ABSTRACT

OBJECTIVE

To understand the potential and limits of care for childhood obesity from the perspective of comprehensiveness, in the context of Primary Health Care, in Brazilian municipalities.

METHODS

A qualitative approach was adopted, with an electronic form of a dissertative nature being applied in 11 municipalities in the five Brazilian regions, derived from the four axes of comprehensiveness defined by Ayres (needs, purposes, articulations, and interactions).

RESULTS

Among the strengths for comprehensive care, the following were observed: the provision of services at different levels of care; the relevance of intersectoral programs in the development of actions aimed at the multidimensionality of childhood obesity; the implementation of strategies for systematizing care and tools that encourage the expansion of dialogue and humanization; and intersectoral coordination to create appropriate responses to the expanded needs of children and their families. Limitations include: the centralization of actions in nutrition professionals and in the care sphere; the failure to prioritize childhood obesity in health agendas; and the lack of trained professionals to deal with the complexity of obesity.

CONCLUSIONS

The findings suggest that child obesity care practices, in order to be transformative, need to be understood in the context of comprehensiveness. And this includes (re)thinking public policies, professional practices, and the organization of work processes so that they are, in fact, more inclusive, participatory, dialogical, humanized, supportive, fair, and, therefore, effective.

Comprehensive Health Care; Child Care; Childhood Obesity; Primary Health Care

INTRODUCTION

In Brazil, in 2022, data from the Ministry of Health’s Food and Nutrition Surveillance System indicated that the prevalence of overweight in children between 5 and 10 years of age, treated in primary care, was 25.37%¹1. Ministério da Saúde (BR). Sistema de Vigilância Alimentar e Nutricional. Relatórios de acesso público. Brasília, DF: Ministério da Saúde; 2023 [cited 2023 Jan 10). Available from: https://sisaps.saude.gov.br/sisvan/relatoriopublico/index
https://sisaps.saude.gov.br/sisvan/relat... . This scenario has significant consequences, including: demand for care, greater risk of developing chronic and metabolic diseases, psychological problems, social and economic impacts, and living with excess weight throughout life²2. Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clin Proc. 2017 Feb;92(2):251-65. https://doi.org/10.1016/j.mayocp.2016.09.017
https://doi.org/10.1016/j.mayocp.2016.09...

3. Handakas E, Lau CH, Alfano R, Chatzi VL, Plusquin, M, Vineis P, et al. A systematic review of metabolomic studies of childhood obesity: state of the evidence for metabolic determinants and consequences. Obes Rev 2022; 23 Suppl 1:e13384. https://doi.org/10.1111/obr.13384
https://doi.org/10.1111/obr.13384... -⁴4. Ling J, Chen S, Zahry NR, Kao T-SA. Economic burden of childhood overweight and obesity: A systematic review and meta-analysis. Obes. Rev 2023; 24(2):e13535:1-13. https://doi.org/10.1111/obr.13535.
https://doi.org/10.1111/obr.13535... . Thus, care for childhood obesity requires processes that dialog with its multicausality⁵5. Institute of Medicine. Preventing childhood obesity: health in the balance. Washington, DC: The National Academies Press; 2005..

In Brazil, various government initiatives are aimed at tackling childhood obesity, including intersectoral strategies such as the Health at School Program (PSE), which created the Growing Up Healthy Program⁶6. Ministério da Saúde (BR). Portaria nº 2.706, de 18 de outubro de 2017. Lista os Municípios que finalizaram a adesão ao Programa Saúde na Escola para o ciclo 2017/2018 e os habilita ao recebimento do teto de recursos financeiros pactuados em Termo de Compromisso e repassa recursos financeiros para Municípios prioritários para ações de prevenção da obesidade infantil com escolares. Diário Oficial União. 2017 Oct 18.. The “Instruction for the care of overweight and obese children and adolescents in Primary Health Care” was also made available to professionals⁷7. Ministério da Saúde (BR), Universidade do Estado do Rio de Janeiro. Instrutivo para o cuidado da criança e do adolescente com sobrepeso e obesidade no âmbito da Atenção Primária à Saúde. Brasília, DF: Ministério da Saúde; 2022 [cited 2024 Fev 14]. Available from: http://189.28.128.100/dab/docs/portaldab/publicacoes/instrutivo_crianca_adolescente.pdf
http://189.28.128.100/dab/docs/portaldab... , and the implementation of the Strategy for the Prevention and Care of Childhood Obesity (PROTEJA) began⁸8. Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Departamento de Promoção da Saúde. PROTEJA: estratégia nacional para prevenção e atenção à obesidade infantil: orientações técnicas. Brasília, DF: Ministério da Saúde; 2022 [cited 2023 Mar 10]. Available from: http://189.28.128.100/dab/docs/portaldab/publicacoes/orienta_proteja.pdf
http://189.28.128.100/dab/docs/portaldab... . In all these references and initiatives, the importance of practicing care from the perspective of comprehensiveness is emphasized.

Integrality in health is opposed to the fragmentation and intense specialization of health care, as it understands the user as a biopsychosocial being with rights to be respected⁹9. Ayres JR. Organização das ações de Atenção à Saúde: modelos e práticas. Saude Soc. 2009;18 suppl 2:11-23. https://doi.org/10.1590/S0104-12902009000600003
https://doi.org/10.1590/S0104-1290200900... ,¹⁰10. Kalichman AO, Ayres JR. Integralidade e tecnologias de atenção à saúde: uma narrativa sobre contribuições conceituais à construção do princípio da integralidade no SUS. Cad Saude Publica. 2016 Aug;32(8):e00183415. https://doi.org/10.1590/0102-311X00183415
https://doi.org/10.1590/0102-311X0018341... , and can be understood from four axes⁹9. Ayres JR. Organização das ações de Atenção à Saúde: modelos e práticas. Saude Soc. 2009;18 suppl 2:11-23. https://doi.org/10.1590/S0104-12902009000600003
https://doi.org/10.1590/S0104-1290200900... . The axis of needs refers to welcoming people, making actions more flexible and looking at broader health needs; the axis of purposes emphasizes the integration and longitudinality of care; the axis of articulations focuses on collective work from an intersectoral and multi-professional perspective; and the axis of interactions refers to dialogical approaches and the articulation between practical and technical knowledge. These propositions indicate ways of expanding our understanding of the elements required to qualify care practices related to childhood obesity.

Thus, this study aims to answer: what are the limits and potentialities of childhood obesity care, aimed at children between 5 and 10 years old, from the perspective of comprehensive health care, in the context of Primary Health Care (PHC) in Brazilian municipalities?

METHODS

A qualitative approach was adopted in order to grasp a set of meanings produced in human relationships, in health processes and practices that cannot be quantified¹¹11. Silva NJ, Fagundes AA, Silva DG, Lima VS. Percepção de gestores e profissionais de saúde sobre o cuidado da obesidade infantojuvenil no Sistema Único de Saúde. Physis. 2022;32(3):1-19. https://doi.org/10.1590/s0103-73312022320318.
https://doi.org/10.1590/s0103-7331202232... .

An electronic form was developed (Chart 1) with four axes that make up the concept of integrality in health⁹9. Ayres JR. Organização das ações de Atenção à Saúde: modelos e práticas. Saude Soc. 2009;18 suppl 2:11-23. https://doi.org/10.1590/S0104-12902009000600003
https://doi.org/10.1590/S0104-1290200900... . The questionnaires were created using Google Forms and sent via e-mail.

The audience for this research participated in the monitoring of the Growing Up Healthy Program - a set of actions carried out under the PSE to tackle childhood obesity⁶6. Ministério da Saúde (BR). Portaria nº 2.706, de 18 de outubro de 2017. Lista os Municípios que finalizaram a adesão ao Programa Saúde na Escola para o ciclo 2017/2018 e os habilita ao recebimento do teto de recursos financeiros pactuados em Termo de Compromisso e repassa recursos financeiros para Municípios prioritários para ações de prevenção da obesidade infantil com escolares. Diário Oficial União. 2017 Oct 18. - in 2018, promoted by the General Coordination of Food and Nutrition of the Ministry of Health (CGAN/MS).

The inclusion criteria were: representation of at least one municipality per region of Brazil and the choice of municipalities with the highest percentage of affirmative responses, in the CGAN/MS monitoring, to themes that referred to the axes of integrality in health. In the end, 11 of the 180 municipalities monitored took part, covering the five Brazilian regions (Chart 2). An exception was the municipality of Aracaju, which, despite not having answered the CGAN/MS monitoring questionnaire, was included because it was implementing the Line of Care for Overweight and Obesity in Children and Adolescents¹²12. Minayo MC. Pesquisa social: teoria, método e criatividade. 21st ed. Petrópolis: Vozes; 2002., which is a differentiated strategy for implementing comprehensive care.

The municipalities were invited via the information recorded on the CGAN/MS form and publications on official websites. The respondents were PHC nutritionists, coordinators of the Expanded Family Health Center, and reference professionals in childhood obesity care.

The data was obtained between May and July 2021 and analyzed using the Thematic Analysis (TA) method¹³13. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. https://doi.org/10.1191/1478088706qp063oa
https://doi.org/10.1191/1478088706qp063o... , which makes it possible to identify, analyze, and report patterns in discourses.

Participation was preceded by acceptance of the Electronic Free and Informed Consent Form. This study was approved by the Research Ethics Committee of the University of Brasília (CEP-FS/UnB) and by the Research Ethics Committee of the Federal District Health Department (CEP-Fepecs) (CAE 33905320.5.3001.5553).

RESULTS AND DISCUSSION

The results of the study have been organized into themes and their derivations (codes), as shown in the figure and analyses below.

Needs Axis

In the 11 participating Brazilian municipalities, children with obesity were seen by spontaneous and scheduled demand in six municipalities (four in the South, one in the Northeast, and one in the Center-West); only by scheduled demand in three (two in the Northeast and one in the Southeast) and by spontaneous demand in two (in the North and Southeast).

The southern region presented more details on how reception is carried out and pointed out projects and flows created to deal with childhood obesity, reinforcing that prioritizing the agenda in the health service expands and strengthens the different forms of reception and their consequences.

In the different regions, the reception via programmed demand took place through: periodic anthropometric evaluations carried out in the school environment, within the scope of the PSE, and/or in health units linked to income transfer programs; and the active search by community health agents for children with obesity. Thus, initial access to care occurred not only through the population’s identification of the need for “care”, but also through actions in the school environment.

Dornelles et al.¹⁴14. Dornelles AD, Anton MC, Pizzinato A. O papel da sociedade e da família na assistência ao sobrepeso e à obesidade infantil: percepção de trabalhadores da saúde em diferentes níveis de atenção. Saude Soc. 2014;23(4):1275-87. https://doi.org/10.1590/S0104-12902014000400013
https://doi.org/10.1590/S0104-1290201400... listed, among the perceptions of health professionals about the role of society and the family in caring for overweight and obese children in the Unified Health System (SUS), that it is difficult for caregivers to recognize it as a health demand to be cared for. Thus, if reception is restricted exclusively or primarily to spontaneous demand, there may be a limitation in identifying the needs of the territory. Furthermore, there is a need for the issue of childhood obesity to be increasingly prioritized, with actions that problematize and reflect this scenario and encompass the different players involved in care¹⁴14. Dornelles AD, Anton MC, Pizzinato A. O papel da sociedade e da família na assistência ao sobrepeso e à obesidade infantil: percepção de trabalhadores da saúde em diferentes níveis de atenção. Saude Soc. 2014;23(4):1275-87. https://doi.org/10.1590/S0104-12902014000400013
https://doi.org/10.1590/S0104-1290201400... .

The Health at School (PSE) and Growing Up Healthy programs, developed under the coordination of PHC, were essential for “provoking” changes in the work process of health teams, through the diagnosis and monitoring of childhood obesity cases, and the development of collective activities, such as health education groups. Studies¹⁵15. Henriques P, O'Dwyer G, Dias PC, Barbosa RM, Burlandy L. Políticas de saúde e de segurança alimentar e nutricional: desafios para o controle da obesidade infantil. Cien Saude Colet. 2018 Dec;23(12):4143-52. https://doi.org/10.1590/1413-812320182312.34972016
https://doi.org/10.1590/1413-81232018231... ,¹⁶16. Pinheiro MC, Moura AL, Bortolini GA, Coutinho JG, Rahal LD, Bandeira LM, et al. Abordagem intersetorial para prevenção e controle da obesidade: a experiência brasileira de 2014 a 2018. Rev Panam Salud Publica. 2019 Nov;43:e58. https://doi.org/10.26633/RPSP.2019.58
https://doi.org/10.26633/RPSP.2019.58... reinforce that intersectoral coordination between health and education - structured by dialogical governance mechanisms, with integration of efforts that minimize the overlapping of actions - is fundamental for effective prevention and control of childhood obesity.

Methods for monitoring the prevalence of childhood obesity have become essential for taking in children with alterations in their nutritional status, despite limitations in terms of: the restriction of human resources and the high demand for work; the insufficient entry of data on nutritional status in the SUS information systems; and the discontinuity and low coverage of assessments of children’s nutritional status.

We observed that the most detailed reports of monitoring were found in municipalities in the southern region that managed to implement protocols/flows, and even the Line of Care for Overweight and Obesity (LCSO), linked to childhood obesity care. A study by Ribeiro et al.¹⁷17. Ribeiro RC, Lima VS, Silva NJ, Souza LM, Silva DG, Fagundes A. Linhas de cuidado: sobrepeso/obesidade de crianças e adolescentes no Sistema Único de Saúde. Rev. Saúde Desenvolv. 2022;16(24):51-64., carried out in Sergipe, points out that the power of the care line requires attributes such as: proactivity and continuity of care; co-responsibility of the actors involved in the process; understanding obesity as a dysfunction that requires treatment; and offering promotion and treatment actions from an intersectoral perspective. Faced with comprehensive care, these elements can culminate in the creation of a sensitive space to respond to the demands of the territory⁹9. Ayres JR. Organização das ações de Atenção à Saúde: modelos e práticas. Saude Soc. 2009;18 suppl 2:11-23. https://doi.org/10.1590/S0104-12902009000600003
https://doi.org/10.1590/S0104-1290200900... .

By understanding how activities are designed to meet the health needs of municipalities, it was observed that the versatility of actions in the field of childhood obesity is connected to both the perception of health professionals and the demands of users. However, Silva et al.¹⁸18. Silva NJ, Fagundes AA, Silva DG, Lima VS. Percepção de gestores e profissionais de saúde sobre o cuidado da obesidade infantojuvenil no Sistema Único de Saúde. Physis. 2022;32(03):e320318. https://doi.org/10.1590/s0103-73312022320318.
https://doi.org/10.1590/s0103-7331202232... point out that the organization of care requires a connection between different agents and also co-responsibility between them and the services. One strategy cited which has strengthened the approach to childhood obesity in PHC is matrix support for the Family Health Strategy (ESF) teams.

In all the municipalities, flexibility was identified in organizing activities related to the prevention and/or care of children with childhood obesity, although in some cases these occurred irregularly and were centered on the nutritionist. Among these were health education groups linked or not to the Health Academies, workshops, lectures, the production of information materials, and interviews in different media.

It was also analyzed whether there was an expanded understanding of the demands of the subjects, based on the ability to adequately contextualize these actions to the different realities¹⁹19. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ, IMS: Abrasco, 2009. p. 43-68.. This refers to the ability of municipalities to produce actions that consider the historicity of children and their families, which goes beyond the physiological condition of obesity.

In all the municipalities, it was reported that the guidelines are not restricted to weight loss and dietary adequacy. The need to consider mental health, active listening to children and family members and attention to social vulnerabilities was also considered. Different publications²⁰20. Rajjo T, Mohammed K, Alsawas M, Ahmed AT, Farah W, Asi N, et al. Treatment of pediatric obesity: an umbrella systematic review. J Clin Endocrinol Metab. 2017 Mar;102(3):763-75. https://doi.org/10.1210/jc.2016-2574
https://doi.org/10.1210/jc.2016-2574... emphasize that impactful strategies for managing childhood obesity involve the social and physical context and the child’s eating environment. However, although all the municipalities confirmed the importance of considering different factors in the care of childhood obesity, some justifications reinforced behaviors centered on food consumption.

It is important to emphasize that comprehensive care is linked to strengthening a more just and supportive society¹⁹19. Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ, IMS: Abrasco, 2009. p. 43-68.. In the context of childhood obesity, stigmatizing actions are part of children’s daily lives. Poulain²³23. Poulain JP. Sociologia da obesidade. São Paulo: Editora Senac; 2013. defines them as the social devaluation and defamation of children due to their excess body weight, which can lead to negative attitudes, stereotypes and discrimination. Faced with the need for sensitive spaces to respond to the demands of the territories studied, we questioned the implementation of activities to identify and prevent stigmatizing practices. Four municipalities - one in the Central-West region, one in the Northeast, one in the Southeast and one in the South - reported carrying out such activities. The activities were similar and were developed in partnership between the Departments of Education and Health, in the school environment, or in professional training. According to one of the reports, the school seems to be a strategic locus, due to its ability to strengthen bonds, as children are there on a daily basis.

However, only one municipality in the southern region reported that stigmas were addressed individually, albeit less frequently, when compared to dialogues on the same subject held in group activities. Two municipalities said they did not address this issue; two said there was nothing explicit/official and it depended on professional practice; and three said they had no such information.

In the context of guaranteeing rights as a prerogative of comprehensive healthcare¹⁰10. Kalichman AO, Ayres JR. Integralidade e tecnologias de atenção à saúde: uma narrativa sobre contribuições conceituais à construção do princípio da integralidade no SUS. Cad Saude Publica. 2016 Aug;32(8):e00183415. https://doi.org/10.1590/0102-311X00183415
https://doi.org/10.1590/0102-311X0018341... , despite the small number of descriptions of explicit concern with protecting children’s rights, responses from the Midwest, South, and Southeast regions made contributions. In the first, the right materialized in access to “information in an easy way for both children and caregivers, through various means of communication (radio, social networks, other communication applications), contributing to awareness and promotion of health and well-being; promotion of leisure and physical activities” (municipality in the Midwest region). In the municipality in the South, one of the facilities that helps to guarantee this is the Social Assistance Reference Center (CRAS), which acts on the social vulnerabilities of families, as well as raising the awareness of health professionals about the increasing prevalence of childhood obesity and the need to intervene. In the Southeast, one of the reports pointed to the difficulty of accessing health facilities and continuity of care as a limitation.

Purposes Axis

Only one municipality in the Southeast and one in the South described the integration of health promotion and protection, treatment, and recovery activities. The municipality in the Southeast has an obesity outpatient service, which establishes communication with the primary health care units, by referring the child and making a counter-referral to PHC. All care related to childhood obesity is channeled to an obesity outpatient clinic.

The municipality in the southern region has a different perspective on the organization and integration of care, since it has implemented the LCSO, in which various health/social facilities are linked. The care provided in the other municipalities is of an assistance nature, with priority given to clinical care, developed mainly by nutritionists. Actions to promote children’s health and prevent childhood obesity take place separately and are concentrated in the Growing Up Healthy Program. Such disarticulation of actions, making them “loose and unaligned” (municipality in the Southeast region), “discontinuous and of punctual and isolated execution” (municipality in the South region), was justified by the lack of professionals.

The fragmentation of care, with health care performed through a sum of specialized and disassociated actions, was listed by Moura and Recine²⁴24. Moura AL, Recine E. O nutricionista e o cuidado integral do indivíduo com excesso de peso na atenção básica. Rev Nutr. 2019;32 e190008:1-14. https://doi.org/10.1590/1678-9865201932e190008
https://doi.org/10.1590/1678-9865201932e... as one of the obstacles to the practice of integrality in the SUS. In order for health actions to operate in an integrated manner, coordinated by a flow of care, they must be based on longitudinal care, achieved by the continuity, permanence and consistency of care, accompanying the transformations of health practices²¹21. Matwiejczyk L, Mehta K, Scott J, Tonkin E, Coveney J. Characteristics of effective interventions promoting healthy eating for pre-schoolers in childcare settings: an umbrella review. Nutrients. 2018 Mar;10(3):1-21. https://doi.org/10.3390/nu10030293
https://doi.org/10.3390/nu10030293... .

According to Rajjo et al.²⁰20. Rajjo T, Mohammed K, Alsawas M, Ahmed AT, Farah W, Asi N, et al. Treatment of pediatric obesity: an umbrella systematic review. J Clin Endocrinol Metab. 2017 Mar;102(3):763-75. https://doi.org/10.1210/jc.2016-2574
https://doi.org/10.1210/jc.2016-2574... , significant results in childhood obesity care are the result of integrated and longitudinal programs to manage children’s lifestyles. Three participating municipalities (Midwest, Northeast, and South regions) in this study said that the practical exercise of longitudinal care is directly dependent on the bond created and the interest of the child and family in continuing the care.

Other factors that made it difficult to achieve longitudinality were the high demand and small number of professionals, and the ESF’s failure to understand the logic of primary care²⁵25. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial União. 21 set 2017., as the coordinator of care.

Articulations Axis

This study adopts intersectorality and multi-professional coordination as components of collective work, which are essential for the exercise of comprehensive care, as well as interdisciplinarity - although this was not evidenced in the municipalities’ responses.

Interdisciplinarity seeks to find the links that connect one area and its historicized foundations to another, seeking to broaden understandings and practices²⁶26. Barbosa SC. Interdisciplinaridade na escola: conceituação e exercício a partir de oficinas. Goiânia: Ed. UFG; 2006.. Multiprofessional means the presence of different professionals working on shared actions²⁵25. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial União. 21 set 2017.. Thus, multi-professional coordination may or may not lead to transformations in professional practices, unlike the interdisciplinary approach. Finally, intersectorality is defined as actions in which different social sectors collaborate to achieve a common goal, through close coordination of their contributions.²⁷27. Biblioteca Virtual em Saúde. Descritores em Ciências da Saúde (DeCS/MeSH): Colaboração intersetorial. 2022 [cited 2022 May 1]. Available from: https://decs.bvsalud.org/ths/resource/?id=29655&filter=ths_exact_term&q=intersetorialidade#Concepts
https://decs.bvsalud.org/ths/resource/?i...

The participants’ understanding of interdisciplinarity was confused with its multiprofessional nature. In municipalities in the Midwest and Northeast regions, although they mentioned that there is interdisciplinary and multiprofessional planning, their justifications only covered the multiprofessional perspective.

One of the municipalities in the Northeast region pointed out that planning “actions with intersectoral and multi-professional support are more likely to achieve the expected results, as each professional involved will add to the fight against obesity”. The collective work involved team discussions of cases, therapeutic groups and matrix support meetings.

On the other hand, the Northern region made it clear that multi-professional work is not always enough, as planning can be disjointed. The lack of qualified and regularly trained multi-professional teams is one of the most frequent barriers to comprehensive care for overweight children²⁰20. Rajjo T, Mohammed K, Alsawas M, Ahmed AT, Farah W, Asi N, et al. Treatment of pediatric obesity: an umbrella systematic review. J Clin Endocrinol Metab. 2017 Mar;102(3):763-75. https://doi.org/10.1210/jc.2016-2574
https://doi.org/10.1210/jc.2016-2574... ,²⁸28. Bauman A, Rutter H, Baur L. Too little, too slowly: international perspectives on childhood obesity. Public Health Res Pract. 2019 Mar;29(1):2911901. https://doi.org/10.17061/phrp2911901
https://doi.org/10.17061/phrp2911901... .

The participation of education and health professionals, children, and their guardians in defining actions aimed at childhood obesity was another topic studied. It was observed that coordination and planning are carried out by health professionals. In one municipality in the Southeast, only the nutritionist takes part in planning. The presence of education professionals was mentioned in the Midwest, Northeast, and South regions during planning, execution and approval by the Education Department managers.

Intersectoral coordination took place mainly with the education sector, through anthropometric assessments and educational activities. As an exception, one of the municipalities in the southern region praised the importance of the Municipal Council for Food and Nutritional Security as a facilitator of dialogue between sectors - health, education, social assistance, sport, and food and nutritional security - and its constitution, which includes civil society.

In nine municipalities, it was difficult to articulate and prioritize childhood obesity on the health agenda. Non-prioritization was due to: lack of implementation of protocols and flows in the care network; insufficient human resources, prioritization of individualized care for more critical cases, concentration of prevention actions in the PSE; and lack of interest on the part of health professionals. This scenario expresses insufficient engagement by the parties involved in childhood obesity care. Thus, it emphasizes that integrality faces barriers in terms of governance, given the incipient communication and cooperation between the different sectors and spheres of management²²22. World Health Organization. Mapping the health system response to childhood obesity in the WHO European Region: an overview and country perspectives. Copenhagen: World Health Organization; 2019 [cited 222 Apr 1]. Available from: https://apps.who.int/iris/bitstream/handle/10665/346468/WHO-EURO-2019-3656-43415-60957-eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... . Where care for children with obesity has been prioritized, it has been strengthened with the implementation of the LCSO.

The engagement of the parties involved is also linked to co-responsibility in care. Although the planning of actions is restricted to a few groups, co-responsibility occurs through the work of managers and health and education professionals. Municipalities in the Midwest, Northeast, North, one in the Southeast, and one in the South mentioned the active participation of children and family members in the care process.

This perspective corroborates comprehensive practices, since there is recognition of the need to create a bond, making the individuals who take part in this long process accountable, considering the ways in which children and their families express their health needs¹⁰10. Kalichman AO, Ayres JR. Integralidade e tecnologias de atenção à saúde: uma narrativa sobre contribuições conceituais à construção do princípio da integralidade no SUS. Cad Saude Publica. 2016 Aug;32(8):e00183415. https://doi.org/10.1590/0102-311X00183415
https://doi.org/10.1590/0102-311X0018341... .

Interactions Axis

Different approaches used by health professionals, in the individual and collective spheres, can exercise aspects of comprehensive care that include the need to: listen more, to understand singularities, subjectivities, and the context in which individuals and collectivities are immersed; see more, be attentive to gestures, to the gaze; and touch more, not just where it hurts, but where there is discomfort, concern, as a power for care⁹9. Ayres JR. Organização das ações de Atenção à Saúde: modelos e práticas. Saude Soc. 2009;18 suppl 2:11-23. https://doi.org/10.1590/S0104-12902009000600003
https://doi.org/10.1590/S0104-1290200900... .

In all the municipalities studied, the exercise of qualified listening and the expanded clinic took place at both an individual and collective level. One municipality in the Northeast and one in the South reported that these strategies “help to uncover children’s needs in a broader way” (municipality in the Northeast), “to define their treatment in the best way” (municipality in the South).

These strategies can strengthen comprehensive practices, since they encourage active participation. Excerpts 1 and 2 describe ways in which the approaches have been applied in health services, both in care practice and in professional training:

The active role of different subjects in child obesity care actions is essential, through the establishment of dialogic relationships. According to Freire²⁹29. Freire P. Pedagogia do oprimido. 42nd ed. Rio de Janeiro: Paz e Terra; 2005., these interactions are moments to reflect on the problems experienced, in order to overcome them, considering the different knowledge and perspectives of those who participate in health care.

All the participants said that there is an exchange of technical and practical knowledge but with different characteristics. A municipality in the North region mentioned that this practice happens occasionally and depends on the professional’s initiative. One municipality in the Southeast stressed the need for management support to raise awareness of the importance of these exchanges.

Only the southern region provided details of these dialogues. Most of them are the result of group activities led by different health professionals, establishing intersectoral partnerships with or without the participation of children and their guardians. The exchanges in these spaces take place in a dialogical way and are powerful in understanding the factors that impact on the development of obesity in a specific group, contributing to the expansion of resolution. The protagonism of children stood out, despite the fact that they are usually excluded and silenced. According to Ehrich et al.³⁰30. Ehrich J, Pettoello-Mantovani M, Lenton S, Damm L, Goldhagen J. Participation of children and young people in their health care: understanding the potential and limitations. J Pediatr. 2015 Sep;167(3):783-4. https://doi.org/10.1016/j.jpeds.2015.05.001
https://doi.org/10.1016/j.jpeds.2015.05.... , including children actively can improve their knowledge, self-confidence, imagination and trust in health professionals, contributing to their autonomy and the effectiveness of comprehensive care.

Regarding the study’s limitations, it should be noted that incomplete questionnaires were received and there were difficulties in contacting the Central-West and North regions. We understand that the pandemic period was a factor that limited the detailing of actions and the implementation of activities developed in the context of childhood obesity.

CONCLUSIONS

Comprehensiveness is a horizon to be reached in the practice of childhood obesity care. It is desired as a guideline for the organization of services in the municipalities studied but it still faces challenges in its implementation.

As strengths for comprehensive care, the following were observed: the provision of services at different levels of care; the relevance of the PSE and the Growing Up Healthy Program in developing actions aimed at the multidimensionality of childhood obesity; strategies for systematizing care, such as the implementation of the LCSO and the expansion of dialogue and humanization in health practices; and intersectoral coordination to create appropriate responses to the expanded needs of children and their families.

Finally, in order for childhood obesity care to be able to bring about changes in the reality of different subjects, it needs to be understood in its complexity, and this is directly related to looking at integrality in health and its dynamism. This includes (re)thinking public policies, professional practices, and work process organizations so that they are, in fact, more inclusive, participatory, dialogical, humanized, supportive, fair, and, therefore, effective. In this sense, there is a need to mobilize different sectors/spaces/subjects in favor of this agenda.

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