Background: Public health strategies to increase physical activity in low-income communities may reduce cardiovascular risk in these populations. This controlled trial compared the cardiovascular risk estimated by the Framingham Risk Score (FRS) over 12 months in formally active (FA), declared active (DA), and physically inactive (PI) patients attended by the ‘Family Health Strategy’ in low-income communities at Rio de Janeiro City, Brazil (known as ‘favelas’). Methods: Patients were matched for age and assigned into three groups: a) FA (supervised training, n=53; 60.5±7.7 yrs); b) DA (self-reported, n=43; 57.0±11.2 yrs); c) PI (n=48; 57.0±10.7 yrs). FA performed twice a week a 50-min exercise circuit including strength and aerobic exercises, complemented with 30-min brisk walking on the third day, whereas DA declared to perform spontaneous physical activity twice a week. Comparisons were adjusted by sex, chronological age, body mass index, and use of anti-hypertensive/statin medications. Results: At baseline, groups were similar in regards to body mass, body mass index, triglycerides, and LDL-C, as well to FRS and most of its components (age, blood pressure, hypertension prevalence, smoking, HDL-C, and total cholesterol; P>0.05). However, diabetes prevalence was 10-15% lower in DA vs. FA and PI (P<0.05). Intention-to-treat analysis showed significant reductions after intervention (P<0.05) in FA for total cholesterol (~10%), LDL-C (~15%), triglycerides (~10%), systolic blood pressure (~8%), and diastolic blood pressure (~9%). In DA, only LDL-C decreased (~10%, P < 0.05). Significant increases were found in PI (P<0.05) for total cholesterol (~15%), LDL-C (~12%), triglycerides (~15%), and systolic blood pressure (~5%). FRS lowered 35% in FA (intention-to-treat, P<0.05), remained stable in DA (P>0.05), and increased by 20% in PI (P<0.05). Conclusions: A supervised multi-modal exercise training developed at primary care health units reduced the cardiovascular risk in adults living in very low-income communities. The risk remained stable in patients practicing spontaneous physical activity and increased among individuals who remained physically inactive. These promising results should be considered within public health strategies to prevent cardiovascular disease in communities with limited resources. Trial registration: TCTR20181221002 (registered December 21, 2018; retrospectively registered).
Background: Public health strategies to increase physical activity in low-income communities may reduce cardiovascular risk in these populations. This controlled trial compared the cardiovascular risk estimated by the Framingham Risk Score (FRS) over 12 months in formally active (FA), declared active (DA), and physically inactive (PI) patients attended by the ‘Family Health Strategy’ in low-income communities at Rio de Janeiro City, Brazil (known as ‘favelas’). Methods: Patients were matched for age and assigned into three groups: a) FA (supervised training, n=53; 60.5±7.7 yrs); b) DA (self-reported, n=43; 57.0±11.2 yrs); c) PI (n=48; 57.0±10.7 yrs). FA performed twice a week a 50-min exercise circuit including strength and aerobic exercises, complemented with 30-min brisk walking on the third day, whereas DA declared to perform self-directed physical activity twice a week. Comparisons were adjusted by sex, chronological age, body mass index, and use of anti-hypertensive/statin medications. Results: At baseline, groups were similar in regards to body mass, body mass index, triglycerides, and LDL-C, as well to FRS and most of its components (age, blood pressure, hypertension prevalence, smoking, HDL-C, and total cholesterol; P>0.05). However, diabetes prevalence was 10-15% lower in DA vs. FA and PI (P<0.05). Intention-to-treat analysis showed significant reductions after intervention (P<0.05) in FA for total cholesterol (~10%), LDL-C (~15%), triglycerides (~10%), systolic blood pressure (~8%), and diastolic blood pressure (~9%). In DA, only LDL-C decreased (~10%, P < 0.05). Significant increases were found in PI (P<0.05) for total cholesterol (~15%), LDL-C (~12%), triglycerides (~15%), and systolic blood pressure (~5%). FRS lowered 35% in FA (intention-to-treat, P<0.05), remained stable in DA (P>0.05), and increased by 20% in PI (P<0.05). Conclusions: A supervised multi-modal exercise training developed at primary care health units reduced the cardiovascular risk in adults living in very low-income communities. The risk remained stable in patients practicing self-directed physical activity and increased among individuals who remained physically inactive. These promising results should be considered within public health strategies to prevent cardiovascular disease in communities with limited resources.
We have read with interest the recent article by Werneck et al. (1) regarding the prospective associations of leisure-time physical activity (LTPA) with psychological distress and well-being. The authors reported that there is an association of higher LTPA intensity and frequency with low psychological distress and increased psychological well-being and that the body mass index (BMI) partially mediates this association. The results of this study offer some novel insights; however, we would like to draw attention to some additional points worth consideration.Although the authors have adjusted for several covariates at baseline (34 years), the effect of other variables like family activities, social participation, and social support, Self-esteem, life skills, friends and social behavior, self-perceived skills, and emotional support is not examined. Many of these variables were recorded during earlier follow-ups of the cohort (2). Studies have reported the associations of these confounding variables with LTPA and psychological distress and well-being (3,4). Thereby, not adjusting them can influence the outcome. In addition, the reverse causation of psychological well-being and distress remains a concern, given that the psychological correlates may discourage people from engaging in physical activities, which cannot be ruled out in the present analysis.The authors analyzed mediators as a secondary aim, but the selection of cognition, BMI, disability, and pain is not substantiated theoretically. Existing literature suggests that these variables can influence the level of physical activity and psychological wellbeing. Therefore, the possibility of these variables as confounders cannot be ruled out, especially in the absence of baseline data for these variables. There is a possibility that BMI and cognition can influence the level of physical activities, and having their baseline assessment could have provided clarity regarding change over time. The basic assumption for the mediation model is a casual chain of effect, where one variable affects the later occurring variable (no reverse causality) (5). In addition, while using longitudinal mediation analysis, the reason for choosing the three specific time points in the cohort is not explained. Consistency of LTPA over different time points is also not reported, which could have substantiated the findings (6). Moreover, for cognition, the only verbal recall was measured and the reason for the same is unexplained. It is unlikely that verbal recall can represent global cognition.Examining the mediators for the effect of physical activity on psychological well-being is an important domain for future research, and a robust mediation model can address these issues for clear interpretation of findings.
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