Obesity and public policies : the Brazilian government ’ s definitions and strategies

O estudo analisa estratégias nacionais de enfrentamento da obesidade no Brasil, no âmbito do Sistema Único de Saúde (SUS) e do Sistema Nacional de Segurança Alimentar e Nutricional (SISAN). Com base no método de análise documental, foram examinados documentos governamentais produzidos nos últimos 15 anos, nas seguintes dimensões: concepções de obesidade, ações propostas e estratégias de articulação entre setores. No âmbito do SUS, a obesidade é abordada como fator de risco e como doença, com enfoques individualizados e socioambientais, visando a alterar práticas alimentares e de atividade física. No SISAN, é concebida também como problema social, de insegurança alimentar e são propostos novos modos de produzir, comercializar e consumir alimentos para alterar as práticas alimentares de forma integrada. As propostas do SUS apontam para uma abordagem integrada e intrassetorial da obesidade, e as do SISAN reforçam a intersetorialidade em uma perspectiva ampliada que desafia as estruturas institucionais setoriais vigentes.


Introduction
Obesity has gained attention on the international public agenda in the last three decades, as an event with global proportions and growing prevalence.In Brazil, overweight and obesity have increased in all age brackets, in both sexes, and at all income levels, while the pace of growth is higher in the population with the lowest family income 1 .Overweight and obesity affected 56.9% and 20.8% of the adult population in 2013, respectively 2 .
The World Health Organization (WHO) considers obesity a global epidemic, caused mainly by the population's eating profile and physical inactivity 3 .Obesity's growing prevalence has been attributed to various biopsychosocial processes, where the "environment" (political, economic, social, cultural), and not only individuals and their choices, occupies a strategic place in the analysis of the problem and proposed interventions 4,5,6,7,8 .Meanwhile, important challenges lie in understanding how these multiple factors interact.
In Brazil, obesity has become the object of public policies in the last 15 years, and the Ministry of Health, through the Brazilian Unified National Health System (SUS), is the main proponent of actions, confirming an international trend.Since the 1990s, the Ministry of Health National Food and Nutrition Policy (PNAN, 1999) has set guidelines for organizing the prevention and treatment of obesity in the SUS 9 , having been revised in 2012 to address the issue more intensively 10 .The following year, the Ministry of Health established the line of care for obesity as part of the Healthcare Network for Persons with Chronic Diseases 11,12 .
In 2006, Brazil established the National Food and Nutritional Security System (SISAN), which organizes actions by different ministries, ranging from food production to consumption.The National Council on Food and Nutritional Security (CONSEA), the National Conferences, and the Inter-Ministerial Chamber for Food and Nutritional Security (CAISAN) comprise the SISAN.From 2011 to 2014, CAISAN led the formulation of an inter-sector plan to fight obesity, which backed an intersector strategy that systematized recommendations for the states and municipalities 13,14 .
The proposed actions demand linkage within the SUS (intra-sector) and between the ministries comprising the SISAN (inter-sector).Dialogue between institutions with different practices involves a complex political and decision-making process, permeated by multiple conflicts of interests 15,16 .Measures that encourage individuals to modify their eating habits and physical activity on their own can be adopted more readily by governments, since they align with the food industry's interests and marketing strategies 17,18 .Meanwhile, measures that aim at transformations of "obesogenic environments", such as regulation of food advertising, can affect commercial interests 15 .Both are equally important, but their operationalization poses different challenges and management approaches 19 .
Given the diversity of definitions, possible solutions, and disputing interests, governments deploy certain types of interventions based on specific justifications and arguments that operate as strategies for convincing the public.Government discourse, simultaneously technical and political, can be grasped differently by the subjects involved in policy action 18 .Thus, in the framework of the scientific debate, one may ask: "Why is obesity a problem and for whom?", "What are the government strategies for dealing with it?","To what extent do the strategies favor intra-and inter-sector action?" 17 .
Studies on obesity in Brazil have addressed the issue from an epidemiological perspective 20 , assessing the impact of specific measures 6 and presenting an overview of the actions taken mainly by the health sector 21,22 .The approach to the issue from the perspective of food and nutritional security is incipient in Brazil, as is the analysis of the underlying concepts used in the public policies.Thus, the current study analyzed how obesity has been approached in policies by the SUS and SISAN, including concepts, indicators, action strategies, and institutional linkage, specifically related to food and nutrition.

Methods
The study was based on references from the field of policy analysis that define policy as a process and practice, the expression of conflicts and convergences of power, interests, and ideas 23,24 .As part of the political process, government documents can be considered social practices that disseminate defi- nitions, are politically appropriated by subjects, produce meaning, and thus shape reality itself 25,26 .
Although policy is not limited to a formal enunciation 27 , government documents are relevant for policy analysis, since they express strategies for governability 25 and reflect possible agreements at a given moment in time 28 .
The study was based on the document analysis method.We selected documents that approach obesity as a public policy issue and have marked the inclusion of the obesity issue on the Brazilian government agenda in the last 15 years.We searched the websites of the Ministry of Health and Ministry of Social Development and Fight against Hunger and selected the overarching or "macro" strategies (that define actions for SUS and SISAN), according to the following descriptors: obesity, chronic diseases, health promotion, and food and nutrition.The analysis included specific rulings that apply to the school system, considering their relevance for dealing with childhood obesity.

Obesity as a disease, diagnostic criteria, conditioning factors, and proposed measures
Nutritional issues have been part of the public agenda under different government administrations in Brazil since the 1930s, while obesity has been viewed as a "public health problem" in the last four decades, thus justifying population-based studies that have shown its increasing prevalence 15,21,41,42 .However, it has only become a public policy priority in the last 15 years, due to its magnitude and the association with non-communicable diseases (NCDs), especially cardiovascular diseases 43 .
WHO defines obesity as a chronic condition characterized by an excessive accumulation of fat, with negative repercussions on health.It is thus categorized in the 10 th revision of the International Classification of Diseases (ICD-10) in the chapter on endocrine, nutritional, and metabolic diseases 3 .In Brazil, different government documents follow the WHO definition and view obesity simultaneously as a disease and as a risk factor for other diseases, as a complex, multi-factor, chronic condition 10,11,29,30,33,34,35 as well as a manifestation of food and nutritional insecurity 11,33 .As for conditioning factors for obesity, the documents emphasize high-fat and high-sugar food intake and excessive consumption of ultra-processed foods, combined with physical inactivity, while acknowledging the complexity of the underlying processes 10, 29,30,33,34,35 .
The diagnosis of overweight/obesity has used body mass index (BMI), calculated as body mass divided by stature-squared, initially conceived for use in adults due to its association with morbidity and mortality risk, reiterating obesity as a risk factor especially for NCDs 44,45 .BMI is also used in children and adolescents 46 , elderly 47 , and pregnant women 48 .In Brazil, the WHO diagnostic criteria were incorporated into food and nutritional surveillance in the SUS 9 .Despite its widespread international use, BMI does not measure body composition 45 , so there appears to be inconsistency in its applicability for diagnosing a disease characterized by the accumulation of fat.Data from population-based studies have demonstrated the high specificity (but low sensitivity) of BMI for diagnosing obesity 20,49 .Evidence points to the need to develop component curves of body composition for the clinical and epidemiological diagnosis of nutritional status 50 .However, the use of BMI as a criterion for identifying overweight/obesity as a risk factor for NCDs, and not for nutritional diagnosis per se, still appears adequate, particularly in health services.
In the framework of the SUS, in 2006 the publication of a specific Primary Care Handbook on obesity emphasized individual aspects both in shaping the problem and dealing with it, while also suggesting collective strategies to promote healthy eating 29 .Other Ministry of Health documents reinforce the individual and patient-care approach 10,11,29,30 .In 2014, a new handbook explained the development of a line of care for obesity in the context of primary care and additionally mentioned health promotion measures 30 .
The analysis of the handbooks and other documents published during the same period shows the Brazilian Ministry of Health's growing interest in organizing measures to deal with obesity in Cad.Saúde Pública 2017; 33(7):e00006016 primary care 11,29,30 .Since 2007, several rulings have been issued that define the organization of the line of care and set criteria for high complexity health care services for patients with overweight and obesity, including the guarantee of surgical treatment 11 .Even though recourse to surgery may reinforce the pathological and curative perspective, this treatment modality has been acknowledged as a right within the SUS.
Without ruling out the importance of individual measures, certain segments in the health industrial complex carry heavy weight in the government decision-making process 51 .The medicalization of obesity should thus be analyzed in light of this context of competing interests for public funds.
It has become necessary to expand the limited concept of obesity as a disease and propose contextual measures to deal with it, due to the limited effectiveness of interventions focused exclusively on the physical body and individualized care 19 .Strategies that extend beyond the health sector's scope are necessary, given the difficulties in implementing universal coverage of individual measures (e.g., bariatric surgery), besides individuals' own limitations in modifying their personal "choices" (eating habits, physical exercise, etc.) in adverse contexts for the adoption of healthy practices.The health promotion approach to obesity thus helps frame the problem in broader terms, beyond disease and treatment.

Obesity and health promotion
Obesity's historical construction as a public health problem in Brazil has been influenced by the health promotion debate, as expressed in the two editions of the National Health Promotion Policy (PNaPS, in Portuguese) 31,32 .Although these policies do not address obesity directly, they consider adequate and healthy eating and physical activity and exercise as priorities, from a perspective that extends beyond (but does not rule out) individualized measures.
The PNaPS highlights the relationship between these two pillars and health promotion, food and nutritional security, poverty reduction, social inclusion, and the human right to adequate and healthy eating.It reinforces the importance of the autonomy and uniqueness of individuals, communities, and territories, since individual choices are "determined" by social, economic, political, and cultural contexts 31,32 .
Different approaches to health promotion can be identified in the PNaPS as an expression of its hybrid nature, conceived as both a set of activities aimed at changing individual behaviors, and as valuing changes in the "social determinants of the health-disease process" and health conditions.From the latter perspective, health is conceived as the product of a broad range of factors, including food and nutrition, consistent with the comprehensive definition of health as a right, as laid out in Brazil's 8 th National Health Conference in 1986 52 .However, this expanded health promotion approach has also fostered at least two distinct types of proposals: those based on the disease or disease-prevention paradigm, backed by risk-factor epidemiological models, and others that operate through a social/environmental approach, focused on building healthy environments and the spread of universal health-friendly processes 53,54 .These two watersheds have influenced the approaches to obesity while suggesting distinct definitions of the problem and the ways to deal with it.

Measures to promote adequate and healthy eating to deal with obesity in Ministry of Health policies
Historically, the central theme on the technical agenda for food and nutrition was poor eating as a basic factor in various nutritional deficiencies.The increase in obesity prevalence raised new challenges for public health 15,21,41,42 .Linking policies around a "single agenda for nutrition", with a focus on the promotion of adequate and healthy eating was justified by the association between poor eating, obesity, and NCDs 21 .Thus, the promotion of adequate and healthy eating was considered strategic for dealing simultaneously with nutritional deficiencies and obesity 10 .
Beyond the concept of healthy eating, some of Brazil's official health documents began to adopt the expanded concept of adequate and healthy eating, in dialogue with the food and nutritional security Cad.Saúde Pública 2017; 33(7):e00006016 policy, and referring to the cultural, social, and economic (and not only nutritional) adequacy of eating 10,32,33,34,35 .The promotion of adequate and healthy eating is one of the components of health promotion and includes measures to encourage, support, and protect adequate and healthy eating and that aim to disseminate information and facilitate and protect adherence to healthy eating practices 10,31,32 , such as mandatory nutritional labeling, dietary guidelines, and regulation of food advertising 10, 34,35 .
Regulation of food advertising has still not made headway in Brazil, despite efforts by the National Health Surveillance Agency (Anvisa), since this type of measure runs counter to the interests of the processed and ultra-processed food products industry, a powerful lobby in policy decisions 18,55 .The least conflictive measures are voluntary agreements to reduce the levels of salt, saturated fats, and sugar in processed foods, as provided in the National Plan for Non-Communicable Diseases, proposing "partnerships" with the food industry and suggesting that industry voluntarily refrain from advertising unhealthy foods 33 , which is highly unlikely.
The 2006 dietary guidelines highlight the risk of high-calorie, high-fat, high-sugar, and high-salt foods associated with the development of obesity and NCDs.The guidelines already backed the concept of food and nutritional security and recommended measures to offset the "obesogenic environment", such as regulation of food advertising 34 .The 2014 dietary guidelines reposition the health sector in the approach to the food issue by expanding the dialogue between the SUS and the SISAN, viewing the promotion of adequate and healthy eating as part of building a "socially and environmentally sustainable" food system and highlighting the conditioning factors for food and nutrition, from production to consumption.The guidelines are based on classification of foods according to the degree of processing 56 , suggesting limits on the consumption of processed foods and avoiding the consumption of ultra-processed foods 35 .These new guidelines introduce a strong element of confrontation with the food industry, as suggested by: "ultra-processed foods tend to negatively affect culture, social life, and the environment" (p.45) and "avoid ultra-processed foods" (p.50).The dietary guidelines can also support measures aimed at changing individual choices, since they state that "dietary guidelines should take into account the ways production and distribution of foods have an impact on social justice and environmental integrity" 35 (p. 18).The document thus marks a turning point in the approach to food issues in the framework of the SUS.
Inter-sector proposals for the school system feature the School Health Program, which involves the Ministries of Education and Health and provides for children's anthropometric assessment, promotion of food and nutritional security, and physical activity and exercise, all of which can be strategic for dealing with obesity 36 , in addition to Inter-Ministerial Ruling n. 1,010/2006 37 , which sets guidelines for healthy eating in the public and private school systems in Brazil.

Intra-and inter-sector action strategies to deal with obesity
A historical analysis of food and nutritional policies in Brazil shows that certain periods of discontinuity and change are crucial for understanding certain principles in a given context 15,21,39,40 .Such breaks and changes help identify the extent to which obesity has been acknowledged as a relevant public policy issue and the degree to which inter-sector action has been incorporated into the respective policies.
A turning point in 1999 was the publication of the National Food and Nutritional Policy (PNAN in Portuguese), which repositions the food and nutrition issue on the agenda of the SUS 9,57 and strengthens the debate on food and nutritional security, both inside and outside the health sector, when the theme was not previously a government priority 58 .The National Food and Nutritional Policy, while emphasizing nutritional deficiencies, already pointed to the need for intervention in NCDs, including obesity 9 .Even with a sector-based approach, the first recommendation refers to "stimulus for inter-sector actions with a view towards universal access to foods" 9 .The PNAN of 2011, while reinforcing the sector-based approach, recommends cooperation and linkage for food and nutritional security 10 .
Another turning point came with the proposals for reorganization of the SUS through the healthcare networks, strengthening the perspective of intra-sector action and indicating, at least in specific cases, the relevance of the principle of inter-sector action for health promotion and the prevention Cad.Saúde Pública 2017; 33(7):e00006016 of NCDs 12 .The line of care for overweight and obesity recommends linkage of inter-sector actions for health promotion, aimed at supporting individuals and communities in the adoption of healthy lifestyles 11 .Although the Primary Care Handbooks mention inter-sector action, the approach to obesity in the sphere of health is reinforced from a perspective of more individualized actions 29,30 .
Brazil's Strategic Action Plan for Non-Communicable Diseases, drafted and coordinated by the Ministry of Health, recommends cooperation between different sectors in a multi-sector (not intersector) approach, since it only compiles the individual contributions by each sector for dealing with NCDs, without explaining how to integrate them 33 .
The PNaPS, especially its most recent edition, is the policy that most reinforces the notions of comprehensiveness and intra-sector action in linkage with the other principles of the SUS 29 .Intersector action is conceived as a process of linkage of the knowledge, potentialities, and experiences of subjects, groups, and sectors in building shared interventions, establishing ties, shared responsibility, and co-management for common objectives, aimed at building and linking cooperative networks with case-resolution capacity 32,59 .The new version features the use of terms such as "promoting healthy habits", "linking", and "mobilizing", unlike the 2006 edition, which featured the term "prevention" and the disease-centered approach 31,32 .
Inter-sector proposals for dealing with obesity indicate a new development in addressing the problem.This change was propelled by the consolidation of the food and nutritional security policy 38 , when the CAISAN published the Inter-Sector Plan for the Prevention and Control of Obesity 13 that backed the Inter-Sector Strategy for the Prevention and Control of Obesity: Recommendations for States and Municipalities (EIPCO in Portuguese) 14 .Its implementation is complex, since food and nutritional security policies and food and nutrition policies link the guarantee of access to foods to the adequacy of the entire food chain and reinforce government's role in the protection of health through regulatory and mediating functions in sector-based public policies.
The EIPCO can be viewed as the product of a new institutional arrangement and a new way of operating policies, partly related to the SISAN from the perspective of integrating actions and inter-sector strategies 13,14 .Shifting the agenda to states and municipalities can mean both a closer approach to different local management realities and difficulties in organizing a linked, joint, and inter-sector strategy at the national level.
By transcending the sphere of public health, obesity is now also acknowledged as a social problem, related (in the documents' own words) to the prevailing food system, with repercussions on health and quality of life.Examples of this development feature the following: expansion of the explanation on the conditioning factors; a shift in focus from "solutions" to the modes of producing, supplying, marketing, and accessing foods; and progress with food and nutrition as a right; strengthening of institutional spaces for inter-sector action and the legal basis of food and nutritional security, aiming at strengthening government intervention in commercial practices, among other measures 13,14 .
Another key result of this development, especially based on the principles of food and nutritional security, is the formulation of the Frame of Reference for Food and Nutritional Education for Public Policies, which aims to promote a common field for reflection and orientation on educational practices and proposes that the actions be considered by the various sectors working in food production, distribution, supply, and consumption 40 .

Discussion
Government action to deal with obesity in Brazil was associated historically with the health sector and has been reconfigured recently based on new approaches led by the SISAN.This historical process has included some key turning points.The first was when malnutrition and hunger, previously the principal focus of intervention 15,21,41,42 , gave way to growing recognition (especially since the 1990s) of obesity as a major public health problem, backed by epidemiological studies showing a steady increase in obesity prevalence and its association with NCDs 1 .
This approach is crucial for dealing with a problem that is in fact specified and materialized at the individual level.However, the approach has favored biomedical interventions that are traditionally limited to the biological dimension and focused on treatment of a disease once it already exists, while Cad.Saúde Pública 2017; 33(7):e00006016 such interventions have not proven effective in reducing its prevalence.Individual or group consultations, bariatric surgery, pharmacological interventions, even if they could be mass-produced, would not be sufficient to attack the problem's main conditioning factors.For example, bariatric surgery is specific to one type of obesity, which is not even the most prevalent, and may lead to relevant complications 60 .In addition, adherence to individualized treatment is low, to a major extent because individuals are still exposed to the same environmental pressures that compete unequally with personal motivation to modify eating habits and behaviors 61,62 .
Individual measures thus require greater efforts than are possible within the obesogenic environment 4,63 .Besides, patients' appointments and educational activities are often heavily prescriptive and fail to favor a sustainable shift to healthy practices 64 .Interventions in the environment can create opportunities for individuals to adopt healthier practices 4,8,63 , besides facilitating their adherence to treatment.It is thus not appropriate to polarize the debate between individual and environmental measures, but to grasp the complexity and challenges for dealing with the problem.While the definition of obesity as a disease may have favored more individualized interventions, this does not mean that the biomedical approach is not important, including to support public policies.Studies showing the biological effects of consuming ultra-processed foods have backed the debate on regulatory measures, as in the example of tobacco control 19,65,66 .
Intra-disciplinary (rather than interdisciplinary) analyses of the problem and institutional fragmentation may have contributed to the fact that obesity prevention and control measures were implemented in isolation, limiting the case-resolution capacity of individual measures.Efforts at building intra-sector and inter-sector action are essential, since they can contribute to greater integration and effectiveness of prevention and control measures as a whole.In the SUS, health promotion policies and the recent movement to build healthcare networks favor these principles.The healthcare networks proposal, which includes the line of care for obesity, is being consolidated in a context of growing importance of primary care and organization of the health services networks, signaling the importance of inter-sector action in the SUS 67 .
As for the repercussions of the principles of inter-sector and intra-sector action in the proposed strategies, different perspectives have emerged in health promotion and influenced the definition of promotion of adequate and health eating.In this context, the narrower definition of obesity as a disease and\or risk factor for NCDs, considering the use of BMI in the diagnosis and demarcation of "disease" versus "no disease", may have implications for the proposed measures.This understanding may favor preventive or curative measures focused on patients or individuals with a high risk of falling ill and dying.Such measures tend to be implemented mainly by the health sector and may not be as effective as universal health promotion measures 68 .Certain health promotion proposals analyzed here thus tend to be "sector-based", since they are based on prevention of the disease "obesity" and its risk factors and focus mainly on changes in eating habits and physical activity, beginning with individual efforts.Meanwhile, measures based on the social/environmental health approach, aimed at guaranteeing healthy environments and life settings, may potentially favor proposals for inter-sector linkage through such measures as guaranteed access to adequate and healthy eating at the workplace and in schools, besides regulation of food advertising.
In the policies analyzed here as a whole, we observed proposals in both the health sector (SUS) that prioritized both individualized and social/environmental measures, and in the SISAN, which emphasized changes in the way foods are produced, supplied, and marketed.The latter approach includes various areas of the Federal government and thus makes the policy process more complex by requiring greater linkage between sectors and expanding the potential points of conflict.The fact that obesity is the object of an inter-sector food and nutritional security policy in Brazil may favor the management of multiple processes that condition the problem and also affect the terms of the various sectors' own policies.
The health sector, which has traditionally approached obesity through the dimension of food consumption, has been interacting in a two-way exchange with proposals that shift the focus of solutions to the policies of the SISAN.Although inter-sector action was present in health policies, in both the PNAN and the PNaPS, in the framework of SISAN it became the structuring principle and identity of a public policy 15 .The approach to obesity in the EIPCO thus establishes links with the processes of food production, supply, commercialization, access, and consumption 14 .This perspective strength-Cad.Saúde Pública 2017; 33(7):e00006016 ens certain actions that constitute the "single agenda" for nutrition in the SUS 21 , especially those to deal with obesity and nutritional deficiencies through the promotion of adequate and healthy eating, which clashes with the solutions based primarily on medicalization and the interests of various industries: food processing, seeds, dietary supplements, and biofortification.The spinoffs of the approach to food and nutritional security for health can be identified in the terms of the new dietary guidelines, in the new meanings of adequate and healthy eating, and in the recognition of obesity as a problem of food insecurity.
The proposed reorganization of Brazil's health services from the network and line-of-care perspective favors a more integrated and intra-sector approach to obesity, and the inter-sector approach expressed in proposals in SISAN can help strengthen the social/environmental perspective in shaping food systems that promote more sustainable adequate and healthy eating.
The scope of the current study was limited to official government documents and a nonsystematic selection of the scientific literature, which could affect the depth of given concepts addressed here, such as inter-sectorial relations.Nevertheless, the study offers an interlinked overview of definitions and proposals for addressing the obesity problem from different angles.We need a better understanding of the various factors that interact to shape obesity (from an interdisciplinary perspective).This highlights the challenges of implementing essential regulatory and fiscal measures for changing eating practices and patterns of physical activity, besides the challenges arising from the prevailing institutional structures in different government sectors and levels, and which still hinder the planning, funding, and implementation of integrated strategies for the food system.Contributors P. C. Dias, P. Henriques, L. A. Anjos, and L. Burlandy participated in the article's conceptualization, data analysis and interpretation, writing and critical revision, and approval of the final version for publication.