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Household food insecurity (HFI) has been related to adverse maternal-child health outcomes and mental health worsening during pregnancy. Few studies evaluated the temporal association between HFI and anxiety and depressive symptoms in pregnant women, and this association remains not completely understood. This study aimed to systematically review the association between HFI and symptoms of depression and anxiety in pregnant individuals. The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (CRD42022373615). Systematic searches were conducted on 10 electronic databases and grey literature. Two researchers independently conducted the study selection, data extraction process, and the risk of bias assessment. Random-effects meta-analysis models were used, and I 2  > 40% indicated high heterogeneity across studies. Eighteen articles were included for the systematic review, comprising n = 27,882, and a total of 18,987 pregnant individuals aged between 14 and 45 years were included in the meta-analysis. The prevalence of HFI reported in studies ranged from 12.6% to 62.1% (n = 17). The prevalence of depressive and anxiety symptoms ranged from 18% to 49% (n = 11) and 23% to 34% (n = 2), respectively. HFI during pregnancy was associated with increased odds of experiencing symptoms of depression [(OR: 2.52; 95% CI: 2.11-3.02), I 2  = 73.23%]. The quality of evidence was very low due to high heterogeneity. Our findings highlighted the association between HFI and depression symptoms during pregnancy. Findings from this study suggest the importance of assessing HFI and mental health during pregnancy., (© 2024 The Author(s). Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

The influence of family meals on nutrition and health for families has been understudied, especially in low- and middle-income countries. We aimed to analyze associations between regular family meals and body mass index (BMI), food consumption, eating, and sedentary behaviors among Brazilian schoolchildren and their caregivers. A cross-sectional study was conducted with 1887 Brazilian schoolchildren aged 6-11 years and their caregivers. Caregivers provided sociodemographic data, their child's weight and height, and the frequency of family meals. Schoolchildren provided data on gender and silhouette scale. Both provided their food consumption, eating, and sedentary behavior data. Associations between regular family meals and BMI, ultra-processed food consumption, and dietary diversity were assessed through multivariate logistic regression models. Correlations of regular family meals with eating and sedentary behaviors were assessed using Pearson chi-square. Regular family meals were frequent (86.6%), and they were associated with less unhealthy BMI in caregivers (AOR: 0.74; 95%CI: 0.5-0.9), as well as higher dietary diversity in caregivers (AOR: 1.66; 95%CI: 1.0-2.7) and in schoolchildren (AOR: 1.78; 95%CI: 1.4-2.3). The coexistence of high dietary diversity and both low ultra-processed food consumption (AOR: 1.45; 95%CI: 1.0-2.1) and healthy BMI (AOR: 1.41; 95%CI: 1.0-1.9) in children was associated with regular family meals. Regular family meals were correlated with healthy eating behaviors in child-caregiver dyads ( p < 0.002) and with sedentary behavior in caregivers ( p = 0.019). Our findings underscore regular family meals as a protective factor against malnutrition among Brazilian families.

Food insecurity (FI) is a critical issue in developing countries, particularly in low-resource settings, where it can worsen women's mental health. Psychosocial factors such as low household income, limited education, multiparity, and vulnerability are linked to depressive symptoms during pregnancy. Additionally, the family environment influences parental practices, which may impact mental health. This study evaluates the association of socioeconomic factors, parental practices, FI risk, and home visit frequency with depressive symptoms in pregnant women enrolled in the Happy Child Program (Programa Criança Feliz-PCF) in the Federal District, Brazil. In this cross-sectional study, 132 pregnant women monitored by PCF from May to July 2023 were assessed using a self-administered questionnaire for socioeconomic data, the two-item Triage for Food Insecurity (TRIA) instrument for FI risk, the Scale of Parental Beliefs and Early Childhood Care Practices, and the Beck Depression Inventory-II for depressive symptoms. Most participants were multiparous (87.9%), had low income (under 200 USD/month; 80.8%), presented depressive symptoms (67.4%) and were at risk of FI (81.8%). About half demonstrated adequate parental practices (50.8%) and received four home visits per month during pregnancy (54.5%). Women who received four PCF home visits had a lower prevalence of depressive symptoms compared to those with fewer visits (PR 0.76, 95% CI 0.59-0.98). No significant association was found between FI or parental practices and depressive symptoms. These findings suggest that the PCF home-visiting program may strengthen vulnerable families, support social networks, and improve mental health during pregnancy. Additionally, the results of this study highlight the need for targeted interventions aimed at reducing food insecurity and promoting mental health during pregnancy, particularly among socially vulnerable populations. Furthermore, they reinforce the importance of expanding access to home-visiting programs as an effective strategy to improve maternal mental health and well-being, while fostering healthier prenatal environments for both mothers and their children.

Background: Obesity is a non-communicable chronic disease which carries a high cost for the Brazilian Unified Health System. Standardized protocols can help primary health care (PHC) professionals manage the disease., Objectives: To describe the validation process of a protocol concerning dietary guidelines for adults with obesity in PHC by non-nutrition professionals., Methods: A validation study of a dietary advice protocol consisting of 6 recommendations was conducted according to Brazilian Dietary Guidelines. The topics incorporated into the recommendations were submitted to a panel of judges for content validity and achieved a Scale Content Validity Index (S-CVI) score >0.80. Subsequently, an online workshop was held and consisted of guiding questions to adequately improve current protocols. Face validity was assessed in a mediation workshop conducted with PHC non-nutrition professionals. Following the validation process, necessary adjustments were made to the eating protocol., Results: The validation process was conducted by a panel of 20 judges and 10 PHC professionals. The content was validated using a 0.98 S-CVI. The online workshop expert panel agreed the instrument provides a trustworthy foundation for appropriate dietary guidelines. Moreover, the judges suggested changes to the flowchart designed to support the professionals' decisions, discussed the absence of quantitative prescription guidelines, and offered additional suggestions to strengthen equity and encourage autonomy in non-nutrition healthcare professionals in PHC., Conclusion: This study describes the validation process of a dietary advice protocol for people with obesity, as well as the importance of its integration into PHC., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Household food insecurity (HFI) during childhood is associated with poor dietary diversity and malnutrition, placing children's growth at risk. Children with growth disorders, such as stunting, are more likely to have poor cognition and educational performance, lower economic status, and an increased risk of nutrition-related chronic diseases in adulthood. Our study aimed to systematically review and conduct a meta-analysis of cohort studies investigating the association between HFI and stunting in children aged 0-59 months. Peer-reviewed and grey literature were systematically searched in electronic databases with no language or date restrictions. Two reviewers independently assessed the studies for pre-established eligibility criteria. Data were extracted using a standard protocol. Random-effects meta-analysis models were used, and I 2  > 40% indicated high heterogeneity across studies. We used the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of the evidence. Nine cohort studies comprising 46,300 children were included. Approximately 80% (n = 7) of the studies found a positive association between HFI and stunting. Pooled odds ratio was 1.00 (95% confidence interval [CI]: 0.87-1.14; I 2 : 76.14%). The pooled hazard ratio between moderate and severe HFI and stunting was 1.02 (95% CI: 0.84-1.22; I 2 : 85.96%). Due to high heterogeneity, the quality of evidence was very low. Individual studies showed an association between HFI and stunting in children aged 0-59 months; however, this association was not sustained in the pooled analysis, possibly because of high heterogeneity across studies., (© 2023 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Investing in early childhood programs such as Brazil's Criança Feliz Program (PCF) to support low-income families in providing a nurturing care environment is critical to ensure that children reach their full developmental potential. We aimed to analyze the influence of the PCF on the nurturing care environment provided by families enrolled in the program in the Federal District, Brazil. A qualitative case study was conducted based on in-depth interviews with a purposive sampling of 22 caregivers enrolled in the PCF for at least six months. Eighteen subthemes emerged from the thematic analysis following the five components of the Nurturing Care Framework (i.e., good health, adequate nutrition, responsive care, early learning, and security and safety). Caregivers recognized the benefits of the PCF on children's mental health (good health) and reported challenges in providing adequate nutrition due to food insecurity (adequate nutrition). A bond between the home visitor and families was identified as critical to promote responsive parenting practices (responsive care). Caregivers appreciated the early stimulation activities provided during PCF home visits (opportunities for early learning). Access to social welfare programs, such as conditional cash transfer and food assistance, were facilitated through PCF multisectoral actions (safety and security). On the other hand, families reported not receiving support from PCF for issues such as breastfeeding, maternal mental health, and disciplinary practices. In summary, PCF enhanced the components of the nurturing care environment provided by families. However, their vulnerabilities and contextual implementation barriers may prevent families from fully benefiting from PCF activities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 dos Santos et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Combined deficiencies of nutrients such as iron and folic acid intake during pregnancy are related to nutritional deficiencies risk, such as anemia. The objective of this study was to analyze the association between risk factors (sociodemographic, dietary and lifestyle) and the intake of iron and folate by pregnant women followed up in Primary Health Care (PHC) in the Federal District, Brazil. A cross-sectional observational study was carried out with adult pregnant women of different gestational ages. A semi-structured questionnaire was applied by researchers trained to collect sociodemographic, economic, environmental, and health data. Two nonconsecutive 24-hour recalls (24hr) were carried out to collect data about food consumption. Multivariate linear regression models were used to analyze the association between sociodemographic and dietary risk factors and the consumption of iron and folate. The mean daily energy intake was 1726 kcal (95% CI 1641-1811), with 22.4% (95% CI 20.09-24.66) derived from ultra-processed foods (UPFs). The mean iron and folate intake were 5.28 mg (95% CI 5.09-5.48) and 193.42 µg (95% CI 182.22-204.61), respectively. According to the multivariate model, the highest quintile of ultra-processed foods intake was associated with lower iron (β = -1.15; IC 95%: -1.74; 0.55; p < 0.001) and folate intake (β = -63.23; IC 95%: -98.32; -28.15; p < 0.001). Pregnant women with high school degree presented higher iron intake (β = 0.74; IC 95%: 0.20; 1.28; p = 0.007) and folate intake (β = 38.95; IC 95%: 6.96; 70.95; p = 0.017) compared to pregnant women with elementary school degree. Folate consumption was also associated with the second gestational period (β = 39.44; IC 95%: 5.58; 73.30; p = 0.023) and pregnancy planning (β = 26.88; IC 95%: 3.58; 50.18; p = 0.024). Further research is warranted to enhance evidence on the relationship between the role of processed foods and micronutrients intake to strengthen the nutritional quality of diet of pregnant women attended in Primary Health Care.

Despite the global tendency of maternal anaemia to decline, the persistence of anaemia in Brazil is an important health problem given its vulnerability to deficiencies and the significant increase in nutritional requirements during pregnancy. The aim of this study was to estimate the prevalence of anaemia in Brazilian pregnant women through a systematic literature review and meta-analysis. The systematic review was carried out according to Systematic Reviews and Meta-Analyses PRISMA checklist recommendations and using the following electronic databases: Medline, Scopus, Embase, Web of Science, Lilacs, Scielo, Google Scholar, and CAPES Catalog of Theses and Dissertations. Studies that presented a prevalence of anaemia data in Brazilian pregnant women, considering all gestational trimesters, were included. The total sample included 12,792 pregnant women covering all gestational trimesters. The pooled prevalence of anaemia in Brazilian pregnant women was 23% (95% CI: 20-27), with the highest prevalence in the Northeast Region at 26% (95% CI 23-29), while the lowest prevalence was observed in the North Region with 17% (95% CI 14-20). Among the subgroups, no statistical difference was observed. The prevalence of anaemia status in Brazil is still classified as a moderate public health problem according to the World Health Organization maternal anaemia classification.

The quality of diet and nutritional status during pregnancy are crucial to optimize maternal and fetal health. Ultra-processed foods (UPFs) are increasingly prevalent in pregnancy groups despite being nutritionally unbalanced and associated with adverse perinatal outcomes. This cross-sectional study, conducted with data from 229 pregnant women, aimed to investigate the association between UPFs consumption and dietary nutrient intake of pregnant women assisted by Primary Health Care (PHC) in Federal District (DF), Brazil. Food consumption was assessed through two non-consecutive 24-h food records and categorized by the extent of processing using the NOVA classification. Multivariate linear regression models were used to analyze the association between the quintiles of UPF consumption and the total energy and nutrients intake. Mean daily energy intake was 1741 kcal, with 22.6% derived from UPFs. Greater UPF consumption was associated with reduced intake of unprocessed and minimally processed food. The highest quintile of UPFs was positively associated with higher total energy, trans fat, and sodium intake; and inversely associated with the diet content of protein, fiber, iron, magnesium, potassium, copper, zinc, selenium, and folate. Greater UPFs intake negatively impacts the nutritional quality of the diet and impoverishes the nutrient intake of pregnant women. Reducing UPF consumption may broadly improve dietary guidelines adherence in pregnant women and promote maternal and neonatal health.

The act of preparing food, especially at home, may be related to improvement in healthy eating patterns. This study analyzed the association between home-prepared meals consumption and the food markers consumption, and weight gain in pregnant women followed up in Primary Health Care in the Federal District (DF), Brazil. This is a cross-sectional study, conducted with pregnant women of all gestational ages. The characteristics of meals preparation and intake, as well as the consumption of food markers, were evaluated through structured questionnaires. Gestational weight gain was evaluated based on data recorded in the pregnant woman's booklet. Variables related to pregnancy, health, lifestyle, and socioeconomic status were analyzed as covariates. A total of 233 pregnant women were included in this study, with a mean age of 28.50 (SD = 6.32) years. Inadequate gestational weight gain was found in 46% of pregnant women. Consumption of soft drinks was 49% lower in pregnant women who prepared all meals at home. Eating home-prepared meals was inversely associated with a high score for unhealthy foods. Home-prepared meals consumption could be an effective health promotion strategy in Primary Health Care, helping to increase the chances of vegetable consumption, and decrease the consumption of soft drinks.

The consumption of ultra-processed food (UPF)-rich diets represents a potential threat to human health. Considering maternal diet adequacy during pregnancy is a major determinant for perinatal health outcomes, this study aimed to systematically review and meta-analyze studies investigating the association between maternal consumption of a UPF-rich diet and perinatal outcomes. Conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, five electronic databases and gray literature using Google Scholar and ProQuest Dissertations and Theses Global were searched up to 31 May 2022. No restrictions were applied on language and publication date. Two reviewers independently conducted the study selection and data extraction process. Meta-analysis was conducted according to the random-effects model. In total, 61 studies were included in the systematic review and the overall population comprised 698,803 women from all gestational trimesters. Meta-analysis of cohort studies showed that maternal consumption of UPF-rich diets was associated with an increased risk of gestational diabetes mellitus (odds ratio (OR): 1.48; 95% confidence interval (CI): 1.17, 1.87) and preeclampsia (OR: 1.28; 95% CI: 1.15, 1.42). Neonatal outcomes showed no association. The overall GRADE quality of the evidence for the associations was very low. The findings highlight the need to monitor and reduce UPF consumption, specifically during the gestational period, as a strategy to prevent adverse perinatal outcomes.

Background/objectives: Iodine deficiency in pregnant women is related to impaired foetal growth and development. The objective of this study was to estimate the prevalence of insufficient iodine intake in pregnant women from different regions of the world., Subjects/methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, five electronic databases and Google Scholar grey literature were searched until 10 April 2021. Two reviewers independently conducted article selection, data extraction, and assessment of the risk of bias. Meta-analyses with random effects, subgroup analyses, and meta-regressions were performed., Results: In total, 4639 observational articles were found, with 61 eligible for inclusion. The population consisted of 163,021 pregnant women adults and adolescents, and the overall prevalence of insufficient iodine intake was 53% (95% confidence interval [CI]: 47-60; I 2  = 99.8%). Pregnant women who live in insufficient iodine status country had a higher prevalence (86%; 95% CI: 78-93; I² =97.0%) of inadequate iodine nutritional status than to those living in country considered sufficient (51%; 95% IC: 45-57; I² = 99.8%)., Conclusion: Despite the progress in iodine fortification policies and periodic monitoring of the iodine nutritional status of the population worldwide, salt iodination alone may not be sufficient to provide adequate iodine status to pregnant women. Thus, other actions may be necessary to improve the nutritional clinical care of pregnant group., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Aim: The present study systematically reviewed the characteristics of the food environment in schools and their immediate vicinities associated with excess weight in adolescents., Methods: We searched for relevant articles in seven databases. No restrictions were applied on language, publication date, and status of publication. The study selection process and data extraction were conducted by two authors independently. For meta-analyses, the random-effects model and the maximum-likelihood method were applied., Results: A total of 9327 publications were identified from the initial search. Of these, 20 studies met the inclusion criteria and were included in the systematic review. The sale of food in school or immediate vicinity was associated with high BMI [Odds ratio (OR)= 1.14, 95% confidence interval (CI) 1.01, 2.06]. The availability of healthy food provided by school significantly decreased the odds of obesity [OR= 0.89, 95%CI 0.82, 0.96]. However, the presence of nutrition policies or programs at school was not associated with obesity (OR= 0.81, 95%CI 0.57, 1.16)., Conclusions: This study highlights the need for improvement in school food environment, including restricting students' exposure to unhealthy foods. The quality of food (healthy vs unhealthy) provided or made available to adolescents in the school food environment influences their weight status. Therefore, promotion of healthy food programs and availability of healthy food at school would limit the prevalence of excess weight in adolescents., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Dietary n -3 polyunsaturated fatty acids (PUFAs) present beneficial effects on counteracting inflammation status, displaying a critical anti-inflammatory role and maintaining physiological homeostasis in obesity. The primary objective of this systematic review was to evaluate the effect of n -3 PUFAs intake on the eicosanoid profile of people with obesity and overweight. The search strategy on Embase, Scopus, PubMed, Web of Science, Cochrane Library, Google Scholar and ProQuest was undertaken until November 2019 and updated January 2021. The effect size of n -3 PUFAs on prostaglandins was estimated by Glass's, type 1 in a random-effect model for the meta-analysis. Seven clinical trials met the eligible criteria and a total of 610 subjects were included in this systematic review, and four of seven studies were included in meta-analysis. The intake of n -3 PUFAs promoted an overall reduction in serum pro-inflammatory eicosanoids. Additionally, n -3 PUFAs intake significantly decreased the arachidonic acid COX-derived PG eicosanoid group levels (Glass's Δ -0⋅35; CI -0⋅62, -0⋅07, I 31⋅48). Subgroup analyses showed a higher effect on periods up to 8 weeks (Glass's Δ -0⋅51; CI -0⋅76, -0⋅27) and doses higher than 0⋅5 g of 2 -3 PUFAs (Glass's Δ -0⋅46; CI -0⋅72, -0⋅27). Dietary n -3 PUFAs intake contributes to reduce pro-inflammatory eicosanoids of people with obesity and overweight. Subgroup's analysis showed that n -3 PUFAs intake contributes to reduce pro-inflammatory eicosanoids of people with obesity and overweight. Subgroup's analysis showed that n -3 PUFAs can reduce the overall arachidonic acid COX-derived PG when adequate dose and period are matched., (© The Author(s) 2021.)

Purpose: This systematic review aimed to synthesize the available evidence on the effects of a high-protein diet on appetite sensations in individuals with overweight and obesity., Methods: Two authors independently conducted literature searches, study selection, design of the method, and quality appraisal. The main inclusion criteria were studies involving protocols that present a protein intake greater than 1.2 g/kg/day or 25% of the total daily energy content compared to a normal protein diet, i.e., 0.8-1.2 g/kg/day or 15%-20% of the total energy content. Studies that evaluated test meals or diet within a period of less than 7 days and participants with diabetes, cancer, or other specific conditions were excluded from this review. The literature search was updated until November 2019 using the main databases available., Results: Of a total of 4191 records, ten articles met the inclusion criteria and included a total of 1079 subjects. In six studies, participants experienced enhanced fullness or satiety in response to a high-dietary protein intake, of which four studies had an intervention period of 10-12 weeks., Conclusion: Our results suggest that among individuals with overweight or obesity, higher dietary protein intake may influence appetite sensations by enhancing fullness or satiety. The low level of evidence, due to the heterogeneity of the protocols and the high risk of bias, highlights the need for further studies to confirm these results.

Objective: To estimate the sensitivity and specificity of self-reported hypertension (HTN) as compared with the clinical diagnosis in epidemiological studies., Methods: We searched MEDLINE, Embase, Scopus, Web of Science, LILACS, Google Scholar, and ProQuest Dissertations & Theses Global: Health & Medicine databases. In addition, we screened the references' lists of relevant reports to identify potentially eligible articles. There were no date or language restrictions. Studies were selected by two independent reviewers, who also extracted data and assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies criteria. A meta-analysis was performed to summarize sensitivity and specificity across studies and estimate heterogeneity., Results: Out of 2304 records, 22 were included, corresponding to a population of 112 517 adults (55% women). There was substantial variation in sensitivity and specificity across countries and age groups. Several different techniques, devices, and reference ranges were used to diagnose HTN, and self-reporting underestimated its prevalence in the majority of studies. The sensitivity was 42.1% (95% confidence interval 30.9-54.2) and the specificity was 89.5% (95% confidence interval 84.0-93.3), with high heterogeneity (I > 99%)., Conclusion: Less than half of patients with HTN would not be identified by self-reporting in epidemiological studies. Self-reported HTN has important limitations and may represent an important source of bias in research depending on regional, socioeconomic, and cultural differences.

Given the high prevalence of hypertension in adolescents, it is important to investigate alternatives for estimating the magnitude of the disease. Our objective was to investigate the accuracy of self-reported hypertension. The study assessed participants of the Study of Cardiovascular Risk in Adolescents (ERICA). The following were calculated: sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The associations between inaccurate self-reporting and socioeconomic factors were investigated. The accuracy of self-reported hypertension had a sensitivity of 7.5% (95% CI, 6.9-8.2), a specificity of 96.6% (95% CI, 96.5-96.7), a PPV of 18.9% (95% CI, 17.4-20.5), and a NPV of 90.8% (95% CI, 90.6-91.0). The prevalence of inaccurate self-reported hypertension was smaller among girls (PR 0.68; 95% CI, 0.55-0.83) and younger boys (PR 0.68; 95% CI, 0.54-0.86) who were attending private schools. The use of self-reported hypertension was not a good strategy for investigating the hypertension in adolescents., (©2018 Wiley Periodicals, Inc.)

Grazing, a type of maladaptive eating behavior, has been associated with poor weight outcomes in bariatric patients. The purpose of this study was to conduct a systematic review of the association between grazing behavior and weight regain post-bariatric surgery. Literature searches, study selection, design of the method, and quality appraisal were carried out by two independent authors. The search strategy was performed until October 2017 in Medline, Embase, Cochrane, Lilacs, Scopus, Web of Science, Google Scholar, ProQuest Dissertation & Theses, and Open Grey. Of a total of 3764 articles, five papers met the inclusion criteria (four original articles and one thesis), comprising 994 subjects, mostly women. The prevalence of grazing behavior ranged from 16.6 to 46.6%, and the highest prevalence of significant weight regain was 47%. The association between grazing and weight regain was observed in four of the five evaluated studies. Our findings support an association between grazing behavior and weight regain after bariatric surgery, regardless of surgery type and contextual concept of grazing. Further studies are needed to confirm the clarity of the real prevalence and interfering factors related to grazing behavior and weight outcomes., Competing Interests: The authors declare no conflict of interest.

Brazilians consume excessive dietary sodium (4700 mg/d); hence, the reduction of dietary sodium intake has been a Brazilian government priority. A set of strategies has been implemented that includes food and nutrition education initiatives and the reduction in the sodium content of processed foods and foods consumed out of the households. Since 2011, the Ministry of Health has selected priority food categories that contribute to over 90% of sodium intake from processed foods and have set biannual voluntary targets for sodium reduction with food industries to encourage food reformulation. Three rounds of monitoring of the sodium content on food labels have been conducted for instant pasta, commercially produced breads, cakes and cake mixes, cookies and crackers, snacks, chips, mayonnaise, salt-based condiments, and margarine. Between 90% and 100% of the food products achieved the first targets in the 2011-2013 period, and the average sodium content of food categories was reduced from 5% to 21% in these first 2 years. These data show that with close monitoring and government oversight, voluntary targets to reduce the sodium content in processed foods can have a significant impact even in a short time frame. The Brazilian strategy will be continuously monitored to maximize its impact, and, if necessary in the future, a transition to regulatory approaches with stronger enforcement may be considered., (©2017 Wiley Periodicals, Inc.)

Non-communicable diseases, including cardiovascular diseases, are responsible for over 70% of deaths in Brazil. Currently, over 25% of Brazilian adults are diagnosed as hypertensive; overall, current dietary sodium intake in Brazil (4700 mg/person) is over twice the international recommendations, and 70-90% of adolescents and adults consume excessive sodium. National sodium reduction strategies consider the main dietary sources of sodium to be added salt to foods, foods consumed outside of the household, and sodium in processed foods. The national voluntary strategy for sodium reduction in priority food categories has been continuously monitored over a 6-year period (2011-2017) and there was a significant 8-34% reduction in the average sodium content of over half food categories. Different food categories have undergone differing reductions in sodium over time, aiding gradual biannual targets to allow industries to develop new technologies and consumers to adapt to foods with less salt. By 2017, most products of all food categories had met the regional targets proposed by the Pan American Health Organization, showing that voluntary sodium reduction strategies can potentially contribute to food reformulation. Nevertheless, regulatory approaches may still be necessary in the future in order to reach all food producers and to allow stronger enforcement to meet more stringent regional targets., Competing Interests: All authors declare no conflicts of interest.