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Background and objectives: Most studies concerning the relationship between depression and chronic physical disease focused on a single physical disease and did not consider multimorbidity or depression severity. We aimed to characterize this relationship considering chronic physical diseases’ type and number, and depression severity. Methods: We undertook a cross-sectional study, using data from a phone household panel, with “chronic physical disease” as the exposure and “depression” as the outcome. The sample is representative of the Portuguese population. Adjusted logistic and multinomial regression analyses were conducted between depression presence/severity and chronic physical disease presence/type/number. Odds ratio and 95% confidence intervals adjusted for possible confounders were calculated. Results: 1027 individuals were included. Of the population, 8.9% had depression and 72.1% had at least one chronic physical disease. There was no statistically significant relationship between depression and physical disease in general (OR=1.68 [CI95%:0.55, 5.15]), but there was with allergy (OR=2.08 [CI95%:1.02, 4.25]) and COPD (OR=3.04 [CI95%:1.21, 7.61]). The risk of depression was smaller with two physical diseases (vs. three or more, OR=0.32 [CI95%:0.15, 0.68]). Conclusions: A relationship between COPD, allergy and a higher number of physical diseases and depression was observed. Clinicians should be aware of these relationships. Evaluating the presence of depression in people with multimorbidity, COPD and allergy is recommended. This study is included in the project ECOS COVID-19, which is funded by Portuguese national funds through the FCT - Foundation for Science and Technology, I.P., within the scope of project n°130 of the 1st edition of the special support Research 4 COVID-19. info:eu-repo/semantics/publishedVersion

Vaccination strategies to control COVID-19 have been ongoing worldwide since the end of 2020. Understanding their possible effect is key to prevent future disease spread. Using a modelling approach, this study intends to measure the impact of the COVID-19 Portuguese vaccination strategy on the effective reproduction number and explore three scenarios for vaccine effectiveness waning. Namely, the no-immunity-loss, 1-year and 3-years of immunity duration scenarios. We adapted an age-structured SEIR deterministic model and used Portuguese hospitalisation data for the model calibration. Results show that, although the Portuguese vaccination plan had a substantial impact in reducing overall transmission, it might not be sufficient to control disease spread. A significant vaccination coverage of those above 5 years old, a vaccine effectiveness against disease of at least 80% and softer non-pharmaceutical interventions (NPIs), such as mask usage and social distancing, would be necessary to control disease spread in the worst scenario considered. The immunity duration scenario of 1-year displays a resurgence of COVID-19 hospitalisations by the end of 2021, the same is observed in 3-year scenario although with a lower magnitude. The no-immunity-loss scenario presents a low increase in hospitalisations. In both the 1-year and 3-year scenarios, a vaccination boost of those above 65 years old would result in a 53% and 38% peak reduction of non-ICU hospitalisations, respectively. These results suggest that NPIs should not be fully phased-out but instead be combined with a fast booster vaccination strategy to reduce healthcare burden.

Background Participation rates in health surveys, recognized as an important quality dimension, have been declining over the years, which may affect representativeness and confidence in results. The Portuguese national health examination survey INSEF (2015) achieved a participation rate of 43.9%, which is in line with participation rates from other similar health examination surveys. The objective of this article is to describe strategies used by the local teams to increase participation rates and to solve practical survey problems.Methods After a literature search, informal interviews were conducted with 14 public health officials from local health examination teams, regional and central authorities. 41 of the local staff members also filled in a short questionnaire anonymously. The interviews and self-administered questionnaires were analysed using mixed methods, informed by thematic analysis.Results The local teams believed that the detailed manual, described as a "cookbook for making a health examination survey", made it possible to maintain high scientific standards while allowing for improvising solutions to problems in the local context. The quality of the manual, supported by a series of training workshops with the central research and support team, gave the teams the confidence and knowledge to implement local solutions. Motivation and cohesion within the local teams were among the goals of the training process. Local teams felt empowered by being given large responsibilities and worked hard to incite people to attend the examination through a close and persuasive approach.Local teams praised their INSA contacts for being available for assistance throughout the survey, and said they were inspired to try harder to reach participants to please their contacts for interpersonal reasons.Conclusions The theory of organizational improvisation or bricolage, which means using limited resources to solve problems, was useful to discuss and understand what took place during INSEF.A detailed manual covering standard procedures and face-to-face workshops, including role-play, were vital to assure high scientific standards and high participation rates in this health examination survey. Close contacts between the central team and local focal points in all regions and all survey sites were key to accommodating unexpected challenges and innovative solutions.

Human biomonitoring has become a pivotal tool for supporting chemicals’ policies. It provides information on real-life human exposures and is increasingly used to prioritize chemicals of health concern and to evaluate the success of chemical policies. Europe has launched the ambitious REACH program in 2007 to improve the protection of human health and the environment. In October 2020 the EU commission published its new chemicals strategy for sustainability towards a toxic-free environment. The European Parliament called upon the commission to collect human biomonitoring data to support chemical’s risk assessment and risk management. This manuscript describes the organization of the first HBM4EU-aligned studies that obtain comparable human biomonitoring (HBM) data of European citizens to monitor their internal exposure to environmental chemicals. The HBM4EU-aligned studies build on existing HBM capacity in Europe by aligning national or regional HBM studies. The HBM4EU-aligned studies focus on three age groups: children, teenagers, and adults. The participants are recruited between 2014 and 2021 in 11 to 12 primary sampling units that are geographically distributed across Europe. Urine samples are collected in all age groups, and blood samples are collected in children and teenagers. Auxiliary information on sociodemographics, lifestyle, health status, environment, and diet is collected using questionnaires. In total, biological samples from 3137 children aged 6–12 years are collected for the analysis of biomarkers for phthalates, HEXAMOLL® DINCH, and flame retardants. Samples from 2950 teenagers aged 12–18 years are collected for the analysis of biomarkers for phthalates, Hexamoll® DINCH, and per and polyfluoroalkyl substances (PFASs), and samples from 3522 adults aged 20–39 years are collected for the analysis of cadmium, bisphenols, and metabolites of polyaromatic hydrocarbons (PAHs). The children’s group consists of 50.4% boys and 49.5% girls, of which 44.1% live in cities, 29.0% live in towns/suburbs, and 26.8% live in rural areas. The teenagers’ group includes 50.6% girls and 49.4% boys, with 37.7% of residents in cities, 31.2% in towns/suburbs, and 30.2% in rural areas. The adult group consists of 52.6% women and 47.4% men, 71.9% live in cities, 14.2% in towns/suburbs, and only 13.4% live in rural areas. The study population approaches the characteristics of the general European population based on age-matched EUROSTAT EU-28, 2017 data; however, individuals who obtained no to lower educational level (ISCED 0–2) are under represented. The data on internal human exposure to priority chemicals from this unique cohort will provide a baseline for Europe’s strategy towards a non-toxic environment and challenges and recommendations to improve the sampling frame for future EU-wide HBM surveys are discussed. The HBM4EU initiative is co-financed under Horizon 2020 (grant agreement No 733032). Additional financial support for the conduct of the studies is provided by each participating country. More information on co-funding of the individual studies is provided in Supplementary Materials, Table S14. info:eu-repo/semantics/publishedVersion

This article belongs to the Special Issue Environmental Exposures and Epidemiological Studies on Maternal and Child Health Early-life exposure occurs during gestation through transfer to the fetus and later, during lactation. Recent monitoring data revealed that the Portuguese population is exposed to mycotoxins, including young children. This study aimed to develop a pilot study to assess the early-life exposure to mycotoxins through a mother-child cohort, and to identify the associated challenges. Participants were recruited during pregnancy (1st trimester) and followed-up in three moments of observation: 2nd trimester of pregnancy (mother), and 1st and 6th month of the child's life (mother and child), with the collection of biological samples and sociodemographic and food consumption data. The earlyMYCO pilot study enrolled 19 mother-child pairs. The analysis of biological samples from participants revealed the presence of 4 out of 15 and 5 out of 18 mycotoxins' biomarkers of exposure in urine and breast milk samples, respectively. The main aspects identified as contributors for the successful development of the cohort were the multidisciplinary and dedicated team members in healthcare units, reduced burden of participation, and the availability of healthcare units for the implementation of the fieldwork. Challenges faced, lessons learned, and suggestions were discussed as a contribution for the development of further studies in this area. The earlyMYCO study was funded by Foundation for Science and Technology (PTDC/DTPMEDTOX/28762/2017), by CESAM (UIDP/50017/2020+UIDB/50017/2020+LA/P/0094/2020) and by the project MYTOX-SOUTH, Ghent University Global Minds programme. info:eu-repo/semantics/publishedVersion

publicado em: Environ Health Perspect. 2021;1. https://ehp.niehs.nih.gov/doi/abs/10.1289/isee.2021.P-457 BACKGROUND AND AIM: Methylmercury (MeHg) is a toxic compound that undergoes bioaccumulation in the aquatic food chain. Predatory fish species are an important human exposure source. Portugal has the highest consumption of fishery products in the European Union (EU), above the EU and world average. The main target of MeHg is the central nervous system and the prenatal period represents a period of greatest vulnerability regarding neurodevelopmental effects on the foetus. Human biomonitoring (HBM) allows direct exposure assessment of human exposure to chemical compounds. Total mercury (THg) concentration in blood is usually considered an appropriate biomarker for estimating short-term internal exposure to MeHg in individuals with regular fish consumption. The aim of the present study was to evaluate the exposure of Portuguese women of childbearing age to MeHg through HBM. METHODS: Three hundred Portuguese women of childbearing age (25 to 44 years) were randomly selected among the participants in a cross-sectional epidemiological study carried out in Portugal (INSEF) in 2015. THg content was determined in whole blood samples by thermal decomposition and amalgamation atomic absorption spectrophotometry (TDA/AAS). RESULTS:Two samples had THg levels below LOQ (0.5 µg/L), and in the remaining (n=298), THg levels ranged from 0.6 to 35.0 µg/L. About 52% of the samples had values below 5 µg/L, a HBM value below which no adverse health effects are expected. However, 48% of samples revealed levels above 5 µg/L and therefore presented risk of adverse health effects. Blood mercury concentration values were higher in older women, in higher education level and residents in the Autonomous Region of Madeira, with statistically significant differences compared to the other groups (p

publicado em: Environ Health Perspect. 2021;1. https://ehp.niehs.nih.gov/doi/abs/10.1289/isee.2021.P-481 BACKGROUND AND AIM:The development of Human Biomonitoring (HBM) surveys is highly dependent on the cooperation and engagement of the individuals being sampled. As such, in the context of the European Human Biomonitoring Initiative (HBM4EU) an online citizen survey was conducted in Europe to gain insights into the perceptions of the population about HBM and exposure to chemicals. METHODS:The survey was undertaken between September 2020 and February 2021 and was available in the languages of all 30 HBM4EU-participating countries (EU, associated countries, Israel) through the HBM4EU website. Dissemination was done by the HBM4EU country representatives (National Hub Contact Points). RESULTS:Responses were received from 5391 participants. Around half were 35-54 years old and the majority were female, with higher education and employed. Concerning the perception of the respondents on HBM, the majority considers it should be done (81.7%), even if the chemicals are considered well managed. Most participants consider it a reliable method (84.0%) that should be performed more often (87.3%) and be more coordinated either at a European (86.2%) or at a national level (83.7%). The large majority of the respondents thinks that HBM results are important to evaluate the chemical exposure of the population (96.2%), to study the health impact of chemical exposure (96.3%) and to support the development of health policies (94.9%). The respondents also consider HBM results highly relevant to raise awareness and promote understanding of the impact of chemical exposure amongst the general population (94.3%), health professionals and policy makers. CONCLUSIONS:The use of HBM as a tool to assess human exposure to chemicals, allowing its management and health protection, was well perceived by respondents across Europe. Furthermore, the need for more studies conducted in a coordinated way was indicated. Future work should comprise population groups less represented here and should also attempt to understand how perceptions change over time. HBM4EU is funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement Nº 733032 info:eu-repo/semantics/publishedVersion

publicado em: Environ Health Perspect. 2021;1. https://ehp.niehs.nih.gov/doi/abs/10.1289/isee.2021.P-062 BACKGROUND AND AIM:Although arsenic is an element naturally present in the environment, it is highly toxic in its inorganic forms. Exposure can occur through consumption of drinking water and contaminated food. Long-term exposure was shown to be associated with negative health outcomes. Nevertheless, data on the Portuguese population’s exposure to arsenic is scarce. As such, the aim of this work was to assess the exposure to Arsenic in the Portuguese population using samples collected in the study "Exposure of the Portuguese Population to Environmental Chemicals: a study nested in INSEF 2015" (INSEF-ExpoQuim), developed as an aligned study of the European Human Biomonitoring Initiative (HBM4EU). METHODS: INSEF-ExpoQuim was an epidemiologic study nested in INSEF 2015 including 270 participants aged 28-39 years,living in Portugal for more than 12 months and able to follow an interview in Portuguese. Fieldwork was developed between June 2019 and February 2020. First morning urine samples were collected along with data on socio-demographic characteristics, living conditions and residential history, habits/lifestyle, nutrition, health, occupation and substance specific information covering nearly all exposure pathways. Procedures followed the guidelines of the HBM4EU project. Total urinary arsenic is currently being determined by inductively coupled plasma mass spectrometry. RESULTS:Preliminary results for 38 samples yielded total urinary arsenic concentrations ranging from 11 to 462 μg/L with an average of 86 ± 94 μg/L. After completion of the determination of the urinary arsenic levels for all the samples a complete analysis of the data will be performed. CONCLUSIONS:Results from this study will contribute to the knowledge on the Portuguese population’s exposure to arsenic and may support the development and implementation of policy measures aimed at minimizing exposure to this chemical and improving the health of the population. HBM4EU is funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement Nº 733032. info:eu-repo/semantics/publishedVersion

The objectives of the study were to estimate the current exposure to cadmium (Cd) in Europe, potential differences between the countries and geographic regions, determinants of exposure and to derive European exposure levels. The basis for this work was provided by the European Human Biomonitoring Initiative (HBM4EU) which established a framework for alignment of national or regional HBM studies. For the purpose of Cd exposure assessment, studies from 9 European countries (Iceland, Denmark, Poland, Czech Republic, Croatia, Portugal, Germany, France, Luxembourg) were included and urine of 20-39 years old adults sampled in the years 2014-2021 (n = 2510). The measurements in urine were quality assured by the HBM4EU quality assurance/quality control scheme, study participants' questionnaire data were post-harmonized. Spatially resolved external data, namely Cd concentrations in soil, agricultural areas, phosphate fertilizer application, traffic density and point source Cd release were collected for the respective statistical territorial unit (NUTS). There were no distinct geographic patterns observed in Cd levels in urine, although the data revealed some differences between the specific study sites. The levels of exposure were otherwise similar between two time periods within the last decade (DEMOCOPHES - 2011-2012 vs. HBM4EU Aligned Studies, 2014-2020). The age-dependent alert values for Cd in urine were exceeded by 16% of the study participants. Exceedances in the different studies and locations ranged from 1.4% up to 42%. The studies with largest extent of exceedance were from France and Poland. Association analysis with individual food consumption data available from participants' questionnaires showed an important contribution of vegetarian diet to the overall exposure, with 35% higher levels in vegetarians as opposed to non-vegetarians. For comparison, increase in Cd levels due to smoking was 25%. Using NUTS2-level external data, positive associations between HBM data and percentage of cropland and consumption of Cd-containing mineral phosphate fertilizer were revealed, which indicates a significant contribution of mineral phosphate fertilizers to human Cd exposure through diet. In addition to diet, traffic and point source release were identified as significant sources of exposure in the study population. The findings of the study support the recommendation by EFSA to reduce Cd exposure as also the estimated mean dietary exposure of adults in the EU is close or slightly exceeding the tolerable weekly intake. It also indicates that regulations are not protecting the population sufficiently. The HBM4EU project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 733032. Co-funding for the HBM4EU Aligned Studies has been provided by the national programs: Sant´e Publique France and the French ministries of Health and the Environment (ESTEBAN, France); MEYS (No. LM2018121), and Cetocoen Plus project (CZ.02.1.01/0.0/0.0/15_003/0000469) (CELSPAC:YA, Czech Republic); the Ministry of Science and Higher Education of Poland (contract no.3764/H2020/2017/2) (POALES, Poland); Public Health Fund (Diet_HBM, Iceland); Croatian Institute of Public Health (HBM survey in Croatia); National Institute of Health Dr Ricardo Jorge (INSEF_ExpoQuim, Portugal); German Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection (BMUV) (ESB, Germany); Luxembourg Institute of Health (LIH), the Laboratoire national de sant´e (human biomonitoring part), the Ministry of Higher Education and Research of Luxembourg and the Ministry of Health of Luxembourg (Oriscav-Lux2, Luxembourg); Candy Foundation (Nos. 2017–224 and 2020–344), Absalon Foundation (No. F-23653-01), The Danish Environmental Protection Agency (Miljøstyrelsen: MST-621-00012 Center on Endocrine Disrupters), The Research council of Capital Region of Denmark (No. E-22717-11), Research council of Rigshospitalet (Nos. E-22717-12, E-22717-07, E-22717-08), Aase og Ejnar Danielsens Fond (No. 10–001874), International Research and Research Training Centre for Male Reproduction and Child Health (EDMaRC, No. 1500321/1604357) (CPHMINIPUB (parents) and DYMS, Denmark). J.Kl. and L.A. thank the CETOCOEN EXCELLENCE project No. CZ.02.1.01/0.0/0.0/17_043/0009632 financed by MEYS for supportive background, and supported from the European Union’s Horizon 2020 research and innovation program under grant agreement No. 857560. This publication reflects only the author’s view, and the European Commission is not responsible for any use that may be made of the information it contains. The authors would like to thank also the participants in the HBM4EU Aligned Studies, the fieldworkers that collected the samples and database managers that made the information available to HBM4EU, the laboratories who performed the analytical measurements and the HBM4EU project partners for the supporting material and organization of the QA/QC scheme. Sí

Sunlight exposure is responsible for a large number of dermatological diseases. The purpose of this study was to estimate the prevalence of hazardous sun exposure and adherence to sun protective behaviours and its associated factors in adults from the Portuguese population. A total of 4,797 participants aged between 25 and 74 years old answered the sun exposure module of the National Health Examination Survey questionnaire, which was performed in 2015. Hazardous sun exposure and sun protective behaviours were assessed for a typical summer day during leisure time. Descriptive statistics and Poisson regression were used to examine associations between hazardous sun exposure and adherence to sun protective behaviours with population characteristics. Among the 4,797 participants, prevalence of hazardous sun exposure was 76.4 and 67.4% among men and women, respectively. It was mainly associated with younger age, lower education level and practice of regular physical activity. The prevalence of nonadherence to sun protective behaviours was 38.6 and 22.3%, among men and women, respectively. Education and income were inversely associated with adherence to sun protective behaviours. Individuals residing in regions displaying higher UV indexes had higher prevalence of sun protective practices. The prevalence of hazardous sun exposure and nonadherence to sun protective behaviours is considerable in the Portuguese population. The association between these indicators and sociodemographic factors in the population, reinforces the importance of developing sun protection messages directed at specific target audiences.

Background: Disability is not just a health problem. It is a wider phenomenon that reflects the gap between a person's capacities and their ability to fully perform the role demanded by society. Both personal and environmental factors are major contributors to disability. Objective: We aimed to estimate the prevalence of self-reported disability, overall and by sex, and associated factors in the Portuguese population in 2014. Methods: This was a cross sectional study based on data from the Portuguese National Health Interview Survey (2014) (n = 18,204). Long-term disability was evaluated based on the respondent reporting reasons for current disability lasting more than 6 months. Sex, age group, region, marital status, self-rated health, having or not health insurance, educational level, income, tobacco and alcohol consumption, physical activity and body mass index were considered as independent variables. A poisson model was performed to identify factors associated with disability. Results: Approximately 40% of the respondents reported having some long-term disability. Disability prevalence was higher in women than men (44.4% and 34.2%, respectively). Results showed age, region, education, self-rated health, physical activity and body mass index were associated with disability (p < 0.05). Conclusions: This study shows that along with personal factors, the context plays an important role in disability. We believe this piece of evidence emphasizes the factor context namely the region, when decision makers design disability related policies. info:eu-repo/semantics/publishedVersion

Background In many European countries, parallel to health examination surveys (HES), human biomonitoring (HBM) studies are conducted to monitor chemical exposures of the population. HES and HBM studies use survey based data collection with similarities in sample selection and recruitment, ethics and data protection, collection of data by questionnaire and through biological samples. Methods In the framework of European Human Biomonitoring Initiative (HBM4EU), evaluation of opportunities and potential obstacles related to combining HES and HBM surveys has been conducted. Experiences and expectations of principal investigators (PI) of studies from 19 European countries have been evaluated. Results The most common reasons for omitting an HBM module from a HES were lack of knowledge related to chemical measurements, lack of funding and capacities for chemical analysis. Many PIs feared that adding an HBM module to their survey would increase the participant burden and decrease participation rate. In surveys where these two different modules were already combined, the biggest benefits were seen on use of same infrastructure for recruitment of survey invitees, collection of questionnaire information and biological samples, and additional information on health, resulting more cost-effective data collection with more information on each participant. Combining these two modules had challenges on fitting together needs from the two study objectives. While survey content broadens, balancing participant burden and research interest of both HES and an HBM module is challenging. The amount of collected biological samples such as blood samples is limited. Coordination of the activities between several research groups can be challenging and time consuming. Conclusions Several examples have shown that combining HBM and health surveys is possible and provide several benefits. However, it requires a good preparation and planning and sufficient coordination capacity to be successful. Key messages Combining HES and HBM is possible but requires detailed planning and good collaboration between research groups. Combined HES and HBM studies provide a wide range of information about population health status and its determinants as well as chemicals levels of exposure.

Aims: Diabetes Mellitus is a major public health threat worldwide and continues to increase in numbers and significance. Estimates of diabetes prevalence, awareness, treatment and control are essential to effectively monitor its trends, plan and evaluate interventions. Methods: We conducted a nationwide health examination survey in the population residing in Portugal aged between 25 and 74 years old in 2015. It consisted in a cross sectional prevalence study which included the measurement of HbA1c, a physical examination and a general health interview of a probabilistic sample of 4911 individuals (Authorization n°9348/2010 of the National Committee for Data Protection). Results: The overall prevalence of diabetes was 9.9% (95%CI: 8.4; 11.5). It was higher in males than in females (12.1% vs 7.8%). Diabetes was more prevalent among individuals of lower education and without any professional activity. The majority of persons with diabetes was aware of their condition (87.1%) and was taking antidiabetic medication (79.7%). Of these, 63.2% had glycated hemoglobin levels lower than 7.0% (53 mmol/mol), but the majority failed to comply with the LDL and blood pressure recommended clinical targets (71.9% and 59.0%). Similarly, the prevalence of prediabetes was 16%, higher among women than men (17.5% vs 14.4%). Conclusion: The prevalence of diabetes and prediabetes remains higher than the global and European estimates, although there is increasing awareness of this disorder. Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation (PDP000039 - Public Health Initiatives Program - EEA Grants) info:eu-repo/semantics/publishedVersion

Introdução: As doenças cardiovasculares (DCV) continuam a ser a principal causa de morbilidade e mortalidade em Portugal, representando em 2015, um total de 32443 mortes (29,8% do total da mortalidade). As DCV representam um elevado custo em termos socioeconómicos pelo que os sistemas de saúde têm vindo a investir na sua prevenção. Neste sentido, ao nível dos cuidados de saúde primários, as recomendações clínicas preveem o uso de modelos matemáticos para avaliação de risco de ocorrência de eventos cardiovasculares com o objetivo de auxiliar na decisão clínica das medidas preventivas terapêuticas e/ou não terapêuticas a adotar. Em Portugal, de acordo com a Norma nº 005/2013 de 19/03/2013 da Direção Geral da Saúde (DGS), é recomendado o uso do algoritmo SCORE (Systematic Coronary Risk Evaluation) para avaliação do risco cardiovascular fatal a 10 anos. O presente trabalho tem como objetivo caracterizar o risco cardiovascular da população portuguesa com idade entre os 40 e os 65 anos de idade, em 2015, usando os parâmetros definidos pelo SCORE. Métodos: Neste estudo foram utilizados dados do Inquérito Nacional de Saúde com Exame Físico (INSEF), estudo transversal de âmbito nacional, realizado em 2015 numa amostra probabilística (n=4911) de indivíduos residentes em Portugal com idades compreendidas entre os 25 e os 74 anos. Para o cálculo do risco cardiovascular foram considerados os participantes do INSEF com idade compreendida entre os 40 e os 65 anos com dados disponíveis sobre sexo, idade, tabagismo, colesterol total e pressão arterial sistólica (n=2946). As estimativas apresentadas de risco cardiovascular baixo (

INTRODUCTION: Oral health is a determinant for quality of life and preventive behaviours such as regular tooth brushing can reduce the risk of a wide spectrum of oral diseases. Adopting preventive behaviours increases the likelihood of being healthy and can be conditioned by demographic and socio-economic factors. OBJECTIVE: This study aims to describe preventive oral hygiene behaviours in the Portuguese population and assess their association with sociodemographic and socioeconomic factors. MATERIAL AND METHODS: A cross-sectional epidemiologic study was developed using data from the first Portuguese National Health Examination Survey. The target population comprised Portuguese community-dwelling residents aged between 25 and 74 years old. The percentage of individuals who brushed their teeth at least twice a day, provided that once was before sleeping, was considered the indicator showing a preventive behaviour, as this is recommended by the General Directorate of Health in Portugal. Poisson regression was used to identify factors independently associated with this behaviour. RESULTS: Sixty-five per cent of the participants reported tooth brushing as recommended. The prevalence of adoption of this preventive behaviour was higher among those living in urban areas and those who have higher educational level. Results show an association between being male and having low educational level with lesser adoption of preventive oral health behaviours. CONCLUSION: These findings suggest a need for integrated approaches, from measures tackling social inequalities to actions focused on improving health literacy. It is also important to expand dental healthcare services and improve effective coverage to increase access for rural population. INSEF was developed as part of the Pre-defined project of the Public Health Initiatives Program, entitled ‘Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health and bilateral cooperation’, that benefited from a 1,500,000€ grant from Iceland, Liechtenstein and Norway through the EEA Grants. info:eu-repo/semantics/publishedVersion

Background: This study aimed to compare self-reported and examination-based prevalence of hypertension and hypercholesterolemia in Portugal in 2015 and to identify factors associated with the measurement error in self-reports. Methods: We used data from the Portuguese National Health Examination Survey (n = 4911), that combines personal interview, blood collection and, physical examination. Sensitivity and specificity of self-reported hypertension and hypercholesterolemia were calculated. Poisson regression was used to estimate prevalence ratios (PRs) of underreport of hypertension and hypercholesterolemia according to sex, age, socioeconomic status (education and income) and general practitioner (GP) consultation in the past year. Results: Sensitivity of self-reports was 69.8% for hypertension and 38.2% for hypercholesterolemia. Underreport of hypertension was associated with male gender (PR = 1.54), lack of GP consultation (PR = 1.70) and being 25–44 years old (PR = 2.45) or 45–54 years old (PR = 2.37). Underreport of hypercholesterolemia was associated with lack of GP consultation (PR = 1.15), younger age (PR = 1.83 for 25–44 age group and PR = 1.52 for 45–54 age group), secondary (PR = 1.30) and higher (PR = 1.27) education. Conclusion: Self-reported data underestimate prevalence of hypertension and hypercholesterolemia. Magnitude of measurement error in self-reports varies by health conditions and population characteristics. Adding objective measurements to self-reported questionnaires improve data accuracy allowing better understanding of socioeconomic inequalities in health. O primeiro Inquérito Nacional de Saúde com Exame Físico foi desenvolvido como parte integrante do projeto “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, que beneficiou de um apoio financeiro de 1.500.000€ concedido pela Islândia, Liechtenstein e Noruega, através do Programa Iniciativas em Saúde Pública (PT06) financiado pelas EEA Grants 2009-2014. info:eu-repo/semantics/publishedVersion

Introduction: Reduction of unfair differences in health between socioeconomic groups and countries constitutes an important public health challenge in the 21st century. To monitor progress on this goal, health inequalities are most frequently estimated based on self-reported data from population surveys. However, it has been shown that self-reported data on cardiovascular disease risk factors is prompt to reporting error. If errors occur more often in specific socioeconomic groups (due to under-diagnosis or lower literacy) they are likely to seriously bias health inequality estimates. This study aims at comparing measurement errors between socioeconomic categories in self-reported hypertension, and their consequences on health inequality estimates. Methods: We used data from the Portuguese National Health Examination Survey (INSEF), a cross-sectional nationwide study conducted in 2015 on a probabilistic sample (n=4911) of community-dwelling individuals aged between 25 and 74 years old. INSEF combines measured biochemical parameters and blood pressure with self-reported data. Self-reported hypertension was defined based on the question: “Do you have any of the following diseases or conditions: hypertension? (Yes/No)”. Examination-based hypertension was defined as having systolic blood pressure of at least 140 mmHg, or diastolic blood pressure of at least 90 mmHg, or using prescribed antihypertensive medication. Participants´ socioeconomic status was measured through the education level (no education/ 1st cycle of basic education, 2nd cycle of basic education, 3rd cycle of basic education, secondary education and higher education). Inequalities in hypertension between the highest and lowest socioeconomic status groups were measured using relative indexes of inequality (RII) and respective confidence intervals (CI 95%), estimated by Poisson regression. Estimates of inequalities were stratified by age and sex, using four population groups (male 25-49 years old, female 25-49 years old, male 50-75 years old, female 50-75 years old). Results: Hypertension was reported by 25.7% [CI 95%: 24.0 to 27.4] of participants, while 35.9% [CI 95%: 34.2 to 37.5] were considered to have hypertension according to examination-based data. The difference between examination-based and self-reported prevalence was 12.7pp for those with no education/ 1st cycle of basic education and 4.6pp for those with higher education. Similar educational gradients were observed for both self-reported (RII=1.87; CI 95%: 1.45 to 2.42) and examination-base (RII=1.91; CI 95%: 1.60 to 2.28) hypertension, with lowest prevalence of disease among the highly educated. Age- and sex-specific results showed considerable discrepancies in inequality indicators between self-reported and examination-based data. Namely, differences in estimated gradients were more pronounced among 25-49 years old males, with RII=0.67 (CI 95%: 0 .29 to 1.54) for self-reported and RII=1.90 (CI 95%: 1.22 to 2.96) for examination-based hypertension. In 25-49 years old females inequalities in self-reported hypertension were not statistically significant (RII=3.18; CI 95%: 0.94 to 10.73), while females with the lowest education were 4.35 (CI 95%: 2.60 to 7.27) times more likely to have examination-based hypertension then compared to the most educated. In 50-75 age group educational inequalities in self-reported hypertension were larger than in examination-based for both, male (RII=1.82 CI 95%: 1.25 to 2.69 vs. RII=1.40; CI 95%: 1.04 to 1.89) and female (RII=1.77; CI 95% 1.30 to 2.41 vs. RII=1.58; CI 95%: 1.22 to 2.04). Conclusions: Our results illustrated the significant effect of measurement error in self-reported hypertension on estimates of socioeconomic inequalities. Use of self-reported data led to underestimation of educational inequalities among young and middle-aged individuals and overestimation in older age groups. Inequality indicators derived from self-report should be interpreted with caution. EEA grants N/A

Background: In Health Examination Surveys interview information is complemented with objective information, providing more accurate indicators than self-reported data. We report the study design, planning and implementation of the first Portuguese Health Examination Survey (INSEF). Methods: INSEF was a cross-sectional population-based study representative at regional and national level. Individuals aged between 25 and 74 years old, residing in Portugal were selected from the national health users’ registry through multi-stage stratified probabilistic sampling. Sample size was set at 4200 individuals. Data was collected in primary care units and included blood pressure, height, weight, hip and waist measurements, blood collection for lipid profile, HbA1c and blood count and a general health questionnaire. European HES procedures were followed. Results: A total of 4911 individuals agreed to participate (43.9% participation rate). Participation rate varied by region, sex and age group, being lower in Lisbon and Tagus Valley (32.8%), for men (41.8%) and for those aged 25–34 years old (36%). Conclusions: INSEF has set up an experienced national and regional structure for HES implementation. Nationally representative quality epidemiological data is now available for public health monitoring, planning and research. The Portuguese National Health Examination Survey 2015 (INSEF) was developed as part of the Pre-defined project of the Public Health Initiatives Program (reference 000039_ PDP), ‘‘Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the European Economic Area Financial Mechanism (EEA Grants), 85%, and from the Portuguese Government, 15%. info:eu-repo/semantics/publishedVersion

© 2017 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved., Obesity is recognised as a serious public health issue, due to its associated morbidity and mortality. This study aimed at estimating the prevalence of overweight and obesity in the Portuguese population through direct measurements obtained by the 1st National Health Examination Survey (INSEF 2015) and to identify its associated sociodemographic factors. INSEF was a nationally representative cross-sectional prevalence study conducted on 4911 Portuguese adults aged 25-74 years, in 2015. Height and weight were measured according to the European Health Examination Survey procedures. Poisson regression was used to estimate the adjusted prevalence ratios of overweight and obesity according to age, marital status, occupational activity, education, urbanization of living area and smoking status. Overall prevalences of overweight and obesity were 39.1% and 28.6%, respectively. The prevalence of overweight was higher among men (45.5% vs 33.2%) while the prevalence of obesity was higher among women (32% vs 25%). The sociodemographic factors associated with overweight and obesity were age, marital status and education. Smoking status was associated with overweight and obesity but only in women. INSEF suggests that a high prevalences of overweight and obesity are found in older individuals, married, with lower education levels and non-smoking women. Public health interventions are urgently required for obesity prevention, namely throughout health literacy strategies., The authors are grateful to all the professionals involved in the INSEF fieldwork and to all the INSEF participants. INSEF was developed as part of the Pre-defined project of the Public Health Initiatives Program, ‘‘Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation’’, that benefits from a 1.500.000D Grant from Iceland, Liechtenstein and Norway through the EEA Grants.

UID/SOC/04647/2013 SFRH/BPD/107722/2015 Descrever as prevalências de excesso de peso e de obesidade na população adulta residente em Portugal em 2015, obtidas através de medições antropométricas diretas, de acordo com as variáveis sexo, idade, região, nível de escolaridade e situação perante o trabalho. As prevalências de excesso de peso e de obesidade tiveram por base o cálculo do Índice de Massa Corporal (IMC), considerando os resultados das medições diretas do peso e da altura obtidos no 1º Inquérito Nacional de Saúde com Exame Físico (INSEF 2015). As prevalências foram estratificadas por sexo, grupo etário, região, nível de escolaridade e situação perante o trabalho. A prevalência nacional de excesso de peso estimada foi de 38,9% (IC95%: 36,9-41,1) e a prevalência de obesidade foi de 28,7% (IC95%: 26,8-30,6). Foi observada uma maior prevalência de excesso de peso nos homens, mas a prevalência de obesidade foi superior para as mulheres. Os mais velhos e os indivíduos com menor nível de escolaridade foram os que apresentaram maiores prevalências de obesidade. Estes resultados evidenciam uma elevada prevalência de excesso de peso e obesidade na população adulta residente em Portugal em 2015 e suportam a manutenção de intervenções dirigidas à redução da incidência e prevalência da obesidade e do excesso de peso na população portuguesa. publishersversion published

Background: Obesity is recognized as a serious public health issue, both as a disease in itself and as an important risk factor for cardiovascular diseases and diabetes. The First Portuguese National Health Examination Survey (INSEF 2015) aimed at obtain in-depth knowledge about health status and determinants and contribute to the reduction of health inequalities. The goal of this analysis was to estimate the prevalence and to assess socioeconomic inequalities in obesity, through direct measurement of weight and height. Methods: INSEF is a nationally representative cross-sectional prevalence study conducted on 4911 adults aged 25-74 years old, in 2015. It included physical examination, blood collection and personal interview. INSEF participants’ height and weight were measured according to European Health Examination Survey procedures. Obesity was defined as body mass index ≥ 30 kg/m2. Poisson regression was applied to estimate prevalence ratios (aPR) of obesity according to sex, age group, education and employment status, adjusted for confounding. Results: Overall national prevalence of obesity was 28.7%, [95% CI 26.8; 30.6]. The prevalence of obesity was higher among females (32.1%, aPR =1.3, [1.2, 1.4]) than males (24.9%). Prevalence was higher in 65-74 years old age group (41.8% vs. 12.5%, aPR=2.4, [1.5, 3.6]). , compared to the 25-34 years old group. Individuals with no education or first grade basic education had double the prevalence of obesity than those with higher education (14.7% vs43.1%, aPR=2.1, [1.6, 2.8]). Conclusions: Obesity affects 287 per 1000 adults aged 25-74 years old in Portugal. INSEF provides evidence that a higher prevalence of obesity is found in older individuals, with lower education levels. Public health interventions that focus on specific population subgroups are required for obesity prevention, namely, throughout health literacy strategies. The Portuguese National Health Examination Survey is developed as a part of the project “Improvement of epidemiological health information to support public health decision and management in Portugal. Towards reduced inequalities, improved health, and bilateral cooperation”, that benefits from a 1.500.000€ Grant from Iceland, Liechtenstein and Norway through the EEA Grants. N/A

Background Health Examination Surveys (HES) were interview data is complemented with objective information from physical examination and laboratory analysis, provide more accurate health indicators than self-reported data. Here we report the study design, planning and implementation of the First Portuguese Health Examination Survey (INSEF) developed during 2014-2015. Methods INSEF was developed as a cross-sectional population-based study representative at regional and national level. Development …

Hydride abstraction from [MCpBz(CO)3H] (M = Mo, W; CpBz = C5(CH2Ph)5) using trityl cations led to [M{η5:η2-C5Bz4CH2Ph}(CO)3]BArF (BArF = B(3,5-C6H3(CF3)2)4; M = Mo (3), W (4)) or [MCpBz(CO)3(FBF3)] (M = Mo (5), W (6)) depending on the trityl counterions. The stabilization of the acidic metal centers in 3 and 4 is made through the coordination of a C═C bond of one phenyl ring, generating ansa-bridged cyclopentadienyl–phenyl carbonyl complexes. 5 and 6 are zwitterionic compounds stabilized by the coordination of the BF4 anion. An exchange process between coordinated and noncoordinated phenyl rings occurs in dichloromethane solutions of 3. VT NMR experiments gave the exchange rate at various temperatures and ΔG⧧298 = 10.1 ± 0.2 kcal mol–1. In 4 the phenyl bonding is static at room temperature, on the NMR time scale. Reactions of 3 and 4 with CO and H2O led to [MCpBz(CO)4]BArF (M = Mo (7), W (8)) and [MCpBz(CO)3(OH2)]BArF (M = Mo (11), W (12)). In CH2Cl2 solutions 3 and 4 convert slowly to 7 and 8, respective...

The dioxomolybdenum and dioxotungsten complexes [MoO2L1] (1-Mo) and [WO2L1] (2-W), supported by a diamine bis(phenolate) ligand (L1 = Me2NCH2CH2N(CH2-2-O-3,5-C6H2tBu2)2) were prepared from MoO2Cl2 and WO2Cl2(dme) in good yields. The solid-state structures of both compounds obtained by single crystal X-ray diffraction reveal distorted octahedral geometries around the metals with cis terminal oxo ligands. Their performance in the catalytic epoxidation of cis-cyclooctene using H2O2 and TBHP as oxidants was evaluated. 2-W displays high activity with H2O2 as terminal oxidant, achieving 84% conversion in 6 h (TOF = 1400 molsub molcat−1 h−1), while its molybdenum counterpart 1-Mo was inactive in the same conditions. Using TBHP as oxidant the opposite trend was observed and 1-Mo attained 93% conversion in 6 h (TOF = 1550 molsub molcat−1 h−1). The Oxovanadium complexes [VOL1Cl] (3-V), [VOL2Cl] (4-V, L2 = Me2NCH2CH(CH3)N(CH2-2-O-3,5-C6H2tBu2)2) and [(VOL1)2(μ-O)] (5-V) were also tested as catalysts in the epoxidation of cis-cyclooctene. The three compounds display high activity when the epoxidation reaction is performed using TBHP as oxidant. Using H2O2, 3-V and 4-V are moderately active while 5-V is inactive.