Logo-hpp
Implementation of public health policies for healthy lifestylespromotion: what Brazil should tell us?

Health Promotion Perspectives, 8(3), 243-248; DOI:10.15171/hpp.2018.33

Case Report

Implementation of public health policies for healthy lifestylespromotion: what Brazil should tell us?

Carlos K. B. Ferrari ,*

1 Instituto de Ciências Biológicas e da Saúde (ICBS), Campus Universitário do Araguaia, Universidade Federal de Mato Grosso. Av. Valdon Varjão, 6390, Setor Industrial, Barra do Garças, 78.600-000, MT, Brazil

Email: drcarlosferrari.ufmt@gmail.com

© 2018 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The objective of this work was to update Brazilian experiences on implementation research (IR)regarding promotion of healthy lifestyles to decrease the risk of chronic non-communicable diseases (CNCD). Some Brazilian governmental activities for promotion of healthy lifestyles have been adopted around the world such as the case of the "World Physical Activity Day" and the"Walking for health program". Following the example of many other developing and developed countries, Brazilian government has been sponsored leisure-time physical activity and healthy eating programs which still were not capable of promoting massive participation, especially from workers, elderly and people from the less privileged socioeconomic classes. Although successful exercise promotion strategies have been done in Brazil, the implementation science on promotion of healthy lifestyles is still rising and more research is necessary to identify the settings, circumstances, and processes for effective and sustainable adoption of healthy dietary and exercise practices. Understanding problems, concerns and barriers for implementation of health promotion (HP) policies in Brazil could be useful for many other developing nations.

Keywords: Promotion, Developing nations, Physical activity, Diet, Pitfalls

Citation: Ferrari CKB. Implementation of public health policies for healthy lifestyles promotion: what Brazil should tell us? Health Promot Perspect. 2018;8(3):243-248. doi: 10.15171/hpp.2018.33.

Introduction

Dissemination and implementation are complex social and organizational processes by which new scientific advances can be translated and disseminated to people, settings, and communities affecting and improving public health.1 Implementation research (IR) should be stimulated in research institutions, schools and universities in order to build investigation, theory and practice of public health promotion (HP) and intervention.2

Given the necessity of HP stated in the 1986’s Ottawa’s Charter, public health policies and practices have been studied, formulated, tested and implemented in many nations.3

The world has been suffering from an epidemic of obesity and other chronic non-communicable diseases (CNCD) which are undoubtedly linked to adoption of unhealthy food, drinking, and behavioral lifestyles.4-7

In this regard, important findings on IR have been linked to face the obesity epidemic as well as the major risk factors for CNCD. Then, IR on obesity prevention should consider the following conceptions (Table 1).8-10

Table 1. Emerging concepts on implementation research for obesity prevention in developing nations
Obesity police research is still rising
Urgency in taking policy preventive actions using mass-media strategies
Necessity of economic research on the theme
Need to investigate quasi-experiments and “natural experiments” from police-based interventions
Need of implementation research beyond the individual level of changing behavior
Improvement of public health educational level regarding behavior change and adoption of healthy lifestyles
Encouragement of individual and social empowerment since it improves adaptability, hope, desires, motivation, wellness, stress control, self-image and self-knowledge, know-how, and problem solving ability
Based on the studies of McKinnon et al8 and Taddeo Pda et al.9

Methods

In this narrative case report, the positive Brazilian experiences and pitfalls on IR regarding promotion of healthy lifestyles were updated and discussed.

Although no systematic review had been performed, studies were searched using three databases (MEDLINE, LILACS and Google Scholar) from 2006 to 2017 using the following terms: health promotion; Brazil; physical activity; dietary habits; sedentary behavior.

Health Promotion Scenario

Considering the growing burden of CNCD and need of HP in Brazil, the National Police of Health Promotion (PNPS) was proposed in 2006.11

Nowadays, the PNPS comprises the following community integrated actions to foster12:

(a) healthy eating habits

(b) alcohol consumption reduction

(c) physical activity

(d) smoking reduction

(e) road safety

(f) peace and non-violence

(g) healthy environment

(h) vaginal delivery

The Brazilian PNPS have focussed on three strategic activities as follows:

Health promoting schools

Promotion of healthy dietary practices

Promotion of physical activities and exercise

Health promoting schools in Brazil

In 1995, the World Health Organization (WHO) launched the WHO Global School Health Initiative.13 A Health-Promoting School (HPS) is a special unit with improved capacity for being a healthy setting for living, learning and working.14 In 2007, WHO pointed the following elements for implementation of HP schools15,16:

Building evidence and experience;

Strengthening implementation processes in HPS;

Alleviating social and economic disadvantage;

Harnessing media influence on youth; and

Improving partnerships among sectors/organizations.

At least 80 nations adopted and implemented the HPS initiative, especially in the Americas.17-19

Established in 2007, the Brazilian “Program Health at School” (“Programa Saúde na Escola”, PSE) was implemented only in 2012 and there are very few reports regarding its result and impact.20

A study realized in Recife, Northeastern Brazil, showed only 13.8% of implementation of HP activities such as healthy eating and physical activities in public schools, revealing many barriers for HP.21

In many Brazilian inner cities, the PSE was announced but not implemented. In this regard, populations from those cities have also excessive levels of unhealthy behaviors such as poor physical activity levels, insufficient sleep, smoking and alcohol drinking.22

Promotion of healthy dietary practices in Brazil

Brazilian State has many different initiatives for encouragement of healthy dietary patterns included in the PNPS and the National Program of School Eating (PNAE) which was born in the 1940s.

Beyond the governmental actions, there are also very interesting community and school activities regarding farming and nutrition education. In many Brazilian communities foods and medicinal plants are cultivated in home and community gardens following sustainable models of the family agriculture and organic production.23-27 A long time ago this sustainable agriculture practices have been taught in Brazilian farming schools.25,27

Evaluating healthy eating in 173 public schools and 122 private schools in Federal District of Brazil, only one elementary private school matched 20 of 24 the established criteria for healthy eating among schools.28 In the same study, only 5 schools (1.7%) have healthy environments; just 4 schools (1.36%) reached the component “participation on school community”, and also in only 5 schools (1.7%) it was found a partnership with health sector and monitoring of nutritional status of schoolchildren.

Promotion of physical activity: The successful Brazilian experiences

It has been suggested that sedentary behavior is declining in Brazil. But, the national prevalence of leisure-time physical activity is still only 15%.29

Notwithstanding, practice of physical exercise is one fundamental pillar of HP since regular engagement on physical activities improves cardiovascular system, prolongs life-span and decreases the risk of CNCD.30

Considering this scenario, a pioneering initiative was launched in the 1996 by the CELAFISCS.31,32 The Agita São Paulo Program (ASPP) is a successful example of IR outside of a developed country. During the 1999–2002 period, this physical activity program increased physical fitness 9.5% to 24% in the most populated Brazilian State– Sao Paulo.31 With a simple marketing message of daily engagement on 30-minutes of physical activities, exercises, and sports, especially walking and dancing, ASPP helped to decrease by 50% hospitalization by both hypertension and stroke, and by 57% type 2 diabetes mellitus in Sorocaba, a city of 600 000 inhabitants in São Paulo State.33 The ASPP has being implemented in many other countries around the world.34

In 2011, the Brazilian federal government put in practice a national program to confront obesity and CNCD. One of the strategic priority was the promotion of an active life through regular practice of leisure-time physical activity.35,36

Following this approach, the Program Academy of the City (AC) (or Academy of Health) is a community-based governmental intervention to for promotion of regular physical activities. It has been implemented in diverse Brazilian cities, but few reports are available. The reports covered the Brazilian state capitals Recife (PE), Curitiba (PR), Vitoria (ES), Aracaju (SE), Belo Horizonte (MG), and Rio Claro (SP), a country town.

In Recife, Northeastern Brazil, the AC was executed in 21 public areas (beaches, parks, recreation centers), and decisively contributed to increase physical activity among Recife’s population.37 However, the AC suffered from security problems related to urban violence, safety problems due to pitfalls in physical structure and necessity of maintenance and acquisition of equipment.38

In Aracaju, AC began in 2004 and reached 5000 people in five years among 15 city regions,39 whereas in Rio Claro, it successfully reduced the use of medicines, blood glucose, and blood pressure among physical activity practitioners.40

In Belo Horizonte, AC was implemented in 2005 and improved the dietary habits and physical activity levels of 400 people.41

In Curitiba, South Brazil, the municipal secretaries of “sports and leisure” and “Health” offered free of charge a great number of physical activities for communities by the “CuritibAtiva”, a sustainable and supportive leisure program which have been associated with an increased physical activity levels of that population.42,43

Another interesting Brazilian initiate is “walking for health” which covered three Brazilian capitals: Curitiba, Recife, and Vitoria. The percentages of attendants meeting the recommended daily physical activity needs were higher in Recife (16%), compared to Curitiba (9.6%), and Vitoria (8.8%). Regular practice of 150 minutes per week or more of walking was significantly associated with better self-rated health, younger age, and higher educational level,44 which means that less privileged people remain physically inactive due to work overload and lacking of leisure time as noted in capitals as well as in inner Brazilian cities.41,45,46

Considering the feasibility of promotion of physical activity in schools47 there is little programs in Brazil focusing this aspect. The “Saude na boa” program in ten schools from Florianopolis (SC) and Recife, increased physical activity levels of the adolescents.48

There are two specific programs for the elderly. The “Vamos program: active living, enhancing health”, and the “Third Age Academies”.49,50

The Vamos Program has been associated with improved prevalence of regular physical activity among middle-age and elderly Brazilians.51 Improving physical activity and diet among elderly people is an essential and cost-effective intervention for this target population.52-54

Among 116 countries, only 12% of nations, including Brazil and Iran, had explicit policies to decrease dietary fats and salt intake, to improve the intake of fruits and vegetables and promotion of regular physical activity.55

Another Brazilian successful health promotion initiative is The World Day of physical activity, created by CELAFISCS in Brazil as “Agita Mundo”. Today, this global initiative is done into the five continents among more than 70 countries.56

Discussion and Critique

In spite of the governmental HP programs, Brazilian population has a raising dietary intake of fried foods, cholesterol-rich processed foods, sugars, soft drinks, confectionery, and fats, instead of adoption of a nutritional breakfast, and increased intake of fruits, vegetables, and a variety-rich diet.57-63

Following the example of many other developing and developed countries, Brazil has sponsored leisure-time physical activity and healthy eating programs56,57 which were not still capable of promoting massive participation, especially among workers, elderly, indigenous and less privileged socioeconomic classes.38,45,64,65

Conclusion

Although successful exercise promotion strategies have been done in Brazil, the implementation science on promotion of healthy lifestyles is still rising and more research is necessary to identify the settings, circumstances, and processes by which sustainable adoption of healthy dietary and body practices occurs.64 Necessities and priorities regarding strengthening for implementation of healthy lifestyle are summarized in Table 2.

Table 2. Priority settings for strengthening of lifestyle-related public health policies
Promotion of healthy dietary practices
Weaknesses:
Lack of nutrition education in public and private schools;
Lack of teachers with basic knowledge regarding basic food and nutrition;
Poor knowledge of children regarding healthy eating;
Poor knowledge of families regarding healthy eating choices
Needs:
Inclusion of dietitians as school teachers; Improvement of teachers' knowledge regarding healthy eating and obesity prevention;
Implementation of a public and private task force to trigger better eating practices to decrease overweight and obesity in children and adults
Health promoting schools
Weaknesses:
Lack of implementation of "Saude na Escola" in many municipalities;
Absence of program integration with educational sector;
Lack of control regarding program implementation and financial costs;
Lack of a complete health examination of students
Needs:
Strengthening of integration with educational secretaries and community engagement;
Necessity of promotion of healthy eating; Necessity of anthropometric and health evaluation;
Evaluation of program coverage and impact;
Inclusion of psychologists in multidisciplinary teams to foster behavior improvement of children and adolescents in order to adopt healthy lifestyles
Promotion of leisure-time physical activities
Weaknesses:
Lack of implementation of public programs on physical activity in all Brazilian Federative States;
Insufficient structure for regular practice of free living physical activities;
Lack of governmental advertising regarding benefits of physical activity
Needs:
Increasing and improvement of public structure for practice of leisure-time physical activity;
Integration of governmental initiatives with regional and local settings, including schools and community centers;
Public and private investment on public structure for practice of sports and exercises

Ethical approval

Not Applicable.

Competing interests

There are no conflicts of interest.

Funding

It was financed by the own author.

Authors’ contributions

The author contributed alone from the conception and design of the study to the acquisition of data, writing and the final revision of the text.

References

  1. Luke DA. Viewing dissemination and implementation research through a network lens. In: Brownson RC, Colditz GA, Proctor EK, eds. Dissemination and implementation research in health: translating science to practice. New York: Oxford University Press; 2012. p. 154-71.
  2. Sanders D, Haines A. Implementation research is needed to achieve international health goals. PLoS Med 2006;3(6):e186. doi: 10.1371/journal.pmed.0030186. [Crossref]
  3. Gagnon F, Bergeron P, Clavier C, Fafard P, Martin E, Blouin C. Why and how political science can contribute to public health? Proposals for collaborative research avenues. Int J Health Policy Manag 2017;6(9):495-9. doi: 10.15171/ijhpm.2017.38. [Crossref]
  4. Gupta N, Goel K, Shah P, Misra A. Childhood obesity in developing countries: epidemiology, determinants, and prevention. Endocr Rev 2012;33(1):48-70. doi: 10.1210/er.2010-0028. [Crossref]
  5. Ferrari CK. Metabolic syndrome and obesity: Epidemiology and prevention by physical activity and exercise. J Exerc Sci Fit 2008;6(2):87-96.
  6. Poulsen SK, Due A, Jordy AB, Kiens B, Stark KD, Stender S, et al. Health effect of the New Nordic Diet in adults with increased waist circumference: a 6-mo randomized controlled trial. Am J Clin Nutr 2014;99(1):35-45. doi: 10.3945/ajcn.113.069393. [Crossref]
  7. Otto MC, Afshin A, Micha R, Khatibzadeh S, Fahimi S, Singh G, et al. The impact of dietary and metabolic risk factors on cardiovascular diseases and type 2 diabetes mortality in Brazil. PLoS One 2016;11(3):e0151503. doi: 10.1371/journal.pone.0151503. [Crossref]
  8. McKinnon RA, Orleans CT, Kumanyika SK, Haire-Joshu D, Krebs-Smith SM, Finkelstein EA, et al. Considerations for an obesity policy research agenda. Am J Prev Med 2009;36(4):351-7. doi: 10.1016/j.amepre.2008.11.017. [Crossref]
  9. Taddeo Pda S, Gomes KW, Caprara A, Gomes AM, de Oliveira GC, Moreira TM. Access, educational practice and empowerment of patients with chronic diseases. Cien Saude Colet 2012;17(11):2923-30. doi:10.1590/S1413-81232012001100009. [Crossref]
  10. Loureiro MI. How to translate health research into policy and practice for citizen empowerment. Rev Port Saude Publica 2013;31(1):1-2. doi: 10.1016/j.rpsp.2013.06.002. [Crossref]
  11. Ministry of Health. Política Nacional de Promoção da Saúde. 3rd ed. Brasília, DF: Ministério da Saúde; 2010. [Portuguese].
  12. Malta DC, Morais OLN, Silva MM, Rocha D, Castro AM, Reis AA, et al. National Health Promotion Policy (PNPS): chapters of a journey still under construction. Cien Saude Colet 2016;21(6):1683-94. doi: 10.1590/1413-81232015216.07572016. [Crossref]
  13. WHO. Global School Health Initiative. Available from: http://www.who.int/school_youth_health/gshi/en/. Accessed October 25, 2017.
  14. IUPHE: Promoting Health in Schools: from Evidence to Action. Paris, International Union for Health Promotion and Education; 2010. Available from: http://www.iuhpe.org/uploaded/Activities/Scientific_Affairs/CDC/School%20Health/PHS_EtA_EN_WEB.pdf. Accessed October 5, 2017.
  15. Arwidson P, Kreft-Jais C. The necessary contribution of science to prevention. Glob Health Promot 2013;20 Suppl 2:63-5. doi: 10.1177/1757975913485686. [Crossref]
  16. Tang KC, Nutbeam D, Aldinger C, St Leger L, Bundy D, Hoffmann AM, et al. Schools for health, education and development: a call for action. Health Promot Int 2009;24(1):68-77. doi: 10.1093/heapro/dan037. [Crossref]
  17. Ippolito-Shepherd J, Cerqueira MT, Ortega DP. Iniciativa Regional Escuelas Promotoras de la Salud en las Americas. Promot Educ 2005;12(3-4):220-9. doi: 10.1177/10253823050120030139. [Crossref]
  18. Militao AG, de Oliveira Karnikowski MG, da Silva FR, Garcez Militao ES, Dos Santos Pereira RM, Grubert Campbell CS. Effects of a recreational physical activity and healthy habits orientation program, using an illustrated diary, on the cardiovascular risk profile of overweight and obese schoolchildren: a pilot study in a public school in Brasilia, Federal District, Brazil. Diabetes Metab Syndr Obes 2013;6:445-51. doi: 10.2147/dmso.s52166. [Crossref]
  19. Honkala S. World Health Organization approaches for surveys of health behaviour among schoolchildren and for health-promoting schools. Med Princ Pract 2014;23 Suppl 1:24-31. doi: 10.1159/000354172. [Crossref]
  20. de Figueiredo TA, Machado VL, de Abreu MM. Health at school: a brief history. Cien Saude Colet 2010;15(2):397-402. doi: 10.1590/s1413-81232010000200015. [Crossref]
  21. de Assuncao Bezerra M, Freese de Carvalho E, Souza Oliveira J, Sa Leal V. Health and nutrition in public and private schools in the city of Recife. Rev Bras Saude Mater Infant 2017;17(1):191-200. doi: 10.1590/1806-930420170001000011. [Crossref]
  22. Bucalen-Ferrari CK, de Souza Carneiro S, da Rocha EM, Vieira dos Santos AL. Sedentarismo, estilo de vida e saúde em adolescentes de um município da Amazônia Legal (Sedentary behavior, lifestyle and health among adolescents in a municipality of Legal Amazon). Revista Inspirar Movimento & Saude 2017;14(3):28-33. [Portuguese].
  23. Carniello MA, Silva RDS, Cruz MAB, Neto GG. Quintais urbanos de Mirassol D’Oeste-MT, Brasil: uma abordagem etnobotânica (Urban homegardens of Mirassol D’Oeste-MT, Brazil: an ethnobotany stady). Acta Amazon 2010;40(3):451-70. doi: 10.1590/S0044-59672010000300005. [Portuguese]. [Crossref]
  24. Ceolin T, Heck RM, Barbieri RL. Conhecimento sobre plantas medicinais entre agricultores de base ecológica da região Sul do Rio Grande do Sul. Cogitare Enferm 2010;15(1):169-70. doi: 10.5380/ce.v15i1.17190. [Portuguese]. [Crossref]
  25. Antonio GD, Tesser CD, Moretti-Pires RO. Contributions of medicinal plants to care and health promotion in primary healthcare. Interface 2013;17(46):615-33. doi: 10.1590/S1414-32832013005000014. [Crossref]
  26. do Amaral CN, Coelho-de-Souza G. Educação popular e agricultura familiar: uma análise sobre a implementação do programa ProJovem campo na baixada Cuiabana – MT. Revista Educação, Cultura e Sociedade 2013;3(1):87-102. [Portuguese].
  27. Miranda VC. Policultivo orgânico como ferramenta de ensino de ciências da natureza e matemática na Escola Estadual Paulo Freire, Barra do Bugres, MT [dissertation]. Brasília: Universidade de Brasília (UnB); 2013. [Portuguese].
  28. da Silva JR, Schmitz Bde A, Rodrigues Mde L, Gabriel CG. Promotion of healthy eating at schools in the Federal District of Brazil. Rev Nutr 2013;26(2):145-158. doi: 10.1590/S1415-52732013000200003. [Crossref]
  29. Hallal PC, Knuth AG, Reis RS, Rombaldi AJ, Malta DC, Iser BP, et al. Time trends of physical activity in Brazil (2006-2009). Rev Bras Epidemiol 2011;14 Suppl 1:53-60. doi: 10.1590/S1415-790X2011000500006. [Crossref]
  30. Lira Ferrari GS, Bucalen-Ferrari CK. Exercise modulation of total antioxidant capacity (TAC): towards a molecular signature of healthy aging. Front Life Sci 2011;5(3-4):81-90. doi: 10.1080/21553769.2011.635008. [Crossref]
  31. Matsudo SM, Matsudo VR, Araujo TL, Andrade DR, Andrade EL, de Oliveira LC, et al. The Agita Sao Paulo Program as a model for using physical activity to promote health. Rev Panam Salud Publica 2003;14(4):265-72.
  32. Matsudo V. The role of partnerships in promoting physical activity: the experience of Agita Sao Paulo. Health Place 2012;18(1):121-2. doi: 10.1016/j.healthplace.2011.09.011. [Crossref]
  33. Fioravanti CH. Brazilian fitness programme registers health benefits. Lancet 2012;380(9838):206. doi: 10.1016/S0140-6736(12)61201-X. [Crossref]
  34. Malta DC, Barbosa da Silva J. Policies to promote physical activity in Brazil. Lancet 2012;380(9838):195-6. doi: 10.1016/s0140-6736(12)61041-1. [Crossref]
  35. Malta DC, Dimech CPN, Moura L, da Silva JB Jr. (Review of the implementation of the Strategic Action Plan to Combat Chronic Non-communicable Diseases in Brazil in the period 2011-2022). Epidemiol Serv Saude 2013;22(1):171-8. doi: 10.5123/S1679-49742013000100018. [Crossref]
  36. Simoes EJ, Hallal P, Pratt M, Ramos L, Munk M, Damascena W, et al. Effects of a community-based, professionally supervised intervention on physical activity levels among residents of Recife, Brazil. Am J Public Health 2009;99(1):68-75. doi: 10.2105/ajph.2008.141978. [Crossref]
  37. Hallal PC, Carvalho YM, Tassitano RM, Tenorio MCM, Warschauer M, Reis RS, et al. Quali-quantitative evaluation of the “Academia da cidade” program from Recife, Brazil: perceptions of the professionals working in the program. Revista Brasileira de Atividade Física Saúde 2009;14(1):9-14. doi: 10.12820/rbafs.v.14n1p9-14. [Crossref]
  38. Mendonça BCA, Toscano JJO, Oliveira ACC. From diagnostics to action: experiences on promotion of physical activity. Academia da cidade program of Aracaju city. Rev Bras Ativ Fis Saude 2009;14:211-6.
  39. Costa BV, Mendonca Rde D, Santos LC, Peixoto SV, Alves M, Lopes AC. (City Academy: a health promotion service in the healthcare network of the Unified Health System). Cien Saude Colet 2013;18(1):95-102. doi: 10.1590/S1413-81232013000100011. [Crossref]
  40. Giraldo AED, Gomes GAO, Serafim THS, Zorzeto LP, Aquino DC, Kokubun E. Influence of a physical activity program on the use of primary care services in the city of Rio Claro, SP. Rev Bras Ativ Fis Saude 2013;18(2):186-96. doi: 10.12820/rbafs.v.18n2p186. [Crossref]
  41. Lopes A, Ferreira A, Mendonça R, Dias MA, Rodrigue R, Santos L. Health promotion strategy: Academia da cidade of Belo Horizonte. Rev Bras Ativ Fis Saude 2016;21(4):379-84. doi: 10.12820/rbafs.v.21n4p379-384. [Crossref]
  42. Reis RS, Hallal PC, Parra DC, Ribeiro IC, Brownson RC, Pratt M, et al. Promoting physical activity through community-wide policies and planning: findings from Curitiba, Brazil. J Phys Act Health 2010;7 Suppl 2:S137-45. doi: 10.1123/jpah.7.s2.s137. [Crossref]
  43. Diaz Del Castillo A, Sarmiento OL, Reis RS, Brownson RC. Translating evidence to policy: urban interventions and physical activity promotion in Bogota, Colombia and Curitiba, Brazil. Transl Behav Med 2011;1(2):350-60. doi: 10.1007/s13142-011-0038-y. [Crossref]
  44. Ferrari CKB, Frania RF. Quality of life and exposition to unhealthy lifestyle risk factors of nocturnal university students from a greater metropolitan city. J Biol Environ Sci 2011;5(15):129-34.
  45. Santos ALV, Ferrari GS, Honorio-Franca AC, Franca EL, Ferrari CKB. Cardiovascular risk factors among a population in Brazilian legal Amazon. Int J Pharm Biomed Res 2011;2(2):124-7.
  46. Sallis JF, Carlson JA, Mignano AM. Promoting youth physical activity through physical education and after-school programs. Adolesc Med State Art Rev 2012;23(3):493-510.
  47. de Barros MV, Nahas MV, Hallal PC, de Farias Junior JC, Florindo AA, Honda de Barros SS. Effectiveness of a school-based intervention on physical activity for high school students in Brazil: the Saude na Boa project. J Phys Act Health 2009;6(2):163-9.
  48. Benedetti TRB, Schwingel A, Gomez LSR, Chodzko-Zajko W. Program “Vamos” (active living, enhancing health): from conception to initial findings. Rev Bras Cineantropom Desempenho Hum 2012;14(6):723-37. doi: 10.5007/1980-0037.2012v14n6p723. [Crossref]
  49. De Paulo TRS, Castellano SM, Queiroz Junior CA, Freitas Junior IF. Academy for the elderly program in the city of Uberaba, MG. Arq Cienc Esport 2012;1:54-9.
  50. Benedetti TRB, Manta SW, Gomez LSR, Rech CR. Logical model of a behavior change program for community intervention– Active life improving Health – VAMOS. Rev Bras Ativ Fis Saude 2017;22(3):309-13. doi: 10.12820/rbafs.v.22n3p309-313. [Crossref]
  51. de Souza RO, Ribeiro IN, de Souza E. Promoção da saúde em idosos: uma revisão sistemática. Revista de APS 2016;19(3):527. [Portuguese].
  52. Wadi JML, Ferrari CKB. Knowledge and intake of functional foods by primary health care professionals from a Legal Amazon region, Brazil. Revista Brasileira de Obesidade, Nutrição e Emagrecimento. Rev Bras Obes Nutr Emagrecim 2017;11(65):313-21.
  53. Chockalingam A. Next major challenge in global noncommunicable diseases. Int J Noncommun Dis 2017;2(2):27-9. doi: 10.4103/2468-8827.211077. [Crossref]
  54. Lachat C, Otchere S, Roberfroid D, Abdulai A, Seret FM, Milesevic J, et al. Diet and physical activity for the prevention of noncommunicable diseases in low- and middle-income countries: a systematic policy review. PLoS Med 2013;10(6):e1001465. doi: 10.1371/journal.pmed.1001465. [Crossref]
  55. Physical Acvitiy Network for the Americas. Available from: http://www.rafapana.org/index.php/en/world-day-of-p-a. Accessed November 18, 2017.
  56. de Oliveira EP, McLellan KC, Vaz de Arruda Silveira L, Burini RC. Dietary factors associated with metabolic syndrome in Brazilian adults. Nutr J 2012;11:13. doi: 10.1186/1475-2891-11-13. doi: 10.1186/1475-2891-11-1.3. [Crossref]
  57. Soriguer F, Rojo-Martinez G, Dobarganes MC, Garcia Almeida JM, Esteva I, Beltran M, et al. Hypertension is related to the degradation of dietary frying oils. Am J Clin Nutr 2003;78(6):1092-7. doi: 10.1093/ajcn/78.6.1092. [Crossref]
  58. Guallar-Castillon P, Rodriguez-Artalejo F, Fornes NS, Banegas JR, Etxezarreta PA, Ardanaz E, et al. Intake of fried foods is associated with obesity in the cohort of Spanish adults from the European Prospective Investigation into Cancer and Nutrition. Am J Clin Nutr 2007;86(1):198-205. doi: 10.1093/ajcn/86.1.198. [Crossref]
  59. Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 2009;120(11):1011-20. doi: 10.1161/circulationaha.109.192627. [Crossref]
  60. Duncan S, Duncan EK, Fernandes RA, Buonani C, Bastos KD, Segatto AF, et al. Modifiable risk factors for overweight and obesity in children and adolescents from Sao Paulo, Brazil. BMC Public Health 2011;11:585. doi: 10.1186/1471-2458-11-585. [Crossref]
  61. de Cassia Spanhol R, Ferrari CKB. Obesity and lifestyle risk factors among an adult population in Legal Amazon, Mato Grosso, Brazil. Rev Salud Publica (Bogota) 2016;18(1):26-36. doi: 10.15446/rsap.v18n1.30570. [Crossref]
  62. Rtveladze K, Marsh T, Webber L, Kilpi F, Levy D, Conde W, et al. Health and economic burden of obesity in Brazil. PLoS One 2013;8(7):e68785. doi: 10.1371/journal.pone.0068785. [Crossref]
  63. Lopes AC, Santos LC, Lima-Costa MF, Caiaffa WT. Nutritional factors associated with chronic non-communicable diseases - the Bambui Project: a population-based study. Cad Saude Publica 2011;27(6):1185-91. doi: 10.1590/S0102-311X2011000600015. [Crossref]
  64. Las Casas RCR, Bernal RTI, de Melo EM, Malta DC. Prevalence of physical activity during leisure time in Brazilian capitals. Rev Med Minas Gerais 2016;26 Suppl 8:S260-5.
  65. Pagoto S. The current state of lifestyle intervention implementation research: where do we go next? Transl Behav Med 2011;1(3):401-5. doi: 10.1007/s13142-011-0071-x. [Crossref]
Submitted: 06 Feb 2018
Revised: 19 Mar 2018
Accepted: 26 Apr 2018
First published online: 07 Jul 2018
EndNote EndNote

(Enw Format - Win & Mac)

BibTeX BibTeX

(Bib Format - Win & Mac)

Bookends Bookends

(Ris Format - Mac only)

EasyBib EasyBib

(Ris Format - Win & Mac)

Medlars Medlars

(Txt Format - Win & Mac)

Mendeley Web Mendeley Web
Mendeley Mendeley

(Ris Format - Win & Mac)

Papers Papers

(Ris Format - Win & Mac)

ProCite ProCite

(Ris Format - Win & Mac)

Reference Manager Reference Manager

(Ris Format - Win only)

Refworks Refworks

(Refworks Format - Win & Mac)

Zotero Zotero

(Ris Format - FireFox Plugin)

Abstract View: 1219
PDF Download: 707
Full Text View: 382
CC-BY © 2018 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.