Rev Chil Nutr Vol. 29, Nº3, Diciembre 2002
VOLUNTARY LIFESTYLE CHANGES AND KNOWLEDGE ABOUT
HEALTHY LIFESTYLES OF CHILEAN PRIMARY HEALTH CARE
CAMBIOS DE ESTILO DE VIDA Y CONOCIMIENTOS
SOBRE ALIMENTACIÓN SALUDABLE Y ACTIVIDAD FÍSICA EN
PROFESIONALES DE ATENCIÓN PRIMARIA EN CHILE
Svenja Jungjohann (1), Isabel Zacarías (2), Ingrid Keller (3)
(1) Justus-Liebig-University Gießen, Germany. World Health Organization, Geneva, Switzerland
(2) Instituto de Nutrición y Tecnología de los Alimentos,Universidad de Chile
(3) World Health Organization, Geneva, Switzerland
Se evaluaron los cambios en los estilos de vida y conocimientos en alimentación
saludable y actividad física en profesionales de atención primaria de salud. Se aplicó una
encuesta a 194 profesionales (médicos, enfermeras, nutricionistas, matronas y asistentes
sociales), de los cuales el 86% eran mujeres. Se observó que durante el último año, la
mayoría de los profesionales modificó sus hábitos hacia estilos de vida mas saludables.
Alrededor del 80% señalaron que consumen menos grasas y consumen mas verduras,
dos tercios indicaron consumir menos azúcar, alrededor de la mitad menos alcohol y un
45% hacen más actividad física. La gente mas joven es la que ha hecho las mayores
modificaciones, a pesar que aumentaron el consumo de bebidas gaseosas, alcohol y
tabaco. Un 80% de los profesionales respondió correctamente las preguntas relacionadas
con alimentación y actividad física. Se encontró diferencias estadísticamente
significativas entre los diferentes grupos de profesionales. Se concluye que muchos
profesionales han efectuado cambios hacia estilos de vida mas saludable, tienen un buen
conocimiento de hábitos alimentarios y actividad física. Estos resultados indican la
importancia del trabajo en equipo para contribuir a la prevención de las enfermedades
crónicas no transmisibles. Términos claves: profesionales de atención primaria, cambios
en estilos de vida, conocimiento, alimentación saludable, actividad física.
Este trabajo fué recibido el 8 de Noviembre de 2002 y aceptado para ser publicado el 7 de Diciembre de 2002.
In the past decades the Chilean public health care system has been very successful in
improving maternal and child health as well as in diminishing infectious diseases through
national programmes. National standard measures carried out among children entering
school (6 years of age) and pregnant women, indicate a steep rise in obesity (compared to
standard weight tables) in both population groups in the past decade: from 6.5% in 1987 to
14% in 1999 among 6 year olds and from 12% in 1987 to 27% in 1999 among pregnant
women. Prevalence of obesity (body mass index (BMI) >30) among the general adult
population in the metropolitan areas of Chile is increasing and is higher in low socio-
economic neighborhoods (1). The risk factors for noncommunicable diseases (NCDs) have
not been evaluated systematically, however the first nationally representative survey on quality of life among adults was carried out in 2000. It was found that 40% are daily smokers and 91% are physically inactive. Some 47% reported to eat fruits and vegetables every day and only 35% said to consume milk products every day (2).
In response to increasing risk for NCDs, Chile, in 1996, joined the CARMEN programme (Conjunto de Acciones para la Reducción Multifactorial de Enfermedades No Transmisibles) of the Pan American Health Organization (PAHO), modelled after the European/Canadian experience of CINDI (Countrywide Integrated Non Communicable Disease Intervention). CARMEN is an integrated programme with activities to date in the demonstration area of the health service in the city of Valparaíso (5th region). All of the health services in the 8th region joined in 2001 (Arauco, Bio-Bio, Concepción, Talcahuano and Ñuble) as did the health service of the south-east area of the capital city Santiago de Chile.
The present study aimed at assessing life style changes, beliefs and knowledge regarding healthy diet and physical activity of primary health care (PHC) professionals working in PHC centres in Valparaíso and Concepción. This study takes into consideration that has been reported elsewhere (3-5), that health professionals who lead healthy life styles
themselves are more credible to patients when prescribing changes in lifestyle and/or that they are more likely to prescribe lifestyle changes.
SUBJECTS AND METHODS
The survey was undertaken during two workshops for PHC workers within the framework of the CARMEN programme. The workshops were held in the area of the health services of Concepción and Valparaíso. Medical doctors, nurses, nutritionists, midwives and social workers participated.
Out of a total of 300 questionnaires were distributed, 194 questionnaires were received back. From the former, 93 questionnaires were received from Valparaíso and 101 from Concepción cities. All questionnaires were valid for the analysis.
Participants came from the following professions: 42 medical doctors, 82 nurses, 59 nutritionists, and 11 others (midwives, social workers).
The questionnaire, in Spanish, included four items and was self-administered. It included questions to be answered with ?yes? or ?no? about positive as well as negative lifestyle changes over the last twelve months for health reasons, including diet, tobacco use and physical activity. For example they would be asked the question: ?Have you smoked less?? Next, participants were asked about what they perceive to be the most important reason for a high prevalence of NCD related deaths in Chile. The last part tested knowledge of PHC workers about healthy diet and physical activity. The participants were asked to state if given phrases about healthy diet and physical activity were true or false (see annex).
PHC professionals were to identify the following statements as true ore false:
TRUE FALSE The second level of the food pyramid X (seen from thebase to the top) are milk products and
Patients with CVD risk should not eat avocado due X to the type of fat it contains.
A large piece of pizza does contain half X of the amount of fat recommended for an adult woman
Soluble dietetic fibre helps in lowing blood cholesterol. X To benefit from physical activity, one has to practise at X least 30 minutes at a time.
All questionnaires were coded on MS Excel 1997 and subsequently analysed using the
same programme and SPSS. Mann-Whitney tests for significance were made taking p<0.05
as the cut-off point.
Of the 194 PHC professionals 86% were women. Forty two percent were nurses. Of the
physicians, fewer than half were men, and of all other health professions, such as nurses,
nutritionists, and others (midwives, social workers), more than 90% were women.
Physicians were, on average, younger than the other professional groups (Table I). TABLE I Characteristics of the primary health care workers
Physician Nurse Nutritionist Other Total
42.0 82.0 59.0 11.0 194.0 Number of
21.6 42.3 30.4 5.7 100.0 Profession (%)
54.8 95.1 94.9 90.9 86.1 Women (%)
21.4 17.3 20.3 9.1 18.7 < 30 years (%)
38.1 21.0 15.3 54.5 24.9 30 - 39 years (%)
33.3 37.0 40.7 27.3 36.8 40 - 49 years (%)
7.1 24.7 23.7 9.1 19.7 50 + years (%)
When asked about changes in their lifestyle habits during the last 12 months, more than
80% reported that they consumed less fat and ate more vegetables. Two-thirds said they ate
less sugar. Half of them asserted that they drank less alcohol. Forty-four percents of the
PHC professionals claimed to do more physical activity, whereas one third of respondents
admitted that they reduced their physical activity. Nearly 25% stated that they ate a higher
amount of high energy foods and just as many reported to have gained weight.
Comparing the changes in diet and other lifestyle habits among the different PHC
professional groups, a significant difference exist in the change of the type of fat used, the
decrease of sugar intake, as well as the increase of high energy food consumption. The
percentage of nutritionists who changed the type of fat they consumed is significantly
higher (p < 0.05) than the percentage of nurses who reported such a change. The percentage
of physicians who said that they ate less sugar is significantly lower than the percentage of
nurses (p < 0.01) and the percentage of nutritionists (p < 0.05) mentioning a reduction of
sugar intake. A significantly higher percentage (p < 0.001) of nurses eat more high energy
foods compared to the percentage of nutritionists who eat high energy foods (Table II). TABLE II
Changes of the primary health care workers in diet or other lifestyle habits over the last 12 months
Changes in lifestyle Physician Nurse in % Nutritionist Total in % habits in % in % ate less fat 76 77 86 81
cc 86 75 changed type of fat 74 70
ate more vegetables 83 83 80 82
a babate less sugar 48 72 73 66 modified diet to reduce 38 34 39 37 weight
consumed less alcohol 50 51 53 51 was more physically 41 40 51 44 active
consumed more energy 19 35cc 7 24 gained weight 31 18 22 23 consumed more soft 10 13 10 11 drinks
bb 4 2 4 was less physically 24 28 41 32 active consumed more alcohol 5
smoked more 5 13 7 9
a statistically significant difference in Mann-Whitney-Test (p < 0.05) between physicians and nurses b statistically significant difference in Mann-Whitney-Test (p < 0.05) between physicians and nutritionists c statistically significant difference in Mann-Whitney-Test (p < 0.05) between nurses and nutritionists Comparing the changes in diet and other lifestyle habits over the last 12 months among the
different age groups, a significant difference exists regarding the consumption of soft
drinks, alcohol and tobacco.The percentage of respondents who reported an increase in the
consumption of soft drinks of the age group <30 years is significantly higher than the age
group 40-49 years (p<0.05) as well as the age group 50+ years (p< 0.05). The percentage of
the youngest age group who admitted to smoking more is significantly higher than all the
other age groups (30 - 39 years: p<0.01; 40 - 49 years: p<0.05; 50+ years: p< 0.01). A
significantly higher percentage of the youngest age group admitted, drank more alcohol
compared to the 40-49 year olds (Table III).
TABLE III Changes of the different age groups in diet or other lifestyle habits
over the last 12 months
Changes in diet or < 30 years 30 - 39 years 40 - 49 years 50 + years other habits of lifestyle in % in % in % in % ate less fat 89 77 76 87 changed type of fat 78 73 73 76 ate more vegetables 92 82 79 82 ate less sugar 75 55 69 68 modified diet to reduce 47 34 31 42 weight
consumed less alcohol 53 52 42 66 was more physically 53 46 38 45 active
took in more energy 28 34 17 21 gained weight 17 27 24 24
b cbc 10 9 5 consumed more soft 25
bbconsumed more alcohol 8 2 0 5 was less physically 36 29 30 37 active
abcabcsmoked more 25 4 7 3
a statistically significant difference in Mann-Whitney-Test (p < 0.05) between <30 years and 30-39 years b statistically significant difference in Mann-Whitney-Test (p < 0.05) between <30 years and 40-49 years c statistically significant difference in Mann-Whitney-Test (p < 0.05) between <30 years and 50+ years The PHC professionals were also asked their personal opinion of what the most important
causes are for the high prevalence of NCDs in Chile today. Participants mentioned
unhealthy diet, obesity, the lack of physical activity and smoking respectively as the most
Looking at the answers to the knowledge questions, 80% or more of the participants
answered each question correctly. Comparing the knowledge among professional groups
regarding healthy diet, significant differences in the knowledge about healthy diet can be
identified. The percentage of correct answers nutritionists gave to the first question about
the food pyramid was 100%, it was 76% among nurses and 67% among physicians. The
fraction of correct answers of the nutritionists was significantly higher (p<0.001) compared
to the other two groups. All professions had >90% of correct answers to the second
question about the type of fat, and no significant difference could be found. A significant
difference (p<0.01) exists between percentage of correct answers the nutritionists and
physicians gave to the third question asking about the amount of fat in pizza. The
nutritionists had 92% correct answers whereas the physicians had 7%. The nutritionists also
had a significantly higher percentage of correct answers given to the fourth question about
soluble dietetic fibre intake compared to both the physicians (p<0.01) and nurses (p<0.05).
Ninety-three percents of the nutritionists, 77% of the nurses, and 74% of the physicians
answered correctly. The fifth question, testing knowledge concerning physical activity,
shows that >80% of correct answers were given from all PHC professionals, and no
significant difference could be identified among them (figure 1). FIGURE I
Percentage of primary health care workers correctly answering knowledge questions about heathy diet and physical activity
DISCUSSION NCDs are, more and more, becoming a major cause of death. It is, therefore, of high
importance to tackle the risk factors such as unhealthy diet, physical inactivity, smoking and alcohol consumption. PHC professionals play a key role in the prevention of NCDs and the reduction of risk factors by passing on their knowledge and advice to patients and the public at large (6). The knowledge, attitudes and beliefs of PHC professionals are an
important aspect. The approach and composition of the present study is unique.
Comparable studies could not be found.
The majority of the sample was female with the major subgroup (36%) being nurses, 40 to 49 years of age. Men were mainly represented in the professional group of physicians and the physicians were younger, on average, than the other professional groups. Due to these unequal distributions of the sample, it must be understood that this sample is not
representative for PHC professionals in Chile in general.
The data show that the PHC workers believe that wrong diet, obesity, lack of physical
activity and smoking are the main risk factors for NCDs in Chile today, which
demonstrates that they are aware of the major risk factors. It can be assumed that
workshops on prevention of NCDs previously offered within the CARMEN programme
provoked this awareness because these subjects were discussed. Data from the general
population confirm the responses from the PHC workers about the main risk factors. For example, the baseline survey for the CARMEN programme shows that 85% of a random
sample in the CARMEN pilot area in the city of Valparaíso were physically inactive, 41% were smokers and 20% had a BMI over 30 (7).
The results of the knowledge questions demonstrate a very high knowledge level in both topics questioned: healthy diet and physical activity. Looking at the knowledge level of the different professions, the nutritionists show the highest level of expertise in healthy diet and physicians the lowest. This result is not surprising when taking into account that nutritional issues are only briefly touch upon in medical curricula. The nurses, too, know slightly more than the physicians about nutrition. This finding can be related to the higher average age of the nurses compared to the physicians, which is presumably linked to a higher average of work experience. A study carried out in the United Kingdom also featured substantially higher nutritional knowledge of practice nurses (PN) compared to general practitioners (GP). Fifty percents of the PN answered a nutritional knowledge questionnaire correctly, compared to only 20% of the GP (8).
The knowledge about the healthier fat type is high in all professional groups and there is no relevant difference among them. All professional groups, show the same high knowledge level in physical activity. It can be assumed that they attended workshops discussing this topic, which were previously offered in the area, thus leading to a higher knowledge level. The changes in diet and other lifestyle habits demonstrate an overall positive and healthy attitude of the PHC workers. The majority of the PHC professionals reported that, in the 12 months prior to the study, they incorporated more vegetables into their diet, reduced the amount of fat in their diet and changed to a healthier fat type. Compared to these positive modifications, the negative changes in diet and other lifestyle habits are rather low. Comparing the different PHC professions, nutritionists show a ?healthier? attitude in their diet and other lifestyle habits. Significantly more nutritionists said that they reduced their sugar intake compared to the nurses or the physicians. Their increased intake of high energy foods is lower than the nurses', and, compared to the physicians, not as many nutritionists have increased their alcohol consumption.
The youngest group differs from the older age groups because they not only show a significantly higher increase in the consumption of soft drinks and alcohol, but also more of them reported to have increased their smoking habit. The consumption of soft drinks, alcohol and tobacco is presumably more integrated into social life and more accepted among young adults than among older adults because of different social interactions. These differences could also be due to varying accessibility and exposure to advertisements and peer influences. The CARMEN baseline survey (7) reports the prevalence of smokers by
age. The highest percentage of smokers is found in the age group 25-34 years and the percentage of smokers decreases with increasing age. In a population study in Santiago de Chile the highest alcohol consumption of females was observed in the age group 25-34 (9).
Due to the way questions were asked, it was not possible to distinguish between, for example, smokers augmenting their tobacco consumption and non-smokers starting to smoke, or likewise between alcohol consumers reducing their intake and participants who never drank alcohol in the first place.
The PHC team plays a major role in tackling NCD risk factors. This analysis highlights the
contribution nutritionists can give to a PHC team, which should not be overlooked. The role
of nutritionists in a PHC team should be enlarged and their advisory function strengthened.
Good teamwork among nutritionists, physicians, nurses and other PHC workers is a
necessity and should be emphasized. These measures can be a great step to improve the
effectiveness of a heath care team especially dealing with NCD prevention.
This study aimed at assessing life style changes and knowledge regarding healthy diet and
physical activity among Chilean primary health care (PHC) professionals. The sample of
194 PHC workers was composed of physicians, nurses, nutritionists, midwives and social
workers, of which 86% were women.The majority reported to have made positive changes
in their lifestyle: more than 80% stated that they consumed less fat and ate more vegetables;
two-thirds said they ate less sugar; around half reported that they drank less alcohol and
45% that they were more physically active. Negative changes like increasing the
consumption of soft drinks, alcohol and tobacco were highest in the youngest of all the age
groups. Eighty percents correctly answered the knowledge questions about healthy diet and
physical activity. Significant differences among the professionals could be identified. Most
of the PHC professionals show a positive change in their lifestyle and have a high
knowledge level about healthy diet and physical activity. It has to be emphasized that good
teamwork among nutritionists, physicians, nurses and other PHC workers is a necessary
pre-condition to improve the effectiveness of a heath care team dealing with non-
communicable disease prevention.
Keywords: primary health care professionals, lifestyle changes, knowledge, healthy diet,
Acknowledgements: The authors would like to express our appreciation and gratefulness to
Dr. B. Legetic, Pan American Health Organization / World Health Organization, Santiago
de Chile, Dr. M. C. Escobar, Ministry of Health, Santiago de Chile and Dr. I. Salas, for
their advice and support of this study.
Author to whom correspondence should be addressed: Isabel Zacarías Instituto de Nutrición y Tecnología de
los Alimentos Universidad de Chile Santiago de Chile Tel.: (56-2) 678 1429 Fax: (56-2) 221 4030
REFERENCES 1. Consejo Nacional para la Promoción de la Salud VIDA CHILE. Cuenta Pública 2001,
Santiago de Chile, 2002
2. Ministerio de Salud Chile, Departamento de epidemiología, Encuesta Calidad de Vida
2000, Santiago de Chile, 2001
3. Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and
counseling practices of primary care physicians: a national survey. Clin J Sport Med
[ Medline ]
4. Connolly MA, Gulanick M, Keough V, Holm K. Health practices of critical care nurses:
are these nurses good role models for patients?. Am J Crit Care 1997; 6(4):261-6
[ Medline ]
5. Frank E, Bryan J, Elon L. Physician Disclosure of Healthy Personal Behaviours
Improves Credibility and Ability to Motivate. Arch Fam Med 2000; 9.
6. Hopper D, Baker ME. Dietary advice, nutritional knowledge, and attitudes towards
nutrition in primary health care. J Human Nutr and Dietetics 1995; 8 (4):279-286
7. Jadue L, Vega J, Escobar MC, Delgado I, Garrido C, Lastra P, Espejo F, Peruga A. Risk
factors for non communicable diseases: methods and global results of the CARMEN
program basal survey. Rev Med Chil 1999; 127(8):1004-
13 [ Medline ] [ Lilacs ] [ SciELO Chile ]
8. Hopper D, Baker ME. Dietary advice, nutritional knowledge, and attitudes towards
nutrition in primary health care. J Human Nutr and Dietet 1995; 8 (4):279-286
9. Berrios X, Jadue L, Zenteno J, Ross MI, Rodriguez H. Prevalence of risk factors for
chronic diseases. A study in the general population of the metropolitan area, 1986-1987.
Rev Med Chil 1990; 118(5):597-604 [ Medline ] [ Lilacs ]