Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 2 - Apr/Jun - 2018

Review Article Imprimir 

Páginas 113 a 120


Modifiable Risk Factors for Noncommunicable Chronic Diseases in Adolescents: Integrative Review

Factores de Riesgo Modificados para las Enfermedades Crónicas no Transmisibles en los Adolescentes: Revisión Integrada

Fatores de Risco Modificáveis para Doenças Crônicas não Transmissíveis em Adolescentes: Revisão Integrativa

Autores: Mariana Rayane Emidio Bezerra1; Maria Julia Lyra2; Marcos André Moura dos Santos3; Viviane Colares4; Valdenice Aparecida de Menezes5

1. Master in Hebiatrics - Determinants of Health in Adolescence by the Pernambuco University (UPE) – Odontology College of Pernambuco. Camaragibe, PE, Brazil
2. Master in Hebiatrics - Determinants of Health in Adolescence by the Pernambuco University (UPE) - Odontology College of Pernambuco. Camaragibe, PE, Brazil
3. Doctor in Nutrition by the Pernambuco Federal University (UFPE). Assistant Professor of the Pernambuco University (UPE) - Physical Education Superior School of Pernambuco. Recife, PE, Brazil
4. Post-doctorate in Pediatric Dentistry by the University of Iowa, United States (UIOWA). Associated Professor of the Pernambuco University (UPE) – Odontology College of Pernambuco. Camaragibe, PE, Brazil. Assistant Professor of the Pernambuco Federal University (UFPE) - Clinical and Preventive Odontologist Department. Recife, PE, Brazil
5. Doctor in Odontology (Pediatric Dentistry) by the Pernambuco University (UPE). Associated Professor of the Pernambuco University (UPE) – Odontology College of Pernambuco. Camaragibe, PE, Brazil

Mariana Rayane Emidio Bezerra
Faculdade de Odontologia de Pernambuco (UPE). Secretaria de Pós-Graduação
Av. Gal. Newton Cavalcanti, 1650
Tabatinga, Camaragibe - PE, 54756-220
(mari_rayane@yahoo.com.br)

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Keywords: Risk factors, adolescent, chronic disease.
Palabra Clave: Factores de riesgo, adolescente, enfermedad crónica.
Descritores: Fatores de risco, adolescente, doença crônica.

Abstract:
OBJECTIVE: Identify the prevalence of modifiable risk factors associated with chronic non communicable diseases (CNCDs) in Brazilian adolescents.
DATA SOURCE: This is an integrative review of the literature, in which an online search was performed in the databases: LILACS, MEDLINE and SciELO, using the descriptors: "risk factors" AND "adolescent" AND "chronic disease". Were selected publications from 2011 to 2016, in Portuguese, Spanish and English, which had Brazil as the reference country.
DATA SYNTHESIS: We selected three complete articles. The main factors analyzed were dietary habits, physical exercise, alcohol consumption, tobacco use and high blood pressure. Two studies focused on municipalities of the South region of Brazil and the third one, a Northeast municipality. The prevalence of CNCD is related to risk factors, being more frequent in older adolescents with greater purchasing power.
CONCLUSION: The most prevalent risk factors for CNCD in adolescents are inadequate nutrition, physical inactivity, harmful alcohol consumption and tobacco use. Research aimed at identifying the presence of these risk factors in this age group is still scarce; however, when risk factors are identified in childhood and adolescence, they may promote changes in relation to modifiable risk behaviors.

Resumen:
OBJETIVO: Identificar la prevalencia de factores de riesgo modificables y asociados a las Enfermedades Crónicas no Transmisibles (ECNT) en adolescentes brasileños.
FUENTES DE DATOS: Se trata de una revisión integral de la literatura, en la cual se realizó una búsqueda online en las bases de datos: LILACS, MEDLINE y SciELO, usando las descripciones: "factores de riesgo" AND "adolescente" AND "enfermedad crónica". 2011-2016. Las publicaciones fueron seleccionados en portugués, español e Inglés que tenía a Brasil como país de referencia.
SÍNTESIS DE LOS DATOS: Se seleccionaron tres artículos completos. Los principales factores analizados fueron los hábitos alimenticios, la práctica de ejercicio físico, el consumo de alcohol, el consumo de tabaco y la presión arterial alta. Dos estudios se centraron en municipios de la región Sur de Brasil y el tercero, en un municipio del Nordeste. La prevalencia de ECNT está relacionada con los factores de riesgo, siendo más frecuentes en adolescentes mayores con mayor poder adquisitivo.
CONCLUSIÓN: Los factores de riesgo más prevalentes para ECNT en los adolescentes son la alimentación inadecuada, la falta de actividad física, el consumo nocivo de alcohol y el uso del tabaco. Las investigaciones que buscan identificar la presencia de estos factores de riesgo en ese grupo de edad todavía son escasas, sin embargo cuando los factores de riesgo son identificados en la niñez y adolescencia, pueden promover cambios en relación a los comportamientos de riesgo modificables.

Resumo:
OBJETIVO: Identificar a prevalência de fatores de risco modificáveis e associados às Doenças Crônicas não Transmissíveis (DCNT) em adolescentes brasileiros.
FONTES DE DADOS: Trata-se de uma revisão integrativa da literatura, na qual se realizou uma busca online nas bases de dados: LILACS, MEDLINE e SciELO, usando os descritores: "fatores de risco" AND "adolescente" AND "doença crônica". Foram selecionadas publicações de 2011 a 2016, nos idiomas português, espanhol e inglês que tiveram o Brasil como país de referência.
SÍNTESE DOS DADOS: Foram selecionados três artigos completos. Os principais fatores analisados foram os hábitos alimentares, prática de exercício físico, consumo de álcool, uso de tabaco e pressão arterial elevada. Dois estudos focaram em municípios da região Sul do Brasil e o terceiro, em um município do Nordeste. A prevalência de DCNT está relacionada aos fatores de risco, sendo mais frequentes em adolescentes mais velhos com maior poder aquisitivo.
CONCLUSÃO: Os fatores de risco mais prevalentes para DCNT nos adolescentes são a alimentação inadequada, inatividade física, consumo nocivo de álcool e o uso do tabaco. Pesquisas que visam identificar a presença destes fatores de risco nesse grupo etário ainda são escassas, no entanto quando os fatores de risco são identificados na infância e adolescência, podem promover mudanças em relação aos comportamentos de risco modificáveis.

INTRODUCTION

Non-communicable chronic diseases (DCNT) are the main causes of death in the world, including diseases of the circulatory system, cancer, diabetes and chronic respiratory disease, among which the main factors associated are tobacco use, unhealthy diet , physical inactivity and harmful alcohol consumption1.

During adolescence, with the various biopsychosocial and behavioral changes specific to this phase2, there is a greater vulnerability to the insertion of these risk behaviors in an early stage and can be extended throughout the life cycle, considering that young people who adopt risk behaviors, with the advancement of age tend to have a greater predisposition to DCNT3.

In this context, the reversal of the CNCD epidemic precedes a comprehensive population approach, with preventive and care interventions from intrauterine life through adolescence, with the purpose of minimizing risks at all stages of life4, considering that modifying poor health habits already installed in adult life are difficult goals to achieve. However, healthy habits acquired in childhood and adolescence that are perpetuated in adulthood may contribute to the primary prevention of CNCDs5.

Thus, the multidisciplinary team has the challenge of implementing effective, long-term and viable strategies in the field of public health that lead to the adoption of a healthy lifestyle in the first two decades of life6. Studies to identify population groups at risk and factors that influence poor health habits in childhood and adolescence are fundamental for the development of policies and programs that may intervene in the control of chronic diseases of adult life7.

Faced with the need to identify risk factors in the adolescent population for the creation, improvement and evaluation of health policies and programs that may prevent the incidence of CNCD, the present study aims to identify the main modifiable risk factors for individual CNCDs and associated with Brazilian adolescents.


METHODS

An integrative review of the literature was carried out, in order to synthesize the results obtained in researches that deal with a theme or question, in a systematic, orderly and comprehensive way8. The question that led to the review was: Which modifiable risk factors for CNCD have been identified and how are these risk factors associated with research conducted with the Brazilian adolescent population? In order to identify the published studies on this question, the following databases were searched online: Latin American and Caribbean Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) and Scientific Electronic Library Online (SciELO). The descriptors used for the search were: "Risk Factors" AND "Adolescent" AND "Chronic Disease". The following inclusion criteria were used to select the articles: Portuguese, Spanish or English surveys that had Brazil as the reference country and were published in the period between 2011 and 2016. This time period was determined by the creation and implementation in 2011 of the Strategic Action Plan for Coping with Chronic Non-communicable Diseases in Brazil 2011-20224. The articles were selected after careful reading of the titles and abstracts. Those not related to the adolescent age group, non-epidemiological studies, as well as those whose title and abstract were not within the objectives proposed for the review were excluded.

The search strategy identified 51 studies in the LILACS, MEDLINE and SciELO databases. After the analysis of the titles and abstracts, 48 studies were excluded: one due to repetition in LILACS and SciELO, and 47 because they were outside the proposed theme, leaving three documents to compose this review (Figure 1).


Figure 1. Flowchart of the article selection process.



RESULTS AND DISCUSSION

The studies analyzed were of the transversal type with a probabilistic sample of school adolescents. The first study selected by Tassitano et al.9 aimed to verify the aggregation of the four main risk behaviors (smoking, alcohol, physical inactivity and low consumption of fruits, vegetables and vegetables) in 600 adolescents aged between 15 and 20 years in a municipality located in the Northeast of Brazil. The second, conducted by Silva et al.10, aimed to estimate the prevalence and patterns of risk factors for non-communicable chronic diseases according to socioeconomic level and age in a sample of 1675 adolescents aged 11 to 17 years in one municipality of the southern region of the country. In the third article, Cureau et al.11 evaluated the grouping of behavioral and biological risk factors for NCDs (unhealthy diets, physical inactivity, smoking, excessive alcohol consumption, overweight and high blood pressure) associated with sociodemographic variables in 1132 adolescents aged 14 -19 years from a municipality in the southern region of Brazil.

The three documents were presented in the original article format; the participants were in the age group from 11 to 20 years old. Two surveys were conducted in the southern region of Brazil and one in the northeast region. Regarding the year of publication, one article was published in 2012 and the other two in 2014. The main risk behaviors for CNCDs investigated in the adolescents population were smoking, alcohol, physical inactivity and inadequate feeding and their respective prevalences (Table 1 and 2 ).






In the first article, to verify the consumption of fruits, vegetables and vegetables, the frequency of consumption was used for the number of days per week and the quantity of the portions ingested each day. Adolescents who reported consuming less than five servings per day were considered to be exposed to the risk factor9. In the second study, the diet was measured from the total caloric intake of fats, being considered high the fat intake by the adolescents that had a percentage greater than 30%10. The third study investigated the frequency of intake of fifteen high fat foods and nine fiber rich foods, being classified as 0 to 4, in which 0 (zero) corresponded to low frequency and 4 to high frequency. Adolescents who scored 27 points on high-fat foods and 20 or fewer points on high-fiber foods were considered on unhealthy diets11.

According to Table 2, the risk factors related to inadequate feeding, being rich in fat and poor in fiber, are the most present in the adolescent populations studied, corresponding in the first and third study to 66.7% and 85,8% respectively.

Tassitano et al.9 estimated the level of physical activity (NAF) by the number of minutes per day and times per week that the adolescents performed moderate to vigorous physical activity (AF) in the various areas: leisure, occupation, domestic activities and displacement. The adolescents who reported having performed less than 300 minutes of PA per week9, a cut-off point also established by Cureau et al.11 with the use of two instruments aiming to have a global view of the AF performed during the week11. Silva et al.10, used an instrument in which the adolescents should remember the AF performed in three days of the last week, being two days of the week, and one day of the week. The days were separated into 36 30-minute periods each, and the intensity was assessed in 30-minute blocks using a scale of one to nine in which each number represented one activity, and as the adolescent would be performing such activity calculated by the amount of time spent in each period multiplied by the value of the metabolic equivalent. The first quintile of energy expenditure (kcal / kg / day)10 is classified as less active.

Regarding tobacco use, the authors considered exposed adolescents who reported having smoked in the last week9 or in the last month 10,11, there is a consensus regarding the classification of exposed independent of the number of cigarettes smoked. Regarding the consumption of alcoholic beverages, the first study considered as an exposure factor the adolescents who reported the consumption of alcoholic beverage at least one day in the previous week9. The second study considered the consumption of a dose of alcoholic beverage in the last thirty days10, and the third study classified as excessive consumption the report of the ingestion of five or more doses of alcohol, at least on one occasion in the previous month11.

The blood pressure (BP) variable was analyzed by two studies obeying the same protocol; the measurement was performed twice in the right arm of the adolescent with an interval of five minutes. For adolescents under 18 years of age, high values were considered values that were above the 90th percentile for gender, age and height. For those older than 18 years, Silva et al.10 used the cutoff point of 120x80 mm Hg, while Cureau et al.11 considered 130x85 mm Hg as the cutoff point.

Only the second study analyzed the variables waist circumference (WC) and cardiorespiratory fitness. The values obtained through the measurement of CC were classified as normal and elevated according to gender, age and skin color. CC is a predictor of cardiovascular diseases and dyslipidemias. To measure the cardiopulmonary fitness, the Progressive Aerobic Cardiovascular Endurance Run (PACER) was used. When the student stopped due to exhaustion or was unable to maintain the required speed, the test was terminated. In order to categorize the fitness levels, the number of complete laps was considered and the criteria proposed in the FITNESSGRAM manual of the Cooper Institute for Aerobics Research, for sex and age, classified as low or adequate / high fitness10.

When the association of risk factors was performed, in the study developed by Tassitano et al.9, it was verified that there is a greater association of one or two risk factors for CNCD in the adolescent population. When the aggregation of three behaviors was carried out, smoking, alcohol and physical inactivity among the boys were the most noteworthy; and among the girls, smoke, alcohol and low consumption of fruits stood out. The study also performed the comparison of the aggregation of two risk behaviors between boys and girls. The prevalence of smoking aggregation and alcohol consumption was observed, as well as smoking and physical inactivity for boys. Among the girls, smoking and alcohol consumption stood out9.

In the aggregation of the risk factors for CNCD in the study developed by Silva et al.10 19.0% presented two or more unhealthy behaviors and 32% had biological risk factors (elevated WC and BP / low respiratory fitness). When the prevalence of tobacco and alcohol consumption was combined, it was 4.1 times higher for boys and 2.2 times higher for girls when compared to the expected value. Combining the prevalence of smoking, alcohol and high fat content in the diet was 4.7 times higher than expected for boys and 3.5 times higher than expected for girls. Elevated WC, high BP and low cardiorespiratory fitness were respectively 85 and 69% higher than expected for boys and girls10.

The combination of risk factors in the study developed by Cureau et al.11 identified 2, 3 and 4 or more risk factors, with their prevalences being 40.9%, 23.1% and 11.5%, respectively. The highest prevalence identified corresponded to the combination of unhealthy diets and physical inactivity, representing a prevalence of 32% higher than expected. When stratified by sex, the combinations with values higher than expected were unhealthy diet, excessive alcohol consumption and smoking for boys. For girls, the combinations were stronger for unhealthy dieting, physical inactivity, excessive alcohol consumption and smoking11.

Cureau et al.11 found 75.5% of the adolescents living in the municipality of the Southern Region of the country with more than one risk factor for CNCD, a percentage higher than those found in the studies conducted by Tassitano et al.9 e Silva et al.10 as shown in table 3.




It was also identified that adolescents with a higher socioeconomic level had up to three risk factors 9,11. Other factors such as being married or having a partner, studying in the daytime and not attending Physical Education classes presented a higher risk for the exposure of three or more health risk behaviors. In the three articles reviewed, the authors reported that older adolescents have a higher prevalence of risk behaviors. There is an increase in the risk factors for NCDs with advancing age, and this is associated with lifestyle, which in adolescence is strongly influenced by social interaction, local culture, peers and fashion trends, with direct consequences in the adoption of habits that can perpetuate throughout life 9-11.

The three studies used different instruments to collect risk factors for CNCD: Tassitano et al., Used the COMCAP Questionnaire, with questions related to lifestyle, general information (sociodemographic and work questions) and health (eating habits, physical activity, risk behaviors, preventive behaviors and health perception)9; Silva et al. Three levels of physical activity and food consumption were collected through reminders, tobacco use and alcohol consumption were collected through questions based on the US Youth Risk Behavior Survey, to assess the socioeconomic level. criteria proposed by the Brazilian Association of Research Companies (ABEP)10. Already Cureau et al., Had the level of physical activity and food consumption collected by means of a reminder, being the use of tobacco and the consumption of alcoholic beverages collected through questionnaires, referring in the article to the questionnaire of the US Youth Risk Behavior Survey and criteria proposed by ABEP11.

The authors of the three papers selected suggest approaches to associated risk factors through health promotion among young people, which could occur in two different ways: interventions aimed at two or more health risk behaviors to investigate whether this would reduce the prevalence risk behavior in order to exploit the impact on other risk factors combined, for example: what combinations of risk behaviors are likely to change others? 9-11

All three selected articles agreed on the creation of health policies and programs that will reduce the prevalence of these factors through health actions during adolescence so that these habits can be modified and reflected in adulthood9-11. Thus, it is possible that the school space is the favorable environment for the identification of this lifestyle, since it is in this space that we find, with greater facility, this population.

It was considered relevant to public health to investigate how these risk factors combine and what their distributions are in different economic classes, since this information promotes intervention strategies aimed at reducing health problems in the young population.


CONCLUSION

In view of these results, it was possible to perceive the need to analyze risk factors for chronic diseases such as: eating habits, physical activity and alcohol and other drugs consumption in the adolescent population, since these habits influence the quality of life and the incidence of DCNT. It was also observed the presence of more than one risk factor for CNCD in adolescents and the association with sociodemographic conditions. More studies of these factors are needed to identify strategies that aim to reduce these behaviors even in adolescence, encompassing not only one but several factors.


REFERENCES

1. Malta DC, Cezário AC, Moura L, Morais Neto OL, Silva Junior JB. A construção da vigilância e prevenção das doenças crônicas não transmissíveis no contexto do Sistema Único de Saúde. Epidemiol Serv Saúde 2006;15(3): 47-65.

2. Secretaria Municipal da Saúde. Manual de atenção à saúde do adolescente. São Paulo: Secretaria Municipal da Saúde; 2006.

3. Silva JEF, Giorgetti KS, Colosio RC. Obesidade e sedentarismo como fatores de risco para doenças cardiovasculares em crianças e adolescentes de escolas públicas de Maringá, PR. Saúde e Pesquisa 2009; 2(1):41-51.

4. Malta DC, Morais Neto OL, Silva Junior JB. Apresentação do plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis no Brazil, 2011 a 2022. Epidemiol Serv Saúde 2011; 20(4):425-38.

5. Mendes MJFL, Alves JGB, Alves AV, Siqueira PP, Freire EFC. Associação de fatores de risco para doenças cardiovasculares em adolescentes e seus pais. Rev Bras Saúde Matern Infant 2006; 6(1): 49-54.

6. Costa PRF, Assis AMO, Silva MCM, Santana MLP, Dias JC, Pinheiro SMC, et al. Mudança nos parâmetros antropométricos: a influência de um programa de intervenção nutricional e exercício físico em mulheres adultas. Cad. Saúde Públ 2009;25(8):1763-73.

7. Abbes PT, Lavrador MSF, Escrivão MAMS, Taddei JAAC. Sedentarismo e variáveis clínico-metabólicas associadas à obesidade em adolescentes inactivity and clinical and metabolic variables associated with adolescent obesity. Rev Nutr 2011;24(4):529-38.

8. Ercole FF, Melo LS, Alcoforado CLGC. Integrative review versus systematic review. Rev Min Enferm 2014;18 (1): 9-12.

9. Tassitano RM, Dumith SC, Chica DAG, Tenório MCM. Agregamento dos quatro principais comportamentos de risco às doenças não transmissíveis entre adolescentes. Rev Bras Epidemiol 2014;17(2):465-48.

10. Silva KS, Lopes AS, Vasques DG, Costa FF, Silva RCR. Simultaneidade dos fatores de risco para doenças crônicas não transmissíveis em adolescentes: prevalência e fatores associados. Rev Paul Pediatr 2012; 30(3):338-45.

11. Cureau FV, Duarte P, Santos DL, Reichert FF. Clustering of risk factors for noncommunicable diseases in brazilian adolescents: prevalence and correlates. J Phys Act Health 2014;11(5): 942-9.
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