Abstract

This study aimed to investigate factors associated with food insecurity in households in the state of Pernambuco, in the Northeast region of Brazil. This is a cross-sectional study carried out in 1,008 private households. The investigation used the Brazilian Food Insecurity Scale (EBIA) and analyzed associations with socioeconomic and demographic variables, as well as practices related to eating. Prevalence ratio and adjustment were calculated using Poisson regression, and associations where p ≤ 0.05 were statistically significant. Food insecurity prevalence was 68.4%. Variables associated with insecurity were: education of the head of the family; per capita income; participation in the Bolsa Família Program; number of residents; occupation of the household; social class; practices and opinions about family eating habits. The greatest insecurity risk was found in those with the worst economic conditions, in beneficiaries of the Bolsa Família Program and in those who considered the lack of ultra-processed products to improve the family’s diet. Food insecurity was linked to conditions of social vulnerability and to those who did not perceive that they had a good diet. Most of the subjects reported using resources of the Bolsa Família program to purchase food, which reinforces the importance of this strategy in promoting access to food.

Keywords:
Food Security; Food Assistance; Socioeconomic Factors; Social Inequality

Introduction

Adequate and healthy food, an achievement resulting from social struggles, is legally a human right (Brasil, 2006BRASIL. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União, Brasília, DF, 18 set. 2006. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11346.htm >. Acesso em: 06 jul. 2021.
http://www.planalto.gov.br/ccivil_03/_at... ). Despite this legal and inalienable recognition, there is an increased number of individuals experiencing situations of hunger, the most serious expression of food and nutritional insecurity (FAO; IFAD; UNICEF; WFP; WHO, 2021FAO; IFAD; UNICEF; WFP; WHO. The State of Food Security and Nutrition in the World 2021: Transforming food systems for food security, improved nutrition and affordable healthy diets for all. Rome: FAO, 2021. DOI: 10.4060/cb4474en
https://doi.org/10.4060/cb4474en... ). In a recent survey carried out in Brazil, it was revealed that 125.2 million people experience some degree of food insecurity (FI) and 33 million face hunger (PENSSAN Network, 2022REDE PENSSAN. II Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da COVID-19 no Brasil. São Paulo, 2022. Disponível em: <Disponível em: https://olheparaafome.com.br/wp-content/uploads/2022/06/Relatorio-II-VIGISAN-2022.pdf >. Acesso em: 1 jul. 2022.
https://olheparaafome.com.br/wp-content/... ).

In the Brazilian scenario, hunger was denounced from the work of Josué de Castro, who showed that this problem is not due to the lack of food production, it is not a natural phenomenon and is directly related to political and social issues (Castro, 2008CASTRO, J. Geografia da fome. 9. ed. Rio de Janeiro: Civilização Brasileira, 2008.). Castro’s studies showed the social determination and biological repercussion of the violation of the Human Right to Adequate Food and Nutrition (Dhana - Direito Humano à Alimentação e Nutrição Adequadas) and served as a basis for the discussion and development of Food and Nutrition Security (FNS) policies in the Brazilian context (Rigon; Bógus, 2016RIGON, S. A.; BÓGUS, C. M. A segurança alimentar e nutricional no Brasil: das concepções norteadoras ao início dos processos de consolidação. In: BEZERRA, I.; PEREZ-CASSARINO, J. (Org.). Soberania Alimentar (SOBAL) e Segurança Alimentar e Nutricional (SAN) na América Latina e Caribe. Curitiba: UFPR, 2016. p. 31-54.).

Conceptually, FNS is defined as:

Two dimensions are articulated to understand FNS: food and nutrition. The first refers to availability, encompassing production, commercialization, and access to food. The second corresponds directly to the choice, preparation, consumption and biological use of the food and is related to health (Leão, 2013LEÃO, M. (Org.). O Direito Humano à Alimentação Adequada e o Sistema Nacional de Segurança Alimentar e Nutricional. Brasília, DF: ABRANDH, 2013.).

FNS has become one of the strategies for promoting development, since it is built from the perspective of Dhana (Direito Humano à Alimentação e Nutrição Adequadas) and relates to food sovereignty, in view of the right of peoples to decide on their food (Maluf; Reis, 2013MALUF, R. S.; REIS, M. C. Conceitos e Princípios de Segurança Alimentar e Nutricional. In: ROCHA, C.; BURLANDY, L.; MAGALHÃES, R. (Ed.). Segurança Alimentar e Nutricional: perspectivas, aprendizados e desafios para as políticas públicas. Rio de Janeiro: Fiocruz, 2013. p. 15-42.). The last Household Budget Survey (POF 2017-2018) showed that 36.7% of Brazilian private households were in FI, which corresponded to about 25.3 million households with some degree of concern about access to food (IBGE, 2020IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro, 2020.). Specifically in the state of Pernambuco, the 2017-2018 POF found a prevalence of 48.3% of FI, which, as observed nationally, was higher than the results of the latest National Household Sample Surveys (PNAD), which found 25.9% (in 2014) and 42.2% (in 2009) of FI in the state (IBGE, 2014IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa Nacional por Amostra de Domicílios: Segurança Alimentar 2013. Rio de Janeiro, 2014.). In addition to these surveys conducted nationwide, a survey conducted previously in Pernambuco found a prevalence of 61.8% of FI (UFPE; IPSA; SUSAN, 2011UFPE; IPSA; SUASAN. Avaliação da (In) Segurança Alimentar nas Regiões de Desenvolvimento do Estado de Pernambuco. Recife: UFPE, 2011. Disponível em: <Disponível em: http://www.sedsdh.pe.gov.br/c/document_library/get_file?uuid=90874565-92cb-4467-bebe-2d79f618eb61&groupId=17459 > Acesso em: 06 jul. 2021.
http://www.sedsdh.pe.gov.br/c/document_l... ). Between the 2013 and 2017-2018 surveys, Pernambuco was among the ten states that had the largest number of households in hunger throughout the period (Ribeiro Junior et al., 2021RIBEIRO JUNIOR, J. R. S. et al. Atlas das situações alimentares no Brasil: a disponibilidade domiciliar de alimentos e a fome no mundo contemporâneo. Bragança Paulista: Universidade São Francisco, 2021.)

Currently, the country is experiencing a scenario of setbacks in relation to the FNS guarantee, which becomes even more worrying in the context of the covid-19 pandemic, in addition to the cuts in investments in social policies, health and education (Alpino et al., 2020ALPINO, T. M. A. et al. COVID-19 e (in)segurança alimentar e nutricional: ações do Governo Federal brasileiro na pandemia frente aos desmontes orçamentários e institucionais. Cadernos de Saúde Pública, Rio de Janeiro, v. 36, n. 8, p. e00161320, 2020. DOI: 10.1590/0102-311X00161320
https://doi.org/10.1590/0102-311X0016132... ; Galindo et al., 2021GALINDO, E. et al. Efeitos da pandemia na alimentação e na situação da segurança alimentar no Brasil. Food for Justice Working Paper Series, Berlin, n. 4, 2021. Disponível em: <Disponível em: https://www.epsjv.fiocruz.br/sites/default/files/files/relatorio%20pesquisa%20Berlim%20UFMG.pdf >. Acesso em 1 jul. 2022.
https://www.epsjv.fiocruz.br/sites/defau... ). Considering this context, the objective of this study is to investigate the factors associated with FI in households in the state of Pernambuco.

Materials and methods

This is a cross-sectional study based on data from the IV State Health and Nutrition Survey (PESN), Chronic Noncommunicable Diseases in the State of Pernambuco: prevalence, associated factors, health actions and services, which occurred in 13 municipalities in the state of Pernambuco, located in the Northeast region of Brazil (SILVA, 2019SILVA, C.S. Insegurança alimentar e nutricional em adultos do estado de Pernambuco: situação e fatores associados ao acesso à alimentação. 2019. Tese (Doutorado em Nutrição) - Programa de Pós-Graduação em Nutrição, Universidade Federal de Pernambuco, Recife, 2019. Disponível em: <Disponível em: https://repositorio.ufpe.br/bitstream/123456789/34101/1/TESE%20Catarine%20Santos%20da%20Silva.pdf >. Acesso em: 30 jun. 2022.
https://repositorio.ufpe.br/bitstream/12... ).

For sample size calculation, the prevalence of 61.8% of FI, 95% confidence level and sampling error of 3% were taken into account, resulting in a minimum sample of 950 households. In total, 1,008 private households from Pernambuco were investigated in urban and rural areas. The sampling plan was probabilistic and stratified into three stages, whose primary selection units were the municipalities, the secondary units were the census tracts and the tertiary units were the households, in which information was collected through questionnaires.

Data collection was developed between 2015 and 2016. The questionnaire used was based on the model adopted by the II and III PESN/97-2006, for comparative purposes and with the necessary extensions to cover the additional objectives of the research. For this study, we used forms related to socioeconomic, demographic, Food Security (FS) and food-related practices.

The situation of FS in the dimension of access to food was evaluated using the Brazilian Food Insecurity Scale (EBIA), composed of 14 questions for households with children and/or adolescents and eight questions for those without this population. Each affirmative answer corresponds to one point, and the sum of the points corresponds to the final score of the scale, whose classification is given according to the presence or absence of children under 18 years of age in the household (MDS, 2014MDS - MINISTÉRIO DO DESENVOLVIMENTO SOCIAL E COMBATE À FOME. Estudo Técnico N.° 01/2014 Escala Brasileira de Insegurança Alimentar - EBIA: análise psicométrica de uma dimensão da Segurança Alimentar e Nutricional. Brasília, DF, 2014.). Households with negative answers to all questions (0 points) are considered to be in a situation of FS; mild FI: 1-5 points (households with people <18 years of age) and 1-3 points (households without people <18 years age); moderate FI: 6-9 points (households with people <18 years of age) and 4-5 points (households without people <18 years of age); severe FI: 10-14 points (households with people <18 years of age) and 6-8 points (households without people <18 years of age) (MDS, 2014MDS - MINISTÉRIO DO DESENVOLVIMENTO SOCIAL E COMBATE À FOME. Estudo Técnico N.° 01/2014 Escala Brasileira de Insegurança Alimentar - EBIA: análise psicométrica de uma dimensão da Segurança Alimentar e Nutricional. Brasília, DF, 2014.). For analysis in this study, we added mild, moderate and severe FI, creating a single category: FI, so that we worked with the dichotomous variable: FS/FI.

To evaluate the socioeconomic conditions of the households, we investigated education and occupation of the head of the family, per capita family income and participation in an income transfer program (Bolsa Família Program [PBF]). The demographic characteristics were evaluated through the area of residence, gender, age and color/race of the head of the family, number of residents and household occupation regime, water treatment for consumption, and social class, according to the criteria of the Brazilian Association of Research Companies (ABEP) (ABEP, 2014ABEP - ASSOCIAÇÃO BRASILEIRA DE EMPRESAS DE PESQUISA. Critério de Classificação Econômica Brasil. São Paulo, 2014. Disponível em: <Disponível em: http://www.abep.org/criterio-brasil >. Acesso em: 6 jul. 2021.
http://www.abep.org/criterio-brasil... ). For social class categorization, it was verified, using descriptive analysis, the need to join categories B and C1, D and E, for better robustness in the multivariate analysis.

Practices and opinions on family food were also analyzed: way of purchasing food for consumption, place of purchase of most of the family’s food, spending in the last month with the BFP benefit, opinion on food from the receipt of the BFP, the quality of the family’s food, and foods missing to improve food consumption. Regarding the latter variable, in addition to the categories none and all, there were the following food options: fruits, vegetables, meats, beans, rice, pasta, yogurt, milk or cheese, cookies or other industrialized products. At the time of analysis, recategorization was performed according to the processing levels of the NOVA classification present in the Food Guide for the Brazilian Population (MS, 2014MS - MINISTÉRIO DA SAÚDE. Guia alimentar para a população brasileira. 2. ed. Brasília, DF, 2014.).

For analysis, the SPSS^® software, version 13.0, was used, with simple frequencies and percentages for descriptive analysis of categorical variables and the chi-square test to verify the association between the independent variables and the outcome, in addition to the calculation of the Prevalence Ratio (PR) to verify the prevalence with the respective confidence interval (CI) of 95%. In all analyses, associations where p≤0.05 were considered statistically significant.

In the variables that had few missing values, the statistical feature of multiple imputation was used. Categories receiving values from the multiple imputation: FS (07 missing values) and PBF participation (01 missing value).

In order to control for possible confounding factors, Poisson regression with robust variance was performed with the variables where p ≤ 0.20 in the bivariate analysis. Before the regression, the occurrence of multicollinearity was tested, which was not detected. The variables were divided into three blocks: in block one, socioeconomic variables were included, in block two, demographic variables, and in block three, practices and opinions on food.

The research was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Pernambuco in compliance with the regulatory standards for research involving human beings - Resolution No. 466/12 of the National Health Council.

Results

Among the 1,008 households evaluated, 68.4% were in a situation of FI (25.3% in mild FI, 31.4% in moderate FI and 11.7% in severe FI). It is noteworthy that approximately 64% of the households were located in the countryside of the state of Pernambuco, and 72.3% had a male head of the family, who, for the most part (61.3%), were between 30 and 59 years old (Table 1). Most of these heads of household did not declare themselves to be white (74%), 39.1% had up to four years of study, and 38% were formally working. Regarding the economic situation of the families, it is observed that most had a per capita income of up to 1/2 minimum wage (71.6%), and 52.2% were beneficiaries of the BFP. As characteristics of households, 63.7% had ≤4 residents, 65.5% lived in their own residence, 77.6% were classified as social class C2, D or E, and about 36% consumed untreated water (Table 1).

There was an association between the place of residence and FI, revealing that 78.4% of the residents of the urban countryside of Pernambuco were in such situation (Table 1). In addition, a significant increase in the prevalence of FI was also observed as there was a decrease in the age and education of the head of the family; among informal and unemployed workers, as there was a decrease in income; and among the beneficiaries of the BFP, in households with more than four residents, in those who were not their own, in those classified in social classes D and E and in households that consumed untreated water (Table 1).

Table 2 shows that most households purchased food for consumption (83.1%), 50.4% had the supermarket as the main place of purchase and, among the beneficiaries of the BFP, most reported buying only food or food and other items for subsistence of the family with the money received from this program. As for the opinion on food from the receipt of the BFP benefit, most of those enrolled in the program reported having improved, and 53% of respondents considered the family diet good or very good. When asked about the food that was missing to improve the family’s diet, 58.3% mentioned fresh foods, such as fruits, vegetables and meats, which also suggests insecurity in the nutritional dimension (Table 2).

Table 2 shows that FI is significantly higher among individuals who reported buying and producing food, among those who used to buy most of the family’s food at the fair or free market, and among those who reported buying food and other items with the benefit of the BFP. In addition, the FI was significantly higher in those who thought the family diet was poor or very poor and in those who reported that they lacked all the food to improve the family diet.

When performing the multivariate analysis, the variables head of household’s education, per capita family income, participation in the BFP, number of residents, household occupation regime and social class remained significantly associated with FI (Table 3). As for the variables related to diet, the place of purchase of most foods and the opinion on diet from the BFP did not remain with a statistically significant association.

Discussion

As a result of a violation of Dhana (Direito Humano à Alimentação e Nutrição Adequadas), FI is originated in social inequalities arising from a model of production and distribution that aims at financial capital above human aspects, i.e., despite constitutional law, food has been increasingly viewed from the perspective of merchandise, in which its existence as a right becomes of secondary importance to obtaining profit (Esteve, 2017ESTEVE, E. V. O negócio da comida: quem controla nossa alimentação? São Paulo: Expressão Popular, 2017.). Hunger has historical roots in economic and social systems, and the globalized increase in food production does not solve this problem, since it involves factors related to political economy and the distribution of power and wealth, as stated by Milton Santos (2003SANTOS, M. Saúde e ambiente no processo de desenvolvimento. Ciência & Saúde Coletiva, Rio de Janeiro, v. 8, n. 1, p. 309-314, 2003. DOI: 10.1590/S1413-81232003000100024
https://doi.org/10.1590/S1413-8123200300... ).

The Brazilian scenario is even more worrying when considering the social inequalities present mainly in the North and Northeast regions, which lead them to have the highest rates of FI (57% and 50.3%, respectively), including severe FI, whose proportion was 10.2% in the North region and 7.1% in the Northeast region (IBGE, 2020IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro, 2020.). The results of this study showed a higher prevalence than that observed in the last POF for the state of Pernambuco and obtained in an investigation carried out in 2011, which found 61.8% of FI (27.5% of moderate FI and 9.6% of severe FI) (UFPE, 2011UFPE; IPSA; SUASAN. Avaliação da (In) Segurança Alimentar nas Regiões de Desenvolvimento do Estado de Pernambuco. Recife: UFPE, 2011. Disponível em: <Disponível em: http://www.sedsdh.pe.gov.br/c/document_library/get_file?uuid=90874565-92cb-4467-bebe-2d79f618eb61&groupId=17459 > Acesso em: 06 jul. 2021.
http://www.sedsdh.pe.gov.br/c/document_l... ). High prevalences such as this study’s were also found in research carried out in municipalities in the Northeast and North regions, such as the investigation of FI in BFP beneficiary families living in Vitória da Conquista (BA), whose percentage was 73.4% (Suzart et al., 2018SUZART, A. S. et al. Repercussões do Programa Bolsa Família na Segurança Alimentar e Nutricional: um estudo de caso. Revista Baiana de Saúde Pública, Salvador, v. 41, n. 3, p. 699-715, 2018. DOI: 10.22278/2318-2660.2017.v41.n3.a2525
https://doi.org/10.22278/2318-2660.2017.... ); and in urban households in 22 municipalities in the state of Tocantins, which observed 63.4% of FI (Schott et al., 2020SCHOTT, E. et al. Fatores associados à insegurança alimentar em domicílios da área urbana do estado do Tocantins, Região Norte do Brasil. Revista Brasileira de Epidemiologia, São Paulo, v. 23, p. e200096, 2020. DOI: 10.1590/1980-549720200096
https://doi.org/10.1590/1980-54972020009... ).

At the regional level, between 2004 and 2013 the Northeast obtained an improvement in the situation of FNS due to greater investments in combating hunger and promoting access to food, placed as a priority on the public agenda during the Lula government (DELGADO; ZIMMERMANN, 2022DELGADO, N. G.; ZIMMERMANN, S. A. Políticas Públicas para soberania e segurança alimentar no Brasil: conquistas, desmontes e desafios para uma (re)construção. Rio de Janeiro: Fundação Oswaldo Cruz, 2022. Disponível em: <Disponível em: https://www.arca.fiocruz.br/bitstream/icict/52128/2/TD_83.pdf > Acesso em: 1 jul. 2022
https://www.arca.fiocruz.br/bitstream/ic... ). However, the increase in the prevalence of FI demonstrates a setback due to the continuing dismantling of public policies aimed at combating inequalities and social inequities (Santarelli et al., 2017SANTARELLI, M. et al. Da democratização ao golpe: avanços e retrocessos na garantia do direito humano à alimentação e à nutrição adequadas no Brasil. Brasília, DF: FIAN Brasil, 2017. Disponível em: <Disponível em: https://fianbrasil.org.br/wp-content/uploads/2017/06/Publica%C3%A7%C3%A3o-Completa-Informe-Dhana.pdf >. Acesso em: 6 dez. 2021.
https://fianbrasil.org.br/wp-content/upl... ; Alpino et al., 2020ALPINO, T. M. A. et al. COVID-19 e (in)segurança alimentar e nutricional: ações do Governo Federal brasileiro na pandemia frente aos desmontes orçamentários e institucionais. Cadernos de Saúde Pública, Rio de Janeiro, v. 36, n. 8, p. e00161320, 2020. DOI: 10.1590/0102-311X00161320
https://doi.org/10.1590/0102-311X0016132... ; Galindo et al., 2021GALINDO, E. et al. Efeitos da pandemia na alimentação e na situação da segurança alimentar no Brasil. Food for Justice Working Paper Series, Berlin, n. 4, 2021. Disponível em: <Disponível em: https://www.epsjv.fiocruz.br/sites/default/files/files/relatorio%20pesquisa%20Berlim%20UFMG.pdf >. Acesso em 1 jul. 2022.
https://www.epsjv.fiocruz.br/sites/defau... ). In the midst of the pandemic situation, regional inequality regarding full access to food was verified, since in the North and Northeast regions the highest percentages of severe FI and the highest intensity of increase in the prevalence of moderate and severe FI are found, when analyzing the national surveys of 2018, 2020 and 2021/22 (PENSSAN Network, 2022REDE PENSSAN. II Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da COVID-19 no Brasil. São Paulo, 2022. Disponível em: <Disponível em: https://olheparaafome.com.br/wp-content/uploads/2022/06/Relatorio-II-VIGISAN-2022.pdf >. Acesso em: 1 jul. 2022.
https://olheparaafome.com.br/wp-content/... ).

The capacity to generate change in the face of a given political-social reality is directly associated with the education of a population. Among the factors related to FI, it is known that there is a higher risk in individuals with a lower level of education (IBGE, 2020IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro, 2020.). Several studies seek to investigate this relationship and, like this study, also found a higher prevalence of FI in households whose reference person had a lower level of education (Sperandio; Priore, 2015SPERANDIO, N.; PRIORE, S. E. Prevalência de insegurança alimentar domiciliar e fatores associados em famílias com pré-escolares, beneficiárias do Programa Bolsa Família em Viçosa, Minas Gerais, Brasil. Epidemiologia e Serviços de Saúde, Brasília, DF, v. 24, n. 4, p. 739-748, 2015. DOI: 10.5123/S1679-49742015000400016
https://doi.org/10.5123/S1679-4974201500... ; Suzart et al., 2018SUZART, A. S. et al. Repercussões do Programa Bolsa Família na Segurança Alimentar e Nutricional: um estudo de caso. Revista Baiana de Saúde Pública, Salvador, v. 41, n. 3, p. 699-715, 2018. DOI: 10.22278/2318-2660.2017.v41.n3.a2525
https://doi.org/10.22278/2318-2660.2017.... ; Pacheco et al., 2018PACHECO, P. M. et al. Food and nutritional security of families assisted by the Bolsa Família cash transfer program in primary health care. O Mundo da Saúde, São Paulo, v. 42, n. 2, p. 459-477, 2018. DOI: 10.15343/0104-7809.20184202459477
https://doi.org/10.15343/0104-7809.20184... ; Schott et al., 2020SCHOTT, E. et al. Fatores associados à insegurança alimentar em domicílios da área urbana do estado do Tocantins, Região Norte do Brasil. Revista Brasileira de Epidemiologia, São Paulo, v. 23, p. e200096, 2020. DOI: 10.1590/1980-549720200096
https://doi.org/10.1590/1980-54972020009... ). It is common knowledge that education has an essential role in the professional development of the individual, in the insertion in the formal labor market and, consequently, in the generation of income (Santos et al., 2018SANTOS, T. G. et al. Tendência e fatores associados à insegurança alimentar no Brasil: Pesquisa Nacional por Amostra de Domicílios 2004, 2009 e 2013. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 4, p. 1-17, 2018. DOI: 10.1590/0102-311X00066917
https://doi.org/10.1590/0102-311X0006691... ). There was a higher probability of FI in households whose level of education of the head of the family was less than four years of study, which may be related to the greater financial vulnerability resulting from this situation, which directly compromises access to food.

In this perspective, associations between FI and lower income and social class levels are also observed, corroborating poverty as a determining factor. The lower the income of a family, the greater the proportion of food expenditure, therefore, the greater the risk of FI (IBGE, 2014IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa Nacional por Amostra de Domicílios: Segurança Alimentar 2013. Rio de Janeiro, 2014.; IBGE, 2020IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro, 2020.). In this research, as well as in the Brazilian context at both national and regional levels, it was observed that the highest frequencies of moderate and severe FI occur in individuals who receive up to 1/4 of the minimum wage and in those who have no income (IBGE, 2014IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa Nacional por Amostra de Domicílios: Segurança Alimentar 2013. Rio de Janeiro, 2014.; Godoy et al., 2017GODOY, K. et al. Food insecurity and nutritional status of individuals in a socially vulnerable situation in Brazil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 2, p. 607-616, 2017. DOI: 10.1590/1413-81232017222.17132016
https://doi.org/10.1590/1413-81232017222... ; Schott et al., 2020SCHOTT, E. et al. Fatores associados à insegurança alimentar em domicílios da área urbana do estado do Tocantins, Região Norte do Brasil. Revista Brasileira de Epidemiologia, São Paulo, v. 23, p. e200096, 2020. DOI: 10.1590/1980-549720200096
https://doi.org/10.1590/1980-54972020009... ). Cabral et al. (2014CABRAL, C. S. et al. Segurança alimentar, renda e Programa Bolsa Família: estudo de coorte em municípios do interior da Paraíba, Brasil, 2005-2011. Cadernos de Saúde Pública, Rio de Janeiro, v. 30, n. 2, p. 393-402, 2014. DOI: 10.1590/0102-311X00140112
https://doi.org/10.1590/0102-311X0014011... ), in a cohort conducted in Paraíba, identified that when families overcome the poverty condition, there is also a significant reduction in moderate and severe FI, confirming the causal relationship between increased income and improvement in the FNS situation.

Given the economic situation that demonstrates social vulnerability, many of these families are beneficiaries of the BFP, an important strategy for poverty reduction in the country, which targets families in situations of poverty and extreme poverty. In agreement with the finding, research shows a higher prevalence of FI among beneficiary families, which suggests a situation of vulnerability and social inequity with repercussions on regular and permanent access to food (Pacheco et al., 2018PACHECO, P. M. et al. Food and nutritional security of families assisted by the Bolsa Família cash transfer program in primary health care. O Mundo da Saúde, São Paulo, v. 42, n. 2, p. 459-477, 2018. DOI: 10.15343/0104-7809.20184202459477
https://doi.org/10.15343/0104-7809.20184... ; Schott et al., 2020SCHOTT, E. et al. Fatores associados à insegurança alimentar em domicílios da área urbana do estado do Tocantins, Região Norte do Brasil. Revista Brasileira de Epidemiologia, São Paulo, v. 23, p. e200096, 2020. DOI: 10.1590/1980-549720200096
https://doi.org/10.1590/1980-54972020009... ). It should be noted that BFP had a great contribution to improving access to food, allowing beneficiary families to be more likely to leave the FI situation (Cabral et al., 2014CABRAL, C. S. et al. Segurança alimentar, renda e Programa Bolsa Família: estudo de coorte em municípios do interior da Paraíba, Brasil, 2005-2011. Cadernos de Saúde Pública, Rio de Janeiro, v. 30, n. 2, p. 393-402, 2014. DOI: 10.1590/0102-311X00140112
https://doi.org/10.1590/0102-311X0014011... ; Suzart et al., 2018SUZART, A. S. et al. Repercussões do Programa Bolsa Família na Segurança Alimentar e Nutricional: um estudo de caso. Revista Baiana de Saúde Pública, Salvador, v. 41, n. 3, p. 699-715, 2018. DOI: 10.22278/2318-2660.2017.v41.n3.a2525
https://doi.org/10.22278/2318-2660.2017.... ).

From the perspective of access to food from the benefit of the BFP, it was verified in this study that those who reported using the money received only to buy food or food and other items were at greater risk for FI, demonstrating, then, that the resource was used as a priority for family subsistence, making it essential to maintain regular access to food in order to avoid the most serious situation, which is hunger. When evaluating the impact of BFP on food consumption, Sperandio et al. (2017) observed that in the Northeast region there was an increase in the consumption of fresh food by the beneficiaries, so that they presented an average increase of 125 kilocalories per capita/day regarding the non-recipients.

In addition to the quantitative issue of access, Cabral et al. (2014CABRAL, C. S. et al. Segurança alimentar, renda e Programa Bolsa Família: estudo de coorte em municípios do interior da Paraíba, Brasil, 2005-2011. Cadernos de Saúde Pública, Rio de Janeiro, v. 30, n. 2, p. 393-402, 2014. DOI: 10.1590/0102-311X00140112
https://doi.org/10.1590/0102-311X0014011... ) emphasize that it is important to promote, by public policies, the realization of actions to stimulate the purchase of healthy foods, i.e., it is one must also think about the acquisition of food in the qualitative aspect to reach other dimensions of FNS. Despite the findings of social improvements resulting from the BFP, in recent years there have been large cuts in the number of beneficiaries, culminating in the recent extinction of the BFP and its replacement by the Auxílio Brasil, a strategy permeated with doubts and uncertainties about its operation, which leads to the risk of a substantial increase in individuals in extreme poverty and consequently in FI, going against several achievements made since the implementation of the BFP.

In addition to the factors mentioned, another exposure that represents the social vulnerability of the populations is the housing condition. A higher prevalence of FI was observed in households with a higher number of residents, which agrees with what has been observed in other studies that demonstrate intrafamily agglomeration as frequently associated with the FI situation (Sperandio; Priore, 2015SPERANDIO, N.; PRIORE, S. E. Prevalência de insegurança alimentar domiciliar e fatores associados em famílias com pré-escolares, beneficiárias do Programa Bolsa Família em Viçosa, Minas Gerais, Brasil. Epidemiologia e Serviços de Saúde, Brasília, DF, v. 24, n. 4, p. 739-748, 2015. DOI: 10.5123/S1679-49742015000400016
https://doi.org/10.5123/S1679-4974201500... ; Santos et al., 2018SANTOS, T. G. et al. Tendência e fatores associados à insegurança alimentar no Brasil: Pesquisa Nacional por Amostra de Domicílios 2004, 2009 e 2013. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 4, p. 1-17, 2018. DOI: 10.1590/0102-311X00066917
https://doi.org/10.1590/0102-311X0006691... ). This association happens since all residents of the household need adequate food on a regular basis, regardless of the socioeconomic context and, consequently, the more people in the household, the greater the proportion of family income destined for food (Sperandio; Priore, 2015SPERANDIO, N.; PRIORE, S. E. Prevalência de insegurança alimentar domiciliar e fatores associados em famílias com pré-escolares, beneficiárias do Programa Bolsa Família em Viçosa, Minas Gerais, Brasil. Epidemiologia e Serviços de Saúde, Brasília, DF, v. 24, n. 4, p. 739-748, 2015. DOI: 10.5123/S1679-49742015000400016
https://doi.org/10.5123/S1679-4974201500... ; Santos et al., 2018SANTOS, T. G. et al. Tendência e fatores associados à insegurança alimentar no Brasil: Pesquisa Nacional por Amostra de Domicílios 2004, 2009 e 2013. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 4, p. 1-17, 2018. DOI: 10.1590/0102-311X00066917
https://doi.org/10.1590/0102-311X0006691... ).

The household occupation regime was also associated, because those who reported living on a rental basis had a higher prevalence of FI. As already observed, the lower the family income, the higher the spending on food, since it is an indispensable need for survival. Therefore, those families that have part of their income committed to the payment of rent have, consequently, less free resources for food acquisition (IBGE, 2014IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa Nacional por Amostra de Domicílios: Segurança Alimentar 2013. Rio de Janeiro, 2014.; IBGE, 2020IBGE - INSTITUTO BRASILEIRO DE GEOGRAFIA E ESTATÍSTICA. Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro, 2020.). These families have a higher cost of living, which makes it difficult to break the intergenerational cycle of poverty and increases the probability of experiencing FI.

It is noteworthy that in the Brazilian context, since 2009, there has been greater investment in the housing issue through the Minha Casa Minha Vida program, a strategy of the Federal Government that aims to combat the housing deficit in the country, providing the acquisition of its own property through better financing conditions according to the family income bracket. Therefore, it is considered that somehow this program could contribute to the promotion of FNS, as it is part of the set of structural actions that need to be covered in the fight against hunger and in the reduction of poverty and inequalities, since Dhana (Direito Humano à Alimentação e Nutrição Adequadas) depends on the realization of other rights, such as housing and improvement of living conditions (Valente, 2003VALENTE, F. L. S. Fome, desnutrição e cidadania: inclusão social e direitos humanos. Saúde e Sociedade, São Paulo, v. 12, n. 1, p. 51-60, 2003. DOI: 10.1590/S0104-12902003000100008
https://doi.org/10.1590/S0104-1290200300... ; Santos et al., 2018SANTOS, T. G. et al. Tendência e fatores associados à insegurança alimentar no Brasil: Pesquisa Nacional por Amostra de Domicílios 2004, 2009 e 2013. Cadernos de Saúde Pública, Rio de Janeiro, v. 34, n. 4, p. 1-17, 2018. DOI: 10.1590/0102-311X00066917
https://doi.org/10.1590/0102-311X0006691... ). In contrast, the current Brazilian government - which extinguished the Minha Casa Minha Vida program, replacing it with the Casa Verde e Amarela program - dismantles housing policies as it drastically reduces the budget allocated to this sector.

As for the form of food acquisition, it was seen that those who reported acquiring them only through purchase were more protected from FI, which may be related to a greater purchasing power of part of this population. In addition, when comparing this group with those who, in addition to buying, produce food, it is believed that the latter probably reside in the countryside, a location that presented the highest percentage of FI. It is noteworthy that this result shows only the issue of regular and permanent access to food, not associated with the quality of food purchased, an aspect that can be discussed with analysis of food consumption.

In the perception aspect, those individuals who did not consider the family diet good or very good were at higher risk of FI, which is coherent, since the situation of insecurity is a reflection of inadequate and irregular food consumption in the quantitative and qualitative aspect (Brasil, 2006BRASIL. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União, Brasília, DF, 18 set. 2006. Disponível em: <Disponível em: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2006/lei/l11346.htm >. Acesso em: 06 jul. 2021.
http://www.planalto.gov.br/ccivil_03/_at... ). When investigating which foods were missing to improve the family’s diet, it was found that most mentioned minimally processed foods, a fact that evidences insecurity not only in the dimension of access to food, but also in the nutritional aspect of it.

In addition, the probability of FI was higher in those who claimed to lack products in the ultra-processed category to improve food at home.²2Ultra-processed products are those manufactured by large industries, in processes that involve the addition of many ingredients, such as salt, sugar, oils, fats, food additives and other substances for exclusively industrial use, with the objective of making them durable and with organoleptic characteristics attractive to the consumer (MS, 2014). These products have wide media dissemination and marketing strategy in order to encourage consumption, which makes it important to highlight that the process of choosing food, in most cases, is not due to nutritional content, but due to the social influences of daily life, which may be in family relationships, in the workplace, at school and in other spaces of coexistence of the individual (Lima; Ferreira Neto; Farias, 2015LIMA, R. S.; FERREIRA NETO, J. A.; FARIAS, R. C. P. Alimentação, comida e cultura: o exercício da comensalidade. DEMETRA: Alimentação, Nutrição & Saúde, Rio de Janeiro, v. 10, n. 3, p. 507-522, 2015. DOI: 10.12957/demetra.2015.16072
https://doi.org/10.12957/demetra.2015.16... ). It is essential to reflect on the sociocultural dimension of diet, since food, as a representative of everyday reality, expresses social relations and differences (Silva, Freitas, Sousa, 2014SILVA, D. O.; FREITAS, M. C. S.; SOUSA, J. R. Significados e representações do conceito de comida na perspectiva da promoção da alimentação saudável. In: FREITAS, M. C.; SILVA, D. O. (Org.). Narrativas sobre o comer no mundo da vida. Salvador: Edufba, 2014. p. 79-94.).

As pointed out by Contreras and Gracia (2011CONTRERAS, J.; GRACIA, M. Alimentação, sociedade e cultura. Rio de Janeiro: Fiocruz, 2011.), food choices are not only economic, since the act of eating is a social and cultural phenomenon and it is not just biological activity, because food is more than a set of nutrients chosen under exclusively dietary rationality. It is important to discuss this topic as a sociocultural construction, related to pleasure, commensality and habit, in order to overcome the Cartesian thought that separates the individual from society (Silva, Freitas, Sousa, 2014SILVA, D. O.; FREITAS, M. C. S.; SOUSA, J. R. Significados e representações do conceito de comida na perspectiva da promoção da alimentação saudável. In: FREITAS, M. C.; SILVA, D. O. (Org.). Narrativas sobre o comer no mundo da vida. Salvador: Edufba, 2014. p. 79-94.).

This research has limitations inherent to cross-sectional studies, as they do not allow the inference of the cause and effect relationship between the variables, since they are carried out in a single moment and that create the possibility of existence of reverse causality. In addition, as for the FNS study, it is suggested to carry out investigations of other dimensions, such as those related to food production, forms of distribution and food environment, in view of the breadth and complexity of the theme.

Final considerations

From this study, it was possible to verify the association between FI and social inequalities, since those with a worse socioeconomic and demographic situation had difficulty in accessing food. Families in classes D/E, with an income of up to 1/4 of the minimum wage and with a head of the family with low education level were more likely to experience the situation of insecurity. In this context, it was also verified that housing conditions are related to insecurity, since the risk of FI was higher in families with rented homes and who had more than four residents.

When investigating the subjects’ opinions about food, higher probabilities of FI were observed in those who did not consider the family diet very good or good - which suggests restriction on access to food -, as well as in those who reported lack of ultra-processed products to improve the family diet, an aspect that promotes reflection on the socio-cultural dimension of food.

It is important to point out the association found between FI and BFP: the highest prevalence of insecurity was observed in the beneficiaries of the program and the risk was higher among those who reported buying only food or food and other items with the resource they received. This result reinforces the relevance of the program as a strategy to promote access to food, considering the poverty and extreme poverty of the beneficiary population.

Finally, it is emphasized that the State has the duty to respect, protect and guarantee Dhana (Direito Humano à Alimentação e Nutrição Adequadas); however, in recent years it has seen a growing violation of this right and non prioritization of public policies that act to combat inequalities. The omission of the government in the face of scenarios of high prevalence of FI reinforces the debate on hunger as a result of political decisions.

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