Introduction : Il existe peu de données sur l’alimentation des Canadiens issus de la diversité culturelle, y compris des immigrants, particulièrement sur la consommation d’aliments ultra-transformés (AUT) associée à une faible qualité nutritionnelle et à un risque accru de maladies chroniques. Objectif : Cette étude vise à estimer les niveaux de consommation d’AUT parmi les adultes issus de la diversité culturelle au Canada et selon certains marqueurs d’acculturation. Méthode : Les données de rappel de 24 h (n= 13 697) issues de l’Enquête sur la santé dans les collectivités canadiennes (ESCC 2015) ont été utilisées afin d’estimer les niveaux d’apport en AUT (pourcentage calorique quotidien) parmi la diversité culturelle. Des analyses ont permis d’estimer la consommation en AUT selon certains marqueurs culturels (statut d’immigration, groupe ethnoculturel) et d’acculturation (pays de naissance, temps depuis l’immigration, langues parlées). Des analyses ANOVA ont permis de comparer la consommation d’AUT avec les groupes de référence sélectionnés. Résultats : La consommation d’AUT était moindre parmi les immigrants canadiens que les non-immigrants et présentait des variations parmi les communautés ethnoculturelles. Celle-ci était significativement plus élevée parmi les immigrants « blancs », ceux d’origine latino-américaine et ceux résidant au Canada depuis plus longtemps. Elle variait aussi selon les groupes ethnoculturels. La consommation d’AUT ne semblait pas associée aux langues parlées. Conclusion : L’apport calorique provenant des AUT varie en fonction de la diversité culturelle et devrait être considéré dans les interventions destinées à ces groupes au Canada. / Background: There is little data on the diet of culturally diverse Canadians, including immigrants, particularly on the consumption of ultra-processed foods (UPF) which is associated with poor nutritional quality and an increased risk of chronic disease. Objective: The aim of this study is to estimate the levels of UPF consumption among culturally diverse adults in Canada and according to selected acculturation markers. Methods: 24h recall data (n=13,697) from the Canadian Community Health Survey (CCHS 2015) was used to estimate the mean of the usual UPF intake levels (daily caloric percentage) among cultural diversity. Statistics helped estimate UPF intake according to certain cultural markers (immigration status, ethnocultural group) and acculturation markers (country of birth, time since immigration, languages spoken). ANOVA analyses were used to compare UPF consumption with selected reference groups. Results: UPF consumption was lower among Canadian immigrants than non-immigrants, and there were variations of consumption between ethnocultural communities. UPF consumption was significantly higher among "white" immigrants, those of Latin American origin and those who had been in Canada for longer. UPF consumption did not appear to be associated with variables of languages spoken. Conclusion: Caloric intake coming from UPF consumption varies according to cultural diversity, and this needs to be considered in interventions targeting ethnocultural groups in Canada.

Plusieurs études à ce jour démontrent que la consommation d’aliments ultra-transformés (AUT) serait associée à une alimentation de faible qualité et à une augmentation du risque de maladies chroniques non-transmissibles (MCNT) et d’obésité. Actuellement, pour les adultes canadiens, il n’existe encore aucun questionnaire permettant de discriminer rapidement entre différents profils de consommateurs d’AUT. Ce mémoire présente donc un projet pilote de développement et de validation initiale d’un Outil pour mesurer la consommation de Produits Ultra-Transformés (le OUTPUT). Pour ce faire, les catégories d’AUT contribuant à 0,5% et plus de l’apport énergétique total des adultes canadiens ont été identifiées d’après les données de consommation nationale (ESCC) de 2015. Ces catégories ont été représentées par des photos d’AUT vendus en épicerie et en restauration rapide. Celles-ci constituaient les deux questionnaires alimentaires simplifiés développés (rappel de 24 heures et questionnaire de fréquence). La validité apparente et de contenu du OUTPUT a été évaluée par un comité d’experts, avec la méthode Delphi. Deux tours d’enquête ont été nécessaires pour observer un consensus (fixé à 80% et plus) quant aux dimensions évaluées. La validité apparente de l’outil a ensuite été évaluée par 11 membres de la communauté de l’UdeM. Les données recueillies à travers cette étude pilote ont permis d’émettre des recommandations pour l’étude future de développement et de validation de l’outil. Une fois validé, celui-ci permettra aux nutritionnistes, aux chercheurs en épidémiologie et aux décideurs politiques une meilleure identification, gestion et prévention des MCNT et d’obésité, en lien avec la consommation d’AUT. / Several studies to date have shown that ultra-processed food consumption (UPF) is associated with low diet quality and increased risk of non-communicable diseases (NCDs) and obesity. Currently, there is no rapid screener to estimate UPF consumption based on Canadian dietary patterns. This research presents a pilot study that addresses the early stages of the development and validation of a screener to this purpose (the OUTPUT). Ultra-processed food categories contributing to 0.5% or more of the total energy intake for Canadian adults (18 years and older) were identified based on 2015 national consumption data (CCHS). Thus, two simplified dietary screeners were developed (a 24-hour recall and a food frequency questionnaire). The face and content validity of the OUTPUT was evaluated by an expert advisory committee, through the Delphi method. Two rounds were required to observe an agreement (set at 80% or more) regarding the different metrics that were assessed. The face validity of the screener was then evaluated by 11 participants from the UdeM community. The data collected through this pilot study made it possible to provide recommendations for the future study in which the development and validation of the tool will take place. Once validated, this tool will enable nutritionists, epidemiology researchers, and policymakers to better identify, manage and prevent NCDs and obesity.

[pt] O consumo de alimentos ultraprocessados, ao lado do consumo do tabaco e do álcool, constitui uma das principais causas de doenças crônicas não transmissíveis – principal causa de mortes em adultos no Brasil –, sendo a publicidade de tais produtos considerada pela Organização Mundial da Saúde um dos fatores comerciais determinantes deste problema de saúde pública. A situação demanda a análise quanto a se o controle jurídico da publicidade no país tutela, de forma suficiente, os direitos fundamentais à saúde e à proteção do consumidor impactados pelas estratégias de marketing da indústria alimentícia. Neste sentido, o trabalho se propõe a realizar esta análise, com o intuito de compreender o regime jurídico de controle da publicidade no Brasil, por meio das normas do Código de Defesa do Consumidor e da autorregulamentação publicitária, assim como a natureza da proteção jurídica da publicidade no Direito brasileiro, a partir dos conceitos de liberdade de expressão comercial e livre iniciativa, a fim de identificar a legitimidade de restrições a estes direitos, com foco em estudos doutrinários e pesquisas em Tribunais brasileiros, sobretudo no âmbito do Superior Tribunal de Justiça e do Supremo Tribunal Federal; realizando, por fim, algumas proposições críticas, com o objetivo de contornar os problemas verificados – em especial a necessidade de regulação específica para estabelecer medidas restritivas à publicidade destes alimentos. / [en] The consumption of ultra-processed foods, together with the consumption of tobacco and alcohol, constitutes one of the main causes of non-communicable diseases – the principal cause of deaths in adults in Brazil –, being the advertisement of such products deemed by the World Health Organization as one of the commercial determinants of such public health problem. The situation demands the analysis of the sufficiency of the legal regulation of commercial speech in the country, with a view to verify if it duly protects the fundamental rights to health and consumer protection once impacted by marketing strategies adopted by the food industry. Thus, this work proposes to carry on such analysis, with the intent to understand the legal regime of commercial speech regulation in the country, through the norms of the Consumer Protection Statute and the self-regulation code, as well as the nature of the legal protection of commercial speech under Brazilian law, related to the notions of rights to freedom of commercial speech and free enterprise, with the purpose to identify the legitimacy of restrictions to such rights. The work will focus in academic studies as well as research on Brazilian courts decisions, specially under the Superior Court of Justice and the Constitutional Supreme Court, finally, from an analytical perspective, aiming to identify existing problems – mainly, the need to implement specific regulation establishing restrictive measures to advertisements of ultra-processed foods.

Introdução - A obesidade infantil está pautada como assunto de saúde pública e exige a análise, implementação e avaliação de novas intervenções. O marketing é apontado como um dos fatores que interferem no aumento do índice de sobrepeso e de obesidade da população. As estratégias de comunicação publicitária se utilizam de processos cognitivos para determinar, através de elementos emocionais do receptor, a escolha e o consumo de alimentos não saudáveis, já que os publicitários respondem à demanda das empresas que buscam lucrar com seus produtos. Já se afirma que a regulamentação legal do marketing dos alimentos infantis não saudáveis deve ser adotada como instrumento de política pública na prevenção da obesidade. Assim, justifica-se a investigação de quais seriam as formas mais apropriadas para regular esse tipo de marketing no Brasil, de forma a garantir o direito à saúde e à alimentação adequada e saudável. Objetivo - Analisar o papel do marketing como um dos determinantes da obesidade infantil, buscando apontar, no campo jurídico, estratégias para a sua regulamentação no Brasil. Métodos - Revisão de literatura, análise de textos legislativos e de programas adotados para controle da obesidade infantil, além de entrevistas com representantes de entidades e profissionais diretamente ligados à implementação de políticas públicas, nacionais e internacionais, de controle da nutrição e saúde infantil, bem como de proteção dos direitos do consumidor infanto-juvenil. A interpretação dos dados levantados deu-se através do método científico dedutivo. Resultados - O crescente índice de obesidade no Brasil está demonstrado através de pesquisa nacional. A presença de alimentos no mercado com excesso de sal, gordura e açúcar precisa ser controlada. As teorias de comunicação explicam a influência do marketing na decisão emocional do consumidor. Os direitos à saúde e à alimentação adequada e saudável estão previstos na Constituição Federal. Conclusão - A regulamentação legal do marketing de alimentos não saudáveis é juridicamente possível e suas diretrizes devem focar os alimentos processados e ultraprocessados, além dos fatores que facilitam a persuasão da criança, impedindo o uso de elementos emocionais. / Introduction - Childhood obesity is considered a public health issue and requires the analysis, implementation and evaluation of new interventions. Marketing is considered as one of the factors that play a role in the increase of overweight and obesity rates in the population. Advertisement strategies use cognitive processes to determine, by means of emotional elements of the receptor, the choice and consumption of unhealthy foods, since advertisement professionals respond to the demand of companies willing to make a profit by selling their their products. The regulation of the marketing of unhealthy foods for children must be adopted as a public policy instrument for the prevention of obesity. Thus, we should investigate what are the most appropriate ways to regulate this kind of marketing in Brazil to guarantee the right to health and to adequate and healthy foods. Objective - Analyze the role of marketing as one of the determinants of childhood obesity, and try to identify legal strategies for its regulation in Brazil. Methods - Literature review, analysis of legal texts and programs implemented for the control of childhood obesity and interviews with representatives of institutions and professionals directly related to the implementation of public national and international policies for the control of childhood nutrition and health, as well as the protection of children and youth consumer rights. Deductive scientific method was used to interpret data. Results - Increasing obesity rates have been demonstrated by national surveys. The presence of foods with excessive salt, fat and sugar in market must be controlled. Communication theories explain the influence of marketing in the emotional decision of consumers. The right to health and to adequate and healthy foods is determined by the Federal Constitution. Conclusion - It is possible to regulate the marketing of unhealthy foods according to the law. The guidelines for regulation must focus on processed and ultra processed foods and the factors that facilitate persuasion of children, by prohibiting the use of emotional elements.

Introdução - A obesidade infantil está pautada como assunto de saúde pública e exige a análise, implementação e avaliação de novas intervenções. O marketing é apontado como um dos fatores que interferem no aumento do índice de sobrepeso e de obesidade da população. As estratégias de comunicação publicitária se utilizam de processos cognitivos para determinar, através de elementos emocionais do receptor, a escolha e o consumo de alimentos não saudáveis, já que os publicitários respondem à demanda das empresas que buscam lucrar com seus produtos. Já se afirma que a regulamentação legal do marketing dos alimentos infantis não saudáveis deve ser adotada como instrumento de política pública na prevenção da obesidade. Assim, justifica-se a investigação de quais seriam as formas mais apropriadas para regular esse tipo de marketing no Brasil, de forma a garantir o direito à saúde e à alimentação adequada e saudável. Objetivo - Analisar o papel do marketing como um dos determinantes da obesidade infantil, buscando apontar, no campo jurídico, estratégias para a sua regulamentação no Brasil. Métodos - Revisão de literatura, análise de textos legislativos e de programas adotados para controle da obesidade infantil, além de entrevistas com representantes de entidades e profissionais diretamente ligados à implementação de políticas públicas, nacionais e internacionais, de controle da nutrição e saúde infantil, bem como de proteção dos direitos do consumidor infanto-juvenil. A interpretação dos dados levantados deu-se através do método científico dedutivo. Resultados - O crescente índice de obesidade no Brasil está demonstrado através de pesquisa nacional. A presença de alimentos no mercado com excesso de sal, gordura e açúcar precisa ser controlada. As teorias de comunicação explicam a influência do marketing na decisão emocional do consumidor. Os direitos à saúde e à alimentação adequada e saudável estão previstos na Constituição Federal. Conclusão - A regulamentação legal do marketing de alimentos não saudáveis é juridicamente possível e suas diretrizes devem focar os alimentos processados e ultraprocessados, além dos fatores que facilitam a persuasão da criança, impedindo o uso de elementos emocionais. / Introduction - Childhood obesity is considered a public health issue and requires the analysis, implementation and evaluation of new interventions. Marketing is considered as one of the factors that play a role in the increase of overweight and obesity rates in the population. Advertisement strategies use cognitive processes to determine, by means of emotional elements of the receptor, the choice and consumption of unhealthy foods, since advertisement professionals respond to the demand of companies willing to make a profit by selling their their products. The regulation of the marketing of unhealthy foods for children must be adopted as a public policy instrument for the prevention of obesity. Thus, we should investigate what are the most appropriate ways to regulate this kind of marketing in Brazil to guarantee the right to health and to adequate and healthy foods. Objective - Analyze the role of marketing as one of the determinants of childhood obesity, and try to identify legal strategies for its regulation in Brazil. Methods - Literature review, analysis of legal texts and programs implemented for the control of childhood obesity and interviews with representatives of institutions and professionals directly related to the implementation of public national and international policies for the control of childhood nutrition and health, as well as the protection of children and youth consumer rights. Deductive scientific method was used to interpret data. Results - Increasing obesity rates have been demonstrated by national surveys. The presence of foods with excessive salt, fat and sugar in market must be controlled. Communication theories explain the influence of marketing in the emotional decision of consumers. The right to health and to adequate and healthy foods is determined by the Federal Constitution. Conclusion - It is possible to regulate the marketing of unhealthy foods according to the law. The guidelines for regulation must focus on processed and ultra processed foods and the factors that facilitate persuasion of children, by prohibiting the use of emotional elements.

Contexte : La rémission du diabète de type 2 (DT2) à la suite d'une chirurgie bariatrique ou d'une restriction calorique sévère a été démontrée possible. Cependant, la faisabilité d’un programme d’interventions comportementales ne comprenant pas l’une de ces deux approches thérapeutiques, ainsi que son impact sur le taux de rémission du DT2 et la santé cardiovasculaire (CV), demeure à explorer. Aussi, les programmes de rémission du DT2 ont rarement été évalués dans le contexte d’un centre terciaire de cardiologie préventive et de réadaptation cardiaque. Méthodes : L'étude pilote DIABÉPIC 2 a évalué la faisabilité d'un programme de rémission du DT2 de 6 mois, basé sur une rééducation nutritionnelle (réduction des aliments ultra-transformés et adoption d'un régime méditerranéen modéré en glucides) et un entraînement aérobique et en résistance (3 x 60 min/semaine). De plus, une portion des participants (randomisation 2 :1) a ajouté le jeûne intermittent (JI) au cours des trois derniers mois. L’étude s’est déroulée au centre de cardiologie préventive et de réadaptation cardiaque de l’Institut de cardiologie de Montréal. Il avait été établi approprié de procéder à une étude clinique plus importante si le taux de recrutement atteignait 6 participants/mois et si un minimum de 70% des participants complétait le programme de 6 mois, avec un minimum de 70% de participation aux visites cliniques et de recherche. L'étude a aussi exploré l’impact des interventions sur le taux de rémission du DT2 et sur la santé cardiométabolique, les paramètres anthropométriques, la capacité cardiorespiratoire, la qualité de la matrice alimentaire et les performances neurocognitives. Résultats : La faisabilité a été démontrée avec un taux de recrutement de 6,4 participants/mois, 34 participants sur 42 (81 %) ayant complété le programme (41,2 % de femmes, âge moyen de 63,6 ± 9,2 ans, durée du DT2 de 7,4 ± 6,7 ans, Hb1Ac 6,7 ± 0,7 %) et une participation moyenne aux visites cliniques et de recherche de 87 %. Treize de ces 34 participants ont obtenu une rémission du DT2 (38 %), avec une perte de poids moyenne de 6,8 kg (-9,3 à -4,4, p <0,001). Les analyses exploratoires ont montré une amélioration significative des paramètres cardiométaboliques et anthropométriques, de la capacité cardiorespiratoire et de la qualité de la matrice alimentaire. Les participants randomisés pour l'intervention additionnelle de JI n’ont pas obtenu d’améliorations significativement différentes comparé au groupe contrôle. Conclusion : Les personnes atteintes de DT2 recevant des soins dans un centre tertiaire de cardiologie ont montré un intérêt et une capacité à s’engager dans un programme de rémission du DT2. Les interventions comportementales ont permis à 38% des participants d’atteindre les critères de rémission du DT2. Des études randomisées plus larges sont nécessaires pour confirmer l'efficacité d’un programme basé sur la rééducation nutritionnelle, l’entraînement physique et le JI. / Background: Remission of type 2 diabetes (T2D) following bariatric surgery or severe caloric restriction has been shown to be possible. However, the feasibility of a behavioral intervention program not including one of these two therapeutic approaches, as well as its impact on the remission rate of T2D and cardiovascular (CV) health, remains to be explored. Also, T2D remission programs have rarely been evaluated in the context of a tertiary preventive cardiology and cardiac rehabilitation center. Methods: The DIABÉPIC 2 pilot study evaluated the feasibility of a 6-month T2D remission program, based on nutritional re-education (reduction of ultra-processed foods and adoption of a Mediterranean diet moderate in carbohydrates) and training aerobic and resistance training (3 x 60 min/week). Additionally, a portion of participants (2:1 randomization) added intermittent fasting (IF) in the last three months. The study took place at the preventive cardiology and cardiac rehabilitation center of the Montreal Heart Institute. It was deemed appropriate to proceed with a larger clinical study if the recruitment rate reached 6 participants/month and if a minimum of 70% of participants completed the 6-month program, with a minimum of 70% participation in clinical and research visits. The study also explored the impact of interventions on T2D remission rate and on cardiometabolic and anthropometric parameters, cardiorespiratory fitness, quality of food matrix and neurocognitive performance. Results: Feasibility was demonstrated with a recruitment rate of 6.4 participants/month, 34 of 42 participants (81%) who completed the program (41.2% women, mean age of 63.6 ± 9.2 years, duration of T2D 7.4 ± 6.7 years, HbA1c 6.7 ± 0.7%) and with 87% attendance at assessment and intervention sessions. Thirteen of these 34 participants achieved remission of T2D (38 %), with a mean weight loss of 6.8 kg (-9.3 to -4.4, p < 0.001). Exploratory analyzes showed a significant improvement in cardiometabolic and anthropometric parameters, cardiorespiratory capacity and quality of the food matrix. Participants randomized to the additional IF intervention did not achieve significantly different improvements compared to the control group. Conclusion: People living with T2D and receiving care in a terciary cardiology center showed interest and ability to engage in a T2D remission program. Behavioral interventions enabled 38% of participants to achieve T2D remission criteria. Larger randomized studies are needed to confirm the effectiveness of a program based on nutritional re-education, physical training and IF.