Children's nutritional status-the impacts of the pandemic and their perspectives for prevention

Brazil currently lives in a new scenario of serious nutritional problems in childhood. In addition to malnutrition in several regions of the country, another nutritional disorder is raised: excessive weight. In addition to this context, in 2020, COVID-19 appears, making this scenario even more problematic. Thus, this study aimed to evaluate the effects of the pandemic on the nutritional health of children aged 0 to 10 years, in relation to their overweight, in the national territory. A cross-sectional, retrospective and quantitative approach was developed. Data for research were taken from official government websites, namely: SISVAN Web (Food and Nutrition Surveillance), DATASUS and e-SUS Web, in which sociodemographic data from Brazil were analyzed and in its five socio-political regions. The variables analyzed were: gender, age group and zone of occurrence. The profile showed no statistically significant differences in the prevalence of children’s overweight in Brazil, regardless of age group, in the period between 2017 and 2021. However, there was a clear trend, although not significant, of increased prevalence of children with overweight, except in the age groups from 0 to 6 months and from 6 months to two years, which showed a stationary trend. In relation to the socio-political regions, it was possible to identify a trend of increasing weight gain for age, in all regions, being lower in the North and higher to the Southeast region. It should be noted that this trend of increasing weight gain was only significant in the southern region, where the prevalence of overweight was significantly higher (G Test; p<0.0001) in 2021. There is no statistically significant difference between gender groups, despite the greater number of cases being male. Thus, it can be concluded that child weight gain is closely related to multifactorial causes, among which we can highlight the socioeconomic region, culture, social isolation in the pandemic and purchasing power. In this way, the importance of the nutritionist professional in the health units is reinforced, as the main propagator of actions aimed to promote, treat and rehabilitate children's health, especially through the pandemic.


Introduction
Disorders related to overweight, considered by the World Health Organization -WHO as resulting from the accumulation of fat in the body, derived from an energy imbalance (WHO, 2000), have become, in recent years, one of the greatest health challenges of the contemporary generation, as such health problems affect the whole world exponentially, since from 1980 to 2013, there was a 27.5% increase in overweight in adults (Ng et al., 2014), evidence that also is being identified in the child population, particularly in recent decades and in all countries (Batch & Baur, 2005).
In Brazil, about 40% of the adult population has excessive body weight, which is a disorder identified in all social stratifications (Monteiro et al., 2004), a fact that culminates in a worrying and contrasting evidence, according to which Brazil follows the global trend of a nutritional transition, which occurs when a nation stops having many cases of child malnutrition and starts to present high numbers of children's overweight and obesity (Clemente et al., 2011;Cohen et al., 2013;Batista Filho & Rissin, 2003;Bermudez & Tucker, 2003).
It is possible to exemplify the severity of this problem through data published by the World Health Organization (WHO, 2018), which showed that the number of school-age young people with obesity in the last 40 years raised from 11 to 124 million, representing an increase of approximately 11 times the value detected since the beginning of the world historical series. In Brazil, a survey was published by the Food and Nutrition Surveillance System -SISVAN, in 2019, from which it became evident that about 10% of the Brazilian population between 5 and 10 years old is overweight for their age, surpassing the same survey carried out in 2009, in which only 3.8% of the population belonging to this same age group was overweight (SISVAN, 2009).
In view of the above, a greater proportion of children may suffer the consequences of overweight, presenting a greater risk of developing cardiovascular problems, resulting from the increase in the amount of body fat (Silva, 2010), and probable future cases of aggravation of these conditions, with an increased probability of developing chronic non-communicable diseases such as hypertension, glucose resistance, dyslipidemia and hyperinsulinemia (Del Río-Navarro et al., 2004). It is also worth noting that among children with obesity, the chance of remaining overweight in adulthood is double higher (Bleich et al., 2018;Balaban & Silva, 2001), which makes weight gain in children a major challenge for Public Health.
In this worrying contemporary scenario, COVID-19 appears as an aggravating factor, which affects the respiratory system of its victims and, due to its high transmissibility, has spread exponentially worldwide, which resulted in the declaration of a pandemic by the World Health Organization. (WHO) on March 11, 2020(OPAS, 2020. In Brazil, this disease caused 100,000 deaths, until August 8, 2020 (ECDC, 2020) and due to such circumstances, precautionary measures were taken by Governmental Bodies such as the closing of secondary businesses, cancellation of face-to-face classes and suspension of meetings (Aquino et al., 2020), measures that, although important, can potentially add to an increase in the occurrence of disorders related to the mental and physical condition of individuals and their respective family relationships (Brooks et al., 2020;Lima et al., 2020), which can also have an important impact on children, since such circumstances make them more susceptible to changes in their diet (CFN, 2020), which can affect their nutritional status.
The present study aimed to identify and evaluate sociodemographic and epidemiological aspects related to the increase in child weight and to identify how the pandemic due to COVID-19 may have influenced these indicators.

Methodology
This is a cross-sectional, retrospective study with a quantitative approach, in which sociodemographic data were analyzed in Brazil in general, and in their respective administrative regions (South, Southeast, Midwest, North and Northeast), with regard to the obesity-related morbidity coefficients. Data collection was carried out using official government websites as a source of data, in the last 5 years, namely: SISVAN -Web (Food and Nutrition Surveillance), DATASUS and e-SUS Web, in order to assess the prevalence of overweight for age in children under 10 years of age and associated factors. The variables analyzed were: gender, age group and zone of occurrence. The weight-for-age index was chosen due to the greater coverage of children's age groups.
The results obtained were arranged in Excel spreadsheets and statistically evaluated, using the G test, in order to verify differences between the epidemiological data obtained, and the Bioestat 5.3 software as a support tool.

Discussion
After collecting and analyzing data on the weight of children belonging to the age groups addressed in this study, it was observed that there were no statistically significant differences in the prevalence of children with overweight in Brazil, regardless of age group, in the period between the years 2017 to 2021, as shown in Figure 1.
The absence of a statistically significant increase in children with high body weight may be related to the purchasing power of the families to which such children belong (Silva et al., 2018), since the data evaluated in the present work come from a child population probably less privileged families, since the database that served as the basis for the composition of the results, namely the SISVAN, concerns children registered and treated in public health units, which normally do not serve children with high purchasing power, as they usually undergo consultations with nutritionists and pediatricians from the private network. (Ribeiro et al., 2003) This hypothesis can be reinforced based on the national health survey carried out in 2019 (IBGE, 2020), according to which 64.7% of users of public primary care services had a per capita household income of less than one minimum wage and the next 32.3% were in the range of 1 to 3 minimum wages, reaching a total of 97% of users belonging to families with low purchasing power.
In addition, in the period of the pandemic, the financial crisis that was established may have made it even more difficult to acquire food with higher cost, including ultra-processed and industrialized foods, which are possibly possessing a higher content of calories (ILO, 2020). According to Aquino & Philippi (2002) eating practices are important factors in determining health conditions in childhood, being closely linked to family purchasing power, on which the qualitative and quantitative availability of food consumed depends. Also according to these authors, the consumption of chocolate, yogurt and powdered milk is much more frequent among children belonging to families with higher purchasing power, not occurring frequently in those from poorest families, a factor that can influence a less weight gain, even in the conditions of social isolation that were necessary in the pandemic, and which led to a greater sedentary lifestyle in children, which theoretically should have resulted in a greater number of individuals with excessive body weight.
It is worth noting that, despite the fact that they are children from families with lower purchasing power, in the age groups of two to five years, from five to seven years and from seven to ten years, there was a clear trend, although not significant, of an increase in the prevalence of children with overweight, which culminated in the year 2021, the same not occurring in the age groups from 0 to 6 months and from 6 months to two years, which showed a stationary trend, demonstrating that the occurrence of weight in excess in children is probably linked to advancing age, so that as they grow and move away from the birth period, the diet is modified, with the introduction of new foods, many of which are ultra-processed and hypercaloric, as cited by Matos et al. (2011).
Such trends may be related to the typical food profile of each age group, since in those with a stationary trend, the predominant food is breast milk, and its consumption is intensely stimulated, healthy, safe and necessary. In fact, according to the food guide for children under 2 years of age, the WHO recommends that breastfeeding be the only source of food for children up to 6 months of age, and, if possible, should be continued at least until the second year of life (Brazil, 2002).
However, in age groups above the age of 2 years, there is a tendency to increase adherence to unbalanced diets in terms of calories, which maximizes the possibility of weight gain, beyond what is acceptable, and which can worsen during the pandemic and of the consequent social distancing, where a sedentary lifestyle prevails over activities that allow energy expenditure, such as the practice of sports and access to public leisure places (Black & Hurley, 2007;Garcia & Duarte, 2020). It is worth noting that the trend was not statistically significant, and this evidence may be linked to the fact that the analysis of the study was carried out on children registered in the public health system, as mentioned above, and because the country is still in development, since overweight is more common in developed countries, being, over the years, detected more frequently and initially in higher social classes in developing countries, such as Brazil, modifying this scenario only recently (Zeferino et al. , 2003;Costa et al., 2006;Wang et al.,2002).
This statement can be proven by Aquino and Philippi (2002), who claim that a country's income is proportionally associated with the degree of refinement and industrialization of the food consumed. In the United States, for example, approximately 46% of household food expenditures are on meals away from home, of which 34% are on fast foods (Nicklas et al., 2001), negatively impacting the health of the population, since approximately 18.5% of North American children and adolescents are obese (Hales et al., 2017), while in Brazil, this number drops to 13.2% (Brasil, 2021).
It is still worth noting that, in developed countries, most cases of excess weight are from lower social classes due to the greater ease of contact with high-calorie foods, while in underdeveloped or developing countries, cases of increased body weight are more prevalent in high-income children, given the greater difficulty in accessing these foods (Sobal et al., 2003;Monteiro et al., 2004). In a cross-sectional study produced by Rech et al. (2010), in Serrana-RS, overweight and obese children were evaluated according to their families' income. In this study, it was found that overweight children represented 30.3% among those with high and intermediate income, in contrast to only 17.6% among low-income children, which demonstrates that children with better economic conditions may have approximately twice the chance of developing overweight concomitant with obesity.
The same scenario can be observed in studies carried out before the aforementioned one, such as the study carried out by Siqueira and Monteiro (2007) and by Fagundes et al. (2008), in which overweight and obese children were analyzed, both carried out with children aged between six and fourteen years, but in groups with different economic conditions, namely, low and high socioeconomic status. In their results, a prevalence of 26% was found for overweight children from high-income families and 14.7% for low-income children. Finally, it is worth mentioning that although low-income children have a lower prevalence of comorbidity, it has increased over the years, as already reported in the literature (Ferreira et al., 2010;Pimenta et al., 2015).
Regarding the regions of Brazil, there is a divergence between the respective prevalences, which may be related to the diversified development of each region of the country, and its popular culture, which is related to immigration influences, miscegenation, the regional climate and the food disposal (Abreu et al., 2001;Ferreira & Magalhães, 2006;Pinheiro, 2001). It is important to emphasize that the peak in the number of cases of overweight in Brazil and its regions was precisely between 2020 and 2021, as shown in Figure 1, with 2020 being the first year impacted by the pandemic in the country, as well as the introduction of the respective prevention measures (Croda & Garcia, 2020;Rodriguez-Morales et al., 2020;Pires, 2020), thus making the increase in the prevalence of overweight linked to social isolation and the suspension of public events and which can cause psychological disorders arising from fear, stress, loneliness (McElroy et al., 2020;Brooks et al., 2020;Deighton et al., 2019;Loades et al., 2020), causing a greater preference for high-calorie foods by children (Abbas et al., 2020;Ruíz-Roso et al., 2020;Pietrobelli et al., 2020) and sedentary lifestyle, from the longer time spent in the virtual world, and lower frequency of physical activities (Lourenço et al., 2019).
Regarding the prevalence of overweight for the gender, it is possible to verify, according to figure 3, that there was no significant difference, but with a greater tendency to increase body weight among men, to the detriment of women. This tendency may be related to children's eating habits by sex. According to Souza e Enes (2013), female children are more susceptible to a healthier diet rich in vegetables and fruits, while male children opt for more fatty foods, which demonstrates the greater difficulty of boys to adapt to a healthier lifestyle. Likewise, regarding sociocultural arguments, the strong impact of beauty standards imposed by society can be highlighted, which affect females more intensely, even if at an early stage, making parents more attentive to the weight of girls than boys (Huang et al., 2007;He & Evans, 2007) and causing them to seek a thin body and develop an aversion to gaining weight more often than males (Gonçalves et al., 2013). It is emphasized, however, that although there was a tendency for boys to be overweight than girls, this difference was not significant, and this fact is probably related to the strong impacts of isolation resulting from the pandemic, which brought, as previously mentioned, anxiety, predilection for hypercaloric foods and greater involvement with activities in the so-called "virtual environment", which together ended up affecting, in a practically equitable way, both girls and boys.

Conclusion
It is concluded, therefore, that child weight gain is closely related to multifactorial causes, with this condition being the most prevalent health condition in the age groups of two to five years, five to seven years and seven to ten years, probably due to change in food profile, linked to social isolation resulting from restrictive measures related to the COVID-19 pandemic, since there was a clear trend, although not significant, of an increase in the prevalence of children with overweight, in the year 2021, compared to the age groups from 0 to 6 months and from 6 months to two years, which showed a stationary trend, demonstrating that the occurrence of excess weight in children is also closely related to growing up, since a tendency to practice of inadequate eating habits is developed, with a decrease in the consumption of foods composed exclusively of breast milk.
Thus, the importance of the professional nutritionist in health units is reinforced, as the main propagator of actions to promote, treat and rehabilitate children's health. Since nutritional monitoring will act in the development of eating habits in childhood, with the aim of promoting healthy eating in the quality of life promotion.
Finally, for the design of future research, it is suggested to direct efforts aimed at assessing whether there is excessive weight gain in families with greater economic power, as well as studies aimed at verifying whether the epidemiological behavior highlighted in the present work will be maintained or will set back with the return of economic activities in Brazil.