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Abstract

Men generally have a lower life expectancy and higher mortality than women in nearly all age groups. Military police, whose main activity in Brazil is the maintenance of public order and the prevention of crimes and transgressions of the laws, is mostly composed of men; it is also a risky and stressful profession generally related to poor quality of life. Considering that risk factors for disease and death from cardiovascular causes—including the multiple risk factor metabolic syndrome—are mostly related to lifestyle and associated with impaired quality of life, this study aims to provide a theoretical basis for other studies about the prevalence of metabolic syndrome among police officers. In a theoretical study, the authors present an interdisciplinary review based on studies on the health and quality of life of men in general and policemen in their specificity; published studies were selected according to the key words: men, health, quality of life, police, metabolic syndrome; they should also have been published in the past 15 years and available in the Scientific Electronic Library Online—SciELO—and in the Public Medline—PubMed. In conclusion, military policemen have a risky profession, whose conditions may contribute to low quality of life, illness, and mortality from cardiovascular causes; these conditions indicate a need for the characterization of metabolic syndrome in this population as an important element for promotion of health. Studying these conditions may contribute to the adoption of comprehensive and continuing care for military policemen’s integral health.

Keywords

men’s health quality of life metabolic syndrome military police

Men have a shorter lifespan and a higher mortality rate than women in almost all age groups. Male gender is the most important demographic factor contributing to premature death (Braz, 2005). Although the labor market has undergone great changes in industrial societies, men are still characteristically identified with heavy load services, such as mining, tunneling, construction, work on offshore platforms, and so on. Thus, they are more exposed to accidents and occupational diseases, which result in varying degrees of morbidity, disability, and death. Between 2004 and 2006, the frequency of accidents recorded by the Brazilian Social Welfare Ministry distributed according to gender were as follows: in 2004, men: 77.34%, women: 22.65%; in 2005, men: 76.88%, women: 23.12%; and in 2006, men: 76.61%, women: 23.39% (Ministry of Social Welfare, 2006).

According to the Ministry of Health of Brazil (2011), 1,136,947 deaths occurred in 2010, including 649,378 men (57.16%), 487,137 women (42.85%), and 432 people of unknown gender (0.04%). Diseases of the circulatory system caused 326,371 deaths (28.71% of total), 52.47% of which were men (171,263 cases) and 47.52%, women (155,082 cases). Neoplasias were the second largest cause of death, with 178,990 cases (15.74% of total mortality). The third largest group includes external causes of morbidity and mortality with 143,256 cases (12% of overall mortality), of which 118,192 were men (82.50%), 24,957 women (17.42%), and 107 cases of unknown gender (0.07%). When looking in more detail at the diagnosis, myocardial infarction appears as a cause of death in 79,668 cases (7% of overall mortality), of which 47,017 were men (59.01%) and 32,645 women (40.99%); diabetes mellitus caused 48,340 deaths (4.25%); stroke unspecified as hemorrhagic or ischemic appears as the cause of 44,891 cases of deaths (3.95%); assault by firearms was the cause of death in 33,304 cases (2.93% of total mortality), of which 31,328 were men (94.07% specific mortality), 1,955 women (5.87%), and 21 cases of unknown gender (0.06%); (Ministry of Health, 2011). We highlight the importance of cardiovascular events and external causes (with violent events, such as accidents and assaults) in overall mortality, predominantly in the male population, confirming the vulnerability of the male gender as a risk factor for disease and death. Hence, the importance of studying the prevalence of risk factors—including the clinical condition of metabolic syndrome (MS), which is a multiple risk factor for cardiovascular events—in the male population.

The World Health Organization (WHO; 1999) defines health as a state of complete physical, mental, social, and spiritual well-being, avoiding the prior reductionist view wherein health is understood as merely the absence of disease. In the absence of a uniform concept on the quality of life, the WHO sponsored a multi-center study that culminated in an assessment instrument, namely the World Health Organization Quality of Life (WHOQOL; Fleck, 2000; Minayo, Hartz, & Buss, 2000). For this purpose, experts from around the world were brought together, establishing the concept of quality of life as the individual’s perception of his position in life in the context of the culture and the value systems in which he lives, and in relation to his goals, expectations, standards, and concerns. This concept goes beyond the basic notion of health (which includes central events related to morbidity and mortality), and involves multiple dimensions that link physical to psychological aspects, the social environment, social relations, levels of independence, and personal beliefs (The WHOQOL Group, 1995, cited in Fleck, 2000). The original instrument is a questionnaire covering 6 domains, broken down into 24 areas, totaling 100 questions. The need for a faster application tool led to the development of an abbreviated version of the WHOQOL-100, namely, the WHOQOL-bref, with 26 questions covering 4 domains (physical, psychological, environmental, and social). The WHOQOL-bref briefly addresses aspects in the original questionnaire.

The concept of quality of life has a polysemic semantic range (i.e., characterized by several meanings) and relates to: the conditions, style and way of life, the state of development of society, the values reflected in human and social rights, and finally, in relation to health, quality of life as a result of those standards of comfort and acceptance that social groups establish as parameters for themselves (Castellanos, 1997, cited in Minayo et al., 2000).

It can be seen that the variable of quality of life, in its most positive form, is deeply related to protection against risk factors for illness and death, especially for those that are predisposed to the emergence of chronic degenerative diseases as well as cardiovascular morbidity and mortality. Thus, the components of MS appear. MS is a multiple risk factor for cardiovascular disease including dyslipidemia, obesity, insulin resistance, hypertension, and altered glucose metabolism. For clinical control, these chronic conditions usually require changes in lifestyle, such as a balanced and healthy diet, regular physical activity, and practices that reduce the stress of everyday life to finally promote an improved quality of life (Reaven, 1988; Grundy, Brewer, Cleeman, Smith, & Lenfant, 2004; National Cholesterol Education Program [NCEP], 2002).

Given that the military corps in Brazil—including the military police—are mostly male, the authors assert that studying health among the military is intertwined with the study of men’s health.

Metabolic Syndrome: Historical Aspects, Definition, Pathogenesis, and Clinical Manifestations

Reaven (1988) noted that several risk factors—such as dyslipidemia, hypertension, and hyperglycemia—commonly occur in clusters. He termed this grouping Syndrome X, and since then considered the condition a multiple risk factor for cardiovascular disease. Reaven and other scientists suggested that insulin resistance was the underlying condition of Syndrome X, which led to the designation of this state as insulin resistance syndrome, and later as MS (Rosenbaum & Ferreira, 2003; Grundy et al., 2004). The latter is the term used by the Adult Treatment Panel III (ATP III) of the NCEP, a scientific organization in the United States whose main objective is to reduce illness and death from coronary heart disease. The NCEP-ATP III Report (NCEP, 2002) considered MS as a multiple risk factor for cardiovascular disease, which deserves greater clinical attention. Consequently, with evidence that the majority of individuals who develop cardiovascular disease have multiple risk factors, the Report also defined cardiovascular disease as the primary clinical outcome of MS. Even if one considers that the majority of people with the syndrome present insulin resistance, which results in an increased risk for diabetes mellitus type 2, when diabetes manifests clinically the risk for the occurrence of cardiovascular disease increases sharply. It is known that in addition to an increased risk for the emergence of type 2 diabetes mellitus and cardiovascular disease, people who have MS also have an increased incidence of other disorders, such as fatty liver disease, polycystic ovary syndrome, cholesterol gallstones, sleep disorders, and some cancers (Balkau, Valensi, Eschwège, & Slama, 2007; NCEP, 2002).

The I Brazilian Guidelines for the Diagnosis and Treatment of MS (I-DBSM, 2005) defined this clinical entity as a complex picture characterized by a set of cardiovascular risk factors usually related to the central deposition of body fat and insulin resistance. Associating the syndrome with cardiovascular disease stands out, resulting in a 1.5-fold increase in overall mortality, and a 2.5-fold increase in specific cardiovascular mortality.

At least three scientific organizations have established criteria for the diagnosis of MS; the definition by the WHO requires the assessment of insulin resistance and glucose metabolism disorder, which makes it difficult to operationalize in general practice (WHO, 2003). The International Diabetes Federation (IDF) considered the following as diagnostic criteria for MS: waist circumference ≥90 cm, and at least two of the following findings: HDL cholesterol <40 mg/dL; triglycerides ≥150 mg/dL; fasting glucose ≥100 mg/dL or having been previously diagnosed with diabetes; blood pressure ≥130/85 mmHg or having been previously diagnosed with hypertension (Alberti, Zimmet, & Shaw, 2005). The NCEP-ATP III established diagnostic criteria that have facilitated its clinical use since it does not require proof of insulin resistance. For ATP III, when at least three of the five criteria listed below are present, then diagnosis of MS should be affirmed. The explicit demonstration of insulin resistance is not required, but most people who meet the ATP III criteria will also be insulin resistant. The convenience of checking the NCEP-ATP III criteria led to the adoption of this recommended methodology by the I-DBSM Table 1)

Table 1.

Criteria for Diagnosis of MS According to the NCEP-ATP III.

MS Component Factors—According to NCEP-ATP III
Risk Factor	Definition
Abdominal obesity, checked by measuring waist circumference
Men	>102 cm (>40 in.)
Women	>88 cm (>35 in.)
Triglycerides	≥150 mg/dL
HDL cholesterol
Men	<40 mg/dL
Women	<50 mg/dL
Blood pressure	≥130/85 mmHg
Fasting glycemia	≥110 mg/dL

Note. The diagnosis is made when at least three of the criteria are met. The American Diabetes Association has recommended that the proposed cutoff point for fasting glucose as a component of MS changes from 110 mg to 100 mg/dL; in addition, the I-DBSM has also recommended that the prior use of lipid-lowering and antihypertensive drugs, and a previous diagnosis of diabetes by themselves fulfill the criteria for measurement of triglyceride levels, of blood pressure, and of fasting blood glucose levels (I-DBSM, 2005).

As the focus of its approach, the ATP-III assumed that considering multiple risk factors: (a) elevates people with diabetes and no cardiovascular disease (most of which have multiple risk factors) to a cardiovascular disease risk equivalent; (b) uses the Framingham projections of absolute risk of cardiovascular disease in 10 years (i.e., the percentage of probability of having a cardiovascular event in 10 years) to identify certain patients with two or more risk factors for more intensive treatment; and (c) identifies people with multiple metabolic risk factors (MS) as candidates for intensified therapy to bring about changes in lifestyle (Grundy et al., 2004; I-DBSM, 2005; NCEP, 2002).

The ATP III enumerated six MS components that influence the emergence of cardiovascular disease: abdominal obesity, atherogenic dyslipidemia, increased blood pressure, insulin resistance—glucose intolerance, pro-inflammatory state, and pro-thrombotic state (Grundy et al., 2004). These components are related in a particular combination that the ATP III termed underlying, major, and emerging risk factors. Thus, the following would be considered underlying risk factors for cardiovascular disease: obesity (especially abdominal obesity), physical inactivity, and an atherogenic diet. The following would be major risk factors: smoking, hypertension, high LDL cholesterol, low HDL cholesterol, family history of premature coronary heart disease, and age. In turn, emerging risk factors related to cardiovascular disease are as follows: elevated triglycerides, small LDL particles, insulin resistance, glucose intolerance as well as a pro-inflammatory and pro-thrombotic state (NCEP, 2002). Besides obesity and insulin resistance, each of the MS risk factors is subject to their own regulation through genetic and acquired factors, which leads to variability in their particular expression; advancing age probably affects all elements that contribute to the pathogenesis, which must explain why the prevalence of MS increases with advancing age (NCEP, 2002).

The ATP III considered the “obesity epidemic” as the main factor responsible for an increased prevalence of MS. Obesity contributes to the development of hypertension, high serum cholesterol, low HDL cholesterol, and hyperglycemia, and is, at any rate, associated with an elevated risk of cardiovascular disease. Abdominal obesity—clinically characterized by an increase in abdominal circumference—is the form of obesity most strongly associated with MS. Atherogenic dyslipidemia is characterized by increased triglycerides and low levels of HDL cholesterol. However, a more detailed analysis usually identifies other abnormalities, such as an increase in remnant lipoproteins, in apolipoprotein B as well as in small LDL and HDL particles; each of these abnormalities is recognized as having an independent role in atherogenesis. Although recognized by many authors as a lesser “metabolic” factor, high blood pressure, usually multifactorial, is strongly associated with obesity and is frequently observed in insulin-resistant subjects. Insulin resistance is strongly associated with metabolic risk factors and invariably correlates with the risk of cardiovascular disease; it is present in most people with MS. Insulin resistance generally increases with an increase in body fat content, and there is a great variety of insulin sensitivity for any given level of body fat. Most obese people—that is, people with a body mass index greater than or equal to 30 kg/m²—have postprandial hyperinsulinemia and relatively low insulin sensitivity. When patients have long lasting insulin resistance, they often manifest glucose intolerance. When glucose intolerance evolves to the level of hyperglycemia in diabetes, high blood glucose will be an independent and higher risk factor for cardiovascular disease. A pro-inflammatory state, recognized by elevations of C-reactive protein—the main cause of which, among multiple factors, would be the release of inflammatory cytokines by excess adipose tissue—is another condition often present in individuals with MS. In response to increased plasma levels of cytokines, there is an increase in plasma fibrinogen levels—an acute phase reactant similar to C-Reactive Protein—thus characterizing a pro-thrombotic state in MS (Grundy et al., 2004; I-DBSM, 2005; NCEP, 2002; Reaven, 1988).

The risk of a cardiovascular event in 10 years in men with MS is typically between 10% and 20%. The Framingham researchers investigated if MS implies additional risk beyond the usual risk factors of the Framingham algorithm. After analyzing the results, researchers concluded that no advantage is added in the risk assessment when including the risk factors unique to MS by the ATP III criteria for estimating risk factors in the Framingham score. It is believed that most risk factors associated with MS are related to age and diabetes as well as to levels of blood pressure, total cholesterol, and HDL cholesterol (Grundy et al., 2004).

Considering the poor prognosis implied by the presence of MS elements, this should be treated rigorously, and decreasing cardiovascular risk in affected individuals should be aimed for. In general, the emphasis in the treatment of MS should be placed on changing lifestyles, encouraging the practice of regular physical activity, healthy eating as well as working toward and maintaining appropriate body weight. A balanced diet, which is individualized according to the specific needs of each patient, must reduce body weight to appropriate levels, correct dyslipidemia, decrease visceral fat, as well as lower blood pressure and hyperglycemia, thereby reducing cardiovascular risk. There is evidence that diets most suitable for these purposes should be high in fiber and must contain a low proportion of simple sugars and saturated fats (Steemburgo, Dall’Alba, Gross, & Azevedo, 2007). Likewise, regular physical activity, between 30 and 40 minutes per day, is associated with a reduction in cardiovascular risk. Additionally, the aim should be reducing the intake of alcoholic beverages to 30 ml of ethanol/day for men and half that amount for women (equivalent to 720 ml of beer, 240 ml of wine, and 60 ml of spirits for men). Values higher than these are related to increased blood pressure and triglyceride levels. While not constituting an integral element of MS, the habit of smoking should be discouraged due to the associatedhigh cardiovascular risk (Grundy et al., 2004; I-DBSM, 2005; NCEP, 2002; Reaven, 1988).

Quality of Life and Health of Military Policemen

The total effective force of public safety professionals in Brazil, including the military police, civilian police, and firefighters, in the year 2007, was 599,973 professionals distributed as follows: 63,387 military firefighters (11%), 123,403 civilian police (21%), and 412,096 military police (68%). In the State of Bahia, a force of 36,866 professionals was constituted as follows: 2,000 military firefighters (5.42%), 6,385 civilian police (17.32%), and 28,481 military police (77.25%) (SENASP, 2010, 2013).

Also, in 2011 in the State of Bahia the Military Police consisted of 31,869 officers. The lower ranking men with degrees lower than cadet (a Military Police Officer Training student) accounted for 29,041 (91.13% of total), with 22,622 soldiers (70.98%); (SENASP, 2010, 2013). Other demographics aspects are described in Table 2.

Table 2.

Gender and Age Groups in the Military Police of the State of Bahia, 2011.

Gender		Age group (years)
Male	Female	18-24	25-30	31-35	36-40	41-45	46-50
27,554 (86.46%)	4,315 (13.54%)	968 (3.04%)	2,006 (6.29%)	7,219 (22.65%)	7,699 (24.16%)	6,614 (20.75%)	2,559 (8.03%)

Source: SENASP, 2013.

One study involving 1,110 military police of the city of Rio de Janeiro revealed that most of the force was male (96.3%) in the age group of 31 to 40 years (43.1%); 48.2% were of mixed race and 75.4% married; 52.9% reported practicing some form of religion; about 67.8% had obtained 2nd degree education, complete and incomplete, although 27.9% had completed or were enrolled in upper level or graduate studies. As for family income, 31.2% of police officers earned in the range of R$1,001.00 to R$1,500.00. Using the Self-Reporting Questionnaire (SRQ-20) scale for the detection of psychological distress and minor psychiatric disorders, a prevalence of psychological distress in 35.7% (95% confidence interval = 32.9% to 38.6%) of the military police of the city of Rio de Janeiro was reported. It was also reported that dissatisfaction in the ability to react to difficult situations, which are frequent in the execution of police activities, and dissatisfaction with life as a whole explained more the psychological distress than sociodemographic characteristics (Souza, Minayo, Silva, & Pires, 2012).

Being a police officer is a risky profession, with high rates of victimization and professional mortality. A study of the military police in the State of Rio de Janeiro between 1994 and 2004 revealed that mortality rates due to violence were 3.65 times higher than those for the male population of the city of Rio de Janeiro, and 7.2 times higher than those for the general population of that city. With regard to the statistics in Brazil, the rates were 7.17 times those of the male population and 13.34 times those of the general population. The risk of death among military police is also higher than among agents of other security corps: 6.44 times that of the Municipal Guard and 1.72 times that of the Civilian Police (Minayo, Souza, & Constantino, 2008; Souza & Minayo, 2005). There are no national studies on the prevalence of MS among military police, and the studies found in search engines such as SciELO tend to focus on specific variables, such as obesity or physical activity and inactivity.

There are also no studies on the prevalence of MS in groups known to be representative of the Brazilian population. Depending on the criteria used and the characteristics of the study population, studies with other populations, such as in Mexico, North America, and Asia, revealed a high prevalence of MS, with frequencies ranging from 12.4% to 28.5% in men and 10.7% to 40.5% in women (I-DBSM, 2005). In a population-based study in a capital of the Brazilian Northeast, with a random sample consisting of 1,663 individuals between 25 and 64 years, Salaroli, Barbosa, Mill, and Molina (2007) reported a MS prevalence of 29.8%, with no difference between the genders and a progressive increase with age. Parameters often higher in men were, in descending order: hypertension, hypertriglyceridemia, low HDL cholesterol, hyperglycemia, and abdominal obesity. In women, the most prevalent parameters, also in descending order, were hypertension, low HDL cholesterol, abdominal obesity, hypertriglyceridemia, and hyperglycemia. In an outpatient clinic for patients with cardiovascular disease in a southern state of the country, the prevalence of MS using the NCEP-ATP III was evaluated. In a final sample of 151 patients aged between 26 and 84 years, the following was observed: a frequency of 50% of excessive weight and 23% of obesity; increased abdominal circumference in 30.8%; and, a 61.5% prevalence of MS. Here, it should be emphasized that this was a service for secondary prevention in specialized clinics. In other words, the individuals of the sample had already previously been diagnosed with cardiovascular disease (Bopp & Barbiero, 2009). Other authors studied the prevalence of MS and its components through the agreement of two diagnostic criteria in a population of 719 patients aged more than 13 years, who attended outpatient cardiology clinics in a capital of the region of the Brazilian Northeast. The prevalence of MS was 62.3% in men and 64.5% in women according to the IDF criteria, and 48.9% in men and 59% in women according to the NCEP-ATP III. The most prevalent elements, according to the NCEP-ATP III and IDF, respectively, were as follows: hypertension at 87.2% and 86%; hypertriglyceridemia at 84.4% and 82.5%; increased waist circumference at 77.8% and 100%; low HDL cholesterol at 58.1% and 49.9%; and altered glucose levels at 59.9% and 51.9% (Barbosa, Silva, Barbosa, Monteiro Júnior, Figueiredo Neto, Nina, Ribeiro, Figuerêdo, Melo Filho, Chein, 2010).

A study on the prevalence of MS and its components in individuals from the city of Salvador, Bahia (Barbosa, Lessa, Almeida Filho, Magalhães, Araújo, 2010) reported subjects with skin color described as White, mixed, or Black respectively, having frequencies of 23.3%, 23.3%, and 23.4%; in men, these frequencies were 26.2%, 21.9%, and 17.5%; in women, the frequencies were 20.5%, 23.8%, and 27.0%. Based on multivariate analysis, being Black was considered a protective factor for men and a risk factor for women. Despite the high prevalence of hypertension, men of African descent had a lower frequency of increased waist circumference, low HDL cholesterol, and hypertriglyceridemia. Such findings are consistent with the assessment made in a study of the prevalence of MS in the U.S. population (Ford, Giles, & Dietz, 2002). The age-adjusted prevalence was similar for men (24%) and women (23.4%), although among African American individuals, women had a 57% higher prevalence than men.

Using the diagnostic criteria proposed by the IDF, one study (Costa, Montenegro, Lopes, & Costa, 2011) on 1,383 men aged between 18 and 62 years, all navy personnel from a capital of the Northeast, reported a prevalence of 17.6% MS. Abdominal obesity was the most frequent component among the elements of the syndrome.

Teixeira and Pereira (2010) studied 1,011 men in a military unit in the South and evaluated their performance on physical fitness tests (aerobic endurance, muscular strength, and flexibility), and reported a positive correlation between age and nutritional status impairment in physical performance scores.

A study of 50,523 active duty military men of the Brazilian Army compared anthropometric data (body mass index and waist circumference) with the cardiorespiratory performance data (VO_2max) and reported an inverse relationship between waist circumference and abdominal cardiorespiratory fitness (Oliveira & Dos Anjos, 2008).

Another study involving a sample of 70 individuals from a population of 86 military police from the 22nd Battalion of the city of Trindade, in the state of Goiás, all aged between 28 and 46 years, reported that 1% of individuals were underweight, 39% of normal weight, 52% were overweight, and 8% obese (Junior, 2009).

Using the criteria proposed by the IDF, Costa et al. (2011) studied 1,383 men belonging to military organizations in the city of Natal, finding an MS prevalence of 17.6%, with about one third of the subjects presenting two or more risk factors for the syndrome.

In summary, studies report that being a military police officer is a risky profession with a high level of occupational stress and professional victimization. Although the data do not specify the prevalence of MS in population-based studies, other risk factors are demonstrated, such as overweight/obesity, these associated with other factors that may increase the prevalence of disease and death from cardiovascular causes in this occupational category.

Final Remarks

Metabolic syndrome is a risk factor for multiple cardiovascular diseases, including obesity (especially abdominal fat accumulation), hypertension, abnormal glucose metabolism, and dyslipidemia. Controlling this multifactorial condition necessarily involves changes in lifestyle, including a balanced and healthy diet and regular physical activity. The recommended changes in lifestyle merge with the adoption of objective standards for the quality of life, such as those presented in the World Health Organization’s assessment instruments. The study of the component factors of the prevalence of MS in the military police corps can help in planning and adopting a preventive and therapeutic approach that is able to improve the living conditions and health of members of the group—mostly men—the objective of which is intertwined with the discipline of health care in men.

Footnotes

Acknowledgements

The authors thank the professional service of translation and improvement of language performed by Editage.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Metabolic Syndrome and Military Policemen’s Quality of Life

Abstract

Keywords

Metabolic Syndrome: Historical Aspects, Definition, Pathogenesis, and Clinical Manifestations

Quality of Life and Health of Military Policemen

Final Remarks

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Funding

References