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Revista Brasileira de Educação Médica

Print version ISSN 0100-5502On-line version ISSN 1981-5271

Rev. bras. educ. med. vol.43 no.1 Brasília Jan./Mar. 2019

https://doi.org/10.1590/1981-52712015v43n1rb20180112 

ARTIGOS ORIGINAIS

Guidance on Healthy Eating Habits from the Medical Student’s Perspective

Orientação de Hábitos Alimentares Saudáveis sob o Olhar do Estudante de Medicina

Talita Cardoso RossiI 

Vânia Hercilia Talarico BrunoI 

Fernanda Martin CatarucciI 

Ivan da Silva BetetoI 

Pedro Henrique Leonetti HabimoradI 

Karina Pavão PatrícioI 

I Universidade Estadual Paulista Júlio de Mesquita Filho , Botucatu , São Paulo , Brasil .


ABSTRACT

Although nutrition is one of the most significant aspects of good health and well-being, preventing many diseases and reducing premature death and disability, most medical curricula still do not cover this topic in depth, devoting only a few hours to it. This leaves an important gap in the training of medical professionals, in a context of an increase in chronic diseases, where healthy eating is essential, not only for prevention but also to guarantee treatment success. The present study interviewed medical students from the first to the sixth years of graduation, in order to understand what they consider to be a healthy diet and whether they consider themselves capable of guiding their future patients in the adoption and practice healthy eating habits. This is a qualitative study in which semi-structured interviews were conducted with 28 undergraduate medical students of a public university in the state of São Paulo. The data were analyzed using the technique of Content Analysis, with a thematic representational approach. Two major themes emerged, showing possible gaps in the students’ knowledge about nutrition and the difficulty they have in helping their patients switch to healthier eating habits, given that they themselves have difficulty doing the same. There is a need for medical schools to promote students’ health, both physical and mental, in response to the high demands of the courses. This may include health promotion activities aimed at the students themselves, encouraging them to adopt healthier lifestyles, especially healthier eating habits, so that they can share their own experiences with future patients. This may benefit their professional practice, giving them greater confidence when giving nutrition guidance to their patients, as they will have already experienced and applied the principles in their own lives. Patient-centered care can be a way to address this system and help patients effectively switch to healthier habits, thereby reducing suffering and improving quality of life. Empowerment through activities that receive and support the student and the patient is an essential tool for behavioral change.

Key words: Medical Education; Curriculum; Nutritional Sciences; Healthy Diet

RESUMO

The rising number of students leagues in the Escola Paulista de Medicina of the Universidade Federal de São Paulo (EPM–Unifesp) leads to questions about their meaning to students and their role in medical training, as well as concerns about learning distortions, early specialization, social relevance, and insertion in the Brazilian national health system, called the Sistema Único de Saúde (SUS). In order to try and clarify these questions, this qualitative study analyzes the statues of the leagues, and the statements of tutors and students, gathered by means of four focal groups with students and two interviews with the tutors. We found 45 leagues currently running at the EPM–Unifesp, most of them associated with a medical specialty. The main motivators for joining in a league were: the search for practical activities, the desire to gain more experience of a particular specialty, the desire for more knowledge, and the need to be recognized as a responsible adult. Of the leagues studied, few conducted research or university extension activities, focusing on treatment and theoretical classes, supervised by professors, non-teacher physicians, resident doctors, or more senior students. The tutors are in charge of the organizational aspects. The leagues can reproduce graduation models, such as an overburdoning with activities and poor expository classes. Concerning insertion in the SUS, the leagues could be a means of training future SUS professionals. Although students claim that they intend to specialize in the league’s field, the tutors disagree that they lead to early specialization. We consider that while leagues fill gaps in the learning and expectations of the course, they are limited in regards to the impact of their activities on medical training and their social relevance. They can subvert the curricular structure and favor early specialization. We recommend that universities pay closer attention to students leagues, observing their number, selection process, activities, tutors involved and explicit objectives, with the purpose of evaluating their roles in the curriculum and medical training.

Palavras-Chave: Educação Médica; Currículo; Ciências da Nutrição; Dieta Saudável

INTRODUCTION

Nutrition, defined by the World Health Organization as “the intake of food, considered in relation to the body’s dietary needs” 1 has been the object of numerous studies correlating food consumption with the development or prevention of various chronic and non-communicable diseases. These include the relationship between high meat consumption and the increased risk of colon cancer 2,3 ; increased fiber consumption and the reduced risk of cardiovascular disease 4 ; increased DHA intake (polyunsaturated fat) and a reduction in the risk of glucose intolerance, decrease in tissue inflammation and promotion of memory improvement 5,6 ; and the consumption of probiotics, which helps balance the intestinal flora, and has been known to benefit some autistic children 7 . According to a review published by Myles in 2014, scientific studies have emphasized the role of diet in the immune system. That author suggests that high intakes of sodium, refined sugar and omega 6 type fatty acids, and low consumption of omega 3, associated with Western dietary patterns, can damage the immune system, compromising the health of individuals 8 .

Despite the fact that nutrition is one of the most significant aspects of good health and wellbeing, playing a part in the prevention of many diseases, as well as being one of the main factors in reducing premature death and disability 9 , most medical school curricula still do not offer in depth coverage of the subject, devoting only twenty to thirty hours of study to it, on average, throughout the whole six years of graduation. Furthermore, the course content tends to be presented mainly in the first semester, with no little or no practice to support the theory 10,11,12 . The insufficient representation of the subject in the curricula can result in poor training of medical professionals, who often lack consistent knowledge of this subject, which is so important in today’s global epidemiological scenario, with the increased prevalence of chronic diseases, where a healthy diet is essential not only to for prevention but also to ensure successful treatment of illnesses 13 .

Some deterrents to introducing the subject of Nutrition in the medical curriculum are the common belief among health professionals that nutritional guidance should be the role of dietitians rather than medical practitioners, and the claim that there is not enough scientific basis for the treatment/prevention of diseases through nutrition. There is also a prevailing welfare and medical paradigm that disregards the disease prevention approach; and finally, with the indecision over which are the most relevant topics to be covered in the medical curricula, limitations on teaching time, and stretched financial resources, teaching on nutrition is often low on the list of priorities 14,11 .

The poor eating habits often practiced by students and doctors themselves are, in many cases, contradictory to the guidelines of the WHO and the Brazilian Ministry of Health 15,16 . A 2010 study among Greek medical students found that 36.9% of males consumed fast food more than three times a week, in spite of 82.4% of them knowing the implications of the long-term practice of poor eating habits 17 . Other studies have shown similar results within the medical student population. A research study conducted in Lithuania pointed to the fact that eating habits were irregular among first and third year students, and that only 20% of the study population consumed the World Health Organization’s recommended daily intake for fruits and vegetables 18 .

In view of this issue, the current study interviews medical students in their first to sixth years of university, seeking to understand what they consider a healthy diet to consist of, and whether they consider themselves capable of guiding future patients in practicing healthy eating habits.

METHODS

The data for this qualitative study was collected through semi-structured interviews with medical students at a public university in the state of São Paulo, Brazil, who were taking part as volunteers in another study on meditation (Fapesp – Process 2015/10854-2). We interviewed students in their first to sixth years.

The group was randomly selected. Out of every three students who came to collect data for the meditation study, one underwent an interview with the researcher, in which two initial key questions were asked: 1) What do you consider a healthy diet?; and 2) How would you help your patients to change harmful eating habits? The whole process took place at the university research unit facilities.

The interviews were recorded with a digital audio recorder and were conducted in a way that allowed the interviewee to bring out their own ideas, without interruptions, ensuring that that no questions or comments from the interviewer could influence the interviewee’s reply. After 28 interviews, the researcher judged that the replies were saturated, and ended the data collection. All the recorded material was then transcribed for analysis.

To assess the collected data, Content Analysis of inductive thematic type was used, as proposed by Bardin 19 , with a thematic representational approach. This method was chosen because it aims to understand both the manifested/explicit and the latent/implicit meanings within the replies, allowing the respondents to dictate the themes to be discussed. Content analysis relates to words and their meanings, with the purpose of understanding what is implied in the subject’s statements.

Firstly, a reading of the transcribed data was carried out, to identify key excerpts to be analyzed. The quotes were chosen based on their proximity or distance to the concepts discussed in the recent literature. This was followed by three stages: 1) pre-analysis (organization and systematization of the initial ideas, hypothesis formulation and objectives), 2) exploration of the material (coding, classification and categorization) and 3) treatment of the results, inference and interpretation for the final analysis. The final data was revised by three other researchers with experience in qualitative studies 19 .

RESULTS AND DISCUSSION

A total of 28 students were interviewed, comprising 28.57% first-year students, 14.28% second-year students, 28.57% third-year students, 14.28% fourth-year students, 10.71% fifth-year students and 3.57% sixth-year students. The mean age was 25.53 years of age, ranging from 18 to 28 years old. Of the group, 39,29% were male and 60,71% were female students.

Based on the analysis of the interview, the following themes and subthemes emerged:

Understanding medical students’ limited knowledge about nutrition

Through the interviewees’ replies, some major shortcomings were identified regarding what medical students consider to be a healthy diet. In our results, four subthemes were representative of the group’s knowledge about the subject: the need to have a balance of several sources of nutrients; eating at regular intervals; eating more natural foods, avoiding processed products; purchasing low fat/low sugar products.

The need for balancing several sources of nutrients

In this subtheme, a healthy diet was considered to be one in which there is a balance between macro and micronutrients, with an adequate intake of fruits and vegetables.

I think it is keeping a balance between vegetables, fruits and carbohydrates and proteins. I think that’s it basically. (E17, fourth year)

Although these concepts are well-known and widespread even among the general public, we noted that on various occasions, the respondents appeared to have a superficial knowledge on the subject:

I don’t know. A balanced diet in the sense that you get all the nutrients you ... I have a very vague idea, you know? But ... but I think it’s something like that. (E11, third year)

Despite the fact that a balanced nutrient intake is important to maintaining good health, the concept of healthy eating goes beyond the boundaries of chemistry and biology, and relates also to cultural habits, traditional values and the environment.

According to the Brazilian National Policy for Food and Nutrition (PNAN), a healthy diet is defined as:

An adequate eating pattern for both the biological and sociocultural aspects of individuals and the sustainable use of the environment. That is, it must be in alignment with age requirements as well as specific dietary needs; referenced by traditional food practices and the aspects of gender, race and ethnicity; available both within the physical and financial perspectives; balanced in quantity and quality; based on an adequate and sustainable production system, with as little physical, chemical and biological contaminants as possible [...] considering that there are other purposes to food than merely supplying for biological needs, since it has unique cultural, behavioral and emotional meanings that cannot be ignored.20

Studies have shown that medical students may present limited knowledge in the field of nutrition 21,22 . A research study evaluating students’ knowledge of general and clinical nutrition showed an average accuracy of 60 and 52 percent in the replies, respectively. However, when specific food categories were assessed individually, the margin of correct answers ranged from 17.35% to 77%, a clear indication of superficial and uneven knowledge on the subject 21 .

From this perspective, our results highlight the limitations and lack of knowledge about healthy diet among respondents.

The limited knowledge on the subject observed in our study may be related to the fact that the majority of the participants of this research (71.42%) were in their first, second or third years of the medical course. However, it is worth highlighting that in the university in our study, students do not take the discipline in Nutrition and Public Health until their third year, with a total of 58 hours, and they take other disciplines in the internship (from the 4 th to 6 th year) with 176 hours (2.37 % of the total training time as described in the Course Plan). The contents related to nutrition are distributed across different disciplines, such as Public Health, Internal Medicine, Pediatrics and Gastroenterology.

Feeding at more regular intervals

The theme of meal frequency was also present in the students’ replies. Eating at frequent intervals, not skipping meals and avoiding going for long periods without food were considered essential by the group for maintaining a healthy diet, as shown by the following excerpts:

It’s knowing how to eat at the appropriate intervals, not going through long periods without eating, like, every two hours you should be eating something... (E8, fifth year)

Doctors and health care professionals usually advise their patients to eat at shorter intervals. The scientific evidence corroborates this idea, showing the correlation between eating at shorter intervals and better glucose metabolism 23 , as well as bringing benefits for people with diabetes 24 and obesity 25 . There is, however, an important factor that must be acknowledged when eating more frequently: the availability of healthy snacks, since most snack products on the market can be considered low in nutritional value, being produced primarily with low-quality fat and simple carbohydrates 26 . In Brazil, frequent consumption of highly processed food increased by 300% in metropolitan areas, with 28% of total energy intake per household coming from ultra-processed products 27 .

Eating more frequently can be beneficial to health, provided food choices are made consciously, especially snacks taken between meals. Barnes (2014) has shown that consumption of vegetables between meals is associated with a lower body mass index (BMI). However, only 1.4% of the participants in this study displayed this eating habit 26 .

Therefore, when advising patients to eat at shorter intervals, it must be ensured that the patient is able to choose what they eat, and to eat sensibly, especially when it comes to snacking.

Eating more natural foods, avoiding processed products

The interviewees stressed the importance of a diet consisting predominantly of whole, fresh foods, with low intake of processed and ultra-processed foods. They also mentioned the consumption of organic food for maintaining good health.

Trying to avoid eating stuff with lots of preservative, too processed... I think healthy eating has to do with fresh, unprocessed food. (E10, fourth year)

It’s the most unprocessed, freshest foods as possible, erm […] without too much sugar, without many colorings, without lots of preservatives, as wholesome and with as many organic vegetables as possible. (E16, fifth year)

We are experiencing rapid changes in the dietary patterns around the globe as the consumption of traditional diets are becoming obsolete due to the broad access to commercially appealing, low cost and foods with high palatability but little or no nutritional value.

The effects of long-term, over consumption of ultra-processed food could damage the body in several ways, including the development of chronic illnesses through various paths, such as systemic inflammation, causing cardiovascular diseases 28 , asthma, and allergies 29,30 . The increased intake of ultra-processed food has also been linked to the development of dysbiosis, increased intestinal permeability, and Crohn’s disease in mice 31 .

The discussion regarding the consumption of highly processed foods is essential in the healthcare context, since these products have substances which could be potentially harmful to the health of individuals.

This is thoroughly discussed topic in the Dietary Guidelines for the Brazilian Population, which recommends that whole or minimally processed foods, with no additives, should be the basis of Brazilian’s diet 16 . Therefore, a more thorough discussion of the topic is needed in medical degree courses.

Purchasing low fat/low sugar products

Our results showed a trend among students, who perceived low fat/low sugar products as being healthy. This can be seen in the following statement:

[...] low fat goods erm [...] buying everything low fat, you know? Low fat cream cheese, erm… skimmed milk. (E8, fifth year)

Low fat/low sugar products are those with a reduced content of at least 25% of a particular nutrient, mainly sugar or fat. Another category of goods with low or zero nutrient content is diet products, such as sweeteners used to replace sugar 32 .

In relation to the consumption of diet and low fat/low sugar products, some major points should be taken into account when purchasing these items. For example, the lack of regulations on marketing and labeling may lead the consumer to make mistaken choices. A US study showed that 23% of food labels claiming nutritional benefits had high levels of saturated fat and simple sugars. This may be due to misleading advertising that highlights the presence or absence of a particular nutrient in order to downplay components that might lead consumers to reject the product 33 .

With regards to diet products and sweeteners, there is extensive scientific material available. However, the evidence supporting the use or misuse of these substances is often contradictory and inconclusive 34 . In his review, Wiebe et al . 35 questions the effectiveness of dietary sweeteners in glucose control, even for patients with diabetes. There is, however, a growing body of evidence linking long-term consumption of non-calorie sweeteners with the development of obesity 36 , type 2 diabetes mellitus, hypertension, cardiovascular disease, glucose intolerance and metabolic syndrome 37 possibly mediated by the gut microbiota 38 .

Faced with the controversial debate of these products’ beneficial or harmful effects on the body, health care professionals should be up-to-date with the scientific evidence and prepared to point out the potential advantages and disadvantages of consuming low fat/low sugar and diet products, as well as their recommended maximum intakes, as well as being able to advertise the potential harmful effects to patients of over consuming these products, which unfortunately was not pointed out by our interviewees.

Difficulty in helping patients change harmful eating behaviors

From our interviews, we noted that students showed little knowledge or experience of helping patients change harmful habits. A total of four representative subthemes of the group’s knowledge on the subject were considered: knowing what to say but not being able to do it, the difficulty of changing patient’s habits, it being the dietitian’s job, and the importance of patients participating in their treatment process.

Knowing what to say but not being able to do it

When asked about how they would help their patients change their eating habits, the respondents acknowledged that they did not feel able to apply their advice in their own lives, as evidenced in the following excerpts:

Oh, I think I could, even though I don’t eat properly myself, but I think it is to make them believe what we’re doing [...] I mean, telling them to do it, right? [...] Well, I hope I’ll be able to change their life habits even though I can’t change my own, I hope. (E4, fourth year)

It was also noted in some replies that the ability or inability to practice healthy eating habits themselves could influence their conviction at the time of prescription.

And then sometimes we blame the patient: well, you weren’t doing what I told you to… but we don’t do it either... I think that is not quite the right way, we don’t have a lot…, we don’t apply it to our own lives, you know? (e8, fifth year)

First of all because I already made these changes to my own life, so maybe I have a true understanding, not just… I’m not… I won’t be just talking the talk because I have experienced this process and because I think… I know there is ... the patient is more likely to believe the doctor and maybe follow his instructions, so perhaps I can help like that. (E9, sixth year)

Studies show that the prescription of healthy behaviors by physicians who practice a healthy lifestyle themselves may engender greater trust among patients and encourage them to stick to the advised treatment. This may be because these physicians serve as role models, demonstrating that it is possible to adopt healthy lifestyle habits. A doctor who shares his own experience with a patient, even if the outcome was not positive, may increase the chances of a change in habits. On the other hand, physicians who do not seek to practice healthy, balanced lifestyle habits in their own lives report difficulties in prescribing them 39,40 .

It is known that many college students, including medical students, have inadequate eating and lifestyle habits that can potentially damage health, turning them into a vulnerable group for the development of chronic and non-communicable diseases 17,18,41 . However, doctors with healthy lifestyles are more likely to practice preventive medicine with their patients, and to do so more confidently 40 . For this reason, some studies propose the inclusion of health promotion practices throughout the university or college period, on the basis that it could encourage students to adopt healthier lifestyles, motivating them to share this with their patients 42,43 .

The difficulty of changing patient habits

The students participating in this study reported difficulty in helping their patients change their lifestyle habits, showing a lack of skill, confidence and knowledge at times when this type of approach is needed:

We keep saying what they have to do and not really helping them to actually change, which I think is the hardest bit when it comes to changing lifestyle habits and which is a major part in treating diseases, isn’t it? In drugless treatments that is, which I believe interferes much more than just prescribing drugs […] to be honest we don’t have a strategy to help patients, so I can’t really tell you: ok, let’s come up with a strategy to help patients to change their bad habits, because there isn’t one and that makes me really sad. (E8, fifth year)

We noted that students felt out of their depth when addressing the need to change behaviors. In our study, we evaluated the ability to change eating behaviors, but it could be applied to various other lifestyle changes, leading to health problems such as drug and tobacco addiction, alcoholism and sedentarism. Here, behavioral theories could be useful tools, if students were given more knowledge about them during graduation. Behavioral tools have proven to be effective in cases of addiction, improving eating habits, and following an exercise regime 44 . In addition to these theories, practitioners may teach their patients various strategies, such as self-monitoring, problem solving, setting goals, cognitive restructuring, stress management techniques, developing self-efficacy, and mindfulness techniques, among others 45,46,47 .

Currently, about 50% of deaths in the US are due to poor lifestyle habits. Studies with primary health care services show that 97% of patients have at least one harmful lifestyle habit and 80% have two. Although these habits are potentially reversible, less than 5% of the US national health budget goes towards preventive medicine 48,49 .

There is significant evidence confirming that physician counseling can be effective for changing patients’ habits, but for various reasons, such as the excessive demands on healthcare professionals, a lack of time, the drug current prescription paradigm in hospitals and healthcare centers, and a shortage of available personnel, preventive medicine and health promotion actions are not prioritized.

Therefore, it is imperative to insert more tools in medical education to assist students in developing communication skills, enhanced listening, and empathy, in order to help their patients more to effectively change harmful behaviors 48,49 .

It being the dietitian’s job

Respondents’ attribute the role of advising patients on changing eating habits to dietitians. While this could favor a multidisciplinary approach, it could also exempt doctors from having a broader vision of patients’ health care.

Oh, I don’t know... because it has a lot to do with the dietitians work and… I wouldn’t know how. (E6, first year)

Depending on the case ... I would probably recommend a dietitian or perhaps he himself could try and create an eating diary, but I think the dietitian would be best suited, right? I don’t know. (E13, third year)

It is a fact that professional dietitians are important when it comes to optimizing changes in eating habits. However, with the growing concerns over food related diseases, all healthcare professionals should be better prepared to address these matters. There are currently less than 100,000 registered dietitians in the USA, compared to 841,000 registered doctors. In Australia, the dietitian to doctor ratio is 3 to 1000; in the United Kingdom, ratio is 3 to 100 12,50 .

The United States Department of Agriculture (USDA) recognizes that effective changes in the eating habits in the American population would require a joint effort from all sectors of society; individuals, families, communities, healthcare professionals, retailers and farmers, such is the scale and size of food related issues 51 .

Every healthcare professional should be able to guide patients on healthy food choices, which are sustainable and don’t present risks to human and envinronmental health 16,52 .

The importance of patients participating in their treatment process

Finally, students remembered the importance of patient’s participation in their own treatment and healing process, as seen in this excerpt:

I believe in a self-healing medicine, where the doctor is just facilitating health promotion, where health comes from within the person and this is reflected in their own body systems [...] one should always make them believe that they have the power to heal themselves, if they are ill they are the ones who can cure the disease, it’s their attitudes that will make the difference, and not the drugs I prescribe. That’s what I believe. (E12, second year)

Patient Centered Care (PCC) was recommended by the American Institute of Medicine as one of six measures to be adopted in improving the quality of healthcare on the 21st century. Since then, there has been a growing interest in this approach by professionals in the field 53 .

One of the premises of the PCC is to treat the patient as a unique individual, taking into account their wishes and points of view, and encouraging them to participate in the decision-making process. In the PCC the patient is seen in a holistic way; as a complex human being, and not merely as fragmented organs and systems, separate from each other. In addition to the benefits of the individual’s empowerment in their own healing process, the adoption of the PCC method could also result in lower healthcare costs, especially in the long-term 54 . However, the patient’s wishes should be taken into account even when deciding whether to adopt PCC or the prescriptive approach, as some patients prefer not to actively take part in the decision making process 53 .

Despite promises of a more human and efficient healthcare service, the transition to this new paradigm would require a lot of effort by professionals, who would have to work in unfamiliar scenarios, and learn new skills, such as listening and talking to their patients more effectively, and helping them to overcome unhealthy habits. It is known that PCC can improve the quality of healthcare service; its concepts are well founded, and its methodology has already been proven effective. The challenge still remains to overcome a system that has, for some time, been claiming advocacy for change. Patient Centered Care is an approach that requires humility, dedication and openness to changes among the healthcare team, which is not always realistic 55 . This study points to a need to include new approaches and tools for future doctors in the medical curricula, so that they can be better equipped to help their patients change their eating habits.

This study has some limitations; we interviewed only a small number of students, who were participating in another study, following a qualitative methodology to understand the problem. It is suggested that more research be developed, with different methodologies, in order to ensure a representative sample, including spreading the subject in a more balanced way, across different years of the course.

More qualitative studies are needed on medical student’s perceptions about their ability to counsel patients on changing unhealthy eating habits, since this is so important to an individual’s health. This could lead to further research on potential interventions focused on teaching students effective techniques to work with patients and helping them to achieve better quality of life, resulting in less disease.

FINAL CONSIDERATIONS

This study reveals how the interviewed medical students show an apparent limited knowledge about what constitutes a healthy diet, both in their personal lives, as reflected in their own poor eating habits, and in their professional life in which they feel insecure in how to guide their future patients to adopt new habits for a healthier life. However, in the investigated group the majority of students were coursing from first to third medical year. Studies such as this are suggested to investigate students during internship years to verify if these findings still remain.

The need for medical schools to promote the student’s health, both physical and mental, in response of a high-load course is noted. This could include health promotion practices aimed at the students themselves, encouraging them to adopt healthier lifestyles, especially healthier eating habits, so that they can share their own experience with future patients. This may benefit their professional practice, giving them greater confidence when giving nutrition guidance to their patients, as they will have already experienced and applied the principles in their own lives. Patient-centered care can be a way to address this system and help patients effectively switch to healthier habits, thereby reducing suffering and increasing quality of life. Empowerment through activities that welcome and support the student and the patient is therefore an essential tool for promoting behavioral change.

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Received: September 3, 2018; Accepted: September 19, 2018

POSTAL ADDRESS . Karina Pavão Patrício: Av. Prof. Mário Rubens Guimarães Montenegro, s/n Bairro: UNESP – Departamento de Saúde Pública, Faculdade de Medicina, Campus de Botucatu, Botucatu/SP, Brasil, CEP 18618-687; telephone: +55 (14) 38801366. E-mail: pavao@fmb.unesp.br

CONTRIBUTIONS

Talita C. Rossi and Karina P. Patrício participated from drawing this study, collecting and analyzing data until the final essay of the paper. The other authors participated in the interpretation of the data, writing of the article and approved the final version.

CONFLICT OF INTERESTS

No conflicts of interest are declared by of any of the named authors.

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