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Lifestyle medicine: The importance of considering all the causes of disease
Medicina del estilo de vida: la importancia de considerar todas las causas de la enfermedad
Ramon Mora Ripoll
Red Española de Investigación en ciencias de la Risa (REIR), Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In the developed world&#44; lifestyle is one of the major determining factors concerning the health condition of a population&#46; A high percentage of medical consultations in primary and specialist healthcare are due to lifestyle-related illnesses &#40;which are&#44; therefore&#44; preventable&#41;&#46; Likewise&#44; the great majority of practice guidelines recommend lifestyle changes as the first line of treatment&#46; Consequently&#44; lifestyle is not only a public health issue&#44; but also very clinically relevant in current therapeutic management of illnesses especially chronic pathologies&#46; The advent of &#8220;lifestyle medicine&#8221; seeks to resolve the current shortcomings and provide continuity between preventative medicine and current patient-centred clinical practice&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The burden of chronic disease&#58; mental health</span><p id="par0010" class="elsevierStylePara elsevierViewall">Coronary disease&#44; stroke&#44; hypertension&#44; high cholesterol&#44; obesity&#44; diabetes&#44; chronic obstructive pulmonary disease &#40;COPD&#41;&#44; many types of neoplasms&#44; osteoporosis&#44; back and muscle pain&#44; migraines&#44; constipation&#44; allergic pathologies&#44; sexually transmitted diseases &#40;STD&#41;&#44; infertility&#44; erectile dysfunction and many mental disorders&#44; among other diseases&#44; are health conditions directly related to lifestyle&#46; Out of these&#44; mental illnesses enormously contribute to the total disease burden&#44; due to the combination of high prevalence&#44; early onset&#44; persistence and dysfunction&#46; The World Health Organization &#40;WHO&#41; attributes 31&#37; of collective years lived with a disability and 1&#46;4&#37; of collective years lost<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> to neuropsychiatric disorders&#46; However&#44; the latter figure is most likely underestimated&#44; as it does not include suicides&#46; Schizophrenia and related psychoses&#44; bipolar affective disorder&#44; major depression and panic disorder are those that contribute most to the global disease burden&#46; By the year 2030&#44; it unipolar depression is predicted to be the primary cause of the total disease burden&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What is a lifestyle&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">The author and futurist Alvin Toffler<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> used the concept &#8220;lifestyle&#8221; for the first time in 1979 when he predicted the explosion of different lifestyles in a post-industrial society&#46; The way we eat&#44; exercise&#44; rest&#44; play&#44; behave with others&#44; think&#44; plan&#44; drive a vehicle&#44; sleep&#44; work&#44; do other things&#8211;in general&#44; the way we live&#8211;are all included under the term &#8220;lifestyle&#46;&#8221; It includes patterns for social relations&#44; leisure and clothing and it also reflects the typical individual&#39;s attitude&#44; values or self-image&#46; A specific lifestyle indicates the conscious or unconscious choice between one type of behaviour or another and can affect the basic biological mechanisms that lead to disease&#58; changes in genetic expression&#44; inflammation&#44; oxidative stress and metabolic dysfunction&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What is lifestyle medicine&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall">Lifestyle medicine is a clinical discipline based on facts &#40;&#8220;evidence&#8221;&#41; that deals with lifestyle interventions that affect health and quality of life&#46; It could also be defined as the &#8220;application of medical&#44; environmental&#44; motivational and behavioural principles to clinical and therapeutic management of health problems related to lifestyle&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In addition to prevention of illness &#40;risk reduction&#41;&#44; lifestyle medicine also focuses on its therapeutic management &#40;if such a condition is already present&#41;&#44; often in a more cost-effective way<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> than conventional treatments based on drugs and surgery&#46; The enormous potential effects of such lifestyle interventions on mortality&#44; morbidity and healthcare costs are more than sufficient incentives for interest in lifestyle medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Examples of such interventions include&#44; but are not limited to&#44; all of the following&#58; cessation of tobacco use&#44; balanced diet&#44; weight control&#44; increased physical activity&#44; moderate alcohol consumption&#59; adequate sleep and rest&#44; and increased mental and emotional well-being&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lifestyle medicine was originally developed in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> There&#44; as well as in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> various medical associations and ongoing projects exist related to lifestyle medicine&#46; Furthermore&#44; the <span class="elsevierStyleItalic">American Journal of Lifestyle Medicine</span> &#40;<a href="http://ajl.sagepub.com/">http&#58;&#47;&#47;ajl&#46;sagepub&#46;com&#47;</a>&#41;&#44; the first publication specialising in this issue&#44; has been available since January 2007&#46; While it is a new discipline&#44; lifestyle medicine does not purport to be an alternative to conventional medicine&#44; but rather a complementary strategy to deal with the clinical challenges that modern lifestyle changes represent&#46; Nonetheless&#44; lifestyle medicine is not lucrative and is not typically funded by public health systems or private insurers&#46; For that reason&#44; its use in current clinical practice is very limited and is not usually part of medical training programs&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">The causes of illness</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the present day&#44; the therapeutic approach to disease&#44; and particularly to chronic pathologies&#44; usually focuses on risk factors and biological markers&#46; However&#44; these factors and markers have numerous &#8220;causes&#8221; that precede the disease &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In lifestyle medicine&#44; all preceding risks and causes of disease are considered&#44; on all levels of causality&#46; Consequently&#44; its therapeutic management includes a combination of preventative health interventions &#40;public and individual&#41; and clinical activities personalised for each patient&#46; For example&#44; the prevalence of high blood pressure in the population could be reduced with not only individualised treatment at the clinical practice level&#44; but also with community activities to raise awareness of the environmental effects of using fossil fuels instead of human powered transport &#40;like riding a bicycle or walking&#41;&#46; This intervention would also result in an increase in physical activity and a decrease in obesity<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or depressive and anxiety symptoms&#44; among other risk factors for cardiovascular and mental disease&#46; Thus&#44; the final impact might be superior to the present approach to high blood pressure in conventional medicine&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">General and specific recommendations in lifestyle medicine</span><p id="par0035" class="elsevierStylePara elsevierViewall">Many studies &#40;&#8220;evidence&#8221;&#41; guarantee the effectiveness of lifestyle interventions in reducing the risk of developing a chronic disease&#44; as well as aiding in the therapeutic management of an existing health condition&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Based on available data&#44; national and international guides emphasise the relevance of lifestyle interventions to general good health&#44; as well as to the majority of conditions and diseases&#46; The general consensus of these recommendations include&#44; but are not limited to&#44; various changes in diet&#44; toxic habits&#44; physical exercise&#44; weight control and emotional and mental well-being&#44; among others &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a> For specific medical conditions&#44; there are other recommendations &#40;occasionally&#44; there are variations of the general ones&#41;&#44; yet they always stress the following 2 key points&#58; they specify healthy behaviour and they highlight that even small lifestyle improvements&#44; if maintained over time&#44; can also help reduce risk of disease or slow the progression of a disease&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Lifestyle medicine in mental health</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients with a mental illness usually have worse physical health than the general population&#44; with higher morbidity and mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Comorbidity with other disorders is frequent and can occur at 4 levels&#58; with other mental illnesses&#44; with substance abuse and dependence&#44; with other chronic diseases&#44; or with accidental or intentional injuries&#59; comorbidity can also be attributed to social factors and lifestyle&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> In particular&#44; a greater percentage of patients suffer from inadequate diets&#44; physical inactivity&#44; tobacco abuse&#44; diabetes&#44; obesity or hyperlipidaemia&#44; among other health conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> Furthermore&#44; secondary effects from the mental illness drugs themselves can aggravate or add additional risks&#44; such as obesity&#44; diabetes&#44; cardiovascular disease or metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Consequently&#44; promoting and maintaining a healthy lifestyle become very important for these patients&#46; Lifestyle changes can be effective in decreasing morbidity and mortality and increasing quality of life&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> as well as in optimising clinical performance of treatments used&#44; increasing their observance or improving the doctor&#8211;patient relationship&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#8211;28</span></a> Therefore&#44; the most cost-effective therapeutic strategies would include a combination of pharmacological therapies with different preventative and psychosocial lifestyle interventions&#44; which would be facilitated at a community or primary healthcare level&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> The major barriers for the implementation of lifestyle medicine are factors derived from the disease itself and from its treatment&#44; such as lack of motivation&#44; low self-esteem and confidence&#59; or side effects such as sedation or weight increase associated with pharmacological treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This suggests that it is necessary to ensure that health professionals&#44; in addition to setting an example&#44; have certain abilities and have a positive and encouraging attitude towards lifestyle intervention&#44; which is preferentially applied in groups &#40;although this is not always recommended&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Competency to prescribe lifestyle medicine</span><p id="par0045" class="elsevierStylePara elsevierViewall">Motivating someone effectively to change their lifestyle can be highly frustrating and a great challenge&#44; for all types of patients&#46; In addition to establishing a plan of action in collaboration with the patient and to arranging a follow-up&#44; motivational interviewing<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> has been shown to be a useful technique in clinical practice for improving the results o desired from these prescribed changes&#46; Behavioural techniques&#44; the most recommended method to influence change in risk factors&#44; include all of the following<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#58; evaluating the patient&#44; establishing goals&#44; increasing awareness&#44; overcoming barriers&#44; managing stress effectively&#44; cognitive restructuring&#44; preventing relapse and providing adequate support and treatment&#46; Nevertheless&#44; health professionals express a lack of knowledge and ability needed to motivate and to advise their patients to undergo lifestyle interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Among the competencies proposed for being able to prescribe lifestyle medicine&#44; all the following are included<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#58; &#40;a&#41; leadership to practice and promote healthy lifestyles&#59; &#40;b&#41; knowing how to identify markers of a patient&#39;s health condition related to lifestyle and to demonstrate knowledge of specific and precise changes&#59; &#40;c&#41; evaluating how motivated and willing the patients and their families are to perform such changes and establishing joint plans of action&#59; &#40;d&#41; using clinical practice guides in order to help patients manage their own health behaviour and lifestyle&#59; and &#40;e&#41; working with a multidisciplinary team in order to treat the patient from all aspects necessary&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Lifestyle medicine has shown to be a more cost-effective strategy than the approaches currently used in disease prevention and treatment&#44; particularly chronic pathologies&#46; Nevertheless&#44; health professionals currently lack the training and resources to manage lifestyle interventions for their patients&#46; Among other limiting factors&#44; there are not sufficient incentives and support programs to encourage professionals to treat the true causes of disease with lifestyle interventions&#44; rather than intervening at the level of risk factors or markers&#46; Effective application of lifestyle medicine should be considered a priority within the changes needed in current health systems and in public health policies&#46; In this day and age&#44; health spending is rationalised and available resources are put to optimal use&#46; Lifestyle medicine&#44; as well as reducing total costs&#44; has the potential to notably increase the indicators of physical and mental health and the population&#39;s quality of life&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflict of interest to declare&#46;</p></span></span>"
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          "titulo" => "The burden of chronic disease&#58; mental health"
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          "titulo" => "What is a lifestyle&#63;"
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          "titulo" => "What is lifestyle medicine&#63;"
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          "titulo" => "The causes of illness"
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          "titulo" => "General and specific recommendations in lifestyle medicine"
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          "identificador" => "sec0035"
          "titulo" => "Lifestyle medicine in mental health"
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            1 => "Preventive medicine"
            2 => "Chronic disease"
            3 => "Emotional well-being"
            4 => "Mental health"
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            0 => "Medicina del estilo de vida"
            1 => "Medicina preventiva"
            2 => "Enfermedades cr&#243;nicas"
            3 => "Bienestar emocional"
            4 => "Salud mental"
            5 => "Humor y risa"
            6 => "Calidad de vida"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The enormous potential effects of health behavior change on mortality&#44; morbidity&#44; and health care costs provide ample motivation for the concept of lifestyle medicine&#46; Lifestyle medicine involves the therapeutic use of lifestyle interventions on health and quality of life&#44; and considers not only risk factors and markers&#44; but also a range of antecedent factors from all levels of causality&#46; Treatment would ultimately employ a combination of clinical &#40;patient-centered&#41; and public-health interventions&#46; Examples of target patient behaviors include&#44; but are not limited to&#44; eliminating tobacco use&#44; moderating alcohol consumption&#44; increasing physical activity&#44; improving diet&#44; sleep&#44; and emotional and mental well-being&#46; The effective implementation of lifestyle medicine should be a priority within the necessary changes in current healthcare systems and public health policies&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los enormes efectos potenciales de determinadas intervenciones en el estilo de vida sobre la mortalidad&#44; morbilidad y costes sanitarios son motivaci&#243;n m&#225;s que suficiente para el inter&#233;s actual en la medicina del estilo de vida&#46; La medicina del estilo de vida se ocupa de las intervenciones sobre el estilo de vida que afectan a la salud y a la calidad de vida&#44; y tiene en cuenta todas las causas anteriores a la enfermedad y al riesgo de enfermar&#44; desde todos los niveles de causalidad&#46; En consecuencia&#44; en su manejo terap&#233;utico se incluye una combinaci&#243;n de intervenciones preventivas de salud con actuaciones cl&#237;nicas personalizadas para cada paciente&#46; Ejemplos de dichas intervenciones incluyen&#44; sin limitarse a&#44; el abandono tab&#225;quico&#59; una dieta equilibrada&#59; el control de peso corporal&#59; el aumento de la actividad f&#237;sica&#59; el consumo moderado de alcohol&#59; el sue&#241;o y descanso adecuados&#59; y el incremento del bienestar emocional y mental&#44; entre otros&#46; La aplicaci&#243;n efectiva de la medicina del estilo de vida deber&#237;a considerarse prioritaria dentro de los cambios necesarios en los actuales sistemas sanitarios y en las pol&#237;ticas p&#250;blicas de salud&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Mora Ripoll R&#46; Medicina del estilo de vida&#58; la importancia de considerar todas las causas de la enfermedad&#46; Rev Psiquiatr Salud Ment &#40;Barc&#46;&#41;&#46; 2012&#59;5&#40;1&#41;&#58;48&#8211;52&#46;</p>"
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        "fuente" => "Source&#58; adapted and expanded by American College of Preventive Medicine 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Practice some moderately intense physical activity at least 5 days a week&#44; preferably each day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Quit using tobacco &#40;if a smoker&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Moderate alcohol consumption&#58; limit to 2 standard units<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#47;day &#40;men&#41;&#59; 1 standard unit&#47;day &#40;women&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">&#8226; Lose 5&#8211;10&#37; of body weight &#40;if overweight or obese&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Reduce caloric intake by 500 cal&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Gradually increase intensity of physical exercise to 60<span class="elsevierStyleHsp" style=""></span>min&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">&#8226; Ensure a healthy&#44; varied and balanced diet&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Rich in fruits and vegetables&#58; at least 2 fruits&#47;3 vegetables per day&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Choose whole grain foods&#44; with high content of fibre &#40;at least half of grains consumed should be whole grains&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Limit intake of saturated fatty acids to 10&#37; of total calories and trans fatty acids &#40;margarine&#44; pastries&#44; fried foods&#41; to 1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Reduce cholesterol intake to 300<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; choosing lean meats&#44; vegetable alternatives and skim milk products&#44; and minimising intake of partially hydrogenated oils&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Consume fish&#44; especially oily fish&#44; at least twice a week&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Minimise intake of food and drink with added sugar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Limit salt consumption &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>g&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Drink plenty of water &#40;&#62;1&#46;5<span class="elsevierStyleHsp" style=""></span>l&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Increase emotional and mental well-being&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Exhibit a positive and optimistic attitude towards life<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Practice&#47;experience being in a good mood and laughing<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> &#40;&#8805;3<span class="elsevierStyleHsp" style=""></span>min of intense laughter per day<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8728; Effectively manage stress&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Get adequate amount of sleep &#40;7&#8211;9<span class="elsevierStyleHsp" style=""></span>h for adults and seniors&#41;&nbsp;\t\t\t\t\t\t\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos