JPediatr(RioJ).2016;92(6):546---548
www.jped.com.br
EDITORIAL
Maternal
food
intake
and
socioeconomic
status
to
tackle
childhood
malnutrition
夽
,
夽夽
Alimentac
¸ão
maternal
e
status
socioeconômico
na
luta
contra
a
má-nutric
¸ão
infantil
Vitor
Hugo
Teixeira
a,b,∗,
Pedro
Moreira
a,b,caUniversidadedoPorto,FaculdadedeCiênciasdaNutric¸ãoeAlimentac¸ão,Porto,Portugal
bUniversidadedoPorto,CentrodeInvestigac¸ãoemAtividadeFísica,SaúdeeLazer,Porto,Portugal
cUniversidadedoPorto,InstitutodeSaúdePública,Porto,Portugal
This issue features a study by Géa-Horta et al.,1 which
describes the association between maternal
socioecono-micfactors (employment and level of schooling) and the
occurrenceofsomenutritionalindicators(shortstatureand
excessweight)inchildrenunder5yearsofageina
represen-tativesampleoftheBrazilianpopulation.Thefinalsample
comprised4356 women witha mean age of 27 yearsand
theirrespectivechildren,withameanageof2years,52%of
whomweremales.Maternalemploymentratewas40%and
themothershadameanof 8yearsofschooling.The
chil-dren hada lowermeanheight/age than theinternational
standards,while thebodymassindex(BMI)/age ratiowas
higher.2
Oneofthe mainresults ofthisstudy wasthefour-fold
higherchanceofmotherswithlowmaternallevelof
school-ingtohave childrenwithshortstature (height/agebelow
−2standarddeviations).Thisassociationmaybeexplained
byalessfavorablesocioeconomicstatus,eitherreflecting
thereduced possibilityofacquiring healthyfoods, or due
tothe lower awareness of the roleof foodin the future
夽
Pleasecitethisarticleas:TeixeiraVH,MoreiraP.Maternalfood intakeandsocioeconomicstatustotacklechildhoodmalnutrition. JPediatr(RioJ).2016;92:546---8.
夽夽
SeepaperbyGéa-Hortaetal.inpages574---80.
∗Correspondingauthor.
E-mail:[email protected](V.H.Teixeira).
developmentoftheoffspring.Thefirstreasonprobably
pre-vails,sincetherewasnoassociationbetweenmaternallevel
ofschoolingandexcessweight,similarlytootherstudies.
Thisstudy indicatedthat childrenwhose motherswere
employedwere57%morelikelytobeoverweight(BMI/age
>2standarddeviations)whencomparedwithchildrenwith
unemployed mothers or who worked at home. However,
employability had noimpact on the children’s height, as
shown by other studies.Thus, ontheone hand,maternal
employmentbenefitsthechild’sgrowthduetothegreater
access to food and health services, which are facilitated
by a higher income. On the other hand, it deprives the
child of full-time maternal care, particularly for the
preparation of healthy meals and performance of leisure
activities,inadditiontothefactthatitcanbeabarrierto
breastfeeding.
Theoriginoftheanalyzeddata---theNationalSurveyon
ChildrenandWomen’sDemographicsandHealth2006---2007
--- reinforcestheexternal validityof theresults, asit is a
representative sample of thatpopulation, but limitstheir
quality,becausesomeconfoundingvariableswerenot
con-trolled,suchasthechildren’sactivitylevels,breastfeeding
duration, maternal weight gain, and birth weight,among
others.
This study reinforcesthe concept that in several
geo-graphicalareas,suchasinBrazil,disconcertingprevalence
rates of obesityand malnutritionstillcoexist. Italso
sug-geststhatthedefinitionandimplementationofpublichealth
http://dx.doi.org/10.1016/j.jped.2016.08.002
Maternalfoodintakeandsocioeconomicstatus 547
policiesaiming todecreasetheserates must considerthe
socioeconomicfactors.Itisnoteworthytheimprovementin
someparameters,suchasbasicsanitationconditions,access
tohealthcare,andpercapitaincome,whichhaveimproved
some nutritional indicators. However, the new dynamics
of societies regarding work, with the increase of
mater-nalemploymentincountrieswithlesssocialwelfare,raise
considerablechallenges,particularlyinensuringhealthcare
accesstofamiliesbeforeandafterthechild’sbirth,which
canbetranslatedintobettermaternal---fetalenvironment,
immediately reflectedinbirth weightandthe many
asso-ciated factors, such as the acquired human capital, risk
factorsfordiseases,andevenproblematiceatingbehaviors.
In a study by Oliveira et al.3 in three European birth
cohorts (GenerationXXI, fromPortugal;ALSPAC, fromthe
United Kingdom; and EDEN, fromFrance), the reports on
difficulties when feeding children, such as eating small
amountsor needfor stimulationtoeat,weresignificantly
morefrequentinthosebornsmallforgestationalage.
InPortugal,thestudyonthebirthcohortGenerationXXI
disclosedotherlevelsofinfluencethatrequireurgent
inter-ventiontoobtaingoodresultsinrelationtonutritionalstatus
andfoodintakeupto4yearsofage.
In the study by Durão et al.,4 in a subsample of 3422
mothers and their children, the influence of family
char-acteristics wasanalyzed,includingbehaviorsand lifestyle
(physicalactivity,smoking,andeatinghabitsofmothersand
children),onthedietarypatternsofchildrenat4yearsof
age,conceptualizingthisactionaccordingtoa
sociodemo-graphicmodelwithfourlevels(socioeconomicstatusofthe
motherat12yearsofage,maternal socioeconomicstatus
and sociodemographiccharacteristics at the child’sbirth,
family characteristics at 4 years of age of the child, and
maternal characteristics and behaviors at 4 years of age
ofthe child).It wasverifiedthat aworse maternal
socio-economicstatusat12yearsofageandlowmaternallevel
of schoolingwereassociatedwithworse dietarypatterns,
represented by the consumption of foods that arelow in
micronutrientsandwithhighenergydensity(low
socioeco-nomicstatusat12yearsofageversushigh,OR=1.76,95%CI:
1.42---2.18;maternallevelofschooling≤9yearsversus>12
years,OR=2.19,95%CI:1.70---2.81).Childrenwhose
moth-ershadaworsedietqualityweresignificantlymorelikely
to have an unhealthy eating pattern, especially of foods
low in micronutrients and with high energy density (first
quartileoflowermaternalfoodqualityversusfourth
quar-tileofreferenceofhigher-qualitymaternalfood,OR=9.94,
95%CI:7.35---13.44,p-trend<0.001afteradjustingfor
con-founders).Inthissamecohort,theanalysisofinfantfeeding
practices through a questionnaire validated for Portugal5
and combining the scales of the Child Feeding
Question-naire by Birch etal.6 andof overtand covert controlby
Ogdenetal.7showedthathigherlevelsofmaternal
monitor-ingandrestrictionofintakewereinverselyassociatedwith
theoccurrenceofinadequatedietarypatternsinchildren,
such as the intake of high-energy density foods
(respec-tively,OR=0.84,95% CI:0.77---0.91and OR=0.85,95% CI:
0.78---0.93).Thatis,inthegroupofstudiedfactors,
mater-nal nutrition appears to be a key factor associated with
thechild’sdietat 4yearsofage, farabovethe
socioeco-nomic, demographic, and education factors, and dietary
behavior,contributingwithapproximatelyone-thirdofthe
determinationcoefficient(Nagelkerke’sR2)intheadjusted
model.
Once thetrackingof dietaryhabitsisknown,fromthe
growthperiodtoadulthood,andtheimportancethat
chil-dren’seatingbehaviorsmighthaveduringthefirstyearsof
lifeforfuturefoodintake,itisessentialtoproducetoolsand
studieswithapproachescapable ofdefiningthe behaviors
in their different dimensions and their impact on
nutri-tionalstatus.8In astudy ontheeatingbehaviorsin three
Europeancohorts(Generation XXI,fromPortugal;ALSPAC,
fromthe United Kingdom; and EDEN, from France),
chil-drenwhoexhibitedgreaterdifficultyiningestingfood,food
refusal/neophobia, and difficulties in establishing a daily
intakeroutineat 12---15months,24,and48---54 monthsof
agehad a lowerfruitand vegetablesintake.9 The
impor-tance of eating behaviors in food inadequacy in children
aged4yearswasdemonstratedintheXXIGenerationcohort,
whichshowedthatmaternalpracticessuchaspressure(at
anappropriatelevel)andanovertcontroloverwhatiseaten
maybeassociatedwithmoreadequateconsumptionoffruit,
vegetables,anddairyproducts.10Thepossibilitythatthere
canbe bidirectionaleffects between infantfeeding
prac-ticesand children’s BMI should be considered; awareness
of this phenomenon can improve the knowledge of the
parentalroleinthechild’snutritionalstatusandchildhood
obesity. The results are also difficult to interpret when,
forinstance,inanexperimentalenvironment,restrictionis
identifiedasafactorthatcancauseexcessivefoodintake,11
although in longitudinal studies, restriction may12 or may
notdemonstrateaneffectonthechild’sfeedingbehavior13
or BMI.14 Conversely, body weight can also influence the
feedingbehavior,asatendencytogreaterrestrictionsand
lowerlevelsofpressuretoeatat4yearsofage14havebeen
describedinparentsofchildrenwithhigherBMIat2years
ofage.InthestudybyAfonsoetal.15intheGenerationXXI
cohort,thelongitudinal studyofthebidirectional
associa-tionsbetweeninfantfeedingpracticesandBMIat4---7years
ofage showedthat the parents’practices respondtothe
child’sweight,butthechild’sweightalsoinfluencethem.
Thus,pressuretoeatandmoreovertcontrolofnutritionat
4yearsofageweresignificantlyassociatedwithalowerBMI
atage7, whileahigherBMI at4yearsof agewas
associ-atedwithhigherlevelsofrestrictionandcovertcontrolof
nutrition.
Therefore,itappearsevident tofavortheintervention
at thepre-school agein groups that combine the
charac-teristicsofpoormaternalnutritionandlowsocioeconomic
status.Thebattleagainstchildmalnutritionwillbealong
one,butitcannolongerbepostponed.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
548 TeixeiraVH,MoreiraP
2.WHOMulticentreGrowth ReferenceStudyGroup.WHOChild GrowthStandardsbasedonlength/height,weightandage.Acta PaediatrSuppl.2006;450:76---85.
3.OliveiraA,deLauzon-GuillainB, JonesL,EmmettP,Moreira P,RamosE,etal.Birthweightandeatingbehaviorsofyoung children.JPediatr.2015;166:59---65.
4.DurãoC,SeveroM,OliveiraA,MoreiraP,GuerraA,BarrosH, et al.Associationofmaternal characteristicsand behaviours with4-year-oldchildren’sdietarypatterns.MaternChildNutr. 2016, http://dx.doi.org/10.1111/mcn.12278 [Epub ahead of print].
5.RealH,OliveiraA,SeveroM,MoreiraP,LopesC.Combination andadaptationoftwotoolstoassessparentalfeedingpractices inpre-schoolchildren.EatBehav.2014;15:383---7.
6.BirchLL, FisherJO,Grimm-ThomasK,MarkeyCN,SawyerR, Johnson SL. Confirmatory factor analysis of the Child Feed-ingQuestionnaire:ameasureofparentalattitudes,beliefsand practicesaboutchildfeedingandobesityproneness.Appetite. 2001;36:201---10.
7.Ogden J, Reynolds R, Smith A. Expanding the concept of parentalcontrol:aroleforovertandcovertcontrolinchildren’s snackingbehaviour?Appetite.2006;47:100---6.
8.deLauzon-GuillainB,OliveiraA,CharlesMA,GrammatikakiE, JonesL,RigalN,etal.Areviewofmethodstoassessparental feeding practices and preschool children’s eating behavior: theneedforfurtherdevelopmentoftools.JAcadNutrDiet. 2012;112:1578---602,1602.e1---8.
9.OliveiraA,JonesL,deLauzon-GuillainB,EmmettP,MoreiraP, CharlesMA,etal.Earlyproblematiceatingbehavioursare asso-ciatedwithlowerfruitandvegetableintakeandlessdietary variety at4---5 yearsof age. Aprospective analysisof three Europeanbirthcohorts.BrJNutr.2015;114:763---71.
10.DurãoC,AndreozziV,OliveiraA,MoreiraP,GuerraA,BarrosH, etal.Maternalchild-feedingpracticesanddietaryinadequacy of4-year-oldchildren.Appetite.2015;92:15---23.
11.FisherJO,BirchLL.Restrictingaccesstopalatablefoodsaffects children’sbehavioralresponse,foodselection,andintake.Am JClinNutr.1999;69:1264---72.
12.RollinsBY,LokenE,SavageJS,BirchLL.Maternalcontrolling feedingpracticesandgirls’inhibitorycontrolinteracttopredict changesinBMIandeatingintheabsenceofhungerfrom5to7 y.AmJClinNutr.2014;99:249---57.
13.GregoryJE,PaxtonSJ,BrozovicAM.Maternalfeedingpractices, childeatingbehaviourandbodymassindexinpreschool-aged children: a prospective analysis. IntJ Behav NutrPhys Act. 2010;7:55.
14.Jansen PW, Tharner A, van der Ende J, Wake M, Raat H, Hofman A, et al.Feeding practicesand child weight: is the associationbidirectionalinpreschoolchildren?AmJClinNutr. 2014;100:1329---36.
