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Preterm birth (PB) is a syndrome resulting from a complex relationship between multiple factors which do not have fully understood relationships and causality. This article discusses a hierarchical theoretical model of PB determinants, considering maternal characteristics such as sociodemographic, psychosocial, nutritional, behavioral and biological aspects, traditionally associated with increased risk of PB. The variables were distributed in six dimensions within three hierarchical levels (distal, intermediate and proximal). In this model, the socioeconomic determinants of the mother, family, household and neighborhood play indirect effects on PB through variables at the intermediate level, which in turn affect biological risk factors at the proximal level that have a direct effect on PB. The study presents a hierarchical theoretical model of the factors involved in the PB determination chain and their interrelationships. Understanding these interrelationships is an important step in trying to break the causal chain that makes some women vulnerable to preterm birth.O nascimento prematuro (NP) é uma síndrome resultante de uma complexa relação entre múltiplos fatores que não possuem relações e causalidade totalmente compreendidas. Esse artigo traz uma discussão de um modelo teórico hierarquizado dos determinantes de NP, considerando características maternas como aspectos sociodemográficos, psicossociais, nutricionais, comportamentais e biológicos, tradicionalmente associados ao risco aumentado de NP. As variáveis foram distribuídas em seis dimensões, alocadas em três níveis hierárquicos (distal, intermediário e proximal). Nesse modelo, os determinantes socioeconômicos da mãe, da família, do domicílio e do bairro exercem efeitos indiretos sobre o NP por meio de variáveis no nível intermediário, que por sua vez afetam fatores biológicos de risco no nível proximal, os quais apresentam um efeito direto sobre o NP. O estudo adota um modelo teórico hierarquizado dos fatores envolvidos na cadeia de determinação do NP e suas inter-relações. O entendimento dessas inter-relações é um passo importante na tentativa de interromper a cadeia causal que torna algumas mulheres vulneráveis ao parto prematuro.

Resumo O nascimento prematuro (NP) é uma síndrome resultante de uma complexa relação entre múltiplos fatores que não possuem relações e causalidade totalmente compreendidas. Esse artigo traz uma discussão de um modelo teórico hierarquizado dos determinantes de NP, considerando características maternas como aspectos sociodemográficos, psicossociais, nutricionais, comportamentais e biológicos, tradicionalmente associados ao risco aumentado de NP. As variáveis foram distribuídas em seis dimensões, alocadas em três níveis hierárquicos (distal, intermediário e proximal). Nesse modelo, os determinantes socioeconômicos da mãe, da família, do domicílio e do bairro exercem efeitos indiretos sobre o NP por meio de variáveis no nível intermediário, que por sua vez afetam fatores biológicos de risco no nível proximal, os quais apresentam um efeito direto sobre o NP. O estudo adota um modelo teórico hierarquizado dos fatores envolvidos na cadeia de determinação do NP e suas inter-relações. O entendimento dessas inter-relações é um passo importante na tentativa de interromper a cadeia causal que torna algumas mulheres vulneráveis ao parto prematuro.

Background Preterm births increase mortality and morbidity during childhood and later life, which is closely associated with poverty and the quality of prenatal care. Therefore, income redistribution and poverty reduction initiatives may be valuable in preventing this outcome. We assessed whether receipt of the Brazilian conditional cash transfer programme - Bolsa Familia Programme, the largest in the world - reduces the occurrence of preterm births and explored how this association differs according to prenatal care and quality of Bolsa Familia Programme management.Methods A retrospective cohort study was performed involving live singleton births from 2012–2015 to mothers registered in the 100 Million Brazilian Cohort from 2004–2015, considering a deterministic linkage with the Bolsa Familia Programme payroll datasets and similarity linkage with the Brazilian Live Birth Information System. The exposed group consisted of newborns to mothers who received Bolsa Familia from conception to delivery. Our outcomes were infants born with a gestational age Results 1,031,053 infants were analyzed; 65.9% of the mothers were beneficiaries. Bolsa Familia Programme was not associated with all sets of preterm births, moderate-to-late, and severe preterm births, but was associated with a reduction in extreme preterm births (weighted OR: 0.69; 95%CI: 0.63–0.76). This reduction can also be observed among mothers receiving adequate prenatal care (weighted OR: 0.66; 95%CI: 0.59–0.74) and living in better Bolsa Familia management municipalities (weighted OR: 0.56; 95%CI: 0.43–0.74).Conclusions An income transfer programme for pregnant women of low-socioeconomic status, conditional to attending prenatal care appointments, has been associated with a reduction in extremely preterm births. These programmes could be essential in achieving Sustainable Development Goals.

OBJECTIVE To investigate the recurrence of preterm birth (PTB) among the poorest half of the Brazilian population. METHODS A population-based retrospective study was conducted in Brazil with the live births of multiparous women extracted from the CIDACS Birth Cohort between 2001 and 2015. We used multivariate logistic regression to estimate the odds of recurrent PTB in second and third births. RESULTS A total of 3 528 050 live births from 1 764 025 multiparous women were analyzed. The adjusted odds for the occurrence of a PTB given a previous PTB was 2.58 (95% confidence interval [CI] 2.53-2.62). Lower gestational age increased the odds of a subsequent PTB (

Resumo A avalição da efetividade de vacinas é feita com dados do mundo real e é essencial para monitorar o desempenho dos programas de vacinação ao longo do tempo bem como frente a novas variantes. Até o momento, a avaliação da efetividade das vacinas para COVID-19 tem sido baseada em métodos clássicos como estudos de coorte e caso controle teste-negativo, que muitas vezes podem não permitir o adequado controle dos vieses intrínsecos da alocação das campanhas de vacinação. O objetivo dessa revisão foi discutir os desenhos de estudo disponíveis para avaliação de efetividade das vacinas, enfatizando os estudos quase-experimentais, que buscam mimetizar os estudos aleatorizados ao introduzir um componente exógeno para atribuição ao tratamento, bem como suas vantagens, limitações e aplicabilidade no contexto dos dados brasileiros. O emprego de métodos quase-experimentais, incluindo as séries temporais interrompidas, o método de diferença em diferenças, escore de propensão, variáveis instrumentais e regressão descontínua, são relevantes pela possibilidade de gerar estimativas mais acuradas da efetividade de vacinas para COVID-19 em cenários como o brasileiro, que se caracteriza pelo uso de várias vacinas, com respectivos número e intervalos entre doses, aplicadas em diferentes faixas etárias e em diferentes momentos da pandemia.

The Institute of Medicine provides references of daily nutrient intake stratified by age and gender groups, considering that the basal metabolic rate varies according to these aspects. In this context, this study aimed to evaluate the recommendation of zinc in healthy adults according to the energy expenditure. The study database "Influence of Gender and SNPs in GPX1 Gene on Biomarkers of Selenium Status in Healthy Brazilians" was used, which collected information from 116 apparently healthy adults recruited in São Paulo. The mean age of the sample was 28.7 ± 7.2 years and the mean for zinc intake was 7.63 ± 3.32 mg, with a statistically significant correlation observed between energy expenditure and zinc intake (R = 0.321; p = 0.004). No linear correlation was found between age and energy expenditure and the difference between sex was not statistically significant. Conclusion: The metabolic rate can be considered as a reference variable for the recommendation of the daily intake of the nutrient, aiming to avoid deficiencies and food poisoning because of its poor intake.

Introdução: Políticas públicas são fundamentais para a redução da morbimortalidade na infância. O presente estudo descreve uma evolução política relacionada à Atenção Primária à Saúde da Criança no âmbito da Atenção Primária Saúde (APS) no Brasil, desde a criação do Sistema Único de Saúde (SUS). Metodologia: Revisão narrativa da literatura com base nos principais marcos normativos com influência na Atenção à Saúde da Criança no âmbito da APS, publicados entre 1990 e 2017. Resultados: Foram analisados 31 documentos oficiais, distribuídos numa linha do tempo, classificados em: I) normatização do SUS e da APS; II) orientação aos serviços de saúde materno-infantil no âmbito da APS e III) políticas intersetoriais. Conclusão: A evolução das políticas pensadas no Brasil está marcada para serviços e como soluções da série de direitos sociais e como possibilidades de vistas da vida. Porém, além das desigualdades sociais, desafios no acesso e na qualidade do cuidado na APS se fazem persistentes, com retrocessos são persistentes agravados com a capacidade de trabalhar1 em medidas de austeridade curso desde 206.

The Institute of Medicine stratifies the references for daily nutrient intake into age and sex groups, considering that the basal metabolic rate varies according to these aspects, and in most cases, it extrapolates the values calculated for adults to children, because their body weights are different. In this context, this study aimed to evaluate the recommendation for magnesium in children according to energy expenditure.This was an observational study using the database of the Social Changes, Asthma and Allergy in Latin America (SCAALA) cohort, which randomly collected information from 1445 children ages 4 to 11 y. Of these, 480 (33%) were part of the present study (children between 7 and 11 y old with eutrophic body mass index and adequate growth). Information on food intake was obtained from the child's parents or legal guardians through a 24-h recall. The population was characterized using static analyses such as the Student t test, Pearson correlation coefficient, and linear regression.The mean age of the sample was 8.5 ± 0.96 y, and 54% were males. The mean magnesium intake was 149 ± 70 mg, with a high correlation observed between energy expenditure and magnesium intake (boys: R, 0.716; P0.001; girls: R, 0.641; P0.001).The metabolic rate can be considered a reference variable for recommending the daily intake of the studied nutrient, aiming to avoid deficiencies and food poisoning because of poor intake.

Background Factors associated with low birth weight at term (TLBW), a proxy for intrauterine growth restriction (IUGR), are not well-elucidated in socioeconomically vulnerable populations. This study aimed to identify the factors associated with TLBW in impoverished Brazilian women. Methods Records in the 100 Million Brazilian Cohort database were linked to those in the National System of Information on Live Births (SINASC) to obtain obstetric, maternal, birth and socioeconomic data between 2001 and 2015. Multivariate logistic regression was performed to investigate associations between variables of exposure and TLBW. Results Of 8,768,930 term live births analyzed, 3.7% presented TLBW. The highest odds of TLBW were associated with female newborns (OR: 1.49; 95% CI: 1.47–1.50), whose mothers were black (OR: 1.20; 95% CI: 1.18–1.22), had a low educational level (OR: 1.57; 95% CI: 1.53–1.62), were aged ≥35 years (OR: 1.44; 95% CI: 1.43–1.46), had a low number of prenatal care visits (OR: 2.48; 95% CI: 2.42–2.54) and were primiparous (OR: 1.62; 95% CI: 1.60–1.64). Lower odds of TLBW were found among infants whose mothers lived in the North, Northeast and Center-West regions of Brazil compared to those in the South. Conclusion Multiple aspects were associated with TLBW, highlighting the need to comprehensively examine the mechanisms underlying these factors, especially in more vulnerable Brazilian populations, in order to contribute to the elaboration of health policies and promote better conditions of life for poor and extremely poor mothers and children.

Resumo A avalição da efetividade de vacinas é feita com dados do mundo real e é essencial para monitorar o desempenho dos programas de vacinação ao longo do tempo bem como frente a novas variantes. Até o momento, a avaliação da efetividade das vacinas para COVID-19 tem sido baseada em métodos clássicos como estudos de coorte e caso controle teste-negativo, que muitas vezes podem não permitir o adequado controle dos vieses intrínsecos da alocação das campanhas de vacinação. O objetivo dessa revisão foi discutir os desenhos de estudo disponíveis para avaliação de efetividade das vacinas, enfatizando os estudos quase-experimentais, que buscam mimetizar os estudos aleatorizados ao introduzir um componente exógeno para atribuição ao tratamento, bem como suas vantagens, limitações e aplicabilidade no contexto dos dados brasileiros. O emprego de métodos quase-experimentais, incluindo as séries temporais interrompidas, o método de diferença em diferenças, escore de propensão, variáveis instrumentais e regressão descontínua, são relevantes pela possibilidade de gerar estimativas mais acuradas da efetividade de vacinas para COVID-19 em cenários como o brasileiro, que se caracteriza pelo uso de várias vacinas, com respectivos número e intervalos entre doses, aplicadas em diferentes faixas etárias e em diferentes momentos da pandemia. Abstract The evaluation of vaccine effectiveness is conducted with real-world data. They are essential to monitor the performance of vaccination programmes over time, and in the context of the emergence of new variants. Until now, the effectiveness of COVID-19 vaccines has been assessed based on classic methods, such as cohort and test-negative case-control studies, which may often not allow for adequate control of inherent biases in the assignment of vaccination campaigns. The aim of this review was to discuss the study designs available to evaluate vaccine effectiveness, highlighting quasi-experimental studies, which seek to mimic randomized trials, by introducing an exogenous component to allocate to treatment, in addition to the advantages, limitations, and applicability in the context of Brazilian data. The use of quasi-experimental approaches, such as interrupted time series, difference-in-differences, propensity scores, instrumental variables, and regression discontinuity design, are relevant due to the possibility of providing more accurate estimates of COVID-19 vaccine effectiveness. This is especially important in scenarios such as the Brazilian, which characterized by the use of various vaccines, with the respective numbers and intervals between doses, applied to different age groups, and introduced at different times during the pandemic.

ObjectivesTo investigate the combined association of obesity, diabetes mellitus (DM), and cardiovascular disease (CVD) with severe COVID-19 outcomes in adult and elderly inpatients.DesignCross-sectional study based on registry data from Brazil’s influenza surveillance system.SettingPublic and private hospitals across Brazil.ParticipantsEligible population included 21,942 inpatients aged ≥20 years with positive RT-PCR test for SARS-CoV-2 until Jun 9th, 2020.Main outcome measuresSevere COVID-19 outcomes were non-invasive and invasive mechanical ventilation use, ICU admission, and death. Multivariate analyses were conducted separately for adults (20-59 years) and elders (≥60 years) to test the combined association of obesity (without and with DM and/or CVD) and degrees of obesity with each outcome.ResultsA sample of 8,848 adults and 12,925 elders were included. Among adults, obesity with DM and/or CVD showed higher prevalence of invasive (PR 3.76, 95%CI 2.82-5.01) and non-invasive mechanical ventilation use (2.06, 1.58-2.69), ICU admission (1.60, 1.40-1.83), and death (1.79, 1.45-2.21) compared with the group without obesity, DM, and CVD. In elders, obesity alone (without DM and CVD) had the highest prevalence of ICU admission (1.40, 1.07-1.82) and death (1.67, 1.00-2.80). In both age groups, obesity alone and combined with DM and/or CVD showed higher prevalence in all outcomes than DM and/or CVD. A dose-response association was observed between obesity and death in adults: class I 1.32 (1.05-1.66), class II 1.41 (1.06-1.87), and class III 1.77 (1.35-2.33).ConclusionsThe combined association of obesity, diabetes, and/or CVD with severe COVID-19 outcomes may be stronger in adults than in elders. Obesity alone and combined with DM and/or CVD had more impact on the risk of COVID-19 severity than DM and/or CVD in both age groups. The study also supports an independent relationship of obesity with severe outcomes, including a dose-response association between degrees of obesity and death in adults.Article summaryStrengths and limitations of this study: This is the first study that describes the independent and combined relationship of obesity with COVID-19 severity in Brazil, one of the biggest epicenters of the pandemic worldwide.The study was based on registry data of a large nationwide sample of patients admitted, due to severe SARS-CoV-2 infection, to public and private hospitals across the country.The large sample size and data availability allowed us to analyze the combined association of obesity, diabetes and cardiovascular disease with severe COVID-19 outcomes, separately by age groups and controlled by important confounding variables, e.g. underlying comorbidities.The cross-sectional study design does not allow causal inference, and generalization of results must be cautious since only hospitalized cases of severe COVID-19 were included.As the study used routinely collected data, which has not been designed primarily for research purposes, it may bring well-known limitations related to missing, underestimation, and potential misclassification.

The COVID-19 pandemic may accentuate existing problems, hindering access to legal abortion, with a consequent increase in unsafe abortions. This scenario may be even worse in low- and middle-income countries, especially in Latin America, where abortion laws are already restrictive and access to services is already hampered. Our objective was to understand how different countries, with an emphasis on Latin Americans, have dealt with legal abortion services in the context of the COVID-19. Thus, we conducted a narrative review on abortion and COVID-19. The 75 articles included, plus other relevant references, indicate that the pandemic affects sexual and reproductive health services by amplifying existing problems and restricting access to reproductive rights, such as legal abortion. This impact may be even stronger in low- and middle-income countries, especially in Latin America, where access to legal abortion is normally restricted. The revision of sources in this article underlines the urgent need to maintain legal abortion services, both from women’s perspective, in support of their reproductive rights, but also from that of the international commitment to achieving the Millennium Development Goals. Thereby, Latin American countries must place reproductive rights as a priority on their agendas and adapt legislation to accommodate alternative models of abortion care. Furthermore, our results underscore the need for clear information on the functioning of sexual and reproductive health services as essential for understanding the impact of the pandemic on legal abortion and to identify the groups most affected by the changes.

No Abstract available. Declaration CIDACS

BACKGROUND: The COVID-19 pandemic has spread across the world and, along with it, a considerable degree of fear and uncertainties that impact on various aspects of societal life, including on people’s Mental Health (MH). Understanding how the COVID-19 pandemic affects MH can help to implement interventions and adequate public policies, providing more effective responses to mitigate its effects.OBJECTIVES: To summarize the scientific evidence on the possible influence of the Covid-19 pandemic on MH, critically evaluating the methods and scientific validity of the studies found, in addition to summarizing the recommendations on strategic measures to reduce the impact of COVID-19 on MH.METHODOLOGY: The current scoping review was conducted from a screening of 465 articles on COVID-19 and MH outcomes, based on the main database of scientific references on health, assessed throughout PubMed. RESULT: Of the 43 papers selected for summary and critical analysis 77% (n=33) indicated a relationship between the COVID-19 pandemic and anxiety symptoms, 56% (n=26) with depression or depressive symptoms, seven with changes in sleep pattern and seven with obsessive behaviours or Obsessive Compulsive Disorder. In addition to studies that showed an influence of the COVID-19 pandemic on trauma or post-traumatic stress disorder (PTSD), psychological distress, stress and fear. Most of the studies were carried out in China, and primarily evaluated the presence of anxiety and depression, through scales and questionnaires. Health professionals and the elderly were cited among the most affected population groups. CONCLUSIONS: Most studies presented significant methodological limits. Investments in new research, with controlled studies, including representative and randomized samples, and longitudinal follow-up, are necessary, to further explore the relationships between the COVID-19 pandemic and people's MH and long-term effects. Pending such studies, given the effects (during and after) of previous epidemics on MH, government measures need to be implemented to reduce the potential catastrophic effects of the COVID-19 pandemic on MH, and the burden that will remain after the pandemic. The timely identification of psychological distress and the identification of MH needs among populations, facilitate the development of targeted psychological interventions, in addition to the organization of health services and systems, during the pandemic.

The COVID-19 pandemic has challenged researchers and policy makers to identify public safety measures forpreventing the collapse of healthcare systems and reducingdeaths. This narrative review summarizes the available evidence on the impact of social distancing measures on the epidemic and discusses the implementation of these measures in Brazil. Articles on the effect of social distancing on COVID-19 were selected from the PubMed, medRXiv and bioRvix databases. Federal and state legislation was analyzed to summarize the strategies implemented in Brazil. Social distancing measures adopted by the population appear effective, particularly when implemented in conjunction with the isolation of cases and quarantining of contacts. Therefore, social distancing measures, and social protection policies to guarantee the sustainability of these measures, should be implemented. To control COVID-19 in Brazil, it is also crucial that epidemiological monitoring is strengthened at all three levels of the Brazilian National Health System (SUS). This includes evaluating and usingsupplementary indicators to monitor the progression of the pandemic and the effect of the control measures, increasing testing capacity, and making disaggregated notificationsand testing resultstransparentand broadly available.

Background: Preterm birth (25 times higher for LBW (HR=25.8; (95% CI:25.5-26.1) compared to normal birth weight (NBW). 18% of all live births were included in one of the small vulnerable newborn phenotypes. Of those 8.2% were term-SGA (4.7%NBW, 3.5%LBW), 0.6% were term-AGA-LBW, 8.3% preterm-AGA (3.8%NBW, 4.5%LBW) and 1.0% preterm-SGA-LBW. Compared to term-AGA-NBW, the highest mortality risk was for preterm-LBW phenotypes (HR=36.2(95%CI 35.6-36.8) preterm-AGA-LBW, HR=62.0(95%CI 60.8-63.2) preterm-SGA-LBW). The increased mortality risk associated with vulnerable newborn phenotypes was highest in the first month of life, with attenuated but continued high risk in the post-neonatal period and 1-4 years of age. Interpretation: Our findings support the value of using more detailed phenotypes to identify those at highest risk. More granular data can inform care at the individual level, advance research, especially for prevention, and accelerate progress towards global targets such as the Sustainable Development Goals. Funding: Wellcome Trust

No studies showing that food consumption is a modifier of the association of variants of the leptin receptor gene (LEPR) with body weight have involved a Brazilian population. The aim of this study was to evaluate the modifying effect of dietary intake on the association between the LEPR gene and excess weight. In this study, 1211 children and adolescents aged 4–11 years were assessed. Participants were genotyped for 112 single-nucleotide variants of the LEPR gene. Anthropometric measurements were performed, and dietary data were obtained. Logistic regressions were used to study the associations of interest. Of the participants, 13.4% were overweight/obese. The risk allele (G) of the rs1137100 variant was associated with excess weight in individuals with fat consumption below the median (odds ratio OR = 1.92; 95% confidence interval CI = 1.18–3.14), with daily frequency of consumption of drink/artificial juice (OR = 2.15; 95% CI = 1.26–3.68) and refined cereals (OR = 2.17; 95% CI = 1.31–3.62) above the median. The risk allele (G) of variant rs1177681 was also associated with excess weight (OR = 2.74; 95% CI = 1.65–4.57) in subjects with a daily frequency of refined cereal consumption above the median. The association between LEPR and excess weight can be modulated by the type and distribution of dietary fatty acids, sugary drinks, and refined cereals.

Previous studies have shown associations of variants of the FTO gene with body weight, but none of these have involved Latin American populations with a high level of miscegenation, as is seen in the north-eastern Brazilian population. This study evaluated the association between SNP in the FTO gene and excess weight in Salvador, Bahia, Brazil. In addition, the effect of diet as a modifier on this association was also investigated. This cross-sectional study included 1191 participants aged 4–11 years, who were genotyped for 400 variants of the FTO gene. Direct anthropometric measures were made and dietary data were obtained by 24-h food recall. Multivariate logistic regression analyses were used to assess the associations of interest. Overall, 11·2 % of the individuals included in the study were overweight/obese. Interactions were identified between the percentage energy intake from proteins and obesity risk linked to the rs62048379 SNP (Pinteraction=0·01) and also between fat intake (PUFA:SFA ratio) and obesity risk linked to the rs62048379 SNP (Pinteraction=0·01). The T allele for the variant rs62048379 was positively associated with overweight/obesity in individuals whose percentage energy intake from protein was above the median (OR 2·00; 95 % CI 1·05, 3·82). The rs62048379 SNP was also associated with overweight/obesity in individuals whose PUFA:SFA ratio was below the median (OR 1·63; 95 % CI 1·05, 2·55). The association between FTO gene variants and excess body weight can be modulated by dietary characteristics, particularly by fatty acid distribution and dietary protein intake in children.

Resumo: O presente estudo verificou o conhecimento dos professores do Ensino Fundamental I acerca do papel da escola na formação dos hábitos alimentares dos escolares. Estudo longitudinal, quali-quantitativo realizado em escolas públicas municipais na cidade de Amargosa, BA, que estiveram imersas em um Programa de Educação para o Trabalho para a Saúde (PET/Saúde) por um período de três meses. Utilizou-se um questionário estruturado abordando questões sobre nutrição e saúde. Verificou-se os acertos e erros obtidos antes e após a intervenção do programa. Participaram do estudo 14 professoras, com mediana de idade de 41 anos, sendo a maioria pedagoga. Verificou-se diferença significante na questão referente à importância da escola na formação de hábitos alimentares dos escolares (p=0,0425). Concluiu-se que os professores reconheceram o papel da escola na formação dos hábitos alimentares dos escolares e reconheceram-se como agentes fundamentais na promoção da alimentação saudável e da qualidade de vida no ambiente escolar. Abstract: This study verified the knowledge of elementary school teachers about the school's role in shaping the students' eating habits. The paper describes a longitudinal study, qualitative and quantitative, conducted in public schools in the city of Amargosa, BA, which were immersed in an Education Program of Work for Health (PET/Health) for a period of three months. We used a structured questionnaire addressing issues of nutrition and health. It revealed the successes and mistakes made before and after the program intervention. The sample was composed of 14 teachers, with a median age of 41 years, most of them, pedagogues. There was statistical difference in the question of the importance of school in forming eating habits of children (p = 0.0425). It was concluded that teachers recognized the school's role in shaping the students' eating habits and were recognized themselves as key players in promoting healthy eating and quality of life at school.