Prevalence of factors associated with chronic diseases in university students: PNS 2013 and 2019ABSTRACT
OBJECTIVE To assess the prevalence of risk and protective factors for non-communicable diseases among Brazilian university students.
METHODS Data from the 2013 and 2019 National Health Survey were used to assess undergraduate students (≥ 18 years). Risk factors included consumption of unhealthy foods, sedentary behavior, insufficient physical activity, alcohol and tobacco consumption, overweight, and obesity, while protective factors involved consumption of healthy foods and leisure-time physical activity. Prevalences and confidence intervals were described for each year, stratified by sex, professional occupation, race/skin color, and age group.
RESULTS The prevalence of regular consumption of soft drinks (men: 27.9% to 12.5%; women: 22.8% to 10.7%), sweets (men: 27.1% to 17.6%; women: 33.2% to 20.4%), and insufficient physical activity (men: 37.6% to 22.7%; women: 57.7% to 37.3%) decreased, while the prevalence of regular fruit and vegetable consumption (men: 16.1% to 27.2%; women: 22.6% to 34%) and leisure-time physical activity (women: 28.3% to 37.3%) increased. Regular consumption of beans (65.1% to 55.8%) and leisure-time physical activity (32.4% to 42.9%) increased among students with jobs. Leisure-time physical activity (37.2% to 46.4%) increased and sweet consumption (33.7% to 17.5%) decreased among white/Asian students, while regular consumption of beans decreased among Black/indigenous students (69.9% to 57.1%).
CONCLUSION The prevalence of most risk factors decreased. The prevalence of fruit and vegetable consumption and physical activity remained low but increased.
DESCRIPTORS
Life Style; Non-communicable Disease; Health Surveys; Universities
RESUMO
OBJETIVO Avaliar a prevalência de fatores de risco e proteção para doenças crônicas não transmissíveis entre estudantes universitários brasileiros.
MÉTODOS Foram utilizados dados da Pesquisa Nacional de Saúde de 2013 e 2019 para avaliar estudantes de graduação (≥ 18 anos). Fatores de risco incluíram consumo de alimentos não saudáveis, comportamento sedentário, atividade física insuficiente, consumo de álcool e de tabaco, excesso de peso e obesidade, enquanto fatores de proteção envolveram consumo de alimentos saudáveis e atividade física no lazer. Prevalências e intervalos de confiança foram descritos para cada ano, estratificadas por sexo, ocupação profissional, raça/cor da pele e faixa etária.
RESULTADOS A prevalência de consumo regular de refrigerantes (homens: 27,9% para 12,5%; mulheres: 22,8% para 10,7%), de doces (homens: 27,1% para 17,6%; mulheres: 33,2% para 20,4%) e de atividade física insuficiente (homens: 37,6% para 22,7%; mulheres: 57,7% para 37,3%) diminuiu, enquanto a prevalência de consumo regular de frutas e hortaliças (homens: 16,1% para 27,2%; mulheres: 22,6% para 34%) e de atividade física no lazer (mulheres: 28,3% para 37,3%) aumentou. O consumo de feijão (65,1% para 55,8%) e a prática de atividade física no lazer (32,4% para 42,9%) aumentaram entre estudantes com ocupação. A prática de atividade física no lazer (37,2% para 46,4%) aumentou e o consumo de doces (33,7% para 17,5%) reduziu entre estudantes brancos/amarelos, enquanto o consumo de feijão diminuiu entre estudantes negros/indígenas (69,9% para 57,1%).
CONCLUSÃO A prevalência da maioria dos fatores de risco diminuiu. As prevalências de consumo de frutas e hortaliças e prática de atividade física seguem baixas, mas tiveram aumento.
DESCRITORES
Estilo de vida; Doença Crônica; Inquéritos Epidemiológicos; Universidades
INTRODUCTION
Going to university can lead to changes in social relationships, family distancing, and behavioral changes, resulting in unhealthy lifestyle habits, which are risk factors for non-communicable diseases (NCDs)1. These diseases, understood as a set of conditions with a gradual onset, of long or indefinite duration, are the main cause of death and morbidity in Brazil2. Most NCDs develop from modifiable risk factors, such as unhealthy diet, insufficient physical activity, alcohol consumption, and smoking3.
In Brazil, national health surveys have become indispensable tools for monitoring these risk factors4, especially among the adult and elderly population. However, there are few studies identifying risk factors in a national sample of university students. With the enactment of the National Student Assistance Policy (PNAES)5 in 2024, it has become even more necessary to understand the health and lifestyle profile of this population, in order to help plan actions that prioritize the most urgent needs and justify the allocation of resources to implement the Policy. In addition, the analysis of health risk and protection factors can make it possible to assess the impact of PNAES over time, as well as playing a crucial role in the surveillance of risk factors for NCDs, as recommended in the Strategic Actions Plan for Takle Chronic Diseases and Noncommunicable Diseases in Brazil 2021–2030 (NCD Plan)3.
Therefore, to monitor the health-related aspects of university students, the aim of this study was to describe the prevalence and evolution of risk and protective factors for NCDs among Brazilian undergraduate students.
METHODS
Cross-sectional study developed with data from the Pesquisa Nacional de Saúde (PNS – National Health Survey) carried out in 2013 and 2019. The PNS is a nationwide, household-based survey carried out in Brazil by the Instituto Brasileiro de Geografia e Estatística (Brazilian Institute of Geography and Statistics) in partnership with the Ministry of Health and the Fundação Oswaldo Cruz. Detailed information on the PNS sampling strategy and data collection can be found in the survey reports4,6,7. The PNS was approved by the Ministry of Health’s National Human Research Ethics Committee under number 328.159 for the 2013 edition, and under number 3.529.376 for the 2019 edition.
The population surveyed corresponds to selected residents (aged 18 or over in 2013 and 15 or over in 2019) of a sample of permanent private households in Brazil6,7. In this study, the PNS samples were cut to include only adult individuals (≥ 18 years of age) who answered the individual questionnaire, in order to harmonize the age of the respondents in the two editions, and focusing on those who were enrolled in an undergraduate course6,7. The sample corresponded to 3,246 adults in 2013 and 3,618 in 2019. Although the PNS sample was not designed to specifically represent university students, the choice to focus on this group is justified by the importance of investigating health behaviors at a critical stage in the life cycle.
To analyze risk and protective factors for NCDs, questions were used regarding anthropometry, eating habits, alcohol consumption, physical activity and tobacco use.
The sociodemographic and geographic characteristics of the study population were analyzed using the following variables: gender (male, female), age group (18–23 years, 24–29 years, ≥ 30 years), geographic region (North, Northeast, Central-West, Southeast, South), area of residence (capital cities, non-capital cities), race/skin color, and professional occupation. The race/skin color variable, from the five original categories (white, black, brown, Asian, and indigenous), was categorized into white/Asian and black/indigenous8, considering that the second group may be the target of racial quotas for university admission and the proximity of these groups in terms of structural inequalities. Professional occupation was checked based on a positive answer to the question: “In the (reference week), did you work/internship for at least one hour in any activity remunerated with money?” Negative answers were classified as having no occupation. Given that there is no information on the type of university (public or private), the type of teaching (face-to-face or remote), and the individual’s study shift, the information on professional occupation was intended to help characterize study conditions.
The risk and protective factors analyzed are presented below. All the variables were analyzed dichotomously (yes/no), based on cut-off points previously established in the literature or on the response categories available in the PNS.
Diet
The healthy eating markers assessed were regular consumption of fruit and vegetables and regular consumption of beans, both of which were consumed on five or more days a week. The markers of an unhealthy diet were regular consumption of soft drinks and regular consumption of sweets, five or more days a week, and perception of excessive salt intake7. The analysis of people’s perception of salt intake was based on the question “Considering freshly prepared food and processed food, do you think your salt intake is”. The original response categories were grouped and classified as High and Adequate/Low.
Physical Activity
Leisure-time physical activity recommendations were met when the sum of the minutes spent on physical activity totaled 75 minutes or more per week - for vigorous activities - or 150 minutes or more per week - for light or moderate physical activities, as categorized by the PNS6,7. Insufficient practice of physical activity was considered when the sum of the min spent on physical activity during leisure time, commuting to work/school and occupational activity did not reach the equivalent of at least 150 minutes per week of light or moderate activity or at least 75 minutes per week of vigorous activity. The time spent on sedentary behaviors was assessed by spending three or more hours a day of free time watching television, considered to be prolonged screen time.
Alcohol Consumption
Habitual consumption of alcoholic beverages was considered to be the intake of alcoholic beverages by men or women in the last 30 days, regardless of the dose. For the alcohol abuse indicator, the classification criteria were maintained as defined in each edition of the PNS. In 2013, abusive consumption was considered to be the intake, on a single occasion, of five or more doses for men and four or more doses for women in the last 30 days6; in 2019, the criterion was standardized at five or more doses for both genders7.
Smoking
Smokers were individuals who, regardless of the frequency and/or number of cigarettes, reported using cigarettes or other tobacco products, characterized by the binary variable Yes and No.
Nutritional Status
Based on the reported weight and height data, the individuals’ Body Mass Index (BMI) (kg/m2) was calculated to assess their nutritional status. The indicators of excess weight (BMI ≥ 25 kg/m2) and obesity (BMI ≥ 30 kg/m2) were assessed.
Data Analysis
A descriptive analysis was carried out showing the prevalence and 95% confidence intervals (95%CI) of sociodemographic and geographical variables and risk and protective factors for NCDs. The prevalence of the indicators was described for each year of the survey and stratified by gender, professional occupation, race/skin color, and age group.
The indicators were compared between the two years of the survey to assess possible changes over the period, but also within each year of the survey to assess possible differences between the groups in the same period. Based on the comparison between the 95%CI and the absence of overlap between the intervals, a significant difference was assumed, considering a significance level of 5%.
Moreover, a sensitivity analysis was carried out on the subgroup of individuals who reported having received a medical diagnosis of at least one of the following NCDs: stroke, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease. This step was conducted considering that a previous diagnosis of a chronic condition can lead to changes in health-related behaviors.
The analyses were carried out using Stata SE software version 15 (Statacorp. College Station), in survey analysis mode, which considers the complex sampling of the PNS.
RESULTS
Table 1 shows the distribution of the sociodemographic characteristics of the study population according to the year of the survey and gender. There was a predominance of female students, aged between 18 and 23, living in the Southeast and working in some kind of occupation in 2013 and 2019.
Between the years, the percentage of students who did not meet the recommendations for physical activity fell (men: 37.6% to 22.7%; women: 57.7% to 37.3%) and there was also a reduction in prolonged screen time (men: 20.2% to 7.5%; women: 23.5% to 9.8%). Regular consumption of soft drinks decreased (men: 27.9% to 12.5%; women: 22.8% to 10.7%), as did regular consumption of sweets (men: 27.1% to 17.6%; women: 33.2% to 20.4%). Regular consumption of fruit and vegetables increased in both genders (men: 16.1% to 27.2%; women: 22.6% to 34.0%). The regular consumption of beans decreased from 60.5% to 51.2% among women, while the practice of physical activity during leisure time increased from 28.3% to 37.3% in this group (Table 2).
Among students with a professional occupation, there was a significant reduction in the percentage of insufficiently active individuals between 2013 and 2019, from 53.2% to 29.4%, and in prolonged screen time, from 19.7% to 7.3%. Among those with no professional occupation, the reduction in screen time was from 27.3% to 11.3%. Regular consumption of soft drinks decreased among students with and without a professional occupation (from 24.8% to 12.2% and from 23.9% to 9.2%, respectively), being more significant among those without an occupation. Regular consumption of sweets fell from 31.7% to 19.4% among students in employment and from 30.6% to 19.2% among those not in employment. Regular consumption of fruit and vegetables increased from 17.3% to 31.6% among students who had no occupation and from 20.7% to 31.7% among those who reported having a professional occupation. Regular consumption of beans fell among students with some kind of occupation, from 65.1% to 55.8%. On the other hand, physical activity during leisure time increased from 32.4% to 42.9% in this group (Table 3).
Smoking, alcohol abuse and excessive salt consumption, as well as the prevalence of excess weight and obesity, showed no significant variations between the years and between gender and occupation (Tables 2 and 3).
In relation to race/skin color, it was observed that the practice of physical activity during leisure time increased among white/Asian students, from 37.2% to 46.4%, and there was a reduction in the consumption of sweets in this group (33.7% to 17.5%). On the other hand, the reduction in bean consumption occurred only among black/indigenous students, with a decrease from 69.9% to 57.1%. The other indicators showed similar prevalence rates between the groups in the period (Table 4).
A reduction in insufficient physical activity was observed among all the age groups analyzed (18–23 years: from 43.2% to 29.1%; 24–29 years: from 50.8% to 32.1%; ≥ 30 years: from 55.9% to 33.3%), as was regular consumption of soft drinks (18–23 years: from 27.2% to 15.6%; 24–29 years: from 28.1% to 8.8%; ≥ 30 years: from 22.4% to 7.0%). Consumption of sweets decreased between the ages of 18–23 (from 36.5% to 23.0%) and 24–29 (from 33.8% to 14.8%), as did television time (≥ 3h) (18–23: from 24.6% to 5.6%; 24–29: from 25.9% to 11.3%). There was a reduction in regular consumption of bean among 24–29 year olds (from 65.4% to 52.2%) and an increase in regular consumption of fruit and vegetable among 24–29 year olds (from 14.2% to 24.4%) and ≥ 30 year olds (from 23.0% to 37.3%) (Table 5).
The sensitivity analyses showed similar results to those obtained for university students as a whole, reinforcing the robustness of the estimates and suggesting that the inclusion of individuals with NCDs did not significantly influence the findings (results not shown in table).
DISCUSSION
The main findings of this study reveal a significant reduction in most risk indicators for NCDs among university students, especially those relating to diet and physical activity. Among the protective indicators, there was an increase in the frequency of fruit and vegetable consumption and physical activity during leisure time; however, these indicators have a lower prevalence than desirable. Furthermore, the differences observed between white/Asian and black/indigenous students show inequalities in eating patterns and physical activity, which may reflect structural barriers related to access to safe environments for physical activity and healthy foods.
The reduction in the consumption of soft drinks and sweets reflects patterns also observed among Brazilian adults9,10, indicating a positive scenario of a decrease in the consumption of unhealthy foods. This progress may reflect the effects of public policies aimed at improving the health and dietary conditions of the Brazilian population, including the National Food and Nutrition Policy11 and the Guia Alimentar para a População Brasileira (Dietary Guideline for the Brazilian Population)12. However, the percentage of individuals who regularly consume fruit and vegetables is still less than half of the student population, and continuous monitoring of these indicators in this population is necessary.
The regular consumption of beans, an important marker of the cultural and healthy dietary pattern of the Brazilian population, has decreased over the years and it is estimated that it will not increase until 203013. This phenomenon can be attributed both to the weakening of the transmission of cooking skills between generations12, and to the increase in the purchase of ultra-processed foods due to the convenience they offer14. Among university students, the reduction in regular bean consumption among women and among students with professional occupations indicates that, in addition to the barriers already known, lack of planning and economic limitations may be additional factors that hinder the adoption of a healthy diet during the student period15.
In this context, the presence of university restaurants on campuses is a strategy that can contribute to improving students’ eating conditions, as it is a space that facilitates the adoption of healthy eating practices, as pointed out by a previous study16. It is also essential to consider the university food environment, where there is a predominance of ultra-processed foods on offer and advertising, as well as the high cost of healthy foods - when available17.
Estimates of leisure-time physical activity among university students exceed those of the adult population in the period (22.7% in 2013 and 30.1% in 2019)18. However, this practice could be even higher considering the benefits that activities provide to health and well-being. Among students with a professional occupation, the increase in the percentage of recommended physical activity suggests that, although the accumulation of study and work can reduce the time available for exercise, active commuting could contribute to greater physical activity. This aspect, however, requires future studies to assess its real impact in comparison with other forms of physical activity. In addition, working results in an increase in income, which may favor access to places for physical exercise, such as gyms.
Despite the reduction in the daily time spent watching television, it is important to note that questions about the time spent with other screens, such as computers, smartphones, and tablets, were not assessed, which could increase the time spent with sedentary behaviors, as reported in previous studies20,21. The use of screens for leisure combined with the use of computers for studies can intensify sedentary behavior among students21, setting up a challenging scenario for the promotion of actions aimed at reducing this behavior in this population.
In this study, excess weight was higher among male students, with an increase observed in older age groups. This pattern is similar to that described in the PNS 2019 for the set of individuals studied, in which the prevalence of excess weight increases with age, being slightly higher in males (58.3%) compared to females (57.0%)22. Moreover, another study carried out with data from the PNS 2013 and 2019 identified a positive association between schooling and obesity in men, and an inverse association in women, reinforcing that socioeconomic and educational factors can have a different influence on nutritional status between the genders, with relevant implications for public health strategies23.
Alcohol consumption among students has remained high over the years, exceeding that of the adult population in general (13.6% in 2013 and 17.1% in 2019)24. Psychological issues such as stress and poor sleep quality, experienced by many students during the academic period, may contribute to this practice2. The excessive consumption of alcoholic beverages by students, already reported in another study26, indicates the vulnerability of this group, which increases not only the chance of developing NCDs, but also other risks, such as traffic accidents, acts of violence under the influence of alcohol, unprotected sexual intercourse and damage to academic performance27.
The prevalence of tobacco use also remained stable in the period evaluated, in line with the national trend of low smoking prevalence, observed after the adoption of successful regulatory measures in recent years24. On the other hand, the use of electronic devices for smoking has been increasing, even with the ban in the country, representing a return to smoking among young people28. It is already known that the use of these devices is related to lung damage and other pathological organic changes29, justifying the need to strengthen anti-tobacco actions and the National Tobacco Control Policy.
In short, the low percentage of fruit and vegetable consumption, the high alcohol consumption among students and the reduction in bean consumption between the years suggest the need to create and strengthen actions aimed at reversing this scenario. Although NCDs are one of the priorities on the global and national agendas, the strategies for reducing risk factors proposed in isolation do not seem to be enough to significantly change the scenario of all risk factors. Therefore, although many health actions are not specifically aimed at the university environment, structural policies such as nutritional labeling of foods, taxation of ultra-processed foods, alcoholic beverages, and tobacco, encouraging the purchase of family and local agriculture, and the installation of parks and areas for physical activity can positively influence this context, contributing to improving the health and quality of life of university students.
This study has some limitations. Although PNS is a nationally representative survey, it is not possible to say that this is a representative study of university students, since the survey was not designed to represent this group, but rather individuals over the age of 15 or 18, depending on the edition. The information was obtained through self-reporting by the participants and is subject to recall bias. However, self-reported information is often used in large health surveys and is sufficiently accurate in this context30. It was also not possible to differentiate whether the students came from public or private higher education institutions, the shift of study and whether the undergraduate course took place in person or via distance education, factors that can lead to the adoption of different behaviors due to the different demands of the student routine. This was due to the absence of this information in the PNS questionnaires. To deal with this limitation, even partially, stratification by professional occupation was used, as working students may spend less time at university and have a more complex daily routine. The data used was collected in a period prior to the Covid-19 pandemic, which should be considered when interpreting the findings, given that the scenario may have changed. There was a change in the collection of information on abusive alcohol consumption by the PNS, which in 2013 considered the intake on a single occasion of five or more doses for men and four or more doses for women, and in 2019 considered five or more doses for both genders. Therefore, the abusive consumption of women in 2019 may be underestimated compared to the 2013 estimate.
On the other hand, the unprecedented evaluation of data from a large sample of Brazilian university students (almost 7,000 individuals) and representative of the population of Brazilian adults distributed in all regions of the country stands out as a potentiality. Furthermore, the opportunity to assess the prevalence and evolution of risk indicators for NCDs between 2013 and 2019 is worth highlighting, allowing for the identification of aspects that could be continuously monitored in future surveys. This is even more important given the lack of studies evaluating the Brazilian university population. The construction of evidence aimed at this public is necessary to subsidize the successful implementation of student assistance policies, such as PNAES5 and contribute to the monitoring of the Brazilian targets for reducing risk factors for NCDs set out in the NCD Plan3.
It can be concluded that the scenario has improved over the period studied, although the prevalence of some protective indicators remains low.
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Data Availability:
The microdata from the National Health Survey are publicly available, on the official IBGE website: https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?=&t=microdados
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Funding:
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES - Funding Code 001). Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ - process no. E-26/SEI-260003/017405/2022, Master’s Scholarship for MECP; process no. E-26/201.328/2022, Young Scientist of Our State Scholarship for DSC).
Edited by
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Associate Editor:
Marly Augusto Cardoso https://orcid.org/0000-0003-0973-3908
The microdata from the National Health Survey are publicly available, on the official IBGE website: https://www.ibge.gov.br/estatisticas/sociais/saude/9160-pesquisa-nacional-de-saude.html?=&t=microdados
