FórumDCNTs e Membros submetem recomendação sobre Obesidade à OMS
Conforme publicamos em 20 de agosto de 2021, a OMS abriu Consulta Pública em relação às suas Recomendações para Prevenção e Gerenciamento da Obesidade ao Longo da Vida. Abaixo, as sugestões elaboradas e submetidas pelo FórumDCNTs e seus membros com interesse no tema.
Intersectoral Forum to Fight NCDs in Brazil - ForumDCNTs' Recommendations to the World Health Organization (WHO) on the Prevention and Management of Obesity Over the Life Course
The ForumDCNTs, since 2017, unites organizations from the different sectors dedicated to policies and programs on NCDs prevention and care. It was planned from its conception to assist the country in achieving the SDG 3.4 through SDG 17 (additional details here). Nowadays, over a hundred organizations from the public, private and not-for-profit/civil society sector join efforts in the key alliance for partnerships to fight NCDs that is the ForumDCNTs. It is worth mentioning that since 2019 PAHO and WHO have also joined the ForumDCNTs in several opportunities. Regarding the web-based consultation for Member States, UN organizations, and non-State actors on a draft global strategy for the prevention and management of obesity over the life course, including potential targets (WHO Discussion Paper dated 16 August) that WHO is convening from 16 August to 17 September 2021, the ForumDCNTs, the institutions that comprise it - especially the ones co-signing below - share the following comments and recommendations.
Obesity and overweight are growing epidemics in Brazil, where more than 20% of adults live with obesity and over 60% with overweight. For this reason, the ForumDCNTs has a Working Group exclusively dedicated to this theme. The concerns associated with the high prevalence of obesity may not be due to its direct morbimortality, but mostly to its long term direct and indirect consequences to quality of life and health - including development of additional NCDs that have obesity as a risk factor, social stigma, impact on individuals’ productivity and consequent burden on the society.
The WHO Recommendations is overall a very well designed document, citing the most pressing challenges leading to the current obesity pandemic, as well as the most effective interventions. We sum our voices with the recommendations of providing preventive care for obesity in the form of shaping the food market with national policies, stimulating physical activity and improving nutritional status of people around the world with national dietary guides. We praise the recommendation of managing obesity as a condition which requires a multidisciplinary approach, with psychological, nutritional, medical, physical education and pharmacological support. In line with the emphasis on the life course approach, we suggest use of new technological tools for improving and broadening educational strategies to prevent obesity since childhood.
Among the recommendations, we appreciated that multisectoral actions are advised. However, we missed a specific recommendation on the engagement of people living with obesity in all phases of policies and programs development, implementation and M&E, as GCM-WHO, WHO/UHC2030, and NCD Alliance also recommend. The document recognizes the relevance of advocacy. Thus, we emphasize the need to include people with obesity among the key stakeholders for decision making. In addition, they may become key allies to educate the population, also organizing and mobilizing individuals for system changes to improve population health.
One of the recommendations in the document includes dietary and weight counselling for pregnant women. We understand that pregnancy is a particular moment in which behavior changes can be performed, however, we would suggest this dietary and weight counselling to be extended for all and every person attending primary care services. It is also fundamental to clearly state in the document the need to reduce ultraprocessed foods consumption and sugar-sweetened beverages. Brazil has a globally recognized positive experience to share within its food guides for the Brazilian population and for children under 2 years old. Both of them value local culture, consumption of minimally processed and fresh food, and encourage limiting ultraprocessed foods rich in salt, sugar and fat. As a consequence, they are important tools for effective actions to prevent obesity and other NCDs.
While there is a pledge to provide pharmacological therapy and surgery, in line with the suggestions submitted by Instituto Obesidade Brasil, we believe that they appear in a too general, non-specific manner. The first aspect is the absence of medicines to treat obesity in the WHO Essential Medicine List. While there is Fluoxetine listed, its use for weight loss is not an on-label recommendation. Thus, our suggestion on this aspect is to perform a careful literature review to include a more specific recommendation of molecules - such as Sibutramine/Phentermine, Orlistat and/or Liraglutide - and when to use them. Regarding bariatric or metabolic surgery, Brazil has good experience on its incorporation in the public health system. Thus, we would suggest a more detailed description in the document on when to prescribe it and who would be a candidate for this procedure, as well as available references.
Concerning the time scheduled for physical education classes in schools, our suggestion is to use the minimum amount of 100 minutes of vigorous activity weekly, as well as providing space and encouraging physical activity and sports during the recreation or break periods. Physical activity presents an important role in the development of children and as a major factor that prevents weight gain and regain after weight loss. Since school is the ideal place to meet the children's needs, promote socialization and adoption of behaviors, it is where we recommend that the minimum WHO’s recommendation for physical activity takes place. In Brazil, the just published physical activity guide for the population recommends 150 minutes of moderate activity and 75 minutes of vigorous activity per week for children, in addition to other recommendations for each age group, over the life course.
The ForumDCNTs reinforces that the multisectoral discussion for the development of these recommendations is quintessential, and strengthens the commitment for their effective adoption. Therefore, we suggest a legislative and multi-ministerial engagement to address this serious NCD, including especially the ministries of health, finances/economy, education and infrastructure. This diversity is essential to establish, keep and consolidate the structural determinants of health, as well as empowering the society and partnering with the press. We emphasize that the presence of civil society, comprising scientific societies and people who live with the condition is essential in order to successfully address its real needs. Moreover, we suggest that the contextual and commercial determinants of obesity are more highlighted due to their dangerous effects, including reference to the PAHO’s document on this matter. Eventually, citing the syndemic phenomenon where climate changes exacerbates obesity and undernutrition would also assist countries to develop mid to long term plans to mitigate it. We would conclude expressing our feeling that as obesity reached the current prevalence and complexity, it would be worth increasing its visibility by including it in a 6x6 NCDs and risk factors agenda/framework.
We believe that the experiences and guides from different countries would be useful references for the WHO’s recommendations on obesity prevention and management, such as the Canadian and the Brazilian’s on the care of children and adolescents with obesity in the primary healthcare, care of people with obesity in the primary healthcare, national strategy to prevent and manage infant obesity, among other.
We cordially acknowledge WHO’s attention and the opportunity for this contribution, and put ourselves at its disposal to assist in global and regional recommendations, as well as to collaborate for their implementation in Brazil and abroad.
Mark Thomaz Ugliara Barone, PhD
Founder and General Manager
Intersectoral Forum to Fight NCDs in Brazil (ForumDCNTs)
Andrea Pereira, MD, PhD
Andrea Levy, Psychologist
Financial manager 2019-2021
NGO Obesidade Brasil - Brazil
President and Founder
Instituto Correndo pelo Diabetes
Domingos Malerbi, MD, PhD
Sociedade Brasileira de Diabetes (SBD)
Fadlo Fraige Filho, MD, PhD
Associação Nacional de Atenção ao Diabetes (ANAD)
Federação Nacional das Associações e Entidades de Diabetes (FENAD)
Gilberto Soares Casanova
Ronaldo José Pineda Wieselberg, MD
Member of the Administrative and Scientific Board
ADJ Diabetes Brasil
Gustavo San Martin
Associação Amigos Múltiplos pela Esclerose - AME
Associação Crônicos do Dia a Dia - CDD
Luiz Aparecido Bortolotto, PhD, MD
Brazilian Society of Hypertension (SBH) - Brasil
Mônica Andreis, MSc
ACT Health Promotion
Patricia Vieira de Luca, MSc
Associação Brasileira de Hipercolesterolemia Familiar (AHF)
Sheila Martins, MD, PhD
President and Founder
Rede Brasil AVC