Abstract

The aim of this study was to identify social determinants of health associated with the experience of hunger among school-age adolescents in Brazil. We conducted a cross-sectional study with a sample of 16,526 adolescents using data from the 2015 National School-based Student Health Survey. Experience of hunger was determined based on the answer to the question “In the last 30 days, how often have you been hungry because there wasn’t enough food at home?” The social determinants of health were analyzed using Poisson regression with robust variance. The prevalence of the experience of hunger was 22.8% (95%CI: 21.9-23.7). The experience of hunger was directly associated with being male (PR = 1.12; 95%CI: 1.07-1.16); not being overweight (PR = 1.08; 95%CI: 1.04-1.13 ); irregular consumption of beans (PR = 1.20; 95%CI: 1.13-1.26), vegetables (PR=1.16; 95%CI: 1.09-1.22) and fruit (PR = 1.19; 95%CI: 1.13-1.24); body dissatisfaction (PR = 1.26; 95%CI: 1.18-1.35); and not regularly eating lunch or dinner with parents or guardians (PR = 1.41; 95%CI: 1.32-1.52). An inverse association was found between the experience of hunger and maternal education level and living in the Mid-West, Southeast and South. The findings show that the experience of hunger among Brazilian adolescents coexists with risky eating behaviors, body dissatisfaction, and social inequality.

Key words:
Hunger; Adolescents; Social determinants of health

Introduction

Adolescence is a period of physical and psychological development characterized by changes in the body and peer group relations¹1 Golden NH, Schneider M, Wood C. Preventing Obesity and Eating Disorders in Adolescents. Pediatrics 2016; 138(3):e20161649.

2 Kim Y, Austin SB, Subramanian SV, Thomas JJ, Eddy KT, Franko DL, Rodgers RF, Kawachi I. Risk factors for disordered weight control behaviors among Korean adolescents: Multilevel analysis of the Korea Youth Risk Behavior Survey. Int J Eat Disord 2018; 51(2):124-138.

3 Nagata JM, Garber AK, Tabler JL, Murray SB, Bibbins-Domingo K. Differential Risk Factors for Unhealthy Weight Control Behaviors by Sex and Weight Status Among U.S. Adolescents. J Adolesc Health 2018; 63(3):335-341.

4 Ferreira CS, Andrade FB. Desigualdades socioeconômicas associadas ao excesso de peso e sedentarismo em adolescentes brasileiros. Cien Saude Colet 2021; 26(3):1095-1104.

5 Militello LK, Kelly S, Melnyk BM, Smith L, Petosa R. A Review of Systematic Reviews Targeting the Prevention and Treatment of Overweight and Obesity in Adolescent Populations. J Adolesc Health 2018; 63(6):675-687.^-66 Beserra JB, Soares NIS, Marreiros CS, Carvalho CMRG, Martins MCC, Freitas BJSA, Santos MM, Frota KMG. Crianças e adolescentes que consomem alimentos ultraprocessados possuem pior perfil lipídico? Uma revisão sistemática. Cien Saude Colet 2020; 25(12):4979-4989.. In Brazil, despite the creation of the Child and Adolescent Statute⁷7 Gubelmann A, Berchtold A, Barrense-Dias Y, Akre C, Newman CJ, Suris J-C. Youth With Chronic Conditions and Risky Behaviors: An Indirect Path. J Adolesc Health 2018; 63(6):785-791. (Law 8069/90) to protect the rights of this group, problems during this phase of health vulnerability are aggravated by the socioeconomic inequalities facing a large proportion of adolescents⁸8 Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União 1990; 26 set.. One way of recognizing these unequal and unfair realities, which constitute social determinants of health, is to identify the experience of hunger or difficulty accessing adequate food among this group⁹9 Terribele FBP, Munhoz TN. Violência contra escolares no Brasil: Pesquisa Nacional da Saúde do Escolar (PeNSE, 2015). Cien Saude Colet 2021; 26(1):241-254.^,1010 Marin-Leon L, Francisco PMSB, Segall-Corrêa AM, Panigassi G. Bens de consumo e insegurança alimentar: diferenças de gênero, cor de pele autorreferida e condição socioeconômica. Rev Bras Epidemiol 2011; 14(3):398-410., otherwise known as food and nutrition insecurity¹¹11 Maluf RS, Reis MC. Conceitos e Princípios de Segurança Alimentar e Nutricional. In: Rocha C, organizador. Segurança Alimentar e Nutricional: perspectivas, aprendizados e desafios para as políticas públicas. Rio de Janeiro: Editora Fiocruz; 2013. p. 15-42..

The concept of food and nutrition insecurity gained greater visibility after the creation of the Organic Law on Food and Nutrition Security, which sets out strategies to guarantee the right to adequate food¹²12 Brasil. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional (SISAN) com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 set.. Food insecurity among adolescents is associated with poor infrastructure and low levels of human capital, income, employment, social support and education¹⁰10 Marin-Leon L, Francisco PMSB, Segall-Corrêa AM, Panigassi G. Bens de consumo e insegurança alimentar: diferenças de gênero, cor de pele autorreferida e condição socioeconômica. Rev Bras Epidemiol 2011; 14(3):398-410.^,1313 Sousa LRM, Segall-Corrêa AM, Ville AS, Melgar-Quiñonez H. Food security status in times of financial and political crisis in Brazil. Cad Saude Publica 2019; 35(7):e00084118.

14 Nascimento AL, Andrade SLLS. Segurança alimentar e nutricional: pressupostos para uma nova cidadania? Cien Cultura 2010; 62(4):34-38.^-1515 Bezerra MS, Jacob MCM, Ferreira MAF, Vale D, Mirabal IRB, Lyra CO. Insegurança alimentar e nutricional no brasil e sua correlação com indicadores de vulnerabilidade. Cien Saude Colet 2020; 25(10):3833-3846., which are categorized as structural and intermediary determinants of health¹⁶16 World Health Organization (WHO). A conceptual framework for action on the social determinants of health. Geneva: WHO; 2010.^,1717 World Health Organization (WHO). Declaração Política do Rio sobre Determinantes Sociais da Saúde. Rio de Janeiro: WHO; 2011..

Researchers began to investigate the denial of the right to food in Brazil from the perspective of food and nutrition insecurity in the 1990s. At the beginning of the twentieth century, the problem was assessed using different categories of hunger. However, hunger was normalized and it was only later that the condition was assigned the status of a social problem by researchers such as Josué de Castro, author of Geography of Hunger, published in 1946¹⁸18 Castro J. Geografia da fome: o dilema brasileiro: pão ou aço. 11ª ed. Rio de Janeiro: Civilização Brasileira; 2011.. Maria do Carmo Freitas¹⁹19 Freitas MCS. Agonia da fome. Rio de Janeiro: Editora Fiocruz, Salvador: EDUFBA; 2003. discussed hunger as a public health problem in her work Agonia da Fome (The Agony of Hunger), highlighting that it was caused by processes of social exclusion and revealed “in every context of political and economic domination”. Hunger is a complex and multifactorial social phenomenon and should therefore be monitored in different contexts in Brazil, especially considering that the situation is worsening due to increasing social vulnerability caused by the current sociopolitical context²⁰20 Rede PENSSAN. Olhe para a fome [Internet]. [acesso 2021 ago 3]. Disponível em: http://olheparaafome.com.br.
http://olheparaafome.com.br... .

Given the urgency of developing actions to tackle this problem in Brazil, it is important to investigate how hunger manifests itself in different contexts (individual, household and regional) and the relationship with behavioral, physical and social factors²¹21 Food and Agriculture Organization of the United Nations (FAO). O Estado Da Segurança Alimentar e Nutricional no Brasil: Um retrato multidimensional - Relatório 2014. Brasília: FAO; 2014.. It is important to highlight that in recent studies hunger is described as severe food insecurity, which negatively affects nutrition and food outcomes²²22 Amuna P, Zotor FB. Epidemiological and nutrition transition in developing countries: impact on human health and development. Proc Nutr Soc 2008; 67(1):82-90.^,2323 Kepple AW, Segall-Corrêa AM. Conceituando e medindo segurança alimentar e nutricional. Cien Saude Colet 2011; 16(1):187-199..

The prevalence of severe food insecurity in Brazilian households dropped from 9.5% in 2004 to 4.2% in 2013. However, the rate has begun to rise again, reaching 9% in 2020²⁰20 Rede PENSSAN. Olhe para a fome [Internet]. [acesso 2021 ago 3]. Disponível em: http://olheparaafome.com.br.
http://olheparaafome.com.br... . The prevalence of severe food insecurity and its social and physical effects is higher among structurally vulnerable groups, such as children, adolescents, women and older persons²⁴24 Carmo ME, Guizardi FL. O conceito de vulnerabilidade e seus sentidos para as políticas públicas de saúde e assistência social. Cad Saude Publica 2018; 34(4):1-14.. The findings of the 2017-2018 national household budget survey illustrate different levels of vulnerability across Brazil, showing that the prevalence of severe food insecurity was higher in households with children and/or adolescents²⁵25 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares: 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020..

Hence, it is evident that adolescents are one of the most vulnerable groups in Brazil and therefore more likely to experience hunger. This is confirmed by the literature, including a study with adolescents living in municipalities with a low human development index in Brazil’s semi-arid region conducted in 2005 showing that the prevalence of severe food insecurity among this group was between 34.0% and 48.8%²⁶26 Oliveira JS, Lira PIC, Veras ICL, Maia SR, Lemos MCC, Andrade SLLS, Viana Junior MJ, Pinto FCL, Leal VS, Bastista Filho M. Estado nutricional e insegurança alimentar de adolescentes e adultos em duas localidades de baixo índice de desenvolvimento humano. Rev Nutr 2009; 22(4):453-465.. In addition, a survey of state capitals conducted between 2011 and 2012 estimated that prevalence of severe food insecurity was 2.6% among adolescents and 13.9% among those whose mothers were illiterate²⁷27 Coelho SEAC, Gubert MB. Insegurança alimentar e sua associação com consumo de alimentos regionais brasileiros. Rev Nutr 2015; 28(5):555-567..

The evidence of food insecurity among adolescents warrants further research at national level to inform food and nutrition surveillance²⁸28 Brasil. Ministério da Saúde (MS). Marco de referência da vigilância alimentar e nutricional na atenção básica. Brasília: MS; 2015. aimed at identifying the most vulnerable groups and associations between hunger and different factors, such as nutritional status, behavior and living standards. These studies can generate quality data to inform policies and actions to address food insecurity and guarantee the right to adequate food among this age group. The aim of this study was therefore to identify social determinants of health associated with the experience of hunger among school-age adolescents.

Methods

Study design and data

We conducted a cross-sectional study using microdata²⁹29 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde do Escolar: 2015. Microdados. Arquivos de Microdados da PeNSE 2015 [Internet]. [acessado 2021 ago 22]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/9134-pesquisa-nacional-de-saude-do-escolar.html?edicao=9135&t=microdados.
https://www.ibge.gov.br/estatisticas/soc... from Sample 2 of the 2015 National School-based Student Health Survey (PeNSE 2015). The questionnaire-based survey was performed by the Brazilian Institute of Geography and Statistics (IBGE) in conjunction with the Ministry of Health and Ministry of Education.

The sample consisted of students regularly attending private and public schools in urban and rural areas between the sixth year of junior high school and third year of high school. A total of 16,608 questionnaires were completed, 16,556 of which were considered valid. Sample 1 permitted comparisons with national and international indicators for this age group, unlike Sample 1, which only represented students in the ninth year of junior high school³⁰30 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2015. Rio de Janeiro: IBGE; 2016..

The survey used a cluster sampling approach involving the following stages: 1) division of the sample area into strata; 2) random selection of schools in each strata (primary sampling unit); and 3) random selection of classes in each school (secondary sampling unit). All students in the selected classes were invited to participate in the survey. The sample size for each stratum was calculated using the following parameters: sampling error of 3% at a 95 percent level of confidence, estimated prevalence of 50%, and sample design effect of “3” in the first stage. This made it possible to estimate the population parameters for each of the country’s five regions (North, Northeast, Southeast, South and Mid-West) and Brazil as a whole³⁰30 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2015. Rio de Janeiro: IBGE; 2016..

The data were collected between April and September 2015 using a self-administered electronic questionnaire. Further details on the methodology and sample design can be found in the survey report published by the IBGE³⁰30 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2015. Rio de Janeiro: IBGE; 2016..

The present study used data obtained from the IBGE database on 16,526 students who answered the dependent variable question, representing only 30 losses (0.18%) in relation to the original survey sample.

Study variables

The dependent variable was the experience of hunger, derived from the question “In the last 30 days, how often have you been hungry because there wasn’t enough food at home?” The possible answers were: (a) “never”, (b) “rarely”, (c) “sometimes”, (d) “most of the time”, and (e) “always”. Outcome (0), “Hasn’t experienced hunger in the last month”, was derived from the answer “never” and the answers b, c, d, e were grouped together to provide the outcome (1), “Experienced hunger in the last month”.

In order to gain a better understanding of the inherent complexity of adolescence³¹31 Vale D. Alimentação e nutrição de adolescentes no Brasil: notas epidemiológicas. Mossoró: Editora UERN; 2020., the independent variables represented dimensions of the social determinants of health model adapted to adolescent dietary patterns and nutrition, which encompasses eating behaviors and body dissatisfaction³¹31 Vale D. Alimentação e nutrição de adolescentes no Brasil: notas epidemiológicas. Mossoró: Editora UERN; 2020. (Chart 1).

For the variables food consumption and eating routines, “regular” was defined as at least five days a week. Nutritional status was assessed based on weight and height, measured by trained interviewers using an electronic scale and portable stadiometer in a private room after the respondent has completed the questionnaire. These data were not collected from students who were unable or refused to undergo anthropometric measurements. Weight and height were measured twice and when the second measurement was different, a third measurement was taken. Only one measurement was recorded for each variable³²32 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2015: manual de instrução. Rio de Janeiro: IBGE; 2015..

Nutritional status was classified based on the BMI-for-age percentile for 10 to 19 years, 11 months and 29 days. Body mass index (BMI) was calculated using the following formula: [weight (kg)/height²2 Kim Y, Austin SB, Subramanian SV, Thomas JJ, Eddy KT, Franko DL, Rodgers RF, Kawachi I. Risk factors for disordered weight control behaviors among Korean adolescents: Multilevel analysis of the Korea Youth Risk Behavior Survey. Int J Eat Disord 2018; 51(2):124-138. (m)]. Excess weight, thinness and short stature were assessed based on weight, height, age and sex using the WHO AnthroPlus software³³33 World Health Organization (WHO). WHO AnthroPlus. Version 1.0.4 [computer program]. Geneva: WHO; 2016. to calculate z-scores. We adopted the WHO Child Growth Standards³⁴34 World Health Organization (WHO). WHO child growth standards: Length/height for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for age. Methods and development. Geneva: WHO; 2006. as the reference for BMI-for-age (BMI/A) and height-for-age (H/A). Nutritional status was classified according to the thresholds for individuals aged between 10 and 19 years, 11 months and 29 days recommended by Brazil’s Food and Nutritional Surveillance System (SISVAN)³⁵35 Brasil. Ministério da Saúde (MS). Orientações para a coleta e análise de dados antropométricos em serviços de saúde: Norma Técnica do Sistema de Vigilância Alimentar e Nutricional. Brasília: MS; 2011..

Ethical aspects

The PeNSE 2015 was approved by the National Research Ethics Committee (CONEP) on 30 March 2015 (code 1.006.467). Just like the other editions (2009 and 2012), the survey provided valuable data for studies investigating risk factors for non-communicable chronic diseases³⁰30 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde do escolar: 2015. Rio de Janeiro: IBGE; 2016.. The present study used data made available by the IBGE and was conducted in accordance with ethical norms and standards for research involving human subjects set out in National Health Council Resolution 510 (April 7 2016)³⁶36 Brasil. Ministério da Saúde (MS). Conselho Nacional de Saúde (CNS). Resolução nº 510, de 7 de abril de 2016. Diário Oficial da União 2016; 24 mar..

Data analysis

The descriptive statistics (prevalence ratios and their respective 95% confidence intervals) were analyzed using SPSS version 20³⁷37 IBM Corp. IBM SPSS Statistics for Windows, Version 20.0. Armonk: IBM Corp; 2011.. The statistical significance (p < 0.05) of differences in the frequencies of the experience of hunger was determined using Pearson’s chi-square test.

The association between the experience of hunger and the independent variables was tested by performing Poisson regression using Stata 13.0 (StataCorp LP, College Station, United States)³⁸38 StataCorp. Stata Statistical Software: Release 13. College Station: StataCorp LP; 2013.. The answer “Hasn’t experienced hunger in the last month” was the reference category for the dependent variable in the Poisson regression models.

First, we performed bivariate Poisson regression (Model 1), estimating crude prevalence ratios (PR) and their respective 95% confidence intervals (95% CI). Only variables with a p-value of < 0.02 were retained in the multivariate Poisson regression model with robust variance. This approach was adopted based on the recommendations for this type of modelling³⁹39 Mickey J, Greenland S. A study of the impact of confounder-selection criteria on effect estimation. Am J Epidemiol 1989; 129(1):125-137.

40 Hosmer DW, Lemeshow S. Applied Logistic Regression. New York: Wiley; 2000.^-4141 Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med 2008; 3(17):1-8. to ensure a best-fitting final model (Model 2). Only variables with a p-value of < 0.05 were retained in the final adjusted model (Model 2). The adjusted prevalence ratios of the variables retained in this model were calculated together with their respective 95% confidence intervals.

The analyses were performed taking into account PeNSE 2015’s complex sampling design using the SPSS Complex Samples module and Stata 13.0 survey data analysis command (svy) to incorporate the post-stratification weights in order to correct for the effect of clustering the primary sampling units (design effect).

Results

Most of the adolescents were male, non-white, aged between 15 and 19 years, not working, did not know their mother’s education level, lived in households with up to four people, and were from the Southeast. The prevalence of the experience of hunger among the sample was 22.8% (95%CI: 21.9-23.7%) (Table 1).

Prevalence of the experience of hunger was higher among respondents who were non-white (23.6%); whose mothers had no basic qualifications (30.4%); who lived in the North (27.0%); who did not eat beans, legumes and vegetables, and fruit regularly (27.0%, 25.4%, and 25.1%, respectively); who did not eat lunch or dinner regularly with parents or guardians (30.4%); and who were indifferent to or dissatisfied with their bodies (28.9% and 26.9%, respectively) (Table 1).

The following variables maintained their association with the experience of hunger in the bivariate Poisson regression model (Model 1): region representative of the sociopolitical and economic context; markers of socioeconomic status and individual and family characteristics (sex, maternal education level); and physical, behavioral and psychosocial factors (excess weight, regular consumption of beans, regular consumption of legumes and vegetables, regular consumption of fruit, regularly eating lunch or dinner with parents or guardians, and body dissatisfaction) (Table 2).

In the multivariate model (Model 2), the likelihood of the experience of hunger was associated with socioeconomic status and individual and family characteristics, being 12% higher in males than in females and 33% lower among individuals whose mothers had completed higher education than in those whose mothers had no basic qualifications. The latter reveals an inversely proportional relationship between maternal education level and the experience of hunger. With regard to sociopolitical and economic context, students living in the North were more likely to experience hunger than those living in other regions.

Associations were also found between the experience of hunger and physical, behavioral and psychosocial factors. The likelihood of experiencing hunger was 8% higher in respondents who were not overweight, 20% higher in those who did not eat beans regularly, 16% higher among those who did not eat legumes and vegetables regularly, 19% higher in those who did not eat fruit regularly, and 41% higher among adolescents who did not Regularly eats lunch or dinner with parents or guardians. The experience of hunger was also associated with level of body satisfaction, being higher among those who reported being indifferent (PR = 1.33; 95%CI 1.18-1.49) and those who were dissatisfied or very dissatisfied (PR = 1.26; 95%CI 1.18-1.35) (Table 2).

Discussion

The prevalence of the experience of hunger among Brazilian adolescents in 2015 (22.8%) was approximately ten times higher than the rate of severe food insecurity (classified as hunger) found by a study with adolescents living in state capitals and the Federal District (2.6%) conducted between 2011 and 2012²⁷27 Coelho SEAC, Gubert MB. Insegurança alimentar e sua associação com consumo de alimentos regionais brasileiros. Rev Nutr 2015; 28(5):555-567.. This rate is also higher than the rates of severe food insecurity found in households with people aged 5-17 years between 2017 and 2018²⁵25 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares: 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020. and in Brazilian households in 2020⁴²42 Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar e Nutricional (Rede PENSSAN). VIGISAN: Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da Covid-19 no Brasil. Brasil: Rede PENSSAN; 2020. (7.3% and 9.0%, respectively).

These differences should be interpreted with caution as each study used different methods. The present study used the answer to a specific question as a marker of the experience of hunger, while the other studies used the Brazilian Food Insecurity Scale²³23 Kepple AW, Segall-Corrêa AM. Conceituando e medindo segurança alimentar e nutricional. Cien Saude Colet 2011; 16(1):187-199.. These comparisons were chosen because we were only able to identify studies of adolescents from state capitals²⁷27 Coelho SEAC, Gubert MB. Insegurança alimentar e sua associação com consumo de alimentos regionais brasileiros. Rev Nutr 2015; 28(5):555-567. or specific regions²⁶26 Oliveira JS, Lira PIC, Veras ICL, Maia SR, Lemos MCC, Andrade SLLS, Viana Junior MJ, Pinto FCL, Leal VS, Bastista Filho M. Estado nutricional e insegurança alimentar de adolescentes e adultos em duas localidades de baixo índice de desenvolvimento humano. Rev Nutr 2009; 22(4):453-465.. Despite these limitations, the findings of the present study confirm increased vulnerability among this age group.

The association between the experience of hunger and a set of characteristics that increase social vulnerability, such as living in the North (sociopolitical and economic context), being male and low maternal education level (socioeconomic status and individual and family characteristics) corroborate the findings of other studies with adolescents in state capitals. In the present study, the prevalence of severe food insecurity was higher among boys, students with mothers without any basic qualifications and those living in the North²⁷27 Coelho SEAC, Gubert MB. Insegurança alimentar e sua associação com consumo de alimentos regionais brasileiros. Rev Nutr 2015; 28(5):555-567.. The relationship between hunger and being male warrants further investigation, as explanations for this association were not found in the literature. The lack of studies for comparison purposes may be explained by the fact that studies of food insecurity usually assess hunger at household level and the variable sex tends to refer to the head of the household and is related to occupation and family income⁴²42 Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar e Nutricional (Rede PENSSAN). VIGISAN: Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da Covid-19 no Brasil. Brasil: Rede PENSSAN; 2020..

With regard to sociopolitical context, the findings suggest that heightened levels of social inequality in the North contribute to increased food insecurity in this region, which is made up of states with the lowest human development index⁴³43 Vale D, Morais CMM, Pedrosa LFC, Ferreira MAF, Oliveira AGRC, Lyra CO. Correlação espacial entre o excesso de peso, aquisição de alimentos ultraprocessados e o desenvolvimento humano no Brasil. Cien Saude Colet 2019; 24(3):983-996.. The region is characterized by poor sociopolitical and economic conditions, which have a negative impact on health outcomes, despite improvements between 2000 and 2016⁴⁴44 Albuquerque MV, Viana ALÁ, Lima LD, Ferreira MP, Fusaro ER, Iozzi FL. Desigualdades regionais na saúde: mudanças observadas no Brasil de 2000 a 2016. Cien Saude Colet 2017; 22(4):1055-1064;.

The coexistence of hunger along with low maternal education level highlights the effect of this variable as a key marker, as shown by studies of social determinants of health⁴⁵45 Barata RB. Como e Por Que as Desigualdades Sociais Fazem Mal à Saúde. Rio de Janeiro: Editora Fiocruz; 2009.. Another study in Brazil shows that, in addition to hunger, adolescents with mothers with a low level of education - which is a proxy for low socioeconomic status - are more prone to the co-occurrence of risk factors for non-communicable chronic diseases (regular consumption of ultra-processed foods, irregular consumption of fruit and legumes, insufficient physical activity, smoking and drinking)⁴⁶46 Ricardo CZ, Azeredo CM, Machado de Rezende LF, Levy RB. Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: Analysis of a national school-based survey. PLoS One 2019; 14(7):1-13.. These findings demonstrate the need to strengthen policies that address the structural causes of hunger and improve the education and living standards of women, focusing on eating patterns, nutrition and family health.

The following physical, behavioral and psychosocial factors were associated with the experience of hunger among the adolescents from our sample: not being overweight, irregular consumption of beans, fruit, legumes and vegetables, not regularly eating lunch or dinner with parents or guardians, and indifference to or dissatisfaction with their bodies.

The lack of association between hunger and anthropometric markers of malnutrition (thinness and short stature) corroborate the findings of other Brazilian studies investigating the relationship between these outcomes and different levels of food insecurity (absence of hunger and hunger)²⁶26 Oliveira JS, Lira PIC, Veras ICL, Maia SR, Lemos MCC, Andrade SLLS, Viana Junior MJ, Pinto FCL, Leal VS, Bastista Filho M. Estado nutricional e insegurança alimentar de adolescentes e adultos em duas localidades de baixo índice de desenvolvimento humano. Rev Nutr 2009; 22(4):453-465.^,4747 Trivellato PT, Morais DC, Lopes SO, Miguel ES, Franceschini SCC, Priore SE. Insegurança alimentar e nutricional em famílias do meio rural brasileiro: revisão sistemática. Cien Saude Colet 2019; 24(3):865-874.. However, a meta-analysis with 55,173 individuals from 21 studies in 12 countries found that household food insecurity increased the risk of stunting⁴⁸48 Moradi S, Mirzababaei A, Mohammadi H, Moosavian SP, Arab A, Jannat B, Mirzaei K. Food insecurity and the risk of undernutrition complications among children and adolescents: A systematic review and meta-analysis. Nutrition 2019; 62:52-60.. Our findings suggest that using anthropometric indicators of malnutrition alone is not the best option for identifying adolescents experiencing hunger.

It is worth highlighting that the lack of association between hunger and nutrition outcomes (thinness, excess weight and short stature) may be the result of the economic and social development witnessed in Brazil in the years leading up to the PeNSE 2015. This period saw large-scale investments in actions to address food and nutrition insecurity, such as the National School Lunch Program and the family benefit program Programa Bolsa Família. These actions improved access to adequate dietary energy intake, correcting nutritional deficiencies in most of the population. However, some studies have reported an increase in the consumption of foods of high energy density and minimal nutritional value, which is related to excess weight and obesity⁴⁹49 Cotta RMM, Machado JC. Programa Bolsa Família e segurança alimentar e nutricional no Brasil: revisão crítica da literatura. Rev Panam Salud Publica 2013; 33(1):54-60..

Another important finding is irregular consumption of fruit, legumes, vegetables (FLV) and beans among adolescents who experienced hunger. It is worth highlighting that households experiencing moderate or severe food insecurity tend to give preference to high energy density foods, resulting in lower availability of low energy density foods, such as fruit, legumes and vegetables⁵⁰50 Panigassi G, Segall-Correa AM, Marin-Leon L, Pérez-Escamilla R, Maranha LK, Sampaio MFA. Insegurança alimentar intrafamiliar e perfil de consumo de alimentos. Rev Nutr 2008; 21(Supl.):135s-144s.. The findings therefore indicate that food consumption is associated with nutritional risk due to the low intake of vitamins, minerals, fiber and bioactive compounds, which coexists with the experience of hunger. This situation results in poor nutritional intake caused by food consumption patterns that are restricted to certain food groups⁵¹51 Raizel R, Godois AM, Silva VG, Ravagnani CFC. Fatores associados ao consumo de frutas e verduras entre adolescentes. Cien Saude 2018; 11(4):258-272..

Similar results were found by a study with adolescents living in the Amazon, which showed that the prevalence of household food and nutrition insecurity was related to low consumption of vegetables, fruit and legumes⁵²52 Guerra LDS, Espinosa MM, Bezerra ACD, Guimarães LV, Martins MSAS. Desafios para a Segurança Alimentar e Nutricional na Amazônia: disponibilidade e consumo em domicílios com adolescentes. Cien Saude Colet 2018; 23(12):4043-4054.. In addition, a systematic literature review examining the relationship between food insecurity and dietary indicators also reported lower consumption of food builders and regulators and sources of iron, which include FLV and beans, in people experiencing food insecurity⁵³53 Morais DC, Dutra LV, Franceschini SCC, Priore SE. Insegurança alimentar e indicadores antropométricos, dietéticos e sociais em estudos brasileiros: uma revisão sistemática. Cien Saude Colet 2014; 19(5):1475-1488..

Irregular consumption of beans (despite being a staple food for poorer populations) may be explained by a general reduction in the consumption of this food by the Brazilian population. The annual per capita consumption of beans dropped by half between 2008 and 2018 (12.4 kg in 2002-2003, 9.12 kg in 2008-2009, and 5.91 kg in 2017-2018). The share of beans in daily calorie intake also fell over the same period: 5.8% in 2002-2003, 4.8% in 2008-2009, and 4.3% in 2017-2018⁵⁴54 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares: 2017-2018: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil. Rio de Janeiro: IBGE; 2020.. The results of the food consumption component of the household budget survey show that the consumption of beans fell between the periods 2008-2009 and 2017-2018 across all regions, income strata and age groups. The frequency of consumption among adolescents dropped from 71.7% (2008-2009) to 58.2% (2017-2018)⁵⁵55 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares: 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2020..

The association between the experience of hunger and indifference and body dissatisfaction is noteworthy. It is known that body dissatisfaction among adolescents increases the risk of developing eating disorders, such as compensatory behavior to prevent weight gain⁵⁶56 Stice E, Shaw HE. Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. J Psychosom Res 2002; 53:985-993.. In addition to food and nutrition insecurity, this aspect poses a risk to physical and mental health. Worrying about one’s body from an aesthetic rather than health perspective when linked to dissatisfaction with self-image amounts to a social construction influenced by the media and appears to have a greater impact on more vulnerable groups⁵⁷57 Fernandez S, Pritchard M. Relationships between self-esteem, media influence and drive for thinness. Eat Behav 2012; 13(4):321-325..

Adolescents who worry about their bodies tend to create multiple needs (supplements, clothes, cosmetic interventions, etc.) that take precedence over food consumption and interfere with other basic needs and aspects of development, such as education and social interaction. Body dissatisfaction is one of the main factors associated with risk behaviors for eating disorders and emerging evidence indicates that food insecurity is cross-sectionally associated with these disorders⁵⁸58 Hazzard VM, Loth KA, Hooper L, Becker CB. Food Insecurity and Eating Disorders: a Review of Emerging Evidence. Curr Psychiatry Rep 2020; 22(12):74-83..

Another interesting association identified in the adjusted model was that between the experience of hunger and behavioral aspects of eating routines (frequency of eating lunch or dinner with parents or guardians). The relationship between this variable and lower socioeconomic status was identified by a study using data from Sample 1 of the PeNSE 2015. The findings showed that the prevalence of regularly eating lunch or dinner with parents or guardians was higher among adolescents from more advantaged groups (white, higher goods and services scores, from the South)⁵⁹59 Martins BG, Ricardo CZ, Machado PP, Rauber F, Azeredo CM, Levy RB. Fazer refeições com os pais está associado à maior qualidade da alimentação de adolescentes brasileiros. Cad Saude Publica 2019; 35(7):e00153918..

Regularly eating together as a family is a positive marker of dietary patterns, nutrition and health and is consistently emphasized in guidance about eating a healthy, balanced diet, such as the Dietary Guidelines for the Brazilian Population⁶⁰60 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. Brasília: MS; 2014.. It is during meals that families share food knowledge and experiences, creating bonds and developing eating habits⁶¹61 Fischler C. Commensality, society and culture. Social Science Information 2011; 50(3-4):528-548.. This is why we chose to test eating behavior variables in the statistical models. Future research should investigate factors associated with low frequency of family meals among socially vulnerable populations in Brazil.

Dallacker et al.⁶²62 Dallacker M, Hertwig R, Mata J. The frequency of family meals and nutritional health in children: a metaanalysis. Obes Rev 2018; 19:638-653. suggest four possible types of association between family meal frequency and health: (1) these meals are a causal factor in improving adolescent eating behaviors and nutritional health; (2) health-conscious families eat together more frequently; (3) the link between meal frequency and nutritional health are explained by other variables, such as socioeconomic status or family functioning; and (4) there is reciprocal relationship between meal frequency and nutritional health, where healthy families have more regular family meals and, at the same time, more regular family meals promote family nutritional health⁶²62 Dallacker M, Hertwig R, Mata J. The frequency of family meals and nutritional health in children: a metaanalysis. Obes Rev 2018; 19:638-653..

Frequency of family meals therefore appears to be a marker of food consumption and nutrition quality of diets and may be linked to socioeconomic status. In this sense, Gomes and Pereira⁶³63 Gomes MA, Pereira MLD. Família em situação de vulnerabilidade social: uma questão de políticas públicas. Cien Saude Colet 2005; 10(2):357-363. suggest that not eating meals together regularly illustrates the ambivalence of poor families towards sentiments of “bringing together/pushing apart”⁶³63 Gomes MA, Pereira MLD. Família em situação de vulnerabilidade social: uma questão de políticas públicas. Cien Saude Colet 2005; 10(2):357-363.. In practice, poor families with exhausting study and workloads find it difficult to eat together, which in turn hampers the construction of spaces to share mealtimes as health promoters.

Study limitations include the fact that we did not examine economic factors such as family income, which could have resulted in a model with a better fit. In addition, we used the answer to a specific question as a marker of the experience of hunger rather than a validated psychometric scale for assessing food insecurity. We suggest that the dependent variable question about the experience of hunger is modified for future studies to make it clear whether the participant experienced hunger because there was not enough food at home or because there was not the food that the participant likes to eat. This observation is important in relation to the comparison of results.

Despite these limitations, our findings present innovative and valid measures for assessing hunger among adolescents in different contexts in Brazil, using appropriate estimates that take into account the effect of PeNSE’s complex sampling design. Another important strength of this study is that we used a wide range of variables to assess food and nutrition security, illustrating the complementarity of markers of hunger and multi-factorial nature of this phenomenon⁵³53 Morais DC, Dutra LV, Franceschini SCC, Priore SE. Insegurança alimentar e indicadores antropométricos, dietéticos e sociais em estudos brasileiros: uma revisão sistemática. Cien Saude Colet 2014; 19(5):1475-1488.. This type of study offers a good alternative for screening severe food insecurity in a given population, especially considering the sampling method and representativeness of the data used.

Our findings reveal an important association between the experience of hunger among adolescents in Brazil and social determinants of health related to the sociopolitical and economic context, socioeconomic status, individual and family characteristics, and behavioral and psychosocial factors, such as food consumption, eating routines and body dissatisfaction. These factors create a context of vulnerability, posing a worrying risk of food insecurity and negative health and nutrition outcomes.

This complex context should therefore be monitored and taken into account in the planning of policies and actions to tackle food insecurity and promote health among this group. Focusing on nutritional care and health promotion, these initiatives should foster improvements in living standards and encompass individual and family behaviors, emphasizing food and nutrition education and the promotion of food environments that promote health and access at all times to adequate food. Finally, it is important to highlight that adolescents’ rights should be protected in accordance with the legislation so that they are able to develop their full potential as Brazilian citizens.

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