Poor Trunk Flexibility is Associated with Cardiovascular Risk Factors

Rafael Felipe Cardoso Maria Sebastiana Silva Cristiane Cominetti Maria Margareth V. Naves About the authors

Abstract

Background:

Poor flexibility is a predictor of reduced physical activity. The association between trunk flexibility and cardiovascular risk factors (CVRFs) is not well understood.

Objective:

To identify the prevalence of CVRFs and their association with trunk flexibility in individuals participating in a community-based health education program.

Methods:

Volunteers (51 men, 48 women) aged 20-85 years old, participants in a community-based health education program in the city of Santo Antônio de Goiás, Brazil, were selected for this study. Anthropometric measures including body mass, height, body mass index (BMI), waist circumference (WC) and waist/height ratio (WHtR) were evaluated. Physical activity level was evaluated based on leisure activity participation, and trunk flexibility was evaluated by the sit and reach test. Data distribution was assessed using the Shapiro-Wilk test; Pearson's chi-square or Fisher's exact and Student t tests were performed for comparisons. To analyze the association between trunk flexibility and concomitant CVRFs, Spearman’s correlation test and linear regression were employed. Statistical significance was defined as p < 0.05.

Results:

7.2% of the volunteers had no CVRF, 10.3% had only one CVRF and 82.5% had two or more CVRFs, with no differences between sexes. Increased abdominal adiposity, as assessed by WHtR (p = 0.0097), and systemic arterial hypertension (p = 0.0003) were the most prevalent CVRFs, with differences between age groups. A strong negative correlation was found between mean trunk flexibility and the number of concomitant CVRFs (r = -0.96, p < 0.0028).

Conclusion:

The strong negative correlation between trunk flexibility and concomitant CVRF indicates an increased risk for cardiovascular events. Therefore, trunk flexibility measurement may be an additional tool for health promotion and prevention of cardiovascular and associated diseases in community health programs.

Keywords:
Cardiovascular Diseases; Risk Factors; Abdominal Adiposity; Flexibility; Waist Height Ratio

Introduction

Cardiovascular diseases (CVDs) are the leading cause of death in the world,11 Nascimento BR, Brant LCC, Oliveira GMM, Malachias MVB, Reis GMA, Teixeira RA, et al. Cardiovascular disease epidemiology in portuguese-speaking countries: data from the Global Burden of Disease, 1990 to 2016. Arq Bras Cardiol. 2018;110(6):500-11. doi:10.5935/abc.20180098.
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accounting for 18 million deaths in 2016.22 World Health Organization.(WHO). World health statistics 2018: monitoring health for The Sdgs, sustainable development goals. Geneva; 2018. In Brazil, CVDs cause 31% of deaths,33 Brasil. Ministério da Saúde. Vigitel Brasil 2016: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Vigitel. Brasilia; 2017. and have been considered the main cause of mortality since the 1960s.44 Ribeiro ALP, Duncan BB, Brant LCC, Lotufo PA, Mill JG, Barreto SM. Cardiovascular health in Brazil. Circulatiom. 2016;133(4):422-33. doi:10.1161/CIRCULATIONAHA.114.008727.
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, 55 Petribú MMV, Cabral PC, Arruda IKG. Estado nutricional, consumo alimentar e risco cardiovascular: um estudo em universitários. Rev Nutr. 2009;22(6):837-46. doi:10.1590/S1415-52732009000600005.
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The cardiovascular risk factors (CVRFs) with the greatest impact on the development of CVDs are obesity, systemic arterial hypertension, insufficient physical activity, smoking and unhealthy diet.66 World Health Organization. (WHO) Noncommunicable diseases progress monitor. Geneva; 2017. doi:10.2766/120051.
https://doi.org/10.2766/120051...
Central obesity or abdominal adiposity is one of the most studied CVRFs because it is directly related to hypertension, stroke and myocardial ischemia.77 Brown RE, Randhawa AK, Canning KL, Fung M, Jiandani D, Wharton S, et al. Waist circumference at five common measurement sites in normal weight and overweight adults: which site is most optimal? Clin Obes. 2018;8(1):21-9. doi:10.1111/cob.12231.
https://doi.org/10.1111/cob.12231...

Abdominal adiposity can be easily determined by simple anthropometric measures that are as efficient as the most sophisticated and costly devices.88 Barreira T V., Staiano AE, Harrington DM, Heymsfield SB, Smith SR, Bouchard C, et al. Anthropometric correlates of total body fat, abdominal adiposity, and cardiovascular disease risk factors in a biracial sample of men and women. Mayo Clin Proc. 2012;87(5):452-60. doi:10.1016/j.mayocp.2011.12.017.
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Waist circumference (WC) measurement is easily applicable and widely recognized as a reliable tool for estimating abdominal adiposity and predicting risks for chronic non-communicable diseases.77 Brown RE, Randhawa AK, Canning KL, Fung M, Jiandani D, Wharton S, et al. Waist circumference at five common measurement sites in normal weight and overweight adults: which site is most optimal? Clin Obes. 2018;8(1):21-9. doi:10.1111/cob.12231.
https://doi.org/10.1111/cob.12231...
The waist-to-height ratio (WHtR) is less widely known in public health, but also a reliable anthropometric measure in the identification of CVRFs when associated with other anthropometric parameters, such as body mass index (BMI).99 Corrêa MM, Tomasi E, Thumé E, Oliveira ERA, Facchini LA. Razão cintura-estatura como marcador antropométrico de excesso de peso em idosos brasileiros. Cad Saude Publica. 2017;33(5):3-14. doi:10.1590/0102-311x00195315.
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, 1010 Ashwell M, Hsieh SD. Six reasons why the waist-to-height ratio is a rapid and effective global indicator for health risks of obesity and how its use could simplify the international public health message on obesity. Int J Food Sci Nutr. 2005;56(5):303-7. doi:10.1080/09637480500195066.
https://doi.org/10.1080/0963748050019506...

Increased abdominal adiposity and obesity are associated with various metabolic disturbances, such as type 2 diabetes, insulin resistance, hyperlipidemia, and high blood pressure,1111 Robson EM, Costa S, Hamer M, Johnson W. Life course factors associated with metabolically healthy obesity: a protocol for the systematic review of longitudinal studies. Syst Rev. 2018;7(1):1-6. doi:10.1186/s13643-018-0713-x.
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12 Winter M, Rioux B V, Boudreau JG, Bouchard DR, Sénéchal M. Physical activity and sedentary patterns among metabolically healthy individuals living with obesity. J Diabetes Res. 2018;2018:1-8. doi:10.1155/2018/7496768.
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- 1313 Hruby A, Manson JAE, Qi L, Malik VS, Rimm EB, Sun Q, et al. Determinants and consequences of obesity. Am J Public Health. 2016;106(9):1656-62. doi:10.2105/AJPH.2016.303326.
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and can negatively affect the individuals’ physical fitness, including a reduced flexibility. This term is defined as the physical capacity to perform movements with adequate amplitude without risk of injury.1414 Achour JA. Alongamento e flexibilidade: definições e contraposições. Rev Bras Ativ Fís e Saúde. 2007;12(1):54-8.

15 Almeida TT, Amorim TP, Sousa FM, Augusto J. Mitos e verdades sobre flexibilidade: reflexões sobre o treinamento de flexibilidade na saúde dos seres humanos. Motriz Rev Educ Física. 2007;3(1):337-44.
- 1616 Dantas EHM. Alongamento & flexionamento. Rio de Janeiro: Shape; 2005. In the last 20 years, flexibility has gained special attention because health care institutions, such as the American College of Sports Medicine (ACSM) and the American Heart Association (AHA), started recommending flexibility training for all populations.1717 Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1094-105. doi:10.1161/ CIRCULATIONAHA.107.185650.
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, 1818 Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423-34. doi:10.1249/mss.0b013e3180616b27.
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Poor trunk flexibility seems to be related to arterial stiffness,1919 Nishiwaki M, Yonemura H, Kurobe K, Matsumoto N. Four weeks of regular static stretching reduces arterial stiffness in middle-aged men. Springerplus. 2015;4(1):555. doi:10.1186/s40064-015-1337-4.
https://doi.org/10.1186/s40064-015-1337-...
, 2020 Yamamoto K, Kawano H, Gando Y, Iemitsu M, Murakami H, Sanada K, et al. Poor trunk flexibility is associated with arterial stiffening. Am J Physiol Circ Physiol. 2009;297(4):H1314-H1318. doi:10.1152/ajpheart.00061.2009.
https://doi.org/10.1152/ajpheart.00061.2...
which is present in obesity2121 Wong A, Figueroa A. Eight weeks of stretching training reduces aortic wave reflection magnitude and blood pressure in obese postmenopausal women. J Hum Hypertens. 2014;28:246-50. doi:10.1038/jhh.2013.98.
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and CVDs,2222 Alvim RO, Santos PCJL, Bortolotto LA, Mill JG, Pereira AC. Arterial stiffness: pathophysiological and genetic aspects. Int J Cardiovasc Sci. 2017;30(5):433-41. doi:10.5935/2359-4802.20170053.
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and is a predictor of cardiovascular events.2323 Logan JG, Kim S, Lee M, Byon H Do, Yeo S. Effects of static stretching exercise on lumbar flexibility and central arterial stiffness. J Cardiovasc Nurs. 2018;33(4):322-8. doi:10.1097/JCN.0000000000000460.
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, 2424 Mitchell GF, Hwang S, Vasan RS, Larson MG, Pencina MJ, Hamburg NM, et al. Arterial stiffness and cardiovascular events. Circulation. 2010;121(4):505-11. doi:10.1161/CIRCULATIONAHA.109.886655
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In addition, some diseases in the spinal column, for example, increase the risk for CVDs due to the physical inactivity associated with the disease.2525 Niedermann K, Sidelnikov E, Muggli C, Dagfinrud H, Hermann M, Tamborrini G, et al. Effect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitis. Arthritis Care Res. 2013;65(11):1844-52. doi:10.1002/acr.22062.
https://doi.org/10.1002/acr.22062...
Increased flexibility has been shown to improve the physical function of people with these conditions.2121 Wong A, Figueroa A. Eight weeks of stretching training reduces aortic wave reflection magnitude and blood pressure in obese postmenopausal women. J Hum Hypertens. 2014;28:246-50. doi:10.1038/jhh.2013.98.
https://doi.org/10.1038/jhh.2013.98...
, 2525 Niedermann K, Sidelnikov E, Muggli C, Dagfinrud H, Hermann M, Tamborrini G, et al. Effect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitis. Arthritis Care Res. 2013;65(11):1844-52. doi:10.1002/acr.22062.
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, 2626 Sveaas SH, Berg IJ, Provan SA, Semb AG, Hagen KB, Vøllestad N, et al. Efficacy of high intensity exercise on disease activity and cardiovascular risk in active axial spondyloarthritis: A randomized controlled pilot study. PLoS One. 2014;9(9). doi:10.1371/journal.pone.0108688.
https://doi.org/10.1371/journal.pone.010...
Nevertheless, studies on the association between trunk flexibility and CVRFs, as abdominal adiposity and obesity, are scarce in the literature. Thus, the aim of our study was to identify the prevalence of CVRFs and to investigate the association between trunk flexibility and CVRFs in individuals participating in a community-based health education program.

Methods

Study design and sample

This was a cross-sectional study, carried out with a convenience sample composed of 99 individuals (51 men and 48 women), aged between 20 and 85 years (47.5 ± 13.9 years; mean ± standard deviation [SD]), living in Santo Antônio de Goiás, GO, Brazil. Participants were recruited during two events of a community-based health education program – “Pink October” and “Blue November” ( Figure 1 ). All data were collected at the event site, including the administration of a sociodemographic interview to each participant.

Figure 1
Flowchart of participants’ recruitment. Volunteers participating in the health education events “Pink October” and “Blue November” in Santo Antônio de Goiás city, GO, Brazil

Anthropometric evaluation

The anthropometric measures included body mass (BM), height (H), BMI, WC and WHtR. All measurements were collected according to standardized procedures.2727 Heyward VH. Avaliação física e prescrição de exercício: técnicas avançadas. 4th ed. Porto Alegre: ArtMed; 2004.

BMI was calculated by dividing BM (kg) by squared H (m), according to the equation: BMI (kg/m2) = BM (kg) / H2 (m), and classified according to the cut-off points proposed by the World Health Organization.2828 World Health Organization.(WHO). Obesity: preventing and managing the global epidemic. Geneva; 2000.

WC (cm) was measured using a body measure tape (Sanny®, São Bernardo do Campo, Brazil) placed at the midpoint between the last lower rib and the iliac crest, to estimate abdominal adiposity and cardiovascular risk.2727 Heyward VH. Avaliação física e prescrição de exercício: técnicas avançadas. 4th ed. Porto Alegre: ArtMed; 2004. Lean et al.2929 Lean MEJ, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. BMJ.1995;311(6998):158. doi:10.1136/bmj.311.6998.158.
https://doi.org/10.1136/bmj.311.6998.158...
proposed the use of WC as an indicator of cardiovascular risk, and respective cut-offs: men > 94 cm and women > 80 cm. From WC and H measurements, the WHtR was determined: WHtR = WC (cm) / H (m) and the cut-offs for cardiovascular risk was > 0.50 for adult and elderly men and women.99 Corrêa MM, Tomasi E, Thumé E, Oliveira ERA, Facchini LA. Razão cintura-estatura como marcador antropométrico de excesso de peso em idosos brasileiros. Cad Saude Publica. 2017;33(5):3-14. doi:10.1590/0102-311x00195315.
https://doi.org/10.1590/0102-311x0019531...
, 1010 Ashwell M, Hsieh SD. Six reasons why the waist-to-height ratio is a rapid and effective global indicator for health risks of obesity and how its use could simplify the international public health message on obesity. Int J Food Sci Nutr. 2005;56(5):303-7. doi:10.1080/09637480500195066.
https://doi.org/10.1080/0963748050019506...

Assessment of physical activity level

Physical activity level was assessed from data on leisure-time activity. Individuals who practiced at least 30 minutes of mild or moderate physical activity on five or more days during the week, or at least 20 minutes of vigorous physical activity on three or more days during the week were classified as sufficiently active. Those who did not reach these values were classified as insufficiently physically active.3030 World Health Organization.(WHO). Global recommendations on physical activity for health.Geneva; 2010. doi:10.1080/11026480410034349.
https://doi.org/10.1080/1102648041003434...
, 3131 Brasil. Ministério da Saúde. VIGITEL BRASIL 2009: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Vigitel. Brasilia; 2010. p.150.

Blood pressure measurement

A digital blood pressure measuring device (G-Tech model MA100, Duque de Caxias – Brazil) was used for the measurements. Systolic and diastolic blood pressures were measured twice; the first measurement was taken after a resting period of at least five minutes, followed by the second measurement two minutes later. The second measurement was considered for analysis. The cutoff point for systemic arterial hypertension was a systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, as recommended by the 7th Brazilian Guidelines of Arterial Hypertension.3232 Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Sociedade Brasileira de Cardiologia. 7a Diretriz Brasileira de hipertensão arterial. Arq Bras Cardiol. 2016;107:1-103. doi:10.5935/abc.2013S010.
https://doi.org/10.5935/abc.2013S010...

Assessment of trunk flexibility

Trunk flexibility was measured using the sit and reach test using a sit-and-reach box (Sanny®, São Bernardo do Campo, Brazil). The subject was instructed to sit on a mat, without shoes and with knees extended. Then, with one hand on top of the other, the volunteer flexed the trunk and reached forward along the measuring line as far as possible. Values were expressed in centimeters and the best of three attempts was included in the analysis.3333 Wells KF, Dillon EK. The sit and reach—a test of back and leg flexibility. Res Quart. 1952; 23(1):115-8. doi:10.1080/10671188.1952.10761965.
https://doi.org/10.1080/10671188.1952.10...
Trunk flexibility was classified as “excellent”, “above mean”, “mean”, “below mean” and “poor”, by sex and age group, according to the Canadian Standardized Test of Fitness.3434 Fitness Canada. Canadian Standardized Test of Fitness (CSTF): Operations Manual. 3rd ed. Ottawa: Fitness and Amateur Sport; 1986.

Concomitant cardiovascular risk factors

The prevalence of single and concomitant (grouped) risk factors was determined.3535 Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de fatores de risco cardiovascular em idosos usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol. 2010;95(5):621-8. doi:10.1590/S0066-782X2010005000141.
https://doi.org/10.1590/S0066-782X201000...

Statistical analysis

Categorical variables (CVRFs and classification of trunk flexibility) were presented as absolute and relative frequencies. The risk factors evaluated were obesity, abdominal adiposity (WC and WHtR), insufficient physical activity, hypertension and smoking. Pearson's chi-square test or Fisher's exact test were performed to compare the prevalence of risk factors between the age groups (20-39, 40-59 and 60+ years). Continuous variables were subjected to descriptive analysis and the Shapiro-Wilk test was applied to verify data distribution. Data were presented as mean ± standard deviation (SD) when normally distributed, and as median (interquartile range) when not normally distributed. Trunk flexibility between individuals with and without CVRF was analyzed by the Student’s t -test for unpaired samples. Spearman’s correlation test was carried out to evaluate the correlation between the number of concomitant CVRFs (discrete quantitative variable) and mean trunk flexibility, followed by linear regression analysis (the necessary assumptions were verified and met).

Statistical analysis was performed using the R software version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria)3636 R Core Team (2020). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna,(Austria) URL https://www.R-project.org/.
https://www.R-project.org/...
. Statistical significance was defined as p < 0.05.

Results

Anthropometry, trunk flexibility and blood pressure

The sample comprised 99 volunteers, with the following characteristics: BM = 71.5 (62.2 – 83.2) kg; H = 1.62 ± 0.08 m; BMI = 27.0 (24.1 – 30.1) kg/m²; WC = 91.3 ± 13.0 cm; WHtR = 0.56 ± 0.08; trunk flexibility = 22.7 ± 9.4 cm; systolic blood pressure = 129.6 ± 19.2 mmHg and diastolic blood pressure = 81.6 ± 11.6 mmHg.

Prevalence of cardiovascular risk factors by age group

Among the volunteers, 7.2% featured no CVRF, 10.3% presented only one CVRF and 82.5% showed two or more CVRFs, with no statistical difference between sexes. Increased abdominal adiposity, as assessed by WHtR (p = 0.0097), and systemic arterial hypertension (p = 0.0003) were the most prevalent CVRFs in the sample, especially in the group aged from 40 to 59 years ( Table 1 ).

Table 1
Prevalence of cardiovascular risk factors in participants of a community-based health education program in the city of Santo Antúnio de Goiás, Brazil, by age group

Classification of trunk flexibility and its relation to CVRFs

According to the classification of trunk flexibility ( Table 2 ), 21.7% of the volunteers showed below mean flexibility, and 43.5% had poor flexibility. In the analysis of trunk flexibility according to the presence or absence of CVRF, individuals without CVRF showed significantly higher flexibility as compared with those with elevated WC (p = 0.0001) and WHtR (p = 0.0001) ( Figure 2 ). There was a strong negative correlation between mean trunk flexibility and concomitant CVRFs (r = -0.96, p < 0.0028). The adjustment of the original values by linear regression generated the following equation: y = 27.2 – 1.50 x (adjusted R2 = 0.80, p < 0.0040, RSE = 1.559) ( Figure 3 ).

Table 2
Classification of trunk flexibility of individuals participating in a community-based health education program in the city of Santo Antônio de Goiás, Brazil, by age group
Figure 2
Trunk flexibility (mean ± SD) of individuals with (dark gray bars) and without cardiovascular risk factors (light gray bars); *p < 0.05, Student’s t-test; CVRF: cardiovascular risk factor; WC: waist circumference; WHtR: waist/height ratio
Figure 3
Linear regression between number of concomitant cardiovascular risk factors and mean trunk flexibility (y = 27.2 – 1.5 x, adjusted R2 = 0.80; p = 0.00397); CVRFs: cardiovascular risk factors

Discussion

Increased abdominal adiposity was the most prevalent CVRF and it was negatively associated with trunk flexibility. In addition, we found a strong correlation between trunk flexibility and presence of CVRF, which suggests the use of this biomarker as an indicator of increased cardiovascular risk.

We observed a high prevalence of increased abdominal adiposity according to the WHtR (76.3%). Some studies99 Corrêa MM, Tomasi E, Thumé E, Oliveira ERA, Facchini LA. Razão cintura-estatura como marcador antropométrico de excesso de peso em idosos brasileiros. Cad Saude Publica. 2017;33(5):3-14. doi:10.1590/0102-311x00195315.
https://doi.org/10.1590/0102-311x0019531...
, 3737 Rodrigues SL, Baldo MP, Mill JG. Associação entre a razão cintura-estatura e hipertensão e síndrome metabólica: estudo de base populacional. Arq Bras Cardiol. 2010;95(2):186-91. doi:10.1590/S0066-782X2010005000073.
https://doi.org/10.1590/S0066-782X201000...

38 Ashwell M, Gunn P, Gibson S. Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: Systematic review and meta-analysis. Obes Rev. 2012;13(3):275-86. doi:10.1111/j.1467-789X.2011.00952.x.
https://doi.org/10.1111/j.1467-789X.2011...
- 3939 Lee CMY, Huxley RR, Wildman RP, Woodward M. Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis. J Clin Epidemiol. 2008;61(7):646-53. doi:10.1016/ j.jclinepi.2007.08.012.
https://doi.org/10.1016/j.jclinepi.2007....
have shown that the WHtR has high accuracy in the identification of abdominal adiposity and could be a more efficient indicator than the WC, the waist-to-hip ratio (WHR) and the BMI in the cardiovascular risk assessment. Considering that excess abdominal fat is associated with CVD, WHtR is an important and useful tool for professionals in basic health care to identify individuals at increased risk.4040 Haun DR, Pitanga FJG, Lessa I. Razão cintura/estatura comparado a outros indicadores antropométricos de obesidade como preditor de risco coronariano elevado. Rev Assoc Med Bras. 2009;55(6):705-11. doi:10.1590/S0104-42302009000600015.
https://doi.org/10.1590/S0104-4230200900...

The prevalence of systemic arterial hypertension was 54.6%. The Surveillance of Risk Factors and Protection for Chronic Diseases by Telephone Inquiry (VIGITEL, Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico ), conducted in all capitals of the 26 Brazilian federal states and the Federal District, registered a prevalence of hypertension of 25.7% in Brazil.33 Brasil. Ministério da Saúde. Vigitel Brasil 2016: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Vigitel. Brasilia; 2017. Our results were approximately twice as high as the prevalence found in the Brazilian population.33 Brasil. Ministério da Saúde. Vigitel Brasil 2016: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Vigitel. Brasilia; 2017. Considering that the prevalence of hypertension is increasing every year, it is necessary to implement programs focused on its reduction and prevention.

According to trunk flexibility classification, we found 64.1% of the individuals with trunk flexibility below the recommended values.3434 Fitness Canada. Canadian Standardized Test of Fitness (CSTF): Operations Manual. 3rd ed. Ottawa: Fitness and Amateur Sport; 1986. A similar result was found in the evaluation of 46 workers at the Federal University of Viçosa, MG, Brazil, including men and women aged around 40 years old, in which 66.5% of them had trunk flexibility below the recommended values.4141 Silva CD, Juvêncio JF. Diagnóstico da aptidão física relacionada à saúde em trabalhadores de escritório da Universidade Federal de Viçosa. Rev Bras Cineantropom Desempenho Hum. 2004;6(1):63-71. Flexibility is important for athletes as well as for sedentary and/or physically active people, as less mobility of the hip joint, for example, can contribute to back pain and compromise work, sports and/or daily life activities.1515 Almeida TT, Amorim TP, Sousa FM, Augusto J. Mitos e verdades sobre flexibilidade: reflexões sobre o treinamento de flexibilidade na saúde dos seres humanos. Motriz Rev Educ Física. 2007;3(1):337-44.

When comparing trunk flexibility between individuals with and without CVRF, we found a significant difference in the flexibility of individuals with adequate WC compared to those with WC above the recommended values. We also observed significant difference in flexibility of individuals with adequate WHtR compared to those with elevated WHtR.

Studies evaluating the relationship between trunk flexibility and CVRFs are scarce in the literature. However, studies have shown that poor trunk flexibility has been associated with arterial stiffness in young and elderly individuals.1919 Nishiwaki M, Yonemura H, Kurobe K, Matsumoto N. Four weeks of regular static stretching reduces arterial stiffness in middle-aged men. Springerplus. 2015;4(1):555. doi:10.1186/s40064-015-1337-4.
https://doi.org/10.1186/s40064-015-1337-...
, 2020 Yamamoto K, Kawano H, Gando Y, Iemitsu M, Murakami H, Sanada K, et al. Poor trunk flexibility is associated with arterial stiffening. Am J Physiol Circ Physiol. 2009;297(4):H1314-H1318. doi:10.1152/ajpheart.00061.2009.
https://doi.org/10.1152/ajpheart.00061.2...
, 4242 Nishiwaki M, Kurobe K, Kiuchi A, Nakamura T, Matsumoto N. Sex differences in flexibility-arterial stiffness relationship and its application for diagnosis of arterial stiffening: a cross-sectional observational study. PLoS One. 2014;9(11):e113646. doi:10.1371/journal.pone.0113646.
https://doi.org/10.1371/journal.pone.011...
Thus, flexibility may be a predictor of arterial stiffness, regardless of other physical fitness components.1919 Nishiwaki M, Yonemura H, Kurobe K, Matsumoto N. Four weeks of regular static stretching reduces arterial stiffness in middle-aged men. Springerplus. 2015;4(1):555. doi:10.1186/s40064-015-1337-4.
https://doi.org/10.1186/s40064-015-1337-...
, 2020 Yamamoto K, Kawano H, Gando Y, Iemitsu M, Murakami H, Sanada K, et al. Poor trunk flexibility is associated with arterial stiffening. Am J Physiol Circ Physiol. 2009;297(4):H1314-H1318. doi:10.1152/ajpheart.00061.2009.
https://doi.org/10.1152/ajpheart.00061.2...
In addition, after only four weeks of flexibility training, a reduction in arterial stiffness was observed,1919 Nishiwaki M, Yonemura H, Kurobe K, Matsumoto N. Four weeks of regular static stretching reduces arterial stiffness in middle-aged men. Springerplus. 2015;4(1):555. doi:10.1186/s40064-015-1337-4.
https://doi.org/10.1186/s40064-015-1337-...
thereby suggesting flexibility as an indicator of cardiovascular health and cardiorespiratory fitness.4343 Douris PC, Ingenito T, Piccirillo B, Herbst M, Petrizzo J, Cherian V, et al. Martial arts training attenuates arterial stiffness in middle aged adults. Asian J Sports Med. 2013;4(3):201-7. doi:10.5812/asjsm.34259.
https://doi.org/10.5812/asjsm.34259...
These findings reinforce the importance of flexibility training and the inclusion of this measure in community health programs.

Cardiovascular risk factors can occur simultaneously and represent a greater risk for cardiovascular events when compared with isolated risk factors.3535 Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de fatores de risco cardiovascular em idosos usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol. 2010;95(5):621-8. doi:10.1590/S0066-782X2010005000141.
https://doi.org/10.1590/S0066-782X201000...
, 4444 Ebrahim S, Montaner D, Lawlor DA. Clustering of risk factors and social class in childhood and adulthood in British women’s heart and health study: cross sectional analysis. BMJ. 2004;328(7444):861. doi:10.1136/ bmj.38034.702836.55.
https://doi.org/10.1136/bmj.38034.702836...
When the risk factors were grouped, 82.5% of the subjects were found to be at increased risk for CVD. A previous study reported that concomitant CVRFs were found in 72.5% adults and elderly in the city of Salvador, Brazil.4545 Lessa I, Araújo MJ, Magalhães L, Almeida Filho N, Aquino E, Costa MCR. Simultaneidade de fatores de risco cardiovascular modificáveis na população adulta de Salvador (BA), Brasil. Rev Panam Salud Publica. 2004;16(2):131-137. doi:10.1590/S1020-49892004000800009.
https://doi.org/10.1590/S1020-4989200400...

We found a strong negative correlation between the number of concomitant CVRFs and mean trunk flexibility. Therefore, flexibility seems to be a sensitive indicator of increased cardiovascular risk. According to the equation obtained by linear regression analysis, we observed that for each additional risk factor, flexibility was reduced by 1.50 cm, or each 1.50 cm reduction in trunk flexibility indicated the addition of one CVRF ( Figure 3 ). Accordingly, it is possible to estimate cardiovascular risk by the measurement of trunk flexibility using the sit-and-reach test, which is simple and easy to apply. Trunk flexibility, therefore, may be an additional tool to be applied in the detection and control of CVDs.

One limitation of our study was the inability to perform blood biochemical tests to identify other risk factors, such as dyslipidemia and glycemic disturbances. However, studies in the literature about the relationship between flexibility and CVRFs are scarce. Thus, our study is important as a basis for future research on trunk flexibility and CVRFs, including analysis of metabolic biomarkers in larger samples, to provide a better understanding of the association between the variables studied.

Conclusion

Increased abdominal adiposity was the most prevalent CVRF and it was negatively associated with trunk flexibility among participants in a community-based health program in the city of Santo Antônio de Goiás, located in the mid-west of Brazil. Moreover, there was a high prevalence of concomitant CVRFs, which were strongly and negatively correlated with trunk flexibility. Considering these findings and that flexibility training can reduce arterial stiffness, trunk flexibility is suggested as an indicator of increased cardiovascular risk. Therefore, trunk flexibility measurement may be an additional tool for health promotion and prevention of cardiovascular and associated diseases in community health programs.

  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This study is associated with Rafael Felipe Cardoso's master thesis.
  • Ethical approval and informed consent
    The study was approved by the Research Ethics Committee of the Federal University of Goiás (protocol number 784.446/2014). All procedures involved in this study were in accordance with the Declaration of Helsinki, 1975, updated in 2013. All participants included in the study signed an informed consent form.

Acknowledgment

The authors thank the Fundação de Amparo à Pesquisa do Estado de Goiás (FAPEG) for financial support (master scholarship); to the volunteers for participation and collaboration with the study; and the colleagues who assisted with physical assessments.

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Publication Dates

  • Publication in this collection
    11 Feb 2022
  • Date of issue
    May-Jun 2022

History

  • Received
    17 Nov 2020
  • Accepted
    01 Sept 2021
  • Reviewed
    03 Apr 2021
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