What Brazilian Mothers Believe
Nutrition, Weight and Early Feeding
One Brazilian mother was embarrassed because her children were thin. She thought family and neighbors would think she could not provide enough food for her children.
Another insisted that it is preferable to have a chubby child (“bigger is better”); a perception influenced by social pressures. She equated thinness with lack of health.
As the developed world battles eating disorder and obesity, the developing world—including some of Brazil’s poorest regions—face a seeming contradiction: an environment in which obesity and malnutrition co-exist. In fact, studies show that the pace of the nutrition transition faced by many developing countries, like Brazil, has increased the likelihood that under- and over-nutrition will coexist in the same population group, and perhaps within the same household. Brazil’s level right now is about where the United States was in the 1970s. While some studies have been made on the more prosperous southeast, the poorer sections of the country previously have been overlooked because of their association with malnutrition.
Our study explores Brazilian mothers’ child feeding practices and their perceptions of their association with child weight status, as well as the role of socioeconomic, cultural and organizational factors on these relationships.
We selected 41 women from rural, urban, coastal and indigenous areas in Ceara State in northeastern Brazil to participate in four focus groups. How and what the mothers fed their children depended on economic resources, but the mothers’ social support networks such as neighbors and family and participation in nutrition assistance programs also were important. All mothers in the groups were enrolled in the Family Health/Community Workers Program.
MOTHERS’ PERCEPTIONS AND BELIEFS RELATED TO CHILD WEIGHT STATUS
It was evident from mothers’ discussions that child malnutrition, food insecurity and hunger were the main concerns with respect to questions related to child weight status.
Mothers often spoke of their struggle to make sure that their children “gained enough weight” and that they were “at the right” or “at targeted” weight for their age. Mothers’ perceptions of “right” or “targeted” weight for their children appeared to be influenced mainly by their own judgment of their child’s appearance (e.g. “too skinny”, “have enough flesh”), and in some cases, by information they received from health professionals including doctors, nurses, and health agents.
Despite the belief that is better for children to be chubby when they are small, they would prefer that their children were “thin” or “normal weight” as they grow older. Some mothers explained their belief that once the child grew older they would lose excess weight and “be at normal weight.” Only a few mothers reported that some of their children were overweight.
In spite of worrying most about child malnutrition, food insecurity and in some cases child hunger, mothers were also aware that child obesity was bad. However, they often didn’t understand what caused obesity, thinking that birth control pills and stimulants given to children could make them fat. Several reported their own struggles with overweight. Some of these mothers appeared to be bothered by the harsh comments about their personal appearance, while others seemed to believe that they were “destined” to be overweight or that “it was the way God intended them to be”.
Mothers in all focus groups made a distinction between foods they considered “good,” and therefore, “healthy” for their children and foods they considered “bad” and “unhealthy.” Mothers believed that good, healthy foods included those with protein and calcium, those with fewer chemicals and additives and fruits and vegetables. Sweets were seen as bad.
For mothers who did not face such serious problems associated with hunger, gender of the offspring played a more significant role in mothers’ perceptions of ideal weight and body type, mothers tended to equate thinness with their daughters being physically attractive and acceptable in society. These same mothers aspired for their daughters to enter professions that place high value on thinness and beauty.
For their sons, several mothers described an ideal body type as strong and healthy as opposed to a thin body they envisioned for their daughters. Overall, mothers in our study associated unhealthy eating habits in early childhood with the development of subsequent overweight and obesity in later childhood and adulthood. Mothers were also aware of the social stigma attached to being “fat”, especially for females, resulting in mental health issues such as depression, poor self-esteem, humiliation and shame. Other recent studies, conducted among mothers of different race and ethnicity, have demonstrated that mothers are knowledgeable of the connection between weight status and health, including the relationship between overweight and obesity and health and social problems.
MOTHERS’ DAILY FEEDING PRACTICES
Mothers reported being responsible for planning, cooking, and deciding what their children eat. Family members, especially grandmothers, also appeared to be involved in decisions involving children’s diets and mothers’ feeding practices. Money and unemployment emerged as the main factors influencing how they fed their children. Mothers spoke of not having enough money or being unemployed as a barrier to providing the foods they wanted for their children. In a few cases, by contrast, competing demands of work outside of the home emerged as factors influencing mothers’ feeding practices.
Family members, especially grandmothers, have a powerful influence on mothers’ child feeding practices, and consequently on the child’s diet. This finding is consistent with conceptualizations of the family as ‘a setting of health practice’ at the center of network of social systems. This way of thinking about nutrition and other aspects of health highlights the role of the family in integrating interactions with organizations and the community that have a bearing on children’s lifestyle behaviors. Most recent literature in the field describes the ‘health-promoting family,’ as well as the ‘eco-cultural pathway’ (family values, goals, needs, health practices), as significant influences on child health behavior and status that can mediate community and societal factors. Mothers seemed to agree that they all wanted the best for their children in all aspects of their lives including making sure that their children eat a healthy diet. Despite mothers’ discussions of their efforts to avoid feeding their children unhealthy foods, several mothers spoke of using strategies such as promises of sweets (e.g. ice cream), candies, and toys to make their children eat or to reward children’s good behaviors.
SOCIOECONOMIC STATUS AND FOOD ASSISTANCE
Money and unemployment emerged as the main factors influencing children’s diet and mothers’ feeding practices. Consistently, mothers spoke of not having enough money or being unemployed as a barrier to providing the foods they wanted for their children. In a few cases, by contrast, competing demands of work outside of the home emerged as factors influencing mothers’ feeding practices.
Mothers’ comments reflected the degree to which their food practices were tied to their family socioeconomic status. Mothers spoke about their children being hungry and the personal sacrifices they made (e.g., going without food) to better provide for their children. For poorer mothers, hunger appeared to be a far greater family concern than obesity. These mothers spoke of having to give their children sugar water or “herbal tea” when there was no money for food, of not being able to afford foods recommended by their pediatrician and feeling stressed and worried about not being able to provide food for their children on a daily basis.
For mothers describing dire socioeconomic situations, the Food Grant Program was seen as a valuable form of assistance. The Bolsa Alimentação (BA) program is a relatively new federal program administered by the Ministry of Health and designed to reduce nutritional deficiencies and infant mortality among poor households. The target group includes low-income families (means tested) with pregnant and lactating women, and/or infants and young children aged 6 months to 6 years of age. The program provides beneficiaries monthly cash benefit (R$15.00) conditioned upon their commitment to a “Charter of Responsibilities,” which ensures regularly attendance at antenatal care and growth monitoring, compliance with vaccination schedules, and health education. This “partnership of trust” reinforces the bond between local health services and marginalized families of limited resources.
Many mothers said that the Food Grant Program was commonly underutilized because of difficulties with the registration process. Others said they didn’t receive benefits despite registration. Still others simply didn’t know about the program. Among Food Grant Program recipients in the focus groups, many said that the money was not only used for food but also school supplies clothes, shampoo, medicine and cooking gas. Many of the mothers enjoyed this aspect of the program.
Our findings revealed the important influence of food assistance programs on children’s nutrition. For some mothers in our study, the Food Grant Program (Bolsa Alimentação) was an important resource that helped mothers address many of the daily barriers they face in providing foods to their children including food insecurity. However, our results also revealed that families often utilizing monthly cash benefit for family needs other than food. Food assistance programs, however, may serve as a resource not only for the provision of food to families in need, but may offer promise in helping low-income families with nutrition education and building of parenting capacity and skills to increase the effectiveness of nutritional education and the adoption of healthy lifestyle behaviors. Other studies in Latin America that have suggested obesity prevention be incorporated into nutrition programs and that note that while providing food to low income stunted populations may be beneficial for some, it may be detrimental for others, contributing to increased risk of overweight and obesity especially in urban areas. Finally, our findings suggest that nutrition programs should provide more detailed, explanatory models about the causes and consequences of overweight and obesity. Nutrition education should focus on the importance of proper nutrition and healthy weight status for health sake rather than for beauty sake. It is especially important that mothers learn not to overly focus on thinness and beauty for their young daughters as a means of reducing the subsequent risk of eating disorders. Given the well established logistic and success of the PSF/PACS programs, these could also be important vehicle of nutrition education for low-income families.
Mothers’ explanatory models of health and nutrition for their children are important to guide the design of public health interventions targeted at mothers’ child feeding practices and behaviors, and thus, ultimately the health and nutritional status of their children. Formative research such as ours is essential for developing interventions for which existing information is limited. Our research findings have important applications in developing nutrition education strategies for child health promotion that adequately account for the social and cultural context of minority, low-income care givers. Nutrition education interventions could be implemented through the existing PSF/PACS program and work in conjunction with the Food Grant program to educate mothers on important factors associated with early child feeding and nutritional status. Our results can form the basis for the design of interventions to prevent childhood under- and over-weight in low-income populations in Brazil and other Latin American countries with similar epidemiological profile. Something should be done before the situation worsens. As our study shows, the poorer are the ones that carry the heaviest burden of nutritional problems. In transitional societies like Brazil, the poor are now bearing not only the problems of child malnutrition, food insecurity and hunger but are also starting to feel the negative effects of obesity. While obesity is still more prevalent among adults, especially women, than children, only preventative education can keep poor children from bearing a double burden.
Spring 2007, Volume VI, Number 3
Ana Lindsay, DDS, MPH, DrPH (Principal Investigator) is a Research Scientist and Co-Director of Public Health Nutrition in the Department of Nutrition at Harvard School of Public Health. Her research focuses on problems affecting child’s health with a special focus on early childhood nutrition, including health behaviors and parental influences among low-income, multi-ethnic mothers and children linked to burgeoning rates of obesity and chronic disease in the U.S. and Latin America. She has worked for the past 13 years in Ceara, collaborating with Brazilian colleagues at the Federal University of Ceara, the Ceara School of Public Health, UNICEF/Ceara, and the State Secretariat of Health on a number of research projects ranging from infant mortality and child undernutrition to more recent studies focusing on HIV/AIDS and child overweight.
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