Images of malnourished Yanomami children began circulating in the press again in January, a year after the federal government had declared a public health emergency in the territory occupied by the ethnic group in the extreme north of Brazil and after 307 of them had recovered. The scenes are shocking because they portray a severe health problem that persists among the Indigenous populations decades after it was eliminated in the rest of the country, with weight problems becoming an issue in early childhood.
A significant increase in the proportion of Brazilian children with greater than the recommended weight for their age and height was recorded in a study published in October 2023 in a supplement of scientific journal Cadernos de Saúde Pública. In the study, the team of nutritionists Gilberto Kac, of the Federal University of Rio de Janeiro (UFRJ) and Inês Rugani Castro, of Rio de Janeiro State University (UERJ), compared the nutritional situation of thousands of boys and girls below 5 years of age, assessed in two surveys. The first was the Brazilian National Demographic and Health Survey of Women and Children (PNDS), carried out in 2006 with 4,817 children from all regions of Brazil; the second is the Brazilian National Survey on Child Nutrition (ENANI), conducted in 2019 with 14,558 participants of the same age group. In this 13-year period, the proportion that are overweight grew from 6% to 10.1%.
The difference of a little over four percentage points may seem small, but it serves as a warning for potentially severe future effects. Overweight children tend to remain overweight into adulthood, facing an increased risk of cardiovascular and metabolic diseases, such as diabetes and increased cholesterol.
In population terms, the proportion of children over the desired weight in this age range should not exceed 2.5%, which experts say is the percentage of children expected to be overweight as a result of genetic conditions. The increased frequency of overweight children, however, is a global phenomenon and, according to data from the World Health Organization (WHO), the numbers went from 4.9% in 2000 to 5.6% in 2019.
Alexandre Affonso / Revista Pesquisa FAPESP
“The value measured by the ENANI-2019 should raise the alarm of the Brazilian public authorities. If nothing is done to change this pattern of weight gain, a much higher proportion of these children will likely be overweight or become obese in adulthood,” says pediatrician Antônio Augusto Moura da Silva, of the Federal University of Maranhão (UFMA), who analyzed the study at the request of Pesquisa FAPESP.
Silva is a collaborator in a study that, from time to time, reevaluates the health of children born in Ribeirão Preto (São Paulo) and in São Luís (Maranhão). “Among those born in 1978 in Ribeirão Preto, 15% were overweight at age 10. At 40 years of age, 74% were overweight or obese. In São Luís, we are beginning to see this effect in the wealthier layers of society,” she says.
Other studies of a regional nature, representative of the population of the South and Southeast, those in which ENANI found a higher proportion of overweight children, observed the same effect.
In Pelotas, in Rio Grande do Sul, once every 11 years the team led by epidemiologist César Victora and pediatrician Fernando Barros, both from the Federal University of Pelotas (UFPel), reassesses the health of the people born in the municipality in 1982, 1993, 2004, and 2015. “At 18 years old, 20% of the people born in 1982 were overweight or obese. At 22 years old, almost 30%, and at 40 years old, 74%,” says Bernardo Horta, an epidemiologist from the team in Pelotas.
In a study published in 2019 in International Journal of Epidemiology, the researchers from the state of Rio Grande do Sul verified that the frequency of being overweight in the first year of life almost doubled in four generations. It was 6.5% among the children born in 1982 and rose to 12.2% among those from 2015.
This effect recorded between generations appears to be maintained over time. “When the people born in 1982 turned 33 years of age, 54% were overweight or obese. Among those born in 1993, the proportion reached 63%,” says Horta. “We are witnessing an explosion in the number of people who are overweight in Brazil.”
The causes of the excess weight epidemic among adults and children are complex and similar. Besides genetic factors, they involve sedentary lifestyle habits, increased levels of stress, a lack of reparative sleep, and a diet with significant amounts of highly caloric industrialized foods — highly palatable, ultra-processed foods that are rich in sugars, salt, and fats. A worrying factor is that these foods are included in children’s diets from the first months of life.
With the aim of discovering the composition of the diet in one of the earliest phases of childhood, nutritionist Elisa de Aquino Lacerda, of UFRJ, analyzed the data of 4,354 children aged between 6 months and 2 years of age when the mothers or caregivers were interviewed for the ENANI-2019. In this stage, the child should start receiving other foods besides breast milk.
Lacerda found that, based on the diet of the previous day, 63% of the children presented a minimally diversified diet, with the consumption of foods from at least five of these eight groups: breast milk, dairy products; grains, roots, and tubers; legumes, nuts, and seeds; meat; eggs; fruit and vegetables; and fruits and vegetables rich in vitamin A.
According to the study, published in the supplement of scientific journal Cadernos de Saúde Pública, the proportion of children with a diversified diet was higher (69.4%) in the Southeast and lower (54.8%) in the North. This frequency was also highest (76.5%) among those with mothers or caregivers with more than 12 years of schooling and lowest (50.6%) among those whose mother or caregiver attended school for less than seven years.
The most surprising, however, was the consumption of ultra-processed foods, common throughout the country. On average, 80.5% of the children in this age group already ate this type of product, in general, crackers and cookies, instant flours for baby food, as well as industrialized yogurts, and sweetened drinks. Once again, the proportion was higher (84.5%) in the North, and this time, lower (76.1%) in the Central-West. Only 8.4% of the children presented a minimally diversified diet and that did not include ultra-processed foods.
Alexandre Affonso / Revista Pesquisa FAPESP
Not only worrying data emerged from the comparison between the surveys from 2006 and 2019. In this period, the nutritional status of the children improved a lot.
A problem that reduced significantly was anemia. Caused by a lack of micronutrients or by the occurrence of frequent infections and parasites, it affects 40% of under-fives in the world, according to WHO estimations. Children with anemia can feel tired and present low performance in physical and intellectual activities. Around 40 or 50 years ago, around 60% of Brazilian children under the age of five were anemic. This proportion, which had already fallen to 20.5% in 2006, fell to 10% in 2019.
Another alleviated public health issue was vitamin A deficiency. Acquired by the ingestion of foods of animal origin and yellow or orange colored fruit and vegetables (rich in beta-carotene), this nutrient is important for the multiplication of cells and the functioning of the nervous and immunological systems. Vitamin A deficiency affected 17.2% of under-fives in Brazil in 2006 and 6% in 2019.
“The country achieved important victories in this period. Normally, the improvement of these indicators takes much longer,” affirms Moura da Silva, of UFMA. Overall, assesses Inês Rugani Castro, of UERJ, the nutritional profile of Brazilian children is at an intermediate level. “We are better than the poor countries and, in some aspects, worse than the rich ones,” she reports.
These advances, according to the researchers, are the result of currency stabilization and the control of hyperinflation in the 1990s, and the continued implementation of public policies that allow increased family income, improving the educational level of the parents, and increasing access to the Brazilian Public Health System (SUS). Several socioeconomic indicators that influence children’s health progressed between 2006 and 2019. The proportion of families with mothers or caregivers with more than 11 years of schooling increased from 32% to 56%, access to treated water went from 79% to 93%, and sewage collection from 46% to 75%.
The evolution of one indicator, however, intrigued the researchers: that of short stature. Easily measurable, short stature usually results from nutritional deficiency, repeated infections, or a lack of psychosocial stimulation experiences for long periods. In public health, it is interpreted as a cumulative indicator of malnutrition. It affected 37.1% of under-fives in Brazil in 1974 and its levels reduced in the three following decades, reaching a mark of 7.1% in 2007, as epidemiologist Carlos Augusto Monteiro, of the School of Public Health of the University of São Paulo (FSP-USP) recorded, in the Bulletin of the World Health Organization in 2010.
Since then, its level has remained at 7%. “The percentage was relatively low in 2006, but we expected that it would improve. It hasn’t improved,” says Castro.
One possible explanation is the fact that the 2019 survey assessed children that were born before and after the start of the economic crisis and the reduction in cover of social assistance and health programs observed from 2016. The proportion of children with low stature was lower among those who were born before the crisis (older) than among those born after (younger). In scenarios of stability, it is expected that low stature would be more frequent among older children because they would have gone through more episodes of food insecurity and infection than the younger ones. The comparison between the two surveys also showed that the older children from ENANI fared better than the older ones from the PNDS, a sign of the improvement from 2006 to 2019, and that the younger ones from the ENANI fared worse than the younger children from the PNDS, suggesting that the progress in the period was not sustained. “For the rate of the indicator to improve, the virtuous cycle that began in the 2000s could not have been interrupted,” explains the nutritionist from UERJ.
One region of the country stands out from the others in some aspects: The North. With 17.3 million inhabitants (8.5% of the population of Brazil) and an area equivalent to almost half the national territory, the North region is one of the poorest, with the population with the lowest educational level and with the most difficulty to access the public health system. The frequencies in the region for low stature and anemia were 8.4% and 17%, respectively.
“The ENANI represents a huge advance in quality in relation to the previous surveys. But its design does not allow the characterization of the differences between the populations of urban and rural environments or those that inhabit remote areas, such as riverside dwellers, quilombolas, and Indigenous people,” says nutritionist Marly Cardoso, of FSP-USP.
Fernando Frazão / Agência BrasilWomen and children in the Yanomami Indigenous Reservation, in RoraimaFernando Frazão / Agência Brasil
She is coordinating a study that follows the health of just over 1,000 children born in 2015 in Cruzeiro do Sul, a city with 90,000 inhabitants in the state of Acre, close to the border with Peru. There, Cardoso and her colleagues have observed some more serious conditions and others that are different from those recorded in the rest of the country. In Cruzeiro do Sul, 39% of the mothers were anemic when giving birth and 42% of the children had anemia at the end of the first year of life. The rate fell as the children grew and was 5.2% at 5 years old, according to the data presented in November in a supplement of the journal Revista de Saúde Pública. Additionally, the proportion of children with low stature at 5 years of age (2.3%) was much lower than the national average, whereas those who were overweight was higher (12.7%).
What generally is not going well in the country may be even worse among the Indigenous populations. In 2008 and 2009, Bernardo Horta, of UFPel, and collaborators carried out the first — and only — national survey about Indigenous health and nutrition. They analyzed the health conditions of around 12,000 people in 113 communities from across the entire country and presented the results in 2013 in the journal BMC Public Health. Among the children up to five years of age, 51.2% had anemia and 25.7% low stature — these proportions were 66.4% and 40.8%, respectively, among the Indigenous people from the North region.
“In order to improve the national outlook, especially the North region and the more remote communities,” says Cardoso, “it is necessary that a political decision be taken to implement and expand the coverage of programs for the promotion of health, health infrastructure, and increasing income, but with a commitment to continue these actions.”
Project MINA mother and child study in Acre: Birth cohort from the Brazilian Western Amazon (nº 16/00270-6); Grant Mechanism Thematic Project; Principal Investigator Marly Augusto Cardoso (FSP-USP); Investment R$3,440,351.93.
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