[Show abstract][Hide abstract] ABSTRACT: The raising prevalence of weight excess and of non-communicable diseases in indigenous populations, as well as changes in food consumption and reduction in the frequency and intensity of physical activity, suggest that the prevalence of metabolic syndrome (MS) is also elevated. The objective of this study was to evaluate the prevalence of MS and the frequency of its components in the Xavante adult population living in the Indian reservations of São Marcos and Sangradouro/Volta Grande, in the state of Mato Grosso, Brazil. A cross-sectional study was carried out among 932 Xavante Indians aged 20 years or more, in the 2008–2012 period. The variables analysed were gender, age, weight, height, waist circumference, blood pressure, initial and 2-h capillary glycemia in a 75 g OGTT, levels of triglycerides and HDL-cholesterol. The diagnostic criteria for MS proposed by the IDF and AHA/NHLBI were used.
The prevalence of MS was 66.1 % (95 % CI 63.0–69.2), being 76.2 % (95 % CI 72.4–80.0) in women and 55.6 % (95 % CI 51.0–60.2) in men. Women had higher prevalence of MS in all age groups. Elevated waist circumference and lower levels of HDL-cholesterol were the more frequent components in those with MS, and elevated blood pressure was the less frequent.
The high prevalence of MS in the Xavante Indians is mainly due to the increased prevalence of weight excess that resulted from an intense change in their life-style, in a short period of time in a population with a genetic predisposition. These findings highlight the magnitude of this health problem and make an alert about the necessity to implement specific preventive interventions.
[Show abstract][Hide abstract] ABSTRACT: To estimate the prevalence of diabetes, hypertension, obesity, and describe demographic, anthropometric and medical characteristics, in a genetically distinct population: the Brazilian Xavante Indians.
Population-based survey carried out among 948 Xavante from Mato Grosso, Brazil. Fasting and 2-hour after 75 g glucose capillary glycemia were measured by a portable glucometer (HemoCue Glucose201+). Diabetes was defined according to WHO criteria. Anthropometric data and medical characteristics were measured, and fat mass (%) was evaluated using bioelectrical impedance. Blood pressure was measured by an automated device (OMRON 742INTC), and hypertension was defined according to WHO criteria.
Age-adjusted prevalence rates with 95% confidence intervals were diabetes: 28.2% (25.3-31.1) in general, 18.4% (14.9-22.2) in men and 40.6% (36.2-45.1) in women (P<.001); impaired glucose tolerance: 32.3% (20.5-26.0) in general, 29.7% (25.4-33.9) in men and 34.4% (30.2-38.8) in women (P>.05); hypertension: 17.5% (15.1-19.9) in general. Obesity was found in 50.8% of the individuals. Fat mass (%) was associated with diabetes in men (P<.05) and women (P<.05). Thigh circumference and waist/ thigh ratio were lower in those with diabetes, in men and women (P<.001).
The high prevalence of diabetes and obesity in Xavante is likely related to their recent change in food habits and physical activities. Our results should raise awareness about the magnitude of this health problem and also indicate that it could increase dramatically in the future if no preventive actions are adopted.
[Show abstract][Hide abstract] ABSTRACT: Aims
To examine the properties of HbA1c to detect diabetes and IGT in adult Brazilian Xavante Indians, a high risk population for diabetes.
The survey was carried out between October 2010 and January 2012 and based on a 75 g oral glucose tolerance test (OGTT). Basal and 2 hour capillary glycaemia were measured by HemoCue Glucose 201+; HbA1c using an automated high-performance liquid chromatography analyzer (Tosoh G7).
630 individuals aged ≥ 20 years were examined and 80 had a previous diagnosis of diabetes. Sensitivity, specificity and accuracy for HbA1c ≥ 6.5% (≥ 48 mmol/mol) were 71.3%, 90.5% and 87.2%. The areas under the ROC curve (AUC) was 0.88 (95%CI: 0.83-0.93). To identify IGT, HbA1c values between 5.7% and 6.4% (39 - 47 mmol/mol) presented sensitivity, specificity, and accuracy of 87.2%, 24.7% and 51.4%, with an AUC of 0.62 (95%CI: 0.57-0.67).
The ADA/WHO proposed cut-off of 6.5% (48 mmol/mol) for HbA1c was adequate to detect diabetes among the Xavante. However, the performance of the ADA proposed cut-off points for pre-diabetes, when used to detect IGT was inadequate and should not be recommended.
Diabetes Research and Clinical Practice 09/2014; 106(2). DOI:10.1016/j.diabres.2014.08.027 · 2.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This present study aimed to test the association between fried food intake estimated by a semi-quantitative food frequency questionnaire (FFQ), multiple 24 h dietary recalls (24hRs), and the application of the multiple source method (MSM), in relation to gestational weight gain at the second and third trimesters and weight gain ratio (observed weight gain/expected weight gain). We hypothesized that distinct relationships with weight gain would be found, given the measurement errors of self-reported dietary approaches. A prospective study was conducted with 88 adult pregnant women. Fried food intake during pregnancy was assessed using a validated 85-item FFQ, two to six 24hRs per woman, and the MSM with and without frequency of food intake as covariate. Linear regression models were used to evaluate the relationship between fried food estimated by the methods and weight gain. For every 100-g increment of fried food intake, the ß (95% CI) for weight gain was [ß 1.87 (0.34, 3.40)] and [ß 2.00 (0.55, 3.45)] for estimates using MSM with and without the frequency of intake as covariate, respectively, after multiple adjustments. We found that fried food intake estimated by the FFQ and 24hRs [ß 0.40 (-0.68, 1.48)] and [ß 0.49 (-0.53, 1.52)], respectively, were unrelated to weight gain. In relation to weight gain ratio, a positive association was found for estimates using the MSM with [ß 0.29 (0.03, 0.54)], and without the frequency of intake as covariate [ß 0.31 (0.07, 0.55)], and no associations were found for estimates by the FFQ or 24hRs. The data showed that fried food intake estimated the MSM, but nor by the FFQ and 24hRs, is associated with excessive weight gain during pregnancy.
Nutrition Research 08/2014; 34(8). DOI:10.1016/j.nutres.2014.07.008 · 2.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective To estimate food and dietary folate inadequacies in the diets of adult pregnant women. Methods A prospective study was conducted with 103 healthy pregnant adult users of the Public Health Care System of Ribeirao Preto, Sao Paulo, Brazil. The present study included the 82 women with complete food intake data during pregnancy, which were collected by three 24-hour dietary recalls. Food folate (folate naturally present in foods) and dietary folate (food folate plus folate from fortified wheat flour and cornmeal) inadequacies were determined, using the Estimated Average Requirement as cutoff. Results The diets of 100% and 94% of the pregnant women were inadequate in food folate and dietary folate, respectively. However, fortified foods increased the medium availability of the nutrient by 87%. Conclusion The large number of pregnant women consuming low-folate diets was alarming. Nationwide population studies are needed to confirm the hypothesized high prevalence of low-folate diets among pregnant women.
Revista de Nutrição 05/2014; 27(3):321-327. DOI:10.1590/1415-52732014000300006 · 0.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous studies conducted among pregnant women to test the accuracy of food frequency questionnaires (FFQ) for estimating food group intake were restricted to one specific trimester of pregnancy. The present study aimed to validate a FFQ for assessing the intake of food groups throughout pregnancy.
In total, 75 adult pregnant Brazilian women were evaluated. Dietary intake was assessed by the FFQ (completed at the third trimester of pregnancy) and by three 24-h dietary recalls; one in each trimester of pregnancy.
The food items were classified into 20 groups. Adequate deatenuatted Pearson correlation coefficients (>0.4) were observed for the intake of bread/cake, butter/margarine; milk/dairy products; soft drinks/artificial juices; coffee/tea; and pastries/sandwiches. The FFQ served poorly for estimating fruit and vegetable intake. A high percentage (>70%) of women were classified into the same or adjacent quartiles for estimates of cookies/crackers, butter/margarine, milk/dairy products, fruit juices, soft drinks/artificial juices, coffee/tea, roots, rice, beans, meat/chicken/sausages, fried foods, fish, eggs, sweets/sugars, and pastries/sandwiches. Nevertheless, the agreement of joint classification between the dietary methods was mostly into adjacent quartiles, rather than in the same quartile, and low values of kappa were found.
The data reported in the present study suggest that the FFQ might not be an appropriate dietary method for evaluating food group intake throughout pregnancy. The joint classification between methods by categories of intake of food groups was mostly into adjacent quartiles, which could lead to attenuated associations when investigating diet-disease relationships during pregnancy.
Journal of Human Nutrition and Dietetics 03/2014; 28(s1). DOI:10.1111/jhn.12224 · 1.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To verify the reproducibility of a questionnaire about perceived food environment and produce (fruits and non-starchy vegetables) intake by pregnant women. METHODS: The study was conducted in 2010 and included 48 pregnant women followed by the public health care service of Ribeirão Preto, São Paulo. The questionnaire consists of 11 multiple-choice questions on the perceived food environment for produce intake. Reproducibility was determined by administering the questionnaire twice, 15 to 45 days apart. Result agreement was measured by the kappa or weighted kappa coefficient. RESULTS: Strong agreement (Kappa from 0.6 to 0.79) occurred for: number of meals per day, habit of eating at work, distance from home to a produce retailer, and produce quality at the produce retailer. Moderate agreement (Kappa from 0.4 to 0.59) occurred for: habit of eating away from home, habit of eating at self-service or pay-by-weight restaurants, habit of eating at fast food restaurants, preferred food retailers (grocery, convenience store, bakery), reason for picking the produce retailer of choice, and produce variety. CONCLUSION: The questionnaire about perceived food environment and produce intake for pregnant women is consistent.
Revista de Nutrição 12/2013; 26(6):727-735. DOI:10.1590/S1415-52732013000600011 · 0.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to investigate how maternal polyunsaturated fatty acid intake at different periods during pregnancy affects the composition of polyunsaturated fatty acids in mature human milk.
A prospective study was conducted involving 45 pregnant women, aged between 18 and 35 y, who had full-term pregnancies and practiced exclusive or predominant breast-feeding. Mature breast milk samples were collected after the 5th postpartum week by manual expression; fatty acid composition was determined by gas chromatography. Fatty acid intake during pregnancy and puerperium was estimated through multiple 24-h dietary recalls. Linear regression models, adjusted by postpartum body mass index and deattenuated, were used to determine associations between estimated fatty acids in maternal diet during each trimester of pregnancy and fatty acid content in mature human milk.
A positive association was identified between maternal intake of eicosapentaenoic acid (β, 1.873; 95% confidence interval [CI], 0.545, 3.203) and docosahexaenoic acid (β, 0.464; 95% CI, 0.212-0.714) during the third trimester of pregnancy, as well as the maternal dietary ω-3 to ω-6 ratio (β, 0.093; 95% CI, 0.016-0.170) during the second and third trimesters and postpartum period, with these fatty acids content in mature breast milk.
The maternal dietary docosahexaenoic acid and eicosapentaenoic acid content during late pregnancy may affect the fatty acid composition of mature breast milk. Additionally, the maternal dietary intake of ω-3 to ω-6 fatty acid ratio, during late pregnancy and the postpartum period, can affect the polyunsaturated fatty acid composition of breast milk.
[Show abstract][Hide abstract] ABSTRACT: Objective:
To estimate the prevalence of nutritional deficiencies in Angolan children.
A cross-sectional population based study. World Health Organization (2006) criteria were used to classify nutritional state.
A high prevalence of low height for age, weight for height and weight for age was observed (22%, 13% and 7%, respectively) among the children.
Nutritional deficiencies in children represents a serious public health problem in Bom Jesus, Angola.
Revista de saude publica 08/2013; 47(4):817-820. DOI:10.1590/S0034-8910.2013047004576 · 0.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives:
To evaluate the fatty acid composition of mature human milk of women living far from the coastal area of Brazil.
Mature breast milk samples were obtained from 47 lactating women aged between 18 and 35 years, who delivered their babies at term and who exclusively or predominantly breastfed. Milk collection took place after the fifth week postpartum by hand expression. The fatty acid composition of the milk was determined by gas chromatography.
It was observed that the concentration of eicosapentaenoic acid (0.08%) was higher than that observed in previous studies in Brazil. However, the content of docosahexaenoic acid (0.09%) found in human milk was one of the lowest verified in the world. The content of trans fatty acids (2.05%) was similar to that reported in national studies previous to the mandatory declaration of this fatty acid content in food labels, suggesting that this measure had no effect on reducing the content of this fatty acid in the usual diet of women.
Low levels of docosahexaenoic acid and high concentrations of trans fatty acids were observed in mature breast milk of women living far from the coastal area in Brazil.
Jornal de pediatria 04/2013; 89(3). DOI:10.1016/j.jped.2012.11.007 · 1.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: to evaluate the influence of level of schooling on the reproducibility of a quantitative food frequency questionnaire (QQFA), previously designed for pregnant women, to estimate nutrient intake pregnancy. METHODS: the QQFA was applied in duplicate (between 15 and 45 days) to a sample of 95 pregnant women. The intra-class correlation coefficient (CCI) was calculated and the pregnant women classified into quartiles of nutrient estimates, stratified by eight years of schooling. RESULTS: after adjustment for energy, the mean CCI was 0.66 (varying between 0.33 for linoleic fatty acid and 0.88 for potassium and folate) and 0.72 (varying from 0.44 for arachidonic fatty acid to 0.84 for potassium) among applications of the QQFA to pregnant women with lower and higher levels of schooling, respectively. On average, 78% and 84% of pregnant women were classified in the same quartile or in adjacent quartiles on subsequent applications of the QQFA to pregnant women with lower and higher levels of schooling, respectively. CONCLUSIONS: the questionnaire presented a high level of precision in estimating nutrient intake during pregnancy, except for some fatty acids. The QQFA was shown to be more accurate among women with more than eight years of schooling.
Revista Brasileira de Saúde Materno Infantil 03/2013; 13(1):23-28. DOI:10.1590/S1519-38292013000100003
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: It has been extensively shown, mainly in US populations, that sugar-sweetened beverages (SSBs) are associated with increased risk of type 2 diabetes (T2D), but less is known about the effects of artificially sweetened beverages (ASBs). OBJECTIVE: We evaluated the association between self-reported SSB, ASB, and 100% fruit juice consumption and T2D risk over 14 y of follow-up in the French prospective Etude Epidémiologique auprès des femmes de la Mutuelle Générale de l'Education Nationale-European Prospective Investigation into Cancer and Nutrition cohort. DESIGN: A total of 66,118 women were followed from 1993, and 1369 incident cases of T2D were diagnosed during the follow-up. Cox regression models were used to estimate HRs and 95% CIs for T2D risk. RESULTS: The average consumption of sweetened beverages in consumers was 328 and 568 mL/wk for SSBs and ASBs, respectively. Compared with nonconsumers, women in the highest quartiles of SSB and ASB consumers were at increased risk of T2D with HRs (95% CIs) of 1.34 (1.05, 1.71) and 2.21 (1.56, 3.14) for women who consumed >359 and >603 mL/wk of SSBs and ASBs, respectively. Strong positive trends in T2D risk were also observed across quartiles of consumption for both types of beverage (P = 0.0088 and P < 0.0001, respectively). In sensitivity analyses, associations were partly mediated by BMI, although there was still a strong significant independent effect. No association was observed for 100% fruit juice consumption. CONCLUSIONS: Both SSB consumption and ASB consumption were associated with increased T2D risk. We cannot rule out that factors other than ASB consumption that we did not control for are responsible for the association with diabetes, and randomized trials are required to prove a causal link between ASB consumption and T2D.
American Journal of Clinical Nutrition 01/2013; 97(3). DOI:10.3945/ajcn.112.050997 · 6.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
To calibrate the food list and relative portion sizes of a food frequency questionnaire (FFQ) for application to a free-living, healthy, elderly population.
Cross-sectional study. One hundred free-living, healthy participants, aged from 60 to 75 y, randomly selected from among individuals in the area served by the Family Health Program, School of Medicine of Ribeirao Preto, University of São Paulo. A Food Frequency Questionnaire (FFQ) and a Diet History Questionnaire (DH) were applied by trained dietitians. Each food item of the FFQ had its portion size recalculated according to the percentiles referenced by the volunteers in the DH (25th = small, 50th = medium, and 75th = large). The list of foods and portion sizes of the original FFQ and those obtained by the application of the DH were compared. The percent contribution of energy, protein, fat, carbohydrate, folic acid, vitamin C, calcium, and fiber of each food item mentioned in the FFQ was determined from the data obtained by the application of the DH.
FFQ, as compared with the DH, provided good estimation of the intake of protein, calcium, folic acid, and fiber (paired t test P < 0.05). Portion sizes of the FFQ differed from those obtained by the application of the DH (-23% to 300%).
Adjustments to the FFQ in particular, new portion sizes and a reduction of the food list were found to be appropriate for application to healthy, urban, free-living elderly people in Ribeirao Preto, Brazil.
[Show abstract][Hide abstract] ABSTRACT: Background/objectives:
To assess the performance of a food frequency questionnaire (FFQ) for estimating ω-3, ω-6 and trans fatty acid intake during pregnancy. Moreover, we determined whether the fatty acid composition of mature breast milk represents a valuable biomarker for fatty acid intake during pregnancy.
A prospective study in 41 pregnant women, aged 18-35 years, was conducted. Food intake during pregnancy was evaluated by three 24-h recalls (24 hR), and 2 FFQ. The fatty acid composition of mature breast milk was determined by gas chromatography. The method of triads and joint classification between quartiles of intake were applied.
The FFQ was accurate for estimating docosahexanoic (DHA), linoleic and total ω-6 fatty acids according to validity coefficients. Higher agreements (>70%) into the same or adjacent quartiles between the dietary methods were found for α-linolenic, total ω-3, linoleic and trans fatty acid intake. High validity coefficients for eicosapentanoic (EPA) and DHA acids of human milk were found (0.61 and 0.73, respectively), and the method was adequate for categorizing the intake of α-linolenic, total ω-3 and trans fatty acids compared with FFQ estimates, and for arachidonic acid and trans fatty acids compared with food recall estimates, during pregnancy.
The FFQ was an accurate tool for categorizing α-linolenic, total ω-3 and trans fatty acid intake. According to the validity coefficients observed, the FFQ accurately estimated DHA, linoleic and total ω-6 fatty acids and the composition of mature breast milk was shown to be a suitable biomarker for EPA and DHA fatty acid intake during pregnancy.
European journal of clinical nutrition 09/2012; 66(11). DOI:10.1038/ejcn.2012.127 · 2.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To evaluate the ability of an FFQ, designed for use in Brazilian pregnant women, to estimate nutrient intakes during pregnancy. DESIGN: A prospective study was conducted among 103 pregnant women attended by the Brazilian national health-care service. Food intake during pregnancy was evaluated by three 24 h dietary recalls (24hR), one per trimester of pregnancy, and also by two FFQ. The FFQ with eighty-five food items included questions about frequency of intake and portion sizes during two periods: the first 24 weeks of pregnancy and the pregnancy period as a whole. Deattenuated Pearson's correlation coefficients and joint classification into quartiles of nutrient intake were applied. SETTING: Ribeirão Preto, São Paulo State, Brazil. SUBJECTS: One hundred and three pregnant women, aged 18-35 years. RESULTS: Acceptable correlation coefficients (r > 0·35) were found for Ca, K, Zn, Mg, fibre, vitamin C, niacin and folic acid for intake for the first 24 weeks; and for energy, lipids, protein, carbohydrate, Fe, K, Zn, fibre, vitamin B6, riboflavin and niacin for the gestational period as a whole. A high proportion of study participants (≥70 %) were categorized into the same or adjacent quartiles for estimated energy, carbohydrate, Ca, K, fibre, Zn, cholesterol, vitamin A, riboflavin, niacin, vitamin C, vitamin E and folic acid. Gross misclassification ranged from 2·3 % (dietary fibre) to 12·5 % (vitamin A, thiamin and SFA). CONCLUSIONS: The FFQ is a useful tool for assessing categories of nutrient intake during pregnancy, since a high proportion of women were classified into the same or adjacent quartiles.
Public Health Nutrition 08/2012; 16(8):1-8. DOI:10.1017/S1368980012003783 · 2.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The food groups conventionally applied in activities of nutritional counseling were established according to their macronutrient content. However, it does not consider recent scientific evidences of the association between food consumption and risk of developing non-communicable chronic diseases.
To propose food groups for the investigation of the association between food consumption and risk of developing type 2 diabetes and associated diseases among Japanese-Brazilians.
Cross-sectional analysis of baseline data of a lifestyle intervention study conducted among Japanese-Brazilians of Bauru, SP, Brazil, from 2005 to 2007. Food intake was assessed by three 24-hour recalls of 640 participants, both genders, aged 30 to 88 years old.
Eighteen new food groups were proposed according to their quantity and quality of fat, carbohydrates, sodium, and fiber.
The new food groups incorporate recent evidences of the association between diet and the risk of developing type 2 diabetes.
Revista Brasileira de Epidemiologia 09/2011; 14(3):531-6. DOI:10.1590/S1415-790X2011000300017
[Show abstract][Hide abstract] ABSTRACT: The prevalence of type 2 diabetes has shown a significant increase in parallel with health care costs. The objective of the Brazilian Study on Diabetes Costs (ESCUDI study) was to estimate direct and indirect costs of type 2 diabetes outpatient care in the Brazilian Public Health Care System.
Data were collected from different levels of health care in eight Brazilian cities in 2007. A total of 1000 outpatients were interviewed and had their medical records data analyzed. Direct medical costs included expenses with medications, diagnostic tests, procedures, blood glucose test strips, and office visits. Nonmedical direct costs included expenses with diet products, transportation, and caregivers. Absenteeism, sick leave, and early retirement were classified as indirect costs.
Total annual cost for outpatient care was US$2108 per patient, out of which US$1335 per patient of direct costs (63.3%) and US$773 per patient of indirect costs (36.7%). Costs escalated as duration of diabetes and level of health care increased. Patients with both microvascular and macrovascular complications had higher costs (US$3199 per patient) compared to those with either microvascular (US$2062 per patient) or macrovascular (US$2517 per patient) complications only. The greatest portion of direct costs was attributed to medication (48.2%).
Diabetes treatment leads to elevated costs both to Brazilian Public Health Care System and society. Costs increased along with duration of disease, level of care and presence of chronic complications, which suggested a need to reallocate health resources focusing on primary prevention of diabetes and its complications.
Value in Health 07/2011; 14(5 Suppl 1):S137-40. DOI:10.1016/j.jval.2011.05.009 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: HIV-infected children and adolescents treated with highly active antiretroviral therapy (HAART) regimens that include a protease inhibitor (PI) can show significant improvements in clinical outcomes, nutritional status and quality of life. The study aimed to report nutritional and metabolic alterations for pediatric patients continuously exposed to HAART and for healthy controls for up to 1 year.
Clinical, anthropometric, lipid profile and food intake data were collected prospectively over approximately 12-months for each patient.
Fifty-one individuals were studied, of these, 16 were healthy. After 12 months follow-up, HIV-positive individuals remained below the healthy control group parameters. No change was observed concerning food intake. Triglyceride serum levels were higher in patients using protease inhibitor at the onset of the study [PI groups: 114 (43 - 336), and 136 (63 - 271) versus control group: 54.5 (20 - 162); p = 0.003], but after twelve months follow-up, only the group using protease inhibitor for up to two months presented higher values [140 (73 - 273) versus 67.5 (33 - 117); p = 0.004]. HDL-cholesterol was lower in HIV-positive individuals [HIV-positive groups: 36 (27 - 58) and 36 (23 - 43); control 49.5 (34 - 69); p = 0.004].
HIV-infected children and adolescents treated with highly active antiretroviral therapy showed compromised nutritional parameters compared to a paired healthy control group. Individuals using protease inhibitor presented worse triglyceride serum levels compared to their healthy counterparts.
Revista da Sociedade Brasileira de Medicina Tropical 06/2011; 44(3):274-81. DOI:10.1590/S0037-86822011005000039 · 0.98 Impact Factor