Abstract

Introduction

In Brazil, the right to food, just like health, is guaranteed in the constitution and recognized as a determinant of health, which must be ensured through public policies ¹1. Brasil. Lei nº 8.080, de 19 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.. Since 1999, the Brazilian National Food and Nutrition Policy (PNAN) has regulated food and nutrition actions under The Brazilian Unified National Health System (SUS), aiming to improve the conditions of food, nutrition and health of the Brazilian population through the organization of food and nutrition surveillance, promotion of adequate healthy food, prevention and comprehensive care of complications related to food and nutrition, particularly in primary health care (PHC) ²2. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 1999.^,33. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2011..

Due to its capillarity, PHC has an important role in PNAN consolidation at the local level; however, the consolidation, expansion and universalization of nutrition actions proposed for PHC in Brazil are challenges in the health sector ⁴4. Jaime PC, Silva ACF, Lima AMC, Bortolini GA. Ações de alimentação e nutrição na atenção básica: a experiência de organização no governo brasileiro. Rev Nutr 2011; 24:809-24.. Then, this study aimed to systematize the history of food and nutrition actions in PHC along the 20-year history of the PNAN, identifying advances in this period.

Methods

Documents published between 1999 and 2020 were analyzed in this study, such as regulations, technical materials, and administration reports produced by the General-Coordination of Food and Nutrition (CGAN) of the Brazilian Ministry of Health or documents with CGAN contribution, in addition to scientific articles, theses and dissertations that described or analyzed food and nutrition actions actions from the Federal Government.

Searches were conducted in scientific databases PubMed, LILACS and Web of Science and the gray literature, including official government websites, the SUS Food and Nutrition Network, as well as the Brazilian Digital Library of Theses and Dissertations (Box 1).

The documents and their descriptions were inserted in a spreadsheet. They were divided among the authors. After reading the documents, each author categorized the actions by type (federal administration, food and nutrition surveillance, promotion of adequate healthy food, nutritional care - multiple burdens of poor nutrition and training), according to the PNAN guidelines (2011) ³3. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2011.. After that, these classifications were discussed by all authors for alignment and definition by consensus. In addition, the evolutionary trajectory of PHC and PNAN was analyzed.

Food and nutrition actions were also assessed by the Food and Nutrition Surveillance System (SISVAN), based on microdata from an external evaluation of the National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB), of 2011, 2013, and 2017, and coverage of nutritional status monitoring (2008 to 2019). Coverage was assessed in an ecological analysis stratified by age group, based on follow-up in PHC. Temporal trend by linear regression considered coverage as a dependent variable and the follow-up year as an independent variable, with significant variation of a regression coefficient when statistically different from zero (p value ≤ 0.05).

Table 1 and Supplementary Material (Box S1. http://cadernos.ensp.fiocruz.br/static//arquivo/supl-e00152620-ingles_4620.pdf) show the main milestones found in the results. The documents are mentioned in the Supplementary Material (Box S2. http://cadernos.ensp.fiocruz.br/static//arquivo/supl-e00152620-ingles_4620.pdf).

Results

Trajectory of PHC AND PNAN

The first version of the PNAN was published a few years after the approval of the Basic Operating Standards of 1996 (NOB 96) and the creation of the Community Health Agents Program (PACS) and the Family Health Program (PSF). PACS and the PSF guidelines included, among the assignments of the PHC professionals, food and nutrition actions for the population. In 2002, guidelines for infant food were developed, with steps to facilitate their adoption in PHC.

Between 2003 and 2006, the whole technical and operational regulatory framework of micronutrient supplementation programs and SISVAN were revised (Supplementary Material. Box S1. http://cadernos.ensp.fiocruz.br/static//arquivo/supl-e00152620-ingles_4620.pdf), monitoring the creation of the National Primary Care Policy (PNAB) and the consolidation of the Family Health Strategy (FHS), as a priority model for PHC expansion in states and municipalities.

The PNAB (2006) established the priority actions of eradication of child malnutrition, control of diabetes and hypertension, and emphasized the promotion of health and the health of children, women and the elderly as strategic areas for the PHC operations. In this context, in line with the nutritional profile of Brazilians, food and nutrition actions in PHC were focused on child malnutrition, nutritional deficiency, child health, and recommendations for healthy food, including promotion of breastfeeding and healthy complementary feeding. In parallel, the first recommendations and strategies for adequate food were developed for the Brazilian population, in line with the PNAB.

In the evolution of PHC, the creation of the Family Health Support Centers (NASF) in 2008 is also an important step for food and nutrition actions. This strategy set up multidisciplinary teams, with the possibility of including nutritionists, including food and nutrition actions among the assignments of all professionals. Then, the Food and Nutrition Action Matrix⁵5. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Matriz de ações de alimentação e nutrição na atenção básica de saúde. Brasília: Ministério da Saúde; 2009. (Série A. Normas e Manuais Técnicos). and the Primary Care Reports⁶6. Secretaria de Atenção à Saúde, Ministério da Saúde. Cadernos de Atenção Básica. https://aps.saude.gov.br/biblioteca/index. (acessado em Ago/2020).
https://aps.saude.gov.br/biblioteca/inde... focused on NASF and nutritional care were published, addressing the main food and nutrition actions, and training strategies were developed, prioritizing NASF professionals and administrators (Supplementary Material (Box S1. http://cadernos.ensp.fiocruz.br/static//arquivo/supl-e00152620-ingles_4620.pdf).

In 2011, PNAB and PNAN were updated. As part of the work process of the PHC teams, the PNAB defined actions focused on risk groups and factors, such as food, to prevent diseases and damage. The PNAN was revised according to the new guidelines of the PNAB, incorporating PHC in its provisions for the organization of nutritional care, which reinforces comprehensive care in the Health Care Network, with primary care as a priority space for the actions. Also in 2011, the PMAQ-AB was also created, which, even with few food and nutrition indicators with an impact on the transfer of resources, included assessment of administration, structure and actions that were directly or indirectly related to food and nutrition, contributing to encourage it in the territories.

In 2017, the PNAB was updated again, highlighting health promotion as a principle for health care and reinforcing proper healthy food as a relevance aspect of its approach. In 2019, the PHC funding scheme changed with Previne Brasil, as it started to pay municipalities for service and performance indicators; however, until the time of writing this article, nutrition indicators had not been included. In 2019, a service portfolio was created, assuming the essential attributes and derivatives of PHC to guide the actions, inserting food and nutrition actions in PHC. These attributes can strengthen the food and nutrition actions in PHC, which in turn can strengthen the attributes, since the identification of individuals with nutritional problems and the monitoring for health promotion and disease prevention can expand the first contact access, leading to promotion of adequate healthy food actions and organization of nutritional care for these individuals, ensuring longitudinal and comprehensive care, family and community guidance, and cultural competences.

It should be noted that, in addition to the strategies adopted in PHC, a wide range of PNAN actions can cause an impact on the life of the Brazilian population by reducing the problems related to inadequate nutrition and the demand in PHC; for instance, with flour fortification with iron and folic acid, salt iodation, and the Brazilian Regulation for Marketing of Infant and Young Child Formula, Nipple Protectors, Pacifiers, and Feeding Bottles. In addition, efforts have been made for the adoption of national regulatory measures to protect healthy food, such as regulation of advertising and front-of-package nutritional labeling of foods, restricted sale of food in school cafeterias, and taxation of sugar-sweetened beverages, which, if adopted, can, in the long run, reduce obesity and other non-communicable diseases (NCDs) in the country; however, none of these measures had been approved by the end of 2019.

Specific actions performed in each area are described as follow.

Federal administration

The analysis of the study period showed food and nutriton actions were prioritized in instruments of federal administration. From 2000 to 2011, the actions were intersectoral, focused on fighting hunger and preventing malnutrition and nutritional deficiency, with PHC essential for the implementation of measures. In the second decade, the Brazilian Ministry of Health promoted more food and nutrution actions, with an expansion of measures for promotion of adequate healthy food and prevention of obesity. Due to the multiple burdens of poor nutrition in the country, the goals to reduce malnutrition and prevent nutritional deficiency were still present, but focused on specific groups (Table 1).

Other policies, such as the National Health Promotion Policy (PNPS) and initiatives like the Strategic Action Plan for NCDs, the National Food and Nutrition Security Plan, and the Intersectoral Strategy for Obesity Prevention and Control, also had food and nutriton actions, reinforcing PHC as a field of action.

At the same time, the CGAN budget also increased (Table 1). Despite presenting higher amounts between 2000 and 2003, a large part of this fund was allocated to the Food Assistance Program . With the incorporation of the federal income transfer programs into the Brazilian Income Transfer Program, this fund was transferred to Brazilian Ministry of Social Development and Fight Against Hunger, with the Ministry of Health responsible for monitoring health conditions and assessing the nutritional status of children and pregnant women.

In 2006, a financial transfer was instituted to structure food and nutrition actions in states and municipalities. In 2009, this resource was dedicated to the PNAN implementation, and continuously expanded starting in 2017 to include more states, covering, in 2019, 1,132 municipalities with more than 30,000 inhabitants.

The CGAN budget is one of pillars in the promotion of food and nutrition actions and initiatives in PHC by the federal government, either through direct federal actions or by transferring funds to states. The transfer of resources to states and municipalities, reinforcing PHC as a care provider and coordinator, can also induce the prioritization of such actions at local level.

In addition to financial support, a network of food and nutrition administrators was also created over the years, responsible for the PNAN administration in states and municipalities, involving PHC administrators locally in case of separate areas. This network is supported by the federal administration through virtual or in-person meetings or another communication system that enable constant debate about food and nutrition actions in PHC across the SUS network, without which, such implementation would not be possible.

Food and nutrition surveillance

Food and nutrition surveillance allows PHC teams to assess the health and nutrition conditions of the enrolled population and, based on a local diagnosis, organize required actions. The information recorded from the PHC health services, which comprised SISVAN, was initially linked with child malnutrition control actions and programs related to this condition. With the food and nutrition surveillance strengthening as a PNAN guideline, the concept of surveillance was expanded to incorporate food and nutrition surveillance actions into the PHC routine, including the evaluation of food and nutrition indicators.

Computerization of SISVAN (2003) was a milestone for the standardization and expansion of the system in PHC; however, the system received information from local health departments and then sent it to the national base. This system had the support from SUS professionals and administrators through training, but due to its limited coverage and operational issues, the SISVAN-web online platform was developed in 2008, fed directly at the primary health care units (UBS). The main milestones of SISVAN-web include the incorporation of food consumption markers and the use of anthropometric indices recommended by the World Health Organization (WHO) by age group; in addition to interfaces with other systems used in PHC, such as the Brazilian Income Tranfer Porgram Health Monitoring System and e-SUS AB. Also, in order to support food and nutrition surveillance structuring in the municipalities, the acquisition of anthropometric equipment has been funded according to the local reality since 2011. By 2019, resources were invested to equip 24,742 UBS and 730 centers of the Health Academy Program.

Since SISVAN-web was launched, 98% of the municipalities have submitted at least one anthropometric record and, in 2014, all of them had these records. Regarding food consumption, 28% of the municipalities presented some data in the period, reaching 62% in 2019 (data not available). Table 2 shows a favorable and significant evolution in Sisvan coverage, with more data about children, especially those under five years of age, with an increase of two percentage points per year.

Promotion of adequate healthy food

Food guides publications were used for the organization of actions in PHC, which for the first time defined Brazilian recommendations of healthy food, guiding the organization of promotion of adequate healthy food actions. The first Food Guide for Brazilian Children Under Two Years⁷7. Ministério da Saúde; Organização Pan-Americana da Saúde. Guia alimentar para crianças menores de 2 anos. Brasília: Ministério da Saúde; 2002. (Série A. Normas e Manuais Técnicos). was published in 2002 and the first Food Guide for the Brazilian Population⁸8. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira: promovendo a alimentação saudável. Brasília: Ministério da Saúde; 2006. (Série A. Normas e Manuais Técnicos)., in 2006. In 2014 ⁹9. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. 2ª Ed. Brasília: Ministério da Saúde; 2014., the Food Guide for the Brazilian Population was updated with an innovation as it included a new classification based on food processing and broader approaches to food systems, commensality, and overcoming food-related obstacles to increase the autonomy of individuals. In 2019 ¹⁰10. Departamento de Promoção da Saúde, Secretaria de Atenção Primaria à Saúde, Ministério da Saúde. Guia alimentar para crianças brasileiras menores de 2 anos. 2ª Ed. Brasília: Ministério da Saúde; 2019., the Food Guide for Brazilian Children Under Two Years was also revised to align it with new scientific evidence and the new Food Guide for the Brazilian Population.

In order to implement the Food Guide for Brazilian Children Under Two Years in PHC, the Brazilian Breastfeeding Program was created in 2008 and, in 2009, the Brazilian National Strategy for Complementary Healthy Food, which were unified in 2013 in the Brazilian Breastfeeding and Food Assistance Program, aiming to promote breastfeeding and healthy complementary food. In 2018, the Brazilian Breastfeeding and Food Assistance Program adaptation to indigenous people started and is still in progress. Several materials have also been published to drive Food Guide for the Brazilian Population implementation in promotion of adequate healthy food. The Programa Saúde na Escola, created in 2007, which promoted promotion of adequate healthy food actions in schools by PHC teams, and Healthy Chidlhood Growth Program, launched in 2017, also supported the adoption of promotion of adequate healthy food actions in PHC.

In 2011, a new version of the PNAN introduced an expanded concept of promotion of adequate healthy food, with actions related to food and nutrition education, food regulation and incentive to create promotion of adequate healthy food spaces, as well as intersectoral articulations promoted by the health sector. It also described the responsibility of health teams to go beyond the UBS limits to perform promotion of adequate healthy food actions.

The collective activities in PHC started to be registered in e-SUS AB; in 2019, of all 1,153,898 collective activities developed by the teams, 26.9% addressed the theme.

Nutritional care: multiple burdens of poor nutrition

Malnutrition

The incentive to fight nutritional deficiency, created in 1998 as part of the variable Primay Care Floor (PAB), transferred resources directly to the municipalities for milk and oil acquisition and distribution in UBS to malnourished children. In 2001, the Food Assistance Program was created to replace the Incentive to Fight Nutritional Deficiency (ICCN); it ensured a direct transfer of funds to beneficiary families for the food acquisition (in 2003 it was incorporated into the Brazilian Income Transfer Program).

For malnutrition management in PHC, the recommendations of the Integrated Care to Childhood Illnesses (AIDPI) strategy were considered. In 2005, a protocol was published for treating malnutrition in children in hospitals. Complementary protocols for PHC and outpatient care were developed at the time, but were not officially published.

In 2012, the agenda for Scaling Up Nutritional Care of Childhood Malnutrition (ANDI) was created to address malnutrition in 256 municipalities that had a prevalence of underweight above 10% through fund transfer, definition of goals, and qualification of actions. This strategy had the publication of support material for the teams, including the organization of malnutrition care. The evaluation of nutritional care for child malnutrition assessment showed the municipalities presenting the best performance in goal achievement were those with the highest PHC and food and nutrition surveillance coverage, among other factors ¹¹11. Ramos MKP, Lima AMC, Gubert MB. Agenda para intensificação da atenção nutricional à desnutrição infantil: resultados de uma pactuação interfederativa no Sistema Único de Saúde. Rev Nutr 2015; 28:641-53..

Prevention of micronutrient deficiency

Strategies to control micronutrient deficiency in PHC have been performed in a focused manner in the country since the 1970s. With the publication of PNAN, it was defined as a priority theme, assuming a Social Commitment for the Prevention and Control of Anemia in Children, which, at the time, affected 50% of children and was reduced to 20% in 2006. In 2005, supplementation programs were implemented across the nation: the National Supplementation Program for Iron (PNSF) and the National Supplementation Program for Vitamin A (PNSVA), both in PHC.

The PNSF first recommended universal supplementation in weekly preventive doses for children aged 6 to 18 months and daily supplementation for pregnant women and postpartum women across the country. In 2013, the program was reformulated, and its recommendation of daily dosing has been in force until now; it also decentralized acquisitions to the municipalities. In 2014, after a multicenter study that assessed the effectiveness of supplementation with multivitamins and minerals, the Strategy for Infant Feeding Fortification with Micronutrient Powders (NutriSUS) was launched to help prevent anemia and other nutritional deficiencies by adding sachets of micronutrients for children enrolled in daycare centers.

The PNSVA first recommended that children aged 6 to 59 months and postpartum women should be supplemented with megadoses of vitamin A in the UBS of the municipalities of the Northeast Region, Vale do Jequitinhonha, Minas Gerais State, and Vale do Ribeira, São Paulo State, where hypovitaminosis A is endemic, with subsequent expansion to municipalities in the Legal Amazon, indigenous areas and priority municipalities of Frindly Brazil Action. In 2016, postpartum women supplementation was discontinued due to a lack of association with morbidity and mortality outcomes.

In 2006, cases of beriberi were reported in Maranhão, Tocantins and Pará; in 2008, among indigenous people in Roraima. Since then, 2,312 cases and 50 deaths have been reported, mostly of young black or indigenous adults from municipalities presenting low Human Development Index (HDI), low income and low educational level. The outbreak required the adoption of local intersectoral actions, with support from national and state administration, and a guide for the disease identification and treatment was developed for PHC, in addition to ensuring thiamine provision.

Obesity

During the 20-year history, national surveys showed a reduction in malnutrition and a significant increase in obesity in all life cycles, forcing the PNAN to incorporate new actions for disease control. In 2019, over 60% of all adult individuals in Brazil were overweight ¹²12. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019: informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020..

For PHC organization, early disease identification instruments were the first to become available through the food and nutrition survellance. Between 2006 and 2007, the first milestones were published for structuring obesity prevention and control actions in the SUS and support to the prevention and treatment of individuals in this condition in PHC. With the creation of the Chronic Diseases Network and the Obesity Care Line (LCSO) in 2013, the organization process of overweight prevention and treatment was intensified, with materials updated with new approach strategies.

Data from PMAQ-AB, based on interviews with PHC professionals about obesity care, revealed in the first cycle (2011) that 39.9% of the teams planned care provision. In the second cycle (2013), 56.2% organized follow-up consultations, 54% invited individuals to participate in collective activities on healthy food and physical activity, and 55.3% used matrix support for such follow-up. In the third cycle (2017), 80.7% of the teams claimed to perform follow-ups, 75.5% offered actions focused on healthy food, and 72.2% used matrix support to monitor these individuals at the UBS. However, referral to a specialized service is still a common practice, reported by 80.2% of the teams.

In childhood obesity, health promotion actions have always been prioritized; however, in 2017, the Healthy Childhood Growth Program was launched to help PHC teams identify, through the Health at School Program, overweight children for care actions, by transferring resources and setting goals.

Training

The temporal analysis of training and qualification actions of SUS professionals shows a connection between the themes and types of strategies adopted in the different institutional, political and epidemiological contexts, in which the two versions of the PNAN were outlined. Three important periods can be identified, considering the different strategies:

The first period (1999-2006) was characterized by the provision of training to PHC administrators and professionals about the following themes: human right to adequate food, food and nutritional security, health promotion in the life cycle. It also included the adoption of child malnutrition control and prevention programs, nutritional deficiency, and PTR. The training strategies involved in-person workshops at all levels of administration. During this period, Collaborating Centers for Food and Nutrition (CECAN) were created, which conducted training about program management and FNS, in partnership with the Technical Areas of Food and Nutrition of the states and the Federal District, until 2011.

The second period (2007-2014) is marked by the provision of specialization courses to local health administrators and PHC professionals. In-person and distance training in management of food and nutrition policies and nutrition in PHC, in partnership with the Oswaldo Cruz Foundation (Fiocruz). Other relevant milestones were: institutionalization of CECAN, formalizing the national collaborative network, and the creation of RedeNutri in 2003, which, in 2009, started to contribute to professional training through self-instructional courses. However, its last update was in 2017 as information was incorporated to the PHC and the Ministry of Health portal.

In the third period (2015-2019), other strategies were adopted, such as: public selection for research project funding, extension and training of PHC professionals to qualify the diagnosis, prevention and treatment of obesity; development of a course about the promotion of adequate healthy food actions in PHC; and free and specialization courses for training and qualification in obesity.

Discussion

In the last 20 years, PNAN has been the main guide for food and nutrition policies, programs and actions in SUS, also impacting other sectors due to its intersectoral character. In this sense, the PNAN update maintained most of its guidelines and priorities, but reflected the changes in the health sector and food and nutrition security, reinforcing nutritional care, expanding the insertion of nutrition actions in SUS and ensuring more visibility to the actions implemented in PHC.

In the first decade of PNAN, prevention of nutritional deficiency and malnutrition had emphasis in PHC, with the creation of training programs and actions focused on obesity and recommendations and materials for the PHC about promotion of adequate healthy food. The results were analyzed in a study that identified actions according to the epidemiological scenario in the country ¹³13. Jaime PC, Delmuè DCC, Campello T, Silva DO, Santos LMP. Um olhar sobre a agenda de alimentação e nutrição nos trinta anos do SUS. Ciênc Saúde Colet 2018; 23:1829-36..

Addressing the multiple burdens of malnutrition requires a stronger participation of the health sector in articulation with other sectors ¹⁴14. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, et al. The global syndemic of obesity, undernutrition, and climate change. Lancet 2019; 393:791-846., reflecting the need for larger PHC teams. They must develop health promotion actions for the treatment of diseases, consider territory particularities, identify factors that impact the health of individuals, and establish intersectoral articulation to support the assembly of spaces to promote healthy food ¹⁵15. Botelho FC, França Junior I. Como a APS pode fortalecer a alimentação adequada enquanto direito na América Latina? Rev Panam Salud Pública 2018; 42:e159.. In addition, the territory requires diagnosis and monitoring of the food and nutritional situation ¹⁶16. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Marco de referência da vigilância alimentar e nutricional na atenção básica. Brasília: Ministério da Saúde; 2015..

Based on data from services, investigations, and surveys, the actions in PHC have already impacted nutritional outcomes and increased SISVAN coverage. For example, reduction in child malnutrition rates between 1996 and 2006 was due to universalization of health care, with the expansion of PHC ¹⁷17. Monteiro CA, Benício MHD'A, Konno SC, Silva ACF, Lima ALL, Conde WL. Causas do declínio da desnutrição infantil no Brasil, 1996-2007. Rev Saúde Pública 2009; 43:35-43., among other factors. The increase in SISVAN coverage occurred as a result of Brazilian Income Transfer Program monitoring and funding for UBS structuring and computerization. A broader coverage of nutritional status was positively correlated with the FHS coverage between 2008 and 2013 ¹⁸18. Nascimento FA, Silva SA, Jaime PC. Cobertura da avaliação do estado nutricional no sistema de vigilância alimentar e nutricional brasileiro: 2008 a 2013. Cad Saúde Pública 2017; 33:e00161516..

Federal income transfer programs, designed to contribute to the food and nutrition security, incorporated conditions related to food and nutrition in health care, which explains a larger amount of SISVAN data coming from pbf, indicating a possibility to universalize coverage beyond this population. Regular monitoring of Brazilian Income Transfer Program beneficiaries in PHC proved to be a protective factor against malnutrition, anemia and child overweight ¹⁹19. Jaime PC, Vaz ACN, Nilson EAF, Finseca JCG, Guadagnin SC, Silva SA, et al. Desnutrição em crianças de até cinco anos beneficiárias do Programa Bolsa Família: análise transversal e painel longitudinal de 2008 a 2012. In: Sousa MF, Ximenez DA, Jaime PC, organizadores. Cadernos de Estudos Desenvolvimento Social em Debate: resultados, avanços e desafios das condicionalidades de saúde do Bolsa Família. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2014. p. 49-63., reinforcing the positive impact of PHC while ensuring the right to health and adequate food for families in situation of social vulnerability ¹⁴14. Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, Brinsden H, et al. The global syndemic of obesity, undernutrition, and climate change. Lancet 2019; 393:791-846.^,2020. Alves KPS, Jaime PC. A Política Nacional de Alimentação e Nutrição e seu diálogo com a Política Nacional de Segurança alimentar e Nutricional. Ciênc Saúde Colet 2014; 19:4331-40..

The adequacy of nutritional deficiency prevention programs depends on a continuous production of evidence, inherent to expanded food and nutrition surveillance. However, population surveys and national surveys have not been developed with proper frequency to monitor the changes in population diet and nutrition and guide a reformulation of these programs in a timely manner; the last survey with data about the prevalence of micronutrient deficiency in children was conducted in 2006, and in adults, in 2013 ²¹21. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: acesso e utilização de saúde, acidentes e violência. Brasil, grandes regiões e unidades da federação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2014.. The Brazilian National Study of Infant Food and Nutrition (ENANI. https://enani.nutricao.ufrj.br/), conducted between 2019 and 2020, presents an updated profile of nutritional deficiency among Brazilian children, allowing improvements in these actions.

Regarding promotion of adequate healthy food, food guides were the main milestones and guided recommendations, development of materials, and creation of programs implemented in PHC in the period. The current version of the Food Guide for the Brazilian Population changed how meals and foods are seen, strengthened the sociocultural dimensions of food, with a focus on cooking practices, food and commensality ²²22. Oliveira MSS, Amparo-Santos L. Food-based dietary guidelines: a comparative analysis between the Dietary Guidelines for the Brazilian Population 2006 and 2014. Public Health Nutr 2018; 21:210-17.. Promotion of adequate healthy food in PHC requires adaptation to local realities, considering food systems and food supply in the territories, going beyond guidance and food and nutrition education to include intersectoral articulations in its practice.

National studies reported promotion of adequate healthy food actions in 72% of UBS, and PHC team guidance about food in care routine ²³23. Ramos LR, Malta DC, Gomes GAO, Bracco MM, Florindo AA, Mielke GI, et al. Prevalence of health promotion programs in primary health care units in Brazil. Rev Saúde Pública 2014; 48:837-44. in more than 30% of respondents ²⁴24. Silva SM, Facchini LA, Tomasi E, Piccini R, Thumé E, Silveira DS, et al. Recebimento de orientação sobre consumo de sal, açúcar e gorduras em adultos: um estudo de base nacional. Rev Bras Epidemiol 2013; 16:995-04.. However, the impact of these approaches was not assessed. Local data show that when PHC teams prioritize promotion of adequate healthy food actions according to national guides or strategies, benefits are reported in the health and nutrition of the population ²⁵25. Baldissera R, Issler RMS, Giugliani ERJ. Efetividade da Estratégia Nacional para Alimentação Complementar Saudável na melhoria da alimentação complementar de lactentes em um município do Sul do Brasil. Cad Saúde Pública 2016; 32:e00101315..

In Brazil, meals with in natura or minimally processed foods has been gradually replaced by ultra-processed foods ²⁶26. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2017-2018. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019., while the consumption of critical nutrients associated with NCDs has not decreased, leading to an increased risk of these diseases in the population ²⁷27. Monteiro CA, Cannon G, Lawrence M, Louzada MLC, Machado PP. Ultra-processed foods, diet quality, and health using the NOVA classification system. Rome: Food and Agriculture Organization of the United Nations; 2019.. The prioritization of promotion of adequate heathy food themes, therefore, remains a challenge in PHC. Enhancing the implementation of the guides in PHC will significantly contribute to change the current food and nutritional profile of communities, complementing policies and measures for the protection of food environments ²⁸28. Bortolini GA, Moura ALP, Lima AMC, Moreira HOM, Medeiros O, Diefenthaler ICM, et al. Guias alimentares: estratégia para redução do consumo de alimentos ultraprocessados e prevenção da obesidade. Rev Panam Salud Pública 2019; 43:e59..

The main issue resulting from these changes in food consumption in Brazil is overweight, requiring efforts from multiple segments to resolve it - with PHC playing a strategic role in the health sector. In 2007 and 2013, regulations and materials were published to qualify the actions and ensure intersectoral organization for the prevention and control of obesity, an innovative model for intersectoral policy coordination ²⁹29. Pinheiro MC, Moura ALSP, Bortolini GA, Coutinho JG, Rahal LS, Bandeira LM, et al. Abordagem intersetorial para prevenção e controle da obesidade: a experiência brasileira de 2014 a 2018. Rev Panam Salud Pública 2019; 43:e58.. However, despite the obesity care efforts of the teams over the years, the percentage of obese people referred to other health centers is high. In addition, of all over 105 million annual visits reported in PHC, only 2.85% were related to obesity, 10.51% to diabetes, and 26.38% to arterial hypertension, indicating that obesity may not be identified as a problem by PHC professionals ³⁰30. Bortolini GA, Oliveira TFV, Silva SA, Santin RC, Medeiros OL, Spaniol AM, et al. Ações de alimentação e nutrição na atenção primária à saúde no Brasil. Rev Panam Salud Pública 2020; 44:e39..

Poor adherence of patients to therapeutic processes and the consequent feelings of frustration and helplessness experienced by professionals, working in a multidisciplinary team, and lack of preparation to deal with the complexity of the health/disease process related to obesity were reported by health professionals as their main challenges when providing care to people with obesity ³¹31. Burlandy L, Teixeira MRM, Castro LMC, Cruz MCC, Santos CRB, Souza SR, et al. Modelos de assistência ao indivíduo com obesidade na atenção básica em saúde no Estado do Rio de Janeiro, Brasil. Cad Saúde Pública 2020; 36: e00093419.. Limited knowledge of health professionals to provide nutritional guidance and control weight was found in a Brazilian study ³²32. Hidalgo KD, Mielke GI, Parra DC, Lobelo F, Simões EJ, Gomes GO, et al. Health promoting practices and personal lifestyle behaviors of Brazilian health professionals. BMC Public Health 2016; 16:1114., emphasizing investments should be made in training to improve the way obesity is approached in PHC. In recent years, efforts from the federal administration have developed training strategies for PHC professionals and administrators through partnerships with universities and the provision of courses about this theme.

In addition to training, the LCSO, as part of the Network of Non-communicable Diseases, was an administration strategy to ensure obesity care. Rearranging health services into networks and care lines favors a more integrated and intrasectoral approach to obesity, with the possibility of strengthening food systems that promote proper healthy food in a sustainable way ³³33. Dias PC, Henriques P, Anjos LA, Burlandy L. Obesidade e políticas públicas: concepções e estratégias adotadas pelo governo brasileiro. Cad Saúde Pública 2017; 33:e00006016.. The proposal of the LCSO promoted the contact among health centers from different states and municipalities to ensure comprehensive care, but the end of mandatory care lines in 2017, approved for the provision of highly complex hospital care to individuals with obesity has been criticized ¹³13. Jaime PC, Delmuè DCC, Campello T, Silva DO, Santos LMP. Um olhar sobre a agenda de alimentação e nutrição nos trinta anos do SUS. Ciênc Saúde Colet 2018; 23:1829-36..

Despite the Brazilian effort to address obesity through international agreements and goals in health and food and nutrition security plans ³⁰30. Bortolini GA, Oliveira TFV, Silva SA, Santin RC, Medeiros OL, Spaniol AM, et al. Ações de alimentação e nutrição na atenção primária à saúde no Brasil. Rev Panam Salud Pública 2020; 44:e39., obesity is still growing in the country, requiring the adoption of public regulatory policies that affect health environments and the food system ³⁴34. Castro IRR. Obesidade: urge fazer avançar políticas públicas para sua prevenção e controle. Cad Saúde Pública 2017; 33:e00100017.. If no effective measure is implemented, the country will have more than 7 million obese children and adolescents by 2030, according to estimates ³⁵35. World Obesity Federation. Atlas of childhood obesity. London: World Obesity Federation; 2019.. In 2018, around BRL 3.45 billion ³⁶36. Nilson EAF, Andrade RCS, Brito DA, Oliveira ML. Custos atribuíveis a obesidade, hipertensão e diabetes no Sistema Único de Saúde, Brasil, 2018. Rev Panam Salud Pública 2020; 44:e32. had been spent with obesity, hypertension and diabetes, demonstrating how urgent this issue is, not only for the health of the population, but also for the country’s economy.

Improvements in food and nutrition in PHC must occur based on scientific evidence. However, a systematic review conducted in 2017 shows the academic production cannot generate enough evidence to support the public administration ³⁷37. Pereira TN, Monteiro RA, Santos LMP. Alimentación y nutrición en atención primaria en Brasil. Gac Sanit 2018; 32:297-303.. Gaps are seen in the proposal for innovative, viable and effective interventions, in the evaluation of actions and programs, particularly those related to obesity, special dietary needs and nutritional therapy in PHC. Also few studies have addressed PHC articulation with other centers in the health care network and other sectors besides education. Regarding the PHC administration, the literature has no study that identifies its weaknesses and tools to help overcome them, proposes innovative methods of continuing education, or that assesses the impact of actions and economic analyses related to this theme ³⁷37. Pereira TN, Monteiro RA, Santos LMP. Alimentación y nutrición en atención primaria en Brasil. Gac Sanit 2018; 32:297-303.^,3838. Canella DS, Silva ACF, Jaime PC. Produção científica sobre nutrição no âmbito da atenção primária à saúde no Brasil: uma revisão de literatura. Ciênc Saúde Colet 2013; 18:297-308.. These findings confirm the demand for studies in food and nutrition identified by the CGAN, as seen in research request for proposal launched in recent years.

This is the first study to systematize the 20-year history of PNAN in PHC, providing important contributions based on a collection of documents and scientific publications about this theme. However, it has limitations because it is only a documentary analysis. Interviews with the main actors involved could clarify issues not presented in the analyzed documents. In addition, all authors are directly involved with this theme as workers of the CGAN, from the Brazilian Ministry of Health, which may have generated bias in the analysis of food and nutrition evolution in PHC.

Conclusion

Food and nutrition actions in PHC evolved to respond to the main food and nutrition issues in the country - first they prioritized malnutrition reduction and, more recently, placed a stronger emphasis on obesity. Important milestones were identified, which contributed to the advancement of nutrition organization in primary care. However, the universalization of these actions at the local level is still an important challenge to be overcome. In addition, it is clear the multiple burdens of malnutrition demand intersectoral articulation, which can also be enhanced in PHC.

References

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History