Abstract

The study aimed to describe health and living conditions and analyze factors associated with the quality of the diet of women and children under 5 years of age in 9 rural quilombola communities, certified and without land title in the state of Goiás. Cross-sectional study, in which were constructed the indicators of consumption of ultra-processed foods, diet diversity and diet quality. The association of socioeconomic factors with indicators of dietary diversity and quality was assessed using Pearson’s chi-square test, Fischer’s exact test and logistic regression analysis. 203 women and 73 children aged 0 to 59 months participated in the study. In women, greater dietary diversity associated with higher income, non-participation in an income transfer program and higher education; in children, fewer people living in the household, B/C socioeconomic classification and diverse maternal diet. Low diet quality in children associated with less diversity in the maternal diet; in women, the income variable was associated with lower diet quality in the chi-square analysis, but the multiple analysis showed an opposite result for this variable. There is an urgency to implement effective actions to guarantee the right to health and adequate and healthy food for this population.

Key words:
Health; Nutrition; Groups with ancestors from the African continent

Introduction

The quilombo’s remaining communities, whose historical origin refers to spaces of resistance to slavery, contributed essentially to the formation of Brazilian history and identity. Throughout history, the term “quilombo” has gained other contours, but it remains a reference to a movement of resistance to historical oppression, with black ancestry and a differentiated relationship with the territory, maintaining a set of traditional manifestations and practices transmitted for generations¹1 Calheiros FP, Stadtler HHC. Identidade étnica e poder: os quilombos nas políticas públicas brasileiras. Rev Katálysis 2010; 13:133-139.^,22 Instituto de Pesquisa Econômica Aplicada (Ipea). Quilombos das Américas. Articulação de Comunidades Afrorurais. Brasília: Ipea; 2012..

Despite the legal recognition³3 Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out. and the institution of public policies that try to “compensate” for centuries of exclusion and invisibility, there is still no realization of the basic rights of this population. Low education, precarious health care, food insecurity (InSAN) and poor housing and sanitation conditions are among the main problems and violations to which these communities are subjected⁴4 Afonso LFC, Correa NAF, Silva HP. Segurança Alimentar e Nutricional em comunidades quilombolas no Brasil. Segur Aliment Nutr 2019; 27:e020003.

5 Freitas DA, Caballero AD, Marques AS, Hernández CIV, Antunes SLNO. Saúde e comunidades quilombolas: uma revisão da literatura. Rev CEFAC 2011; 13(5):937-943.

6 Gubert MB, Segall-Corrêa AM, Spaniol AM, Pedroso J, Coelho SEAC, Pérez Escamilla R. Household food insecurity in black-slaves descendant communities in Brazil: has the legacy of slavery truly ended? Public Health Nutr 2017; 20(8):1513-1522.

7 Pinto AR, Borges JC, Novo MP, Pires PS. Quilombos do Brasil: segurança alimentar e nutricional em territórios titulados. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2014^-88 Silva EKP, Medeiros DS, Martins PC, Sousa LA, Lima GP, Rêgo MAS, Silva TO, Freire AS, Silva FM. Insegurança alimentar em comunidades rurais no Nordeste brasileiro: faz diferença ser quilombola? Cad Saude Publica 2017; 33(4):e00005716..

Even with the expansion of studies on health and nutrition of the quilombola population, gaps persist on demography, health, and food and nutrition, especially when it comes to the maternal-child audience, a group admittedly more vulnerable to human rights violations⁹9 Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP, Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP. Saúde materno-infantil em comunidades quilombolas no norte de Minas Gerais. Cad Saude Colet 2014; 22(3):307-313.. Two population-based surveys stand out in the literature, the Quilombola Nutritional Call (2006), and the Census of titled quilombola territories (2011), which provided data on health conditions, access to public policies, food availability, nutritional status and food security⁷7 Pinto AR, Borges JC, Novo MP, Pires PS. Quilombos do Brasil: segurança alimentar e nutricional em territórios titulados. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2014^,1010 Taddei JA, Colugnati F, Cobayashi F. Chamada nutricional: uma avaliação nutricional de crianças quilombolas de 0 a 5 anos. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2008..

The trend of increasing overweight among children and adults in quilombola communities¹¹11 Cordeiro MM, Monego ET, Martins KA. Overweight in Goiás' quilombola students and food insecurity in their families. Rev Nutr 2014; 27(4):405-412.^,1212 Rodrigues RAC, Oliveira FP, Santos RA. Transição nutricional e epidemiológica em comunidades tradicionais da amazônia brasileira. Braz J Develop 2020; 6(3):11290-11305. and infant feeding practices and the low quality of food available to this population are worrying aspects of a scenario that reflects the process of food and nutritional transition observed in Brazil, and food and nutritional insecurity in these communities⁷7 Pinto AR, Borges JC, Novo MP, Pires PS. Quilombos do Brasil: segurança alimentar e nutricional em territórios titulados. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2014^,1212 Rodrigues RAC, Oliveira FP, Santos RA. Transição nutricional e epidemiológica em comunidades tradicionais da amazônia brasileira. Braz J Develop 2020; 6(3):11290-11305..

Given this panorama, the study aimed to describe health and life conditions and analyze the factors associated with the quality of food of women and children under 5 years old in quilombola communities in Goiás.

Methods

Study design and population

Cross-sectional study, being an excerpt from the research Health Promotion and Quality of Life in Quilombola Communities from Different Brazilian Regions: a Multicenter Study.

The quilombola communities included in this study were selected by lottery, from the records of communities certified in Goiás by the Palmares Cultural Foundation (reference year: 2016). Certified, rural and non-titled communities were considered eligible.

All households in the communities were eligible to participate in the matrix survey. In the present study, a cutout was made for those with women and/or children under 5 years of age. After two unsuccessful attempts to find the residents, the household was excluded from the survey. All women aged 19 to 59 years and all children under 60 months were eligible, stratified into two age groups: 0 to 23 months and 24 to 59 months. When there was more than one child in the same age group in the household, only one was drawn to participate. The final sample consisted of 203 women and 73 children.

Data collection

Data collection took place between July 2017 and July 2018 through home visits, with the application of semi-structured questionnaires and anthropometric measurements, carried out by previously trained undergraduate and graduate students of the health area. Questions about socioeconomic characteristics of the household and family were preferably answered by a female resident over 18 years of age. Questions about children under 5 years of age were answered by the mother or guardian.

Variables

Socioeconomic, infrastructure and food and nutrition security characterization

Variables related to public services and infrastructure (water source; waste disposal); participation in income transfer programs; monthly family income; gender, education and working conditions of the head of the family were evaluated. The socioeconomic classification of households was based on an adaptation of the Brazil 2019 socioeconomic classification criterion¹³13 Associação Brasileira de Empresas de Pesquisa (ABEP). Critério Brasil 2019 [Internet]. 2019 [acessado 2021 jun 5]. Disponível em: http://www.abep.org/criterio-brasil.
http://www.abep.org/criterio-brasil... .

The food and nutrition security situation of the household was assessed using the Brazilian Food Insecurity Scale, an instrument to measure perception and experience with hunger composed of 14 questions. The final classification is based on the sum of affirmative answers to the questions. The cutoff points, considering the presence or absence of residents under 18 years of age in the household, are, respectively: Food and nutrition Security (0 points), or Food Insecurity level Mild (1-3; 1-5), Moderate (4-5; 6-9) or Severe (6-8; 10-14) (14).

Health, nutritional status and diet quality

Children: Information on vaccination was collected with direct consultation of the Child Handbook, requested by the interviewer from the family; and vitamin A and iron supplementation (children aged 6 to 24 months), based on the mother’s report.

To assess nutritional status, weight and height were measured using a digital scale of the brand Seca with a capacity of 200 kg, graduation of 100 g, portable stadiometer of the brand Seca, for measurements up to 205 cm, and a child stadiometer of the brand Seca for children under 2 years. The indicators height for age and Body Mass Index for age were calculated and classified according to the cutoff points recommended by the WHO¹⁵15 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 [Internet]. 2006 [cited 2021 jun 5]. Available from: https://www.who.int/publications-detail-redirect/924154693X.
https://www.who.int/publications-detail-... .

Food consumption data were collected through a 24-hour Food Recall (R24hr) and, for children under 24 months, a form was also applied containing questions related to breastfeeding (BF) and food consumption the previous day, based on the food consumption markers recommended by the Ministry of Health¹⁶16 Brasil. Ministério da Saúde (MS). Orientações para avaliação de marcadores de consumo alimentar na atenção básica. Brasília: MS; 2015..

BF was evaluated based on the indicators proposed by the WHO¹⁷17 World Health Organization (WHO). Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6-8 November 2007 in Washington D.C., USA. Washington, D.C.: WHO; 2008.: exclusive breastfeeding (EBF) in children under 6 months; continued breastfeeding at 12 months; breastfeeding among children under 24 months.

Diet assessment was performed for children aged 6 to 59 months and included three indicators:

(a) dietary diversity (DD)¹⁸18 Arimond M, Wiesmann D, Becquey E, Carriquiry A, Daniels MC, Deitchler M, Fanou-Fogny N, Joseph ML, Kennedy G, Martin-Prevel Y, Torheim LE. Simple Food Group Diversity Indicators Predict Micronutrient Adequacy of Women's Diets in 5 Diverse, Resource-Poor Settings. J Nutr 2010; 140(11):2059S-2069S.^,1919 Kennedy G, Ballard T, Dop M-C. Guidelines for measuring household and individual dietary diversity. Rome: FAO; 2011.: a diverse diet was considered if, in the previous day, at least 5 of the 6 food groups (cereals/roots/tubers, beans, legumes and vegetables, fruits, meat and eggs, milk and cheeses) were consumed, defined in accordance with the dietary recommendations for the Brazilian population²⁰20 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. Brasília: MS; 2014. and for Brazilian children under 2 years of age²¹21 Brasil. Ministério da Saúde (MS). Guia alimentar para crianças brasileiras menores de 2 anos. Brasília: MS; 2019., regardless of the amount ingested. For children aged 6 to 23 months, the same food groups as for children older than 23 months were used. But, in this first age group, consumption in the milk and cheese group was scored if there was ingestion of breast milk, when the child was breastfed, or other milk, for children who were not being breastfed. It is noteworthy that the recommendation is to maintain breastfeeding until at least two years of age, and in this case, it would not be necessary to offer another type of milk, other than maternal²¹21 Brasil. Ministério da Saúde (MS). Guia alimentar para crianças brasileiras menores de 2 anos. Brasília: MS; 2019.. However, considering that more than half of the children in this age group no longer received breast milk at the time of the research, and that dividing the group of children under 2 years of age into breastfed and non-breastfed children could further reduce the robustness of the analysis, it was decided to construct the indicator as described.

(b) consumption of Ultra-processed Foods (UPF) on the previous day: considered the intake of one or more foods from this group on the previous day, according to the NOVA Classification, as proposed by the Food Guide for the Brazilian Population²⁰20 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. Brasília: MS; 2014..

(c) overall diet quality: aggregation of the two previous indicators, it was considered as a low-quality diet when the minimum diet diversity was not reached and the consumption of at least one UPF on the previous day occurred concomitantly. This indicator was inspired by the proposal of Contreras et al.²²22 Contreras M, Blandón EZ, Persson L-Å, Hjern A, Ekström E-C. Socio-economic resources, young child feeding practices, consumption of highly processed snacks and sugarsweetened beverages: a population-based survey in rural northwestern Nicaragua. BMC Public Health 2015; 15(1):25., who evaluated exposure to double suboptimal feeding load (at least one practice of inadequate complementary feeding + consumption of an UPF) among children between 6 and 35 months. In the present study, only the failure to achieve the minimum diversity of the diet was considered as an inadequate dietary practice.

In addition, the proportion of each of the food groups by degree of processing was also calculated in relation to the total food recorded in the R24h. Foods were listed and classified in one of the groups: Group 1: fresh and minimally processed foods + culinary ingredients; Group 2: processed foods; Group 3: UPF. Subsequently, the proportion of the 3 groups was calculated, considering the quantity of food in each of the groups, in relation to the total number of foods recorded.

Women: The anthropometric measurements used to assess nutritional status were weight, height and waist circumference, collected using the same equipment used to assess children, except for the infant stadiometer. Nutritional status was classified by Body Mass Index (BMI) and waist circumference, following the cutoff points recommended by the World Health Organization. For waist circumference, the cutoff point of 80 cm was used (WHO)²³23 World Health Organization (WHO). Obesity: preventing and managing the global epidemic: report of a WHO consultation. Geneva: WHO; 2000..

Diet assessment encompassed the same three indicators used for children: (a) diet diversity; (b) UPF consumption the day before; and (c) overall diet quality. The proportional participation of food groups by degree of processing in the total food consumed was also calculated.

Statistical analysis

The frequencies and proportion of sociodemographic, health and nutrition variables were presented. For the number of food groups consumed, the means and standard deviations by age groups were presented.

Fisher’s exact test or Pearson’s chi-square test were used to evaluate the factors associated with the indicators diet diversity and quality. The independent variables included in the analysis of women were age, education and marital status of the woman; monthly family income; socioeconomic classification, number of residents and sex of the head of household; household food and nutrition security situation; and participation in an income transfer program. For children, the diversity and quality of the maternal diet and the sex of the child were included in addition to the variables already mentioned. Only cases with all complete data were included in this analysis. The analysis with a p-value<0.05 was considered statistically significant.

In addition, a logistic regression analysis was carried out with the estimation of the cross-product ratio (Odds ratio) and a 95% confidence interval, having as outcomes the diverse diet and the low quality of the diet of children aged 6 to 59 months and women. The crude analyzes were performed and the variables that had p<0.20 were included in the multiple regression, which then went through the backward method until only variables with a p-value of approximately 0.2 remained in the final model. The analyses were conducted in the Statistical Package for the Social Sciences (SPSS) version 21.

The power of the sample in the group of children was calculated considering the results of the multiple regression analyses for the association between the diverse diet of these and their mothers (two-tailed, Odds Ratio of 0.4, proportion of 42.6% of diverse diet, sample of 47, alpha of 0.05, R² of 0.5% and binomial distribution) and returned the value of 20%. Similarly, this was done for women using the association between diverse diet and estimate of monthly family income in minimum wages (two-tailed, Odds Ratio of 4.9, proportion of 25.8% diverse diet, sample of 186, alpha of 0.05, R² of 25.4% and binomial distribution) which resulted in a test power of 99%. These calculations were conducted on a post hoc basis for logistic regression in G*Power 3.1.9.7.

Ethical aspects

The research was initiated after the consent of the representatives of the communities and the signing of the Informed Consent Form by the participants. The research was approved by the Research Ethics Committee of the Federal University of Alagoas under number 4735646415.4.0000.5013.

Results

We evaluated 203 adult women and 73 children under 60 months of age (8 children <6 months; 24 children aged 6 to 23 months; 41 children aged 24 to 59 months) living in nine quilombola communities in Goiás. Among the women, 65 were biological mothers or guardians of the children included in the study.

Socioeconomic, infrastructure and food and nutrition security characterization

Except for one, the other communities visited are located more than 5 km from the municipality’s center, where they accessed most of the public services. Three communities had a public school within the territory, and one had a Primary Health Unit. Regarding household conditions, 47% of women (n=95) and 38.3% of children (n=28) lived in households whose estimated monthly income was up to 1 minimum wage (R$937.00 at the time of collection) and about 80% were in socioeconomic strata D and E. Most households were headed by men and 60.6% of women’s families and 76.7% of children’s families participated in income transfer programs. Regarding the situation of food and nutrition security, 27.2% of women and 26% of children lived in households with moderate or severe insecurity. Among women, 52.2% had less than 8 years of education and more than 80% reported having an informal job or not being working (Table 1).

Health, nutritional status and diet quality

Children: The vaccination record was adequate to the vaccination schedule recommended by the Ministry of Health for 86.3% of the children. Vitamin A supplementation was offered to 55.4% (n=36) of the children between 6 and 59 months. Only 17.4% (n=4) of mothers of children between 6 and 23 months reported that they received the ferrous sulfate supplement in the last 3 months. Of the children investigated, 5.8% (n=4) had stunting, and 20.2% were overweight or obese (Table 2).

Among the 8 children under 6 months assessed, none were on EBF. Continued BF was prevalent among 77.7% (n=7) of children younger than 12 months and BF in children younger than 24 months was 46.9% (n=15) (Table 2).

The mean DD score for children aged 6 to 23 months (n=23) was 3.83 (SD=1.26) (not shown in table) and 73.9% did not reach the minimum dietary diversity. Among those older than 24 months (n=34), the mean DD score was 4.32 (SD=1.27), and 88.2% of them did not have a diverse diet the previous day. Almost half of the children evaluated (47.4%) had a low-quality diet (Table 2). On the other hand, only 10.5% of the children reached the minimum diversity and did not consume any UPF the previous day.

Of the 57 children aged 6-59 months with food consumption data, 75.4% consumed at least one UPF, and more than half (52.6%) consumed 2 or more UPF the previous day. The most consumed UPFs were salted and sweet biscuits and powdered artificial juices. In the group of children under 24 months, among the 51 foods recorded from the R24h, 37.3% (n=19) were ultra-processed. For older children, of the 89 foods mentioned, 30.3% (n=27) were ultra-processed.

The analysis of factors related to diversity and diet quality was performed for 47 children between 6 and 59 months with complete data for the independent variables evaluated. The higher DD was associated with the lower number of residents in the household (p=0.039), the socioeconomic classification B/C (p=0.026) and the diverse maternal diet (p<0.001). For children, the only variable that showed a significant association with poor diet quality was lower maternal DD (p=0.046) (Table 3).

Crude and multiple analyses for children are presented in Table 4. In the multiple model, there was a greater chance of a diverse diet in children whose mothers also had a diverse diet. A lower chance of poor diet quality was also observed when the mothers had a diverse diet (the only variable that remained in the multiple model with p<0.20) (Table 4).

Women: The mean age of the women was 39 years (SD=11.71). Regarding nutritional status, the BMI assessment showed that 61.2% (n=123) were overweight or obese, and 2.5% (n=5) were underweight; 61.6% (n=119) had high waist circumference, indicating an increased risk of cardiovascular disease.

In the evaluation of food consumption (n=191), the DD score was 3.81 (SD=1.02), and 26% of them had a diverse diet. For the subgroup of women mothers of children under 5 years of age (n=63), the mean DD score was 3.75 (SD=1.07), and 30% had a diet considered diverse (Table 2).

The prevalence of consumption of at least one UPF the previous day was 57.9% among all women, with the most consumed being salty and sweet biscuits and powdered artificial juices. Of the 137 types of food consumed by women the previous day, 34 (24.8%) were ultra-processed.

The analysis of factors related to dietary diversity and quality included 186 women with complete data for the independent variables evaluated. An adequate DD was related to higher income (p<0.001), non-participation in an income transfer program (p=0.038) and higher education (p<0.001). Regarding the low quality of the diet, only one significant relationship was found, with lower income (p<0.001).

In the multiple model for diverse diet in women, there was a lower chance of this outcome in those who lived in households with 5 or more residents and a higher chance of diverse diet in those with estimated family income with more than 1 monthly minimum wage and in those with 8 years of study or more. In the model of low diet quality in women, it was found that there was a lower chance of this outcome if they lived in households with 5 or more residents and a higher chance for those with an estimated monthly family income of more than 1 minimum wage (Table 5).

Discussion

The women and children of the quilombola communities evaluated in the study experience a situation of economic vulnerability and social exclusion, have a low-quality diet and a high prevalence of overweight, reinforcing existing findings for the quilombola population of Goiás and other regions of the country and pointing to an invisibility of these groups by public agents⁴4 Afonso LFC, Correa NAF, Silva HP. Segurança Alimentar e Nutricional em comunidades quilombolas no Brasil. Segur Aliment Nutr 2019; 27:e020003.^,55 Freitas DA, Caballero AD, Marques AS, Hernández CIV, Antunes SLNO. Saúde e comunidades quilombolas: uma revisão da literatura. Rev CEFAC 2011; 13(5):937-943.^,1010 Taddei JA, Colugnati F, Cobayashi F. Chamada nutricional: uma avaliação nutricional de crianças quilombolas de 0 a 5 anos. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2008.^,1111 Cordeiro MM, Monego ET, Martins KA. Overweight in Goiás' quilombola students and food insecurity in their families. Rev Nutr 2014; 27(4):405-412.. Women and young children are more susceptible to the negative consequences of socioeconomic and health inequalities, which is aggravated when it comes to the black population²⁴24 Theophilo RL, Rattner D, Pereira ÉL. Vulnerabilidade de mulheres negras na atenção ao pré-natal e ao parto no SUS: análise da pesquisa da Ouvidoria Ativa. Cien Saude Colet 2018; 23(11):3505-3516., especially Afro-rural communities⁹9 Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP, Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP. Saúde materno-infantil em comunidades quilombolas no norte de Minas Gerais. Cad Saude Colet 2014; 22(3):307-313.. The location of communities in the rural region can be a hindrance to access to public services, such as schools and health facilities. This implies rethinking the organization of these services, considering not only the distance from urban centers, but the characteristics of communities, the human and technological resources necessary to ensure equitable care in health and other areas⁹9 Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP, Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP. Saúde materno-infantil em comunidades quilombolas no norte de Minas Gerais. Cad Saude Colet 2014; 22(3):307-313.^,2525 Franco CM, Lima JG, Giovanella L. Atenção primária à saúde em áreas rurais: acesso, organização e força de trabalho em saúde em revisão integrativa de literatura. Cad Saude Publica 2021; 37(7):e00310520..

The inequities found in this study are also experienced in titled communities⁷7 Pinto AR, Borges JC, Novo MP, Pires PS. Quilombos do Brasil: segurança alimentar e nutricional em territórios titulados. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2014. The process of land titling does not, by itself, guarantee the improvement of living conditions in communities when there is, in fact, no political agenda committed to the fulfillment of the rights of this population. Data from the research carried out in those communities showed that half of the families were in severe food and nutrition insecurity⁶6 Gubert MB, Segall-Corrêa AM, Spaniol AM, Pedroso J, Coelho SEAC, Pérez Escamilla R. Household food insecurity in black-slaves descendant communities in Brazil: has the legacy of slavery truly ended? Public Health Nutr 2017; 20(8):1513-1522., a worse situation in relation to the communities evaluated in this study, where less than 10% of the households were in such a situation. Even so, more than 60% of the households of the quilombola communities of Goiás visited had some degree of food and nutrition insecurity.

Silva et al.⁸8 Silva EKP, Medeiros DS, Martins PC, Sousa LA, Lima GP, Rêgo MAS, Silva TO, Freire AS, Silva FM. Insegurança alimentar em comunidades rurais no Nordeste brasileiro: faz diferença ser quilombola? Cad Saude Publica 2017; 33(4):e00005716. evaluated rural quilombola and non-Quilombola communities in Northeast Brazil and identified that, although the prevalence of insecurity was high in all communities studied, it was higher and more severe among quilombolas. In a population-based study with households with Brazilian children under 5 years of age, levels of food and nutrition insecurity observed in the Central-West region were almost 3 times lower than in our study, reinforcing the higher frequency of inequalities in quilombola communities²⁶26 Universidade Federal do Rio de Janeiro (UFRJ). Características sociodemográficas: aspectos demográficos, socioeconômicos e de insegurança alimentar 2: ENANI 2019 [Internet]. Rio de Janeiro: UFRJ; 2021 [acessado 2022 out 5]. Disponível em: https://enani.nutricao.ufrj.br/index.php/relatorios/., which may have worsened during the COVID-19 pandemic²⁷27 Fundação Friedrich Ebert. Rede PENSSAN. Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da COVID-19 no Brasil: II VIGISAN: relatório final/Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar - PENSSAN [Internet]. São Paulo: Fundação Friedrich Ebert, Rede PENSSAN; 2022..

In the context of infant feeding practices, the maintenance of EBF for 6 months seems to be one of the greatest challenges, with early supply of teas, other milks and foods, practices permeated by cultural issues and traditional knowledge²⁸28 Martins LA, Oliveira RM, Camargo CL, Aguiar ACSA, Santos DV, Whitaker MCO, Souza JMM. Practice of breastfeeding in quilombola communities in the light of transcultural theory. Rev Bras Enferm 2020; 73(4):e20190191.^,2929 Silva GPC, Padilha LL, Silveira VNC, Frota MTBA. Fatores associados à duração do aleitamento materno em mulheres quilombolas. DEMETRA Aliment Nutr Saude 2019; 14(Supl. 1):e42600.. In the context of food and nutrition insecurity in which quilombola communities live, BF, which has great importance for child nutrition and health, with lifelong repercussions³⁰30 Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387(10017):475-490., can have an even greater relevance, being a safe and low-cost strategy for infant feeding³¹31 Ferreira HS, Xavier Júnior AFS, Assunção ML, Santos EA, Horta BL. Effect of Breastfeeding on Head Circumference of Children from Impoverished Communities. Breastfeed Med 2013; 8(3):294-301.^,3232 Gomes GP, Gubert MB. Breastfeeding in children under 2 years old and household food and nutrition security status. J Pediatr (Rio J) 2012; 88(3):279-282.. Therefore, it is essential that actions to promote, protect and support BF, consider the social and cultural specificities of these families.

The analysis of the food consumption of quilombola women and children showed a monotonous eating pattern, with restricted food diversity and variety and high consumption of UPF, data that follow the trend observed for the Brazilian and world population³³33 Gibson E, Stacey N, Sunderland TCH, Adhuri DS. Dietary diversity and fish consumption of mothers and their children in fisher households in Komodo District, eastern Indonesia. PLoS One 2020; 15(4):e0230777.. In a study with Brazilian children between 6 and 36 months, only 20% had a diverse diet³⁴34 Bortolini GA, Vitolo MR, Gubert MB, Santos LMP. Iniquidades sociais influenciam a qualidade e a diversidade da dieta de crianças brasileiras de 6 a 36 meses. Cad Saude Publica 2015; 31(11):2413-2424., and another population-based study showed that at least 50% of Brazilian and Central-West children had a diverse diet, being more prevalent in children aged between 6 and 23 months³⁵35 Universidade Federal do Rio de Janeiro (UFRJ). Alimentação Infantil I: Prevalência de indicadores de alimentação de crianças menores de 5 anos: ENANI 2019 [Internet]. Rio de Janeiro: UFRJ; 2021 [acessado 2022 out 5]. Disponível em: https://enani.nutricao.ufrj.br/index.php/relatorios/.. Factors that denote inequities, such as living at home with food and nutrition insecurity, low maternal education, domicile in the rural area and lack of contact between the mother and the health service aggravate the situation and point to an association with an even lower DD²²22 Contreras M, Blandón EZ, Persson L-Å, Hjern A, Ekström E-C. Socio-economic resources, young child feeding practices, consumption of highly processed snacks and sugarsweetened beverages: a population-based survey in rural northwestern Nicaragua. BMC Public Health 2015; 15(1):25.^,3535 Universidade Federal do Rio de Janeiro (UFRJ). Alimentação Infantil I: Prevalência de indicadores de alimentação de crianças menores de 5 anos: ENANI 2019 [Internet]. Rio de Janeiro: UFRJ; 2021 [acessado 2022 out 5]. Disponível em: https://enani.nutricao.ufrj.br/index.php/relatorios/.

36 Faber M, Laubscher R, Berti C. Poor dietary diversity and low nutrient density of the complementary diet for 6- to 24-month-old children in urban and rural KwaZulu-Natal, South Africa: Complementary diet for urban and rural babies. Matern Child Nutr 2016; 12(3):528-545.

37 Gebremedhin S, Baye K, Bekele T, Tharaney M, Asrat Y, Abebe Y, Reta N.. Predictors of dietary diversity in children ages 6 to 23 mo in largely food-insecure area of South Wollo, Ethiopia. Nutrition 2017; 33:163-168.

38 Issaka AI, Agho KE, Page AN, L. Burns P, Stevens GJ, Dibley MJ. Determinants of suboptimal complementary feeding practices among children aged 6-23 months in seven francophone West African countries: Complementary feeding in francophone West Africa. Matern Child Nutr 2015; 11:31-52.

39 Kamran A, Sharifirad G, Nasiri K, Soleymanifard P, Savadpour M, Akbar Haghighat M. Determinants of Complementary Feeding Practices among Children Aged 6-23: a Community based Study. Int J Pediatr 2017; 5(3):4551-4560.^-4040 Ruel MT, Menon P. Child Feeding Practices Are Associated with Child Nutritional Status in Latin America: Innovative Uses of the Demographic and Health Surveys. J Nutr 2002; 132(6):1180-1187..

DD is associated with linear growth in children and with the adequacy of macro and micronutrients in children and adults, being a good proxy for diet quality and being related to positive health outcomes¹⁹19 Kennedy G, Ballard T, Dop M-C. Guidelines for measuring household and individual dietary diversity. Rome: FAO; 2011.^,4040 Ruel MT, Menon P. Child Feeding Practices Are Associated with Child Nutritional Status in Latin America: Innovative Uses of the Demographic and Health Surveys. J Nutr 2002; 132(6):1180-1187.^,4141 Nithya DJ, Bhavani RV. Dietary diversity and its relationship with nutritional status among adolescents and adults in rural India. J Biosoc Sci 2018; 50(3):397-413.. Our study pointed out that the possibility of the child having a diverse diet and a better quality diet is greater when the mother also has a diverse diet. However, due to the characteristic of the study, it is not possible to state whether this is an influence of maternal or caregiver eating behavior on the child or a result of the greater access of the family to varied foods.

If among children a direct influence of socioeconomic factors on dietary diversity could not be observed, among quilombola women, education and income had a substantial impact on this indicator. However, conversely, higher income was a risk factor for poor diet quality in the multiple analyses. This result may suggest, as already found in other studies, that in some groups with higher income there is a higher consumption of UPF, an element that makes up the analysis of diet quality in the present study and may be causing this effect. However, it is necessary to deepen the understanding of the role of income and UPF consumption in different social groups. However, it should be noted that there is already an important set of evidence on social inequalities in food and nutrition, showing that population groups with lower socioeconomic status, including low income and education, of black color/race and living in rural areas, have more difficulty in achieving an adequate and healthy diet⁴²42 Leite FMB, Ferreira HS, Bezerra MKA, Assunção ML, Horta BL. Food intake and nutritional status of preschool from maroon communities of the state Alagoas, Brazil. Rev Paul Pediatr 2013; 31(4):444-451.

43 Canuto R, Fanton M, Lira PIC. Iniquidades sociais no consumo alimentar no Brasil: uma revisão crítica dos inquéritos nacionais. Cien Saude Colet 2019; 24(9):3193-3212.^-4444 Borges CA, Claro RM, Martins APB, Villar BS. Quanto custa para as famílias de baixa renda obterem uma dieta saudável no Brasil? Cad Saude Publica 2015; 31(1):137-148..

More than 75% of the children and about 30% of the women in the study had consumed at least one UPF the previous day. Similar results were found in a study that evaluated the food consumption of children between 12 and 60 months in quilombola communities in Alagoas, Brazil⁴²42 Leite FMB, Ferreira HS, Bezerra MKA, Assunção ML, Horta BL. Food intake and nutritional status of preschool from maroon communities of the state Alagoas, Brazil. Rev Paul Pediatr 2013; 31(4):444-451. and also in a national survey with Brazilian children under 5 years of age³⁵35 Universidade Federal do Rio de Janeiro (UFRJ). Alimentação Infantil I: Prevalência de indicadores de alimentação de crianças menores de 5 anos: ENANI 2019 [Internet]. Rio de Janeiro: UFRJ; 2021 [acessado 2022 out 5]. Disponível em: https://enani.nutricao.ufrj.br/index.php/relatorios/., but in this last study, children older than 2 years of age ingested more UPF than younger children. In a research on UPF consumption and metabolic syndrome in quilombola women from Alagoas, this dietary practice was frequent and the high consumption of these foods was associated with a higher prevalence of hypertension, while a lower UPF consumption score was protective against diabetes and low HDL⁴⁵45 Barbosa LB, Vasconcelos NBR, Santos EA, Santos TR, Ataide-Silva T, Ferreira HDS. Ultra-processed food consumption and metabolic syndrome: a cross-sectional study in Quilombola communities of Alagoas, Brazil. Int J Equity Health 2023; 22(1):14..

The situation of food availability in titled quilombola territories, in which cookies, biscuits, soft drinks and artificial juices were more common in households than vegetables⁷7 Pinto AR, Borges JC, Novo MP, Pires PS. Quilombos do Brasil: segurança alimentar e nutricional em territórios titulados. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2014, dialogues with the results found. There is already robust evidence that high consumption of UPF is associated with negative health outcomes, especially the development of obesity and chronic non-communicable diseases in children and adults⁴⁶46 Elizabeth L, Machado P, Zinöcker M, Baker P, Lawrence M. Ultra-Processed Foods and Health Outcomes: A Narrative Review. Nutrients 2020; 12(7):1955..

High prevalences of overweight were found in children and women, and in children, the prevalence was higher than in national surveys⁴⁷47 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde. Rio de Janeiro: IBGE; 2020.^,4848 Brasil. Ministério da Saúde (MS). Atlas da Obesidade Infantil no Brasil. Brasília: MS; 2019.. Despite this scenario, it is known that the quilombola population is still more susceptible to malnutrition and nutritional deficiencies⁹9 Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP, Oliveira SKM, Pereira MM, Freitas DA, Caldeira AP. Saúde materno-infantil em comunidades quilombolas no norte de Minas Gerais. Cad Saude Colet 2014; 22(3):307-313.^,4949 Ferreira HS, Lamenha MLD, Xavier Júnior AFS, Cavalcante JC, Santos AM. Nutrição e saúde das crianças das comunidades remanescentes dos quilombos no Estado de Alagoas, Brasil. Rev Panam Salud Publica 2011; 30:51-58.^,5050 Santos KMP, Garavello MEPE. Segurança alimentar em comunidades quilombolas de São Paulo. Segur Aliment Nutr 2016; 23(1):786.. Understanding and acting on malnutrition in its different forms, which are interrelated and often coexist, involves considering that its roots include, in addition to biological and nutritional elements, a socioeconomic and political component, deeply related to the quality of food to which the population has access⁵¹51 Scrinis G. Reframing malnutrition in all its forms: A critique of the tripartite classification of malnutrition - ScienceDirect. Glob Food Secur 2020; 26:1-10..

In addition to broader actions, such as income transfer programs and food and nutritional security policies, more specific initiatives have been implemented for the quilombola population, such as the Brazil Quilombola Program⁵²52 Brasil. Decreto nº 6.261, de 20 de novembro de 2007. Dispõe sobre a gestão integrada para o desenvolvimento da Agenda Social Quilombola no âmbito do Programa Brasil Quilombola, e dá outras providências. Diário Oficial da União; 2007.. However, the program functioned more as a device for the symbolic inclusion of quilombola communities in the Brazilian public agenda, than as a realizer of effective actions for change in reality⁵³53 Teixeira TG, Sampaio CAM. Análise orçamentária do Programa Brasil Quilombola no Brasil e no Maranhão: o ocaso de uma política pública. Rev Adm Publica 2019; 53:461-480..

The sample size, the heterogeneity in the number of families per community and the scarcity of more complete official demographic records made more robust and stratified analyses per community difficult, being important limitations of the study. It is estimated that the total number of households included in the survey in Goiás (without considering the number of households with women and children) represented 60 to 70% of the total number of households in these communities at the time of the study, according to information provided by quilombola leaders. Even with some results similar to those found for women, most of the analyzes for the group of children did not present statistical significance, which was possibly due to the low sample size for this age group.

Despite the limitations, the study innovates in making an evaluation of multiple aspects in quilombola communities in Goiás, covering different regions of the state, and focusing on food practices. Although the results cannot be extrapolated to other populations, the scenario found possibly resembles that of other rural quilombola communities in the state and in other regions of the country, contributing to the understanding of the living conditions of this population. The panorama outlined by this study highlights the urgency of effective and culturally adapted actions to improve access to adequate food and health for this population.

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