Factors associated with feeding practices among Brazilian children aged 12 to 23 months old

Rebouças, Adriana Gama; Bernardino, Ítalo de Macedo; Dutra, Emiliane Rodrigues; Imparato, José Carlos Pettorossi; Duarte, Danilo Antonio; Flório, Flávia Martão

doi:10.1590/1806-93042020000400007

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Revista Brasileira de Saúde Materno Infantil

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ORIGINAL ARTICLES • Rev. Bras. Saude Mater. Infant. 20 (04) • Oct-Dec 2020 • https://doi.org/10.1590/1806-93042020000400007 copy

Factors associated with feeding practices among Brazilian children aged 12 to 23 months old

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives:

a quantitative analytical cross-sectional study aimed to identify demographic characteristics to access health services and housing conditions in relation to inadequate feeding practices among Brazilian children from 12 to 23 months of age.

Methods:

the analysis of the feeding practices (consumption of recommended food groups) of 2541 Brazilian children (aged 12-23 months old) was performed using data from the Pesquisa Nacional de Saúde 2013 (National Health Survey). Descriptive and multivariate statistics used the Decision Tree Analysis based on CHAID (Chi-squared Automatic Interaction Detector) algorithm, as well as hierarchically adjusted Poisson regression analyses were performed. The variables were entered in a hierarchical model at distal (demographic), intermediate (access to health) and proximal (housing conditions) levels.

Results:

the results showed a high prevalence of sugar consumption (85.5%; CI95%=83.7-87.2) and highlighted inadequate feeding practices among non-white children (p=0.001), resident in the North (p<0.001) and Northeast (p=0.010) of Brazil and in towns in the countryside (p<0.001) presented feeding practices that were not recommended for consumption in the food groups.

Conclusions:

non-white children, who lived in the North and Northeast regions of Brazil and in the countryside, which are known to be more socioeconomically vulnerable, were more likely to experience inadequate feeding practices.

Key words:
Complementary feeding; Inequality in Health; Child health; Brazil

Variables	N^a a Unweighted estimates;	%^b b Weighted estimates considering complex sampling plan.	CI95%^b b Weighted estimates considering complex sampling plan.
Food characteristics

Consumes food with sugar
Yes	2158	85.5	83.7-87.2
No	383	14.5	12.8-16.3
Feeding practice
Adequate	1238	51.2	48.8-53.7
Inadequate	1303	48.8	46.3-51.2
Milk
No	121	4.5	3.6-5.6
Yes	2420	95.5	94.4-96.4
Fruit
No	491	17.9	16.1-19.9
Yes	2050	82.1	80.1-83.9
Vegetables/Legumes
No	771	28.7	26.5-30.9
Yes	1770	71.3	69.1-73.5
Grains
No	554	20.0	18.1-22.0
Yes	1987	80.0	78.0-81.9
Cereal/tubers
No	330	11.5	10.1-13.1
Yes	2211	88.5	86.9-89.9
Iron consumption
No	295	10.5	9.1-12.0
Yes	2246	89.5	88.0-90.9

Demographic characteristics

Sex
Male	1293	53.0	50.5-55.4
Female	1248	47.0	44.6-49.5
Skin color
White	1055	43.7	41.2-46.1
Non-white	1486	56.3	53.9-58.8
Region in Brazil
North	744	19.4	17.8-21.2
Northeast	786	36.0	33.7-38.5
Midwest	303	16.2	14.3-18.2
Southeast	461	17.4	15.6-19.3
South	247	11.0	9.5-12.6
Area of residence
Urban	1980	79.8	77.7-81.7
Rural	561	20.2	18.3-22.3
Type of residence
State Capital/Metropolitan Region	1531	58.4	55.9-60.8
Rural region of state	1010	41.6	39.2-44.1

Access to health care services

Health insurance
Yes	598	25.8	23.7-28.0
No	1943	74.2	72.0-76.3
Child's health status as reported by the respondent
Very good or good	2247	89.1	87.5-90.5
Fair, poor or very poor	294	10.9	9.5-12.5
Last medical appointment
< 1 Year	2307	92.1	90.6-93.3
> 1 Year	162	5.6	4.6-6.8
Never	72	2.3	1.7-3.2
Number of medical appointments in the last 12 months
0 to 1 appointment	664	24.7	22.6-26.9
2 to 6 appointments	1287	51.8	49.3-54.3
≥ 7 appointments	590	23.5	21.4-25.6
Has child been to the dentist
Yes	452	17.5	15.7-19.4
No	2089	82.5	80.6-84.3
Where is the child's growth monitored
Private or company clinic	548	23.8	21.7-26.0
Public hospital, polyclinic or health unit	1694	65.4	63.0-67.7
Other	69	2.5	1.8-3.5
No follow-up monitored	230	8.3	7.0-9.7
Is household registered at the Family Health Unit
Yes	1471	59.6	57.2-62.0
No	1070	40.4	38.0-42.8
Have you received visits from a Community Health Agent
Yes	1245	51.0	48.6-53.5
No	1296	49.0	46.5-51.4

Housing conditions

Number of residents per room (median = 0.8)
≤ 0.8	1391	58.6	56.1-61.0
>0.8	1150	41.4	39.0-43.9
Status of resident at home
Child of parent/guardian and spouse	1672	66.1	63.7-68.3
Child or stepchild of parent/guardian only	244	9.8	8.4-11.4
Grandchild or great-grandchild	552	21.2	19.3-23.3
Other	73	3.0	2.2-3.9
Predominant material of the house walls
Masonry with cladding + suitable wood	2161	84.0	82.1-85.8
Finished wood / straw / rammed earth / other	85	3.2	2.4-4.2
Uncoated masonry	295	12.8	11.2-14.6
Water supply at home
General network	1854	75.7	73.6-77.8
Other	687	24.3	22.2-26.4
Water used for drinking
Treated (mineral, boiled filtrate or other home treatment)	1642	66.6	64.2-68.8
Untreated (without home treatment)	899	33.4	31.2-35.8
Residence with kitchen
Yes	2407	96.2	95.3-97.0
No	134	3.8	3.0-4.7
Residence with television
Yes	2427	96.7	95.7-97.4
No	114	3.3	2.6-4.3
Residence with microwave
Yes	988	40.5	38.1-43.0
No	1553	59.5	57.0-61.9
Residence with internet access
Yes	888	36.3	33.9-38.7
No	1653	63.7	61.3-66.1

Variables	Dietary practice						PR Gross (CI95%)	P ^a
	Adequate		Inadequate		Total
	n	%	n	%	n	%
Demographic characteristics

Sex
Male	619	50.6	674	49.4	1293	100.0	1
Female	619	52.0	629	48.0	1248	100.0	0.97 (0.88-1.07)	0.575
Skin Color
White	594	58.5	461	41.5	1055	100.0	1
Non-white	644	45.6	842	54.4	1486	100.0	1.31 (1.18-1.46)	<0.001 ^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Region in Brazil
North	250	35.9	494	64.1	744	100.0	1
Northeast	349	44.2	437	55.8	786	100.0	0.96 (0.74-1.23)	0.731
Midwest	185	63.7	118	36.3	303	100.0	0.97 (0.75-1.25)	0.817
Southeast	298	64.2	163	35.8	461	100.0	1.49 (1.21-1.83)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
South	156	62.6	91	37.4	247	100.0	1.71 (1.39-2.10)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Area of residence
Urban	1034	54.4	946	45.6	1980	100.0	1
Rural	204	38.7	357	61.3	561	100.0	1.34 (1.21-1.50)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Type of residence
State Capital/Metropolitan Region	825	57.2	706	42.8	1531	100.0	1
Rural region of the State	413	42.8	597	57.2	1010	100.0	1.34 (1.21-1.48)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.

Characteristics of access to health services

Health insurance
Yes	392	65.6	206	34.4	598	100.0	1
No	846	46.2	1097	53.8	1943	100.0	1.56 (1.35-1.81)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Child's health status as reported by the respondent
Very good or good	1118	52.3	1129	47.7	2247	100.0	1
Fair, poor or very poor	120	42.6	174	57.4	294	100.0	1.20 (1.05-1.38)	0.008^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Last medical appointment
< 1 Year	1169	52.9	1138	47.1	2307	100.0	1
> 1 Year	54	35.9	108	64.1	162	100.0	1.36 (1.16-1.60)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Never	15	21.5	57	78.5	72	100.0	1.67 (1.39-1.99)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Has child ever been to the dentist
Yes	268	60.8	184	39.2	452	100.0	1
No	970	49.2	1119	50.8	2089	100.0	1.30 (1.11-1.51)	0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Where is the child's growth monitored
Private or company clinic	355	64.6	193	35.4	548	100.0	1
Public hospital, polyclinic or health unit	784	48.9	910	51.1	1694	100.0	1.45 (1.24-1.68)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Other	29	39.7	40	60.3	69	100.0	1.70 (1.27-2.29)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
No follow-up on monitoring	70	34.9	160	65.1	230	100.0	1.84 (1.52-2.23)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Is household registered with Family
Health Unit
Yes	709 ()	50.1	762	49.9	1471	100.0	1
No	529 ()	52.8	541	47.2	1070	100.0	0.95 (0.85-1.05)	0.287
Have you received visits from a Community
Health Agent
Yes	578	47.5	667	52.5	1245	100.0	1
No	660	55.0	636	45.0	1296	100.0	0.86 (0.77-0.95)	0.003^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Characteristics related to housing conditions
Number of residents per room
≤0.8	775	56.8	616	43.2	1391	100.0	1
>0.8	463	43.4	687	56.6	1150	100.0	1.30 (1.19-1.45)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Status of resident at home
Child of parent/guardian and spouse	842	52.7	830	47.3	1672	100.0	1
Child or stepchild of parent/guardian	117	47.2	127	52.8	244	100.0	1.12 (0.94-1.32)	0.196
Grandchild or great-grandchild	248	49.4	304	50.6	552	100.0	1.07 (0.95-1.21)	0.274
Other	31	45.4	42	54.6	73	100.0	1.15 (0.88-1.51)	0.306
Predominant material of house walls
Masonry with cladding + suitable wood	1093	53.3	1068	46.7	2161	100.0	1
Finished wood / straw / rammed earth / other	21	25.7	64	74.3	85	100.0	1.59 (1.35-1.88)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Uncoated masonry	124	43.7	171	56.3	295	100.0	1.21 (1.05-1.39)	0.008^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Water supply at home
General network	977	54.3	877	45.7	1854	100.0	1
Other (water tank, cistern, well, river, lake, stream, other)	261	41.8	426	58.2	687	100.0	1.27 (1.15-1.41)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Water used for drinking
Treated	873	55.6	769	44.4	1642	100.0	1
Untreated	365	42.6	534	57.4	899	100.0	1.29 (1.17-1.43)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Residence with kitchen
Yes	1196	51.5	1211	48.5	2407	100.0	1
No	42	44.4	92	55.6	134	100.0	1.15 (0.93-1.42)	0.210
Residence with television
Yes	1211	52.2	1216	47.8	2427	100.0	1
No	27	23.6	87	76.4	114	100.0	1.60 (1.38-1.84)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Residence with microwave
Yes	606	62.4	382	37.6	988	100.0	1
No	632	43.6	921	56.4	1553	100.0	1.50 (1.34-1.68)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.
Residence with internet access
Yes	553	63.0	335	37.0	888	100.0	1
No	685	44.5	968	55.5	1653	100.0	1.50 (1.33-1.69)	<0.001^* * p<0.05; a Variables with p<0.25 in the bivariate analysis or considered epidemiological determinants (such as the sex of the child) were incorporated into the multivariate analysis.

Variables	Model 1^a a Model 1 adjusted for individual characteristics (demographic variables);		Model 2^b b Model 2 adjusted for individual characteristics (demographic variables and those related to access to health services);		Model 3^c c Model 3 adjusted for individual and contextual characteristics (demographic variables, related to access to health services and housing conditions);		Model 4^d d Model 4 final.
Variables	PR Adjusted (CI95%)	p	PR Adjusted (CI95%)	p	PR Adjusted (CI95%)	p	PR Adjusted (CI95%)	p
Block 1

Demographic characteristics
Sex
Male	1		1		1		-	-
Female	0.95 (0.87-1.95)	0.346	0.94 (0.86-1.04)	0.242	0.95 (0.86-1.05)	0.270	-	-
Skin Color
White	1		1		1		1
Non-white	1.19 (1.07-1.33)	0.002^* * p<0.05;	1.14 (1.02-1.27)	0.021^* * p<0.05;	1.12 (1.01-1.25)	0.038^* * p<0.05;	1.19 (1.07-1.33)	0.001^* * p<0.05;
Region
North	1.49 (1.21-1.84)	<0.001^* * p<0.05;	1.40 (1.13-1.72)	0.002^* * p<0.05;	1.35 (1.08-1.68)	0.008^* * p<0.05;	1.46 (1.18-1.80)	<0.001^* * p<0.05;
Northeast	1.30 (1.06-1.61)	0.013^* * p<0.05;	1.25 (1.01-1.53)	0.038^* * p<0.05;	1.25 (1.01-1.55)	0.046^* * p<0.05;	1.31 (1.07-1.62)	0.010^* * p<0.05;
Midwest	0.89 (0.69-1.15)	0.366	0.88 (0.68-1.14)	0.343	0.90 (0.69-1.16)	0.401	0.89 (0.69-1.15)	0.366
Southeast	0.88 (0.69-1.12)	0.303	0.89 (0.70-1.14)	0.376	0.93 (0.72-1.19)	0.554	0.88 (0.69-1.13)	0.317
South	1		1		1		1
Area of residence
Urban	1		1		1		-	-
Rural	1.15 (1.03-1.29)	0.014^* * p<0.05;	1.10 (0.98-1.23)	0.121	1.03 (0.90-1.18)	0.708	-	-
Type of residence
State Capital/Metropolitan Region	1		1		1		1
Rural region in the State	1.21 (1.09-1.35)	<0.001^* * p<0.05;	1.15 (1.03-1.28)	0.016^* * p<0.05;	1.12 (1.01-1.25)	0.047^* * p<0.05;	1.26 (1.14-1.38)	<0.001^* * p<0.05;

Block 2

Characteristics of access to health services:
Health insurance
Yes			1		1		-	-
No			1.22 (1.01-1.48)	0.044^* * p<0.05;	1.16 (0.95-1.41)	0.139	-	-
Child's health status as reported by the respondent
Very good or good			1		1		-	-
Fair, poor or very poor			1.07 (0.94-1.22)	0.307	1.06 (0.92-1.21)	0.417	-	-
Last medical appointment
< 1 Year			1		1		1
> 1 Year			1.24 (1.05-1.47)	0.011^* * p<0.05;	1.24 (1.05-1.46)	0.012^* * p<0.05;	1.26 (1.06-1.49)	0.007^* * p<0.05;
Never			1.24 (1.03-1.48)	0.022^* * p<0.05;	1.21 (1.02-1.44)	0.031^* * p<0.05;	1.33 (1.12-1.57)	0.001^* * p<0.05;
Has child ever been to the dentist
Yes			1		1		-	-
No			1.10 (0.94-1.29)	0.245	1.08 (0.92-1.26)	0.357	-	-
Where is the child's growth monitored
Private or company clinic			1		1		-	-
Public hospital, polyclinic or health unit			1.04 (0.86-1.26)	0.694	0.96 (0.78-1.17)	0.662	-	-
Other			1.03 (0.75-1.42)	0.852	0.96 (0.70-1.31)	0.779	-	-
No follow-up on monitoring			1.17 (0.93-1.47)	0.192	1.06 (0.83-1.34)	0.644	-	-
Have you received visits from a Community
Health agent
Yes			1		1		-	-
No			0.99 (0.89-1.09)	0.805	0.99 (0.90-1.10)	0.937	-	-

Block 3

Characteristics related to housing conditions:
Number of residents per room
≤0.8					1		-	-
>0.8					1.08 (0.98-1.20)	0.134	-	-
Predominant material of the house walls
Masonry with cladding + suitable wood					1		-	-
Finished wood / straw / rammed earth / other					1.08 (0.90-1.28)	0.411	-	-
Unclad masonry					1.05 (0.92-1.20)	0.474	-	-
Water supply of residence
General network					1		-	-
Other (water tank, cistern, well, river, lake, stream, other)					1.02 (0.91-1.15)	0.735	-	-
Water used for drinking
Treated					1		-	-
Untreated					1.10 (0.99-1.22)	0.083	-	-
Residence with television
Yes					1		-	-
No					1.14 (0.99-1.33)	0.078	-	-
Residence with microwave
Yes					1		-	-
No					1.05 (0.91-1.21)	0.487	-	-
Residence with internet access
Yes					1		-	-
No					1.12 (0.97-1.29)	0.121	-	-

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