Physical activity in Brazil: lessons from ELSA-Brasil. Narrative review

Atividade física no Brasil: lições do ELSA-Brasil. Revisão narrativa

ABSTRACT

CONTEXT AND OBJECTIVE:

The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) was conducted among civil servants at six higher education institutions located in six Brazilian state capitals. The objective of this review was to identify the publications produced within the scope of ELSA-Brasil that analyzed the participants’ physical activity.

DESIGN AND SETTING:

Review study using baseline data from ELSA-Brasil.

METHODS:

Narrative review of Brazilian studies on physical activity produced using data from ELSA-Brasil participants.

RESULTS:

The prevalence of leisure-time physical activity (LTPA) among ELSA-Brasil participants was low (44.1% among men and 33.8% among women). The main factors associated were social (higher schooling and family income), environmental (living in places with conditions and opportunities for physical activity) and individual (not being obese, being retired, not smoking and positive perception of body image). The perception of facilities for walking in the neighborhood was positively associated with both LTPA and commuting-related physical activity. An active lifestyle was a protective factor against several cardiometa-bolic variables (hypertension, diabetes, lipid abnormalities and cardiovascular risk over the next 10 years). Comparison between LTPA and commuting-related physical activity showed that only LTPA had a protective effect against arterial hypertension.

CONCLUSIONS:

The prevalence of physical activity among ELSA-Brasil participants was low. The main determinants were social, environmental and personal. LTPA had a greater protective efect on cardio-metabolic outcomes than did commuting-related physical activity.

KEY WORDS:
Exercise; Social determinants of health; Epidemiology; Epidemiologic factors; Hypertension; Diabetes mellitus

RESUMO

CONTEXTO E OBJETIVO:

O Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) é um estudo longitudinal com servidores públicos de seis instituições de nível superior localizadas em seis capitais brasileiras. O objetivo desta revisão foi identifcar as publicações realizadas no âmbito do ELSA-Brasil que tenham analisado a atividade física dos participantes.

TIPO DE ESTUDO E LOCAL:

Estudo de revisão com dados da linha de base do ELSA-Brasil.

MÉTODOS:

Revisão narrativa dos estudos sobre atividade física no Brasil produzidos com dados de participantes do ELSA-Brasil.

RESULTADOS:

A prevalência da atividade física no tempo livre (AFTL) em participantes do ELSA-Brasil foi baixa, (44,1% em homens e 33,8% em mulheres). Os principais fatores associados foram de ordem social (maior escolaridade e renda familiar), ambiental (viver em locais com condições e oportunidades para prática de atividade física) e individual (não ser obeso, ser aposentado/a, não ser tabagista, e ter percepção positiva da imagem corporal). A percepção de facilidades para caminhar na vizinhança foi positivamente associada tanto a AFTL quanto a atividade física no deslocamento (AFD). O estilo de vida ativo fsicamente foi fator de proteção para diversas variáveis cardiometabólicas (hipertensão arterial, diabetes, alterações lipídicas e risco cardiovascular nos próximos 10 anos). Após comparação entre AFTL e AFD, observou-se que apenas a AFTL apresenta efeito protetor para hipertensão arterial.

CONCLUSÕES:

A prevalência da atividade física em participantes do ELSA-Brasil foi baixa, os principais determinantes foram de ordem social, ambiental e pessoal. A AFTL apresentou maior efeito de proteção para desfechos cardiometabólicos do que a AFD.

PALAVRAS-CHAVE:
Exercício; Determinantes sociais da saúde; Epidemiologia; Fatores epidemiológicos; Hipertensão; Diabetes mellitus

INTRODUCTION

At the beginnings of humankind, during the prehistoric period, people depended on their physical strength and ability to survive. They were nomads and, in their constant migrations in search of food and shelter, they made long walks along which they fought, ran and jumped. Thus, they were extremely physically active.¹ Over the centuries, humans have undergone progressive reduction in their levels of physical activity, which was accentuated by the industrial revolution and more forcefully by the current technological revolution, although this reduction varies according to culture and social class. Currently, physical activity is defned as any body movement produced by the skeletal muscles that results in energy expenditure above the levels of resting metabolism.² It is contextualized into four domains: leisure time, work, commuting and household-related physical activity.

For the Brazilian Longitudinal Study of Adult Health (ELSABrasil), it was decided to include only the domains of leisure time and commuting in the data collection. Physical activity at work and household activities were not recommended for assessment because of a tendency to overestimate the results from these domains in Latin America.³ In addition, these domains not included in ELSA-Brasil have only shown slight associations with possible health benefts.⁴,⁵,⁶

Epidemiological studies on physical activity can be categorized in accordance with the model for population studies on physical activity and health proposed by Pitanga.⁷ In this model, physical activity can be investigated both as a dependent variable and as an independent variable. When used as a dependent variable, the prevalence of physical activity and associated factors in population groups is studied. As an independent variable, the main consequences of physical activity are analyzed in relation to diferent outcomes. In the case of ELSABrasil, these were mainly cardiometabolic outcomes.

OBJECTIVE

The objective of this narrative review was to identify the epidemiological studies conducted within the scope of ELSA-Brasil that have analyzed the participants’ physical activity both as a dependent variable and as an independent variable.

METHODS

This was a narrative review of Brazilian studies on physical activity produced using data from ELSA-Brasil participants.

What is ELSA-Brasil?

ELSA-Brasil was a cohort study on 15,105 women and men between the ages of 35 and 74 who were active or retired civil servants. They were recruited at six higher education and research institutions located in the cities of Salvador, Vitória, Belo Horizonte, Rio de Janeiro, São Paulo and Porto Alegre. The methodological details of the study have been described previously.⁸,⁹

Briefy, the data analyzed in the articles included in the present review were obtained at the baseline of ELSA-Brasil, between 2008 and 2010. The data had been gathered by a team of interviewers and certifers, who had been trained and certifed by a quality control committee⁹ to implement the study protocol at any ELSA-Brasil Research Center. A questionnaire had been applied then by means of face-to-face interviews. The protocol for ELSA-Brasil was approved by research ethics committees at the six centers involved in the study.

Assessment of physical activity

To identify and quantify physical activity, the International Physical Activity Questionnaire (IPAQ) was used in the Elsa-Brasil. This consists of questions relating to the frequency and duration of physical activities (walking and moderate or vigorous exercise) that are developed at work, in going from place to place (commuting), in domestic activities and during leisure time.¹⁰ In ELSA-Brasil, only the domains of leisure time and commuting were evaluated. Physical activity was measured in minutes/week by multiplying the duration of each of the activities performed by the respective weekly frequency. The prevalence of leisure-time physical activity (LTPA) stratifed according to some variables analyzed in ELSABrasil is presented in Table 1.

Table 1.
Prevalence of leisure-time physical activity (LTPA), stratifed according to the variables analyzed in the Longitudinal Study of Adult Health (ELSA-Brasil), 2008-2010¹³

Variables		Men		Women
Prevalence of LTPA	6788	44.1 (42.9-45.3)	8088	33.8 (32.8-34.8)
Age (years)
34-50	3168	44.9 (42.3-47.6)	3750	31.4 (28.7-34.1)
51-59	2102	40.2 (37.1-43.8)	2619	33.5 (30.4-36.7)
≥ 60	1518	47.6 (43.8-51.2)	1719	39.7 (36.0-43.5)
Education
Incomplete elementary	564	27.8 (21.2-35.7)	326	19.0 (10.4-31.4)
Complete elementary	569	34.4 (28.5-41.8)	444	20.7 (12.9-30.4)
High school	2221	39.8 (36.6-43.1)	2918	25.8 (22.7-29.1)
College	3434	51.2 (48.8-53.6)	4400	41.6 (39.3-43.9)
Monthly family income
Up to 2 MW	79	32.9 (17.2-55.7)	112	19.6 (5.2-40.3)
2 MW to 8 MW	2654	35.8 (32.8-38.9)	3217	24.9 (21.9-28.0)
8 MW to 18 MW	2238	46.0 (42.9-49.1)	3069	34.7 (31.8-37.6)
Above 18 MW	1791	54.8 (51.6-57.9)	1654	50.9 (47.5-54.4)
Suitable conditions for physical activity
No	1706	36.1 (31.3-39.0)	2281	26.0 (22.5-2973)
Yes	4703	47.5 (45.4-49.5)	5390	37.6 (35.5-39.8)
Opportunities for physical activity
No	1659	35.5 (31.6-39.5)	1971	22.9 (19.2-27.2)
Yes	4911	47.7 (45.7-49.8)	5903	37.8 (35.8-39.9)
Functional status
Active	5698	43.0 (41.0-45.0)	6239	31.7 (29.6-33.4)
Retired	1087	49.9 (45.6-54.2)	1844	41.3 (37.7-44.9)

• MW = minimum wage.

RESULTS

Up to the present time, six papers using ELSA-Brasil baseline data that allow refection on the main characteristics of physical activity in this population have been published. These papers deal with leisure-time and commuting-related physical activity both as dependent variables and as independent variables. In addition, another study compares the efects of leisure-time physical activity with those from commuting, with hypertension as the outcome.

Physical activity as the outcome (prevalence and associated factors)

The frst study on leisure-time physical activity published within the scope of ELSA-Brasil aimed to identify the associations of body image and obesity with physical activity, and considered 13,286 participants aged 35-64 years. The main results showed that body image dissatisfaction was less likely associated with moderate physical activity among women and of vigorous physical activity among men. It was also observed that men and women with central obesity and total obesity were less likely to engage in both high and moderate-intensity physical activity. Furthermore, overweight men were more likely to engage in vigorous physical activity.¹¹

Subsequently, the associations between the perceived characteristics of the neighborhood and physical activity were explored. This was a cross-sectional analysis on 14,749 ELSA-Brasil participants and the associations were tested through multinomial logistic regression. The main results observed were that the perception that the neighborhood was more walkable was positively associated with reports of participation in leisure-time physical activity, and with greater likelihood of practicing this for a longer time during the week. The perception that the neighborhood was more walkable increased the likelihood of practicing physical activity for more than 150 min/week or up to 150 min/week (in comparison with no physical activity). The perception that the neighborhood was more accessible for walking was also positively associated with active commuting (Table2).¹²

Table 2.
Association between perceived walkability and physical activity. ELSA-Brasil, 2008-2010¹²

Variables	Better walkability
Leisure-time physical activity
< 150	1.40 (1.28-1.52)
≥ 150	1.69 (1.57-1.83)
Commuting-related physical activity
< 150	1.08 (0.99-1.17)
≥ 150	1.19 (1.09-1.30)

Next, the prevalence and factors associated with leisure-time physical activity were identifed. A hierarchical ecological model was built with the possible factors associated with LTPA grouped into blocks. Odds ratios (ORs) and 95% confdence intervals (95% CIs) were estimated using logistic regression. The prevalence of LTPA among the ELSA-Brasil participants was 44.1% among men and 33.8% among women. Among men, having a higher education level, having a higher family income, living in environments with conditions and opportunities for physical activity, being retired and being overweight were positively associated with LTPA, while current smoking, obesity and abdominal obesity were negatively associated. Among women, being over 60 years old, having a higher education level, having a higher family income, living in an environment with conditions and opportunities for physical activity and being retired were positively associated with LTPA, while being overweight or obese and having abdominal obesity were negatively associated.¹³

Physical activity as independent variable (cardiometabolic consequences)

In Brazil, studies on the main cardiometabolic consequences of physical activity are very important because they provide specifc interpretations for the Brazilian population. Much of the existing information has been based on studies carried out abroad.

The frst study published within the scope of ELSA-Brasil with physical activity as an independent variable had the main objective of identifying the association of leisure-time physical activity with cardiometabolic health. This study was developed with 10,585 participants aged 35-74, without cardiovascular diseases. Leisuretime physical activity status was defned using the American Heart Association and World Health Organization recommendations (= 150 min/week of moderate activity or 75 min/week of vigorous activity). Afer adjusting for confounding factors, the positive efects of leisure-time physical activity on cardiometabolic parameters were evident. The main results demonstrated an inverse association between leisure-time physical activity and arterial hypertension, diabetes and cardiovascular risk over the next 10 years, among both men and women¹⁴ (Table 3).

Table 3.
Association between physical activity and cardiometabolic outcomes. ELSA-Brasil, 2008-2010^14,16

Variables	Leisure-time physical activity	Commuting-related physical activity
Hypertension
Men	0.75 (0.65-0.87)	No associations
Women	0.78 (0.66-0.92)	1.11 (1.01-1.21)
Diabetes
Men	0.73 (0.61-0.87)	Data unavailable
Women	0.83 (0.67-1.03)	Data unavailable
Cardiovascular diseases over next 10 years
Men	0.67 (0.57-0.78)	Data unavailable
Women	0.78 (0.65-0.93)	Data unavailable

Subsequently, a more recent paper aimed to assess the association of leisure-time physical activity intensity and duration with HDL-C, LDL-C and triglyceride levels. This was a cross-sectional study on 12,688 participants who were not on lipid-lowering medication. Afer adjusting for confounding factors, multiple linear regression was used to evaluate the association of intensity and duration of leisure-time physical activity with HDL-C, LDL-C and triglyceride levels. Both moderate and vigorous physical activity were found to be signifcantly associated with higher levels of HDL-C and lower levels of triglycerides. Tere were no signifcant associations of leisure-time physical activity with LDL-C levels.¹⁵

Associations of leisure-time and commuting physical activity with cardiometabolic outcomes

Finally, associations of leisure-time physical activity and commuting-related physical activity with high blood pressure were investigated among ELSA-Brasil participants. Hypertension was defned as systolic/diastolic blood pressure of > 140/90 mmHg or use of antihypertensive medications. Out of the total samples of 15,105 participants, 13,857 subjects without previous cardiovascular diseases were analyzed. The association between physical activity and hypertension was determined using Poisson regression with adjustment for confounding variables. The results showed that among both men and women, leisure-time physical activity was inversely associated with hypertension. However, in relation to commuting, the association with hypertension was positive among women and without statistical signifcance among men¹⁶ (Table 3).

Final remarks

One possible limitation of this study is that the information on physical activity was obtained through self-reporting questionnaires. Nevertheless, these instruments are widely used in national and international studies.

The results presented here are examples of the potential for analysis of physical activity within ELSA-Brasil. This also includes the possibility that, in the near future, longitudinal data analyses may become feasible. Measurements of greater objectivity, such as accelerometry, can be expected to become incorporated, which may increase the validity of information on physical activity.

CONCLUSIONS

Trough these results, it can be stated that the prevalence of leisure-time physical activity was low among ELSA-Brasil participants. This is probably reproduced in similar populations, especially those involved in academic work, and it deserves to be studied in Brazil.

The results show that diferent variables within the social environment (greater schooling and family income) physical setting (living in places with conditions and opportunities for physical activity) and individual sphere (obesity, being retired and smoking) present associations with physical activity. Trough these results, it can also be inferred that body image and nutritional status present relationships with physical activity, for both sexes, but that the nature of the association with physical activity difers according to sex. It can also be stated that perceived walkability was independently associated with the practice of physical activity, both during leisure time and in relation to commuting.

Regarding the consequences of physical activity practices, the results confrm that leisure time physical activity was a protective factor against cardiometabolic disorders in the ELSA-Brasil cohort, both for men and for women, whereas active commuting did not have any cross-sectional association with cardiometabolic outcomes.

It can be suggested that incentive programs promoting physical activity practices should be implemented in populations similar to ELSA-Brasil that work in academic environments and are exposed to a sedentary daily life, considering that physically active behavior is a protective factor against diferent metabolic and cardiovascular diseases.

REFERENCES

• ¹
  Pitanga FJG. Epidemiologia, atividade física e saúde [Epidemiology, physical activity and health]. Revista Brasileira de Ciência e Movimento. 2002;10(3):49-54. Available from: https://portalrevistas.ucb.br/index. php/RBCM/article/view/463/489 Accessed in 2017 (Apr 26).
  » https://portalrevistas.ucb.br/index. php/RBCM/article/view/463/489
• ²
  Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical ftness: definitions and distinctions for health-related research. Public Health Rep. 1985;100(2):126-31.
• ³
  Hallal PR, Gomes L F, Parra DC, et al. Lessons learned after 10 years of IPAQ use in Brazil and Colombia. J Phys Act Health. 2010;7 Suppl 2:S259-64.
• ⁴
  Pitanga CPS, Pitanga FJG, Beck CC, Gabriel RECD, Moreira MHR. Nível de atividade física para prevenção do excesso de gordura visceral em mulheres pós-menopáusicas: quanto é necessário? [Level of physical activity in the prevention of excess visceral fat in postmenopausal women: how much is needed?]. Arq Bras Endocrinol Metab. 2012;56(6):358-63.
• ⁵
  Pitanga FJG, Barbosa SJO, Barbosa PJB, et al. Atividade física na prevenção de diabetes em etnia negra: quanto é necessário? [Physical activity in the prevention of diabetes in black ethnicity: how much is required?]. Rev Assoc Med Bras (1992). 2010;56(6):697-704.
• ⁶
  Pitanga FJG, Beck CC, Pitanga CPS, Freitas MM, Almeida LAB. Atividade física como discriminador da ausência de hipertensão arterial em homens adultos [Physical activity as discriminator of the absence of hypertension in adult men]. Rev Bras Med Esporte. 2014;20(6):456-60.
• ⁷
  Pitanga FJG. Epidemiologia da atividade física, exercício físico e saúde. 3^a ed. São Paulo: Phorte Editora; 2010.
• ⁸
  Aquino EM, Barreto SM, Bensenor IM, et al. Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): objectives and design. Am J Epidemiol. 2012;175(4):315-24.
• ⁹
  Schmidt MI, Griep RH, Passos VM, et al. Estratégias e desenvolvimento de garantia e controle de qualidade no ELSA-Brasil [Strategies and development of quality assurance and control in the ELSA-Brasil]. Rev Saúde Pública. 2013;47 suppl. 2:105-12.
• ¹⁰
  Matsudo S, Araújo T, Marsudo V, et al. Questionário internacional de atividade física (IPAQ): estudo de validade e reprodutibilidade no Brasil [International physical activity questionnaire (IPAQ): study of validity and reliability in Brazil]. Rev Bras Ativ Fís Saúde. 2001;6(2):5-18.
• ¹¹
  Coelho CG, Giatti L, Molina MD, Nunes MA, Barreto SM. Body Image and Nutritional Status Are Associated with Physical Activity in Men and Women: The ELSA-Brasil Study. Int J Environ Res Public Health. 2015;12(6):6179-96.
• ¹²
  Chor D, Cardoso LO, Nobre AA, et al. Association between perceived neighbourhood characteristics, physical activity and diet quality: results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). BMC Public Health. 2016;16:751.
• ¹³
  Pitanga FJ, Matos SM, Almeida Mda C, Molina Mdel C, Aquino EM. Factors associated with leisure time physical activity among ELSA-Brasil participants: Ecological model. Prev Med. 2016;90:17-25.
• ¹⁴
  Lin X, Alvim SM, Simoes EJ, et al. Leisure Time Physical Activity and Cardio-Metabolic Health: Results From the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). J Am Heart Assoc. 2016;5(6):pii. e003337.
• ¹⁵
  Silva RC, Barreto SM, Fedeli LMG, et al. Atividade Física e Perfl Lipídico no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) [Physical Activity and Lipid Profle in the ELSA-Brasil Study]. Arq Bras Cardiol. 2016;107(1):10-9.
• ¹⁶
  Tref C, Benseñor IM, Lotufo PA. Leisure-time and commuting physical activity and high blood pressure: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). J Hum Hypertens. 2017;31(4):278-83.

• 1
  Six higher education and research institutions located in the cities of Salvador, Vitória, Belo Horizonte, Rio de Janeiro, São Paulo and Porto Alegre, Brazil

• Sources of funding: Brazilian Ministry of Health (Science and Technology Department) and the Brazilian Ministry of Science and Technology (Studies and Projects Funding Office and CNPq National Research Council), nos. 01 06 0010.00 RS, 01 06 0212.00 BA and 01 06 0300.00 E

• Erratum

  DOI: 10.1590/1516-3180.2017.0023190317errata
  In the paper “Physical activity in Brazil: lessons from ELSA-Brasil. Narrative review”, with DOI number 10.1590/1516-3180.2017.0023190317, published in the Sao Paulo Medical Journal, volume 135, issue number 4, pages 391-5, on page 391:
  Where it read:
  “^IVMD, PhD. Full Professor, Institute of Public Health, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil.”
  It should read:
  “^IVMD, PhD. Full Professor, Instituto de Saúde Coletiva, Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil.”

Publication Dates

• Publication in this collection
  31 July 2017
• Date of issue
  Jul-Aug 2017

History

• Received
  10 Mar 2017
• Accepted
  19 Mar 2017