Rev Chil Nutr Vol

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Rev Chil Nutr Vol

    Rev Chil Nutr Vol. 29, Nº3, Diciembre 2002







    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.


    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

    per day.

    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

    important causes.

    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,

    physical activity.

    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

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