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 CRF exception. Association between MS and CRF found exclusively among men can be partly justified by hypertension high prevalence installed in this group. 19 In recent decades, it has become increasingly evident that hypertensive patients prognosis is strongly affected by renal impairment especially in terms of mortality and cardiovascular events. 37 In relation to the greater number of comorbidities associated to MS among women in the study, it can be explained in part by the low demand of men for health services, which generates an underdiagnosis. 2 CVDs are the leading cause of death in Brazil, 2 and should be a public health priority, through policies for their prevention and control. Association between DCV and MS was demonstrated in a Danish cohort, in which older women with MS presented risk of 1.7 (95% CI 1.44-2.05) for CVD development. 38 Correlation can also be explained by Salas et al., 16 who showed that obese adults, mainly women, are particularly at risk of developing MS, with significant implications for their health, especially CVD and diabetes. These results highlight the weight loss importance to reduce morbidities associated to MS. 16 Another disease condition associated with MS was depression, with higher prevalence found among women. Similarly, study conducted in Korea with middle-aged individuals aged 40-64 years found high prevalence among women with 11.7%, compared to 4.1% in men. 39 These findings may be similar to what was found in disease prospective cohort among the Dutch population, where depression was significantly associated with higher WC and triglyceride levels during a 6-year follow-up. 40 In this context these results may imply that older age may be associated with an increased response to stress and cortisol levels, more frequently among women than men. 39 Methodological pattern reinforced presented results robustness; however, some limitations must be addressed. Up to the time of submission of this study, IBGE had not published HDL laboratory data, which led us to characterize MS in the occurrence of three of the four - and not five - components available in the database. Another point refers to the use of self-reported medical diagnoses. The investigated population answered if " some doctor already gave him the diagnosis of diabetes ?" Or "(...) hypercholesterolemia ?", which reduces classification bias, because they were considered present when there was a positive response to the previous medical diagnosis of these diseases; On the other hand, given the issues of underdiagnoses, there is a real possibility of the presence of individuals who did not know their health condition at the time of the interview. In any case, even in these situations, we observed that MS high prevalence in our study is consistent with the literature, 7,10,16 which warns of the possibility that this prevalence may be underestimated, implying a negative prognosis for Brazilian population aged ≥18 years. Another limitation of this study is its cross-sectional design, which is why socioeconomic, behavioral and comorbidities factors analyzed here can not be unequivocally considered causal for MS. Especially in reference to comorbidities, it is important to highlight reverse causality role in identified associations, since clinical course start for CVD, stroke, depression and CRI would be in MS, despite the fact that delineation does not allow to affirm that this fact occurred in the studied population. However, use of data with national representativeness and conceptual model to base not only variables selection, but also analytical strategy, allows relevant information production for Brazilian population health conditions diagnosis, in which refers to MS, aligned with national public health priorities. Conclusion We identified high prevalence of MS in adult and elderly population in Brazil, being associated with sociodemographic variables (age, schooling, conjugal status and housing region), behavioral (self-perception of health) and comorbidities (stroke, CVD, weight, depression and CRF) differently between the sexes. Finally, the relevance of the burden of each MS component, reiterates MS as a clinical and epidemiological tool in the identification of individuals and population groups with greater vulnerability to CVD occurrence and as a guideline to cost-effective interventions on factors presented. Thus, our results suggest the need to strengthen public policies for health promotion in order to encourage the adoption of healthy behaviors; otherwise, it will be unlikely to fulfill the goals set forth in the Strategic Action Plan to Tackle Noncommunicable Diseases (NCD) in Brazil 2011-2022. Author contributions Conception and design of the research and Analysis and interpretation of the data: Ramires EKNM, Menezes RCE, Silveira JAC, Longo-Silva G, Santos TG; Acquisition of data: Marinho PM; Statistical analysis: Ramires EKNM, Menezes RCE, Silveira JAC, Marinho PM; Writing of the manuscript: Ramires EKNM, Menezes RCE, Silveira JAC; Critical revision of the manuscript for intellectual content: Menezes RCE, Silveira JAC, Santos TG. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This article is part of the thesis of master submitted by Elyssia Karine Nunes Mendonça Ramires, from Universidade Federal de Alagoas. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Brazil Platform, directed to the Comissão Nacional de Ética em Pesquisa (CONEP) the protocol number 10853812.7.0000.0008. All the procedures in this study were in accordancewith the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 464