Identifying biologically implausible values in big longitudinal data: an example applied to child growth data from the Brazilian food and nutrition surveillance system.

BACKGROUND: Several strategies for identifying biologically implausible values in longitudinal anthropometric data have recently been proposed, but the suitability of these strategies for large population datasets needs to be better understood. This study evaluated the impact of removing population outliers and the additional value of identifying and removing longitudinal outliers on the trajectories of length/height and weight and on the prevalence of child growth indicators in a large longitudinal dataset of child growth data. METHODS: Length/height and weight measurements of children aged 0 to 59 months from the Brazilian Food and Nutrition Surveillance System were analyzed. Population outliers were identified using z-scores from the World Health Organization (WHO) growth charts. After identifying and removing population outliers, residuals from linear mixed-effects models were used to flag longitudinal outliers. The following cutoffs for residuals were tested to flag those: -3/+3, -4/+4, -5/+5, -6/+6. The selected child growth indicators included length/height-for-age z-scores and weight-for-age z-scores, classified according to the WHO charts. RESULTS: The dataset included 50,154,738 records from 10,775,496 children. Boys and girls had 5.74% and 5.31% of length/height and 5.19% and 4.74% of weight values flagged as population outliers, respectively. After removing those, the percentage of longitudinal outliers varied from 0.02% (<-6/>+6) to 1.47% (<-3/>+3) for length/height and from 0.07 to 1.44% for weight in boys. In girls, the percentage of longitudinal outliers varied from 0.01 to 1.50% for length/height and from 0.08 to 1.45% for weight. The initial removal of population outliers played the most substantial role in the growth trajectories as it was the first step in the cleaning process, while the additional removal of longitudinal outliers had lower influence on those, regardless of the cutoff adopted. The prevalence of the selected indicators were also affected by both population and longitudinal (to a lesser extent) outliers. CONCLUSIONS: Although both population and longitudinal outliers can detect biologically implausible values in child growth data, removing population outliers seemed more relevant in this large administrative dataset, especially in calculating summary statistics. However, both types of outliers need to be identified and removed for the proper evaluation of trajectories.

Time trends and social inequalities in infant and young child feeding practices: national estimates from Brazil's Food and Nutrition Surveillance System, 2008-2019.

OBJECTIVE: To describe the time trends and socio-economic inequalities in infant and young child feeding practices in accordance with the Brazilian deprivation index (BDI). DESIGN: This time-series study analysed the prevalence of multiple breast-feeding and complementary feeding indicators based on data from the Brazilian Food and Nutrition Surveillance System, 2008-2019. Prais-Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated. SETTING: Primary health care services, Brazil. PARTICIPANTS: Totally, 911 735 Brazilian children under 2 years old. RESULTS: Breast-feeding and complementary feeding practices differed between the extreme BDI quintiles. Overall, the results were more favourable in the municipalities with less deprivation (Q1). Improvements in some complementary feeding indicators were observed over time and evidenced such disparities: minimum dietary diversity (Q1: Δ 47·8-52·2 %, APC + 1·44, P = 0·006), minimum acceptable diet (Q1: Δ 34·5-40·5 %, APC + 5·17, P = 0·004) and consumption of meat and/or eggs (Q1: Δ 59·7-80·3 %, APC + 6·26, P < 0·001; and Q5: Δ 65·7-70·7 %, APC + 2·20, P = 0·041). Stable trends in exclusive breast-feeding and decreasing trends in the consumption of sweetened drinks and ultra-processed foods were also observed regardless the level of the deprivation. CONCLUSIONS: Improvements in some complementary food indicators were observed over time. However, the improvements were not equally distributed among the BDI quintiles, with children from the municipalities with less deprivation benefiting the most.

[Recommendations to strengthen nutritional care in the primary care setting in BrazilRecomendaciones para el fortalecimiento de la atención nutricional en la atención primaria de salud en Brasil]. / Recomendações para o fortalecimento da atenção nutricional na atenção primária à saúde brasileira.

Objective: To develop recommendations to strengthen nutritional care in the primary health care (PHC) setting in Brazil based on expert consensus. Method: A descriptive and exploratory study was performed using the Delphi technique. Of 172 invited PHC experts in nutrition, 116 accepted the invitation and 72 participated in the first Delphi round. The second round had 56 participants from the five Brazilian regions, including managers, healthcare professionals, representatives from civil society organizations, and researchers. The recommendations were developed based on thematic analysis of the responses to open-ended questions about barriers, strategies, actions, and initiatives from five components of the National Food and Nutrition Policy (food and nutrition surveillance, coordination of nutritional care, health promotion, intersectoral focus, and management of food and nutrition actions). In the second round, experts classified each proposed item regarding its pertinence and relevance for the purpose of recommendation. Results: A consensus was reached on 35 recommendations distributed in six categories: structure; PHC nutritional agenda; organization of the healthcare network and PHC; nutritional work processes in PHC; planning, monitoring and evaluation of nutritional actions in PHC; and information systems. These categories were further classified into two blocks: "PHC structuring actions to strengthen nutrition" and "nutrition structuring actions to strengthen PHC." Conclusions: The recommendations were developed by experienced participants who are familiar with both nutritional and PHC pathways from diverse perspectives, and will be useful for the management and proposition of public policies to strengthen nutritional care in the PHC setting in Brazil.

Objetivo: Elaborar recomendaciones para el fortalecimiento de la alimentación y la nutrición en la atención primaria de salud (APS) en Brasil a partir del consenso de especialistas. Métodos: Se realizó un estudio descriptivo y exploratorio con la técnica de Delfos. En total, 172 especialistas en alimentación y nutrición del sistema de APS recibieron una invitación para participar, 116 la aceptaron y 72 intervinieron en la primera ronda. En la segunda ronda hubo 56 participantes de las cinco macrorregiones brasileñas, entre gestores, profesionales de salud, representantes de la sociedad civil e investigadores. Las recomendaciones se formularon mediante un análisis temático de las respuestas a preguntas abiertas sobre obstáculos, estrategias, medidas e iniciativas referentes a cinco aspectos técnicos de la política nacional de alimentación y nutrición (vigilancia alimentaria y nutricional, atención y coordinación del cuidado nutricional, promoción de la salud, intersectorialidad y gestión de las medidas relativas a alimentación y nutrición). En la segunda ronda, los especialistas clasificaron cada punto propuesto según su pertinencia y relevancia para efecto de las recomendaciones. Resultados: Los especialistas formularon 35 recomendaciones, organizadas en seis categorías: estructura; agenda de alimentación y nutrición en la APS; organización en red y organización de la APS; procesos de trabajo relativos a la alimentación y nutrición en la APS; planificación, monitoreo y evaluación de las medidas relativas a la alimentación y nutrición en la APS; y sistema de información. Las categorías se dividieron en dos grupos: medidas estructurantes de la APS para el fortalecimiento de la alimentación y la nutrición y medidas estructurantes de alimentación y nutrición para el fortalecimiento de la APS. Conclusiones: Las recomendaciones provinieron de personas expertas que siguen la trayectoria tanto de la alimentación y la nutrición como de la APS desde diferentes puntos de vista, útiles para la gestión y la propuesta de políticas públicas destinadas a fortalecer la alimentación y la nutrición en la APS de Brasil.

Breastfeeding reduces ultra-processed foods and sweetened beverages consumption among children under two years old.

BACKGROUND: Breastfeeding and adequate complementary feeding are associated with healthy eating habits, prevention of nutritional deficiencies, obesity and non-communicable diseases. Our aim was to identify feeding practices and to evaluate the association between breastmilk intake and complementary feeding, focusing on ultra-processed foods (UPF) and sweetened beverages, among children under 2 years old. METHODS: We conducted a cross-sectional study including 847 children from 20 Primary Health Units. We evaluated children's food consumption using a food intake markers questionnaire. We conducted a logistic regression to evaluate the effect of breastmilk intake on feeding practices. RESULTS: The breastmilk intake was associated with lower odds of consuming non-recommended foods, such as cookies or crackers (OR: 0.29; IC 95%: 0.20-0.41) for children under 6 months, yogurt (OR: 0.33; CI 95%: 0.12-0.88) for children between 6 and 12 months and soft drinks (OR: 0.36; CI 95%: 0.17-0.75) for children between 12 and 24 months. Moreover, the breastmilk intake was associated with lower odds of consuming UPF (OR: 0.26; CI 95%: 0.09-0.74) and sweetened beverages (OR: 0.13; CI 95%: 0.05-0.33) for children under 6 months. For children between 12 and 24 months, breastmilk intake was associated with lower odds of consuming sweetened beverages (OR: 0.40; CI 95%: 0.24-0.65). CONCLUSION: Breastmilk intake was associated with a reduced consumption of UPF and sweetened beverages. Investment in actions to scale up breastfeeding can generate benefits, besides those of breastmilk itself, translating into better feeding habits and preventing health problems in childhood.

[Feeding and nutrition efforts in the context of primary healthcare in BrazilMedidas relativas a la alimentación y la nutrición en la atención primaria de salud en Brasil]. / Ações de alimentação e nutrição na atenção primária à saúde no Brasil.

In Brazil, the promotion, protection, and recovery of health are among the initiatives provided by the public and universal Unified Health System (SUS). The primary healthcare level (PHC), the preferred point of access to the system, plays the role of coordinating and ordinating health care services and actions in the network. In the context of PHC, feeding and nutrition efforts must be aligned with National Feeding and Nutrition Policy (PNAN) guidelines and may be supported by feeding and nutritional surveillance actions. Data from PHC information systems and population surveys show that excess weight affects more than half the adult population of Brazil, and that consumption of ultra-processed foods is on the rise. This scenario requires that health care teams be prepared to prioritize initiatives for users with chronic diseases, using risk stratification, stabilization of the disease, and enhancement of supported self-care with a focus on diet and physical activity. At the same time, considering the country's epidemiological profile, teams must carry out initiatives to fight undernutrition and prevent anemia and hypovitaminosis A to address the multiple burden of malnutrition. The present article describes the current scenario of feeding and nutrition initiatives implemented at the PHC level in Brazil via the SUS.

En Brasil, el Sistema Único de Salud (SUS), que es público y universal, ofrece medidas de promoción, protección y recuperación de la salud. La atención primaria de salud es la puerta preferida de acceso de la población al SUS, y su función es coordinar y ordenar las medidas y los servicios de salud disponibles en la red. En el ámbito de la atención primaria de salud, las medidas de alimentación y nutrición deben estar en consonancia con las directrices de la política nacional de alimentación y nutrición, y pueden potenciarse a partir de medidas de vigilancia alimentaria y nutricional. Los datos de los sistemas de información disponibles en todas las unidades básicas de salud y en encuestas poblacionales indican que más de la mitad de la población adulta en Brasil presenta exceso de peso y que ha aumentado el consumo de alimentos ultraprocesados. Esa situación exige que los equipos de salud se organicen con objeto de priorizar ciertas medidas para las personas con trastornos crónicos, según la estratificación del riesgo, la estabilización del trastorno y la potenciación del autocuidado apoyado, con enfoque en la alimentación y la actividad física. Al mismo tiempo, según el perfil epidemiológico, los equipos deben emprender actividades de lucha contra la desnutrición y de prevención de la anemia y de la carencia de vitamina A, teniendo en cuenta la múltiple carga de la malnutrición en el país. El objetivo del presente artículo es presentar el panorama actual de las medidas relativas a la alimentación y nutrición que se llevan a cabo en el ámbito de la atención primaria de salud en el SUS.

[Intersectoral approach to obesity prevention and control: the Brazilian experience from 2014 to 2018Enfoque intersectorial para la prevención y el control de la obesidad: la experiencia de Brasil en el período 2014-2018]. / Abordagem intersetorial para prevenção e controle da obesidade: a experiência brasileira de 2014 a 2018.

The present article aims to describe and discuss the actions implemented from 2014 to 2018 at the federal level in the context of the Intersectoral Strategy to Prevent and Control Obesity issued by the Brazilian federal government. The goal of the Intersectoral Strategy is to prevent and control obesity based on six action plans: 1) availability and access to adequate and healthy foods; 2) education, communication, and information; 3) promotion of healthy lifestyles in specific environments/territories; 4) food and nutrition surveillance; 5) comprehensive care for individuals presenting obesity in the health care network; and 6) regulation and control of the quality and harmlessness of food. To gather information, semi-structured questionnaires were submitted to representatives from the ministries of Education, Health, Planning, Citizenship, and Agrarian Development. The actions implemented in the period were described in terms of the six action plans. Positive results were achieved through the shared management model adopted, even though many challenges still remain. The agenda for action proposed in the Intersectoral Strategy is attuned to the Brazilian context, and intersectoral management was still in place until the writing of the present article.

El objetivo del presente artículo es describir las actividades realizadas a nivel federal en el período 2014-2018 dentro del marco de la estrategia intersectorial de prevención y control de la Obesidad, publicada por el Gobierno Federal de Brasil, y hacer algunos comentarios pertinentes. La estrategia tiene por objetivo prevenir y controlar la obesidad y se ha organizado en seis grandes ejes de acción: 1) disponibilidad de alimentos adecuados y saludables y acceso a los mismos; 2) educación, comunicación e información; 3) promoción de estilos de vida saludables en entornos y territorios específicos; 4) vigilancia alimentaria y nutricional; 5) atención integral a la salud de las personas con sobrepeso y obesidad en la red asistencial, y 6) regulación y control de la calidad y la inocuidad de los alimentos. Para recopilar información se enviaron cuestionarios semiestructurados a representantes de los Ministerios de Educación, Salud, Planificación, Ciudadanía y Desarrollo Agrario. Las actividades realizadas se presentan según los ejes de acción de la estrategia. Se lograron resultados positivos a partir del modelo de coordinación adoptado, con gestión compartida, aunque fue preciso superar varios desafíos. El programa de trabajo sobre los ejes de acción propuestos en la estrategia está en consonancia con el contexto brasileño y el modelo intersectorial de gestión permaneció vigente hasta el momento de preparación de este artículo.

[Food guides: a strategy to reduce the consumption of ultra-processed foods and prevent obesityGuías alimentarias: estrategia para reducir el consumo de alimentos ultraprocesados y prevenir la obesidad]. / Guias alimentares: estratégia para redução do consumo de alimentos ultraprocessados e prevenção da obesidade.

Obesity is a serious public health problem whose increase has been associated with the growing consumption of ultra-processed foods in several world regions, including Latin America. Food guides are official guidelines used to promote healthy eating habits and may serve as a tool to prevent obesity. Brazil was the first country to adopt the level of processing to categorize food items and make recommendations based on these categories in its food guides. Thus, the objective of the present article is to share the Brazilian experience with incorporating processed food recommendations as official guidelines and with the development of food guides. In the development of Brazilian food guides, the Ministry of Health emphasized a collective construction, with participation and discussion of contents by strategic stakeholders. The process was refined in the Food Guide for Brazilian Children below 2 Years of Age, with establishment of a management committee and a political monitoring committee, public call for participation by researchers and health care professionals, and input workshops with key stakeholders to define scope. The validation process relied on additional input workshops with key stakeholders, in addition to workshops held in all Brazilian states for debate and mobilization for online public consultation. Highlights of this learning process included the involvement of key stakeholders and the importance of transparency across all steps of development and validation of food guides.

La obesidad es un grave problema de salud pública cuyo aumento se ha relacionado con el incremento del consumo de alimentos ultraprocesados en diversas regiones del mundo, incluida América Latina. Las guías alimentarias son directrices oficiales usadas para promover la alimentación saludable y pueden servir de herramienta para prevenir la obesidad. Brasil fue el primer país en adoptar el grado de procesamiento como criterio para clasificar los alimentos y formular recomendaciones en sus guías alimentarias usando como base esa clasificación. El objetivo de este artículo es compartir la experiencia brasileña al incorporar esas recomendaciones como directrices oficiales y elaborar las guías alimentarias. En la elaboración de las guías alimentarias brasileñas, el Ministerio de Salud valoró la construcción colectiva, a saber, la participación de actores estratégicos y el debate que estos actores entablaron sobre sus contenidos. En la Guía alimentaria para los niños brasileños menores de dos años, el proceso se perfeccionó gracias al establecimiento de un comité gestor y un comité de monitoreo político, un llamamiento público a la participación de investigadores y profesionales de salud, y la realización de talleres participativos con actores clave para definir el objetivo de la directriz. Para el proceso de validación se realizaron otros talleres, con la presencia de actores estratégicos, así como talleres realizados en todos los estados del país a fin de fomentar un debate y promover la participación en una consulta pública en línea. Como resultado de este aprendizaje, se destaca la importancia de que participen los actores estratégicos y la necesidad de que el proceso de elaboración y validación de las guías alimentarias sea transparente.

Household food insecurity, nutritional status and morbidity in Brazilian children.

OBJECTIVE: To identify the association of household food insecurity (HFI) with anthropometric status, the risk of vitamin A deficiency and anaemia, morbidities such as cough and fever, and hospitalizations for diarrhoea and pneumonia in children under 5 years old. DESIGN: Cross-sectional study using data from the 2006 Brazilian Demographic and Health Survey. HFI was measured with the Brazilian Food Insecurity Measurement Scale (EBIA). Vitamin A deficiency and anaemia were assessed in blood samples. Child morbidities were reported by the child's mother and included cough, fever, and hospitalizations for diarrhoea and pneumonia. Regression results were expressed as unadjusted and adjusted OR and corresponding 95 % CI for severe food insecurity, with statistical significance set at P<0·05. SETTING: Nationally representative survey. SUBJECTS: Children (n 4064) under 5 years old. RESULTS: There was no association between HFI and vitamin A deficiency, pneumonia, wasting or overweight. The prevalence of cough, fever, hospitalization for diarrhoea and stunting were associated with degree of HFI severity. There was a significant association of morbidities and stunting with severe food insecurity (v. food secure). After controlling for confounders, the association between severe food insecurity (v. food secure/rest of food insecurity categories) and the prevalence of common morbidities remained strong, showing that severely food-insecure children had a greater likelihood of experiencing cough (adjusted OR=1·79) and of being hospitalized for diarrhoea (adjusted OR=2·55). CONCLUSIONS: Severe HFI was associated with cough and severe diarrhoea among Brazilian children.

Barriers and Facilitators Related to the Adoption of Policies to Reduce Ultra-Processed Foods Consumption: A Scoping Review.

Cost-effective regulatory and fiscal interventions are recommended to address non-communicable diseases. While some countries are advancing regarding these actions, others have found it difficult to approve them. AIM: to conduct a scoping review to answer the question "What factors have influenced the adoption of food taxes, front-of-pack labeling and restrictions on marketing to children?". METHODS: A scoping review was developed from four databases. Studies that described and analyzed policy processes were included. Analysis was performed to identify the barriers and enablers mentioned under the guidance of Swinburn et al., Huang et al., Mialon et al., and Kingdon. RESULTS: 168 documents were identified, describing experiences from five regions or groups and 23 countries, which have generated 1584 examples of 52 enablers (689 examples; 43.5%) and 55 barriers (895 examples; 56.5%) that may have influenced policies. The main enablers were related to the government environment and governance and to civil society strategies. Corporate political activity strategies were the main examples of barriers. CONCLUSIONS: This scoping review consolidated barriers and facilitators related to policies aimed at reducing ultra-processed foods consumption, demonstrating that factors related to the actions of governments and civil society are the main facilitators. On the other hand, as the most interested actor in promoting the consumption of these products, the strategies adopted by the companies that produce these products constitute the main barrier to these policies in all the studied countries and should be overcome.

Analysis of the elaboration and proposal of a Brazilian intersectoral strategy for the prevention and care of childhood obesity.

The Brazilian Strategy for the Prevention and Care of Childhood Obesity (PROTEJA) aims to implement a set of actions to prevent obesity in Brazil. As such, this qualitative and descriptive documentary study presents the Strategy's stages of the operational design, general proposal, evaluation and monitoring conducted by the Brazilian Ministry of Health's technical coordination. After analyzing the epidemiological data on children and the existing policies aimed at obesity prevention, and reviewing the scientific literature and recommendations, PROTEJA was formulated and approved by the Brazilian Ministry of Health, and 1,320 municipalities committed to implementing 20 essential and 5 complementary actions, from 41, including some structural to improve environments. Coordinated by the Brazilian Ministry of Health in partnership with subnational governments and universities, the Strategy also relies on a local team for implementation support, as well as implementation and impact evaluations. Actions will be monitored annually, and the indicators will impact financial incentives. As a strong, evidence-based and innovative strategy aiming to promote healthy environments in cities, PROTEJA has the potential to open a path to childhood obesity reversal, as well as add to the implementation science and contribute to the development and improvement of public policies for obesity prevention; however, its implementation remains a challenge.

Quality of child anthropometric data from SISVAN, Brazil, 2008-2017.

OBJECTIVE: To evaluate the quality of anthropometric data of children recorded in the Food and Nutrition Surveillance System (SISVAN) from 2008 to 2017. METHOD: Descriptive study on the quality of anthropometric data of children under five years of age admitted in primary care services of the Unified Health System, from the individual databases of SISVAN. Data quality was annually assessed using the indicators: coverage, completeness, sex ratio, age distribution, weight and height digit preference, implausible z-score values, standard deviation, and normality of z-scores. RESULTS: In total, 73,745,023 records and 29,852,480 children were identified. Coverage increased from 17.7% in 2008 to 45.4% in 2017. Completeness of birth date, weight, and height corresponded to almost 100% in all years. The sex ratio was balanced and approximately similar to the expected ratio, ranging from 0.8 to 1. The age distribution revealed higher percentages of registrations from the ages of two to four years until mid-2015. A preference for terminal digits "zero" and "five" was identified among weight and height records. The percentages of implausible z-scores exceeded 1% for all anthropometric indices, with values decreasing from 2014 onwards. A high dispersion of z-scores, including standard deviations between 1.2 and 1.6, was identified mainly in the indices including height and in the records of children under two years of age and residents in the North, Northeast, and Midwest regions. The distribution of z-scores was symmetric for all indices and platykurtic for height/age and weight/age. CONCLUSIONS: The quality of SISVAN anthropometric data for children under five years of age has improved substantially between 2008 and 2017. Some indicators require attention, particularly for height measurements, whose quality was lower especially among groups more vulnerable to nutritional problems.

Evolution of nutrition actions in primary health care along the 20-year history of the Brazilian National Food and Nutrition Policy. / Evolução das ações de nutrição na atenção primária à saúde nos 20 anos da Política Nacional de Alimentação e Nutrição do Brasil.

This study aimed to systematize food and nutrition actions developed in primary health care (PHC) from 1999 to 2019, identifying advances in this period and current perspectives. This is a qualitative study that analyzed documents published between 1999 and 2020, available in scientific databases and in the gray literature. In addition, a quantitative analysis was conducted using information systems from the Brazilian Ministry of Health, such as the Food and Nutrition Surveillance System and the Health Information System for Primary Care, and microdata from the Program for Improving Access and Quality of Primary Health Care (PMAQ-AB). The actions and regulatory milestones identified were categorized as federal administration, food and nutrition surveillance, promotion of proper healthy food, nutritional care - multiple burdens of poor nutrition and training. The results showed food and nutrition actions followed the pace of the epidemiological scenario, considering the multiple burdens of poor nutrition. The first decade was more focused on handling issues involved in hunger, malnutrition and micronutrient deficiency and, in 2006, it started to emphasize prevention and care for people with obesity and other non-communicable chronic diseases and promote proper healthy food, developing actions in the period with a strong intersectoral character and understanding PHC as a priority field of action in the Brazilian Unified National Health System (SUS). The universalization of food and nutrition actions in PHC is still a current challenge.

O objetivo do estudo é sistematizar as ações de alimentação e nutrição desenvolvidas na atenção primária à saúde (APS), de 1999 a 2019, identificando os avanços no período e perspectivas atuais. É uma pesquisa qualitativa realizada baseando-se na análise de documentos publicados entre 1999 e 2020, disponíveis em bases de dados científicos e na literatura cinza. Adicionalmente, realizou-se análise quantitativa valendo-se de sistemas de informação do Ministério da Saúde, como o Sistema de Vigilância Alimentar e Nutricional e o Sistema de Informação em Saúde para a Atenção Básica e dos microdados do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). As ações e marcos normativos identificados foram categorizados em gestão, vigilância alimentar e nutricional, promoção da alimentação adequada e saudável, atenção nutricional - múltipla carga de má nutrição e formação. Os resultados revelam que as ações de alimentação e nutrição acompanharam o cenário epidemiológico, considerando-se a múltipla carga da má nutrição, estando a primeira década mais direcionada ao enfrentamento da fome, da desnutrição e carências de micronutrientes e; a partir de 2006, passou a dar ênfase à prevenção e cuidado de pessoas com obesidade e outras doenças crônicas não transmissíveis, além da promoção da alimentação adequada e saudável, desenvolvendo, durante todo o período, ações com forte caráter intersetorial e compreendendo o lócus da APS como campo prioritário de atuação no Sistema Único de Saúde. A universalização das ações de alimentação e nutrição na APS, contudo, é ainda um desafio atual.

El objetivo del estudio es sistematizar las acciones de alimentación y nutrición desarrolladas en la atención primária a la salud (APS), de 1999 a 2019, identificando los avances durante este período y perspectivas actuales. Es una investigación cualitativa, realizada basándose en el análisis de documentos publicados entre 1999 y 2020, disponibles en bases de datos científicas y en literatura gris. Asimismo, se realizó un análisis cuantitativo, valiéndose de sistemas de información del Ministerio de Salud, como el Sistema de Vigilancia Alimentario y Nutricional y el Sistema de Información en Salud para la Atención Básica, así como de los microdatos procedentes del Programa Nacional de Mejoría de Acceso y Calidad de la Atención Básica (PAMQ-AB). Las acciones y marcos normativos identificados fueron categorizados en gestión, vigilancia alimentaria y nutricional, promoción de la alimentación adecuada y saludable, atención nutricional - múltiple carga de mala nutrición y formación. Los resultados revelan que las acciones de alimentación y nutrición acompañaron el escenario epidemiológico, considerándose la múltiple carga de la mala nutrición, estando la primera década más dirigida al combate del hambre, desnutrición y carencias de micronutrientes y, a partir de 2006, pasó a dar énfasis a la prevención y cuidado de personas con obesidad y otras enfermedades crónicas no transmisibles, además de la promoción de la alimentación adecuada y saludable, desarrollando, durante todo el período, acciones con un fuerte carácter intersectorial y comprendiendo el locus de la APS como campo prioritario de actuación en el Sistema Único de Salud. La universalización de las acciones de alimentación y nutrición en la APS constituye un desafío todavía actual.

Breastfeeding is associated with children's dietary diversity in Brazil.

The aim of this study was to describe food consumption patterns in Brazilian children aged 6-24 months and to assess differences between breastfed children who do not consume non-human milks, breastfed children who consume non-human milks, and non-breastfed children. This study used data from the Brazilian National Demographic and Health Survey (2006). The food consumption patterns of 1,455 children were assessed using a food frequency questionnaire. One indicator adopted in this study was the healthy diverse diet. The association between breastfeeding and food consumption was tested using multivariate Poisson regression. At the interview, 15.8% of the children were breastfed without consuming non-human milk, 30.7% consumed breast milk in conjunction with non-human milk, and 53% were not breastfed anymore. Over half consumed the recommended foods, 78% consumed foods rich in sugar, fat, and salt, and only 3.4% were on a healthy diverse diet. The breastfed children who did not consume non-human milks were almost five times more likely to be on a healthy diverse diet and were 19% less likely to consume foods rich in sugar, fat, and salt than the breastfed children who also consumed non-human milks and the non-breastfed children.

Effectiveness of a nutrition program in reducing symptoms of respiratory morbidity in children: a randomized field trial.

OBJECTIVES: To assess the effectiveness of home visits advising mothers about breast feeding and weaning in reducing symptoms of respiratory morbidity at the age of 12 months. METHODS: A randomized field trial was conducted with mothers who gave birth within the public health system in the Brazilian city of Sao Leopoldo (2001/2002). The intervention group received dietary advice during the first year based on a Brazilian national health policy for primary care, which is based on WHO guidelines. Morbidity data was assessed in 397 children at 12 months. RESULTS: A total of 23.3% of the children in the intervention group and 39.7% of the controls had one or more of the following symptoms during the month preceding assessment: cough, stuffy nose, runny nose, or breathlessness. The risk of respiratory morbidity symptoms was 41% lower for the intervention group (RR: 0.59; 95% CI: 0.43-0.81). The number of families needed to be visited to avoid one children presenting symptoms of respiratory morbidity (Number Needed to Treat) was 6.1. The intervention-group status was also associated with a longer duration of exclusive (RR:1.59; 95% CI: 1.21-2.07; p=0.001) and total breastfeeding (RR: 1.25; 95% CI:1.02-1.55; p=0.032) later introduction of solid foods (RR:1.11; 95% CI: 1.02-1.21; p=0.023), and a lower proportion of current medication use (RR:0.56; 95% CI:0.34-0.91;p=0.016). CONCLUSION: A nutrition education program during the first year of life has a positive impact on reducing respiratory symptoms in infants.

Fortalecimento das ações de cuidado às pessoas com obesidade no contexto da pandemia de COVID-19: o caso do Brasil / Enhancing care measures for people with obesity in the context of the COVID-19 pandemic: the case of Brazil

Resumo O presente estudo ecológico descritivo objetivou analisar o papel indutor de um incentivo financeiro federal repassado aos municípios brasileiros em 2020, em meio à pandemia de COVID-19, no aumento do número de atendimentos individuais para a condição de obesidade na atenção primária à saúde (APS). Utilizaram-se dados secundários, obtidos no Sistema de Informação em Saúde para a Atenção Básica e no Sistema de Vigilância Alimentar e Nutricional (SISVAN). Em 2021, 74,8% dos 5.504 municípios que receberam o incentivo financeiro apresentaram aumento no número de atendimentos individuais para a condição avaliada como obesidade na APS, em relação a 2020. O número de pessoas identificadas com obesidade e o número de atendimentos individuais para esta condição foram maiores em 2021 do que nos demais anos analisados (2017 a 2020). Na comparação de 2021 com 2020 (ano de recebimento do incentivo financeiro), observou-se que o percentual de aumento de atendimentos individuais foi superior ao percentual de aumento de pessoas com obesidade registradas no SISVAN (77,6% vs. 39,1%). Em conclusão, incentivos financeiros federais, canalizados para o fortalecimento do cuidado às pessoas com obesidade no âmbito da APS, figuram como importantes mecanismos de indução de ações em nível local.

Abstract This descriptive ecological study sought to analyze the inductive role of a federal financial incentive passed on to Brazilian municipalities in 2020, during the COVID-19 pandemic, in increasing the number of individual consultations for the condition of obesity in primary health care (PHC). Secondary data obtained from the Health Information System for Primary Care and from the Food and Nutrition Surveillance System (SISVAN) were used. In 2021, 74.8% of the 5,504 municipalities that received the financial incentive, showed an increase in the number of individual obesity consultations in PHC, compared to 2020. The number of people identified with obesity and the number of individual visits for this condition were higher in 2021 than in the other years analyzed (2017 to 2020). Comparing 2021 with 2020 (year of receipt of the financial incentive), it was observed that the percentage of increase in the number of individual consultations for the condition of obesity was higher than the increase in the number of people identified with obesity in the SISVAN (77.6 % vs. 39.1%). In conclusion, federal financial incentives for municipalities, channeled to enhance care for people with obesity within the scope of PHC, are important mechanisms for inducing actions at the local level.

Analysis of the elaboration and proposal of a Brazilian intersectoral strategy for the prevention and care of childhood obesity / Análise do processo de construção e proposta de uma estratégia intersetorial brasileira para prevenção e atenção à obesidade infantil / Análisis del proceso de construcción y propuesta de una estrategia intersectorial brasileña para la prevención y atención de la obesidad infantil

Abstract: The Brazilian Strategy for the Prevention and Care of Childhood Obesity (PROTEJA) aims to implement a set of actions to prevent obesity in Brazil. As such, this qualitative and descriptive documentary study presents the Strategy's stages of the operational design, general proposal, evaluation and monitoring conducted by the Brazilian Ministry of Health's technical coordination. After analyzing the epidemiological data on children and the existing policies aimed at obesity prevention, and reviewing the scientific literature and recommendations, PROTEJA was formulated and approved by the Brazilian Ministry of Health, and 1,320 municipalities committed to implementing 20 essential and 5 complementary actions, from 41, including some structural to improve environments. Coordinated by the Brazilian Ministry of Health in partnership with subnational governments and universities, the Strategy also relies on a local team for implementation support, as well as implementation and impact evaluations. Actions will be monitored annually, and the indicators will impact financial incentives. As a strong, evidence-based and innovative strategy aiming to promote healthy environments in cities, PROTEJA has the potential to open a path to childhood obesity reversal, as well as add to the implementation science and contribute to the development and improvement of public policies for obesity prevention; however, its implementation remains a challenge.

Resumo: A Estratégia de Prevenção e Atenção à Obesidade Infantil (PROTEJA) visa promover a implementação de um pacote de ações para prevenção da obesidade no Brasil. Este estudo apresenta as etapas de desenho operacional, proposta geral, avaliação e monitoramento do PROTEJA realizadas pela coordenação técnica do Ministério da Saúde. Trata-se de um estudo qualitativo baseado em análise descritiva documental. A formulação da estratégia envolveu análise de dados epidemiológicos de crianças brasileiras, análise de políticas existentes, e uma revisão da literatura científica e das recomendações O PROTEJA foi então formulado e aprovado pelo Ministério da Saúde e 1.320 municípios se comprometeram a implementar 20 ações essenciais e 5 complementares das 41 ações, incluindo algumas estruturais para melhoria dos ambientes. A estratégia é coordenada pelo Ministério da Saúde em parceria com governos subnacionais e universidades. Sua implementação conta com apoio de uma equipe em nível local, e prevê a avaliação da implementação e de impacto. As ações serão monitoradas anualmente, e os indicadores também implicarão nos incentivos financeiros. O PROTEJA é uma estratégia forte, baseada em evidências e inovadora que visa promover ambientes saudáveis nas cidades, mas sua implementação é desafiadora. Não obstante, apresenta um possível caminho para a reversão da obesidade infantil. Também pode agregar à ciência de implementação e contribuir para o desenvolvimento e aprimoramento de políticas públicas de prevenção da obesidade.

Resumen: La Estrategia Brasileña para la Prevención y Atención de la Obesidad Infantil (PROTEJA) tiene como objetivo promover la implementación de un conjunto de acciones para prevenir la obesidad en Brasil. Este estudio presenta las etapas del diseño operativo, la propuesta general, la evaluación y el seguimiento de PROTEJA realizadas por la coordinación técnica del Ministerio de Salud brasileño. Se trata de un estudio cualitativo basado en el análisis descriptivo de documentos. La formulación de la estrategia implicó el análisis de datos epidemiológicos de niños brasileños, el análisis de las políticas existentes y una revisión de la literatura científica y de las recomendaciones. PROTEJA fue entonces formulado y aprobado por el Ministerio de Salud, y 1.320 municipios se comprometieron a implementar 20 acciones esenciales y 5 complementarias de las 41 acciones, incluidas algunas estructurales para mejorar los entornos. La estrategia es coordinada por el Ministerio de Salud en colaboración con gobiernos subnacionales y universidades. Su implementación cuenta con el apoyo de un equipo a nivel local, y prevé una evaluación de la implementación y de impacto. Las acciones se monitorearán anualmente, y los indicadores también implicarán incentivos económicos. PROTEJA es una estrategia sólida, basada en evidencias e innovadora que busca promover entornos saludables en las ciudades, pero su implementación es un desafío. Sin embargo, presenta una posible vía para revertir la obesidad infantil. También puede agregar a la ciencia de implementación y contribuir al desarrollo y a la mejora de políticas públicas para prevenir la obesidad.

Quality of child anthropometric data from SISVAN, Brazil, 2008-2017 / Qualidade dos dados antropométricos infantis do Sisvan, Brasil, 2008-2017

ABSTRACT OBJECTIVE To evaluate the quality of anthropometric data of children recorded in the Food and Nutrition Surveillance System (SISVAN) from 2008 to 2017. METHOD Descriptive study on the quality of anthropometric data of children under five years of age admitted in primary care services of the Unified Health System, from the individual databases of SISVAN. Data quality was annually assessed using the indicators: coverage, completeness, sex ratio, age distribution, weight and height digit preference, implausible z-score values, standard deviation, and normality of z-scores. RESULTS In total, 73,745,023 records and 29,852,480 children were identified. Coverage increased from 17.7% in 2008 to 45.4% in 2017. Completeness of birth date, weight, and height corresponded to almost 100% in all years. The sex ratio was balanced and approximately similar to the expected ratio, ranging from 0.8 to 1. The age distribution revealed higher percentages of registrations from the ages of two to four years until mid-2015. A preference for terminal digits "zero" and "five" was identified among weight and height records. The percentages of implausible z-scores exceeded 1% for all anthropometric indices, with values decreasing from 2014 onwards. A high dispersion of z-scores, including standard deviations between 1.2 and 1.6, was identified mainly in the indices including height and in the records of children under two years of age and residents in the North, Northeast, and Midwest regions. The distribution of z-scores was symmetric for all indices and platykurtic for height/age and weight/age. CONCLUSIONS The quality of SISVAN anthropometric data for children under five years of age has improved substantially between 2008 and 2017. Some indicators require attention, particularly for height measurements, whose quality was lower especially among groups more vulnerable to nutritional problems.

RESUMO OBJETIVOS Avaliar a qualidade dos dados antropométricos de crianças registradas no Sistema de Vigilância Alimentar e Nutricional (Sisvan) no período 2008-2017. MÉTODOS Estudo descritivo sobre a qualidade dos dados antropométricos de crianças menores de 5 anos atendidas nos serviços de atenção primária do Sistema Único de Saúde, a partir das bases de dados individuais do Sisvan. A qualidade dos dados foi avaliada anualmente por meio dos indicadores: cobertura, completude, razão entre sexos, distribuição da idade, preferência por dígitos de peso e estatura, valores de escore-z implausíveis, desvio-padrão e normalidade dos escores-z. RESULTADOS No total, 73.745.023 registros e 29.852.480 crianças foram identificados. A cobertura aumentou de 17,7% em 2008 para 45,4% em 2017. A completude da data de nascimento, peso e estatura correspondeu a quase 100% para todos os anos. A razão entre sexos foi equilibrada e aproximadamente similar a razão esperada, variando entre 0,8 e 1. A distribuição da idade revelou maiores percentuais de registros entre as idades de 2 a 4 anos até meados de 2015. Uma preferência pelos dígitos terminais "zero" e "cinco" foi identificada entre os registros de peso e estatura. As porcentagens de escores-z implausíveis excederam 1% para todos os índices antropométricos, com redução dos valores a partir de 2014. Uma alta dispersão dos escores-z, incluindo desvios-padrão entre 1,2 e 1,6, foi identificada principalmente nos índices incluindo estatura e nos registros de crianças menores de 2 anos e residentes das regiões Norte, Nordeste e Centro-Oeste. A distribuição dos escores-z foi simétrica para todos os índices e platicúrtica para estatura/idade e peso/idade. CONCLUSÕES A qualidade dos dados antropométricos do Sisvan para crianças menores de 5 anos melhorou substancialmente entre 2008 e 2017. Alguns indicadores requerem atenção, sobretudo para medidas de estatura, cuja qualidade foi principalmente inferior entre os grupos mais vulneráveis a agravos nutricionais.

Iron bioavailability as a protective factor against anemia among children aged 12 to 16 months.

OBJECTIVE: This study investigates the nutritional factors that determine the absence of anemia in infants from families with a low socioeconomic background submitted to a nutrition intervention program, as well as iron intake according to recommendations. METHODS: The study included 369 children from a cohort of inhabitants of São Leopoldo, state of Rio Grande do Sul, Brazil, who were randomized at birth into an intervention group and into a control group. The intervention group had nutritional guidance in the first year of life, with monthly follow-up home visits, whereas the control group was visited at 6 and 12 months, without nutritional intervention. At the end of the first year of life, a 24-hour recall was used. Anemia was diagnosed based on a hemoglobin level less than 11 g/dL. The children's diets were classified according to iron bioavailability. RESULTS: The prevalence of anemia amounted to 63.7% in this study. The proportion of children with adequate iron intake relative to the recommendations was statistically higher in the nonanemic group (26.8%) than in the anemic one (17.7%). Nonanemic children had a greater intake of iron (p = 0.019), vitamin C (p = 0.001), energy density at dinner (p = 0.006), iron density per 1,000 calories (p = 0.045); and 16.3% of them had a diet with high iron bioavailability (p = 0.002). CONCLUSIONS: A diet with high iron bioavailability protects children from anemia and can be used as an intervention measure by basic health services and by the municipal departments of children's education.

Recomendações para o fortalecimento da atenção nutricional na atenção primária à saúde brasileira / Recommendations to strengthen nutritional care in the primary care setting in Brazil / Recomendaciones para el fortalecimiento de la atención nutricional en la atención primaria de salud en Brasil

RESUMO Objetivo. Elaborar recomendações para o fortalecimento da alimentação e nutrição (A&N) na atenção primária à saúde (APS) brasileira a partir de um consenso de especialistas. Métodos. Realizou-se estudo descritivo e exploratório utilizando a técnica Delphi. De 172 especialistas em A&N na APS convidados a participar, 116 aceitaram o convite e 72 participaram da primeira rodada. A segunda rodada teve 56 participantes das cinco macrorregiões brasileiras, entre gestores, profissionais de saúde, representantes da sociedade civil e pesquisadores. As recomendações foram construídas por análise temática das respostas a perguntas abertas sobre obstáculos, estratégias, ações e iniciativas de cinco componentes técnicos da Política Nacional de Alimentação e Nutrição (vigilância alimentar e nutricional, atenção e coordenação do cuidado nutricional, promoção da saúde, intersetorialidade e gestão das ações de A&N). Na segunda rodada, os especialistas classificaram cada item proposto quanto à sua pertinência e relevância para fins de recomendação. Resultados. Os especialistas elaboraram 35 recomendações, organizadas em seis categorias: estrutura; agenda de A&N na APS; organização em rede e organização da APS; processos de trabalho de A&N na APS; planejamento, monitoramento e avaliação das ações de A&N na APS; e sistema de informação. As categorias foram organizadas em dois blocos: "ações estruturantes da APS para o fortalecimento da A&N" e "ações estruturantes da A&N para o fortalecimento da APS". Conclusões. As recomendações foram produzidas por pessoas experientes que acompanham a trajetória da A&N e da APS por diferentes pontos de vista, sendo úteis para a gestão e proposição de políticas públicas rumo ao fortalecimento da A&N nas APS brasileira.

ABSTRACT Objective. To develop recommendations to strengthen nutritional care in the primary health care (PHC) setting in Brazil based on expert consensus. Method. A descriptive and exploratory study was performed using the Delphi technique. Of 172 invited PHC experts in nutrition, 116 accepted the invitation and 72 participated in the first Delphi round. The second round had 56 participants from the five Brazilian regions, including managers, healthcare professionals, representatives from civil society organizations, and researchers. The recommendations were developed based on thematic analysis of the responses to open-ended questions about barriers, strategies, actions, and initiatives from five components of the National Food and Nutrition Policy (food and nutrition surveillance, coordination of nutritional care, health promotion, intersectoral focus, and management of food and nutrition actions). In the second round, experts classified each proposed item regarding its pertinence and relevance for the purpose of recommendation. Results. A consensus was reached on 35 recommendations distributed in six categories: structure; PHC nutritional agenda; organization of the healthcare network and PHC; nutritional work processes in PHC; planning, monitoring and evaluation of nutritional actions in PHC; and information systems. These categories were further classified into two blocks: "PHC structuring actions to strengthen nutrition" and "nutrition structuring actions to strengthen PHC." Conclusions. The recommendations were developed by experienced participants who are familiar with both nutritional and PHC pathways from diverse perspectives, and will be useful for the management and proposition of public policies to strengthen nutritional care in the PHC setting in Brazil.

RESUMEN Objetivo. Elaborar recomendaciones para el fortalecimiento de la alimentación y la nutrición en la atención primaria de salud (APS) en Brasil a partir del consenso de especialistas. Métodos. Se realizó un estudio descriptivo y exploratorio con la técnica de Delfos. En total, 172 especialistas en alimentación y nutrición del sistema de APS recibieron una invitación para participar, 116 la aceptaron y 72 intervinieron en la primera ronda. En la segunda ronda hubo 56 participantes de las cinco macrorregiones brasileñas, entre gestores, profesionales de salud, representantes de la sociedad civil e investigadores. Las recomendaciones se formularon mediante un análisis temático de las respuestas a preguntas abiertas sobre obstáculos, estrategias, medidas e iniciativas referentes a cinco aspectos técnicos de la política nacional de alimentación y nutrición (vigilancia alimentaria y nutricional, atención y coordinación del cuidado nutricional, promoción de la salud, intersectorialidad y gestión de las medidas relativas a alimentación y nutrición). En la segunda ronda, los especialistas clasificaron cada punto propuesto según su pertinencia y relevancia para efecto de las recomendaciones. Resultados. Los especialistas formularon 35 recomendaciones, organizadas en seis categorías: estructura; agenda de alimentación y nutrición en la APS; organización en red y organización de la APS; procesos de trabajo relativos a la alimentación y nutrición en la APS; planificación, monitoreo y evaluación de las medidas relativas a la alimentación y nutrición en la APS; y sistema de información. Las categorías se dividieron en dos grupos: medidas estructurantes de la APS para el fortalecimiento de la alimentación y la nutrición y medidas estructurantes de alimentación y nutrición para el fortalecimiento de la APS. Conclusiones. Las recomendaciones provinieron de personas expertas que siguen la trayectoria tanto de la alimentación y la nutrición como de la APS desde diferentes puntos de vista, útiles para la gestión y la propuesta de políticas públicas destinadas a fortalecer la alimentación y la nutrición en la APS de Brasil.