Nutrition in Kindergartens of Kosovo

Transcrição

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:
2
nd
Supervisor:
Prof. Dr. Angelika Ploeger
Prof. Dr. Tahire Maloku Gjergji
Examiner:
Prof. Dr. Freytag-Leyer
Examiner:
Prof. Dr. Christoph Klotter
i
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
ii
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. FreytagLeyer 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.
iii
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
v
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
vi
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)
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)
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
served in Kindergarten 2 (Prishtine) according to gender and age ...................................178
served in Kindergarten 3 (Obiliq) according to gender and age ........................................179
served in Kindergarten 4 (Kamenicë) according to gender and age .................................180
served in Kindergarten 5 (Prishtine private) according to gender and age........................181
served in Public Kindergartens according to gender and age ...........................................182
Annex 27 Mean values of amino acids consumed by children attending kindergarten 1 (Ferizaj)
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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)
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
Annex 33 Mean values of minerals, trace elements and sterols consumed by children attending
kindergarten 1 (Ferizaj) according to gender and age ......................................................189
kindergarten 2 (Prishtine) according to gender and age ...................................................190
kindergarten 3 (Obiliq) according to gender and age ........................................................191
kindergarten 4 (Kamenicë) according to gender and age .................................................192
kindergarten (Prishtine private) according to gender and age ..........................................193
public kindergarten according to gender and age .............................................................194
Annex 39: Mean values of vitamins consumed by children attending kindergarten 1 (Ferizaj)
Annex 40 Mean values of vitamins consumed by children attending kindergarten 2 (Prishtine)
Annex 41 Mean values of vitamins consumed by children attending kindergarten 3 (Obiliq)
Annex 42 Mean values of vitamins consumed by children attending kindergarten 4 (Kamenicë)
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
viii
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
ix
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
x
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
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
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
3.4
Dietary Intake .................................................................................................................... 40
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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4
3.5.3
Data Processing of Frequency Food Intake of Specific Food Groups ..................... 47
3.5.4
Statistical Analyses .......................................................................................................... 47
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
4.3.1
Main Ingredients, Special Carbohydrates and Fatty Acids ........................................ 71
4.3.2
Results and Discussions for Micronutrients ................................................................. 81
4.4
5
Results and Discussions of Food and Nutrient Intake........................................................ 70
Results and Discussions of Dietary Habits and Food Frequency Intake......................... 93
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
xii
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
1
Figure 1: Structure of thesis
Background
Introduction
Statement of the Problem
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
Research Methods
Data Collection
Data Analyses
Anthropometrics
Results and Discussion
Conclusions and
Recommendations
Dietary Habits and Food Frequency
Intake
Conclusions
Recommendations
Further Needed Studies
Limitations of the Studies
Source: Own sources (2013)
2
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.
th
Kosovo has declared independence in February 17 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
1
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.
4
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
5
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.
6
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
7
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.
8
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.
9
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,
morbidity, disability productivity
Long-term consequences: Adult
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 weightfor-age, and efforts to reduce malnutrition should be a policy priority. Dossou et al., (2003) have
10
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
11
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 lowerincome 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.
12
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
13
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
14
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
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 wellbalanced 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).
15
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
Plant and animal
Amino acids (n = 20):
source proteins
aliphatic, aromatic, sulfur-containing, acidic,
Proteins (macronutrients)
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)
Vitamins (micronutrients)
Minerals and
Calcium, sodium, phosphate, potassium,
electrolytes, trace
iron, zinc, selenium, copper, manganese,
elements
molybdenum, fluoride, chromium
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.
16
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
17
(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
18
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. bcarotene, 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
19
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 energyadjusted 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
20
macronutrients and the majority of micronutrients. However, low intakes of fibre and n-3 longchain 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
Biomarkers 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.
3
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).
22
Table 2: Advantages and limitations of the Nutritional Anthropometry
Advantages
Disadvantages
Methods are precise and accurate, provided
standardized techniques are used
Procedures use simple, safe and non-invasive
techniques
The relative insensitivity to detect changes
in nutritional status following inadequacy of
food over short periods of time
The inability to distinguish the effect of
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
and durable, and can be made or purchased
locally
The inability to pinpoint the principal
causality of undernutrition, as the poor
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
measurement procedures
The relative higher costs and organization
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
23
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).
24
Table 3: WHO and CDC available charts
Weight for age
Length/ height/
stature for age
Weight for length/
height /stature
BMI for age
WHO (percentiles and Z
scores)
0-6 months
0-2 years
6 months – 2 years
2 – 5 years
0-5 years
5-10 years
0-6 months
0-2 years
6 months – 2 years
2 – 5 years
0-5 years
5-19 years
0-2 years
2-5 years
CDC (percentiles only)
0-3 years
2-20 years
0-3 years
2-20 years
0-3 years(45-103 cm)
2-5 years (77-121 cm)
2-20 years
2-20 years
0-2 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.
25
Table 4: Available Computer software for WHO growth references and CDC growth charts
WHO (WHO 2009)
Software
Description
WHO
Incorporates growth
AnthroPlus 2009 standards. Includes
Anthropometric
calculator (AC)
Individual
assessment (IA)
Nutritional survey
(NS),
Macros
SAS, S-Plus, SPSS
and STATA
WHO Anthro
Mobile
Devices
CDC (CDC 2000)
Software
Description
Epi Info™
Includes NutStat which
calculates percentiles and
zscores using either the 2000
CDC or the 1978 CDC/WHO
growth reference
SAS program
Generates a dataset that
contains indices of the
anthropometric status of
children from birth to 20
years of age based on the
2000 CDC growth charts
Program for Palm OS or
Windows Mobile Pocket
PC19
Software for use on
STAT
mobile devices
Growth BP
running
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
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 respondentbased 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
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 20072012 (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.
28
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).
29
Figure 5: Nutrition Circle
Source: Peter Stehle, 2007, p.22
30
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.
31
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 (StOnge 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
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
33
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
34
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 2
Kindergarten 1
Ferizaj
Kindergarten 2
Prishtine
Kindergarten 3
Obiliq
Kindergarten 4
Kamenice
Kindergarten 4
Kindergarten 5
Prishtine-Priv.
Kindergarten 1
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
35
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.
36
Table 5: Sample size, research locations and gender aspects of the samples
Sex and age
(12-83 months)
Location of
Kindergartens
n
Anthropometry
Dietary intake
n
n
measuring in measuring at home
kindergarten
Boys
Ferizaj
Prishtine 1
Obiliq
Kamenicë
Prishtine 2
102
64
31
21
46
264
All Boy samples
Girls
Ferizaj
Prishtine 1
Obiliq
Kamenicë
Prishtine 2
All Girls samples
All Boys and Girls samples
3.2.2
92
48
25
16
41
222
486
Source: Own data (2013)
102
64
31
21
46
264
62
29
16
8
25
140
92
48
25
16
41
222
486
44
16
13
5
14
92
232
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).
37
Figure 10 Meeting with parents and teachers
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.
38
Figure 11: Creation of a good environment for participation of the children in the study
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
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
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
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
41
Figure 14: Wasted foods and Leftovers
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
42
Figure 15: The Seca 856
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
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).
44
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).
45
Figure 18: Measurement of wasted foods
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
46
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 Chisquare statistics. The difference is significant if P<0.05.
47
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.
48
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
Age groups
(months)
Female
N
Male
%
Total
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.
49
Figure 19: Structure of study subjects by sex
X2=3.63
P =0.057
Female
222
45.7%
Male
264
54.3%
Table 7: Means and standard deviations for weight across sex and age groups
Weight (kg)
Age
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
Female
Male
Total
P-value
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).
50
Table 8: Means and standard for weight across sex and age groups deviations
Height (cm)
Age
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
Female
Male
P-value
Total
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
Weight in kg
20
15
girls
10
boys
5
0
12-23 m 24-35 m 36-47 m 48-59 m 60-71 m 72-83 m
Age in months
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).
51
Figure 21: Average Height for boys and girls
25
Weight in kg
20
15
girls
10
boys
5
0
12-23 m 24-35 m 36-47 m 48-59 m 60-71 m 72-83 m
Age in months
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), weightfor-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 weightfor-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.
52
Table 9: Mean and standard deviations of WAZ scores by age and sex
Weight for age (z-scores)
Age
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
Female
Male
Total
P-value
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
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.
53
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
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
Female
Male
Total
P-value
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
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.
54
Table 11: Mean and standard deviations of WHZ scores by age and sex
Weight for height (z-scores)
Age
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
Female
Male
Total
P-value
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
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.
55
Table 12: BMI for age (z-scores) according to sex and age groups
BMI for age
Age
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
Female
Male
Total
P-value
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
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
56
Figure 26: Weight for age by gender: a) children 12-60 month; b) children 61-83 months
a
b
Figure 27: Height for age by gender: a) children 12-60 months; b) children 61-83 months
a
b
Source own data (2013)
57
Figure 28: Weight for height by gender a) children 12-60 months
a
Figure 29: BMI for age by gender; a) 12-60 months and b) 61-83 months
b
a
The specific results showing the nutritional indicators of children by kindergartens are attached
as annexes (Annexes from 16 to 20).
58
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)
Private
Age
Public
groups
(months)
PN
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
Table 14: Means and standard deviations for stature in public and private kindergarten
Height (cm)
Private
Age
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
59
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
Age groups
(months)
Private
Public
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
87
0.5
1.0
399
0.4
1.1
Total
60
Table 16: Differences in the means and SD of HAZ
HAZ
Age groups
(months)
Private
Public
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
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
1.0
0.5
1.2
399
61
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
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.
62
Table 19: Length/height-for age indicator (%)
Combined
(all ages)
N
12 to < 24
Length/height-for-age (%)
% < 3SD
(95% CI)
% < 2SD
(95% CI)
43
0
(-, -)
0
(-, -)
24 to < 36
70
1.4
(0.1%,
28.3%)
4.3
(1.1%, 15.1%)
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
(-, -)
Weight-for-age indicator (%) is presented in Table 20
63
Table 20: Weight-for-age indicator (%)
Weight-for-age (%)
(95% CI)
% < -2SD
Combined
(all ages)
N
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%)
% <-3SD
(95% CI)
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
(-, -)
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 (%)
64
Table 21: Weight -for length/height indicator (%)
Weight-for-length/height (%)
Combined
(all ages)
N
% < -3SD
12 to < 24
44
2.3
24 to < 36
70
0
36 to < 48
124
0.8
48 to < 60
121
0
(95% CI)
(0.2%,
19.5%)
% < -2SD
2.3
(-, -)
2.9
(0.1%,
7.2%)
2.4
(-, -)
0
(95% CI)
(0.2%,
19.5%)
(0.3%,
23.2%)
(0.8%,
6.7%)
(-, -)
% > +1SD
34.1
44.3
22.6
25.6
(95% CI)
(13.7%,
62.8%)
(25%,
65.5%)
(9.6%,
44.6%)
(14.7%,
40.7%)
% > +2SD
6.8
12.9
5.6
9.1
(95% CI)
(2.4%,
17.8%)
(3.1%,
40.1%)
(1.4%,
19.8%)
(3.8%,
20.3%)
% > +3SD
0
4.3
0.8
0.8
(95%
CI)
(-, -)
(1.9%,
9.3%)
(0%,
11.7%)
(0.1%,
5.3%)
Boys (all ages)
(0.3%,
30.4%)
3.7
0
(-, -)
2.9
58
0
(-, -)
1.7
73
0
(-, -)
0
(-, -)
26
(-, -)
41.2
12 to < 24
27
3.7
24 to < 36
35
36 to < 48
48 to < 60
(0.3%,
30.4%)
(0.2%,
28.9%)
(0.1%,
24%)
29.6
51.4
24.1
(7.4%,
68.8%)
(34.6%,
68%)
(11.2%,
44.4%)
(13.5%,
44.2%)
7.4
14.3
8.6
9.6
(1.9%,
24.8%)
(5.6%,
31.7%)
(1%,
46.9%)
(3.9%,
21.8%)
0
2.9
0
1.4
(-, -)
(0.1%,
38%)
(-, -)
(0.2%,
8.4%)
Girls (all ages)
12 to < 24
17
0
(-, -)
0
24 to < 36
35
0
(-, -)
2.9
36 to < 48
66
1.5
48 to < 60
48
0
(0.2%,
12.3%)
3
(-, -)
0
(0.1%,
49.9%)
(0.6%,
14.5%)
(-, -)
37.1
21.2
25
(15.8%,
72.3%)
(18.2%,
61.1%)
(7.1%,
48.5%)
(13.4%,
41.9%)
5.9
11.4
3
8.3
(0.3%,
58.5%)
(1.1%,
59.6%)
(1%,
8.9%)
(2.8%,
22.5%)
0
5.7
1.5
0
(-, -)
(1.5%,
19.2%)
(0.1%,
19.5%)
(-, -)
65
Table 22: BMI-for-age indicator (%)
Combined
(all ages)
N
12 to < 24
44
2.3
(0.2%,
19.5%)
24 to < 36
70
1.4
(0%, 31.9%)
2.9
36 to < 48
124
0.8
(0.1%, 7.2%)
2.4
48 to < 60
124
0
(-, -)
0
60 to < 72
91
0
(-, -)
72 to < 83
33
0
(-, -)
12 to < 24
27
3.7
24 to < 36
35
36 to < 48
%<3SD
(95% CI)
Boys (all ages)
%<2SD
(95% CI)
2.3
(0.2%,
19.5%)
(0.3%,
23.2%)
(0.8%, 6.7%)
BMI-for-age (%)
%>
(95% CI)
+1SD
(13.7%,
34.1
62.8%)
(23.2%,
45.7
70.1%)
%>
+2SD
(95% CI)
4.5
12.9
22.6
(9.6%, 44.6%)
5.6
(-, -)
25
(13.8%, 41%)
10.5
0
(-, -)
22
(9.3%, 43.5%)
6.6
3
(0.2%,
33.6%)
21.2
(7.5%, 47.1%)
9.1
29.6
(7.4%, 68.8%)
7.4
51.4
(34.6%, 68%)
14.3
(0.1%, 24%)
24.1
(11.2%,
44.4%)
8.6
(0.3%,
30.4%)
3.7
0
(-, -)
2.9
58
0
(-, -)
1.7
48 to < 60
75
0
(-, -)
0
(-, -)
26.7
(14%, 44.7%)
12
60 to < 72
46
0
(-, -)
0
(-, -)
21.7
(11%, 38.5%)
6.5
72 to < 83
23
0
(-, -)
4.3
(0.2%,
45.2%)
21.7
(7.9%, 47.4%)
13
12 to < 24
17
0
(-, -)
0
(-, -)
41.2
24 to < 36
35
2.9
36 to < 48
66
1.5
Girls (all
ages)
(0.1%,
49.9%)
(0.2%,
12.3%)
2.9
3
(0.3%,
30.4%)
(0.2%,
28.9%)
(0.1%,
49.9%)
(0.6%,
14.5%)
40
21.2
(15.8%,
72.3%)
(15.3%,
71.1%)
(7.1%, 48.5%)
0
11.4
3
48 to < 60
49
0
(-, -)
0
(-, -)
22.4
(10%, 42.9%)
8.2
60 to < 72
45
0
(-, -)
0
(-, -)
22.2
(5.1%, 60.2%)
6.7
72 to < 83
10
0
(-, -)
0
(-, -)
20
(3.4%, 63.7%)
0
(0.4%,
34.5%)
(3.1%,
40.1%)
(1.4%,
19.8%)
(4.1%,
24.1%)
(3.1%,
13.4%)
(4.5%,
17.6%)
(0.6%, 50%)
(5.6%,
31.7%)
(1%, 46.9%)
(3.8%,
31.9%)
(2.2%,
17.5%)
(5.4%,
28.3%)
(-, -)
%>
+3SD
(95% CI)
0
4.3
(1.9%, 9.3%)
0.8
(0%, 11.7%)
2.4
(0.6%, 10%)
1.1
3
0
2.9
0
4
2.2
4.3
0
(1.1%,
59.6%)
5.7
(1%, 8.9%)
1.5
(2.6%,
22.6%)
(2.3%,
17.6%)
(-, -)
(-, -)
(0.1%,
17.5%)
(0.2%,
33.6%)
(-, -)
(0.1%, 38%)
(-, -)
(0.9%,
15.9%)
(0.1%,
32.5%)
(0.2%,
45.2%)
(-, -)
(1.5%,
19.2%)
(0.1%,
19.5%)
0
(-, -)
0
(-, -)
0
(-, -)
66
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-heightfor-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 Zscores 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
67
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
The Weight-for-height indicator is used also for describing risk of overweight and obesity in 1224 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
68
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.
Percentage
Figure 31: Prevalence of overweight
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Boys (N=264)
Girls (N=222)
Prevalence of overnutrition (According to WHO indicators)
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).
69
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)
70
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.
71
Table 23: Mean values of main nutrients, special carbohydrates and fatty acids consumed by children from all kindergartens
according to gender and age
Special
Carbohydrates
Main Ingredients
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
n
257
25
36
64
65
48
19
212
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
19
34
59
46
45
9
469
12 to < 24
44
70
123
111
93
28
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Kindergarten
All
kindergart
ens
All
kindergart
ens
All
kindergart
ens
Carbohyd
rates g
Fat g
Kilocalories
Kilojoule
Protein
g
Mean
Mean
Mean
Mean
Mean
Total
dietary
fibre¹ g
Water g
Mean
Mean
Fatty Acids
Starch¹ g
Sucrose¹
g
Monounsat
urated fatty
acids¹ g
Polyunsat
urated
fatty
acids¹ g
Saturated
fatty
acids¹ g
Mean
Mean
Mean
Mean
Mean
88.1
92.0
101.6
117.6
118.8
135.8
21.4
18.6
20.5
22.2
22.3
29.9
636.9
631.3
701.5
796.9
804.0
960.4
2664.3
2640.7
2934.4
3333.4
3363.1
4016.8
21.2
22.2
25.7
29.5
30.0
34.6
5.5
5.7
6.9
7.7
7.4
9.6
307.3
300.8
346.1
380.1
386.2
433.4
50.9
55.4
62.3
73.7
73.7
87.5
15.2
16.2
15.2
17.6
18.6
18.1
2.2
2.3
2.2
2.4
2.6
2.8
1.1
1.4
1.3
1.5
1.5
2.0
3.4
3.1
2.9
3.2
3.5
3.6
82.5
93.5
99.7
120.5
123.8
134.5
19.4
18.3
21.8
24.1
23.3
29.4
590.0
639.7
702.8
832.9
836.4
946.6
2468.0
2675.9
2939.5
3483.9
3498.4
3959.3
19.7
23.5
25.1
31.4
30.8
33.9
4.7
5.8
7.0
7.8
7.6
9.0
299.5
298.0
335.2
399.9
402.3
414.1
45.5
57.2
61.2
76.4
78.0
87.7
15.0
15.0
14.5
18.1
19.7
18.0
2.3
2.3
2.1
2.6
2.7
3.1
0.8
1.2
1.4
1.6
1.7
2.2
3.9
3.2
2.5
3.4
3.4
3.8
85.7
20.6
616.7
2579.5
20.6
5.2
303.9
48.6
15.1
2.2
1.0
3.6
92.7
18.5
635.4
2657.8
22.8
5.7
299.4
56.3
15.6
2.3
1.3
3.1
100.7
21.1
702.1
2936.8
25.4
6.9
340.9
61.8
14.9
2.1
1.3
2.7
118.8
23.0
811.8
3395.7
30.3
7.7
388.3
74.9
17.8
2.5
1.5
3.3
121.2
22.8
819.7
3428.5
30.4
7.5
394.0
75.8
19.2
2.7
1.6
3.4
135.4
29.7
956.0
3998.3
34.4
9.4
427.2
87.6
18.0
2.9
2.0
3.7
72
Table 24: Energy distribution from macronutrients according to gender and age l
Sex and
age
n
(months)
Boys (all
Kindergarten
257
ages)
All
kindergartens
Carbohydrates
Fat
Protein
Kilocalories
calories
calories
calories
Mean
%
%
%
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
ages)
212
All
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 ages
All
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
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
73
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 1-7year-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
74
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
(months)
Combined
Kindergarten
87
(all ages)
Carbohydrates
Fat
Protein
Kilocalories
calories
calories
calories
Mean
%
%
%
Private
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 ages)
All
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
75
Table 26: Distribution of starch and sucrose in public and private kindergartens
Special
Carbohydrates
Sex and age
(months)
Combined (all
n
87
ages)
Kindergarten
Starch¹ g
Sucrose¹ g
Mean
Mean
Private
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
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.
76
Table 27: Proportion of starch and sucrose intake in all kindergartens
Special
Carbohydrates
Sex and age
(months)
Boys (all
ages)
n
257
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
25
36
64
65
48
19
Girls (all
ages)
212
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
19
34
59
46
45
9
469
12 to < 24
44
70
123
111
93
28
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Kindergarten
All
kindergartens
Starch¹ g
Sucrose¹
g
Mean
Mean
50.9
55.4
62.3
73.7
73.7
87.5
15.2
16.2
15.2
17.6
18.6
18.1
45.5
57.2
61.2
76.4
78.0
87.7
15.0
15.0
14.5
18.1
19.7
18.0
48.6
15.1
56.3
15.6
61.8
14.9
74.9
17.8
75.8
19.2
87.6
18.0
All
kindergartens
All
kindergartens
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.
77
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 day8 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%).
78
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 fatsoluble 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.
79
Table 28: Mean values of amino acids consumed by children from all kindergartens
Arginin Cystine¹ Histidine¹ Isoleucine¹ Leucine¹ Lysine¹
e¹ mg mg
mg
mg
mg
mg
Methionin Phenylala Threonin Tryptopha Tyrosin Valine¹
e¹ mg
nine¹ mg e¹ mg
ne¹ mg
e¹ mg
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
1033.5
1016.5
1207.6
1298.9
1333.3
1588.6
262.8
286.7
343.7
407.8
412.8
487.3
524.1
530.4
630.1
688.1
714.3
817.6
974.9
956.9
1142.0
1264.0
1287.4
1583.0
1613.4
1572.8
1850.6
2059.9
2096.5
2540.5
1245.4
1167.4
1392.0
1454.4
1509.1
1786.4
376.5
381.8
454.1
510.1
530.6
600.3
955.3
937.1
1106.9
1241.5
1252.6
1552.8
795.5
773.2
915.6
996.2
1019.7
1218.1
218.3
220.9
258.7
289.0
297.2
348.1
722.6
691.0
791.8
855.8
871.4
1064.4
1106.8
1076.6
1267.4
1395.4
1421.1
1745.6
19
34
59
46
45
9
469 All
kindergartens
957.9
1094.7
1201.8
1432.5
1332.7
1535.6
240.7
306.8
337.0
425.7
428.8
481.8
493.9
577.3
619.7
754.0
718.0
793.8
898.4
1020.4
1143.3
1367.1
1317.5
1525.7
1487.5
1653.4
1834.9
2212.2
2148.2
2444.3
1172.3
1261.3
1371.1
1624.2
1500.6
1700.3
356.8
403.7
441.9
554.6
539.1
599.5
872.1
988.2
1105.4
1322.4
1290.7
1489.4
739.6
828.0
908.1
1088.4
1033.3
1177.9
203.1
234.7
256.1
313.1
303.7
342.8
665.6
732.8
784.3
930.0
900.5
1026.9
1018.9
1133.0
1268.2
1506.3
1453.9
1680.6
44
70
123
111
93
28
1000.9 253.2
511.1
941.8
1559.1
1213.8
368.0
919.4
771.3
211.7
698.0
1068.8
1054.5 296.4
553.2
987.7
1611.9
1213.0
392.4
961.9
799.8
227.6
711.3
1104.0
1204.8 340.5
625.1
1142.6
1843.1
1382.0
448.2
1106.2
912.0
257.4
788.2
1267.7
1354.3 415.2
715.4
1306.7
2123.0
1524.7
528.5
1275.0
1034.4
299.0
886.6
1441.3
1333.0 420.5
716.1
1302.0
2121.5
1505.0
534.7
1271.0
1026.3
300.4
885.5
1437.0
1571.6 485.5
809.9
1564.6
2509.6
1758.7
600.1
1532.5
1205.2
346.4
1052.3
1724.7
Sex and age
(months)
n
Boys (all ages)
257 All
kindergartens
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
25
36
64
65
48
19
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
212
Kindergarten
All
kindergartens
80
Table 29: Differences between mean values of amino acids consumed by children of public and private kindergartens
Sex and age
(months)
Combined (all
ages)
n
87
Kinder- Arginine¹ Cystine¹ Histidine¹ Isoleucine¹ Leucine¹
garten
mg
mg
mg
mg
mg
Mean
Mean
Mean
Mean
Mean
Private
Prishtine
12 to < 24
15
24 to < 36
12
36 to < 48
29
48 to < 60
14
60 to < 72
8
72 to < 83
9
Combined (all
382 Public
ages)
12 to < 24
29
24 to < 36
58
36 to < 48
94
48 to < 60
97
60 to < 72
85
72 to < 83
19
One Way ANOVA
1217.7
1179.9
1483.9
1515.6
1522.3
1765.8
302.7
313.2
395.8
406.9
419.1
463.0
Lysine¹
mg
Mean
Methionine Phenylala Threonine¹ Tryptopha Tyrosine¹ Valine¹
¹ mg
nine¹ mg
mg
ne¹ mg
mg
mg
Mean
Mean
Mean
Mean
Mean
Mean
605.8
567.5
696.3
713.1
719.0
817.2
1192.0
1163.0
1439.7
1482.2
1497.7
1696.9
1986.7
1875.4
2272.5
2331.7
2358.4
2651.3
1493.9
1386.5
1677.0
1716.7
1717.8
1950.4
429.0
403.3
495.0
502.6
514.1
552.0
1192.2
1157.2
1419.6
1463.2
1482.1
1679.2
957.5
916.2
1127.0
1154.5
1164.6
1314.0
888.7
227.6
462.1
1028.5
293.0
550.2
1118.7
323.4
603.1
1331.0
416.4
715.7
1315.2
420.6
715.8
1479.5
496.2
806.5
P<0.05 P<0.05 P<0.05
812.4
951.5
1051.0
1281.4
1283.6
1501.9
P<0.05
1337.8
1557.4
1710.6
2092.8
2099.3
2442.5
P<0.05
1068.9
1177.1
1291.0
1497.0
1485.0
1667.9
P<0.05
336.5
390.2
433.8
532.3
536.7
622.8
P<0.01
778.3
921.5
1009.5
1247.9
1251.1
1462.9
P<0.01
675.0
775.7
845.6
1017.1
1013.3
1153.6
P<0.01
257.0
244.8
305.0
311.4
316.7
351.7
881.2
827.1
1001.4
1024.3
1032.9
1161.5
1359.2
1301.6
1606.5
1651.6
1668.7
1883.0
188.2
603.2
224.1
687.4
242.8
722.4
297.2
866.7
298.8
871.6
343.8
1000.6
P<0.01
P<0.01
918.7
1063.1
1163.2
1411.0
1415.2
1649.7
P<0.05
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).
81
Table 30: Mean values of minerals, trace elements and sterols according to gender and age (all kindergartens)
Minerals and Trace Elements
Sex and age
(months)
n
Kindergarten
Sterols
Calcium Chloride¹ Iodide¹ Iron¹
mg
mg
µg
mg
Magnesi Phospho Potassi Sodium¹ Zinc¹
um¹ mg rus mg um¹ mg mg
mg
Cholesterol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean Mean
Boys (all
ages)
257 All
kindergartens
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
25
36
64
65
48
19
217.8
202.7
222.8
263.7
267.3
324.5
917.4
891.7
1101.8
1259.2
1273.2
1458.8
9.6
8.9
10.6
11.9
12.0
15.4
3.3
3.0
3.6
3.8
3.7
4.9
84.0
79.3
91.3
101.3
99.9
128.5
361.0
352.4
392.2
437.1
440.7
541.7
952.1
878.9
1002.1
997.9
1010.9
1276.5
828.7
780.0
999.8
1159.8
1164.8
1359.9
2.6
2.7
3.2
3.6
3.7
4.2
60.0
61.3
65.7
74.6
76.4
96.8
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages)
19
34
59
46
45
9
469 All
kindergartens
201.6
198.1
215.8
261.4
288.3
304.3
904.9
943.3
1107.9
1375.3
1312.5
1511.2
8.9
8.8
11.1
12.1
12.5
15.1
3.0
3.1
3.8
4.2
3.8
4.7
73.5
79.0
94.7
106.3
101.8
117.4
333.4
367.7
386.5
460.4
458.5
506.0
874.2
926.6
1023.1
1077.9
998.2
1128.2
773.4
831.2
1022.0
1265.5
1200.2
1409.0
2.4
3.0
3.2
4.0
3.8
4.2
60.6
61.6
70.2
80.4
78.3
99.9
210.8
200.4
219.4
262.8
277.5
318.0
P>0.05
912.0
916.8
1104.7
1307.3
1292.2
1475.6
P>0.05
9.3
8.8
10.8
12.0
12.2
15.3
P>0.05
3.2
3.1
3.7
3.9
3.7
4.9
P>0.05
79.5
79.1
92.9
103.4
100.8
125.0
P>0.05
349.1
359.8
389.5
446.8
449.3
530.3
P>0.05
918.5
902.1
1012.1
1031.1
1004.8
1228.8
P>0.05
804.8
804.9
1010.5
1203.6
1182.0
1375.7
P>0.05
2.5
60.3
2.8
61.4
3.2
67.9
3.8
77.0
3.7
77.3
4.2
97.8
P>0.05 P>0.05
12 to <
24 to <
36 to <
48 to <
60 to <
72 to <
All
212 kindergartens
44
24
70
36
123
48
111
60
93
72
28
83
One Way ANOVA
82
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
Sex and
age
(months)
n
Kindergar
ten
Calcium Chloride¹ Iodide¹
mg
mg
µg
Iron¹
mg
Mean
Mean
Mean
Mean
Sterols
Magne Phosp Potass
sium¹ horus ium¹ Sodium¹
mg
mg
mg
mg
Zinc¹
mg
Cholest
erol¹ mg
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
24 to < 36
12
265.3 1046.6
12.8
4.6 106.0 418.5 1118.3
36 to < 48
29
260.1 1355.7
16.3
5.9 131.5 473.6 1408.3
48 to < 60
14
267.5 1340.3
16.5
6.0 134.7 490.8 1438.8
60 to < 72
8
272.5 1345.6
17.0
5.9 133.9 492.1 1418.3
72 to < 83
9
287.9 1483.7
18.1
7.0 157.1 575.9 1674.0
Combined
382
Public
(all ages)
12 to < 24
29
160.4
865.3
7.3
2.5
60.3 293.6 745.0
24 to < 36
58
187.0
889.9
8.0
2.8
73.5 347.7 857.3
36 to < 48
94
206.9 1027.3
9.2
3.0
81.0 363.5 889.9
48 to < 60
97
262.1 1302.6
11.4
3.6
98.9 440.4 972.2
60 to < 72
85
277.9 1287.2
11.8
3.5
97.7 445.3 965.9
72 to < 83
19
332.3 1471.8
14.0
3.9 109.8 508.6 1018.0
One Way ANOVA
P<0.01 P<0.05 P<0.01 P<0.01 P<0.01 P<0.05 P<0.01
Mean
944.7
1048.4
1358.1
1337.1
1343.5
1494.3
2.9
2.9
3.7
3.7
3.7
4.1
61.3
62.5
94.9
107.8
111.6
126.0
732.5
2.2
59.8
754.5
2.8
61.2
903.2
3.0
59.5
1184.3
3.8
72.5
1166.8
3.7
74.1
1319.5
4.2
84.4
P<0.01 P>0.05 P<0.05
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
83
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
84
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 47 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
85
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.
86
Table 32: The mean values of vitamins which were consumed by children (12-83 months old) in all five kindergartens
Sex and age
(months)
Boys (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
Kindergarten
257 All kindergartens
25
36
64
65
48
19
Pantot
Folic Niacine henic
Biotin¹ acid¹ quivale acid¹
µg
nt¹ µg mg
µg
Retin
olequi
valent
¹ µg
Vitami
nA
Vitami Vitami Vitami Vitami Vitami Vitami
Retinol n B1¹ n B12¹ n B2¹ n B6¹ n C¹ n D¹
¹ mg mg
µg
mg
mg
mg
µg
Vitami
nE
Vitami
activ.¹ n K¹
mg
µg
Mean Mean Mean
Mean
Mean Mean Mean Mean Mean Mean Mean Mean Mean
Mean
13.9
12.6
14.4
15.3
14.9
20.0
66.2
56.5
69.9
75.0
70.4
105.0
5617.2
6116.6
7052.6
7407.9
7822.3
8330.4
1.4
1.3
1.5
1.7
1.7
2.1
230.9
174.0
184.1
170.6
152.8
258.0
0.1
0.1
0.1
0.1
0.1
0.1
0.3
0.3
0.3
0.4
0.4
0.5
0.8
0.8
0.9
1.0
1.0
1.1
0.3
0.3
0.3
0.4
0.4
0.5
0.5
0.5
0.6
0.6
0.6
0.7
21.2
18.7
26.8
27.1
26.6
32.7
0.3
0.3
0.3
0.4
0.4
0.5
7.6
6.0
7.1
6.9
6.5
11.3
26.3
19.7
25.4
21.0
17.5
36.2
12.8
11.9
15.5
15.6
15.0
18.5
55.2
54.7
77.0
77.5
71.0
92.4
5317.3
6859.8
7026.9
8741.9
7792.1
8745.4
1.2
1.3
1.6
1.8
1.7
2.1
193.4
145.0
213.1
184.2
160.9
244.5
0.1
0.1
0.1
0.1
0.1
0.1
0.3
0.3
0.4
0.4
0.4
0.4
0.8
0.9
0.9
1.1
1.1
1.2
0.3
0.3
0.3
0.4
0.4
0.4
0.5
0.5
0.6
0.7
0.6
0.7
19.2
18.0
28.4
26.2
22.9
30.1
0.3
0.3
0.3
0.4
0.4
0.5
6.1
5.7
8.6
7.8
6.8
10.7
19.6
16.2
32.5
22.6
18.8
36.9
Girls (all ages) 212 All kindergartens
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
19
34
59
46
45
9
Combined (all 469 All kindergartens
ages)
12 to < 24
44
24 to < 36
70
36 to < 48
123
48 to < 60
111
60 to < 72
93
72 to < 83
28
One Way ANOVA
13.4 61.5 5487.7
12.2 55.6 6477.6
14.9 73.3 7040.3
15.4 76.0 7960.7
14.9 70.7 7807.7
19.5 100.9 8463.8
P<0.01P<0.01P>0.05
1.3
214.7 0.1
0.3
0.8
0.3
0.5
20.3 0.3
7.0
23.4
1.3
159.9 0.1
0.3
0.9
0.3
0.5
18.4 0.3
5.8
18.0
1.6
198.0 0.1
0.3
0.9
0.3
0.6
27.6 0.3
7.8
28.8
1.7
176.2 0.1
0.4
1.0
0.4
0.6
26.8 0.4
7.3
21.7
1.7
156.7 0.1
0.4
1.0
0.4
0.6
24.8 0.4
6.7
18.2
2.1
253.7 0.1
0.4
1.1
0.4
0.7
31.9 0.5
11.1
36.4
P<0.05 P<0.01P>0.05 P>0.05P>0.05P>0.05P>0.05 P<0.01 P<0.01 P<0.01 P<0.01
87
Table 33: Difference between consumption of vitamins in public and private kindergartens according to gender and age
Sex and age
(months)
n
Pantot
Vitamin
Kinderg
Folic Niacine henic Retinole Vitamin A
Vitami Vitami Vitami Vitami Vitami
E
arten Biotin¹ acid¹ quivalen acid¹ quivalen Retinol¹ Vitamin n B12¹ n B2¹ n B6¹ n C¹
n D¹ activ.¹ Vitamin
µg
µg
t¹ µg
mg
t¹ µg
mg
B1¹ mg µg
mg
mg
mg
µg
mg
K¹ µg
Mean Mean
Combined (all
ages)
87
Private
Prishtin
e
12 to < 24
15
19.3 103.3
24 to < 36
12
18.3 103.0
36 to < 48
29
24.2 134.2
48 to < 60
14
25.4 136.3
60 to < 72
8
24.3 134.4
72 to < 83
9
28.1 156.7
Combined (all 382 Public
ages)
12 to < 24
29
10.4 39.8
24 to < 36
58
11.0 45.8
36 to < 48
94
12.0 54.6
48 to < 60
97
14.0 67.3
60 to < 72
85
14.0 64.7
72 to < 83
19
15.5 74.5
One Way ANOVA
P<0.01P<0.01
Mean
5783.3
5709.5
7862.9
7702.3
7604.7
8475.9
Mean
1.9
1.8
2.3
2.3
2.4
2.5
Mean
348.7
340.8
440.7
415.3
407.2
462.1
Mean
0.1
0.1
0.1
0.1
0.1
0.1
Mean
0.4
0.4
0.5
0.5
0.5
0.6
Mean Mean
0.8
0.7
0.9
1.0
1.0
1.0
0.4
0.4
0.4
0.4
0.4
0.4
Mean
0.6
0.5
0.6
0.6
0.6
0.7
Mean
32.5
32.0
47.6
45.7
43.2
50.7
Mean
0.4
0.4
0.6
0.7
0.7
0.8
Mean
14.0
14.6
19.7
18.6
18.1
20.8
Mean
47.7
55.8
83.1
72.9
68.0
79.7
5334.7
1.0
145.4
0.1
0.2
0.8
0.3
0.4
14.0
0.3
3.3
10.8
6636.5
1.2
122.5
0.1
0.3
0.9
0.3
0.5
15.5
0.3
4.0
10.2
6786.5
1.3
123.1
0.1
0.3
0.9
0.3
0.6
21.4
0.3
4.2
12.1
7998.0
1.7
141.7
0.1
0.3
1.0
0.4
0.6
24.0
0.3
5.7
14.3
7826.8
1.7
133.1
0.1
0.3
1.0
0.4
0.6
23.1
0.3
5.6
13.5
8458.1
1.9
155.0
0.1
0.4
1.2
0.4
0.6
23.0
0.4
6.4
15.9
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
88
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
89
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 14 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
90
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.
91
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
Public
Calcium
Private
Iodine
Public
Iodine
Private
Iron
Public
Iron
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
92
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.
93
Table 34: Typical daily intake of food and beverages
Is the reported food intake typical for
your child?
Yes
No
Total
Age groups
(months)
12-23
N
%
N
%
N
%
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
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
P>0.05
15.5
232
100.0
94
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
more
Less than once a
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
Total
4
97
30.8
41.8
9
135
69.2
58.2
13
232
100.0
100.0
P>0.05
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).
95
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
P>0.05
95.7
232
100.0
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
98.3
232
100.0
228
P>0.05
96
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
99.1
232
100.0
230
P>0.05
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.
97
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
P>0.05
70
30.2
232
100.0
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
98
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
(months)
N
Water
Soft
drinks/sodas
Milk
Tea
fruit/vegetable
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
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
99
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
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
100
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
Cheese
Pasta,
potatoes,
rice
Bread,
rolls,
muffin
Crackers
Cereals
Fruits
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
Age groups
(months)
N
12-23
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
101
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
Age groups
(months)
N
Vegetable
s
Soups/stews/casserole
s
Pretzels
, chips
Candy
Ice
cream
Fried
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
23
2
0.7
0.6
0.3
0.7
0.5
0.4
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
Total
P>0.05
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).
102
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
103
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 childfeeding 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
104

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).
105

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 micronutrientpoor 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
106
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.
107
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
108
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.
109
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 24Hour 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
110
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
111
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.
112
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
113
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
114
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
115
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.
116
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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.
136
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): Semiquantitative 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
eliminated from the body in the form of carbon dioxide (C18O2) and
water (H218O), and the deuterium is eliminated in water (2H2O). The
137
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 withinsubject 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)
138
Annex 2 Strengths and Limitations of Various Dietary Assessment Methods Used in Clinica
Settings
24-Hour Recall
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
May be conducted in-
intake of a variety of
Requires skilled staff
nutrients
Time consuming
and assessment of meal
person
or over the telephone
patterning and food group
Single recall does not
intake
represent usual intake
Useful counseling tool
Food Frequency
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
In a clinical setting, may
Can’t assess meal
of
be
patterning
useful as a screening tool
nutrients
May not be appropriate for
some population groups
intake
139
Does not rely on memory
Food portions may be
Recording foods eaten
Appropriate for literate and
may
motivated population
influence what is eaten
groups
Requires literacy
Food Record
measured at the time of
consumption
of
Multiple days of records
Relies on self-reported
provide valid measure of
information
nutrients
intake for most nutrients
Requires skilled staff
intake
Time consuming
Able to assess usual
Relies on memory
intake in a single interview
people as it does not
Time consuming (1 to 1-
Diet History
1/2
people
hours)
require literacy
Useful for assessing intake
of
Requires skilled
nutrients, meal patterning
interviewer
and
food group intake
Source: Stang & Story, (2005) chapter 4 p.40
140
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
energy
About
About
About
About
About
Abo
35%
35%
35%
35%
35%
ut
35%
Total
% of
carbohydrate
energy
About
About
About
About
About
Abo
50%
50%
50%
50%
50%
ut
50%
Non-milk
% of
extrinsic
energy
MAX
11%
11%
11%
11%
11%
11%
MIN
70%
40%
30%
10%
30%
20%
MIN
70%
40%
30%
10%
30%
20%
MIN
70%
40%
30%
10%
30%
20%
MIN
70%
40%
30%
10%
30%
20%
MIN
70%
40%
30%
10%
30%
20%
sugars
Protein
% of the
Reference
Nutrient
Intake
(RNI)
Vitamin A
% of the
RNI
Vitamin D
% of the
RNI
Vitamin C
% of the
RNI
Folate
% of the
RNI
141
Calcium
% of the
MIN
70%
40%
30%
10%
30%
20%
MIN
80%
45%
35%
10%
35%
25%
MIN
80%
45%
35%
10%
35%
25%
MAX
70%
40%
30%
10%
30%
20%
MAX
70%
40%
30%
10%
30%
20%
RNI
Iron
% of the
RNI
Zinc
% of the
RNI
Sodium
% of the
SACN
target
average
Salt
% of the
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
142
Annex 4 Nutrient-Based Guidelines for Food Prepared for 1-4 Years Old in Child Care
Nutrient
Full
Morning
Afternoon SNACK
day
Session: Session:
care *
Snack
Snack
and
and tea
only
LUNCH
TEA
only
only
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
MAX
g
26.6
15.2
11.4
3.8
11.4
7.6
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
carbohydrate
Non-milk
extrinsic
sugars
Source: www.cwt.org.uk
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
KËRKESË
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.
144
Annex 6 Consent and Support Letter from the Ministry of Education of Kosovo. Albanian
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.
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.
147
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
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 ____________________
Time of
day
Meal
8:30
Breakfast
11:30
Lunch
14:00
Snack
Type of food
Weighted food
before consumption
Weighted left
food after
consumption
Quantity of
eaten food
ASSESSMENT DAY 2 ____________________
Time of
day
Meal
8:30
Breakfast
11:30
Lunch
14:00
Snack
Type of food
Weighted food
before consumption
Weighted left
food after
consumption
Quantity of
eaten food
ASSESSMENT DAY 3 ____________________
Time of
day
8:30
Meal
Type of food
Weighted food
before consumption
Weighted left
food after
consumption
Quantity of
eaten food
Breakfast
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 ____________________
Koha
Racioni
8:30
Mëngjesi
11:30
Dreka
14:00
Mes-racioni
Lloji i ushqimit
Sasia e ushqimit
para ngrënies
Ushqimi i
Sasia e
mbetur pas
ushqimit të
konsumimit
ngrënë
Koha
Racioni
8:30
Mëngjesi
11:30
Dreka
14:00
Mes-racioni
Lloji i ushqimit
Sasia e ushqimit
Ushqimi i mbetur
para ngrënies
pas konsumimit
Sasia e
ushqimit të
ngrënë
150
Koha
Racioni
8:30
Mëngjesi
11:30
Dreka
14:00
Mes-racioni
Lloji i ushqimit
Sasia e ushqimit
Ushqimi i mbetur
para ngrënies
pas konsumimit
Sasia e
ushqimit të
ngrënë
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
Food after Kindergarten
152
FOOD DIARY DAY 3 ____________________
Food eaten
Time of the day
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
153
kthehet nga kopshti
DITARI I USHQIMIT DITA 2 - E Martë
Koha gjatë ditës
shkojë në kopsht
kthehet nga kopshti
DITARI I USHQIMIT DITA 3 - E Mërkurë
Koha gjatë ditës
shkojë në kopsht
kthehet nga kopshti
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
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
Data e vlerësimit: E diel
Emri i fëmijës __________________________
Shënoni çdo gjë që fëmiu i juaj ka ngrënë gjatë ditës së DJESHME, duke përfshirë ushqimin, pijet dhe mesracionet; 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
Pije të ëmbla/gazuara
_____ herë në D(ditë) J (javë) M (muaj) V (vit) ___asnjëherë
_____ 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
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
157
Annex 12 The Recipes and Served Food Types in Five Selected Kindergartens
Kindergarten 1 Ferizaj
DAY 1 Breakfast
DAY 1 Lunch
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
17/05/2011 and 31/05/2011
DAY 1 Snack
DAY 2 Lunch
DAY 2 Snack
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
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:
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
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
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
Banana
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
Sunflower oil
130 g
flour 1000 g
Flour
130 g
Peciva 2000 g
Salt
200 g
special bread (gjevrek) weight = 96 g
vegeta
200 g
White yoghurt
red pepper
100 g
water
19500 g
Breakfast Milling rice (grize) + chocolate or special
bread
+ soft cheese + white yogurt
average weight = 17.5
soft cheese
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
160
35 g
carrots
2260 g
oil
140 g
salt
210 g
vegeta
210 g
bizele
280 g
water
21150 g
spinach
280 g
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
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
1/3/2011
Chicken pate = 20 g
DAY 3 Breakfast
DAY 3 Lunch
DAY 3 Snack
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
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
Fruit juice (Frutti)
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
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
Cake
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)
9g
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
162
Biscuits with tea
Water (ml)
1000 (g)
Preparation of tea
packed soup (g)
62 (g)
20 g
Water (g)
5202 g
Bread in pieces
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)
Local fruit juice Tango 250 ml
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
packed soup (g)
62 g
Bread in pieces
15 g
local fruit yoghurt
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
163
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
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
for babies
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
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
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-
Sausage
It was the Chicken parizer produced by
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
Frutolino - cereal flakes enriched with fruit,
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)
166
Annex 14 Serving Size Pictures as an Estimated Aid, English and Albanian
167
168
169
170
Arginine¹ Mg
Ingredients
Methionine¹ Mg
Carbohydrates G
Histidine¹ Mg
Isoleucine¹ mg
Leucine¹ mg
Phenylalanine¹
Threonine¹
Tryptophane¹
Tyrosine¹
Valine¹
Mg
Mg
Mg
mg
mg
mg
Fat G
Kilocalories
Kilojoules
Protein g
dietary
Water g
ydrates
fibre¹ g
Elements
Trace
Lysine¹
Cystine¹ Mg
Total
Acids
Carboh
Vitamins
Sterols
and
Minerals
Fatty
Special
Main
Amino acids
Annex 15 Calculated nutrients-from nutrition tables (Umschau Verlag-2002)
Starch¹ G
Sucrose¹ G
Monounsaturate
Polyunsaturate
Saturated
d fatty acids¹ G
d fatty acids¹ G
fatty acids¹ g
Calcium Mg
Chloride¹ Mg
Iodide¹ µg
Iron¹mg
Phosphorus mg
Potassium¹ Mg
Sodium¹ mg
Zinc¹ mg
Biotin¹
Folic acid¹
Niacinequival
Pantothenic
Retinolequivalen
µg
µg
ent¹µg
acid¹ mg
t¹ µg
Vitamin B12¹
Vitamin B2¹
Vitamin B6¹
µg
Mg
mg
Vitamin C¹ mg
Vitamin D¹ µg
Magnesium¹mg
Cholesterol¹ mg
Vitamin A
Retinol¹
mg
Vitamin
B1¹ mg
Vitamin E
Vitamin
activ.¹ mg
K¹ µg
171
Annex 16 Height, weight and nutritional status of children from Kindergarten 1 (Ferizaj) according to gender and age
Sex and age
(months)
n
Boys (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
102
6
14
20
33
23
6
92
1
18
26
18
26
3
194
Kindergarten
Weight (kg)
Ferizaj
7
32
46
51
49
9
Weight for
age
(z-scores)
Mean
SD
Mean
SD
Mean
SD
12.8
14.1
16.3
18.6
20.4
21.0
0.7
2.0
1.7
2.8
3.1
2.8
89.8
91.3
100.9
106.9
113.6
114.1
3.9
5.2
5.0
4.0
4.8
8.4
1.3
0.4
0.4
0.5
0.3
-0.1
11.6
14.5
15.1
17.1
19.2
21.6
2.6
2.1
2.6
2.8
3.5
83.0
93.3
99.2
104.1
110.3
113.1
12.6
14.4
15.6
18.1
19.8
21.2
0.8
2.3
2.0
2.8
3.0
2.8
88.8
92.4
99.9
105.9
111.8
113.7
Ferizaj
Ferizaj
Height (cm)
Height for
age
(z-scores)
Mean
SD
1.5
1.2
0.8
1.0
1.0
1.1
3.1
-0.3
0.1
0.0
0.2
-0.6
5.6
6.2
4.2
4.9
5.1
0.4
0.7
0.0
-0.1
0.1
0.2
1.2
0.9
0.9
0.9
0.9
-0.3
0.4
0.1
-0.5
-0.2
-0.7
1.6
1.4
0.8
1.0
0.9
4.4
5.4
5.7
4.3
5.1
7.1
1.2
0.6
0.2
0.3
0.2
0.0
1.4
1.2
0.9
1.0
1.0
1.0
2.6
0.1
0.1
-0.1
0.0
-0.6
3.7
1.4
1.2
0.8
1.0
1.4
3.8
1.3
1.0
0.7
0.9
1.7
Weight for
height
(z-scores)
Mean
SD
0.0
0.8
0.5
0.6
0.2
0.6
1.0
0.9
1.1
0.1
0.7
0.7
-0.1
0.2
0.3
1.0
1.1
1.1
1.5
0.1
0.7
0.2
0.5
0.3
0.6
1.0
1.0
1.1
1.2
BMI for age
Mean
SD
-0.4
0.8
0.4
0.7
0.3
0.5
0.9
0.9
0.9
1.1
1.0
1.3
0.8
0.7
-0.1
0.2
0.2
0.8
1.0
1.2
1.1
0.9
0.7
-0.2
0.8
0.2
0.5
0.3
0.6
1.0
0.9
1.1
1.1
0.9
1.1
172
Annex 17 Height, weight and nutritional status of children from Kindergarten 2 (Prishtine) according to gender and age
Sex and age
(months)
n
Boys (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
64
6
11
15
17
10
5
48
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
3
5
14
11
12
3
112
Kindergarten
Weight (kg)
Height (cm)
Weight for
age
(z-scores)
Mean
SD
Height for
age
(z-scores)
Mean
SD
Weight for
height
(z-scores)
Mean
SD
Mean
SD
Mean
SD
13.4
14.6
17.2
20.2
21.3
22.6
2.2
2.0
2.6
4.0
3.7
7.8
86.6
91.8
101.4
109.7
113.7
118.5
6.2
5.0
5.4
6.5
3.9
7.6
1.2
0.7
0.8
1.0
0.6
-0.1
1.2
1.0
1.0
1.3
1.1
2.5
0.7
0.0
0.3
0.7
0.2
0.1
1.7
0.8
1.1
1.2
0.7
1.6
1.2
1.0
0.9
0.8
1.0
12.1
16.1
16.2
20.1
22.7
21.3
2.7
2.4
2.2
2.3
4.4
3.2
83.4
93.2
99.0
110.4
116.0
118.2
8.1
5.6
4.6
4.2
6.9
5.8
0.8
1.6
0.4
1.1
0.9
0.1
1.2
1.3
0.9
0.6
1.4
1.0
0.3
0.5
-0.1
1.0
0.7
0.3
1.6
1.3
1.0
0.7
1.4
1.1
13.0
15.1
16.7
20.1
22.0
22.1
2.3
2.2
2.4
3.4
4.1
6.2
85.5
92.2
100.2
110.0
114.9
118.4
6.5
5.1
5.1
5.6
5.7
6.6
1.1
1.0
0.6
1.0
0.8
0.0
1.2
1.1
1.0
1.1
1.2
2.0
0.6
0.2
0.1
0.8
0.5
0.1
1.6
1.0
1.0
1.0
1.2
1.3
BMI for age
Mean
SD
0.7
1.3
1.1
1.2
0.8
1.2
1.0
0.9
0.9
0.7
-0.2
0.5
1.3
1.2
1.3
1.3
2.3
0.8
1.9
0.7
0.7
2.6
0.6
0.9
0.9
0.6
0.9
1.9
0.7
0.7
0.8
-0.1
0.6
0.9
1.0
0.6
1.1
0.5
1.1
1.3
0.8
0.7
1.5
0.6
1.2
1.0
1.0
1.1
1.1
1.3
0.8
0.8
0.7
-0.1
0.5
1.2
1.1
1.1
1.2
1.8
Prishtine
Prishtine
Prishtine
9
16
29
28
22
8
173
Annex 18 Height, weight and nutritional status of children from Kindergarten 3 (Obiliq) according to gender and age
Kindergarten
Sex and age
(months)
n
Boys (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
31
3
2
8
10
7
1
25
4
5
7
6
3
0
56
Weight (kg)
Obiliq
Obiliq
Height (cm)
Weight for
age
(z-scores)
Height for
age
(z-scores)
Weight for
height
(z-scores)
BMI for age
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
11.6
14.5
16.3
16.3
18.8
21.2
0.7
0.3
1.5
1.5
1.7
0.0
81.8
92.2
102.6
103.9
111.3
116.0
1.1
1.0
4.0
4.2
4.5
0.0
0.3
0.3
0.3
-0.4
-0.1
-0.1
0.6
0.3
0.7
0.7
0.8
0.0
-0.3
-0.7
0.4
-0.5
-0.1
-0.47
0.6
0.1
1.0
1.0
1.0
0.0
0.7
0.9
0.1
-0.2
0.4
0.4
0.4
0.6
0.7
1.0
0.0
-0.2
-0.1
0.28
0.4
0.5
0.4
0.6
1.0
0.0
11.1
12.5
15.0
17.9
20.8
1.0
1.8
2.2
1.8
2.5
80.8
87.6
99.7
107.2
112.6
3.8
6.5
3.2
3.1
1.4
0.7
-0.1
-0.3
0.3
0.6
0.2
1.2
1.0
0.8
0.9
0.5
-0.6
-0.1
0.3
0.2
0.7
2.1
0.7
0.7
0.3
0.7
0.3
-0.3
0.1
0.4
0.7
1.2
0.7
0.6
0.4
-0.3
0.2
0.6
0.5
0.8
1.2
0.7
1.0
11.3
13.0
15.7
16.9
19.4
21.2
0.9
1.8
1.9
1.7
2.1
0.0
81.2
88.9
101.2
105.1
111.7
116.0
2.8
5.7
3.8
4.0
3.8
0.0
0.5
0.0
0.0
-0.2
0.1
-0.1
0.5
1.0
0.9
0.8
0.8
0.0
0.1
-0.6
0.2
-0.2
0.0
-0.5
0.7
1.7
0.9
0.9
0.8
0.0
0.7
0.5
-0.1
-0.1
0.4
0.7
0.8
0.7
0.7
0.6
-0.1
0.0
0.1
0.3
0.4
0.8
0.8
0.7
1.0
0.0
Obiliq
7
7
15
16
10
1
174
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
Weight
(kg)
Height
(cm)
age
age
height
BMI for age
n
Sex and age
(z-scores)
(months)
Boys (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
21
3
1
3
3
6
5
16
3
2
2
2
6
1
37
(z-scores)
(z-scores)
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
10.8
18.5
15.6
16.1
18.9
20.1
0.8
0.0
2.1
2.8
3.3
1.8
82.1
97.9
99.1
105.0
110.6
117.8
3.6
0.0
5.4
4.5
5.2
4.2
-0.7
2.5
0.1
-0.6
-0.4
-0.5
0.8
0.0
1.0
1.3
1.3
0.8
-0.9
1.3
-0.2
-0.3
-0.6
-0.1
1.0
0.0
1.0
1.0
1.3
1.0
-0.4
2.6
0.3
-0.7
0.9
0.0
0.9
1.1
-0.2
2.5
0.3
-0.6
0.0
-0.7
0.9
0.0
0.9
1.1
1.3
0.7
11.9
13.7
17.6
16.2
21.1
22.2
2.6
2.9
0.4
0.4
3.3
0.0
82.7
97.2
105.4
103.7
117.8
120.0
7.1
1.2
0.8
2.5
7.2
0.9
0.4
0.7
-0.5
0.6
0.6
1.7
1.2
0.2
0.2
1.2
0.0
0.5
1.6
0.7
-0.6
1.2
0.9
2.0
1.3
0.2
0.6
1.4
0.0
0.8
-0.8
0.4
-0.1
1.1
2.6
0.1
0.3
0.9
-1.0
0.4
-0.2
-0.1
0.1
0.9
3.0
0.1
0.3
0.6
0.0
11.3
15.3
16.4
16.1
20.0
20.5
1.8
3.4
1.8
2.0
3.4
1.8
82.4
97.4
101.6
104.4
114.2
118.2
5.0
1.0
5.2
3.5
7.1
3.9
0.1
1.1
0.3
-0.5
0.1
-0.3
1.4
1.5
0.7
0.9
1.3
0.8
-0.2
1.5
0.2
-0.4
0.3
0.0
1.6
0.9
0.9
0.8
1.6
1.0
0.2
0.4
0.3
-0.4
1.1
2.7
0.6
0.8
0.3
0.2
0.3
-0.4
-0.1
-0.6
1.0
2.9
0.6
0.8
1.0
0.7
Kamenicë
Kamenicë
Kamenicë
6
3
5
5
12
6
175
Annex 20 Height, weight and nutritional status of children from Kindergarten 5 (Private Prishtine) according to gender and
age
Kindergarten
Sex and age
(months)
n
Boys (all ages)
46
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
9
7
12
8
4
6
41
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
6
5
17
6
4
3
87
Weight (kg)
Height (cm)
Weight for
age
(z-scores)
Height for
age
(z-scores)
Weight for
height
(z-scores)
BMI for age
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
Mean
SD
11.8
14.5
15.6
18.8
21.3
22.9
1.6
1.7
2.5
1.9
3.1
3.1
83.2
92.5
99.8
107.9
113.8
118.0
5.9
4.6
4.2
4.7
6.8
4.0
0.8
0.6
0.1
0.8
0.7
0.3
1.1
0.7
1.3
0.8
0.9
1.1
1.1
0.1
0.2
0.6
0.4
-0.2
1.1
1.0
0.9
1.1
1.2
0.8
0.4
0.8
0.0
0.6
1.6
1.4
1.4
0.6
0.3
0.8
0.0
0.6
0.8
0.6
1.7
1.5
1.3
0.7
0.4
1.0
11.3
13.9
15.4
16.9
21.1
26.2
1.2
0.7
2.4
1.6
4.8
2.7
79.9
91.4
98.2
103.5
108.6
124.9
2.9
2.4
4.5
2.4
8.7
1.6
0.9
0.8
0.4
0.0
0.4
1.3
0.9
0.2
1.1
0.6
1.3
0.6
0.3
0.4
0.3
-0.3
-0.8
1.4
0.9
0.5
0.9
0.5
1.4
0.3
1.0
0.7
0.3
0.3
0.8
0.4
1.3
0.7
1.0
0.8
0.3
0.3
1.3
0.8
0.7
0.5
1.3
0.7
1.2
0.6
11.6
14.2
15.5
18.0
21.2
24.0
1.4
1.3
2.4
2.0
3.7
3.3
81.9
92.0
98.9
106.0
111.2
120.3
5.1
3.8
4.4
4.4
7.8
4.7
0.9
0.7
0.3
0.5
0.6
0.7
1.0
0.6
1.2
0.8
1.0
1.0
0.8
0.2
0.2
0.2
-0.2
0.4
1.0
0.8
0.9
1.0
1.4
1.0
0.7
0.8
0.2
0.5
1.3
1.0
1.3
0.7
0.6
0.8
0.2
0.5
1.0
0.7
1.4
1.2
1.3
0.7
0.9
0.9
Private
Prishtine
Private
Prishtine
Private
Prishtine
15
12
29
14
8
9
176
Annex 21 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 1 (Ferizaj)
Special
Carbohydrates
Main Ingredients
Sex and age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
102
4
15
25
28
24
6
92
3
17
21
23
25
3
194
7
32
46
51
49
9
Kindergarten
Carbohydrates g
Mean
Fat g
Kilocalories
Kilojoule
Protein g
Total
dietary
fibre¹ g
Mean
Mean
Mean
Mean
Mean
Water g
Mean
Fatty Acids
Starch¹ g
Sucrose¹
g
Monounsat
urated fatty
acids¹ g
Polyuns
aturated
fatty
acids¹ g
Saturate
d fatty
acids¹ g
Mean
Mean
Mean
Mean
Mean
Ferizaj
Ferizaj
Ferizaj
109.4
118.2
133.0
162.2
151.7
191.1
19.4
19.8
23.9
30.5
27.7
34.8
739.7
774.6
886.9
1090.9
1010.9
1269.5
3094.1
3239.5
3709.6
4563.0
4227.9
5309.5
29.9
28.6
32.7
39.1
36.0
44.7
6.5
7.0
7.7
9.3
8.8
11.3
293.3
340.5
394.4
470.1
454.1
529.8
75.4
74.5
85.8
108.6
98.9
132.6
13.4
18.7
19.9
22.0
22.4
24.3
2.9
2.7
3.2
3.4
3.2
3.0
1.1
1.2
1.4
1.6
1.5
1.6
3.8
3.7
4.5
4.9
4.5
4.6
95.4
107.3
121.2
151.2
148.8
199.4
15.1
17.3
20.3
28.4
27.8
38.5
631.0
699.2
792.9
1021.4
999.2
1358.1
2639.4
2924.3
3316.1
4272.5
4179.2
5680.5
26.7
26.6
29.1
37.5
35.8
50.0
5.5
6.5
7.1
8.7
8.5
11.4
280.9
307.9
353.3
471.1
456.8
526.6
62.5
68.0
76.7
100.2
98.5
137.7
12.7
17.1
18.6
21.4
21.2
27.6
1.9
2.3
2.6
3.2
3.2
4.5
0.7
1.0
1.2
1.5
1.5
2.1
2.4
3.0
3.6
4.6
4.5
6.3
103.4
112.4
127.6
157.2
150.3
193.8
17.6
18.5
22.2
29.6
27.8
36.0
693.1
734.5
834.0
1059.6
1004.9
1299.0
2899.2
3072.0
3530.0
4432.0
4203.1
5433.1
28.6
27.5
31.0
38.4
35.9
46.4
6.1
6.7
7.4
9.0
8.6
11.3
288.0
323.1
375.6
470.5
455.5
528.7
69.9
71.0
81.6
104.9
98.7
134.3
13.1
17.8
19.3
21.7
21.8
25.4
2.5
2.5
2.9
3.4
3.2
3.5
1.0
1.1
1.3
1.6
1.5
1.7
3.2
3.3
4.1
4.8
4.5
5.1
177
Annex 22 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 2 (Prishtine)
Special
Carbohydrates
Main Ingredients
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
64
6
11
15
17
10
5
48
3
5
14
11
12
3
112
9
16
29
28
22
8
Kindergarten
Carbohyd
rates g
Mean
Fat g
Kilocalo
ries
Kilojoule
Protein g
Total
dietary
fibre¹ g
Mean
Mean
Mean
Mean
Mean
Water g
Mean
Starch¹ g
Sucrose¹
g
Monouns
aturated
fatty
acids¹ g
Mean
Mean
Mean
Fatty Acids
Polyunsat
urated
fatty
acids¹ g
Saturate
d fatty
acids¹ g
Mean
Mean
Prishtine
Prishtine
Prishtine
65.9
59.8
59.8
76.9
83.2
85.9
13.1
11.0
8.3
10.1
12.0
12.1
446.5
400.1
381.5
479.0
534.9
552.0
1867.9
1674.1
1595.3
2002.9
2236.7
2308.5
14.8
14.4
16.0
19.3
21.4
23.5
3.9
3.5
4.1
5.1
5.2
5.3
310.0
251.1
245.7
260.8
279.1
304.5
31.7
32.5
31.6
42.1
45.6
47.2
22.3
18.2
16.0
19.1
21.3
19.2
2.1
2.1
1.4
1.7
2.2
2.3
1.8
2.1
1.3
1.5
2.1
2.3
2.7
2.2
1.5
1.9
2.2
2.3
55.5
59.4
61.9
78.2
87.4
72.9
11.1
11.7
9.3
10.9
12.4
12.1
378.8
411.8
401.1
492.7
553.4
490.2
1585.0
1723.9
1677.4
2060.3
2314.3
2050.4
13.1
16.2
16.5
19.4
21.7
21.5
3.6
3.8
4.2
5.1
5.4
4.5
281.5
260.9
234.9
260.8
310.9
266.8
26.6
34.1
32.5
42.1
45.4
42.8
18.8
14.9
16.8
20.1
23.4
14.5
1.8
2.5
1.6
2.0
2.2
2.1
1.3
2.5
1.5
1.9
2.3
2.3
2.5
2.7
1.7
2.1
2.0
1.9
62.4
59.7
60.8
77.4
85.9
81.0
12.4
11.2
8.8
10.4
12.2
12.1
423.9
403.8
391.0
483.4
545.0
528.8
1773.6
1689.7
1635.0
2025.5
2279.0
2211.7
14.2
14.9
16.2
19.3
21.6
22.7
3.8
3.6
4.2
5.1
5.3
5.0
300.5
254.1
240.5
260.8
296.4
290.4
30.0
33.0
32.0
42.1
45.5
45.6
21.1
17.2
16.4
19.5
22.4
17.4
2.0
2.2
1.5
1.8
2.2
2.3
1.6
2.2
1.4
1.6
2.2
2.3
2.6
2.4
1.6
2.0
2.1
2.1
178
Annex 23 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 3 (Obiliq)
Special
Carbohydrates
Main Ingredients
Sex and
age
(months)
n
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
31
3
2
8
10
7
1
25
4
5
7
6
3
0
56
7
7
15
16
10
1
Kindergarten
Carbohydr
ates g
Mean
Fat g
Kilocalo
ries
Kilojoule
Protein g
Total
dietary
fibre¹ g
Mean
Mean
Mean
Mean
Mean
Fatty Acids
Water g
Starch¹
g
Sucrose¹
g
Monounsat
urated fatty
acids¹ g
Mean
Mean
Mean
Mean
Polyuns
aturated
fatty
acids¹ g
Saturated
fatty
acids¹ g
Mean
Mean
Obiliq
Obiliq
86.4
81.2
83.5
76.8
78.5
101.3
20.6
19.2
14.8
13.1
14.4
19.2
630.9
583.9
578.9
529.5
559.8
741.2
2640.3
2443.6
2422.8
2216.0
2343.0
3102.4
23.2
19.8
25.8
24.1
26.9
38.2
5.1
4.5
6.8
6.7
6.6
8.8
263.7
255.3
338.3
327.8
349.2
406.7
47.3
42.2
45.0
40.0
40.7
59.2
17.4
17.7
13.0
11.3
11.8
13.5
3.2
3.1
2.0
1.5
1.9
2.7
0.9
0.8
0.8
0.7
0.8
1.2
5.4
5.6
2.6
1.9
2.3
3.2
75.7
82.3
75.5
81.0
88.4
17.8
19.5
14.0
16.6
18.0
547.1
598.2
529.4
605.9
652.9
2289.5
2503.6
2215.4
2535.7
2732.5
19.4
21.7
23.6
31.3
32.6
3.9
4.7
5.9
6.4
7.5
244.9
257.6
309.3
333.0
330.5
39.9
44.6
40.0
46.8
53.2
15.7
16.7
11.8
10.3
10.5
2.9
3.1
1.8
2.2
2.3
0.7
0.8
0.8
1.0
1.0
5.0
5.2
2.4
2.5
2.6
80.3
19.0
583.0
2439.9
21.0
4.4
253.0
43.1
16.4
3.1
0.8
5.2
82.0
19.4
594.1
2486.4
21.2
4.6
256.9
43.9
17.0
3.1
0.8
5.3
79.8
14.4
555.8
2326.0
24.8
6.4
324.8
42.7
12.4
1.9
0.8
2.5
78.4
14.4
558.1
2335.9
26.8
6.6
329.8
42.6
11.0
1.8
0.8
2.1
81.5
15.5
587.8
2459.9
28.6
6.9
343.6
44.5
11.4
2.0
0.9
2.4
101.3
19.2
741.2
3102.4
38.2
8.8
406.7
59.2
13.5
2.7
1.2
3.2
Obiliq
179
Annex 24 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Kindergarten 4 (Kamenicë)
Special
Carbohydrates
Main Ingredients
Sex and
age
(months)
n
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
13
3
1
3
2
3
1
Kindergarten
Carbohydr
ates g
Mean
Fat g
Kilocalo
ries
Kilojoule
Protein
g
Mean
Mean
Mean
Mean
Total
dietary
fibre¹ g
Water g
Mean
Mean
Starch¹ g
Sucrose¹
g
Monounsa
turated
fatty
acids¹ g
Mean
Mean
Mean
Fatty Acids
Polyunsat
urated
fatty
acids¹ g
Saturated
fatty
acids¹ g
Mean
Mean
Kamenice
50.0
40.6
47.2
59.1
67.1
91.2
8.7
6.7
7.2
10.9
11.6
16.6
320.0
257.6
298.4
394.3
446.4
632.2
1339.8
1078.4
1249.3
1650.4
1868.9
2647.3
9.7
8.0
10.3
14.1
17.2
27.7
1.5
1.1
1.4
2.2
2.5
4.1
218.4
178.1
197.1
262.4
250.0
396.3
20.3
13.1
20.0
28.3
37.4
56.6
11.0
8.9
8.4
10.2
9.2
11.2
1.9
1.6
1.3
1.9
1.9
2.6
0.3
0.3
0.3
0.4
0.4
0.6
3.7
3.1
2.5
3.5
3.4
4.2
3
2
1
55.6
79.8
43.1
11.8
12.0
6.8
374.6
502.1
272.0
1568.2
2101.2
1138.8
10.3
17.9
8.9
1.4
3.4
1.2
281.4
296.2
200.3
22.2
44.7
15.7
14.7
11.1
8.8
2.8
2.1
1.4
0.5
0.4
0.3
5.7
3.9
2.6
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
52.8
66.7
46.2
59.1
68.9
91.2
10.3
10.2
7.1
10.9
11.9
16.6
347.3
420.6
291.8
394.3
457.5
632.2
1454.0
1760.3
1221.7
1650.4
1915.3
2647.3
10.0
14.6
10.0
14.1
17.5
27.7
1.4
2.6
1.3
2.2
2.6
4.1
249.9
256.8
197.9
262.4
264.1
396.3
21.2
34.1
18.9
28.3
38.2
56.6
12.9
10.4
8.5
10.2
9.8
11.2
2.4
2.0
1.3
1.9
1.9
2.6
0.4
0.4
0.3
0.4
0.4
0.6
4.7
3.6
2.5
3.5
3.4
4.2
7
20
6
3
4
2
4
1
Kamenice
Kamenice
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
Carbohydrates
Main Ingredients
Sex and
age
(months)
n
Boys (all
ages)
46
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
9
7
12
8
4
6
41
12 to < 24
6
5
17
6
4
3
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
87
15
12
29
14
8
9
Kindergarten
Carbohydra
tes g
Fat g
Kilocalories
Kilojoule
Protein g
Total
dietary
fibre¹ g
Mean
Mean
Mean
Mean
Mean
Mean
Water g
Starch¹ g
Sucrose¹
g
Mean
Mean
Mean
Fatty Acids
Monounsa
turated
fatty
acids¹ g
Polyuns
aturated
fatty
acids¹ g
Saturate
d fatty
acids¹ g
Mean
Mean
Mean
Private
Prishtine
Private
Prishtine
Private
Prishtine
106.6
96.7
113.3
114.0
117.3
135.3
32.4
29.7
34.8
33.5
37.0
43.9
825.9
754.7
882.8
878.5
931.4
1082.8
3453.7
3156.0
3692.3
3674.3
3895.7
4528.3
24.9
23.5
27.0
28.2
30.3
34.3
7.6
7.2
9.7
10.0
10.1
12.6
355.9
324.7
408.2
413.5
413.1
454.9
64.3
60.1
72.8
72.4
78.2
85.9
12.0
8.2
8.4
8.9
8.5
12.8
1.7
1.5
1.5
1.9
2.2
2.9
1.0
1.1
1.6
1.9
2.0
2.4
3.0
2.3
1.6
1.9
2.2
3.6
107.5
30.6
811.4
3392.7
24.3
7.1
363.2
61.8
14.1
1.9
0.9
3.7
97.2
30.0
761.8
3185.9
24.0
7.5
342.7
61.5
7.7
1.4
1.2
1.9
118.7
39.0
951.3
3978.7
29.1
10.2
419.0
78.2
8.8
1.9
1.9
1.9
120.0
39.2
960.9
4018.9
29.7
10.6
449.2
77.7
9.2
1.9
2.0
2.0
115.1
34.6
892.0
3730.7
28.1
9.7
413.9
75.5
8.5
1.8
1.8
1.9
131.1
37.5
991.6
4147.1
30.2
11.1
448.9
82.5
11.9
2.7
2.1
3.4
107.0
96.9
116.3
116.6
116.2
133.9
31.7
29.8
37.1
36.0
35.8
41.8
820.1
757.7
920.6
913.8
911.7
1052.4
3429.3
3168.5
3850.3
3822.0
3813.2
4401.2
24.6
23.7
28.2
28.9
29.2
32.9
7.4
7.3
10.0
10.3
9.9
12.1
358.8
332.2
414.2
428.8
413.5
452.9
63.3
60.7
75.8
74.7
76.8
83.8
12.8
8.0
8.6
9.0
8.5
12.5
1.8
1.5
1.7
1.9
2.0
2.8
0.9
1.1
1.8
2.0
1.9
2.3
3.3
2.1
1.8
1.9
2.0
3.5
181
Annex 26 Mean values of main ingredients, special carbohydrates and fatty acids of the food served in Public Kindergartens
Special
Carbohydrates
Main Ingredients
n
Sex and age
(months)
Kindergarten
Boys (all ages)
210
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
16
29
51
57
44
13
172
13
29
43
40
41
6
Public
Combined (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
382
Public
29
58
94
97
85
19
Carboh
ydrates
g
Fat g
Kilocalories
Kilojoule
Mean
Mean
Mean
Mean
Fatty Acids
Protein g
Total
dietary
fibre¹ g
Water g
Starch¹ g
Sucrose¹ g
Monou
nsatur
ated
fatty
acids¹
g
Polyu
nsatur
ated
fatty
acids¹
g
Saturate
d fatty
acids¹ g
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Public
77.6
90.9
98.7
118.2
119.0
136.0
15.3
16.0
16.9
20.7
20.9
23.5
530.6
601.6
655.3
785.5
792.4
903.9
2220.3
2516.3
2741.2
3285.5
3314.6
3780.7
19.2
21.9
25.4
29.7
29.9
34.7
4.3
5.3
6.1
7.3
7.2
8.3
279.9
295.1
330.3
375.4
383.7
423.4
43.4
54.2
59.6
73.9
73.3
88.3
17.0
18.1
17.0
18.9
19.6
20.5
2.5
2.5
2.4
2.5
2.7
2.7
1.2
1.5
1.2
1.4
1.5
1.8
3.7
3.3
3.2
3.4
3.6
3.5
71.0
92.8
92.6
120.6
124.6
136.2
14.3
16.3
15.4
21.8
22.2
25.3
487.8
618.7
610.3
813.7
831.0
924.1
2041.2
2588.0
2552.7
3403.6
3475.7
3865.4
17.5
23.4
23.6
31.6
31.0
35.7
3.6
5.5
5.8
7.4
7.4
7.9
270.1
290.3
304.1
392.5
401.2
396.7
38.0
56.5
54.9
76.2
78.2
90.3
15.5
16.2
16.7
19.4
20.8
21.0
2.4
2.4
2.1
2.7
2.8
3.3
0.8
1.2
1.2
1.5
1.7
2.2
4.0
3.4
2.8
3.6
3.6
4.1
74.6
91.8
95.9
119.2
121.7
136.1
14.8
16.1
16.2
21.1
21.6
24.1
511.4
610.1
634.7
797.1
811.0
910.3
2140.0
2552.2
2655.0
3334.2
3392.3
3807.4
18.5
22.6
24.6
30.5
30.5
35.0
4.0
5.4
6.0
7.3
7.3
8.1
275.5
292.7
318.3
382.5
392.1
415.0
41.0
55.4
57.4
74.9
75.7
88.9
16.3
17.2
16.8
19.1
20.2
20.7
2.4
2.5
2.3
2.6
2.7
2.9
1.0
1.3
1.2
1.4
1.6
1.9
3.8
3.3
3.0
3.5
3.6
3.7
182
Annex 27 Mean values of amino acids consumed by children attending kindergarten 1 (Ferizaj) according to gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
Kindergarten
102
Ferizaj
4
15
25
28
24
6
92
3
17
21
23
25
3
194
7
32
46
51
49
9
Ferizaj
Ferizaj
Methion
ine¹ mg
Mean
Phenyla
lanine¹
mg
Mean
Threon
ine¹
mg
Mean
Tryptop
hane¹
mg
Mean
Tyrosine
¹ mg
Mean
Valine¹
mg
Mean
1578.3
1396.2
1574.2
1658.5
1546.7
1727.9
516.6
475.2
549.7
633.8
582.3
699.4
1182.8
1115.3
1288.6
1531.5
1405.3
1762.6
1031.8
943.0
1076.0
1212.1
1121.2
1328.0
296.8
278.8
318.0
368.9
340.7
412.2
909.4
833.7
952.5
1072.8
987.9
1194.9
1356.1
1262.6
1446.3
1667.7
1538.8
1863.8
1799.8
1733.1
1875.5
2438.8
2314.3
3222.1
1492.5
1316.2
1353.2
1685.5
1541.3
2179.9
474.8
440.9
475.0
622.1
583.1
819.9
1053.0
1030.4
1124.8
1469.4
1404.0
1954.1
947.4
879.9
937.6
1197.0
1117.3
1579.3
268.7
258.6
280.4
360.2
338.2
479.4
831.0
776.2
818.0
1048.3
989.2
1372.7
1233.5
1172.2
1262.8
1626.7
1533.9
2151.7
1907.1
1799.3
2027.5
2483.7
2316.4
2973.8
1541.5
1353.7
1473.3
1670.7
1544.0
1878.5
498.7
457.0
515.6
628.5
582.7
739.5
1127.2
1070.2
1213.8
1503.5
1404.6
1826.4
995.6
909.5
1012.8
1205.3
1119.2
1411.8
284.7
268.1
300.8
365.0
339.4
434.6
875.8
803.2
891.1
1061.8
988.6
1254.1
1303.6
1214.6
1362.6
1649.2
1536.3
1959.7
Arginine¹
mg
Mean
Cystine¹
mg
Mean
Histidine¹
mg
Mean
Isoleucine¹
mg
Mean
Leucine¹
mg
Mean
1400.5
1254.0
1417.1
1564.2
1454.0
1685.0
397.2
378.8
441.8
548.1
499.1
655.6
738.7
685.4
765.0
841.1
790.5
912.0
1231.2
1135.0
1306.2
1511.4
1394.7
1683.8
1987.5
1874.3
2155.2
2520.5
2318.5
2849.6
1283.4
1178.6
1250.2
1566.1
1442.3
2087.8
339.8
348.2
388.2
515.1
499.5
696.6
682.8
643.1
680.1
837.6
777.6
1103.5
1117.1
1055.3
1144.4
1479.5
1390.0
1966.0
1350.3
1213.9
1340.9
1565.0
1448.0
1819.2
372.6
362.6
417.3
533.2
499.3
669.3
714.7
662.9
726.3
839.5
783.9
975.8
1182.3
1092.6
1232.3
1497.0
1392.3
1777.9
Lysine¹
mg
Mean
183
Annex 28 Mean values of amino acids consumed by children attending kindergarten 2 (Prishtine) according to gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
Kindergarten
64
Prishtine
6
11
15
17
10
5
48
3
5
14
11
12
3
112
9
16
29
28
22
8
Prishtine
Prishtine
Methio
nine¹
mg
Mean
Phenyl
alanine
¹ mg
Mean
Threoni
ne¹ mg
Mean
Tryptoph
ane¹ mg
Mean
Tyrosine¹
mg
Mean
Valine¹
mg
Mean
815.1
762.2
843.7
959.7
1153.2
1320.2
277.0
267.1
297.5
365.8
436.9
489.9
636.0
618.7
683.8
837.4
978.2
1093.3
522.2
495.1
544.0
649.8
761.1
849.9
148.3
143.3
155.5
191.0
223.5
247.3
510.9
452.8
449.9
536.0
635.7
735.2
770.8
749.2
813.6
981.0
1158.3
1320.7
953.4
1186.4
1259.3
1479.5
1726.4
1710.8
684.2
805.5
902.1
1017.6
1192.5
1218.3
230.6
284.7
318.6
375.9
446.0
451.3
541.0
706.6
734.4
872.3
1008.1
995.4
442.9
542.4
582.2
679.0
781.7
773.2
124.7
153.9
167.7
199.4
230.6
223.4
427.5
501.5
492.3
568.3
673.9
665.2
652.0
831.5
875.7
1028.0
1203.7
1188.8
1072.9
1105.9
1213.5
1440.3
1700.0
1823.1
771.5
775.7
871.9
982.5
1174.6
1282.0
261.5
272.6
307.7
369.7
441.9
475.4
604.3
646.2
708.2
851.2
994.5
1056.6
495.7
509.8
562.4
661.2
772.4
821.2
140.4
146.6
161.4
194.3
227.4
238.3
483.1
468.0
470.4
548.7
656.5
709.0
731.2
774.9
843.6
999.5
1183.1
1271.2
Arginine¹
mg
Mean
Cystine¹
mg
Mean
Histidine¹
mg
Mean
Isoleucine¹
mg
Mean
Leucine¹
mg
Mean
637.1
648.0
703.1
825.4
953.0
1041.5
164.0
172.3
208.2
272.0
310.3
328.6
323.8
326.4
388.6
467.3
546.6
606.8
633.8
642.5
730.2
888.1
1051.5
1211.9
1132.6
1069.3
1170.9
1415.0
1668.3
1890.6
548.7
678.6
737.2
859.3
964.5
953.0
144.4
209.0
219.9
273.0
310.2
303.9
273.1
348.7
413.8
491.1
561.8
545.4
541.3
747.5
786.2
929.5
1090.0
1081.8
607.6
657.6
719.5
838.7
959.2
1008.3
157.5
183.7
213.8
272.3
310.3
319.3
306.9
333.4
400.7
476.7
554.9
583.7
603.0
675.3
757.2
904.3
1072.5
1163.1
Lysine¹
mg
Mean
184
Annex 29 Mean values of amino acids consumed by children attending kindergarten 3 (Obiliq) according to gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
Kindergarten
31
Obiliq
3
2
8
10
7
1
25
Obiliq
4
5
7
6
3
0
56
7
7
15
16
10
1
Arginine¹
mg
Mean
Cystine¹
mg
Mean
Histidine¹
mg
Mean
Isoleucine¹
mg
Mean
Leucin
e¹ mg
Mean
Lysine¹
mg
Mean
Methioni
ne¹ mg
Mean
Phenylala
nine¹ mg
Mean
Threoni
ne¹ mg
Mean
Tryptoph
ane¹ mg
Mean
Tyrosin
e¹ mg
Mean
Valine¹
mg
Mean
1322.0
1089.6
1456.0
1354.0
1542.8
2243.9
281.9
243.9
312.0
294.4
324.9
459.9
679.9
565.7
743.1
695.4
790.4
1127.5
1187.6
1007.8
1287.0
1192.5
1324.1
1917.2
1889.8
1632.0
2058.1
1903.1
2116.4
2997.6
1634.5
1358.3
1811.7
1690.2
1954.9
2789.8
436.7
372.6
510.1
473.6
567.5
783.8
1110.3
958.3
1181.3
1094.9
1183.9
1702.2
986.3
831.6
1060.4
979.4
1106.7
1582.1
255.4
217.0
271.7
250.0
283.5
398.3
864.8
737.5
846.4
769.9
848.5
1189.2
1308.8
1119.8
1414.9
1307.0
1455.1
2079.6
1086.9
240.1
565.6
973.7
1558.8
1352.2
382.3
904.0
817.2
215.8
716.9
1076.6
1229.5
266.5
635.9
1103.6
1761.0
1523.2
417.3
1029.1
920.5
240.4
807.1
1218.0
1323.2
286.1
683.9
1176.4
1893.3
1675.7
475.4
1079.3
974.3
249.6
780.5
1296.2
1827.6
374.8
934.8
1581.9
2505.8
2341.0
658.1
1408.7
1318.6
331.0
1012.2
1726.2
1877.9
400.6
961.8
1625.9
2558.9
2349.6
657.6
1466.7
1349.9
342.9
1061.0
1768.3
1187.6
1189.5
1394.0
1531.6
1643.3
2243.9
258.0
260.0
299.9
324.6
347.6
459.9
614.6
615.9
715.4
785.2
841.8
1127.5
1065.4
1076.2
1235.4
1338.5
1414.6
1917.2
1700.7
1724.1
1981.2
2129.1
2249.2
2997.6
1473.2
1476.1
1748.2
1934.2
2073.3
2789.8
405.6
404.5
493.9
542.8
594.5
783.8
992.4
1008.9
1133.7
1212.6
1268.8
1702.2
889.7
895.1
1020.2
1106.6
1179.6
1582.1
232.8
233.7
261.4
280.4
301.3
398.3
780.3
787.2
815.7
860.7
912.2
1189.2
1176.1
1190.0
1359.5
1464.2
1549.1
2079.6
Obiliq
185
Annex 30 Mean values of amino acids consumed by children attending kindergarten 4 (Kamenicë) according to gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
Kindergarten
21
Kamenice
Methion
ine¹ mg
Mean
Phenyla
lanine¹
mg
Mean
Threon
ine¹
mg
Mean
Tryptop
hane¹
mg
Mean
Tyrosine¹
mg
Mean
Valine¹
mg
Mean
469.4
401.8
537.5
774.5
980.1
1737.2
169.2
141.8
188.9
269.8
342.1
590.8
366.1
284.2
395.8
566.5
721.7
1203.0
306.0
250.1
333.9
482.7
611.4
1061.0
92.6
72.4
99.6
141.9
185.0
316.7
248.8
188.7
270.1
391.5
508.8
864.0
430.2
347.6
470.2
670.0
855.0
1458.0
682.9
1250.2
572.5
515.0
902.3
460.6
188.7
335.9
161.8
398.5
757.1
330.3
333.2
606.9
284.9
98.3
181.1
83.7
269.1
489.7
228.2
470.5
859.4
398.1
832.5
1346.5
1054.9
371.5
787.8
662.0
198.4
552.9
926.2
400.2
627.1
404.0
605.2
784.2
1313.6
647.9
996.8
654.7
971.2
1260.9
2060.4
492.2
735.5
518.3
774.5
998.8
1737.2
178.9
271.2
182.2
269.8
349.5
590.8
382.3
599.5
379.4
566.5
738.2
1203.0
319.6
487.9
321.7
482.7
624.0
1061.0
95.4
144.9
95.6
141.9
188.3
316.7
258.9
389.4
259.6
391.5
519.8
864.0
450.4
688.8
452.1
670.0
872.8
1458.0
Arginin
e¹ mg
Mean
Cystine¹
mg
Mean
Histidine¹
mg
Mean
Isoleucine¹
mg
Mean
Leucine¹
mg
Mean
410.7
335.9
442.4
649.4
811.4
1427.7
124.2
92.4
132.2
190.2
240.7
389.6
213.6
169.7
244.6
349.8
442.8
744.2
385.9
310.5
420.7
605.2
768.1
1313.6
612.9
489.9
682.1
971.2
1232.3
2060.4
3
2
2
435.2
811.5
373.2
132.2
268.5
107.0
231.0
442.0
198.6
414.4
785.5
354.1
6
870.7
263.6
478.4
423.0
653.0
425.1
649.4
826.2
1427.7
128.2
209.8
125.9
190.2
246.4
389.6
222.3
351.2
233.1
349.8
451.7
744.2
3
1
3
3
6
5
13
34
6
3
5
3
12
5
Kamenice
Lysine¹
mg
Mean
Kamenice
186
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Annex 31 Mean values of amino acids consumed by children attending kindergarten 5 (Prishtine private) according to gender and
age
n
Kindergarten
46
Private
Prishtine
9
7
12
8
4
6
41
6
5
17
6
4
3
87
15
12
29
14
8
9
Private
Prishtine
Private
Prishtine
Arginine¹
mg
Mean
Cystine¹
mg
Mean
Histidine¹
mg
Mean
Isoleucine¹
mg
Mean
Leucine
¹ mg
Mean
Lysine¹
mg
Mean
Methi
onine
¹ mg
Mean
Phenylala
nine¹ mg
Mean
Threoni
ne¹ mg
Mean
Tryptop
hane¹
mg
Mean
1246.1
1162.8
1410.6
1470.0
1585.5
1865.7
308.6
309.0
379.5
401.4
433.5
472.0
613.9
560.5
668.7
697.2
746.6
859.5
1213.8
1147.1
1378.9
1450.9
1558.6
1780.7
2009.1
1855.4
2190.9
2286.0
2448.6
2777.0
1513.2
1368.5
1613.3
1666.0
1790.3
2074.3
429.6
398.7
477.7
489.3
531.7
564.3
1212.0
1142.6
1364.2
1437.2
1540.6
1759.5
972.1
904.4
1080.8
1125.9
1211.2
1380.4
259.5
241.2
292.3
303.0
328.7
364.8
891.3
818.2
963.9
999.6
1073.4
1220.8
1378.1
1284.5
1539.9
1614.3
1736.3
1973.7
1175.0
293.8
593.6
1159.4
1953.2
1464.9
428.1
1162.6
935.5
253.3
866.1
1330.7
1204.0
319.1
577.3
1185.4
1903.3
1411.8
409.7
1177.6
932.8
249.8
839.6
1325.7
1543.5
409.1
718.7
1489.1
2338.8
1728.9
509.0
1464.5
1164.4
315.2
1031.9
1660.7
1576.4
414.1
734.3
1523.9
2392.7
1784.4
520.2
1497.8
1192.8
322.6
1057.2
1701.2
1459.1
404.7
691.4
1436.9
2268.3
1645.3
496.5
1423.5
1118.0
304.7
992.4
1601.0
1566.0
444.9
732.6
1529.2
2400.0
1702.8
527.5
1518.7
1181.3
325.5
1042.7
1701.5
1217.7
1179.9
1483.9
1515.6
1522.3
1765.8
302.7
313.2
395.8
406.9
419.1
463.0
605.8
567.5
696.3
713.1
719.0
817.2
1192.0
1163.0
1439.7
1482.2
1497.7
1696.9
1986.7
1875.4
2272.5
2331.7
2358.4
2651.3
1493.9
1386.5
1677.0
1716.7
1717.8
1950.4
429.0
403.3
495.0
502.6
514.1
552.0
1192.2
1157.2
1419.6
1463.2
1482.1
1679.2
957.5
916.2
1127.0
1154.5
1164.6
1314.0
257.0
244.8
305.0
311.4
316.7
351.7
881.2
827.1
1001.4
1024.3
1032.9
1161.5
1359.2
1301.6
1606.5
1651.6
1668.7
1883.0
Tyrosine¹
mg
Mean
187
Valine¹
mg
Mean
Annex 32 Mean values of amino acids consumed by children attending public kindergartens according to gender and age
Sex and age
(months)
Boys (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
Kindergarten
210
16
29
51
57
44
13
172
13
29
43
40
41
6
382
Public
29
58
94
97
85
19
Public
Public
Arginine¹
mg
Cystine¹
mg
Histidine¹
mg
Isoleuc
ine¹
mg
Leucin
e¹ mg
Lysine¹
mg
Methio
nine¹
mg
Phenyl
alanin
e¹ mg
Threoni
ne¹ mg
Tryptop
hane¹
mg
Tyrosine¹
mg
Valine¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
913.9
981.1
1155.9
1274.9
1310.4
1460.7
237.0
281.3
334.5
408.7
410.9
494.3
473.6
523.2
620.2
686.8
711.3
798.3
840.5
911.0
1081.7
1237.8
1262.8
1491.8
1390.9
1504.5
1763.8
2028.1
2064.5
2431.4
1094.7
1118.8
1335.6
1424.6
1483.6
1653.5
346.6
377.7
448.1
513.0
530.5
616.9
811.0
887.5
1041.3
1214.0
1226.4
1457.5
696.1
741.5
873.4
978.0
1002.3
1143.2
195.1
216.0
250.1
287.0
294.3
340.3
627.7
660.4
747.9
835.6
853.0
992.2
954.1
1026.4
1197.9
1364.6
1392.4
1640.3
857.7
1075.8
1074.6
1410.9
1320.4
1520.4
216.1
304.6
310.2
427.5
431.1
500.3
447.9
577.2
582.8
756.9
720.6
824.4
777.9
991.9
1014.6
1343.6
1305.9
1523.9
1272.6
1610.4
1647.5
2185.1
2136.5
2466.4
1037.2
1235.3
1238.0
1600.1
1486.5
1699.1
324.0
402.6
416.9
559.8
543.2
635.6
737.9
955.5
971.8
1296.1
1277.7
1474.8
649.2
809.9
812.7
1072.8
1025.0
1176.3
179.8
232.1
234.1
311.6
303.7
351.4
573.1
714.4
692.1
910.9
891.5
1019.0
875.0
1099.8
1122.1
1477.0
1439.6
1670.2
888.7
1028.5
1118.7
1331.0
1315.2
1479.5
227.6
293.0
323.4
416.4
420.6
496.2
462.1
550.2
603.1
715.7
715.8
806.5
812.4
951.5
1051.0
1281.4
1283.6
1501.9
1337.8
1557.4
1710.6
2092.8
2099.3
2442.5
1068.9
1177.1
1291.0
1497.0
1485.0
1667.9
336.5
390.2
433.8
532.3
536.7
622.8
778.3
921.5
1009.5
1247.9
1251.1
1462.9
675.0
775.7
845.6
1017.1
1013.3
1153.6
188.2
224.1
242.8
297.2
298.8
343.8
603.2
687.4
722.4
866.7
871.6
1000.6
918.7
1063.1
1163.2
1411.0
1415.2
1649.7
188
Annex 33 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 1 (Ferizaj) according to
gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
102
4
15
25
28
24
6
92
3
17
21
23
25
3
194
Kindergarten
Sterols
Calcium
mg
Chloride¹
mg
Iodide¹ µg
Iron¹ mg
Magnesium¹
mg
Phosphorus
mg
Potassium¹
mg
Sodium¹
mg
Zinc¹ mg
Cholesterol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
999.4
954.4
1189.3
1493.2
1433.4
1528.3
7.3
8.3
9.9
12.2
11.7
13.8
Ferizaj
Ferizaj
Ferizaj
7
32
46
51
49
9
198.3
222.4
263.9
343.6
315.1
420.0
180.9
206.1
225.0
307.7
320.8
370.2
190.9
213.7
246.2
327.4
318.0
403.4
942.7
876.1
1084.2
1543.9
1408.6
2002.5
975.1
912.8
1141.3
1516.1
1420.7
1686.4
6.7
7.3
8.7
11.6
11.5
14.1
7.1
7.8
9.4
11.9
11.6
13.9
3.4
3.3
3.8
4.6
4.2
5.0
79.6
91.6
100.5
125.5
117.9
147.1
448.4
439.0
495.6
581.5
534.5
679.6
1029.4
1068.2
1112.9
1121.2
1094.6
1221.2
846.6
766.0
1011.2
1323.7
1277.9
1359.5
4.1
3.8
4.3
5.1
4.7
5.6
73.2
68.5
78.7
91.0
83.0
98.2
3.1
3.1
3.5
4.5
4.2
6.2
71.3
83.0
94.7
118.8
113.7
156.4
401.7
409.9
433.2
546.7
534.3
703.9
976.5
996.8
1016.2
1110.4
1038.7
1346.0
806.6
705.6
917.9
1384.3
1270.1
1802.8
3.8
3.6
3.9
5.0
4.7
6.8
62.0
61.9
67.5
87.8
83.3
120.0
3.3
3.2
3.7
4.6
4.2
5.4
76.0
87.0
97.8
122.5
115.8
150.2
428.3
423.6
467.1
565.8
534.4
687.7
1006.7
1030.2
1068.8
1116.4
1066.1
1262.8
829.4
733.9
968.6
1351.0
1273.9
1507.2
4.0
3.7
4.1
5.0
4.7
6.0
68.4
65.0
73.6
89.6
83.2
105.4
189
Annex 34 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 2 (Prishtine) according
to gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
64
6
11
15
17
10
5
48
3
5
14
11
12
3
112
Kindergarten
Sterols
Calcium
mg
Chloride¹
mg
Iodide¹ µg
Iron¹ mg
Magnesium¹
mg
Phosphorus
mg
Potassium¹
mg
Sodium¹
mg
Zinc¹ mg
Cholesterol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Prishtine
Prishtine
Prishtine
9
16
29
28
22
8
199.6
153.8
162.1
194.4
237.0
293.6
777.1
752.0
941.9
1106.5
1150.9
1257.4
8.7
7.9
9.1
11.9
13.5
15.3
1.9
1.8
1.9
2.0
2.2
2.0
64.1
52.1
54.7
61.1
66.4
72.5
258.3
216.4
214.6
250.9
292.4
341.6
663.4
522.2
543.5
596.9
646.7
738.0
660.5
666.3
849.8
1010.4
1024.6
1098.4
1.4
1.4
1.5
1.8
2.1
2.3
59.4
53.6
44.5
56.7
65.1
62.3
167.3
185.4
178.2
202.2
262.6
267.3
726.6
901.3
941.1
1097.2
1164.2
1144.0
7.6
9.6
9.8
12.1
14.1
12.8
1.7
1.8
1.8
2.1
2.2
1.9
54.7
51.8
56.6
66.3
72.4
59.4
220.8
240.5
232.8
265.0
312.2
300.3
571.5
527.1
572.8
655.6
726.8
572.5
639.4
847.6
843.4
980.3
1014.1
1023.0
1.2
1.5
1.6
1.9
2.1
2.1
53.4
56.3
50.8
58.9
66.1
55.3
188.8
163.7
169.9
197.5
250.9
283.7
760.3
798.6
941.6
1102.8
1158.2
1214.9
8.3
8.5
9.4
12.0
13.8
14.3
1.8
1.8
1.8
2.0
2.2
2.0
61.0
52.0
55.6
63.1
69.7
67.6
245.8
223.9
223.4
256.4
303.2
326.1
632.8
523.8
557.6
620.0
690.4
676.0
653.5
722.9
846.7
998.6
1018.9
1070.1
1.4
1.4
1.6
1.8
2.1
2.2
57.4
54.5
47.5
57.6
65.7
59.7
190
Annex 35 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 3 (Obiliq) according to
gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
31
3
2
8
10
7
1
25
4
5
7
6
3
0
56
Kindergarten
Sterols
Calcium
mg
Chloride¹
mg
Iodide¹ µg
Iron¹ mg
Magnesium¹
mg
Phosphorus
mg
Potassium¹
mg
Sodium¹
mg
Zinc¹ mg
Cholesterol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Obiliq
Obiliq
142.0
148.0
187.4
181.5
188.2
210.1
1102.3
966.2
1073.8
939.9
1023.6
1516.1
8.3
8.2
9.3
8.7
9.3
11.3
3.9
3.4
3.9
3.4
3.5
5.3
85.5
77.5
98.8
91.8
89.0
122.6
380.9
337.6
389.0
363.3
384.5
521.7
1117.5
966.7
1183.8
1139.6
1173.9
1562.7
1013.0
844.5
996.5
936.9
1011.4
1496.0
3.1
2.6
3.3
2.9
3.4
4.9
69.4
64.6
48.5
39.8
52.6
72.3
120.8
134.5
176.4
183.6
189.6
904.5
1036.3
928.7
1219.1
1230.9
7.6
8.1
8.7
9.4
9.9
3.0
3.5
3.4
4.3
4.4
64.3
76.9
87.8
98.8
103.3
310.8
353.2
360.3
444.9
468.2
902.8
1030.8
1081.8
1290.5
1388.1
836.8
950.2
892.2
1211.2
1310.0
2.6
3.0
3.0
4.0
4.2
63.9
67.3
46.0
61.4
61.3
129.9
989.3
7.9
3.4
73.4
340.8
994.8
912.3
2.9
66.2
138.3
1016.3
8.1
3.5
77.1
348.7
1012.5
920.0
2.8
66.5
182.2
1006.1
9.0
3.7
93.7
375.6
1136.2
947.9
3.1
47.3
182.3
1044.6
9.0
3.7
94.4
393.9
1196.2
1039.8
3.3
47.9
188.6
1085.8
9.5
3.7
93.3
409.6
1238.2
1101.0
3.6
55.2
210.1
1516.1
11.3
5.3
122.6
521.7
1562.7
1496.0
4.9
72.3
Obiliq
7
7
15
16
10
1
191
Annex 36 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten 4 (Kamenicë) according
to gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
13
3
1
3
2
3
1
Kindergarten
Sterols
Calcium
mg
Chloride¹
mg
Iodide¹ µg
Iron¹ mg
Magnesium¹
mg
Phosphorus
mg
Potassium¹
mg
Sodium¹
mg
Zinc¹ mg
Cholesterol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Kamenice
108.2
100.5
117.6
138.2
153.2
203.0
513.5
318.5
435.6
717.3
842.0
1552.5
5.3
4.2
5.1
6.9
8.8
14.4
1.4
1.1
1.3
1.7
2.1
3.6
25.1
21.5
24.7
33.4
40.8
70.2
142.6
127.4
144.8
191.0
219.8
343.9
323.3
278.2
324.2
437.2
566.6
1005.5
435.3
279.2
414.4
690.0
809.6
1448.1
0.9
0.7
0.8
1.3
1.6
3.0
40.3
35.3
30.1
44.0
55.7
105.5
3
2
1
127.9
160.0
113.5
986.4
1097.1
364.6
5.9
9.5
4.7
1.5
2.1
1.2
26.0
43.8
23.1
163.5
230.3
136.8
309.6
505.8
302.4
620.8
994.7
331.6
0.8
1.6
0.8
51.1
48.9
32.3
1
175.5
929.9
9.6
2.3
45.0
240.8
589.5
898.6
1.7
56.1
118.1
140.2
116.6
138.2
158.8
203.0
750.0
837.6
417.8
717.3
864.0
1552.5
5.6
7.7
5.0
6.9
9.0
14.4
1.5
1.8
1.3
1.7
2.1
3.6
25.5
36.3
24.3
33.4
41.9
70.2
153.1
196.0
142.8
191.0
225.0
343.9
316.5
430.0
318.8
437.2
572.3
1005.5
528.0
756.2
393.7
690.0
831.9
1448.1
0.8
1.3
0.8
1.3
1.6
3.0
45.7
44.4
30.7
44.0
55.8
105.5
7
20
Kamenice
Kamenice
6
3
4
2
4
1
192
Annex 37 Mean values of minerals, trace elements and sterols consumed by children attending kindergarten (Prishtine private)
Sex and
age
(months)
n
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
46
Girls (all
ages)
12 to < 24
41
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
all ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
9
7
12
8
4
6
Kindergarten
Calcium
mg
Chloride¹
mg
Iodide¹ µg
Iron¹ mg
Magnesium¹
mg
Phosphorus
mg
Potassium¹
mg
Sodium¹
mg
Zinc¹ mg
Cholesterol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Private
Prishtine
15
12
29
14
8
9
300.4
267.6
260.0
265.6
280.6
294.1
1047.5
1037.6
1289.1
1299.1
1377.6
1531.9
13.2
12.6
15.8
16.0
17.4
17.9
4.7
4.5
5.6
5.8
6.1
7.4
118.4
104.3
126.5
131.0
138.9
167.4
456.8
417.1
457.3
481.6
513.1
606.9
1264.7
1094.5
1362.6
1381.8
1467.0
1777.9
1002.7
1041.7
1288.2
1299.8
1372.1
1540.9
3.0
2.8
3.5
3.5
3.8
4.3
58.1
60.6
84.0
105.9
122.1
126.9
319.9
934.6
13.1
4.2
114.0
455.7
1237.5
857.8
2.8
66.0
262.2
1059.1
13.0
4.7
108.4
420.4
1151.7
1057.7
2.9
65.2
260.1
1409.8
16.7
6.2
135.5
486.8
1445.4
1414.9
3.8
103.7
270.0
1395.4
17.1
6.3
139.7
503.1
1514.9
1386.9
3.9
110.4
264.3
1313.7
16.6
5.7
128.8
471.0
1369.5
1314.9
3.6
101.1
275.5
1387.2
18.3
6.0
136.5
513.9
1466.0
1401.1
3.8
124.4
308.2
265.3
260.1
267.5
272.5
287.9
1002.4
1046.6
1355.7
1340.3
1345.6
1483.7
13.2
12.8
16.3
16.5
17.0
18.1
4.5
4.6
5.9
6.0
5.9
7.0
116.6
106.0
131.5
134.7
133.9
157.1
456.4
418.5
473.6
490.8
492.1
575.9
1253.8
1118.3
1408.3
1438.8
1418.3
1674.0
944.7
1048.4
1358.1
1337.1
1343.5
1494.3
2.9
2.9
3.7
3.7
3.7
4.1
61.3
62.5
94.9
107.8
111.6
126.0
Private
Prishtine
6
5
17
6
4
3
87
Sterols
Private
Prishtine
193
Annex 38 Mean values of minerals, trace elements and sterols consumed by children attending public kindergarten according to
gender and age
Sex and age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
210
Kindergarten
Calcium
mg
Chloride¹
mg
Iodide¹ µg
Iron¹ mg
Magnesium¹
mg
Phosphorus
mg
Potassium¹
mg
Sodium¹
mg
Zinc¹ mg
Cholesterol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Public
16
29
51
57
44
13
172
171.3
187.0
213.4
263.5
266.1
338.5
844.2
856.5
1054.1
1253.6
1263.7
1425.0
7.6
8.0
9.3
11.4
11.5
14.2
2.6
2.7
3.1
3.5
3.5
3.8
64.7
73.2
82.3
97.1
96.3
110.6
307.1
336.8
375.6
430.9
434.1
511.6
776.3
826.8
910.2
944.1
969.4
1045.1
730.9
716.8
926.4
1140.2
1146.0
1276.4
2.3
2.7
3.1
3.6
3.7
4.1
61.1
61.4
61.1
70.1
72.3
82.9
147.0
187.0
199.3
260.1
290.6
318.7
891.2
923.3
995.6
1372.3
1312.4
1573.2
7.0
8.0
9.0
11.4
12.1
13.4
2.4
2.9
2.9
3.8
3.6
4.1
54.9
73.9
79.5
101.3
99.2
107.9
277.0
358.6
349.2
454.0
457.3
502.1
706.5
887.8
865.9
1012.4
962.0
959.3
734.4
792.2
875.8
1247.2
1189.0
1412.9
2.2
3.0
2.9
4.0
3.8
4.5
58.1
61.0
57.7
75.9
76.0
87.6
160.4
187.0
206.9
262.1
277.9
332.3
865.3
889.9
1027.3
1302.6
1287.2
1471.8
7.3
8.0
9.2
11.4
11.8
14.0
2.5
2.8
3.0
3.6
3.5
3.9
60.3
73.5
81.0
98.9
97.7
109.8
293.6
347.7
363.5
440.4
445.3
508.6
745.0
857.3
889.9
972.2
965.9
1018.0
732.5
754.5
903.2
1184.3
1166.8
1319.5
2.2
2.8
3.0
3.8
3.7
4.2
59.8
61.2
59.5
72.5
74.1
84.4
Public
13
29
43
40
41
6
382
Sterols
Public
29
58
94
97
85
19
194
Annex 39: Mean values of vitamins consumed by children attending kindergarten 1 (Ferizaj) according to gender and age
Vitamins
Sex and age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
102
4
15
25
28
24
6
92
3
17
21
23
25
3
194
7
32
46
51
49
9
Kinde
rgart
en
Biotin¹
µg
Folic
acid¹
µg
Mean
Mean
Niacinequi
valent¹ µg
Panto
thenic
acid¹
mg
Mean
Mean
Retinolequ
ivalent¹ µg
Vitamin A
Retinol¹
mg
Vitamin
B1¹ mg
Vitamin
B12¹ µg
Mean
Mean
Mean
Mean
Vitamin
B2¹ mg
Vitami
n C¹
mg
Mean
Mean
Mean
Me
an
Feriz
aj
Feriz
aj
Feriz
aj
Vita
min
D¹
µg
Vitami
n B6¹
mg
Vitamin
E activ.¹
mg
Vitami
n K¹
µg
Mean
Mean
9.2
12.1
13.0
15.5
14.8
17.3
43.1
49.1
57.0
74.4
68.8
87.7
9916.0
9024.0
9842.5
10776.5
10013.2
10759.5
1.3
1.4
1.6
1.9
1.8
2.1
73.4
82.9
110.8
144.1
129.0
151.2
0.0
0.1
0.1
0.1
0.1
0.1
0.3
0.3
0.3
0.4
0.4
0.5
1.3
1.1
1.2
1.3
1.2
1.2
0.3
0.3
0.4
0.4
0.4
0.5
0.6
0.7
0.7
0.8
0.8
0.8
13.7
18.2
19.1
21.3
20.8
21.0
0.2
0.2
0.3
0.4
0.4
0.5
4.5
4.7
5.5
7.5
6.8
8.8
7.6
8.8
11.0
13.7
12.1
14.8
9.0
10.4
12.3
14.6
14.1
17.5
38.2
44.5
53.2
70.7
66.8
90.0
9268.3
8446.4
9145.2
11173.5
9792.4
15481.7
1.2
1.2
1.4
1.9
1.8
2.4
50.9
66.9
88.1
135.0
129.4
162.0
0.0
0.0
0.0
0.1
0.1
0.1
0.3
0.3
0.3
0.4
0.4
0.6
1.2
1.0
1.0
1.3
1.2
1.7
0.3
0.3
0.3
0.4
0.4
0.5
0.6
0.7
0.7
0.8
0.7
1.1
14.3
15.9
19.4
21.8
18.9
24.6
0.1
0.2
0.2
0.3
0.4
0.5
3.9
4.1
5.1
7.3
6.7
10.0
6.2
6.8
9.6
12.8
12.0
14.7
9.1
11.2
12.7
15.1
14.4
17.4
41.0
46.7
55.3
72.7
67.8
88.4
9638.4
8717.2
9524.2
10955.5
9900.5
12333.6
1.3
1.3
1.5
1.9
1.8
2.2
63.7
74.4
100.4
140.0
129.2
154.8
0.0
0.0
0.1
0.1
0.1
0.1
0.3
0.3
0.3
0.4
0.4
0.5
1.2
1.0
1.1
1.3
1.2
1.4
0.3
0.3
0.4
0.4
0.4
0.5
0.6
0.7
0.7
0.8
0.7
0.9
14.0
17.0
19.2
21.6
19.8
22.2
0.2
0.2
0.3
0.4
0.4
0.5
4.2
4.4
5.3
7.4
6.8
9.2
7.0
7.8
10.3
13.3
12.0
14.8
195
Annex 40 Mean values of vitamins consumed by children attending kindergarten 2 (Prishtine) according to gender and age
Vitamins
Sex and age
(months)
n
Kinder Biotin¹ Folic Niacinequ Pantothen Retinoleq Vitamin A
µg
acid¹ µg ivalent¹ µg ic acid¹
uivalent¹ Retinol¹
garten
Mean
Boys (all ages)
64
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
6
11
15
17
10
5
48
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
3
5
14
11
12
3
112
9
16
29
28
22
8
Prishti
ne
Prishti
ne
Prishti
ne
Mean
Mean
mg
Mean
µg
Mean
mg
Mean
Vitamin
B1¹ mg
Vitamin
B12¹ µg
Vitamin
B2¹ mg
Vitamin
B6¹ mg
Vitamin
C¹ mg
Vitamin
D¹ µg
Mean
Mean
Mean
Mean
Mean
Mean
Vitamin Vitamin
E activ.¹ K¹ µg
mg
Mean
Mean
12.8
10.1
9.8
11.6
12.9
14.7
47.4
42.3
45.2
52.3
55.7
61.4
2654.0
2854.5
2648.9
2799.1
3277.3
3921.0
1.0
0.9
1.0
1.3
1.4
1.6
258.3
208.1
167.0
165.7
153.1
157.8
0.1
0.1
0.1
0.1
0.1
0.1
0.2
0.2
0.2
0.2
0.2
0.2
0.7
0.6
0.5
0.6
0.8
0.9
0.3
0.3
0.2
0.3
0.4
0.4
0.4
0.3
0.4
0.4
0.4
0.4
15.4
13.0
16.1
19.3
18.9
19.2
0.5
0.4
0.3
0.4
0.4
0.4
2.9
3.1
2.4
3.0
3.6
3.8
15.6
14.3
16.1
19.5
18.3
18.1
11.0
10.8
10.6
12.4
14.3
11.5
43.8
48.4
47.7
54.7
59.5
50.7
2210.6
3074.2
2776.9
3131.1
3460.4
3141.1
0.9
1.0
1.0
1.3
1.5
1.3
242.6
233.2
170.1
170.0
163.3
152.3
0.1
0.1
0.1
0.1
0.1
0.1
0.2
0.2
0.2
0.2
0.2
0.2
0.6
0.6
0.6
0.6
0.8
0.8
0.3
0.3
0.3
0.3
0.4
0.4
0.3
0.3
0.4
0.4
0.4
0.3
16.6
14.1
16.3
17.9
20.7
16.0
0.4
0.4
0.3
0.4
0.4
0.3
2.5
3.5
2.6
3.3
3.9
3.6
18.7
18.3
15.6
16.0
18.8
18.3
12.2
10.3
10.2
11.9
13.7
13.5
46.2
44.2
46.4
53.2
57.8
57.4
2506.2
2923.2
2710.7
2929.6
3377.2
3628.5
1.0
0.9
1.0
1.3
1.4
1.5
253.0
215.9
168.5
167.4
158.7
155.8
0.1
0.1
0.1
0.1
0.1
0.1
0.2
0.2
0.2
0.2
0.2
0.2
0.7
0.6
0.5
0.6
0.8
0.9
0.3
0.3
0.3
0.3
0.4
0.4
0.4
0.3
0.4
0.4
0.4
0.4
15.8
13.3
16.2
18.8
19.8
18.0
0.5
0.4
0.3
0.4
0.4
0.4
2.8
3.2
2.5
3.1
3.7
3.7
16.6
15.6
15.8
18.2
18.6
18.2
196
Annex 41 Mean values of vitamins consumed by children attending kindergarten 3 (Obiliq) according to gender and age
Vitamins
Sex and age
(months)
n
Kindergarte
n
Biotin¹
µg
Mean
Boys (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
31
3
2
8
10
7
1
25
4
5
7
6
3
0
56
Obiliq
Obiliq
Folic acid¹ µg Niacinequi Pantothe Retinolequiva Vitamin Vitamin Vitamin Vitamin Vitami Vitamin Vitamin Vitamin Vitamin
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
13.8
13.6
15.9
15.0
15.1
17.8
61.4
55.6
83.7
79.9
74.3
107.2
7903.5
6182.8
7860.0
6772.5
8332.3
12339.4
1.3
1.2
1.7
1.6
1.7
2.3
146.6
147.0
128.8
95.3
103.7
154.0
0.1
0.1
0.0
0.0
0.0
0.0
0.3
0.3
0.4
0.4
0.4
0.5
1.1
0.9
1.0
0.8
1.1
1.4
0.3
0.3
0.4
0.3
0.4
0.5
0.6
0.5
0.7
0.6
0.7
0.9
15.2
14.6
45.2
47.2
52.1
60.4
0.3
0.3
0.1
0.1
0.1
0.1
5.4
4.5
4.7
4.5
4.7
6.6
10.0
9.9
11.8
11.4
11.3
13.2
11.9
13.0
14.7
15.3
15.2
43.2
53.7
72.2
80.2
86.7
6754.7
7456.4
7063.1
10066.4
10146.0
1.1
1.3
1.5
1.8
1.9
127.6
138.6
113.8
123.7
114.0
0.1
0.1
0.0
0.0
0.0
0.3
0.3
0.3
0.4
0.4
1.0
1.1
0.9
1.3
1.3
0.3
0.3
0.3
0.4
0.4
0.5
0.6
0.6
0.8
0.8
14.0
14.7
35.6
33.8
39.3
0.2
0.3
0.1
0.1
0.1
4.4
5.0
4.4
5.6
6.2
9.6
9.8
11.1
11.7
11.5
12.7
13.2
15.4
15.1
15.1
17.8
51.0
54.3
78.3
80.0
78.0
107.2
7247.0
7092.5
7488.1
8007.7
8876.4
12339.4
1.2
1.2
1.6
1.7
1.8
2.3
135.8
141.0
121.8
106.0
106.8
154.0
0.1
0.1
0.0
0.0
0.0
0.0
0.3
0.3
0.4
0.4
0.4
0.5
1.1
1.0
0.9
1.0
1.2
1.4
0.3
0.3
0.4
0.4
0.4
0.5
0.5
0.5
0.6
0.7
0.7
0.9
14.5
14.7
40.7
42.2
48.3
60.4
0.3
0.3
0.1
0.1
0.1
0.1
4.9
4.8
4.6
4.9
5.1
6.6
9.8
9.8
11.5
11.6
11.4
13.2
Obiliq
7
7
15
16
10
1
197
Annex 42 Mean values of vitamins consumed by children attending kindergarten 4 (Kamenicë) according to gender and age
Vitamins
Sex and age
(months)
n
Folic Niacinequ Pantothen Retinoleq
Kindergar Biotin¹
µg
acid¹ µg ivalent¹ µg ic acid¹
uivalent¹
ten
Mean
Boys (all ages)
13
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
3
1
3
2
3
1
7
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Mean
Mean
mg
µg
Vit. A
Retinol¹
mg
Mean
Mean
Mean
Vit. B1¹
mg
Vitamin
B12¹ µg
Mean
Mean
Vit.
Vit.
B2¹ mg B6¹ mg
Vit.
Vitamin Vitamin Vit. K¹ µg
C¹ mg D¹ µg E activ.¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Kamenice
6.1
5.9
6.0
7.3
8.0
11.7
16.7
13.3
16.4
23.8
30.2
53.4
2341.7
2073.1
2265.1
3463.1
4245.0
8333.7
0.5
0.5
0.5
0.7
0.9
1.7
77.8
54.6
61.5
112.2
103.4
150.5
0.1
0.0
0.0
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.2
0.3
0.3
0.3
0.3
0.5
0.6
1.2
0.1
0.1
0.1
0.2
0.2
0.3
0.1
0.1
0.1
0.2
0.3
0.5
11.7
10.4
11.0
15.0
18.2
33.1
0.2
0.2
0.2
0.2
0.3
0.6
1.4
0.9
1.4
2.5
2.4
3.5
7.2
6.5
6.6
7.9
8.1
11.0
3
2
1
6.7
8.4
6.0
15.1
32.4
14.7
2309.5
3738.2
2094.1
0.5
1.0
0.5
103.5
112.8
57.4
0.1
0.1
0.0
0.1
0.2
0.1
0.3
0.5
0.3
0.1
0.2
0.1
0.1
0.2
0.1
9.9
15.2
10.9
0.3
0.3
0.2
1.3
2.7
1.1
8.4
9.0
6.5
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
6.4
7.6
6.0
7.3
8.2
11.7
15.9
26.1
16.0
23.8
30.9
53.4
2325.6
3183.1
2222.4
3463.1
4273.8
8333.7
0.5
0.8
0.5
0.7
0.9
1.7
90.7
93.4
60.4
112.2
107.2
150.5
0.1
0.1
0.0
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.2
0.3
0.3
0.4
0.3
0.5
0.6
1.2
0.1
0.1
0.1
0.2
0.2
0.3
0.1
0.2
0.1
0.2
0.3
0.5
10.8
13.6
11.0
15.0
18.3
33.1
0.3
0.2
0.2
0.2
0.3
0.6
1.4
2.1
1.4
2.5
2.5
3.5
7.8
8.2
6.5
7.9
8.2
11.0
20
Kamenice
Kamenice
6
3
4
2
4
1
198
Annex 43 Mean values of vitamins consumed by children attending kindergarten 5 (Prishtine Private) according to gender and age
Vitamins
Sex and age
(months)
n
Kinderga Biotin¹ Folic acid¹ µg Niacinequival Pantothe Retinoleq Vitamin A Vitamin Vitamin Vitamin Vitamin
µg
ent¹ µg
nic acid¹ uivalent¹ Retinol¹ B1¹ mg B12¹ µg B2¹ mg B6¹ mg
rten
Mean
Mean
Mean
mg
µg
mg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Vitamin
C¹ mg
Mean
Vitamin Vitami Vitamin
D¹ µg
nE
K¹ µg
activ.¹
mg
Mean Mean
Mean
Boys (all ages)
46
Private
Prishtine
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all ages)
9
7
12
8
4
6
41
107.2
101.2
127.0
131.6
139.5
166.8
6011.7
5571.5
7376.7
7192.0
7830.8
8907.2
1.9
1.8
2.2
2.3
2.4
2.6
361.8
340.4
406.9
382.3
417.6
483.5
0.1
0.1
0.1
0.1
0.1
0.1
0.5
0.4
0.5
0.5
0.5
0.6
0.8
0.7
0.9
0.9
1.0
1.0
0.4
0.4
0.4
0.4
0.4
0.5
0.6
0.5
0.6
0.6
0.6
0.7
33.6
31.0
46.2
41.9
42.8
51.1
0.3
0.4
0.5
0.7
0.8
0.8
14.9
14.4
18.3
17.0
18.5
22.0
53.5
56.2
76.7
65.0
66.4
80.7
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined (all
ages)
6
5
17
6
4
3
19.3
18.1
23.5
24.9
25.0
28.9
Private
Prishtine
19.2
18.6
24.9
26.0
23.7
26.5
Private
Prishtine
97.6
105.5
140.0
142.7
129.2
136.5
5440.7
5902.7
8257.9
8382.7
7378.5
7613.3
1.8
1.8
2.3
2.4
2.3
2.4
329.0
341.4
468.1
459.3
396.8
419.2
0.1
0.1
0.1
0.1
0.1
0.1
0.4
0.4
0.6
0.6
0.5
0.5
0.8
0.8
1.0
1.0
0.9
1.0
0.4
0.4
0.4
0.4
0.4
0.4
0.6
0.5
0.7
0.7
0.6
0.6
30.9
33.3
48.8
50.9
43.5
49.8
0.4
0.4
0.6
0.7
0.6
0.8
12.6
15.0
20.8
20.7
17.7
18.4
38.9
55.3
88.2
83.3
69.5
77.7
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
15
12
29
14
8
9
19.3
18.3
24.2
25.4
24.3
28.1
103.3
103.0
134.2
136.3
134.4
156.7
5783.3
5709.5
7862.9
7702.3
7604.7
8475.9
1.9
1.8
2.3
2.3
2.4
2.5
348.7
340.8
440.7
415.3
407.2
462.1
0.1
0.1
0.1
0.1
0.1
0.1
0.4
0.4
0.5
0.5
0.5
0.6
0.8
0.7
0.9
1.0
1.0
1.0
0.4
0.4
0.4
0.4
0.4
0.4
0.6
0.5
0.6
0.6
0.6
0.7
32.5
32.0
47.6
45.7
43.2
50.7
0.4
0.4
0.6
0.7
0.7
0.8
14.0
14.6
19.7
18.6
18.1
20.8
47.7
55.8
83.1
72.9
68.0
79.7
87
199
Annex 44 Mean values of vitamins consumed by children attending public kindergartens according to gender and age
Sex and
age
(months)
Boys (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Girls (all
ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
Combined
(all ages)
12 to < 24
24 to < 36
36 to < 48
48 to < 60
60 to < 72
72 to < 83
n
210
16
29
51
57
44
13
172
13
29
43
40
41
6
382
29
58
94
97
85
19
Kinde
rgarte
n
Vitamins
Biotin¹
µg
Folic acid¹
µg
Niacinequi
valent¹ µg
Pantothenic
acid¹ mg
Retinolequiv
alent¹ µg
Vit. A
Retinol¹
mg
Mean
Mean
Mean
Mean
Mean
Mean
Vit. B1¹
mg
Vit.
B12¹
µg
Vit.
B2¹
mg
Vit.
B6¹
mg
Vit. C¹
mg
Vit. D¹
µg
Vit. E
activ.¹
mg
Vit. K¹
µg
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Mean
Public
Public
Public
10.8
11.2
12.1
14.0
13.9
15.9
43.2
45.8
55.4
67.0
64.1
76.4
5395.2
6248.2
6970.0
7438.2
7821.6
8064.2
1.1
1.1
1.4
1.6
1.6
1.9
157.3
133.9
127.3
140.9
128.7
153.9
0.1
0.1
0.1
0.1
0.1
0.1
0.2
0.2
0.3
0.3
0.3
0.4
0.8
0.8
0.9
1.0
1.0
1.1
0.3
0.3
0.3
0.4
0.4
0.5
0.4
0.5
0.6
0.6
0.6
0.6
14.3
15.7
21.8
25.0
25.2
24.3
0.3
0.3
0.3
0.3
0.3
0.4
3.5
3.9
4.2
5.5
5.4
6.3
11.0
10.9
12.4
14.9
13.1
15.6
9.8
10.8
12.0
14.1
14.1
14.5
35.7
45.9
53.6
67.7
65.3
70.3
5260.3
7024.8
6568.9
8795.8
7832.5
9311.4
1.0
1.2
1.3
1.7
1.7
1.9
130.9
111.1
118.3
142.9
137.9
157.2
0.1
0.1
0.0
0.1
0.1
0.1
0.2
0.3
0.3
0.4
0.3
0.4
0.8
0.9
0.8
1.1
1.1
1.3
0.2
0.3
0.3
0.4
0.4
0.4
0.4
0.5
0.6
0.7
0.6
0.7
13.7
15.4
20.8
22.5
20.9
20.3
0.3
0.2
0.2
0.3
0.4
0.4
3.1
4.1
4.1
5.9
5.8
6.8
10.7
9.5
11.7
13.5
13.9
16.5
10.4
11.0
12.0
14.0
14.0
15.5
39.8
45.8
54.6
67.3
64.7
74.5
5334.7
6636.5
6786.5
7998.0
7826.8
8458.1
1.0
1.2
1.3
1.7
1.7
1.9
145.4
122.5
123.1
141.7
133.1
155.0
0.1
0.1
0.1
0.1
0.1
0.1
0.2
0.3
0.3
0.3
0.3
0.4
0.8
0.9
0.9
1.0
1.0
1.2
0.3
0.3
0.3
0.4
0.4
0.4
0.4
0.5
0.6
0.6
0.6
0.6
14.0
15.5
21.4
24.0
23.1
23.0
0.3
0.3
0.3
0.3
0.3
0.4
3.3
4.0
4.2
5.7
5.6
6.4
10.8
10.2
12.1
14.3
13.5
15.9
200

Nutrition in Kindergartens of Kosovo

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