ABSTRACT

Objective:

To select indicators of the Sustainable Development Goals (SDGs) that determine child malnutrition (CM) in Brazil and to monitor the achievement of SDG targets by region in 2022.

Methods:

This is a cross-sectional, ecological study that used the Brazilian Sustainable Development indices and analyzed the 100 SDG monitoring indicators in the 5,570 Brazilian municipalities. A decision tree was created and sensitivity analysis was performed to predict CM determinants. Data were analyzed using the χ² test at 5% significance level. Descriptive analyses and the decision tree were carried out using the R software.

Results:

The CM determinants according to percentage, most affected regions of the country, and impact order were: illiteracy in the population aged ≥15 years (Northeast), insufficient prenatal care (North), low birth weight (South), young women aged 15-24 years who neither study nor work (North and Northeast), and employed population aged 10-17 years (South). We observed an individual and cumulative effect on the CM prevalence, ranging from 1.73 to 15.1%, in Brazilian municipalities according to the occurrence and overlap of these indicators.

Conclusion:

The results denote that Brazil will not achieve the intended reduction of CM by 2025. There must be substantial investments in education and health mainly aimed at the maternal and child population and especially in the North and Northeast regions.

Keywords:
Child nutrition disorders; Sustainable development; Social determinants of health; Maternal and child health

INTRODUCTION

Child malnutrition (CM) is characterized by a deficiency of basic nutrients that culminates in weight and height deficits¹1 Xavier DSS, Rodrigues NA, Souza IMC, Franco CASO, Santiago MCF. Levantamento epidemiológico de óbitos infantis por desnutrição no Brasil e revisão bibliográfica da atuação do estado e da pastoral da criança no combate a desnutrição infantil. Rev Saúde Mult 2022; 11(1): 98-105. https://doi.org/10.53740/rsm.v11i1.392
https://doi.org/10.53740/rsm.v11i1.392... , and is considered a public health issue in middle- and low-income countries²2 Büttner N, Heemann M, De Neve JW, Verguet S, Vollmer S, Harttgen K. Economic growth and childhood malnutrition in low- and middle-income countries. JAMA Netw Open 2023; 6(11): e2342654. https://doi.org/10.1001/jamanetworkopen.2023.42654
https://doi.org/10.1001/jamanetworkopen.... . Indices — such as weight for age (W/A) and height for age (H/A) — were adopted by the United Nations (UN) for the diagnosis of CM, with W/A being a measure of recent nutritional status and H/A, a history of nutrition and health conditions since birth, making them important requirements for assessing the country's socioeconomic and political situation³3 Brasil. Presidência da República. Governo da República Federativa do Brasil. Objetivos de desenvolvimento do milênio: relatório nacional de acompanhamento. Brasília: Ipea; 2014.

4 Roma JC. Os objetivos de desenvolvimento do milênio e sua transição para os objetivos de desenvolvimento sustentável. Cienc Cult 2019; 7(1): 33-9. https://doi.org/10.21800/2317-66602019000100011
https://doi.org/10.21800/2317-6660201900... -⁵5 Ribeiro-Silva RC, Silva NJ, Felisbino-Mendes MS, Falcão IR, Andrade RCS, Silva SA, et al. Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017. Public Health Nutr 2022; 25(12): 1-11. https://doi.org/10.1017/S1368980021004882
https://doi.org/10.1017/S136898002100488... .

In 2000, the Millennium Development Goals (MDGs) were established by UN member states, and one of the targets was to reduce the global prevalence of stunting in children aged <5 years by half, by the year 2015³3 Brasil. Presidência da República. Governo da República Federativa do Brasil. Objetivos de desenvolvimento do milênio: relatório nacional de acompanhamento. Brasília: Ipea; 2014.. Since then, food and nutritional security has become the target of public policies to combat poverty and CM in Brazil⁶6 Pike V, Bradley B, Rappaport AI, Zlotkin S, Perumal N. A scoping review of research on policies to address child undernutrition in the Millennium Development Goals era. Public Health Nutr 2021; 24(13): 4346-57. https://doi.org/10.1017/S1368980021001890
https://doi.org/10.1017/S136898002100189... , and the prevalence of CM has reduced from 13.5% in 1996 to 6.8% in 2007 — attributed to the expansion of health coverage, education, sanitation, and increased family income⁷7 Monteiro CA, Benicio MHDA, Konno SC, Silva ACF, Lima ALL, Conde WL. Causas do declínio da desnutrição infantil no Brasil, 1996-2007. Rev Saúde Pública 2009; 43(1): 35-43..

Following the success in achieving many MDGs targets, in 2012, the 2030 Agenda was established, with 17 Sustainable Development Goals (SDGs), in force as of 2016⁸8 Organização das Nações Unidas. Objetivos de Desenvolvimento Sustentável. Transformando nosso mundo: a Agenda 2030 para o Desenvolvimento Sustentável [Internet]. 2015 [cited on Feb. 15, 2024]. Available at: https://brasil.un.org/sites/default/files/2020-09/agenda2030-pt-br.pdf
https://brasil.un.org/sites/default/file... ,⁹9 Organización Mundial de la Salud. Metas mundiales de nutrición 2025. Serie de documentos normativos [Internet]. Geneva: OMS; 2014 [cited on Mar. 14, 2024]. Available at: https://iris.who.int/bitstream/handle/10665/255736/WHO_NMH_NHD_14.2_spa.pdf?sequence=1
https://iris.who.int/bitstream/handle/10... . One of the international targets is to end all forms of malnutrition by 2030, and to achieve the international targets on stunting (reduce it by 40%) and underweight (reduce it and maintain <5%) in children aged <5 years by 2025⁹9 Organización Mundial de la Salud. Metas mundiales de nutrición 2025. Serie de documentos normativos [Internet]. Geneva: OMS; 2014 [cited on Mar. 14, 2024]. Available at: https://iris.who.int/bitstream/handle/10665/255736/WHO_NMH_NHD_14.2_spa.pdf?sequence=1
https://iris.who.int/bitstream/handle/10... . National targets were adjusted by Brazilian experts to H/A <3%¹⁰10 Instituto de Pesquisa Econômica Aplicada. Agenda 2030: ODS - metas nacionais dos objetivos de desenvolvimento sustentável [Internet]. 2018 [cited on Mar. 14, 2024]. Available at: https://portalantigo.ipea.gov.br/agencia/images/stories/PDFs/livros/livros/180801_ods_metas_nac_dos_obj_de_desenv_susten_propos_de_adequa.pdf
https://portalantigo.ipea.gov.br/agencia... ,¹¹11 Fuller G. Índice de Desenvolvimento Sustentável das Cidades. Metodologia [Internet]. 2022 [cited on Mar. 18, 2024]. Available at: https://idsc-sp.cidadessustentaveis.org.br/static/Metodologia.pdf
https://idsc-sp.cidadessustentaveis.org.... . It should be noted that low W/A is an acute condition that can change frequently and rapidly, which makes it difficult to generate reliable trends over time¹²12 UNICEF. Briefing notes on SDG: global indicators related to children [Internet]. 2024 [cited on Apr. 02, 2024]. Available at: https://data.unicef.org/resources/briefing-notes-on-sdg-global-indicators-related-to-children/
https://data.unicef.org/resources/briefi... , while stunting refers to a chronic condition, regardless of the child's ethnicity, socioeconomic status, and type of feeding¹³13 United Nations. SDG indicator metadata [Internet]. New York: Department of Economic and Social Affairs; 2024 [cited on Aug. 13, 2024]. Available at: https://unstats.un.org/sdgs/metadata/files/Metadata-01-01-01b.pdf
https://unstats.un.org/sdgs/metadata/fil... .

The socioeconomic and political crisis that took place in the country in 2014 impacted the increase in poverty, the adoption of tax austerity measures, the increase in food prices, and the reduction of social protection measures for the most socioeconomically vulnerable groups, contributing to the increase in CM¹⁴14 Gouveia AVS, Carvalho RES, Correia MEG, Silveira JAC. Temporal trend in the prevalence of malnutrition in children under five assisted by the Brazilian Income Transfer Program (2008-2019). Cad Saude Publica 2024; 40(1): e00180022. https://doi.org/10.1590/0102-311XPT180022
https://doi.org/10.1590/0102-311XPT18002... . In 2019, the prevalence of stunting reached 13.4%, reducing to 11.7% in 2022, with the lowest prevalence values observed in the South (9%) and Southeast (11.5%), and the highest in the North (15.4%) and Northeast (12.9%), according to data from the Food and Nutrition Surveillance System (Sistema de Vigilância Alimentar e Nutricional - SISVAN)¹⁵15 Brasil. Ministério da Saúde. Sistema de Vigilância Alimentar e Nutricional. Sistema de Vigilância Alimentar e Nutricional - SISVAN [Internet]. [cited on Apr. 05, 2024]. Available at: https://sisaps.saude.gov.br/sisvan/
https://sisaps.saude.gov.br/sisvan/... . This system presents data on the population served by Primary Health Care (PHC) and beneficiaries of income transfer programs⁵5 Ribeiro-Silva RC, Silva NJ, Felisbino-Mendes MS, Falcão IR, Andrade RCS, Silva SA, et al. Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017. Public Health Nutr 2022; 25(12): 1-11. https://doi.org/10.1017/S1368980021004882
https://doi.org/10.1017/S136898002100488... , as nutritional monitoring is part of their conditionalities¹⁶16 Silva RPC, Vergara CMAC, Sampaio HAC, Vasconcelos Filho JE, Strozberg F, Ferreira Neto JFR, et al. Food and Nutrition Surveillance System: temporal trend of coverage and nutritional status of adults registered on the system, Brazil, 2008-2019. Epidemiol Serv Saude 2022; 31(1): e2021605. https://doi.org/10.1590/S1679-49742022000100019
https://doi.org/10.1590/S1679-4974202200... .

There is a need to monitor SDG indicators to achieve the target of reducing CM by 2025, as it is a persistent problem in Brazil. Furthermore, CM presents regional disparities and consists of a complex process influenced by intrinsic (physiological) and extrinsic (food, housing, environment, family income, parents' education and access to goods, essential services¹⁷17 Pedraza DF, Oliveira MM. Nutritional status of children and health services provided by Family Health teams. Cien Saude Colet 2021; 26(8): 3123-34. https://doi.org/10.1590/1413-81232021268.14582020
https://doi.org/10.1590/1413-81232021268... , and maternal and child care¹⁸18 Garcia LRS, Roncalli AG. Socioeconomic and health determinants of child malnutrition: an analysis of spatial distribution. Saúde e Pesquisa 2020; 13(3): 595-606. https://doi.org/10.17765/2176-9206.2020v13n3p595-606
https://doi.org/10.17765/2176-9206.2020v... ) causes that integrate several SDG indicators¹⁹19 Amaral LR, Oliveira MAD, Cardoso RB, Ávila SPAR. Atuação do enfermeiro como educador no programa saúde da família: importância para uma abordagem integral na atenção primária. In: Seminário Internacional de Pesquisa e Educação em Enfermagem; 2011. p. 1-21.. In Brazil, there are no studies whose authors have investigated the interactions between SDG indicators and the prevalence of CM.

The application of robust statistical methods, such as decision and regression trees (DRT)²⁰20 Breiman L, Friedman J, Olshen RA, Stone CJ. Classification and regression trees. New York: Chapman and Hall/CRC; 1984., enables to identify the interaction of different factors with the prevalence of CM. From this analysis, we can identify the SDG indicators that determine CM in children aged <5 years in Brazilian municipalities as well as its individual and cumulative effects on this prevalence.

In this study we aimed to select the SDG indicators that determine CM in Brazil using the DRT in 2022 and monitor the achievement of CM targets, by region. The findings of this study may provide information that guides decision-making in the implementation of social and health public policies.

METHODS

This is an ecological study with the use of data from the Sustainable Development Index of Cities — Brazil (Índice de Desenvolvimento Sustentável das Cidades - IDSC-BR) to monitor the implementation of the SDGs. IDSC-BR uses data produced by national sources, such as the Brazilian Institute of Geography and Statistics (IBGE), the Department of Informatics of the Brazilian Unified Health System (Datasus), the Anísio Teixeira National Institute of Studies and Educational Research (Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira - INEP), the Institute for Applied Economic Research (Instituto de Pesquisa e Economia Aplicada - Ipea); information-producing agencies; and executors of government policies linked to the UN¹¹11 Fuller G. Índice de Desenvolvimento Sustentável das Cidades. Metodologia [Internet]. 2022 [cited on Mar. 18, 2024]. Available at: https://idsc-sp.cidadessustentaveis.org.br/static/Metodologia.pdf
https://idsc-sp.cidadessustentaveis.org.... . The data used in this study were published in 2022 and are available on the IDSC-BR website (https://www.cidadessustentaveis.org.br/).

In this study, the 5,570 Brazilian municipalities²¹21 Instituto Brasileiro de Geografia e Estatística. Prévia da população calculada com base nos resultados do Censo Demográfico 2022 até 25 de dezembro de 2022 [Internet]. 2022 [cited on Mar. 14, 2024]. Available at: https://ftp.ibge.gov.br/Censos/Censo_Demografico_2022/Previa_da_Populacao/POP2022_Brasil_e_UFs.pdf
https://ftp.ibge.gov.br/Censos/Censo_Dem... were evaluated by the 100 indicators of the 17 SDGs, including CM, whose data come from SISVAN⁵5 Ribeiro-Silva RC, Silva NJ, Felisbino-Mendes MS, Falcão IR, Andrade RCS, Silva SA, et al. Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017. Public Health Nutr 2022; 25(12): 1-11. https://doi.org/10.1017/S1368980021004882
https://doi.org/10.1017/S136898002100488... . The dependent variable was the prevalence of CM in children aged <5 years, measured by the H/A index, while the independent variables were the other 99 SDG indicators (Chart 1).

According to IDSC-BR, the recommended nomenclature and categorization for SDG indicators are: target value (represented by the color green), green threshold (in yellow), red threshold (in orange), and lower threshold (in red). It also considers achieved targets to be the combination of the target value and green threshold, which were, didactically, represented in this study only by the color green; and unachieved targets to be the combination of the red threshold and the lower threshold, represented by the color red¹¹11 Fuller G. Índice de Desenvolvimento Sustentável das Cidades. Metodologia [Internet]. 2022 [cited on Mar. 18, 2024]. Available at: https://idsc-sp.cidadessustentaveis.org.br/static/Metodologia.pdf
https://idsc-sp.cidadessustentaveis.org.... . The values established by the SDGs to assess the prevalence of CM were: <1% (target value); 1 to <3% (green threshold); 3 to <5% (red threshold); and ≥5% (lower threshold)¹¹11 Fuller G. Índice de Desenvolvimento Sustentável das Cidades. Metodologia [Internet]. 2022 [cited on Mar. 18, 2024]. Available at: https://idsc-sp.cidadessustentaveis.org.br/static/Metodologia.pdf
https://idsc-sp.cidadessustentaveis.org.... (https://www.cidadessustentaveis.org.br/methodology).

In the descriptive analysis, categorical variables were presented in absolute and relative frequencies, while continuous variables were presented as means and standard errors of the sample mean (SE).

To select the indicators determining the prevalence of CM, the DRT was used²⁰20 Breiman L, Friedman J, Olshen RA, Stone CJ. Classification and regression trees. New York: Chapman and Hall/CRC; 1984.. Once the tree was created, the sensitivity to predict the main independent variables determining CM was calculated. DRT is a method that divides data into segments that are as homogeneous as possible in relation to the outcome variable (prevalence of CM). A node is considered homogeneous when all cases have the same value for the outcome based on a specific determinant²⁰20 Breiman L, Friedman J, Olshen RA, Stone CJ. Classification and regression trees. New York: Chapman and Hall/CRC; 1984.. The χ² test was performed to verify the statistical significance of these correlations and a 5% significance level was adopted. Descriptive analyses and the decision tree were performed using the R software, version 4.3.0.

This study does not require an Informed Consent Form or submission to the Research Ethics Committee as it uses data from IDSC-BR, which do not include confidential information and are freely accessible. Ethical issues, guidelines, and standards that regulate research in Brazil were respected.

RESULTS

The distribution of CM in Brazil, according to the SDG color panel, and the achievement of its targets are presented in Figure 1. The concentration of municipalities that reached the target for the prevalence of CM in the South and Southeast regions is clear: 76.5% of municipalities, with 16.2% classified as red threshold and 7.3% as lower threshold (Table 1).

The South region had 86.5% of municipalities that reached the CM reduction target, followed by the Southeast region, with 81.8%. In the Northeast, North, and Midwest regions, the percentages of municipalities that reached the target were 70, 67.1, and 66%, respectively (Table 1).

The following indicators were selected by the DRT as determinants of CM in Brazil: illiteracy in the population aged ≥15 years (Illiterate population aged ≥15 years), insufficient prenatal care (IPC), low birth weight (LBW), young women aged 15 to 24 years who neither study nor work (Women aged 15-24 years neither-nor), and employed population aged 10 to 17 years (Employed population aged 10-17 years). We estimated the cumulative effect of the increase in these indicators on the prevalence of CM (Figure 2).

The prevalence of municipalities that achieved the target of reducing illiteracy among people aged ≥15 years was 60.3% and the target of exceeding the IPC was 85.8%. The South, Midwest, and Southeast regions had the highest number of municipalities that reached the target. Nonetheless, 93% of municipalities in the Northeast did not reach the target of reducing illiteracy, and 55.8% of municipalities in the North did not reach the target of exceeding the IPC (Table 1).

In Brazil, 84.7% of municipalities reached the target of exceeding LBW. The South and Southeast regions had the highest number of municipalities that did not reach the target: 22.3 and 20.1%, respectively (Table 1).

Among Brazilian municipalities, 85% achieved the target of reducing the indicator Women aged 15-24 years neither-nor. The Northeast and North regions had the highest number of municipalities that did not reach the target for this indicator (28.7 and 27.2%, respectively). 87.3% of municipalities reached the target of reducing the Employed Population aged 10-17 years, and the South region had the highest percentage of municipalities that did not reach the target (39%) (Table 1).

According to the DRT analysis, in 2,713 municipalities, in which the percentage of Illiterate population aged ≥15 years was <13%, the prevalence of CM was 1.73% (SE±0.04). In 2,017 municipalities, where the percentage of Illiterate population aged ≥15 years was ≥13%, associated with IPC <34%, the prevalence of CM rose to 2.37% (SE±0.05). In 596 municipalities, where the percentages of Illiterate population aged ≥15 years were >13%, IPC ≥34%, and LBW <9%, the prevalence of CM was 2.86% (SE±0.09). In 122 municipalities that, in addition to Illiterate population aged ≥15 years >13%, IPC ≥34%, LBW ≥9%, Women aged 15-24 years neither-nor accounted for <35%, the prevalence of CM increased to 2.89% (SE±0.22) (Figure 2).

In 115 municipalities that presented >13% of Illiterate population aged ≥15 years, IPC ≥34%, LBW ≥9%, Women aged 15-24 years neither-nor ≥35%, and Employed population aged 10-17 years <19%, the prevalence of CM was 4.07% (SE±0.40). In seven municipalities, where Employed population aged 10-17 years was ≥19% and all other inequities remained, the prevalence of CM increased to 15.4% (SE±5.54) (Figure 2).

DISCUSSION

In this study we showed that the SDG target for reducing CM was achieved by 76.5% of Brazilian municipalities, with the South and Southeast regions standing out. The Midwest had the highest percentage of municipalities that did not reach this target. Five SDG indicators were selected as determinants of the CM according to percentages and order of impact (according to the emergence of the indicator in the DRT): Illiterate population aged ≥15 years, IPC, LBW, Women aged 15-24 years neither-nor, and Employed population aged 10-17 years.

The fact that the Midwest region has a higher prevalence than the North raises questions about underreporting and incomplete data in this region, which are common in national surveys and can mask results and impact decision-making²²22 Queiroz BL, Gonzaga MR, Vasconcelos AMN, Lopes BT, Abreu DMX. Comparative analysis of completeness of death registration, adult mortality and life expectancy at birth in Brazil at the subnational level. Popul Health Metr 2020; 18(Suppl 1): 11. https://doi.org/10.1186/s12963-020-00213-4
https://doi.org/10.1186/s12963-020-00213... .

The prevalence of CM due to H/A in Brazil, according to data from the National Demographic and Health Survey (Pesquisa Nacional de Demografia e Saúde - PNDS/2007), was 6.8%⁷7 Monteiro CA, Benicio MHDA, Konno SC, Silva ACF, Lima ALL, Conde WL. Causas do declínio da desnutrição infantil no Brasil, 1996-2007. Rev Saúde Pública 2009; 43(1): 35-43., reaching the target established by the MDGs³3 Brasil. Presidência da República. Governo da República Federativa do Brasil. Objetivos de desenvolvimento do milênio: relatório nacional de acompanhamento. Brasília: Ipea; 2014.. However, data from SISVAN showed higher values, ranging from 15.1% (2008) to 13.4% (2019), with a small reduction in 2022 (11.7%), being greater in the North (15.4%) and Northeast (12.9%)¹⁵15 Brasil. Ministério da Saúde. Sistema de Vigilância Alimentar e Nutricional. Sistema de Vigilância Alimentar e Nutricional - SISVAN [Internet]. [cited on Apr. 05, 2024]. Available at: https://sisaps.saude.gov.br/sisvan/
https://sisaps.saude.gov.br/sisvan/... . Conversely, authors of the Brazilian National Survey on Child Nutrition (Estudo Nacional de Alimentação e Nutrição Infantil - ENANI/2019), representative of the Brazilian population, demonstrated a prevalence of 7% of low H/A, being higher in the North (8.4%), Southeast (7.3%), and South (7%)²³23 Universidade Federal do Rio de Janeiro. Estado Nutricional antropométrico da criança e da mãe: prevalência de indicadores antropométricos de crianças brasileiras menores de 5 anos de idade e suas mães biológicas: ENANI 2019. Rio de Janeiro: UFRJ; 2022..

Due to the gap between PNDS/2007 and ENANI/2019, since 2008, SISVAN data have been used to monitor these targets⁵5 Ribeiro-Silva RC, Silva NJ, Felisbino-Mendes MS, Falcão IR, Andrade RCS, Silva SA, et al. Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017. Public Health Nutr 2022; 25(12): 1-11. https://doi.org/10.1017/S1368980021004882
https://doi.org/10.1017/S136898002100488... . SISVAN presents data from all regions and enables the study of the population served by PHC²⁴24 Bortolini GA, Pereira TN, Nilson EAF, Pires ACL, Moratori MF, Ramos MKP, et al. Evolution of nutrition actions in primary health care along the 20-year history of the Brazilian National Food and Nutrition Policy. Cad Saude Publica 2022; 37 Suppl 1(Suppl 1): e00152620. https://doi.org/10.1590/0102-311X00152620
https://doi.org/10.1590/0102-311X0015262... and beneficiaries of the Bolsa Família Program (a cash transfer program of the Brazilian government)⁵5 Ribeiro-Silva RC, Silva NJ, Felisbino-Mendes MS, Falcão IR, Andrade RCS, Silva SA, et al. Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017. Public Health Nutr 2022; 25(12): 1-11. https://doi.org/10.1017/S1368980021004882
https://doi.org/10.1017/S136898002100488... ,¹⁶16 Silva RPC, Vergara CMAC, Sampaio HAC, Vasconcelos Filho JE, Strozberg F, Ferreira Neto JFR, et al. Food and Nutrition Surveillance System: temporal trend of coverage and nutritional status of adults registered on the system, Brazil, 2008-2019. Epidemiol Serv Saude 2022; 31(1): e2021605. https://doi.org/10.1590/S1679-49742022000100019
https://doi.org/10.1590/S1679-4974202200... . Subsequently, data from ENANI/2019 began to be incorporated into SDG monitoring reports to analyze these indicators²⁵25 VI Relatório Luz da Sociedade Civil da Agenda 2030 de Desenvolvimento Sustentável do Brasil. Grupo de Trabalho da Sociedade Civil para a Agenda 2030 [Internet]. 2022 [cited on May 02, 2024]. Available at: https://gtagenda2030.org.br/wp-content/uploads/2022/07/pt_rl_2022_final_web-1.pdf
https://gtagenda2030.org.br/wp-content/u... .

Regardless of regional differences, the socioeconomic and political crisis that has taken hold in Brazil since 2014 has had an impact on the increase in poverty; increased food prices; the adoption of tax austerity measures; and the reduction of social protection measures, contributing to the increase in CM¹⁴14 Gouveia AVS, Carvalho RES, Correia MEG, Silveira JAC. Temporal trend in the prevalence of malnutrition in children under five assisted by the Brazilian Income Transfer Program (2008-2019). Cad Saude Publica 2024; 40(1): e00180022. https://doi.org/10.1590/0102-311XPT180022
https://doi.org/10.1590/0102-311XPT18002... .

Despite the COVID-19 pandemic in 2020, the protective measures adopted by the government, at all levels — through the creation of Emergency Aid; Emergency Employment and Income Maintenance Program²⁶26 Hecksher M, Foguel MN. Benefícios emergenciais aos trabalhadores informais e formais no Brasil: estimativas das taxas de cobertura combinadas da Lei n° 13.982/2020 e da Medida Provisória n° 936/2020. Brasília: Ipea; 2022. https://doi.org/10.38116/978-65-5635-042-4/capitulo24
https://doi.org/10.38116/978-65-5635-042... ; and specific financial incentives for PHC to combat malnutrition, focused on children and pregnant women —, contributed to mitigating the effect of food insecurity and attenuating the impact of the pandemic on CM²⁷27 Gurgel ADM, Santos CCS, Alves KPS, Araujo JM, Leal VS. Government strategies to ensure the human right to adequate and healthy food facing the COVID-19 pandemic in Brazil. Cienc Saude Colet 2020; 25(12): 4945-56. https://doi.org/10.1590/1413-812320202512.33912020
https://doi.org/10.1590/1413-81232020251... .

The severity of functional illiteracy was evident in the Northeast and North, where a large proportion of municipalities did not reach the target, in contrast to other regions. Authors of a study conducted in southern Africa found that the prevalence of CM varied between 3.4 and 30.2%, and was associated with illiteracy²⁸28 Mkhize M, Sibanda M. A review of selected studies on the factors associated with the nutrition status of children under the age of five years in South Africa. Int J Environ Res Public Health 2020; 17(21): 7973. https://doi.org/10.3390/ijerph17217973
https://doi.org/10.3390/ijerph17217973... . The latter can trigger fewer job opportunities, lower income, and difficulty in acquiring food and accessing health services, contributing to CM⁷7 Monteiro CA, Benicio MHDA, Konno SC, Silva ACF, Lima ALL, Conde WL. Causas do declínio da desnutrição infantil no Brasil, 1996-2007. Rev Saúde Pública 2009; 43(1): 35-43..

The target of reducing illiteracy was not achieved by the National Education Plan 2014-2024 due to the non-implementation of public education policies aimed at the public aged ≥15 years²⁹29 Oliveira BA. É possível erradicar o analfabetismo absoluto no Brasil até 2024? Cadernos de Estudos e Pesquisas em Políticas Educacionais 2022; 6: 181-208. https://doi.org/10.24109/9786558010531.ceppe.v6.5382
https://doi.org/10.24109/9786558010531.c... . Furthermore, no mechanisms were established to make working hours compatible, nor was there a specific income transfer program³⁰30 Silva SCV, Ferreira VS, Boeing RFR. As políticas de combate ao analfabetismo no Brasil: continuidades e descontinuidades. Horizontes 2020; 38(1): e020057. https://doi.org/10.24933/horizontes.v38i1.1041
https://doi.org/10.24933/horizontes.v38i... . Only in 2024 the Pé de Meia [Nest Egg] Program (a financial-educational government support in the form of savings aimed at promoting student retention and school completion) was instituted, aimed at students aged 14 to 24 years in public schools and those belonging to the Youth and Adult Education (EJA) category, aged 19 to 24 years³¹31 Brasil. Câmara dos Deputados. Decreto n° 11.901, de 26 de janeiro de 2024. Regulamenta a Lei nº 14.818, de 16 de janeiro de 2024, que institui incentivo financeiro-educacional, na modalidade de poupança, aos estudantes matriculados no ensino médio público, e cria o Programa Pé-de-Meia [Internet]. 2024 [cited on Aug. 16, 2024]. Available at: https://www2.camara.leg.br/legin/fed/decret/2024/decreto-11901-26-janeiro-2024-795291-publicacaooriginal-170974-pe.html
https://www2.camara.leg.br/legin/fed/dec... .

The target of exceeding the IPC was achieved by many municipalities in Brazilian regions, with the exception of the North region. Prenatal coverage in Brazil accounted for 89% from 2013³²32 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, et al. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: Indicadores e desigualdades sociais. Cad Saúde Pública 2017; 33(3): e00195815. https://doi.org/10.1590/0102-311X00195815
https://doi.org/10.1590/0102-311X0019581... to 2019³³33 Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares 2017-2018: primeiros resultados [Internet]. Rio de Janeiro: IBGE; 2019 [cited on Apr. 29, 2024]. Available at: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101670.pdf
https://biblioteca.ibge.gov.br/visualiza... . It is worth noting that the North has a higher level of precarious services, low prenatal coverage, and worse quality indicators³⁴34 Leal MC, Esteves-Pereira AP, Viellas EF, Domingues RMSM, Gama SGN. Prenatal care in the Brazilian public health services. Rev Saude Publica 2020; 54(8). https://doi.org/10.11606/s1518-8787.2020054001458
https://doi.org/10.11606/s1518-8787.2020... , related to territorial coverage, difficulty in accessing health services, and low retention of professionals in the region³⁵35 Sousa DS, Cunha CLF, Rodrigues DP, Lemos M, Parente AT, Oliveira BLCA, et al. Assistência pré-natal e puerpério no âmbito da atenção básica no Brasil. Contribuciones a Las Ciencias Sociales 2020; 16(9): 18564-80. https://doi.org/10.55905/revconv.16n.9-281
https://doi.org/10.55905/revconv.16n.9-2... .

Nutritional monitoring during prenatal care is essential to prevent inadequate weight gain and control complications³⁶36 Teixeira CSS, Cabral ACV. Nutritional status of pregnant women under monitoring in pre distinct prenatal services: the metropolitan area and the rural environment. Rev Bras Ginecol Obstet 2016; 38(1): 27-34. https://doi.org/10.1055/s-0035-1570111
https://doi.org/10.1055/s-0035-1570111... that may predispose the pregnant woman to premature birth and the child to intrauterine growth restriction (IUGR) and LBW³⁷37 Brasil. Ministério da Saúde. Guia rápido para o acompanhamento de gestantes e crianças com desnutrição na atenção primária à saúde [Internet]. Brasília; 2022 [cited on Nov. 06, 2023]. Available at: https://189.28.128.100/dab/docs/portaldab/publicacoes/guia_rapido_acompanhamento_gestantes_criancas_desnutricao_aps.pdf
https://189.28.128.100/dab/docs/portalda... . Pregnant women should be advised on breastfeeding and adequate nutrition to prevent CM³⁸38 Tinôco LS, Lyra CO, Mendes TCO, Freitas YNL, Silva AS, Souza AMS, et al. Feeding practices in the first year of life: challenges to food and nutrition policies. Rev Paul Pediatr 2020; 38: e2018401. https://doi.org/10.1590/1984-0462/2020/38/2018401
https://doi.org/10.1590/1984-0462/2020/3... .

In this research, a high frequency of Brazilian municipalities in the North, Northeast, and Midwest exceeded the LBW target; this did not occur in the South and Southeast. The prevalence of LBW is 37.7% in the South and 13.5% in the Southeast³⁹39 Brasil. Ministério da Saúde. DATASUS. Notas técnicas. Nascidos vivos - Brasil [Internet]. 2021 [cited on July 25, 2024]. Available at: https://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinasc/cnv/nvuf.def
https://tabnet.datasus.gov.br/cgi/tabcgi... .

The LBW paradox was observed in the North and South regions. This can be attributed to the improvement in prenatal care in more developed regions with a concomitant reduction in the prevalence of stillbirths and an increase in LBW⁴⁰40 Veloso HJF, Silva AAM, Bettiol H, Goldani MZ, Lamy Filho F, Simões VMF, et al. Low birth weight in São Luís, northeastern Brazil: trends and associated factors. BMC Pregnancy Childbirth 2014; 14(1): 155. https://doi.org/10.1186/1471-2393-14-155
https://doi.org/10.1186/1471-2393-14-155... , as observed in the South region. We observed the opposite in the North, with a lower prevalence of LBW and a high percentage of municipalities with IPC. Possible explanations would be the high rates of underreporting of live births in the North⁴¹41 Andrade CLT, Szwarcwald CL, Castilho EA. Low birth weight in Brazil according to live birth data from the Ministry of Health, 2005. Cad Saude Publica 2008; 24(11): 2564-72. https://doi.org/10.1590/s0102-311x2008001100011
https://doi.org/10.1590/s0102-311x200800... and the high rate of cesarean sections in the South⁴²42 Pires RCR, Silveira VNC, Leal MC, Lamy ZC, Silva AAM. Temporal trends and projections of caesarean sections in Brazil, its administrative macro-regions, and federative units. Cien Saude Colet 2023; 28(7): 2119-33. https://doi.org/10.1590/1413-81232023287.14152022
https://doi.org/10.1590/1413-81232023287... , related to the interruption of high-risk pregnancies, with a consequent reduction in gestational age, increase in prematurity, and viability of newborns with extremely low birth weight⁴³43 Brasil. Diretrizes de Atenção à Gestante: a operação cesariana. Relatório de recomendação [Internet]. 2016 [cited on Aug. 16, 2024]. Available at: https://www.gov.br/conitec/pt-br/midias/relatorios/2016/relatorio_diretrizes-cesariana_final.pdf
https://www.gov.br/conitec/pt-br/midias/... .

Brazil has one of the highest rates of cesarean sections in the world. In 2019, 56.3% of births were cesarean sections and carried out mainly in the Midwest, Southeast, and South regions⁴⁴44 Belarmino V, Carlotto K, Maduell MCP, Gonçalves CG. Spatial distribution of cesarean sections in Brazil from 2000 to 2019. Res Soc Dev 2022; 11(4): e43211427657. https://doi.org/10.33448/rsd-v11i4.27657
https://doi.org/10.33448/rsd-v11i4.27657... , highlighting the inequalities in the country. Subsequently, researchers indicated an increasing trend in the North and Northeast, and a decline in the South and Southeast⁴²42 Pires RCR, Silveira VNC, Leal MC, Lamy ZC, Silva AAM. Temporal trends and projections of caesarean sections in Brazil, its administrative macro-regions, and federative units. Cien Saude Colet 2023; 28(7): 2119-33. https://doi.org/10.1590/1413-81232023287.14152022
https://doi.org/10.1590/1413-81232023287... . Despite the decline, the South region still has higher prevalence rates, and Brazil continues to have cesarean section rates well above the recommended level⁴³43 Brasil. Diretrizes de Atenção à Gestante: a operação cesariana. Relatório de recomendação [Internet]. 2016 [cited on Aug. 16, 2024]. Available at: https://www.gov.br/conitec/pt-br/midias/relatorios/2016/relatorio_diretrizes-cesariana_final.pdf
https://www.gov.br/conitec/pt-br/midias/... .

Public policies developed since the 1980s, which culminated in the implementation of the Rede Cegonha [Stork Network] Program (a strategy of the Brazilian Ministry of Health intended at improving the care provided to women and children)⁴⁵45 Leal MC, Szwarcwald CL, Almeida PVB, Aquino EML, Barreto ML, Barros F, et al. Reproductive, maternal, neonatal and child health in the 30 years since the creation of the Unified Health System (SUS). Cien Saude Colet 2018; 23(6): 1915-28. https://doi.org/10.1590/1413-81232018236.03942018
https://doi.org/10.1590/1413-81232018236... , were essential for improving important practices related to childbirth and the postpartum period in Brazil. Other policies and strategies related to the protection of breastfeeding and the introduction of adequate and healthy complementary feeding were paramount for protecting children's health, especially that of infants, as it is observed that complications in the neonatal period are more related to pregnancy and childbirth and, after this period, they are more related to the child's socioeconomic context⁴⁶46 Rebouças P, Falcão IR, Barreto ML. Social inequalities and their impact on children's health: a current and global perspective. J Pediatr (Rio J) 2022; 98 Suppl 1(Suppl 1): S55-S65. https://doi.org/10.1016/j.jped.2021.11.004
https://doi.org/10.1016/j.jped.2021.11.0... .

The target of reducing the Women aged 15-24 years neither-nor indicator was achieved by 85% of municipalities, with the worst results in the North and Northeast. In 2018, 23% of young people found themselves in this situation, the majority of whom were low-income women¹⁰10 Instituto de Pesquisa Econômica Aplicada. Agenda 2030: ODS - metas nacionais dos objetivos de desenvolvimento sustentável [Internet]. 2018 [cited on Mar. 14, 2024]. Available at: https://portalantigo.ipea.gov.br/agencia/images/stories/PDFs/livros/livros/180801_ods_metas_nac_dos_obj_de_desenv_susten_propos_de_adequa.pdf
https://portalantigo.ipea.gov.br/agencia... . The reasons are related to cognitive abilities, domestic obligations, and the lack of public policies that can mitigate gender inequality and increase the prospects of overcoming poverty⁴⁷47 Sawaya AL, Peliano AM, Albuquerque MP, Domene SMA. A família e o direito humano à alimentação adequada e saudável. Estud Av 2019; 33(97): 363-82. https://doi.org/10.1590/s0103-4014.2019.3397.020
https://doi.org/10.1590/s0103-4014.2019.... . Low levels of education, low income, and teenage pregnancy are more related to IUGR and a higher risk of producing malnourished children⁴⁸48 Ota E, Ganchimeg T, Morisaki N, Vogel JP, Pileggi C, Ortiz-Panozo E, et al. Risk factors and adverse perinatal outcomes among term and preterm infants born small-for-gestational-age: secondary analyses of the WHO multi-country survey on maternal and newborn health. PLoS One 2014; 9(8): e105155. https://doi.org/10.1371/journal.pone.0105155
https://doi.org/10.1371/journal.pone.010... ,⁴⁹49 Muhihi A, Sudfeld CR, Smith ER, Noor RA, Mshamu S, Briegleb C, et al. Risk factors for small-for-gestational-age and preterm births among 19,269 Tanzanian newborns. BMC Pregnancy Childbirth 2016; 16: 110. https://doi.org/10.1186/s12884-016-0900-5
https://doi.org/10.1186/s12884-016-0900-... . Investing in the human capital²2 Büttner N, Heemann M, De Neve JW, Verguet S, Vollmer S, Harttgen K. Economic growth and childhood malnutrition in low- and middle-income countries. JAMA Netw Open 2023; 6(11): e2342654. https://doi.org/10.1001/jamanetworkopen.2023.42654
https://doi.org/10.1001/jamanetworkopen.... of these women can contribute to better family planning and the reduction of CM⁵⁰50 Alonso C, Brussevich M, Dabla-Norris E, Kinoshita Y, Kochhar K. Reducing and redistributing unpaid work: stronger policies to support gender equality [Internet]. IMF Working Paper; 2019 [cited on May 02, 2024]. Available at: http://www.imf.org/external/pubs/cat/longres.aspx?sk=48688
http://www.imf.org/external/pubs/cat/lon... .

Women's education is a strong predictor of their children's health and survival, as it influences access to health services, care in situations of illness, better job opportunities, and income generation for childcare⁵¹51 Oyekale AS, Maselwa TC. Maternal education, fertility, and child survival in Comoros. Int J Environ Res Public Health 2018; 15(12): 2814. https://doi.org/10.3390/ijerph15122814
https://doi.org/10.3390/ijerph15122814... . Mothers tend to manage family expenses better, directing them towards food, clothing, and school supplies⁵²52 Kamamura HC. Efeitos do Programa Bolsa Família no consumo de nutrientes e índices Antropométricos [tese de doutorado]. Piracicaba: Universidade de São Paulo; 2014..

The South region is the most affected by child labor, and has a high prevalence of the Employed population aged 10-17 years indicator. Child labor can cause harm to the physical and mental health of children and adolescents, in addition to the risk of adopting unhealthy lifestyle habits and developing chronic noncommunicable diseases⁵³53 Santana VS, Kiss L, Andermann A. The scientific knowledge on child labor in Latin America. Cad Saude Publica 2019; 35(7)): e00105119. https://doi.org/10.1590/0102-311X00105119
https://doi.org/10.1590/0102-311X0010511... . It also perpetuates low levels of education, income⁵⁴54 Ciríaco JS, Anjos Júnior OR, Lombardi Filho SC. Uma análise do trabalho infantil na região sul do Brasil. Braz J Dev 2019; 5(8): 13500-14. https://doi.org/10.34117/bjdv5n8-148
https://doi.org/10.34117/bjdv5n8-148... , and CM⁴⁶46 Rebouças P, Falcão IR, Barreto ML. Social inequalities and their impact on children's health: a current and global perspective. J Pediatr (Rio J) 2022; 98 Suppl 1(Suppl 1): S55-S65. https://doi.org/10.1016/j.jped.2021.11.004
https://doi.org/10.1016/j.jped.2021.11.0... . Paradoxically, in the South region, this scenario may be related to the culture that considers work as an educational tool⁵⁵55 Oliveira LE, Rios-Neto EG, Oliveira AMHC. O efeito trabalhador adicional para filhos no Brasil. Rev Bras Est Popul 2014; 31(1): 29-49. https://doi.org/10.1590/S0102-30982014000100003
https://doi.org/10.1590/S0102-3098201400... , as it did not negatively impact illiteracy rates, prenatal care, gender inequalities, and CM.

In other regions, in order to increase family income, child labor contributes to high rates of student retention, withdrawal, and school dropout, requiring the implementation of policies to discourage it. Households managed only by women increase the risk of child labor when compared to those managed by men or both sexes. The higher the parents' level of education and income, the lower the risk of dropping out of school⁵⁵55 Oliveira LE, Rios-Neto EG, Oliveira AMHC. O efeito trabalhador adicional para filhos no Brasil. Rev Bras Est Popul 2014; 31(1): 29-49. https://doi.org/10.1590/S0102-30982014000100003
https://doi.org/10.1590/S0102-3098201400... ,⁵⁶56 Cabanas P, Komatsu BK, Menezes Filho NA. Crescimento da renda e as escolhas dos jovens entre os estudos e o mercado de trabalho [trabalho acadêmico]. São Paulo: Insper Instituto de Ensino e Pesquisa, Centro de Políticas Públicas; 2014.

The cut-off points for each CM indicator, identified by the DRT, were within the target proposed by the SDGs. Nevertheless, these contributed to the increased prevalence of CM. Furthermore, the cumulative effect (combined effect of these indicators in the order they appear in the DRT) was even more impactful in increasing the prevalence of CM.

Some researchers have also observed the cumulative effect of indicators of social and health inequities associated with CM. A higher level of maternal education is associated with a reduction in CM⁵⁷57 Ramos CV, Dumith SC, César JA. Prevalence and factors associated with stunting and excess weight in children aged 0-5 years from the Brazilian semi-arid region. J Pediatr (Rio J) 2015; 91(2): 175-82. https://doi.org/10.1016/j.jped.2014.07.005
https://doi.org/10.1016/j.jped.2014.07.0... ,⁵⁸58 Casale D, Espi G, Norris SA. Estimating the pathways through which maternal education affects stunting: evidence from an urban cohort in South Africa. Public Health Nutr 2018; 21(10): 1810-8. https://doi.org/10.1017/S1368980018000125
https://doi.org/10.1017/S136898001800012... and greater adherence to prenatal care⁵⁹59 Matozinhos FP, Mendes LL, Andrade CJM, Velasquez-Melendez G. Avaliação da atenção pré-natal: estudos de base populacional. Rev APS 2014; 17(4): 469-75.. In the state of Rio Grande do Sul, an association was found between adequate prenatal care and reduced LBW⁶⁰60 Pires PHAF, Triaca LM, Trindade CS, Ribeiro FG. Efeitos do programa de primeira infância melhor sobre indicadores de pré-natal e neonatal [Internet]. [cited on Aug. 14, 2024]. Available at: https://www.anpec.org.br/sul/2022/submissao/files_I/i2-3f11e98a002e38d5d6b6526269483cdc.pdf
https://www.anpec.org.br/sul/2022/submis... . In the state of Pernambuco, an association between CM and lower maternal education and LBW was observed⁶¹61 Menezes RCE, Lira PIC, Leal VS, Oliveira JS, Santana SCS, Sequeira LAS, et al. Determinants of stunting in children under five in Pernambuco, northeastern Brazil. Rev Saude Publica 2011; 45(6): 1079-87. https://doi.org/10.1590/s0034-89102011000600010
https://doi.org/10.1590/s0034-8910201100... . Authors of a review carried out in the North region associated CM with low maternal education and having an illiterate father/stepfather⁶²62 Corrêa EM. Vigilância epidemiológica da desnutrição infantil na Região Norte brasileira de 2008 a 2017 [tese de doutorado]. São Paulo: Universidade de São Paulo, Faculdade de Saúde Pública; 2020..

The complexity of the outcome of this study is contemplated through the impact that each indicator, identified as a determinant of CM, has on its prevalence, as well as through the interrelations and interdependencies that these indicators exert on the succession of events that favored the increase in the prevalence of CM in Brazil.

The regional inequalities observed were closely related to the achievement or distance from the targets of the studied indicators, which made them vulnerable to an increase in CM.

As study limitations we mention the use of the IDSC-BR database, which: considered information from years near 2022 for the indicators, as some did not provide updated information; and uses data from SISVAN to monitor CM. However, the information obtained through IDSC-BR constitutes a robust database of the Brazilian population, created from the combination of information from various entities and agencies linked to the UN¹¹11 Fuller G. Índice de Desenvolvimento Sustentável das Cidades. Metodologia [Internet]. 2022 [cited on Mar. 18, 2024]. Available at: https://idsc-sp.cidadessustentaveis.org.br/static/Metodologia.pdf
https://idsc-sp.cidadessustentaveis.org.... . Moreover, although SISVAN presents flaws in data collection, its information is considered official for statistical purposes due to its coverage and the amount of information per state¹⁴14 Gouveia AVS, Carvalho RES, Correia MEG, Silveira JAC. Temporal trend in the prevalence of malnutrition in children under five assisted by the Brazilian Income Transfer Program (2008-2019). Cad Saude Publica 2024; 40(1): e00180022. https://doi.org/10.1590/0102-311XPT180022
https://doi.org/10.1590/0102-311XPT18002... .

As positive aspects, it is worth highlighting that all SDG monitoring indicators, in all Brazilian municipalities — available in the database — were used in this study, enabling a broad investigation of the issue in question. In addition, DRT was used to select the indicators determining CM and establish the cutoff points in an isolated and cumulative manner.

We conclude that the SDG monitoring indicators that determine CM in Brazil, individually and together, were Illiterate population aged ≥15 years, IPC, LBW, Women aged 15-24 years neither-nor, and Employed population aged 10-17 years. The impact of these indicators on the prevalence of CM showed an average of 1.73%, when the prevalence of Illiterate population aged ≥15 years was less than 13%; up to an average of 15.1%, when all other indicators exceeded the percentages identified by the DRT. Furthermore, most Brazilian municipalities achieved the targets for the indicators selected by the DRT.

All indicators determining CM are related to poverty and social inequalities, making it difficult to achieve the target for CM in the country. It is necessary to implement multidimensional socioeconomic policies by managers at all levels, which improve, in the short and long term, the income of vulnerable families and access to education and health services, especially for adolescents/young people and women, in such a way to minimize and stop the increase in existing inequalities.

In addition, the North and Northeast regions of the country should also be prioritized in terms of investments in maternal and child health care, in which women are monitored from prenatal care, through childbirth, the postpartum period, and the first years of the child's life — consequently minimizing health risks.

ACKNOWLEDGMENTS:

The authors would like to thank the Instituto Cidades Sustentáveis [Cidades Sustentáveis Institute] for making publicly available the data from the Sustainable Development Index of Cities — Brazil (IDSC-BR) used in this article.

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