Denise Costa Coitinho

What Brazil is doing to promote healthy diets and active lifestyles

OBJECTIVES To present the way the Brazilian government is addressing the prevention of nutrition-related non-communicable diseases (NR-NCDs). RESULTS Innovative legislative and regulatory actions, mass communications and capacity building have been combined to create a comprehensive approach for addressing poor dietary and activity patterns in Brazil that are leading to obesity and NR-NCDs. Included are new nutrition-related initiatives in the labelling area, shifts in the types of food purchased for the school food programme, use of mass media to communicate components of the food guidelines, establishment of a smart shopping initiative, and training of teachers and health workers. CONCLUSIONS The entire effort has taken several years to get underway. This paper describes the process and some of the initial changes seen.

Obesity and weight change related to parity and breast-feeding among parous women in Brazil

OBJECTIVE Studies on the independent role of parity in long-term body weight change in economically developing countries are scarce and inconclusive, and only a few studies have taken into account patterns of breast-feeding. This association was examined in a national cross-sectional survey representative of Brazilian parous women. DESIGN AND SETTING The survey conducted in 1996 measured womens height and weight in the household and data on weight prior to the first pregnancy, parity and breast-feeding were recalled. SUBJECTS A sample of 2338 parous women, 15 to 49 years of age, 29 months after last delivery on average, had current body mass index (BMI, in kg m(-2)) modelled through hierarchical multiple linear regression analysis. Explanatory variables included parity, days of predominant breast-feeding, BMI pre-pregnancy, socio-economic, geographic, demographic and other reproductive variables. RESULTS Prevalences of overweight (BMI = 25.0-29.9 kg m(-2)) and obesity (BMI > or = 30.0 kg m(-2)) were 25.2% and 9.3%. The overall mean weight gain per year after the first pregnancy was 0.90 kg for an average time since first pregnancy of eight years. BMI pre-pregnancy modified the association between current BMI and parity. Therefore, weight change attributed to parity calculated for a woman of average height (1.56 m) was 0.60 kg greater for primiparous women with a BMI pre-pregnancy of 30 kg m(-2), compared with women with BMI pre-pregnancy of 25 kg m(-2). This greater weight retention among obese women was 1.21 kg for women with two children and 1.82 kg for women with three or more children. Parity reduced the effect of weight loss associated with lactation (1.75 kg for six months of lactation among primiparous women and 0.87 kg among women with three or more children). For the sub-sample of 793 primiparous women, a weight decrease of 300 g was associated with each month of predominant breast-feeding for all prior BMI levels. CONCLUSIONS In this study, weight change associated to reproduction was highly dependent on BMI previous to pregnancy and the effects of parity and lactation were small.

Panorama das ações de controle da deficiência de vitamina A no Brasil

OBJECTIVE: This manuscript aims to describe the implementation of actions to control vitamin A deficiency in Brazil. METHODS: The study was based on secondary data obtained from official reports and technical documents from the former Instituto Nacional de Alimentacao e Nutricao (inactivated in 1997), from the Coordenacao Geral da Politica Nacional de Alimentacao e Nutricao, Ministry of Health and information obtained from key informants employing the multidimensional approach based on the triad: structure-process-result. RESULTS: Brazil was pioneer in taking the initiative of linking vitamin A distribution to the National Immunization Days, a strategy that later on was recommended by the World Health Organization and the United Nations Childrens Fund. Since 1983, vitamin A megadoses are employed as a strategy to fight this micronutrient deficiency by the Ministerio da Saude. Coverage of the target population (children 6-59 months old) is steadily increasing, reaching 72% and 68% in the years 2002 and 2003 respectively. These coverage rates are similar to those reported in the 40 countries that have also adopted this strategy. Since 2001 the program was extended to lactating women, in the immediate post-partum period. CONCLUSION: The program achievements until 1992 were very modest, fact that could be explained by the irregularity of vitamin A capsule distribution. From 1994 on the distribution was more constant, but the need to promote more integrated actions in the health services, as well as far reaching social actions, beyond the routine distribution of vitamin A capsules, still remains.

Evaluation of the impact of a nutritional program for undernourished children in Brazil

To assess the effectiveness on child growth and body composition of a supplementary feeding program (Milk Supplement Program), a prospective, controlled study was conducted in Northeast Brazil. When entering the Program, children from 10 municipalities with the highest coverage rates in the Program (intervention group) were compared to non-beneficiary children from 10 municipalities with the lowest coverage rates (control group). A total of 219 children aged 6-18 months were enrolled. At entry, both groups were comparable in terms of age, sex, and nutritional status. There were frequent gaps in delivery of the supplement, no extra milk was provided to siblings less than 5 years of age, intra-household redistribution of milk was high, and maternal compliance with recommendations was low. Adjusted analyses by multilevel modelling showed average changes in weight, length, weight-age and length-age Z-scores, and % body water (deuterium method), at 6 months, of 1.53 kg, 6.34 cm, 0.33, 0.05, and 1.11% respectively among supplemented children as compared to 1.54 kg, 6.5 cm, 0.26, 0.07, and 4.10% among controls, with no statistically significant difference between groups. Thus, the Program failed to compensate for nutritional deficiencies in undernourished children in Northeast Brazil.

Prevalence of iron-deficiency anemia in Brazilian pregnant women: a review of the last 40 years

Iron-deficiency anemia is known as one of the main nutritional deficiencies around the world and its occurrence can be observed in many populations. Some groups still present a high prevalence of iron-deficiency anemia, compromising many body functions. Pregnant women are among the groups at risk given their vulnerability to deficiencies and the significant increase in their requirements, which are not accompanied by a sufficiently higher iron intake or absorption. This paper analyzes data from articles published in the last 40 years in English, Spanish or Portuguese found in the Lilacs and Medline databases about the prevalence of iron-deficiency anemia during pregnancy. Every paper found reports a high prevalence of anemia in pregnant women, characterizing this situation as a public health problem in Brazil, despite current Brazilian policies to fight iron deficiency.

Variações temporais do estado nutricional e do consumo alimentar no Brasil

Este estudo avalia as modificacoes do estado nutricional e da dieta da populacao brasileira nas ultimas duas decadas. As modificacoes ocorridas no estado nutricional mantem importantes discrepâncias regionais; o aumento da prevalencia de sobrepeso ocorreu em todas as regioes e. se, inicialmente, o excesso de peso se concentrava nas faixas de maior renda, trajetoria inversa ocorreu em curto espaco de tempo, principalmente entre as mulheres. Os padroes de consumo tem se modificado com o aumento para os oleos, refrigerantes, leite e derivados e mais recentemente, parece ter havido aumento no consumo de frutas e verduras. Estas variacoes, contudo, dificilmente explicam, isoladamente, as modificacoes observadas em relacao ao aumento de peso.

Avaliação do impacto do Programa Nacional do Leite em Alagoas, através de métodos isotópicos: aspectos metodológicos e resultados preliminares

OBJETIVOS: Descrever aspectos metodologicos e resultados preliminares de um estudo de intervencao planejado para medir o impacto de um programa de suplementacao alimentar sobre a promocao do crescimento infantil de criancas desnutridas. METODOS: Estudo longitudinal, controlado, desenvolvido no estado de Alagoas, com grupos comparados antes e depois da intervencao. Vinte municipios foram selecionados atraves de um indicador de cobertura do programa de suplementacao alimentar. Essa cobertura foi estimada pela diferenca entre a proporcao de criancas desnutridas e a proporcao de criancas atendidas pelo programa. Os dez municipios com indicador de alta cobertura foram selecionados para o grupo intervencao e aqueles de menor cobertura para o grupo controle. Em cada municipio do grupo intervencao foram selecionadas 15 criancas ingressando no Programa. Em cada municipio do grupo controle foram incluidas 15 criancas elegiveis, mas que nao conseguiram vaga no Programa. RESULTADOS: Foram aplicados 111 e 102 questionarios em criancas dos municipios do grupo intervencao e controle, respectivamente. A comparacao em relacao as caracteristicas de base mostra que a distribuicao das variaveis demograficas e nutricionais foi semelhante entre as criancas dos grupos intervencao e controle. Por outro lado, as criancas do grupo intervencao sao provenientes de familias com menor renda familiar e seus pais apresentaram menor escolaridade quando comparadas as do grupo controle. CONCLUSOES: Os resultados preliminares mostram que os grupos sao comparaveis em relacao as variaveis demograficas e nutricionais e que as diferencas observadas quanto ao nivel socioeconomico deverao ser consideradas na analise ajustada, na segunda fase do estudo.

Considerações Sobre o Plano de Combate à Fome e à Miséria

Encaminhamos algumas observacoes referentesao artigo “Consideracoes sobre o plano decombate a fome e a miseria”, das autoras GilzaS. Pereira e Ines R. R. de Castro, publicado nosCadernos de Saude Publica, 9 (supl. 1): 106-113, 1993, com vistas a contribuir para o debatesobre possiveis propostas para a minimizacao doproblema da fome no Brasil, que possam serdesenvolvidas pelo Ministerio da Saude.Na pagina 108, no primeiro paragrafo, asautoras criticam o fato de “vincular o Sisvan, narede de saude, a suplementacao alimentar”. Naverdade o programa refere que os municipiosselecionados serao aqueles com Sistema deVigilância Alimentar e Nuntricional (Sisvan),conforme referido pelas autoras (p. 106), ou seja,o programa reforca as acoes de saude incluindoa de vigilância nutricional e nao como discutido,reduzindo a acao do Sisvan. Neste inicio doprograma, quando foram incluidos menos de20% dos municipios, varios municipios estaoentrando em contato com o Instituto Nacional deAlimentacao e Nutricao (Inan) no sentido depromover acoes de vigilância nutricional, quelhes permitam participar do programa. O Inan,em conjunto com a Fiocruz, espera viabilizar umtreinamento a nivel nacional permitindo que,pelo menos, as acoes de vigilância nutricionalpossam ser desenvolvidas em grande parcela dosmunicipios. O programa, portanto, tanto reforcaas acoes basicas de saude, em relacao a criancae a gestante, quanto estimula, mesmo de formaainda timida, um arcabouco para o desenvol-vimento de vigilância nutricional a nivel nacio-nal.As autoras criticam, tambem, “a retomada deum programa de suplementacao alimentar viaunidade de saude (p. 109, 2o paragrafo). Narealidade, o programa nao estipula que a distri-buicao deve ser feita a nivel de unidade desaude, inclusive e previsto o uso de leite fluido,que dificilmente pode ter sua distribuicao viaservico de saude. Ficou, sim, a criterio dasunidades de saude o diagnostico da populacao--alvo. O programa ainda fortalece o SistemaUnico de Saude, na medida em que o municipiodeve possuir Fundo Municipal de Saude eConselho Municipal de Saude em funcionamentopara participar do programa.Em relacao a definicao de contatos peloprograma, as autoras referem e criticam o fatode que todas as criancas menores de 2 anos saobeneficiarias (p. 110) e indagam o que seriaconsiderado como contato de uma crianca des-nutrida. Na realidade, o programa nao inclui ascriancas de 0 a 6 meses de vida com a finalida-de de proteger o aleitamento natural. Quanto adefinicao de contatos: sao todas aquelas criancasde 24 a 60 meses de vida irmao de criancadesnutrida. Pretende-se com esta medida reduzira distribuicao intrafamiliar da suplementacao.Ainda na pagina 110, as autoras referem ainadequacao de usar leite desnatado e suple-menta-lo com oleo de soja. O programa especi-fica que o leite a ser adquirido pela prefeituradeve ser integral, podendo ser em po ou fluido.A utilizacao do leite fluido, que e consideradapelas autoras uma boa estrategia, so depende deexistir oferta na area e da vontade do municipioem criar mecanismos de distribuicao do mesmo.Entendemos que este programa avanca emrelacao aos programas existentes no passadouma vez que abre ao municipio um leque depossibilidades, reforcando o poder local e a suacapacidade de gerenciamento. Inicia-se, inclusi-ve, no Inan, a proposta de estimular os munici-pios a suplementarem o leite com ferro, visandoa prevencao de anemia ferropriva, que e hoje oproblema nutricional de maior prevalencia nopais.A sugestao apresentada pelas autoras de incluiro percentil 3 para avaliacao da clientela de maiorrisco nos parece ser bastante adequada e deveraser contemplada pelo programa, bem como asugestao de incluir na avaliacao indicadores deoperacionalizacao do programa.Carlos Alberto Guimaraes