ABC | Volume 110, Nº5, May 2018

Original Article Ramires et al Prevalence of metabolic syndrome in Brazil Arq Bras Cardiol. 2018; 110(5):455-466 In our study, a possible explanation for elevated WC high prevalence can be derived from the lower cut-off points established by ethnicity standardization for abdominal obesity (≥ 90 cm for men and ≥ 80 cm for women), 4 when compared with limit values NCEP-ATPIII (102 cm for men and 88 cm for women). 23 Therefore, this high and worrisome abdominal obesity prevalence in Brazilian population reflects in the increased risk of developing some cardiovascular disease 22 and consequent risk for increased morbidity and mortality and impact on the health system. 2 Positive relationship between MS prevalence and increase in age, found here, has been widely disseminated, especially due to differences attributed to sex, 17 not only due to cumulative effect, reflecting the exposure time to risk factors related to inappropriate eating behaviors and unhealthy lifestyles, as well as the biological factors contribution in both sexes, due to direct relationship with testosterone/estrogen levels balance, specifically among women. 20 MS has been slightly more diagnosed among men with less than fifty years of age, fact that is reversed after fifty years, affecting female population with greater magnitude. 17 From sociodemographic point of view, this study showed that living in SE/S/CW regions was presented as factor associated with MS, which can be explained, in part, by these regions concentrating the country main urban centers, contributing to lifestyles promotion characterized by unhealthy eating habits and physical exercises low frequency, which have as consequence, increased risk of obesity, type 2 DM, arterial hypertension, CVD and MS. 5 In a systematic review carried out among South American countries, this hypothesis was confirmed by showing that western eating habits and lifestyle pattern were found in greater proportion in large urban areas where chronic no communicable diseases were related to these behaviors. 24 In addition, through an investigation conducted in Brazil, it was evident that there was a high calories consumption in the capitals located in the South, Southeast and Center-West regions, while in the capitals in the North and the Northeast a consumption below average was observed among the population. 25 It is important to point out that in these large urban centers regions, society is increasingly induced by food offers messages, diets and western behaviors. 26 In recent years, in Brazil, metropolitan regions have shown reduction in household consumption of polished rice, beans, cereals and legumes (down 60%, 49% and 25%, respectively), with a concomitant continuous consumption increase of foods such as: beverages and infusions (22% and 24%), prepared foods and industrial mixtures (67%), highlighting 490% increase in the amount of non-alcoholic beverage purchased between 1974 and 2009, evidencing a change in food behavior that is not always favoring healthy choices in developed regions. 27 Our results showed that education lowest level was associated with MS prevalence in women, but this association was not evident among male population. This finding is consistent with the international literature, as observed in a study conducted in China, where educational level was also inversely related to MS prevalence strictly among women. 28 In Korea, distinctly, it was identified that men with less schooling had lower odds ratios (OR) for both SM (OR 0.76, 95% CI 0.60-0.96), as well as for two of its isolated components: high WC (OR 0.73, 95% CI 0, 60-0.91) and low HDL cholesterol (OR 0.73, 95% CI 0.59-0.91), compared to men with higher education. 29 In this study, a higher MS prevalence was observed among the socially disadvantaged women who had lower education level, unemployed, lower income level and who performed manual labor, as highlighted in our results in educational level terms. 29 However, an antagonistic result was observed in high educational level male population, where cardiovascular risk factors distribution was more observed in this population stratum. This may be a reflection of the socioeconomic environment, which increases MS risk in one of the genders more specifically. 30 In relation to conjugal situation variable, it is not clear how civil status contributes to MS. In the present study, the situation of living with a partner was associated to MS and to a greater extent in male population. This finding was also evident among Australians, where women who married gained more weight compared to unmarried women, after adjusting for potential confounding factors. 31 Similarly, in the study by Averett et al., 32 marriage was associated with an increased risk of overweight/ obesity, both for men and women. 32 Ortega et al., 33 identified that sex affects the relationship between obesity, cardiometabolic risk factors and marital status due to changes in behavioral factors. 33 Although most studies have reported that married people became more sedentary, 34 with direct reflection in overweight and impact on MS comorbidities, collaborating with the results found in this work, other studies show different results, attributing to marital relationship type the MS outcome. 26,35 In this case, it is considered that positive conjugal relationships can protect from stressful situations, providing both material and support benefits, while negative relationships or lack of relationship can increase exposure to conflicts, with consequent stress level elevation, 35 factor recognized as associated to MS. 10 Regarding behavioral aspects, we identified that "regular to very bad" health negative self-perception was important factor associated to MS. Health self-perception is global indicator in which the person considers, in addition to possible diseases, the impact they generate on physical, social and mental well-being. 32 In Spain, by contrasting our results, in a multicenter study performed with DM and/or MS carriers recently diagnosed, 42.2% of the individuals believed to have good or excellent health, representing little awareness of the cardiovascular risk they presented. 36 In this work, the association of negative self-perception "regular to very bad "with MS draws attention, because it may reflect that the studied population was aware of their health condition, but remains within the risk range for metabolic complications development, assuming that there may be other factors that prevent them from leaving this condition and deserve to be better investigated. Regarding MS prevalence and association with comorbidities (CVD, stroke and depression), all were more frequent among females compared to males, with 463