Abstracts

Introduction

A healthy diet is widely recognized as an important strategy to promote health, and also as an essential part of non-pharmacological therapy for several health conditions¹1. Parekh S, Vandelanotte C, King D, Boyle FM. Improving diet, physical activity and other lifestyle behaviours using computer-tailored advice in general practice: a randomised controlled trial. Int J Behav Nutr Phys Act 2012; 9: 108..

Many studies show that counseling for a heath diet is extremely important for healthy individuals, since it could decrease the incidence of the main risk factors for problems such as arterial hypertension, hypercholesterolemia, diabetes and obesity However, the benefits of counseling are also relevant for individuals who are already affected by these conditions, with the objective of a more favorable progress of the issue²2. De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J, et al. European guidelines on cardiovascular disease prevention in clinical practice. Atheroscleosis 2004; 173(2): 381-91..

The National Policy of Health Promotion provides the universal access to information about healthy lifestyles by means of recommendations, campaigns, programs, messages, warnings and monitoring from health and media professionals, as well as teachers³3. Ministério da Saúde. Política Nacional de Promoção da Saúde. Brasília: Ministério da Saúde; 2010.. However, the role of health professionals in general, especially those working in primary health care, is extremely important to promote a healthy lifestyle, since they deal directly with patients who have high risk of non-communicable diseases and conditions¹1. Parekh S, Vandelanotte C, King D, Boyle FM. Improving diet, physical activity and other lifestyle behaviours using computer-tailored advice in general practice: a randomised controlled trial. Int J Behav Nutr Phys Act 2012; 9: 108. ^{, 4}4. Milder IE, Blokstra A, de Groot J, van Dulmen S, Bemelmans WJ. Lifestyle counseling in hypertension-related visits-analysis of video-taped general practice visits. BMC Fam Pract 2008; 9: 58..

Together with the purposes of health promotion, the National Policy of Nourishment and Nutrition was created with the objective of improving the nutrition conditions of the Brazilian population, which promotes, among other actions, adequate and healthy eating practices⁵5. Ministério da Saúde. Política nacional de alimentação e nutrição. Série B Textos Básicos de Saúde. Brasília: Ministério da Saúde; 2012.. Therefore, the Eating Guide for the Brazilian Population was elaborated to publicize the diet and the adoption of healthy lifestyles in order to prevent and control chronic non-communicable diseases and nutritional deficiencies⁶6. Ministério da Saúde. Guia alimentar para a população brasileira: promovendo a alimentação saudável. Brasília: Ministério da Saúde; 2006..

As to receiving counseling, a study conducted in the United States detected in patients who had just left the appointment that nutritional counseling occurred in 24% of the appointments; out of these, 17% were caused by acute problems, 30% by chronic diseases and 41% by preventive and prophylactic measures. The mean time of these orientations was five minutes⁷7. Eaton CB, Goodwin MA, Stange KC. Direct observation of nutrition counseling in community family practice. Am J Prev Med 2002; 23(3): 174-9.. In another study conducted in the same country, 55% of the interviewed medical doctors reported advising their patients on health diet⁸8. Livaudais JC, Kaplan CP, Haas JS, Perez-Stable EJ, Stewart S, Des Jarlais G. Lifestyle behavior counseling for women patients among a sample of California physicians. J Womens Health 2005; 14(6): 485-95..

A national-based cross-sectional study performed with American patients found a 70% prevalence of diet counseling⁹9. Lobo IE, Loeb DF, Ghushchyan V, Schauer IE, Huebschmann AG. Missed opportunities for providing low-fat dietary advice to people with diabetes. Prev Chronic Dis 2012; 9: E161.. A study with obese individuals who saw a doctor in the 12 months prior to the interview found prevalence of only 39% of receiving information for weight loss. Besides, only 64% of those who received counseling were advised to change diet, which configures as a major lost opportunity¹⁰10. Ko JY, Brown DR, Galuska DA, Zhang J, Blanck HM, Ainsworth BE. Weight loss advice US obese adults receive from health care professionals. Prev Med 2008; 47(6): 587-92..

Evidence shows that the population receives relatively little information about the benefits of a healthy diet¹¹11. Bell RA, Kravitz RL. Physician counseling for hypertension: what do doctors really do? Patient Educ Couns 2008; 72(1): 115-21., and there are only a few national-based studies that assess the prevalence of receiving this type of orientation in the Brazilian population.

Diet guidance should not be seen only as a transfer of information to reduce the intake of some specific nutrients or food⁵5. Ministério da Saúde. Política nacional de alimentação e nutrição. Série B Textos Básicos de Saúde. Brasília: Ministério da Saúde; 2012.. However, considering the recommendation of the sixth guideline of the Eating Guide for the Brazilian Population⁶6. Ministério da Saúde. Guia alimentar para a população brasileira: promovendo a alimentação saudável. Brasília: Ministério da Saúde; 2006., this study aimed to examine the receiving of advice about the intake of salt, sugar and fat in the adult population living in urban areas.

Methodology

Between the months of August 2008 and March 2009, a cross-sectional study was conducted in a sample of adult individuals, aged between 20 and 59 years old, living in the urban area of 100 cities of the five geopolitical regions. The study about receiving orientation for low salt, sugar and fat intake integrates the project "AQUARES", which aimed at assessing the access, the use and the quality of the health care network in Brazil.

In order to locate the representative sample of the adult Brazilian population, a complex process was conducted in multiple levels, considering the size of the population, the census sectors and the households. The cities and urban census sectors were selected by the territorial division using the official mesh of the Population Census of 2000¹²12. IBGE - Instituto Brasileiro de Geografia e Estatística. Dados populacionais, censo 2000. Rio de Janeiro: IBGE; 2000 [cited 2012]. Available from: http://www.ibge.gov.br.
Available from: http://www.ibge.gov.br... . After organizing as to the size of the population, the cities were randomly selected, and the census sectors were equally sorted out according to the proportion of valid sectors and size of the population. In each of the 638 selected sectors, 10 households were visited, according to a systematic "leap" between the residencies, hoping to find 17 adults per sector¹³13. Szwarcwald CL, Damacena GN. Amostras complexas em inquéritos populacionais: planejamento e implicações na análise estatística dos dados. Rev Bras Epidemiol 2008; 11(Suppl. 1): 38-45.. All of the adults living in the selected household were eligible for the interviews.

Data collection was performed with an electronic questionnaire in Personal Digital Assistant (PDA) by 55 trained interviewers. Quality control was performed by supervisors in the work field, after a second visit and the application of a questionnaire reduced to 5% of the interviewees, with a maximum interval of three days after the first interview. With the final sample of 12,402 adults, the margin of error for the prevalence of receiving orientations was in average 0.9 percentage points.

Eating orientation was defined as the reference for receiving orientation concerning low salt, sugar and fat intake from some professional during contact with a health service or through the media. The themes in questions were studied with a broader set of recommendations about the adoption of healthy behaviors expressed by different social agents, vehicles and formats, including, among others, means of mass communication, gyms, clubs and health services.

The questionnaire used in the study was standardized and pre-tested. The following questions demonstrate the sequence of items referring to the intake of salt: "Have you been advised to eat little salt since <MONTH> from the past year until now?". All of the individuals who gave a positive response to this question were asked: "Where have you received the orientation to eat little salt since <MONTH> from the past year until now?", "Who advised you to eat little salt since <MONTH> from the past year until now?" and "Has this orientation since <MONTH> from the past year until now helped you to eat with little salt?". The questions to assess the receiving of orientation to eat little sugar and fat had the same standards.

The independent variables included in the analysis were: gender, age (20 to 29 years old, 30 to 39 years old, 40 to 49 years old, and 50 to 59 years old); skin color reported by the interviewee and categorized as white, mulatto (composed by the categories mulatto, dark, and mestizo), black and other (composed by yellow and indigenous); marital status (with or without a partner); economic level (classification of the Brazilian Association of Research Companies)¹⁴14. Associação Brasileira de Empresas em Pesquisa - ABEP. Critério de Classificação Econômica Brasil. 2008., categorized in A/B (richer), C and D/E; smoking, categorized as never (those who have never smoked), former smokers and current smokers (the ones who have been smoking more than one cigarette a day for more than one month); sedentary lifestyle in leisure time (obtained from the International Physical Activity Questionnaire - IPAQ)¹⁵15. Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35(8): 1381-95., categorized as sedentary (individuals who practice less than 150 minutes a week of physical activity) and active; systemic arterial hypertension and diabetes mellitus, obtained by the questioning about receiving a medical diagnosis of these problems; and excessive weight, obtained by the reference to this problem in the 12 months prior to the interview.

The descriptive analysis included calculations of proportions of the different outcomes with the independent variables. The place and origin of the orientations were verified (Tables 1 and 2). For the crude and adjusted analyses, the act of receiving each of the different orientations in health services was used as outcome, therefore, media and other places were excluded (Table 3). This strategy was chosen in order to delimit the outcome, which makes the analysis more precise, and also because of the large proportion of orientations received in the health service.

The prevalence ratio (PR) and the 95% confidence interval (95%CI) were estimated by the Poisson regression, with robust variance since it was easy to interpret the results with the obtained effect measure¹⁶16. Barros A, Hirakata V. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3(1): 21.. Both in the crude and in the adjusted analysis, the significance was assessed by the Wald test for heterogeneity, and, when adequate, the Wald test for linear trend. All the analyses considered the design effect.

A three-level hierarchical model guided the order of entrance of the variables in the adjusted model. In the first level, as a distal determinant, the variables gender, age, skin color, marital status and economic level were inserted; in the second one, smoking and sedentary lifestyle; and in the third one, as a proximal determinant, the selected health problems - arterial hypertension, diabetes and excessive weight. The adjustment was made for all of the variables in the same hierarchical level and those of superior levels. The variables with p < 0.20 were maintained to control confusion factors. For all of the analysis, a 5% significance level was adopted. Analyses were conducted in the Stata 11.0 software.

The study was submitted and approved on November 23, 2007, by the Research Ethics Committee of the Medical School of Universidade Federal de Pelotas, report n. 152/07. All of the participants signed a informed consent form before the beginning of the interviews. The right to not participate in the research and the secrecy regarding the obtained information were secured.

Results

During field work, 13,756 adults that were eligible for the study were identified, and 12,402 were interviewed, accounting for 8% (1,101) of loss and 2% (275) of refusals. The design effects for the different outcomes were: for the intake of little salt - 1.37; for the intake of little sugar - 1.65; and for the ingestion of little fat - 1.53.

Out of the interviewees, most were females (55.0%), aged between 20 and 39 years old (57.0%), mulattos (52.9%), living with a partner (64.1%), in the C economic level (51.5%), who had never smoked (63.2%), BMI>25.0 kg/m²(50.5%) and with sedentary lifestyle (82.5%). As to chronic health issues, 16.3% reported having medical diagnosis of arterial hypertension, 3.6% of diabetes and 17.5% of excessive weight in the 12 months prior to the interview.

The orientation that was mostly reported was the little fat intake (38.2%), followed by the little salt (36.3%) and sugar (28.7%) intake. The profile of receiving orientation was similar between the different topics. Most of the prevalence was observed among women, older individuals, with a partner, with higher economic level, former smokers, physically active and with chronic selected conditions - arterial hypertension, diabetes and excessive weight. However, the variable skin color diverged between the different orientations; the advice concerning the low salt and sugar intake were more prevalent among black individuals, and the proportions of blacks and whites who received the orientation concerning the intake of sugar was very similar (Table 1). It is worth to mention that black individuals presented significantly higher prevalence of excessive weight and arterial hypertension in comparison to the others (data not shown). When assessing the place where participants received information, who provided it and if the orientations contributed for the attempt to follow the recommendations, the standard was also very similar between orientations. More than 30.0% were advised in Basic Health Units, approximately 72.0% was guided by a doctor, and, in the perception of more than 81.0% of the interviewees, the advice collaborated with the attempt to maintain a healthier diet (Table 2).

Afterwards, the associated factors in the adjusted analysis about receiving different orientations stand out, according to the hierarchical model. Orientations were more frequent among women (p < 0.001) and increased linearly with the age of the interviewees (p < 0.001), regardless of the type of orientation. Black individuals reported receiving significantly more orientation when compared to mulattos (p < 0.001). Among married individuals or those with a partner, the number of orientations was higher (p < 0.001). There was a linear growth tendency of receiving information according to the increasing economic level of the individuals (p < 0.001). Former smokers reported receiving different orientations significantly more, except for the advice to intake little sugar; in that aspect, individuals who have never smoked received more orientation (p < 0.001). Those who were physically active, with arterial hypertension, diabetes and excessive weight reported receiving different types of orientation significantly more (Table 3).

Discussion

The prevalence of receiving orientation for the set of the sample was of 38.2% for the low fat intake, 36.3% for salt and 28.7% for sugar. The prevalence of orientation in the Brazilian sample were similar to those found in studies conducted in the United States and in Finland⁷7. Eaton CB, Goodwin MA, Stange KC. Direct observation of nutrition counseling in community family practice. Am J Prev Med 2002; 23(3): 174-9. ^{, 17}17. Viera AJ, Kshirsagar AV, Hinderliter AL. Lifestyle modification advice for lowering or controlling high blood pressure: who's getting it? J Clin Hypertens 2007; 9(11): 850-8.

18. McAlpine DD, Wilson AR. Trends in obesity-related counseling in primary care: 1995-2004. Med Care 2007; 45(4): 322-9. ^{- 19}19. Korhonen M, Kastarinen M, Uusitupa M, Puska P, Nissinen A. The effect of intensified diet counseling on the diet of hypertensive subjects in primary health care: A 2-year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland. Prev Med 2003; 36(1): 8-16..

The most frequent place for receiving orientations was the basic health unit, regardless of the received advice. The reasons to look for care are varied, both to treat a problem that had just been observed or a recent one and for prevention, resulting from the perception of the individuals. In all of the situations, broad guidance is desirable, thus avoiding to lose a great opportunity to treat and prevent diseases and to promote health³3. Ministério da Saúde. Política Nacional de Promoção da Saúde. Brasília: Ministério da Saúde; 2010..

It is worth to mention the high proportion of guidance attributed to the media (26.5%). This finding demonstrates how important means of communication are to provide information to the population, especially because of the great reach of this approach. A literature review concluded that campaigns publicized on means of communication can produce positive changes in behaviors related to health in large populations²⁰20. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behavior. Lancet 2010; 376(9748): 1261-71.. Another important aspect is the broad participation of the means of mass communication to publicize campaigns, messages and recommendations sponsored by institutions from the government and from the civil society, in order to promote healthy behaviors²¹21. Victora CG, Barreto ML, do Carmo Leal M, Monteiro CA, Schmidt MI, Paim J, et al. Health conditions and health-policy innovations in Brazil: the way forward. Lancet 2011; 377(9782): 2042-53..

Medical doctors were the professionals mainly in charge of guiding the studied population, regardless of the presence of chronic health issues. Advisement from health professionals, especially medical doctors, is related to the level of knowledge of the professional on the subject. Attitudes and skills of the health professional concerning the advisement of healthy habits can also be related to his or her academic background and the profile of users he or her usually cares for. In this case, professionals who deal with people with chronic health issues can be more aware of the need to recommend the adoption of a healthy lifestyle during appointments²²22. Dallongeville J, Banegas JR, Tubach F, Guallar E, Borghi C, De Backer G, et al. Survey of physicians' practices in the control of cardiovascular risk factors: the EURIKA study. Eur J Prev Cardiol 2012; 19(3): 541-50. ^{, 23}23. Bock C, Diehl K, Schneider S, Diehm C, Litaker D. Behavioral counseling for cardiovascular disease prevention in primary care settings: a systematic review of practice and associated factors. Med Care Res Review 2012; 69(5): 495-518..

Nutritionists were the second most mentioned professional, despite their scarce presence in the Brazilian primary care. The Center of Support to Family Health (NASF) was created with the objective to meet this demand and other deficiencies in the health system, focusing on shared care for the interdisciplinary attention. This initiative promotes the exchange of experiences between the involved professionals, thus prioritizing case discussion, elaboration of therapeutic projects and orientation to the population and primary care professionals²⁴24. Ministério da Saúde. Diretrizes do NASF: Núcleo de Apoio ao Saúde da Família. Brasília: Ministério da Saúde; 2010..

It is important to point out that the orientation for healthy habits is an attribution of all of the professionals who are part of primary health care³3. Ministério da Saúde. Política Nacional de Promoção da Saúde. Brasília: Ministério da Saúde; 2010.. However, considering that the most mentioned place for advisement was the basic health unit, the participation of other professionals usually found in these units, for instance, nurses and dentists, was very scarce.

Being advised in health services varied from 19.9% for the low sugar intake and 27.7% for the low fat intake. The factors associated with receiving more and different orientations were very similar, being more frequent among women, older individuals, black people, with a partner, with a higher economic level, former smokers and people with the selected chronic issues - arterial hypertension, diabetes and excessive weight. This profile of a representative sample of the Brazilian population is in accordance with the data from a study conducted in Canada, which pointed out to the higher probability of being advised by a health professional in relation to the age of the individuals and the presence of chronic problems²⁵25. Sinclair J, Lawson B, Burge F. Which patients receive advice on diet and exercise? Do certain characteristics affect whether they receive such advice? Can Fam Physician 2008; 54(3): 404-12..

Evidence shows that the use of health services is socially determined and affects the standards for receiving orientations²⁶26. Facchini L, Piccini RX, Tomasi E, Thumé E, Silveira DS. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da Atenção Básica à Saúde. Cien e Saude Colet 2006; 11(3): 669-81.. Regardless of the previous health conditions, richer populations tend to use more outpatient and preventive services, to consume more medication and to obtain more information about healthy habits in comparison to poorer countries²⁷27. Andrade MV, Noronha K, Menezes RM, Souza MN, Reis CDB, Martins D, et al. Desigualdade socioeconômica no acesso aos serviços de saúde no Brasil: um estudo comparativo entre as regiões brasileiras em 1998 e 2008. REAP. 2013..

Several studies point to the use of primary health services being strongly associated with the presence of morbidities, to the detriment of preventive actions and health education²²22. Dallongeville J, Banegas JR, Tubach F, Guallar E, Borghi C, De Backer G, et al. Survey of physicians' practices in the control of cardiovascular risk factors: the EURIKA study. Eur J Prev Cardiol 2012; 19(3): 541-50. ^{, 23}23. Bock C, Diehl K, Schneider S, Diehm C, Litaker D. Behavioral counseling for cardiovascular disease prevention in primary care settings: a systematic review of practice and associated factors. Med Care Res Review 2012; 69(5): 495-518. ^{, 26}26. Facchini L, Piccini RX, Tomasi E, Thumé E, Silveira DS. Desempenho do PSF no Sul e no Nordeste do Brasil: avaliação institucional e epidemiológica da Atenção Básica à Saúde. Cien e Saude Colet 2006; 11(3): 669-81.. Patients with chronic problems are more exposed to receiving orientation about healthy lifestyles since they use the health services more frequently²²22. Dallongeville J, Banegas JR, Tubach F, Guallar E, Borghi C, De Backer G, et al. Survey of physicians' practices in the control of cardiovascular risk factors: the EURIKA study. Eur J Prev Cardiol 2012; 19(3): 541-50.. Even though the higher number of orientations is more evident among people with chronic conditions, the identified prevalence is still far from desirable, considering its relevance to handle the approached problems.

On the other hand, the action of receiving orientation was remarkably low among "healthy" individuals, that is, those who did not report the occurrence of the studied chronic issues. These results can be partly a result of the opinion that the adoption of healthy behaviors is essentially an individual responsibility, thus minimizing the proactive participation of health services as opposed to their attributions in the scope of promoting health²⁸28. Fleming P, Godwin M. Lifestyle interventions in primary care: systematic review of randomized controlled trials. Can Fam Physician 2008; 54(12): 1706-13. ^{, 29}29. Mellen PB, Palla SL, Goff DC Jr., Bonds DE. Prevalence of nutrition and exercise counseling for patients with hypertension. United States, 1999 to 2000. J Gen Intern Med 2004; 19(9): 917-24..

However, in the broader perspective of health, as it is defined in the scope of the Brazilian Sanitary Reform, the Unified Health System (SUS) and the Letters of Health Promotion, the way subjects and groups elect specific lifestyle options as being desirable are socially established, therefore, it is a responsibility of the society as a group³3. Ministério da Saúde. Política Nacional de Promoção da Saúde. Brasília: Ministério da Saúde; 2010.. In this context, orientations to adopt healthy habits should be provided to all of the individuals, regardless of the presence of some chronic morbidity, considering their contribution to prevent and control these problems¹⁰10. Ko JY, Brown DR, Galuska DA, Zhang J, Blanck HM, Ainsworth BE. Weight loss advice US obese adults receive from health care professionals. Prev Med 2008; 47(6): 587-92. ^{, 28}28. Fleming P, Godwin M. Lifestyle interventions in primary care: systematic review of randomized controlled trials. Can Fam Physician 2008; 54(12): 1706-13. ^{, 29}29. Mellen PB, Palla SL, Goff DC Jr., Bonds DE. Prevalence of nutrition and exercise counseling for patients with hypertension. United States, 1999 to 2000. J Gen Intern Med 2004; 19(9): 917-24..

Among the positive aspects of this study, its comprehensiveness, the national representative sample, the collection of primary data and the low non-response rate stand out. Concerning its limitations, it is worth to mention the lack of characterization of hypercholesterolemia as a health condition, the fact that the study was conducted by a cross-sectional design, which prevents the establishment of cause and effect relations, and the lack of characterization of the standard intake of salt, sugar and fat among the individuals in the sample. The inclusion of all of the adults from the same household in the sample may have overestimated the participation of friends and relatives as being responsible for the assessed orientations.

Conclusion

Based on the exposed, it is concluded that the orientation is scarce, especially for younger, poorer and healthier individuals, which configures a lost opportunity to prevent health and to raise awareness of the population. It is extremely important to develop actions aiming at qualifying services and health professionals, according to the National Policy of Health Promotion, so that the whole population can be advised and in contact with much information about the benefits of a healthy lifestyle.

It is believed that by investing in actions that aim at improving primary health care, especially the Family Health Strategy, it will be possible to improve the care provided to the poorer, promoting more equity in health promotion actions, for instance, the advisement for healthy lifestyles.

References

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