ABSTRACT:

Objective:

Evaluate the association between Metabolic Syndrome (MetS), physical activity and socioeconomic conditions among non-institutionalized elderly individuals.

Methodology:

Cross-sectional study with, elderly individuals (≥ 60) living in the city of São Paulo. MetS was evaluated by means of the National Cholesterol Education Program criteria, the Adult Treatment Panel III. Descriptive and bivariate analyses were performed, followed by multiple logistic regression with a 5% significance level. An attributable fraction (AF) and a proportional attributable fraction (PAF) were calculated in relation to physical activity. The magnitude of the socioeconomic inequalities was evaluated using the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII).

Results:

The prevalence of MetS was 40.1%, and 23.3% of the individuals had at least one MetS’ component. Physically inactive elderly had higher chances of having MetS. The prevalence of MetS was higher among those with lower education levels in both absolute and relative terms. AF and PAF were significant among the inactive individuals and for the total population.

Conclusion:

This study demonstrated that physical activity and schooling are significantly associated with MetS, highlighting the importance of these factors for the control of this syndrome.

Keywords:
Metabolic syndrome; Physical activity; Socioeconomic Factors; Elderly

INTRODUCTION

Metabolic syndrome (MetS) is a challenging clinical condition for public health¹1. Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the Metabolic Syndrome A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation [Internet] 2009 [acessado em 20 out. 2017]; 120(16): 1640-5. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/19805654 https://doi.org/10.1161/CIRCULATIONAHA.109.192644
https://www.ncbi.nlm.nih.gov/pubmed/1980... . It is characterized by a set of pathophysiological changes that simultaneously act to increase the risk of developing cardiovascular diseases (CVD), type 2 diabetes mellitus (DM)²2. Raposo L, Severo M, Barros H, Santos AC. The prevalence of the metabolic syndrome in Portugal: the PORMETS study. BMC Public Health [Internet] 2017 [acessado em: 20 out. 2017]; 17. Disponível em: Disponível em: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4471-9 https://doi.org/10.1186/s12889-017-4471-9
https://bmcpublichealth.biomedcentral.co... and death (NCEP-ATP III 2001). Individuals affected by this syndrome are twice as likely to develop CVD and five times more likely to develop DM compared to those without MetS¹1. Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the Metabolic Syndrome A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation [Internet] 2009 [acessado em 20 out. 2017]; 120(16): 1640-5. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/19805654 https://doi.org/10.1161/CIRCULATIONAHA.109.192644
https://www.ncbi.nlm.nih.gov/pubmed/1980... . The elderly is the group with the highest prevalence of unfavorable cardiovascular outcomes³3. Schmidt MI, Duncan BB, Azevedo e Silva G, Menezes AM, Monteiro CA, Barreto SM, et al. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet [Internet] 2011 [acessado em 1º jan. 2017]; 377(9781): 1949-61. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/21561658 https://doi.org/10.1016/S0140-6736(11)60135-9
https://www.ncbi.nlm.nih.gov/pubmed/2156... ^,44. Athyros VG, Ganotakis ES, Elisaf MS, Liberopoulos EN, Goudevenos IA, Karagiannis A. Prevalence of vascular disease in metabolic syndrome using three proposed definitions. Int J Cardiol [Internet] 2007 [acessado em 6 jan. 2017]; 117(2): 204-10. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/16854482 https://doi.org/10.1016/j.ijcard.2006.04.078
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Recent studies show an increasing evolution of MetS, with prevalence ranging from 25% in countries in the Middle East⁶6. Ansarimoghaddam A, Adineh HA, Zareban I, Iranpour S, HosseinZadeh A, Kh F. Prevalence of metabolic syndrome in Middle-East countries: Meta-analysis of cross-sectional studies. Diabetes Metab Syndr [Internet] 2018 [acessado em 21 jan. 2019]; 12(2): 195-201. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/29203060 https://doi.org/10.1016/j.dsx.2017.11.004
https://www.ncbi.nlm.nih.gov/pubmed/2920... to 50.2% in India⁷7. Subramani SK, Mahajan S, Chauhan P, Yadav D, Mishra M, Pakkirisamy U, et al. Prevalence of metabolic syndrome in Gwalior region of Central India: A comparative study using NCEP ATP III, IDF and Harmonized criteria. Diabetes Metab Syndr [Internet]. 2019 [acessado em 21 jan. 2019]; 13(1): 816-21. Disponível em: Disponível em: https://www.sciencedirect.com/science/article/pii/S1871402118305666 https://doi.org/10.1016/j.dsx.2018.12.003
https://www.sciencedirect.com/science/ar... . In Brazil, the review presented by Vidigal et al.⁸8. Vidigal FC, Bressan J, Babio N, Salas-Salvadó J. Prevalence of metabolic syndrome in Brazilian adults: a systematic review. BMC Public Health [Internet] 2013 [acessado em 12 abr. 2018]; 13: 1198. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24350922 https://doi.org/10.1186/1471-2458-13-1198
https://www.ncbi.nlm.nih.gov/pubmed/2435... showed a prevalence of 29.6% (14.9-65.3%). Recently, Vieira et al.⁹9. Vieira DAS, Hermes Sales C, Galvão Cesar CL, Marchioni DM, Fisberg RM. Influence of Haem, Non-Haem, and Total Iron Intake on Metabolic Syndrome and Its Components: A Population-Based Study. Nutrients [Internet] 2018 [acessado em 20 jun. 2018]; 10(3). Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/29518910 https://doi.org/10.3390/nu10030314
https://www.ncbi.nlm.nih.gov/pubmed/2951... found a prevalence of 32% among adults and elderly residents in the city of São Paulo (SP).

MetS is a widely studied condition, but there are different criteria that define it¹1. Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the Metabolic Syndrome A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation [Internet] 2009 [acessado em 20 out. 2017]; 120(16): 1640-5. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/19805654 https://doi.org/10.1161/CIRCULATIONAHA.109.192644
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https://www.ncbi.nlm.nih.gov/pubmed/1713... ^,1111. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet]. 2001 [acessado em 12 abr. 2018]. Disponível em: Disponível em: http://www.aefa.es/wp-content/uploads/2014/04/NECP-guidelines-.pdf
http://www.aefa.es/wp-content/uploads/20... . Among them, the most widely used is the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) 2001¹¹11. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet]. 2001 [acessado em 12 abr. 2018]. Disponível em: Disponível em: http://www.aefa.es/wp-content/uploads/2014/04/NECP-guidelines-.pdf
http://www.aefa.es/wp-content/uploads/20... , as it is more accessible for clinical practice and epidemiological research¹²12. Márquez-Sandoval F, Macedo-Ojeda G, Viramontes-Hörner D, Fernández Ballart JD, Salas Salvadó J, Vizmanos B. The prevalence of metabolic syndrome in Latin America: a systematic review. Public Health Nutr [Internet] 2011 [acessado em 12 abr. 2018]; 14(10): 1702-13. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/21486521 https://doi.org/10.1017/S1368980010003320
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https://www.ncbi.nlm.nih.gov/pubmed/1583... and because it is considered to be a better risk predictor of cardiovascular events when compared to other criteria⁴4. Athyros VG, Ganotakis ES, Elisaf MS, Liberopoulos EN, Goudevenos IA, Karagiannis A. Prevalence of vascular disease in metabolic syndrome using three proposed definitions. Int J Cardiol [Internet] 2007 [acessado em 6 jan. 2017]; 117(2): 204-10. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/16854482 https://doi.org/10.1016/j.ijcard.2006.04.078
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https://www.ncbi.nlm.nih.gov/pubmed/1729... . In Brazil, this is the criterion proposed by the I Brazilian Guideline for the Diagnosis and Treatment of Metabolic Syndrome¹⁵15. Sociedade Brasileira de Hipertensão. I Diretriz Brasileira de Diagnóstico e Tratamento da Síndrome Metabólica [Internet]. Sociedade Brasileira de Hipertensão; 2005 [acessado em 10 out. 2017]. Disponível em: Disponível em: http://publicacoes.cardiol.br/consenso/2005/sindromemetabolica.pdf
http://publicacoes.cardiol.br/consenso/2... . In this criterion, the syndrome is defined as the presence of three or more of the following criteria: central obesity, arterial hypertension, insulin resistance, low high-density lipoprotein (HDL) and high triglyceride (TG). These components come from modifiable risk factors (ex., sedentary behavior, unhealthy eating, physical inactivity) that result in the accumulation of adipose tissue and the progression of obesity¹⁶16. Ahima RS. Adipose tissue as an endocrine organ. Obesity [Internet] 2006 [acessado em 10 out. 2017]; 14(Supl. 5): 242S-249S. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/17021375 https://doi.org/10.1038/oby.2006.317
https://www.ncbi.nlm.nih.gov/pubmed/1702... .

Regular activity can reduce the chance of developing MetS by 31%¹⁷17. Wu S, Fisher-Hoch SP, Reininger B, McCormick JB. Recommended Levels of Physical Activity Are Associated with Reduced Risk of the Metabolic Syndrome in Mexican-Americans. PLoS One [Internet]. 2016 [acessado em 10 out. 2017]; 11(4): e0152896. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/27054324 https://doi.org/10.1371/journal.pone.0152896
https://www.ncbi.nlm.nih.gov/pubmed/2705... . However, an increase in physical inactivity from the age of 40¹⁸18. Althoff T, Sosic˘ R, Hicks JL, King AC, Delp SL, Leskovec J. Recommended Levels of Physical Activity Are Associated with Reduced Risk of the Metabolic Syndrome in Mexican-Americans. Nature[Internet] 2017 [acessado em 10 out. 2017]; 547(7663): 336-9. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28693034 https://doi.org/10.1038/nature23018
https://www.ncbi.nlm.nih.gov/pubmed/2869... ^,1919. Oguoma VM, Nwose EU, Skinner TC, Richards RS, Digban KA, Onyia IC. Association of physical activity with metabolic syndrome in a predominantly rural Nigerian population. Diabetes Metab Syndr [Internet] 2016 [acessado em 20 nov. 2017]; 10(1): 13-8. Disponível em: Disponível em: https://www.sciencedirect.com/science/article/abs/pii/S1871402115000776 https://doi.org/10.1016/j.dsx.2015.08.010
https://www.sciencedirect.com/science/ar... and the lower adherence to programs to encourage physical activity among the elderly¹⁷17. Wu S, Fisher-Hoch SP, Reininger B, McCormick JB. Recommended Levels of Physical Activity Are Associated with Reduced Risk of the Metabolic Syndrome in Mexican-Americans. PLoS One [Internet]. 2016 [acessado em 10 out. 2017]; 11(4): e0152896. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/27054324 https://doi.org/10.1371/journal.pone.0152896
https://www.ncbi.nlm.nih.gov/pubmed/2705... ^,2020. Lee H, Kim B. Physical activity disparities by socioeconomic status among metabolic syndrome patients: The Fifth Korea National Health and Nutrition Examination Survey. J Exerc Rehabil [Internet]. 2016 [acessado em 20 nov. 2017]; 12(1): 10-4. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/26933654 https://doi.org/10.12965/jer.150269
https://www.ncbi.nlm.nih.gov/pubmed/2693... contribute to the expansion of the prevalence of MetS in this group²¹21. Bergström G, Behre C, Schmidt C. Increased Leisure-Time Physical Activity is Associated With Lower Prevalence of the Metabolic Syndrome in 64-Year Old Women With Impaired Glucose Tolerance. Angiology [Internet] 2012 [acessado em 20 nov. 2017]; 63(4): 297-301. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/21873352 https://doi.org/10.1177/0003319711414867
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In addition to factors related to lifestyle, different studies have shown that the occurrence of MetS is associated with socioeconomic inequalities⁸8. Vidigal FC, Bressan J, Babio N, Salas-Salvadó J. Prevalence of metabolic syndrome in Brazilian adults: a systematic review. BMC Public Health [Internet] 2013 [acessado em 12 abr. 2018]; 13: 1198. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24350922 https://doi.org/10.1186/1471-2458-13-1198
https://www.ncbi.nlm.nih.gov/pubmed/2435... ^,2222. Cho KI, Kim BH, Je HG, Jang JS, Park YH. Gender-Specific Associations between Socioeconomic Status and Psychological Factors and Metabolic Syndrome in the Korean Population: Findings from the 2013 Korean National Health and Nutrition Examination Survey. Biomed Res Int [Internet] 2016 [acessado em: 20 nov. 2017]. Disponível em: Disponível em: https://www.hindawi.com/journals/bmri/2016/3973197/ https://doi.org/10.1155/2016/3973197
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http://www.scielo.br/pdf/ramb/v58n1/v58n... ^,2626. Gronner M, Bosi PL, Carvalho AM, Casale G, Contrera D, Pereira MA, et al. Prevalence of metabolic syndrome and its association with educational inequalities among Brazilian adults: a population-based study. Braz J Med Biol Res [Internet] 2011 [acessado em: 20 nov. 2017]; 44(7): 713-9. Disponível em: Disponível em: http://www.scielo.br/pdf/bjmbr/v44n7/997.pdf https://doi.org/10.1590/S0100-879X2011007500087
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https://www.ncbi.nlm.nih.gov/pubmed/1828... . These are characterized by the higher prevalence of the syndrome and its components among individuals belonging to the groups in the worst socioeconomic conditions when compared to those in the best conditions⁸8. Vidigal FC, Bressan J, Babio N, Salas-Salvadó J. Prevalence of metabolic syndrome in Brazilian adults: a systematic review. BMC Public Health [Internet] 2013 [acessado em 12 abr. 2018]; 13: 1198. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24350922 https://doi.org/10.1186/1471-2458-13-1198
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http://www.scielo.br/pdf/ramb/v58n1/v58n... . When these differences are unjust and avoidable, they are defined as inequities²⁸28. Whitehead M. The Concepts and Principles of Equity and Health. Int J Health Serv [Internet] 1992 [acessado em 20 nov. 2017]; 22(3): 429-45. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/1644507 https://doi.org/10.2190/986L-LHQ6-2VTE-YRRN
https://www.ncbi.nlm.nih.gov/pubmed/1644... .

The most recent report on health conditions issued by the World Health Organization (WHO) in 2018 highlights that the chronic noncommunicable diseases (NCDs) that make up MetS are increasing, and it highlights the need for studies on the risk factors associated with these conditions in order for control measures to be adopted²⁹29. World Health Organization. World health statistics 2018: monitoring health for the SDGs, sustainable development goals [Internet]. Genebra: World Health Organization; 2018 [acessado em 21 jan. 2019]. Disponível em: Disponível em: https://apps.who.int/iris/bitstream/handle/10665/272596/9789241565585-eng.pdf?ua=1
https://apps.who.int/iris/bitstream/hand... . Although the association between MetS, physical activity³⁰30. Beard JR, Officer A, de Carvalho IA, Sadana R, Pot AM, Michel JP, et al. The World report on ageing and health: a policy framework for healthy ageing. Lancet[Internet] 2016 [acessado em 21 jan. 2019]; 387(10033): 2145-54. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/26520231 https://doi.org/10.1016/S0140-6736(15)00516-4
https://www.ncbi.nlm.nih.gov/pubmed/2652... and socioeconomic conditions⁸8. Vidigal FC, Bressan J, Babio N, Salas-Salvadó J. Prevalence of metabolic syndrome in Brazilian adults: a systematic review. BMC Public Health [Internet] 2013 [acessado em 12 abr. 2018]; 13: 1198. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24350922 https://doi.org/10.1186/1471-2458-13-1198
https://www.ncbi.nlm.nih.gov/pubmed/2435... is quite often described, an analysis of the literature reveals that there is a gap in the assessment of factors associated with MetS in developing countries, especially among the elderly, who are in the fastest growing group in the world population and have the highest incidence of the syndrome¹1. Alberti KGMM, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the Metabolic Syndrome A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation [Internet] 2009 [acessado em 20 out. 2017]; 120(16): 1640-5. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/19805654 https://doi.org/10.1161/CIRCULATIONAHA.109.192644
https://www.ncbi.nlm.nih.gov/pubmed/1980... ^,88. Vidigal FC, Bressan J, Babio N, Salas-Salvadó J. Prevalence of metabolic syndrome in Brazilian adults: a systematic review. BMC Public Health [Internet] 2013 [acessado em 12 abr. 2018]; 13: 1198. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24350922 https://doi.org/10.1186/1471-2458-13-1198
https://www.ncbi.nlm.nih.gov/pubmed/2435... ^,2525. Leitão MPC, Martins IS. Prevalência e fatores associados à síndrome metabólica em usuários de unidades básicas de saúde em São Paulo - SP. Rev Assoc Med Bras [Internet] 2012 [acessado em: 20 nov. 2017]; 58(1): 60-9. Disponível em: Disponível em: http://www.scielo.br/pdf/ramb/v58n1/v58n1a16.pdf https://doi.org/10.1590/S0104-42302012000100016
http://www.scielo.br/pdf/ramb/v58n1/v58n... ^,3131. Roos V, Elmståhl S, Ingelsson E, Sundström J, Ärnlöv J, Lind L. Metabolic Syndrome Development During Aging with Special Reference to Obesity Without the Metabolic Syndrome. Metab Syndr Relat Disord [Internet] 2017 [acessado em 21 jan. 2018]; 15(1): 36-43. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/27754771 https://doi.org/10.1089/met.2016.0082
https://www.ncbi.nlm.nih.gov/pubmed/2775... .

Thus, this study was carried out with the objective of evaluating the association of MetS with physical activity and socioeconomic conditions among non-institutionalized Brazilian elderly.

METHODOLOGY

A cross-sectional study was carried out based on data from the Health, Well-Being and Aging (Saúde, Bem-Estar e Envelhecimento - SABE) 2010 study.

The SABE study was started in 2000 as a multi-center study developed in seven countries in Latin America (Argentina, Cuba, Uruguay, Barbados, Mexico, Chile and Brazil) and the Caribbean, with the aim of evaluating and comparing the health condition of people 60 years old or older at different stages of aging. In Brazil, the study was conducted in the city of São Paulo, with a representative sample of community-dwelling people aged 60 or over. In 2006, only in Brazil, SABE was transformed into a longitudinal study of multiple cohorts with follow-up at intervals of approximately five years. Information about the study and sampling has been previously published³²32. Moura RF, Andrade FB, Duarte YAO, Lebrão ML, Antunes JLF. Factors associated with adherence to influenza vaccination among non-institutionalized elderly in São Paulo, Brazil. Cad Saúde Pública [Internet] 2015 [acessado em 21 jan. 2018]; 31(10): 1-11. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v31n10/en_0102-311X-csp-31-10-2157.pdf https://doi.org/10.1590/0102-311X00065414
http://www.scielo.br/pdf/csp/v31n10/en_0... .

In 2010, 1,333 elderly people were interviewed and underwent physical examinations. This study included 1,201 individuals and 143 (9.9%) were excluded due to the lack of information on any of the variables of interest. There was no significant difference between those included in this study and those excluded in relation to sex, age, education level and number of self-reported diseases.

DEPENDENT VARIABLE

MetS was classified based on the criteria adopted by the NCEP ATP III¹¹11. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet]. 2001 [acessado em 12 abr. 2018]. Disponível em: Disponível em: http://www.aefa.es/wp-content/uploads/2014/04/NECP-guidelines-.pdf
http://www.aefa.es/wp-content/uploads/20... . According to this criterion, three or more of the following characteristics are required to determine if it’s present:

INDEPENDENT VARIABLES

The variables considered in the study were: sociodemographic factors (age [60 to 64, 65 to 69, 70 to 74 and 75 or more], sex, marital status [with marital relationship including married or cohabited individuals and no marital relationship including divorced, separated, and single individuals] and education [0 to 3 years (insufficient education), 4 to 7 years (incomplete elementary school) and 8 years or more (completed elementary school or more)])³³33. Andrade JM, Duarte YAO, Alves LC, Andrade FCD, Souza Junior PRB, Lima-Costa MF, et al. Frailty profile in Brazilian older adults: ELSI-Brazil RSP [Internet] 2018 [acessado em 21 jan. 2019]; 52(Supl. 2): 17s. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v52s2/0034-8910-rsp-52-s2-S1518-87872018052000616.pdf https://doi.org/10.11606/S1518-8787.2018052000616
http://www.scielo.br/pdf/rsp/v52s2/0034-... ^,3434. Andrade FB, Lebrão ML, Santos JL, Duarte YA. Relationship Between Oral Health and Frailty in Community‐Dwelling Elderly Individuals in Brazil. J Am Geriatr Soc [Internet] 2013 [acessado em 21 jan. 2019]; 61(5): 809-14. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/23647172 https://doi.org/10.1111/jgs.12221
https://www.ncbi.nlm.nih.gov/pubmed/2364... , health conditions (number of NCDs, depressive symptoms and self-rated health status (good (good and very good) and bad (normal, bad and very bad))) and health behavior (physical activity).

The practice of physical activity was assessed using the reduced version of the International Physical Activity Questionnaire (IPAQ)³⁵35. International Physical Activity Questionnaire. Guidelines for Data Processing and Analysis of the International Physical Activity Questionnaire (IPAQ) - Short and Long Forms [Internet]. 2005 [acessado em 21 jan. 2019]. Disponível em: Disponível em: https://sites.google.com/site/theipaq/
https://sites.google.com/site/theipaq/... . This instrument aims to verify what types of physical activity people do as part of their daily lives. The questions relate to their time spent doing physical activity in the last week, including physical activity carried out at work, commuting from place to place, physical activity for leisure, for sport, for exercise or as part of their activities at home or in the garden. Elderly people who performed at least 150 minutes a week of moderate physical activity or 75 minutes a week of vigorous activity were considered to be active, according to WHO recommendations³⁶36. World Health Organization. Recomendaciones mundiales sobre actividad física para la salud [Internet]. Genebra: World Health Organization ; 2010 [acessado em 10 out. 2017]. Disponível em: Disponível em: https://apps.who.int/iris/bitstream/handle/10665/44441/9789243599977_spa.pdf?sequence=1
https://apps.who.int/iris/bitstream/hand... .

The number of NCDs was assessed based on the answer to the following question: Has a doctor or nurse ever told you that you have (name of the disease)? The diseases questioned were: heart disease (congestive disease, coronary heart disease or infarction), joint disease (arthritis, rheumatism or arthrosis), stroke, diabetes, high blood pressure and chronic obstructive pulmonary disease.

Depressive symptoms were assessed using the Geriatric Depression Scale in an abbreviated format. Individuals with six or more points on the scale were considered to have depressive symptoms³⁷37. Almeida OP, Almeida SA. Confiabilidade da versão brasileira da Escala de Depressão em Geriatria (GDS) versão reduzida. Arq Neuropsiquiatr [Internet] 1999 [acessado em 10 out. 2017]; 57(2-B): 421-6. Disponível em: Disponível em: http://www.scielo.br/pdf/anp/v57n2B/1446.pdf https:// doi.org/10.1590/S0004-282X1999000300013
http://www.scielo.br/pdf/anp/v57n2B/1446... .

ANALYSIS OF THE DATA

A descriptive analysis of the sample was performed according to the outcome and all independent variables, followed by a bivariate analysis between MetS and the independent variables. The association between categorical variables was tested using the chi-square test with a Rao-Scott correction³⁸38. Rao JNK, Scott AJ. On Chi-Squared Tests for Multiway Contingency Tables with Cell Proportions Estimated from Survey Data. Ann Statist [Internet] 1984 [acessado em 10 out. 2017]; 12(1): 46-60. Disponível em: Disponível em: https://projecteuclid.org/euclid.aos/1176346391 https://doi.org/10.1214/aos/1176346391
https://projecteuclid.org/euclid.aos/117... .

All variables that presented p < 0.20 in the bivariate analysis were included in the multiple logistic regression model. The results were presented using odds ratios and respective 95% confidence intervals (CI). Based on the results of the multiple regression model, the attributable fraction (AF) and proportional attributable fraction (PAF) relating to the practice of physical activity were calculated as previously proposed³⁹39. Piola TS, Bacil EDA, Silva MP, Pacífico AB, Camargo EM, Campos W. Impact of physical activity correlates in the isolated and combined presence of insufficient level of physical activity and high screen time among adolescents. Rev Paul Pedriatr [Internet] 2019 [acessado em 21 jan. 2019]; 37(2): 194-201. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/30672979 https://doi.org/10.1590/1984-0462/;2019;37;2;00011
https://www.ncbi.nlm.nih.gov/pubmed/3067... ^,4040. Tanamas SK, Permatahati V, Ng WL, Backholer K, Wolfe R, Shaw JE, et al. Estimating the proportion of metabolic health outcomes attributable to obesity: a cross-sectional exploration of body mass index and waist circumference combinations. BMC Obes [Internet] 2016 [acessado em 21 jan. 2019]; 3: 4. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734864/ https://dx.doi.org/10.1186%2Fs40608-016-0085-5
https://www.ncbi.nlm.nih.gov/pmc/article... ^,4141. Newson RB. Attributable and unattributable risks and fractions and other scenario comparisons. Stata J [Internet] 2013 [acessado em 21 jan. 2019]; 13(4): 672-98. Disponível em: https://ideas.repec.org/a/tsj/stataj/v13y2013i4p672-698.html
https://doi.org/https://ideas.repec.org/... . The first, when expressed as a percentage, indicates the proportion of cases that can be attributed to exposure in exposed individuals and in the population. The second represents the proportion of cases of MetS that could have been avoided in those exposed and in the population, if the exposure were eliminated or changed.

The magnitude of inequalities was assessed by means of absolute and relative measures using, respectively, the absolute index of inequality (slope index of inequality - SII) and the relative index of inequality (RII)⁴²42. Moreno-Betancur M, Latouche A, Menvielle G, Kunst AE, Rey G. Relative Index of Inequality and Slope Index of Inequality: A Structured Regression Framework for Estimation. Epidemiology [Internet] 2015 [acessado em 20 out. 2017]; 26(4): 518-27. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/26000548 https://doi.org/10.1097/EDE.0000000000000311
https://www.ncbi.nlm.nih.gov/pubmed/2600... ^,4343. Mackenbach JP, et al. Socioeconomic Inequalities in Health in 22 European Countries. N Engl J Med [Internet] 2008 [acessado em 20 out. 2017]; 358: 2468-81. Disponível em: Disponível em: https://www.nejm.org/doi/full/10.1056/NEJMsa0707519 https://doi.org/10.1056/NEJMsa0707519
https://www.nejm.org/doi/full/10.1056/NE... , with education used as a measure of socioeconomic position. Each socioeconomic group was assigned a value that corresponds to the midpoint of the cumulative distribution of the socioeconomic position measure⁴³43. Mackenbach JP, et al. Socioeconomic Inequalities in Health in 22 European Countries. N Engl J Med [Internet] 2008 [acessado em 20 out. 2017]; 358: 2468-81. Disponível em: Disponível em: https://www.nejm.org/doi/full/10.1056/NEJMsa0707519 https://doi.org/10.1056/NEJMsa0707519
https://www.nejm.org/doi/full/10.1056/NE... . The SII and RII indices were obtained by regressing the health variable over a relative position score, which was obtained by measuring the socioeconomic position in increasing order, from the worst (score equal to zero) to the best socioeconomic situation (score equal to one). The SII is the absolute difference in the prevalence of MetS among the elderly with the highest socioeconomic position (higher level of education) and those with the lowest socioeconomic status (lower level of education). The RII is the prevalence ratio (relative inequality) between groups in the higher and lower socioeconomic position. An SII value below zero and an RII value less than one indicate that the prevalence of MetS is higher among the group in the lowest socioeconomic position. All analyses were performed using the Stata 13.0 program (Stata Corporation, College Station, TX, United States) using the command survey, which allows for the consideration of the complex structure of the sampling process. All analyses were performed considering the sample weights.

ETHICAL ASPECTS

The SABE study was approved by the Research Ethics Committee of the School of Public Health of the University of Sao Paulo.

RESULTS

The sample consisted of elderly people aged 60 or over, with a mean age of 70.32 years (95%CI 69.03 - 71.62), with the majority of them being female, in a marital relationship, with 0 to 3 years of study, and regular practice of physical activity.

The prevalence of MetS was 40.1% (95%CI 37.1 - 43.2). Regarding the components associated with the diagnosis of MetS, 23.3% (95%CI 20.8 - 25.9) of the elderly had at least one condition, with the increase in SBP being the most prevalent (66.1%; 95%CI 62.8 - 69.2) (Table 1).

Through the bivariate analysis, it was found that MetS was associated with two sociodemographic conditions (age and sex). The prevalence was higher among the elderly who did not perform physical activity and who had a greater number of chronic diseases (Table 2).

Based on the multiple regression model, it was found that the chance of having MetS was significantly lower among older individuals and among those who were physically active. Physically active individuals were 33% less likely to have MetS when compared to those who were not active. The results showed that more educated individuals had significantly less chances of MetS when compared to those with 0-3 years of study (Table 3). There was no interaction between physical activity and education.

Through the analysis of inequalities using the absolute and relative inequality indices, it was observed that less educated individuals had significantly higher prevalence of MetS in absolute and relative terms [SII = -0.12 (95%CI -0.231; -0.017) and RII = 0.73 (95%CI 0.535 - 0.931)].

Figure 1 shows the AFs and PAFs for the population and among those exposed. From the AF analysis, it can be seen that the difference in the prevalence of MetS between the active and inactive elderly in the population is 3.71% (95%CI 1.53 - 5.88). Among the inactive, the AF was 8.75% (95%CI 3.59 - 13.87). With regard to PAF, 9.27% (95%CI 3.56 - 14.65) of cases of MetS could have been prevented if all of the elderly in the population were active. Among the inactive, 19.9% (95%CI 8.33 - 28.94) of the cases would have been prevented.

DISCUSSION

This study used a representative sample of non-institutionalized elderly to evaluate the prevalence of MetS based on the criteria of the NCEP ATP III¹¹11. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet]. 2001 [acessado em 12 abr. 2018]. Disponível em: Disponível em: http://www.aefa.es/wp-content/uploads/2014/04/NECP-guidelines-.pdf
http://www.aefa.es/wp-content/uploads/20... and to evaluate its association with physical activity and socioeconomic conditions. It was observed that 40% of the population met the criterion for MetS. The main findings demonstrate the existence of socioeconomic inequalities related to MetS and the significance of physical activity as a preventive factor, as demonstrated by the AFs, data hitherto unavailable in the Brazilian literature for the elderly population.

The prevalence found in this study is high, but lower than that observed among elderly people from countries that, like Brazil, are in the process of social and economic development. In Mexico the prevalence was 72.9%, using the criteria of the American Heart Association/National Heart, Lung and Blood Institute⁴⁴44. Ortiz-Rodríguez MA, Yáñez-Velasco L, Carnevale A, Romero-Hidalgo S, Bernal D, Aguilar-Salinas C, et al. Prevalence of metabolic syndrome among elderly Mexicans. Arch Gerontol Geriatr [Internet] 2017 [acessado em 12 abr. 2018]; 73: 288-93. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28910752 https://doi.org/10.1016/j.archger.2017.09.001
https://www.ncbi.nlm.nih.gov/pubmed/2891... . In Ecuador, it was observed that 66.0% of women and 47.1% of men presented the syndrome, according to the criteria of the Joint Interim Statement⁴⁵45. Orces CH, Gavilanez EL. The prevalence of metabolic syndrome among older adults in Ecuador: Results of the SABE survey. Diabetes Metab Syndr [Internet] 2017 [acessado em 12 abr. 2018]; 11(Supl. 2): S555-S560. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28427839 https://doi.org/10.1016/j.dsx.2017.04.004
https://www.ncbi.nlm.nih.gov/pubmed/2842... . On the other hand, in China, a prevalence of 22.8% was demonstrated according to the NCEP ATP III⁴⁶46. Li W, Song F, Wang X, Wang L, Wang D, Yin X, et al. Prevalence of metabolic syndrome among middle-aged and elderly adults in China: current status and temporal trends. Ann Med [Internet] 2018 [acessado em 21 jan. 2019]; 50(4): 345-53. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/29637787 https://doi.org/10.1080/07853890.2018.1464202
https://www.ncbi.nlm.nih.gov/pubmed/2963... criterion. When compared to the prevalence in developed countries, it appears that the prevalence observed in this study was lower than that observed among women and men aged 60-69 years in the United States, 55.4 and 59.3%, respectively⁴⁷47. Ford CS, Li C, Zhao G. Prevalence and correlates of metabolic syndrome based on a harmonious definition among adults in the US Journal of Diabetes [Internet] 2010 [acessado em 20 out. 2017]; 2(3): 180-93. Disponível em: Disponível em: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1753-0407.2010.00078.x https://doi.org/10.1111/j.1753-0407.2010.00078.x
https://onlinelibrary.wiley.com/doi/full... . However, as previously mentioned, it should be noted that the differences between the estimates are also associated with the different criteria used in the studies. There is no national estimate of the prevalence of MetS in the literature, especially for the elderly population. The available studies report prevalence rates between 30⁴⁸48. Paula JAT, Moreira OC, da Silva CD, Silva DS, dos Santos Amorim PR. Metabolic syndrome prevalence in elderly of urban and rural communities participants in the HIPERDIA in the city of Coimbra/MG, Brazil. Invest Educ Enferm [Internet] 2015 [acessado em 20 out. 2017]; 33(2): 325-33. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/26535853 https://doi.org/10.1590/S0120-53072015000200015
https://www.ncbi.nlm.nih.gov/pubmed/2653... and 69.8%⁴⁹49. Santos BMP, Daltro C, Farias MCAD, Abreu LC, Valenti VE, Bezerra IMP, et al. Metabolic syndrome in elderly from a northeastern Brazilian city. Int Arch Med [Internet] 2015 [acessado em 20 out. 2017]; 8(20). Disponível em: Disponível em: https://imed.pub/ojs/index.php/iam/article/view/1009/683 https://doi.org/10.3823/1619
https://imed.pub/ojs/index.php/iam/artic... . The Brazilian population survey that investigated the prevalence of MetS (14.2%) did not estimate the specific prevalence for the elderly population and defined the presence of two or more conditions as MetS, which is different from this study⁵⁰50. Sá NNB, Moura EC. Fatores associados à carga de doenças da síndrome metabólica entre adultos brasileiros. Cad Saúde Pública [Internet] 2010 [acessado em 20 out. 2017]; 26(9): 1853-62. Disponível em: Disponível em: http://www.scielo.br/pdf/csp/v26n9/18.pdf https://doi.org/10.1590/S0102-311X2010000900018
http://www.scielo.br/pdf/csp/v26n9/18.pd... .

Physical inactivity is the third major risk factor for mortality among the factors proposed by the WHO for the control of CVD⁵¹51. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, et al. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet [Internet] 2017 [acessado em 12 abr. 2018]; 389(10075): 1229-37. Disponível em: Disponível em: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32380-7/fulltext https://doi.org/10.1016/S0140-6736(16)32380-7
https://www.thelancet.com/journals/lance... . Wu et al.¹⁷17. Wu S, Fisher-Hoch SP, Reininger B, McCormick JB. Recommended Levels of Physical Activity Are Associated with Reduced Risk of the Metabolic Syndrome in Mexican-Americans. PLoS One [Internet]. 2016 [acessado em 10 out. 2017]; 11(4): e0152896. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/27054324 https://doi.org/10.1371/journal.pone.0152896
https://www.ncbi.nlm.nih.gov/pubmed/2705... verified that regular activity can reduce the chance of developing METS by 31%. Corroborating these findings, in this study, active elderly presented a 33% less chance of having MetS when compared to non-active elderly individuals. In addition, this study has made an advancement by demonstrating the impact of physical activity as a preventive measure.

Estimates of proportional AFs demonstrate that prevention strategies aimed at the population and inactive individuals could prevent around 9 and 20% of MetS cases, respectively, if these people were active. Physical activity as a way of preventing NCDs is extremely important, and for this reason, the reduction of physical inactivity was included as one of the goals of the Strategic Action Plan for Coping with Chronic Non-Communicable Diseases in Brazil, which was implemented by the Ministry of Health, and aims to reduce this risk factor by 10% by the year 2025⁵²52. Lübs L, Peplies J, Drell C, Bammann K. Cross-sectional and longitudinal factors influencing physical activity of 65 to 75-year-olds: a pan European cohort study based on the survey of health, ageing and retirement in Europe (SHARE). BMC Geriatr [Internet] 2018 [acessado em 21 maio 2018]; 18(1): 94. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/29661154 https://doi.org/10.1186/s12877-018-0781-8
https://www.ncbi.nlm.nih.gov/pubmed/2966... ^,5353. Wu HF, Tam T, Jin L, Lao XQ, Chung RY, Su XF, et al. Age, gender, and socioeconomic gradients in metabolic syndrome: biomarker evidence from a large sample in Taiwan, 2005-2013. Ann Epidemiol [Internet] 2017 [acessado em 12 abr. 2018]; 27(5): 315-22. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28595736 https://doi.org/10.1016/j.annepidem.2017.04.003
https://www.ncbi.nlm.nih.gov/pubmed/2859... .

With regard to socioeconomic conditions, results from different studies are consistent in showing a higher prevalence of MetS among people with lower income⁵⁴54. Brasil. Ministério da Saúde. Relatório do III Fórum de Monitoramento do Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas não Transmissíveis no Brasil [Internet]. Brasil: Ministério da Saúde; 2018 [acessado em 21 jan. 2019]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/relatorio_iii_forum_monitoramento_plano.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... and educational level⁵⁵55. Malta DC, Stopa SR, Iser BPM, Bernal RTI, Claro RM, Nardi ACF, et al. Risk and protective factors for chronic diseases by telephone survey in capitals of Brazil, Vigitel 2014. Rev Bras Epidemiol [Internet] 2015 [acessado em 12 abr. 2018]; 18(Supl. 2): 238-55. Disponível em: Disponível em: http://www.scielo.br/pdf/rbepid/v18s2/en_1980-5497-rbepid-18-s2-00238.pdf 10.1590/1980-5497201500060021
http://www.scielo.br/pdf/rbepid/v18s2/en... and worse occupations²²22. Cho KI, Kim BH, Je HG, Jang JS, Park YH. Gender-Specific Associations between Socioeconomic Status and Psychological Factors and Metabolic Syndrome in the Korean Population: Findings from the 2013 Korean National Health and Nutrition Examination Survey. Biomed Res Int [Internet] 2016 [acessado em: 20 nov. 2017]. Disponível em: Disponível em: https://www.hindawi.com/journals/bmri/2016/3973197/ https://doi.org/10.1155/2016/3973197
https://www.hindawi.com/journals/bmri/20... . Similarly, in this study, it was observed that elderly people with fewer years of schooling were more likely to have MetS. Additionally, this research contributes to the literature by demonstrating that the magnitude of socioeconomic inequalities was significant from an absolute and relative point of view. Thus, this finding reinforces the proposal of other authors who suggest that socioeconomic condition should be included as a modifiable risk factor in local and global health strategies and policies⁵¹51. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, et al. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet [Internet] 2017 [acessado em 12 abr. 2018]; 389(10075): 1229-37. Disponível em: Disponível em: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32380-7/fulltext https://doi.org/10.1016/S0140-6736(16)32380-7
https://www.thelancet.com/journals/lance... and reaffirms the theory that there is a socioeconomic and cultural gradient in determining chronic diseases⁵²52. Lübs L, Peplies J, Drell C, Bammann K. Cross-sectional and longitudinal factors influencing physical activity of 65 to 75-year-olds: a pan European cohort study based on the survey of health, ageing and retirement in Europe (SHARE). BMC Geriatr [Internet] 2018 [acessado em 21 maio 2018]; 18(1): 94. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/29661154 https://doi.org/10.1186/s12877-018-0781-8
https://www.ncbi.nlm.nih.gov/pubmed/2966... ^,5353. Wu HF, Tam T, Jin L, Lao XQ, Chung RY, Su XF, et al. Age, gender, and socioeconomic gradients in metabolic syndrome: biomarker evidence from a large sample in Taiwan, 2005-2013. Ann Epidemiol [Internet] 2017 [acessado em 12 abr. 2018]; 27(5): 315-22. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28595736 https://doi.org/10.1016/j.annepidem.2017.04.003
https://www.ncbi.nlm.nih.gov/pubmed/2859... .

According to Stringhini et al.⁵¹51. Stringhini S, Carmeli C, Jokela M, Avendaño M, Muennig P, Guida F, et al. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. Lancet [Internet] 2017 [acessado em 12 abr. 2018]; 389(10075): 1229-37. Disponível em: Disponível em: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32380-7/fulltext https://doi.org/10.1016/S0140-6736(16)32380-7
https://www.thelancet.com/journals/lance... , the impact of socioeconomic conditions on health is similar to that of the six key risk factors adopted by the WHO for the prevention of chronic diseases. It suggests the importance of addressing not only proximal risk factors, but also structural solutions, which involve investment in early childhood education and work incentive programs, which is an economic mechanism to reduce health inequalities.

Literature analysis shows a positive association between MetS and age in the adult population⁸8. Vidigal FC, Bressan J, Babio N, Salas-Salvadó J. Prevalence of metabolic syndrome in Brazilian adults: a systematic review. BMC Public Health [Internet] 2013 [acessado em 12 abr. 2018]; 13: 1198. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/24350922 https://doi.org/10.1186/1471-2458-13-1198
https://www.ncbi.nlm.nih.gov/pubmed/2435... ^,5656. França SL, Lima SS, Vieira JRS. Metabolic Syndrome and Associated Factors in Adults of the Amazon Region. PLoS One [Internet] 2016 [acessado em 12 abr. 2018]; 11(12): e0167320. Disponível em: Disponível em: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0167320 https://doi.org/10.1371/journal.pone.0167320
https://journals.plos.org/plosone/articl... ^,5757. Moreira GC, Cipullo JP, Ciorlia LA, Cesarino CB, Vilela-Martin JF. Prevalence of Metabolic Syndrome: Association with Risk Factors and Cardiovascular Complications in an Urban Population. PLoS One [Internet] 2014 [acessado em 31 maio 2018]; 9(9): e105056. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/25180496 https://doi.org/10.1371/journal.pone.0105056
https://www.ncbi.nlm.nih.gov/pubmed/2518... ^,5858. Lim H, Nguyen T, Choue R, Wang Y. Sociodemographic disparities in the composition of metabolic syndrome components among adults in South Korea. Diabetes Care [Internet] 2012 [acessado em 31 maio 2018]; 35(10): 2028-35. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/22837361 https://doi.org/10.2337/dc11-1841
https://www.ncbi.nlm.nih.gov/pubmed/2283... ^,5959. Azizi F, Salehi P, Etemadi A, Zahedi-Asl S. Prevalence of metabolic syndrome in an urban population: Tehran Lipid and Glucose Study. Diabetes Res Clin Pract [Internet] 2003 [acessado em 31 maio 2018]; 61(1): 29-37. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/12849921 https://doi.org/10.1016/s0168-8227(03)00066-4
https://www.ncbi.nlm.nih.gov/pubmed/1284... . However, among the elderly, studies show that there is no association with age⁶⁰60. Khanam MA, Qiu C, Lindeboom W, Streatfield PK, Kabir ZN, Wahlin Å. The metabolic syndrome: prevalence, associated factors, and impact on survival among older persons in rural Bangladesh. PLoS One [Internet] 2011 [acessado em 12 abr. 2018]; 6(6): e20259. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/21697988 https://doi.org/10.1371/journal.pone.0020259
https://www.ncbi.nlm.nih.gov/pubmed/2169... or there is a reduction in prevalence with increasing age⁶¹61. Khosravi-boroujeni H, Sarrafzadegan N, Sadeghi M, Roohafza H, Talaei M, Ng SK, et al. Secular Trend of Metabolic Syndrome and Its Components in a Cohort of Iranian Adults from 2001 to 2013. Metab Syndr Relat Disord [Internet] 2017 [Acessado em: 12 abr. 2018]; 15(3): 137-44. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28135122 https://doi.org/10.1089/met.2016.0073
https://www.ncbi.nlm.nih.gov/pubmed/2813... ^,6262. Kuzuya M, Ando F, Iguchi A, Shimokata H. Age-specific change of prevalence of metabolic syndrome: longitudinal observation of large Japanese cohort. Atherosclerosis [Internet] 2007 [acessado em 12 abr. 2018]; 191(2): 305-12. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/16828779 https://doi.org/10.1016/j.atherosclerosis.2006.05.043
https://www.ncbi.nlm.nih.gov/pubmed/1682... . Longitudinal studies have found that the prevalence of MetS increased with age up to the age range of 60 to 69 years, with a reduction in the older age groups and absence of differences between these age groups⁶²62. Kuzuya M, Ando F, Iguchi A, Shimokata H. Age-specific change of prevalence of metabolic syndrome: longitudinal observation of large Japanese cohort. Atherosclerosis [Internet] 2007 [acessado em 12 abr. 2018]; 191(2): 305-12. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/16828779 https://doi.org/10.1016/j.atherosclerosis.2006.05.043
https://www.ncbi.nlm.nih.gov/pubmed/1682... . Khosravi-Boroujeni et al.⁶¹61. Khosravi-boroujeni H, Sarrafzadegan N, Sadeghi M, Roohafza H, Talaei M, Ng SK, et al. Secular Trend of Metabolic Syndrome and Its Components in a Cohort of Iranian Adults from 2001 to 2013. Metab Syndr Relat Disord [Internet] 2017 [Acessado em: 12 abr. 2018]; 15(3): 137-44. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28135122 https://doi.org/10.1089/met.2016.0073
https://www.ncbi.nlm.nih.gov/pubmed/2813... observed an increase in the prevalence of MetS with increasing age up to 75 years, when a decline was observed. In addition, longitudinal analyses of the Japanese population have shown that there is a cohort effect related to the prevalence of MetS in which the younger cohorts have higher prevalences⁶²62. Kuzuya M, Ando F, Iguchi A, Shimokata H. Age-specific change of prevalence of metabolic syndrome: longitudinal observation of large Japanese cohort. Atherosclerosis [Internet] 2007 [acessado em 12 abr. 2018]; 191(2): 305-12. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/16828779 https://doi.org/10.1016/j.atherosclerosis.2006.05.043
https://www.ncbi.nlm.nih.gov/pubmed/1682... .

As such, the results of this study are in accordance with the literature. The age groups above 65 years are less likely to have MetS when compared to the elderly aged 60 to 64 years old, and there was no gradient between higher age groups. Among the reasons for the lower chance of MetS in the older age groups, the reduction in appetite and abdominal obesity associated with age have been proposed⁶¹61. Khosravi-boroujeni H, Sarrafzadegan N, Sadeghi M, Roohafza H, Talaei M, Ng SK, et al. Secular Trend of Metabolic Syndrome and Its Components in a Cohort of Iranian Adults from 2001 to 2013. Metab Syndr Relat Disord [Internet] 2017 [Acessado em: 12 abr. 2018]; 15(3): 137-44. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28135122 https://doi.org/10.1089/met.2016.0073
https://www.ncbi.nlm.nih.gov/pubmed/2813... ^,6363. Costa CS, Schneider BC, Cesar JA. Obesidade geral e abdominal em idosos do Sul do Brasil: resultados do estudo COMO VAI. Ciênc Saúde Coletiva [Internet] 2016 [acessado em 21 jan. 2019]; 21(11): 3585-96. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v21n11/1413-8123-csc-21-11-3585.pdf https://doi.org/10.1590/1413-812320152111.02492016
http://www.scielo.br/pdf/csc/v21n11/1413... ^,6464. Assumpção D, Borim FSA, Francisco PMSB, Neri AL. Fatores associados ao baixo peso em idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Ciênc Saúde Coletiva [Internet] 2018 [acessado em 21 jan. 2019]; 23(4): 1143-50. Disponível em: Disponível em: http://www.scielo.br/pdf/csc/v23n4/1413-8123-csc-23-04-1143.pdf https://doi.org/10.1590/1413-81232018234.17422016
http://www.scielo.br/pdf/csc/v23n4/1413-... . In addition, premature death due to conditions associated with MetS would lead to the maintenance of a healthier elderly cohort⁵⁴54. Brasil. Ministério da Saúde. Relatório do III Fórum de Monitoramento do Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas não Transmissíveis no Brasil [Internet]. Brasil: Ministério da Saúde; 2018 [acessado em 21 jan. 2019]. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/relatorio_iii_forum_monitoramento_plano.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... ^,6161. Khosravi-boroujeni H, Sarrafzadegan N, Sadeghi M, Roohafza H, Talaei M, Ng SK, et al. Secular Trend of Metabolic Syndrome and Its Components in a Cohort of Iranian Adults from 2001 to 2013. Metab Syndr Relat Disord [Internet] 2017 [Acessado em: 12 abr. 2018]; 15(3): 137-44. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28135122 https://doi.org/10.1089/met.2016.0073
https://www.ncbi.nlm.nih.gov/pubmed/2813... .

Among the strengths of this study is the use of a representative sample of non-institutionalized elderly people in Brazil’s largest city, using criteria that is comparable to other international studies in order to assess the prevalence and factors associated with MetS. In addition, this study was innovative by demonstrating the impact of the practice of activity as a preventive measure. The cross-sectional design and the impossibility of inferring the direction of the associations are among the limitations of the study. The self-reporting of diseases can also be considered one of the limitations, but this measure is considered to be valid⁶⁵65. Haapanen N, Miilunpalo S, Pasanen M, Oja P, Vuori I. Agreement between questionnaire data and medical records of chronic diseases in middle-aged and elderly Finnish men and women. Am J Epidemiol [Internet] 1997 [acessado em 21 jan. 2019]; 145(8): 762-9. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/9126003 https://doi.org/10.1093/aje/145.8.762
https://www.ncbi.nlm.nih.gov/pubmed/9126... . In addition, it is worth noting that in this study only education level was used as a measure of socioeconomic status. Thus, studies using other measures may find different results regarding the magnitude of inequalities, given that each socioeconomic measurement has a way to explain these differences⁶⁶66. Grundy E, Holt G. The socioeconomic status of older adults: How should we measure it in studies of health inequalities. J Epidemiol Community Health [Internet] 2001 [acessado em 21 jan. 2019]; 55(12): 895-904. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1731799/ https://dx.doi.org/10.1136%2Fjech.55.12.895
https://www.ncbi.nlm.nih.gov/pmc/article... ^,6767. Avlund K, Holstein BE, Osler M, Damsgaard MT, Holm-Pedersen P, Rasmussen NK. Social position and health in old age: the relevance of different indicators of social position. Scand J Public Health [Internet] 2003 [acessado em 21 jan. 2019]; 31(2): 126-36. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/12745763 https://doi.org/10.1080/14034940210134130
https://www.ncbi.nlm.nih.gov/pubmed/1274... .

CONCLUSION

This study demonstrated that the practice of physical activity and education level are factors that are significantly associated with MetS. This association reinforces the role of physical activity as a first-line non-pharmacological treatment to control this condition⁶⁸68. Oh SH, Son SH, Kang SH, Kim DK, Seo KM, Lee SY. Relationship Between Types of Exercise and Quality of Life in a Korean Metabolic Syndrome Population: A Cross-Sectional Study. Metab Syndr Relat Disord [Internet] 2017 [acessado em 21 jan. 2019]; 15(4): 199-205. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/28287907 https://doi.org/10.1089/met.2016.0151
https://www.ncbi.nlm.nih.gov/pubmed/2828... ^,1111. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet]. 2001 [acessado em 12 abr. 2018]. Disponível em: Disponível em: http://www.aefa.es/wp-content/uploads/2014/04/NECP-guidelines-.pdf
http://www.aefa.es/wp-content/uploads/20... due to its direct relationship with all of the syndrome’s components¹¹11. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet]. 2001 [acessado em 12 abr. 2018]. Disponível em: Disponível em: http://www.aefa.es/wp-content/uploads/2014/04/NECP-guidelines-.pdf
http://www.aefa.es/wp-content/uploads/20... . In addition, the existence of socioeconomic inequalities related to MetS calls attention to the need for prevention policies to be based on approaches that consider these differences, and go beyond the other factors that are commonly explored, since both the practice of physical activity⁶⁹69. O’Donoghue G, Kennedy A, Puggina A, Aleksovska K, Buck C, Burns C, et al. Socio-economic determinants of physical activity across the life course: A “DEterminants of DIet and Physical ACtivity” (DEDIPAC) umbrella literature review. PLoS One [Internet] 2018 [acessado em: 21 jan. 2019]; 13(1): e0190737. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/29351286 https://doi.org/10.1371/journal.pone.0190737
https://www.ncbi.nlm.nih.gov/pubmed/2935... and the other modifiable factors, are disproportionately inaccessible to the nation’s poorest people⁷⁰70. Cesare MD, Khang Y-H, Asaria P, Blakely T, Cowan MJ, Farzadfar F, et al. Inequalities in non-communicable diseases and effective responses. Lancet [Internet] 2013 [acessado em 31 maio 2018]; 381(9866): 585-97. Disponível em: Disponível em: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61851-0/fulltext https://doi.org/10.1016/S0140-6736(12)61851-0
https://www.thelancet.com/journals/lance... .

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