Temporal analysis of the prevalence of chronic noncommunicable diseases and risk and protective factors by schooling level from 2006 to 2023

Abstract

The aim is to analyze the trends in the prevalence of selected indicators of morbidity and risk and protective factors for non-communicable diseases (NCDs) in the Brazilian adult population between 2006 and 2023, according to education levels. This is a time-series study using data from the Risk and Protective Factors Surveillance System for Chronic Diseases by Telephone Survey. A linear regression model was used for trend analysis, and Poisson regression was applied to assess differences in 2023. A declining trend was observed in the prevalence of smoking and bean consumption, while an increasing trend was found in leisure-time physical activity, overweight, obesity, hypertension, and diabetes across all educational levels. Excessive alcohol consumption, intake of fruits and vegetables, consumption of protective foods, and physical activity were higher among those with higher education levels. Conversely, more educated populations presented lower prevalence rates of smoking, bean consumption, insufficient physical activity, hypertension, and diabetes were observed in this group.

Keywords:
Noncommunicable diseases; Risk Factors; Protective Factors; Educational Status

Resumo

O objetivo é analisar as tendências das prevalências das doenças crônicas não transmissíveis (DCNT), dos seus fatores de risco e de proteção entre 2006 e 2023, segundo escolaridade. Estudo de série temporal com dados do Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel). Utilizou-se o modelo de regressão linear para análise de tendência e Regressão de Poisson a fim de verificar diferenças em 2023. Houve tendência de declínio das prevalências de tabagismo e do consumo de feijão e tendência de aumento da prática de atividade física no lazer, do excesso de peso, da obesidade, hipertensão e diabetes em todos os níveis de escolaridade. O consumo abusivo de álcool, de frutas e hortaliças, de alimentos protetores e a prática de atividade física foram maiores entre os mais escolarizados; em contrapartida, populações mais escolarizadas apresentaram menores prevalências de tabagismo, consumo de feijão, prática insuficiente de atividade física, de hipertensão e diabetes.

Palavras-chave:
Fatores de risco; Fatores de proteção; Doenças não transmissíveis; Escolaridade

Resumen

El objetivo es analizar las tendencias de prevalencia de indicadores seleccionados de morbilidad y factores de riesgo y protección para enfermedades no transmisibles (ENT) en la población adulta brasileña entre 2006 y 2023, por nivel de escolaridad. Este estudio de series temporales utilizó datos del Sistema de Vigilancia de Factores de Riesgo y Protección para Enfermedades Crónicas por Encuesta Telefónica. Se adoptó un modelo de regresión lineal para el análisis de tendencias y se aplicó la regresión de Poisson para evaluar las diferencias en 2023. Se observó una tendencia decreciente en la prevalencia de tabaquismo y consumo de frijoles, mientras que se encontró una tendencia creciente en actividad física en el tiempo libre, sobrepeso, obesidad, hipertensión y diabetes en todos los niveles de escolaridad. El abuso de alcohol, la ingesta de frutas y verduras, el consumo de alimentos protectores y la actividad física fueron mayores entre aquellos con niveles de escolaridad más altos. Por el contrario, las poblaciones con mayor nivel educativo presentaron tasas de prevalencia más bajas de tabaquismo, consumo de frijoles, actividad física insuficiente, hipertensión y diabetes.

Palabras clave:
Enfermedades no transmisibles; Factores de riesgo; Factores de protección; Nivel educativo

Introduction

Noncommunicable Diseases (NCDs) represent a global and national health problem with the highest morbidity and mortality rates. The four main groups (cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes) share common and modifiable behavioral risk factors, such as tobacco use, alcohol abuse, physical inactivity, and inadequate diet^1-3.

These diseases and their risk factors are unevenly distributed, affecting and causing greater disabilities among socially disadvantaged or marginalized individuals with low income and schooling levels⁴. Due to reduced access to health services, these populations have fewer opportunities for disease and condition prevention and health promotion^5,6.

Schooling is a frequently used indicator in epidemiology to gauge inequalities. Since formal education is often completed in young adulthood and is strongly determined by parental characteristics, this measure can be conceptualized as an indicator that partly measures socioeconomic position in early life.^7,8 Although education is often adopted as a generic measure of socioeconomic status, specific interpretations explain its association with health outcomes.^9,10

Higher education levels are a proxy for higher income and better jobs, resulting in better health indicators. In general, individuals with lower schooling levels have a higher prevalence of NCDs, risk factors, and disabilities caused by these diseases. Lower education levels can limit access to information and healthier lifestyle habits, hindering the understanding of the severity of the disease and adherence to treatment^11,12.

Therefore, monitoring NCDs and their risk factors from the schooling perspective can help to understand social inequalities and support strategies for surveillance, prevention, and control of NCDs, besides contributing to political and regulatory agendas aimed at reducing inequalities. Given the above, this study aimed to analyze trends in the prevalence of selected indicators of morbidity and risk and protective factors for NCDs in the Brazilian adult population from 2006 to 2023 by education level.

Methods

Study design

This cross-sectional study used data from the Surveillance System of Risk and Protection Factors for Chronic Diseases by Telephone Survey (Vigitel) from 2006 to 2023. Vigitel is conducted annually by the Ministry of Health and collects information on NCDs, and the main risk and protection factors for these diseases¹³.

Until 2021, the sampling procedures used by Vigitel aimed to obtain probabilistic samples of adults (≥18 years old) living in households with at least one landline in each of the 26 Brazilian states capitals and the Federal District. Vigitel did not collect data in 2022, so it was not presented. Interviews via cell phones were included in 2023. A minimum sample size of approximately 2,000 individuals was established in each city in the 2006-2019 editions. In 2020 and 2021, due to the COVID-19 pandemic, a reduced sample near 1,000 individuals was established in each city. In 2023, data were collected between December 26, 2022, and April 24, 2023, and an additional reduction was necessary, establishing a minimum of 800 interviews in each location.¹³ Even so, the sample size allows us to estimate, with a 95% confidence level and a maximum error of four percentage points, the frequency of risk and protective factors in the adult population of each capital city.^13,14 The interviews conducted are statistically weighted to be representative of the total adult population of each capital city.

Variables

Tobacco use: Current use of tobacco products, regardless of the amount, frequency, and duration of smoking.

Alcohol abuse: Consumption of five or more doses (men) or four or more doses (women) of alcoholic beverages on a single occasion, at least once in the last 30 days.

Recommended consumption of fruits and vegetables (FV): Intake of fruits and vegetables on at least five days a week and when the sum of daily portions totaled at least five.

Regular consumption of beans: Intake of beans on five or more days a week.

Consumption of protective foods: Consumption of five or more groups of non- or minimally processed foods that protect against chronic diseases on the day before the interview. Natural or essential foods were considered: lettuce, cabbage, broccoli, watercress or spinach; pumpkin, carrot, sweet potato or okra/green amaranth; papaya, mango, yellow melon or souari nut; tomato, cucumber, zucchini, eggplant, chayote or beetroot; orange, banana, apple or pineapple; beans, peas, lentils or chickpeas; peanuts, cashew nuts, or Brazil/Pará nuts.

Consumption of ultra-processed foods: Consumption of five or more groups of ultra-processed foods on the day before the interview, obtained from the following questions: We considered industrialized foods or products: soft drinks; carton, small box, or can fruit juice; powdered soft drinks; chocolate drinks; flavored yogurt; packaged snacks (or chips) or cookies/crackers; sweet cookies/crackers, stuffed cookies or packaged cakes; chocolate, ice cream, gelatin, flan, or other industrialized desserts; sausage, salami, mortadella, or ham; sliced bread, hot dog or hamburger buns; mayonnaise, ketchup, or mustard; margarine; instant noodles, packaged soup, frozen lasagna, or other ready-made frozen meals.

Sufficient Physical Activity (PA) during leisure time: Engaging in at least 150 minutes per week of moderate-intensity physical activity or at least 75 minutes per week of vigorous-intensity physical activity during leisure time, regardless of the number of days of PA per week.

Insufficient Physical Activity: Engaging in less than 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity activities, considering leisure time, work, and commuting.

Overweight: Body mass index (BMI) ≥25 kg/m², for which height and weight were self-reported.

Obesity: Body mass index (BMI) ≥30 kg/m², for which height and weight were self-reported.

Hypertension: Medical diagnosis of hypertension based on a positive answer to the question: “Has a doctor ever told you that you have high blood pressure?”

Diabetes: Medical diagnosis of diabetes based on an affirmative answer to the question: “Has a doctor ever told you that you have diabetes?”

The Vigitel report¹⁶ provides further details about the questionnaire, including the definition and questions used to construct the indicators. The following stratifications were used for the schooling level: 0-8, 9-11, and 12 years or more.

Data analysis

All indicators’ prevalence was presented with their respective 95% confidence intervals (95% CI). First, a time series analysis (2006 to 2023) was performed using the linear regression model of the indicators stratified by schooling level. A significant trend was when the model’s regression slope (β) differed from zero and the p-value ≤0.05. Thus, an increase was considered when β was positive, a reduction if negative, and stationary when no statistically significant difference was identified (p>0.05).

Next, we analyzed differences by education level, considering the last year of the survey (2023), estimating the crude and adjusted prevalence ratios (PR) by gender, age, and ethnicity/color, using the Poisson Regression model with robust variance, adopting a significance level of 5%. We also analyzed prevalence stratified by gender.

All analyses considered weighting factors, i.e., the unequal probability of individuals living in households with more telephone lines or fewer residents participating in the sample. Applying these factors adjusts possible biases of over- or underestimation of the Vigitel sample, resulting from the unequal coverage of landline telephony in Brazil¹⁵.

We employed Software for Statistics and Data Science (StataCorp LP, College Station, Texas, United States) version 14.0 to analyze data through the survey module, which considers the sampling plan effects.

Ethical aspects

The company responsible for conducting the research obtained informed consent verbally during telephone contact with the respondents. Vigitel was approved by the National Human Research Ethics Committee of the Ministry of Health (CAAE: 65610017.1.0000.0008) under Opinion N° 4324071.

Results

Table 1 shows trends in the prevalence of risk factors, protective factors for NCDs, hypertension, and diabetes by schooling. We observed a declining trend in tobacco use prevalence in all education levels, which also occurred in the regular consumption of beans. An increasing trend was noted in the prevalence of alcohol abuse among the higher educated individuals (9-11 years: 17% to 22.1%; and 12 years and over: 17.9% to 24.0%), same as with leisure-time physical activity at all schooling levels, overweight, and obesity. Morbidity indicators showed a growing trend in the prevalence of hypertension and diabetes at all schooling levels, although it occurred more intensely among those with 0-8 schooling years (β=0.6 and 0.5), respectively. The trend was stable for the other indicators (Table 1).

Table 1
Trends in the prevalence of risk and protective factors for NCDs, hypertension, and diabetes by schooling level. Vigitel, Brazilian Capitals, 2006 to 2023.

Schooling (years)		2006	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	2023	β
Tobacco use	0-8	19.1	18.9	18.9	18.1	18.1	18.2	16.3	15.0	14.1	14.4	14.3	13.2	13.0	13.8	12.4	12.9	12.2	-0.4*
	9-11	13.8	13.5	12.0	11.9	12.2	10.7	10	10.3	10.3	9.0	9.4	9.9	8.8	9.5	9.2	8.1	8.9	-0.2*
	≥12	10.9	12.1	10.8	10.8	10	9.8	9.1	7.4	6.8	7.2	6.9	7.4	6.2	6.7	7.5	7.2	7.4	-0.3*
Alcohol use	0-8	13.5	14.0	14.5	14.5	14	13.4	15	12.8	12.3	13.2	14.2	13.8	13.0	12.4	15.0	11.7	14.4	-0.0
	9-11	17.0	18.6	19.2	19.8	19.6	17.5	19.4	17.5	18.4	18.1	19.2	20.2	19.1	20.0	22.5	19.4	22.1	0.2*
	≥12	17.9	18.9	19.5	23.7	22.9	20	22	19.7	19.5	20.9	24	22.8	21.2	23.1	23.8	22.5	24.0	0.2*
Fruit and vegetable consumption	0-8			16.9	16.8	15.3	18.9	18.6	19.4	20.2	20.1	19.7	19.5	19.3	19.0	19.1	17.8	17.1	0.1
	9-11			19.6	19	19.1	20.6	21.2	23.1	22.5	23.2	23	22.1	20.9	20.2	19.8	18.7	19.5	-0.0
	≥12			27.1	28.5	27.4	28.9	31.4	30.1	31.9	34.6	30.8	29.7	29.4	29.5	28.3	29.5	27.2	0.0
Bean consumption	0-8		72.5	71.0	71.1	71.2	72.5	72.4	71.0	70.6	69.1	68.2	66.8	66.7	66.6	65.3	67.2	68.0	-0.3*
	9-11		67.5	67.2	65.5	66.4	69	68.7	68.6	67.1	67.3	64.2	61.7	62.6	63.4	61.7	63.2	60.5	-0.4*
	≥12		52.7	52.0	52.3	54.9	57.8	58.4	58.6	58.6	55.7	50.8	49.9	49.7	49.4	48.6	51.7	48.8	-0.3*
Physical activity	0-8				19.5	19.6	21.2	21.6	22	22.9	25.4	24.5	23.3	24.6	25.8	23.6	22.6	26.6	0.4*
	9-11				34.8	34.6	35.3	37.1	37.2	38.5	40.1	40.4	39.7	40.4	39.5	38	37.3	40.4	0.3*
	≥12				41.6	41.3	42.5	45.4	45.4	47.8	49.6	47.9	47	48.1	50	46.2	47.3	51.9	0.5*
Insufficient physical activity	0-8									56.9	56	53.7	54.9	53.4	53.7	57.5	58.4	48.3	-0.3
	9-11									44.9	44.5	41.6	42.9	39.8	43.4	44.1	45.2	34.6	-0.6
	≥12									42.9	41.0	40.2	40.8	40.3	38.6	42.3	43.5	33.0	-0.5
Overweight	0-8	49.0	49.6	50.3	52.1	54.2	54.4	57.3	58.1	58.9	61.7	59.2	59.7	61.8	61.0	63.0	63.3	64.3	0.9*
	9-11	37.6	37.1	40.7	42.2	44.4	45.7	46.7	47.3	51.6	52.0	53.3	53	54.5	53.8	56.0	56.0	61.1	1.3*
	≥12	37.3	40.2	40.7	40.6	43.6	44.6	48.4	45.5	45.0	46.8	48.8	49.6	51.3	52.2	54.6	53.8	59.3	1.1*
Obesity	0-8	15.3	16.9	17.5	18.1	18.8	19.7	21.7	22.3	22.7	23.6	23.5	23.3	24.5	24.2	25.3	25.8	26.9	0.6*
	9-11	9.1	10.7	10.9	12.2	13.1	14.2	15.2	15.1	17.2	17.8	18.3	17.8	19.4	19.9	20.8	22.8	24.1	0.8*
	≥12*	8.7	9.9	10.2	10.7	11.7	13	14.4	14.3	12.3	14.6	14.9	16.0	15.8	17.2	19.3	19.0	22.7	0.7*
Hypertension	0-8	31.9	33.8	36.9	38.5	36.4	36.4	37.9	38	38.1	39.9	41.8	39.7	42.5	41.5	44.7	44.6	45.3	0.6*
	9-11	15.3	15.7	17.3	17.1	17.3	17.6	17.9	17.1	19.3	18.2	20.6	19.6	19.4	20.5	20.2	21.9	24.2	0.4*
	≥12	13.7	14.3	14.7	14.5	13.9	15.3	14.2	14.6	14.6	15.1	15	14.8	14.2	14.3	15.2	17.1	19	0.1*
Diabetes	0-8	9.0	8.6	10.2	10.6	10.4	10.6	12.1	12.2	14.2	13.5	16.5	14.8	15.2	14.8	15.2	17.7	19.4	0.5*
	9-11	2.9	3.5	3.4	3.4	4.6	3.9	5.2	4.2	5.1	4.4	5.9	5.3	5	5.4	6.6	6.8	8.2	0.2*
	≥12	2.8	3	2.6	3.1	4	3.1	3.8	3.2	3.7	3.7	4.6	3.4	3.7	3.5	4.4	5.1	5.5	0.1*

• Note: Blank spaces mean the information was not collected in the year; * Significant p-value <0.05; β Trend slope.

Table 2 presents morbidity indicators’ prevalence and prevalence ratios and risk and protective factors for NCDs in 2023. The prevalence of alcohol abuse was higher among more educated individuals (24.01%; PRadj: 1.24; 95% CI: 1.03-1.48), the consumption of fruits and vegetables (27.24%; PRadj: 1.71; 95% CI: 1.40-2.09), protective foods (36.93%; PRadj: 1.66; 95% CI: 1.46-1.88) and leisure-time physical activity (51.88%; PRadj: 1.76; 95% CI: 1.54-.00). On the other hand, we observed a lower prevalence of tobacco use (7.41%; PRadj: 0.56; 95% CI: 0.44-0.73), bean consumption (48.84%; PRadj: 0.73; 95% CI: 0.69-0.79), insufficient physical activity (32.96%; PRadj: 0.80; 95% CI: 0.72-0.89), hypertension (19.0%; PRadj: 0.66; 95% CI: 0.59-0.76), and diabetes (5.5%; PRadj: 0.51; 95% CI: 0.42-0.63) among individuals with higher schooling levels (Table 2).

Table 2
Prevalence and prevalence ratio of risk and protective factors for NCDs, hypertension, and diabetes by schooling level. Vigitel, Brazilian Capitals, 2023.

Indicators	Schooling (years)	% (95% CI)	Crude PR (95% CI)	Adjusted PR (95% CI)
Tobacco use	0-8	12.21(10.46-14.2)	*	*
	9-11	8. 93(7.67-10.36)	0.73(0.59-0.90)	0.71(0.56-0.89)
	≥12	7.41(6.14-8.92)	0.60(0.47-0.77)	0.56(0.44-0.73)
Alcohol abuse	0-8	14.41(12.44-16.6)	*	*
	9-11	22.13(20.14-24.26)	1.53(1.29-1.82)	1.15(0.96-1.39)
	≥12	24.01(21.85-26.31)	1.66(1.40- 1.97)	1.24(1.03-1.48)
Recommended consumption of fruits and vegetables	0-8	17.05 (14.57-19.86)	*	*
	9-11	19.47 (17.46-21.65)	1.14(0.94-1.37)	1.26(1.02-1.55)
	≥12	27.24 (25.07-29.53)	1.59(1.34-1.90)	1.71(1.40-2.09)
Regular consumption of beans	0-8	67.97 (65.19-70.63)	*	*
	9-11	60.52 (58.28-62.72)	0.89(0.84-0.94)	0.89(0.84-0.94)
	≥12	48.84 (46.36-51.32)	0.71(0.67-0.76)	0.73(0.69-0.79)
Consumption of protective foods	0-8	25.76 (23.22-28.48)	*	*
	9-11	27.48 (25.5-29.56)	1.06(0 .94-1.21)	1.27(1.11-1.45)
	≥12	36.93 (34.66-39.27)	1.43 (1.27-1.61)	1.66 (1.46-1.88)
Consumption of ultra-processed foods	0-8	13.6(11.66-15.8)	*	*
	9-11	21.14(19.29-23.12)	1.55(1.30-1.85)	1.15(0.95-1.39)
	≥12	16.73(14.85-18.79)	1.23(1.01-1.49)	0.93(0.76-1.14)
Sufficient physical activity during leisure time	0-8	26.62(23.82-29.63)	*	*
	9-11	40.36(38.08-42.69)	1.51(1.34-1.71)	1.30(1.14-1.49)
	≥12	51.88(49.41-54.35)	1.94(1.73-2.19)	1.76(1.54-2.00)
Insufficient physical activity	0-8	48.32(45.19-51.47)	*	*
	9-11	34.59(32.39-36.87)	0.71(0.65-0.78)	0.87(0.79-0.96)
	≥12	32.96(30.66-35.33)	0 .68(0.61-0.75)	0.80 (0.72-0.89)
Overweight	0-8	64.33 (61.3-67.25)	*	*
	9-11	61.12 (58.84-63.35)	0 .95(0 .89-1.00)	1.02(0.96-1.09)
	≥12	59.32 (56.87-61.73)	0 .92(0 .86-0.98)	0 .96 (0.90-1.03)
Obesity	0-8	26.92 (24.35-29.65)	*	*
	9-11	24.07 (22.18-26.07)	0 .89(0 .78-1.01)	0 .94(0 .82-1.08)
	≥12	22.67 (20.61-24.87)	0 .84(0.73-0.96)	0 .86(0 .74-1.00)
Arterial hypertension	0-8	45.3 (42.2 - 48.4)
	9-11	24.2 (22.4 - 26.2)	0.53 (0.48 - 0.59)	0.90 (0.80 - 1.01)
	≥12	19.0 (17.3 - 20.8)	0.41 (0.37 - 0.46)	0.66 (0.59 - 0.76)
Diabetes	0-8	19.4 (17.2 - 21.9)
	9-11	8.2 (7.2 - 9.4)	0.42 (0.35 - 0.50)	0.83 (0.69 - 1.00)
	≥12	5.5 (4.7 - 6.5)	0.28 (0.23 - 0.34)	0.51 (0.42 - 0.63)

• Note: 95% CI = 95% Confidence Interval; PR = Prevalence Ratio; *Reference value.

The same indicators were stratified by gender, and the results are shown in Table 3. Notably, for both genders, tobacco use, and consumption of beans are less prevalent among higher educated individuals. The consumption of fruits, vegetables, and protective foods and physical activity were more prevalent among men and women with 12 schooling years or more. The consumption of ultra-processed foods was more prevalent only among men with 9-11 schooling years (26.5% PRadj: 1.35; 95% CI: 1.03-1.78). The prevalence of overweight (54.47% PRadj: 0.85; 95% CI: 0.78-0.93) and obesity (20.36% PRadj: 0.74; 95% CI: 0.62-0.89) was lower among more educated women, while the prevalence of overweight was higher among more educated men (65.51% PRadj: 1.11; 95% CI: 1.01-1.22). Regarding morbidity indicators, the differences occurred only among women, with lower prevalence among the higher educated ones (Table 3).

Table 3
Prevalence and prevalence ratio of risk and protective factors for NCDs, hypertension, and diabetes by schooling level and stratified by gender. Vigitel, Brazilian Capitals, 2023.

Indicators	Schooling (years)	Female			Male
		% (95% CI)	PRadj (95% CI)	% (95% CI)	PRadj (95% CI)
Tobacco use	0-8	10.1 (8.2 - 12.4)	-	14.6 (11.7 - 18.1)	-
	9-11	6.4 (5.0 - 8.2)	0.67 (0.47 - 0.95)	11.7 (9.7 - 14.1)	0.74 (0.54 - 1.00)
	≥12	6.0 (4.8 - 7.5)	0.55 (0.39 - 0.79)	9.2 (6.9 - 12.2)	0.57 (0.40 - 0.81)
Alcohol abuse	0-8	9.5 (7.4 - 12.2)	-	20.0 (16.7 - 23.8)	-
	9-11	15.6 (13.4 - 18.0)	1.16 (0.85 - 1.59)	29.4 (26.1 - 32.9)	1.15 (0.92 - 1.44)
	≥12	18.9 (16.6 - 21.3)	1.32 (0.97 - 1.79)	30.6 (26.8 - 34.6)	1.19 (0.95 - 1.48)
Recommended consumption of fruits and vegetables	0-8	20.3 (16.6 - 24.5)	-	13.4 (10.4 - 17.1)	-
	9-11	20.0 (17.6 - 22.7)	1.15 (0.88 - 1.51)	18.9 (15.7 - 22.5)	1.46 (1.08 - 1.97)
	≥12	29.2 (26.3 - 32.2)	1.59 (1.22 - 2.07)	24.8 (21.5 - 28.4)	1.95 (1.46 - 2.62)
Regular consumption of beans	0-8	62.7 (59 - 66.3)	-	73.9 (69.7 - 77.8)	-
	9-11	56.8 (53.7 - 59.8)	0.91 (0.84 - 0.99)	64.7 (61.5 - 67.8)	0.88 (0.81 - 0.95)
	≥12	44.6 (41.5 - 47.8)	0.72 (0.66 - 0.80)	54.2 (50.3 - 58.0)	0.75 (0.69 - 0.83)
Consumption of protective foods	0-8	27.6 (24.3 - 31.3)	-	23.6 (19.9 - 27.8)	-
	9-11	26.9 (24.5 - 29.5)	1.18 (1.00 - 1.39)	28.1 (25.0 - 31.4)	1.41 (1.15 - 1.73)
	≥12	38.3 (35.4 - 41.3)	1.59 (1.35 - 1.87)	35.2 (31.7 - 38.9)	1.74 (1.41 - 2.13)
Consumption of ultra-processed foods	0-8	12.3 (10.0 - 14.9)	-	15.1 (12.0 - 18.9)	-
	9-11	16.3 (14.4 - 18.6)	0.92 (0.71 - 1.20)	26.5 (23.4 - 29.8)	1.35 (1.03 - 1.78)
	≥12	12.8 (11.0 - 14.8)	0.76 (0.58 - 1.00)	21.8 (18.4 - 25.7)	1.10 (0.82 - 1.47)
Sufficient physical activity during leisure time	0-8	24.8 (21.0 - 29.1)	-	28.7 (24.7 - 33.0)	-
	9-11	34.2 (31.3 - 37.2)	1.17 (0.96 - 1.43)	47.2 (43.7 - 50.7)	1.43 (1.20 - 1.70)
	≥12	47.0 (43.9 - 50.2)	1.68 (1.38 - 2.04)	58.1 (54 - 62.0)	1.84 (1.55 - 2.18)
Insufficient physical activity	0-8	56.3 (52.1 - 60.4)	-	39.3 (34.5 - 44.2)	-
	9-11	41.4 (38.3 - 44.5)	0.87 (0.78 - 0.98)	27.0 (24.0 - 30.3)	0.88 (0.74 - 1.06)
	≥12	37.0 (34.2 - 39.9)	0.77 (0.69 - 0.87)	27.8 (24.1 - 31.9)	0.87 (0.71 - 1.05)
Overweight	0-8	66.74 (62.8 - 70.45)	-	61.59 (56.83 - 66.14)	-
	9-11	59.51 (56.38 - 62.56)	0.96 (0.88 - 1.05)	62.91 (59.57 - 66.13)	1.10 (1.00 - 1.21)
	≥12	54.47 (51.39 - 57.51)	0.85 (0.78 - 0.93)	65.51 (61.42 - 69.39)	1.11 (1.01 - 1.22)
Obesity	0-8	28.9 (25.71 - 32.31)	-	24.65 (20.63 - 29.17)	-
	9-11	26.06 (23.47 - 28.84)	0.96 (0.81 - 1.13)	21.85 (19.15 - 24.81)	0.93 (0.74 - 1.16)
	≥12	20.36 (17.99 - 22.94)	0.74 (0.62 - 0.89)	25.62 (22.14 - 29.44)	1.02 (0.81 - 1.30)
Arterial hypertension	0-8	38.08 (37 - 39.18)		25.18 (24.23 - 26.15)
	9-11	15.73 (14.75 - 16.76)	0.80 (0.75 - 0.86)	15.11 (14.08 - 16.2)	0.99 (0.92 - 1.07)
	≥12	16.33 (15.04 - 17.72)	0.67 (0.61 - 0.74)	20.7 (18.85 - 22.68)	0.98 (0.88 - 1.10)
Diabetes	0-8	13.04 (12.3 - 13.81)		8.73 (8.09 - 9.40)
	9-11	4.59 (4.08 - 5.16)	0.75 (0.65 - 0.87)	4.57 (4.00 - 5.21)	0.91 (0.77 - 1.08)
	≥12	3.64 (3.14 - 4.21)	0.46 (0.38 - 0.56)	6.04 (5.05 - 7.21)	0.79 (0.63 - 1)

• Note: 95% CI = 95% Confidence Interval; PR = Prevalence Ratio; *Reference value.

Discussion

Declining trends in the prevalence of tobacco use and bean consumption have been observed over the years across all schooling levels, contrasting with an increase in leisure-time physical activity, overweight, obesity, hypertension, and diabetes. Regarding consumption of alcoholic beverages, the increasing trend was observed among those with nine or more years of schooling . In general, the lowest prevalence of risk factors for NCDs and the highest prevalence of protective factors were among those with the highest education levels. The prevalence of hypertension and diabetes was lower among those with 12 or more years of schooling.

Schooling is intrinsically linked to life expectancy, morbidity, and health-related behaviors. Its level plays a crucial role in health, influencing opportunities, employment, and income¹⁶. Often used as a indicator of socioeconomic status, schooling is associated with multimorbidity¹⁷ and mortality¹⁸, which are higher in less educated people. Individuals with a higher schooling level tend to have higher incomes¹⁹, which results in greater access to health services¹⁸, better housing and neighborhood conditions²⁰, employement²¹, and healthier lifestyle habits¹⁹, which also form part of the social determinants of health process and involves understanding that economic, social, cultural, and environmental factors directly influence the health of individuals and populations, exceeding biological or behavioral causes. These factors are related and tend to accumulate throughout life, impacting health. They are not distributed equally across the population, generating health inequities that mainly affect socially vulnerable minorities and individuals²². Furthermore, higher schooling levels are associated with greater health literacy²³, implying a better understanding of health information and the motivation and ability to make informed decisions for self-care, health promotion, and prevention actions²⁴. Therefore, public policies aimed at reducing social inequalities, such as expanding access to education and income policies, are essential for promoting more equitable health and improved quality of life, encompassing the absence of disease and physical, mental, and social well-being.

The results of the trends by schooling level were similar for the total population. Studies show a decline in tobacco use throughout Brazil since tobacco control measures has been effective. However, inequalities persist. The least educated group still has the highest rates of tobacco. In other words, less advantaged group with worse indicators than the more socially privileged groups^25,26. There is probably unequal access to health promotion and smoking cessation practices²⁷. This inequality has been observed since adolescence, where those with worse socioeconomic conditions are more likely to smoke²⁸. These findings indicate the need for tobacco control policies focused on the most affected populations²⁵, especially in schools.

Despite the declining trend in bean consumption, its prevalence remained higher among the less educated. A study found that, regading income, the poorest categories had a higher prevalence of bean consumption, as did those with no schooling and incomplete elementary education²⁹. Notably, beans, along with rice, are the basis of the Brazilian diet due to their cultural aspects and because they provide greater satiety due to their high fiber content. They are more commonly consumed by the less educated population^30,31.

Leisure-time physical activity has increased in Brazil, but it remains uneven. More educated individuals were, on average, three times more active than their less educated counterparts. The National Household Sample Survey also revealed inequalities in engaging in sports and activities, more significant among people who reported having at least completed higher education, while decreasing among the other schooling categories. This fact is related to the greater understanding among the most educated regarding the benefits of leisure-time physical activity besides access to private spaces³⁴. Given this, the expanded availability of quality open public spaces³⁵ and the improvement of government programs such as the Health Academy to enhance access to health promotion practices³⁶ could alleviate these inequalities.

However, this dynamic involves multiple facets beyond the availability of places to engage in physical activity. Higher schooling levels are related to better overall living conditions, including better working and commuting conditions. In this context, insufficient physical activity stands out, which, despite also considering commuting and work practices, was still higher in the less educated group. Although individuals with lower schooling levels, lower income, or fewer professional qualifications are subject to higher physical activity levels in commuting or occupation, the social group with higher income, higher schooling levels, and better professional status is still more likely to engage in leisure-time physical activities^32,37.

The increase in overweight and obesity highlights a significant challenge in controlling NCDs, a trend observed in Brazil^38,39 and worldwide⁴⁰. The growing prevalence of excess weight trend can be explained by the greater availability of ultra-processed foods, rich in calories, sugars and fats, which are more accessible and attractive to consumers. Furthermore, although it improved in this study, physical inactivity is still far from the desirable level and may also be driven by the increasing use of technology⁴¹.

The same is true for hypertension and diabetes, which have increased in the population and are more prevalent among the less educated. The relationship between the prevalence of hypertension and diabetes and education can be explained by greater exposure to risk factors and adverse socioeconomic conditions, such as lack of access to health services, lower access to guidance on healthy lifestyles, reduced opportunities for access to protective factors for NCDs, and less understanding of the therapeutic and care plan⁴². Furthermore, individuals in a worse economic situation, when sick, have greater difficulty in accessing health services and face more obstacles regarding medical care and treatments necessary for their rehabilitation⁴³. Studies show a higher prevalence of hypertension⁴⁴ and diabetes in less educated people, which highlights the need to look at health inequalities and direct care efforts towards the most vulnerable population⁴⁵.

The alcohol abuse trend was on the rise among those with 9 schooling years or more and stable among those with 0-8 schooling years. Alcohol consumption has several determinants, including individual risk factors, such as gender and age, and environmental factors, such as availability of access to alcohol; regulation in force and level, such as restrictions on advertising and onerous taxation; and the country’s economic situation⁴⁶. Alcohol abuse has grown worldwide. This consumption also tends to be higher among those with higher socioeconomic status. However, the adverse effects of alcohol abuse are more significant among individuals with lower socioeconomic status⁴⁷. Other studies have also identified higher alcohol abuse among those with higher schooling levels⁴⁸. This indicator measures excessive alcohol consumption on a single occasion, common in young and more educated people in celebrating events²⁵.

The trend was stable for all schooling levels over the years for the regular consumption of fruits and vegetables. A study showed that this consumption trend grew until 2014 among the Brazilian population. However, the trends were reversed from 2015 onwards, with a significant decline in this consumption for the total population, males/females, and individuals with 0-8 and 9-11 schooling years, remaining stable among the most educated³⁹. Another study using data from the PNS showed that the percentage of people with higher income levels who regularly consume fruits and vegetables is almost double that of people with lower income and those with higher schooling levels²⁹. The intake of healthy foods is also associated with better socioeconomic conditions and purchasing power due to the high cost, which directly affect access and are determinants for consuming healthy foods^49-52, with the highest prevalence among the most educated. Moreover, economic, political, and health crises impact this consumption due to increasing unemployment and inequalities, lowering income, and increasing the prices of these foods^39,53.

Food consumption and lifestyle changes during the COVID-19 pandemic can also be discussed. Brazilians have curbed their consumption of healthy foods and grown their intake of ultra-processed foods^54,55, which reinforces the importance of monitoring these indicators to verify the changes that may occur over the years in a post-pandemic context.

Some limitations should be considered. Data were collected in a self-reported fashion, which may result in under- or overestimating the actual prevalence and generating less accurate estimates. However, the questionnaire was validated and showed satisfactory results in the reproducibility and validity analyses^56-58. The fact that the Vigitel sample is composed only of individuals residing in the capitals of Brazilian states and the Federal District, who lived in households with a landline telephone until 2021, represents a potential risk to the sample representativeness. However, this issue is minimized by the use of data weighting factors. Furthermore, reducing the sample size in 2021 implies less accurate estimates and must be confirmed in future Vigitel investigations.

The results showed declining trends in the prevalence of tobacco use and bean consumption and an increase in the practice of leisure-time physical activity, overweight, obesity, hypertension, and diabetes for all schooling levels. The most educated individuals had a higher prevalence of protective factors for NCDs, such as intake of fruits and vegetables, physical activity, and lower prevalence of tobacco use, insufficient physical activity, hypertension, and diabetes. On the other hand, they had a higher prevalence of alcohol abuse and lower consumption of beans than the less educated, which highlights the persistent health inequalities in Brazil.

Combating inequalities is one of the central axes of the 2030 Agenda because they are in people’s daily lives and influence their relationship with their health. Access power, asset ownership, services, education, and wealth will determine their ability to remain healthy or not⁵⁹. Macro-determinants such as spending on housing, food, and regional cost of living affect local well-being differentials⁶⁰, including access to education and academic progression. Hence, the importance of intersectoral public policies that operate beyond improving access to services and actions to promote health and prevent diseases and conditions, also reducing inequalities and poverty so that more vulnerable individuals have access to healthy food, physical activity, and reduce tobacco use and other risk factors for NCDs.

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• Funding
  Fundo Nacional de Saúde/Ministério da Saúde (TED 67/2023); Tobacco Control Alliance (ACT) Health Promotion; Fapemig Universal 01/2021. Fapemig chamada 011/2022.

• Chief Editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  20 Oct 2025
• Date of issue
  2025

History

• Received
  10 Aug 2024
• Accepted
  17 Jan 2025
• Published
  19 Jan 2025