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Karkoszka N, Gibula-Tarlowska E, Kotlinska J, Bielenica A, Gawel K, Kedzierska E. Selenium Intake and Postnatal Depression-A Short Review. Nutrients 2024; 16:1926. [PMID: 38931280 PMCID: PMC11206929 DOI: 10.3390/nu16121926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/07/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Postnatal depression is a common and severe complication of childbirth. It is an important public health problem with significant implications for both mothers and children. The exact mechanisms underlying and the factors influencing the occurrence of postnatal depression remain unclear. The literature suggests that certain dietary deficiencies during pregnancy and the postnatal period may contribute to a greater risk of maternal depression. This review focuses on the role of selenium in postnatal depression. It collects evidence from published interventional and observational studies investigating the relationship between selenium intake during the antenatal and postnatal periods and the mental status of postpartum women and summarises information about biological mechanisms that may underlie the association between selenium status and postnatal depression. The review includes studies identified through electronic searches of Medline (via PubMed) and Google Scholar databases until December 2023. Despite the small number of relevant studies and their potential methodological limitations, the findings suggest that optimizing selenium status may support the prevention and treatment of postnatal depression. Further longitudinal and interventional studies are necessary to confirm the clinical significance of these effects.
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Affiliation(s)
- Natalia Karkoszka
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, 4a Chodźki Street, 20-400 Lublin, Poland; (E.G.-T.); (J.K.); (E.K.)
| | - Ewa Gibula-Tarlowska
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, 4a Chodźki Street, 20-400 Lublin, Poland; (E.G.-T.); (J.K.); (E.K.)
| | - Jolanta Kotlinska
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, 4a Chodźki Street, 20-400 Lublin, Poland; (E.G.-T.); (J.K.); (E.K.)
| | - Anna Bielenica
- Department of Biochemistry, Medical University of Warsaw, 1 Banacha Street, 02-097 Warsaw, Poland;
| | - Kinga Gawel
- Department of Experimental and Clinical Pharmacology, Medical University of Lublin, 8b Jaczewskiego Street, 20-090 Lublin, Poland;
| | - Ewa Kedzierska
- Department of Pharmacology and Pharmacodynamics, Medical University of Lublin, 4a Chodźki Street, 20-400 Lublin, Poland; (E.G.-T.); (J.K.); (E.K.)
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Lee MS, Lee JJ, Park S, Kim S, Lee H. Is social support associated with postpartum depression, anxiety and perceived stress among Korean women within the first year postpartum? J Psychosom Obstet Gynaecol 2023; 44:2231629. [PMID: 37428880 DOI: 10.1080/0167482x.2023.2231629] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 07/12/2023] Open
Abstract
PURPOSE This study aimed to examine the association between social support, postpartum depression (PPD), anxiety and perceived stress among women within 12 months of childbirth in South Korea. METHODS A cross-sectional, web-based survey was conducted from 21 to 30 September 2022 and included women within 12 months of childbirth in Chungnam Province, South Korea. A total of 1486 participants were included. Multiple linear regression models were used to evaluate the association between social support and mental health. RESULTS In total, 40.0% of the participants had mild to moderate PPD; 12.0%, anxiety symptoms; and 8.2%, perceived severe stress. Social support (from family and significant others) is significantly associated with PPD, anxiety and perceived severe stress. Current maternal health problems, unplanned pregnancy and low household income were risk factors for PPD, anxiety and perceived stress. The increase in the time elapsed after childbirth showed a positive association with PPD and perceived severe stress. CONCLUSIONS Our findings provide insights to identify at-risk mothers and emphasize the importance of social support in families, early screening and continuous monitoring for postpartum women to prevent PPD, anxiety and stress.
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Affiliation(s)
- Mi-Sun Lee
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jung Jae Lee
- Department of Psychiatry, Dankook University Hospital, Cheonan, South Korea
- Department of Psychiatry, College of Medicine, Dankook University, Cheonan, South Korea
- Chungcheongnam-do Mental Health Welfare Center, Hongseong, South Korea
| | - Soyeon Park
- Korea Human Resource Development Institute for Health & Welfare, Seoul, South Korea
| | - Seongju Kim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
- Department of Public Health and Healthcare Management, Graduate School, The Catholic University of Korea, Seoul, South Korea
| | - Hooyeon Lee
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Fu J, Wang Q, Wang N, Li S, Zhang H, Zhu Y, Guo H, Wang F, He L, Xia S, Cao B. Serum and urinary essential trace elements in association with major depressive disorders: a case-control study. Front Psychiatry 2023; 14:1297411. [PMID: 38106999 PMCID: PMC10722235 DOI: 10.3389/fpsyt.2023.1297411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The etiology and pathophysiology of major depressive disorders (MDDs) remain unclear. Increasing evidence has demonstrated that essential trace elements (ETEs), such as iodine (I), zinc (Zn), copper (Cu), selenium (Se), cobalt (Co), and molybdenum (Mo), play vital roles in MDDs. Methods In total, 72 patients with MDD and 75 healthy controls (HCs) in the Zhumadian Second People's Hospital, Henan Province, China were recruited in our study. The levels of different ETEs were examined in both serum and urine, using an inductively coupled plasma mass spectrometer (ICP-MS), for both the MDD patients and HCs. Results The serum levels of I, Se, Cu, and Mo were significantly lower in the MDD patients compared to the HCs (p < 0.05), and the urinary levels of I and Zn were significantly higher in the MDD patients compared to the HCs (p < 0.05). The serum concentration of I (Q3: OR = 0.210, Q4: OR = 0.272) was negatively associated with MDD after adjusting for potential confounders, including age, gender, and BMI, and the urinary concentration of I (Q4: OR = 2.952) was positively associated. Conclusions The higher levels of I, Se, Cu, and Mo in serum might be protective against the development of MDD, and the excess I and Zn in urine may be associated with MDD pathogenesis. Future research needs to gain a deeper understanding of the metabolic pathways of ETEs, especially I, Se, Zn, Cu, and Mo, in MDD, and their role in the pathogenesis of depression.
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Affiliation(s)
- Jiyong Fu
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Qinqin Wang
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Na Wang
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, China
| | - Shilong Li
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Hongwei Zhang
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Yuxing Zhu
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Hua Guo
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Fukun Wang
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Lei He
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Shuang Xia
- Zhumadian Second People's Hospital, Zhumadian, Henan, China
| | - Bing Cao
- Key Laboratory of Cognition and Personality, Faculty of Psychology, Ministry of Education, Southwest University, Chongqing, China
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Baj J, Bargieł J, Cabaj J, Skierkowski B, Hunek G, Portincasa P, Flieger J, Smoleń A. Trace Elements Levels in Major Depressive Disorder-Evaluation of Potential Threats and Possible Therapeutic Approaches. Int J Mol Sci 2023; 24:15071. [PMID: 37894749 PMCID: PMC10606638 DOI: 10.3390/ijms242015071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
The multifactorial etiology of major depressive disorder (MDD) includes biological, environmental, genetic, and psychological aspects. Recently, there has been an increasing interest in metallomic studies in psychiatry, aiming to evaluate the role of chosen trace elements in the MDD etiology as well as the progression of symptoms. This narrative review aims to summarize the available literature on the relationship between the concentration of chosen elements in the serum of patients with MDD and the onset and progression of this psychiatric condition. The authors reviewed PubMed, Web of Science, and Scopus databases searching for elements that had been investigated so far and further evaluated them in this paper. Ultimately, 15 elements were evaluated, namely, zinc, magnesium, selenium, iron, copper, aluminium, cadmium, lead, mercury, arsenic, calcium, manganese, chromium, nickel, and phosphorus. The association between metallomic studies and psychiatry has been developing dynamically recently. According to the results of current research, metallomics might act as a potential screening tool for patients with MDD while at the same time providing an assessment of the severity of symptoms. Either deficiencies or excessive amounts of chosen elements might be associated with the progression of depressive symptoms or even the onset of the disease among people predisposed to MDD.
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Affiliation(s)
- Jacek Baj
- Department of Anatomy, Medical University of Lublin, Jaczewskiego 4, 20-090 Lublin, Poland
| | - Julia Bargieł
- Student Research Group of Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, Radziwiłłowska 11, 20-080 Lublin, Poland; (J.B.); (J.C.); (B.S.)
| | - Justyna Cabaj
- Student Research Group of Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, Radziwiłłowska 11, 20-080 Lublin, Poland; (J.B.); (J.C.); (B.S.)
| | - Bartosz Skierkowski
- Student Research Group of Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, Radziwiłłowska 11, 20-080 Lublin, Poland; (J.B.); (J.C.); (B.S.)
| | - Gabriela Hunek
- Student Research Group of Department of Forensic Medicine, Medical University of Lublin, Jaczewskiego 8b, 20-090 Lublin, Poland;
| | - Piero Portincasa
- Clinica Medica “A. Murri”, Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, 70124 Bari, Italy;
| | - Jolanta Flieger
- Department of Analytical Chemistry, Medical University of Lublin, Chodźki 4A, 20-093 Lublin, Poland;
| | - Agata Smoleń
- Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, 20-080 Lublin, Poland;
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de Paiva EL, Ruttens A, Waegeneers N, Laing GD, Morgano MA, Cheyns K, Arisseto-Bragotto AP. Selenium in selected samples of infant formulas and milk commercialized in Belgium and Brazil: Total content, speciation and estimated intake. Food Res Int 2023; 164:112289. [PMID: 36737897 DOI: 10.1016/j.foodres.2022.112289] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
Total selenium (Se) and Se species concentrations were determined in 50 infant formulas and milk samples commercialized in Brazil and Belgium. Infant formula categories were starter, follow-up, specialized and plant-based (soy and rice), while milk samples included whole, skimmed, semi-skimmed and plant-based products. Total Se content was determined by Inductively Coupled Plasma Mass Spectrometry (ICP-MS), after microwave digestion. An enzymatic extraction method was applied to evaluate the Se species, mostly selenomethionine (SeMet), Se(IV) and Se(VI), through High Performance Liquid Chromatography coupled to ICP-MS (LC-ICP-MS). Starters and follow-up samples presented the highest total Se concentrations and values up to 30 µg/kg were observed in the reconstituted product. The lowest level (below the LOQ = 10 µg/kg) was verified in an anti-regurgitation specialized formula. The relative agreement between the measured total Se and the Se content declared on the label varied from 55 % to 317 %. Concentrations in infant formulas were not markedly different from concentrations in milk except for rice and oat milk samples that showed values below the LOQ. SeMet was the main species found in milks, while in infant formulas the species concentrations varied according to the product. The daily intake (DI) of Se via infant formula consumption was calculated and compared with the Adequate Intake (AI) value and the Dietary Reference Intake (DRI) established by the EFSA NDA Panel and ANVISA, respectively. Estimated maximum intakes of total Se obtained for reconstituted infant formula were 40.6 mg/day, corresponding to 400 % and 202 % of the DRI and AI, respectively.
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Affiliation(s)
- Esther Lima de Paiva
- Faculty of Food Engineering, University of Campinas (UNICAMP), Rua Monteiro Lobato 80, 13083-862 Campinas - SP, Brazil; Sciensano, Leuvensesteenweg 17, 3080 Tervuren, Belgium.
| | - Ann Ruttens
- Sciensano, Leuvensesteenweg 17, 3080 Tervuren, Belgium
| | | | - Gijs Du Laing
- Ghent University, Laboratory of Analytical Chemistry and Applied Ecochemistry, Coupure links 653, 9000 Ghent, Belgium
| | - Marcelo Antônio Morgano
- Institute of Food Technology (ITAL), Avenida Brasil 2880, C. P. 139, 13070-178 Campinas - SP, Brazil
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Shayganfard M. Are Essential Trace Elements Effective in Modulation of Mental Disorders? Update and Perspectives. Biol Trace Elem Res 2022; 200:1032-1059. [PMID: 33904124 DOI: 10.1007/s12011-021-02733-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/19/2021] [Indexed: 12/12/2022]
Abstract
The emergence of mental disorders is associated with several risk factors including genetic and environmental susceptibility. A group of nutrients serves an especially important role in a number of essential neurodevelopmental processes through brain areas promoting the high degree of brain metabolism during early life, although almost all nutrients are needed. These include macronutrients and micronutrients (e.g., iron, magnesium, zinc, copper, selenium). Numerous nutritional psychiatry trials have been performed to examine the correlation of many individual nutrients with mental health, such as essential trace elements. The increased accumulation or lack of such components will facilitate an alternative metabolic pathway that can lead to many diseases and conditions of neurodevelopment. Mental functions have biochemical bases, so the impairment of such neurochemical mechanisms due to lack of trace elements can have mental effects. In psychological conditions such as depression, anxiety, schizophrenia, and autism, scientific studies demonstrate the putative role of trace element deficiency. Therefore, given the critical roles played by essential trace elements in the neurodevelopment and mental health, the effect of these elements' intake on the modulation of psychological functioning is reviewed.
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Affiliation(s)
- Mehran Shayganfard
- Department of Psychiatry, Arak University of Medical Sciences, Arak, Iran.
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Samad N, Rao T, Rehman MHU, Bhatti SA, Imran I. Inhibitory Effects of Selenium on Arsenic-Induced Anxiety-/Depression-Like Behavior and Memory Impairment. Biol Trace Elem Res 2022; 200:689-698. [PMID: 33745108 DOI: 10.1007/s12011-021-02679-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/15/2021] [Indexed: 02/07/2023]
Abstract
Elevated arsenic (As) contamination in drinking water was detected in many areas of Pakistan. The intoxication of As causes various neurological diseases in humans, which can be inhibited by the administration of potent antioxidants. Trace elements are also found in drinking water such as selenium (Se), which possess antioxidant potential. The main purpose of the current study is to find out the protective effect of Se against As toxicity which can cause anxiety- and depression-like behaviors as well as memory impairment. Thirty-six male rats were divided into six groups: (1) distilled water (dw)+dw, (2) dw+Se (0.175 mg/ml/kg), (3) dw+Se (0.35mg/ml/kg), (4) dw+As (2.5mg/ml/kg), (5) As (2.5mg/ml/kg) + Se (0.175 mg/ml/kg), and (6) As (2.5mg/ml/kg) + Se (0.35 mg/ml/kg). Rats were treated with respective treatment for 4 weeks. Sub-chronic treatment of As reduced time spent in open arm (elevated plus maze), and lightbox (light-dark activity test) and increased immobility time in forced swim test indicate anxiety- and/or depression-like behavior, respectively. Conversely, rats treated with As+Se (at both doses) increased time spent in open arm (elevated plus maze), and lightbox (light-dark activity test) and decreased immobility time in forced swim test indicate the anxiolytic and anti-depressive effect of Se, respectively. Co-administration of Se (0.175 and 0.35) inhibited As instigated reduction of spatial memory performed in Morris water maze. The reversal in the reduced level of malondialdehyde and activity of acetylcholinesterase in the hippocampus by Se was observed in As-treated animals, while the activity of antioxidant enzymes in the hippocampus was increased in As+Se than dw+As-treated animals. Histopathological studies have shown the reversal of hippocampus deterioration by Se in As-treated rats. The results may imply to prevent the intoxication of As instigated impairment in behavioral and biochemical indices by Se supplementation and/or increased safer intake.
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Affiliation(s)
- Noreen Samad
- Department of Biochemistry, Faculty of Science, Bahauddin Zakariya University, Multan, 60800, Pakistan.
| | - Tazeen Rao
- Department of Biochemistry, Faculty of Science, Bahauddin Zakariya University, Multan, 60800, Pakistan
| | | | - Sheraz Ahmed Bhatti
- Department of Pathobiology, Faculty of Veterinary Science, Bahauddin Zakariya University, Multan, 60800, Pakistan
| | - Imran Imran
- Department of Pharmacology, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, 60800, Pakistan
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Sajjadi SS, Foshati S, Haddadian-Khouzani S, Rouhani MH. The role of selenium in depression: a systematic review and meta-analysis of human observational and interventional studies. Sci Rep 2022; 12:1045. [PMID: 35058530 PMCID: PMC8776795 DOI: 10.1038/s41598-022-05078-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
The results of human studies are inconsistent regarding selenium and depressive disorders. Therefore, we aimed to conduct a systematic review and meta-analysis of observational and interventional studies and provided an overview of the role of selenium in depression. Three databases including Medline, Scopus, and Web of Science were searched on June 30, 2020 and updated on April 12, 2021. Also, we searched in electronical databases of WHO Global Index Medicus and ClinicalTrials.gov. No time or language restrictions were used for the search. A random effects model was used to pool effect sizes. In total, 20 studies were included in the systematic review, and 15 studies were included in the meta-analysis. There were no significant differences in serum selenium levels between patients with depression and healthy subjects (WMD: 2.12 mg/L; 95% CI: - 0.11, 4.36; I2 = 98.0%, P < 0.001). Also, no significant correlation was found between serum levels of selenium and depression scores (r: - 0.12; 95% CI: - 0.33, 0.08; I2 = 73.5%, P = 0.010). Nevertheless, there was a significant negative association between high selenium intake and the risk of postpartum depression (OR: 0.97; 95% CI: 0.95, 0.99; I2 = 0.0%, P = 0.507). In addition, selenium supplementation significantly reduced depressive symptoms (WMD: - 0.37; 95% CI: - 0.56, - 0.18; I2 = 0.0%, P = 0.959). Taken these results together, selenium seems to have a protective role against postpartum depression and can be considered as a beneficial adjuvant therapy in patients with depression. Further studies are necessary to draw definitive conclusions.
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Affiliation(s)
- Sana Sadat Sajjadi
- Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sahar Foshati
- Food Security Research Center, Department of Clinical Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sajjad Haddadian-Khouzani
- Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Hossein Rouhani
- Food Security Research Center, Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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Ferreira de Almeida TL, Petarli GB, Cattafesta M, Zandonade E, Bezerra OMDPA, Tristão KG, Salaroli LB. Association of Selenium Intake and Development of Depression in Brazilian Farmers. Front Nutr 2021; 8:671377. [PMID: 34095192 PMCID: PMC8173156 DOI: 10.3389/fnut.2021.671377] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/14/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Depression and deficiency in the consumption of micronutrients are a public health problem, especially in the rural population. The deficiency in selenium consumption affects mental health, contributing to the development of major depressive disorders. Thus, this study aimed to evaluate selenium intake and its association with depressive symptoms in farmers in southeastern Brazil. Material and Methods: Epidemiological, cross-sectional, and analytical study with 736 farmers aged between 18 and 59. A semistructured questionnaire was used to collect sociodemographic, lifestyle and clinical condition data. For evaluation of food intake, three 24-h recalls were applied, and for identification of depressive episodes, the Mini-International Neuropsychiatric Interview was conducted. Results: A total of 16.1% (n = 119) of the farmers presented symptoms of major depressive episodes, 5.8% (n = 43) presented symptoms of current depressive episodes, and 10.3% (n = 76) presented symptoms of recurrent major depressive episodes. Sociodemographic factors associated with depression were gender (p < 0.001), marital status (p = 0.004), and socioeconomic class (p = 0.015). The consumption of high doses of selenium was associated with a reduction of ~54% in the chances of occurrence of depression (OR = 0.461; 95% CI = 0.236-0.901). Conclusion: High selenium intake is associated with a lower prevalence of depression even after adjusting for sociodemographic variables, lifestyle, and pesticide intoxication. The findings of this study contributed to highlighting the high prevalence of depression in rural areas and its relationship with selenium intake.
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Affiliation(s)
| | - Glenda Blaser Petarli
- Clinical Nutrition Unit of the Cassiano Antonio Moraes Hospital (HUCAM) of the Federal University of Espírito Santo, Vitória, Brazil
| | - Monica Cattafesta
- Postgraduate Program in Public Health, Federal University of Espírito Santo, Vitória, Brazil
| | - Eliana Zandonade
- Department of Statistics and the Graduate Program in Collective Health at the Federal University of Espírito Santo, Vitória, Brazil
| | | | | | - Luciane Bresciani Salaroli
- Department of Integrated Health Education, Postgraduate Program in Nutrition and Health, Postgraduate Program in Collective Health of the Federal University of Espírito Santo, Vitória, Brazil
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