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vol.17 suppl.1Experimentation and use of cigarette and other tobacco products among adolescents in the Brazilian state capitals (PeNSE 2012)Bullying in Brazilian school children: analysis of the National Adolescent School-based Health Survey (PeNSE 2012) author indexsubject indexarticles search
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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790X

Rev. bras. epidemiol. vol.17  supl.1 São Paulo  2014

http://dx.doi.org/10.1590/1809-4503201400050007 

Original Articles

Trend of the risk and protective factors of chronic diseases in adolescents, National Adolescent School-based Health Survey (PeNSE 2009 e 2012)

Deborah Carvalho MaltaI  II 

Marco Antonio Ratzsch de AndreazziIII 

Maryane Oliveira-CamposI 

Silvania Suely Caribé de Araújo AndradeI 

Naíza Nayla Bandeira de SáIV 

Lenildo de MouraV 

Antonio José Ribeiro DiasIII 

Claudio Dutra CrespoIII 

Jarbas Barbosa da Silva JúniorI 

IHealth Surveillance Secretariat, Ministry of Health - Brasília (DF), Brazil

IIUniversidade Federal de Minas Gerais - Belo Horizonte (MG), Brazil

IIIBrazilian Institute of Geography and Statistics - Rio de Janeiro (RJ), Brazil

VIUniversidade Federal do Pará - Belém (PA), Brazil

VPan-American Health Organization - Brasília (DF), Brazil

ABSTRACT

OBJECTIVE:

To compare the prevalence of major risk and protection factors for chronic non-communicable diseases in school-aged children in Brazilian capitals surveyed in the National Adolescent School-based Health Survey in its two editions, 2009 and 2012.

METHODS:

The frequencies, with Confidence Interval of 95%, of the following demographic variables were compared: food intake, body image, physical activity, smoking, alcohol and other drugs. Prevalence was compared in the two editions of the survey.

RESULTS:

The proportion of students who attend two physical education classes a week was maintained at 49% between 2009 and 2012, increasing in public schools from 50.6% (95%CI 49.8 - 51.4) to 52.5% (95%CI 49.2 - 55.7), and decreasing in private schools. There was no change in the proportion of students who watch two hours or more of television daily, about 80%. As for body image, there was no change between the two editions, and about 60% considered themselves being of normal weight. There was a reduction in the percentage of adolescents who experienced cigarettes, from 24.2% (95%CI 23.6 - 24.8) to 22.3% (95%CI 21.4 - 23.2), and the prevalence of smoking was maintained at about 6% (there was no statistical difference between 2009 and 2012). The consumption of beans, fruits, sweets and soft drinks also decreased. Frequency of drug experimentation was of 8.7% (95%CI 8.3 - 9.1) in 2009, and 9.6% (95%CI 9.0 - 10.3) in 2012, with no difference between confidence intervals, and the frequency of alcohol experimentation was maintained at about 70%; the percentage of use in the past 30 days was also maintained at around 27%.

CONCLUSION:

In the Brazilian capitals, the vast majority of prevalence of risk factors were kept stable in the two editions of the National Survey of School. These data generate evidence to guide the implementation of public policies to minimize the exposure of adolescents to risk factors.

Key words: Adolescence; Risk factors; Physical activity; Smoking; Alcohol; Drugs; Food consumption; Body image

INTRODUCTION

Adolescents aged between 10 and 19 years old respond for 18% of the world population, and around 90% of them live in low and mid-income countries1. Adolescence constitutes an important phase of biological, cognitive, emotional and social changes. This phase is marked by increasing autonomy, independence with regard to family and experimentation of new behaviors and facts2-5. Some of these experiences are risk factors for health, as the use of tobacco, alcohol consumption, inadequate diet and sedentary lifestyle. The early exposure to these factors is associated with the development of most Non-Communicable Diseases (NCD) (cardiovascular diseases, diabetes and cancer), which can lead to accumulated exposure throughout life and, therefore, more risks of NCDs. There is evidence showing that establishing health promotion measures early, for instance, in intrauterine life, in childhood and adolescence, improves the quality of life, besides having an impact on the reduction of morbimortality in the population1,6. Studies estimate that 70% of the premature deaths among adults are mainly caused by behaviors that began in adolescence, and, in general, it is common to share several risk factors at any stage of life, thus potentializing the action1.

The control of health among adolescents has been an global tendency1 due to the transitions and experiences that take place in this stage of life, which can lead to present and future risks to health1,7-9. Therefore, it is important to turn adolescence into a target for universal prevention1,2.

In order to guide public policies, the World Health Organization (WHO) has recommended the implantation and the maintenance of surveillance systems of factors that offer risk to health addressed to adolescents. The main monitoring systems related to the health of the students are:

  1. The Global School Based Student Health Survey (GSHS), which is present in more than 70 countries8, coordinated by WHO together with the Center for Disease Control and Prevention (CDC);

  2. The Health Behavior in School-aged Children (HBSC), initiated in 1982 and coordinated by WHO in 40 European countries, besides Israel, Canada and others2;

  3. The Youth Risk Behavior Surveillance System (YRBSS), in the USA, whose data have been collected every two years by the CDC since 199110.

These studies have supported public policies in several countries2,8. In Brazil, the National Adolescent School-Based Survey (PeNSE)3 was the first to investigate the risk and protective factors concerning the health of adolescents. The first edition of the survey, conducted in 2009, represented only the Brazilian capitals and the Federal District. PeNSE 20124, the second edition, amplified the sample in order to represent Brazil, its five major regions and capitals. Besides, the questionnaire was expanded by the insertion of new themes and the adaptation of some questions in order to compare it with other studies, including international ones. The survey is conducted every three years, as a result of the partnership between the Ministry of Health, the Brazilian Institute of Geography and Statistics (IBGE) and the Ministry of Education (MEC). PeNSE contributed with the elaboration of the Plan of Strategic Actions to Tackle Non-Communicable Diseases (NCD) in Brazil, 2011 - 2022, as well as to define goals to monitor this age group6.

This study aimed at comparing the prevalence of the main risk and protective factors for NCDs among students in Brazilian State capitals and in the Federal District, who were investigated in both editions of PenSE, in 2009 and in 2012.

METHODS

The analyzed population was comprised of 9th graders in elementary school (former 8th grade) of public and private schools in Brazilian State capitals and the Federal District, in 2009 and in 2012. The sample of PeNSE 2009 represented the 26 Brazilian capitals and the Federal District (63,411). PeNSE 2012 had a larger sample, representing Brazil, its five major regions and the 26 State capitals and the Federal District (n = 109,104).

In order to compare the results between 2009 and 2012, only the sample representing the 26 Brazilian State capitals and the Federal District was used in this study (n = 61,145)3,4.

Each capital and the Federal District were defined as a geographic stratum. The sample of each geographic stratum was allocated proportionally in relation to the number of schools registered in the School Census, according to the administration of the schools (private and public). For each of these strata, a two-stage cluster sample was selected, being the first stage comprised of schools, and the second stage composed of eligible classrooms in the selected schools (9th grade of elementary school). In the selected classrooms, all students who were present were included in the study sample3,4.

The record excluded schools with less than 15 students in the analyzed grade, because, even if they represented about 10% of the schools, they accounted for less than 1% of the total of students. The record also excluded classrooms in the evening period, because these students are older and may present with differentiated risk in relation to the other students in the same grade. The 9th grade was chosen because most students, aged between 13 and 15 years old, had already acquired the necessary skills to answer the questionnaire, since they were prone to being exposed to several risk factors, and because it was possible to compare these data with systems of other countries2,8.

The interview was conducted by means of a self-applicable structured questionnaire, inserted in a palmtop, in 2009, and in a smartphone, in 2012. Students were guided by the researchers as to how to handle the devices.

The current study compared the variables whose questions remained similar in both editions:

1. Sociodemographic variables: age, ethnicity/color, sex, maternal schooling;

2. Dietary intake:

• Healthy diet:

  • - Intake of beans (percentage of students who reported consuming beans in at least five of the seven days prior to data collection);

  • - Intake of fruits (percentage of students who reported consuming fruits in at least five of the seven days prior to data collection);

• Unhealthy diet:

  • - Intake of dainties (percentage of students who reported consuing dainties, such as candy, caramels, chocolate, bubble gum, bombons or lollypops in at least five of the seven days prior to data collection;

  • - Intake of soft drinks (percentage of students who reported consuming soft drinks in at least five of the seven days prior to data collection);

3. Body image: Percentage of students based on self-perceived body image, in the following categories: very thin, thin, average, fat, and very fat.

4. Smoking:

  1. Lifetime use of tobacco (experimentation): percentage of students who have tried cigarettes at least once;

  2. Use of cigarettes in the past 30 days: percentage of students who reported smoking at least once in the 30 days prior to data collection. The use of tobacco in the past 30 days, regardless of frequency and intensity, was considered as current use of cigarettes;

  3. Students who had at least one smoking parent/person in charge: percentage of students who had at least one parent or person in charge who smoked cigarettes;

  4. Lifetime use of tobacco (experimentation): percentage of students who have tried cigarettes at least once;

  5. Use of cigarettes in the past 30 days: percentage of students who reported smoking at least once in the 30 days prior to data collection. The use of tobacco in the past 30 days, regardless of frequency and intensity, was considered as current use of cigarettes;

  6. Students who had at least one smoking parent/person in charge: percentage of students who had at least one parent or person in charge who smoked cigarettes;

5. Alcohol consumption:

  1. Trying alcohol:

  2. Alcohol consumption in the past 30 days: percentage of students who reported having consumed alcohol at least once in the 30 days prior to data collection;

6. Trying illicit drugs: percentage of students who reported having tried illicit drugs, such as marijuana, cocaine, crack, solvent-based glue, ether and chloroform inhalants, poppers, ecstasy, oxy etc;

7. Physical activity:

  1. Sedentary lifestyle:

  2. Frequency of physical education classes: percentage of students who attended two or more physical education classes at school, in the past seven days.

Frequencies were estimated with a 95% confidence interval (95%CI), concerning the variables age, sex, ethnicity/color, maternal schooling, dietary intake, body image, physical activity, smoking, consumption of alcohol and other drugs. The SAS statistical package was used11. The comparison of prevalence ratios was conducted by the 95%CI, in order to verify if there were differences between 2009 and 2012.

The study was approved by the Research Ethics Committee of the Ministry of Health, report n. 192/2012, concerning registration n. 16805, CONEP/MS, on 27/03/2012.

RESULTS

By comparing the sociodemographic results of PeNSE 2009 and 2012, the proportion of students aged between 13 and 15 years old was maintained in both editions at about 90%, even though there had been a reduction in the proportion of students aged 13 years old in public and private schools, with increasing proportion of 14-year old students in 2012. The percentage of students who reported being mulattos increased from 35.7% (95%CI 34.7 - 36.7) in 2009 to 39.9% (95%CI 38.6 - 41.2), in 2012, with reduced proportion of the ones who declared to be white, from 41.6% (95%CI 40.6 - 42.7) to 37.7% (95%CI 36.2 - 39.3). This happened both in public and private schools, among male and female participants, except for the reduction in the white color, which only occurred among girls. The proportion of students whose mothers had middle schooling (complete high school and incomplete higher education) increased from 32.3% (95%CI 31.2 - 33.4) to 35.0% (95%CI 34.0 - 36.1), and there was a reduced proportion of students whose mothers had completed higher education, from 21.6% (95%CI 20.8 - 22.5) to 16.8 (95%CI 14.9 - 18.7), in 2009 and in 2012, respectively.

Table 1 Distribution of study population by age, ethnicity/color and maternal schooling, by gender, among 9th grade students for all the Brazilian State Capitals and the Federal District. PeNSE, 2009 and 2012. 

Variable 2009 2012
Female % (95%CI) Male % (95%CI) Total % (95%CI) Female % (95%CI) Male % (95%CI) Total % (95%CI)
Age (years)
< 13 0.8 (0.7 – 0.9) 0.6 (0.5 – 0.7) 0.7 (0.6 – 0.8) 0.5 (0.4 – 0.6) 0.5 (0.3 – 0.6) 0.5 (0.4 – 0.6)
13 26.7 (25.8 – 27.6) 20.5 (19.6 – 21.3) 23.7 (23.1 – 24.4) 21.6 (20.5 – 22.7) 15.4 (14.4 – 16.4) 18.5 (17.7 – 19.4)
14 48.2 (47.2 – 49.2) 45.8 (44.8 – 46.9) 47.1 (46.4 – 47.8) 52.1 (51 – 53.3) 48 (46.5 – 49.6) 50.1 (49.0 – 51.2)
15 15.9 (15.3 – 16.6) 20.8 (20.0 – 21.6) 18.2 (17.7 – 18.8) 16.9 (16.1 – 17.7) 21.9 (20.7 – 23.1) 19.4 (18.5 – 20.2)
16 and older 8.3 (7.9 – 8.8) 12.3 (11.7 – 12.9) 10.2 (9.8 – 10.6) 8.9 (8.2 – 9.6) 14.2 (13 – 15.5) 11.5 (10.6 – 12.4)
Color or ethnicity
White 40.1 (39.4 – 40.9) 38.8 (37.8 – 39.8) 41.6 (40.6 – 42.7) 35 (30.1 – 40) 38.7 (33.3 – 44.1) 37.7 (36.2 – 39.3)
Black 12.9 (12.4 – 13.3) 11.0 (10.5 – 11.6) 14.9 (14.2 – 15.7) 11.4 (9.2 – 13.5) 15.5 (13 – 18) 14.2 (13.4 – 14.9)
Mulatto 39.1 (38.4 – 39.8) 42.3 (41.3 – 43.2) 35.7 (34.7 – 36.7) 45.7 (42.6 – 48.8) 38.5 (35.3 – 41.6) 39.9 (38.6 – 41.2)
Yellow 3.7 (3.5 – 4.0) 4.0 (3.7 – 4.40 3.4 (3.1 – 3.8) 4.4 (3.3 – 5.6) 3.8 (3.4 – 4.1) 4.5 (4.2 – 4.8)
Indigenous 4.1 (3.8 – 4.3) 3.9 (3.5 – 4.20 4.3 (3.9 – 4.7) 3.5 (2.8 – 4.2) 3.6 (2.7 – 4.5) 3.7 (3.4 – 3.9)
Maternal schooling*
None or incomplete elementary school 31.8 (31.1 – 32.5) 34.4 (33.4 – 35.4) 28.9 (27.9 – 29.9) 31.6 (29.8 – 33.4) 28.7 (26.7 – 30.7) 30.2 (28.4 – 31.9)
Compl. elementary school./ incomplete high school 16.9 (16.3 – 17.4) 16.6 (15.8 – 17.3) 17.2 (16.4 – 18.1) 18.8 (17.6 – 19.9) 17.3 (16.4 – 18.2) 18 (17.3 – 18.8)
Compl. high school/ incomplete higher education 31.5 (30.8 – 32.3) 30.9 (29.9 – 31.9) 32.3 (31.2 – 33.4) 34.5 (33.2 – 35.9) 35.5 (34.3 – 36.7) 35.0 (34.0 – 36.1)
Superior completo 19.8 (19.3 – 20.4) 18.2 (17.4 – 18.9) 21.6 (20.8 – 22.5) 15.1 (13.2 – 17) 18.5 (16.4 – 20.6) 16.8 (14.9 – 18.7)

*Of the total students, 18.5% in 2009 and 18.9% in 2012 could not inform maternal education.

Table 2 Distribution of the population of adolescent students by age, ethnicity/color and maternal schooling, according the administration of the schools in all Brazilian State Capitals and the Federal District. PeNSE, 2009 and 2012. 

Variable 2009 2012
Administration Administration
Public % (95%CI) Private % (95%CI) Total % (95%CI) Public % (95%CI) Private % (95%CI) Total % (95%CI)
Age (years)
< 13 0.6 (0.5 – 0.7) 1.0 (0.8 – 1.2) 0.7 (0.6 – 0.8) 0.4 (0.3 – 0.6) 0.7 (0.5 – 0.9) 0.5 (0.4 – 0.6)
13 21.2 (20.5 – 21.9) 33.4 (32.1 – 34.7) 23.7 (23.1 – 24.4) 15.8 (14.7 – 16.8) 26.7 (25 – 28.4) 18.5 (17.7 – 19.4)
14 45.4 (44.6 – 46.3) 53.4 (52.0 – 54.8) 47.1 (46.4 – 47.8) 47.9 (46.5 – 49.2) 56.6 (55 – 58.2) 50.1 (49.0 – 51.2)
15 20.6 (20.0 – 21.3) 9.1 (8.4 – 9.9) 18.2 (17.7 – 18.8) 21.9 (20.8 – 23) 11.8 (10.7 – 13) 19.4 (18.5 – 20.2)
16 and older 12.1 (11.6 – 12.6) 3.1 (2.7 – 3.5) 10.2 (9.8 – 10.6) 14 (12.9 – 15.1) 4.2 (3.5 – 4.9) 11.5 (10.6 – 12.4)
Color or ethnicity
White 35.0 (34.2 – 35.8) 59.7 (58.3 – 61.0) 40.1 (39.4 – 40.9) 31.7 (30.4 – 33) 55.3 (52.1 – 58.5) 37.7 (36.2 – 39.3)
Black 14.7 (14.1 – 15.2) 6.1 (5.5 – 6.7) 12.9 (12.4 – 13.3) 16.4 (15.5 – 17.2) 7.8 (6.9 – 8.8) 14.2 (13.4 – 14.9)
Mulatto 42.9 (42.0 – 43.7) 25.1 (24.0 – 26.2) 39.1( 3.4 – 39.8) 44.2 (42.9 – 45.4) 27.5 (25.1 – 29.8) 39.9 (38.6 – 41.2)
Yellow 3.3 (3.1 – 3.6) 5.3 (4.6 – 5.9) 3.7 (3.5 – 4.0) 4 (3.7 – 4.4)) 5.8 (5.1 – 6.5) 4.5 (4.2 – 4.8)
Indigenous 4.2 (3.9 – 4.5) 3.9 (3.4 – 4.4) 4.1 (3.8 – 4.3) 3.7 (3.4 – 4) 3.6 (3.1 – 4.1) 3.7 (3.4 – 3.9)
Maternal schooling*
None or incomplete elementary school 39.4 (38.6 – 40.3) 5.8 (5.2 – 6.5) 31.8 (31.1 – 32.5) 38.2 (36.6 – 39.9) 8.4 (7 – 9.8) 30.2 (28.4 – 31.9)
Compl. elementary school./ incomplete high school 19.3 (18.6 – 20.0) 8.5 (7.8 – 9.3) 16.9 (16.3 – 17.4) 20.8 (20.1 – 21.6) 10.4 (9.5 – 11.4) 18.0 (17.3 – 18.8)
Compl. high school/ incomplete higher education 31.1 (30.3 – 32.0) 32.9 (31.6 – 34.3) 31.5 (30.8 – 32.3) 33.4 (32.1 – 34.6) 39.5 (37.4 – 41.5) 35.0 (34 – 36.1)
Complete higher education 10.1 (9.5 – 10.7) 52.8 (51.4 – 54.2) 19.8 (19.3 – 20.4) 7.5 (6.7 – 8.4) 41.8 (38.5 – 45) 16.8 (14.9 – 18.7)

*Of the total students, 18.5%could not inform maternal education, being excluded.

With regard to dietary intake, after comparing both surveys, there was a reduction in the intake of beans, from 62.5% (95%CI 61.8 - 63.3), in 2009, to 60.0% (95%CI 58.5 - 61.5), and of fruits, from 31.5% (95%CI 30.8 - 32.2) to 29.8% (95%CI 29.1 - 30.5), in 2012. The percentage of students who reported the consumption of soft drinks also decreased, from 37.2% (95%CI 36.5 - 37.5) to 35.4% (95%CI 34.6 - 36.2), and the same was true for the intake of dainties, from 50.9% (95%CI 50.1 - 51.6) to 42.6% (95%CI 41.6 - 43.6). Most changes related to dietary habits occurred in both sexes and in public and private schools, except for the prevalence of the consumption of beans and soft drinks in public schools and the prevalence of fruits in private schools, which remained the same.

Table 3 Frequency (%) of risk and protective factors, by sex, among 9th grade students for all Brazilian State Capitals and the Federal District, PeNSE, 2009 and 2012. 

Variable 2009 2012
Female % (95%CI) Male % (95%CI) Total % (95%CI) Female % (95%CI) Male % (95%CI) Total % (95%CI)
Dietary intake
Beans 57.4 (56.5 – 58.3) 68.3 (67.4 – 69.2) 62.5 (61.8 – 63.3) 54.3 (52.6 – 56) 65.9 (64.3 – 67.6) 60.0 (58.5 – 61.5)
Fruits 31.6 (30.7 – 32.5) 31.4 (30.4 – 32.4) 31.5 (30.8 – 32.2) 29.7 (28.7 – 30.6) 29.9 (28.8 – 30.9) 29.8 (29.1 – 30.5)
Dainties 58.3 (57.4 – 59.3) 42.6 (41.5 – 43.6) 50.9 (50.1 – 51.6) 48.8 (47.6 – 50) 36.2 (34.8 – 37.6) 42.6 (41.6 – 43.6)
Soft drinks 36.6 (35.7 – 37.5) 37.9 (36.9 – 38.9) 37.2 (36.5 – 37.9) 34.5 (33.4 – 35.5) 36.5 (35.4 – 37.6) 35.4 (34.6 – 36.2)
Body image
Very thin or thin 21.4 (20.6 – 22.1) 23.0 (22.1 – 23.8) 22.1 (21.5 – 22.7) 22.7 (21.9 – 23.5) 23.5 (22.6 – 24.5) 23.1 (22.5 – 23.7)
Normal 57.3 (56.4 – 58.3) 63.3 (62.3 – 64.3) 60.1 (59.5 – 60.8) 56.1 (55.0 – 57.2) 62.3 (61.3 – 63.4) 59.1 (58.4 – 59.9)
Fat or very fat 21.3 (20.5 – 22.1) 13.8 (13.1 – 14.5) 17.7 (17.2 – 18.3) 21.2 (20.3 – 22.1) 14.1 (13.4 – 14.9) 17.8 (17.1 – 18.4)
Physical activity
≥ 2 Physical education classes 47.9 (47 – 48.9) 50.8 (49.7 – 51.0) 49.3 (48.6 – 50) 47.7 (44.8 – 50.5) 51.0 (48.1 – 53.9) 49.3 (46.5 – 52.1)
≥ 2 hours in front of TV 79.5 (78.7 – 80.3) 79.4 (78.5 – 80.3) 79.5 (78.9 – 80.0) 78.1 (77.2 – 79.0) 79.1 (78.2 – 80.0) 78.6 (77.9 – 79.3)
Smoking habit
Trying cigarettes 24.0 (23.2 – 24.8) 24.4 (23.5 – 25.2) 24.2 (23.6 – 24.8) 22.2 (21.0 – 23.4) 22.3 (21.2 – 23.4) 22.3 (21.4 – 23.2)
Current smoker 6.3 (5.8 – 6.7) 6.4 (5.9 – 6.9) 6.3 (6.0 – 6.7) 6.1 (5.4 – 6.8) 6.1 (5.6 – 6.6) 6.1 (5.6 – 6.6)
Smoking parents 31.0 (30.3 – 31.6) 31.7 (30.8 – 32.7) 30.1 (29.1 – 31.1) 29.0 (27.9 – 30.0) 27.2 (25.9 – 28.4) 28.1 (27.2 – 29.0)
Consumption of alcohol and other drugs
Trying alcohol 73.1 (72.3 – 73.9) 69.5 (68.5 – 70.5) 71.4 (70.8 – 72.0) 72.7 (71.8 – 73.6) 68.3 (67.0 – 69.5) 70.5 (69.7 – 71.4)
Alcohol in the past 30 days 28.1 (27.2 – 29.0) 26.5 (25.5 – 27.5) 27.3 (26.7 – 28.0) 28.2 (27.1 – 29.3) 25.4 (24.2 – 26.6) 26.8 (25.9 – 27.8)
Trying illicit drugs 6.9 (6.4 – 7.4) 10.6 (10.0 – 11.3) 8.7 (8.3 – 9.1) 9.0 (8.2 – 9.8) 10.3 (9.5 – 11.1) 9.6 (9.0 – 10.3)

Table 4 Frequency (%) of risk and protective factors among school-aged adolescents, by sex and administration of the school, for all Brazilian State Capitals and the Federal District. PeNSE, 2009 and 2012. 

Variable 2009 2012
Administration Administration
Public % (95%CI) Private % (95%CI) Total % (95%CI) Public % (95%CI) Private % (95%CI) Total % (95%CI)
Dietary intake
Beans 65.8 (65.1 – 66.6) 50.1 (48.8 – 51.5) 62.5 (61.8 – 63.3) 63.9 (62.5 – 65.3) 48.6 (46.4 – 50.9) 60.0 (58.5 – 61.5)
Fruits 31.8 (30.5 – 33.0) 31.4 (30.7 – 32.2) 31.5 (30.8 – 32.2) 29.7 (28.9 – 30.5) 30 (28.3 – 31.6) 29.8 (29.1 – 30.5)
Dainties 51.1 (50.3 – 51.9) 49.9 (48.6 – 51.3) 50.9 (50.1 – 51.6) 43.6 (42.4 – 44.8) 39.7 (38.2 – 41.3) 42.6 (41.6 – 43.6)
Soft drinks 36.7 (35.9 – 37.5) 39.1 (37.7 – 40.4) 37.2 (36.5 – 37.9) 35.5 (34.5 – 36.5) 35.3 (33.8 – 36.7) 35.4 (34.6 – 36.2)
Body image
Very thin or thin 22.1 (21.5 – 22.8) 22.1 (21 – 23.3) 22.1 (21.5 – 22.7) 23.4 (22.6 – 24.2) 22.3 (21.3 – 23.3) 23.1 (22.5 – 23.7)
Normal 61.5 (60.7 – 62.3) 54.8 (53.4 – 56.1) 60.1 (59.5 – 60.8) 60.6 (59.7 – 61.6) 54.9 (53.8 – 56.0) 59.1 (58.4 – 59.9)
Fat or very fat 16.3 (15.7 – 16.9) 23.1 (22 – 24.3) 17.7 (17.2 – 18.3) 16.0 (15.3 – 16.7) 22.8 (21.8 – 23.9) 17.8 (17.1 – 18.4)
Physical activity
≥ 2 Physical education classes 50.6 (49.8 – 51.4) 44.3 (43.1 – 45.6) 49.3 (48.6 – 50) 52.5 (49.2 – 55.7) 40.1 (33.7 – 46.5) 49.3 (46.5 – 52.1)
≥ 2 hours in front of TV 80.0 (79.3 – 80.6) 77.5 (76.4 – 78.7) 79.5 (78.9 – 80.0) 79.5 (78.8 – 80.2) 75.9 (74.3 – 77.4) 78.6 (77.9 – 79.3)
Smoking habit
Trying cigarettes 25.7 (25.0 – 26.4) 18.3 (17.2 – 19.3) 24.2 (23.6 – 24.8) 24.6 (23.5 – 25.7) 15.6 (14.5 – 16.6) 22.3 (21.4 – 23.2)
Current smoker 6.6 (6.2 – 7.0) 5.3 (4.7 – 6.0) 6.3 (6.0 – 6.7) 6.8 (6.2 – 7.4) 4.1 (3.5 – 4.6) 6.1 (5.6 – 6.6)
Smoking parents 32.9 (32.1 – 33.7) 23.6 (22.3 – 24.8) 31.0 (30.3 – 31.6) 30.9 (30.0 – 31.8) 20.0 (18.7 – 21.3) 28.1 (27.2 – 29.0)
Consumption of alcohol and other drugs
Trying alcohol 70.3 (69.5 – 71.0) 75.7 (74.6 – 76.8) 71.4 (70.8 – 72.0) 69.5 (68.5 – 70.5) 73.6 (71.9 – 75.3) 70.5 (69.7 – 71.4)
Alcohol in the past 30 days 26.8 (26.1 – 27.5) 29.5 (28.2 – 30.8) 27.3 (26.7 – 28.0) 27.7 (26.5 – 28.9) 24.3 (22.8 – 25.9) 26.8 (25.9 – 27.8)
Trying illicit drugs 9.0 (8.5 – 9.5) 7.6 (6.9 – 8.3) 8.7 (8.3 – 9.1) 10.3 (9.5 – 11.2) 7.7 (6.9 – 8.5) 9.6 (9.0 – 10.3)

The prevalence of students who spent two daily hours watching TV was maintained in both editions, being 79.5% (95%CI 78.9 - 80.0), in 2009, and 78.6% (95%CI 77.9 - 79.3), in 2012, for both sexes and types of school. The prevalence of students who attend two or more physical education classes a week was also maintained: 49.3% (95%CI 48.6 - 50), in 2009, and 49.3% (95%CI 46.5 - 52.1), in 2012, in both sexes and types of schools; there was a higher proportion of physical education classes in public schools, 52% (95%CI 49.2 - 55.7) versus 40.1 (95%CI 33.7 - 46.5).

There were no differences concerning body image in both years. Most students are considered to have normal weight: 60.1%, in 2009, and 59.1%, in 2012; 22.1% (2009) and 23.1% (2012) consider themselves to be thin or very thin, and about 18% reported being fat or very fat in both editions. In general, girls reported being fat more often than boys, and there was no difference in the perception of body image between sexes and schools in both editions. There were no differences in relation to lifetime use of alcohol, being 71.4% (95%CI 70.8 - 72.0) in 2009 and 70.5% (95%CI 69.7 - 71.4) in 2012; the alcohol consumption in the past 30 days was maintained, being 27.3% (95%CI 26.7 - 28.0) and 26.8% (95%CI 25.9 - 27.8). In both indicators, there were no changes in prevalence ratios concerning sex and schools.

As to smoking indicators, there was a reduction in the experimentation of cigarettes, from 24.2% (95%CI 23.6 - 24.8) to 22.3% (95%CI 21.4 - 23.2). There was also a reduction in the frequency of students who reported having parents who smoke, form 30.1% (95%CI 29.1 - 31.1) to 28.1% (95%CI 27.2 - 29.0) in the studied period. The reduction occurred for both sexes and types of school, except for the experimentation of cigarettes in the public school, which did not reduce. The percentage of current smokers remained similar, of 6.3% (95%CI 6.0 - 6.7), in 2009, and 6.1% (95%CI 5.5 - 6.6), in 2012, in both sexes and schools. Lifetime use of illicit drugs was of 8.7% (95%CI 8.3 - 9.1), in 2009, and 9.6% (95%CI 9.0 - 10.3), in 2012, with superposed intervals. The frequencies of tobacco and drug indicators were usually higher in public schools, in comparison to private schools.

DISCUSSION

PeNSE has two editions, and it consists of a system that monitors the health of students focusing on specificities about adolescents. By approaching the school environment as a place of health promotion, it allows to recognize the risk and protective factors involving the population of Brazilian students, therefore generating evidence to guide the implementation of public policies and monitor the changes that take place in future segments.

By comparing both editions, in Brazilian capitals, the prevalence of smokers and the current alcohol consumption, as well as the presence in two or more physical education classes at school remained stable for both years, Among sociodemographic factors, it was observed that 9th graders who were interviewed in 2012 are a bit older than those of 2009, thus presenting a higher percentage of students aged 14 and 15 years old. In this aspect, it is important to consider the influence of the fact that in 2012, data collection lasted until the second semester in some capitals, which may explain part of the difference4. There was an increasing proportion of students whose mothers had complete high school or incomplete higher education, besides a high percentage of students (20%) in both editions who could not inform about maternal schooling. There was an increasing number of participants who claimed to be mulattos. The increasing schooling in the Brazilian population and the reference to being mulattos were also identified in Census 201012.

Among markers indicating a healthy diet, there was a reduction in the consumption of unhealthy foods, such as dainties and soft drinks. However, there was also a reduction related to healthy diets, such as the intake of beans and fruits. Dainties and sweetened drinks increase the risks of excessive weight and CNCDs2,13. Dainties were consumed five days or more a week by half of the students in 2009, and there was a 16% reduction in 2012. With regard to the intake of soft drinks, there was a 5% reduction, even though this frequency is higher than number in Europe (25%) at the age of 15. Unlike European adolescents, Brazilian girls eat more dainties than boys2.

The intake of fruits and vegetables, which is a protective fator against cardiovascular disease and type 2 diabetes13, is still low at this age group. These data are in accordance with other studies by WHO, such as the Health Behavior School-aged Children (HSBC), in Europe, which showed 36% of fruit intake at the age of 13, ranging from 50%, in Belgium, to 15%, in Greeland2. Even though the intake of beans is high, it reduced in 2012, as pointed out among Brazilian adults14,15. In 2012, the regional variation related to the intake of beans remains, being less consumed in the North region and more consumed in the Southeast region4. PeNSe 20093 indicated these same differences, which can be understood by the cultural diversity in dietary habits between regions16.

Another important factor to reduce NCDs is the practice of physical activities. More than 80% of the adolescents aged 13 to 15 years old in the world do not achieve the recommendations concerning the practice of physical activities17. The low levels of physical activity among children and adolescents has been attributed to the declining number of physical education classes in schools, to the increment of time spent in front of the TV, internet and videogames, and to the reduction of active leisure options due to growing urban violence17. The regular practice of physical activities among adolescents and teenagers has an impact on physical and bone development, besides increasing the chances that these people will become active adults18-20.

In PeNSE 2012, only half of the students in both studies reported attending two or more physical education classes a week at school, and this percentage remained stable in both editions. Providing more physical education classes and improving school facilities are part of the NCD plan of action, and it is the object of a partnership involving the Ministry of Education and the Ministry of Health6. There is scientific evidence that promoting physical activities in the school environment is important to make students more active13,20,21.

WHO recommends that children and adolescents should not spend more than two hours watching TV, since this practice is associated with the intake of high-calorie food and soft drinks, and also because it provides little energy consumption1. The results of PeNSE pointed out that the proportion of students who spend two hours or more watching TV is very high, of about 80% in both editions. These data are higher than the ones presented in HBSC, which indicate about 64% of students aged 13 to 15 years old2. There were changes concerning the questions about the practice of physical activity, so it was chosen not to present them in this study, once no comparisons would be possible. The indicators compared here involve similar questions in both editions.

Tobacco is one of the most important risk factors that trigger most chronic diseases13,22. Preventing and delaying the initiation to the habit is essential to reduce the negative effects of the cigarette on the health of the population13,23.

The act of trying cigarettes is a result of curiosity, encouragement from colleagues and example from parents and close adults, and smoking at this stage of life leads to higher chances of smoking as an adul23. PeNSE showed an stabilization tendency for 2009 and 2012, of about 6%, presenting one of the lowest prevalence rates in Latin American countries24, the United States10 and European countries2,24. One positive factor was the average reduction of the presence of father or mother who smoked. These results show the importance of public policies that regulate and forbid tobacco advertisement in the country6,22.

The use of alcohol among Brazilian adolescents is high, and about three times more disseminated than the use of tobacco. It represents an important risk factor for accidents, violence and NCD. This habit has also been described as a predisposing factor for depressive disorders, anxiety, fights at school, bullying, property damage and problems with the police2, besides being a predictor of use during adulthood2,25. However, alcohol consumption is socially acceptable and stimulated25,26. Studies point out that the exposure of adolescents to alcohol advertisement encourages alcohol consumption at this age group27.

Lifetime use of alcohol and the intake of drinks in the past 30 days remained stable in both editions. In the United States, the percentage of 14 to 17-year old students who tried one dose of alcohol was of 70.8%, in 2011, and the consumption of at least one dose in the past 30 days was of 30.8%, which is higher than Brazilian students10. In Brazil, for both indicators, girls consumed more, which has been explained by some authors by the fact that girls reach puberty earlier. With age, these differences are overcome and boys drink more28-30. In Brazil, as well as in other countries, the use of illicit drugs among adolescents and teenagers has become a serious issue, since this habit is a predictor of psychosocial disorders and dependence during adulthood2,31. Frequencies around 9% point out to the need for prevention measures, such as the Drug and Crack Prevention Program, released in 2012. HBSC2 indicated that, among 15 year-old students, 17% had used marijuana at some point in life, and 8% had used it in the past 30 days. Even though the frequency of tobacco and drug indicators are higher in public schools, in other studies of PeNSE, after the adjustment by age, this effect disappeared, once students in public schools are older than those in private schools23,29.

Self-perception and satisfaction with body image are important factors for adolescents with regard to self-acceptance. If this perception is not in accordance with the body that is idealized by the adolescent, this fact can generate inadequate attitudes that damage their growth and development. PeNSE 2009 showed disassociation between measured body weight and body image, with low concordance calculated by the Kappa index between both variables32.

The perception of body image remained stable in the period. About one fifth of the interviewed adolescents thought they were fat or very fat, with discrete reduction of adolescents who considered being normal. A high level of dissatisfaction with body image is a predictive factor of depressive situations, psychosomatic disorders and dietary disorders33. Girls are more critical about their self-image, whose perception is not in accordance with nutritional status34. The level of satisfaction with self-image is closely related to losing or gaining body weight, so it is common to find that weight gain generates more dissatisfaction, especially among girls35.

Data in this study are useful to determine the proper strategies of health prevention and promotion, thus orienting policies for Brazilian adolescents. The approach in schools has the advantage of being easy to access by this population and the benefits resulting from the study, thus enabling the integrated planning of health and educational sectors together with the target audience.

Among the limitations of the study, we can mention making the school population as a proxy of the adolescent population, and the used methodology excludes adolescents who are out of school. This problem is minimized in Brazil due to the broad coverage of the educational system. Adolescents add up to 35 million, and most of them is enrolled in school: 97% and 82% for the age groups of 10 to 14 years old, and 15 to 17 years old, respectively, thus facilitating health control in the school environment4,12.

In 2012, adjustments were made in the questionnaire aiming at its improvement and to provide more comparability with other international studies2,8. PeNSE investigates 9th graders, which allows a relative comparability with other global monitoring systems addressed to adolescents2,8,10. Some of these systems collect information in three age groups (11, 13 and 15 years old)2, and other systems include students aged 14 to 17 years old10. These different methodological strategies can limit comparisons, due to the different age distributions.

Besides, the temporal tendency represented here refers to changes in the population throughout time, and not in the individuals, because cross-sectional studies use a new representative sample of the population in each survey.

CONCLUSION

Nowadays, the NCDs represent the highest disease load in the country, and health promotion actions at early stages of life are very important so that healthy habits from childhood and adolescence can be maintained throughout life. PeNSE constituted an important instrument to subsidize administrators with information, thus sustaining the surveillance system for students in the country. It has been the base to implement programs addressed to the health of students, such as the Program Health in School.

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Financing source: none.

Received: November 07, 2013; Revised: April 25, 2014; Accepted: April 29, 2014

Corresponding author: Deborah Carvalho Malta. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. SAF Sul - Trecho 02, Lotes 05 e 06, Edifício Premium, bloco F, Torre 1, térreo, sala 16, CEP: 70070-600, Brasília, DF, Brasil. E-mail: dcmalta@uol.com.br

Conflict of interests: nothing to declare

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