Cluster and simultaneity of modifiable risk factors for cardiovascular diseases in adolescents of Southeast Brazil

Motriz, Rio Claro, v.26, Issue2, 2020, e10200033 DOI: http://dx.doi.org/10.1590/s1980-6574202000020033 Original Article (short paper) Cluster and simultaneity of modifiable risk factors for cardiovascular diseases in adolescents of Southeast Brazil Camilo Luis Monteiro Lourenço1 , Rodolfo Carlos dos Santos Silva Filho2 Eduardo Hauser1 , Aline Rodrigues Barbosa3 , Edmar Lacerda Mendes4 , 1 Universidade Federal de Santa Catarina, Programa de Pós-Graduação em Educação Física, Florianópolis, SC, Brasil. 2 Universidade Federal do Triângulo Mineiro, Núcleo de Estudos em Atividade Física e Saúde, Uberaba, MG, Brasil. 3 Universidade Federal de Santa Catarina, Centro de Desportos, Florianópolis, SC, Brasil. 4 Universidade Federal do Triângulo Mineiro Departamento de Ciências do Esporte, Uberaba, MG, Brasil. Abstract - Aim: This study aimed to evaluate the cluster of the five major modifiable risk factors for cardiovascular diseases (CVD) and their associated factors and to identify patterns of concurrency of modifiable obesogenic risk factors associated with overweight in Brazilian adolescents. Methods: A survey was conducted (2015) with 1,055 (boys, n = 475; girls, n = 580) high school (public and private schools) adolescents (14-20 years old) in a medium-sized city in Southeast Brazil. The observed prevalence ratio (O) for the expected (E) risk factors (smoking, alcohol, insufficient physical activity, sedentary behavior, and poor diet) greater than one (O/E > 1) was considered as a cluster. We use multinomial and binary logistic regressions (stratified by sex) in the analyzes. Results: Almost 30% of adolescents had three or more risk factors (no factor = 5.4%). The five risk factors tended to cluster in boys (O/E = 2.5; 95% CI = 1.63.5). In both sexes, smoking and alcohol consumption persisted in O/E > 1 ratio. Conclusions: Boys showed a consistent pattern of association for risk factors. Overweight was associated with pairs of obesogenic risk factors in both sexes. The results indicate the need for health interventions that consider the cluster and the simultaneity of risk factors for CVD among Brazilian youth. Keywords: risk factors, cluster analysis, health behavior. Introduction Excessive alcohol consumption, smoking, unhealthy diet, insufficient physical activity1, and sedentary behavior2 (SB) are among the main modifiable risk factors for cardiovascular diseases (CVD) in both developed and developing countries2. In 2016, CVD accounted for 17.9 million deaths (31% of all global deaths)3. Although the manifestation and lethality of CVD typically occur in adulthood or old age3, the most influential factors begin with exposure to risk factors or behaviors learned in childhood or adolescence4. This reinforces the concern regarding detecting the exposure to risk factors in adolescence, in order to promote health interventions5. Clustering of risk factors is the cause of greater concern than isolated risk factors6 and it exists when the observed proportion of risk factors exceeds the expected proportion of the combination of factors in the study population7. The clustering is supported by a rationale that multiple lifestyle behaviors occur in a multifactorial and interactive way6,7. For example, smoking, alcohol con- sumption, low fruit intake, and insufficient physical activity (PA) tended to come together among adolescents from the south and northeast of Brasil8,9. In addition, multiple risk behaviors, such as insufficient physical activity and (SB), tend to cluster and are on the route of pediatric obesity10. Although SB is a modifiable risk factor for CVD2 that favors negative combination patterns10, it is still poorly investigated in studies involving young people, especially in Brazil11. In addition to clustering, some risk behaviors seem to be more prone than others to obesity in young people. A recent review showed that risk factors involving unhealthy diet patterns (e.g. high-fat/high-sugar snacks), SB, and insufficient physical activity in young people tend to converge on healthy and unhealthy patterns for obesogenic pathways, but results were inconclusive10. Five of the studies included in the review showed unhealthy behavior patterns (e.g. insufficient PA + high SB) positively associated with excess body weight, but two other studies found an unexpected inverse association12,13. Moreover, a gap that persists since the review by Leech et al.10 is the 2 Cluster of risk factors in adolescents exploration of specific combinations of risk factor simultaneity involving unhealthy diet (e.g. low consumption of fruits and vegetables) and insufficient PA or unhealthy diet and SB and their obesogenic relationships. No study of clustering of factors conducted with Brazilian youth8,9,11,14 ever investigated this relationship. The clustering analysis of behavioral risk factors can facilitate the proposition of multicomponent health programs, with guidelines directed to the modification of risk behaviors. Strategies focusing on multiple aspects may be more efficient than those directed to a single risk factor5,15. Thus, the present study aimed to analyze the cluster of the five main modifiable risk factors for CVD and their associated factors; and identify patterns of simultaneity of modifiable obesogenic risk factors associated with overweight in adolescents from a municipality in southeastern Brazil. Methods The report of this study is guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. 994,772/2015) and each parent and participant provided written consent before starting the study. The Department of Education of the State of Minas Gerais (SEEMG) and the Regional Superintendency of Education of Uberaba (SRE) authorized the study. The SRE provided the data regarding the school census. The survey was conducted following the Declaration of Helsinki. Data collection The adolescents self-completed anonymously a previously validated questionnaire16, applied in the selected schools during the class period by a pair of trained applicators, between May and October 2015. The questionnaire used in this study was composed of six sections covering sociodemographic information, physical activities and sedentary behaviors, perception of the school environment and physical education classes, eating habits and weight control, alcohol and tobacco use, and perception of health and preventive behavior. A test-retest procedure showed reproducibility rates from 0.51 to 0.9616. Study variables Modifiable risk factors for CVD Study design This cross-sectional study is derived from the epidemiological survey Assessment of Adolescent Health and Lifestyle Behaviors in Uberaba (ACtVU) whose population were adolescents of both sexes enrolled in the public and private high schools of Uberaba, Minas Gerais in 2015. Uberaba has a high municipal human development index (HDI [0.772]), Gini index of 0.50, and life expectancy at birth of 75.7 ye (...truncated)