Revista Adolescência e Saúde

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

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 2 - Apr/Jun - 2019

Original Article Imprimir 

Páginas 16 a 26


Sociodemographic and behavioral factors associated with overweight in Brazilian adolescents - 2015

Factores sociodemográficos y de comportamiento asociados a Sobrepeso en adolescentes brasileños - 2015

Fatores sociodemográficos e comportamentais associados ao excesso de peso em adolescentes brasileiros - 2015

Autores: Maria Andréia Brito Ferreira Leal1; Stephanie Sarah Cordeiro de Paiva2; Semira Selena Lima de Sousa3; Carlos Eduardo Batista de Lima4; Ana Roberta Vilarouca da Silva5; Fernando Ferraz do Nascimento6; Marcio Dênis Medeiros Mascarenhas7

1. Master in Health and Community by the Federal University of Piauí (UFPI). Teresina, PI, Brazil
2. Master in Health and Community by the Federal University of Piauí (UFPI). Teresina, PI, Brazil
3. Mastering of the Post-graduation program in Health and Community of the Federal University of Piauí (UFPI). Teresina, PI, Brazil
4. Doctoring in Medical Sciences by the São Paulo University (USP). Teacher of the Post-graduation program in Health and Community of the Federal University of Piauí (UFPI). Teresina, PI, Brazil
5. Doctorate in Nursing by the Federal University of Ceará (UFC). Teacher Post-graduation program in Health and Community of the Federal University of Piauí (UFPI). Teresina, PI, Brazil
6. Post-Doutorate in Statistics by the University of California (UCSC). Teacher of the Post-graduation program in Health and Community of the Federal University of Piauí (UFPI). Teresina, PI, Brazil.
7. Doctorate in Medical Sciences by the State University of Campinas (UNICAMP). Teacher of the Post-graduation program in Health and Community of the Federal University of Piauí (UFPI). Teresina, PI, Brazil

Correspondência:
Maria Andréia Brito Ferreira Leal
Universidade Federal do Piauí (UFPI) - Programa de Pós- Graduação em Saúde e Comunidade, Centro de Ciências da Saúde (UFPI)
Av. Frei Serafim, nº 2280 - Centro (Sul)
Teresina, PI, Brasil. CEP: 64001-020
(andreiabf_fisio@yahoo.com.br)

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Keywords: Adolescent, School Health Services, Health Surveys, Overweight, Obesity.
Palabra Clave: Adolescente; Servicios de Salud Escolar; Investigaciones Epidemiológicas; Sobrepeso; Obesidad.
Descritores: Adolescente; Serviços de Saúde Escolar; Inquéritos Epidemiológicos; Sobrepeso; Obesidade.

Abstract:
OBJECTIVE: Evaluate the sociodemographic and behavioral factors associated with overweight in Brazilian adolescents.
METHODS: This is a cross-sectional and analytical study with a sample of 10,926 students aged from 13 to 17 years participating in the National School Based Health Survey - PeNSE in 2015. Overweight was considered as a dependent variable and the independent variables were sociodemographic and behavioral aspects (food consumption, physical activity practice and sedentary behavior). Data were analyzed using IBM® SPSS® software, version 21.0, using Complex Samples Module procedures. The variables that showed a significant association with the outcome were submitted to multivariate logistic regression to adjust the Odds Ratio (ORaj).
RESULTS: The prevalence of overweight was 23.7% among the adolescents surveyed, presenting a significant association with: living in the South region (ORaj = 1.40, 95% CI, 1.15-1.71), having 13 to 15 years (ORaj = 1.26, 95% CI 1.08-1.30), living with more than three people (ORaj = 0.82, 95% CI 0.72-0.94), mother with incompleted higher education (ORaj = 1.53, CI95% 1.08-2.18), vegetable consumption greater than or equal to five days (ORaj = 1.23, 95% CI 1.08-1.40), and consumption of sweets up to four days (ORaj = 1.21, 95% CI 1.05-1.39).
CONCLUSION: The significant association between overweight and lower age of  adolescents presents a worrying scenario since unhealthy habits are being incorporated earlier in the life of the individuals provoking deleterious effects in the medium and long term.

Resumen:
OBJETIVO: Evaluar los factores sociodemográficos y comportamentales asociados al exceso de peso en adolescentes brasileños.
MÉTODOS: Se trata de un estudio transversal y analítico con muestra de 10.926 escolares de 13 a 17 años participantes de la Pesquisa Nacional de Salud del Escolar - PeNSE en 2015. Fue considerada como variable dependiente el exceso de peso y las variables independientes fueron los aspectos sociodemográficos y comportamentales (consumo alimenticio, práctica de actividad física y comportamiento sedentario). Los datos fueron analizados en el software IBM® SPSS®, versión 21.0, utilizando procedimientos del Complex Samples Module. Las variables que presentaron asociación significativa con el desenlace fueron sometidas a regresión logística multivariada para ajuste del Odds Ratio (ORaj).
RESULTADOS: La prevalencia de exceso de peso fue de 23,7% entre los adolescentes pesquisados, presentando asociación significativa con: vivir en la región Sur (ORaj = 1,40; IC95% 1,15-1,71), tener de 13 a 15 años (ORaj = 1,26; IC95% 1,08-1,30), vivir con más de tres personas (ORaj = 0,82; IC95% 0,72-0,94), madre con enseñanza superior incompleta (ORaj = 1,53; IC95% 1,08-2,18), consumo de legumbres mayor o igual a cinco días (ORaj = 1,23; IC95% 1,08-1,40) y consumo de golosinas hasta cuatro días (ORaj = 1,21; IC95% 1,05-1,39).
CONCLUSIÓN: La asociación significativa entre el exceso de peso y menor franja etaria de los escolares presenta un escenario preocupante, una vez que hábitos no saludables están siendo incorporados cada vez más temprano en la vida de los individuos, provocando efectos deletéreos a medio y largo plazo.

Resumo:
OBJETIVO: Avaliar os fatores sociodemográficos e comportamentais associados ao excesso de peso em adolescentes brasileiros.
MÉTODOS: Trata-se de um estudo transversal e analítico com amostra de 10.926 escolares de 13 a 17 anos participantes da Pesquisa Nacional de Saúde do Escolar - PeNSE em 2015. Foi considerada como variável dependente o excesso de peso e as variáveis independentes foram os aspectos sociodemográficos e comportamentais (consumo alimentar, prática de atividade física e comportamento sedentário). Os dados foram analisados no software IBM® SPSS®, versão 21.0, utilizando procedimentos do Complex Samples Module. As variáveis que apresentaram associação significativa com o desfecho foram submetidas à regressão logística multivariada para ajuste do Odds Ratio (ORaj).
RESULTADOS: A prevalência de excesso de peso foi de 23,7% entre os adolescentes pesquisados, apresentando associação significativa com: morar na região Sul (ORaj = 1,40; IC95% 1,15-1,71), ter de 13 a 15 anos (ORaj = 1,26; IC95% 1,08-1,30), morar com mais de três pessoas (ORaj = 0,82; IC95% 0,72-0,94), mãe com ensino superior incompleto (ORaj = 1,53; IC95% 1,08-2,18), consumo de legumes maior ou igual a cinco dias (ORaj = 1,23; IC95% 1,08-1,40) e consumo de guloseimas até quatro dias (ORaj = 1,21; IC95% 1,05-1,39).
CONCLUSÃO: A associação significativa entre o excesso de peso e menor faixa etária dos escolares apresenta um cenário preocupante uma vez que hábitos não saudáveis estão sendo incorporados cada vez mais cedo na vida dos indivíduos provocando efeitos deletérios a médio e longo prazo.

INTRODUCTION

For the World Health Organization (WHO), overweight and obesity (overweight) are characterized by too much accumulation of fat tissue, resulting from the energy imbalance between the largest amount of calories consumed and the least amount of calories spent by the body1. Both overweight and obesity are considered global epidemics, which generate real public health problems in many countries2.

In an increasingly premature way, people are being overweight, and adolescence is the phase that has stood out most with this risk and causes multiple health complications. According to data from the Family Budget Survey (POF), conducted by the Brazilian Institute of Geography and Statistics (IBGE), there was a 9.2% increase in the prevalence of overweight between 1974-1975 and 2008-2009. In addition, the obesity rate of this population group also increased by 3.8%3,4. In the Study of Cardiovascular Risks in Adolescents - ERICA conducted in Brazil between 2013 and 2014, a prevalence of obesity of 25.5% was identified among students aged 12 to 17 years5.

Overweight in adolescence can trigger orthopedic, cancer, cardio-metabolic (dyslipidemia, type 2 diabetes) and psychological problems, including compromising professional development in adulthood. There are multiple factors associated with overweight in this phase, which may be of biological, behavioral and environmental origin. Examples include sedentary behavior, such as hours spent watching television, computers and video games, as well as unhealthy eating habits, physical inactivity, sociodemographic characteristics and even parental overweight6,7.

In 2015, the third edition of the National School Health Survey (PeNSE) brought a portrait of Brazilian adolescents, addressing various aspects related to the health of this population, including food consumption, physical activity and sedentary behavior8. Given this, the present study aimed to evaluate the association between sociodemographic and behavioral factors to overweight in Brazilian school adolescents investigated at PeNSE 2015.


METHODOLOGY

This study is an analytical cross-sectional study, developed from data from the third edition of PeNSE, held in 2015, through an agreement between the Brazilian Institute of Geography and Statistics (IBGE) and the Ministry of Health, with the support of Ministry of Education8.

PeNSE 2015 was comprised of two independent student samples, one from students in 9th grade (Sample 1), already investigated in previous PeNSE editions (2019 and 2012), and one from students attending 6th grade from elementary school to the third grade of high school (Sample 2) on day and night shifts in public and private schools located in urban and rural areas. Sample 2 consisted of students aged 13 to 17 years, with the purpose of providing data that would allow comparison with international population-based studies such as the School-based Student Healthy Survey (GSHS), which use this age group8. For the analysis of this article, we used the data from Sample 2, consisting of 10,926 Brazilian students, aged 13 to 17 years.

Anthropometric data were obtained for the classification of nutritional status by IBGE technicians with direct measurement of the weight and height of the students, followed by WHO recommendations for the assessment of the nutritional profile of adolescents by calculating the mass index. Body weight (kilogram weight divided by height squared in meters): BMI-for-age, expressed as Z8 score. PeNSE classified adolescents into four categories regarding nutritional status: weight deficit, normal weight, overweight and obesity8. For this study, the overweight was considered as the dependent variable from the recategorization of the nutritional status variable in relation to overweight: yes (overweight and obesity) and no (weight and eutrophic deficit).

The independent variables were grouped into: sociodemographic - geographic region, school administration, age group, gender, living with mother and/or father, maternal education and how many people reside; and behavioral - food consumption in the seven days prior to the survey (vegetables, fruits, soda, goodies, fried snacks, processed / ultra-processed foods, and fast food), the average time students spent in physical activities in the seven days prior to the survey, considering the following areas: going to and from school, physical education classes and other out-of-school activities in minutes; and time spent on an average weekday, sitting, watching television, using a computer, playing video games, talking to friends, or doing other sitting activities. We also used the variable how many days a week the student practiced at least one hour of physical activity in the seven days prior to the survey to calculate the average.

For analysis purposes, some independent variables were categorized as follows:


Age: 13 to 15 and 16 to 17 years;

How many people do you live with: £3 people and>3 people;

Mother's education: Not studied, incomplete and complete elementary school, incomplete and complete high school and incomplete and complete higher education;

Frequency of food consumption by type of food in the seven days prior to the survey: £ 4 days and >4 days;

Total average time spent on physical activity: insufficient (up to 299 minutes) active (300 more minutes);

Time spent on an average weekday, sitting: horas 3 hours and >3 hours;


Data were analyzed using IBM® SPSS® software, version 21.0, using Complex Samples Module procedures, suitable for analysis of data obtained by complex sampling plan, where weight, stratum and primary sampling unit were considered. Firstly, the prevalence of overweight was calculated according to sociodemographic and behavioral variables. It was calculated the average number of days in the week when the adolescents consumed the food intake of the various foods and the average number of days in which the adolescents practiced physical activity for at least one hour. Then the bivariate analysis was performed by simple logistic regression to obtain the unadjusted Odds Ratio (OR) values. For the variables that were significantly associated with the outcome (p <0.20), the adjusted OR (ORaj) was calculated using multivariate logistic regression, with its 95% confidence intervals (95% CI). All analyzes were performed with a significance level of 5%.

PeNSE 2015 complied with the recommendations of Resolution 466 of December 12, 2012 of the National Health Council and was approved by the National Research Ethics Commission, under opinion no. 1,006,467 of March 30, 2015. All information, both student and school, was confidential and unidentified8.


RESULTS

The presence of overweight (overweight and obesity) was identified in 23.7% (95% CI 22.6-24.9) of students aged 13 to 17 years, being significantly higher among students in the southern region (28, 2%; 95% CI: 26.2 - 30.3), students from private schools (28.4%; 95% CI: 25.8 - 31.2), aged 13 to 15 years (25.1% ; 95% CI: 23.7 - 26.6), who lived with their mother and/or father (23.8%; 95% CI: 22.7 - 25.0), who lived with up to three people (26, 0%; 95% CI: 23.9 - 28.1) and had mothers with higher education (incomplete / complete) (28.5%; 95% CI: 26.0 - 31.2). The prevalence of overweight was similar between genders (Table 1).




Regarding eating behaviors, overweight was more prevalent among those who consumed vegetables (26.0%; 95% CI: 24.2 - 27.9) and fruits (24.5%; 95% CI: 22.6 - 26.6) more regularly (> 4 days a week), and among those who consumed less healthy unhealthy foods (≤ 4 days a week) as soda (24.5%; 95% CI: 23.2 - 25.9), goodies (25.6%; 95% CI: 24.3 - 27.0), fried salted (24.4%; 95% CI: 23.2 - 25.6) and processed foods (24.1%; 95% CI: 22.8 - 25.5). Regarding the performance of physical activity, there was a slight prevalence of active students (24.7%; 95% CI: 22, - 24.8) with the outcome surveyed in relation to the insufficiently active (23.3%; 95% CI: 22, 9 - 26.5) (Table 1). The prevalence of overweight was the same among those who sat on a regular weekday for and for more than three hours.

The variables that were significantly associated with the outcome in the bivariate analysis were: region, school, age, how many people live, mother's education, vegetable consumption, soda consumption, snack foods and fried salty consumption, as shown in Table 1.

Table 2 shows the multivariate analysis where the geographic region (p=0.007; p=0.001), age group (p=0.003), maternal education (p = 0.017), vegetable consumption (p=0.001) remained associated with overweight. ) and goodies (p = 0.006). Adolescents most likely to be overweight are residents in the Southeast (34%) and South (40%) regions, those aged 13 to 15 years (26%), with incomplete/complete maternal education ( 53%), who consumed vegetables more than four days a week (23%) and ate fewer sweets in four days (21%). Living with more than three people also had a significant association (p = 0.007), however it was a protective factor (ORaj = 0.82; 95% CI: 0.72 - 0.94) for the outcome studied (Table 2).




DISCUSSION

The results of this study showed that 23.7% of Brazilian adolescents are overweight and that sociodemographic and behavioral factors influenced this outcome.

Adolescents from the South region had a higher prevalence of being overweight (28.2%) as did those from the Southeast region. These data were similar to ERICA, where the highest prevalence of overweight (overweight and obesity) was identified in adolescents living in the South (29.8%) and Southeast (26.0%)5. Another national population-based survey found that the pattern of food availability in Brazilian households is directly related to the high and rising prevalence of overweight and obesity in the population, and the excess fat content tended to increase with family income, being more evident in the South and Southeast regions4.

In addition, ERICA results also revealed that other aspects related to overweight were more pronounced in these regions, with lower frequencies of healthy eating behaviors observed among adolescents from the Southeast region. This region, as well as the South, is among the most prevalent for physical inactivity and sedentary behavior (spending two or more hours of the day using TV, computer and video games)5,9. Considering this information, it is assumed that adolescents from the South and Southeast regions are more susceptible to the adoption of lifestyle habits that predispose to excessive weight gain, thus having a greater tendency for this finding in these regions.

Despite the higher prevalence observed among private school students (28.4%), the PeNSE 2015 data analysis showed no significant difference regarding overweight between public and private school students. However, the study by Benedetet al. (2013) revealed that studying in a public school increases the chances for overweight in female adolescents, while decreasing for men6. In contrast, Dias et al. (2014) highlight that higher class adolescents, as well as those from private schools, were more likely to have sedentary behaviors because they had greater access to technological means, such as the use of computers and video games10. Thus, because they have a sedentary behavior, it is likely that adolescents from private schools are more likely to develop overweight when compared to those from public schools.

The higher prevalence and higher chances of being overweight in the 13 to 15 age group were similar to other studies conducted internationally, such as in Iraq, with 1,656 students aged 13 and 17 years, with a higher prevalence of obesity and overweight (11, 3% and 22.6%, respectively) also in the age group of 13 to 15 years11. These data are also corroborated with the POF 2008-2009, considering the similar behavior of reducing the prevalence of overweight with advancing age among adolescents4.

A systematic analysis involving global, regional and national surveys of overweight and obesity conducted with children and adults has shown an increase in prevalence from 1980 to 2013 in all age groups, with a substantial increase in children and adolescents in both developed and developing countries, as in Brazil12. Although the analyzes of the present study do not establish a temporal tendency of the prevalence of overweight with the age group of the surveyed adolescents, their findings suggest that this health problem is manifesting itself earlier in this population, which requires an early approach regarding health promotion, prevention and control.

The present study observed a significant association between mothers with higher education and adolescents' overweight. However, in the study by D'Avila et al. (2016), which aimed to verify the association between food intake, physical activity, sociodemographic factors and body fat percentage in schoolchildren, the authors noted that parents' education was not an influencing factor, although the outcome had a higher prevalence of excess of body fat among participants with higher maternal education13.

Although more educated mothers are expected to have more access to information that influences the decision to eat healthier foods, it is also possible to observe that this educational context is related to the higher probability of maternal insertion in the labor market and a more favorable family socioeconomic condition. This impacts on increased purchasing power, greater access to various foodstuffs and their availability to children. However, it is noteworthy that these aspects can also negatively affect the eating habits of adolescents, given that mothers who work outside the home tend to spend less time preparing food, leading to the preference for semi-ready products like industrialized/ultra-processed14,15. This fact could be related to the greater chance of overweight in these adolescents.

The behavioral aspects related to the food intake of adolescents found in this study contradicted the expected results, where higher consumption of vegetables and fruits and lower consumption of sweets were associated with being overweight. In addition, no statistically significant associations were found between the time adolescents spend on physical activities and sitting with overweight.

However, other national and international studies also indicate the association between higher intake of vegetables in the week with overweight in adolescents16,17. Reverse causation may be considered responsible for this finding, as concluded by a study conducted with Brazilian adolescents living in Florianópolis16. Considering that the results of the present study indicate that overweight adolescents have a significantly higher average consumption of vegetables than vegetables without overweight (Figure 1).


Figure 1. Average dietary intake, physical activity and sitting time among overweight and underweight students. Brazil, 2015.



Analyzing the observed results regarding the consumption of sweets, we can also infer that the findings point to reverse causality, since the lower weekly intake was associated with overweight and the highest average of this consumption was observed in adolescents without overweight.

The motivation of overweight adolescents to acquire healthy habits has been investigated in some studies18,19. A survey of adolescents from Los Angeles found that those who were overweight and obese were more motivated to acquire healthier eating habits compared to normal weight adolescents. The researchers concluded that obese adolescents are more vulnerable to external influences from family, friends and health professionals, resulting in changes that would lead to weight loss18.

It is also noteworthy that, according to the researched literature, cross-sectional studies evaluating the effect of eating healthy foods, especially fruits and vegetables, on adolescent body weight are still quite controversial. This suggests that the significant effects of this more frequent consumption may take time to be evidenced as to its influence on nutritional status, thus recognizing the importance of carrying out longitudinal studies for this purpose16,20.


CONCLUSION

It is noteworthy that overweight was significantly associated with the lower age of students, which may show the greater susceptibility of students in the early years of adolescence to external influences, since they are the public of choice for media attacks for the consumption of ultra-processed products. Larger and more effective investments in health promotion and education are recommended, as well as follow-up for those who are already overweight.

It is necessary to warn educators, health professionals, managers and the general community that these individuals are in the biopsychosocial formation phase and that the behavioral and corporal bases established in these years will reflect in the years ahead. The biggest challenge ahead is ensuring that the years that have been added to the life expectancy of future generations also have quality.

Large national-based studies are important for population health assessment processes so that intervention measures can be taken, changed or continued. The inclusion of a sample background to PeNSE has brought visibility to a broader group of students who can more accurately reflect the Brazilian adolescent population.


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