Abstract

Introduction

Healthcare for older adults in the city of São Paulo, Brazil, is provided at different care levels, and the presence of health services grounded on interprofessional teamwork and collaborative practice enables the provision of care to this population from various perspectives and in an extended way. Services like the Specialty Outpatient Clinics for Older Adults (AME Idoso), the Older Adults Health Reference Units (URSI), and the Older Adults Companion Program (PAI), among others, compose the Older Adults Healthcare Network (RASPI) in the city¹1 São Paulo. Prefeitura da Cidade De São Paulo. Secretaria Municipal de Saúde. Diretrizes da Rede de Atenção à Saúde da Pessoa Idosa [Internet]. São Paulo: Secretaria Municipal de Saúde; 2021 [citado 8 Abr 2024]. Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/upload/saude/DIRETRIZES_RASPI_2021.pdf
https://www.prefeitura.sp.gov.br/cidade/... . Primary healthcare (PHC) plays an important role in this Network for two reasons: it organizes care within different healthcare networks and the Primary Care Units (UBS) are the front door through which users access the health system¹1 São Paulo. Prefeitura da Cidade De São Paulo. Secretaria Municipal de Saúde. Diretrizes da Rede de Atenção à Saúde da Pessoa Idosa [Internet]. São Paulo: Secretaria Municipal de Saúde; 2021 [citado 8 Abr 2024]. Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/upload/saude/DIRETRIZES_RASPI_2021.pdf
https://www.prefeitura.sp.gov.br/cidade/... .

Specifically in PHC, the city of São Paulo has been using, since 2014, the Multidimensional Assessment of Older Adults in Primary Care (AMPI-AB). This set of instruments is constituted of a questionnaire, which contains 17 questions about biopsychosocial aspects of older adults, and functional screening tests, which aid the professionals in the construction of Individual Therapeutic Projects (ITP) and in the referral of patients to different professionals, health services, and sectors - like social assistance -, depending on the identified needs²2 São Paulo. Prefeitura da Cidade De São Paulo. Secretaria Municipal de Saúde. Manual avaliação multidimensional da pessoa idosa na atenção básica AMPI-AB [Internet] São Paulo: Secretaria Municipal de Saúde; 2021 [citado 8 Abr 2024]. Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/upload/saude/MANUAL_AMPI_AB_ATUALIZAO_2021(2).pdf
https://www.prefeitura.sp.gov.br/cidade/... .

Concerning the nutritional status of older adults, the AMPI-AB has a specific question about unintentional weight loss and recommends the assessment of body parameters through body mass index (BMI) and calf circumference (CC), a measurement that assesses muscle mass in older adults and may indicate risk of sarcopenia. If any of these items present alterations, the AMPI-AB recommends an assessment performed by a dietitian²2 São Paulo. Prefeitura da Cidade De São Paulo. Secretaria Municipal de Saúde. Manual avaliação multidimensional da pessoa idosa na atenção básica AMPI-AB [Internet] São Paulo: Secretaria Municipal de Saúde; 2021 [citado 8 Abr 2024]. Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/upload/saude/MANUAL_AMPI_AB_ATUALIZAO_2021(2).pdf
https://www.prefeitura.sp.gov.br/cidade/... .

The AMPI-AB encourages professionals to screen this population for weight loss, considering its potential negative implications for health and quality of life. Unintentional weight loss in older adults is associated with the development of sarcopenia, frailty syndrome, and malnutrition, conditions that can generate an important functional loss, decrease quality of life, and increase morbidity and mortality³3 Chapman IM. Weight loss in older persons. Med Clin North Am. 2011; 95(3):579-93.^,44 Boer A, Horst GJ, Lorist MM. Physiological and psychosocial age-related changes associated with reduced food intake in older persons. Ageing Res Rev. 2013; 12(1):316-28.. Recent world estimates indicate that approximately 25% of older adults (≥ 65 years) are malnourished or at risk of malnutrition, and it is believed that this figure may increase due to the accelerated aging of the world population⁵5 Leij-Halfwerk S, Verwijs MH, Van Houdt S, Borkent JW, Guaitoli PR, Pelgrim T, et al. Prevalence of protein-energy malnutrition risk in European older adults in community, residential and hospital settings, according to 22 malnutrition screening tools validated for use in adults ≥65 years: a systematic review and meta-analysis. Maturitas. 2019; 126:80-9..

The causes of unintentional weight loss and malnutrition are associated with physiological factors (changes in smell, taste, teeth, swallowing, and gastrointestinal motility, among others) and psychosocial factors (depression, social isolation, social vulnerability, and food insecurity, among others), which influence food intake in older adults³3 Chapman IM. Weight loss in older persons. Med Clin North Am. 2011; 95(3):579-93.^,44 Boer A, Horst GJ, Lorist MM. Physiological and psychosocial age-related changes associated with reduced food intake in older persons. Ageing Res Rev. 2013; 12(1):316-28.. Furthermore, the Covid-19 pandemic directly affected older adults’ health when social isolation was required to contain the virus, generating losses to the population’s mental health and family income, and affecting many households in Brazil⁶6 Silva MD Jr. Vulnerabilidades da população idosa durante a pandemia pelo novo coronavírus. Rev Bras Geriatr Gerontol. 2020; 23(3):e200319.^,77 Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023; 401(10380):951-66..

To effectively address the multifactorial nature of unintentional weight loss, the dietitian and various other health professionals must be involved. It is expected that PHC teams such as the Family Health Strategy (FHS) and the Multiprofessional Teams (eMulti, formerly Family Health Support Center - NASF), composed of nurses, physicians, psychologists, dietitians, speech pathologists, audiologists, and physiotherapists, among others, propose individual care strategies grounded on the core knowledge of each profession, bringing positive impacts to the dietary patterns of older adults at nutritional risk⁸8 Brasil. Ministério da Saúde. Política Nacional de Atenção Básica (2017). Portaria nº 2.436 de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 21 Set 2017.

9 Brasil. Ministério da Saúde. Portaria GM/MS Nº 635, de 22 de Maio de 2023. Institui, define e cria incentivo financeiro federal de implantação, custeio e desempenho para as modalidades de equipes Multiprofissionais na Atenção Primária à Saúde. Diário Oficial da União. 22 Maio 2023.^-1010 Taveira A, Sousa B, Costa P, Macedo AP. Health management of malnourished elderly in primary health care: a scoping review. BMC Prim Care. 2022; 23:272.. According to international guidelines, healthcare for malnourished older adults must be supported by a screening routine, performed through specific nutritional risk assessment questionnaires, and by laboratory tests, anthropometric assessment, nutritional guidance for dietary changes, and prescription of oral nutritional supplements (ONS) when necessary⁷7 Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023; 401(10380):951-66.. Relatively simple instruments can be used in PHC, like the Mini Nutritional Assessment (MNA). It has questions about anthropometric measures (weight, height, and weight loss), dietary information (number of meals, food and fluid intake, and self-feeding capacity), global assessment (lifestyle, medication, and functional status), and self-assessment (self-perception of health and nutrition) that can be answered in less than 10 minutes¹¹11 Moraes EN. Atenção à saúde do idoso: aspectos conceituais. Brasília: Organização Pan-Americana da Saúde; 2012..

However, it has been found that nutritional care for older adults with unintentional weight loss is not always a priority for PHC professionals for a number of reasons. International studies have shown that health professionals find it difficult to provide nutritional care for older adults due to a lack of knowledge about the matter, the need to deal with the assisted population’s various health demands, uncertainty about which professional should perform the nutritional screening, presence of high productivity goals that must be met, and short-duration consultations⁷7 Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023; 401(10380):951-66..

Based on the perception that nutritional care for older adults in São Paulo’s PHC is not a priority in health services like the Primary Care Units, the present study aimed to investigate PHC professionals’ perception of the nutritional status of older adults who are users of Primary Care Units in São Paulo, focusing on unintentional weight loss, and to identify possibilities of intervention in this problem by the interprofessional team. The study derives from the master’s thesis authored by the main researcher, who works as a dietitian in a Multiprofessional Team in the central area of São Paulo.

Methods

This qualitative study has an explorative and descriptive nature grounded on the interpretivist and constructivist paradigms, as it seeks to understand relationships between people and their interpretations of reality¹²12 Saccol AZ. Um retorno ao básico: compreendendo os paradigmas de pesquisa e sua aplicação na pesquisa em administração. Rev Adm UFSM. 2009; 2(2):250-69.. The study was structured according to the Standards for Reporting Qualitative Research (SRQR)¹³13 O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014; 89(9):1245-51..

It is important to describe the researchers’ field of activity: the first works as a health professional at a Primary Care Unit in the central area of São Paulo and, at the time of data collection, had been working in the territory for four years. The second researcher is a professor with large experience in research with older adults.

Data collection was carried out in 2019 in two phases: individual interviews followed by a focus group. The target audience was PHC professionals with undergraduate degrees working at Primary Care Units located in the central area of São Paulo. The unit where the main researcher works was excluded from the sample to minimize biases, and the collection was carried out in seven of the territory’s eight units. The participants were indicated by the units’ managers based on the following criteria: two professionals per unit with different academic backgrounds, which would total 14 participants in the two phases of the study. The first phase consisted of individual interviews based on a semi-structured script containing 11 questions about the participants’ perceptions of the healthcare provided for older adults assisted at the region’s units, focusing on those with unintentional weight loss. The questions also approached the challenges and possibilities for the provision of healthcare for this population. The second phase, the focus group, was guided by two questions about the challenges and possibilities related to the provision of care for the studied population. The decision to have different data collection methods aimed to stimulate, first, individual reflections on the subject through the interview script; then, in the focus group, dialog and collective problematization to facilitate a deeper exploration of the topic discussed.

The material collected in the two phases was fully transcribed and submitted to a Thematic Content Analysis so that the researchers could identify central themes, organize them into categories, and make inferences about the studied matter¹⁴14 Bardin L. Análise de conteúdo. São Paulo: Edições 70, Almedina Brasil; 2016.^,1515 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14a ed. São Paulo: Hucitec; 2014.. The themes and categories obtained in the two phases were discussed jointly by the researchers, with content triangulation, to ensure a broader and deeper understanding of the investigated phenomenon and increase the reliability of the results¹⁶16 Zappellini MB, Feuerschütte SG. O uso da triangulação na pesquisa científica brasileira em administração. Adm Ensino Pesq. 2015; 16(2):241-73..

The study was approved by the Research Ethics Committees of the School of Medicine of USP (opinion no. 3.342.422 on May 23, 2019) and the Municipal Health Department of São Paulo (opinion no. 3.382.875 on June 11, 2019). All the participants were invited to read the Informed Consent Form before the interviews. Upon acceptance to participate in the two phases of the study, they signed two copies of the form.

Results

The individual interviews were conducted between August and October 2019, and the focus group, in October 2019. Table 1 presents the participants’ demographic data, academic background, and professional practice in the two phases of the study. Fourteen professionals were interviewed; however, in the interval between the two phases of the study, three professionals ceased to work in the health services (two dietitians and one nurse), and the managers were asked to indicate three other participants to compose the sample, totaling 17 interviews. In the second phase, the focus group, 14 professionals were expected but only 12 showed up: one nurse and one physician justified their absence by stating that their participation might affect their productivity goals. Professionals from eight categories participated, mostly nurses, of the female sex, with interprofessional experience in their undergraduate courses, and between 1 and 5 years of work in PHC.

Tables 2 and 3 present the results of the thematic content analysis of the interviews, which resulted in 11 themes (Table 2), and of the focus group, which resulted in 5 themes (Table 3), 4 of which were similar to those identified in the interviews.

Regarding the main theme of the study, the provision of care for older adults with unintentional weight loss, some professionals, both in the interviews and in the focus group, informed that they had never thought about it and did not usually identify older adults with this condition in their practice, even though they noticed that the AMPI-AB, an instrument they frequently use in their work routines, has a specific question about the matter. Despite the non-identification of cases, the participants described possible factors associated with unintentional weight loss, such as severe diseases that generate catabolism of body tissues (like cancer or tuberculosis) and social vulnerability (like situations of violence, neglect, and food insecurity).

Concerning the healthcare demand of the older population that attends primary care units, the professionals reported that the greatest actions are related to chronic noncommunicable diseases (CNCD), usually in group approaches to systemic arterial hypertension (SAH) and diabetes mellitus (DM).

A series of challenges related to older adult care, including those with unintentional weight loss, were broadly discussed in the two phases of the study, such as insufficiency of financial and family support, social isolation, and non-adherence to offers of care. Challenges related to the work process were also observed, like the short duration of medical and nursing consultations, high productivity goals, and problems like scheduled activities being canceled because of priority actions such as vaccination campaigns (at the time the study was being conducted, the State of São Paulo was facing an outbreak of measles). The PHC workers’ psychological suffering emerged in the participants’ discourses in the two phases of the study, especially related to the challenges of the work process. The participants also mentioned stress and burnout among Community Health Agents (CHA), a category with a high level of professionals in the primary care units.

The professionals reflected on possibilities of assistance in PHC for older adults with unintentional weight loss, like the use of the units’ own work devices (consultations and home visits) and meetings to discuss cases. In addition, they emphasized the importance of Matrix Support and Permanent Health Education to increase their knowledge about the theme. The Group Approaches were mentioned many times as a possibility of care for older adults, as they often frequent these spaces. Longitudinality of care in the groups allows the identification of health changes like unintentional weight loss.

Another matter approached in the study phases was the importance of nutritional care for addressing the problem, provided as guidelines on adequate and healthy eating. The dietitian emerged as a fundamental professional to health management and education. The use of oral nutritional supplements was informed as a possibility of care in the context of unintentional weight loss and its outcomes; however, they are not provided in the health services and their cost is high.

Interprofessional action supported by NASF teams and the sharing of cases between the RASPI services, like URSI and PAI, were broadly debated by the participants as spaces to discuss complex cases and share information on nutritional care for older adults assisted at the same time by these services. In addition, intersectoral care for older adults, represented by a partnership between Health and Social Work, emerged in the two phases of the study, highlighting its importance in the fight against vulnerability and food insecurity.

The professionals considered that the Home Meal Service for Older Adults (SADPI), which delivers meals to the homes of vulnerable older adults, or the “Bom Prato” (Good Meal) Popular Restaurants, which offer low-cost meals, are fundamental to increase this population’s food and nutritional security. However, regarding SADPI, some participants expressed concern related to the fact that meals are delivered only on business days and there are no meals adapted to diabetics or people with chewing difficulties.

Discussion

The identified profile of the study participants shows that care activities continue to be performed by women, either receiving payment for them as health professionals, or not, as informal caregivers of older adults and children in their families. Such disparity justifies the lingering difficulties related to the inclusion of women in the labor market and reinforces social stigmas about the roles played by men and women in society¹⁷17 Küchemann BA. Envelhecimento populacional, cuidado e cidadania: velhos dilemas e novos desafios. Soc Estado. 2012; 27(1):165-80..

The PHC professionals’ difficulty in identifying older adults with unintentional weight loss raises concerns and has been observed in the international literature. Research carried out in different countries has shown that PHC professionals report difficulties in identifying older adults’ malnutrition due to challenges like the short duration of consultations, high productivity goals, lack of knowledge about nutritional care, and focus on health actions targeted at combating overweight, not malnutrition⁷7 Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023; 401(10380):951-66.^,1818 Castro PD, Reynolds CM, Kennelly S, Clyne B, Bury G, Hanlon D, et al. General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: a qualitative study. Clin Nutr ESPEN. 2020; 36:116-27.^,1919 Avgerinou C, Bhanu C, Walters K, Croker H, Tuijt R, Rea J, et al. Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals. Br J Gen Pract. 2020; 70(691):e138-45.. In this aspect, it is worth highlighting the importance of the AMPI-AB in helping professionals from different areas identify changes in older adults’ nutritional status. Another important aspect is that the participants did not mention calf circumference (CC), a simple measurement included in the AMPI-AB that can be easily used in PHC assistance and home visits.

Length of service in PHC ranging from 1 to 5 years, as reported by most of the study participants, reflects the high turnover of professionals, a situation that affects the provision of care for users. Attributes like longitudinality and continuity of care, required in this level of healthcare, are necessary for the PHC teams to be acquainted with the assisted population and able to identify and provide effective care for older adults with unintentional weight loss⁸8 Brasil. Ministério da Saúde. Política Nacional de Atenção Básica (2017). Portaria nº 2.436 de 21 de Setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 21 Set 2017..

Although the professionals have difficulties to identify unintentional weight loss in their work routine, they reflected on possible causes of the problem. Situations of violence and neglect related to older adults were broadly discussed in the two phases of the study, which shows that such situations generate concern and demand efforts from the PHC teams. Unfortunately, it is common for this population to experience violence and neglect of care in family settings and public spaces. Informal caregivers of older adults, like relatives, often are not adequately prepared to play this role and feel overloaded, as well as mentally and physically stressed. Policies from different sectors are still necessary for the creation of caregiver programs by the State¹⁷17 Küchemann BA. Envelhecimento populacional, cuidado e cidadania: velhos dilemas e novos desafios. Soc Estado. 2012; 27(1):165-80.. Beyond overloaded caregivers, neglect and violence against older adults originate in cultural paradigms of depreciation regarding the aging process. Usually, older adults are despised and marginalized by society because they are considered unproductive, dependent (in economic, familial, and health aspects), and obsolete from the cultural point of view, based on the mistaken idea that they cannot assimilate new worldviews and attitudes²⁰20 Minayo MCS. Violência contra idosos: o avesso de respeito à experiência e à sabedoria. Brasília: Secretaria Especial dos Direitos Humanos; 2005..

Aspects like social isolation, depression, and financial vulnerability, which affect many older adults in the central area of São Paulo, interfere with this population’s food intake due to difficulties concerning food acquisition and preparation, which may lead to unintentional weight loss and health problems. These aspects were intensified in the Covid-19 pandemic. The need to implement social isolation to contain the health emergency increased anxiety and sadness indexes in older adults and aggravated food insecurity in the Brazilian population⁶6 Silva MD Jr. Vulnerabilidades da população idosa durante a pandemia pelo novo coronavírus. Rev Bras Geriatr Gerontol. 2020; 23(3):e200319.^,2121 Romero DE, Muzy J, Damascena GN, Souza NA, Almeida WS, Szwarcwald CL, et al. Idosos no contexto da pandemia da Covid-19 no Brasil: efeitos nas condições de saúde, renda e trabalho. Cad Saude Pública. 2021; 37(3):e00216620.^,2222 Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar e Nutricional. Insegurança alimentar e Covid-19 no Brasil. Inquérito Nacional sobre insegurança alimentar no contexto da pandemia da Covid-19 no Brasil [Internet]. Rio de Janeiro: Rede PENSSAN; 2021 [citado 8 Abr 2024]. Disponível em: https://olheparaafome.com.br/VIGISAN_Inseguranca_alimentar.pdf
https://olheparaafome.com.br/VIGISAN_Ins... .

Addressing food insecurity in Brazil is urgent, especially in the post-pandemic period. In the central area of São Paulo, some units of the state-run “Bom Prato” Popular Restaurants created special strategies to operate during the pandemic, aiming to assist vulnerable populations²³23 São Paulo. Secretaria de Desenvolvimento Social. Bom Prato passa a servir refeições gratuitas para pessoas em situação de rua cadastradas durante a pandemia da Covid-19 [Internet]. São Paulo: Secretaria de Desenvolvimento Social; 2020 [citado 8 Abr 2024]. Disponível em: https://www.desenvolvimentosocial.sp.gov.br/bom-prato-passa-a-servir-refeicoes-gratuitas-para-pessoas-em-situacao-de-rua-cadastradas-durante-a-pandemia-da-covid-19/
https://www.desenvolvimentosocial.sp.gov... . In addition, in the central area of São Paulo, there is the Home Meal Service for Older Adults (SADPI), linked to the Municipal Department of Social Assistance and Development, which delivers, on business days, meals composed of lunch and soup for older adults experiencing food insecurity due to social vulnerability or mobility impairments²⁴24 Instituição Beneficente Israelita Ten Yad. Alimentação Domiciliar para Pessoa Idosa [Internet]. São Paulo: Ten Yad; 2022 [citado 8 Abr 2024]. Disponível em: https://tenyad.org.br/alimentacao-domiciliar-para-pessoa-idosa/
https://tenyad.org.br/alimentacao-domici... . Other countries have similar programs called “Meals on Wheels”²⁵25 Thomas KS, Gadbols EA, Shleld RR, Akobundu U, Morris AM, Dosa DM. “It’s not just a simple meal. it’s so much more”: interactions between meals on wheels clients and drivers. J Appl Gerontol. 2020; 39(2):151-8.. As far as we know, SADPI currently is the only service that delivers meals to older adults’ homes in the city of São Paulo.

Despite the teams’ efforts to deal with unintentional weight loss and its complications, older adults’ non-adherence to healthcare was mentioned many times by the participants, as it interferes with the therapeutic project. This situation is also common among older adults in other countries: in England, for example, PHC professionals have observed that older adults often do not adhere to guidelines for addressing malnutrition because the orientations they received for many years focused on dietary practices for managing overweight and obesity, which is significantly different from the orientations to address malnutrition²⁶26 Avgerinou C, Bhanu C, Walters K, Croker H, Liljas A, Rea J, et al. Exploring the views and dietary practices of older people at risk of malnutrition and their carers: a qualitative study. Nutrients. 2019; 11(6):1281.. This type of guidance, which is crystallized in society and the area of health, tends to minimize the problem of malnutrition among older adults, who may even avoid speaking about it during healthcare assistance²⁶26 Avgerinou C, Bhanu C, Walters K, Croker H, Liljas A, Rea J, et al. Exploring the views and dietary practices of older people at risk of malnutrition and their carers: a qualitative study. Nutrients. 2019; 11(6):1281.^,2727 Geraghty AA, Browne S, Reynolds CME, Kennelly S, Kelly L, McCallum K, et al. Malnutrition: a misunderstood diagnosis by primary care health care professionals and community-dwelling older adults in Ireland. J Acad Nutr Diet. 2021; 121(12):2443-53..

The findings of this study showed that the complexity of the challenges discussed here generates psychological suffering among the participants. Especially in the focus group, the professionals extensively debated their concerns and anguish regarding the recurring difficulties and problems of the work process. The shortage of human and physical resources to deal with routine adversities has led workers to feel stress and emotional exhaustion. Many of them have developed conditions like anxiety and Burnout Syndrome²⁸28 Ribeiro SFR, Martins STF. Sofrimento psíquico do trabalhador da Saúde da Família na organização do trabalho. Psicol Estud. 2011; 16(2):241-50.. These situations interfere with the quality of the work, and the professionals recognize that they may fail to identify important health conditions like unintentional weight loss in older adults. Similarly, PHC professionals in other countries have reported concerns about the health demands they may fail to identify, like malnutrition in older adults, due to work overload and other priorities in their routine⁷7 Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023; 401(10380):951-66.^,1818 Castro PD, Reynolds CM, Kennelly S, Clyne B, Bury G, Hanlon D, et al. General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: a qualitative study. Clin Nutr ESPEN. 2020; 36:116-27.^,1919 Avgerinou C, Bhanu C, Walters K, Croker H, Tuijt R, Rea J, et al. Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals. Br J Gen Pract. 2020; 70(691):e138-45..

Still regarding the workers’ psychological suffering, the stress experienced by Community Health Agents (CHA) was discussed by the participants and is also discussed in the literature. A study conducted with CHA has shown emotional overload in their routine, as they live in the territories where they work and may have a personal involvement with the assisted patients, which generates anguish and anxiety²⁸28 Ribeiro SFR, Martins STF. Sofrimento psíquico do trabalhador da Saúde da Família na organização do trabalho. Psicol Estud. 2011; 16(2):241-50..

Although work in PHC is marked by many challenges, the interviewees mentioned devices in this level of care, such as group approaches and homecare, that support the assistance provided for the population. Interprofessional work and collaborative practice, which walk together with Matrix Support and Permanent Health Education (PHE), are important possibilities of care for the assisted population, as they allow diversity of ideas and construction of new knowledge. However, the management must stimulate the professionals to use these spaces. Unfortunately, they are often affected by the problems of the work process, which negatively impact communication among professionals and hinder shared assistance in PHC and Specialized Care²⁹29 Lacerda RST, Almeida PF. Desafios da Coordenação do Cuidado na Atenção Primária à Saúde [Internet]. São Paulo: SciELO; 2023 [citado 8 Abr 2024]. Disponível em: https://humanas.blog.scielo.org/blog/2023/09/21/desafios-da-coordenacao-do-cuidado-na-atencao-primaria-a-saude/
https://humanas.blog.scielo.org/blog/202... .

The RASPI and the Intersectoral Network of Services, especially the Older Adults Companion Program and the Social Work services, can aid in the detection and care of unintentional weight loss and address its biopsychosocial causes¹1 São Paulo. Prefeitura da Cidade De São Paulo. Secretaria Municipal de Saúde. Diretrizes da Rede de Atenção à Saúde da Pessoa Idosa [Internet]. São Paulo: Secretaria Municipal de Saúde; 2021 [citado 8 Abr 2024]. Disponível em: https://www.prefeitura.sp.gov.br/cidade/secretarias/upload/saude/DIRETRIZES_RASPI_2021.pdf
https://www.prefeitura.sp.gov.br/cidade/... . An important aspect discussed here is the need for intersectoral work to provide care for older adults in Brazil. Different sectors compose a larger network of services that aim to guarantee rights and healthcare to this population³⁰30 Oliveira AD, Ramos OA, Panhoca I, Alves VLS. A intersetorialidade nas políticas públicas para o envelhecimento no Brasil. Rev Kairos. 2014; 17(2):91-103.^,3131 Dias MAS, Parente JRF, Vasconcelos MIO, Dias FAC. Intersetorialidade e Estratégia Saúde da Família: tudo ou quase nada a ver? Cienc Saude Colet. 2014; 19(11):4371-82.. Almost none of the studies that form the theoretical framework of this research mention that intersectoral work is needed in older adult care.

In addition to the problems in the work process, there are gaps in the participants’ training regarding older adult care in PHC. National studies have shown that PHC nurses, professionals who are extremely important in this level of care, report deficits in their training regarding older adults’ health, and that many of them do not feel equipped to conduct multidimensional assessments³²32 Marques GCS, Rodrigues JS, Rodrigues SG, Souza MR, Barros PS, Borges CJ. Profissional enfermeiro: competências e habilidades para a avaliação multidimensional da pessoa idosa. Rev Kairos. 2018; 21(2):307-26.^,3333 Melo POC, Rozendo CA, Sobral JPCP, Brito FMM. Formação para atuar com a pessoa idosa: percepção de enfermeiras da Atenção Primária à Saúde. Enferm Foco. 2019; 10(2):103-9.. Some participants in this study mentioned they need to acquire knowledge on nutrition and aging from qualified professionals, such as dietitians. Similarly, PHC professionals in Ireland and England have shown insecurity towards technical knowledge on nutrition and aging and reported the need for educational actions to improve the healthcare provided for this population¹⁸18 Castro PD, Reynolds CM, Kennelly S, Clyne B, Bury G, Hanlon D, et al. General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: a qualitative study. Clin Nutr ESPEN. 2020; 36:116-27.^,1919 Avgerinou C, Bhanu C, Walters K, Croker H, Tuijt R, Rea J, et al. Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals. Br J Gen Pract. 2020; 70(691):e138-45..

Nutritional care is fundamental to addressing unintentional weight loss in older adults. We recommend the use of the “Dietary Guidelines for the Brazilian Population”, as it is a document used in the Brazilian National Health System (SUS) to provide the main dietary guidelines for all lifecycles, supported by biological, social, cultural, and environmental dimensions of food consumption. The Guidelines contain simple recommendations that focus on the degree of food processing and value practices like the act of cooking, eating in the company of people, and the regionality of foods³⁴34 Brasil. Ministério da Saúde. Guia alimentar para a população brasileira [Internet]. 2a ed. Brasília: Ministério da Saúde; 2014 [citado 8 Abr 2024]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-brasil/publicacoes-para-promocao-a-saude/guia_alimentar_populacao_brasileira_2ed.pdf
https://www.gov.br/saude/pt-br/assuntos/... . All these aspects are important considering social isolation and the diversity of the places of origin of many older adults who live in the central area of São Paulo. With the purpose of facilitating and enhancing the nutritional orientation in PHC, the “Protocol for using the Dietary Guidelines for the Brazilian Population in the nutritional orientation for older adults” was developed. It presents a flow of guiding questions with orientations to be provided by PHC professionals during assistances³⁵35 Brasil. Ministério da Saúde. Fascículo 2: protocolos de uso do guia alimentar para a população brasileira na orientação alimentar da população idosa. Brasília: Ministério da Saúde; 2021.^,3636 Jesus JGL, Tramontt CR, Santos TSS, Rauber F, Louzada MLC, Jaime PC. Orientação alimentar da pessoa idosa na Atenção Primária à Saúde: desenvolvimento e validação de um protocolo baseado no Guia alimentar para a população brasileira. Rev Bras Geriatr Gerontol. 2021; 24(5):e210157..

The management must encourage the professionals to use these documents, and dietitians can conduct Dietary and Nutritional Education actions for PHC workers, highlighting the singular aspects of older adults’ nutrition. International studies have shown that training in malnutrition in older adults for PHC professionals generated improved knowledge on the subject and enhanced the nutritional care that is provided. The dietitian was considered a key element in the dissemination of specific knowledge³⁷37 Hamirudin AH, Charlton K, Walton K, Bonney A, Potter J, Milosacljevic M, et al. Feasibility of implementing routine nutritional screening for older adults in Australian general practices: a mixed-methods study. BMC Fam Pract. 2014; 15:186.^,3838 Kennelly S, Kennedy NP, Corish CA, Flanagan-Rughoobur G, Glennon-Slattery C, Sugrue S. Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices. J Hum Nutr Diet. 2011; 24(5):496-504..

The use of oral nutritional supplements (ONS), quite common in other countries, is important for addressing malnutrition in older adults. However, English and Irish health professionals have reported difficulties in providing adequate prescriptions due to a lack of knowledge about the matter. They also mentioned some obstacles, like the high cost of ONS⁷7 Dent E, Wright ORL, Woo J, Hoogendijk EO. Malnutrition in older adults. Lancet. 2023; 401(10380):951-66.^,1818 Castro PD, Reynolds CM, Kennelly S, Clyne B, Bury G, Hanlon D, et al. General practitioners’ views on malnutrition management and oral nutritional supplementation prescription in the community: a qualitative study. Clin Nutr ESPEN. 2020; 36:116-27.^,1919 Avgerinou C, Bhanu C, Walters K, Croker H, Tuijt R, Rea J, et al. Supporting nutrition in frail older people: a qualitative study exploring views of primary care and community health professionals. Br J Gen Pract. 2020; 70(691):e138-45.. It is important to mention that there is no official program to provide nutritional supplements for malnourished older adults in São Paulo.

The significant increase in the number of older adults around the world and the complex care demanded by this population, including unintentional weight loss and malnutrition, summon national and international agencies to perform pertinent and interrelated actions. In this perspective, the PAHO, through the document “Decade of Healthy Aging 2020-2030”, has proposed actions of different sectors, such as international agencies, governments, civil society, and the media, among others, so that people can age with dignity, access to work, and high-quality public health, valuing their life experiences and strengthening society³⁹39 Organização Pan-Americana da Saúde. Década do envelhecimento saudável 2020-2030 [Internet]. Brasília: OPAS; 2020 [citado 8 Abr 2024]. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52902/OPASWBRAFPL20120_por.pdf?sequence=1&isAllowed=y
https://iris.paho.org/bitstream/handle/1... .

Conclusion

The study results indicate that, although the PHC professionals understand the possible causes of unintentional weight loss in older adults and its health implications, they still have difficulties in identifying it, especially due to issues related to the work process, like problems in the work routine and the need to meet productivity goals, as studies carried out with PHC professionals in other countries have shown. These issues have generated psychological suffering in health workers. Many challenges to older adult care were identified, such as social vulnerability and its health implications, especially the presence of food insecurity in the central area of São Paulo.

Possibilities of care for older adults with unintentional weight loss were identified by the participants, such as the use of the AMPI-AB results to discuss and develop individual therapeutic projects. Interprofessional care and collaborative practice were also considered valuable possibilities of care to this population, as well as nutritional guidance oriented by dietitians, which can be grounded on the Dietary Guidelines for the Brazilian Population and shared among PHC professionals. We would like to add that calf circumference, although not mentioned by the study participants, is suggested by documents and handbooks published by the Ministry of Health and the municipal government of São Paulo as a measurement to screen weight loss in older adults.

Permanent Health Education was another possibility considered by the participants to address unintentional weight loss in older adults, as well as work conducted jointly by the RASPI and the Intersectoral Network of Services that assist older adults in the city. Finally, further national studies should be carried out to highlight the importance of care for older adults with unintentional weight loss, aiming to avoid negative outcomes and ensure quality of life for this population.

Acknowledgments

To the study participants, for their valuable perceptions about the matter. To Eliana Yogo Yagi and Ademir Alfredo dos Santos, who contributed to data collection. And to Roberto Rubem Silva Brandão, who gave specific contributions to the manuscript concerning the translation of some terms into English.

References

Publication Dates

History