Níveis elevados de lipoproteína de alta densidade (HDL-C) podem ter efeitos positivos para proteção de agravos cardiovasculares, e prática regular de atividade física no tempo livre (AFTL) tem sido associada ao seu aumento. Verificar a existência de possíveis diferenças entre homens e mulheres no efeito dose-resposta na associação entre AFTL e HDL-C. Estudo transversal com dados de 13,931 participantes de ambos os sexos  do Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil). A AFTL foi mensurada por meio do International Physical Activity Questionnary (IPAQ) e classificada em quatro categorias: inativos, pouco ativos, ativos e muito ativos. O poder discriminatório da AFTL para HDL-C elevado, nas diferentes intensidades analisadas  foi testado por meio das curvas ROC. As associações, ajustadas por variáveis de confundimento entre AFTL e HDL-C foram analisadas por meio de regressão logística, estimando-se a odds ratio (OR) com intervalo de confiança (IC) de 95%. Observou-se associação positiva, com efeito dose-resposta, entre AFTL e HDL-C tanto em homens quanto em mulheres. Com relação à intensidade, apenas a atividade física vigorosa discriminou o HDL-C elevado em homens, enquanto tanto a atividade física de caminhada quanto a moderada e a vigorosa discriminaram o HDL-C elevado em mulheres. A AFTL apresenta associação positiva com gradiente dose-resposta com HDL-C; no entanto, entre os homens, a associação não é observada para aqueles classificados como pouco ativos fisicamente. Nas mulheres, tanto a intensidade da caminhada quanto a atividade física moderada ou vigorosa podem discriminar níveis de HDL-C mais altos; já nos homens, essa relação é observada apenas na intensidade vigorosa. Com isso, gera-se a transferência de colesterol, fosfolipídio e proteínas para as partículas nascentes do HDL-C.6Apesar dessas evidências, a intensidade ideal de AF para proporcionar o aumento do HDL-C precisa ser melhor esclarecida, principalmente com ênfase em possíveis diferenças entre homens e mulheres demonstrada em estudos prévios sobre AF e saúde cardiometabólica.7Em recente pesquisa feita em participantes do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil), os resultados mostraram que existe associação entre AF e maiores níveis de HDL-C, tanto em homens quanto em mulheres, Além disso, observou-se que a prática de AF em intensidade vigorosa associava-se com mudanças mais positivas nos perfis lipídicos do que apenas a duração da prática da AF. No entanto, nesse estudo, não foram analisadas possíveis diferenças entre homens e mulheres no que diz respeito à quantidade (tempo e duração) de AF.O conhecimento da existência de efeito dose-resposta entre a AF e o aumento do HDL-C irá agregar a produção de novas informações e pesquisas sobre o tema, considerando que as políticas públicas de promoção da AF poderão usar essas informações como base para novas propostas de intervenção. Além disso, apesar de a associação entre AF e os níveis de HDL-C ser conhecida, estudos que demonstrem o efeito dose-resposta no que diz respeito a possíveis diferenças entre homens e mulheres são escassos na literatura consultada sobre o assunto. Pesquisas que reafirmam a associação entre AF e HDL-C ainda são de suma importância para um melhor entendimento dessa associação, principalmente ao se analisar as possíveis diferenças entre sexos nesses achados.O objetivo do estudo foi verificar a existência de diferenças entre homens e mulheres no efeito dose-resposta na associação entre AF e HDL-C entre participantes do ELSA-Brasil.9 Até o momento, já foram coletadas informações sobre os participantes em três oportunidades: 1ª onda, de 2008 até 2010; 2ª onda, de 2012 até 2014; e 3ª onda, de 2016 até 2018. Para o presente estudo, foram selecionados todos os participantes da Onda 2 (2012-2014) que responderam aos questionários sobre AF e com dados completos relativos às variáveis envolvidas na análise, totalizando 13.931 participantes (7.607 mulheres).O ELSA-Brasil é um estudo de coorte de 15.105 servidores públicos ativos ou aposentados na faixa etária de 35 a 74 anos de seis instituições de nível superior, localizadas nas cidades de Salvador, Vitória, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre, que tem como principal objetivo investigar a incidência e a progressão de diabetes e doenças cardiovasculares e seus fatores associados , cujos detalhes metodológicos foram descritos previamente.O ELSA-Brasil foi aprovado pela Comissão Nacional de Ética em Pesquisa (CONEP) e em todos os Comitês de Ética em Pesquisa dos seis centros de investigações envolvidos. Todos os participantes assinaram o termo de consentimento livre e esclarecido, sendo garantidos o sigilo e a confidencialidade dos dados.9 capacitados a executar o protocolo do estudo em qualquer Centro de Investigação ELSA-Brasil. Realizaram-se entrevistas face a face na aplicação dos blocos de questionários para obtenção das informações sobre idade, escolaridade, renda familiar e tabagismo. Além disso, foram coletadas informações sobre medidas antropométricas de peso, estatura e circunferência da cintura. O peso corporal foi obtido pela manhã, após 8 a 12 horas de jejum e com o participante sem sapatos e com roupas leves. Foi usada balança eletrônica Toledo®, com capacidade para até 200kg. Para medida da estatura, foi usado estadiômetro da marca SECA®, com o participante posicionado de pé e seguindo rigorosamente o plano de Frankfurt. A obesidade foi identificada por meio do índice de massa corporal (IMC), aplicando-se a equação IMC = peso (kg)/altura(m)2, adotando-se o seguinte ponto de corte; obesidade = 0 se IMC <30,0 e obesidade = 1 se IMC ≥30,0.Os dados foram coletados por uma equipe de entrevistadores e aferidores treinados e certificados por um comitê de controle de qualidade,10 No ELSA-Brasil, apenas os domínios do tempo livre e do deslocamento foram avaliados. A AF foi mensurada em minutos/semana por meio da multiplicação da frequência semanal pela duração de cada uma das atividades realizadas. Para efeito desse estudo, utilizou-se apenas a atividade física no tempo livre (AFTL), com a seguinte categorização: 0 = inativo fisicamente ; 1 = pouco ativo ; 2 = fisicamente ativo ; 3 = muito ativo . Para as análises dicotomizadas, foram considerados como insuficientemente ativos aqueles classificados como inativos fisicamente e pouco ativos, e como ativos aqueles classificados como fisicamente ativos e muito ativos.Para identificação e quantificação da AF, foi utilizado o International Physical Activity Questionnary (IPAQ), versão longa, que é constituído de questões relativas à frequência e à duração de atividades físicas  desenvolvidas no trabalho, no deslocamento, nas atividades domésticas e no tempo livre.®.7 O HDL-C foi dicotomizado em <60mg/dL e ≥60mg/dL (HDL-C elevado).A coleta de sangue foi realizada após 12 horas de jejum durante a noite e centrifugadas e armazenadas em criotubos em temperatura de –80°C nos próprios centros de investigação. Como forma de garantir a qualidade e a padronização dos resultados, todas as amostras foram enviadas para processamento e análise em um laboratório central do ELSA-Brasil localizado na cidade de São Paulo. Os valores de HDL-C em mg/dL foram determinados por um método colorimétrico homogêneo usando um equipamento ADVIA 1200 SiemensPara as covariáveis, adotou-se a seguinte categorização: idade = 0, se entre 34 e 50 anos; idade = 1, se entre 51 e 60 anos; e idade = 2, se >60 anos. Para o grau de instrução, foram estabelecidos quatro estratos: 0 = fundamental incompleto; 1 = fundamental completo; 2 = médio completo; e 3 = superior completo/pós-graduação. A renda familiar foi categorizada em: até 2 salários mínimos = 0; de 2 até 8 salários mínimos = 1; de 8 até 18 salários mínimos = 2; e acima de 18 salários mínimos = 3. O tabagismo atual foi categorizado em não = 0 e sim = 1.a priori e comparadas por meio do teste Qui-quadrado. Para testar o poder discriminatório das diferentes intensidades de AFTL  para HDL-C elevado, foram utilizadas curvas ROC (Receiver Operating Characteristic).11 Utilizou-se intervalo de confiança (IC) a 95%. As associações foram analisadas por meio de regressão logística. Foram consideradas como potenciais confundidoras ou modificadoras de efeito as seguintes variáveis: idade, obesidade, tabagismo no momento da entrevista, renda familiar e escolaridade. Foram selecionadas para modelagem as variáveis que, na etapa bivariada (matriz tetracórica), apresentaram na avaliação simultânea p ≤0,05 e coeficiente de correlação rho <0,60.As medidas descritivas (proporções) foram calculadas para todas as variáveis categorizadas. As análises foram estratificadas por sexo backward , por meio de regressão logística. A análise começa com o modelo completo, seguido pela remoção um a um dos potenciais confundidores. Quando observada modificação igual ou superior a 10% na associação pontual entre AFTL e HDL-C, a variável é considerada confundidora.12 No processo de modelagem, não foram identificadas variáveis modificadoras de efeito, e a variável idade foi identificada como confundidora. Portanto, o melhor modelo para análise da associação entre AFTL e HDL-C foi aquele ajustado por idade. Foi também analisado o efeito dose-resposta na associação entre AFTL e HDL-C. Para esta análise, foram criadas variáveis DUMMIES para comparação entre o grupo de referência (inativo fisicamente) e cada um dos outros estratos da variável AF . Foi utilizado o teste de Mantel-Haenszel para testar a homogeneidade dos valores da odds ratio (OR) entre os estratos de cada variável com nível de significância de 5%. O intervalo de confiança foi estabelecido em 95%. Empregou-se o programa estatístico STATA® versão 12.0.A verificação da modificação do efeito foi feita por meio de estratificação com a observação das medidas pontuais estrato-específicas e os seus intervalos de confiança. Quando a medida pontual de um fator, em determinado estrato específico, não estava contida no intervalo de confiança do outro fator no mesmo estrato, isso indicava modificação de efeito. A análise das possíveis variáveis de confundimento foi realizada pelo procedimento Um total de 6.324 homens e 7.607 mulheres foi incluído na análise. As características da amostra estão apresentadas na Na A associação entre AFTL e HDL-C em indivíduos do sexo masculino e feminino está demonstrada na Na O estudo analisou a existência de efeito dose-resposta na associação entre AFTL e o aumento do HDL-C.É importante salientar que a população do estudo se constitui de uma coorte de voluntários de servidores públicos, que, apesar de não ser representativa da população de modo geral, apresenta um número significativo de participantes em seis capitais brasileiras, fato que representa ponto forte do estudo5 Além disso, o tempo médio de vida das partículas de HDL-C é maior em indivíduos mais ativos fisicamente, fato que pode contribuir para que o transporte reverso do colesterol possa ser maximizado.5Os mecanismos que relacionam a maior intensidade de AF e mudanças lipídicas mais positivas são explicados em função de que, durante a AF, há aumento da atividade da LPL e do catabolismo dos triglicérides que resultam na transferência de colesterol, fosfolipídios e proteínas para as partículas nascentes do HDL-C, aumentado assim sua concentração.7Neste contexto, em pesquisa realizada com participantes do ELSA-Brasil, demonstrou-se que há uma associação benéfica entre os níveis de AF e perfil lipídico favorável para HDL-C e triglicérides, tanto em homens quanto em mulheres. Além disso, observou-se que quanto maior fosse a intensidade da AF, mais positivas seriam as mudanças no perfil lipídico.13Em outro estudo, realizado com indivíduos residentes de Caxias do Sul/RS com mais de 60 anos de idade, foi demonstrado que aqueles que praticavam atividades físicas de intensidade moderada tinham níveis de LDL-c reduzidos e HDL-C aumentados quando comparados com os idosos que tinham baixos níveis de AF.14 existem poucas evidências a respeito dos mecanismos responsáveis pela redução dos níveis de LDL-c e lipoproteína de muito baixa densidade (VLDL-c). Contudo, a principal razão para elevação do HDL-C é a maior ação da LPL em resposta a exercícios físicos, fato que aumenta o catabolismo dos triglicérides e provoca a transferência de colesterol, fosfolipídios e proteínas para as partículas de HDL-C, aumentando assim a sua concentração.14 Outros estudos demonstraram que homens e mulheres ativos fisicamente têm maiores níveis de HDL-C e menores níveis de LDL-c e VLDL-c que seus pares inativos fisicamente,15 além de que, em outro trabalho realizado apenas com pessoas do sexo feminino, foi observado que há diferenças significativas nos níveis de HDL-C em mulheres com alta, moderada e baixa aptidão física, e os valores mais altos foram encontrados nas mulheres com níveis altos de aptidão física.16Segundo Matsudo et al.,É importante enfatizar também que, no nosso estudo, a intensidade de AFTL foi classificada em caminhada, AF moderada e AF vigorosa. Neste contexto, apesar de as áreas sob as curvas ROC não apresentarem valores elevados, entre os homens, apenas a AF vigorosa discrimina o HDL-C elevado, enquanto, entre as mulheres, tanto a caminhada quanto a AF moderada ou vigorosa discriminam o HDL-C elevado, demonstrando que os homens precisam de AF mais intensa para aumentar os níveis de HDL-C.Mais um aspecto importante a ser destacado, no presente estudo, é que o efeito dose-resposta entre AFTL e HDL-C tem significância tanto nas mulheres classificadas como pouco ativas quanto nas mulheres classificadas como ativas e muito ativas. Nos homens, por sua vez, a associação é observada apenas naqueles classificados como ativos e muito ativos. Desta forma, é possível compreender que eles têm a necessidade de praticar maior quantidade de AF para que tenham um resultado positivo quanto ao aumento do HDL-C.17Em recente publicação, também com dados do ELSA-Brasil, com objetivo de verificar a associação entre AFTL e AF no deslocamento com escores de risco cardiovascular, foi observado que apenas a AFTL estava inversamente associada com os eventos cardiovasculares, além de que os homens necessitavam de maior quantidade de AF (duração e intensidade), também com efeito dose-resposta, do que as mulheres para que os benefícios fossem alcançados.19 Assim, para quebrar a homeostase de repouso, os homens precisam de maior quantidade de AF (duração e intensidade) do que as mulheres, para, com isso, fazer com que possam ser ativados os mecanismos que desencadeiam a proteção cardiovascular, tais como redução da pressão arterial, redução dos níveis glicêmicos e de triglicérides, além do aumento do HDL-C  para que os benefícios possam ser alcançados. Esses resultados são de grande importância para a saúde pública, considerando que as políticas públicas de promoção de atividades físicas podem ser norteadas com base nessas informações. Sugerem-se estudos longitudinais sobre o tema para que se possa confirmar os presentes resultados. 1 In addition, higher levels of HDL-C may have benefits such as protecting against coronary artery disease, although more recent Mendelian randomization studies have suggested that HDL-C is more of a marker of cardiovascular risk than a risk factor itself.3The regular practice of physical activity (PA) shows a positive association with the increase in high density lipoprotein (HDL-C) and decrease in triglyceride levels, with inconsistent changes in low-density lipoprotein levels.4 However, in more physically active individuals, the HDL-C half-life may reach 6-7 days, while in the physically inactive, it is only 3-4.5The increase of HDL-C associated with PA practice may be explained to the extent that, during PA, there is an increase in lipoprotein lipase activity (LPL), accelerating the breakdown of triglyceride-rich lipoprotein. This generates the transfer of cholesterol, phospholipids and proteins to the nascent particles of HDL-C.6Despite this evidence, the ideal PA intensity to increase HDL-C needs to be better clarified, mainly with emphasis in possible differences between men and women as shown in previous studies about PA and cardiometabolic health.7In a recent research carried out in participants of the Longitudinal Study of Adult Health ELSA-Brasil, the results show that there is an association between PA and higher HDL-C levels, both in men and women. Moreover, it was observed that vigorous-intensity PA practice is associated with more positive changes in lipid profiles, than only the duration of PA practice, However, this study did not analyze possible differences between men and women about the quantities (time and duration) of PA.The knowledge of existence of a dose-response effect between PA and HDL-C increase will contribute to the production of new information and researches on the subject, considering that public policies for PA promotion may use this information as a basis for new intervention proposals. Moreover, although the association between PA and HDL-C levels is already known, studies that demonstrate the dose-response effect in relation the possible differences between men and women are scarce in assessed literature about the subject. Studies that reaffirm the association between PA and HDL-C are still important for better understanding of this association, mainly in the analysis of possible differences between the genders regarding these findings.The objective of study was to verify the existence of differences between the genders in the dose-response effect regarding the association between LTPA and HDL-C in the ELSA-Brasil cohort9 To date, information has been collected about participants in three opportunities: ;  and . For the present study, was selected all participants of the second wave (2012-2014) that answered questionnaires about PA and had complete data on the variables involved in the analysis, totaling 13,931 participants .The ELSA-Brasil is a cohort study of 15,105 active or retired civil servants aged 25 to 74 years from six higher education institutions located in the cities of Salvador, Vitória, Belo Horizonte, Rio de Janeiro, São Paulo e Porto Alegre, which has as its main objective to investigate the incidence and progression of diabetes and cardiovascular diseases and their associated factors , whose methodological details were previously described.The ELSA-Brasil was approved by the National Research Ethics Commission (CONEP) and by all Research Ethics Committees of the six research centers involved. All participants signed the informed consent form and the confidentiality of the data is guaranteed.9 able to perform the study protocol in any ELSA-Brasil Research Center. Face-to-face interviews were conducted when applying the blocks of questionnaires to obtain information on age, level of schooling, family income and smoking. Additionally, information on anthropometric measurements of weight, height and waist circumference was collected. Body weight was obtained in the morning, after 8-12 hours of fasting and with the participant without shoes and wearing light clothes. An electronic Toledo®scale was used to measure weight, with a capacity of up to 200 Kg. A SECA® stadiometer was used to measure height, with the participant in the standing position and strictly following the Frankfurt plan. Obesity was identified through the body mass index (BMI) by applying the equation BMI= weight (Kg)/height(m)2adopting the following cut-off points; obesity = 0 if BMI < 30.0 and obesity = 1 if BMI ≥30.0.The data were collected by a team of interviewers and raters trained and certified by a quality control committee,10 Only leisure time and commuting domains were assessed in the ELSA-Brasil. The PA was measured in minutes/week by multiplying the weekly frequency by the duration of each of the performed activities. For the study effect,, only leisure-time physical activity (LTPA) was utilized, with the following categorization: 0= physically inactive (less than 10 minutes of any PA in the week); 1= unfit ; 2= physically active ; 3= very active . For the dichotomized analyses, those classified as physically inactive and unfit were considered as insufficiently active, and those classified as physically active and very active as active.The long version of the International Physical Activity Questionnaire (IPAQ) was used for the identification and qualification of PA, which consists of questions related to the frequency and duration of physical activities  developed at work, during commuting, in domestic activities and leisure time.7 HDL-C was dichotomized at 60 mg/dL and ≥ 60 mg/dL (high HDL-C).Blood collection was performed after 12 hours of overnight fasting and centrifuged and stored in cryo-tubes at -80°C in the respective research centers. To ensure the quality and standardization of the results, all samples were sent for processing and analysis in a central ELSA-Brasil laboratory located in the city of São Paulo. The HDL-C values in mg/dL were determined by a homogeneous colorimetric method using an ADVIA 1200 Siemens equipment.The following categorization was adopted for the covariates: age=0 if between 34 and 50 years, age=1 if between 51 and 60 years and age=2 if >60years. Four strata were established for the level of schooling: 0= incomplete elementary school; 1=complete elementary school; 2= complete high school; and 3= complete higher education / postgraduation. The family income was categorized as: up to 2 minimum wages=0; from 2 to 8=minimum wages=1; from 8 to 18 minimum wages=2; and above 18 minimum wages=3. The current smoking status was categorized as no=0 and yes=1.a priori and compared using the chi-square test. ROC (Receiver Operating Characteristic) curves were used to test the discriminatory power of different LTPA intensities  for elevated HDL-C levels.11 The 95% confidence interval (95%CI) of was utilized. The associations were analyzed by logistic regression. The following variables were considered as potential confounders or effect modifiers: age, obesity, smoking at the moment of the interview, income family and level of schooling. The variables that showed p ≤ 0.05 and correlation coefficient Rho <0.60 in the simultaneous evaluation in the bivariate stage (tetrachoric matrix) were selected for modeling.The descriptive measures (proportions) were calculated for all categorized variables. The analysis was stratified by gender 12 No effect-modifying variables were identified in the modeling process, and the age variable was identified as a confounder. Therefore, the best model for the analysis of an association between LTPA and HDL-C was the age-adjusted model. The dose-response effect also analyzed the association between LTPA and HDL-C. For this analysis, variables called DUMMIES were created for comparison between the reference group  and each of the other strata of the PA variable . The Mantel-Haenszel test was used to test the homogeneity of the odds ratio (OR) values between the strata of each variable with a significance level of 5%. The confidence interval was set at 95%. The statistical program STATA® version 12.0 was used.The verification of the effect modification was performed by stratification with the observation of stratum-specific point measures and their confidence interval. Effect modification. was indicated when the point measurement of a factor, in a specific stratum, was not contained in the confidence interval of the other factor in the same stratum. The analysis of possible confounding variables was performed using the backward procedure, using logistic regression. The analysis begins with the complete model, followed by removal of the potential confounders one by one. When a change equal to or greater than 10% in the point association between LTPA and HDL-C is observed, the variable is considered to be a confounder.A total of 6,324 men and 7,607 women was included in the analysis. The sample characteristics are shown in The association between LTPA and HDL-C in male and female individuals is shown in The study analyzed the existence of a dose-response effect in the association between LTPA and HDL-C increase.Is important to point out that the study population is a cohort of civil servant volunteers, which although are not representative of the general population, represent a significant number of participants in six Brazilian capitals, a fact that embodies a strong point of the study.5 In addition, the average half-life of HDL-C particles is higher in more physically active individuals, a fact that can contribute to the maximization of the reverse transport of cholesterol.5The mechanisms that associate higher PA intensity and more positive lipid changes are explained by the fact that during the PA there is an increase in LPL activity and triglyceride catabolism, which results in the transfer of cholesterol, phospholipids and proteins to the nascent HDL-C particles, thus increasing its concentration.7In this context, in a study carried out with participants of ELSA-Brasil, it was demonstrated that there is a beneficial association between PA levels and a favorable lipid profile for HDL-C and triglycerides, both in men and women. Moreover, it was also observed that the higher the intensity of PA, the more positive the changes in lipid profile.13 levels.In another study carried out with individuals living in the municipality of Caxias do Sul, state of Rio Grande do Sul, Brazil, who were over 60 years old, it was shown that those who performed physical activities of moderate intensity had reduced LDL-C and increased HDL-C levels, when compared to older adults who had low PA14 there is little evidence regarding the mechanics responsible for the reduction of LDL-C and very low-density lipoprotein (VLDL-C) levels, but the main reason for the increase in HDL-C levels is the greater action of LPL in response to physical exercise, a fact that increase the catabolism of triglycerides and causes the transfer of cholesterol, phospholipids and proteins to HDL-C particles, thus increasing its levels.14 Other studies have shown that physically active men and women have higher HDL-C levels and lower levels of LDL-C and VLDL-C than their physically inactive pairs.15 Moreover, another study conducted only with female individuals, it was observed that there are significant differences in HDL-C levels in women with high, moderate and low levels of physical fitness, and the highest values were found in women with high levels of physical fitness.16According to Matsudo et al.,It is also important to emphasize that in our study, the intensity of LTPA was classified as walking; moderate PA; and vigorous PA. In this context, although the areas under the ROC curves do no show high values, only the vigorous PA discriminates high HDL-C in men, while in women, both the walking and moderate or vigorous PA discriminate high HDL-C levels, demonstrating that men need more intense PA to increase HDL-C levels.Another important aspect to be highlighted in this study is that the dose-response effect between LTPA and HDL-C has significance both in women classified as little active and in women classified as active and very active. In men, the association is observed only in those classified as active and very active. Therefore, it is possible to understand that they need to practice a greater amount of PA to have a positive result regarding the HDL-C increase.17In a recent publication, also with data form the ELSA-Brasil, aiming to verify the association between LTPA and PA during commuting with cardiovascular risk scores, it was observed that only LTPA was inversely associated with cardiovascular events; moreover, the men needed a greater amount of PA (duration and intensity), also with a dose-response effect, than women to reach the benefits.19 Thus, to disrupt the resting homeostasis, the men need a greater amount of PA (duration and intensity) than women, to activate the mechanisms that trigger cardiovascular protection, such as the lowering of blood pressure, reduction of glycemia and triglyceride levels, and increase in HDL-C levels (which at rest show lower levels in men).6These results can be partially explained by the fact that, in men, the resting homeostatic parameters, such as heart rate, blood pressure, glycemic levels, caloric expenditure, among others, are higher than in women, although in the postmenopausal period and with the aging process, blood pressure values may be higher in the female sex.A possible limitation can be attributed to the information on PA, since it was obtained through questionnaires, which, despite being a widely used instrument in national and international studies, may present problems, such as memory bias. In addition, is important to note that only LTPA was analyzed in the present study, and other domains of PA were not considered, such as commuting, PA at work and domestic PA. Moreover, considering this is a cross-sectional study, reverse causality may limit the strength of the results.According to the results observed in this present study, it is suggested that the practice of PA discriminates and is associated with higher levels of HDL-C in adults of both genders. It is important to emphasize that men need a greater amount of physical activities (duration and intensity) for benefits to be achieved. These results are of great importance for public health, considering that public policies for the promotion of physical activities can be guided based on this information. Longitudinal studies on the subject are suggested to confirm the present results.


To analyze the behavior of mortality from diabetes mellitus (DM) for both sexes in Mexico from 1998 to 2018, and its impact on life expectancy (LE) from 60 to 85 years of age in the three-year periods 1998–2000 and 2016–2018, compared with other causes of death, as well as to determine the loss of years of life expectancy associated with DM in each three-year period. The current study is observational and descriptive. Age-adjusted rates of mortality from DM were calculated for each sex from 1998 to 2018. Sex-specific life tables were constructed for 1998–2000 and 2016–2018, and both LE between 60 and 85 years, and years of life expectancy lost (YLELL) due to DM and selected causes between both ages were calculated. Between 1998 and 2018, the adjusted DM-resulting male mortality rate grew 55% in the population aged 60 and over, while the female mortality rate grew 20%. Between 1998–2000 and 2016–2018, male LE for 60–85 age group decreased 0.22 years, while female LE increased 0.24. In 2016-2018, DM was responsible for 1.30 YLEL among men of 60 to 85 years , and 1.24 YLEL for women , more than the other causes analyzed. The increase in mortality from DM has substantially contributed both to reduce LE of older adult men, and to slow the increase of LE among women aged 60 years and older so far this century. Thus, preventive policies should be implemented since early ages to reduce the high levels of overweight and obesity in the country and, therefore, the significant population ratio suffering from DM. In North America and the Caribbean, in 2019 it accounted for 13.8% of deaths from all causes in the age group of 20 to 79 years. In that same year, Mexico had estimated 12.8 million people suffering from DM. This figure placed it in sixth place worldwide among the countries with the highest number of adults with the disease2. In 20 years, the mortality rate from DM in Mexico rose from 43.4 to 80.1 per 100,000 inhabitants , i.e., it almost doubled3. DM has contributed as the first and second causes of death in the 45 to 64 and 65 and older age groups, respectively4.According to the World Health Organization (WHO), diabetes mellitus (DM) is among the leading causes of death on a global scale1 (an increase of 3.2 years), in Mexico the increase was only 2 years5.In fact, the growth in deaths due to non-communicable diseases (NCDs), including DM, coupled with the high rates of violent deaths, have slowed the increase of life expectancy (LE) of the Mexican population. While for the Region of the Americas, LE at birth increased from 73.6 to 76.8 between 2000 and 20166, WHO estimated that if the risk factors that most affect DM and the other three NCDs  were controlled by 2025, premature mortality would decrease by 25%. However, nations such as Mexico would have serious problems in intervening on risk factors7 and, therefore, the impact of DM on the evolution of LE would continue to be notable.In accordance with the objective known as “25 X 25” of the WHO Global Action Plan 2013–2020 for the reduction of mortality between 30 and 70 years of age8. However, there are few studies in Mexico that analyze the impact of DM on the LE of older adults in the last 20 years11.Several authors have studied the effect of mortality from DM on life expectancy, either at birth or starting in a specific age, in different countriesThus, in view of the relevance attained by DM, especially at advanced ages, the current study aims to analyze the behavior of mortality from this cause for both sexes at national level between 1998 and 2018, and the impact of DM mortality on life expectancy in the age group of 60 to 85 years in the three-year periods 1998–2000 and 2016–2018 in comparison with other causes of death. Moreover, it intends to determine the DM-associated loss of years of life expectancy in each three-year period.Cubos Dinámicos) of the General Health Information Board of the Health Secretariat12. Information on population for the years reviewed was obtained from the estimates and forecasts of the National Population Council (CONAPO)13.This is an observational and descriptive study, based on secondary sources of information and focused on the older adult population (persons of 60+ years). Mortality data were extracted from the official databases of deaths : DM; homicide; suicide; motor vehicle traffic accidents (MVA); ischemic heart disease; malignant tumors; cerebrovascular diseases; hepatic cirrhosis and other liver diseases; chronic obstructive pulmonary disease (COPD); and calorie-protein malnutrition.Using existing data on death and population, age-adjusted DM mortality rates were calculated using the direct method for both the general population and those aged 60 years and older, by sex, between 1998 and 2018. For that, DM mortality rates were initially calculated by five-year age and sex groups for each year of the period under analysis. The standard population was the total population of Mexico in 2018 by five-year age groups, to calculate the adjusted rates in the general population. The total population aged 60 years and over in Mexico in 2018 by five-year age groups was used to calculate the adjusted rates in older adult population.14, we estimated the average annual percentage change in adjusted rates and their statistical significance  by sex, for both the general population and the population aged 60 years and over, between 1998 and 2018. This indicator is a summary measure of the trend during a prespecified time interval, such as the one analyzed herein. It should be noted that joinpoint regression models, described in detail in the literature15 identify the points that disclose significant changes in the trend and, in addition, estimate the trend observed in the period of review. Therefore, they provide better fit when compared to linear regression models, which reduce the trend to a single equation.In turn, by means of the joinpoint regression analysis, using the Joinpoint software, version 4.8.0.118 software. The three-year periods of 1998–2000 and 2016–2018 were elected as these allow comparing the most recent situation in the country for which mortality information is available with that existing almost 20 years earlier, in addition to enable working with data referring exclusively to ICD-10. Likewise, the construction of triennial mortality tables intended to reduce possible random variations in mortality that could bias the trend of its behavior.Abridged life tables were also built at national level for both sexes for each of the three-year periods studied, using the EPIDAT v4.219 (described in detail in the literature21), we calculated both the temporary life expectancy (TLE) between 60 and 85 years, and the years of life expectancy lost (YLEL) between both ages . The YLEL were calculated by multiplying the ratio of persons who die between ages x y x + n in the stationary population of the life table, by means of the difference between the average number of years they could have lived from x if they had not died, and the average number of years actually lived between x y x + n by the population that dies in that age group20. Both indicators were calculated using the EPIDAT v4.218 software, assuming zero mortality between 60 and 85 years.Based on the life tables, and in accordance with Arriaga’s methodThe research protocol “Mortality by causes in Jalisco and Mexico”, source of this article, was approved by the Center for Health, Population and Human Development Studies of the University of Guadalajara and registered under the code SyP- 2015-002. The project is developed in accordance with the ethical guidelines set out in the Regulations of the General Health Law on health research in Mexico, since it was considered as “risk-free research”, in that it only works with secondary data, using documentary research techniques and methods with protected data that do not affect any individual.Deaths from DM have increased in each sex between both three-year periods studied , in a hiThis increase in deaths from DM is reflected in mortality rates: the rate more than doubles among men in general and increases by 53% in older men; in women, increases are 72% and 21%, respectively . The facAnalysis of the trend in the adjusted rates of mortality due to DM  reveals While the female rate at the beginning of the period was clearly higher than the male rate, with sharper difference in older adults, still in 2007 in the general population, and in 2012 in the older adult population, it was observed that the male rate exceeded the female rate, a trend that continued until the end of the period. In the last years of the period studied, male excess mortality from DM was higher in the general population than in the population aged 60 years and older.Other relevant causes of death in the male older adult population, such as hepatic cirrhosis, COPD and cerebrovascular diseases, experienced a significant decrease in the number of YLEL, while malignant tumors remained practically at the same level in both three-year periods. The YLEL due to caloric-protein malnutrition had the largest decrease observed in the period , while the causes of violent death studied presented an almost marginal increase in YLEL and accounted for little more than 2% of the total number of YLEL from 60 to 85 years in each three-year period.For women, YLEL between 60 and 85 years old presented an increase of just 0.24 years between 1998–2000 and 2016–2018 . In eachExcept for ischemic heart disease, where there was a slight increase in the number of YLEL between the two three-year periods, there was a significant reduction in YLEL for other major causes, such as cerebrovascular disease, hepatic cirrhosis, and COPD. This was even sharper in the case of calorie-protein malnutrition. Similarly, there was a reduction in the number of deaths due to homicide. In general, the violent deaths analyzed did not account for even 1% of the total number of YLEL in either of the two three-year periods.Finally, the analysis of YLEL due to DM by age group in the older adult population  allowed In contrast to men, the number of DM-related YLEL among women of 60 to 69 years of age reported virtually no increase in the period studied, with a moderate increase observed from the age of 70 years onward. The highest number of YLEL for each three-year period was in the 65–69 years age group. While in 1998–2000 the YLEL between 60 and 69 years accounted for about 57% of the total number of YLEL from 60 to 85 years; in 2016–2018 that ratio decreased to 52%.5, LE at age 60 has not increased in the same way in Latin America. Countries with structural base and socio-political relations similar to that of Mexico, which in 2000 reported a LE at age 60 similar to or even slightly lower than Mexico (20.1 years for men and 22.9 for women), have made greater progress in LE at that age: while in 2016 the figures showed an increase in LE at age 60 in Mexico of 0.9 years for men and 0.6 for women, in Chile the increase was 2.0 and 1.6 respectively; in Costa Rica, 2.0 and 1.7; in Colombia, 2.0 and 2.3; and in Brazil, 3.0 and 2.9.According to WHOIn accordance with the foregoing, the results found in this study reveal the stagnation of the increase in LE among Mexican older adults: the TLE between 60 and 85 years of age barely grew in the case of women and even slightly decreased for men between the three-year periods of 1998–2000 and 2016–2018.In this regard, the analysis of the YLEL by cause highlights that DM was the cause not only of the highest number of YLEL between 60 and 85 years in both sexes in each three-year period , but also the one in which YLEL had the highest rate of growth among the causes of highest mortality in older adults. This result is more transcendent in view of the above-mentioned stagnation of LE at age 60.22.These findings are undoubtedly related to the sharp increase in the adjusted mortality rate due to DM for both sexes, even sharper among men than among women, during the period studied both in the general population and among older adults. The increase in rates in Mexico for the 60+ group  was higher than that observed in countries of the continent such as Brazil and Chile between 1999 and 2015, while in others  a reduction in the rate was even observed in the same periodIn turn, the notable increase in male mortality rate due to DM is reflected in the fact that, in opposition to 1998–2000, in 2016–2018 the YLEL for men between 60 and 85 years of age due to this cause (1.30) exceeded those of women (1.24). In this sense, it is notorious that as DM-related deaths of men increase at relatively younger ages than women (between 60 and 69 years), more years of life are lost.9. In Scotland, a study carried out in a population with and without type II DM from different socioeconomic strata showed a significant reduction in life expectancy in both sexes (greater among women) and in almost all socioeconomic strata in any age segment analyzed10. In Mexico, Davila and Pardo examined the effect of DM on the change in YLEL between 1990–2000 and 2000–2010, observing 0.32 and 0.12 YLEL among women for each period, and 0.31 and 0.34 among men11. In another study comparing YLEL between 20 and 79 years in Colombia and Mexico, they found that for Colombia YLEL went from 0.35 in 1998 to 0.33 in 2007 and in Mexico, on the contrary, it increased from 0.85 to 1.123.Using different methodologies, several studies have analyzed the effect of DM on LE. A recent study in the United States estimated the YLEL for men pf 30 years of age at 0.83, and 0.89 for women, rising to 1.05 years for black womenBoth the demographic and epidemiological transitions have a clear influence on the behavior of DM reviewed in this study. Not only has the population aged 60 years and older, more prone to DM and other NCDs, notably increased, but mortality from this cause has also increased substantially. Comorbidity is not exclusive to the elderly, although in this group it increases the probability of death. The current study shows that two causes commonly associated, namely DM and ischemic heart disease, had the greatest impact on the loss of years of life in both sexes.24 as well as family and economic difficulties28, and is more acute in older adults. For the family, it means concentrating material and psychological support on the patient, and possibly direct expenses related to treatment and hospitalization costs. For countries with low to medium economic level, the burden of NCDs implies an expense that may exceed their capacity to cope with. DM-related expenses in Mexico reached 17.0 billion dollars in 20192, posing an economic and a health challenge.The risk of developing DM (frequently coupled with other NCDs) exposes the person to a series of organic complications29. At the international level, it has been found that obesity in the population aged 55 years and over is associated with a reduction in the number of years lived free of diabetes8. Regarding vigorous physical activity, the age group of 20 to 60 years engages less than 150 minutes per week is exercises29. Particularly in the 55+ group, 60.1% of men and 68.7% of women have declared to be inactive30.Two of the main risk factors for developing DM have had a particularly high impact in Mexico: obesity and physical inactivity. Excess weight is observed in the population over 60 years of age, especially in the 60–69 years age group, where 54% of the population is overweight and 14.3% is obese31, local studies in Mexico have shown that changes are observed after an intervention, but the optimal reduction in clinical and biochemical parameters in diabetic patients is not achieved33. In addition to the so-called “Hawthorne effect”, it should be considered that changes in behavior are not linear, comprising at least two components: life choices and life opportunities. The individual’s range of freedom to choose is confronted with his or her life situation. Structural constraints may be dominant. Attach all responsibility to the individual may be inappropriate and unfair.The importance of lifestyle change in addressing the DM epidemic has been considered. Although educational interventions may succeed in the medium term34 and has improved in recent years35, clearly supporting the consistency of the data used. Even so, it is worth noting that there may be difficulties in the coding of DM as a basic cause of death, mainly because individuals with the disease die from complications associated with cardiovascular or renal diseases, for example, which could to some extent distort the true dimension of the problem36. This situation would deserve, per se, more detailed investigation. This, however, goes beyond the objectives of the present study.The current study may have some limitations, mostly related to the collection of mortality data. The coverage and quality of mortality registries in Mexico has been considered satisfactory by the Pan American Health Organization21 as it facilitates the interpretation of the results, and fully explains the changes in the TLE.Regarding the method used to calculate the YLEL, the use of the assumption of zero mortality among three possible options does not alter the meaning of the results and is recommended by literatureNotwithstanding the aforementioned limitations, the results found allow a reasonable approximation of the recent behavior of mortality from DM in older adults in Mexico. Considering the implications of this research’s findings that DM is substantially reducing the LE of the Mexican population, especially in older adults and more sharply among men, it would be advisable to implement (or intensify) preventive measures against DM from an early age, at the mere suspicion of its potential onset, and not only focusing on those who have been diagnosed. In this regard, effective public policies should be generated to promote healthy lifestyles, such as those aimed at reducing the consumption of sugar-sweetened beverages, and those that favor an adequate diet in schools.Likewise, it is essential to allow patients to express their points of view, from a proactive and co-responsible standing, giving the opportunity to identify the social determinants that restrict the possibility of permanent changes in their lifestyles, to seek possible solutions and thus timely avoid deterioration of health, onset of comorbidities and increased costs of care, both for the population and for the health system. 1. En América del Norte y el Caribe representó en 2019 el 13,8% de las muertes por todas las causas entre los 20 y 79 años. En ese mismo año, en México se estimó que 12.8 millones de personas padecían DM, cifra que lo colocó en el sexto lugar a nivel mundial entre los países con mayor cantidad de adultos con la enfermedad.2 En un lapso de 20 años, la tasa de mortalidad por DM pasó en México de 43,4 a 80,1 por 100 000 habitantes (1.563.896 decesos entre 1998 y 2018), esto es, casi se duplicó3. La DM ha contribuido como primera y segunda causa de muerte en los grupos de edad de 45 a 64 y de 65 y más años respectivamente4.De acuerdo con la Organización Mundial de la Salud (OMS), entre las primeras causas de muerte en escala global figura la diabetes mellitus (DM)1 , en México el aumento fue solo de 2 años5.De hecho, el crecimiento de las defunciones por enfermedades no transmisibles (ENT), obviamente la DM entre ellas, sumado a las elevadas tasas de muertes violentas, han ralentizado el incremento en la esperanza de vida (EV) de la población mexicana. Mientras que para la Región de las Américas la EV al nacer pasó de 73,6 a 76,8 entre 2000 y 20166, la OMS estimó que, si para el año 2025 se controlaran los factores de riesgo que más afectan a la DM y otras tres ENT , la mortalidad prematura disminuiría en un 25%. Sin embargo, naciones como México tendrían serios problemas para incidir sobre los factores de riesgo7 y, por tanto, el impacto de la DM en la evolución de la EV continuaría siendo notable.De acuerdo con el objetivo conocido como “25 X 25” del Plan de Acción Global 2013–2020 de la OMS para la reducción de mortalidad entre los 30 y 70 años de edad8; no obstante, en México son escasos los estudios que analizan el impacto de la DM en la EV de los adultos mayores en los últimos 20 años11.Diversos autores han estudiado el efecto de la mortalidad por DM en la esperanza de vida, ya sea al nacer o a partir de una edad exacta determinada, en diferentes paísesAsí, en atención a la relevancia alcanzada por la DM, sobre todo en edades avanzadas, en el presente estudio se pretende analizar el comportamiento de la mortalidad por dicha causa para ambos sexos a nivel nacional entre 1998 y 2018 y el impacto de la mortalidad por DM sobre la esperanza de vida entre los 60 y 85 años de edad en los trienios 1998–2000 y 2016–2018, en comparación con otras causas de muerte, así como determinar la pérdida de años de esperanza de vida asociados a la DM en cada trienio.12. La información sobre población para los años estudiados fue obtenida de las estimaciones y proyecciones del Consejo Nacional de Población (CONAPO)13.Este es un estudio observacional y descriptivo, basado en fuentes secundarias de información y centrado en la población adulta mayor (personas de 60 años y más); los datos sobre mortalidad se extrajeron de las bases de datos oficiales de defunciones (Cubos Dinámicos) de la Dirección General de Información en Salud de la Secretaría de SaludEn particular, la DM y las otras nueve causas de muerte estudiadas, consideradas entre las principales causas de defunción para la población de 60 años y más, se clasificaron de acuerdo con la Clasificación Internacional de Enfermedades (CIE-10): DM; homicidio; suicidio; accidentes de tráfico de vehículo motor (ATVM); enfermedades isquémicas del corazón; tumores malignos; enfermedades cerebrovasculares; cirrosis hepática y otras enfermedades del hígado; enfermedad pulmonar obstructiva crónica (EPOC); y desnutrición calórico-proteica.Con los datos existentes sobre defunciones y población se calcularon mediante el método directo las tasas de mortalidad por DM ajustadas por edad tanto para la población general como para aquella de 60 años y más, por sexo, entre 1998 y 2018. Para ello, se calcularon inicialmente tasas de mortalidad por DM por grupos quinquenales de edad y sexo para cada año del lapso estudiado. Se consideró como población estándar a la población total de México en 2018 por grupos quinquenales de edad, para el cálculo de las tasas ajustadas en la población en general, y a la población total de 60 años y más de México en 2018 por grupos quinquenales de edad, para el cálculo de las tasas ajustadas en la población adulta mayor.joinpoint”, utilizando el programa Joinpoint, versión 4.8.0.114, se estimó el cambio porcentual anual promedio de las tasas ajustadas y su significación estadística , por sexo, tanto para la población general como para la de 60 años y más, entre 1998 y 2018. Este indicador es una medida resumida de la tendencia durante un intervalo preestablecido, como el analizado en este estudio. Cabe señalar que los modelos de regresión “joinpoint” descritos en detalle en la literatura15 identifican los puntos que revelan cambios significativos en la tendencia y, además, estiman la tendencia observada en el período analizado, por lo que brindan un mejor ajuste si se comparan con los modelos de regresión lineal, que reducen la tendencia a una sola ecuación.A su vez, mediante el análisis de regresión “18. La elección de los trienios 1998–2000 y 2016–2018 respondió a la posibilidad de comparar la situación más reciente del país para la que hay información disponible de mortalidad con la existente casi 20 años atrás, además de poder trabajar con datos referidos solo a la CIE-10. Asimismo, la construcción de tablas de mortalidad trienales tuvo la finalidad de reducir posibles variaciones aleatorias de la mortalidad que pudieran distorsionar la tendencia de su comportamiento.Asimismo, se construyeron para ambos sexos tablas de mortalidad abreviadas a nivel nacional para cada uno de los trienios estudiados, empleando para ello el programa EPIDAT v4.219 , se calcularon tanto la esperanza de vida temporaria (EVT) entre 60 y 85 años como los años de esperanza de vida perdidos (AEVP) entre las dos edades . Los AEVP se calcularon multiplicando la proporción de personas que fallecen entre las edades x y x + n en la población estacionaria de la tabla de mortalidad, por la diferencia entre el número medio de años que podrían haber vivido desde x en caso de no fallecer y el promedio de años realmente vividos entre x y x + n por la población que muere en ese grupo de edad20. Ambos indicadores fueron calculados mediante el programa EPIDAT v4.218, asumiendo una mortalidad nula entre 60 y 85 años.A partir de las tablas de mortalidad, y de acuerdo con el método de ArriagaEl protocolo de investigación “Mortalidad por causas en Jalisco y México”, de donde emana este artículo, fue aprobado por el Centro de Estudios en Salud, Población y Desarrollo Humano de la Universidad de Guadalajara y registrado con la clave SyP- 2015–002. El proyecto se desarrolla en concordancia con los lineamientos éticos expuestos en el Reglamento de la Ley General de Salud en materia de investigación para la salud de México, pues se consideró como “investigación sin riesgo”, en tanto solo se trabaja con datos secundarios, utilizándose técnicas y métodos de investigación documental con datos protegidos que no afectan a ningún individuo.Las defunciones debidas a DM se han incrementado en cada sexo entre ambos trienios estudiados , en una Este aumento de las muertes a causa de la DM se refleja en las tasas de mortalidad: la tasa más que se duplica entre los hombres en general y se incrementa en 53% en los hombres adultos mayores; en las mujeres, los incrementos son de 72% y 21% respectivamente . Que lasEl análisis de la tendencia de las tasas ajustadas de mortalidad por DM  revela eMientras que la tasa femenina al inicio del período fue claramente mayor a la masculina, con una diferencia más marcada en los adultos mayores, ya en 2007 en la población general y en 2012 en la población adulta mayor se observó que la tasa masculina rebasó la femenina, tendencia que se mantuvo hasta el final del período. En los últimos años del lapso estudiado, la sobremortalidad masculina por DM fue mayor en la población general que en la población de 60 años y más.En la Otras causas de muerte relevantes en la población adulta mayor masculina, como la cirrosis hepática, las EPOC y las enfermedades cerebrovasculares, experimentaron un importante descenso en el número de AEVP, mientras que los tumores malignos se mantuvieron prácticamente al mismo nivel en ambos trienios; los AEVP por desnutrición calórico-proteica tuvieron la mayor disminución observada en el período , mientras que las causas de muerte violenta estudiadas presentaron un aumento casi marginal en los AEVP y apenas representaron algo más del 2% del total de AEVP entre 60 y 85 años en cada trienio.En el caso de las mujeres, la EVT entre 60 y 85 años mostró un aumento de apenas 0,24 años entre 1998–2000 y 2016–2018 . La DM eSalvo las enfermedades isquémicas del corazón, en las cuales se observó un ligero incremento en el número de AEVP entre ambos trienios, en el resto de las causas con un mayor peso, como las enfermedades cerebrovasculares, cirrosis hepática y las EPOC, se apreció una importante reducción en los AEVP; esta fue más marcada todavía en el caso de la desnutrición calórico-proteica. Asimismo, se redujeron los AEVP por homicidio. En general, las muertes violentas analizadas no representaron en ninguno de los dos trienios ni el 1% del total de AEVP.Finalmente, el análisis de los AEVP a causa de la DM por grupos de edad en la población adulta mayor  permitióA diferencia de los hombres, en las mujeres la cifra de AEVP por DM entre 60 y 69 años prácticamente no aumentó en el período estudiado, observándose un incremento moderado a partir de los 70 años; el mayor número de AEVP se ubicó en ambos trienios en el grupo de 65 a 69 años. Mientras en 1998–2000 los AEVP entre 60 y 69 años representaron alrededor del 57% del total de AEVP entre 60 y 85 años, en 2016–2018 esa proporción se redujo a 52%.5, la EV a los 60 años no ha aumentado de forma similar en Latinoamérica; países con una base estructural y de relaciones socio-políticas similares a México, que en el año 2000 reportaban una EV a los 60 años semejante o incluso ligeramente inferior a la de México , han logrado mayores avances en la EV a esa edad: mientras que en 2016 las cifras reflejaban un incremento de la EV a los 60 años en México de 0,9 años para los hombres y 0,6 para las mujeres, en Chile el aumento fue de 2,0 y 1,6 respectivamente; en Costa Rica de 2,0 y 1,7; en Colombia, de 2,0 y 2,3; y en Brasil, de 3,0 y 2,9.De acuerdo con la OMSEn concordancia con lo anterior, los resultados obtenidos en el presente estudio revelan el estancamiento del incremento de la EV entre los adultos mayores mexicanos: la EVT entre 60 y 85 años apenas creció en el caso de las mujeres e inclusive se redujo ligeramente para los hombres entre los trienios 1998–2000 y 2016–2018.En tal sentido, el análisis de los AEVP por causas pone de relieve que la DM fue la causa que no solo provocó la cifra más elevada de AEVP entre 60 y 85 años en ambos sexos en cada trienio (representando la quinta parte de todos los AEVP por los hombres y casi la cuarta parte por las mujeres en 2016–2018), sino también aquella en la que los AEVP tuvieron un mayor ritmo de crecimiento entre las causas que ocasionan mayor mortalidad en los adultos mayores. Este resultado es más trascendente en vista del estancamiento previamente mencionado de la EV a los 60 años.22.Estos hallazgos sin dudas están relacionados con el marcado crecimiento de la tasa ajustada de mortalidad por DM para ambos sexos –más acentuado en los hombres que en las mujeres- en el lapso estudiado, tanto en la población en general como entre los adultos mayores. El incremento de las tasas en México para el grupo de 60 y más  fue superior al observado en países del continente como Brasil y Chile entre 1999 y 2015, mientras que en otros  incluso se observó una reducción de la tasa en el mismo períodoA su vez, el notable incremento de la tasa de mortalidad masculina por DM se ve reflejado en que a diferencia de 1998–2000, en 2016–2018 los AEVP por los hombres por esta causa entre 60 y 85 años  superaran a los de las mujeres ; en tal sentido, es notorio el hecho de que al incrementarse las defunciones de hombres por DM en edades relativamente más tempranas que las mujeres (entre 60 y 69 años), se dejan de vivir más años.9; en Escocia, una investigación realizada en población con y sin DM tipo II de diferentes estratos socioeconómicos evidenció una reducción importante en la esperanza de vida en ambos sexos (mayor entre las mujeres) y en casi todos los estratos socioeconómicos en cualquier segmento de edad analizado10; en México, Dávila y Pardo examinaron el efecto de la DM en el cambio de la EVT entre 1990–2000 y 2000–2010 observando 0,32 y 0,12 AEVP en mujeres en cada periodo y 0,31 y 0,34 en hombres11; en otro estudio comparando los AEVP entre 20 y 79 años en Colombia y México, encontraron que para Colombia los AEVP pasaron de 0,35 en 1998 a 0,33 en 2007 y en México, por el contrario, aumentaron de 0,85 a 1,123.Diversos estudios han analizado con diferentes metodologías el efecto de la DM en la EV; un estudio reciente en Estados Unidos estimaba en 0,83 los AEVP por los hombres a los 30 años, y 0,89 para las mujeres, cifra que se elevaba hasta 1,05 años para las mujeres negrasTanto la transición demográfica como la epidemiológica tienen franca influencia sobre el comportamiento de la DM analizado en esta investigación. No solo ha aumentado notablemente la población de 60 años y más, más propensa a padecer DM y otras ENT, sino que la mortalidad por dicha causa se ha incrementado de forma sustancial. La comorbilidad no es exclusiva de la gente mayor, aunque en ese grupo incrementa la probabilidad de muerte. El presente estudio evidencia que dos causas comúnmente asociadas, DM y enfermedades isquémicas del corazón, tuvieron la mayor repercusión en la pérdida de años de vida en ambos sexos.24, así como dificultades de índole familiar y económica28 y se agudiza en los adultos mayores. Para la familia significa concentrar ayuda material y psicológica en el enfermo y posiblemente un gasto directo invertidos en tratamiento y hospitalización. Para países con un nivel económico de bajo a medio la carga de ENT implica un gasto que puede rebasar su capacidad para afrontarlo. El gasto relacionado con la DM en México ascendió a 17.0 mil millones de dólares en 20192, lo cual significa un reto económico y sanitario.El riesgo de desarrollar DM (frecuentemente junto a otras ENT a la vez), expone a la persona a enfrentar una serie de complicaciones orgánicas29. A nivel internacional, se ha encontrado que la obesidad en población de 55 años y más está asociada con una reducción en el número de años vividos libre de diabetes8. En cuanto a la actividad física vigorosa, entre los 20 y 60 años se practica menos de 150 minutos por semana29, y en particular en el grupo de 55 y más años, 60,1% de hombres y 68,7% de mujeres se han declarado inactivos30.Dos de los principales factores de riesgo para desarrollar DM han tenido particularmente un alto impacto en México: obesidad e inactividad física. En el grupo de población mayor a 60 años hay exceso de peso, sobre todo en el grupo de 60 a 69 años, donde 54% de la población presenta sobrepeso y 14,3 % obesidad31, estudios locales en México han evidenciado que tras una intervención se aprecian cambios pero no se llega a la disminución óptima en parámetros clínicos y bioquímicos en pacientes diabéticos33. Además del llamado “Efecto Hawthorne”, hay que tomar en cuenta que las modificaciones en el comportamiento no son lineales; este tiene al menos dos componentes: las elecciones de vida y las oportunidades en la vida; el rango de libertad del individuo para elegir se confronta con su situación en la vida. Las restricciones estructurales pueden ser dominantes. Asignar toda la responsabilidad a la persona puede llegar a ser inapropiado e injusto.Se ha ponderado la importancia en el cambio de estilo de vida para enfrentar la epidemia de DM. Aunque intervenciones educativas pueden ser exitosas a mediano plazo34 y ha mejorado en años recientes35, lo cual sin dudas avala la consistencia de los datos utilizados. Aun así, vale señalar que pudieran existir dificultades en la codificación de la DM como causa básica de defunción, relacionadas en particular con el hecho de que las personas que padecen la enfermedad fallecen por complicaciones asociadas con enfermedades cardiovasculares o renales, por ejemplo, lo que pudiera en cierta medida distorsionar la verdadera dimensión del problema36. Esta situación merecería, en sí misma, una investigación más detallada, la cual rebasa los objetivos del presente estudio.El presente estudio puede tener algunas limitaciones, referidas sustancialmente a la recolección de datos de mortalidad. La cobertura y calidad de los registros de mortalidad en México ha sido considerada como satisfactoria por la Organización Panamericana de la Salud21 en tanto facilita la interpretación de los resultados y explica en su totalidad los cambios en la EVT.En lo concerniente al método empleado para el cálculo de los AEVP, el uso del supuesto de mortalidad nula entre tres posibles opciones no altera el sentido de los resultados y es recomendado por la literaturaNo obstante las limitaciones enunciadas previamente, los resultados hallados permiten una aproximación razonable al comportamiento reciente de la mortalidad por DM en adultos mayores en México. Dadas las implicaciones que tienen los hallazgos de esta investigación , sería recomendable la implementación (o intensificación) de medidas preventivas contra la DM desde edades tempranas, ante la mera sospecha de su potencial aparición, y no solo centradas en quienes han sido diagnosticados. En tal sentido, es necesaria la generación de políticas públicas eficaces que incidan en fomentar estilos de vida saludables, como pueden ser aquellas encaminadas a disminuir el consumo de bebidas azucaradas y las que favorezcan una alimentación adecuada ya desde las escuelas.Igualmente, es fundamental permitir al paciente que manifieste sus puntos de vista, desde una posición pro-activa y corresponsable, dando oportunidad a identificar los determinantes sociales que limitan la posibilidad de cambios permanentes en su estilo de vida, buscar posibles soluciones y evitar así oportunamente el deterioro de la salud, las comorbilidades y el incremento de los costos de la atención, tanto para la población como para el sistema sanitario.