Cardiovascular health profile of an adult population from the metropolitan region of São Paulo

Abstracts

OBJETIVO: Descrever o perfil de saúde cardiovascular de uma população adulta da região metropolitana de São Paulo, segundo critérios da Sociedade Européia de Cardiologia (SEC). MÉTODOS: Foram estudados 200 indivíduos, homens e mulheres, voluntários, participantes do projeto "Avaliação Cardiológica" de um ambulatório geral. Foram coletadas informações sobre nível socioeconômico, tabagismo, consumo de álcool, medidas antropométricas, dieta, atividade física, lipídeos séricos, glicemia e pressão arterial. A ingestão média de colesterol dietético e de lipídeos totais foi estimada a partir de recordatórios de 24 horas. Avaliou-se o nível de atividade física por meio da aplicação do Questionário Internacional de Atividade Física (IPAQ-8) e de testes de esforço. RESULTADOS: A amostra foi composta por 61,5% de indivíduos do sexo feminino e 38,5%, do sexo masculino, com idades médias de 41,7 anos (mediana = 42,6) e 41,0 anos (mediana = 43,0). A prevalência de tabagismo (22%) e de consumo diário de álcool (14% dos homens; nenhuma mulher) foi baixa. A prevalência de sobrepeso foi de 47% (12% de obesos), além de níveis séricos elevados de colesterol total (> 190 mg/dl) em 56% dos indivíduos e de LDL-colesterol (> 115 mg/dl) em 61% dos participantes. Os resultados da aplicação do IPAQ-8 mostraram 6% de sedentários. CONCLUSÃO: A população de estudo apresentou maior risco de doenças cardiovasculares, segundo critérios da SEC, especialmente devido à elevada prevalência de indivíduos com sobrepeso e hipercolesterolemia.

Saúde cardiovascular; adultos; fatores de risco

ORIGINAL ARTICLE

Cardiovascular health profile of an adult population from the metropolitan region of São Paulo

Renata Furlan Viebig; Maria Pastor Valero; Fernando Araújo; Alice Tatsuko Yamada; Alfredo José Mansur

Faculdade de Saúde Pública e Instituto do Coração do Hospital das Clínicas da FMUSP - São Paulo, SP - Brazil

^{Mailing Address}

ABSTRACT

OBJECTIVE: To describe the cardiovascular health profile of an adult population from the metropolitan region of São Paulo, according to the European Society of Cardiology (ESC) criteria.

METHODS: Two hundred volunteers of both sexes enrolled in the "Cardiac Evaluation" project of a general outpatient clinic were studied. Data collected included socioeconomic status, cigarette smoking, alcohol consumption, anthropometric measurements, diet, physical activity, serum lipids, blood glucose and blood pressure. Average intake of dietary cholesterol and total lipids was estimated from a 24-hour dietary recall. Physical activity level was assessed using the International Physical Activity Questionnaire (IPAQ-8) and exercise stress tests.

RESULTS: Sample population composition was 61.5% female and 38.5% male, mean age 41.7 (median = 42.6) and 41.0 (median = 43.0%). Prevalence of smoking (22%) and daily alcohol consumption (14% males; no females) was low. The overweight prevalence was 47% (12% being obese), in addition to high levels of serum total cholesterol (> 190 mg/dl) in 56% and LDL-cholesterol (> 115 mg/dl) in 61%. The IPAQ-8 results showed that 6% were sedentary.

CONCLUSION: The study population showed greater risk of cardiovascular diseases, according to ESC criteria, due especially to the high prevalence of overweight and hypercholesterolemia.

Key words: Cardiovascular health, adults, risk factors.

Cardiovascular diseases are the leading cause of morbidity and mortality in Brazil (300.000 deaths/year), accounting for 34% of deaths in the city of São Paulo^1,2.

According to Lotufo^3,4, ischemic heart diseases predo­minate over cerebrovascular diseases in the state of São Paulo, compared with the rest of the country, which may be attributed to urbanization and adoption of Western lifestyles as well as the ethnic composition of São Paulo state population.

During the last decade, epidemiologic studies on risk factors for cardiovascular diseases were performed in metropolitan regions of Brazil^5-10, most of them based on preventive measures proposed by the American Heart Association (AHA) guidelines¹¹. However, there are no references to Brazilian papers based on recommendations made by the European Society of Cardiology (ESC)¹² in 1998, which like as those of AHA's, are based on the control of major known risk factors, such as: smoking, obesity, dyslipidemias, diabetes mellitus, arterial hypertension, poor diet, and physical inactivity.

Analysis of risk factor prevalence in populations using different approaches is an interesting practice that may generate relevant information for the development and reevaluation of national guidelines designed to address the unique characteristics of each population.

The present study corresponds to the secondary purpose of a survey primarily focused on the development of a Food Frequency Questionnaire (FFQ) devised to investigate relationships between nutrition and non-communicable chronic diseases in different adult populations of Brazilian metropolitan regions^13,14. Using the parameters proposed by ESC in 1998, this article reports the results of cardiovascular risk factor profile of subjects with no previous diagnosis of heart disease that live in the metropolitan region of São Paulo.

METHODS

In 2002, a cross-sectional study was conducted in a general outpatient clinic in the city of São Paulo.

The study population was selected among adult subjects who participated in the Cardiac Evaluation cohort first developed at the General Outpatient Clinic in 1997.

The Cardiac Evaluation study is intended to follow up on male and female subjects, age 18 and above, with no cardiac symptoms nor history of heart disease, who visit the General Outpatient Clinic for a check-up and show normal physical and cardiac examinations, such as stress and resting electrocardiogram, chest radiography and echocardiography.

Patients of the General Outpatient Clinic are adults, live in the city of São Paulo and represent a broad range of socioeconomic levels. Most of these patients (42%) are referred by the Hospital das Clínicas of the University of São Paulo (USP); however, about 14% present themselves voluntarily for cardiac evaluation^15,16.

Patients who met the following criteria were included in the study: a) men and women, age 18 and above; b) normal cardiac examination, ECG, chest radiography, exercise stress testing, and echocardiogram.

Patients who met the following criteria were excluded from the study: a) history of cardiovascular disease or cardiac symptoms; b) chronic diseases, such as chronic obstructive pulmonary disease, asthma, hypertension, chronic inflammatory diseases, osteoarticular diseases, diabetes, renal diseases, neoplasias and Chagas' disease; c) fasting plasma glucose > 110 mg/dl measured on two different occasions.

As already stated, this study was part of a survey aiming at the development of a FFQ for the adult population of Brazilian metropolitan regions^13,14. A number of studies have demonstrated that samples comprising 150 to 200 subjects allow the development of tools (FFQ) capable of producing acceptable validity and reproducibility results whenever tested^17-20.

Therefore, in 2002, two hundred subjects of both sexes randomly selected from the Cardiac Evaluation project were invited to participate in this study.

Cardiovascular health profile evaluation

The proposed ESC recommendations¹² are thoroughly described in chart 1. Data on cardiovascular risk factors established by ESC were collected from questionnaires filled out during personal interviews and from clinical data.

Each and every participant completed a standard questionnaire covering socioeconomic status and lifestyle, including schooling, marital status, ethnicity, occupation, family income, smoking, and alcohol consumption.

A 24-hour dietary recall was administered to every subject to gather information on food and beverage consumption within the previous 24 hours. Questions about fruit and vegetable intake were added to the 24-hour dietary recall.

Physical activity level was assessed, using the International Physical Activity Questionnaire (IPAQ-8, short version). IPAQ is a questionnaire proposed by the World Health Organization to assess physical activity worldwide and is currently being used in 12 countries²¹. In Brazil, the IPAQ-8 questionnaire was validated against results derived from a motion sensor, the Computer Science & Applications (CSA), with a Spearman's correlation coefficient of r = 0.69 (p < 0.01)²². This questionnaire includes questions about duration and intensity of physical activity on a "usual" week in occupational, transport, leisure or sports activities.

To assess physical activity level, we analyzed the answers collected from the questionnaire based on ESC recommendations, that is, active individuals are defined as those who get at least 30 minutes of physical activity per day for a minimum of 2 days a week, and sedentary individuals, as those who get less than 30 minutes of physical activity once a week or no physical activity at all.

Clinical data, anthropometric assessment, body mass index (BMI) – In order to determine body mass index (BMI), anthropometric assessment was performed on each subject. Body weight was measured using a digital scale with maximum capacity of 150 kg and 100g tolerance, and height was measured by a portable stadiometer, with the subject standing erect, looking straight ahead and keeping heels together.

Body mass index was calculated from the formula BMI = weight/(height)².

Waist circumference (WC) was measured using a steel tape measure at the narrowest point between the lowest rib and the iliac crest (three measurements on average)²³.

As part of check-up examinations, all participants of the Cardiac Evaluation project had their systemic blood pressure measured, as well as serum lipid and glucose levels.

Physical capacity was also assessed based on exercise stress test results. Exercise capacity can be expressed in multiples of metabolic equivalents - METS, which represent the normal oxygen consumption at rest, defined as 3.5 ml/min/kg of body weight^24,25. In the General Clinic, where the study was conducted, the Ellestad protocol is commonly used for exercise stress testing²⁶.

Exercise stress test results were translated into risk indicators, owing to its prognostic value for the development of cardiovascular diseases For this purpose, the cut-off points proposed by Morris et al ²⁷were used. Accordingly, exercise capacity less than 6 METS reached during the examination indicated high risk for cardiovascular diseases, from 6 to 9.9 METS indicated moderate risk, and 10 METS or greater represented protection.

STATA software (version 6.0) was used to create a database and analyze data²⁸.

First, distribution of all continuous variables was examined to determine whether it followed a Gaussian distribution. Data on socioeconomic variables, such as age, gender, occupation, schooling, income, place of birth, and ethnic group were descriptively analyzed through measures of central tendency and dispersion, such as mean, median, and standard deviation.

Food items collected from the 24-hour dietary recalls were converted into nutrients using the Virtual Nutri software ²⁹ and, later, current average intake of total fats, dietary cholesterol, salt, fruits, vegetables, and fish of the study population was analyzed^13,14.

Finally, as part of the descriptive analysis of the population, Student's t test was used to compare two means for possible gender-related differences regarding main cardiovascular risk factors, such as BMI, lipid profile, blood glucose and blood pressure, as well as total fat, salt, and dietary cholesterol intake, at a 5% significance level.

Associations between BMI and clinical and laboratory examination results, fat and cholesterol intake plus physical activity were studied using the X² test for association (chi-square) at a 5% significance level. Associations between smoking and alcohol consumption and lipid profile were also analyzed.

RESULTS

Although two hundred volunteers participated in this study, six (3%) patients who had undergone neither exercise stress test nor lipid profile and blood glucose measurements were excluded from the statistical analyses involving these variables.

Study sample comprised 123 (61.5%) female and 77 (38.5%) male subjects, mean age 41.7 (median = 42.6) and 41.0 (median = 43.0), respectively. The population studied was predominantly white (75%), with a small percentage of blacks (4.5%) and Asians (3.5%). Approximately 37.5% were high school graduates or had some college education (12 or more years of schooling). Approximately 75% of the men and 52% of the women were active workers.

Table 1, based on ESC recommendations, shows cardiovascular health indicators distribution in the population studied according to gender.

Thirty percent of the men and 17% of the women were current smokers (p = 0.034), while 21% of both genders were former smokers. More than half of the participants, 49% of the men and 62% of the women, had never smoked. A statistically significant increase in smoking prevalence among older subjects was observed (chi-square test = 10.8; p = 0.013), and the majority of smokers (34%) were in the age group at greatest cardiovascular risk, between 50 and 65 years of age.

Most participants reported not drinking alcohol on a regular basis: about 41% of the men drank once or twice a week, and 58% of the women, only on special occasions.

Overall, our study population showed a high degree of overweight (BMI = 25-29.9 kg/m²) and obesity (BMI > 30.0 kg/m²), which increased with age group (p = 0.011) and was most prevalent in the 40-49 and 50-65 age groups. Mean BMI for men was 25.0 kg/m² (median = 24.2) and for women, 25.4 kg/m² (median = 24.8). BMI was not associated with either gender or socioeconomic levels. Table 2 shows BMI mean, median, plus minimum and maximum values, according to the different age groups of the study population.

Average intake of total fats (around 30% of all energy expended) and dietary cholesterol (236 mg for men and 183.9 mg for women) was within the parameters recommended by ESC. Forty per cent of the study population exceeded the daily limit of salt intake, mostly men (p = 0.011). Only 49% were getting the right amount of fruits and vegetables in their daily diets, but no participant was getting the right amount of fish.

As far as laboratory results are concerned, it was found that 67.6% of the men had serum total cholesterol greater than 190 mg/dL, associated with smoking (p = 0.035), and that cholesterol levels rose with increase in age group (p = 0.002) and BMI (p = 0.013).

The European Society of Cardiology (1998) also proposes that LDL-cholesterol levels equal to or greater than 115 mg/dL may increase cardiovascular risk. In our study population, mean LDL-cholesterol levels were 130.6 mg/dL for men and 127.5 mg/dL for women, and no statistically significant differences were found between genders (p = 0.554).

A statistically significant inverse association was detected between HDL-cholesterol levels greater than 40 mg/dL and BMI (p < 0.001). Serum HDL-cholesterol levels less than 40 mg/dL were significantly associated with smoking (p = 0.009) and with low exercise capacity measured by exercise stress test (p = 0.008).

Physical activity analysis, based on the answers to the IPAQ-8 questionnaire, showed that only 4.5% of the men and 6.5% of the women could be considered sedentary, that is, 95.5% of the men and 93.5% of the women were engaged in some protective activity according to ESC criteria (less than 5 days a week for less than 30 minutes).

With regard to exercise stress tests, mean exercise capacity was 10.0 METS (median = 11.2) for men and 9.1 METS (median = 9.02) for women, a statistically significant difference between means of the genders (p = 0.008).

It was noted that 60.8% of the men and 45% of the women had exercise capacity equal to or greater than 10 METS (Table 3), indicating some protection against cardiovascular diseases; no statistically significant differences were found between genders (p = 0.092), only among age groups (p = 0.011).

DISCUSSION

Distribution by age and ethnic group in our population was very similar to the reality of the city of São Paulo, according to data from the most recent census carried out by IBGE, the Brazilian Institute of Geography and Statistics³⁰. However, socioeconomic level and schooling were slightly higher than those reported by IBGE³⁰.

Patients in our study were randomly selected among those who presented themselves voluntarily to the General Outpatient Clinic to participate in the cardiac check-up program. The voluntary nature of study participation may explain the number of women and the socioeconomic level being higher than those reported by IBGE³⁰, because people concerned about their health and who choose to have a check-up are often women with higher cultural and socioeconomic status and broader access to information.

Female predominance may also be due to the fact that 48% of the study participants were not active workers, but homemakers (17%), unemployed (25%) and retired (6%), unlike most of male subjects (75%), who were active workers. This same predominance was observed in other studies conducted at the Incor General Outpatient Clinic, such as that by Yamada et al¹⁶, in which prevalence was 56% women and 44% men. Araújo et al³¹, in a more recent study conducted at the Incor General Outpatient Clinic, also found a prevalence of women over men, 57% and 43%, respectively.

Overall, the smoking rate in our population (22%) was lower than that found in other studies performed in Brazilian urban areas, such as those by Cardoso et al⁷, Neumann³² and Nogueira et al³³, with rates of 35%, 27% and 38%, respectively.

Our population consisted of subjects who went to a medical center because they wanted to undergo a preventive cardiac evaluation and, therefore, may be more health-concious; hence, the smal number of smokers. This phenomenon is known in epidemiology as the Healthy Effect of volunteers.

The European Society of Cardiology recommends that alcohol consumption does not exceed 30g/day for men and 20g/day for women. One of the limitations of our study, however, was the inability to quantify alcohol consumption, since only weekly alcohol intake was assessed due to the nutritional assessment tool used, the 24-hour dietary recall. Therefor, although daily alcohol use was reported by 14% of the participants, all of them males, alcohol intake in our population may have been underestimated. Nevertheless, despite this limitation regarding alcohol consumption frequency, our results were similar to those found in a study performed in the city of Porto Alegre, in which 14% of the men and women were daily alcohol users¹⁰.

The majority of the study population showed BMI and waist circumference levels above those recommended by ESC. Overweight and obesity are a growing problem throughout the Western world and already a reality in Brazil^34,35. In 1997, obesity rates in this country, according to nutritional investigations, were 8.0% for men and 12.4% for women in the Southeast and 4.7% for men and 12.3% for women in the Northeast.³⁴

Overweight prevalence in Brazil, defined as BMI > 25 kg/m², for the year 2000 was estimated at 47.4% for men and 44.2% for women; for 2005, it was anticipated that 57.5% of the men and 44.9% of the women would have some degree of overweight or obesity³⁵. Our findings seem to corroborate these estimates, and they are higher than rates of overweight and obesity observed in Brazilian metropolitan areas by authors such as Neumann³² and Cardoso et al⁷, of 35% and 39%, respectively.

In a study conducted with Petrobras employees in 2004, Rio de Janeiro, Matos et al³⁶ found total cholesterol levels higher than normal (borderline high and high) in 56.6% of the subjects, 19.3% exceeding 240 mg/dL. With respect to lipid profile, more than half of study subjects showed serum total cholesterol and LDL-cholesterol levels higher than those recommended by ESC, and a statistically significant association was found with other cardiovascular risk factors, such as BMI and smoking. These results are similar to those found by Matos et al³⁶ and higher than those found in other studies performed in Brazilian urban areas.^5,10,32,33 However, the majority of our population showed HDL-cholesterol levels within those recommended by ESC as protective, as well as others found in Rio de Janeiro.³⁶

In our population, prevalence of hypertriglyceridemia, hyperglycemia and hypertension was lower than that observed in other studies conducted in Brazilian cities^5,9,10,32,33. It should be kept in mind that among exclusion criteria were subjects previously diagnosed with diabetes and hypertension, which may explain this low prevalence.

As for physical activity, 8.7% of our population was classified as sedentary, according to the IPAQ results, a much lower rate than that found in a study performed with adults from the São Paulo metropolitan region. Using a five-item questionnaire, this study found 39% of the people physically inactive³⁷. Another study found a 60% sedentary prevalence among employees of a state bank in the City of Rio de Janeiro, using another questionnaire and defining as cut-off point for sedentarism less than 20 minutes of physical activity and less than 2 times per week.³⁸

In a study performed in the northeastern and sou­theastern regions of Brazil, using a six-item questionnaire, only 3.5% of individuals from the Southeast met the recommended minimum of 30 minutes of physical activity at least 5 days a week between 1996-1997.³⁹ Around 64.8% of participants were considered sedentary. As this study took into account only sports and recreational activities performed during leisure time, the number of inactive people may have been overestimated by up to 20%³⁹.

In our study, the IPAQ-8 elicited information on occupational and household activities, which were used for classifying the level of physical activity. Some male participants said that their jobs involved high-energy expenditure (mechanics, bricklayers), and 17% of the interviewed women were "homemakers" and did domestic services daily.

When comparing our findings with those of a recent study performed to assess physical activity level of subjects from 29 cities of São Paulo State⁴⁰ using the IPAQ-8, we observed that sedentary prevalence was even lower than the approximate 6% found in our study conducted in the São Paulo metropolitan region, using the same cut-off points²¹.

Based on the exercise stress test results, it was found that exercise capacity of 39% of the men and 55% of the women was less than 6 METS, which points to a sedentary or high cardiovascular risk population. These findings were a surprise to the authors of this study, since they highly disagreed with those reflected by the IPAQ-8, in which only 8.7% of subjects were classified as sedentary, that is, 79.4% were physically active and were protected against cardiovascular diseases, contrary to these exercise test results.

This study was not designed to develop a predictive model of cardiovascular risk and, therefore, its findings are essentially exploratory. However, they suggest that part of the population studied are at high risk for developing cardiovascular diseases, particularly due to the high BMI, serum total cholesterol and LDL-cholesterol levels.

No potential conflict of interest relevant to this article was reported.

REFERENCES

Received on 11/28/04

Accepted on 04/13/05

• 1. Brasil.Ministério da Saúde. Indicadores de mortalidade por doenças circulatórias.[on-line].Brasilia:MS;2001.[cited 2001 Nov 20].Available from:http://www.saude.gov.br
• 2. Secretaria de Estado de Saúde de São Paulo - Grupo Técnico de Informações de Saúde. Mortalidade do município de São Paulo, 2000. [on-line] São Paulo:SES/SP; 2000.[cited 2001 Nov 20].Available from: http://www.saude.sp.gov.br
• 3. Lotufo PA. A mortalidade precoce por doenças crônicas em capitais de áreas metropolitanas do Brasil. [tese de doutorado]. São Paulo: Faculdade de Saúde Pública Universidade de São Paulo; 1996.
• 4. Lotufo PA. As doenças cardiovasculares no Brasil: estudo de caso da tendência da mortalidade no Estado de São Paulo 1970-1989.[dissertação]. São Paulo: Faculdade de Saúde Pública-Universidade de São Paulo; 1993.
• 5. Barreto SM, Passos VM, Firmo JO, Guerra HL, Vidigal PG, Lima-Costa MF. Hypertension and clustering of cardiovascular risk factors in a community in Southeast Brazil The Bambui Health and Ageing Study. Arq Bras Cardiol 2001;77:576-81.
• 6. Bertolami MC, Faludi AA, Latorre MR, Zaidan Filho T. Lipid profile of metallurgic industry and its relationship with other risks factors. Arq Bras Cardiol 1993;60:293-9.
• 7. Cardoso E, Martins IS, Fornari L, Monachini ME, Mansur AP, Caramelli B. Eletrocardiographic abnormalities and cardiovascular risks factors for ischemic heart disease in na adult population from São Paulo, Brazil. Rev Assoc Med Bras 2002;48:231-6.
• 8. Guedes DP, Guedes ERP. Atividade física, aptidão cardiorrespiratória, composição da dieta e fatores de risco predisponentes às doenças cardiovasculares. Arq Bras Cardiol 2001; 77:243-50.
• 9. Freitas OC, Carvalho FR, Neves JM, Veludo PK, Parreira RS, Gonçalves RM, et al.. Prevalence of hypertension in the urban population of Catanduva, in the State of São Paulo, Brazil. Arq Bras Cardiol 2001;77: 16-21.
• 10. Gus I, Fishman A, Medina C. Prevalência dos fatores de risco da doença arterial coronariana no Estado do Rio Grande do Sul. Arq Bras Cardiol 2002;78:478-83.
• 11. Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP, et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. Circulation 2002;106:388-91.
• 12. European Society of Cardiology ESC. Prevention of coronary heart disease in clinical practice. Eur Heart J 1998; 19: 1434-503.
• 13. Viebig RF. Desenho de um Questionário de Freqüência Alimentar para a população da região metropolitana de São Paulo. [tese de doutorado]. São Paulo: Faculdade de Saúde Pública da Universidade de São Paulo; 2002.
• 14. Furlan-Viebig R, Pastor-Valero M. Development of a food frequency questionnaire to study diet and non-communicable diseases in adult population. Rev Saúde Pública, 2004; 38:581-4.
• 15. Malerbi MCM, Margarido ES, Mansur AJ, da Luz PL, Bellotti G. Expectativa de pacientes que procuram atendimento ambulatorial em hospital de cardiologia. Rev Hosp Clin Fac Med S Paulo 1993;48:186-8.
• 16. Yamada AT, Mansur AJ, Chizzola PR, Atendimento cardiológico ambulatorial: comparação entre pacientes atendidos em hospital de referência e em centro de saúde comunitário. Arq Bras Cardiol 1990;55:181-7.
• 17. Willett WC, Sampson MJ, Stampfer BR, Rosner B, Bain C, Witschi J, et al. Reproducibility and validity of a semiquantitative food frequency questionnaire. Am J Epidemiol .1985;122:51-65.
• 18. Willett WC. Nutritional Epidemiology. 2^nd ed. New York: Oxford University Press; 1998.
• 19. Tucker KL, Bianchi LA, Maras J, Bermudez OI. Adaptation of a Food Frequency Questionnaire to assess diets of Puerto Rican and Non-Hispanic adults. Am J Epidemiol 1998;148:507-18.
• 20. Martin-Moreno JM, Boyle P, Gorgojo L, Maisonneuse P, Fernandez-Rodriguez JC, Salvini S, et al. Development and validation of a food frequency questionnaire in Spain. Int J Epidemiol 1993;22:512-9.
• 21. Marshall A, Baumann A. The internacional physical activity questionnaire summary report of the reliability and validity studies. Document of IPAQ Excecutive Commite, World Heath Organization, 2001.
• 22. Matsudo S, Araujo T, Matsudo V. Questionário Internacional de Atividade Física (IPAQ): estudo de validade e reprodutibilidade no Brasil. Rev Bras Ativ Fis e Saúde. 2001; 6:5-18.
• 23. Lahti-Koski M, Pietinen P, Männistö S, Vartiainen E. Trends in waist-to-hip and its determinants in adults in Finland from 1987 to 1997. Am J Clin Nutr. 2000;72:1436-44.
• 24. Andrade J, Brito FS, Vilas-Boas F. II Diretrizes da Sociedade Brasileira de Cardiologia Sobre Teste Ergométrico. Arq Bras Cardiol. 2002;78(supl 2):1-17.
• 25. Cesar LAM, Mansur AP, Armaganijan D, et al. Diretrizes de doença coronariana crônica angina estável. Arq Bras Cardiol 2004;83(supl 2):2-43.
• 26. Ellestad MH, Wang MK. Predictive implications of stress testing: follow up of 2700 subjects after maximum treadmill stress testing. Circulation 1975;51:363-9.
• 27. Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF. The prognostic value of exercise capacity: A review of the literature. Am Heart J. 1991;122:1423-31.
• 28. Stata Corp. Stata statistical software: release 5.0. College Station, TX: Stata Corporation, 1997.
• 29. Philippi ST, Szarfarc SC, Laterzza AR.Virtual Nutri (software) versão 1.0, for Windows. Departamento de Nutrição da Faculdade de Saúde Pública USP. São Paulo, 1996.
• 30. Instituto Brasileiro de Geografia e Estatística - Censo Demográfico 2000 Resultados do Universo.[on-line].Brasilia:IBGE;2001. [cited 2002 Oct]. Available from: <http://www.ibge.gov.br/home/estatistica/populacao/censo2000>
• 31. Araujo F, Pereira AC, Latorre MRDO, Krieger JE, Mansur AJ. High-sensitivity C-Reactive Protein concentration in a healthy Brazilian population. Int J Cardiol. 2004;97: 433-8.
• 32. Neumann AICP. Consumo de alimentos de risco e proteção para doenças cardiovasculares entre funcionários públicos estaduais do município de São Paulo. [dissertação]. São Paulo: Faculdade de Saúde Pública. Universidade de São Paulo; 2000.
• 33. Nogueira AR, Alves PM, Miranda RF, Boechat NL. Cholesterol and other cardiovascular risk factors among employees of the Universidade Federal do Rio de Janeiro: prevalence and influence of social variables. Arq Bras Cardiol. 1990;55:227-32.
• 34. Monteiro CA, Conde WL. Evolução da obesidade nos anos 90: a trajetória da enfermidade segundo estratos sociais no Nordeste e Sudeste do Brasil. In: Velhos e Novos Males da Saúde no Brasil 2Ş ed. São Paulo: HUCITEC; 2000.p.421-30
• 35. Conde WL, Levy-Costa RL, Monteiro CA. Quantas pessoas têm excesso de peso? Estudos Epidemiológicos em obesidade no Brasil. In: Halpern A, Macini MC. Manual de Obesidade para o Clínico. São Paulo: Ed. Roca; 2002.
• 36. Matos MFD, Silva NAS, Pimenta AJM, Cunha AJ. Prevalência dos fatores de risco para doença cardiovascular em funcionários do Centro de Pesquisas da Petrobrás. Arq Bras Cardiol. 2004;82:1-4.
• 37. Cervato AM, Mazzilli RN, Martins IS, Marucci MF. Dieta habitual e fatores de risco para doenças cardiovasculares. Rev Saúde Pública. 1997;31:227-35.
• 38. Chor D. Perfil de risco cardiovascular de funcionários de banco estatal. [tese de doutorado]. São Paulo: Faculdade de Saúde Pública. Universidade de São Paulo; 1997.
• 39. Monteiro CA, Conde WL, Matsudo SM, Matsudo VR, Bonsenor IM, Lotufo PA. A descriptive epidemiology of leisure-time physical activity in Brazil, 1996-1997. Rev Panam Salud Publica. 2003;14:246-54.
• 40. Matsudo SM, Matsudo VR, Araujo T. Nível de atividade física da população do Estado de São Paulo: análise de acordo com o gênero, idade, nível socioeconômico, distribuição geográfica e de conhecimento. Rev Bras Cien Mov. 2002;10:41-50.

Publication Dates

• Publication in this collection
  29 May 2006
• Date of issue
  May 2006

History

• Accepted
  13 Apr 2005
• Received
  28 Nov 2004