Abstract

This study aimed to review food and nutrition insecurity indicators associated with iron deficiency anemia in Brazilian children below 5 years. We searched in electronic databases (SciELO, Lilacs, and Medline) and selected studies by titles, abstracts and full-text reading. Of the 1,023 studies analyzed, 11 fit the inclusion criteria. The results of the studies evidenced that iron deficiency anemia in Brazilian children was associated with sociodemographic and health indicators (male, age below 24 months, children of adolescent mothers, respiratory infections, diarrhea, low maternal schooling, parents’ working conditions, nursery time, lack of basic sanitation, maternal anemia, lack of ferrous sulfate use by the mother and/or child and late onset of prenatal care), nutritional indicators (low birth weight, diet characteristics, such as the habit of milk consumption close to meals, low exclusive and full breastfeeding time) and economic indicators (low per capita income). The food and nutrition insecurity analyzed in this study from the perspective of different indicators is associated with iron deficiency anemia in children under 5 years in Brazil.

Key words
Iron deficiency anemia; Iron deficiency; Food and nutrition security; Children

Introduction

Micronutrient deficiency is an important public health problem, especially in developing countries. According to the World Health Organization (WHO), approximately 2 billion people worldwide suffer from hidden hunger, which is the subclinical deficiency of micronutrients, and the main ones ate vitamin A, iron, zinc and iodine¹1. Organización Mundial de la Salud (OMS). Documento final de la Segunda Conferencia Internacional sobre Nutrición: Declaracion de Roma sobre la Nutrición. Roma: OMS; 2014..

Iron deficiency is a three-stage process that affects all cells of the human body. The first stage is iron stock depletion, followed by iron-deficient erythropoiesis and then, ultimately, iron deficiency anemia, characterized by reduced hemoglobin levels. Iron deficiency and iron deficiency anemia result from imbalanced amount of bioavailable iron absorbed in the diet and the body's need for this mineral²2. Rodrigues VC, Mendes BD, Gozzi A, Sandrini F, Santana RG, Matioli G. Deficiência de ferro, prevalência de anemia e fatores associados em crianças de creches públicas do oeste do Paraná, Brasil. Rev Nutr 2011; 24(3):407-420..

Iron deficiency anemia is a nutritional disorder that compromises the immune system and impairs children's growth and development³3. World Health Organization (WHO). Growth Reference 5-19 Years. Genava: WHO; 2007. [acessado 2015 Jul 15] Disponível em http://who.org.int/growthref/who.pdf.
http://who.org.int/growthref/who.pdf... . The children's public is a group vulnerable to iron deficiency due to the increased demand of this mineral under the intense growth speed. In addition, some negative childhood dietary factors may step up this vulnerability, such as insufficient iron-source food consumption (beef, liver, chicken, fish and dark green vegetables)²2. Rodrigues VC, Mendes BD, Gozzi A, Sandrini F, Santana RG, Matioli G. Deficiência de ferro, prevalência de anemia e fatores associados em crianças de creches públicas do oeste do Paraná, Brasil. Rev Nutr 2011; 24(3):407-420.^,33. World Health Organization (WHO). Growth Reference 5-19 Years. Genava: WHO; 2007. [acessado 2015 Jul 15] Disponível em http://who.org.int/growthref/who.pdf.
http://who.org.int/growthref/who.pdf... and intake of cow and goat milk in the first six months of life, which, in addition to low iron content, may cause gastrointestinal bleeding and lead to fecal blood loss⁴4. Janus J, Moerschel, SK. Evaluation of anemia in children. Am. Fam. Physician 2010; 81(12):1462-1471..

Anemia affects approximately 1.62 million individuals worldwide, and the occurrence due to iron deficiency is 2.5 times more likely⁵5. Oliveira TSC, Lamounier JA, Alves CRL, Capanema FD, Rocha DS, Silva MC. Anemia entre pré-escolares - um problema de saúde pública em Belo Horizonte, Brasil. Cien Saude Colet 2014; 19(1):59-66.^,66. World Health Organization (WHO). Worldwide prevalence of anemia 1993-2005: WHO global data base on anemia. Geneva: WHO; 2008.. In Brazil, according to data from the National Demography and Women and Child Health Survey⁷7. Brasil. Ministério da Saúde (MS). Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher – PNDS 2006: Dimensões do processo reprodutivo e da saúde da criança. Brasília: MS; 2006., the prevalence of anemia in children under the age of 5 was 20.9%, with highest prevalence observed in the Southeast and Northeast regions of the country (22.6% and 25.5%, respectively).

The Food and Nutrition Security (FNS) refers to ensuring access to adequate and healthy food. It is a multidimensional concept that encompasses the field of production, availability and access to food, adequate health conditions, education, housing and basic sanitation⁸8. Brasil. Lei n° 11.346, de 15 de setembro de 2006. Lei Orgânica de Segurança Alimentar e Nutricional. Dispõe sobre a Criação do Sistema Nacional de Segurança Alimentar e Nutricional–SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 set.. Thus, indicators of multiple vulnerabilities related to access, consumption and biological use of food, social, economic and nutritional status conditions are adopted to characterize situations of violation of this right, that is, food and nutritional insecurity⁸8. Brasil. Lei n° 11.346, de 15 de setembro de 2006. Lei Orgânica de Segurança Alimentar e Nutricional. Dispõe sobre a Criação do Sistema Nacional de Segurança Alimentar e Nutricional–SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 set..

Some indicators, such as low per capita household income, low maternal schooling, higher number of children, high density of inhabitants per room, poor access to public services, such as basic sanitation and electricity, quantitatively and qualitatively inadequate food consumption, among others, evidence situations of food and nutritional insecurity that predispose to the risk of developing deficiency diseases, including iron deficiency anemia⁹9. Oliveira JS, Lira PIC, Maia SR, Sequeira LAS, Amorim RCA, Batista Filho M. Insegurança alimentar e estado nutricional de crianças de Gameleira, zona da mata do Nordeste brasileiro. Rev Bras Saúde Matern Infan 2010; 10(2):237-245.^,1010. Morais DC, Dutra LV, Franceschini SCC, Priore SE. Insegurança alimentar e indicadores antropométricos, dietéticos e sociais em estudos brasileiros: uma revisão sistemática. Cien Saude Colet 2014; 19(5):1475-1488..

While iron deficiency anemia is a public health problem democratically distributed among different socioeconomic classes, situations that characterize a food and nutritional insecurity situation may favor and contribute to the onset of this disease⁹9. Oliveira JS, Lira PIC, Maia SR, Sequeira LAS, Amorim RCA, Batista Filho M. Insegurança alimentar e estado nutricional de crianças de Gameleira, zona da mata do Nordeste brasileiro. Rev Bras Saúde Matern Infan 2010; 10(2):237-245..

In light the above, this paper aimed to review food and nutritional insecurity indicators associated with iron deficiency anemia in Brazilian children under 5 years of age.

Methods

This paper was elaborated following a systematic search in electronic databases SciELO, Lilacs and Medline. We included studies published in the last 11 years starting in 2004, when iron and folic acid compound fortification started to be implemented to meet one of the objectives of the National Food and Nutrition Security Plan, which refers to the prevention of nutritional deficiencies¹¹11. Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Secretaria Nacional de Segurança Alimentar e Nutricional – SESAN. Câmara Interministerial de Segurança Alimentar e Nutricional – CAISAN. Brasília: MDS; 2011.. Keywords used were breastfeeding, nutritional indicators, iron deficiency, hidden hunger and maternal anemia in both Portuguese and English equivalents.

This systematic review included original papers conducted in Brazil that associated iron deficiency anemia in Brazilian children under the age of five with possible food and nutritional insecurity indicators, categorized as: economic, nutritional, sociodemographic and health. Review papers, monographs, dissertations, theses, book chapters and studies with children from other countries were excluded.

Papers were systematically reviewed and, initially, two authors participated in the analysis of titles and abstracts. Any disagreement between the two evaluators ensued the participation of a third author, who analyzed the papers.

For the preparation of the systematic review, we first searched for keywords in the databases previously described and identified 1,023 studies published in the period of interest. The next step consisted of selecting and reviewing works, evaluating the titles first, in which 972 studies were excluded, of which 569 did not address the topic of this review, 81 were duplicated studies and 322 were conducted on a non-Brazilian population.

After reading abstracts of the remaining 51 studies, 31 were excluded because they did not analyze the association with food and nutritional insecurity indicators. A total of 20 papers were fully analyzed, of which 9 were excluded as they included children older than 5 years. Thus, 11 studies fit the inclusion criteria and were adopted in this systematic review (Figure 1).

Results

The 11 selected studies reflect the relationship between food and nutritional insecurity indicators with iron deficiency anemia, and in all of them iron deficiency anemia was associated with some sociodemographic and health indicator; association with economic indicators was observed in four, and seven were associated with nutritional indicators.

The sociodemographic and health indicators described by studies, which were associated (p < 0.05) with iron deficiency anemia were: age less than 24 months¹²12. Neves MBP, Silva EMK, Morais MB. Prevalência e fatores associados à deficiência de ferro em lactentes atendidos em um centro de saúde-escola em Belém, Pará, Brasil. Cad Saude Publica 2005; 21(6):1911-1918.

13. Oliveira MAA, Osório MM, Raposo MCF. Concentração de hemoglobina e anemia em crianças no Estado de Pernambuco, Brasil: fatores socioeconômicos e de consumo alimentar associados. Cad Saude Publica 2006; 22(10):2169-2178.

14. Vieira ACF, Diniz AS, Cabral PC, Oliveira RS, Lóla MMF, Silva SMM, Kolsteren P. Avaliação do estado nutricional de ferro e anemia em crianças menores de 5 anos de creches públicas. Jornal de Pediatria 2007; 83(4):370-376.

15. Leal LP, Filho MB, Lira PIC, Figueiroa JN, Osório MM. Prevalência da anemia e fatores associados em crianças de 6 a 59 meses de Pernambuco. Rev Saude Publica 2011; 45(3):457-466.^-1616. Lisboa MBMC, Oliveira EO, Lamounier JA, Silva CAM, Freitas RN. Prevalência de anemia ferropriva em crianças menores de 60 meses: estudo de base populacional no Estado de Minas Gerais, Brasil. Rev Nutr 2015; 28(2):121-131., maternal age less than 20 years¹⁷17. Spinelli MGN, Marchioni DML, Souza JMP, Souza SB, Szarfarc SC. Fatores de risco para anemia em crianças de 6 a 12 meses no Brasil. J Public Health 2005; 17(2):84-91.^,1818. Konstantyner T, Taddei JAAC, Oliveira MN, Palma D, Colugnati FAB. Isolated and combined risks for anemia in children attending the nurseries of daycare centers. Jornal de Pediatria 2009; 85(3):209-216., male children¹⁷17. Spinelli MGN, Marchioni DML, Souza JMP, Souza SB, Szarfarc SC. Fatores de risco para anemia em crianças de 6 a 12 meses no Brasil. J Public Health 2005; 17(2):84-91.^,1919. Castro TG, Nunes MS, Conde WL, Muniz PT, Cardoso MA. Anemia e deficiência de ferro em pré-escolares da Amazônia Ocidental brasileira: prevalência e fatores associados. Cad Saude Publica 2011; 27(1):131-142., number of residents at home²2. Rodrigues VC, Mendes BD, Gozzi A, Sandrini F, Santana RG, Matioli G. Deficiência de ferro, prevalência de anemia e fatores associados em crianças de creches públicas do oeste do Paraná, Brasil. Rev Nutr 2011; 24(3):407-420.^,1515. Leal LP, Filho MB, Lira PIC, Figueiroa JN, Osório MM. Prevalência da anemia e fatores associados em crianças de 6 a 59 meses de Pernambuco. Rev Saude Publica 2011; 45(3):457-466.^,2020. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236., low maternal schooling¹³13. Oliveira MAA, Osório MM, Raposo MCF. Concentração de hemoglobina e anemia em crianças no Estado de Pernambuco, Brasil: fatores socioeconômicos e de consumo alimentar associados. Cad Saude Publica 2006; 22(10):2169-2178.^,1515. Leal LP, Filho MB, Lira PIC, Figueiroa JN, Osório MM. Prevalência da anemia e fatores associados em crianças de 6 a 59 meses de Pernambuco. Rev Saude Publica 2011; 45(3):457-466.^,2020. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236., geographical area¹³13. Oliveira MAA, Osório MM, Raposo MCF. Concentração de hemoglobina e anemia em crianças no Estado de Pernambuco, Brasil: fatores socioeconômicos e de consumo alimentar associados. Cad Saude Publica 2006; 22(10):2169-2178., no home ownership¹⁹19. Castro TG, Nunes MS, Conde WL, Muniz PT, Cardoso MA. Anemia e deficiência de ferro em pré-escolares da Amazônia Ocidental brasileira: prevalência e fatores associados. Cad Saude Publica 2011; 27(1):131-142., respiratory infections and diarrhea²2. Rodrigues VC, Mendes BD, Gozzi A, Sandrini F, Santana RG, Matioli G. Deficiência de ferro, prevalência de anemia e fatores associados em crianças de creches públicas do oeste do Paraná, Brasil. Rev Nutr 2011; 24(3):407-420.^,1919. Castro TG, Nunes MS, Conde WL, Muniz PT, Cardoso MA. Anemia e deficiência de ferro em pré-escolares da Amazônia Ocidental brasileira: prevalência e fatores associados. Cad Saude Publica 2011; 27(1):131-142., parental work conditions²¹21. Netto MP, Rocha DS, Franceschini SCC, Lamounier JA. Fatores associados à anemia em lactentes nascidos a termo e sem baixo peso. Rev Assoc Med Bras 2011; 57(5):550-558., day-care time²2. Rodrigues VC, Mendes BD, Gozzi A, Sandrini F, Santana RG, Matioli G. Deficiência de ferro, prevalência de anemia e fatores associados em crianças de creches públicas do oeste do Paraná, Brasil. Rev Nutr 2011; 24(3):407-420., lack of basic sanitation²2. Rodrigues VC, Mendes BD, Gozzi A, Sandrini F, Santana RG, Matioli G. Deficiência de ferro, prevalência de anemia e fatores associados em crianças de creches públicas do oeste do Paraná, Brasil. Rev Nutr 2011; 24(3):407-420.^,1515. Leal LP, Filho MB, Lira PIC, Figueiroa JN, Osório MM. Prevalência da anemia e fatores associados em crianças de 6 a 59 meses de Pernambuco. Rev Saude Publica 2011; 45(3):457-466. and maternal anemia¹⁹19. Castro TG, Nunes MS, Conde WL, Muniz PT, Cardoso MA. Anemia e deficiência de ferro em pré-escolares da Amazônia Ocidental brasileira: prevalência e fatores associados. Cad Saude Publica 2011; 27(1):131-142. (Chart 1).

Regarding economic indicators associated with iron deficiency anemia, in children under the age of five, low per capita income was unanimous among studies¹⁷17. Spinelli MGN, Marchioni DML, Souza JMP, Souza SB, Szarfarc SC. Fatores de risco para anemia em crianças de 6 a 12 meses no Brasil. J Public Health 2005; 17(2):84-91.^,2020. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236.^,2121. Netto MP, Rocha DS, Franceschini SCC, Lamounier JA. Fatores associados à anemia em lactentes nascidos a termo e sem baixo peso. Rev Assoc Med Bras 2011; 57(5):550-558. (Chart 1).

As to nutritional indicators, there is a lack of or low total breastfeeding¹⁷17. Spinelli MGN, Marchioni DML, Souza JMP, Souza SB, Szarfarc SC. Fatores de risco para anemia em crianças de 6 a 12 meses no Brasil. J Public Health 2005; 17(2):84-91.^,2020. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236.^,2121. Netto MP, Rocha DS, Franceschini SCC, Lamounier JA. Fatores associados à anemia em lactentes nascidos a termo e sem baixo peso. Rev Assoc Med Bras 2011; 57(5):550-558. and exclusive breastfeeding¹⁸18. Konstantyner T, Taddei JAAC, Oliveira MN, Palma D, Colugnati FAB. Isolated and combined risks for anemia in children attending the nurseries of daycare centers. Jornal de Pediatria 2009; 85(3):209-216. time, low birth weight¹⁷17. Spinelli MGN, Marchioni DML, Souza JMP, Souza SB, Szarfarc SC. Fatores de risco para anemia em crianças de 6 a 12 meses no Brasil. J Public Health 2005; 17(2):84-91.^,1919. Castro TG, Nunes MS, Conde WL, Muniz PT, Cardoso MA. Anemia e deficiência de ferro em pré-escolares da Amazônia Ocidental brasileira: prevalência e fatores associados. Cad Saude Publica 2011; 27(1):131-142., early introduction of food²⁰20. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236., milk intake close to meals¹³13. Oliveira MAA, Osório MM, Raposo MCF. Concentração de hemoglobina e anemia em crianças no Estado de Pernambuco, Brasil: fatores socioeconômicos e de consumo alimentar associados. Cad Saude Publica 2006; 22(10):2169-2178.^,2020. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236., non-use of ferrous sulfate by mother and/or child and late onset of prenatal care²¹21. Netto MP, Rocha DS, Franceschini SCC, Lamounier JA. Fatores associados à anemia em lactentes nascidos a termo e sem baixo peso. Rev Assoc Med Bras 2011; 57(5):550-558. (Chart 1).

Discussion

Iron deficiency anemia is one of the greatest public health problems in the world, and stands out as the main nutritional deficiency due to negative health effects. Children under the age of five are among the vulnerable groups, due to increased demands for growth and development, typical of this stage¹⁶16. Lisboa MBMC, Oliveira EO, Lamounier JA, Silva CAM, Freitas RN. Prevalência de anemia ferropriva em crianças menores de 60 meses: estudo de base populacional no Estado de Minas Gerais, Brasil. Rev Nutr 2015; 28(2):121-131.^,1717. Spinelli MGN, Marchioni DML, Souza JMP, Souza SB, Szarfarc SC. Fatores de risco para anemia em crianças de 6 a 12 meses no Brasil. J Public Health 2005; 17(2):84-91.. Among the main consequences of iron deficiency anemia are impaired psychomotor development and cognitive function and increased susceptibility to infections⁷7. Brasil. Ministério da Saúde (MS). Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher – PNDS 2006: Dimensões do processo reprodutivo e da saúde da criança. Brasília: MS; 2006.^,1616. Lisboa MBMC, Oliveira EO, Lamounier JA, Silva CAM, Freitas RN. Prevalência de anemia ferropriva em crianças menores de 60 meses: estudo de base populacional no Estado de Minas Gerais, Brasil. Rev Nutr 2015; 28(2):121-131.^,1717. Spinelli MGN, Marchioni DML, Souza JMP, Souza SB, Szarfarc SC. Fatores de risco para anemia em crianças de 6 a 12 meses no Brasil. J Public Health 2005; 17(2):84-91..

Regarding the sociodemographic factors quoted by studies of this review, we highlight the age of less than 24 months, the high number of residents in the household and maternal schooling²2. Rodrigues VC, Mendes BD, Gozzi A, Sandrini F, Santana RG, Matioli G. Deficiência de ferro, prevalência de anemia e fatores associados em crianças de creches públicas do oeste do Paraná, Brasil. Rev Nutr 2011; 24(3):407-420.^,1212. Neves MBP, Silva EMK, Morais MB. Prevalência e fatores associados à deficiência de ferro em lactentes atendidos em um centro de saúde-escola em Belém, Pará, Brasil. Cad Saude Publica 2005; 21(6):1911-1918.

13. Oliveira MAA, Osório MM, Raposo MCF. Concentração de hemoglobina e anemia em crianças no Estado de Pernambuco, Brasil: fatores socioeconômicos e de consumo alimentar associados. Cad Saude Publica 2006; 22(10):2169-2178.

14. Vieira ACF, Diniz AS, Cabral PC, Oliveira RS, Lóla MMF, Silva SMM, Kolsteren P. Avaliação do estado nutricional de ferro e anemia em crianças menores de 5 anos de creches públicas. Jornal de Pediatria 2007; 83(4):370-376.^-1515. Leal LP, Filho MB, Lira PIC, Figueiroa JN, Osório MM. Prevalência da anemia e fatores associados em crianças de 6 a 59 meses de Pernambuco. Rev Saude Publica 2011; 45(3):457-466.^,2020. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236.. In addition to these sociodemographic factors, other studies⁹9. Oliveira JS, Lira PIC, Maia SR, Sequeira LAS, Amorim RCA, Batista Filho M. Insegurança alimentar e estado nutricional de crianças de Gameleira, zona da mata do Nordeste brasileiro. Rev Bras Saúde Matern Infan 2010; 10(2):237-245.^,2222. Araújo TS, Muniz PT, Cardoso MA, Oliveira CSM. Anemia em crianças de 6 a 59 meses e fatores associados no Município de Jordão, Estado do Acre, Brasil. Cad Saude Publica 2011; 27(5):1008-1020. found an association of iron deficiency anemia with lower age and maternal schooling.

Situations of multiple vulnerabilities, such as the high number of residents in the household, lower level of maternal schooling, lower per capita monthly income and lower purchasing power influence and hinder the conditions of access to adequate and healthy food, which may favor the onset of nutritional deficiencies, such as iron deficiency anemia²³23. Vieira RCS, Ferreira HS, Costa ACS, Moura FA, Florêncio TAMT, Torres ZMC. Prevalência e fatores de risco para anemia em crianças pré-escolares, Alagoas, Brasil. Rev Bras Saúde Matern Infant 2010; 10(1):107-116..

The association of iron deficiency anemia with the lowest maternal age, especially in relation to adolescent pregnant women can be attributed to lower child care experience (mother-child bonding), which reflects, in most cases, the lack of knowledge or appropriate guidance during prenatal care, which in some situations is not even adequately performed⁹9. Oliveira JS, Lira PIC, Maia SR, Sequeira LAS, Amorim RCA, Batista Filho M. Insegurança alimentar e estado nutricional de crianças de Gameleira, zona da mata do Nordeste brasileiro. Rev Bras Saúde Matern Infan 2010; 10(2):237-245.^,2222. Araújo TS, Muniz PT, Cardoso MA, Oliveira CSM. Anemia em crianças de 6 a 59 meses e fatores associados no Município de Jordão, Estado do Acre, Brasil. Cad Saude Publica 2011; 27(5):1008-1020..

The low per capita monetary income was the economic indicator most cited by studies associated with anemia¹²12. Neves MBP, Silva EMK, Morais MB. Prevalência e fatores associados à deficiência de ferro em lactentes atendidos em um centro de saúde-escola em Belém, Pará, Brasil. Cad Saude Publica 2005; 21(6):1911-1918.^,1313. Oliveira MAA, Osório MM, Raposo MCF. Concentração de hemoglobina e anemia em crianças no Estado de Pernambuco, Brasil: fatores socioeconômicos e de consumo alimentar associados. Cad Saude Publica 2006; 22(10):2169-2178.^,1818. Konstantyner T, Taddei JAAC, Oliveira MN, Palma D, Colugnati FAB. Isolated and combined risks for anemia in children attending the nurseries of daycare centers. Jornal de Pediatria 2009; 85(3):209-216.. Besides providing access to food, income is related to housing and basic sanitation conditions, important for the biological use of food nutrients, and thus low income situations are directly related to two important determinants of FNS – body access and utilization of food – which may lead to situations of insecurity, especially in cases where low income is found in conjunction with other indicators mentioned in this review.

Regarding the observed association of anemia with the age of less than 24 months, it is believed that the risk of developing iron deficiency anemia in this age group is due to the accelerated growth characteristic of this stage, along with nutritional indicators, such as the transition diet, which is usually composed of food with low iron bioavailability, low prevalence of breastfeeding and respiratory infections and diarrhea⁹9. Oliveira JS, Lira PIC, Maia SR, Sequeira LAS, Amorim RCA, Batista Filho M. Insegurança alimentar e estado nutricional de crianças de Gameleira, zona da mata do Nordeste brasileiro. Rev Bras Saúde Matern Infan 2010; 10(2):237-245.^,1212. Neves MBP, Silva EMK, Morais MB. Prevalência e fatores associados à deficiência de ferro em lactentes atendidos em um centro de saúde-escola em Belém, Pará, Brasil. Cad Saude Publica 2005; 21(6):1911-1918.^,2424. World Health Organization (WHO). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and mineral nutrition information system. Geneva: WHO; 2011..

Food and nutritional insecurity nutritional indicators shown in this review were summarized in birth conditions (low birth weight), breastfeeding and early introduction of complementary foods.

In a national study regarding factors associated with anemia in Brazilian children aged 6 to 12 months, authors described a prevalence of anemia of 65.45%, and its association (p<0.05) with low birth weight and prematurity¹²12. Neves MBP, Silva EMK, Morais MB. Prevalência e fatores associados à deficiência de ferro em lactentes atendidos em um centro de saúde-escola em Belém, Pará, Brasil. Cad Saude Publica 2005; 21(6):1911-1918.. One of the possible explanations for this association was the low iron reserves at birth, mainly due to prematurity and low weight, and the higher demand of this mineral for the growth process²¹21. Netto MP, Rocha DS, Franceschini SCC, Lamounier JA. Fatores associados à anemia em lactentes nascidos a termo e sem baixo peso. Rev Assoc Med Bras 2011; 57(5):550-558..

In a study on anemia and iron deficiency in preschoolers in the Brazilian Western Amazon, authors observed a prevalence of anemia, iron deficiency anemia and iron deficiency of 30.6%, 20.9% and 43.5%, respectively, and association (p <0.05) with low birth weight and male gender¹⁹19. Castro TG, Nunes MS, Conde WL, Muniz PT, Cardoso MA. Anemia e deficiência de ferro em pré-escolares da Amazônia Ocidental brasileira: prevalência e fatores associados. Cad Saude Publica 2011; 27(1):131-142.. The association between iron deficiency anemia and male gender is related to greater weight gain, increased erythropoiesis activity in fetal life, lower reserves, greater intestinal losses and lower iron absorption observed in boys in relation to girls²⁵25. Domellof M, Lonnerdal B, Dewey KG, Cohen RJ, Rivera LL, Hernell O. Sex differences in iron status during infancy. Pediatrics 2002; 110(3):545-552..

Studies²⁰20. Netto MP, Priore SE, Sant'ana HMP, Peluzio MCG, Sabarense CM, Silva DG, Franceschini SCC. Prevalência e fatores associados à anemia e deficiência de ferro em crianças de 18 a 24 meses. Arch Latinoam Nutr 2006; 56(3):229-236.^,2626. Gondim SSR, Diniz AS, Souto RA, Bezerra RGS, Albuquerque EC, Paiva AA. Magnitude, tendência temporal e fatores associados à anemia em crianças do Estado da Paraíba. Rev Saude Publica 2012; 46(4):649-656.

27. Souto TE, Oliveira MN, Casoy F, Machado EHS, Juliano Y, Gouvêa LC. Anemia e renda per capita familiar de crianças frequentadoras da creche do Centro Educacional Unificado Cidade Dutra, no Município de São Paulo. Rev Paul Pediatr 2007; 25(2):161-166.

28. Assunção MCF, Santos IS, Barros AJD, Gigante DP, Victora CG. Anemia em menores de seis anos: estudo de base populacional em Pelotas, RS. Rev Saude Publica 2007; 41(3):328-335.^-2929. Reis MCG, Nakano AMS, Silva IA, Gomes FA, Pereira MJB. Prevalence of Anemia in Children Three to 12 Months Old in a Health Service in Ribeirão Preto, São Paulo, Brazil. Rev Latino-Am Enfermagem 2010; 18(4):792-799. related to factors associated with anemia and iron deficiency in children showed association (p <0.05) with other nutritional indicators, such as age of introduction of juices and/or fruits, milk consumption close to meals and total breastfeeding time, and the highest prevalence was found in children younger than 24 months of age. We must emphasize that it is difficult to establish critical hemoglobin values as a cutoff point in children younger than 6 months of life due to the rapid changes in concentration of this biochemical indicator in this life stage³⁰30. Szarfarc SC, Souza SB, Furumoto RAV, Brunken GS, Assis AMO, Gaudenzi EM, Silva RCR, Souza JMP. Concentração de hemoglobina em crianças do nascimento até um ano de vida. Cad Saude Publica 2004; 20(1):266-274..

The consumption of fluid cow milk was one of the main determinants of anemia in the first year of life; cow milk's casein and whey proteins, which are the protein fraction of most milk formulas and industrialized infant foods have a negative influence on iron absorption, which are aggravated by increased nutritional requirements as a result of children's accelerated growth²⁴24. World Health Organization (WHO). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and mineral nutrition information system. Geneva: WHO; 2011.. Milk and its derivatives, such as yogurt and cheese have calcium and, when consumed during or near meals, inhibit iron absorption³¹31. Sociedade Brasileira de Pediatria (SBP). Anemia ferropriva em lactentes: revisão com foco em prevenção. Departamento Científico de Nutrologia. São Paulo: SBP; 2012..

It is believed that the situation of food and nutritional insecurity analyzed under the perspective of different indicators that encompass the multidetermination involved with the Brazilian concept of FNS is influenced by inequalities related to the exclusionary social and economic system³²32. Barroso GS, Sichieri R, Salles-Costa R. Fatores associados ao déficit nutricional em crianças residentes em uma área de prevalência elevada de insegurança alimentar. Rev Brasileira de Epidemiologia 2008; 11(3):484-494., and poverty and social inequities are determinants of this phenomenon³³33. Sicoli JL. Pactuando conceitos fundamentais para a construção de um sistema de monitoramento da SAN. Instituto Pólis, São Paulo, 2005. [acessado 2012 Jul 25]. Disponível em: http://www.polis.org.br/download/65.pdf.
http://www.polis.org.br/download/65.pdf... ^,3434. Segall-Corrêa AM, Marin-Leon L, Helito H, Pérez-Escamilla R, Santos LMP, Paes-Sousa R. Transferência de renda e segurança alimentar no Brasil: análise dos dados nacionais. Rev Nutr 2008; 21(Supl.):39-51..

Most of the studies analyzed in this systematic review that evaluated food and nutritional insecurity indicators associated with iron deficiency anemia in Brazilian children under five years of age are cross-sectional observational studies. This type of epidemiological design hinders the establishment of causal relationships, which is a limitation of this systematic review and highlights the importance of conducting longitudinal studies with determinants of iron deficiency anemia in Brazilian children.

Conclusion

Analyzed from the perspective of different indicators, food and nutritional insecurity is related to iron deficiency anemia in Brazilian children under 5 years of age. The insecurity conditions evaluated according to the indicators mentioned above indicate the need for investments to improve living conditions, as well as the need to promote breastfeeding and appropriate introduction of complementary feeding.

This review evidenced that iron deficiency anemia was associated with sociodemographic and health (male gender, age less than 24 months, no nursery attendance, children of adolescent mothers, high number of residents in the same household, respiratory infections, diarrhea, low level of maternal schooling), nutritional (low birth weight, dietary characteristics, “habit of ingesting milk close to meal times” and early introduction of complementary food) and economic (low per capita income) indicators that reflect the social determination of this deficiency.

In order to ensure FNS, it is necessary to adopt intersectoral measures that focus on the multiple determinants involved in this right, especially those related to access to adequate and healthy food and food biological utilization, which are directly related to micronutrient deficiencies that affect a significant proportion of the population, especially children.

References

Publication Dates

History