ijcsInternational Journal of Cardiovascular SciencesInt. J. Cardiovasc. Sci.2359-48022359-5647Sociedade Brasileira de CardiologiarbzrqjrfdDyLWy5nvSXfDmPS2359-56472022005001204S2359-56472022000300391ijcs.2021004510.36660/ijcs.20210045Original ArticlePoor Trunk Flexibility is Associated with Cardiovascular Risk Factors0000-0001-5329-1866CardosoRafael FelipeSilvaMaria SebastianaCominettiCristiane0000-0003-4332-6206NavesMaria Margareth V.Universidade Federal de GoiásGoiâniaGOBrazilUniversidade Federal de Goiás, Goiânia, GO - BrazilMailing Address: Maria Margareth V. Naves, Rua 227, sn, Quadra 68, Setor Leste Universitário, Postal Code: 74605-080 , Goiânia, GO - Brazil. E-mail: maria_margareth_veloso@ufg.br
Author contributions
Conception and design of the research: Silva MS, Cominetti C, Naves MMV. Data acquisition: Cardoso RF, Silva MS. Data synthesis, analysis and interpretation: Cardoso RF, Silva MS, Cominetti C, Naves MMV. Statistical analysis and manuscript writing: Cardoso RF. Critical review of the writing and the intellectual content of the manuscript: Cominetti C, Naves MMV.
Potential Conflict of Interest
No potential conflict of interest relevant to this article was reported.
11022022May-Jun2022353391399171120200109202103042021This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.AbstractBackground:
Poor flexibility is a predictor of reduced physical activity. The association between trunk flexibility and cardiovascular risk factors (CVRFs) is not well understood.
Objective:
To identify the prevalence of CVRFs and their association with trunk flexibility in individuals participating in a community-based health education program.
Methods:
Volunteers (51 men, 48 women) aged 20-85 years old, participants in a community-based health education program in the city of Santo Antônio de Goiás, Brazil, were selected for this study. Anthropometric measures including body mass, height, body mass index (BMI), waist circumference (WC) and waist/height ratio (WHtR) were evaluated. Physical activity level was evaluated based on leisure activity participation, and trunk flexibility was evaluated by the sit and reach test. Data distribution was assessed using the Shapiro-Wilk test; Pearson's chi-square or Fisher's exact and Student t tests were performed for comparisons. To analyze the association between trunk flexibility and concomitant CVRFs, Spearman’s correlation test and linear regression were employed. Statistical significance was defined as p < 0.05.
Results:
7.2% of the volunteers had no CVRF, 10.3% had only one CVRF and 82.5% had two or more CVRFs, with no differences between sexes. Increased abdominal adiposity, as assessed by WHtR (p = 0.0097), and systemic arterial hypertension (p = 0.0003) were the most prevalent CVRFs, with differences between age groups. A strong negative correlation was found between mean trunk flexibility and the number of concomitant CVRFs (r = -0.96, p < 0.0028).
Conclusion:
The strong negative correlation between trunk flexibility and concomitant CVRF indicates an increased risk for cardiovascular events. Therefore, trunk flexibility measurement may be an additional tool for health promotion and prevention of cardiovascular and associated diseases in community health programs.
Cardiovascular diseases (CVDs) are the leading cause of death in the world,1 accounting for 18 million deaths in 2016.2 In Brazil, CVDs cause 31% of deaths,3 and have been considered the main cause of mortality since the 1960s.4 , 5
The cardiovascular risk factors (CVRFs) with the greatest impact on the development of CVDs are obesity, systemic arterial hypertension, insufficient physical activity, smoking and unhealthy diet.6 Central obesity or abdominal adiposity is one of the most studied CVRFs because it is directly related to hypertension, stroke and myocardial ischemia.7
Abdominal adiposity can be easily determined by simple anthropometric measures that are as efficient as the most sophisticated and costly devices.8 Waist circumference (WC) measurement is easily applicable and widely recognized as a reliable tool for estimating abdominal adiposity and predicting risks for chronic non-communicable diseases.7 The waist-to-height ratio (WHtR) is less widely known in public health, but also a reliable anthropometric measure in the identification of CVRFs when associated with other anthropometric parameters, such as body mass index (BMI).9 , 10
Increased abdominal adiposity and obesity are associated with various metabolic disturbances, such as type 2 diabetes, insulin resistance, hyperlipidemia, and high blood pressure,11 - 13 and can negatively affect the individuals’ physical fitness, including a reduced flexibility. This term is defined as the physical capacity to perform movements with adequate amplitude without risk of injury.14 - 16 In the last 20 years, flexibility has gained special attention because health care institutions, such as the American College of Sports Medicine (ACSM) and the American Heart Association (AHA), started recommending flexibility training for all populations.17 , 18
Poor trunk flexibility seems to be related to arterial stiffness,19 , 20 which is present in obesity21 and CVDs,22 and is a predictor of cardiovascular events.23 , 24 In addition, some diseases in the spinal column, for example, increase the risk for CVDs due to the physical inactivity associated with the disease.25 Increased flexibility has been shown to improve the physical function of people with these conditions.21 , 25 , 26 Nevertheless, studies on the association between trunk flexibility and CVRFs, as abdominal adiposity and obesity, are scarce in the literature. Thus, the aim of our study was to identify the prevalence of CVRFs and to investigate the association between trunk flexibility and CVRFs in individuals participating in a community-based health education program.
MethodsStudy design and sample
This was a cross-sectional study, carried out with a convenience sample composed of 99 individuals (51 men and 48 women), aged between 20 and 85 years (47.5 ± 13.9 years; mean ± standard deviation [SD]), living in Santo Antônio de Goiás, GO, Brazil. Participants were recruited during two events of a community-based health education program – “Pink October” and “Blue November” ( Figure 1 ). All data were collected at the event site, including the administration of a sociodemographic interview to each participant.
Flowchart of participants’ recruitment. Volunteers participating in the health education events “Pink October” and “Blue November” in Santo Antônio de Goiás city, GO, Brazil
Anthropometric evaluation
The anthropometric measures included body mass (BM), height (H), BMI, WC and WHtR. All measurements were collected according to standardized procedures.27
BMI was calculated by dividing BM (kg) by squared H (m), according to the equation: BMI (kg/m2) = BM (kg) / H2 (m), and classified according to the cut-off points proposed by the World Health Organization.28
WC (cm) was measured using a body measure tape (Sanny®, São Bernardo do Campo, Brazil) placed at the midpoint between the last lower rib and the iliac crest, to estimate abdominal adiposity and cardiovascular risk.27 Lean et al.29 proposed the use of WC as an indicator of cardiovascular risk, and respective cut-offs: men > 94 cm and women > 80 cm. From WC and H measurements, the WHtR was determined: WHtR = WC (cm) / H (m) and the cut-offs for cardiovascular risk was > 0.50 for adult and elderly men and women.9 , 10
Assessment of physical activity level
Physical activity level was assessed from data on leisure-time activity. Individuals who practiced at least 30 minutes of mild or moderate physical activity on five or more days during the week, or at least 20 minutes of vigorous physical activity on three or more days during the week were classified as sufficiently active. Those who did not reach these values were classified as insufficiently physically active.30 , 31
Blood pressure measurement
A digital blood pressure measuring device (G-Tech model MA100, Duque de Caxias – Brazil) was used for the measurements. Systolic and diastolic blood pressures were measured twice; the first measurement was taken after a resting period of at least five minutes, followed by the second measurement two minutes later. The second measurement was considered for analysis. The cutoff point for systemic arterial hypertension was a systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, as recommended by the 7th Brazilian Guidelines of Arterial Hypertension.32
Assessment of trunk flexibility
Trunk flexibility was measured using the sit and reach test using a sit-and-reach box (Sanny®, São Bernardo do Campo, Brazil). The subject was instructed to sit on a mat, without shoes and with knees extended. Then, with one hand on top of the other, the volunteer flexed the trunk and reached forward along the measuring line as far as possible. Values were expressed in centimeters and the best of three attempts was included in the analysis.33 Trunk flexibility was classified as “excellent”, “above mean”, “mean”, “below mean” and “poor”, by sex and age group, according to the Canadian Standardized Test of Fitness.34
Concomitant cardiovascular risk factors
The prevalence of single and concomitant (grouped) risk factors was determined.35
Statistical analysis
Categorical variables (CVRFs and classification of trunk flexibility) were presented as absolute and relative frequencies. The risk factors evaluated were obesity, abdominal adiposity (WC and WHtR), insufficient physical activity, hypertension and smoking. Pearson's chi-square test or Fisher's exact test were performed to compare the prevalence of risk factors between the age groups (20-39, 40-59 and 60+ years). Continuous variables were subjected to descriptive analysis and the Shapiro-Wilk test was applied to verify data distribution. Data were presented as mean ± standard deviation (SD) when normally distributed, and as median (interquartile range) when not normally distributed. Trunk flexibility between individuals with and without CVRF was analyzed by the Student’s t -test for unpaired samples. Spearman’s correlation test was carried out to evaluate the correlation between the number of concomitant CVRFs (discrete quantitative variable) and mean trunk flexibility, followed by linear regression analysis (the necessary assumptions were verified and met).
Statistical analysis was performed using the R software version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria)36 . Statistical significance was defined as p < 0.05.
ResultsAnthropometry, trunk flexibility and blood pressure
The sample comprised 99 volunteers, with the following characteristics: BM = 71.5 (62.2 – 83.2) kg; H = 1.62 ± 0.08 m; BMI = 27.0 (24.1 – 30.1) kg/m²; WC = 91.3 ± 13.0 cm; WHtR = 0.56 ± 0.08; trunk flexibility = 22.7 ± 9.4 cm; systolic blood pressure = 129.6 ± 19.2 mmHg and diastolic blood pressure = 81.6 ± 11.6 mmHg.
Prevalence of cardiovascular risk factors by age group
Among the volunteers, 7.2% featured no CVRF, 10.3% presented only one CVRF and 82.5% showed two or more CVRFs, with no statistical difference between sexes. Increased abdominal adiposity, as assessed by WHtR (p = 0.0097), and systemic arterial hypertension (p = 0.0003) were the most prevalent CVRFs in the sample, especially in the group aged from 40 to 59 years ( Table 1 ).
Prevalence of cardiovascular risk factors in participants of a community-based health education program in the city of Santo Antúnio de Goiás, Brazil, by age group
Risk factor
Age group (years)
p value
Total (n = 97)
20 – 39 (n = 30)
40 – 59 (n = 45)
60+ (n = 22)
n
%
n
%
n
%
n
%
Obesity *
25
25.8
6
20.0
16
35.6
3
13.6
0.1071
Elevated AA
- WC *
59
60.8
14
46.7
31
68.9
14
63.6
0.1477
- WHtR *
74
76.3
17
56.7
38
84.4
19
86.4
0.0097
Insufficient PA *
46
47.4
15
50.0
22
48.9
9
40.9
0.7815
Hypertension *
53
54.6
11
36.7
22
48.9
20
90.9
0.0003
Smoking **
14
14.4
3
10.0
8
17.8
3
13.6
0.7070
Missing data for two volunteers. AA: abdominal adiposity; WC: waist circumference; WHtR: waist-to-height ratio; PA: physical activity.
Pearson’s chi-square test;
Fisher's exact test. Bolded values indicate statistical differences (p<0.05) between age groups.
Classification of trunk flexibility and its relation to CVRFs
According to the classification of trunk flexibility ( Table 2 ), 21.7% of the volunteers showed below mean flexibility, and 43.5% had poor flexibility. In the analysis of trunk flexibility according to the presence or absence of CVRF, individuals without CVRF showed significantly higher flexibility as compared with those with elevated WC (p = 0.0001) and WHtR (p = 0.0001) ( Figure 2 ). There was a strong negative correlation between mean trunk flexibility and concomitant CVRFs (r = -0.96, p < 0.0028). The adjustment of the original values by linear regression generated the following equation: y = 27.2 – 1.50 x (adjusted R2 = 0.80, p < 0.0040, RSE = 1.559) ( Figure 3 ).
Classification of trunk flexibility of individuals participating in a community-based health education program in the city of Santo Antônio de Goiás, Brazil, by age group
Trunk flexibility
Age group (years)
Total (n = 92)
20 – 39 (n = 28)
40 – 59 (n = 44)
60+ (n = 20)
n
%
n
%
n
%
n
%
Excellent
7
7.6
2
7.1
3
6.8
2
10.0
Above mean
14
15.2
3
10.8
7
15.9
4
20.0
Mean
11
12.0
2
7.1
7
15.9
2
10.0
Below mean
20
21.7
7
25.0
10
22.7
3
15.0
Poor
40
43.5
14
50.0
17
38.7
9
45.0
Trunk flexibility according to sex and age group34
Trunk flexibility (mean ± SD) of individuals with (dark gray bars) and without cardiovascular risk factors (light gray bars); *p < 0.05, Student’s t-test; CVRF: cardiovascular risk factor; WC: waist circumference; WHtR: waist/height ratio
Linear regression between number of concomitant cardiovascular risk factors and mean trunk flexibility (y = 27.2 – 1.5 x, adjusted R<sup>2</sup> = 0.80; p = 0.00397); CVRFs: cardiovascular risk factors
Discussion
Increased abdominal adiposity was the most prevalent CVRF and it was negatively associated with trunk flexibility. In addition, we found a strong correlation between trunk flexibility and presence of CVRF, which suggests the use of this biomarker as an indicator of increased cardiovascular risk.
We observed a high prevalence of increased abdominal adiposity according to the WHtR (76.3%). Some studies9 , 37 - 39 have shown that the WHtR has high accuracy in the identification of abdominal adiposity and could be a more efficient indicator than the WC, the waist-to-hip ratio (WHR) and the BMI in the cardiovascular risk assessment. Considering that excess abdominal fat is associated with CVD, WHtR is an important and useful tool for professionals in basic health care to identify individuals at increased risk.40
The prevalence of systemic arterial hypertension was 54.6%. The Surveillance of Risk Factors and Protection for Chronic Diseases by Telephone Inquiry (VIGITEL, Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico ), conducted in all capitals of the 26 Brazilian federal states and the Federal District, registered a prevalence of hypertension of 25.7% in Brazil.3 Our results were approximately twice as high as the prevalence found in the Brazilian population.3 Considering that the prevalence of hypertension is increasing every year, it is necessary to implement programs focused on its reduction and prevention.
According to trunk flexibility classification, we found 64.1% of the individuals with trunk flexibility below the recommended values.34 A similar result was found in the evaluation of 46 workers at the Federal University of Viçosa, MG, Brazil, including men and women aged around 40 years old, in which 66.5% of them had trunk flexibility below the recommended values.41 Flexibility is important for athletes as well as for sedentary and/or physically active people, as less mobility of the hip joint, for example, can contribute to back pain and compromise work, sports and/or daily life activities.15
When comparing trunk flexibility between individuals with and without CVRF, we found a significant difference in the flexibility of individuals with adequate WC compared to those with WC above the recommended values. We also observed significant difference in flexibility of individuals with adequate WHtR compared to those with elevated WHtR.
Studies evaluating the relationship between trunk flexibility and CVRFs are scarce in the literature. However, studies have shown that poor trunk flexibility has been associated with arterial stiffness in young and elderly individuals.19 , 20 , 42 Thus, flexibility may be a predictor of arterial stiffness, regardless of other physical fitness components.19 , 20 In addition, after only four weeks of flexibility training, a reduction in arterial stiffness was observed,19 thereby suggesting flexibility as an indicator of cardiovascular health and cardiorespiratory fitness.43 These findings reinforce the importance of flexibility training and the inclusion of this measure in community health programs.
Cardiovascular risk factors can occur simultaneously and represent a greater risk for cardiovascular events when compared with isolated risk factors.35 , 44 When the risk factors were grouped, 82.5% of the subjects were found to be at increased risk for CVD. A previous study reported that concomitant CVRFs were found in 72.5% adults and elderly in the city of Salvador, Brazil.45
We found a strong negative correlation between the number of concomitant CVRFs and mean trunk flexibility. Therefore, flexibility seems to be a sensitive indicator of increased cardiovascular risk. According to the equation obtained by linear regression analysis, we observed that for each additional risk factor, flexibility was reduced by 1.50 cm, or each 1.50 cm reduction in trunk flexibility indicated the addition of one CVRF ( Figure 3 ). Accordingly, it is possible to estimate cardiovascular risk by the measurement of trunk flexibility using the sit-and-reach test, which is simple and easy to apply. Trunk flexibility, therefore, may be an additional tool to be applied in the detection and control of CVDs.
One limitation of our study was the inability to perform blood biochemical tests to identify other risk factors, such as dyslipidemia and glycemic disturbances. However, studies in the literature about the relationship between flexibility and CVRFs are scarce. Thus, our study is important as a basis for future research on trunk flexibility and CVRFs, including analysis of metabolic biomarkers in larger samples, to provide a better understanding of the association between the variables studied.
Conclusion
Increased abdominal adiposity was the most prevalent CVRF and it was negatively associated with trunk flexibility among participants in a community-based health program in the city of Santo Antônio de Goiás, located in the mid-west of Brazil. Moreover, there was a high prevalence of concomitant CVRFs, which were strongly and negatively correlated with trunk flexibility. Considering these findings and that flexibility training can reduce arterial stiffness, trunk flexibility is suggested as an indicator of increased cardiovascular risk. Therefore, trunk flexibility measurement may be an additional tool for health promotion and prevention of cardiovascular and associated diseases in community health programs.
Sources of Funding
There were no external funding sources for this study.
Study Association
This study is associated with Rafael Felipe Cardoso's master thesis.
Ethical approval and informed consent
The study was approved by the Research Ethics Committee of the Federal University of Goiás (protocol number 784.446/2014). All procedures involved in this study were in accordance with the Declaration of Helsinki, 1975, updated in 2013. All participants included in the study signed an informed consent form.
Acknowledgment
The authors thank the Fundação de Amparo à Pesquisa do Estado de Goiás (FAPEG) for financial support (master scholarship); to the volunteers for participation and collaboration with the study; and the colleagues who assisted with physical assessments.
ReferencesNascimentoBRBrantLCCOliveiraGMMMalachiasMVBReisGMATeixeiraRACardiovascular disease epidemiology in portuguese-speaking countries: data from the Global Burden of Disease, 1990 to 2016Arq Bras Cardiol2018110650051110.5935/abc.201800981 Nascimento BR, Brant LCC, Oliveira GMM, Malachias MVB, Reis GMA, Teixeira RA, et al. Cardiovascular disease epidemiology in portuguese-speaking countries: data from the Global Burden of Disease, 1990 to 2016. Arq Bras Cardiol. 2018;110(6):500-11. doi:10.5935/abc.20180098.World Health OrganizationWHOWorld health statistics 2018: monitoring health for The Sdgs, sustainable development goalsGeneva20182 World Health Organization.(WHO). World health statistics 2018: monitoring health for The Sdgs, sustainable development goals. Geneva; 2018.BrasilMinistério da Saúde. Vigitel Brasil 2016: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito TelefônicoVigitelBrasilia20173 Brasil. Ministério da Saúde. Vigitel Brasil 2016: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Vigitel. Brasilia; 2017.RibeiroALPDuncanBBBrantLCCLotufoPAMillJGBarretoSMCardiovascular health in BrazilCirculatiom2016133442243310.1161/CIRCULATIONAHA.114.0087274 Ribeiro ALP, Duncan BB, Brant LCC, Lotufo PA, Mill JG, Barreto SM. Cardiovascular health in Brazil. Circulatiom. 2016;133(4):422-33. doi:10.1161/CIRCULATIONAHA.114.008727.PetribúMMVCabralPCArrudaIKGEstado nutricional, consumo alimentar e risco cardiovascular: um estudo em universitáriosRev Nutr200922683784610.1590/S1415-527320090006000055 Petribú MMV, Cabral PC, Arruda IKG. Estado nutricional, consumo alimentar e risco cardiovascular: um estudo em universitários. Rev Nutr. 2009;22(6):837-46. doi:10.1590/S1415-52732009000600005.World Health OrganizationWHONoncommunicable diseases progress monitorGeneva201710.2766/1200516 World Health Organization. (WHO) Noncommunicable diseases progress monitor. Geneva; 2017. doi:10.2766/120051.BrownRERandhawaAKCanningKLFungMJiandaniDWhartonSWaist circumference at five common measurement sites in normal weight and overweight adults: which site is most optimal?Clin Obes201881212910.1111/cob.122317 Brown RE, Randhawa AK, Canning KL, Fung M, Jiandani D, Wharton S, et al. Waist circumference at five common measurement sites in normal weight and overweight adults: which site is most optimal? Clin Obes. 2018;8(1):21-9. doi:10.1111/cob.12231.BarreiraT VStaianoAEHarringtonDMHeymsfieldSBSmithSRBouchardCAnthropometric correlates of total body fat, abdominal adiposity, and cardiovascular disease risk factors in a biracial sample of men and womenMayo Clin Proc201287545246010.1016/j.mayocp.2011.12.0178 Barreira T V., Staiano AE, Harrington DM, Heymsfield SB, Smith SR, Bouchard C, et al. Anthropometric correlates of total body fat, abdominal adiposity, and cardiovascular disease risk factors in a biracial sample of men and women. Mayo Clin Proc. 2012;87(5):452-60. doi:10.1016/j.mayocp.2011.12.017.CorrêaMMTomasiEThuméEOliveiraERAFacchiniLARazão cintura-estatura como marcador antropométrico de excesso de peso em idosos brasileirosCad Saude Publica201733531410.1590/0102-311x001953159 Corrêa MM, Tomasi E, Thumé E, Oliveira ERA, Facchini LA. Razão cintura-estatura como marcador antropométrico de excesso de peso em idosos brasileiros. Cad Saude Publica. 2017;33(5):3-14. doi:10.1590/0102-311x00195315.AshwellMHsiehSDSix reasons why the waist-to-height ratio is a rapid and effective global indicator for health risks of obesity and how its use could simplify the international public health message on obesityInt J Food Sci Nutr200556530330710.1080/0963748050019506610 Ashwell M, Hsieh SD. Six reasons why the waist-to-height ratio is a rapid and effective global indicator for health risks of obesity and how its use could simplify the international public health message on obesity. Int J Food Sci Nutr. 2005;56(5):303-7. doi:10.1080/09637480500195066.RobsonEMCostaSHamerMJohnsonWLife course factors associated with metabolically healthy obesity: a protocol for the systematic review of longitudinal studiesSyst Rev2018711610.1186/s13643-018-0713-x11 Robson EM, Costa S, Hamer M, Johnson W. Life course factors associated with metabolically healthy obesity: a protocol for the systematic review of longitudinal studies. Syst Rev. 2018;7(1):1-6. doi:10.1186/s13643-018-0713-x.WinterMRiouxB VBoudreauJGBouchardDRSénéchalMPhysical activity and sedentary patterns among metabolically healthy individuals living with obesityJ Diabetes Res201820181810.1155/2018/749676812 Winter M, Rioux B V, Boudreau JG, Bouchard DR, Sénéchal M. Physical activity and sedentary patterns among metabolically healthy individuals living with obesity. J Diabetes Res. 2018;2018:1-8. doi:10.1155/2018/7496768.HrubyAMansonJAEQiLMalikVSRimmEBSunQDeterminants and consequences of obesityAm J Public Health201610691656156210.2105/AJPH.2016.30332613 Hruby A, Manson JAE, Qi L, Malik VS, Rimm EB, Sun Q, et al. Determinants and consequences of obesity. Am J Public Health. 2016;106(9):1656-62. doi:10.2105/AJPH.2016.303326.AchourJAAlongamento e flexibilidade: definições e contraposiçõesRev Bras Ativ Fís e Saúde2007121545814 Achour JA. Alongamento e flexibilidade: definições e contraposições. Rev Bras Ativ Fís e Saúde. 2007;12(1):54-8.AlmeidaTTAmorimTPSousaFMAugustoJMitos e verdades sobre flexibilidade: reflexões sobre o treinamento de flexibilidade na saúde dos seres humanosMotriz Rev Educ Física20073133734415 Almeida TT, Amorim TP, Sousa FM, Augusto J. Mitos e verdades sobre flexibilidade: reflexões sobre o treinamento de flexibilidade na saúde dos seres humanos. Motriz Rev Educ Física. 2007;3(1):337-44.DantasEHMAlongamento & flexionamentoRio de JaneiroShape200516 Dantas EHM. Alongamento & flexionamento. Rio de Janeiro: Shape; 2005.NelsonMERejeskiWJBlairSNDuncanPWJudgeJOKingACPhysical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart AssociationCirculation2007116910941010510.1161/CIRCULATIONAHA.107.18565017 Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1094-105. doi:10.1161/ CIRCULATIONAHA.107.185650.HaskellWLLeeIMPateRRPowellKEBlairSNFranklinBAPhysical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart AssociationMed Sci Sports Exerc20073981423143410.1249/mss.0b013e3180616b2718 Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423-34. doi:10.1249/mss.0b013e3180616b27.NishiwakiMYonemuraHKurobeKMatsumotoNFour weeks of regular static stretching reduces arterial stiffness in middle-aged menSpringerplus20154155555510.1186/s40064-015-1337-419 Nishiwaki M, Yonemura H, Kurobe K, Matsumoto N. Four weeks of regular static stretching reduces arterial stiffness in middle-aged men. Springerplus. 2015;4(1):555. doi:10.1186/s40064-015-1337-4.YamamotoKKawanoHGandoYIemitsuMMurakamiHSanadaKPoor trunk flexibility is associated with arterial stiffeningAm J Physiol Circ Physiol20092974H1314H131810.1152/ajpheart.00061.200920 Yamamoto K, Kawano H, Gando Y, Iemitsu M, Murakami H, Sanada K, et al. Poor trunk flexibility is associated with arterial stiffening. Am J Physiol Circ Physiol. 2009;297(4):H1314-H1318. doi:10.1152/ajpheart.00061.2009.WongAFigueroaAEight weeks of stretching training reduces aortic wave reflection magnitude and blood pressure in obese postmenopausal womenJ Hum Hypertens20142824625010.1038/jhh.2013.9821 Wong A, Figueroa A. Eight weeks of stretching training reduces aortic wave reflection magnitude and blood pressure in obese postmenopausal women. J Hum Hypertens. 2014;28:246-50. doi:10.1038/jhh.2013.98.AlvimROSantosPCJLBortolottoLAMillJGPereiraACArterial stiffness: pathophysiological and genetic aspectsInt J Cardiovasc Sci201730543344110.5935/2359-4802.2017005322 Alvim RO, Santos PCJL, Bortolotto LA, Mill JG, Pereira AC. Arterial stiffness: pathophysiological and genetic aspects. Int J Cardiovasc Sci. 2017;30(5):433-41. doi:10.5935/2359-4802.20170053.LoganJGKimSLeeMByonH DoYeoSEffects of static stretching exercise on lumbar flexibility and central arterial stiffnessJ Cardiovasc Nurs201833432232810.1097/JCN.000000000000046023 Logan JG, Kim S, Lee M, Byon H Do, Yeo S. Effects of static stretching exercise on lumbar flexibility and central arterial stiffness. J Cardiovasc Nurs. 2018;33(4):322-8. doi:10.1097/JCN.0000000000000460.MitchellGFHwangSVasanRSLarsonMGPencinaMJHamburgNMArterial stiffness and cardiovascular eventsCirculation2010121450551110.1161/CIRCULATIONAHA.109.88665524 Mitchell GF, Hwang S, Vasan RS, Larson MG, Pencina MJ, Hamburg NM, et al. Arterial stiffness and cardiovascular events. Circulation. 2010;121(4):505-11. doi:10.1161/CIRCULATIONAHA.109.886655NiedermannKSidelnikovEMuggliCDagfinrudHHermannMTamborriniGEffect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitisArthritis Care Res201365111844185210.1002/acr.2206225 Niedermann K, Sidelnikov E, Muggli C, Dagfinrud H, Hermann M, Tamborrini G, et al. Effect of cardiovascular training on fitness and perceived disease activity in people with ankylosing spondylitis. Arthritis Care Res. 2013;65(11):1844-52. doi:10.1002/acr.22062.SveaasSHBergIJProvanSASembAGHagenKBVøllestadNEfficacy of high intensity exercise on disease activity and cardiovascular risk in active axial spondyloarthritis: A randomized controlled pilot studyPLoS One20149910.1371/journal.pone.010868826 Sveaas SH, Berg IJ, Provan SA, Semb AG, Hagen KB, Vøllestad N, et al. Efficacy of high intensity exercise on disease activity and cardiovascular risk in active axial spondyloarthritis: A randomized controlled pilot study. PLoS One. 2014;9(9). doi:10.1371/journal.pone.0108688.HeywardVHAvaliação física e prescrição de exercício: técnicas avançadas4th ed.Porto AlegreArtMed200427 Heyward VH. Avaliação física e prescrição de exercício: técnicas avançadas. 4th ed. Porto Alegre: ArtMed; 2004.World Health Organization.(WHO)Obesity: preventing and managing the global epidemicGeneva200028 World Health Organization.(WHO). Obesity: preventing and managing the global epidemic. Geneva; 2000.LeanMEJHanTSMorrisonCEWaist circumference as a measure for indicating need for weight managementBMJ1995311699815815810.1136/bmj.311.6998.15829 Lean MEJ, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. BMJ.1995;311(6998):158. doi:10.1136/bmj.311.6998.158.World Health Organization.(WHO)Global recommendations on physical activity for healthGeneva201010.1080/1102648041003434930 World Health Organization.(WHO). Global recommendations on physical activity for health.Geneva; 2010. doi:10.1080/11026480410034349.Brasil. Ministério da SaúdeVIGITEL BRASIL 2009: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônicoVigitelBrasilia201015015031 Brasil. Ministério da Saúde. VIGITEL BRASIL 2009: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Vigitel. Brasilia; 2010. p.150.MalachiasMVBSouzaWKSBPlavnikFLRodriguesCISSociedade Brasileira de Cardiologia. 7a Diretriz Brasileira de hipertensão arterialArq Bras Cardiol2016107110310.5935/abc.2013S01032 Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Sociedade Brasileira de Cardiologia. 7a Diretriz Brasileira de hipertensão arterial. Arq Bras Cardiol. 2016;107:1-103. doi:10.5935/abc.2013S010.WellsKFDillonEKThe sit and reach—a test of back and leg flexibilityRes Quart195223111511810.1080/10671188.1952.1076196533 Wells KF, Dillon EK. The sit and reach—a test of back and leg flexibility. Res Quart. 1952; 23(1):115-8. doi:10.1080/10671188.1952.10761965.Fitness CanadaCanadian Standardized Test of Fitness (CSTF): Operations Manual3rd ed.OttawaFitness and Amateur Sport198634 Fitness Canada. Canadian Standardized Test of Fitness (CSTF): Operations Manual. 3rd ed. Ottawa: Fitness and Amateur Sport; 1986.FerreiraCCCPeixotoMRGBarbosaMASilveiraEAPrevalência de fatores de risco cardiovascular em idosos usuários do Sistema Único de Saúde de GoiâniaArq Bras Cardiol201095562162810.1590/S0066-782X201000500014135 Ferreira CCC, Peixoto MRG, Barbosa MA, Silveira EA. Prevalência de fatores de risco cardiovascular em idosos usuários do Sistema Único de Saúde de Goiânia. Arq Bras Cardiol. 2010;95(5):621-8. doi:10.1590/S0066-782X2010005000141.R Core Team2020R: A language and environment for statistical computingR Foundation for Statistical ComputingVienna,(Austria)URL https://www.R-project.org/36 R Core Team (2020). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna,(Austria) URL https://www.R-project.org/.RodriguesSLBaldoMPMillJGAssociação entre a razão cintura-estatura e hipertensão e síndrome metabólica: estudo de base populacionalArq Bras Cardiol201095218619110.1590/S0066-782X2010005000073">10.1590/S0066-782X201000500007337 Rodrigues SL, Baldo MP, Mill JG. Associação entre a razão cintura-estatura e hipertensão e síndrome metabólica: estudo de base populacional. Arq Bras Cardiol. 2010;95(2):186-91. doi:10.1590/S0066-782X2010005000073.AshwellMGunnPGibsonSWaist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: Systematic review and meta-analysisObes Rev201213327528610.1111/j.1467-789X.2011.00952.x38 Ashwell M, Gunn P, Gibson S. Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: Systematic review and meta-analysis. Obes Rev. 2012;13(3):275-86. doi:10.1111/j.1467-789X.2011.00952.x.LeeCMYHuxleyRRWildmanRPWoodwardMIndices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysisJ Clin Epidemiol200861764665310.1016/j.jclinepi.2007.08.01239 Lee CMY, Huxley RR, Wildman RP, Woodward M. Indices of abdominal obesity are better discriminators of cardiovascular risk factors than BMI: a meta-analysis. J Clin Epidemiol. 2008;61(7):646-53. doi:10.1016/ j.jclinepi.2007.08.012.HaunDRPitangaFJGLessaIRazão cintura/estatura comparado a outros indicadores antropométricos de obesidade como preditor de risco coronariano elevadoRev Assoc Med Bras200955670571110.1590/S0104-4230200900060001540 Haun DR, Pitanga FJG, Lessa I. Razão cintura/estatura comparado a outros indicadores antropométricos de obesidade como preditor de risco coronariano elevado. Rev Assoc Med Bras. 2009;55(6):705-11. doi:10.1590/S0104-42302009000600015.SilvaCDJuvêncioJFDiagnóstico da aptidão física relacionada à saúde em trabalhadores de escritório da Universidade Federal de ViçosaRev Bras Cineantropom Desempenho Hum200461637141 Silva CD, Juvêncio JF. Diagnóstico da aptidão física relacionada à saúde em trabalhadores de escritório da Universidade Federal de Viçosa. Rev Bras Cineantropom Desempenho Hum. 2004;6(1):63-71.NishiwakiMKurobeKKiuchiANakamuraTMatsumotoNSex differences in flexibility-arterial stiffness relationship and its application for diagnosis of arterial stiffening: a cross-sectional observational studyPLoS One2014911e11364610.1371/journal.pone.011364642 Nishiwaki M, Kurobe K, Kiuchi A, Nakamura T, Matsumoto N. Sex differences in flexibility-arterial stiffness relationship and its application for diagnosis of arterial stiffening: a cross-sectional observational study. PLoS One. 2014;9(11):e113646. doi:10.1371/journal.pone.0113646.DourisPCIngenitoTPiccirilloBHerbstMPetrizzoJCherianVMartial arts training attenuates arterial stiffness in middle aged adultsAsian J Sports Med20134320120710.5812/asjsm.3425943 Douris PC, Ingenito T, Piccirillo B, Herbst M, Petrizzo J, Cherian V, et al. Martial arts training attenuates arterial stiffness in middle aged adults. Asian J Sports Med. 2013;4(3):201-7. doi:10.5812/asjsm.34259.EbrahimSMontanerDLawlorDAClustering of risk factors and social class in childhood and adulthood in British women’s heart and health study: cross sectional analysisBMJ2004328744486186110.1136/bmj.38034.702836.5544 Ebrahim S, Montaner D, Lawlor DA. Clustering of risk factors and social class in childhood and adulthood in British women’s heart and health study: cross sectional analysis. BMJ. 2004;328(7444):861. doi:10.1136/ bmj.38034.702836.55.LessaIAraújoMJMagalhãesLAlmeidaNFilhoAquinoECostaMCRSimultaneidade de fatores de risco cardiovascular modificáveis na população adulta de Salvador (BA), BrasilRev Panam Salud Publica200416213113710.1590/S1020-4989200400080000945 Lessa I, Araújo MJ, Magalhães L, Almeida Filho N, Aquino E, Costa MCR. Simultaneidade de fatores de risco cardiovascular modificáveis na população adulta de Salvador (BA), Brasil. Rev Panam Salud Publica. 2004;16(2):131-137. doi:10.1590/S1020-49892004000800009.