0247/2025 - IMPACT OF A NUTRITION EDUCATION PROGRAM ON FOOD CONSUMPTION AND NUTRITIONAL STATUS OF FAMILY FARMERS
Impacto de um programa de educação nutricional no consumo alimentar e status nutricional de famílias rurais
Autor:
• Marianna Junger de Oliveira Garozi - Garozi, MJO - <nutricionista.marianna.junger@gmail.com>ORCID: https://orcid.org/0000-0002-9246-6486
Coautor(es):
• Alexandre Vinco Pimenta - Pimenta, AV - <alexandre.vinco@gmail.com>ORCID: https://orcid.org/0000-0001-6625-9486
• Cíntia Tomaz Sant` Ana - Sant` Ana, CT - <cintia_santana28@hotmail.com>
ORCID: https://orcid.org/0000-0002-1385-9274
• Mariana Grancieri - Grancieri, M - <marianagrancieri@gmail.com>
ORCID: https://orcid.org/0000-0001-8888-5496
• Luciane Daniele Cardoso - Cardoso, LD - <luciane.cardoso@ufes.br>
ORCID: https://orcid.org/0000-0002-7527-946X
• Maria das Graças Vaz Tostes - Tostes, MGV - <mgvaztostes@gmail.com>
ORCID: https://orcid.org/0000-0003-3309-7526
• Neuza Maria Brunoro Costa - COSTA, NMB - <neuzambc@gmail.com>
ORCID: https://orcid.org/0000-0002-4967-9937
Resumo:
This study analyzed the impact of a nutrition education program on the food consumption and nutritional status of family farmers in Alegre, Espírito Santo, Brazil. A longitudinal and interventional study, with 81 individuals of both sexes (3 to 74 years old) was carried out. Nutrition education program with 7 activities throughout 8 months period was applied. Food consumption, anthropometric measurements, blood pressure, complete blood count, fasting glucose, total proteins, serum iron, ferritin, C-reactive protein, and lipid profile were evaluated, before and after the intervention. Data was analyzed using the t-test and Wilcoxon test (p<0.05). The Revised Diet Quality Index increased from 49.44 to 58.72 (p = 0.001), indicating a significant improvement. There was a significant reduction in energetic and lipid intake, free sugar, sodium, saturated, and trans fatty acids. These changes were associated with decreases in BMI, body fat percentage, waist circumference, plasma cholesterol, and triacylglycerol levels. The nutrition education program had a positive impact on the participants' eating habits and health, contributing to the improvement of public and other intervention health programs.Palavras-chave:
family farmers, eating habits, food security, diet quality, nutrition education.Abstract:
Este estudo analisou o impacto de um programa de educação nutricional no consumo alimentar e status nutricional de famílias rurais em Alegre, Espírito Santo, Brasil. Foi um estudo longitudinal e intervencional, com 81 individuos (3 a 74 anos) de ambos os sexos. O programa incluiu 7 atividades ao longo de 8 meses. Avaliou-se o consumo alimentar, medidas antropométricas, pressão sanguínea, hemograma completo, glicose, proteínas totais, ferro sérico, ferritina, proteína C reativa e perfil lipídico, antes e após a intervenção. Dados foram analisados utilizando teste t pareado e teste Wilcoxon (p<0,05). O Índice Revisado de Qualidade da Dieta aumentou de 49,44 para 58,72 (p = 0,001), indicando melhora significativa. Houve redução significativa no consumo energético, lipídico, açúcar livre, sódio, ácidos graxos saturados e trans. Essas mudanças foram associadas a redução no IMC, percential de gordura corporal, circunferência da cintura, colesterol total e triglicerídeos. O programa de educação nutricional teve um impacto positivo nos hábitos alimentares e na saúde dos participantes, contribuindo para o aprimoramento dos programas de saúde publica e outros programas de intervenção.Keywords:
famílias rurais, hábitos alimentares, segurança alimentar, qualidade da dieta, educação nutricional.Conteúdo:
Food insecurity is defined as the uncertain or limited availability of nutritionally adequate and safe foods required for normal human growth and a healthy life. This condition negatively affects the mental, physical, and social aspects of the health and well-being of those experiencing it.1 The latest demographic data demonstrate that 46.6% of families living in the rural region of Brazil are in a situation of food insecurity.2 Rural areas are where most food is produced to supply both rural and urban populations, yet they still experience high levels of food insecurity.2,3
This situation is mainly influenced by the food monotomy, characteristic of regional producers.3 However, the globalization and easy access to foods high in simple carbohydrates and lipids but low in dietary fiber and essential vitamins and minerals has been worsening the food insecurity in this population.4 This condition has contributed to a high prevalence of nutritional deficiencies, which coexists with the increased risk of chronic non-communicable diseases such as obesity, diabetes mellitus, and dyslipidemia.5
In this way, nutritional interventions carried out in rural communities offer preventive resources capable of improving the life quality of the local population.6 In addition, food education strategies in rural areas can stimulate interest in learning the appropriate cooking techniques and in consuming healthy foods.7 It is also noteworthy that the lack of knowledge about the nutritional value of food influences the dietary profile of individuals living in rural areas, and the more intense the approach to healthy food, hygiene, and food preparation, the greater the exchange of experiences and interest in improving the eating pattern.8
Therefore, food and nutrition education programs provide information and assist in making decisions, encouraging the development of healthier eating habits, and favoring food security of the rural population.9,10 Then, nutritional interventions carried out with family farmers are effective strategies to diversify productivity and enhance local commercialization.11
Given the aspects above, this work aimed to characterize the food consumption and nutritional status of family farmers in Alegre (Espirito Santo, Brazil) and develop, apply, and analyze the impact of a food and nutrition education program on their food consumption and nutritional status.
MATERIAL AND METHODS
Study design
This was a longitudinal and interventional study. It took place between March 2015 and April 2016 and was divided into three stages (T1: blood collection, anthropometric measurements, and food consumption; T2: intervention period with the nutritional education program; T3: blood collection, anthropometric measurements, and food consumption) (Figure 1).
The study focused on all rural households, therefore the inclusion criterion consisted of all family members living in the farmhouse. The exclusion criterion was family members who did not live in the house during working days or did not have their meals at home.
Participants and Recruitment
81 volunteers of both sexes, aged between 3 and 74, participated in the study. The communities of Bom Sucesso do Coqueiro (BSC, n=20), Gabriel Vargas (GV, n=14), Lagoa Seca (LS, n=22) and São Esperidião (SE, n=25), all of these located in Alegre (Brazil), were selected to participate in the study.
This study was conducted according to the guidelines laid down in the Declaration of Helsinki. All procedures involving research study participants were approved by the Institutional Review Board at Federal University of Espírito Santo (approval number 997.573) under Full Board Review. All participants or their parents/legal guardians for children under the age of 18 received the written Informed Consent Form (ICF) to authorize the collection of food consumption, anthropometric, blood pressure, and biochemical data.
Assessment of food consumption
We applied an identification form associated with a questionnaire to the head of each family to assess the monthly family consumption of olive oil, soybean oil, and animal fat. Individual food consumption data was obtained by averaging three food records applied on one weekend day and two weekdays interspersed. The adults were responsible for helping to inform the consumption data of children under the age of 10 and those over 70 to obtain data on eating habits with greater precision. Added sugar was calculated using coffee and juice recipes described individually in the food records.
All data were collected using household measures and converted into units of measure using the Food Survey Critics Manual and the Food Table Composition.12,13 Data were inserted in the REC24h-ERICA® program to obtain codes for food, preparations, and homemade measures based on the Table of Reference for Foods Consumed in Brazil. We added food with the preparation reported in each food record during this process. The salt of the preparations was considered since there was no report of additional salt. Then, we used the Stata® program version 14, which compiles the data obtained in REC24h-ERICA® with the information from the Table of Reference Foods Consumed in Brazil, generating nutritional macro and micronutrient information.
Qualitative analysis
The Revised Diet Quality Index (DQI-R) was used to assess the diet quality of families of rural producers. This index is based on the Healthy Eating Index (HEI) adapted for the Brazilian population.14,15 This index consists of 12 components, each of which has portions determined according to the Food Guide for the Brazilian Population, based on the energy density (portion/1,000 kcal) that reflects different aspects of the diet quality.16 Each component has a score ranging from zero (no consumption) to 5, 10, or 20. The intermediate score of each component was obtained through proportionality of what was consumed over the recommended maximum and minimum scores. The intake of “sodium”, “saturated fat” and “solid, saturated and trans fat, alcohol, and added sugar” is a proportionally inverse score, while the other components have scores directly proportional to their consumption.
The maximum score of the DQI-R is 100, and the higher the value obtained, the better the diet quality evaluated. However, the diet quality is not categorized based on the total score. Thus, the final DQI-R score was classified according to Bowman et al. (1998), who consider values <51 points = inadequate diet, 51 to 80 points = diet that needs modification, and >80 points = healthy diet.17
Quantitative analysis
Caloric consumption was analyzed based on the Estimated Energy Requirement (EER) calculation.18 The intake of protein, carbohydrate, lipid, polyunsaturated fatty acids (PUFA), omega-6, omega-3, fibers, sodium, iron, zinc, vitamin C, retinol, and calcium was compared with that recommended by Institute of Medicine.19,20 The intake of monosaturated fatty acids (MUFAs), saturated fatty acids (SFAs), trans fatty acids (TFAs), and cholesterol was standardized according to the recommendation of the Brazilian Society of Cardiology.21 The consumption of free sugar was compared to that suggested by the World Health Organization (WHO).22
Values of macronutrient intake were determined as insufficient (below the recommendation), within recommended (according to the recommendation), and excessive (above the recommendation). The values of fibers and micronutrients were classified as below the recommendations, within recommended, and above the recommendations, according to their respective reference values, with fibers and sodium based on estimates of Adequate Intake (AI), while calcium, iron, zinc, vitamin C and retinol were evaluated according to the Estimated Average Requirement (EAR).18
Anthropometric and body composition assessment
The participants were weighed using a tetrapolar bioimpedance scale (Tanite® BC553, Arlington Heights, IL, USA), and their height was determined using a stadiometer (Alturexata®, Belo Horizonte, Brazil).23 Participants' body fat percentage was classified according to age and gender.24,25
Children and adolescents (up to 19 years old) were analyzed using the anthropometric index: body mass index for age (BMI/Age), expressed in Z-score, analyzed according to the growth curves.26 Thinness was defined for a Z score < -2; eutrophy for a Z score ? -2 and < +1; overweight for a Z score ? + 1 and < +2, and obesity for a Z score ? + 2. BMI was determined following the WHO reference for adults (20-59 years), while for the elderly (? 60 years), the one proposed by OPAS (2001) was used.27,28
Waist circumference (WC) was measured at the midpoint between the lower rib and the iliac crest by using an inextensible and inelastic measuring tape (Cescorf®, Porto Alegre, Brazil).29 Values ? 90th percentile were determined as indicative of cardiovascular risk factors.30 Waist circumference values ?94 cm for men ?19 years old, adults, and elderly, and ?80 cm for women ?19 years old, adults, and elderly were considered an increased risk of metabolic complications associated with abdominal obesity.26
Clinical and biochemical evaluation
Blood pressure was measured with a digital device, using the right arm, in triplicates, with an average interval of 1 minute between each measurement. Blood pressure was classified according to the Brazilian Society of Cardiology.21
Blood was collected from participants after 12 hours of fasting. Platelets, white blood cells, red blood cells, hematocrit, and hemoglobin were determined using the Hematoclin 5.4 device (Bioclin®, Belo Horizonte, Brazil). Reference values were stipulated according to Burtis, Ashwood and Bruns (2012).31 For hemoglobin, the one proposed by WHO (2020) was used, which determines the cutoff points for the diagnosis of iron deficiency anemia.32 Plasma cholesterol, triacylglycerol, LDL-c, and HDL-c were dosed with the enzymatic colorimetric method, using commercial kits (Bioclin®, Belo Horizonte, Brazil). C-reactive protein (CRP) was analyzed using the immunoturbidimetric method according to the manufacturer's information.
Fasting glucose was analyzed using the colorimetric method with the Monoreagent Glucose kit (Bioclin®, Belo Horizonte, Brazil), according to the manufacturer's information. The reference values for fasting glucose were determined based on the Brazilian Diabetes Society Guidelines.33 Total proteins were quantified using the colorimetric method, with the aid of the Monoreagent Total Proteins kit (Bioclin®, Belo Horizonte, Brazil), according to the manufacturer's information.
Serum iron was dosed using the colorimetric method, and the ferritin concentration was obtained by an immunoturbidimetric method using the ferritin kit, both according to the manufacturer's information (Bioclin®, Belo Horizonte, Brazil). Ferritin was classified according to WHO (2020)34, and serum iron according to Dale et al. (2002).35
Nutrition Education Program
The nutrition education program was designed and applied for eight months, totaling seven interventions in each community with a one-month interval between each. Audiovisual resources were used through interactive lectures with the presentation of informative slides, written materials were prepared in the format of a folder and a cookbook, play activities, a cooking workshop, and tasting sessions were applied considering the age group, socioeconomic and cultural level of the families, as follows:
• Intervention 1: presentation of the results of biochemical tests and nutritional diagnosis, associated with an interactive lecture through a slide show with the theme “Chronic non-communicable diseases and nutritional deficiencies”, addressing obesity, dyslipidemias, type 2 diabetes mellitus, arterial hypertension, iron deficiency anemia, zinc deficiency, and hypovitaminosis A, explaining what they are and how each of these changes in the body is developed.
• Intervention 2: presentation of the results of the evaluation of food consumption, with an interactive lecture through a slide presentation, on “Healthy eating and the implications of poor and excessive food consumption”.
• Intervention 3: interactive lecture through a slide presentation, on “nutritional composition of foods”, showing the amount of salt, sugar, and fat present in various commonly consumed foods.
• Intervention 4: interactive fixation activity with the aid of material written in the form of a folder, covering the importance of diversifying agricultural production for consumption and marketing, with a focus on healthy eating, aiming to reduce salt intake, sugar-free, saturated, and trans fat, as well as stimulating an increase in the consumption of fruits, vegetables and natural homemade spices.
• Intervention 5: playful fixation activity through contests on the themes addressed in interventions 1, 2, 3, and 4.
• Intervention 6: interactive cooking workshop through experimental cuisine, stimulating the preparation and tasting of habitual recipes in a more nutritious way, using the knowledge acquired in interventions 1, 2, 3, 4, and 5.
• Intervention 7: elaboration and availability of a recipe book for all rural producer families, adding the nutritional preparations adapted in intervention 6.
Statistical analyses
The Kolmogorov-Smirnov test was applied to observe the normality of the variables. Data were presented for both central tendency and dispersion measures: mean ± standard deviation and median (minimum; maximum), as some parameters followed a normal distribution and others did not. We compared parametric data before and after the intervention using the paired t-test, while the Wilcoxon test was applied to non-parametric data. All analyses were performed using significance level (p < 0.05). Statistical Package for the Social Sciences (SPSS®), version 19.0. was used to analyze the data.
RESULTS
Food consumption
The DQI-R score before the intervention was 49.44, indicating an inadequate diet, evidenced by the low score obtained in some groups, such as “total fruits”, “whole fruits”, and “total vegetables” in addition to the high intake of solids fats, and added sugar. After the intervention, we observed a total score of 58.72 (p < 0.001), classified as a diet that needs modification; it shows progress in the quality of the participant's diet, with improvement in the scores of “oils” (p < 0.001), “sodium” (p = 0.046), and “solid, saturated and trans fat, alcohol and added sugar” (p < 0.001) (Table 1).
After the intervention, there was an improvement in the score of the “sodium” group (p < 0.05) was detected, indicating a decrease in the use of this ingredient in the usual preparations. The same was true for the “oils” group (p < 0.001) and the “solid, saturated and trans fat, alcohol and added sugar” group (p < 0.001), represented by the decrease in the intake of soy oil, animal fat, and added sugar, respectively (Table 1).
After the intervention, there was a reduction in the ingested VET (p < 0.001) simultaneously with the decrease of lipid (p < 0.001), free sugar (p < 0.001), sodium (p = 0.043), zinc (p = 0.027), and iron (p = 0.003). The protein (p < 0.001), carbohydrate (p < 0.001), and dietary fiber (p < 0.002) consumption also reduced after intervention period. Concomitant to the decrease in lipid intake, there was also a reduction in the consumption of all fatty acids, including PUFA, omega-3 and 6, MUFA, and also SFAs (p < 0.001) and TFAs (p = 0.008). On the other hand, cholesterol, calcium, vitamin C, and retinol were similar between before and after intervention (p > 0.05) (Table 2).
Anthropometry, body composition, and blood pressure
There was a decrease in the values of BMI (p < 0.001), body fat (p < 0.001), and waist circumference (p < 0.001) after the intervention period. However, the systolic and diastolic blood pressure did not change their values after the intervention period (p > 0.05) (Table 3).
Biochemical data
A reduction in fasting glycemia was observed (p = 0.001). There was an increase in ferritin rates (p < 0.001), although the changes in C-reactive protein are not significant (p > 0.05). A reduction in the rates of plasma cholesterol (p = 0.009), HDL-c (p < 0.001), and triacylglycerol (p < 0.001) was detected, while LDL-c concentrations did not show a significant difference (p = 0.118). The values of platelets, white blood cells, red blood cells, hemoglobin, serum iron, and total proteins showed no alterations after the intervention period (p > 0.05) (Table 3).
DISCUSSION
The nutritional intervention program in this study resulted in qualitative and quantitative changes in dietary parameters and improvements in clinical and anthropometric data, indicating health benefits and its contribution against food insecurity in people from rural communities, modifying the eating habits of the rural population and enabling adequate consumption of nutrients, favoring the reduction of food insecurity.
This nutritional education program impacted on food consumption, demonstrated by the reduced caloric value associated with decreased consumption of carbohydrates, lipids, and added sugars. These changes could reduce the prevalence of chronic non-communicable diseases, such as diabetes, obesity, and dyslipidemia, demonstrating the benefits of implementing the current program in public health. Furthermore, there was a significant reduction in sodium consumption after the intervention period. This is an important point, given that the population consumes sodium at values higher than recommended, which is currently the cause of the prevalence of high blood pressure and cardiovascular diseases.36 According to recent data, in recent years, sodium consumption in Brazilian rural populations has been rising, with this trend being closely related to the increase in consumption of processed and ultra-processed foods.37
Another relevant parameter focuses on changes to the types of fatty acids, with a significant reduction in the consumption of saturated and trans fatty acids after the nutritional education program intervention, which may reduce the risk of cardiovascular diseases.38,39 This reduction may be related to lower food consumption, demonstrated by lower energetic density, resulting from the nutritional intervention practices applied, generating dietary changes.
The reduction in protein consumption may be related to the dietary changes observed after the nutritional education program, with an increase in the consumption of vegetables and legumes to the detriment of meat. Other factors may be related to reduced protein consumption, such as economic factors, since high biological value protein consumption is related to the population's socioeconomic level; the lower the income, the lower the meat intake.40,41 However, this was not verified in the present study.
It is worth highlighting that the population consisted of family farmers who live in rural areas and are currently strongly influenced by the presence of foods from different categories, including processed foods. Furthermore, this is a low-income population, and most have a low diversity of foods in their usual diet. This evidence demonstrates that financial need influences food preferences and knowledge about the nutritional value of food, contributing to food monotony; this makes it difficult to improve the nutrition of the evaluated population, even if strategies for food and nutrition education are developed and applied effectively, as carried out in this research.
The changes described above in food components after implementing the nutritional education program were reflected in the results of clinical examinations, with a reduction in glucose, total cholesterol and triglyceride levels. It is known that the consumption of simple carbohydrates and saturated fats is the leading dietary cause related to changes in glucose metabolism and dyslipidemia.42,43 There were also reductions in HDL-c levels, the lipoprotein responsible for the reverse transport of cholesterol and protection of blood vessels against atherogenesis by removing oxidized lipids from LDL-c. However, despite the observed decrease, these values remain higher than recommended by the Brazilian Cardiology Society, which recommends rates >40 mg/dL.44 The reduction in blood glucose levels after the nutritional education program intervention may be related to the reduction in the consumption of added sugar. Changes in glucose metabolism are strongly associated with eating habits characterized by high simple sugar intake, resulting in a high prevalence of diabetes mellitus, which is currently a significant public health problem.42
The positive impact of nutritional intervention on food consumption contributed to improvements in BMI and body composition, characterized by a reduction in the percentage of body fat and waist circumference. Among the strategies for weight reduction and associated measures, there is a reduction in total caloric value, as well as excess fat and simple carbohydrates, as observed in the present study. It is known that a higher percentage of body fat is strictly associated with the prevalence of diseases such as cardiovascular, inflammatory, dyslipidemia, and diabetes.45 Although the participants in the present study are classified as eutrophic, according to BMI, this reduction continues to be important to keep this parameter further away from the obesity thresholds. Even more important than BMI is the percentage of body fat and waist circumference, where high values are associated with a greater chance of developing cardiovascular diseases. This condition is a major public health problem, closely related to current eating patterns high in fats and simple carbohydrates.46,47
It is noted that different studies report the benefits of interventions with food and nutrition education programs in rural areas but have difficulty in determining their effectiveness due to the need to add prior knowledge of the sample with periodic and contextualized interventions, which consider economic, cultural, social and psychological aspects of the individuals in question.9,48
During nutritional interventions, it is necessary to focus on local problematization and to address strategies that favor healthy eating using resources that facilitate learning instead of being limited to expository techniques.49 The use of audiovisual resources favors content retention, showing that it is more favorable to use auditory and visual resources simultaneously for learning.50 In addition, recreational activities such as educational games, represent communication tools that stimulate interest and participation in the subject addressed, benefiting the construction of interpersonal relationships.51 The development of a culinary and tasting workshop makes it possible to live and exchange experiences about what was addressed during the intervention, favoring content retention.52 It is noteworthy that all the learning resources mentioned above were addressed in this study, favoring the positive impact observed. Therefore, the limitations of the present study include the small number of participants per age group, which restricted a more detailed analysis of subgroups by age group.
CONCLUSION
The qualitative assessment of food consumption showed a modification in the scores of the important groups, highlighting the increased fruits and vegetables and decreased intake of sodium, soy oil, animal fat, and added sugar. In the quantitative consumption assessment, there was a reduction in caloric and lipid consumption of all fatty acids, notably saturated and trans fatty acids, free sugar, and sodium, associated with decreased BMI, body fat percentage, body circumference waist, plasma cholesterol, and triacylglycerol, showing that the nutrition education program generated behavioral and lifestyle changes, which had a positive impact on the eating habits and, consequently, on the participants' health. These findings could support the development of other intervention programs, public or private, targeting similar populations.
Practice implications
This research provides important information about the impacts that nutritional education actions can have on the food choices of populations. Our data provides a basis for future research that can determine the best nutritional education strategy for a given age group and specific groups with greater precision. In our research, the nutritional education program applied resulted in changes in eating habits, which positively affected health parameters. However, more research is needed to understand better how the application of nutritional education programs best adapts to each specific group. The conclusions of this study suggest that investments in nutritional education programs can provide an essential contribution to the promotion of healthier eating and can shape public policies aimed at preventing the development of diseases related to malnutrition.
CONFLICT OF INTEREST DISCLOSURE
The authors declare no competing financial interest.
ACKNOWLEDGMENTS
This work was supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq - Brazil), and Fundação de Amparo a Pesquisa e Inovação do Espírito Santo (FAPES - grant n. 027/2012).
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