Abstract

Introduction

The Unique system of Health (SUS) was instituted after several years of sanitary movement, amid crisis of the health section, with their incongruities, disarticulation and difficulties in rendering reasonable attendance to most of the population. Its origin dates from 1988, after the ⁸8 Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília (DF): MS; 2011.th National Conference of Health, which originated the text of the Constitution of the same year. Ever since, the effort that principles of universality, justness and decentralization be respected¹1 Mano MA. A educação em saúde e o PSF resgate histórico, esperança eterna. Bol Saúde. 2004; 18(1):195-202. configures element of importance and prominence in the politics of health.

However, this system has not been capable, by itself, of putting in practice the guarantees already legally conquered . The magnitude of health problems of the Brazilian people is evident, caused by environmental, biological, physical and social factors, resulting from and permanently worsened by the social crisis of the last years, and direct repercussion translates itself in increase of violence, unemployment and exclusion²2 Forattini OP. A saúde pública no século XX. Rev Saude Publica. 2000; 34(3):211-3..

Due to the need of consolidation of Unique System of Health ( SUS,) in 1994,commences the implantation of the Family Health Program - PSF¹1 Mano MA. A educação em saúde e o PSF resgate histórico, esperança eterna. Bol Saúde. 2004; 18(1):195-202.^,33 Alves VS. Um modelo de educação em Saúde para o Programa Saúde da Família: pela integralidade da atenção e reorientação do modelo assistencial. Interface (Botucatu). 2005; 9(16): 39-52., as instrument for reorganization of Unique System of Health (SUS) and of the municipalization. In 1997 and 1998, new documents published by Ministry of Health reinforce the understanding of Family Health Program ( PSF) as strategy for reorganization of the basic attention, implanted in order to bring a new conception of health, aiming for promotion of life quality, reverting to the principles of Unique System of Health (SUS) then, seeking to improve and enlarge the service to the population⁴4 Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Programa Saúde da Família. Rev Saude Publica. 2000; 34(3):316-9..

In spite of being a recent strategy, according to Mano¹1 Mano MA. A educação em saúde e o PSF resgate histórico, esperança eterna. Bol Saúde. 2004; 18(1):195-202., in Family Health Program PSF (now known as Family Health Strategy ( ESF), it is already possible to see and to question some principles that were part of its implantation, among them: possibility of expansion of the basic team, lack of professionals(quantitative and qualitative character), new limitation of areas and multiprofessionality.

When considering the professionals' lack of qualification, some modalities appear as form of potentiating the work developed in Family Health Strategy (ESF), as courses of Specialization in Family Health , destined for professionals of graduate level, training and capacitation of the team and creation of Multiprofessional Residency in Family Health⁵5 Campos FE, Belisário SA. O programa de saúde da família e os desafios para a formação profissional e a educação continuada. Interface (Botucatu). 2001; 5(9):133-42..

Due to crescent demands of the health sector and to the possibility of using the space of these services as fields for teaching and research, Multiprofessional Residencies were instituted (specific or multiprofessional), with the intention to define and produce technologies of the care, important aspects for the qualification of Unique Health System (SUS)⁶6 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília (DF): MS; 2006..

The main goal of the Multiprofessional Residencies is the development of actions in the area of health, mainly the priority areas (Biomedicine, Biological Sciences, Physical education, Nursing, Pharmacy, Physiotherapy, Speech Therapy, Veterinary Medicine, Nutrition, Dentistry, Psychology, Social Service and Occupational therapy) seeking qualification of the health professionals in Unique Health System (SUS) based on the needs of health of the population, with the purpose of transformation of the reality⁶6 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília (DF): MS; 2006..

Based on survey accomplished by the General office of Administration of the Work and Education in the Health (SGTES) and Executive Management of Administration of the Higher education - DEGES⁷7 Ministério da Saúde. Residência Multiprofissional em Saúde: experiências, avanços e desafios. Brasília (DF): MS; 2006., Multiprofessional Residency programs in Health financed by Ministry of Health are present in the areas North (Rondônia), Northeast (Bahia, Maranhão, Pernambuco, Sergipe), South (Paraná, Rio Grande do Sul, Santa Catarina) and Southeast (Minas Gerais, São Paulo). The proposal of Multiprofessional Residencies in Health is becoming better known and Improved year by year.

Multiprofessional Residency programs in Family Health are different from other Multiprofessional Residencies, because it has as “ loco of activities”, the scenery of the basic attention, can contribute to the revision of the assistencial model, because they form a new profile of the professional of health, humanized and prepared to attend to the needs of the users' health, family and community, contribution to the construction of new paradigms of attendance to the health, enlarging the resourcefulness of the Family Health Strategy⁷7 Ministério da Saúde. Residência Multiprofissional em Saúde: experiências, avanços e desafios. Brasília (DF): MS; 2006..

In some Multiprofessional Residency in Family Health the RD-registered dietician is inserted, opening space to develop their relevant attributions facing the current nutritional profile of the Brazilian population.

Currently, several countries, including Brazil, experience fast epidemic and nutritional transition marked by the coexistence of the malnutrition with the increase of the prevalence of the obesity, overweight, malnutrition and high incidence of, not transmissible, chronic diseases ⁸8 Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília (DF): MS; 2011., generating overload to Unique Health System (SUS) as they demand great number of actions, procedures and services of health, mainly when they involve chronic diseases ⁹9 Coutinho JG, Gentil PC, Toral N. A desnutrição e obesidade no Brasil: o enfrentamento com base na agenda única da nutrição. Cad Saude Publica. 2008; 24 Supl 2:332-40..

The nutritional transition associated with the epidemic is closely related to the sedentarism, high consumption of industrialized foods, fast food, less ingestion of fruits, green vegetables and vegetables and high consumption of saturated fats⁹9 Coutinho JG, Gentil PC, Toral N. A desnutrição e obesidade no Brasil: o enfrentamento com base na agenda única da nutrição. Cad Saude Publica. 2008; 24 Supl 2:332-40.^,1010 Levy-Costa RB, Sichieri R, Pontes NS, Monteiro CA. Disponibilidade domiciliar de alimentos no Brasil: distribuição e evolução (1974-2003). Rev Saude Publica. 2005; 39(4):530-40..

The actions promoting health and prevention of damages are particularly relevant before this phenomenon that brings the inversion in the traditional distribution of the nutritional problems associated to the pattern of determination of diseases attributed to modern times¹¹11 Kac G, Velásquez-Meléndez G. Editorial. A transição nutricional e a epidemiologia da obesidade na América Latina. Cad Saude Publica. 2003; 19 Supl.1:4-5..

This phenomenon is currently considered one of the largest challenges of the public politics, the need for a model of attention to the health based on the individual's integrality and his/her family, with approach centered in the promotion of health⁹9 Coutinho JG, Gentil PC, Toral N. A desnutrição e obesidade no Brasil: o enfrentamento com base na agenda única da nutrição. Cad Saude Publica. 2008; 24 Supl 2:332-40..

Considering that in Family Health Strategy (ESF) the service to the user and family is accomplished in an integral and continuous way, aiming to develop promotion actions, protection and recovery of the health, focusing on the physical and social atmosphere,this strategy is noticed as a space of the dietician's performance, a professional capable to work concepts and strategies that approach pertinent subjects to the feeding and nutrition ¹²12 Assis AMO. O programa saúde da família: contribuições para uma reflexão sobre a inserção do Nutricionista na equipe multidisciplinar. Rev Nutr. 2002; 15(3):255-66.

13 Santos AC. A inserção do nutricionista na estratégia da saúde da família: o olhar de diferentes trabalhadores da saúde. Fam Saude Desenv. 2005; 7(3):257-65.^-1414 Carvalho AMM. A inserção do profissional nutricionista no Sistema Único de Saúde: reflexões a partir da experiência de um município da região metropolitana de Porto Alegre - RS [dissertação]. Porto Alegre (RS): Escola de Saúde Pública do Estado do Rio Grande do Sul; 2005., contributing to recreate practices of attention to the health in Brazil. The principle of integrality also justifies approaching feeding actions and nutrition, as their purpose is to elevate the quality of life of the population¹³13 Santos AC. A inserção do nutricionista na estratégia da saúde da família: o olhar de diferentes trabalhadores da saúde. Fam Saude Desenv. 2005; 7(3):257-65..

However, this scenery of performance for the dietician is still very recent, making us question how to develop the performance of this professional after being inserted in Family Health Strategy (ESF). As such, this article aimed to investigate the health professionals conceptions, including dieticians, in relation to the dietician's performance in the Family Health Strategy (ESF)after insertion in a Multiprofessional Residency Program in Family Health.

Methods

The study presented here is an excerpt of the dissertation entitled Multiprofessional Residency in Family Health and the dieticians's formation for the Family Health Program, elaborated for obtaining Professional Master's title in Teaching in Sciences of the Health for the Center of Development of the Higher Education in Health (CEDESS) of the Federal University of São Paulo (Unifesp).

The venue chosen for the study was the Multiprofessional Residency in Family Health (RMSF), developed in partnership with Ministry of Health, Faculdade Santa Marcelina and Casa de Saude Santa Marcelina, from 2005 to 2007. In that period,the referred Residency absorbed ninety professionals of ten categories, with, at the most, two years of graduation of superior level in the area of the Health and Social Service, : Nursing, Pharmacy, Physiotherapy, Speech Therapy, Medicine, Nutrition, Dentistry, Psychology, Social Service and Occupational Therapy.

To reach the objective, former participants,from the 2005-2007 administration took part, and developed their activities together with dieticians, totaling 13 individuals, chosen in random draw. The participants were: a physician, a nurse (tutor), a physiotherapist, a speech therapist, an occupational therapist, a pharmacist, a dentist and six dieticians (residents).

The present study is the exploratory, descriptive, analytical, traverse cut type, with qualitative approach. The data were collected in 2008, instrument of collection: semistructured interview with equal contents for all participants. The main subjects contemplated in the study, that relate the dietician´s performance in the Family Health Strategy (ESF) were: a) In your conception, which is the dieticians's performance in Family Health Units? b) starting from the experience with the dietician's performance, do describe a situation that you witnessed which demonstrates that professional's performance.

The interviews were recorded and transcribed integrally, and analyzed later with base in the Analysis of Content, whose objective is to obtain indicators that allow the inference of relative knowledge to the production conditions / reception of a group of messages, through systematic and objective procedures. Facing the presuppositions of the content analysis technique, the thematic analysis was chosen, for noticing that the use of the theme, while unit of analysis for the interpretation of answers of certain groups of people, results in great number of answers permeated by different meanings¹⁵15 Franco MLPB. Análise de conteúdo. 2a ed. Brasília (DF): Líber Livro; 2007..

The analysis of the data respected the following precepts: pre-analysis, definition of the units of analysis (unit of context and unit of registration) and analysis categories. The criteria of semantic categorization was chosen, as the "proposal was to select categories, containing them according to the meaning of the themes, later confronted with discoveries of other investigations on the subject"¹⁵15 Franco MLPB. Análise de conteúdo. 2a ed. Brasília (DF): Líber Livro; 2007. (p. 62). All of the categories found in the research emerged of the interviewees' speeches, not having been, therefore, created a priori.

To preserve the participants' identity, they were numbered by sequential order from 1 to 13 and their speeches also marked by sequential order in agreement with the unit of registration, for instance: interviewee 1 - unit of registration 15 (E1 - UR15).

The study had approval of the Commission of Ethics in Research of Faculdade Santa Marcelina, institution that authenticates the Multiprofessional Residency in Family Health, of the Committee of Ethics in Research of the Federal University of São Paulo and accepted through the Term of Free and Illustrious Consent, signed by the participants of the study.

Results and discussions

The participants of this health study are predominantly female(92,3%), with age between 25 and 35 years. Referring to the period of graduation of the subjects, 53,8% (n = 7) graduated about four years ago; 23,1% (n = 3) concluded the university three years ago, followed by 7,7% of graduated professionals, five (n = 1), seven (n = 1) and 11 (n = 1) years.

Upon questioned regarding higher educational levels, 100% of specialists were found, also unanimous in the participation of the Multiprofessional Family Health Residency Program, lato sensu character. At the time of the research, only three professionals (23,1%), participants of the study, worked in the Family Health Strategy, for ten, four or two years. The others awaited selective process or they had changed their field of performance.

The questions presented in this study brought forward the interviewees' conception regarding the dietician´s performance in Family Health Strategy (ESF), considering her experience during the Multiprofessional Residency in Family Health period.There were 68 units of context, that resulted in 111 units of registration, of which, six analysis categories emerged: No clear understanding of the dietician's performance; Valorization of the specific performance; Enlarged vision of sceneries of performance; Performance in the promotion and prevention; Performance in the multiprofessional perspective;Performance enhanced by the dynamics of the work process of Family Health Strategy ( ESF). To proceed, each category is presented and discussed in the light of scientific literature.

No clear understanding of the dietician's performance

The speeches indicate that the dietician's performance is still little known. It is important to point out that as 46,2% (n = 6) of the interviewed were dieticians, the answers could express the need the professionals themselves had who to have their attributions known and be recognized by others of the health team. However, when analyzing the data not differentiating the professions, it is noticed that this professional's presence can take the service to a broader range, independently of the complexity or care line that the user is at that time. The speeches analyzed show that the incipient understanding certainly is potentiated by the professional's absence in FHS (ESF), echoing in the difficulty, in some moments, of understanding which activities are, in fact, pertinent to the dietician's performance, as this professional, at the moment of the study was inserted only in the masters degree program.

Another point learned concerns the difficulty of developing actions when the way to proceed is ignored, in other words, lack of direction for the performance in FHS ( ESF), for specific activities (area of Nutrition) as for the other professionals' little understanding, although inserted in that strategy, thus, sometimes, limiting development of actions. It is worth to point out that the subcategory entitled lack of direction for the performance is intimately linked to the absence the professional dietician in the Strategy of the Family during development of Multiprofessional Residency, when collecting this data. Therefore this professional's absence as integral part of FHS (ESF) showed the inexistence of a structured work to which the resident could relate to in order to develop or to improve daily actions. This lead for development of activities was created starting from the local demand and actions proposed by the National Politics of Feeding and Nutrition.

The nutritionist's small insert in ESF was considered by Santos¹³13 Santos AC. A inserção do nutricionista na estratégia da saúde da família: o olhar de diferentes trabalhadores da saúde. Fam Saude Desenv. 2005; 7(3):257-65. as one of the reasons of the lack of knowledge of their functions and attributions by other professionals, even considering the current epidemic profile of the Brazilian population, characterized by the frightening growth of not transmissible chronic diseases, nutritional deficiencies and its close relationship with unhealthy life habits and feeding ⁸8 Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília (DF): MS; 2011.^,1616 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Matriz de ações de alimentação e nutrição na Atenção Básica à Saúde. Brasília (DF): MS; 2008..

Such data are concurrent to a survey accomplished by Federal Council of Dieticians¹⁷17 Conselho Federal de Nutricionistas. Notícias. 3ª Conferência Nacional de SAN [Internet]. Brasília: Conselho Federal de Nutricionistas;2007 [acesso 2015 Jan 9]. Disponível em: http://www.cfn.org.br/eficiente/sites/cfn/pt-br/site.php?secao=noticias&pub=166
http://www.cfn.org.br/eficiente/sites/cf... , which verified that the area of inclusion of Regional Council of Dieticians (CRN7), which contemplates the states of Pará, Rondônia, Roraima, Amazon, Amapá and Acre, is where the largest indice of the dietician's insert,19%, is verified in Public Health. In spite of considering this very low percentage, this value still more expressive if compared to other areas where the frequency is inferior to 12%. This fact was also verified in the research accomplished by Akutsu¹⁸18 Akutsu RC. Brazilian dieticians: professional and demographic profiles. Rev Nutr. 2008; 21(1):7-19.. Of the 587 Brazilian dieticians that participated in the study, only 60 work in the area of Public Nutrition.

The mentioned studies reinforce this professional's small insert in Public Health. It is important to mention that, in this area, no works were found demonstrating how many dieticians act specifically in FHS(ESF) throughout Brazil. These numbers are altered now in view the creation of the Nucleus of Support to the Family Health (NASF), where it is possible to insert this professional. NASF is constituted by a multiprofessional team, acting directly in the support to teams and in the family health unit, with the objective of enlarging the coverage and the focus of the actions of basic attention, improving the quality and the resoluteness of the attention to health¹⁹19 Barros CML, Farias Junior G. Avaliação da atuação do nutricionista nos Núcleos de Apoio à Saúde da Família (NASF) do município de Picos/PI. Rev Saude Des. 2012; 1(1):1..

In 2005, Federal Council of Dieticians²⁰20 Conselho Federal de Nutricionistas. Resolução - CFN n° 380/2005, de 28 de dezembro de 2005. Dispõe sobre a definição das áreas de atuação do Nutricionista e suas atribuições. Estabelece parâmetros numéricos de referência, por área de atuação, e dá outras providências [Internet]. Brasília (DF): CFN; 2005 [acesso 2008 Jun 6]. Disponível em: http://nutricao.saude.gov.br/documentos/resolucao_cfn_380.pdf
http://nutricao.saude.gov.br/documentos/... established the dieticians's attributions in several fields of performance, in which the Public Health is included, considering FHS(ESF) as integral of this scenery. It is fact that the resolution emitted by FCD (CFN) represented an important gain for the profession; however, when the reports point out the lack of direction to act in FHS (ESF), they refer to the difficulty of developing these attributions, as there are hardly any guidelines on how to act specifically in this strategy. For Boog²¹21 Boog MCF. Atuação do nutricionista em saúde pública na promoção da alimentação saudável. Cienc Saude. 2008; 1(1):33-42., in spite of the resolution in force, it is necessary to consider that the institutionalization process depends on the creation of a new reality of performance.

As such, Santos¹³13 Santos AC. A inserção do nutricionista na estratégia da saúde da família: o olhar de diferentes trabalhadores da saúde. Fam Saude Desenv. 2005; 7(3):257-65. punctuates the moment of the Residency in Family Health as opportune for the dietician's performance in teams of family health , to divulge their actions and to enlarge work field. This new area of performance should allow that the professional demonstrates detachment, daring, involvement and creativity.

Valorization of the specific performance

Although the FHS ( ESF) constitutes a field of performance in which the multiprofessional work is fundamental, the interviewees' speeches emphasize the need of specific performance as primordial point in the actions developed by the dietician,as her specificity brings a technical knowledge pertaining to the profession. Let us see some:

The prominences of the reports regarding the dietician's specific knowledge come to the encounter of the competences foreseen in her formation which contemplate, among other standpoints, the capacity to evaluate, to diagnose and to accompany the nutritional state; to plan, to prescribe, to analyze, to supervise and to evaluate diets and dietary supplements for healthy and sick individuals, as well as to accomplish diagnosis and interventions in the area of feeding and nutrition, considering the sociocultural and economical influences that determine the availability, the consumption and the biological use of the foods by the individual and by the population²²22 Conselho Nacional de Educação. Câmara de Educação Superior. Resolução CNE/CES 5/2001. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Nutrição. Diário Oficial da União. 9 Nov 2001. Seção 1, p. 39..

With the dieticians specific knowledge, looking at situations that involve the feeding and nutrition, it becomes much easier to detect problems in that area. In study developed by Santos¹³13 Santos AC. A inserção do nutricionista na estratégia da saúde da família: o olhar de diferentes trabalhadores da saúde. Fam Saude Desenv. 2005; 7(3):257-65., physicians and nurses refer that, with the dietician's insert, there is an improvement in the attention to the user, as the interviewees mentioned difficulties in approaching subjects related to the feeding and nutrition.

Assis¹²12 Assis AMO. O programa saúde da família: contribuições para uma reflexão sobre a inserção do Nutricionista na equipe multidisciplinar. Rev Nutr. 2002; 15(3):255-66. reaffirms this fact when looking at the dietician as a professional with relevant participation in FHS (ESF),as she possesses specific knowledge that is an instrument to observe sociocultural values, to accomplish diagnosis and like this to propose the proper dietary orientations, always appropriate to the family reality.

Considering the demand originating from the epidemic and nutritional transition that is closely associated to inadequate alimentary habits, mainly starting from the decades of eighty and ninety, with low consumption of fibers and micronutrients and excessive ingestion of saturated fats ¹⁰10 Levy-Costa RB, Sichieri R, Pontes NS, Monteiro CA. Disponibilidade domiciliar de alimentos no Brasil: distribuição e evolução (1974-2003). Rev Saude Publica. 2005; 39(4):530-40., it is primordial that the dietician develop constant support for the promotion of healthy feeding, culminating in the prevention and treatment of obesity and other nutricional disturbances ⁸8 Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília (DF): MS; 2011..

Considering this situation and based on the dietician´s technical knowledge, it is necessary to plan for preventive actions against the diseases related to the feeding and nutritional interventions, seeking to promote a better nutritional state of the population, in which the work with other professionals only increases and potentiates the results.

The dietician working with the multiprofessional team should act as other professionals' model, as articulator of action strategies, together with the social equipments of the area of territorial inclusion, contributing to promotion of healthy feeding, of Alimentary and Nutritional Safety and to the Human Right to Adequate Feeding¹⁶16 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Matriz de ações de alimentação e nutrição na Atenção Básica à Saúde. Brasília (DF): MS; 2008..

Considering FHS (ESF) as a strategy for the promotion of life quality, Assis¹²12 Assis AMO. O programa saúde da família: contribuições para uma reflexão sobre a inserção do Nutricionista na equipe multidisciplinar. Rev Nutr. 2002; 15(3):255-66. reinforces that an attendance of health where objective is to transform the history of the alimentary practices and of intervention results, cannot be developed without the dietician's performance.

Ample vision of performance sceneries

The speeches of the subjects also allow to observe an enlarged vision of sceneries of performance in which the dietician can contribute adding their knowledge to a range of activities, all within the wide structure of actions developed by ESF.

It is expected that the dietician exercises her attributions in several sceneries of performance, because she is considered a professional qualified to act, ensuring the alimentary safety and dietary attention, in all areas of the knowledge where feeding and nutrition are fundamental²⁰20 Conselho Federal de Nutricionistas. Resolução - CFN n° 380/2005, de 28 de dezembro de 2005. Dispõe sobre a definição das áreas de atuação do Nutricionista e suas atribuições. Estabelece parâmetros numéricos de referência, por área de atuação, e dá outras providências [Internet]. Brasília (DF): CFN; 2005 [acesso 2008 Jun 6]. Disponível em: http://nutricao.saude.gov.br/documentos/resolucao_cfn_380.pdf
http://nutricao.saude.gov.br/documentos/... .

Enlarging sceneries of performance in Public Health, a whole range of possibilities open up, allowing education regarding feeding and nutrition, populational diagnosis of the alimentary and nutritional situation, incentive to the production and the consumption of healthy foods produced regionally and attendance for diseases related to feeding and nutrition²³23 Silva NFS. O nutricionista na Atenção Básica [Internet]. Brasília (DF): Conselho Federal de Nutricionistas; 2008 [acesso 2009 Jun 2]. Disponível em: http://www.cfn.org.br/novosite/arquivos/artigo_atencao.pdf
http://www.cfn.org.br/novosite/arquivos/... .

These attributions can be developed in FHS(ESF), recognizing the territory as a suitable place for such, always considering the community spaces, working with the intersectoriality and with multiprofessional approach.

The amplitude of these sceneries of the dietician's performance in the primary attention answers to the demand of responsibility of promoting the teaching of healthy alimentary practices to the services and teams of health, established by the National Politics of Feeding and Nutrition and for the National Politics of Promotion of the Health, added to the guidelines of FHS (ESF) that aims for promotion of health and prevention of damages.

Performance in the promotion and prevention

The speeches revealed, in a predominant way, that the work aiming at promotion and prevention is what is expected of a dietician´s performance. They consider that she should further contemplate actions in the sense of promoting the people's understanding of the healthy lifestyle, possibly reducing or avoiding damages to the health, extrapolating the assistance character, based on need to educate and to guide for promotion of health and prevention of diseases.

To manage to develop the promotion premises and prevention, the units of registration bring, in a very expressive way, the need of diversity of education strategies as tool used by the dietician, responsible for trying to modify alimentary habits or to make people understand the need to improve them.

Based on the reports that defend the dietician's participation in promotion actions and prevention, the need to understand these two terms appears : in the prevention , they are considered actions to privilege interventions to avoid the emergence of specific diseases. In that perspective, they should minimize the incidence and the prevalence of diseases associated to malnutrition in the populations, aiming to control the transmission of infectious diseases and to promote the reduction of risk of degenerative diseases²⁴24 Czeresnia D. The concept of heath and the difference between prevention and promotion. Cad Saude Publica. 1999; 15(4):701-9.. Dealing with promotion to health, there is an enlarged vision, considering actions addressed not to a specific disease, but with the purpose of contributing to health and social well-being.

Though, the prevention differentiation and promotion is still little understood due to the way they occur, and, for Czeresnia²⁴24 Czeresnia D. The concept of heath and the difference between prevention and promotion. Cad Saude Publica. 1999; 15(4):701-9., some projects of promotion of health also use concepts of disease, transmission and risk, same subject, therefore, of the prevention.

The social changes, politics and cultural, the exhaustion of biomedical paradigm and the change of the epidemic profile urgently require the proposal of Promotion to the Health, fundamental that the strategies used adapt to the local needs and the possibilities of each area, always observing the diversities in their social, cultural and economical systems.

Facing the large demand under the care of the primary attention, Silva²³23 Silva NFS. O nutricionista na Atenção Básica [Internet]. Brasília (DF): Conselho Federal de Nutricionistas; 2008 [acesso 2009 Jun 2]. Disponível em: http://www.cfn.org.br/novosite/arquivos/artigo_atencao.pdf
http://www.cfn.org.br/novosite/arquivos/... and Santos¹³13 Santos AC. A inserção do nutricionista na estratégia da saúde da família: o olhar de diferentes trabalhadores da saúde. Fam Saude Desenv. 2005; 7(3):257-65. consider that the main problems of health in Brazil could be avoided by preventive measures, as prevention, control and treatment of damages to health are intimately linked to the individuals' nutrition, recognizing the relevance of the dietician's participation, considering her dedication to the promotion of healthy feeding,with intention to avoid the aggravation of not transmissible chronic diseases.

Recognizing this important function, recently Ministry of Health launched the Matrix of Actions of Feeding and Nutrition in the Basic Attention of Health, whose purpose is to guide the dietician through specific technical knowledge on how to proceed in the promotion actions and prevention in health for the subject of the actions (individual, family and community), regarding the intervention levels that contemplate the administration of the feeding actions and Nutrition and, also, in what refers to the nutritional care, understanding diagnosis, promotion of health, prevention of diseases, treatment, care and assistance¹⁶16 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Matriz de ações de alimentação e nutrição na Atenção Básica à Saúde. Brasília (DF): MS; 2008.. These actions should be developed in the whole life cycle, because nutritional exposures, environmental and growth patterns during the intrauterine life and in the first years of life can relate directly to the conditions of health in adulthood⁹9 Coutinho JG, Gentil PC, Toral N. A desnutrição e obesidade no Brasil: o enfrentamento com base na agenda única da nutrição. Cad Saude Publica. 2008; 24 Supl 2:332-40..

Performance in the multiprofessional perspective

The work accomplished together with other professionals emerges as other important practice in the scope of the dietician's performance. The actions, whether consultations, home visits, educational groups, among other, during the period of FHMR (RMSF), would be accomplished with the multiprofessional interface allowing to enlarge and to qualify this professional's performance.

Czeresnia ²⁴24 Czeresnia D. The concept of heath and the difference between prevention and promotion. Cad Saude Publica. 1999; 15(4):701-9. pointed out the precepts of the multiprofessionality when considering primordial that professional develop their activities based on the delimitation of the problems, which will make it possible to implement effective practices, because, otherwise, the focus will be restricted to her specialty.

When looking to enlarge the view over the specificity, the need of experience with other professionals appears. The manner and intensity of the interaction among the professions will entitle and characterize its structure of performance.

For Ceccim and Feuerwerker²⁵25 Ceccim RB, Feuerwerker LCM. Mudança na graduação das profissões de saúde sob o eixo da integralidade. Cad Saude Publica. 2004; 20(5):1400-10., to consider the complex phenomenon, in this case the process health-disease, reinforces the need of a performance in which the teams interact multiprofessionally, as model of health centered in the user and his/her family, as the FHS (ESF), imposes the ressignification of the work process for the integrality, fundamental with an appropriate work of the multiprofessional team.

In this perspective, to aim for development of programs that contemplate the model of multiprofessional, performance, can, for Gil²⁶26 Gil CRR. Formação de recursos humanos em saúde da família: paradoxos e perspectivas. Cad Saude Publica. 2005; 21(2):490-8., characterize opportunity for a reflection, considering alternatives to propitiate review of means for the professionals' formation, aiming at an integrated work, in team, with more effective changes of knowhow and practices, as can be verified in the Multiprofessionai Residencies.

The dietician finds space in multiprofessional work, sharing her knowledge regarding the nutritional care in the basic attention, contributing to effectiveness of actions of Nutrition, with base in the shared construction of knowledge¹⁶16 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Matriz de ações de alimentação e nutrição na Atenção Básica à Saúde. Brasília (DF): MS; 2008., considering the dimension of nutrition in the individual's life / family / community. Benefits from the know-how of other professionals, improving her specificity and enlarging her knowledge.

Performance enhanced by the dynamics of the work process in Family Health Program

The interviewees observed,that the dietician's performance was potentiated when considered the dynamics of work of FHS (ESF), due to the bond formation with the user, his/her family and community. It is also emphasized that to act with other professionals, of the minimal team (physician, nurse, nurses aid , community agent of health) or enlarged, dentist, physiotherapist, occupational therapist, speech therapist), strengthens the dietician's performance.

By acting in FHS ( ESF) the dietician learned the guidelines of this program that develop guided by the substitutive character, in which the new work process leaves the conventional practices behind and establishes itself centered in the surveillance in health; works with the integrality and hierarchization, so that the family health unit is inserted in the first level of actions and services of the local system of health and it accomplishes actions in an integral way; it develops its practices of health considering the territory range and always with the aid of a multiprofessional team⁶6 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília (DF): MS; 2006..

As well as other professionals of FHS ( ESF), the resident nutritionist can develop actions that extrapolate her specificity for several reasons, among them: the experience in the territorialization process and mapping of the adjoining area , identifying groups, families and individuals exposed to risks; to accomplish cares in health of that population, also considering community spaces; to notify diseases and activate search; to develop, to plan and to evaluate actions of the team of health with base in the survey of available information, among others⁶6 Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília (DF): MS; 2006..

Besides, the proposal of the reception is added, responsabilization and work about the needs of health, propitiating the professionals that there develop their work opportunity to establish more satisfactory, human, committed and effective relationship, close to the population²⁷27 Feuerwerker LCM. Impulsionando o movimento de mudanças na formação dos profissionais de saúde. Olho Mágico Enfoque [Internet]. 2001 [acesso 2009 Jun 11]; 8(2). Disponível em: http://www.ccs.uel.br/olhomagico/v8n2/index.html
http://www.ccs.uel.br/olhomagico/v8n2/in... .

These relationships established in FHS (ESF) permit the interaction with the individual and the community, allow to know their needs through the bond established and of a focus not only targeted to the individual, but for her family, which becomes object of attention.

Machado et al.²⁸28 Machado NMV, Viteritte PL, Goulart DAS, Pinheiro ARO. Reflexões sobre saúde, nutrição e a estratégia de saúde da família [acesso 2009 Jun 20]. Disponível em: http://nutricao.saude.gov.br/documentos/noticia_01_09_06.pdf
http://nutricao.saude.gov.br/documentos/... considered the relevance of this bond during experience observed in a Multiprofessional Family Health Residence, where this aspect permitted the dietician to develop successful promotion actions to the health in what refers to the sensitivity and the users' empowerment.

Final considerations

The Family Health Program, strategy for consolidation of Unique Health System (SUS), appears as fundamental field for the dieticians's performance, permitting approach with assumptions that anchor that strategy, as well as her insert in a Multiprofessional Family Health Residency Program.

In the coexistence with the other professionals, the dietician was seen as promotion agent to health and prevention of damages in the wide range of sceneries that FHS ( ESF) allows to develop strategies. The valorization of her specific knowledge became relevant due to her differentiated view for nutrition and her close relationship with the cultural, social and psychological factors.

On the other hand, the structure of the Residence, added to the work process of FHS ( ESF), allowed this professional to develop actions that extrapolated her specificity, resulting in an enhancment of performance, permitting to enlarge views and practices through the multiprofessional experience.

In spite of the report that there is little understanding of the dietician's performance in FHS (ESF), is believed that this vision can be modified, with this professional's insert in other areas, besides the multiprofessional residences. It is seen as an opportunity because of the implantation of the Nuclei of Support to the Family Health, which suggest the dieticians's presence, considered necessary as per the epidemic and nutritional profile of Brazil.

The experience of the dieticians's insert in the Family Health Program, through the Multiprofessional Residecy in Family Health, allowed exercise, in practice,of precepts demanded in her profile, in other words, the program aimed to develop an overall formation , humanistic and critical, enlarging knowledge, abilities and sufficient attitudes to act in the diversity of the social, economical, political and educational demands.

However, when considering the several factors that involve an individual's life and of his/her family, it is recommended to look at the nutritionist's actual formation carefully, seeking a greater interprofessionality so that after graduation, that professional may navigate in this new field of performance.

References

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