Flávia Mori Sarti

Investigating Environmental Determinants of Diet, Physical Activity, and Overweight among Adults in Sao Paulo, Brazil

There is worldwide recognition that the burden of noncommunicable diseases (NCDs) and obesity-related health problems is rapidly increasing in low- and middle-income countries. Environmental determinants of obesity are likely to differ between countries, particularly in those undergoing rapid socioeconomic and nutrition transitions such as Brazil. This study aims to describe some built environment and local food environment variables and to explore their association with the overweight rate and diet and physical activity area-level aggregated indicators of adults living in the city of Sao Paulo, the largest city in Brazil. This formative study includes an ecological analysis of environmental factors associated with overweight across 31 submunicipalities of the city of Sao Paulo using statistical and spatial analyses. Average prevalence of overweight was 41.69% (95% confidence interval 38.74, 44.64), ranging from 27.14% to 60.75% across the submunicipalities. There was a wide geographical variation of both individual diet and physical activity, and indicators of food and built environments, favoring wealthier areas. After controlling for area socioeconomic status, there was a positive correlation between regular fruits and vegetables (FV) intake and density of FV specialized food markets (r = 0.497; p < 0.001), but no relationship between fast-food restaurant density and overweight prevalence was found. A negative association between overweight prevalence and density of parks and public sport facilities was seen (r = −0.527; p < 0.05). Understanding the relationship between local neighborhood environments and increasing rates of poor diet, physical activity, and obesity is essential in countries undergoing rapid economic and urban development, such as Brazil, in order to provide insights for policies to reduce increasing rates of NCDs and food access and health inequalities.

Analysis of the evolution and determinants of income-related inequalities in the Brazilian health system, 1998 - 2008

OBJECTIVE To analyze the evolution and determinants of income-related inequalities in the Brazilian health system between 1998 and 2008. METHODS Data from the National Household Sampling Surveys of 1998, 2003, and 2008 were used to analyze inequalities in health and health care. Health was measured by self-reported health status, physical limitations, and chronic illness. Hospitalization and physician and dentist visits were proxies for health care utilization. Income was a proxy for socioeconomic status. Concentration indices were calculated before and after standardization for all dependent variables. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. RESULTS In all three periods analyzed, the poor reported worse health status, while the wealthy reported more chronic diseases; health care utilization was pro-rich for medical and dental services. Yet, income-related inequality in health care utilization has been declining. Private health insurance, education, and income are the major contributors to the inequalities identified. CONCLUSIONS Income-related inequality in the use of medical and dental health care is gradually declining in Brazil. The decline is associated with implementation of pro-equity policies and programs, such as the Community Health Agents Program and the Family Health Program.

Contribuições de estudos sobre demanda de alimentos à formulação de políticas públicas de nutrição

Food choice in diet composition is a determinant of individual health status. Currently, there are gradually fewer conditions involving food scarcity and more involving excess food. Changes in income and relative prices generate measurable effects on the populations food intake patterns. Economic models have significant explanatory power for food demand, and the interactions between consumption, income, and prices are usually expressed as elasticity. However, the construction of some studies shows important shortcomings, especially for public policy application. This conceptual article discusses the potential contribution of food demand studies, suggesting improvements in the structural design of such studies with the inclusion of current nutritional concepts for redirecting the nutritional transition from under-nutrition to healthy eating, avoiding the present trend towards epidemic obesity.

Measuring evolution of income-related inequalities in health and health care utilization in selected Latin American and Caribbean countries

OBJECTIVE To describe the methodology used to measure and explain income-related inequalities in health and health care utilization over time in selected Latin American and Caribbean countries. METHODS Data from nationally representative household surveys in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru were used to analyze income-related inequalities in health status and health care utilization. Health was measured by self-reported health status, physical limitations, and chronic illness when available. Hospitalization, physician, dentist, preventive, curative, and preventive visits were proxies for health care utilization. Household income was a proxy for socioeconomic status except in Peru, which used household expenditures. Concentration indices were calculated before and after standardization for all dependent variables. Standardized concentration indices are also referred to as horizontal inequity index. Decomposition analysis was used to identify the main determinants of inequality in health care utilization. RESULTS Results of analysis of the evolution of income-related inequality in health and health care utilization in Brazil, Chile, Colombia, Jamaica, Mexico, and Peru are presented in separate articles in this issue. CONCLUSIONS The methodology used for analysis of equity in all six country research studies attempts not to determine causality but to describe and explain income-related inequalities in health status and health care utilization over time. While this methodology is robust, it is not free of errors. When possible, errors have been identified and corrected.

Beyond protein intake: bushmeat as source of micronutrients in the Amazon

Wild meat is critical for the food security and income of millions of people, especially for poor rural households. Its role as a primary source of macronutrients worldwide has been recognized, but there have been few attempts to evaluate the contribution of bushmeat consumption to micronutrient intake. This is so particularly in the context of nutritional transitions induced by modernization and globalization. Here, we calculated the role of bushmeat as a source of micronutrients in the diets of urban and periurban inhabitants within the Tres Fronteras (Peru, Brazil, Colombia) region in the Amazon. We gathered food intake data from 35 households using 3-day 24-h food recalls combined with food weighing. Additionally, we interviewed 105 households on food consumption frequency. Our results indicate that 14.3% of the households consumed bushmeat, which represented approximately 32% of their caloric intake, 72% of consumed protein, and 77% of iron. Typically, households consuming bushmeat presented higher a nutritional status, i. e., lower intake of carbohydrates (-10%) and higher intake of proteins (+46%), iron (+151%), and zinc (+23%), than households not consuming bushmeat. Most of the sampled households did not achieve standard nutritional requirements for calories (94%), fiber, vitamin C, or iron (97%) per adult per day. None of the households achieved the recommended daily intake for calcium. Households consuming bushmeat consumed statistically significantly higher levels of iron, zinc, and vitamin C than households that did not eat bushmeat. The latter consumed an excess of 31% calories from processed foods per adult per day, and lower amounts of iron (-60%) and zinc (-19%). We argue that households not consuming bushmeat are at greater risk of anemia in the short run and other chronic health problems in the long run.

Falhas de mercado e redes em políticas públicas: desafios e possibilidades ao Sistema Único de Saúde

The principles and guidelines of the Brazilian Unified Health System (SUS) impose a healthcare service structure based on public policy networks which, combined with the financing model adopted, leads to market failings. This imposes barriers to the management of the public health system and the enactment of SUS objectives. The institutional characteristics and the heterogeneity of players, allied to the existence of different healthcare approaches, generate analytical complexity in the study of the global dynamics of the SUS network. There are limitations in the use of quantitative methods based on static analysis of retrospective SUS data. Thus, an approach taking SUS as a complex system using innovative quantitative methodology based on computational simulation is proposed. This paper sought to analyze challenges and possibilities of the combined application of cellular automata modeling and agent-based modeling for simulation of the evolution of the SUS healthcare service network. This approach should permit better understanding of the organization, heterogeneity and structural dynamics of the SUS service network and a minimization of the effects of market failings on the Brazilian health system.

Indices for the assessment of nutritional quality of meals: a systematic review.

This systematic review aimed to synthesise information on indices developed to evaluate nutritional quality of meals. A strategy for systematic search of the literature was developed using keywords related to assessment of meal quality. Databases searched included ScienceDirect, PubMed, Lilacs, SciELO, Scopus, Cochrane, Embase and Google Scholar. The literature search resulted in seven different meal quality indices. Each article was analysed in order to identify the following items: authors, country, year, study design, population characteristics, type of meal evaluated, dietary assessment method, characteristics evaluated (nutrients or food items), score range, index components, nutritional references, correlations performed, validation and relationship with an outcome (if existing). Two studies developed instruments to assess the quality of breakfast, three analysed lunch, one evaluated dinner and one was applied to all types of meals and snacks. All meal quality indices reviewed were based on the evaluation of presence or absence of food groups and relative contributions of nutrients, according to food-based guidelines or nutrient references, adapting the daily dietary recommendations to one specific meal. Most of the indices included three items as components for meal quality assessment: (I) total fat or some specific type of fat, (II) fruits and vegetables and (III) cereals or whole grains. This systematic review indicates aspects that need further research, particularly the numerous approaches to assessing meals considering different foods and nutrients, and the need for validation studies of meal indices.

Considerações sobre avaliação de estabelecimentos de saúde sob gestão de OSS: o caso do Hospital Geral do Grajaú

OBJETIVOS: A partir da decada de 1990, em face de um cenario de limitacoes de recursos do Estado para financiamento de servicos essenciais a populacao, novas formas de administracao publica comecam a ser implementadas. Uma das principais formas adotadas refere-se a delegacao da administracao de hospitais publicos do estado de Sao Paulo as Organizacoes Sociais de Saude (OSS). O artigo propoe um formato de avaliacao da gestao das politicas publicas de saude via OSS no municipio de Sao Paulo, a partir do caso do Hospital Geral do Grajau. PROCEDIMENTOS METODOLOGICOS: A avaliacao concentrou-se em variaveis socio-economicas e demograficas da populacao local e sua articulacao com variaveis estruturais da rede basica de saude disponiveis; alem de dados sobre infra-estrutura da instituicao selecionada e relatorios da organizacao social de saude no periodo entre 2004 e 2007. RESULTADOS: A regiao apresenta deficit de unidades basicas de saude, que gera sobrecarga de atendimentos de baixa complexidade no hospital. Os resultados da avaliacao comparativa entre oferta e demanda por servicos publicos de saude, a partir do perfil populacional da regiao e caracteristicas de atendimentos realizados pela organizacao social, indicam que a unidade buscou adaptar-se as necessidades prioritarias da regiao. No entanto, verificou-se, tambem, que a implantacao de um unico hospital em uma regiao de alta vulnerabilidade social e insuficiente para suprir as necessidades da populacao, sendo necessaria uma rede de unidades basicas de saude para auxiliar na realizacao de atendimentos de baixa complexidade, permitindo focalizacao do atendimento hospitalar sobre atendimentos de media e alta complexidade.

Cost-effectiveness of procedures for treatment of ostium secundum atrial septal defects occlusion comparing conventional surgery and septal percutaneous implant.

Objectives The study performs a cost-effectiveness analysis of procedures for atrial septal defects occlusion, comparing conventional surgery to septal percutaneous implant. Methods A model of analytical decision was structured with symmetric branches to estimate cost-effectiveness ratio between the procedures. The decision tree model was based on evidences gathered through meta-analysis of literature, and validated by a panel of specialists. The lower number of surgical procedures performed for atrial septal defects occlusion at each branch was considered as the effectiveness outcome. Direct medical costs and probabilities for each event were inserted in the model using data available from Brazilian public sector database system and information extracted from the literature review, using micro-costing technique. Sensitivity analysis included price variations of percutaneous implant. Results The results obtained from the decision model demonstrated that the percutaneous implant was more cost effective in cost-effectiveness analysis at a cost of US

Duas décadas da Norma Brasileira de Comercialização de Alimentos para Lactentes: há motivos para comemorar?

8,936.34 with a reduction in the probability of surgery occurrence in 93% of the cases. Probability of atrial septal communication occlusion and cost of the implant are the determinant factors of cost-effectiveness ratio. Conclusions The proposal of a decision model seeks to fill a void in the academic literature. The decision model proposed includes the outcomes that present major impact in relation to the overall costs of the procedure. The atrial septal defects occlusion using percutaneous implant reduces the physical and psychological distress to the patients in relation to the conventional surgery, which represent intangible costs in the context of economic evaluation.