Area: 8.514.876,599 km² States:26 and a FD

Municipalities: 5.564População: 190.732.694 inhabitants (IBGE 2010)

83% of the population lives in urban areasHuman development Index 2007(HDI): 0,800

BrasiliaRio de Janeiro

BRAZIL

“HEALTH – Right for all and Duty of State Federal Constitution - 1988

Article 196

Universality -Equity -Integrality –Participation and Social Control

Population using public health system : 143.610.047

Unified Health System - SUS

75% (99,1% a 66%)Population using health insurance plans (complementary

health system): 47.870.583 (21,1%)

Challenges:Continental scale with social and regional inequalitiesTotal of 5 564 municipalities: 71% up to 20.000 inhabitants

Epidemiological transition

Population ageing

Risk Factors %

1ºOverweight(Obesity)

43,3 (H:47,3M:39,5)13,0 (H:12,0 M:13,6)

2ºMeat-fat consumption

33,8 (H:44,0 M:25,1)

2000

2050

3ºSedentarism

26,3 (H:29,5 M:23,5)

4ºAbusive alcohol consumption

19,0 (H:29,0 M:10,5)

5º Smokers15,2 (H:19,1 M:11,9)

PENSE-Pesquisa Nacional de Saúde na Escola(THINK-National Survey of School Health)

Health PromotionFocus:üHealthy diet and Physical activityü Tobacco prevention and controlü Decrease the morbidity and mortality associated with alcohol abuse and illicit drug useü Decrease the morbidity and mortality associated with motor vehicle accidentsü Prevent violence and promote non violent behaviorü Promote sustainable development

(Actions are implemented especially in primary care level)

ü Promote sustainable development

Priorities: programs/actions :Social Determinants of Health School’s Health ProgramEstimulate Physical Activities (network iniciatives)

Initiatives on Food and Nutrition for Health Promotion

� Promoting Healthy Eating in School -

Interministerial Decree MS/MEC 1010,

from 08/05/2006

� Nutritional Labeling of Foods

� Encouraging the consumption of Fruit &

Vegetables in Brazilian biodiversity

� Reduction of Sodium Content in Food

� Regulation of Food Advertising

Feb 2011-Family Care Teams :

31.800 teams with 01 physician, 01

Primary Health Care

Family Care: principal estrategy

31.800 teams with 01 physician, 01 nurse, 01 or 02 nurse technicians and 06 or 08 comunity health agents.

Pop coverage:100,8 milions-52,8%

245.500 comunity health agents Pop coverage:120,4 milions-63,0%

Partnerships� The brazilian public health system called Unified Health

System - SUS, is a sharing network with States and Municipalities

Others:Others:� Scientific Societies� Research Institutes� Universities� Patient Associations� International entities : OPAS,OMS, World Diabetes

Foundation

Ricardo MeirellesRicardo MeirellesState Institute of Diabetes and Endocrinology

Rio de Janeiro

Evolução de indicadores antropométricos na população de 10 a 19 anos de idade, por sexo – Brasil – períodos 1974-75, 1989 e 2008-2009

Evolution of the antrhropometric indexes in the population from 10 to 18 years old, by sex, Brazil 1974-75, 1989 and 2008-2009

Fontes: IBGE, Diretoria de Pesquisas, Coordenação de Trabalho e Rendimento, Estudo Nacional da Despesa Familiar1974-1975 e Pesquisa de Orçamentos Familiares 2002-2003/2008-2009; Instituto Nacional de Alimentação eNutrição, Pesquisa Nacional sobre Saúde e Nutrição 1989.

Evolução de indicadores antropométricos na população de 5 a 9 anos de idade, por sexo – Brasil – períodos 1974-75, 1989 e 2008-2009

Evolution of the antrhropometric indexes in the population from 5 to 9 years old, by sex, Brazil 1974-75, 1989 and 2008-2009

Rio de Janeiro State Law 5196March 5th, 2008

Authorizes the government to settle the programme of combat to obesity of student programme of combat to obesity of student

of the public and private schools.

Target

Children up to 14 years old with overweight orobesity according to World Healthobesity according to World Health

Organization criteria

Treatment goals for children

� a) If BMI > 85th and < 95th percentile →maintenance weight

� b) If BMI > 95th percentile → loose weight, 0.500 kg/monthly

� c) If, > 85th percentile with complications (diabetes, hypertension and others), just like b)

Program History� 2008, May: first outpatient unit for Childhood Obesity;

beginning of the program

� 2009, April: the endocrinologist moved to other sector

� 2009, November: two endocrinologists assigned to theprogram

Objectives� Relationship with a Public School near our hospital to

identify overweight and obese students and offer treatment� Integration with the patient school to fight bullying� Clinical assistance� Meeting with parents for nutritional information and

counseling on how to choose the food to buy� Search for a safe place for physical activity in the patient

neighborhood, avoiding the prolonged use of computer or TV

� Playful and pedagogical workshops with healthy snacks

Multidisciplinary Staff

Social Worker

Psychologist Endocrinologist

Nutritionist

First consultation� History of the disease� Clinical examination� Laboratory tests

� Blood count� Transferrin, Ferritin

� Insulin� Leptin� 2 h Glucose tolerance test� Cortisol suppression test 1

mg dexametasonLipid profile

� Transferrin, Ferritin� Plasma iron� C Reactive Protein� Fibrinogen, � Uric acid� Urea, Creatinin� Albumin, globulin� Liver function tests� TSH, FT4

� Lipid profile� Urinalysis� Parasitológic stool test

� Image tests� Bone age� Abominal ultrasonography

� Cardiologic examination� EKG

Step-by-step procedures

� Clinical appointment for medical investigation and teaching lifestyle modification.

� Nutritional orientation of patients and their families.� Social worker evaluation for detecting opportunities of � Social worker evaluation for detecting opportunities of

physical activities in a safe place in the neighborhood of children´s homes and socioeconomic status and orientation about buying appropriate food.

� Psychologist consultation for detecting familiar psychological problems and social bullying.

Step-by-step procedures

� Group physical activity orientation.� Healthy snack day with playful activities, twice a year

(World Food Day and Christmas).� Bi-monthly meetings with the health care team, � Bi-monthly meetings with the health care team,

children and families, to discuss some aspects of the program which need to be emphasized or altered.

� Hospitalization

Hospitalization (maximum 1 week)� Relapsing cases� Diagnosis

reevaluation� Difficult weight

� Nutritional reeducation of the patient and parent (practical examples of healthy meals)� Difficult weight

control� Psychiatric

recommendation (eating disorders)

(practical examples of healthy meals)

� Clinical reassessment� Physical activity

orientation (rope skip, ball playing, stair exercises, hula hoop)

Patients Data� Total of patients: 250� Secondary causes of obesity: 30 (12%)� Comorbidities: 183 (73.2%)

Dyslipidemia: 37 (14.8%)� Dyslipidemia: 37 (14.8%)� Carbohydrate Metabolism Disorder: 30 (12%)� Snoring: 17 (6.8%)� Hypertension: 15 (6%)� Others: 84 (33.6%)

Preliminary results (79 children)� Age (mean ± SD): 10.0 ± 3.0 years

� BMI (mean ± SD): 29.7 ± 5.6 kg/m²

� Duration of treatment (mean ± SD): 0.8 ± 0.7 years

� Lost weight: 28 (35%)

� Mean weight loss: 1.97 kg (0 to 6.5 kg)

� Interval: 0.3 years (0.1 to 0.8 years)

Proposals

� We show that it is possible and necessary to settle multidisciplinary programs for the treatment of obesity in children

� We emphasize that obesity is a disease and should be � We emphasize that obesity is a disease and should be diagnosed and treated in hospitals

� Schools should be advised to seek for overweght or obese children and send them for treatment

� Schools should teach children and their parents on nutritional orientation, buying food and exercise practice

� Schools should offer only healthy food for children, avoiding fatty and salty food.

� Programs like this should be multiplied as a government initiative, involving not only health staff

Proposals

government initiative, involving not only health staff but also teachers and families.

� Education and Health Ministries should talk each other to develop comprehensive programs in this way.

Multidisciplinary team� Project leaders:

� Ricardo Meirelles� Vera Leal� Carmen Assumpção

� Endocrinologists:

� Social Workers: � Angela Willemes� Carla Santana de Oliveira

� Psychologists: � Claudia Ramundo� Endocrinologists:

� Carmen Assumpção� Karen de Marca Seidel

� Residents: � Wellington Santana da Silva Jr.� Letícia Dinis da Costa Braga� Alessandra Schiapacassa� Amanda Dias Bicudo

� Claudia Ramundo� Daniela Coelho

� Nutrictionists: � Tania Cristina C. D. Bruno� Lilian Fernandes Magalhães

� Physical Education Teacher: � Alessandra Costa