Artigos

Conteúdo (article):

Consumption of Alcoholic Beverages and Abdominal Obesity: cross-sectional analysis of ELSA-Brasil

Gabrielle Guidoni Torres
Universidade Federal do Espirito Santo - UFES – Programa de pós graduação em Saúde Coletiva.
gabrielleguidoni@gmail.com - https://orcid.org/0000-0003-3091-4076
Jordana Herzog Siqueira
Universidade Federal do Espirito Santo - UFES – Programa de pós graduação em Saúde Coletiva.
jo_herzog@hotmail.com - https://orcid.org/0000-0003-0116-7411
Oscar Geovanny Enriquez Martinez
Universidade Federal do Espirito Santo - UFES – Programa de pós graduação em Saúde Coletiva.
ndoscar.enriquez@gmail.com https://orcid.org/0000-0003-4561-122X
Taísa Sabrina Silva Pereira
Nutrition Science, Department of Health Sciences, University of the Americas Puebla
taisa.silva@udlop.mx - https://orcid.org/0000-0002-5922-7424
Jorge Gustavo Velásquez Meléndez
Universidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Enfermagem Materno-Infantil e Saúde Pública.
guveme@ufmg.br- https://orcid.org/0000-0001-8349-5042
Bruce Bartholow Duncan
Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Departamento de Medicina Social.
bbduncan@ufrgs.br - https://orcid.org/0000-0002-7491-2630
Alessandra Carvalho Goulart
Hospital Universitário da Universidade de São Paulo, Hospital Universitário da Universidade de São Paulo, Clinical and Epidemiological Research Center
alecgoulart@yahoo.com.br - https://orcid.org/0000-0003-1076-5210

Maria Del Carmen Bisi Molina
Universidade Federal de Ouro Preto UFOP – Programa de pós graduação em Saúde e Nutrição. Universidade Federal do Espirito Santo - UFES – Programa de pós graduação em Saúde Coletiva.
mdcarmen2007@gmail.com - https://orcid.org/0000-0001-8746-5860


Objective: To analyze the association between alcohol consumption and abdominal adiposity in adults.
Methods: Cross-sectional study conducted at baseline data from ELSA-Brasil (2008- 2010). The sample consisted of 15,065 civil servants from six education and research institutions (35 to 74 years old, both sexes). In a face-to-face interview, sociodemographic data, lifestyle, and consumption of alcoholic beverages (doses/week) were collected. Anthropometric measurements were taken according to standard procedures. To identify central adiposity by measuring waist circumference (WC) and waist-to-hip ratio (WHR), the cutoff points recommended by the World Health Organization were used. Poisson regression models adjusted for potentially confounding variables were tested.
Results: About 40% of the sample had elevated WC and WHR. The probability of having elevated WC was 5% and 3% higher in the most exposed group of beer consumption (fifth quintile) in men and women when compared to the reference group [PR= 1.05 (95% CI 1.02-1.08) and PR= 1.03 (95% CI 1.00-1.07)]. A higher probability of having a high WHR was also found among the highest beer consumers (fifth quintile) [PR= 1.03 (95% CI 1.00-1.07) in men and PR= 1.10 (95% CI 1.04-1.15) in women]. No association was found between the consumption of wine and spirits with WC and WHR.
Conclusion: A greater number of doses/week of alcoholic drink increased the probability of occurrence of high WC and WHR, with the beer contribution being more important.

Keywords: Obesity, Abdominal obesity, Alcohol Drinking, Waist circumference, Waist-to-hip ratio.

INTRODUCTION
Obesity is an important public health problem and has been gaining prominence in the global epidemiological scenario. Its prevalence has increased significantly worldwide in recent decades(1) and it is believed that the determinants of excess weight comprise a complex set of biological, behavioral, environmental, social, and economic factors. In addition to being considered a disease, obesity is also an important risk factor for the development of numerous adverse health conditions(2), as abdominal fat has a major contribution to determining cardiovascular risk(3),(4) and to metabolic alterations(5),(6). In this sense, waist circumference (WC) seems to better explain obesity-related health risk than body mass index (BMI)(7).
Several factors are associated with abdominal obesity, such as age, gender, race/color, socioeconomic conditions, and behavioral variables related to lifestyle(8),(9), among which is included the consumption of alcoholic beverages(10),(11). Although this consumption represents a common and ancient habit in many societies(12), recent meta-analyses(13),(14) have shown that the use of alcohol, regardless of the quantity, represents a risk to health.
Worldwide, around 2 billion people consume alcoholic beverages per year, which corresponds to approximately 40% of the world population over 15 years of age(12). In Brazil, the annual consumption of alcohol per capita was estimated at 8.7 liters of pure alcohol per adult per year, a quantity above the world average (6.2 liters)(12).
Alcohol is obtained through the fermentation of carbohydrates present in some foods and provides 7.1 kcal/g to the body, although it is a different energy source due to its toxicity. There is evidence that excessive consumption of alcoholic beverages can produce an increase in fat deposits in the abdominal region via alcohol metabolism(15). As alcohol cannot be stored in the body, it is quickly metabolized, changing other metabolic pathways, including lipid oxidation, favoring the body\'s fat storage, with deposition preferentially in the abdominal area(16).
Several cross-sectional studies have evaluated the association between alcohol consumption and abdominal obesity, but the results are still inconclusive, especially due to the wide methodological variation found in the literature on the analysis of the frequency and amount of ethanol consumed, in addition to the variables used in the adjustments of the statistical models. Although studies have found a null or negative association between alcohol consumption and abdominal obesity (17),(18),(19) others have shown that beer consumption is positively associated with abdominal obesity and that wine can be a protective factor (11),(20),(21).
Given this scenario, the aim of this study was to analyze the association between alcohol consumption and abdominal adiposity in Brazilian adults.

METHODS
Study design and population
This is a cross-sectional study carried out with baseline data (2008-2010) from the Longitudinal Study of Adult Health (ELSA-Brasil), comprising 15,105 public servants, active and retired, between 35 and 74 years of age, of both sexes, from six higher education institutions located in six Brazilian states (São Paulo, Minas Gerais, Bahia, Rio Grande do Sul, Rio de Janeiro, and Espírito Santo). The main objective of ELSA-Brasil was to investigate, first, the incidence and then the determinants of chronic non-communicable diseases in the Brazilian population, with a focus on cardiovascular diseases and diabetes. The general characteristics of the cohort were previously published (22).
The participants, on a previously scheduled day, went to the Research Center (RC) in the morning for clinical, biochemical, and interview examinations. General information on measurement and clinical examinations can be found in a previous publication(23). Participants who answered the alcohol consumption assessment questionnaire and who had complete anthropometric and sociodemographic data at baseline were considered for analysis. Thus, participants who did not have data on BMI (n=26), WC (n=12), and hip circumference (HC) (n=2) were excluded from this analysis. The final sample consisted of 15,065 participants.

Variables of interest
Anthropometric data
Body measurements (weight, height, WC, and HC) were measured according to standardized procedures(24). All anthropometric measurements were taken with the participants fasting and with an empty bladder. Body weight was measured with the participant barefoot, wearing a standard uniform over underwear. An electronic scale (Toledo®, model 2096PP) was used, with a capacity of 200 kg and an accuracy of 50 g. Height was measured with a wall stadiometer (Seca®, Hamburg, FRG) with a precision of 1 mm, affixed to a smooth wall and without a baseboard. The individual was barefoot, leaning his head, buttocks, and heels against the wall and with his gaze fixed on the horizontal plane. Height was checked during the inspiratory period of the respiratory cycle. From the weight and height data, the BMI (body weight divided by the height squared - kg/m²) was calculated and the WHO criteria were used to classify the nutritional status.
WC was measured with the participant in an upright position, breathing normally, with feet together, the upper part of the garment (shirt) raised and arms crossed in front of the chest. The measurement was taken with an inextensible measuring tape at the midpoint between the iliac crest and the lower edge of the last costal arch. High WC was identified when greater than or equal to 94 and 80 cm, respectively, for men and women. HC was measured at the greatest prominence of the buttocks and from these measurements, the waist-hip ratio (WHR) was calculated. Elevated WHR was identified when ≥ 1 and ≥ 0.85, respectively, for men and women. The variables WC and WHR were categorized according to the cutoff points recommended by the World Health Organization(25), thus defining high WC and WHR, which were the dependent variables of the study.

Alcohol consumption
The consumption of alcoholic beverages was reported through structured questionnaires with closed questions, carried out at each RC of ELSA-Brasil, to determine the types of alcoholic beverages (beer, wine, and spirits - cachaça, vodka, and whiskey). The frequency (daily, weekly, monthly) and the amount of consumption in mL/day were also determined(26).
The classification of a unit was established for the different alcoholic beverages considering: a glass of red or white wine (120 mL), one can/long neck beer (350 mL) or one 620 mL beer bottle (two doses). For distilled beverages, 50 mL were considered for a dose of cachaça, vodka, or whiskey.
Thus, each type of beverage (beer, wine, and spirits) and all alcoholic beverages (sum) were classified into dose/week and, subsequently, this consumption in dose/week was divided into quintiles for all analyses.

Covariates
Sociodemographic
Sociodemographic variables were collected through a standardized questionnaire in an interview carried out at each RC of ELSA-Brasil. Age was categorized into 4 groups (35-44 years, 45-54 years, 55-64 years, and 65-74 years). Race/skin color was self-reported, categorized as white and non/white (brown, black, yellow, and indigenous). Education was categorized as incomplete elementary school, complete high school, and college/graduate. The per capita family income was calculated based on the total net income of the family in Brazilian reais, in the past three months, and divided by the number of people who depend on the income to live and subsequently subdivided into tertiles.
Lifestyle Variables
Regarding smoking, the variable was categorized as “ex-smoker”, “current smoker”, and “never smoked”. To measure the level of leisure-time physical activity, the long version of the International Physical Activity Questionnaire (IPAQ) was used, validated for Brazil(27), in the leisure physical activity and commuting physical activity domains. The physical activity variable was recorded in minutes/week and subdivided into weak, moderate, and strong.

Statistical analysis
The chi-square test was used to assess the difference in proportions. The association between dependent variables (high WC and WHR) and alcohol consumption quintiles (independent variable) was analyzed using Poisson models (PR and 95% CI), adjusted for age, per capita income, BMI, smoking, and physical activity.
The criteria used to select the adjustment variables in the model were the biological and theoretical plausibility assessed using the DAG, not including the colliding variables, and applying the minimum adjustment model and the statistical criterion (p≤0.20 in the bivariate analysis). As education and per capita income are collinear, only one was chosen.
The significance level for all tests was p < 0.05. Data were analyzed using the Statistical Package for Social Sciences – SPSS 17.0 [SPSS Inc., Chicago, IL, USA].

RESULTS
A total of 15,065 participants were evaluated (45.6% men and 54.4% women) with a mean age of 52 years (SD ± 9.0) and about 40% of the sample had high WC and WHR. The consumption of alcoholic beverages was observed in almost half of the individuals studied, with beer being the most consumed beverage in both sexes, followed by distilled beverages for men and wine among women. Men consumed, on average, twice as much beer and spirits in doses/week when compared to women. Mean wine consumption in servings/week also differed among men (3.6 servings/week in men vs. 2.8 servings/week in women) (data not shown in tables). When analyzing the distribution of the sample according to the classification of WC and WHR, statistical significance was observed for all sociodemographic and lifestyle variables analyzed (Table 1).
Higher prevalence of WC was observed in individuals between 45 and 54 years of age, who reported practicing weak physical activity, who had a high level of education (higher education/graduate) and who reported not being smokers, in both sexes. In men, high WC is associated with overweight, white race/color, and last tertile of per capita income, while in women an association with obesity, non-white race/color, and lower tertile of per capita income was observed. Higher WHR prevalence was found in participants who practiced weak physical activity, in both sexes. In men, high WHR was associated with age (55 to 64 years), obesity, complete high school, white race/color, former smokers, and the highest tertile of per capita income. In women, age (45 to 54 years), overweight, higher education/graduate level, non-white race/color, non-smokers, and the lowest tertile of per capita income were associated (Table 1).
Among men, the consumption quintiles (dose/week) of wine (p=0.002), beer (p<0.001), and all alcoholic beverages analyzed (p>0.005) were associated with high WC. Among women, the association was found only for beer (p<0.001) and all alcoholic beverages analyzed (p=0.004). Regarding WHR, among men, the consumption quintiles (dose/week) of all alcoholic beverages analyzed (p<0.001), wine (p=0.004), and beer (p<0.001) and, among women, beer (p<0.001) and all alcoholic beverages analyzed (p<0.001), were associated with high WHR (Table 2).
After adjustment for confounding variables, the probability of having high WC was 5% and 3% higher in the most exposed group of beer consumption (fifth quintile of doses/week) in men and women when compared to the reference group [PR=1.05 (95% CI 1.02-1.08) and PR=1.03 (95% CI 1.00-1.07), respectively]. A higher probability of having a high WHR was also found among the highest beer consumers (fifth quintile of doses/week) [PR=1.03 (95% CI 1.00-1.07) in men and PR=1.10 (95% CI 1.04-1.15) in women]. No association was found between the consumption of wine and distilled beverages with high WC and WHR (Tables 3 and 4).

DISCUSSION
About 40% of the sample had high WC and WHR and almost half reported consuming alcoholic beverages. Beer being the most consumed beverage in both sexes, followed by distilled beverages for men and wine among women. Beer consumption was associated with high WC and WHR in men and women, after adjustment for confounding variables.
Beer consumption was associated with WC and WHR, both in men and women. In Brazil, Ferreira et al. (2008), in a cross-sectional study with 1,749 men, blood donors, showed that the prevalence of inadequacy of both WC and WHR linearly increased with the amount of alcohol ingested(28). A study carried out with data from the Nutrition and Health Survey (PNS) identified that the prevalence of high WHR among men was associated with a higher daily amount of beer and there was no association with the consumption of distilled beverages. The prevalence of high WHR increased with age in both sexes and was more pronounced in women over 50 years old(29).
A systematic review addressed the relationship between beer consumption and abdominal obesity, through the assessment of WC and WHR, in cross-sectional and experimental studies. The findings showed positive associations in men, but inconsistent data in women(30). These results are explained by the difference in the consumption of alcoholic beverages between genders, with a higher consumption among men(31).
In this scenario, most studies related to the consumption of alcoholic beverages treat men and women separately due to the difference between metabolism and consumption(32), with the largest proportion of men being excessive drinkers (5 doses or more on one occasion in the last 12 months)(33). In epidemiological studies, the association between alcohol consumption and body weight varies according to sex. Therefore, first-pass gastric metabolism is reduced in women and the volume of distribution of an alcohol dosage is lower in women. Due to the greater body fat mass, women obtain a higher blood alcohol concentration after ingesting a defined dosage of alcohol than men(15).
The prevalence of overweight and obesity in this sample was higher than that found in the Brazilian population in general(34). Unlike the present study, a survey conducted by Pinho and collaborators with individuals 25 to 59 years of age in the State of Pernambuco identified a higher prevalence of abdominal obesity in females and especially from the third decade of life onwards, in the lowest level of education, in addition to higher consumption of alcoholic beverages in men when compared to women(8).
Although other studies have shown that light and moderate alcohol consumption represents protection against increased WC and WHR and overweight(35,36,37), in this study we did not verify this association, as a comparison was not made between non-drinkers and the quintiles of alcohol consumption. A case-control study conducted in the United States showed lower percentages of abdominal adiposity among those who consumed alcoholic beverages compared to those who did not, and in women, abdominal adiposity tended to decrease with the increase in beverage consumption. The study identified that in addition to the amount of alcohol consumed, the pattern of consumption can affect the distribution of body fat(38).
A British study with 7,735 men, 40 to 59 years of age, observed that the consumption of alcoholic beverages was positively associated with the means for BMI, WC, and WHR. The results showed greater effects on WHR and WC than on BMI. Despite this, the variables were not significant for the types of beverages separately(11). It is important to mention that high consumption of alcoholic beverages increases the risk of exceeding the recommended daily energy intake. In the long term, daily energy intake that exceeds daily energy expenditure is the driving force for weight gain. Alcohol can represent from 5 to 10% of the energy ingested by adults, being a significant component of the diet(39).
It is important to emphasize that there is no consensus on the effect of alcohol consumption and changes in anthropometric parameters, which may show both positive, negative, and null associations(31). In the present study, an association was found for high WC and WHR with beer consumption, which can be explained by the predominant beer consumption among Brazilians(25). Furthermore, as beer is consumed in larger quantities, it provides greater energy intake when compared to other types of alcoholic beverages, which can influence a greater accumulation of fat.
In this context, the pattern of drinking and eating is crucial, that is, whether alcohol is added to usual food sources or whether alcohol replaces energy from the usual diet has a different impact. Furthermore, the composition of the food to which alcohol is added is of great relevance. Correct assessment of this consumption behavior in epidemiological studies is not possible. The absolute quantity and frequency of alcoholic beverage consumption determine the metabolic pathway (via alcohol dehydrogenase - ADH - or via microsomal ethanol oxidation - MEOS -) of alcohol degradation and thus interactions with energy metabolism, as well as another physiological system(15), (40), (41). The ADH pathway is responsible for greater energy release and occurs in social drinkers and MEOS is more frequently used in heavy drinkers. The liver is a determinant of both lipid and alcohol metabolism, since lipid metabolism does not occur to give preference to alcohol, there is a positive energy balance of fats and their consequent accumulation, that is, weight gain(15).
The study has some limitations, among which is the cross-sectional design. As the participants were not followed up, it is not possible to establish a cause-and-effect relationship between the outcomes and alcohol consumption. Another limitation is the data collection instrument, which, as a self-report questionnaire, can overestimate or underestimate the consumption of alcoholic beverages, such as the consumption of distilled beverages that can be omitted because of the harmful effect on health, in addition to having its consumption stigmatized for being more consumed by chronic alcoholics. However, it is a type of data collection widely used in large epidemiological studies.
Since obesity has a multifactorial determination, it is indeed complex to assess the independent influence of alcohol consumption and the risk of abdominal adiposity. Epidemiological studies are important to showing an effect of this consumption on the vulnerability of increased WC and WHR. For future studies on this association, it is important to evaluate the relationship between the individuals\' diet and alcohol consumption. Although it is known that the energy contribution of alcoholic beverage consumption is considerable in the diet, it is important to understand the contribution of other foods in the genesis of abdominal adiposity.

CONCLUSION
An association was found between beer consumption and inadequacy of WC and WHR in men and women. It is possible to identify the relevance of the results of this study for a better understanding of the impact of alcohol consumption in the context of public health, since alcohol is an important risk factor for health and its consumption has been increasing, especially among younger people. This fact can greatly contribute to the early increase in cardiovascular risk, with the reduction of consumption being a challenge for public health policies.



REFERENCES

1. Abarca-Gómez L, Abdeen ZA, Hamid ZA, Abu-Rmeileh NM, Acosta-Cazares B, Acuin C, et al. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet [Internet]. 2017;390(10113):2627–42. Available from: http://10.0.3.248/s0140-6736(17)32129-3
2. Romdhani A. Apovian CM. Obesity: definition, comorbidities, causes, and burden. Am J Manag Care 2016;22(7 Suppl):176-85. 2016;X:1–21.
3. Després JP, Moorjani S, Lupien PJ, Tremblay A, Nadeau A, Bouchard C. Regional distribution of body fat, plasma lipoproteins, and cardiovascular disease. Arterioscler An Off J Am Hear Assoc Inc [Internet]. 1990;10(4):497–511. Available from: http://10.0.4.137/01.atv.10.4.497
4. Choi D, Choi S, Son JS, Oh SW, Park SM. Impact of Discrepancies in General and Abdominal Obesity on Major Adverse Cardiac Events. J Am Heart Assoc [Internet]. 2019;8(18). Available from: http://10.0.4.137/jaha.119.013471
5. Bennasar-Veny M, Lopez-Gonzalez AA, Tauler P, Cespedes ML, Vicente-Herrero T, Yañez A, et al. Body Adiposity Index and Cardiovascular Health Risk Factors in Caucasians: A Comparison with the Body Mass Index and Others. PLoS One [Internet]. 2013;8(5):e63999. Available from: http://10.0.5.91/journal.pone.0063999
6. Mitsuhashi K, Hashimoto Y, Tanaka M, Toda H, Matsumoto S, Ushigome E, et al. Combined effect of body mass index and waist-height ratio on incident diabetes; a population based cohort study. J Clin Biochem Nutr [Internet]. 2017;61(2):118–22. Available from: http://10.0.12.92/jcbn.16-116
7. Janssen I, Katzmarzyk PT, Ross R. Waist circumference and not body mass index explains obesity-related health risk. Am J Clin Nutr [Internet]. 2004;79(3):379–84. Available from: http://10.0.4.69/ajcn/79.3.379
8. Pinho CPS, Diniz ADS, Arruda IKG De, Batista Filho M, Coelho PC, Sequeira LADS, et al. Prevalência e fatores associados à obesidade abdominal em indivíduos na faixa etária de 25 a 59 anos do Estado de Pernambuco, Brasil. Cad Saude Publica [Internet]. 2013;29(2):313–24. Available from: http://10.0.6.54/s0102-311x2013000200018
9. Ferreira APDS, Szwarcwald CL, Damacena GN. Prevalência e fatores associados da obesidade na população brasileira: estudo com dados aferidos da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol [Internet]. 2019;22. Available from: http://10.0.6.54/1980-549720190024
10. Wannamethee SG, Shaper AG, Whincup PH. Alcohol and adiposity: effects of quantity and type of drink and time relation with meals. 2005;29(12):1436–44. Available from: http://10.0.4.14/sj.ijo.0803034
11. Lourenço S, Oliveira A, Lopes C. The effect of current and lifetime alcohol consumption on overall and central obesity. Eur J Clin Nutr [Internet]. 2012;66(7):813–8. Available from: http://10.0.4.14/ejcn.2012.20
12. World Health Organization. World Health Organization (WHO). Global Status Report on Alcohol and Health. Geneva: WHO; 2014. Dep Ment Heal Subst Abus Geneva [Internet]. 2014;472. Available from: https://books.google.co.in/books?hl=en&lr=&id=-juzDwAAQBAJ&oi=fnd&pg=PA1&dq=WHO.+(1997).+Tobacco+or+Health:+a+global+status+report+(Geneva,+World+Health+Organization).+Substance+Abuse+Department&ots=sRZFYqG1xz&sig=FB9zrNNiBxYkBb3ow9QEPhxwPmM&redir_esc=y#v
13. Griswold MG, Fullman N, Hawley C, Arian N, Zimsen SRM, Tymeson HD, et al. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet [Internet]. 2018;392(10152):1015–35. Available from: http://10.0.3.248/s0140-6736(18)31310-2
14. Stockwell T, Zhao J, Panwar S, Roemer A, Naimi T, Chikritzhs T. Do “Moderate” Drinkers Have Reduced Mortality Risk? A Systematic Review and Meta-Analysis of Alcohol Consumption and All-Cause Mortality. J Stud Alcohol Drugs [Internet]. 2016;77(2):185–98. Available from: http://10.0.59.184/jsad.2016.77.185
15. Suter PM, Hasler E, Vetter W. Effects of Alcohol on Energy Metabolism and Body Weight Regulation: Is Alcohol a Risk Factor for Obesity? Nutr Rev [Internet]. 2009;55(5):157–71. Available from: http://10.0.4.87/j.1753-4887.1997.tb06470.x
16. Lieber CS. Perspectives: do alcohol calories count? Am J Clin Nutr [Internet]. 1991;54(6):976–82. Available from: http://10.0.4.69/ajcn/54.6.976
17. Haffner SM, Stern MP, Hazuda HP, Pugh J, Patterson JK, Malina R. Upper body and centralized adiposity in Mexican Americans and non-Hispanic whites: relationship to body mass index and other behavioral and demographic variables. Int J Obes [Internet]. 1986;10(6):493—502. Available from: http://europepmc.org/abstract/MED/3804566
18. Kaye SA, Folsom AR, Prineas RJ, Potter JD, Gapstur SM. The association of body fat distribution with lifestyle and reproductive factors in a population study of postmenopausal women. Int J Obes. 1990 Jul;14(7):583–91.
19. Enríquez Martínez OG, Luft VC, Faria CP de, Molina MDCB. [Alcohol consumption and lipid profile in participants of the Longitudinal Study of Adult Health (ELSA-BRASIL)]. Nutr Hosp. 2019 Jul;36(3):665–73.
20. Duncan BB, Chambless LE, Schmidt MI, Folsom AR, Szklo M, Crouse JR 3rd, et al. Association of the waist-to-hip ratio is different with wine than with beer or hard liquor consumption. Atherosclerosis Risk in Communities Study Investigators. Am J Epidemiol. 1995 Nov;142(10):1034–8.
21. Vadstrup ES, Petersen L, Sørensen TIA, Grønbæk M. Waist circumference in relation to history of amount and type of alcohol: results from the Copenhagen City Heart Study. 2003;27(2):238–46. Available from: http://10.0.4.14/sj.ijo.802203
22. Schmidt MI, Duncan BB, Mill JG, Lotufo PA, Chor D, Barreto SM, et al. Cohort profile: Longitudinal study of adult health (ELSA-Brasil). Int J Epidemiol. 2015;44(1):68–75.
23. Mill JG, Pinto K, Griep RH, Goulart A, Foppa M, Lotufo PA, et al. Afericoes e exames clinicos realizados nos participantes do ELSA-Brasil. Rev Saude Publica [Internet]. 2013;47(suppl 2):54–62. Available from: http://10.0.6.54/s0034-8910.2013047003851
24. Lohman TG, Roche AFA MR. Antthropometric standardization reference manual. Human Kinetics Books. 1988. 1988;(Il):1988.
25. WHO. World Health Organization. Obesity: preventing and managing the global epidemic: report of a Who Consultation on Obesity. Geneva; 1998. World Heal Organ [Internet]. 1998;1998. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11234459
26. Tsigos, C., & Chrousos GP. National Center for Health Statistics. Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-1994. Series 1: programs and collection procedures. Vital Health Stat: 1994. Endocrinol Metab Clin North Am. 1994;23(3)(Physiology of the hypothalamic-pituitary-adrenal axis in health and dysregulation in psychiatric and autoimmune disorders.):451–66.
27. Matsudo S, Araújo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questionário Internacional De Atividade Física (Ipaq): Estupo De Validade E Reprodutibilidade No Brasil. Rev Bras Atividade Física Saúde [Internet]. 2012;6(2):5–18. Available from: https://periodicos.ufpel.edu.br/ojs2/index.php/RBAFS/article/view/931
28. Ferreira MG, Valente JG, Gonçalves-Silva RMV, Sichieri R. Alcohol consumption and abdominal fat in blood donors. Rev Saude Publica. 2008;42(6):1067–73.
29. Machado PAN, Sichieri R. Relação cintura-quadril e fatores de dieta em adultos. Rev Saude Publica [Internet]. 2002;36(2):198–204. Available from: http://10.0.6.54/s0034-89102002000200012
30. Bendsen NT, Christensen R, Bartels EM, Kok FJ, Sierksma A, Raben A, et al. Is beer consumption related to measures of abdominal and general obesity? A systematic review and meta-analysis. Nutr Rev. 2013 Feb;71(2):67–87.
31. Sernizon Guimarães N, Silva De Aguiar Nemer A, Arlene Fausto M. Influência do consumo de álcool nas alterações antropométricas: Uma revisão sistemática. Nutr Clin y Diet Hosp. 2013;33(3):68–76.
32. Pajari M, Pietilainen KH, Kaprio J, Rose RJ, Saarni SE. The Effect of Alcohol Consumption on Later Obesity in Early Adulthood -- A Population-based Longitudinal Study. 2010;45(2):173–9. Available from: http://10.0.4.69/alcalc/agp090
33. Wolle CC, Sanches M, Zilberman ML, Caetano R, Zaleski M, Laranjeira RR, et al. Differences in drinking patterns between men and women in Brazil. Rev Bras Psiquiatr [Internet]. 2011;33(4):367–73. Available from: http://10.0.6.54/s1516-44462011000400010
34. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet [Internet]. 2014;384(9945):766–81. Available from: http://10.0.3.248/s0140-6736(14)60460-8
35. Wakabayashi I. Relationship Between Alcohol Intake and Lipid Accumulation Product in Middle-aged Men. 2013;48(5):535–42. Available from: http://10.0.4.69/alcalc/agt032
36. Janssens JP, Bruckers L, Joossens J V., Molenberghs G, Vinck J, Renard D, et al. Overweight, obesity and beer consumption Alcohol drinking habits in Belgium and body mass index. Arch Public Heal. 2001;59(5–6):223–38.
37. Traversy G, Chaput J-P. Alcohol Consumption and Obesity: An Update. Curr Obes Rep [Internet]. 2015;4(1):122–30. Available from: http://10.0.3.239/s13679-014-0129-4
38. Dorn JM, Hovey K, Muti P, Freudenheim JL, Russell M, Nochajski TH, et al. Alcohol Drinking Patterns Differentially Affect Central Adiposity as Measured by Abdominal Height in Women and Men. J Nutr [Internet]. 2003;133(8):2655–62. Available from: http://10.0.4.69/jn/133.8.2655
39. Schröder H, Morales-Molina JA, Bermejo S, Barral D, Mándoli ES, Grau M, et al. Relationship of abdominal obesity with alcohol consumption at population scale. Eur J Nutr [Internet]. 2007;46(7):369–76. Available from: http://10.0.3.239/s00394-007-0674-7
40. Frezza M, Di Padova C, Pozzato G, Terpin M, Baraona E, Lieber CS. High Blood Alcohol Levels in Women. N Engl J Med [Internet]. 1990;322(2):95–9. Available from: http://10.0.4.32/nejm199001113220205
41. Vannucchi H, Marchini JS. Nutrição Clínica. In: Vannucchi H. Alcoolismo e nutrição. Rio de Janeiro: Guanabara Koogan; 2007. p. 137-155. 2007;2007.