Moreover, correlations of TNI component scores with nutritional biomarkers for vitamins A, C, D, and E were significantly higher when compared with those obtained via the diet alone.</p> <p>Taken together, the research findings from the studies presented in this dissertation contribute evidence supporting the use of multiple modes of DS assessment to improve the comprehensiveness of DS exposure assessment, as well as the importance of capturing micronutrient exposures from all sources. These results also highlight the broad applicability of the TNI framework as a tool for comprehensively representing the totality of nutrient exposures, inclusive of DS. Our outcomes point towards a need for additional investigation into the random and systematic error that pervades DS assessment, the development of tools that can be used to describe micronutrient exposures more completely and how those relate to nutritional status, as well as further applications of the TNI. </p>

<p dir="ltr">Undernutrition affects millions of children in low- and middle- income countries, causing poor growth, poor development, and increased risk of mortality. Many nutrition-sensitive interventions for rural areas increase household access to nutritious foods through increasing home production, a strategy that has small positive effects on child diets. However, there is growing evidence that local markets are also important for dietary quality. Despite the importance of rural markets, the rural food environment and food purchasing practices among rural households are not well-characterized in the literature. It is possible that promoting improved household food purchase practices is an effective method for improving child nutrition in rural areas. Tanzania experiences a high prevalence of undernutrition among children under the age of 5 years, particularly among rural populations. This dissertation utilizes data from the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS), a cluster randomized controlled trial that was conducted in rural Mara, Tanzania. The EFFECTS trial promoted improved diets through both home production and through food purchases through a social and behavior change strategy. We measured changes in dietary diversity (a proxy for diet quality), children’s nutrient intake adequacy, and diversity of foods purchased and produced. This dissertation presents evidence that food purchase diversity is positively associated with dimensions of the rural food environment, including high market food diversity (+0.37 food groups, p=0.01), living within 30 minutes of a market (+0.36 food groups, p=0.001) and household purchasing power (+0.14 food groups per additional million Tanzanian shillings spent by the household, p<0.001). In turn, purchase diversity is positively associated with dietary diversity (b=0.22, p<0.001), and intake adequacy of folate, vitamin B12, and calcium (all p<0.05) among children 9-23 months. Promoting food purchase diversity was effectively integrated into the EFFECTS interventions, resulting in purchasing +0.54 food groups at endline compared to changes in the control (p<0.01), which mediated 25% of the total improvement in child dietary diversity. In contrast, production diversity was associated with increased intake adequacy of vitamin A only (p<0.05), households produced +0.44 food groups at endline compared to control (p<0.05), and this mediated 15% of the total improvement in child dietary diversity. These findings suggest that promoting diverse food purchases, alongside diverse home production, is an effective way to improve children’s diets in similar settings.</p>

Introdução: Dentre as carências nutricionais de maior relevância destacam-se, neste estudo, anemia e deficiência de vitamina A, que constituem as principais preocupações das políticas públicas, na área de alimentação e nutrição. Apesar de medidas de prevenção e controle já terem sido implantadas no Brasil há algum tempo, suas prevalências continuam elevadas, com profundas repercussões na saúde infantil. Assim, embora reconhecidos como problemas de saúde pública e bastante explorados, politicamente, ainda há espectros de interesse epidemiológico a serem investigados. Objetivo: Analisar os determinantes da anemia e da deficiência de vitamina A (DVA), bem como a presença concomitante dessas duas carências nutricionais em crianças brasileiras. Métodos: Reanálise dos dados da Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS) de 2006, abrangente inquérito das condições de saúde de mulheres e crianças brasileiras cuja 3ª edição incorporou a avaliação dos níveis de hemoglobina e vitamina A. Essa reanálise baseou-se numa amostra probabilística complexa com representação nacional, o que permitiu descrever a situação de anemia e DVA nas macrorregiões brasileiras e suas áreas urbanas e rurais. O presente estudo incluiu a análise de 3.417 crianças de 6 a 59 meses. Anemia foi definida como hemoglobina (Hb) <11g/dL, determinada pelo método da cianometa-hemoglobina. DVA foi definida como retinol sérico <0,7mol/L, avaliado por cromatografia líquida de alta eficiência. Para expansão da amostra utilizaram-se critérios adotados pela PNDS. As variáveis respostas foram presença de anemia, de DVA e carência concomitante de DVA e anemia, enquanto as explanatórias, analisadas considerando-se três dimensões, foram vinculação aos processos estruturais da sociedade (variáveis socioeconômicas e ambientais); ao ambiente imediato da criança (variáveis maternas, de segurança e consumo alimentar); e individual (características biológicas da criança). A força de associação entre as variáveis respostas e as explanatórias foi avaliada pelo odds ratio (OR), tanto na análise univariada (OR bruta) quanto na múltipla (OR ajustada), com nível de significância de 5%. Resultados: Determinantes da anemia: A prevalência de anemia no País foi de 20,5%. Na análise múltipla, permaneceram associadas à anemia residir no Nordeste [OR: 3,45; IC: 2,21-5,40] Sudeste [OR: 2,55; IC: 1,60-4,06] e Sul [OR: 2,22; IC: 1,39-3,55]; na zona urbana [OR: 2,01; IC: 1,35-3,00]; e ter insegurança alimentar grave [OR: 1,78; IC: 1,00-3,16], destacando-se como proteção ter mãe com 5 a 8 anos de estudo [OR: 0,62; IC: 0,41-0,92] e consumir carne pelo menos uma vez na semana [OR: 0,45; IC: 0,22-0,93]. Determinantes da DVA: A prevalência de DVA no País foi de 17,5%. Após ajuste para as variáveis de confusão, permaneceram associadas ao DVA residir no Nordeste [OR: 1,77; IC: 1,16-2,77] e Sudeste [OR: 1,74; IC: 1,16-2,72]; na zona urbana [OR: 1,29; IC: 0,91-1,87]; e ter mãe com idade 36 anos [OR: 3,14; IC: 1,48-7,09], considerando-se proteção consumir carne pelo menos uma vez na semana [OR: 0,19; IC: 0,09-0,40]. Determinantes da DVA e da anemia: A prevalência concomitante de DVA e anemia foi de 3,9%, sem associação entre elas (p>0,05). As variáveis estatisticamente associadas (p<0,05) com DVA e anemia na análise múltipla foram residir no Sudeste [OR: 4,28; IC: 1,96-11,68] e Nordeste [OR: 2,92; IC: 1,31-7,96]; na zona urbana [OR: 3,66; IC: 1,46-12,30]; e ter insegurança alimentar grave [OR: 3,64; IC: 1,41-8,84]; revelando-se proteção ter idade 2 anos de idade [OR: 0,51; IC: 0,26-0,99]; e consumir carne pelo menos uma vez na semana [OR: 0,04; IC: 0,00-0,23]. Conclusões: Os resultados mostram redução importante na prevalência de anemia e DVA infantil no Brasil, embora, de acordo com o critério de importância epidemiológica da Organização Mundial da Saúde (OMS), continuem como problema moderado de saúde pública. Apesar das fortes evidências de que a DVA contribui para o desenvolvimento da anemia, constatou-se baixa prevalência concomitante dessas duas carências nutricionais entre as crianças brasileiras, e sem associação entre elas. Entretanto, anemia e DVA apresentam determinantes comuns (residir em macrorregiões menos e mais desenvolvidas e em área urbana), que reiteram o caráter trans-social dessas carências estudadas. O fato de terem como determinante a insegurança alimentar e como proteção consumir carne pelo menos uma vez por semana reforça a determinação social dessas deficiências nutricionais, embora a insegurança alimentar não tenha se associado à DVA. Os resultados evidenciaram como principais determinantes da anemia e da DVA aqueles relacionados aos processos estruturais da sociedade e do ambiente imediato da criança e não os individuais. Constatou-se, também, que as estratégias governamentais têm contribuído para a prevenção e controle dessas carências nutricionais no País, porém, sinaliza-se a necessidade de expansão da estratégia governamental no sentido de prevenção e controle da DVA, até então restrita a áreas de risco (região Nordeste e áreas pobres da região Sudeste). / Introduction: Among the most relevant nutritional deficiencies, anemia and vitamin A deficiency stand out, constituting the main concerns of public policy in food and nutrition area. Even though prevention and control measures have already been implemented in Brazil some time ago, their prevalence remains high, with profound effects on child health. Thus, in spite of recognized as problems of public health and plenty explored, politically, there are still spectra of epidemiological interest to be investigated. Objective: To analyze the determinants of anemia, vitamin A deficiency (VAD), as well as these two concomitant nutritional deficiencies in Brazilian children. Methods: Reanalysis of data from the National Survey on Demography and Health of Women and Children (PNDS) of 2006, comprehensive survey of health of women and children in Brazil, whose 3rd edition incorporated the evaluation of hemoglobin and vitamin A levels. This reanalysis was based on a complex random sampling with national representation, which allowed describing the situation of VAD and anemia in Brazilian regions and their urban and rural areas. This study included analysis of 3.417 children aged from 6 to 59 months. Anemia was defined as hemoglobin (Hb) <11g/dL, determined by cyanometahemoglobin method. VAD was set as serum retinol <0.7 mol/L, evaluated by high performance liquid chromatography. To expand the sample, the criteria adopted by PNDS were used. The variable responses were presence of anemia, VAD and concomitant deficiency of VAD and anemia, while the explanatory, analyzed considering three dimensions, were link to the structural processes of society (socioeconomic and environmental variables), to the immediate environment of the child (maternal variables, of safety and food consumption); and individual (biological characteristics of the child). The strength of association between the response and the explanatory variables was evaluated by odds ratio (OR), both in univariate (crude OR) and in multiple analysis (adjusted OR), with a significance level of 5%. Results: Determinants of anemia: The prevalence of anemia in the Country was 20.5%. In multiple analysis, remained associated with anemia living in the Northeast [OR: 3,45, CI; 2,21-5,40], Southeast [OR: 2,55; CI: 1,60-4,06] and South [OR:2,22;IC:1,39-3,55]; in urban area [OR: 2,01; CI: 1,35-3,00], and having severe food insecurity [OR: 1,78; CI :1,00-3,16], highlighting as protection having a mother with 5 to 8 years of study [OR: 0,62; CI: 0,41-0,92] and consuming meat at least once a week [OR: 0,45; CI: 0,22-0,93]. Determinants of VAD: The prevalence of VAD in the Country was 17.5%. After adjustment for confounding variables, remained associated with DVA living in the Northeast [OR: 1,77; CI: 1,16-2,77] and Southeast [OR: 1,74; CI: 1,16-2,72]; in urban area [OR: 1,29; CI: 0,91-1,87]; and having a mother aged 36 years [OR: 3,14; CI :1,48-7,09], considering protection to consume meat at least once a week [OR: 0,19; CI: 0,09-0,40]. Determinants of anemia and VAD: The concomitant prevalence of VAD and anemia was 3.9%, with no association between them (p>0,05). Variables statistically associated (p <0.05) with VAD and anemia in multiple analysis were living in the Southeast [OR: 4,28; CI: 1,96-11,68] and Northeast [OR: 2,92; IC: 1,31-7,96]; in urban area [OR: 3,66; CI: 1,46-12,30], and having severe food insecurity [OR: 3,64; CI: 1,41-8,84]; revealing protection being 2 years old [OR: 0,51; CI: 0,26-0,99] and consuming meat at least once a week [OR: 0,04; CI: 0,00-0,23]. Conclusions: The results show a significant reduction in the prevalence of child anemia and VAD in Brazil, although according to the criterion of epidemiological importance of the World Health Organization (WHO), they continue as a moderate public health problem. Despite strong evidences that VAD contributes to the development of anemia, it was verified a low prevalence of these two concomitant nutritional deficiencies among Brazilian children, and no association between them. However, anemia and VAD present common determinants (living in macro-regions less and more developed and in urban areas), reaffirming the transocial character of these nutritional deficiencies. The fact they have as a determinant food insecurity and as protection consuming meat at least once a week reinforce the social determination of these nutritional deficiencies, although food insecurity was not associated with VAD. The results showed as major determinants of anemia and VAD, those related to structural processes of society and the immediate environment of the child and not the individuals. It was also verified that government strategies have contributed to the prevention and control of these nutritional deficiencies in the Country, but it is signalized the need for expansion of the government\'s strategy for prevention and control of VAD, so far restricted to high-risk areas (Northeast and poor areas of the Southeast).

Introdução: Dentre as carências nutricionais de maior relevância destacam-se, neste estudo, anemia e deficiência de vitamina A, que constituem as principais preocupações das políticas públicas, na área de alimentação e nutrição. Apesar de medidas de prevenção e controle já terem sido implantadas no Brasil há algum tempo, suas prevalências continuam elevadas, com profundas repercussões na saúde infantil. Assim, embora reconhecidos como problemas de saúde pública e bastante explorados, politicamente, ainda há espectros de interesse epidemiológico a serem investigados. Objetivo: Analisar os determinantes da anemia e da deficiência de vitamina A (DVA), bem como a presença concomitante dessas duas carências nutricionais em crianças brasileiras. Métodos: Reanálise dos dados da Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher (PNDS) de 2006, abrangente inquérito das condições de saúde de mulheres e crianças brasileiras cuja 3ª edição incorporou a avaliação dos níveis de hemoglobina e vitamina A. Essa reanálise baseou-se numa amostra probabilística complexa com representação nacional, o que permitiu descrever a situação de anemia e DVA nas macrorregiões brasileiras e suas áreas urbanas e rurais. O presente estudo incluiu a análise de 3.417 crianças de 6 a 59 meses. Anemia foi definida como hemoglobina (Hb) <11g/dL, determinada pelo método da cianometa-hemoglobina. DVA foi definida como retinol sérico <0,7mol/L, avaliado por cromatografia líquida de alta eficiência. Para expansão da amostra utilizaram-se critérios adotados pela PNDS. As variáveis respostas foram presença de anemia, de DVA e carência concomitante de DVA e anemia, enquanto as explanatórias, analisadas considerando-se três dimensões, foram vinculação aos processos estruturais da sociedade (variáveis socioeconômicas e ambientais); ao ambiente imediato da criança (variáveis maternas, de segurança e consumo alimentar); e individual (características biológicas da criança). A força de associação entre as variáveis respostas e as explanatórias foi avaliada pelo odds ratio (OR), tanto na análise univariada (OR bruta) quanto na múltipla (OR ajustada), com nível de significância de 5%. Resultados: Determinantes da anemia: A prevalência de anemia no País foi de 20,5%. Na análise múltipla, permaneceram associadas à anemia residir no Nordeste [OR: 3,45; IC: 2,21-5,40] Sudeste [OR: 2,55; IC: 1,60-4,06] e Sul [OR: 2,22; IC: 1,39-3,55]; na zona urbana [OR: 2,01; IC: 1,35-3,00]; e ter insegurança alimentar grave [OR: 1,78; IC: 1,00-3,16], destacando-se como proteção ter mãe com 5 a 8 anos de estudo [OR: 0,62; IC: 0,41-0,92] e consumir carne pelo menos uma vez na semana [OR: 0,45; IC: 0,22-0,93]. Determinantes da DVA: A prevalência de DVA no País foi de 17,5%. Após ajuste para as variáveis de confusão, permaneceram associadas ao DVA residir no Nordeste [OR: 1,77; IC: 1,16-2,77] e Sudeste [OR: 1,74; IC: 1,16-2,72]; na zona urbana [OR: 1,29; IC: 0,91-1,87]; e ter mãe com idade 36 anos [OR: 3,14; IC: 1,48-7,09], considerando-se proteção consumir carne pelo menos uma vez na semana [OR: 0,19; IC: 0,09-0,40]. Determinantes da DVA e da anemia: A prevalência concomitante de DVA e anemia foi de 3,9%, sem associação entre elas (p>0,05). As variáveis estatisticamente associadas (p<0,05) com DVA e anemia na análise múltipla foram residir no Sudeste [OR: 4,28; IC: 1,96-11,68] e Nordeste [OR: 2,92; IC: 1,31-7,96]; na zona urbana [OR: 3,66; IC: 1,46-12,30]; e ter insegurança alimentar grave [OR: 3,64; IC: 1,41-8,84]; revelando-se proteção ter idade 2 anos de idade [OR: 0,51; IC: 0,26-0,99]; e consumir carne pelo menos uma vez na semana [OR: 0,04; IC: 0,00-0,23]. Conclusões: Os resultados mostram redução importante na prevalência de anemia e DVA infantil no Brasil, embora, de acordo com o critério de importância epidemiológica da Organização Mundial da Saúde (OMS), continuem como problema moderado de saúde pública. Apesar das fortes evidências de que a DVA contribui para o desenvolvimento da anemia, constatou-se baixa prevalência concomitante dessas duas carências nutricionais entre as crianças brasileiras, e sem associação entre elas. Entretanto, anemia e DVA apresentam determinantes comuns (residir em macrorregiões menos e mais desenvolvidas e em área urbana), que reiteram o caráter trans-social dessas carências estudadas. O fato de terem como determinante a insegurança alimentar e como proteção consumir carne pelo menos uma vez por semana reforça a determinação social dessas deficiências nutricionais, embora a insegurança alimentar não tenha se associado à DVA. Os resultados evidenciaram como principais determinantes da anemia e da DVA aqueles relacionados aos processos estruturais da sociedade e do ambiente imediato da criança e não os individuais. Constatou-se, também, que as estratégias governamentais têm contribuído para a prevenção e controle dessas carências nutricionais no País, porém, sinaliza-se a necessidade de expansão da estratégia governamental no sentido de prevenção e controle da DVA, até então restrita a áreas de risco (região Nordeste e áreas pobres da região Sudeste). / Introduction: Among the most relevant nutritional deficiencies, anemia and vitamin A deficiency stand out, constituting the main concerns of public policy in food and nutrition area. Even though prevention and control measures have already been implemented in Brazil some time ago, their prevalence remains high, with profound effects on child health. Thus, in spite of recognized as problems of public health and plenty explored, politically, there are still spectra of epidemiological interest to be investigated. Objective: To analyze the determinants of anemia, vitamin A deficiency (VAD), as well as these two concomitant nutritional deficiencies in Brazilian children. Methods: Reanalysis of data from the National Survey on Demography and Health of Women and Children (PNDS) of 2006, comprehensive survey of health of women and children in Brazil, whose 3rd edition incorporated the evaluation of hemoglobin and vitamin A levels. This reanalysis was based on a complex random sampling with national representation, which allowed describing the situation of VAD and anemia in Brazilian regions and their urban and rural areas. This study included analysis of 3.417 children aged from 6 to 59 months. Anemia was defined as hemoglobin (Hb) <11g/dL, determined by cyanometahemoglobin method. VAD was set as serum retinol <0.7 mol/L, evaluated by high performance liquid chromatography. To expand the sample, the criteria adopted by PNDS were used. The variable responses were presence of anemia, VAD and concomitant deficiency of VAD and anemia, while the explanatory, analyzed considering three dimensions, were link to the structural processes of society (socioeconomic and environmental variables), to the immediate environment of the child (maternal variables, of safety and food consumption); and individual (biological characteristics of the child). The strength of association between the response and the explanatory variables was evaluated by odds ratio (OR), both in univariate (crude OR) and in multiple analysis (adjusted OR), with a significance level of 5%. Results: Determinants of anemia: The prevalence of anemia in the Country was 20.5%. In multiple analysis, remained associated with anemia living in the Northeast [OR: 3,45, CI; 2,21-5,40], Southeast [OR: 2,55; CI: 1,60-4,06] and South [OR:2,22;IC:1,39-3,55]; in urban area [OR: 2,01; CI: 1,35-3,00], and having severe food insecurity [OR: 1,78; CI :1,00-3,16], highlighting as protection having a mother with 5 to 8 years of study [OR: 0,62; CI: 0,41-0,92] and consuming meat at least once a week [OR: 0,45; CI: 0,22-0,93]. Determinants of VAD: The prevalence of VAD in the Country was 17.5%. After adjustment for confounding variables, remained associated with DVA living in the Northeast [OR: 1,77; CI: 1,16-2,77] and Southeast [OR: 1,74; CI: 1,16-2,72]; in urban area [OR: 1,29; CI: 0,91-1,87]; and having a mother aged 36 years [OR: 3,14; CI :1,48-7,09], considering protection to consume meat at least once a week [OR: 0,19; CI: 0,09-0,40]. Determinants of anemia and VAD: The concomitant prevalence of VAD and anemia was 3.9%, with no association between them (p>0,05). Variables statistically associated (p <0.05) with VAD and anemia in multiple analysis were living in the Southeast [OR: 4,28; CI: 1,96-11,68] and Northeast [OR: 2,92; IC: 1,31-7,96]; in urban area [OR: 3,66; CI: 1,46-12,30], and having severe food insecurity [OR: 3,64; CI: 1,41-8,84]; revealing protection being 2 years old [OR: 0,51; CI: 0,26-0,99] and consuming meat at least once a week [OR: 0,04; CI: 0,00-0,23]. Conclusions: The results show a significant reduction in the prevalence of child anemia and VAD in Brazil, although according to the criterion of epidemiological importance of the World Health Organization (WHO), they continue as a moderate public health problem. Despite strong evidences that VAD contributes to the development of anemia, it was verified a low prevalence of these two concomitant nutritional deficiencies among Brazilian children, and no association between them. However, anemia and VAD present common determinants (living in macro-regions less and more developed and in urban areas), reaffirming the transocial character of these nutritional deficiencies. The fact they have as a determinant food insecurity and as protection consuming meat at least once a week reinforce the social determination of these nutritional deficiencies, although food insecurity was not associated with VAD. The results showed as major determinants of anemia and VAD, those related to structural processes of society and the immediate environment of the child and not the individuals. It was also verified that government strategies have contributed to the prevention and control of these nutritional deficiencies in the Country, but it is signalized the need for expansion of the government\'s strategy for prevention and control of VAD, so far restricted to high-risk areas (Northeast and poor areas of the Southeast).