www.jped.com.br
ORIGINAL
ARTICLE
Influence
of
the
Bolsa
Família
program
on
nutritional
status
and
food
frequency
of
schoolchildren
夽
Ariene
Silva
do
Carmo
a,∗,
Lorena
Magalhães
de
Almeida
a,
Daniela
Rodrigues
de
Oliveira
a,
Luana
Caroline
dos
Santos
baUniversidadeFederaldeMinasGerais(UFMG),BeloHorizonte,MG,Brazil
bDepartmentofNutrition,EscoladeEnfermagem,UniversidadeFederaldeMinasGerais(UFMG),BeloHorizonte,MG,Brazil
Received20July2015;accepted9October2015 Availableonline20May2016
KEYWORDS
Foodconsumption; Anthropometry; Children; Government programs
Abstract
Objective: Toevaluatethefoodfrequencyandnutritionalstatusamongstudentsaccordingto participationintheBolsaFamíliaprogramfundedbythegovernment.
Methods: Cross-sectionalstudycarriedoutwithstudentsfromthefourthgradeofelementary school inthe municipal capitalofthesoutheastern regionofBrazil.Food consumption and anthropometrywereinvestigatedbyaquestionnaireadministeredinschool,whileparticipation intheBolsaFamília programandothersocio-economicinformationwasobtained througha protocolappliedtomothers/guardians.StatisticalanalysisincludedtheMann---Whitneytest, thechi-squaredtest,andPoissonregressionwithrobustvariance,andthe5%significancelevel wasadopted.
Results: Therewere319childrenevaluated;56.4%weremale,withamedianof9.4(8.6---11.9) years,and37.0%werebeneficiariesofBolsaFamíliaprogram.Betweenthetwogroups,there washighprevalenceofregularsodaconsumption(34.3%),artificialjuice(49.5%),andsweets (40.3%), whileonly54.3%and51.7% consumedfruits andvegetablesregularly,respectively. Among participantsofBolsaFamíliaprogram,aprevalence1.24times higherintheregular consumptionofsoftdrinks(95%CI:1.10---1.39)wasidentifiedcomparedtonon-beneficiaries. Theprevalenceofoverweightwashigherinthesample(32.9%),withnodifferenceaccording toparticipationintheprogram.
Conclusion: ThestudyfoundincreasedconsumptionofsoftdrinksamongBFPparticipants.The high rateofoverweight andpooreatinghabits denotetheneedto developactionsto pro-motehealthyeating,especiallyforthebeneficiariesoftheBolsaFamíliaprogram,topromote improvementsinnutritionalstatusandpreventchronicdiseasesthroughoutlife.
©2016SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/ 4.0/).
夽
Pleasecitethisarticleas:CarmoAS,AlmeidaLM,OliveiraDR,SantosLC.InfluenceoftheBolsaFamíliaprogramonnutritionalstatus
andfoodfrequencyofschoolchildren.JPediatr(RioJ).2016;92:381---7.
∗Correspondingauthor.
E-mail:[email protected](A.S.doCarmo). http://dx.doi.org/10.1016/j.jped.2015.10.008
PALAVRAS-CHAVE
Consumoalimentar; Antropometria; Crianc¸as; Programas governamentais
InfluênciadoprogramaBolsaFamílianoestadonutricionalefrequênciaalimentarde
escolares
Resumo
Objetivo: Avaliar a frequência alimentar e estado nutricional entre escolares segundo a participac¸ãonoprogramagovernamentalBolsaFamília(PBF).
Metodologia: Estudodedelineamentotransversal realizadocomalunosdo4◦ ano doensino
fundamentaldaredemunicipaldeumacapitaldaregiãosudestedoBrasil.Oconsumoalimentar eantropometriaforaminvestigadosmedianteformulárioaplicadocomosescolares,enquantoa participac¸ãonoPBFeoutrasinformac¸õessocioeconômicasforamobtidaspormeiodeprotocolo aplicadoàsmães/responsáveis.AanáliseestatísticacontemplouostestesMann---Whitney, Qui-quadradoeRegressãodePoissoncomvariânciarobusta,sendoadotadoovalordesignificância de5%.
Resultados: Foram avaliadas 319 crianc¸as, 56,4% do sexo masculino, com mediana de 9,4 (8,6---11,9)anos,sendo37,0%beneficiáriosdoPBF.Entreosdoisgruposavaliados(participantes enão-participantesdoPBF),observou-seelevadaprevalênciadeconsumoregularde refrig-erante(34,3%),sucoartificial(49,5%),eguloseimas(40,3%),enquantoapenas54,3%e51,7% consumiramfrutasehortalic¸asregularmente,respectivamente.EntreosparticipantesdoPBF, identificou-seprevalênciade1,24vezesmaiornoconsumoregularderefrigerantes(IC95%: 1,10---1,39),comparadoaosnãobeneficiários.Aprevalênciadeexcessodepesofoielevadana amostra(32,9%),semdiferenc¸asegundoaparticipac¸ãonoprograma.
Conclusão: OestudoreveloumaiorconsumoderefrigerantesentreparticipantesdoPBF.Aalta taxadeexcessodepesoehábitosalimentaresinadequadosdenotaanecessidadededesenvolver ac¸õesdepromoc¸ãodaalimentac¸ãosaudável,emespecialcomosbeneficiáriosdoPBF,afimde promovermelhoriasnascondic¸õesnutricionaiseprevenirdoenc¸ascrônicasaolongodavida. ©2016SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4. 0/).
Introduction
In Brazil, the right to food as a human right is a recent achievement. In2010, a legal determinationthat ensures foodasaright totheentire populationwasaddedtothe Brazilian Constitution through Constitutional Amendment No.64.1
TheHumanRighttoAdequateFood(HRAF)mustbe guar-anteedthroughpublicpoliciesofFoodandNutritionSecurity (FNS).2TheBolsaFamíliaProgram(BFP)isinsertedinthis
context, which, in addition toproviding income transfer, aimstoguaranteeaccesstobasicsocialrights.Thisprogram wasestablished by LawNo. 10.836 of 20043 and consists
ofthemonthlypayment ofcashbenefitstoenrolled fami-lies,aimingtobenefitthoseinsituationsoffooddeprivation andextremepoverty.TheBFPispartofthe‘‘Brazilwithout PovertyPlan’’andbenefitsapproximately14millionfamilies inallBrazilianmunicipalities.4
Inthisprogram,themonitoringoftheconditions,which are commitments made by the families and by the gov-ernment,occursinthreeareas:education,socialsecurity, and health. The latter includes the monitoring of chil-dren’s immunization schedule and nutritional status.5 To
achieve the objectives proposed by the program, it must beintegrated withother types of governmental interven-tions and be carried out intersectorally.2 These practices
aimto empowerfamilies regardingthe use of the money receivedfromthegovernmentbyprovidingaccesstofood inasafeandhealthymanner, consideringthat thisaccess
should besanitary, nutritional, culturally appropriate and sustainable.2
Althoughtheincometransferprogramsincludedisputes astohowfamiliesusetheresources,thereisevidencethat theincometransferisusedprimarilyfortheacquisitionof foods6thatarenotalwaysadequate.Astudyconductedwith
BFPbeneficiariesfromMaceio(StateofAlagoas)showedthat mostofthepurchasedfoodconsistedofprocesseditems,at theexpenseoffruits,vegetables,anddairyproducts,which mayhave anegativeimpactonthechildren’sfoodintake andnutritionalstatus.6
Inthis sense,itis important toassessthe influence of participatinginthisprogramonschoolchildren’sfoodintake andnutritionalstatus.7TherearestillfewstudiesinBrazil
on this issue; many of them were notcarried out with a representativesampleanddidnotadjusttheiranalysesfor confoundingfactors.7
Giventheabove,thisstudyaimedtoevaluatethefood frequencyandnutritionalstatusofschoolchildrenaccording toparticipationinagovernmentassistanceprogram.
Methods
Studydesign
datafromalargerproject entitled‘‘Integratedactionsof foodandnutritioneducationinmunicipaleducationalunits: promotionofhealthandfoodsecurityandnutrition.’’
Inthepresentstudy,forthesamplesizecalculation,the criteriaproposedbyHulleyetal.8foradescriptivestudyof
a dichotomous variable were used,considering the value of35.0% astheexpectedproportionfor theBFP benefici-aries,asidentifiedin a studycarried outwithchildrenin Belo Horizonte, MG9 and with the population of the city
ofVic¸osa,MG,10 an amplitudeof10%,significancelevelof
5%,andastudypowerof80%.Moreover,thesampleweight wasconsideredas1.48,calculatedbasedonthedataofthe numberofclassesandschools,duetothesamplingdesign used.Thus,thesamplesizewasestimatedat230students. Two-stageclustersamplingwasused.Inthefirststage, thestratification wasperformed accordingtotheregional districtsofthemunicipality.Thus,withtheaidofalistof allpublicschoolsinBeloHorizontewithfourth-yearclasses, madeavailablebytheMunicipalSecretariatofEducationof BeloHorizonte,oneschoolfromeachofthenineregionswas selectedbydrawinglots.Itisnoteworthythattheselected schoolswerelocatedinareaswithdifferentclassifications ofUrbanQualityofLifeIndex:verylow,low,medium,high, and very high.11,12 At the second stage, the classes were
selectedineveryschool,withaprobabilityproportionalto thenumberof fourth-yearstudentsenrolledin theschool belongingtoeachregionaldistrict.Thus,allstudentsfrom theselectedclasseswereinvitedtoparticipateinthestudy (n=724).Of these, thosewhomissed theassessment day (n=101)orhadmentalhealthimpairmentaccordingtothe teachers’reports(n=12)wereexcluded.
Throughoutthestudy,therewasalossof 47.7%dueto refusaltoparticipateinthestudy(n=1)andfailuretoapply thesocioeconomicquestionnairethroughtelephonecontact withthechildren’smothersorguardians(n=291).Thelatter losseswerecaused bywrongorinexistentphonenumbers orabsenceoftherespondentatthetimeofthecallasthe mainreasons forthemissedinterview(n=261),refusalto participateinthestudy(n=16),andnotelephonecontact (n=14).Itisworthmentioningthatatleastthreeattempts of telephone contactwith parents/guardians were made, includingthethreeperiodsoftheday.
Therefore, the final sample consisted of 319 students. Children that had their evaluations excluded from the study showed nostatistically significant differences when comparedthosewhoremainedregardinggender, age,and nutritionalstatus(p>0.05).
Datacollection
Anin-personformwasappliedtotheschoolchildrenintheir ownschools and another wasappliedto theirmothers or guardiansthroughtelephonecontact.Itisnoteworthythat such assessment tools were developed for the study, and werepreviouslytestedandcoded.Datacollectionwas per-formedbystudentnutritionistsofUniversidadeFederalde Minas Gerais (UFMG) and previously trained nutritionists, supervisedbythemaininvestigator.
Information such as date of birth, gender, and the student’sphonecontactwereprovidedbyschool documen-tation.
The form applied to the mother or guardian included sociodemographic and economic data. The latter included the mother’s and/or guardian’s age, level of schooling,marital status and employment status, partici-pationintheBFP,familyincome,andnumberofhousehold residents.Basedonthefamilyincomeandthe numberof residents,thepercapitaincomewascalculated.
The schoolchildren’s food consumption was evaluated through the Food Frequency Questionnaire (FFQ) and anthropometricmeasurementswereperformed.
RegardingtheFFQ,itwasasimplifiedqualitative ques-tionnaire,relatedtotheintakeofninetypesoffoodsinthe lastsixmonths(softdrinks,artificialjuices,snacks, cream-filledbiscuits,candies/sweets,fruits,vegetables,milk,and beans).TheFFQwasadaptedfromatoolproposedforadults inthecityofBeloHorizonte.13 Thefrequencyof
consump-tionof thesefoodswasclassifiedintoregular(≥5timesa
week)andirregular(<5timesaweek)accordingtothe cat-egorizationusedbytheNationalSurveyofStudents’Health (PesquisaNacionaldeSaúdedoEscolar[PeNSE]).14
Anthropometric assessment of the students consisted of weight and height measurements, which allowed the calculation of the height-for-age index and body mass index-for-age (BMI=weight [kg]/height [m]2),both
classi-fied according to the criteria proposed by the Food and NutritionSurveillanceSystem15 basedonthegrowthcurves
oftheWorldHealthOrganization(WHO).16
Dataanalysis
Descriptiveanalysisofthedatawascarriedoutbasedonthe calculationofthefrequency distribution,andcentral ten-dency and dispersion measures. The Kolmogorov---Smirnov normalitytestwasapplied,andasthequantitative varia-blesdidnotshow anormaldistribution,itwasdecidedto presentthemasmedian(minimum−maximum)values.
At the bivariate analysis, the Mann---Whitney and chi-squared tests were applied to compare the sociode-mographic, nutritional status, and food intake variables between beneficiaries and non-beneficiaries of the Bolsa Famíliaprogram.
For the variables of nutritional status/food consump-tionthatweresignificantinthebivariateanalysis,Poisson regressionmodelswithrobustvariancewereused. Partic-ipation in the BFP wasused as the explanatory variable, andwasadjustedforsociodemographicandeconomic indi-catorsthatshowedp-valuesequaltoorlessthan0.20inthe bivariateanalyses.
ThedatawereprocessedusingtheEpiInfoprogram, ver-sion3.4.5(CentersforDiseaseControlandPrevention,USA) and,analyzedusingthesoftwareStata,version11.0 (Stat-aCorp. 2009. Stata Statistical Software, College Station, USA).A5%significancelevelwasusedinallanalyses.
Ethicalaspects
Table1 Socioeconomiccharacteristicsofschoolchildrenbeneficiariesandnon-beneficiariesoftheBolsaFamíliaProgram,Belo Horizonte(MG),Brazil.
Variables Total BeneficiaryofBolsaFamíliaprogram p-valuea
No Yes
Characteristicofthestudent
Age(years)(median) 9.4(8.6---11.9) 9.4(8.6---11.9) 9.5(8.7---11.6) 0.121 Student’sgender(%)
Female 43.6 45.3 42.1 0.586
Male 56.4 54.7 57.9
Characteristicsoftheparent/guardianresponsibleforthestudent’scare/familyenvironment
Ageoftheparent/guardian(years)(median) 36(24---83) 36(25---83) 35(24---62) 0.336 Levelofschoolingoftheparent/guardianresponsibleforthestudent’scare(%)
<9yearsofschooling 53.0 43.7 68.4 <0.001
≥9yearsofschooling 47.0 56.3 31.6
Percapitaincome(classification)(%)b
≤½ minimumwage 52.5 33.7 85.2 <0.001
>½ minimumwage 47.5 66.3 14.8
Employmentstatus(%)
Unemployed 36.5 31.8 43.0 0.048
Employed 63.5 68.2 57.0
Maritalstatus(%) 0.001
Married 62.1 68.5 50.0
Single,divorced,orwidowed 37.9 31.5 50.0
aMann---Whitneyandchi-squaredtests.
b Minimumwagein2013:R$678.00.
approvedbytheResearchEthicsCommitteeofUFMG(CAAE 00734412.0.0000.5149).
Results
Atotalof319childrenwereevaluated,ofwhom56.4%were males,withamedianageof9.4years(8.6---11.9),and37.0% wereBFPbeneficiaries(Table1).Inrelationtothe respon-dentforthechild,88.5%wererepresentedbythemother, 2.7%bythefather,and8.8%byothers(grandparents, step-mother,aunt,orgreat-grandmother).
Regardingthesociodemographicandeconomicdata,the proportion of individuals with a per capita income<1/2 a minimum wage (85.2% vs. 33.7%, p<0.001) and mother’s/guardian’s level of schooling <9 years of study (68.4%vs.43.7%p<0.001)washigheramongthosewhowere beneficiariesofthe BFP. Alsoamongthesefamilies,there wasa higher prevalence of unmarried/divorced/widowed maritalstatus (50.0% vs. 31.5%, p=0.001) and unemploy-ment rate (43.0% vs. 31.8, p=0.048) among mothers or guardians(Table1).
Regardingthenutritionalstatus,therewasahigh preva-lenceofoverweightamongchildrenthatwerebeneficiaries (30.7%) and non-beneficiaries (36.3%) of the program. The proportion of children with low or very low height-for-age was 1.8% and 0.5% among the beneficiaries and non-beneficiariesof the BFP, respectively. There were no statistically significant differences regarding the anthro-pometric parameters assessed between these individuals (Table2).Regardingfoodconsumption,itwasobservedthat
bothschoolchildrenwhowerebeneficiariesandthosewho were non-beneficiaries of the BFP showed a high preva-lenceofregularsodaconsumption(34.3%),artificialjuices (49.5%), and candies/sweets (40.3%), whereasonly 54.3% and51.7%ofthemregularlyconsumedfruitsandvegetables, respectively(Table3).
Atthebivariateanalysis,ahigherfrequency ofregular consumptionofcandies/sweets(49.1%vs.35.3%,p=0.016) and soft drinks (42.1% vs. 29.9%, p=0.028) among the program beneficiaries was observed, when compared to non-beneficiaries(Table3).TheresultsofthePoisson regres-sionmodels,adjustedforcategoricalindicatorsofincome, schooling,employmentstatus,andmaritalstatus,havingas dependent variables the binaryindicators of consumption of softdrinks andcandies/sweets, andas predictive vari-abletheparticipationinBFP,showedthatchildrenthatwere beneficiariesoftheprogramhada1.24-foldhigher preva-lenceofregularsoftdrinkconsumption(95%CI:1.10---1.39,
p<0.001). As for the consumption of candies/sweets, no differencewas observed in theadjusted model according to participation in the BFP (PR: 1.01; 95% CI: 0.83---1.25,
p=0.850).
Discussion
Table 2 Anthropometric profile ofschoolchildren beneficiaries and non-beneficiaries of the Bolsa Família Program, Belo Horizonte(MG),Brazil.
Variables Total BolsaFamíliaprogrambeneficiary p-valuea
No Yes
Bodymassindexforage(%)
Malnutrition 1.9 2.0 1.8
Normalweight 65.2 67.3 61.9 0.594
Excessweight 32.9 30.7 36.3
Statureforage(%)
Shortorveryshort 0.9 0.5 1.8 0.270
Adequate 99.1 99.5 98.2
a Chi-squaredtest.
Table3 Frequencyoffoodconsumptionbyschoolchildrenbeneficiariesandnon-beneficiariesoftheBolsaFamíliaprogram, BeloHorizonte(MG),Brazil.
Variables Total BolsaFamíliaprogrambeneficiary(%) p-valuea
No Yes
Softdrinks
Irregular 65.7 70.1 57.9 0.028
Regular 34.3 29.9 42.1
Artificialjuice
Irregular 50.5 50.7 50.0 0.899
Regular 49.5 49.3 50.0
Snacks
Irregular 84.1 84.1 84.2 0.976
Regular 15.9 15.9 15.8
Cream-filledbiscuits
Irregular 67.3 69.7 63.2 0.238
Regular 32.7 30.3 36.8
Candies/sweets
Irregular 59.7 64.7 50.9 0.016
Regular 40.3 35.3 49.1
Fruits
Irregular 45.7 43.8 49.1 0.360
Regular 54.3 56.2 50.9
Vegetables
Irregular 48.3 47.8 49.1 0.816
Regular 51.7 52.2 50.9
Milk
Irregular 33.3 31.8 36.0 0.456
Regular 66.7 68.2 64.0
Beans
Irregular 11.7 10.9 13.2 0.558
Regular 88.3 89.1 86.8
a Chi-squaredtest.
Itwasobservedthatthefamiliesparticipatinginthe pro-gramhadlowersocioeconomicstatus,confirmingthehigh socialvulnerabilityoftheprogrambeneficiaries.The prob-lemsexperiencedbyfamiliesinpovertyarenotlimitedto monetaryincomeshortageandare,mostly,associatedwith
reducedability toexercisetheirrightsascitizensandthe fewopportunitiestheyhavetoimprovetheirqualityoflife.5
elementaryschool),whichgreatlyhindersaccesstobetter employmentopportunitiesorincomegeneration.5
Regardingnutritionalstatus,thestudyresultsshoweda high rate of overweight among the students, whether or nottheywereBFPbeneficiaries,corroboratingthefindings ofother studies.6,17 InBrazil, according tothe Household
Budget Survey 2008---2009, there has been a significant increaseinexcessweightratesamongchildreninthelast 34years(10.9---34.8% and from8.6% to32.0%in boysand girlsaged5---9-yearsold,respectively).17Theincreaseinthe
prevalence of childhoodexcess weightis alsoa reality in low-incomeclasses,possiblyduetoincreasedconsumption offoodsrichinfatandcarbohydrates,eitherduetolackof knowledgeofwhatwouldbeahealthydiet,aswellasthe lowerpriceofthesefoods.18
Nosignificantheightdeficitswereobserved,asonly1.8% oftheBFPbeneficiariesand0.5%of non-beneficiarieshad thiscondition. These valuesarewithin theexpected pro-portionofchildrenwiththisdeficitwhenthereareoptimal food,health,andnutritionalconditionsinthepopulation,19
andareinaccordancewiththeproportionsobservedinthe Brazilianpopulationregardingthisagegroup.17
Theguaranteeoffoodandnutritionsecurityrequires pro-gramsthatencompassboththefightagainstmalnutritionas wellasoverweightand obesity.20 Incomedistribution
pro-gramssuchasBFPcan moreeffectively contributetothe nutritionalwell-beingof thebeneficiarieswhen combined withothertypesinterventions,suchasthosethatpromote healthyeating.20
As for the food, excessive consumption --- identified amongthebeneficiariesandnon-beneficiariesoftheBFP ---offoodsknowntocompriseanunhealthydiet,characterized bythegroupofultraprocessedfoodsandinsufficientintake of minimally-processed foods, corroborates the results of other studies of school-aged children in Brazil and other countries.21---23 Such inadequacies may contribute to the
increasedriskofdevelopingobesityandotherchronic dis-eases,indicating the need for nutritional interventionsin thispopulation.
Interventions become even more important for BFP beneficiarieswhen one considers the increased consump-tion of soft drinks compared to non-beneficiaries of the program, even after adjusting for socio-demographic and economic factors. Other authors had similar findings.24,25
In a study carried out with children under 5 years of age in the semi-arid northeast region of Brazil, it was observedthattheparticipantsoftheBFPhadathree-fold higherriskofconsumingcandies/sweets(OR:3.06,95%CI: 1.35---6.95).24 The levelof incomedependency ontheBFP
benefitandthe increasedconsumption ofsugar have also beenhighlighted.25
The increase in income provided by program has gen-eratedgreater accesstofoodforthebeneficiaryfamilies. However, this income transfer does not guarantee that the supply is adequate in terms of quality.26 According
totheBrazilian Institute of Social andEconomic Analyses (Instituto Brasileiro de Análises Sociais e Econômicas ---IBASE),which evaluatedthechanges infood consumption ofthe BFP beneficiaryfamilies,increasedconsumption of food regarding quantity and variety was observed among theprogrambeneficiaries.26However,thechoiceofhigher
caloricdensity andlowernutritionalvaluefoodprevailed.
Amongthemostoftenmentionedfoodswereindustrialized ones,richinenergy,sugar,saturatedfat,andsodium.26
Althoughintriguing,theresultsobtainedinthisstudydo notallow establishingacausalassociation, consideringits cross-sectionaldesign.Thus,longitudinal studiesthattake intoaccounthowlongthefamilieshavereceivedthebenefit areindicated.7However,thepotentialofthisstudyto
sup-plementthelimitedstudiescarriedoutinBrazilonthistopic isnoteworthy, withsample representativenessand adjust-mentsforpossibleconfoundingfactors.
Thehigh rateof excessweightand theintakeof high-energydensityandlowernutritionalvaluebeveragesamong thechildrenparticipatingintheBFP,asdemonstratedinthis study,indicatetheneedtopromotehealthyeatingactions directedtowardsthesefamilies.Healthyfoodchoicesshould be encouraged in order topromote improvements in the nutritionalstatusofthesechildrenandpreventchronic dis-easesthroughoutlife.
Funding
Fundac¸ãodeAmparoàPesquisadoestadodeMinasGerais (FAPEMIG)andCoordenac¸ãodeAperfeic¸oamentodePessoal deNívelSuperior(CAPES).
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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