On the association between dietary oily fish intake and bone mineral density in frequent fish consumers of Amerindian ancestry. The three villages study.

Reports addressing the effects of oily fish intake on bone health are inconsistent. This study shows that consumption of ≥ 5.2 oily fish servings/week (728 g) is associated with lower prevalence of osteopenia/osteoporosis in elderly women of Amerindian ancestry. Results suggest a beneficial effect of oily fish intake in this population. OBJECTIVES: Oily fish is a major dietary source of omega-3 polyunsaturated fatty acids and other nutrients that may have a positive effect on bone health. However, this association is inconsistent and seems to be more evident in certain ethnic groups. We aimed to assess the association between oily fish intake and bone mineral density (BMD) in frequent fish consumers of Amerindian ancestry living in rural Ecuador. METHODS: This study included 399 individuals aged ≥ 60 years living in three neighboring rural villages of coastal Ecuador. Dietary oily fish intake was quantified systematically using validated surveys and BMD was determined by dual-energy x-ray absorptiometry. Ordinal logistic regression models, adjusted for demographics and cardiovascular risk factors, were fitted to assess the independent association between oily fish intake and bone health. RESULTS: Participants had a mean age of 68.8 ± 6.8 years, and 58% were women. The mean intake of oily fish was 8.5 ± 4.7 servings/week, with 308 (77%) reporting high fish intake (≥ 5.2 servings/week [728 g]). Ninety-four (24%) participants had normal BMD T-scores, 149 (37%) had osteopenia, and 156 (39%) had osteoporosis. Ordinal logistic regression models showed no association between high fish intake and bone health in the total population. When men and women were analyzed separately, the association became significant for women only in both unadjusted (OR: 2.52; 95% C.I.: 1.22 - 5.23) and fully-adjusted models (OR: 2.23; 95% C.I.: 1.03 - 4.81). CONCLUSION: Consumption of ≥ 5.2 oily fish servings/week is associated with lower prevalence of osteopenia and osteoporosis in elderly women of Amerindian ancestry.

Dietary oily fish intake is inversely associated with moderate-to-severe intracranial artery stenosis in older adults of indigenous Ecuadorian ancestry.

BACKGROUND AND AIMS: Information on the association between dietary oily fish intake and intracranial atherosclerosis is limited and contradictory. Inconsistencies might be in part related to heterogeneous designs and differences in race/ethnicity of study populations. We aim to assess whether oily fish intake is inversely associated with intracranial artery stenosis (ICAS) in frequent fish consumers of indigenous ancestry living in coastal Ecuador. METHODS: The study included 384 participants aged ≥60 years enrolled in the Atahualpa Project Cohort. Dietary oily fish intake was quantified systematically via validated surveys and all participants received a time-of-flight MRA of intracranial vessels. Poisson regression models, adjusted for demographics, level of education, traditional risk factors and severe tooth loss, were fitted to assess the association between amounts of oily fish intake and the number of intracranial arteries with moderate-to-severe (≥50 %) stenosis. RESULTS: Participants had a mean age of 67.7 ± 7 years, and 56 % were women. The mean oily fish intake was 8.9 ± 5.2 servings/week; 283 (74 %) participants consumed ≥5.2 servings/week (2nd to 4th quartiles of fish intake). Forty-three (11 %) participants had at least one major intracranial artery with moderate-to-severe stenosis. Both univariate and multivariate models showed a significant inverse association between consumption of oily fish in the 2nd to 4th quartiles and ≥50 % stenosis in at least one artery (ß: 0.46; 95 % C.I.: 0.27-077, and ß: 0.52; 95 % C.I.: 0.30-0.90, respectively). CONCLUSIONS: Consumption of more than five oily fish servings/week is associated with lower prevalence of moderate-to-severe ICAS in indigenous Ecuadorians.

Dietary oily fish intake reduces the risk of all-cause mortality in frequent fish consumers of Amerindian ancestry living in coastal Ecuador: the Atahualpa project.

PURPOSE: To assess the relationship between dietary oily fish intake and all-cause mortality in a population of frequent fish consumers of Amerindian ancestry living in rural Ecuador. METHODS: Individuals aged ≥ 40 years enrolled in the prospective population-based Atahualpa Project cohort received annual questionnaires to estimate their dietary oily fish intake. Only fish served broiled or cooked in the soup were included for analysis. Poisson regression and Cox-proportional hazards models adjusted for demographics, education level and cardiovascular risk factors were obtained to estimate mortality risk according to the amount of oily fish intake stratified in tertiles. RESULTS: Analysis included 909 individuals (mean age: 55.1 ± 12.8 years) followed by a median of 7.5 ± 3 years. Mean oily fish intake was 9.4 ± 5.7 servings per week. A total of 142 (16%) individuals died during the follow-up. The mortality rate for individuals in the first tertile de oily fish intake (0.0-6.29 servings) was 2.87 per 100 person-years, which decreased to 1.78 for those in the third tertile (10.59-35.0 servings). An adjusted Cox-proportional hazards model showed that individuals allocated to the second (HR 0.61; 95% CI 0.41-0.92) and third (HR 0.60; 95% CI 0.40-0.91) tertiles of dietary oily fish intake had significantly lower mortality risk than those in the first tertile. CONCLUSION: Sustained oily fish intake of more than six servings per week reduces mortality risk in middle-aged and older adults of Amerindian ancestry.

Dietary oily fish intake and progression of diffuse subcortical damage of vascular origin: A longitudinal prospective study in community-dwelling older adults.

Introduction: Oily fish intake may reduce the progression of white matter hyperintensities (WMH) of presumed vascular origin due to their high content of omega-3 polyunsaturated fatty acids and other nutrients. However, information on this relationship is limited. We aimed to assess the association between oily fish intake and WMH progression in older adults living in rural coastal Ecuador. Methods: Participants of the Atahualpa Project Cohort received baseline clinical interviews and brain MRIs. Oily fish intake was calculated at every annual door-to-door survey from enrollment to the end of the study. Individuals who also received a follow-up brain MRI were included. Poisson regression models were fitted to assess the incidence rate ratio (IRR) of WMH progression according to the amount of oily fish intake, after adjusting for demographics, level of education and traditional vascular risk factors. Results: The study included 263 individuals of Amerindian ancestry aged ⩾60 years (mean age: 65.7 ± 6.2 years; 57% women). The mean oily fish intake was 8.3 ± 4 servings per week. Follow-up MRIs demonstrated WMH progression in 103 (39%) individuals after a median follow-up of 6.5 years. A multivariate Poisson regression model showed an inverse relationship between oily fish intake and WMH progression (IRR: 0.89; 95% CI: 0.84-0.95; p < 0.001). A similar model also revealed an inverse relationship between tertiles of oily fish intake and probabilities of WMH progression, which became significant when individuals allocated to the third tertile were compared to those in the first and second tertiles. Conclusion: Study results show an inverse relationship between the amount of oily fish intake and WMH progression in frequent fish consumers of Amerindian ancestry.

Risk of exposure to Hg and pesticides residues in a traditional fishing community in the Amazon: a probabilistic approach based on dietary pattern.

Exposure to mercury (Hg) and pesticides (o.p'DDT, p.p'DDT, o.p'DDE, and p.p'DDE) in the Amazon through eating fish is of concern due to the large participation of this food in the diet of traditional fishing communities. The aim of this study was to evaluate the estimated daily intake (EDI) and the incremental lifetime cancer risk associated with Hg and o.p'DDT, p.p'DDT, o.p'DDE, and p.p'DDE in an Amazonian community. The results showed that for Hg, the EDI from carnivorous and detritivorous fish had the highest values, while for pesticides, the EDI from detritivorous fish intake had the highest value. The incremental lifetime cancer risk was below the permitted limit. A recommendation for controlling the high risk of exposure includes the reduction of detritivorous fish ingestion and/or replacement with herbivorous fish, which had lower EDI. We highlight the importance of investigating the human dietary patterns when estimating risk of exposure to Hg and pesticides.

Human health impacts of exposure to metals through extreme consumption of fish from the Colombian Caribbean Sea.

The health risks of metal exposure due to the high consumption of fish were assessed for a riverine population living on the Caribbean coast of Colombia. The concentrations of metals (Cd, Cr, Cu, Hg, Ni, Pb and Zn) in the edible tissues of fish were determined and used for risk assessment. The daily fish consumption of residents (n = 95) was as high as 283, 366 and 469 g/day in children (CH), women of childbearing age (WCHA) and the remaining population groups (RP), respectively. The estimation of the potential risk (HQ) indicated that there was no health risk from most of the metals, because they did not exceed their related reference doses, with values of HQ < 1. Although the concentrations of Pb and Hg were not particularly high in fish (<0.2 µg/g), their possible health effects for vulnerable groups are of great concern due to the extremely high fish intake. The Pb intake for all groups was higher than the lower confidence limit of the benchmark dose for nephrotoxicity and neurodevelopmental effects in children. The weekly intake of methylmercury was also elevated, with values approximately 3, 2 and 1.5 times the provisional tolerable weekly intake for CH, WCHA and RP, respectively. Moreover, higher Hg levels were found in top predators, whereas maximum levels for other metals were found in bottom-feeding fish. This study highlights that an accurate data of daily intake, a continuous monitoring of metals in fish and their related fish consumption advisories to protect subsistence fishing communities are recommended in a local and worldwide context.

Low prevalence of atrial fibrillation in Amerindians: a population-based study in frequent fish consumers living in rural coastal Ecuador (The Atahualpa Project).

BACKGROUND: Information on the burden of atrial fibrillation (AF) in rural areas of developing countries is limited. Here, we aimed to assess AF prevalence in community-dwelling older adults living in rural Ecuador. METHODS: Atahualpa residents aged ≥60 years (mean age 70.5 ± 8.1 years) underwent 24-h Holter monitoring. Participants belong to the Amerindian ethnic group. The mean height in the study population was 147.9 ± 8.9 cm. Oily fish was a major source of food (mean intake: 8 ± 4 servings/week). RESULTS: Seven of 298 participants (2.3%) had AF. Persons with AF were older than those without (p = 0.051), but there were no differences in cardiovascular risk factors across groups. None of the seven AF cases had been detected in routine 12-lead ECGs taken at enrollment. CONCLUSIONS: Prevalence of AF in older Amerindians living in rural Ecuador is low. Both, racially-determined short stature and frequent dietary oily fish intake might explain the low prevalence of AF in this rural setting.

Factors associated with mercury levels in human placenta and the relationship to neonatal anthropometry in Jamaica and Trinidad & Tobago.

The aim of this study was to investigate the mercury levels in human placenta and its relationship to neonatal anthropometry for a group of selected pregnant women in Kingston and Manchester in Jamaica and St. Joseph in Trinidad & Tobago. The participants were interviewed on their fish intake. Neonatal anthropometric data were also recorded. The placental mercury concentrations ranged from 0.64±0.5µg/kg to 1.4±0.6µg/kg. The most significant associated factor for prenatal mercury exposure was maternal fish intake. Those pregnant women who regularly ate shark recorded the highest placenta mercury concentrations. Their neonates also had slightly smaller mean head circumference and lower birth weight. The mean placental mercury concentrations in this study were found to be lower than the literature values. Therefore it was difficult to detect any significant changes in neonatal anthropometry. This type of study can contribute to the extent of mercury exposure in the region.

Fish consumers in the pioneer northern Region of the State of Paraná / Perfil dos consumidores de peixes na região Norte Pioneiro do Paraná

The social, economic and cultural situation and the habits and preferences of fish consumers are analyzed. The municipalities focused for current research are Bandeirantes, Cambará, Santo Antônio da Platina, Andirá, Cornélio Procópio and Itambaracá, within the meso-region of the so-called Pioneer Northern Region of the state of Paraná, Brazil. Three hundred and forty-six structured questionnaires with seventeen multiple choice objective questions, featuring qualitative and quantitative variables, were handed out. Results show that 92% of the interviewed people ate fish; 55% earned more than three Brazilian minimum wages; 41% went to secondary school and 66% of the families comprised between three and five members. Mean fish consumption reached 18 kg/inhab/year; 54% of interviewed were over 40 years old; 37% preferred fish fillet; mostly prepared as fried fish. Moreover, the main obstacles for increase in consumption for 53% of the interviewed were high prices and non-availability of the product. The supermarket was the preferred place for purchase. Consumers in the Pioneer Northern Region of the Paraná have a relevant preference for fish, with a high capacity for per capita consumption increase even though supply and prices are strategic issues which require investigation.(AU)

Este estudo teve como objetivo analisar a situação socioeconômica, cultural e conhecer os hábitos e preferências dos consumidores de peixes. Os municípios selecionados para realização da pesquisa foram Bandeirantes, Cambará, Santo Antônio da Platina, Andirá, Cornélio Procópio e Itambaracá, que estão inseridos na mesorregião do Norte Pioneiro do Paraná. Um total de 346 questionários estruturados com 17 questões objetivas de múltipla escolha foi aplicado, com variáveis qualitativas e quantitativas. Dentre o total de entrevistados 92% afirmam consumir peixes, 55% apresentam renda superior a três salários mínimos, 41% possuem nível escolar médio, 66% das famílias tem composição de três a cinco pessoas. O consumo médio de peixes verificado é de 18 kg/hab/ano, onde 54% apresentam idade superior a 40 anos, com frequência semanal de consumo de 37%, a forma de compra predileta do produto é o filé, e a forma de preparo mais utilizada pela grande maioria é peixe frito. Para 53% o alto preço no varejo e a disponibilidade do produto são os principais entraves para o aumento do consumo e tem o supermercado como o local preferido para compra. Verificou-se que os consumidores do Norte Pioneiro do Paraná apresentam grande aceitação ao consumo de peixes, bem como potencial para aumento de consumo per capta, entretanto, foi observada a necessidade que questões estratégicas como oferta e preço sejam trabalhadas.(AU)

Fish consumers in the pioneer northern Region of the State of Paraná / Perfil dos consumidores de peixes na região Norte Pioneiro do Paraná

The social, economic and cultural situation and the habits and preferences of fish consumers are analyzed. The municipalities focused for current research are Bandeirantes, Cambará, Santo Antônio da Platina, Andirá, Cornélio Procópio and Itambaracá, within the meso-region of the so-called Pioneer Northern Region of the state of Paraná, Brazil. Three hundred and forty-six structured questionnaires with seventeen multiple choice objective questions, featuring qualitative and quantitative variables, were handed out. Results show that 92% of the interviewed people ate fish; 55% earned more than three Brazilian minimum wages; 41% went to secondary school and 66% of the families comprised between three and five members. Mean fish consumption reached 18 kg/inhab/year; 54% of interviewed were over 40 years old; 37% preferred fish fillet; mostly prepared as fried fish. Moreover, the main obstacles for increase in consumption for 53% of the interviewed were high prices and non-availability of the product. The supermarket was the preferred place for purchase. Consumers in the Pioneer Northern Region of the Paraná have a relevant preference for fish, with a high capacity for per capita consumption increase even though supply and prices are strategic issues which require investigation.

Este estudo teve como objetivo analisar a situação socioeconômica, cultural e conhecer os hábitos e preferências dos consumidores de peixes. Os municípios selecionados para realização da pesquisa foram Bandeirantes, Cambará, Santo Antônio da Platina, Andirá, Cornélio Procópio e Itambaracá, que estão inseridos na mesorregião do Norte Pioneiro do Paraná. Um total de 346 questionários estruturados com 17 questões objetivas de múltipla escolha foi aplicado, com variáveis qualitativas e quantitativas. Dentre o total de entrevistados 92% afirmam consumir peixes, 55% apresentam renda superior a três salários mínimos, 41% possuem nível escolar médio, 66% das famílias tem composição de três a cinco pessoas. O consumo médio de peixes verificado é de 18 kg/hab/ano, onde 54% apresentam idade superior a 40 anos, com frequência semanal de consumo de 37%, a forma de compra predileta do produto é o filé, e a forma de preparo mais utilizada pela grande maioria é peixe frito. Para 53% o alto preço no varejo e a disponibilidade do produto são os principais entraves para o aumento do consumo e tem o supermercado como o local preferido para compra. Verificou-se que os consumidores do Norte Pioneiro do Paraná apresentam grande aceitação ao consumo de peixes, bem como potencial para aumento de consumo per capta, entretanto, foi observada a necessidade que questões estratégicas como oferta e preço sejam trabalhadas.

Fish consumers in the pioneer northern Region of the State of Paraná / Perfil dos consumidores de peixes na região Norte Pioneiro do Paraná

The social, economic and cultural situation and the habits and preferences of fish consumers are analyzed. The municipalities focused for current research are Bandeirantes, Cambará, Santo Antônio da Platina, Andirá, Cornélio Procópio and Itambaracá, within the meso-region of the so-called Pioneer Northern Region of the state of Paraná, Brazil. Three hundred and forty-six structured questionnaires with seventeen multiple choice objective questions, featuring qualitative and quantitative variables, were handed out. Results show that 92% of the interviewed people ate fish; 55% earned more than three Brazilian minimum wages; 41% went to secondary school and 66% of the families comprised between three and five members. Mean fish consumption reached 18 kg/inhab/year; 54% of interviewed were over 40 years old; 37% preferred fish fillet; mostly prepared as fried fish. Moreover, the main obstacles for increase in consumption for 53% of the interviewed were high prices and non-availability of the product. The supermarket was the preferred place for purchase. Consumers in the Pioneer Northern Region of the Paraná have a relevant preference for fish, with a high capacity for per capita consumption increase even though supply and prices are strategic issues which require investigation.

Este estudo teve como objetivo analisar a situação socioeconômica, cultural e conhecer os hábitos e preferências dos consumidores de peixes. Os municípios selecionados para realização da pesquisa foram Bandeirantes, Cambará, Santo Antônio da Platina, Andirá, Cornélio Procópio e Itambaracá, que estão inseridos na mesorregião do Norte Pioneiro do Paraná. Um total de 346 questionários estruturados com 17 questões objetivas de múltipla escolha foi aplicado, com variáveis qualitativas e quantitativas. Dentre o total de entrevistados 92% afirmam consumir peixes, 55% apresentam renda superior a três salários mínimos, 41% possuem nível escolar médio, 66% das famílias tem composição de três a cinco pessoas. O consumo médio de peixes verificado é de 18 kg/hab/ano, onde 54% apresentam idade superior a 40 anos, com frequência semanal de consumo de 37%, a forma de compra predileta do produto é o filé, e a forma de preparo mais utilizada pela grande maioria é peixe frito. Para 53% o alto preço no varejo e a disponibilidade do produto são os principais entraves para o aumento do consumo e tem o supermercado como o local preferido para compra. Verificou-se que os consumidores do Norte Pioneiro do Paraná apresentam grande aceitação ao consumo de peixes, bem como potencial para aumento de consumo per capta, entretanto, foi observada a necessidade que questões estratégicas como oferta e preço sej

Polymorphisms in glutathione-related genes modify mercury concentrations and antioxidant status in subjects environmentally exposed to methylmercury.

Methylmercury (MeHg) toxicity may vary widely despite similar levels of exposure. This is hypothetically related to genetic differences in enzymes metabolizing MeHg. MeHg causes oxidative stress in experimental models but little is known about its effects on humans. The aims of the present study was to evaluate the effects of polymorphisms in glutathione (GSH)-related genes (GSTM1, GSTT1, GSTP1 and GCLM) on Hg concentrations in blood and hair, as well as MeHg-related effects on catalase (CAT) and glutathione-peroxidase (GPx) activity and GSH concentrations. Study subjects were from an Amazonian population in Brazil chronically exposed to MeHg from fish. Hg in blood and hair were determined by ICP-MS, CAT, GPx and GSH were determined by spectrophotometry, and multiplex PCR (GSTM1 and GSTT1) and TaqMan assays (GSTP1 and GCLM) were used for genotyping. Mean Hg concentrations in blood and hair were 48±36 µg/L and 14±10 µg/g. Persons with the GCLM-588 TT genotype had lower blood and hair Hg than did C-allele carriers (linear regression for Hg in blood ß=-0.32, p=0.017; and hair ß=-0.33; p=0.0090; adjusted for fish intake, age and gender). GSTM1*0 homozygous had higher blood (ß=0.20; p=0.017) and hair Hg (hair ß=0.20; p=0.013). Exposure to MeHg altered antioxidant status (CAT: ß=-0.086; GSH: ß=-0.12; GPx: ß=-0.16; all p<0.010; adjusted for gender, age and smoking). Persons with GSTM1*0 had higher CAT activity in the blood than those with GSTM1. Our data thus indicate that some GSH-related polymorphisms, such as GSTM1 and GCLM may modify MeHg metabolism and Hg-related antioxidant effects.

Relação entre a freqüência de consumo de carne e pescado e os níveis de hexaclorobenzeno, lindano, aldrin e 4,4' - diclorodifenil - 1,1' dicloroetileno, em tecido adiposo de glândulas mamárias de mulheres espanholas

The levels of organochlorine pesticide residues FONT FACE=Symbol>¾ /FONT> hexaclorobenzene (HCB), lindane (gamma-HCH), aldrin and 4,4'dichloro diphenil 1,1'dichloroethylene (p,p'-DDE) - present in mammary adipose tissue samples from women living in Cordoba (Spain) were evaluated. The compound found at the highest concentration was p,p´-DDE (1.869(mug/g of adipose tissue), which was present in 100% of the analyzed samples. The average levels of HCB, gamma-HCH and aldrin were 0.236, 0.003 and 0.006mug/g of adipose tissue, respectively. The tissue levels of organochlorine residues were correlated with the weekly intake of meat and fish by donors. Only the tissue levels of p-p´-DDE were significantly (p FONT FACE=Symbol>£ /FONT>0.05) affected by the frequency of meat intake. Donors with a meat intake higher than four times a week presented an average level of 2.833mug/g of adipose tissue.

Níveis de resíduos dos pesticidas organoclorados, hexaclorobenzeno (HCB), lindano gama-HCH), aldrin e 4,4'-diclorodifenil-1,1'dicloroetileno (p,p'-DDE) foram determinados em tecido adiposo mamário de mulheres residentes em Córdoba, Espanha. A maior concentração média foi detectada para o p,p'-DDE (1,869 mig/g de tecido adiposo), que estava presente em 100% das amostras. As concentrações médias de HCB, gama-HCH e aldrin encontrados foram 0,236, 0,003 e 0,006mig/g de tecido adiposo, respectivamente. Os níveis dos resíduos detectados nas amostras foram relacionados ao consumo semanal de carne e pescado pelas doadoras. O único composto cujos níveis variaram significativamente (p FONT FACE=Symbol>£ /FONT>0,05) em função da freqüência de consumo de carne foi o p,p'-DDE, tendo apresentado concentração média de 2,833 mig/g de tecido adiposo quando as doadoras relataram uma freqüência de consumo de carne superior a quatro vezes por semana.

Relação entre a freqüência de consumo de carne e pescado e os níveis de hexaclorobenzeno, lindano, aldrin e 4,4' - diclorodifenil - 1,1' dicloroetileno, em tecido adiposo de glândulas mamárias de mulheres espanholas

The levels of organochlorine pesticide residues FONT FACE=Symbol>¾ /FONT> hexaclorobenzene (HCB), lindane (gamma-HCH), aldrin and 4,4'dichloro diphenil 1,1'dichloroethylene (p,p'-DDE) - present in mammary adipose tissue samples from women living in Cordoba (Spain) were evaluated. The compound found at the highest concentration was p,p´-DDE (1.869(mug/g of adipose tissue), which was present in 100% of the analyzed samples. The average levels of HCB, gamma-HCH and aldrin were 0.236, 0.003 and 0.006mug/g of adipose tissue, respectively. The tissue levels of organochlorine residues were correlated with the weekly intake of meat and fish by donors. Only the tissue levels of p-p´-DDE were significantly (p FONT FACE=Symbol>£ /FONT>0.05) affected by the frequency of meat intake. Donors with a meat intake higher than four times a week presented an average level of 2.833mug/g of adipose tissue.

Níveis de resíduos dos pesticidas organoclorados, hexaclorobenzeno (HCB), lindano gama-HCH), aldrin e 4,4'-diclorodifenil-1,1'dicloroetileno (p,p'-DDE) foram determinados em tecido adiposo mamário de mulheres residentes em Córdoba, Espanha. A maior concentração média foi detectada para o p,p'-DDE (1,869 mig/g de tecido adiposo), que estava presente em 100% das amostras. As concentrações médias de HCB, gama-HCH e aldrin encontrados foram 0,236, 0,003 e 0,006mig/g de tecido adiposo, respectivamente. Os níveis dos resíduos detectados nas amostras foram relacionados ao consumo semanal de carne e pescado pelas doadoras. O único composto cujos níveis variaram significativamente (p FONT FACE=Symbol>£ /FONT>0,05) em função da freqüência de consumo de carne foi o p,p'-DDE, tendo apresentado concentração média de 2,833 mig/g de tecido adiposo quando as doadoras relataram uma freqüência de consumo de carne superior a quatro vezes por semana.