Nutrition-Related-Practices in Brazilian Preschoolers: Identifying Challenges and Addressing Barriers

Abstract

Over the past decades, Brazil has faced important challenges regarding the nutrition of toddlers. Changes in dietary intake and feeding habits switched the scenario from undernutrition to increased rates of overweight and obesity. Determinants related to that issue involve the disparity in income distribution, the structure of food production and access, and the role of programs and policies, mostly related to its historical context. The feeding of Brazilian toddlers is characterized by low consumption of fruits, vegetables, and fiber, and high and early intake of fried foods, salty snacks, and sugar. Skipping important meals, e.g., breakfast, and poor snacking habits are also important practices related to excess weight. Integrated actions aiming to establish healthy eating habits in children must involve families, schools, governments, and food industry. Exploring the variety of fruits and vegetables available in the country helps to provide a healthy nutrition environment. Increasing the availability of nutrient-dense foods in the home environment improves the quality of food directed to children. Improving children's diet quality goes beyond promoting nutrition education. A favorable environment enabling to translate intentions into practice is essential, and it involves a multisectoral and an integrated framework with individual modifications and political interventions.    
 
Introduction

Adequate nutrition in early life stages is an aspect of vital importance that affects growth, development, and health. However, it is still challenging to provide nu-trient-rich diets and adequate feeding during childhood. Knowing the relevance of good nutrition is still not enough to establish healthy eating habits. A key strategy to overcome this problem involves identifying and facing barriers related to child nutrition all over the world. To discuss challenges and opportunities in different contexts and realities, we wanted to contribute some aspects related to the situation of eating habits in Brazilian toddlers.

A Historical Pathway throughout Nutrition in Brazil

The context of nutrition in Brazil is parallel to its history and linked to some as-pects of Brazilian development. The disparity in income distribution, the structure of food production and access, and the role of programs and policies that attempt to modify the nutritional context are factors significantly related to the issue of malnutrition in the country.

For centuries, Brazil was a colony following the European settlement, which was reflected by its national economy. The circumstances of segregation during its expansion brought social differences with contemporary impacts on its population. In contrast to other Latin-American countries, African slaves and not natives were the most import labor workers in the colonial period, and mixing with European settlers was intense. Natives were segregated outside the cities and lived in very poor conditions, not used frequently as slaves. The migration history also played an important role in Brazilian cuisine and food patterns. The mix of native and immigrant influences coming from Africa, Europe, and later Asia reflected the country's food habits and the regional differences in Brazilian feeding. African descendants and indigenous natives, for example, are two historically important cultures for the country's development. Nevertheless, even nowadays, these groups are the ones that mostly live in a socially vulnerable situation. The racial inequality in the population income aggravates the existence of malnutrition. In 2018, a total of 60% of the overall population received less than the minimum wage. White workers received, on average, about 75% more than blacks and browns [1].

Income influences the nutritional status of toddlers through various mecha-nisms. Poverty affects toddlers' growth and development because it forces people to live in environments prone to diseases without clean water or adequate sanitation. Besides, low-income families tend to have less access to fresh food due to lack of its affordability in terms of income and its availability in their home environment.

The demographic scenario is another determinant for food access and avail-ability apart from exacerbating social and health disparities. Brazil is a country of continental proportions and, therefore, qualified to stand as one of the largest food producers in the world. It is a leader in the global market and exportation of commodities such as coffee, soybeans, corn, sugar cane, cocoa, and beef. Ad-ditionally, due to its biodiversity and tropical climate, a large variety of fruits and vegetables can be cultivated. On the other hand, however, the dimensional territory did not develop equally in all regions. There is a concentration of income and resources in some areas, while other places struggle to meet the basic needs. Most of the food products are exported, while the distribution and access to affordable healthy food vary disparately across the country.

Developmental challenges such as poverty, social inequalities, and food inse-curity were determinants in the scenario of malnutrition in Brazil. For many decades, children undernutrition was a key situation in the country, and the number of malnourished children was high. Inadequate intake of essential nu-trients, because of poor eating habits, is one of the main unresolved problems in the country even today. A multicenter study found a high prevalence of inade-quate intake, i.e., below the recommendations for fibers, calcium, and vitamins D and E in children aged 2-6 years. On the other hand, sodium intake was higher than the upper intake level in 90% of children younger than 4 years [2].

Policy initiatives to improve the dietary habits of children, especially those from socially vulnerable families, were developed in Brazil particularly in the last 2 decades. The established programs and policies attempted to tackle the structural causes of hunger, poverty, and malnutrition. A reference initiative in the country is the Bolsa Familia Program (small amounts of money for needed families) that aims to supplement income and improve health and educational opportunities. The program was part of “The Zero Hunger Strategy,” which incorporated a range of existing initiatives to guarantee universal access to quality food, based in a multisectoral framework [3].

However, increasing income did not seem to be enough to solve the problem of malnutrition and overcome the challenges in Brazilian nutrition history. Families in socially vulnerable situations did not necessarily turn access to financial resources into healthy food acquisitions. Data from the last “Research of Family Budget” (Pesquisa de Orẹamentos Familiares - POF) showed a tendency to increase food consumption outside the home with increased income as well as the intake of some unhealthy foods, such as soft drinks and fast foods [4]. Instead of healthier food choices, and the inclusion of fruits and vegetables in their diets, these families seem to choose food items that are extensively consumed by higher strata of society. These vulnerable communities are also exposed to higher rates of violence and discrimination, with a built environment that is not conducive to physical activity practice. There are fewer parks and sidewalks, and there is less open space. As a result, low-income communities tend to have higher rates of obesity. This context of poor diet quality and inadequate feeding and lifestyle habits had contributed to the nutritional transition in the country. There is an increase in overweight and obesity rates in people at all income levels, which is paralleled with important nutrient deficiencies, in a hidden hunger condition. A different context facing the historically unsolved problem in the country is malnutrition.

Current Challenges regarding the Feeding of Brazilian Toddlers

Even with efforts in different sectors and contexts, overweight and obesity rates in children are still rising, and feeding and lifestyle practices are far from those recommended. Where did we fail? Why did the initiatives and strategies not work? Some specific actions in the country, but with discreet results, include programs aimed at combating malnutrition and hunger. Currently, the main problem is the lack of a well-established and multisectoral policy to tackle obesity that goes beyond discussions and takes effective actions.

Among the initiatives in the country, we can highlight the iron and folate fortification. Due to high rates of iron and folic acid deficiencies, since 2002 food fortification with these two micronutrients to all wheat and maize flours indus-trialized in Brazil is mandatory. However, this is not an individual strategy but a generalized fortification. Besides, there is no follow-up or surveillance of this initiative [5]. Considering that wheat and maize flours are mainly used in bread, cake, and cookie industry, the strategy is not in accordance with the promotion of universal healthy eating habits. Even with the increase in pasta and whole bread at some socioeconomic levels, without the application of other strategies such as formula milk and follow-up formulas after weaning, anemia rates rise. Complementary feeding of toddlers is expected to present a food pattern based on fresh foods such as fruits and vegetables. Therefore, in order to be efficient in overcoming hidden hunger and micronutrient deficiencies in this age group, this initiative may increase the consumption of high energy-dense and nutrition-poor foods, which are related to increased rates of overweight and obesity.

The Brazilian National School Feeding Program (Programa Nacional de Ali- mentaẹão Escolar - PNAE) is one of the largest initiatives in school feeding in the world. However, due to the country's complexities and its large territory, schoolers are not feeding equally, and the program strategy has not worked properly. The program is funded by the federal government and complemented with funds from municipalities and states. In Brazil, the discrepancy in devel-opment, income, and regional food availability might reflect the quality of foods purchased and, consequently, the meals served to children. Besides, Brazil has a dual educational system with private and public schools. In private schools, students usually purchase their food in the cafeterias or bring it from home. Therefore, the availability of adequate food options at school is an important barrier. The availability of several products of low nutritional content such as candies, sweet snacks, artificial juice, and soft drinks is still a reality in the school settings. Restrictions without awareness of healthy habits tend to exacerbate this trade in an uncontrolled way. To provide adequate feeding to schoolers around the country, both the educational system and families are important actors (Fig.1).
Because this initiative does not contemplate children in preschool age, effective and pertinent participation of the family is even more needed for the feeding of toddlers. The composition of snacks, especially those served at home, is important because they are opportunities for adequate nutritional support for this age group. A study with mothers of >1,000 children aged 4-6 years from all regions of the country showed that Brazilian preschool children have the intermediate snacking habit. Positively, the fruit group was frequent in 98.8% of the snack compositions. The compositions of the morning and afternoon snacks were similar, mostly containing fruits, cookies, and yogurts. However, the afternoon snack proved to be more caloric and with more frequent intake of foods high in added sugars and of nutrient-poor content, such as candies, ice cream, and chocolates [6].

Habits involving complementary feeding are also among the families' re-sponsibilities. There is an early and high intake of inadequate food choices, es-pecially added sugar, sweets, biscuits, and candies, in Brazilian toddlers [7]. Most children receive cow's milk prematurely as a substitute for breast milk, which is consumed by approximately 80% of children aged 12-60 months in a national survey. In the same age group, infant formulas were consumed by less than 1% of the children [8]. Even with milk substitutes specific to the needs of toddlers, families, especially those in a vulnerable situation, cannot always afford it. In the context of children with feeding difficulties, the reality is even worse. There is an excessive daily protein intake from milk-based supplements, which tends to reduce the consumption of non-milk-based foods. Milk intake alone provided 80-138% of daily protein needs in children with feeding difficulties below 8 years of age [9]. This may result in important nutrient deficiencies, e.g., in iron, vitamin A, and fiber. The permissive parenting style has consequences not only on food patterns of toddlers but also on their eating habits. Skipping breakfast, poor snacking habits, inadequate meal timing, and lack of active participation in children feeding are important consequences in the overweight and obesity context.

Concomitant with advances in technology, early exposure to electronic devices is a worrying practice during toddler feeding. Associated with permissive parenting, the use of TVs, tablets, and cell phones has been employed as a controlling tool during mealtime. This practice affects the child's capacity to selflimit the portion sizes in addition to the development of inadequate eating habits that can affect later life. Strict strategies in the school environment are not sufficient to support healthy habits if children derive from a deficient home condition. In addition, early exposure to unhealthy food marketing can influence children's diets. The ineffective control of the government tackling aggressive marketing towards children is another barrier to the promotion of healthy feeding habits in Brazilian toddlers.

Due to the multidimensional context of the challenges, initiatives designed to promote adequate nutrition to children should be based on a framework aiming to modify families, schools, and obesogenic environments.

Opportunities to Enhance Toddlers' Feeding

Family Level

The home environment is an important space with a range of opportunities for toddlers' feeding. A potential intervention is the concept of Nurturing Children’s Healthy Eating, a family-centered approach that recognizes the pivotal role of families in promoting and supporting children's healthy eating habits. It presents key strategies that encourage and support adequate eating practices among children. A positive parenting style avoids food restriction and encourages chil-dren's role in food choices and self-control of portion sizes. A healthy home food environment promotes the accessibility of children to appropriate foods. Positive eating practices that stimulate regular family meals, children cooking skills, and pleasure to eat are important implementations at the family level [10].
Based on the previously stated challenges, some meals play a fundamental role in promoting healthier eating habits. Toddles' breakfast, which consists mainly of milk or dairy products with chocolate flavor, is usually inadequate or incomplete. A strategy to increase the intake of other nutrients and food groups usually deficient in toddles' feeding is to use milk only as a basic ingredient of breakfast to be supplemented with fruits and cereals. Intermediate snacks are other relevant meals commonly inadequate in toddlers' eating habits. Families should invest more time, organization, and planning of their meals ahead. Din-nertime could be used as a moment to set a positive example and encourage healthy-eating socialization, i.e., a time when families have the potential to create a regular meal pattern with children and spend more time together.

Parents and caregivers should play their role of responsibility in toddlers' feeding and especially provide a healthy home environment, not be permissive regarding inadequate eating practices, such as the use of electronic devices during mealtime, and be a model of positive parenting and show active participation. We do emphasize that Brazil has one of the highest rates of using of electronic devices in small children.

School Setting

School settings are another excellent space for interventions aimed to modify food habits. Promoting nutrition education should not be a single intervention in exploring all the potential of the school environment. These initiatives must be concomitant with the promotion of activities as part of the school curriculum in a multidimensional context directed at parents, students, education professionals, and cookers.

Even if meals are served as part of the school feeding program, healthy items, such as fruits and vegetables, should be provided on a daily basis. These products have to be part of the children's food patterns and not the exception, such as oc-casional activities like the Fruit Day at School. The implementation of rules or legislation restricting unhealthy products sold in canteens is not enough to en-courage the adoption of healthy habits. Children should be educated regarding healthy habits and not being exposed to inadequate food items in this environ-ment. It is worthless to control school selling of some goods if they are available at the school doors or in close vicinity.
We should still consider the school as a space where children are educated to be conscious of adequate habits. This awareness can be unconsciously transmitted to the home environment, where children will act as a mentor in promoting healthy eating practices from school to other settings.

Obesogenic Environment

An integrated approach directed to improve toddlers' feeding includes the mod-ification of obesogenic environment. The food industry should be even more committed to providing high-quality and nutrient-rich foods. There is a need for discussing the mandatory decrease in ingredients such as sugar and sodium and increase in nutrients such as fibers and vitamins, which is currently voluntary, without compromising the palatability of foods produced. Considering the high intake of milk products as an opportunity to increase other nutrient intake, its quality and composition could be modified to enhance the nutritional content. Fiber, w-3 fatty acids, and vitamins, which are commonly deficient in this age group, could be introduced to create milk-rich products. Growing-up formulas could be considered, but prices are one of the possible factors to prevent it.

Even with the intention of the food industry to provide adequate milk substi-tutes during feeding transition, people still choose to feed their toddlers with products based on cow's milk for economic reasons. An initiative may consider public and private subsidies to provide adequate milk substitutes for people who cannot afford it. Governments should control the aggressive marketing of energy-dense and nutrient-poor foods and beverages directed at children. Technologies and new communication spaces as digital influencers can be used to transmit positive messages regarding healthy feeding. Children may use them as models and examples, so they can play an important role in children's eating habits.

Brazilian food diversity should be explored. Why do we see diversity in food production but not in food intake and equal availability? To reduce inequality in food access, a possible initiative could be reducing food wasting, especially during distribution. Creative cooking skills presented in a socially vulnerable community using the variety of fruits and vegetables available in the country are one way to promote healthy eating habits.

A favorable environment for translating intentions to improve children's feeding into practice is essential. This includes an integrated system involving families, schools, governments, and the food industry. With the commitment of all sectors involved in children feeding, effective outcomes could be achieved in order to reduce children's overweight and obesity and promote healthy eating habits that will impact their life course (Fig. 2).

Conflict of Interest Statement

M.F. receives speaker fees and research grants from Abbott, Cereal Partners Worldwide (CPW), Danone Research, Novo Nordisk, and Nutrociencia. He was a member of the ILSI (International Life Sciences Institute) Brazil Board of Directors and the Danone Institute International Board. L.D.B. declares no conflicts of interest. 

References

1    Institute Brasileiro de Geografia e Estatística (IBGE): Pesquisa Nacional per Amostra de Do- micílios Contínua: rendimento de todas as fontes: 2018. Rio de Janeiro, IBGE, Coordena^ao de Tra- balho e Rendimento, 2018.
2    Bueno MB, Fisberg RM, Maximino P, et al: Nutri-tional risk among Brazilian children 2-6 years old: a multicenter study. Nutrition 2013;29:405- 410.
3    International Policy Centre for Inclusive Growth. The Food Security Policy Context in Brazil. Country Study. Number 22. Brasilia, 2011.
4    Instituto Brasileiro de Geografia e Estatística (IBGE): Pesquisa de Or^amentos Familiares 2008-2009: análise do consumo alimentar pes- soal no Brasil. Rio de Janeiro, IBGE, Coordena^ao de Trabalho e Rendimento, 2011.
5    Martins JM: Universal iron fortification of foods: the view of a hematologist. Rev Bras Hematol Hemoter 2012;34: 459-463.
6    Fisberg M, Del'arco APWT, Previdelli NA, Tosatti AM, Nogueira-de-Almeida CA: Between meal snacks and food habits in preschool Brazilian children: national representative sample survey. Int J Nutrol 2015;8:58-71.
7    Saldiva SRDM, Venancio SI, de Santana AC, et al: The consumption of unhealthy foods by Brazilian children is influenced by their mother's educational level. Nutr J 2014; 13: 33.
8    Bortolini GA, Vitolo MR, Gubert MB, Santos LMP: Early cow's milk consumption among Brazilian children: results of a national survey. J Pe- diatr (Rio J) 2013; 89: 608-613.
9    Maximino P, Machado RHV, Ricci R, et al: Children with feeding difficulties tend to high protein and milk-based supplements' intake - how to break this cycle? Demetra 2019; 14: 1-17.
10    Haines J, Haycraft E, Lytle L, et al: Nurturing children's healthy eating: position statement. Appetite 2019; 137: 124-133.