INTRODUCTION

The COVID-19 pandemic has presented itself as one of the biggest health challenges around the world, especially in low- and middle-income countries like Brazil, which has become the epicenter of the pandemic¹. The disease represented a critical global humanitarian situation whose course, severity and consequences on the health, economic, social, political and cultural dynamics of the population made the need to contain the infection of new individuals and reduce the social burden of the disease and its mortality a priority^1,2. Thus, social isolation measures were adopted in many countries, however, with changes in people’s lives and society in general^1-3.

In Brazil, progressive social distancing measures included raising awareness among the population to stay at home, closing schools, universities and workplaces, suspending some types of commerce, banning mass events and gatherings, restricting travel and public transport, limited access to recreational facilities and the prohibition of circulation on the streets, except for purchasing food and medicine or seeking health care. Some indicators suggest that there have been important reductions in the movement of people in parks and for recreation purposes, in commercial activities and at transport stations. In the state of Paraíba, acts of public authorities decreed social distancing measures related to the holding of events, in the area of education and the movement of people⁴.

Although scientific evidence suggests that measures of social distancing of the population, associated with the isolation of cases and the quarantine of contacts combined, had a positive impact on the expansion of the epidemic⁴, it is also recognized the possibility of losses in access to essential goods and services, with potential socioeconomic and behavioral repercussions and clinics, especially among socially vulnerable families^3-5. Social distancing can result in reduced income and economic instability, adoption of unhealthy lifestyles (decreased physical activity, sleep disorders, and greater consumption of unhealthy foods, alcoholic beverages and tobacco) and increased stress^6-8. Additionally, lost opportunities due to interruptions in education, health, nutrition and social protection services limited preventive care and the receipt of school meals, accentuating vulnerability^8-10.

Collectively, these changes can have a lasting impact on health³, with marked increases in the risk of mental illness, food and nutritional insecurity, all forms of malnutrition and maternal and child morbidity and mortality^7-11. The concern is of such magnitude that it is believed that there are possible intergenerational consequences for child growth and development, lifelong impacts on education, illness due to chronic diseases and human capital, and the risk of losing the progress made in the last decade on the child’s nutritional status^9,10. According to estimates by the Food and Agriculture Organization of the United Nations, the number of undernourished people increased drastically from 82 to 132 million in 2020 due to the COVID-19 pandemic¹².

While topics such as socioeconomic consequences^13,14, lifestyles^6,15, mental health^14,16 and food and nutritional security^11,17 have been the target of interest among researchers concerned about the repercussions of COVID-19, studies focusing on nutritional status have not received attention^6,9,10,14. As it constitutes an important indicator of health¹⁸ and resilience against destabilization processes, such as that caused by the COVID-19 pandemic in which individual and community resilience emerged as the main defense resource⁷, knowing the relation between COVID-19 and nutritional status is of critical importance for decision-making on measures that can protect the post-COVID-19 population and mitigate negative effects of the disease.

Additionally, research on the effects of COVID-19 on children’s lives and health behaviors is still limited^3,6. Families with children may be more impacted by COVID-19, with greater consequences on income, food security and poverty levels^19,20. Evidence suggests that children’s absence from school and changes in routine, separation from loved ones and friends, and the worsening of family finances can cause changes in behavior and lifestyles, with unfavorable results in sleep quality, nutritional status and health in general^6,21-23. Social isolation, absence from school life and more time at home have been related to an increase in sedentary behaviors, a decrease in physical activity and the consumption of foods with high energy density, with impacts on children’s overweight rates^21,22.

Therefore, the objective is to evaluate the Body Mass Index (BMI) of preschool children during the COVID-19 pandemic.

METHODS

RESULTS

The distribution according to their characteristics of the 126 preschool children that participated in the study is available in table 1. As can be seen, hospital admission for 24 hours or more since birth (38.9%) was the most common negative health condition. Regarding food, regular consumption of fruits was 73.2%, while vegetables and/or legumes were 41.1%. For unhealthy eating markers, regular consumption of stuffed biscuits, sweets or sweets (56.3%) was higher than that of hamburgers and/or sausages (43.7%). With regard to recreational screen time, in 86.5% of children it was above 60 minutes. During the COVID-19 pandemic, 82.5% of children wore a mask in their routine, 78.6% were in the habit of washing their hands and 63.5% were in social isolation whenever/almost always when recommended. For the variables of satisfaction with home and school life, in all aspects, satisfaction was greater than 70%, except for the items liking being at home (47.4%) and not rejecting school (61.9%).

When characterizing mothers, proportions of overweight/obesity, age over 34 years and incomplete secondary education or less were observed at 66.7%, 34.1% and 57.9%, respectively. The majority of mothers responded positively to questions related to child care, while coexistence with the child during the COVID-19 pandemic was fair/poor in 38.1% of cases. The repercussions of the pandemic were visible, from the need to use mental health medications (13.5%) to concern about the disease (72.0%). Of the 126 mothers, 96.0% reported having been vaccinated against the disease and 19.0% having contracted it (table 2).

Not breastfeeding in the first hour of life (p = 0.046) and regular consumption of stuffed biscuits, sweets or candys (p = 0.042) were the characteristics of children that represented the highest BMI-for-age average (table 1). Children of overweight/obese mothers (p = 0.034), who did not complete high school (p = 0.042), who expressed difficulty in caring for the child and guiding them in health aspects also had higher BMI-for-age average (p = 0.010), as well as those whose mothers needed psychological care (p = 0.047) and used mental health medications (p = 0.036) during the COVID-19 pandemic (table 2).

After adjustment, differences in the children’s BMI-for-age average recorded through bivariate analyzes were confirmed. Not breastfeeding in the first hour of life, despite not having shown a significant difference in model 1 (adjusted for the children’s characteristics), gained statistical significance in model 2. The explanatory power of the model was 31.3% (table 3).

DISCUSSION

The objective of the current study was to analyze differences in the BMI-for-age of preschoolers who grew up during the COVID-19 pandemic according to the characteristics of the children and their mothers. The findings showed that the nutritional status of children was mainly influenced by maternal factors such as the presence of overweight/obesity, lower education, difficulties in caring for the child and the repercussions of the pandemic on mental health.

Around the world, the COVID-19 outbreak has forced the implementation of social distancing measures and the need to reinforce individual health care such as hand hygiene and the use of face masks4. It is noteworthy that these measures are well evaluated for their functionality, safety and preventive nature, which justifies the good adherence shown among the participants in this study, as previously reported³⁰. The proportion of women who said they had been vaccinated (96.0%), in turn, reinforces acceptance and adherence to pandemic contingency measures. The finding converges with that obtained among residents of Rio Grande do Sul where the intention to be vaccinated against COVID-19 was 96.0% and favored by the acceptance of individual protection actions, including social distancing³¹. In this spectrum of data, another important result observed was the frequency of women who self-reported having contracted the disease (19.0%), which is also consistent with the profile observed in the Brazilian population³². These factors did not influence the average BMI-for-age of the children in the present study.

Other aspects of life that also underwent changes with the COVID-19 pandemic and the restrictions on its control were the social situation, routine, health behaviors and emotional well-being. Financial losses and concerns, food and nutritional insecurity, sedentary lifestyle, unhealthy diet and stress were circumstances highlighted in the COVID-19 pandemic that can increase the risk of weight gain in children. Associated with the pandemic, the repercussions of these factors on weight are not restricted and isolated, but influenced by each other and by the parents habits.

This scope of knowledge resulting from literature reviews^{6,11,13-17,23,33-35} becomes visible in the results of this study, especially in the variety of problems reported in significant quantities by mothers, such as the need to use mental health medications (13.5%) and psychological care (49.2%), difficulty in living with the child (38.1%) and adapting to remote learning (44.4%), and concern about the disease (72. 2%), with an emphasis on the repercussions on mental health that influenced children’s BMI-for-age. Parental stress and anxiety caused by COVID-19 can hamper support for their children and can often be passed on to children, increasing the risk of childhood obesity³³. Considering special attention to mothers is pertinent, as women stand out for having been more emotionally affected during the pandemic¹⁶.

The association between mothers mental health and excess weight in their children has been suggested in the literature, namely the presence of depression. The mechanisms described for this relationship reinforce the role of parental practices that affect children’s behaviors related to physical activity, eating and screen use^36,37. In Brazil, recent studies have also reported similar results^38,39. In a study developed with children treated at a pediatric endocrinology out patient clinic located in the city of Fortaleza, Ceará, researchers showed a bidirectional relationship between mothers’ depression and children’s obesity³⁸. In turn, data from a retrospective cohort of children from a hospital in the state of Minas Gerais revealed an association between maternal depression and a composite indicator of maternal health and care, including information on BMI, breastfeeding, vaccination, iron deficiency anemia prophylaxis, illnesses and accidents³⁹.

The mother’s difficulty in providing care to the child (p = 0.010) and lower education (p = 0.042) also contributed to higher BMI-for-age mean. This can be explained based on the importance of parents interaction with their offspring and their educational level in maintaining the child’s weight, as highlighted in Chile in a study whose results were similar to those observed in our research³⁶. Parent-child interactions can affect children’s behavior, such as food choices and those related to physical activity, which are fundamental pillars of healthy weight. On the other hand, school level is directly related to socioeconomic level, whose influence on weight is unquestionable⁴⁰.

Regarding the characteristics of the children, it was evident that not breastfeeding in the first hour of life (p = 0.046) and the consumption of stuffed biscuits, sweets or candys on a regular basis (p = 0.042) resulted in higher BMI-for-age average, reflecting the importance of food in the child’s nutritional status^15,41. The differences in children’s BMI-for-age according to breastfeeding immediately after birth reflect the importance of breastfeeding for the child’s growth and development and are plausible in supporting an analogy with the greater risk of excess body weight in the second year of life in the absence of exclusive breastfeeding, according to a study developed in Joinville, Santa Catarina⁴². Despite this, another study found no association between breastfeeding in the first hour of life and overweight/obesity in children aged 2 to 6 years⁴³. In turn, the consumption of processed foods is one of the determining characteristics of obesity and is increasingly present in the diet of the Brazilian population, starting from childhood⁴¹. Healthy eating, on the other hand, reduces the risk of overweight and obesity in children, as shown in Chile⁴⁰. During the pandemic, behaviors that were harmful to health were exacerbated, such as greater consumption of unhealthy foods and less consumption of healthy foods^3,6,15,22.

Finally, it was shown that children of overweight/obese mothers had higher BMI-for-age than those whose mothers were of adequate weight. Along the same lines, other studies have shown that living with overweight mothers was associated with childhood obesity^43,44. In fact, for some researchers, this association can be explained by the child’s susceptibility to obesity due to genetics, which greatly determines energy balance⁴³. However, in the view of other researchers, the determination of a child’s excess weight due to the same condition in the mother is shaped by the influence of social and behavioral factors, namely eating and physical activity habits, in addition to biological determinants⁴⁴.

The closure of schools significantly influenced children’s lifestyles with an increase in sedentary lifestyle, screen time and consumption of low-nutrient foods, factors that lead to excessive weight gain^{6,21,22,34,35,40}. This situation is compared to the vacation period when there is an increase in children’s weight in relation to the school year, since the school environment favors healthier behaviors^22,34. Therefore, it is argued that the repercussions of social isolation on weight are more pronounced in children than in adults. In addition to the environment, greater energy needs and physical activity demands, as well as less autonomy, make children more susceptible to the consequences of the pandemic^6,34,35,40. In this sense, the findings of the present study revealed the role of mothers mental health during the pandemic on children’s BMI-for-age, becoming relevant knowledge that reinforces how children are influenced by family stimuli⁴⁰.

CONCLUSION

Children’s BMI-for-age mean were significantly higher when their mothers were overweight/obese, had a lower level of education and had difficulty caring for the child. Furthermore, children who were not breastfed in the first hour of life and who regularly consumed sandwich cookies, sweets or candys also contributed to higher BMI-for-age values. Examining the repercussions of the pandemic of COVID-19 in maternal and child life, it is highlighted that maternal mental health during the COVID-19 pandemic had an impact on the child’s nutritional status.