Trastornos cardiometabólicos en personas con VIH en el interior de la Amazonia brasileña
Resumen
Introducción: La infección por VIH, junto con el uso de terapia antirretroviral (TAR), predispone a personas que viven con VIH (PVVIH) a desarrollar alteraciones metabólicas en la distribución de la grasa corporal y mayor riesgo cardiovascular (RCV). Objetivo: Analizar la relación entre el síndrome metabólico (SM), la dislipidemia, la lipodistrofia y el RCV con las características sociodemográficas y clínicas de las PVVIH en el interior de la Amazonia, Brasil. Métodos: Estudio transversal, compuesto por 115 PVVIH, atendidas en un Ambulatorio Especializado. Se buscó información sociodemográfica, clínica, de laboratorio, de composición corporal, así como la presencia de SM, dislipidemia, lipodistrofia y RCV. Los datos se analizaron mediante estadística descriptiva e inferencial, adoptando p<0,05. Resultados: Predominó el sexo masculino (59,1%), al igual que la dislipidemia (81,7%). Se observó que el 22,6% de las PVVIH tenía SM, el 37,4% lipodistrofia y el 8,7% RCV moderado. La edad ≥40 años se asoció con EM y lipodistrofia, y una mayor duración del uso de TAR se asoció con lipodistrofia (p<0,05). El tabaquismo y la lipodistrofia se asociaron con RCV moderado (p<0,05). Los valores alterados de perímetro abdominal, glucosa, c-LDL, c-HDL, índice de masa corporal y presión arterial se asociaron con EM (p<0,05). Conclusión: Según los datos, la alta frecuencia de PVVIH con dislipidemia, lipodistrofia y EM, así como la asociación de EM y lipodistrofia con RCV moderado, es preocupante. Por lo tanto, se enfatiza la necesidad de monitoreo continuo e intervenciones asertivas para prevenir la aparición o el empeoramiento de enfermedades cardiometabólicas en esta población.
Referencias
Addy, C.L., Gavrilla, A., Tsiodras, S., Brodovicz, K., Karchmer, A.W., e Mantzoros, C.S. (2023). Hypoadiponectinemia is associated with insulin resistance, hypertriglyceridemia, and fat redistribution in human immunodeficiency virus-infected patients treated with highly active antiretroviral therapy. The Journal of Clinical Endocrinology & Metabolism, 88(2), 627-636. https://doi.org/10.1210/jc.2002-020795
Alikhani, A., Morin, H., Matte, S., Alikhani P., Tremblay, C., e Durand, M. (2019). Association between lipodystrophy and length of exposure to ARTs in adult HIV-1 infected patients in Montreal. BMC Infectious Diseases, 19(1), e820. https://doi.org/10.1186/s12879-019-4446-9
Araujo, I.B., Silva, C.F., Fernandes, E.V., Siqueira M.A., Xavier, M.B., e Gouvêa-e-Silva, L.F. (2025). Risk factors for metabolic syndrome are associated with low handgrip strength in people with HIV. Sport Sciences for Health, 21, 465-474. https://doi.org/10.1007/s11332-024-01278-6
Ballocca, F., Gili, S., D’Ascenzo, F., Marra, WG, Canillo, M., Calcagno, A., Bonora, S., Flammer, A., Coppola, J., Moretti, C., e Gaita, F. (2016). HIV infection and primary prevention of cardiovascular disease: lights and shadows in the HAART Era. Progress in Cardiovascular Diseases, 58(5), 565-576. https://doi.org/10.1016/j.pcad.2016.02.008
Bazmandegan, G., Abbasifar, M., Nadimi, A.E., Alinejad, H., e Kamiab, Z. (2023). Cardiovascular risk factors in diabetic patients with and without metabolic syndrome: a study based on the Rafsanjan cohort study. Scientific Reports, 13(1), e559. https://doi.org/10.1038/s41598-022-27208-5
Bica, I., McGovern, B., Dhar, R., Stone, D., McGowan, K., Scheib, R., e Snydman, D.R. (2001). Increasing mortality due to end-stage liver disease in patients with human immunodeficiency virus infection. Clinical Infectious Diseases, 32(3), 492-497. https://doi.org/10.1086/318501
Bloomfield, G.S. Hogan, J.W., Keter, A., Sang, E., Carter, E.J., Velazquez, E.J., e Kimaiyo, S. (2011). Hypertension and obesity as cardiovascular risk factors among HIV seropositive patients in western Kenya. PLoS One, 6(7), e22288. https://doi.org/10.1371/journal.pone.0022288
Boccara, F. (2017). Cardiovascular health in an aging HIV population. AIDS, (31), S157-S163. https://doi.org/10.1097/qad.0000000000001384
Brasil. Ministério da Saúde. Boletim Epidemiológico - HIV e Aids 2024 (2024). https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2024/boletim_hiv_aids_2024e.pdf/view
Cabrera, D.M., Diaz, M.M., Grimshaw, A., Salvatierra, J., Garcia, P.J., e Hsieh, E. (2021).
Aging with HIV in Latin America and the Caribbean: a systematic review. Current HIV/AIDS reports, 18(1), 1-47. https://doi.org/10.1007/s11904-020-00538-7
Ciolac, E.G., e Guimarães, G.V. (2004). Exercício físico e síndrome metabólica. Revista Brasileira de Medicina do Esporte, 10(4), 319-324. https://doi.org/10.1590/s1517-86922004000400009
Costa, C.R.B., Melo, E.S., Antonini, M., Jesus, G.J., Pontes, P.S., Gir, E., e Reis, R.K. (2019). Associação entre fatores sociodemográficos e comportamentais com a síndrome metabólica em pessoas vivendo com HIV. Revista Gaúcha de Enfermagem, 40, e20180379. https://doi.org/10.1590/1983-1447.2019.20180379
Craig, W.Y., Palomaki, G.E., e Haddow, J.E. (1989). Cigarette smoking and serum lipid and lipoprotein concentrations: an analysis of published data. BMJ, 298(6676), 784-788. https://doi.org/10.1136/bmj.298.6676.784
Dos Santos, AP, Navarro, AM, Schwingel, A., Alves, TC, Abdalla, PP, Venturini, ACR, Santana, RC, e Machado, DRL (2018). Lipodystrophy diagnosis in people living with HIV/AIDS: prediction and validation of sex-specific anthropometric models. BMC Public Health, 18(1), e806. https://doi.org/10.1186/s12889-018-5707-z
Dourado, I., Veras, M.A.S.N., Barreira, D., e Brito, A.M. (2006). Tendências da epidemia de Aids no Brasil após a terapia anti-retroviral. Revista de Saúde Pública, 40, 9-17. https://doi.org/10.1590/s0034-89102006000800003
Estrada, V., Martínez-Larrad, MT, González-Sánchez, JL, Villar, NGP, Sabena, C., Fernández, C., e Serrano-Ríos, M. (2006). Lipodystrophy and metabolic syndrome in HIV-infected patients treated with antiretroviral therapy. Metabolism - clinical and Experimental, 55(7), 940-945. https://doi.org/10.1016/j.metabol.2006.02.024
Faludi, AA, Izar, MCO, Saraiva, JFK, Chacra, APM, Bianco, HT, Afiune Neto, A., Bertolami, A., Pereira, AC, Lottenberg, AM, Sposito, AC, Chagas, ACP, Casella Filho, A., Simão, AF, Alencar Filho, AC, Caramelli, B., Magalhães, CC, Negrão, CE, Ferreira, CEDS, Scherr, C., Feio, CMA, Kovacs, C., Araújo, DB, Magnoni, D., Calderaro, D., Gualandro, DM, Mello Junior, EP, Alexandre, ERG, Sato, EI, Moriguchi, EH, Rached, FH, Santos, FCD, Cesena, FHY, Fonseca, FAH, Fonseca, HARD, Xavier, HT, Mota, ICP, Giuliano, ICB, Issa, JS, Diament, J.., Pesquero, JB, Santos, JED, Faria Neto, JR, Melo Filho, JX, Kato, JT, Torres, KP, Bertolami, MC, Assad, MHV, Miname, MH, Scartezini, M., Forti, NA, Coelho, OR, Maranhão, RC, Santos Filho, RDD, Alves, RJ, Cassani, RL, Betti, RTB, Carvalho, T., Martinez, TLDR, Giraldez, VZR, e Salgado Filho, W. (2017). Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose - 2017. Arquivos Brasileiros de Cardiologia, 109(2Supl.1), 1-76. https://doi.org/10.5935/abc.20170121
Fernandes Filho, J. (2003). A prática da avaliação física (2ª ed.). Shape Editora.
Finkelstein, J.L., Gala, P., Rochford, R., Glesby, M.J., e Mehta, S. (2015). HIV/AIDS and lipodystrophy: Implications for clinical management in resource-limited settings. Journal of the International AIDS Society, 18(1), e19033. https://doi.org/10.7448/IAS.18.1.19033
Gallant, JE, Staszewski, S., Pozniak, AL, DeJesus, E., Suleiman, JMAH, Miller, MD, Coakley, DF, Lu, B., Toole, JJ, Cheng, AK, e 903 Study Group (2004). Efficacy and safety of tenofovir DF vs stavudine in combination therapy in antiretroviral-naive patients: a 3-year randomized trial. JAMA, 292(2), 191-201. https://doi.org/10.1001/jama.292.2.191
Garcia-Viejo, M.A., Hernández, L., e Martínez, E. (2001). Strategies for treating HIV-related lipodystrophy. Expert Opinion on Investigational Drugs, 10(8), 1443-1456. https://doi.org/10.1517/13543784.10.8.1443
Grinspoon, S. (2001). Insulin resistance in the HIV-lipodystrophy syndrome. Trends in Endocrinology and Metabolism, 12(9), 413-419. https://doi.org/10.1016/s1043-2760(01)00472-6
Grundy, SM, Cleeman, JI, Daniels, SR, Donato, KA, Eckel, RH, Franklin, BA, Gordon, DJ, Krauss, RM, Savage, PJ, Smith Jr, SC, Spertus, JA, e Costa F. (2005). Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation, 112(17), 2735-2752. https://doi.org/10.1161/CIRCULATIONAHA.105.169404
Hanna, DB, Guo, M., Buzkova, P., Miller, TL, Post, WS, Stein, JH, Currier, JS, Kronmal, RA, Freiberg, MS, Bennett, SN, Shikuma, CM, Anastos, K., Li, Y., Tracy, RP, Hodis, HN, Delaney, JA, e Kaplan, RC (2016). HIV Infection and carotid artery intima-media thickness: pooled analyses across 5 cohorts of the NHLBI HIV-CVD Collaborative. Clinical Infectious Diseases, 63(2), 249-256. https://doi.org/10.1093/cid/ciw261
Heath, KV, Hogg, RS, Chan, KJ, Harris, M., Montessori, V., O’Shaughnessy, MV, e Montaner, JSG (2001). Lipodystrophy-associated morphological, cholesterol and triglyceride abnormalities in a population-based HIV/AIDS treatment database. AIDS, 15(2), 231-239. https://doi.org/10.1097/00002030-200101260-00013
Helleberg, M., Afzal, S., Kronborg, G., Larsen, CS, Pedersen, G. Pedersen, C., Gerstoft, J., Nordestgaard, BG, e Obel, N. (2013). Mortality attributable to smoking among HIV-1-infected individuals: A nationwide, population-based cohort study. Clinical Infectious Diseases, 56(5), 727-734. https://doi.org/10.1093/cid/cis933
Hussain, I., Patni, N., e Garg, A. (2019). Lipodystrophies, dyslipidaemias and atherosclerotic cardiovascular disease. Pathology, 51(2), 202-212. https://doi.org/10.1016/j.pathol.2018.11.004
Ioannou, G.N., Bryson, C.L., Weiss, N.S., e Boyko, E.J. (2015). Associations between lipodystrophy or antiretroviral medications and cirrhosis in patients with HIV infection or HIV/HCV coinfection. European Journal of Gastroenterology & Hepatology, 27(5), 577-584. https://doi.org/10.1097/meg.0000000000000290
Jericó, C., Knobel, H., Montero, M., Ordoñez-Llanos, J., Guelar, A., Gimeno, JL, Saballs, P., López-Colomés, JL, e Pedro-Botet, J. (2005). Metabolic syndrome among HIV-infected patients. Diabetes Care, 28(1), 132-137. https://doi.org/10.2337/diacare.28.1.132
Johnston, PI, Wright, SW, Orr, M., Pearce, FA, Stevens, JW, Hubbard, RB, e Collini, PJ (2021). Worldwide relative smoking prevalence among people living with and without HIV. AIDS, 35(6), 957-970. https://doi.org/10.1097/qad.0000000000002815
Kim, H.C., Kang, D.R., Choi, K.S., Nam, C.M., Thomas, G.N., e Suh, I. (2006). Spousal concordance of metabolic syndrome in 3141 Korean couples: A nationwide survey. Annals of Epidemiology, 16(4), 292-298. https://doi.org./10.1016/j.annepidem.2005.07.052
Koethe, JR, Lagathu, C., Lake, JE, Domingo, P., Calmy, A., Falutz, J., Brown, TT, e Capeau, J. (2020). HIV and antiretroviral therapy-related fat alterations. Nature Reviews Disease Primers, 6(1), e54. https://doi.org/10.1038/s41572-020-0181-1
Lagathu, C., Béréziat, V., Gorwood, J., Fellahi, S., Bastard, JP, Vigouroux, C., Boccara, F., e Capeau, J. (2019). Metabolic complications affecting adipose tissue, lipid and glucose metabolism associated with HIV antiretroviral treatment. Expert Opinion on Drug Safety, 18(9), 829-840. https://doi.org/10.1080/14740338.2019.1644317
Martinez, E., Mocroft, A., García-Viejo, M., Pérez-Cuevas, J., Blanco, J., Mallolas, J., Bianchi, L., Conget, I., Blanch, J., Phillips, A., e Gatell, J. (2001). Risk of lipodystrophy in HIV-1-infected patients treated with protease inhibitors: a prospective cohort study. The Lancet, 357(9256), 592-598. https://doi.org/10.1016/S0140-6736(00)04056-3.
Meirelles, R.M.R. (2014). Menopausa e síndrome metabólica. Arquivos Brasileiros de Endocrinologia & Metabologia, 58(2), 91-96. https://doi.org/10.1590/0004-2730000002909
Menezes, J.D.S., Souza, A.M., Fraga, V.T.O., e Godoy, M.F. (2021). Fatores de risco em adultos jovens para o desenvolvimento de doenças cardiovasculares: o que a literatura mostra? Research, Society and Development, 10(11), e492101119949. https://doi.org/10.33448/rsd-v10i11.19949
Mikhail, N. (2003). Insulin resistance in HIV-related lipodystrophy. Current Hypertension Reports, 5(2), 117-121. https://doi.org/10.1007/s11906-003-0067-0
Møller, SP, Amare, H., Christensen, DL, Yilma, D., Abdissa, A., Friss, H., Faurholt-Jepsen, D., e Olsen, MF (2020). HIV and metabolic syndrome in an Ethiopian population. Annals of Human Biology, 47(5), 457-464. https://doi.org/10.1080/03014460.2020.1781929
Moraes, A.C.F., Fulaz, C.S., Netto-Oliveira, E.R., e Reichert, F.F. (2009). Prevalência de síndrome metabólica em adolescentes: uma revisão sistemática. Cadernos de Saúde Pública, 25(6), 1195-1202. https://doi.org/10.1590/s0102-311x2009000600002
Moura, ARA, Nogueira, RT, Vasconcelos, RT, Silva, PB, Silva, CBP, Barroso, ACS, e Barros, JCM (2021). Avaliação do consumo alimentar e associação com o diagnóstico clínico e fatores de risco em pacientes cardiopatas. Revista Eletrônica Acervo Saúde, 13(2), e6116. https://doi.org/10.25248/reas.e6116.2021
Narla, V.A. (2021). Sudden cardiac death in HIV‐infected patients: A contemporary review. Clinical Cardiology, 44(3), 316-321. https://doi.org/10.1002/clc.23568
Ngcobo, S., Molatlhegiet, RP, Osman, F., Ngcapu, S., Samsunder, N., Garret, N.J., Karim, SSA, Karim, QA, McKinnon, LR, e Sivro, A. (2022). Pre-infection plasma cytokines and chemokines as predictors of HIV disease progression. Scientific Reports, 12(1), e2437. https://doi.org/10.1038/s41598-022-06532-w
Nguyen, K.A., Peer, N., Mills, E.J., e Kengne, A.P. (2016). A meta-analysis of the metabolic syndrome prevalence in the global HIV-infected population. PLoS ONE, 11(3), e0150970. https://doi.org/10.1371/journal. pone.0150970
Nix, L.M., e Tien, P.C. (2014). Metabolic syndrome, diabetes, and cardiovascular risk in HIV. Current HIV/AIDS Reports, 11(3), 271-278. https://doi.org/10.1007/s11904-014-0219-7
Njelekela, M., Mpembeni, R., Muhihi, A., Ulenga, N., Aris, E., e Kakoko, D. (2017). Lipodystrophy among HIV-infected patients attending care and treatment clinics in Dar es Salaam. AIDS Research and Treatment, 2017, e3896539. https://doi.org/10.1155/2017/3896539
Obare, LM, Simmons, J., Oakes, J., Zhang, X., Nochowicz, C., Priest, S., Bailin, SS, Warren, CM, Mashayekhi, M., Beasley, HK, Shao, J., Meenderink, LM, Sheng, Q., Stolze, J., Gangula, R., Absi, T., Ru Su, Y., Neikirk, K., Chopra, A., Gabriel, CL, Temu, T., Pakala, S., Wilfong, EM, Gianella, S., Phillips, EJ, Harrison, DG, Hinton, A., Kalams, SA, Kirabo, A., Mallal, SA, Koethe, JR, e Wanjalla, CN (2025). CD3+ T-cell: CD14+ monocyte complexes are dynamic and increased with HIV and glucose intolerance. The Journal of Immunology, 214(3), 516-531. https://doi.org/10.1093/jimmun/vkae054
Park, K-H., Shin, D-G., e Cho, K-H. (2014). Dysfunctional lipoproteins from young smokers exacerbate cellular senescence and atherogenesis with smaller particle size and severe oxidation and glycation. Toxicological Sciences, 140(1), 16-25. https://doi.org/10.1093/toxsci/kfu076
Pereira, ÍI, Muto, AKTM, Dias, RFG, Menezes Filho, HR, Fernandes, EV, Gouvêa-e-Silva, LF, e Cardoso, LPV (2024). Impact of metabolic syndrome and cardiovascular risk on the quality of life of people living with HIV. Current HIV Research, 22(3),170-180. https://doi.org/10.2174/011570162X299815240507070904
Petoumenos, K., Worm, S., Reiss, P., Wit, S., d'Arminio Monforte, A., Sabin, C., Friis-Møller, N., Weber, R., Mercie, P., Pradier, C., El-Sadr, W., Kirk, O., Lundgren, J., Law, M., e D.A.D. Study Group. (2011). Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the D:A:D study. HIV Medicine, 12(7), 412-421. https://doi.org/10.1111/j.1468-1293.2010.00901.x
Phan, V., Thai, S., Choun, K., Lynen, L., van Griensven, J., e Maartens, G. (2012). Incidence of treatment-limiting toxicity with stavudine-based antiretroviral therapy in Cambodia: A retrospective cohort study. PLoS One, 7(1), e30647. https://doi.org/10.1371/journal.pone.0030647
Ray, G.M. (2009). Antiretroviral and statin drug-drug interactions. Cardiology in Review, 17(1), 44-47. https://doi.org/10.1097/crd.0b013e3181903b7f
Rodrigues, D.D.A., e Toigo, A.M. (2015). Efeitos de diferentes tipos de exercício físico em portadores de HIV/Aids com lipodistrofia. Revista de Atenção à Saúde, 13(43), 73-78. https://doi.org/10.13037/rbcs.vol13n43.2627
Sacilotto, L.B., Papini, S.J., Mendes, A.L., Gatto, M., Pereira, P.C.M., Corrente, J.E., e da Silva, J.F. (2021). Relationship between lipodystrophy, body composition, metabolic profile, and serum levels of adipocytokines. Frontiers in Nutrition, 8, e750721. https://doi.org/10.3389/fnut.2021.750721
Scherzer, R., Heymsfield, SB, Lee, D., Powderly, WG, Tien, PC, Bacchetti, P., Shlipak, MG, e Grunfeld, C. (2011). Decreased limb muscle and increased central adiposity are associated with 5 year all cause mortality in HIV infection. AIDS, 25,1405-1414. https://doi.org/10.1097/qad.0b013e32834884e6
Segatto, AFM, Freitas Junior IF, Santos, VR, Alves, KCP, Barbosa DA, Portelinha Filho, AM, e Monteiro, HL (2011). Lipodystrophy in HIV/AIDS patients with different levels of physical activity while on antiretroviral therapy. Revista da Sociedade Brasileira de Medicina Tropical, 44(4), 420-424. https://doi.org/10.1590/s0037-86822011000400004
Sekizkardes, H., Chung, ST, Chacko, S., Haymond, MW, Startzell, M., Walter, M., Walter, PJ, Lightbourne, M., e Brown, RJ (2020). Free fatty acid processing diverges in human pathologic insulin resistance conditions. The Journal of Clinical Investigation, 130(7), 3592-3602. https://www.jci.org/articles/view/135431
Silva, K.S.C., Duprat, I.P., Dórea, S.A., Melo, G.C., e Macêdo, A.C. (2020). Emergência cardiológica: principais fatores de risco para infarto agudo do miocárdio. Brazilian Journal of Health Review, 3(4), 11252-11263. https://doi.org/10.34119/bjhrv3n4-372
Sonaglio, E.P., Pedro, F.L., Silva, Q.H., e Kirsten, V.R. (2011). Síndrome da lipodistrofia em crianças e adolescentes com HIV/Aids em uso de terapia antirretroviral. Revista da Associação Médica do Rio Grande do Sul, 55(3), 224-228.
Spinler, S.A. (2006). Challenges associated with metabolic syndrome. Pharmacotherapy, 26(12 Pt 2), 209S-217S. https://doi.org/10.1592/phco.26.12part2.209s
Sun, A., e Ren, J. (2012). Estrogen replacement therapy and cardiac function under metabolic syndrome: a treacherous art. Hypertension, 59(3), 552-554. https://doi.org/10.1161/hypertensionaha.111.186817
Teixeira, MEF, Vitorino, PVO, Amodeo, C., Martinez, T., Brandão, AA, Barbosa, ECD, Feitosa, ADM, Souza, ALL, Jardim, PCBV, e Barroso, WKS (2021). Fatores de risco cardiovascular em cardiologistas especialistas pela Sociedade Brasileira de Cardiologia. Arquivos Brasileiros de Cardiologia, 116(4), 774-781. https://doi.org/10.36660/abc.20200125
Trevillyan, J.M., Cheng, A.C., e Hoy, J. (2013). Abacavir exposure and cardiovascular risk factors in HIV-positive patients with coronary heart disease: a retrospective case-control study. Sexual Health, 10(2), 97-101. https://doi.org/10.1071/sh12081
Unaids (2024). Global HIV & AIDS statistics - Fact sheet. https://www.unaids.org/en/resources/fact-sheet
Watanabe, B.T., Araujo, I.B., Menezes Filho, H.R., Oliveira, D.M., Fernandes, E.V., e Gouvêa-e-Silva, L.F. (2022). Health condition of HIV patients: evaluation of metabolic syndrome and cardiovascular risk. Journal of Health Sciences, 24(4), 277-282. https://doi.org/10.17921/2447-8938.2022v24n4p277-282
Whisman, M.A., Uebelacker, L.A., e Settles, T.D. (2010). Marital distress and the metabolic syndrome: Linking social functioning with physical health. Journal of Family Psychology, 24(3), 367-370. https://doi.org/10.1037/a0019547
WHO (2023). Obesity: preventing and managing the global epidemic report of a WHO consultation on obesity. World Health Organization.
Yanai, H., Tomono, Y., Ito, K., Furutani, N., Yoshida, H., Tada, N. (2008). The underlying mechanisms for development of hypertension in the metabolic syndrome. Nutrition Journal, 7(1), e10. https://doi.org/10.1186/1475-2891-7-10
Zanuzzi, M.G., Cattaneo, M.J., López, S.M., Pérez Maure, M.L.A., Romero, C.A. (2020). Hipertensión y síndrome metabólico en pacientes con virus de la inmunodeficiencia-humana. Medicina (Buenos Aires), 8(5), 453-461. https://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S0025-76802020000700453
Biografía del autor/a
http://lattes.cnpq.br/2109467799397782
http://lattes.cnpq.br/2610000639728202
http://lattes.cnpq.br/4263879851541384
http://lattes.cnpq.br/4471996108642896
http://lattes.cnpq.br/8129687213854509
http://lattes.cnpq.br/0548879430701901
Derechos de autor 2025 Lecturas: Educación Física y Deportes
Esta obra está bajo licencia internacional Creative Commons Reconocimiento-NoComercial-SinObrasDerivadas 4.0.
