Recommendation and physical activity practice in Brazilians with chronic diseases

SUMMARY

OBJECTIVE:

To analyze the prevalence and factors associated with professional recommendation and leisure-time physical activity (LTPA) in Brazilian individuals diagnosed with hypertension (HBP), diabetes, and/or hypercholesterolemia.

METHODS:

This is a cross-sectional population-based study with a representative sample of the Brazilian population (aged ≥20 years) in 2013, with self-reported HBP (n=11.098), diabetes (n=3.176), and/or hypercholesterolemia (n=7.252). Prevalence and gross odds ratios were estimated and adjusted for both outcomes.

RESULTS:

Professional recommendation and LTPA were more prevalent in individuals who received recommendation and presented with hypercholesterolemia (85.9 and 23.4%, respectively). Adjusted analysis showed an association in people 40 to 59 years of age and public programs in most diseases. Higher educational level was associated with receiving recommendations in all non-communicable diseases (NCDs). LTPA was associated in people 40 to 59 years of age for HBP and diabetes and in all investigated NCDs, higher educational level, positive perception of health, and a favorable environment in those who received recommendation.

CONCLUSIONS:

Education presented the greatest magnitude in the associations, clearly showing the need for equitable methods to increase recommendation and LTPA levels for the most vulnerable population. Further studies analyzing other variables and NCD are needed, corroborating the Ministry of Health.

KEYWORDS:
Physical activity; Adherence, patient; Chronic disease; Non-communicable; Health surveys; Health personnel

INTRODUCTION

Non-communicable diseases (NCDs) are responsible for 41 million deaths in the world¹ annually. In Brazil, approximately 45% of the adult population presents at least one NCD². The main risk factors for NCDs are smoking, excessive consumption of alcoholic beverages, poor food quality, overweight, and insufficient physical activity on prescription (PAP)^1,3. PAP accounts for the annual costs for health systems worldwide, which is estimated to exceed $50 billion⁴. Conversely, sufficient PAP has a positive effect on the prevention of health-related diseases, in addition to contributing to control and prevention of early mortality attributed to NCDs⁵.

Environmental, demographic, socioeconomic, and psychocognitive factors⁶ are PAP conditioning factors. In addition, the literature indicates the important role of health professionals and services in stimulating PAP. Some studies show that the recommendation of physical activity by health professionals to service users⁷, especially by physicians^8,9, is associated with behavioral changes and an increase in PAP^7,10. However, few studies have investigated this association in Brazil^7,8,11, especially in Brazilian individuals with NCDs.

Investigating the knowledge on PAP recommendation by health professionals in individuals with a NCD is particularly important in middle-income countries, such as Brazil, which have high social and individual costs attributed to NCDs and scarce resources to deal with such health conditions^2,4,12. Moreover, Brazil has the goal of increasing the prevalence of leisure-time PAP (LPAP) and decreasing the growth of obesity among Brazilian adults, according to the Strategic Action Plan for NCDs³.

This study aimed to analyze the prevalence and factors associated with professional recommendation and LPAP in Brazilian individuals diagnosed with HBP, diabetes, and/or hypercholesterolemia.

METHODS

This is a cross-sectional study based on microdata from the 2013 National Health Plan (PNS) conducted by the Brazilian Institute of Geography and Statistics (IBGE). This study has a domiciliary characteristic, national representativeness, and a population base with three-stage sampling by conglomerates. The questionnaire was completed by 60,202 adults¹³.

This study included adults aged ≥20 years who self-reported HBP, diabetes, and/or hypercholesterolemia. To identify the pathological condition, they were asked: “Has any doctor ever diagnosed you with [pathology]?” with the option of answering “yes” or “no.”

The professional recommendation for physical activity variable was also self-referred (yes, no), and the enough leisure-time physical activity variable considered sufficiently active participants those who performed at least 150 min/week of light or moderate PAP or at least 75 min/week of vigorous PAP at leisure time, or a combination of moderate and vigorous activities totaling 150 min a week⁵. The classification of the activity intensity was based on weekly frequency, duration, and intensity^14,15.

The exploratory variables were sex (male or female); self-reported race/skin color (black, brown, white); age group (20–39, 40–59, ≥60 years); marital status (married, separated/divorced/widowed, single); education (no education, incomplete/complete elementary school, incomplete/complete high school); self-perception of health status (positive, good and very good; negative, other answers); self-reported presence of public space near the household for PAP (yes, no); and self-reported presence of public programs that stimulate PAP (yes, no) in the city.

The analyses described the prevalence of the outcomes and their 95% confidence intervals (95%CI) by exploratory variables. Subsequently, logistic regression was performed, and gross odds ratio (OR) values were estimated and adjusted with the respective 95%CI. The Stata 12.0 software was used, considering individual sample weights and complex sampling.

RESULTS

The study sample consisted of individuals with hypercholesterolemia (n=7,252), diabetes (n=3,176), and hypercholesterolemia (n=11,098), and its distribution included more women and individuals aged ≥40 years, were whites and brown were married, had completed elementary school education, had negative health perception, and reported no space for PAP or public programs that stimulate PAP. The prevalence of both professional PAP and LPAP in those who received recommendation were higher in individuals with hypercholesterolemia (85.9 and 23.4%, respectively). In all NCDs, the two outcomes investigated were less prevalent in older individuals, who had a lower educational level and negative health perception (except for recommendations to individuals with diabetes), and to those who declared to have no space and PAP public programs (Table 1).

Table 1.
Prevalence of “having received a recommendation for physical activity on prescription from a health professional” and “leisure-time physical activity on prescription in people who received a recommendation” in adults (≥20 years) with HBP, diabetes, and hypercholesterolemia. Brazil, 2013.

Variables	Received PAP recommendation			LPAP in individuals who received a recommendation
	Hypertension	Diabetes	Hypercholesterolemia	Hypertension	Diabetes	Hypercholesterolemia
	95%CI	95%CI	95%CI	95%CI	95%CI	95%CI
Total sample	81.8 (80.5–83.1)	83.9 (81.8–86.0)	85.9 (84.4–87.3)	18.2 (16.8–19.5)	18.0 (15.4–20.6)	23.4 (21.5–25.3)
Sex
Female	81.9 (80.4–83.5)	83.5 (81.1–85.8)	86.0 (84.4–87.7)	17.5 (15.8–19.2)	18.7 (16.0–21.4)	22.9 (20.7–25.0)
Male	81.7 (79.7–83.6)	84.5 (82.0–87.0)	85.6 (83.1–88.1)	19.3 (17.2–21.3)	17.0 (13.8–20.2)	24.4 (21.2–27.7)
Age group (years)
20–39	84.8 (82.6–87.0)	90.1 (87.7–92.6)	89.2 (86.1–92.3)	19.8 (16.6–23.0)	22.0 (18.5–25.4)	29.0 (24.4–33.6)
40–59	84.8 (82.9–86.7)	89.8 (87.7–91.9)	87.3 (85.5–89.1)	20.6 (18.3–22.9)	22.5 (18.7–26.4)	24.4 (21.7–27.1)
≥60	78.0 (76.0–80.0)	78.6 (75.8–81.3)	82.3 (80.0–84.7)	15.0 (13.2–16.8)	13.4 (10.7–16.2)	19.0 (16.5–21.5)
Race/skin color
Black	79.4 (75.8–83.0)	77.6 (73.6–81-5)	84.9 (81.8–88.0)	14.2 (10.7–17.8)	16.2 (13.1–19.4)	17.5 (13.0–21.9)
Brown	79.9 (78.2–81.7)	82.9 (80.8–84.9)	84.3 (81.7–86.9)	18.7 (16.8–20.6)	16.1 (13.6–18.7)	23.3 (20.6–26.1)
White	83.9 (82.2–85.5)	85.7 (82.6–88.8)	87.5 (85.7–89.3)	18.5 (16.5–20.5)	19.2 (15.3–23.2)	24.1 (21.5–26.8)
Marital status
Separated/divorced/widowed	79.4 (77.0–81.8)	83.1 (80.2–85.9)	81.9 (79.0–84.8)	16.3 (14.3–18.4)	16.4 (13.4–19.4)	21.6 (18.6–26.7)
Single	79.4 (77.1–81.7)	83.7 (81.8–85.6)	85.8 (83.5–88.2)	17.9 (15.7–20.1)	14.4(11.6–17.2)	25.0 (21.2–28.7)
Married	83.8 (82.1–85.4)	84.4 (81.6–87.2)	87.4 (85.3–89.4)	19.0 (17.2–20.9)	20.0 (16.5–23.5)	23.4 (21.0–25.9)
Education
No education	71.1 (68.4–73.7)	72.9 (69.6–76.1)	76.7 (73.6–79.8)	11.3 (9.2–13.5)	11.4 (8.2–14.7)	13.0 (10.5–15.6)
Completed elementary education	80.0 (78.0–82.0)	84.2 (81.7–86.6)	82.4 (79.8–85.0)	15.0 (13.2–16.7)	14.0(11.2–16.9)	17.2 (14.7–19.7)
Completed high school education	89.0 (87.2–90.9)	92.4 (90.1–94.7)	91.2 (89.4–92.9)	22.1 (19.2–25.0)	26.8 (20.0–33.7)	25.8 (22.6–29.1)
Completed higher education	94.6 (92.9–96.2)	92.2 (88.0–96.3)	95.7 (94.5–96.9)	30.8 (26.3–35.3)	29.3 (24.7–33.9)	41.5 (36.8–46.2)
Self-perception of health
Negative	79.1 (77.4–80.8)	82.6 (80.4–84.8)	83.2 (81.3–85.1)	14.3 (12.5–16.1)	15.1 (12.3–18.0)	15.8 (13.7–17.9)
Positive	85.6 (83.6–87.6)	87.1 (83.4–90.9)	88.9 (87.1–90.7)	23.2 (21.0–25.4)	24.8 (21.1–28.5)	31.5 (28.5–34.5)
Public space for PAP
No	78.2 (76.3–80.0)	81.4 (78.4–84.4)	83.7 (81.9–85.6)	13.9 (12.4–15.5)	15.1 (12.0–18.2)	17.5 (15.3–19.7)
Yes	86.8 (85.2–88.5)	87.3 (84.8–89.8)	88.5 (86.8–90.2)	23.5 (21.2–25.8)	21.7 (17.8–25.6)	30.2 (27.2–33.2)
Public programs that stimulate PAP
No	79.9 (78.4–81.4)	82.8 (80.5–85.1)	83.8 (82.0–85.5)	15.8 (14.4–17.2)	15.1 (12.5–17.7)	20.3 (18.2–22.4)
Yes	88.3 (86.2–90.3)	87.6 (84.3–90.8)	92.2 (90.2–94.3)	25.4 (22.8–28.0)	27.4 (23.1–31.7)	32.2 (28.8–35.6)

• Source: Brazilian Institute of Geography and Statistics; 2013. *p<0.001 (χ² test). PAP: physical activity on prescription; LPAP: leisure-time physical activity on prescription

An adjusted analysis showed distinct associations among different investigated NCDs. Individuals with HBP aged 40–59 years had a 27% higher chance of receiving a recommendation than older individuals. Public space and public programs were also associated with PAP. In individuals with diabetes, those aged 40–59 years who were white had 105 and 60% higher chances of receiving a recommendation, respectively, compared to older and black individuals. Married individuals with hypercholesterolemia had a 46% higher chance of receiving a recommendation compared to separated/divorced/widowed individuals. For all investigated NCDs, an educational level of high school or college was positively associated with receiving a recommendation (Table 2).

Table 2
Gross and adjusted odds ratio of “having received a recommendation for physical activity on prescription from a health professional” in adults (≥20 years) with hypertension blood pressure, diabetes, and hypercholesterolemia. Brazil, 2013.

Variables	Hypertension				Diabetes				Hypercholesterolemia
	Crude		AdjustedA		Crude		AdjustedB		Crude		AdjustedC
	OR	95%CI	OR	95%CI	OR	95%CI	OR	95%CI	OR	95%CI	OR	95%CI
Sex
Female	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Male	0.98	(0.83–1.16)	0.88	(0.74–1.05)	1.08	(0.79–1.48)	0.92	(0.65–1.29)	0.97	(0.75–1.24)	0.78	(0.60–1.01)
Age group (years)
≥60	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
40–59	1.57	(1.30–1.91)	1.27	(1.03–1.56)	2.40	(1.65–3.51)	2.05	(1.34–3.14)	1.48	(1.15–1.89)	1.12	(0.86–1.46)
20–39	1.58	(1.23–2.02)	1.16	(0.87–1.55)	2.49	(1.21–5.14)	1.60	(0.85–4.49)	1.77	(1.20–2.63)	1.05	(0.66–1.69)
Race/skin color
Black	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Brown	1.04	(0.80–1.34)	1.03	(0.80–1.33)	1.40	(0.95–2.06)	1.41	(0.93–2.12)	0.96	(0.61–1.49)	0.88	(0.57–1.38)
White	1.35	(1.04–1.75)	1.14	(0.88–1.47)	1.73	(1.12–2.66)	1.60	(1.03–2.48)	1.24	(0.82–1.88)	0.95	(0.63–1.45)
Marital status
Separated/divorced/widowed	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Single	1.00	(0.81–1.24)	0.86	(0.68–1.10)	1.05	(0.70–1.56)	0.78	(0.48–1.26)	1.34	(0.97–1.85)	1.17	(0.79–1.73)
Married	1.34	(1.11–1.61)	1.15	(0.95–1.40)	1.10	(0.80–1.51)	0.82	(0.59–1.15)	1.53	(1.13–2.07)	1.46	(1.07–1.98)
Education
No education	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Completed elementary education	1.63	(1.36–1.96)	1.40	(1.15–1.70)	1.98	(1.43–2.73)	1.68	(1.19–2.37)	1.42	(1.06–1.91)	1.29	(0.97–1.72)
Completed high school education	3.30	(2.59–4.22)	2.49	(1.91–3.26)	4.54	(2.69–7.65)	3.12	(1.79–5.48)	3.14	(2.25–4.39)	2.78	(1.95–3.97)
Completed higher education	7.11	(4.85–10.43)	5.00	(3.31–7.55)	4.39	(1.56–12.37)	2.93	(1.04–8.29)	6.81	(4.50–10.29)	5.40	(3.14–8.53)
Self-perception of health
Negative	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Positive	1.57	(1.29–1.90)	1.21	(0.99–1.49)	1.43	(0.93–2.19)	1.14	(0.73–1.78)	1.62	(1.28–2.05)	1.07	(0.83–1.39)
Public space for PAP
No	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Yes	1.85	(1.53–2.22)	1.47	(1.20–1.79)	1.58	(1.13–2.20)	1.39	(0.98–1.97)	1.50	(1.17–1.91)	1.11	(0.85–1.45)
Public programs that stimulate PAP
No	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Yes	1.89	(1.52–2.36)	1.40	(1.11–1.77)	1.46	(0.92–2.33)	1.07	(0.65–1.76)	2.29	(1.67–3.14)	1.89	(1.33–2.67)

• Source: Brazilian Institute of Geography and Statistics, 2013. All variables were kept in the adjusted analysis, with sex^B, age-group^A,C, race^C, marital status^B, health status^B,C, program^B, and space^C, p>0.20. OR: odds ratio; PAP: physical activity on prescription.

Among those who received a PAP recommendation, an adjusted analysis in all NCDs showed that a positive self-perception of health, the presence of space and PAP public programs, and a high educational level were positively associated with adequate LPAP. A high educational level increased the chances of LPAP 2.5 times in individuals with HBP, 2.1 times in those with diabetes, and 3.1 in those with hypercholesterolemia compared to individuals with a low educational level (Table 3).

Table 3
Gross and adjusted odds ratio for sufficient leisure-time physical activity on prescription in adults (≥20 years) with hypertension blood pressure, diabetes, and hypercholesterolemia who received recommendation from health professionals. Brazil, 2013.

	HBP				Diabetes				Hypercholesterolemia
Variables	Crude		AdjustedA		Crude		AdjustedB		Crude		AdjustedC
	OR	95%CI	OR	95%CI	OR	95%CI	OR	95%CI	OR	95%CI	OR	95%CI
Sex
Female	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Male	1.13	(0.94–1.36)	1.05	(0.87–1.28)	0.89	(0.63–1.26)	0.73	(0.51–1.03)	1.09	(0.87–1.37)	0.97	(0.77–1.22)
Age group (years)
≥60	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
40–59	1.47	(1.20–1.81)	1.26	(1.00–1.59)	1.86	(1.35–2.60)	1.66	(1.13–2.43)	1.37	(1.10–1.72)	1.13	(0.88–1.45)
20–39	1.40	(1.05–1.86)	1.08	(0.80–1.47)	1.81	(1.04–3.17)	1.72	(0.91–3.24)	1.74	(1.29–2.34)	1.03	(0.74–1.43)
Race/skin color (3)
Black	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Brown	1.38	(0.97–1.99)	1.45	(0.99–2.13)	0.99	(0.62–1.58)	0.99	(0.59–1.66)	1.44	(0.93–2.21)	1.30	(0.82–2.06)
White	1.37	(0.96–1.94)	1.20	(0.84–1.72)	1.23	(0.75–2.01)	1.10	(0.65–1.85)	1.50	(0.99–2.27)	1.07	(0.69–1.66)
Marital status
Separated/divorced/widowed	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Single	1.11	(0.85–1.46)	0.99	(0.73–1.33)	0.85	(0.53–1.39)	0.71	(0.40–1.26)	1.21	(0.89–1.64)	0.97	(0.71–1.32)
Married	1.20	(0.97–1.49)	1.01	(0.80–1.27)	1.27	(0.85–1.91)	1.14	(0.73–1.77)	1.11	(0.87–1.41)	0.99	(0.75–1.30)
Education
No education	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Completed elementary education	1.38	(1.06–1.80)	1.18	(0.90–1.55)	1.26	(0.80–2.00)	0.90	(0.57–1.42)	1.39	(0.97–1.99)	1.19	(0.81–1.74)
Completed high school education	2.22	(1.64–2.99)	1.63	(1.19–2.22)	2.84	(1.67–4.82)	1.91	(1.11–3.31)	2.32	(1.61–3.36)	1.66	(1.11–2.48)
Completed higher education	3.48	(2.50–4.85)	2.49	(1.76–3.51)	3.21	(1.82–5.66)	2.07	(1.14–3.75)	4.74	(3.24–6.94)	3.07	(2.03–4.64)
Self-perception of health
Negative	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Positive	1.81	(1.48–2.21)	1.48	(1.21–1.81)	1.85	(1.29–2.65)	1.62	(1.13–2.32)	2.45	(1.98–3.03)	1.75	(1.38–2.22)
Public space for PAP
No	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Yes	1.90	(1.57–2.29)	1.59	(1.29–1.95)	1.56	(1.11–2.20)	1.42	(0.99–2.03)	1.56	(1.11–2.20)	1.56	(1.25–1.97)
Public programs that stimulate PAP
No	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–	1.00	–
Yes	1.81	(1.50–2.19)	1.49	(1.21–1.83)	2.12	(1.41–3.21)	1.85	(1.19–2.89)	1.87	(1.51–2.31)	1.64	(1.30–2.07)

• Source: Brazilian Institute of Geography and Statistics, 2013. All variables were kept in the adjusted analysis, with sex^A,C, age-group^A,C, race^A,B,C, and marital status^A,B,C, p>0.20. OR: odds ratio; PAP: physical activity on prescription; HBP: hypertension blood pressure.

DISCUSSION

The results showed that receiving a PAP recommendation was positively associated with the age group 40–59 years (except for hypercholesterolemia), with being white (in individuals with diabetes), with being married (in individuals with hypercholesterolemia), and with having space (in individuals with HBP) and public PAP programs (except for individuals with diabetes). Educational level was the only variable associated with the outcome in all NCDs. In those who received a recommendation, LPAP presented positive association with higher educational level, positive self-perception of health, and presence of space and public PAP programs in all NCDs.

In Brazil, approximately 59.3% of individuals received some recommendation for adopting a healthy behavior in primary care⁹. One of the associated factors is the presence of an NCD^8,11,16, justifying the high prevalence of recommendations. Corroborating the results of this study, other studies also reported higher prevalence of both PAP recommendation^11,16 and sufficient LPAP^10,14,15,17 in married individuals, with a higher educational level, and access to public spaces and programs.

As for the age group, there was a higher prevalence of recommendations for older adults and younger elderly individuals¹⁶. The demand for health services and professional recommendation is highly prevalent in elderly individuals⁷ but, with advancing age, NCD and physical limitations may hinder PAP, reducing recommendations for older individuals who cannot perform them. LPAP was more prevalent among adults, which may be justified by better health status and lower limitations resulting from NCD in this group¹³. Although there was a higher prevalence of recommendations and PAP in individuals with positive health perception, only PAP showed an association in an adjusted analysis, corroborating a study investigating the same NCD¹⁷. Positive health perception presupposes greater susceptibility to adhere to LPAP⁶, which may justify the association.

As in other studies, the favorable environment for PAP was associated with receiving recommendations¹¹ and LPAP^10,17,18. Places such as health units, gym centers, and green spaces in the area increase recommendations and LPAP¹¹, possibly because the health professional considers that the user would be able to comply with the recommendations. Decision making for PAP considers the effects of space and context¹⁹, highlighting a person’s sense of safety, urbanization, geography, and climate^6,18. Some studies highlight the importance of environments built to address PAP inequalities. Although wealthier individuals have more knowledge on the existing public programs, individuals with lower income participate more often in these programs²⁰. Adequate spaces for PAP close to the household are associated with higher PAP¹⁸; therefore, public health promotion policies can help fight inequalities when aimed at the most vulnerable regions.

Having a higher educational level increased the chances of both outcomes. Studies identified the same bias for recommendation¹¹ and LPAP^10,14,15,17. The lower occurrence of recommendation for individuals with a lower educational level replicates a perverse logic, in which those who need it most have less access or use a service of lower quality. Similar behavior was found in patients with high cardiovascular risk, where those with lower income had less access to diagnostic health services²¹. Considering the positive relationship between education and income²², higher education provides individuals with objective conditions to meet the recommendations. Professional recommendation is a way to promote health and, according to the principle of equity, greater attention to the most vulnerable population is expected. They need more social support, objective conditions, and motivation for behavioral changes²³. Another hypothesis for the results obtained would be the greater engagement of individuals with higher educational level for LPAP since they were more knowledgeable¹⁵.

One limitation of this study is its cross-sectional design, which makes it impossible to infer causality, and self-reported NCD leads to a memory bias of the participants. Considering that the presence of NCD is associated with an increased use of health services, a possible selection bias cannot be excluded, especially because individuals with undiagnosed disease are not included in the analyzed sample.

CONCLUSIONS

Being in the 40–59 years of age group and having a higher educational level, a positive perception of health, and the existence of public spaces and PAP programs were associated with both receiving professional PAP recommendation and being more leisure-time physically active in individuals who received professional recommendation.

Educational level was the variable associated with the greatest magnitude, pointing to the need for strategies capable of attenuating the evident inequalities found to increase LPAP recommendation in the most vulnerable population.

• Funding: none.

REFERENCES

• ¹
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Publication Dates

• Publication in this collection
  27 Aug 2021
• Date of issue
  Mar 2021

History

• Received
  02 Sept 2020
• Accepted
  29 Sept 2020