Abstract

The present study aimed to compare changes in risk and protective behaviors for non-communicable diseases (NCDs), self-reported morbidity, and preventive cancer tests prior to and at the end of the third wave of the COVID-19 pandemic in Brazil. This study analyzes a historical series from the Surveillance System of Risk and Protective Factors for Chronic Diseases by Telephone Survey (VIGITEL) for the years 2006 and 2021. Trends were analyzed using linear regression, and the Student’s t test was used to calculate differences between years. A decline in the prevalence of leisure-time physical activity (PA) and PA while commuting; and increased prevalence of adults with insufficient PA practice, sedentary behavior, and physical inactivity were observed. A worsening of the indicators of overweight, obesity, and diabetes was also observed during the pandemic. Hypertension was stable during the period from 2009 to 2019 and increased during the years of the pandemic. There was a reduction in the coverage of preventive mammograms and cervical cytology exams, differing from the previous trend. In conclusion, the findings point to the worsening of NCD indicators. Therefore, health promotion actions are a priority in this context.

Key words:
Risk factors; Chronic disease; Pandemics; Health surveys; Cross-sectional studies; Brazil

Introduction

The COVID-19 pandemic was declared by the World Health Organization (WHO) on March 11, 2020¹1 World Health Organization (WHO). WHO Director-General's opening remarks at the media briefing on COVID-19 [Internet]. 2020. [cited 2022 maio 28]. Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/dg/speeches/detail/w... . In Brazil, the first case was confirmed on February 26th²2 Croda JHR, Garcia LP. Immediate health surveillance response to COVID-19 epidemic. Epidemiol Serv Saude 2020; 29(1):e2020002.. By March 28, 2022, more than 30.9 million cases and more than 666,000 deaths were registered in the country³3 Conselho Nacional de Secretários de Saúde. Painel COVID-19 [Internet]. 2022. [acessado 2022 maio 28]. Disponível em: https://www.conass.org.br/painelconasscovid19/
https://www.conass.org.br/painelconassco... . The excess mortality rate due to COVID-19 in Brazil reached levels above the global average in 2020 and 2021⁴4 World Health Organization (WHO). Global excess deaths associated with COVID-19, January 2020 [Internet]. 2022. [cited 2022 maio 15]. Available from: https://www.who.int/data/stories/global-excess-deaths-associated-with-covid-19-january-2020-december-2021
https://www.who.int/data/stories/global-... .

Socioeconomic inequalities and vulnerability shape the spread and impacts of COVID-19 in Brazil⁵5 Rocha R, Atun R, Massuda A, Rache B, Spinola P, Nunes L, Lago M, Castro MC. Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysis. Lancet Glob Health 2021; 9(6):e782-e792.. However, there is evidence that the tragic political actions taken by the federal government influenced morbimortality caused by the disease in the country due to the lack of national guidelines to fight the disease, to the delay in obtaining vaccines, to denial of the pandemic and of science, and to the lack of coordination and national handling of the problem⁶6 Xavier DR, Lima E Silva E, Lara FA, E Silva GRR, Oliveira MF, Gurgel H, Barcellos C. Involvement of political and socio-economic factors in the spatial and temporal dynamics of COVID-19 outcomes in Brazil: a population-based study. Lancet Reg Health Am 2022; 10:100221.

7 Castro MC, Kim S, Barberia L, Ribeiro AF, Gurzenda S, Ribeiro KB, Abbott E, Blossom J, Rache B, Singer BH. Spatiotemporal pattern of COVID-19 spread in Brazil. Science 2021; 372(6544):821-826.^-88 Ventura D, Aith F, Reis R. Crimes against humanity in Brazil's COVID-19 response-a lesson to us all. BMJ 2021; 375:n2625.. All of this resulted in unnecessary and avoidable casualties. Moreover, it is a well-known fact that good governmental action is a fundamental aspect in the fight against a pandemic⁹9 COVID-19 National Preparedness Collaborators. Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. Lancet 2022; 399(10334):1489-1512..

Pandemics have damaging and multidimensional effects on the health of a population, which go beyond statistics of morbimortality¹⁰10 Werneck GL. The COVID-19 pandemic: challenges in assessing the impact of complex and multidimensional problems on the health of populations. Cad Saude Publica 2022; 38(4):PT045322.. Studies have indicated that the social isolation measures adopted in the fight against the pandemic also resulted in changes in the behavior and health of the Brazilian people, including the feelings of loneliness, sadness, stress, and anxiety¹¹11 Barros MBA, Lima MG, Malta DC, Szwarcwald CL, Azevedo RCS, Romero D, Souza Júnior PRB, Azevedo LO, Machado ÍE, Damacena GN, Gomes CS, Werneck AO, Silva DRPD, Pina MF, Gracie R. Report on sadness/depression, nervousness/anxiety and sleep problems in the Brazilian adult population during the COVID-19 pandemic. Epidemiol Serv Saude 2020; 29(4):e2020427.; worse lifestyles (less physical activity (PA) and an increase in the consumption of alcoholic beverages, cigarettes, and unhealthy food)¹²12 Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado IE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Pina MF, Freitas MIF, Werneck AO, Silva DRPD, Azevedo LO, Gracie R. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saude 2020; 29(4):e2020407.

13 Malta DC, Gomes CS, Barros MBA, Lima MG, Almeida WDS, Sá ACMGN, Prates EJS, Machado ÍE, Silva DRPD, Werneck AO, Damacena GN, Souza Júnior PRB, Azevedo LO, Montilla DER, Szwarcwald CL. Noncommunicable diseases and changes in lifestyles during the COVID-19 pandemic in Brazil. Rev Bras Epidemiol 2021; 24:e210009.^-1414 Malta DC, Gomes CS, Souza Júnior PRB, Szwarcwald CL, Barros MBA, Machado ÍE, Romero DE, Lima MG, Silva AGD, Prates EJS, Cardoso LSM, Damacena GN, Werneck AO, Silva DRPD, Azevedo LO. Factors associated with increased cigarette consumption in the Brazilian population during the COVID-19 pandemic. Cad Saude Publica 2021; 37(3):e00252220.; as well as less healthcare follow-up¹⁵15 Malta DC, Gomes CS, Silva AGD, Cardoso LSM, Barros MBA, Lima MG, Souza Junior PRB, Szwarcwald CL. Use of health services and adherence to social distancing by adults with Noncommunicable Diseases during the COVID-19 pandemic, Brazil, 2020. Cien Saude Colet 2021; 26(7):2833-2842., especially among adults with non-communicable diseases (NCD)¹⁶16 Horta BL, Silveira MF, Barros AJD, Hartwig FP, Dias MS, Menezes AMB, Hallal PC. COVID-19 and outpatient care: a nationwide household survey. Cad Saude Publica 2022; 38(4):e00194121., a decline in the hospitalization of patients with cardiovascular diseases (CVD)¹⁷17 Ribeiro EG, Pinheiro PC, Nascimento BR, Cacique JPP, Teixeira RA, Nascimento JS, Franco TB, Brant LCC, Malta DC. Impact of the COVID-19 pandemic on hospital admissions for cardiovascular diseases in a large Brazilian urban center. Rev Soc Bras Med Trop 2022; 55(supl. 1):e0264.; and an increase in mortality caused by CVD¹⁸18 Brant LCC, Nascimento BR, Teixeira RA, Lopes MACQ, Malta DC, Oliveira GMM, Ribeiro ALP. Excess of cardiovascular deaths during the COVID-19 pandemic in Brazilian capital cities. Heart 2020; 106(24):1898-1905.^,1919 Jardim BC, Migowski A, Corrêa FM, Silva GAE. COVID-19 in Brazil in 2020: impact on deaths from cancer and cardiovascular diseases. Rev Saude Publica 2022; 56:22..

Taking this into account, measuring of one’s state of health, self-referred morbidity, and the performance of preventative exams before and after the COVID-19 pandemic, are essential in order to subsidize the elaboration and reformulation of public policies, to plan measures to reduce social inequalities and evidence-based health measures, as well as to contribute in the planning and organization of health services and programs after the pandemic. Therefore, this study aims to compare changes that occurred in risk and protective behaviors against NCD, reported morbidity, and the performance of preventative exams for cancer, before and after the third wave of the COVID-19 pandemic in Brazil.

Methodology

Study design

This is an epidemiological study analyzing the data banks from the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (VIGITEL, in Portuguese) from 2006 to 2021. Data was collected from September 21, 2021, to February 2022, which corresponded to the final months of 2021 and the third wave of the COVID-19 pandemic in 2022.

Context

VIGITEL was created by the Brazilian Ministry of Health (MH) in 2006. It is an annual population-based survey that monitors NCDs and their risk and protection factors by telephone surveys, with adults (≥18 years of age) residing in homes with at least one telephone landline.

Sampling

The sampling procedures, for each state capital of the 26 Brazilian States, sought to obtain probabilistic samples from the adult population residing in homes with at least one telephone landline.

Adults (≥ 18 years of age) who resided in the capitals of the 26 Brazilian states and the Federal District, who had a telephone landline, were interviewed. Between 2006 and 2019, approximately 54,000 individuals were interviewed, and all the estimates were pondered so that they were representative of the entire adult population of each town. To estimate the frequency of the indicators, a 95% confidence interval (95%CI) was considered, with a maximum error of approximately three percentage points. In 2020 and 2021, the minimum sample size of 1,000 individuals per town was established, with nearly 27,000 interviews in total. Such a sample allows us to estimate, with a 95%CI and a maximum error of four percentage points, the frequency of any risk or protective factor within the adult population. A maximum error of five percentage points is to be expected in specific estimates according to sex, assuming that women and men appear in similar proportions in the sample.

Post-stratification weights, calculated by the rake method, are attributed to the interviews, considering the variables of sex, age group, and education level, so that the samples are representative of the adult population from each town. Further detail on the sampling process and data collection are provided by VIGITEL²⁰20 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2019. Brasília: MS; 2020.^,2121 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Análise em Saúde e Vigilância de Doenças não Transmissíveis. Vigitel Brasil 2021: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2021. Brasília: MS; 2022..

Variables

The following indicators were analyzed, and remained similar throughout the entire period of data collection. As shown below, not every indicator was available in each edition:

The prevalence of the indicators was estimated using the total number of interviewed adults as a denominator, not including the indicators for cancer detection, which were specific for females in certain age groups.

Statistical analysis

The prevalence of the indicators is shown in proportions (%), and their 95%CI. The trend analysis was conducted using the linear regression method for two periods: 2006 to 2019 and 2006 to 2021.

This study also compared the years prior to the pandemic (2019) and the year after the third wave of the pandemic (2021) by means of annual variation (∆) during the period, expressed as percentages, according to sex. To test the differences between the two editions of the survey, the Student’s t Test was applied, considering H0 : ∆ = 0 and H1 : ∆ ≠ 0, and a significance level (α) equal to 0.05. The variation is significant when the 95%CI does not contain zero.

Processing and data analysis were conducted using the Statistical Software for Data Science (Stata Corp LP, College Station, Texas, United States), version 16.0, considering the post-stratification weights.

Ethical considerations

Free and informed consent was obtained orally upon telephone contact with the interviewees. VIGITEL was approved by the National Ethics Committee for Research with Human Beings from the Ministry of Health (CAAE: 65610017.1.0000.0008).

Results

Approximately 54,000 interviews were conducted each year, and nearly 27,000 in 2020 and 2021.

Table 1 shows the tendencies of the indicators in two periods, 2006 to 2019 and 2006 to 2021. Between 2006 and 2019, a significant decrease can be seen in the prevalence of smokers (p < 0.001), second-hand smokers at home (p < 0.001), second-hand smokers in the workplace (p < 0.001), consumption of soft drinks (p < 0.001), consumption of beans (p < 0.001), and insufficient practice of physical activities (p = 0.022). By contrast, an increase was found in the prevalence of the abusive consumption of alcoholic beverages (p = 0.032), recommended consumption of fruits and vegetables (p = 0.006), practice of leisure-time physical activities (PA) (p < 0.001), overweight (p = 0.001), obesity (p < 0.001), diabetes (p < 0.001), and having a mammogram among women (p = 0.001). The prevalence of the regular consumption of fruits and vegetables, the practice of PA while commuting, physical inactivity, sedentary behavior, hypertension, and having an oncotic cytology exam in women, all remained stable (Table 1).

When comparing the entire period (2006-2021), some indicators changed tendency during the pandemic: “insufficient practice of PA”, which had previously shown a decline in prevalence, increased after 2019, reaching the same prevalence of 2014; “sedentary behavior”, stable until 2019, showed an increase (1.144 per year) in 2020 and 2021; “practice of leisure -time PA” showed a progressive increase (0.942 per year) until 2019 and declined in the following years; “PA while commuting” dropped in 2020 and 2021 (p = 0.019); “self-reported diabetes”, although with an increasing trend throughout the entire period, showed an increase in 2020 and 2021 (reaching 9.1% in 2021). Mammogram and oncotic cytology dropped in 2020 and 2021, given that mammograms were less often covered by healthcare insurance in 2009, whereas oncotic cytology - which previously showed stability - declines significantly in the last two years (p = 0.013), when the two last years of the series were included. Obesity and overweight also worsened over the last two years. The remaining indicators showed no changes in their trend in the final years of the series (Table 1).

Comparing the pre-pandemic year (2019) and after the third wave (2021) (Tables 2, 3 and 4), the practice of leisure-time PA dropped from 39.0% (95%CI: 38.0; 39.9) in 2019 to 36.7% (95%CI: 35.3; 38.2) for the total population and 46.7% (95%CI: 45.2; 48.3) to 43.1% (95%CI: 40.8; 45.5) for the male sex. The prevalence of PA for while commuting went from 14.2% (95%CI: 13.4; 14.9) in 2019 to 10.4% (95%CI: 9.4; 11.4) in 2021for the total population; 14.5% (95%CI: 13.4; 15.7) to 10.8% (95%CI: 9.4; 12.4) in men; and 13.8% (95%CI: 13.0; 14.7) to 10.0% (95%CI: 8.8; 11.5) in women. By contrast, the prevalence of adults with insufficient practice of PA increased in the total population (44.8%; 95%CI: 43.9; 45.7 to 48.2%; 95%CI: 46.7; 49.7), among men (36.1%; 95%CI: 34.7; 37.6 to 39.3%; 95%CI: 37.0; 41.6) and among women (52.2%; 95%CI: 51.0; 53.4 to 55.7%; 95%CI: 53.7; 57.7). The lack of physical activity increased in the total population (13.9%; 95%CI: 13.3; 14.5 to 15.8%); 95%CI: 14.7; 16.9) and among women (14.0%; 95%CI: 13.3; 14.7 to 16.0; 95%CI: 14.5; 17.6). Sedentary behavior also increased, rising from 62.7% (95%CI: 61.8; 63.6) to 66.0% (95%CI: 64.6; 67.4) in the total population, 63.9% (62.4; 65.3) to 66.7% (64.4; 68.8) among men and 61.7% (95%CI: 60.5; 62.8) to 65.4% (95%CI: 63.6; 67.2) among women (Table 2).

An increase in the prevalence of overweight was also observed, which in 2019 was 55.4% (95%CI: 54.4; 56.3) and rose to 57.2%; (95%CI: 55.7; 58.8) in 2021. The prevalence of obesity also increased, from 20.3% (95%CI: 19.5; 21.0) in 2019 and to 22.4% (95%CI: 21.1; 23.6) in 2021. Obesity also increased among men, rising from 19.5% (95%CI: 18.3; 20.7) to 22.0% (95%CI: 20.0; 24.0) (Table 2).

In terms of self-reported morbidity, an increase in the prevalence of self-reported hypertension was observed in the total population (24.5%; 95%CI: 23.8; 25.3 to 26.3%; 95%CI: 25.1; 27.6), and among men (21.2%; 95%CI: 20.0; 22.4 to 25.4%; 95%CI: 23.4; 27.4). The prevalence of self-reported diabetes increased from 7.5% (95%CI: 7.0; 7.9) to 9.1% (95%CI: 8.5; 9.8) in the total population, from 7.8% (95%CI: 7.3; 8.3) to 9.6% (95%CI: 8.8; 10.5) among women, and from 7.1% (95%CI: 6.4; 7.8) to 8.6% (95%CI: 7.6; 9.7) among men (Table 3).

In terms of having early detection cancer exams among women, a decline was observed in the coverage of mammograms in the last two years, dropping from 76.9% (95%CI: 75.4; 78.3) in 2019 to 72.8% (95%CI: 70.7; 75.0) in 2021/2022. There was also a decrease in the coverage of cervical cytology exams in the last three years, dropping from 81.5% (95%CI: 80.4; 82.6) in 2019 to 77.2% (95%CI: 75.2; 79.1) in 2021. A decline was found in the prevalence of second-hand smokers at the workplace (6.6%; 95%CI: 6.0; 7.1 in 2019 to 5.4%; 95%CI: 4.6; 6.3 in 2021), as well as for males (10.0%; 95%CI: 9.0; 11.0 in 2019 and 8.1%; 95%CI: 6.7; 9.7 in 2021) (Table 2).

The remainder of the indicators remained stable: prevalence of smokers, second-hand smokers at home; abusive consumption of alcoholic beverages; food consumption, with stability for a regular and recommended consumption of fruits and vegetables; the consumption of beans, soft drinks, five or more groups of protection foods, and five or more groups of ultra-processed foods.

Discussion

Between 2006 (start of the VIGITEL system) and 2019 (pre-pandemic), positive changes occurred, including the decrease in the prevalence of smokers and of physical inactivity, and increase in the consumption of fruits and vegetables, coverage by mammograms, and practice of leisure-time PA. During the period, the indicators for alcohol consumption, obesity, and diabetes worsened, whereas a stability was observed in such indicators as hypertension and most PA. After the pandemic period of 2020, a rapid change took place in the NCD indicators, which had previously been in either positive evolution or stable. The prevalence of adults with insufficient PA practice, sedentary behavior and physical inactivity increased; a decline in PA for while commuting was also observed. The Coverage of preventive breast cancer screenings, which had previously shown an increasing trend, and cervical cytology, which had been stable, both decreased. A decrease in the indicators of overweight, obesity, and self-reported prevalence of diabetes was also observed. Hypertension, which had previously been stable, showed an increase in the prevalence.

The present study showed that all of the PA indicators were affected during the pandemic, making it more difficult to attain the goals of the NCD plan established by the WHO, which made a commitment to reduce physical inactivity by 10%, or practice PA for at least 150 minutes per week in different contexts (leisure, while commuting, at work)²⁴24 World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. 2013. [cited 2022 maio 28]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... . The findings show unprecedented evidence that there has been a decline in active while commuting of nearly 30%. In other words, two years after the beginning of the pandemic, the levels of active while commuting still remain low, possibly due to the persistence of remote work, in home office, but also due to the increase in unemployment²⁵25 Mattei L, Heinen VL. Impactos da crise da Covid-19 no mercado de trabalho brasileiro. J Polit Econ 2020; 40(4):647-668.. Previous studies have indicated that the COVID-19 pandemic resulted in a decrease in the practice of leisure-time PA among Brazilian adults¹²12 Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado IE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Pina MF, Freitas MIF, Werneck AO, Silva DRPD, Azevedo LO, Gracie R. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saude 2020; 29(4):e2020407.^,2626 Malta DC, Gomes CS, Szwarcwald CL, Barros MBA, Silva AG, Prates EJS, Machado ÍE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Azevedo LO, Pina MF, Werneck AO, Silva DRP. Distanciamento social, sentimento de tristeza e estilos de vida da população brasileira durante a pandemia de Covid-19. Saude Debate 2020; 44(4):177-190..

The increase in sedentary behavior during the COVID-19 pandemic has been explained as a direct effect of the social distancing measures. Therefore, social distance provoked a decline in social interactions and forced the population to spend more time in front of the TV, the tablet, the computer, and the cell phone, as an alternative for leisure and for remote work²⁷27 Silva DRPD, Werneck AO, Malta DC, Souza Júnior PRB, Azevedo LO, Barros MBA, Szwarcwald CL. Changes in the prevalence of physical inactivity and sedentary behavior during COVID-19 pandemic: a survey with 39,693 Brazilian adults. Cad Saude Publica 2021; 37(3):e00221920.^,2828 Silva DR, Werneck AO, Malta DC, Souza-Júnior PRB, Azevedo LO, Barros MBA, Szwarcwald CL. Incidence of physical inactivity and excessive screen time during the first wave of the COVID-19 pandemic in Brazil: what are the most affected population groups? Ann Epidemiol 2021; 62:30-35.. The decrease in physical activity and subsequent increase in sedentary behavior negatively affect the quality of life and health²⁶26 Malta DC, Gomes CS, Szwarcwald CL, Barros MBA, Silva AG, Prates EJS, Machado ÍE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Azevedo LO, Pina MF, Werneck AO, Silva DRP. Distanciamento social, sentimento de tristeza e estilos de vida da população brasileira durante a pandemia de Covid-19. Saude Debate 2020; 44(4):177-190., and have damaging effects for cardiovascular health²⁹29 Peçanha T, Goessler KF, Roschel H, Gualano B. Social isolation during the COVID-19 pandemic can increase physical inactivity and the global burden of cardiovascular disease. Am J Physiol Heart Circ Physiol 2020; 318(6):H1441-H1446., worsening COVID-19 cases³⁰30 Gualano B. Evidence-based physical activity for COVID-19: what do we know and what do we need to know? Br J Sports Med 2022; 56(12):653-654. and causing subsequent repercussions on mental health³¹31 Ai X, Yang J, Lin Z, Wan X. Mental health and the role of physical activity during the COVID-19 pandemic. Front Psychol 2021; 12:759987., all resulting in higher numbers of avoidable and premature deaths³²32 Stamatakis E, Gale J, Bauman A, Ekelund U, Hamer M, Ding D. Sitting time, physical activity, and risk of mortality in adults. J Am Coll Cardiol 2019; 73(16):2062-2072.. Consequently, it is urgent to adopt measures that encourage the population to practice PA, especially among the most highly affected population groups, as in the case of patients with NCDs³³33 Malta DC, Gomes CS, Barros MBA, Lima MG, Almeida WDS, Sá ACMGN, Prates EJS, Machado ÍE, Silva DRPD, Werneck AO, Damacena GN, Souza Júnior PRB, Azevedo LO, Montilla DER, Szwarcwald CL. Noncommunicable diseases and changes in lifestyles during the COVID-19 pandemic in Brazil. Rev Bras Epidemiol 2021; 24:e210009.^,3434 Silva LESD, Oliveira MM, Stopa SR, Gouvea ECDP, Ferreira KRD, Santos RO, Valença Neto PDF, Macário EM, Sardinha LMV. Temporal trend of overweight and obesity prevalence among Brazilian adults, according to sociodemographic characteristics, 2006-2019. Epidemiol Serv Saude 2021; 30(1):e2020294..

Overweight and obesity were in continuous growth before³⁵35 Ferreira APS, Szwarcwald CL, Damacena GN, Souza Júnior PRB. Increasing trends in obesity prevalence from 2013 to 2019 and associated factors in Brazil. Rev Bras Epidemiol 2021; 24(supl. 2):e210009.^,3636 Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar e Nutricional. VIGISAN: Inquérito Nacional sobre Insegurança Alimentar no Contexto da Pandemia da Covid-19 no Brasil [Internet]. 2021. [acessado 2022 maio 10]. Disponível em: http://olheparaafome.com.br/VIGISAN_Inseguranca_alimentar.pdf
http://olheparaafome.com.br/VIGISAN_Inse... , and those problems had important increases in annual variation during the pandemic, affecting up to 60% and 20% of the Brazilian population, respectively. Those problems can be explained by insufficient PA, but are also affected by worsening nutrition¹²12 Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado IE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Pina MF, Freitas MIF, Werneck AO, Silva DRPD, Azevedo LO, Gracie R. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saude 2020; 29(4):e2020407.^,2626 Malta DC, Gomes CS, Szwarcwald CL, Barros MBA, Silva AG, Prates EJS, Machado ÍE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Azevedo LO, Pina MF, Werneck AO, Silva DRP. Distanciamento social, sentimento de tristeza e estilos de vida da população brasileira durante a pandemia de Covid-19. Saude Debate 2020; 44(4):177-190.. A study conducted during the pandemic identified an increase in nutritional insecurity, affecting 100 million Brazilians. Nearly 20 million people are starving³⁷37 Santos LPD, Schäfer AA, Meller FO, Harter J, Nunes BP, Silva ICMD, Pellegrini DDCP. Tendências e desigualdades na insegurança alimentar durante a pandemia de COVID-19: resultados de quatro inquéritos epidemiológicos seriados. Cad Saude Publica 2021; 37(5):e00268520.. Moreover, it is important to point out the increase in the consumption of cheap ultra-processed foods, such as instant noodles, which may have been caused by their low price and high caloric value²⁶26 Malta DC, Gomes CS, Szwarcwald CL, Barros MBA, Silva AG, Prates EJS, Machado ÍE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Azevedo LO, Pina MF, Werneck AO, Silva DRP. Distanciamento social, sentimento de tristeza e estilos de vida da população brasileira durante a pandemia de Covid-19. Saude Debate 2020; 44(4):177-190.. We should also mention the absence of regulatory policies for the control of ultra-processed foods and the lack of incentives for production and access to quality nutrition. Fruits and vegetables, for example, have a high cost, thus reducing their consumption, especially among the low-income population²⁶26 Malta DC, Gomes CS, Szwarcwald CL, Barros MBA, Silva AG, Prates EJS, Machado ÍE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Azevedo LO, Pina MF, Werneck AO, Silva DRP. Distanciamento social, sentimento de tristeza e estilos de vida da população brasileira durante a pandemia de Covid-19. Saude Debate 2020; 44(4):177-190.^,3737 Santos LPD, Schäfer AA, Meller FO, Harter J, Nunes BP, Silva ICMD, Pellegrini DDCP. Tendências e desigualdades na insegurança alimentar durante a pandemia de COVID-19: resultados de quatro inquéritos epidemiológicos seriados. Cad Saude Publica 2021; 37(5):e00268520.^-3838 Silva AGD, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26(4):1193-1206.. Moreover, the serious sanitary, social and political crisis in Brazil had a damaging impact on socioeconomic indicators, highlighting the inequalities which had already reached their maximum levels due to austerity measures and reductions in social policies which had been previously adopted for the country³⁹39 Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Colet; 24(12):4375-4384.

40 Oliveira TC, Abranches MV, Lana RM. Food (in)security in Brazil in the context of the SARS-CoV-2 pandemic. Cad Saude Publica 2020; 36(4):e00055220.^-4141 The Lancet. COVID-19: a new lens for non-communicable diseases. Lancet 2020; 396(10252):649..

There is evidence that, besides the worsening of overweight and obesity, there was also an increase in hypertension and diabetes during the COVID-19 pandemic over the short term, further exacerbating the scenario of NCD in Brazil. Arterial hypertension had remained stable up to 2019, when it started to increase significantly. Diabetes grew at a slower pace (0.181) per year, and accelerated in the two initial years of the pandemic to approximately four times the annual variation in comparison to the previous period. There is evidence that the crisis caused by the pandemic resulted in the worsening of NCD⁴²42 Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238):1678-1680.^,4343 Kohli P, Virani SS. Surfing the Waves of the COVID-19 Pandemic as a Cardiovascular Clinician. Circulation 2020; 142(2):98-100., as if it were a “fourth wave” of the pandemic, and its effects will remain for many years⁴⁴44 Bispo Júnior JP, Santos DBD. COVID-19 como sindemia: modelo teórico e fundamentos para a abordagem abrangente em saúde. Cad Saude Publica 2021; 37(10):e00119021.. The worsening of NCD was caused by the systemic effects of the after-effects of COVID-19, as well as by the changes in the population’s lifestyle, such as the reduction in access to preventive health services because of the interruption of the follow-up of patients in terms of primary and secondary health care, aggravating NCDs¹⁵15 Malta DC, Gomes CS, Silva AGD, Cardoso LSM, Barros MBA, Lima MG, Souza Junior PRB, Szwarcwald CL. Use of health services and adherence to social distancing by adults with Noncommunicable Diseases during the COVID-19 pandemic, Brazil, 2020. Cien Saude Colet 2021; 26(7):2833-2842.^,1616 Horta BL, Silveira MF, Barros AJD, Hartwig FP, Dias MS, Menezes AMB, Hallal PC. COVID-19 and outpatient care: a nationwide household survey. Cad Saude Publica 2022; 38(4):e00194121.^,4545 Ribeiro CM, Correa FM, Migowski A. Short-term effects of the COVID-19 pandemic on cancer screening, diagnosis and treatment procedures in Brazil: a descriptive study, 2019-2020. Epidemiol Serv Saude 2022; 31(1):e2021405.. Moreover, it has been discussed that the worsening of mental health with the increase in stress levels, combined with the economic damage resulting from COVID-19, may result in a “fifth wave” of the pandemic⁴⁴44 Bispo Júnior JP, Santos DBD. COVID-19 como sindemia: modelo teórico e fundamentos para a abordagem abrangente em saúde. Cad Saude Publica 2021; 37(10):e00119021..

Furthermore, the current study showed a decline in exams for the early detection of cancer in women. There was a reduction in mammograms, which had been on the rise, as well as in oncotic cytology exams, which had been stable before the pandemic. The decline in mammograms and cervical oncotic cytology can be explained by difficulties in access to health services and by a limited availability of these exams at private and public health facilities due to the pandemic⁴⁶46 World Health Organization (WHO). The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. Geneva: WHO; 2020.. The interruption or reduction in access to health services compromised the follow-up of patients, increasing morbimortality and avoidable disability¹⁵15 Malta DC, Gomes CS, Silva AGD, Cardoso LSM, Barros MBA, Lima MG, Souza Junior PRB, Szwarcwald CL. Use of health services and adherence to social distancing by adults with Noncommunicable Diseases during the COVID-19 pandemic, Brazil, 2020. Cien Saude Colet 2021; 26(7):2833-2842.^,1616 Horta BL, Silveira MF, Barros AJD, Hartwig FP, Dias MS, Menezes AMB, Hallal PC. COVID-19 and outpatient care: a nationwide household survey. Cad Saude Publica 2022; 38(4):e00194121.. Studies conducted by WHO identified that 75% of the responding countries reported interruptions in NCD prevention and treatment services⁴⁷47 Organização Mundial de Saúde (OMS). Serviços essenciais de saúde enfrentam interrupções contínuas durante pandemia de COVID-19 [Internet]. 2022. [acessado 2022 maio 28]. Disponível em: https://www.paho.org/pt/noticias/7-2-2022-servicos-essenciais-saude-enfrentam-interrupcoes-continuas-durante-pandemia-covid#:~:text=Interrup%C3%A7%C3%B5es%20cont%C3%ADnuas%20foram%20relatadas%20em,sa%C3%BAde%20durante%20a%20COVID%2D19
https://www.paho.org/pt/noticias/7-2-202... ^,4848 Pan American Health Organization (PAHO). Rapid assessment of service delivery for NCDs during the COVID-19 pandemic in the Americas [Internet]. 2020. [cited 2022 maio 28]. Available from: https://www.paho.org/en/documents/rapid-assessment-service-delivery-ncds-during-covid-19-pandemic-americas-4-june-2020
https://www.paho.org/en/documents/rapid-... . In the Americas, a study by the Pan-American Health Organization (PAHO) showed limited access to services related to NCDs in 64% of the countries, caused by cancellations of elective medical appointments (58%), the reallocation of professionals for the response to COVID-19 (50%), and the lack of attendance to health appointments (50%)⁴⁹49 Ramalho R, Adiukwu F, Gashi Bytyçi D, El Hayek S, Gonzalez-Diaz JM, Larnaout A, Orsolini L, Pereira-Sanchez V, Pinto da Costa M, Ransing R, Shalbafan M, Syarif Z, Grandinetti P. Alcohol and tobacco use during the COVID-19 pandemic. A call for local actions for global impact. Front Psychiatry 2021; 12:634254., often motivated by fear of contracting COVID-19, especially before the introduction of mass vaccination.

Although there is evidence of an increase in the consumption of cigarettes and alcohol beverages in Brazil during the first wave of COVID-19¹²12 Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado IE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Pina MF, Freitas MIF, Werneck AO, Silva DRPD, Azevedo LO, Gracie R. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saude 2020; 29(4):e2020407.^,1414 Malta DC, Gomes CS, Souza Júnior PRB, Szwarcwald CL, Barros MBA, Machado ÍE, Romero DE, Lima MG, Silva AGD, Prates EJS, Cardoso LSM, Damacena GN, Werneck AO, Silva DRPD, Azevedo LO. Factors associated with increased cigarette consumption in the Brazilian population during the COVID-19 pandemic. Cad Saude Publica 2021; 37(3):e00252220.^,2626 Malta DC, Gomes CS, Szwarcwald CL, Barros MBA, Silva AG, Prates EJS, Machado ÍE, Souza Júnior PRB, Romero DE, Lima MG, Damacena GN, Azevedo LO, Pina MF, Werneck AO, Silva DRP. Distanciamento social, sentimento de tristeza e estilos de vida da população brasileira durante a pandemia de Covid-19. Saude Debate 2020; 44(4):177-190., the present study did not identify changes in the prevalence of tobacco and alcoholic beverages consumption, except for a decrease in second-hand smoking in the workplace. Therefore, new studies are warranted, since they may contribute to the identification of changes in the prevalence of smoking and abusive alcoholic beverages consumption among Brazilian adults, considering that both habits are risk factors for worsening COVID-19 infections⁵⁰50 United Nations (UN). UN Sustainable Development Goals Goal 3: ensure healthy lives and promote well-being for all at all ages [Internet]. 2020. [cited 2022 maio 28]. Available from: http://www.un.org/sustainabledevelopment/health/
http://www.un.org/sustainabledevelopment... .

Some limitations must be taken into consideration. First, the fact that the indicators are self-reported and liable to information bias. Second, the representativeness is limited to Brazilian state capitals and with coverage connected to having a telephone landline, requiring post-stratification methodologies to minimize possible biases. Third, the period of data collection by VIGITEL, from 2021 to 2022 (September through February) was different from the period surveyed in 2019 (throughout the entire year), and may be related to bias due to seasonal influence on behaviors related to risk and protective factors. Moreover, the reduction in sample size in 2021 resulted in a reduction in terms of the precision of the estimates, and must therefore be confirmed by future editions of VIGITEL.

On the other hand, it is important to show that our findings allow us to describe a scenario of health behaviors among the Brazilian adult population during the period before and during the pandemic, which may serve as a baseline for future evaluations, and may support the fight against future post-pandemic challenges. Moreover, the results may support the monitoring of global commitments to fight against NCDs²⁴24 World Health Organization (WHO). Global Action Plan for the Prevention and Control of NCDs 2013-2020 [Internet]. 2013. [cited 2022 maio 28]. Available from: http://www.who.int/nmh/events/ncd_action_plan/en/
http://www.who.int/nmh/events/ncd_action... , especially those set forth in the 2030 Agenda⁵¹.

In conclusion, the sanitary crisis caused by COVID-19 resulted in the worsening of indicators for PA, obesity, overweight, and morbidity by NCDs, and showed a decline in cancer prevention exams by women in Brazil, thus accentuating the economic and social inequalities in the country.

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