Silvia Cristina Konno

Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974-2007

OBJECTIVE To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. METHODS The prevalence of stunting (height-for-age z score below -2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34,409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. FINDINGS Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. CONCLUSION In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.

Wheezing conditions in early childhood: prevalence and risk factors in the city of São Paulo, Brazil

OBJECTIVE To investigate the prevalence and risk factors for wheezing disorders in early childhood in São Paulo, Brazil, the largest metropolitan area of South America. METHODS A population-based cross-sectional survey of 1132 children aged 6-59 months was carried out between 1995 and 1996 to obtain information on recent wheezing and on independent variables such as demographic, socioeconomic, environmental, maternal and nutritional variables and immunization status. Intestinal parasitic infections were diagnosed using standard techniques. Multiple unconditional logistic regression was used to describe associations between outcome and independent variables. FINDINGS The prevalence of recent wheezing (one or more reported episodes in the past 12 months) was 12.5%; 93% of children with wheezing were also reported to have a medical diagnosis of asthma. Recent wheezing was associated with low per capita income, poor quality of housing, day-care attendance, low birth weight and infection with intestinal helminths. CONCLUSION Wheezing in early childhood in São Paulo, although more common than in most developing countries, remains less prevalent than in urban areas of industrialized countries. Low income and conditions associated with poverty (poor housing, low birth weight and parasitic infections) are some of the main risk factors for wheezing disorders among young children in this city.

Causas do declínio acelerado da desnutrição infantil no Nordeste do Brasil (1986-1996-2006)

OBJECTIVE To describe changes in prevalence of child undernutrition in Northeastern Brazil in two successive time periods, identifying, in each period, the major factors responsible for these changes. METHODS Data analyzed are from probabilistic samples of underfives from three Demographic Health Surveys carried out in 1986 (n=1,302), 1996 (n=1,108), and 2006 (n=950). Identification of factors responsible for temporal changes in child undernutrition (height-for-age below < -2 z) took into account time changes in five potential determinants of child nutritional status, statistical modeling of the independent association between determinants and risk of undernutrition, and calculation of attributable fractions. RESULTS Prevalence of child undernutrition fell by one-third between 1986 and 1996 (from 33.9% to 22.2%) and by almost three-quarters between 1996 and 2006 (from 22.2% to 5.9%). Improvements in maternal schooling and in the coverage of water and sewage services were particularly important for the decline in child undernutrition in the first period, while increasing purchasing power of the poorest families and, again, maternal schooling were more relevant in the second period. CONCLUSIONS The acceleration of the decline in child undernutrition between the two periods was consistent with accelerated improvement of maternal schooling, water supply and sewage, health care, and maternal reproductive antecedents, as well as with the outstanding increase in purchasing power among the poor during the second period. If the rate of decline in growth deficits is kept at around the rate of the most recent period, child undernutrition will be controlled in the Brazilian Northeast in less than ten years. Achieving this will depend on sustaining the increase in purchasing power among the poor and on ensuring public investment in completing the universalization of access to essential services such as education, health, and sanitation.OBJETIVO: Descrever a variacao temporal na prevalencia de desnutricao infantil na regiao Nordeste do Brasil, em dois periodos sucessivos, identificando os principais fatores responsaveis pela evolucao observada em cada periodo. METODOS: Os dados analisados provem de amostras probabilisticas da populacao de criancas menores de cinco anos estudadas por inqueritos domiciliares do programa Demographic Health Surveys realizados em 1986 (n=1.302), 1996 (n=1.108) e 2006 (n=950). A identificacao dos fatores responsaveis pela variacao na prevalencia da desnutricao (altura para idade < -2 z) levou em conta mudancas na frequencia de cinco determinantes potenciais do estado nutricional, modelagens estatisticas da associacao independente entre determinante e risco de desnutricao no inicio de cada periodo e calculo de fracoes atribuiveis. RESULTADOS: A prevalencia da desnutricao foi reduzida em um terco de 1986 a 1996 (de 33,9% para 22,2%) e em quase tres quartos de 1996 a 2006 (de 22,2% para 5,9%). Melhorias na escolaridade materna e na disponibilidade de servicos de saneamento foram particularmente importantes para o declinio da desnutricao no primeiro periodo, enquanto no segundo periodo foram decisivos o aumento do poder aquisitivo das familias mais pobres e, novamente, a melhoria da escolaridade materna. CONCLUSOES: A aceleracao do declinio da desnutricao do primeiro para o segundo periodo foi consistente com a aceleracao de melhorias em escolaridade materna, saneamento, assistencia a saude e antecedentes reprodutivos e, sobretudo, com o excepcional aumento do poder aquisitivo familiar, observado apenas no segundo periodo. Mantida a taxa de declinio observada entre 1996 e 2006, o problema da desnutricao infantil na regiao Nordeste poderia ser considerado controlado em menos de dez anos. Para se chegar a este resultado sera preciso manter o aumento do poder aquisitivo dos mais pobres e assegurar investimentos publicos para completar a universalizacao do acesso a servicos essenciais de educacao, saude e saneamento.

Fatores associados à evolução ponderal de gestantes: uma análise multinível

OBJETIVO: Avaliar a influencia de fatores socioeconomicos, reprodutivos e comportamentais sobre a evolucao do peso durante a gestacao. METODOS: O peso corporal foi mensurado prospectivamente em uma coorte de 215 gestantes saudaveis atendidas por um servico publico de pre-natal do Municipio de Sao Paulo, no periodo de 1997 a 1998. Os criterios de inclusao foram: idade > 18 anos e inicio do pre-natal com idade gestacional 4 anos, ausencia de companheiro e primiparidade proporcionam acrescimos de 3,0 kg, 1,9 kg, 2,3 kg e 2,4 kg, respectivamente, no ganho de peso total durante a gestacao. CONCLUSOES: O IMC inicial, escolaridade e paridade sao caracteristicas maternas que, com o estado marital, devem ser consideradas no desenvolvimento de estrategias para a promocao de um ganho de peso adequado durante a gestacao.

Causes of the accelerated decline in child undernutrition in Northeastern Brazil (1986-1996-2006)

OBJECTIVE To describe changes in prevalence of child undernutrition in Northeastern Brazil in two successive time periods, identifying, in each period, the major factors responsible for these changes. METHODS Data analyzed are from probabilistic samples of underfives from three Demographic Health Surveys carried out in 1986 (n=1,302), 1996 (n=1,108), and 2006 (n=950). Identification of factors responsible for temporal changes in child undernutrition (height-for-age below < -2 z) took into account time changes in five potential determinants of child nutritional status, statistical modeling of the independent association between determinants and risk of undernutrition, and calculation of attributable fractions. RESULTS Prevalence of child undernutrition fell by one-third between 1986 and 1996 (from 33.9% to 22.2%) and by almost three-quarters between 1996 and 2006 (from 22.2% to 5.9%). Improvements in maternal schooling and in the coverage of water and sewage services were particularly important for the decline in child undernutrition in the first period, while increasing purchasing power of the poorest families and, again, maternal schooling were more relevant in the second period. CONCLUSIONS The acceleration of the decline in child undernutrition between the two periods was consistent with accelerated improvement of maternal schooling, water supply and sewage, health care, and maternal reproductive antecedents, as well as with the outstanding increase in purchasing power among the poor during the second period. If the rate of decline in growth deficits is kept at around the rate of the most recent period, child undernutrition will be controlled in the Brazilian Northeast in less than ten years. Achieving this will depend on sustaining the increase in purchasing power among the poor and on ensuring public investment in completing the universalization of access to essential services such as education, health, and sanitation.OBJETIVO: Descrever a variacao temporal na prevalencia de desnutricao infantil na regiao Nordeste do Brasil, em dois periodos sucessivos, identificando os principais fatores responsaveis pela evolucao observada em cada periodo. METODOS: Os dados analisados provem de amostras probabilisticas da populacao de criancas menores de cinco anos estudadas por inqueritos domiciliares do programa Demographic Health Surveys realizados em 1986 (n=1.302), 1996 (n=1.108) e 2006 (n=950). A identificacao dos fatores responsaveis pela variacao na prevalencia da desnutricao (altura para idade < -2 z) levou em conta mudancas na frequencia de cinco determinantes potenciais do estado nutricional, modelagens estatisticas da associacao independente entre determinante e risco de desnutricao no inicio de cada periodo e calculo de fracoes atribuiveis. RESULTADOS: A prevalencia da desnutricao foi reduzida em um terco de 1986 a 1996 (de 33,9% para 22,2%) e em quase tres quartos de 1996 a 2006 (de 22,2% para 5,9%). Melhorias na escolaridade materna e na disponibilidade de servicos de saneamento foram particularmente importantes para o declinio da desnutricao no primeiro periodo, enquanto no segundo periodo foram decisivos o aumento do poder aquisitivo das familias mais pobres e, novamente, a melhoria da escolaridade materna. CONCLUSOES: A aceleracao do declinio da desnutricao do primeiro para o segundo periodo foi consistente com a aceleracao de melhorias em escolaridade materna, saneamento, assistencia a saude e antecedentes reprodutivos e, sobretudo, com o excepcional aumento do poder aquisitivo familiar, observado apenas no segundo periodo. Mantida a taxa de declinio observada entre 1996 e 2006, o problema da desnutricao infantil na regiao Nordeste poderia ser considerado controlado em menos de dez anos. Para se chegar a este resultado sera preciso manter o aumento do poder aquisitivo dos mais pobres e assegurar investimentos publicos para completar a universalizacao do acesso a servicos essenciais de educacao, saude e saneamento.

Desigualdades socioeconômicas na baixa estatura infantil: a experiência brasileira, 1974-2007

The paper aims to assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. The prevalence of stunting (height-for-age z score below -2 using the Child Growth Standards of the World Health Organization) among children aged less than five years was estimated from data collected during national household surveys carried out in Brazil in 1974-1975 (n = 34,409), 1989 (n = 7,374), 1996 (n = 4,149) and 2006-07 (n = 4,414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last ten years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under five were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.

Causas de la disminución acelerada de la desnutrición infantil en Noreste de Brasil (1986-1996-2006)

OBJECTIVE To describe changes in prevalence of child undernutrition in Northeastern Brazil in two successive time periods, identifying, in each period, the major factors responsible for these changes. METHODS Data analyzed are from probabilistic samples of underfives from three Demographic Health Surveys carried out in 1986 (n=1,302), 1996 (n=1,108), and 2006 (n=950). Identification of factors responsible for temporal changes in child undernutrition (height-for-age below < -2 z) took into account time changes in five potential determinants of child nutritional status, statistical modeling of the independent association between determinants and risk of undernutrition, and calculation of attributable fractions. RESULTS Prevalence of child undernutrition fell by one-third between 1986 and 1996 (from 33.9% to 22.2%) and by almost three-quarters between 1996 and 2006 (from 22.2% to 5.9%). Improvements in maternal schooling and in the coverage of water and sewage services were particularly important for the decline in child undernutrition in the first period, while increasing purchasing power of the poorest families and, again, maternal schooling were more relevant in the second period. CONCLUSIONS The acceleration of the decline in child undernutrition between the two periods was consistent with accelerated improvement of maternal schooling, water supply and sewage, health care, and maternal reproductive antecedents, as well as with the outstanding increase in purchasing power among the poor during the second period. If the rate of decline in growth deficits is kept at around the rate of the most recent period, child undernutrition will be controlled in the Brazilian Northeast in less than ten years. Achieving this will depend on sustaining the increase in purchasing power among the poor and on ensuring public investment in completing the universalization of access to essential services such as education, health, and sanitation.OBJETIVO: Descrever a variacao temporal na prevalencia de desnutricao infantil na regiao Nordeste do Brasil, em dois periodos sucessivos, identificando os principais fatores responsaveis pela evolucao observada em cada periodo. METODOS: Os dados analisados provem de amostras probabilisticas da populacao de criancas menores de cinco anos estudadas por inqueritos domiciliares do programa Demographic Health Surveys realizados em 1986 (n=1.302), 1996 (n=1.108) e 2006 (n=950). A identificacao dos fatores responsaveis pela variacao na prevalencia da desnutricao (altura para idade < -2 z) levou em conta mudancas na frequencia de cinco determinantes potenciais do estado nutricional, modelagens estatisticas da associacao independente entre determinante e risco de desnutricao no inicio de cada periodo e calculo de fracoes atribuiveis. RESULTADOS: A prevalencia da desnutricao foi reduzida em um terco de 1986 a 1996 (de 33,9% para 22,2%) e em quase tres quartos de 1996 a 2006 (de 22,2% para 5,9%). Melhorias na escolaridade materna e na disponibilidade de servicos de saneamento foram particularmente importantes para o declinio da desnutricao no primeiro periodo, enquanto no segundo periodo foram decisivos o aumento do poder aquisitivo das familias mais pobres e, novamente, a melhoria da escolaridade materna. CONCLUSOES: A aceleracao do declinio da desnutricao do primeiro para o segundo periodo foi consistente com a aceleracao de melhorias em escolaridade materna, saneamento, assistencia a saude e antecedentes reprodutivos e, sobretudo, com o excepcional aumento do poder aquisitivo familiar, observado apenas no segundo periodo. Mantida a taxa de declinio observada entre 1996 e 2006, o problema da desnutricao infantil na regiao Nordeste poderia ser considerado controlado em menos de dez anos. Para se chegar a este resultado sera preciso manter o aumento do poder aquisitivo dos mais pobres e assegurar investimentos publicos para completar a universalizacao do acesso a servicos essenciais de educacao, saude e saneamento.