Risk factors related to obesity in adolescents in the face of the COVID-19 pandemic: a scoping review

João Cruz Neto1, Alécia Hercídia Araújo1, Antonio Coelho Sidrim1, Raquel Linhares Sampaio1, Rosely Leyliane dos Santos1

1 Regional University of Cariri, CE, Brazil

ABSTRACT

Objective: to map the scientific evidence linking the risks of developing obesity in adolescents during the COVID-19 pandemic. Method: a scoping review as recommended by the Joanna Briggs Institute. The guiding question was as follows: What scientific evidence relates the risks of developing obesity in adolescents during the COVID-19 pandemic? The searches were carried out in five databases and in another three sources from the gray literature. Thus, 12 studies comprised the final sample. Results: the risk factors related to the development of obesity among adolescents during the COVID-19 pandemic are physical inactivity in daily living, fragility in psychological care, difficulty in nutritional education, and lack of body and complementary care measures. Conclusion: the risks related to adolescents' health during the COVID-19 pandemic are modifiable and Nursing plays an essential role for health promotion, disease prevention and encouraging the adoption of healthy habits.

Descriptors: Obesity; COVID-19; Nursing.

INTRODUCTION

The prevalence of people with obesity has increased. Worldwide, between 1980 and 2014, the proportion of obese people more than doubled(1). In Brazil, the estimates regarding the prevalence of obesity increased from 15% to 18% from 2010 to 2014, in both genders(2).

Obesity is conceptualized as a socioenvironmental and food insecurity risk factor influenced by the ways of producing, selling and consuming food products, which causes serious public health problems(3).

Obesity is considered a potentiating factor for other diseases such as diabetes, hypertension, cancer and cardiovascular pathologies. Thus, discussing obesity in adolescents becomes relevant in order to support the clinical practice and give a new meaning to the care measures aimed at prevention and health promotion, within this population(4).

With the advent of the COVID-19 pandemic, the associations between the disease and obesity have become an object of discussion. However, the scarcity of related studies reveals direct implications regarding obesity and the risk for clinical manifestations of the severe forms of COVID-19(4).

Considerable increases in the Body Mass Index (BMI) of 432,302 individuals aged between 2 and 19 years old were identified during the course of the pandemic(5). In addition, it was found that overweight or obesity among children and adolescents increased during the pandemic, with an 8.7% increase in those aged from 5 to 11 years old, 5.2% between the ages of 12 and 15 and 3.1% among young people aged between 16 and 17 years old(6).

There is a relationship between obesity and deterioration of the clinical presentation of COVID-19, which is due to the propensity to infections, risk of sepsis and mortality. Chronic inflammation in the body reduces immunity and deregulates functioning of the immune system, causing oxidative stress, endothelial dysfunction and cardiovascular abnormalities due to excess adipose tissue(4,7).

The epidemiological bulletin of the Ministry of Health, published in April 2021, found a high record of deaths due to Severe Acute Respiratory Syndrome (SARS) by COVID-19 in obese individuals, aged under 60 years old(8).

The adoption of a healthy lifestyle has become a global challenge due to social behaviors, especially when it comes to obesity caused by social isolation and also in the face of bullying suffered by the adolescents(9). In this context, Nursing care promotes changes in attitudes and prevention of risk behaviors, especially in Primary Health Care(10). Nurses perform education in health, stimulate interpersonal relationships and prevent health problems(11). Therefore, it is essential that nurses recognize the risk factors for the development of obesity in adolescents in the face of the COVID-19 pandemic.

Given the relevance of the theme, in view of the knowledge gap on the topic, the objective is to map the risk factors for developing obesity in adolescents in the face of the COVID-19 pandemic.

METHOD

Type of study

This is a scoping review, based on the guidelines proposed by the Joanna Briggs Institute(12), following nine stages, namely: (1) title; (2) title and question development; (3) introduction; (4) inclusion criteria; (5) research strategy; (6) selection of evidence sources; (7) data extraction; (8) analysis of the evidence; and (9) presentation of the results. The scoping review protocol has been registered in the Open Science Framework (OSF) and can be accessed at the following link: https://osf.io/q4mdf/.

Methodological procedure

The Population, Concept and Context (PCC) method was applied to elaborate the research guiding question, namely: Population: Adolescents; Concept: Risk factors for obesity during the COVID-19 pandemic; Context: COVID-19 pandemic. Thus, the guiding question was defined as follows: “Which are the risk factors for developing obesity in adolescents in the face of the COVID-19 pandemic?”

Data sources

Two researchers conducted the research by means of a paired search, with consolidated data from November 2020 to April 2021, using the following Descriptors in Health Sciences (Descritores em Ciências da Saúde, DeCS) and Medical Subject Headings (MeSH): “adolescent”, “Adolescent Behavior”, “Adolescent Nutrition”, “Adolescent Health”, “Adolescent Health Services”, “obesity”, “obese”, “obesity in adolescents”, “COVID-19”, “coronavirus infections”. Furthermore, in case of disagreement between the two researchers, a third researcher was consulted to reach a consensus.

The search was carried out in the following databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Base de Dados de Enfermagem (BDENF), Web of Science (WoS), Medical Literature Analysis and Retrieval System Online (MEDLINE) via EBSCO Information Services, and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

Regarding the gray literature, PUBMEDCOVID-19 was searched in two topics (reviews and meta-analyses, obesity and nutrition) or (child and obesity and nutrition); as well as medRiv with the following strategy: (adolescent) OR (adolescent nutrition) AND (obesity) OR (obesity in adolescents) AND (COVID-19) and the CAPES Theses and Dissertations Catalog.

Data collection

The inclusion criteria for each PCC method mnemonic were the following: Population (adolescents of both genders aged between 10 and 19 years old who were or were not vaccinated against COVID-19); Concept (obesity in adolescents during the COVID-19 pandemic); Context (during the COVID-19 pandemic). Full studies available, empirical qualitative and quantitative, theoretical-reflective studies, in Portuguese, English or Spanish and that answered the guiding question were also included.

Review studies were excluded. After applying the criteria, the articles selected were read in full, followed by the analysis of their references, in search of potential studies that could be incorporated. Figure 1 displays the search strategies conducted by the authors.

Figure 1 – Search strategies applied in the databases referring to the research. Crato, CE, Brazil, 2021

Source: Prepared by the authors, 2021.

Furthermore, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist(13) was applied to the methodological quality of this study and presents the search and selection stages, as shown in Figure 2(14).

Data analysis and organization

The studies were reviewed by two researchers and, in case of divergence, a third evaluator was consulted. The data extracted from the studies were organized in tables, followed by the reference and pertinent information that answered the guiding question.

Figure 2 – Flowchart of the study search and selection process, adapted from PRISMA. Crato, CE, Brazil, 2021

Source: PRISMA flowchart adapted from Moher et al, 2009.

RESULTS

Of the twelve included studies, seven were found in MEDLINE, two in CINAHL and WoS, respectively, and one in MedRxiv. The number of studies per country was as follows: Italy (2), China (3), Spain (1), Chile (1), Sahrawi Arab Democratic Republic (1), South Korea (1), Ireland (1), Greece (1), and India (1), according to Figure 3.

Figure 3 – Characterization of the studies included in the scoping review. Crato, CE, Brazil, 2021

Source: Prepared by the authors, 2021.

The study population varied from 41(22) to 10,085(19,25). The studies reveal the overweight and obesity trend in the female adolescent population, both in undergraduate and regular education(16). In addition to that, there is a significant reduction in leisure time and an increase in physical inactivity and screen time(15,21,22-23,25).

The unavailability of vegetables rich in vitamins C and polyphenols, fruit, fish, beans and olive oil in the diet increases the predisposition to obesity. Physical exercises that involve metabolic expenditure, aerobic training, coordination, endurance and agility are reinforced(17-18,23).

Increased food intake, reduced physical activity, sedentary lifestyle and weight gain were found to be risk factors that support development of obesity(26).

Predisposition to a sedentary lifestyle is high, and stress interferes negatively with weight gain. The main variables associated with the occurrence of weight gain were gender, stress, low physical activity and unbalanced diet. Low physical activity is a risk factor for obesity(16,19,21,24). Biochemical monitoring is highlighted as an important protective factor(20).

Closed leisure spaces, health concerns, low motivation, excessive school work, too much time in a sitting position and lack of routine predisposed people to an increase in obesity(21).

Sleep interferes with the adolescents' metabolism. During the pandemic, they spent more than 3 h/day in front of electronic screens(15). Increased body weight was correlated with snack food and red meat consumption, screen time, decreased physical activity, and physical distancing(15,24).

Thus, the risks related to the development of obesity in adolescents during the COVID-19 pandemic were as follows: inactivity in daily living; fragility in psychological care; difficulty in nutritional education; and lack of body and complementary care measures(4,7,10-14,18,22-23,25).

DISCUSSION

Inactivity in daily living combined with the use of Information and Communication Technologies (ICTs) may have contributed to obesity among the adolescents. They were exposed to excessive screen time due to, among other reasons, the online format of the classes, decreased sleep and increased stress(27). Sleep quality among the adolescents decreased as cell phone exposure increased at night. In this sense, sleeping less than eight to ten hours a night is considered a risk factor for obesity(28).

It is noteworthy that psychological stress contributes to high consumption of food products. Unrestricted consumption of processed food products, consumption of alcoholic beverages and drug use were unhealthy habits that exert a direct impact on the adolescents' health(29).

Thus, during the Nursing consultation, patterns of risk behaviors are identified supporting the development of educational practices necessary for the construction of strategies affecting the adolescents(30).

In relation to the risk of fragility in psychological care, social distancing/isolation were necessary measures to prevent contamination by COVID-19. However, the change in the daily routine may have triggered negative outcomes related to emotional and psychological aspects such as increased binge eating, bulimia and anorexia(30).

According to the United Nations(31), increased levels of anxiety and depression symptoms were spurred by the COVID-19 pandemic. In this context, the Nursing team works in intersectoral planning to propose multisectoral actions that offer care to the individuals and the community(32).

As for the nutritional risk, the studies identified the presence of spices, sugars and fats. According to a study (33), overweight and obese people are more likely to experience changes in their eating habits during the social isolation period. A study conducted during social isolation with 820 Brazilian adolescents aged from 10 to 19 years old showed that binge eating and the reduction in the consumption of vegetables and legumes triggered obesity(34). On the other hand, nurses follow-up individuals in situations of nutritional imbalance, strategic planning and monitoring(35). Nutritionists must act as members of these collective actions.

The study in question evidenced lack of physical exercise as a risk factor. A study(16) showed that practicing physical exercise is protective to prevent obesity. However, 30.4% of the adolescents interviewed during the pandemic answered positively to the practice of physical activity, which reduced obesity(36).

Absence of complementary care measures was identified as a predictor of obesity. Complementary care included vaccination and referral of the adolescents to specialized care services, when necessary. In this sense, attention is drawn to the aggravation of risks among girls, brown-skinned, aged up to 19 years old and from rural areas(37).

Immunization is a field of competence of Nursing. In addition to that, it is a prevention strategy that promotes control of pandemics such as COVID-19. With the evolution of the vaccines, the national plan reinforces that the use of Pfizer's immunizer (Biontec) for adolescents, from 12 years old, is indicated; although it does not rule out the use of Coronavac (Sinovac)(38).

In this context, Nursing can help to strengthen health promotion strategies, group screening and harm reduction. Knowledge of the risk factors related to obesity assist in the situational diagnosis and can support the proposal of efficient actions that exert an influence on the adolescents' health.

The classification of obesity can have different parameters depending on the country, which is the limitation of the study. In this way, new studies are encouraged in order to elucidate possible tools that enable the care and comprehensive monitoring of adolescents.

The contributions of this study refer to the identification of risk factors for the development of obesity in adolescents in the face of the COVID-19 pandemic and guide Nursing actions for the prevention of obesity. The adolescents' needs require actions carried out by nurses, which can reduce the complications that reverberate in that population.

CONCLUSION

Physical inactivity, fragility in psychological care, difficulty in nutritional education, and lack of body and complementary care measure were the risk factors related to obesity in adolescents in the face of the COVID-19 pandemic.

In this sense, the results reflect that the risk factors identified are amenable to health interventions. In this context, the role of Nursing is essential in the development of activities aimed at promoting health, preventing diseases and encouraging the adoption of healthy habits through the implementation of care programs and mapping strategic points for the practice of physical exercise, in addition to conducting therapies and nutritional guidance with the multidisciplinary team. Thus, this study points to the need for protocols aimed at the care of adolescents in situations of vulnerability to obesity and to new research studies on the theme, in order to support the approach and interventions to prevent obesity among adolescents during the COVID-19 pandemic.

REFERENCES

1. Ferreira APS, Szwarcwald CL, Damacena GN. Prevalência e fatores associados da obesidade na população brasileira: estudo com dados aferidos da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol. 2019;22:e190024. https://doi.org/10.1590/1980-549720190024.   PMid:30942330.

2. Ministério da Saúde (BR). Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. [Internet]. Brasília (DF): Ministério da Saúde; 2018 [citado 2021 mar 13]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/vigi tel_brasil_2017_vigilancia_fatores_riscos.pdf

3. Martinelli SS, Cavalli SB. Alimentação saudável e sustentável: uma revisão narrativa sobre desafios e perspectivas. Cien Saude Colet. 2019;24(11):4251-62. http://dx.doi.org/10.1590/1413-812320182411.30572017. PMid:31664397.

4. Silva JN. Obesidade e COVID-19: Quais as evidências? Artigos@ [Internet]. 2020 [citado 2021 mar 14];21:1-7. Disponível em: https://acervomais.com.br/index.php/artigos/article/view/5346/2937  

5. Lange SJ, Kompaniyets L, Freedman DS, Kraus EM, Porter R, Blanck HM, et al. Longitudinal trends in body mass index before and during the COVID-19 pandemic among persons aged 2 to 19 years - United States, 2018-2020. MMWR. 2021;70(37):1278-83. http://dx.doi.org/10.15585/mmwr.mm7037a3. PMid:34529635.

6. Woolford SJ, Sidell M, Li X, Else V, Young DR, Resnicow K, et al. Changes in body mass index among children and adolescents during the COVID-19 pandemic. JAMA. 2021;326(14):1434-6. http://dx.doi.org/10.1001/jama.2021.15036. PMid:34448817.

7. Stefan N, Birkenfeld AL, Schulze MB, Ludwig DS. Obesity and impaired metabolic health in patients with COVID-19. Nat Rev Endocrinol. 2020;16(7):341-2. http://dx.doi.org/10.1038/s41574-020-0364-6. PMid:32327737.

8. Ministério da Saúde (BR). Boletim Epidemiológico Especial - Doença pelo Coronavírus COVID-19 [Internet]. Brasília (DF): Ministério da Saúde; 2021 [citado 2021 out 28]. 107 p. Disponível em: https://www.gov.br/saude/pt-br/media/pdf/2021/ abril/22/boletim_epidemiologico_covid_59.pdf

9. Buainain AM, Garcia JR, Vieira PA. O desafio alimentar no século XXI. Estud Soc Agric. 2016;24(2):497-522.

10. Braga VAS, Jesus MCP, Conz CA, Silva MH, Tavares RE, Merighi MAB. Atuação de enfermeiros voltada para a obesidade na Unidade Básica de Saúde. Rev Bras Enferm. 2020;73(2):1-9. PMid:32159690.

11. Teixeira LA, Freitas RJM, Moura NA, Monteiro ARM. Necessidades de saúde mental de adolescentes e os cuidados de enfermagem: revisão integrativa. Texto Contexto Enferm. 2020;29(1):1-15.

12. Peters M, Godfrey C, McInerney P, Munn Z, Trico A, Khalil H. Chapter 11: Scoping Reviews. In: Aromataris E, Munn Z, organizators. JBI Database System Rev Implement Rep. Adelaide: JBI; 2020 https://doi.org/10.46658/JBIMES-20-12.

13. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. http://dx.doi.org/10.7326/M18-0850. PMid:30178033.

14. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. http://dx.doi.org/10.1371/journal.pmed.1000097. PMid:19621072.

15. Androutsos O, Perperidi M, Georgiou C, Chouliaras G. Lifestyle changes and determinants of children’s and adolescents’ body weight increase during the first COVID-19 lockdown in Greece: the COVEAT study. Nutrients. 2021;13(3):1-11. http://dx.doi.org/10.3390/nu13030930. PMid:33805678.

16. Boukrim M, Obtel M, Kasouati J, Achbani A, Razine R. COVID-19 and confinement: effect on weight load, physical activity and eating behavior of higher education students in southern Morocco. Ann Glob Health. 2021;87(1):7. http://dx.doi.org/10.5334/aogh.3144. PMid:33505866.

17. Calcaterra V, Vandoni M, Pellino VC, Cena H. Special attention to diet and physical activity in children and adolescents with obesity during the Coronavirus Disease-2019 pandemic. Front Pediatr. 2020;8:407. http://dx.doi.org/10.3389/fped.2020.00407. PMid:32676491.

18. Fernandez-Rio J, Cecchini JA, Mendez-Gimenez A, Carriedo A. Weight changes during the COVID-19 home confinement. Effects on psychosocial variables. Obes Res Clin Pract. 2020;14(4):383-5. http://dx.doi.org/10.1016/j.orcp.2020.07.006. PMid:32763110.

19. Jia P, Zhang L, Yu W, Yu B, Liu M, Zhang D, et al. Impact of COVID-19 lockdown on activity patterns and weight status among youths in China: the COVID-19 Impact on Lifestyle Change Survey (COINLICS). Int J Obes (Lond). 2021;45(3):695-9. http://dx.doi.org/10.1038/s41366-020-00710-4. PMid:33277588.

20. Kim ES, Kwon Y, Choe YH, Kim MJ. COVID-19 related school closing aggravate obesity and glucose intolerance in pediatric patients with obesity. Sci Rep. 2021;11(1):5494. PMID: 33750841.

21. Ng K, Cooper J, McHale F, Clifford J, Woods C. Barriers and facilitators to changes in adolescent physical activity during COVID-19. BMJ Open Sport Exerc Med. 2020;6(1):e000919. http://dx.doi.org/10.1136/bmjsem-2020-000919. PMid:33262893.

22. Pietrobelli A, Pecoraro L, Ferruzzi A, Heo M, Faith M, Zoller T, et al. Effects of COVID-19 lockdown on lifestyle behaviors in children with Obesity Living in Verona, Italy: a longitudinal study. Obesity (Silver Spring). 2020;28(8):1382-5. http://dx.doi.org/10.1002/oby.22861. PMid:32352652.

23. Reyes-Olavarría D, Latorre-Román PÁ, Guzmán-Guzmán IP, Jerez-Mayorga D, Caamaño-Navarrete F, Delgado-Floody P. Positive and negative changes in food habits, physical activity patterns, and weight status during covid-19 confinement: associated factors in the chilean population. Int J Environ Res Public Health. 2020;17(15):1-14. http://dx.doi.org/10.3390/ijerph17155431. PMid:32731509.

24. Roy S, Tiwari S, Kanchan S, Bajpai P. Impact of Covid-19 pandemic led lockdown on the lifestyle of adolescents and young adults. medRxiv. 2020;1-10. https://doi.org/10.1101/2020.08.22.20180000.

25. Yang S, Guo B, Ao L, Yang C, Zhang L, Zhou J, et al. Obesity and activity patterns before and during COVID -19 lockdown among youths in China. Clin Obes. 2020;10(6):e12416. http://dx.doi.org/10.1111/cob.12416. PMid:33009706.

26. Zhu Q, Li M, Ji Y, Shi Y, Zhou J, Li Q, et al. “Stay‐at-Home” Lifestyle Effect on Weight Gain during the COVID-19 Outbreak Confinement in China. Int J Environ Res Public Health. 2021;18(4):1-13. http://dx.doi.org/10.3390/ijerph18041813. PMid:33673375.

27. Sociedade Brasileira de Pediatria. Departamento Científico de Endocrinologia. Obesidade em crianças e adolescentes e COVID-19 [Internet]. Rio de Janeiro: SBP; 2020 [citado 2021 mar 18]. Disponível em: https://www.sbp.com.br/fileadmin/user_upload /22443c-NA_-_Obesid_ em_Crianc_Adolesc_e_COVID-19_.pdf

28. Amra B, Shahsavari A, Shayan-Moghadam R, Mirheli O, Moradi-Khaniabadi B, Bazukar M, et al. The association of sleep and latenight cell phone use among adolescents. J Pediatr (Rio J). 2017;93(6):560-7. http://dx.doi.org/10.1016/j.jped.2016.12.004. PMid:28257717.

29. Raphaelli CO, Pretto ADB, Dutra GF. Prevalência de hábitos de vida em escolares de um Município do Sul do Brasil. Adolesc Saude. 2016;13(2):16-23.

30. Amaral-Moreira Mota B, Moura-Lanza F, Nogueira-Cortez D. Efetividade da consulta de enfermagem na adesão ao tratamento da hipertensão arterial sistêmica. Rev Salud Publica (Bogota). 2019;21(3):1-9. http://dx.doi.org/10.15446/rsap.V21n3.70291.

31. World Health Organization (WHO). Policy Brief: COVID-19 and the Need for Action on Mental Health [Internet]. Geneva: WHO; 2020 [citado 2021 mar 22]. Disponível em: https://unsdg.un.org/sites/default/files/2020-05/UN-Policy-Brief-COVID-19-and-mental-health.pdf

32. Nunes VV, Feitosa LGGC, Fernandes MA, Almeida CAPL, Ramos CV. Saúde mental na atenção básica: atuação do enfermeiro na rede de atenção psicossocial. Enferm Psiquiatr e Saúde Ment. 2020;73(1):1-7.

33. Sidor A, Rzymski P. Dietary choices and habits during COVID-19 lockdown: experience from Poland. Nutrients. 2020;12(6):1-13. http://dx.doi.org/10.3390/nu12061657. PMid:32503173.

34. Ruiz-Roso MB, de Carvalho Padilha P, Mantilla-Escalante DC, Ulloa N, Brun P, Acevedo-Correa D, et al. Covid-19 Confinement and Changes of Adolescent’s Dietary Trends in Italy, Spain, Chile, Colombia and Brazil. Nutrients. 2020;12(6):E1807. PMid:32560550.

35. Pedraza DF. Percepção de enfermeiros sobre o cuidado nutricional à criança na Estratégia Saúde da Família. Saúde Debate. 2020;44(124):141-51. http://dx.doi.org/10.1590/0103-1104202012410.

36. Kriaucioniene V, Bagdonaviciene L, Rodríguez-Pérez C, Petkeviciene J. Associations between changes in health behaviours and body weight during the covid-19 quarantine in lithuania: the lithuanian covidiet study. Nutrients. 2020;12(10):1-9. http://dx.doi.org/10.3390/nu12103119. PMid:33065991.

37. Hillesheim D, Tomasi YT, Figueiró TH, Paiva KM. Síndrome respiratória aguda grave por COVID-19 em crianças e adolescentes no Brasil: perfil dos óbitos e letalidade hospitalar até a 38a Semana Epidemiológica de 2020. Epidemiol Serv Saude. 2020;29(5):e2020644. http://dx.doi.org/10.1590/s1679-49742020000500021. PMid:33175011.

38. Ministério da Saúde (BR). Plano Nacional de Operacionalização da Vacinação Contra a Covid-19 [Internet]. Brasília (DF): Ministério da Saúde; 2021 [citado 2021 abr 5]. 113 p. Disponível em: https://www.gov.br/saude/pt-br/media/pdf/2021/marco/23/plano-nacional-de-vacinacao-covid-19-de-2021

Submission: 10-Aug-2021

Approved: 23-Dec-2021