Food insecurity as a barrier to care for people with diabetes in Brazil: gaps and challenges for public health, food, and social protection policies

Silva, Daniel Ferreira da; Marchioni, Dirce Maria Lobo

doi:10.1590/0102-311XEN054726

According to the most recent edition of the IDF Diabetes Atlas¹, approximately 16.6 million Brazilians had diabetes in 2024, with a projected 24 million cases by 2050, placing the country among those with the highest prevalence in the Americas and ranking sixth worldwide by absolute number of cases. The microvascular complications of diabetes, such as retinopathy, diabetic kidney disease, and neuropathy, and macrovascular complications, such as cardiovascular, cerebrovascular, and peripheral arterial diseases, are major causes of disability, loss of quality of life, and premature mortality in these individuals ². In this context, adequate and healthy eating is recognized as one of the fundamental pillars of glycemic management and the prevention of associated adverse outcomes ³.

In Latin American and Caribbean countries, such as Brazil, approximately 80% of the burden of type 2 diabetes mellitus, the most prevalent form of the disease, has been attributed to inadequate diets, characterized mainly by low consumption of whole grains, legumes, fruits, and vegetables ³. This scenario reinforces the central role of diet as a modifiable determinant of diabetes risk and management, as well as a strategic target for the development of preventive and care interventions ⁴. However, a substantial portion of the Brazilian population experiences some level of food insecurity ⁵, a condition traditionally measured by the Brazilian Food Insecurity Scale (EBIA, acronym in Portuguese), which assesses household perceptions and experiences of worry, uncertainty, or restricted access to food in adequate quantities and of adequate quality, including situations of hunger in the most severe cases ⁶. Food insecurity, therefore, represents a violation of the human right to adequate food ⁷.

In 2022, nearly 59% of Brazilian families experienced some degree of food insecurity ⁸, as a result of the weakening of public food and nutrition policies ⁹ and the worsening of socioeconomic inequalities during the COVID-19 pandemic ¹⁰. Although this figure has decreased as a result of the resumption and strengthening of public policies on social protection, food, and nutrition, approximately 24.2% of households still experience some level of food insecurity, according to the 2024 Continuous Brazilian National Household Sample Survey (Continuous PNAD, acronym in Portuguese) ⁵. Among the groups most affected by this scenario are women, Black people, and individuals with low levels of education and income, who are also among those most affected by the increase in the prevalence of diabetes in the country ¹¹^,¹². This overlap of social and economic vulnerabilities increases the challenges of adequately managing the disease, highlighting the need to develop public policies that integrate health interventions, food and nutrition surveillance, and social protection ¹³.

National evidence indicates that food insecurity is associated with reduced dietary diversity and lower consumption of protective foods such as fruits and vegetables ¹⁴. In addition to providing vitamins, minerals, and fiber - essential components for glycemic control and metabolic health - these foods are important sources of bioactive compounds with recognized antioxidant, anti-inflammatory, and cardioprotective activities that play a fundamental role in preventing microvascular and macrovascular complications associated with diabetes ¹⁵.

Moreover, in a context of economic constraint, families tend to prioritize low-cost, energy-dense basic and traditional foods over purchasing fruits and vegetables. Data from the latest Brazilian Household Budget Survey (POF, acronym in Portuguese) indicated that, among low-income families, cereals, roots, and tubers accounted for approximately 41% of the calories purchased for household consumption, whereas legumes accounted for only 3.6% ¹⁶. Although these foods are mostly unprocessed or minimally processed, the predominance of carbohydrate-rich food sources, combined with the lower consumption of fiber- and protein-rich foods, may favor dietary patterns with a greater glycemic impact ¹⁷. In this regard, Brazilian food guidance protocols for people with diabetes have emphasized the importance of meal composition ¹⁸, including the traditional combination of rice and beans, which may contribute to better glycemic management ¹⁹.

Although there is no specific diet for people with diabetes, the main guidelines for nutritional management recommend adopting dietary patterns based primarily on whole grains, legumes, fruits, vegetables, and low-fat animal-source foods, such as lean meats and nonfat dairy products ²⁰. However, the high cost of these foods in Brazil may represent an additional barrier to diabetes treatment, particularly among socioeconomically vulnerable populations. In this context, national studies have shown that the cost of a healthy diet has become significantly higher than that of dietary patterns based on ultra-processed foods with lower nutritional quality ²¹, especially during extreme climate events and health emergencies that may affect food production, distribution, and prices ²²^,²³.

Evidence also shows that individuals experiencing food insecurity have lower adherence to recommendations for regular physical exercise and a higher risk of sedentary behaviors ²⁴, a relationship that may be explained, in part, by factors such as stress and fatigue, as well as energy-conservation strategies in contexts of food restriction ²⁵. Thus, food insecurity represents an obstacle not only to adherence to healthy dietary patterns but also to regular physical exercise, two fundamental pillars of self-care for people with diabetes ¹³.

Moreover, the socioeconomic conditions that often determine food insecurity may compromise adherence to pharmacological treatment for diabetes. Families facing budget constraints frequently need to make financial trade-offs, such as choosing between purchasing food and paying for other basic needs, including medications, transportation, and and housing-related expenses. This instability may reduce the regularity of medication use, increasing the risk of glycemic decompensation and, consequently, chronic complications related to the disease ¹³. This phenomenon may be particularly important in Brazil, as some individuals with diabetes still incur direct out-of-pocket expenses for medications, despite the existence of public pharmaceutical assistance policies ²⁶. Data from the latest Brazilian National Health Survey (PNS, acronym in Portuguese), for example, indicated that only 51.5% of individuals with diabetes reported obtaining medications through the Brazilianj Popular Pharmacy Program ²⁷.

Despite the relevance of the topic, public policies aimed at caring for people with diabetes in Brazil still insufficiently address the role of food security in successful treatment ²⁸^,²⁹^,³⁰. Only recently was the Food Insecurity Risk Screening (TRIA, acronym in Portuguese) incorporated into primary health care (PHC), the main entry point to the Brazilian Unified National Health System (SUS, acronym in Portuguese) for the follow-up of people with chronic diseases ³¹. In addition, the role of food insecurity in diabetes-related health outcomes remains absent from the main Brazilian clinical guidelines and normative instruments, such as clinical protocols and therapeutic guidelines ²⁸^,²⁹. This gap reinforces the need to incorporate guidance that considers the social determinants of health and the reality of people in situations of socioeconomic vulnerability into these documents ³².

While food insecurity is insufficiently addressed in the main Brazilian clinical guidelines for diabetes management, international documents already recognize this problem as an important barrier to achieving therapeutic goals. The American Diabetes Association (ADA), for example, highlights food insecurity as a factor that may hinder treatment adherence, self-care, and glycemic control, recommending that health professionals assess this condition among their patients ³³. Similarly, the International Society for Pediatric and Adolescent Diabetes (ISPAD) recognizes food insecurity as a social determinant that may compromise diabetes management in children and adolescents, especially in low- and middle-income countries characterized by pronounced social inequalities ³⁴.

Given the limitations imposed by food insecurity, it is essential that nutritional recommendations for people with diabetes be adapted to the socioeconomic and cultural realities of the populations served ³⁵. Strategies such as prioritizing regional foods and lower-cost seasonal fruits and vegetables ³⁶, as well as promoting traditional dishes with more favorable nutritional profiles and providing guidance on food combinations that reduce glycemic impact, may be viable alternatives for improving glycemic management in these individuals ³⁵^,³⁷.

Addressing food insecurity in the care of people with diabetes also requires integrating therapeutic care with food security policies and social protection programs ³³^,³⁴. Among the immediate response measures, the expansion of direct cash transfer programs - preferably with benefit amounts adjusted to the cost of a healthy diet - stands out, alongside the strengthening of public food and nutrition security facilities, such as community and solidarity kitchens and popular restaurants, so that they prioritize menus appropriate for people with chronic conditions ³⁸. It is also essential to expand the supply and availability of fresh foods through family farming, community gardens, and local farmers’ markets, especially in areas with limited availability of these foods ³⁶^,³⁹.

In this context, the Brazilian National Strategy for Food and Nutritional Security in Cities, established by Decree n. 11,822 of December 12, 2023 ⁴⁰, represents an important government initiative aimed at expanding the availability of and access to healthy foods in urban centers, especially among socially vulnerable populations. In addition, the establishment of the New National Basic Food Basket represents a relevant advance by recognizing unprocessed or minimally processed foods as central elements in promoting the human right to adequate food and prohibiting the inclusion of ultra-processed foods in the basic food basket ⁴¹. More than a reference for food procurement, the new basic food basket serves as a policy instrument to promote public policies aimed at reducing the price of healthy foods through tax incentives, public procurement, and other regulatory strategies ⁴².

PHC, which is fundamental to care coordination and continuity of care within the SUS ⁴³, should be integrated with social assistance services so that the identification of people and families in vulnerable situations through the TRIA results in timely access to social protection measures ³¹. The effectiveness of this strategy depends not only on identifying food insecurity but also on the existence of integrated care pathways capable of ensuring continuous follow-up and intersectoral care. In this context, Interministerial Ordinance n. 25/2023⁴⁴ of the Brazilian Ministry of Development and Social Assistance, Family, and Fight Against Hunger/Brazilian Ministry of Health represents an important advance by establishing guidelines for integrating social assistance, health, and food security actions, strengthening the identification, follow-up, and care of populations in situations of socioeconomic vulnerability.

Therefore, advancing the integration of the food security and diabetes management agendas is essential to improve the quality of care, reduce inequalities, and ensure better living conditions for the most vulnerable populations ³³. Incorporating routine assessment of food insecurity into health services, strengthening intersectoral actions, and ensuring access to adequate and healthy foods should be viewed as strategic components of the response to the increasing prevalence of diabetes in Brazil.

Acknowledgments

The authors thank the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES) for its support of academic training and research. They also thank the National Institute of Science and Technology for Combating Hunger (INCT Combate à Fome) for supporting the development of studies on food and nutrition security in Brazil.

Data availability

Not applicable.

Reviewer who authorized identification:

Felipe Silva Neves (0000-0002-3294-5979)

References

¹ International Diabetes Federation. IDF diabetes atlas. 11th Ed. https://diabetesatlas.org/ (accessed on 03/Mar/2026).
» https://diabetesatlas.org/
² Harding JL, Pavkov ME, Magliano DJ, Shaw JE, Gregg EW. Global trends in diabetes complications: a review of current evidence. Diabetologia 2019; 62:3-16.
³ O'Hearn M, Lara-Castor L, Cudhea F, Miller V, Reedy J, Shi P, et al. Incident type 2 diabetes attributable to suboptimal diet in 184 countries. Nat Med 2023; 29:982-95.
⁴ Wylie-Rosett J, Hu FB. Nutritional strategies for prevention and management of diabetes: consensus and uncertainties. Diabetes Care 2019; 42:727-30.
⁵ Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Contínua - segurança alimentar, 2024. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2025.
⁶ Segall-Corrêa AM, Marin-León L, Melgar-Quiñonez H, Pérez-Escamilla R. Refinement of the Brazilian Household Food Insecurity Measurement Scale: recommendation for a 14-item EBIA. Rev Nutr 2014; 27:241-51.
⁷ Brasil. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 sep.
⁸ Rede PENSSAN. II Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da COVID-19 no Brasil. São Paulo: Fundação Friedrich Ebert; 2022.
⁹ Castro IRR. A extinção do Conselho Nacional de Segurança Alimentar e Nutricional e a agenda de alimentação e nutrição. Cad Saúde Pública 2019; 35:e00009919.
¹⁰ Ribeiro-Silva RC, Pereira M, Campello T, Aragão É, Guimarães JMM, Ferreira AJ, et al. Implicações da pandemia COVID-19 para a segurança alimentar e nutricional no Brasil. Ciênc Saúde Colet 2020; 25:3421-30.
¹¹ Malta DC, Bernal RTI, Sá ACMGN, Silva TMR, Iser BPM, Duncan BB, et al. Diabetes autorreferido e fatores associados na população adulta brasileira: Pesquisa Nacional de Saúde, 2019. Ciênc Saúde Colet 2022; 27:2643-53.
¹² Malta DC, Gomes CS, Silva AG, Souza JB, Morais ÉAH, Freitas PC, et al. Temporal analysis of the prevalence of chronic noncommunicable diseases and risk and protective factors by schooling level from 2006 to 2023. Ciênc Saúde Colet 2025; 30 Suppl 2:e14172024.
¹³ Levi R, Bleich SN, Seligman HK. Food insecurity and diabetes: overview of intersections and potential dual solutions. Diabetes Care 2023; 46:1599-608.
¹⁴ Silva EEMS, Steluti J. O consumo alimentar de brasileiros residentes em domicílios com insegurança alimentar: resultados da POF-2017-2018. Ciênc Saúde Colet 2025; 30:e20042023.
¹⁵ Fernández-Fígares Jiménez MC. Plant foods, healthy plant-based diets, and type 2 diabetes: a review of the evidence. Nutr Rev 2024; 82:929-48.
¹⁶ Silva MAL, Rodrigues LB, Brito SA, Lage LG, Louzada MLC. Aquisição de alimentos que compõem a nova cesta básica pelas famílias brasileiras de baixa renda em 2017-18: distribuição socioeconômica e demográfica. SciELO Preprints 2024; 12 jul. https://preprints.scielo.org/index.php/scielo/preprint/view/9349/version/9884
» https://preprints.scielo.org/index.php/scielo/preprint/view/9349/version/9884
¹⁷ Whiteley C, Benton F, Matwiejczyk L, Luscombe-Marsh N. Determining dietary patterns to recommend for type 2 diabetes: an umbrella review. Nutrients 2023; 15:861.
¹⁸ Secretaria de Atenção Primária à Saúde, Ministério da Saúde; Universidade de Brasília. Orientação alimentar de pessoas adultas com diabetes mellitus - protocolos de uso do guia alimentar para a população brasileira. v. 4. Brasília: Ministério da Saúde; 2022.
¹⁹ Thompson SV, Winham DM, Hutchins AM. Bean and rice meals reduce postprandial glycemic response in adults with type 2 diabetes: a cross-over study. Nutr J 2012; 11:23.
²⁰ Hou L, Ge L, Wang Q, He J, Qin T, Cao L, et al. Nutritional recommendations for type 2 diabetes: an international review of 15 guidelines. Can J Diabetes 2023; 47:197-206.
²¹ Maia EG, Passos CM, Levy RB, Bortoletto Martins AP, Mais LA, Claro RM. What to expect from the price of healthy and unhealthy foods over time? The case from Brazil. Public Health Nutr 2020; 23:579-88.
²² Kotz M, Kuik F, Lis E, Nickel C. Global warming and heat extremes to enhance inflationary pressures. Commun Earth Environ 2024; 5:116.
²³ Andrade GC, Caldeira TCM, Mais LA, Bortoletto Martins AP, Claro RM. Food price trends during the COVID-19 pandemic in Brazil. PLOS One 2024; 19:e0303777.
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²⁵ Gough T, Brown O, Christiansen P, Hardman CA, Keenan GS. Investigating the mediating role of physical activity within the association between food insecurity and BMI. Appetite 2025; 204:107724.
²⁶ Bahia LR, da Rosa MQM, Araujo DV, Correia MG, dos Rosa RS, Duncan BB, et al. Economic burden of diabetes in Brazil in 2014. Diabetol Metab Syndr 2019; 11:54.
²⁷ Costa KS, Tavares NUL, Tierling VL, Leitão VBG, Stopa SR, Malta DC. Pesquisa Nacional de Saúde 2019: obtenção de medicamentos por adultos em tratamento para hipertensão e diabetes no Programa Farmácia Popular do Brasil. Epidemiol Serv Saúde 2022; 31(spe1):e2021366.
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³¹ Ministério da Saúde. Insegurança alimentar na atenção primária à saúde. Manual de identificação dos domicílios e organização da rede. Brasília: Ministério da Saúde; 2021.
³² Hill-Briggs F, Adler NE, Berkowitz SA, Chin MH, Gary-Webb TL, Navas-Acien A, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care 2021; 44:258-79.
³³ El Sayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, et al. 1. Improving care and promoting health in populations: standards of care in diabetes - 2024. Diabetes Care 2024; 47 Suppl 1:S11-9.
³⁴ Annan SF, Higgins LA, Jelleryd E, Hannon T, Rose S, Salis S, et al. Clinical Practice Consensus Guidelines 2022: nutritional management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1297-321.
³⁵ Shapiro J, Grajower MM. The influence of diverse cultures on nutrition, diabetes management and patient education. Nutrients 2024; 16:3771.
³⁶ Departamento de Promoção da Saúde, Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Recomendações para o aumento do consumo frutas, legumes e verduras. Brasília: Ministério da Saúde; 2022.
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⁴⁴ Ministério do Desenvolvimento e Assistência Social, Família e Combate à Fome; Ministério da Saúde. Portaria Interministerial MDS/MS nº 25, de 1 de setembro de 2023. Estabelece as orientações para priorização e organização da atenção aos indivíduos e famílias em insegurança alimentar e nutricional no âmbito da assistência social, saúde e segurança alimentar e nutricional. Diário Oficial da União 2023; 4 sep.

Correspondence

D. M. L. Marchioni Departamento de Nutrição, Faculdade de Saúde Pública, Universidade de São Paulo. Av. Dr. Arnaldo 715, São Paulo, SP 01246-904, Brasil. marchioni@usp.br

Associate Editor

Evaluation coordinator: Inês Rugani Ribeiro de Castro (0000-0002-7479-4400)

Publication Dates

Publication in this collection
05 Oct 2026
Date of issue
2026

History

Received
08 Mar 2026
Reviewed
27 July 2026
Accepted
03 Aug 2026

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹ International Diabetes Federation. IDF diabetes atlas. 11th Ed. https://diabetesatlas.org/ (accessed on 03/Mar/2026).
» https://diabetesatlas.org/

[2] ² Harding JL, Pavkov ME, Magliano DJ, Shaw JE, Gregg EW. Global trends in diabetes complications: a review of current evidence. Diabetologia 2019; 62:3-16.

[3] ³ O'Hearn M, Lara-Castor L, Cudhea F, Miller V, Reedy J, Shi P, et al. Incident type 2 diabetes attributable to suboptimal diet in 184 countries. Nat Med 2023; 29:982-95.

[4] ⁴ Wylie-Rosett J, Hu FB. Nutritional strategies for prevention and management of diabetes: consensus and uncertainties. Diabetes Care 2019; 42:727-30.

[5] ⁵ Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Contínua - segurança alimentar, 2024. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2025.

[6] ⁶ Segall-Corrêa AM, Marin-León L, Melgar-Quiñonez H, Pérez-Escamilla R. Refinement of the Brazilian Household Food Insecurity Measurement Scale: recommendation for a 14-item EBIA. Rev Nutr 2014; 27:241-51.

[7] ⁷ Brasil. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 sep.

[8] ⁸ Rede PENSSAN. II Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da COVID-19 no Brasil. São Paulo: Fundação Friedrich Ebert; 2022.

[9] ⁹ Castro IRR. A extinção do Conselho Nacional de Segurança Alimentar e Nutricional e a agenda de alimentação e nutrição. Cad Saúde Pública 2019; 35:e00009919.

[10] ¹⁰ Ribeiro-Silva RC, Pereira M, Campello T, Aragão É, Guimarães JMM, Ferreira AJ, et al. Implicações da pandemia COVID-19 para a segurança alimentar e nutricional no Brasil. Ciênc Saúde Colet 2020; 25:3421-30.

[11] ¹¹ Malta DC, Bernal RTI, Sá ACMGN, Silva TMR, Iser BPM, Duncan BB, et al. Diabetes autorreferido e fatores associados na população adulta brasileira: Pesquisa Nacional de Saúde, 2019. Ciênc Saúde Colet 2022; 27:2643-53.

[12] ¹² Malta DC, Gomes CS, Silva AG, Souza JB, Morais ÉAH, Freitas PC, et al. Temporal analysis of the prevalence of chronic noncommunicable diseases and risk and protective factors by schooling level from 2006 to 2023. Ciênc Saúde Colet 2025; 30 Suppl 2:e14172024.

[13] ¹³ Levi R, Bleich SN, Seligman HK. Food insecurity and diabetes: overview of intersections and potential dual solutions. Diabetes Care 2023; 46:1599-608.

[14] ¹⁴ Silva EEMS, Steluti J. O consumo alimentar de brasileiros residentes em domicílios com insegurança alimentar: resultados da POF-2017-2018. Ciênc Saúde Colet 2025; 30:e20042023.

[15] ¹⁵ Fernández-Fígares Jiménez MC. Plant foods, healthy plant-based diets, and type 2 diabetes: a review of the evidence. Nutr Rev 2024; 82:929-48.

[16] ¹⁶ Silva MAL, Rodrigues LB, Brito SA, Lage LG, Louzada MLC. Aquisição de alimentos que compõem a nova cesta básica pelas famílias brasileiras de baixa renda em 2017-18: distribuição socioeconômica e demográfica. SciELO Preprints 2024; 12 jul. https://preprints.scielo.org/index.php/scielo/preprint/view/9349/version/9884
» https://preprints.scielo.org/index.php/scielo/preprint/view/9349/version/9884

[17] ¹⁷ Whiteley C, Benton F, Matwiejczyk L, Luscombe-Marsh N. Determining dietary patterns to recommend for type 2 diabetes: an umbrella review. Nutrients 2023; 15:861.

[18] ¹⁸ Secretaria de Atenção Primária à Saúde, Ministério da Saúde; Universidade de Brasília. Orientação alimentar de pessoas adultas com diabetes mellitus - protocolos de uso do guia alimentar para a população brasileira. v. 4. Brasília: Ministério da Saúde; 2022.

[19] ¹⁹ Thompson SV, Winham DM, Hutchins AM. Bean and rice meals reduce postprandial glycemic response in adults with type 2 diabetes: a cross-over study. Nutr J 2012; 11:23.

[20] ²⁰ Hou L, Ge L, Wang Q, He J, Qin T, Cao L, et al. Nutritional recommendations for type 2 diabetes: an international review of 15 guidelines. Can J Diabetes 2023; 47:197-206.

[21] ²¹ Maia EG, Passos CM, Levy RB, Bortoletto Martins AP, Mais LA, Claro RM. What to expect from the price of healthy and unhealthy foods over time? The case from Brazil. Public Health Nutr 2020; 23:579-88.

[22] ²² Kotz M, Kuik F, Lis E, Nickel C. Global warming and heat extremes to enhance inflationary pressures. Commun Earth Environ 2024; 5:116.

[23] ²³ Andrade GC, Caldeira TCM, Mais LA, Bortoletto Martins AP, Claro RM. Food price trends during the COVID-19 pandemic in Brazil. PLOS One 2024; 19:e0303777.

[24] ²⁴ Chen S, Li Z, Zhang Y, Chen S, Li W. Food insecurity, physical activity, and sedentary behavior in middle to older adults. Nutrients 2025; 17:1011.

[25] ²⁵ Gough T, Brown O, Christiansen P, Hardman CA, Keenan GS. Investigating the mediating role of physical activity within the association between food insecurity and BMI. Appetite 2025; 204:107724.

[26] ²⁶ Bahia LR, da Rosa MQM, Araujo DV, Correia MG, dos Rosa RS, Duncan BB, et al. Economic burden of diabetes in Brazil in 2014. Diabetol Metab Syndr 2019; 11:54.

[27] ²⁷ Costa KS, Tavares NUL, Tierling VL, Leitão VBG, Stopa SR, Malta DC. Pesquisa Nacional de Saúde 2019: obtenção de medicamentos por adultos em tratamento para hipertensão e diabetes no Programa Farmácia Popular do Brasil. Epidemiol Serv Saúde 2022; 31(spe1):e2021366.

[28] ²⁸ Ministério da Saúde. Protocolo clínico e diretrizes terapêuticas do diabetes mellitus tipo I. Brasília: Ministério da Saúde; 2020.

[29] ²⁹ Ministério da Saúde. Protocolo clínico e diretrizes terapêuticas do diabetes mellitus tipo II. Brasília: Ministério da Saúde; 2024.

[30] ³⁰ Ramos S, Campos LF, Baptista DR, Strufaldi M, Gomes DL, Guimarães DB, et al. Terapia nutricional no pré-diabetes e no diabetes mellitus tipo 2. In: Bertoluci M, editor. Diretriz da Sociedade Brasileira de Diabetes. Brasília: Conectando Pessoas; 2023. https://diretriz.diabetes.org.br/terapia-nutricional-no-pre-diabetes-e-no-diabetes-mellitus-tipo-2/.

[31] ³¹ Ministério da Saúde. Insegurança alimentar na atenção primária à saúde. Manual de identificação dos domicílios e organização da rede. Brasília: Ministério da Saúde; 2021.

[32] ³² Hill-Briggs F, Adler NE, Berkowitz SA, Chin MH, Gary-Webb TL, Navas-Acien A, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care 2021; 44:258-79.

[33] ³³ El Sayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, et al. 1. Improving care and promoting health in populations: standards of care in diabetes - 2024. Diabetes Care 2024; 47 Suppl 1:S11-9.

[34] ³⁴ Annan SF, Higgins LA, Jelleryd E, Hannon T, Rose S, Salis S, et al. Clinical Practice Consensus Guidelines 2022: nutritional management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1297-321.

[35] ³⁵ Shapiro J, Grajower MM. The influence of diverse cultures on nutrition, diabetes management and patient education. Nutrients 2024; 16:3771.

[36] ³⁶ Departamento de Promoção da Saúde, Secretaria de Atenção Primária à Saúde, Ministério da Saúde. Recomendações para o aumento do consumo frutas, legumes e verduras. Brasília: Ministério da Saúde; 2022.

[37] ³⁷ Pasmans K, Meex RCR, van Loon LJC, Blaak EE. Nutritional strategies to attenuate postprandial glycemic response. Obes Rev 2022; 23:e13486.

[38] ³⁸ Miranda SHG, Silva MC, editors. Propostas de combate à fome e à insegurança alimentar: relatório final. Piracicaba: Escola Superior de Agricultura Luiz de Queiroz, Universidade de São Paulo; 2023.

[39] ³⁹ Ministério do Desenvolvimento Agrário e Agricultura Familiar. Plano nacional de abastecimento alimentar 2025-2028. Brasília: Ministério do Desenvolvimento Agrário e Agricultura Familiar; 2024.

[40] ⁴⁰ Brasil. Decreto nº 11.822, de 12 de dezembro de 2023. Institui a Estratégia Nacional de Segurança Alimentar e Nutricional nas Cidades. Diário Oficial da União 2023; 12 dec.

[41] ⁴¹ Brasil. Decreto nº 11.936, de 5 de março de 2024. Dispõe sobre a composição da cesta básica de alimentos no âmbito da Política Nacional de Segurança Alimentar e Nutricional e da Política Nacional de Abastecimento Alimentar. Diário Oficial da União 2024; 6 mar.

[42] ⁴² Rahal LS, Gentil PC, Bortolini GA, Neves FS, Arguelhes BP. Ultra-processed foods in research and policy. Lancet 2026; 407:948-9.

[43] ⁴³ Portela GZ. Atenção primária à saúde: um ensaio sobre conceitos aplicados aos estudos nacionais. Physis (Rio J.) 2017; 27:255-76.

[44] ⁴⁴ Ministério do Desenvolvimento e Assistência Social, Família e Combate à Fome; Ministério da Saúde. Portaria Interministerial MDS/MS nº 25, de 1 de setembro de 2023. Estabelece as orientações para priorização e organização da atenção aos indivíduos e famílias em insegurança alimentar e nutricional no âmbito da assistência social, saúde e segurança alimentar e nutricional. Diário Oficial da União 2023; 4 sep.