Abstract
Objective
To describe the scenario of child undernutrition in Brazil and its determinants.
Data source
Narrative review of the literature with inclusion of data from population surveys, surveillance and monitoring systems, and active search in favelas and underserved communities carried out by CREN.
Data synthesis
Household surveys carried out from 1974 to 2019 indicate that undernutrition (<5 years) decreased until 2006. Underweight (W/A ≤-2 Z) and stunting (H/A ≤-2 Z) showed a decrease of 17% to 3% and 37% to 7%, respectively. After 2006, there was an increase in underweight of 53% and 76% for wasting (BMI/A ≤-2 Z), with the prevalence of stunting being stagnant at around 7%. Active search data in favelas and underserved communities show that the prevalence of stunting is 11% in those <5 years. In 2021, 30% of the population lived in poverty, 73% of which were black or brown. Stunting in black and brown children <5 years old is, respectively, 9% and 12% higher when compared to white children. Poverty decreased between 2012 and 2015 (27 to 25%), but increased again (2016=26% to 2021=30%), in parallel with food insecurity, which decreased between 2004 and 2013 (12% to 6%), but reached its worst level in the historical series (2022:15%).
Conclusion
Despite advances, Brazil's social protection system was not able to reduce inequalities and the reversal of the trend towards decreasing child undernutrition could be observed from 2006 onwards.
Keywords
Child undernutrition; Stunting; Wasting; Underweight; Poverty; Social inequality
Introduction
Child undernutrition represents an important public health problem in low- and middle-income countries and its acute condition, characterized by being underweight, with a body mass index for age (BMI/A) ≤ −2 z-score, is associated with half of deaths of children under 5 years of age worldwide.11 United Nations Children's Fund (UNICEF), World Health Organization (WHO), International Bank for Reconstruction and Development/The World Bank. Levels and Trends in Child malnutrition: Key Findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: WHO; 2019. Its chronic condition, characterized by short stature associated with poverty, with a height-for-age index (H/A) ≤ −2 z-score, is the most prevalent form of undernutrition and is associated with a 4.8-fold increase in the chance of death from preventable causes.22 Victora C.G., Christian P., Vidaletti L.P., Gatica-Domínguez G., Menon P., Black R.E. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet. 2021;397:1388-99. Stunting, in addition, to bring the best indicator of children's general well-being, is an accurate reflection of the social inequalities in which they live.33 de Onis M., Branca F. Childhood stunting: a global perspective. Matern Child Nutr. 2016;12 Suppl 1:12-26.
When it occurs early in life, undernutrition can cause irreversible damage to cognitive development, in addition to increasing the chance of obesity and chronic non-communicable diseases in adulthood. Therefore, child undernutrition has consequences throughout the entire life cycle, and at an individual and collective level, generating important social and economic impacts, in a trajectory of intergenerational perpetuation of poverty and undernutrition.44 Dewey K.G., Begum K. Long-term consequences of stunting in early life. Matern Child Nutr. 2011;7 Suppl 3:5-18.,55 Wells J.C., Sawaya A.L., Wibaek R., Mwangome M., Poullas M.S., Yajnik C.S., et al. The double burden of malnutrition: aetiological pathways and consequences for health. Lancet. 2020;395:75-88.
The determinants of primary child undernutrition are multifactorial, with deep roots in poverty,66 Sawaya A.L. Desnutrição: consequências em longo prazo e efeitos da recuperação nutricional. Estud Av. 2006;20:147-58. of which the main ones are: food and nutrition insecurity; low weight at birth; low maternal level of schooling; lack of access to water, sanitation and health services; maternal stunting and underweight.77 MAL-ED Network Investigators. Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: the MAL-ED longitudinal birth cohort study. PLoS Med. 2017;14:e1002408.,33 de Onis M., Branca F. Childhood stunting: a global perspective. Matern Child Nutr. 2016;12 Suppl 1:12-26.
In Brazil, despite the advances attained with investments in health, education and social income distribution programs, social inequality remains high and keeps the country among the most unequal worldwide.88 Chancel L., Piketty T., Saez E., Zucman G. World Inequality Report 2022, World Inequality Lab. 2022. wir2022.wid.world With the political crises of the first two decades of the 2000s, the freezing of resources for social programs and the advent of the COVID-19 pandemic, poverty worsened in Brazil and undernutrition and hunger returned to the debate table.99 Júnior J.G., de Amorim L.M., Lima N.N., Neto M.L. Challenges to food safety for children and adolescents in Brazil. J Pediatr Nurs. 2022;65:e7-e8.,1010 Souza P.H. Uma História De desigualdade: a Concentração De Renda Entre Os Ricos No Brasil, 1926 - 2013. São Paulo: Hucitec Editora; 2018.
This study aimed to review the historical series of the prevalence of child undernutrition in Brazil, as well as some of its determinants. Moreover, it sought to elucidate the singularities of the most vulnerable groups, which are sometimes made invisible by national averages.
Methods
This was a narrative review of the literature using the following descriptors in the search strategy: child undernutrition, stunting, wasting, underweight, poverty, social inequality and food insecurity in the PubMed and SciELO databases. Articles that addressed child undernutrition in Brazil, with data on prevalence, impacts or determinants of child undernutrition and those on structural poverty or social inequality in Brazil were selected.
Population-based household surveys were used to represent the historical series of the prevalence of child undernutrition, namely: National Family Expenditure Study - ENDEF (Estudo Nacional de Despesa Familiar) 1974-1975;1111 Instituto Brasileiro de Geografia e Estatística (IBGE). Estudo Nacional da Despesa Familiar - ENDEF 1974-1975. Rio de Janeiro: IBGE; 1977. National Survey on Health and Nutrition - PNSN (Pesquisa Nacional sobre Saúde e Nutrição) 1989;1212 Brasil. Ministério da Saúde. Instituto Nacional de Alimentação e Nutrição (INAN). Pesquisa Nacional Sobre Saúde e Nutrição - PNSN. Brasília: Ministério da Saúde; 1990. National Survey on Demography and Health - PNDS (Pesquisa Nacional sobre Demografia e Saúde) 1996;1313 Instituto Brasileiro de Geografia e Estatística (IBGE). Sociedade Civil Bem-Estar Familiar no Brasil. Pesquisa Nacional Sobre Demografia e Saúde - PNDS 1996. Rio de Janeiro: IBGE; 1996. National Survey of Demography and Health of Children and Women - PNDS (Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher) 2006;1414 Brasil. Ministério da Saúde. Departamento de Ciência e Tecnologia. Centro Brasileiro de Análise e Planejamento. Pesquisa Nacional De Demografia e Saúde Da Criança e da Mulher - PNDS 2006. Brasília: Ministério da Saúde; 2008. Family Budget Survey - POF (Pesquisa de Orçamentos Familiares) 2002;1515 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa De Orçamentos Familiares - POF 2002-2003: Análise Da Disponibilidade Domiciliar De Alimentos e Do Estado Nutricional No Brasil. Rio de Janeiro: IBGE; 2004. and National Survey of Food and Child Nutrition - ENANI (Estudo Nacional de Alimentação e Nutrição Infantil) 2019.1616 Universidade Federal do Rio de Janeiro (UFRJ). Estudo Nacional de Alimentação e Nutrição Infantil - ENANI 2019. Estado Nutricional Antropométrico da Criança e da Mãe: Prevalência de Indicadores Antropométricos De Crianças Brasileiras Menores De 5 Anos De Idade e Suas Mães Biológicas. Rio de Janeiro: UFRJ; 2022. The studies used similar methods to assess nutritional status, with the diagnosis of underweight, wasting or stunting being carried out according to the recommendations of the World Health Organization (WHO), considering 2 (two) standard deviations from the median weight for age (W/A), body mass index (BMI) for age (BMI/A) or height for age (H/A).
Data from public reports from the Food and Nutrition Surveillance System - SISVAN (Sistema de Vigilância Alimentar e Nutricional)1717 Sistema de Vigilância Alimentar e Nutricional (SISVAN) [Internet]. Relatórios públicos de estado nutricional. Distrito Federal: Ministério da Saúde [cited 2023 Jun 30]. Available from: https://sisaps.saude.gov.br/sisvan/relatoriopublico/index
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were also used to represent the prevalence and temporal trend of child undernutrition in the country.
Active search data from the Center for Nutritional Recovery and Education - CREN (Centro de Recuperação e Educação Nutricional), carried out through coordination with territories and local leaders, were included to represent the prevalence of child undernutrition in favelas and underserved communities in the city of São Paulo, where children in more serious situations of vulnerability experience gaps in care and generally do not reach health services or do not remain under treatment.
To describe the historical series of poverty in Brazil, studies and databases were used that considered national and international poverty lines, namely: Programa Auxílio Brasil (R$ 105.00 to 210.00 per month per person); Fundação Getúlio Vargas - FGV (US$ 5.0 per day per person); United Nations Economic Commission for Latin America and the Caribbean - CEPAL (US$2.00 per day per person); and World Bank (R$499.00 per month per person).
Population-based household surveys were also used to represent the historical series of food insecurity, namely: National Household Sample Survey - PNAD (Pesquisa Nacional por Amostra de Domicílios) 2003-2004, 2008-2009 and 2013-2014; Family Budget Survey - POF (Pesquisa de Orçamentos Familiares) 2017-2018; I and II Population Food and Nutrition Security Survey - VIGISSAN (Inquérito Populacional de Segurança Alimentar e Nutricional) 2020 and 2021-2022.1818 Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar (Rede PENSSAN). II Inquérito Nacional Sobre Insegurança Alimentar No Contexto da Pandemia da COVID-19 No Brasil - II VIGISAN: Relatório Final. São Paulo: Fundação Friedrich Ebert; 2022. The studies assessed food security and mild, moderate or severe food insecurity using the Brazilian Food Insecurity Scale (EBIA, Escala Brasileira de Insegurança Alimentar).
Data from the National Sanitation Information System - SNIS (Sistema Nacional de Informações sobre Saneamento) and studies carried out with data from the Demographic Census of the Brazilian Institute of Geography and Statistics (IBGE, Instituto Brasileiro de Geografia e Estatística) were used to investigate the history of basic sanitation coverage.
Reports from the United Nations Interagency Group for Child Mortality Estimation (UN IGME), studies with data from the Mortality Information System - SIM (Sistema de Informações sobre Mortalidade), the Information Technology Department of the Unified Health System - Datasus (Departamento de Informática do Sistema Único de Saúde) and Observatório de Saúde da Infância da Fundação Oswaldo Cruz - Fiocruz, were used to record the history of the child mortality rate and the current record of hospitalizations for undernutrition in children under one year of age in Brazil.
Results and discussion
Evolution of the prevalence and racial characteristics of child undernutrition in Brazil
Brazilian population-based household surveys carried out from 1974 to 2019 indicate that undernutrition in children under 5 years of age showed a large decrease until 2006 (Figure 1A). During this period, underweight, characterized by the weight-for-age index (W/A ≤ −2 z-score) showed a very significant decrease (16.6-2.9%); with stunting (H/A ≤ −2 z-score) decreasing even more (37.1-7%). However, after 2006 it is possible to observe an increase in the prevalence of underweight by 52.6% and wasting by 76.4%, with stagnation in the prevalence of stunting (calculated from Figure 1A). When compared with SISVAN data (Figure 1B), even higher prevalences of wasting and stunting are observed, most likely due to differences in the data collection methods.
A. Prevalence of underweight, wasting and stunting in children aged <5 years in Brazilian population surveys (Brazil, 1974 to 2019); B. Trend of underweight, wasting and stunting in children aged <5 years in Brazil according to public reports from SISVAN (Brazil, 2012-2022); C. Prevalence of stunting in children aged <5 years in the city of São Paulo: CEInfo/SMS/SP comparison with active search by CREN (São Paulo, 2019); D. Prevalence of underweight, wasting and stunting in children aged <5 years according to skin color/ethnicity (Brazil, 2019).
Specific data from the city of São Paulo indicate different prevalence rates of child undernutrition depending on the region of the city and the data collection method, with much higher prevalences being observed when actively searching for malnourished children in regions of greater vulnerability and with gaps in care, through surveys and collective efforts directly in the community, such as the that carried out by the Nutritional Recovery and Education Center - CREN (Figure 1C). Additionally, data from CREN and the Municipal Health Department of São Paulo indicate that, in children living in favelas and underserved communities, stunting and the risk of being stunted (H/A ≤−1 z-score) can affect 25% of children under 5 years of age,1919 Sawaya A.L., Albuquerque M.P., Domene S.M. Violência em favelas e saúde. Estud Av. 2018;32:243-50. and that children who benefit from the Bolsa Família (cash transfer) Program have a 12% higher prevalence of stunting when compared to non-beneficiary children.2020 Secretaria Municipal de Saúde. Coordenação De Epidemiologia e Informação - CEInfo. Sistema De Vigilância Alimentar e Nutricional - SISVAN, Município De São Paulo. Relatório Técnico Anual 2019. Análise descritiva De Indicadores De Nutrição e saúde. Atenção Primária à Saúde. São Paulo: Secretaria Municipal de Saúde; 2022.
According to data from the Municipal Health Department, the prevalence of stunting in children under 5 years of age in the second district with the highest proportion of favelas and underserved communities in the city of São Paulo (Brasilândia)2121 Rede Nossa São Paulo. Mapa Da Desigualdade 2019. São Paulo: Rede Nossa São Paulo; 2019. was among the highest percentages in the municipality, reaching 9.5% in 2019. Using the active search method, in that same year and district, CREN found an even higher prevalence: 11.1%.
Other studies also observed a higher risk of undernutrition in economically disadvantaged children (class D)2222 da Rocha Neves K., de Souza Morais R.L., Teixeira R.A., Pinto P.A. Growth and development and their environmental and biological determinants. J Pediatr. 2016;92:241-50. and in federative units of medium and high social vulnerability (relative risk of 1.17 and 1.39, respectively, compared to places of low social vulnerability), based on the multidimensional analysis of the economic situation (urban infrastructure, human capital, income and work).2323 Gouveia A.V., Carvalho R.E., Correia M.E., Silveira J.A. Time trend of the prevalence of malnutrition in children under five years of age assisted by the Bolsa Família Program (2008-2019). SciELO Preprints. 2022 [cited 2023 Jul. 19]. https://doi.org/10.1590/SciELOPreprints.4965
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Regarding differences in ethnicity and skin color, the last population survey showed that the prevalence of stunting among black and brown children under 5 years of age is, respectively, 9.2% and 12.3% higher when compared to white children (calculated from prevalence data in Figure 1D). In relation to underweight and wasting, this difference is even greater, with much higher prevalence rates in black children and intermediate values in brown children (Figure 1D). Data from the city of São Paulo also indicate an 8.1% higher prevalence of stunting in black, brown and indigenous children under 5 years of age, when compared to white children.2020 Secretaria Municipal de Saúde. Coordenação De Epidemiologia e Informação - CEInfo. Sistema De Vigilância Alimentar e Nutricional - SISVAN, Município De São Paulo. Relatório Técnico Anual 2019. Análise descritiva De Indicadores De Nutrição e saúde. Atenção Primária à Saúde. São Paulo: Secretaria Municipal de Saúde; 2022.
A study of temporal trends based on data from SISVAN showed that among children from more vulnerable subgroups (blacks, beneficiaries of conditional cash transfers and residents of undeserved areas), the trend toward a higher prevalence of stunting persists.2424 Ribeiro-Silva R.C., Silva N.J., Felisbino-Mendes M.S., Falcão I.R., de Andrade R.D., Silva S.A., et al. Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017. Public Health Nutr. 2021;25:1-11.
Another study that analyzed the temporal trend of undernutrition in infants (0 to 23 months) and preschool children (24 to 59 months) assisted by the Bolsa Família Program (PBF) in Brazil using data from SISVAN from 2008 to 2019, concluded that there was a reduction in undernutrition prevalence until mid-2013 (2 to 4% per year) when trends became stationary for preschoolers (1 to 4% per year) and increased for infants (3 to 8% per year).2323 Gouveia A.V., Carvalho R.E., Correia M.E., Silveira J.A. Time trend of the prevalence of malnutrition in children under five years of age assisted by the Bolsa Família Program (2008-2019). SciELO Preprints. 2022 [cited 2023 Jul. 19]. https://doi.org/10.1590/SciELOPreprints.4965
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SISVAN is an excellent monitoring tool and provides a method for rapid and permanent assessment of food consumption patterns and nutritional status; however, it is underutilized in the studied country. The system average coverage for the Brazilian population in 2008 was just 4.7%. A study carried out in Belo Horizonte, state of Minas Gerais, shows that, for children under 5 years of age, the average SISVAN coverage was only 5.6%, varying from 0.5% to 35.8% between municipalities in 2018.2525 Ferreira C.S., Rodrigues L.A., Bento I.C., Villela M.P., Cherchiglia M.L., César C.C. Factors associated with Sisvan Web coverage for children under 5 years of age, in the municipalities of the Regional Health Inspectorate of Belo Horizonte, Brazil. Cien Saude Colet. 2018;23:3031-40. Portuguese.
The few studies that analyzed the temporal trend of SISVAN data indicate trends of higher prevalence of child undernutrition among black people, beneficiaries of conditional cash transfer programs and residents of underserved areas. These studies concluded that as of mid-2013, child undernutrition in Brazil increased again among infants and plateaued among preschoolers.2323 Gouveia A.V., Carvalho R.E., Correia M.E., Silveira J.A. Time trend of the prevalence of malnutrition in children under five years of age assisted by the Bolsa Família Program (2008-2019). SciELO Preprints. 2022 [cited 2023 Jul. 19]. https://doi.org/10.1590/SciELOPreprints.4965
https://doi.org/10.1590/SciELOPreprints....
,2424 Ribeiro-Silva R.C., Silva N.J., Felisbino-Mendes M.S., Falcão I.R., de Andrade R.D., Silva S.A., et al. Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017. Public Health Nutr. 2021;25:1-11.
Disparities in child undernutrition by age group
According to data from the National Survey of Food and Child Nutrition - ENANI, in children under 5 years of age, the highest prevalence of stunting is found in the age groups from 0 to 11 months and from 12 to 23 months, where the percentage reaches 9% and 10.2%, respectively. Wasting also shows a higher prevalence among children aged 0 to 11 months (5%), when compared to other age groups up to 5 years old (3%).1616 Universidade Federal do Rio de Janeiro (UFRJ). Estudo Nacional de Alimentação e Nutrição Infantil - ENANI 2019. Estado Nutricional Antropométrico da Criança e da Mãe: Prevalência de Indicadores Antropométricos De Crianças Brasileiras Menores De 5 Anos De Idade e Suas Mães Biológicas. Rio de Janeiro: UFRJ; 2022.
Data from the Municipal Health Secretariat indicate that in the city of São Paulo, the prevalence of stunting in children under 5 years of age in 2019 was 7.7%, and among children aged 18 to 24 months, 10.4%.2020 Secretaria Municipal de Saúde. Coordenação De Epidemiologia e Informação - CEInfo. Sistema De Vigilância Alimentar e Nutricional - SISVAN, Município De São Paulo. Relatório Técnico Anual 2019. Análise descritiva De Indicadores De Nutrição e saúde. Atenção Primária à Saúde. São Paulo: Secretaria Municipal de Saúde; 2022. CREN data collected through active searches carried out in favelas and underserved communities also indicate a higher prevalence of stunting among children aged 0 to 11 months and 12 to 23 months, 17.8% and 20.9%, respectively (author's database).
Global target to reduce child undernutrition
Among the WHO global targets established in 2012 to reduce child undernutrition is to reduce the number of children under 5 years of age with undernutrition by 40% by 2025.2626 World Health Organization (WHO). Resolution WHA65.6. Maternal, infant and young child nutrition. In: Sixty-fifth World Health Assembly, Geneva, 21-26 May. Resolutions and Decisions, Annexes. Geneva: WHO; 2012. However, the trend of this indicator in Brazil over the last 10 years shows stagnation, as demonstrated by the SISVAN data illustrated in Figure 1, showing that we are far from reaching the global target established for the 2012-2025 period.
Considering data from the last national survey,1616 Universidade Federal do Rio de Janeiro (UFRJ). Estudo Nacional de Alimentação e Nutrição Infantil - ENANI 2019. Estado Nutricional Antropométrico da Criança e da Mãe: Prevalência de Indicadores Antropométricos De Crianças Brasileiras Menores De 5 Anos De Idade e Suas Mães Biológicas. Rio de Janeiro: UFRJ; 2022. to achieve the global target of reducing child undernutrition, Brazil would need to reach the following prevalence rates among children under 5 years of age: 1.74% of underweight; 1.8% of wasting and 4.9% of stunting.
Determinants of child undernutrition
Poverty and income concentration
Although national and international poverty lines adopt different cutoff points, they all point out that poverty in Brazil, one of the main determinants of primary child undernutrition, showed a reduction or stagnation until 2014, when it increased again with the established political and economic crises (Figure 2A and B). In 2020, the emergency expansion of cash transfers caused poverty to decline for the first time in many years. However, in 2021, with the prolongation of the COVID-19 pandemic and with a lower volume of cash transfers, the poverty level in Brazil reached the worst level in the historical series and extreme poverty returned to the level of the 2000s.2727 de Souza P.H., Hecksher M., Osório R.G. Um País Na contramão: a Pobreza No Brasil Nos Últimos Dez Anos. Brasília: Instituto de Pesquisa Econômica Aplicada (IPEA); 2022. 18p. 10.38116/ntdisoc102
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A. Historical series of people in poverty in Brazil considering the line below US$5.50/day (Brazil, 2012 to 2020); B. Historical series of the prevalence of poverty and extreme poverty in Brazil considering the lines below US$2.00 and US$1.00/day, respectively (Brazil, 2001 to 2021).
Between 2001 and 2021, it can be observed that poverty decreased by 58%, but extreme poverty increased by 12.2%. The best level was reached in 2014, when poverty increased again and extreme poverty reached the worst level in the historical series, affecting 8 out of every 100 Brazilians (Figure 2B).
Poverty is directly associated with racial issues, a mark of inequalities that have persisted since the days of colonial and slave-owning Brazil. In 2022, 73% of people in poverty in Brazil declared themselves to be black or brown, with 3 in 10 people living in poverty in the country being black women living in urban areas and 63% of people living in favelas and underserved communities being black or brown.2828 World Bank. Brazil Poverty and Equity Assessment: Looking Ahead of Two Crises. Washington DC: World Bank; 2022. http://hdl.handle.net/10986/37657 License: CC BY 3.0 IGO.”
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,1919 Sawaya A.L., Albuquerque M.P., Domene S.M. Violência em favelas e saúde. Estud Av. 2018;32:243-50.
Among the quilombola and indigenous populations, 73% and 79%, respectively, were in the extreme poverty range (R$178/month) and 91% and 96% were in the poverty range (R$499/month) in 2019.2828 World Bank. Brazil Poverty and Equity Assessment: Looking Ahead of Two Crises. Washington DC: World Bank; 2022. http://hdl.handle.net/10986/37657 License: CC BY 3.0 IGO.”
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Regarding income concentration, Brazil continues to be one of the most unequal countries in the world, with a high concentration of income in 1% of the population and with the richest 10% concentrating around 59% of total national income.88 Chancel L., Piketty T., Saez E., Zucman G. World Inequality Report 2022, World Inequality Lab. 2022. wir2022.wid.world
Data from the World Bank also indicate that, between 2012 and 2019, the profile of people in chronic poverty, with monetary and non-monetary deprivation (low access to health services, poor quality housing and low accumulation of human capital), consisted mostly of Afro-Brazilians. During this period, the percentage of black and brown people in chronic poverty increased from 71.7% to 74.8%.2828 World Bank. Brazil Poverty and Equity Assessment: Looking Ahead of Two Crises. Washington DC: World Bank; 2022. http://hdl.handle.net/10986/37657 License: CC BY 3.0 IGO.”
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According to Souza,1010 Souza P.H. Uma História De desigualdade: a Concentração De Renda Entre Os Ricos No Brasil, 1926 - 2013. São Paulo: Hucitec Editora; 2018. despite the optimism of reducing inequalities indicated by household surveys, data based on Personal Income Tax (IRPF) declarations demonstrate the maintenance of the high concentration of income in Brazil and the underestimation of the income of the richest people in sample surveys. The author states that democracy in Brazil served more to contain the increase in inequality in Brazil than to reduce it.
The World Bank also points out that, despite advances in income distribution, the social protection strategies used in Brazil were not able to effectively serve as a countercyclical protection system, that is, stable during crises and government changes, and that the structural poverty and few possibilities for social mobility persist.2828 World Bank. Brazil Poverty and Equity Assessment: Looking Ahead of Two Crises. Washington DC: World Bank; 2022. http://hdl.handle.net/10986/37657 License: CC BY 3.0 IGO.”
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Food insecurity
Despite the advances in food security highlighted in household surveys in 2004, 2009 and 2013, after this period a very disturbing scenario was observed (Figure 3). Between 2013 and 2022, hunger increased by 262%, reaching the worst level in the historical series, and food insecurity, in all its forms, increased by 156% (data calculated from Figure 3). In 2022, only 4 in 10 Brazilians had food security.1818 Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar (Rede PENSSAN). II Inquérito Nacional Sobre Insegurança Alimentar No Contexto da Pandemia da COVID-19 No Brasil - II VIGISAN: Relatório Final. São Paulo: Fundação Friedrich Ebert; 2022.
Historical series of the prevalence of people experiencing food security and mild, moderate or severe food insecurity (Brazil, 2004 to 2022).
Basic sanitation
Basic sanitation (water supply, sewage and garbage collection) is one of the factors most frequently associated with child undernutrition. A systematic review with meta-analysis concluded that children who live in homes without basic sanitation conditions and with open sewage are 10 percentage points or 29 to 46% more likely to have stunting.2929 Mudadu Silva J.R., Vieira L.L., Murta Abreu A.R., de Souza Fernandes E., Moreira T.R., Dias da Costa G., et al. Water, sanitation, and hygiene vulnerability in child stunting in developing countries: a systematic review with meta-analysis. Public Health. 2023;219:117-23.
A study carried out with data from the IBGE Demographic Census of 2000 and 2010 showed that, in general, the percentage of basic sanitation in Brazilian households improved during this period. However, regional and skin color/ethnicity disparities still persist, with lower prevalence rates of access in rural areas and among indigenous, black and brown people.3030 Raupp L., Cunha G.M., Fávaro T.R., Santos R.V. Sanitation conditions of Indigenous and nonindigenous households in Brazil according the 2000 and 2010 national censuses. Cien Saude Colet. 2020;25:3753-63. Portuguese, English.
The most recent data from the National Sanitation Information System - SNIS for 2021 shows that the percentage of sewage collection in Brazil is 60.24%, of which 80.84% is treated and 51.17% is treated for consumption. The worst Brazilian scenario is in the North region, where only 22.96% of sewage is collected, followed by the Northeast, with 39.27%. Regarding water supply, the national coverage is 84.2%. However, the disparity between macro-regions repeats itself: 59.97% in the North, 74.72% in the Northeast, 89.88% in the Midwest, 91.53% in the Southeast and 91.35% in the South region.3131 Sistema Nacional sobre Informações de Saneamento (SNIS) [Internet]. Brasília: Ministério da Integração e do Desenvolvimento Regional [cited 2023 Jul 05]. Available from: http://appsnis.mdr.gov.br/indicadores/web/agua_esgoto/mapa-esgoto/?cod=13
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History of child mortality and hospitalizations due to undernutrition
When analyzing the history of child mortality in Brazil, one of the main indicators of health and economic development, a great decrease can be observed between 1980 and 2010, and since then the rate has plateaued, at around 13.5 deaths per thousand live births.3232 Brasil. Ministério da Saúde. Boletim Epidemiológico. Secretaria de Vigilância em Saúde. Departamento de Análise de Saúde e Vigilância De Doenças Não Transmissíveis (DASNT/SVS). Boletim Epidemiológico. Brasília: Ministério da Saúde; 2021.
When considering the infant mortality rates (Figure 4) of the emerging countries that make up the BRICS nations, created in 2006 and which include Brazil, Russia, India, China, and South Africa, the percentage of reduction in the child mortality rate in Brazil (48.6%) between 2003 and 2021 was the second lowest among the BRICS countries, behind India (57.5%), Russia (68.5%) and China (78.3%).3333 United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels & Trends in Child Mortality: Report 2020, Estimates Developed by the United Nations Inter-agency Group for Child Mortality Estimation. New York: United Nations Children's Fund; 2020.
Regarding mortality due to undernutrition in children under 5 years of age, an ecological study carried out with data from the Mortality Information System - SIM, from the Information Technology Department of the Unified Health System - Datasus, showed a rate reduction between the period 2003-2007 and 2013-2016, which went from 17.2% to 5.2%.3434 Rissi G.P., Shibukawa B.M., Góes H.L., de Oliveira R.R. Crianças menores de 5 anos ainda morrem por desnutrição? Rev Enferm UFPE. 2019;13: e239889. [cited 2023 Jul 21]. More recent data from Observatório de Saúde da Infância da Fundação Oswaldo Cruz - Fiocruz, indicate that in 2022 Brazil recorded the worst level of hospitalizations of children under one year of age due to undernutrition in the last 13 years.3535 Portal Fiocruz. Hospitalização De Bebês Por Desnutrição Atinge Pior Nível Dos últimos 13 Anos. Rio de Janeiro: Fundação Oswaldo Cruz; 2022 [cited 2023 Jun 04]. Available from: https://portal.fiocruz.br
https://portal.fiocruz.br...
Final discussion
The present study showed a lag in data on the prevalence of child undernutrition in Brazil. Population-based household surveys took place over a long period of time and showed results on the nutritional status of children only in 1974, 1989, 1996, 2002, 2006, and 2019, with wasting being diagnosed only in the 1996 survey, while in the 2002 survey, only underweight data were considered. Lagging data make it difficult to compare historical nutritional status, as well as possible correlations with its determinants.
Moreover, household surveys have the set of private households as the research population and exclude indigenous people who live in reservations, homeless people, foreigners living in households where the Portuguese language is not spoken, and those with any condition that prevented anthropometry from being carried out. and residents of collective homes (orphanages, boarding houses, etc.).1616 Universidade Federal do Rio de Janeiro (UFRJ). Estudo Nacional de Alimentação e Nutrição Infantil - ENANI 2019. Estado Nutricional Antropométrico da Criança e da Mãe: Prevalência de Indicadores Antropométricos De Crianças Brasileiras Menores De 5 Anos De Idade e Suas Mães Biológicas. Rio de Janeiro: UFRJ; 2022. Therefore, data on nutritional status and food insecurity may be underestimated.
It is also worth highlighting that the data presented in the last household survey are prior to the COVID-19 pandemic period, indicating that the current scenario may surpass the scenario found in 2019. Data from the World Bank indicate that, with the COVID-19 pandemic, the poverty situation in Brazil reached even worse prevalence rates than in 2000 and informal work surpassed that seen in 2012.2828 World Bank. Brazil Poverty and Equity Assessment: Looking Ahead of Two Crises. Washington DC: World Bank; 2022. http://hdl.handle.net/10986/37657 License: CC BY 3.0 IGO.”
http://hdl.handle.net/10986/37657...
Although the few studies on temporal trends indicate that the reversal of the trend towards reducing child undernutrition in Brazil occurred in mid-2013, when Brazil entered a technical and political recession with several macroeconomic imbalances, extreme poverty and mild food insecurity were already showing warning signs since 2006. The situation worsened in 2016 with the freezing of public spending established by Constitutional Amendment 95,3636 Brasil. Constituição (1988). Emenda Constitucional n° 95, 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir no Novo Regime Fiscal e dá outras providências. Brasília: Diário Oficial da União, 15 dez 2016. which affected primary spending on health, education, social assistance, culture, sports, and national defense, among others, and by 2025 it is estimated that this situation could leave 20 million people without due assistance during this period.3737 Mattei L.F. Sistema de proteção social Brasileiro enquanto instrumento de combate à pobreza. Rev Katálysis. 2019;22:57-65.
The trajectories of primary child undernutrition determinants assessed in this review indicate that Brazil has plateaued or worsened in the last 10 years. The most recent prevalence data indicate an increase in acute undernutrition (wasting) in 2019 and a stagnation in the prevalence of chronic undernutrition (stunting) for more than 10 years.1616 Universidade Federal do Rio de Janeiro (UFRJ). Estudo Nacional de Alimentação e Nutrição Infantil - ENANI 2019. Estado Nutricional Antropométrico da Criança e da Mãe: Prevalência de Indicadores Antropométricos De Crianças Brasileiras Menores De 5 Anos De Idade e Suas Mães Biológicas. Rio de Janeiro: UFRJ; 2022.
According to Monteiro et al.3838 Monteiro C.A., Benicio M.H., Konno S.C., Silva A.C., Lima A.L., Conde W.L. Causes for the decline in child under-nutrition in Brazil, 1996-2007. Rev Saude Publica. 2009;43:35-43. English, Portuguese., the reduction in child undernutrition between 1996 and 2006 can be attributed 25.7% to improvements in maternal education, 21.7% to the increase in family purchasing power, 11.6% to the expansion of health care and 4.3% to improvements in basic sanitation conditions. Another study also demonstrated a significant association between coverage of the Bolsa Família Program (PBF) and the Family Health Program (PSF, Programa Saúde da Família) with the reduction in infant mortality between 2004 and 2009.3939 Rasella D., Aquino R., Santos C.A., Paes-Sousa R., Barreto M.L. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet. 2013;382:57-64.
According to projections, if Brazil had intensified public policies aimed at increasing the purchasing power of the poorest and access to essential services such as education, health, and sanitation, the prevalence of children under 5 years of age with stunting would have reached less than 3% in 2017, ceasing to be a public health problem since that year.3838 Monteiro C.A., Benicio M.H., Konno S.C., Silva A.C., Lima A.L., Conde W.L. Causes for the decline in child under-nutrition in Brazil, 1996-2007. Rev Saude Publica. 2009;43:35-43. English, Portuguese.
Conclusion
Population-based household surveys tend to underestimate the real scenario of child undernutrition in Brazil because they do not consider groups with greater vulnerability when designing the study population. The 13-year interval between the last and penultimate surveys makes it difficult to compare the periods but indicates an increase in the prevalence of undernutrition from 2006 onwards, which is confirmed by studies of temporal trends with data from SISVAN, indicating an increase from mid-2013 onwards. Furthermore, the presented data are prior to the COVID-19 pandemic period, indicating that the current scenario may surpass the data collected by the last household survey.
Despite advances since the 1980s, Brazil's fragile social protection system has not been able to reduce social inequalities throughout history, but only to contain them temporarily. The reversal of the trend toward reducing child undernutrition has been accompanied by an increase in poverty and inequality.
Faced with the scenario of spending freezes for a social security system that was not even properly constituted, in 2019 the authors observed that hunger, food insecurity, extreme poverty, and acute undernutrition (wasting) in children under 5 years of age reached the worst levels in the historical series. Moreover, child mortality has not shown a significant reduction since 2015 and basic sanitation is progressing at a slow pace, maintaining large regional disparities.
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Publication Dates
-
Publication in this collection
13 May 2024 -
Date of issue
Mar-Apr 2024
History
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Received
25 Sept 2023 -
Accepted
26 Sept 2023 -
Published
08 Nov 2023