Ideal cardiovascular health prevalence in the Brazilian population - National Health Survey (2013)

Velasquez-Melendez, Gustavo; Felisbino-Mendes, Mariana Santos; Matozinhos, Fernanda Penido; Claro, Rafael; Gomes, Crizian Saar; Malta, Deborah Carvalho

doi:10.1590/1980-5497201500060009

ABSTRACT:

Primordial prevention is defined as the initial prevention of risk factors, through the adoption of healthier behaviors. Within this concept, the American Heart Association (AHA) has defined seven metrics, based on evidence, to achieve ideal cardiovascular health. The aim of this study was to evaluate the prevalence of cardiovascular health in the Brazilian population, according to sex, age, and region of residence, using data from the latest National Health Survey (2013). We assessed the risk factors, as recommended by the AHA, combined (number of factors) and individually: four behavioral (smoking, physical activity, body mass index and diet) and three biological factors (blood pressure, blood glucose and cholesterol levels). The Brazilian population has reached very low prevalence (1%), for the sum of 7 factors in ideal level. Individually, 3.2% of the population consumed ideal diet, followed by physical activity (23.6%) and body mass index (43.7%). The subjects aged between 18 and 35 years showed higher prevalence of metrics combined at the optimal levels (0.5%), which was also reached by the population of the Northern region. These results indicate that greater efforts are urgent by public policies at the level of primordial prevention in order to achieve appropriate targets of cardiovascular health in the Brazilian population.

Keywords:
Cardiovascular diseases; Disease prevention; Health promotion; Risk factors; Epidemiology; Prevalence.

INTRODUCTION

Despite the decreasing mortality rates caused by cardiovascular diseases (CVDs) verified in Brazil from 2000 to 2011¹1. Malta DC, Moura LD, Prado RRD, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608., the CVDs are still among the main causes of death in the country¹1. Malta DC, Moura LD, Prado RRD, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608.. A similar reality is observed in high-, low-, and medium-income countries²2. Mendis S, Puska P, Norrving B. Global atlas on cardiovascular disease prevention and control. World Health Organization; 2011. ³3. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics-2011 update: a report from the American Heart Association. Circulation 2011; 123(4): 18-209..

In this context, in 2010, the American Heart Association (AHA)⁴4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613. came up with the concept of ideal cardiovascular health (CVH), with the objective of improving the CVH of the American population and of reducing the mortality caused by CVD in 20% until 2020. This concept is based on primordial prevention and includes four behavioral factors - smoking, physical activity, body mass index (BMI), and diet - and three biological factors - blood pressure, blood glucose, and cholesterol levels⁴4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613..

The reach of the higher number of factors for ideal CVH is associated with significant synergetic effects on the reduction of CVD incidence and population mortality⁵5. Liu Y, Chi HJ, Cui LF, Yang XC, Wu YT, Huang Z, et al. The ideal cardiovascular health metrics associated inversely with mortality from all causes and from cardiovascular diseases among adults in a Northern Chinese industrial city. PLoS One 2014; 9(2): e89161. ⁶6. Kim JY, Ko YJ, Rhee CW, Park BJ, Kim DH, Bae JM, et al. Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study. J Prev Med Public Health 2013; 46(6): 319-28. ⁷7. Zhang Q, Zhou Y, Gao X, Wang C, Zhang S, Wang A, et al. Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke. Stroke 2013; 44(9): 2451-6. ⁸8. Rasmussen-Torvik LJ, Shay CM, Abramson JG, Friedrich CA, Nettleton JA, Prizment AE, et al. Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study. Circulation 2013; 127(12): 1270-5.. Studies involving different populations have shown that the adherence to 6 of the proposed metrics at an ideal level is associated with a 51% reduction in the incidence of cancer⁸8. Rasmussen-Torvik LJ, Shay CM, Abramson JG, Friedrich CA, Nettleton JA, Prizment AE, et al. Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study. Circulation 2013; 127(12): 1270-5., 80% in the incidence of CVD⁹9. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community Prevalence of Ideal Cardiovascular Health, by the AHA Definition, and Relation to Cardiovascular Disease Incidence. J Am Coll Cardiol 2011; 57(16): 1690-6., 51% in mortality for all causes¹⁰10. Yang Q, Cogswell ME, Flanders WD, Hong Y, Zhang Z, Loustalot F, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA 2012; 307(12): 1273-83., 76% in mortality for CVD¹⁰10. Yang Q, Cogswell ME, Flanders WD, Hong Y, Zhang Z, Loustalot F, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA 2012; 307(12): 1273-83., and 70% in mortality caused by ischemic heart disease¹⁰10. Yang Q, Cogswell ME, Flanders WD, Hong Y, Zhang Z, Loustalot F, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA 2012; 307(12): 1273-83., when compared with the presence of 0 and 1 metric at an ideal level.

Unlike the prevention of the development of a disease, the primordial prevention is conceived as the initial prevention of risk factors by adopting healthier behaviors, which has been suggested as being essential to reach CVH and to reduce the high mortality rates caused by CVDs⁴4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613.. In this context, knowing the CVH situation of a population is essential to create efficient public policies, and national surveys can be useful surveillance tools that lead to population diagnoses.

In Brazil, for our awareness, studies that assess the CVH of the national population using criteria from the AHA have been published in a population restricted to the rural area¹¹11. Felisbino-Mendes MS, Jansen AK, Gomes CS, Velásquez-Meléndez G. Avaliação dos fatores de risco cardiovasculares em uma população rural brasileira. Cad Saúde Pública 2014; 30(6): 1183-94.. This concept is believed to be very useful to encourage that ideal goals can be reached, consequently improving the CVH of the population. Therefore, the objective of this study was to assess the prevalence of the ideal CVH in the Brazilian population according to gender, age group, and region of household, using the data from the last National Health Survey (PNS), 2013.

METHODS

This is a population-based cross-sectional study that used data from the PNS, 2013. PNS is a result of a partnership between the Ministry of Health and the Brazilian Institute of Geography and Statistics (IBGE), which collected information regarding health status perception, lifestyles, and chronic noncommunicable diseases (CNCD) in private households around the country. The sample of PNS was based on the sample of the National Household Sample Survey (PNAD), increasing its geographic range and improving the accuracy for specific indicators, selected in 3 stages: census tract, households, and inhabitants aged 18 years old or more. Other data about the sample and data collection for PNS are described in a specific publication¹²12. Instituto Brasileiro de Geografia e Estatística - IBGE. Pesquisa Nacional de Saúde 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: IBGE; 2014..

Of the 64,308 adults interviewed (18 years or older), 60,202 responded to the modules regarding lifestyle and medical diagnosis of CNCD, self-reported. This loss (about 6.5%) refers to refusals and inhabitants that were not present in the household. Besides, for this study, pregnant women (n = 800; 1.24%), the ones who did not know if they were pregnant (n = 176; 0.27%), and those who did not answer all of the 7 factors assessed (n = 25,840; 40.18%) were excluded, thereby accounting for a sample of 34,362 individuals.

The prevalence of ideal CVH in the population of this study was assessed according to that proposed by AHA⁴4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613., based on self-reported behavioral (smoking, BMI, physical activity, and diet) and biological factors (diagnosis of dyslipidemia, diabetes, and arterial hypertension).

The diet was assessed with four of the five criteria in the original proposal:

1. Regular intake of fruits and vegetables (at least five times per day, at least five times per week), based on the questions: "On how many days of the week do you usually eat lettuce and tomato or any other salad containing greens or raw vegetables?" and "In general, how many times a day do you eat this type of salad: once, twice or three times or more?"; "On how many days of the week do you usually eat greens or cooked vegetables with the food or in a soup, for instance, cabbage, carrot, chayote, eggplant, zucchini, not to mention potato, manioc or yam?" and "In general, how many times per day do you eat cooked greens or vegetables: once, twice, or three times or more?"; "On how many days of the week do you usually drink fruit juices?" and "In general, how many times per day do you drink fruit juices?"; and "On how many days of the week do you usually eat fruit"?, and "In general, how many times per day do you eat fruit: once, twice, or three times or more?";
2. Consumption of fish (twice per week), based on the question: "On how many days of the week do you usually eat fish?";
3. Intake of sugar-sweetened soft drinks and drinks (less than 5 glasses per week), based on the questions: "On how many days of the week do you usually drink soft drinks (or artificial juice)?" and "In general, how many glasses of soft drinks (or artificial juice) do you take per day: one, two, three or more?";
4. Adequate intake of salt (adequate, low, and very low), based on the question: "By considering fresh food and industrialized food, do you think your salt consumption is: very high, high, adequate, low, very low?".

The intake of whole grains was not assessed, because it was not measured in PNS, 2013. For each one of these items at an ideal level, the person got 1 point or 0 for the opposite. After adding these diet components, individuals were classified in three groups, according to the number of ideal criteria presented: poor (0-1), intermediate (2-3), and ideal (4).

Besides the diet, three other behaviors were analyzed, and the ideal levels were considered as follows:

1. Nonsmoking or having stopped smoking for more than 12 months, based on the questions: "When you bought cigarettes for consumption for the last time, how many cigarettes did you buy?"; "In average, how many industrialized cigarettes did you smoke per day or per week?"; and "How long has it been since you stopped smoking?";
2. Presenting BMI lower than 25 kg/m², based on the questions: "Do you know how much you weight (even if an approximate value)?" and "Do you know your height?";
3. To perform physical activity at goal levels (>150 minutes per week of moderate physical activity or >75 minutes of vigorous physical activity), based on the questions: "In the past three months, have you practiced any type of physical exercise or sport?"; "What is the main type of physical activity or sport that you have practiced?"; "Do you practice physical exercises at least once a week?"; "How many days of the week do you usually practice physical activities or sports?"; and "On the day you practice exercises or sports, how long does this activity take?".

Finally, the three biological measurements were assessed similarly, as follows:

1. Not referring diagnosis of dyslipidemia, diabetes, and arterial hypertension, based on the questions: "Has any doctor ever said you have diabetes?"; "Has any doctor ever said that you have high blood pressure?"; and "Has any doctor ever said you have high cholesterol or triglycerides?".

The score 1 was attributed to each condition at ideal levels and 0 for the opposite (except for the diet component, for which it was necessary that the ideal condition was reached in all of the four assessed situations). At the end, the indicator of CVH ranged from zero (poor) to seven (ideal). An ideal CVH was considered when the individual presented ideal levels for the seven factors. Besides, behavioral and biological measurements were groups originating the behavioral measures index (0 - 4) and the biological measures index (0 - 4), respectively. Despite not being a biological characteristic, smoking was included in both the groups owing to the importance of not smoking and of stopping smoking for health promotion⁴4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613..

The prevalence and 95% confidence interval (95%CI) of the ideal values of isolated variables and behavioral, biological, and total indexes were presented according to gender (male and female), age group (18 - 35, 36 - 59, and 60 years or more), and the region of the country (North, Northeast, Center-west, Southeast, and South). In each of these situations, significant differences were identified by not overlapping 95%CI data of the analyzed prevalence rates. For all of the analyses, an α = 0.05 significance level was considered.

All of the analyses were conducted by considering the complex sampling design of PNS 2013, by the Survey module of the application Stata 12.1. PNS was approved by the National Research Ethics Commission (CONEP), from the National Health Council (CNS), in June, 2013, report n. 328.159.

RESULTS

This study included 34,362, being 51.3% female participants, and mean age (±EP) of 43.8 years old (±0.2). Regarding age group, it was observed that 35.8% of the studied population was aged between 18 and 35 years; 46.5%, between 36 and 59 years; and 17.7%, 60 years or older. Besides, 5.5% was residing in the North region; 21.5%, in the Northeast; 48.7%, in the Southeast; 16.5%, in the South; and 7.7%, in the Center-west.

The Brazilian population reached prevalence rates lower than 1% in the seven measurements at the ideal level. Separately, 3.2% presented ideal diets, followed by physical activity (23.6%) and BMI (43.7%). These factors presented lower rates in all of the analyzed stratifications. The prevalence of ideal values for smoking, BMI, blood pressure, and total cholesterol presented differences between the genders. Women showed more prevalence of ideal levels for: smoking (89.5%) and BMI < 25 kg/m² (46.8%). On the other hand, men presented higher prevalence of ideal levels for arterial hypertension, because 77.7% reported not having been diagnosed with the disease and 87.3% referred not having high total cholesterol (Table 1). Regarding age group, it was observed that younger individuals (18 - 35 years) presented higher prevalence rates of ideal factors, except for diet and smoking habits (Table 2).

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Table 1:
Prevalence of ideal cardiovascular health and cardiovascular health measurements according to gender: Brazilian adult population (≥18 years old) - National Health Survey, 2013.

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Table 2:
Prevalence of ideal cardiovascular health and cardiovascular health measurements, according to age group: Brazilian adult population (≥ 18 years old) - National Health Survey, 2013.

Individuals living in the North region presented higher prevalence of ideal levels for most of the assessed factors, except for physical activity and BMI; for these factors, the highest values were obtained in the center-south and northeast regions, respectively. The lowest prevalence rates of ideal levels were found in the South region, except for smoking and diabetes; for these factors, the minimum values were obtained in the Southeast region (Table 3).

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Table 3:
Prevalence of ideal cardiovascular health and cardiovascular health measures, according to the region of the country: Brazilian adult population (≥ 18 years of age) - National Health Survey, 2013.

After the isolated evaluation, the set of the seven measures composing the total CVH index was analyzed, with emphasis on the differences found between age groups, because the younger individuals (18 - 35 years) showed higher prevalence rates of ideal levels in relation to individuals in the other age groups. Still, concerning the total score of ideal levels, the elderly people (60 years or older) were below the population average, with lower prevalence rates of ideal levels for CVH (Figure 1).

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Figure 1:
Number of total measures (0 - 7) at ideal levels, according to gender (A), age group (B), and region of the country (C) - National Health Survey, 2013.

By analyzing the indexes of behavioral and biological measures, it was observed that, for gender, age group, and geographic region, the highest prevalence rates were those of biological factors, that is, individuals showed worse performance regarding the behavioral aspects (Figure 2).

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Figure 2:
Index of behavioral measures and index of biological measures, according to gender (A), age group (B), and region of the country (C) - National Health Survey, 2013.

DISCUSSION

This is the first study that assesses the frequency of ideal CVH and its components, in a sample representing the adult Brazilian population. The prevalence rates of seven self-reported measures of CVH were estimated, being four behavioral and three biological ones, and CVH indexes using the criteria recommended by AHA. Less than 1% of the population presented an ideal scenario in all of the analyzed factors, therefore, it can be considered as low prevalence of ideal CVH. The ideal level ranged according to the factor analyzed, being higher for the absence of diabetes (92.8%) and lower for adequate diet (3.3%). Women present the best results for smoking and BMI and men for cholesterol and blood pressure. Generally, the group aged between 18 and 35 years and those living in the North region presented the highest prevalence rates with ideal levels.

Caution is recommended to compare the results of this study with those available in the literature about the subject, conducted with populations from other countries, once the number and the measurements are different. It is also possible to admit there are differences of age between regions, which make the comparison of interest only descriptive.

In this study, all of the data used were self-reported, whereas in some of the studies conducted in high-income countries (similar to the United States of America) only information directly measured in the population of interest was used¹³13. Shay CM, Ning H, Allen NB, Carnethon MR, Chiuve SE, Greenlund KJ, et al. Status of cardiovascular health in US adults prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008. Circulation 2012; 125: 45-56.. Once self-reported measures tend to be less precise than those measured directly, the prevalence rates presented here tend to be less accurate than those in studies in which factors were directly investigated¹⁴14. Hardman CM, Barros SSH, Oliveira ESA, Nahas MV, Barros MVG. Inatividade nos deslocamentos para o trabalho e fatores associados em industriários. Saúde Soc 2013; 22(3): 760-72. ¹⁵15. Xavier GS. Avaliação da estimação da imagem corporal em mulheres adultas a partir de dois métodos perceptivos [Dissertação de Mestrado]. Ribeirão Preto: Universidade de São Paulo; 2014.. It is a known fact that, based on survey data similar to PNS, the adult population of the country tends to overestimate positive behaviors (such as the recommended consumption of fruits and vegetables) and to underestimate those with negative connotation (such as smoking) and biological markers (such as high total cholesterol, blood glucose and blood pressure), which compose the underdiagnosed conditions¹⁶16. Mendes LL, Campos SF, Malta DC, Bernal RTI, Sá NNB, Velásquez-Meléndez G. Validade e reprodutibilidade de marcadores do consumo de alimentos e bebidas de um inquérito telefônico realizado na cidade de Belo Horizonte (MG), Brasil. Rev Bras Epidemiol 2011; 14(Supl.1): 80-9. ¹⁷17. Neves ACM, Gonzaga LAA, Martens IBG, Moura EC. Validação de indicadores do consumo de alimentos e bebidas obtidos por inquérito telefônico em Belém, Pará, Brasil. Cad Saúde Pública 2010; 26(12): 2379-88., leading us to the conclusion that the ideal CVH of the Brazilian population is even worse than that described in our results. Besides, while some studies contemplate the number of factors at ideal levels⁴4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613. ¹⁸18. Maclagan LC, Park J, Sanmartin C, Mathur KR, Roth D, Manuel DG, et al. The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population. CMAJ 2014; 186(3): 180-7., others use scores and score categories (inadequate or poor, intermediate, and ideal)¹³13. Shay CM, Ning H, Allen NB, Carnethon MR, Chiuve SE, Greenlund KJ, et al. Status of cardiovascular health in US adults prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008. Circulation 2012; 125: 45-56.. In this study, the choice was to contemplate both the approaches, allowing the maximum comparability between the estimated results. About these limitations, in other studies considered for comparison, similar results were observed, with low prevalence of ideal CVH¹⁹19. Crichton GE, Elias MF, Robbins MA. Cardiovascular health and arterial stiffness: the Maine-Syracuse Longitudinal Study. J Hum Hypertens 2014; 28(7):444-9. ²⁰20. Zeng Q, Dong SY, Song ZY, Zheng YS, Wu HY, Mao LN. Ideal cardiovascular health in Chinese urban population. Int J Cardiol 2013; 167(5): 2311-7.. For example, a study using cross-sectional data in high-income countries shows that only 0.02 and 8.2% of the adults presented 7, 6, or 5 factors at ideal levels, respectively²¹21. Jankovi´c S, Stojisavljevi´c D, Jankovi´c J, Eri´c M, Marinkovi´c J. Status of cardiovascular health in a transition European country: findings from a population-based cross-sectional study. Int J Public Health 2014; 59(5): 769-78..

In a study conducted with a rural population in Brazil, it was observed that only 0.4% of the individuals presented the seven factors at ideal levels, similar to the frequency described for the population in this study¹¹11. Felisbino-Mendes MS, Jansen AK, Gomes CS, Velásquez-Meléndez G. Avaliação dos fatores de risco cardiovasculares em uma população rural brasileira. Cad Saúde Pública 2014; 30(6): 1183-94.. In this same study, the low prevalence of individuals presenting ideal behavior in the four behaviors stands out: only 1%, regardless of gender.

Estimations indicating CVH in the populations are important instruments to predict the morbimortality for several CVDs and cancers⁴4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613. ⁸8. Rasmussen-Torvik LJ, Shay CM, Abramson JG, Friedrich CA, Nettleton JA, Prizment AE, et al. Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study. Circulation 2013; 127(12): 1270-5. ⁹9. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community Prevalence of Ideal Cardiovascular Health, by the AHA Definition, and Relation to Cardiovascular Disease Incidence. J Am Coll Cardiol 2011; 57(16): 1690-6.. The importance of keeping high frequencies of ideal levels in populations has been demonstrated in recent studies⁷7. Zhang Q, Zhou Y, Gao X, Wang C, Zhang S, Wang A, et al. Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke. Stroke 2013; 44(9): 2451-6. ⁹9. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community Prevalence of Ideal Cardiovascular Health, by the AHA Definition, and Relation to Cardiovascular Disease Incidence. J Am Coll Cardiol 2011; 57(16): 1690-6.. All evidence indicates lower risk of CVDs in groups with high scores and/or higher numbers at ideal levels. In a cohort with more than 22,000 adults older than 45 years, followed-up for 5 years, it was possible to identify a 25% reduction in the risk of cerebral ischemia adjusted by important confounding variables²²22. Kulshreshtha A, Vaccarino V, Judd SE, Howard VJ, McClellan WM, Muntner P, et al. Life's Simple 7 and risk of incident stroke: the reasons for geographic and racial differences in stroke study. Stroke 2013; 44(7): 1909-14.. Recently, in a cohort with 12,538 men aged between 40 and 59 years, the group presenting between 6 and 7 ideal measurements showed reductions from 58 to 90% in mortality rates for all causes and caused by cardiovascular conditions, respectively, when compared with the group that presented between 0 and 2 ideal factors⁶6. Kim JY, Ko YJ, Rhee CW, Park BJ, Kim DH, Bae JM, et al. Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study. J Prev Med Public Health 2013; 46(6): 319-28. . In 2001, the ARIC cohort, with 15,792 participants of both the genders, showed the reducing risks of incidence of cardiovascular events according to the increasing number of ideal factors, ranging from 89 to 55% when compared with the incidence among individuals who did not have any ideal factor⁹9. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community Prevalence of Ideal Cardiovascular Health, by the AHA Definition, and Relation to Cardiovascular Disease Incidence. J Am Coll Cardiol 2011; 57(16): 1690-6..

Some limitations of this study are the high number of exclusions from the analysis, which can lead to some sort of bias. Besides, there is limitation in the comparison between the regions because of the differences in the age structure. Therefore, better results in the North region, in particular, regarding biological aspects, may have been caused by the younger population in the region.

It is important to mention some methodological advantages of this paper. This study has a probability sample and representativeness of major regions, besides a national scope. Even if the measurement of exposures of interest had been self-reported, it provides an essential image of the CVH of the Brazilian population, as it allows obtaining information in a reliable way, at a more adequate cost. More accurate approximations can be conducted in the future with the liberation of cholesterol and blood glucose values, measured in the laboratory, in a subsample of this research.

CONCLUSION

The isolated and combined estimations of biological and behavioral factors of CVH in the Brazilian population and in the major regions of the country show low prevalence rates at ideal levels. The magnitude of these events in the age group from 18 to 35 years can, at first, be considered as a goal to be reached by all population subgroups. Therefore, the follow-up of CVH measures can potentially be a good surveillance and protective instrument for the CVH of Brazilian populations and the reach of satisfactory primordial prevention levels.

References

1. Malta DC, Moura LD, Prado RRD, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608.
2. Mendis S, Puska P, Norrving B. Global atlas on cardiovascular disease prevention and control. World Health Organization; 2011.
3. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics-2011 update: a report from the American Heart Association. Circulation 2011; 123(4): 18-209.
4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613.
5. Liu Y, Chi HJ, Cui LF, Yang XC, Wu YT, Huang Z, et al. The ideal cardiovascular health metrics associated inversely with mortality from all causes and from cardiovascular diseases among adults in a Northern Chinese industrial city. PLoS One 2014; 9(2): e89161.
6. Kim JY, Ko YJ, Rhee CW, Park BJ, Kim DH, Bae JM, et al. Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study. J Prev Med Public Health 2013; 46(6): 319-28.
7. Zhang Q, Zhou Y, Gao X, Wang C, Zhang S, Wang A, et al. Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke. Stroke 2013; 44(9): 2451-6.
8. Rasmussen-Torvik LJ, Shay CM, Abramson JG, Friedrich CA, Nettleton JA, Prizment AE, et al. Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study. Circulation 2013; 127(12): 1270-5.
9. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community Prevalence of Ideal Cardiovascular Health, by the AHA Definition, and Relation to Cardiovascular Disease Incidence. J Am Coll Cardiol 2011; 57(16): 1690-6.
10. Yang Q, Cogswell ME, Flanders WD, Hong Y, Zhang Z, Loustalot F, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA 2012; 307(12): 1273-83.
11. Felisbino-Mendes MS, Jansen AK, Gomes CS, Velásquez-Meléndez G. Avaliação dos fatores de risco cardiovasculares em uma população rural brasileira. Cad Saúde Pública 2014; 30(6): 1183-94.
12. Instituto Brasileiro de Geografia e Estatística - IBGE. Pesquisa Nacional de Saúde 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: IBGE; 2014.
13. Shay CM, Ning H, Allen NB, Carnethon MR, Chiuve SE, Greenlund KJ, et al. Status of cardiovascular health in US adults prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008. Circulation 2012; 125: 45-56.
14. Hardman CM, Barros SSH, Oliveira ESA, Nahas MV, Barros MVG. Inatividade nos deslocamentos para o trabalho e fatores associados em industriários. Saúde Soc 2013; 22(3): 760-72.
15. Xavier GS. Avaliação da estimação da imagem corporal em mulheres adultas a partir de dois métodos perceptivos [Dissertação de Mestrado]. Ribeirão Preto: Universidade de São Paulo; 2014.
16. Mendes LL, Campos SF, Malta DC, Bernal RTI, Sá NNB, Velásquez-Meléndez G. Validade e reprodutibilidade de marcadores do consumo de alimentos e bebidas de um inquérito telefônico realizado na cidade de Belo Horizonte (MG), Brasil. Rev Bras Epidemiol 2011; 14(Supl.1): 80-9.
17. Neves ACM, Gonzaga LAA, Martens IBG, Moura EC. Validação de indicadores do consumo de alimentos e bebidas obtidos por inquérito telefônico em Belém, Pará, Brasil. Cad Saúde Pública 2010; 26(12): 2379-88.
18. Maclagan LC, Park J, Sanmartin C, Mathur KR, Roth D, Manuel DG, et al. The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population. CMAJ 2014; 186(3): 180-7.
19. Crichton GE, Elias MF, Robbins MA. Cardiovascular health and arterial stiffness: the Maine-Syracuse Longitudinal Study. J Hum Hypertens 2014; 28(7):444-9.
20. Zeng Q, Dong SY, Song ZY, Zheng YS, Wu HY, Mao LN. Ideal cardiovascular health in Chinese urban population. Int J Cardiol 2013; 167(5): 2311-7.
21. Jankovi´c S, Stojisavljevi´c D, Jankovi´c J, Eri´c M, Marinkovi´c J. Status of cardiovascular health in a transition European country: findings from a population-based cross-sectional study. Int J Public Health 2014; 59(5): 769-78.
22. Kulshreshtha A, Vaccarino V, Judd SE, Howard VJ, McClellan WM, Muntner P, et al. Life's Simple 7 and risk of incident stroke: the reasons for geographic and racial differences in stroke study. Stroke 2013; 44(7): 1909-14.

Financial support: Ministry of Health

Publication Dates

Publication in this collection
Dec 2015

History

Received
13 Apr 2015
Accepted
05 Aug 2015

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] 1. Malta DC, Moura LD, Prado RRD, Escalante JC, Schmidt MI, Duncan BB. Mortalidade por doenças crônicas não transmissíveis no Brasil e suas regiões, 2000 a 2011. Epidemiol Serv Saúde 2014; 23(4): 599-608.

[2] 2. Mendis S, Puska P, Norrving B. Global atlas on cardiovascular disease prevention and control. World Health Organization; 2011.

[3] 3. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics-2011 update: a report from the American Heart Association. Circulation 2011; 123(4): 18-209.

[4] 4. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association's strategic Impact Goal through 2020 and beyond. Circulation 2010; 121(4): 586-613.

[5] 5. Liu Y, Chi HJ, Cui LF, Yang XC, Wu YT, Huang Z, et al. The ideal cardiovascular health metrics associated inversely with mortality from all causes and from cardiovascular diseases among adults in a Northern Chinese industrial city. PLoS One 2014; 9(2): e89161.

[6] 6. Kim JY, Ko YJ, Rhee CW, Park BJ, Kim DH, Bae JM, et al. Cardiovascular health metrics and all-cause and cardiovascular disease mortality among middle-aged men in Korea: the Seoul male cohort study. J Prev Med Public Health 2013; 46(6): 319-28.

[7] 7. Zhang Q, Zhou Y, Gao X, Wang C, Zhang S, Wang A, et al. Ideal cardiovascular health metrics and the risks of ischemic and intracerebral hemorrhagic stroke. Stroke 2013; 44(9): 2451-6.

[8] 8. Rasmussen-Torvik LJ, Shay CM, Abramson JG, Friedrich CA, Nettleton JA, Prizment AE, et al. Ideal cardiovascular health is inversely associated with incident cancer: the Atherosclerosis Risk In Communities study. Circulation 2013; 127(12): 1270-5.

[9] 9. Folsom AR, Yatsuya H, Nettleton JA, Lutsey PL, Cushman M, Rosamond WD. Community Prevalence of Ideal Cardiovascular Health, by the AHA Definition, and Relation to Cardiovascular Disease Incidence. J Am Coll Cardiol 2011; 57(16): 1690-6.

[10] 10. Yang Q, Cogswell ME, Flanders WD, Hong Y, Zhang Z, Loustalot F, et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA 2012; 307(12): 1273-83.

[11] 11. Felisbino-Mendes MS, Jansen AK, Gomes CS, Velásquez-Meléndez G. Avaliação dos fatores de risco cardiovasculares em uma população rural brasileira. Cad Saúde Pública 2014; 30(6): 1183-94.

[12] 12. Instituto Brasileiro de Geografia e Estatística - IBGE. Pesquisa Nacional de Saúde 2013. Percepção do estado de saúde, estilos de vida e doenças crônicas. Rio de Janeiro: IBGE; 2014.

[13] 13. Shay CM, Ning H, Allen NB, Carnethon MR, Chiuve SE, Greenlund KJ, et al. Status of cardiovascular health in US adults prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008. Circulation 2012; 125: 45-56.

[14] 14. Hardman CM, Barros SSH, Oliveira ESA, Nahas MV, Barros MVG. Inatividade nos deslocamentos para o trabalho e fatores associados em industriários. Saúde Soc 2013; 22(3): 760-72.

[15] 15. Xavier GS. Avaliação da estimação da imagem corporal em mulheres adultas a partir de dois métodos perceptivos [Dissertação de Mestrado]. Ribeirão Preto: Universidade de São Paulo; 2014.

[16] 16. Mendes LL, Campos SF, Malta DC, Bernal RTI, Sá NNB, Velásquez-Meléndez G. Validade e reprodutibilidade de marcadores do consumo de alimentos e bebidas de um inquérito telefônico realizado na cidade de Belo Horizonte (MG), Brasil. Rev Bras Epidemiol 2011; 14(Supl.1): 80-9.

[17] 17. Neves ACM, Gonzaga LAA, Martens IBG, Moura EC. Validação de indicadores do consumo de alimentos e bebidas obtidos por inquérito telefônico em Belém, Pará, Brasil. Cad Saúde Pública 2010; 26(12): 2379-88.

[18] 18. Maclagan LC, Park J, Sanmartin C, Mathur KR, Roth D, Manuel DG, et al. The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population. CMAJ 2014; 186(3): 180-7.

[19] 19. Crichton GE, Elias MF, Robbins MA. Cardiovascular health and arterial stiffness: the Maine-Syracuse Longitudinal Study. J Hum Hypertens 2014; 28(7):444-9.

[20] 20. Zeng Q, Dong SY, Song ZY, Zheng YS, Wu HY, Mao LN. Ideal cardiovascular health in Chinese urban population. Int J Cardiol 2013; 167(5): 2311-7.

[21] 21. Jankovi´c S, Stojisavljevi´c D, Jankovi´c J, Eri´c M, Marinkovi´c J. Status of cardiovascular health in a transition European country: findings from a population-based cross-sectional study. Int J Public Health 2014; 59(5): 769-78.

[22] 22. Kulshreshtha A, Vaccarino V, Judd SE, Howard VJ, McClellan WM, Muntner P, et al. Life's Simple 7 and risk of incident stroke: the reasons for geographic and racial differences in stroke study. Stroke 2013; 44(7): 1909-14.