Abstract

Introduction

Physical inactivity is recognized as one of the greatest public health challenges of the 21st century due to its association with several noncommunicable diseases (NCDs) and other harmful effects to health¹1. Blair S. Physical inactivity: the biggest public health problem of the 21st century. Br. J. Sports Med. 2009; 43(1):1-2.. It is estimated that 6% of heart disease, 7% of type 2 diabetes, 10% of breast and colon cancer and 9% of premature mortality worldwide are due to physical inactivity²2. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380(9838):219-229..

Besides increasing the risk of NCDs, studies have shown that physical inactivity can have a direct economic impact on the public health care system³3. Bielemann RM, Knuth AG, Hallal PC. Atividade física e redução de custos por doenças crônicas ao Sistema Único de Saúde. Rev Bras Ativ Fís Saúde 2010; 15(1):9-14., significantly increasing medication consumption⁴4. Bertoldi AD, Hallal PC, Barros AJ. Physical activity and medicine use: evidence from a population-based study. BMC Public Health2006; 6:224. and demand for medical services⁵5. Codogno JS, Fernandes RA, Monteiro HL. Prática de atividades físicas e custo do tratamento ambulatorial de diabéticos tipo 2 atendidos em unidade básica de saúde. Arq Bras Endocrinol Metab 2012; 56(1):6-11., varying from basic to high complexity.

Being characterized as an articulated network between primary, medium and high complexity health care, the Brazilian National Health System currently faces many problems, including the disorderly flow of people and the high and unscheduled demand for services, causing poor regulation of access to health care services by the population, especially in primary care, the gateway to health care services with high coverage in the country⁶6. Pires MRGM, Gottems LBD, Martins CMF, Guilhem D, Alves ED. Oferta e demanda por média complexidade/SUS: relação com atenção básica. Cien Saude Colet 2010; 15(Supl. 1):1009-1019..

As an alternative, in order to reduce the burden of diseases, the development of policies and programs aimed at increasing physical activity at the population level have been prioritized⁷7. Heath GW, Parra DC, Sarmiento OL, Andersen LB, Owen N, Goenka S, Montes F, Brownson RC; Lancet Physical Activity Series Working Group. Evidence-based intervention in physical activity: lessons from around the world.Lancet 2012; 380(9638):272-281., and among the types of physical activity, walking has the highest adherence rate. Walking is recommended for people with NCDs and/or the elderly, conditions that make them more susceptible to physical inactivity and functional limitation, in addition to being a low cost and widely accessible physical activity. Walking on a regular basis can provide several health benefits, among them, fitness, body composition and physiological improvements⁸8. Silva MP, Santos Filho JAA, Gobbi S. Aptidão funcional de mulheres idosas mediante programa supervisionado de atividades físicas generalizadas ou caminhadas regulares sem supervisão. Rev Bras Ativ Fís Saúde2006; 11:3-12.

9. Kelly P, Kahlmeier S, Götschi T, Orsini N, Richards J, Roberts N, Scarborough P, Foster C. Systematic review and meta-analysis of reduction in all-cause mortality from walking and cycling and shape of dose response relationship. Int J Behav Nutr Phys Act 2014; 11(1):132.^-1010. Hamer M, Chida Y. Walking and primary prevention: a meta-analysis of prospective cohort studies. Br J Sports Med 2008; 42(4):238-243..

Due to its feasibility and the potential benefits that walking can provide as well as the growing economic impact of physical inactivity, the aim of this study was to determine, among users of the Brazilian National Health System, whether there are associations between walking during leisure-time, risk factors and expenditure related to health care services in primary care.

Methods

Study design, population and sample

This is a cross-sectional study with a retro-analytical component, conducted in the city of Bauru, Sao Paulo State, and approved by the Ethics Committee Group from the Universidade Estadual Paulista, Bauru campus, and the Ethics Committee Group of the Department of Health, Bauru/Sao Paulo State.

The present study was based on a larger study, which randomly selected a representative group of users of the Brazilian National Health System in Bauru – SP, Brazil (963 participants were randomly selected and interviewed)¹¹11. Turi BC, Codogno JS, Fernandes RA, Monteiro HL. Prática de atividade física, adiposidade corporal e hipertensão em usuários do Sistema Único de Saúde. Rev bras epidemiol 2014; 17(4):925-937.. For this study, the nonexistence of previous parameters for this population were considered (walking among users of primary health care system), the sample size estimation equation was based on percentage values with an outcome of 50% (which generates the largest sample size in this type of equation). Added to the 50%, the following parameters were used; 3.5% error (arbitrary because there are no similar studies) and 5% statistical significance [z = 1.96 using a 95% confidence interval (95%CI)]. Finally, the minimum representative sample size for this study was set at 784 people. The inclusion criteria were defined as follows: i) being registered for a minimum of one year at the Basic Healthcare Unit (BHU); ii) aged≥ 50 years; iii) having an active registration in the health care service (having scheduled at least one medical visit in the previous six months); iv) signing the standard written consent form.

Initially, in each of the five selected BHUs, the medical agendas were screened to identify all patients with at least one scheduled appointment in the previous six months. Next, the medical record numbers of the patients who met the inclusion criteria were inserted in a computer spreadsheet and 250 to 500 randomly selected from each BHU. This procedure was performed using the Statistical Package for Social Sciences (SPSS) software, version 13.0. All the selected patients were invited to attend the BHU interview¹¹11. Turi BC, Codogno JS, Fernandes RA, Monteiro HL. Prática de atividade física, adiposidade corporal e hipertensão em usuários do Sistema Único de Saúde. Rev bras epidemiol 2014; 17(4):925-937.. The study was conducted from August to December 2010.

Walking

Information regarding walking was extracted using the “physical activity during leisure-time” section of the Baecke¹²12. Baecke JAH, Burema J, Frijters JER. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr 1982; 36(5):936-942. questionnaire, validated by Florindo and Latorre¹³13. Florindo AA, Latorre MA. Validation and reliability of the Baecke questionnaire for the evaluation of habitual physical activity in adult men.Cad Saude Publica 2006; 22(3):535-541. for the Brazilian population. This section evaluates the frequency of walking during leisure-time with the following options: (i) never; (ii) seldom; (iii) sometimes; (iv) often; (v) always.

Healthcare expenditure

Healthcare expenditure per year was estimated, including all items registered in the medical records of the patients for one year prior to the date of the interview. The following data were gathered: medication dispensed, laboratory tests performed and number of medical consultations. To transform the procedures into currency, a specific standard table was provided by the Department of Health for the year 2012. For statistical procedures, expenditure was ranked and stratified into quartiles and the highest quartile (> P75) was adopted as the indicator of high healthcare expenditure¹⁴14. Codogno JS, Fernandes RA, Sarti FM, Freitas Júnior IF, Monteiro HL. The burden of physical activity on type 2 diabetes public healthcare expenditures among adults: a retrospective study. BMC Public Health 2011; 11:275..

Potential confounders

The face-to-face interviews and anthropometric measurements were performed in a quiet room at the BHU by a researcher. The following data were obtained through interviews and confirmed in the medical records, which, for statistical procedures, were dichotomized, as follow: (i) socio-demographic variables (sex [female or male] and chronological age [structured as categorical variable: < 65 years-old (adult) and ≥ 65 years-old (elderly)]); (ii) smoking habits [categorized as “yes” (current smokers independent of number of cigarettes per day) or “no” (former smokers or non-smokers)]; (iii) economic status, assessed using a specific and previously validated Brazilian questionnaire¹⁵15. Associação Brasileira de Empresas de Pesquisa (ABEP). Dados com base no Levantamento Sócio Econômico 2008. ABEP; 2010. [acessado 2010 mar 10]. Disponível em: www.abep.com.br
www.abep.com.br... , which estimates the family income (dichotomized into either low or high income) and includes level of formal education; (iv) general obesity, identified through the body mass index (BMI), calculated using measurements of weight and height¹⁶16. Organização Mundial de Saúde (OMS). Obesity, Preventing and Managing the Global Epidemic: Report of the WHO Consultation on Obesity. Geneva: OMS; 1998. and obtained by dividing weight by height squared (kg/m²). Overweight was defined as BMI ≥ 25 kg/m² and obesity as 30kg/m²; (v) abdominal obesity, identified by waist circumference (WC) with the cut-off point set at 1.02 meters for men and 0.88 meters for women¹⁷17. Peixoto MRG, Benício MHD, Latorre MRDO, Jardim PCBV. Circunferência da cintura e índice de massa corporal como preditores da hipertensão arterial.Arq Bras Cardiol 2006; 87(4):462-470.; (vi) blood pressure was measured in a seated position at rest and values lower than 120/80 mmHg for systolic (SBP) and diastolic blood pressure (DBP) were considered normal, respectively. Diagnosis of arterial hypertension was identified through the medical records of the participant.

Statistical analysis

Categorical variables were expressed as rates and the 95%CI calculated. The chi-square test analyzed the existence of associations between walking, risk factors and healthcare expenditure. Next, binary logistic regression was performed to identify the same associations adjusted by potential confounders. This procedure generated odds ratio (OR) and 95%CI values. Statistical significance was set at p-value ≤ 0.05 and all statistical analyses were performed using the software BioEstat (release 5.0). Adjustment of the multivariable models was identified using the Hosmer-Lemeshow goodness-of-fit test [non-significant results (p-value > 5%) indicated an adequate adjustment].

Results

Considering the total sample, 963 adults of both sexes were selected and interviewed (women 73.4% [95%CI: 70.6 to 76.2]) with ages ranging between 50 and 96 years (Table 1). Walking during leisure-time was reported as follows: 15.8% never (95%CI: 13.4% - 18.1%), 4.5% seldom, 13% sometimes, 2.4% often and 64.4% always (95%CI: 61.3% - 67.4%). The groups with a higher frequency of walking during leisure-time presented lower ages (“always” group 1.5% younger compared to the “never” group; p-value = 0.009), lower BMI values (“always” group values 1.4% lower compared to the “never” group; p-value = 0.019), WC (“always” group values 4% lower compared to the “never” group; p-value = 0.001) and medicine expenditure (“always” group 25.9% lower expenditure compared to the “never “ group; p-value = 0.014). In the same groups it was also possible to identify lower occurrences of abdominal obesity (“never” group 75.1% [95%CI: 68.1% - 81.8%] and “always” group 66.3% [95%CI: 62.5% - 70.1%]; p-value = 0.003) and arterial hypertension (“never” group 83.6% [95%CI: 77.6% - 89.4%] and “always” group 74.8% [95%CI: 71.4% -78.2%]; p-value = 0.015).

In the analyzed sample, walking was not associated with higher expenditure on consultations, tests or medication (all p-values > 5%). However, it was observed that higher engagement in walking was associated with a lower percentage of patients classified in the highest total expenditure group (p-value = 0.002) (Table 2).

Moreover, even after adjustment for potential confounders, it was identified that patients with the highest engagement in walking during leisure-time (when compared to patients inserted in the “Never” category) were 41% less likely to be in the highest quartile of total expenditure (OR = 0.59 [0.39 - 0.89]). The multivariate model also showed that obesity (BMI ≥ 30 kg/m²; OR = 1.32 [1.01 - 1.74]) and a diagnosis of arterial hypertension (OR = 2.07 [1.34 - 3.22]) remained associated with higher total expenditure, regardless of walking.

It is noteworthy that the created multivariate model explained 75.4% of variation related to outcome, and the Hosmer-Lemeshow goodness-of-fit test showed that all models were well fitted to the data (p-value > 5%) (Table 3).

Regarding expenditure according to frequency of walking, there was a significant difference between the median of the “always” group “and the cluster of the other groups for medication (5.9 Reais per patient; p-value for Mann-Whitney test = 0.012) and total expenditure (9.5 Reais per patient; p-value for Mann-Whitney test = 0.010).

Discussion

The main findings of the present study were: (i) a high adherence to walking as a leisure-time physical activity; (ii) the association of walking with lower expenditure on medication and a lower percentage of people engaged in walking classified in the highest total expenditure group. In addition, obesity and the diagnosis of arterial hypertension were associated with higher total expenditure regardless of walking.

Regarding the high adherence to walking, it was found that 64.4% of participants reported walking as a leisure-time physical activity. This finding is consistent with other studies conducted in Brazil that assessed physical activity patterns through a telephone survey, and found that 67.9% of men and 79.8% of women aged less than 45 years old walk for at least 30 minutes on five or more days per week¹⁸18. Malta DC, Moura, EC, Castro AM, Cruz DKA, Morais Neto OL, Monteiro CA. Physical activities pattern among Brazilian adults: Results of phone survey, 2006. Epidemiol. Serv. Saúde 2009; 18(1):7-16.. In agreement with data from Brazil, an American study found that the prevalence of walking increased significantly from 2005 to 2010, being a common type of physical activity for 62% of the population¹⁹19. Centers for Disease Control and Prevention. Vital Signs: Walking Among Adults — United States, 2005 and 2010. MMWR 2012; 61(31):595-601.. These findings indicate that in Brazil and other countries, walking presents itself as an important manifestation of physical activity during leisure-time and thus should be considered as an important promotional agent of physical activity in adults.

Although walking has become popular among the adult population, this does not mean that the number of minutes performed by participants reaches the recommendations of the American College of Sports Medicine, which defines that health benefits can be achieved with an accumulation of at least 150 minutes of physical activity at moderate intensity during the week. In this sample, among subjects reporting walking with the frequency “always”, only 19.5% (95%CI: 16.4% - 22.6%) met these recommendations. Likewise, the inclusion of this variable in the multivariate model did not affect the association between walking and health care expenditure (OR = 0.62 [0:41 - 0.94]) and did not increase the explanation power of the model (maintained at 75.4%). These findings demonstrate that, even when below current recommendations, walking can be associated with health benefits. Thus, for additional health benefits, public health strategies should provide the population with information on the current recommendations for walking, regarding optimal intensity, duration and frequency.

Moreover, it was found that participants engaged in walking presented a lower age, BMI and WC, corroborating the findings of CDC¹⁹19. Centers for Disease Control and Prevention. Vital Signs: Walking Among Adults — United States, 2005 and 2010. MMWR 2012; 61(31):595-601.. Contrary to these results, Malta et al.¹⁸18. Malta DC, Moura, EC, Castro AM, Cruz DKA, Morais Neto OL, Monteiro CA. Physical activities pattern among Brazilian adults: Results of phone survey, 2006. Epidemiol. Serv. Saúde 2009; 18(1):7-16. observed an increase in walking levels with an increase in age for both sexes, with the explanation that, when older, physical activity motivation becomes more related to health maintenance than leisure practice²⁰20. Monteiro CA, Conde WL, Matsudo SM, Matsudo VR, Bonsenor IM, Lotufo PA. A descriptive epidemiology of leisure-time physical activity in Brazil, 1996-1997. Rev Panam Salud Publica 2003; 14(4):246-254.. However, it should be considered that the sample in the present study was composed of people treated at BHUs of 50+ years old, unlike the sample in the Malta study¹⁸18. Malta DC, Moura, EC, Castro AM, Cruz DKA, Morais Neto OL, Monteiro CA. Physical activities pattern among Brazilian adults: Results of phone survey, 2006. Epidemiol. Serv. Saúde 2009; 18(1):7-16..

Regarding the association between health care expenditure and walking, it was found that the most active group presented lower expenditure on medicine and was 41% less likely to be classified in the highest total expenditure group. Consistent with these findings, a Brazilian study showed that a one-year intervention of a guided walking program was able to reduce medication use by 25% and the outpatient expenditure among women with hypertension by 35%²¹21. Rolim LM, Amaral SL, Monteiro HL. Hipertensão e exercício: custos do tratamento ambulatorial, antes e após a adoção da prática regular e orientada de condicionamento físico. Hipertensão 2007; 10(2):2-10..

In this respect, Bertoldi et al.⁴4. Bertoldi AD, Hallal PC, Barros AJ. Physical activity and medicine use: evidence from a population-based study. BMC Public Health2006; 6:224. found that insufficiently active individuals used 39% more medication compared to active participants, and, similarly, Codogno et al.⁵5. Codogno JS, Fernandes RA, Monteiro HL. Prática de atividades físicas e custo do tratamento ambulatorial de diabéticos tipo 2 atendidos em unidade básica de saúde. Arq Bras Endocrinol Metab 2012; 56(1):6-11. found that insufficiently active diabetic patients presented 63% more expenditure on consultations and 128% more on medication for the treatment of other diseases when compared to the active group.

Extrapolating data on economic impact and physical activity, an Australian study estimated that, if all inactive adults in the country walked for an hour a day at least five days a week, the annual savings would be A$419.9 million²²22. Zheng H, Ehrlich F, Amin J. Economic evaluation of the direct health care cost savings resulting from the use of walking interventions to prevent coronary heart disease in Australia. Int J Health Care Finance Econ 2010; 10(2):187-201.. A similar study conducted in Pelotas/RS found that, if all citizens were active, savings to the Brazilian public healthcare system, including medication and hospitalizations from arterial hypertension and diabetes, would be approximately RS$2.2 million³3. Bielemann RM, Knuth AG, Hallal PC. Atividade física e redução de custos por doenças crônicas ao Sistema Único de Saúde. Rev Bras Ativ Fís Saúde 2010; 15(1):9-14..

In the present sample, the median difference between the “always” group and the cluster of other walking groups for medication (R$5.9 per patient; p-value for Mann-Whitney test = 0.012) and total health care expenditure (R$9.5 per patient; p-value for Mann-Whitney test = 0.010) were significant. If we consider that the population of Bauru city includes 83,104 adults over 50 years old living in the urban area²³23. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico 2010. [acessado 2014 maio 18]. Disponível em: http://www.cidades.ibge.gov.br/xtras/temas.php?lang=&codmun=350600&idtema=90&search=sao-paulo|bauru|censo-demografico-2010:-resultados-da-amostra-caracteristicas-da-populacao
http://www.cidades.ibge.gov.br/xtras/tem... , of which 60% would be exclusively attended by the Brazilian National Health System (49,862 inhabitants) and 35.6% of these (17,751 inhabitants) are not engaged in walking in the “always” frequency, if all these patients became more active, i.e., reporting the frequency “always” in walking during leisure-time, the projected annual savings would be R$104,730.90 on medication expenditure and R$168,634.50 on total expenditure in primary care alone, without considering the demand for specialized care, the costs of which are potentially higher. It is important to mention that this sample is representative only of users of primary care in the city of Bauru/SP and, thus, implications for the general population cannot be assumed. On the other hand, even considering this limitation, this simple estimation, provides interesting information about the association between walking and lower health care expenditure in the general population.

It is also important to highlight the low percentage of participants reporting “always” walking that did not meet the recommendations for physical activity of moderate to vigorous intensity in the preceding four months²⁴24. Fernandes RA, Christofaro DG, Casonatto J, Codogno JS, Rodrigues EQ, Cardoso ML, Kawaguti SS, Zanesco A. Prevalence of dyslipidemia in individuals physically active during childhood, adolescence and adult age.Arq Bras Cardiol 2011; 97(4):317-323.^,2525. Fernandes RA, Zanesco A. Early physical activity promotes lower prevalence of chronic diseases in adulthood. Hypertens Res2010; 33(9):926-931., demonstrating that if this type of physical activity were better supervised, the observed associations could be strengthened.

With regard to obesity and arterial hypertension being associated with higher total expenditure, there is worldwide evidence confirming the findings of the present study. A Brazilian study on diabetes mellitus found that a higher BMI and waist-hip ratio were significantly related to higher expenditure on medications for chronic diseases other than diabetes¹⁴14. Codogno JS, Fernandes RA, Sarti FM, Freitas Júnior IF, Monteiro HL. The burden of physical activity on type 2 diabetes public healthcare expenditures among adults: a retrospective study. BMC Public Health 2011; 11:275.. In addition, Bahia et al.²⁶26. Bahia L, Coutinho ES, Barufaldi LA, Abreu Gde A, Malhão TA, de Souza CP, Araújo DV. The costs of overweight and obesity-related diseases in the Brazilan public health system: cross-sectional study. BMC Public Health 2012; 12:440. found that estimated total costs in one year on all diseases related to overweight and obesity were US$2.1 billion, 68.4% being due to hospitalizations, and US$679,000 due to outpatient procedures. In our sample, medication use was significantly affected by walking and represented a total burden of 35% of total health expenditure. These findings indicate that interventions aimed at increasing physical activity levels during leisure-time could affect a significant portion of primary care costs.

Regarding the economic impact of hypertension, there is a consensus that the medical, monetary and human costs of untreated and/or inadequately controlled blood pressure are enourmous²⁷27. Elliott WJ. The economic impact of hypertension. J Clin Hypertens 2003; 5(3 Supl. 2):3-13.. A population-based survey in southern Brazil showed that treatment for this disease costs around 23% of income per capita of hypertensive patients²⁸28. Dias da Costa JS, Fuchs SC, Olinto MT, Gigante DP, Menezes AM, Macedo S, Gehrke S. Cost-effectiveness of hypertension treatment: a population-based study. Sao Paulo Med J 2002; 120(4):100-104.. In addition, another study indicated that, in 2001, blood pressure above recommended levels cost US$370 million, which represented about 10% of total health care expenditure in the world²⁹29. Gaziano TA, Bitton A, Anand S, Weinstein MC. The global cost of nonoptimal blood pressure. J Hypertens. 2009; 27(7):1472-7.. In Brazil, the Ministry of Health has programs for the treatment of patients with hypertension and/or diabetes and increased access to medication, known as HiperDia³⁰30. Brasil. Ministério da Saúde (MS). Plano de Reorganização da Atenção à Hipertensão Arterial e ao Diabetes mellitus: programa de educação permanente em Hipertensão Arterial e Diabetes mellitus para os municípios com população acima de 100 mil habitantes. Brasília: MS; 2002. and Farmácia Popular³¹31. Brasil. Decreto no 5.090, de 20 de maio de 2004. Regulamenta a Lei no 10.858, de 13 de abril de 2004, e institui o programa “Farmácia Popular do Brasil”, e dá outras providências. Diário Oficial da União 2004; 21 maio.. Such initiatives increase knowledge on the epidemiological profile of these diseases in the country and give patients regular and systematic access to medicines, however, none of the programs have recommendations for physical activities, since inclusion of a physical education trainer is new in the context of the national health care system³²32. Malta DC, Castro AM, Gosch CS, Cruz DKA, Bressan A, Nogueira JD, Morais Neto OL, Temporão JG. A Política Nacional de Promoção da Saúde e a agenda da atividade física no contexto do SUS. Epidemiol Serv Saúde2009; 18(1):79-86..

Thus, taking into account the highlighted benefits of walking to reduce mortality³³33. Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol 2011; 40(1):121-138., its advantages for diabetic³⁴34. Yates T, Davies M, Gorely T, Bull F, Khunti K. Effectiveness of a pragmatic education program designed to promote walking activity in individuals with impaired glucose tolerance: a randomized controlled trial. Diabetes Care 2009; 32(8):1404-1410. and cardiovascular patients³⁵35. Lee LL, Watson MC, Mulvaney CA, Tsai CC, Lo SF. The effect of walking intervention on blood pressure control: a systematic review. Int J Nurs Stud 2010; 47(12): 1545-1561.^,3636. Murphy MH, Nevill AM, Murtagh EM, Holder RL. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomised, controlled trials. Prev Med 2007; 44(5):377-385. as well as those with mental diseases³⁷37. Roe J, Aspinall P. The restorative benefits of walking in urban and rural settings in adults with good and poor mental health. Health Place 2011; 17(1):103-113., the gains in physiological components and functional capacity⁸8. Silva MP, Santos Filho JAA, Gobbi S. Aptidão funcional de mulheres idosas mediante programa supervisionado de atividades físicas generalizadas ou caminhadas regulares sem supervisão. Rev Bras Ativ Fís Saúde2006; 11:3-12., in addition to the contribution of walking in reducing expenditure related to health care services³3. Bielemann RM, Knuth AG, Hallal PC. Atividade física e redução de custos por doenças crônicas ao Sistema Único de Saúde. Rev Bras Ativ Fís Saúde 2010; 15(1):9-14., the stimulation of programs and actions to promote walking is recommended, since control of risk factors has been identified as a priority for the Brazilian government action plan³⁸38. Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise de Situação em Saúde. Avaliação de Efetividade de Programas de Atividade Física no Brasil. Brasília: MS; 2011..

The following can be considered limitations of the present study: i) the self-reporting of walking as a leisure-time physical activity, which may have been overestimated due to the high awareness of the importance of physical activity; ii) the lack of quantitative data on walking, since interpretation of the categories of perception “seldom, sometimes, often and always” can differ from person to person, and iii) the cross-sectional design, which does not establish causal relationships.

In conclusion, it was found that among the study population, there was an association between walking during leisure-time and lower expenditure on medication, as well as a lower percentage of walking participants entered in the highest total expenditure group. In addition, obesity and a diagnosis of hypertension were associated with higher total expenditure regardless of walking.

References

Publication Dates

History