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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790X

Rev. bras. epidemiol. vol.16 no.4 São Paulo Dec. 2013

http://dx.doi.org/10.1590/S1415-790X2013000400019 

Original Articles

Advice for salt, sugar and fat intake habits among adults: a national-based study

Suele Manjourany SilvaI 

Luiz Augusto FacchiniI 

Elaine TomasiI 

Roberto PicciniII 

Elaine ThuméIII 

Denise Silva da SilveiraII 

Fernando Vinholes SiqueiraIV 

Alitéia Santiago DilélioI 

Bruno Pereira NunesI 

Mirelle de Oliveira SaesV 

IPostgraduate Program in Epidemiology, School of Medicine, Universidade Federal de Pelotas - Pelotas (RS), Brazil

IIDepartment of Social Medicine, School of Medicine, Universidade Federal de Pelotas - Pelotas (RS), Brazil

IIINursing school, Universidade Federal de Pelotas - Pelotas (RS), Brazil

IVSchool of Occupational Therapy, Universidade Federal de Pelotas - Pelotas (RS), Brazil

VPostgraduation Program in Health Sciences, Universidade Federal do Rio Grande - Rio Grande (RS), Brazil

ABSTRACT

INTRODUCTION

: A healthy diet is recognized as an important strategy for promoting health as an essential part of non-pharmacological therapy of various health problems.

OBJECTIVE

: To analyze the reported advice for the intake of salt, sugar and fat for the Brazilian adults living in urban areas.

METHODOLOGY

: National-based cross-sectional study with 12,402 adults interviewed in 100 Brazilian cities.

RESULTS

: The most prevalent advice was to low fat intake (38%), followed by the advice to low salt and sugar intake (36%) and sugar (29%). The percentage of receiving different advice was similar and more common among women, older people, those with a partner, higher economic class, former smokers, active and in person with physician diagnoses of hypertension, diabetes and overweight. People with white skin color received more advice to eat healthy food, except for the orientation to low salt intake.

CONCLUSION

: The results show a low prevalence of advice, which configures a missed opportunity to prevent health problems. Although dietary counseling should not be understood only as the transmission of advice regarding some nutrients, it is important to develop actions in order to qualify services and health professionals, allowing the population to have access to qualified information about the benefits of having healthy lifestyles.

Key words: Orientation; Feeding; Healthy behavior; Cross-sectional studies; Primary health care; Health promotion

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 conditions1.

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 issue2.

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 teachers3. 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 conditions1 , 4.

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 practices5. 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 deficiencies6.

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 minutes7. In another study conducted in the same country, 55% of the interviewed medical doctors reported advising their patients on health diet8.

A national-based cross-sectional study performed with American patients found a 70% prevalence of diet counseling9. 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 opportunity10.

Evidence shows that the population receives relatively little information about the benefits of a healthy diet11, 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 food5. However, considering the recommendation of the sixth guideline of the Eating Guide for the Brazilian Population6, 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 200012. 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 sector13. 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)14, 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)15, 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.

Table 1  Distribution of population characteristics and prevalence of advice to low salt, sugar and fat intake. Brazil, 2009 (n = 12,402).  

Variable Total Salt* (%) Sugar* (%) Fat* (%)
n %
Gender
Male 5,574 45.0 32.2 24.8 32.6
Female 6,828 55.0 39.6 31.8 42.7
Age (years)
20 to 29 3,938 31.8 26.5 22.2 28.9
30 to 39 3,114 25.2 34.2 26.8 35.7
40 to 49 2,958 23.9 40.4 31.6 42.5
50 to 59 2,361 19.1 50.3 38.3 51.7
Skin color
White 4,752 39.7 38.1 31.2 41.0
Mulatto 6,355 52.9 34.0 26.1 35.5
Black 770 6.4 42.1 31.0 42.4
Other 102 1.0 28.0 26.0 35.0
Marital status
With partner 4,454 35.9 30.3 24.8 32.9
Without partner 7,939 64.1 39.6 30.8 41.1
Economic level
A/B (higher) 3,302 28.3 45.9 39.9 48.7
C 6,013 51.5 34.6 25.9 36.1
D/E 2,359 20.2 27.9 20.3 29.1
Smoking
Never 7,816 63.2 36.4 29.7 38.7
Former smoker 1,985 16.0 43.4 34.0 45.8
Yes 2,575 20.8 30.1 21.2 30.4
Sedentary lifestyle
No 2,147 17.5 39.8 35.6 44.1
Yes 10,156 82.5 35.5 27.2 36.9
Hypertension
No 10,320 83.7 29.0 25.1 32.3
Yes 2,004 16.3 73.3 47.0 68.3
Diabetes
No 11,904 96.4 34.9 26.8 36.7
Yes 440 3.6 72.0 78.1 77.5
Excessive weight
No 10,185 82.5 32.5 25.3 34.0
Yes 2,161 17.5 53.9 44.2 57.5
Total 12,402 100.0 36.3 28.7 38.2

*Low intake

SAH: Systemic Arterial Hypertension.

Table 2  Characteristics of advice. Brazil, 2009 (n = 12,402).  

Advice Salt* Sugar* Fat*
n % n % n %
Place of advisement
Basic Health Unit 1,618 36.3 1,125 32.0 1,605 34.3
Public outpatient clinics 568 12.7 423 11.9 611 13.1
Doctor’s office by insurance 860 19.3 782 22.2 995 21.2
Private doctor’s office 363 8.2 302 8.6 397 8.5
Media 1,179 26.5 948 26.9 1,235 26.4
Another place 1,040 23.4 859 24.4 1,036 22.1
Advisor
Doctor 3,251 73.0 2,470 70.2 3,396 72.5
Nurse 334 7.5 237 6.7 303 6.5
Nutritionist 322 7.2 351 10.0 399 8.5
Friends/relatives 343 7.7 664 18.9 796 17.0
Others 1,078 24.2 267 7.6 322 6.9
Did the advice help 3,845 86.4 2,920 82.9 4,011 85.6
Being advised by a health professional 3,227 26.2 2,472 19.9 3,430 27.7

*Low intake.

Table 3  Crude and adjusted analyses of advice from health professional to low salt, sugar and fat intake according to population characteristics. Brazil, 2009 (n=12,402).  

Variable Low salt intake Low sugar intake Low fat intake
P (%) Crude Adjusted P (%) Crude Adjusted P (%) Crude Adjusted
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
Gender* < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001****
Male 21.4 1.00 1.00 15.8 1.00 1.00 21.8 1.00 1.00
Female 29.8 1.39(1.31 – 1.48) 1.41(1.33 – 1.51) 23.3 1.48(1.38 – 1.59) 1.52(1.41 – 1.64) 32.5 1.49(1.41 – 1.58) 1.53(1.44 – 1.62)
Age (years)** < 0.001***** < 0.001***** < 0.001***** < 0.001***** < 0.001***** < 0.001*****
20 to 29 15.4 1.00 1.00 12.5 1.00 1.00 17.2 1.00 1.00
30 to 39 23.1 1.50(1.36 – 1.66) 1.43(1.29-1.59) 17.5 1.40(1.26 – 1.56) 1.34 (1.19 – 1.50) 24.6 1.43(1.31 – 1.56) 1.36 (1.24 – 1.49)
40 to 49 30.4 1.98(1.80 – 2.17) 1.89(1.29 – 1.59) 23.2 1.85(1.67 – 2.06) 1.75(1.56 – 1.96) 32.0 1.86(1.70 – 2.03) 1.78(1.62 – 1.95)
50 to 59 42.2 2.74 (2.51 – 3.00) 2.67(1.70 – 2.09) 31.6 2.53(2.28 – 2.80) 2.42(2.17 – 2.70) 44.0 2.56(2.35 – 2.78) 2.47 (2.26 – 2.70)
Skin color* < 0.001**** 0.001**** < 0.001**** 0.03**** < 0.001**** 0.003****
White 27.1 1.08(1.02 – 1.16) 0.97(0.90 – 1.03) 22.3 1.23(1.14 – 1.33) 1.05(0.97 – 1.14) 30.3 1.17(1.10 – 1.25) 1.04(0.97 – 1.11)
Mulatto 25.0 1.00 1.00 18.1 1.00 1.00 25.8 1.00 1.00
Black 30.3 1.21(1.07 – 1.36) 1.17 (1.04 – 1.32) 21.8 1.21 (1.04 – 1.40) 1.15(0.99 – 1.35) 31.0 1.20(1.08 – 1.35) 1.14(1.01 – 1.27)
Other 16.7 0.67(0.43 – 1.02) 0.57 (0.37 – 0.87) 11.8 0.65(0.38 – 1.10) 0.57(0.35 – 0.93) 17.8 0.68(0.46 – 1.02) 0.58(0.39 – 0.86)
Marital status* < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001****
Without
partner
19.7 1.00 1.00 15.2 1.00 1.00 21.9 1.00 1.00
With
partner
29.6 1.51(1.40 – 1.62) 1.30(1.21 – 1.40) 22.6 1.49(1.37 – 1.62) 1.32(1.21 – 1.44) 30.9 1.41(1.31 – 1.51) 1.26(1.18 – 1.36)
Economic level* < 0.001***** < 0.001***** < 0.001***** < 0.001***** < 0.001***** < 0.001*****
A/B (higher) 32.8 1.51 (1.38 – 1.67) 1.48(1.34 – 1.64) 28.3 1.87(1.65 – 2.12) 1.81(1.59 – 2.06) 35.3 1.54(1.40 – 1.69) 1.47(1.34 – 1.63)
C 24.5 1.13(1.03 – 1.24) 1.15 (1.05 – 1.27) 17.5 1.16(1.02 – 1.31) 1.17(1.03 – 1.33) 25.6 1.11(1.01 – 1.23) 1.12(1.02 – 1.23)
D/E 21.7 1.00 1.00 15.1 1.00 1.00 23.0 1.00 1.00
Smoking## < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001****
Never 25.8 1.17(1.08 – 1.28) 1.16(1.06 – 1.26) 20.3 1.39(1.25 – 1.53) 1.31(1.18 – 1.47) 27.5 1.24(1.14 – 1.35) 1.20(1.10 – 1.30)
Former smoker 32.6 1.49(1.34 – 1.64) 1.25 (1.13 – 1.38) 25.3 1.72(1.52 – 1.95) 1.45(1.28 – 1.65) 35.8 1.62 (1.47 – 1.78) 1.38(1.25 – 1.52)
Current 21.9 1.00 1.00 14.7 1.00 1.00 22.1 1.00 1.00
Sedentary
lyfestyle**
0.02**** 0.04**** < 0.001**** < 0.001**** < 0.001**** < 0.001****
No 28.0 1.09(1.01 – 1.18) 1.08(1.00 – 1.16) 24.5 1.29(1.18 – 1.41) 1.22(1.12 – 1.33) 31.4 1.17(1.09 – 1.26) 1.15(1.07 – 1.24)
Yes 25.6 1.00 1.00 19.0 1.00 1.00 26.9 1.00 1.00
Variable Low salt intake Low sugar intake Low fat intake
P (%) Crude Adjusted P (%) Crude Adjusted P (%) Crude Adjusted
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
PR
(95%CI)
Hypertension*** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001****
No 18.0 1.00 1.00 15.6 1.00 1.00 20.9 1.00 1.00
Yes 67.5 3.75
(3.55 – 3.97)
2.87
(2.69 – 3.06)
42.5 2.73
(2.54 – 2.92)
1.81(1.67 – 1.96) 62.7 3.00
(2.84 – 3.17)
2.21
(2.08 – 2.35)
Diabetes*** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001****
No 24.6 1.00 1.00 18.0 1.00 1.00 26.0 1.00 1.00
Yes 67.1 2.73
2.53 – 2.94)
1.46
(1.34 – 1.58)
74.8 4.15
(3.87 – 4.48)
2.66(2.43 – 2.91) 73.6 2.83
(2.65 – 3.03)
1.67
(1.54 – 1.80)
Excessive
weight***
< 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001**** < 0.001****
No 22.6 1.00 1.00 16.7 1.00 1.00 23.8 1.00 1.00
Yes 42.3 1.87(1.75 – 2.00) 1.32(1.24 – 1.40) 35.1 2.10
(1.93 – 2.27)
1.54
(1.42 – 1.66)
46.0 1.94
(1.82 – 2.06)
1.41
(1.33 – 1.50)

*First hierarchical level

**Second level hierarchical

***Third hierarchical level

****Heterogeneity p-value

*****Trend p-value

P: Prevalence

PR: Prevalence Ratio

95%CI: Confidence interval of 95%.

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 measure16. 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 Finland7 , 17 - 19.

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 health3.

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 populations20. 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 behaviors21.

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 appointments22 , 23.

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 professionals24.

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 care3. 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 problems25.

Evidence shows that the use of health services is socially determined and affects the standards for receiving orientations26. 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 countries27.

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 education22 , 23 , 26. Patients with chronic problems are more exposed to receiving orientation about healthy lifestyles since they use the health services more frequently22. 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 health28 , 29.

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 group3. 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 problems10 , 28 , 29.

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

1. 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. [ Links ]

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Received: March 21, 2013; Revised: August 30, 2013; Accepted: October 28, 2013

Corresponding author: Suele Manjourany Silva Departamento de Medicina Social Avenida Duque de Caxias, 250, CEP: 96030-000, Pelotas, RS, Brazil E-mail: sumanjou@gmail.com

Financial support: Ministry of Health, Secretariat of Primary Care, Primary Care Department. Process n. 25000.222781/2007-05.

Conflict of interests: nothing to declare.

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