Abstract

The aim of this study was to evaluate the intake of ultra-processed foods and associated factors in prepubertal children. It is a cross-sectional study with 378 children aged 8 and 9 years enrolled in public and private schools in Viçosa-MG. Food intake was assessed by three 24-hour dietary recalls. Dietary data were entered into the Diet Pro® 5i software to quantify energy intake. The Two-Step Cluster technique was used to analyze food consumption groups, with the Stata 13 software package. The foods were grouped and classified as “healthy” and “unhealthy” eating markers. The association between the sociodemographic variables and the groups formed was examined by Poisson Regression. Two food groups were formed: “healthy” and “unhealthy”. The caloric intake of ultra-processed foods was lower in the “healthy” group (20.5%) than in the “unhealthy” group (24.1%; P = 0.043). The multivariate model showed that private school children (PR = 1.25, P <0.001), who did not receive Bolsa Familia (PR = 1.13, P = 0.036) and had working mothers (PR = 1.38, P <0.001) had increased probability of unhealthy food consumption. Ultra-processed food intake was associated with greater purchasing power of families of prepubertal children.

Key words
Child; Processed foods; Socioeconomic factors

Introduction

In recent decades, the dietary pattern of the Brazilian population has been changed, with a decrease in the consumption of fresh and minimally processed foods andincrease in intake of processed and ultra-processedfoods¹1 Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutrition 2010;14(1):5-13.^,22 Barcelos GT, Rauber F, Vitolo MR. Produtos processados e ultraprocessados e ingestão de nutrientes em crianças. Ciência & Saúde 2014;7(3):155-161.. These changes result in a higher energy density diet, in association with an increase in the intake of chemical additives, sugar, sodium, saturated and trans fat, and a decrease in fiber intake²2 Barcelos GT, Rauber F, Vitolo MR. Produtos processados e ultraprocessados e ingestão de nutrientes em crianças. Ciência & Saúde 2014;7(3):155-161.^,33 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Participação crescente de produtos ultraprocessados na dieta brasileira (1987-2009). Rev Saude Publ 2013;47(4):656-665..

Ultra-processedfoods (UPF) are industry formulations made from food-derived substances³3 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Participação crescente de produtos ultraprocessados na dieta brasileira (1987-2009). Rev Saude Publ 2013;47(4):656-665.^,44 Louzada MLC, Martins APB, Canella DS, Baraldi LG, Levy RB, Claro RM, Moubarac JC, Cannon G, Monteiro CA. Alimentos ultraprocessados e perfil nutricional da dieta no Brasil. Rev Saude Publ 2015;49(38):1-11.. The National School Health Survey (PeNSE)shows an increase in the intake of unhealthy foods such as fried foods, sausages, sweet or savoury packaged snacks,and carbonated soft drinks⁵5 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar. Brasília: IBGE; 2012.. This increase may be related to the school environment that influences students’ dietary choice, since most of the food advertisements in the media refer to industrialized products²2 Barcelos GT, Rauber F, Vitolo MR. Produtos processados e ultraprocessados e ingestão de nutrientes em crianças. Ciência & Saúde 2014;7(3):155-161..

Even though there are still few studies evaluating the individual UPF intake, it is known that household availability of ultra-processedfoods increased with overweightprevalence⁶6 Bielemann RM, Motta JVS, Minten GC, Horta BL, Gigante DP. Consumo de alimentos ultraprocessados e impacto na dieta de adultos jovens. Rev Saude Publ 2015;49(28):1-10.. According to data from the Family Budget Survey (POF 2008-2009), 14% of Brazilian children aged 5 to 9 years were obese and 33.5% overweight⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2008-2009: avaliação nutricional da disponibilidade de alimentos no Brasil. Rio de Janeiro: IBGE; 2010.. This scenario is worrisome, since the nutritional status and eating pattern acquired in childhood tend to remain in adulthood⁸8 Bertuol CD, Navarro AC. Consumo alimentar e prevalência de sobrepeso/obesidade em pré-escolares de uma escola infantil pública. Revista Brasileira de Obesidade, Nutrição e Emagrecimento 2015;9(52):127-134..

Sociodemographic factors such as parental income and education may be associated with the consumption of ultra-processed foods; however, studies are conflicting regarding these associations. Some studies have found an association between higher UPFintake and poorer diet quality with lower income and education of individuals⁹9 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Participação crescente de produtos ultraprocessados na dieta brasileira (1987-2009). Rev Saude Publ 2013;47(4):656-665.

10 Wijtzes AI, Jansen W, Jansen PW, Jaddoe VW, Hofman A, Raat H. Maternal educational level and preschool children's consumption of high-calorie snacks and sugar-containing beverages: mediation by the family food environment. Prev Med 2013;57(5):607-612.^-1111 Momm N, Hofelmann DA. Qualidade da dieta e fatores associados em crianças matriculadas em uma escola municipal de Itajaí, Santa Catarina. Cad Saude Colet 2014;22(1):32-39., while other studies show higher UPFintakewithincreasing income and education¹²12 Karnopp EVN, Vaz JS, Schafer AA, Muniz LC, Souza RLV, Santos I, Gigante DP, Assunção MCF. Food consumption of children younger than 6 years according to the degree of food processing. J Pediatr 2017;93(1):70-78.

13 Bielemann RM, Motta JVS, Minten GC, Horta BL, Gigante DP. Consumo de alimentos ultraprocessados e impacto na dieta de adultos jovens. Rev Saude Publ 2015;49(28):1-10.^-1414 Sparrenberger K, Friedrich RR, Schiffner MD, Schuch I, Wagner MB. Ultra-processed food consumption in children from a Basic Health Unit. J Pediatr 2015;91(6):535-542.. From the foregoing, therefore, this study aimed to evaluate the intake of ultra-processedfoods and associated factors in prepubertal children.

Methods

Population and study design

This is a quantitative, descriptive, cross-sectional study with a representative sample of 378 children aged 8 and 9 years enrolled in public and private schools in the urban area of Viçosa, Minas Gerais. The participants of this study came from the School Health Assessment Survey (PASE), a population-based cross-sectional investigation aimed at investigating the cardiovascular health of children in Viçosa, MG, Brazil.

The municipality of Viçosa is located in Zona da Mata Region and has a landarea of 299 km² and 72,244 inhabitants, 93.2% of the population livingin urban areas⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2008-2009: avaliação nutricional da disponibilidade de alimentos no Brasil. Rio de Janeiro: IBGE; 2010.. In 2015, the municipality had 24 urban public and private schools with 1,464 children aged 8 and 9 yearsenrolled.

The sample was calculated using the statistical programEpi Info (version 7.2; Atlanta, GA),based on thetotal population of students aged 8 and 9 years according to data collected in urban schools in 2014/2015. The calculationconsidered the total student population (n = 1464 students); prevalence of 50% since the study considered multiple outcomes; desired accuracy of 5%; 95% confidence level, and 20% increase to cover losses¹⁵15 Luiz RR, Magnanini MMF. O tamanho da amostra em investigações epidemiológicas. In: Medronho RA, Bloch KV, Luiz RR, Werneck GL. Epidemiologia. 2ª Edição. São Paulo: Atheneu; 2009. p. 415-429., totaling 366 children. Then, considering the numerical proportion of each school, the number of children to be sampled in each school was proportional to the total number of students of each school. Students were randomly selected until the number of students required for each school was completed.

The non-inclusion criteria were:regular use of medications that could alter nutritional status, body composition, lipid profile, blood pressure and/or glycemic metabolism; physical disabilityto perform anthropometric measurements; and disorders of the gastrointestinal or oropharyngeal tract leading to changes in food intake. A pilot study was conducted with 39 children aged 8 and 9 years, corresponding to 10% of the sample. These children were randomly selected to test the questionnaires and food surveys. Children selected for the pilot study were not included in the final sample.

This study was carried out accordingto the guidelines of the Declaration of Helsinki and approved by the Human Research Ethics Committee of the Federal University of Viçosa (UFV). All parents and children were informed about the purpose of the study, as all participants signed the Informed Consent Form.

Socioeconomic and demographic conditions of families

The interviews with the parents or guardians were conducted by nutritionists using a semi-structured questionnaire related to socioeconomic and environmental conditions, includingself-declared race, income, education, participation in health care programs, type of school, and physical activities. To evaluate family income, data on the income of all household residents and the number of people dependent on the declared income were collected to calculate the per capita income. For the individuals’classification, it was consideredthe median of per capita income.

Food consumption

Dietary intake was assessed by three 24-hour dietary recalls, conducted by a nutritionist, over non-consecutive days, including one on the weekend day.The children responded the food survey accompanied by their parents or guardians, preferably the one directly involved with the child’s diet.

Household utensils and a photograph album with food serving sizes were used to assist participants in estimating the portion sizes¹⁶16 Zabotto CB, Vianna RPT, Gil MF. Registro fotográfico para inquéritos dietéticos: utensílios e porções. Goiânia: Nepa-Unicamp; 1996.. Dietary data analysis was performed using Diet Pro^® 5i software (version 5.8) to quantify energy intake¹⁷17 DIET, PRO. "VERSÃO 5. i.". Software de avaliação nutricional e prescrição dietética. UFV, Viçosa, MG, Brasil. AS Sistema; 1997.. The foods were grouped and classified as “healthy” and “unhealthy” eating markers. For this classification, we took into consideration the recommendations of the Food Guide for the Brazilian population¹⁸18 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica, Coordenação Geral de Alimentação e Nutrição. Guia alimentar para a população brasileira (versão para consulta pública). Brasília: MS; 2014., which promotesconsumption of fresh or minimally processed foods (“healthy” eating markers) overultra-processedfoods (“unhealthy” eating markers) (Box 1).

In this study, the industrial formulations made with five or more ingredients such as additives, antioxidants, stabilizers, and preservatives¹⁹19 Monteiro CA, Cannon G, Levy R, Moubarac JC, Jaime P, Martins AP, Canella D, Louzada M, Parra D. NOVA. A estrela brilha. Word Nutrition 2016;7(1-3):28-40.were considered as ultra-processedfoods. As we found no recommendations regarding UPF consumption, we considered as “regular” when it was below the 75^th percentile of the sample, while for the consumption of healthy dietary marker foods, we considered as “regular” when the intake was above the 75^th percentile.

Data analysis

The analysis of food intake profilesof children was performed using the Two-Step Cluster (TSC) technique in the Stata software version 13.0. The method allows clustering the sample into profiles of individuals with similar food consumption. After forming the clusters, their association with the sociodemographic variableswas assessed.

Intake of food groups among the clusters formedwas compared by the Student’s t test. The bivariate analysis was performed using Poisson regression models with robust variance, with the clusters formed as the dependent variable and the eating habits and socioeconomic aspects as the explanatory variables. The Prevalence Ratio (PR) was calculated using a 95%confidence interval (95% CI).A significance of 5% was adopted for all the analyses.

Results

In this study, 52.1% (n = 197) of the children were female, 50.3% (n = 190) were 9 years old, 68.5% (n = 259) were non-white, and 70.9% (n = 268) were enrolled in public schools.

The dietary profile of the individualswas classified in two groups: “healthy” and “unhealthy”. The “healthy” group consisted of 116 children (30.7%), representing less than half of the children in the sample (Table 1).

Rice and beans, vegetables, milk, fruit, and meat were present in both groups. However, among the markers of unhealthy eating, we highlight the presence of ultra-processed foods (fast foods, cookies, and sausages), which differentiate between “healthy” and “unhealthy” profiles (Table 1).

The contribution of each variable to the formation of the profiles is measured by the regular or irregular consumption of the food groups (according to the 75^th percentile). Some groups (condiments, industrialized beverages, instant noodles, and sweets) had a similar consumption in all clusters, therefore, they could not differentiate them and, at the end of the statistical analysis,they were not included in the food groupsformed.

The “healthy” group showed higherintake of vegetables and milk, while the children of the “unhealthy” group showed higher intake of fast foods, cookies and sausages (Table 2).

The assessment of the caloric intake of UPF consumed in each group showed that the energy contribution in the “healthy” group (20.5%) was lower than in the “unhealthy” group (24.1%) (p = 0.043).

The univariate analysis showed an association between sociodemographic and environmental variables with children dietary profile. We found that the “unhealthy” consumption was higher in children from private schools (PR = 1.28 (1.20-1.37), p = <0.001), who always brought snacks to school (PR = 1 , 13 (1.01-1.27), p = 0.022), did not receive Bolsa Familia/BFP (Family Grant) (PR = 1.22 (1.10-1.36), p = <0.001), had higher family income (PR = 1.13 (1.05-1.23), p = 0.001), and had working mother (PR = 1.26 (1.21-1.31), p = <0.001). In contrast, non-white children (PR = 0.91 (0.84-0.99), p = 0.031) and those who did not engage in physical activity (PR = 0.91 (0.84-0.98), p = 0.026) had less consumption of the “unhealthy” group (Table 3). The adjusted multivariate regression model showed that private school children, who did not receive a family grant (BolsaFamília) and had working mothers showed higher consumption of food from the “unhealthy” group (Table 4).

Discussion

This study identified two food consumption profiles (clusters) and the intake of fast foods, cookies, and sausages differentiated the “healthy” and “unhealthy” profiles.

The “healthy” food group had lower prevalence in the sample (30.7%), reflecting the reality found by another study, in which only 9% of Brazilian children reached the recommended servings of fruits and vegetables²⁰20 Chafee BW. Early life factors among the many influences of child fruit and vegetable consumption. J Pediatr 2014;90(5):437-439.. The results showed no difference between the groups for fruit intake, because in both groups the consumption was below the recommended. However, these foods are essential for health since they are sources of vitamins and minerals, besides preventing the risk of chronic diseases²¹21 Castanho GKF, Marsola FC, Mclellan KCP, Nicola M, Moreto F, Burini RC. Consumo de frutas, verduras e legumes associados à Síndrome Metabólica e seus componentes em amostra populacional adulta. Ciên Saude Colet 2013;18(2):385-392.^,2222 Muniz LC, Zanini RV, Schneider BC, Tassitano RM, Feitosa WMN, Gonzáles-Chica DA. Prevalência e fatores associados ao consumo de frutas, legumes e verduras entre adolescentes de escolas públicas de Caruaru, PE. Ciên Saude Colet 2013;18(2):393-404..

Fast foods, cookies and sausages consumed by children in the “unhealthy” group havelow nutrients and high energy density³3 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Participação crescente de produtos ultraprocessados na dieta brasileira (1987-2009). Rev Saude Publ 2013;47(4):656-665.. Currently, there is a great advertising appeal regarding this group of foods, which leads to an increasingly frequent consumption among children²³23 Porto RB, Oliveira-Castro JM. Say - do correspondence in brand choice: Interaction effects of past and current contingencies. The Psychological Record 2013;63(2):345-362.. This higher consumption may predispose children to overweight and hypertension²⁴24 Payab M, Kelishad R, Qorbani M, Motlagh ME, Ranjbar SH, Ardalan G, Zahedi H, Chinian M, Asayesh H, Larijani B, Heshmat R. Association of junk food consumption with high blood pressure and obesity in Iranian children and adolescents: the Caspian-IV study. J Pediatr 2015;91(2):196-205..

According to the Family Budget Survey(POF2008-2009), UPF contributed 28% of daily energy intake⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2008-2009: avaliação nutricional da disponibilidade de alimentos no Brasil. Rio de Janeiro: IBGE; 2010.. This result is close to our findings, in which UPF contributed with 20.5% in the “healthy” group and 24.1% in the “unhealthy” group and is in line with other studies that evaluated the consumption of ultra-processed foods by children and identified a contribution of 19.7 to 47.0% of this group to total caloric intake¹²12 Karnopp EVN, Vaz JS, Schafer AA, Muniz LC, Souza RLV, Santos I, Gigante DP, Assunção MCF. Food consumption of children younger than 6 years according to the degree of food processing. J Pediatr 2017;93(1):70-78.^,1414 Sparrenberger K, Friedrich RR, Schiffner MD, Schuch I, Wagner MB. Ultra-processed food consumption in children from a Basic Health Unit. J Pediatr 2015;91(6):535-542.^,2424 Payab M, Kelishad R, Qorbani M, Motlagh ME, Ranjbar SH, Ardalan G, Zahedi H, Chinian M, Asayesh H, Larijani B, Heshmat R. Association of junk food consumption with high blood pressure and obesity in Iranian children and adolescents: the Caspian-IV study. J Pediatr 2015;91(2):196-205..

It is of note that the consumption of processed products has become a habit since the early years of life, with the introduction of complementary feeding²2 Barcelos GT, Rauber F, Vitolo MR. Produtos processados e ultraprocessados e ingestão de nutrientes em crianças. Ciência & Saúde 2014;7(3):155-161.. In Brazil, one out of every three children under two has consumed soda and 60.8% have had cookies or cakes²⁵25 Jaime PC, Frias PG, Monteiro HOC, Almeida PVB, Malta DC. Assistência em saúde e alimentação não saudável em crianças menores de dois anos: dados da Pesquisa Nacional de Saúde, Brasil, 2013. Rev Bras Saude Mater Infant 2016;16(2):159-167.. Among schoolchildren, this scenario is no different. A study conducted among schools in Maranhão found higher consumption of soda than fresh fruit juices and the intake in private schools was significantly higher than in the public ones²⁶26 Conceição SIO, Santos CJN, Silva AAM, Silva JS, Oliveira TC. Consumo alimentar de escolares das redes pública e privada de ensino em São Luís, Maranhão. Rev Nutr 2010;23(6):993-1004..

It is believedthat this high consumption by the child group is due to stores around schools that favor the consumption of UPF products. In Santos (SP), stores that soldUPF were significantly closer to schools than those that sold fresh and minimally processed foods²⁷27 Leite FHM, Oliveira MA, Cremm EC, Abreu DSC, Maron LR, Martins PA. Availability of processed foods in the perimeter of public schools in urban areas. J Pediatr 2012;88(4):328-334.. In addition, food advertising has increasingly focused on encouraging UPF consumption, focusing on the benefits of fortified products. These issues lead the consumer to believe that fortified industrialized products are characterized as healthy. Even 30-second exposures to televised food commercials is believed to influence children’s choice of a particular food²⁸28 Momm D, Hofelmann DA. Qualidade da dieta e fatores associados em crianças matriculadas em uma escola municipal de Itajaí, Santa Catarina. Cad Saude Colet 2014;22(1):32-39..

In this study, “unhealthy” consumption was higher among children enrolled in private schools. It is known that in this case, students tend to eat snacks brought from home or bought in the school cafeteria. A study conducted in Rio de Janeiro showed that these snacks are usually high energy densityfoods²⁹29 Barros MS, Fonseca VM, Meio MDBB, Chaves CR. Excesso de peso entre adolescentes em zona rural e a alimentação escolar oferecida. Cad Saude Colet 2013;21(2):201-208.. Moreover, the National School Feeding Program (PNAE) intervenes to promote healthy eating in public schools³⁰30 Libermann AP, Bertolini GRF. Tendências de pesquisa em políticas públicas: uma avaliação do Programa Nacional de Alimentação Escolar - PNAE. Ciên Saude Colet 2015;20(11): 3533-3546.. Another study carried out in Paraíba evaluated the height/age index and identified greater nutritional vulnerability of children who did not eat school meals³¹31 Pedraza DF, Silva FA, Melo NLS, Araujo EMN, Souza CPC. Estado nutricional e hábitos alimentares de escolares de Campina Grande, Paraíba, Brasil. Ciên Saude Colet 2017;22(2):469-477..

Children with working mothers had a higher prevalence of food consumption in the “unhealthy” group. It is important to point out that UPfoodshave become attractive to the populationbecause of their practicality, since they require almost nocooking/food preparation.Their consumption increases with the greater participation of women in the labor market and contemporary lifestyle, characterized by lack of time to prepare meals³3 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Participação crescente de produtos ultraprocessados na dieta brasileira (1987-2009). Rev Saude Publ 2013;47(4):656-665..

According to data from the Family Budget Survey (POF 2008/2009), 28% of food expenses were attributed to foodspurchased for consumption away from home, part of which consisted of UPF⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2008-2009: avaliação nutricional da disponibilidade de alimentos no Brasil. Rio de Janeiro: IBGE; 2010.. However, this change in food profile is not restricted to the Brazilian population.Recent studies have shown that it consists of a consumption phenomenon characterized by the emergence of transnational food industries, followed by a reduction in the relative price of these products³3 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Participação crescente de produtos ultraprocessados na dieta brasileira (1987-2009). Rev Saude Publ 2013;47(4):656-665.^,3232 Moubarac JC, Claro KM, Baraldi LG, Levy RB, Martins AP, Cannon G, Monteiro CA. International diferences in cost and consumption of ready to consume food and drink products: United Kingdom and Brazil 2008-2009. Global Public Health 2013;8(7):845-856.. In Canada, the participation of UPFs in the population’s diet increased from 24.4% to 54.9% between 1938-1939 and 2001³²32 Moubarac JC, Claro KM, Baraldi LG, Levy RB, Martins AP, Cannon G, Monteiro CA. International diferences in cost and consumption of ready to consume food and drink products: United Kingdom and Brazil 2008-2009. Global Public Health 2013;8(7):845-856..

“Unhealthy” consumption was more prevalent among children whose families did not receive Bolsa Familia. It is believed that the families use the BFP benefits to purchase healthy foods, which improves the quality and quantity of families’ food³³33 Vasconcelos PN, Cavalcanti DS, Leal LP, Osório MM, Fialho MB. Tendência temporal e fatores determinantes da anemia em crianças de duas faixas etárias (6-23 e 24-59 meses) no Estado de Pernambuco, Brasil, 1997-2006. Cad Saude Publica 2014;30(8):1777-1787.. Furthermore, Pedraza et al.³⁴34 Pedraza DF, Rocha ACD, Sousa CPC. Crescimento e deficiências de micronutrientes: perfil das crianças assistidas no núcleo de creches do governo da Paraíba, Brasil. Ciên Saude Colet 2013;18(11):3379-3390. observed that the BFP program was effective regarding the recovery and maintenance of children’s nutritional status.

It is also noteworthy that in order to receive the BFP benefit,the families are required to meet some conditioning factors, including periodic monitoring of the nutritional and health status of the families; participation in actions of food and nutrition education; and children’s school attendance³⁵35 Wolf MR, Barros Filho AA. Estado nutricional de beneficiários do programa Bolsa Família no Brasil - um revisão sistemática. Ciên Saude Colet 2014;19(5):1331-1338.. Theschool attendance guarantees access toschool meals, and as already mentioned, it is a nutritionally adequate diet.

Somestrong points of thiswork should be highlighted. It is one of the few studies conducted in developing countries that investigated factors associated with the consumption of ultra-processed foods in childhoodand is the first population-based study with prepubertal children in Brazil. Because there is a relationship between the intake of ultra-processed foods and the increase of overweight/obesity³⁶36 Mendonça RD, Pimenta AM, Gea A, Fuente-Arrillaga C, Martinez-Gonzales MA, Lopes ACS, Bes-Rastrollo M. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-up (SUN) cohort study. Am J Clin Nutr 2016;104(5):1433-1440., thechildhood is an important phase to evaluate the factors associated with this consumption.It is a critical period in the formation of healthy eating habits, and every effort must be made to maintain these in adulthood. These findings are consistent with other studies suggesting that the consumption of ultra-processed foods has increased. A limitation to consider in this studyis the lack of some information in the food composition tables, especially in relation to ultra-processedfoods, since every day new products appear in the market.

This study allows us to conclude that the consumption of ultra-processed products was associated with the highest socioeconomic conditions of the children’s families. These findingspoint out the importance of adopting preventive measures, with emphasis on reducing the consumption of ultra-processedfoods. This will be done through actions of food and nutrition education involving parents and educators to improve the living conditions of children and their families, as well as the access to information on purchase and consumption of healthy foods.

References

Publication Dates

History