Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: Analysis of a national school-based survey

RESEARCH ARTICLE Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: Analysis of a national school-based survey Camila Zancheta Ricardo ID1*, Catarina Machado Azeredo2, Leandro Fórnias Machado de Rezende ID1, Renata Bertazzi Levy1 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, SP, Brazil, 2 Faculdade de Medicina, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil * Abstract OPEN ACCESS Background Citation: Ricardo CZ, Azeredo CM, Machado de Rezende LF, Levy RB (2019) Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: Analysis of a national school-based survey. PLoS ONE 14(7): e0219370. https://doi.org/10.1371/ journal.pone.0219370 The major non-communicable chronic diseases (NCD) are associated with a small group of modifiable lifestyle-related risk factors, including smoking, insufficient physical activity, unhealthy eating, and alcohol abuse. In this study, we evaluated the co-occurrence and clustering of the major NCD risk factors among Brazilian adolescents. Editor: Arsham Alamian, East Tennessee State University, UNITED STATES This cross-sectional study analyzed data of 101,607 adolescents from the Brazilian National Survey of School Health (PeNSE) 2015. The risk factors included were: regular consumption of ultra-processed foods, irregular consumption of fruits and vegetables, insufficient physical activity, smoking, and alcohol consumption. Clustering was defined through the ratio between observed and expected prevalences of combination of risk factors greater than 1. Expected prevalence of the co-occurrence of risk factors was calculated from the joint probability of the behaviors. Additionally, we examined the presence of at least four risk factors according to socioeconomic characteristics. Received: January 7, 2019 Accepted: June 22, 2019 Published: July 3, 2019 Copyright: © 2019 Ricardo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Brazilian National Survey of School Health (Pesquisa Nacional de Saúde do Escolar - PeNSE) database is available on a Brazilian Institute of Geography and Statistics website (https://ww2.ibge.gov.br/home/estatistica/ populacao/pense/2015/default.shtm). Funding: C.Z.R. received a master’s scholarship from the Coordination for the Improvement of Higher Education Personnel (CAPES) and from the São Paulo Research Foundation (FAPESP; grant Methods Results Of the 32 combinations of risk factors, 13 corresponded to clustering. We observed a strong correlation between alcohol consumption and smoking, which were found together in 8 of the 13 clusters identified. The most frequent combinations of risk factors involved unhealthy eating and insufficient physical activity. Only 2.9% of the adolescents did not present any risk behaviors, while 38.0%, 32.9%, 9.4% and 1.8% accumulated two, three, four and five risk factors, respectively. The accumulation of risk factors was higher in girls, older adolescents, those who did not live with both parents, children of less-educated mothers, students attending public school, and residents of cities in more developed urban areas of the country. PLOS ONE | https://doi.org/10.1371/journal.pone.0219370 July 3, 2019 1 / 13 Co-occurrence and clustering of non-communicable disease risk factors in Brazilian adolescents number 2014/26711-3). https://bv.fapesp.br/pt/. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Conclusions The main risk factors for NCD are frequent and not randomly distributed among Brazilian adolescents. Our results provide information for policymakers to target specific groups and joint behavioral risk factors for health improvement in adolescents. Introduction Non-communicable diseases (NCD) are the leading cause of death worldwide and impact both quality of life and social and economic development, particularly in low and middleincome countries [1]. A recent analysis of the burden of disease showed that NCD have grown significantly in Brazil between 1990 and 2016, and have become the leading cause of death and years of life lost [2]. Similarly, the contribution of NCD risk factors to disability-adjusted life years (DALY) sharply increased in this period. In 2016, the main risk factors that contributed to DALY in Brazil were alcohol and drug use, high blood pressure, high body mass index, inadequate diet, smoking and low physical activity [2]. These main risk behaviors are often acquired during adolescence and tend to remain in adulthood [3, 4]. In addition, epidemiological studies suggest an association between risk factors during adolescence and the development of NCD later in life, regardless of exposures in adulthood [5–7]. Therefore, it is important to monitor NCD risk factors in adolescents, including their co-occurrence in the population, as risk factors can interact with each other, thereby producing greater risk than the sum of individual risks [8–11]. Despite the increasing number of studies aimed at identifying how major NCD risk and protective behaviors are related, the majority of the studies focus mainly on the adult population [12–16] with some studies focusing on adolescents in developed countries [17–20]. The literature in this field is highly heterogeneous, with different methodologies and risk factors assessment and definition, and no consensus about which risk factors usually occur together [21, 22]. In Brazil, the co-existence of NCD risk factors among adolescents has been studied previously [23–27]. For example, clustering of risk factors including physical activity, sedentary behavior, and diet has been reported using data from a school-based national and representative survey [25, 26]. Another study evaluated patterns of multiple health-related behaviors including diet, physical activity, alcohol consumption, smoking, drug use, aggressive behavior, and unsafe sex, exploring the correlation between these behaviors [27]. These studies provided some evidence on how risk factors interact in Brazilian adolescents, but they did not provide information regarding the prevalence and co-occurrence of all the four main risk factors for NCD. In this study, the two primary objectives were: 1) to evaluate the prevalence and clustering of NCD risk factors (smoking, insufficient physical activity, unhealthy eating, and alcohol abuse); and 2) to verify the co-occurrence of risk factors according to the sociodemographic characteristics of (...truncated)