Overweight in Goiás'quilombola students and food insecurity in their families¹

Excesso de peso de estudantes quilombolas de Goiás e a insegurança alimentar em suas famílias

Abstracts

Objective:

To characterize the nutritional status of quilombola students and determine the food security status of their households.

Methods:

This is a cross-sectional study with students aged six to nineteen years from quilombola communities in twelve municipalities of Goiás categorized by age, gender, school location (urban/rural), and nutritional status based on the World Health Organization's height-for-age and body mass index for-age charts. The Brazilian Food Insecurity Scale was used for measuring food (in)security in their families. Descriptive and association analyses were conducted using the Chi-square test at a significance level of 5% (p<0.05).

Results:

In a sample of 226 students, overweight (17.2%) was more common than malnutrition (1.3%), especially in students attending urban schools (28.2%) (p<0.05). Most (75.2%) quilombola families experienced food insecurity, especially mild.

Conclusion:

The apparent contradiction of excess weight and food insecurity occurring simultaneously indicates the need of revising the study instruments and the causal network that identify poverty.

African continental ascestry; Food security; Nutritional status; School feeding

Objetivo:

Caracterizar o estado nutricional de estudantes quilombolas e a segurança alimentar nos seus domicílios.

Métodos:

Estudo transversal com estudantes na faixa etária de 6 a 19 anos, de comunidades quilombolas de 12 municípios goianos, categorizados quanto à idade; ao sexo; à localização da escola em que estavam matriculados, e ao estado nutricional, classificado segundo os critérios do World Health Organization para os parâmetros estatura para idade e índice de massa corporal para idade. Por meio da Escala Brasileira de Medida de Insegurança Alimentar, foi estudada a (in)segurança alimentar das famílias dos respectivos alunos. Realizaram-se análises descritivas e de associação utilizando-se o Qui-quadrado com significância estatística quando p-valor<0,05.

Resultados:

Em amostra de 226 estudantes, observou-se maior frequência de excesso de peso (17,2%) em comparação à desnutrição (1,3%), com maior ocorrência entre os alunos matriculados nas escolas da zona urbana (28,2%) (p<0,05). A insegurança alimentar esteve presente em 75,2% das famílias quilombolas, sendo a insegurança alimentar leve a mais frequente.

Conclusão:

A aparente contradição da ocorrência simultânea de excesso de peso e insegurança alimentar aponta para a necessidade de que sejam revistos os instrumentos de estudo, bem como a rede de causalidade que identifica a pobreza e o excesso de peso.

Grupo com ancestrais do continente africano; Segurança alimentar e nutricional; Estado nutricional; Alimentação escolar

INtrODUCTION

The remaining quilombolas are considered ethnic/racial groups according to self-attribution criteria and have a history of their own¹. A close bond with the land is one of the most striking quilombola characteristics, with mostly subsistence agriculture being the main economic activity. A small part of the farm products is sold at very low prices, generating low income for the families^2-4.

Studies have found that quilombola communities have poor basic sanitation, characterized by frequent water shortages and no garbage collection or sewerage. In addition to these vulnerabilities, low education level and illiteracy are common, and access to primary health care services is difficult, compromising quilombola health, characterized by nutritional deficiencies, malnutrition, and chronic Noncommunicable Diseases (NCD)^2,3,5-7.

Although quilombola children aged less than five years are often malnourished^2,8, some are overweight. Quilombola individuals aged more than seventeen years have frequencies of overweight and NCD, such as high blood pressure, of 41.9% and 41.6%, respectively⁹.

Economic changes in rural communities, such as wage labor, retirement pensions, and access to welfare programs such as Bolsa Família, may change food habits because they enable the acquisition of processed foods at urban grocery stores instead of those grown in the community, which may increase the intake of processed and high-fat foods. Such transitions and exposure to the urban environment may explain the changes in the nutritional profile of the quilombola population^10,11. Quilombola youth frequently move to cities because their communities lack high schools, so they move to cities to continue their education and find work, losing touch with their cultural and social center^12-14.

Studies on the nutritional status and health profile of quilombola children aged more than five years and adolescents are few. Their nutritional profile is concerning because 7.5% of the population aged eleven or more years consume fewer than three meals a day, and 32.5% of children aged three to eleven years have a maximum of three meals a day².

It is plausible to assume that the causal network of the nutritional status of quilombola communities has changed given their usually difficult access to food and resultant hunger, characterizing a situation of food insecurity in these families^2,15. The availability of affordable energy-dense foods may be a factor that explains this paradigm shift^16-18.

Given the need to expand the discussion about food (in)security and its relationships with the nutritional status-related epidemiologic landscape, the objective of this study was to characterize the nutritional status of quilombola students and food (in)security in their households.

METHODS

This cross-sectional study was conducted from March to August 2012 in 12 municipalities in Goiás with quilombola communities recognized by the Fundação Cultural Palmares¹⁹, selected according to the local leaders' interest in participating in the study.

The study target population was estimated based on the 2011 school census²⁰ and consisted of male and female quilombola children aged six to nine years and adolescents aged ten to nineteen years enrolled in municipal and state elementary, middle, and high schools. Since the study universe was diverse, all schools with quilombola students were visited. The local quilombola leader helped to determine the schools with quilombola students by examining the enrollment forms.

Ninety-one schools had quilombola students, but twelve (13.2%) were not included because of their remoteness (n=4) or absence of a teacher or another person in charge (n=4), being closed and/or abandoned (n=2), and not having enough time to conduct the study (n=2).

Therefore, the study population consisted of 2,413 quilombola students from 79 schools.

Students were randomly selected at each school taking into account an error estimate of 6%, a Confidence Interval of 95% (95%CI), and a desired proportion of 50% since there is no data on the percentage of quilombola children and adolescents at nutritional risk. The sample was defined in 175 students with an extra 30% to compensate for losses²¹, thereby totaling 226 quilombola students considering a loss by refusal. The sample size was given by calculating sampling weights to maintain proportionality with the quilombola students in each municipality²².

The field team consisted of properly trained dieticians who collected sociodemographic data, such as age, gender, and school location (rural/urban), anthropometric data (weight and height), and Food Security (FS) and Food Insecurity (FI) data of the students' families.

Anthropometric assessment included measuring weight (kg) and height (cm) as recommended by the World Health Organization (WHO)²³, using a solar digital scale with a capacity of 150 kg and accuracy of 0.1 kg of the brand Tanita, and compact stadiometer of the brand Seca with a total length of 210 cm and accuracy of 0.1 cm. Nutritional status was also classified as recommended by the WHO according to height-for-age and Body Mass Index (BMI)-for age Z-scores²⁴.

The Escala Brasileira de Insegurança Alimentar (EBIA, Brazilian food Insecurity Scale) was used for assessing food (in)security in the households, classifying it as follows: (1) mild food insecurity - poor diet and family concerned with running out of food soon; (2) moderate food insecurity - quantitative food restriction in the household; (3) severe food insecurity - food deficit and even hunger among the family's adults and/ or children²⁵. Although this instrument was developed for assessing traditional populations, changes were not proposed because the instrument is validated and has already been used in Brazilian quilombola surveys and other studies^2,25-27.

The software Stata version 12.0^(r) treated the data, and the WHO's program AnthroPlus version 1.0.4^(r) assessed the participants' nutritional profile. The Chi-square test measured the association between the study variables and the food security indicator of the quilombola students with a significance level of α<5.0% (p<0.05).

The study "Food, health, and quality of life of quilombola schoolchildren from Goiás" upon which the present study is based was approved by the Research Ethics Committee of the Universidade Federal de Goiás under Protocol number 263/2011, and all participants signed an Informed Consent Form before entering the study.

RESULTS

The mean age and standard deviation of the 226 study students was 10.5±3.3 years, 51.8% (n=117) were females, and 52.2% (n=118) were enrolled in urban schools. Only three adolescents were stunted, and another three students (1.3%), two children (66.7%) and one adolescent (33.3%), were underweight. Thirty-nine (17.2%) participants were overweight (overweight or obese). Table 1 shows the quilombola student profiles.

Table 1
Profile of quilombola students attending public schools.

Characteristics	Age group
	6 to 9 years		10 to 19 years
	n	%	n	%
Gender
Female Male	55 49	47.0 45.4	62 60	53.0 55.0
Height-for-age
Low height-for-age Appropriate height-for-age	0 104	00.0 46.6	3 119	100.0 53.4
BMI-for-age
Underweight Normal weight Overweight	2 84 18	66.7 45.7 46.2	1 100 21	33.3 54.3 53.8
Location
Rural Urban	56 48	51.9 40.7	52 70	48.1 59.3

• Note: BMI: Body Mass Index.

A total of 214 families were interviewed to collect food access information, classifying the household as food secure or insecure. The number of families is smaller than the number of participants because some households had more than one participant. Food insecurity was found in 160 (75.2%) households, most of which were mildly (45.1%) and moderately (21.6%) food insecure (Table 2).

Table 2
Food (in)security distribution in quilombola students' households. Goiás, Brazil, 2012 (n=214).

Characteristics	n	%	95%CI
Food (in)security
Food security Mild food insecurity Moderate food insecurity Severe food insecurity	54 96 46 18	24.8 45.1 21.6 8.5	19.0 - 30.6 38.4 - 51.8 16.1 - 27.1 04.8 - 12.2

• Note: 95%CI: Confidence Interval of 95%.

The following groups had similar percentages of food insecurity: females (74.4%), males (76.1%), children (73.1%), adolescents (77.0%), students from rural schools (78.7%), and students from urban schools (72.0%). Table 3 shows that these sociodemographic variables were not associated with food insecurity (p>0.05).

Table 3
Food security/insecurity frequency by the sociodemographic variables of quilombola children and adolescents. Goiás, Brazil, 2012 (n=226).

Characteristics	Food (in)security				p1
	Food security		Food insecurity
	n	%	n	%
Gender
Female Male	30 26	25.6 23.9	87 83	74.4 76.1	0.497
Age
6 to 9 years 10 to 19 years	28 28	26.9 23.0	76 94	73.1 77.0	0.242
School location
Rural Urban	23 33	21.3 28.0	85 85	78.7 72.0	0.069

• Note: ¹Chi-square test.

Most (19.6%) overweight children and adolescents lived in food secure households. Excess weight was more frequent among girls (19.7%) than boys (14.7%) but the difference was not significant (p>0.05). There was a statistically significant association (p<0.05) between school location (urban/rural) and the students' nutritional status: 28.2% of the children attending urban schools were overweight (Table 4).

Table 4
Nutritional status distribution of quilombola children and adolescents by sociodemographic and food security/insecurity variables. Goiás, Brazil, 2012 (n=226).

Characteristics	Food (in)security				p1
	Not overweight		Overweight
	n	%	n	%
Gender
Female Male	94 93	80.4 85.3	23 16	19.7 14.7	0.294
Age
6 to 9 years 10 to 19 years	86 101	82.7 82.8	18 21	17.3 17.2	0.888
School location
Rural Urban	103 84	95.4 71.8	5 33	04.6 28.2	0.000
Food (in)security
Food security Food insecurity	45 142	80.4 83.6	11 28	19.6 16.5	0.690

• Note: ¹Chi-square test.

DISCUSSION

Stunting was found in only three adolescents, no children were affected. Adolescents were also more likely to be overweight or obese than children. Moreover, the frequency of food insecurity for the study sample was high.

The small number of studies on the nutritional status of quilombola children aged six to nineteen years limits the discussion of the results, justifying comparison with other population groups with similar sociocultural trajectory.

The increasing prevalence of overweight has already been observed in other specific populations, such as Xavante in Mato Grosso, with an overweight prevalence of 27.5% in adolescents²⁸, and in Alto Xingu where the adolescents' BMI was higher than the country's average BMI, also suggesting a high frequency of overweight²⁹. The nutritional profile of students from public schools in Juiz de Fora (MG) with a mean age of 10.8 years was also similar to that of the present sample given that 7.5% and 10.4% of the women were overweight and obese, respectively, and 13.5% and 7.6% of the men were overweight and obese, respectively³⁰.

The 2008/2009 Family Budget Survey found that more than 30% of Brazilian children aged five to nine years and roughly 20% of Brazilian adolescents were overweight³¹. The Pesquisa Nacional de Saúde do Escolar (PeNSE, National Schoolchild Health Survey) found that 23% of the students aged 11 to 19 years attending public and private schools in Brazilian capitals were overweight³².

An association was found between nutritional status and school location (urban/rural) as most overweight students attended urban schools. A study of adolescents aged 10 to 17 years attending public schools found that those living in urban areas were 75% more likely to be overweight than those living in rural areas³³. Although the present study did not investigate where the sample lived, the fact that they studied in urban schools may have facilitated access to processed foods, uncommon in rural areas, a factor that may promote weight gain.

The proximity between quilombola communities and roads going to large cities may impact the socioeconomic, and consequently, the behavioral aspects of this population. In other words, greater proximity to cities may change the eating habits of quilombola communities, justifying the increase in the prevalence of overweight in this population. New fields of work, such as tourism, wage labor, and ease of distributing agricultural products lead communities near roads to adopt a new pattern of subsistence, characterized by smaller involvement with subsistent farming and greater access to foods common in urban areas. These pieces of evidence may be indicative of nutritional transition in this population and thereby, higher food insecurity^3,10,11,34.

The impact of this change on the subsistence model was observed by ecological farmers from Paraná. They believe that purchased foods are important because their production does not meet all their nutritional requirements, but they know that purchased foods have a negative impact on their health. Some farmers also wanted to buy processed foods, such as sweets, bouillon cubes, soft drinks, and others, regardless of their unhealthiness³⁵.

Although the frequency of overweight was high, the number of food insecure families was also high. This result reaffirms the evidence found by some studies regarding the broken paradigm that food insecurity is a synonym of malnutrition, introducing a new concept where hunger is associated with overweight^16-18. However, nutritional status was not associated with food insecurity in the study quilombola families.

The identified food insecurity confirms the vulnerable situation of quilombola families^2,3,5-7 and corroborates a study of quilombolas in Tocantins that found percentages of mild and moderate food insecurity of 85.1% and 70.2%, respectively¹⁵.

The frequency of food insecurity in quilombola families and the nutritional profile of the study children and adolescents are concerning and deserve the attention of public policies. The Programa Nacional de Alimentação Escolar (PNAE, National School Food Program) is an example of the students' right to appropriate food, that is, food quality and amount that meet their nutritional requirements while at school, especially its teaching nature³⁶. However, in practice the recommendations of the program are distorted since schools in some quilombola communities served foods alien to the local food habits³.

One of Programa Nacional de Alimentação Escolar's principles is the respect for local food habits. The traditional practices that are part of a healthy food culture must be considered along with the guideline of buying diverse, locally produced foods³⁶.

In 2009 Programa Nacional de Alimentação Escolar determined that schools should purchase foods from family farms, which is a way of providing better quality meals to the students and food and nutrition security to the farmers, improving everyone's quality of life. Schools should also prefer foods produced by quilombola farmers³⁶. However, the percentage of Brazilian municipalities that buy food from family farms is still small (47.4%), especially in the Midwest region (35.3%)³⁷.

The Programa de Aquisição de Alimentos (PAA, Food Acquisition Program) also aims to promote farmer food and nutrition security and school meals of higher quality by purchasing foods from family farms and donating the foods to schools³⁸. However, these programs require farmers to own the land, but land ownership is not very common in quilombola communities^11,13.

Given the nutritional status profile of the study quilombola students and the importance of public policies that aim to improve their quality of life, one must investigate the obstacles that must be overcome for implementing and ensuring the effectiveness of these policies for the proposition to actually improve the quality of life of individuals living in quilombola communities.

CONCLUSION

The simultaneous presence of overweight and food insecurity raises questions regarding new life and consumption habits, and even about today's poverty profile in Brazil. Therefore we suggest new studies to expand the discussion about this apparent paradigm shift.

ACKNOWLEDGEMENTS

We thank Denise Oliveira e Silva, Maria Sebastiana Silva, Maria do Rosário Peixoto, Lucilene Maria de Sousa, Veruska Alexandre, and Mário Piscoya for their contributions, and the Fundo Nacional de Desenvolvimento da Educação for sponsoring the study.

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  Araújo C, Toral N, Silva ACF, Velásquez-Melendez G, Dias AJR. Estado nutricional dos adolescentes e sua relação com variáveis sociodemográficas: Pesquisa Nacional de Saúde do Escolar (PeNSE), 2009. Ciênc Saúde Colet. 2010; 15(Supl 2):3077-84. doi: 10.1590/S1413-81232010000800012
  » https://doi.org/10.1590/S1413-81232010000800012
• ³³
  Pelegrini A, Silva DAS, Petroski EL, Glaner MF. Estado nutricional e fatores associados em escolares domiciliados na área rural e urbana. Rev Nutr. 2010; 23(4):839-46. doi: 10.1590/S1415-52732010000 500014
  » https://doi.org/10.1590/S1415-52732010000500014
• ³⁴
  Cruz KCMS, Valente ALEF. A cachoeira do Poço Encantado: empreendimento familiar e presença Kalunga na cadeia do ecoturismo em Teresina de Goiás. Rev Econ Rural. 2005; 43(4):779-804. doi: 10.1590/S0103-20032005000400008
  » https://doi.org/10.1590/S0103-20032005000400008
• ³⁵
  Ell E, Silva DO, Nazareno ER, Brandenburg A. Concepções de agricultores ecológicos do Paraná sobre alimentação saudável. Rev Saúde Pública. 2012; 46(2):218-25. doi: 10.1590/S0034-891020 12005000020
  » https://doi.org/10.1590/S0034-891020
• ³⁶
  Brasil. Ministério da Educação. Fundo Nacional de Desenvolvimento da Educação. Resolução/FNDE/ CD/ nº 26, de 17 de junho de 2013. Dispõe sobre o atendimento da alimentação escolar aos alunos de educação básica no âmbito do Programa Nacional de Alimentação Escolar - PNAE. Brasília: Ministério da Educação; 2013 [acesso 2013 nov 19]. Disponível em: <http://www.fnde.gov.br/fnde/legislacao/resolucoes>.
  » http://www.fnde.gov.br/fnde/legislacao/resolucoes
• ³⁷
  Saraiva EB, Silva APF, Sousa AA, Cerqueira GF, Chagas CMS, Toral N. Panorama da compra de alimentos da agricultura familiar para o Programa Nacional de Alimentação Escolar. Ciênc Saúde Colet. 2013; 18(4):927-36. doi: 10.1590/S1413-81 232013000400004
  » https://doi.org/10.1590/S1413-81232013000400004
• ³⁸
  Brasil. Presidência da República. Decreto nº 6.447, de 7 de maio de 2008. Regulamenta o Art. 19 da Lei nº 10.696, de 2 de julho de 2003, que institui o Programa de Aquisição de Alimentos. Brasília: Presidência da República; 2003 [acesso 2013 fev 18]. Disponível em: <http://www.conab.gov.br/OlalaCMS/uploads/arquivos/e92958f6d2e68089e67a514ec5e9fdb2.pdf>.
  » http://www.conab.gov.br/OlalaCMS/uploads/arquivos/e92958f6d2e68089e67a514ec5e9fdb2.pdf

• Support: Fundo Nacional de Desenvolvimento da Educação (TC 16882).
• 1
  Article based on the master's thesis of "Excesso de peso em estudantes quilombolas e a insegurança alimentar em seus domicílios". Universidade Federal de Goiás; 2013.

Publication Dates

• Publication in this collection
  Jul-Aug 2014

History

• Received
  13 June 2013
• Reviewed
  07 May 2014
• Accepted
  25 June 2014