Análisis del proceso de construcción y propuesta de una estrategia intersectorial brasileña para la prevención y atención de la obesidad infantil

Bortolini, Gisele Ane; Pereira, Tatiane Nunes; Carmo, Ariene Silva do; Martins, Ana Maria Thomaz Maya; Silva, Jéssica Pedroso da; Silva, Sara Araújo da; Marinho, Paloma Abelin Saldanha; Lima, Ana Maria Cavalcante de; Spaniol, Ana Maria; Claumann, Gaia Salvador; Silveira, Jonas Augusto Cardoso da; Silva, Juliana Rezende Melo da

Gisele Ane Bortolini

contributed to the study design, data collection, analysis

interpretation, writing, and review

approved the final version

Ministério do Desenvolvimento e Assistência Social, Família e Combate à Fome, Brasília, Brasil.

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0002-7830-9134

Tatiane Nunes Pereira

contributed to the study design, data collection

analysis, and interpretation, writing, and review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0001-9312-5758

Ariene Silva do Carmo

contributed to the study design, data collection

analysis, and interpretation, writing, and review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0002-3421-9495

Ana Maria Thomaz Maya Martins

contributed to the writing and review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0001-6519-5193

Jéssica Pedroso da Silva

contributed to the writing and review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0001-5446-4319

Sara Araújo da Silva

contributed to the review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0002-2605-378X

Paloma Abelin Saldanha Marinho

contributed to the review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0001-5381-1761

Ana Maria Cavalcante de Lima

contributed to the writing and review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0003-3537-9674

Ana Maria Spaniol

contributed to the review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0003-4017-9597

Gaia Salvador Claumann

contributed to the writing and review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0002-3859-9106

Jonas Augusto Cardoso da Silveira

contributed to the writing and review

approved the final version

Universidade Federal do Paraná, Curitiba, Brasil.

https://orcid.org/0000-0003-3838-6212

Juliana Rezende Melo da Silva

contributed to the review

approved the final version

Ministério da Saúde, Brasília, Brasil.

https://orcid.org/0000-0002-0357-9631

Correspondence
G. A. Bortolini Esplanada dos Ministérios, bloco C, sala 448, Brasília, DF 70054-906, Brasil. gisele.bortolini@gmail.com

Additional information

ORCID: Gisele Ane Bortolini (0000-0002-7830-9134); Tatiane Nunes Pereira (0000-0001-9312-5758); Ariene Silva do Carmo (0000-0002-3421-9495); Ana Maria Thomaz Maya Martins (0000-0001-6519-5193); Jéssica Pedroso da Silva (0000-0001-5446-4319); Sara Araújo da Silva (0000-0002-2605-378X); Paloma Abelin Saldanha Marinho (0000-0001-5381-1761); Ana Maria Cavalcante de Lima (0000-0003-3537-9674); Ana Maria Spaniol (0000-0003-4017-9597); Gaia Salvador Claumann (0000-0002-3859-9106); Jonas Augusto Cardoso da Silveira (0000-0003-3838-6212); Juliana Rezende Melo da Silva (0000-0002-0357-9631).

RECOMMENDATIONS ON ACTIONS
Primary health care	Actions that allow to integrate different health services for obesity care, including strategies such as the training of health professionals; continuous monitoring of the nutritional status of children and families; actions to promote adequate and healthy food, breastfeeding and physical activity, and actions to prevent excessive weight gain, early diagnosis and adequate care for children, adolescents, and pregnant women
Schools	Protective measures that limit the promotion and availability of ultra-processed foods and sugary drinks, ensuring the availability of water and healthy foods. Educational actions with the school community, with strategies that promote the practice of physical activity, are recommended in these spaces
Healthy cities	Intersectoral actions and policies are needed to promote local food production and facilitate physical and financial access to healthy foods, strengthening family farming and agroecological production. It is also important to implement protective measures aimed at reducing exposure to unhealthy foods, and to create urban spaces for children to play and exercise
Public campaigns	Health communication campaigns that contribute to the dissemination of official guidelines for adequate and healthy eating and physical activity are recommended
Breastfeeding	Actions to protect, promote and support breastfeeding
RECOMMENDATIONS ON GOVERNANCE
Strengthen national governance and ensure state leadership in solving the issue
Create political will and increase political commitment and state responsibility toward the problem
Reduce the influence of private interests in the definition of public policies and establish mechanisms to prevent and reduce conflicts of interest
Expand social participation and transparency in the decision-making process
Base the program on rights defined in the Federal Constitution as support to justify actions
Monitor population data and partner with the academic sector, fund and use evidence in defining actions
Act in an intersectoral manner, with adequate coordination and ensuring policy coherence
Generate and guarantee sufficient and continuous resources (financial, personnel, infrastructure)
Set measurable goals and independent monitoring
Create accountability mechanisms for key policy stakeholders

FIRST CONTACT (DIAGNOSIS AND CARE ACTIONS IN PHC)
Monitor the nutritional status and food consumption markers of children, adolescents and pregnant women according to the Brazilian Ministry of Health’s official documents Provide individual and collective multidisciplinary PHC care for pregnant women with pregestational excess weight or excessive gestational weight gain, according to the Brazilian Ministry of Health’s official documents Provide individual and collective multidisciplinary PHC care for children and adolescents diagnosed with overweight and obesity, according to the Brazilian Ministry of Health’s official documents Equip the UBS with at least one scale and stadiometer for adults and children, according to the Brazilian Ministry of Health’s regulations
ACCOUNTABILITY (COMMITMENT)
Elaborate the step-by-step plan for implementing PROTEJA
ORGANIZATION (MANAGEMENT)
Include, in the municipal health plan, goals for the prevention and care of childhood obesity agreed by the formal management and social control of the SUS, including representatives from other public management sectors Intersectoral articulation with the various related sectors for the local management of PROTEJA Include in the annual management reports the progress of the actions agreed by the municipality
TRANSFORMATION (FOOD AND NUTRITION EDUCATION AND STIMULUS OF PHYSICAL ACTIVITY)
Implement, strengthen and/or expand the EAAB in the municipality Carry out individual and collective actions of food and nutrition education and physical activity in UBS and other public spaces for children, adolescents and pregnant women Carry out food and nutrition education and physical activity actions in schools, mainly through the PHC Ensure at least 15 minutes of physical activity per day, in addition to curricular physical education classes, in all schools and at all levels of education
EDUCATION (TRAINING)
Qualify education and PHC professionals, including community health and social workers, on childhood obesity, based on the Brazilian Ministry of Health’s manuals, guides, and protocols
WINDOW OF OPPORTUNITY (COMMUNICATION)
Carry out institutional campaigns in the mass media on childhood obesity Make available PROTEJA’s printed and digital materials and the Brazilian Ministry of Health’s official guidelines on adequate and healthy food and physical activity in UBSs, CRAS, CAPS, Academy of Health centers, hospitals, and schools
ENVIRONMENTS
Comply with the provisions of article 22 of Resolution n. 06/2020 of the FNDE on the PNAE Ensure healthy school canteens Create circuits of fairs and other healthy food marketing strategies that serve all regions of the municipality, especially in more vulnerable territories Promote and support urban agriculture, vegetable gardens in institutional settings, such as schools and health services, and in community spaces Map and qualify existing spaces and, if necessary, create new spaces for physical activity

Actions	n	%
Actions within PHC
Manage excessive weight gain, gestational diabetes, and pregnancy-induced hypertension	851	64.5
Qualify the monitoring of physical activity actions	709	53.7
Organize care for childhood obesity, making other points in the health care network available for referral of severe cases of obesity	592	44.8
Provide at least one integrative and complementary practice option as part of the prevention and care of childhood obesity in PHC	544	41.2
Training actions (continuing education)
Make available a workload so that PHC professionals in the municipality who work in the prevention of childhood obesity can attend at least one training or course per year, offered by the Brazilian Ministry of Health on the subject	854	64.7
Provide at least one training per year to PHC professionals who work, mainly with the maternal and child population, in anthropometric collection and evaluation of food consumption markers	821	62.2
Offer at least one training per year on healthy eating, physical activity and obesity for media professionals (journalists, advertisers, designers, etc.)	300	22.7
Establish partnerships with universities and colleges that have health courses to conduct research/outreach projects on the theme of childhood obesity in the municipality	181	13.7
Actions in schools
Guarantee the free supply of drinking water (water fountains in adequate sanitary conditions) in public schools	774	58.6
Carry out the minimum purchase of family farming products for the PNAE with Federal Government resources, in accordance with current legislation, creating mechanisms to gradually increase the percentage of purchases in partnership with local producers and other municipalities	440	33.3
Establish guidelines for the Municipal Health and Education Departments to provide food and nutrition education activities, based on the principles and guidelines of the Brazilian Ministry of Health’s food guides, the NBCAL, and the regulations of the FNDE	315	23.9
Invest in the construction and maintenance of school infrastructure for physical activity	258	19.5
Create local legislation to prevent the association of unhealthy foods with food and nutrition education activities, textbooks and sponsored events in schools	170	12.9
Install bike racks in schools and lockers to store school supplies	104	7.9
Comprehensive measures for health promotion and prevention of childhood obesity
Hold a public hearing together with the Legislative Branch to discuss childhood obesity prevention	202	15.3
Present bills on structuring measures that promote environments conducive to appropriate and healthy habits and behaviors, and prevention of childhood obesity	124	9.4
Municipalities that promote healthy eating
Publicize the support network for the promotion of adequate and healthy eating and physical activity in the municipality	471	35.7
Stimulate production chains that promote adequate and healthy eating, considering the stages of storage, supply and/or distribution of fruits and vegetables, which follow good agricultural practices and integrated production systems, valuing local food culture	172	13.0
Create contact networks between local producers and traders to stimulate the circulation and sale of fresh and minimally processed foods in the municipality	150	11.4
Train local traders and retailers in strategies to transform the food retail trade into a healthier environment	144	10.9
Implement subsidies for the production of fresh and minimally processed foods	128	9.7
Establish rules on the receipt of food donations in public establishments, either for on-site consumption or for distribution, promoting adequate and healthy food, health and dignity of the recipients of donations, in accordance with the principles of food guides for the Brazilian population	107	8.1
Create local legislation to make it mandatory to provide free filtered water in public spaces, such as parks and squares, and in restaurants, cafeterias, bars and similar establishments	98	7.4
Create and disseminate an application mapping places that sell fresh and minimally processed foods	81	6.1
Create local legislation to establish a minimum height of 120cm for shelves displaying ultra-processed foods to protect children from grabbing these products at points of sale	81	6.1
Actions to support and protect breastfeeding
Promote actions to encourage and support breastfeeding in daycare centers and schools, aiming at breastfeeding continuity	654	49.5
Extend maternity leave to at least six months and paternity leave to at least 20 days for municipal employees	198	15.0
Implement municipal laws that guarantee the right of women to breastfeed in any space, whether public or private	198	15.0
Strengthen and improve the implementation and inspection of the NBCAL and its regulation (Law n. 11,265/2006 and Decree n. 9,579/2018)	119	9.0
Implement breastfeeding support rooms for breastfeeding working women in municipal public offices and encourage their implementation in workplaces in other governmental and private spheres, as well as in places with large circulation of informal breastfeeding working women	118	8.9
Encourage the private sector to join the Corporate Citizen program, pursuant to Law n. 11,770/2008 and regulated by Decree n. 7,052/2009	89	6.7
Implement and/or expand the network of collection points and Human Milk Banks	80	6.1
Implement and/or strengthen and expand the IHAC in the municipal public health care network, as well as encourage this initiative in hospitals managed by other governmental and private spheres (Ordinance n. 1,153/2014 - PRC n. 06/2017)	74	5.6
Municipalities that promote physical activity
Carry out regular leisure activities that involve physical activity in public places in cities	652	49.4
Invest in adapting and adjusting physical activity equipment for children with obesity	295	22.3
Prioritize areas of greater social vulnerability for investment in adequate structure for exercising	253	19.2
Create “leisure streets” (streets open to pedestrians) for at least one day a week for physical activity and sports	231	17.5
Implement programs and actions that provide adequate conditions for the active commuting of children and adolescents from home to school	204	15.5
Establish partnerships with clubs and other private establishments so that they can be used free of charge by the general public for practice physical activities and sports	167	12.7
Invest in the construction and maintenance of sidewalks and bike lanes, prioritizing areas of greater social vulnerability	156	11.8
Create and encourage the use of an online platform to identify and assess the quality of public, community and social spaces and facilities that can be used for physical activity	94	7.1

[1] Correspondence
G. A. Bortolini Esplanada dos Ministérios, bloco C, sala 448, Brasília, DF 70054-906, Brasil. gisele.bortolini@gmail.com

I	Food and nutrition surveillance, health promotion and prevention of excessive weight gain, early diagnosis and adequate care for children, adolescents and pregnant women within primary health care
II	Health promotion actions in schools to promote the consumption of adequate and healthy foods and the regular practice of physical activity
III	Education, communication, and information to promote healthy eating and physical activity for the Brazilian population
IV	Training and continuing education for professionals working in childcare
V	Intersectoral and community-based articulations that promote healthy environments and support healthy eating and the practice of physical activity in the cities

Brasil

Brasil

Análisis del proceso de construcción y propuesta de una estrategia intersectorial brasileña para la prevención y atención de la obesidad infantil

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