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Factors Associated with the Intake of Ultra-Processed Cariogenic Foods by Preschoolers During the COVID-19 Pandemic

ABSTRACT

Objective:

To evaluate the characteristics and factors associated with the intake of ultra-processed cariogenic foods (UFC) by preschoolers during the COVID-19 pandemic.

Material and Methods:

This is a cross-sectional study involving parents of 672 children from two to five years old enrolled at public schools in Curitiba, Brazil. Parents answered a questionnaire about socioeconomic and demographic data, their behavior regarding the dietary education of their children (Parent Mealtime Action Scale - translated and validated for use in Brazil), and children's food intake (qualitative food frequency questionnaire - list of foods based on a report from the Pan American Health Organization). The data were analyzed using Poisson regression analysis (α=0.05).

Results:

About 43% of parents/guardians reported changes in their children's diet during the pandemic, being that diet got worse and better in 19% and 24% of the cases, respectively. The ultra-processed cariogenic foods with the highest daily intake frequencies were sweetened juices/sweetened drinks (0.52), followed by cookies (0.37), and candies (0.35). Parents with a lower level of education reported a daily frequency of UCF intake 1.36 times higher (PR=1.359; CI 95%: 1.106-1.669) in their children compared to those with a higher level of education. On the other hand, parents’/guardians’ report of higher intake and greater offer of fruits and vegetables to children was associated with low UCF intake (PR=0.716; CI 95%: 0.592-0.866).

Conclusion:

The lower level of formal education of parents/guardians and lower availability of fruits and vegetables were related to higher consumption of ultra-processed cariogenic foods by children.

Keywords:
Coronavirus Infections; Diet; Cariogenic; Child; Preschool

Introduction

In March 2020, the World Health Organization (WHO) characterized the outbreak of Coronavirus Disease - 2019 (COVID-19) as a pandemic [1[1] World Health Organization. Novel Coronavirus (2019-nCoV): Situation Report - 22. 2020. Available from: https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200211-sitrep-22-ncov.pdf?sfvrsn=fb6d49b1_2. [Accessed on May 10, 2022].
https://www.who.int/docs/defaultsource/c...
]. The International Committee on Taxonomy of Viruses defined the name of the etiologic agent of this pathology as Severe Acute Respiratory Syndrome - Related Coronavirus 2 (SARS-CoV-2) [2[2] Gorbalenya A, Baker SC, Baric R, De Groot R. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol 2020; 5:536-44. https://doi.org/10.1038/s41564-020-0695-z
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]. Once the forms of viral dissemination were determined, strategies were applied to cope with and mitigate contagion. Restrictive measures, despite being effective and necessary to control the spread of SARS-CoV-2, have caused negative impacts on the quality of life of individuals [3[3] Melo-Oliveira ME, Sá-Caputo D, Bachur JA, Paineiras-Domingos LL, Sonza A, Lacerda AC, et al. Reported quality of life in countries with cases of COVID19: a systematic review. Expert Rev Respir Med 2021; 15(2):213-20. https://doi.org/10.1080/17476348.2021.1826315
https://doi.org/10.1080/17476348.2021.18...
]. In children, home isolation has been associated with a higher incidence of domestic violence and child abuse [4[4] Rodriguez CM, Lee SJ, Ward KP, Pu DF. The perfect storm: hidden risk of child maltreatment during the Covid-19 pandemic. Child Maltreat 2021; 26(2):139-51. https://doi.org/10.1177/1077559520982066
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], reduced levels of physical activity [5[5] Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020; 28(8):1382-5. https://doi.org/10.1002/oby.22861
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], higher rates of sedentary lifestyle and obesity [5[5] Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020; 28(8):1382-5. https://doi.org/10.1002/oby.22861
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,8[8] Aguilar-Farias N, Toledo-Vargas M, Miranda-Marquez S, Cortinez-O'Ryan A, Cristi-Montero C, Rodriguez-Rodriguez F, et al. Sociodemographic predictors of changes in physical activity, screen time, and sleep among toddlers and preschoolers in Chile during the COVID-19 pandemic. Int J Environ Res Public Health 2020; 18(1):176. https://doi.org/10.3390/ijerph18010176
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], increased screen time [8[8] Aguilar-Farias N, Toledo-Vargas M, Miranda-Marquez S, Cortinez-O'Ryan A, Cristi-Montero C, Rodriguez-Rodriguez F, et al. Sociodemographic predictors of changes in physical activity, screen time, and sleep among toddlers and preschoolers in Chile during the COVID-19 pandemic. Int J Environ Res Public Health 2020; 18(1):176. https://doi.org/10.3390/ijerph18010176
https://doi.org/10.3390/ijerph18010176...
], altered sleep patterns [5[5] Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020; 28(8):1382-5. https://doi.org/10.1002/oby.22861
https://doi.org/10.1002/oby.22861...
,6[6] Tso WWY, Wong RS, Tung KTS, Rao N, Fu KW, Yam JCS, et al. Vulnerability and resilience in children during the COVID-19 pandemic. Eur Child Adolesc Psychiatry 2022; 31(1):161-76. https://doi.org/10.1007/s00787-020-01680-8
https://doi.org/10.1007/s00787-020-01680...
,8[8] Aguilar-Farias N, Toledo-Vargas M, Miranda-Marquez S, Cortinez-O'Ryan A, Cristi-Montero C, Rodriguez-Rodriguez F, et al. Sociodemographic predictors of changes in physical activity, screen time, and sleep among toddlers and preschoolers in Chile during the COVID-19 pandemic. Int J Environ Res Public Health 2020; 18(1):176. https://doi.org/10.3390/ijerph18010176
https://doi.org/10.3390/ijerph18010176...
], behavioral changes, such as increased irritability and stress [9[9] Francisco R, Pedro M, Delvecchio E, Espada JP, Morales A, Mazzeschi C, et al. Psychological symptoms and behavioral changes in children and adolescents during the early phase of COVID-19 quarantine in three European countries. Front Psychiatry 2020; 11:570164. https://doi.org/10.3389/fpsyt.2020.570164
https://doi.org/10.3389/fpsyt.2020.57016...
], and diet modifications [5[5] Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020; 28(8):1382-5. https://doi.org/10.1002/oby.22861
https://doi.org/10.1002/oby.22861...
,7[7] Androutsos O, Perperidi M, Georgiou C, Chouliaras G. Lifestyle changes and determinants of children's and adolescents' body weight increase during the first COVID-19 lockdown in Greece: The COV-EAT study. Nutrients 2021; 13(3):930. https://doi.org/10.3390/nu13030930
https://doi.org/10.3390/nu13030930...
,10[10] Adams EL, Caccavale LJ, Smith D, Bean MK. Food insecurity, the home food environment, and parent feeding practices in the era of COVID-19. Obesity 2020; 28(11):2056-63. https://doi.org/10.1002/oby.22996
https://doi.org/10.1002/oby.22996...

[11] Campagnaro R, Collet GO, Andrade MP, Salles JPDSL, Calvo Fracasso ML, Scheffel DLS, et al. COVID-19 pandemic and pediatric dentistry: fear, eating habits and parent's oral health perceptions. Child Youth Serv Rev 2020; 118:105469. https://doi.org/10.1016/j.childyouth.2020.105469
https://doi.org/10.1016/j.childyouth.202...

[12] Janssen M, Chang BPI, Hristov H, Pravst I, Profeta A, Millard J. Changes in food consumption during the COVID-19 pandemic: analysis of consumer survey data from the first lockdown period in Denmark, Germany, and Slovenia. Front Nutr 2021; 8:635859. https://doi.org/10.3389/fnut.2021.635859
https://doi.org/10.3389/fnut.2021.635859...
-13[13] Philippe K, Chabanet C, Issanchou S, Monnery-Patris S. Child eating behaviors, parental feeding practices and food shopping motivations during the COVID-19 lockdown in France: (How) did they change?. Appetite 2021; 161:105132. https://doi.org/10.1016/j.appet.2021.105132
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].

Since 2015, WHO has set clear targets to decrease the intake of free sugars [14[14] World Health Organization. Guideline: Sugars intake for adults and children, 2015. Available from: http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/. [Accessed on May 10, 2022].
http://www.who.int/nutrition/publication...
]. However, its reduction is still a major challenge [15[15] Souza MS, Vaz JDS, Martins-Silva T, Bomfim RA, Cascaes AM. Ultra-processed foods and early childhood caries in 0-3-year-olds enrolled at Primary Healthcare Centers in Southern Brazil. Public Health Nutr 2021; 24(11):3322-30. https://doi.org/10.1017/S1368980020002839
https://doi.org/10.1017/S136898002000283...
]. Reducing the intake of ultra-processed foods seems to be a promising initiative to achieve this goal, as it is directly associated with a high intake of fats and free sugars [16[16] Louzada MLDC, Ricardo CZ, Steele EM, Levy RB, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutr 2018; 21(1):94-102. https://doi.org/10.1017/S1368980017001434
https://doi.org/10.1017/S136898001700143...
,17[17] Rauber F, Louzada MLDC, Martinez SE, Rezende LFM, Millett C, Monteiro CA, et al. Ultra-processed foods and excessive free sugar intake in the UK: a nationally representative cross-sectional study. BMJ Open 2019; 9(10):e027546. https://doi.org/10.1136/bmjopen-2018-027546
https://doi.org/10.1136/bmjopen-2018-027...
] and a risk factor for the development of several health problems [14[14] World Health Organization. Guideline: Sugars intake for adults and children, 2015. Available from: http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/. [Accessed on May 10, 2022].
http://www.who.int/nutrition/publication...
,15[15] Souza MS, Vaz JDS, Martins-Silva T, Bomfim RA, Cascaes AM. Ultra-processed foods and early childhood caries in 0-3-year-olds enrolled at Primary Healthcare Centers in Southern Brazil. Public Health Nutr 2021; 24(11):3322-30. https://doi.org/10.1017/S1368980020002839
https://doi.org/10.1017/S136898002000283...
,18[18] Matos RA, Adams M, Sabaté J. Review: the consumption of ultra-processed foods and non-communicable diseases in latin america. Front Nutr 2021; 8:622714. https://doi.org/10.3389/fnut.2021.622714
https://doi.org/10.3389/fnut.2021.622714...
]. Furthermore, during the pandemic, a reduction in children’s dietary quality has been reported, with increased food insecurity [19[19] Manfrinato CV, Marino A, Condé VF, Franco Mdo CP, Stedefeldt E, Tomita LY. High prevalence of food insecurity, the adverse impact of COVID-19 in Brazilian favela. Public Health Nutrition 2021; 24(6):1210-15. https://doi.org/10.1017/S1368980020005261
https://doi.org/10.1017/S136898002000526...
] and intake of processed or ultra-processed foods [5[5] Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020; 28(8):1382-5. https://doi.org/10.1002/oby.22861
https://doi.org/10.1002/oby.22861...
]. This is significant because recent research has associated early childhood dental caries with the intake of these types of foods [15[15] Souza MS, Vaz JDS, Martins-Silva T, Bomfim RA, Cascaes AM. Ultra-processed foods and early childhood caries in 0-3-year-olds enrolled at Primary Healthcare Centers in Southern Brazil. Public Health Nutr 2021; 24(11):3322-30. https://doi.org/10.1017/S1368980020002839
https://doi.org/10.1017/S136898002000283...
].

Parents’/Guardians' behavior and food availability influence children's feeding practices [20[20] Litchford A, Savoie Roskos MR, Wengreen H. Influence of fathers on the feeding practices and behaviors of children: A systematic review. Appetite 2020; 147:104558. https://doi.org/10.1016/j.appet.2019.104558
https://doi.org/10.1016/j.appet.2019.104...
] and are associated with the development of dental caries [21[21] Bonotto DV, Montes GR, Ferreira FM, Assunção LRDS, Fraiz FC. Association of parental attitudes at mealtime and snack limits with the prevalence of untreated dental caries among preschool children. Appetite 2017; 108:450-5. https://doi.org/10.1016/j.appet.2016.11.007
https://doi.org/10.1016/j.appet.2016.11....
]. Although family and sociodemographic characteristics probably influenced children's eating patterns during the pandemic, the factors associated with increased intake of ultra-processed cariogenic foods are still unclear. Knowing and understanding the factors associated with the intake of ultra-processed cariogenic foods during this period of health crisis and social isolation can contribute to the development of health education strategies that positively impact the reduction of sugar intake by children. Therefore, this study aimed to evaluate the characteristics and factors associated with the intake of ultra-processed cariogenic foods (UCF) in preschoolers during the COVID-19 pandemic, such as carbonated soft drinks, sweetened juices, candies, cakes, pastries, desserts, and cookies.

Material and Methods

Study Design and Ethical Clearance

This is a cross-sectional study involving 672 parents/guardians of children from two to five years old of both sexes enrolled in the Municipal Public School System (MPSS) in Curitiba, Paraná, Brazil. In addition to fulfilling the aforementioned requirements, parents/guardians had to fill out and sign the Informed Consent Form (ICF) to be included in the study. Furthermore, preschoolers with special dietary needs (based on information from guardians) were excluded.

This study was approved by the Human Research Ethics Committee of the Health Sciences Center of the Federal University of Parana (CCAE: 29188620.3.0000.0102) and also by Municipal Health Secretariat (CAAE: 291777620.3.3001.0101) from Curitiba, according to CNS Resolution 466/12, being conducted in accordance to Declaration of Helsinki.

A pilot study involving the parents/guardians of 71 preschoolers from MPSS with the same age range as the study population was previously conducted one month before the beginning of the study. The families were selected by convenience to test the understanding of the data collection instruments and the data collection dynamics. The necessary adjustments to the instruments and methodology were made from the analysis of the conduct and results of the pilot study, being necessary small adjustments with regard to the graphic layout of the questionnaire.

Sample Calculation

A sample calculation for the cross-sectional study using the proportion estimation formula was performed to gather a sufficient number of individuals to compose the group to be investigated, with a finite population correction. The calculations were carried out through the website www.openepi.com. A 50% prevalence of the outcome variable 'high intake of cariogenic foods' was used for sample size calculation. The adopted confidence level (1-α) was 95% and the precision of estimation was 5%. Since 33,531 children from two to five years old are enrolled in the Municipal Public School System of Curitiba, the sample was multiplied by 1.5 to compensate for clustering effects and cluster sampling, which resulted in a minimum of 574 children. The total sample was distributed over 10 city regions to maintain the proportion of students enrolled in each region. The website random.org was used for the drawing of the schools. Questionnaires were sent to all parents/guardians of children from two to five years old in each of the 28 randomly selected MPSS schools, reaching the predetermined number in each region to maintain the appropriate proportion of students.

Data Collection

Data collection was conducted between October 2020 and February 2021 using a questionnaire that was answered by parents/guardians regarding socioeconomic and demographic status, parental behavior during children's meals, and the characterization of food intake, with questions related to usual food intake, intake modification in the COVID-19 pandemic, and assessment of the frequency of food intake. It also contained a brief explanation of the survey, a guidance on filling out the forms, and presented how to contact the researchers in case of doubts. During the COVID-19 pandemic, the MPSS schools started to operate remotely, but still provided basic food baskets and educational activities on a monthly basis. Therefore, the way parents/guardians were approached varied according to the context experienced during the pandemic. To establish more restrictive measures to combat the pandemic, Curitiba relied on the effective reproduction number (Rt), which determines the potential for the virus to spread at a specific time ‘t’ under the control measures in place. An Rt value <1 indicates the deceleration of the spread, and when this was the case, the questionnaires were delivered in person. An Rt value >1 indicates acceleration, so the questionnaires were e-mailed.

Socioeconomic and Demographic Evaluation

Socioeconomic and demographic characteristics data were collected through an easy-to-understand questionnaire used in a previous study in this same population [21[21] Bonotto DV, Montes GR, Ferreira FM, Assunção LRDS, Fraiz FC. Association of parental attitudes at mealtime and snack limits with the prevalence of untreated dental caries among preschool children. Appetite 2017; 108:450-5. https://doi.org/10.1016/j.appet.2016.11.007
https://doi.org/10.1016/j.appet.2016.11....
] that was answered by parents/guardians. Moreover, data regarding household characteristics (family income and the number of residents in the household), parents/guardians (marital status, formal education, work activity), and preschoolers (sex and age) were collected.

Usual Intake of Ultra-Processed Cariogenic Foods and Dietary Modification during the COVID-19 Pandemic

To assess dietary modifications during the COVID-19 pandemic, questions about the report of previous usual food intake and about changes that occurred during the pandemic were formulated. The list of food items used in the questionnaire, developed by the authors, was based on the report developed by the Pan American Health Organization (PAHO) on the intake of ultra-processed food and drinks in Latin America [22[22] Organización Panamericana de la Salud. Alimentos y bebidas ultraprocesados na América Latina: ventas, fuentes, perfis de nutrientes e implicaciones. 2019. Available from: http://iris.paho.org/xmlui/handle/123456789/51523. [Accessed on May 10, 2022]. [In Spanish].
http://iris.paho.org/xmlui/handle/123456...
]. Therefore, the three ultra-processed items indicated as the main sources of free sugars, according to the PAHO report, were considered in this study: carbonated soft drinks; sweetened juices, drinks and candies (candy, caramel, lollipops, ice cream, chocolate) [22[22] Organización Panamericana de la Salud. Alimentos y bebidas ultraprocesados na América Latina: ventas, fuentes, perfis de nutrientes e implicaciones. 2019. Available from: http://iris.paho.org/xmlui/handle/123456789/51523. [Accessed on May 10, 2022]. [In Spanish].
http://iris.paho.org/xmlui/handle/123456...
].

Parents/guardians were instructed to report whether their child usually ate the food item before the pandemic (previous usual intake) and whether there was a change (increase, decrease, or no change) in their child's intake of the item during the pandemic. The questionnaire also included aspects about the parent’s/guardian’s perception of change in the family and child's diet. Three categories were assigned to the dietary changes: ‘improved’, ‘worsened’, or ‘not changed’.

Evaluation of the Frequency of Intake of Ultra-Processed Cariogenic Foods

Parents/guardians also answered questions about the frequency of intake of food items in the past three months. A questionnaire developed by the authors containing a list of ultra-processed cariogenic food items and an intake frequency scale for each item was applied. Food items based on the report developed by the Pan American Health Organization (PAHO) on the intake of ultra-processed food and drinks in Latin America [22[22] Organización Panamericana de la Salud. Alimentos y bebidas ultraprocesados na América Latina: ventas, fuentes, perfis de nutrientes e implicaciones. 2019. Available from: http://iris.paho.org/xmlui/handle/123456789/51523. [Accessed on May 10, 2022]. [In Spanish].
http://iris.paho.org/xmlui/handle/123456...
] were included. The five ultra-processed items indicated as the main sources of free sugars, according to the PAHO report, were considered: carbonated soft drinks; sweetened juices, drinks; candies (candy, caramel, lollipops, ice cream, chocolate); cakes, pastries, desserts; and cookies (biscuits) [22[22] Organización Panamericana de la Salud. Alimentos y bebidas ultraprocesados na América Latina: ventas, fuentes, perfis de nutrientes e implicaciones. 2019. Available from: http://iris.paho.org/xmlui/handle/123456789/51523. [Accessed on May 10, 2022]. [In Spanish].
http://iris.paho.org/xmlui/handle/123456...
].

Parents/guardians were instructed to fill in the frequency of intake of each food item. The categories used for reporting the frequency of intake were: ‘never or rarely’, ‘1 to 2 times a week’, ‘3 to 6 times a week’, ‘1 to 2 times a day’, ‘3 or more times a day’. The reported frequency categories were converted into a value indicating the daily intake of each food item. The values used in the conversion of the frequencies expressed in the questionnaire were: ‘never or rarely’ = 0; ‘1 to 2 times a week’ = 0.214 (1.5 times/7 days a week); ‘3 to 6 times a week’ = 0.643 (4.5/7); ‘1 to 2 times a day’ = 1.5 (1.5/1); ‘3 or more times a day’ = 3 (3/1). The daily intake frequency obtained for each of the food items with free sugars (range zero to three) was summed to obtain the equivalent daily frequency for the set of ultra-processed cariogenic foods (range zero to 15).

Evaluation of Parental Behavior during Children's Meals

To evaluate the parents' behavior relating to their children's food education, three domains of the Brazilian version of the Parental Mealtime Action Scale (PMAS) were used after being translated and validated for Brazilian Portuguese [23[23] Petty ML, Escrivão MA, Souza AA. Preliminary validation of the Parent Mealtime Action Scale and its association with food intake in children from São Paulo, Brazil. Appetite 2013; 62:166-72. https://doi.org/10.1016/j.appet.2012.11.024
https://doi.org/10.1016/j.appet.2012.11....
]. The domains used were 'Daily fruits and vegetables availability', 'Snack modeling', and 'Snack limit'. The domain 'Snack limit' reflects limits set by parents for daily intake of sweets. The domain 'Daily fruits and vegetables availability' indicates parents’ intake of fruits and vegetables and their offer to children. Finally, the domain 'Snack modeling' reflects parents’ intake of sweets, soft drinks, and snacks. A one-to-three-point rating scale (‘never’ = 1; ‘sometimes’ = 2; ‘always’ = 3) was used to obtain the guardians' reports on how often they adopt each behavior. Each domain's value was acquired from the sum of the answers for each question divided by the number of questions in the domain (three), then this result was used as a numerical variable (range one to three for each domain). For the first and third domains, higher averages represented a greater frequency of behavior by those responsible for their children’s nutritional education. For the second domain, higher averages represented a less favorable behavior to the child`s oral health [23[23] Petty ML, Escrivão MA, Souza AA. Preliminary validation of the Parent Mealtime Action Scale and its association with food intake in children from São Paulo, Brazil. Appetite 2013; 62:166-72. https://doi.org/10.1016/j.appet.2012.11.024
https://doi.org/10.1016/j.appet.2012.11....
].

Statistical Analyses

The statistical data analysis was performed using the SPSS software (IBM Corp., IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA). Non-parametric tests were used to evaluate the association between variables due to the asymmetric distribution of the data. The median daily intake of ultra-processed cariogenic foods was divided into ‘high UCF intake’ and ‘low UCF intake’. The independent variables were categorized as follows: degree of kinship to the child (‘mother/father’ or ‘other’), level of education of the guardian ('less than or equal to 8 years of formal education’ or ‘more than 8 years of formal education’), marital status of the guardian - married/in a common-law marriage ‘yes’ or ’no’), and sex of the child (‘male’ or ‘female’). The independent numerical variables - ‘per capita household income’, ‘age of the child in years’, and ‘age of the guardian in years’ - were measured using mean and median. The questions of PMAS were categorized into 'never', 'sometimes', and 'always', and assigned them a value of 1, 2, and 3, respectively. The value of each PMAS domain was obtained from the mean of the question.

The association between the previous usual food intake and dietary changes reported by the parents/guardians in the COVID-19 pandemic was analyzed using the Chi-square test. The association between food frequency was dichotomized into high and low intake, and the independent covariates were assessed using the Chi-square Test and Mann-Whitney Test. Variables with p <0.20 in the univariate analyses were selected to construct the multiple Poisson regression model with robust variance for the response variable (intake of ultra-processed cariogenic foods), and kept in the final model those that provided the best fit and remained significant (p <0.05) in the set of variables. A significance level of 5% was adopted.

Results

The vast majority of respondents were parents of children (97.6%), married/in a common-law marriage (60.6%), and with more than 8 years of formal education (85.7%). Children had a mean age of 3.7 years (SD= 1.0) and 51.3% were male (Table 1). None of the children met the exclusion criteria. Parents/guardians reported that most children had no dietary modifications during the pandemic (57%). However, for the parents, children's diet got worse in 19% and better in 24% of the cases during the pandemic. Table 2 shows the changes in the intake of each food. The biggest change occurred in the group of candies, in which 29.8% of parents/guardians reported an increase and 15.0% a decrease in the child's intake.

Table 1
Socioeconomic and demographic characteristics of the studied population.
Table 2
Changes in the food intake of preschoolers during the covid-19 pandemic.

The children’s frequency of intake of the evaluated ultra-processed cariogenic foods over the past three months is shown in Table 3. The ultra-processed cariogenic foods with the highest daily intake frequencies were sweetened juices/sweetened drinks, with a daily mean intake of 0.52 (SD=0.72), followed by cookies, with 0.37 (SD=0.48), and candies, with 0.35 (SD=0.49). The mean daily frequency of UCF intake was 1.63 (SD=1.75), the median was 1.07 (Minimum=0, Maximum=15) and the interquartile range was 1.49.

Table 3
Food intake frequency in preschoolers during the pandemic.

When the frequency of intake of ultra-processed cariogenic foods was dichotomized into high and low, it was observed that high intake was associated with parents’ lower level of formal education and lower availability of fruits or vegetables, assessed using PMAS (Table 4). This association is also shown in the multivariate regression model (Table 5).

Table 4
Association of frequency of intake of ultra-processed cariogenic foods and covariates in preschoolers during the pandemic.
Table 5
Multivariate Poisson regression model with robust variance for intake of ultra-processed cariogenic foods.

Parents with a lower level of education consumed 1.36 times more ultra-processed cariogenic foods when compared to those with a higher level of formal education (p=0.003). The lower the PMAS daily fruit and vegetables availability values, the higher the prevalence of intake of ultra-processed cariogenic foods (RP=0.716; 95%CI:0.592-0.866) (Table 5).

The analyses made showed that there was no significant difference between the group that answered the form in its physical version and the group that used the virtual version regarding formal education (p=0.060), per capita income (p=0.068), and age of the responsible person (p=0.245).

Discussion

This study showed that the COVID-19 pandemic modified the intake of ultra-processed cariogenic foods in preschoolers. The factors associated with high intake of this group of food items were the parents’/guardians’ lower level of formal education and lower values in the domain 'daily fruits and vegetables availability', which reflects the intake of these food items by parents and their offer to children. No studies investigating specifically the intake of ultra-processed cariogenic foods during the pandemic were found; however, some studies have investigated changes in food intake in children during this period [5[5] Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020; 28(8):1382-5. https://doi.org/10.1002/oby.22861
https://doi.org/10.1002/oby.22861...
,7[7] Androutsos O, Perperidi M, Georgiou C, Chouliaras G. Lifestyle changes and determinants of children's and adolescents' body weight increase during the first COVID-19 lockdown in Greece: The COV-EAT study. Nutrients 2021; 13(3):930. https://doi.org/10.3390/nu13030930
https://doi.org/10.3390/nu13030930...
,10[10] Adams EL, Caccavale LJ, Smith D, Bean MK. Food insecurity, the home food environment, and parent feeding practices in the era of COVID-19. Obesity 2020; 28(11):2056-63. https://doi.org/10.1002/oby.22996
https://doi.org/10.1002/oby.22996...

[11] Campagnaro R, Collet GO, Andrade MP, Salles JPDSL, Calvo Fracasso ML, Scheffel DLS, et al. COVID-19 pandemic and pediatric dentistry: fear, eating habits and parent's oral health perceptions. Child Youth Serv Rev 2020; 118:105469. https://doi.org/10.1016/j.childyouth.2020.105469
https://doi.org/10.1016/j.childyouth.202...

[12] Janssen M, Chang BPI, Hristov H, Pravst I, Profeta A, Millard J. Changes in food consumption during the COVID-19 pandemic: analysis of consumer survey data from the first lockdown period in Denmark, Germany, and Slovenia. Front Nutr 2021; 8:635859. https://doi.org/10.3389/fnut.2021.635859
https://doi.org/10.3389/fnut.2021.635859...
-13[13] Philippe K, Chabanet C, Issanchou S, Monnery-Patris S. Child eating behaviors, parental feeding practices and food shopping motivations during the COVID-19 lockdown in France: (How) did they change?. Appetite 2021; 161:105132. https://doi.org/10.1016/j.appet.2021.105132
https://doi.org/10.1016/j.appet.2021.105...
].

This study showed that almost half of parents/guardians reported a change in the quality of their children's food intake. In a survey conducted in France [13[13] Philippe K, Chabanet C, Issanchou S, Monnery-Patris S. Child eating behaviors, parental feeding practices and food shopping motivations during the COVID-19 lockdown in France: (How) did they change?. Appetite 2021; 161:105132. https://doi.org/10.1016/j.appet.2021.105132
https://doi.org/10.1016/j.appet.2021.105...
], 60% of the parents of 498 children from 3 to 12 years old reported a change in at least one dimension of their children’s eating behavior during the restrictive measures when compared to the previous period. In Brazil [11[11] Campagnaro R, Collet GO, Andrade MP, Salles JPDSL, Calvo Fracasso ML, Scheffel DLS, et al. COVID-19 pandemic and pediatric dentistry: fear, eating habits and parent's oral health perceptions. Child Youth Serv Rev 2020; 118:105469. https://doi.org/10.1016/j.childyouth.2020.105469
https://doi.org/10.1016/j.childyouth.202...
], in a study with 1003 parents of children from 0 to 12 years old, 61.5% of parents/guardians reported changes in their children's eating habits during the pandemic. The modifications have occurred to a greater or lesser degree depending on the period or place where they happened. These changes reveal the need for family monitoring of aspects of eating behavior to evaluate and minimize the impacts observed during the pandemic. Within the reported changes in children’s food intake, increased or decreased intake of certain food items [5[5] Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020; 28(8):1382-5. https://doi.org/10.1002/oby.22861
https://doi.org/10.1002/oby.22861...
,7[7] Androutsos O, Perperidi M, Georgiou C, Chouliaras G. Lifestyle changes and determinants of children's and adolescents' body weight increase during the first COVID-19 lockdown in Greece: The COV-EAT study. Nutrients 2021; 13(3):930. https://doi.org/10.3390/nu13030930
https://doi.org/10.3390/nu13030930...
,10[10] Adams EL, Caccavale LJ, Smith D, Bean MK. Food insecurity, the home food environment, and parent feeding practices in the era of COVID-19. Obesity 2020; 28(11):2056-63. https://doi.org/10.1002/oby.22996
https://doi.org/10.1002/oby.22996...
,11[11] Campagnaro R, Collet GO, Andrade MP, Salles JPDSL, Calvo Fracasso ML, Scheffel DLS, et al. COVID-19 pandemic and pediatric dentistry: fear, eating habits and parent's oral health perceptions. Child Youth Serv Rev 2020; 118:105469. https://doi.org/10.1016/j.childyouth.2020.105469
https://doi.org/10.1016/j.childyouth.202...
,13[13] Philippe K, Chabanet C, Issanchou S, Monnery-Patris S. Child eating behaviors, parental feeding practices and food shopping motivations during the COVID-19 lockdown in France: (How) did they change?. Appetite 2021; 161:105132. https://doi.org/10.1016/j.appet.2021.105132
https://doi.org/10.1016/j.appet.2021.105...
] were observed. A systematic review assessed eating behavior during COVID-19 and indicated changes in food consumption, characterized by an increased frequency of snacking and a preference for sweets and ultra-processed foods over fruits, vegetables, and fresh foods [24[24] González-Monroy C, Gómez-Gómez I, Olarte-Sánchez CM, Motrico E. Eating behaviour changes during the COVID-19 pandemic: a systematic review of longitudinal studies. Int J Environ Res Public Health 2021; 18(21):11130. https://doi.org/10.3390/ijerph182111130
https://doi.org/10.3390/ijerph182111130...
]. Among the reasons that could lead to this modification of eating habits during the pandemic are increased food insecurity [10[10] Adams EL, Caccavale LJ, Smith D, Bean MK. Food insecurity, the home food environment, and parent feeding practices in the era of COVID-19. Obesity 2020; 28(11):2056-63. https://doi.org/10.1002/oby.22996
https://doi.org/10.1002/oby.22996...
] and the confinement itself, which modified parental eating practices [25[25] Luo W, Cai Q, Zhou Y, Cai Y, Song H, Zhang Y, et al. Variation of parental feeding practices during the COVID-2019 pandemic: a systematic review. BMC Public Health 2022; 22(1):1600. https://doi.org/10.1186/s12889-022-14027-6
https://doi.org/10.1186/s12889-022-14027...
] by decreasing people's ability to acquire fresh food, increased consumption of takeout, and a preference for long shelf-life foods to minimize going out to buy groceries [26[26] Wang Y, Chen X, Yang Y, Cui Y, Xu R. Risk perception and resource scarcity in food procurement during the early outbreak of COVID-19. Public Health 2021; 195:152-7. https://doi.org/10.1016/j.puhe.2021.04.020
https://doi.org/10.1016/j.puhe.2021.04.0...
].

The literature indicates that parental education can influence the intake of unhealthy foods [27[27] Wijtzes AI, Jansen W, Jansen PW, Jaddoe VW, Hofman A, Raat H. Maternal educational level and preschool children's consumption of high-calorie snacks and sugar-containing beverages: mediation by the family food environment. Prev Med 2013; 57(5):607-12. https://doi.org/10.1016/j.ypmed.2013.08.014
https://doi.org/10.1016/j.ypmed.2013.08....
], even during the pandemic [13[13] Philippe K, Chabanet C, Issanchou S, Monnery-Patris S. Child eating behaviors, parental feeding practices and food shopping motivations during the COVID-19 lockdown in France: (How) did they change?. Appetite 2021; 161:105132. https://doi.org/10.1016/j.appet.2021.105132
https://doi.org/10.1016/j.appet.2021.105...
]. In this study, the association between parents’/guardians’ level of formal education and the intake of ultra-processed cariogenic foods was demonstrated. Children of parents with a lower level of formal education consumed more ultra-processed cariogenic foods than children of parents with more than 8 years of education. The literature shows that low parental education is related to lack of access to information and lower purchasing power of families, which triggers inappropriate eating practices such as increased consumption of UFC [28[28] Pereira AM, Buffarini R, Domingues MR, Barros FCLF, Silveira MFD. Ultra-processed food consumption by children from a Pelotas birth cohort. Rev Saude Publica 2022; 56:79. https://doi.org/10.11606/s1518-8787.2022056003822
https://doi.org/10.11606/s1518-8787.2022...
]. The pandemic led to a crisis in the food supply and distribution system and an increase in food insecurity due to the decrease in household income, which can be more aggressive in those with low education [26[26] Wang Y, Chen X, Yang Y, Cui Y, Xu R. Risk perception and resource scarcity in food procurement during the early outbreak of COVID-19. Public Health 2021; 195:152-7. https://doi.org/10.1016/j.puhe.2021.04.020
https://doi.org/10.1016/j.puhe.2021.04.0...
]. A lower level of education may be associated with negative changes in eating behavior, indicating that parents/guardians with different levels of education may exhibit different eating behaviors during the pandemic [13[13] Philippe K, Chabanet C, Issanchou S, Monnery-Patris S. Child eating behaviors, parental feeding practices and food shopping motivations during the COVID-19 lockdown in France: (How) did they change?. Appetite 2021; 161:105132. https://doi.org/10.1016/j.appet.2021.105132
https://doi.org/10.1016/j.appet.2021.105...
,27[27] Wijtzes AI, Jansen W, Jansen PW, Jaddoe VW, Hofman A, Raat H. Maternal educational level and preschool children's consumption of high-calorie snacks and sugar-containing beverages: mediation by the family food environment. Prev Med 2013; 57(5):607-12. https://doi.org/10.1016/j.ypmed.2013.08.014
https://doi.org/10.1016/j.ypmed.2013.08....
].

Even before the covid pandemic, the literature indicated a high intake of ultra-processed foods in young children in Brazil [29[29] Leme ACB, Fisberg RM, Thompson D, Philippi ST, Nicklas T, Baranowski T. Brazilian children's dietary intake in relation to Brazil’s new nutrition guidelines: a systematic review. Curr Nutr Rep 2019; 8(2):145-66. https://doi.org/10.1007/s13668-019-0261-6
https://doi.org/10.1007/s13668-019-0261-...
]. This food intake profile shows increased availability of energy-rich, nutrient-poor, and sugar-sweetened snacks and drinks, especially in low and middle-income countries, where home-cooked meals are replaced by ultra-processed foods [30[30] Pries AM, Filteau S, Ferguson EL. Snack food and beverage consumption and young child nutrition in lowand middle-income countries: A systematic review. Matern Child Nutr 2019; 15(Suppl 4):e12729. https://doi.org/10.1111/mcn.12729
https://doi.org/10.1111/mcn.12729...
]. The consumption of ultra-processed foods is related to several adverse health outcomes, particularly in children, as shown in a recent systematic review. These outcomes include poor nutritional quality of the diet, adiposity and lipid profile changes, overweight, poor dietary practices, respiratory diseases, and an increased occurrence of dental caries [31[31] de Oliveira PG, de Sousa JM, Assunção DGF, de Araujo EKS, Bezerra DS, Dametto JFDS, et al. Impacts of consumption of ultra-processed foods on the maternal-child health: a systematic review. Front Nutr 2022; 9:821657. https://doi.org/10.3389/fnut.2022.821657
https://doi.org/10.3389/fnut.2022.821657...
]. Childhood eating practices contribute to lifelong nutritional habits and are influenced by family attitudes and eating patterns [20[20] Litchford A, Savoie Roskos MR, Wengreen H. Influence of fathers on the feeding practices and behaviors of children: A systematic review. Appetite 2020; 147:104558. https://doi.org/10.1016/j.appet.2019.104558
https://doi.org/10.1016/j.appet.2019.104...
]. Changes in food intake are mainly influenced by income and food demand [32[32] Popkin BM. Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. Am J Clin Nutr 2006; 84(2):289-98. https://doi.org/10.1093/ajcn/84.2.289
https://doi.org/10.1093/ajcn/84.2.289...
], both of which were affected during the pandemic [33[33] Jafri A, Mathe N, Aglago EK, Konyole SO, Ouedraogo M, Audain K, et al. Food availability, accessibility and dietary practices during the COVID-19 pandemic: a multi-country survey. Public Health Nutr 2021; 24(7):1798-1805. https://doi.org/10.1017/S1368980021000987
https://doi.org/10.1017/S136898002100098...
]. The increasing trends in the consumption of ultra-processed foods verified in Brazil [34[34] Monteiro CA, Levy RB, Claro RM, de Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr 2011; 14(1):5-13. https://doi.org/10.1017/S1368980010003241
https://doi.org/10.1017/S136898001000324...
] may have influenced the result of our study, however, it should be considered that was also an increase in the purchase of ultra-processed foods during the confinement period [12[12] Janssen M, Chang BPI, Hristov H, Pravst I, Profeta A, Millard J. Changes in food consumption during the COVID-19 pandemic: analysis of consumer survey data from the first lockdown period in Denmark, Germany, and Slovenia. Front Nutr 2021; 8:635859. https://doi.org/10.3389/fnut.2021.635859
https://doi.org/10.3389/fnut.2021.635859...
]. As a consequence of home confinement, children started having their meals exclusively at home, which increases parental responsibility in food preparation and changes their eating practices [10[10] Adams EL, Caccavale LJ, Smith D, Bean MK. Food insecurity, the home food environment, and parent feeding practices in the era of COVID-19. Obesity 2020; 28(11):2056-63. https://doi.org/10.1002/oby.22996
https://doi.org/10.1002/oby.22996...
], especially within the working from home context.

The excessive consumption of sugary drinks is a risk factor for the development of several chronic diseases [35[35] Imamura F, O'Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ 2015; 351:h3576. https://doi.org/10.1136/bmj.h3576
https://doi.org/10.1136/bmj.h3576...
], and its consumption has remained high, especially in countries burdened by diet-related chronic diseases [36[36] Ooi JY, Wolfenden L, Sutherland R, Nathan N, Oldmeadow C, Mclaughlin M, et al. A systematic review of the recent consumption levels of sugar-sweetened beverages in children and adolescents from the World Health Organization regions with high dietary-related burden of disease. Asia Pac J Public Health 2022; 34(1):11-24. https://doi.org/10.1177/10105395211014642
https://doi.org/10.1177/1010539521101464...
]. In our study, the ultra-processed food that showed the highest increase in consumption was sweetened juices/sweetened drinks, which is consistent with literature data that indicate higher consumption of this type of ultra-processed beverage when compared to other foods [37[37] Costa CDS, Buffarini R, Flores TR, Neri D, Freitas Silveira M, Monteiro CA. Consumption of ultra-processed foods and growth outcomes in early childhood: 2015 Pelotas Birth Cohort. Br J Nutr 2022; 12:1-22. https://doi.org/10.1017/S0007114522002926
https://doi.org/10.1017/S000711452200292...
]. One factor that could favor a more expressive increase in sweetened juices/sweetened drinks over other CFUs would be the fact that young children regularly consume sweetened fruit drinks, in part because parents may falsely believe them to be healthy due to the claims and images on the front of the package [38[38] Musicus AA, Hua SV, Moran AJ, Duffy EW, Hall MG, Roberto CA, et al. Front-of-package claims & imagery on fruit-flavored drinks and exposure by household demographics. Appetite 2022; 171:105902. https://doi.org/10.1016/j.appet.2021.105902
https://doi.org/10.1016/j.appet.2021.105...
].

The results pointed out that, regarding parents' behavior during children's meals, the lower the values of the 'daily fruits and vegetables availability' domain of PMAS, the higher the prevalence of intake of ultra-processed cariogenic foods. Thus, it can be considered that a family in which parents offer fruits and vegetables to their children and also consume this type of food, acting as a model, usually has a low intake of ultra-processed cariogenic foods. A nationwide study [39[39] Groele B, Głąbska D, Gutkowska K, Guzek D. Mother's fruit preferences and consumption support similar attitudes and behaviors in their children. Int J Environ Res Public Health 2018; 15(12):2833. https://doi.org/10.3390/ijerph15122833
https://doi.org/10.3390/ijerph15122833...
] showed that mothers' fruit intake influenced their children's attitudes and behavior toward fruit intake, highlighting the importance of the parental model in the child's dietary profile. The other PMAS domains assessed were not associated with a high intake of ultra-processed cariogenic foods in the multiple analysis. In the studied group, offering and consuming food items from a 'healthy' category was the most important factor in defining the frequency of intake of ultra-processed cariogenic foods. Thus, parental modeling showed a greater positive impact on feeding than setting limits.

On the other hand, a systematic review with meta-analysis [40[40] Yee AZ, Lwin MO, Ho SS. The influence of parental practices on child promotive and preventive food consumption behaviors: a systematic review and meta-analysis. Int J Behav Nutr Phys Act 2017; 14(1):47. https://doi.org/10.1186/s12966-017-0501-3
https://doi.org/10.1186/s12966-017-0501-...
], which included studies out of the pandemic context, demonstrated that parenting may depend on the context of food intake and the child's age. It also indicated that regarding the intake of healthy foods, active guidance and education may be more effective, while regarding the intake of unhealthy foods, rules and guidelines may be more effective. Yet, the particular context of social isolation, which narrowed family relationships, must be taken into account.

Because the pandemic brought several difficulties for the elaboration and development of epidemiological surveys, the results of this study must be analyzed in light of its limitations. Among them, the differences in the way the questionnaire was delivered (physically or virtually) may have resulted in selection bias. It should also be pointed out that this is a cross-sectional study and the attribution of causality to its results needs to be confirmed in longitudinal research.

Conclusion

The pandemic of COVID-19 affected the lives and daily lives of the population globally, and in our study, we observed that modifications in the consumption of ultra-processed foods in preschoolers occurred. Furthermore, this change in consumption was associated with parents' low education level and parental behavior during the child's mealtime. Therefore, considering the data found in our work, we suggest that parents make more fruits, vegetables, and healthy foods available to their children to attempt to reduce the consumption of ultra-processed foods.

  • Academic Editor: Lucianne Cople Maia
  • Financial Support
    This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Data Availability

The data used to support the findings of this study can be made available upon request to the corresponding author.

Acknowledgements

The authors would like to thank the Academic Publishing Advisory Center (Centro de Assessoria de Publicação Acadêmica, CAPA) of the Federal University of Paraná (UFPR) for assistance with English language translation and developmental editing.

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Publication Dates

  • Publication in this collection
    10 July 2023
  • Date of issue
    2023

History

  • Received
    13 May 2022
  • Reviewed
    01 Oct 2022
  • Accepted
    24 Nov 2022
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