INTRODUCTION

Ensuring food and nutrition security (FNS) is a critical global goal, both for the sustainable development of nations and for the promotion of the nutritional well-being and health of populations ¹. However, its implementation at the local level has been insufficient, since there were still 811 million people in the world facing famine in 2020, most of them children. Estimates from the same year suggest a worrying nutritional scenario for children under five years of age: 149 million stunted, 45 million underweight and almost 39 million overweight ². These figures show that a great effort needs to be made in order to achieve the global eradication of hunger and the different forms of malnutrition, including Brazil as a signatory of such proposals ^1,2. In 2018, one fifth of Brazilian families were in a situation of hunger ³. Furthermore, in 2019, 7.0%, 3.0% and 13.1% of children under five years of age were undersized, thin and overweight, respectively ⁴.

Food and nutrition insecurity (FNI) is associated with decreased food intake, inadequate child feeding practices and poor health conditions ⁵. In Brazil, FNS implies that the population should have guaranteed access to food, with adequate quantity and quality, without compromising other essential needs ⁶. In fact, there are several factors that determine the levels of FNI, with low buying power and lack of access to nutritious food being the most predominant factors ^7-9.

A systematic review with meta-analysis of articles published between 2004 and 2013 reported that the prevalence of FNI among Brazilian populations with social inequities was 87.2%, evidencing social determination ¹⁰. Likewise, for samples obtained from schools and kindergartens, the same study reported that 61.8% of families were in the same situation ¹⁰, despite the role of the National School Feeding Program in ensuring FNS of students in the public education system ¹¹. Thus, Brazilian studies on FNS have identified socioeconomic factors as important determinants of this problem ^6,10. However, studies focused on the analysis of the influence of other social conditions ⁶ and the identification of high-risk groups¹² are needed. In this context, it is important to note that FNI in children may compromise caloric and nutrient intake, with possible negative outcomes such as significant growth and development deficiency, compromised health, changes in cognitive development and poor performance at school ^8,9. Therefore, this study aimed to analyze the association between the social context (demographic, socioeconomic and social support factors) and moderate-severe food and nutrition insecurity (M-SFNI) in families with children aged 0-59 months enrolled in municipal kindergartens in the state of Paraíba, Brazil.

MATERIALS AND METHODS

RESULTS

We included 382 families; 17.0% of the children were younger than 25 months. In addition, most families had mothers who did not work outside the home (62.6%), were poorer (68.1%) and benefited by the Bolsa Família Program (78.0%). Regarding social support, affective support was the most frequent (67.3%) and material support was the least frequent (40.0%); while 65.2% of the families were functional. The prevalence of M-SFNI was 27.2%, mostly in families with children under 25 months of age (p=0.025), from poorer condition (p=0.003) and beneficiaries of the Bolsa Família Program (p=0.003). Likewise, deficiencies in material social support (p=0.024), emotional/informational (p=0.020) and interaction (p=0.003), as well as family dysfunctionality (p=0.034) had high proportions of M-SFNI (Table 1).

Table 2 shows the factors associated with M-SFNI. The adjusted analysis showed that families with children younger than 25 months of age (aPR: 1.53; 95%CI: 1.22-1.90), from poorer conditions (aPR: 1.88; 95% CI: 1.60-2.52) and beneficiaries of the Bolsa Família Program (aPR: 2.16; 95% CI: 1.88-2.67) had higher probabilities of presenting M-SFNI. In turn, the lack of material, emotional/informational and interaction support, as well as family dysfunctionality, increased the probability of M-SFNI with aPR values ranging from 1.49 (95%CI: 1.33-1.79) (material support) to 1.73 (95%CI: 1.44-2.01) (interaction support).

The distribution of households according to the BFIS responses is shown in Table 3. Data for the first four items includes the total study sample (n = 382), while items 5 to 14 include data from families that responded positively to at least one of the items 1 to 4 (n=251). The item regarding the concern with food (running out of food before being able to buy or receive more) had the highest number of positive responses (53.7%) and closest to the FNI classification (65.7%). Item 2 (food ran out before having money to buy more) and item 4 (household members only ate some of the food they had left because money ran out) were answered positively by 26.2% of respondents.

DISCUSSION

Our results show a M-SFNI prevalence of 27.2% in families with children under five in their family nucleus, who attend kindergartens. In addition, we found that families with young children, of lower socioeconomic level and participants of the Bolsa Família Program had a higher probability of M-SFNI. Regarding social support, the probability of M-SFNI was higher for families with limited material, emotional/informational and social interaction support, as well as in dysfunctional families.

The families participating in this study had a socioeconomic configuration marked by social vulnerability, which is an accentuated characteristic of the Brazilian population ^8,9. Unfavorable socioeconomic conditions are important determinants of FNI ^6-10. The eradication of hunger requires a different view of vulnerable groups as a way to support sustainable development ¹. In this context, in addition to the social situation, households with children under two years of age expressed another characteristic that requires attention, as these families were more likely to have M-SFNI.

In this study, the prevalence of M-SFNI (27.2%) found in families with children enrolled in kindergartens was slightly higher than that reported by a meta-analysis of samples obtained in school settings between 2004-2013 (23.7%) ¹⁰ and in the Brazilian population in 2017 (23.0%)²². This prevalence rate may be linked to the economic crisis experienced in Brazil from 2014 to 2017 (a period that coincides with the time of data collection in this study), with negative consequences for the social situation of families and access to food, especially among the most vulnerable populations ²². This period also coincides with the weakening or dismantling of social protection and food security policies, depriving the poor of the right to food in times of economic decline ^1,22. Changes in the FNS situation in Latin American countries and in Brazil during the economic recession (2014 to 2017) have been reported in the literature, even for the most severe degrees of FNI ²³. Thus, these data reinforce the need for emergency measures to protect and ensure access to food for the most vulnerable families, as well as the constant monitoring of FNS as a way to predict trends and inform decision making in a timely manner.

The socioeconomic conditions that were associated with M-SFNI in our study were the socioeconomic condition of the family and the Bolsa Família Program benefit, which reinforces the extensive literature with emphasis on Latin American countries and particularly Brazil^6,8,10,23,24. Similar results have also been reported in other countries such as Ethiopia ²⁵. Socioeconomic factors have an impact on the access to food and, therefore, on FNS ¹⁰. Social indicators may be associated with FNS directly or mediated by income and/or other indicators of the social context ²⁴. In turn, the association between M-SFNI and the Bolsa Família Program benefit is based on the social vulnerability of the families receiving this support, delimiting the Program’s inability to improve the social situation and FNI of its public ¹⁰. Therefore, it is necessary to prioritize social protection programs that really allow increasing buying power and high-quality food to minimize FNI.

Our findings show that mothers who reported lower levels of social support and family functionality belonged to families with a higher probability of having M-SFNI, which agrees with the conceptual model of FNS determinants proposed by Kepple and Segall-Correa ²⁶. Other studies have also reported low social support as a factor related to FNI, as is the case of a study conducted in Latin America with 65,146 participants ²³ and a study involving 107 countries ²⁷. In Brazil, studies conducted with nationwide data ²² and a population-based study in the metropolitan region of Rio de Janeiro ²⁸ also reported similar findings ^22,28. FNS can be affected by social support, as it is a strategy for promoting access to adequate quantity and/or quality of food by allowing loans of money or food, support in food production and preparation, help in childcare, building connections to find employment, and emotional support that improves the ability to cope with stressful events ^22,23,27,28. In addition, social support has been reported to be important for the adherence to health care and services, as well as environmental control and autonomy ²⁹. These results highlight social support as a protective factor and the importance of the availability of family and/or friends for FNS, pointing to the need for further research on the subject, given that it is still a recent research topic. Our findings support the importance of providing opportunities for social interaction and companionship as part of the services offered to the community and/or social programs.

Finally, the positive responses to each of the BFIS questions showed that concern with food (53.7%) was one of the items that had one of the highest frequencies of FNI (65.7%), while the frequency of items related to food running out before having money to buy more and members only eating some of the food they had left because money ran out (26.2%) was very close to the prevalence of M-SFNI. These results are similar to those of previous studies in which BFIS questions were considered as a proxy for FNI and its severity ^30,31. It is important to note that FNS can be assessed based on isolated BFIS questions, since even a single positive response on the scale classifies the family as FNI. The order of the BFIS questions, from mild to more severe situations, may explain the fact that the first item (concern with lack of food) is the one that best represents FNS ³⁰. In turn, the different FNI levels may be represented by aspects related to deprivations in the quantity and quality of food, and not with the concern with the lack of food ^30,31. In this sense, a recent study showed that the use of items 2 and 4 of the BFIS as parameters for differentiating FNI levels is useful ³¹, providing credibility to our results regarding the similarity of the prevalence of M-SFNI and the frequency of positive response to these aspects. Thus, we consider that these items should be used to identify early FNI risks and to propose interventions to reverse this situation, including routine health services, social assistance and as a tool for food and nutritional surveillance ^31,32.

This study has some limitations. Our results should be generalized with caution, since the sample includes families with specific characteristics. In addition, it is important to note the possibility of residual confounding, as the multifactorial nature of FNI was not fully explored, and potential factors that may act as confounders and contribute to a more complete analyses were not included. The inclusion of data such as children’s food consumption and eating habits, as well as parental interaction with children, not considered in the study, could lead to a broader discussion of the results. From a methodological perspective, it is important to note that the cross-sectional design of this study does not assess causality. However, reverse causality is not so important when dealing with variables, such as those included in this study, that do not change over time and can be collected retrospectively. Additionally, it is pertinent to note that the 2017-2018 indicators presented in this study may not represent the current reality due to the potential consequences of the COVID-19 pandemic in FNS. Regardless, our results are important for future comparisons with studies analyzing the effects of the COVID-19 pandemic on FNS.

Our results showed that M-SFNI was present in 27.2% of families with children aged 0 to 59 months attending kindergartens, being higher in families with children younger than 25 months, of lower socioeconomic level, beneficiaries of the Bolsa Família Program, dysfunctional and without material, emotional/informational and interaction support. Thus, we recommend that the Bolsa Família Program and the social support of families could be improved with social protection mechanisms that can optimize FNS.