Chapter 2. The Improvement in Child Nutritional Status

Low Weight-for-Age During Childhood
Height at the End of Preschool Age
Infant Mortality
Regional and Socio-economic Differentials

In this section the evolution of the nutritional status of Brazilian children is traced back throughout the past two decades (1970-1989 period). The analysis is based on three indicators:

i. the prevalence of low weight-for-age during the first five years of childhood;
ii. height attained at the end of the pre-school age; and
iii. rate of mortality in the first year of life.

Height attained at the end of pre-school age is studied by comparing heights of 6 and 7 year-old children evaluated only in 1975 and 1989, since the 1986 survey was restricted to underfives.

Yearly infant mortality rates (number of deaths under one year of age by thousand live births) were available for the whole country from 1977 to 1989, and for the state of São Paulo (located in the Southeast region and nearly one quarter of the total Brazilian population) from 1970 to 1989. Mortality rates in São Paulo represent crude infant mortality rates, since under-reporting of births and deaths is virtually non-existing in the state (Fundação SEADE, 1977). Mortality rates in the rest of the country are adjusted for the coverage attained by the official registration of births and deaths in each region using correction factors published by the IBGE (Simões, 1989).

Before beginning the discussion of the trends observed with respect to the three indicators it should be noted that, although affected by the same determinants - morbidity, food intake and the general access to basic needs - they respond with different lags to the changes in child nutritional status. Prevalence of low weight-for-age in underfives reflects the average child nutritional status existing for a period of five years, since weight-for-age translates both recent and past disturbances in child growth (WHO, 1986). Height attained at the end of pre-school age is mainly an indication of the nutritional status prevailing a couple of years before the survey, since retardation in linear growth concentrates in the first two years of life (Waterlow, 1988). Finally, no substantial lag should occur with infant mortality rates and yearly changes in this indicator should point to virtually simultaneous changes in child nutritional status.

Low Weight-for-Age During Childhood

The prevalence of underweight children found by the national surveys of 1975 and 1989 is presented in Table 6. Highly significant decreases in prevalence, around 60%, is observed for both the urban and the rural population. This indicates, as noted before, that an impressive improvement in child nutritional status has occurred in a period of time situated between the first half of the seventies and the second half of the eighties.

Table 7 focuses on the Northeast region, displaying estimates of underweight children obtained in 1975, 1986 and 1989. Highly significant decreases in the prevalence of underweight children, around 50%, are observed from 1975 to 1986, which points to a substantial improvement in child nutritional status occurring between the first half of the seventies and the first half of the eighties. No further reduction in prevalence is observed from 1986 to 1989 suggesting that improvements in nutritional status could have been discontinued in the second half of the eighties

Height at the End of Preschool Age

Changes in the mean height attained by 6 and 7 year-old Brazilian children are presented in Tables 8 and 9. Both urban and rural children studied in 1989 are significantly taller than those studied in 1975. The average height deficit found in Brazil, or the difference in mean height with the NCHS/WHO standard, was cut by one half between the two surveys: from about 7.0 cm in 1975 to about 3.5 cm in 1989. This fact reinforces the hypothesis that impressive gains in child nutritional status had place in a period of time situated between the early seventies and the early eighties.

Table 6
Prevalence (%) of Low Weight for Age* in Children Under 5 Years of Age
Brazil, 1975 and 1989

Strata	Sample size		1975	1989	% change**
	1975	1989	Survey A	Survey B
Brazil urban	24,784	3,895	14.6	5.6	-61.6
Brazil rural	11,623	3,571	22.9	10.6	-53.7
Total	36,407	7,466	18.4	7.1	-61.4

Source: Monteiro et. al. (1992).

Notes:

* Weight for age below -2 z-scores (NCHS/WHO standard);
** [(B-A)/A].100. All changes in prevalence are significant at p<0.001.

Table 7
Prevalence (%) of Low Weight for Age* in Children Under 5 Years of Age
Brazil, Northeast Region, 1975, 1986 and 1989

	Strata
	Northeast Urban	Northeast Rural	Total
SAMPLE SIZE
1975 Survey	7,378	5,642	13,020
1986 Survey	550	582	1,132
1989 Survey	866	1,259	2,125
PREVALENCE
1975 Survey (A)	22.9	29.6	27.0
1986 Survey (B)	9.8	15.5	12.7
1989 Survey (C)	10.3	15.2	12.8
% CHANGE
[(B-A)/A].100**	-57.2	-47.6	-53.0
[(C-B)/B].100***	5.1	-1.9	0.8

Source: Monteiro et al. (1992); Arruda et al. (1987).

Notes:

* Underfives with weight for age below minus 2 z-scores (NCHS/WHO standard).
** p<0.001.
*** Non-significant.

Table 8
Mean height (cm) of 6 and 7 year-old Boys
Brazil, 1975 and 1989

Age	Strata
	Brazil Urban	Brazil Rural	Total
6 YEAR-OLD
1975 Survey
Sample size	2,467	1,184	3,651
Mean height (A)	113.0	110.1	111.7
Standard deviation	7.4	7.0	7.4
1989 Survey
Sample size	450	371	821
Mean height (B)	116.1	112.5	115.7
Standard deviation	6.4	6.1	6.5
Height increment (B-A)*	3.1	2.4	4.0
7 YEAR-OLD
1975 Survey
Sample size	2,521	1,200	3,721
Mean height (A)	118.4	115.3	117.0
Standard deviation	7.9	7.1	7.4
1989 Survey
Sample size	495	380	875
Mean height (B)	121.2	118.2	120.4
Standard deviation	6.9	7.3	7.1
Height increment (B-A)*	2.8	2.9	3.4

Source: National Health and Nutrition Surveys: 1975, 1989.
Note: * All increments significant at p<0.001.

Table 9
Mean height (cm) of 6 and 7 year-old Girls
Brazil, 1975 and 1989

Age	Strata
	Brazil Urban	Brazil Rural	Total
6 YEAR-OLD
1975 Survey
Sample size	2,492	1,168	3,660
Mean height (A)	112.3	110.3	111.4
Standard deviation	7.2	6.7	7.0
1989 Survey
Sample size	386	361	747
Mean height (B)	115.4	113.2	114.7
Standard deviation	6.7	6.0	6.5
Height increment (B-A)*	3.1	2.9	3.3
7 YEAR-OLD
1975 Survey
Sample size	2,402	1,095	3,497
Mean height (A)	118.0	115.1	116.8
Standard deviation	7.7	6.8	7.4
1989 Survey
Sample size	452	351	803
Mean height (B)	120.8	118.9	120.3
Standard deviation	6.3	7.0	7.2
Height increment (B-A)*	2.8	3.8	3.5

Source: National Health and Nutrition Surveys: 1975, 1989.
Note: * All increments significant at p<0.001.

Infant Mortality

Infant mortality rates for the whole country (1977-1989) and for the state of São Paulo (1970-1989) are presented in Table 10 and plotted in Figure 5. The series for the whole country shows intense and systematic declines in mortality from 1977 to 1982. These declines are interrupted in 1983 and 1984 and then followed by a period of relatively lower but continuous reductions up to 1989.

The longer series available for the state of São Paulo points to stagnant rates of infant mortality up to 1975. Intense and systematic declines occur from 1975 to 1980, followed by relatively lower declines up to 1989. A peak of mortality is registered in 1984. Indeed, from 1977 to 1989, trends in infant mortality in Sao Paulo were not far from trends described for the whole country. In this 12-year interval, infant mortality was reduced in 55% in São Paulo and 54% in Brazil (from 68.8 to 30.9 ‰ and from 98.3 to 45.0, respectively).

Table 10
Infant Mortality Rates
Brazil and State of São Paulo, 1970-1989

Year	Infant Mortality Rate*
	Brazil	State of São Paulo
1970	-	84.3
1971	-	90.1
1972	-	86.2
1973	-	89.2
1974	-	82.3
1975	-	85.3
1976	-	74.2
1977	98.3	68.8
1978	90.9	65.3
1979	82.8	58.5
1980	75.0	51.2
1981	68.4	49.3
1982	64.5	47.9
1983	66.7	42.3
1984	65.9	44.9
1985	58.1	36.4
1986	53.2	36.2
1987	51.0	33.7
1988	47.5	33.9
1989	45.0	30.9

Sources:

IBGE - Estatísticas do Registro Civil, 1977-1989;
SEADE - Movimento do Registro Civil, 1970-1989

Note: * Infant deaths per 1,000 live births.

Taking together the pattern of changes observed with the three indicators of child nutritional status, and accepting that trends observed in particular Brazilian regions may inform on what has occurred in the whole country, the period of interest (1970-1989) could be divided into the three following periods: a period of stagnant nutritional status (1970 to 1975), a period of exceptional and systematic gains (1975 to 1982), and a period of moderate and not continuous gains (1982 to 1989).

Regional and Socio-economic Differentials

During the last two decades a substantial net improvement in indicators of child nutritional status was observed all over the country and in different socio-economic strata.

A detailed and comparable study of all sources of family income present in the national surveys of 1975 and 1989 allows for the description of changes in indicators of child growth in specific income strata. Figure 6 describes changes in the prevalence of underweight children, while Figure 7 describes changes in height deficits at 7.0 years of age. In both cases it is clear that the degree of improvement was related to the level of family income, with the already high differentials that existed between rich and poor in 1975 increasing in the 1989 survey.

Figure 6. UNDERWEIGHT CHILDREN BY INCOME STRATA - BRAZIL, 1975 AND 1989

Table 11 synthesizes the changes occurring in the two most contrasting Brazilian regions: the poor Northeast and the rich Southeast. As far as child survival is concerned, the gap between the two regions was kept virtually unchanged from 1977 to 1989. Indicators of child growth, however, point to a further increase in the Southeast/Northeast gap.

The differences existing in 1989 between the poor Northeast and the rich Southeast can be illustrated by comparing the prevalence of underweight children found in these two regions viz a viz estimates reported for other Latin American countries¹¹. This comparison places the Brazilian Northeast region (12.8% prevalence) together with poor and stagnant developing countries as Bolivia (13.3% prevalence in 1989) or Peru (10.8% prevalence in 1991). The same comparison places the Brazilian Southeast (4.1% prevalence) amongst developing countries widely recognized as leaders in indicators of human development (UNDP, 1992) as Costa Rica (6.0% prevalence in 1982) and Chile (2.5% in 1986).

¹¹ Estimates as reported by the WHO International Data Base on Child Growth, Update 1992.

Table 11
Indicators of Child Nutritional Status
Brazil, Northeast and Southeast Regions, 1975-77 and 1989

Period and Region	Underweight Children %	Height Deficit at 7 years cm		Infant Mortality ‰
		Boys	Girls
1975-1977
Northeast (A)	27.0	10.1	9.1	156.6
Southeast (B)	13.4	5.6	6.0	63.0
Ratio (A)/(B)	2.0	1.9	1.5	2.5
1989
Northeast (A)	12.8	6.3	5.7	75.0
Southeast (B)	4.1	2.3	1.5	33.3
Ratio (A)/(B)	3.0	2.7	3.5	2.4