Download Eating habits and physical activity Health in Sweden

459473
2012
SJP0010.1177/1403494812459473Short TitleM. Axelsen et al.
Scandinavian Journal of Public Health, 2012; 40(Suppl 9): 164–175
Eating habits and physical activity
Health in Sweden: The National Public Health Report 2012. Chapter 8.
Mette Axelsen1, Maria Danielsson2, Margareta Norberg3 &
Agneta SjÖBerg4
1Department
of Internal Medicine, Gothenburg University, Gothenburg, Sweden, 2Swedish National Board of Health and
Welfare, Stockholm, Sweden, 3Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden, and
4Department of Food and Nutrition, and Sport Science, University of Gothenburg, Gothenburg, Sweden
Summary
Although eating habits in Sweden have largely deteriorated since 1980, some improvements have been
observed in the most recent years. Between 1980 and
2010, the consumption of sweets rose from 10 to 15
kilos per person per year, while consumption of soft
drinks increased from 30 to 90 litres. The average
amount of energy consumed rose by 11 per cent,
probably contributing to an increase in the number
of overweight people.
Moreover, our energy intake is almost 10 per cent
higher compared to 1980. Protein intake has shown a
particularly stable rise. Swedes continue to eat too
little fruit, vegetables and fish, according to the
Swedish National Food Agency’s dietary recommendations. Fewer than one person in ten eats fruit and
vegetables five times a day. Women have better eating
habits than men, well-educated people have better
eating habits than the less well-educated, and male
workers on low incomes eat the least amount of fruit
and vegetables.
The eating habits of children have improved in
recent years. More children eat fruit and vegetables,
and the consumption of soft drinks and sweets
declined markedly between 2001 and 2005. However,
children continue to consume excessive amounts of
sweets, soft drinks, ice cream, snacks and pastry. On
average, children drank 2 decilitres of soft/fruit drinks
a day and ate 1.5 hectograms of sweets a week in
2003. Children who regularly eat breakfast often
have better eating habits than other young people.
The desire to lose weight is fairly prevalent. Just
over half the adult population have tried to lose
weight or plan to do so. Nowadays, there are a number of methods for losing weight, and the debate
between those who are for or against fat in the diet
has become polarised. Most of these methods, however, involve increasing one’s consumption of vegetables, fruit and pulses and lowering one’s consumption
of chocolate, sweets, soft drinks and snacks.
Physical activity has many positive effects on health
and helps prevent the most common diseases. People
who are least fit have the most to gain in terms of
improved health by increasing their physical activity.
Physical inactivity during leisure time is more
widespread among men than women. It is three times
more common among women and men born outside
Europe than among native-born Swedes. Physical
inactivity has become less common among women in
all socioeconomic groups according to the Survey of
Living Conditions. In the case of men physical inactivity has only decreased among upper-level white-collar
employees. Several other studies show no appreciable
improvement, inactivity during leisure time is just as
common today as it was 20 years ago.
Approximately two-thirds of adults are physically
active for at least half an hour every day. The level of
activity may be described as at least moderate, thus
fulfilling the minimum recommended physical activity requirement. According to the Västerbotten
Health Studies, the proportion of the population
Correspondence: Mette Axelsen, Department of Internal Medicine, Gothenburg University, 405 30, Gothenburg, Sweden. E-mail: [email protected]
© 2012 the Nordic Societies of Public Health
DOI: 10.1177/1403494812459473
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Eating habits and physical activity 165
who are moderately active has declined in recent
years. On the other hand, the amount of intense physical activity has risen, particularly among women. A
higher level of physical activity is recommended for
children and young people. However, this recommendation is only met by 10–20 per cent of children
in Sweden, a lower figure than in most other
European countries.
Introduction
On one level, the explanation for the rise in the number of overweight people is simple – we eat too much
in proportion to the amount of exercise we do.
However, the underlying causes of this are complex;
they have to do with our whole lifestyle, with its
declining levels of daily physical activity and an
unlimited supply of energy-rich food. Due to this
imbalance between how much we eat and the amount
of exercise we do we usually put on more and more
weight in the course of our lives, often in the form of
abdominal fat. Preventing weight gain is easier than
losing weight when one is already overweight.
Preventive measures are, therefore, the most effective
means of breaking the trend towards an increasingly
overweight population. Several studies have shown
that in practice simply being more physically active in
one’s leisure time is not enough [1]. In order to maintain one’s weight or to lose weight, dietary changes
involving a lower energy intake are also required. A
healthy diet and physical activity also have significant
effects on one’s health apart from weight loss, even if
one’s weight remains unchanged (see Chapter 7,
Overweight, Cardiovascular Disease, and Diabetes).
As a result, prolonged sedentariness and a nutritionally poor diet, regardless of their effect on weight, are
damaging to people’s health. People who are most
inactive have the most to gain in terms of improved
health by increasing their physical activity, for example by taking daily walks.
•• Increased consumption of vegetables and fruit, to
a level of 500 grams per day (double the population’s current consumption level)
•• A switch to oil and unsaturated fats, low-fat dairy
and cured meat products
•• Fish three times a week
•• Salt intake limited to 5–6 grams a day (a 50 per
cent reduction in the population’s current consumption level)
•• A switch to wholemeal varieties of bread and
other cereals
The aim of the guidelines is to meet nutritional needs
while lowering the incidence of overweight, diabetes,
cardiovascular disease and certain forms of cancer.
The importance of food energy density
Human beings have an inability to register when they
have taken in the right amount of energy, a limitation
which contributes to their tendency to overeat. On
the other hand, they are well equipped to know when
they have taken in a sufficient volume of food [3].
The foods that make us feel most full are fruit and
vegetables since fibre-rich foods bind with water,
which in turn gives them a considerable volume in
proportion to their energy content [4]. Increased
intake of fruit and vegetables therefore plays a critical
role in preventing weight gain; one feels full before
the energy intake has become too great [5]. As fats
and sugar do not bind with water, a high proportion
of dietary fats and sugar contribute large amounts of
energy (calories) in relation to their volume. The
more fat and sugar food contains, the greater the
energy intake is before one feels full. Restaurant food
and fast food often contain a high percentage of fat
and sugar. Eating habits that are more likely to
involve high energy intake include: regularly eating
restaurant and fast food, eating large portions, drinking high-calorie drinks, eating too little fruit and vegetables, and irregular breakfast habits [6].
What are good eating habits?
Good eating habits and nutritious food in moderate
amounts are vital prerequisites of good health. The
National Food Agency’s guidelines on what we
should eat are based on the Nordic nutritional guidelines [2]. Based on the current food habits of an average person, the National Food Agency recommends
the following:
•• Reduced consumption of sweets, ice cream, baked
goods, snacks and energy-rich drinks such as soft
drinks and alcohol (a 50 per cent reduction in the
population’s current consumption level)
Fat types and their significance
All types of fat (polyunsaturated, monounsaturated,
saturated, and trans fatty acids) contain the same
amount of calories per gram. However, it is not only
the number of calories but also the type of fat that is
important to our health [2].
Polyunsaturated and monounsaturated fat are
preferable to saturated fat from the standpoint of cardiovascular health. Long-chain polyunsaturated fatty
acids are involved in the regulation of blood circulation, blood pressure and immune response. The
long-chain polyunsaturated fatty acids, so-called
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166 M. Axelsen et al.
Eating habits and physical activity 166
omega-3 fatty acids are considered especially beneficial in preventing cardiovascular disease. These are
found in fatty fish, shellfish and rapeseed oil. As the
body is unable to produce long-chain polyunsaturated fatty acids, it must obtain them through food.
Important sources of monounsaturated fat include
rapeseed and olive oil, nuts, and chicken.
Saturated fatty acids are mainly found in cured
meat and dairy products. Unlike the case of polyunsaturated fatty acids, the body has no need for saturated fatty acids. Moreover, saturated fats have
harmful effects. They raise LDL (bad) cholesterol
levels, promote fat storage in and around the intestines and contribute to arteriosclerosis.
Trans fat accounts for only a small proportion of
the fat we eat: approximately 2 per cent of our energy
intake. Trans fat not only has the same adverse effect
on our LDL cholesterol level as saturated fat, it also
lowers the HDL (good) cholesterol level, which protects against cardiovascular disease. Consequently,
trans fat is more harmful to the heart and blood vessels than saturated fat. Trans fat occurs naturally in
fatty milk products, such as cream and butter, but
can also be produced chemically using, among other
things, olive and rapeseed oil. This method of production, called hydrogenation, alters the characteristics of the fat, giving it a longer shelf life and firmer
consistency. It is used, for example, in sweet biscuits
and potato crisps. Partially hydrogenated fat is the
most harmful. It contains a high percentage of trans
fat, whereas complete hydrogenation mainly produced fully saturated fat. There is no evidence that
there is any distinction between the health effects of
naturally occurring and chemically produced trans
fats. It is hard for consumers to avoid trans fats on
the basis of guidance printed on food labels. To avoid
the major sources of trans fat, one should follow general nutritional guidelines. Above all, it is important
to lower one’s consumption of fatty milk products,
chips, biscuits and snacks.
Carbohydrate types and their significance
The brain relies on a continuous supply of sugar to
function optimally, which in turn presupposes a regular supply of carbohydrates from food. Like fats,
carbohydrates are of several different types [2]. These
are usually divided into two groups: those which raise
blood sugar (glucose) levels, i.e. sugar and starch,
and those which do not, i.e. dietary fibres. The reason why dietary fibres do not raise blood sugar levels
is that they cannot be absorbed into the blood circulation from the small intestine but, instead, pass
down into the large intestine, where they stimulate
the growth of beneficial intestinal bacteria.
Sugar, white bread, and sweets supply a lot of
energy but provide little nutrition in relation to their
volume. They can also heighten the risk of obesity
and cardiovascular disease among other things.
Foods that are rich in fibre, on the other hand, such
as wholemeal bread, hulled grain and many vegetables and fruits, protect against weight gain since they
replace food with higher energy density, such as
sugar and fat [7]. Dietary fibres also have a beneficial
effect on caries prevention, intestinal transit, blood
sugar and blood fats levels, in addition to lowering
the risk of obesity, diabetes, cardiovascular diseases
and certain forms of cancer. Moreover, they are
sources of bioactive substances, e.g. phytosterols,
antioxidants and phytooestrogens, minerals and vitamins, which help prevent nutritional deficiencies and
cardiovascular disease.
Glycemic index
The glycemic index (GI) is a rating given to individual foods according to how rapidly they raise blood
sugar levels. Low-fibre, finely ground carbohydraterich foods result in a sharp and significant increase in
blood sugar levels, while the structure of many wholemeal products causes them to be absorbed more
slowly. However, the rate at which blood sugar levels
rise is not solely determined by a product’s degree of
refinement; it is also affected by the type of food in
which the carbohydrates occur and by whatever else
we are eating at the same time. Factory-produced
pasta, for example, raises blood sugar levels less than
bread made from the same flour because pasta is broken down more slowly. If, for example, a fatty sauce
or dressing is added, blood sugar levels rise more
slowly as fat of whatever type inhibits carbohydrate
uptake. However, when foods are ranked according
to the GI no account is taken of how other meal components affect the uptake of sugar.
Some studies of the link between eating habits and
health suggest that foods with a low GI, i.e. that slow
down the uptake of sugar, reduce the risk of developing obesity, cardiovascular diseases and type 2 diabetes. However, experimental studies in which subjects
were given food with a high or low GI found no evidence of any effect on the weight of the subjects [8].
In practice, it has been shown that choosing food
products on the basis of their GI has no appreciable
effect on blood sugar levels [9, 10].
It is still unclear what part food with a low GI
plays in preventing sickness in healthy people.
However, low-GI foods are usually wholesome; they
contain nourishing, fibre-rich products and are generally associated with a healthy food choices, making
it difficult to distinguish the effect of low GI per se.
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Eating habits and physical activity 167
With a few exceptions, the National Food Agency’s
nutritional guidelines are consistent, with a low-GI
diet, i.e. increased consumption of wholemeal products, pulses, fruit and vegetables and reduced consumption of sweets, pastry and sweet drinks. The
most important difference is that GI proponents
exclude root vegetables, whereas the National Food
Agency considers that the low-energy and highnutrient density of root vegetables meet the criteria
for healthy food products. The food group most
associated with low GI are leguminous plants –
beans, peas, and lentils. The National Food Agency
recommends a higher daily intake of pulses – up to
25 grams (dry weight) or more, i.e. three times more
than the present level.
Salt
Too much salt may be a cause of high blood pressure,
thereby increasing the risk of heart attack, heart failure, stroke and kidney damage. We eat an average of
10–12 grams of salt per day, twice the recommended
amount. Most salt, 60–70 per cent, comes from prepared foods, including cured meat products, bread,
cooking fat, cheese and ready-made meals, and is
thus difficult for the individual consumer to avoid.
Changes in eating habits
The Swedish Board of Agriculture’s production statistics are based on sales volumes and provide an estimate of how much food is available for consumption.
These statistics give a rough estimate of how our eating habits have changed in recent decades [11].
Between 1980 and 2010, annual consumption of
chocolate, confectionery products and sweets
increased from approximately 10 to 15 kilos per person. Soft drink consumption rose from 30 to 90
litres. Despite these increases, sugar consumption
fell by about 10 per cent to 36 kilos per person per
year. This is explained by a reduction in the amount
of sugar contained in other products.
Consumption of cooking fat dropped from 25 to
17 kilograms between 1980 and 2010. While more
butter than light margarine was consumed in 1980,
the reverse is now the case. Milk consumption fell
from 185 to 130 litres. In 1980, most people drank
regular milk (3 per cent fat) while semi-skimmed
milk (1.5 per cent fat) is the most common type consumed today.
Consumption of meat, vegetables, fruit and grain
has increased, although consumption of fruit and
vegetables amounts to less than 200 grams of fruit
per person per day, significantly below the recommended amount of 500 grams.
Average energy intake has risen by 11 per cent
since 1980, which has probably contributed to the
increase in the number of overweight people. We
now consume on average twice as much sweets,
snacks, ice cream, soft drinks and alcohol as we
should in order to meet our nutritional needs. This
applies to adults and children [12].
Few persons follow the recommended intake of
fish, fruit and vegetables
In 2005 and 2006, a national survey was conducted
among adults in order to measure a selected number
of food products, so-called indicators, which, in previous surveys of eating habits, had been shown to
reflect diet quality with respect to fat, dietary fibre
and sugar [13]. Only a small proportion of the adult
population met the recommendations of the National
Food Agency regarding fruit, vegetables and fish.
Fewer than one person in ten ate fruit and vegetables
five times a day (approximately 500 grams). Only
one in ten people ate fish as a main course three
times a week; on average, people ate fish and shellfish
as a main course 1.4 times a week. Forty per cent of
the population met the recommended minimum of
three slices of wholemeal bread per day. Three out of
ten people ate sweet and fatty food products, such as
sweets, soft/fruit drinks and pastries at least once a
day. These dietary guidelines were followed least
often by the less well educated and younger people.
Women and the well educated have better
eating habits
Our most up-to-date information about eating habits
comes from the Public Health Survey conducted by
the Swedish National Institute of Public Health in
2007–2010. It shows that women meet the recommended intake of fruit and vegetables (five times a
day or more, corresponds approximately to a minimum of 500 gram) more than twice as often as men
do, 13 per cent compared with 5 per cent respectively. People on low incomes or with lower educational qualifications eat less fruit and vegetables than
others. Male workers earning low incomes eat the
least amount of fruit and vegetables; 40 per cent of
them eat little fruit and vegetables (1.3 times a day
or less, on average) (Figure 1). Mid- or senior level
white-collar women on high incomes eat the most
fruit and vegetables. Only 11 per cent of women in
this group eat little vegetables and fruit.
Questionnaire surveys carried out by the National
Food Agency also show that groups differ in their
eating habits [13]. Men eat fruit and vegetables less
often than women but consume more soft/fruit drinks
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168 M. Axelsen et al.
Per cent
Women
Men
40
30
20
10
0
Labourers
Low-level
Midwhite-collars level/senior
workers
white-collars
workers
Figure 1. Low consumption of fruits and vegetables.
Percentage of people who eat fruit and vegetables less often than
an average of 1.3 times a day, by socioeconomic group. Women
and men aged 16–84, 2010. Standardised by age.
Source: National Public Health Survey, Swedish National Institute of
Public Health.
and chips. Women, on the other hand, eat slightly
more sweets than men. It is more common for
younger people and less well-educated people to eat
too little fruit, vegetables and fish, and to drink too
many soft/fruit drinks. People aged 70–84 eat more
pastries, buns and cake than people in other age
groups.
Eating habits of children and young
people
Children consume excessive amounts of sweets, soft
drinks, ice cream, snacks and cakes/pastries, according to a survey of children aged 4, 8 and 11 conducted by the Swedish National Food Agency [14].
Almost a quarter of their energy intake came from
these food products, i.e. double the recommended
amount. Children drank an average of approximately
2 decilitres of soft/fruit drinks daily and ate 1.5 hectograms of sweets a week. One in every ten children
drank more than 4 decilitres of soft/fruit drinks a day
and ate more than 3 hectograms of sweets a week.
Only one in every ten children meets the recommendation of 400 grams of fruit and vegetables per day,
i.e. as few as in the adult population. All in all, children consume too many saturated fatty acids, too
much added sugar and salt, and too little fibre and
vitamin D.
Young people who regularly eat breakfast often
have more healthy eating habits than those with
irregular breakfast habits [15, 16]. Instead of breakfast, young people often eat sweets, soft drinks, ice
cream, cookies, snacks, etc. between meals. Alcohol
consumption and smoking are also often more common among young people with irregular breakfast
habits.
A Gothenburg study of the eating habits of 15- to
16-year-olds [15] charts a number of changes in eating habits between 1994 and 2000. The changes
were mostly negative: meals became more irregular,
and young people drank more soft/fruit drinks.
However, an improvement was also noted: young
people were eating more vegetables. The study also
found a slight increase – from 2 to 8 per cent – in the
number of girls who did not eat meat .
A more recent, nationally representative study
[17] of 11-, 13-, and 15-year-olds’ eating habits
between 2001 and 2005 showed an improvement in
eating habits. More young people were eating fruit
and vegetables, and the consumption of sweets and
soft drinks had declined markedly. Eating habits had
improved more among 11- and 13-year-olds than
among 15-year-olds. Children of well-educated
mothers ate school lunches and fruit and vegetables
more often than young people with less-educated
mothers [16].
Eating habits of the elderly
It is never too late to prevent illness by following a
healthy lifestyle [18]. A diet rich in fibre, fruit and
vegetables, along with a low intake of saturated fat, is
recommended for the elderly as well as for younger
people [19]. According to a study conducted in 11
European countries, healthy eating habits were associated with a 40 per cent decline in cardiovascular
mortality and with a 20 per cent decline in overall
mortality in people aged 70–90 [20].
Slight overweight in elderly people should be
viewed as a sign of health rather than as a disease
risk. It is important for elderly people to maintain
their weight. Among other things, weight loss heightens the risk of hip fractures and impaired immune
response. Among the reasons for weight loss is lack of
appetite, a common complaint among elderly people.
Conditions leading to loss of appetite include deteriorating dental status, medication, sedentariness,
difficulty in swallowing, constipation, few social contacts, and a deteriorating sense of smell and taste.
The elderly’s nutritional needs are as great as or
greater than those of younger people. It is even more
important for the elderly than for people in the
younger, more active age groups that food be nutritious in relation to the amount of energy it contains.
The ability to maintain a healthy diet is enhanced by
good dental and oral hygiene, reduced sedentariness,
and the preservation of a social network.
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Eating habits and physical activity 169
Weight loss a common aspiration
A slim body ideal combined with an actual increase
in weight in the population has encouraged a perception among many people that their weight is
above the normal range. In 2007, the Swedish National
Board of Health and Welfare commissioned a
nationally representative survey of people over the
age of 16. Its purpose was to determine the prevalence of attempts to lose weight and whether people
were following any particular dietary recommendations. It found that a third of all women were trying
to lose weight (Table I). This applied to all age
groups, with the exception of women over the age of
65. A comparable percentage was not found among
men as a group until they were approaching the age
of 50. Men with a compulsory school education
were more likely to try to lose weight than men with
a higher level of education. In contrast, no differences were found among women of different educational levels.
Just over half of all men and 40 per cent of all
women have never tried to lose weight. Nor do they
plan to do so. Table I shows that no men in the 16–
24 age bracket are concerned about losing weight,
compared with 33 per cent of women in the same
group (Table I). This gender disparity decreases as
people grow older; beyond the age of 45 it becomes
too small to be statistically significant.
Table I. Attempts to lose weight.
Percentage of people in various age groups who reported that
they were trying to lose weight, 2007.
Age
Women
Men
Per cent
Per cent
16–24
25–35
35–44
45–54
55–64
65+
33
30
34
33
32
18
0
15
20
33
28
28
Source: Synovate and Swedish National Board of Health and Welfare.
Table II. Inspired by different dietary recommendations.
Percentage of people who reported being inspired by various
dietary recommendation in their choice of food.
Diet/dietary recommendation
Per cent
‘Diet Plate’ method or National Food Administration
guidelines
Other, e.g. vegan, diabetes, ecological diet
GI method (glycemic index)
Weight Watchers
‘Stone Age’ diet
Atkins-dieten
No special dietary recommendation (≈)
11
6
6
2
<1
<1
70
Source: Synovate and Swedish National Board of Health and Welfare.
Most people believe sugar causes weight gain
Few people follow radical dietary
recommendations
Just over a quarter of adults of both sexes reported
having been inspired by a special diet or special dietary recommendations which they actively tried to
follow (Table II). Eleven per cent stated that they
followed dietary recommendations in line with those
of the National Food Agency. Six per cent of the
population – 8 and 4 per cent of women and men
respectively – reported having been inspired by the
GI method. Only a minority of the population, the
majority of them men, followed a low-carbohydrate
diet (Atkins) or the so-called Stone Age diet.
People in later middle age more frequently follow
some type of diet or dietary recommendation than
any other group (Figure 2). Elderly people are more
likely to have a health complaint requiring adherence
to a particular dietary recommendation. Although
women follow dietary recommendations to a greater
extent than men, a statistically significant gender disparity only shows up in the 35–44 age group. Welleducated men are more likely to follow a diet than
those with less education, whereas no such difference
is found among women.
When asked what they thought contributed most
to weight gain, approximately 60 per cent of
respondents cited sugar, 15 per cent named fat, 4
per cent opted for white flour, and 15 per cent
believed that all three food products contributed
equally (Figure 3). The fact that most people
regarded sugar, and not fat, as the main cause of
overweight may be the result of the sugar debate in
recent years, which may have led to the notion that
sugar, as opposed to fat, leads to weight gain. The
main difference between those who follow the GI
method and others is that GI proponents are far
more insistent that white flour, and not fat, is the
most important cause of obesity (Figure 3).
The belief that fat is the foremost contributor to
weight problems was held by just 10 per cent of people trying to lose weight, compared with 17 per cent
of people who were not interested in losing weight.
There was a similar difference in perception concerning the extent to which white flour caused weight
gain. Seven per cent of people who wanted to lose
weight believed that white flour was the most important cause of weight gain, compared with 3 per cent
among those who were not trying to lose weight.
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170 M. Axelsen et al.
Per cent
50
45
40
35
30
25
20
15
10
5
0
16–24 25–34 35–44 45–54 55–64 65+
Women
Men
Total
Total
16–24 25–34 35–44 45–54 55–64 65+
Follow GI
Follow GI
Age
Figure 2. Follow special dietary recommendations.
Percentage of women and men in various age groups who actively attempt to follow special dietary recommendations, and percentage who
follow the GI method.
The difference between women and men is statistically significant only in the 35–44 age group (p<0.05).
Source: Synovate and Swedish National Board of Health and Welfare.
Per cent
80
70
60
50
40
30
20
10
0
Fat
White flour
Follow GI
Sugar
All three Don’t know
equally
Do not follow GI
Figure 3. Sugar, fat or white flour (refined carbohydrates)
as the cause of weight gain.
Percentage of respondents who hold that weight gain is caused
by sugar, fat or white flour, by adherents/non-adherents of the GI
method.
Source: Synovate and Swedish National Board of Health and Welfare.
Weight loss methods
Human beings are equipped with effective protective
mechanisms against weight loss, such as hunger and
lowered metabolism in the event of starvation. On the
other hand, we are poorly equipped to deal with
weight gain. Signs of fullness are weaker than hunger
signs, nor do we raise our metabolism when we have
eaten too much. With age the body’s energy consumption declines due to reduced muscle mass, making it easier to gain weight in middle age, even if one’s
lifestyle remains unchanged. Weight loss can only
occur if the body’s energy expenditure is greater than
its energy intake [21]. Most people succeed in losing
weight but the effect is seldom permanent. Failed
attempts at weight loss, so-called yo-yo dieting, result
in chaotic eating habits and in the replacement of
muscle tissue by fat. This can lead to further weight
problems. Extreme weight-loss methods such as lowcarbohydrate diets result in rapid initial weight loss.
In general, they exclude a large amount of what one is
used to eating, facilitating weight loss. Lowcarbohydrate diets cause an initial loss of water and
lead to appetite suppression. More moderate weightloss methods, such as the GI method or the ‘diet
plate’ method involve fibre-rich food and less nutrient-poor food (sweets, soft drinks, snacks and alcohol). These guidelines do not exclude any food
products, and weight loss occurs at a slower pace than
with more extreme methods. Results show that people lose just as much weight a year after a change of
diet whether they have adhered to established dietary
guidelines or followed an extreme weight-loss method.
Many diets claim to have nutritional-physiological
benefits and that these are the basic principles of
weight loss (increased calorie burning, reduced blood
sugar level fluctuation, etc.). However, the scientific
evidence for this is weak. On the other hand, they
have varying effects on eating behaviour, and may
also have varying effects on people’s psychological
rewards systems. There is probably no single optimal
method for all individuals. What has been shown,
however, is that a sense of active involvement in the
diet process is important to successful weight loss,
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Eating habits and physical activity 171
i.e. the individual is able to influence its course and
feels strengthened by success.
The population is constantly getting contradictory
messages via the media, and the debate has been polarised between the proponents and opponents of fat.
Nevertheless, more unites the various weight-loss
methods than divides them. Most of them involve a
greater intake of vegetables and in many cases of fruit
and pulses as well, and in a lower intake of chocolate,
confectionery products, sweets, soft drinks and snacks.
People have lost weight and succeeded in maintaining
their weight loss after a year report eating more vegetables and fibre, regardless of whether the method used
focused on carbohydrates or fat. Those who have cut
down on carbohydrates do not consume more fat [22],
and those who have cut down on fat consumption have
not increased their carbohydrate intake [23]. Common
to both groups is the substitution of vegetables for a
number of other food products.
Physical activity critical to good health
Regular physical activity has many beneficial effects
on our health and helps prevent our most common
diseases. People who are physically inactive are twice
as likely to develop cardiovascular disease as those
who are active [24, 25]. Physical activity prevents or
delays the onset of high blood pressure and lowers
blood pressure in people with hypertension [26].
Similarly, physical activity prevents the development
of type 2 diabetes [27–29] and lowers blood sugar
levels in diabetics [30]. It improves balance and muscle strength and helps prevent osteoporosis, thus
reducing, among other things, the number of falling
accidents and bone fractures [24]. It also strengthens
the immune response and helps prevent depression
[24]. The risk of developing cancer, including colon
and breast cancer, is lowered [31]. Physical activity
slows down the genetically programmed aging process so that a person’s chromosomes retain the structure of those of someone ten years younger but
physically inactive [32].
Although some of the above health effects are due
indirectly to overweight prevention, physical activity
in itself has significant health-promoting effects,
regardless of changes in a person’s weight [33, 34]. It
has even been shown that a fit, overweight or abdominally fat man runs a lower risk of dying of a cardiovascular disease than an unfit man of normal weight [35].
What is physical activity and how much
do we need?
Physical activity involves exercise, i.e. the use of
one’s muscles. Using one’s muscles stimulates the
build-up of muscle and the breakdown of fat. It
affects the metabolism of carbohydrates, fats and
proteins, preventing increased blood sugar levels and
heightened levels of harmful blood fats. Achieving
these positive effects requires regular physical activity, since the effect on metabolism only lasts one to
two days [36, 37].
To promote and maintain good health, adults
should engage in at least moderately intense physical
activity, equivalent to 30 minutes of brisk walking at
least five times a week but preferably every day.
These 30 minutes can be divided into smaller periods, for example three 10-minute walks, and still
have an effect on metabolism [38].
Alternatively, intense physical activity for at least
20 minutes at least three times a week is recommended. Moderate physical exertion is defined as
activities resulting in a moderate increase in pulse
rate. The physical activity can be considered intense
if the breathing rate also increases and the pulse rate
rises noticeably. Intense physical activity is needed if
a person wants to improve his/her fitness, i.e., oxygen
uptake capacity. An adequate level of physical activity can also be achieved if moderate and intense
physical activity are combined, for example a brisk
30-minute walk twice a week combined with a more
intensive training session, e.g. jogging twice a week
[39]. In addition, it is recommended that adults
engage in strength training at least twice a week, in
order to maintain and improve muscle strength.
The equivalent of 45–60 minutes of brisk walking
on a daily basis is probably required to prevent a person of normal weight from becoming overweight
over the course of several years, given the average
energy intake. People who have lost weight need
more exercise, 60–90 minutes daily, in order to
maintain their new weight; alternatively, they can
engage in less frequent, but more intense, physical
activity.
More physical activity is recommended for children and young people than for adults [40–42],
namely the equivalent of 60 minutes of moderate to
intense physical activity daily [43]. Physical exercise
is important for elderly people as well. It helps them
maintain the function of muscles and joints, thereby
reducing the risk of illness and premature death [24].
Although health benefits increase with increased
activity, people who go from being physically inactive
to taking up some form of regular activity, for example short walks, obtain the most visible benefits [44].
Those who are least fit thus have the most to gain
from stepping up their physical activity, since a small
increase from a very low level already yields positive
effects [24]. Physical activity also has a beneficial
effect among people who have become ill, improving,
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172 M. Axelsen et al.
among other things, their prognosis in cases of heart
disease and diabetes [45].
Current research also shows that extensive sedentariness in itself – independent of physical exercise – has an adverse effect on metabolism, with a
risk of metabolic disturbances [46]. Working from a
standing position instead of sitting would prevent
this, because standing involves continuous lowintensity activity involving the major muscle groups.
Physical activity and performance fitness affect the
metabolism of children (9–10 years of age) and
young people (15–16 years) and disturbances in
blood pressure, blood fat and blood sugar are more
prevalent among inactive people while still at an
early age [47].
Changes in physical activity
It is difficult to assess the degree of physical activity
in a population. It is often measured by surveys and
interviews, in which questions are asked about people’s exercise habits in their leisure time. Exercise
involves conscious physical activity with the aim of
improving strength and fitness. There is a lack of
knowledge about the extent of daily physical activity,
such as regularly climbing stairs or walking short distances every day.
The Swedish National Institute of Public Health
has proposed three indicators for measuring physical activity in the population: (1) the percentage of
adults who do no exercise in their leisure time, (2)
the percentage of adults who are physically active at
least at a moderately intense level, that is, at least
30 minutes a day, and (3) the percentage of young
people who have at least a passing school grade in
physical education and health.
Physical inactivity during leisure time most
common among men
Lack of exercise can be assessed with the aid of
Statistics Sweden’s studies of living conditions (the
ULF studies), using the percentage of people who
report that they “do practically no exercise at all in
their leisure time.” A clear improvement has taken
place in the past 25 years, above all among women.
The percentage of people aged 16–74 who reported
“no exercise in their leisure time” was 14 per cent
for both sexes in 1980–1981, and 7 per cent and 11
per cent for women and men respectively in
2004–2005.
Inactivity during leisure time has become less
common among women in all socioeconomic groups.
In the case of men, however, it has only become less
common among upper-level white-collar workers.
Among blue-collar workers, it is as common to do no
exercise today as it was 15 years ago; among lowlevel white collar workers it has become even more
common. In 2004–2005, lack of exercise was three
times more common among male blue-collar workers than among upper-level male white-collar workers (14 and 5 per cent, respectively), and twice
as common for female blue-collar workers as
for female white-collar workers (8 and 4 per cent,
respectively).
Other studies show no appreciable improvement
in the past 15 years in terms of physical inactivity
during leisure time. The MONICA study in
Västerbotten and Norrbotten shows that there has
been no change from the approximately 20 per cent
of women and men aged 25–64 who were mostly
sedentary in their free time (1990 and 2004) [48].
In the Public Health Survey by the Swedish
National Institute of Public Health for the period
2004–2011, 13–14 per cent of women and men
reported that they did no exercise in their leisure
time, with no significant change throughout the
period. One third of women and men born outside
Europe – three times as many as native-born Swedes
– reported doing no exercise in their free time.
Nor, in the Västerbotten Health Studies of 90,000
people aged 40, 50, and 60 for the years 1990–2010,
could any substantial decline in physical inactivity
over the past 20 years be observed (Figure 4). In this
study, physical inactivity was defined as “never taking an exercise break, a bike ride or a walk at least
2–3 times a month in one’s free time, and walking
walks or cycling less than 2 kilometres to work”. This
study, too, shows disparities in leisure time physical
inactivity between groups with different educational
levels, particularly among men.
In an international study of schoolchildren’s
health habits, TV viewing was used as an indicator of
lack of leisure-time exercise among children [49].
Among 11-year-olds, 56 per cent of girls and 60 per
cent of boys watched TV more than 2 hours a day on
weekdays, in 2009–2010. Watching TV was even
slightly more common among 15-year-olds, and
approximately 60 per cent of girls and 63 per cent of
boys watched more than 2 hours a day on weekdays.
According to these data, TV viewing among children
in Sweden is close to the average for the 39 countries
included in the study.
Moderate and intense physical activity
The second proposed indicator is being physically
active for at least half an hour every day, at a level of
activity that would at minimum be considered moderate. Although two-thirds of the population between
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Eating habits and physical activity 173
Per cent
Per cent
Women
50
45
45
40
40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
1990
95
2000
Men
50
05
2010
1990
Low educational
level
Medium
educational level
Higher
education
95
2000
05
2010
Figure 4. Low physical activity, by level of education, 1990–2010.
Percentage of people who are physically inactive*. Women and men with different levels of education, aged 40, 50 and 60.
Low educational level: maximum of 9 years (compulsory education only or equivalent).
Medium educational level: maximum of 12 years (trade school, vocational training school or upper-secondary school).
Higher education: more than 12 years (university or institute of higher education).
*Never takes a walk, a bike ride or an exercise break in leisure time, and walks or cycles less than 2 kilometres to work.
Source: Västerbotten Intervention Programme, Umeå University.
Per cent
Per cent
Women
50
45
45
40
40
35
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
1990
95
2000
Men
50
05
2010
1990
Low educational
level
Medium
educational level
Higher
education
95
2000
05
2010
Figure 5. Intense physical activity, by levels of education, for the period 1990–2010.
Percentage of people who engage in intense physical activity*. Women and men with different levels of education, aged 40, 50, and 60.
Low educational level: maximum of 9 years (compulsory education only or equivalent).
Medium educational level: maximum of 12 years (trade school, vocational training school or upper-secondary school).
Higher education: more than 12 years (university or institute of higher education).
*Takes an exercise break in a tracksuit at least 2–3 times a week, or walks or cycles more than 5 kilometres to work daily, all year round, or
walks or cycles daily in free time.
Source: Västerbotten Intervention Programme, Umeå University.
the ages of 16 and 84 fulfil this criterion of physical
activity according to the Public Health Survey conducted by the Swedish National Institute of Public
Health, a small decline in the percentage of people
who are physically active occurred between 2004–
2011. The percentage of people who are physically
active is lower among those with fewer educational
qualifications, among blue-collar workers and among
people born outside Europe. However, these differences are less pronounced than in the case of leisuretime inactivity.
The Västerbotten Health Studies show that the
percentage of people who are moderately active has
declined. In this study, being moderately active
means exercising sometimes but not regularly,
cycling or walking at least 2–3 times a week in one’s
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174 M. Axelsen et al.
free time, or cycling or walking 2–5 kilometres to
work all year round.
However, the percentage of those who engage in
intense physical activity has increased in the 2000s
(Figure 5). Intense physical activity in leisure time
has increased more among women than among men,
and that it is now more common among women.
Intense physical activity in leisure time has increased
in Västerbotten among people with both low and
high educational levels.
Children and young people are recommended to
engage in twice as much daily physical activity as
adults, i.e. an hour a day. Moreover, the activity
should be both moderate and high-intensity. As in
the case of adults, the activity may be divided up into
several sessions during the day. This recommendation was followed by only 17 per cent of girls and 19
per cent of boys aged 11, and by only approximately
9 per cent of girls and 13 per cent of boys aged 15,
according to an international study of schoolchildren’s health habits conducted in 2009–2010 [49]. It
was less common for Swedish children to meet these
recommendations than for children in most of the 39
countries in the study.
Funding
This research received no specific grant from any
funding agency in the public, commercial or not-forprofit sectors.
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