Functional Capacity, Lipid Profile, and Associated Factors in Older Adults Living in Urban and Rural Areas

This study aimed to analyze the relationship between sociodemographic and lifestyle variables, functional strength, aerobic capacity, and lipid profile of older adults living in urban and rural areas. For this purpose, 208 older adults were evaluated (132 living in rural areas and 73 living in urban areas). Sociodemographic data were collected, and functional strength, aerobic capacity, and lipid profile of older adults living in the southern region of Brazil were evaluated. Only total cholesterol and LDL cholesterol were associated with place of residence (p < 0.05), and living in the countryside was associated with low aerobic capacity (p=0.010). The use of medication (OR = 3.01; p=0.012) and smoking (OR = 0.30; p=0.027) were the only variables that explained aerobic performance, regardless of place of residence. In conclusion, place of residence is not a factor that, alone or in combination with other conditions, affects the functional performance or lipid profile of the older adult population.


Introduction
Population aging is a global and multidimensional phenomenon that takes place in a close relationship with the environment in which older adults are inserted, involving factors such as family and community life, culture, lifestyle, and economic condition. As a natural consequence of this phenomenon, there is a concomitant increase in the incidence of chronic diseases and length of time living with diseases such as diabetes, hypertension, dementia, and dyslipidemia [1]. In this context, several studies around the world have focused on rural populations. *ese studies have mainly assessed aspects such as falls [2], psychological aspects [3], hypertension [4], functional capacity [5] dyslipidemias [6], and quality of life [7,8].
*e relationship between changes in the lipid profile and risk of mortality from cardiovascular diseases is well established in the scientific literature. An active lifestyle shown to be closely related to lower mortality from cardiovascular diseases and physical activity or exercise significantly reduces the overall risk for all cardiovascular diseases [9].
In the literature to which we had access, we did not find studies assessing the profile of older adults according to their place of residence and taking aspects into consideration such as functional strength and aerobic capacity. Considering that functional strength is associated with greater autonomy in activities of daily living (ADL) and that aerobic capacity is a good indicator of general physical fitness, assessing how these factors affect the lipid profile depending on the place of residence will allow us to identify in which dimensions policies and actions aimed at promoting the health of older adults living in rural or urban areas should be similar or different.
In his doctoral thesis, Mattos [10] assessed rural and urban older adults in the state of São Paulo and highlighted that the practice of high-intensity physical activity was more prevalent in the former (72.7%), while moderate or lowintensity physical activity prevailed among urban older adults (36.2 and 11.2%, respectively). In this study, dyslipidemia was more prevalent among older adults living in rural areas. Zhou et al. [6] also showed higher prevalence of dyslipidemia in the rural population. However, functional assessments were not performed in these studies, and older adults were not included in one of them.
Several factors that influence the health of older adults may be aggravated by the place of residence. For example, access to healthcare services is less accessible to the rural population due to the distance, poor conditions of the road or absence thereof, poor transportation, and so on [11].
In view of the abovementioned aspects, rural and urban older adults may have differences in the lipid profile. Nevertheless, several social and economic factors or even factors related to the level of physical fitness may be more relevant for the lipid profile than the place of residence itself. *ese multiple factors have unique interactions in different countries or different regions of the same country. *us, determining to what extent factors associated with the place of residence (e.g., lifestyle, sociodemographic characteristics, and functional performance) influence the lipid profile of older adults is essential to plan strategic actions and public policies with the potential to positively affect the lipid profile and, consequently, the risk for the development of cardiovascular diseases.
Population aging is a global reality and one of the greatest current public health challenges, especially when it comes to the identification of potential conditions for the prevention of chronic noncommunicable diseases or reduction of associated problems in the older adult population. Sociodemographic factors and lifestyle may affect older adults who reside in urban and rural environments differently. In this sense, this study aimed to analyze the relationships between sociodemographic and lifestyle variables, functional strength, aerobic capacity, and lipid profile of urban and rural older adults.

Method
A cross-sectional descriptive study was conducted in the period from November 2019 to March 2020, where older adults living in the city of São Miguel do Oeste, located in the far western region of the state of Santa Catarina, Brazil, were assessed.

Study Participants.
We randomly selected 205 older adults from 13 urban neighborhoods (N � 132) and seven rural locations or rural settlements in the city (N � 73). *e sample was equalized by place of residence, sex, and age group (60 to 79 years and 80 years or more). Participants who did not obtain the minimum score in the Mini-Mental State Examination (MMSE) for their level of education [12,13] and those who were not found at home in up to three visits on nonconsecutive days were excluded from the study.

Procedures
2.2.1. Cognitive Assessment. *e Mini-Mental State Examination (MMSE) was used to assess global cognitive functioning. *is test investigates orientation to time and space, attention, language, constructive skills, and immediate/ delayed memory [12,14]. *e cutoff points suggested by Bertolucci et al. [13] were used (13 points for illiterates, 18 points for individuals with low or medium level of education, and 26 points for individuals with high level of education). Older adults who did not obtain the minimum scores (adjusted for education level) were not included in the sample.

Sociodemographic Aspects and Lifestyle.
For the collection of sociodemographic and lifestyle data, an interview was carried out using a questionnaire adapted from the study by Morais et al. [15]. Sections 1, 3-5 of the instrument were used, addressing the following aspects: (i) Personal information: sex, skin color, place of birth, length of residence in the urban and/or rural area, marital status, schooling, religion, retirement, retirement amount, economic assistance from third parties, and previous occupation (ii) Housing conditions: type of construction, piped water, water source, sewage, existence of bathrooms, existence of electricity, garbage collection, existence of household goods, greater expenditure of money in the last 6 months, means of communication used, and means of transport used by older adults (iii) Family composition: assessed whether the research participant lived alone or with a companion and detailed who the companions were (spouse, child, caregivers, etc.). (iv) Health conditions and lifestyle: self-perception of health, comparison with the health of other people of the same age, use of medication, weekly physical activity, smoking habits, number of meals per day, use of alcohol, type of diet, hydration, hearing problems, vision problems, presence of teeth, presence of dental prosthesis, number of falls in the last year, fracture sites, and self-reported health problems

Assessment of Functional Strength and Aerobic
Capacity. *e chair stand test [16] and the two-minute step test [17] were used to assess the functional strength and aerobic capacity, respectively.

Collection and
Analysis of Blood Samples. All blood samples were collected at homes of the participants on previously scheduled dates and times. *e participants were informed about the necessary requirements for the collection of blood samples on the scheduled date. On the day before collection, each participant was contacted again to confirm the collection and review the procedures. *e samples were collected after a fasting period of 10 to 12 hours. A new date was scheduled in the case of individuals who were not fasting at the time of collection. Nine milliliters of blood were collected from each participant in a vacuum system with a clot activator. *e entire blood collection procedure was performed by trained and qualified professionals, thus respecting all biosafety procedures recommended for this purpose. Immediately after collection, all samples were properly stored and sent to the Biochemical Chemistry Laboratory of the Western University of Santa Catarina, São Miguel do Oeste Campus. A biochemical analyzer was used for the analysis of the lipid profile (total cholesterol, triglycerides, HDL cholesterol, and LDL cholesterol) (Cobas C111, Roche Diagnostics ™ , Switzerland).

Data Collection.
All data collection was performed at homes of the participants in the period from November 2019 to March 2020 (data collection was stopped due to the COVID-19 pandemic). After the initial contact made by community health workers, home visits were scheduled. In this first visit, the researcher explained all procedures of data collection and the objectives of the study. *e older adults who agreed to participate in the research were assessed by the Mini-Mental State Examination, and when they obtained the minimum score according to their level of education, they signed the informed consent form, agreeing to participate in the research. After that, each participant filled out a form addressing sociodemographic data and family composition, housing conditions, and lifestyle. *en, they performed the chair-stand test and, 10 minutes later, the two-minute step test. *e collection of blood samples was scheduled for a later date, considering the logistics of collection at the participant's home, which aimed at the collection of the largest number of variables possible at the same time and viability of the samples, considering the adequate storage time before the analyses.

Ethical
Aspects. *is study was conducted in accordance with the recommendations of resolution number 466/2012 of the National Health Council, which establishes the guidelines and regulatory standards for research involving human beings. *is project was approved by the Human Research Ethics Committee (protocol number 3,624,101).

Data Analysis.
A double-entry spreadsheet database was built using the Microsoft Excel ® program. Descriptive statistics were used to present the results through absolute (n) and relative (%) frequencies. *e analyses of associations between the variables of the functional tests and the lipid profile were performed using the chi-square test (χ 2 ). Logistic regression was used to estimate the influence of variables on the behavior of functional tests and biochemical factors. *e statistical procedures were performed using STATA (version 16.0), adopting a significance level of p ≤ 0.050.

Results
*e sample consisted of 205 older adults, predominantly living in the urban area (64.4%). *e sociodemographic characteristics, housing conditions, health conditions, and lifestyle aspects of the participants are shown in Table 1.
*e performance in the chair stand test and the twominute step test (Table 2) showed that only aerobic capacity had a statistically significant association with place of residence (x 2 � 9.25; df � 2; p � 0.010). Regarding the lipid profile (Table 3), only total cholesterol (x 2 � 6.52; df � 2; p � 0.038) and LDL cholesterol (x 2 � 9.35; df � 3; p � 0.025) showed a statistically significant association with place of residence.
*e logistic regression (Table 4) showed that changes in total cholesterol were explained by sex (OR � 1.99; p � 0.032), while changes in LDL cholesterol were explained by the number of full meals (OR � 2.75; p � 0.026). *e other analyzed factors (housing, age group, skin color, marital status, medication use, smoking, alcoholism, physical activity, fluid intake, hearing problems, vision problems, dental problems, falls, and performance in the chair stand test and the two-minute step test) did not show statistical significance to be included in the model (p > 0.05).
*e analysis of the factors that influenced the performance in the chair stand test and two-minute step test, only medication use, and smoking were identified as factors significantly affecting (p < 0.05) the performance in the twominute step test [17]. None of the analyzed factors showed statistical significance to be included in the regression model to explain the performance in the chair stand test (p > 0.05).

Profile of Participants According to the place of Residence.
Of the older adults who participated in this study, most were female (urban � 67.4%, rural � 56.2%), aged between 60 and 69 years (urban � 78.0%, rural � 89.0%), and declared to be literate (urban � 94.0%, rural � 90.4%). All residences visited had piped water and electricity, and 87.9% of urban older adults and 91.8% of the ones from rural areas lived in their own homes. Only 3% of rural and 5% of urban older adults were not retired or pensioners.
*e higher number of women in our study in relation to men can be explained by longer life expectancy of women resulting from their lower exposure to risk factors and their adherence to health care, as well as to the existence of health services and preventive and therapeutic programs aimed specifically at women. Practically all over the world, women live longer than men do. *is is a phenomenon called the feminization of aging. *is advantage of women over men can partially be attributed to the differences in diseases that affect these two groups. *e rate of lethal diseases has shown to be higher among men. Nonfatal but disabling diseases and   Journal of Aging Research chronic diseases, including arthritis and hypertension predominate among women, while ischemic heart disease prevails in men. Older women have shown higher morbidity rates than older men, but mortality rates are lower in women than in men for the same diseases [18]. As for working conditions, only 13.5% of the older adults from urban areas were still working, while in rural areas, 53.4% were still engaged in their work activities. *e profile of rural properties in the far western region of Santa Catarina, characterized by small family farms based on the cultivation of tobacco, corn, fruit crops, and dairy products [19], is a determining factor for older adults to continue working in the field, even after retirement.
Living alone was not common among urban and rural older adults (22.7% and 5.5%, respectively); 66.7% of older adults from urban areas and 43.5% of those from rural areas lived with their spouses. *e participants from both the rural and urban areas believed that their health was good or excellent (58.3% and 60.3%, respectively). Conversely, comparative health was rated as good or excellent by more than 70% of older adults (urban � 74.2%, rural � 76.7%). Among the study participants, more than 82% used medications (urban � 78.9% and rural � 82.2%).
Both urban and rural older adults reported relatively high alcohol consumption, especially the latter (urban-� 40.9%, rural � 53.4%). Conversely, eating three full meals and drinking more than five glasses of water per day prevailed in both urban (85.6% and 70.5%, respectively) and rural (82.2% and 80.8%, respectively) settings.
Studies show that the greater the exposure to smoking, the worse the physical health. Also, higher levels of nicotine dependence are associated with lower quality of life scores, higher levels of disability, and lower life expectancy [20,21]. In this study, smoking was reported by 17.8% of the older adults living in rural areas and only 3% of those living in urban areas. *ese data indicate the need for actions to combat smoking, especially among older adults living in rural areas.
Problems related to vision and dentition were the most prevalent (vision problems: urban � 87.1%, rural � 76.7%; total absence of teeth: urban � 56.1%, rural � 82.2%). Hearing problems were reported by 18% and 49.3% of the older adults living in rural and urban areas, respectively.
Although the number of falls reported by the older adults in the last 12 months was low (urban � 21.2%, rural � 10.1%), it is important to note that the lack of physical exercise (reported as "no practice of physical exercise") was quite high, especially in the rural population (urban � 56.1%, rural � 82.2%). On the other hand, some studies, such as Ferretti et al. [22], state that rural older adults remain more active than urban older adults because physical activities performed by these two groups can differ in the type and intensity of activity. In rural environments, occupational activities prevail, predominantly agricultural work (family and extensive or subsistence agriculture), domestic activities, livestock rearing, plant extraction, beekeeping, among others. In turn, the activities practiced by older adults in urban areas are more related to the use of technologies (e.g., cell phones and TV), with a consequent tendency to lower intensity of work and domestic activities.
Although this study did not assess the level of physical activity using the International Physical Activity Questionnaire (IPAQ), our data showed, in general, a predominance of older adults with low performance in functional tests. Low aerobic performance was predominant among rural older adults: 74% of them did not practice any kind of physical activity. Ribeiro et al. [7] found a different result, with a predominance of active older adults in rural areas, while insufficiently active or sedentary individuals prevailed in urban areas. *is contrast reflects a set of characteristics peculiar to each region. Although the study by Ribeiro et al. [7] also included older adults from the Palmas region of the state of Paraná in Southern Brazil, the characteristics of rural areas differ from those of the present study. In another study with rural and urban older adults in the city of Florianópolis, Santa Catarina, the former remained in work for a longer time than the latter [23]. In a study conducted in Peru, Hernandez-Huayta et al. [24] demonstrated that most of the older population of rural areas still works, which is associated, in this case, with the need to maintain income and the short time analyzed in the study.

Functional Strength and Aerobic Capacity.
One of the main findings of the present study was the fact that the place of residence was not a determining factor for performance in tests of functional strength and aerobic capacity. In the chair stand test, 66.8% of the older adults had low functional strength performance, although the prevalence of this condition was not associated with the place of residence. Low performance in the two-minute step test was more prevalent in rural than that in urban areas (rural � 89%, urban � 74%). Low performance in the two-minute step test reflected the practice of physical exercises in the rural older adult population, since 74% of them said that they did not practice any type of physical exercise.
A sedentary lifestyle is a factor that increases the risk of developing chronic diseases, including hypertension. It is known that a sedentary lifestyle is related to a reduction in maximal aerobic capacity, muscle strength, motor responses, and overall functional capacity [25], which is compatible with reduced ability to perform ADLs. *e fact that, in this study, 57.5% and 72% of the rural and urban older adults, respectively, showed low performance in functional strength is worrisome, considering the relationship between low functional performance and falls in this population. *e regression analysis showed that the place of residence, sex, and all sociodemographic or lifestyle factors analyzed in this study did not predict functional strength performance. *is reinforces the importance of regionalized studies, since the set of factors that potentially affect functional strength performance may differ considerably in different contexts.
Although low performance in the two-minute step test was more prevalent among rural older adults, the place of residence was not a predictor of aerobic performance. *e only predictors of aerobic capacity were the use of medications and smoking. In this study, the use of medications decreased the aerobic performance of older adults by three times in relation to nonconsumption of medicines. *is result may be explained by the fact that the use of medications is associated with a greater number of comorbidities and chronic diseases, conditions often associated with worse general physical fitness. Conversely, the practice of smoking was associated with a 70% reduction in aerobic capacity. *e deleterious effects of smoking on aerobic fitness are well established by science; however, it should be noted that smoking is also an independent risk factor for cognitive decline [26] and has important deleterious effects on the cardiac structure and function [27].
In the study by Silva et al. [28], the level of physical activity was inversely associated with medication use. A Brazilian population-based study by Bertoldi [29] with 3,182 individuals who answered the IPAQ-short version and selfreported consumption of medications found that sedentary individuals consumed 23% more medications than more active individuals. *ese data differ from those used in this study. We found that urban older adults reported using more medications and showed higher adherence to weekly physical exercises (62.1%), while only 26% rural older adults reported practicing some type of physical exercise. Lower practice of physical exercise in the rural population may be related to factors such as less access to exercise centers such as gyms or groups of older adults who come together for this purpose and the large distance among properties which make social gatherings and even access to residences difficult.

Lipid Profile of Rural and Urban Older Adults.
Among the lipid profile, only total cholesterol and LDL cholesterol were associated with place of residence. Desirable or optimal total cholesterol and LDL cholesterol values were more prevalent in urban than in rural older adults (total cholesterol: rural � 60.3%, urban � 74.2%; HDL cholesterol: rural � 60.3%, urban � 72.7%).
Among the studied variables, only sex explained the behavior of total cholesterol according to the regression analysis. In this study, being male increased the risk of having altered total cholesterol by two times regardless of place of residence. In turn, LDL cholesterol concentrations were explained only by the number of full meals the older adults had per day, regardless of sex and place of residence.
Each additional full meal taken per day (two or three) increased the chance that the surveyed older adults had altered LDL cholesterol levels by 2.7.
Although the adequate distribution of meals is important, the quality of food, observing the appropriate proportions of macronutrients and micronutrients, is a determining factor for the prevention and control of dyslipidemia. An adequate diet is one of the first-choice treatments for dyslipidemia and other metabolic diseases because it promotes the reduction of weight and visceral fat, thus directly affecting the lipid profile. A study by Jacondino et al. [30] showed that 66.1% of the surveyed older adults were classified as nonadherent to lifestyle modification proposals, especially regarding dietary practices. According to these authors, the main reasons for nonadherence to the diet were: "lack of persistence" (38.9%) and "perceived context" [17]. *is last justification was related to the palatable aspects of food; that is, the older adults do not think that whole foods are tasty, opting for white flour foods, preferring sugar over the sweetener, and consuming more salt than recommended. *ey said that they do not find food appetizing if these elements are absent or reduced. *e lack of persistence was also justified by other reasons (15.3%), including lack of financial resources or because they considered the measure unnecessary. In addition, psychological factors may be relevant in eating behaviors, particularly among individuals diagnosed with depression, since the presence of some manifestations of this mood disorder, such as appetite distortion, feelings of worthlessness, low selfesteem, fatigue, and loss of energy and motivation, may affect treatment adherence.
Dyslipidemia is a risk factor for noncommunicable diseases (NCDs), including cardiovascular disorders, which are responsible for 35% of the deaths in older adults aged 80 years or more and around 32% among older adults aged between 60 and 79 years [31]. In this sense, dietary education strategies, including food choices, preservation, and preparation forms, among others, should be implemented among the older adult population to enhance the effects of good eating habits on the lipid profile.
In this study, low performance in the two-minute step test and low prevalence of the practice of physical exercise, especially among older adults in rural areas, constitute a risk factor for dyslipidemia. *ey are, consequently, important risk factors for cardiovascular diseases. In this context, it is important to underline the importance of actions to promote the practice of physical exercise, especially among older adults living in rural areas, considering that the regular practice of physical exercise combined with adequate nutrition improves the lipid profile and reduces the risk of development of chronic diseases, especially cardiovascular diseases.
In general, our data highlighted that the promotion of the regular practice of physical exercise among older adults regardless of their place of residence is urgently needed, and although eating habits were not within the scope of this research, there is important evidence pointing to the need to include nutritional education strategies for this population.

Conclusion
*e analysis of the collected data allows us to conclude that regardless of the place of residence (urban or rural), the use of medication worsens aerobic performance by three times, while smoking reduces aerobic capacity by 70%. Each full meal per day increases the chance of having increased LDL cholesterol levels by 2.7 times among older adults.
*erefore, the place of residence is not a factor that, alone or in combination with other conditions, affects the functional performance or the lipid profile of the older adult population.

Data Availability
Data from the present study can be made available upon request from the corresponding author

Additional Points
*is study adds the following to the existing knowledge: most of the studies comparing health and physical fitness aspects of rural and urban older adults compare the rural population with large urban centers. *is study showed that the place of residence is not a determining factor to predict the motor performance and lipid profile of older adults when evaluating small countryside cities. Regardless of the place of residence (urban or rural), (i) the use of medication worsens aerobic performance by three times and smoking reduces aerobic capacity by 70%; (ii) each full meal per day increases the chance of older adults having increased LDL cholesterol levels by 2.7 times. What are the key implications for public health interventions, practice, or policy? (i) *ere are no effective strategies for preventing dyslipidemia and promoting physical exercise among older adults regardless of place of residence. (ii) Health promotion and disease prevention actions must be based on data that take into account knowledge about the local reality. (iii) Data from studies that assess locoregional characteristics are critical to the design of global health promotion policies for the older adult population.

Conflicts of Interest
*e authors declare that there are no conflicts of interest.