ABC | Volume 113, Nº2, August 2019

Original Article Lima et al The VICTIM register- Intra-hospital counseling Arq Bras Cardiol. 2019; 113(2):260-269 Table 3 – Presence of nutritional counseling registered by professionals and self-referenced by patients with STEMI receiving care at hospitals in Sergipe, based on the type of service (Public vs. Private) Nutritional counseling Total (188) Public (151) Private (37) p value Nutritional counseling, self-referenced by patient, n (%)* 113 (60.1) 87 (57.6) 26 (70.3) 0.191 † Counseling presentation method, n (%)* Verbal only 63 (55.8) 50 (57.5) 13 (50.0) 0.288 † Writing only 38 (44.2) 33 (37.9) 5 (19.2) 0.064 ‡ Verbal + Writing 12 (10.6) 4 (4.6) 8 (30.8) <0.001 ‡ Professional that counseled, n (%)* Physician 97 (85.8) 77 (88.5) 20 (76.9) 0.196 † Nutritionist 23 (20.4) 10 (11.5) 13 (50.0) < 0.001 † Others 3 (2.7) 3 (3.4) 0 (0.0) 1.000 ‡ Counseling documented in patient record, n (%) 18 (9.6) 4 (2.6) 14 (37.8) < 0.001 ‡ Professional who registered the counseling in the record, n (%) Nutritionist 9 (50.0) 0 (0) 9 (64.3) 0.082 ‡ Physician 9 (50.0) 4 (100) 5 (35.7) Pre-hospitalization counseling, n (%) 75 (39.9) 51 (33.8) 24 (64.9) 0.001 † (*) Information declared by the patient via telephone call, after discharge from the hospital; (†) Chi-square test; (‡) Fisher's exact test. However, with the current weakening in the structure of counter-referral in the country, it is clear that individuals, who depend exclusively on the SUS, need logistics to be easy in order to attend these sessions. In this context, the existence of adequate in-hospital nutritional counseling could, in theory, partially repair this deficiency. 30-32 The physician was the professional who acted the most, transferring these guidelines. This fact can be interpreted in some ways: inexistence, or lack of communication between the multidisciplinary team in the institution where the patient was hospitalized; conduct of important lifestyle changes, only at the time of discharge, is routinely performed by the physician. Current guidelines indicate that nutritional counseling should be performed and encouraged by the entire, specialized, multi-professional team involved in patient care. This team must be composed of a cardiologist, nurse, nutritionist, and other professionals, with the purpose of promoting health education for the patient, and encouraging changes in lifestyle habits. 9,16,20,26 In more specific situations, the nutritionist can intercede with more individualized guidelines, as she is the most qualified professional for such intervention. Another important finding is the disparity in the quality of nutritional guidance between public and private health services. The observation of the constituent elements of the guidelines provided reveals that private service users were privileged, especially with the inclusion of foods considered to be cardioprotective. It should be emphasized that this type of guidance is part of the nutritional recommendations currently recommended. 7,9,10,26,27 Although private service patients reported receiving more nutritional counseling than public service patients, both received less than 50% on most of the items analyzed. This low prevalence evidences that the moment of providing information to the patient and/or companion still needs greater attention by health professionals, in both services, as the change in eating habits is related to the cardioprotective effect. 7,11,14,15 One of the pioneer studies with AMI survivors, conducted by Lorgeril et al., 11 the Lyon Diet Heart Study, showed that adherence to a diet rich in fruits, vegetables, α -linolenic acid, as well as low saturated fats and salt can reduce up to 70% cardioprotective effect of up to 4 years after the first AMI. More recently, Miller et al. 15 in the Prospective Urban Rural Epidemiology (PURE) study, demonstrated that the daily consumption of fruits, vegetables, and legumes was inversely associated with the onset of CVD, especially AMI, and, mortality. The low prevalence of nutritional counseling in the public service may have been affected by the lower concentration of health professionals in this type of service. Although SUS serves the majority of the Brazilian population, the private health network now has three times as many physicians than the public service. 33 In relation to other professions, in Sergipe, this scenario is not different. Despite the fact that the SUS hospital has a larger number of beds, compared to the private health network, a lower number of nutritionists were observed in this service, in accordance with CFN resolution 600/2018. 34 This lower number of professionals for a high demand can affect the integral care of the patient, and, consequently, the quality of the nutritional orientation. The manner of providing this orientation may also have been another point that influenced the low prevalence of nutritional orientation in the SUS, as the majority of respondents of this service reported that it was done verbally. On the other hand, many of those who received the recommendations in written form reported that they were brief, precarious and lacked verbal information, making 264