ABSTRACT

Objective

To identify dietary patterns and analyze factors associated with the consumption profile of socially vulnerable children, Maceió, state of Alagoas, Brazil, August 2019 to December 2021.

Methods

This was a cross-sectional study; sociodemographic, anthropometric and food consumption variables were collected, factor analysis was used to identify dietary patterns; associations were analyzed using Poisson regression.

Results

Among the 567 children studied, two dietary patterns were identified, healthy and unhealthy; age ≥ 24 months (PR = 2.75; 95%CI 1.83;4.14), male gender (PR = 0.66; 95%CI 0.49;0.87) and maternal schooling ≤ 9 years (PR = 0.61; 95%CI 0.46;0.81) was higher in the healthy pattern; the unhealthy pattern was associated with age ≥ 24 months (PR = 1.02; 95%CI 1.01;1.03) and male gender (PR = 1.46; 95%CI 1.08;1.98).

Conclusion

The healthy pattern was more frequent in children aged ≥ 24 months, less frequent in male children and mothers with low level of schooling; children aged ≥ 24 months and males showed a higher prevalence of the unhealthy pattern.

Palabras clave
Patrones Alimentarios; Consumo de Alimentos; Salud de los Niños; Vulnerabilidad Social; Estudios Transversales

Study contributions

Main results

Two dietary patterns were defined, healthy and “unhealthy”, which were associated with male gender, age ≥ 24 months and maternal schooling ≤ 9 years of study.

Implications for services

The study data can assist health professionals dedicated to primary healthcare services, such as nutritionists, in planning interventions to promote healthy eating habits aimed at children.

Perspectives

Prospective studies with these populations are necessary to assess the causality of the associations found in this study, aiming to plan more effective public health actions.

Palabras clave
Patrones Alimentarios; Consumo de Alimentos; Salud de los Niños; Vulnerabilidad Social; Estudios Transversales

RESUMEN

Objetivo

Identificar hábitos alimentarios de niños socialmente vulnerables y analizar su relación con factores vinculados al perfil de consumo de Maceió, Alagoas, Brasil.

Métodos

Estudio transversal de base poblacional llevado a cabo de agosto de 2019 a diciembre de 2021; se recogieron variables sociodemográficas, antropométricas y de consumo de alimentos, los patrones alimenticios se identificaron mediante análisis factorial; las asociaciones se analizaron mediante regresión de Poisson.

Resultados

De los 567 niños estudiados se identificaron dos hábitos de alimentación, “saludable” y “no saludable”; edad ≥ 24 meses (RP = 2,75; IC₉₅% 1,83;4,14), sexo masculino (RP = 0,66; IC₉₅% 0,49;0,87) y educación materna ≤ 9 años (RP = 0,61; IC₉₅% 0,46;0,81) se asociaron al patrón “saludable”; el patrón “no saludable” se asoció con la edad ≥ 24 meses (RP = 1,02; IC₉₅% 1,01;1,03) y el sexo masculino (RP = 1,46; IC₉₅% 1,08;1,98).

Conclusión

El patrón “saludable” fue más frecuente en niños ≥ 24 meses y menos frecuente en niños varones y madres con menor educación; los niños de ≥ 24 meses y los varones tuvieron una mayor prevalencia del patrón “no saludable”.

Palabras clave
Patrones Alimentarios; Consumo de Alimentos; Salud de los Niños; Vulnerabilidad Social; Estudios Transversales

INTRODUCTION

Dietary patterns are defined as a set of foods frequently consumed, based on the usual diet, as people do not consume only isolated nutrients or foods.¹1 Cunha CML, Canuto R, Rosa PBZ, Longarai LS, Schuch I. Associação entre padrões alimentares com fatores socioeconômicos e ambiente alimentar em uma cidade do Sul do Brasil. Cien & Saúde Colet. 2022; 27(2):687-700. DOI: 10.1590/1413-81232022272.37322020,²2 Krieger JP, Pestoni G, Cabaset S, Brombach C, Sych J, Schader C, Faeh D, Rohrmann S. Dietary patterns and their sociodemographic and lifestyle determinants in Switzerland: results from the National Nutrition Survey menu CH. Nutrients 2018; 11(1):62. During childhood, in addition to behavioral factors, maternal characteristics such as age, schooling, quality of life, and others, as well as the implications of the social environment within which the family is situated, may be associated with dietary patterns, given that the mother and family play a fundamental role in child care.³3 de Menezes LRD, e Souza RCV, Cardoso PC, dos Santos LC. Factors Associated with Dietary Patterns of Schoolchildren: A Systematic Review. Nutrients. 2023; 15(11):2450. https://doi.org/10.3390/nu15112450
https://doi.org/10.3390/nu15112450...

In developing countries, such as Brazil, social inequality is one of the determinants of food insecurity, defined as the situation when the general population, or a certain segment of it, lack access to adequate food.⁴4 BRASIL. Pesquisa de orçamentos familiares 2017-2018: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil / IBGE, Coordenação de Trabalho e Rendimento. – Rio de Janeiro: IBGE, 2020. Disponível em: https://loja.ibge.gov.br/pof-2017-2018-avaliac-o-nutricional-da-disponibilidade-domiciliar-de-alimentos-no-brasil.html Acesso em: ago. 2020
https://loja.ibge.gov.br/pof-2017-2018-a... A significant portion of Brazilians live in social vulnerability, especially in municipalities where human development index (HDI) is lower. In the Northeast region, particularly in the state of Alagoas, the HDI is only 0.684 and 60.8% of households face difficulties in accessing food.⁴4 BRASIL. Pesquisa de orçamentos familiares 2017-2018: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil / IBGE, Coordenação de Trabalho e Rendimento. – Rio de Janeiro: IBGE, 2020. Disponível em: https://loja.ibge.gov.br/pof-2017-2018-avaliac-o-nutricional-da-disponibilidade-domiciliar-de-alimentos-no-brasil.html Acesso em: ago. 2020
https://loja.ibge.gov.br/pof-2017-2018-a... The low purchasing power of families and low maternal schooling contribute to the sharing of unhealthy environments, reduced ability to purchase nutritionally adequate foods, and the provision of unhealthy items to children.⁴4 BRASIL. Pesquisa de orçamentos familiares 2017-2018: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil / IBGE, Coordenação de Trabalho e Rendimento. – Rio de Janeiro: IBGE, 2020. Disponível em: https://loja.ibge.gov.br/pof-2017-2018-avaliac-o-nutricional-da-disponibilidade-domiciliar-de-alimentos-no-brasil.html Acesso em: ago. 2020
https://loja.ibge.gov.br/pof-2017-2018-a... ,⁵5 Figueroa Pedraza D, Santos EES. Marcadores de consumo alimentar e contexto social de crianças menores de 5 anos de idade. Cad Saúde Colet, 2021;29(2):163-178. https://doi.org/10.1590/1414-462X202129020072
https://doi.org/10.1590/1414-462X2021290...

Socially vulnerable people are those living in poverty and/or lack of access to basic rights to survival, such as food security.⁶6 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. Despite the significance of this issue, studies covering socially vulnerable children are still scarce in the literature.⁷7 da Silva Melo, K; Kleres, LGDS; dos Santos, MMD. “Avaliação do estado nutricional e consumo alimentar de pré-escolares e escolares residentes em Caetés-PE.” RBONE-Revista Brasileira de Obesidade, Nutrição e Emagrecimento. 2018; 12(76): 1039-1049.,⁸8 Oliveira Brugger, D. “Fatores associados ao consumo alimentar de marcadores saudáveis e não saudáveis em crianças menores de cinco anos.” Rev Med Minas Gerais. 2019; 29: e-2034. Nevertheless, assessing child nutrition and its associated factors is crucial for the design of early interventions in the face of this challenge, when necessary, and for supporting public policies aimed at ensuring appropriate child development.

Habits formed in childhood are determinants for health in adulthood. Slum residents experience social vulnerability and food insecurity, with a higher likelihood of having an unhealthy diet and developing chronic non-communicable diseases in adulthood.⁵5 Figueroa Pedraza D, Santos EES. Marcadores de consumo alimentar e contexto social de crianças menores de 5 anos de idade. Cad Saúde Colet, 2021;29(2):163-178. https://doi.org/10.1590/1414-462X202129020072
https://doi.org/10.1590/1414-462X2021290... Studying this group can contribute to reducing expenses on primary health care and providing higher quality service for the population as a whole.⁷7 da Silva Melo, K; Kleres, LGDS; dos Santos, MMD. “Avaliação do estado nutricional e consumo alimentar de pré-escolares e escolares residentes em Caetés-PE.” RBONE-Revista Brasileira de Obesidade, Nutrição e Emagrecimento. 2018; 12(76): 1039-1049.

The objective of this study was to identify dietary patterns of socially vulnerable children and their associated factors.

METHODS

This was a cross-sectional population-based study, conducted in the slums of Maceió, the capital of the state of Alagoas, in Northeastern Brazil, between August 2019 and December 2021, aiming to assess the sense of coherence among socially vulnerable mothers and its influence on the linear growth of their children.

Slums are comprised of populations lacking essential public services and, due to this condition, employ various strategies to autonomously and collectively meet their housing needs and associated uses, given the insufficiency and inadequacy of resources allocated to ensure citizens’ rights.⁹9 BRASIL. CENSO Características da população e dos domicílios: resultados do universo demográfico, 2010. Rio de Janeiro: IBGE, 2011. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=793 Acesso em: ago. 2018.
https://biblioteca.ibge.gov.br/index.php...

The study included 10% of the 95 favelas identified in the 2010 Population Census (data available during the study period), selected randomly. All mothers living in these slums and who had at least one child aged between 6 months and 71 months and 29 days were considered eligible by the researchers. In order to minimize memory bias related to child information, when the mother had more than one child within the specified age group, the youngest child was selected. Pregnant women, mothers of preterm infants, or those with children having motor impairment, chronic diseases, or genetic syndromes interfering with growth and development were excluded from the study.

Data were collected during home visits by trained interviewers. The emergence of the COVID-19 pandemic interrupted data collection between March and November 2020.

Information on the child’s birth weight was obtained from the vaccination booklet. Additional information was collected through interviews with the mother. Maternal quality of life was assessed using the World Health Organization Quality of Life.¹⁰10 Cruz LN, Polanczyk CA, Camey AS, Hoffmann JF, Fleck MP. Quality of life in Brazil: normative values for the Whoqol-bref in a southern general population sample. Qual. life res. 2011; 20(7): 1123–1129. doi: 10.1007/s11136-011-9845-3
https://doi.org/10.1007/s11136-011-9845-... Food security was assessed using the Brazilian Household Food Insecurity Measurement Scale (Escala Brasileira de Insegurança Alimentar),¹¹11 Pérez-escamilla R, Segall-corrêa AM, Maranha LK, Sampaio MFA, Marín-León L, Panigassi G. An Adapted Version of the U.S. Department of Agriculture Food Insecurity Module Is a Valid Tool for Assessing Household Food Insecurity in Campinas. Br J Nutr, 2004; 134(3): 1923–1928. while data on the environmental sanitation were evaluated using questions from the Water, Sanitation and Hygiene protocol.¹²12 World Health Organization (WHO). Core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals. Joint WHO/UNICEF Expert Consultation. Geneva: WHO, 2018. Maternal sense of coherence (SOC)¹³13 Bonanato K, Branco DBT, Mota JPT, Ramos-Jorge ML, Paiva SM, Pordeuset IA, al. Trans-Cultural Adaptation and Psychometric Properties of the ‘Sense of Coherence Scale’ in Mothers of Preschool Children. Rev Interam Psicol, 2009; 43(1):144-153. was scored between 13 and 65 points; scores above the median indicated strong SOC.

Data on the child’s dietary pattern were obtained using a form adapted from the National Demographic and Health Survey,¹⁴14 BRASIL. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher. PNDS 2006: Banco de dados. Brasília, DF: Ministério da Saúde; 2009. Disponível em: Acesso em: ago. 2018. gathering information on breastfeeding and the frequency of consumption of ultra-processed food groups, vegetables, fruits, candies and soft drinks, among others. The foods included in this instrument were fresh fruit juice, fruits, leafy greens, vegetables, processed meats, cookies/biscuits, processed juice, soft drinks, instant noodles, coffee, eggs, rice/noodles, beans and meat. Regarding breastfeeding history, mothers were asked if the child had been breastfed and for how long (in months).

The weight and length/height of the children and their mothers were measured using a Plenna portable digital scale (precision of 100 g and capacity of 150 kg) and mobile stadiometer manufactured by Alturexata (precision of 1 mm and capacity up to 2.13 m, which can be adapted for use as an infantometer), according to techniques standardized by Lohman.¹⁵15 Lohman TG. Advances in Body Composition Assessment. Current Issues in Exercise Science. Champaing, Illinois: Editora Human Kinetics Publishers; 1992.

Anthropometric assessment was performed using the Anthro software (for children up to 5 years old) and Anthro Plus software (for children 5 years and older and adolescent mothers).The body mass index-for-age z-score was adopted for the analysis of nutritional status: underweight (< -2); normal weight (≥ -2 and ≤ +1); overweight (> +1 and ≤ +2) and obesity (> +2).¹⁴14 BRASIL. Ministério da Saúde. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher. PNDS 2006: Banco de dados. Brasília, DF: Ministério da Saúde; 2009. Disponível em: Acesso em: ago. 2018. mothers aged 19 years and older had their body mass index classified according to the World Health Organization (WHO) criteria.¹⁶16 World Health Organization. Physical status: the use of and interpretation of anthropometry, report of a WHO expert committee. World Health Organization; 1995. “Excess weight” was defined as the combination of the categories “overweight” and “obesity”. In order to measure the waist circumference of the mothers, an inelastic tape measure was used, and abdominal obesity was identified when waist circumference > 80 cm.¹⁷17 Ministério da Saúde do Brasil. Diretrizes para coleta e análise de dados antropométricos em serviços de saúde. 2011. Norma Técnica do Ministério da Saúde do Sistema de Vigilância Alimentar e Nutricional. Brasília: MS.

The dependent variables were the two dietary patterns defined by the researchers, healthy and unhealthy, generated by principal component analysis (PCA), based on child dietary intake data reported by mothers when answering the food frequency questionnaire (FFQ). The dichotomization of the variables is described in the data processing item.

The independent variables were:

1. Socioeconomic and family information

2. household income per capita (in minimum wages, categorized by the median: ≥ ¼ and < ¼ of the minimum wage);

3. poverty level (according to the Alvarez score, categorized according to the score obtained: 45 to 54 points, higher low poverty; 20 to 44 points, lower poverty and extreme poverty);

4. number of people in the household (categorized by the median: ≤ 4 and > 4);

5. number of children in the household (categorized by median: 1 to 2; > 2);

6. type of drinking water (adequate; inadequate);

7. presence of sanitary sewage (adequate; inadequate);

8. waste management (adequate; inadequate);¹²12 World Health Organization (WHO). Core questions and indicators for monitoring WASH in health care facilities in the Sustainable Development Goals. Joint WHO/UNICEF Expert Consultation. Geneva: WHO, 2018.12

9. food security (food security, 0 points; mild food (in)security, 1 to 5 points; moderate/severe food insecurity, 6 to 14 points).¹¹11 Pérez-escamilla R, Segall-corrêa AM, Maranha LK, Sampaio MFA, Marín-León L, Panigassi G. An Adapted Version of the U.S. Department of Agriculture Food Insecurity Module Is a Valid Tool for Assessing Household Food Insecurity in Campinas. Br J Nutr, 2004; 134(3): 1923–1928.

1. Maternal information

2. age (in years: 14 to 18; 19 to 29; ≥ 30);

3. schooling (in years of study: ≤ 9; >9).

4. Quality of life, analyzed according to the following parameters:

5. physical health (adequate; inadequate);

6. psychological aspects of behavior (appropriate; inappropriate);

7. social relationships (adequate; inadequate);

8. environment (adequate; inadequate);

9. SOC (strong; weak);

10. excess weight (yes; no);

11. abdominal obesity (yes; no);

12. height (≤ 150 cm; > 150 cm);

13. prenatal care (yes; no).

1. Child-related information

2. age (in months: < 24; ≥ 24);

3. sex (female; male);

4. birth weight (low weight, < 2,500 g; adequate weight, 2,500 to 3,999 g; and high weight, ≥ 4,000 g);

5. excess weight (yes; no);

6. breastfeeding history (yes; no); and

7. duration of breastfeeding (in months: ≥ 6; < 6).

Data were independently entered in duplicate, and analyzed using the Stata/SE software version 14.1 (StataCorp LP. College Station, TX, USA). Dietary patterns were defined based on food group consumption frequency data using the principal component analysis (PCA) statistical method, followed by Varimax orthogonal rotation. This method aims to reduce a large number of variables to a smaller number by grouping those that are strongly correlated, thus enabling the clustering of foods contained in the FFQ based on the degree of correlation between them. As a result of this statistical analysis, factor loadings were generated, and those with values ≥ 0.20 or ≤ -0.20 were considered.¹⁸18 Flores, ME; Rivera-Pasquel, M; Macías, N; Sánchez-Zamorano, LM; Rodríguez-Ramírez, S; Contreras-Manzano, A; Denova-Gutiérrez, E. Dietary patterns in Mexican preschool children are associated with stunting and overweight. Rev Saúde Púb. 2021; 55(53). https://doi.org/10.11606/s1518-8787.2021055002350
https://doi.org/10.11606/s1518-8787.2021... Items that did not show saturation were excluded from the correlation matrix because they did not meet the minimum value established for factor loading: 0.20 (exclusion of liver). Dietary patterns were defined after evaluating eigenvalues, with factors having eigenvalues > 1.5. The patterns were named according to the characteristics of the foods grouped in each factor.

The factor scores for each child were calculated. These scores were dichotomized (high consumption of food groups within dietary patterns: yes; no), considering high consumption of each dietary pattern when the consumption score was > 75th percentile (P75); and moderate/low consumption, when ≤ P75.19 Thus, a consumption score of a specific dietary pattern > P75 indicated greater adherence to the analyzed dietary pattern.

Descriptive analysis was performed, and the data were expressed as absolute and relative frequencies and respective 95% confidence intervals (95%CI).

The associations between dietary patterns [healthy and unhealthy (outcomes)] and the independent variables were assessed by calculating crude and adjusted prevalence ratios (PRs) and respective confidence intervals (95%CI), estimated using Poisson regression with robust variance adjustment. Analyses were performed separately for each dietary pattern. In the crude analysis, independent variables with a significance level of up to 20% (p < 0.2) were included in the adjusted analysis. The adjusted analysis was performed using the theoretical model proposed by Mendes et al.²⁰20 Mendes MMe, Marçal Gde M, Rinaldi AEM, Bueno NB, Florêncio TMde MT, Clemente APG. Dietary patterns of children aged 6–24 months assisted by the Bolsa Família Program. Public Health Nutrition. 2022;25(10):2794-2804. doi:10.1017/S1368980021004110 – with adaptations –, organized as follows: model 1 included family socioeconomic variables that showed p < 0.2 in the crude analysis; model 2 included maternal variables with p < 0.2 in the crude analysis, and the variables from model 1 with p < 0.05; and model 3, the final model, included child-related variables with p < 0.2 in the crude analysis and variables from models 1 and 2 with p < 0.05 (Supplementary material Figure 1). In each model, the backward stepwise technique was applied to eliminate variables that did not show a statistically significant association. Variables with p < 0.05 were considered significant in the final model.

The research project was approved by the Research Ethics Committee of the Universidade Federal de Alagoas (CEP/UFAL): Certificate of Submission for Ethical Appraisal (CAAE) protocol No. 06340218.7.0000.5013. After being informed about the aspects of the research, the mothers signed the Free and Informed Consent Form opinion No. 3,375,586, approved on 06/06/2019.

RESULTS

Data were collected from 602 eligible mother-child pairs, of which 35 pairs with outliers, noticed during data tabulation and considered losses of the study, were excluded. The final sample was comprised of 567 mother-child pairs. There was a slight predominance of male children (51.3%) and child’s age ≥ 24 months (57.1%). The average age of the mothers was 28.3 years (± 9.7 years), with most of them in the age group of 19 to 29 years (55.2%). There was a higher prevalence of overweight mothers (57.0%) with less than 9 years of schooling (60.3%), monthly household income per capita of less than ¼ of the minimum wage (67.9%) and moderate/severe food insecurity (61.4%) (Table 1).

The PCA identified two dietary patterns, unhealthy and healthy, which explained 38% of the total variance. The unhealthy eating pattern included coffee, eggs, processed meat, cookies/biscuits, processed juice, soft drinks and instant noodles; and the healthy dietary pattern consisted of fresh fruit juice, fruits, leafy greens, vegetables, rice/noodles, beans and meat (Table 2). Figure 1 shows the prevalence of consumption of the components of the unhealthy and healthy patterns.

In the crude analysis, the unhealthy dietary pattern was associated with: (i) low level of maternal schooling, (ii) weak SOC, (iii) maternal overweight, (iv) abdominal obesity, (v) child’s age ≥ 24 months, (vi) male gender, and (vii) breastfeeding history. The healthy dietary pattern was associated with (i) low level of maternal schooling, (ii) male gender, (iii) child’s age ≥ 24 months, (iv) low birth weight, (v) childhood excess weight, and (vi) breastfeeding history; there were no socioeconomic variables associated with this pattern (Supplementary Table 1).

In the final adjusted analysis model, the unhealthy pattern was higher in children aged ≥ 24 months (PR = 1.02; 95%CI 1.01;1.03) and males (PR = 1.46; 95%CI 1.08;1.98). Regarding the healthy pattern, it was found that the frequency was higher in children aged ≥ 24 months (PR = 2.75; 95%CI 1.83;4.14) and lower in males (PR = 0.66; 95% CI 0.49;0.87) and when mothers had low level of schooling (PR = 0.61; 95%CI 0.46;0.81) (Table 3).

DISCUSSION

In this study, two dietary patterns were identified: healthy and unhealthy. The highest consumption of the healthy dietary pattern was associated with child’s age ≥ 24 months, while the lowest consumption was associated with male children and mothers with lower level of schooling. These findings corroborate the hypothesis that lower level of schooling is associated with less healthy food choices.²¹21 Bogea EG, Martins MLB, Carvalho WRC, Arruda SPM, França AKTC, Silva AAM. Padrões alimentares de crianças de 13 a 35 meses de idade e associação com características maternas. Cad. Saúde Pública 2019; 35(4):e00072618. doi: 10.1590/0102-311X00072618
https://doi.org/10.1590/0102-311X0007261... The lowest consumption of the unhealthy pattern was associated with the child’s age ≥ 24 months and male children.

The number of dietary patterns identified was similar to that found in a study analyzing the dietary pattern of Brazilian children.²²22 Carvalho RBN de, Louzada ML da C, Rauber F, Levy RB. Characteristics associated with dietary patterns in Brazilian children under two years of age. Rev Saúde Pública. 2022;56:118. Available from: https://doi.org/10.11606/s1518-8787.2022056003757
https://doi.org/10.11606/s1518-8787.2022... The number of patterns that can be identified in a given population varies depending on the diversity of food groups, sample size, and the pattern extraction techniques used in the studies.³3 de Menezes LRD, e Souza RCV, Cardoso PC, dos Santos LC. Factors Associated with Dietary Patterns of Schoolchildren: A Systematic Review. Nutrients. 2023; 15(11):2450. https://doi.org/10.3390/nu15112450
https://doi.org/10.3390/nu15112450... A systematic review aimed at identifying dietary patterns in children aged 7 to 10 years and their associated factors found a variable number of dietary patterns, from two to five, with a predominance of three.³3 de Menezes LRD, e Souza RCV, Cardoso PC, dos Santos LC. Factors Associated with Dietary Patterns of Schoolchildren: A Systematic Review. Nutrients. 2023; 15(11):2450. https://doi.org/10.3390/nu15112450
https://doi.org/10.3390/nu15112450...

In studies conducted by Brazilian²³23 Barbosa, LB; Gama, IRS; Vasconcelos, NBR; Santos, EA; Ataide-Silva, T; Ferreira, HS. Dietary patterns according to gender and ethnicity associated with metabolic syndrome: a systematic review and meta-analysis. Cien Saude Colet 2023; Está disponível em: http://cienciaesaudecoletiva.com.br/artigos/dietary-patterns-according-to-gender-and-ethnicity-associated-with-metabolic-syndrome-a-systematic-review-and-metaanalysis/18910
http://cienciaesaudecoletiva.com.br/arti... and American researchers,²⁴24 Lara KM, Levitan EB, Gutierrez OM, Shikany JM, Safford MM, Judd SE et al. Dietary Patterns and Incident Heart Failure in U.S. Adults Without Known Coronary Disease. J Am Coll Cardiol. 2019;73(16):2036-2045. aimed at linking dietary patterns to metabolic syndrome and cardiovascular diseases, and identifying dietary patterns derived from a posteriori analysis, as decided in the present study, eggs were included in the unhealthy dietary patterns. The inclusion of high biological value protein source in this pattern was possibly due to the high social vulnerability of the analyzed population, which uses sausages and eggs as the primary protein sources in their meals because of their affordability. The high frequency of egg consumption among the children influenced the statistical analyses, resulting in eggs having a higher correlation with unhealthy foods.

Regardless of the number of dietary patterns obtained and component foods, it is crucial to identify factors associated with each pattern. A study conducted with children aged 13 to 35 months, in São Luís, the capital of the state of Maranhão, concluded that multiparity, lower level of maternal schooling and maternal age under 20 years were associated with lower consumption of healthy foods.²¹21 Bogea EG, Martins MLB, Carvalho WRC, Arruda SPM, França AKTC, Silva AAM. Padrões alimentares de crianças de 13 a 35 meses de idade e associação com características maternas. Cad. Saúde Pública 2019; 35(4):e00072618. doi: 10.1590/0102-311X00072618
https://doi.org/10.1590/0102-311X0007261... Similar findings were found in a study involving 300 children aged 4 to 24 months in Porto Alegre, the capital of the state of Rio Grande do Sul, where lower level of maternal schooling was associated with a higher number of ultra-processed products consumed by children,¹⁹19 Giesta, JM; Zoche, E; Corrêa, RS; Bosa, VL. Fatores associados à introdução precoce de alimentos ultraprocessados na alimentação de crianças menores de dois anos. Ciênc Saúde Colet. 2019; 24(7): 2387-2397. Disponível em: <https://doi.org/10.1590/1413-81232018247.24162017>.
https://doi.org/10.1590/1413-81232018247... corroborating our findings: lower maternal level of schooling was associated with a reduction in the healthy dietary pattern. A possible explanation for this finding is the fact that mothers with a higher level of education have greater access to information on healthy eating practices. Maternal schooling influences children’s lifestyle.⁴4 BRASIL. Pesquisa de orçamentos familiares 2017-2018: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil / IBGE, Coordenação de Trabalho e Rendimento. – Rio de Janeiro: IBGE, 2020. Disponível em: https://loja.ibge.gov.br/pof-2017-2018-avaliac-o-nutricional-da-disponibilidade-domiciliar-de-alimentos-no-brasil.html Acesso em: ago. 2020
https://loja.ibge.gov.br/pof-2017-2018-a...

Although no associations were found, it is widely acknowledged that environmental, nutritional, psychological, social and cultural factors may be related to eating behavior.²⁵25 Silva GP, Almeida SS, Costa TMB. Family influence on the nutritional status and eating habits of six to nine year-old children. Rev Nutr,2021;34:e200165. Children rely on their parents/guardians to buy/prepare their meals, their eating habits are directly influenced by food beliefs and culture of their families.²⁵25 Silva GP, Almeida SS, Costa TMB. Family influence on the nutritional status and eating habits of six to nine year-old children. Rev Nutr,2021;34:e200165. Among families that do not practice a diversified diet and show a low frequency of consumption of healthy foods, there is a higher likelihood of growth retardation in their children.²⁶26 Freitas LG, Cortés MAP, Sten C, Cousin E, Faustino-Silva DD, Hilgert JB. Qualidade do consumo alimentar e fatores associados em crianças de um ano de vida na Atenção Primária à Saúde. Ciênc Saúde Colet, 2020; 25(7): 2561-2570.

One of the findings from the multiple analysis showed an association between the child’s age ≥ 24 months and a higher frequency of consumption of both healthy and unhealthy patterns, which was similar to that of a study conducted in the South of Brazil, where an association between dietary patterns of children aged 12 months and older was found;²⁷27 Guedes, J. R. D., Höfelmann, D. A., Madruga, F. P., de Oliveira, E. C. V., de Cerqueira, M. M. O., Lobo, A. C. S., et al. Associated factors with dietary patterns among children under 2 years of age: a study in childcare centres and homes of South Brazil. J nutr sci. 2021;10:e37. doi:10.1017/jns.2021.26 this finding was based on a greater independence of these children in choosing foods and their access to a wider variety of them, when compared to younger children²⁸28 Godinho APK, Conceição A de O da, Rodrigues EL, Siqueira IMBJ, Taconeli CA, Crispim SP, et al. Dietary patterns and associated factors of children under two years of age born prematurely. Rev paul pediatr [Internet]. 2022;40:e2021177. Available from: https://doi.org/10.1590/1984-0462/2022/40/2021177IN
https://doi.org/10.1590/1984-0462/2022/4... – however, it is worth highlighting that the study population consisted of children from socially vulnerable families, predominantly without access to a diversified diet; as children grow older, they gain physiological capability and autonomy in food choices, within the possibilities existing in their environment.

The lack of association between male gender and higher frequency of consumption of the unhealthy dietary pattern among children is not a consensus in the literature. Studies have shown that male gender is associated with both healthy²⁹29 Antunes ABS, Cunha DB, Baltar VT, Steluti J, Pereira RA, Yoko EM, et al. Padrões alimentares de adultos brasileiros em 2008–2009 e 2017–2018. Rev Saude Publica. 2021;55 Supl 1:8s. https://doi.org/10.11606/s1518-8787.2021055003437
https://doi.org/10.11606/s1518-8787.2021... and unhealthy patterns;¹1 Cunha CML, Canuto R, Rosa PBZ, Longarai LS, Schuch I. Associação entre padrões alimentares com fatores socioeconômicos e ambiente alimentar em uma cidade do Sul do Brasil. Cien & Saúde Colet. 2022; 27(2):687-700. DOI: 10.1590/1413-81232022272.37322020 However, it can be hypothesized that, in socially vulnerable communities, boys have greater independence and autonomy, including in their food choices.

As for the healthy pattern, children of mothers with low level of schooling showed a lower frequency of consumption of foods in this pattern, a fact also observed in the cohort study conducted in São Luís, state of Maranhão.²¹21 Bogea EG, Martins MLB, Carvalho WRC, Arruda SPM, França AKTC, Silva AAM. Padrões alimentares de crianças de 13 a 35 meses de idade e associação com características maternas. Cad. Saúde Pública 2019; 35(4):e00072618. doi: 10.1590/0102-311X00072618
https://doi.org/10.1590/0102-311X0007261... Low parental level of education may indicate a lack of adequate nutrition literacy, which promotes satisfactory self-care in matters related to children’s food and nutrition.¹⁹19 Giesta, JM; Zoche, E; Corrêa, RS; Bosa, VL. Fatores associados à introdução precoce de alimentos ultraprocessados na alimentação de crianças menores de dois anos. Ciênc Saúde Colet. 2019; 24(7): 2387-2397. Disponível em: <https://doi.org/10.1590/1413-81232018247.24162017>.
https://doi.org/10.1590/1413-81232018247...

According to a study conducted in Araraquara, state of São Paulo, in the period from 2015 to 2016, when evaluating families that were or were not Bolsa Família beneficiaries, those who were not covered by the Program were more likely to have a restricted dietary pattern, less likely to follow a healthy diet, regardless of the age of their members.³⁰30 Cardozo DR, Rossato SL, Costa VMHM, Oliveira MRM, Almeida LMMC, Ferrante VLCB. Padrões alimentares e (in)segurança alimentar e nutricional no Programa Bolsa Família. INTERAÇÕES. 2020; 21(2):363-377. A study conducted in the state of Paraíba also found that children with different types of social vulnerability were more likely to have an unhealthy dietary pattern.⁵5 Figueroa Pedraza D, Santos EES. Marcadores de consumo alimentar e contexto social de crianças menores de 5 anos de idade. Cad Saúde Colet, 2021;29(2):163-178. https://doi.org/10.1590/1414-462X202129020072
https://doi.org/10.1590/1414-462X2021290...

These data reinforce expectations: among children from socially vulnerable families, lower level of maternal schooling negatively impacts their dietary patterns. Adequate eating habits are extremely important in childhood because, over the long term, they can influence nutritional status and the development of chronic non-communicable diseases.⁵5 Figueroa Pedraza D, Santos EES. Marcadores de consumo alimentar e contexto social de crianças menores de 5 anos de idade. Cad Saúde Colet, 2021;29(2):163-178. https://doi.org/10.1590/1414-462X202129020072
https://doi.org/10.1590/1414-462X2021290... ,²⁹29 Antunes ABS, Cunha DB, Baltar VT, Steluti J, Pereira RA, Yoko EM, et al. Padrões alimentares de adultos brasileiros em 2008–2009 e 2017–2018. Rev Saude Publica. 2021;55 Supl 1:8s. https://doi.org/10.11606/s1518-8787.2021055003437
https://doi.org/10.11606/s1518-8787.2021...

The development of public policies aimed at promoting healthy eating for socially vulnerable children, especially those living in slums, presents a significant challenge for policymakers. Improving the diet of children living in disadvantaged environments is crucial for the development of these policies and can contribute to reducing unfavorable health outcomes, such as obesity.⁴4 BRASIL. Pesquisa de orçamentos familiares 2017-2018: avaliação nutricional da disponibilidade domiciliar de alimentos no Brasil / IBGE, Coordenação de Trabalho e Rendimento. – Rio de Janeiro: IBGE, 2020. Disponível em: https://loja.ibge.gov.br/pof-2017-2018-avaliac-o-nutricional-da-disponibilidade-domiciliar-de-alimentos-no-brasil.html Acesso em: ago. 2020
https://loja.ibge.gov.br/pof-2017-2018-a...

The study has limitations: the use of extensive questionnaires, the comprehension of which may be difficult for mothers with low level of maternal schooling to understand; and the interviewer bias, who is familiar with the population, may influence the way questions are asked, leading to biased responses. Both limitations imply information bias, although this was minimized by using questionnaires from instruments adopted for large national surveys and administered by trained researchers. Another limitation is the cross-sectional design, which prevents establishing causal relationships and may result in reverse causality, where the association between the variables differs from expectations. The use of multiple analysis mitigated this bias. Using a retrospective method (FFQ) to assess food consumption can lead to errors in the answers about food consumed, since it relies on the respondent’s memory. However, it is a method widely used in population-based surveys³3 de Menezes LRD, e Souza RCV, Cardoso PC, dos Santos LC. Factors Associated with Dietary Patterns of Schoolchildren: A Systematic Review. Nutrients. 2023; 15(11):2450. https://doi.org/10.3390/nu15112450
https://doi.org/10.3390/nu15112450... ,²³23 Barbosa, LB; Gama, IRS; Vasconcelos, NBR; Santos, EA; Ataide-Silva, T; Ferreira, HS. Dietary patterns according to gender and ethnicity associated with metabolic syndrome: a systematic review and meta-analysis. Cien Saude Colet 2023; Está disponível em: http://cienciaesaudecoletiva.com.br/artigos/dietary-patterns-according-to-gender-and-ethnicity-associated-with-metabolic-syndrome-a-systematic-review-and-metaanalysis/18910
http://cienciaesaudecoletiva.com.br/arti... to assess habitual dietary intake of groups, and its limitation was mitigated by the short frequency adopted (the previous week). Another obstacle in the study methods, the temporal gap in data collection, did not compromise the homogeneity of the sample: individuals included in the study before the pandemic did not show statistically significant differences in socioeconomic and environmental conditions, when compared to those included after the pandemic outbreak (Supplementary Table 2).

A strong point of this research is the careful methodological approach in participant selection: all residents of the selected communities who met the eligibility criteria were recruited, minimizing the risk of selection bias. Another strong point was the use of validated instruments for data collection. These characteristics demonstrate the internal and external validity of the study; allowing the results to be extrapolated to similar populations in Brazil.

It can be concluded that the diet of socially vulnerable children was related to both intrinsic and extrinsic factors, the highest frequency of the healthy pattern was associated with age ≥ 24 months; and the lowest frequency of this pattern, with low level of maternal schooling and male children. Increased frequency of the unhealthy pattern was prevalent in children aged ≥ 24 months and in males. In order to elucidate the causality of variables associated with diet in this population, prospective studies are necessary.

REFERENCES

Supplementary Figure 1   Flowchart regarding the two statistical models for both outcomes, unhealthy dietary pattern and healthy dietary pattern

Supplementary Table 1

Supplementary Table 2

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