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Arquivos Brasileiros de Cardiologia

Print version ISSN 0066-782XOn-line version ISSN 1678-4170

Arq. Bras. Cardiol. vol.81 no.6 São Paulo Dec. 2003

http://dx.doi.org/10.1590/S0066-782X2003001400006 

ORIGINAL ARTICLE

 

Lipid profile and cardiovascular risk in two Amazonian populations

 

 

Claudine Maria Alves Feio; Francisco A. H. Fonseca; Simone S. Rego; Max N. B. Feio; Maria C. Elias; Eduardo A. S. Costa; Maria C. O. Izar; Ângelo A. V. Paola; Antonio C. C. Carvalho

Universidade Federal do Pará - UFPA and Universidade Federal de São Paulo - UNIFESP. Belém, PA - São Paulo, SP - Brazil

Correspondence

 

 


ABSTRACT

OBJECTIVE: To compare the lipid profiles and coronary heart disease risks of 2 Brazilian Amazonian populations as follows: a riverside population (village of Vigia) and an urban population (city of Belém in the state of Pará).
METHODS: Fifty individuals controlled for age and sex were assessed in each region, and the major risk factors for coronary heart disease were analyzed.
RESULTS: According to the National Cholesterol Education Program (NCEP III) and using the Framingham score, both populations had the same absolute risk of events (Vigia = 5.4 ± 1 vs Belém = 5.7 ± 1), although the population of Vigia had a lower consumption of saturated fat (P<0.0001), a greater consumption of mono- and polyunsaturated fat (P<0.03), in addition to lower values for body mass index (25.4± 0.6 vs 27.6 ± 0.7 kg/m2, P<0.02), of biceps skin fold (18.6 ± 1.1 vs 27.5 ± 1.3 mm, P<0.0001), of triceps skin fold (28.7 ± 1.2 vs 37.3 ± 1.7 mm, P<0.002), and of total cholesterol (205 ± 5 vs 223 ± 6 mg/dL, P< 0.03) and triglycerides (119 ± 9 vs 177 ± 18 mg/dL, P<0.005). Both populations did not differ in regard to HDL-C (46 ± 1 vs 46 ± 1 mg/dL), LDL-C (135 ± 4 vs 144 ± 5 mg/dL) and blood pressure (SBP 124 ± 3 vs 128 ± 3 mmHg; DBP 80 ± 2 vs 82 ± 2 mmHg).
CONCLUSION: The riverside and urban populations of Amazonia had similar cardiovascular risks. However, the marked difference in the variables studied suggests that different strategies of prevention should be applied.

Key words: lipids, risk factors, nutrition


 

 

Atherosclerotic cardiovascular disease is the major cause of death in our country and occurs at earlier ages than that observed in the United States of America 1,2.

The initial results of the Framingham Study have associated serum cholesterol level, smoking, and arterial hypertension with ischemic heart disease 3. More recently, the National Cholesterol Education Program (NCEP III, USA) 4 published the recommendations for estimating absolute coronary risk, considering the total cholesterol level, age, HDL-C level, values of systolic and diastolic blood pressure, and smoking habit, with different scores for men and women.

In the past decade, several studies suggested that a more active lifestyle and higher consumption of fish could be beneficial, because they resulted in a lower incidence of cardiovascular events, a better lipid profile, and a reduction in blood pressure and in thrombotic risk 5-8.

Among the Eskimos in Greenland and the Japanese of Kohama Island, lower levels of total cholesterol and triglycerides and an extremely low incidence of coronary heart disease were observed as compared with those in the populations living on the continent 9-11.

In Brazil, epidemiological data of the Ministry of Health for the City of Belém, in the State of Pará 12, showed that mortality due to cardiovascular disease was the major cause of death in that city despite the proximity to rivers and forests, and the high consumption of fish and typical fruits in that region.

This study aimed at comparing the cardiovascular risk of the urban population of Belém in the State of Pará with that of an Amazonian riverside population (village of Vigia) living mainly on fish and with very scarce contact with large urban centers.

 

Methods

The study sample comprised 100 individuals of both sexes with no personal antecedents of heart disease or diabetes, whose ages ranged from 35 to 65 years, 50 in each municipality. They signed a written consent required by the Committee on Ethics in Research of the Federal University of Pará. The sample was estimated with a power of 80% and an alpha risk of 5% to differentiate the lipid variables based on differences obtained for these variables in a previous study, comparing different regions of the country 13. Table I shows the major characteristics of the populations.

 

 

In the village of Vigia, the fishermen and their families were included in the study because their nutritional intake was mainly fish. The population selected underwent clinical examination and answered, during anamnesis, a questionnaire 14,15 about profession, dietary habits, and personal and familial antecedents. During a physical examination, blood pressure was measured according to the IV Brazilian Consensus on Systemic Hypertension 16, and the body mass index (weight/height2) was determined, as were the biceps and triceps skin folds with the Lange pachymeter 17,18. The lipid variables were obtained after a 12-hour fasting period through an automated enzymatic method, and the LDL-C fraction was estimated according to the Friedewald formula19. General biochemical tests were performed. For the analysis of the data obtained in the food questionnaire, a score was established for each food according to the recommendations of Block et al 14,15 used for analyzing the data of the National Health and Nutrition Examination Survey (NHANES II) on food frequency.

The absolute risk of coronary events in 10 years was estimated with the score proposed by the NCEP III 4. This score was based on the Framingham Study recently validated for other distinct populations, such as white and black individuals, North American Indians, and North Americans of Japanese or Hispanic descent 20. The absolute risk of coronary events estimated with that score in 10 years was classified as low (< 10%), intermediate (10 – 20%), or high (> 20%) 4. That score does not compute the diabetic patients, because they are considered at high risk independently of other variables.

All data are shown as mean ± SEM. The nonpaired t test was used for continuous variables, and the chi-square test was used for categorical variables. The significance level adopted for all tests was P<0.05.

 

Results

The population in the village of Vigia consumed a lower amount of saturated fat and a higher amount of mono- and polyunsaturated fat. They also had lower values for body mass index and biceps and triceps skin folds (tab. II).

 

 

The population in the village of Vigia had lower total cholesterol values (205 ± 5 vs 223 ± 6 mg/dL, P <0.03) and triglycerides (119 ± 9 vs 177 ± 18 mg/dL, P < 0.005) compared with those of the population in the city of Belém. On the other hand, the values obtained for HDL-C (46 ± 1 vs 46 ± 1 mg/dL) and LDL-C (135 ± 4 vs 144 ± 5 mg/dL) did not differ between the 2 populations (fig. 1).

 

 

All variables composing the Framingham score (NCEP III) were analyzed and their distribution is shown in figure 2, but only the smoking habit differentiated the 2 populations. The greatest score belonged to the population of Vigia as compared with that of the City of Belém (tab. II and fig. 3).

 

 

 

 

Discussion

Our study found that the 2 populations, the riverside (Vigia) and the urban (Belém), had low cardiovascular risk for coronary events. However, important differences were observed in the lipid and anthropometric parameters, which were more favorable to the population from Vigia. On the other hand, excessive smoking was observed in this same population.

The better lipid profile in the riverside community seems to be associated with a healthier diet rich in mono- and polyunsaturated fat.

Lower values for body mass index and biceps and triceps skin folds may also have contributed for this better lipid profile, which may have been associated with greater physical activity as compared with that of the urban population of Belém. The latter had a greater prevalence of sedentary lifestyle and obesity, which are findings classically related to an unfavorable lipid profile 21,22.

In fact, the values of total cholesterol and triglycerides obtained in Vigia are in accordance with the findings by Kagawa et al 9 in Japanese on Kohama Island, where those lipids were also reduced compared with those of the other Japanese in the country.

The greater frequency of smoking in Vigia and of a sedentary lifestyle in Belém may be associated with the similar levels of HDL-C found in the 2 populations. Smoking causes lower activity in LCAT 23, reduces reverse cholesterol transport, and causes a reduction in the HDL-C level. This could attenuate the HDL-C level increased by the greater physical activity of the population in Vigia 24,25.

In regard to the LDL-C level, no differences were observed between the 2 populations, suggesting that this variable is less influenced by lifestyle. In fact, data from the Framingham Study have shown that the LDL-C level, especially for the lowest values of its distribution, does not allow differentiation between coronary and noncoronary populations 26.

Although lower values of blood pressure were reported for communities with a high intake of fish 10, our study showed no difference between the populations studied. The community in Vigia, especially the fishermen, spent most of their time at sea, and alcoholism was a frequent association. Although alcoholism was not assessed in the present study, the greater alcohol consumption in the population of Vigia may have contributed to a greater elevation in blood pressure, attenuating the possible benefit of a healthier diet and greater physical activity 27,28.

Based on NCEP III, and assessing the entire set of the variables in that score, both populations had the same absolute risk of events, which was low (< 10%). However, aiming at an additional reduction in the cardiovascular risk, the study identified the need for greater attention to smoking and possibly to alcoholism and stress in riverside populations of Amazonia.

These findings seem even more relevant when populations considered at low cardiovascular risk, but exposed to inadequate habits of modern society, reached an alarming prevalence of smoking, obesity, and sedentary lifestyle 29,30.

In fact, considering the values obtained for blood pressure, total cholesterol, and nutritional status in populations of 3 continents (Italian urban population, African populations of Tanzania and Uganda, and Amazonian population of Brazil), the African diet poor in salt and rich in fish and vegetables was associated with lower levels of blood pressure, total cholesterol, and body mass index compared not only with those of the Italian population, but also with those of the Brazilian population, which differed from the African diet in regard to the greater consumption of salt and meat 31. Another study in Tanzania, confirmed the substantial increase in cardiovascular risk as compared with that obtained 10 years before 32.

Pavan et al 33, comparing an isolated population in Amazonia with 2 progressively more urbanized ones (in Poland and Italy, respectively), reported that the Brazilian population had normal values for blood pressure, which did not increase with age, the systolic pressure being < 100mmHg in 46% of the cases. In addition, all individuals had normal values of cholesterol (< 200 mg/dL), and 90% had glycemia < 80 mg/dL.

All these studies show that the transition from a rural lifestyle to an urban lifestyle causes an increase in cardiovascular risk, suggesting that the environment plays a crucial role in the cardiovascular risk of populations.

 

References

1. Chor D, Fonseca MJM, Andrade CR, et al. Doenças cardiovasculares, panorama de mortalidade no Brasil. In: Minayo, MC, ed. Os Muitos Brasis: Saúde e População na Década de 80. São Paulo; Rio de Janeiro: Hucitec/ABRASCO, 1995: 57-86.        [ Links ]

2. Adam PF, Benson, V. National Center for Health Statistics. Current estimates from the National Heart Interview Survey, United State. 1989. Vital and Health Statistic DHHS Publ. Washington, NO (PHS) 1989:90-1504.        [ Links ]

3. Dawber TR, Kannel WB, Revotskie N. Some factors associated with the development of coronary heart disease. Am J Public Health 1959; 49:1349-54.        [ Links ]

4. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285: 2486-97.        [ Links ]

5. Gibson RA. The effects of diets containing fish oils on disease risk factors in humans. Aust N Z J Med 1988;18:713-20.        [ Links ]

6. Katan MB. Fish and heart disease: what is real story? Nutr Rev 1995;53:228-9.        [ Links ]

7. Hirai A, Hanazaki T, Terano T, et al. Eicosapentaenoic acid and platelet function in Japanese. Lancet 1980;2:1132-3.        [ Links ]

8. Batlouni M. Ácidos Graxos Omega-3 e cardiopatia Isquêmica. Arq Bras Cardiol 1989;2:175-80.        [ Links ]

9. Kagawa Y, Nishizawa M, Suzuki M, et al. Eicosapolyenoic acids of serum, lipids of Japanese islanders with low incidence of cardio vascular diseases. J Nutr Sci Vitaminol 1982;28: 441-53.        [ Links ]

10. Singer P, Jarger W, Wirth M, et al. Lipid and blood pressure -lowering effect of mackered diet in man. Atherosclerosis 1983;49:99-108.        [ Links ]

11. Simons LA, Hickie JB, Balasobramanian S. On the effects of dietary n-3 fatty acids (maxepa) on plasma lipids and lipoproteins in patients with hyperlipidemia. Atherosclerosis 1985;54: 75-88.        [ Links ]

12. Brasil. Ministério da Saúde - Programas e Projetos. Doenças Cardiovasculares: Aspectos Epidemiológicos. Brasília 1999.        [ Links ]

13. Forti N, Fukushima J, Giannini SD. Perfil lipídico de indivíduos submetidos à cinecoronariografia em diferentes regiões do Brasil. Arq Bras Cardiol 1997; 68:333-42.        [ Links ]

14. Block G, Hartman AM, Dresser CM, Carrol MD, Gannon J, Gardner L. A data – based aproach to diet, questionnaire design and testing. Am J Epidemiol 1986;124:453-69.        [ Links ]

15. Block G; Dresser CM, Hartman AM, et al. Nutrient source in the American diet: quantitative data from the NHANES II Survey I Vitamins and minerals. Am J Epidemiol 1985;122:13-26.        [ Links ]

16. IV Diretrizes Brasileiras de Hipertensão Arterial. Sociedade Brasileira de Hipertensão, Sociedade Brasileira de Cardiologia, Sociedade Brasileira de Nefrologia 2002: 1-40.        [ Links ]

17. Frisancho AR. New standards of weight and body composition by frame size and height for assessment of nutritional status of adults and the elderly. Am J CIin Nutr 1984;40:808-19.        [ Links ]

18. Philipp ST, Szarfarc SC, Latterza AR. Virtual nutr (software) Departamento de Nutrição/ Faculdade de Saúde Pública/ USP. São Paulo, 1996.        [ Links ]

19. Friedewald WT, Levy RI, Friedrickson DS. Estimation of the concentration of low density lipoprotein cholesterol in plasma without use of the preparative ultracentrifuge. Clin Chem 1972;18:499-502.        [ Links ]

20. D'Agostino RB Sr, Grundy S, Sullivan LM, Wilson P. CHD Risk Prediction Group. Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. JAMA 2002;286:180-7.        [ Links ]

21. Berlin JA, Colditz A. Meta-analysis of physical activity in the prevention of coronary heart disease. Am J Epidemiol 1990;132:612-28.        [ Links ]

22. Gurney JM, Jelliffe DB. Arm anthropometry in nutrional assessment: nomogram for rapid calculation os muscle circunference and cross-sectional muscle and fat areas. American J Clin Nutr 1973;26: 912-5.        [ Links ]

23. Bielicki JK, Knoff LJ, Tribble DL, Forte TM. Relative sensitivities of plasma:cholesterol acyltransferase, platelet-activating factor acetylhydrolase, an paraoxonase to in vitro gas-phase cigarette smoke exposure. Atherosclerosis 2001;155:71-8.        [ Links ]

24. Puska P, Neittaamaki L, Tuomileto J. A Survey of local health personnel and decision makers concerning the North Karelia Project: a community program for control of cardiovascular diseases. Evaluation of a comprehensive community programme for control of cardiovascular diseases. 1981;10:564-76.        [ Links ]

25. Barnard RF. Effects of lifestyle modification on serum lipids. Arch Intern Med 1991;151:1389-94.        [ Links ]

26. Castelli W. Cholesterol and lipids in the risk of coronary artery disease – The Framingham Heart Study. Can J Cardiol 1988;4 (suppl A):5-10.        [ Links ]

27. Kojima S, Rawano Y, Abe H - Acute effects of alcohol ingestion on blood pressure and erythrocyte sodium concentration. J Hypertens 1993;11: 185-90.        [ Links ]

28. Marmot MG. Alcohol and coronary heart disease. Int J Epidemiol 2001;30:724-9.        [ Links ]

29. Hanson RL, Imperatore G, Bennett PH, Knowler KC. Components of the "metabolic syndrome" and incidence of type 2 diabetes. Diabetes 2002;51:3120-7.        [ Links ]

30. Gohdes D, Harvell TS, Cummings S, Moore KR, Smilie JG, Helgerson SD. Smoking cessation and prevention: an urgent public health priority for american indians in the northern plains. Public Health Rep 2002;117:281-90.        [ Links ]

31. Pavan L, Casiglia E, Pauletto P, et al. Blood pressure, serum cholesterol and nutritional state in Tanzania and in the Amazon: comparison with an Italian population. J Hypertens 1997;15:1083-90.        [ Links ]

32. Njelekela M, Negish H, Nara Y, et al. Cardiovascular risk factors in Tanzania: a revisit. Acta Trop 2001;79:231-9.        [ Links ]

33. Pavan L, Casiglia E, Braga LM, et al. Effects of a traditional lifestyle on the cardiovascular risk profile: the Amondava population of the Brazilian Amazon. Comparison with matched African, Italian and Polish populations. J Hypertens 1999;17:749-56.        [ Links ]

 

 

Correspondence to
Francisco A. H. Fonseca
Disciplina de Cardiologia/Escola Paulista de Medicina - UNIFESP
Rua Pedro de Toledo, 458
São Paulo, SP, Brazil - Cep 04039-001
E-mail: lipides.dmed@unifesp.epm.br

Received: 10/15/02
Accepted: 5/5/03

 

 

English version by Stela Maris C. e Gandour

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