Abstract

The undernutrition and obesity pandemics associated with climate change are a global syndemic. They have a point of convergence, which is the unsustainable current food systems. This paper aims to discuss the role of public health policies, particularly the Brazilian Unified Health System (SUS) in the context of Primary Health Care, in combating the global syndemic and in the development of sustainable food systems. In this scenario, the National Food and Nutrition Policy is a leading intersectoral tool for an adequate and healthy diet and food and nutrition security. Also, the Dietary Guidelines for the Brazilian population is a strategic tool to support food and nutrition education. We highlight the need to articulate health, agriculture, and environmental policies to achieve sustainable development. Thus, SUS can be the arena to promote the main discussions on this topic, potentiating individual, group, and institutional actions to provide a fairer, healthy, and sustainable food system.

Key words:
Unified Health System; Health policy; Food and nutrition security; Sustainable development

Introduction

There are three severe global threats to human health and survival: the undernutrition and obesity pandemics - which includes their relationship with the development of chronic noncommunicable diseases (NCDs) - and climate change, which together establish a global syndemic¹1 Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, De Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393(10173):791-846.. Once seen as divergent and isolated conditions from each other, they have been recognized as synergistic factors that coexist in time and space and share common social determinants on a global scale. They also share interactions in the biological, psychological, and social fields¹1 Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, De Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393(10173):791-846..

In synergy with what the term global syndemic proposes, the Food and Agriculture Organization of the United Nations (FAO) recognizes the latent challenge of the prevalence of malnutrition in all its forms, including undernutrition, specific nutritional deficiencies, overweight, obesity, and NCDs associated with eating habits²2 The High Level Panel of Experts on Food Security and Nutrition (HLPE). Investing in smallholder agriculture for food security: a report by the High Level Panel of Experts on Food Security and Nutrition. Rome: FAO; 2013.. In Brazil, despite several advances in this field, with particular attention to the impact of the Bolsa Família (Family Aid) Program (PBF) in improving the availability and purchase of food among low-income households³3 Duarte GR, Sampaio B, Sampaio Y. Programa Bolsa Família: impacto das transferências sobre os gastos com alimentos em famílias rurais. Rev Econ Sociol Rural 2009; 47(4):903-918.

4 Martins APB, Monteiro CA. Impact of the Bolsa Família program on food availability of low-income Brazilian families: a quasi experimental study. BMC Public Health 2016; 16(1):827.^-55 Sperandio N, Rodrigues CT, Franceschini SCC, Priore SE. Impacto do Programa Bolsa Família no consumo de alimentos: estudo comparativo das regiões Sudeste e Nordeste do Brasil. Cien Saude Colet 2017; 22(6):1771-1780., it is still possible to find Brazilian homes living with some degree of food insecurity. According to the 2017-2018 Brazilian Household Budget Survey (POF), severe food insecurity was found in the homes of 10.3 million people (4.9% of the population), which means that there was a lack of food among all residents, including children⁶6 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de orçamentos familiares 2017-2018: análise da segurança alimentar no Brasil. Rio de Janeiro: IBGE; 2020..

On the other hand, recent data from the National Health Survey (PNS) show that, in 2019, 25.9% of the population over 18 years old were obese (41.2 million people), and about 60.3% of the people in this age group (96 million people) were overweight⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019: atenção primária à saúde e informações antropométricas. Rio de Janeiro: IBGE; 2020.. The proportion of obese people in the population aged 20 years and over more than doubled between the POF 2002-2003 and the PNS 2019, hiking from 12.2% to 26.8%⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019: atenção primária à saúde e informações antropométricas. Rio de Janeiro: IBGE; 2020.. Simultaneously, data from the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel) for 2019 indicate an advance in NCDs among Brazilians - 7.4% have diabetes, and 24.5% have hypertension⁸8 Coordenação-Geral de Vigilância de Agravos e Doenças Não Transmissíveis. Vigitel Brasil 2019: principais resultados. Bol Epidemiol 2020; 51(16):20-26..

NCDs are the leading cause of global morbimortality, and unhealthy eating is one of its main risk factors⁹9 World Health Organization (WHO). Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: WHO; 2013.. Given its direct adverse effects on health, along with the indirect effects resulting from associated chronic diseases, undernutrition is a double burden for health systems, with high socioeconomic costs and overly affecting the impoverished population and low-income countries¹⁰10 Nilson EAF, Andrade RCS, Brito DA, Oliveira ML. Custos atribuíveis à obesidade, hipertensão e diabetes no Sistema Único de Saúde, Brasil, 2018. Rev Panam Salud Publica 2020; 44:e32..

Furthermore, food production, including agriculture and livestock, is responsible for about 70% of all greenhouse gases released in Brazil¹¹11 Azevedo TR, Costa Junior C, Brandão Junior A, Cremer MS, Piatto M, Tsai DS, Barreto P, Martins H, Sales M, Galuchi T, Rodrigues A, Morgado R, Ferreira AL, Silva FB, Viscondi GF, Santos KC, Cunha KB, Manetti A, Coluna IME, Albuquerque IR, Watanabe Junior S, Leite C, Kishinami R. SEEG initiative estimates of Brazilian greenhouse gas emissions from 1970 to 2015. Sci Data 2018; 5:180045.. These gases are directly linked to global warming and climate change, contributing to an increased risk for chronic diseases and pose challenges for food production itself¹²12 Rossati A. Global warming and its health impact. Int J Occup Environ Med 2017; 8(1):7-20.

13 Giorgini P, Di Giosia P, Petrarca M, Lattanzio F, Stamerra CA, Ferri C. Climate changes and human health: a review of the effect of environmental stressors on cardiovascular diseases across epidemiology and biological mechanisms. Curr Pharm Des 2017; 23(22):3247-3261.^-1414 Quam VGM, Rocklöv J, Quam MBM, Lucas RAI. Assessing greenhouse gas emissions and health co-benefits: a structured review of lifestyle-related climate change mitigation strategies. Int J Environ Res Public Health 2017; 14(5):468..

At the common root of the three problems - undernutrition, obesity, and climate change - is the unsustainability of current food systems¹1 Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, De Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393(10173):791-846.^,1515 The High Level Panel of Experts on Food Security and Nutrition (HLPE). Nutrition and food systems. Rome: FAO; 2017.. According to FAO¹⁶16 Food and Agriculture Organization of the United Nations (FAO). Sustainable food systems: concept and framework. Rome: FAO; 2018., food systems are elements and activities related to the production, processing, distribution, preparation, consumption, and disposal of foods that affect health and socioeconomic and environmental issues. This system is influenced by several factors, including sociocultural, demographic, and political determinants.

In this sense, a radical change is required in the systems that guide lifestyles, consumption, transport, and food, which, unlike the current orientation, must be conceived holistically, understanding the impact on the health of individuals and the reverberations on planet Earth. This change supports the urgency of a reorientation based on sustainability, including the construction of fairer and more resilient, healthy, and sustainable food systems; the development of synergistic actions between different sectors of society; and the strengthening and improvement of health systems, which must integrate nutrition as an essential service, and planetary health, including human and planet health and well-being¹1 Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, De Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393(10173):791-846.^,1717 Whitmee S, Haines A, Beyrer C, Boltz F, Capon AG, Dias BFS, Ezeh A, Frumkin H, Gong P, Head P, Horton R, Mace GM, Marten R, Myers SS, Nishtar S, Osofsky SA, Pattanayak SK, Pongsiri MJ, Romanelli C, Soucat A, Vega J, Yach D. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation-Lancet Commission on planetary health. Lancet 2015; 386(10007): 1973-2028.

18 Haines A. Addressing challenges to human health in the Anthropocene epoch - an overview of the findings of the Rockefeller/Lancet Commission on Planetary Health. Int Health 2017; 9(5):269-271.^-1919 Development Initiatives Poverty Research Ltd. 2020 Global Nutrition Report: action on equity to end malnutrition. Bristol: Development Initiatives; 2020..

Considering the emergence of actions and public policies based on healthier and more sustainable food systems, this paper aims to discuss the role of public health policies, particularly the Brazilian Unified Health System (SUS) in the context of Primary Health Care (PHC), in combating the global syndemic and in the development of sustainable food systems. Without intending to exhaust the subject, this work contributes to current discussions by reflecting on what has been developed and what needs to be done.

Brazilian Unified Health System, public policies, and food systems

SUS was established in 1988 and aims to promote universal and comprehensive access to health care for all Brazilians (or not) in the national territory. It is governed by several organizational and doctrinal principles, including equity, universality, integrality, social control, and decentralization²⁰20 Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set.. Far from acting only in clinical and hospital care, the SUS is also responsible for health promotion and disease prevention, vaccination, campaigns to prevent infectious diseases, among other actions²¹21 Duarte E, Eble LJ, Garcia LP. 30 anos do Sistema Único de Saúde. Epidemiol Serv Saude 2018; 27(1):e00100018.. Over the past few years, SUS has made consistent progress in providing universal and comprehensive health care to the Brazilian population, reducing inequalities in access to health care²²22 Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, Noronha KVMS, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 394(10195):345-356..

SUS works together with other policies, essentially through Primary Health Care PHC, to fight the global syndemic, promote the control of the prevalence of obesity and malnutrition, and mitigate and adapt to climate change²³23 Ebi KL, Hess JJ, Watkiss P. Health risks and costs of climate variability and change. In: Mock CN, Nugent R, Kobusingye O, Smith KR, organizadores. Injury prevention and environmental health. 3ª ed. Washington: The World Bank; 2017. p. 153-169..

In this context, the Brazilian government has been working with guiding documents for the planning, monitoring, and evaluation of programs and policies to guide the actions of the SUS at the federal level. For this purpose, the National Health Plan (PNS), which establishes guidelines, priorities, goals, and indicators for the period, is proposed every four years. The current PNS (2020-2023)²⁴24 Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2020-2023. Brasília: MS; 2020. is supported by other initiatives to improve internal controls and continuous improvement in the governance process. Its objectives provide for the expansion and resolution of integrated and planned PHC actions and services. Since its actions must be in line with society’s demands and government guidelines, the plan provides for the convergence between internal and external guiding actors, among other documents in the Guidelines of the National Health Conference, which in its guideline 12 provides for ensuring the implementation of the National Food and Nutrition Policy (PNAN), the National Food and Nutrition Security Policy (PNSAN), and the National Policy on Agroecology and Organic Production (PNAPO), encouraging the production of environmentally, socially, and economically sustainable food²⁴24 Brasil. Ministério da Saúde (MS). Plano Nacional de Saúde 2020-2023. Brasília: MS; 2020..

In turn, the PNAN gathers the efforts of the Brazilian State in a set of public policies that encompass protection, respect, and promotion of human rights to health and food²⁵25 Brasil. Ministério da Saúde (MS). Política Nacional de Alimentação e Nutrição. Brasília: MS; 2012.. In this sense, PNAN is an essential link between the health sector and others related to the human right to adequate and healthy food and to food and nutrition security (FNS)²⁶26 Jaime PC. Políticas públicas de alimentação e nutrição. Rio de Janeiro: Atheneu; 2019., which are part of the essence of the SUS for the sustainable development of the food system. One of its goals refers to improving the conditions of food, nutrition, and health of the Brazilian people, through food and nutrition surveillance, the promotion of adequate and healthy eating practices, prevention, and comprehensive care of diseases associated with food and nutrition²⁵25 Brasil. Ministério da Saúde (MS). Política Nacional de Alimentação e Nutrição. Brasília: MS; 2012.. Thus, the PNAN is situated within the SUS, facing the current global syndemic setting and reinforcing the need for intersectoral actions that transcend the health sector.

Dialoguing with PNAN, within the National Food and Nutrition Security System (SISAN), the PNSAN provides as one of its guidelines the promotion of supply and structuring of sustainable and decentralized systems, based on agroecology, production, extraction, processing, and distribution of food²⁷27 Brasil. Emenda Constitucional nº 64, de 4 de fevereiro de 2010. Altera o art. 6º da Constituição Federal, para introduzir a alimentação como direito social. Diário Oficial da União 2010; 4 fev.. As this policy reaches different spheres (production, distribution, sale, access, and consumption of food), the participation of the health, agriculture, economy, education, supply, protection, work, environment, and social promotion sectors is required for its effective implementation²⁸28 Rigon SA, Schmidt ST, Bógus CM. Desafios da nutrição no Sistema Único de Saúde para construção da interface entre a saúde e a segurança alimentar e nutricional. Cad Saude Publica 2016; 32(3):e00164514..

In line with such policies, the National Health Promotion Policy (PNPS) understands sustainable development as a reference for the formation of health promotion agendas and the adoption of priority strategies and themes, a cross-cutting theme of this policy²⁹29 Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde (PNPS): Anexo I da Portaria de Consolidação nº 2, de 28 de setembro de 2017, que consolida as normas sobre as políticas nacionais de saúde do SUS. Brasília: MS; 2018.. For its realization, the PNPS adopts the values of solidarity, happiness, ethics, respect for diversity, humanization, shared responsibility, social justice, and social inclusion, contributing to the development of broader and transformative strategies that bring the population closer to sustainable development²⁹29 Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde (PNPS): Anexo I da Portaria de Consolidação nº 2, de 28 de setembro de 2017, que consolida as normas sobre as políticas nacionais de saúde do SUS. Brasília: MS; 2018.. The National Primary Health Care Policy (PNAB), addressed here as PHC, understands health promotion as a principle for health care for its work process, highlighting adequate and healthy eating and promoting sustainable development as relevant themes that should be considered in this approach³⁰30 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Brasília: MS; 2012..

In the context of the federal administration’s actions, in 2014, the Ministry of Health published the second edition of the Dietary Guidelines for the Brazilian population³¹31 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2a ed. Brasília: MS; 2014., which is one of the strategies for implementing the guideline to promote adequate and healthy eating underlying the PNAN. Also, the Dietary Guidelines support SUS food and nutrition education actions, guiding food practices that aim to promote health and prevent nutrition-related diseases within a sustainable food system³¹31 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2a ed. Brasília: MS; 2014.^,3232 Verly Junior E, Carvalho AM, Fisberg RM, Marchioni DML. Adesão ao guia alimentar para população brasileira. Rev Saude Publica 2013; 47(6):1021-1027., considering the social and environmental impacts of the current agri-food system in effect. Thus, the Dietary Guidelines recognize that adopting an adequate, healthy, and culturally appropriate diet must act as a promoter of socially and environmentally sustainable food systems³¹31 Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2a ed. Brasília: MS; 2014.. In this sense, by guiding healthy and sustainable choices, this instrument can be recognized as a triple work action; that is, it can simultaneously influence the malnutrition and obesity pandemics and climate change¹1 Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, Calvillo A, De Schutter O, Devarajan R, Ezzati M, Friel S, Goenka S, Hammond RA, Hastings G, Hawkes C, Herrero M, Hovmand PS, Howden M, Jaacks LM, Kapetanaki AB, Kasman M, Kuhnlein HV, Kumanyika SK, Larijani B, Lobstein T, Long MW, Matsudo VKR, Mills SDH, Morgan G, Morshed A, Nece PM, Pan A, Patterson DW, Sacks G, Shekar M, Simmons GL, Smit W, Tootee A, Vandevijvere S, Waterlander WE, Wolfenden L, Dietz WH. The global syndemic of obesity, undernutrition, and climate change: The Lancet Commission report. Lancet 2019; 393(10173):791-846..

Such actions were corroborated with the launch of the Decade of Action on Nutrition 2016-2025 by the United Nations (UN), in which Brazil led these discussions and was the first country to sign commitments in the context of the Decade³³33 Bortolini GA, Oliveira TFV, Silva SA, Santin RC, Medeiros OL, Spaniol AM, Pires ACL, Alves MFM, Faller LA. Ações de alimentação e nutrição na atenção primária à saúde no Brasil. Rev Panam Salud Publica 2020; 44:e39.. Furthermore, the commitments assumed also dialogue with the PNAN guidelines, which indicate the lines of action to improve the food, nutrition, and health conditions of the Brazilian population³³33 Bortolini GA, Oliveira TFV, Silva SA, Santin RC, Medeiros OL, Spaniol AM, Pires ACL, Alves MFM, Faller LA. Ações de alimentação e nutrição na atenção primária à saúde no Brasil. Rev Panam Salud Publica 2020; 44:e39.. In this context, Chart 1 brings documents published nationally and internationally with recommendations for healthy and sustainable food systems.

As described, Brazilian public policies try to integrate the sustainability and nutrition agendas. However, the complexity of the challenges to achieving essential goals, such as equity, eradicating hunger and poverty, and combating all forms of undernutrition, and sustainability, have required greater integration between public policy agendas for health, agriculture, and the environment. At the international level, a leading example of this articulation was establishing the Sustainable Development Goals (SDGs)⁴⁰40 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development. New York: UN; 2015..

The SDGs were created in 2015 to promote the progress and learning of the eight Millennium Development Goals established by the UN, and are aligned with the concept of planetary health, therefore having a transdisciplinary nature¹⁷17 Whitmee S, Haines A, Beyrer C, Boltz F, Capon AG, Dias BFS, Ezeh A, Frumkin H, Gong P, Head P, Horton R, Mace GM, Marten R, Myers SS, Nishtar S, Osofsky SA, Pattanayak SK, Pongsiri MJ, Romanelli C, Soucat A, Vega J, Yach D. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation-Lancet Commission on planetary health. Lancet 2015; 386(10007): 1973-2028.^,4040 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development. New York: UN; 2015.. All SDGs are directly or indirectly related to promoting more sustainable food systems and population health, emphasizing SDGs 2 and 3.

The SDG 2 (Zero Hunger) aims to end hunger, achieve food security, improve food and nutrition, and promote sustainable agriculture⁴⁰40 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development. New York: UN; 2015.. Therefore, the entire food production chain must be considered, developing more resilient agricultural practices with less environmental impact, and establishing and strengthening incentive policies for small farmers, including women, indigenous people, and family farmers⁴⁰40 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development. New York: UN; 2015.. Also, expanding existing programs, such as the PBF, qualified technical assistance for small producers, increasing public purchases from family farming, developing food and nutrition education programs, and regulatory measures for the production and sale of food are necessary strategies for achieving this goal⁴¹41 Organização Pan-Americana da Saúde (OPAS). Sistemas alimentares e nutrição: a experiência brasileira para enfrentar todas as formas de má nutrição. Brasília: OPAS; 2017..

In turn, SDG 3 (Good Health and Well-Being) guarantees access to quality health care and the promotion of well-being for the entire population. Two points that should be highlighted in this SDG are reducing early mortality from NCDs and the number of deaths and diseases resulting from hazardous chemicals and air, soil, and water contamination⁴⁰40 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development. New York: UN; 2015.. This last point is closely related to the unsustainability of food systems and the indiscriminate use of land to produce monocultures and livestock, raising the need for regulation and tightening of policies aimed at controlling the use of land, fertilizers, and pesticides. Furthermore, it is worth noting that one of the strategies of this SDG is that health systems are universal and strongly guided by PHC, with evidence-based health policies for the management, mitigation, and adaptation of climate change and the environment⁴⁰40 United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development. New York: UN; 2015..

Challenges of the Brazilian Unified Health System

Strengthening the SUS is essential for promoting more sustainable food systems. However, there are numerous obstacles and challenges to this. In the field of health, there is still a lack of integration between the public policy agendas for health, agriculture, and the environment despite the great capillarity of the SUS and its access to different Brazilian realities.

The involvement of all actors of the food system (government, industry, and civil society) is required to construct intersectoral public policies. However, few agents participate in developing policies, which hinders the expansion of views on the subject. Furthermore, this limited engagement means that these policies can serve private interests at the expense of society’s demands⁴²42 Marques ECL. Notas sobre redes, Estado e políticas públicas. Cad Saude Publica 2019; 35(Supl. 2): e00002318..

Thus, the horizontal organization of these public policies, which allows for greater integration between them⁴³43 Lotta G, Favareto A. Desafios da integração nos novos arranjos institucionais de políticas públicas no Brasil. Rev Sociol Polit 2016; 24(57):49-65., is the first step towards developing more sustainable food systems. Social participation is also fundamental for these policies to be effective. It includes the population’s actions, civil society organizations, social movements, non-governmental organizations, and multilateral entities⁴²42 Marques ECL. Notas sobre redes, Estado e políticas públicas. Cad Saude Publica 2019; 35(Supl. 2): e00002318..

Furthermore, the recent dismantling of social policies related to income distribution, poverty reduction, and the promotion of FNS deserves attention. Some examples are the cost reduction of structuring programs, such as the PBF, Family Agriculture Food Acquisition Program, and family farming incentive programs⁴⁴44 Ribeiro-Silva RC, Pereira M, Campello T, Aragão E, Guimarães JMM, Ferreira AJF, Barreto ML, Santos SMC. Implicações da pandemia COVID-19 para a segurança alimentar e nutricional no Brasil. Cien Saude Colet 2020; 25(9):3421-3430.. Moreover, the extinction of the National Council for Food and Nutritional Security and the increase in the number of people in poverty and social vulnerability should also be mentioned as threats to the FNS in Brazil⁴⁵45 Santarelli M, David G, Burity V, Rocha NC. Informe Dhana 2019: autoritarismo, negação de direitos e fome. Brasília: FIAN Brasil; 2019.^,4646 Nery C. Agência IBGE Notícias. Extrema pobreza atinge 13,5 milhões de pessoas e chega ao maior nível em 7 anos. [acessado 2020 out 09]. Disponível em: https://agenciadenoticias.ibge.gov.br/agencia-noticias/2012-agencia-de-noticias/noticias/25882-extrema-pobreza-atinge-13-5-milhoes-de-pessoas-e-chega-ao-maior-nivel-em-7-anos
https://agenciadenoticias.ibge.gov.br/ag... .

Thus, ensuring the FNS and health of the population and the planet requires actions at individual, institutional, and national and international political levels (Figure 1) for the right of social production of health, which runs from the production to the consumption of adequate and healthy food, to be guaranteed to all²⁸28 Rigon SA, Schmidt ST, Bógus CM. Desafios da nutrição no Sistema Único de Saúde para construção da interface entre a saúde e a segurança alimentar e nutricional. Cad Saude Publica 2016; 32(3):e00164514.. Moreover, the rational use of natural resources is essential for complying with article 225 of the Brazilian Constitution⁴⁷47 Brasil. Constituição da República Federativa do Brasil. Brasília: Senado Federal; 1988.: “Everyone has the right to an ecologically balanced environment, a common good for the people and essential to a healthy quality of life, imposing on public authorities and the community the duty to defend and preserve it for present and future generations.”

Final considerations

SUS has a fundamental role in care regarding food and nutrition, promoting and protecting health, and acting in the prevention, diagnosis, and treatment of diseases. SUS actions are merged with the current food system, performing as a potential influencer in several areas of the system, such as the food production chain, the food environment, and food consumption, impacting health, the environment, and the economy.

SUS can be understood as a leading tool for sustainable development. Therefore, there is an urgent need to converge the existing policies, with greater integration between actions and dialogue between actors from different sectors, acting collaboratively. The advancement of planetary health, which also studies the actions of humans in the environment and their impacts on the health and sustainability of the planet, plays a critical role in promoting sustainability in public health policies. Also, with access to education, health, and agency on its rights and duties, people can exercise their role as citizens, demanding the realization of the human right to adequate food for all and access to healthier food environments. Thus, SUS can be the articulator to develop a fairer, healthier, and more sustainable food system.

References

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