A alimentação é uma necessidade biológica e um fenômeno social. Estudos recentes registram aumento no desenvolvimento de doenças crônicas não transmissíveis relacionadas à alimentação. No Brasil, pesquisas tem identificado que a alimentação fora do domicílio tem contribuído para o aumento do sobrepeso e da obesidade O restaurante de refeição por peso tornou-se um ambiente rotineiro de refeições para muitos trabalhadores e apresenta-se como um espaço promissor para ações de promoção da saúde. OBJETIVO: Identificar representações sociais sobre fatores que influenciam as escolhas alimentares de clientes de restaurantes de refeição por peso e apreender a percepção de nutricionistas sobre possibilidades de desenvolvimento de ações de educação nutricional nesses locais. MÉTODO: Estudo transversal, qualitativo, tendo como referencial teórico as representações sociais na ótica da psicologia social de Moscovici. A pesquisa foi desenvolvida em duas etapas: a primeira ocorreu em dois restaurantes comerciais no município de São Paulo com a participação de 60 sujeitos, adultos de ambos os gêneros, e na segunda foram entrevistadas duas nutricionistas que atuam na área de alimentação coletiva. Os dados foram coletados após a aprovação do Comitê de Ética em Pesquisa da Faculdade de Saúde Pública da Universidade de São Paulo e assinatura de Termo de Consentimento Livre e Esclarecido. Utilizou-se entrevista gravada, seguindo roteiro semiestruturado para: investigar os condicionantes das escolhas alimentares de clientes em restaurantes de refeições por peso, identificar as representações sociais sobre a relação alimentação, saúde e doença, identificar conhecimento sobre alimentação saudável e apreender a percepção dos sujeitos sobre a necessidade de mudanças na sua rotina de alimentação visando a promoção de sua saúde. Para a análise dos dados utilizou-se a técnica do Discurso do Sujeito Coletivo, com o apoio do software Qualiquantsoft. Os resultados foram discutidos em um encontro com nutricionistas que atuam no ramo de restaurantes de refeição por peso, para se pensar estratégias de promoção da saúde nesses locais. RESULTADOS: Foram identificadas seis categorias para fatores que determinam as escolhas da refeição em restaurantes de refeição por peso. Sobre a escolha entre o sabor e a saúde (43 por cento ) da amostra pensa na saúde quando escolhe a refeição, (30 por cento ) tentam equilibrar a saúde e o sabor e (27 por cento ) se decidem pelo sabor. O conhecimento sobre escolhas saudáveis foi representado pelas seguintes Ideias Centrais (IC): saladas, alimentos com pouca gordura e frutas (36 por cento ); equilíbrio entre os grupos alimentares e um prato colorido (33 por cento ); comida simples e alimentos crus (19 por cento ). Também foram identificadas as representações de que as escolhas saudáveis incluem alimentos naturais; que depende da necessidade do organismo. Quanto à percepção do sujeito sobre a necessidade de mudança na sua rotina alimentar foram identificadas 12 Ideias Centrais, que representam categorias de análise. Apresentamos as cinco categorias que apresentaram maior frequência de contribuições: Não vê necessidade de mudança porque já cuida da dieta (24 por cento ); Mudaria várias coisas (23 por cento ); Comeria menos carne e frituras (15 por cento ); Comeria menos doces (13 por cento ); Comeria menos pão e massas à noite (11,6 por cento ). As nutricionistas que atuam em restaurantes de refeição de autosserviço não se surpreenderam com o fato dos clientes conhecerem as bases da alimentação saudável. Quanto às razões dos sujeitos não utilizarem essa informação no seu cotidiano as nutricionistas entendem que o preparo da comida exige tempo e que eles não gostam de cozinhar. As profissionais acreditam que os clientes fazem associação da alimentação com a saúde ou doença, mas que não se importam com essa questão no momento de servir-se. Referem que é contraditório atuar em ações de educação em saúde porque os restaurantes têm metas para vendas, e que estas iniciativas poderão ser possíveis se houver projetos aprovados em parceria com os responsáveis da empresa. As nutricionistas apresentaram como ações alternativas: atuar na produção das preparações reduzindo sal e gordura; desenvolver um projeto em parceria com o pessoal do setor financeiro; adaptar receitas reduzindo a densidade calórica e fazendo testes de aceitabilidade com os clientes. CONSIDERAÇÕES FINAIS: A maioria dos sujeitos valorizou o aspecto visual e estético relacionados à apresentação dos alimentos no balcão de autosserviço, sua aparência e qualidade como fatores decisivos para suas escolhas alimentares. A variedade na oferta de alimentos, o tempo reduzido de espera para tomar sua refeição, o preço e a fome influenciam a qualidade e a quantidade de alimento a ser consumido. De uma forma geral, os sujeitos que almoçam em restaurantes de refeição por peso convivem com o dilema de decidirse entre o sabor e a saúde e que o nutricionista convive com o conflito entre as metas de venda e a promoção da saúde de sua clientela. As representações sociais demonstram que essa clientela conhece conceitos básicos da alimentação saudável. Os sujeitos reconhecem a necessidade de melhorar sua alimentação para promover sua saúde, contudo referem dificuldades para alterar sua rotina. Apontam causas sociais como morar sozinho, não saber cozinhar, não ter tempo para essas tarefas e também falta de motivação para essas mudanças. Frente à urgência do enfrentamento das doenças crônicas não transmissíveis no Brasil, recomenda-se que o tema educação nutricional para escolhas saudáveis em restaurantes de autosserviço seja explorado em outras pesquisas / The feeding is a biological necessity and a social phenomenon. Recent studies registeincrease in the development nontransmissible chronic diseases related to the feeding. In Brazil, research has identified that out-of-home feeding has contributed for thincrease of the overweight and the obesity. The meal by weight restaurant became routine environment of meals for many workers and is presented as a promising spacfor action of health promotion. OBJECTIVE: Identify social, cultural and symbolicquestions that support the alimentary choices of customers who frequent meal by weightrestaurant, aiming to contribute with subsidies to instrument the educative interventionsin the area of the feeding. Identify nutritionist´s perceptions about possibilities of health promotion actions in meal by weight restaurant. METHOD: Transversal studyqualitative, supported for the theory of the social representations and for the theory ofthe social determination of the health-illness process. The research was developed intwo commercial restaurants in the city of São Paulo with the participation of 60 adultsubjects of both genders, and two nutritionists who acts in the area of collective feedingThe data were collected after approval of the Committee of Ethics in Research of theFaculty of Public Health of the University of São Paulo and after signature of Term ofFree and Clarified Assent. Recorded interview was used, following semi-structuredscript to investigate the conditions of the alimentary choices of subjects who frequents meal by weight restaurant, to explore the social representations on the feeding- healthillness relation, to identify knowledge about healthful feeding and to know the perception of the subject on the necessity of changes in your feeding routine to promotehis health. For data analysis was used the technique of Discourse of the CollectiveSubject, with the support of Qualiquantsoft software. The results were discussed in meeting with nutritionists who acts in the meal by weight restaurant, to think health promotion strategies in these places. RESULTS: Six categories were identified forfactors that determine the choices of meals in meal by weight restaurant. About the decision between the taste and health, (43 per cent ) of the sample thinks in health when picks the meal, (30 per cent ) try to balance the health and taste and (27 per cent ) is decided by the taste.The knowledge about healthy choices was represented by the following Central Idea(IC): salads, foods with low fat and fruits (36 per cent ); balance between the alimentary groups and a colorful plate (33 per cent ); simple food and raw foods (19 per cent ). Also it was identified representations that healthy choices include natural foods; and that depends on the needof the organism. Regarding the perception of the subject about need for change in your alimentary routine, were identified 12 IC that represents analysis categories. We showthe five categories that presented higher frequency of contributions: Sees no need to change because already takes care of the diet (24 per cent ); Would change many things (23 per cent );Would eat less meat and fried foods (15 per cent ); Would eat less candies (13 per cent ); Would ealess bread and pasta at night (11.6 per cent ). The nutritionists who acts in auto servicrestaurants were not surprised at the fact of the customers know the bases of the healthyfeeding. Referring to the question of them do not use this information in their everydaythe nutritionists understand that cooking demands time and they do not like to cook. They believe that the customers make association of the feeding with the health or disease, but that they do not care with this in the time of serving themselves. Regarding the nutritionist´s acting in heath education actions, two IC were identified: it´s contradictory to nutritionist to act it in the health education because it has sales goals; it is possible if partnership with the responsible of the company exists. The nutritionists presented three alternatives of action to promote the health of the customers: To act in meals production reducing salt and fat; to develop a project together with the financial department staff; to adapt recipes reducing the caloric density and making acceptability tests with the customers. CONCLUSION: That despite the inconvenient of offering of alimentary item with high caloric density, this service appears as a possibility for individuals to have access to a varied diet and regular offering of vegetables and products from more traditional Brazilian cuisine. In general, the subjects that lunch in meal by weight restaurants coexist with the dilemma of deciding between taste and health, and the nutritionist coexist with the conflict between the goals of sales and the promotion of the health of its clientele. The subjects of common sense demonstrate knowledge of basic concepts of healthy feeding and identify points for improvement in your feeding routine to promote their health, but report difficulties to change their feeding routine. The justifications show social causes like living alone, not to know to cook, do not have time for these tasks and also lack of motivation for these changes. Considering the urgency of confronting the nontransmissible chronic diseases in Brazil, it is recommended that the theme of nutrition education and healthy choices for autonomy in self-service restaurants to be explored in other studies

DE CAMARGO, M. A. G. Fatores preditores do alcance das metas do programa de intervenção no estilo de vida em nipo-brasileiros de Bauru - SP. 2008. 99 f. Dissertação (Mestrado em Saúde na Comunidade). Faculdade de Medicina de Ribeirão Preto-USP. Objetivos: Identificar fatores associados ao alcance das metas de um programa de intervenção no estilo de vida em Nipo-Brasileiros de Bauru, SP. Metodologia: Os fatores associados ao alcance das metas (perda de peso de 5%, prática de 150 minutos de atividades físicas semanal, consumo alimentar com teor de gordura saturada inferior a 10% das calorias totais, consumo diário de 400g de frutas, verduras e legumes), após 12 meses de intervenção foram investigados em modelos de regressão logística ajustados, As avaliações do estilo de vida e perfil de saúde foram conduzidas no início do estudo e após 12 meses de seguimento. Resultados: No total, 458 nipo-brasileiros, 56% do sexo feminino, 84% de 2ª geração, idade média (DP) de 60 (11) anos foram analisados. Foram incluídos nos modelos múltiplos para cada desfecho investigado os indivíduos com excesso de peso (n=329), que reportaram não terem o hábito da prática de 150 minutos de atividades físicas semanal (n=278), consumo alimentar com teor de gordura saturada superior a 10% das calorias totais (n=107) e consumo diário inferior a 400g de frutas, verduras e legumes (n=265). Após 12 meses, 11% dos indivíduos com excesso de peso alcançaram a meta de perda de peso, 24, 55 e 16% dos participantes alcançaram as metas de prática de atividades físicas, teor da dieta de gordura saturada e consumo de frutas, verduras e legumes, respectivamente. Após ajuste por variáveis de confusão, maior razão de chance [OR (95%)] para o alcance da meta de perda de peso foi verificada entre mulheres [2,4 (1,3; 4,5)], e menor razão de chance entre portadores de diabetes, hipertensão e dislipidemia [0,4 (0,1; 0,8)] e indivíduos classificados em estágio de mudança de pré-contemplação / contemplação para redução do consumo de carnes vermelhas [0,4 (0,2; 0,9)]. Os participantes de 2ª geração apresentam menor razão de chance para o alcance da meta do consumo de frutas, verduras e legumes [0,3 (0,1; 0,9)]. Nenhuma associação foi verificada para as metas da prática de atividades físicas e de gordura saturada. Conclusões: Entre os Nipo-Brasileiros, as estratégias do programa de intervenção no estilo de vida foram mais eficientes no alcance das metas entre as mulheres, indivíduos de 1ª geração, não portadores de morbidades e participantes classificados nos estágios de mudança de ação / manutenção para a redução do consumo de carnes vermelhas. Palavras-chave: intervenção no estilo de vida, Nipo-Brasileiros; metas / Objectives: To verify factors associated with reaching goals in a lifestyle intervention program in Japanese-Brazilians living in Bauru, SP. Methodology: The factors associated with reaching the goals (5% of weight loss, practice of 150 minutes of physical activity/ week, less than 10% of energy from saturated fat and the intake of 400g of fruits and vegetables daily), after 12 months of intervention were investigated by adjusted logistic regression models. The assessments of lifestyle and health profile were conducted at baseline and after 12 months of intervention. Results: In total, 458 Japanese-Brazilians, 56% females, 84% of 2nd generation, mean (SD) age of 60 (11) were investigated. At baseline, 329 individuals were overweight, 278 reported less than 150 minutes/ week of physical activity, 107 reported food intakes with more than 10% of calories from saturated fat and 265 reported less than 400g of fruits and vegetables/day, and were included in the models. After 12 months, 11% of the overweight individuals reached the goal of weight loss, and 24, 55, and 16% of the participants reached the goals of the practice of physical activity, and intakes of saturated fat and fruits and vegetables, respectively. After adjustments for potential confounding variables, higher odds ratios [OR (95%)] for achieving weight loss were verified among women [2.4 (1.3; 4.5)], and lower chances among individuals with diabetes, hypertension or dyslipidemia [0.4 (0.1; 0.8)], and on precontemplation / contemplation stages of change for reducing red meat intakes [0.4 (0.2; 0.9)]. Individuals of 2nd generation had lower chances of achieving the goal of fruits and vegetables intake [0.3 (0.1; 0.9)]. No associations were verified for achieving the goals of practice of physical activity and saturated fat intakes. Conclusion: Among Japanese-Brazilians, the lifestyle intervention strategies were more efficient on reaching the goals among women, individuals of 1st generation, those without diseases and participants on stages of change of action/maintenance for reducing red meat intakes. Key-words: Lifestyle intervention, Japanese-Brazilians, lifestyle goals, prevention of chronic diseases, nutrition epidemiology.

Made available in DSpace on 2016-04-26T14:55:07Z (GMT). No. of bitstreams: 1 Maria Elisa Gonzalez Manso.pdf: 1100752 bytes, checksum: a79f3c4334cb3dc3edbfbcb83487718d (MD5) Previous issue date: 2015-02-05 / This research aims to understand the explanatory model and the therapeutic itinerary of a group of patients affected by chronic diseases who are assisted by disease management programs carried out by operators of health plans and identify strategies of self-care that relate with the explanatory model. The thesis that moves this study is that the route that the patient uses for its treatment has deep roots in his own culture, being much larger than the model used by health professionals, also generated by the culture, but restricted by the biomedical vision. The meanings of terms such as health, cure, treatment, disability, dependence and others are not always equal in both models. If the meaning is too different, adherence to the treatment will be impaired, but the patient may still have obtained relief from their suffering. The methodology applied is qualitative, gathered through interviews with people with confirmed previous medical diagnosis of chronic disease who were already undergoing treatment, accompanied by chronic diseases management programs, which, according to the hegemonic healthy model, should know the diseases that affect them with a sufficient degree of information that would allow their full compliance. Because these are people linked to health plans, with a higher socioeconomic strata, they would fit the criteria of information, income, education and access to health care that would turn them into ideal patients and adherent to therapy. Reasons for non-adherence to treatment among these participants are what motivated this research and generated the hypothesis that the therapeutic itinerary of these patients, generated and engraved in their culture, originates from an explanatory model of the illness process much wider than the hegemonic model. So these diseased would present strategies of self-care, as part of this layman model, which allows them to carry on and manage their treatment both within and without the current prevailing model, strategies those that can be seen by health professionals as noncompliance. We believe that this study achieved its objectives, supporting the initial hypothesis of the research, showing that even in a theoretically disciplined group within criteria taken as ideal for joining the biomedical model of illness and treatment, people are immersed in their culture and find loopholes for the exercise of self-care. The work also showed that the crisis of the biomedical model, in this case, stems from the microphysics power relations and from the structural conditions of the health system and the people in the group are able to identify some of these flaws. We hope this research will contribute to this relevant nowadays debate as well as collaborate in the reflections on medicine and health education, broadening the discussion to incorporate the experiences and narratives of this group of patients / Esta pesquisa tem como objetivo perceber o modelo explicativo e o itinerário terapêutico de um grupo de doentes acometidos por afecções crônicas assistidos por programas de gerenciamento de doenças realizados por operadoras de planos de saúde e identificar estratégias de cuidar de si que se inter-relacionam com seu modelo explicativo. A tese que move este estudo é de que o itinerário que o doente utiliza para seu tratamento tem profundas raízes na cultura, sendo muito mais amplo do que o modelo dos profissionais de saúde, por sua vez também gerado na cultura, porém restringido pela visão da biomedicina. Os significados de termos como saúde, cura, tratamento, incapacidade, dependência, entre outros, nem sempre são correspondentes em ambos os modelos. Caso o significado seja muito diferente, a adesão ao tratamento ficará prejudicada, mas o doente pode ter obtido alívio para seu sofrimento. A metodologia empregada é qualitativa, realizada mediante entrevistas com pessoas com diagnóstico médico prévio confirmado de doença crônica e que já se encontravam em tratamento, acompanhadas por programas de gerenciamento de doenças crônicas, as quais, segundo o modelo de atenção à saúde hegemônico, deveriam conhecer as doenças que os acometem com um grau de informação suficiente que permitisse sua adesão plena ao tratamento. Por se tratarem de pessoas vinculadas a planos de saúde, portanto de estratos socioeconômicos mais elevados, preencheriam os quesitos de informação, renda, educação e acessibilidade ao sistema de saúde que os transformaria em pacientes ideais e aderentes à terapêutica. O porquê da não adesão ao tratamento entre estes participantes é que despertou esta pesquisa e gerou a hipótese de que o itinerário terapêutico destes enfermos, gerado e inscrito na cultura, origina-se de um modelo explicativo do processo de adoecer mais amplo do que o modelo hegemônico. Estes adoecidos apresentariam assim estratégias de cuidar de si próprios, como parte deste modelo dito leigo, que faz com que convivam e gerenciem seu tratamento tanto dentro quanto à revelia do modelo predominante, estratégias estas que podem ser vistas pelos profissionais de saúde como não adesão. Acreditamos que esta pesquisa atingiu seus objetivos, corroborando a hipótese inicial do trabalho, demonstrando que, mesmo em um grupo teoricamente disciplinado dentro de critérios tidos como ideais para a adesão ao modelo biomédico de adoecimento e tratamento, as pessoas estão imersas na cultura e encontram brechas para o exercício do cuidar de si. O trabalho mostrou ainda que a crise do modelo biomédico, neste caso, advém tanto das relações microfísicas de poder quanto das condições estruturais do sistema de saúde e que as pessoas do grupo conseguem identificar algumas destas falhas. Esperamos que esta pesquisa possa contribuir para este debate tão atual, além de colaborar nas reflexões sobre a medicina e sobre o ensino na saúde, ampliando a discussão ao incorporar as experiências e narrativas deste grupo de enfermos

A alimentação é uma necessidade biológica e um fenômeno social. Estudos recentes registram aumento no desenvolvimento de doenças crônicas não transmissíveis relacionadas à alimentação. No Brasil, pesquisas tem identificado que a alimentação fora do domicílio tem contribuído para o aumento do sobrepeso e da obesidade O restaurante de refeição por peso tornou-se um ambiente rotineiro de refeições para muitos trabalhadores e apresenta-se como um espaço promissor para ações de promoção da saúde. OBJETIVO: Identificar representações sociais sobre fatores que influenciam as escolhas alimentares de clientes de restaurantes de refeição por peso e apreender a percepção de nutricionistas sobre possibilidades de desenvolvimento de ações de educação nutricional nesses locais. MÉTODO: Estudo transversal, qualitativo, tendo como referencial teórico as representações sociais na ótica da psicologia social de Moscovici. A pesquisa foi desenvolvida em duas etapas: a primeira ocorreu em dois restaurantes comerciais no município de São Paulo com a participação de 60 sujeitos, adultos de ambos os gêneros, e na segunda foram entrevistadas duas nutricionistas que atuam na área de alimentação coletiva. Os dados foram coletados após a aprovação do Comitê de Ética em Pesquisa da Faculdade de Saúde Pública da Universidade de São Paulo e assinatura de Termo de Consentimento Livre e Esclarecido. Utilizou-se entrevista gravada, seguindo roteiro semiestruturado para: investigar os condicionantes das escolhas alimentares de clientes em restaurantes de refeições por peso, identificar as representações sociais sobre a relação alimentação, saúde e doença, identificar conhecimento sobre alimentação saudável e apreender a percepção dos sujeitos sobre a necessidade de mudanças na sua rotina de alimentação visando a promoção de sua saúde. Para a análise dos dados utilizou-se a técnica do Discurso do Sujeito Coletivo, com o apoio do software Qualiquantsoft. Os resultados foram discutidos em um encontro com nutricionistas que atuam no ramo de restaurantes de refeição por peso, para se pensar estratégias de promoção da saúde nesses locais. RESULTADOS: Foram identificadas seis categorias para fatores que determinam as escolhas da refeição em restaurantes de refeição por peso. Sobre a escolha entre o sabor e a saúde (43 por cento ) da amostra pensa na saúde quando escolhe a refeição, (30 por cento ) tentam equilibrar a saúde e o sabor e (27 por cento ) se decidem pelo sabor. O conhecimento sobre escolhas saudáveis foi representado pelas seguintes Ideias Centrais (IC): saladas, alimentos com pouca gordura e frutas (36 por cento ); equilíbrio entre os grupos alimentares e um prato colorido (33 por cento ); comida simples e alimentos crus (19 por cento ). Também foram identificadas as representações de que as escolhas saudáveis incluem alimentos naturais; que depende da necessidade do organismo. Quanto à percepção do sujeito sobre a necessidade de mudança na sua rotina alimentar foram identificadas 12 Ideias Centrais, que representam categorias de análise. Apresentamos as cinco categorias que apresentaram maior frequência de contribuições: Não vê necessidade de mudança porque já cuida da dieta (24 por cento ); Mudaria várias coisas (23 por cento ); Comeria menos carne e frituras (15 por cento ); Comeria menos doces (13 por cento ); Comeria menos pão e massas à noite (11,6 por cento ). As nutricionistas que atuam em restaurantes de refeição de autosserviço não se surpreenderam com o fato dos clientes conhecerem as bases da alimentação saudável. Quanto às razões dos sujeitos não utilizarem essa informação no seu cotidiano as nutricionistas entendem que o preparo da comida exige tempo e que eles não gostam de cozinhar. As profissionais acreditam que os clientes fazem associação da alimentação com a saúde ou doença, mas que não se importam com essa questão no momento de servir-se. Referem que é contraditório atuar em ações de educação em saúde porque os restaurantes têm metas para vendas, e que estas iniciativas poderão ser possíveis se houver projetos aprovados em parceria com os responsáveis da empresa. As nutricionistas apresentaram como ações alternativas: atuar na produção das preparações reduzindo sal e gordura; desenvolver um projeto em parceria com o pessoal do setor financeiro; adaptar receitas reduzindo a densidade calórica e fazendo testes de aceitabilidade com os clientes. CONSIDERAÇÕES FINAIS: A maioria dos sujeitos valorizou o aspecto visual e estético relacionados à apresentação dos alimentos no balcão de autosserviço, sua aparência e qualidade como fatores decisivos para suas escolhas alimentares. A variedade na oferta de alimentos, o tempo reduzido de espera para tomar sua refeição, o preço e a fome influenciam a qualidade e a quantidade de alimento a ser consumido. De uma forma geral, os sujeitos que almoçam em restaurantes de refeição por peso convivem com o dilema de decidirse entre o sabor e a saúde e que o nutricionista convive com o conflito entre as metas de venda e a promoção da saúde de sua clientela. As representações sociais demonstram que essa clientela conhece conceitos básicos da alimentação saudável. Os sujeitos reconhecem a necessidade de melhorar sua alimentação para promover sua saúde, contudo referem dificuldades para alterar sua rotina. Apontam causas sociais como morar sozinho, não saber cozinhar, não ter tempo para essas tarefas e também falta de motivação para essas mudanças. Frente à urgência do enfrentamento das doenças crônicas não transmissíveis no Brasil, recomenda-se que o tema educação nutricional para escolhas saudáveis em restaurantes de autosserviço seja explorado em outras pesquisas / The feeding is a biological necessity and a social phenomenon. Recent studies registeincrease in the development nontransmissible chronic diseases related to the feeding. In Brazil, research has identified that out-of-home feeding has contributed for thincrease of the overweight and the obesity. The meal by weight restaurant became routine environment of meals for many workers and is presented as a promising spacfor action of health promotion. OBJECTIVE: Identify social, cultural and symbolicquestions that support the alimentary choices of customers who frequent meal by weightrestaurant, aiming to contribute with subsidies to instrument the educative interventionsin the area of the feeding. Identify nutritionist´s perceptions about possibilities of health promotion actions in meal by weight restaurant. METHOD: Transversal studyqualitative, supported for the theory of the social representations and for the theory ofthe social determination of the health-illness process. The research was developed intwo commercial restaurants in the city of São Paulo with the participation of 60 adultsubjects of both genders, and two nutritionists who acts in the area of collective feedingThe data were collected after approval of the Committee of Ethics in Research of theFaculty of Public Health of the University of São Paulo and after signature of Term ofFree and Clarified Assent. Recorded interview was used, following semi-structuredscript to investigate the conditions of the alimentary choices of subjects who frequents meal by weight restaurant, to explore the social representations on the feeding- healthillness relation, to identify knowledge about healthful feeding and to know the perception of the subject on the necessity of changes in your feeding routine to promotehis health. For data analysis was used the technique of Discourse of the CollectiveSubject, with the support of Qualiquantsoft software. The results were discussed in meeting with nutritionists who acts in the meal by weight restaurant, to think health promotion strategies in these places. RESULTS: Six categories were identified forfactors that determine the choices of meals in meal by weight restaurant. About the decision between the taste and health, (43 per cent ) of the sample thinks in health when picks the meal, (30 per cent ) try to balance the health and taste and (27 per cent ) is decided by the taste.The knowledge about healthy choices was represented by the following Central Idea(IC): salads, foods with low fat and fruits (36 per cent ); balance between the alimentary groups and a colorful plate (33 per cent ); simple food and raw foods (19 per cent ). Also it was identified representations that healthy choices include natural foods; and that depends on the needof the organism. Regarding the perception of the subject about need for change in your alimentary routine, were identified 12 IC that represents analysis categories. We showthe five categories that presented higher frequency of contributions: Sees no need to change because already takes care of the diet (24 per cent ); Would change many things (23 per cent );Would eat less meat and fried foods (15 per cent ); Would eat less candies (13 per cent ); Would ealess bread and pasta at night (11.6 per cent ). The nutritionists who acts in auto servicrestaurants were not surprised at the fact of the customers know the bases of the healthyfeeding. Referring to the question of them do not use this information in their everydaythe nutritionists understand that cooking demands time and they do not like to cook. They believe that the customers make association of the feeding with the health or disease, but that they do not care with this in the time of serving themselves. Regarding the nutritionist´s acting in heath education actions, two IC were identified: it´s contradictory to nutritionist to act it in the health education because it has sales goals; it is possible if partnership with the responsible of the company exists. The nutritionists presented three alternatives of action to promote the health of the customers: To act in meals production reducing salt and fat; to develop a project together with the financial department staff; to adapt recipes reducing the caloric density and making acceptability tests with the customers. CONCLUSION: That despite the inconvenient of offering of alimentary item with high caloric density, this service appears as a possibility for individuals to have access to a varied diet and regular offering of vegetables and products from more traditional Brazilian cuisine. In general, the subjects that lunch in meal by weight restaurants coexist with the dilemma of deciding between taste and health, and the nutritionist coexist with the conflict between the goals of sales and the promotion of the health of its clientele. The subjects of common sense demonstrate knowledge of basic concepts of healthy feeding and identify points for improvement in your feeding routine to promote their health, but report difficulties to change their feeding routine. The justifications show social causes like living alone, not to know to cook, do not have time for these tasks and also lack of motivation for these changes. Considering the urgency of confronting the nontransmissible chronic diseases in Brazil, it is recommended that the theme of nutrition education and healthy choices for autonomy in self-service restaurants to be explored in other studies

Com a atual transição demográfica refletida no envelhecimento populacional, as doenças crônicas transmissíveis foram substituídas pelas doenças crônicas não transmissíveis (DCNT), que ocasionam implicações no processo do envelhecimento saudável, para o idoso e para as famílias, havendo a necessidade da procura por Instituições de Longa Permanência para Idosos (ILPI). Nesse contexto, o objetivo desse trabalho foi descrever o perfil de saúde de idosos residentes em instituições de longa permanência públicas do município de Bauru/SP, possibilitando o tratamento e monitoramento para melhor qualidade de vida dessa população. Trata-se de um estudo transversal descritivo analítico, realizado entre os anos 2015 e 2017, com amostra constituída por 146 idosos residentes das duas únicas ILPI públicas do município de Bauru/Sp. Foram realizados exames de hemograma, glicemia de jejum, e perfil lipídico para avaliar respectivamente anemia, diabetes e dislipidemia nessa população. Foram utilizados dados sóciodemográficos dos prontuários médicos dos residentes e utilizado o IMC dos idosos para avaliação nutricional. Os resultados obtidos destacam que 72 (49%) idosos eram do sexo masculino e 74 (51%) do sexo feminino, com prevalência de indivíduos com idade entre 60 e 69 anos (40%) com pele branca (68,5%). Quanto ao hemograma, 33 (22,6%) idosos estavam com valores indicativos de anemia, 54 (37%) resultados abaixo do aceitável de HDL-colesterol, 44 (30,1%) idosos com resultados elevados de LDL-colesterol, característicos de dislipidemias. 77% dos idosos apresentaram peso normal, indicando boa condição nutricional. As mulheres foram as mais acometidas (17,6%) pelo baixo peso na faixa etária entre 60 e 69 anos em associação com os casos de anemia. Concluímos que as condições de saúde da maioria dos idosos residentes em ILPI públicas no município de Bauru foram consideradas de boa qualidade frente aos desafios diários, fragilidades individuais e a complexidade de fatores envolvidos nesta avaliação. A prática de exercícios físicos para o controle das dislipidemias é de extrema importância durante o envelhecimento, porém nas instituições os exercícios são realizados com moderação respeitando as individualidades. Ressalta-se a importância dos cuidados multiprofissionais adequados e aos exames de sangue periódicos para que haja integração do conhecimento sobre o perfil de saúde e monitoramento das doenças crônicas, promovendo a melhor qualidade de vida dos idosos, especialmente os institucionalizados. / With the current demographic transition reflected in population aging, chronic communicable diseases have been replaced by chronic noncommunicable diseases (NCDs), which have implications for the aging process for the elderly and for families. Long Stay for the Elderly people (ILPI). In this context, the objective of this study was to describe the health profile of elderly people living in long-term public institutions in the city of Bauru/SP, allowing treatment and monitoring to improve the quality of life of this population. This is a descriptive cross-sectional analytical study, carried out between 2015 and 2017, with a sample of 146 elderly residents of the only two public ILPI in the city of Bauru/SP. Hemogram, fasting glycemia, and lipid profile tests were performed to assess anemia, diabetes and dyslipidemia in this population, respectively. Data from medical records and BMI of the elderly were used for nutritional evaluation. The results showed that 72 (49%) of the elderly were male and 74 (51%) were female, with a prevalence of individuals aged between 60 and 69 years (40%) and white skin (68.5%). Regarding the CBC, 33 (22.6%) elderly patients had values indicative of anemia, 54 (37%) below-acceptable HDL-cholesterol, 44 (30.1%) elderly patients with high LDL-cholesterol Of dyslipidemias. 77% of the elderly presented normal weight, indicating an excellent nutritional condition. The women were the most affected (17.6%) due to the low weight in the age group between 60 and 69 years, all of them being associated with anemia. We conclude that the health conditions of the majority of the elderly people living in public ILPI in the city of Bauru were considered of good quality in face of daily challenges, individual fragilities and the complexity of factors involved in this evaluation. The practice of physical exercises for the control of dyslipidemias is extremely important during aging, but in institutions the exercises are performed with moderation respecting the individualities. The importance of appropriate multiprofessional care and periodic blood exams is important in order to integrate knowledge about the health profile and monitoring of chronic diseases, promoting the better quality of life of the elderly, especially the institutionalized ones.

L’étude du temps de survenue d’un événement représente un champ très important des statistiques. Lorsque l’événement étudié est le décès, on cherche à décrire la survie des individus ainsi que leur taux de mortalité, c’est-à-dire la « force de mortalité » qui s’applique à un instant donné. Les patients atteints d’une maladie chronique présentent en général un excès de mortalité par rapport à une population ne présentant pas la maladie en question. En épidémiologie, l’étude du taux de mortalité en excès des patients, et notamment de l’impact des facteurs pronostiques sur celui-ci, représente donc un enjeu majeur de santé publique. D’un point de vue statistique, la modélisation du taux de mortalité (en excès) implique de prendre en compte les effets potentiellement non-linéaires et dépendants du temps des facteurs pronostiques ainsi que les interactions. Les splines de régression, polynômes par morceaux paramétriques et flexibles, sont des outils particulièrement bien adaptés pour modéliser des effets d’une telle complexité. Toutefois, la flexibilité des splines de régression comporte un risque de sur-ajustement. Pour éviter ce risque, les splines de régression pénalisées ont été proposées dans le cadre des modèles additifs généralisés. Leur principe est le suivant : à chaque spline peuvent être associés un ou plusieurs termes de pénalité contrôlés par des paramètres de lissage. Les paramètres de lissage représentent les degrés de pénalisation souhaités. En pratique, ils sont inconnus et doivent être estimés tout comme les paramètres de régression. Dans le cadre de cette thèse, nous avons développé une méthode permettant de modéliser le taux de mortalité (en excès) à l’aide de splines de régression multidimensionnelles pénalisées. Des splines cubiques restreintes ont été utilisées comme splines unidimensionnelles ou bien comme bases marginales afin de former des splines multidimensionnelles par produits tensoriels. Le processus d’optimisation s’appuie sur deux algorithmes de Newton-Raphson emboîtés. L’estimation des paramètres de lissage est effectuée en optimisant un critère de validation croisée ou bien la vraisemblance marginale des paramètres de lissage par un algorithme de Newton-Raphson dit externe. A paramètres de lissage fixés, les paramètres de régression sont estimés par maximisation de la vraisemblance pénalisée par un algorithme de Newton-Raphson dit interne.Les bonnes propriétés de cette approche en termes de performances statistiques et de stabilité numérique ont ensuite été démontrées par simulation. La méthode a ensuite été implémentée au sein du package R survPen. Enfin, la méthode a été appliquée sur des données réelles afin de répondre aux deux questions épidémiologiques suivantes : l’impact de la défavorisation sociale sur la mortalité en excès des patients atteints d’un cancer du col de l’utérus et l’impact de l’âge courant sur la mortalité en excès des patients atteints de sclérose en plaques / Time-to-event analysis is a very important field in statistics. When the event under study is death, the analysis focuses on the probability of survival of the subjects as well as on their mortality hazard, that is, on the "force of mortality" that applies at any given moment. Patients with a chronic disease usually have an excess mortality compared to a population that does not have the disease. Studying the excess mortality hazard associated with a disease and investigating the impact of prognostic factors on this hazard are important public health issues in epidemiology. From a statistical point of view, modelling the (excess) mortality hazard involves taking into account potentially non-linear and time-dependent effects of prognostic factors as well as their interactions. Regression splines (i.e., parametric and flexible piecewise polynomials) are ideal for dealing with such a complexity. They make it possible to build easily nonlinear effects and, regarding interactions between continuous variables, make it easy to form a multidimensional spline from two or more marginal one-dimensional splines. However, the flexibility of regression splines presents a risk of overfitting. To avoid this risk, penalized regression splines have been proposed as part of generalized additive models. Their principle is to associate each spline with one or more penalty terms controlled by smoothing parameters. The smoothing parameters represent the desired degrees of penalization. In practice, these parameters are unknown and have to be estimated just like the regression parameters. This thesis describes the development of a method to model the (excess) hazard using multidimensional penalized regression splines. Restricted cubic splines were used as one-dimensional splines or marginal bases to form multidimensional splines by tensor products. The optimization process relies on two nested Newton-Raphson algorithms. Smoothing parameter estimation is performed by optimizing a cross-validation criterion or the marginal likelihood of the smoothing parameters with an outer Newton-Raphson algorithm. At fixed smoothing parameters, the regression parameters are estimated by maximizing the penalized likelihood by an inner Newton-Raphson algorithm.The good properties of this approach in terms of statistical performance and numerical stability were then demonstrated through simulation. The described method was then implemented within the R package survPen. Finally, the method was applied to real data to investigate two epidemiological issues: the impact of social deprivation on the excess mortality in cervical cancer patients and the impact of the current age on the excess mortality in multiple sclerosis patients

The fragmented approaches to delivering health care services in the United States, along with the associated structural inefficiencies and unsustainable increases in health care costs affecting all payers, compel the need for reform. Various federal and state-level delivery system reform models have emerged in response. The Medical Home (MH) is one of such reform models. In 2004 a national initiative entitled "The Future for Family Medicine Project" identified the lack of emphasis on comprehensive primary care, especially for chronic care patients, and proposed the introduction of MHs to improve comprehensive primary care delivery for every patient. Oregon's MH variant, the Patient-Centered Primary Care Home (PCPCH), was introduced in 2009 as part of a state-wide health reform initiative ushered in by the passage of House Bill 2009 to promote the Triple Aim. Since 2011, over 600 primary care clinics have been recognized as PCPCHs. Proponents of the model argued that it will help improve comprehensive primary care services upstream and reduce inappropriate utilization of Emergency Department (ED) and Inpatient (IP) care and expenditures downstream. Evidence on the model's application to reduce ED and IP utilization and expenditures have so far been mixed. Based on growing interests in the effects of the model's application to provide care for different types of patients, this research was designed to evaluate the policy effects of the application of PCPCHs, with a focus on PCPCHs that treat greater proportions of chronic care patients, to answer the following questions: (1) What is the average chronic disease burden of PCPCHs, and how does their average chronic disease burden compare to the communities PCPCHs are in pre-post PCPCH recognition? (2) How do primary care expenditures change based on the chronic disease burden of PCPCHs? (3) Do PCPCHs that engage more high chronic disease burden patients have more reductions in ED and IP expenditures? For this research, a chronic disease burden measure was developed from 10 markers of chronic conditions. This measure was then used to stratify PCPCH clinics and their comparators into high and low chronic disease burden clinics. The research was designed as a natural experiment, utilizing difference-in-difference methods to measure outcome differences pre-post PCPCH policy implementation and comparing outcome differences between PCPCHs and their control groups. The unit of analysis was PCPCH clinics. The theoretical perspectives that informed this research were Risk Selection and Complex Adaptive Systems (CAS). Data from Oregon's All Payer All Claims (APAC) data system, which included 16 quarters of claims and eligibility data from fourth quarter 2010 to third quarter 2014, as well as PCPCH attestation data on 525 clinics were utilized for this research. The results suggest that the chronic disease burden for PCPCHs was significantly lower than their comparator groups before clinics recognition as PCPCHs, but the chronic disease burden did not change after clinics recognition as PCPCHs. Average primary care expenditures did not change after PCPCH recognition. Average ED and average IP expenditures for high chronic disease burden PCPCHs did not change but rather decreased significantly for low chronic disease burden PCPCHs. The results imply that the distribution of chronic disease burden in PCPCHs is important and related to ED and IP expenditures, but in a different direction than expected. The results also suggest that focusing on low chronic disease burden patients in PCPCHs could help reduce ED and IP expenditures in the short and medium terms. Policies to engage a broader mix of chronic disease burden patients in PCPCHs could help increase savings from ED and IP utilization. The results also suggest the need for more research to improve current understanding of how PCPCHs are impacting health care trajectories in the current delivery system environment.

Diabetes, a chronic disease with devastating but preventable consequences, is common in the United States, especially within African American communities. Earlier research has indicated that 21.7% of African American parents have children diagnosed with Type 1 diabetes in the Mississippi Delta Region. Researchers have examined coping, stress, and behaviors of African American parents of children diagnosed with Type 1 diabetes; however, there is a gap in literature regarding how African American parents can cope with stress and how changes in health behavior due to Type 1 diabetes impact African American families. The purpose of this qualitative phenomenological study was to explore the lived experiences of African American parents, examining how they can cope with stress and how their families are impacted by the changes in health behavior due to Type 1 diabetes. The transtheoretical model, used to evaluate a person's preparedness to pursue a new healthier behavior, was applied. Through semi-structured interviews, data collected from 13 families were recorded, transcribed, and coded into themes. Phenomenological data analysis was performed based on the descriptive technique, using a computer-based NVivo model and preset codes. In this study, African Americans are likely to accept and acknowledge the impact of denial as a coping mechanism, while accepting the behavioral changes, and this will likely alert professionals in this field of study. Also, this will lead to a positive social change in the study of Type 1 Diabetes.

Hintergrund: Ein signifikanter Anteil der Patienten mit einer chronischen körperlichen Erkrankung weist eine komorbide psychische Störung auf. Ob und in welchem Ausmaß sich die Prävalenzraten psychischer Störungen bei Patienten mit einer chronischen Erkrankung von denen der Allgemeinbevölkerung unterscheiden, ist bislang noch kaum untersucht. Fragestellung: Die vorliegende epidemiologische Studie untersucht geschlechts- und altersadjustierte 4-Wochen, 12-Monats- und Lebenszeitprävalenzen psychischer Störungen bei Rehabilitationspatienten mit muskuloskelettalen und kardiovaskulären Erkrankungen im Vergleich zu Prävalenzraten der Allgemeinbevölkerung. Methode: Die Daten der drei Stichproben (N = 4192) basieren jeweils auf einem zweistufigen, epidemiologischen Untersuchungsansatz mit einer schriftlichen Befragung der Patienten bzw. Probanden zu ihrem psychischen Befinden (GHQ-12; M-CIDI-S) und einem anschließenden Interview (M-CIDI) bei einem randomisiert ausgewählten Teil der Gesamtstichprobe. Ergebnisse: Mit adjustierten Lebenszeitprävalenzen von 59.3 % (OR: 1.6) und 56.2 % (OR: 1.4) weisen die Patienten mit einer muskuloskelettalen und kardiovaskulären Erkrankung im Vergleich zur Allgemeinbevölkerung (47.9 %) eine deutlich erhöhte Prävalenz psychischer Störungen auf. Am häufigsten sind affektive Störungen (22.5 % bis 34.9%) und Angststörungen (18.4 % bis 33.8 %). Schlussfolgerung: Der im Vergleich zur Allgemeinbevölkerung deutliche Zusammenhang zwischen chronischen körperlichen Erkrankungen und psychischen Störungen verdeutlicht die Bedeutsamkeit einer verstärkten Diagnostik und Behandlung komorbider psychischer Störungen bei chronisch erkrankten Patienten. / Background: A significant part of patients with chronic diseases have comorbid mental disorders. However, by now it is nearly unexplored if and to what extend the prevalence rates of mental disorders in patients with chronic diseases differ from the rates of the general population. Objective: The present epidemiologic study investigates sex- and age-adjusted 4-week, 12-months, and lifetime prevalence rates of mental disorders in inpatients with musculoskeletal and cardiovascular diseases compared to prevalence rates of the general population. Methods: In each sample (N = 4192), the data based on a two-stage epidemiologic design. The first stage entailed the use of a screening questionnaire for mental disorders (GHQ-12; M-CIDI-S). The second stage consisted of an interview (M-CIDI) of a randomised part of the sample. Results: The adjusted lifetime prevalence in both clinical samples (musculoskeletal: 59.3 %, OR 1.6; cardiovaskular: 56.2 %, OR 1.4) is high compared to the rate of the general population (47.9 %). Affective disorders (22.5 % to 34.9 %) and anxiety disorders (18.4% to 33.8 %) are the most common disorders. Conclusions: Compared to the general population there is a clear correlation between chronic diseases and mental disorders, that shows the importance of an improved diagnostic and treatment of patients suffering from comorbid mental disorders.

Cette recherche sur les barrières à l’accès pour les pauvres atteints de maladies chroniques en Inde a trois objectifs : 1) évaluer si les buts, les objectifs, les instruments et la population visée, tels qu'ils sont formulés dans les politiques nationales actuelles de santé en Inde, permettent de répondre aux principales barrières à l’accès pour les pauvres atteints de maladies chroniques; 2) évaluer les types de leviers et les instruments identifiés par les politiques nationales de santé en Inde pour éliminer ces barrières à l’accès; 3) et évaluer si ces politiques se sont améliorées avec le temps à l’égard de l’offre de soins à la population pour les maladies chroniques et plus spécifiquement chez les pauvres. En utilisant le Framework Approach de Ritchie et Spencer (1993), une analyse qualitative de contenu a été complétée avec des politiques nationales de santé indiennes. Pour commencer, un cadre conceptuel sur les barrières à l’accès aux soins pour les pauvres atteints de maladies chroniques en Inde a été créé à partir d’une revue de la littérature scientifique. Par la suite, les politiques ont été échantillonnées en Inde en 2009. Un cadre thématique et un index ont été générés afin de construire les outils d’analyse et codifier le contenu. Finalement, les analyses ont été effectuées en utilisant cet index, en plus de chartes, de maps, d'une grille de questions et d'études de cas. L’analyse a tété effectuée en comparant les barrières à l’accès qui avaient été originalement identifiées dans le cadre thématique avec celles identifiées par l’analyse de contenu de chaque politique. Cette recherche met en évidence que les politiques nationales de santé indiennes s’attaquent à un certain nombre de barrières à l’accès pour les pauvres, notamment en ce qui a trait à l’amélioration des services de santé dans le secteur public, l’amélioration des connaissances de la population et l’augmentation de certaines interventions sur les maladies chroniques. D’un autre côté, les barrières à l’accès reliées aux coûts du traitement des maladies chroniques, le fait que les soins de santé primaires ne soient pas abordables pour beaucoup d’individus et la capacité des gens de payer sont, parmi les barrières à l'accès identifiées dans le cadre thématique, celles qui ont reçu le moins d’attention. De plus, lorsque l’on observe le temps de formulation de chaque politique, il semble que les efforts pour augmenter les interventions et l’offre de soins pour les maladies chroniques physiques soient plus récents. De plus, les pauvres ne sont pas ciblés par les actions reliées aux maladies chroniques. Le risque de les marginaliser davantage est important avec la transition économique, démographique et épidémiologique qui transforme actuellement le pays et la demande des services de santé. / This research on the barriers to access chronic disease care for the poor in India has three objectives: 1) to assess whether the goals, objectives, instruments and targeted populations, as formulated in current national health policies in India, address the main barriers to access chronic disease care for the poor; 2) to assess the types of policy levers and instruments identified in current national health policies to address these barriers to access; 3) And to assess whether national health policies in India have improved over time with respect to ensuring chronic disease care to the population and more specifically to the poor. Using Ritchie and Spencer’s framework approach (1993), a qualitative content analysis was completed on selected Indian national health policies. To begin with, a conceptual framework on the barriers to access chronic disease care for the poor in India was generated from a review of the scientific literature. Policy documents were then sampled in India in 2009. A thematic framework and index scheme were generated to build the analysis tools and codify the content. Finally, the analysis was conducted using indexing, charts, maps, questions grids and case studies. It was achieved by comparing the barriers to access identified in the original conceptualization to those identified by the content analysis of each policy. This research highlights that a number of barriers to access for the poor in India are addressed by national health policies as they relate to upgrading services in the public sector, improving the knowledge of the population and scaling up some interventions for chronic disease care. On the other hand, barriers related to the costs of chronic disease care, the affordability of outpatient services and people’s ability to pay for them were the least addressed from the framework that was previously established. Moreover, when looking at the timeline of our sample of policies, it appears that efforts to scale up interventions for physical chronic diseases are more recent. In addition, the poor are not targeted specifically for actions related to chronic disease care. The risk of marginalizing them further is important as economic, demographic and epidemiologic transitions are transforming the country and the demand for health services.