Reference in the fight against child malnutrition, CREN has been operating with excellence for 30 years

Maria Conceição lives on the outskirts of São Paulo. She is a single mother of two young children. Without a steady job, sometimes there is a lack of food in her home. Other times, there’s no gas. To stave off hunger, she often offers cookies and water to her children. Her eldest daughter, Larissa, appears to be six years old. However, she says that she is ten. The youngest, Davi, is four and visibly overweight.

Conceição confides that the children suffer from dermatitis, infections, and frequent diarrhea. The last time they went to the health center, they left with a diagnosis and a referral: the children were suffering from child malnutrition and needed urgent nutritional care. Through the Sistema Único de Saúde – SUS (‘Unified Health System’), they managed to secure a spot in one of the units of the Centro de Recuperação e Educação Nutritional (CREN) (‘Center for Recovery and Nutritional Education’).

This is a fictional story based on facts. And it’s more common than you might think. CREN serves about three thousand children between the ages of 3 and 19 in São Paulo. According to the latest report from the Sociedade de Pediatria (‘Pediatric Society’), about 10 children under the age of five are hospitalized every day due to malnutrition and other nutritional deficiencies in Brazil.

“Unlike that child who is extremely thin, with ribs showing, today there is urban malnutrition, where you might think a child is three years old if you don’t know their age, but in reality, they’re seven. Malnutrition also includes those children who are overweight,” explains pediatrician and general manager of CREN, Maria Paula Albuquerque.

CREN 

Founded in 1993 by Professor Ana Lydia Sawaya, CREN is a nonprofit organization that emerged to serve families in vulnerable situations around the Escola Paulista de Medicina (‘School of Medicine of São Paulo’), which is now part of the Universidade Federal de São Paulo (UNIFESP) (‘Federal University of São Paulo’). At the time, there were about 22 favelas in the region, and even though it was close to the hospital complex, residents of the favelas did not access that health service.

A favela is an informal settlement or slum, typically found in urban areas of Brazil. These communities are characterized by densely populated, improvised housing often built on hillsides or in low-income areas. 

“Professor Ana Lydia observed that it was necessary to bring the service to the children and families living 500 meters away from the Escola Paulista and not wait for them to come because there was a whole exclusion framework: lack of address, documentation, and even a lack of understanding of what malnutrition is”, recalls Albuquerque.

“There is a political aspect in the history of the Escola Paulista de Medicina (‘School of Medicine of São Paulo’) that involves a lot of resistance and dissent. The first health project that looked at Indigenous peoples was from the epidemiology department of the School, the Projeto Xingu (‘Xingu Project’). It was in this context that CREN was born. It was an extension project, along with epidemiology, physiology, and paediatrics. These three departments materialized the centre”, she continues.

Jardim Matarazzo, USP and Haiti

Currently with two units, one in Vila Mariana and another in Jardim Matarazzo, neighbourhoods in São Paulo, nutritional care is directed especially towards children and adolescents. There are cooking workshops, agroecological gardens, stingless beekeeping, and partnerships with organic farmers. Mothers, in particular, are invited to participate in food culture recovery circles, where they exchange memories about smells, tastes, and cooking methods. The dietary transformation ends up reverberating throughout the entire family.

In addition to providing care, CREN also conducts research and advocacy. The research group Nutrição e Pobreza (‘Nutrition and Poverty’) has been operating at the Instituto de Estudos Avançados, da Universidade de São Paulo (IEA-USP) (‘Institute of Advanced Studies of the University of São Paulo’) since 2003. “We are within this academic space, publishing, researching, and discussing public policies. This gives us strength when applying for grants, making agreements with secretariats, offering consultancy to the Ministério Público (‘Public Prosecutor’s Office’), etc.”, says Albuquerque.

Through advocacy, CREN has been replicating all the experience gained over the past 30 years in various states of Brazil and has already been to 18 countries, during times of high demand for humanitarian aid, such as in the case of the disasters that hit Haiti and the intense migratory flow that occupied the Venezuela-Brazil border. Soon, CREN is preparing to go to Ecuador, a country recently devastated by an intense political crisis.

“Many times, malnutrition and poor nutrition have been treated as a health and education problem. But in reality, it’s a matter of inequality, of poverty. And it’s structural”, warns the paediatrician.

Child Malnutrition

According to a report from the Estudo Nacional de Alimentação e Nutrição Infantil (ENANI) (‘National Study of Child Feeding and Nutrition’), child malnutrition in Brazil mainly affects babies up to two years old and children aged 5 to 10 years old. In this age group, malnutrition is primarily expressed through overweight.

“It is a mistake to think that childhood obesity is not food insecurity. Obesity is a reflection of diseased food systems and is related to income distribution and inequality. We know that the ultra-processed food industry reigns supreme with its lobbying efforts”, ponders Albuquerque.

For her, the significant number of babies with malnutrition, especially among indigenous and quilombola communities (communities of descendants of slaves who escaped slavery and formed settlements, known as quilombos), is concerning. “The last major national epidemiological study was conducted in 2019, before the pandemic. And it showed that chronic malnutrition in babies up to two years old was increasing. This is a reflection of dismantling policies, but we also need to be vigilant about this form of malnutrition, which declined in the 1980s but has not yet been eradicated”.

Innovative Methodology 

Maria Paula Albuquerque was a medical student when she met Professor Ana Lydia Sawaya. A paediatrician and nutritionist, she began working at CREN during her residency. Since then, she has dedicated more than 20 years to the organization. I ask her: what makes CREN such an innovative organization? “Research is important, of course. But we never lose touch with the field, so as not to be disconnected from reality. Reality is the mistress of all things”, she defends. 

It is the Unidades Básicas de Saúde (UBS) (‘Primary Healthcare Units’) that refer children for nutritional care. CREN receives referrals from all six health coordination offices in the municipality of São Paulo. “But we don’t wait for the UBS to send the children; we go in search of them through the mobile CREN, which conducts active searches and contacts community leaders”, she warns. 

“This is a characteristic of CREN: this persistent focus on reality. We have noticed that the educational profile of mothers, for example, has improved significantly. But why are malnutrition rates still significant? There has been a change in family dynamics, in the mental health of caregivers. What does that caregiver do when they are not well enough to provide care? Especially in early childhood? So that’s one point”, she explains. 

“The second point is to consider malnutrition as a systemic problem. Many times, attempts have been made to combat malnutrition with programs like Leve Leite, lectures on breastfeeding and child feeding. But it’s not that simple. It’s a complex, systemic problem. That’s why here we tackle malnutrition from the perspective of holistic development”, she concludes.

Do you want to support this cause?

CREN acts through agreements with the city hall, public calls for proposals, partnerships with companies and institutes, as well as parliamentary amendments. The centre also encourages donations from individuals, through the website and the Nota Fiscal Paulista (‘Paulista Fiscal Receipt’). “This unrestricted funding is important for addressing aspects that are not covered by agreements”, Albuquerque adds. 

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