*Manuscript (All Manuscript Text Pages in MS Word format, including Title Page, References and Figure Legends)

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INTERNATIONAL PHYSICAL ACTIVITY QUESTIONNAIRE

OVERESTIMATION IS AMELIORATED BY INDIVIDUAL ANALYSIS OF
THE SCORES
Valmore J. Bermdez, MD, MPH, PhD1
Joselyn J. Rojas, MD, MgSc1
Evelyn B. Crdova, MgSc2
Roberto Aez BSc1
Alexandra Toledo, BSc1
Miguel A. Aguirre, MD, MgSc1
Climaco Cano, PharmD1
Nailet Arraiz, MgSc, PhD1
Manuel Velasco, MD, PhD3
Jos Lpez Miranda, MD, PhD4
1 Endocrine and Metabolic Diseases Research Center. The University of Zulia, Maracaibo,
Venezuela.
2 Quantitative Methods Department, School of Economics, The University of Zulia, Maracaibo,
Venezuela.
3 Clinical Pharmacologic Unit. Vargas Medical School, Central University of Venezuela.
Caracas-Venezuela
4 Lipid and Atherosclerosis Unit, Department of Medicine. IMIBIC/Reina Sofia University
Hospital/University of Cordoba, and CIBER Fisiopatologa Obesidad y Nutricin (CIBEROBN),
Instituto de Salud Carlos III, Spain.
Short Title: IPAQ in The Maracaibo City Metabolic Syndrome Prevalence Study
Corresponding Author: Valmore Bermdez P. The University of Zulia, Endocrine and Metabolic
Diseases Research Center, 20th Avenue, Maracaibo 4004, Venezuela. Telephone/Fax Number:
58-261-7597279. *E-mail: vbermudez@hotmail.com

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Abstract
Background: Sedentarism is considered a risk factor for Coronary Heart Disease and Death from
any cardiovascular disease. The International Physical Activity Questionnaire (IPAQ) assesses
physical activity (PA) in metabolic equivalents, using four dimensions: occupation,
transportation, household activities and leisure time physical activity.
Objective: The purpose of this investigation was to assess physical activity levels in the patients
enrolled in The Maracaibo City Metabolic Syndrome Prevalence Study, currently undertaken by
the Dr. Flix Gmez Endocrine-Metabolic Research Center.
Materials and Methods: 2108 individuals were recruited and subjected to a standard Medical
chart, Graffar scale and IPAQ-Long Form, applied by trained personnel. Description of the
population was done using mean, standard deviation and coefficient of variation. IPAQ scores
were analyzed as medians and distributed by percentiles.
Results: from the 2108 individuals 46.9% were males and 53.1% were females. The most
prevalent physical activity was High-PA with 39.9%, followed by Moderate-PA with 36.9%, and
Low-PA with 23.2%. Medians for each IPAQ dominion were: Occupation with 0.00 (0.00
66.00), Transportation with 165.00 (0.00-463.00), Household activities with 772.50 (0.00
2,520.00), and Leisure time with 0.00 (0.00 594.00). Using Leisure time scores, a new
reclassification was conducted, obtaining 1245 subjects with 0 METs in this dominion. From this
new subsample, 43,6% had High-PA, 56.95% had Moderate-PA, and 91% had Low-PA,
demonstrating an important overestimation in the former sample results.
Conclusions: IPAQ overestimates moderate and vigorous activity in the adult population of the
Maracaibo Municipality. Overestimation is mainly located in the Household and gardening
related activity.
Key words: international physical activity questionnaire, exercise, cardiovascular risk,
overestimation, household and gardening physical activity, leisure time

Introduction
Inactivity was first considered as a risk factor for coronary artery disease by the American Heart
Association in 1992 [1] after a series of studies analyzing the role of exercise in primary and
secondary prevention of cardiovascular disease, ensuring that aerobic physical activity during
leisure time is a favorable [2-6] and needed trait in an individuals lifestyle [7-8]. Physical
activity is defined as any movement realized by skeletal muscles which consumes energy and its
expressed in kilocalories [9-10]. Since physical activity evaluation is rather subjective, relying on
the patients ability to recall and the physicians knowledge as well as spared time to actually

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ask such details there was tremendous pressure to develop standard international surveys to
measure physical activity objectively, either in a medical appointment or in large population
studies [11]. Several data gathering methods to measure physical activity have been devised [1112], which have gained popularity over the years due to their ease of use and answering [13-15].
In spite of these apparent virtues, it has been reported overtime that these questionnaires are
subject to overestimation of physical activity, especially in the case of the International Physical
Activity Questionnaire (IPAQ) [16]. Even though this survey method has been validated [14-17],
during the last decade several reports have suggested that IPAQ is inadequate for certain age
groups [18]; i.e., that overestimates physical activity, especially among Hispanic populations [1920].
The Maracaibo City Metabolic Syndrome Prevalence Study (MMSPC) [21] is a research program
currently undertaken in the city of Maracaibo-Venezuela by the Endocrine and Metabolic
Diseases Research Center at the University of Zulia, whose main goals are to define and describe
risk factors associated with Metabolic Syndrome in the urban population of Venezuelan. In this
study, the objectives included the assessment of physical activity within the population according
to IPAQ and analyzing whether or not these results were subject to overestimation as it has been
observed in other countries.

Materials and Methods

Ethics Statement
All participants signed a written consent before being interrogated and physically examined. The
study was approved by the Ethics Committee of the Endocrine and Metabolic Diseases Research
Center.
Subjects
Currently, the study has 2108 enrolled subjects, male and female, beyond 18 years of age,
randomly chosen from Maracaibo parishes through July 2008 till July 2010 as previously
described21.. The subjects were interviewed to obtain a full medical history using a medical
history chart approved by the Venezuelan Popular Powers Health Ministry. Socioeconomic status
was assessed using the Graffar Scale modified by Mendez-Castellano [22] which is an adapted
version of the original Graffar instrument for Venezuelan sociocultural variables.
Physical Activity
The IPAQ-Long Form was applied via personal interview by trained personnel from the study.
The IPAQ was designed to assess physical activity within four specific domains: leisure time,
occupation, transportation and household activities. The reported minutes used in each asked task
in every category were weighted by metabolic equivalents, which gives a physical activity

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estimate expressed in MET/minutes/week, defined as the energy consumed by an individual in a

resting state, which is roughly 1 kcal/kg/hour [23]. All the scores were added and the final result
is used to classify the subject either in: a) Low physical activity, known as physically inactive
or sedentary; b) Moderate physical activity level, which consists of at least 3 days of vigorous
physical activity of >20 minutes, or 5 days of moderate activity, or walking for > 30 minutes a
day for >10 minutes at a time, or a combination of any of the previous, which assures
achievement of at least 600 MET/min/week; and c) High physical activity which agrees with
either any of these two criteria or both: vigorous activity on >3 days a week accumulating at least
1500 MET/minutes/week, or >5 days of any combination of activities which achieve 3000
MET/minutes/week [24].
Statistical analysis
The data were analyzed using the Statistical Package for the Social Sciences (SPSS) v. 19 for
Windows (SPSS IBM Chicago, IL). Age was expressed as arithmetic mean SD (standard
deviation), complemented with the Coefficient of Variation (CV). Qualitative variables were
expressed as absolute and relative frequencies. Normal distribution was evaluated using Gearys
test. IPAQ score medians were distributed in percentiles and were analyzed according to their
distribution. Proportions difference test was used applying Pearsons 2 Test between Physical
Activity Patterns, which was significant if p<0,05.

Results
Gender, Age, Ethnicity and Socioeconomic Status
A total of 2108 individuals were cross-examined, where 46.9% were males (n=988) and 53.1%
(n=1120) were females. Mean Age was 38.68 15,42 years (CV=42.04%), men with a mean age
of 36.97 14.94 years old (CV= 40.41%) and women with 40.19 15.67 years old (CV=
38.99%). The sample was classified according to age groups, depicted in Table 1. The
predominant racial group was the Venezuelan Mixed Race with 75.2% (n=1585), followed by
Hispanic Whites with 16.2% (N=341), Amerindians with 4.8% (n=101), Afro-Venezuelans with
3.1% (n=66), Asian descendants with 0.6% (n=13) and Middle Eastern descendants with 0.1%
(n=2). Graffar Scale stratifying is shown in Table 1. Current Professional and Working Statuses
are depicted in Figure 1 Panels A and B respectively.
Physical Activity Patterns
The most prevalent activity pattern was High Physical Activity (HPA) with a percentage of
39.9% (n=841), followed by Moderate Physical Activity (MPA) with 36.9% (n=778), and
Low Physical Activity (LPA) in the last place, with 23.2% (n=489). Comparing the results
according to Gender, Women had 20.6% (n=435) for HPA, while Men had 19.3% (n=406); for
MPA Women had 20.4% (n=430) and Men had 16.5% (n=348); and, for LPA Women had 12.1%

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(n=255) while Men had 11.1% (n=234). Pearsons 2 test between proportions according to
Gender showed no significant difference (p=0.319). Physical Activity according to the age
groups, Occupational Status and Gender is shown in Table 2.
The overall MET/min/week median was 2383.50 (795.25 5,480.75), while each dominion
obtained the following: Occupation 0.00 (0.00 66.00), Transportation 165.00 (0.00-463.00),
Household activities 772.50 (0.00 2,520.00), and Leisure time 0.00 (0.00 594.00). It is
remarkable that both Occupation and Leisure time have medians equal to 0 MET/min/week
indicating that over half of the subjects do not expend any metabolic equivalents in these
dominions. Given this fact, we decided to analyze each dominion separately according to gender,
and try to find the anomaly observed in these results.
Physical Activity and Dominion according to the Pattern
Figure 2 Panel A shows overall METs medians from the whole sample distributed in
percentiles. Percentiles 10th, 20th, and 30th dont match the values observed in the Total bar, not
even the lowest percentile in the bar (p10th = 139.95 MET/Min/week). Household and related
activities had the highest MET/Min/week values (p90th = 4,186.50). Leisure time activity was the
one with the lowest values, p90th with 1.260 MET/Min/week. When analyzing the Total bar in
the HPA pattern (Figure 2 Panel B), the 10th percentile had 3,399.60 MET/Min/week, and none
of the domains had METs consumed at p10th. This finding repeats itself at percentiles 20th, 30th,
40th and 50th within the Total bar, in comparison with their correspondent dominions, which
raises the matter of overestimation. In the MPA pattern (Figure 2 Panel C) the 10th percentile in
the Total bar has a value 693.85 MET/Min/week, while the 10th percentiles within the dominions
have zero as value. This also occurs in the p20th which has 844.50 MET/Min/week but in the rest
of the bars this percentile are empty, showing the same phenomena as HPA. In the LPA pattern
(Figure 2 Panel D) the subjects had no physical activity associated to their workplace or do not
work at all. Moreover, they dont do any physical activity during their leisure time, and
Household and gardening activities take up the majority of the physical activity found in this
group. The HPA, MPA and LPA according to gender are shown is shown in Figure 3.
New Distribution according to Leisure Time
Since overestimation appears to be evident within this sample, we reselected the patients who had
obtained 0 MET/Min/week in the Leisure Time score and correlated the results with the original
ones. In Figure 3 Panel A those who had 0 MET/Min/week in the Leisure time score (n=1245,
59.06%) were redistributed, being expressed in MET/Min/week medians and distributed in
percentiles. It can be observed that in this subsample, Household and Gardening activities
predominate in caloric consumption (p90th = 4,350 MET/Min/week), followed by Occupation
(p90th = 2,924.40 MET/Min/week), and finally Transportation (p90th = 990 MET/Min/week). The
HPA pattern was recalibrated with those who had 0 MET/Min/week, were classified as HPA, and
it is shown in Figure 3 Panel B. The original sample with HPA had n=841 subjects and after
reclassification 43,6% (n=367) had 0 MET/Min/week in Leisure Time. In regards of the other

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dominions, Occupation had p90th of 7,624.80 MET/Min/week, Transportation with p90th with
2,772 MET/Min/week, and Household with p90th of 8,820 MET/Min/week (and interestingly a
p10th of 78 MET/Min/week). The MPA reclassification is depicted in Figure 3 Panel C. The
original sample this pattern had 778 subjects, and within 443 of these individuals have 0
MET/Min/week (56,95%). The subjects were redistributed in percentiles, showing that
Occupation had only p90th with 654 MET/Min/week and the rest of the percentiles with zero
value, in Transportation the p90th was 822.60 MET/Min/week, and in Household p90th was 2,373
MET/Min/week. Finally, those with LPA were also reclassified and it is shown in Figure 3
Panel D, with 91% (n=445) of the subjects with 0 MET/Min/week. Occupation and Leisure Time
have zero values. Transportation had p90th 231 MET/Min/week, p80th with 99 MET/Min/week
and the rest of the percentiles at zero value. Finally, in Household, p90 th is predominant, with
1,080 MET/Min/week in the 90th percentile and a p60th of 55 MET/Min/week.

Discussion
The following investigation conveys several results which raise concern regarding IPAQs use in
our population. Perhaps the most important finding is that HPA was the most prevalent PAP in
our group, yet 59.06% of the sample had 0 METs when Leisure Time score was analyzed.
Similar results have been published, such as the case of the World Health Survey estimated
physical inactivity in 51 countries (Venezuela was not included) using the IPAQ-7days form,
reporting that 15% of the men and 20% of the women were physically inactive, sedentarism was
more prevalent in wealthier countries, and migration was associated with sedentary behavior
[25]. These results are similar to other Latin American based studies like Secln-Palacn and
Jacoby [26] in Per and Hernandez et al. [27] in Mexico, which show a high sedentarism
prevalence in urban areas.
In the present study, Professional Women employed or unemployed had MPA or HPA;
nevertheless, the majority of these women were found in the Household activities area, having
higher Household and gardening activities IPAQ Scores, which relates to the prevalence observed
in Figure 3 - Panel A. Stamatakis et al. [28] studied the actual preventive value of domestic
physical activity in 13,726 individuals, reporting that this type of physical activity offers no
protection on CVD, and that efforts should be focused in promoting moderate and/or vigorous
physical activity during leisure time. Household and gardening activities dont consume high
amounts of calories due to the use of smaller muscles in the upper body and the application of
intermittent and less intense vigorous movements, so even though it is highly prevalent it doesnt
confer cardiovascular protection [29].
Occupation related physical activity is the second most prevalent in our study. The role of this
kind of activity in preventing CVD is still unclear. Even though almost all the evidence points

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towards Leisure Time physical activity as the cardioprotective feature of the four domains [3031], Occupational physical activity is associated with lower body weight in Chinese adults, as it
was published by Monda et al. [32] while studying data from the China Health and Nutrition
Surveys. Salmon et al. [33] reported that less-skilled workers were unlikely to do any form of
activity during leisure time and that homemakers and those subjects to lower occupation status
werent prone to do vigorous activity during leisure time. In our study, Illiterate subjects
(employed or unemployed) were most likely to report MPA, while Unprofessionals (employed or
unemployed) resulted in either MPA or HPA. Employed Professionals tended to report LPA or
MPA, while Professionals who were Unemployed reported higher HPA, which relates to what
Hernndez et al. [27] published.
In regards to the Transportation score, its almost doubled in Males compared to Females and this
tendency is maintained among the 3 PAP. The prevalence of physical activity associated to nonmotorized transportation depends on several factors including enjoyable scenery, available
sidewalks and traffic [34-35]. Cervero et al. [19] conducted a survey in an urban neighborhood of
Bogot assessing the influence of planned bicycle pathways within such areas and the amount of
Leisure Time and Transportation physical activities, comparing measurements between IPAQ
and accelerometer, reporting that cycling, car ownership, education level, and age are associated
with active Transportation.
The only type of physical activity truly related to a favorable profile concerning CVD is physical
activity during Leisure Time, which is basically exercise of moderate or vigorous intensity [3639]. Slattery et al. [40] reports that leisure time physical activity is inversely correlated to death
and Cerebrovascular disease, being responsible for 30-40% of the deaths by any cause, even after
adjusting age, blood pressure, smoking and cholesterol levels. Cardiorespiratory fitness is a
strong protective feature against metabolic syndrome, and in this way, against CVD, especially in
high risk patients who engage in >3hour/week of moderate or vigorous physical activity during
Leisure Time [41]. In the study, Leisure time physical activity was found to be non-predominant,
not even in HPA. In regards to Gender Men prevailed over Women but there were discrepancies
in HPA and MPA. The minimum MET/week/minute required to be qualified as HPA is 3,000
MET/week/minute, which should be considered as the lowest value to be had within the chart,
yet not even in the lowest percentiles in each gender graphic do the subjects achieve such
requirements. In MPA, the same phenomenon is observed, with 10th percentiles with zero value
on both sexes.
In regards to the overestimation observed in the former figures, we decided to select all the
subjects that had 0 MET/Min/week in their Leisure Score, obtaining 1,245 individuals from the
original sample (n=2108). The HPA was reanalyzed only with those subjects who had 0
MET/Min/week in the Leisure time score, obtaining 841 subjects, of whom 367 (43,6%) had 0
MET/Min/week, yet it was observed that Household had a high predominance with p10 th of 78
MET/Min/week and a p90th of 8,820 MET/Min/week. In the MPA the same phenomena is

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observed, yet the overestimation is more than half of the original sample (56.95%). Between
Moderate and Vigorous patterns 810 subjects have been misclassified, pointing out a serious
problem with the evaluation or scoring which would lead to over-reporting.
Rzewnicki et al. [16] were one of the first ones to point-out the overestimation of the
questionnaire, publishing that over 40% of the subjects over-reported moderate/vigorous physical
activity and walking, while 44% of the individuals under-reported physical activity. In relation to
this, Ekelund et al. [42] reported that IPAQ had 45% sensibility to identify insufficiently active
subjects, and has a 77% specificity to identify those with moderate/vigorous physical activity.
Bauman et al. [43] and Ainsworth et al. [44] have published overestimations in MPA, suggesting
that the problem might be the mishandling of the 30x5 rule, because this is not measured in
Leisure Time specifically, its added up with the scores from Occupational, Transportation and
Household. As a final point, Hallal et al. [20] suggested that Leisure Time and Transport related
physical activities scores should be used individually while surveilling Latin American countries,
due to language barrier and academic deficiencies seen in these populations.
In regards to our study, several factors can be outlined as possible influencers concerning
overestimation. The instrument is originally an English material which was designed in a higher
academic level, and even though it has a validated translated Spanish version, it lacks the local
sociocultural language aspects of this specific Latin-American population, making it subject to
interpretation errors. Moreover, there are some concerns in regards to its inespecificity when
evaluating physical activities (i.e. light weight or heavy weight concepts). And perhaps the
most important factor, it is not adapted to Latin American culture, so questions involving snow,
wood work or other Anglo-Saxon customs are not understood and answered out of context. In
relation to the latter, Venezuelas scholarity level is not the same as that observed in developed
countries like USA. Even though the literacy in Venezuela has risen over time, with 93% literacy
in the adult population (15 years and older) [45] and enrollment in education of 91% for primary
and secondary education [45], there is still the matter of ~7% illiteracy in the population, which is
predominant in the indigenous populations, rural areas and poverty/extreme poverty strata. The
degree of desertion is actually high with an overall frequency of 35% for our country [46-47],
where 40-70% of children drop out before finishing primary school, and there are serious
limitations in the coverage of secondary high school material. All these factors render a
population profile which seems unfit to fully understand and properly answer the questions in the
instrument, suggesting the necessity for an adaptation, just as it has been done previously in other
cultures [48-50].
Our study has several strengths such as a representative sample, leveled gender distribution, and
trained personnel who applied the questionnaire. As for the limitations of the study, this is a
cross-sectional design hence so no follow-up on the patients was done nor comparison with a
direct method for physical activity measurement such as pedometers or accelerometers.

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Conclusions
This study highlights the degree of sedentarism in this population, in spite of having been
classified as physically active by the instrument. We suggest that IPAQ scores be analyzed and
interpreted individually, to properly assess physical activity status in the subjects.

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FIGURE TITLES

Figure 1. Professional and Occupational Status according to Gender, Maracaibo Municipality 2010.
Panel A - Current Professional Status. The categories were distributed according to incidence: Students
19.8% (n= 418), Household activities 17.7% (n=373), Manual Labor Workers 14.0% (n=295),
Engineer/Architect and Craftsmanship with a combined result of 4.3% (n=91). The rest of the population
were distributed in the remainder of the categories. According to Gender and Occupation, Household
activities (99.7%) was the predominant occupation for the women, while men was Transport (99.4%).
Panel B - Current Occupational Status. Employed Unprofessional 29.9% (n=631), Employed Professional
24.4% (n=515), Unemployed Unprofessional 18.4% (n=388), University Student 14.8% (n=313),
Unemployed Professional 4.8% (n=101), Non-University Student 3.2% (n=68), Retired 2.1% (n=44),
Unemployed Illiterate 1.4% (n=30) and Employed Illiterate with 0.9% (n=18). Within the Unemployed
Unprofessional category, 72.7% (n=282) are in the Household activities section. In the Unemployed
Illiterate, over 75% are women, while in the Employed Illiterate over 65% are men. In regards of the
Professional venue, men dominated the Employed and Unemployed aspects. It is noteworthy to point out
that women predominate (>80%) in the Unemployed Unprofessional.

Figure 2. Behavior of Physical Activity in the General Population expressed in MET/Min/Week

Maracaibo Municipality 2010.
The figure depicts MET/Min/Week medians distributed in percentiles according to each dominion. Panel
A shows the overall MET/Min/Week amounts in each category with the data obtained from the whole
sample. Physical Activity Patterns are described according to their classification, with High Physical
Activity in Panel B , Moderate Physical Activity in Panel C and Low Physical Activity in Panel D.

Figure 3. Behavior of Physical Activity in all the dominions expressed in MET/Min/Week, according
to Gender, Maracaibo Municipality 2010.
Panel A shows the overall MET/Min/Week amounts in each category according to sex. Physical Activity
Patterns are further depicted according to their classification, Panel B for High Physical Activity, Panel C
for Moderate Physical Activity and Panel D for Low Physical Activity.

Figure 4. New distribution according to Leisure Time MET/Min/Week, Maracaibo Municipality

2010. Using Leisure time as a standpoint, a new distribution of the sample was obtained. Panel A shows
the overall MET/Min/Week amounts in each dominon within the new subsample. Physical Activity
Patterns are described according to their classification, High Physical Activity is shown in Panel B ,
Moderate Physical Activity in Panel C and Low Physical Activity in Panel D.

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Table 1. Distribution of the subjects according to Age groups, Socioeconomic Status and Gender,
Maracaibo Municipality 2010.

Female

Age groups

Socioeconomic Status

Male

Total

18-19

100

4,7

81

3,8

181

8,6

20-29

249

11,8

332

15,7

581

27,6

30-39

193

9,2

187

8,9

380

18,0

40-49

253

12,0

170

8,1

423

20,1

50-59

187

8,9

133

6,3

320

15,2

60-69

96

4,6

58

2,8

154

7,3

70 and more

42

2,0

27

1,3

69

3,3

Stratum I: High class

15

0,7

16

0,8

31

1,5

Stratum II: Middle-High

class

197

9,3

188

8,9

385

18,3

Stratum III: Middle class

415

19,7

423

20,1

838

39,8

Stratum IV: Working class

429

20,4

322

15,3

751

35,6

Stratum V: Extreme
Poverty

64

3,0

39

1,9

103

4,9

Total

1120

53,1

988

46,9

2108

100,0

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Table 2. Distribution of the subjects according to Occupational Status, Physical Activity and Gender, Maracaibo Municipality 2010.

Unemployed
Illiterate

Employed
Illiterate

NonUniversity
Student

University
Employed
Employed Unemployed Unemployed
Student
Unprofessional Professional Professional Unprofessional

Female

85,7

33,3

50,0

48

Male

14,3

66,7

50,0

Female

12

70,6

22,2

27

Male

29,4

77,8

Female

100,0

Male

0,0

Female

24

Male

Physical Activity
Pattern
Low

Moderate

High

Total

Retired

71,6 37

27,0

86

51,8

14

63,6

57

81,4

27,3

19

28,4 100

73,0

80

48,2

36,4

13

18,6

72,7

81,8

71

56,3 70

34,5

96

53,0

15

37,5

126

86,9

11

45,8

18,2

55

43,7 133

65,5

85

47,0

25

62,5

19

13,1

13

54,2

50,0

21

72,4

48

40,0 116

39,9

69

41,1

24

61,5

144

83,2

44,4

50,0

27,6

72

60,0 175

60,1

99

58,9

15

38,5

29

16,8

55,6

80,0

33,3

51

75,0

167

53,4 223

35,3

251

48,7

53

52,5

327

84,3

18

40,9

20,0

12

66,7

17

25,0

146

46,6 408

64,7

264

51,3

48

47,5

61

15,7

26

59,1

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