Challenges in Assessment of Health Systems Decentralization: The Role of Path Dependence and Choice of Indicators Comment on "The Effects of Health Sector Fiscal Decentralisation on Availability, Accessibility, and Utilisation of Healthcare Services: A Panel Data Analysis".

Optimal resource allocation within national health systems represents the ultimate challenge in diverse countries worldwide. Major part of the literature points that health systems decentralization potentially address the challenge. The present commentary focuses on the debate referring to effects of health systems decentralization, based on the evidence of the study of Arianna Rotulo and colleagues. Studies on the subject emphasize the role of path dependence and the influence of choice of indicators for measurement of effects in the assessment of health systems decentralization. Acknowledging the complexity of the phenomena, the results of the study of Rotulo et al on health system decentralization in Italy are highlighted through the analysis of recent evidence from the literature. The present commentary shows that there are diverse indicators adopted in the literature on the subject, pointing to mixed results, depending on country characteristics and selection of indicators in the analysis. The synthesis of indicators gathered in recent studies also indicate that health system indicators are sensitive to path dependence, thus, requiring additional attention to assumptions of studies on health systems decentralization. Thus, studies should consider the influence of path dependence on organizational practices and institutional structures involved in decentralization processes, in addition to acknowledging that assessments on decentralization vary substantially according to indicators adopted in the analysis, and their links with previous decisions within health systems.

Evolution of global food trade network and its effects on population nutritional status.

Changes in food systems during the last decades fostered the establishment of global food networks based on exchanges between countries with different income levels. Recent studies explored configuration and factors associated with trade networks of specific food items during limited periods; however, there is lack of evidence on evolution of trade networks of foods for human consumption and its potential effects on population nutritional status. We present the evolution of the global trade network of foods for human consumption from 1986 to 2020, according to country income level, and we explore potential effects of country network centrality and globalization processes on the prevalence of overweight and obesity. Results show intensification of international food trade and globalization processes in the period of analysis with implications for population nutritional status worldwide.

An empirically validated framework for measuring patient's acceptability of health care in Multi-Island Micro States.

Measuring health-care acceptability presents conceptual and contextual challenges, particularly in data-poor Multi-Island Micro States (MIMSs). Thus, there has been limited evidence on the acceptability of health care in MIMS and scarce use of acceptability metrics in policy design and health system evaluation. In the present study, we developed and empirically validated a theoretical framework for measuring users' acceptability of health care in a MIMS in the Caribbean. Using a minimum-data approach, we used a synoptic review of health-care literature and consultations with experts and health system stakeholders to define, scope and select constructs for the theoretical framework of health-care acceptability. Empirical validation of the modelled framework was performed using data collected from household expenditure and health-care utilization surveys in Carriacou and Petite Martinique (n = 226), island dependents of Grenada in the Caribbean. Data were used to create health utilization profiles and analyse measurement scales of the health-care acceptability framework using non-linear partial least square structural equation modelling. The modelled framework included 17 items integrating economic and psychosocial concepts, with 1 dependent construct (utilization) and 3 independent constructs (users' perception, experience and knowledge of health facility). Model analysis and validation indicated that the framework was significant, explaining 19% of the variation in health-care acceptability. Users' experience construct was influenced by perception and knowledge of health facility and was the only construct with a significant negative relationship with acceptability. Health-care acceptability declined with increased waiting and travel times and unsuitable opening hours. We conclude that acceptability comprises a complex multidimensional concept, which is highly dependent on various interacting variables and contextual characteristics of the health system. Therefore, policies and actions to improve acceptability should be context specific and focused on evaluating factors infringing health-care acceptability. Routine acceptability and/or satisfaction studies represent baseline evidence towards understanding and integrating acceptability in health-care assessment.

Acute Muscle Mass Loss Predicts Long-Term Fatigue, Myalgia, and Health Care Costs in COVID-19 Survivors.

OBJECTIVE: We examined the impact of loss of skeletal muscle mass in post-acute sequelae of SARS-CoV-2 infection, hospital readmission rate, self-perception of health, and health care costs in a cohort of COVID-19 survivors. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: Tertiary Clinical Hospital. Eighty COVID-19 survivors age 59 ± 14 years were prospectively assessed. METHODS: Handgrip strength and vastus lateralis muscle cross-sectional area were evaluated at hospital admission, discharge, and 6 months after discharge. Post-acute sequelae of SARS-CoV-2 were evaluated 6 months after discharge (main outcome). Also, health care costs, hospital readmission rate, and self-perception of health were evaluated 2 and 6 months after hospital discharge. To examine whether the magnitude of muscle mass loss impacts the outcomes, we ranked patients according to relative vastus lateralis muscle cross-sectional area reduction during hospital stay into either "high muscle loss" (-18 ± 11%) or "low muscle loss" (-4 ± 2%) group, based on median values. RESULTS: High muscle loss group showed greater prevalence of fatigue (76% vs 46%, P = .0337) and myalgia (66% vs 36%, P = .0388), and lower muscle mass (-8% vs 3%, P < .0001) than low muscle loss group 6 months after discharge. No between-group difference was observed for hospital readmission and self-perceived health (P > .05). High muscle loss group demonstrated greater total COVID-19-related health care costs 2 ($77,283.87 vs. $3057.14, P = .0223, respectively) and 6 months ($90,001.35 vs $12, 913.27, P = .0210, respectively) after discharge vs low muscle loss group. Muscle mass loss was shown to be a predictor of total COVID-19-related health care costs at 2 (adjusted ß = $10, 070.81, P < .0001) and 6 months after discharge (adjusted ß = $9885.63, P < .0001). CONCLUSIONS AND IMPLICATIONS: COVID-19 survivors experiencing high muscle mass loss during hospital stay fail to fully recover muscle health. In addition, greater muscle loss was associated with a higher frequency of post-acute sequelae of SARS-CoV-2 and greater total COVID-19-related health care costs 2 and 6 months after discharge. Altogether, these data suggest that the loss of muscle mass resulting from COVID-19 hospitalization may incur in an economical burden to health care systems.

Associations among diet costs, food prices and income: Elasticities of risk and protection food groups for cardiometabolic diseases in Sao Paulo, Brazil (2003-2015).

Background: Economic dimension comprises important determinants of food choices, particularly income and prices. Aim: Identification of the influence of food prices and diet costs on the consumption of food groups considered protection and risk factors for cardiometabolic diseases. Methods: Food groups classification follows the proposal of "What we eat in America?" from the National Health and Nutrition Examination Survey (NHANES), adapted to Latin America. Data on food consumption from the Health Survey of Sao Paulo (2003, 2008, and 2015), representative at population level, was used. Log-linear regressions were estimated for food groups, controlling for endogeneity through augmented regression-test Results: Results showed increase in prices per calorie of whole grains and red meat from 2003-2015 and a decrease in prices per calorie of fruits, vegetables, beans, legumes, oilseeds and fish/seafood. Food groups had price elasticities between -0.01 and -1.6, i.e., decrease in consumption associated with increase in prices. Results showed statistically significant effects of substitution and complementarity, particularly substitution between sweetened beverages and fruits (2003, ß = 0.606; 2008: ß = 0.683; 2015, ß = 0.848), complementarity between nuts and seeds and whole grains (2003, ß = -0.646; 2008, ß = -0.647; 2015,ß = -0.901), and vegetables and processed meat (2003, ß = -1.379; 2015, ß = -1.685). Conclusion: Findings of the study represent relevant evidence for design strategies towards the adoption of healthier diets, particularly through subsidies to protection food groups, promoting lower prices and higher diet quality. The evidence may be useful for policymakers and researchers in fields of nutrition and health in diverse countries worldwide, especially due to absence of robust evidence in literature.

Social inequalities in the incidence, mortality, and survival of neoplasms in women from a municipality in Southeastern Brazil.

This study aims to analyze inequalities in the incidence, mortality, and survival of the main types of cancer in women according to the Social Vulnerability Index (SVI). The study was conducted in Campinas, São Paulo State, Brazil, from 2010 to 2014, and used data from the Population-based Cancer Registry and the Mortality Information System. Incidence and mortality rates standardized by age and 5-year survival estimates were calculated according to the social vulnerability strata (SVS), based on the São Paulo Social Vulnerability Index. Three SVS were delimited, with SVS1 being the lowest level of vulnerability and SVS3 being the highest. Rate ratios and the concentration index were calculated. The significance level was 5%. Women in SVS1 had a higher risk of breast cancer (0.46; 95%CI: 0.41; 0.51), colorectal cancer (0.56; 95%CI: 0.47; 0.68), and thyroid cancer (0.32; 95%CI: 0.26; 0.40), whereas women from SVS3 had a higher risk of cervical cancer (2.32; 95%CI: 1.63; 3.29). Women from SVS1 had higher mortality rates for breast (0.69; 95%CI: 0.53; 0.88) and colorectal cancer (0.69; 95%CI: 0.59; 0.80) and women from SVS3 had higher rates for cervical (2.35; 95%CI: 1.57; 3.52) and stomach cancer (1.43; 95%CI: 1.06; 1.91). Women of highest social vulnerability had lower survival rates for all types of cancer. The observed inequalities differed according to the location of the cancer and the analyzed indicator. Inequalities between incidence, mortality, and survival tend to revert and the latter is always unfavorable to the segment of highest vulnerability, indicating the existence of inequality in access to early diagnosis and timely treatment.

Impacts of bariatric surgery in health outcomes and health care costs in Brazil: Interrupted time series analysis of multi-panel data.

BACKGROUND: The increasing burden of obesity generates significant socioeconomic impacts for individuals, populations, and national health systems worldwide. The literature on impacts and cost-effectiveness of obesity-related interventions for prevention and treatment of moderate to severe obesity indicate that bariatric surgery presents high costs associated with high effectiveness in improving health status referring to certain outcomes; however, there is a lack of robust evidence at an individual-level estimation of its impacts on multiple health outcomes related to obesity comorbidities. METHODS: The study encompasses a single-centre retrospective longitudinal analysis of patient-level data using micro-costing technique to estimate direct health care costs with cost-effectiveness for multiple health outcomes pre-and post-bariatric surgery. Data from 114 patients who had bariatric surgery at the Hospital of Clinics of the University of Sao Paulo during 2018 were investigated through interrupted time-series analysis with generalised estimating equations and marginal effects, including information on patients' characteristics, lifestyle, anthropometric measures, hemodynamic measures, biochemical exams, and utilisation of health care resources during screening (180 days before) and follow-up (180 days after) of bariatric surgery. RESULTS: The preliminary statistical analysis showed that health outcomes presented improvement, except cholesterol and VLDL, and overall direct health care costs increased after the intervention. However, interrupted time series analysis showed that the rise in health care costs is attributable to the high cost of bariatric surgery, followed by a statistically significant decrease in post-intervention health care costs. Changes in health outcomes were also statistically significant in general, except in cholesterol and LDL, leading to significant improvements in patients' health status after the intervention. CONCLUSIONS: Trends multiple health outcomes showed statistically significant improvements in patients' health status post-intervention compared to trends pre-intervention, resulting in reduced direct health care costs and the burden of obesity.

Differences in Cost-Effectiveness of Adherence to Nutritional Recommendations: Why, Where, and What?

Cost-effectiveness analysis of diets may comprise an important tool to promote food security; however, studies show divergent evidence regarding the relationship between diet quality and cost in diverse populations. Thus, this study assesses differences in cost-effectiveness ratios regarding adherence to nutritional recommendations using data representative of the population level in Sao Paulo municipality, Brazil. Information from adolescents and adult individuals (n = 1742) was used to estimate diet quality and cost in 2015. Differences in cost-effectiveness ratios were investigated through application of two diet quality indexes and exploration of individuals' personal and contextual characteristics. Results indicated that higher diet cost was associated with higher adherence to nutritional recommendations at the national level and inversely associated with adherence to international recommendations. Purchasing foods in street markets was linked to healthier diets at lower costs, and protein consumption was associated with higher diet cost regardless of diet quality; however, diet quality was linked to type of protein consumed by individuals. Differences in cost-effectiveness ratios were attributable to methodological choices in measuring dietary quality (why); individuals' personal and contextual characteristics, in particular, access to retail equipment (where); and certain food choices (what). Therefore, cost-effectiveness analyses should be tailored to policy goals and local environments to ensure proper assessment of nutrition programs and to foster improvements in nutritional diet quality at lower cost.

Cost-utility analysis of traditional drug therapy with and without exercise program for hypertensive patients in real-life data primary health care

Abstract Aim: The study aimed to conduct a cost-utility analysis of traditional drug therapy (TDT) provided for hypertensive patients at primary care in comparison to the protocol based on combination with an exercise program (TDT+E) in real-life conditions, adopting a health system perspective. Methods: Longitudinal study based on enrollment of 49 hypertensive adults distributed into two groups, for 12 months. Quality-adjusted life years were estimated using health-related quality of life. Direct health care costs were calculated including inputs and human resources in primary care from medical records. Sensitivity analysis was performed based on multivariate and probabilistic scenarios. Results: Incremental cost-effectiveness ratios of TDT+E in comparison to TDT were +79.69. Sensitivity analysis showed that TDT+E presented advantages considering uncertainties. Conclusion: Our findings show that exercise programs may improve quality of life and life expectancy among hypertensive patients.

Social inequalities in the incidence, mortality, and survival of neoplasms in women from a municipality in Southeastern Brazil / Desigualdades sociais na incidência, mortalidade e sobrevida de câncer em mulheres em um município do Sudeste do Brasil / Inequidades sociales en la incidencia, mortalidad, y supervivencia relacionada con neoplasmas en mujeres de una municipalidad en el sudeste de Brasil

This study aims to analyze inequalities in the incidence, mortality, and survival of the main types of cancer in women according to the Social Vulnerability Index (SVI). The study was conducted in Campinas, São Paulo State, Brazil, from 2010 to 2014, and used data from the Population-based Cancer Registry and the Mortality Information System. Incidence and mortality rates standardized by age and 5-year survival estimates were calculated according to the social vulnerability strata (SVS), based on the São Paulo Social Vulnerability Index. Three SVS were delimited, with SVS1 being the lowest level of vulnerability and SVS3 being the highest. Rate ratios and the concentration index were calculated. The significance level was 5%. Women in SVS1 had a higher risk of breast cancer (0.46; 95%CI: 0.41; 0.51), colorectal cancer (0.56; 95%CI: 0.47; 0.68), and thyroid cancer (0.32; 95%CI: 0.26; 0.40), whereas women from SVS3 had a higher risk of cervical cancer (2.32; 95%CI: 1.63; 3.29). Women from SVS1 had higher mortality rates for breast (0.69; 95%CI: 0.53; 0.88) and colorectal cancer (0.69; 95%CI: 0.59; 0.80) and women from SVS3 had higher rates for cervical (2.35; 95%CI: 1.57; 3.52) and stomach cancer (1.43; 95%CI: 1.06; 1.91). Women of highest social vulnerability had lower survival rates for all types of cancer. The observed inequalities differed according to the location of the cancer and the analyzed indicator. Inequalities between incidence, mortality, and survival tend to revert and the latter is always unfavorable to the segment of highest vulnerability, indicating the existence of inequality in access to early diagnosis and timely treatment.

O estudo teve como objetivo analisar desigualdades na incidência, mortalidade e sobrevida de câncer em mulheres de acordo com o Índice de Vulnerabilidade Social (IVS). O estudo foi realizado em Campinas, Estado de São Paulo, Brasil, no período de 2010 a 2014 e usou dados do Registro de Câncer de Base Populacional (RCBP) e do Sistema de Informação de Mortalidade (SIM). Foram calculadas as taxas de incidência e mortalidade padronizadas por idade e estimativas de sobrevida em cinco anos de acordo com estratos de vulnerabilidade social. Foram demarcados três estratos com base no IVS de São Paulo, onde o estrato 1 representava o nível de menor vulnerabilidade e o estrato 3 o de maior vulnerabilidade. Foram calculadas razões de taxas e índice de concentração, com nível de significância de 5%. Foram encontrados riscos mais elevados de câncer de mama (0,46; IC95%: 0,41; 0,51), colorretal (0,56; IC95%: 0,47; 0,68) e tireoide (0,32; IC95%: 0,26; 0,40) em mulheres do estrato 1 e de colo uterino em mulheres do estrato 3 (2,32; IC95%: 1,63; 3,29). Mulheres do estrato 1 tiveram taxas mais elevadas de câncer de mama (0,69; IC95%: 0,53; 0,88) e colorretal (0,69; IC95%: 0,59; 0,80), e mulheres do estrato 3 tiveram taxas mais elevadas de câncer do colo uterino (2,35; IC95%: 1,57; 3,52) e estômago (1,43; IC95%: 1,06; 1,91). Para todos os tipos de câncer, a sobrevida era mais baixa em mulheres do estrato de maior vulnerabilidade social. As desigualdades observadas mostraram diferenças de acordo com a localização do tumor e o indicador utilizado. Além disso, há uma tendência de inverter as desigualdades entre incidência, mortalidade e sobrevida, onde a sobrevida sempre é desfavorável para o estrato de maior vulnerabilidade, indicando a existência de desigualdades em acesso ao diagnóstico precoce e tratamento precoce.

El objetivo fue analizar las inequidades en la incidencia, mortalidad y supervivencia de los principales tipos de cáncer en mujeres, según el Índice de Vulnerabilidad Social (IVS). El estudio se llevó a cabo en Campinas, estado de São Paulo, Brasil, durante el período 2010-2014, y se usaron datos del Registro de Cáncer de Base Poblacional (RCBP) y el Sistema de Información de Mortalidad (SIM). Las tasas de incidencia y mortalidad estandarizadas por edad, así como las estimaciones de supervivencia durante cinco años, se calcularon según los estratos de vulnerabilidad social (SVS). Se delimitaron tres SVS, basados en el IVS de São Paulo, con SVS1 siendo el nivel más bajo de vulnerabilidad y SVS3 siendo el nivel más alto de vulnerabilidad. Se calcularon los cocientes de tasas y el índice de concentración. El nivel de significancia fue 5%. Se encontró un riesgo más alto de cáncer de la mama (0,46; IC95%: 0,41; 0,51), colorrectal (0,56; IC95%: 0,47; 0,68), y tiroides (0,32; IC95%: 0,26; 0,40) en mujeres de SVS1, y cáncer cervical en mujeres de SVS3 (2,32; IC95%: 1,63; 3,29). Respecto a la mortalidad, las mujeres de SVS1 tuvieron tasas más altas en cáncer de la mama (0,69; IC95%: 0,53; 0,88) y colorrectal (0,69; IC95%: 0,59; 0,80) y las mujeres de SVS3 tuvieron tasas más altas en cáncer cervical (2,35; IC95%: 1,57; 3,52) y estómago (1,43; IC95%: 1,06; 1,91). Para todos los tipos de cáncer, las tasas de supervivencia fueron más bajas en mujeres del estrato social con más alta vulnerabilidad social. Las inequidades sociales observadas difirieron según la localización del cáncer y el indicador analizado, y no hubo una tendencia para revertir las inequidades entre incidencia, mortalidad y supervivencia, las últimas siempre fueron desfavorables para el segmento de más alta vulnerabilidad, indicando la existencia de desigualdad en el acceso a un diagnóstico temprano y un tratamiento oportuno.

How to Estimate Food Prices and Diet Costs in Population-Based Studies?

Health and nutrition surveys usually comprise detailed information on health characteristics and food consumption of certain population groups; however, the lack of data collection on the food prices may pose challenges for the estimation of the diet costs for the comprehensive analysis of food demand. The Household Budget Survey (HBS) represents an opportunity to obtain the data on the food prices for the nutrition surveys in the diverse countries worldwide. Although the HBS and the health and nutrition surveys may correspond to different periods, the application of the appropriate Consumer Price Index (CPI) allows to address the changes in the relative prices to perform the linkage between the data of food consumption with information on the food prices. Therefore, the aim of this study was to present the methods for the extraction and linkage of the food prices data from the Brazilian HBS (2002-2003 and 2008-2009) by using the pairing features related to the household characteristics to match the Health Survey of São Paulo [Inquérito de Saúde de São Paulo (ISA-Capital)] conducted in 2003, 2008, and 2015. Data referring to the household characteristics and food prices acquired by the household members living in São Paulo municipality were selected from the HBS datasets for integration with the ISA-Capital dataset. Specific deflators referring to the food items surveyed in São Paulo were obtained from the datasets of the Brazilian Broad Consumer Price Index (BCPI). Therefore, the pairing criteria referring to time, location, and household characteristics were adopted to allow linking foods consumed by the individuals in the ISA-Capital with the prices from the foods acquired by household members interviewed in the HBS. Matching data on the key pairing criteria (location/year/household income per capita/number of residents/family profile) resulted in the linkage of 94.4% (2003), 92.6% (2008), and 81.2% of the cases (2015). Following the data linkage, it was possible to estimate diet costs per gram and per calorie including application of cooking and conversion factors. Data were presented in the International Monetary Unit under the purchasing power parity (PPP) to allow the comparison at the international level. The mean diet costs identified in the population of São Paulo municipality were $8.45 (dp = 0.38) per capita per day in 2003, $8.72 (dp = 0.24) per capita per day in 2008, and $9.62 (dp = 0.23) per capita per day in 2015. Thus, it was possible to estimate the diet costs based on the prices of food items through pairing linkage of information from the household surveys, such as the Brazilian HBS, with the health and nutrition surveys lacking information on the expenditures or prices such as the ISA-Capital. Similar procedures may be used in the diverse countries with availability of the datasets of the household expenditures and health and nutrition surveys, allowing the researchers worldwide to associate the diet quality with food demand.

Integrative Strategies for Preventing Nutritional Problems in the Development of Children in Brazil.

Child healthcare has been a priority subject in several programs and public policies developed over the decades. However, initiatives implemented seem insufficient to overcome the challenges regarding the integral development and improvement of the nutritional status of children in Brazil. The initial developmental stages of a child include pregnancy, breastfeeding, and complementary feeding, which are determinants in future aspects of health and nutritional status. Therefore, the strategies addressing problems during these three periods of life have the potential to positively impact the promotion of healthy eating habits and food security throughout life. Developing countries with huge dimensions and vast inequalities, like Brazil, are marked by differences in regional, cultural, and social contexts that may hinder the implementation of programs and policies with a broad scope. Extensive operational and professional costs, in addition to time-consuming activities that are necessary to apply, monitor, and evaluate interventions may jeopardize the proper assessment of programs and policy goals, generating the inefficiency and waste of resources in the health system. Thus, programs and policies aimed at creating and modifying habits should consider an intersectoral action within local contexts, involving health professionals, universities, policy managers, and the community. Therefore, this article aimed to discuss the preliminary conception of an integrated approach of decentralized strategies to promote healthy eating habits and food security of children in Brazil.

Prevalence and Factors Associated with Iron Deficiency and Anemia among Residents of Urban Areas of São Paulo, Brazil.

Anemia is a worldwide concern. This cross-sectional population-based study examined the prevalence of iron-deficiency anemia (IDA) among residents of São Paulo (n = 898; 12-93 years), considering sociodemographic factors, dietary iron inadequacy, and food contributors to iron intake. Blood cell count and iron biomarkers were quantified. Dietary iron intake was measured using two 24-h dietary recalls. Iron intake inadequacy was estimated using a probabilistic approach. The prevalence of anemia was 6.7%, depleted iron stores 5.1%, and IDA 1.1%. Women of all age groups, older adults, and those who were underweight or obese had the highest prevalence of anemia, and female adolescents had the highest prevalence of depleted iron stores. Female adolescents and adults were more vulnerable to depleted iron stores. Male adults and older adults had a considerable prevalence of iron overload. Except for female adolescents and adults, all groups had mild probabilities of inadequate iron intake. The main food iron contributor was wheat flour. Hemoglobin concentrations were directly associated with being an adult, having a higher income, and inversely associated with being female. Serum ferritin concentrations were directly associated with age and inversely correlated with female sex. Residents of São Paulo had a low prevalence of anemia, iron deficiency, and IDA, and sociodemographic factors interfered with these parameters.

Association of Iron Supplementation Programs with Iron-Deficiency Anemia Outcomes among Children in Brazil.

Anemia remains a condition with high prevalence in populations worldwide, and the prevalence of anemia among children under five years old in Brazil is approximately 40%, being higher in communities marked by social inequities. Diverse government programs during recent decades targeted iron-deficiency anemia, considering its impacts throughout the lifetime. The objective of this study was to investigate the effects of two government iron supplementation programs on health outcomes related to iron-deficiency anemia among children up to 4 years old in Brazilian municipalities. A longitudinal panel encompassing data from 5570 municipalities from 1998 to 2019 was investigated using a difference-in-differences framework with multiple interventions and distinct times of adhesion, and fixed-effects models were estimated to control for invariant municipal characteristics throughout the period in order to ensure comparability. The results indicate significant effects of the federal programs in reducing hospitalizations and lengths of stay due to iron-deficiency anemia, especially in non-poor municipalities. There was complementarity in the effects of the programs; however, neither of the programs influenced mortality rates. Thus, it is important to consider possible improvements in the operationalization of the programs, in order to achieve better results in the reduction of severe iron-deficiency anemia among children up to 4 years old.

Trends in sociodemographic and lifestyle factors associated with sedentary behavior among Brazilian adults.

OBJECTIVE: To analyze sociodemographic and lifestyle factors associated with screen-based sedentary behavior (watching television ≥ 3 hours/day) among adult individuals in Brazil. METHODS: Quantitative analysis of ten editions of the cross-sectional health survey VIGITEL, representative at the population level. Individuals from states' capitals living in households with land-line telephone were randomly selected and interviewed with a structured questionnaire, through the telephone. A multivariate logistic regression model was estimated for identification of factors associated with screen-based sedentary behavior. RESULTS: There was stability in trends referring to prevalence of sedentary behavior from 2008 to 2017. Prevalence of sedentary behavior was higher between individuals with unhealthier lifestyles: consumption of < two in natura food items (vegetables, fruits, and beans) per day (26.73% [95%CI 25.2 - 28.31]) in comparison with ≥ two items per day (23.79% [95%CI 21.92 - 25.77]); consumption of soft drinks ≥ five days per week (31.24% [95%CI 29.58 - 32.95]) than < five days per week (23.82% [95%CI 22.2 - 25.52]); and practice of < 150 minutes of physical activity per week (28.2% [95%CI 26.17 - 30.33]) than ≥ 150 minutes per week (22.54% [95%CI 21.27 - 23.86]). Regular consumption of in natura food items (OR = 0.984), practice of physical activity (OR = 0.798), and living in richer municipality (OR = 0.826) represented protective factors in relation to screen-based sedentary behavior, whilst regular consumption of soft drinks (OR = 1.440), smoking (OR = 1.375) and alcohol abuse (OR = 1.334) represented risk factors. CONCLUSION: The adoption of screen-based sedentary behavior among adult individuals in Brazil presented significant association with modifiable behavioral factors in the period 2008-2017.

Feasibility in meeting nutrient amounts of the National School Feeding Program and its relationship with the menu cost. / Viabilidade no atendimento às normas do Programa Nacional de Alimentação Escolar e sua relação com custo dos cardápios.

We evaluated the feasibility of the menu adequacy regarding the nutritional constraints established by the National School Feeding Program (PNAE) and its relation to the cost. Each menu accounted for a given food combination within each food group. A diet optimization model comprising each set of foods was designed to obtain food quantities in order to meet the exigences of the PNAE at the lowest cost (menus with 20% and 30% of dietary reference intake for energy, macronutrients, calcium, iron, magnesium, zinc, vitamins A and C, also restrictions for sodium, saturated and trans fats, and added sugar). There was no feasible solution that accommodated all nutrient targets. Limiting components were calcium, sodium, and carbohydrates; but the menus were adequate for the other nutrients. There was a positive correlation between the menu cost and the frequency of meat and fruits, and a negative correlation with the contents of sodium and carbohydrates, and with the frequencies of rice and beans. The probability of obtaining carbohydrate adequacy was close to zero when the meat frequency was higher than one serving per week. In conclusion, it is unlikely to obtain menus that meet all the requirements of the PNAE.

O estudo avaliou a viabilidade da adequação de cardápios em relação às exigências nutricionais estabelecidas pelo Programa Nacional de Alimentação Escolar (PNAE) e a relação entre o custo do cardápio. Cada cardápio semanal contou de uma combinação de alimentos dentro de cada grupo. Para cada combinação de alimentos foi elaborado um modelo de otimização de dados para obter as quantidades de cada alimento de forma a atender às exigências do PNAE ao menor custo possível (cardápios com 20% e 30% da ingestão dietética de referência para energia, macronutrientes, cálcio, ferro, magnésio, zinco, vitaminas A e C, além de restrições para sódio, gorduras saturada e trans, e açúcar de adição). Não foi obtida nenhuma solução que acomodasse todas as exigências do PNAE. Os componentes limitantes foram cálcio, sódio e carboidratos; para os demais os cardápios foram adequados. O custo foi diretamente correlacionado com a frequência de carne e frutas, e inversamente com os conteúdos de sódio e carboidratos, e com as frequências de arroz e feijão. A probabilidade de adequação de carboidratos foi próxima de zero quando a frequência de carne foi acima de 1 vez por semana. Concluindo, é pouco provável a obtenção de cardápios que atendam à todas as exigências do PNAE.

Study protocol: health survey of Sao Paulo: ISA-Physical Activity and Environment.

BACKGROUND: Many studies have investigated the association between the built environment and physical activity behavior in urban settings. However, most of the studies conducted in low- and middle-income countries were cross-sectional, which are limited to identify behavioral determinants. We propose a prospective cohort study to verify the relationship between built environment features and leisure-time and transport-related physical activity in adults from Sao Paulo city, Brazil. METHODS: Prospective multilevel cohort, denominated "ISA-Physical Activity and Environment". It will build on the Health Survey of Sao Paulo in 2015 ("Inquérito de Saúde de São Paulo (ISA)" in Portuguese). The Health Survey of Sao Paulo, originally designed as a cross-sectional survey, had a multi-stage sample, covering 150 census tracts distributed in five health administrative areas. Data collection was performed by face-to-face interviews until December 2015 and the sample comprised 4043 individuals aged 12 years or more. The ISA-Physical Activity and Environment study will reassess people who are aged 18 years or more in 2020, including telephone and household interviews. The primary outcome will be leisure-time and transport-related physical activity, assessed through the International Physical Activity Questionnaire long version. Exposure variables will be built environment features in the areas participants live and work in the follow-up. Data analysis will include multivariate multilevel linear and logistic models. We will also conduct cost-effectiveness analysis and develop agent-based models to help inform decision-makers. The study will be conducted by an interdisciplinary research team specialized in physical activity epidemiology, nutritional epidemiology, georeferencing applied to health, statistics, agent-based modeling, public health policy, and health economics. DISCUSSION: There are few longitudinal studies on the relationship between the built environment and physical activity behavior in low- and middle-income countries. We believe that the ISA-Physical Activity and Environment study will contribute with important results for the progress of the knowledge in this field and for the implementation of policies that promote leisure-time physical activity and active travel in Sao Paulo and similar cities across the world.

Viabilidade no atendimento às normas do Programa Nacional de Alimentação Escolar e sua relação com custo dos cardápios / Feasibility in meeting nutrient amounts of the National School Feeding Program and its relationship with the menu cost

Resumo O estudo avaliou a viabilidade da adequação de cardápios em relação às exigências nutricionais estabelecidas pelo Programa Nacional de Alimentação Escolar (PNAE) e a relação entre o custo do cardápio. Cada cardápio semanal contou de uma combinação de alimentos dentro de cada grupo. Para cada combinação de alimentos foi elaborado um modelo de otimização de dados para obter as quantidades de cada alimento de forma a atender às exigências do PNAE ao menor custo possível (cardápios com 20% e 30% da ingestão dietética de referência para energia, macronutrientes, cálcio, ferro, magnésio, zinco, vitaminas A e C, além de restrições para sódio, gorduras saturada e trans, e açúcar de adição). Não foi obtida nenhuma solução que acomodasse todas as exigências do PNAE. Os componentes limitantes foram cálcio, sódio e carboidratos; para os demais os cardápios foram adequados. O custo foi diretamente correlacionado com a frequência de carne e frutas, e inversamente com os conteúdos de sódio e carboidratos, e com as frequências de arroz e feijão. A probabilidade de adequação de carboidratos foi próxima de zero quando a frequência de carne foi acima de 1 vez por semana. Concluindo, é pouco provável a obtenção de cardápios que atendam à todas as exigências do PNAE.

Abstract We evaluated the feasibility of the menu adequacy regarding the nutritional constraints established by the National School Feeding Program (PNAE) and its relation to the cost. Each menu accounted for a given food combination within each food group. A diet optimization model comprising each set of foods was designed to obtain food quantities in order to meet the exigences of the PNAE at the lowest cost (menus with 20% and 30% of dietary reference intake for energy, macronutrients, calcium, iron, magnesium, zinc, vitamins A and C, also restrictions for sodium, saturated and trans fats, and added sugar). There was no feasible solution that accommodated all nutrient targets. Limiting components were calcium, sodium, and carbohydrates; but the menus were adequate for the other nutrients. There was a positive correlation between the menu cost and the frequency of meat and fruits, and a negative correlation with the contents of sodium and carbohydrates, and with the frequencies of rice and beans. The probability of obtaining carbohydrate adequacy was close to zero when the meat frequency was higher than one serving per week. In conclusion, it is unlikely to obtain menus that meet all the requirements of the PNAE.

Cost-effectiveness analysis of Baby-Friendly Hospital Initiative in promotion of breast-feeding and reduction of late neonatal infant mortality in Brazil.

OBJECTIVE: To analyse the cost-effectiveness of Baby-Friendly Hospital Initiative (BFHI) in promoting breast-feeding during the first hour of life (BFFHL) and reducing late neonatal mortality. DESIGN: Cost-effectiveness economic assessment from the health system perspective, preceded by a prospective cohort of mother-baby followed from birth to 6 months of life. The direct costs associated with two health outcomes were analysed: intermediate end point (BFFHL) and final end point (reduction in late neonatal mortality). SETTING: Study was carried out in six hospitals in the city of São Paulo (Brazil), three being Baby-Friendly Hospitals (BFH) and three non-BFH. PARTICIPANTS: Mothers with 24 h postpartum, over 18 years old, single fetus and breast-feeding at the time of the interview were included. Poisson regressions adjusted for maternal age and level of education were estimated to identify factors related to BFFHL and late neonatal mortality. Sensitivity analysis was performed to ensure robustness of the economic assessment. RESULTS: Cost-effectiveness analysis showed that BFHI was highly cost-effective in raising BFFHL by 32·0 % at lower cost in comparison with non-BFHI. In addition, BFHI was cost-effective in reducing late neonatal mortality rate by 13·0 % from all causes and by 13·1 % of infant mortality rate from infections. CONCLUSIONS: The cost-effectiveness of the BFHI in promoting breast-feeding and reducing neonatal mortality rates justifies the investments required for its expansion within the Brazilian health system.