Papel mediador da atividade física no tempo livre na associação entre espaços públicos abertos e hipertensão em adultos: um estudo prospectivo

Contexto : O acesso a áreas verdes e recreativas tem sido associado à saúde cardiovascular, mas as evidências em megacidades de baixa e média renda ainda são limitadas. Este estudo investigou a associação prospectiva entre espaços públicos abertos (EPAs) e a incidência de hipertensão em adultos residentes em São Paulo, Brasil, e se a atividade física no tempo livre (AFTL) medeia essa relação. Métodos : Foram analisados ​​dados de 1056 participantes sem hipertensão na linha de base, coletados por meio da coorte “Pesquisa de Saúde de São Paulo: Atividade Física e Meio Ambiente” (2014–2021). A exposição a EPAs, incluindo parques, praças, academias ao ar livre e ciclovias, foi avaliada utilizando sistemas de informação geográfica em áreas de 500 m ao redor das residências dos participantes. O número de tipos de EPAs foi categorizado como 0, 1 a 2 ou 3 a 4. A hipertensão foi autorrelatada e a AFTL foi mensurada por meio do Questionário Internacional de Atividade Física (IPAQ) em sua versão longa. Modelos de regressão de Poisson estimaram os riscos relativos de desenvolvimento de hipertensão, e a mediação foi testada utilizando os métodos de Sobel e bootstrap. Resultados : Morar perto de 3 ou 4 tipos de espaços de lazer foi associado a um menor risco de hipertensão (risco relativo: 0,93; IC 95%, 0,87–0,99). A atividade física de lazer (AFL) mediou significativamente essa associação. Entre os indivíduos que praticavam ≥150 minutos por semana de AFL, a proximidade a 3 ou 4 tipos de espaços de lazer foi associada a um risco ainda menor (risco relativo: 0,88; IC 95%, 0,79–0,98), enquanto nenhum efeito foi observado entre os participantes inativos. Conclusões : Uma maior variedade de espaços de lazer perto de casa está associada a um risco reduzido de hipertensão, parcialmente explicado pelo aumento da AFL. Esses achados apoiam estratégias de planejamento urbano que promovam ambientes recreativos diversificados para a promoção da saúde cardiovascular em cidades urbanas de renda média.

References

1. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217–223. doi:10.1016/S0140-6736(05)17741-1

2. Mills KT, Bundy JD, Kelly TN, et al. Global disparities of hypertension prevalence and control: a systematic analysis of populationbased studies from 90 countries. Circulation. 2016;134(6):441–450. doi:10.1161/CIRCULATIONAHA.115.018912

3. Bundy JD, Li C, Stuchlik P, et al. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol. 2017;2(7):775–781. doi: 10.1001/jamacardio.2017.1421

4. Ferrari AJ, Charlson FJ, Norman RE, et al. Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted lifeyears (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2024;403(10440):2133–2161. doi:10. 1016/S0140-6736(24)00757-8

5. Cohen DL, Townsend RR, Angell SY, DiPette DJ. The World Health Organization recognizes noncommunicable diseases and raised blood pressure as global health priority for 2025. J Clin Hypertens. 2014; 16(9):624. doi:10.1111/jch.12384

6. Poulter NR, Prabhakaran D, Caulfield M. Hypertension. Lancet. 2015;386(9995):801–812. doi:10.1016/S0140-6736(14)61468-9

7. Instituto Brasileiro de Geografia e Estatística (IBGE). Panorama das cidades. 2022. Accessed January 15, 2025. https://cidades.ibge.gov. br/brasil/sp/sao-paulo/panorama

8. McMichael AJ. The urban environment and health in a world of increasing globalization: issues for developing countries. Bull World Health Organ. 2000;78:1117–1126. PubMed ID: 11019460

9. Nowak DJ, Dwyer JF. Understanding the Benefits and Costs of Urban Forest Ecosystems. Springer; 2007.

10. Ngom R, Gosselin P, Blais C, Rochette L. Type and proximity of green spaces are important for preventing cardiovascular morbidity and diabetes: a cross-sectional study for Quebec, Canada. Int J Environ Res Public Health. 2016;13(4):423. doi:10.3390/ijerph13040423

11. Astell-Burt T, Mitchell R, Hartig T. The association between green space and mental health varies across the lifecourse: a longitudinal study. J Epidemiol Community Health. 2014;68(6):578–583. doi:10. 1136/jech-2013-203767

12. VandenBerg AE, Maas J, Verheij RA, Groenewegen PP. Green space as a buffer between stressful life events and health. Soc Sci Med. 2010;70:1203–1210. doi:10.1016/j.socscimed.2010.01.002

13. Yeager RA, Smith TR, Bhatnagar A. Green environments and cardiovascular health. Trends Cardiovasc Med. 2020;30(4):241– 246. doi:10.1016/j.tcm.2019.06.005

14. Bu Y, Zhang X, Song S, et al. Association of greenspace with hypertension in adults: a systematic review and meta-analysis of epidemiological studies. Int J Environ Health Res. 2024;34(6):2556– 2577. doi:10.1080/09603123.2023.2259817

15. Pescatello LS, Arena R, Riebe D, Thompson PD. Physical activity to prevent and treat hypertension: a systematic review. Med Sci Sports Exerc. 2019;51(6):1314–1323. doi:10.1249/MSS.0000000000001943

16. Lee LL, Watson MC, Mulvaney CA, Tsai CC, Lo SF. Walking for hypertension. Cochrane Database Syst Rev. 2021;2021(3): CD008823. doi:10.1002/14651858.CD008823.pub2

17. Markevych I, Schoierer J, Hartig T, et al. Exploring pathways linking greenspace to health: theoretical and methodological guidance. Environ Res. 2017;158:301–317. doi:10.1016/j.envres.2017.06.028

18. Astell-Burt T, Feng X. Urban green space, tree canopy and prevention of cardiometabolic diseases: a multilevel longitudinal study of 46,786 Australians. Int J Epidemiol. 2020;49(3):926–933. doi:10.1093/ije/ dyz239

19. Moreira TCL, Polizel JL, Santos IS, et al. Green spaces, land cover, street trees and hypertension in the megacity of São Paulo. Int J Environ Res Public Health. 2020;17(3):725. doi:10.3390/ijerph17030725

20. Florindo AA, Goulardins GS, Teixeira IP. Ciclovias, atividade física no lazer e hipertensão arterial: um estudo longitudinal. Estud Av. 2023;37:109. doi:10.1590/s0103-4014.2023.37109.008

21. Florindo AA, Barrozo LV, Cabral-Miranda W, et al. Public open spaces and leisure-time walking in Brazilian adults. Int J Environ Res Public Health. 2017;14(6):553. doi:10.3390/ijerph14060553

22. Florindo AA, Teixeira IP, Barrozo LV, et al. Study protocol: health survey of São Paulo: ISA-physical activity and environment. BMC Public Health. 2021;21(1):283. doi:10.1186/s12889-021-10262-5

23. Selem SSC, Pierin AMG, Ferreira SRG, et al. Validade da hipertensão autorreferida associa-se inversamente com escolaridade em brasileiros. Arq Bras Cardiol. 2013;100(1):52–59. doi:10.1590/S0066- 782X2012005000119

24. Teixeira IP, Barbosa JPAS, Barrozo LV, et al. Built environments for physical activity: a longitudinal descriptive analysis of São Paulo city, Brazil. Cities Health. 2022;7(1):137–147. doi:10.1080/23748834. 2022.2127173

25. World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation. WHO Technical Report Series, No. 894. 2000. Leisure-Time Physical Activity, Public Open Spaces, and Hypertension 7 (Ahead of Print) Unauthenticated | Downloaded 12/29/25 11:28 AM UTC

26. Pan American Health Organization. Health of Older Persons. 2006.

27. Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35(8):1381–1395. doi:10.1249/01.MSS.00000 78924.61453.FB

28. Hallal PC, Gomez LF, Parra DC, et al. Lessons learned after 10 years of IPAQ use in Brazil and Colombia. J Phys Act Health. 2010;7(suppl 2):S259–S264. doi:10.1123/jpah.7.s2.s259

29. MacKinnon DP, Lockwood CM, Hoffman JM, West SG, Sheets V. A comparison of methods to test mediation and other intervening variable effects. Psychol Methods. 2002;7(1):83–104. doi:10.1037/ 1082-989X.7.1.83

30. Sobel ME. Asymptotic confidence intervals for indirect effects in structural equation models. In: Leinhardt S, ed. Sociological Methodology. American Sociological Association; 1982:290–312.

31. Shrout PE, Bolger N. Mediation in experimental and nonexperimental studies: new procedures and recommendations. Psychol Methods. 2002;7(4):422–445. doi:10.1037/1082-989X.7.4.422

32. McCormack GR, Shiell A. In search of causality: a systematic review of the relationship between the built environment and physical activity among adults. Int J Behav Nutr Phys Act. 2011;8(1):125. doi:10.1186/1479-5868-8-125

33. Tamosiunas A, Grazuleviciene R, Luksiene D, et al. Accessibility and use of urban green spaces, and cardiovascular health: findings from a Kaunas cohort study. Environ Health. 2014;13(1):20. doi:10.1186/ 1476-069X-13-20

34. Twohig-Bennett C, Jones A. The health benefits of the great outdoors: a systematic review and meta-analysis of greenspace exposure and health outcomes. Environ Res. 2018;166:628–637. doi:10.1016/j. envres.2018.06.030

35. Florindo AA, Onita BM, Knebel MTG, et al. Public open spaces and leisure-time walking: a longitudinal study with Brazilian people in the COVID-19 pandemic. J Phys Act Health. 2023;20(1):38–47. doi:10. 1123/jpah.2022-0487

36. Saco-Ledo G, Valenzuela PL, Castillo-García A, et al. Exercise reduces ambulatory blood pressure in patients with hypertension: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2020;9(24):e018487. doi:10.1161/JAHA.120.018487

37. Giles-Corti B, Vernez-Moudon A, Reis R, et al. Urban design, transport, and health 1: city planning policies to support health and sustainability: an international comparison of policy indicators for 25 cities. Lancet Glob Health. 2022;10(6):e865–e875. doi:10.1016/ S2214-109X(22)00069-9

38. World Health Organization. Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. WHO Press; 2013.

39. Giles-Corti B, Lowe M, Arundel J, et al. Creating healthy and sustainable cities: what gets measured, gets done. Lancet Glob Health. 2022;10(6):e896–e908. doi:10.1016/S2214-109X(22)00113-1

40. Ulrich RS, Simons RF, Losito BD, Fiorito E, Miles MA, Zelson M. Stress recovery during exposure to natural and urban environments. J Environ Psychol. 1991;11(3):201–230. doi:10.1016/ S0272-4944(05)80184-7

41. Maas J, Verheij RA, Groenewegen PP, de Vries S, Spreeuwenberg P. Green space, urbanity, and health: how strong is the relation? J Epidemiol Community Health. 2009;63(12):967–973. doi:10.1136/ jech.2008.079038

42. Mueller W, Milner J, Loh M, Vardoulakis S, Wilkinson P. Exposure to urban greenspace and pathways to respiratory health: an exploratory systematic review. Sci Total Environ. 2022;829:154447. doi:10. 1016/j.scitotenv.2022.154447

43. Sugiyama T, Francis J, Middleton NJ, Owen N, Giles-Corti B. Associations between recreational walking and attractiveness, size, and proximity of neighborhood open spaces. Am J Public Health. 2010;100(9):1752–1757. doi:10.2105/AJPH.2009.182006

44. Sugiyama T, Gunn LD, Christian H, et al. Quality of public open spaces and recreational walking. Am J Public Health. 2015;105(12): 2490–2495. doi:10.2105/AJPH.2015.302890

Acessar