Factors associated with anemia and vitamin A deficiency in Brazilian children under 5 years old: <i>Brazilian National Survey on Child Nutrition</i> (ENANI-2019)

Castro, Inês Rugani Ribeiro de; Normando, Paula; Farias, Dayana Rodrigues; Berti, Talita Lelis; Schincaglia, Raquel Machado; Andrade, Pedro Gomes; Bertoni, Neilane; Lacerda, Elisa Maria de Aquino; Anjos, Luiz Antonio dos; Boccolini, Cristiano Siqueira; Reis, Marta Citelli dos; Bezerra, Flávia Fioruci; Pedrosa, Lucia Fatima Campos; Jordão Junior, Alceu Afonso; Lira, Pedro Israel Cabral de; Kac, Gilberto; ,

doi:10.1590/0102-311XEN194922

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ARTICLE • Cad. Saúde Pública 39 (Suppl 2) • 2023 • https://doi.org/10.1590/0102-311XEN194922 copy

Factors associated with anemia and vitamin A deficiency in Brazilian children under 5 years old: Brazilian National Survey on Child Nutrition (ENANI-2019)

Fatores associados à anemia e deficiência de vitamina A em crianças brasileiras menores de cinco anos: Estudo Nacional de Alimentação e Nutrição Infantil (ENANI-2019)

Factores asociados con la anemia y la deficiencia de vitamina A en niños brasileños menores de cinco años: Estudio Nacional de Alimentación y Nutrición Infantil (ENANI-2019)

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Factors associated with anemia and vitamin A deficiency were investigated in 7,716 children 6-59 months of age studied in the Brazilian National Survey on Child Nutrition (ENANI-2019). We adopted a hierarchical approach based on a United Nations Children’s Fund (UNICEF) theoretical model with three levels, stratifying by age (6-23; 24-59 months). Prevalence ratio (PR) and 95% confidence interval (95%CI) were estimated. Enabling determinants: a higher prevalence of anemia was observed in children 6-23 months whose mothers had ≤ 7 years of schooling (PR = 1.92; 95%CI: 1.10; 3.34), < 20 years old (PR = 2.47; 95%CI: 1.34; 4.56) or 20-30 years old (PR = 1.95; 95%CI: 1.11; 3.44), mixed-race (PR = 1.57; 95%CI: 1.06; 2.23); and in children 24-59 months in the North Region (PR = 3.11; 95%CI: 1.58; 6.13). A higher prevalence for vitamin A deficiency was observed in children 6-23 months from Central-West (PR = 2.32; 95%CI: 1.33; 4.05), and in children 24-59 months living in the North (PR = 1.96; 95%CI: 1.16; 3.30), South (PR = 3.07; 95%CI: 1.89; 5.01), and Central-West (PR = 1.91; 95%CI: 1.12; 3.25) and whose mothers were 20-34 years (PR = 1.62; 95%CI: 1.11; 2.35). Underlying determinants: the presence of more than one child < 5 years old in the household was associated with a higher prevalence of anemia (PR = 1.61; 95%CI: 1.15; 2.25) and vitamin A deficiency (PR = 1.82; 95%CI: 1.09; 3.05) in children 6-23 months. Immediate determinants: consumption of 1-2 groups of ultra-processed foods in children 24-59 months (PR = 0.44; 95%CI: 0.25; 0.81) and lack of breastfeeding in the day before in children 6-23 months (PR = 0.56; 95%CI: 0.36; 0.95) were associated with lower prevalence of anemia and vitamin A deficiency. Public policies focused on geographically and socially vulnerable groups are needed to promote equity.

Keywords:
Preeschool Child; Micronutrients; Social Determinants of Health; Surveys and Questionnaires

Variables	6-59 months (n = 7,709)		6-23 months (n = 2,434)		24-59 months (n = 5,275)
Variables	%	95%CI	%	95%CI	%	95%CI
Enabling determinants
Brazilian macroregions
Southeast	39.3	39.3; 39.3	39.1	39.1; 39.2	39.3	39.3; 39.4
North	10.9	10.9; 10.9	11.0	11.0; 11.0	10.9	10.9; 10.9
Northeast	28.1	28.1; 28.1	28.2	28.2; 28.2	28.1	28.0; 28.1
South	13.4	13.4; 13.5	13.4	13.4; 13.4	13.4	13.4; 13.5
Central-West	8.3	8.3; 8.3	8.3	8.3; 8.3	8.3	8.3; 8.3
Mother or caregiver educational level (completed years)
0-7	23.5	21.3; 25.8	22.2	18.8; 25.6	24.2	21.7; 26.7
8-10	21.8	19.5; 24.0	23.8	20.3; 27.4	20.7	18.3; 23.1
11	37.5	35.0; 39.9	37.1	33.2; 40.9	37.7	34.7; 40.6
≥ 12	17.2	14.9; 19.6	16.9	13.2; 20.7	17.4	14.9; 19.9
Maternal or caregiver race/skin color
White	30.9	28.0; 33.7	31.0	26.7; 35.3	30.8	27.8; 33.8
Mixed-race	55.8	52.1; 59.5	55.0	50.9; 59.2	56.2	51.9; 60.4
Black	12.3	10.3; 14.2	12.8	9.8; 15.7	12.0	9.7; 14.4
Yellow/Indigenous	1.1 *	0.4; 1.7	1.2 *	0.3; 2.0	1.0 *	0.3; 1.8
Access to digital information technologies (number of items) **
0	7.1	5.8; 8.4	6.6	4.7; 8.5	7.3	5.9; 8.7
1	31.0	27.6; 34.5	30.8	26.3; 35.3	31.1	27.1; 35.1
2-3	61.9	58.2; 65.6	62.6	57.8; 67.3	61.6	57.4; 65.7
Mother or caregiver age (years)
< 20	6.3	5.2; 7.5	10.8	8.7; 13.0	4.1	2.9; 5.2
20-34	66.8	64.2; 69.3	69.0	64.9; 73.2	65.7	63.1; 68.2
≥ 35	26.9	24.5; 29.3	20.1	16.8; 23.5	30.3	27.6; 32.9
Underlying determinants
Number of people per bedroom
1	4.9	3.9; 5.9	4.4	2.9; 5.9	5.2	4.0; 6.3
2	50.8	47.3; 54.3	47.3	43.8; 50.8	52.6	48.6; 56.5
3	28.2	25.7; 30.6	31.9	28.6; 35.3	26.3	23.6; 29.0
≥ 4	16.1	13.6; 18.6	16.4	13.8; 18.9	16.0	13.2; 18.7
Presence of more than one resident < 5 years of age
Yes	29.1	25.8; 32.3	30.2	26.2; 34.1	28.5	25.0; 32.0
Sewage system
Yes	72.9	69.4; 76.3	70.9	66.5; 75.2	73.9	70.4; 77.4
Brazilian Food Insecurity Scale
Security	51.6	45.4; 57.8	53.2	46.1; 60.2	50.8	44.7; 56.9
Mild insecurity	37.8	32.3; 43.4	36.6	30.3; 42.8	38.5	32.8; 44.2
Moderate insecurity/Severe insecurity	10.6	8.8; 12.4	10.2	8.4; 12.1	10.7	8.7; 12.8
Immediate determinants
Breastfeeding in the previous day ***
Yes	24.4	22.8; 26.1	52.2	48.2; 56.3	-	-
Minimal dietary diversity
Yes	61.3	58.2; 64.4	64.1	60.6; 67.5	60.0	56.2; 63.8
Vitamin A supplement use ^#
Yes	36.1	31.1; 41.2	45.9	39.5; 52.3	31.2	26.1; 36.4
Iron supplement use ^#
Yes	20.7	18.3; 23.1	33.7	30.4; 37.0	14.2	11.1; 17.3
Consumption of ultra-processed foods (groups)
0	10.3	8.8; 11.7	18.6	15.7; 21.5	6.1	4.8; 7.4
1-2	46.4	42.9; 49.9	47.6	43.6; 51.6	45.7	41.7; 49.8
≥ 3	43.4	39.2; 47.5	33.8	28.9; 38.8	48.2	43.6; 52.7

Variables	6-23 months					24-59 months
	%	Model 1 *		Model 2 **		%	Model 1 *		Model 2 **
	%	PR	95%CI	PR	95%CI		PR	95%CI	PR	95%CI
Enabling determinants
Brazilian macroregion
Southeast	18.2	Reference		Reference		3.1 ***	Reference		Reference
North	29.9	1.64	1.13; 2.37	1.40	0.99; 1.99	10.6	3.42	1.58; 7.39	3.11	1.58; 6.13
Northeast	21.3	1.18	0.70; 1.98	1.13	0.67; 1.91	8.3 ***	2.71	0.99; 7.44	2.44	0.87; 6.83
South	14.0	0.77	0.50; 1.20	0.92	0.57; 1.47	3.5	1.15	0.51; 2.61	1.11	0.46; 2.69
Central-West	18.7	1.04	0.70; 1.55	0.99	0.67; 1.48	4.7	1.51	0.72; 3.14	1.43	0.71; 2.87
Educational level of mother or caregiver (completed years)
0-7	28.0	2.26	1.41; 3.62	1.92	1.10; 3.34	6.7	2.51	1.18; 5.36	1.59	0.67; 3.79
8-10	22.1	1.80	1.21; 2.68	1.56	0.98; 2.47	7.1	2.46	1.03; 5.89	1.79	0.65; 4.94
11	17.1	1.41	0.88; 2.27	1.25	0.72; 2.17	5.2	1.87	0.76; 4.59	1.51	0.58; 3.94
≥ 12	12.1	Reference		Reference		2.8 ***	Reference		Reference
Maternal or caregiver race/skin color
White	13.1	Reference		Reference		4.6	Reference		Reference
Mixed-race	24.2	1.83	1.30; 2.58	1.57	1.06; 2.33	5.6	1.21	0.75;1.95	0.81	0.51; 1.29
Black	18.0	1.40	0.84; 2.32	1.17	0.68; 2.02	8.0	1.74	0.95; 3.19	1.42	0.84; 2.40
Access to digital information technologies (number of items) ^#
0	27.5	1.62	1.02; 2.58	1.26	0.76; 2.08	9.1	2.23	1.26; 3.93	1.67	0.88; 3.18
1	23.4	1.36	1.03; 1.80	1.06	0.78; 1.43	7.8	1.93	1.41; 2.64	1.48	1.11; 1.97
2-3	17.3	Reference		Reference		4.0	Reference		Reference
Age of mother or caregiver (years)
< 20	34.2	2.88	1.56; 5.32	2.47	1.34; 4.56	13.7	2.33	1.04; 5.25	1.84	0.86; 3.95
20-34	20.4	1.80	1.04; 3.11	1.95	1.11; 3.44	5.3	1.02	0.62; 1.66	0.95	0.55; 1.62
≥ 35	10.4	Reference		Reference		5.0 ***	Reference		Reference
Underlying determinants
Number of people per bedroom
1	14.0 ***	Reference		Reference		5.2 ***	Reference		Reference
2	16.3	0.95	0.51; 1.78	0.83	0.45; 1.54	3.5	0.66	0.24; 1.82	0.56	0.21; 1.49
3	22.6	1.35	0.72; 2.53	0.95	0.50; 1.82	7.7	1.44	0.52; 3.97	1.02	0.36; 2.87
≥ 4	26.4	1.57	0.81; 3.04	0.94	0.43; 2.04	8.8	1.64	0.63; 4.28	1.00	0.37; 2.71
Presence of more than one resident aged under < 5 years
No	15.9	Reference		Reference		4.4	Reference		Reference
Yes	29.0	1.78	1.33; 2.39	1.61	1.15; 2.25	8.5	2.02	1.30; 3.16	1.61	1.00; 2.60
Sewage system
Yes	18.3	Reference		Reference		4.6	Reference	Reference
No	23.8	1.26	0.93; 1.72	1.05	0.77; 1.43	8.3	1.84	1.30; 2.62	1.16	0.88; 1.52
Brazilian Food Insecurity Scale
Security	18.4	Reference		Reference		3.9	Reference		Reference
Mild insecurity	19.9	1.09	0.80; 1.49	0.96	0.72; 1.29	5.9	1.51	0.99; 2.30	1.22	0.80; 1.84
Moderate insecurity/Severe insecurity	27.3	1.51	0.93; 2.45	1.03	0.60; 1.75	11.8	2.94	1.93; 4.49	1.50	0.92; 2.42
Immediate determinants
Breastfeeding in the previous day ^##
Yes	24.1	Reference		Reference		-	Reference		Reference
No	15.2	0.73	0.49; 1.09	0.71	0.49; 1.02	-	-	-	-	-
Minimal dietary diversity
Yes	17.1	Reference		Reference		4.8	Reference		Reference
No	24.9	1.29	0.91; 1.82	1.20	0.86; 1.68	6.7	1.47	1.00; 2.18	1.16	0.78; 1.73
Consumption of ultra-processed foods (groups)
0	22.0	Reference		Reference		10.3	Reference		Reference
1-2	20.1	1.14	0.73; 1.78	1.20	0.81; 1.78	3.5	0.33	0.17; 0.65	0.44	0.25; 0.81
≥ 3	18.3	1.21	0.71; 2.05	1.20	0.70; 2.07	6.9	0.68	0.35; 1.32	0.81	0.49; 1.35
Iron supplement use ^###
Yes	17.5	Reference		Reference		4.7	Reference		Reference
No	21.1	1.19	0.86; 1.65	1.04	0.75; 1.45	5.7	1.28	0.68; 2.41	1.23	0.68; 2.22

Variables	6-23 months					24-59 months
	%	Model 1 *		Model 2 **		%	Model 1 *		Model 2 **
	%	PR	95%CI	PR	95%CI		PR	95%CI	PR	95%CI
Enabling determinants
Brazilian macroregions
Southeast	5.6	Reference		Reference		4.2	Reference		Reference
North	7.6	1.36	0.81; 2.28	1.48	0.86; 2.56	8.8	2.10	1.24; 3.56	1.96	1.16; 3.30
Northeast	6.4	1.15	0.60; 2.19	1.08	0.57; 2.05	4.9	1.18	0.73; 1.91	1.15	0.70; 1.88
South	8.7 ***	1.54	0.73; 3.26	1.50	0.67; 3.35	11.1	2.67	1.60; 4.44	3.07	1.89; 5.01
Central-West	12.2	2.17	1.26; 3.74	2.32	1.33; 4.05	8.1	1.94	1.14; 3.33	1.91	1.12; 3.25
Mother or caregiver educational level (completed years)
0-7	9.3	1.39	0.65; 2.95	1.73	0.69; 4.33	6.0	1.22	0.73; 2.03	1.16	0.73; 1.84
8-10	7.9	1.17	0.56; 2.46	1.41	0.63; 3.18	7.8	1.58	0.96; 2.58	1.44	0.91; 2.27
11	5.2	0.78	0.35; 1.71	0.86	0.37; 2.01	5.9	1.20	0.73; 1.98	1.16	0.72; 1.87
≥ 12	6.7 ***	Reference		Reference		4.9	Reference		Reference
Maternal or caregiver race/skin color
Whhite	6.9	Reference		Reference		5.4	Reference		Reference
Brown	7.6	1.10	0.60; 2.01	1.18	0.61; 2.25	6.4	1.19	0.81; 1.75	1.42	0.99; 2.05
Black	5.3 ***	0.77	0.28; 2.10	0.81	0.28; 2.40	6.7	1.24	0.65; 2.35	1.50	0.80; 2.81
Access to digital information technologies (number of items) ^#
0	9,9 ***	1.29	0.60; 2.75	0.97	0.40; 2.36	5.8 ***	0.95	0.42; 2.12	0.95	0.43; 2.07
1	5.0	0.66	0.42; 1.04	0.54	0.33; 0.87	6.4	1.05	0.71; 1.53	0.91	0.60; 1.39
2-3	7.7	Reference		Reference		6.1	Reference		Reference
Mother or caregiver age (years)
< 20	7.0 ***	0.93	0.37; 2.37	0.87	0.33; 2.29	5.8 ***	1.42	0.64; 3.15	1.20	0.57; 2.56
20-34	6.9	0.92	0.52; 1.64	0.99	0.56; 1.75	7.1	1.73	1.18; 2.52	1.62	1.11; 2.35
≥ 35	7.5	Reference		Reference		4.1	Reference		Reference
Underlying determinants
Number of people per bedroom
1	7.0 ***	Reference		Reference		3.7 ***	Reference		Reference
2	6.8	0.97	0.45; 2.08	0.99	0.41; 2.43	5.6	1.51	0.75; 3.06	1.44	0.73; 2.85
3	6.5	0.92	0.39; 2.13	0.79	0.31; 2.03	7.4	2.01	0.87; 4.67	2.02	0.92; 4.43
≥ 4	8.6	1.22	0.50; 2.97	0.95	0.30; 2.97	6.6	1.79	0.89; 3.60	1.72	0.84; 3.49
Presence of more than one resident < 5 years of age
No	5.5	Reference		Reference		5.7	Reference		Reference
Yes	10.5	1.90	1.15; 3.13	1.82	1.09; 3.05	7.3	1.28	0.87; 1.87	1.14	0.80; 1.63
Sewage system
Yes	6.5	Reference		Reference		6.3	Reference		Reference
No	8.3	1.27	0.77; 2.11	1.14	0.69; 1.90	5.8	0.93	0.59; 1.45	0.66	0.43; 1.02
Brazilian Food Insecurity Scale
Security	6.5	Reference		Reference		5.8	Reference		Reference
Mild insecurity	6.2	0.94	0.55; 1.61	0.96	0.57; 1.64	6.5	1.11	0.75; 1.63	1.08	0.73; 1.59
Moderate insecurity/Severe insecurity	12.6	1.93	1.01; 3.68	1.84	0.89; 3.81	6.5	1.11	0.66; 1.86	0.99	0.53; 1.84
Immediate determinants
Breastfeeding in the previous day ^##
Yes	8.4	Reference		Reference		-	Reference		Reference
No	5.5	0.66	0.43; 1.02	0.56	0.34; 0.93	-	-	-	-	-
Minimal dietary diversity
Yes	5.8	Reference		Reference		5.4	Reference		Reference
No	9.1	1.57	0.93; 2.63	1.76	0.94; 3.31	7.3	1.36	0.98; 1.89	1.29	0.95; 1.75
Consumption of ultra-processed foods (groups)
0	6.8	Reference		Reference		5.4	Reference		Reference
1-2	7.2	1.05	0.57; 1.94	1.57	0.79; 3.10	6.0	1.11	0.65; 1.89	1.22	0.72; 2.08
≥ 3	6.9	1.01	0.55; 1.84	1.57	0.71; 3.46	6.4	1.19	0.64; 2.21	1.24	0.67; 2.30
Vitamin A supplement use ^###
Yes	7.1	Reference		Reference		6.1	Reference		Reference
No	7.0	0.99	0.61; 1.59	0.91	0.56; 1.50	6.2	1.01	0.71; 1.44	0.97	0.67; 1.39

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[1] Correspondence
G. Kac Departamento de Nutrição Social e Aplicada, Instituto de Nutrição Josué de Castro, Universidade Federal do Rio de Janeiro. Av. Carlos Chagas Filho 373, Centro de Ciências da Saúde, Bloco J, 2° andar, sala 29, Rio de Janeiro, RJ 21941-902, Brasil. gilberto.kac@gmail.com