ABSTRACT:

Objective:

To compare lifestyle changes during the COVID-19 pandemic according to the presence or absence of noncommunicable diseases (NCDs) in Brazilian adults.

Methods:

Cross-sectional study, using data from the ConVid survey, between April and May 2020. The following variables were evaluated: lifestyle and presence of one or more NCDs (diabetes, hypertension, respiratory disease, heart disease, and cancer). Sociodemographic characteristics were used as adjustment. Relative frequencies and confidence intervals (CI) of 95% of the explanatory variables were calculated before and during the pandemic. For the comparison of groups, with or without NCDs, crude and adjusted (PRadj) prevalence ratios were estimated by Poisson regression.

Results:

There was a reduction in physical activity (60% in those without NCDs and 58% in those with NCDs) and in vegetable consumption (10.8% in those without NCDs and 12.7% in those with NCDs). On the other hand, there was an increase in the time spent watching television and on screens of computer/tablet (302% and 43.5% in those without NCDs and 196.5% and 30.6% with NCDs, respectively); consumption of frozen meals (43.6% in those without NCDs and 53.7% with NCDs), snacks (42.3% without NCDs and 31.2% with NCDs), and chocolate (14.8% without NCDs). During the pandemic, patients with NCDs were less active (PRadj = 0.77; 95%CI 0.65 - 0.92), had greater habit of watching TV (PRadj = 1.16; 95%CI 1.08 - 1.26), and consumed less vegetables (PRadj = 0.88; 95%CI 0.81 - 0.96).

Conclusion:

It was evident that adults with NCDs had their lifestyles more altered during the COVID-19 pandemic.

Keywords:
Quarantine; Coronavirus; Lifestyle; Risk factors; Noncommunicable diseases; Brazil

INTRODUCTION

Globally, it is estimated that noncommunicable diseases (NCDs) are responsible for 41 million deaths (70% of all deaths) per year¹1. World Health Organization. Noncommunicable Diseases Progress Monitor 2020. Genebra: World Health Organization; 2020.. In Brazil, the high burden of NCDs is similar, corresponding to 76% of the causes of death²2. Malta DC, França E, Abreu DMX, Perillo RD, Salmen MC, Teixeira R, et al. Mortality due to non-communicable diseases in the Brazil, 1990 to 2015, according to estimates from the Global Burden of Disease study. São Paulo Med J 2017; 135(3): 213-21. https://doi.org/10.1590/1516-3180.2016.0330050117
https://doi.org/https://doi.org/10.1590/... . NCDs result in devastating consequences for individuals, families, and communities in addition to overloading healthcare systems¹1. World Health Organization. Noncommunicable Diseases Progress Monitor 2020. Genebra: World Health Organization; 2020.^,33. World Health Organization. World health statistics 2018: monitoring health for the SDGs, sustainable development goals. Genebra: World Health Organization ; 2019.^,44. Malta DC, Duncan BB, Schmidt MI, Teixeira R, Ribeiro ALP, Felisbino-Mendes MC, et al. Trends in mortality due to non-communicable diseases in the Brazilian adult population: national and subnational estimates and projections for 2030. Popul Health Metrics 2020; 18(Supl. 1): 16. https://doi.org/10.1186/s12963-020-00216-1
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Several national and global initiatives have been proposed for the prevention and control of NCDs. The United Nations has included goals for the reduction of NCDs and risk factors by 2030 in the Sustainable Development Goals (SDGs)⁵5. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2016 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://sustainabledevelopment.un.org/post2015/transformingourworld
https://sustainabledevelopment.un.org/po... . It should be noted that this commitment was already challenging and, considering the pandemic of the new coronavirus (Sars-CoV-2), such goal may not be achieved⁶6. World Health Organization. The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. Genebra: World Health Organization ; 2020., as the pandemic can affect lifestyles and compromise the health care of people with NCDs⁷7. The Lancet. COVID-19: a new lens for non-communicable diseases. Lancet 2020; 396(10252): 649. https://doi.org/10.1016/S0140-6736(20)31856-0
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NCDs are the main comorbidities of patients with COVID-19⁷7. The Lancet. COVID-19: a new lens for non-communicable diseases. Lancet 2020; 396(10252): 649. https://doi.org/10.1016/S0140-6736(20)31856-0
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https://doi.org/https://doi.org/10.1016%... , being responsible for the worsening of the clinical condition and for the increase in hospital stay and mortality rates¹⁰10. Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, et al. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238): 1678-80. https://doi.org/10.1016/S0140-6736(20)31067-9
https://doi.org/https://doi.org/10.1016/... ^,1111. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA 2020; 323(20): 2052-9. https://doi.org/10.1001%2Fjama.2020.6775
https://doi.org/https://doi.org/10.1001%... . Furthermore, social distancing measures have a potential impact on the health and quality of life of people with NCDs⁶6. World Health Organization. The impact of the COVID-19 pandemic on noncommunicable disease resources and services: results of a rapid assessment. Genebra: World Health Organization ; 2020., although they are essential to reduce the spread of the virus¹²12. Nussbaumer-Streit B, Mayr V, Dobrescu AI, Chapman A, Persad E, Klerings I, et al. Quarantine alone or in combination with other public health measures to control COVID‐19: a rapid review. Cochrane Database of Syst Rev 2020; (4): CD013574. https://doi.org/10.1002/14651858.cd013574
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Studies carried out in Brazil¹⁴14. Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado ÍE, Souza Júnior PRB, et al. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saúde 2020; 29(4): e2020407. https://doi.org/10.1590/s1679-49742020000400026
https://doi.org/https://doi.org/10.1590/... and in other countries¹⁵15. van Zyl-Smit RN, Richards G, Leone FT. Tobacco smoking and COVID-19 infection. Lancet Respir Med 2020; 8(7): 664-5. https://doi.org/10.1016/S2213-2600(20)30239-3
https://doi.org/https://doi.org/10.1016/... ^,1616. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, Anxiety and Stress during COVID-19: Associations with Changes in Physical Activity, Sleep, Tobacco and Alcohol Use in Australian Adults. Int J Environ Res Public Health 2020; 17(11): 4065. https://doi.org/10.3390%2Fijerph17114065
https://doi.org/https://doi.org/10.3390%... ^,1717. García-Álvarez L, Fuente-Tomás L, Sáiz PA, García-Portilla MP, Bobes J. Will changes in alcohol and tobacco use be seen during the COVID-19 lockdown? Adicciones 2020; 32(2): 85-9. https://doi.org/10.20882/adicciones.1546
https://doi.org/https://doi.org/10.20882... ^,1818. Clay JM, Parker MO. Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis?. Lancet Public Health 2020; 5(5): e259. https://doi.org/10.1016/S2468-2667(20)30088-8
https://doi.org/https://doi.org/10.1016/... observed changes in adults’ lifestyles as a result of the COVID-19 pandemic such as increased consumption of alcohol and tobacco¹⁷17. García-Álvarez L, Fuente-Tomás L, Sáiz PA, García-Portilla MP, Bobes J. Will changes in alcohol and tobacco use be seen during the COVID-19 lockdown? Adicciones 2020; 32(2): 85-9. https://doi.org/10.20882/adicciones.1546
https://doi.org/https://doi.org/10.20882... and ultra-processed foods¹⁴14. Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado ÍE, Souza Júnior PRB, et al. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saúde 2020; 29(4): e2020407. https://doi.org/10.1590/s1679-49742020000400026
https://doi.org/https://doi.org/10.1590/... and sedentary behavior¹⁴14. Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado ÍE, Souza Júnior PRB, et al. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saúde 2020; 29(4): e2020407. https://doi.org/10.1590/s1679-49742020000400026
https://doi.org/https://doi.org/10.1590/... ^,1616. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, Anxiety and Stress during COVID-19: Associations with Changes in Physical Activity, Sleep, Tobacco and Alcohol Use in Australian Adults. Int J Environ Res Public Health 2020; 17(11): 4065. https://doi.org/10.3390%2Fijerph17114065
https://doi.org/https://doi.org/10.3390%... . Anxiogenic and stressful situations, such as job loss, unsafe work situations, and reduced income, can worsen health behaviors such as increased consumption of tobacco and alcohol¹⁵15. van Zyl-Smit RN, Richards G, Leone FT. Tobacco smoking and COVID-19 infection. Lancet Respir Med 2020; 8(7): 664-5. https://doi.org/10.1016/S2213-2600(20)30239-3
https://doi.org/https://doi.org/10.1016/... ^,1616. Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, Anxiety and Stress during COVID-19: Associations with Changes in Physical Activity, Sleep, Tobacco and Alcohol Use in Australian Adults. Int J Environ Res Public Health 2020; 17(11): 4065. https://doi.org/10.3390%2Fijerph17114065
https://doi.org/https://doi.org/10.3390%... ^,1717. García-Álvarez L, Fuente-Tomás L, Sáiz PA, García-Portilla MP, Bobes J. Will changes in alcohol and tobacco use be seen during the COVID-19 lockdown? Adicciones 2020; 32(2): 85-9. https://doi.org/10.20882/adicciones.1546
https://doi.org/https://doi.org/10.20882... ^,1818. Clay JM, Parker MO. Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis?. Lancet Public Health 2020; 5(5): e259. https://doi.org/10.1016/S2468-2667(20)30088-8
https://doi.org/https://doi.org/10.1016/... .

Within the context of NCDs, in view of the high burden and transcendence of chronic conditions, the scenario imposed by the COVID-19 pandemic reinforces the importance in prioritizing a comprehensive approach to the population’s health, of disease surveillance and care actions during and after the pandemic¹⁸18. Clay JM, Parker MO. Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis?. Lancet Public Health 2020; 5(5): e259. https://doi.org/10.1016/S2468-2667(20)30088-8
https://doi.org/https://doi.org/10.1016/... . The health crisis caused changes in the forms of care in the health system¹⁹19. Pan American Health Organization. Diretora da OPAS afirma que luta contra a pandemia de COVID-19 deve incluir tratamento de doenças crônicas [Internet]. Washington, D.C.: Pan American Health Organization; 2020 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6181:diretora-da-opas-afirma-que-luta-contra-a-pandemia-de-covid-19-deve-incluir-tratamento-de-doencas-cronicas&Itemid=839
https://www.paho.org/bra/index.php?optio... , which culminated in lack of medication, difficulties in accessing services¹⁹19. Pan American Health Organization. Diretora da OPAS afirma que luta contra a pandemia de COVID-19 deve incluir tratamento de doenças crônicas [Internet]. Washington, D.C.: Pan American Health Organization; 2020 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6181:diretora-da-opas-afirma-que-luta-contra-a-pandemia-de-covid-19-deve-incluir-tratamento-de-doencas-cronicas&Itemid=839
https://www.paho.org/bra/index.php?optio... ^,2020. Barone MTU, Harnik SB, Luca PV, Lima BLS, Wieselberg RJP, Ngongo B, et al. The impact of COVID-19 on people with diabetes in Brazil. Diabetes Res Clin Pract 2020; 166: 108304. https://doi.org/10.1016/j.diabres.2020.108304
https://doi.org/https://doi.org/10.1016/... ^,2121. Barone MTU, Villarroel D, Luca PV, Harnik SB, Lima BLS, Wieselberg RJP, et al. COVID-19 impact on people with diabetes in South and Central America (SACA region). Diabetes Res Clin Pract 2020; 166: 108301. https://doi.org/10.1016/j.diabres.2020.108301
https://doi.org/https://doi.org/10.1016/... and increase in risk factors for NCDs¹⁴14. Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado ÍE, Souza Júnior PRB, et al. The COVID-19 Pandemic and changes in adult Brazilian lifestyles: a cross-sectional study, 2020. Epidemiol Serv Saúde 2020; 29(4): e2020407. https://doi.org/10.1590/s1679-49742020000400026
https://doi.org/https://doi.org/10.1590/... .

Therefore, considering the need to monitor the health status and behaviors of patients with NCDs, especially in the context of the COVID-19 pandemic, it is relevant to investigate whether changes in lifestyle have occurred among this population, as there are scarce studies addressing this topic in the Brazilian context. Thus, this investigation aimed to compare lifestyle changes in Brazilian adults during the COVID-19 pandemic, according to the presence or absence of NCDs.

METHODS

This is a cross-sectional study, which used data from ConVid - Pesquisa de Comportamentos (Behavior Survey), a virtual health survey carried out during the COVID-19 pandemic to assess changes that have occurred in the lives of Brazilian adults²²22. Fundação Oswaldo Cruz. Instituto de Comunicação e Informação Científica e Tecnológica em Saúde. ConVid - Pesquisa de Comportamentos [Internet]. Rio de Janeiro: Fundação Oswaldo Cruz; 2020 [acessado em 10 dez. 2020]. Disponível em: Disponível em: https://convid.fiocruz.br/index.php?pag=questionario_adulto
https://convid.fiocruz.br/index.php?pag=... . The questionnaire²²22. Fundação Oswaldo Cruz. Instituto de Comunicação e Informação Científica e Tecnológica em Saúde. ConVid - Pesquisa de Comportamentos [Internet]. Rio de Janeiro: Fundação Oswaldo Cruz; 2020 [acessado em 10 dez. 2020]. Disponível em: Disponível em: https://convid.fiocruz.br/index.php?pag=questionario_adulto
https://convid.fiocruz.br/index.php?pag=... addressed sociodemographic characteristics, adherence to measures of social restriction, economic losses, chronic diseases, changes in lifestyles and mood, among other topics.

Data collection was carried out between April and May 2020. Participants were invited to participate in the research through a chain sampling process²³23. Costa BRL. Bola de neve virtual: o uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interdiscip Gestão Social [Internet] 2018 [acessado em 11 out. 2020]; 7(1): 15-37. Disponível em: Disponível em: https://portalseer.ufba.br/index.php/rigs/article/view/24649
https://portalseer.ufba.br/index.php/rig... . In the first stage, the involved researchers chose a total of 200 other researchers from different states in Brazil and, additionally, each one of them selected 20 people from their respective social networks. People chosen in the first stage invited at least 12 people from their own social networks, following the stratification by sex, age group (18-39; 40-59; ≥ 60 years) and education level (some high school or less; high school or more). Each guest was asked to invite at least three other people from their social networks. With this process, the final sample consisted of 45,160 individuals. Post-stratification weights were used based on data from the National Household Sample Survey (PNAD) - 2019²⁴24. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Contínua - PNAD Contínua [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2019 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://www.ibge.gov.br/estatisticas/sociais/trabalho/9171-pesquisa-nacional-por-amostra-de-domicilios-continua-mensal.html?=&t=o-que-e
https://www.ibge.gov.br/estatisticas/soc... ^,2525. Silva PLN. Calibration estimation. When and why, how much and how [Internet]. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística ; 2004 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://biblioteca.ibge.gov.br/bibliotecacatalogo?id=281040&view=detalhes
https://biblioteca.ibge.gov.br/bibliotec... to obtain the same distribution of the Brazilian population per Federation Unit, sex, age group, ethnicity/skin color, and education level.

The study is a partnership between researchers from Fundação Oswaldo Cruz, Universidade Federal de Minas Gerais, and Universidade Estadual de Campinas. Participants filled out the informed consent form and all responses were anonymous. The research was approved by the National Research Ethics Committee (opinion number: 3.980.277).

In this study, the variable “having one or more NCDs” was assessed by the question: “Has any doctor ever diagnosed you with any of these diseases (diabetes, hypertension, respiratory disease, heart disease, cancer)?”

The following variables, related to lifestyle before and during the pandemic, were analyzed.

Initially, a descriptive analysis of the lifestyle variables was performed before and during the pandemic by calculating relative frequencies and 95% confidence intervals (95%CI), followed by the calculation of the percentage of behavioral change during the pandemic. Statistically significant differences were identified by the non-overlapping of the 95%CI of the prevalence values in question.

The two population groups (those with one or more NCDs and those without NCDs) were also compared in relation to lifestyles during the pandemic by calculating the prevalence and the crude and adjusted prevalence ratio (PR) by sex (men and women), age group (18 to 39; 40 to 59; ≥ 60 years), and education level (elementary school or less; high school; higher education or more), and respective 95%CI.

The Poisson regression with robust variance was applied. The Software for Statistics and Data Science (Stata) version 14 was used to process the information, using the survey module, which considers the post-stratification weights.

RESULTS

A total of 45,161 individuals were evaluated, being: 53.6% (95%CI 52 - 55) women; 45.7% (95%CI 44.3 - 47.1) aged between 18 and 39 years; and 72.4% (95%CI 71.3 - 73.5) with high school education level (data not shown).

The prevalence of hypertension, diabetes, respiratory disease, heart disease, and cancer was 19.3% (95%CI 18.2 - 20.4); 7.2% (95%CI 6.5 - 8); 11.3% (95%CI 10.4 - 12.2); 4.3% (95%CI 3.7 - 5); and 2.4 (95%CI 2.1 - 2.9), respectively (Figure 1A). The prevalence of one or more NCDs was 33.9% (95%CI 32.5 - 35.3), being higher with increasing age (38.3%; 95%CI 36 - 40.6 between 40 and 59 years; and 58.6%; 95%CI 55.3 - 61.9 for those aged 60 years and older) and among those with lower education level (39.3%; 95%CI 34.4 - 44.5), with no differences according to sex (Figure 1B).

Table 1 shows the prevalence and the percentage (%) of changes in the PA and food consumption indicators before and during the pandemic according to the presence of NCDs. There was a 60% reduction in PA in groups without NCDs, and 58% in those with NCDs. The increase in time spent watching television and using computer/tablet was 302 and 43.5%, respectively, in the group without NCDs; and 196.5 and 30.6% in those with NCDs.

Regarding the consumption of healthy foods, in the population without NCDs, the consumption of vegetables decreased by 10.8% and that of fruits by 3.5%; and, in those with NCDs, it decreased by 12.7% and increased by 37.4%, respectively. It is noteworthy that the reduction in fruit consumption was not significant in both groups. Regarding the consumption of unhealthy foods, in the population without NCDs, the consumption of frozen meals increased 43.6%; of snacks, 42.3%; of chocolate, 14.8%; and of processed meats, 0.72%. There were statistically significant differences in all foods, except processed meats. For people with NCDs, the increase in the consumption of frozen meals, snacks, and chocolates was 53.7, 31.2, and 12.5%, and the reduction was 6% for processed meats; however, the change was not significant for consumption of processed meats and chocolates (Table 1).

Table 2 shows the prevalence and crude and adjusted (PRadj) prevalence ratio of PA, sedentary behaviors, and eating habits during the pandemic, among the population with and without one or more NCDs. It was verified that, during the pandemic, people with one or more NCDs were less active (PRadj = 0.77; 95%CI 0.65 - 0.92) and had greater habit of watching television for 4 hours or more/day (PRadj = 1.16; 95%CI 1.08 - 1.26). The time spent using the computer/tablet did not differ between groups (PRadj = 0.96; 95%CI 0.90 - 1).

As for the consumption of healthy and unhealthy foods, it was observed that, during the pandemic, people with NCDs reported inadequate intake of vegetables (PRadj = 0.88; 95%CI 0.81 - 0.96). In addition, people with NCDs had a lower prevalence for the consumption of unhealthy foods, but there were no significant differences after adjusting for age, education level, and sex (Table 2).

In Table 2, when analyzing the increase in consumption of alcoholic beverages and cigarettes during the pandemic according to the diagnosis of NCDs, it is evident that people with at least one NCD had a lower increase in the consumption of alcoholic beverages (15.1%; 95%CI 13.3 - 17.2) compared with those without NCDs (18.9%; 95%CI 17.3 - 20.6). Nevertheless, when the analyses were adjusted, there was no difference between groups. The increase in cigarette consumption was 34.8% (95%CI 28.9 - 41.2) among people with NCDs and 33.7% (95%CI 29.1 - 38.6) among those who did not report NCDs, but without statistically significant differences between groups (Table 2).

DISCUSSION

The study indicated there were changes in the lifestyles of the population with and without NCDs after the pandemic such as reduced PA and increased sedentary time, reduced consumption of vegetables and increased consumption of ultra-processed foods - such as frozen meals and snacks. When analyzing the prevalence of lifestyles during the pandemic between the two groups, it was observed that people with NCDs were less active, had inadequate consumption of vegetables, and spent more sedentary time watching television. Regarding the consumption of tobacco, alcohol, fruits, and unhealthy foods, there was no difference between groups.

The National Survey of Health (PNS)³⁰30. Malta DC, Stopa S, Szwarcwald CL, Gomes NL, Silva Júnior JB, Reis AAC. Surveillance and monitoring of major chronic diseases in Brazil - National Health Survey, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 3-16. https://doi.org/10.1590/1980-5497201500060002
https://doi.org/https://doi.org/10.1590/... found similar self-reported prevalence of arterial hypertension (21.4%), diabetes (6.2%), asthma (4.4%), heart disease (4.8%), and cancer (1.8%). The prevalence of one or more NCDs was higher (45.1%); however, the list of NCDs evaluated was more extensive, containing thirteen. In addition, higher prevalence of NCDs was observed with increasing age and low education level³⁰30. Malta DC, Stopa S, Szwarcwald CL, Gomes NL, Silva Júnior JB, Reis AAC. Surveillance and monitoring of major chronic diseases in Brazil - National Health Survey, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 3-16. https://doi.org/10.1590/1980-5497201500060002
https://doi.org/https://doi.org/10.1590/... . Chronic conditions are known to affect social groups with greater deprivation and more vulnerable to social determinants³¹31. Abrams EM, Szefler SJ. COVID-19 and the impact of social determinants of health. Lancet Respir Med 2020; 8(7): 659-61. https://doi.org/10.1016/S2213-2600(20)30234-4
https://doi.org/https://doi.org/10.1016/... . Consequently, including NCDs in a scenario of social and economic inequalities individually exacerbates the adverse effects of each disease, as COVID-19, being considered a syndemic, has systemic effects and increases inequities³²32. Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396(10255): 874. https://doi.org/10.1016/S0140-6736(20)32000-6
https://doi.org/https://doi.org/10.1016/... . Furthermore, when addressing COVID-19, attention should also be given to NCDs and their risk factors such as hypertension, obesity, diabetes, chronic cardiovascular and respiratory diseases, and cancer³²32. Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396(10255): 874. https://doi.org/10.1016/S0140-6736(20)32000-6
https://doi.org/https://doi.org/10.1016/... .

The worsening of lifestyles during the pandemic observed in this study was also identified in other surveys²⁰20. Barone MTU, Harnik SB, Luca PV, Lima BLS, Wieselberg RJP, Ngongo B, et al. The impact of COVID-19 on people with diabetes in Brazil. Diabetes Res Clin Pract 2020; 166: 108304. https://doi.org/10.1016/j.diabres.2020.108304
https://doi.org/https://doi.org/10.1016/... ^,2121. Barone MTU, Villarroel D, Luca PV, Harnik SB, Lima BLS, Wieselberg RJP, et al. COVID-19 impact on people with diabetes in South and Central America (SACA region). Diabetes Res Clin Pract 2020; 166: 108301. https://doi.org/10.1016/j.diabres.2020.108301
https://doi.org/https://doi.org/10.1016/... ^,3333. Rehm J, Kilian C, Ferreira-Borges C, Jernigan D, Monteiro M, Parry CDH, et al. Alcohol use in times of the COVID 19: Implications for monitoring and policy. Drug Alcohol Rev 2020; 39(4): 301-4. https://doi.org/10.1111/dar.13074
https://doi.org/https://doi.org/10.1111/... ^,3434. Di Renzo L, Gualtieri P, Pivari F, Soldati L, Attinà A, Cinelli G, et al. Eating habits and lifestyle changes during COVID-19 lockdown: an Italian survey. J Transl Med 2020; 18(1): 229. https://doi.org/10.1186/s12967-020-02399-5
https://doi.org/https://doi.org/10.1186/... . Such changes may impact the quality of life and health of the population, resulting in an epidemic of preventable deaths among people affected with NCDs¹⁹19. Pan American Health Organization. Diretora da OPAS afirma que luta contra a pandemia de COVID-19 deve incluir tratamento de doenças crônicas [Internet]. Washington, D.C.: Pan American Health Organization; 2020 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6181:diretora-da-opas-afirma-que-luta-contra-a-pandemia-de-covid-19-deve-incluir-tratamento-de-doencas-cronicas&Itemid=839
https://www.paho.org/bra/index.php?optio... . Hence, it is essential to implement a health promotion agenda³⁵35. Van den Broucke S. Why health promotion matters to the COVID-19 pandemic, and vice versa. Health Promot Int 2020; 35(2): 181-6. https://doi.org/10.1093/heapro/daaa042
https://doi.org/https://doi.org/10.1093/... and to strengthen primary health care in facing the impacts of the pandemic and in social distancing³⁶36. Daumas RP, Silva GA, Tasca R, Leite IC, Brasil P, Greco DB, et al. The role of primary care in the Brazilian healthcare system: limits and possibilities for fighting COVID-19. Cad Saúde Pública 2020; 36(6): e00104120. https://doi.org/10.1590/0102-311X00104120
https://doi.org/https://doi.org/10.1590/... , with emphasis on maintaining comprehensive follow-up actions for NCD patients, using telemonitoring and telehealth³⁷37. Caetano R, Silva AB, Guedes ACCM, Paiva CCN, Ribeiro GR, Santos DL, et al. Challenges and opportunities for telehealth during the COVID-19 pandemic: ideas on spaces and initiatives in the Brazilian context. Cad Saúde Pública 2020; 36(5): e00088920. https://doi.org/10.1590/0102-311x00088920
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This study identified that people with one or more NCDs had irregular practice of PA during the pandemic. It is noteworthy that PA is essential for the maintenance and promotion of health and quality of life³⁸38. Ferreira MJ, Irigoyen MC, Consolim-Colombo F, Saraiva JFK, Angelis K. Physically Active Lifestyle as an Approach to Confronting COVID-19. Arq Bras Cardiol 2020; 114(4): 601-2. https://doi.org/10.36660/abc.20200235
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https://doi.org/https://doi.org/10.1590/... , and the recommendation is to maintain an active life⁴⁰40. Sallis JF, Adlakha D, Oyeyemi A, Salvo D. An international physical activity and public health research agenda to inform coronavirus disease-2019 policies and practices. J Sport Health Sci 2020; 9(4): 328-34. https://doi.org/10.1016/j.jshs.2020.05.005
https://doi.org/https://doi.org/10.1016/... . The World Health Organization⁴¹41. Pan American Health Organization. OPAS incentiva comunidades a apoiarem as pessoas no enfrentamento da pandemia de COVID-19 [Internet]. Washington, D.C.: Pan American Health Organization ; 2020 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://www.paho.org/bra/index.php?option=com_content&view=article&id=6278:opas-incentiva-comunidades-a-apoiarem-as-pessoas-no-enfrentamento-da-pandemia-de-covid-19&Itemid=839
https://www.paho.org/bra/index.php?optio... encourages health professionals and managers to seek strategies to maintain active and healthy habits during the period of social distancing, especially for population groups considered at risk and, therefore, more vulnerable such as older adults and the population affected with NCDs⁹9. Azarpazhooh MR, Morovatdar N, Avan A, Phan TG, Divani AA, Yassi N, et al. COVID-19 Pandemic and Burden of Non-Communicable Diseases: An Ecological Study on Data of 185 Countries. J Stroke Cerebrovasc Dis 2020; 29(9): 105089. https://doi.org/10.1016%2Fj.jstrokecerebrovasdis.2020.105089
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The results indicate that the population with NCDs spent more time watching television during the pandemic. This fact is worrying, considering that a sedentary behavior has a detrimental effect on health, which can contribute to the onset and worsening of NCDs in addition to rapidly deteriorating cardiovascular health and causing premature deaths⁴³43. 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): H1441‐6. https://doi.org/10.1152/ajpheart.00268.2020
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It has been discussed that social distancing implies changes in eating habits of the population in general, with reduced consumption of fruits and vegetables and increased consumption of frozen meals, snacks, and sweets. In Italy, 34.4% of individuals had their diet worsened during the pandemic³⁴34. Di Renzo L, Gualtieri P, Pivari F, Soldati L, Attinà A, Cinelli G, et al. Eating habits and lifestyle changes during COVID-19 lockdown: an Italian survey. J Transl Med 2020; 18(1): 229. https://doi.org/10.1186/s12967-020-02399-5
https://doi.org/https://doi.org/10.1186/... . In the United States of America, there was an increase in the volume of purchases in supermarkets, with a stock of ultra-processed foods with high energy density such as chips, popcorn, chocolate, and ice cream⁴⁵45. Bhutani S, Cooper JA. COVID-19 related home confinement in adults: weight gain risks and opportunities. Obesity (Silver Spring) 2020; 28(9): 1576-7. https://doi.org/10.1002/oby.22904
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People with NCDs showed lower consumption of vegetables and similar consumption of ultra-processed foods. These findings can be explained by the difficulty in supplying and replacing fresh and healthy food as well as by the ease of purchase and storage of ultra-processed products⁴⁷47. Silva Filho OJ, Gomes Júnior NN. The future at the kitchen table: COVID-19 and the food supply. Cad Saúde Pública 2020; 36(5): e00095220. https://doi.org/10.1590/0102-311X00095220
https://doi.org/https://doi.org/10.1590/... . A study carried out among diabetic patients in Brazil identified an important adherence to social distancing due to the perceived increased risk for COVID-19; however, this population reduced the use of healthcare services and there was a report of difficulty in purchasing foods²⁰20. Barone MTU, Harnik SB, Luca PV, Lima BLS, Wieselberg RJP, Ngongo B, et al. The impact of COVID-19 on people with diabetes in Brazil. Diabetes Res Clin Pract 2020; 166: 108304. https://doi.org/10.1016/j.diabres.2020.108304
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The increase in alcohol consumption during the COVID-19 pandemic, identified in this study, has also occurred in other contexts and has been attributed to psychological distress and financial difficulties³³33. Rehm J, Kilian C, Ferreira-Borges C, Jernigan D, Monteiro M, Parry CDH, et al. Alcohol use in times of the COVID 19: Implications for monitoring and policy. Drug Alcohol Rev 2020; 39(4): 301-4. https://doi.org/10.1111/dar.13074
https://doi.org/https://doi.org/10.1111/... , in addition to greater physical availability and accessibility³³33. Rehm J, Kilian C, Ferreira-Borges C, Jernigan D, Monteiro M, Parry CDH, et al. Alcohol use in times of the COVID 19: Implications for monitoring and policy. Drug Alcohol Rev 2020; 39(4): 301-4. https://doi.org/10.1111/dar.13074
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https://doi.org/https://doi.org/10.1111/... . Although there were no differences between the population with and without NCDs after adjustment, the risk of this finding is emphasized, as alcohol can potentially worsen the clinical course of COVID-19 infection⁴⁹49. Szabo G, Saha B. Alcohol’s Effect on Host Defense. Alcohol Res [Internet] 2015 [acessado em 11 out. 2020]; 37(2): 159-70. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590613/pdf/arcr-37-2-159.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... , increasing the susceptibility to viral infection and aggravating the situation of people with NCDs⁵⁰50. Sidor A, Rzymski P. Dietary Choices and Habits During COVID-19 Lockdown: Experience From Poland. Nutrients 2020; 12(6): 1657. https://doi.org/10.3390/nu12061657
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Tobacco consumption increased in more than a third of smokers, with or without NCDs. Tobacco is an important risk factor for NCDs, both for cancer and respiratory diseases, being contraindicated in any situation⁵¹51. Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FM, Prates EJS, et al. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45(5): e20180384. https://doi.org/10.1590/1806-3713/e20180384
https://doi.org/https://doi.org/10.1590/... . Still, there is evidence that smoking can aggravate the course of COVID-19⁵²52. Olds JL, Kabbani N. Is Nicotine Exposure Linked to Cardiopulmonary Vulnerability to COVID-19 in the General Population? FEBS J 2020; 287(17): 3651-5. https://doi.org/10.1111/febs.15303
https://doi.org/https://doi.org/10.1111/... ^,5353. Leung JM, Yang CX, Tam A, Shaipanich T, Hackett TL, Singhera GK, et al. ACE-2 Expression in the Small Airway Epithelia of Smokers and COPD Patients: Implications for COVID-19. Eur Respir J 2020; 55(5): 2000688. https://doi.org/10.1183/13993003.00688-2020
https://doi.org/https://doi.org/10.1183/... . Among factors involved in the relation between smoking and this viral infection are the increase in angiotensin-converting enzyme 2 (ECA2) among smokers⁵²52. Olds JL, Kabbani N. Is Nicotine Exposure Linked to Cardiopulmonary Vulnerability to COVID-19 in the General Population? FEBS J 2020; 287(17): 3651-5. https://doi.org/10.1111/febs.15303
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https://doi.org/https://doi.org/10.1183/... , the increase in viral contamination by taking the cigarette to the mouth⁵⁴54. Silva ALO, Moreira JC, Martins SR. COVID-19 and smoking: a high-risk association. Cad Saúde Pública 2020; 36(5): e00072020., and the worsening in cardiorespiratory performance⁵⁵55. Cattaruzza MS, Zagà V, Gallus S, D'Argenio P, Gorini G. Tobacco smoking and COVID-19 pandemic: old and new issues. A summary of the evidence from the scientific literature. Acta Biomed 2020; 91(2): 106-12. https://doi.org/10.23750/abm.v91i2.9698
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In South Africa, in order to tackle smoking during the COVID-19 pandemic, the sale of tobacco and nicotine products has been banned, which should be understood as a double attempt to protect the population against COVID-19 and the avoidable burden of tobacco⁵⁶56. Egbe CO, Ngobese SP. COVID-19 lockdown and the tobacco product ban in South Africa. Tob Induc Dis 2020; 18: 39. https://doi.org/10.18332/tid/120938
https://doi.org/https://doi.org/10.18332... . Therefore, advancing new regulatory measures⁵⁷57. World Health Organization. Tackling NCDs: “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. Genebra: World Health Organization ; 2017. and monitoring the actions of tobacco industries⁵⁸58. Zatoński M, Gilmore AB, Hird TR. The two faces of the tobacco industry during the COVID-19 pandemic [Internet]. Tobacco Control 2020 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://blogs.bmj.com/tc/2020/05/10/the-two-faces-of-the-tobacco-industry-during-the-covid-19-pandemic/
https://blogs.bmj.com/tc/2020/05/10/the-... should be a priority in government agendas, especially during pandemic periods, in order to save lives⁵⁸58. Zatoński M, Gilmore AB, Hird TR. The two faces of the tobacco industry during the COVID-19 pandemic [Internet]. Tobacco Control 2020 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://blogs.bmj.com/tc/2020/05/10/the-two-faces-of-the-tobacco-industry-during-the-covid-19-pandemic/
https://blogs.bmj.com/tc/2020/05/10/the-... .

It should be noted that the study showed a worsening of lifestyles, with these changes being even more intense in the adult population with NCDs. Thus, a scenario of worsened indicators can be predicted, including increased mortality from NCDs, which may compromise the achievement of global goals such as reducing premature mortality by 30% by 2030⁵5. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development [Internet]. 2016 [acessado em 11 out. 2020]. Disponível em: Disponível em: https://sustainabledevelopment.un.org/post2015/transformingourworld
https://sustainabledevelopment.un.org/po... .

In this context, it is worth highlighting the contemporaneity of intersectoral policies for the prevention and control of NCDs in response to COVID-19. Prevention measures concerning NCDs should not be interrupted. Healthcare services, especially primary health care, must adapt to this new reality in order to support and manage the increase in risks and to continue providing health care for NCDs patients. Professionals in the field must be involved in planning strategies to respond to COVID-19, in such a way they can guarantee the right to health. Nevertheless, specific recommendations should be nationally and locally made available for patients with NCDs, their families, and their caregivers³²32. Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020; 396(10255): 874. https://doi.org/10.1016/S0140-6736(20)32000-6
https://doi.org/https://doi.org/10.1016/... . Furthermore, the COVID-19 pandemic and the NCD epidemic show the urgency in advancing stricter regulatory measures for tobacco, alcohol, and unhealthy food, promoting PA, and strengthening health systems during and after the pandemic¹1. World Health Organization. Noncommunicable Diseases Progress Monitor 2020. Genebra: World Health Organization; 2020..

Among the limitations of the study, it is pointed out the fact that data were collected through the Web, which may not reach all population strata, considering that not everyone has access to this means of communication, which may lead to under- or overestimation of proportion of indicators. This limitation was minimized by sample calibration by applying post-stratification weights. Another issue refers to the fact that the questions are self-reported, and may be subject to memory bias. The fact that data collection took place at the beginning of the pandemic (3^rd month) may be subject to situational changes throughout the temporal evolution of the pandemic.

All in all, our findings suggest that adults with NCDs had their lifestyles more altered due to reduced PA, increased sedentary lifestyle, reduced consumption of healthy foods, and increased consumption of ultra-processed foods. Within this context, it is imperative to adopt public policies that foment health promotion actions as well as regulatory measures for the protection and prevention of NCDs and the expansion of primary health care for patients with NCDs. If urgent measures are not taken, there is a risk of not achieving the goals of Agenda 2030 - SDG concerning the reduction of NCDs.

ACKNOWLEDGEMENTS

Malta DC, Barros MBA, and Szwarcwald CL would like to thank the National Council for Scientific and Technological Development (CNPq), which financed the research productivity grant. Prates EJS would like to thank the National Health Fund of the Brazilian Ministry of Health for the research grant. Sá ACMGN would like to thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for the doctoral scholarship.

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