Nutritional therapy assessment – Outpatient mobility monitoring (MAM)

AVALIAÇÃO NUTROLÓGICA – MONITORIZAÇÃO AMBULATORIAL DA MOBILIDADE (MAM)

Associação Brasileira de Nutrologia (Abran) DF RIBAS RS SIMÕES RF BUZZINI G KELMAN WM BERNARDO About the authors

EVIDENCE COLLECTION METHOD

This policy followed the pattern of a systematic review with retrieval of evidence based on the principles of evidence-based medicine (EBM), according to which clinical experience is integrated with the ability to critically analyze and rationally apply scientific information, thus improving the quality of medical care. EBM uses existing scientific evidence available at the time, with good internal and external validity, applying its results to the clinical practice.11 Nobre MR, Bernardo WM, Jatene FB. A prática clínica baseada em evidências. Parte I - Questões clínicas bem construídas. Rev Assoc Med Bras. 2003; 49(4):445-9.,22 Bernardo WM, Nobre MR, Jatene FB. A prática clínica baseada em evidências. Parte II - Buscando as evidências em fontes de informação. Rev Assoc Med Bras. 2004; 50(1):104-8. (D)

Systematic reviews are considered today as level I evidence for any clinical question as systematically summarize information on a particular topic based on primary studies (clinical trials, cohort studies, case-control or cross-sectional studies). The method used for this is reproducible, and integrates information on effectiveness, efficiency, efficacy and safety.11 Nobre MR, Bernardo WM, Jatene FB. A prática clínica baseada em evidências. Parte I - Questões clínicas bem construídas. Rev Assoc Med Bras. 2003; 49(4):445-9.,22 Bernardo WM, Nobre MR, Jatene FB. A prática clínica baseada em evidências. Parte II - Buscando as evidências em fontes de informação. Rev Assoc Med Bras. 2004; 50(1):104-8. (D)

We use a structured way to ask the question, summarized by the acronym PICO, where P is the patient or population, I intervention or indicator, C comparison or control, and O is the outcome. Based on structured question, the keywords or descriptors that will form the basis of the search for evidence in the various available databases are identified (Annex I).11 Nobre MR, Bernardo WM, Jatene FB. A prática clínica baseada em evidências. Parte I - Questões clínicas bem construídas. Rev Assoc Med Bras. 2003; 49(4):445-9.,22 Bernardo WM, Nobre MR, Jatene FB. A prática clínica baseada em evidências. Parte II - Buscando as evidências em fontes de informação. Rev Assoc Med Bras. 2004; 50(1):104-8. (D)

CLINICAL QUESTION

What is the role of outpatient mobility monitoring (MAM) in the monitoring of physical activity and energy expenditure in children, adolescents or adults?

GRADE OF RECOMMENDATION AND STRENGTH OF EVIDENCE

A: Experimental or observational studies of higher consistency.

B: Experimental or observational studies of lower consistency.

C: Case reports/non-controlled studies.

D: Opinions without critical evaluation, based on consensus, physiological studies, or animal models.

OBJECTIVE

To determine the role of outpatient nutritional therapy assessment in the monitoring of physical activity and energy expenditure of children, adolescents and adults.

INTRODUCTION

Physical activity is an important health indicator and regular practice provides a broad spectrum of benefits, impacting on the prevention of cardiovascular risk factors and the development of chronic diseases such as obesity, type 2 diabetes mellitus, dyslipidemia and hypertension.33 Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). NCD prevention: investments [corrected] that work for physical activity. Br J Sports Med. 2012; 46(10):709-12. (D) Epidemiological studies have unequivocally demonstrated that mortality from any cause is lower among physically active individuals in contrast to that observed in inactive individuals, respecting the parameters of age, gender, and co-morbidities.44 Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012; 380(9838):219-29.,55 Blair SN, Kohl HW 3rd, Barlow CE, Paffenbarger RS Jr, Gibbons LW, Macera CA. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA. 1995; 273(14):1093-8. (B) Furthermore, it has been noted that the adequacy of the lifestyle, including the practice of physical activity, is related to a reduction of all causes of mortality, showing unique importance in maintaining functional independence and good quality of life in the elderly population.66 Paffenbarger RS Jr, Kampert JB, Lee IM, Hyde RT, Leung RW, Wing AL. Changes in physical activity and other lifeway patterns influencing longevity. Med Sci Sports Exerc. 1994; 26(7):857-65. (B) Physical activity as a form of therapeutic exercise is also important in rehabilitation programs for cardiovascular, neuromuscular, motor control and cortical plasticity aspects.77 Kurtze N, Rangul V, Hustvedt BE. Reliability and validity of the international physical activity questionnaire in the Nord-Trøndelag health study (HUNT) population of men. BMC Med Res Methodol. 2008; 8:63. (B) Thus, with the measurement of physical activity becoming more common in clinical practice, it is imperative to search for simple, practical and non-invasive tools that are suitable for assessing the level of physical activity and energy expenditure.

WHAT ARE THE ASSESSMENT METHODS FOR PHYSICAL ACTIVITY AND ENERGY EXPENDITURE?

Although individuals are able to describe their daily physical activity habits in general terms, detailed and accurate measurement is an extremely difficult task because it is a complex and multidimensional health-related behavior. The literature has described a variety of measurement methods and techniques, which are classified as direct and indirect. Examples of direct techniques include the use of double labeled water, calorimetry, and portable monitoring through the use of heart rate monitors, pedometers and accelerometers. As for indirect methods, we can highlight questionnaires, and self-reports involving the use of instruments in the form of self-administered questionnaires, interviews and activity diaries.88 Shephard RJ. Limits to the measurement of habitual physical activity by questionnaires. Br J Sports Med. 2003; 37(3):197-206.

9 Troiano RP. A timely meeting: objective measurement of physical activity. Med Sci Sports Exerc. 2005; 37(11 Suppl):S487-9.
-1010 Chen KY, Bassett DR Jr. The technology of accelerometry-based activity monitors: current and future. Med Sci Sports Exerc. 2005; 37(11 Suppl):S490-500. (D) The combination of the calorimetry and doubly labeled water measurements provides a method for accurate measurement of energy expenditure due to physical activity. However, they require specific knowledge for application and interpretation of the results, in addition to being expensive and inconvenient when used in large populations. Direct calorimetry is based on measuring the amount of total heat produced by the body in a given period of time. In turn, indirect calorimetry is based on the total amount of energy produced from the oxygen consumed in the use of energy substrates and the production of carbon dioxide eliminated by breathing.1111 Ferrannini E. The theoretical bases of indirect calorimetry: a review. Metabolism. 1988; 37(3):287-301. (D)

The method of double labeled water is considered the gold standard for determining energy expenditure. It is based on the ingestion of water labeled with radioactive isotopes of oxygen and hydrogen (the oxygen isotope is eliminated from the body incorporated into carbon dioxide molecules and water; the hydrogen isotope is eliminated only as water). As such, the difference between these two isotopes can predict the measurement of carbon dioxide production and thereby the energy expenditure, indirectly.1212 Schoeller DA, van Santen E. Measurement of energy expenditure in humans by doubly labeled water method. J Appl Physiol Respir Environ Exerc Physiol. 1982; 53(4):955-9. (C) This technique is accurate in assessing the energy expenditure. However, it does not enable an analysis of the type of physical activity, which is the main limitation of this method.

Traditionally, subjective methods such as self-administered questionnaires, notes in diaries and interviews (surveys) are the techniques used the most for estimating the total amount of daily or weekly physical activity, remaining as low-cost tools, and the option used the most in epidemiological studies.77 Kurtze N, Rangul V, Hustvedt BE. Reliability and validity of the international physical activity questionnaire in the Nord-Trøndelag health study (HUNT) population of men. BMC Med Res Methodol. 2008; 8:63. (B) Nevertheless, there are limitations inherent in these instruments, given that they ate dependent on individual observation and subjective interpretation and therefore prone to inconsistent evaluations. The use of motion sensors such as accelerometers and pedometers has been consolidated as the most frequently used objective methods for measuring physical activity.88 Shephard RJ. Limits to the measurement of habitual physical activity by questionnaires. Br J Sports Med. 2003; 37(3):197-206. (D)

A study analyzing the Physical Activity Scale for the Elderly (PASE) questionnaire aimed at quantifying the level of physical activity in patients undergoing total knee arthroplasty demonstrated deficiencies in the validity and reproducibility of the results when compared to the accelerometer.1313 Bolszak S, Casartelli NC, Impellizzeri FM, Maffiuletti NA. Validity and reproducibility of the Physical Activity Scale for the Elderly (PASE) questionnaire for the measurement of the physical activity level in patients after total knee arthroplasty. BMC Musculoskelet Disord. 2014; 15:46. (B) However, in view of the low cost and simplicity, in epidemiological research, especially largescale observational studies, questionnaires are generally used in the assessment of physical activity, with measurement of varying complexity from the self-administered form to interviews.

Questionnaires generally provide descriptions of the patterns of physical activity and can estimate how much energy individuals spend on a given activity. However, despite their large scale applicability, the reliability and validity of the measurement are low.1414 Treuth MS, Sherwood NE, Baranowski T, Butte NF, Jacobs DR Jr, McClanahan B, et al. Physical activity self-report and accelerometry measures from the Girls health Enrichment Multi-site Studies. Prev Med. 2004; 38 Suppl:S43-9.,1515 Samuel-Hodge CD, Fernandez LM, Henríquez-Roldán CF, Johnston LF, Keyserling TC. A comparison of self-reported energy intake with total energy expenditure estimated by accelerometer and basal metabolic rate in African-American women with type 2 diabetes. Diabetes Care. 2004; 27(3):663-9. (B) A systematic review conducted in order to evaluate questionnaires aimed at the young population (under 18 years of age) found that none of the 61 questionnaires identified were reliable and valid. The same findings were identified when the focus of the analysis was the adult population.1616 Chinapaw MJ, Mokkink LB, van Poppel MN, van Mechelen W, Terwee CB. Physical activity questionnaires for youth: a systematic review of measurement properties. Sports Med. 2010; 40(7):539-63.,1717 van Poppel MN, Chinapaw MJ, Mokkink LB, van Mechelen W, Terwee CB. Physical activity questionnaires for adults: a systematic review of measurement properties. Sports Med. 2010; 40(7):565-600. (A) To compare the subjective methods (via questionnaires) with the objective methods (using accelerometers), for the assessment of physical activity in the population of children and adolescents (from 3.7 to 19 years), it has been shown that subjective methods overestimated physical activity by more than 70% to the detriment of the objective methods.1818 Adamo KB, Prince SA, Tricco AC, Connor-Gorber S, Tremblay M. A comparison of indirect versus direct measures for assessing physical activity in the pediatric population: a systematic review. Int J Pediatr Obes. 2009; 4(1):2-27. (A)

Another method for the objective assessment of physical activity is heart rate monitoring based on the linear relationship between heart rate and energy expenditure. Relatively inexpensive and with the capacity for minute by minute heart rate storage, continuous recording by means of monitors is a method considered feasible and attractive for the assessment of physical activity. However, factors such as age, proportion of muscle mass, emotional and cardiorespiratory stress, state of hydration and fatigue can influence the heart rate/oxygen consumption ratio. Another limitation is due to the fact that monitoring can mask the patterns of activity given that even after the cessation of motion the heart rate tends to remain high, and that in sedentary individuals the heart rate measured over 24 hours barely surpasses the rest limits, making it difficult to distinguish between light and moderate activities.1919 Melanson EL Jr, Freedson PS. Physical activity assessment: a review of methods. Crit Rev Food Sci Nutr. 1996; 36(5):385-96. (D)

On the other hand, mechanical and electronic motion detectors such as pedometers and accelerometers eliminate many problems of subjectivity by providing an objective measurement of physical activity. However, as with all assessment methods, they possess measurement limitations, such as the ability to discriminate the different activity types and the seasonal bias inherent at the moment when the mechanical device is applied.2020 Robertson W, Stewart-Brown S, Wilcock E, Oldfield M, Thorogood M. Utility of accelerometers to measure physical activity in children attending an obesity treatment intervention. J Obes. 2011; 2011:398-918. (C)

Pedometers are the simplest portable sensors used for monitoring human movement and record movements in response to vertical acceleration. Using a mechanism that detects the impacts produced by steps during locomotion, it is possible to calculate the distance covered and therefore the energy expenditure. The main disadvantages are the inability to evaluate static activities, isometric exercises and activities involving the arms, thereby resulting in inaccurate energy expenditure estimates. To analyze the effectiveness of physical activity based on the use of pedometers among adults in an outpatient setting, a study identified that pedometer users significantly increased their physical activity by around 2,500 steps per day compared to participants in the control group (who did not use the pedometer), as well as being associated with a reduction in body mass index and systolic blood pressure.2121 Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007; 298(19):2296-304. (A) Another systematic review analyzing the use of the pedometer identified that this intervention provided a modest, yet significant reduction in body weight, while the magnitude of the weight loss was associated with the time using the device.2222 Richardson CR, Newton TL, Abraham JJ, Sen A, Jimbo M, Swartz AM. A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med. 2008; 6(1):69-77. (A) The use of pedometers by overweight or normal weight children was identified as an imprecise method at slower speeds, and was shown to be more accurate at higher speeds. For the control group, a smaller error was identified at all speeds, and it was concluded that for overweight or obese children the use of the pedometer is related to a lack of precision.2323 Mitre N, Lanningham-Foster L, Foster R, Levine JA. Pedometer accuracy for children: can we recommend them for our obese population? Pediatrics. 2009; 123(1):e127-31. (B)

Accelerometers are electronic devices that measure the acceleration of body’s movement in the vertical and horizontal direction by means of a microprocessor that scans and filters the acceleration signal and converts it into a numerical sign, presenting this value as movement counts over a time interval. As such, they provide an objective way of quantifying the frequency, duration and intensity of physical activity given that they are able to assess the magnitude and the total volume of movement as a function of time. They are classified into uniaxial, unidirectional or triaxial, based on their ability to measure the acceleration of movement on one or more planes (vertical, mid-lateral and anteroposterior).2424 Mathie MJ, Coster AC, Lovell NH, Celler BG. Accelerometry: providing an integrated, practical method for long-term, ambulatory monitoring of human movement. Physiol Meas. 2004; 25(2):R1-20. (D) The combination of heart rate monitoring and accelerometer as a way of measuring energy expenditure compensates for the limitations of both techniques, especially with regard to discriminating between different types of physical activity. A study with the aim of estimating energy expenditure used the combination of accelerometry and heart rate as a measurement method, identifying a good level of agreement with the adopted gold standard (double labeled water).2525 Villars C, Bergouignan A, Dugas J, Antoun E, Schoeller DA, Roth H, et al. Validity of combining heart rate and uniaxial acceleration to measure freeliving physical activity energy expenditure in young men. J Appl Physiol (1985). 2012; 113(11):1763-71. (B)

Recommendation

Technological development has enabled the establishment of techniques for the assessment of physical activity and the quantification of energy expenditure. Each method has advantages and disadvantages that depend heavily on the type of activity, age group and body composition. As such, until an instrument that fulfills all of the desired features is identified, a combination of methods could provide more reliable and accurate data. It is important to apply an objective questionnaire that helps monitor the increase or reduction in physical activity, as well as to identify the style of activity practiced, which may be associated with heart rate monitoring and accelerometry.

  • Final draft: March 11, 2016

Annex I

CLINICAL QUESTION

What is the role of outpatient mobility monitoring (MAM) in the monitoring of physical activity and energy expenditure in children, adolescents or adults?

STRUCTURED QUESTION

P: Children, adolescents or adults

I: Outpatient ambulatory monitoring

C: ----------------------------------

O: Monitoring of physical activity and energy expenditure

strAtegy for seArch of evidence

PubMed-Medline

Strategy 1: (Weight reduction OR Weight Loss OR Diet, Reduction OR Nutrition Disorder OR Nutritional Disorders OR Nutritional Disorder OR Nutritional Status OR Nutrition Status OR Nutrition Assessment OR Nutrition Disorders OR Malnutrition OR Deficiency Diseases OR Overnutrition OR Obesity OR Avitaminosis OR Ascorbic Acid Deficiency OR Vitamin A Deficiency OR Vitamin B Deficiency OR Vitamin D Deficiency OR Vitamin E Deficiency OR Vitamin K Deficiency OR Magnesium Deficiency OR Potassium Deficiency OR Protein Deficiency OR Protein-Energy Malnutrition OR Swayback OR Scurvy OR Choline Deficiency OR Folic Acid Deficiency OR Hyperhomocysteinemia OR Pellagra OR Riboflavin Deficiency OR Thiamine Deficiency OR Beriberi OR Wernicke Encephalopathy OR Vitamin B 12 Deficiency OR Anemia, Pernicious OR Subacute Combined OR Degeneration OR Vitamin B 6 Deficiency OR Rickets OR Osteomalacia OR Renal Osteodystrophy OR Steatitis OR Kwashiorkor OR Overweight OR Obesity, Abdominal OR Obesity, Morbid OR Wasting Syndrome) = 623,855.

Strategy 2: (Activities of Daily Living OR Mobility OR Wireless Technology OR Motor Activity OR Physical Activity OR Daily Ambulatory Activity OR Walking OR Exercise Test OR Energy OR Monitoring, Ambulatory OR Ambulatory Monitoring of Mobility) = 1,029,052.

Strategy 3: (Strategy 1 AND Strategy 2) = 77,330.

Methodological search filter: (Strategy 4) = ((specificity[Title/ Abstract]) OR random* OR ((prognos*[Title/Abstract] OR (first[Title/ Abstract] AND episode[Title/Abstract]) OR cohort[Title/Abstract]))) = 1,813,617.

Total 1a Retrieval: (Strategy 3 AND Strategy 4) = 12,535.

STUDIES RETRIEVED
Database Number of studies Primary PubMed-Medline 12,535 Number of studies retrieved using search strategies. Final search: 12/20/2014.
EXCLUSION CRITERIA

Selection of studies, assessment of titles and abstracts obtained from the search strategy in the consulted databases was conducted by two researchers with skills in the preparation of systematic reviews, both independent and blinded, who separated the studies with potential relevance. Whenever the title and the summary were not enlightening, researchers sought the full article.

Articles that did not meet the specificities of PICO, that were not available for access in full, and those written in languages other than English, Portuguese or Spanish were excluded.

REFERENCES

  • 1
    Nobre MR, Bernardo WM, Jatene FB. A prática clínica baseada em evidências. Parte I - Questões clínicas bem construídas. Rev Assoc Med Bras. 2003; 49(4):445-9.
  • 2
    Bernardo WM, Nobre MR, Jatene FB. A prática clínica baseada em evidências. Parte II - Buscando as evidências em fontes de informação. Rev Assoc Med Bras. 2004; 50(1):104-8.
  • 3
    Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). NCD prevention: investments [corrected] that work for physical activity. Br J Sports Med. 2012; 46(10):709-12.
  • 4
    Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012; 380(9838):219-29.
  • 5
    Blair SN, Kohl HW 3rd, Barlow CE, Paffenbarger RS Jr, Gibbons LW, Macera CA. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA. 1995; 273(14):1093-8.
  • 6
    Paffenbarger RS Jr, Kampert JB, Lee IM, Hyde RT, Leung RW, Wing AL. Changes in physical activity and other lifeway patterns influencing longevity. Med Sci Sports Exerc. 1994; 26(7):857-65.
  • 7
    Kurtze N, Rangul V, Hustvedt BE. Reliability and validity of the international physical activity questionnaire in the Nord-Trøndelag health study (HUNT) population of men. BMC Med Res Methodol. 2008; 8:63.
  • 8
    Shephard RJ. Limits to the measurement of habitual physical activity by questionnaires. Br J Sports Med. 2003; 37(3):197-206.
  • 9
    Troiano RP. A timely meeting: objective measurement of physical activity. Med Sci Sports Exerc. 2005; 37(11 Suppl):S487-9.
  • 10
    Chen KY, Bassett DR Jr. The technology of accelerometry-based activity monitors: current and future. Med Sci Sports Exerc. 2005; 37(11 Suppl):S490-500.
  • 11
    Ferrannini E. The theoretical bases of indirect calorimetry: a review. Metabolism. 1988; 37(3):287-301.
  • 12
    Schoeller DA, van Santen E. Measurement of energy expenditure in humans by doubly labeled water method. J Appl Physiol Respir Environ Exerc Physiol. 1982; 53(4):955-9.
  • 13
    Bolszak S, Casartelli NC, Impellizzeri FM, Maffiuletti NA. Validity and reproducibility of the Physical Activity Scale for the Elderly (PASE) questionnaire for the measurement of the physical activity level in patients after total knee arthroplasty. BMC Musculoskelet Disord. 2014; 15:46.
  • 14
    Treuth MS, Sherwood NE, Baranowski T, Butte NF, Jacobs DR Jr, McClanahan B, et al. Physical activity self-report and accelerometry measures from the Girls health Enrichment Multi-site Studies. Prev Med. 2004; 38 Suppl:S43-9.
  • 15
    Samuel-Hodge CD, Fernandez LM, Henríquez-Roldán CF, Johnston LF, Keyserling TC. A comparison of self-reported energy intake with total energy expenditure estimated by accelerometer and basal metabolic rate in African-American women with type 2 diabetes. Diabetes Care. 2004; 27(3):663-9.
  • 16
    Chinapaw MJ, Mokkink LB, van Poppel MN, van Mechelen W, Terwee CB. Physical activity questionnaires for youth: a systematic review of measurement properties. Sports Med. 2010; 40(7):539-63.
  • 17
    van Poppel MN, Chinapaw MJ, Mokkink LB, van Mechelen W, Terwee CB. Physical activity questionnaires for adults: a systematic review of measurement properties. Sports Med. 2010; 40(7):565-600.
  • 18
    Adamo KB, Prince SA, Tricco AC, Connor-Gorber S, Tremblay M. A comparison of indirect versus direct measures for assessing physical activity in the pediatric population: a systematic review. Int J Pediatr Obes. 2009; 4(1):2-27.
  • 19
    Melanson EL Jr, Freedson PS. Physical activity assessment: a review of methods. Crit Rev Food Sci Nutr. 1996; 36(5):385-96.
  • 20
    Robertson W, Stewart-Brown S, Wilcock E, Oldfield M, Thorogood M. Utility of accelerometers to measure physical activity in children attending an obesity treatment intervention. J Obes. 2011; 2011:398-918.
  • 21
    Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007; 298(19):2296-304.
  • 22
    Richardson CR, Newton TL, Abraham JJ, Sen A, Jimbo M, Swartz AM. A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med. 2008; 6(1):69-77.
  • 23
    Mitre N, Lanningham-Foster L, Foster R, Levine JA. Pedometer accuracy for children: can we recommend them for our obese population? Pediatrics. 2009; 123(1):e127-31.
  • 24
    Mathie MJ, Coster AC, Lovell NH, Celler BG. Accelerometry: providing an integrated, practical method for long-term, ambulatory monitoring of human movement. Physiol Meas. 2004; 25(2):R1-20.
  • 25
    Villars C, Bergouignan A, Dugas J, Antoun E, Schoeller DA, Roth H, et al. Validity of combining heart rate and uniaxial acceleration to measure freeliving physical activity energy expenditure in young men. J Appl Physiol (1985). 2012; 113(11):1763-71.

Publication Dates

  • Publication in this collection
    Dec 2016
Associação Médica Brasileira R. São Carlos do Pinhal, 324, 01333-903 São Paulo SP - Brazil, Tel: +55 11 3178-6800, Fax: +55 11 3178-6816 - São Paulo - SP - Brazil
E-mail: ramb@amb.org.br