Chewing impairment and associated factors among adults

Transcription

1 Rev Súde Públic 2013;47(6):1-10 Originl Articles DOI: /S Dniel de Rossi Figueiredo I Mrco Aurélio Peres I,II,III Crl Antoni Luchi I Chewing impirment nd ssocited fctors mong dults Kren Glzer Peres I,II,III ABSTRACT OBJECTIVE: The im of this study ws to estimte the prevlence of chewing impirment ccording to sex, nd its ssocited fctors in dults. METHODS: A cross-sectionl popultion-bsed study ws crried out with 2,016 subjects ged between 20 nd 59 yers in Florinopolis, SC, Southern Brzil, in The smpling ws undertken in two stges, census trcts nd households. The outcome chewing impirment ws obtined from the question How often do you hve chewing impirment due to teeth or denture problems?. Anlyses were crried out with demogrphics nd socioeconomic fctors, dentl services utiliztion, nd self-relted orl helth using multivrible logistic regression nd strtified by sex. RESULTS: The response rte ws 85.3% (1,720 dults). The prevlence of chewing impirment ws 13,0% (95%CI 10.3;15.8) nd 18,0% (95%CI 14.6;21.3) mong men nd women, respectively. Women nd men fifty yers old nd over, who hd ten or fewer nturl teeth nd those who reported toothche were more likely to hve chewing impirment. The combintion of tooth loss nd toothche on chewing impirment ws lmost four times higher mong women. CONCLUSIONS: The mgnitude of the ssocitions mong socioeconomic, demogrphics nd self-relted orl helth fctors ws different ccording to sex, in generl higher for women, with emphsis on toothche. The findings suggest tht the impct of orl conditions vries by sex. I Progrm de Pós-Grdução em Odontologi. Centro de Ciêncis d Súde. Universidde Federl de Snt Ctrin. Florinópolis, SC, Brsil DESCRIPTORS: Adult. Mstiction. Socioeconomic Fctors. Gender nd Helth. Orl Helth. Dentl Helth Surveys. II Progrm de Pós-Grdução em Súde Coletiv. Centro de Ciêncis d Súde. Universidde Federl de Snt Ctrin, Florinópolis, SC, Brsil III Austrlin Reserch Centre for Popultion Orl Helth. School of Dentistry. The University of Adelide. Adelide SA, Austrli Correspondence: Kren Glzer Peres Austrlin Reserch Centre for Popultion Orl Helth School of Dentistry The University of Adelide 122 Frome Street Adelide, SA, Austrli 5000 E-mil: kren.peres@delide.edu.u Received: 2/20/2013 Approved: 8/2/2013 Article vilble from:

2 2 Chewing impirment in dults Figueiredo DR et l INTRODUCTION Mstiction is one of the principle orl functions nd n impirment in its bility, understood by ssessing the individul on difficulty chewing, 5 is one of the most immedite consequences of orl helth problems nd disorders, such s missing teeth. 16 The number of teeth influences fiber intke, in positive reltionship with chewing: the more teeth, the better the individul cn chew nd the greter the untke of foods rich in fiber, vitmins, folic cid, clcium nd protein. 11,14,21 Difficulty in chewing fiber rich foods cn be ssocited with incresed risk of systemic illness, such s crdiovsculr disese, nd with orl diseses, such s orophryngel cncer. 14,23 In helth survey of dults in the South of Brzil, it ws highlighted tht 27.0% of individuls hd difficulty chewing. 1 A ntionwide study in Brzil in 2010 showed 31.0% prevlence of difficulty chewing in dults. Mstiction perceived s regulr or bd in dults is ssocited with the externl environment (for exmple, loction of residence) nd with individul chrcteristics (sex, ge, self-reported skin color, income nd schooling). 6,7 Adults from low income groups, who reported hving blck skin color, with low levels of schooling, tooth loss nd no use of dentl prosthesis reported being more disstisfied with their bility to chew, compred with their peers. 6 Helth relted behvior such s mking little use of helth cre services nd poor self-perceived orl helth hve negtive influence on reports of difficulty chewing. 7 Men nd women hve different ttitudes to helth relted behvior. 13 There re differences between sexes in the rtes of prevlence in the ssessment of bility to chew, s women more often reported difficulty chewing. 7,16,20 Although there re studies on difficulties chewing, 1,6,7,16,20,21 no study ws found which investigted these fctors ccording to sex. The pttern of orl helth problems my ffect mstiction in different wys in men nd women. The im of this study ws to estimte the prevlence in dults of difficulties chewing, ccording to sex, nd to nlyze ssocited fctors. METHODS This is prt of cross-sectionl popultion bsed prospective study of dults in the urbn zone of Florinópolis, SC, Southern Brzil, nmed EpiFlorip Adultos. b The dt were collected between September 2009 nd Jnury 2010, nd the trget popultion of the study (n = 249,530) ws composed of dults ged 20 to 59 yers old, resident in the urbn re of the municiplity of Florinópolis, stte of Snt Ctrin, with n estimted popultion in 2009 of 408,161 inhbitnts. c This ge group included pproximtely 60.0% of the popultion of the municiplity in To clculte the smple size the following prmeters were tken into considertion: trget popultion (N = 249,530 individuls) 95% confidence intervl, prevlence of unknown outcomes (50.0%), smpling error of 3.5 percentge points, design effect = 2, n dditionl 10.0% to cover losses nd refusls nd nother 15.0% to control for confounders. The clculted smple size ws 2,016 individuls fter pplying these prmeters. The smple size ws clculted to test ssocitions of the outcome, strtified by sex. The finl smple size ws 1,720 individuls, nd the response rte ws 85.3%, sufficient to obtin sttistic power of 80.0% or more to test ssocitions between ge, income, schooling, number of nturl teeth, toothche nd difficulty chewing in men nd women. Frequency of exposure between 7.0% nd 47.0%, n lph error of 5% nd minimum prevlence rtios between 1.6 nd 1.7 were considered. Self-reported skin color, most recent dentl ppointment, plce of the ppointment, symptoms of dry mouth nd wering full dentl prosthesis hd power of < 80.0%. The urbn census trcts, totl of 420, were strtified ccording to the hed of household income deciles nd hd vlues from R$ to R$ 13, (bsed on the 2000 census). The smpling selection process took plce in two stges: selecting first the census trcts nd then the households. First, 60 census trcts were systemticlly selected, six for ech income decile. Residences in these trcts, vrying between 61 nd 810, were contcted by the reserch tem. Second, to reduce vribility between the number of residences in ech census trct, some were merged nd some were divided, giving totl of 63 trcts. The initil coefficient of vrition ws 55.0% (n = 60 trcts) nd the finl one ws 32.0% (n = 63 trcts). Finlly, the households were systemticlly selected, 18 in ech trct, totling 1,134 households. Losses were defined s refusls to tke prt or not finding the dult t home fter four ttempts on Ministério d Súde, Secretri de Atenção à Súde, Deprtmento de Atenção Básic, Coordenção Ncionl de Súde Bucl. Pesquis Ncionl de Súde Bucl, SBBrsil 2010: resultdos principis. Brsíli (DF); b The EpiFlorip study imed to investigte the helth nd life conditions of the dult popultion of Florinopolis City, SC, Southern Brzil. The conditions included: self-ssessed helth, self-reported comorbidities, self-reported orl helth sttus, use of helth services nd mjor risk fctors for chronic diseses (demogrphic nd socioeconomic dt, dietry hbits, physicl ctivity, blood pressure, nthropometric mesurements, lcohol nd tobcco). Avilble from: c Instituto Brsileiro de Geogrfi e Esttístic. Populção brsileir. Rio de Jneiro; 2012 [cited 2012 Feb 5]. Avilble from:

3 Rev Súde Públic 2013;47(6): different dys nd t different times during the week, with t lest one ttempt being mde t the weekend nd one t night. Structured fce to fce interviews were crried out by 35 interviewers with ll of the dults residing in the selected households. The interviewers were trined by the study coordintors nd supervisors nd technicins from the Brzilin Institute of Geogrphy nd Sttistics (IBGE). The questionnire ws pretested with 30 dults in the sme ge group s the study in n re of the municiplity covered by primry helth cre unit. After the interviewers were trined, pilot study took plce with 100 individuls in two census trcts selected, with the results not being included in this study. Dt were collected by the interviewers using Personl Digitl Assistnts (PDA) by fce to fce interviews, which lsted on verge n hour. Telephone interviews were conducted with nerly 15.0% of the smple (n = 248) using reduced form of the questionnire composed of ten questions, in order to control the qulity of dt. Kpp sttistics nd intr-clss correltion coefficient were clculted, with vlues between 0.6 nd 0.9. The dependent vrible ws obtined by sking ech of the interviewees: How often do you hve difficulty eting becuse of problems with your teeth or dentures? (never, rrely, sometimes, often, lwys). 12 The outcome ws ctegorized s never nd sometimes/ often/lwys. The independent vribles were ge in complete yers (20 to 29, 30 to 39, 40 to 49 nd 50 to 59), selfreported skin color (white, prd [brown] nd blck subjects who referred to themselves s yellow or indigenous were excluded from the nlyses due to their low frequency, n = 17 nd 20, respectively), per cpit household income (in reis) nd ctegorized into terciles (1 st tercile: R$ ; 2 nd tercile: R$ R$ 1, nd 3 rd tercile: R$ 1,314.00), d nd schooling in completed yers of study (fewer thn five yers, five to eight yers, nine to 11 yers nd 12 yers). With regrds use of helth cre services, the selected vribles were lst visit to the dentist (< 1, one to two nd 3 yers) nd type of service used (privte, public nd other). For self-reported orl helth, the vribles were dry mouth (never/sometimes nd often/lwys), 22 wering full dentures, dichotomized s no (no prosthesis used) nd yes (full dentures for t lest one dentl rch), number of nturl teeth (more thn ten teeth in dentl rches, fewer thn ten teeth in t lest one rch nd no nturl teeth) nd hving experienced toothche in the lst six months, dichotomized into no/yes. Stt 9.0 sttisticl softwre ws used. Complex smple design nd smpling weights were considered in the sttisticl nlyses. Descriptive nlysis nd ssocition of prevlence ws crried out ccording to the explortory vribles strtified by sex. A 5% vlue of significnce ws dopted nd the Ro-Scott Chi-squre test, which djusts nlyses for design effect, ws used. Non-conditionl logistic regression ws crried out in the univrite nd multivrible nlysis to estimte odds rtios (OR) nd respective confidence intervls (95%CI). Potentil confounders were those vribles identified s such in the literture nd were ssocited with exposure nd with the outcome with p < The determintion model bsed on Victor et l 24 nd Bstos et l 4 ws followed in the multivrible nlyses in order to hypotheticlly ssume temporl nd determintion reltionship between the exposure vrible nd the outcome. The demogrphic vribles of ge nd self-reported skin color my influence socioeconomic conditions in the cse of income nd schooling, which in turn influence use of helth cre services, which cn determine orl helth conditions such s dry mouth, use of prosthesis nd number of nturl teeth, which hve closer reltionship with the self-reported condition of difficulty chewing. Interctions between number of nturl teeth (two ctegories: > 10 teeth in both dentl rches < 10 teeth in t lest one dentl rch) nd dichotomized toothche (yes/ no) with difficulty chewing were tested, controlling for confounders. Sttisticl significnce ws determined by the Wld test nd p vlues below 5% were considered sttisticlly significnt. The study ws pproved by the Reserch Ethics Committee of the Universidde Federl de Snt Ctrin (Process no. 351/2008) nd prticipnts were sked to sign consent form. RESULTS The men ge of the interviewees ws 38 yers old (stndrd devition SD = 11.6 yers) nd 55.8% were women. Fewer thn hlf of the men nd women hd more thn 12 yers of studies. Most men nd women hd visited dentist within the pst yer nd hd more thn ten nturl teeth in both dentl rches (Tble 1). Around 1/6 of the prticipnts reported difficulty chewing due to orl helth problems. The prevlence of difficulty in chewing ws higher in women thn in men (p = 0.009). Higher prevlence of difficulty chewing ws observed in older men nd women (50 to 59 yers old) compred with the younger ones (20 to 29 yers old); mong those in the first income tercile compred with those in the third tercile; in those with fewer thn four d Equivlent dollr: 1 st tercile: US$244.00, 2 nd tercile: US$ US$ nd 3 rd tercile: US$566.00

4 4 Chewing impirment in dults Figueiredo DR et l Tble 1. Totl smple nd strtified by sex, ccording to socioeconomic nd demogrphic chrcteristics, ccess to dentl services nd self-reported orl helth condition. Florinopolis, SC, Southern Brzil, (N = 1,720) Vrible Smple Men Women n % n % n % Age (yers) (n = 1,720) 20 to to to to Self-reported skin color (n = 1,678) White 1, Prd/Blck Per cpit income in terciles (reis) (n = 1,685) 3 rd tercile (highest income) nd tercile st tercile (lowest income) Schooling (yers of study) (n = 1,716) to to Most recent dentl visit (yers) (n = 1,705) < 1 1, to Type of service (n = 1,707) Privte 1, Public Other Dry mouth (n = 1,716) Never/Sometimes 1, Often/Alwys Wering full prosthesis (n = 1,698) No 1, Yes Number of nturl teeth (n = 1,717) 10 in both dentl rches 1, < 10 in t lest one rch None Toothche (n = 1,717) No 1, Yes Difficulty chewing (n = 1,712) Never 1, Sometimes/Often/Alwys Prevlence of the outcome, strtified by sex, ccording to the Ro-Scott test, p = yers of schooling compred with those with more thn 12 yers of studies. Higher prevlence ws observed mong those who wore full dentures, those with fewer thn ten nturl teeth in t lest one dentl rch or who were edentulous nd those who reported toothche within the lst six months. Men who used public dentl services nd women who reported dry mouth hd higher prevlence of difficulty chewing (Tble 2). In the multivrible nlysis for men, it ws observed tht those ged between 50 nd 59 hd n lmost three times greter chnce of hving difficulty chewing

5 Rev Súde Públic 2013;47(6): Tble 2. Prevlence of difficulty chewing in men nd women ccording to socioeconomic nd demogrphic chrcteristics, ccess to dentl services nd self-reported orl helth condition. Florinopolis, SC, Southern Brzil, (N = 1,720) Vrible Men Women % 95%CI p % 95%CI p Age (yers) < to ; ; to ; ; to ; ; to ; ;30.8 Self-reported skin color White ; ;20.9 Prd/Blck ; ;30.5 Per cpit income in terciles (reis) rd tercile (highest income) ; ; nd tercile ; ; st tercile (lowest income) ; ;16.6 Schooling (yers of study) < ; ; to ; ; to ; ; ; ;38.6 Most recent dentl visit (yers) < ; ; to ; ; ; ;30.7 Type of service Privte ; ;20.4 Public ; ;28.1 Other ; ;29.6 Dry mouth Never/Sometimes ; ;19.7 Often/Alwys ; ;42.8 Wering full dentures No ; ;20.2 Yes ; ;41.1 Number of nturl teeth < < in both dentl rches ; ;17.3 < 10 in t lest one rch ; ;39.7 None ; ;61.8 Toothche < No ; ;14.8 Yes ; ;58.4 Ro-Scott test thn those ged 20 to 29. Schooling ws prtilly nd positively confounded by ge nd per cpit income, ttenuting the effect of the OR mong those with lower levels of schooling compred with those with 12 or more yers of studies. The ssocition between wering dentures nd difficulty chewing cesed to be significnt when ge, per cpit income nd schooling were considered. Edentulous mles hd n OR lmost six times greter for hving difficulty chewing thn those with ten or more teeth in both dentl rches. Hving reported toothche incresed the chnce of difficulty chewing by more thn two times (Tble 3).

6 6 Chewing impirment in dults Figueiredo DR et l Tble 3. Assocition between difficulty chewing in men ged 20 to 59 yers nd independent vribles. Florinopolis, SC, Southern Brzil, (N = 761) Vrible Undjusted nlysis Model 1 Model 2 b Model 3 c OR 95%CI OR 95%CI OR 95%CI OR 95%CI Demogrphic block Age (yers) p < p < to to ; ; to ; ; to ; ;5.9 Self-reported skin color p = p = White 1 1 Prd/Blck ; ;1.4 Socioeconomic block Per cpit income terciles (reis) p = p = rd tercile (highest income) nd tercile ; ;2.8 1 st tercile (lowest income) ; ;2.1 Schooling in yers of study p < p = to ; ;2.1 5 to ; ; ; ;5.2 Use of dentl services block Most recent dentl visit (yers) p = p = < to ; ; ; ;2.3 Type of service p = Privte 1 Public ;2.7 Other ;1.3 Bloco de condições bucis utorreferids Wering full dentures p = p = No 1 1 Yes ; ;1.4 Number of nturl teeth p < p < in both rches 1 1 < 10 in t lest one rch ; ;7.1 None ; ;21.8 Toothche p = p = No 1 1 Yes ; ;3.8 Number of nturl teeth x p < toothche ;2.2 p < 0.20 nd Multivrible Logistic Regression (odds rtio - 95%CI) Model 1: block 1 vribles djusted for vribles in the sme block. b Model 2: block 2 vribles djusted for vribles in the sme block nd for ge. c Model 3: block 3 vribles djusted for vribles in the sme block nd for ge, income nd schooling. d p > 0.20

7 Rev Súde Públic 2013;47(6): In women, disstisfction with chewing incresed with ge nd with decresing income. Although t the limit of sttisticl significnce, women whose self-reported skin color ws prd or blck hd 60.0% higher chnce of being disstisfied with chewing thn those whose self-reported skin color ws white. Edentulous women hd n lmost seven times higher chnce of the outcome compred with those with ten or more nturl teeth in both dentl rches. A similr figure ws obtined for those who hd reported toothche, compred with those without pin (Tble 4). There ws significnt interction between the number of teeth nd toothche in both men nd women. However, the mgnitude of the ssocition of the combined effect mong hving more thn ten teeth in the dentl rches nd the presence of toothche ws lmost four times greter mong women (Figure 1). DISCUSSION There ws higher prevlence of difficulty chewing mong women. Although the fctors ssocited with difficulty chewing were similr between the sexes, the effect of simultneously hving more thn ten teeth in both dentl rches nd toothche ws lmost four times higher mong women. The prevlence of difficulty chewing in the totl smple ws lower thn the findings in interntionl literture, which indicted prevlence rnging from 20.0% in dults ged 45 nd over in Florid 20 to 30.0% in dults ged over 45 in Tiwn. 11 The prevlence of the outcome in dults in Brzil ws 31.0%. The difference between this study nd the findings of the ntionl survey cn be explined by living n helth cre conditions in Florinópolis, which re bove verge for Brzil. b The rtes of prevlence between the sexes confirm wht is found in the literture. A study with dults in the USA 20 showed tht the prevlence of difficulty chewing in women ws double tht in men. In Brzil, the prevlence of this outcome for men ws 25.0%, nd 34.0% for women. The chnce of experiencing the outcome increses with ge mong men, s in the study of dult nd older men in the USA. 14 This study indictes tht, the greter the ge, the more compromised nturl dentition is nd the lower the intke of food considered to be helthy, such s fruit nd fiber. Although this study does not ssess qulity of food intke, previous studies 12,14,21,23 hve shown positive ssocition between ge nd difficulty chewing nd stressed tht not eting foods deemed helthy ffects generl helth. Men with lower levels of schooling hd greter chnce of being disstisfied with chewing. Men t lower socioeconomic levels re more dedicted to providing for their household thn to looking fter themselves nd mke less use of helth cre services thn women. 9 In ddition, they re more prone to stressful environments, tend to dopt less helthy lifestyles, with higher lcohol nd tobcco consumption. These substnces cn led to chronic helth problems, 10 including mouth cncer, which is more prevlent mong men nd produces countless negtive impcts on the individul, including difficulty chewing. 18 Prd nd blck women hd more chnce of hving difficulty chewing. Blck women tended to report more difficulty chewing 20 nd more tooth loss thn white women. 3 A possible explntion for this is tht blck women usully work in poorly pid positions demnding lower qulifictions, live in res with poorer bsic infrstructure nd experience limittions to helth cre service use. 2 The results of this reserch confirm those in the literture. When considering the socioeconomic position of women, skin color is confounded with income nd schooling, nd remins t the limit of sttisticl significnce. In both men nd women, hving no nturl teeth increses the chnce of hving difficulty chewing by t lest six times, compre with those who hve more thn ten nturl teeth in t lest one dentl rch. On the other hnd, uthors hve shown differences in reports of stisfction with chewing between the sexes in the bsence of nturl teeth. Women wering conventionl dentures show more disstisfction with chewing thn men nd report more periorl sensitivity to the movement of the prosthesis. 19 The results of this study indicte differences in the mgnitude of the ssocition between difficulty chewing nd toothche in men nd women. A study of dults nd the older individuls in Spin showed greter prevlence of toothche in women thn in men. 17 There ws stronger ssocition between hving more teeth nd suffering toothche mong women thn men. Men nd women, due to socil nd culturl issues, tend to hve different concepts of pinful senstions nd well-being ssocited with the mouth. Women py more ttention to the fct tht missing teeth or toothche cn determine qulity of life, whether becuse it ffects ppernce nd mood or whether providing better opportunities in the job mrket. 13 According to Pn et l, 19 difference relted to biologicl spects in dult women, such s hormonl ltertions, menopuse or osteoporosis should be considered in reports of disstisfction with chewing. There re some limittions to this reserch. Although the sttisticl power diminished due to strtifying the smple by sex, power bove 80.0% ws observed in both sexes for the vribles of ge, income, schooling, number of nturl teeth nd toothche. Other limittions of the study were obtining mesures of orl helth using

8 8 Chewing impirment in dults Figueiredo DR et l Tbl 4. Assocition between difficulty chewing in women ged 20 to 59 yers nd independent vribles. Florinopolis, SC, Southern Brzil, (N = 959) Vrible Undjusted nlysis Model 1 Model 2 b Model 3 c RC 95%CI RC 95%CI RC 95%CI RC 95%CI Demogrphic block Age (yers) p = p = to to ; ; to ; ; to ; ;3.6 Cor d pele utorreferid p = p = White 1 1 Prd/Blck ; (1.0;2.4) Socioeconomic block Per cpit income terciles (reis) p = p = rd tercile (highest income) nd tercile ; ;2.8 1 st tercile (lowest income) ; ;3.2 Schooling in yers of study p = p = ; ; ; ; ; ;2.8 Use of dentl services block Most recent dentl visit (yers) p = d < to ; ;2.1 Self-reported orl helth conditions block Dry mouth p = p = Never/Sometimes 1 1 Often/Alwys ; ;3.3 Wering full dentures p = p = No 1 1 Yes ; ;1.3 Number of nturl teeth p < p = in both rches 1 1 < 10 in t lest one rch ; ;4.3 None ; ;24.4 Toothche p < p < No 1 1 Yes ; ;11.3 Number of nturl teeth x p < toothche ;3.3 p < 0.20 nd Multivrible Logistic Regression (odds rtio - 95%CI) Model 1: block 1 vribles djusted for vribles in the sme block. b Model 2: block 2 vribles djusted for vribles in the sme block nd for ge. c Model 3: block 3 vribles djusted for vribles in the sme block nd for ge, income nd schooling. d p > 0.20

9 Rev Súde Públic 2013;47(6): Odds rtio (OR) < 10 teeth in t lest one dentl rch nd without toothche b < 10 teeth in t lest one dentl rch nd with toothche b 2.5 Men Womn 10 teeth in both rches nd with toothche b Context of the finl modelling for men nd women djusted for sociodemogrphic nd economic vribles nd use of services. b Comprison with best ctegory 10 teeth in both rches nd without toothche1 9.4 Figure. Interction between number of nturl teeth nd toothche on difficulty chewing, in dults ccording to sex. Florinópolis, SC, Test for heterogeneity (p < 0.001) ntionl 15, nd interntionl 22 surveys. High rtes of relibility were observed between the interviewees for the self-reporting questions nd the interviewer guide for the reserch questions, suggesting tht there ws no observtion bis. The multivrible nlysis ws guided by theoreticl model tht enbled possible confounding fctors to be controlled, s well s testing plusible interctions. Moreover, the self-reporting question used in the study: How often do you hve difficulty eting becuse of problems with your teeth or dentures? enbles systemtic ssessment to be crried out by long-term helth surveillnce system for the outcome in question. It is suggested tht this question be included in popultion surveys. There re different mgnitudes in the fctors ssocited with difficulty chewing between men nd women, generlly higher mong women, with toothche stnding out. The results suggest tht the impct of orl helth conditions vries ccording to sex. self-reporting questions. b However, the self-reported number of teeth hs been shown to be vlid mesure in other contexts. 8 Another limittion of the study could be tht it is not possible to generlize it to pply to other contexts, s Florinópolis hs better living nd helth cre conditions tht most Brzilin cities. b High internl vlidity ws identified, s the estimtes of the IBGE for sex, ge nd income for the dult popultion of Florinopolis in 2009 b were shown to be similr to those in this study. Although the questions used in this study hd not been vlidted for Brzil, strong point ws using questions tht hd been used in other ACKNOWLEDGEMENTS To the Brzilin Institute of Geogrphy nd Sttistics (IBGE) for support in the trining stge of the study; to Professor Nilz Nunes d Silv of the Deprtment of Epidemiology, Fculdde de Súde Públic, Universidde de São Pulo, for contributions to the smpling procedure; to the Municipl Helth Deprtment of Florinópolis, for ssistnce in crrying out the reserch; nd to the students from the Post-Grdute Progrms in Public Helth, Physicl Eduction nd Nutrition from the Universidde Federl de Snt Ctrin, for supervising the study.

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