Comments of Prevention and health promotion

Diet and physical activity

The goal of tobacco reduction is very clear: to reduce its use as much as possible in individuals and populations, and ideally to create a smoke-free world. The aim with respect to diet and physical activity is less clear and there continues to be intense debate over what should be recommended in both cases; the same applies to determining what actions will produce the greatest benefit, for whom and under what conditions.

The WHO recommends the following guidelines for individuals who wish to improve their
diet (10):

- Achieve energy balance and a healthy weight.

- Limit energy intake from total fats and shift fat consumption from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids.

- Increase consumption of fruits and vegetables, and legumes, whole grains and nuts.

- Limit the intake of free sugars.

- Limit salt consumption from all sources and ensure that salt is iodised.

With respect to physical activity, the WHO recommends «at least 30 minutes of regular, moderate-intensity physical activity on most days» (10).This level of activity is expected to reduce the risk of cardiovascular disease, diabetes, colon cancer and breast cancer. More activity may be required for weight control. A recent Cochrane review of 43 randomised trials with 3,476 participants found that exercise increased weight loss compared with no treatment, but dieting was more effective (11).

Exercisers lost 0.5 to 4.0 kg, whereas subjects randomized to no treatment groups gained 0.7 kg or lost 0.1 kg. Exercise had more effect on risk factors for heart disease than on weight and more intense exercise led to more weight loss. The effects of exercise seem to be different in men and women, with women needing to reduce their calorie intake more actively to lose weight (12). Many people with multiple chronic conditions will not be able to exercise for 30 minutes on most days, although, counter to general opinion, the Diabetes Prevention Program showed that people aged 60 or older were more likely than younger people to follow advice to exercise more and improve their diet (13).

Increasing physical activity may be more beneficial than improving diet in that, as well as reducing the chance of developing chronic disease, it also improves quality of life, which may be particularly important in people with complex chronic disease (14).

The WHO recently completed a systematic review of the evidence as to what works in increasing physical activity and improving diet (15). It examined the evidence using the following categories: policy and environment, mass media, school settings, workplace, community, primary health care, older adults and religious settings (Table 1).

 Table 1.  A systematic review of interventions  to improve diets and promote physical activity (15)



The reviewers identified 395 studies that met their inclusion criteria, but only 13 were related to low or middle-income countries and only 18 were concerned with older adults.

The review considered psychosocial, behavioural and clinical outcomes and classified interventions as effective, moderately effective, promising but based on limited evidence, minimally effective, based on insufficient evidence or not shown to be effective, or with outcomes which were not measured or reported. Taking into consideration the limitations of the studies that were included in the analysis, the main findings of the review are summarized as follows:

- Policy and environment: Three interventions were found to be effective:

1) government regulation that supports healthier staple foods; for example, replacing palm oil with soya oil, thus reducing dietary fatty acid content; 2) building, planning and transport policies that reduce the barriers to physical activity; and 3) point of decision prompts that encourage the use of stairs. Moderately effective interventions include pricing policies, point of purchase prompts to support healthier choices and multi-targeted approaches to encourage more walking and

- Mass media: Campaigns to encourage physical activity are effective if they are combined with community based support programmes or associated with policies to reduce environmental barriers to physical activity. Moderately effective interventions include intensive campaigns that concentrate on one simple message (like increasing consumption of low fat milk), national health brands or logos that signal healthier foods to consumers and long-term, intensive campaigns that promote healthy diets.

- School settings: High intensity school programmes can work if they are comprehensive and have many components, including teaching provided by trained individuals, supportive school policies, a physical activity programme, a parental/family component and access to healthy food options in schools. Focused programmes and assessments of the needs of schools and their cultural context are moderately effective.

- Workplace: Multi-component workplace programmes that include the provision of healthy foods and space for exercise, involving the staff in planning and implementation, incorporating family interventions and helping individuals to change, and monitoring, are effective.

-Community: Three interventions have been shown to be effective in the community. Firstly, multi-component diet education programmes that target high-risk groups. Secondly, community development programmes that either involve intersectorial cooperation or have a single goal, for example, reducing the risk of a cardiovascular event. Thirdly, community-based programmes for a homogenous group. Several interventions have been shown to be moderately effective: using existing phone-in services to provide dietary advice; community interventions performed as part of
a national or global campaign; programmes that target the poor or illiterate and include dietary advice; computer-based interventions that provide personalised feedback to high-risk groups; supermarket tours to support the purchase of healthier foods; and walking school buses.

- Primary care: Primary care interventions that target individuals at risk of chronic disease can be effective if they include people who are inactive, eat less than five portions of fruit or vegetables a day, consume a lot of fat, are overweight or have a family history of chronic disease; if they include at least one session with a health professional who negotiates reasonable goals with follow-up provided by trained staff; and if they are supported by targetted information. Interventions which are linked with actions taken by other stakeholders, for example, sports organisations or the mass media, can also be effective. Programmes that identify patients with raised blood cholesterol levels and provide follow-up are moderately effective, as are weight loss programmes that include telephone or internet consultations over a period of at least four weeks and a self-help programme with self-monitoring.

- Older adults: Although the systematic review found 18 studies of 17 interventions in older adults, it did not identify any effective interventions in this particular age group, which is very relevant to our focus on people with multiple chronic conditions. Moderately effective interventions included those encouraging physical activity in a group setting that used an existing social structure or meeting place, and homebased interventions in which older adults are given increased access to fruit and vegetables using an existing infrastructure.

- Religious settings: Culturally appropriate and multi-component dietary interventions, which are planned and implemented in conjunction with religious leaders and include group education sessions and self-help strategies, are effective. Culturally appropriate interventions that target weight loss, healthy diets and increased physical activity are moderately effective.

This review identifies many interventions in which there is evidence to show that they are effective and then notes characteristics that seem to be shared by interventions that work. These tend to be: multi-component in design, adapted to the local context culturally and environmentally, appropriate use, existing social structures and involving participation by stakeholders throughout the process.

The authors of the review also note that most of the studies are short-term, meaning that most of the outcomes are psychosocial rather than clinical and that we have little evidence about programme sustainability. Few of the studies provided evidence about cost effectiveness or examined unintended consequences.

The limited evidence from low and middle-income countries makes it clear that involving communities in all stages of planning, implementation and evaluation is important for success.With respect to polypathologies, there is a real need for a review that takes these concepts and approaches and examines their relevance to prevention, as well as the trajectory that leads to polypathology. If X practices and policies were in place, could we reduce the incidence of CCD and delay its onset and impact? What populations are at the highest risk for CCD? Should we focus on high-risk populations in terms of population health intervention and policy? What efforts are required to effect change in these populations? What analyses are required? A comprehensive analysis of neighbourhoods and diabetes in Toronto, Canada (ICES, 2007) provides very valuable insights into the social and physical context as a determinant of chronic illness and who is most at risk, and into approaches that may be useful in reducing its incidence. This research is a good example of new approaches to studying polypathology and its prevention (16).

Existing comments

28/12/2014 Eva Martin Ruiz
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las claves del éxito de estas intervenciones preventivas recaen en la variedad, en el intervenir desde varios niveles y lugares, actuar desde las edades tempranas....

Poner a las personas como los protagonistas activos de su propio estado de salud, con la formaicón y el apoyo necesario, pero intervenir desde varios niveles y desde diversas iniciativas. Hacer más para dejar de adoptar posturas "más cómodas" y pasivas como puede ser la toma de una pastilla

09/12/2014 Agustín Martín
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El horario laboral continuado al que nos quieren dirigir acabará totalmente con los beneficios de la dieta mediterranea. ¿Que hay de malo en poder ir a casa a comer comida casera y pasar un rato con la familia?

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Me gustaría ser realista, dejar de lado los tecnicismos y contar lo que veo día a día, en la infancia y adolescencia se les inculca alimentación saludable en los colegios tanto por parte del profesorado como incluso nosotros mismos en charlas periódicas, pero resulta que los niños y adolescentes no comen, por lo general, frutas ni verduras y además existe una importante prevalencia de obesidad en estas franjas etarias; en edades medias de la vida nos hartamos de indicar a las personas el como deben alimentarse en pro de un mejor estado de salud y nos encontramos con que en la mayoría de las ocasiones al salir de la consulta suelen hacer lo que les viene en gana o lo que culturalmente vienen haciendo cotidianamente por decirlo de una manera mas suave.Entre todos ellos me encuentro alguno, los menos, caminando de cuando en cuando. La tercera parte del cupo de enfermos ya tiene mas de 65 años y muchos de ellos poliartrósicos que no pueden mas que caminar para ir a casa de la vecina de frente y ya es mucho pedir, y con unos hábitos dietéticos imposible de cambiar.

Todo lo expuesto no quiero que se interprete como una visión pesimista del problema sino que seamos conscientes del mucho trabajo a realizar en este campo y la dificultad que entraña conseguir metas sin que nos lleve al desánimo. 

18/06/2012 Mª Teresa Hernandez
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Las conclusiones de los estudios sobre dieta y ejercicio físico deberían hacerse más públicas de fácil acceso a toda la población, para que así también ellos pudieran aportar y exigir esas medidas.

Me gustaría comentar que en la edad adulta, ha un porcentaje de personas, que si bien tambien hay que modificar hábitos, no comen con tanto exceso, en cambio hay una falta de actividad física, que sería el denominador de la obesidad y de determinadas enfermedades. A veces insistimos mucho en la alimentación y poco en la actividad física

Otro comentario la palabra "dieta", es muy restrictiva e implica limitación en la comida, creo que es mejor que se hable de alimentación saludable o algo similar


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Las recomendaciones de actividad física segón la OMS para personas mayores de 65 años en adelante consisten en actividades recreativas o de ocio,
desplazamientos (por ejemplo, paseos caminando o en bicicleta), actividades ocupacionales (cuando la persona
todavía desempeña actividad laboral), tareas domésticas, juegos, deportes o ejercicios programados en el contexto
de las actividades diarias, familiares y comunitarias.
Con el fin de mejorar las funciones cardiorrespiratorias y musculares y la salud ósea y funcional, y de reducir el riesgo
de ENT, depresión y deterioro cognitivo, se recomienda que:
1. Los adultos de 65 en adelante dediquen 150 minutos semanales a realizar actividades físicas moderadas
aeróbicas, o bien algún tipo de actividad física vigorosa aeróbica durante 75 minutos, o una combinación
equivalente de actividades moderadas y vigorosas.
2. La actividad se practicará en sesiones de 10 minutos, como mínimo.
3. A fin de obtener mayores beneficios para la salud, los adultos de este grupo de edades deberían aumentar
hasta 300 minutos semanales la práctica de actividad física moderada aeróbica, o bien acumular 150 minutos
semanales de actividad física aeróbica vigorosa, o una combinación equivalente de actividad moderada y
4. Los adultos de este grupo de edades con movilidad reducida deberían realizar actividades físicas para mejorar
su equilibrio e impedir las caídas, tres días o más a la semana.
5. Convendría realizar actividades que fortalezcan los principales grupos de músculos dos o más días a la semana.
6. Cuando los adultos de mayor edad no puedan realizar la actividad física recomendada debido a su estado de
salud, se mantendrán físicamente activos en la medida en que se lo permita su estado.
En conjunto, considerando los tres grupos de edades, los beneficios que pueden reportar las actividades aquí
recomendadas y la actividad física en general son mayores que los posibles perjuicios. Cuando se invierten 150
minutos semanales en actividades de intensidad moderada, las tasas de lesión del aparato locomotor son muy bajas.
Para la población en general, el riesgo de lesiones del aparato locomotor podría disminuir si se fomentase un plan de
actividad física inicialmente moderado, que progresara gradualmente hasta alcanzar una mayor intensidad.

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La actividad fisica y la dieta esta demostrado que influyen en la prevalencia de enfermedades cronicas, es fundamental una buena educacion en este sentido y segun este estudio de la OMS la intervencion es menos eficaz en adultos mayores , con malos habitos ya adquiridos, por lo cual tenemos que poner mas empeño en este tramo de poblacion, fomentando la actividad fisica incluso mas que la dieta.

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Las medidas sobre la dieta y ejercicio físico esta bien que comience en las edades tempranas de la vida para así fortalecer habitos saludables pero no debemos olvidarnos de las edades medias y avanzadas de la vida ya que la mayoría de las actuaciones son llevadas a cabo en la prevencion secundaria, al ser las campañas gubernamentales muy escasas para el resto develas edades que no son la infancia y la adolescencia.

Se debe cambiar muchos habitos de vida que se han impuesto en las ultimas décadas en nuestra sociedad

20/02/2012 Lola Nieto
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La educación en dieta y ejercicio debería de imponerse para todos los públicos y todas las edades. Cada vez nos movemos menos y comemos mas, desde los pequeños a los mayores. Pienso que el sedentarismo y la dieta no saludable nos ha llevado a la situación actual donde las enfermedades cardiovasculares encabezan el ranking cuando hablamos de mortalidad. 

Desde los colegias, a la publicidad, a la empresas, a los gobiernos etc, todo debería de favorecer y fomentar el ejercicio  y la dieta sana. Pienso que es el origen de muchos de nuestros problemas y por tanto el mayor foco de intervención. 

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Creo que uno de los objetivos fundamentales en la prevención primordial es la educación infantil y juvenil, pero no solo a nivel de las escuelas, sino a nivel de la familia. Aquí incluiría políticas de conciliación familiar que permitan a los padres preocuparse de la alimentación de sus hijos y de realizar actividad física conjunta para crear el hábito.

Me sumo a la pregunta de por qué las personas no asumen la responsabilidad de conductas poco saludables y cuando llega el momento prefieren mantenerlas y que otros le solucionen el problema de forma fácil (si pueden, claro).

13/02/2012 Conchi Candela
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Una pregunta por comentario:

¿porque es tan difícil modificar un hábito de comportamiento insano y tan fácil tomarse una pastilla?

¿porque la población espera del sector salud un remedio que les permita una conducta insana?

¿porque la responsabilidad de nuestras acciones, pensamos que no tienen trascendencia cuando se habla de salud?

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