Report No. 16010-BR

BrazilAddressing Nutritional Problems in BrazilOctober 18, 1996

Social ancl Hduman (Capital Development GroupCouLntrv I Department ILatin America andi the Caribbean Regional Office

FDLE COPYlDocument of the World Bank

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CURRENCY EQUIVALENTS

Currency Unit since July 1, 1994 Real (R$)Old Currency still in circulation Cruzeiro Real (CR$)R$ 1,00 CR$ 2,750.00US$ 1.00 R$ 0.92 (June 1995)R$ 1.00 US$1.087 (June 1995)

FISCAL YEAR

January 1 to December 1

LIST OF ACRONYMS

COBAL Brazilian Food Company; Companhia Brasileira de Alimentos

ENDEF National Survey of Household Expenditures; Estudo Nacional deDespesa Familiar

FAE Foundation for Student Assistance; Fundacao de Assistencia aoEstudante

IBGE Brazilian Statistical Institute; Fundacao Instituto Brasileiro deGeografia e Estatistica

IMR Infant Mortality Rate

INAN National Institute of Food and Nutrition; Instituto Nacional deAlimentacao e Nutricao

IPEA Institute for Economic and Social Planning; Instituto dePlanejamento Economico e Social

LBA Brazilian League of Social Assistance; Legiao Brasileira deAssistencia Social

LBW Low Birth Rate

PAP Popular Feeding Program; Programa de Alimentacao Popular

PAT Workers' Feeding Program; Programa de Alimentacao Popular

PCA Complementary Feeding Program; Programa de ComplementacaoAlimentar

PISA Integrated Food Suplementation Program; Programa Integrada deSuplementacao Alimentar

PNAD National Household Survey; Pesquisa National por Amostra deDomicilios

PROAB Supply of Basic Foods in Low-Income Areas Program; Programade Alimentos Basicos em Areas de Baixa Renda

PROCAB Purchase of Basic Foods in Rural Low-Income Areas; Programade Aquisicao de Alimentos Basicos era Areas de Baixa Renda

PSA Supplementary Food Program; Programa de SuplementacaoAlimentar

PINS Integrated Nutrition and Health Project; Projecto Integrado deNutricao e Saude

PNSMIPF National Demographic and Health Survey; Pesquisa NacionalSobre Saude Matemo-Infantil e Planejamento Familiar

PNSN National Health and Nutrition Survey; Pesquisa Nacional SobreSaude e Nutricao

PRAMENSE Program for Food Production and Improvement of NutritionalStatus in Sergipe; Projeto Experimental de Producao de Alimentose Melhoria do Estado Nutricional em areas de Baixa Renda emSergipe

PROAPE Program to Help Preschool Children; Projeto de Atendimento aoPre-Escolar

WHO World Health Organization

Vice President Shahid Javed BurkiDirector Gobind T. NankaniDivision Chief Alain ColliouStaff Member Helen Saxenian

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ADDRESSING NUTRITIONAL PROBLEMS IN BRAZIL

Table of Contents

Page No

EXECUTIVE SUMMARY ...................................................... i

ADDRESSING NUTRITIONAL PROBLEMS IN BRAZIL .. 1........................

Introduction .................................................... IWorld Bank Involvement in Nutrition in Brazil ............................................ 3

Nutritional Problems in Brazil .................................................... 4Changes in the Prevalence of Malnutrition from 1974/75 and 1989 ........ ............ 6Factors Affecting Malnutrition .................................................... , 8Diet and Micronutrient Deficiencies . 12

Effectiveness of Major Nutrition Programs ....................... 14The School Lunch Program .17Workers' Feeding Program ................................................... 18Food Supplementation Programs . 19Evidence of Program Targeting and Program Enrollments .21The Milk and Health Program for Malnourished Children and

Pregnant Women . 24Programs to Lower Food Prices to Consumers .24Emergency Feeding Programs .25Other Programs .25

Recommendations to Government .27

BIBLIOGRAPHY.. 29

ANNEX 1

Nutritional Status of Children under Five Years-of-Ageand Pregnant and Lactating Women in Brazil ........................................ ,.36

LIST OF TABLES AND FIGURES

Reptor

Table 1: Prevalence of stunting among children under five years . . 4

iii

Recommended Intakes of Selected Nutrients, Sao Paulo, 1984-85 ....................... 64Table 14: Changes in the Prevalence of Anemia Among Children Under Five in

Urban Sao Paulo, 1973/74 to 1984/85 ...................................................... 65Table 15: Proportion of Families (with Children 1-5 Years) With Diets that Fail to Meet

Recommended Intakes of Vitamin A, ENDEF 1974-75 ................................. 65Table 16: Proportion of Infants Currently being Breastfed, by Age, Region and

Rural/Urban, 1989, PNSN ................................................................ 66Table 17: Median Duration of Breastfeeding in Months by Family Income,

Sao Paulo, 1973-74 to 1984-85 ............................................................... 67Table 18: Cause-Specific Changes in Infant Mortality Associated with Breastfeeding ........ 67Table 19: Trends in Infant Mortality by Geographic Region, 1979-86 .......................... 67Table 20: Cause-Specific Infant Mortality Rates, Northeast 1977-85 ............................ 68Table 21: Infant and Child Mortality from Malnutrition, Sao Paulo, 1979-84 ................. 68Table 22: Trends in Incidence of Low Birthweight by Type of Hospital,

Northeast 1980-87 ................................................................ 69Table 23: Prevalence of Anemia Among Pregnant Women (> 36 weeks gestation) by

Income ................................................... 69Table 24: Proportion of Families with Pregnant and/or Lactating Women

Whose Diets Not Meet Recommended Intake of Iron, ENDEF 1974-75 ............ 70Table 25: Prevalence of Malnutrition in Women (15-49) Years in Ceara by Urban/Rural

Location and Age, 1988 .................................................... 70

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EXECUTIVE SUMMARY

i. Brazil has made laudable progress in improving the nutritional status of thepopulation over the past two decades. The overall prevalence of underweight childrenfell by 61 percent between 1974/75 to 1989 for children under five. I)espite significantprogress, however, malnutrition is far from eradicated in Brazil, particularly in theNortheast and in rural areas. Chronic (as opposed to acute) malnutrition is the mostcommon form of malnutrition in Brazil today. It is estimated that 15 percent of childrenunder five in Brazil are chronically malnourished (stunted). About 27 percent of childrenin the Northeast are malnourished by this measure, in contrast to 8 and 9 percent,respectively, in the South and Southeast. In the rural Northeast, prevalence of stuntingrises to 31 percent.

ii. Public spending on nutrition programs increased substantially in real termsover the 1980s, and then fell dramatically in the 1990s. At the peak, in 1990, annualexpenditures on an array of different nutrition programs--almost exclusively administeredat the federal level--equalled about US$ 1.4 billion, or U;S$ 10 per capita. Majornutrition programs were suspended over the period 1991-93, and, while some newmeasures were introduced, overall federal spending fell sharply, averaging about $0.4billion annually over the period. Against this backdrop, popular concern over theproblem of hunger in Brazil mounted and local groups began to support feeding programsand food distribution to the needy.

iii. The evidence examined in this report suggests that govermnent nutritionprograms were not primarily responsible for the improvement registered in averagenutritional status. Instead, the fall in malnutrition is probably due more to improvementsin incomes over much of the period, educational levels, sanitation, coverage ofimmunization programs (especially measles) and oral rehydration programs, and to lowerfertility. The economic recession in the 1980s interrupted the steady downward declinein the infant mortality rate and some nutritional indicators worsened dluring this period.In the context of these broader changes, nutrition programs probably played a small roleoverall, yet they served as a critical safety net for some of the most nlutritionallyvulnerable in the population.

iv. The report reviews the costs and impact of t]he major nutrition programs inBrazil over the period 1982-1993. Over this period, funding for individual programsfluctuated greatly, some favored for a period of two or three years arud then neglected.Many programs were disbanded in the early 1990s and for some months all programs thatwere targeted to the most vulnerable groups completely stopped. The report finds thatthe Government eliminated many nutrition programs that were duplicative or not verycost-effective, such as the National Milk Program. It made sound changes in 1992 and1993 to the operation of the School Lunch Program, and established a new supplementaryfeeding program in 1993, the Milk and Health Program for Malnourished Children andPregnant Women that appears to have built on the positive experiences of earliersupplementary feeding programs. In terms of nutrition, the least cost-effective program

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supported today is the Workers' Feeding Program. This program gives tax incentives forcompanies to provide meals to their workers, and is an income supplement enjoyedprimarily by workers in the Southeast. It does not address subgroups of the population atmost nutritional risk--young children and pregnant and lactating women.

v. The School Lunch Program was the largest remaining nutrition program in1993, absorbing about 85 percent of all nutrition spending. Because it is school-based,the School Lunch Program does not reach the very young children most at risk ofmalnutrition. It probably does, however, play an important role in attracting children toschool and keeping them in school, and, potentially, in enhancing their ability to learn.Recent efforts to decentralize its operation are likely to result in reduced costs and greateracceptability of the foods to students. The School Lunch Program is not well targetedacross regions; due in large part to management deficiencies, schools least likely to offerschool meals are those in the Northeast and in rural areas.

vi. Of the smaller federally supported micronutrient programs, the Program toCombat Endemic Goiter was so successful in raising compliance with salt iodinationamong producers that iodine deficiency was no longer considered a public health problemin the late 1980s. This program was widely seen as a model outside Brazil. But theProgram's success may have been threatened in recent years by lack of budgetarysupport. Programs directed at vitamin A and iron deficiencies have not had such a largeimpact, and widespread, serious problems of vitamin A and iron deficiencies continue.

vii. The major challenge for Govermment in the coming years is assure adequatefinancing to the Milk and Health Program for Malnourished Children and PregnantWomen and to the School Lunch Program, to improve the targeting of public subsidies tothese programs, and to strengthen nutrition and nutrition program monitoring,micronutrient programs, and nutrition education. Continued support for gradualdecentralization of program responsibility is likely to generate positive benefits as well.The report recommends the following priorities for govermnent action:

* assure adequate financing for the most cost-effective nutrition programs so thatprograms can operate smoothly and can be held accountable for results. Theerratic financing of programs over the past decade greatly impaired theirfunctioning. Not all financing must be federal--states and municipalities cancontribute part of the resources for nutrition programs.

* continue to improve program targeting so that vulnerable groups not reached inthe past are included. The prevalence of malnutrition has fallen in Brazil to adegree that targeting is essential to cost-effectiveness. Many programs have failedto target the malnourished in the North and Northeast, especially in rural areas.Low-income young children and pregnant and lactating women in these areas tendto be missed by public nutrition programs. It is often politically andadministratively challenging to improve targeting, and in some cases it will increaseunit costs per person enrolled.

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ADDRESSING NUTRITIONAL PRO13LEMS IN BRAZIL

INTRODUCTION

1. Brazil has a long history of large-scale nutrition programs, with many governmentagencies involved in planning and program implementation. Nutrition spending rosesteadily in the 1980s, peaking in 1990 at US$1.4 billion dollars, or almost $10 percapita--a significant share of all federal spending on health. 1/ The largest programsin the late 1980s were the School Lunch Program, the National Milk Program, and theComplementary Feeding Program (PCA). These programs, which reached overlappingage groups, claimed to reach 28 million, 7.7 million, andi 1.9 million children,respectively, in 1989. 2/ While these program statistics tend to exaggerate the numberof beneficiaries, they do provide some indication of program scale near the peak offederal support for nutrition programs. According to the 1989 National Health andNutrition Survey, one out of every four children under five was reported to be receivingfood from at least one nutrition program in 1989. 3/ Spending dropped by about 70percent from its peak in 1990 to 1991, and most of the programs in operation in the1980s were disbanded in the early 1990s, including the programs that were most targetedto young children and pregnant and lactating women. Some new programs wereintroduced in 1992 and 1994, mostly of an emergency nature, and a targetedsupplemental feeding program was initiated.

2. The oldest program still in operation today is the 'School Lunch Program, whichwas first introduced in the 1950s. Largefluctuations in funding for this program, typicalfor federal nutrition programs in general, make its operation difficult: in 1992, forexample, children only received school lunch for an estinated 38 days of the 200 days inthe school year. Duplication in coverage is another problem that has reduced theefficiency of nutrition programs. There were four programs in 1989, for example, alldistributing free food to children under the age of seven. The cost-effectiveness ofnutrition spending has been greatly impaired by very weaik targeting to the nutritionallyvulnerable: poor children under age three and pregnant and lactating women, particularlyin rural areas and in the North and Northeast. Another factor inhibiting program

1/ Expenditures in 1994 dollars. The subsidies to the Workers' Feeding Program are not included in thisestimate.

2I The School Lunch Program beneficiary population refers to 1988.

3/ The estimate of the number of children under five participating in nutrition programs from the NationalHealth and Nutrition Survey is probably a more accurate estimate (for that age group) than programstatistics, since it is a population-based estimate referring to programm participation within a specific timeinterval.

2

effectiveness is due to the fact that most programs have not been integrated with healthservices or nutrition education.

3. Federal nutrition programs were initiated, at least in part, due to concern over thelevels of malnutrition in Brazil. Concern about the nutritional status of the Brazilianpopulation in the early 1970s led to the first national-level nutrition survey, the 1974/75National Survey of Household Expenditures (ENDEF), which showed that malnutrition inBrazil was manifested mainly in the form of stunting (low stature and weight for age),rather than as acute malnutrition, or wasting (low weight for height). The survey alsoshowed clearly that malnutrition was closely associated with poverty, and that those mostat risk were pregnant and lactating women and young children. Overall, 18 percent ofchildren under age five were classified as underweight 4/; prevalence was highest inthe Northeast, at 27 percent.

4. A second national nutrition survey was undertaken in 1989. In the 15 years sincethe 1974/75 ENDEF survey, Brazilian society has undergone profound changes. Afteryears of high growth, the country endured a difficult recession in the 1980s.Urbanization increased throughout this period, and fertility rates fell sharply. Manyobservers expected to see little change in the prevalence of underweight children in 1989,but the 1989 National Health and Nutrition Survey (PNSN) revealed that the prevalencein children under five declined 61 percent since the mid-1970s. Seven percent ofchildren in this age group were malnourished by this measure in 1989. Although theseprevalence estimates are much lower than those reported in similar surveys for manyother countries in LAC, they are still serious. Moreover, there are significant geographicvariations in the prevalence of malnutrition, and among certain subgroups of thepopulation malnutrition is as prevalent now as it was for the population as a whole in theearly 1970s. As before, malnutrition is most common in the Northeast. It is also higherin rural areas.

5. A complex web of factors influence malnutrition, including income, disease,breastfeeding patterns, food habits, and availability of health services. Some of the majorgovernmental nutrition programs probably played a critical, but relatively small role inthe overall decline in prevalence of malnutrition. But the biggest ones such as the SchoolLunch Program and the National Milk Program probably did not. Some nutritionprograms, such as the Salt Iodination Program and the Program to Promote Breastfeedinghave had clearly measurable impacts in reducing iodine-deficiency disorders andincreasing breastfeeding, respectively. Evaluation studies of food supplementation

4I/ This report uses two measures of childhood malnutrition. The first is stunting (height/age, assessed asthe proportion of children with height/age measures < -2 z scores, NCHS/WHO standards). Stunting canbe calculated from the 1989 PNSN survey. The second measure is underweight, assessed as the proportionof children with weight/age measures < -2 z scores, NCHS/WHO standard. The underweight indicatorpermits comparison between the 1974/75 ENDEF and 1989 PNSN surveys, because the lack of adequateequipment for measuring height in the 1974175 survey precluded the calculation of stunting. The proportionof children wasted, or with acute malnutrition, is low in Brazil, at about 2 percent. At these levels, it isnot a public health problem, being equivalent to levels found in well-nourished and healthy populations andso it is not analyzed in this report.

3

programs rarely demonstrate a strong impact on growth. :'/ Because of the difficultiesof measuring impact as well as with measuring program costs (made even more difficultby the very rapid inflation over the past few years), rigorous comparisons of cost-effectiveness between nutrition programs are difficult to nmake. But useful conclusionscan be drawn about program effectiveness in terms of strategy, targeting, and costs.

6. Given the reductions is the overall prevalence of malnutrition, the persistingproblems in micronutrient deficiencies, and the growing problems of obesity, theGovernment faces several challenges in the upcoming years in designing effectivenutrition policies and programs. These challenges include improving targeting to reachsubgroups in the population at risk of malnutrition, reducing iron deficiency anemia andvitamin A deficiency, and strengthening nutrition education, particularly concerningbreastfeeding and, increasingly, diet and chronic disease prevention.

7. This report (i) summarizes nutritional problems in Brazil and the implications ofthese problems for nutrition programming, (ii) reviews what is known about theeffectiveness of major governmental programs; and (iii) identifies what programs orchanges in programs are likely to be most cost-effective in reducing malnutrition in the1990s.

World Bank Involvement in Nutrition in Brazil

8. The World Bank's involvement in nutrition in Brazil has been mainly through theBrazil Nutrition Research and Development Project, sector work, and the school healthcomponent of the proposed Innovations in Basic Education Project. Ihe Brazil NutritionResearch and Development Project (Ln. 1302-BR, US$ 19 million) was the first free-standing nutrition project to be financed by the Bank. The project, which becameeffective in 1976 and closed in 1983, was designed to support institutional strengtheningof the National Food and Nutrition Institute (INAN), testing of alternative nutritiondelivery systems, research, and development of low-cost nutritious foods. The projectwas formally amended in 1981 to finance four nutrition clelivery programs. Theexperience with the nutrition delivery programs was mixed, the institutional developmentcomponent fell short of expectations and INAN's planning and evaluation capacityremained limited. The Bank has also done a number of sector reports over the past 15years that have included analyses of nutrition issues. 61 This report is an effort toupdate understanding of nutrition problems and programs, particularly given the rapidgrowth in nutrition spending over the past few years, its sharp decline in the 1990s,

5/ However, this may be due to problems in research design and measurement, rather than an actual lackof effect. For ethical reasons, case control studies are rarely used. Several serious efforts to evaluate theimpact of nutrition programs have been undertaken in Brazil. These are carefully reviewed in Musgrove(1989).

6/ Human Resources Special Report, 1979; "Nutrition Sector Review", January, 1984; Policies for Reformof Health Care. Nutrition, and Social Security in Brazil, January, 1988; and Public SRending on SocialPrograms: Issues and Options, May, 1988.

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poorer countries such as El Salvador. And when Brazil's overall levels of stunting arecompared with countries in terms of GNP, three countries in Latin America with lowerper capita income levels--Chile, Costa Rica and Jamaica--report much lower rates ofstunting. Brazil's level of stunting is on par with Colombia and Paraguay--countries withper capita incomes less than half that of Brazil's (Monteiro, 1994).

11. In Brazil, both household income and region exert independent, and important rolesin determining childhood growth and nutritional status. Figure 1 shows how theprevalence of stunting decreases sharply as income increases. Children in the lowestincome quartile have a prevalence of stunting of 31 percent. This same rate is only 3percent for children in the highest income quartile. But for families of similar incomelevels, children are much more likely to be malnourished if they reside in the Northeastand North regions of Brazil. Regression analyses indicate that both family income andregion of origin exert independent and significant influence on the probability of beingstunted (Monteiro, 1994). Child growth patterns are alvways lower in the North andNortheast for equivalent household income levels. These regional differences are likelyto be due, in large part, to differential access to health, water and sanitation services, andparents educational status. Monteiro found that poor families in the North and Northeasthad significantly worse access to these services than equally poor families in otherregions of the country (Monteiro, 1994).

Figure 1. Prevalence of stunting among under f ive year oldsby per capita household Income, 1989 PNSN

35

30

25-

20

1I3 -

10

5

Ist 2nd 3r, c 4tti

Income quart ile

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12. Changes in the Prevalence of Malnutrition from 1974/75 to 1989. The overallprevalence of malnutrition as measured by weight-for-age fell by 61 percent from1974/75 to 1989 (Table 2). Declines were similar for males and females. Even thoughthe South and Southeast started from a lower base, the decline was sharper over theperiod (79 and 70 percent, respectively), than in the Northeast, where malnutrition fell by52 percent (Table 3). The least declines were obse-ved, not surprisingly, in rural areasof the Northeast (Table 4).

Table 2. Changes in the prevalence of underweight among childrenunder five years, 1974-75 (ENDEF) and 1989 (PNSN)

Sample Size Underweight Children (Percent)

1974 survey 1989 survey 1974 survey 1989 survey Percent change

Female 17,938 3,665 18.1 7.4 -60

Male 18,469 3,801 18.7 6.8 -64

Total 36,407 7,466 18.4 7.1 -61Note: Underweight refers to the proportion of under five-year olds with weight-for-age indices< -2 z-scores, NCHS/WHO standards.

Source: 1974/75 ENDEF and 1989 PNSN Surveys, reported in Monteiro, 1994.

13. These patterns in the reduction of malnutrition are similar to infant mortalitytrends, summarized in Table 5, over the same period. All regions recorded significantdeclines in infant mortality over the 1970s and 1980s, but the declines were almost twiceas large in the Southeast than in the Northeast regions. These declines were not constant:the economic recession of 1983 and 1984 had a noticeable effect on infant mortality rates.Infant mortality rates recorded what appears to be a real increase (of perhaps 10 percent)from 1982 to 1983 in the Northeast; no increases were observed in the Southeast.Researchers from the Brazilian Statistical Institute (IBGE) concluded that better sanitationand health services infrastructure in the Southeast, as well as higher educational levels ofmothers, helped insulate infants from the consequences of the recession. In theNortheast, on the other hand, the economic crisis appears to have had a larger impact onliving standards and on infant mortality. 8/

8/ Celso Cardoso Simoes, "Novas Estimativas Da Mortalidade Infantil - 1980-87", in Perfil Estatistico deCriancas e Maes no Brasil: Mortalidade Infantil e Saude na Decada de 80, IBGE, 1989.

7

Table 3. Changes in the prevalence of underweiglit among childrenunder five years by region,

1974-75 (ENDEF) and 1989 (PNSN)

Sample Size Underweight Children (Percent)

Region 1974 survey 1989 survey 1974 survey 1989 survey Percent change

North* 2,967 1,020 24.5 10.6 -57

Northeast 13,020 2,125 27.0 12.8 -53

Southeast 11,665 1,430 13.4 4.1 -69

South 5,660 1,405 11.7 2.5 -79

Center-West** 3,095 1,486 13.3 4.1 -69* Only urban areas in the 1974 and 1989 surveys.** Only urban areas in the 1974 survey.

Note: Underweight refers to the proportion of under five-year olds with weight-for-age indices< -2 z-scores, NCHS/WHO standards.

Source: 1974/75 ENDEF and 1989 PNSN Surveys, reported in Monteiro, 1994.

Table 4. Changes in the prevalence of underweight children inthe urban and rural population, 1974-75 (ENDE]F) and 1989 (PNSN)

Underweight Children (Percent)

Region 1974 survey 1989 survey Percent change

Urban 14.6 5.6 -62

North 24.5 10.6 -57Northeast 22.9 10.3 -58Southeast 10.7 3.7 -67South 10.3 2.1 -80Center-West 13.3 3.8 -71

Rural 22.9 10.6 -54

Northeast 29.6 15.2 -49Southeast 19.3 6.2 -68South 12.6 3.0 -76Center-West N.A. 4.9 N.A.

Note: Underweight refers to the proportion of under five-year olds with weight-for-age indices< -2 z-scores, NCHS/WHO standards.

Source: 1974/75 ENDEF and 1989 PNSN Surveys, reported in Monteiro, 1994.

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Table 5. Summary of the findings of studies on infant mortality trends in the1970s and 1980s in Brazl (deaths per 1,000 live births)

Population Data Sources Period Infant Mortality Percentcovered of Rate at change Reference

Study endpoints

Brazil Census, 1970-84 114 - 88 -40 Simoes and OrtizPNADs (1988)

Brazil BDC 1977-84 104 - 74 -29 Becker and Lechtig(1986)

Northeast Census, 1970-84 146 - 105 -28 Simoes and OrtizRegion PNADs (1988)

Southeast Census, 1970-84 98 - 49 -50 Simoes and OrtizRegion PNADs (1988)

Rio de BDC 1977-86 71 - 43 -39 Szwarcwald et al.Janeiro State (1988)

Sao Paulo BDC 1975-86 85 - 36 -57 Ortiz (1988)State

Sao Paulo BDC 1973-85 87 - 37 -58 Monteiro (1988)City

Source: censuses, national household surveys (PNADs), and birth and death certificates (BDC).Compiled and reported by Monteiro, 1994, p. 28.

Factors Affecting Malnutrition

14. The determinants of malnutrition are complex; some of the most importantinterrelationships are presented in Figure 2. lt is impossible to calculate how much of thedecline in malnutrition in Brazil is due to various factors: increases in income, improvedsanitation, greater coverage of immunization programs (especially measles) and oralrehydration programs, lower fertility, increased levels of education in parents,urbanization, changes in breastfeeding, food buying and feeding habits, and participationin nutrition programs. The impact from nutrition supplementation programs per se isclearly just one (probably small) piece of the picture. Major improvements in sanitationoccurred in Brazil over this period, although certain areas, such as the Northeast, lag farbehind the South and Southeast (Table 6). Immunization rates also increased, althoughprogress in the 1980s faltered in many states. The total fertility rate fell from 5.8 in1970 to about 3.0 in 1989, and this decline appears to have continued. Parents' level ofeducation has improved steadily; while in 1970, 32 percent of women aged 25-29 could

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Figure 2. Determinants of child growth

Prices-Food Food Consumptlon-Nonfood by the Child

. . + . § E!ILIfetionE

Availability of Health.,Sanitation and Related Child's NutritionalServices \ NuStatu i

Government Policies S tatuand Expenditures on N suluterittionHealth, Sanitation uppleentationand Related Programe /r/rI

|Prenatl Care

Real Household Income, Breastfeeding andL-J4 Haternal Educstion, - We[ ning Practices

Employment

Birth Order,Birth Interval.Family Size Iuirthweight.1

7 Lactation

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Table 6. Changes in the coverage of basic services, literacyand fertility in Brazil, 1970-88

1970 1980 1988

Percent of households with access tobasic services:

water 32.8 53.2 70.9sewage system 26.9 41.5 47.9*rubbish collection N.A. 49.2 62.9electricity 47.6 67.4 85.9

Total Fertility Rate 5.8 births 4.3 births 3.0 births**

Literacy Rates

Literacy rate forwomen aged 25-29years 68% 81 90%

' refers to 1985** refers to 1989

Source: 1970, 1980 Censuses. 1986 National Demographic and Health Survey. Data on basicservices compiled in Monteiro, 1994.

not read, this figure had fallen to about 10 percent in 1988. The duration ofbreastfeeding declined over the 1970s, but this was reversed in the early 1980s with anextensive campaign to promote its health benefits. Per capita income grew by 7.7percent per year over the period 1970 to 1975, but dropped sharply to roughly zeropercent per year growth from 1981 to 1989.

15. Thus interventions to reduce malnutrition can take many forms, as malnutritionderives not only from inadequate food intake, but also from disease, maternalmalnutrition, and food and health behaviors. These proximate causes are in turn affectedby income, education, access to health services and sanitation, and other factors.Children under age three face the largest risks of malnutrition.

16. Parental Education. Parents' education, particularly the mother's, is an importantdetermining factor in the risk of stunting. In his analysis of the 1986 Demographic andHealth Survey in the Northeast of Brazil, Thomas found that even after controlling forhousehold income and community service variables, the effect of mother's education on

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her child's height-for-age is strong. 2/ Although this education effect works in partthrough income, most of the education effect is independent of household income. Thus,increases in education have an important, but lagged effect in reducing the prevalence ofmalnutrition. The current cohort of young children in Brazil has benefited from theincreased education of their parents, particularly their mothers. Thomas also found thatunearned income (such as social security benefits) in the hands of mothers is as much as20 times more effective in improving child survival and nut:ritional status as theequivalent amount of unearned income in the hands of fathers.

17. Low Birthweight. Among proximate causes of infant malnutrition is lowbirthweight, which is in turn related to many factors, especially low maternal weightgain. There may also be an effect of poor maternal iron status on the risk of prematuredelivery. Low birthweight is strongly associated with infant mortality. 10/ There issome evidence from hospital data that the incidence of low birthweight increased incertain populations during the 1980s in Brazil, possibly related to the economic crisis.Interventions to reduce the prevalence of low birthweight babies include targetedprograms of food and iron supplementation during pregnancy, improved prenatal care (toreduce risks of premature deliveries), and nutrition education.

18. Infectious Disease. Infection and diarrhea are well-known risk factors formalnutrition in young children. Age-specific and geograpLic risk patterns for diarrheaclosely resemble those for malnutrition. As reported in the 1989 PNSN, children livingin the Northeast and North have the highest incidence of diarrhea, and children living inrural areas are slightly more likely to have diarrhea. Chilciren under age two are athighest risk, especially between the ages six to 18 months. Data indicate that theprevalence of diarrhea. at least in the Northeast for which comparable data exist, hasdecreased from 1986 to 1989 (see Annex 1). In one study of low-income children in Riode Janeiro, risk factors for diarrhea and severe respiratory infections included lowincome, age less than two years, environmental sanitation. marital stress, and length ofseparation during the week between the child and the mother, which is related tomother's employment. This last risk factor could possibly be attenuated or even reversedwith improved child care conditions for low-income workinag mothers. .11/

19. Breastfeeding. As has been documented in many other countries, data from Brazilshow that breastfeeding protects children from the risk of death from irifectious diseases.In a longitudinal study of infants in Southern Brazil, Victora et al. (1987) showed that thechance of dying from diarrhea is 14 times greater for weaned infants than for babies

9/ Duncan Thomas, 1989.

10/ In a longitudinal study in the City of Pelotas in Rio Grande do Sul, low birthweight babies were almost36 times more likely to die of perinatal causes than non-low birthweight babies.

L/ In the United States, children attending day care centers are at greater risk for illness than those caredfor at home. This relationship may not hold, however, for children of working mothers in low-incomehouseholds in Brazil, depending upon the care the children would receive in day care centers compared withno care, care by an older sibling, or by another relative at home.

12

exclusively breastfed, after controlling for confounding variables. The benefits of partialbreastfeeding are less dramatic but also significant: fully weaned infants are 1.6 timesmore likely to die of respiratory infection and 4.2 times more likely to die from diarrheathan babies who are partially breastfed. In a case-control study in Sao Paulo, Monteiro etal. (1988) estimated that, between 1980 and 1987, nearly half of the reduction in infantmortality from diarrhea. respiratory infections, and other infectious diseases could beattributed to increased breastfeeding. When all causes of mortality were considered,increased breastfeeding accounted for 25 percent of the mortality reduction.

20. In response to declines in breastfeeding in the 1970s, the government initiated theB'reastfeeding Promotion Program in 1981, which supported health education programs onthe benefits of breastfeeding aimed at health professionals (who provide prenatal, deliveryand post-partum care) and women. The media programs peaked in 1983/84 and werediscontinued in 1985. Data from the 1989 PNSN survey show that breastfeeding hasincreased among all age groups since the 1974/75 ENDEF (see Annex 1). According tothe 1989 survey, breastfeeding is widespread during the first three months of life: 84percent of infants in that age group are currently breastfeeding. However, after the firstthree months of life, breastfeeding declines markedly: by six months, fewer than halfbreastfeed. An infant under 12 months of age is most likely to be currently breastfeedingin rural areas and in the North, and least likely in the Northeast.

21. Early Introduction of Supplemental Liquids and Foods. While breastfeedingduring the first three months of life is common, exclusive breastfeeding is rare. This is acause for concern, given that early introduction of other liquids and foods increases therisk of diarrhea morbidity and mortality. Barros and Victora found that only six percentof babies below the age of two months were exclusively breastfed according to data froma 1986 nationwide survey, the Pesquisa Nacional Sobre Saude Materno-Infantil ePlanejamento Familiar (Barros and Victora, March 1990). Common supplemental foodsinclude water, cow's milk and formula.

22. To increase the duration of breastfeeding and promote healthy weaning practices,continued breastfeeding promotion activities geared at health professionals and low-income women are needed. Mothers and health workers need health education, inparticular, concerning risks from the early introduction of supplemental foods and thebenefits of exclusive breastfeeding in the first few months of life.

Diet and Micronutrient Deficiencies

23. According to the 1974/75 ENDEF survey, nine foods (rice, wheat, beans, meat,fats, manioc flour, milk, sugar, and fish) are the most common sources of energy andprotein in the regions studied. The diets of poor children in Brazil are generally limitedto a few foods. More than half of 1-3 years olds in an urban slum in Fortaleza, forexample, commonly consume just five foods: rice, bread, beans, coffee and sugar. Thefoods most commonly given to infants in a very low-income community near Brasilia arereported to be milk, grains, grain-based products, beans and bean broth, herb teas and,occasionally, fruits and vegetables. According to a study of age-specific dietary risk

13

patterns for a group of low-income Sao Paulo children under five, large proportions ofchildren failed to consume the recommended level of calories after age one.

24. Iron. It is well established that anemia adversely affects productivity. Irondeficiency anemia also impairs immune and cognitive function. The problem ofcontrolling iron deficiency is complex, because the form as well as the amount of ironconsumed is important. and other substances can either enhance or retard iron utilization.Both moderate and severe forms of anemia are very common among children under agefive, especially among babies ages six to 24 months throughout Brazil. Less informationis available on the prevalence of anemia in school-age children. All children, butespecially children under two, are at risk for inadequate iron intake. In children undertwo, the prevalence of anemia appears to be related more to feeding pattems and/or theavailability of specific foods rich in iron than to lack of food. In children over age two,it seems more related to lack of food. Several feeding prac:tices put infants and youngchildren at risk of anemia in Brazil. Early termination of breastfeeding, for example,removes a highly bio-available source of iron from the diet. Cow's milk, in contrast, is apoor source of iron. Low consumption of meat also puts young children at risk foranemia; meat is an excellent source of iron and also promotes the absorption of iron fromnon-meat sources.

25. Promising interventions that appear to be cost-effective ways to reduce anemia inBrazil include iron sulfate supplementation, food fortification, nutrition education, andbreastfeeding promotion. These approaches are not mutually exclusive. Forschoolchildren and young children enrolled in childcare programs, iron deficiencies couldbe treated through institution-based interventions, such as fortification of the mealprovided or iron supplementation at the school or childcare center.

26. Anemia is also a widespread problem in pregnant ancl lactating women, especiallylow-income women. Anemia can result in maternal mortality, low birthweight infants,premature births and fetal wastage. Although it is inexpensive to treat throughsupplementation, routine prenatal care frequently does not address nutritional anemia.Even when iron supplements are provided during pregnancy, however, post-partumanemia can be a problem as a result of inadequate levels of supplementation or thecommon problem of low compliance with taking the supplement. More operationalstudies are needed to determine the most cost-effective ways to implement successful ironsupplementation during pregnancy.

27. Hypovitaminosis A. Vitamin A deficiency is also a serious public health problemin Brazil, especially in the Northeast. Vitamin A deficiency causes a weakening of bodytissues, resulting in reduced resistance to infection; disorders of the eye tissues that canlead to blindness; growth stunting; and poor tooth developrnent. Infancy and earlychildhood appear to be the period of greatest risk for vitamtin A deficiency in Brazil.Interestingly, in parts of Brazil this deficiency is found in young children across incomegroups. Early weaning may be largely responsible for the high risk among this agegroup because breastmilk is the principal source of retinol in the first years of life. Manyof the weaning foods used in Brazil contain very little vitarnin A. Plant foods rich in

14

vitamin A are widely available, however, and nutrition education to increase consumptionof these foods could help reduce this problem. Other cost-effective interventions couldinclude breastfeeding promotion, food fortification with vitamin A, and supplementationwith vitamin A capsules. As with iron, meals for schoolchildren and children attendingday-care centers, could be fortified with foods rich in A, or capsules could be given twoto three times per year.

28. Iodine. While continued monitoring is needed. surveys of schoolchildren forevidence of goiter indicate that iodine deficiency is no longer a public health problem inBrazil. Iodine deficiencies can result in goiter, or, at its extreme, crippling cretinism anddceaf-mutism. Pockets of Brazil (Pocone, Luziania and Balsas) have long suffered fromendemic goiter. Salt for animal and human consumption is required by law to be iodized,but for many years compliance was a problem. Since 1983, however, INAN hasmanaged a highly successful effort to increase compliance, although these efforts mayhave been compromised in recent years.

EFFECTIVENESS OF MAJOR NUTRITION PROGRAMS

29. The Brazilian government has had considerable experience over the past fifteenyears with supplementary feeding programs, either through the provision of meals orfoodstuffs, food subsidies, nutrition education and micronutrient programs, and, mostrecently, the emergency distribution of food from public stocks. All programs except forthe Sao Paulo Fluid Milk Program/Integrated Food Supplementation Program (PISA)have been financed and administered at the federal level, although the School LunchProgram is now being decentralized for execution at the municipal level. Most programshave suffered large year to year variations in program financing, which may be due, inpart, to the diversion of financing of ongoing programs to new programs. In order todraw some conclusions about their relative effectiveness, these programs can be analyzedin terms of the groups they seek to reach, the strategy they have adopted. and the typesof food they promote. With the large and important exceptions of the consumer wheatsubsidy, which was in place until the late 1980s, the Workers' Feeding Program 12/and to a lesser extent the National Milk Program, targeting of nutrition programs hasbeen fairly good. In the context of the reduced prevalence of chronic malnutrition inBrazil today, appropriate targeting is fundamental to program effectiveness. There isconsiderable scope for addressing micronutrient deficiencies and nutrition education moreeffectively, and for experimenting with program decentralization.

30. Program Financing. Federal nutrition spending grew dramatically from 1982 to1990, from approximately US$320 million to US$1.38 billion in 1990 (in 1994 constantUS$) (Table 7). The programs receiving the largest increases over this period were theSchool Lunch Program, the Complementary Feeding Program (PCA) and the National

12/ For nutrition purposes, the Workers' Feeding Program is grossly mistargeted because it is aimedlargely at adult male workers in the formal sector.

Table 7. Consolidated federal expenditures on food and nutrition, 1982-93(constant 1994 US$ 1,000)

Program 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993

Supplementary feeding programsSchool lunch program 170,157 122,693 169,198 309,823 487,931 385,829 355,219 370,196 431,165 294,614 156,077 469,559

PSA: supplementary feeding 106,561 109,917 130,007 233,230 232,785 186,045 118,173 92,999 123,888 50,144 16,528 0program

PCA: complementary feeding 27,758 16,250 13,570 11,759 44,562 87,498 139,251 167,099 95,029 6,260 0 0program

National milk program 0 0 0 0 41,958 308,129 411,368 529,262 717,424 6,971 0 0

Food SubsidiesPROAB: supply of basic foods in 7,307 21,058 20,393 21,009 17,623 18,014 3,027 1,009 0 0 0 0

low-income areas program(J

Improvement of small agriculturePROCAB: supply of basic foods in 6,843 2,639 1,186 779 2,694 4,336 451 1,223 0 0 0 0

rural low-income areas

Lower food prices to consumers through improved distributionPopularfeeding program 0 0 0 126 34,203 930 545 0 0 0 0 0

Nutrition education/micronutrient programsProgram to combat micronutrient 48 351 429 523 1,823 275 250 103 0 0 0 0

deficienciesProgram to combat endemic goiter 0 1,145 3,196 4,027 3,377 3,807 2,481 2,465 0 0 0 0

Program to promote breastfeeding 0 31 42 7 0 143 0 0 0 0 0 0

Breastfeeding Promotion andMicronutritients (INAN) 7,090 3,054 1,301 866

Table 7. Cont.

Program _____ 1982 1983 1984 1985 1986 1987 1988 1989 '1990 1991 1992 1993

New Programs in the 1990s

Supplementary feeding programsMilk and health program (for pregnant women and young children) 0 0 0 33,419

Emergency Food Distribution from Public StocksPeople to people I 0 63,440 0 0People to people 11 0 0 35,326 0Emergency Food Distribution at Beans

to the needy 0 0 0 32,086PRODEA: emergency food

distribution in the Northeast 0 0 0 20,282

Total 320,655 276,067 340,004 583,268 868,942 996,994 1,032,754 1,166,345 1,376,585 426,475 211,224 558,205

Notes: Data from 1982-1989 were compiled by Lucia Pontes de Miranda Baptista (MEFP-IPEA). Data from 1990-1993 were compiled byCPS/IPEA and are presented in Peliano and Beghin, April 1994.The table excludes data on the Workers' Feeding Program because of data availability.For 1982, spending was incurred on research under the Program to Combat Endemic Goiter, but expenditures are unavailable.For 1985, spending on iodine deficiency was taken from the category under the program to Combat Micronutrient Deficiencies.For 1986-89, spending on iodine deficiency was taken from the cateogry under PSA.Expenditures for the Program to promote Breastfeeding for 1986, 1988 and 1989 are unavailable.For 1990-93, expenditures on breasffeeding promotion and combatting micronutrient deficiencies appear combined under a separate entry.

17

Milk Program. Most of these increases occurred over the period 1984-90. Federalnutrition spending reached about US$10 per capita in 1990. The School Lunch Programwas the largest program over most of this period, only surpassed from 1988 to 1990 bythe National Milk Program. The Programs to Combat Micronutrient Deficiencies,Endemic Goiter and to Promote Breastfeeding have been low-cost. The Program toCombat Endemic Goiter, for example, cost about US$2.5 million in 1989, or aboutUS$0.02 per capita per year for the population as a whole. Federal spending on nutritionfell sharply in 1991 and 1992 and recovered somewhat in 1993. Most programs weredropped over this period. One new supplemental feeding program was introduced and,for the first time, the government supported emergency distribution of food to the needyffom public stocks.

The School Lunch Program

31. The School Lunch Program, operated by the Foundation for Student Assistance(FAE) within the Ministry of Education, finances meals for children in public andphilanthropic preschools and primary schools, and students in federal technical secondaryschools. The program does not reach children at the age when they are most vulnerableto malnutrition, as children attending these schools are not under the age of three.Although it is difficult to document the program's impact on students' nutritional status, itclearly serves other objectives as well. The program may play an important role inattracting children to school, in keeping them in school, and, potentially,in enhancingtheir ability to learn.

32. The operation of the School Lunch Program was repeatedly criticized throughoutthe 1980s for several reasons: erratic financing, heavy reliance on higher-cost formulatedfoods, poor targeting, and overcentralization. Erratic financing and program managementresulted in irregular supply of school meals. Schools in rural areas, where malnutritionis highest, have been the most affected by these supply prolblems. Heavy reliance onformulated foods raised costs and decreased the acceptability of the school lunch tostudents. While there is an element of self-targeting in the School Lunch Program, thereis no explicit targeting across schools. Self targeting refers to the fact that children whohave been fed at home, or have a meal waiting at home, often skip the rneal prepared bythe school. In urban areas, some of the public schools have private snack bars, and somepublic school students purchase their food instead of eating the school lunch. If there issufficient food, some schools permit students (presumably in large part those who arehungriest) to have additional helpings. But there is no explicit targeting across schools tothe neediest students, and in practice schools in the Northeast and in rural areas, wheremalnutrition rates are highest, are less likely to offer school lunches and to offer themregularly, in part because of lack of kitchen and storage facilities.

33. For most of its life, the program has been highly centralized, finaLced andadministered by FAE at the federal level. Decentralization to the municipal level wastried by FAE, experimentally, in 1986, with mixed results. (The federal governmenttransferred funds to the municipalities to design school menus and purchase foods

18

locally). 13/ In some cases, funds were diverted to other uses and the quality andquantity of the meals provided in the schools declined. Other municipalities, however,increased the proportion of fresh foods on the school menu. donated foods to supplementthe resources from the federal government, and reported better acceptance by the studentsof the foods prepared by municipal prograrrms. Purchasing foods locally did not appear toraise program costs. because of the inefficiencies of highly centralized food distribution insuch a large country. In addition, some of the municipalities targeted the poorest schoolswith larger meals by reducing the size of the meal provided to schools serving moremiddle-income neighborhoods.

34. But the advantages of decentralization were seen to outweigh the disadvantages, andin 1992 FAE started passing resources directly to the states to implement the school lunchprogram. In an evaluation at the end of 1993, school administrators reported markedimprovements in the program in terms of reduced costs, improved quality of food offeredand better acceptability by the students.

35. Total resources are still inadequate to supply the program's goals. In 1993, thebudget for the School Lunch Program provided for 113 of the 200 school days. Theprogram might still be improved with the following measures:

* the targeting of resources could be improved so that the poorer municipalities receivedhigher amounts per student;

* guidelines could be adopted to support provision of the meal earlier in the day. Themeal, or at least a snack, could be offered when the children first arrive at school--ratherthan in the middle of the school session, as is now the case--to minimize short-termhunger that interferes with learning;

* greater emphasis could be placed as well on improving the composition of the meal,so that micronutrient deficiencies as well as calories and protein requirements are betteraddressed.

Workers' Feeding Program

36. The Workers' Feeding Program has been widely and strongly criticized for failingto serve key subgroups of the population at nutritional risk, while at the same timeabsorbing considerable resources. The program consists of tax incentives for providingmeals to workers. As such, it is more of an element in a benefits package for formalsector workers than a nutrition program. This income supplement is enjoyed largely byworkers in the Southeast. Despite the sharp constraints on resources for nutritionalprograms, the Workers' Feeding Program continues to enjoy considerable support withinthe government. For the purposes of this report, it will not be considered a nutritionprogram and is not analyzed further in this report.

13/ Because foods are purchased locally, decentralization almost necessarily implied a sharp drop in the useof formulated food products.

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Food Supplementation Programs

37. Most of the large food supplementation programs in operation in the 1980s werecancelled by 1991 or 1992, and a new food supplementation program, the Milk andHealth Program for Malnourished Children and Pregnant 'Women was introduced in late1993. Before describing the new program, which builds on the experience of earlierprograms, the large programs of the 1980s will be quickly reviewed. The major foodsupplementation programs--the PCA, PSA, National Milk Program, and the Sao PauloFluid Milk Program/Integrated Food Supplementation Program (PISA)--were operated bythree different agencies, and relied on varying strategies to reach the malnourished. Asuimmary of the characteristics of these programs is presented in Table 8.

Table 8. Characteristics of food supplementation programs in place in the 1980s

Intervention Characteristics PSA PCA National Milk Sao Paulo FluidF'rogram Milk Program

IPISA

Group Targeted

Pregnant and Lactating Women * *

Children < 36 months of age *

Children from 6 to 36 *

months of age

Children up to 59 months ofage, with growth faltering

Families with children under *7 years of age

Type of Food Supplement

Traditional *

Emphasis on formulated foods

Fluid Milk * *

Method of Food Distribution

Direct food distribution * *

Coupons * *

Integrated with health actions *** *

38. National Milk Program. The National Milk Program used coupons to distributemilk. Coupons can be an efficient mechanism for distribut:ing milk to beneficiarieswithout creating heavy administrative machinery. The National Milk Program suffered

20

from the lack of transparent distribution criteria, and, as a result, for evolving into aprogram of political patronage. The program was intended for families with income upto two minimum salaries and with children under seven years of age. However,municipalities and community groups selected beneficiary families and it is not knownhow many beneficiary families actually met these criteria. The distribution of milk wasnot linked to health actions, and was not targeted to the population subgroups most at riskof malnutrition. Some of the nutritional impact was certainly diluted by other familymembers consuming the milk.

39. National Milk Program Inpact on Nutritional Status. Araujo (1989) conductedafl evaluation of the impact of the National Milk Program on children's growth and serumretinol levels. His study found no significant changes in weight-for-age in the childrenenrolled in the program, but did find a small improvement in serum retinol levels(indicative of reductions in levels of vitamin A deficiencies).

40. Geographic distribution of the milk program did not correspond to areas with thehighest prevalence of malnutrition. Moreover, fluid milk was relatively expensive inrelation to the nutrients it provides. The program was finally suspended in 1991. Theprogram's cost-effectiveness could have been improved by: linking coupon distributionwith health actions, narrowing the age group served to low-income children under the ageof three, substituting fluid milk with a food that offers similar nutritional benefits at alower cost, and targeting distribution more closely to the areas of the country with thehighest prevalence of malnutrition.

41. PCA and PSA Programs. The Complementary Feeding Program (PCA), operatedby the Brazilian Legion of Social Assistance (LBA) and the Supplementary FeedingProgram (PSA), operated by INAN and State Secretariats of Health, targeted similarpopulations: pregnant and lactating women and children under age 3. In other respects,however, they were very different. The PCA program relied heavily on more expensiveformulated foods that are easy to store and that minimize the likelihood that the food willbe shared with other members of the family. Some of these foods were poorly acceptedby PCA's clients. The distribution of foods was much less tied to health activities thanthe PSA program. The PSA program distributed traditional foods, such as dried milk,sugar, flour, rice, and beans, through health centers. Health activities, such as growthmonitoring, prenatal care, and immunizations were linked to the distribution. Given theclose link between health and nutrition, combining these services is a sensible approach.The PCA was officially stopped in 1992. LBA, the organization that administered PCA,had been accused as waste and corruption. PSA, administered by INAN, was suspendedin 1992.

42. The cost-effectiveness of the PSA might have been irnproved by replacing directdistribution of foodstuffs with distribution of coupons that could be exchanged for food inthe private retail market or in centralized distribution centers. 14/ This would have

14/ see Antonio Carlos Campino, June 1987.

21

overcome the problem that many health centers are not equipped to manage and storefood. This approach has been tried in the State of Sao Paulo. The distribution ofcoupons could still be linked to basic health services, but the health centers would not befaced with the tasks of food storage and distribution. Losses due to spoilage and leakagemight also be reduced.

43. PSA and PCA Program Impact on Nutritional Status. Evaluation studies(reviewed in Musgrove, 1989) of the PSA and PCA programs concluded, rather weakly,that the programs "are capable of improving the weight of children who are underweightfor their age or height". However, cost per child improved is high, in part due to theldrge number of normal children enrolled in the program. The programs have hadnegligible impact on the height of enrolled children, a more long run measure ofnutritional status. In addition, the evaluation studies record significant groups of enrolledchildren who suffer a deterioration in their nutritional statLs. Musgrove points out thatthis could be due to declines in family income (outside the realm of the program), or dueto health problems which could be addressed by strengthening the health care activitiesassociated with the programs.

44. Sao Paulo Fluid Milk Program/Integrated Food Supplementation Program.The Sao Paulo Fluid Milk Program/Integrated Food Supplementation Program (PISA)tried to target benefits on the basis of biological vulnerability, rather than on the moregeneral socioeconomic and age-group criteria used by the PSA and PCA programs, whichtarget low-income vulnerable age groups. The program established guidelines linkingfood distribution to growth faltering. The growth of children attending basic healthcenters in Sao Paulo was monitored over the period of several months, and those notmeeting certain growth guidelines were enrolled in the distribution program. However,often these guidelines were not strictly observed, because of heavy pressures fromclientele to distribute food more generally to low-income children. To improve theprogram's efficiency, it relied on food coupons for distribution. Depending on theirlocation, clients exchange the coupons either at participating retail stores or at centralizedfood distribution depots. It is appropriate that strict criteria that tie food distribution togrowth faltering be adopted in Sao Paulo. because Sao Paulo has a much lowerprevalence of malnutrition than in other parts of the country. Targeting, therefore,beyond simply age and income is desirable in this area. EBasic health serviceinfrastructure is much weaker in parts of the Northeast and North where the prevalenceof malnutrition is higher. It would be more difficult to link food supplementation tightlyto growth monitoring in these regions.

Evidence of Program Targeting and Program Enrollments as of 1989

45. The 1989 PNSN provides information about the degree to which these nutritionsupplementation programs were targeted to low-income households. This is not the sameas targeting based on biological vulnerability, but is nonetheless useful because of theclose relationship between low income and malnutrition. The survey questionnaire didnot ask what nutrition programs children were enrolled in by name; instead, it asked ifthe children were enrolled in any program and if so, wherz the food was received. From

22

Table 9. we can infer what programs the young children in the PNSN survey wereenrolled in from the locations where the food was reported to have been received. Of themajor nutrition programs, the National Milk Program distributed coupons throughcommunity groups, but the coupons are traded for milk at stores. The PSA distributedfood through health centers, and the PCA distributed food through community groups andpossibly the category "other." "Other" may also partly include the Sao Paulo Fluid MilkProgram. because clients received their food at centralized depots or stores. As isapparent from Table 9, of these three programs, the National Milk Program was leasteffective in targeting low-income households. Only 17 percent of children under four inthis program were in the lowest two income deciles. The PSA, Fluid Milk Program, andPFCA, in contrast, targeted distribution much more effectively to the lowest incomegroups. About 53 percent of children enrolled in supplementation programs throughhealth centers were in households with per capita income in the lowest two incomedeciles. Forty-seven percent of children receiving food from comnmunity organizationswere in these two income groups.

46. Geographic Targeting. The 1989 PNSN survey and program statistics alsoprovide informnation on program targeting by region. The School Lunch Program'scoverage of public primary schools was higher in the wealthier Southeast than in theNortheast: the 1989 PNSN survey indicated that in the poorer Northeast, only 54 percentof public primary schoolchildren attended schools that provide school meals. In thewealthier South and Southeast, 81 percent and 91 percent, respectively, of public primaryschoolchildren attended schools offering the meals. The distribution of milk couponsunder the National Milk Program did not follow patterns of malnutrition. According toprogram statistics, in 1989 42 percent of the milk program coupons went to theSoutheast. This region accounted for 21 percent of all children with moderate to severemalnutrition according to the 1989 PNSN survey. The Northeast accounted for 65percent of all children with moderate to severe malnutrition, but received only 30 percentof the milk tickets. In contrast to the National Milk Program, the PSA and PCAprograms were well-targeted to the Northeast. The PSA reported 71 percent of theirbeneficiaries in the Northeast in 1988; the PCA reported that 60 percent of theirbeneficiaries were in that region in 1989.

47. Household-Based Data versus Program Statistics. Data from the 1989 PNSNalso permit the rough calculation of participation in supplementation programs, which canthen be compared to enrollments reported by the programs. After applying weights tomake the survey nationally representative and equivalent in size to the population ofBrazil, about 1.1 million children ages 0-3 years received food assistance from a store inthe four weeks prior to the survey, presumably through the National Milk Program(Table 6). The program, on the other hand, reported 7.7 million children under ageseven enrolled in 1989. Even if the 1. 1 million children aged 0-3 estimate is doubled toarrive at an estimate of 2.2 million children ages 0-6 enrolled in the program, the

23

Table 9. Children 0-3 years of age, by household income percapita (percentage), by participation in fooddistribution programs, 1989,

Where Food is Received

Income Store Health Post/ Community Others Total(Milk Program) Center (PSA) Organ:Lzation

(PC'A)

1 7.5% 22.4% 26.0% 18.1% 14.9%

2 9.4 30.6 21.0 25.6 18.4

3 11.5 16.4 17.6 15.2 14.0

4 15.5 13.0 7 5 14.9 13.8

5 22.7 7.4 6.5 12.5 15.5

6 12.0 4.4 IC.6 2.0 8.5

7 14.4 3.6 5.9 4.3 9.3

8 4.6 0.9 3.3 5.1 3.6

9 2.1 1.1 0.7 1.9 1.6

10 0.3 0.0 0.9 0.4 0.3

Total 1,094,513 547,671 270,721 100.0% 32'7,185 2,240,090Enrolled 100.0% 100.0% 100.0% 100.0%

Source: PNSN, 1990.

discrepancy between program statistics and survey estimates is still enormous--more thanfive million. The difference may be attributable to: irregularities in supply, such thatsome of those enrolled did not receive milk in the four weeks prior to the survey; theftand leakages; inadequate program accounting; pressure to inflate program statistics; or toa combination of these factors. In any event, it suggests that reliance on programstatistics to compare programs may result in serious errors.

48. While it is difficult to evaluate rigorously the cost-effectiveness of foodsupplementation programs, the following characteristics appear to enhance their costeffectiveness:

o targeting low-income pregnant and lactating worrmen and childLren up to 24 or 36months and integrating health actions with food supplementation programs. Iron

24

supplementation should be a routine component of prenatal care. 15/ In theNortheast, vitamin A should be given to young children periodically at the health centers.

o decentralizing program financial and management responsibility to state and locallevels, in order to improve program efficiency. As an example, Sao Paulo receives littlefederal funding for its nutrition programs. On its own, it has developed innovativeapproaches to its nutrition programs. The School Lunch Program has been decentralizedto the municipal level in many areas of the state. The food supplementation programsthrough health centers rely on coupons and tie supplementation to growth monitoring.

o emphasizing traditional foods because of their low cost and acceptability.

The Milk and Health Program for Malnourished Children and Pregnant Women

49. The new supplementary feeding program, introduced in late 1993, addresses theseconcerns. It targeted to malnourished children aged 6 to 24 months, their siblings up toage five, and pregnant women. Siblings are included to minimize the intrafamily dilutionof the supplemental foods. Milk, either powdered or fluid, is provided to the targetgroups. In addition, young children receive vegetable oil. Milk was chosen as the maincommodity mainly because of pressures from the community who had previously receivedthe National Milk Program, and from milk producers. 16/ The program isadministered by the Ministry of Health and INAN. The Ministry of Health passesresources to municipalities who execute the program. The program is expensive,estimated to cost about US$9 per beneficiary per month. Early indications are that it iswell targeted geographically. In 1993, 42 percent of the beneficiaries resided in theNortheast, 34 percent in the Southeast, 11 percent in the North, and 6 percent each in theSouth and Center-West.

Programs to Lower Food Prices to Consumers

50. Two programs, the Popular Feeding Program (PAP) and the Supply of Basic Foodsin Low-Income Areas Program (PROAB), were operated in the 1980s by the BrazilianFood Company (COBAL), under INAN's oversight, with the objective of lowering foodprices to consumers in low-income areas. Both programs targeted geographic areas,rather than individual beneficiaries in age-groups at risk of malnutrition. By spreadingprogram access to all age groups in low-income neighborhoods, they concentratedbenefits much less on nutritionally vulnerable groups than do the food supplementationprograms discussed above. In both programs, COBAL supplied participating retailers

15/ The United Nations Subcommnittee on Nutrition (SCN) recently concluded that all pregnant womenshould receive iron supplements and counselling, without screening, because the advantages of hemoglobinscreening are more than offset its cost and non-specificity, especially in comparison to the cheapness of ironsupplements (USSI per 1000 tables).

16/ Near the height of government spending on nutrition in 1989, the govermnent purchased about 15percent of national milk production. By 1992, this had fallen to about I percent (Peliano and Beghin, April1994, p.19).

25

with basic foods, such as rice, beans, and manioc flour. Under the PROAB program,prices were set according to an established formula with a subsidy built in for consumers.The PAP program operated without direct subsidies. 17/ Its approach rested on theassumption that COBAL could supply private retailers at Lower prices than commercialsuppliers because of the belief that the private sector is inefficient and monopolistic. Nothorough testing of this assumption was done, and the existing evidence is mixed withrespect to PAP's ability to lower prices to the consumer. In addition, if the privatesector is inefficient, other policy tools can promote competition in food distributionwithout resorting to direct government participation.

5L. PROAB Program Impact on Nutritional Status, ]Food Consumption andHousehold Income. A study by Sampaio (not dated) designed to examine PROAB'simpact in Recife, found that the program has had little, if any, measurable impact onimproving food or calorie consumption, nutritional status of young children, orbirthweight in program areas. The program did, however, provide a small incometransfer, but it was a clumsy way to effect an income transfer. In general, the smallincreased purchasing power was used to purchase non-food items. The basic foodssubsidized by PROAB tended to have low income elasticities of demand and higher priceelasticities, so this finding is not surprising.

Emergency Feeding Programs

52. The government supported several emergency feeding actions from 1991 to 1993,largely in response to the drought in the Northeast (Table 7). States, municipalities andcommunity groups were involved in these programs, as well as other programs in anationwide movement that emerged in the 1990s to fight hunger. Most of the publicprograms were supplied by public stocks of food, although the People to People IIprogram also purchased foodstuffs. While it is difficult tD precisely quantify the cost ofthese programs, but they were small in comparison with i:otal federal nutrition spending.

Other Programs

53. INAN supports a group of programs, including the Program to Combat EndemicGoiter, the Program to Promote Breastfeeding, the Program to Combat NutritionalAnemias, and the Program to Combat Hypovitaminosis A. The goiter and breastfeedingprograms were inexpensive and highly successful in the 1980s, although they sufferedfrom severe budget cuts in the early 1990s. The other two have been less effective.

54. The Program to Combat Endemic Goiter was so successful in raising compliancewith salt iodination among producers that iodine deficiency is no longer considered apublic health problem in the late 1980s. The program, ait a cost of US$0.02 per capitaper year in 1989, continues to monitor salt producers and. survey children for signs ofgoiter. The Program to Promote Breastfeeding publicized norms (regarding labelling,

17/ However the program is not entirely self-fmancing (Table 4 presents program cost data for PAP). It isnot clear if these program cost data capture all the indirect costs of FPAP.

26

etc.) for the sale of breastmilk substitutes to nursing women and supported healtheducation programs for health professionals and women. The health education programspeaked in 1983/84 and were discontinued in 1985. Program activities in the late 1980sconsisted of supporting technical committees and milk banks, without any large-scalepublic education campaigns. Program evaluations based on surveys in 1981 and 1987/88showed a significant increase in the proportion of women initiating breastfeeding and, toa lesser extent, in the duration of breastfeeding in the metropolitan areas of Recife andSao Paulo (Rea, 1988), as well as greater receptiveness on the part of health professionalsto the importance of prolonged breastfeeding. 18/

55. The activities of the Pastoral da Crianca. a Catholic Church based group thatpromotes maternal-child health, illustrate the potential impact of health educationprograms on nutritional status. In this program, community leaders promote healtheducation regarding the importance of prenatal care, good diet during pregnancy,breastfeeding, proper weaning, immunizations, management of diarrhea, as well as carryout growth monitoring of infants and young children. The Pastoral da Crianca relies onthe health system to back up its messages--it does not give ifimmunizations nor providefood supplementation. An evaluation of the program compared health indicators inhouseholds participating in the program with households in communities where theprogram was not active (Victora and Barros, 1990), and the differences were striking.While the conclusions of this evaluation are limited by the methodological problems ofthe study, Victora and Barros conclude nonetheless that the program has had a substantialimpact on child nutrition and health.

56. Government programs directed at vitamin A and iron deficiencies have notappeared to have a large or sustained impact. Under the vitamin A program, which wasdiscontinued in 1990, INAN distributed doses of vitamin A in the form of capsules toNortheast states, to be distributed to children aged 1-4 through health centers and in thecourse of immunization campaigns. From 1983-85, INAN distributed iron sulfate topublic schoolchildren. In 1986, the agency shifted its emphasis to supporting thetreatment of anemia in health centers and to providing dried milk fortified with iron inthe food distributed by PSA. The government needs to address the widespread andserious problems of vitamin A and iron deficiencies on a much larger scale. Possibilitiesfor broader interventions include: fortifying basic foods, such as cooking oil, milk, ormanioc flour, with iron and vitamin A; ensuring that the school meal is high in thesemicronutrients; providing iron sulfate and vitamin A supplements to infants and youngchildren at health centers, day-care centers, preschools and primary schools; promotingtreatment of iron deficiency anemia in prenatal care, and nutrition education.

18/ The evaluation used a baseline survey and a post-program survey to evaluate its impact. An index ofdie proportion of children being breastfed peaked in 1984 (the peak period of program activities) in bothcities.

27

RECOMMENDATIONS TO GOVERNMENT

57. The Government has eliminated many nutrition programs that were duplicative oronly weakly effective. It made positive changes to the School Lunch Program bydecentralizing its operation, and the new supplementary feeding program, the Milk andHealth Program for Malnourished Children and Pregnant Women, has built wisely onlessons and evaluations of earlier supplementary feeding programs to enhance its cost-effectiveness. Policy efforts could usefully be placed on stabilizing and assuringfinancing for these two programs, improving targeting of public subsidies both for theschool lunch program and the supplementary feeding program to the extentadministratively feasible, and strengthening nutrition monitoring, micronutrient programs,and nutrition education. The recent efforts to move away from highly centralizednutrition programs could be reinforced as well. Continued improvements in nutrition inyoung children can be expected as well from intersectorail interventions: pro-pooreconomic growth policies, improvements in water and sanitation, and investments in basiceducation and health services.

58. Targeting. Malnutrition continues Eo be a serious problem in subgroups of theBrazilian population. Although the prevalence of underweight children under aged fivehas dropped by about 61 percent over the past 15 years, malnutrition continues to besignificant in the North and Northeast and in rural areas. Costly and generalized foodsubsidies are not appropriate mechanisms to address these groups at risk. Even the foodsubsidies under the PROAB program in the 1980s, directed at low-income areas, werenot sufficiently targeted to be justifiable, in terms of cost:-effectiveness, when comparedwith alternative programs such as the Milk and Health Program for MalnourishedChildren and Pregnant Women. Continued monitoring will be necessary to ensure thatthis program is serving the population that it is intended to reach, particularly the moredifficult groups in rural areas. Any reintroduction of food supplementation programs thatreach a larger age group and that are not linked with health actions, such as the NationalMilk Program, are likely to be much less cost-effective.

59. Nutrition Research and Monitoring. The Federal government has spentenormous resources on nutrition programs--over US$8 billion from 1982 to 1993 (1994constant dollars). Yet it has spent relatively little on program evaluation. There is acontinuing need for population-based statistics to evaluate programs and nutritioni status.The introduction of a living standards measurement-type survey is under consideration bythe government. This survey would collect anthropometric data and information onhousehold participation in nutrition programs on a continuous basis, as well as

28

expenditure and income data and other information. 19/ It would provide a rich andtimely data base for policy-oriented research on nutrition, including the multisectoralinfluences on nutrition. More generally, evaluation of the School Lunch Program as it isincreasingly decentralized and the new supplemental feeding program is needed.

60. Micronutrient Deficiencies. More systematic attention to vitamin A and irondeficiency anemia is needed. A mix of approaches can be adopted, including nationwidefood fortification, consumer education and aggressive distribution of micronutrientsupplements. All of these interventions are inexpensive and cost-effective. Foodfortification alternatives would need to be studied carefully in terms of the technicalaspects of adding micronutrients to selected foods without altering taste and color; thedifficulties in ensuring producer compliance; the extra costs that would be passed on toconsumers or subsidized by the government; and the consumption levels of the product bythe most vulnerable groups. Programs to education, persuade and change the behavior ofconsumers can also play a major role in eliminating micronutrient deficiencies.Micronutrient supplementation can be delivered not just through the health system butthrough schools and the workplace.

61. Nutrition Education. The Breastfeeding Promotion Program was very successfulin the early 1980s, but its activities virtually stopped in 1985. This program also appearsto have been highly cost-effective. Continuing health education efforts on the benefits ofbreastfeeding, particularly exclusive breastfeeding in the first few months of life areneeded on a permanent basis, as well as nutrition education programs that focusing onother important topics such as diet and chronic disease prevention'.

62. Decentralization. The government has moved in the past two to three years awayfrom its highly centralized approach to nutrition programs to a more decentralizedapproach in the school lunch program and in the new food supplementation program.Decentralization can introduce flexibilitv into program management, permittinginnovation and improvements in efficiency. In this process, the wealthier states canassume more financial responsibility. Over the long run the federal government couldexplore moving to a system of block grants to states for nutrition programs. This wouldgive states the autonomy to develop appropriate programs, and more incentives to addtheir own resources to these programs. The only type of programs that would need toremain at the federal level would be food fortification programs, because they requirestandard-setting and compliance throughout the country to be effective, and monitoringand evaluation.

19/ The objective of a Living Standards Measurement-type survey is to develop a household-based welfare,monitoring and evaluation system that covers key sectors, including housing, community infrastructure,health, nutrition and education. The approach uses an integrated questionnaire format, innovative fieldtechniques, and a computer-based data management system designed to improve data quaiity and reduce theelapsed time between the collection of raw data and their ultimate use in policy analysis. This surveyapproach has been used in a number of countries (Cote d'lvoire, Ghana, Peru, Jamaica, Morocco) withWorld Bank technical input and in most cases financing. Data are used to understand the extent of poverty,the determinants of living standards, and the effect of government policies on the population's livingconditions. See Glewwe, 1990 for more information.

29

BIBLIOGRAPHY

Anderson JE et al. "Analysis of Breastfeeding in Northeastern Brazil: Methodological andPolicy Considerations." Studies in Family Planning. 1983; 14:210-217.

Araujo, Rocival. Situacao Alimentar e Nutricional do Brasil, Editora Grafica TipogressoLtda., Brasilia, 1989.

Arruda, JM, N Ruttenberg, L Morris and EA Ferraz, Pesiuisa Nacional Sobre SaudeMaterno-Infantil e Planeiamento Familiar (PNSMIPF). Sociedade Civil Bem Estar Familiarno Brasil (BEMFAM), Instituto para Desenvolivmento de Resursos (IRD) Brasil. 1987.

Barros FC et al. "Perinatal Mortality in Southern Brazil: A Population--Based Study of 7392Births." Bulletin. World Health Organization. 1987;65:95-104.

Barros FC et al. "Bajo Peso al Nacer en el Municipio de Plelotas, Brasil: Factors de Riesgo."Boletin Sanitaria Panamamericana. 1987;102:541-553.

Barros FC et al. "Infant Mortality in Southern Brazil: A Population Based Study of Causesof Death." Archives of Disease in Children. 1987;62:487-490.

Barros and Victora. "Breastfeeding and Diarrhea in Braziliian Children."Demographic and Health Surveys Further Analysis Series, Number 3, March 1990.

Batista Filho, M. and H. Amigo Cartagena. "Epidemiologia das Principais EndemiasCarenciais no Brasil." in CNPq 1985:87-132.

Bastista Filho M. "A Crise e as Condicoes Nutricionais das Criancas No Nordeste." in Crisee Infancia no Brasil: 0 Impacto das Politicas de Aiustamento Economico (Chahad JPZ,Cervini R. eds). UNICEF 1988.

Becker RA. "Brasil: Principais Causas de. Mortalidade Infantil." in Crise e Infancia noBrasil: 0 Impacto das Politicas de Aiustamento Economico (Chahad JPZ, Cervini R. eds).UNICEF 1988.

Becker RA and Lechtig. "Brazil: evolucao da mortalidade infantil no periodo 1977-1984".Centro de Documentacao do Ministerio da Saude. Brasilia. (Serie C: Estudos e Projetos,3].

Benigna MJC et al. "Crescimento e Estado Nutricional de Criancas 0-11 Anos, Estado daParaiba (Nordeste Brasileiro)." Revista de Saude Publica. 1987;21:480-489.

30

Campino, ACC. "Nutrition Interventions in Brazil: The Possible Impact of Food PriceSubsidies". Kellogg International Fellowship Program/Food Systems, Vols I and II.

Campino. ACC. "A Review of Nutrition Programs in Brazil." Report prepared for theWorld Bank Public Social Expenditure Review. June 1987.

Campino. ACC. "The Feasibility of a Food Coupon Program in Brazil. ' Mimeo, not dated.

CarValho da Silva, A. "Annex 2." in Nutrition Strategy Review. 1983.

Carvalho da Silva, A. "Politicas de Alimentacao e Nutricao no Brasil," Sao Paulo, January,1987.

Carvalho da Silva, A. "Research and Training in Food and Nutrition," January 17, 1985.

Cyrillo, D. and Campino, A. "Analise da Viabilidade Economica da Descentralizacao doPrograma de Merenda Escolar na Grande Sao Paulo," Secretaria da Educacao do Estado deSao Paulo, October, 1989.

de Moura Castro, C. and M. Coimbra. "0 Problema Alimentar no Brasil." Almed Editoria eLivraria. LTDA. Sao Paulo.

de Moura Castro, C. and P. Fletcher. "A Escola que os Brasileiros Frequentaram em1985." IPEA/IPLAN, 1986.

Dias L et al. "Drought, Recession and Prevalence of Low Birthweight Babies in Poor UrbanPopulations of the North-East of Brazil." Journal of Tropical Pediatrics. 1986;32:140-141.

Donangelo GM et al. "Iron, Zinc, Folate and Vitamin B12 Nutritional Status and MilkComposition of Low-Income Brazilian Mothers." European Journal of Clinical Nutrition.1989;43:253-266.

Ferreira H da S, Ott AMT. "Avaliacao do Estado Nutricional de Criancas Menores de CincoAnos do Estado de Rondonia - Brasil." Revista de Saude Publica. 1988;22:179-183.

Ferras de Lucena MA et al. "Padroes AliInentares de Familias Rurais do Tropico Semi-Arido(Nordeste do Brasil)." Alimentacao e Nutricao. 1984;5:51-58.

Fundacao Instituto Brasileiro de Geografia e Estatistica - IBGE. Perfil estatistico de criancase maes no Brasil: asDectos nutricionais 1974-75. Rio de Janeiro 1982.

Fundacao de Assistencia ao Estudante -FAE. "Programa de Municipalizacao da AlimentacaoEscolar, 1987.

31

Fundacao de Assistencia ao Estudante -FAE. "Avaliacao do Programa Municipalizado deAlimentacao Escolar", 1986.

Fundacao de Assistencia ao Estudante -FAE. "Execucao Fisico Financeiro." 1985-88,DIPLAN/DESIT.

Fundacao Instituto Brasileiro de Geografia e Estatistica -IBGE. Perfil Estatistico da Criancase Maes no Brasil Mortalidade Infantil e Saude na Decada de 80. Sao Paulo. 1989.

Glewwe, Paul. "Improving Data on Poverty in the Third World: The 'World Bank's LivingStandards Measurement Survey." Policy, Research, and External Affairs Working Papers416, May 1990.

Gross R et al. "The Influence of Economic Deterioration in. Brazil on the Nutritional Statusof Children in Rio de Janeiro, Brazil." Ecologv of Food and Nutrition. 1987;19:265-279.

Gross R and CA Monteiro. "Urban Nutrition in Developingr Countries: Some Lessons toLearn." Food and Nutrition Bulletin. 1989; 11:14-20.

Instituto Nacional de Alimentacao e Nutricao - INAN. Pesciuisa nacional sobre saude enutricao: resultados nreliminares. March 1990.

Instituto Nacional de Alimentacao e Nutricao -INAN. Relatorio Anual de Atividades, 1988.

Instituto Nacional de Alimentacao e Nutricao -INAN. Balainco Geral, Prestacao de Contasde 1989. Volume 1.

Jackson MJ et al. "Stable Isotaope Metabolic Studies of Zinc Nutrition in Slum-DwellingLactating Women in the Amazon Valley." Brazilian Journal of Nutrition. 1988;59:193-203.

Jamison, DT and J Leslie. "Health and Nutrition Considerations in Educational Planning."February 5, 1990 (first draft).

LBA, Relatorio Geral. 1987, 1988, 1989.

Lima M et al. "Malnutrition Among Children of Adolescent Mothers in A SquatterCommunity of Recife, Brazil." Journal of Tropical Pediatrics. 1990;36::14-19.

Martins IS et al. "As Determinacoes Biologica e Social da Doenca: Um Estudo de AnemiaFerropriva." Revista de Saude Publica. 1987;21:73-89.

Medici, A. "Estudo Sobre a Infra-Estrutura Social Do Nordeste." Preliminary Draft,Fundacao Joaquim Nabuco, Recife, December 1989.

32

Mendeiros-Neto GA. Towards the Eradication of Iodine-Deficiencv Disorders in BrazilThrough a Salt Iodination Programme. WHO 1988:637-642.

Molina MCB et al. "Nutritional Status of Children of Urban Low-Income Communities,Brazil (1986)." Revista de Saude Publica. 1989;23:89-97.

Monte CM, Lechtig A. "Impact of a Programme of Food Supplementation During Pregnancyon the Proportion of Low Birthweight Babies in Brazil." Journal of Tropical Pediatrics.33:58-59.

Monteiro CA. "Crescimento Economico, Intervencoes Medico-Sanitarias e Saude Infantil naCidade de Sao Paulo." in Crise e Infancia no Brasil: 0 Impacto das Politicas de AiustamentoEconomico." (Chahad JPZ, Cervini R. eds). UNICEF 1988.

Monteiro. CA. Saude e Nutricao das Criancas de Sao Paulo. Editoria HUCITEC. Editoria daUniversidade de Sao Paulo. Sao Paulo. 1988.

Monteiro, CA. "What do we know about Child Malnutrition in Brazil?". Background paperprepared for the World Bank. April 1994.

Monteiro CA et al. "Estudo das Condicoes de Saude das Criancas do Municipio de SaoPaulo, SP, (Brasil), 1984-85. II. Anthropometria Nutricional." Revista de Saude Publica.1986;20:446-453.

Monteiro CA et al. "The Recent Revival of Breast-Feeding in the City of Sao Paulo, Brasil."Arnerican Journal of Public Health. 1987;77:964-966.

Monteiro et al. "Is It Possible to Reduce Infant Mortality Through Breast-FeedingProgrammes? The Case of Sao Paulo City." Short version of paper presented to the ThirdInternational Conference on Oral Rehydration Therapy. Washington DC, December 14-16,1988.

Monteiro CA and SC Szarfarc. "Estudo das Condicoes de Saude das Criancas no Municipiode Sao Paulo, SP (Brasil), 1984-85. V. Anemia." Revista de Saude Publica. 1987;21:255-260.

Musgrove, P. "Fighting Malnutrition: An Evaluation of Brazilian Food and NutritionPrograms." World Bank Discussion Paper No. 60. The World Bank. Washington, D.C.1989.

Musgrove, P. "Report of Activities and Findings Related to Nutrition," prepared for thePublic Social Expenditure Review Mission, July 15, 1987.

33

Ortiz, LP. "A mortalidade em Sao Paulo durante o perio(io 1975/87" in Crise e Infancia noBrasil: 0 Impacto das Politicas de Ajustamento Economico." (Chahad JPZ, Cervini R. eds).UNICEF 1988.

Peliano, AM. "Os Programas Alimentares e Nutricionais no Contexto da RecessaoEconomica: 1980-84." in Crise e Infancia no Brasil: 0 Irnpacto das Politicas de AjustamentoEconomico. edited by Jose Paulo Zeetano Chahad and Ruben Cervini, UNICEF, 1988.

Peliano, AM and N. Beghin. "Brasil: Os Programas Fedlerais de Aliinantacao e Nutricao noInicio da Decada de 90", Brasilia, April 1994.

Rea, Maria F. The Brazilian National Breastfeeding Programme: A Success Story. SaoPaulo. November, 1988.

Rees DG et al. "Measures of Nutritional Status: Survey oL Young Children in North-EastBrazil." The Lancet. January 10, 1987:87-89.

Reichenheim M and T Harpham. "Child Health in a Brazilian Squatter Settlement: AcuteInfections and Associated Risk Factors." Journal of Tropical Pediatrics. 1989;35:315-320.

Reichenheim M and GJ Ebrahim. "Obtaining Best Value for Money in Nutrition: AnEmerging New Priority for the Urban Poor." Journal of l'ropical Pediatrics. 1986;32:93-96.

Roncada MJ et al. "Prevalencia de Hipovitaminose a Em Pre-Escolares de Municipio daArea Metropolitana de Sao Paulo, Brasil." Revista de Saude Publica. 1984;18:218-224.

Salzano AC et al. "Anemias em Criancas de Dois Servicos de Saude de Recife, PE (Brasil)."Revista de Saude Publica. 1985;19:499-507.

Sampaio, Y. "The Experience of PROAB", mimeo, not (iated.

Sampaio, Y and AC Campino "Food and Nutrition Interventions in Brazil." mimeo, 1990.

Santos LMP et al. "Xeropthalmia in the State of Paraiba, Northeast of Brazil: ClinicalFindings. " American Journal of Clinical Nutrition. 1983;38: 139-144.

Shrimpton R. Vitamin A Deficiency in Brazil: Perspectives for food production orientedinterventions. Unpublished manuscript. Not dated.

Shrimpton R. The Ecologv of Childhood Malnutrition: Analysis of the Evidence forRelationships Between Socio-Economic Variables and Nutritional Status. With SpecialEmphasis on Latin American. and in Particular Brazil. UNICEF 1984.

34

Simoes, C and Ortiz. "A Mortalidade infantil do Brasil nos anos 80." in Crise e Infancia noBrasil: 0 Impacto das Politicas de Ajustamento Economico (Chahad JPZ, Cervini R. eds).UNICEF 1988.

Strauss, J and D Thomas. "The Shape of the Calorie-Expenditure Curve." Economic GrowthCenter, Yale University, Center Discussion Paper No. 595, March, 1990.

Szarfarc SC et al. "Estudo das Condicoes de Saude das Criancas do Municipio de Sao Paulo,SP (13rasil), 1984-85. X. Consumo Alimentar." Revista de Saude Publica. 1988;22:266-272.

Szarfarc SC. "A Anemia Nutricional Entre Gestantes Atendidas em Centros de Saude doEstrato de Sao Paulo (Brasil)." Revista de Saude Publica. 1985; 19:450-457.

Thomas, D. "Intra-Household Resource Allocation: An Inferential Approach." EconomicGrowth Center, Yale University, Center Discussion Paper No. 586, October, 1989.

Thomas D et al. How Does Mother's Education Affect Child Height? Unpublishedmanuscript. July 1988.

UNICEF/Secretaria de Assistencia Social. "Projeto de Avaliacao do Programa deComplementacao Alimentar: Relatorio Final." Brasil. 1982.

Vianna, SM et al. "A Conta Social Revisitada 1980-1987," IPEA/IPLAN/CSP, Brasilia,December 1988.

Victora CG et al. "Prevencao da Diarrhia em Criancas Brasileiras: Uma Revisao de PossiveisIntervencoes." mimeo, not dated.

Victora CG et al. "Birthweight, Socio-Economic Status and Growth of Brazilian Infants."Annals of Human Biologv. 1987;14:49-57.

Victora CG et al. "Water Supply, Sanitation and Housing in Relation to the Risk of InfantMortality from Diarrhoea." International Journal of EDidemiologv. 17:651-654.

Victoria CG et al. Epidemiolozia da Desiaualdade. Editoria HUCITEC. Sao Paulo. 1988.

Victora CG et al. "Birthweight and Infant Mortality: A Longitudinal Study of 5914 BrazilianChildren." International Journal of Epidemiology. 16:239-245.

Victora CG et al. "Infant Feeding and Deaths Due to Diarrhea: A Case-Control Study."American Journal of Epidemiologv. 1989; 129 1032-1041.

Victora CG et al. "Risk Factors for Malnutrition in Brazilian Children: The Role of Socialand Environmental Variables." Bulletin. World Health Organization. 1986;64:299-309.

35

Victora CG and Barros FC. A Saude das Criancas Cearenses. Unpublished manuscript,1989.

Victora CG and Barros FC. "Avaliacao Preliminar do Impacto da Pastoral da Crianca SobreAlguns Indicadores de Saude e de Utilizacao de Servicos", 1990.

Victora CG et al. "Evidence for Protection by Breast-Feeding Against ]nfant Deaths fromInfectious Diseases in Brazil." The Lancet. August 8 1987:,319-322.

World Bank. Brazil: Women's Reproductive Health. Report No. 8215-]BR. Washington,D.C. December 29, 1989.

World Bank, "Policies for the Reform of Health Care, Nutrition and Social Security inBrazil." Report No. 6741-BR. January 6, 1988.

World Bank. "Nutrition Sector Review," January 1984.

World Bank, "Enriching Lives: Overcoming Vitamin and Mineral Malnutrition inDeveloping Countries," Development in Practice, 1994.

World Bank, "Project Completion Report: Brazil Nutrition Research and DevelopmentProject," (Loan 1302-BR), August 1, 1985.

Wright M da GM and JED de Oliveira. "Infant Feeding in A Low Income BrazilianCommunity." Ecology of Food and Nutrition. 1989;23:1-12.

36 ANNEX 1

NUTRITIONAL STATUS OF CHILDREN UNDER FIVE YEARS-OF-AGEAND PREGNANT AND LACTATING WOMEN IN BRAZIL

Introduction

1. This annex summarizes what is known about the nutritional status of children underage six and pregnant and lactating women in Brazil. Its objective is to identify majornutritional deficiencies and risk factors for these deficiencies. These groups were studiedbecause they are particularly vulnerable for various nutritional deficiencies.

Preschool Children

Anthropometric Data

2. The most common measures of malnutrition as assessed through anthropometry areheight-for-age, weight-for height, and weight-for-age 1/. Low height-for-age is indicative ofstunting or chronic malnutrition, while low weight-for-height indicates wasting or acutemalnutrition. Low weight-for-age is a composite indicator that can signal either chronic oracute malnutrition.

Geographic Distribution and Urban-Rural Differences

3. Representative surveys. Nationally representative data on anthropometry areavailable from three sources: 1) the National Survey of Household Expenditures (ENDEF),conducted in 1974-75; 2) the National Demographic and Health Survey (PNSMIPF),conducted in 1986; and 3) the National Health and Nutrition Survey (PNSN), conducted in

1/ The reference standard used in all anthropometric calculations of nutritional status is fromthe U.S. National Center for Health Statistics. The appropriateness of this referencestandard for assessing the growth of Brazilian children is documented in the 1989 PNSN,which shows the distribution of height-for-age of Brazilian children in the highest incometercile to be exactly the same as that of U.S. children, indicating similar growth potential.

37 ANNEX 1

1989 2/. The 1974/75 ENDEF and the 1989 PNSN collecl:ed anthropoinetric datanationally. The 1986 PNSMIPF was a national level survey but collected anthropometricdata in only the Northeast.

4. Chronic malnutrition is the major form of malnutrition in Brazil. As Table 1shows, malnutrition is most prevalent, 3/ as assessed by low height-for-age (indicatingstunting), in the Northeast and the North. About 27 percenit of children in the Northeasthave low height-for-age--more than three times the proportion in the Southeast and Center-West. Children living in rural areas are more likely be stunted than those living in urbanareas.

5. Small studies. Existing studies of nutritional stat,us that are not nationallyrepresentative have tended to focus on low-income communities in urban areas. Stratifiedrandom or cluster sampling techniques have been used in many studies, making themrepresentative for the types of communities they describe. There is wide geographicvariation in the prevalence of low weight-and height-for-age even in low-income communities(Table 2). In urban Sao Paulo, for example, 5 percent of children had weight-for-age lessthan 75 percent (corresponding to Gomez grades II and IlI) compared with 23 percent inurban Recife. Similarly, height-for-age less than 90 percenit (corresponding to the Waterlowcutoff for stunting) ranged from 6 percent in urban Rio de Janeiro to 28 percent in the urbanareas of Ceara and Recife.

Trends in Indicators of Nutritional Status

6. Representative surveys. The prevalence of underweight children declined by morethan half between 1974-75 (ENDEF) and 1989 (PNSN) for all regions studied (Table 3). Itdeclined less in the Northeast than in the other regions, however.

7. Data from the Northeast suggest that the decline in the prevalence of low weight-for-age occurred by 1986). Although significant decreases were recorded in both urban andrural areas between 1974-75 and 1986, the decline was greater in urban areas (Table 5). Theproportion of babies under five months of age who had low height-for-age remained roughly

2/ The largest of the three surveys is the 1974-75 ENDEF survey, which includedapproximately 55,000 households, with weight and height measurements of all householdmembers, including 17,066 children aged zero to 59 monthls. The 1986 PNSMIPF survey isthe smallest. Anthropometric measurements were taken for 1,132 children aged zero to 59months. The 1989 PNSN survey interviewed 17,920 households. As in the ENDEF,anthropometric measurements were taken of all household members, including 7,437 childrenaged 0-59 months.

3/ Prevalence measures the frequency of a condition at a particular point in time. In thiscase it refers to the proportion of children measured who are malnourished.

38 ANNEX 1

constant, indicating that the conditions that resulted in improved nutritional status amongchildren under the age of five years did not benefit very young infants. These data for younginfants most likely reflect continued problems in maternal nutrition and birthweights and/orpoor infant feeding practices.

8. Small studies. Four studies provide data on changes in anthropometric indicatorsover the past 15 years. Of these, two show no change in the prevalence of malnutrition, onefinds an increase, and one shows a decrease (Table 6). In a large study of clinic records forthe years 1980 to 1983, Gross et al. (1987) conclude that the economic recession did notalter the frequency of low weight- or height-for-age as measured by either the Gomez orWaterlow classifications. The only significant change was a reduction in the prevalence ofwasting, an unexpected finding given deteriorating economic conditions. Anthropometricdata from two low-income urban populations in Sao Paulo randomly sampled in 1973-74 and1984-85 also show no change in the prevalence of low weight-for-age (Monteiro et al.,1986) 4/. When data from a stratified random sample in three communities in urban andrural Rondonia in 1985 are compared to data collected in 1974-75 (ENDEF) for theNortheast, however, the prevalence of weight-for-age less than 75 percent (Gomez II and III)declines from 21.7 percent to 4.8 percent, while the prevalence of height-for-age less than 90percent (Waterlow-stunting) drops from 24.9 to 6.0 percent (Ferreira and Ott, 1988). Incontrast, a comparison of a random sample of children in Paraiba in 1981-82 to Northeastchildren in 1974-75 (ENDEF), shows that at all ages children in Paraiba had greater deficitsin weight and height (Benigna et al., 1987). Because these small studies cover differentregions, use different sampling procedures and demonstrate conflicting results, it is difficultto draw strong conclusions from them with respect to malnutrition over time.

Age-specific Risk Patterns for Malnutrition

9. Anthropometric data from both national surveys and studies of low-incomepopulations show age-specific risk patterns for growth faltering that begin soon after birth,increase sharply during the second year of life, and plateau during the third year (Table 7).In the 1989 PNSN survey, the proportion of children withv weight-for-age below 90 percentincreases rapidly until 24 months, and very slowly thereafter. The last three months ofinfancy (9 to 12 months) appear to be a particularly at-risk period; among urban low-incomeinfants in Belo Horizonte, mean weight of 10-12 month-old-infants was 0.5 kg less than that

4/ A stratified random sampling frame was used in 1973-74 to ensure that children from allincome groups were included. The sampling frame included only those homes that hadelectricity and excluded favelas. As the most economically disadvantaged were excludedfrom the sample, the prevalence of malnutrition is most likely underestimated relative to thesampling frame used in 1984-85, which was not so restrictive. Hence, these data may bebiased towards finding a deterioration in nutritional status.

39 ANNEX 1

of 7-9 month-old-infants in 1986 (Molina et al., 1989) 5/. Data from the 1989 PNSN alsoshow that infants six to 12 months-of-age are most likely to have weight-for-age less than 75percent (corresponding to Gomez grades II and III). This is consistent with a pattern ofwasting, as measured by weight-for-height, among Northeastern infants under six months-of-age in the 1986 PNSMIPF (Thomas et al., 1988).

Sex-specific Risk Patterns for Malnutrition

10. No sex-specific risk patterns were noted for any indicators of nutritional status.This indicates that sex is not a factor in how food within the household is distributed or howcare is given during illness.

Risk Factors for Malnutrition

11. Infant and child morbidity. Nationally representative data on morbidity fromdiarrheal disease show age-specific and geographic risk patterns that coincide with those formalnutrition (Table 8): children living in the Northeast and North have the highest incidenceof diarrhea, and children living in rural areas are slightly more likely to have diarrhea.Children under age two are at highest risk, especially between the ages six to 18 months.For all age groups, however, diarrhea was less prevalent in 1989 than in 1986 (Table 9).The 1986 PNSMIPF shows no sex-specific patterns of risk. However, maternal education isa strong predictor of risk: children whose mothers did not go to school are almost twice aslikely to become ill with diarrhea compared to children whose mothers have more than sixyears of schooling.

12. Among specific population subgroups, rates of diarrheal morbidity vary widelydepending on the population studied. Thirty percent of children in a study of 600 childrenunder age five in a squatter settlement in Rio de Janeiro had diarrhea within the previous twoweeks (Reichenheim and Harpham, 1989). Twenty-six percent of all under 20 months inPelotas had diarrhea within the previous month (Victora, et al., not dated). Children of allincome levels were at risk: 31 percent of children in the poorest families and 21 percent ofthose in the highest income suffered from diarrhea during the month before the study.However, children from poor families were much more likely to have suffered severediarrhea resulting in hospitalization or death (Table 10).

13. The only study examining changes in diarrhea over time shows that the proportionof low-income children in Sao Paulo suffering from diarrhea declined from 11.2 percent in1973-74 to 4.6 percent in 1984-85 (Monteiro, not dated). Over this same time period, theproportion with intestinal parasites dropped from 60.2 to 33.2 percent.

5/ Numerous studies, including some in Brazil, show this to be the period when theprevalence of diarrheal disease peaks.

40 ANNEX 1

14. In another study, nearly 80 percent of poor children in Rio de Janeiro werereported to have had an acute respiratory infection within the previous two weeks, 12 percentof which were severe (Reichenheim and Harpham, 1989). Risk factors associated withsevere respiratory infections or diarrhea were low income, age less than two years,environmental conditions, marital stress, and length of separation during the week betweenchild and mother. The relationship between serious illness and mother-child separationremained after controlling for socioeconomic status and mental state of the mother. Howchildren of working mothers were cared for was not reported; in the U.S., children attendingday care centers are at greater risk for illness than those cared for at home. An alternativeexplanation for this finding is that mothers working outside the home have less time to carefor their children when they become ill or to seek medical attention, thus increasing thelikelihood that a given illness will become severe.

15. Family income. In the 1989 PNSN survey, the distribution of height-for-ageamong children under age ten in the highest income tercile does not differ from that of U.S.children. Children in the middle and lowest income terciles show increasing levels ofstunting, however. In the 1974-75 ENDEF, family income is associated with inadequatedietary intake and diarrheal disease, the two most proximal causes of poor nutritional statusamong children. Indirectly, family income affects child nutritional status throughenvironmental variables, such as type of house, water supply, and sanitation. Family incomeis also inversely associated with the number of children in the household. In a studyconducted in Rio Grande do Sul, per capita family income and father's education showed thestrongest associations with child nutritional status among the socioeconomic variables studied.Mother's education, employment status of household head (defined as unemployed, retired,

employed, self-employed or employer), number of siblings, and ethnic background were alsoassociated with nutritional status, but the strength of these associations was reduced whenfamily income was also considered (Victora et al., 1988).

16. Not only does family income negatively affect child nutritional status, but resultsfrom the 1974-75 ENDEF show that children under age five and pregnant and lactatingwomen are also more likely to live in poor families (Table 11). Forty percent of all childrenaged 1-5 live in families in the lowest income quartile; only 13 percent are in the highestincome quartile. Similarly, 47 percent of all pregnant and lactating women are found in thepoorest families, and only 13 percent live in the highest income quartile.

17. Maternal age and education. Maternal age and education are strongly associatedwith the height-for-age of their children in the 1974-75 ENDEF. In the rural Northeast, 51percent of children of women younger than 20 are stunted, compared with 36 percent ofthose whose mothers are over age 40. Forty percent of children of illiterate mothers in therural Northeast are stunted compared with 17 percent of children of mothers who havecompleted high school. Analyses carried out on the 1986 PNSMIPF data show that maternaleducation affects child height even when family income is considered, probably chieflythrough access to and use of information about child health and nutrition (Thomas et al.,1988).

41 ANNEX 1

MICRONUTRIENT DEFICIENCIES

Anemia

18. Children ages six to 60 months are known to be at particular risk for anemia.This micronutrient deficiency is important because it causes apathy and loss of appetite, andin its most severe form can be life threatening. Recent research has focused on the possiblecausal relationship between iron-deficiency and poor behavioral-test performance.

19. Age-specific risk patterns for anemia. Age-specific changes in meanhemoglobin levels follow those of U.S. children, but they are more pronounced, puttingBrazilian children at even greater risk for anemia 6/. Both rnoderate and severe forms ofanemia are very common among children under the five, especially among babies ages six to24 months (Table 12). The age-specific risk pattern remains constant regardless of thepopulation sampled. A review of 10 studies on the iron statuis of children also reports highlevels of anemia, ranging from 16 percent among preschool children in the state of Paraiba to89 percent among children 6-60 months in Joao Pessoa (Batista Filho and Cartagena, 1985).Intestinal parasites, a frequent cause of anemia among the poor, do not explain thewidespread anemia among children under two because parasites are more common amongolder children (Monteiro and Szarfarc, 1987), and are not associated with. hemoglobin levels(Molina et al., 1989).

20. Dietary intake of iron. Overall risk for anemia, as well as age-specific riskpatterns, are consistent with dietary data: the diets of a large proportion of age groups fail toreach the recommended intake for iron (Table 13). Although the proportion is highestamong children under the age of two, the inverse association between risk of inadequateenergy and iron intake across different age groups suggests tlhat different mechanisms causethe age-dependent patterns of anemia. For example, because dietary intake of children undertwo more closely approximates energy requirements than iron requirements, the highprevalence of anemia among these age groups is related to feeding patterns and/or availabilityof specific foods rather than lack of food. In contrast, among older children the proportionof diets that fail to reach recommended levels of energy is similar to that which fail to reachrecommended levels of iron, suggesting that anemia is related to lack of food (Szarfarc,1988).

21. Several feeding patterns put infants and young children at risk for anemia: 1)early cessation of breastfeeding, which removes a highly bioavailable source of iron from thediet; 2) early introduction of cow's milk, which is a poor source of iron aLnd can cause

6/ Using definitions proposed by the World Health Organizalion (WHO), anemia is defmedas hemoglobin levels less than 11 g/dl and severe anemia as less than 9.5 g/dl.

42 ANNEX 1

intestinal hemorrhaging in infants and consequent blood loss; and 3) low consumption ofmeat, which is an excellent source of iron and also promotes the absorption of iron fromnon-meat sources. Data from 24-hour recalls of intake by parents among low-incomechildren in urban Sao Paulo show that meat is rarely given to infants, and that only 50percent of children ages one to two had received any meat the previous day (Szarfarc, 1988).

22. Children who receive fruit in their diets have significantly higher hemoglobinlevels than children who do not (Molina et al., 1989). This association has two possibleexplanations. Fruit is a rich source of vitamin C, which enhances iron absorption. Inaddition, the presence of fruit in the diet may be an indication of dietary diversity, which ispositively associated with nutrient intake.

23. Data from the 1974-75 ENDEF show that a large proportion of families withchildren have diets with lower-than-recommended levels of iron 7/. Iron deficiency varieswidely by region, ranging from 25 percent in the urban Northeast to 44 percent in rural SaoPaulo, and differs from the regional variation in energy intake. In the Northeast, forexample, diets are more likely to be deficient in energy, while the reverse is true in SaoPaulo. As these relationships are present for both rural and urban areas of each region, theycan be attributed to geographic, rather than rural-urban, differences in food consumption.

24. Trends in anemia. Changes in the prevalence of anemia among children arereported in only one study, which shows that between 1973-74 and 1984-85 prevalenceincreased more than fifty percent, from 23 to 36 percent, among low-income children underthe age of five in Sao Paulo (Table 14). During this same time period the prevalence ofsevere anemia more than doubled, from 6 to 15 percent.

25. Correlates of anemia. Anemia in children was positively associated withmalnutrition, as defined by Gomez (Salzano et al., 1985), and inversely associated witheducational level of the household head (Monteiro and Szarfarc, 1987) and income (Molina etal., 1989). There were no sex-specific differences in risk. Dietary data from the 1974-75ENDEF also show that iron intake is inversely associated with family income (Batista Filhoand Cartagena, 1985).

7/ Dietary data in the 1974-75 ENDEF were collected over a seven-day period for the entirehousehold by food weighing. Therefore, adequacy of intake can only be assessed forfamilies and not for children themselves. Depending on how food is distributed within thefamily, children may be at greater or lesser risk than their families. Although these datacannot be used to directly assess children's diets, they are included here because they showimportant rural-urban and geographical differences, which most likely also affect children.

43 ANNEX I

HYPOVITAMINOSIS A

26. The importance of clinically observed vitamin A defiiciency as a cause of blindnessis well established. Recently, the impact of subclinical vitamin A deficiency on mortalityand the possible effects on morbidity have been recognized. Vitamin A deficiencies causea weakening of body tissues resulting in reduced resistance to infection; diisorders of the eyetissues that can lead to blindness; growth stunting; and poor tooth development. Data onvitamin A status come from three sources: 1) dietary consurrLption of vitamin A; 2) serumretinol levels; and 3) clinical signs of deficiency.

27. Dietary intake of vitamin A. The only nationally representative data are from the1974-75 ENDEF. They show that at least three-quarters of families with children under agefive consume less than the recommended levels of vitamin A (Table 15). The proportion ishighest in rural areas--nearly 90 percent of families in rural Sao Paulo--indicating that a verylarge number of children may be at-risk for vitamin A deficiency. In contrast, dietary dataobtained in 1984-85 from a small sample of randomly selecteid low-income children in urbanSao Paulo show vitamin A intakes to meet recommended levels (Szarfarc et al., 1988). Thehigh intake of vitamin A is attributed to milk consumption. There are two possibleexplanations for the differences between the results of the two studies: 1) changes in milkconsumption during the 10-year interval between the two studies; or 2) failure of aggregatehousehold data from the ENDEF to reflect consumption levels of individual children. Oneadvantage of the Sao Paulo study is that children's actual intake is assessed. However,because vitamin A adequacy is related to milk consumption and representative data on milkconsumption are not available, the results of the Sao Paulo study cannot be extrapolated.

28. The ENDEF data show that diary products are the principal source of vitamin A inthe south of Brazil (Shrimpton, not dated). Consumption of dairy products also explainsmost of the variation in vitamin A intake associated with income. In the Northeast, plantfoods are the most important sources of vitamin A; however, many plants that are availableor easily cultivated are not being consumed.

29. Serum retinol. Data on serum retinol levels from a sample of low-income childrenin Sao Paulo and children in the Amazon corroborate the ENDEF data in the 1974-75ENDEF and confirm that vitamin A deficiency is a serious public health problem. Nearly athird of randomly sampled children ages 3-6 in Sao Paulo and 15 percent of those in theAmazon have serum retinol levels below 20 ug/dl (Roncada et al., 1984; Shrimpton, 1984).(A serum retinol level below 20 ug/dl in more than 15 percernt of the population surveyed isconsidered a deficiency problem at the public health level.) T[here are no age or sexdifferences in the Sao Paulo study.

30. Clinical studies. A 1981-82 clinical study of nearly 11,000 children under age 11in Paraiba also confirms that vitamin A deficiency is a public health problem (Santos et al.,1983). Clinical signs of deficiency were significantly more prevalent in the Sertao, during

44 ANNEX 1

the interharvest period, and among school-aged children compared to preschoolers. Onepercent and 0.3 percent of school-aged and preschool children, respectively, had Bitot'sspots 8/ during the harvest season. Among preschool children living in the Sertao,however, levels reached 1.9 percent in the interharvest period -- far above the 0.5 percentceiling established by WHO for vitamin A deficiency to be considered a public healthproblem. A review of the literature prior to 1984 on clinical vitamin A deficiency showsthat clinical signs vary depending on the population studied (Batista Filho and Cartagena,1985). In a study of 1500 preschool children in the Northeast, for example, no clinical signswere found while four percent of 841 children studied in Para had Bitot's spots. A recentrepresentative survey by UNICEF in the state of Ceara found Bitot's spots in only four of3,482 children under age three (Victora and Barros, 1989).

31. Age-specific risk patterns. Several studies point to infancy and earlychildhood as the period of greatest risk for vitamin A deficiency. In the Northeast, childrenunder two are more likely to be diagnosed with xerophthalmia than older children. Also,liver retinol levels of Brazilian children are lowest in the first two years of life (Shrimpton,1984). It has been suggested that early weaning is, in part, responsible for the high risk forVitamin A deficiency among infants and very young children. Milk, and particularlybreastmilk, is the principal source of retinol in the first years of life. In contrast, many ofthe weaning foods used in Brazil contain very little vitamin A.

Iodine

32. Results from two surveys show an overall decline in the prevalence of goiter-- achronic enlargement of the thyroid gland associated with iodine deficiency -- from 20.6percent in 1955 to 14.1 percent (11.7 and 16.3 percent for boys and girls, respectively) in1975. In 10 of the 25 regions studied, however, prevalence increased (Batista Filho andCartagena, 1984).

33. The extent to which iodine deficiency continues to be a problem can be inferredfrom 1983-85 data on concentrations of iodine in salt, when the Ministry of Healthimplemented a salt iodination program (Medeiros-Neto, 1988). During this period, thepercentage of samples with no iodine fell from 10.8 to 0.1 and the percentage within theacceptable range of 10-30 mg of iodine/kg increased from 88.4 to 89.7 percent. The majorproblem in 1985, therefore, was not a lack of iodine in salt, but a six-fold increase ofsamples with iodine levels exceeding 30 mg/kg. Universal salt iodination appears to haveaffected the at-risk populations: in three areas of endemic goiter (Pocone, Luziania, andBalsas), mean urinary excretion of iodine increased from <40ug/g creatinine in 1975-79 to125 in 1987. No details on the sample from which these data were obtained were reported.

8/ Bitot's spots are a type of discoloration of the pupil that is a stage in the development ofxerophthalmia, preliminary to blindness.

45 ANNEX 1

34. Since 1984, iodine deficiency has been monitored every two years in high-riskareas. Examination of school children ages 9-14 years by physicians trained to diagnosestages of goiter development indicates that iodine deficiency is no longer a public healthconcern, due to the improvement in implementation of the salt iodination program in the1980s.

DIETARY DATA

Intake of Macro and Micro Nutrients

35. Age-specific dietary risk patterns for a group of low-income Sao Paulo childrenunder age five show that: 1) after the first year of life large proportions of children fail toconsume the recommended level of energy; 2) all age groups, but especially children undertwo are at-risk for inadequate iron intake; and 3) protein and vitamin A irntakes meetrequirements, in most cases, though as noted previously, protein may not meet physiologicalrequirements because diets are lacking in energy (Table 13). Adequacy of protein andvitamin A in the diet is attributed to milk consumption, since 91 percent of children sampledhad consumed 400-500 ml of milk in the previous 24-hours (Szarfarc et al., 1988).

Typical Foods Consumed

36. The diets of poor children are not very diverse. More than half of 1-3 year olds ina squatter settlement in Fortaleza, for example, commonly consume only five foods (rice,bread, beans, coffee, and sugar), even though 26 other foods of comparable nutritional valueare available at similar prices per calorie in community shops (Reichenheim and Ebrahim,1986). The foods most commonly given to infants in a squatter settlemernt near Brasilia aremilk, grains and grain-based products, beans and bean broth, herb teas, and, occasionally,fruits and vegetables (Wright and Oliveira, 1989).

37. Although data on infant and child feeding practices are limited, they appear toreflect both economic status including living circumstances, and cultural influences. Rice,beans, and cassava flour are popular not only because they are inexpensive sources ofnutrients, but also because they require no refrigeration and have a long shelf life, makingthem highly practical for slum dwellers. Reichenheim and Ebrahim have shown that onlyfive foods are consumed by preschoolers even though many others are available at the samecost, suggesting a lack of knowledge about the importance of diversity in a child's diet.Fruits and vegetables may not be frequently given to children because they are considered"weak" and "insufficient" foods (Wright and Oliveira, 1989).

38. According to the ENDEF, nine foods (rice, wheat, beans, meat, fats, manioc flour,milk, sugar, and fish) are the most common sources of energy and protein for the regionsstudied (Batista Filho and Cartagena, 1985). In the Northeast, cereals account for 34 percentall calories, beans for 18 percent, roots and tubers for 17 percent, sugar for 12 percent, meat

46 ANNEX 1

for 10 percent, milk products (almost exclusively milk) for five percent, and fats for onlythree percent (Ferras de Lucena et al., 1984).

Breastfeeding

39. Breastmilk is the most complete source of nutrients for infants from birth to 4-6months, and an important source thereafter. In addition to its nutritional value, breastfeedinghas important health benefits: breastfed infants are less likely to experience diarrhea,respiratory infections, allergies, and other infections. Because both the incidence andseverity of illness is reduced, the mortality rate of breastfed infants is lower than that ofbottle-fed infants.

40. Geographic distribution and rural-urban differences. According to the 1989PNSN, infants were mostly likely to be currently breastfeeding in the North, where 68percent of all infants under 12 months were reported to be currently breastfeeding. Theywere least likely to be breastfeeding in the Northeast, where 53 percent of all infants under12 months were currently breastfeeding. As would be expected, infants were more likely tobe currently breastfeeding in rural areas than in urban areas. Breastfeeding is widespreadduring the first three months of life: 84 percent of infants in that age group were currentlybreastfeeding. Thereafter, however, breastfeeding declines markedly: by six months of age,fewer than half are breastfed.

41. Age-specific prevalence of breastfeeding. In a squatter community outside ofBrasilia, less than 20 percent of infants younger than three months were exclusivelybreastfed, while 67 percent were partially breastfed (Wright and Oliveira, 1989). In thiscommunity, cow's milk rather than powdered milk was given to infants, which is a matter ofconcern since, as noted earlier, cow's milk can cause intestinal hemorrhaging, resulting inblood loss and anemia.

42. Trends in breastfeeding. The National Program to Promote Breastfeeding wasinitiated in 1981 and is considered highly successful. Data from the 1989 PNSN show thatbreastfeeding has increased among all age groups since the 1974-75 ENDEF (Table 16). InSao Paulo, the mean duration of breastfeeding increased at all income levels between 1973-74 to 1984-85; by the mid-1980s, weaning occurred after three months compared with 1-2months in the earlier period (Table 17). These changes primarily affect the initiation ofbreastfeeding and breastfeeding in early infancy. For example, while over 90 percent ofinfants are breastfed at birth, only a third are still receiving any breastmilk at six months.And while the proportions of infants breastfed at three and six months have increased sincethe mid-1970s, the increase is greater among the younger age group. Unfortunately, theincreases in breastfeeding have not affected all socioeconomic groups equally. Infants inupper income families have enjoyed the largest increases. The only exception to the risingprevalence of breastfeeding has been a decline among six-month-old infants in the verylowest income group. Also, as increases have been greater among higher income groups, theinverse relationship between income and breastfeeding in 1973-74 no longer holds (Table

47 ANNEX 1

17). The mean duration of exclusive breastfeeding is three months among mothers withmore than high school education compared to only one month among uneducated women.

43. Correlates of breastfeeding. The 1980 Northeastern Brazil Survey of Maternal-Child Health/Family Planning found longer breastfeeding durations amongr low-income andless educated women (Anderson et al., 1983). (Note that this survey was done before thestart of the National Program to Promote Breastfeeding). Breastfeeding was alsosignificantly less common among younger, low-parity women and women who received pre-and postnatal medical care, delivered in a medical facility, anld received medical care fortheir infant. These maternal characteristics appeared to influence the duration ofbreastfeeding more than its initiation. For example, 81 percent of women with less thanprimary education initiated breastfeeding compared with 72 percent of women with morethan primary education. The mean duration of breastfeeding for the two education groupswas 7.7 and 3.4 months, respectively. A strong inverse relationship between breastfeedingand contraceptive use was also seen.

44. Data for Sao Paulo for 1973-74 and 1984-85, however, show that breastfeeding isnow more common among higher income groups, so that, as noted in para. 44, the inverserelationship between breastfeeding and income no longer holdls (Monteiro, 1987). Thissuggests that the National Campaign to Promote Breastfeeding has been more successfulamong higher income women than among the poor. Monteiro has suggested that because ofeconomic considerations, it may be easier to achieve increases in the initiation rather than theduration of breastfeeding. Thus, the decline in breastfeeding; of six-month-old infants in thepooresr families may reflect the fact that breastfeeding is incompatible with other maternalactivities. There are limited data available on employment and breastfeeding. In a squattercommunity outside of Brasilia only housewives breastfed exc:lusively 9/; however, partialbreastfeeding was equally frequent among housewives and women who worked outside thehome (Wright and Oliveira, 1989). In a 1980 survey in the Northeast, women who workedbreastfed, on average, about two months longer than women who did not work (Anderson etal., 1983). The survey did not define, however, whether this work took place inside oroutside the home.

45. Association of breastfeeding and infant mortality. As in manry studies fromdeveloping countries, data from Brazil show that breastfeediag protects children from risk ofdeath from infectious diseases (Victora et al., 1987). After adjusting for potentialconfounding variables and age, the risk of dying from diarrhea for infants up to 12 months of

2/ The exact meaning of this is difficult to interpret because the mean age of infants in thedifferent feeding categories was not provided. As employment in this group was reported tobe unstable and mothers of very young infants are more likely to stay home, very younginfants who are also more likely to breastfeed may be over represented in the housewifecategory. Also, among housewives, only 17.4 percent of infants were exclusively breastfedcompared to 51 percent who were partially breastfed.

48 ANNEX 1

age is 14.2 times greater for weaned infants than for babies exclusively breastfed. The riskof death from respiratory infections is almost four times greater. This protective effect ofbreastfeeding is greatest during the first two months of life: completely weaned infants are23.3 times more likely to die from diarrhea than those exclusively breastfed. The benefits ofpartial breastfeeding are less dramatic but also significant: fully weaned infants are 4.2 timesmore likely to succumb to diarrhea and 1.6 times more likely to die of respiratory infectionthan babies who are partially breastfed. The breastmilk substitute used did not appear tomatter; the risk of death was similar among infants fed cow's milk and formula.

46. Increases in breastfeeding are associated with a decline in infant mortality in SaoPaulo between 1980 and 1987 (Monteiro et al., 1988). Using data on the relative risk ofbottle-feeding compared to breastfeeding calculated from a case-control study, Monteiroestimates that nearly half of the reduction in mortality from diarrhea, respiratory infections,and other infectious diseases can be attributed to increased breastfeeding (Table 18). Whenall causes of mortality are considered, increased breastfeeding accounts for 25 percent of thereduction.

MORTALITY

Secular Trends and Trends in Cause-specific Mortality

47. As Table 19 shows mortality declined in the five regions between 1979-85. (Theincreases in 1983-84 appeared to be related to the economic crisis, not to signal a reversal inthe decline). Nevertheless, very large geographic differences in mortality rates persist.

48. Moreover, although overall rates of infant mortality declined, analysis of seculartrends in cause-specific mortality show that mortality associated with poor nutrition may haveincreased (Table 20). For example, while death due to diarrhea declined in the Northeastbetween 1977 and 1985, death attributable to prematurity and low birthweight (LBW) 10/and malnutrition showed a slight increase. In Sao Paulo, infant and child mortality frommalnutrition also slightly increased between 1979 and 1984, while mortality from all causesdecreased (Table 21).

49. The increase in mortality due to prematurity/LBW most likely resulted from anincrease in the incidence of LBW rather than increases in risk associated with being LBW.Data from several sources show an increase in the incidence of LBW during the last 12years: from 9.4 to 10.2 LBW babies per 1000 live births between 1978-82, from 10.2 to15.3 between 1982-84 in Recife (Dias et al., 1986) and 7.4 to 23.1 between 1980-83 among

10/ Low birthweight is defined as weight less than 2500 grams; it is predictive of futuremortality risk.

49 ANNEX 1

the very poor in Fortaleza (Batista Filho, 1988). Not surprisingly, the incidence of LBWvaries widely depending on the urban center and the socioeconomic status of the womenserved, although it has been consistently low among high income women (Table 22). Thelargest increases occurred in a public hospital serving very poor women in Fortaleza, whereLBW increased threefold, from 7.4 to 23.1, between 1980 and 1983. Although theincidence declined thereafter, in 1986 it was still double the 1980 level (14.3 versus 7.4). InBrazil, as in the rest of the world, low birthweight is strongly associated with mortality. In astudy of all infants born in 1982 in the city of Pelotas, LBW infants were almost 36 timesmore likely to die of perinatal causes than non-LBW infants (Barros et al., 1987c).

Social and Biological Characteristics Associated with LBW and Infant Mortality

50. The most comprehensive information on correlates of LBW and infant mortality inBrazil comes from the city of Pelotas, where a longitudinal study of all infants (7,392) bornin 1982 has been carried out. Although the mean birthweight of 3202 + 577 g (mean +SD) and incidence of LBW of 8.1/1000 compare favorably to levels in the U.S., both theperinatal and infant mortality rates are significantly greater (3:2 and 38/1000, respectively),suggesting very different probabilities of survival for a given 'birthweight.

51. Almost half (45 percent) of infant deaths occurred in the first week of life; theremainder were about equally divided between the next five and the second six months (42and 58 percent, respectively) (Barros et al., 1987b). One important implication of thismortality pattern for health and nutrition programs is that, theoretically, a large fraction ofinfant deaths could be prevented by reducing risk factors that operate during pregnancy andat delivery. However, as the major cause of death was undefined "perinatal problems," it isdifficult to specify the exact risk factors that should be targeted. The second major cause ofdeath was infectious diseases (32 percent), with respiratory infections and diarrhea eachaccounting for 12 percent of deaths. Infectious diseases were more likely to be fatal in the0-6 month age group than the 6-12 month age group: 84 percent of diarrheal deaths, 64percent of respiratory deaths, and 78 percent of deaths from other infections occurred duringthis period (Barros et al., 1987c). Therefore, efforts to reduce mortality associated withinfectious diseases (such as breastfeeding) should be targeted to infants under six months.Congenital and genetic abnormalities accounted for 13 percenit of all deaths, and ill-definedcauses for the remaining 11 percent.

52. The distribution of premature versus full-term LBW babies is important becauseeach is associated with different mortality risks and antecedent conditions linked to maternalhealth and nutrition. In Pelotas, the 42 percent of LBW babies who were premature weresignificantly more likely to die than those born at term (one in three and one in 10 forpreterm and term babies, respectively) (Barros et al., 1987a). Low maternal weight gain is awell established risk factor for term LBW babies. In Pelotas, babies of mothers whosemothers gained less than seven kg were twice as likely to die as those who gained 10-13 kg

50 ANNEX 1

and three times as likely to die as those who gained more than 16 kg 11/. There may bean effect of poor maternal iron status on risk of premature delivery, though this association isstill controversial and was not studied in Pelotas.

53. Low birthweight babies are at greater mortality risk from infectious diseases thannon-LBW babies (Victora et al., 1987). They are 6.7 times more likely to die fromrespiratory infections, 2.5 times more likely to die from diarrhea, and 3.9 times more likelyto die from other infections. The extent to which maternal characteristics, such as lowincome, put an infant at risk for both LBW and death from infectious diseases has not beenexamined. However, family income is strongly associated with birthweight, suggesting thatthe relationship between income and mortality is mediated, in part, by the effects of incomeon birthweight. The relationship between family income and birthweight is, in turn,mediated by more proximate maternal characteristics, such as weight at delivery, prenatalvisits, and smoking (Barros et al., 1987b). Family income is also significantly associatedwith perinatal mortality: babies born into families earning less than one minimum wage permonth are three times more likely to die than babies in families earning more than 10 timesthe minimum wage per month (Barros et al., 1987a). Thus, income could be used to identifypregnant women at risk of having a LBW baby and/or a baby with elevated mortality risk.

54. Among risk factors for perinatal mortality that could be identified at the beginningof pregnancy, history of previous abortion, stillbirth, or LBW baby are significant, andhistory of cesarean section nearly so (Barros et al., 1987a). In contrast, parity, birth-interval, and previous neonatal death are not significant risk factors. The relationshipbetween maternal age and perinatal mortality is J-shaped, with babies of women aged 25-29years at lowest risk. When number of prenatal visits and family income are controlled,however, adolescents have no higher risk than women under 29, which suggests that prenatalvisits, in part, mediate teenagers' risk but not that of women over the age of 30. Twoindicators of maternal nutritional status, height and weight at the beginning of pregnancy, arenot associated with perinatal mortality which indicates that these factors would not be usefulin identifying at-risk women 12/.

55. During pregnancy, gestational age, number of prenatal visits, and maternal weightgain explain perinatal mortality (Barros et al., 1987a). The number of prenatal visits isstrongly associated with perinatal mortality risk and remains important after controlling for

11/ Weight gain, however, is also significantly associated with gestational age, a verysignificant predictor of mortality. Information on the effect of weight gain where gestationalage is controlled is not reported for Pelotas, though most likely would reduce the magnitudeof the association.

12/ The only significant relationship between maternal height and perinatal mortality is areduced risk for women whose height is greater than 165 cm, which disappeared whenincome was controlled.

51 ANNEX 1

family income (56/1000 for babies of women with no visits compared with 16/1000 forbabies of women with 10 or more visits) (Barros et al., 1987a). Two sources of bias,however, may attenuate this relationship. First, the extent to which self-selection influencesboth prenatal visits and other unidentified behaviors linked to good pregnancy outcomes isnot known. Second, as length of gestation influences both mmber of visits and goodpregnancy outcomes, an automatic bias in the relationship betLween visits and good outcomesoccurs. However, as the relationship between prenatal visits and perinatal mortality riskoccurred in all income categories, it is likely that prenatal visits do affect mortality risk.Information on the specific components of prenatal care responsible for reduced mortalityrisk would be useful 13/. Weight gain, an indicator of maternal nutritional status duringpregnancy, is very important: babies of mothers who gained less than seven kg were twice aslikely to die as those of mothers who gained more than 16 kg.

56. Understanding the relationship between maternal characteristics, LBW, and infantmortality in Pelotas, and the role of maternal health and nutrition is complicated by twofindings. First, characteristics that affect LBW do not always affect mortality risk. Forexample, smoking is associated with a two-fold increased risk of LBW, but no excess risk ofmortality (Barros et al., 1987a). Therefore, although theoretically the incidence of LBWcould be reduced by 20 percent if women were to stop smoking (Barros et al., 1987b), thiswould have no effect on mortality (though it would reduce the hospital costs associated withLBW). Also, maternal weight at the beginning of pregnancy, is the single most importantpredictor of birthweight (Barros et al., 1987b) but is not important in explaining perinatalmortality (Barros et al., 1987a). Second, the relationship between LBW and mortalitydepends on family income; the risk of mortality associated with LBW is much greater forhigh income compared to poor infants (the relative risk is 30.4 and 8.7 for the highest andlowest income groups, respectively) (Victora et al., 1987). Although the reasons for thiswere not reported, poor women are more likely to have characteristics associated with LBWthat do not necessarily affect gestational age, such as smoking, while LBW babies of highincome women may be more likely to be premature and hence at higher risk of dying.

Changes in Risk Factors Associated with Malnutrition

57. Malnutrition is directly linked to both inadequate dietary intake and diarrhealdisease. Several findings suggest that the increased risk for nutritional deficiencies, such aslow height-for-age and anemia, are related to inadequate diet-ary intake rather than todiarrheal disease. Although few data are available, one study in Sao Paulo documents adecrease in the prevalence of diarrhea, and diarrhea-related ieaths between 1973-74 and1984-85 (Monteiro, 1988). During this same period, however, the cost of food relative towages rose sharply (Becker, 1988; Monteiro, 1988). The increasing incidence of LBW is

13/ A similar relationship between prenatal visits and mortality risk exists in the U.S., evenwhen length of gestation has been controlled. As in Brazil, however, the specificcomponents of prenatal care responsible for this relationship are not known.

52 ANNEX 1

further indication of inadequate dietary intake. Increases in the incidence of anemia areconsistent with a decline in overall quality and quantity of food.

PREGNANT AND LACTATING WOMEN

Anemia

58. The most comprehensive data on iron status during pregnancy come from a studyof women receiving care through the Programa de Atendimento a Gestante in Sao Paulo(Szarfarc, 1985). This program serves an estimated 20 percent of all pregnant women in thestate, and is a particularly important source of care for women at risk of anemia because oflow socioeconomic status, poor diet, and parasitic infections. Analysis of more than 4,000blood samples taken between 1977 and 1981 in 15 clinics during the patient's first visit(occurring from the first to last month of pregnancy) showed that 35 percent of all womenwere anemic, although the proportion ranged from 6.3 percent to 65.2 percent depending onthe clinic sampled 14/. Mean hemoglobin levels were highest during the first month ofpregnancy (12.7 g/dl) and fell consistently until the eighth month (11.0 g/dl). Widespreadanemia and risk factors for anemia were also found in a small study of pregnant women(Table 23). An inverse relationship between the prevalence of anemia and income was alsoshown: low-income women were more than twice as likely to be anemic as medium-low andmedium income women (Martins et al. 1987). Dietary data from the 1974-75 ENDEF areconsistent with clinical data; they show a substantial proportion of families with pregnant andlactating women to be at-risk for inadequate iron intake (Table 24). As was the case forfamilies with children, urban families with pregnant and lactating women are more likely tohave poor iron intake than rural families.

59. Even when iron supplements are provided during pregnancy, however, post-partumanemia can be a problem, as a result of either inadequate levels of supplementation or failureto use the supplements. In one study for example 15/ low-income women who received25-65 mg/day of supplemental iron during the latter half of pregnancy were anemic(Donangelo et al., 1989). Although the authors suggest that the level of supplementation wasinadequate to meet the demands of pregnancy and lactation, they provide no data to showthat women actually consumed the supplements provided. Poor compliance with thesupplemental regime could explain their finding and points to the need to assess complianlcein any supplementation program. Understanding the reasons for failure of ironsupplementation to prevent post-partum anemia would help define how futuresupplementation programs could be more effective.

14/ Anemia during pregnancy was defined as hemoglobin less than 1 1g/dI as suggested byWHO.

15/ Defined for nonpregnant women as less than 12 g/dl.

53 ANNEX 1

60. Among these same women, no relationship was found between maternal bloodlevels of zinc, folate, and vitamin B12 and concentrations of these nutrien,ts in breastrnilk,despite the risk of poor status observed in some women (Donangelo et al., 1989). Low zincintake was reported in a group of lactating Amazon women, and balance studies showedadaptation to a chronically low intake (Jackson et al. 1988).

Weight Gain during Pregnancy

61. The mean weight gain during pregnancy of 12.3 +4.5 kg (mean + SD) among 83low-income women at the maternity ward of a public hospital in Rio de Janeiro (Donangeloet al., 1989) compares favorably with U.S. figures. This weight gain resulted in a meanbirthweight of 3277 grams. In Pelotas, mean weight gain was 3202 gramis.

62. Maternal nutritional status during pregnancy can be evaluated indirectly byexamining data on the incidence of LBW. The increasing incidence of L]BW among poorwomen associated with the economic recession is indicative of inadequate dietary intakeduring pregnancy. Further support for this observation comes from results of asupplementary feeding program during pregnancy, which shciws a lower incidence of LBWamong women who participated for at least one month (Monte and Lechtig, 1987).

Maternal Arm Circumference

63. A representative study carried out in Ceara measured the arm circumference ofwomen ages 15-49. Using a cut-off of less than 23.5 cm to classify womLen as malnourished,21.3 percent and 24.9 percent of the urban and rural women, respectively weremalnourished 16/ (Table 25). In addition, younger women were more likely to bemalnourished, which is of particular concern since they also have higher fertility rates thanolder women.

SUMMARY OF MAJOR NUTRITIONAL PROBLEMS AND IMPLICATIONSFOR NUTRITION PROGRAMIS

64. Analysis of nutritional problems from both represenitative surveys and small studiesof low-income populations shows that:

a. Although malnutrition has declined substantially over the past15 years, chronic malnutrition that results in stunting is a

16/ This cut-off point differs from that recently agreed upon at a WHO meeting on maternalanthropometry. A cut-off of 21 cm was suggested, which if used on the data from Cearawould put fewer women at-risk.

54 ANNEX 1

significant problem. In addition to stunting, wastingcontinues to be a problem in infants.

b. Infants and children under the age of three years are atgreatest risk for malnutrition. Deficits in height relative toage increase rapidly during the first three years of life andthen plateau. This is also the age group at greatest risk ofdiarrheal disease.

c. Children in the Northeast are at greatest risk. Malnutrition isnot only most common among these children, it declinedmore slowly between the 1974-75 ENDEF and the 1989PNSN than among children in other regions.

d. Iron deficiency anemia is a major public health problem andis related to both the quantity and the quality of foodsprovided. Age-specific risk patterns for anemia are similar tothose for malnutrition. The prevalence of anemia hasincreased over time, suggesting that dietary quantity and/orquality has deteriorated. Anemia during pregnancy appears tobe a public health problem and merits further study.

e. Vitamin A deficiency is also a major public health problem among allincome groups, which suggests that income is not the only constraint toadequate intake and that broad nutrition education and/or foodfortification programs aimed at improving consumption of foods rich invitamin A should be considered.

f. Programs to promote breastfeeding have been more successfulin increasing the number of women who initiate breastfeedingthan in extending the time they nurse. These programs havealso been more successful among relatively low-risk mothersand infants. Thus, programs to help low-income womennurse their babies should be considered.

g. While overall infant mortality continues to decline, infant mortality dueto malnutrition and prematurity/LBW may have increased slightly inthe early 1980s. In addition the incidence of LBW appears to haveincreased among low-income women. These findings indicate thatmaternal health care and supplementary feeding programs duringpregnancy and lactation continue to be important interventions.

55 ANNEX 1

Implications for Nutrition Programs

65. Risk factors for malnutrition point to the importanice of targeting specific agegroups and geographic regions. Infants and children 6-36 months and pregnant and lactatingwomen are at greatest risk and should receive the highest priority in supplementary feedingprograms. Low-income children in the Northeast should also be considered high priority.

66. To address the problems of anemia and hypovitarninosis A, consideration could begiven to the fortification of milk or another common food vith iron and vitamin A.Nutrition education campaigns to promote the consumption of vitamins A and C and toincrease dietary diversity could also be considered. In addition to the promotion ofbreastfeeding, specific educational campaigns on appropriate and feasible infant feedingpractices should be considered.

67. Areas where data are inadequate to assess risk., Data on children focus on thoseunder age five. Hence, little information is available to assess the nutritional status ofchildren between the ages of five and six years. This age group is particularly importantbecause it is the age at which children in Brazil begin school. Because nutritionaldeficiencies such as anemia may be causally linked to poor cognitive development,information on iron status among this age group is particularily important.

68. Information on the nutritional status of pregnant and lactating women is extremelylimited. However, available data suggest that iron deficiency anemia is widespread.Programs to monitor the iron status of pregnant women and to assess the inpact of ironsupplementation during pregnancy are needed in order to formulate public health policy inthis area.

69. Need for operational research. In general, operational research is needed todetermine the amount and kind of supplements that should be provided and the setting inwhich they can be most efficiently distributed. Operational research is also needed todetermine the most effective way to fortify foods to combat micronutrienit deficiencies.

56 ANNEX 1

Table 1. Prevalence of stunting among childrenunder five years, by sex, region, and urban/rural, 1989 (PNSN)

Category Sample size Total Urban Rural

By sex:Female 3,717 16.3Male 3,597 14.5

By region:North 1,000 23.0 23.0 N.A.Northeast 2,080 27.3 23.9 30.7Southeast 1,397 8.1 7.2 12.7South 1,379 8.7 7.0 11.7Centerwest 1,458 8.2 7.4 10.2

Total 7,314 15.4 12.3 22A

Note: Stunting refers to the proportion of under five-years olds with height-for-ageindices < -2 z-scores, NCHS/WHO standards.

Source: 1989 PNSN survey, reported in Monteiro, 1994.

57 . ANNEX 1

Table 2. Prevalence of low weight-.and height-for-age among children, Brazil 1980-86

Weight Heightfor age for age

age <75% < 90%Age (Gomez (Waterlow

Year Sample N Location (yrs) II, III) stunting) Reference

1984 not reported 701 urban <5 17.0 28.0 Rees, 1987Ceara, NE

1986 cluster 241 urban <6 7.1 12.0 Molina,Belo Horizonte 1989

1984/85 random 1013 urban <5 4.6 N.A. Monteiro,Sao Paulo 1986

not children in 4 312 urban <3 23.0 28.0 Lima, 1990*reported communities Recife

1985 stratified 1274 urban rural <5 4.8 6.0 Ferreira,random Rondonia 1988

1980-84 clinic -4000 urban <2 5.1 5.7 Gross, 1987records Rio de Janeiro

* weight-for-age data reported as 10th percentile, which corresponds to less than 80%.Height-for-age data reported as less that the 10th percentile.

58 ANNEX 1

Table 3. Changes in the prevalence of underweight among children underfive years by region, 1974-75 (ENDEF) and 1989 (PNSN)

Sample Size Underweight Children (Percent)

Region 1974 survey 1989 survey 1974 survey 1989 survey Percent change

North* 2,967 1,020 24.5 10.6 -57

Northeast 13,020 2,125 27.0 12.8 -53

Southeast 11,665 1,430 13.4 4.1 -69

South 5,660 1,405 11.7 2.5 -79

Center-West** 3,095 1,486 13.3 4.1 -69* Only urban areas in the 1974 and 1989 surveys.** Only urban areas in the 1974 survey.

Note: Underweight refers to the proportion of under five-year olds with weight-for-age indices< -2 z-scores, NCHS/WHO standards.

Source: 1974/75 ENDEF and 1989 PNSN Surveys, reported in Monteiro, 1994.

Table 4. Changes in the prevalence of underweight children inthe urban and rural population, 1974-75 (ENDEF) and 1989 (PNSN)

Underweight Children (Percent)

Region 1974 survey 1989 survey Percent change

Urban 14.6 5.6 -62North 24.5 10.6 -57Northeast 22.9 10.3 -58Southeast 10.7 3.7 -67South 10.3 2.1 -80Center-West 13.3 3.8 -71

Rural 22.9 10.6 -54Northeast 29.6 15.2 -49Southeast 19.3 6.2 -68South 12.6 3.0 -76Center-West N.A. 4.9 N.A.

Note: Underweight refers to the proportion of under five-year olds with weight-for-age indices< -2 z-scores, NCHS/WHO standards.

Source: 1974/75 ENDEF and 1989 PNSN Surveys, reported in Monteiro, 1994.

59 ANNEX 1

Table 5. Prevalence of low height-for-age among children < 5 yearsNortheast 1974-75 (ENDEF) to 1986 (PNSMIPF)

Height-for.-age<90%(Waterlow stunting)

Urban 1973-74 1986

0-5 months 4 60-60 months 24 12

Rural

0-5 months 10 80-60 months 35 22

Source: Thomas et al., 1988.

60 ANNEX 1

Table 6. Changes in indicators of nutritional status over time:results of four studies

AgeYears Sample Location (yrs) Conclusion Reference

1980-83 Clinic urban <2 No change in the Gross,records Rio de Janeiro prevalence of 1987

malnutrition as measuredby Gomez and Waterlowclassifications, exceptfor a decline in wasting

1974-75 random Paraiba, NE <11 At each age the Benigna,(ENDEF) sample of prevalence of 1987to 81-82 7,990 in malnutrition among

1981-82 children in Paraiba in1981-82 (as measured bylow weight- andheight-for-age) isgreater than that ofrural NE children in1974-75

1973-74 random urban <5 No change in the Monteiro,to 84-85 Sao Paulo prevalence of 1986

malnutrition as measuredby Gomez classification

1974-75 stratified urban and <5 Sharp declines in the Ferreira,(ENDEF) random rural prevalence of 1988to 1985 Rondonia malnutrition as measured

by Gomez and Waterlowclassifications.Prevalence of second andthird degreemalnutrition declinedfrom 21.7 to 4.8 andprevalence of stuntingdeclined from 24.9 to 6.0among children inRondonia compared to NEchildren sampled in ENDEF

61 ANNEX 1

Table 7. Age-specific risk patterns for low wewight-for-ageamong children <5 years, PNSN 1989

Weight-for -age Weight- for -age Weight-for-age>75-90% <60-75% <90% (Gomezl,

Age (Months) (Gomez I) (Gomez II, IIi) II and III)

0-6 15.8 6.0 21.86-12 19.7 6.7 26.412-24 26.3 5.4 31.724-60 27.9 4.6 32.5Total 25.6 5.1 30.7

Source: INAN, Pesquisa Nacional Sobre Saude e Nutricao: ResultadosPreliminares, March 1990.

Table 8. Infants and children under five withdiarrhea in previous two weeks by region andage, PNSN 1989

Diar rhea (%)

Region

North 12.3Northeast 15.2Southeast 8.0South 6.0Center- 8.7West

Urban/Rural

Urban 9.9Rural 11.6

Age (months)

0< age <=6 9.96<age<=12 19.712< age <= 18 17.618< age <= 24 13.624< age <= 36 8.536< age <= 48 7.748 <age< 60 6.1

Source: tabulations from 1989 PNSN. Observationsare weighted with IBGE expansion weights to benationally representative.

62 ANNEX 1

Table 9. Risk patterns for diarrhea among children < 5 years byage, sex, region, and mother's education, PNSMIPF 1986

Diarrhea (%)Age (months) Previous 24 hours Previous 2 weeks n

1-5 12.3 21.9 2926-11 9.6 25.3 31512-23 12.5 26.7 57824-35 8.3 17.7 61536-47 4.3 10.5 75248-59 2.8 8.2 654

Sexmale 7.3 17.2 1,649female 7.7 16.4 1,556

Urban/Ruralurban 7.1 15.0 2,170rural 83 20.6 1,035

RegionRio de Janeiro 7.7 15.2 255Sao Paulo 5.2 11.0 612South 3.7 13.6 546Central East 8.0 17.4 457Northeast 9.7 21.0 1,144North, Central West 10.5 20.7 191

Education (years)0 9.4 22.7 428<primary 9.6 20.5 971primary 6.9 16.0 555>primary 5.4 12.3 1,251

Brazil 7.5 16.8 3,205

Source: PNSMIPF 1987.

63 ANNEX 1Table 10. Diarrheal morbidity and mortality for childre:n under 20 months of age,

by family income, Pelotas 1982-84

Family Income (numbers of minimum salaries)1982-84 <=1 >1-3 >3-6 >6-10 >10 total

Mortality (/1000) 13.9 3 0 0 0 4.5Hospitalized 15.9 9 6.1 1.3 1.8 8.9Ill in previous month 30.7 26.6 24.6 18.3 21.1 26.2N 1228 2789 1091 382 335 5885

Source: Victora et al., not dated.

Table 11. Distribution of families with children 1-5 years and/or lactating womenby lowest and highest income quartile, ENDEF 1974-75

Families with children Families with pregnant1-5 years of age and/or lactating women

Income Quartile Income QuartileRegion lowest* highes;t lowest highest

Northeastrural 36 13 37.4 13.7urban 36 14 43.4 11.1

Sao Paulorural 39 13 47.4 10.5urban 42 13 47.2 12.9

Source: IBGE 1982, pgs 56-57.

Note: Income quartiles per region, which represent 25% of all households sampled.

64 ANNEX I

Table 12. Age-specific risk pattems for anemia among children <5 years

Anemia (Hbg < 1lg/dl) Severe anemia(Hbg<9.5g/dl)

Age Sao Paulo, 1984-85*77 Recife, 1985** Sao Paulo, 1984-85*(mo.) low-income, urban low-income urban low-income urban

stable employment unstable employment

% n % n % n % n0-6 34.7 (75) (N/A) (N/A) (N/A) (NIA) 16.0 (75)6-12 53.7 (82) 41.1 (129) 76.0 (129) 26.8 (82)12-24 58.1 (186) 51.0 (149) 77.4 (195) 28.0 (186)24-36 32.0 (206) 20.5 (132) 54.2 (131) 11.6 (206)36-48 26.1 (199) 14.1 (128) 25.0 (100) 6.5 (199)48-60 17.7 (164) 7.7 (104) 13.9 (109) 6.7 (164)Total 35.6 (912) 28.3 (642) 55.1 (66) 14.7 (912)

* Monteiro and Szarfarc, 1987.** Salazno et al, 1985.

Table 13. Percent of childiets that fail to meet recommendedintakes of selected nutrients, Sao Paulo, 1984-85

Age (months) n energy protein iron vitamin A

0-6 33 12% 6%o 97% 3%6-12 25 4 4 60 012-24 67 37 5 49 1224-36 68 54 0 42 1336-48 59 49 5 34 1248-60 53 49 0 38 13

Source: Compiled fom data presented in Szarfarc et al., 1988.

65 ANNEX I

Table 14. Changes in the prevalence of anemia among childrenunder five in urban Sao Paulo, 1973-74 to 1984-85

Year N Anemia Severe Anemia(Hbg< 1 lg/dl) (Hbg<9.5g/d1)

1973-74 278 22.7 6.11984-85 837 35.5 14.6

Source: Monteiro and Szarfarc, 1987.

Table 15. Proportion of families (with children 1-5 years) with diets that fail to meetrecommended intakes of Vitamin A, ElNDEF 1974-75

Recommended Northeast Sao PauloIntake (percent)

Urban Rural Urban Rural

<50 57.7 68.8 38.2 66.1>=50-75 13.8 8.8 23.5 16.9>75-100 8.3 5.6 14.5 6.4Total<100 74.8 83.2 76.2 89.4

Source: IBGE 1982, pg. 185.

66 ANNEX 1

Table 16. Proportion of infants currently being breastfed,by age, region, and rural/urban, 1989 PNSN

Age of Infant Proportion Number of(in months) Currently Breastfed Observations

0< age <=3 0.84 4243 < age <= 6 0.50 3246 < age <= 9 0.43 3219 < age <= 12 0.39 358

Region 1/

North 0.68 187Northeast 0.53 359Southeast 0.57 265South 0.55 239Center-West 0.60 264

Urban/Rural 1/

Urban 0.54 812Rural 0.61 502

Source: tabulations from 1989 PNSN. Prevalence estimates are weighted witIBGE expansion weights to be nationally representative. The number ofunweighted observations in each category is shown in the table.

1/ For all children under 12 months of age.

67 ANNEX 1

Table 17. Median duration of breastfeeding in months byfamily income, Sao Paulo, 1973-74 to 1984-85

Year low low/middle middle middle/high high

1973-74 1.7 1.0 0.9 0.9 0.8(n=100) (n=100) (n=100) (n=100) (n=100)

1984-85 3.8 3.1 3.1 41.2 3.2(n=224) (n=261) (n=109) (n=59) (n=66)

Source: Monteiro, 1987.

Table 18. Cause-specific changes in infant mortality

Infant Reduction in mortality attributable to:Mortality

Rate breast-Cause 1980 1987 overall(a) feeding (b) b/a

diarrhea 10.7 2.9 72.8 32.3 0.4respiratory infections 12.2 6.5 47.2 22.3 0.5other infectious disease 2.9 1.9 34.0 17.7 0.5other causes 29.3 25.6 14.5 0.0 0.0all causes 55.2 36.9 49.4 11.8 0.2

Source: Monteiro et al., 1988.

Table 19. Trends in infant mortality by geographic region*, 1979-86

Region Infant mortality Rate1979 1980 1981 1982 1983 1984 1985 1986

North 119 103 90 87 90 96 88 82Northeast 110 101 90 84 88 88 72 71Southeast 55 49 48 46 41 45 37 36South 45 39 33 32 32 32 30 27Central West 54 46 44 41 41 37 35 31

* Estimates are for urban centers only.Source: Becker, 1988.

68 ANNEX 1

Table 20. Cause-specific infant mortality rate, Northeast 1977-85

Cause

Year Diarrhea Acute Respiratory LBW/Prematurity Malnutrition InfectiousInfections Diseases

1977 42.7 14.9 9.2 3.8 1.81978 49.2 12.8 6.9 3.8 1.81979 46.4 12.2 7.2 3.9 2.01980 44.6 11.3 7.1 4.8 1.91981 41.4 12.6 6.1 4.6 2.01982 38.9 12.7 4.8 4.3 1.31983 38.4 11.9 5.1 4.6 2.21984 33.9 13.2 6.8 5.6 2.11985 30.0 12.6 13.7 7.7 1.5

Source: Becker 1988, pg. 273.

Table 21. Infant and child mortality from malnutrition, Sao Paulo 1979-84

Infant mortality Child mortality (1 -4yrs)

year malnutrition all causes malnutrition all causes

1979 2.65 57.9 ** 5.49 *** (N/A)1980 2.17 50.6 4.95 1.50 *1981 2.01 49.3 5.32 1.331982 2.06 47.9 4.69 1.271983 2.19 41.5 5.69 1.021984 3.19 48.4 8.55 1.31

*deaths /100,000 live births

* deaths /1,000 live births*** deaths /100,000 children -4years*** deaths / 1,000 children 1-4 years

Source: Becker 1988, pg. 301.

69 ANNEX 1

Table 22. Trends in incidence of low birthweight by trpe of hospital,Northeast 1980-87

Fortaleza Recife

Maternity Maternityhospital Hospital State Social

Maternity serving serving hospital Securityhospital urban more serving Hospitalserving periphery, middle low serving Private

lowincome low income income income formal sector MaternityYear clients clients patients clients workers Hospital

1980 7.4 7.1 5.4 11.0 8.3 4.21981 13.0 9.1 6.4 10.9 11.0 3.01982 19.5 11.3 5.8 10.9 10.9 4.51983 23.1 11.5 5.9 12.8 10.8 4.21984 19.0 7.8 5.2 15.1 14.8 3.81985 21.8 5.8 4.9 13.7 1986 14.3 4.7 4.7 14.8 --

Source: From data presented in Batista Filho, 1988.

Table 23. Prevalence of anemia among pregnant woimen(>36 weeks gestation) by income

Income N Anemia At-risk for(Hbg<11g<Cdl) anemia*

low 29.0 41.4 34.5medium low 90.0 16.7 28.9medium 23.0 8.7 38.4

Source: Martins et al., 1987.

* defined as serum iron < 90mg/dl and transferrin saturation <25%

70 ANNEX 1

Table 24. Proportion of families with pregnant and/or lactating women whose dietsthat do not meet recommended intake of iron, ENDEF 1974-75

Recommended Intake Northeast Sao Paulo(percent) urban rural urban

<50 0.8 0.3 2.7>=50-75 8.2 4.3 13.0>75-100 18.8 11.3 19.7total 27.8 15.9 35.4

Source: IBGE 1982, pg 237.

Table 25. Prevalence of malnutrition in women (15-49) years in Cearaby urban rural location and age, 1988

Arm circumference <23.5 cm (%) Total n

RegionFortaleza 21.3 2188.0Interior 24.9 6425.0

Age (years)15-19 37.2 1760.020-24 27.4 1734.025-29 20.3 1423.030-34 18.6 1108.035-39 17.4 1118.040-44 17.4 788.045-49 15.0 655.0

Total 23.9 8586.0

Source: Victora and Barros, 1989.