Lifestyle Medicine

Se não consegues explicar uma ideia por uma
forma simples…
É porque não a percebes !
A.Einstein
A Nova Medicina da
Qualidade de Vida
por
Manuel NevesNeves-e-Castro
Ginecologista/Endocrinologista
http://neves-e-castro.pt
Junho, 2013
Keeping Quality of Life and
staying Healthy
by
Manuel Neves-e-Castro, M.D.
Clinica de Feminologia Holistica
http://neves-e-castro.pt
Lisboa, Portugal
17th World Congress on Controversies in Obstetrics,
Gynecology & Fertility (COGI)
Lisbon, Portugal, November 8-11, 2012
I shall talk about...
•
•
•
•
•
Life Style Medicine
Aging
Genetics
Psychosomatics
Hormonal and non-Hormonal treatments
menopause
menarche
postmenopause
Puberty
reproductive years
Fertilarche
Infants
adolescents
Climacteric
gerontarche
geronarche
Fertilpause
adults
aged
quality of life
compression
morbidity
Chronobiology
The Time Table of a Woman’s Life Span
M.Neves--e-Castro,2008
M.Neves
old
“ The Compression of Morbidity “
Fries JF et al. 1981
Physical activity, the compression of morbidity,
and the health of the elderly
Fries JF. Journal of the Royal Society of Medicine 1996;89:64-68
Since WHO defines
Health
as
“a state of complete physical, mental and
social well-being and not merely the
absence of disease or infirmity“
“this holistic concept sets the targets (a
tripod) for which a good clinical practice
must aim”
WELLNESS
Wellness is first and foremost a
choice to assume responsibility for
the quality of your life.
It begins with a conscious decision
to shape a healthy lifestyle.
Wellness is a mind set, a
predisposition to adopt a series of
key principles in varied life areas
that lead to high levels of well-being
and life satisfaction.
--Don Ardell, Ph.D., Living Well Center, University at
Buffalo
wellness is generally viewed
from a holistic perspective;
it represents a perceived positive state of being and embraces a
body-mind-spirit concept.
Many factors contribute to wellness in a series
of complex and interacting ways, but
wellness, like health, is more than the absence of disease;
it involves important subjective concepts by individuals about
themselves.
Disease
any impairment of normal
physiological function
affecting all or part of an
organism producing
characteristic symptoms;
illness or sickness in general
Collins English Dictionary – Complete and
Unabridged © HarperCollins Publishers 1991,
1994, 1998, 2000, 2003
“Our main goal, as attending physicians
of postmenopausal women, is the
maintenance of their health and the
primary and secondary prevention of the
diseases, which are more prevalent after
age 50”.
Neves-e-Castro M. When hormone replacement therapy is not
possible. The Management of the Menopause. The Millennium
Review, Parthenon 2000:91-102.
O cancro é uma doença do estilo de
vida ocidental
ALIMENTOS ANTICANCRO
O cancro alimenta-se de açúcar
Alimentos de baixo indice glicémico
Elevado indice Glicémico
(evitar)
• Açúcar: branco ou amarelo; mel;
xaropes: ácer; frutose, dextrose
• Farinhas brancas/refinadas: pão
branco, arroz branco, massas
brancas bem passadas, bolinhos,
croissants, galetes de arroz
• Batatas (exceto a rara variedade
Nicola), sobretude em puré
• Flocos de milho, arroz tufado (e a
maior parte dos outros cereais de
pequeno-almoço branqueados ou
adoçados)
• Doces e geleias, fruta cozinhada
em açúcar, fruta em xarope
Baixo Índice Glicémico
(consumir à vontade)
•
•
•
•
•
Extratos de açúcar naturais: néctar de
agave, stevia (uma planta do Pacífico),
xilitol, glicínia, chocolate preto (>70%)
Mistura de cereais integrais: pão de
mistura (não apenas trigo) ou pão
tradicional (“massa azeda”); arroz:
integral, basmati ou tailandês; massas
cozinhadas al dente (de preferência de
mistura), quinoa, flocos de aveia, milho
painço, trigo-mourisco
Lentilhas, ervilhas, feijão, batata-doce,
inhame
Papas de aveia, muesli, All Bran, Especial K
Fruta no seu estado natural: sobretudo
mirtilos, cerejas e framboesas, que
ajudam a regular os níveis de açúcar no
sangue (se necessário, utilizar néctar de
agave para adoçar)
Alimentos de baixo indice glicémico
Elevado indice Glicémico
(evitar)
• Bebidas adoçadas: sumos
de fruta industriais,
refrigerantes
• Álcool (exceto às refeições)
Baixo Índice Glicémico
(consumir à vontade)
• Água aromatizada com limão,
tomilho ou salva. Chá verde
(sem açúcar, ou néctar de
agave), que combate
diretamente o cancro
• Um copo de vinho tinto por
dia, à refeição
• Alho, cebolas, chalotas:
quando misturados com
outros alimentos, ajudam a
baixar os picos de insulina
Cancro da mama e alimentação
Quantidade de células de tumor cerebral
Anticancro – um novo estilo de vida. Servan-Schreiber D
Vitetta L and Anton B; Clinical Interventions in Aging 2007:2(4) 537–543
O que inibe e o que ativa as células
imunitárias
Inibe
• Dieta ocidental tradicional
(pró-inflamatória)
• Stress, raiva, depressão
• Isolamento social
• Negação da sua identidade
(por exemplo, a sua
homosexualidade)
• Estilo de vida sedentário
Ativa
• Dieta mediterrânica,
cozinha indiana, cozinha
asiática (anti-inflamatória)
• Serenidade, alegria
• Apoio da família e amigos
• Aceitação de si próprio com
os seus próprios valores e
passado
• Atividade física regular
O exercício físico pode estimular as
defesas imunitárias em sobreviventes
de Ca mama, aumentando a atividade
cancerígena das NKC
Em mulheres de 45 a 64 anos houve
Redução de:
- 40% em todas as causas de mortalidade
- 35% em DCV
Quando:
-
comeram 5 frutos e vegetais/dia
fizeram exercício de 2,5 horas/semana
mantiveram o IMC entre 18.5 e 30
não fumaram
Am J Medicine 2007;120(7):598-603
E...
que tal com os
produtos “naturais”
?...
90% of people die
due to errors in life style
A good counselling technique
is to demonstrate and persuade women that
• lifestyle modifications are independent of the
use of drugs, and may
• diminish the need to use drugs to prevent
diseases and preserve Health
Lifestyle Medicine
requires the patient
to change their high risk health behaviors
to adopt a lifestyle that includes health
behaviors that will help to reverse the
pathology and or reduce the likelihood of
disease progression.
Lifestyle modifications included a
lowfat (10% of calories from fat),
whole foods,
plant-based diet high in fruits,
vegetables,
unrefined grains,
legumes, and
low in refined carbohydrates;
moderate aerobic exercise (walking 30 min/day, 6
days/week);
stress management (gentle yoga-based stretching,
breathing, meditation, imagery, and progressive
relaxation techniques 60 min/day, 6 days/week), and
a 1-h group support session once per week.
‘Lifestyle Medicine’
Exercise and nutrition are the ‘penicillin’ of
Lifestyle Medicine;
psychology is the ‘syringe’
through which these are delivered.
Egger G, Binns A and Rossner S. Med J Aust. 2009 Feb 2;190(3):143-5.
Lifestyle Medicine
can prevent risk factors
• We are today using only medicines to modify
risk factors but we are not looking at what
causes risk factors.
• Women’s health must be primarily the
medicine of lifestyles
Effect of Intensive Lifestyle Changes on
Endothelial Function and
on Inflammatory Markers of Atherosclerosis
Intensive lifestyle changes have been shown to
regress atherosclerosis,
improve cardiovascular risk profiles, and
decrease angina pectoris and cardiac events.
events
Dod HS et al. Am J Cardiol 2010;105:362–367
Combined impact of lifestyle factors on mortality:
prospective cohort study in US women
even modest differences in lifestyle
can have a
substantial impact on reducing mortality.
Van Dam RM, Li T, Spiegelman D et al.BMJ 2008;337:a1440
The recent INTERHEART study of 30.000
patients from 52 countries
found that
almost 95% of coronary heart disease
could be prevented by changing diet and
lifestyle.
And the only side effects are beneficial ones.
Ornish D et al. The Journal of Urology 2005;174:1065-1070
Is aging a disease ?
The fact that genes explain only part of individual
varibility in aging means that aging
75% must be accounted for by other factors:
factors:
- life style variables
(nutrition, exercise)
- powerful effects of environment
(effects on older age)
Anti--Aging ?
Anti
One cannot stop aging ...
One cannot stop growing older ...
but
One can prevent senescence !
There are two forms of age :
chronological age i.e. how old you are in years
and
biological age whereby the cells of some
individuals are older (or younger) than
suggested by their actual age
age..
Issued on 07 February 2010 by University of Leicester at
http://www2.le.ac.uk
Anti--Aging ?
Anti
Anti--senescence ?
Anti
Is to prevent
Biological age
to be greater than
Chronological age
Restricting caloric intake
Is the most proven method to
extend life
Avoid high caloric foods
Try short term fasting
Undereating is antianti-aging !
Okinawa Island:
Island
A model of “healthy” aging
The exceptional longevity of the Okinawa
population may result from a combination of
favorable factors and not only genetic
determinants.
Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008;8(43):35-41.
Okinawa Island:
Island
A model of “healthy” aging
The association of a protect environment with a way
of life which combines specific
food habits,
low energy intake,
physical activities,
stress reduction,
good familial support and
rich social relations
could explain this exception despite the low income
in this population.
Nguyen C. NPG Neurologie-Psychiatrie-Geriatrie 2008;8(43):35-41.
and don’t overlook…
The MIND !
A woman
environment
psycho
environment
soma
Depression and Cancer
Depression also affects components of
immune function that may affect cancer
surveillance.
Spiegel D. Biol Psychiatry 2003; Vol 54(3):269-82
Effect of a psychosocial treatment on survival
of patients with metastatic breast cancer
Survival from time of randomisation and
onset of intervention was:
- a mean 36.6 (SD 37.6) months in the
intervention group
- compared with 18.9 (10.8) months in the
control group.
Spiegel D. Lancet 1989; 2(8668):888-91
Psychosomatics
Benson Institute for
Mind Body Medicine
The Relaxation Response
1. Sit quietly in a comfortable position.
2. Close your eyes.
3. Deeply relax all your muscles, beginning at your feet and progressing up
to your face. Keep them relaxed.
4. Breathe through your nose.
5. Become aware of your breathing.
6. As you breathe out, say the word, "one"* silently to yourself. For
example, breathe in ... out, "one"; breath in .. out, "one", etc.
7. Breathe easily and naturally.
8. Continue for 10 to 20 minutes.
the relaxation response is a physical state of deep
rest that changes the physical and emotional
responses to stress (e.g., decreases in heart rate,
blood pressure, rate of breathing, and muscle
tension).
When eliciting the relaxation response:
response:
• Your metabolism decreases
• Your heart beats slower and your muscles relax
• Your breathing becomes slower
• Your blood pressure decreases
• Your levels of nitric oxide are increased
A stress response pathway
regulates DNA damage…
damage…
through β(2)-adrenoreceptors and β-arrestin-1
This stress-induced DNA damage may promote :
aging,
tumorigenesis,,
tumorigenesis
neuropsychiatric conditions
Hara Mr et al. Nature 2011 Aug 21.
Exactly how psychological and social factors,
personal beliefs, and stress affect the
development of disease continues to be
studied.
It is known, however, that the mind and body
communicate constantly..
what the mind thinks, perceives, and
experiences is sent from our brain to the rest
of the body.
body.
Chronic stress - reduces telomere lenght maintenance
A SOBERING THOUGHT ...
“Every stress leaves an
indelible scar and the
organism pays for its
survival after a stressful
situation by becoming a
litle older”. (Hans Selye)
Dr. E. Blackburn,
Nobel Laureate 2009
Lifestyle medicine stimulates telomerase thus
avoiding DNA damage and maintaining
chromossomal integrity.
the incorporation of new lifestyles may lead to
a better compliance and better outcomes in
terms of health and longevity
A stress response pathway
regulates DNA damage…
damage…
through β(2)-adrenoreceptors and β-arrestin-1
The human mind and body respond to stress… by
activating the sympathetic nervous system and
secreting the catecholamines adrenaline and
noradrenaline in the 'fight-or-flight' response.
Hara Mr et al. Nature 2011 Aug 21.
"Shorter telomere length...equated to an
estimated 4.5 years of accelerated aging"
"In several studies conducted at UCSF,
researchers have found shortened telomere
length to be associated with depression,
childhood trauma and other conditions. Dr.
Wolkowitz says. The study was published last
year in Biological Psychiatry."
Telomers
These cellular clocks, known as telomers, may
act as barometers of wether a person will
remain healthy or not
Elizabeth Blackburn
Nobel Laureate 2009
Sedentary life 'speeds up aging'
Leading a sedentary lifestyle may make us
genetically old before our time, a study suggests:
A study of twins found those who were physically
active during their leisure time appeared biologically
younger than their sedentary peers.
Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/7212698.stm
Published: 2008/01/29
Telomers
• The little tips of chromosomes get shorter
every time a cell divides, and this shortening is
a mark of cellular aging.
• If they get short enough, the cell dies or stops
dividing
• Exercise correlates with longer telomers,
telomers, as
does levels of omega-3 fatty acids in the blood
Elizabeth Blackburn
Nobel Laureate 2009
Genes reveal 'biological aging'
From birth, every time a cell divides, the
telomeres get shorter and there is some
evidence that people with shorter telomeres,
telomeres,
may be at higher risk from ageage-related illness.
illness
Feb.2010 at http://crabsalloverhealth.blogspot.com/
Vitamin D
for Cancer Prevention:
Global Perspective
Garland CF, et al
Ann Epidemiol 2009;19:468–483.
Vitamin D for Cancer Prevention: Global
Perspective
Raising the minimum year-around serum 25(OH)D level to
40 to 60 ng/mL (100–150 nmol/L) would prevent
• 58,000 new cases of breast cancer and
• 49,000 new cases of colorectal cancer each year, and
• ¾ of deaths from these diseases in the USA and Canada.
There are no unreasonable risks from intake of 2000 IU
per day of vitamin D3
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Relative risk of breast cancer mortality
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Colon CancerCancer-free survival
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Relative risk of colon cancer mortality
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Vitamin D for Cancer Prevention: Global
Perspective
Raising the minimum year-around serum 25(OH)D level to
40 to 60 ng/mL (100–150 nmol/L) would prevent
• 58,000 new cases of breast cancer and
• 49,000 new cases of colorectal cancer each year, and
• ¾ of deaths from these diseases in the USA and Canada.
There are no unreasonable risks from intake of 2000 IU
per day of vitamin D3
Garland CF et al. Ann Epidemiol 2009:19(7);468-483
Hormones…
are not forgoten !
7 de junho – resumo 1
Apresentação 3
Why so much interest in HRT?
• To improve quality of life?
• To prevent diseases?
• Too much concerns and interest about HRT
• Too little attention to the life styles that
prevent risks, diseases and increase longevity
Interventions investigated…
Only “hormone
replacement therapy”!...
therapy
Thus,
Studies based ONLY on the use of hormones
do not reflect good clinical practice!...
MNC
Hormonal Treatments
are very good
for symptom relief
to improve quality of life
for the prevention of some diseases
Os estudos publicados esta semana revelam
que, ao contrário do que muitos pensavam,
os tratamentos durante a menopausa não só
não causam o cancro da mama mas também
reduzem para metade os riscos de doenças
do coração que são a principal causa de
morte das mulheres idosas.
KEEPS Reports Hormone Therapy Provides
Quality of Life Benefits for Newly
Menopausal Women
KEEPS Reports Hormone Therapy
Provides Quality of Life Benefits
for Newly Menopausal Women
Hormone Therapy Has Many Favorable Effects in
Newly Menopausal Women:
Initial Findings of the Kronos Early Estrogen
Prevention Study (KEEPS)
PHOENIX, (October 3, 2012) – Estrogen /progesterone treatment
started soon after menopause appears safe and relieves many of
the symptoms menopausal women face as well as improving
mood and markers of cardiovascular risk, according to a
multicenter randomized study presented at the North American
Menopause Society (NAMS) Annual Meeting in Orlando, Florida.
for release October 3, 2012
08 October, 2012
• The good news is that, in this young cohort,
no safety issues were found to be related to
HT.
• In conclusion, KEEPS found many favorable
effects of HT in newly menopausal women.
The results provide reassurance for women
who are recently menopausal and taking HT
for short-term treatment of menopausal
symptoms.
Effect of hormone replacement therapy on
cardiovascular events in recently postmenopausal
women: randomised trial
Louise Lind Schierbeck registrar1, Lars Rejnmark associate
professor, consultant2, Charlotte Landbo Tofteng staff specialist 1 1,
Lis Stilgren consultant 3, Pia Eiken consultant, senior endocrinologist
4, Leif Mosekilde professor, senior consultant 2, Lars Køber
professor, consultant 5, Jens-Erik Beck Jensen associate professor,
consultant
BMJ 2012;345:e6409 doi: 10.1136/bmj.e6409
(Published 9 October 2012)
Greater-Than
GreaterThan--50% Reduction in CV
Events Without Increasing Cancer Risk
• The 1006 healthy women aged 45 to 58 who
were recently postmenopausal or had
perimenopausal symptoms were participants in
the Danish Osteoporosis Prevention Study and
were randomized to receive HRT (n=502) or no
treatment (control, n=504).
Lisa Nainggolan at Medscape News, Oct 15, 2012
Greater-Than
GreaterThan--50% Reduction in CV
Events Without Increasing Cancer Risk
• The 1006 healthy women aged 45 to 58 who
were recently postmenopausal or had
perimenopausal symptoms were participants in
the Danish Osteoporosis Prevention Study and
were randomized to receive HRT (n=502) or no
treatment (control, n=504).
Lisa Nainggolan at Medscape News, Oct 15, 2012
HRT Cuts CVD by 50%,
Latest 'Unique' Data Show
• October 12, 2012 (Hvidovre, Denmark) — Hormone
replacement therapy (HRT) in postmenopausal women
with a mean age of 50 significantly reduced the risk of
the combined end point of mortality, MI, or heart
failure in a new randomized Danish study published
online October 9, 2012 in BMJ. The participants, who
used HRT for more than 10 years, were not at
significantly increased risk of breast cancer or stroke
either, report Dr Louise Schierbeck (Hvidovre Hospital,
Denmark) and colleagues.
Lisa Nainggolan at Medscape News, Oct 15, 2012
15 Top Medical Organizations Agree
on Hormone Therapy Use
Press release July 9, 2012
Global Consensus Statement on
Menopausal Hormone Therapy (MHT)
endorsed by
The American Society for Reproductive Medicine,
The Asia Pacific Menopause Federation,
The Endocrine Society,
The European Menopause and Andropause Society,
The International Menopause Society,
The International Osteoporosis Foundation and
The North American Menopause Society.
Villiers TJ et al. Climacteric 2013; 16:203–204
Global Consensus Statement on
Menopausal Hormone Therapy (MHT)
MHT is the most effective treatment for
vasomotor symptoms associated with
menopause at any age, but benefits are
more likely to outweigh risks for
symptomatic women before the age of 60
years or within 10 years after menopause.
Villiers TJ et al. Climacteric 2013; 16:203–204
Global Consensus Statement on
Menopausal Hormone Therapy (MHT)
MHT is effective and appropriate for the
prevention of osteoporosis-related
fractures in at-risk women before age 60
years or within 10 years after menopause.
Villiers TJ et al. Climacteric 2013; 16:203–204
Global Consensus Statement on
Menopausal Hormone Therapy (MHT)
Standard-dose estrogen-alone MHT may
decrease coronary heart disease and
all-cause mortality in women younger than
60 years of age and within 10 years of
menopause.
Villiers TJ et al. Climacteric 2013; 16:203–204
Global Consensus Statement on
Menopausal Hormone Therapy (MHT)
Data on estrogen plus progestogen MHT
in this population show a similar trend for
mortality but in most randomized clinical
trials no significant increase or decrease in
coronary heart disease has been found.
Villiers TJ et al. Climacteric 2013; 16:203–204
HT’s are safe for
menopausal women
The studies published last month clearly
show that Hormonal Treatments
are safe,
do not induce breast cancer and
sharply decrease heart diseases
CLIMACTERIC 2012;00:1–2 (on line, November 6)
IWH: an Initiative for Women’s Health
with a better quality of life
M. Neves-e-Castro
Clinica de Feminologia Holistica, Lisbon, Portugal
Menopause in crisis post-Women's
Health Initiative?
A view based on personal
clinical experience
Neves-e-Castro M.
Human Reproduction Vol.18,
No.12 pp. 2512-2518, 2003
Menopausal hormonal treatments
are very good
but ...
Treatments without hormones
may also be very good for a
woman’s health
MNC/02
Preventing a woman from the
benefits of a
sound postmenopausal
hormone therapy
because of the fear of rare side
effects
does not seem to be
satisfactory Medicine...
M.Neves-e-Castro, 2000
Let us not medicalize the Menopause..
instead…
Let us holistically approach the
Climacteric and aging women.
women
MNC
I am not a Menopauselogist…
instead
my Speciality (?!...) is
Women’s Holistic Health
The Take Home
Messages
1. Promote changes in Life Style:
Style they avoid risk factors that
cause Diseases.
2. See if you can make the Biological Age to be younger than
the Chronological Age.
3. Promote Mental Health,
Health proper Nutrition and frequent
Exercice, based on what one knows about the Telomers.
Exercice
4. Give Vitamin D
5. Remember that Estrogens are the best treatment for
Vasomotor Symptoms and to improve Quality of Life.
6. Hormonal Treatments have more benefits than risks if
started early in the postmenopause
7. The Wellness of a Woman is the TARGET !
Conhecer
a doença que uma mulher tem
é tão importante como
conhecer
a mulher que tem a doença
Sir William Osler
e mesmo para terminar,
a propósito de disfunções sexuais...
Numa prova de entrada para a Universidade ...
Questão: Interpretar o seguinte trecho do poema de
Camões:
“Amor...
é fogo que arde sem se ver,
é ferida que dói e não se sente,
é um contentamento descontente,
é dor que desatina sem doer”.
Uma aluna deu a sua interpretação:
“Ah! Camões,
se vivesses hoje em dia,
tomarias uns antipiréticos,
uns quantos analgésicos
e Prozac para a depressão,
Comprarias um computador,
consultarias a Internet
e descobririas que essas dores que sentias,
esses calores que te abrasavam,
essas mudanças de humor repentinas,
esses desatinos sem nexo,
não eram feridas de amor,
amor,
mas sómente falta de sexo!"
Teve nota máxima.
Foi a primeira vez, depois de mais de 500 anos, que
alguém entendeu qual era a ideia do Camões...
and now...
and now...
as Sir Winston Churchill said in a
speech, at the end of a War...
I also say,
at the end of the
Menopause War...
War...
This is not the end...
nor even the begining of the
end.
But it is, perhaps,
the end of the begining !
Therefore…
and in
conclusion…
And...as I told you before,
The best Anti
Anti--Aging (?)
(Anti--Senescence !) Treatment
(Anti
is
The practice of GOOD MEDICINE
Please remember:
Our main target is
Mature Woman’s Health and
Disease Prevention
by all means,
drug and non-drug related.
MNC
Holistic Model
The aim of the therapy is not only to
produce a physical cure but also
to cure whole person.
Ruiz R, et al. La incorporacion de um nuevo modelo en medicina:
consequencias teórico-práticas. Aten Primaria 1992;10:629-34
Muito obrigado
pela vossa atenção
e... para mais esclarecimentos...
Consultem o meu website:
http://neves-e-castro.pt
Viver bem a Vida não é tarefa fácil…
(Palestra do dia 7 de Junho)
Os Humanos são seres sociais. Como tal, influenciam e são responsáveis pela
sociedade em que se integram,; são também por ela influenciados e
responsabilizados.
Conservar e promover a Saude é uma responsabilidade individual e social de
todos nós.
A nossa população está a envelhecer assustadoramente e não se renova devido a
uma baixa taxa de natalidade. Se Portugal contar com um rejuvenescimento
social apenas à custa dos imigrantes é de prever que a longo prazo possamos vir
perder a nossa identidade nacional…
Os custos da doença dos idosos são cada vez mais elevados uma vez que
também são uma percentagem cada vez maior da nossa população.
A prevenção da doença é uma obrigação individual e social de todos os
portugueses, que infelizmente cumprem mal esse seu dever..
O objetivo desta palestra é informar e aconselhar sobre a forma de manter
uma boa qualidade de vida.