Artigos

INTRODUCTION
Exclusive breastfeeding is recommended for the first 6 months of life of infants, followed by a gradual introduction of appropriate and healthy complementary foods between the ages of 6 and 23 months1,2,3. Timely complementary feeding based on natural and minimally processed foods, along with breastfeeding until 2 years or older, are essential for the proper growth and development of children1,2.
However, ultra-processed foods (UPF) are also introduced during this period3, which contribute to a diet high in sugar, fat, additives, and artificial food dyes1,2,3,4. The Brazilian Dietary Guidelines for children under two years of age recommend that diets be predominantly composed of natural and minimally processed foods, such as rice, beans, fruits and vegetables, while the consumption of UPF should be avoided1. According to United Nations Children's Fund (UNICEF) data (2019), approximately 44% of children aged 6–23 months worldwide do not consume any fruits or vegetables, and only 29% have a minimum dietary diversity that includes at least five different food groups, such as fruits, vegetables, eggs, and dairy products3. These data are corroborated by the National Study of Child Nutrition (ENANI-2019), which found low minimum dietary diversity and high UPF consumption among children under 5 years of age in Brazil5. Another study conducted by UNICEF on Brazilian children who are beneficiaries of the national cash transfer program, Bolsa Família (BFP), found that among children under 2 years of age, 58% consumed iron-rich foods, 58% consumed sources of vitamin A, and 72% consumed UPF the day before consultation4.
The consumption of UPF is associated with adverse childhood and long-term health outcomes, including the development of chronic noncommunicable diseases (NCDs) and various forms of malnutrition, such as overweight and stunting1,4. Stunting and overweight can occur simultaneously in the same individual, which is classified as double burden of malnutrition (DBM)7,8. A recent study reported that the prevalence rates of DBM range from 56% in Indonesia6 to 4.3% in the Middle East and North Africa9. In 2021, the global prevalence of stunting and overweight in children under 5 years of age was 6.1% and 7.3%, respectively10. According to the national ENANI data in 2019, 10.1% of children under 5 years of age were overweight and 7.0% were stunted11. A national cross-sectional analysis conducted by Ribeiro Silva et al. (2021), using data from the Food and Nutritional Surveillance System (SISVAN), found that 3.1% of children aged under 5 years of age had DBM in 201712.
In Brazil, children receiving primary health care (PHC) have a higher level of social vulnerability due to social, political, and economic inequalities13. SISVAN is considered one of the tools of Food and Nutrition Surveillance (VAN) and integrates the third guideline of the Brazilian National Food and Nutrition Policy13,16. Therefore, the SISVAN facilitates the monitoring of nutritional status and enables the diagnosis of anthropometric profiles and dietary intake of the population through routine PHC14,15 and is considered a strategy to achieve one of the Sustainable Development Goals (SDGs), which is to eradicate forms of malnutrition and reduce overweight and obesity by 203017.
Thus, the high worldwide prevalence of forms of malnutrition, associated with low dietary diversity and early introduction of UPF during childhood, represent a form of food insecurity and significant public health burden. Therefore, this study aimed to evaluate the prevalence of double burden of malnutrition in children aged 6–23
months and its association with food consumption, using routine SISVAN records from 2019 of those followed in PHC.
METHODS
Study design and population
This cross-sectional study was performed using microdata from SISVAN (referring to the year 2019), and included anthropometric nutritional status and food consumption data of Brazilian children aged 6–23 months. The SISVAN data were obtained through assessments carried out as part of routine multi-professional care in PHC services throughout Brazil.
The data, from two separate databases, were provided by the Ministry of Health in two separate databases, and contained information on food consumption and anthropometric nutritional status. They were provided with a unique identifier and without nominal identification of the children. The original anthropometric nutritional status database contained information on 11,032,579 children and 43,888,869 observations from 2008 to 2019. We excluded 227,207 observations of infants aged ? 182 days and ?730 days, 6,006 of other nationalities, 11,714,364 duplicates, 10,708,343 same-day measurements, 957,688 children with different measurements on the same day, 27,576,633 measurements before 2019, 2,689,369 with repeated measurements in 2019 (the last visit of the year was taken as reference and the other visits were excluded), 102,105 with implausible Z-scores of weight-for-age (W/A), body mass index-for-age (BMI/A), height-for-age (H/A) (H/A Z-score < -6 or Z-score > 6; BMI/A Z-score < -6 or Z-score > 5; W/A Z-score < -6 or Z-score > 5), leaving a total of 1,591,795 children.
The original food consumption database included 1,173,756 observations from 490,260 children in the years 2018 and 2019. We excluded 385,542 children and observations from the year 2018, 378,314 children aged ?182 days and ?730 days, 3,533 repeated rows, 6,591 duplicates from the source system, 12,766 same-day follow-ups, and 2,529 observations without information on food consumption markers.
The pooled databases contained data from 163,740 children and 316,743 observations. In addition, 138,489 anthropometric measurements and data on food consumption collected more than 90 days apart were excluded, as were 48,406 repeated measurements from 2019. The final linked database included the data of 119,848 children.
Dependent and independent variables
The children's nutritional status was classified using the anthropometric indices BMI/A, which uses the child's weight, height, and age, and H/A using z-scores. The classifications of wasting (Z-score < -2), overweight risk (between Z-score > +1 and Z-score ? +2), overweight (between Z-score > +2 and Z-score ? +3), and obesity (Z-score > +3) were defined using the BMI/A index17,21. Stunting (Z-score< -2) was defined using the H/A index15,18. The excessive weight variable was classified using the BMI/A index (Z-score > +2), and the double burden of malnutrition was identified by combining excessive weight (overweight + obesity) with stunting in the same child.
Dietary intake was assessed using the SISVAN Food Consumption Markers form, with "yes" or "no" responses for the previous day’s dietary intake. Complementary feeding indicators were calculated using both the World Health Organization (WHO) indicators of infant feeding practices and SISVAN indicators for children aged under 2 years of age. The indicators evaluated by the WHO include iron-rich foods (meat or eggs, liver or beans), unhealthy foods (burgers and/or processed meats; or filled biscuits, sweets, and snacks; or instant noodles, packaged snacks, and savory biscuits), consumption of sweetened beverages, and no consumption of vegetables and fruits19,20. Meanwhile, the indicators assessed through SISVAN included continued breastfeeding, consumption of vitamin A-rich foods (orange-colored vegetables or fruits or dark green leafy vegetables), introduction of solid and semi-solid foods (whole fruits, chopped or mashed or salty foods) for the 6–8 months age group, and minimum dietary diversity through consumption of six food groups (breast milk or other milk, porridge or yogurt; fruits, vegetables; orange-colored vegetables or fruits or dark green leafy vegetables; meats and eggs; beans; cereals and tubers)21.
The following sociodemographic characteristics were assessed: geographic region (Northeast, North, Southeast, South, and Center-West), sex (female and male), participation in the national cash transfer program–Bolsa Família (BFP) (BFP = yes and NBFP = no), and age group (6–11 months and 12–23 months).
Statistical analysis
Descriptive analyses of sociodemographic, food consumption, and nutritional characteristics of the study population were performed according to H/A, BMI/A, and double burden of malnutrition. Data are presented as absolute frequencies (n) and relative frequencies (%) with estimates of 95% confidence intervals (95% CI).
Subsequently, logistic regression models were constructed to assess the association of dietary consumption indicators with stunted growth (no vs. yes) and double burden of malnutrition (no vs. yes), adjusted for age, sex, participation in the BFP, and geographic region. In addition, multinomial regression was performed between food consumption indicators and BMI/A classification, adjusted for age, sex, BFP, and geographic region, with normal weight as the reference.
Analyses were performed using the STATA statistical software (version 15.0; Stata Corp., College Station, Texas, USA).
Ethical aspects
The study was submitted to and approved by the Research Ethics Committee of the IPPMG, at the Federal University of Rio de Janeiro (CAAE:18447919.0000.5264, approval granted on August 23, 2019). The study complies the ethical principles of non-maleficence, beneficence, justice, and autonomy, as established by the Brazilian National Health Council Resolution No. 466/12 and its complementary regulations.
RESULTS
A total of 119,848 children were eligible, of whom 49.1% were female and 50.9% were male. The prevalence of children from the Southeast (50.2%) and Northeast (32.0%) regions was higher than that from the North (6.3%), South (9.1%) and Center-West (2.3%) regions. Children who were not beneficiaries of BFP (73.6%) were more prevalent than those who were beneficiaries (26.4%), and children aged 12–23 months (66.4%) were more prevalent than those aged 6–11 months (33.6%).
Regarding complementary feeding indicators, 54.7% of the children were continually breastfed, 90.9% consumed iron-rich foods, and 63.0% consumed vitamin A-rich foods. Unhealthy food consumption was observed in 40.5%, sweetened beverages in 32.1%, minimum dietary diversity in 44.4%, no fruits or vegetables in 7.4%, while solid and semi-solid foods were introduced at 6–8 months of age in 88.2% (Table 1).
Among the main regional differences, the North region had a higher frequency of continued breastfeeding (69.0%), lower prevalence of consumption of iron-rich foods (81.7%), and minimum dietary diversity (25.0%) than the other regions of the country. The Southeast (4.8%) and South (5.2%) regions had the lowest prevalence of no fruit and vegetable consumption compared to the other regions. The frequency of consuming unhealthy foods on the previous day of assessment was higher among BFP children (48.0%) than among non-BFP children (37.8%), and among children aged 12–23 months (48.8%) than among children aged 6–11 months (24.0%); sweetened beverages were consumed more frequently (38.2% vs. 29.9%) by BFP beneficiaries and children aged 12–23 months (38.5% vs. 19.4%). The frequency of the minimum dietary diversity indicator was higher among non-BFP children (43.6% vs. 40.1%) and children aged 12–23 months (46.4% vs. 35.5%) than among BFP children and children aged 6–11 months (Table 1).
Among the children, 23.4% were classified as being at risk of overweight (95% CI 23.1; 23.6), 10.6% as overweight (95% CI 10.4; 10.8), 4.4% as obese (95% CI 4.3; 4.5), and 3.4% as wasting (95% CI 3.3; 3.5) (Table 2). Children at risk of overweight were most prevalent in the 12–23 months age group (24.4%) and among those who were not continually breastfeed (24.8%). The prevalence of overweight and obesity was higher among children participating in the BFP (12.4% vs. 5.8% among those not participating) and among those aged 12–23 months (11.5% vs. 8.9% among those aged 6–11 months) (Table 2).
Of the children surveyed, 13.3% were stunted (95% CI 13.1; 13.5). The prevalence of stunting was higher in BFP children (16.8%), males (15.1%), and in the North region (20.1%) than in non-BFP children, females, and other regions of the country. In addition, a lower prevalence of consumption of iron-rich foods (16.4%), vitamin A-rich foods (14.8%), minimum dietary diversity (14.4%), and no fruits or vegetables (17.2%) was observed in stunted children (Table 3). The prevalence of double burden of malnutrition was 3.9%, and was higher among children from the North region (6.3%) than in those from other regions of the country, and among BFP beneficiaries (5.5%) than among non-BFP beneficiaries (3.4%) (Table 3).
The consumption of iron-rich foods (odds ratio (OR) = 0.77; 95% CI = 0.72; 0.81), vitamin A-rich foods (OR = 0.85; 95% CI = 0.82; 0.88), minimum dietary diversity (OR = 0.83; 95% CI = 0.80; 0.86), and introduction of solid and semi-solid foods (OR = 0.71; 95% CI = 0.62; 0.81) were protective against stunting. Meanwhile, zero intake of vegetables and fruits (OR = 1.32; 95% CI = 1.24; 1.41) increased the odds of stunting (Table 4).
Consumption of iron-rich foods (OR = 0.79; 95% CI = 0.71; 0.87) and vitamin A-rich foods (OR = 0.83; 95% CI = 0.78; 0.89), and minimum dietary diversity (OR = 0.82; 95% CI = 0.76; 0.87), were protective against the double burden of malnutrition. Contrarily, the consumption of unhealthy foods (OR = 1.12; 95% CI = 1.05; 1.20), sweetened beverages (OR = 1.13; 95% CI = 1.06; 1.21), and no vegetables and fruits (OR = 1.13; 95% CI = 1.01; 1.26) increased the odds of having double burden of malnutrition (Table 4).
Consumption of iron-rich foods (OR = 0.80; 95% CI = 0.72; 0.89), minimal dietary diversity (OR = 0.92; 95% CI = 0.86; 0.99), and introduction of solid and semi-solid foods (OR = 0.78; 95% CI = 0.62; 0.97) protected against wasting. Consumption of unhealthy foods increased the odds of being at risk of overweight (OR = 1.04; 95% CI = 1.01; 1.08), overweight (OR = 1.09; 95% CI = 1.05; 1.14), and obesity (OR = 1.11; 95% CI = 1.05; 1.19). Meanwhile, the consumption of sweetened beverages increased the odds of being at risk of overweight (OR = 1.04; 95% CI = 1.01; 1.08) and overweight (OR = 1.08; 95% CI = 1.03; 1.12). Continued breastfeeding protected against the risk of overweight (OR = 0.86; 95% CI = 0.83; 0.89), overweight (OR = 0.89; 95% CI = 0.85; 0.93), and obesity (OR = 0.92; 95% CI = 0.86; 0.98). Consumption of minimal dietary diversity decreased the odds of being at risk of overweight (OR = 0.92; 95% CI = 0.88; 0.96) and obesity (OR = 0.90; 95% CI = 0.84; 0.95), whereas consumption of vitamin A-rich foods protected against overweight (OR = 0.92; 95% CI = 0.88; 0.96) and obesity (OR = 0.90; 95% CI = 0.84; 0.95). Consumption of iron-rich foods protected against obesity (OR = 0.89; 95% CI = 0.80; 0.99) (Table 5).

DISCUSSION
The present study found that among complementary feeding indicators, the consumption of iron- and vitamin A-rich foods and minimum dietary diversity were protective against the double burden of malnutrition and stunting. Conversely, an indirect association was observed between the double burden of malnutrition and the consumption of unhealthy foods, sugary beverages, and no fruit and vegetables. The introduction of solid and semi-solid foods was considered to be protective against stunting.
Double burden of malnutrition refers to the coexistence of two forms of malnutrition7,22, that is undernutrition and overweight, assessed in the same individual, and is determined by social, economic, and political conditions, and access to food3,23,24,25. The indicators of adequate complementary feeding provide protection against the double burden of malnutrition. The results of this study strengthen the relationship between inadequate complementary feeding and the risk of double burden of malnutrition and support previous studies that indicate an association between excessive consumption of UPF rich in sodium, sugar, and fat and an increased prevalence of double burden of malnutrition3,7,26.
In the present study, the prevalence of double burden of malnutrition was 3.9%, with higher rates in the North region among participants in the BFP and in the 12–23 months age group. These findings are consistent with those presented by Ribeiro Silva et al. (2021) in a study of Brazilian children aged 0–59 months enrolled in the SISVAN system. The authors reported a prevalence of 3.1% in 2017 and observed a higher prevalence among children from the North region and among beneficiaries of the BFP12. At the time of review, no studies were found on population aged 6–23 months.
There are no national baseline data on the prevalence of double burden of malnutrition in children. However, the slight difference in prevalence found between the studies may represent a deterioration in the nutritional status of children at more critical political, social, and economic conditions27. The prevalence of double burden of malnutrition may have increased in subsequent years, reflecting the health, political, economic, and food and nutrition crises that occurred during the COVID-19 pandemic27. According to a UN report, there has been an increase in the number of people experiencing food insecurity worldwide, with 811 million people suffering from hunger in 202128. This increase was also observed in Brazil by the Brazilian Network for Research in Food Sovereignty and Security, which found an increase in food insecurity in households with children under 10 years old, from 9.4% in 2020 to 18.1% in 202229.
In this study, the prevalence of stunting was 13.3%, which was higher than that found in Brazilian children under 5 years of age, according to ENANI data (7.0%)11. Among the Brazilian regions, the prevalence of stunting was significantly higher in the North region (20.1%) than in the other regions. This finding is similar to that observed by Ribeiro-Silva et al. (2021)12 and the National Survey of Child and Maternal Health (PNDS, 2006)30. As expected, this difference was not corroborated by ENANI data11, which may be partly explained by the profile of children under nutritional surveillance in the PHC units that make up the SISVAN database. The higher prevalence of stunting among child beneficiaries of the BFP, observed in this cross-sectional study, is supported by other Brazilian and international studies that have observed a higher prevalence of stunting among child beneficiaries of income transfer programs31,32. Similarly, the prevalence of stunting observed among male children was similar to that found in other national33,34 and international studies conducted in Ethiopia31 and Thailand35 among children under 5 years of age.
Indicators of zero fruit and vegetable consumption and inadequate dietary diversity, along with their association with the risk of stunting, reflect the vulnerability faced by children in PHC in Brazil. Social, demographic, and economic factors combined with difficulties in accessing good quality and sufficient food are directly related to stunting3,36,37,38. This finding is supported by several international studies showing a link between inadequate dietary diversity and stunting31,39,40. Additionally, prolonged breastfeeding has been identified as a risk factor for stunting. This finding underscores the fact that at this age, breastfeeding alone cannot meet all the energy needs of a child, although it is an important source of vitamins and minerals1. Stunting is associated with chronic or acute food and nutrient deprivation throughout life, reduced access to healthcare services, and an increased odds of infectious and parasitic diseases due to lack of basic sanitation32,36,41,42,43.
In terms of nutritional status, the consumption of iron-and vitamin A-rich foods and minimum dietary diversity were found to be protective against wasting, overweight, and obesity. The introduction of solid and semisolid foods reduced the likelihood of wasting among the children studied. These indicators highlight the importance of a more diverse, nutrient-rich, and complementary diet in promoting adequate nutritional status1. Consumption of different food groups that are considered healthy, can help prevent forms of malnutrition1 and vitamin and mineral deficiencies, especially iron and vitamin A, which affect the development and growth of children3,4,44. The introduction of solid and semi-solid foods in the 6–8 months age group has shown that appropriate and timely complementary feeding can prevent the development of forms of malnutrition3. During this period, continued breastfeeding should be encouraged, as it can still provide nutrition and prevent dehydration in special circumstances, such as infections and recurrent childhood gastroenteritis1,45. Our findings also demonstrate its potential to protect against overweight and obesity. According to the meta-analysis by Victora et al. (2016), prolonged breastfeeding reduced the risk of overweight and obesity throughout life46.
In terms of nutritional status, the consumption of unhealthy foods was found to increase the odds of being at risk of overweight, obese, or overweight. Similarly, the consumption of sugar-sweetened beverages increased the odds of being overweight or obese. Unhealthy food indicators consist primarily of UPFs that are high in sugar, sodium, and fat, along with additives and artificial food dyes1,45. Consumption of these foods contributes to a diet high in energy density and low in nutrients and fiber, which is detrimental to children's health and contributes to the development of forms of malnutrition8. Sugary beverages contain sugar and many also contain caffeine, which competes with essential nutrients for growth, such as iron. Therefore, the quality of the dietary intake of children, and the lack of necessary intake are directly related to forms of malnutrition7,14,22.
The overall prevalence of wasting was 3.4%, while in ENANI, it was 3.0% in children under 5 years of age, with no significant difference between the different age groups11. Excessive weight was prevalent in 15.0%, which was higher than that reported by ENANI (10.1%) in children under 5 years of age, although they observed a higher prevalence of excessive weight (13.7%) in children aged 12–23 months11. As mentioned above, this percentage difference was expected in the present study, since it involved a population monitored in PHC and a younger age group, thereby confirming the importance of nutritional surveillance in preventing the development of nutritional deficiencies and disorders in children under 24 months of age.
In addition, the prevalence of wasting and excessive weight was higher among children who participated in the BFP. Studies have suggested that children followed up in PHC have a high prevalence of wasting and excessive weight42,12. According to Ribeiro-Silva et al. (2021), the prevalence of overweight among children aged 0–5 years was higher in BFP beneficiaries12, but another study found that the prevalence of overweight was higher in NBFP participants42, which is not consistent with the findings of the present study. This highlights the fact that excessive weight is currently associated with children in situations of social vulnerability3, and that children and their families who are not enrolled in the BFP may be eligible to receive it but have not yet received it47. The prevalence of wasting and excessive weight was also higher in male children and in children aged 12–23 months.
The complementary feeding indicators were not only related to the forms of malnutrition discussed above, but also to the social and demographic determinants of the population served by PHC. The lowest frequency of consumption of foods rich in iron and vitamin A and minimum dietary diversity were found in the North region. The highest frequency of zero consumption of fruits and vegetables and continued breastfeeding were also observed in this region. Except for continued breastfeeding, which is a strategy for food and nutrition security in the face of poverty and forms of malnutrition, these findings clearly demonstrate the vulnerability of introducing complementary feeding in the North region. Breastfeeding promotes food consumption in the early years of life in the face of food scarcity and monotony1,4, a finding similar to that observed by ENANI, with a higher prevalence of breastfeeding among children under 2 years of age in the North Region (66.3%)48. According to the PENSSAN network (2022), the North region has the most social inequalities, and consequently, the most difficulties in accessing food29.
Regarding the child population using PHC services, the majority of children aged 6–23 months were from the Southeast (50.2%) and Northeast (32.0%) regions. This high prevalence in the Northeast region is due to the priority given to nutrition and feeding interventions in this region4,14. The NBFP population was larger than the BFP population, which differs from the findings of a previous study on the general population, where an increase in coverage of the BFP beneficiary population from 57.1% to 85.7% was observed4.
Another noteworthy aspect of the results is the higher prevalence of indicators of unhealthy food and sugar-sweetened beverage consumption, as well as the lower frequency of introduction of solid and semi-solid foods among the BFP compared to the NBFP population. One hypothesis is that the consumption of more UPFs and sugary beverages is directly related to family income49. Recent UNICEF data on children benefiting from BFP show that the most consumed UPFs are sugary beverages (41.0%) and savory or filled biscuits (59.0%), which are unhealthy foods4. In this context, the second most cited reason for consuming UPFs was their affordability4. However, in this sample, beneficiary children were more likely to report consuming unhealthy foods the day before their PHC visit. The quantity consumed is unknown, which could have been low or excessive, resulting in underconsumption with low nutritional value or overconsumption with high energy density, both of which have implications for nutritional status. In addition to the association with these complementary feeding indicators, BFP population showed a higher prevalence of stunting, double burden of malnutrition, wasting, and risk of overweight, overweight and obesity.
In terms of age group, children aged 12–23 months consumed more unhealthy foods and sugary beverages and had a higher minimum dietary diversity than children aged 6–11 months. This is likely because children in this age group are more integrated into the family dietary context1 and consequently have a higher consumption of UPFs and greater diversity, as they already consume all food groups. According to Flores et al. (2021), in a study using data from the National Health Survey, children aged 12–23 months had a higher prevalence of soda and artificial juice consumption49.
The present study has limitations that need to be addressed. The first concerns the use of secondary data collected in routine health services, which may be of limited quality. The Ministry of Health has a protocol for taking measurements, but the equipment and techniques may not always be standardized. To mitigate potential problems in data collection, different stages of data verification were applied, and inconsistent and implausible values were excluded. The system has non-mandatory fields, resulting in a high percentage of missing data for variables, such as birth weight, education level, and skin color, which could not be used in this study. In addition, inconsistencies were observed in the proportions of the race/skin color variable (16.4% Asian and 2.6% Black) compared to the distribution of the Brazilian population, which could lead to misinterpretation of the results. Regarding the assessment of dietary intake, a food consumption marker form was used, which only referred to the day before the consultation and is a qualitative form, which does not report on the usual intake. Finally, it is important to emphasize that although the coverage of the system has increased in recent years, it is still low, especially for food consumption data, which limits the generalizability of the results to the population.
The strengths of this study include the large sample size and the assessment of children from different regions of the country. The results of this study represent an important source of information for Brazil and other low- and middle-income countries with similar characteristics of the population included in SISVAN, as studies on markers of dietary intake and growth in children under 2 years of age are limited in these countries.
In conclusion, this study demonstrated a direct relationship between complementary feeding indicators and BMI/A, stunting, and double burden of malnutrition. In addition, a social determination of poverty was observed in food consumption and different forms of malnutrition. This reinforces the need to monitor nutritional status through the SISVAN and emphasizes the need for an appropriate and healthy introduction of food for children under 2 years of age under PHC. It further highlights that the period from 6 to 23 months represents an important window of opportunity for proper development, growth, and formation of eating habits.

Declaração de Disponibilidade de Dados

As fontes dos dados utilizados na pesquisa estão indicadas no corpo do artigo.



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