ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 global percentage of individuals with a BMI ≥ 25 kg/m 2 rose from 28.8 to 36.9% in men and 29.8 to 38.0% in women. 115 In Brazil, 52.4% of the population was overweight in 2014, with 17.9% of them classified as obese. 116 According to data from the 2018 Risk Factors Surveillance and Chronic Disease Protection by Telephone Survey (VIGITEL), the incidence of overweight reached 55.8% and of obesity, 18.7% among men over 20 years of age; while for women, these values were 53.9% and 20.7%, respectively. 117 In 34 years, the prevalence of obesity increased over four times for men (from2.8 to 12.4%) andmore than twice for women (from 8 to 16.9%). 118,119 Brazil currently holds the fourth place among the countries with the highest prevalence of obesity and the number of overweight adults will exceed those with low weight. 118 There is a significant rise in overweight and obesity among children and adolescents, regardless of gender and social status, and a considerable proportion of these individuals will become obese adults.  Obesity has a multifactorial nature and is one of the leading factors to explain the growth in the chronic NCD burden, given its frequent association with CVD, such as arterial hypertension (AH), CVA, HF, 120 dyslipidemias, type 2 diabetes, atrial fibrillation, 121,122 osteoarthritis, and certain types of cancer. Also, obesity is an important condition that predisposes the individual to mortality. 118,119 In addition, weight gain over time is associated with MS, increased risk for CVA, and death in late stages of life. 123-125 Many patients who present some of these changes have hypertriglyceridemia and increased levels of plasma fatty acids, stored as lipid droplets in the heart. Intramyocardial lipids that exceed the storage and oxidation capacity can become toxic and lead to non-ischemic and non-hypertensive cardiomyopathy, known as diabetic or lipotoxic cardiomyopathy. 126 Significant weight loss (≥ 5% of initial weight) improves BP, LDL-c, TG, and glucose levels, delaying the onset of type 2 diabetes. 127 4.2. Primary Prevention According to the World Health Organization (WHO), an inadequate diet is the main risk factor for early mortality worldwide. 128 Therefore, a healthy diet is recommended for everyone, and the ability to prepare healthy meals has beneficial correlations with the consumption of equally healthy foods. 129 However, studies have shown a reduction in the habit of cooking in some countries, which has encouraged health specialists to elaborate nutritional education strategies focused on nutrients and tools, such as the proper purchase and storage of food, and planning and preparing meals at home. 130 Also, we emphasize that the biological moment that could prevent weight gain is of the utmost importance. In females, the moment of greatest risk seems to be the reproductive age, specifically during pregnancy and the first two years postpartum, and the period post-menopause. 131,132 Among children and adolescents, prevention of excessive weight gain was expected precisely because the growth phase requires extra energy, and the possibility of energy expenditure is higher compared to other life stages. These potential facilitators, however, do not seem to overcome the factors associated with obesity and those responsible for the epidemic growth also in these age groups and life stages. 133 In this regard, we underline the so-called “obesogenic environment,” that is, the role of the food industry, fast food chains, advertisements, TV shows, movies, and videogames, leading to situations that keep the children more sedentary and subjected to excessive energy intake. The most appropriate interventions should combine environmental and behavioral changes. 134-136 A study conducted with 422 adolescents, with a mean age of 12.5 years, compared students who practiced competitive physical activity daily for 2 hours with those from a standard school who have only one hour of physical activity per week. The percentage of overweight/obesity in the first group was 49.8% and in the second, 37.3%, which reveals the high prevalence of this change in the two groups. 137 A similar sample submitted to a multidisciplinary program of moderate intensity, that could be easily incorporated in the daily routine, showed positive advances in risk factors when compared to the control group. 138 Among adults, studies show a decline in the consumption of rice and beans, increase in the intake of processed products (particularly cookies and soft drinks), excessive consumption of sugar, more saturated fats, and insufficient intake of fruits and vegetables, creating an environment with habits that do not favor a healthy dietary pattern, directly associated with the increase in chronic NCD, especially obesity. 139-142 A recommendation from the 2014 Dietary Guidelines for the Brazilian Population proposes 10 steps for a healthy diet: 1. Prioritize natural or minimally processed foods; 2. Use oil, salt, and sugar moderately; 3. Limit the consumption of processed foods; 4. Avoid the intake of ultra-processed foods; 5. Eat regularly and carefully; 6. Buy food at the street market; 7. Cook; 8. Plan the purchase of foods and preparation of meals; 9. Avoid fast food; 10. Be critical of food advertising. Some other useful pieces of advice are: 143,144 • Eat regularly throughout the day and at similar times every day to establish a healthy dietary pattern; • Pay attention to food labels and choose products without trans and hydrogenated fats; • Avoid soft drinks and processed juices, cakes, cookies, sandwich cookies, and sweet desserts; • Give preference to drinking water between meals; • Practice at least 30 minutes of vigorous physical activity on most weekdays or 40 minutes of moderate physical activity; • However, individuals with a tendency towards obesity or with family profile should practice moderate physical activity for 45-60 minutes per day; those who were obese and lost weight should practice for 60-90 minutes to avoid regaining the weight lost; • The practice of physical activities and exercises can prevent weight gain and obesity even in older adults. Table 4.1 lists the recommendations on how to approach overweight and obese adults. 811