ABSTRACT:

Introduction:

Regular physical activity (PA) generates several health benefits. This study aimed to analyze the predictors of moderate PA (MPA) and vigorous PA (VPA) separately, as well as some health outcomes related to each intensity.

Method:

A population-based, cross-sectional study, with adults and the elderly in the urban area of the city of Rio Grande, RS, Brazil. PA was collected through the leisure section of the International Physical Activity Questionnaire (IPAQ). The cutoff points used for MPA and VPA were, respectively, 150min/wk and 75min/wk. The health conditions analyzed were: obesity, stress, hypertension, diabetes, depression and self-perception of health.

Results:

A total of 1,290 individuals participated in the study, with a mean age of 46.0 years (SD = 17.3); 14.3% (95%CI 11.7 - 16.8) were classified as active for MPA, and 14.6% (95%CI 12.1 - 17.1) for VPA. Male gender, higher schooling, more favorable perception of the neighborhood and more hours of sleep were associated with higher prevalence of MPA. Males, aged 20 to 39 years, white skin color, absence of smoking, higher schooling and higher index of assets were associated with higher prevalence of VPA. Regarding health outcomes, MPA conferred protection for stress, while VPA was a protective factor for obesity, hypertension, and diabetes.

Conclusions:

It was observed that both the predictors and the health outcomes differed according to the intensity of the PA.

Keywords:
Leisure activities; Exercise; Risk factors; Chronic disease; Epidemiology

INTRODUCTION

Evidence shows that physical inactivity considerably increases the risk of many adverse health conditions and reduces life expectancy, becoming one of the ten major risk factors for mortality worldwide¹1. 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): 219-29. https://doi.org/10.1016/S0140-6736(12)61031-9
https://doi.org/10.1016/S0140-6736(12)61... ^,22. World Health Organization. Global Recommendations on Physical Activity for Health. Genebra: World Health Organization; 2010. and accounting for 1 to 4% of total global healthcare costs³3. Ding D, Lawson KD, Kolbe-Alexander TL, Finkelstein EA, Katzmarzyk PT, van Mechelen W, et al. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet 2016; 388(10051): 1311-24. https://doi.org/10.1016/S0140-6736(16)30383-X
https://doi.org/10.1016/S0140-6736(16)30... . In addition, studies indicate that regular physical activity (AF) practice generates several health benefits⁴4. Powell KE, Paluch AE, Blair SN. Physical activity for health: What kind? How much? How intense? On top of what? Annu Rev Public Health 2011; 32: 349-65. https://doi.org/10.1146/annurev-publhealth-031210-101151
https://doi.org/10.1146/annurev-publheal... and is one of the main protective behavioral factors for chronic noncommunicable diseases¹1. 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): 219-29. https://doi.org/10.1016/S0140-6736(12)61031-9
https://doi.org/10.1016/S0140-6736(12)61... .

Even with this evidence, according to the World Health Organization (WHO), 23% of adults aged 18 years or older are insufficiently active, reaching 32% in the Americas²2. World Health Organization. Global Recommendations on Physical Activity for Health. Genebra: World Health Organization; 2010.. In Brazil, data from the Surveillance System of Risk and Protection Factors for Chronic Diseases by Telephone Inquiry (VIGITEL) of 2016 indicate that the percentage of insufficient practice of PA was 47.5%⁵5. Brasil. VIGITEL Brasil 2015: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Brasília: Ministério da Saúde: Secretaria de Vigilância em Saúde; 2016.. Although the benefits of PA practice are well emphasized in the literature⁶6. United States Department of Health and Human Services. Physical Activity Guidelines Advisory Committee Report 2008. Washington, D.C.: United States Department of Health and Human Services; 2008., the vast majority of studies do not assess the intensity of PA separately, investigating only whether individuals meet the recommendations.

However, since the 1990s, it has been demonstrated that meeting the recommendation of vigorous physical activity (VPA) strengthens the health benefits of PA and also guarantees increased longevity, with a reduction in mortality rates⁷7. Lee IM, Paffenbarger RS, Jr. Associations of light, moderate, and vigorous intensity physical activity with longevity. The Harvard Alumni Health Study. Am J Epidemiol 2000; 151(3): 293-9.. In this sense, investigation of whether the factors associated with meeting the recommendations for each intensity are the same and if the health effects are also equivalent is justified. Thus, this study aimed to analyze the predictors of moderate physical activity (MPA) and VPA, separately, as well as some health outcomes related to the practice of PA in each intensity, in adults and elderly in southern Brazil.

METHOD

This is a cross-sectional, population-based study that integrates a larger study called Health of the Rio Grande Population, conducted in 2016 with the objective of evaluating health aspects of the population of the city of Rio Grande (RS), Brazil. The research project was submitted and approved by the Research Ethics Committee in the Health Field (CEPAS) of Universidade Federal do Rio Grande (FURG), under protocol number 20/2016.

This study included individuals aged 18 years or older residing in the urban area of Rio Grande, excluding those institutionalized in nursing homes, hospitals and prisons, or who demonstrated any physical and/or mental incapacity to answer the questionnaire. Themunicipality of Rio Grande is located in the extreme south of Brazil, approximately 350 km from the capital of Rio Grande do Sul, Porto Alegre. According to the 2010 census of the Brazilian Institute of Geography and Statistics (IBGE)⁸8. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010: Características da População e dos domicílios: Resultados. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2010., its population was 197,228 inhabitants in that year, 96% of them living in the urban area, and the Human Development Index (HDI) was 0.744.

The sample size was calculated considering a 95% confidence interval, 80% power, outcome prevalence of 10%, frequency of exposition between 20 and 60%, and prevalence ratio (PR) of 2.0, obtaining N of 784 individuals. An additional 50% were included for the sampling design effect and 15% for possible confounding factors, resulting in 1,294 individuals. In addition, 10% were added for possible losses and refusals, thus totaling 1,423 individuals.

The sampling process took place in two stages: the first one was the selection of census tracts and the second was the selection of households. For the selection of census tracts, a list was drawn in descending order according to the monthly income of the head of the household, of all households. Thus, the first domicile was drawn and the selection interval was established to identify the sector of which the household was a part, totaling 72 sectors. In these census tracts, the household selection was carried out in a systematic way, proportional to the size of the sector. Thus, 711 households were sampled to contemplate the sample size calculation of 1,423 individuals, as, on average, two residents were expected per household, with an age equal to or greater than 18 years.

PA was evaluated as an outcome of some risk factors and as a predictor of some health conditions. For this, the leisure section of the International Questionnaire of Physical Activity (IPAQ), long version, instrument previously validated in some countries, including Brazil, was used⁹9. Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35(8): 1381-95. https://doi.org/10.1249/01.MSS.0000078924.61453.FB
https://doi.org/10.1249/01.MSS.000007892... . The practice of PA was surveyed in a typical week, with questions about duration and frequency of walking, moderate intensity activities, and vigorous activities. MPA is characterized by activities that require medium physical effort and make the individual breathe a little faster than normal, such as swimming, pedaling at medium pace, and playing sports for fun; VPA, on the other hand, includes activities that require a lot of physical effort and make the individual breathe much faster than normal, such as running, gymnastics, fast pedaling, and competitive sports.

O cálculo do tempo de atividade física por semana foi obtido por meio da multiplicação da duração (em minutos) pela frequência (em dias), obtendo-se um escore em min./sem. Individuals who practiced 150min./week of moderate activities (including walking) were classified as physically active. The cutoff point used for VPA was practicing for at least 75min./week.

The independent variables were: gender (male/female), age group (18-39/40-59/greater than or equal to 60), skin color (white/other), marital status (not married/married, separated or widower), schooling in years (0-8/9-11/greater than or equal to 12), index of assets in tertiles (from lowest to highest), smoking (non-smoker/ex-smoker/smoker), daily hours of sleep (less than 6 h/day, from 6.0 to 7.9, and greater or equal to 8.0 h/day), daily hours watching television (up to 3.0 h/day and more than 3.0 h/day), self-perception of the neighborhood for the practice of physical activities (less friendly, intermediate, more friendly).

In order to create the variable “index of assets”, 11 items were considered among house characteristics and household goods, and a main components analysis was performed¹⁰10. Filmer D, Pritchett LH. Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India. Demography 2001; 38(1): 115-32. https://doi.org/10.2307/3088292
https://doi.org/10.2307/3088292... , in which the first component was extracted, which explained 31% of the variability of all items. The perception of the neighborhood for the practice of PA was evaluated by modified scale of perception of the environment and validated for Brazilian adults¹¹11. Florindo AA, Salvador EP, Reis RS. Physical activity and its relationship with perceived environment among adults living in a region of low socioeconomic level. J Phys Act Health 2013; 10(4): 563-71.. This scale was adapted from the international Neighborhood Environment Walkability Scale questionnaire¹²12. Saelens BE, Sallis JF, Black JB, Chen D. Neighborhood-Based Differences in Physical Activity: An Environment Scale Evaluation. Am J Publ Health 2003; 93(9): 1552-8.. Then, the sum of the scale items was performed, those that had negative connotations were inverted, and the sum was divided into tertiles.

The health conditions analyzed were: obesity (body mass index - BMI ≥ 30.0 kg/m², calculated from self-reported weight and height); stress (obtained by the Perceived Stress Scale and defined as the highest quartile of the sum of the scale); hypertension and diabetes (obtained by medical diagnosis, self-reported by the individual); nd depression (assessed by the Patient Health Questionnaire - PHQ-9, validated for the Brazilian population)¹⁴14. Santos IS, Tavares BF, Munhoz TN, Almeida LSPd, Silva NTBd, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saúde Pública 2013; 29(8): 1533-43. http://dx.doi.org/10.1590/0102-311X00144612
http://dx.doi.org/10.1590/0102-311X00144... . For the operationalization of the depression score, the algorithmic form of the scale was used¹⁵15. Munhoz TN, Nunes BP, Wehrmeister FC, Santos IS, Matijasevich A. A nationwide population-based study of depression in Brazil. J Affect Disord 2016; 192: 226-33. https://doi.org/10.1016/j.jad.2015.12.038
https://doi.org/10.1016/j.jad.2015.12.03... . The perception of health was self-reported by the individual and categorized as regular/poor and good/very good/excellent.

Data collection occurred from April to July 2016 in the households of the individuals selected. The questionnaire, with a mean duration of 30minutes, was applied by previously trained interviewers to those who consented to participate in the study and signed the Informed Consent. Concomitantly with the data collection, quality control was performed in 10% of the sample, through a telephone re-interview containing key questions to identify possible fraud in the application of the instrument. The data collected were doubly entered in EpiData software, version 3.1.

Univariate analysis was used to describe the sample (absolute frequency and relative frequency). For crude and adjusted analysis, Poisson regression was used, with robust adjustment for variance, taking into account the effect of sample design. The measures presented were PR and 95%CI, together with p-value. The multivariate analysis followed a hierarchical model elaborated for the control of possible confounding factors. In this model, demographic variables (gender, age group, skin color and marital status) were placed on the first level; in the second level, socioeconomic variables (education and index of assets); in the third level, behavioral variables (smoking, hours of sleep and daily hours watching television); and on the fourth level, the neighborhood perception variable. Each variable was controlled for those of the same level or levels above. The level of significance for maintenance of the variables in the adjusted model was 20%, and the level of statistical significance was 5% for two-tailed tests. For the ordinal variables, the p-value of the linear trend test was used.

When analyzing MPA and VPA as possible predictors of some health conditions, Poisson regression was also used, taking into account the effect of the sampling design. In this approach, the adjusted analysis included all variables with p-value < 0.20 in the multivariate analysis described in the previous paragraph. The level of statistical significance remained at 5% for two-tailed tests. Statistical analyzes were performed in the Stata package, version 11.2.

RESULTS

Of the 1,429 subjects eligible for this study, 1,300 answered the questionnaire, generating a response rate of 91%. Of the 129 who did not respond, 99 were refusals (77%) and 30losses (23%), being more prevalent in men (12%) than in women (6.5%) (p <0.01). There was no difference in the mean age of participants and nonparticipants. The Centro district had a higher non-response rate (20%). Ten subjects did not provide information on MPA and VPA in this study, resulting in N = 1,290 for the analyzes. The effects of design and intraclass correlation coefficient for MPA were 1.68 and 0.023, and for VPA, 1.60 and 0.030, respectively.

The majority of the individuals were females (56.7%), 24% were 60 years old or more, 82.9% had white skin color, 46.2% were not married and 41.8% had up to 8 years of schooling. About a fifth (18%) of the respondents were smokers, 12.5% reported sleeping less than 6 hours a day, and 31.8% were watching more than 3 hours of television daily. Approximately one quarter (23.8%) of the participants were obese and 28.2% had a medical diagnosis of hypertension. Diabetes accounted for 7.0% of the sample and depression, 11.2%. One-third (33.6%) considered their health either regular or poor.

The prevalence of MPA was 14.3% (95%CI 11.7 - 16.8), ranging from 8.7% for the group that slept less than 6 hours per day to 18.3% for the group that perceived their neighborhood as more frendly for practicing PA. In the crude analysis, it was found that males and former smokers had a higher prevalence of MPA in relation to females and smokers, respectively. There was a positive association between schooling, the index of assets and self-perception of the neighborhood with MPA. In the adjusted analysis, the number of hours of sleep per day was positively associated with the outcome and the index of assets lost its association. Males, higher schooling, and more favorable perception of the neighborhood continued to be associated with a higher prevalence of MPA. Skin color, age, marital status and television hours had no association either in the crude analysis or in the adjusted analysis (Table 1).

The prevalence of VPA was 14.6% (95%CI 12.1 - 17.1), The prevalence of VPA was 14.6% (95%CI 12.1 - 17.1), varying from 5.4% for the group with lower schooling to 21.8% for the group with the highest index of assets. In the crude analysis, male, not married, non-smoker individuals, with 6.0 to 7.9 hours of sleep per day and who watched television for up to 3 hours daily, showed a higher prevalence of VPA compared to their peers. A negative association of VPA with age group was observed, and positive association with schooling, index of assets and self-perception of the neighborhood. In the adjusted analysis, the prevalence of VPA remained higher for males, nonsmokers and smokers, compared to females and former smokers. The age group remained inversely associated with VPA, while schooling and the index of assets were directly associated. Marital status, daily hours of sleep, habit of watching television and self-perception of the neighborhood lost association with the practice of VPA. Skin color (white) had a statistically significant association after adjustments (Table 2).

Table 3 presents the analyzes for health outcomes associated with reaching the recommendations for MPA and VPA. It was verified that the practice of MPA was associated with less occurrence of stress, depression and poor or regular health, and depression lost association after adjusting for possible confounders. In turn, VPA was a protective agent for all outcomes analyzed, remaining with a statistically significant association, after adjustments, for obesity, hypertension, diabetes, and regular or poor health.

DISCUSSION

The present study evaluated compliance with the recommendations of MPA and VPA practice, in the leisure domain, in adults and in elderly residents of a city in Southern Brazil, investigating health predictors and outcomes. It was observed that about 15% of the individuals met the recommendations for the practice of MPA and VPA, respectively. Male subjects with higher schooling were more active at both intensities. Regarding the health outcomes, it was verified that MPA conferred protection for stress, while VPA constituted a protective factor for obesity, hypertension and diabetes.

The prevalence of MPA in this study was lower than that found by the Brazilian VIGITEL survey (37.6%) for individuals aged 18 years or older (N = 54,174)⁵5. Brasil. VIGITEL Brasil 2015: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Brasília: Ministério da Saúde: Secretaria de Vigilância em Saúde; 2016.. One likely explanation for this difference is the use of different instruments. A study conducted between 2003 and 2006 with adult males (aged 20-64 years) living in the United States (N = 1,841) found a prevalence of MPA of 28.8%¹⁶16. Janssen I, Ross R. Vigorous intensity physical activity is related to the metabolic syndrome independent of the physical activity dose. Int J Epidemiol 2012; 41(4): 1132-40. https://doi.org/10.1093/ije/dys038
https://doi.org/10.1093/ije/dys038... . However, in this study, AF was investigated using an accelerometer, and the leisure domain was not the only one analyzed. On the other hand, the prevalence of VPA was 1.7%¹⁶16. Janssen I, Ross R. Vigorous intensity physical activity is related to the metabolic syndrome independent of the physical activity dose. Int J Epidemiol 2012; 41(4): 1132-40. https://doi.org/10.1093/ije/dys038
https://doi.org/10.1093/ije/dys038... , but the authors used the same cut-off point of MPA, which would be equivalent to 150min./week. If the present study used this cutoff point for VPA, the prevalence would decrease to 11.1%.

In a study conducted in the city of Pelotas (RS), in 2002, with individuals aged 20 years or older (N = 3,182), the prevalence of MPA was 34.5%, and 29.2% for VPA¹1. 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): 219-29. https://doi.org/10.1016/S0140-6736(12)61031-9
https://doi.org/10.1016/S0140-6736(12)61... . However, in this study, the instrument used was the short version of IPAQ, which does not distinguish the PA domains. In addition, VPA had a cutoff of 60min./week. If this study used this same cutoff point for VPA, the prevalence would increase by 1.5 percentage points, becoming 16.1%.

Regarding the predictors to meet recommendations for MPA and VPA, it was observed that males had a higher prevalence than females for both intensities. Several studies¹⁷17. Hallal PC, Siqueira FV. Compliance with Vigorous Physical Activity Guidelines in Brazilian Adults: Prevalence and Correlates. J Phys Act Health 2004; 1(4): 389-97. https://doi.org/10.1123/jpah.1.4.389
https://doi.org/10.1123/jpah.1.4.389... ^,1818. Almeida OP, Khan KM, Hankey GJ, Yeap BB, Golledge J, Flicker L. 150minutes of vigorous physical activity per week predicts survival and successful ageing: a population-based 11-year longitudinal study of 12 201 older Australian men. Br J Sports Med 2014; 48(3): 220-5. https://doi.org/10.1136/bjsports-2013-092814
https://doi.org/10.1136/bjsports-2013-09... ^,1919. Shiroma EJ, Sesso HD, Moorthy MV, Buring JE, Lee IM. Do moderate-intensity and vigorous-intensity physical activities reduce mortality rates to the same extent? J Am Heart Assoc 2014; 3(5): e000802. https://doi.org/10.1161/JAHA.114.000802
https://doi.org/10.1161/JAHA.114.000802... indicate that men are physically more active than women, being more present in collective and competitive PA, while women practice individual activities that require less physical effort²⁰20. Salles-Costa R, Heilborn ML, Werneck GL, Faerstein E, Lopes CS. [Gender and leisure-time physical activity]. Cad Saúde Pública 2003; 19(Supl. 2):S325-33. http://dx.doi.org/10.1590/S0102-311X2003000800014
http://dx.doi.org/10.1590/S0102-311X2003... . In addition, men engage in more intense activities such as running, swimming, pedaling, and bodybuilding²¹21. Thomaz PMD, Costa THMd, Silva EFd, Hallal PC. Fatores associados à atividade física em adultos, Brasília, DF. Rev Saúde Pública 2010; 44(5): 894-900. http://dx.doi.org/10.1590/S0034-89102010005000027
http://dx.doi.org/10.1590/S0034-89102010... , while women are more likely to walk and do housework²¹21. Thomaz PMD, Costa THMd, Silva EFd, Hallal PC. Fatores associados à atividade física em adultos, Brasília, DF. Rev Saúde Pública 2010; 44(5): 894-900. http://dx.doi.org/10.1590/S0034-89102010005000027
http://dx.doi.org/10.1590/S0034-89102010... .

Regarding age groups, younger adults were more likely to meet recommendations for VPA. Similar to this finding, a study conducted in the nearby city of Pelotas (RS) pointed out that individuals with ages between 20 and 39 years practiced more VPA¹⁷17. Hallal PC, Siqueira FV. Compliance with Vigorous Physical Activity Guidelines in Brazilian Adults: Prevalence and Correlates. J Phys Act Health 2004; 1(4): 389-97. https://doi.org/10.1123/jpah.1.4.389
https://doi.org/10.1123/jpah.1.4.389... . Other epidemiological studies reinforce this inversely proportional association to the age group²²22. Hallal PC, Victora CG, Wells JC, Lima RC. Physical inactivity: prevalence and associated variables in Brazilian adults. Med Sci Sports Exerc 2003; 35(11): 1894-900. https://doi.org/10.1249/01.MSS.0000093615.33774.0E
https://doi.org/10.1249/01.MSS.000009361... ^,2323. Mielke GI, Malta DC, de Sá GB, Reis RS, Hallal PC. Regional differences and correlates of leisure time physical activity in Brazil: results from the Brazilian National Health Survey-2013. Rev Bras Epidemiol 2015; 18(Supl. 2):158-69. https://doi.org/10.1590/1980-5497201500060014
https://doi.org/10.1590/1980-54972015000... . Itshould be pointed out that for MPA, no significant difference was found between the age groups, being slightly higher for the elderly (16.5% versus 12.9% for adults aged 18 to 39years, p = 0.12).

White skinned individuals practiced more VPA, but this association was lost after adjusting for socioeconomic status (data not shown). This may be explained more by the fact that white-skinned individuals have higher family incomes than by factors such as racial discrimination against brown or black individuals.

The higher the educational level, the greater the probability of meeting the recommendations, both for MPA and, mainly, for VPA. This finding is in line with other national and international studies⁵5. Brasil. VIGITEL Brasil 2015: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Brasília: Ministério da Saúde: Secretaria de Vigilância em Saúde; 2016.^,1616. Janssen I, Ross R. Vigorous intensity physical activity is related to the metabolic syndrome independent of the physical activity dose. Int J Epidemiol 2012; 41(4): 1132-40. https://doi.org/10.1093/ije/dys038
https://doi.org/10.1093/ije/dys038... ^,2323. Mielke GI, Malta DC, de Sá GB, Reis RS, Hallal PC. Regional differences and correlates of leisure time physical activity in Brazil: results from the Brazilian National Health Survey-2013. Rev Bras Epidemiol 2015; 18(Supl. 2):158-69. https://doi.org/10.1590/1980-5497201500060014
https://doi.org/10.1590/1980-54972015000... ^,2424. Brown BM, Peiffer JJ, Sohrabi HR, Mondal A, Gupta VB, Rainey-Smith SR, et al. Intense physical activity is associated with cognitive performance in the elderly. Transl Psychiatry 2012; 2(11): e191. https://dx.doi.org/10.1038%2Ftp.2012.118
https://dx.doi.org/10.1038%2Ftp.2012.118... ^,2525. Gebel K, Ding D, Chey T, Stamatakis E, Brown WJ, Bauman AE. Effect of Moderate to Vigorous Physical Activity on All-Cause Mortality in Middle-aged and Older Australians. JAMA Intern Med 2015; 175(6): 970-7. https://doi.org/10.1001/jamainternmed.2015.0541
https://doi.org/10.1001/jamainternmed.20... . One hypothesis is that individuals with higher schooling have more access to information, which provides greater knowledge about the benefits of practicing PA. In addition, individuals with higher schooling had higher family income (data not shown), which may favor participation in gyms, sports clubs and other non-free institutions. Even after adjustment for socioeconomic status, schooling remained associated with MPA and VPA, being the strongest predictor for both intensities. The index of assets remained positively associated only with AFV. Other studies²⁶26. Hughes JP, McDowell MA, Brody DJ. Leisure-time physical activity among US adults 60 or more years of age: results from NHANES 1999-2004. J Phys Act Health 2008; 5(3): 347-58.^,2727. del Duca GF, Rombaldi AJ, Knuth AG, Azevedo MR, Nahas MV, Hallal PC. Associação entre nível econômico e inatividade física em diferentes domínios. Rev Bras Ativ Fis Saúde 2009; 14(2). https://doi.org/10.12820/rbafs.v.14n2p123-131
https://doi.org/10.12820/rbafs.v.14n2p12... ^,2828. Dias-da-Costa JS, Hallal PC, Wells JCK, Daltoé T, Fuchs SC, Menezes AMB, et al. Epidemiology of leisure-time physical activity: a population-based study in southern Brazil. Cad Saúde Pública 2005; 21(1): 275-82. https://doi.org//S0102-311X2005000100030
https://doi.org//S0102-311X2005000100030... ^,2929. Bryan SN, Katzmarzyk PT. Are Canadians meeting the guidelines for moderate and vigorous leisure-time physical activity? Appl Physiol Nutr Metab 2009; 34(4): 707-15. https://doi.org/10.1139/H09-060
https://doi.org/10.1139/H09-060... Other studies demonstrate that leisure PA is more practiced by individuals with a higher socioeconomic status.

It was found that smokers practiced less MPA and VPA than nonsmokers, an outcome found in other studies³⁰30. Sousa CA, César CLG, Barros MBA, Carandina L, Goldbaum M, Marchioni DML, et al. Prevalência de atividade física no lazer e fatores associados: estudo de base populacional em São Paulo, Brasil, 2008-2009. Cad Saúde Pública 2013; 29(2): 270-82. http://dx.doi.org/10.1590/S0102-311X2013000200014
http://dx.doi.org/10.1590/S0102-311X2013... ^,3131. Chomistek AK, Cook NR, Flint AJ, Rimm EB. Vigorous-intensity leisure-time physical activity and risk of major chronic disease in men. Med Sci Sports Exerc 2012; 44(10): 1898-905. https://doi.org/10.1249/MSS.0b013e31825a68f3
https://doi.org/10.1249/MSS.0b013e31825a... . This finding indicates that nonsmokers (including former smokers) are more likely to take care of their health than those who smoke. Sleep was also positively associated with PA, but remained significant only for MPA. It is assumed that individuals who sleep more also take more care of their health. Another finding worthy of note was the more favorable perception of the neighborhood as a facilitator for MPA practice, but not for VPA. It is believed that favorable neighborhood conditions, such as security, infrastructure and public spaces, are friendly to the practice of mild and moderate activities, especially walking³²32. Foster C, Hillsdon M, Thorogood M. Environmental perceptions and walking in English adults. J Epidemiol Community Health 2004; 58(11): 924-8. https://dx.doi.org/10.1136%2Fjech.2003.014068
https://dx.doi.org/10.1136%2Fjech.2003.0... ^,3333. Giles-Corti B, Donovan RJ. The relative influence of individual, social and physical environment determinants of physical activity. Soc Sci Med 2002; 54(12): 1793-812.^,3434. Granner ML, Sharpe PA, Hutto B, Wilcox S, Addy CL. Perceived individual, social, and environmental factors for physical activity and walking. J Phys Act Health 2007; 4(3): 278-93.^,3535. Humpel N, Owen N, Iverson D, Leslie E, Bauman A. Perceived environment attributes, residential location, and walking for particular purposes. Am J Prev Med 2004; 26(2): 119-25..

When the health conditions were analyzed, it was verified that VPA conferred greater protective effect against chronic diseases such as obesity, hypertension and diabetes. Thisfinding reinforces the evidence that some PA is better than none at all, and that the higher the intensity of PA, the greater the health benefits⁶6. United States Department of Health and Human Services. Physical Activity Guidelines Advisory Committee Report 2008. Washington, D.C.: United States Department of Health and Human Services; 2008.. In turn, MPA provided stronger protection for stress. This indicates that to reduce stress levels, it is estimated that no such intense physical effort is required. It is likely that mild to moderate physical activity will also protect against stress and have mental health benefits³⁶36. Shephard RJ. Absolute versus relative intensity of physical activity in a dose-response context. Med Sci Sports Exerc 2001; 33(6 Supl.):S400-18; discussion S19-20.^,3737. Hamer M, Stamatakis E, Steptoe A. Dose-response relationship between physical activity and mental health: the Scottish Health Survey. Br J Sports Med 2009; 43(14): 1111-4. https://doi.org/10.1136/bjsm.2008.046243
https://doi.org/10.1136/bjsm.2008.046243... . It is also noteworthy that active individuals, in any of the intensities, perceived their health as better, and this effect was more significant for VPA than for MPA.

As limitations of this study, the cross-sectional design, which is not the most appropriate to establish cause-effect relationships, and the instrument used to measure PA, are mentioned. However, it is believed that the study was not affected by reverse causality, as all the associations found occurred in the expected direction. Nevertheless, if this bias had any influence, the association measures were underestimated. Regarding the instrument, although subjective, IPAQ is one of the most used questionnaires in studies on PA. In addition, objective measures, such as the accelerometer, have the disadvantage of not distinguishing PA domains nor capturing all activities.

One of the positive points of this study was evaluating the intensity of PA (moderate and vigorous) separately, since most studies do not make this distinction, simply classifying individuals as physically active or inactive. The present study also innovates in relation to other studies on this subject because it analyzed both predictors (associated factors) and health outcomes related to the practice of MPA and VPA. Another advantage was working with a representative sample of the adult and elderly population of a municipality in Southern Brazil, which allows extrapolating the results to other urban centers with similar characteristics.

CONCLUSIONS

The results of this study allowed to identify the groups most likely to practice MPA and VPA: males, with higher schooling levels, and nonsmokers. It was also observed that the health outcomes differed for those who met the recommendations for MPA and VPA. Such findings can be used by health managers to promote the practice of PA among less active groups, as well as to intervene on some diseases and health conditions through the promotion of PA. Longitudinal (cohort and intervention) studies are recommended, stratifying data analyzes by the intensity of PA, since the associated factors and health benefits differ for MPA and VPA.

ACKNOWLEDGEMENTS

Samuel C. Dumith is a research productivity fellow at the National Council for Scientific and Technological Development (CNPq). Jenifer L. Borchardt, Vitória S. Alam and Renata G. Paulitsch received scholarships from the Coordination for Improvement of Higher Education Personnel (CAPES).

References

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