Aggregation of risk indicators to cardiometabolic and musculoskeletal health in Brazilian adolescents in the periods 2008/09 and 2013/14 夽,夽夽

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www.jped.com.br

ORIGINAL ARTICLE

Aggregation of risk indicators to cardiometabolic and musculoskeletal health in Brazilian adolescents in the periods 2008/09 and 2013/14 ^夽,夽夽

Anelise R. Gaya

^a^,^b^,∗

, Arieli F. Dias

^b

, Vanilson B. Lemes

^b^,^c

,

Juliana Correa Gonc ¸alves

^b

, Priscila A. Marques

^b

, Gabriela Guedes

^b

, Caroline Brand

^b^,^d

, Adroaldo C.A. Gaya

^a^,^b

aUniversidadedoPorto,Porto,Portugal

bUniversidadeFederaldoRioGrandedoSul(UFRGS),PortoAlegre,RS,Brazil

cCentroUniversitárioLeonardodaVinci(UNIASSELVI),Indaial,SC,Brazil

dUniversidadedeSantaCruzdoSul(UNISC),SantaCruzdoSul,RS,Brazil

Received15December2016;accepted22March2017 Availableonline23August2017

KEYWORDS Health;

Physicalﬁtness;

Obesity

Abstract

Objective: Toassesstheoccurrenceofanaggregaterisktocardiometabolicandmusculoskele- talhealthofBrazilianadolescentsintheperiod2008/09and2013/14andtoidentifywhether therearedifferencesinriskbetweenthegendersandintheseperiods.

Methods: This was a trend epidemiological study with a quantitative approach, consisting of a voluntary sample of adolescents from 16 Brazilian states. Data were extracted from thedatabaseofBrazilSportsProject(ProjetoEsporteBrasil).Health-relatedphysicalfitness was evaluated basedonbody massindex,cardiorespiratory fitness,flexibility, andabdomi- nalstrength/resistance.Descriptiveanalysis,chi-squaredtest,andPoissonlogregressionwere usedforthestatisticaltreatment.

夽 Pleasecitethisarticleas:GayaAR,DiasAF,LemesVB,Gonc¸alvesJC,MarquesPA,GuedesG,etal.Aggregationofriskindicatorsto cardiometabolicandmusculoskeletalhealthinBrazilianadolescentsintheperiods2008/09and2013/14.JPediatr(RioJ).2018;94:177---183.

夽夽StudycarriedoutatUniversidadeFederal doRioGrandedoSul(UFRGS),EscolaSuperiordeEducac¸ãoFísica,FisioterapiaeDanc¸a (ESEFID),ResearchGroup:BrazilSportsProject(PROESP-Br),PortoAlegre,RS,Brazil.

∗Correspondingauthor.

E-mail:anegaya@gmail.com(A.R.Gaya).

https://doi.org/10.1016/j.jped.2017.04.006

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Results: Intheyears2008/09,14.6%ofBrazilianyoungstersshowedanaggregaterisktocar- diometabolic healthand17.1% anaggregaterisk for musculoskeletalindicators,whereasin 2013/14,thevaluesoftheriskindicatorswere,respectively40.0%and22.4%.Itwasobserved that,intheyears2013/14,therisktothecardiometabolichealthofboyswas2.51timesgreater thanin2008/09,whileforgirls,athree-foldincreaseinriskwasobserved.Concerningmuscu- loskeletalhealth,girlsshoweda2.21riskofbeingintheriskzonein2013/14whencompared with2008/09.

Conclusion: Theoccurrenceofanaggregaterisktothecardiometabolicandmusculoskeletal healthofBrazilianadolescentsincreasedinthe2008/09and2013/14periods.Regardinggender, anincreaseinthecardiometabolicandmusculoskeletalriskbetweentheseperiodswasobserved ingirls.Asforboys,anincreasewasobservedonlyincardiometabolicrisk.

4.0/).

PALAVRAS-CHAVE Saúde;

Aptidãofísica;

Obesidade

Agregac¸ãodosindicadoresderiscoàsaúdecardiometabólicaemusculoesquelética emadolescentesbrasileirosnosperíodosde2008/09e2013/14

Resumo

Objetivo: Verificar a ocorrência de risco agregado à saúde cardiometabólica e muscu- loesqueléticade adolescentesbrasileiros noperíodo de2008/09 e2013/14e identificar se existemdiferençasnoriscoentreossexosenessesperíodos.

Métodos: Trata-se deumestudoepidemiológico detendência comabordagemquantitativa, compostoporuma amostravoluntáriadeadolescentes, de16 estadosbrasileiros. Osdados foramextraídosdabasededadosdoProjetoEsporteBrasil.Aaptidãofísicarelacionadaasaúde foiavaliadaapartirde:índicedemassacorporal,aptidãocardiorrespiratória,ﬂexibilidade, eforc¸a/resistênciaabdominal.Paraotratamentoestatísticofoi utilizadoanálisedescritiva, qui-quadradoeregressãoPoissonlog.

Resultados: Nosanosde2008/09,14,6%dejovensbrasileirosapresentaramriscoàsaúdecar- diometabólicaagregadae17,1%riscoagregadodosindicadoresmusculoesqueléticos.Enquanto em 2013/14, os valores dos indicadores de risco foram, respectivamente 40,0% e 22,4%.

Observou-sequenosanosde2013/14oriscoàsaúdecardiometabólicadosmeninosera2,51 vezesmaiorqueem2008/09.Jáparaasmeninasoaumentodesseriscofoide3vezes.Noque serefereàsaúdemusculoesquelética,asmeninasapresentaramriscode2,21deestarnazona deriscoem2013/14emrelac¸ãoà2008/09.

Conclusão: Aocorrênciaderiscoagregadoàsaúdecardiometabólicaemusculoesqueléticade adolescentesbrasileirosaumentou noperíodo de 2008/09e 2013/14.Com relac¸ão ao sexo houveumaumentonoriscocardiometabólicoemusculoesqueléticonasmeninasentreesses períodos.Jáparaosmeninoshouveaumentoapenasdoriscocardiometabólico.

0/).

Introduction

Recentstudieshavedemonstratedan associationbetween health risk factors such as overweight/obesity and low levels of cardiorespiratory fitness (CRF), with the early risk of developing metabolic diseases.¹ Low levels of musculoskeletal fitness, i.e., of flexibility and muscular strength/resistance criteria, have also been considered predictors of problems such as postural deviations and other musculoskeletal disorders.² According to Thomas etal.,³ cardiorespiratory,musculoskeletal,neuropsycholo- gical,endocrine,andmetabolichealth dependdirectly on thelevelofphysicalfitnessand,thus,fitnesshasbecomean importantmarkerofhealthinchildrenandadolescents.⁴

However,thispopulationhasshownlowlevelsofhealth- relatedphysicalﬁtness(HRPF).⁵IntheUnitedStatesandin Brazil,theseinadequatelevelshavealarminglyincreasedin recentyears,withoccurrencesrangingfrom42%to63%.^6---8 Thegreatestimpactofthesedataisdisclosedwhenstudies indicatethat lowlevelsofCRFcombinedwithoverweight and obesity indicators (such as body mass index [BMI]) have become predictors of early risk for cardiometabolic diseases, such as insulin resistance, typeII diabetes, and myocardial infarction.^1,2 Additionally, according toOrtega etal.,²alowlevelofCRF,whenconsideredalone,isalready an indicatorofhealthrisk,sinceitisassociatedwithhigh mortalityrates.⁸ThesamecanbesaidaboutBMI,whichis evenmoreofaconcern,consideringthatapproximately30%

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ofBrazilianchildrenandyoungindividualsareoverweightor obese.⁹

Regardingmusclestrengthandﬂexibility,Meisleretal.¹⁰ stated that these are physical capacities that prevent trauma andbone fracturerisks.Furthermore,when these two indicators are aggregated at low levels, they may acceleratemoreseveremusculoskeletaldisorders,suchas sarcopenia,leanmassloss,andbonemassloss.¹¹Allthese associatedfactorstendtolimitbodyfunctionsthroughout life,alsoinﬂuencingthepracticeofphysicalactivity.¹²

Infact,maintaininggoodlevelsofHRPFisimportantto provideadequatemotorskillstocarryoutdailyactivities,¹³ whichisassociatedwithdirecthealthmarkers.²Whatisnew inthisregardis thatwhenHRPFcomponentsareassessed together,theyarelikelytoindicateamuchhigherriskcondi- tionthanwhenassessedalone,astheydeterminedifferent healthrisks.However,littleisknownabouttheprevalence ofaggregateinadequatephysicalﬁtnesslevelsintheyoung Brazilianpopulation.

Inthissense,itisimportanttostudy HRPF,considering allitscomponents.Inaddition,HRPFassessmentinschools isaveryadequatemethodforthispurpose,sinceitiseasy to apply, effective, low-cost, and can be performed in a large numberof subjects.^14---16 Subsequently,interventions thatconsiderHRPFbroadlycanbecreated.Moreover,phys- icaleducationclassescanbedevelopedwiththepurposeof promotinghealth.¹⁷Thus,thepresentstudyaimedtoverify theoccurrenceofanaggregaterisktothecardiometabolic andmusculoskeletalhealth ofBrazilian adolescentsin the period2008/09and2013/14andtoidentifywhetherthere are differencesin risk between the genders and in those periods.

Methods

Thiswasantrendepidemiologicalstudywithaquantitative approach, consisting of a voluntary sample of schoolchildren aged 12---17 years, from public and private schools of 16 Brazilian states, namely: Amazonas, Bahia, Ceará, Distrito Federal,EspiritoSanto, Goiás,MinasGerais,Mato Grosso, Piauí, Paraná, Rio de Janeiro, Rio Grande do Norte,Rio GrandedoSul, Santa Catarina,São Paulo, and Tocantins.TheadolescentswereevaluatedregardingHRPF, bytheirPhysicalEducationteachersineachvoluntaryedu- cation institution in 2008/2009 (n=4538) and 2013/2014 (n=3106).Teachers,students,parents,andtheeducational institutions agreed to carry out the study by signing the authorizationandinformedconsentforms,conﬁdentialityof thestudents’identities,andthesendingofdataandautho- rizationdocumentstoanationaldatabase,wheretheycould obtain resultsandreports withfeedbackonthe healthof theschoolchildrenfroman interactivewebsite.The inclu- sioncriteriaintheanalysesofthepresentstudywere:(1)all studentswhovolunteeredtoparticipate;(2)thosewhohad all theauthorizationdocumentation previouslydescribed;

and(3)whohadundergoneallHRPFtests.

Asreferenceforconductingthetests,theteachersused the manual of tests and measures of physical ﬁtness in thehealthcomponents:measuresofbodymassandheight:

calculationofBMI;nine-minuterun/walktest:cardiorespi- ratoryﬁtness;ﬂexibility:sitandreachtestwithoutabench;

andabdominalresistance-strength: sit-upsin oneminute.

Thismethodwascreatedby BrazilSportsProject(Projeto EsporteBrasil[PROESP-Br]).¹⁵Theinstructionsforapplying thesetestsareavailableat:www.proesp.ufrgs.br.Itshould benotedthat thesetoolsweredevelopedconsidering the reality of Brazilian schools, offering low-cost, applicable resources,whilefollowingvalid,reproducible,andreliable scientiﬁcqualitystandardstoestimatesomehealthparam- etersinchildrenandadolescents.¹⁸

Therefore, body mass was measured using a digital anthropometricscale, graduated from0to 150kg, witha resolutionof 0.05kgandrecordedin kilograms,usingone digitafterthedecimalpoint.Theadolescentswereevalu- atedpreferentiallywhilewearingphysicaleducationclothes andbarefoot,standingwiththeirelbowsextendedcloseto thebody.Heightwasmeasuredusingametrictapeﬁxedto thewallandextendedfromthebottomupwards,withthe studentsintheuprightposition,withfeetandtrunktouch- ingthewall.Thismeasurewasrecordedincentimeterswith onedigitafterthedecimalpoint.Thedescribedprocedures followedthePROESP-Brstandard.Subsequently,theBMIwas calculatedbydividingbodymass(inkilograms)byheight(in squaremeters). The cutoffpoint of PROESP-Br was used, consideringgenderandage.¹⁵

Forthenine-minuterun/walktest,theadolescentswere dividedintogroupsthatwereadequatefortherunningtrack dimensions.Theywereinstructedtorunaslongaspossible, avoidingvelocitypeaksinterspersedbylongwalksfornine minutes.Duringthetest,thepassageoftimewasinformed tothe studentsat two, four,and sixminutes.(‘‘Warning:

1minutetoﬁnish’’).Additionally,participantswereverbally encouraged.Attheendofthetest,afterasignalwasgiven, the students interrupted the running, remaining in place wheretheywerestandinguntil thedistance traveled was recordedorsignaled.

Thesitandreachtestwasperformedwithameasuring tapeﬁxedtotheground.Atthe38-cmmarkonthetape,a pieceof30-cmadhesive tapewasﬁxatedperpendicularly.

Adolescentswerebarefoot,withextendedkneesandover- lapping hands; the assessed individual slowly bowed and stretchedoutthehandsasfaraspossibleintwoattempts, ofwhichthehigheronewasrecorded.

The one-minute sit-up test was performed with the assessedindividualinthesupinepositionwithkneesflexed at45degrees,armscrossedoverthethorax,andanklesfix- atedtothefloorbytheevaluator. Attheevaluator’ssign, thestudentflexedthetrunkuntilhe/shetouchedthethighs withtheelbow,returningtothestartingposition,asmany timesaspossibleinoneminute.

In accordance with the PROESP-Br manual, which considers gender and age, data from the HRPF variables were categorized in the risk zone or in the healthyzone,followinganadequatestatisticalassumption (www.proesp.ufrgs.br).¹⁵

Furthermore, the present study was approved by the EthicsCommitteeofUniversidadeFederaldoRioGrandedo Sul,undernumber2008010.

In the statistical analysis, the characteristics of the sample were ﬁrst described in the two assessed periods (2008/09 and 2013/14), reporting the absolute and per- centagevaluesoftheoccurrenceofgender,age,regionof Brazil,andtheriskzoneoftheHRPFvariables.Considering

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theobjectivesofthepresent investigation,therisk variables of the HRPF were grouped into cardiometabolic risk (BMI+CRF)andmusculoskeletalrisk(ﬂexibility+abdominal strength/resistance).Thus, only the frequency of individ- ualswithaggregateriskandthoseinthehealthyzonewas considered.Itshouldbenotedthatstudentswhoonlyhad one risk of the HRPF variables were not included in the subsequent analyses, which refer to the statistical tests.

Todescribetheaggregationofcardiometabolicandmuscu- loskeletalrisk,absoluteandpercentagevalueswereusedin theyears2008/09and2013/14,asillustratedinabarchart.

After this description, the chi-squared test was performed to measure the prevalence ratio (PR) of the aggregateriskonthefrequencyofhealthyindividualsinthe differentgenders,ineach evaluatedyearperiod(2008/09 and2013/14).The associationbetweenageandaggregate risk was also veriﬁed using Spearman’s correlation test.

Finally,consideringtheresultsoftheseprimaryanalyses,a Poissonlogregressionwasperformed,stratifiedbygender, wheretheaggregaterisk PRwasverifiedfor healthyindi- vidualsbetween2008/09and2013/14.Theseanalyseswere performedusingtheSPSS(IBMSPSSStatisticsforWindows, Version22.0,NY,USA),consideringalevelofsignificancefor analpha<0.05.

Results

Table1showsthecharacteristicsofthesamplein2008/09 and2013/14.Atotalof4538adolescentswereevaluatedin

Table1 Samplecharacteristicsinthe2008/09and2013/14 periods.

Samplecharacteristics 2008/09 2013/14

n % n %

Gender

Male 2649 58.4 1706 54.9

Female 1889 41.6 1400 45.1

Age(years)

12 1023 22.5 566 18.2

13 1113 24.5 653 21.0

14 1002 22.1 659 21.2

15 792 17.5 551 17.7

16 497 11.0 428 13.8

17 111 2.4 249 8.0

Region

North 1 0.0 8 0.2

Northeast 324 5.2 109 2.7

Midwest 731 11.6 728 18.0

Southeast 2297 36.6 289 7.1

South 2928 46.6 2918 72.0

Physicalﬁtnessrisk

BMI 344 10.1 71 4.5

Cardiorespiratoryﬁtness 810 23.7 774 44.1 Abdominalﬂexibility 676 16.1 618 24.1

1042 24.9 443 17.3

n,absolutevalue;%,percentage;BMI,bodymassindex.

50 40

14.6 17.1

22.4 40.0

Cardiometabolic Musculoskeletal

Percentage (%)

30 20 10 0

2008/09 2013/14

Figure 1 Aggregation ofrisk indicators to cardiometabolic andmusculoskeletalhealthintheperiods2008/09and2013/14.

theyears2008/09and3106intheyearsof2013/14,inthe agegroupof12---17years.

The occurrences of aggregate risks added to car- diometabolicandmusculoskeletalhealthareshowninFig.1.

It can be observed that there was an increase in car- diometabolicandmusculoskeletalriskbetweentheyears.In 2008/09,cardiometabolicrisk(totaln:2260;nataggregate risk:332)wasproportionallylowerthanin2013/14(totaln:

901;n atrisk: 370).Regardingmusculoskeletal risk,there wasanincreaseintheproportionbetweentheyears2008/09 (totaln:2472;natrisk:437)and2013/14(totaln:1499;n atrisk:360).

Table2showstheassociationofgenderandagewiththe aggregationofcardiometabolicandmusculoskeletalriskin the differentevaluationperiods.Regarding gender, itwas observed that thereis a differencebetween being in the risk intheassessedperiods.It wasalsoobserved thatthe strengthofthecorrelationsbetweenageandaggregaterisk, bothcardiometabolicandmusculoskeletal, areveryweak, althoughsomeassociationshaveasigniﬁcancelevelwithin theexpected.

The comparisons between the aggregate risks to car- diometabolicandmusculoskeletalhealthoftheadolescents assessed in the years 2008/09 and 2013/14, stratiﬁed by gender, are shown in Table 3. In males, cardiometabolic riskincreasedby2.5-foldin2013/14whencomparedwith 2008/09. In females, an increase inrisk of approximately three-foldwasobserved.Musculoskeletalriskincreasedby approximately 2.2-fold (CI: 1.71---2.84) in 2013/14, when comparedwiththe2008/09periodinfemales;nosigniﬁcant increasewasobservedinmales.

Discussion

Themainresultsofthepresentstudyindicatedthatinthe years2008/09,14.6%ofBrazilianyoungstershadanaggre- gatecardiometabolichealthriskand17.1%hadanaggregate riskofmusculoskeletalindicators,whilein2013/14,therisk indicatorvalueswere,respectively,40.0%and22.4%.Itwas observedthatin2013/14,thecardiometabolichealthriskof theboyswas2.51-foldgreaterthanin2008/09.Forgirls,the increaseinriskwasthree-fold.Concerningmusculoskeletal health,girlsshowedaPRof2.21ofbeingintheriskzonein 2013/14whencomparedwith2008/09.

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Table2 Aggregationofcardiometabolicandmusculoskeletalriskinrelationtogenderandageofadolescentsintheyears 2008/09and2013/14.

2008/09 2013/14

Risk n(%)

Healthy n(%)

OR(95%CI) p Risk

n(%)

Healthy N(%)

OR(95%CI) p

Cardiometabolic Gender

Male 192(13.9) 1189(86.1) 0.85(0.67---1.08) 0.18 164(34.9) 306(65.1) 0.58(0.44---0.76) 0.001

Female 140(15.9) 739(84.1) 1 206(47.8) 225(52.2) 1

Musculoskeletal Gender

Male 333(24.3) 1036(75.7) 3.08(2.43---3.91) 0.001 217(26.7) 596(73.3) 1.38(1.08---1.75) 0.001

Female 104(9.4) 999(90.6) 1 143(20.8) 543(79.2) 1

N r p n r p

Cardiometabolic

Age 2260 0.05 0.006 901 −0.05 0.06

Musculoskeletal

Age 2472 0.03 0.06 1499 0.04 0.86

n,absolutevalue;%,relativevalue;r,Spearman’scorrelationcoefﬁcient;95%CI,95%conﬁdenceinterval(chi-squaredtest);OR,odds ratio.

Table3 Prevalenceratioofaggregateriskstocardiometabolicandmusculoskeletalhealthbetweentheyears2008/09and 2013/14,stratiﬁedbygender.

Male Female

% PR 95%CI p % PR 95%CI p

Cardiometabolic

2008/09 13.9 1 15.9 1

2013/14 34.9 2.51 2.03---3.09 <0.001 47.8 3.00 2.42---3.71 <0.001

Musculoskeletal

2008/09 24.3 1 9.4 1

2013/14 26.7 1.09 0.92---1.30 0.28 20.8 2.21 1.71---2.84 <0.001

%,relativevalue;PR,prevalenceratio;95%CI,95%conﬁdenceinterval(chi-squaredtest).

The cardiometabolic and musculoskeletal health risk increased considerably between the evaluation periods.

To the best of the authors’ knowledge, this is the first studytoinvestigatetheoccurrenceofcardiometabolicand musculoskeletal risk aggregates for BMI+CRF andflexibil- ity+abdominalstrength/resistance.It isknownthat when thevariablesareconsideredalone,theprevalenceofobe- sity and cardiorespiratory impairment shows a trend of concern. In that sense, a study published in the United Statesindicatedthatthepercentageofobeseadolescents intheperiod1988---1994 was10.5%,increasingto20.6%in 2013---2014.¹⁹ RegardingCRF,thefindingspointinthesame direction,indicatingadecreasebetween1992and1999and between1992and2012inAfricanchildrenandadolescents.

Thesameoccurswhenconsideringthevariablesofmuscular strength/resistanceandﬂexibility:childrenandyoungsters weremoreﬂexible,agile,andfastin1992thanin2012.²⁰

TheincreaseintheaggregateriskofHRPFindicatorsmay have occurred due to several behavioral factors, such as decrease inphysical activity levels, increase insedentary

behaviorandconsumptionofunhealthyfoods,anddecrease inactivedisplacement, inadditiontothehighoccurrence ofoverweight and obesity inBrazilian youngsters.^9,21 It is noteworthythatcardiometabolicriskincreasedatanalarm- ing rate between the periods, which may be due to the fact that Brazilian adolescents have been showing lower levelsofCRF. Oneof theconsequencesof lowCRFandits declineovertimeistheassociationwithanincreaseincar- diometabolicdiseasessuchastypeIIdiabetes,hypertension, anddyslipidemia.²²Consideringtheseaspects,whichmakes theﬁndingsofthepresentstudyevenmoreofamatterof concernisthatthepresenceoftwosimultaneousriskindi- catorsincreasesthelikelihoodthattheindividualwillhave sometypeofhealthprobleminthefuture.

Regardingcardiometabolichealthbetweenthegenders, therewasanincreasein riskfor bothboysandgirlswhen comparingthe twoperiods.It is noteworthy thatthe risk washigherforgirls.Theseﬁndingscanbeexplainedbythe factthatgirlshavealessactivelifestyle,aswellascultural factorsthatlead themtopracticeless sportand physical

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activities.^23---25Additionally,girlstendtohavegreatergains in fat mass, which may also be related to the hormonal changesofpuberty.²⁶Inboys,however,thesehormonalfac- torsareassociatedwithincreasedleanmassfromtheend ofchildhoodtoearlyadolescence.²⁷

Regardingmusculoskeletal health, girlsshowedaPR of 2.21of beingin therisk zone in2013/14 when compared with2008/09, i.e., 9.4%werein therisk zone intheﬁrst considered period,increasing to20.8%. In boys,however, nodifferencewasfoundbetweentheperiods,butthismay haveoccurred because24.3% of theboyswere alreadyin therisk zone in 2008/09, increasingto26.7% in 2013/14.

Therefore,inthetwoanalyzedperiods,thepercentageof boysintheriskzone formusculoskeletal healthwashigh, andhigherthanthevaluesfoundingirls.

Consideringthemusculoskeletalhealthindicatorsalone, a study on Spanish adolescents showed a decrease in muscular strength of boys and girls between the periods 2001---2002 and 2006---2007.²⁸ As for Mozambican adolescents,theresultsindicatedadecreaseinmusclestrengthin girlsbetween1992and2012,andanincreasewasobserved in boys.²⁰ In fact, according tothe literature, boys show lower risks in the variable muscle strength because hor- monalfactors naturally increase thisvariable.²⁹ Similarly, regardingﬂexibility,adeclineinperformancewasobserved overtime.^20,30

Consideringtheaforementionedaspects,itisimportant toknowtherealityregardingtheHRPFofBrazilianadoles- cents, sothat, based on this, intervention programsthat promote health can be created, taking into accountthat one of the places to develop these actions is the school environment, through the physical education teacher, by encouragingthepracticeofphysicalactivity,activebehav- ior,anddecreaseofsedentarylifestyle.

Therefore, it should benoted that this study makes a greatcontributiontotheHRPFarea,sinceallitsindicators wereinvestigated.Itisalsoemphasizedthattheaggregated mannerasthedatawereconsideredallowedananalysisper- spectivethat wasdifferent fromthe studies in this area.

Additionally, adolescents from all regions of Brazil were assessed,althoughthesamplewassmallintheNorth.Nev- ertheless,thesedataallowanoverviewofHRPFinBrazil.

Nevertheless,somelimitationsmustbeconsidered.The sample was selected by convenience and had a different numberof subjects in thetwo analysisperiods. Addition- ally,thesame subjectswere notassessed inboth periods ofanalysis.DuetotheavailabilityofdatainthePROESP-Br database,aheterogeneityinthenumberofadolescentsin each regionwasobserved. Itshould benoted thatsexual maturationwasnotassessed.

Therefore, the presence of an aggregate risk to the cardiometabolic and musculoskeletal health of Brazilian adolescentsincreasedfrom2008/09to2013/14.Regarding gender was an increase in the PR of cardiometabolic and musculoskeletal risk in girls was observed between these periods. For boys, there was an increase only in cardiometabolicrisk.Consideringthesedata,itcanbecon- cludedthattheHRPFofadolescentshasworsenedoverthe years.Thesedatapointtoascenarioofconcern,sincelow levelsofCRF,abdominalstrength/resistance,andﬂexibility, aswell as high levelsof BMI are associated with several healthproblems.

Funding

National Council for Scientiﬁc andTechnological Develop- ment (CNPq) and Coordination for the Improvement of HigherLevel-orEducation-Personnel(CAPES).

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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