University of Kassel Faculty 11 Organic Agricultural Sciences Department of Organic Food Quality and Food Culture
Nutrition in Kindergartens of Kosovo
A Doctor Thesis
Submitted By:
Agim Rysha Uni. Spec. M.Eng.
Witzenhausen, October 2013
Agim Rysha (2013): PhD Thesis
Dissertation submitted in fulfillment for the degree of Doktor der Agrarwissenschaften (Dr. agr.) at the Faculty of Organic Agricultural Sciences University of Kassel Department of Organic Food Quality and Food Culture
Date of defense: November 12th 2013
1st Supervisor: Prof. Dr. Angelika Ploeger 2nd Supervisor: Prof. Dr. Tahire Maloku Gjergji Examiner: Prof. Dr. Freytag-Leyer Examiner: Prof. Dr. Christoph Klotter
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Hiermit versichere ich, dass ich die vorliegende Dissertation selbstständig, ohne unerlaubte Hilfe Dritter angefertigt und andere als die in der Dissertation angegebenen Hilfsmittel nicht benutzt habe. Alle Stellen, die wörtlich oder sinngemäß aus veröffentlichten oder unveröffentlichten Schriften entnommen sind, habe ich als solche kenntlich gemacht. Dritte waren an der inhaltlich-materiellen Erstellung der Dissertation nicht beteiligt; insbesondere habe ich hierfür nicht die Hilfe eines Promotionsberaters in Anspruch genommen. Kein Teil dieser Arbeit ist in einem anderen Promotions- oder Habilitationsverfahren verwendet worden.
Witzenhausen, October 2013
Agim Rysha
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ACKNOWLEDGEMENTS
I would like to express my heartfelt gratitude to my principal supervisor, Prof. Dr. Angelika Ploeger. She patiently advised, motivated and encouraged me from our first encounter to the end of the thesis. The good advice and support of my second supervisor, Prof. Dr. Tahire Maloku-Gjergji has been very valuable, for which I am extremely grateful. Besides My supervisors, I would like to thank the rest of my thesis committee: Prof. Dr. Freytag- Leyer and Prof. Dr. Klotter for their insightful comments and hard questions I would like to thank Ass. Dr. Sanije Hoxha – Gashi and Mrs. Hannah Günther for their advices and support during data processing. A sincere appreciation goes out to the children of five kindergartens, parents, teachers, cooking ladies and directors. Without their support, there would be no research Most importantly, this dissertation would not have been possible without love and patience of my family. My wife Ilmije, my daughters Aurora and Sara and my son Orges were powerful source of inspiration and energy to come to an end of my study.
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List of Tables Table 1: Classes of nutrients for human nutrition ...... 16 Table 2: Advantages and limitations of the Nutritional Anthropometry ...... 23 Table 3: WHO and CDC available charts ...... 25 Table 4: Available Computer software for WHO growth references and CDC growth charts .....26 Table 5: Sample size, research locations and gender aspects of the samples ...... 37 Table 6: Distribution of study subjects by age and sex ...... 49 Table 7: Means and standard deviations for weight across sex and age groups ...... 50 Table 8: Means and standard for weight across sex and age groups deviations ...... 51 Table 9: Mean and standard deviations of WAZ scores by age and sex ...... 53 Table 10: Mean and standard deviations of HAZ scores by age and sex ...... 54 Table 11: Mean and standard deviations of WHZ scores by age and sex ...... 55 Table 12: BMI for age (z-scores) according to sex and age groups ...... 56 Table 13: Means and standard deviations for weight in public and private kindergarten ...... 59 Table 14: Means and standard deviations for stature in public and private kindergarten ...... 59 Table 15: Differences in the means and SD of WAZ ...... 60 Table 16: Differences in the means and SD of HAZ ...... 61 Table 17: Differences in the means and SD of WHZ ...... 61 Table 18: Differences in the means and SD of BAZ ...... 62 Table 19: Length/height-for age indicator (%) ...... 63 Table 20: Weight-for-age indicator (%) ...... 64 Table 21: Weight -for length/height indicator (%) ...... 65 Table 22: BMI-for-age indicator (%) ...... 66 Table 23: Mean values of main nutrients, special carbohydrates and fatty acids consumed by children from all kindergartens according to gender and age ...... 72 Table 24: Energy distribution from macronutrients according to gender and age l ...... 73 Table 25: Energy distribution from macronutrients in public and private kindergartens ...... 75 Table 26: Distribution of starch and sucrose in public and private kindergartens ...... 76 Table 27: Proportion of starch and sucrose intake in all kindergartens ...... 77 Table 28: Mean values of amino acids consumed by children from all kindergartens ...... 80 Table 29: Differences between mean values of amino acids consumed by children of public and private kindergartens ...... 81 Table 30: Mean values of minerals, trace elements and sterols according to gender and age (all kindergartens) ...... 82 Table 31: Difference between consumption of minerals, trace elements and sterols in public and private kindergartens according to gender and age ...... 83 Table 32: The mean values of vitamins which were consumed by children (12-83 months old) in all five kindergartens ...... 87 Table 33: Difference between consumption of vitamins in public and private kindergartens according to gender and age...... 88 Table 34: Typical daily intake of food and beverages ...... 94 Table 35: Food intake during the weekend ...... 94
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Table 36: Food frequency intake outside home ...... 95 Table 37: Children eating out of the control ...... 96 Table 38: Children on special diet ...... 96 Table 39: Children showing an allergy towards foods...... 97 Table 40: Children skipping their meals ...... 98 Table 41: Frequency intake of beverages (water, soft drinks, tea and fruit/vegetable juice) ...... 99 Table 42: Frequency intake of red meat, poultry, fish, sausages and eggs ...... 100 Table 43: Frequency intake of cheese, pasta, potatoes, rice, bread, rolls, muffin, crackers, cereals and fruits ...... 101 Table 44: The frequency intake of vegetables, soups, stews, casseroles, pretzels, candy ice cream and fried foods ...... 102
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List of Figures
Figure 1: Structure of thesis ...... 2 Figure 2: Framework of the relations between basic causes (i.e. poverty, food insecurity) and underlying and immediate causes to child undernutrition ...... 10 Figure 3: Framework for possible causes and factors associated with obesity and overweight .13 Figure 4: The dietary assessment process ...... 29 Figure 5: Nutrition Circle ...... 30 Figure 6: The 10 Nutrition Guidelines ...... 31 Figure 7: The 3D Food Guide Pyramid, 2006...... 32 Figure 8: Research methods ...... 34 Figure 9: Locations of Kindergartens ...... 35 Figure 10 Meeting with parents and teachers ...... 38 Figure 11: Creation of a good environment for participation of the children in the study ...... 39 Figure 12: Seca instruments used for anthropometric measurements ...... 40 Figure 13: Food intake by children ...... 41 Figure 14: Wasted foods and Leftovers ...... 42 Figure 15: The Seca 856 ...... 43 Figure 16: Anthropometric measurements ...... 44 Figure 17: Recipe content ...... 45 Figure 18: Measurement of wasted foods ...... 46 Figure 19: Structure of study subjects by sex ...... 50 Figure 20: Average Weight for boys and girls ...... 51 Figure 21: Average Height for boys and girls ...... 52 Figure 22: Distribution of weight for age Kosovo preschool children compared with WHO standard distribution a) all children 12-60 month and b) Children 61-83 month ...... 53 Figure 23 Distribution of height for age Kosovo preschool children compared with WHO standard distribution a) all children 12-60 month and b) children 61-83 month ...... 54 Figure 24: Distribution of weight for height of Kosovo preschool children compared with the WHO standard distribution (children 12-60 months) ...... 55 Figure 25: Distribution of BMI for age z-scores of Kosovo preschool children compared with the WHO standard distribution a) children 12-60 months b) children 61-83 month ...... 56 Figure 26: Weight for age by gender: a) children 12-60 month; b) children 61-83 months ...... 57 Figure 27: Height for age by gender: a) children 12-60 months; b) children 61-83 months ...... 57 Figure 28: Weight for height by gender a) children 12-60 months ...... 58 Figure 29: BMI for age by gender; a) 12-60 months and b) 61-83 months ...... 58 Figure 30: Prevalence of undernutrition ...... 68 Figure 31: Prevalence of overweight ...... 69 Figure 32: The % of the daily recommended intake (full day-8 hours) of calcium, iron and iodine ...... 92 Figure 33: The % of the daily recommended intake (full day-8 hours) of folic acid, vitamin A, Vitamin C and vitamin D ...... 92
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List of Annexes Annex 1 Definition and Abbreviations for Dietary Assessment Methods and Reference Method ...... 136 Annex 2 Strengths and Limitations of Various Dietary Assessment Methods Used in Clinica Settings ...... 139 Annex 3 Nutrient-Based Guidelines for Food Prepared for 1-4 Years Old in Child Care ...... 141 Annex 4 Nutrient-Based Guidelines for Food Prepared for 1-4 Years Old in Child Care ...... 143 Annex 5 Letter to the Ministry of Education for Access to the Kindergartens - Albanian...... 144 Annex 6 Consent and Support Letter from the Ministry of Education of Kosovo. Albanian ...... 145 Annex 7 Letter to Parents- English and Albanian ...... 146 Annex 8 The Information Poster about the Start and Time Frame of the Study in a Kinderdarden English and Albanian ...... 148 Annex 9 The Weighted Dietary Record (WDR) Form: English and Albanian ...... 149 Annex 10 Estimated Food Record Form (EFR). English and Albanian ...... 152 Annex 11 A Combined 24H and DH Form, English and Albanian ...... 155 Annex 12 The Recipes and Served Food Types in Five Selected Kindergartens ...... 158 Annex 13 The Explanation of Some Local Used Foods ...... 166 Annex 14 Serving Size Pictures as an Estimated Aid, English and Albanian ...... 167 Annex 15 Calculated nutrients-from nutrition tables (Umschau Verlag-2002) ...... 171 Annex 16 Height, weight and nutritional status of children from Kindergarten 1 (Ferizaj) according to gender and age...... 172 Annex 17 Height, weight and nutritional status of children from Kindergarten 2 (Prishtine) according to gender and age...... 173 Annex 18 Height, weight and nutritional status of children from Kindergarten 3 (Obiliq) according to gender and age ...... 174 Annex 19 Height, weight and nutritional status of children from Kindergarten 4 (Kamenicë) according to gender and age...... 175 Kindergarten ...... 175 Annex 20 Height, weight and nutritional status of children from Kindergarten 5 (Private Prishtine) according to gender and age ...... 176 Annex 21 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 1 (Ferizaj) according to gender and age ...... 177 Annex 22 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 2 (Prishtine) according to gender and age ...... 178 Annex 23 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 3 (Obiliq) according to gender and age ...... 179 Annex 24 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 4 (Kamenicë) according to gender and age ...... 180 Annex 25 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 5 (Prishtine private) according to gender and age...... 181 Annex 26 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Public Kindergartens according to gender and age ...... 182 Annex 27 Mean values of amino acids consumed by children attending kindergarten 1 (Ferizaj) according to gender and age...... 183
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Annex 28 Mean values of amino acids consumed by children attending kindergarten 2 (Prishtine) according to gender and age ...... 184 Annex 29 Mean values of amino acids consumed by children attending kindergarten 3 (Obiliq) according to gender and age...... 185 Annex 30 Mean values of amino acids consumed by children attending kindergarten 4 (Kamenicë) according to gender and age...... 186 Annex 31 Mean values of amino acids consumed by children attending kindergarten 5 (Prishtine private) according to gender and age ...... 187 Annex 32 Mean values of amino acids consumed by children attending public kindergartens according to gender and age...... 188 Annex 33 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 1 (Ferizaj) according to gender and age ...... 189 Annex 34 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 2 (Prishtine) according to gender and age ...... 190 Annex 35 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 3 (Obiliq) according to gender and age ...... 191 Annex 36 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 4 (Kamenicë) according to gender and age ...... 192 Annex 37 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten (Prishtine private) according to gender and age ...... 193 Annex 38 Mean values of minerals, trace elements and sterols consumed by children attending public kindergarten according to gender and age ...... 194 Annex 39: Mean values of vitamins consumed by children attending kindergarten 1 (Ferizaj) according to gender and age...... 195 Annex 40 Mean values of vitamins consumed by children attending kindergarten 2 (Prishtine) according to gender and age...... 196 Annex 41 Mean values of vitamins consumed by children attending kindergarten 3 (Obiliq) according to gender and age...... 197 Annex 42 Mean values of vitamins consumed by children attending kindergarten 4 (Kamenicë) according to gender and age...... 198 Annex 43 Mean values of vitamins consumed by children attending kindergarten 5 (Prishtine Private) according to gender and age ...... 199 Annex 44 Mean values of vitamins consumed by children attending public kindergartens according to gender and age...... 200
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List of abbreviations and acronyms
24HR 24-Hour Recall AC Anthropometric Calculator AI Adequate Intake AMDR Acceptable Macronutrient Distribution Range BMI Body Mass Index CDC Centers for Disease Control CVD Cardiovascular Diseases DH Diet History DHQ Diet History Questionnaires DLW Doubly Labeled Water Method DO Direct Observation DRI Dietary Reference Intake DRV Dietary Reference Value EAR Estimated Average Requirement EER Estimated Energy Requirements EFR Estimated Food Record EHF Extensively Hydrolyzed Casein EI Energy intake EU European Union FAO Food Agricultural Organization FBDG Food Based Dietary Guidelines FFQ Food Frequency Questionnaires FNP Food and Nutrition Policy FR Food Record HAZ Height-for-age HFFQ Health Habits and History Questionnaire MUFA Monounsaturated Fats NCI National Cancer Institute NGO Non Governmental Organization NHANES National Health and Nutrition Survey NIV Nutrient Intake Value PEM Protein – Energy Malnutrition
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PRI Population Reference Intake PUFA Polyunsaturated Fats RDA Recommended Daily Allowances RNI Reference Nutrient Intake RR Relative Risk SACN Scientific Advisory Committee on Nutrition SAS Statistical Analyses System SDI Suggested Dietary Intake SFA Saturated Fatty Acids SOK Statistical Office of Kosovo SPSS Statistical Package for the Social Sciences - SS Skinfold Thickness TEE Total Energy Expenditure UK United Kingdom UNICEF The United Nations Children's Fund USA United States of America WAZ Weight-for-age WB World Bank WDR Weighted Dietary Record WHO World Health Organization WHZ Weight-for-height
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Contents
1 Introduction ...... 1 1.1 Background ...... 1 1.2 Brief introduction ...... 1 1.3 Statement of the Problem ...... 3 1.4 Research Assumption and Hypotheses ...... 5 1.5 Research Contribution ...... 5 2 Review of Literature ...... 7 2.1 Nutrition in Childhood ...... 7 2.2 Actual Nutritional Problems and Nutritional Status of Preschool Aged Children ...... 7 2.2.1 Undernutrition and Malnutrition ...... 8 2.2.2 Overnutrition ...... 12 2.2.3 Food and Nutrient Intake ...... 15 2.3 Nutritional Assessments of Children ...... 21 2.3.1 Methods for Anthropometric Assessment...... 21 2.3.2 Methods for Dietary Intake Assessment ...... 27 2.3.3 Development of Dietary Guidelines/ Nutrition Recommendations ...... 28 3 Research Methods ...... 34 3.1 Introduction ...... 34 3.2 Research Design ...... 35 3.2.1 The Sample Size of the Study ...... 36 3.2.2 Preparation for the Performance of Survey ...... 37 3.3 Instruments ...... 39 3.3.1 Anthropometrics...... 39 3.3.2 Dietary Intake ...... 40 3.4 Data Collection ...... 43 3.4.1 Measurement Procedure for Anthropometrics ...... 43 3.4.2 Measurement Procedure of Dietary Data ...... 44 3.5 Data Analyses ...... 46 3.5.1 Anthropometric Data Processing ...... 46 3.5.2 Dietary Intake Assessment Data Processing ...... 47
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3.5.3 Data Processing of Frequency Food Intake of Specific Food Groups ...... 47 3.5.4 Statistical Analyses ...... 47 4 Results and Discussions ...... 48 4.1 Introduction ...... 48 4.2 Anthropometric Results and Discussions ...... 48 4.2.1 Results by Public and Private Kindergarten ...... 59 4.2.2 Results and Discussions of Growth Indicators ...... 62 4.3 Results and Discussions of Food and Nutrient Intake ...... 70 4.3.1 Main Ingredients, Special Carbohydrates and Fatty Acids ...... 71 4.3.2 Results and Discussions for Micronutrients ...... 81 4.4 Results and Discussions of Dietary Habits and Food Frequency Intake ...... 93 5 Conclusions and Recommendations ...... 103 5.1 Conclusions ...... 103 5.2 Recommendations ...... 107 5.2.1 Recommendations for Kosovo Institutions ...... 107 5.2.2 Recommendations for kindergartens and parents ...... 108 5.2.3 Recommendations for further research ...... 109 5.2.4 Limitations of the study ...... 109 6. Summary ...... 110 Zusammenfassung...... 113 References ...... 117 ANNEXES ...... 136
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1 Introduction
1.1 Background
The assessment of nutritional status in childhood helps in estimating growth patterns and is useful to identify and prevent disorders which are associated with malnutrition or excessive food intake. Different diseases of adults are considered to have close relationship with malnutrition and incorrect or improper nutrition in childhood. The association between childhood diet and being underweight or overweight as children or even as an adult has been shown in numerous studies (Dennison et al., 1997; Gonzales-Suarez et al., 2009; Nuruddin et al., 2008). The family attention and awareness on the need to improve child’s nutrition from an early age, as well as nutrition policy are also considered of great importance for improving diet in preschool and school institutions. Nutritional status is determined through anthropometric, biochemical, clinical, dietary, and socioeconomic assessments. Each of these components reflects a child’s nutrient requirements for optimal health and nutritional status (Mahan & Escott-Stump 2000).
1.2 Brief introduction
This dissertation is divided into five chapters as outlined in the Figure 1. An introduction to the thesis is provided in Chapter one. It comprises of a brief Introduction, the problem statement of the research and description of the current situation related in the field. The research assumptions, hypothesis and research contribution are also presented and highlighted in the first part. Chapter two consists of a review of relevant current literature on nutritional problems of preschool aged children. This Chapter presents also a literature overview on the evaluation of nutritional status of children attending kindergartens. Chapter three explains the research methodology used in this study, including data collection methods and processing of collected data. Chapter four presents the findings and discussions, providing a review of results and discussions on dietary intake and anthropometric components. This Chapter is also focused in comparison and evaluation of results of the study with other relevant results from the literature. The last fifth Chapter describes conclusions and recommendations based on study results, including proposals for further research
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Figure 1: Structure of thesis
Background
Statement of the Problem Introduction Research Assumption Research Contribution
Nutrition in Childhood Undernutrition and overnutrition Review of Literature Food and Nutrient Intake Nutrition Assessment of Childre
Research Design and Sample Size
Instruments Data Collection Research Methods Data Analyses
Anthropometrics Food and Nutrient Intake Dietary Habits and Food Frequency Results and Discussion Intake
Conclusions Conclusions and Recommendations Recommendations Further Needed Studies Limitations of the Studies
Source: Own sources (2013)
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1.3 Statement of the Problem
Kosovo1 as the youngest country in the world is amongst a few countries without any National Nutrition Strategy. According to the Kosovo education statistics of the year 2008/2009, there were 443.912 children enrolled in the pre-primary, primary and secondary schools (Kosovo education statistics 2008/2009). The number of preschool establishments (kindergartens) was 40 with a total of 5.091 children enrolled, divided into two groups: a) toddlers with the children aged 1-3 years and b) preschoolers with the children of aged 4-5 or 6 years. The total number of preschool children participating in pre-preschool education system (5-6 years) was 19.674. As a part of the ex- Yugoslavia, Kosovo was the most under-developed region. The war of 1998-1999, severely affected the health and welfare of the population in this country. Based on literature exploration statistics and investigation on nutrition and health characteristics of the country seem to be scarse. The pre-war official ex-Yugoslav health and nutrition statistics for Kosovo should be taken with caution because almost all Albanians (95% of the entire Kosovo population) did not use state health care but rather utilized the alternative health care system operated with the support of NGO Mother Teresa society (Lefevre-Cholay, 1999 p. 9). Although there are little available statistics on health and nutritional status of the population in Kosovo before the war, but also after the war, some surveys have been carried out by international organization such as WHO, FAO, UNICEF, WB etc. A 1998 survey of Kosovo children aged from 6 months to 5 years (UNICEF 1998) reported the prevalence of acute malnutrition at 2% (including 0.2% severe). Chronic malnutrition was present in 9, 4% (including 2.1% severe). The next survey of July 1999 showed slight deterioration (UNICEF 1999). Acute malnutrition was detected in 3.1% of the children from 0 to 5 years (including 1% severe) and chronic malnutrition was present in 10.7% of the children (including 3% severe). A survey conducted by Action against Hunger –UK (2000) indicated that acute malnutrition was present in 4.7 % (95% CI: 3.0 – 7.2) of children under 5 and that this rate had been constantly increasing since December 1998. Chronic Malnutrition was instead present in 7.5 % (95% CI: 5.4 – 10.4) of the children. In 2001 United Nations Children’s Fund (UNICEF 2001) in collaboration with the Institute for Public Health of Kosovo promoted a survey on the health and nutrition of women and children.
1 Kosovo has declared independence in February 17th 2008 and has been recognized by more than 100 independent countries from all over the world. Kosovo covers the area of about 11.000 square kilometers and is bordered by Albania in the South-West, by Macedonia in the South-East, by Serbia in the North - East and by Montenegro in the West. The current population number of Kosovo is uncertain with an estimate of around 2 million of inhabitants Agim Rysha (2013): PhD Thesis 3
Besides anthropometric assessments, (height for age; weight for age) they have worked in the identification of iron deficiency and levels of Vitamin A deficiency in children aged 6-59 months. Low height-for-age was found in 10% of the children aged 6-59 months while the prevalence of low weight –for- height was 4%. One fifth of the children studied had low values of Ferritin and the Vitamin A deficiency was observed in one third of children under five. These surveys give a useful information at not only the quantitative indicators, but also at qualitative data about existing beliefs and practices in infant feeding, like: early introduction of the sweetened tea/water and biscuits to infant before 4-6 months; cow’s milk is given to children before 1 year of age; infants are fed using bottle; there is a confusion concerning the timing of introduction of weaning foods introducing them to early or too late; the variety is not appropriate; the amount (caloric content, nutritional value) of weaning foods given is insufficient and some other qualitative data. There are no reports showing evidence that these negative habits were considered and improved as well as evidence of further studies about the effects of the war on the prevalence of chronic malnutrition. The Poverty Assessment in Kosovo, which was done jointly by World Bank (WB) and Statistical Office of Kosovo –SOK (Kosovo Poverty Assessment 2007) showed that about 45 percent of the population in Kosovo is poor. Most of them are concentrated in rural areas. Report shows that economic growth and poverty are remaining stable. Health and nutrition indicators are far below from those o neighboring countries and in particular from EU average. Besides the fact that poverty is remaining stable, the above-mentioned report reveals that the family consumption showed slight increase in urban areas. On the other hand, according to the Nutritional Survey of pregnant women and school children in Kosovo, supported by UNICEF and implemented by the National Institute of Public Health of Kosovo (UNICEF 2010), the overweight amongst school children age 6-13 years, was above the expected prevalence of 2.3%, therefore it is necessary to asses and get data on children overweight in Kosovo preschool institutions, which could help in the prevention of nutritional disorders. This is achieved by performing nutritional evaluation and the interpretation of risk factors for malnutrition and obesity, as well the growth patterns and body changes during childhood. There are very limited data on malnutrition and overweight of preschool -children in Kosovo, but one can assume that it is quite possible to have these phenomena in children coming from families, which differ in terms of incomes and food consumption attitudes. Therefore, it is necessary to know about nutrition (nutritional values of served food in kindergartens; the frequency of meals, adequate presence of fruit and vegetables in children meals, etc.) of children in kindergartens of Kosovo. There is no national nutrition education program in Kosovo.
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This is due to the current economic problems in the country, but also due to limited knowledge capacities in the creation of such programs. Development of dietary guidelines or nutrition programs for schools and kindergartens is considered to be of great importance for improving diet in country’s preschools and schools, thus it is very important to influence nutrition policy and the family care, as well as the awareness on the need to improve child’s nutrition from an early age. From this point of view, the study aims to influence the nutrition policy of Kosovo on long term bases introducing regular nutrition surveys in many different nutrition related issues, such as: how energy and nutrient requirements for children vary depending upon age, sex and activity level as well as awareness about the influence of the number of meals and snacks that are eaten during the day, the energy density of foods consumed, portion size, etc. To this end regular surveys will help improve the nutrition in kindergartens of Kosovo.
1.4 Research Assumption and Hypotheses
It is assumed that nutrition improvement in childhood plays a role in development of adult’s health. Obtained results from this study are assumed to be seriously taken into consideration by Kosovo institutions for development of dietary guidelines or nutrition programs for kindergartens. Furthermore, it is assumed that parents are interested in answering Food Record Questionnaires and Dietary History Questionnaires. Hypotheses 1: The growth of preschool children in Kosovo is not in line with international standards and references for weight - for – age, height - for – age, weight -for - height and BMI Hypotheses 2: The served food varieties in preschool-institutions of Kosovo as well as the food nutrient values are not in line with international recommendations for nutrition of preschool children. Hypotheses 3: The survey on nutrition of preschool children in kindergartens of Kosovo will Influence nutrition policy of Kosovo in developing of dietary guidelines or nutrition programs for schools and kindergartens of Kosovo Hypotheses 4 Development of nutrition programs will improve diet in preschool and school institutions of the Country.
1.5 Research Contribution
This research will contribute to the nutrition of preschool children in Kosovo and give for the first time the overview of the current nutrition situation in kindergartens of Kosovo including the overview of current energy and nutrition values of served meals in kindergartens. The obtained
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results of this study including recommendations will be presented to parents, personnel of kindergartens and state institutions in order to draw the attention and awareness on the need to improve child’s nutrition from an early age. In addition, this study will recommend development of national dietary guidelines and healthy feeding programs. Since the nutrition situation in preschool and school institutions is continually followed by scientific assessments, the Ministry of Education and the Ministry of Health will be recommended to develop University education programs related to nutrition.
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2 Review of Literature
The second chapter presents the literature overview on actual nutritional status and nutritional problems of preschool aged children, evaluation of nutritional status of preschool aged children through measurements of food and nutrient intake, nutritional assessment using anthropometric information and development of nutrition programs and dietary guidelines for schools and kindergartens.
2.1 Nutrition in Childhood
Proper nutrition in childhood is considered to play a crucial role in the physical, mental and emotional development of children through to their later adult age. Children are therefore considered the priority population for intervention strategies (Deghan et al. 2005). Because of the importance of adequate nutrition for children, many nutrition assessment studies are taking place in the preschool institutions to identify their health status. Kindergartens are examples of such preschool institutional settings. In order to determine whether children who attend a kindergarten are receiving proper nutrition, researches include different components while assessing nutritional status of preschool children such as: dietary intake, anthropometric measurements and biochemical testing. Searching of the current literature on the nutritional status of preschool-aged children, we identified very few studies which have used all components for nutritional assessment. This review of literature describes research studies done on dietary intake components and anthropometric measurements of nutritional assessment as well as studies which promote a healthy nutrition in schools and kindergartens through national dietary guidelines and healthy feeding programs.
2.2 Actual Nutritional Problems and Nutritional Status of Preschool Aged Children
All living organisms require nutrients for growth and activity, which are determined by different factors such as: age, gender, environment and genetics, but requirements are also altered by stress, illness, smoking, trauma etc. The amount of intake for children is different to those of adults, or requirements of pregnant or lacing women will be of different qualitative and quantitative nature. Eastwood, (2003, p. 52) defined the optional dietary requirements as “those dietary intakes of nutrients that are most likely to ensure that the individual will attain optimum potential nutritional status for: successful development in utero; growth; learning potential; quality of life; body function, successful pregnancies; adequate milk production for baby’s needs; expectation of long and healthy life; freedom from infection and resistance to diseases
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and response to diseases”. Thus, there is a need for recommendations and guidelines for groups and individuals about the proportional amounts of all needed nutrients, carbohydrates, lipids, proteins, vitamins, minerals and water. Countries throughout the world are at various stages of the nutrition transition. Increasingly, countries are documenting that food insecurity and undernutrition exist side by side with problems of overnutrition and chronic diseases. Investment in applied nutrition research is desperately needed to identify and implement effective approaches for promoting healthy lifestyles (Kennedy, 2005).
2.2.1 Undernutrition and Malnutrition
The problems of under consumption and poor nutritional status continue to exist in developing countries. Over three million worldwide deaths occur from protein –energy malnutrition (PEM) in children under five worldwide annually and malnutrition accounts for a large majority of these deaths (FAO World Food Summit 2008). In the UNICEF model that seeks to explain the etiology of child undernutrition (UNICEF, 1998), the three major contributing factors at the household level are the insufficient access to food, inadequate maternal and child caring practices, poor water and sanitation and inadequate health services. A framework developed also by UNICEF (Fig.2) shows that malnutrition occurs as a result of two immediate causes: inadequate dietary intake and diseases, but also recognizes that poverty, human and environmental resources, economic systems and political and ideological factors are basic causes, thus malnutrition in developing countries (i.e. Rwanda) has high social and economical costs, such as increased mortality and morbidity, loss of human potential, decrease in skills and qualifications, lower productivity and higher poverty rates2. Use of appropriate growth references is very important for identification of malnutrition, particularly for children suffering from severe acute malnutrition. Binagwaho et al., (2011) examined the growth references used prior to 2009 in Rwanda to assess nutritional status of children under the age of five. Because of incorrect use of growth references in Rwanda, a number of children under five who were severely underweight were not identified, and therefore were not treated for malnutrition. It was concluded that due to the high prevalence of malnutrition worldwide in children under five and the implications for morbidity and mortality, it is essential that health professionals and paraprofessionals have access to the best tools possible
2 National Nutrition Policy of Rwanda – October 2005.
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for determining a child’s general nutritional status in community, health center and hospital settings. Pelletier et al., (1995) estimated the percentage of child deaths (aged 6-59 months) which could be attributed to the potentiating effects of malnutrition in infectious disease. The results from 53 developing countries with nationally representative data on child weight-for-age indicate that 56% of child deaths were attributable to malnutrition's potentiating effects, and 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition. For individual countries, malnutrition's total potentiating effects on mortality ranged from 13% to 66%, with at least three-quarters of this arising from mild-to-moderate malnutrition in each case. These results show that malnutrition has a far more powerful impact on child mortality than is generally appreciated, and suggest that strategies involving only the screening and treatment of the severely malnourished will do little to address this impact. The next study conducted by Caulfield et al., (2004) examined whether the risk of dying because of underweight varies by cause of death and to estimate the fraction of deaths by cause attributable to underweight. Their results showed that the relative risk (RR) of mortality because of low weight-for-age was elevated for each cause of death and for all-cause mortality.
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Figure 2: Framework of the relations between basic causes (i.e. poverty, food insecurity) and underlying and immediate causes to child undernutrition
Short - term consequences : Mortality, Long-term consequences: Adult morbidity, disability productivity size, intellectual ability, economic reproductive performance, metabolic and cardiovascular disease
Source: Ruel, 2008 p.22
Overall, 52.5% of all deaths in young children were attributable to undernutrition, varying from 44.8% for deaths caused by measles to 60.7% for deaths attributed to diarrhea. They concluded that a significant proportion of deaths in young children worldwide is attributable to low weight- for-age, and efforts to reduce malnutrition should be a policy priority. Dossou et al., (2003) have
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investigated the nutritional, biological and growth status of Senegalese preschool children previously hospitalized for severe malnutrition. At 5 years after nutritional rehabilitation, the post-marasmic children remained stunted with nutritional indices significantly lower than the control children. Victora et al.; (2008) reviewed the associations between child undernutrition and risk of adult diseases in low-income and middle-income countries. They concluded that under nutrition is associated with reduced adult height, schooling and economic productivity. India is amongst countries with the highest percentage (around 43%) of children under the age of five who are malnourished or undernourished. It is estimated that one in every three malnourished children in the world live in India (UNICEF statistics 2008). Malnutrition is considered to be a leading cause of child mortality in India (Mitra et al., 2004). Das and Bose, (2009) assessed the prevalence of undernutrition among 2-6 year old preschool children of Bauri caste of Nituria Block, Purulia, West Bengal, India. Height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height (WHZ) <-2 z-scores were used to assess stunting, underweight and wasting. Their results revealed that the overall (age and sex combined) rates of stunting, underweight and wasting were 37.0 %, 48.4 % and 21.5%, respectively, demonstrating that the nutritional situation of these children was serious. Ramachandran & Gopalan (2011) has compared the pattern of growth of Indian children as assessed by WAZ, HAZ and WHZ with the WHO standards for growth (2006) and explored the implications of differences in undernutrition rates in the 0-59 months of age group as assessed by these three indices. Their results showed that during the first three months there was no increase in underweight and stunting rates. There was progressive increase in underweight and stunting rates between 3-23 months of age. Low BMI for age and wasting rates were highest at birth. They concluded that poor growth is an adaptation to chronic low energy intake and stunting is a measure of cumulative impact of chronic energy deficiency on linear growth. It is important to prevent stunting because it is not readily reversible. Low BMI is an indicator of current energy deficit. Early detection of energy deficit using BMI for age and expeditious interventions to correct the deficit might be effective in prevention of stunting. Allen (2006) examined the causes of nutrition-related public health problems of preschool children. He considered that many children in developing countries are already nutritionally depleted when they become preschool children. Many are born preterm and with low birth weight because of poor maternal undernutrition during pregnancy. Low infant nutrient deposition in utero and poor micronutrient status during lactation lead to nutritional deficiency in infancy and thus later in life. He added also that during the period of complementary feeding many households will not be able to provide their children with adequately energy dense foods in order to meet the growing needs of the child. The preschool
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children undernutrition (energy, protein, vitamin and mineral deficiencies) is associated with the immunity of the body of the children who can get diseases such as pneumonia, malaria, and diarrhea measles. Ramachandran & Gopalan (2009) in one of their studies investigated undernutrition and infection interactions, exploring which of the five anthropometric indices for assessment of undernutrition (WAZ, HAZ, WHZ and wasting and stunting with low BMI) is associated with more consistent and higher risk of morbidity due to infection in preschool children. They concluded that relative risk (RR) for morbidity due to infections is higher in children with low BMI for age and in children with wasting, therefore the balanced supply of both macronutrients and micronutrients is very important in preventing wasting and infection risk
2.2.2 Overnutrition
On the other hand, developed but also developing countries are facing an increase of diseases where nutrition is considered one of the main determinants. In addition to these consequences on morbidity and mortality, pathologies have considerable economic costs (Hercberg et al., 2008). Davison & Birch, (2001) presented a framework on possible causes and factors associated with childhood overweight and obesity (Figure 3). Wang & Lobbstein, (2006) summarized the available information on recent trends in child overweight and obesity prevalence. They searched PubMed for data in papers published between January 1980 and October 2005. Additional studies identified by citations in retrieved papers and by consultation with experts were included. Data for trends over time were found for school-age populations in 25 countries and for preschool populations in 42 countries. Using these reports, and data collected for the World Health Organization’s Burden of Disease Program, they estimated the global prevalence of overweight and obesity among school-age children for 2006, and likely prevalence levels for 2010. They found out that the prevalence of childhood overweight has increased in almost all countries for which data were available. Exceptions are found among school-age children in Russia and to some extent Poland during the 1990s. Exceptions are also found among infant and preschool children in some lower- income countries. Obesity and overweight has increased more dramatically in economically developed countries and in urbanized populations. They concluded that there was a growing global childhood obesity epidemic, with a large variation in secular trends across countries and recommended effective programs and policies at global, regional and national levels to limit the problem among children. De Onis et al., (2010) analyzed the worldwide prevalence and trends of overweight and obesity among preschool children on the basis of the new World Health Organization standards.
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Analyzing a total of 450 nationally representative cross-sectional surveys from 144 countries they found out that 43 million children (35 million in developing countries) were estimated to be overweight and obese; 92 million were at risk of overweight.
Figure 3: Framework for possible causes and factors associated with obesity and overweight
Source: (Davison & Birch, 2001, p 161).
The worldwide prevalence of childhood overweight and obesity increased from 4.2% (95% CI: 3.2%, 5.2%) in 1990 to 6.7% (95% CI: 5.6%, 7.7%) in 2010. This trend is expected to reach 9.1% (95% CI: 7.3%, 10.9%), or ’60 million, in 2020. The estimated prevalence of childhood overweight and obesity in Africa in 2010 was 8.5% (95% CI: 7.4%, 9.5%) and is expected to reach 12.7% (95% CI: 10.6%, 14.8%) in 2020. They concluded that Childhood overweight and obesity have increased dramatically since 1990 and recommended effective interventions
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starting as early as infancy to reverse anticipated trends. There are also studies which show the prevalence of overweight and obesity in infants and preschool children in the European Union. Cattaneo et al., ( 2010) tried to synthesize available information on prevalence and time trends of overweight and obesity in preschool children in the European Union using the International Obesity Task Force reference and cut-offs, and the WHO standard. Out of available data from 18/27 countries they reported prevalence of overweight plus obesity at 4 years ranges from 11.8% in Romania (2004) to 32.3% in Spain (1998–2000). Another review on existing data on overweight and obesity in infants and children in the European Union was conducted by van Stralen et al., (2012), who studied the prevalence of overweight indices in European preschoolers (4-7 years); energy balance-related behaviors associated with overweight/obesity; and identification of children at risk for overweight/obesity. Secondary analyses of six European data sets were conducted according to standardized protocols. The prevalence of overweight and obesity across the countries ranged from 8% to 30% and 1% to 13%, respectively, with highest rates in Southern European countries (i.e. Spain and Greece). According to the study, children of parents with high body mass index or low socioeconomic status were at increased risk of overweight/obesity. In conclusion, large differences in prevalence of overweight and obesity among preschoolers across Europe were observed. Future obesity prevention interventions in preschoolers should target screen time giving specific attention to children from overweight and/or low socioeconomic status parents. They concluded also that there is a need for high methodological quality studies, preferably with a long-term prospective design using sensitive, valid and reliable measures of behaviors, assessing whether and which physical activity and dietary behaviors are associated with Childhood overweight and obesity on the rise. Childhood obesity is considered to be one of the most serious public health challenges of the 21st century (World Health Organization 2012). The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings. Overweight and obese children are likely to stay obese into adulthood and more likely to develop non communicable diseases like diabetes and cardiovascular diseases at a younger age. The relation between childhood diet and being overweight or obese as children have been shown in many numerous other studies (Jouret et al., 2007; Gonzalez et al., 2009; Rapp et al., 2005; Bayer et al., 2009). While about 50% of the adults are overweight and obese in many countries, it is difficult to reduce excessive weight once it becomes established. Childhood overweight and obesity has become a major global public health issue putting them at risk of serious health conditions such as diabetes, cardiovascular disease and certain cancers. Prevention may be achieved through a variety of
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interventions targeting built environment, physical activity, and diet. Some of these potential strategies for intervention in children can be implemented by targeting preschool institutions (Dehghan et al., 2005).
2.2.3 Food and Nutrient Intake
People eat food, not nutrients; however, it is the combination and amounts of nutrients in consumed foods that determine health. There are more than 50 known nutrients (Table 1) and many more chemicals in food thought to influence human function and health (Gibney et al., 2009). The first attempt to set standards for nutrient intakes was by the Food and Nutrition Board of the National Research Council of the USA in 1941 and Recommended Daily Allowances (RDAs) were published in 1943. Even though the concept of RDAs remained unchanged, some changes occurred with regard to terminology, so the UK adopted the term Dietary Reference Value (DRV), the EU introduced the term Population Reference Intake (PRI), the USA and Canada introduced the term Dietary Reference Intake (DRI), and Australia and New Zealand now use the term Nutrient Intake Value (NIV). All are precisely equivalent to the original concept of the RDA, a term that many countries prefer to continue to use. There are many countries and international agencies that nowadays publish dietary standards or dietary guidelines for nutrient intakes for different groups or populations. Berdanier et al., (2001) in the Handbook of Nutrition and Food has classified the human nutrients needs in the human life cycle as following: nutrition during pregnancy and lactation; feeding the premature infant; feeding the term infant; nutrition for healthy children and adolescents ages 2 to 18 years; the health-promoting diet throughout life: adults and nutrition in the later years. The same author considered that young children cannot innately choose a well- balanced diet, thus they depend on adults to offer them a variety of nutritious and developmentally appropriate foods. (The accurate assessment of food intakes in children and adolescents is an essential prerequisite for monitoring the nutritional status of these age groups, as well as for conducting epidemiological and clinical research on the links between diet and health (Livingstone et al., 2004).
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Table 1: Classes of nutrients for human nutrition
Class/category Subclass/category Nutrient examples
Carbohydrates Monosaccharides Glucose, fructose, galactose (macronutrients) Disaccharides Sucrose, maltose, lactose Polysaccharides Starch and dietary fiber Proteins (macronutrients) Plant and animal Amino acids (n = 20): source proteins aliphatic, aromatic, sulfur-containing, acidic, basic Fats and oils (lipids) Saturated fatty Palmitic and stearic acid acids (macronutrients) Monounsaturated Oleic (cis) and elaidic (trans) fatty acids fatty acids Polyunsaturated Linoleic, α-linolenic, arachidonic, fatty acids (n-3, n-6, eicosapentaenoic, docosahexaenoic acid n-9) Minerals (micronutrients) Minerals and Calcium, sodium, phosphate, potassium, electrolytes, trace iron, zinc, selenium, copper, manganese, elements molybdenum, fluoride, chromium Vitamins (micronutrients) Fat soluble Retinol (A), calciferols (D), tocopherols (E), vitamin K Water soluble Ascorbic acid (C), thiamine (B1), ribofl avin (B2), niacin (B3), pyridoxine (B6), folate, cobalamin (B12) Water Water Water Source: Michael J Gibney et al., 2009. p. 5
The DRI-s covers macronutrients (e.g., proteins, carbohydrates and fats) and micronutrients (e.g., vitamins and minerals) are calculated based on the nutritional need of each age group and gender. There are numerous research studies on dietary intake. Pitsi et al., (2003) evaluated kindergarten menus in the frame of the National Health Program for Children in Estonia in order to guarantee optimal food intake for children. They concluded that there was a need to alter the balance of carbohydrates and fats in favor of increasing starch and lowering saturated fats.
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Insufficient amount of vitamins C and D in meals should be supplemented by adding casseroles, fruit juices and fish dishes. A correction should be made in favor of calcium and iron, and for lower sodium content. Bernardi et al., (2010) used a cross-sectional study of 362 preschool children to estimate the energy and macronutrient intake at home and in the kindergarten in children aged 2 to 6. They investigated as well the differences in consumption and intake between children at public and private kindergartens. Nutritional status was assessed in terms of weight to height ratios, while foods consumed in the kindergarten were evaluated by weighing the actual foods eaten by the children and home intakes were calculated from a food diary kept by parents or guardians. They found that 28 children (7.7%) were overweight, 92 (25.4%) were at risk of becoming overweight and seven (1.9%) were classified as having wasting. Analysis of 24-hour nutritional intake demonstrated that 51.3% of the energy, 60.3% of the lipids and 51.6% of the proteins consumed by children were eaten at home, despite the children spending the whole day in the kindergarten programs. Preschool children at kindergartens ate greater quantities of energy (p = 0.001), carbohydrates (p < 0.001), and lipids (p = 0.04) than did children at public kindergartens, but their total daily intakes were similar, irrespective of which type of kindergarten program children attended. Huybrechts & De Henauw, (2007) through 3 days estimated diet records have investigated energy and nutrient intakes in preschool children (between 2·5 and 6·5 years) in Flanders-Belgium. Usual energy and nutrient intakes were compared with national and international recommendations. Statistical modeling was used to account for within-individual variation. Mean daily energy intakes (boys, 6543 kJ; girls, 5757 kJ) approached the estimated energy requirements (EER) (boys, 6040 kJ; girls, 5798 kJ) for children 4 years old. For children at least 4 years old, mean energy intakes (boys, 6408 kJ; girls, 5914 kJ) were below the EER of 6995 and 6740 kJ/d, respectively. Mean energy percentage (en %) derived from saturated fatty acids (SFA) (13–14 en%) was above the acceptable macronutrient distribution range (AMDR) upper level of 12 en%. Mean percentages derived from monounsaturated fats MUFA (10–11 en%) and polyunsaturated fats PUFA (4–5 en%) were below the AMDR lower levels of 12 and 8 en%, respectively. For fibre, iron and vitamin D intakes, 15% of the children reached the recommended dietary allowances. Everybody exceeded the tolerable upper intake levels for sodium. Although diets in Belgian children were adequate in most nutrients, the implications of low iron, vitamin D and fibre intakes should be investigated. Furthermore, this affluent diet, characterized by SFA, MUFA and PUFA intakes differing from the recommendations and excessive sodium intakes, might increase the risk for CVD (cardiovascular diseases in later life). In the next study, Huybrechts et al., (2008) compared food group intakes among preschool children (2.5–6.5 years) living in Flanders
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(Belgium) with Food-Based Dietary Guidelines (FBDG) and determined the proportion of children meeting these guidelines. Mean daily intakes of most food groups (beverages, vegetables, fruit and milk) were below the minimum recommendations. Only ‘grains and potatoes’ and ‘meat products’ were in line with the recommendations and ‘bread and cereals’ showed borderline intakes. Mean intakes of energy-dense and low-nutritious foods, which are discouraged within a healthy diet (like snacks and sugared drinks), were high. Furthermore, the percentage of children complying with the different food-based dietary guidelines was for most food groups extremely low (ranging from approximately 4% for fluid and vegetable intakes up to 99% for potato intakes). Boys had in general higher mean intakes of the recommended food groups. In conclusion, preschool children in Flanders follow eating patterns that do not meet Flemish FBDG. Although the impact of these eating habits on preschooler’s current and future health should be further investigated, it is clear that nutrition education and intervention are needed among preschool children and their parents in Flanders. Mishra et al., (2001) have assessed nutritional status and the dietary intake of the preschool children of urban slums in India. Their study reveals gross deficiency in dietary intake; about 75% of preschool children were malnourished with 20% suffering from severe degree of malnutrition. Although intake of protein and vitamin A was comparatively better in more than 90% of study subjects, consumption of calories, iron calcium was below 50% of RD). Grover & Singh, (2006) have analyzed the Food and Nutrient Intake of Rural Preschool Children in Punjab. The diet of rural preschool children was found to be imbalanced with plenty intake of milk and milk products and low intake of cereals, pulses and green leafy vegetables. The data of present study revealed that the requirement of macronutrients was adequately met with the intake of milk. The intake of protein and fat of rural preschool children was one and a half to two times of RDA in all the regions. Further, intake of energy was adequate in sub - mountain (103%) and nearly adequate in central plains (89%) and south -western (88%), whereas the intake of iron, ascorbic acid and niacin was inadequate. The study highlighted that the intake of food and nutrient by rural preschool children of sub-mountain region was significantly higher than those of southwestern region. Kim et al., (2008) have estimated the selected nutrient intakes of young Korean children, and compared these intakes with current Dietary Reference Intakes for Koreans. This study included 136 healthy children (65 boys, 71 girls), 2-6 y old, living in Kwangju, Korea. Weights and heights were measured. Three consecutive 24-h food recalls were obtained. The energy intakes of 40% were less than Korean Estimated Energy Requirements, while all subjects consumed more than Korean Estimated Average Requirement (EAR) for protein. The majority of the children consumed more than Korean EAR for iron, zinc, vitamin B1, vitamin B2, vitamin
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B6, and niacin. Vitamin E intakes of 65% of the Korean children were less than Korean Adequate Intake, and approximately half of the subjects had less than Korean EAR for calcium and for folate. Many young children in Kwangju, Korea, likely have inadequate status of calcium, folate, and vitamin E. After an increasing prevalence of overweight and obesity has been documented in preschool children in Ho Chi Minh City (HCMC), Vietnam, Huynh et al., (2008) investigated about what preschool children in HCMC eat and how well their nutrient intake meets nutrient recommendations. They found that the dietary intake of the participants contained more energy from protein and fat, particularly animal protein and fat, and less energy from carbohydrates, than the RDA. Most children (98.1%) had mean energy intake from protein greater than the recommended level of 15%, and no child obtained energy from animal fat that was in accordance with the recommendation of less than 30% of the total fat intake. Nearly one half of children (46.5%) consumed less than the advised range of mean energy intake from carbohydrate (60%–70%). They recommended development of healthy eating programs as a part of an obesity prevention program for young children in HCMC. Golder et al., (2000) studied possible macro- and micronutrient deficiencies in the traditional Maldivian diet using a 24-hour recall. They concluded that the women's and children's diets were sufficient in protein (14%) and carbohydrates 67%) but deficient in fat, which contributed only 19% to the total energy intake. Consumption of dietary substances that depend on vegetable and fruit intake (e.g. b- carotene, vitamin C, dietary fibre and folic acid) was low. The low intake of b-carotene was underlined by low plasma concentration. The estimated iron intake was low, although blood hemoglobin levels were normal. They concluded that marginal nutritional status and marginal malnutrition are due to low fat intake and selected micronutrient deficiency. Higher intakes of locally available vegetables and fruits and fat (especially for children) on a regular basis might reverse the deficits documented on the atolls. Kranz et al., (2008) used Revised Children’s Diet Index to determine the level of overall diet quality, sociodemographic predictors (age, sex, sociodemographic, ethnic group, household income, preschool attendance, federal food program participation) of diet quality, and the association between diet quality and body weight status in a nationally representative sample of preschoolers. They found out the following: On average, preschooler consumed suboptimal levels of whole grains, fruits, vegetables, and dairy. Overall diet quality decreased with increasing age (beta-coefficient: -2.38, p < 0.001) but improved with increasing family income in the full sample (beta-coefficient: 1.22, p < 0.001) but not in the low-income sub populations. Mexican American children had significantly better diet quality than non-Hispanic white children (beta-coefficient: 2.18, p < 0.033) especially in the low income group (beta-coefficient: 3.57, p < 0.006). Childhood obesity prevalence decreased
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significantly with increasing diet quality. A study on food consumption and nutrient intake in Finnish 1-6-year old children was conducted by Kyttälä et al., (2010). Their assessment of the effect of age and sex on food consumption and nutrient intake has shown that the energy- adjusted consumption of fruits and berries, cereal products, infant formulas and meat dishes was higher and the consumption of vegetables, salads, breads, dairy products, fat spreads, drinks, sweets and sugar was lower among 1-year-old children than older age groups. The mean daily energy intake increased with age and was higher among boys than girls in all age groups, except among the 2-year-olds while the diet of the 2-6-year-old children contained too much saturated fat and sucrose, and too little PUFA compared with the current Nordic Nutrition Recommendations. They concluded that the nutrient density of the diet decreased after the age of 1 year at the time that the children adapted to the regular family diet, thus they recommended evaluating the diet of the whole family. Lehtisalo et al.; (2010) compared food consumption and nutrient intake in day care and at home in 3-year-old Finish children. They found out that amongst the children cared for outside the home, there were more consumers of recommendable foods as fresh vegetables, fruits, berries, rye bread, fish, skimmed milk and vegetable margarines, than among those cared for at home. The day-care group had higher intake of protein, dietary fibre, thiamine, potassium and magnesium, and lower intake of sucrose compared with the group cared for at home. Adjustment for sociodemographic factors did not change the results. In all children, food consumption was more varied on weekdays compared with weekends. On weekdays, children had higher intake of dietary fibre and protein and lower intake of sucrose compared to weekends. They concluded that the type of day care was associated with food consumption and nutrient intake among preschool children and hence might have an impact on their nutrition and health. The diet of the children attending day care outside the homes was more balanced and closer to the national recommendations. Nutrient intakes and status of preschool children in Adelaide, South Australia was determined by Zhou et al., (2012). The results of their survey showed that median energy intakes were within dietary recommendations for the age group and the overall energy contributions from carbohydrate, protein, fat and saturated fat intakes were 50%, 17%, 33% and 16%, respectively. The rates of inadequate intake of iron, zinc, calcium and vitamin C were low, as was the prevalence of iron deficiency (5%). Only a minority of children achieved the adequate intake for n-3 long-chain polyunsaturated fatty acids (32%) and dietary fibre (18%). There was no association between socioeconomic status and intakes of macronutrients and key micronutrients. Fourteen per cent of children were obese (BMI, > 95th percentile); no association between BMI and energy intake was shown. They concluded that the dietary intake of children in the study was adequate for
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macronutrients and the majority of micronutrients. However, low intakes of fibre and n-3 long- chain polyunsaturated fatty acids and high saturated fat intakes have raised concerns that this dietary pattern may be associated with adverse long-term health effects.
2.3 Nutritional Assessments of Children
Nutritional assessment in children is needed to determine their nutritional status and problems, which might occur, and if identified, to treat such problems in order to prevent them from becoming larger and threatening children’s health. Lee & Nieman, (1996) have defined the nutritional assessment as "an evaluation of the nutritional status of individuals or populations through measurements of food and nutrient intake and evaluation of nutrition-related health indicators". Nutritional status cannot be defined by a single method of a nutrition assessment but rather a combination of different methods (Mascarenhas et al., 1998). Therefore, a nutritional assessment typically consists of anthropometrics, biochemical data, clinical data, dietary data, socioeconomic demographics, and drug- nutrient interactions. According to Rutishauser & Black, (2002) nutritional status can be assessed by combining measurements of dietary intake, anthropometric indicators, Biomarkers3 and clinical and or physical indicators. Biomarkers provide an indication of a limited number or range of nutrient level, or can be used with varying precision as a proxy measure for the intake of some nutrients (Nelson et al., 2004). One example of combined measurements is National Diet and Nutrition Survey (NDNS) in UK which collects different data using a variety of collection methods. After food diaries and anthropometric data are taken, they are analyzed alongside with blood and urine samples, Blood samples are analyzed in order to determine the concentration and functional adequacy of nutrients absorbed by the body and those held in body stores, while urine analysis is used to see the indication of sodium and thus, is used as a proxy for salt intake. These analyses and assessments provide an indicator for nutritional status (Nelson et al., 2007).
2.3.1 Methods for Anthropometric Assessment
Anthropometry is the study of the measurement of the human body in terms of the body size, shape and composition. The word “anthropometry” is derived from the Greek word “anthropo” meaning “human” and the Greek word “metron” meaning “measure” (Ulajaszek, 1994). The field
3Biomarkers are biochemical indicators that can be assessed in blood, bodily fluids, body tissues or excreta and provide an indication of a limited number and range of nutrient levels. Agim Rysha (2013): PhD Thesis 21
of anthropometry encompasses a variety of human body measurements such as: weight, height, skin fold thicknesses, circumferences, limb lengths, and breadths. The measurements vary with age (and sometimes with sex and race) and degree of nutrition and they are particularly useful in circumstances where chronic imbalances of protein and energy are likely to have occurred. In some cases they can detect moderate and severe malnutrition, but the methods cannot be used to identify specific nutrient deficiency states. Anthropometry methods have the additional advantage of providing information on past nutritional history which cannot be obtained with equal confidence using other assessment techniques (Gibson, 2005). Several advantages and limitations of nutritional anthropometry are summarized in Table 2. In childhood, height (stature) and weight are the two most frequently used measures of growth and nutritional status, while indices of weight for height, especially BMI are used as a proxy for body fatness or obesity. For the children less than two years the infant stature is measured as recumbent length and height in the standing position is measured for children over two years of age. Body weight is measured with the child in underwear or in light clothing, without shoes. BMI (weight/height²) provides a guideline based on weight and height to determine underweight or overweight. There are two international growth standards which are mainly used for the screening, surveillance, and monitoring of preschool children; WHO Child Growth Standards (World Health Organization) and U.S. CDC Growth Charts (Centers for Disease Control and Prevention). Both standards describe weight for age, length (or stature) for age, weight for length (or stature), and body mass index for age. Whereas the WHO charts are growth standards, describing the growth of healthy children in optimal conditions, the CDC charts are a growth reference, describing how certain children grew in a particular place and time. However, in practice, clinicians use growth charts as standards rather than references (Laurence et al., 2010). In 2006, the WHO, in collaboration with a number of institutions worldwide has developed and released new growth standards for infants and young children (De Onis et al., 2004; De Onis et al., 2006). Growth references for children over 5 years were released in mid 2007 (De Onis et al., 2007). The WHO recommends the application of these standards for all children worldwide, regardless of ethnicity, socioeconomic status and type of feeding (Onyango et al., 2007).
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Table 2: Advantages and limitations of the Nutritional Anthropometry
Advantages Disadvantages
Methods are precise and accurate, provided The relative insensitivity to detect changes standardized techniques are used in nutritional status following inadequacy of food over short periods of time Procedures use simple, safe and non-invasive The inability to distinguish the effect of techniques specific nutrient deficiencies (e.g. zinc deficiency) that affect growth in children from that due to inadequacy of food in general Equipment required is inexpensive, portable The inability to pinpoint the principal and durable, and can be made or purchased causality of undernutrition, as the poor locally nutritional status may be the result of factors such as repeated insults owing to infections and poor care in children Relatively unskilled personnel can perform The relative higher costs and organization measurement procedures required to obtain representative and quality data for the purpose of estimating numbers of undernourished Methods can be used to quantify the degree of undernutrition (or overnutrition) and provide a continuum of assessment from under-to overnutrition Methods are suitable for large sample sizes such as representative population samples
Methods can be used to monitor and evaluate changes in nutritional status over time, seasons, generations, etc. Methods can be adopted to develop screening tests in situations such as nutrition emergencies to identify those at high risk
Source: Gibson 2005, p. 234 On the other hand, in 2000, the CDC produced a revised set of reference growth curves. These are based on more recent data solely collected from the USA National Health and Nutrition Survey (NHANES) program. In 2006, CDC, the National Institutes of Health, and the American Academy of Pediatrics convened an expert panel to review scientific evidence and discuss the potential use of the new WHO growth charts in clinical settings in the United States. On the
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basis of input from this expert panel, CDC recommends that clinicians in the United States use the 2006 WHO international growth charts, rather than the CDC growth charts, for children aged <24 months, while the CDC growth charts should continue to be used for the assessment of growth in persons aged 2--19 years (Kuczmarski et al., 2002). De Onis et al., (2007) compared the WHO and CDC curves and evaluated the growth performance of healthy breast-fed infants according to both. They found important differences between the WHO and CDC charts that vary by age group, growth indicator, and specific Z-score curve. Differences were particularly important during infancy, which they considered to be likely due to differences in study design and characteristics of the sample, such as type of feeding. Overall, the CDC charts reflected a heavier, and somewhat shorter, sample than the WHO sample. According to Mercedes de Onis et al. this resulted in lower rates of undernutrition (except during the first 6 months of life) and higher rates of overweight and obesity when based on the WHO standards. There are also other studies which have compared the WHO growth standards with other growth references and assessments, analyzing whether the WHO standards can affect the prevalence of underweight worldwide, as well as the distribution of Z scores. Numerous conducted studies have documented that the WHO standards in general correspond with assessment of malnutrition (Nash et al., 2006; Yang & de Onis, 2008; Mei & Grummer-Strawn, 2007; Sguassero et al., 2008). The WHO (WHO 2007) and CDC (CDC 2000) data are available as percentile charts for both males and females. CDC data only provides tables to calculate Z scores, whereas Z scores from the WHO dataset are available as a chart in the Table 3. Available software is shown in the Table 4 (WHO 2009). Anthropometry is a practical and immediately applicable technique for assessing children's development patterns. Even though, the anthropometric indicators are less accurate than clinical and biochemical techniques when it comes to assessing individual nutritional status, however, anthropometry can be used as a screening device to identify individuals at risk of undernutrition, followed by a more elaborate investigation using other techniques (Gorstein & Akre, 1988). On the other side, BMI has been recommended as the most appropriate single indicator of overweight and obesity in children and adolescents outside of research settings (Himes & Dietz, 1994; Barlow & Dietz, 1998; Krebs et al., 2007).
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Table 3: WHO and CDC available charts WHO (percentiles and Z scores) CDC (percentiles only) Weight for age 0-6 months 0-3 years 0-2 years 2-20 years 6 months – 2 years 2 – 5 years 0-5 years 5-10 years Length/ height/ stature for age 0-6 months 0-3 years 0-2 years 2-20 years 6 months – 2 years 2 – 5 years 0-5 years 5-19 years Weight for length/ 0-2 years 0-3 years(45-103 cm) height /stature 2-5 years 2-5 years (77-121 cm) 2-20 years BMI for age 0-2 years 2-20 years 2-5 years 5-19 years Source: Adopted from WHO growth references (2007) and CDC growth charts (2000)
Ramachandran & Gopalan, (2011) conducted an assessment of nutritional status in Indian preschool children using WHO 2006 Growth Standards. They have compared the pattern of growth of Indian children as assessed by weight for age, height for age and BMI for age with the WHO standards for growth (2006). Their results have showed a progressive increase in overweight and stunting rates between 3-23 months of age while low BMI for age and wasting rates were highest at birth.
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Table 4: Available Computer software for WHO growth references and CDC growth charts WHO (WHO 2009) CDC (CDC 2000) Software Description Software Description WHO Incorporates growth Epi Info™ Includes NutStat which AnthroPlus 2009 standards. Includes calculates percentiles and Anthropometric zscores using either the 2000 calculator (AC) CDC or the 1978 CDC/WHO Individual growth reference assessment (IA) Nutritional survey (NS), Macros SAS, S-Plus, SPSS SAS program Generates a dataset that and STATA contains indices of the anthropometric status of children from birth to 20 years of age based on the 2000 CDC growth charts WHO Anthro Software for use on STAT Program for Palm OS or Mobile mobile devices Growth BP Windows Mobile Pocket Devices running PC19 MS PocketPC 2003 or MS Windows Mobile 5.0 Source: Adopted from WHO Growth references (2009) and CDC growth charts (2000)
They considered the low BMI as an indicator of current energy deficit and concluded that early detection of energy deficit using BMI for age and interventions to correct the deficit might be effective in prevention of stunting. Shoeps et al., (2011) evaluated growth and nutritional status of preschool children between 2 and 6 years old from low income families from 14 daycare centers of Santo Andre, Brazil. Weight, height and BMI were classified according to 2000 CDC. Mean z-scores of H, W and BMI in assessed children was above the median of CDC reference and tended to rise with age. The frequency of children below – 2 z scores was lower than they expected while the prevalence of overweight and obesity was 16.8% and 10.8%, respectively. They have concluded that low income preschool children are in an advance stage of nutritional transition with a high prevalence of overweight. Freedman et al., (2009) have studied the relation of BMI and skinfold thickness (SS) to cardiovascular diseases (CVD) risk factors in children. Their results have shown that BMI was more strongly related to risk factor levels than was the SF and that the BMI is at least as accurate as SF in identifying children and adolescents who
Agim Rysha (2013): PhD Thesis 26
are at metabolic risk. Rzehak et al, (2009) have investigated the potential differences in BMI and growth in children fed with partially hydrolyzed formula. Analyses of weight and length revealed differences due to a slightly diminished weight gain in the first year of life. The authors concluded that feeding with EHF-C (extensively hydrolyzed casein) led to a transient lower weight gain in the first year of life
2.3.2 Methods for Dietary Intake Assessment
The dietary intake is one of components for the nutritional assessment among preschool-aged children. Accurate assessment of dietary intake among preschool-aged children is important for clinical care and research, for nutrition monitoring and evaluating nutrition interventions, and for epidemiologic research (Serdula et al., 2001). Dietary data which might be collected through different assessment methods can provide information on food consumption at the national level, household level and individual level. There are different dietary assessment methods. Techniques commonly used to assess the diets of preschool-aged children include respondent- based methods, such as dietary recalls, dietary records, and food frequency questionnaires (FFQs), investigator-based techniques, such as direct observation and collection of duplicate portions, and physiologic measures, such as doubly labeled water, or biomarkers of dietary intake, such as serum carotenoids (Gibson, 1990). Most studies of dietary data collection methods focus on the ability of a method to estimate nutrient intake accurately, and the validity of a diet method depends on the use of a standardized methodology, the interviewer’s skill, and the subject’s ability to report intake accurately. On the other side the reliability or reproducibility of a diet method relates to actual within person variability in intake as well as to measurement error which may be introduced by the subject (the interviewer), the methodology (such as the food measurement aids used to estimate portion size), and functions such as food coding (Committee on Dietary Risk 2002). In choosing a dietary assessment it is important to make clear whether the research intends to document intake of foods or intake of nutrients. Annex 1 provides definitions and abbreviations for dietary assessment methods and reference methods while Annex 2 (Stang & Story, 2005) presents Strengths and Limitations of Various Dietary Assessment Methods Used in Clinical Settings. The different methods about food intake should be tested for reliability and validity. Reliability refers to the likelihood that an instrument will measure the same thing each time it is used - either with the same or a different respondent. Validity refers to how accurately the instrument reflects the actual behavior (Roberts et al., 2009). The accurate assessment of food intakes in children is very important. The reporting accuracy when assessing the dietary intakes of
Agim Rysha (2013): PhD Thesis 27
children is also very important. Livingstone et al., (2004) have evaluated the impact of measurements issues on reporting accuracy when assessing the dietary intakes of children and adolescents and, in addition they have reviewed validation studies using doubly labeled water as a biomarker of energy intake (EI), variables associated with misreporting, and issues related to the identification of misreporters and data interpretation. They concluded that much of dietary data on children and adolescents is prone to reporting error, mostly in the form of underreporting. Improvement of estimates of dietary intake depends also on the food composition database systems, which besides the food names contains also the level of different food components, thus the accuracy of the data base is very important during the assessment of the dietary intake. The synergy between food composition data and dietary assessment was shown by Pennington et al., (2007) in the Figure 4, where food intake data are converted into food component intake using food composition database and then compared to intake standards. They stated also that the “credibility of the final intake evaluation is increased synergistically if both the food composition data and the dietary intake methods are of the highest quality.
2.3.3 Development of Dietary Guidelines/ Nutrition Recommendations
Different Countries develop nutrient-based and food-based guidelines for food served to different population groups in public sector settings such as preschool and school institutions, hospitals, armed forces, prison services, residential care for old people, but also to population groups in residential premises. The aim of the guidelines is to help food providers with menu planning and to ensure that certain served population groups have access to a healthy food and to the balanced diet. In addition the guidelines help to promote specific menu choices, increase nutritional quality in the public sector and suggestions for healthy eating. In 2007, the WHO Regional Committee for Europe has endorsed the Action Plan inviting member states to develop and implement food and nutrition policies since the burden of diseases associated with poor nutrition continue s to grow in the European region (WHO European Action Plan for food and nutrition policy 2007- 2012 (2008). According to the EU Food Nutrition (European Nutrition and Health Report 2009), the development of policies addressing food and nutrition in Europe is focusing in prevention of nutrition – related health problems.
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This Report showed that twenty one of 25 countries provided data about FNP (Food and Nutrition Policy). All of them had a specific policy document on food and nutrition or various nutrition related programs.
Figure 4: The dietary assessment process
Source: Jean A.T. Pennington et al. 2007, p. 2109
On the other side, nutritional knowledge is very important in prevention of diseases originated from a non proper nutrition in all ages. It is very common that countries develop instruments and materials for nutrition education. Stehle, (2007) has evaluated the material used for nutrition education and teaching in Germany. He concluded that in Germany, nutritional knowledge is successfully disseminated using instruments, which are based on actual scientific evidence. He considered that quantitative aspects can be easily enlightened with the help of Nutrition Circle (Figure 5) than the importance in using of a flyer wording 10 Nutrition Guidelines (Figure 6) as a lifestyle factor to stay healthy and finally use of 3D Food Guide Pyramide (Figure 7) for establishment of new teaching programs with a high level of acceptance. Another assessment of evaluated programs for preschool children with the main focus on obesity prevention, promotion of physical activities and nutrition education in kindergartens in Germany was conducted by Wagner et al., (2005).
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Figure 5: Nutrition Circle
Source: Peter Stehle, 2007, p.22
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Figure 6: The 10 Nutrition Guidelines
Source: Peter Stehle 2007, p.23
Their results showed an enormous demand on evaluated intervention programs for kindergartens children, their relatives and teachers.
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Interventions targeted at healthy nutrition need to occur early in childhood and adolescence in order to prevent or reverse the adverse health effects of overweight and poor eating habits (St- Onge et al., 2003).
Figure 7: The 3D Food Guide Pyramid, 2006.
Source: Peter Stehle 2007, p.24
The WHO Regional Office for Europe considers that a single European school food and nutrition policy cannot be formulated due to wide cross-country variation among schooling systems; therefore it is essential for each country, authority or school to decide which of the suggestions for school nutrition and food policy are most appropriate and applicable to their circumstances. (Steps To health, 2007; WHO Regional Office for Europe, 2006) The examples on how some Countries set food or nutrient guidelines are presented below. Health nutrition in schools and kindergartens is done through national dietary guidelines and healthy feeding programs designing quality diets for preschool and school children. The guidelines are based on national nutrition recommendation and show clearly how the meal should be organized, and describe the nutrition composition of the food (Lund-Iversen & Rimestad, 2007). In the UK, dietary reference values provide population-wide guidance on intakes of energy (calories) and various nutrients (vitamins and minerals). In Scotland for
Agim Rysha (2013): PhD Thesis 32
instance caterings are provided with the computers in order to plan and monitor the food served against the nutrient-based standards (Nutritional Guidelines for Food Served in Public institution (UK Food Standards Agency www.cwt.org.uk). Tables (Annex 3 and Annex 4) presented in the same Report outline the derived nutrient based guidelines for 1-4 years olds children summarizing the proportion of nutrients that each eating occasion should achieve for children in child care In 2010 the Dietary Guidelines for Americans (2010) was introduced which was intended to be used in developing of educational materials and aiding policymakers in designing and carrying out nutrition - related programs, nutrition education and information programs in order to improve the public health. The Guideline consist of the following key recommendations: balancing calories to manage weight; foods and food components to reduce; foods and nutrients to increase and building healthy eating patterns. This Report amongst other gives guidance for specific population groups, estimated calorie needs per day by age, gender and physical activity level, recommended macro and micronutrient proportions by age as well as nutritional goals for age-gender groups, based on DRI and Dietary Guidelines Recommendations. Detailed information related to DRI: RDA and AI are available in the web page. 4
4 http://www.iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files /Nutrition/DRIs/5_Summary%20Table%20Tables%201-4.pdf
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3 Research Methods
3.1 Introduction
Preschool–aged children attending kindergartens in Kosovo were chosen as subjects in this research study titled “Nutrition in Kindergartens of Kosovo”. Nutritional status of the children was assessed through combining measurements of anthropometric indicators and dietary intake. This Chapter as outlined in Figure 8 includes the introduction, research design, instruments data collection and data analyses. The main objective of this study was to provide a nutritional status profile of children who attend public and private kindergartens from different regions of Kosovo (Prishtinë; Ferizaj; Kamenicë and Obiliq) Figure 8: Research methods
Data analyses
Data collection
Instruments
Introduction
RESEARCH METHODS
Source: Own picture (2012)
The specific objectives of this study were the following: 1. Profile of anthropometric indicators of selected samples (weight-and height-for-age, as well as weight-for-height and BMI). 2. Profile on food and nutrient intake (compared with Dietary Reference Values) 3. Frequency food intake of specific foods
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3.2 Research Design
This was the first cross-sectional study conducted in preschool settings (kindergartens) in Kosovo that sought to construct for the first time a profile of the nutritional status of preschool children. This study represents the nutritional status of preschool children attending the five randomly selected kindergartens from different regions of Kosovo. Figure 9 presents the mapping of locations where the research has taken place. Preschool education in Kosovo is currently organised as follows: in public preschool settings (kindergartens including children of 1-3 years of age and 3-6 years of age); in private preschool settings (kindergartens, including children from birth to 5-6 years of age); in pre-primary classes (children of 5-6 years of age, manly in pre-primary classes in schools) and in community based centers (Kosovo Education Strategic Plan, 2011)
Figure 9: Locations of Kindergartens
Kindergarten 3 Kindergarten 5 Kindergarten 1 Kindergarten 2 Ferizaj
Kindergarten 2
Prishtine
Kindergarten 3 Obiliq
Kindergarten 4 Kamenice
Kindergarten 4 Kindergarten 5 Prishtine-Priv. Kindergarten 1
Source: Own picture (2012)
According to the Kosovo education statistics for 2010/2011, the number of children enrolled in kindergartens and in pre-primary classes in schools were 36.364. The number of kindergartens was 52, while the number of pre-primary classes in schools was 593 (Statistical Agency of
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Kosovo (ASK -2011). The previous Kosovo Education Statistics for 2008/2009 showed that the number of children attending kindergartens was only 5.091, distributed in 40 kindergartens (Kosovo Education Statistics 2009). The aim of this study was to gather data from public kindergartens, but considering recent establishment of the private kindergartens, the nutrition assessment was also performed in one private kindergarten. The study covered four public and one private kindergarten from different regions of Kosovo (Prishtinë; Ferizaj; Kamenicë and Obiliq). Prishtinë and Ferizaj are urban areas, while Kamenicë and Obiliq are also urban areas, though smaller and less developed. There are no kindergartens in villages.
3.2.1 The Sample Size of the Study
The sample size for this research differed according to the used components for nutritional status. The inclusion criteria for the recruited subjects were: a) children are registered and attend the selected kindergarten b) Children are between 12 and 83 months of age. Exclusion criteria were: 1. Children who did not attend the kindergarten during the three consecutive days when the research took place. The goal was to have 100% sampling, however 486 (more than 90%) children participated in 3 days dietary intake assessment through food measuring in kindergarten (the weighted dietary record), 486 children participated in anthropometric assessment and 232 dietary food questionnaires (an estimated food record form and a combined 24-Hour recall and dietary history form) were completed for three consecutive days by parents with data on food consumption after children left the kindergarten. The survey started in December- 2010, and completed by December 2011. An overview on sample size, research locations and gender aspects of the samples is presented in Table 5.
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Table 5: Sample size, research locations and gender aspects of the samples
Dietary intake Sex and age Location of n n n (12-83 months) Kindergartens Anthropometry measuring in measuring at home kindergarten
Boys Ferizaj 102 102 62 Prishtine 1 64 64 29 Obiliq 31 31 16 Kamenicë 21 21 8 Prishtine 2 46 46 25 All Boy samples 264 264 140 Girls Ferizaj 92 92 44 Prishtine 1 48 48 16 Obiliq 25 25 13 Kamenicë 16 16 5 Prishtine 2 41 41 14 All Girls samples 222 222 92 All Boys and Girls samples 486 486 232 Source: Own data (2013)
3.2.2 Preparation for the Performance of Survey
In order to conduct a study involving preschool children, institutional consent for access to the kindergartens as well as parental consent was needed. The request for access to preschool settings was addressed to the Ministry of Education, Science and Technology of Kosovo (Annex 5). The Ministry has issued a consent letter (Annex 6), inviting Municipal Education Directors as well as the Kindergarten Directors to support this study as the first nutritional assessment research in preschool settings of Kosovo. The concept and the objective of the study were explained to the parents and teachers (nursery governess) through group meetings (Figure 10), as well as through distributing of an information letter to each parent personally (Annex 7). An information poster about the start and time frame of the study was placed on the entrance door of each kindergarten prior to the beginning of the research (Annex 8).
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Figure 10 Meeting with parents and teachers
Source: Own picture (2011) While explaining the concept and the objective of the study to teachers and kitchen ladies, the researcher spent couple of hours with children before collecting data (Figure 11). This was very useful because gained trust helped during the data collection period.
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Figure 11: Creation of a good environment for participation of the children in the study
Source: Own picture (2011)
3.3 Instruments
The data needed to fulfill the objectives of nutritional status profile of preschool aged children derived from two nutritional assessment components: anthropometric measurements and dietary intake assessment at selected kindergartens.
3.3.1 Anthropometrics
Since Kosovo did not develop yet its own national standards for nutritional assessment, the growth of preschool children was examined to determine whether and how it differs from actual WHO standards and references for weight - for – age, height - for - age and weight -for - height Anthropometric measurements used for this study were weight, height and BMI of the preschoolers (12-83 months) according to the techniques which were suggested by WHO (1995). Measuring board was used for measuring of length/height of children less than two years. Digital weight and height scale Seca 763 was used for measuring of weight for all assessed children and height of preschool children taller than 110 cm. The measuring range of
Agim Rysha (2013): PhD Thesis 39
the equipment is between 110-200 cm with the graduation weight of 50 g and graduation length of 1 mm. Height measuring instrument Seca 213 with graduation length of 1 mm was used for measuring of height for children who were shorter than 110 cm. Both, Seca 763 and Seca 213 are shown in the Figure 12.
Figure 12: Seca instruments used for anthropometric measurements
Source: Own picture (2011)
3.3.2 Dietary Intake
The intention of the researcher was to collect dietary data which could provide information on intake of food nutrients at national level (in preschool institutions or kindergartens of Kosovo). Several methods are used to assess the dietary intake of preschool children such as dietary recalls, dietary records, food frequency questionnaires (FFQs), direct observation, physiologic measures etc. Different previous and recent reviews (Fisher et al., 2008; Collins et al., 2013) aimed to determine the dietary assessment that provide an accurate estimate of energy intake by comparison with double labeled water (DLW) which is considered as a “gold standard measure”. The weighted dietary record (WDR) method was found to be in close agreement and
Agim Rysha (2013): PhD Thesis 40
to provide the best estimate total energy intake in children aged 0.5-4.5 years compared to total energy expenditure measured by DLW (Davies et al., 1994; Harbottle & Duggan, 1994; Burrows et al., 2010). Dietary intake data for this study were obtained through combination of techniques. The WDR method was the main assessment method. The focus was to weight and record food intake at the time of consumption over three consecutive days in kindergartens (four public and one private) Figure 13 and 14.
Figure 13: Food intake by children
Source: Own picture (2011)
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Figure 14: Wasted foods and Leftovers
Source: Own picture (2011)
The WDR method was chosen to be as a main method because researcher decided to stay himself in kindergartens and to record food intake by each child in as much as accurate way. Seca 856 Digital Scale with the fine 1 g graduation was used for weighting foods. The Seca 856 is shown in the Figure 15. A dietary record form for weighted food was developed (Annex 9). An Estimated Food Record form –EFR (Annex 10) was also developed and distributed to parents who received written and oral instruction for the recording of all food and beverages consumed by their child before and after they left the kindergarten. Since this was the first assessment of food intake in kindergartens of Kosovo, the researcher found useful to assess also the meal patterning and food group intake. A combined 24-Hour recall -24H and Dietary History-DH form (Annex 11) was developed and distributed to parents
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Figure 15: The Seca 856
Source: Own picture (2011)
3.4 Data Collection
Data collection was conducted in five selected kindergartens- four public and one private kindergarten. All five kindergartens had the space and capacity to conduct measuring of nutritional status of preschool children.
3.4.1 Measurement Procedure for Anthropometrics
The birth date of the assessed children was taken from the data register in the kindergartens and has been checked using the forms which were completed and submitted by the parents. For the children less than two years the infant stature was measured as recumbent length and height in the standing position is measured for children over two years. The length or height was taken nearest to 0.1 cm. Even though it is considered that the weight should be determined with the child wearing no clothing, in our case the body weight was measured with the child in underwear or in light clothing, without shoes. Measurements on weight and height were taken from children aged 12-83 months directly in five kindergartens. The data were recorded by
Agim Rysha (2013): PhD Thesis 43
principal investigator who was supported by trained nurses in conducting measurement of child’s length/height and weight (Figure 16). The principal investigator stayed in kindergartens for the duration of survey. The weight measurement in this study was taken nearest to 0.1 kg.
Figure 16: Anthropometric measurements
Source: Own pictures (2011)
3.4.2 Measurement Procedure of Dietary Data
The WDR method was used in all five selected kindergartens. In four out of five kindergartens, the food was cooked in kindergarten’s kitchen; while in one out of five the food was prepared elsewhere and distributed to the children as ready to eat food. The researcher followed the preparation of all meals during three consecutive days in all five kindergartens of Kosovo. The recipe content was accurately measured and recorded (Figure 17). The recipes and served food types in five selected kindergartens are presented in (Annex 12).
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Figure 17: Recipe content
Source: Own Pictures (2011)
The explanation of some local used foods is given in Annex 13. All foods and drinks consumed for a period of three days were measured and recorded and wasted foods and leftovers had been measured and subtracted from the record correctly (Figure 18). An EFR form was distributed to all parents in order to record all foods and beverages consumed by their child before and after they left the kindergarten. In order to provide as detailed as possible description of each food, including recipes and brand, parents were given also a serving size pictures as an estimating aid (Annex 14). After collection, the EFR were checked on quality and completeness. Only qualitative EFR, which contained completed record for three days as well as reliable detailed description of foods and portion sizes consumed were included in the analyses. A combined 24H recall and DH form was also distributed to parents. They were asked to recall and describe all foods and beverages consumed by their children in the preceding 24 hours (the preceding day). Parents were also asked to answer for frequency food intake of specific foods by their children (the main typical foods from the food groups).
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Figure 18: Measurement of wasted foods
Source: Own picture (2011)
3.5 Data Analyses
3.5.1 Anthropometric Data Processing
The WHO anthro software (WHO Anthro 2007) provided by WHO, was used as a tool for nutritional assessment of children under 5 years old. This software was developed to facilitate application of the WHO Child Growth Standards in monitoring growth and motor development in individuals and populations of children up to 5 years of age. The software derives nutritional status information for WAZ, HAZ, WHZ, and BAZ. The age of children who are attending kindergartens in Kosovo is from 12 to 83 months, thus for all children older than 5 years we have used WHO AnthroPlus software (WHO AnthroPlus 2009) which was developed to facilitate the application of WHO References 2007 for 5-19 years to monitor the growth of school children and adolescents. This software derives status information for the indicators weight-for-age (up to 10 years) height-for-age and BMI for age. Statistical analyses were carried out using statistical package SPSS version 17.0
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3.5.2 Dietary Intake Assessment Data Processing
The consulting nutritionist checked the coding before the food record was linked to the nutrient database for conversion of food items to their constituent nutrients. The completed records were analyzed with the program PRODI (version 5.9, NutriScience, Freiburg, Germany). The records were analyzed for the values as described in Annex 15. The PRODI data were transferred into SPSS (version 17.0) for calculation and comparison with reference values for nutrient intake in Germany, Austria and Switzerland (Frankfurt am Main. Umschau/Braus-2002) as well as with other reference values such as: Dietary Reference Intake for Energy, Carbohydrates, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids; (2002/2005), Dietary Reference Intakes for Calcium, Phosphorous, Magnesium, Vitamin D and Fluoride (1997); Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline (1998); Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids (2000), Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and zinc (2001), Dietary Reference Intakes for Calcium and Vitamin D 2011), IOM. DRI-Applications in Dietary Assessment (National Academy Press; Washington, DC: 2003)
3.5.3 Data Processing of Frequency Food Intake of Specific Food Groups
The frequency food intake of specific foods (the main typical foods from the food groups) was calculated.
3.5.4 Statistical Analyses
Statistical analyses were carried out using statistical package SPSS version 17.0. Data were analyzed with descriptive statistics, and differences between groups are assessed with t-test or One Way ANOVA for normally distributed numerical variables, or nonparametric test for two independent groups (Mann-Whitney test) in case of not normally distributed numerical variables. Normality is tested with Kolmogorov-Smirnov test. Qualitative variables are tested with Chi- square statistics. The difference is significant if P<0.05.
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4 Results and Discussions
4.1 Introduction
Chapter four presents the results of research of anthropometric indicators; food and nutrient intake and frequency food intake of specific foods. The results are presented according to the used components for a nutritional status. This chapter provides also the discussions of the results of the study drawn from the data analysis which focuses on evaluation and comparison of the obtained results with other results from literature, than a comparison with international anthropometric standards and references and finally with international nutrition recommendations for preschool aged children. This study provides for the first time an overview of the current nutrition status of children attending kindergartens In Kosovo, including the food varieties, food frequency, energy and nutrition values of served meals (by different methods being used) . This study discovered that the growth of preschool children in Kosovo is not fully in line with international standards and references. It was also discovered that the served food varieties as well as nutrient and energy values of such served foods do fulfill only partially international recommendations for nutrition guidelines of preschool aged children. The children who participated in this research study represented different age groups (six age groups), genders and locations. Nutritional status and food intake for each child was recorded, thus each of them had a different status
4.2 Anthropometric Results and Discussions
Growth assessment of infants and children is considered to be an essential component for monitoring and promotion of optimal growth and adequate child development. As we have described in the literature part, there are different methods for measuring underweight, overweight and obesity in preschool aged children. These differences between methods could affect the results. Results of the measurements of weight and height of preschool children in Kosovo have been compared with the new growth charts from the World Health Organization. The 2006 WHO Child Growth Standards were applied for the children aged 12-60 months (352 children or 72.5% of the total cohort) and the Growth Reference 2007 for children aged 60-83 months (134 children or 27.5%). A total of 486 preschool aged children were evaluated from five kindergartens (4 public and 1 private) in Kosovo. The age of the children varied from 12 to 83 months.
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The distribution of the study subjects by age and sex are presented in Table 6 and Figure 19. There was no significant sex difference in boys and girls (X²=3.63; p= 0.057).
Table 6: Distribution of study subjects by age and sex Gender
Female Male Total Age groups (months) N % N % N %
12-23 17 7.7 27 10.2 44 9.1
24-35 35 15.8 35 13.3 70 14.4
36-47 66 29.7 58 22.0 124 25.5
48-59 43 19.4 71 26.9 114 23.5
60-71 51 23.0 50 18.9 101 20.8
72-83 10 4.5 23 8.7 33 6.8
Total 222 100.0 264 100.0 486 100.0
Source: Own calculation (2013)
The children in this study had mean values for body mass ranging from 12.0 kg (SD ± 1.6 kg) for the age group 12-23 months to 22.1 kg (SD±3.9kg) for the age group of 72-83 months. The mean body mass for girls ranged from 11, 5 kg (SD ± 1.6 kg) for the age group 12-23 months to 23.0 kg (SD ±3.4kg) for the age group of 72-83months. The boys in this study had mean weight ranging from 12.3 kg ± 1.6 kg (12-23 months) to 21.7kg ± 4.1kg (72-83 months). There was no significant sex differences in the mean values of body mass across sex and age groups (P>0.05). Table 7 presents the mean weight and standard deviation values (SD) across sex and age groups (12-83 months). The mean stature of the children (both sexes) participating in this study ranged from 83 cm (SD for±5.5 cm) for the age group 12-23 months to 117.5 cm (SD for±6.0 cm) for the age group of 72-83 months. The girls in this study had mean stature ranging from 81.4 cm ± 4.7 (the age group 12-23 months) to 118.8 cm ±6.1cm (72-83 months), while the boys had mean stature ranging from 85.2 ± 5.6 cm for the age group of 12-23 months and 117.0 ± 6.1 cm for the age group of 72-83 months.
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Figure 19: Structure of study subjects by sex
X2=3.63 P =0.057 Female 222 45.7%
Male 264 54.3%
Source: Own calculation (2013)
Table 7: Means and standard deviations for weight across sex and age groups Weight (kg)
Age Female Male Total P-value groups (months) Mean SD Mean SD Mean SD
12-23 11.5 1.6 12.3 1.6 12.0 1.6 0.138
24-35 14.3 2.4 14.5 1.9 14.4 2.2 0.756
36-47 15.5 2.2 16.4 2.1 15.9 2.2 0.129
48-59 17.9 2.5 18.6 3.1 18.3 2.9 0.199
60-71 20.5 3.6 20.3 3.1 20.4 3.4 0.820
72-83 23.0 3.4 21.7 4.1 22.1 3.9 0.381
Source: Own calculation (2013) There were no significant sex differences in the mean values of the stature across sex and age groups (P>0.05). Table 8 presents the mean stature and standard deviation values (SD) across sex and age groups (12-83 months).
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Table 8: Means and standard for weight across sex and age groups deviations
Height (cm) P Age Female Male Total -value groups (months) Mean SD Mean SD Mean SD 12-23 81.4 4.7 85.2 5.6 83.7 5.5 0.026 24-35 92.4 5.5 91.9 4.8 92.2 5.1 0.659 36-47 99.2 5.2 100.9 4.8 100.0 5.0 0.049 48-59 106.0 4.6 107.2 5.1 106.7 4.9 0.237 60-71 112.5 6.5 113.0 4.8 112.7 5.7 0.697 72-83 118.8 6.1 117.0 6.1 117.5 6.0 0.423 Source: Own calculation (2013)
The findings of this study indicate that there is a gradual increase in average weight and height for both boys and girls from 12 to 83 months. It was observed that boys are heavier at the age groups 12-60 months and that girls are heavier at the age groups 60-83 months (Figure 20).
Figure 20: Average Weight for boys and girls
25
20
15 girls 10
Weight kgWeight in boys
5
0 12-23 m 24-35 m 36-47 m 48-59 m 60-71 m 72-83 m Age in months
Source: Own calculation (2013)
On the other side, boys were slightly taller than girls in more age groups except age groups from 24 to 35 months and 72 to 83 months where girls on average were taller than boys (Figure 21).
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Figure 21: Average Height for boys and girls
25
20
15 girls 10
Weight kgWeight in boys
5
0 12-23 m 24-35 m 36-47 m 48-59 m 60-71 m 72-83 m Age in months
Source: Own calculation (2013)
In general, no significant differences were observed in the mean values of body mass and the stature across sex and age groups. The only significant difference was observed between mean values of girls and boys of the age group 12-23 months. The mean height value for boys in this age group was 85.2 while for girls was 81.4 (p=0.026). Anthropometric software’s provided by the WHO were used for conversion of data into anthropometric indices according to both, WHO 2006 standards and WHO 2007 references. Anthropometric indices were constructed by comparing the study data (12-83 months aged children) with those of comparable individuals in the WHO reference data. Z-scores (standard deviation score) were used for expressing these comparisons. Anthropometric indicators: weight-for-age (z-scores), length-or height-for-age (z-scores), weight- for-height (z-scores) and BMI-for-age (z-scores) were used for children of the age group 12-60 months, while weight-for-age (z-scores), height-for-age (z-scores) and BMI-for-age (z-scores) parameters were used for the children aged 60-83 months. Table 9 presents the gender-and age-specific means and standard deviations (SD) of weight- for-age z-score (WAZ). The mean Z-scores of weight –for-age in children (12-83 months) from 0.1- 0.8 (SD= 1.0-1.3). No significant differences were noted in WAZ between boys and girls.
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Table 9: Mean and standard deviations of WAZ scores by age and sex Weight for age (z-scores)
Age Female Male Total P-value groups (months) Mean SD Mean SD Mean SD
12-23 0.8 0.9 0.8 1.2 0.8 1.1 0.979
24-35 0.7 1.2 0.6 1.0 0.7 1.1 0.700
36-47 0.2 1.0 0.4 1.0 0.3 1.0 0.200
48-59 0.2 0.9 0.5 1.1 0.4 1.1 0.278
60-71 0.4 1.1 0.3 1.1 0.3 1.1 0.572
72-83 0.6 0.9 -0.1 1.4 0.1 1.3 0.196
Source: Own calculation (2013)
Distribution of weight for age of the Kosovo preschoolers aged 12-59 months and 60-83 respectively, compared to the standard distribution of the World Health Organization is presented in the Figure 22 (a, b)
Figure 22: Distribution of weight for age Kosovo preschool children compared with WHO standard distribution a) all children 12-60 month and b) Children 61-83 month
a b b
Source: Own data (2013) The gender-and age-specific means and standard deviations (SD) of height-for-age z-score (HAZ) values are presented in Table 10. There were no significant differences in HAZ between boys and girls.
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Distribution of height for age of children in kindergartens of Kosovo (aged-12-83 months), compared to the standard distribution of the World Health Organization are presented in the Figure 23 (a, b).
Table 10: Mean and standard deviations of HAZ scores by age and sex Height for age (z-scores)
Age Female Male Total P-value groups (months) Mean SD Mean SD Mean SD
12-23 0.3 1.1 1.1 2.3 0.8 2.0 0.664
24-35 0.3 1.5 -0.1 1.0 0.1 1.3 0.191
36-47 0.1 1.1 0.2 1.0 0.1 1.0 0.524
48-59 0.0 0.9 0.2 1.0 0.1 1.0 0.418
60-71 0.2 1.3 0.1 1.0 0.1 1.1 0.640
72-83 0.4 1.1 -0.2 1.2 0.0 1.2 0.179
Source: Own data (2013)
Figure 23 Distribution of height for age Kosovo preschool children compared with WHO standard distribution a) all children 12-60 month and b) children 61-83 month
b a
Source: Own data (2013)
Table 11 presents the mean z-scores for weight-for-height z-score (WHZ). There were no significant differences in WHZ between boys and girls.
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Table 11: Mean and standard deviations of WHZ scores by age and sex Weight for height (z-scores)
Age Female Male Total P-value groups (months) Mean SD Mean SD Mean SD
12-23 0.8 0.7 0.4 1.1 0.6 1.0 0.207
24-35 0.7 1.1 0.9 1.1 0.8 1.1 0.458
36-47 0.2 1.1 0.4 1.0 0.3 1.1 0.233
48-59 0.3 0.9 0.5 1.1 0.4 1.0 0.634
60-71 0.7 1.7 0.6 0.7 0.7 1.3 0.904
Source: Own data (2013)
Distribution of weight-for-height z-scores of children attending the kindergartens of Kosovo (aged-12-60 months), compared to the standard distribution of the World Health Organization are presented in the Figure 24.
Figure 24: Distribution of weight for height of Kosovo preschool children compared with the WHO standard distribution (children 12-60 months)
a
Source: Own data (2013)
The mean values of Body Mass Index (BMI) for age (z-scores) for children aged between 12 and 83 months are presented in Table 12.
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Table 12: BMI for age (z-scores) according to sex and age groups BMI for age
Age Female Male Total P-value groups (months) Mean SD Mean SD Mean SD
12-23 0.9 0.6 0.3 1.3 0.5 1.1 0.123
24-35 0.8 1.2 0.9 1.1 0.8 1.2 0.520
36-47 0.2 1.2 0.4 1.0 0.3 1.1 0.266
48-59 0.3 0.9 0.5 1.1 0.5 1.0 0.524
60-71 0.4 1.0 0.3 1.1 0.4 1.0 0.663
72-83 0.5 0.7 0.1 1.4 0.2 1.2 0.427
Source: Own data (2013) Distribution of BMI for age z-scores for children (aged 12-83 months), compared to the standard distribution of the World Health Organization are presented in the Figure 25.
Figure 25: Distribution of BMI for age z-scores of Kosovo preschool children compared with the WHO standard distribution a) children 12-60 months b) children 61-83 month
a b
Source: Own data (2013) There were no significant differences (P>0.05) in the BMI for age z-scores between boys and girls. Distribution of WAZ, HAZ, WHZ and BMI by gender compared with the WHO standard distribution is shown in the Figures 26; 27; 28 and 29
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Figure 26: Weight for age by gender: a) children 12-60 month; b) children 61-83 months
a b
Source: Own data (2013)
Figure 27: Height for age by gender: a) children 12-60 months; b) children 61-83 months
a b
Source own data (2013)
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Figure 28: Weight for height by gender a) children 12-60 months
a
Source: Own data (2013)
Figure 29: BMI for age by gender; a) 12-60 months and b) 61-83 months
a b
Source: Own data (2013) The specific results showing the nutritional indicators of children by kindergartens are attached as annexes (Annexes from 16 to 20).
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4.2.1 Results by Public and Private Kindergarten
Anthropometric indicators of the children attending public kindergartens were compared with the anthropometric indicators of the children attending private kindergartens. Tables 13 and 14 show the weight and height of the subjects divided by public and private kindergartens.
Table 13: Means and standard deviations for weight in public and private kindergarten Weight (kg) Age Private Public groups P- (months) N Mean SD N Mean SD value 12-23 15 11.6 1.4 29 12.2 1.7 0.295 24-35 12 14.2 1.3 58 14.4 2.3 0.767 36-47 29 15.5 2.4 95 16.0 2.2 0.272 48-59 14 18.0 2.0 100 18.4 3.0 0.652 60-71 8 21.2 3.7 93 20.3 3.3 0.494 72-83 9 24.0 3.3 24 21.3 3.9 0.072 Total 87 16.5 4.3 399 17.4 3.8 Source: Own data (2013)
Table 14: Means and standard deviations for stature in public and private kindergarten Height (cm) Age Private Public groups P- (months) N Mean SD N Mean SD value 12-23 15 81.9 5.1 29 83.7 5.6 0.117 24-35 12 92.0 3.8 58 92.2 5.4 0.901 36-47 29 98.9 4.4 95 100.3 5.2 0.179 48-59 14 106.0 4.4 100 106.8 5.0 0.553 60-71 8 111.2 7.8 93 112.9 5.5 0.429 72-83 9 120.3 4.7 24 116.5 6.2 0.109 Total 87 99.5 12.2 399 103.5 10.4 Source: Own data (2013)
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The mean weight of the children attending public kindergartens ranged from 12.2 kg (SD for±1.7 kg) for the age group 12-23 months to 21.3 kg (SD for±3.9 kg) for the age group of 72-83 months. The children from private kindergarten had mean weight ranging from 11.6 kg (the age group 12-23 months) to 24 kg (72-83 months). The mean stature of the children attending public kindergartens ranged from 83.7 cm (SD for±5.6 cm) for the age group 12-23 months to 116.5 cm (SD for±6.2 cm) for the age group of 72-83 months, while the children attending private kindergarten had mean stature ranging from 81.9 cm ± 5.1 (the age group 12-23 months) to 120.3 cm ±4.7 cm (72-83 months). As evident from tables 19 and 20, there were no significant differences in the mean values of the weight and stature for all age groups of the children between the public and private kindergartens (P>0.05). Tables 15, 16, 17 and 18 present the differences in the means and SD of WAZ, HAZ, WHZ and BAZ of the children attending public kindergartens and private kindergarten. Table 15: Differences in the means and SD of WAZ WAZ
Private Public Age groups (months) N Mean SD N Mean SD P-value
12-23 15 0.8 0.9 29 0.8 1.2 0.940
24-35 12 0.7 0.6 58 0.7 1.2 0.883
36-47 29 0.3 1.2 95 0.3 0.9 0.957
48-59 14 0.5 0.8 100 0.4 1.1 0.791
60-71 8 0.6 1.0 93 0.3 1.1 0.483
72-83 9 0.7 1.0 24 -0.1 1.3 0.125
Total 87 0.5 1.0 399 0.4 1.1
Source: Own data (2013)
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Table 16: Differences in the means and SD of HAZ HAZ
Private Public Age groups (months) N Mean SD N Mean SD P-value
12-23 15 0.6 0.9 29 0.8 2.3 0.806
24-35 12 0.2 0.8 58 0.1 1.4 0.794
36-47 29 0.2 0.9 95 0.1 1.1 0.627
48-59 14 0.2 1.0 100 0.1 1.0 0.756
60-71 8 -0.2 1.4 93 0.1 1.1 0.379
72-83 9 0.4 1.0 24 -0.2 1.3 0.236
Total 87 0.3 1.0 399 0.1 1.3
Source: Own data (2013)
Table 17: Differences in the means and SD of WHZ WHZ
Private Public Age groups (months) N Mean SD N Mean SD P-value
12-23 15 0.7 1.3 29 0.6 0.8 0.776
24-35 12 0.8 1.0 58 0.8 1.1 0.941
36-47 29 0.2 1.3 95 0.3 1.0 0.594
48-59 14 0.5 0.7 100 0.4 1.0 0.770
60-71 8 93 0.7 1.3
72-83 9 24
Total 87 0.5 1.2 399 0.5 1.0
Source: Own data (2013)
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Table 18: Differences in the means and SD of BAZ BAZ
Private Public Age groups (months) N Mean SD N Mean SD P-value
12-23 15 0.6 1.4 29 0.5 0.9 0.837
24-35 12 0.8 1.2 58 0.9 1.2 0.876
36-47 29 0.2 1.3 95 0.3 1.1 0.571
48-59 14 0.5 0.7 100 0.5 1.1 0.910
60-71 8 1.0 0.9 93 0.3 1.0 0.062
72-83 9 0.7 0.9 24 0.0 1.3 0.183
Total 87 0.5 1.2 399 0.4 1.1
Source: Own data (2013)
No significant differences were noted in WAZ, HAZ, WHZ and BAZ between public and private kindergartens.
4.2.2 Results and Discussions of Growth Indicators
Detailed tables with 95% confidence intervals are shown below. Table 19 presents the length/height-for age (%) of 12-83 months aged children as well as for girls and boys separately.
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Table 19: Length/height-for age indicator (%)
Combined Length/height-for-age (%) N (all ages) % < 3SD (95% CI) % < 2SD (95% CI) 12 to < 24 43 0 (-, -) 0 (-, -) (0.1%, 24 to < 36 70 1.4 4.3 (1.1%, 15.1%) 28.3%) 36 to < 48 124 0 (-, -) 1.6 (0.5%, 5.4%)
48 to < 60 124 0 (-, -) 1.6 (0.4%, 6.7%)
60 to < 72 91 0 (-, -) 4.4 (1.6%, 11.3%)
72 to < 83 33 3 (0.2%, 31.1%) 6.1 (1.3%, 23.7%) Boys all ages
12 to < 24 26 0 (-, -) 0 (-, -)
24 to < 36 35 0 (-, -) 5.7 (0.6%, 38.5%)
36 to < 48 58 0 (-, -) 0 (-, -)
48 to < 60 75 0 (-, -) 1.3 (0.1%, 25.2%)
60 to < 72 46 0 (-, -) 2.2 (0.1%, 35.6%)
72 to < 83 23 4.3 (0.3%, 41.2%) 8.7 (1.7%, 34.6%) Girls (all ages) 12 to < 24 17 0 (-, -) 0 (-, -)
24 to < 36 35 2.9 (0.1%,43.5%) 2.9 (0.1%, 43.5%)
36 to < 48 66 0 (-, -) 3 (0.8%, 10.6%)
48 to < 60 49 0 (-, -) 2 (0.3%, 13.3%)
60 to < 72 45 0 (-, -) 6.7 (1.8%, 21.8%)
72 to < 83 10 0 (-, -) 0 (-, -) Source: Own data (2013)
Weight-for-age indicator (%) is presented in Table 20
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Table 20: Weight-for-age indicator (%)
Combined Weight-for-age (%) N (all ages) % <-3SD (95% CI) % < -2SD (95% CI) 12 to < 24 44 0 (-, -) 0 (-, -)
24 to < 36 70 0 (-, -) 0 (-, -)
36 to < 48 124 0 (-, -) 1.6 (0.5%, 5.4%)
48 to < 60 124 0 (-, -) 0 (-, -)
60 to < 72 91 0 (-, -) 0 (-, -)
72 to < 83 33 3 (0.2%, 33.6%) 3.0 (0.2%, 33.6%) Boys (all ages) 12 to < 24 27 0 (-, -) 0 (-, -)
24 to < 36 35 0 (-, -) 0 (-, -)
36 to < 48 58 0 (-, -) 3.4 (0.8%, 13%)
48 to < 60 75 0 (-, -) 0 (-, -)
60 to < 72 46 0 (-, -) 0 (-, -)
72 to < 83 23 4.3 (0.2%, 45.2%) 4.3 (0.2%, 45.2%) Girls (all ages) 12 to < 24 17 0 (-, -) 0 (-, -)
24 to < 36 35 0 (-, -) 0 (-, -)
36 to < 48 66 0 (-, -) 0 (-, -)
48 to < 60 49 0 (-, -) 0 (-, -)
60 to < 72 45 0 (-, -) 0 (-, -)
72 to < 83 10 0 (-, -) 0 (-, -) Source: Own data (2013)
Table 21 presents results of the weight-for length/height indicator (%) which applies for 0-60 months aged children, while Table 22 presents BMI-for-age (%)
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Table 21: Weight -for length/height indicator (%)
Weight-for-length/height (%) Combined (95% (all ages) N % < -3SD (95% CI) % < -2SD (95% CI) % > +1SD (95% CI) % > +2SD (95% CI) % > +3SD CI) (0.2%, (0.2%, (13.7%, (2.4%, 12 to < 24 44 2.3 2.3 34.1 6.8 0 (-, -) 19.5%) 19.5%) 62.8%) 17.8%) (0.3%, (25%, (3.1%, (1.9%, 24 to < 36 70 0 (-, -) 2.9 44.3 12.9 4.3 23.2%) 65.5%) 40.1%) 9.3%) (0.1%, (0.8%, (9.6%, (1.4%, (0%, 36 to < 48 124 0.8 2.4 22.6 5.6 0.8 7.2%) 6.7%) 44.6%) 19.8%) 11.7%) (14.7%, (3.8%, (0.1%, 48 to < 60 121 0 (-, -) 0 (-, -) 25.6 9.1 0.8 40.7%) 20.3%) 5.3%) Boys (all ages) (0.3%, (0.3%, (7.4%, (1.9%, 12 to < 24 27 3.7 3.7 29.6 7.4 0 (-, -) 30.4%) 30.4%) 68.8%) 24.8%) (0.2%, (34.6%, (5.6%, (0.1%, 24 to < 36 35 0 (-, -) 2.9 51.4 14.3 2.9 28.9%) 68%) 31.7%) 38%) (0.1%, (11.2%, (1%, 36 to < 48 58 0 (-, -) 1.7 24.1 8.6 0 (-, -) 24%) 44.4%) 46.9%) (13.5%, (3.9%, (0.2%, 48 to < 60 73 0 (-, -) 0 (-, -) 26 9.6 1.4 44.2%) 21.8%) 8.4%) Girls (all ages) (15.8%, (0.3%, 12 to < 24 17 0 (-, -) 0 (-, -) 41.2 5.9 0 (-, -) 72.3%) 58.5%) (0.1%, (18.2%, (1.1%, (1.5%, 24 to < 36 35 0 (-, -) 2.9 37.1 11.4 5.7 49.9%) 61.1%) 59.6%) 19.2%) (0.2%, (0.6%, (7.1%, (1%, (0.1%, 36 to < 48 66 1.5 3 21.2 3 1.5 12.3%) 14.5%) 48.5%) 8.9%) 19.5%) (13.4%, (2.8%, 48 to < 60 48 0 (-, -) 0 (-, -) 25 8.3 0 (-, -) 41.9%) 22.5%) Source: Own data (2013)
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Table 22: BMI-for-age indicator (%) Combined BMI-for-age (%) (all ages) N % < - % < - % > % > % > (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 3SD 2SD +1SD +2SD +3SD (0.2%, (0.2%, (13.7%, (0.4%, 12 to < 24 44 2.3 2.3 34.1 4.5 0 (-, -) 19.5%) 19.5%) 62.8%) 34.5%) (0.3%, (23.2%, (3.1%, 24 to < 36 70 1.4 (0%, 31.9%) 2.9 45.7 12.9 4.3 (1.9%, 9.3%) 23.2%) 70.1%) 40.1%) (1.4%, 36 to < 48 124 0.8 (0.1%, 7.2%) 2.4 (0.8%, 6.7%) 22.6 (9.6%, 44.6%) 5.6 0.8 (0%, 11.7%) 19.8%) (4.1%, 48 to < 60 124 0 (-, -) 0 (-, -) 25 (13.8%, 41%) 10.5 2.4 (0.6%, 10%) 24.1%) (3.1%, (0.1%, 60 to < 72 91 0 (-, -) 0 (-, -) 22 (9.3%, 43.5%) 6.6 1.1 13.4%) 17.5%) (0.2%, (4.5%, (0.2%, 72 to < 83 33 0 (-, -) 3 21.2 (7.5%, 47.1%) 9.1 3 33.6%) 17.6%) 33.6%) Boys (all ages) (0.3%, (0.3%, 12 to < 24 27 3.7 3.7 29.6 (7.4%, 68.8%) 7.4 (0.6%, 50%) 0 (-, -) 30.4%) 30.4%) (0.2%, (5.6%, 24 to < 36 35 0 (-, -) 2.9 51.4 (34.6%, 68%) 14.3 2.9 (0.1%, 38%) 28.9%) 31.7%) (11.2%, 36 to < 48 58 0 (-, -) 1.7 (0.1%, 24%) 24.1 8.6 (1%, 46.9%) 0 (-, -) 44.4%) (3.8%, (0.9%, 48 to < 60 75 0 (-, -) 0 (-, -) 26.7 (14%, 44.7%) 12 4 31.9%) 15.9%) (2.2%, (0.1%, 60 to < 72 46 0 (-, -) 0 (-, -) 21.7 (11%, 38.5%) 6.5 2.2 17.5%) 32.5%) (0.2%, (5.4%, (0.2%, 72 to < 83 23 0 (-, -) 4.3 21.7 (7.9%, 47.4%) 13 4.3 45.2%) 28.3%) 45.2%) Girls (all
ages) (15.8%, 12 to < 24 17 0 (-, -) 0 (-, -) 41.2 0 (-, -) 0 (-, -) 72.3%) (0.1%, (0.1%, (15.3%, (1.1%, (1.5%, 24 to < 36 35 2.9 2.9 40 11.4 5.7 49.9%) 49.9%) 71.1%) 59.6%) 19.2%) (0.2%, (0.6%, (0.1%, 36 to < 48 66 1.5 3 21.2 (7.1%, 48.5%) 3 (1%, 8.9%) 1.5 12.3%) 14.5%) 19.5%) (2.6%, 48 to < 60 49 0 (-, -) 0 (-, -) 22.4 (10%, 42.9%) 8.2 0 (-, -) 22.6%) (2.3%, 60 to < 72 45 0 (-, -) 0 (-, -) 22.2 (5.1%, 60.2%) 6.7 0 (-, -) 17.6%) 72 to < 83 10 0 (-, -) 0 (-, -) 20 (3.4%, 63.7%) 0 (-, -) 0 (-, -) Source: Own data (2013)
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The following cut-offs recommended by the WHO, were used in our study for screening of undernutrition and over nutrition: Parameter 2006 WHO Standards 2007 WHO Reference Underweight (Weight-for-age) <-2 Z-scores <-2 Z-scores Sever underweight (Weight-for-age <-3 Z-scores <-3 Z-scores Stunting (Length-height-for-age) <-2 Z-scores <-2 Z-scores Sever stunting (Length-height-for-age) <-3 Z-scores <-3 Z-scores Wasting (Weight-for-length-BMI-for-age*) <-2 Z-scores <-2 Z-scores Sever Wasting (Weight-for-height) <-3 Z-scores <-3 Z-scores Risk of overweight (weight-for-length/BMI-for-age*) >+1 Z-scores n/a Overweight (weight-for-length/BMI-for-age*) >+2 Z-scores >+1 Z-score Obese (weight-for-length/BMI-for-age*) >+3 Z-scores >+2 Z-score Severe Obesity (BMI-for-age) n/a >+3 Z-scores
* Weight-for-length from birth-2 years; BMI-for-age > 2 years
The percentage of underweight amongst the children attending preschool institutions (12-83 months) is 0.7% while 0.5% of the children are severely underweight. This percentage is lower than the average percentage from the study conducted in 2001 by UNICEF (UNICEF, 2001), where the prevalence of underweight was 4%. In terms of gender, the 0.7% respectively 0.5% of boys and 0% of girls were underweight or severely underweight. Results of Length-height- for-age indicator shows that the percentage of stunted children attending 5 kindergartens in Kosovo is 3%, and that 0, 7% are severely stunted. This 3% is lower than the percentage from the study conducted in 2001 by UNICEF, where, Low height-for-age was found in 10% of the children aged 6-59 months. In terms of gender 2.9% of boys and 2.4% of girls were stunted while 0.7% of boys and 0.5% of girls were severely stunted. The weight-for-length-height indicator which is used to determine whether a child is acutely malnourished showed that 1,9% of children (12-60 months) are less than -2 Z-scores, thus suffering from moderate acute malnutrition or wasting and 0.8% of children are less than -3 Z- scores suffering from severe acute malnutrition. This percentage is much lower than results from the UNICEF survey of July 1999 (UNICEF, 1999) in which the acute malnutrition was detected in 3.1% of the children from 0 to 5 years (including 1% severe) and chronic malnutrition was present in 10.7% of the children (including 3% severe). Analyzing weight-for
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age, length-height-for age and weight-for-length-height indicators, we saw that there is a reduction in underweight, stunting and wasting of preschool aged children from the year 1999 or 2001 to the time of this research. Prevalence of undernutrition as assessed by anthropometric indicators in this study is presented in the Figure 30.
Figure 30: Prevalence of undernutrition
Source: Own calculation (2013)
The Weight-for-height indicator is used also for describing risk of overweight and obesity in 12- 24 months aged children. Our results showed that 0% of children aged 12-24 months were seen to be obese, 6.8 % were overweight (>+2 Z-scores) and 34.1% had a possible risk of being overweight (>+1 Z-scores). In terms of gender no girls and no boys were obese. 7.4% of boys and 5.9% of girls were overweight and 29.6 % of boys and 41.2 % of girls had a possible risk of being overweight. BMI for age was used for screening of risk of being overweight, the overweight and obesity of 24-83 months aged children. The percentage of obese children was 2.3%, further 8.94% were screened as overweight and 27.3% had a possible risk of being overweight. It was observed that 2.68% of boys and 1.44% of girls of the aged group 24-83 months were obese, 10.88% of boys and 5.86% of girls were overweight and 29.12% of boys and 25.16% of girls are at risk of being overweight. The findings showed that overweight and obesity in the 24 to 36 months-old group has the highest prevalence to other groups. Prevalence of overweight in this group was 12.9% and obesity 4.3%, whereas 45.7% were at risk of being overweight. Since there were no
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available data on overweight among preschool aged children attending kindergartens, the only data we could find to compare our results are those from the Nutritional Survey of pregnant women and school children supported by UNICEF (UNICEF, 2010), where the overweight amongst school children age 6-13 was above 2.3%. Prevalence of overweight as assessed by anthropometric indicators is shown in Figure 31.
Figure 31: Prevalence of overweight
45.00%
40.00% 35.00% 30.00% 25.00% 20.00% 15.00%
Percentage 10.00% 5.00% 0.00% Boys (N=264) Girls (N=222)
Prevalence of overnutrition (According to WHO indicators)
Source: Own calculation (2013)
These results are in line with other studies which show that the childhood overweight and obesity is increasing in less developed countries as well as in transitional societies. (De Onis et al., 2010; Cattaneo et al., 2010; Stralen et al., 2012; Poskitt, 2009; 129 Jafar et al., 2008). Kosovo is a Country in transition and the co-existence of over and under-nutrition might be a case similar to those observed through researches in other countries. A study conducted in Mexico by Fernald & Neufeld, (2007), showed that the prevalence of overweight/obesity was 20% but in the same children (24-72 months), 5% of indigenous and 10% of non-indigenous overweight children were stunted. The results which of our study are also similar to other worldwide studies on prevalence of overweight and obesity in preschool aged children which report a growing trend in childhood overweight (Maffeis, et al., 2006; Manios, et al., 2007; Gaeini, et al., 2011; Juliusson, et al., 2010; Taheri et al., 2012).
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4.3 Results and Discussions of Food and Nutrient Intake
The program PRODI was used to convert food items to the constituent nutrients. The PRODI data were transferred into SPPS (version 17.0) for calculation and comparison of the following nutrient values: main nutrients, amino acids, special carbohydrates, fatty acids, minerals and trace elements, sterols and vitamins. To current knowledge, this is the first study having evaluated the dietary practices at preschool aged children in kindergartens of Kosovo and the first study to examine children’s nutrient intake. Child care in kindergartens of Kosovo cover full day program (8 hours) and meals served include breakfast, lunch and afternoon snack. Actually, Kosovo does not have the Dietary Guidelines for preschool aged children, thus meal planning does not refer to any recommendations on dietary allowances or dietary reference intakes and recommendations on proportional share of nutrient requirements according to servings is missing, too. Countries usually recommend about how much food a child in a full - day program should receive in order to meet certain percentage of daily nutrition needs. In USA for instance, children in full-day program should receive foods that meet at least half to two thirds of child’s daily nutrition needs (American Dietetic Association, 2005). Another example could be Estonia, where kindergartens provide three meals a day and food served should cover 80-85% of a child’s daily energy requirements (Regulation on health protection requirements and nutrition in catering facilities in preschool institutions and schools 2002). In our study, foods and drinks consumed in kindergartens over the period of three days were recorded through weighted dietary record method and then converted into nutrients and calculated the values of main ingredients, amino acids, special carbohydrates, fatty acids, minerals and trace elements, sterols and vitamins. The comparison was made to show the differences between nutrient consumption in public and private kindergartens. The obtained results were also compared with references of dietary intake recommended in other Countries. There are many disparities in the recommendations about nutrient intake by children (Prentice et al., 2004), and since Kosovo did not develop official advice on feeding practices for preschool children, our dietary intake results were compared mostly with reference values for nutrition intake recommended by German, Austrian and Swiss societies for nutrition (Reference Values for Nutrient Intake Frankfurt am Main. Umschau/Verlag 2002) as well as with other reference values (120-127)
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4.3.1 Main Ingredients, Special Carbohydrates and Fatty Acids
Table 23 presents the mean values of main ingredients, special carbohydrates and fatty acids consumed by children from all kindergarten according to gender and age. The specific results showing the values of main ingredients, special carbohydrates and fatty acids by kindergartens are attached as annexes (Annexes from 21 to 25), while the annex 26 presents mean results only from public kindergartens. Energy distribution from macronutrients (carbohydrates, fat and proteins) in all kindergartens according to gender and age is shown in Table 24.
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Table 23: Mean values of main nutrients, special carbohydrates and fatty acids consumed by children from all kindergartens according to gender and age
Special Main Ingredients Carbohydrates Fatty Acids Polyunsat Sex and Total Monounsat urated Saturated n age Kinder- Carbohyd Protein dietary Sucrose¹ urated fatty fatty fatty (months) garten rates g Fat g Kilocalories Kilojoule g fibre¹ g Water g Starch¹ g g acids¹ g acids¹ g acids¹ g Boys (all 257 All ages) kindergart Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean ens 12 to < 24 25 88.1 21.4 636.9 2664.3 21.2 5.5 307.3 50.9 15.2 2.2 1.1 3.4 24 to < 36 36 92.0 18.6 631.3 2640.7 22.2 5.7 300.8 55.4 16.2 2.3 1.4 3.1 36 to < 48 64 101.6 20.5 701.5 2934.4 25.7 6.9 346.1 62.3 15.2 2.2 1.3 2.9 48 to < 60 65 117.6 22.2 796.9 3333.4 29.5 7.7 380.1 73.7 17.6 2.4 1.5 3.2 60 to < 72 48 118.8 22.3 804.0 3363.1 30.0 7.4 386.2 73.7 18.6 2.6 1.5 3.5 72 to < 83 19 135.8 29.9 960.4 4016.8 34.6 9.6 433.4 87.5 18.1 2.8 2.0 3.6 Girls (all All ages) 212 kindergart ens 12 to < 24 19 82.5 19.4 590.0 2468.0 19.7 4.7 299.5 45.5 15.0 2.3 0.8 3.9 24 to < 36 34 93.5 18.3 639.7 2675.9 23.5 5.8 298.0 57.2 15.0 2.3 1.2 3.2 36 to < 48 59 99.7 21.8 702.8 2939.5 25.1 7.0 335.2 61.2 14.5 2.1 1.4 2.5 48 to < 60 46 120.5 24.1 832.9 3483.9 31.4 7.8 399.9 76.4 18.1 2.6 1.6 3.4 60 to < 72 45 123.8 23.3 836.4 3498.4 30.8 7.6 402.3 78.0 19.7 2.7 1.7 3.4 72 to < 83 9 134.5 29.4 946.6 3959.3 33.9 9.0 414.1 87.7 18.0 3.1 2.2 3.8 Combined 469 All (all ages kindergart ens 12 to < 24 44 85.7 20.6 616.7 2579.5 20.6 5.2 303.9 48.6 15.1 2.2 1.0 3.6 24 to < 36 70 92.7 18.5 635.4 2657.8 22.8 5.7 299.4 56.3 15.6 2.3 1.3 3.1 36 to < 48 123 100.7 21.1 702.1 2936.8 25.4 6.9 340.9 61.8 14.9 2.1 1.3 2.7 48 to < 60 111 118.8 23.0 811.8 3395.7 30.3 7.7 388.3 74.9 17.8 2.5 1.5 3.3 60 to < 72 93 121.2 22.8 819.7 3428.5 30.4 7.5 394.0 75.8 19.2 2.7 1.6 3.4 72 to < 83 28 135.4 29.7 956.0 3998.3 34.4 9.4 427.2 87.6 18.0 2.9 2.0 3.7
Source: Own calculation (2013)
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Table 24: Energy distribution from macronutrients according to gender and age l Sex and
age n Kinder- Carbohydrates Fat Protein (months) garten Kilocalories calories calories calories Boys (all 257 All Mean % % % ages) kindergartens
12 to < 24 25 636.9 55.3 30.3 13.3 24 to < 36 36 631.3 58.3 26.6 14.1 36 to < 48 64 701.5 57.9 26.3 14.7 48 to < 60 65 796.9 59.0 25.1 14.8 60 to < 72 48 804.0 59.1 24.9 14.9 72 to < 83 19 960.4 56.5 28.0 14.4 Girls (all All 212 ages) kindergartens
12 to < 24 19 590.0 55.9 29.6 13.3 24 to < 36 34 639.7 58.4 25.8 14.7 36 to < 48 59 702.8 56.7 27.9 14.3 48 to < 60 46 832.9 57.9 26.0 15.1 60 to < 72 45 836.4 59.2 25.1 14.7 72 to < 83 9 946.6 56.8 27.9 14.3 Combined 469 All (all ages kindergartens
12 to < 24 44 616.7 55.6 30.0 13.3 24 to < 36 70 635.4 58.4 26.2 14.4 36 to < 48 123 702.1 57.4 27.1 14.5 48 to < 60 111 811.8 58.6 25.5 14.9 60 to < 72 93 819.7 59.2 25.0 14.8 72 to < 83 28 956.0 56.6 28.0 14.4 One Way ANOVA, P>0.05 Source: Own calculation (2013)
The mean energy intake values for children (girls and boys) staying for 8 hours in kindergartens ranged from 616.7 Kilocalories (2579.5 Kilojoules) for the age group 12-23 months to 956.0 Kilocalories (3998.3 Kilojoules) for the age group 72-83 months. The energy intake of 1-4 years
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old children during their 8 hours stay in kindergartens was 63% for boys and 69% for girls of the daily recommended energy intake (1100 Kcal for mails and 1000 for females of 1 to 4 years old children). On the other side, the energy intake of the age group 4-7 years was 60% for boys and 64% for girls of the daily recommended energy intake (1500 Kcal for males and 1400 for females of 4 to 7 years old children. In terms of data related to average energy intake in public and private kindergartens, children (12-83 months) in public kindergartens consumed in average 896 calories, while children in private kindergartens in average took 712 kilocalories during their (full day-8 hours) stay in kindergartens. The percentage of the total energy intake derived from carbohydrates, fat and protein was approximately the same for 1-4 and 4-7 years old children: carbohydrates 58%; fat 27% and proteins 15%. The difference in energy distribution from macronutrients in the public and private kindergartens shows that the energy from carbohydrate intake was slightly greater in public kindergartens (60%) than in the private (51%). Evaluation of the energy from the fat intake indicated that children at private kindergartens get more energy from lipids (35%) in comparison with those in public kindergartens (24%). Protein calories were little bit higher at the public kindergartens (15%) than at private kindergarten (12%). In terms of data on carbohydrate, lipids and protein intake quantities in the public and private kindergartens (full day program-8 hours), was observed that the mean carbohydrate intake was 116 g for 1-7- year-old children in public kindergartens and 114 g in private kindergartens. The mean fat intake was 19 g in public and 35 g in private kindergartens. The average protein consumption was 27g for 1-7-year-old children attending public kindergartens and 28 g for 1-7 year old children attending private kindergartens. When comparing our results with these recommended by German, Austrian and Swiss Societies on fat % of energy, we observed that the energy derived from fat consumed in kindergartens (full day -8 hours) covered almost 100 % of recommended fat percentage of energy in private kindergartens and about 70% in public. The mean total protein intake for 1-4- year-old children was about 25 g (full day-8 hours) covering for 180% the recommended daily intake (13-14 g), while the total protein intake for 4-7-year-old children was 32.5 g covering 93% of recommended daily intake (17-18g). When analyzing the energy intake and its distribution from macronutrients separately for each kindergarten (full day-8 hours), we found important differences in mean energy and macronutrient served. The mean energy served ranged from 455 kcal in the kindergarten 4, than 481 kcal in kindergarten 2 followed by 618 kcal in kindergarten 3 and 992 kcal in the kindergarten 1. The percentage of recommended energy intake (according to guidelines for Germany, Austria and Swiss) ranged from 36% to 79% of the recommended daily intake. There were also significant differences in the mean carbohydrate, fat and protein intake. Children in kindergarten 4 consumed about 68 g of
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carbohydrates while children in kindergarten 1 about 148 grams. The mean fat intake ranged from 11, 9 grams in the kindergarten 4 up to 26.9 g in the kindergarten 1. The mean protein intake ranged from 17.3 in the kindergarten four up to 36.2 grams in kindergarten 2. The difference in energy distribution from macronutrients in the public and private kindergartens according to age is shown in Table 25. Means and proportional distribution of starch and sucrose in public and private kindergartens is presented in Table 26.
Table 25: Energy distribution from macronutrients in public and private kindergartens Sex and
age n Kinder- Carbohydrates Fat Protein (months) garten Kilocalories calories calories calories Mean % % %
Combined 87 Private (all ages) Prishtine 12 to < 24 15 820.1 52.2 34.8 12.0 24 to < 36 12 757.7 51.2 35.4 12.5 36 to < 48 29 920.6 50.5 36.3 12.2 48 to < 60 14 913.8 51.0 35.4 12.6 60 to < 72 8 911.7 51.0 35.3 12.8 72 to < 83 9 1052.4 50.9 35.7 12.5 Combined 382 All (all ages) Public 12 to < 24 29 511.4 58.4 26.1 14.4 24 to < 36 58 610.1 60.2 23.8 14.8 36 to < 48 94 634.7 60.4 23.0 15.5 48 to < 60 97 797.1 59.8 23.9 15.3 60 to < 72 85 811.0 60.0 23.9 15.0 72 to < 83 19 910.3 59.8 23.8 15.4 One Way ANOVA, P<0.05 Source: Own calculation (2013)
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Table 26: Distribution of starch and sucrose in public and private kindergartens Special Carbohydrates Sex and age Kinder- n (months) garten Starch¹ g Sucrose¹ g Mean Mean Combined (all 87 Private ages) Prishtine 12 to < 24 15 63.3 12.8 24 to < 36 12 60.7 8.0 36 to < 48 29 75.8 8.6 48 to < 60 14 74.7 9.0 60 to < 72 8 76.8 8.5 72 to < 83 9 83.8 12.5 Combined (all 382 Public ages) 12 to < 24 29 41.0 16.3 24 to < 36 58 55.4 17.2 36 to < 48 94 57.4 16.8 48 to < 60 97 74.9 19.1 60 to < 72 85 75.7 20.2 72 to < 83 19 88.9 20.7 Source: Own calculation (2013)
Proportion of starch and sucrose intake in all kindergartens according to gender and age is shown in Table 27 Special carbohydrates: The mean intake of special carbohydrates (starch and sucrose) showed that the average starch intake in four public kindergartens (full day-8 hours) for children 1-7 years old was about 73 grams while sucrose was taken in average 10 grams. Children attending private kindergarten consumed in average 65 g of starch and about 18 grams of sucrose.
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Table 27: Proportion of starch and sucrose intake in all kindergartens Special Carbohydrates
Sex and age n Kinder- Sucrose¹ (months) garten Starch¹ g g Boys (all 257 All ages) kindergartens Mean Mean 12 to < 24 25 50.9 15.2 24 to < 36 36 55.4 16.2 36 to < 48 64 62.3 15.2 48 to < 60 65 73.7 17.6 60 to < 72 48 73.7 18.6 72 to < 83 19 87.5 18.1
Girls (all All ages) 212 kindergartens 12 to < 24 19 45.5 15.0 24 to < 36 34 57.2 15.0 36 to < 48 59 61.2 14.5 48 to < 60 46 76.4 18.1 60 to < 72 45 78.0 19.7 72 to < 83 9 87.7 18.0 Combined 469 All (all ages kindergartens 12 to < 24 44 48.6 15.1 24 to < 36 70 56.3 15.6 36 to < 48 123 61.8 14.9 48 to < 60 111 74.9 17.8 60 to < 72 93 75.8 19.2 72 to < 83 28 87.6 18.0 Source: Own calculation (2013) The proportion between starch and sucrose intake in public kindergartens was 7.5:1 in favor of starch, while in private kindergartens this report was 3.5:1 in favor of starch. We noticed significant differences between average intake of starch and sucrose when analyzing separately for each kindergarten. So, the starch intake ranged from 32 grams in the kindergarten 4 and 93 grams in the kindergarten 1, while the intake of sucrose was 10.5 grams in the kindergarten 4 and about 20 grams in the kindergarten 1 (full day-8 hours). Even though our results show good proportion between starch and sucrose, we observed that starch options are refined starches coming from grains that have been processed where the fiber-rich parts are removed and only starchy interior remains. In daily menus of assessed kindergartens the starch came mostly from white flour, white bread, milling rice, biscuits, muffins and shelled potatoes.
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Dietary fiber intake: The mean total fiber intake for 1-3 year old children was 5.6 grams in public and 8.7 grams in private kindergartens covering for about 30% and 46% respectively the recommended adequate intake (19 grams) (120 Dietary Reference Intakes 2002/2005). On the other side, the total fiber intake for 4-7 old children was 7.7 grams in public and 11 g in private kindergartens covering for about 31% and 44% respectively the recommended AI (25 grams). There was a significant difference observed in fiber intake when intake was calculated separately for each kindergarten. The lowest fiber intake of 2.3 grams was recorded in the kindergarten 4 followed by 4.5 g in the kindergarten 2, than 6.3 grams in kindergarten 3 and 8.1 grams in kindergarten 1. The preschool age children when at kindergartens as well as at home are not provided with the enough foods rich in fiber and consumption of fruits and vegetables as well as other high-fiber foods is very limited. These findings are in line with findings from other studies which confirm low consumption of high–fiber foods and consumption of low–fiber items and processed and refined foods by preschool children (Gehlhar & Regmi, 2005; WHO, 2003; Monteiro, 2009; Monteiro et al., 2010; Kranz et al., 2005; Piernas & Popkin, 2010; Piernas & Popkin, 2011; Kranz et al., 2012). Lack of nutrition education in preparation of daily meals and low financial capacities of kindergartens and families could be the main factors for not consumption of fiber rich foods in Kosovo. There are studies showing inadequate intake of fiber in children coming from families which have low socioeconomic status (Wilson et al., 2009) and association of low intake with higher body fatness (Johnson, et al., 2008). SFA, MUFA and PUFA intake: The mean intake of SFA (Saturated fatty acids) for 1-7 years old children was in average 3.4 grams in public and 2.4 grams in private kindergartens (full day- 8 hours). The mean percentage of energy derived from saturated fatty acids (full day-8 hours) was 3.5% in public and 3% in private kindergartens, covering 35% and 30% respectively of maximum recommended daily energy intake from SFA (German, Austrian and Swiss Societies recommend maximum 10%). The intake of MUFA (Monounsaturated fatty acids) was in average 2.5 grams in public and 1.9 grams in private kindergartens (full day-8 hours). The mean percentage of energy derived from MUFA was about 2.5% in both, public and private kindergartens, reaching only 35% of recommended MUFA intake (about 7%). The average of PUFA intake (Polyunsaturated fatty acids) by children attending public kindergartens was 1.4 grams, while children in private kindergartens took little bit more, in average 1.6 grams. The mean percentage of energy derived from PUFA ranged from 1.5% in public up to 2.1% in private kindergartens, covering only about 21% and 30% respectively of recommended daily intake (about 7%).
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Despite the average intake of 27% of the total fat, the mean percentage of energy derived from SFA, MUFA and PUFA was not more than 35% of recommended daily intake. The percentage of trans-fatty acids was not calculated but we assume that TFA contributed as well in the level of the total fat and requires investigation. Fat intake is considered to be important energy source in the childhood, as a source of essential fatty acids and fat-soluble vitamins. Findings from other studies indicate that children with low fat intake can be at risk of unsatisfactory intakes of fat- soluble vitamins (Vobecky et al., 1995). On the other side, low MUFA and PUFA intake by preschool age children indicates that the energy balance and optimal nutrient intake is not in place and influences maintenance of healthy weight and optimal good health. FAO experts found relationship and evidences that replacing SFA with MUFA and PUFA reduces LDA cholesterol concentration and total CHD cholesterol ratio as well as relationship between PUFA and reduced risk of diabetes (FAO/WHO, 2008) Amino acids: Mean values of amino acids consumed by children from all kindergartens according to age and gender are presented in Table 28, while values of main amino acids consumed by children of each public and private kindergarten are attached as annexes (Annexes; 27-32). Our results showed that consumption of amino acids by children from all kindergartens are higher than it is required for preschool age children (Joint FAO/WHO/UNU Expert Consultation, 2002).The difference between values consumed by children attending public and private kindergartens is shown in Table 29. Significant differences when comparing consumption of amino acids by children attending public and private kindergartens. Children attending private kindergarten consumed far more amino acids than children attending public kindergartens. We observed also significant difference between consumption of amino acids when intake was calculated separately for each public kindergarten. Children attending kindergarten in Kamenicë consumed far less amino acids than children attending other kindergartens.
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Table 28: Mean values of amino acids consumed by children from all kindergartens
Arginin Cystine¹ Histidine¹ Isoleucine¹ Leucine¹ Lysine¹ Methionin Phenylala Threonin Tryptopha Tyrosin Valine¹ Sex and age n Kindergarten (months) e¹ mg mg mg mg mg mg e¹ mg nine¹ mg e¹ mg ne¹ mg e¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 257 All kindergartens 12 to < 24 25 1033.5 262.8 524.1 974.9 1613.4 1245.4 376.5 955.3 795.5 218.3 722.6 1106.8 24 to < 36 36 1016.5 286.7 530.4 956.9 1572.8 1167.4 381.8 937.1 773.2 220.9 691.0 1076.6 36 to < 48 64 1207.6 343.7 630.1 1142.0 1850.6 1392.0 454.1 1106.9 915.6 258.7 791.8 1267.4 48 to < 60 65 1298.9 407.8 688.1 1264.0 2059.9 1454.4 510.1 1241.5 996.2 289.0 855.8 1395.4 60 to < 72 48 1333.3 412.8 714.3 1287.4 2096.5 1509.1 530.6 1252.6 1019.7 297.2 871.4 1421.1 72 to < 83 19 1588.6 487.3 817.6 1583.0 2540.5 1786.4 600.3 1552.8 1218.1 348.1 1064.4 1745.6 Girls (all ages) All 212 kindergartens 12 to < 24 19 957.9 240.7 493.9 898.4 1487.5 1172.3 356.8 872.1 739.6 203.1 665.6 1018.9 24 to < 36 34 1094.7 306.8 577.3 1020.4 1653.4 1261.3 403.7 988.2 828.0 234.7 732.8 1133.0 36 to < 48 59 1201.8 337.0 619.7 1143.3 1834.9 1371.1 441.9 1105.4 908.1 256.1 784.3 1268.2 48 to < 60 46 1432.5 425.7 754.0 1367.1 2212.2 1624.2 554.6 1322.4 1088.4 313.1 930.0 1506.3 60 to < 72 45 1332.7 428.8 718.0 1317.5 2148.2 1500.6 539.1 1290.7 1033.3 303.7 900.5 1453.9 72 to < 83 9 1535.6 481.8 793.8 1525.7 2444.3 1700.3 599.5 1489.4 1177.9 342.8 1026.9 1680.6 Combined (all ages) 469 All kindergartens 12 to < 24 44 1000.9 253.2 511.1 941.8 1559.1 1213.8 368.0 919.4 771.3 211.7 698.0 1068.8 24 to < 36 70 1054.5 296.4 553.2 987.7 1611.9 1213.0 392.4 961.9 799.8 227.6 711.3 1104.0 36 to < 48 123 1204.8 340.5 625.1 1142.6 1843.1 1382.0 448.2 1106.2 912.0 257.4 788.2 1267.7 48 to < 60 111 1354.3 415.2 715.4 1306.7 2123.0 1524.7 528.5 1275.0 1034.4 299.0 886.6 1441.3 60 to < 72 93 1333.0 420.5 716.1 1302.0 2121.5 1505.0 534.7 1271.0 1026.3 300.4 885.5 1437.0 72 to < 83 28 1571.6 485.5 809.9 1564.6 2509.6 1758.7 600.1 1532.5 1205.2 346.4 1052.3 1724.7 Source: Own calculation (2013)
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Table 29: Differences between mean values of amino acids consumed by children of public and private kindergartens
Sex and age n Kinder- Arginine¹ Cystine¹ Histidine¹ Isoleucine¹ Leucine¹ Lysine¹ Methionine Phenylala Threonine¹ Tryptopha Tyrosine¹ Valine¹ (months) garten mg mg mg mg mg mg ¹ mg nine¹ mg mg ne¹ mg mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Combined (all 87 Private ages) Prishtine
12 to < 24 15 1217.7 302.7 605.8 1192.0 1986.7 1493.9 429.0 1192.2 957.5 257.0 881.2 1359.2 24 to < 36 12 1179.9 313.2 567.5 1163.0 1875.4 1386.5 403.3 1157.2 916.2 244.8 827.1 1301.6 36 to < 48 29 1483.9 395.8 696.3 1439.7 2272.5 1677.0 495.0 1419.6 1127.0 305.0 1001.4 1606.5 48 to < 60 14 1515.6 406.9 713.1 1482.2 2331.7 1716.7 502.6 1463.2 1154.5 311.4 1024.3 1651.6 60 to < 72 8 1522.3 419.1 719.0 1497.7 2358.4 1717.8 514.1 1482.1 1164.6 316.7 1032.9 1668.7 72 to < 83 9 1765.8 463.0 817.2 1696.9 2651.3 1950.4 552.0 1679.2 1314.0 351.7 1161.5 1883.0 Combined (all 382 Public ages) 12 to < 24 29 888.7 227.6 462.1 812.4 1337.8 1068.9 336.5 778.3 675.0 188.2 603.2 918.7 24 to < 36 58 1028.5 293.0 550.2 951.5 1557.4 1177.1 390.2 921.5 775.7 224.1 687.4 1063.1 36 to < 48 94 1118.7 323.4 603.1 1051.0 1710.6 1291.0 433.8 1009.5 845.6 242.8 722.4 1163.2 48 to < 60 97 1331.0 416.4 715.7 1281.4 2092.8 1497.0 532.3 1247.9 1017.1 297.2 866.7 1411.0 60 to < 72 85 1315.2 420.6 715.8 1283.6 2099.3 1485.0 536.7 1251.1 1013.3 298.8 871.6 1415.2 72 to < 83 19 1479.5 496.2 806.5 1501.9 2442.5 1667.9 622.8 1462.9 1153.6 343.8 1000.6 1649.7 One Way ANOVA P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.01 P<0.01 P<0.01 P<0.01 P<0.01 P<0.05 Source: Own calculation (2013)
4.3.2 Results and Discussions for Micronutrients
Intake of minerals, trace elements and sterols. Mean values of minerals, trace elements and sterols consumed by children of all kindergartens are presented in Table 30. The difference between mean consumption of minerals, trace elements and sterols by children attending public and private kindergartens is presented in Table 31. The results showing the mean values of minerals, trace elements and sterols consumed by children of each public and private kindergarten are attached as annexes (Annexes; 33-38).
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Table 30: Mean values of minerals, trace elements and sterols according to gender and age (all kindergartens)
Minerals and Trace Elements Sterols
Sex and age n Kindergarten Calcium Chloride¹ Iodide¹ Iron¹ Magnesi Phospho Potassi Sodium¹ Zinc¹ Cholesterol¹ (months) mg mg µg mg um¹ mg rus mg um¹ mg mg mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 257 All ages) kindergartens 12 to < 24 25 217.8 917.4 9.6 3.3 84.0 361.0 952.1 828.7 2.6 60.0 24 to < 36 36 202.7 891.7 8.9 3.0 79.3 352.4 878.9 780.0 2.7 61.3 36 to < 48 64 222.8 1101.8 10.6 3.6 91.3 392.2 1002.1 999.8 3.2 65.7 48 to < 60 65 263.7 1259.2 11.9 3.8 101.3 437.1 997.9 1159.8 3.6 74.6 60 to < 72 48 267.3 1273.2 12.0 3.7 99.9 440.7 1010.9 1164.8 3.7 76.4 72 to < 83 19 324.5 1458.8 15.4 4.9 128.5 541.7 1276.5 1359.9 4.2 96.8 Girls (all All ages) 212 kindergartens 12 to < 24 19 201.6 904.9 8.9 3.0 73.5 333.4 874.2 773.4 2.4 60.6 24 to < 36 34 198.1 943.3 8.8 3.1 79.0 367.7 926.6 831.2 3.0 61.6 36 to < 48 59 215.8 1107.9 11.1 3.8 94.7 386.5 1023.1 1022.0 3.2 70.2 48 to < 60 46 261.4 1375.3 12.1 4.2 106.3 460.4 1077.9 1265.5 4.0 80.4 60 to < 72 45 288.3 1312.5 12.5 3.8 101.8 458.5 998.2 1200.2 3.8 78.3 72 to < 83 9 304.3 1511.2 15.1 4.7 117.4 506.0 1128.2 1409.0 4.2 99.9 Combined (all 469 All ages) kindergartens 12 to < 24 44 210.8 912.0 9.3 3.2 79.5 349.1 918.5 804.8 2.5 60.3 24 to < 36 70 200.4 916.8 8.8 3.1 79.1 359.8 902.1 804.9 2.8 61.4 36 to < 48 123 219.4 1104.7 10.8 3.7 92.9 389.5 1012.1 1010.5 3.2 67.9 48 to < 60 111 262.8 1307.3 12.0 3.9 103.4 446.8 1031.1 1203.6 3.8 77.0 60 to < 72 93 277.5 1292.2 12.2 3.7 100.8 449.3 1004.8 1182.0 3.7 77.3 72 to < 83 28 318.0 1475.6 15.3 4.9 125.0 530.3 1228.8 1375.7 4.2 97.8 One Way ANOVA P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 Source: Own calculation (2013)
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One Way Anova test doesn’t show significant differences between consumption of minerals, trace elements and sterols according to gender and age in all kindergartens but significant difference was observed when consumption of most minerals, trace elements and sterols were compared in public and private kindergartens. These differences are shown in Table 31.
Table 31: Difference between consumption of minerals, trace elements and sterols in public and private kindergartens according to gender and age
Minerals and Trace Elements Sterols
Sex and Kindergar Magne Phosp Potass n age ten Calcium Chloride¹ Iodide¹ Iron¹ sium¹ horus ium¹ Sodium¹ Zinc¹ Cholest (months) mg mg µg mg mg mg mg mg mg erol¹ mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean
Combined 87 Private (all ages) Prishtine 12 to < 24 15 308.2 1002.4 13.2 4.5 116.6 456.4 1253.8 944.7 2.9 61.3 24 to < 36 12 265.3 1046.6 12.8 4.6 106.0 418.5 1118.3 1048.4 2.9 62.5 36 to < 48 29 260.1 1355.7 16.3 5.9 131.5 473.6 1408.3 1358.1 3.7 94.9 48 to < 60 14 267.5 1340.3 16.5 6.0 134.7 490.8 1438.8 1337.1 3.7 107.8 60 to < 72 8 272.5 1345.6 17.0 5.9 133.9 492.1 1418.3 1343.5 3.7 111.6 72 to < 83 9 287.9 1483.7 18.1 7.0 157.1 575.9 1674.0 1494.3 4.1 126.0 Combined 382 Public (all ages) 12 to < 24 29 160.4 865.3 7.3 2.5 60.3 293.6 745.0 732.5 2.2 59.8 24 to < 36 58 187.0 889.9 8.0 2.8 73.5 347.7 857.3 754.5 2.8 61.2 36 to < 48 94 206.9 1027.3 9.2 3.0 81.0 363.5 889.9 903.2 3.0 59.5 48 to < 60 97 262.1 1302.6 11.4 3.6 98.9 440.4 972.2 1184.3 3.8 72.5 60 to < 72 85 277.9 1287.2 11.8 3.5 97.7 445.3 965.9 1166.8 3.7 74.1 72 to < 83 19 332.3 1471.8 14.0 3.9 109.8 508.6 1018.0 1319.5 4.2 84.4 One Way ANOVA P<0.01 P<0.05 P<0.01 P<0.01 P<0.01 P<0.05 P<0.01 P<0.01 P>0.05 P<0.05 Source: Own calculation (2013)
Children attending private kindergartens consumed more minerals, trace elements and sterols than those from public kindergartens. Significant differences were also observed when intake was calculated separately for each kindergarten. Mean values of minerals and trace elements consumed by children were compared with reference values for nutrient intake recommended by German, Austrian and Swiss societies for nutrition (Reference Values for Nutrient Intake Frankfurt am Main. Umschau/Verlage, 2002).The average calcium consumption for 1-4 year old children was 210 mg covering for about 35% the recommended intake (600 mg per day). The 4-7 years old children consumed in average 286 mg of calcium that covers only about 40% of recommended daily intake (700 mg) for this age. We observed that 1-4 and 4-7 old children
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attending public kindergartens (full day-8 hours) covered about 31% respectively 40% of recommended daily intake for calcium. Calcium intake by children attending private kindergarten was slightly higher compared to those attending public kindergartens, covering 46% of recommended daily intake for 1-4 year old children and about 39% of 4-7 year old children. Insufficient calcium intake was caused by limited consumption of milk and milk products and. We observed that many children did not want to consume milk even when it was served during the assessment days. Low intake of calcium in childhood may be critical having in mind the essential role of calcium in bone and tooth formation, prevention of different disorders but also regulation of body weight (Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride, 1997; Heaney, 2000; Carruth & Skinner, 2001). The chloride and sodium intake by children attending both public and private kindergartens was much higher than the recommended daily intake. The exceeded intake of chloride and sodium was observed in all children regardless gender, age and place of the attendance. The mean chloride intake for 1-4 years old children was 978 mg covering 217% of recommended daily intake (450 mg) and 1358 mg for 4-7 years covering 219% of recommended daily intake (620 mg). Sodium intake for 1-4 and 4-7 years old children was also much more than recommended intake. The average intake ranged from 873 mg for 1-4 years old children, covering 291% of recommended daily intake and 1253 mg for 4-7 years old children covering about 306% of recommended daily intake. These results indicate that consumption of high sodium and chloride by preschool children in kindergartens is very critical and should be reduced because even though childhood is not the target group for hypertension disease, the consumption behavior is established at that stage. Sodium and chloride sources were from cooking, and also from processed foods, bread, sausages and other sources. High levels of sodium and chloride intake by all ages remain prevalent around the world and despite this, only few countries make efforts to reduce the consumption (Brown et al., 2009). High sodium intake can lead to hypertension which causes cardiovascular diseases and WHO predicts that by 2025 the number of people suffering from hypertension will increase to 60 percent (He & Macgregor, 2006; Hajjar et al.; 2006). Findings of this study are in line with many other researches which have reported the increase in sodium and chloride intake. A survey of sodium intake of preschool children in USA and Canada reveals high consumption level of sodium. The same conclusions have also derived from other studies (Garriguet, 2007; Shibata et al., 2008; Klunkin & Channoonmuang, 2006; Hollenberg, 2006). The iodine and iron intake by children participating in our study is below recommended daily intake. Particularly, the iodine intake was very low in all children regardless gender, age and kindergarten. The mean iodine intake for 1-4 years old children was only 9.6 µg covering only
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9.6% the recommended daily intake (100 µg) and 13 µg for 4-7 years covering only about 11% of recommended daily intake (120 µg). The Iron intake for 1-4 and 4-7 years old children was 3.3 mg and 4.1 respectively, covering 41% respectively 52% of daily recommended intake for the two age group children. The One Way Anova test shows significant difference when the consumption of iodine and iron in public and private kindergartens were compared. Despite high intake of sodium and chloride (which mostly come from salt consumption) by children attending kindergartens in Kosovo, the low level of iodine may be due to consumption of not iodized salt and low intake of foods with higher content of iodine. The deficiency of iodine, iron and vitamin A in women and school children of Kosovo was shown also in the micronutrient status survey in 2001 (9), where half of the women and half of the studied school children had low values of urinary iodine concentration as well as deficiency of iron and vitamin A. Iron and iodine deficiencies are reported all over the world, especially in developing countries (WHO, 2011). Low iodine intake should be of concern having in mind its role for the synthesis of the thyroid hormones which regulate number of physiologic processes such as growth, metabolism and reproductive function (Hetzel et al., 1999; Dunn, 1998). On the other side, iron deficiency as the most common nutritional deficiency in the world may lead to anemia, poor cognitive development, efficient transmission of nerve impulses and nucleic acid synthesis (Thomas D.G. et al., 2009; Lozoff, 2007; Beard, 2001). Magnesium mean intake ranged from 83 mg for 1-4 years old children and 110 mg for 4-7 old children. Daily intake of magnesium in all kindergartens (full day-8 hours) covered 105% of recommended intake for 1-4 years old children (80 mg) and 91% of recommended intake for 4-7 year old children (120 mg). Children attending private kindergartens consume in average significantly more magnesium than those attending public kindergartens, covering for 147% of recommended daily intake for 1-4 year old children (80 mg) and 118% for 1-7 years old children (120 mg). Phosphorus intake ranged from 366 mg for 1-4 age children covering 73% of recommended dietary intake (500 mg) and 475 mg covering 79% of recommended dietary intake (600 mg). Phosphorus is consumed more by children attending private kindergartens then those from public kindergartens. The average intake of phosphorus covers about 89% and 86% of recommended intake for 1-4 respectively 4- 7 year old children. Potassium intake was higher in private than in public kindergartens. The intake of Potassium in private kindergartens (full day-8 hours) covered 126% and 108% of recommended daily intake for 1-4 respectively 4-7 years old children. The average intake in public kindergartens ranged from 830 mg for 1-4 years old children up to 985 mg for 4-7 years old children covering 83% and 71% of recommended daily need for two age groups of children. As far as zinc intake is concerned it was observed that 1-4 year old children attending private
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kindergarten exceeded the recommended daily intake (3 mg) during their stay in kindergarten. On the other side 4-7 years old children consumed about 77% of recommended daily intake (5 mg). The mean zinc intake by 1-4 year old children attending public kindergartens was about 2.7 mg covering 78% of recommended daily intake (3 mg) and about 3.9 mg for 4-7 years old children covering 78% of recommended daily intake (5 mg). Vitamins. The mean values of vitamins which were consumed by children (12-83 months old) in all five kindergartens are presented in Table 32. The results showing the mean values of vitamins consumed by children of each public and private kindergarten are attached as annexes (Annexes; 39-44).The statistical test shows significant differences (P<0.05) in consumption of vitamins (according to gender and age) such as: biotin, retinol equivalent and vitamin K. Table 33 presents the difference between consumption of vitamins in public and private kindergartens. One Way ANOVA test showed significant differences between consumption of certain vitamins in public and private kindergarten. The differences have been shown for biotin, Retinol and Vitamin K.
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Table 32: The mean values of vitamins which were consumed by children (12-83 months old) in all five kindergartens Pantot Retin Vitami Vitami Folic Niacine henic olequi n A Vitami Vitami Vitami Vitami Vitami Vitami n E Vitami n Kindergarten Sex and age Biotin¹ acid¹ quivale acid¹ valent Retinol n B1¹ n B12¹ n B2¹ n B6¹ n C¹ n D¹ activ.¹ n K¹ (months) µg µg nt¹ µg mg ¹ µg ¹ mg mg µg mg mg mg µg mg µg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 257 All kindergartens 12 to < 24 25 13.9 66.2 5617.2 1.4 230.9 0.1 0.3 0.8 0.3 0.5 21.2 0.3 7.6 26.3 24 to < 36 36 12.6 56.5 6116.6 1.3 174.0 0.1 0.3 0.8 0.3 0.5 18.7 0.3 6.0 19.7 36 to < 48 64 14.4 69.9 7052.6 1.5 184.1 0.1 0.3 0.9 0.3 0.6 26.8 0.3 7.1 25.4 48 to < 60 65 15.3 75.0 7407.9 1.7 170.6 0.1 0.4 1.0 0.4 0.6 27.1 0.4 6.9 21.0 60 to < 72 48 14.9 70.4 7822.3 1.7 152.8 0.1 0.4 1.0 0.4 0.6 26.6 0.4 6.5 17.5 72 to < 83 19 20.0 105.0 8330.4 2.1 258.0 0.1 0.5 1.1 0.5 0.7 32.7 0.5 11.3 36.2
Girls (all ages) 212 All kindergartens 12 to < 24 19 12.8 55.2 5317.3 1.2 193.4 0.1 0.3 0.8 0.3 0.5 19.2 0.3 6.1 19.6 24 to < 36 34 11.9 54.7 6859.8 1.3 145.0 0.1 0.3 0.9 0.3 0.5 18.0 0.3 5.7 16.2 36 to < 48 59 15.5 77.0 7026.9 1.6 213.1 0.1 0.4 0.9 0.3 0.6 28.4 0.3 8.6 32.5 48 to < 60 46 15.6 77.5 8741.9 1.8 184.2 0.1 0.4 1.1 0.4 0.7 26.2 0.4 7.8 22.6 60 to < 72 45 15.0 71.0 7792.1 1.7 160.9 0.1 0.4 1.1 0.4 0.6 22.9 0.4 6.8 18.8 72 to < 83 9 18.5 92.4 8745.4 2.1 244.5 0.1 0.4 1.2 0.4 0.7 30.1 0.5 10.7 36.9
Combined (all 469 All kindergartens ages) 12 to < 24 44 13.4 61.5 5487.7 1.3 214.7 0.1 0.3 0.8 0.3 0.5 20.3 0.3 7.0 23.4 24 to < 36 70 12.2 55.6 6477.6 1.3 159.9 0.1 0.3 0.9 0.3 0.5 18.4 0.3 5.8 18.0 36 to < 48 123 14.9 73.3 7040.3 1.6 198.0 0.1 0.3 0.9 0.3 0.6 27.6 0.3 7.8 28.8 48 to < 60 111 15.4 76.0 7960.7 1.7 176.2 0.1 0.4 1.0 0.4 0.6 26.8 0.4 7.3 21.7 60 to < 72 93 14.9 70.7 7807.7 1.7 156.7 0.1 0.4 1.0 0.4 0.6 24.8 0.4 6.7 18.2 72 to < 83 28 19.5 100.9 8463.8 2.1 253.7 0.1 0.4 1.1 0.4 0.7 31.9 0.5 11.1 36.4 One Way ANOVA P<0.01P<0.01P>0.05 P<0.05P<0.01P>0.05P>0.05P>0.05P>0.05P>0.05P<0.01P<0.01 P<0.01P<0.01 Source: Own calculation (2013)
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Table 33: Difference between consumption of vitamins in public and private kindergartens according to gender and age Pantot Vitamin Kinderg Folic Niacine henic Retinole Vitamin A Vitami Vitami Vitami Vitami Vitami E n Sex and age arten Biotin¹ acid¹ quivalen acid¹ quivalen Retinol¹ Vitamin n B12¹ n B2¹ n B6¹ n C¹ n D¹ activ.¹ Vitamin (months) µg µg t¹ µg mg t¹ µg mg B1¹ mg µg mg mg mg µg mg K¹ µg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean
Combined (all 87 Private ages) Prishtin e 12 to < 24 15 19.3 103.3 5783.3 1.9 348.7 0.1 0.4 0.8 0.4 0.6 32.5 0.4 14.0 47.7 24 to < 36 12 18.3 103.0 5709.5 1.8 340.8 0.1 0.4 0.7 0.4 0.5 32.0 0.4 14.6 55.8 36 to < 48 29 24.2 134.2 7862.9 2.3 440.7 0.1 0.5 0.9 0.4 0.6 47.6 0.6 19.7 83.1 48 to < 60 14 25.4 136.3 7702.3 2.3 415.3 0.1 0.5 1.0 0.4 0.6 45.7 0.7 18.6 72.9 60 to < 72 8 24.3 134.4 7604.7 2.4 407.2 0.1 0.5 1.0 0.4 0.6 43.2 0.7 18.1 68.0 72 to < 83 9 28.1 156.7 8475.9 2.5 462.1 0.1 0.6 1.0 0.4 0.7 50.7 0.8 20.8 79.7 Combined (all 382 Public ages) 12 to < 24 29 10.4 39.8 5334.7 1.0 145.4 0.1 0.2 0.8 0.3 0.4 14.0 0.3 3.3 10.8 24 to < 36 58 11.0 45.8 6636.5 1.2 122.5 0.1 0.3 0.9 0.3 0.5 15.5 0.3 4.0 10.2 36 to < 48 94 12.0 54.6 6786.5 1.3 123.1 0.1 0.3 0.9 0.3 0.6 21.4 0.3 4.2 12.1 48 to < 60 97 14.0 67.3 7998.0 1.7 141.7 0.1 0.3 1.0 0.4 0.6 24.0 0.3 5.7 14.3 60 to < 72 85 14.0 64.7 7826.8 1.7 133.1 0.1 0.3 1.0 0.4 0.6 23.1 0.3 5.6 13.5 72 to < 83 19 15.5 74.5 8458.1 1.9 155.0 0.1 0.4 1.2 0.4 0.6 23.0 0.4 6.4 15.9 One Way ANOVA P<0.01P<0.01 P>0.05 P<0.05 P<0.01 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P<0.01 P<0.01 P<0.01 P<0.01
Source: Own calculation (2013)
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Examination of mean vitamin intakes showed that there were vitamins below the recommended daily intake as well as vitamins which exceeded the recommendations (full day-8 hours). Biotin intake exceeded lower and upper recommended intake levels (10-15 µg) in both children age groups 1-4 years and 4-7 years old children, who attend private kindergartens. The children attending public kindergartens exceeded as well the recommended lower level for biotin intake, while the upper level was covered for about 74% of recommended intake for 1-4 years old children and about 97% for 4-7 years old children. Folic acid intake by children attending kindergartens (full day-8 hours) was in general quite low. The average intake of 1-4 years old children attending public kindergartens was 46.7 µg covering only 23.4% the recommended intake for this age (200 µg). The 4-7 years old children consumed in average 68.8 µg of folic acid covering only 22.9% of recommended daily intake for this age group (300 µg). Children attending private kindergarten took more folic acid than children attending public kindergartens but still the intake was lower than the recommendations. 1-4 age old children in average consumed about 113 µg of folic acid during their stay in kindergarten covering 56.7% the recommended daily intake for folic acid, while 4-7 years old children from private kindergartens, in average consumed 142.5 µg of folic acid covering about 47% of recommended daily intake of folic acid). Deficiency and low level of folic acid, particularly in public kindergartens is most likely due to consumption of micronutrient-poor foods, lack of adjusted dietary folate intake, insufficient consumption of fruit and vegetables as well as consumption of refined and not diverse foods. Folic acid is an essential vitamin and is important for production and maintenance of new cells and amino acid metabolism, thus it is critical during periods of child growth and development (Picciano et al.; 2009; Zeisel, 2009). Niacinequivalent intake in public and private kindergartens (full day-8 hours) was between 6 mg for 1-4 years old children and about 8 mg for 4-7 years old children covering 90% of recommended daily intake for 1-4 years old age group and 80% of recommended daily intake for 4-7 years old children. Average intake of Pantothenic acid by children attending public kindergartens was 1.2 mg for 1-4 years old age children, covering 29.3% of recommended daily intake (4 mg) and 1.7 mg for 4-7 years age group covering 43.2% of recommended daily intake (4 mg). In private kindergartens the average consumption was 2 mg for 1-4 years old children covering 49.4% of recommended daily intake and 2.4 mg for 4-7 years old children covering 60.1% of recommended daily intake. Retinol equivalent as a unit of measurements used to determine the value of vitamin A in sources of vitamin A as well as Retinol/Vitamin A were also calculated. An average intake of retinol equivalent and retinol/Vitamin A in public kindergartens
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was quite a low. The average intake of retinolequivalent by 1-4 years old children was 130.4 µg covering only 21.7% of recommended daily allowances (600 µg) and 143.3 µg by 4-7 years old children covering 20.5% of recommended daily intake (700 µg). Children attending private kindergartens in average consumed more retinol equivalent than children attending public kindergartens. So, 1-4 years old children consumed in average 376.7 µg covering 62.8%of recommended daily intake, while 4-7 years old children in average consumed 428.2 µg, covering for 61.2% of daily recommendations. The intake of vitamin A/Retinol was similar in both, private and public kindergartens. In average children consumed around 0.1 mg of Vitamin A covering for about 16.7% of recommended dietary intake for 1-4 years old children (0.6 mg) and 14.3% for 4- 7 years old children. The average intake of Vitamin B1, Vitamin B2 and Vitamin C by children attending public kindergartens was below 50 % of daily recommended allowances. The average intake of Vitamin B1 was 0.3 mg for 1-4 years old children and 0.4 mg for 4-7 years old children covering 42.4% of recommended daily intake or children of 1-4 years (0.6 mg) and 44% of recommended intake for 4-7 years old children (0.8 mg). The intake of Vitamin B2 ranged between 0.3 and 0.4 mg covering 41.6 % of recommended daily intake for 1- 4 years old children and 44.9 % for 4-7 years old children. The daily intake of Vitamin C by children attending public kindergartens was in average around 17 mg for 1-4 years old children, covering only 28.3% of daily recommended intake (60 mg) and around 23.4 mg for 4-7 years old children, covering 33.4% of daily recommended intake (70 mg). On the other side, the intake of Vitamin B1, Vitamin B2 and Vitamin C by children attending private kindergartens was higher than in public kindergartens Consumption of Vitamin B1 by children attending private kindergarten was in average 0.5 mg for 1-4 years old children and 0.6 mg for 4-7 years old children covering 77.8% of daily recommendations for 1-4 years old children (0.6 mg) and 69% of recommended daily recommendation for 4-7 years old children (0.8 mg). The average intake of Vitamin B2 in the private kindergarten was 0.4 mg, covering 56.6% of daily recommended intake for 1-4 years old children (0.7 mg) and 48.1% for 4-7 years old children (0.9 mg). The average intake of Vitamin C, by 1-4 years old children attending private kindergartens was 37.4 mg, covering 62.3% of recommended daily intake (60 mg) and 46.5 mg by 4-7 years old children, covering 66.5% of daily recommended intake (70 mg). The average intake of Vitamin B12 by children attending private and public kindergartens ranged from 0.8 and 0.9 µg for 1-4 years old children up to 1.0 and 1.1 µg for 4-7 years old children, covering between 82.2% and 86.3% of daily recommended intake for 1-4 years old children (1 µg) and 64.7 and 71.9% of daily recommended intake for 4-7 years old children (1.5 µg). Significant difference was observed when comparing the consumption of Vitamin E and Vitamin K by children attending
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private and those attending public kindergartens. Children attending private kindergartens consumed far more of mentioned vitamins than those in public kindergartens did. The average intake of vitamin E in public kindergartens ranged between 3.8 mg for 1-4 years old children up to 5.9 mg for 4-7 years old children, covering 63.9% of recommended daily intake for 1-4 years old children (6.0 mg) and 73.7% for 4-7 years old children (8.0 mg). On the other side, 1-4 years old children attending private kindergartens consumed in average 16.1 mg covering for 268.2% of recommended daily intake (6.0mg) and 4-7 years old children consumed in average 19.2 mg covering 239.7% of the recommended daily intake (8.0 mg). It was very similar difference in consumption of Vitamin K. The 1-4 years old children attending public kindergartens in average consumed 11 µg, covering 73.5% of the recommended daily intake (15 µg) and 4-7 years old children consumed in average 14.5 µg of Vitamin K, covering for about 72.8% of daily recommended intake (20 µg) . Consumption of Vitamin K by children attending private kindergartens exceeded very much the recommended daily intake. So, the 1-4 years old children in average consumed around 62 µg of vitamin K, covering for about 414.5% the daily recommended intake (15 µg) and 4-7 years old children consumed in average 73.4 µg, covering for about 367.5% the recommended daily intake (20 µg). Average consumption of vitamin B6 was above daily recommended intakes in both, private and private kindergartens. So, the mean intake ranged between 0.5 and 0.6 mg covering for about 128% up to the 144.5% of recommended daily intake for 1-4 years old children and 4-7 years old children. The Vitamin D intake ranged from 0.3 µg up to maximum 0.7 µg. Even though the Vitamin D intake was much below the recommended daily intake (20 µg for 1 to 15 years old children), the body can produce Vitamin D, when it is exposed to sunlight. These results indicate deficiencies in intake of several micronutrients which are essential for adequate growth of children but excessive intake of certain micronutrients occurred too. Diets of kindergartens indicate deficits in micronutrient intake, particularly of calcium, iron, iodide, folic acid, vitamin A, vitamin C in public kindergartens and vitamin D. The average intake of calcium, iron and iodine during children’s stay in kindergartens (full day-8 hours) is presented in Figure 32 and the average intake of folic acid, vitamin A, Vitamin C and vitamin D is presented in Figure 33.
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Figure 32: The % of the daily recommended intake (full day-8 hours) of calcium, iron and iodine
90% 80% 70% 60% 50% 1-4 Years 40% 4-7 Years 30% 20% 10% 0% Calcium Calcium Iodine Iodine Iron Iron Public Private Public Private Public Private.
Source: Own Calculation (2013)
Figure 33: The % of the daily recommended intake (full day-8 hours) of folic acid, vitamin A, Vitamin C and vitamin D
Source: Own Calculation (2013)
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This is due to inadequate intake and also due to limited food diversity. It can be observed that foods served in kindergartens of Kosovo are not nutrient balanced. The access to the appropriate dietary habits is also missing. Our results are in line with many other studies worldwide which report micronutrient deficiencies or micronutrient malnutrition, mostly in developing countries (Okoroigwe & Okeke, 2009; Golder et al.; 2000) and with findings which show the inadequate intake of some micronutrients also in developed countries due to consumption of energy-dense but nutrient-poor foods (Swaminathan, et al., 2013; Arsenault et al., 2013; Moshefeg, et al., 2005). Kosovo is not implementing any program on food fortification like other countries do. WHO and FAO issued Guidelines on food fortification with micronutrients which is used by different Countries for development and implementation of fortification programs (WHO & FAO 2006).
4.4 Results and Discussions of Dietary Habits and Food Frequency Intake
In this study, parents reported the dietary habits and frequency intake of specific eaten foods from the food groups when their children are at home. Parents have answered to the combined 24-hour recall and Dietary History form. Table 34 shows results out of answers to the question whether the 24-hour recalled foods and beverages were typical day’s intakes for their children. For 74.1% of the children, it was a typical intake while 25.9% answered that this was not a typical intake for their children. Statistically, there were no significant differences between age groups in terms of typical daily intake of food and beverages.
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Table 34: Typical daily intake of food and beverages Is the reported food intake typical for your child?
Yes No Total
Age groups N % N % N % (months) 12-23 17 81.0 4 19.0 21 100.0
24-35 23 74.2 8 25.8 31 100.0
36-47 47 71.2 19 28.8 66 100.0
48-59 36 73.5 13 26.5 49 100.0
60-71 37 71.2 15 28.8 52 100.0
72-83 12 92.3 1 7.7 13 100.0
Total 172 74.1 60 25.9 232 100.0
P>0.05
Source: Own calculation (2013)
Table 35 and 36 present the results from the question about the food intake during the weekends and frequency eating outside.
Table 35: Food intake during the weekend Does your child eat differently on weekends? Yes No Total Age groups (months) N % N % N %
12-23 16 76.2 5 23.8 21 100.0
24-35 28 90.3 3 9.7 31 100.0
36-47 58 87.9 8 12.1 66 100.0
48-59 41 83.7 8 16.3 49 100.0
60-71 42 80.8 10 19.2 52 100.0
72-83 11 83.6 2 15.4 13 100.0 Total 196 83.5 36 15.5 232 100.0 P>0.05 Source: Own calculation (2013)
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83.5% out of 232 children do eat differently on weekends and 41.8% of the children eat out once a week or more, whereas 58.2 % eat out less than once o week.
Table 36: Food frequency intake outside home
How often does your child eat out? Once a week or Less than once a more week Total Age groups (months) N % N % N %
12-23 11 52.4 10 47.6 21 100.0
24-35 10 32.3 21 67.7 31 100.0
36-47 31 47.0 35 53.0 66 100.0
48-59 19 38.8 30 61.2 49 100.0
60-71 22 42.3 30 57.7 52 100.0
72-83 4 30.8 9 69.2 13 100.0 Total 97 41.8 135 58.2 232 100.0 P>0.05 Source: Own calculation (2013)
There were no statistically significant differences between age groups in terms of eating habits during weekends and frequency of eating out. The role of parents in creation of dietary habits in childhood is very crucial having in mind the fact that children at the preschool age are very dependent. Kosovo did not develop yet the healthy eating guidelines for preschool aged children even though children usually develop their food preferences and dietary habits at this age. Other Countries have develop food based dietary guidelines (FBDGs) which show people how they can eat healthy and balanced diets and include advices about content (protein, sugar, fat, carbohydrates, dietary fiber, salt etc). Nearly all European countries have developed FBDG which are shown in different graphics such as diet pyramid, plate or wheel and vary depending on culture that certain countries may have. Although the details may vary- there are many similarities between all European FBDG. Principles for development and establishment of FBDG went through the process of agreements, cooperation, communication and evaluations (Gibney & Sandstrom, 2001; EU Food Safety Authority, 2007; EU Food Safety Authority, 2008).
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This study found that 4.3% out of 232 parents consider that their children are eating out of control and there were no significant statistical difference shown between age groups (table 37). The percentage of children who used to be on special diets was 1.7% (table 38).
Table 37: Children eating out of the control
Do you ever feel that yours child eating is out of control?
Yes No Total Age groups (months) N % N % N %
12-23 2 9.5 19 90.5 21 100.0
24-35 - - 31 100.0 31 100.0
36-47 1 1.5 65 98.5 66 100.0
48-59 1 2.0 48 98.0 49 100.0
60-71 5 9.6 47 90.4 52 100.0
72-83 1 7.7 12 92.3 13 100.0
Total 10 4.3 222 95.7 232 100.0 P>0.05 Source: Own calculation (2013)
Table 38: Children on special diet
Has your child ever been on special diet?
Yes No Total Age groups (months) N % N % N %
12-23 - - 21 100.0 21 100.0
24-35 2 6.5 29 93.5 31 100.0
36-47 - - 66 100.0 66 100.0
48-59 1 2.0 48 98.0 49 100.0
60-71 1 1.9 51 98.1 52 100.0
72-83 - - 13 100.0 13 100.0
Total 4 1.7 228 98.3 232 100.0 P>0.05 Source: Own calculation (2013)
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There is no statistically significant difference between age groups in terms of being in special diets. Only 0.9% out of 223 children was allergic towards certain foods (table 39).
Table 39: Children showing an allergy towards foods
Is your child allergic to any foods?
Yes No Total Age groups (months) N % N % N %
12-23 - - 21 100.0 21 100.0
24-35 - - 31 100.0 31 100.0
36-47 1 1.5 65 98.5 66 100.0
48-59 1 2.0 48 98.0 49 100.0
60-71 - - 52 100.0 52 100.0
72-83 - - 13 100.0 13 100.0
Total 2 0.9 230 99.1 232 100.0 P>0.05 Source: Own calculation (2013)
Statistical analyses did not show significant differences between age groups in terms of food allergies. Preschoolers in average eat more than once a week outside from their homes. Thirty parents (12, 9%) have considered that their children skip meals while the percentage of children who sometimes skip their meals was 30.2 %. Results are shown in Table 40. The statistical analyses did not show significant differences between age groups in terms of skipping meals.
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Table 40: Children skipping their meals
Does your child skip meals?
Yes No Sometimes Total Age groups (months) N % N % N % N %
12-23 5 23.8 10 47.6 6 28.6 21 100.0
24-35 2 6.5 23 74.2 6 19.4 31 100.0
36-47 9 13.6 39 59.1 18 27.3 66 100.0
48-59 3 6.1 25 51.0 21 42.9 49 100.0
60-71 9 17.3 28 53.8 15 28.8 52 100.0
72-83 2 15.4 7 53.8 4 30.8 13 100.0
Total 30 12.9 132 56.9 70 30.2 232 100.0 P>0.05 Source: Own calculation (2013)
Skipping meals is a negative habit in various populations and our findings are in line with other studies which also showed that skipping meals may affect nutritional status of children but also influence concentration and poor performances (American Dietetic Association, 2008; Hoyland et al., 2009). The results of some studies suggest that eating breakfast is associated also with low risk of overweight and obesity and cardio metabolic health (Szajewska & Ruszczynski, 2010; Smith et al.; 2010). Parents answered also on frequency of food and beverage intake by their children. Even though, the answers were given on daily, weekly, monthly and yearly intake, the results were all converted into daily intake frequency (for example: 4 times a week = 0.6 times a day) and showed only as a daily intake. Table 41 presents frequency intake of water, drinks, milk, tea and fruit/vegetable juices. As it is shown in the table, consumption of milk and soft drinks was significantly different between different age groups. The 12-23 months aged children used to consume the milk in average of 2.4 times a day, while the 72-83 month old children consume the milk in average of 1.1 times a day. The soft drinks are consumed in average 0.6 times a day or more than 4 times a week. The results have shown also that soft drinks are taken by the all age groups of children (12-83 months). There were no statistically significant differences between age groups in terms of frequency intake of water, tea and fruit/vegetable juices. The children drink water for about 5.2 times a day and in average they drink tea once a day. The fruit
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and vegetable juices are taken in the average of 1.7 times a day. Served tea in the most cases is black tea with added sugar, while some fruit juices are declared as such but in fact are only fruit-flavored drinks of poor nutrient content.
Table 41: Frequency intake of beverages (water, soft drinks, tea and fruit/vegetable juice)
How often does your child drink ….?
Age groups Soft fruit/vegetable (months) N Water drinks/sodas Milk Tea juice 12-23 21 5.8 0.3 2.4 0.8 1.9 24-35 31 5.1 0.3 1.7 0.9 1.9 36-47 66 5.4 0.6 1.7 1.0 2.0 48-59 49 5.2 0.7 1.5 1.1 1.4 60-71 52 4.7 0.9 1.2 1.0 1.7 72-83 13 5.4 0.8 1.1 0.8 1.3 Total 232 5.2 0.6 1.6 1.0 1.7 P>0.05 P<0.001 P<0.05 P>0.05 P>0.05 Source: Own calculation (2013)
Use of these beverages may negatively contribute to the appetite of children for more nutritious foods and also lower milk intake. The concerns that high calories and nutrient poor beverages displace nutrient rich beverages such as milk were shown in other studies (Gartner et al., 2005). Researchers consider that consumption of sugar –sweetened beverages begins during the preschool years and generally increases with age (Skinner & Carruth, 2001, Wang et al., 2008). In numerous studies, high intake of sugar-sweetened beverages was shown to be associated with increased energy intake and body weight. This phenomenon was observed by other authors to happen as well in preschool children (Dietary Guidelines for Americans, 2010; Dubois et al., 2007; Vartanian et al., 2007; Fiorito et al., 2009; O’Connor et al., 2006). Consumption of fruit juices has been considered to have impact over the childhood obesity in USA where fruit juices were thought as healthy and as replacement for fruits (Lustig, 2006). Parents of preschool age children should be advised that consumption of fruit-flavored drinks but also fruit juices cannot replace the role of fresh fruits. Table 42 presents frequency intake of red meat, poultry, fish, sausages and eggs. There was no significant difference in consumption of foods shown in table 42 by different age groups of children. Red meat is consumed in the average between two and three times a week. Poultry is eaten in the average between two and three times a week. Fish is consumed in average once in 10 days. The sausage is consumed in average between
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two and three times a week. The average of the eggs consumption was between three to four times a week.
Table 42: Frequency intake of red meat, poultry, fish, sausages and eggs
How often does your child eat …….? Age groups (months) N Red meat Poultry Fish Sausage Eggs 12-23 21 0.5 0.3 0.1 0.2 0.5 24-35 31 0.4 0.3 0.1 0.4 0.5 36-47 66 0.4 0.3 0.1 0.3 0.5 48-59 49 0.4 0.3 0.1 0.5 0.5 60-71 52 0.4 0.3 0.1 0.4 0.6 72-83 13 0.4 0.3 0.1 0.3 0.5 Total 232 0.4 0.3 0.1 0.4 0.5 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 Source: Own Calculation (2013)
These results show that consumption of foods from the meat group is not satisfactory, thus it would be advisable to moderate consumption of meats which are good sources of proteins of high biological values, iron, vitamins in the form that are best used, zinc, minerals etc. (McAffe, et al., 2010; Cleghorn, 2007; Crowe et al., 2010; Morley et al., 2010; Milman, 2011). Recommended lean meat for children is quite expensive in Kosovo and majority of the population including preschool children consume less lean meat and much more low quality processed sausages which cost less. It is important to include foods such as fish in order to improve fat balance in preschoolers. Table 43 presents frequency intake of cheese, pasta, potatoes, rice, bread, rolls, muffins, crackers, cereals and fruits. Statistically, no significant differences were shown between age groups in terms of frequency consumption of mentioned foods. Cheese is consumed in average 5 times a week. Pasta, potatoes and rice are taken between 3 and 4 times a week. Bread, rolls and muffins are consumed in average 1.5 times a day. Crackers are eaten about five times a week. The average of cereals consumption was between one and two times a week. The average consumption of fruits was 1.1 times a day. Cheese as a dairy product is which is consumed in average about five times a week is mostly a white soft cheese but also autochthonous hard cheese which is preserved in brine. The content of NaCl in almost all served varieties of soft cheeses is quite high and chemical analyses show the hard cheese
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called as Sharri cheese showed that the percentage of NaCl was up to 8.4% (Rysha et al., 2013).
Table 43: Frequency intake of cheese, pasta, potatoes, rice, bread, rolls, muffin, crackers, cereals and fruits
How often does your child eat …….? Pasta, Bread, Age groups potatoes, rolls, (months) N Cheese rice muffin Crackers Cereals Fruits 12-23 21 0.6 0.6 1.2 0.8 0.3 1.0 24-35 31 0.9 0.4 1.6 0.7 0.2 1.2 36-47 66 0.8 0.5 1.4 0.7 0.2 1.1 48-59 49 0.8 0.5 1.5 0.6 0.2 1.0 60-71 52 0.7 0.5 1.5 0.6 0.2 1.1 72-83 13 0.4 0.4 1.7 0.7 0.2 1.1 Total 232 0.7 0.5 1.5 0.7 0.2 1.1 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 Source: Own calculation (2013)
Potatoes, rice and pasta in average are consumed 3-4 times a week while bread, rolls and muffins about 1.5 times a day. Foods which belong to the breads, cereals and potato group which are recommended to be as the bases of all groups are taken in very limited. Almost all products from this group are made from white flour. It appears prudent to promote frequent consumption of whole grains which are rich in fiber, iron and many B vitamins. Consumption of cereals should be of concern since parents reported that children get cereals only once a week. Potatoes are traditionally peeled, so lot of fiber is removed. White rice is consumed while brown rice despite its advantages (minerals, fiber, vitamins) is not consumed by children in Kosovo. Fruit and vegetable intake by preschool aged children is much lower than the recommended amounts of more servings a day. According to WHO, an adequate intake of fruit and vegetables is associated with lower risk of different diseases (WHO 2004). Our findings are in line with many other studies which have also shown inadequate intake of fruit and vegetables (Skinner et al., 2002; Siega-Riz et al., 2010; Cockroft et al., 2005). Table 44 shows the frequency intake of vegetables, soups, stews, casseroles, pretzels, candy ice cream and fried foods. Statistical analyses did not show significant differences between age groups in terms of frequency intake of foods listed in the mentioned table. As shown in the
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table, the vegetables are taken about once a day; while soups, stews and casseroles are consumed in averages 0.7 times a day or about five times a week. The pretzels and chips are consumed about two times a week and candy between 3 and 4 times a week. The average consumption of the ice cream and fried foods was about three times a week.
Table 44: The frequency intake of vegetables, soups, stews, casseroles, pretzels, candy ice cream and fried foods
How often does your child eat …….?
Age groups Vegetable Soups/stews/casserole Pretzels Ice Fried (months) N s s , chips Candy cream foods 12-23 21 0.9 0.8 0.4 0.5 0.3 0.3 24-35 31 0.8 0.7 0.4 0.4 0.3 0.4 36-47 66 0.9 0.7 0.3 0.5 0.4 0.4 48-59 49 0.9 0.7 0.2 0.5 0.4 0.4 60-71 52 0.9 0.8 0.3 0.5 0.5 0.5 72-83 13 0.7 0.6 0.3 0.7 0.5 0.4 23 Total 2 0.9 0.7 0.3 0.5 0.4 0.4 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 P>0.05 Source: Own calculation (2013)
The average consumption of candies, ice creams and fried foods was between three and four times a week. These findings indicate consumption of high calorie and poor nutrient foods. Our data support findings by other authors who consider that children are not eating fruit and vegetables but prefer high density energy foods, sugary drinks, sweet foods, which dietary behavior than explain an increasing of overweight among preschool children (Birch & O.Fisher, 1998; Fox et al., 2006). The obtained results indicate that it is important to develop education programs for educators and parents about the range of foods they give to the children when in kindergartens and at home. They should also be educated about the nutritional conditions as well as about the feeding attitudes and infant feeding practices, because as it was shown in different studies, the feeding patterns at childhood will continue to remain present in their later life and have an important role in children’s food preferences (Skinner et al., 2002; Scaglioni et al., 2008, Picciano et al., 2000) and that overweight children are at high risk to become as overweight in their adult age (Must & Strauss, 1999).
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5 Conclusions and Recommendations
5.1 Conclusions
The conclusions presented are based on results and discussions. This study provides information that Kosovo is going through a nutritional transition. In comparison to the results of the previous studies conducted in Kosovo, our findings showed that underweight amongst preschool aged children is slightly decreasing but the prevalence of overweight and obesity is increasing. The observed increase of overweight and obesity is a likely consequence of a rapid change in nutrition behavior after the war in Kosovo. The Country did not yet develop national and local policies and programs which regulate routine assessments of children in order to follow and reverse eventual negative trends. Anthropometric growth standards (WHO or other) are not officially adopted as a tool for monitoring of nutritional status of children on the basis of anthropometric indicators. Currently, there are no nutrition guidelines and there is very little guidance on menu design in kindergartens of Kosovo. Meals which are served in public and private kindergartens are not planned by dietitians and do not follow recommendations for promotion of balanced healthy diets. Dietary plans are done very often by people who have never received any training and who use their own concepts and experiences. Educators who are responsible for feeding of preschool children are not trained to encourage adoption of healthy dietary habits in kindergartens of Kosovo. Current teacher training curricula at the universities of Kosovo do not have any specific subject related to child nutrition. Children when at kindergarten consume more foods with high energy density and are not encouraged to eat diverse and health supporting foods. Consumption of fruits and vegetables as well as other high-fiber foods is very limited. The obtained data from this study show inadequate fruit and vegetables intake by preschool aged children. The average consumtion of proteins/aminoacids by children from all kindergartens was higher than it is required for preschool aged children but with remarkable differences between values consumed by children attending public and private kindergartens as well as significant differences between consumption of amino acids when intake was calculated separately for each kindergarten. Despite the average intake of 27% of the total fat, the mean percentage of energy derived from SFA, MUFA and PUFA was not more than 35% of recommended daily intake. Lack of nutrition education in preparation of daily meals and low financial capacities of kindergartens could be the main factors for poor consumption of fiber rich foods in Kosovo. Processed and refined foods are consumed by preschool aged children starting even from their
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first year of life. The mean energy and macronutrient intakes were significantly different when calculating separately for each public kindergarten. Deficiencies in intake of several micronutrients which are essential for adequate growth of children but excessive intake of certain micronutrients occurred too. Diets of kindergartens indicate deficits in micronutrient intake, particularly of calcium, iron, iodide, folic acid, vitamin A, vitamin C in public kindergartens and vitamin D. This is due to inadequate intake and also due to limited food diversity. The exceeded intake of chloride and sodium was observed in all children regardless gender, age and place of the attendance. The foods served in kindergartens of Kosovo are not nutrient balanced and access to the appropriate dietary habits is also missing. The parents are not guided to assist preschool children in establishing of healthy dietary habits, thus children’s eating behaviors and child- feeding practices are influenced by parents as well as by their own eating style. Healthy eating patterns in preschool aged children in Kosovo are not established. Specific conclusions which were obtained from this study are listed below: The percentage of underweight amongst the children attending preschool institutions is 0.7% while 0.5% of the children are severely underweight. 3% of children were stunted and 0, 7% were severely stunted. 1,9% of children suffer from moderate acute malnutrition or wasting and 0.8% of children suffer from severe acute malnutrition. Weight-for-height indicator (12-24 months aged children) showed that 0% of children were seen to be obese, 6.8 % were overweight and 34.1% had a possible risk of being overweight. In terms of gender no girls and no boys were obese. 7.4% of boys and 5.9% of girls were overweight, and 29.6 % of boys and 41.2 % of girls had a possible risk of being overweight. BMI for age indicator (24-83 months aged children) showed that the percentage of obese children was 2.3%, than 8.94% were overweight and 27.3% had a possible risk of being overweight. In terms of gender 2.68% of boys and 1.44% of girls were obese, 10.88% of boys and 5.86% of girls were overweight and 29.12% of boys and 25.16% of girls were at risk of being overweight. The findings showed that overweight and obesity in the 24 to 36 months-old group has the highest prevalence to other groups. Prevalence of overweight in this group was 12.9% and obesity 4.3%, whereas 45.7% were at risk of being overweight
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The mean energy intake (full day-8 hours) ranged from 455 kcal in the kindergarten 4 up to 992 kcal in the kindergarten 1, covering between 36 and 79% of the recommended daily intake (German, Austrian and Swiss recommendations). Significant differences were observed also in the mean carbohydrate, fat and protein intake. Children in kindergarten 4 consumed about 68 g of carbohydrates while children in kindergarten 1 about 148 grams. The mean fat intake ranged from 11, 9 grams in the kindergarten 4 up to 26.9 g in the kindergarten 1. The mean protein intake ranged from 17.3 in the kindergarten 4 up to 36.2 grams in kindergarten 2. The total fiber intake (full day-8 hours) ranged between 2.3 grams and 8.1 grams covering from 30 up to 46% of the recommended adequate daily intake. The mean percentage of energy derived from SFA, MUFA and PUFA was no more than 35% of recommended daily intake (SFA 3-3.5%; MUFA 2.5% and PUFA, 1.5-2.1%). The percentage of trans-fatty acids was not calculated but we assume that TFA contributed also to the level of the total fat and requires investigation. No significant differences were shown in intake of minerals, trace elements and sterols according to gender and age in all kindergartens, but significant difference was observed when compared consumption of the most minerals, trace elements and sterols in public and private kindergartens. Children attending private kindergartens consumed more minerals, trace elements and sterols then those from public kindergartens. Significant differences were also observed when intake was calculated separately for each kindergarten. The intake of calcium, iron and in particular iodine was below recommendations while chloride and sodium intake was much higher than the recommended daily intake. Consumption of Calcium (full day-8 hours) covered between 31 and 40% of recommended daily intake. Insufficient calcium intake was caused by limited consumption of milk and milk products and fruit and vegetables. We observed that many children did not want to consume milk even when it was served during the assessment days. The iodine intake was in particular very low in all children regardless gender, age and kindergarten. The mean iodide intake for 1-4 years old children was only 9.6 µg covering only 9.6% the recommended daily intake (100 µg) and 13 µg for 4-7 years covering only about 11% of recommended daily intake (120 µg).
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Despite high intake of sodium and chloride (which mostly come from salt consumption) by children attending kindergartens in Kosovo, the low level of iodine may be due to consumption of not iodised salt and low intake of foods with higher content of iodine. The iron intake (full day-8 hours) covered between 41 and 52% of daily recommended intake. The mean chloride intake was between 978 mg and 1358 mg, covering between 217 and 219% of recommended daily intake. Sodium intake was also much more than recommended intake ranging from 873 up to 1253 mg, covering between 291 and 306% of recommended daily intake. Examination of mean vitamin intakes showed that there were vitamins below the recommended daily intake as well as vitamins that exceeded the recommendations (full day-8 hours). Folic acid intake was quite low in public kindergartens (full day-8 hours) covering only about 23% of recommended daily intake. Deficiency and low level of folic acid, particularly in public kindergartens is most likely due to consumption of micronutrient- poor foods, lack of adjusted dietary folate intake, insufficient consumption of fruit and vegetables as well as consumption of refined and not divers foods. The daily intake of Vitamin C by children attending public kindergartens was in average quite low covering between 23 and 28% of daily recommended intake. The percentage of children who skip their meals is 12.9% and of those who sometimes skip their meals were 30.2%. Soft drinks/fruit-flavored drinks are taken in average 4 times a week; further fruit juices are taken in average 1.7 times a day and sweetened tea is consumed in average once a day. Increased consumption of sweet drinks may be one factor, which contributes to overweight. The dietary pattern was shown to be low in wholegrain products, fruits and vegetable and high in soft drinks, sweet and salty foods
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5.2 Recommendations
5.2.1 Recommendations for Kosovo Institutions
As a first step, it is recommended that the Kosovo Society and Institutions acknowledge the problem of malnutrition, overweight and obesity and its negative impact over the general health statues of different population groups, particularly children. It is recommended to establish an expert panel that will be in charge for development of a framework of nutrition policy in Kosovo. The healthy growing and control of malnutrition and overweight in childhood should involve all levels of the society. Health and education authorities should develop National programs on recommended dietary intakes as well as dietary guidelines for nutrition of preschool aged children attending preschool institutions in Kosovo. The guidelines have to advice on energy, macronutrients and micronutrients to be included in the daily diets, but also on eating styles/behaviors, structuring of meals for preschool aged children and other population groups. Dietary guidelines will assist teachers in kindergartens and parents at home in the selection of necessary dietary patterns which will help normal growth of children and minimize the risk of nutritional deficiencies and diseases. There is a need to develop nutrition systems as well as to adopt international growth standards (WHO or other), which regulate monitoring of nutritional status of children through routine assessments in order to follow and reverse eventual negative trends. It is recommended to start as soon as possible an assessment of child development patterns in the Country. An evaluation of child growth may provide also insights into nutrition situation of other population groups. Although anthropometric indicators are considered to be less accurate than clinical and biochemical techniques, it is recommended that anthropometry as a practical technique is initially used for screening of children at risk of undernutrition or overnutrition. This initial screening would then be followed by more detailed investigations such as clinical and biochemical methods Development of University education programs related to nutrition as well as introduction of a subject related to healthy diet and lifestyle into the curricula of educational institutions of Kosovo is strongly recommended. It is recommended that when kindergartens start with applications for registration, they have to demonstrate their abilities to provide healthy food and appropriate physical activities. It is also recommended that Kosovo institutions support research activities in the field of nutrition with a particular focus in nutrition of preschool and school aged children.
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5.2.2 Recommendations for kindergartens and parents
Nutrition education should have an important role in the daily activities in kindergartens. Since there are no background anthropometric data on which to compare the present anthropometric status of preschool aged children with the past ones, the periodic anthropometric assessments in kindergartens are strongly recommended. Kindergartens in Kosovo have capacities to receive only a part of the preschool aged children, thus it is recommended that periodic monitoring of nutritional status is taken also amongst children who do not attend kindergartens. Observed deficiencies in micronutrient intake such as calcium, iron, iodine, folic acid, vitamin A, and vitamin C and vitamin D as well as exceeded intake of chloride and sodium in public kindergartens should be addressed immediately. Teachers in kindergartens should be educated about development of nutritional behaviors in preschool aged children and also in understanding of the definition of malnutrition and overweight and its prevention. Partnership between kindergartens and parents is needed in order to establish healthy food choice in preschoolers. Preschool institutions need to be educated on the advantages of healthy foods promoting wholemeals, fruit and vegetables, but at the same time they should be also encouraged to reduce energy intake from unhealthy food (sweetened drinks, high-energy snacks and fat). Since little children tend to copy or to take over parental food preferences, parents should also be educated about the importance of healthy food habits for their children. Fruit and vegetable intakes in our sample of preschool children were far lower than the recommended levels and since dietary adequacy is also related to the socio - economic factors, in Kosovo the emphasis should be placed on use of local products, especially fruit and vegetables at reasonable prices. Preschool aged children as well as children across all groups should be encouraged to increase fruit, vegetables, wholegrain breads and cereals as well as unsaturated fatty acids, thus more plant products such as vegetable and fruits should be added to the menus; this would also increase the dietary fibre content, which is very important in childhood. It is recommended to avoid as much as possible processed foods and to use unprocessed or minimally processed foods. Kindergarten will have to enable children enough playing space and families should be educated for the importance of bedtimes and limited television viewing
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5.2.3 Recommendations for further research
Deficiencies in intake of several micronutrients which are essential for adequate growth of children such as: calcium, iron, iodine, folic acid, vitamin A, vitamin C and vitamin D indicate the need for multi-dimensional studies of preschool and school aged children in various parts of Kosovo to confirm the data obtained in the present study. These studies would help in planning and developing of appropriate guidelines and strategies for interventions on nutritional deficiencies and eventual micronutrient supplementation. Further researches of preschool age children health status and diet quality would provide additional insights into the impact early life has over relationship between childhood diet and diseases. Assessments on how health risks are associated with unhealthy eating habits of preschool aged children are recommended. More studies are needed for assessment of dietary intake in kindergartens, but preschool aged children who are not enrolled in kindergartens should be included as well. Studies are needed also to show how increased consumption of sweet drinks and other low nutrient foods contribute to overweight and obesity Further researches are recommended to identify health effects of children’s dietary pattern in childhood, and periodic studies are needed to compare the changes in prevalence of overweight and obesity in children in future. Identification of risk factors in obese children through periodic studies is necessary to compare the prevalence of obesity of children in future years We were unable to check for some other factors which could be also associated with overweight such as physical activities, television viewing and parental overweight.
5.2.4 Limitations of the study
The limitation of this study is that kindergartens in Kosovo have capacities to receive only a part of the preschool aged children (less than 10%), so the results, may not be indicative of the all preschool aged children living in the country. Next limitation of this study is that there are no background results on which to compare the present status of preschool children.
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6. Summary
Proper nutrition in childhood is considered to play a crucial role in the physical, mental and emotional development of children through to their later adult age. The main objective of this research was assessment of nutritional status of preschool aged children attending public and private kindergartens in Kosovo. Furthermore, this research intends to influence nutrition policy and the family attention and awareness on need to improve child’s nutrition from an early age. Anthropometric measurements used in this study were weight, height and BMI of the preschoolers (12-83 months) according to the techniques which were suggested by WHO. The WDR method (3d waited dietary record) was the main assessment method for dietary intake, while a combined 24-Hour recalls -24H and Dietary History- methods were used for assessment of dietary habits and frequency intake of specific eaten foods from the food groups. 486 children participated in 3d waited dietary record and anthropometric assessment, while combined 24- Hour recall and dietary history forms were completed by 232 parents. This study provides information that Kosovo is going through a nutritional transition showing that underweight amongst preschool aged children is slightly decreasing but the prevalence of overweight and obesity is increasing. The percentage of underweight was 0.7%, while 0.5% of the children are severely underweight. 3% of children were stunted and 0, 7% were severely stunted. 1, 9% of children suffer from moderate acute malnutrition or wasting and 0.8% of children suffer from severe acute malnutrition. Weight-for-height indicator (12-24 months aged children) showed that no children were seen to be obese, 6.8 % were overweight and 34.1% had a possible risk of being overweight. In terms of gender no girls and no boys were obese. 7.4% of boys and 5.9% of girls were overweight and 29.6 % of boys and 41.2 % of girls had a possible risk of being overweight. BMI for age indicator (24-83 months aged children) showed that the percentage of obese children was 2.3%, than 8.94% were overweight and 27.3% had a possible risk of being overweight. In terms of gender 2.68% of boys and 1.44% of girls were obese, 10.88% of boys and 5.86% of girls were overweight and 29.12% of boys and 25.16% of girls were at risk of being overweight. Children when at kindergartens are consuming more foods with high energy density and are not encouraged to eat diverse and healthier foods. The mean energy intake (full day-8 hours ) ranged from 455 kcal in the kindergarten 4 up to 992 kcal in the kindergarten 1, covering between 36 and 79% of the recommended daily intake. The average consumtion of proteins/aminoacids by children from all kindergartens was higher than it is required for preschool aged children. Despite the average intake of 27% of the total fat, the mean
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percentage of energy derived from SFA, MUFA and PUFA was not more than 35% of recommended daily intake. The total fiber intake (full day-8 hours) ranged between 2.3 grams and 8.1 grams covering from 30 up to 46% of the recommended adequate daily intake. Diets of kindergartens indicate deficits in micronutrient intake, particularly of calcium, iron, iodine, folic acid, vitamin A, vitamin C, vitamin D, and exceeded intake of chloride and sodium. The intake of calcium, iron and in particular iodine was below recommendations while chloride and sodium intake was much higher than the recommended daily intake. Folic acid intake was quite low in public kindergartens (full day-8 hours) covering only about 23% of recommended daily intake. The daily intake of Vitamin C by children attending public kindergartens was in average quite low covering between 23 and 28% of daily recommended intake. Processed and refined foods are consumed by preschool aged children starting even from their first year of life. The foods served in kindergartens of Kosovo are not nutrient balanced and the access to the appropriate dietary habits is also missing. The dietary pattern was shown to be low in wholegrain products, fruits and vegetable and high in soft drinks, sweet and salty foods. Fruit and vegetable intake by preschool aged children is much lower than the recommended amounts of more servings a day. The parents are not guided to assist preschool children in establishing of healthy dietary habits, thus children’s eating behaviors and child-feeding practices are influenced by parents as well as by their own eating style. It is recommended that the Kosovo Society and Institutions acknowledge the problem of malnutrition, overweight and obesity and its negative impact over the general health statues of different population groups, particularly children. Health and education authorities should develop National programs on recommended dietary intakes as well as dietary guidelines for nutrition of preschool aged children attending preschool institutions in Kosovo. The guidelines have to advice on energy, macronutrients and micronutrients to be included in the daily diets but also on eating styles/behaviors, structuring of meals for preschool aged children and other population groups. Educators who are responsible for feeding of preschool children should be trained and encouraged to adopt healthy dietary habits in kindergartens of Kosovo. Partnership between kindergartens and parents is needed in order to establish healthy food choice in preschoolers. Preschool aged children as well as children across all groups should be encouraged to increase fruit, vegetables, wholegrain breads and cereals as well as unsaturated fatty acids, thus more plant products such as vegetable and fruits should be added to the menus; this would also increase the dietary fiber content, which is very important in childhood. It is recommended to
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avoid as much as possible processed foods and to use unprocessed or minimally processed foods. Development of University education programs related to nutrition as well as introduction of a subject related to healthy diet and lifestyle into the curricula of educational institutions of Kosovo is strongly recommended. It is also recommended that Kosovo institutions support research activities in the field of nutrition with a particular focus in nutrition of preschool and school aged children. These further researches would provide additional insights into the impact early life have over relationship between childhood diet and diseases. Assessments on how health risks are associated with unhealthy eating habits of preschool aged children are recommended.
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Zusammenfassung
Einer physiologisch angemessenen Ernährung in der Kindheit wird eine wichtige Rolle in der physischen, mentalen und emotionalen Entwicklung vom Kindes- bis zum späteren Erwachsenenalter zugeschrieben. Obwohl es bisher nur wenige Daten zum Gesundheits- und Ernährungsstatus im Kosovo gibt, zeigen diese Studien aus der Zeit vor und nach dem Kosovokrieg, dass Unterernährung und der Mangel einiger wichtiger Mikronährstoffe bei Kindern im Vorschulalter vorherrschen. Deshalb ist es erforderlich, die Daten von Kindern im Vorschulalter zu erfassen und zu untersuchen, was zum einen durch anthropometrische Parameter als auch durch die Analyse des Nährstoffgehaltes der Mahlzeiten in Kindergärten (Häufigkeit der Mahlzeiten, adäquate Mengen an z.B. Obst und Gemüse, etc.) in dieser Arbeit erfolgt. Diese wissenschaftliche Untersuchung stellt fest, dass das Wachstum der Vorschulkinder und die angebotene Lebensmittelvielfalt ebenso wie die Nähr- und Energiewerte der dargebotenen Mahlzeiten in Kindergärten im Kosovo nur teilweise den internationalen Ernährungsempfehlungen für diese Altersstufe genügen. Der Anteil an untergewichtigen Kindern wird mit 0,7% ermittelt, während 0,5% stark untergewichtig sind. 1,9% der Kinder leiden unter moderater und 0,8% der Kinder leiden unter schwerer akuter Unterernährung. Der Gewicht/Größe Indikator (12-24 Monate alter Kinder) zeigt, dass keine Kinder als adipös einzustufen sind, während 6,8% übergewichtig sind und 34,1% ein mögliches Risiko für Übergewicht zeigen. Die Verteilung der Geschlechter spielt bei Adipositas keine Rolle, da weder Jungen noch Mädchen adipös sind. Jedoch sind 7,4% der Jungen und 5,9% der Mädchen übergewichtig und 29,6% der Jungen und 41,2% der Mädchen zeigen ein mögliches Risiko für Übergewicht. Der BMI Indikator (24-83 Monate alte Kinder) zeigt, dass der Anteil der adipösen Kinder bei 2,3% liegt, während 8,94% übergewichtig sind und 27,3% ein Risiko für mögliches Übergewicht aufweisen. Was das Geschlecht anbelangt, sind 2,68% der Jungen und 1,44% der Mädchen adipös, 10,88% der Jungen und 5,86% der Mädchen sind übergewichtig und 29,12% der Jungen sowie 25,16% der Mädchen zeigen die Tendenz zu einem möglichen Übergewicht. Die durchschnittliche Energieaufnahme (ganztags – 8 Stunden) reicht von 455 kcal im Kindergarten 4 bis hin zu 992 kcal im Kindergarten 1, was 36% und 79% der empfohlenen Tageszufuhr ausmacht. Der durchschnittliche Verzehr von Proteinen/Aminosäuren der Kinder aus allen untersuchten Kindergärten erweist sich als höher als erforderlich für diese Altersstufe. Trotz der durchschnittlichen Aufnahme von 27% der absoluten Fettmenge beträgt der durchschnittliche Anteil der Energie von SFA, MUFA und PUFA nicht mehr als 35% der
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empfohlenen Menge. Der Gesamtballaststoffaufnahme (ganztags – 8 Stunden) liegt zwischen 2,3 Gramm und 8,1 Gramm, was 30% und 46% der empfohlenen Tageszufuhr ausmacht. Die Aufnahme von Kalzium, Eisen und besonders Jod liegt unter den Empfehlungen, während die Aufnahme von Chlorid und Natrium wesentlich höher ist als die empfohlene tägliche Menge. Die Aufnahme von Folsäure ist in öffentlichen Kindergärten (ganztags – 8 Stunden) relativ gering und deckt lediglich 23% der empfohlenen Tageszufuhr. Die tägliche Vitamin C Aufnahme der Kinder aus öffentlichen Kindergärten ist ziemlich gering und deckt 23% und 28% der empfohlenen Tageszufuhr. Die Ernährung im Kindergarten zeigt Defizite in der Aufnahme von Mikronährstoffen, besonders von Kalzium, Eisen, Jod, Folsäure, Vitamin A, Vitamin C in öffentlichen Kindergärten und Vitamin D. Die überschrittene Aufnahme von Chlorid und Natrium konnte in allen Kindern beobachtet werden, unabhängig von Geschlecht, Alter und dem Kindergarten. Im Kindergarten konsumieren Kinder mehr Lebensmittel mit einer höheren Energiedichte und werden nicht dazu ermutigt, abwechslungsreichere und gesündere Lebensmittel zu wählen. Verarbeitete und raffinierte Lebensmittel werden von Vorschulkindern bereits ab dem ersten Lebensjahr konsumiert. Der Anteil der Kinder, welche ihre Mahlzeiten auslassen beträgt 12,9%, während 30,2% manchmal ihre Mahlzeiten auslassen. Das Ernährungsmuster zeigt geringe Werte für Vollkornprodukte, Früchte und Gemüse, jedoch hohe Werte für Softdrinks, süße und salzige Lebensmittel. Die Aufnahme von Obst und Gemüse der Vorschulkinder ist viel geringer als die täglich empfohlene Portionsmenge. Die Eltern werden nicht angeleitet, Vorschulkindern bei der Schaffung gesunder Ernährungsgewohnheiten zu helfen, demzufolge ist das kindliche Essverhalten und die Ernährungspraxis von den Eltern und ihrem eigenen Ernährungsstil beeinflusst. Nach dieser Studie muss festgestellt werden, dass gesunde Ernährungsmuster bei Vorschulkindern im Kosovo nicht etabliert sind. Im Vergleich zu den bereits durchgeführten Untersuchungen zeigt diese Studie, dass sich im Kosovo eine Ernährungswende andeutet: das Untergewicht im Vorschulalter nimmt leicht ab, jedoch steigt die Prävalenz von Übergewicht und Adipositas. Der beobachtete Anstieg von Übergewicht und Adipositas ist wahrscheinlich eine Konsequenz des rapiden Wandels des Ernährungsverhaltens nach dem Kosovokrieg. Das Land hat bis jetzt noch keine nationalen und lokalen Strategien oder Programme entwickelt, welche die Routineuntersuchungen von Kindern regulieren, um eventuelle negative Trends zu verfolgen und umzukehren. Zur Zeit gibt es keine Ernährungsrichtlinien und nur sehr wenig Beratung für die Menügestaltung in Kindergärten im Kosovo. Als erster Schritt wird empfohlen, dass die Gesellschaft und die Institutionen im Kosovo die Probleme der Unterernährung, des Übergewichts und der Adipositas sowie deren negativen
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Auswirkungen auf den gesamten Gesundheitsstatus verschiedener Bevölkerungsgruppen, insbesondere der Kinder, anerkennen. Gesundes Wachstum und die Kontrolle der Unterernährung und des Übergewichts im Kindesalter sollte alle Stufen der Gesellschaft einbeziehen. Gesundheits- und Bildungsbehörden im Kosovo sollten nationale Programme zur empfohlenen täglichen Aufnahme und zu Ernährungsrichtlinien für Kinder im Vorschulalter entwickeln. Die Richtlinien sollten Empfehlungen bezüglich Energie, Makro- und Mikronährstoffe in der täglichen Ernährung Auskunft erteilen aber auch über Ernährungsstile und – verhalten sowie das Strukturieren von Mahlzeiten für Vorschulkinder und andere Bevölkerungsgruppen informieren. Die beobachteten Defizite im Bereich der Mikronährstoffaufnahme wie zum Beispiel von Kalzium, Eisen, Jod, Folsäure, Vitamin A, Vitamin C, Vitamin D ebenso wie die zu hohe Aufnahme und Chlorid und Natrium in öffentlichen Kindergärten sollten sofort angesprochen werden. Erzieher in Kindergärten sollten eine Weiterbildung im Bereich der Entwicklung des Ernährungsverhalten bei Vorschulkindern erhalten und die Definitionen von Unterernährung und Übergewicht und deren Prävention kennen. Partnerschaften zwischen Kindergärten und Eltern sind erforderlich, um den Kindern eine gesündere Lebensmittelwahl zu ermöglichen. Kinder im Vorschulalter und auch Kinder anderer Altersgruppen sollten ermutigt werden, ihren Verzehr an Früchten, Gemüse, Vollkornbrot und –getreide sowie ungesättigten Fettsäuren zu steigern und somit mehr pflanzliche Produkte wie Gemüse und Obst zu ihren Gerichten hinzuzufügen. Dies würde auch den Gehalt an Ballaststoffen erhöhen, der in der Kindheit sehr wichtig ist. Es wird empfohlen, verarbeitete Lebensmittel so häufig wie möglich zu vermeiden und unverarbeitete oder minimal verarbeitete Lebensmittel zu bevorzugen. Es ist erforderlich, ein Ernährungssystem zu entwickeln und außerdem die internationalen Wachstumsstandards (WHO oder andere) anzuwenden, welche das Beobachten des Ernährungsstatus‘ bei Kindern durch Routineuntersuchungen regeln, damit eventuelle Negativtrends verfolgt und umgekehrt werden können. Die Entwicklung universitärer Bildungsprogramme mit Bezug auf Ernährung und die Einführung eines Faches zur gesunden Ernährung und zu gesunden Lebensstilen in die Curricula der Bildungsinstitutionen im Kosovo werden empfohlen. Weitere Untersuchungen zum Gesundheitsstatus und zur Ernährungsqualität bei Vorschulkindern würden zusätzliche Einblicke in die der Auswirkung der frühen Lebensjahre auf Beziehung von Kindheitsernährung und Krankheiten gewähren. Die Untersuchung von Gesundheitsrisiken gekoppelt mit ungesunden Ernährungsgewohnheiten bei Vorschulkindern wird empfohlen. Weitere Studien sind nötig, um die Nahrungszufuhr im Kindergarten zu untersuchen, jedoch sollten Vorschulkinder, welche keinen Kindergarten besuchen, ebenfalls mit eingeschlossen werden. Außerdem sind Studien erforderlich, welche die Auswirkungen des
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steigenden Konsums gesüßter Getränke und anderer Lebensmittel auf Übergewicht und Adipositas untersuchen. Ferner werden Studien empfohlen, um den Gesundheitseffekt der Ernährungsmuster in der Kindheit zu identifizieren. Außerdem sind periodische Studien erforderlich, um die Veränderung der Prävalenz von Übergewicht und Adipositas bei Kindern zukünftig zu vergleichen. Risikofaktoren für Adipositas bei Kindern durch periodische Studien zu identifizieren ist ebenfalls erforderlich, um die Prävalenz der Adipositas bei Kindern in den künftigen Jahren zu vergleichen.
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ANNEXES
Annex 1 Definition and Abbreviations for Dietary Assessment Methods and Reference Method
Food Record (FR) Food records are used to record food intake at the time of consumption, over a number of days that are not necessarily sequential. Most studies ask respondents to enter the information on hard copy form, although tape-recording, bar-coding, and electronic weighing also have been used to collect descriptive and quantity information. Weighed FR: The respondent weighs on a small scale all food and beverages consumed. Estimated FR: The respondent estimates all food consumed using household measures or portion size estimating aides.
Diet History (DH) Diet History questionnaires are a retrospective assessment method ascertaining a respondent's "usual" food intake by collecting descriptive detail and amount information about each food. DHs may include questions on meal patterns, lists of common foods and groups of generic food. DH questionnaires are typically administered by a trained interviewer either in-person or by telephone, but also can be self-reported.
24-Hour Recall (24HR) The 24HR is a retrospective assessment method in which an interviewer prompts a respondent to recall and describe all foods and beverages consumed in the preceding 24 hours or the preceding day. The interview may be conducted in-person or by telephone and may be paper and pencil or computer assisted. Portion size estimating aides assist the respondent to recall amounts consumed. The methodology for conducting the 24HR has evolved during the last two decades. Among the methods reported are: 3-pass method, 5-pass method, U.S. Department of Agriculture protocol, University of Minnesota protocol, Bogalusa Heart Study protocol.
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Food Frequency The food frequency questionnaire is a retrospective method asking Questionnaire (FFQ) respondents to report their usual frequency of consumption of each food from a list of foods for a specific period (several months or a year). Food lists vary by the purpose of the study and study population. Frequency of consumption categories also vary by questionnaire but usually include per day, week, or month. Semi quantitative FFQ: In this type of FFQ, portion size information is collected; portion sizes are specified as standardized portions or choice (range of portions). Non-quantitative FFQ: Portion size information not collected. NCI Health Habits and History Questionnaire (HHHQ): Semi- quantitative FFQ developed at the National Cancer Institute under the direction of Gladys Block. Harvard FFQ (HFFQ): FFQ developed at Harvard University by Walter Willett and colleagues. Portion size information is included as part of the food item rather than as a separate listing. NCI Diet History Questionnaire (DHQ): Semi-quantitative FFQ, using an embedded question approach, developed at the NCI under the direction of Subar et al (2001) & Subar, (2004).
Propensity Comprehensive FFQ-type questionnaire designed to supplement Questionnaire other dietary assessment method. Information on portion size information is not collected. May provide information on infrequently consumed foods (Dwyer et al., 2003).
Direct Observation Intakes are watched and recorded by trained observers. (DO)
Doubly Labeled Water The DLW method is used to measure energy expenditure in free- Method (DLW) for total living subjects. This method involves the administration of water energy expenditure containing enriched quantities of the stable isotopes deuterium (2H) (TEE) and oxygen-18 (18O). The label of "doubly" labeled comes from the fact that both the hydrogen and oxygen are labeled. The oxygen-18 is 18 eliminated from the body in the form of carbon dioxide (C O2) and 18 2 water (H2 O), and the deuterium is eliminated in water ( H2O). The
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difference in elimination rate between these two isotopes is a measure of carbon dioxide production. Carbon dioxide production can then be used to calculate energy expenditure by use of standard equations for indirect calorimetry (Trabulsi & Schoeller, 2001). The DLW method has been shown to be accurate to 1%, with within- subject precision of 5 to 8% (Schoeller, 2002). Because the method is expensive and analysis requires specialized, expensive equipment, it cannot be considered routine. However, the method is widely available and is being applied to dietary assessment validations with sample sizes ranging from 20 to 500.
Test Method (TM) Dietary assessment method being validated.
Reference Method Method against which the TM is being compared and validated. (RM)
Source: (McNutt, 2003; Thompson & Byers, 1994)
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Annex 2 Strengths and Limitations of Various Dietary Assessment Methods Used in Clinica Settings Strengths Limitations Applications Does not require literacy Dependent on Appropriate for most Relatively low respondent respondent’s people as it does not burden memory require literacy
Data may be directly Relies on self-reported Useful for the assessment entered into a dietary information of analysis program intake of a variety of
Hour Recall Hour Requires skilled staff nutrients -
24 May be conducted in- Time consuming and assessment of meal person patterning and food group or over the telephone Single recall does not intake represent usual intake Useful counseling tool Quick, easy and affordable Does not provide valid Appropriate for literate and estimates of absolute motivated population May assess current as intake groups well as past diet of individuals
Useful for the assessment In a clinical setting, may Can’t assess meal of be patterning intake of a variety of useful as a screening tool nutrients May not be appropriate for and assessment of meal Food Frequency Food some population groups patterning and food group intake
Useful counseling tool
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Does not rely on memory Recording foods eaten Appropriate for literate and may motivated population Food portions may be influence what is eaten groups measured at the time of
consumption Requires literacy Useful for the assessment of Multiple days of records Relies on self-reported intake of a variety of provide valid measure of information nutrients
Food Record Food intake for most nutrients and assessment of meal Requires skilled staff patterning and food group intake Time consuming Useful counseling tool Able to assess usual Relies on memory Appropriate for most intake in a single interview people as it does not Time consuming (1 to 1- require literacy Appropriate for most 1/2
people hours) Useful for assessing intake of Requires skilled nutrients, meal patterning Diet Diet History interviewer and food group intake
Useful counseling tool
Source: Stang & Story, (2005) chapter 4 p.40
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Annex 3 Nutrient-Based Guidelines for Food Prepared for 1-4 Years Old in Child Care Nutrient Full Morning Afternoon SNACK LUNCH TEA day Session: Session: only only only care * Snack Snack and and tea lunch Energy % of the 70% 40% 30% 10% 30% 20% Estimated Average Requirmen t (EAR) Fat % of About About About About About Abo energy 35% 35% 35% 35% 35% ut 35% Total % of About About About About About Abo carbohydrate energy 50% 50% 50% 50% 50% ut 50% Non-milk % of MAX 11% 11% 11% 11% 11% 11% extrinsic energy sugars Protein % of the MIN 70% 40% 30% 10% 30% 20% Reference Nutrient Intake (RNI) Vitamin A % of the MIN 70% 40% 30% 10% 30% 20% RNI Vitamin D % of the MIN 70% 40% 30% 10% 30% 20% RNI Vitamin C % of the MIN 70% 40% 30% 10% 30% 20% RNI Folate % of the MIN 70% 40% 30% 10% 30% 20% RNI
Agim Rysha (2013): PhD Thesis 141
Calcium % of the MIN 70% 40% 30% 10% 30% 20% RNI Iron % of the MIN 80% 45% 35% 10% 35% 25% RNI Zinc % of the MIN 80% 45% 35% 10% 35% 25% RNI Sodium % of the MAX 70% 40% 30% 10% 30% 20% SACN target average Salt % of the MAX 70% 40% 30% 10% 30% 20% SACN target average * Full-day care (8 hours or more) % of energy = Percentage of calories consumed RNI = Reference Nutrient Intake EAR = Estimated Average Requirment SACN = Scientific Advisory Committee on Nutrition Source: www.cwt.org.uk
Agim Rysha (2013): PhD Thesis 142
Annex 4 Nutrient-Based Guidelines for Food Prepared for 1-4 Years Old in Child Care Nutrient Full Morning Afternoon SNACK LUNCH TEA day Session: Session: only only only care * Snack Snack and and tea lunch Energy kcals 903.0 516.0 387.0 129.0 387.0 258.0 Fat About g 35.0 20.0 15.0 5.0 15.0 10.0 Total About g 120.4 68.8 51.6 17.2 51.6 34.4 carbohydrate Non-milk MAX g 26.6 15.2 11.4 3.8 11.4 7.6 extrinsic sugars Protein MIN g 11.0 6.3 4.7 1.6 4.7 3.1 Vitamin A MIN μg 300.0 170.0 130.0 40.0 130.0 90.0 Vitamin D MIN μg 5.0 2.9 2.1 0.7 2.1 1.4 Vitamin C MIN mg 21.0 12.0 9.0 3.0 9.0 6.0 Folate MIN mg 60.0 35.0 25.0 8.0 25.0 17.0 Calcium MIN mg 260.0 150.0 110.0 40.0 110.0 70.0 Iron MIN mg 5.5 3.1 2.4 0.7 2.4 1.7 Zinc MIN mg 4.3 2.4 1.9 0.5 1.9 1.4 Sodium MAX mg 630.0 360.0 270.0 90.0 270.0 180.0 Salt MAX g 1.6 0.9 0.7 0.2 0.7 0.5
Source: www.cwt.org.uk
Agim Rysha (2013): PhD Thesis 143
Annex 5 Letter to the Ministry of Education for Access to the Kindergartens - Albanian.
Ministria e Arsimit Shkencës dhe Teknologjisë
Data: 22/07/2010
Prishtinë
K Ë R K E S Ë
Përmes kësaj letre i drejtohem Ministrisë së Arsimit Shkencës dhe Teknologjisë që të më mundësojë qasje në institucionet parashkollore të Kosovës gjatë hulumtimit në kuadër të tezës së doktoratës me titull “Të ushqyerit në çerdhet e fëmijëve në Kosovë”. Propozimi i kësaj teme të disertacionit është pranuar nga Universiteti i Kasselit në Gjermani dhe do të mbikëqyret nga mentori: Prof.Dr. Dr. h.c. mult. Angelika Ploeger –profesor ne Universitetin e Kasselit si dhe nga ko- mentori Prof. Dr. Tahire Maloku- Gjergji nga Universiteti i Prishtinës.
Kësaj kërkese ia bashkëngjiss edhe vërtetimin e lëshuar nga Fakulteti i Edukimit që preferon qasje të autorit të hulumtimit në institucionet parashkollore.
Me respekt
Agim Rysha Spec. M. Ing.
Agim Rysha (2013): PhD Thesis 144
Annex 6 Consent and Support Letter from the Ministry of Education of Kosovo. Albanian
Agim Rysha (2013): PhD Thesis 145
Annex 7 Letter to Parents- English and Albanian
Dear Parents, What do we love more than our children? Nothing I suppose! Do we like to see our child growing up happy and smiling? Yes we do! Then, let’s work together and find out what your children are eating and how healthy they are eating. I invite you to join and cooperate in our assessments for benefit of your children. Through this assessment we expect to obtain some measurements and information that will help in assessing your child's nutritional status. This assessment will provide also an overview of the nutritional status of children attending kindergartens of Kosovo. One of the components to be used as part of this study is dietary intake questionnaire using the technique through 24 hours measurements. The dietary intake questionnaire will require you to indicate your child's consumption of all kinds of foods when your child is not in kindergarten. (Questionnaires will be distributed to you and you have to fill them up every day and submit next day during 3 consecutive days. We deeply believe in your cooperation in this study because nutritional status of your children helps define their health status, well-being, and response to illness. Proper nutrition levels are generally associated with better health among children and better health status later on when they reach adolescence and adulthood. Current researches have shown that many diseases that occur later in life have originated in childhood. This study will have full support from the Ministry of Education and the kindergarten. Thank you so much for taking the time to read this letter. We are available to discuss this study and to answer any questions you may have. Thanks again, ______Manager of the Kindergarten Agim Rysha Uni. Spec. M.Eng.
Agim Rysha (2013): PhD Thesis 146
Të dashur prindër, Çka duam më shumë se fëmijët tanë? Asgjë, mendoj! A dëshirojmë t’i shohim fëmijët tanë duke u rritur të lumtur dhe të buzëqeshur? Po, dëshirojmë! Atëherë, le të punojmë së bashku dhe të gjejmë se çka, dhe sa shëndetshëm ata janë duke ngrënë. Ju ftoj të na bashkoheni dhe të bashkëpunoni në hulumtimin tonë për të mirën e fëmijëve tuaj. Ne presim, që përmes këtij hulumtimi të sigurojmë disa matje dhe informacione të cilat do të na ndihmojnë në vlerësimin e gjendjes së të ushqyerit të fëmijës tuaj. Ky hulumtim do të na jep gjithashtu një pasqyrë të gjendjes së të ushqyerit të fëmijëve të cilët i frekuentojnë kopshtet e fëmijëve në Kosovë. Një nga komponentët që do të përdoret si pjesë e këtij hulumtimi do të jetë pyetësori për konsumimin e racionit ushqimor, duke përdorë teknikën përmes matjeve gjatë 24 orëve. Pyetësori për konsumimin e racionit ushqimor do të kërkojë që ju të tregoni konsumimin e të gjitha llojeve të ushqimeve dhe pijeve nga fëmiu i juaj kur ai/ajo nuk është në kopsht. (Pyetësorët do t’ju shpërndahen juve e ju duhet t’i plotësoni për çdo ditë dhe t’i dorëzoni në ditën e ardhshme, përgjatë 3 ditëve njëpasnjëshëm). Ne, thellësisht besojmë për bashkëpunimin tuaj në këtë hulumtim sepse gjendja e të ushqyerit të fëmijëve tuaj ndihmon në përcaktimin e gjendjes së tyre shëndetësore, mirëqenies dhe reagimit ndaj sëmundjeve. Shkalla e duhur e të ushqyerit është zakonisht e lidhur me shëndet më të mirë të fëmijëve dhe gjendje më të mirë shëndetësore më vonë, kur ata do të arrijnë adoleshencën dhe moshën madhore. Hulumtimet aktuale, tregojnë që shumë sëmundje të cilat paraqiten më vonë në jetë, e kanë fillin në fëmijëri. Ky studim do ta ketë përkrahjen e plotë nga Ministria e Arsimit dhe nga kopshtet. Ju falënderoj shumë që gjetët kohë për të lexuar këtë letër. Ne jemi në dispozicionin tuaj për të diskutuar këtë studim dhe për t’ju përgjigjur të gjitha pyetjeve që ju mund t’i keni. Edhe një herë ju faleminderit, ______Drejtori i Kopshtit Agim Rysha Uni.Spec. M. Eng.
Agim Rysha (2013): PhD Thesis 147
Annex 8 The Information Poster about the Start and Time Frame of the Study in a Kinderdarden English and Albanian
Agim Rysha (2013): PhD Thesis 148
Annex 9 The Weighted Dietary Record (WDR) Form: English and Albanian No______
NUTRITION ASSESSMENT IN KINDERGARTENS
The purpose of the study: General nutrition assessment of children in kindergarten
Name of the kindergarten ______Place/Town______
Date of the assessment ______
Child name ______Gender M F Child age ______
Child date of birth______
ASSESSMENT DAY 1 ______
Weighted left Time of Weighted food Quantity of Meal Type of food food after day before consumption eaten food consumption 8:30 Breakfast 11:30 Lunch
14:00 Snack
ASSESSMENT DAY 2 ______
Weighted left Time of Weighted food Quantity of Meal Type of food food after day before consumption eaten food consumption 8:30 Breakfast
11:30 Lunch 14:00 Snack
ASSESSMENT DAY 3 ______
Weighted left Time of Weighted food Quantity of Meal Type of food food after day before consumption eaten food consumption 8:30 Breakfast
Agim Rysha (2013): PhD Thesis 149
11:30 Lunch
14:00 Snack
Nr.______
VLERËSIMI I USHQYESHMËRISË NË KOPSHTE
Qëllimi i studimit: Vlerësimi i përgjithshëm i ushqyeshmërisë së fëmijëve në kopsht
Emri i kopshtit ______Vendi/Qyteti______
Data e vlerësimit ______
Emri i fëmijës ______Gjinia M F Mosha e fëmijës ______
Data e lindjes së fëmijës ______
DITA 1 E VLERËSIMIT ______
Ushqimi i Sasia e Sasia e ushqimit Koha Racioni Lloji i ushqimit mbetur pas ushqimit të para ngrënies konsumimit ngrënë 8:30 Mëngjesi 11:30 Dreka 14:00 Mes-racioni
DITA 2 E VLERËSIMIT ______
Sasia e Sasia e ushqimit Ushqimi i mbetur Koha Racioni Lloji i ushqimit ushqimit të para ngrënies pas konsumimit ngrënë 8:30 Mëngjesi 11:30 Dreka 14:00 Mes-racioni
Agim Rysha (2013): PhD Thesis 150
DITA 3 E VLERËSIMIT ______
Sasia e Sasia e ushqimit Ushqimi i mbetur Koha Racioni Lloji i ushqimit ushqimit të para ngrënies pas konsumimit ngrënë 8:30 Mëngjesi 11:30 Dreka 14:00 Mes-racioni
Agim Rysha (2013): PhD Thesis 151
Annex 10 Estimated Food Record Form (EFR). English and Albanian
CHILD NUTRITION QUESTIONNAIRE FOR PARENTS
The purpose of the study: General nutrition assessment of your child
Name of the kindergarten ______Place/Town______
Date of the assessment ______
Child name ______Gender M F
Child age ______Child date of birth______
Parent name ______Parent age______
Parent occupation ______
Monthly family income in Euros______
Please complete this 3 day diary record of all food and beverage intake by your child when she/he is outside from the kindergarten. Please provide as much details as possible. Include the following: Name of brands of foods; how the food was prepared; quantities eaten etc. For food items with different types of foods please list out each food induded. For example salad with tomatoes, cucumber, etc.
FOOD DIARY DAY 1 ______
Food eaten Time of the day Please be specific for the amount, brand name, type of food and location
Food before kindergarten
Food after Kindergarten
FOOD DIARY DAY 2 ______
Food eaten Time of the day Please be specific for the amount, brand name, type of food and location Food before kindergarten Food after Kindergarten
Agim Rysha (2013): PhD Thesis 152
FOOD DIARY DAY 3 ______
Food eaten Time of the day Please be specific for the amount, brand name, type of food and location Food before kindergarten Food after kindergarten
PYETËSOR PËR PRINDËR RRETH USHQYESHMËRISË SË FËMIUT
Qëllimi i studimit: Vlerësimi i përgjithshëm i të ushqyerit të fëmijës suaj
Emri i kopshtit ______Vendi/Qyteti______
Data e vlerësimit ______
Emri i fëmijës ______Gjinia M F
Mosha e fëmijës ______Data e lindjes ______
Emri i prindit ______Mosha e prindit ______
Profesioni i prindit ______
Të hyrat mujore të familjes në Euro ______
Ju lutemi plotësoni këtë dokument për gjatë 3 ditëve me të dhëna për të gjitha ushqimet dhe pijet që fëmija i juaj ka marrë kur është jashtë kopshtit. Ju lutemi jepni të dhëna sa më shumë që është e mundur siç janë: emri dhe marka e ushqimit; si është përgatitur ushqimi; sasia e konsumuar etj. Për artikujt ushqimor me lloje të ndryshme të ushqimeve, ju lutemi shënoni secilin ushqim të përfshirë. Për shembull: sallatë me domate, tranguj etj.
DITARI I USHQIMIT DITA 1 - E Hënë
Ushqimi i ngrënë nga fëmija i juaj. Ju lutemi specifikoni sasinë, markën, Koha gjatë ditës llojin e ushqimit dhe lokacionin (p.sh. në shtëpi, në restorant etj.) Ushqimi para se fëmija të shkojë në kopsht
Ushqimi pasi që fëmija të
Agim Rysha (2013): PhD Thesis 153
kthehet nga kopshti
DITARI I USHQIMIT DITA 2 - E Martë
Ushqimi i ngrënë nga fëmija i juaj. Ju lutemi specifikoni sasinë, markën, Koha gjatë ditës llojin e ushqimit dhe lokacionin (p.sh. në shtëpi, në restorant etj.) Ushqimi para se fëmija të shkojë në kopsht
Ushqimi pasi që fëmija të
kthehet nga kopshti
DITARI I USHQIMIT DITA 3 - E Mërkurë
Ushqimi i ngrënë nga fëmija i juaj. Ju lutemi specifikoni sasinë, markën, Koha gjatë ditës llojin e ushqimit dhe lokacionin (p.sh. në shtëpi, në restorant etj.) Ushqimi para se fëmija të shkojë në kopsht
Ushqimi pasi që fëmija të
kthehet nga kopshti
Agim Rysha (2013): PhD Thesis 154
Annex 11 A Combined 24H and DH Form, English and Albanian No. ______DIETARY HISTORY IN COMBINATION WITH 24 HOUR FOOD RECORD
Child name ______Assessment day ______
Record everything that your child has eaten YESTERDAY, including beverages and eaten snacks; amount eaten and how food was Meal 1 Meal 2 Meal 3 Snacks Snacks Snacks 1. Is this a typical day's intake for your child? __Yes__No If no explain:______2. Does your child eat differently on weekends? __Yes__No If yes, explain: ______3. How often does your child eat out? ______4. When he eats out, what and where does he typically eat? ______5. Does your child skip meals? ______6. Do you ever feel that yours child eating is out of control ___ Yes ___No 7. Has your child ever been on special diet ___ Yes ___ No If yes, when, what type, how long and who has given to him? ______8. Is your child allergic to any foods?______9. How often does your child drink? Water _____times per D W M Y _____ never Soft drinks/sodas _____times per D W M Y _____ never Milk (type:______) _____times per D W M Y _____ never Tea (sugar Y N) _____times per D W M Y _____ never Fruit/vegetable juice _____times per D W M Y _____ never 10. How often does your child eat? Red meat _____times per D W M Y _____ never Poultry _____times per D W M Y _____ never Fish _____times per D W M Y _____ never Sausage _____times per D W M Y _____ never Eggs _____times per D W M Y _____ never Cheese _____times per D W M Y _____ never Pasta, potatoes, rice _____times per D W M Y _____ never Bread, rolls, muffin, _____times per D W M Y _____ never Agim Rysha (2013): PhD Thesis 155
Crackers _____times per D W M Y _____ never Cereal _____times per D W M Y _____ never Fruit _____times per D W M Y _____ never vegetables _____times per D W M Y _____ never soups/stews/casseroles _____times per D W M Y _____ never pretzels, chips etc. _____times per D W M Y _____ never Candy _____times per D W M Y _____ never ice cream _____times per D W M Y _____ never fried foods _____times per D W M Y _____ never
Nr. ______
HISTORIA DIETALE E KOMBINUAR ME TË DHËNA PËR USHQIMIN E KONSUMUAR BRENDA 24 ORËVE
Emri i fëmijës ______Data e vlerësimit: E diel Shënoni çdo gjë që fëmiu i juaj ka ngrënë gjatë ditës së DJESHME, duke përfshirë ushqimin, pijet dhe mes- racionet; sasinë e ngrënë dhe mënyrën e përgatitjes
Racioni 1 Racioni 2 Racioni 3 Mes – racioni Mes – racioni Mes – racioni 1 A është ky konsumim ditor tipik për fëmijën tuaj? __Po__Jo Nëse jo, sqaroni: ______2 A ushqehet fëmija i juaj ndryshe gjatë fundjavës? __Po__Jo Nëse po, sqaroni: ______3. Sa shpesh, fëmija i juaj ushqehet jashtë shtëpisë? ______4. Kur ai ushqehet jashtë, me çka dhe ku zakonisht ushqehet? ______5. A i kapërcen fëmija i juaj racionet? ______6. A iu duket që fëmija i juaj është duke ngrënë pa kontroll? ___ Po ___Jo 7. A ka qenë fëmija i juaj ndonjëherë në dietë të veçantë? ___ Po ___ Jo Nëse po, kur, cilin lloj, sa gjatë dhe kush ia ka dhënë? ______8. A është fëmija i juaj alergjik në ndonjë ushqim?______9. Sa shpesh fëmija i juaj pi? ujë _____ herë në D(ditë) J (javë) M (muaj) V (vit) ___asnjëherë Pije të ëmbla/gazuara _____ herë në D J M V ____ asnjëherë Qumësht (lloji:______) _____ herë në D J M V ____ asnjëherë çaj (sheqer Po N) _____ herë në D J M V ____ asnjëherë Lëng pemësh/perimesh _____ herë në D J M V ____ asnjëherë
Agim Rysha (2013): PhD Thesis 156
10. Sa shpesh fëmija i juaj ha? mish të kuq _____ herë në D J M V ____ asnjëherë Mish pule _____ herë në D J M V ____ asnjëherë Peshk _____ herë në D J M V ____ asnjëherë Suxhuk,salsiçe,sallam _____ herë në D J M V ____ asnjëherë Vezë _____ herë në D J M V ____ asnjëherë Djathë _____ herë në D J M V ____ asnjëherë Brumëra, patate, oriz _____ herë në D J M V ____ asnjëherë bukë, kifle _____ herë në D J M V ____ asnjëherë Biskota _____ herë në D J M V ____ asnjëherë Ushqim drithërash _____ herë në D J M V ____ asnjëherë Pemë _____ herë në D J M V ____ asnjëherë Perime _____ herë në D J M V ____ asnjëherë Supë /gjyveç/gjellë në tavë _____ herë në D J M V ____ asnjëherë Gjevrek, patatine etj. _____ herë në D J M V ____ asnjëherë Sheqerka, karamele, bonbone _____ herë në D J M V ____ asnjëherë Akullore _____ herë në D J M V ____ asnjëherë Ushqime të fërguara _____ herë në D J M V ____ asnjëherë
Agim Rysha (2013): PhD Thesis 157
Annex 12 The Recipes and Served Food Types in Five Selected Kindergartens Kindergarten 1 Ferizaj
DAY 1 Breakfast DAY 1 Lunch DAY 1 Snack
16/05/2011 and 30/05/2011 16/05/2011 and 30/05/2011 16/05/2011 and 30/05/2011 Breakfast Chamomile tea + bread + Lunch: Pasta (macaroni) Snack: Sweet (Krosant) chicken pate (argeta) Preparation of pasta + fruit juice (Tango
Preparation of tea Sunflower oil = 1206 g Sweet = 60 g net weight
Tea bags 60 x 1.2 g Egs 20 (1 eg = 52 g) Fruit juice = 250 net weight
Water 20 liters Milk (alpsko) = 1200 g sugar 1.5 kg Ketchup = 1510 g slice of bread average 22 g white cheese = 4000 g slice of bread with chicken pate 32 g Water = 40 l chicken pate average 10 g Macaroni = 16000 g
DAY 2 Breakfast DAY 2 Lunch DAY 2 Snack
17/05/2011 and 31/05/2011 17/05/2011 and 31/05/2011 17/05/2011 and 31/05/2011 Puree with mincemeat + mixed Breakfast: Bread + marmalade salad Snack: banana and milk (Alpsko) Preparation of mincemeat: sugar in 27 liters = 258 g Calf mince meat 7000 g slice of bread average 24 g Red pepper 50 g slice of bread + marmalade 42g Sunflower oil 302 g marmalade average = 18 g Salt 56 g
Vegeta 77 g
Onion 400 g
Preparation of potatoes puree
Milk (Alpsko) 3000 g Ready puree 4320 g Margarine (Vital) 500 g Salt 121 g Vegete 116 g Water 27000 g Preparation of vegetable salad Cucumbers 3000 g Tomatoes 6627 g Salt 75 g Lunch: Soup + puree + mincemeat Preparation of soup:
Agim Rysha (2013): PhD Thesis 158
Ready soup: 620 g (podravka) Pasta soup: 400 g Mincemeat 1500 g Ready puree: 1080 g DAY 3 Breakfast DAY 3 Lunch DAY 3 Snack 18/05/2011 and 01/06/2011 18/05/2011 and 01/06/2011 18/05/2011 and 01/06/2011 bread + white cheese+tea Rice + mincemeat + salad Fruit yogurt Preparation of tea (chamomile) Preparation of rice+mincemeat Frutis 125 g Tea bags 60 x 1.2 g mincemeat 7000 g Water 20 liters rice 3200 g sugar 1.5 kg unfried gjyveq 1700 g slice of bread average 23 g onion 633 g slice of bread with white sunflower oil 395 g cheese average 33 g red pepper 100 g white cheese average 10 g salt 120 g vegeta 147 g Preparation of salad tomatoes 6410 g cucumbers 5417 g rice + mincemeat + bread 30% of prepared food is used for 78 children Kindergarten 2 Prishtinë DAY 1 Breakfast DAY 1 Lunch DAY 1 Snack 28/03/2011 28/03/2011 28/03/2011 Cooked white bean + vegetable Mashed biscuits with milk or tea; salad Banana sausage and cheese White bean 5720 g
Preparation of mashed biscuits with milk Onion 2290 g Mashed biscuits 600 g Carrots 2100 g Milk (TEJ) 2550 g Sunflower oil 140 g Total: 3150 g for 17 children Flour 140 g Preparation of tea Salt 210 g Tea bags 209 g Vegeta 210 g Sugar 1512 g Red pepper 110 g Lemon 126 g Water 21450 g
Agim Rysha (2013): PhD Thesis 159
32560 g for 143 Water 18270 g Total children Total 20120 g for 126 children Preparation of fresh salad Cabbage 4410 g Tomatoes 1890 g Cucumber 1890 g Sunflower oil 130 g Vinegar 100 g Salt 190 g Total 8610 kg DAY 2 Breakfast DAY 2 Lunch DAY 2 Snack 29/03/2011 29/03/2011 29/03/2011 Milling rice (grize) + chocolate Cabbage with Mincemeat Snack: Preparation Preparation Snack - Cake (Rovani) Milling rice 400 g Mincemeat 4550 g Preparation of cake (rovani) Milk (TEJ) 2400 g Cabbage 17550 g 35 eggs Chocolate 20 g Carrot 2080 g Sugar 2000 g sugar 190 g Onion 2080 g sunflower 100 ml Total: 3010 g for 16 children Sunflower oil 130 g flour 1000 g Breakfast Milling rice (grize) + chocolate or special bread + soft cheese + white yogurt Flour 130 g Peciva 2000 g average weight = 17.5 soft cheese g Salt 200 g special bread (gjevrek) weight = 96 g vegeta 200 g White yoghurt red pepper 100 g water 19500 g preserved vegetables 130 g bread average = 15 g Total 46650 g for 130 children DAY 3 Breakfast DAY 3 Lunch DAY 3 Snack 30/03/2011 30/03/2011 30/03/2011 Frutolino or bread with Rise with mincemeat and spinach Snack - Krofne chocolate (autocream) Mincemeat 4940 g Slice of bread 25 g rise 3530 g Slice of bread + chocolate onion 2260 g
Agim Rysha (2013): PhD Thesis 160
35 g carrots 2260 g oil 140 g salt 210 g vegeta 210 g bizele 280 g water 21150 g spinach 280 g Total: 35260 g for 141 children Served white yoghurt (50 g for each) Kindergarten 3 Obiliq DAY 1 Breakfast DAY 1 Lunch DAY 1 Snack 28/02/2011 28/02/2011 28/02/2011 Mashed biscuits with milk Mashed potatoes + mincemeat Cake or orange Preparation and tomatoes salad 610 g of biscuits Preparation 2 liters of milk (Alpsko) or 3050 g of mincemeat Chicken sausage; white cheese; bread 1300 g of ready puree and milk 322 g of sunflower oil 78 g of vegeta 23 g of salt 161 g of onion DAY 2 Breakfast DAY 2 Lunch DAY 2 Snack 1/3/2011 1/3/2011 1/3/2011 clear beef soup with paste + bread Cooked white bean + bread Snack - banana (average bread = 45g) (average bread = 25g) or Tea + bread + chicken pate or Cooked white bean + Preparation of soup tomatoes salad 2 soup packages of 45 g Preparation of white bean 3 liters of water White bean = 1825 g Preparation of tea Sunflower oil = 195 g Water 6750 ml vegeta = 28 g sugar = 374 g salt = 29 g tea bags = 8 g red pepper = 10 g Two slices of bread = 80 g onion = 145 g Chicken pate = 20 g DAY 3 Breakfast DAY 3 Lunch DAY 3 Snack
Agim Rysha (2013): PhD Thesis 161
2/3/2011 2/3/2011 2/3/2011 Milling biscuits + milk Cooked rice with minced meat average of milling biscuits 35 g or Cooked rice with minced meat Fruit juice (Frutti) average of milk 75 g and tomatoes Or Preparation Crunchy cereal with cocoa + milk minced meat = 3066 g average crunchy cereal = 25 g rice = 1793 g average milk = 175 g oil = 137 g vegeta = 25 g salt for meat and rice = 43 g carrots = 347 g onions = 125 g Kindergarten 4 Kamenicë DAY 1 Breakfast DAY 1 Lunch DAY 1 Snack 13/12/2010 13/12/2010 13/12/2010 Biscuits with tea Soup and Musaka - Preparation of tea Potatoes with calf Snack Cake Water (g) 5202 g mince meat chamomile (g) 36 g Preparation of soup sugar (g) 282 g Water 1000g average biscuits = 35 g packed soup 62g average tea = 90 g Bread in pieces Preparation of Musaka Raw potatoes 3691g minced meat (g) 1015g onion (g) 230g 6 eggs (g) 401g Milk (ml) 500g salt (g) 35g vegetal (g) 24g red pepper (g) 9 g spoon of oil (ml) 10 g water (ml) 200g DAY 2 Breakfast DAY 2 Lunch DAY 2 Snack 14/12/2010 14/12/2010 14/12/2010 Biscuits with tea Soup or Pizza or Boiled chicken sausages with tea Preparation of soup
Agim Rysha (2013): PhD Thesis 162
Biscuits with tea Water (ml) 1000 (g) Local fruit juice Tango 250 ml Preparation of tea packed soup (g) 62 (g) Water (g) 5202 g Bread in pieces 20 g chamomile (g) 36 g Preparation of Pizza sugar (g) 282 g White flour (g) 2958 (g) average biscuits = 35 g Ham (g) 964 (g) average tea = 90 g Milk (g) 268 (g) Vegetable oil 189 (g) Salt (g) 45 (g) Cheese 701 (g) Mushroom (g) 475 (g) Passata di pomodoro 1000 (g) yeast (g) 22 (g) water (g) 1200 (g) DAY 3 Breakfast DAY 3 Lunch DAY 3 Snack 15/12/2010 15/12/2010 15/12/2010 Biscuits with milk 11:00 Lunch: Soup and goulash Preparation of soup Water (ml) 1000 g local fruit yoghurt packed soup (g) 62 g Bread in pieces 15 g Preparation of goulash 542 g of meat in pieces 592 g of minced meat 697 g of onions 38 g of salt 37 g of vegeta 193 g of vegetable oil 218 g of white flour 956 g xhyveq 17 g of red pepper Water 4519 (g) Preparation of pure 618 g of milk 250 g of ready packed pure 10 g of salt 2 spoons with vegetable oil
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624 (g)water Kindergarten 5 Prishtinë (Private) DAY 1 Breakfast DAY 1 Lunch DAY 1 Snack 14/11/2011 14/11/2011 14/11/2011 Tea + fried eggs + white cheese White beans + cabbage salad apple+piece of cake and bread Preparation or squeezed banana Preparation of tea: Beans 3000 g for babies water 30 l onions 1000 g sugar 600 g s.oil 700 g tea begs 12 (nana) carrots 300 g fried eggs average = 65 g red pepper 38 g white cheese average = 10 g salt 40 g bread = 10 g vegeta 43 g For babies: milling rice+ egg +honey Preparation of cabbage salad Milling rice = 177 g Cabbage 2000 g 1 red of the egg salt 15 g honey = 30 g s.oil 100 g Milk = 1000 ml (for babies 20 g bread mixed with white beans) DAY 2 Breakfast DAY 2 Lunch DAY 2 Snack 15/11/2011 15/11/2011 15/11/2011 Potatoes + vegetables+ biscuits + milk for babies mincemeat Special bread Preparation: Preparation and fruit juice biscuits (plazma) 300 g green pepper 302 g milk (Alpsko) 1000 ml carrots 486 g chocolate cream + bread onion 890 g for other children potatoes 10903 g slice of bread 20 g s.oil 1000 g slice of bread + chocolate cream = 30g mincemeat 974 g slice of bread = 20 g DAY 3 Breakfast DAY 3 Lunch DAY 3 Snack 16/11/2011 16/11/2011 16/11/2011 Special bread with milk rice with vegetables biscuits with milk and mince meat Fruits onions 1111 g green pepper 368 g
Agim Rysha (2013): PhD Thesis 164
carrots 486 g9 mince meat 916 g v.oil 1000 g spinach 1000 g salt 43 g vegeta 46 g pepper 23 g rice 1750 g slice of bread=20g
Agim Rysha (2013): PhD Thesis 165
Annex 13 The Explanation of Some Local Used Foods Type of food Explanation Bread White bread made of white flour type 400 % of fat in milk and white yoghurt % of fat in milk 3.5 and yoghurt 0.5% Salt 99-99.5% of the salt is clear natrium chloride Minced meat Mince meat was made out of caw/calf meat Chicken pate Chicken pate (Argeta). White cheese It is a local cheese like Greek Feta Natural fruit juice Tango (apple); Fruit juice Fruit content =52%;Peach fruit juice " "Bravo" Kind of fruit the marmalade is made from Marmalade was made from mixed fruits Ready soup Beef soup (Aleva 45 g) or Takovo 62 Sterilized Gjuvetch in German: Strilisierter Guwetsch (Progres 850 g). ingredients: Unfried "Gjyveç” tomatoes, peppers; carrots, aubergine, onion, okra; tomatoes juice; cooking oil and salt (see the picture) Fruit yoghurt Strawberry and cherry Semi-hard cheese Trapist cheese produced by Sole- It was the Chicken parizer produced by Sausage IMF SOLE –KORAL Flour type White flour type 400 Milling rice It is milling/grinding white rice in powder Soft cheese Nature MEDVE (soft cheese) 18X17.5g “Gjevrek” It is a special white bread “Peciva” Baking powder 12g for 1/2kg of flour Frutolino - cereal flakes enriched with fruit, Frutolino milk and vitamins Vegetable oil Sunflower oil “Krofne” It is a local made doughnut Cream cake ( 55 g popkek), Swisslion Kind of cake Takovo; Biscuits with filling and cacao; home made cake like muffins Fruit juice Natural fruit juice Tango (apple)
Agim Rysha (2013): PhD Thesis 166
Annex 14 Serving Size Pictures as an Estimated Aid, English and Albanian
Agim Rysha (2013): PhD Thesis 167
Agim Rysha (2013): PhD Thesis 168
Agim Rysha (2013): PhD Thesis 169
Agim Rysha (2013): PhD Thesis 170
Annex 15 Calculated nutrients-from nutrition tables (Umschau Verlag-2002)
Lysine¹ Arginine¹ Mg Cystine¹ Mg Histidine¹ Mg Isoleucine¹ mg Leucine¹ mg mg Phenylalanine¹ Threonine¹ Tryptophane¹ Tyrosine¹ Valine¹ Methionine¹ Mg
Amino Amino acids Mg Mg Mg mg mg
Total Carbohydrates G Fat G Kilocalories Kilojoules Protein g dietary Water g Main Main fibre¹ g Ingredients
l s Starch¹ G Sucrose¹ G Specia Carboh ydrate Monounsaturate Polyunsaturate Saturated
Fatty Fatty d fatty acids¹ G d fatty acids¹ G fatty acids¹ g
Acids
Calcium Mg Chloride¹ Mg Iodide¹ µg Iron¹mg Magnesium¹mg and
Trace Trace Phosphorus mg Potassium¹ Mg Sodium¹ mg Zinc¹ mg Minerals Minerals Elements
Cholesterol¹ mg Sterols Vitamin A Biotin¹ Folic acid¹ Niacinequival Pantothenic Retinolequivalen Vitamin Retinol¹ µg µg ent¹µg acid¹ mg t¹ µg B1¹ mg mg
Vitamins Vitamin B12¹ Vitamin B2¹ Vitamin B6¹ Vitamin E Vitamin Vitamin C¹ mg Vitamin D¹ µg µg Mg mg activ.¹ mg K¹ µg
Agim Rysha (2013): PhD Thesis 171
Annex 16 Height, weight and nutritional status of children from Kindergarten 1 (Ferizaj) according to gender and age Weight for Height for Weight for Sex and age n Kindergarten Weight (kg) Height (cm) age age height BMI for age (months) (z-scores) (z-scores) (z-scores) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Boys (all ages) 102 Ferizaj 12 to < 24 6 12.8 0.7 89.8 3.9 1.3 1.5 3.1 3.8 0.0 0.6 -0.4 0.9 24 to < 36 14 14.1 2.0 91.3 5.2 0.4 1.2 -0.3 1.3 0.8 1.0 0.8 0.9 36 to < 48 20 16.3 1.7 100.9 5.0 0.4 0.8 0.1 1.0 0.5 0.9 0.4 0.9 48 to < 60 33 18.6 2.8 106.9 4.0 0.5 1.0 0.0 0.7 0.6 1.1 0.7 1.1 60 to < 72 23 20.4 3.1 113.6 4.8 0.3 1.0 0.2 0.9 0.2 0.1 0.3 1.0 72 to < 83 6 21.0 2.8 114.1 8.4 -0.1 1.1 -0.6 1.7 0.5 1.3 Girls (all ages) 92 Ferizaj 12 to < 24 1 11.6 83.0 0.4 -0.3 0.7 0.8 24 to < 36 18 14.5 2.6 93.3 5.6 0.7 1.2 0.4 1.6 0.7 1.0 0.7 1.0 36 to < 48 26 15.1 2.1 99.2 6.2 0.0 0.9 0.1 1.4 -0.1 1.1 -0.1 1.2 48 to < 60 18 17.1 2.6 104.1 4.2 -0.1 0.9 -0.5 0.8 0.2 1.1 0.2 1.1 60 to < 72 26 19.2 2.8 110.3 4.9 0.1 0.9 -0.2 1.0 0.3 1.5 0.2 0.9 72 to < 83 3 21.6 3.5 113.1 5.1 0.2 0.9 -0.7 0.9 0.8 0.7 Combined (all 194 Ferizaj ages 12 to < 24 7 12.6 0.8 88.8 4.4 1.2 1.4 2.6 3.7 0.1 0.6 -0.2 1.0 24 to < 36 32 14.4 2.3 92.4 5.4 0.6 1.2 0.1 1.4 0.7 1.0 0.8 0.9 36 to < 48 46 15.6 2.0 99.9 5.7 0.2 0.9 0.1 1.2 0.2 1.0 0.2 1.1 48 to < 60 51 18.1 2.8 105.9 4.3 0.3 1.0 -0.1 0.8 0.5 1.1 0.5 1.1 60 to < 72 49 19.8 3.0 111.8 5.1 0.2 1.0 0.0 1.0 0.3 1.2 0.3 0.9 72 to < 83 9 21.2 2.8 113.7 7.1 0.0 1.0 -0.6 1.4 0.6 1.1
Agim Rysha (2013): PhD Thesis 172
Annex 17 Height, weight and nutritional status of children from Kindergarten 2 (Prishtine) according to gender and age Kindergarten Weight for Height for Weight for Sex and age n Weight (kg) Height (cm) age age height BMI for age (months) (z-scores) (z-scores) (z-scores) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Boys (all ages) 64 Prishtine 12 to < 24 6 13.4 2.2 86.6 6.2 1.2 1.2 0.7 1.7 1.2 0.7 1.2 0.5 24 to < 36 11 14.6 2.0 91.8 5.0 0.7 1.0 0.0 0.8 1.0 1.3 1.0 1.3 36 to < 48 15 17.2 2.6 101.4 5.4 0.8 1.0 0.3 1.1 0.9 1.1 0.9 1.2 48 to < 60 17 20.2 4.0 109.7 6.5 1.0 1.3 0.7 1.2 0.8 1.2 0.9 1.3 60 to < 72 10 21.3 3.7 113.7 3.9 0.6 1.1 0.2 0.7 1.0 0.8 0.7 1.3 72 to < 83 5 22.6 7.8 118.5 7.6 -0.1 2.5 0.1 1.6 -0.2 2.3 Girls (all ages) 48 Prishtine 12 to < 24 3 12.1 2.7 83.4 8.1 0.8 1.2 0.3 1.6 0.8 0.6 0.9 0.6 24 to < 36 5 16.1 2.4 93.2 5.6 1.6 1.3 0.5 1.3 1.9 0.9 1.9 0.9 36 to < 48 14 16.2 2.2 99.0 4.6 0.4 0.9 -0.1 1.0 0.7 0.9 0.7 1.0 48 to < 60 11 20.1 2.3 110.4 4.2 1.1 0.6 1.0 0.7 0.7 0.6 0.7 0.6 60 to < 72 12 22.7 4.4 116.0 6.9 0.9 1.4 0.7 1.4 2.6 0.8 1.1 72 to < 83 3 21.3 3.2 118.2 5.8 0.1 1.0 0.3 1.1 -0.1 0.5 Combined (all 112 Prishtine ages) 12 to < 24 9 13.0 2.3 85.5 6.5 1.1 1.2 0.6 1.6 1.1 0.6 1.1 0.5 24 to < 36 16 15.1 2.2 92.2 5.1 1.0 1.1 0.2 1.0 1.3 1.2 1.3 1.2 36 to < 48 29 16.7 2.4 100.2 5.1 0.6 1.0 0.1 1.0 0.8 1.0 0.8 1.1 48 to < 60 28 20.1 3.4 110.0 5.6 1.0 1.1 0.8 1.0 0.7 1.0 0.8 1.1 60 to < 72 22 22.0 4.1 114.9 5.7 0.8 1.2 0.5 1.2 1.5 1.1 0.7 1.2 72 to < 83 8 22.1 6.2 118.4 6.6 0.0 2.0 0.1 1.3 -0.1 1.8
Agim Rysha (2013): PhD Thesis 173
Annex 18 Height, weight and nutritional status of children from Kindergarten 3 (Obiliq) according to gender and age Kindergarten Weight for Height for Weight for Sex and age n Weight (kg) Height (cm) age age height BMI for age (months) (z-scores) (z-scores) (z-scores) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Boys (all ages) 31 Obiliq 12 to < 24 3 11.6 0.7 81.8 1.1 0.3 0.6 -0.3 0.6 0.7 0.4 0.7 0.4 24 to < 36 2 14.5 0.3 92.2 1.0 0.3 0.3 -0.7 0.1 0.9 0.4 1.0 0.5 36 to < 48 8 16.3 1.5 102.6 4.0 0.3 0.7 0.4 1.0 0.1 0.4 0.0 0.4 48 to < 60 10 16.3 1.5 103.9 4.2 -0.4 0.7 -0.5 1.0 -0.2 0.6 -0.2 0.6 60 to < 72 7 18.8 1.7 111.3 4.5 -0.1 0.8 -0.1 1.0 -0.1 1.0 72 to < 83 1 21.2 0.0 116.0 0.0 -0.1 0.0 -0.47 0.0 0.28 0.0 Girls (all ages) 25 Obiliq 12 to < 24 4 11.1 1.0 80.8 3.8 0.7 0.2 0.5 0.7 0.7 0.4 0.6 0.5 24 to < 36 5 12.5 1.8 87.6 6.5 -0.1 1.2 -0.6 2.1 0.3 0.7 0.4 0.8 36 to < 48 7 15.0 2.2 99.7 3.2 -0.3 1.0 -0.1 0.7 -0.3 1.2 -0.3 1.2 48 to < 60 6 17.9 1.8 107.2 3.1 0.3 0.8 0.3 0.7 0.1 0.7 0.2 0.7 60 to < 72 3 20.8 2.5 112.6 1.4 0.6 0.9 0.2 0.3 0.6 1.0 72 to < 83 0 Combined (all 56 Obiliq ages 12 to < 24 7 11.3 0.9 81.2 2.8 0.5 0.5 0.1 0.7 0.7 0.4 0.7 0.4 24 to < 36 7 13.0 1.8 88.9 5.7 0.0 1.0 -0.6 1.7 0.5 0.7 0.6 0.8 36 to < 48 15 15.7 1.9 101.2 3.8 0.0 0.9 0.2 0.9 -0.1 0.8 -0.1 0.8 48 to < 60 16 16.9 1.7 105.1 4.0 -0.2 0.8 -0.2 0.9 -0.1 0.7 0.0 0.7 60 to < 72 10 19.4 2.1 111.7 3.8 0.1 0.8 0.0 0.8 0.1 1.0 72 to < 83 1 21.2 0.0 116.0 0.0 -0.1 0.0 -0.5 0.0 0.3 0.0
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Annex 19 Height, weight and nutritional status of children from Kindergarten 4 (Kamenicë) according to gender and age Kindergarten Weight for Height for Weight for Sex and age n Weight (kg) Height (cm) age age height BMI for age (months) (z-scores) (z-scores) (z-scores) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Boys (all ages) 21 Kamenicë 12 to < 24 3 10.8 0.8 82.1 3.6 -0.7 0.8 -0.9 1.0 -0.4 0.9 -0.2 0.9 24 to < 36 1 18.5 0.0 97.9 0.0 2.5 0.0 1.3 0.0 2.6 0.0 2.5 0.0 36 to < 48 3 15.6 2.1 99.1 5.4 0.1 1.0 -0.2 1.0 0.3 0.9 0.3 0.9 48 to < 60 3 16.1 2.8 105.0 4.5 -0.6 1.3 -0.3 1.0 -0.7 1.1 -0.6 1.1 60 to < 72 6 18.9 3.3 110.6 5.2 -0.4 1.3 -0.6 1.3 0.0 1.3 72 to < 83 5 20.1 1.8 117.8 4.2 -0.5 0.8 -0.1 1.0 -0.7 0.7 Girls (all ages) 16 Kamenicë 12 to < 24 3 11.9 2.6 82.7 7.1 0.9 1.7 0.5 2.0 0.8 1.1 0.9 0.9 24 to < 36 2 13.7 2.9 97.2 1.2 0.4 1.2 1.6 1.3 -0.8 2.6 -1.0 3.0 36 to < 48 2 17.6 0.4 105.4 0.8 0.7 0.2 0.7 0.2 0.4 0.1 0.4 0.1 48 to < 60 2 16.2 0.4 103.7 2.5 -0.5 0.2 -0.6 0.6 -0.1 0.3 -0.2 0.3 60 to < 72 6 21.1 3.3 117.8 7.2 0.6 1.2 1.2 1.4 -0.1 0.6 72 to < 83 1 22.2 0.0 120.0 0.6 0.0 0.9 0.0 0.1 0.0 Combined (all 37 Kamenicë ages 12 to < 24 6 11.3 1.8 82.4 5.0 0.1 1.4 -0.2 1.6 0.2 1.1 0.3 1.0 24 to < 36 3 15.3 3.4 97.4 1.0 1.1 1.5 1.5 0.9 0.4 2.7 0.2 2.9 36 to < 48 5 16.4 1.8 101.6 5.2 0.3 0.7 0.2 0.9 0.3 0.6 0.3 0.6 48 to < 60 5 16.1 2.0 104.4 3.5 -0.5 0.9 -0.4 0.8 -0.4 0.8 -0.4 0.8 60 to < 72 12 20.0 3.4 114.2 7.1 0.1 1.3 0.3 1.6 -0.1 1.0 72 to < 83 6 20.5 1.8 118.2 3.9 -0.3 0.8 0.0 1.0 -0.6 0.7
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Annex 20 Height, weight and nutritional status of children from Kindergarten 5 (Private Prishtine) according to gender and age Kindergarten Weight for Height for Weight for Sex and age n Weight (kg) Height (cm) age age height BMI for age (months) (z-scores) (z-scores) (z-scores) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Boys (all ages) 46 Private Prishtine 12 to < 24 9 11.8 1.6 83.2 5.9 0.8 1.1 1.1 1.1 0.4 1.6 0.3 1.7 24 to < 36 7 14.5 1.7 92.5 4.6 0.6 0.7 0.1 1.0 0.8 1.4 0.8 1.5 36 to < 48 12 15.6 2.5 99.8 4.2 0.1 1.3 0.2 0.9 0.0 1.4 0.0 1.3 48 to < 60 8 18.8 1.9 107.9 4.7 0.8 0.8 0.6 1.1 0.6 0.6 0.6 0.7 60 to < 72 4 21.3 3.1 113.8 6.8 0.7 0.9 0.4 1.2 0.8 0.4 72 to < 83 6 22.9 3.1 118.0 4.0 0.3 1.1 -0.2 0.8 0.6 1.0 Girls (all ages) 41 Private Prishtine 12 to < 24 6 11.3 1.2 79.9 2.9 0.9 0.9 0.3 0.9 1.0 0.8 1.0 0.7 24 to < 36 5 13.9 0.7 91.4 2.4 0.8 0.2 0.4 0.5 0.7 0.4 0.8 0.5 36 to < 48 17 15.4 2.4 98.2 4.5 0.4 1.1 0.3 0.9 0.3 1.3 0.3 1.3 48 to < 60 6 16.9 1.6 103.5 2.4 0.0 0.6 -0.3 0.5 0.3 0.7 0.3 0.7 60 to < 72 4 21.1 4.8 108.6 8.7 0.4 1.3 -0.8 1.4 1.3 1.2 72 to < 83 3 26.2 2.7 124.9 1.6 1.3 0.6 1.4 0.3 0.8 0.6 Combined (all 87 Private ages) Prishtine 12 to < 24 15 11.6 1.4 81.9 5.1 0.9 1.0 0.8 1.0 0.7 1.3 0.6 1.4 24 to < 36 12 14.2 1.3 92.0 3.8 0.7 0.6 0.2 0.8 0.8 1.0 0.8 1.2 36 to < 48 29 15.5 2.4 98.9 4.4 0.3 1.2 0.2 0.9 0.2 1.3 0.2 1.3 48 to < 60 14 18.0 2.0 106.0 4.4 0.5 0.8 0.2 1.0 0.5 0.7 0.5 0.7 60 to < 72 8 21.2 3.7 111.2 7.8 0.6 1.0 -0.2 1.4 1.0 0.9 72 to < 83 9 24.0 3.3 120.3 4.7 0.7 1.0 0.4 1.0 0.7 0.9
Agim Rysha (2013): PhD Thesis 176
Annex 21 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 1 (Ferizaj) according to gender and age Special Main Ingredients Carbohydrates Fatty Acids
Polyuns n Total Monounsat aturated Saturate Sex and age Kinder- Carbohy- Kilo- dietary Sucrose¹ urated fatty fatty d fatty (months) garten drates g Fat g calories Kilojoule Protein g fibre¹ g Water g Starch¹ g g acids¹ g acids¹ g acids¹ g Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 102 Ferizaj ages) 12 to < 24 4 109.4 19.4 739.7 3094.1 29.9 6.5 293.3 75.4 13.4 2.9 1.1 3.8 24 to < 36 15 118.2 19.8 774.6 3239.5 28.6 7.0 340.5 74.5 18.7 2.7 1.2 3.7 36 to < 48 25 133.0 23.9 886.9 3709.6 32.7 7.7 394.4 85.8 19.9 3.2 1.4 4.5 48 to < 60 28 162.2 30.5 1090.9 4563.0 39.1 9.3 470.1 108.6 22.0 3.4 1.6 4.9 60 to < 72 24 151.7 27.7 1010.9 4227.9 36.0 8.8 454.1 98.9 22.4 3.2 1.5 4.5 72 to < 83 6 191.1 34.8 1269.5 5309.5 44.7 11.3 529.8 132.6 24.3 3.0 1.6 4.6 Girls (all 92 Ferizaj ages) 12 to < 24 3 95.4 15.1 631.0 2639.4 26.7 5.5 280.9 62.5 12.7 1.9 0.7 2.4 24 to < 36 17 107.3 17.3 699.2 2924.3 26.6 6.5 307.9 68.0 17.1 2.3 1.0 3.0 36 to < 48 21 121.2 20.3 792.9 3316.1 29.1 7.1 353.3 76.7 18.6 2.6 1.2 3.6 48 to < 60 23 151.2 28.4 1021.4 4272.5 37.5 8.7 471.1 100.2 21.4 3.2 1.5 4.6 60 to < 72 25 148.8 27.8 999.2 4179.2 35.8 8.5 456.8 98.5 21.2 3.2 1.5 4.5 72 to < 83 3 199.4 38.5 1358.1 5680.5 50.0 11.4 526.6 137.7 27.6 4.5 2.1 6.3 Combined 194 Ferizaj (all ages 12 to < 24 7 103.4 17.6 693.1 2899.2 28.6 6.1 288.0 69.9 13.1 2.5 1.0 3.2 24 to < 36 32 112.4 18.5 734.5 3072.0 27.5 6.7 323.1 71.0 17.8 2.5 1.1 3.3 36 to < 48 46 127.6 22.2 834.0 3530.0 31.0 7.4 375.6 81.6 19.3 2.9 1.3 4.1 48 to < 60 51 157.2 29.6 1059.6 4432.0 38.4 9.0 470.5 104.9 21.7 3.4 1.6 4.8 60 to < 72 49 150.3 27.8 1004.9 4203.1 35.9 8.6 455.5 98.7 21.8 3.2 1.5 4.5 72 to < 83 9 193.8 36.0 1299.0 5433.1 46.4 11.3 528.7 134.3 25.4 3.5 1.7 5.1
Agim Rysha (2013): PhD Thesis 177
Annex 22 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 2 (Prishtine) according to gender and age Special Main Ingredients Carbohydrates Fatty Acids Monouns Polyunsat Sex and Total aturated urated Saturate n age Kinder- Carbohyd Kilocalo dietary Sucrose¹ fatty fatty d fatty (months) garten rates g Fat g ries Kilojoule Protein g fibre¹ g Water g Starch¹ g g acids¹ g acids¹ g acids¹ g
Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 64 Prishtine ages) 12 to < 24 6 65.9 13.1 446.5 1867.9 14.8 3.9 310.0 31.7 22.3 2.1 1.8 2.7 24 to < 36 11 59.8 11.0 400.1 1674.1 14.4 3.5 251.1 32.5 18.2 2.1 2.1 2.2 36 to < 48 15 59.8 8.3 381.5 1595.3 16.0 4.1 245.7 31.6 16.0 1.4 1.3 1.5 48 to < 60 17 76.9 10.1 479.0 2002.9 19.3 5.1 260.8 42.1 19.1 1.7 1.5 1.9 60 to < 72 10 83.2 12.0 534.9 2236.7 21.4 5.2 279.1 45.6 21.3 2.2 2.1 2.2 72 to < 83 5 85.9 12.1 552.0 2308.5 23.5 5.3 304.5 47.2 19.2 2.3 2.3 2.3 Girls (all 48 Prishtine ages) 12 to < 24 3 55.5 11.1 378.8 1585.0 13.1 3.6 281.5 26.6 18.8 1.8 1.3 2.5 24 to < 36 5 59.4 11.7 411.8 1723.9 16.2 3.8 260.9 34.1 14.9 2.5 2.5 2.7 36 to < 48 14 61.9 9.3 401.1 1677.4 16.5 4.2 234.9 32.5 16.8 1.6 1.5 1.7 48 to < 60 11 78.2 10.9 492.7 2060.3 19.4 5.1 260.8 42.1 20.1 2.0 1.9 2.1 60 to < 72 12 87.4 12.4 553.4 2314.3 21.7 5.4 310.9 45.4 23.4 2.2 2.3 2.0 72 to < 83 3 72.9 12.1 490.2 2050.4 21.5 4.5 266.8 42.8 14.5 2.1 2.3 1.9 Combined 112 Prishtine (all ages) 12 to < 24 9 62.4 12.4 423.9 1773.6 14.2 3.8 300.5 30.0 21.1 2.0 1.6 2.6 24 to < 36 16 59.7 11.2 403.8 1689.7 14.9 3.6 254.1 33.0 17.2 2.2 2.2 2.4 36 to < 48 29 60.8 8.8 391.0 1635.0 16.2 4.2 240.5 32.0 16.4 1.5 1.4 1.6 48 to < 60 28 77.4 10.4 483.4 2025.5 19.3 5.1 260.8 42.1 19.5 1.8 1.6 2.0 60 to < 72 22 85.9 12.2 545.0 2279.0 21.6 5.3 296.4 45.5 22.4 2.2 2.2 2.1 72 to < 83 8 81.0 12.1 528.8 2211.7 22.7 5.0 290.4 45.6 17.4 2.3 2.3 2.1
Agim Rysha (2013): PhD Thesis 178
Annex 23 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 3 (Obiliq) according to gender and age Special Main Ingredients Carbohydrates Fatty Acids Polyuns Sex and Total Monounsat aturated Saturated n age Kinder- Carbohydr Kilocalo dietary Starch¹ Sucrose¹ urated fatty fatty fatty (months) garten ates g Fat g ries Kilojoule Protein g fibre¹ g Water g g g acids¹ g acids¹ g acids¹ g
Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 31 Obiliq ages) 12 to < 24 3 86.4 20.6 630.9 2640.3 23.2 5.1 263.7 47.3 17.4 3.2 0.9 5.4 24 to < 36 2 81.2 19.2 583.9 2443.6 19.8 4.5 255.3 42.2 17.7 3.1 0.8 5.6 36 to < 48 8 83.5 14.8 578.9 2422.8 25.8 6.8 338.3 45.0 13.0 2.0 0.8 2.6 48 to < 60 10 76.8 13.1 529.5 2216.0 24.1 6.7 327.8 40.0 11.3 1.5 0.7 1.9 60 to < 72 7 78.5 14.4 559.8 2343.0 26.9 6.6 349.2 40.7 11.8 1.9 0.8 2.3 72 to < 83 1 101.3 19.2 741.2 3102.4 38.2 8.8 406.7 59.2 13.5 2.7 1.2 3.2 Girls (all 25 Obiliq ages) 12 to < 24 4 75.7 17.8 547.1 2289.5 19.4 3.9 244.9 39.9 15.7 2.9 0.7 5.0 24 to < 36 5 82.3 19.5 598.2 2503.6 21.7 4.7 257.6 44.6 16.7 3.1 0.8 5.2 36 to < 48 7 75.5 14.0 529.4 2215.4 23.6 5.9 309.3 40.0 11.8 1.8 0.8 2.4 48 to < 60 6 81.0 16.6 605.9 2535.7 31.3 6.4 333.0 46.8 10.3 2.2 1.0 2.5 60 to < 72 3 88.4 18.0 652.9 2732.5 32.6 7.5 330.5 53.2 10.5 2.3 1.0 2.6 72 to < 83 0 Combined 56 Obiliq (all ages 12 to < 24 7 80.3 19.0 583.0 2439.9 21.0 4.4 253.0 43.1 16.4 3.1 0.8 5.2 24 to < 36 7 82.0 19.4 594.1 2486.4 21.2 4.6 256.9 43.9 17.0 3.1 0.8 5.3 36 to < 48 15 79.8 14.4 555.8 2326.0 24.8 6.4 324.8 42.7 12.4 1.9 0.8 2.5 48 to < 60 16 78.4 14.4 558.1 2335.9 26.8 6.6 329.8 42.6 11.0 1.8 0.8 2.1 60 to < 72 10 81.5 15.5 587.8 2459.9 28.6 6.9 343.6 44.5 11.4 2.0 0.9 2.4 72 to < 83 1 101.3 19.2 741.2 3102.4 38.2 8.8 406.7 59.2 13.5 2.7 1.2 3.2
Agim Rysha (2013): PhD Thesis 179
Annex 24 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 4 (Kamenicë) according to gender and age Special Main Ingredients Carbohydrates Fatty Acids Monounsa Polyunsat Sex and n Total turated urated Saturated age Kinder- Carbohydr Kilocalo Protein dietary Sucrose¹ fatty fatty fatty (months) garten ates g Fat g ries Kilojoule g fibre¹ g Water g Starch¹ g g acids¹ g acids¹ g acids¹ g Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 13 Kamenice ages) 12 to < 24 3 50.0 8.7 320.0 1339.8 9.7 1.5 218.4 20.3 11.0 1.9 0.3 3.7 24 to < 36 1 40.6 6.7 257.6 1078.4 8.0 1.1 178.1 13.1 8.9 1.6 0.3 3.1 36 to < 48 3 47.2 7.2 298.4 1249.3 10.3 1.4 197.1 20.0 8.4 1.3 0.3 2.5 48 to < 60 2 59.1 10.9 394.3 1650.4 14.1 2.2 262.4 28.3 10.2 1.9 0.4 3.5 60 to < 72 3 67.1 11.6 446.4 1868.9 17.2 2.5 250.0 37.4 9.2 1.9 0.4 3.4 72 to < 83 1 91.2 16.6 632.2 2647.3 27.7 4.1 396.3 56.6 11.2 2.6 0.6 4.2 Girls (all Kamenice 7 ages) 12 to < 24 3 55.6 11.8 374.6 1568.2 10.3 1.4 281.4 22.2 14.7 2.8 0.5 5.7 24 to < 36 2 79.8 12.0 502.1 2101.2 17.9 3.4 296.2 44.7 11.1 2.1 0.4 3.9 36 to < 48 1 43.1 6.8 272.0 1138.8 8.9 1.2 200.3 15.7 8.8 1.4 0.3 2.6 48 to < 60 60 to < 72 1 74.3 12.7 490.8 2054.5 18.6 2.9 306.5 40.8 11.3 2.0 0.5 3.5 72 to < 83 Combined 20 Kamenice (all ages 12 to < 24 6 52.8 10.3 347.3 1454.0 10.0 1.4 249.9 21.2 12.9 2.4 0.4 4.7 24 to < 36 3 66.7 10.2 420.6 1760.3 14.6 2.6 256.8 34.1 10.4 2.0 0.4 3.6 36 to < 48 4 46.2 7.1 291.8 1221.7 10.0 1.3 197.9 18.9 8.5 1.3 0.3 2.5 48 to < 60 2 59.1 10.9 394.3 1650.4 14.1 2.2 262.4 28.3 10.2 1.9 0.4 3.5 60 to < 72 4 68.9 11.9 457.5 1915.3 17.5 2.6 264.1 38.2 9.8 1.9 0.4 3.4 72 to < 83 1 91.2 16.6 632.2 2647.3 27.7 4.1 396.3 56.6 11.2 2.6 0.6 4.2
Agim Rysha (2013): PhD Thesis 180
Annex 25 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 5 (Prishtine private) according to gender and age Special Main Ingredients Carbohydrates Fatty Acids Monounsa Polyuns Sex and Total turated aturated Saturate n age Kinder- Carbohydra dietary Sucrose¹ fatty fatty d fatty (months) garten tes g Fat g Kilocalories Kilojoule Protein g fibre¹ g Water g Starch¹ g g acids¹ g acids¹ g acids¹ g Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 46 Private ages) Prishtine 12 to < 24 9 106.6 32.4 825.9 3453.7 24.9 7.6 355.9 64.3 12.0 1.7 1.0 3.0 24 to < 36 7 96.7 29.7 754.7 3156.0 23.5 7.2 324.7 60.1 8.2 1.5 1.1 2.3 36 to < 48 12 113.3 34.8 882.8 3692.3 27.0 9.7 408.2 72.8 8.4 1.5 1.6 1.6 48 to < 60 8 114.0 33.5 878.5 3674.3 28.2 10.0 413.5 72.4 8.9 1.9 1.9 1.9 60 to < 72 4 117.3 37.0 931.4 3895.7 30.3 10.1 413.1 78.2 8.5 2.2 2.0 2.2 72 to < 83 6 135.3 43.9 1082.8 4528.3 34.3 12.6 454.9 85.9 12.8 2.9 2.4 3.6 Girls (all 41 Private ages) Prishtine 12 to < 24 6 107.5 30.6 811.4 3392.7 24.3 7.1 363.2 61.8 14.1 1.9 0.9 3.7 24 to < 36 5 97.2 30.0 761.8 3185.9 24.0 7.5 342.7 61.5 7.7 1.4 1.2 1.9 36 to < 48 17 118.7 39.0 951.3 3978.7 29.1 10.2 419.0 78.2 8.8 1.9 1.9 1.9 48 to < 60 6 120.0 39.2 960.9 4018.9 29.7 10.6 449.2 77.7 9.2 1.9 2.0 2.0 60 to < 72 4 115.1 34.6 892.0 3730.7 28.1 9.7 413.9 75.5 8.5 1.8 1.8 1.9 72 to < 83 3 131.1 37.5 991.6 4147.1 30.2 11.1 448.9 82.5 11.9 2.7 2.1 3.4 Combined 87 Private (all ages) Prishtine 12 to < 24 15 107.0 31.7 820.1 3429.3 24.6 7.4 358.8 63.3 12.8 1.8 0.9 3.3 24 to < 36 12 96.9 29.8 757.7 3168.5 23.7 7.3 332.2 60.7 8.0 1.5 1.1 2.1 36 to < 48 29 116.3 37.1 920.6 3850.3 28.2 10.0 414.2 75.8 8.6 1.7 1.8 1.8 48 to < 60 14 116.6 36.0 913.8 3822.0 28.9 10.3 428.8 74.7 9.0 1.9 2.0 1.9 60 to < 72 8 116.2 35.8 911.7 3813.2 29.2 9.9 413.5 76.8 8.5 2.0 1.9 2.0 72 to < 83 9 133.9 41.8 1052.4 4401.2 32.9 12.1 452.9 83.8 12.5 2.8 2.3 3.5
Agim Rysha (2013): PhD Thesis 181
Annex 26 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Public Kindergartens according to gender and age Special Main Ingredients Carbohydrates Fatty Acids Monou Polyu nsatur nsatur ated ated n Carboh Total fatty fatty Saturate Sex and age Kinder- ydrates dietary acids¹ acids¹ d fatty (months) garten g Fat g Kilocalories Kilojoule Protein g fibre¹ g Water g Starch¹ g Sucrose¹ g g g acids¹ g Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 210 Public
12 to < 24 16 77.6 15.3 530.6 2220.3 19.2 4.3 279.9 43.4 17.0 2.5 1.2 3.7 24 to < 36 29 90.9 16.0 601.6 2516.3 21.9 5.3 295.1 54.2 18.1 2.5 1.5 3.3 36 to < 48 51 98.7 16.9 655.3 2741.2 25.4 6.1 330.3 59.6 17.0 2.4 1.2 3.2 48 to < 60 57 118.2 20.7 785.5 3285.5 29.7 7.3 375.4 73.9 18.9 2.5 1.4 3.4 60 to < 72 44 119.0 20.9 792.4 3314.6 29.9 7.2 383.7 73.3 19.6 2.7 1.5 3.6 72 to < 83 13 136.0 23.5 903.9 3780.7 34.7 8.3 423.4 88.3 20.5 2.7 1.8 3.5 Girls (all ages) 172 Public 12 to < 24 13 71.0 14.3 487.8 2041.2 17.5 3.6 270.1 38.0 15.5 2.4 0.8 4.0 24 to < 36 29 92.8 16.3 618.7 2588.0 23.4 5.5 290.3 56.5 16.2 2.4 1.2 3.4 36 to < 48 43 92.6 15.4 610.3 2552.7 23.6 5.8 304.1 54.9 16.7 2.1 1.2 2.8 48 to < 60 40 120.6 21.8 813.7 3403.6 31.6 7.4 392.5 76.2 19.4 2.7 1.5 3.6 60 to < 72 41 124.6 22.2 831.0 3475.7 31.0 7.4 401.2 78.2 20.8 2.8 1.7 3.6 72 to < 83 6 136.2 25.3 924.1 3865.4 35.7 7.9 396.7 90.3 21.0 3.3 2.2 4.1
Combined (all 382 Public ages) 12 to < 24 29 74.6 14.8 511.4 2140.0 18.5 4.0 275.5 41.0 16.3 2.4 1.0 3.8 24 to < 36 58 91.8 16.1 610.1 2552.2 22.6 5.4 292.7 55.4 17.2 2.5 1.3 3.3 36 to < 48 94 95.9 16.2 634.7 2655.0 24.6 6.0 318.3 57.4 16.8 2.3 1.2 3.0 48 to < 60 97 119.2 21.1 797.1 3334.2 30.5 7.3 382.5 74.9 19.1 2.6 1.4 3.5 60 to < 72 85 121.7 21.6 811.0 3392.3 30.5 7.3 392.1 75.7 20.2 2.7 1.6 3.6 72 to < 83 19 136.1 24.1 910.3 3807.4 35.0 8.1 415.0 88.9 20.7 2.9 1.9 3.7
Agim Rysha (2013): PhD Thesis 182
Annex 27 Mean values of amino acids consumed by children attending kindergarten 1 (Ferizaj) according to gender and age Sex and Phenyla Threon Tryptop age n Kinder- Arginine¹ Cystine¹ Histidine¹ Isoleucine¹ Leucine¹ Lysine¹ Methion lanine¹ ine¹ hane¹ Tyrosine Valine¹ (months) garten mg mg mg mg mg mg ine¹ mg mg mg mg ¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 102 Ferizaj ages) 12 to < 24 4 1400.5 397.2 738.7 1231.2 1987.5 1578.3 516.6 1182.8 1031.8 296.8 909.4 1356.1 24 to < 36 15 1254.0 378.8 685.4 1135.0 1874.3 1396.2 475.2 1115.3 943.0 278.8 833.7 1262.6 36 to < 48 25 1417.1 441.8 765.0 1306.2 2155.2 1574.2 549.7 1288.6 1076.0 318.0 952.5 1446.3 48 to < 60 28 1564.2 548.1 841.1 1511.4 2520.5 1658.5 633.8 1531.5 1212.1 368.9 1072.8 1667.7 60 to < 72 24 1454.0 499.1 790.5 1394.7 2318.5 1546.7 582.3 1405.3 1121.2 340.7 987.9 1538.8 72 to < 83 6 1685.0 655.6 912.0 1683.8 2849.6 1727.9 699.4 1762.6 1328.0 412.2 1194.9 1863.8 Girls (all 92 Ferizaj ages) 12 to < 24 3 1283.4 339.8 682.8 1117.1 1799.8 1492.5 474.8 1053.0 947.4 268.7 831.0 1233.5 24 to < 36 17 1178.6 348.2 643.1 1055.3 1733.1 1316.2 440.9 1030.4 879.9 258.6 776.2 1172.2 36 to < 48 21 1250.2 388.2 680.1 1144.4 1875.5 1353.2 475.0 1124.8 937.6 280.4 818.0 1262.8 48 to < 60 23 1566.1 515.1 837.6 1479.5 2438.8 1685.5 622.1 1469.4 1197.0 360.2 1048.3 1626.7 60 to < 72 25 1442.3 499.5 777.6 1390.0 2314.3 1541.3 583.1 1404.0 1117.3 338.2 989.2 1533.9 72 to < 83 3 2087.8 696.6 1103.5 1966.0 3222.1 2179.9 819.9 1954.1 1579.3 479.4 1372.7 2151.7 Combined 194 Ferizaj (all ages 12 to < 24 7 1350.3 372.6 714.7 1182.3 1907.1 1541.5 498.7 1127.2 995.6 284.7 875.8 1303.6 24 to < 36 32 1213.9 362.6 662.9 1092.6 1799.3 1353.7 457.0 1070.2 909.5 268.1 803.2 1214.6 36 to < 48 46 1340.9 417.3 726.3 1232.3 2027.5 1473.3 515.6 1213.8 1012.8 300.8 891.1 1362.6 48 to < 60 51 1565.0 533.2 839.5 1497.0 2483.7 1670.7 628.5 1503.5 1205.3 365.0 1061.8 1649.2 60 to < 72 49 1448.0 499.3 783.9 1392.3 2316.4 1544.0 582.7 1404.6 1119.2 339.4 988.6 1536.3 72 to < 83 9 1819.2 669.3 975.8 1777.9 2973.8 1878.5 739.5 1826.4 1411.8 434.6 1254.1 1959.7
Agim Rysha (2013): PhD Thesis 183
Annex 28 Mean values of amino acids consumed by children attending kindergarten 2 (Prishtine) according to gender and age Sex and Methio Phenyl age n Kinder- Arginine¹ Cystine¹ Histidine¹ Isoleucine¹ Leucine¹ Lysine¹ nine¹ alanine Threoni Tryptoph Tyrosine¹ Valine¹ (months) garten mg mg mg mg mg mg mg ¹ mg ne¹ mg ane¹ mg mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 64 Prishtine ages) 12 to < 24 6 637.1 164.0 323.8 633.8 1132.6 815.1 277.0 636.0 522.2 148.3 510.9 770.8 24 to < 36 11 648.0 172.3 326.4 642.5 1069.3 762.2 267.1 618.7 495.1 143.3 452.8 749.2 36 to < 48 15 703.1 208.2 388.6 730.2 1170.9 843.7 297.5 683.8 544.0 155.5 449.9 813.6 48 to < 60 17 825.4 272.0 467.3 888.1 1415.0 959.7 365.8 837.4 649.8 191.0 536.0 981.0 60 to < 72 10 953.0 310.3 546.6 1051.5 1668.3 1153.2 436.9 978.2 761.1 223.5 635.7 1158.3 72 to < 83 5 1041.5 328.6 606.8 1211.9 1890.6 1320.2 489.9 1093.3 849.9 247.3 735.2 1320.7 Girls (all 48 Prishtine ages) 12 to < 24 3 548.7 144.4 273.1 541.3 953.4 684.2 230.6 541.0 442.9 124.7 427.5 652.0 24 to < 36 5 678.6 209.0 348.7 747.5 1186.4 805.5 284.7 706.6 542.4 153.9 501.5 831.5 36 to < 48 14 737.2 219.9 413.8 786.2 1259.3 902.1 318.6 734.4 582.2 167.7 492.3 875.7 48 to < 60 11 859.3 273.0 491.1 929.5 1479.5 1017.6 375.9 872.3 679.0 199.4 568.3 1028.0 60 to < 72 12 964.5 310.2 561.8 1090.0 1726.4 1192.5 446.0 1008.1 781.7 230.6 673.9 1203.7 72 to < 83 3 953.0 303.9 545.4 1081.8 1710.8 1218.3 451.3 995.4 773.2 223.4 665.2 1188.8 Combined 112 Prishtine (all ages) 12 to < 24 9 607.6 157.5 306.9 603.0 1072.9 771.5 261.5 604.3 495.7 140.4 483.1 731.2 24 to < 36 16 657.6 183.7 333.4 675.3 1105.9 775.7 272.6 646.2 509.8 146.6 468.0 774.9 36 to < 48 29 719.5 213.8 400.7 757.2 1213.5 871.9 307.7 708.2 562.4 161.4 470.4 843.6 48 to < 60 28 838.7 272.3 476.7 904.3 1440.3 982.5 369.7 851.2 661.2 194.3 548.7 999.5 60 to < 72 22 959.2 310.3 554.9 1072.5 1700.0 1174.6 441.9 994.5 772.4 227.4 656.5 1183.1 72 to < 83 8 1008.3 319.3 583.7 1163.1 1823.1 1282.0 475.4 1056.6 821.2 238.3 709.0 1271.2
Agim Rysha (2013): PhD Thesis 184
Annex 29 Mean values of amino acids consumed by children attending kindergarten 3 (Obiliq) according to gender and age Sex and age n Kinder- Arginine¹ Cystine¹ Histidine¹ Isoleucine¹ Leucin Lysine¹ Methioni Phenylala Threoni Tryptoph Tyrosin Valine¹ (months) garten mg mg mg mg e¹ mg mg ne¹ mg nine¹ mg ne¹ mg ane¹ mg e¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 31 Obiliq ages) 12 to < 24 3 1322.0 281.9 679.9 1187.6 1889.8 1634.5 436.7 1110.3 986.3 255.4 864.8 1308.8 24 to < 36 2 1089.6 243.9 565.7 1007.8 1632.0 1358.3 372.6 958.3 831.6 217.0 737.5 1119.8 36 to < 48 8 1456.0 312.0 743.1 1287.0 2058.1 1811.7 510.1 1181.3 1060.4 271.7 846.4 1414.9 48 to < 60 10 1354.0 294.4 695.4 1192.5 1903.1 1690.2 473.6 1094.9 979.4 250.0 769.9 1307.0 60 to < 72 7 1542.8 324.9 790.4 1324.1 2116.4 1954.9 567.5 1183.9 1106.7 283.5 848.5 1455.1 72 to < 83 1 2243.9 459.9 1127.5 1917.2 2997.6 2789.8 783.8 1702.2 1582.1 398.3 1189.2 2079.6 Girls (all 25 Obiliq ages) 12 to < 24 4 1086.9 240.1 565.6 973.7 1558.8 1352.2 382.3 904.0 817.2 215.8 716.9 1076.6 24 to < 36 5 1229.5 266.5 635.9 1103.6 1761.0 1523.2 417.3 1029.1 920.5 240.4 807.1 1218.0 36 to < 48 7 1323.2 286.1 683.9 1176.4 1893.3 1675.7 475.4 1079.3 974.3 249.6 780.5 1296.2 48 to < 60 6 1827.6 374.8 934.8 1581.9 2505.8 2341.0 658.1 1408.7 1318.6 331.0 1012.2 1726.2 60 to < 72 3 1877.9 400.6 961.8 1625.9 2558.9 2349.6 657.6 1466.7 1349.9 342.9 1061.0 1768.3 72 to < 83 0 Combined 56 Obiliq (all ages 12 to < 24 7 1187.6 258.0 614.6 1065.4 1700.7 1473.2 405.6 992.4 889.7 232.8 780.3 1176.1 24 to < 36 7 1189.5 260.0 615.9 1076.2 1724.1 1476.1 404.5 1008.9 895.1 233.7 787.2 1190.0 36 to < 48 15 1394.0 299.9 715.4 1235.4 1981.2 1748.2 493.9 1133.7 1020.2 261.4 815.7 1359.5 48 to < 60 16 1531.6 324.6 785.2 1338.5 2129.1 1934.2 542.8 1212.6 1106.6 280.4 860.7 1464.2 60 to < 72 10 1643.3 347.6 841.8 1414.6 2249.2 2073.3 594.5 1268.8 1179.6 301.3 912.2 1549.1 72 to < 83 1 2243.9 459.9 1127.5 1917.2 2997.6 2789.8 783.8 1702.2 1582.1 398.3 1189.2 2079.6
Agim Rysha (2013): PhD Thesis 185
Annex 30 Mean values of amino acids consumed by children attending kindergarten 4 (Kamenicë) according to gender and age Sex and Phenyla Threon Tryptop age n Kinder- Arginin Cystine¹ Histidine¹ Isoleucine¹ Leucine¹ Lysine¹ Methion lanine¹ ine¹ hane¹ Tyrosine¹ Valine¹ (months) garten e¹ mg mg mg mg mg mg ine¹ mg mg mg mg mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 21 Kamenice ages) 12 to < 24 3 410.7 124.2 213.6 385.9 612.9 469.4 169.2 366.1 306.0 92.6 248.8 430.2 24 to < 36 1 335.9 92.4 169.7 310.5 489.9 401.8 141.8 284.2 250.1 72.4 188.7 347.6 36 to < 48 3 442.4 132.2 244.6 420.7 682.1 537.5 188.9 395.8 333.9 99.6 270.1 470.2 48 to < 60 3 649.4 190.2 349.8 605.2 971.2 774.5 269.8 566.5 482.7 141.9 391.5 670.0 60 to < 72 6 811.4 240.7 442.8 768.1 1232.3 980.1 342.1 721.7 611.4 185.0 508.8 855.0 72 to < 83 5 1427.7 389.6 744.2 1313.6 2060.4 1737.2 590.8 1203.0 1061.0 316.7 864.0 1458.0 Girls (all Kamenice ages) 13 12 to < 24 3 435.2 132.2 231.0 414.4 682.9 515.0 188.7 398.5 333.2 98.3 269.1 470.5 24 to < 36 2 811.5 268.5 442.0 785.5 1250.2 902.3 335.9 757.1 606.9 181.1 489.7 859.4 36 to < 48 2 373.2 107.0 198.6 354.1 572.5 460.6 161.8 330.3 284.9 83.7 228.2 398.1 48 to < 60 60 to < 72 6 870.7 263.6 478.4 832.5 1346.5 1054.9 371.5 787.8 662.0 198.4 552.9 926.2 72 to < 83 Combined 34 Kamenice (all ages 12 to < 24 6 423.0 128.2 222.3 400.2 647.9 492.2 178.9 382.3 319.6 95.4 258.9 450.4 24 to < 36 3 653.0 209.8 351.2 627.1 996.8 735.5 271.2 599.5 487.9 144.9 389.4 688.8 36 to < 48 5 425.1 125.9 233.1 404.0 654.7 518.3 182.2 379.4 321.7 95.6 259.6 452.1 48 to < 60 3 649.4 190.2 349.8 605.2 971.2 774.5 269.8 566.5 482.7 141.9 391.5 670.0 60 to < 72 12 826.2 246.4 451.7 784.2 1260.9 998.8 349.5 738.2 624.0 188.3 519.8 872.8 72 to < 83 5 1427.7 389.6 744.2 1313.6 2060.4 1737.2 590.8 1203.0 1061.0 316.7 864.0 1458.0
Agim Rysha (2013): PhD Thesis 186
Annex 31 Mean values of amino acids consumed by children attending kindergarten 5 (Prishtine private) according to gender and age Sex and Methi Tryptop age n Kinder- Arginine¹ Cystine¹ Histidine¹ Isoleucine¹ Leucine Lysine¹ onine Phenylala Threoni hane¹ Tyrosine¹ Valine¹ (months) garten mg mg mg mg ¹ mg mg ¹ mg nine¹ mg ne¹ mg mg mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 46 Private ages) Prishtine 12 to < 24 9 1246.1 308.6 613.9 1213.8 2009.1 1513.2 429.6 1212.0 972.1 259.5 891.3 1378.1 24 to < 36 7 1162.8 309.0 560.5 1147.1 1855.4 1368.5 398.7 1142.6 904.4 241.2 818.2 1284.5 36 to < 48 12 1410.6 379.5 668.7 1378.9 2190.9 1613.3 477.7 1364.2 1080.8 292.3 963.9 1539.9 48 to < 60 8 1470.0 401.4 697.2 1450.9 2286.0 1666.0 489.3 1437.2 1125.9 303.0 999.6 1614.3 60 to < 72 4 1585.5 433.5 746.6 1558.6 2448.6 1790.3 531.7 1540.6 1211.2 328.7 1073.4 1736.3 72 to < 83 6 1865.7 472.0 859.5 1780.7 2777.0 2074.3 564.3 1759.5 1380.4 364.8 1220.8 1973.7 Girls (all 41 Private ages) Prishtine 12 to < 24 6 1175.0 293.8 593.6 1159.4 1953.2 1464.9 428.1 1162.6 935.5 253.3 866.1 1330.7 24 to < 36 5 1204.0 319.1 577.3 1185.4 1903.3 1411.8 409.7 1177.6 932.8 249.8 839.6 1325.7 36 to < 48 17 1543.5 409.1 718.7 1489.1 2338.8 1728.9 509.0 1464.5 1164.4 315.2 1031.9 1660.7 48 to < 60 6 1576.4 414.1 734.3 1523.9 2392.7 1784.4 520.2 1497.8 1192.8 322.6 1057.2 1701.2 60 to < 72 4 1459.1 404.7 691.4 1436.9 2268.3 1645.3 496.5 1423.5 1118.0 304.7 992.4 1601.0 72 to < 83 3 1566.0 444.9 732.6 1529.2 2400.0 1702.8 527.5 1518.7 1181.3 325.5 1042.7 1701.5 Combined 87 Private (all ages) Prishtine 12 to < 24 15 1217.7 302.7 605.8 1192.0 1986.7 1493.9 429.0 1192.2 957.5 257.0 881.2 1359.2 24 to < 36 12 1179.9 313.2 567.5 1163.0 1875.4 1386.5 403.3 1157.2 916.2 244.8 827.1 1301.6 36 to < 48 29 1483.9 395.8 696.3 1439.7 2272.5 1677.0 495.0 1419.6 1127.0 305.0 1001.4 1606.5 48 to < 60 14 1515.6 406.9 713.1 1482.2 2331.7 1716.7 502.6 1463.2 1154.5 311.4 1024.3 1651.6 60 to < 72 8 1522.3 419.1 719.0 1497.7 2358.4 1717.8 514.1 1482.1 1164.6 316.7 1032.9 1668.7 72 to < 83 9 1765.8 463.0 817.2 1696.9 2651.3 1950.4 552.0 1679.2 1314.0 351.7 1161.5 1883.0
Agim Rysha (2013): PhD Thesis 187
Annex 32 Mean values of amino acids consumed by children attending public kindergartens according to gender and age Isoleuc Methio Phenyl Tryptop Arginine¹ Cystine¹ Histidine¹ Leucin Lysine¹ Threoni Tyrosine¹ Valine¹ Sex and age n Kinder- ine¹ nine¹ alanin hane¹ mg mg mg e¹ mg mg ne¹ mg mg mg (months) garten mg mg e¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 210 Public 12 to < 24 16 913.9 237.0 473.6 840.5 1390.9 1094.7 346.6 811.0 696.1 195.1 627.7 954.1 24 to < 36 29 981.1 281.3 523.2 911.0 1504.5 1118.8 377.7 887.5 741.5 216.0 660.4 1026.4 36 to < 48 51 1155.9 334.5 620.2 1081.7 1763.8 1335.6 448.1 1041.3 873.4 250.1 747.9 1197.9 48 to < 60 57 1274.9 408.7 686.8 1237.8 2028.1 1424.6 513.0 1214.0 978.0 287.0 835.6 1364.6 60 to < 72 44 1310.4 410.9 711.3 1262.8 2064.5 1483.6 530.5 1226.4 1002.3 294.3 853.0 1392.4 72 to < 83 13 1460.7 494.3 798.3 1491.8 2431.4 1653.5 616.9 1457.5 1143.2 340.3 992.2 1640.3 Girls (all ages) 172 Public 12 to < 24 13 857.7 216.1 447.9 777.9 1272.6 1037.2 324.0 737.9 649.2 179.8 573.1 875.0 24 to < 36 29 1075.8 304.6 577.2 991.9 1610.4 1235.3 402.6 955.5 809.9 232.1 714.4 1099.8 36 to < 48 43 1074.6 310.2 582.8 1014.6 1647.5 1238.0 416.9 971.8 812.7 234.1 692.1 1122.1 48 to < 60 40 1410.9 427.5 756.9 1343.6 2185.1 1600.1 559.8 1296.1 1072.8 311.6 910.9 1477.0 60 to < 72 41 1320.4 431.1 720.6 1305.9 2136.5 1486.5 543.2 1277.7 1025.0 303.7 891.5 1439.6 72 to < 83 6 1520.4 500.3 824.4 1523.9 2466.4 1699.1 635.6 1474.8 1176.3 351.4 1019.0 1670.2 Combined (all 382 Public ages) 12 to < 24 29 888.7 227.6 462.1 812.4 1337.8 1068.9 336.5 778.3 675.0 188.2 603.2 918.7 24 to < 36 58 1028.5 293.0 550.2 951.5 1557.4 1177.1 390.2 921.5 775.7 224.1 687.4 1063.1 36 to < 48 94 1118.7 323.4 603.1 1051.0 1710.6 1291.0 433.8 1009.5 845.6 242.8 722.4 1163.2 48 to < 60 97 1331.0 416.4 715.7 1281.4 2092.8 1497.0 532.3 1247.9 1017.1 297.2 866.7 1411.0 60 to < 72 85 1315.2 420.6 715.8 1283.6 2099.3 1485.0 536.7 1251.1 1013.3 298.8 871.6 1415.2 72 to < 83 19 1479.5 496.2 806.5 1501.9 2442.5 1667.9 622.8 1462.9 1153.6 343.8 1000.6 1649.7
Agim Rysha (2013): PhD Thesis 188
Annex 33 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 1 (Ferizaj) according to gender and age
Minerals and Trace Elements Sterols
Sex and n Kindergarten age Calcium Chloride¹ Magnesium¹ Phosphorus Potassium¹ Sodium¹ Cholesterol¹ (months) mg mg Iodide¹ µg Iron¹ mg mg mg mg mg Zinc¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 102 Ferizaj ages) 12 to < 24 4 198.3 999.4 7.3 3.4 79.6 448.4 1029.4 846.6 4.1 73.2 24 to < 36 15 222.4 954.4 8.3 3.3 91.6 439.0 1068.2 766.0 3.8 68.5 36 to < 48 25 263.9 1189.3 9.9 3.8 100.5 495.6 1112.9 1011.2 4.3 78.7 48 to < 60 28 343.6 1493.2 12.2 4.6 125.5 581.5 1121.2 1323.7 5.1 91.0 60 to < 72 24 315.1 1433.4 11.7 4.2 117.9 534.5 1094.6 1277.9 4.7 83.0 72 to < 83 6 420.0 1528.3 13.8 5.0 147.1 679.6 1221.2 1359.5 5.6 98.2 Girls (all 92 Ferizaj ages) 12 to < 24 3 180.9 942.7 6.7 3.1 71.3 401.7 976.5 806.6 3.8 62.0 24 to < 36 17 206.1 876.1 7.3 3.1 83.0 409.9 996.8 705.6 3.6 61.9 36 to < 48 21 225.0 1084.2 8.7 3.5 94.7 433.2 1016.2 917.9 3.9 67.5 48 to < 60 23 307.7 1543.9 11.6 4.5 118.8 546.7 1110.4 1384.3 5.0 87.8 60 to < 72 25 320.8 1408.6 11.5 4.2 113.7 534.3 1038.7 1270.1 4.7 83.3 72 to < 83 3 370.2 2002.5 14.1 6.2 156.4 703.9 1346.0 1802.8 6.8 120.0 Combined 194 Ferizaj (all ages 12 to < 24 7 190.9 975.1 7.1 3.3 76.0 428.3 1006.7 829.4 4.0 68.4 24 to < 36 32 213.7 912.8 7.8 3.2 87.0 423.6 1030.2 733.9 3.7 65.0 36 to < 48 46 246.2 1141.3 9.4 3.7 97.8 467.1 1068.8 968.6 4.1 73.6 48 to < 60 51 327.4 1516.1 11.9 4.6 122.5 565.8 1116.4 1351.0 5.0 89.6 60 to < 72 49 318.0 1420.7 11.6 4.2 115.8 534.4 1066.1 1273.9 4.7 83.2 72 to < 83 9 403.4 1686.4 13.9 5.4 150.2 687.7 1262.8 1507.2 6.0 105.4
Agim Rysha (2013): PhD Thesis 189
Annex 34 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 2 (Prishtine) according to gender and age
Minerals and Trace Elements Sterols Sex and age n Kindergarten Calcium Chloride¹ Magnesium¹ Phosphorus Potassium¹ Sodium¹ Cholesterol¹ (months) mg mg Iodide¹ µg Iron¹ mg mg mg mg mg Zinc¹ mg mg
Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 64 Prishtine ages) 12 to < 24 6 199.6 777.1 8.7 1.9 64.1 258.3 663.4 660.5 1.4 59.4 24 to < 36 11 153.8 752.0 7.9 1.8 52.1 216.4 522.2 666.3 1.4 53.6 36 to < 48 15 162.1 941.9 9.1 1.9 54.7 214.6 543.5 849.8 1.5 44.5 48 to < 60 17 194.4 1106.5 11.9 2.0 61.1 250.9 596.9 1010.4 1.8 56.7 60 to < 72 10 237.0 1150.9 13.5 2.2 66.4 292.4 646.7 1024.6 2.1 65.1 72 to < 83 5 293.6 1257.4 15.3 2.0 72.5 341.6 738.0 1098.4 2.3 62.3 Girls (all 48 Prishtine ages) 12 to < 24 3 167.3 726.6 7.6 1.7 54.7 220.8 571.5 639.4 1.2 53.4 24 to < 36 5 185.4 901.3 9.6 1.8 51.8 240.5 527.1 847.6 1.5 56.3 36 to < 48 14 178.2 941.1 9.8 1.8 56.6 232.8 572.8 843.4 1.6 50.8 48 to < 60 11 202.2 1097.2 12.1 2.1 66.3 265.0 655.6 980.3 1.9 58.9 60 to < 72 12 262.6 1164.2 14.1 2.2 72.4 312.2 726.8 1014.1 2.1 66.1 72 to < 83 3 267.3 1144.0 12.8 1.9 59.4 300.3 572.5 1023.0 2.1 55.3 Combined 112 Prishtine (all ages) 12 to < 24 9 188.8 760.3 8.3 1.8 61.0 245.8 632.8 653.5 1.4 57.4 24 to < 36 16 163.7 798.6 8.5 1.8 52.0 223.9 523.8 722.9 1.4 54.5 36 to < 48 29 169.9 941.6 9.4 1.8 55.6 223.4 557.6 846.7 1.6 47.5 48 to < 60 28 197.5 1102.8 12.0 2.0 63.1 256.4 620.0 998.6 1.8 57.6 60 to < 72 22 250.9 1158.2 13.8 2.2 69.7 303.2 690.4 1018.9 2.1 65.7 72 to < 83 8 283.7 1214.9 14.3 2.0 67.6 326.1 676.0 1070.1 2.2 59.7
Agim Rysha (2013): PhD Thesis 190
Annex 35 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 3 (Obiliq) according to gender and age
Minerals and Trace Elements Sterols Sex and n Kindergarten age Calcium Chloride¹ Magnesium¹ Phosphorus Potassium¹ Sodium¹ Cholesterol¹ (months) mg mg Iodide¹ µg Iron¹ mg mg mg mg mg Zinc¹ mg mg
Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 31 Obiliq ages) 12 to < 24 3 142.0 1102.3 8.3 3.9 85.5 380.9 1117.5 1013.0 3.1 69.4 24 to < 36 2 148.0 966.2 8.2 3.4 77.5 337.6 966.7 844.5 2.6 64.6 36 to < 48 8 187.4 1073.8 9.3 3.9 98.8 389.0 1183.8 996.5 3.3 48.5 48 to < 60 10 181.5 939.9 8.7 3.4 91.8 363.3 1139.6 936.9 2.9 39.8 60 to < 72 7 188.2 1023.6 9.3 3.5 89.0 384.5 1173.9 1011.4 3.4 52.6 72 to < 83 1 210.1 1516.1 11.3 5.3 122.6 521.7 1562.7 1496.0 4.9 72.3 Girls (all 25 Obiliq ages) 12 to < 24 4 120.8 904.5 7.6 3.0 64.3 310.8 902.8 836.8 2.6 63.9 24 to < 36 5 134.5 1036.3 8.1 3.5 76.9 353.2 1030.8 950.2 3.0 67.3 36 to < 48 7 176.4 928.7 8.7 3.4 87.8 360.3 1081.8 892.2 3.0 46.0 48 to < 60 6 183.6 1219.1 9.4 4.3 98.8 444.9 1290.5 1211.2 4.0 61.4 60 to < 72 3 189.6 1230.9 9.9 4.4 103.3 468.2 1388.1 1310.0 4.2 61.3 72 to < 83 0 Combined 56 Obiliq (all ages 12 to < 24 7 129.9 989.3 7.9 3.4 73.4 340.8 994.8 912.3 2.9 66.2 24 to < 36 7 138.3 1016.3 8.1 3.5 77.1 348.7 1012.5 920.0 2.8 66.5 36 to < 48 15 182.2 1006.1 9.0 3.7 93.7 375.6 1136.2 947.9 3.1 47.3 48 to < 60 16 182.3 1044.6 9.0 3.7 94.4 393.9 1196.2 1039.8 3.3 47.9 60 to < 72 10 188.6 1085.8 9.5 3.7 93.3 409.6 1238.2 1101.0 3.6 55.2 72 to < 83 1 210.1 1516.1 11.3 5.3 122.6 521.7 1562.7 1496.0 4.9 72.3
Agim Rysha (2013): PhD Thesis 191
Annex 36 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 4 (Kamenicë) according to gender and age
Minerals and Trace Elements Sterols Sex and n Kindergarten age Calcium Chloride¹ Magnesium¹ Phosphorus Potassium¹ Sodium¹ Cholesterol¹ (months) mg mg Iodide¹ µg Iron¹ mg mg mg mg mg Zinc¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 13 Kamenice ages) 12 to < 24 3 108.2 513.5 5.3 1.4 25.1 142.6 323.3 435.3 0.9 40.3 24 to < 36 1 100.5 318.5 4.2 1.1 21.5 127.4 278.2 279.2 0.7 35.3 36 to < 48 3 117.6 435.6 5.1 1.3 24.7 144.8 324.2 414.4 0.8 30.1 48 to < 60 2 138.2 717.3 6.9 1.7 33.4 191.0 437.2 690.0 1.3 44.0 60 to < 72 3 153.2 842.0 8.8 2.1 40.8 219.8 566.6 809.6 1.6 55.7 72 to < 83 1 203.0 1552.5 14.4 3.6 70.2 343.9 1005.5 1448.1 3.0 105.5 Girls (all Kamenice 7 ages) 12 to < 24 3 127.9 986.4 5.9 1.5 26.0 163.5 309.6 620.8 0.8 51.1 24 to < 36 2 160.0 1097.1 9.5 2.1 43.8 230.3 505.8 994.7 1.6 48.9 36 to < 48 1 113.5 364.6 4.7 1.2 23.1 136.8 302.4 331.6 0.8 32.3 48 to < 60 60 to < 72 1 175.5 929.9 9.6 2.3 45.0 240.8 589.5 898.6 1.7 56.1 72 to < 83 Combined 20 Kamenice (all ages 12 to < 24 6 118.1 750.0 5.6 1.5 25.5 153.1 316.5 528.0 0.8 45.7 24 to < 36 3 140.2 837.6 7.7 1.8 36.3 196.0 430.0 756.2 1.3 44.4 36 to < 48 4 116.6 417.8 5.0 1.3 24.3 142.8 318.8 393.7 0.8 30.7 48 to < 60 2 138.2 717.3 6.9 1.7 33.4 191.0 437.2 690.0 1.3 44.0 60 to < 72 4 158.8 864.0 9.0 2.1 41.9 225.0 572.3 831.9 1.6 55.8 72 to < 83 1 203.0 1552.5 14.4 3.6 70.2 343.9 1005.5 1448.1 3.0 105.5
Agim Rysha (2013): PhD Thesis 192
Annex 37 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten (Prishtine private) according to gender and age
Minerals and Trace Elements Sterols Sex and age n Kindergarten Calcium Chloride¹ Magnesium¹ Phosphorus Potassium¹ Sodium¹ Cholesterol¹ (months) mg mg Iodide¹ µg Iron¹ mg mg mg mg mg Zinc¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 46 Private ages) Prishtine 12 to < 24 9 300.4 1047.5 13.2 4.7 118.4 456.8 1264.7 1002.7 3.0 58.1 24 to < 36 7 267.6 1037.6 12.6 4.5 104.3 417.1 1094.5 1041.7 2.8 60.6 36 to < 48 12 260.0 1289.1 15.8 5.6 126.5 457.3 1362.6 1288.2 3.5 84.0 48 to < 60 8 265.6 1299.1 16.0 5.8 131.0 481.6 1381.8 1299.8 3.5 105.9 60 to < 72 4 280.6 1377.6 17.4 6.1 138.9 513.1 1467.0 1372.1 3.8 122.1 72 to < 83 6 294.1 1531.9 17.9 7.4 167.4 606.9 1777.9 1540.9 4.3 126.9
Girls (all 41 Private ages) Prishtine 12 to < 24 6 319.9 934.6 13.1 4.2 114.0 455.7 1237.5 857.8 2.8 66.0 24 to < 36 5 262.2 1059.1 13.0 4.7 108.4 420.4 1151.7 1057.7 2.9 65.2 36 to < 48 17 260.1 1409.8 16.7 6.2 135.5 486.8 1445.4 1414.9 3.8 103.7 48 to < 60 6 270.0 1395.4 17.1 6.3 139.7 503.1 1514.9 1386.9 3.9 110.4 60 to < 72 4 264.3 1313.7 16.6 5.7 128.8 471.0 1369.5 1314.9 3.6 101.1 72 to < 83 3 275.5 1387.2 18.3 6.0 136.5 513.9 1466.0 1401.1 3.8 124.4
Combined 87 Private all ages Prishtine 12 to < 24 15 308.2 1002.4 13.2 4.5 116.6 456.4 1253.8 944.7 2.9 61.3 24 to < 36 12 265.3 1046.6 12.8 4.6 106.0 418.5 1118.3 1048.4 2.9 62.5 36 to < 48 29 260.1 1355.7 16.3 5.9 131.5 473.6 1408.3 1358.1 3.7 94.9 48 to < 60 14 267.5 1340.3 16.5 6.0 134.7 490.8 1438.8 1337.1 3.7 107.8 60 to < 72 8 272.5 1345.6 17.0 5.9 133.9 492.1 1418.3 1343.5 3.7 111.6 72 to < 83 9 287.9 1483.7 18.1 7.0 157.1 575.9 1674.0 1494.3 4.1 126.0
Agim Rysha (2013): PhD Thesis 193
Annex 38 Mean values of minerals, trace elements and sterols consumed by children attending public kindergarten according to gender and age
Minerals and Trace Elements Sterols
Sex and age n Kindergarten Calcium Chloride¹ Magnesium¹ Phosphorus Potassium¹ Sodium¹ Cholesterol¹ (months) mg mg Iodide¹ µg Iron¹ mg mg mg mg mg Zinc¹ mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 210 Public ages) 12 to < 24 16 171.3 844.2 7.6 2.6 64.7 307.1 776.3 730.9 2.3 61.1 24 to < 36 29 187.0 856.5 8.0 2.7 73.2 336.8 826.8 716.8 2.7 61.4 36 to < 48 51 213.4 1054.1 9.3 3.1 82.3 375.6 910.2 926.4 3.1 61.1 48 to < 60 57 263.5 1253.6 11.4 3.5 97.1 430.9 944.1 1140.2 3.6 70.1 60 to < 72 44 266.1 1263.7 11.5 3.5 96.3 434.1 969.4 1146.0 3.7 72.3 72 to < 83 13 338.5 1425.0 14.2 3.8 110.6 511.6 1045.1 1276.4 4.1 82.9
Girls (all Public 172 ages) 12 to < 24 13 147.0 891.2 7.0 2.4 54.9 277.0 706.5 734.4 2.2 58.1 24 to < 36 29 187.0 923.3 8.0 2.9 73.9 358.6 887.8 792.2 3.0 61.0 36 to < 48 43 199.3 995.6 9.0 2.9 79.5 349.2 865.9 875.8 2.9 57.7 48 to < 60 40 260.1 1372.3 11.4 3.8 101.3 454.0 1012.4 1247.2 4.0 75.9 60 to < 72 41 290.6 1312.4 12.1 3.6 99.2 457.3 962.0 1189.0 3.8 76.0 72 to < 83 6 318.7 1573.2 13.4 4.1 107.9 502.1 959.3 1412.9 4.5 87.6
Combined 382 Public (all ages) 12 to < 24 29 160.4 865.3 7.3 2.5 60.3 293.6 745.0 732.5 2.2 59.8 24 to < 36 58 187.0 889.9 8.0 2.8 73.5 347.7 857.3 754.5 2.8 61.2 36 to < 48 94 206.9 1027.3 9.2 3.0 81.0 363.5 889.9 903.2 3.0 59.5 48 to < 60 97 262.1 1302.6 11.4 3.6 98.9 440.4 972.2 1184.3 3.8 72.5 60 to < 72 85 277.9 1287.2 11.8 3.5 97.7 445.3 965.9 1166.8 3.7 74.1 72 to < 83 19 332.3 1471.8 14.0 3.9 109.8 508.6 1018.0 1319.5 4.2 84.4
Agim Rysha (2013): PhD Thesis 194
Annex 39: Mean values of vitamins consumed by children attending kindergarten 1 (Ferizaj) according to gender and age
Vitamins
Kinde Panto Vita n rgart Folic thenic Vitamin A Vitami Vitami min Vitamin Vitami Sex and age en Biotin¹ acid¹ Niacinequi acid¹ Retinolequ Retinol¹ Vitamin Vitamin Vitamin n B6¹ n C¹ D¹ E activ.¹ n K¹ (months) µg µg valent¹ µg mg ivalent¹ µg mg B1¹ mg B12¹ µg B2¹ mg mg mg µg mg µg Me Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean an Boys (all 102 Feriz ages) aj 12 to < 24 4 9.2 43.1 9916.0 1.3 73.4 0.0 0.3 1.3 0.3 0.6 13.7 0.2 4.5 7.6 24 to < 36 15 12.1 49.1 9024.0 1.4 82.9 0.1 0.3 1.1 0.3 0.7 18.2 0.2 4.7 8.8 36 to < 48 25 13.0 57.0 9842.5 1.6 110.8 0.1 0.3 1.2 0.4 0.7 19.1 0.3 5.5 11.0 48 to < 60 28 15.5 74.4 10776.5 1.9 144.1 0.1 0.4 1.3 0.4 0.8 21.3 0.4 7.5 13.7 60 to < 72 24 14.8 68.8 10013.2 1.8 129.0 0.1 0.4 1.2 0.4 0.8 20.8 0.4 6.8 12.1 72 to < 83 6 17.3 87.7 10759.5 2.1 151.2 0.1 0.5 1.2 0.5 0.8 21.0 0.5 8.8 14.8 Girls (all 92 Feriz ages) aj 12 to < 24 3 9.0 38.2 9268.3 1.2 50.9 0.0 0.3 1.2 0.3 0.6 14.3 0.1 3.9 6.2 24 to < 36 17 10.4 44.5 8446.4 1.2 66.9 0.0 0.3 1.0 0.3 0.7 15.9 0.2 4.1 6.8 36 to < 48 21 12.3 53.2 9145.2 1.4 88.1 0.0 0.3 1.0 0.3 0.7 19.4 0.2 5.1 9.6 48 to < 60 23 14.6 70.7 11173.5 1.9 135.0 0.1 0.4 1.3 0.4 0.8 21.8 0.3 7.3 12.8 60 to < 72 25 14.1 66.8 9792.4 1.8 129.4 0.1 0.4 1.2 0.4 0.7 18.9 0.4 6.7 12.0 72 to < 83 3 17.5 90.0 15481.7 2.4 162.0 0.1 0.6 1.7 0.5 1.1 24.6 0.5 10.0 14.7 Combined (all 194 Feriz ages aj 12 to < 24 7 9.1 41.0 9638.4 1.3 63.7 0.0 0.3 1.2 0.3 0.6 14.0 0.2 4.2 7.0 24 to < 36 32 11.2 46.7 8717.2 1.3 74.4 0.0 0.3 1.0 0.3 0.7 17.0 0.2 4.4 7.8 36 to < 48 46 12.7 55.3 9524.2 1.5 100.4 0.1 0.3 1.1 0.4 0.7 19.2 0.3 5.3 10.3 48 to < 60 51 15.1 72.7 10955.5 1.9 140.0 0.1 0.4 1.3 0.4 0.8 21.6 0.4 7.4 13.3 60 to < 72 49 14.4 67.8 9900.5 1.8 129.2 0.1 0.4 1.2 0.4 0.7 19.8 0.4 6.8 12.0 72 to < 83 9 17.4 88.4 12333.6 2.2 154.8 0.1 0.5 1.4 0.5 0.9 22.2 0.5 9.2 14.8
Agim Rysha (2013): PhD Thesis 195
Annex 40 Mean values of vitamins consumed by children attending kindergarten 2 (Prishtine) according to gender and age Vitamins Sex and age n Kinder Biotin¹ Folic Niacinequ Pantothen Retinoleq Vitamin A Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin (months) garten µg acid¹ µg ivalent¹ µg ic acid¹ uivalent¹ Retinol¹ B1¹ mg B12¹ µg B2¹ mg B6¹ mg C¹ mg D¹ µg E activ.¹ K¹ µg mg µg mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 64 Prishti ne 12 to < 24 6 12.8 47.4 2654.0 1.0 258.3 0.1 0.2 0.7 0.3 0.4 15.4 0.5 2.9 15.6 24 to < 36 11 10.1 42.3 2854.5 0.9 208.1 0.1 0.2 0.6 0.3 0.3 13.0 0.4 3.1 14.3 36 to < 48 15 9.8 45.2 2648.9 1.0 167.0 0.1 0.2 0.5 0.2 0.4 16.1 0.3 2.4 16.1 48 to < 60 17 11.6 52.3 2799.1 1.3 165.7 0.1 0.2 0.6 0.3 0.4 19.3 0.4 3.0 19.5 60 to < 72 10 12.9 55.7 3277.3 1.4 153.1 0.1 0.2 0.8 0.4 0.4 18.9 0.4 3.6 18.3 72 to < 83 5 14.7 61.4 3921.0 1.6 157.8 0.1 0.2 0.9 0.4 0.4 19.2 0.4 3.8 18.1 Girls (all ages) 48 Prishti ne 12 to < 24 3 11.0 43.8 2210.6 0.9 242.6 0.1 0.2 0.6 0.3 0.3 16.6 0.4 2.5 18.7 24 to < 36 5 10.8 48.4 3074.2 1.0 233.2 0.1 0.2 0.6 0.3 0.3 14.1 0.4 3.5 18.3 36 to < 48 14 10.6 47.7 2776.9 1.0 170.1 0.1 0.2 0.6 0.3 0.4 16.3 0.3 2.6 15.6 48 to < 60 11 12.4 54.7 3131.1 1.3 170.0 0.1 0.2 0.6 0.3 0.4 17.9 0.4 3.3 16.0 60 to < 72 12 14.3 59.5 3460.4 1.5 163.3 0.1 0.2 0.8 0.4 0.4 20.7 0.4 3.9 18.8 72 to < 83 3 11.5 50.7 3141.1 1.3 152.3 0.1 0.2 0.8 0.4 0.3 16.0 0.3 3.6 18.3 Combined (all 112 Prishti ages) ne 12 to < 24 9 12.2 46.2 2506.2 1.0 253.0 0.1 0.2 0.7 0.3 0.4 15.8 0.5 2.8 16.6 24 to < 36 16 10.3 44.2 2923.2 0.9 215.9 0.1 0.2 0.6 0.3 0.3 13.3 0.4 3.2 15.6 36 to < 48 29 10.2 46.4 2710.7 1.0 168.5 0.1 0.2 0.5 0.3 0.4 16.2 0.3 2.5 15.8 48 to < 60 28 11.9 53.2 2929.6 1.3 167.4 0.1 0.2 0.6 0.3 0.4 18.8 0.4 3.1 18.2 60 to < 72 22 13.7 57.8 3377.2 1.4 158.7 0.1 0.2 0.8 0.4 0.4 19.8 0.4 3.7 18.6 72 to < 83 8 13.5 57.4 3628.5 1.5 155.8 0.1 0.2 0.9 0.4 0.4 18.0 0.4 3.7 18.2
Agim Rysha (2013): PhD Thesis 196
Annex 41 Mean values of vitamins consumed by children attending kindergarten 3 (Obiliq) according to gender and age
Vitamins
Sex and age n Kindergarte Biotin¹ Folic acid¹ µg Niacinequi Pantothe Retinolequiva Vitamin Vitamin Vitamin Vitamin Vitami Vitamin Vitamin Vitamin Vitamin (months) n µg valent¹ µg nic acid¹ lent¹ µg A B1¹ mg B12¹ µg B2¹ mg n B6¹ C¹ mg D¹ µg E activ.¹ K¹ µg mg Retinol¹ mg mg mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 31 Obiliq 12 to < 24 3 13.8 61.4 7903.5 1.3 146.6 0.1 0.3 1.1 0.3 0.6 15.2 0.3 5.4 10.0 24 to < 36 2 13.6 55.6 6182.8 1.2 147.0 0.1 0.3 0.9 0.3 0.5 14.6 0.3 4.5 9.9 36 to < 48 8 15.9 83.7 7860.0 1.7 128.8 0.0 0.4 1.0 0.4 0.7 45.2 0.1 4.7 11.8 48 to < 60 10 15.0 79.9 6772.5 1.6 95.3 0.0 0.4 0.8 0.3 0.6 47.2 0.1 4.5 11.4 60 to < 72 7 15.1 74.3 8332.3 1.7 103.7 0.0 0.4 1.1 0.4 0.7 52.1 0.1 4.7 11.3 72 to < 83 1 17.8 107.2 12339.4 2.3 154.0 0.0 0.5 1.4 0.5 0.9 60.4 0.1 6.6 13.2 Girls (all ages) 25 Obiliq 12 to < 24 4 11.9 43.2 6754.7 1.1 127.6 0.1 0.3 1.0 0.3 0.5 14.0 0.2 4.4 9.6 24 to < 36 5 13.0 53.7 7456.4 1.3 138.6 0.1 0.3 1.1 0.3 0.6 14.7 0.3 5.0 9.8 36 to < 48 7 14.7 72.2 7063.1 1.5 113.8 0.0 0.3 0.9 0.3 0.6 35.6 0.1 4.4 11.1 48 to < 60 6 15.3 80.2 10066.4 1.8 123.7 0.0 0.4 1.3 0.4 0.8 33.8 0.1 5.6 11.7 60 to < 72 3 15.2 86.7 10146.0 1.9 114.0 0.0 0.4 1.3 0.4 0.8 39.3 0.1 6.2 11.5 72 to < 83 0 Combined (all 56 Obiliq ages 12 to < 24 7 12.7 51.0 7247.0 1.2 135.8 0.1 0.3 1.1 0.3 0.5 14.5 0.3 4.9 9.8 24 to < 36 7 13.2 54.3 7092.5 1.2 141.0 0.1 0.3 1.0 0.3 0.5 14.7 0.3 4.8 9.8 36 to < 48 15 15.4 78.3 7488.1 1.6 121.8 0.0 0.4 0.9 0.4 0.6 40.7 0.1 4.6 11.5 48 to < 60 16 15.1 80.0 8007.7 1.7 106.0 0.0 0.4 1.0 0.4 0.7 42.2 0.1 4.9 11.6 60 to < 72 10 15.1 78.0 8876.4 1.8 106.8 0.0 0.4 1.2 0.4 0.7 48.3 0.1 5.1 11.4 72 to < 83 1 17.8 107.2 12339.4 2.3 154.0 0.0 0.5 1.4 0.5 0.9 60.4 0.1 6.6 13.2
Agim Rysha (2013): PhD Thesis 197
Annex 42 Mean values of vitamins consumed by children attending kindergarten 4 (Kamenicë) according to gender and age
Vitamins
Sex and age n Kindergar Biotin¹ Folic Niacinequ Pantothen Retinoleq Vit. A Vit. B1¹ Vitamin Vit. Vit. Vit. Vitamin Vitamin Vit. K¹ µg (months) ten µg acid¹ µg ivalent¹ µg ic acid¹ uivalent¹ Retinol¹ mg B12¹ µg B2¹ mg B6¹ mg C¹ mg D¹ µg E activ.¹ mg µg mg mg
Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 13 Kamenice 12 to < 24 3 6.1 16.7 2341.7 0.5 77.8 0.1 0.1 0.3 0.1 0.1 11.7 0.2 1.4 7.2 24 to < 36 1 5.9 13.3 2073.1 0.5 54.6 0.0 0.1 0.3 0.1 0.1 10.4 0.2 0.9 6.5 36 to < 48 3 6.0 16.4 2265.1 0.5 61.5 0.0 0.1 0.3 0.1 0.1 11.0 0.2 1.4 6.6 48 to < 60 2 7.3 23.8 3463.1 0.7 112.2 0.1 0.1 0.5 0.2 0.2 15.0 0.2 2.5 7.9 60 to < 72 3 8.0 30.2 4245.0 0.9 103.4 0.1 0.2 0.6 0.2 0.3 18.2 0.3 2.4 8.1 72 to < 83 1 11.7 53.4 8333.7 1.7 150.5 0.1 0.3 1.2 0.3 0.5 33.1 0.6 3.5 11.0 Girls (all ages) 7 Kamenice 12 to < 24 3 6.7 15.1 2309.5 0.5 103.5 0.1 0.1 0.3 0.1 0.1 9.9 0.3 1.3 8.4 24 to < 36 2 8.4 32.4 3738.2 1.0 112.8 0.1 0.2 0.5 0.2 0.2 15.2 0.3 2.7 9.0 36 to < 48 1 6.0 14.7 2094.1 0.5 57.4 0.0 0.1 0.3 0.1 0.1 10.9 0.2 1.1 6.5 48 to < 60 60 to < 72 1 8.7 32.7 4360.1 1.0 118.7 0.1 0.2 0.7 0.2 0.3 18.4 0.3 2.8 8.5 72 to < 83 Combined (all 20 Kamenice ages 12 to < 24 6 6.4 15.9 2325.6 0.5 90.7 0.1 0.1 0.3 0.1 0.1 10.8 0.3 1.4 7.8 24 to < 36 3 7.6 26.1 3183.1 0.8 93.4 0.1 0.1 0.4 0.1 0.2 13.6 0.2 2.1 8.2 36 to < 48 4 6.0 16.0 2222.4 0.5 60.4 0.0 0.1 0.3 0.1 0.1 11.0 0.2 1.4 6.5 48 to < 60 2 7.3 23.8 3463.1 0.7 112.2 0.1 0.1 0.5 0.2 0.2 15.0 0.2 2.5 7.9 60 to < 72 4 8.2 30.9 4273.8 0.9 107.2 0.1 0.2 0.6 0.2 0.3 18.3 0.3 2.5 8.2 72 to < 83 1 11.7 53.4 8333.7 1.7 150.5 0.1 0.3 1.2 0.3 0.5 33.1 0.6 3.5 11.0
Agim Rysha (2013): PhD Thesis 198
Annex 43 Mean values of vitamins consumed by children attending kindergarten 5 (Prishtine Private) according to gender and age Vitamins Sex and age n Kinderga Biotin¹ Folic acid¹ µg Niacinequival Pantothe Retinoleq Vitamin A Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Vitami Vitamin (months) rten µg ent¹ µg nic acid¹ uivalent¹ Retinol¹ B1¹ mg B12¹ µg B2¹ mg B6¹ mg C¹ mg D¹ µg n E K¹ µg mg µg mg activ.¹ mg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all ages) 46 Private Prishtine 12 to < 24 9 19.3 107.2 6011.7 1.9 361.8 0.1 0.5 0.8 0.4 0.6 33.6 0.3 14.9 53.5 24 to < 36 7 18.1 101.2 5571.5 1.8 340.4 0.1 0.4 0.7 0.4 0.5 31.0 0.4 14.4 56.2 36 to < 48 12 23.5 127.0 7376.7 2.2 406.9 0.1 0.5 0.9 0.4 0.6 46.2 0.5 18.3 76.7 48 to < 60 8 24.9 131.6 7192.0 2.3 382.3 0.1 0.5 0.9 0.4 0.6 41.9 0.7 17.0 65.0 60 to < 72 4 25.0 139.5 7830.8 2.4 417.6 0.1 0.5 1.0 0.4 0.6 42.8 0.8 18.5 66.4 72 to < 83 6 28.9 166.8 8907.2 2.6 483.5 0.1 0.6 1.0 0.5 0.7 51.1 0.8 22.0 80.7 Girls (all ages) 41 Private Prishtine 12 to < 24 6 19.2 97.6 5440.7 1.8 329.0 0.1 0.4 0.8 0.4 0.6 30.9 0.4 12.6 38.9 24 to < 36 5 18.6 105.5 5902.7 1.8 341.4 0.1 0.4 0.8 0.4 0.5 33.3 0.4 15.0 55.3 36 to < 48 17 24.9 140.0 8257.9 2.3 468.1 0.1 0.6 1.0 0.4 0.7 48.8 0.6 20.8 88.2 48 to < 60 6 26.0 142.7 8382.7 2.4 459.3 0.1 0.6 1.0 0.4 0.7 50.9 0.7 20.7 83.3 60 to < 72 4 23.7 129.2 7378.5 2.3 396.8 0.1 0.5 0.9 0.4 0.6 43.5 0.6 17.7 69.5 72 to < 83 3 26.5 136.5 7613.3 2.4 419.2 0.1 0.5 1.0 0.4 0.6 49.8 0.8 18.4 77.7 Combined (all 87 Private ages) Prishtine 12 to < 24 15 19.3 103.3 5783.3 1.9 348.7 0.1 0.4 0.8 0.4 0.6 32.5 0.4 14.0 47.7 24 to < 36 12 18.3 103.0 5709.5 1.8 340.8 0.1 0.4 0.7 0.4 0.5 32.0 0.4 14.6 55.8 36 to < 48 29 24.2 134.2 7862.9 2.3 440.7 0.1 0.5 0.9 0.4 0.6 47.6 0.6 19.7 83.1 48 to < 60 14 25.4 136.3 7702.3 2.3 415.3 0.1 0.5 1.0 0.4 0.6 45.7 0.7 18.6 72.9 60 to < 72 8 24.3 134.4 7604.7 2.4 407.2 0.1 0.5 1.0 0.4 0.6 43.2 0.7 18.1 68.0 72 to < 83 9 28.1 156.7 8475.9 2.5 462.1 0.1 0.6 1.0 0.4 0.7 50.7 0.8 20.8 79.7
Agim Rysha (2013): PhD Thesis 199
Annex 44 Mean values of vitamins consumed by children attending public kindergartens according to gender and age
Vitamins Sex and Kinde Vit. A Vit. Vit. Vit. Vit. E age n rgarte Biotin¹ Folic acid¹ Niacinequi Pantothenic Retinolequiv Retinol¹ Vit. B1¹ B12¹ B2¹ B6¹ Vit. C¹ Vit. D¹ activ.¹ Vit. K¹ (months) n µg µg valent¹ µg acid¹ mg alent¹ µg mg mg µg mg mg mg µg mg µg Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Mean Boys (all 210 Public ages) 12 to < 24 16 10.8 43.2 5395.2 1.1 157.3 0.1 0.2 0.8 0.3 0.4 14.3 0.3 3.5 11.0 24 to < 36 29 11.2 45.8 6248.2 1.1 133.9 0.1 0.2 0.8 0.3 0.5 15.7 0.3 3.9 10.9 36 to < 48 51 12.1 55.4 6970.0 1.4 127.3 0.1 0.3 0.9 0.3 0.6 21.8 0.3 4.2 12.4 48 to < 60 57 14.0 67.0 7438.2 1.6 140.9 0.1 0.3 1.0 0.4 0.6 25.0 0.3 5.5 14.9 60 to < 72 44 13.9 64.1 7821.6 1.6 128.7 0.1 0.3 1.0 0.4 0.6 25.2 0.3 5.4 13.1 72 to < 83 13 15.9 76.4 8064.2 1.9 153.9 0.1 0.4 1.1 0.5 0.6 24.3 0.4 6.3 15.6 Girls (all Public 172 ages) 12 to < 24 13 9.8 35.7 5260.3 1.0 130.9 0.1 0.2 0.8 0.2 0.4 13.7 0.3 3.1 10.7 24 to < 36 29 10.8 45.9 7024.8 1.2 111.1 0.1 0.3 0.9 0.3 0.5 15.4 0.2 4.1 9.5 36 to < 48 43 12.0 53.6 6568.9 1.3 118.3 0.0 0.3 0.8 0.3 0.6 20.8 0.2 4.1 11.7 48 to < 60 40 14.1 67.7 8795.8 1.7 142.9 0.1 0.4 1.1 0.4 0.7 22.5 0.3 5.9 13.5 60 to < 72 41 14.1 65.3 7832.5 1.7 137.9 0.1 0.3 1.1 0.4 0.6 20.9 0.4 5.8 13.9 72 to < 83 6 14.5 70.3 9311.4 1.9 157.2 0.1 0.4 1.3 0.4 0.7 20.3 0.4 6.8 16.5 Combined 382 Public (all ages) 12 to < 24 29 10.4 39.8 5334.7 1.0 145.4 0.1 0.2 0.8 0.3 0.4 14.0 0.3 3.3 10.8 24 to < 36 58 11.0 45.8 6636.5 1.2 122.5 0.1 0.3 0.9 0.3 0.5 15.5 0.3 4.0 10.2 36 to < 48 94 12.0 54.6 6786.5 1.3 123.1 0.1 0.3 0.9 0.3 0.6 21.4 0.3 4.2 12.1 48 to < 60 97 14.0 67.3 7998.0 1.7 141.7 0.1 0.3 1.0 0.4 0.6 24.0 0.3 5.7 14.3 60 to < 72 85 14.0 64.7 7826.8 1.7 133.1 0.1 0.3 1.0 0.4 0.6 23.1 0.3 5.6 13.5 72 to < 83 19 15.5 74.5 8458.1 1.9 155.0 0.1 0.4 1.2 0.4 0.6 23.0 0.4 6.4 15.9
Agim Rysha (2013): PhD Thesis 200