J. Pediatr. (Rio J.) vol.93 número1

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JPediatr(RioJ).2017;93(1):47---57

www.jped.com.br

ORIGINAL

ARTICLE

Nutritional

quality

of

dietary

patterns

of

children:

are

there

differences

inside

and

outside

school?

夽

Diva

Aliete

dos

Santos

Vieira

a

_,

_Michelle

_Alessandra

_Castro

a

_,

_Mauro

_Fisberg

b

_,

Regina

Mara

Fisberg

a,∗

a_Universidade_de_São_Paulo_(USP),_Faculdade_de_Saúde_Pública,_Departamento_de_Nutric_¸ão,_São_Paulo,_SP,_Brazil b_Hospital_Infantil_Sabará,_Instituto_PENSI,_Centro_de_Dificuldades_Alimentares,_São_Paulo,_SP,_Brazil

Received9December2015;accepted23March2016 Availableonline28June2016

KEYWORDS Foodconsumption; Dietarypatterns; Children; Schoolfeeding; Factoranalysis

Abstract

Objectives: Todescribethedietarypatternsofchildreninsideandoutsideschooland

investi-gatetheirassociationswithsociodemographicfactorsandnutritionalstatus.

Methods: Thiswasamulticentercross-sectionalstudyinwhichchildrenofbothsexes,aged1---6

years,attendingprivateandpublicdaycarecentersandpreschoolsinBrazil,wereevaluated (n=2979).Demographic,socioeconomicanddietarydata(weighedfoodrecordsandestimated food records)werecollected.Dietary patternswerederivedbyfactoranalysisfrom36food groups.

Results: Fourdietarypatternswereidentifiedinsideschool,andthreeoutside.Insideschool,

the‘‘traditional’’patternwasassociatedtolowincomeandpresentedhighnutritionalquality. The‘‘dual’’patternwasassociatedwithlowincomeandwithhighintakeofaddedsugarand glycemicload.The‘‘snack’’patternwasassociatedwithchildrenenrolledatprivateschools andwithhighintakeofaddedsugarandglycemicload.The‘‘breadandbutter’’patternwas associated withhighintakeofaddedsugarandtransfat.Outsideschool, the‘‘traditional’’ patternwasassociatedwithhighintakeofsaturatedfat,transfats,sodium,andtotalfiber. The‘‘breadandbutter’’patternwasassociatedwithhighintakeoftransfatsandglycemicload, whereasthe‘‘snack’’patternwasassociatedwithoverweight,privateschools,highincome, andhighintakeoftransfats,sodium,andtotalfiber.

Conclusion: Therearedifferencesinthenutritionalqualityofdietarypatternsinsideand

out-sideschool,andheterogeneityinadherencetothesepatternswereobservedacrossregions andsocioeconomicclasses.

夽

Pleasecitethisarticleas:VieiraDA,CastroMA,FisbergM,FisbergRM.Nutritionalqualityofdietarypatternsofchildren:arethere

differencesinsideandoutsideschool?JPediatr(RioJ).2017;93:47---57.

∗_{Corresponding}_author.

E-mails:regina.fisberg@gmail.com,rfisberg@usp.br(R.M.Fisberg). http://dx.doi.org/10.1016/j.jped.2016.03.008

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PALAVRAS-CHAVE Consumoalimentar; Padrõesalimentares; Crianc¸as;

Alimentac¸ãoescolar; Análisefatorial

Qualidadenutricionaldospadrõesalimentaresdecrianc¸as:existemdiferenc¸as dentroeforadaescola?

Resumo

Objetivos: Descreverospadrõesalimentaresdecrianc¸asdentroeforadaescolaeinvestigara

suaassociac¸ãocomfatoressociodemográficoseestadonutricional.

Métodos: Trata-sedeum estudomulticêntricotransversal,noqualforamavaliadascrianc¸as

de1a6anosdeambosossexos,atendidasemcrechespúblicaseprivadasepré-escolasno Brasil(n=2979).Foramcoletadosdadosdemográficos,socioeconômicosedietéticos.Ospadrões alimentaresforamderivadosporanálisefatorialapartirde36gruposdealimentos.

Resultados: Quatropadrõesalimentaresforamidentificadosdentrodacrecheetrêsforada

creche.Dentrodacreche,opadrão‘‘tradicional’’foiassociadoamenorrendaeapresentou melhorqualidadenutricional.Opadrão‘‘dual’’associou-seamenorrendaemaioringestãode açúcardeadiçãoecargaglicêmica.Opadrão‘‘lanches’’foiassociadoacriançasmatriculadas emescolasprivadasecommaioringestãodeaçúcardeadiçãoecargaglicêmica.Opadrão ‘‘pãocommanteiga’’associou-seamaioringestãodeaçúcardeadiçãoegorduratrans.Fora dacreche,opadrão‘‘tradicional’’foiassociadoamaioringestãodegordurasaturada,trans, sódioefibra.Opadrão‘‘pãocommanteiga’’associou-seamaioringestãodegorduratranse cargaglicêmica,enquantoopadrão‘‘lanches’’associou-seàscriançascomexcessodepeso, decrechesprivadas,maiorrendaecommaioringestãodegorduratrans,sódioefibra.

Conclusão: Houvediferenc¸anaqualidadenutricionaldospadrõesdentroeforadaescolaea

aderênciaaessesocorreudeformaheterogêneanasregiõeseclassessocioeconômicas. ©2016SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4. 0/).

Introduction

Theinvestigationofdietarypatternscanhelpelucidatethe complexrelationshipbetweendietandhealthby consider-ingthesimultaneouseffectofmultiple foodsanddietetic components,aswellastheirinteractions,ontheoccurrence ofoneormoreoutcomesofinterest.1

Inthepastdecades,transitionsindietaryintakeamong childrenhavebeenobservedandcharacterizedbyahigher intake of foods rich in fats, sodium, and sugar and by lower intakes of nutrient dense foods such as fruit and vegetables.2,3 _These _changes _in _food _intake _have _had _a majorimpactonthedevelopmentofobesityandnutritional deficits.Inaddition,studieshavesuggestedtheroleof child-hoodnutritiononthedevelopmentofmorbidityinfurther lifecycles,suchasinadulthood.4,5

Therefore,identifyingthedietarypatternsexperienced by children in different environment settings is essential toguidepublicpoliciesand educationalactionsregarding health andnutrition in theearly stages of life. Thus,the objectiveofthepresentstudywastodescribethedietary patternsinsideandoutsidetheschoolsettingandto inves-tigatetheirassociationswithdemographic,socioeconomic, andnutritionalstatusofchildreninBrazil.

Methods

Studypopulation

Dataweregatheredfromamulticentercross-sectionalstudy conducted in 2007 among children aged 1---6 years who attendedprivateandpublicdaycarecentersandpreschools.

Atotalof85primaryschools(54publicand31private)were included fromnineBraziliancities (Manaus,Recife,Natal, Brasília,Cuiabá,CaxiasdoSul,Vic¸osa,RiodeJaneiro,and SãoPaulo)locatedinfiveregions.Theeligibilitycriteriafor inclusion of the schools in the study were: belocated in theurbanareaofthecity,full-dayattendance,andhavea conventionalservingsystemformeals.6

Ineach city,350 children wereassessed, ofwhom 250 were frompublic and 100 from privateschools. The pro-portionofinterviewsinpublicandprivateschoolsineach citywasbasedonthenumberofenrolmentsindaycare cen-ters and preschools according to data from the National SchoolCensus conductedin 2005by theBrazilian Ministry ofEducation.The samplesizeforeachcitywasestimated at350subjectsbasedontheestimatedprevalenceof inade-quatenutritionalintake(approximately65%),withamargin of error of5% and aconfidence level of 95%.All children whose parents or guardiansauthorized datacollection by signing an informed consent were assessed, comprising a total sample of 3058 preschoolers.Forthe present study, 79childrenwereexcludedfromtheanalysisdueto incom-plete food intake data,leading toa final sample of 2979 childrenofbothgenders.

Data was collected between February and December of 2007 by undergraduate nutritionstudents, trained and supervisedbynutritionresearchersineachcity.Inorderto standardizedatacollection,structuredformsandmanuals withspecific guidelinesforthe studyweredeveloped and used.6

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Dietarypatternsofpreschoolchildren 49

obtainedfromtheparentsorguardiansofthechildren eval-uated.

Socioeconomicdata

Socioeconomic data were collected from parents or guardians usingthe structuredquestionnaire publishedin 2003bytheAssociac¸ãoBrasileiradeEmpresasdePesquisa (APEP). This questionnaire was designed to estimate the purchasing power of families. The economic classes and meanfamilyincomewere definedby applyingthecut-off scores of the Brazilian Economic Classification Criterion,7 which is used by ABEP and takes into account the num-berofconsumergoodsavailableinthehousehold,suchas TVs,refrigerators,andcars,amongothers,andthelevelof educationoftheheadofthehousehold.

Anthropometricdata

Dataonweightandheightweremeasured induplicateby the study team. Weight was measured in kilograms using a calibrated digital scale, model Glass-6, accuracy: 100g (G-Tech®,USA),whereasheightwasmeasuredin centime-tersusingaportablewall-mountedstadiometeraffixedtoa smoothwallwithoutbaseboardmodel206,accuracy:1mm (Seca®,USA).

Height datafor childrenyoungerthan 2yearswas cor-rectedbyadding0.7cmtothemeasurement,8_since_children inthisagegroupshouldbemeasuredintherecumbent posi-tion.Theclassificationofnutritionalstatuswasdetermined basedonz-scorevaluesofbodymassindex(BMI)-for-ageand cutoffs proposed by the WorldHealth Organization8 _(<₋₂ SD;≥−2SDand≤+1SD;>+1SDand≤+2SD;>+2SD); chil-drenwerethencategorizedasunderweight,normalweight, overweight,orobese,respectively.

Dietarydata

At schools,dietary datawereobtained usingthe weighed foodrecords(WFRs).Forthis,threesamplesofeach food andbeveragewereportionedoutbythefoodservice atten-dant andweighed bythe undergraduate nutritionstudent on a calibrated electronic scale, model MEA06030, maxi-mumcapacity:3kg, accurate to1g(Plenna®, SP, Brazil). Thearithmeticmeansofthethreesampleswerecalculated andconsideredastheamountoffoodandbeveragesoffered toallchildren.

Allleftoversfromeachplatewerecollectedinindividual bagsandweighed.Thebeverageswereweighedseparately. A proportional estimate of the contribution of individual foodstothetotalplatewastewascalculatedforeachchild. Theamountsoffoodsandbeverageseatenatschool meal-timewereestimatedbythedifferencebetweentheportion offeredandtheindividualplatewasteofeachchild.

Dietaryintakeoutsidetheschoolenvironmentwas eval-uated using the estimated food record (EFR) method, completedbyparentsorguardiansonthesamedayofthe WFRcompletion,inordertodeterminethetotalfoodintake ofoneday.

Food questionnaires were entered into the software NutritionDataSystemfor Research(NutritionCoordinating Center,2007version---UniversityofMinnesota,USA),which usestheAmericanfoodcompositiondatabasedevelopedby theUnitedStatesDepartmentofAgriculture(USDA).

Asecond dietary measurementwasperformed on non-consecutivedaysinabout25%ofthesample.Ineachcity,a maximumof87childrenwererandomlyselectedfor reeval-uation.

Statisticalanalysis

Inordertoidentifythedietarypatternsinsideandoutside theschoolenvironment,828differentfoodswerecollapsed into36groups,accordingtotheirnutritionalvalue,culinary usage,anddietaryhabits.

Foodgroupsweresubmittedtoexploratoryfactor analy-sis,inordertoderivethedietarypatternsinsideandoutside school. Initially, factors with Eigenvalues greater than or equalto1.25 wereretained,yielding ninefactorsto rep-resentthedietarypatterninsideschoolversusfivefactors outside school. In the second stage, the screen plot was visuallyinspected,suggestingtheretentionoffourfactors inside and three factors outside school. Varimax ortho-gonalrotationwasappliedtoimprovethe interpretability of the matrix of factor loadings. Factor loadings greater thanorequalto|0.30|wereconsideredtocontributetothe pattern.

Factorscoreswereestimatedinordertoinvestigatethe association ofthe adherenceto thedietary patternswith demographicand socioeconomicvariables aswell as with nutritionalstatus. Forthis,the Mann---WhitneyU-test and Kruskal---Wallis were performed in Stata software (Stata-Corp.2011,StataStatisticalSoftware:Release12,College Station,USA).

Aimingtoevaluatetheassociationbetweenadherenceto dietarypatternsandusualintakeofnutritionalquality mark-ers,namelysaturatedfat,transfats,salt,addedsugar,total fiber,andglycemicload,thestatisticalmodelingtechniques incorporated in the multiple source method online plat-formwereapplied.Individualusual nutrient intakeswere expressedingramsormicrogramsper1000kcalofenergy, andtheir associations withadherence todietary patterns wasevaluatedusingtheKruskal---Wallis.

Results

Thesampleconsistedof2979children,mostofwhomwere boys(51.16%),withnormalweight(63.48%),agedbetween3 and6years(69.22%),livingintheSoutheastregion(36.93%), andfromlow-incomefamilies(73.83%;familyincomeunder 520.77dollarspermonth).

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Table1 Factorloadingfordietarypatternsinsideandoutsidetheschoolofpreschoolersinamulticenterstudyconductedin Brazil(n=2979),Brazil,2007.

Foodgroups Insideschool Outsideschool

Traditional Dual Snack Breadand butter

Traditional Breadand butter

Snack

Dairy −0.11 0.49 −0.21 0.08 0.04 0.02 0.21

Pastas 0.22 −0.16 0.09 0.36 −0.02 0.03 0.34

Meat 0.29 0.40 0.05 −0.01 0.57 0.00 0.05

Sandwichesandpastries −0.02 −0.06 0.37 0.11 −0.01 0.06 0.31

Juice 0.13 0.40 0.42 0.16 0.13 0.39 0.14

Porridge 0.06 −0.04 −0.25 −0.23 0.05 −0.05 −0.03

Soda −0.03 −0.14 0.30 0.10 0.13 0.17 0.31

Coffeeandtea −0.01 −0.11 0.07 0.36 0.09 0.34 −0.09

Soups 0.07 −0.02 −0.10 −0.05 −0.26 −0.00 −0.01

Bread −0.04 −0.01 0.05 0.66 −0.06 0.76 0.05

Cookies 0.21 −0.01 −0.06 −0.14 0.08 0.14 0.11

Vegetables 0.61 0.21 0.08 0.15 0.39 −0.00 −0.05

Candies −0.04 0.30 0.32 −0.04 0.06 0.13 0.21

Fruit 0.24 0.08 −0.15 0.02 0.15 0.09 0.15

Cakesandpies −0.05 −0.15 0.31 0.13 0.07 0.02 0.14

Eggs −0.06 0.26 −0.43 0.21 0.10 0.09 −0.19

Butterandmargarine −0.02 0.18 −0.22 0.61 0.03 0.62 −0.14

Instantnoodles −0.06 −0.03 0.62 0.01 −0.07 0.04 0.33

Flour 0.27 0.64 −0.09 −0.09 −0.06 0.14 −0.37

Salt −0.02 −0.01 −0.01 −0.06 0.16 0.16 −0.33

Processedmeatand sausages

0.66 0.13 0.08 −0.09 0.17 0.13 0.04

Sauces −0.14 0.18 0.52 −0.11 −0.02 0.11 0.47

Sugar 0.09 0.66 0.10 0.21 −0.06 0.22 −0.44

Beans 0.59 −0.20 −0.13 0.11 0.78 −0.04 0.02

Legumes −0.09 −0.03 −0.15 0.11 0.09 0.00 0.03

Tubers −0.04 0.49 0.05 −0.21 0.02 0.02 0.02

Cheese 0.12 −0.04 0.24 0.48 −0.08 0.36 0.10

Milk 0.02 0.27 −0.16 0.15 −0.01 −0.13 −0.26

Chocolatepowdersand chocolatemilk

−0.15 0.09 −0.22 0.33 0.10 −0.04 0.18

Cereals 0.41 0.04 0.07 −0.17 0.03 0.13 −0.22

Snack 0.01 −0.04 0.13 0.03 0.15 0.06 0.11

Rice 0.81 0.08 −0.08 −0.03 0.83 0.00 −0.02

Infantformulaandspecial supplements

−0.05 0.09 0.33 −0.03 −0.08 −0.09 −0.29

Couscous --- --- --- --- −0.21 −0.06 −0.24

Puree −0.14 0.28 0.16 −0.21 0.10 0.03 0.02

Potatoes 0.35 0.11 −0.01 0.37 0.32 0.06 −0.03

Varianceexplained(%) 8.24 5.96 5.61 5.36 6.32 4.48 4.38 Explainedcumulative

variance(%)

8.24 14.20 19.82 25.17 6.32 10.80 15.18

Kaiser---Meyer---Olkin(KMO) 0.56 0.56

Theboldvaluesarefoodgroupswithfactorloadingsgreaterthanorequalto−0.30or+0.30.

sauces,sandwichesandpastries,soda,juice,cakesandpies, candies,andinfantformulaandspecialsupplements (posi-tiveloadings),andeggs(negativeloading);andthe‘‘bread and butter’’ pattern comprised bread, butter and mar-garine, coffee and tea, chocolate powders andchocolate milk, cheese, and pastas (positive loadings). The assess-mentofdietarypatternoutsideschoolalsoidentifiedthree patterns,labeled‘‘traditional,’’ ‘‘breadandbutter,’’and ‘‘snack,’’ which explained 15.18% of the total variance

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Dietary

patterns

of

preschool

children

51

Table2 Median scoreofeachdietarypatterninside schoolaccordingtosocio-demographiccharacteristicsandnutritional statusofpreschoolersinamulticenterstudy conductedinBrazil(n=2979),Brazil,2007.

Characteristics Insideschool

Traditional Dual Snack Breadandbutter

Median IQR p-Value Median IQR p-Value Median IQR p-value Median IQR p-Value

Nutritionalstatusa

Underweight −0.25 0.95 0.19 −0.27 0.97 0.51 −0.14 0.69 0.09 −0.25 0.93 0.00

Eutrophic −0.19 1.06 −0.25 0.95 −0.09 0.82 −0.27 1.01

Overweight −0.21 1.06 −0.31 0.86 −0.10 0.82 −0.16 0.95

Obese −0.18 1.30 −0.20 0.93 −0.07 1.01 −0.01 1.28

Schooltype

Private −0.22 1.02 0.47 −0.43 0.76 0.00 0.01 0.70 0.00 −0.24 0.90 0.36

Public −0.20 1.11 −0.20 0.98 −0.14 0.87 −0.24 1.06

Socioeconomicclasses

A −0.29 0.82 0.00 −0.47 0.67 0.00 −0.04 0.63 0.00 −0.39 0.73 0.00

B −0.21 0.99 −0.44 0.69 −0.05 0.81 −0.23 0.91

C −0.21 1.07 −0.27 0.90 −0.13 0.85 −0.19 1.04

D −0.17 1.14 −0.03 1.32 −0.08 0.85 −0.24 1.09

E 0.00 1.29 0.40 1.35 −0.13 1.03 −0.52 1.08

Regions

North −0.80 0.47 0.00 −0.29 0.53 0.00 −0.08 0.41 0.00 −0.16 0.72 0.00

Northeast −0.10 1.39 0.90 1.58 −0.04 0.84 −0.50 1.01

Midwest 0.23 0.98 −0.43 0.51 0.11 0.78 0.24 1.42

Southeast −0.16 0.89 −0.42 0.70 −0.24 0.82 −0.38 0.86

South −0.62 0.83 −0.26 0.90 −0.19 1.15 0.02 1.28

Percapitafamilyincome(US$)

<520.77 −0.19 1.12 0.11 −0.16 1.06 0.00 −0.11 0.85 0.00 −0.21 1.07 0.28

≥520.77 −0.23 0.96 −0.45 0.69 −0.04 0.74 −0.28 0.88

Age(completeyears)

1---2 −0.14 0.86 0.00 −0.33 0.77 0.00 −0.08 0.69 0.12 −0.30 0.91 0.00

3---6 −0.24 1.16 −0.22 0.99 −0.11 0.89 −0.17 1.04

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Table3 Medianscoreofeachdietarypatternoutsideschoolaccordingtosocio-demographiccharacteristicsandnutritional statusofpreschoolersinamulticenterstudyconductedinBrazil(n=2979),Brazil,2007.

Characteristics Outsideschool

Traditional Breadandbutter Snack

Median IQR p-Value Median IQR p-Value Median IQR p-Value

Nutritionalstatusa

Underweight −0.43 1.40 0.10 −0.49 0.81 0.00 −0.14 0.92 0.00 Eutrophic −0.40 1.48 −0.30 1.15 −0.04 0.93

Overweight −0.30 1.47 −0.23 1.18 0.05 0.91

Obese −0.26 1.55 −0.17 1.34 0.01 1.06

Schooltype

Private −0.48 1.25 0.34 −0.17 1.17 0.01 0.06 0.88 0.00 Public −0.30 1.54 −0.32 1.17 −0.06 0.96

Socioeconomicclasses

A −0.31 1.38 0.00 −0.08 1.29 0.00 −0.03 0.84 0.00

B −0.33 1.42 −0.25 1.10 0.09 0.95

C −0.10 1.51 −0.28 1.18 −0.01 0.91

D −0.59 1.46 −0.36 1.10 −0.12 0.99

E −0.82 0.49 −0.60 1.19 −0.39 0.89

Regions

North −0.03 1.49 0.00 0.32 1.70 0.00 −0.14 1.16 0.00 Northeast −0.82 0.27 −0.40 1.06 −0.46 0.98

Midwest −0.01 1.40 −0.43 1.01 0.14 0.75

Southeast 0.49 1.65 −0.31 1.10 0.02 0.86

South −0.53 1.04 −0.12 1.11 0.18 1.00

Percapitafamilyincome(US$)

<520.77 −0.39 1.40 0.13 −0.32 1.16 0.01 −0.06 0.96 0.00 ≥520.77 −0.31 1.50 −0.18 1.18 0.05 0.89

Age(completeyears)

1---2 −0.30 1.39 0.62 −0.48 0.88 0.00 −0.06 0.85 0.01

3---6 −0.40 1.54 −0.19 1.28 −0.01 0.99

a_According_to_the_body_mass_index_(BMI)_cutoff_points_for_age_and_sex_proposed_by_the_World_Health_Organization_(WHO).8

sociodemographicvariablesandnutritionalstatus.Agreater adherence to the ‘‘traditional’’ pattern was observed in childrenfromsocioeconomicclassEthaninthosefromclass A,livingintheMidwestregion.Theadherencetothe‘‘dual’’ patternwashigherin childrenfromsocioeconomicclassE thaninthosefromclassAandthosewholivedinthe North-east region. The adherence to the ‘‘snack’’ pattern was higherinchildrenenrolledat privateschools andlivingin Midwestregion, while adherence tothe ‘‘bread and but-ter’’pattern washigher in children living in the Midwest andSouthregions.

Considering the dietary patterns identified outside school,adherencetothe‘‘traditional’’ washigherin chil-drenfromSoutheastregion,whileadherencetothe‘‘bread and butter’’ pattern was higher in children from North region.Theadherencetothe‘‘snack’’patternwashigherin overweightandobesechildren,enrolledatprivateschools, fromsocioeconomic class B than from classE, from Mid-west,SoutheastandSouthregionsandwithpercapitafamily income≥520.77US$(Table3).

The association between nutrient intake and the fac-torscoresofthedietarypatternsinsideandoutsideschool

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Dietary

patterns

of

preschool

children

53

Table4 MediannutrientintakeaccordingtotertilesofadherencetodietarypatternsinsideandoutsideschoolofpreschoolersinamulticenterstudyconductedinBrazil (n=2979),Brazil,2007.

Escores fatoriais

Nutrients

Addedsugar (g/1000kcal)

Totalsaturated fattyacids (g/1000kcal)

Totaltrans fattyacids (g/1000kcal)

Sodium (mg/1000kcal)

Totaldietary fiber (g/1000kcal)

Glycemicload (g/1000kcal)

Median IQR Median IQR Median IQR Median IQR Median IQR Median IQR

Insideschool

Tradicional

Tertile1 39.30 14.54 10.30 1.86 1.47 0.51 1289.82 211.47 9.43 2.52 74.72 9.48 Tertile2 36.18 14.44 9.65 1.68 1.46 0.50 1338.93 214.91 10.76 2.36 74.48 8.45 Tertile3 32.38 12.43 9.15 1.61 1.34 0.50 1366.20 212.09 11.56 2.91 74.63 8.86

p-Value 0.00a,b,c _0.00a,b,c _0.00b,c _0.00a,b,c _0.00a,b,c _0.30

Dual

Tertile1 32.07 13.47 9.85 1.86 1.49 0.54 1373.34 207.09 11.23 3.16 72.44 7.51 Tertile2 35.26 13.21 9.88 1.73 1.48 0.50 1344.13 206.29 10.50 2.70 73.42 8.36 Tertile3 40.32 14.24 9.21 1.78 1.30 0.47 1272.22 227.83 10.09 2.25 78.17 8.64 p-Value 0.00a,b,c _0.00b,c _0.00b,c _0.00a,b,c _0.00a,b,c _0.00a,b,c

Snack

Tertile1 32.66 13.81 9.73 1.73 1.49 0.58 1354.10 231.88 11.22 2.83 73.07 8.66 Tertile2 35.97 13.88 9.72 1.86 1.48 0.52 1335.89 198.66 10.49 2.67 74.73 9.08 Tertile3 38.75 14.38 9.58 1.96 1.38 0.44 1308.35 218.15 9.97 2.42 75.76 9.02 p-Value 0.00a,b,c _0.01b _0.00a,b,c _0.00b,c _0.00a,b,c _0.00a,b,c

Breadandbutter

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V

ieira

DA

et

al.

Table4 (Continued) Escores

fatoriais

Nutrients

Addedsugar (g/1000kcal)

Totalsaturated fattyacids (g/1000kcal)

Totaltrans fattyacids (g/1000kcal)

Sodium (mg/1000kcal)

Totaldietary fiber (g/1000kcal)

Glycemicload (g/1000kcal)

Median IQR Median IQR Median IQR Median IQR Median IQR Median IQR

Outsideschool

Tradicional

p-Value 0.00b,c _0.00a,b,c _0.00a,b,c _0.00a,b,c _0.00b,c _0.00a,b,c

Breadandbutter

p-Value 0.00a _0.01a,c _0.00b,c _0.00a,c _0.14 _0.00a,b

Snack

Tertile1 36.50 14.74 9.59 2.00 1.36 0.50 1302.98 236.18 10.31 2.52 75.78 10.39 Tertile2 34.34 14.42 9.75 1.85 1.47 0.53 1363.47 212.40 10.80 2.93 73.59 9.14 Tertile3 36.91 14.57 9.72 1.74 1.46 0.49 1331.31 206.50 10.58 2.77 74.58 7.91 p-Value 0.00a,c _0.03a _0.00a,b _0.00a,b,c _0.00a,b,c _0.00a,b,c

IQR,interquartilerange.

a _Significant_difference_between_tertiles₁_and₂_of_the_factor_scores.

b _Significant_difference_between_tertiles₁_and₃_of_the_factor_scores.

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Discussion

Inthepresentstudy,conductedamongchildrenfrom differ-entregionsof Brazil,disparities betweendietarypatterns insideandoutsideschoolwereobserved.Inaddition, asso-ciationsofthesepatternswithsociodemographicvariables andnutritionalstatuswerealsodetected.

Dietarypatternsinsideschool

The ‘‘traditional’’ pattern identified inside school essen-tially comprised the typical foods from Brazilian cuisine, such asrice and beans, and foods rich in fiber, vitamins, andminerals,suchasvegetablesandcereals,inadditionto thepresenceoffoods,suchasprocessedmeatandsausages. Childrenwithhigheradherencetothispatternhadahigher nutritionalqualitythanthosewithloweradherencetothis pattern,astheyconsumedlessaddedsugar,saturated,and trans fats and had a higher intake of total dietary fiber. Thispatternwasassociatedwithchildrenfromlow-income familiesliving in theMidwest region.Similarresults were reportedinthestudybyNobreetal.3_assessing preschool-ers, inwhich theyidentified adietary pattern comprising thetypicalfoodsconsumedintheBraziliandiet.

The second pattern,‘‘dual,’’wascharacterizedby the presenceoffoodsoflownutritionalquality,withthe excep-tion of the dairy group, which are important sources of calcium,andtubersgroup(cassava,sweetpotato,andyam) ---typicalfoodsfromtheNortheastofBrazilthataresources ofcomplexcarbohydrates.Thispatternwasassociatedwith higherintakeofaddedsugarandglycemicloadandlower intakeof saturatedfat, trans fat, sodium, andtotal fiber intake.Inaddition,therewasgreateradherencetothis pat-ternamonglow-incomechildrenfromtheNortheastregion. The thirdpattern,‘‘snack,’’wascomposedby easy-to-prepareorready-to-eatfoodswithlownutritionalquality, suchasinstantnoodles,sandwiches,soda,pies,andcandies. Thispatternhadgreateradherenceamongchildrenenrolled at privateschools fromtheMidwest region.Adherenceto thispatternwasassociatedwithhigherintakeofaddedsugar andglycemicload.

Ford,Slining,andPopkin2_assessed_trends_in_the_dietary intakeamongchildrenfromtheUnitedStatesagedbetween 2and6years;overatwenty-yearperiod,theyidentifiedan increase in148kcal/dayin theper capitaintake offoods richinsugarsandsolidfats.

However,itis noteworthythatnutrient-richfoods such as dairy, tubers, and cereals were featured only in pat-terns described inside school. These foods are sourcesof nutrients whose adequate intake can help promote bone growthand development,aswellasprevent anumberof non-communicablediseases,suchascardiovasculardiseases andsometypesof cancer.9---15 _It_should_be_mentioned _that the adherence to the dietary pattern composed by foods richinfat,sodium,andaddedsugarwasloweramong chil-drenenrolledinpublicschoolsthanamongthoseenrolledin privateschools.Theseresultscanbeascribedtothe Brazil-ianNationalSchoolFeedingProgram(ProgramaNacionalde Alimentac¸ãoEscolar[PNAE]),implementedinBrazilin1955, whichhas ascore principlestheprovision ofhealthy food andmeals,respectinglocaleatinghabitsinaccordancewith

age andhealth status.16 _This _program _covers _all _students enrolledin basiceducationinpublicschools,providingup to70%oftherecommendeddailynutrientintake.ThePNAE hasalsoreleasedarecommendationforreducingprocessed foodsthatarehighinfat,sodium,andsugarinschoolmeals ofBrazilianchildren.

The school plays a key role in the dietary intake of children,bycreatingopportunitiestothemtoexpandthe repertoire of foods consumed and create a reference of healthy eating,as they areexposed to a wide variety of nutrient-richfoodsatschoolmeals.Moreover,schools sup-portthenutritioneducationandpublicpoliciesforensuring thequalityofschoolmeals.

Dietarypatternsoutsideschool

The ‘‘traditional’’ pattern identified outside school com-prisedtraditionalfoodsfromBrazilianculturesuchasrice, bean,meat,vegetables,potatoes,anditwassimilartothe patternsidentifiedinside school.Similarresultswerealso describedbyMatosetal.17_in_a_{population-based}_study_that assessedthedietarypatternsof children,whereadietary patternconsistingofrice,beans,andmeatinchildrenaged 2---5yearswasidentified.Thispatternwasassociatedwitha higherintakeofsaturatedfat,transfat,sodium,andtotal dietaryfiber,aswellaswithalowerintakeofaddedsugar andglycemicload.Furthermore,the‘‘traditional’’pattern wasassociatedwithchildrenfromtheSoutheastregion.

Higheradherencetothe‘‘breadandbutter’’patternwas observed amongchildren from Northregion. This pattern wasassociatedwithahigherintakeoftransfatandglycemic load.Souzaetal.,18_who_evaluated_the_dietary_patterns_of childrenaged1---6yearsfromSouthernBrazil,identifieda similardietary pattern, characterized by the presence of bread,butter/margarine,rice/pastas,coffee,andsugar.

Conversely, a ‘‘snack’’ pattern was characterized by easy-to-prepareorready-to-eatfoods andshowedgreater adherenceamongchildrenenrolledatprivateschools,from high-income families from the Midwest, Southeast, and Southregions,andwithoverweightandobesity.

Inthisregard,Romani19_observed_that_post-modern fam-ilieshaveadeconstructionoftheclassicroleofthefamily inrelation tofeeding practices,and notedan increase in theconsumptionofeasy-to-preparefoodsinItalianfamilies. Severalfactorsmayinfluencetheincreaseofthe consump-tionofthesefoods,includingwomen’sparticipationinthe labormarket,convenienceinpreparation,andavailability ofthese products.Osman etal.20 _evaluated_factors influ-encing the consumption of easy-to-prepare foods among workingwomenandidentifiedthattimehassignificant pos-itiveimpactonconsumptionofthistypeoffood.Theyalso observedthatfactorssuchashealthawareness,price,and familyinfluence did not have a significant effect on con-sumptionofeasy-to-preparefoods.

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literature,thereisnoconsensusyetonthecontributionof foodsconsumedinthe‘‘snack’’dietarypatterntothetrend inoverweightamongchildren.26

Althoughsomedietarypatternsidentifiedinsideand out-sideschoolsweresimilar,theydifferintermsofnutritional quality. It was noted that children from private schools showed greater adherence to patterns with worse nutri-tionalquality,suchasthe‘‘snack’’pattern.

Thepresentstudyhassomelimitationsthatmustbe out-lined.Exploratoryfactoranalysisisamultivariatestatistical method involving decision-making by researchers at vari-ous stages of the modeling process, such as during food grouping,choosingfactor rotationmethod, defining crite-riaforretentionoffactors,andestablishingacut-offpoint to factor loadings. However, aiming to ensure methodo-logicalstrictness,theauthorsappliedanalyticalprocedures widelyestablishedinnutritionalepidemiologyforthestudy ofdietarypatterns.Furthermore,thecross-sectionalnature does not allow for establishing causal inference. Another limitationofthestudyisthatdatacollectionoccurred dur-ing2007,andchangesineconomic,food,andhealthpolicies have taken placein recent years in Brazil. However,this study was the first multicenter study of dietary patterns inside and outside the school, showing the relevance of publicpoliciestothenutritionalqualityofinfantfeeding. Moreover,this studyisinnovative withregardtotheissue investigated and is relevant to public health and policy-makers.

In conclusion, there are differences in the nutritional qualityofdietarypatternsinsideandoutsideschool.Also, heterogeneityinadherencetothesepatternswasobserved acrossregionsandsocioeconomicclasses.Thepresentstudy reinforcestheimportanceofnutritioneducationactionsand moreeffectivepublicpoliciesforpromotinghealthierfood choicesinchildhood.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

Tothe institutionsthat collaboratedwiththedata collec-tion and to the São Paulo Research Foundation (FAPESP) forgrantingascholarshiptothefirstauthor(ProceduralN◦ 2013/06979-9).

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