REVISTA
PAULISTA
DE
PEDIATRIA
www.rpped.com.br
ORIGINAL
ARTICLE
Short
stature
in
children
of
Karapotó
ethnic
background,
São
Sebastião,
Alagoas,
Brazil
Samara
Bomfim
Gomes
Campos
a,
Risia
Cristina
Egito
de
Menezes
a,∗,
Maria
Alice
Araújo
Oliveira
a,
Danielle
Alice
Vieira
da
Silva
a,
Giovana
Longo-Silva
a,
Juliana
Souza
Oliveira
b,
Leiko
Asakura
a,
Emília
Chagas
Costa
b,
Vanessa
Sá
Leal
baUniversidadeFederaldeAlagoas(UfAl),Maceió,AL,Brazil
bUniversidadeFederaldePernambuco(UFPE),VitóriadeSantoAntão,PE,Brazil
Received14May2015;accepted30August2015 Availableonline26February2016
KEYWORDS
Indigenous population; Nutritionalstatus; Anthropometry; Malnutrition
Abstract
Objective: To describe the prevalence ofshort stature among children ofKarapotó ethnic background.
Methods: Cross-sectional, population-based study that included children between 6 and 59 months of age from the Plak-Ô native village and the Terra Nova settlement, São Sebastião,Alagoas,carriedoutbetween2008and2009.Shortstaturewasevaluatedbythe Height/Ageindex,usingascutoffzscore≤−2.Theprevalenceofshortstaturewasdetermined bycompa-ringsimpleandrelativefrequencies.Thepopulationgrowthcurveswerecompared totheWHOreferencecurves.Data analysisincludedtheoutcome variable:Height/Ageand thepredictorvariables:placeofresidence,gender,age,anemia,birthweight,familyincome, maternalliteracy.Thechi-squaretestwasusedtocomparethecategoricalvariables,where asthechi-squaretestwithYatescorrectionwasusedfordichotomousvariables,consideringas statisticallysignificantp-values≤0.05.
Results: Theprevalenceofshortstaturewas15.6%forchildrenfromtheTerraNovasettlement and 9.1%for thosefrom Plak-Ô native village. The prevalence ofshort statureamong the Karapotó ethnicitywas13.4%.Thevariables:maternal literacy,familyincomeandlowbirth weightwerestatisticallyassociatedwithshortstature.
Conclusions: Theobservedshortstatureprevalenceratesaresignificant,beingcharacterized asapublichealthproblem.Amongtheassociatedfactors,thefollowingarenoteworthy: unfa-vorableconditionsofmaternalliteracy,familyincomeandlowbirthweight.Theplanningof strategiestoreversethesituationmusttakesuchfactorsintoconsideration.
©2015SociedadedePediatriadeSãoPaulo.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(https://creativecommons.org/licenses/by/4.0/).
∗Correspondingauthor.
E-mail:[email protected](R.C.E.Menezes). http://dx.doi.org/10.1016/j.rppede.2016.02.006
PALAVRAS-CHAVE
Populac¸ãoindígena; Estadonutricional; Antropometria; Desnutric¸ão
Déficitestaturalemcrianc¸asdopovoKarapotó,SãoSebastião,Alagoas,Brasil
Resumo
Objetivo: Descreveraprevalênciadodéficitestaturalentrecrianc¸asdapovokarapotó. Métodos: Estudotransversal,debasepopulacional,incluiucrianc¸asentreseise59mesesda aldeiaPlak-ÔedopovoadoTerraNova,SãoSebastião(AL),feitoentre2008e2009.Odéficit estaturalfoiavaliadopeloíndiceestatura/idade,adotou-secomopontodecorteescorez≤−2. Aprevalênciadedéficitestaturalfoideterminadapelacomparac¸ãodasfrequênciassimplese relativas.Ascurvasdecrescimentodapopulac¸ãoforamcomparadascomascurvasde refer-ência daOMS. A análisedos dadoscontemplou avariável dedesfecho estatura/idade eas variáveis preditoraslocal de moradia,sexo, idade,anemia, pesoao nascer, rendafamiliar, alfabetizac¸ãomaterna.Paracomparac¸ãodasvariáveiscategóricasdosgruposfoiusadooteste doqui-quadradoeotestedoqui-quadradocomcorrec¸ãodeYatesparaasvariáveisdicotômicas, consideraram-secomosignificânciaestatísticap-valores≤0,05.
Resultados: Aprevalênciadedéficitestaturalfoide15,6%paraascrianc¸asdopovoado Terra-Novae 9,1%para as daaldeiaPlak-Ô. A prevalênciade déficit estatural dapovo karapotó foide13,4%. Asvariáveis:alfabetizac¸ãomaterna, rendafamiliarebaixopesoao nascerse relacionaramestatisticamentecomodéficitestatural.
Conclusões: Asprevalênciasdedéficitestaturalverificadassãoexpressivas,sãocaracterizadas comoproblemadesaúdepública.Destacam-se,entreosfatoresassociados,condic¸ões desfa-voráveisdealfabetizac¸ãomaterna,rendafamiliarebaixopesoaonascer.Oplanejamentode estratégiasparamudarasituac¸ãoprecisalevartaisfatoresemconsiderac¸ão.
©2015SociedadedePediatriadeSãoPaulo.PublicadoporElsevierEditoraLtda.Esteéumartigo OpenAccesssobalicençaCCBY(https://creativecommons.org/licenses/by/4.0/deed.pt).
Introduction
Despite their importance, there are few available stud-iesonthesocial,demographicandepidemiologicalprofile oftheBrazilianindigenouspopulation,especiallythefood and nutritional profile. In spite of this lack of informa-tion,recentstudiesshowasocialmarginalization,whichhas resultedinnegativeimpactsonthehealth-diseaseprocess ofthesepopulations.1---3Regardingthenutritionalprofileof
theindigenouspopulationsinBrazil,itisclearthattheyare
goingthroughacomplextransitionprocess,characterized
bytheincreaseinoverweightamongadultsandthe
persis-tenceofhealthproblemsrelatedtonutritionaldeficiencies,
especiallydelayedgrowthinchildren.4---6Thissituationcan
beattributedtoconsiderablesocialdiversityinvolved,ifone
considersthatBrazilhasrecordedmorethan200indigenous
populationsthroughout the national territory.7 As for the
delayedgrowthofindigenouschildren,therearerecordsof
populationsinwhichmorethanhalfwasidentifiedasbeing
affectedby thedisorder. This scenario couldhaveserious
implicationsforthehealthofthispopulation.8
Thus, for Brazil’s indigenous population, there is an
importantoverlap ofdiseases: the increase inoverweight
amongadults, whereas the occurrence of malnutrition in
childrenhas notbeen solved.1,7,9 Consideringtheseissues
havenotyetbeenfullyexploredandinordertocontribute
toabetter understanding of the diseasedynamicsin this
population, this study aimed to describe the prevalence
ofstuntingamongchildren ofkarapotóethnicbackground
residingintwolocationsoftheStateofAlagoas, withthe
purposeof assessing the disease during a period of rapid
nutritionaltransitionthecountryhasbeengoingthrough.
Method
These data are part of the research ‘Food and nutri-tion surveillance: implementationof sentinel areain two populations of karapotó ethnic background’. This is a cross-sectional study, which considered as study unit the populationofchildrenbetweensixand59monthslivingin the Plak-Ô reservation andTerra Nova settlement, in São Sebastião,stateofAlagoas.Theproceduresemployedinthe survey,regardingthestudypopulationanddatacollection, havebeenpreviouslydescribed.9
The modelingprocess wasperformed by censussurvey
carriedoutbynativehealthagents,whoidentifiedthe
chil-dren whoseagewaswithintheage rangespecified bythe
study.Ofthese,fivechildrenwerenotfoundatthetimeof
datacollection,sothestudypopulationconsistedof98
chil-dren. Onechild wasexcludedduetoanthropometricdata
inconsistencyandthefinalsampleconsistedof97children.
The fieldworkwas carriedout between 2008 and 2009
byappropriatelytrainedteam,whowenttothereservation
andthesettlementfourtimesfordatacollection.
Interviewswerecarriedoutwithmothers/tutorsofthe
children through home visits and questionnaires,
consist-ingofquestionsrelatedtosocioeconomic,demographicand
biologicalinformation.Afterthequestionnaireswerefilled
out,theywerereviewedtoassessandcorrect
inconsisten-ciesaboutthecollectedinformation.
The collectionof anthropometricdata andhemoglobin
measurementswerecarriedoutatthereservationandthe
settlement.Theanthropometricassessmentwasperformed
aftertheteam’straining,accordingtotherecommendations
Ministryof Health.10,11 Body weightwasobtainedusingan
anthropometric scale, with a capacity of 200kg and
pre-cision of 50g. To measure the length of children younger
than24 months,awoodeninfantometerwasused,witha
rangeof 100cmand precision of 0cm, and for older
chil-dren, a vertical stadiometer was used, with a range of
213cm.These children wereweighedand measured
bare-footwithminimal clothing.Childrenageduptotwoyears
were measured in thesupine positionand thosebetween
twoandfiveyearsoldinthestandingposition.Two
measure-mentswerecollectedandtheircorrespondingmeanswere
calculated.
TheAnthro2007softwarewasusedtoevaluatethe
nutri-tionalstatus,usingtheheight/ageindexforthediagnosisof
stunting/malnutrition.TheWHOgrowthcurveswereusedas
areference.12,13 Theclassificationofchildrenaccordingto
height/agewasexpressedinz-scores,usingthecutoffpoints
forstunting(≤−2zscores)andnormalheight(>−2zscores).
For the diagnosis of anemia, hemoglobin (Hb) was
measured using a Hemocueportable hemoglobin analyzer
(FreseniusKabi,Uppsala, Sweden),followingthestandard
procedure of collecting a blood drop by fingertip
punc-ture.Thecutoffusedforanemiadiagnosiswashemoglobin
<11g/dL.14 Ironsupplementation wasprovided toall
chil-drendiagnosedwithanemia,withthesupportoftheSpecial
IndigenousDistrict(DSEI-AL).
Forthestoolsamplecollectionforparasitological
analy-sis,containerswerehandedtotheparents/tutors,whowere
asked tocollect stool intheir respectivehouseholds. The
fecalsampleswerecollected,placedinarefrigeratedcool
boxandsentforlaboratoryanalysisusingthespontaneous
sedimentationandKato-Katzmethods.15,16
Doubledataentry, aswell asvalidationandprocessing
oftheanalysiswerecarriedoutusingtheEpi-Infosoftware,
version 6.04 (CDC, Atlanta, USA). The analyzed variables
werecategorizedasplaceofresidence:Plak-Ôreservation
and Terra Nova settlement; garbage collection: classified
as‘adequate’(garbagecollected)or‘inadequate’(garbage
wasburied,burnedorplacedinavacantlot).Thevariable
child’sbirthplacewasdividedbetweenthosewhowereborn
at the hospitalor maternity and thosewhowere born at
home.AboutvitaminAsupplementation,thechild’shealth
card was checked regarding the micronutrient
supple-mentation record. Children born weighing ≥2500g were
classifiedashaving ‘adequateweight’. Those born
weigh-ing <2500gwere classifiedashaving ‘inadequateweight’,
withtheinformationbeingobtainedfromthechild’shealth
card.17Thepercapitafamilyincome(incomeearnedinthe
monthprecedingtheinterview)wasclassifiedaslowerand
higherthanaminimumwage.Thematernallevelof
educa-tionwasclassifiedasmotherswhocouldreadandwriteand
illiterateones.
Theprevalenceofstuntingwasdeterminedbycomparing
thesimpleandrelativefrequencies. Tocompare
categori-calvariables,weusedthechi-squaretestorchi-squaretest
withYatescorrectionandthevalueofp≤0,050was
consid-eredasstatisticallysignificantfordichotomousvariables.To
comparethegrowthcurvesofthestudiedpopulationwith
theWHOreferencecurves,chartsforheight/agewere
pre-paredusingtheAnthrosoftware,accordingtotheplaceof
residence.12 TheprojectwasapprovedbytheInstitutional
Review Board, under protocol number 009 429/2006-15.
Table 1 Characterization of the population of children younger than five years of the karapotó people. São Sebastião-Alagoas,2008/2009.
Variables nwith
information
%
Placeofresidence
Plak-Ô 33 66.0
TerraNova 64 34.0
Gender
Male 44 45.4
Female 53 54.6
Age
<2years 32 33.0
≥2years 65 67.0
Garbagecollection
Adequate ---
---Inadequate 97 100.0
Birthplacea
Maternity/hospital 94 97.9
Home 2 2.1
VitaminAsupplementationa
Yes 67 77.0
No 20 23.0
Irondeficiencyanemia
No 41 42.3
Yes 56 57.7
Presenceofparasiticinfestationa
No 24 32.9
Yes 49 67.1
a Samplelossasdescribed.
Thestudywassubmittedtoandapprovedby theNational ResearchEthicsCommission,asrequiredbythedecree on studiesof indigenous populations, underprotocol number 1,013,414.
Results
The characterization of the population is described in
Table1,whichshowedapredominanceofthefemale
gen-der(54.6%)andthoseaged≥2years(67%).Italsoshowsthat
66%ofthechildrenfromthestudiedpopulationliveinthe
Plak-Ôreservationand34%intheTerraNovasettlement.
Aprevalenceofstuntingof15.6%wasobservedin
chil-drenwhosefamilieslivedintheTerraNovasettlementand
9.1% for those living in the Plak-Ô reservation. For
chil-drenofkarapotóethnicity,theprevalenceofstuntingwas
found tobe13% (Fig.1). The stunting,in mean z-scores,
wasnotsignificantlyassociatedwithgender,age,presence
ofanemiaandplaceofresidence.Forthevariables
mater-naleducation,familyincomeandbirthweight,statistically
significantdifferenceswerefoundamongtheanalyzed
cat-egoriesandweobservedlowermeanzscoresforheight/age
amongchildrenwithlowbirthweight,thosewhosemothers
wereilliterateandinthosebelongingtofamilieswithaper
Table2 Stunting,inmeanzscore,inchildrenyoungerthanfiveyearsofkarapotópeople,accordingtochildandmaternal variables.SãoSebastião-Alagoas,2008/2009.
Variables n % Height/agezscore
¯
x±DP p-value
Placeofresidence
Plak-Ô 33 66.0 −0.27±1.52 0.288
TerraNova 64 34.0 −0.68±1.24
Gender
Male 44 45.4 −0.43±1.33 0.228
Female 53 54.6 −0.64±1.37
Age(years)
<2 32 33.0 −0.56±1.32 0.894
≥2 65 67.0 −0.54±1.37
Anemiainchildren
No 41 42.3 −0.29±1.32 0.098
Yes 56 57.7 −0.73±1.35
Birthweight
Adequate 88 90.7 −0.46±1.28 0.025
Inadequate 9 9.3 −1.35±1.80
Familyincomea
≥1minimumwage 56 58.3 −0.22±1.40 0.026
<1minimumwage 40 41.7 −0.78±1.28
Maternalliteracy
Canreadandwrite 62 63.9 −0.30±1.25 0.011
Illiterate 35 36.8 −0.97±1.42
aValuefortheminimumwagein2008/2009.
86.6 % 90.9 % 84.4 %
9.1 % 13.4 %
Karapotó Plak-Ô Terra Nova
Normal growth (>–2 z scores) Stunting (≤–2 z scores)
15.6 %
Figure1 Nutritionalstatusaccordingtoheight/ageindexin children younger thanfive years ofthe karapotó people, by placeofresidence.SãoSebastião-Alagoas,2008/2009.
Fig.2showsacomparisonofgrowthdeficitaccordingto
the height/age indexof the studied population, withthe
WHO reference curves. The children showed, in general,
lowervaluesofz-scorewhencomparedtotheanalyzed
ref-erencespoints,andshowed,inthetwoplacesofresidence,
growthcurveswithaleft-trendslope.
Discussion
The assessed population inhabits two locations in a city in northeasternBrazil, Sao Sebastião, state of Alagoas, a
semiarid region. The karapotó people consists of an esti-mated populationof1067inhabitants, whoselifestyleand means of support resembles those of the non-indigenous populationofBrazil.18
Regarding the environmental condition, particularly
regardingthegarbagecollectionvariable,itisobservedthat
theassessedpopulationdidnothaveaccesstoadequate
col-lectionofwasteduringtheanalyzedperiod.Thiscondition,
aswell asthe high rateof intestinal parasitic infestation
(67%),amongother issues,hasoftenbeen associatedwith
malnutritioninchildren.1,19Inthecontextofmultiplecauses
associatedtothedisease,thesesanitaryconditionsshould
beconsideredtoestablishthenutritionalcare,whichis
usu-allyalongprocess,especiallywhentheimplementationof
measures toimproveenvironmentalsanitationandquality
oflifehasnotbeenplanned.1,2
In spite of access to hospital childbirth identified in
almostallthestudiedpopulation(approximately98%),poor
accessof thesepeopletohealth services isshown by the
low coverage of supplementation with vitamin A
mega-dosesand itis noteworthythat 23%of thepopulation did
not receive this supplementation. Malnourished children
often hadvitamin Adeficiency, whichsurely compromises
their prognostic.20 Vitamin A should be administered at
prophylactic doses, as determined by the Brazilian
strat-egyofdiseasecontrol.21Theadministrationofthisvitamin
would provide these children with increased resistance
toinfections, particularlyin the respiratoryand digestive
45%
40%
35%
30%
25%
15%
5% 20%
10%
0%
–5 –4.5 –3.5 –2.5 –1.5 –0.5 0 z-score
WHO reference
Karapotó ethnic background
Children
45%
40%
35%
30%
25%
15%
5% 20%
10%
0%
Children
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 –1
–2 –3
–4 –5 –4.5 –3.5 –2.5 –1.5 –0.5 0
z-score
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 –1
–2 –3 –4
45%
40%
35%
30%
25%
15%
5% 20%
10%
0%
Children
–5 –4.5 –3.5 –2.5 –1.5 –0.5 0 z-score
0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 –1
–2 –3 –4
WHO reference Terra Nova settlement
WHO reference Plak-Ô reservation
Figure2 Comparisonofthegrowthcurveofchildrenyoungerthanfiveyearsoldofthekarapotópeople,withtheWHOcurve, accordingtoheight/ageindex,byplaceofresidence.SãoSebastião-Alagoas,2008/2009.
anddiarrhea,extremelycommondiseases atthisstageof life.21
Anothernutritionalproblemidentifiedinthispopulation
wasiron-deficiencyanemia,whichaffected almost60%of
thepopulationinthisperiod.Thistypeofanemia,common
amongBrazilianchildren,negativelyaffectstheindividual’s
neurologicaldevelopmentandcognitivecapacity,especially
when it occurs early (in the first yearsof life),the most
vulnerableagegrouptothedisease.22
Stunting affects more than 13% of children, a higher
prevalencethantheonefoundamongnon-indigenous
chil-dreninthestateofAlagoas(10.3%).23Itisnoteworthythat
the prevalence found here is almost twice that of
non-indigenouschildreninBrazil(7%),accordingtotheNational
DemographicandHealthSurvey.24
Importantreportsofmalnutritionamongindigenous
chil-dren were recorded in the National Survey of Indigenous
People’s Health and Nutrition/2009.7 The study brought
to light relevant information onthe profile of indigenous
peopleinBrazil,asitshowsthepresenceofnutritional
tran-sitioninthispopulation,withtheemergenceofoverweight
(30.2%) and obesity (15.7%) in women aged14---49 years,
whereastheoccurrenceofmalnutritioninchildrenhasnot
beensolved.The reportdisclosesthat26%ofthechildren
youngerthanfiveyearsoldhavestunting,withevenhigher
ratesinthenorthernregionofBrazil(41.1%).7
Regarding delayed growth according to the children’s
placeofresidence,gender andage, therewere no
signif-icantdifferencesfromastatisticalpointofview.This fact
indicates that regarding the assessed categories, the
dis-easeaffectedchildren,intermsofmagnitude,tothesame
extent.
Usingthe−2standarddeviationsasalimitimpliesthat
2.3%ofthereferencepopulationis classifiedas
‘malnour-ished’, even if the individuals are actually ‘healthy’ and
have no growth difficulties. Therefore, 2.3% can be
con-sidered as the ‘baseline value’ or expected prevalence.
Althoughtheprevalenceratesindisadvantagedpopulations
aregenerallyhigherthan2.3%,25 thesignificantnutritional
vulnerabilityofthispopulationisdemonstratedbythe
val-ues found herein (approximately 9---16%, according tothe
placeofresidence),beingfourtoseven-foldhigherthanthe
thresholdvalue.AlthoughitisclearthatBrazilianindigenous
childrenstillshowahighprevalenceofdelayedgrowth,the
understandingofthemainfactorsrelatedtothisdiseaseis
stilllimited.7,8
Regarding the association between stunting and
chil-dren’sage,theresultsshownherearesimilartothestudies
withthe Kaingangchildren, forwhich agewasnot
signifi-cantlyassociatedwithweightdeficit.26 Incontrast,astudy
carriedoutwiththexavantepeopleshowedaninverse
asso-ciationbetweenstuntingwiththechild’sage:theyounger
theage,thebetterthenutritionalstate.27Thestudyauthors
pointedtobreastfeedingasaprotectivefactorforthe
dis-easeinthestudiedgroup.
Maternalliteracyfavorablyinfluencedthenutritional
sta-tusoftheirchildren.Highermeanzscoreswereidentified
amongthechildren of literate mothers.When these
find-ingsarecomparedwithstudies carriedoutin thegeneral
population,theresultsshown herecorroboratethe
litera-ture.Studiesindicatelowmaternalschoolingasapredictive
factorformalnutritioninchildren.Unquestionably,
malnu-tritionismorecommoninindividualswithloweducational
levels,dueinparttotheassociationbetweenmaternal
edu-cationandinclusionofwomen inthelabormarket,which
allowsthe increase in familyincome and directly affects
foodavailabilityandaccess.28,29
Regardingtheanalysisofthefamilies’income,itisknown
that involves different aspects that hinder the
communities,suchasthoseofindigenouspopulation,
con-stitutesocialorganizationsthatoperateeconomicalmodels
withlittlecapitalaccumulationandheavydependence on
subsistenceactivities.Thus,themeasurementof
purchas-ing power through family income may not be the most
appropriatewaytomeasureaccesstofoodinthistypeof
population.30Itisknown,however,thatstuntingis
predom-inantlyassociatedtofamilies’economic status.Thus,the
positive association found here between low income and
children’sstuntingreferstothepremisethattheincreasein
families’incomeisdirectlyrelatedtonutritionalstatus,as
ahigherincomeenablesgreateraccesstofood.28 Thedata
shown herecorroborate this premise,asthe highermean
z scores were identified amongchildren belonging tothe
higher-incomefamilies,whencomparedwiththosewhose
incomewasbelowtheusedcutoffpoint.
Thesensitiveassociationbetweenthepresenceof
iron-deficiency anemia and delayed growth in children has
beenreportedin scientific literature.However,therewas
no statistically significant association between stunting
and anemia in this group, despite the high prevalence
rates found for the two diseases. In fact, malnourished
childrenoftenhaveanemia,amongotherassociated
nutri-tionaldeficiencies, and it is considered that malnutrition
ischaracterizedby thesimultaneousdeficiency ofseveral
nutrients.31 Considering the high prevalence of delayed
growth (13.4%) and the simultaneous occurrence of iron
deficiencyanemia(57.7%)inthispopulationgroup,itis
rec-ommendedthattheinvestigationofthesediseasesandtheir
associatedfactorsbemorethorough.Aboutthisaspect,it
isnoteworthythat,whenanalyzingthevariablesassociated
withnutritional statusinthis group,wedid notintendto
establishacause-and-effectassociation.Thisstudycarried
outanassessmentaimingtodetectmoreorlessnutritional
vulnerabilityinastilllittle-investigatedpopulationgroup.
Itcanbepresupposed,asanimmediatecauselevel,that
theinadequatebirthweightmaypreventchildrenfromthis
populationfromreachingtheirfulllineargrowthpotential.32
The statistical association between malnutrition and low
birth weight found here, may result from factors related
topregnancythatwerenotinvestigatedhere.33The
estab-lished hypothesis is that a poor nutritional status at this
stageoflifeisanimportantandsignificantriskfactorforthe
subsequentoccurrenceofdelayedgrowth.Thatiswhatthe
datashownhereseemtoconfirm,identifyinglowermeanz
scoresinchildrenwithlowbirthweight,32 afactalso
con-firmedbyKühl etal.,26 whofound anassociationbetween
delayedgrowthandlowbirthweightinKaingangchildren.
Regarding the comparison of the growth curvesof the
studiedpopulation withthe WHOreferencecurves,itcan
beclearlyobservedthatthechildrenofthekarapotó
peo-pleliving inPlak-Ô reservationandTerraNovasettlement
havelowerzscorevaluesthantheusedcutoffpoint.The
WHOcurvesconstituteasetofdatathatrepresentsthebest
description of physiological linear growth of healthy
chil-drenunderfavorableenvironmentalconditions,regardless
of their ethnic background. It is also noteworthy that an
importantfeatureofthesecurvesistorepresentan
inter-nationalandmultiethnicsample usedtoassessindigenous
populations.1---3,5,26,27
Thus,theslopesdisplacedtotheleftfoundinthethree
curvesinrelationtotheusedreferencestandard,according
to place of residence, show lower mean z scores than
expectedinahealthypopulation.Thatis,theslopesofthe
curvesshown here definedelayed growth observedin the
childrenoftheassessedpopulation.
Alimitationofthestudyisitscross-sectionaldesign,an
aspect that prevents cause-and-effect inferences.
There-fore, the findings should be treated with caution until
a longitudinal assessment of risk factors is carried out.
Althoughcross-sectionalstudiesdonotallowcausality
infer-ence,theyareessentialtoestablishhypothesesanddirect
theplanningofprospectivestudiestoestablishclear
asso-ciations between the conditioning/determinant factors of
children’sstunting.Despitetheaforementionedlimitations,
thestudyisunprecedentedfor thispeople,representsthe
universe ofkarapotóchildrenandshows thatmalnutrition
is stillpresent asan important nutritionaldisorderin this
population.
It is important toemphasize that malnutrition in
chil-dren has a multiple determination of a complex network
offactors,involvingbiological,demographic,socioeconomic
andculturalaspects,amongothers.5,6,8,27,34Thus,thechild,
especially those from traditional people, cannot be seen
asasingleunit.To explainthedynamismand diversityof
the nutritional status of Brazilian indigenous populations
demand an interaction of anthropological, biological and
socialfactors,consideringchildrenintheircontext.Inthis
population,theobservedprevalenceofdelayedgrowthwas
significantwhencomparedtothenon-indigenouspopulation
in the country, divergent fromthe references established
bytheWHO.Amongtheassociatedfactors,theunfavorable
conditionsofmaternalliteracy,familyincomeandlowbirth
weightareemphasized.
Thus, given the known sensitivity of these factors to
expressapopulation’slifestandard,itiscrucialtoconsider
thespecificsoftheassessedgroup,inordertoimplement
appropriate strategies to solve the identified problems.
Therefore, it is considered essential to establish policies
that take into accountthe culture and eatinghabits and
respecttraditionalknowledgeandbiodiversityofthis
peo-ple.
Funding
ThestudyreceivedfundingfromtheFundac¸ãodeAmparoà PesquisadoEstadodeAlagoas/FAPEAL.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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