Principal investigator: Viviane Pires Ribeiro
Article title: OBESITY AND PUBLIC POLICIES: THE BRAZILIAN GOVERNMENT'S DEFINITIONS AND STRATEGIES
Article authors: Patricia Camacho Dias, Patrícia Henriques, Luiz Antonio dos Anjos and Luciene Burlandy
Location of the intervention: Brazil
Sample size: 18 documents
Sector: Education
Type of InterventionAnalysis of strategies for tackling obesity in Brazil
Primary variable of interest: Obesity
Evaluation method: Others Document Analysis Method
Evaluation Context
In recent decades, obesity has gained prominence on the national and international public agenda, being characterized as an event of global proportions and increasing prevalence. In Brazil, overweight and obesity affected 56,9% and 20,8% of the adult population in 2013, respectively. Furthermore, overweight and obesity are increasing in all age groups and income levels, especially among the population with lower family incomes.
The increasing prevalence of obesity has been attributed to various biopsychosocial processes, influenced not only by the individual and their choices, but also by the political, economic, social, and cultural environment. In Brazil, obesity has become the subject of public policies, and the Ministry of Health, through the Unified Health System (SUS), is the main proposer of actions, following the international trend.
Between 2011 and 2014, the Interministerial Chamber for Food and Nutritional Security (CAISAN) spearheaded the formulation of the intersectoral plan to combat obesity, supporting an intersectoral strategy that systematizes recommendations for Brazilian states and municipalities. CAISAN, the National Council for Food and Nutritional Security (CONSEA), and the National Conferences are part of the National System for Food and Nutritional Security (SISAN). SISAN was established in 2006 to organize actions implemented by different ministries, encompassing everything from food production to consumption.
Intervention Details
Unlike studies on obesity in Brazil that address the topic from an epidemiological perspective, evaluating the impact of specific measures and presenting an overview of actions that have been implemented mainly by the health sector, Dias et al. (2017) analyze how obesity has been addressed in SUS and SISAN policies, including concepts, indicators, action strategies and institutional articulation, especially those related to food and nutrition.
The analysis was based on frameworks from the field of policy analysis that conceive of politics as a process and practice, an expression of conflicts and convergences of power, interests, and ideas. The authors used document analysis because, according to them, government documents are relevant to policy analysis, since they express strategies of governance and reflect possible agreements at a given moment.
Methodology Details
To carry out the analysis of national strategies for tackling obesity in Brazil, within the scope of the Unified Health System and the National Food and Nutrition Security System, Dias et al. (2017) adopted the document analysis method, using government documents produced in the last 15 years – documents that address obesity as a public policy issue.
The authors analyzed 13 documents produced within the scope of the SUS (Brazilian Unified Health System) and 5 from the SISAN (National Food and Nutrition Security System), based on the following analytical dimensions grounded in document analysis frameworks: conceptions about obesity and its determinants; proposed interventions; the principle of intersectorality and the arguments used.
The websites of the Ministry of Health (http://portalsaude.saude.gov.br/) and the Ministry of Social Development and Fight against Hunger (http://www.mds.gov.br) were searched, and the "macro-strategies" (which define actions for the SUS and SISAN) were selected according to the following descriptors: obesity, chronic diseases, health promotion, and food and nutrition. Specific regulations for the school system were also included, considering the relevance of this space for tackling childhood obesity.
Results
The results found by Dias et al. (2017) show that the fight against obesity by the Brazilian public authorities has historically been linked to the health sector and has recently been reconfigured based on new approaches led by instances of the National Food and Nutrition Security System. Within the SISAN, obesity is conceived as a social problem, a food insecurity issue, and new ways of producing, marketing, and consuming food are proposed to change dietary practices in an integrated way. Meanwhile, within the Unified Health System (SUS), obesity is addressed as a risk factor and as a disease, with individualized and socio-environmental focuses, aiming to change dietary and physical activity practices.
According to the authors, the new approaches implemented by SISAN (Brazilian National Food and Nutrition Security System) agencies are fundamental to addressing a problem that, in fact, is particularized and manifested in the individual. However, it has favored biomedical interventions traditionally restricted to the biological dimension and focused on treating an already established disease, which, by themselves, have not been effective in reducing its prevalence. Individual or group consultations, bariatric surgery, and drug interventions, even if they could be mass-produced, would not be sufficient to affect the main determinants of the problem. Furthermore, adherence to individualized treatment is low, largely because individuals continue to be subjected to the same environmental pressures that compete unequally with personal motivation to modify dietary and behavioral practices.
It is observed that certain health promotion proposals tend to be "sectoral" because they are based on the prevention of the disease "obesity" and its risk factors, and are mainly focused on changes in diet and physical activity, based on individual efforts. However, health promotion proposals guided by the socio-environmental approach to health, aiming to guarantee healthy environments and living contexts, can favor intersectoral articulation proposals through measures such as guaranteeing access to adequate and healthy food in workplaces and schools, and regulating food advertising.
Therefore, efforts to build intrasectoral and intersectoral collaboration are essential, as they can contribute to greater integration and effectiveness of the set of prevention and control measures. In the Brazilian context, the proposals of the SUS (Unified Health System) point to an integrated and intrasectoral approach to obesity, while the proposals of SISAN (National System for Food and Nutritional Security) reinforce intersectorality from a broader perspective that challenges the current sectoral institutional structures.
Lessons in Public Policy
In the set of policies analyzed by Dias et al. (2017), the authors observed both proposals from the health sector, which prioritize individualized and socio-environmental measures, and those from SISAN, which emphasize transformations in the way food is produced, supplied, and marketed. In this context, the SISAN approach encompasses various institutional spaces of the federal government and, therefore, complicates the political process by requiring greater coordination between sectors and expanding potential points of conflict.
Dias et al. (2017) state that the fact that obesity is the subject of intersectoral food and nutritional security policy in Brazil may favor the management of the multiple processes that condition the problem and affect the terms of the sectoral policies themselves. Therefore, the authors highlight the challenge of implementing regulatory and fiscal measures that are fundamental to transforming dietary and physical activity practices, as well as the challenges inherent in the institutional and sectoral structures in place at different levels of government, which still hinder the planning, financing, and implementation of integrated strategies that affect the food system.
References
DIAS, Patricia Camacho et al. Obesity and public policies: the Brazilian government's definitions and strategies. Public health notebooks, v. 33, p. e00006016, 2017.
