Abstract

People who have been diagnosed with cancer tend to adopt healthier lifestyles. This study analyzes the prevalence of smoking, eating fruits and vegetables, exercise and the use of alcoholic beverages among individuals who reported to have been diagnosed with cancer in the PNS (Pesquisa Nacional de Saúde or National Health Survey). The prevalence and corresponding 95% confidence intervals were calculated for consuming fruits and vegetables, sedentary lifestyle (no exercise), use of alcoholic beverages, being overweight and tobacco use. The associa-tion between having received a diagnosis of cancer and the risk and protection factors was analyzed using a Poisson regression, adjusted by sociodemographic variables and other chronic comorbidities. The analyses were stratified by time since the diagnosis and the type of cancer related to the factors analyzed. The types of cancer most often reported were breast and cervix in women, and prostate and stomach in men. Among those who had cancer diagnoses, there was a higher consumption of fruits and vegetables, higher proportion of ex-smokers, however, increased use of alcohol. There was no difference in the frequency of exercise or incidence of being overweight between the two groups. Measures to promote health and prevent chronic diseases should be implemented in the follow-up of people who have had cancer, in an effort to ensure integrated healthcare.

Population surveys; Malignant neoplasms; Risk factors

Introduction

The diminished lethality of some types of cancer has allowed a growing number of individuals to survive a diagnosis of cancer.

In high-income countries, one observes that for the less lethal cancers, such as breast, prostate and colorectal, mortality has dropped significantly, despite the fact that for some types the incidence has remained flat or even increased. However, the more lethal forms of cancer such as lung, stomach and pancreas still have very low survival rates¹1. Allemani C, Weir HK, Carreira H, Harewood R, Spika D, Wang XS, Bannon F, Ahn JV, Johnson CJ, Bonaventure A, Marcos-Gragera R, Stiller C, Azevedo e Silva G, Chen WQ, Ogunbiyi OJ, Rachet B, Soeberg MJ, You H, Matsuda T, Bielska-Lasota M, Storm H, Tucker TC, Coleman MP; CONCORD Working Group. Global surveillance of cancer survival 1995-2009: analysis of individual data for 25,676,887 patients from 279 population-based registries in 67 countries (CONCORD-2). Lancet 2015; 385(9972):977-1010.. The situation in Brazil as a whole is unclear, although this trend is emerging among those living in state capitals in the South and Southeast with diagnoses of cancer of the breast or prostate²2. Azevedo e Silva G, Gamarra CJ, Girianelli, Valente JG. Tendência da mortalidade por câncer nas capitais e interior do Brasil entre 1980 e 2006. Rev Saude Publica, 2011; 45(6):1009-1018..

A diagnosis of cancer can motivate people to adopt healthier lifestyles. Recommendations made to people who have survived cancer treatment focus primarily on weight control, regular exercise and healthy eating habits³3. Denlinger CS, Ligibel JA, Are M, Baker KS, Demark-Wahnefried W, Dizon D, Friedman DL, Goldman M, Jones L, King A, Ku GH, Kvale E, Langbaum TS, Leonardi-Warren K, McCabe MS, Melisko M, Montoya JG, Mooney K, Morgan MA, Moslehi JJ, O’Connor T, Overholser L, Paskett ED, Peppercorn J, Raza M, Rodriguez MA, Syrjala KL, Urba SG, Wakabayashi MT, Zee P, McMillian NR, Freedman-Cass DA; National comprehensive cancer network. Survivorship: healthy lifestyles, version 2.2014. J Natl Compr Canc Netw 2014; 12(9):1222-1237.^,44. Balneaves LG, Van Patten C, Truant TL, Kelly MT, Neil SE, Campbell KL. Breast cancer survivors’ perspectives on a weight loss and physical activity lifestyle intervention. Support Care Cancer. 2014; 22(8):2057-2065.. There is evidence that cancer survivors who are no longer undergoing active treatment also benefit from the disease prevention recommendations geared towards the general population⁵5. World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington: AICR; 2007., reducing their risk of death⁶6. Arem H, Pfeiffer RM, Engels EA, Alfano CM, Hollenbeck A, Park Y, Matthews CE. Pre- and postdiagnosis physical activity, television viewing, and mortality among patients with colorectal cancer in the National Institutes of Health-AARP Diet and Health Study. J Clin Oncol 2015; 33(2):180-188..

For the first time, the joint IBGE and Ministry of Health PNS (National Health Survey)⁷7. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas – Brasil, Grandes Regiões e Unidades da Federação [Internet]. Rio de Janeiro: IBGE; 2014 [acessado 2015 jan 9]. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf conducted between 2013 and 2014 collected nationally representative data on people who received the medical diagnosis of cancer. The survey also provided data on the sociodemographic characteristics and variables indicative of lifestyle that enable looking at distinctions between adults who at some point in life were diagnosed with cancer, and those who were not. The goal of this study was to analyze factors related to lifestyle (tobacco use, eating fruits and vegetables, regular exercise and the use of alcoholic beverages) among people who have been diagnosed with cancer.

Methods

Study population, sampling and data collection

Data collected by the PNS National Health Survey was used. This is a household survey conducted by the Ministry of Health and the IBGE to assess the health, lifestyles and attention to health among adults in Brazil⁷7. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas – Brasil, Grandes Regiões e Unidades da Federação [Internet]. Rio de Janeiro: IBGE; 2014 [acessado 2015 jan 9]. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf.

The PNS sample plan used clusters in three stages. The primary units were the census sectors, the secondary units were the households, and the tertiary units household members 18 years or older. Census sectors were stratified according to four criteria: administrative (state capital, remainder of the metropolitan region or integrated economic development region (RIDE) and other cities in the State), geography (sub-divides state capitals and other large cities), status (rural or urban) and statistical.

69,954 households were selected, with one person in each chosen for a one-on-one interview. 60,202 individuals were willing to participate in the survey (final response rate of 86%)⁷7. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013: percepção do estado de saúde, estilos de vida e doenças crônicas – Brasil, Grandes Regiões e Unidades da Federação [Internet]. Rio de Janeiro: IBGE; 2014 [acessado 2015 jan 9]. Disponível em: ftp://ftp.ibge.gov.br/PNS/2013/pns2013.pdf^,88. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol. Serv. Saúde 2015; 24(2):207-216..

PNS data was collected using trained interviewers carrying hand-held computers (PDAs). A questionnaire was applied to the adult selected in each household. The questionnaire included questions about sociodemographics, self-assessed health status, lifestyle, morbidity, accidents and violence, women’s health, the health of children under 2 oral health, elderly health and performance of the healthcare system. We also conducted anthropometric and blood pressure measurements, and collected biological material. Additional information describing PNS sampling and data collection has been described by Souza-Junior et al.⁸8. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Antonaci GA, Szwarcwald CL. Desenho da amostra da Pesquisa Nacional de Saúde 2013. Epidemiol. Serv. Saúde 2015; 24(2):207-216..

Sociodemographics and referred morbidities

The variables selected for analyses were gender, age (18-29, 30-39, 40-49, 50-59, 60-69, 70-79, ≥ 80), race/color (white, black, yellow, brown, native Indian), marital status (married, separated/divorced, widowed, single), education (no education or incomplete primary school, complete primary school or incomplete secondary school, complete secondary school or incomplete university and university graduate).

Also included were questions about the diagnosis of other chronic, non-transmissible morbidities (hypertension, diabetes, coronary disease, stroke, depression, other mental health issues, asthma, rheumatism, backache, chronic obstructive pulmonary disease or other lunch diseases, chronic renal failure or other chronic non-transmissible diseases).

Cancer diagnosis

Participants were asked if they had even been diagnosed with cancer by a physician, its primary location and age at first diagnosis. To classify individuals with a diagnosis of cancer, we used the following primary locations: lung, intestine, stomach, breast, cervix, prostate and other. Individuals who reported a history of cancer were grouped by years since the first cancer diagnosis into less than ten years or ten years or more. As most skin cancers are non-melanocytic, and most of these tumors evolve satisfactorily, reports of skin cancer were not considered⁹9. Instituto Nacional de Câncer (INCA). Estatísticas de Câncer. Registros de Câncer de Base Populacional. Estimativa 2014: Incidência de Câncer no Brasil. Rio de Janeiro: INCA; 2014., which excluded 182 subjects from this analysis.

Finally, respondents were grouped by type of cancer based on the etiological relationship with the risk and protection factors analyzed in this study, and related to food (lung, intestines and stomach)⁵5. World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington: AICR; 2007.^,66. Arem H, Pfeiffer RM, Engels EA, Alfano CM, Hollenbeck A, Park Y, Matthews CE. Pre- and postdiagnosis physical activity, television viewing, and mortality among patients with colorectal cancer in the National Institutes of Health-AARP Diet and Health Study. J Clin Oncol 2015; 33(2):180-188.^,1010. Riboli E, Norat T. Epidemiologic evidence of the protective effect of fruit and vegetables on cancer risk. Am J Clin Nutr 2003; 78(Supl. 3):559S-569S.

11. Larsson SC, Orsini N, Wolk A. Processed meat consumption and stomach cancer risk: a meta-analysis. J Natl Cancer Inst 2006; 98(15):1078-1087.

12. Shikata K, Kiyohara Y, Kubo M, Yonemoto K, Ninomiya T, Shirota T, Tanizaki Y, Doi Y, Tanaka K, Oishi Y, Matsumoto T, Iida M. A prospective study of dietary salt intake and gastric cancer incidence in a defined Japanese population: the Hisayama study. Int J Cancer 2006; 119(1):196-201.

13. D’Elia L, Rossi G, Ippolito R, Cappuccio FP, Strazzullo P. Habitual salt intake and risk of gastric cancer: a meta-analysis of prospective studies. Clin Nutr 2012; 31(4):489-498.

14. Aune D, Lau R, Chan DS, Vieira R, Greenwood DC, Kampman E, Norat T. Nonlinear reduction in risk for colorectal cancer by fruit and vegetable intake based on meta-analysis of prospective studies. Gastroenterology 2011; 141(1):106-118.^-1515. Chan DS, Lau R, Aune D, Vieira R, Greenwood DC, Kampman E, Norat T. Red and processed meat and colorectal cancer incidence: meta-analysis of prospective studies. PLoS One 2011; 6:e20456., exercise (intestine, breast and prostate)¹⁶16. Boyle T, Keegel T, Bull F, Heyworth J, Fritschi L. Physical activity and risks of proximal and distal colon cancers: a systematic review and meta-analysis. J Natl Cancer Inst 2012; 104(20):1548-1561

17. Wu Y, Zhang D, Kang S. Physical activity and risk of breast cancer: a meta-analysis of prospective studies. Breast Cancer Res Treat 2013; 137(3):869-882.^-1818. Liu Y, Hu F, Li D, Wang F, Zhu L, Chen W, Ge J, An R, Zhao Y. Does physical activity reduce the risk of prostate cancer? A systematic review and meta-analysis. Eur Urol 2011; 60(5):1029-1044., use of alcohol and excess weight (intestine, stomach and breast)¹⁹19. Harriss DJ, Atkinson G, George K, Cable NT, Reilly T, Haboubi N, Zwahlen M, Egger M, Renehan AG; C-CLEAR group. Lifestyle factors and colorectal cancer risk (1):systematic review and meta-analysis of associations with body mass index. Colorectal Dis 2009; 11(6):547-563.^,2020. Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet 2008; 371(9612):569-578. and tobacco use (lung, stomach and cervix)²¹21. Bonequi P, Meneses-González F, Correa P, Rabkin CS, Camargo MC. Risk factors for gastric cancer in Latin America: a meta-analysis. Cancer Causes Control 2013; 24(2):217-231.

22. Thun MJ, Apicella LF, Henley SJ. Smoking vs other risk factors as the cause of smoking-attributable mortality: confounding in the courtroom. JAMA 2000; 284(6):706-712.^-2323. Cogliano VJ, Baan R, Straif K, Grosse Y, Lauby-Secretan B, El Ghissassi F, Bouvard V, Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Wild CP. Preventable exposures associated with human cancers. J Natl Cancer Inst 2011; 103(24):1827-1839..

Risk and protection factors

Eating cooked or raw fruits and vegetables was analyzed based on the weekly frequency (0 to 7 days), and the number of portions a day (0 to 3 or more a day). Eating 12 or more portions a week, as recommended by the World Health Organization (WHO) was considered a protection factor²⁴24. Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley & Sons Inc.; 1987..

Activities were assessed based on time spent and weekly frequency for leisure, work, household chores, going to and from work or regular activities reported in the past three months. We used two indicators for this: exercise as leisure (no/yes) and level of physical activity according to WHO recommendations²⁴24. Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley & Sons Inc.; 1987. (less than or more than 150 minutes a week).

The use of alcoholic beverages was assessed based on weekly frequency as follows: alcoholic beverages consumed in lifetime (does not drink or > once a week) and abusive use of ethanol (less than or more than 5 times a week).

Tobacco use was described as the use of any tobacco product as the share of daily smokers (smokes daily or does not smoke/smokes less than one cigarette a day) and former smokers (yes or no).

Nutritional status was assessed by calculating Body Mass Index (BMI) using self-referred weight and height data. Individuals with BMI ≥ 25 kg/m²2. Azevedo e Silva G, Gamarra CJ, Girianelli, Valente JG. Tendência da mortalidade por câncer nas capitais e interior do Brasil entre 1980 e 2006. Rev Saude Publica, 2011; 45(6):1009-1018. were considered overweight.

Treatment of missing data

Simply deleting observations with missing data is one of the most inefficient ways of treating missing data²⁵25. Schafer JL. Analysis of incomplete multivariate data. London: Chapman & Hall, CRC; 1997.^,2626. Silva PLN. Crítica e imputação de dados quantitativos utilizando o SAS [dissertação]. Rio de Janeiro: IMPA; 1989., and damages the structural information of the survey sample design, decreasing the precision of the estimates. This is why we decided to impute the relevant missing data.

Of the 60,202 respondents, 15.6% (n = 9,412) were missing weight, 27.3% were missing height (n = 16,408) and 10.9% were missing both weight and height (n = 6,559), either because the individual did not fill in this information or refused to answer. Imputation of these variables used a modeling of the sub-set of data available and auxiliary variables predictive of the missing data, specifically gender and age, added to the residuals of the adjusted model²⁷27. Little RJA, Smith PJ. Editing and imputing for quantitative survey data. Journal of the American Statistical Association 1987; 82(397):58-68.. There were no instances of missing data for the two auxiliary variables. Data was inputted using the Box-Cox transformation of the data available to achieve normalcy, followed by an estimate of the parameters of the normal multivariate model, adjusted to the data based on a robust version of the EM (Expectation-Maximization) variable developed by Little & Smith²⁸28. Breiman L, Friedman JH, Olshen RA. Classification and regression trees. Belmont: Wadsworth International Group; 1984.. Finally, the missing data was imputed using a regression with the available data used as predictors, and adding residuals from the adjusted model²⁷27. Little RJA, Smith PJ. Editing and imputing for quantitative survey data. Journal of the American Statistical Association 1987; 82(397):58-68..

We also found instances of missing information regarding the diagnosis of hypertension (3%, n = 1,787) and diabetes (11.6%, n = 6,986. As these variables might also influence the outcome and therefore had to be included in the models to avoid confounding, they were both imputed. As these losses were distributed randomly, the missing data was imputed using decision trees, a multivariate, non-parametric classification technique that enables identifying the variables to be imputed based on the predictive variables available for the entire set of individuals²⁹29. Nordbotten S. Neural Network Imputation Applied to the Norwegian 1990 Population Census Data. J Off Stat 1996; 12(4):385-401.^,3030. Wang Z, McLoone P, Morrison DS. Diet, exercise, obesity, smoking and alcohol consumption in cancer survivors and the general population: a comparative study of 16 282 individuals. Br J Cancer 2015; 112(3):572-575.. In this case, in addition to gender and age we also used the date of the last blood glucose assay for diabetes, and the date of the most recent blood pressure measurement for hypertension, as auxiliary variables to predict the missing diagnostic data.

Statistical Analysis

The relative frequency of outcomes related to food consumption (high consumption of fruits and vegetables), exercise (sedentary, failure to achieve 150 minutes/week of physical activity), drinking (alcoholic beverages ≥ 5 days a week and ≥ 1 day a week) and tobacco use (daily smoker and former smokers) were also calculated for adults with and without a diagnosis of cancer.

Poisson regressions were used to estimate prevalence ratios and their 95% confidence intervals for the association between a diagnosis of cancer and the risk and protection factors, using as a reference the population without a cancer diagnosis. Model 1 was adjusted using sociodemographic variables (age, gender, race/color and education), while model 2 used sociodemographic variables and other morbidities (hypertension, diabetes, coronary disease, stroke, depression, chronic obstructive pulmonary disease). We then ran analyses stratified by time since the cancer diagnosis (< 10 years or ≥10 years), adjusted by sociodemographic variables and other morbidities. We finally calculated the prevalence of the risk and protection factors for the types of cancer related to nutrition (lung, intestine and stomach), physical activity (intestine, breast and prostate) and tobacco use (lung, stomach and cervix). As the PNS describes only the more frequent types of cancer and consigns al others to the “other cancer” category, the tumors related to obesity we were able to study were limited to the same tumors that are related to the use of alcoholic beverages (stomach, intestine and breast). All analyses used Stata 12.1 and considered the sample design. Statistical significance was considered for p < 0.05.

Ethical Aspects

The PNS was approved by the Brazilian National Research Ethics (CONEP), and complies with National Health Board (CNS) Resolution n. 466 of December 12 2012.

Results

This study analyzed data from 59,179 individuals who had not been diagnosed with cancer and 841 who had (1,023 less 182 with a diagnosis of non-melanoma skin cancer and thus excluded from the analysis). The population diagnosed with cancer included more women and elderly, whites (Caucasians) and people with a university degree than the population that had never been diagnosed with cancer (Table 1).

The relative frequency of individuals with a diagnosis of cancer in Brazil was 1.5%, with little difference between genders (1.3% among men and 1.7% among women). The types of cancer most often reported by women were breast (0.79%, cervix (0.23%), intestine (0.16%), stomach (0.03%) and lung (0.02%). Among men, the most frequent diagnoses were prostate (0.59%), intestine (0.16%), stomach (0.08%) and lung (0.02%). The largest percentage of the cancer diagnoses (34%) had been received within the past 2 years.

Adults who had been diagnosed with cancer ate fruits and vegetables more often (PR = 1,37; CI 95% 1,11 a 1,67), and also exercised more frequently (PR = 0.90; CI 95% 0.83 - 0.98). When adjusted for other morbidities, exercise was not statistically significant. On the other hand, drinking an alcoholic beverage five or more days a week was almost twice as prevalent (PR = 2.03; IC 95% 1.23 - 3.35) among those who had been diagnosed with cancer than among those who had not. The number of former smokers was also higher in the population who had been diagnosed with cancer (PR = 1.29; IC 95% 1.08 - 1.55) (Table 2).

The frequency of eating fruits and vegetables was higher among individuals who had been diagnosed with cancer less than 10 years previously than in the population who had never been diagnosed with cancer (PR = 1,45; CI 95% 1,12 - 1,89). The proportion of former smokers in the population who had received a cancer diagnosis was only larger than in the population without a cancer diagnosis in those who had been diagnosed less than 10 years previously (RP = 1,41; IC 95% 1,16 - 1,72). On the other hand, drinking an alcoholic beverage five or more days a week was more than double (PR = 2.37; CI 95% 1.03 - 5.44), and smoking daily was almost half (PR = 0.52; CI95% 0.29 - 0.93) among those who had been diagnosed with cancer 10 years prior or more (Table 3).

The prevalence of eating fruits and vegetables among those reporting to have had any type of cancer was always higher than among those who were never diagnosed with cancer. Among those reporting having been diagnosed with cancers related to obesity or the use of ethanol, we found a diminished use of alcoholic beverages. Among those claiming to have been diagnosed with cancers related to tobacco use, the proportion of former smokers was larger. On the other hand, the percentage of people not reaching 150 minutes of exercise a week was larger among those with a diagnosis of cancer related to inactivity than among those never diagnosed with cancer (Table 4).

Discussion

The results of this study show that people who have had cancer seem to adopt, in part, healthier lifestyles, tending to eat fruits and vegetables more frequently and stop smoking. However, we found no difference in terms of exercise or obesity, and the use of alcoholic beverages was almost twice as frequent among this population.

A number of studies have shown that following a diagnosis of cancer people eat more healthy foods such as fruits and vegetables, and more of them stop smoking³¹31. Hawkins NA, Smith T, Zhao L, Rodriguez J, Berkowitz Z, Stein KD. Health-related behavior change after cancer: results of the American cancer society’s studies of cancer survivors (SCS). J Cancer Surviv 2010; 4(1):20-32.^,3232. Travis LB, Demark Wahnefried W, Allan JM, Wood ME, Ng AK. Aetiology, genetics and prevention of secondary neoplasms in adult cancer survivors. Nat Rev Clin Oncol 2013; 10(5):289-301.. Wang et al.³¹31. Hawkins NA, Smith T, Zhao L, Rodriguez J, Berkowitz Z, Stein KD. Health-related behavior change after cancer: results of the American cancer society’s studies of cancer survivors (SCS). J Cancer Surviv 2010; 4(1):20-32. looked at over 16,000 cancer survivors and concluded that they eat more fruits and vegetables and smoke less than the general population. At the same time, other studies show that for patients treated for colorectal cancer, exercise is inversely associated with the risk of death, while watching TV as leisure increases this risk⁶6. Arem H, Pfeiffer RM, Engels EA, Alfano CM, Hollenbeck A, Park Y, Matthews CE. Pre- and postdiagnosis physical activity, television viewing, and mortality among patients with colorectal cancer in the National Institutes of Health-AARP Diet and Health Study. J Clin Oncol 2015; 33(2):180-188..

Changes in lifestyle following a diagnosis of cancer have been shown to be related to improved health, both physical as well as psychological (specifically regarding tobacco and alcohol use), and to a decrease in the probability of cancer recurrence and other comorbidities³³33. Low CA, Beckjord E, Bovbjerg DH, Dew MA, Posluszny DM, Schmidt JE, Lowery AE, Nutt SA, Arvey SR, Rechis R. Correlates of positive health behaviors in cancer survivors: results from the 2010 LIVESTRONG survey. J Psychosoc Oncol 2014; 32(6):678-695.^,3434. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2008-2009. Antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. Rio de Janeiro: IBGE; 2010..

This study shows that the relationship between exercise and a diagnosis of cancer disappears after adjusting for other chronic diseases, which may indicate that exercising is recognized as an important factor for preventing other chronic diseases such as diabetes and cardiovascular disease, but not so much for cancer prevention. We found no difference in the prevalence of obesity between those with and without a cancer diagnosis, a fact that caught our attention.

Although eating more fruits and vegetables is recognized as an important cancer prevention factor, weight control requires reducing the consumption of energy-dense foods and sugary drinks⁵5. World Cancer Research Fund, American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington: AICR; 2007..

In Brazil, the rapid increase in the prevalence of excess weight and obesity is a nation-wide phenomenon³⁵35. Gomes FS, Castro IRR, Monteiro CA. Publicidade de alimentos no Brasil: avanços e desafios. Cienc. Cult. 2010; 62(4):48-51.. Exposure to advertising and other forms of marketing for these products is not well regulated, and their use is viewed as natural, with the penetration of advertising for these products facing off against the recommendations of the health authorities³⁶36. Henriques P, Dias PC, Burlandy L. A regulamentação da propaganda de alimentos no Brasil. Cad Saude Publica 2014; 30(6):1219-1228.,³⁷ making it difficult for the population to follow health authority guidelines. Furthermore, it takes more time to detect changes in excess weight due to the accumulation of body fat over our lifetimes, sometimes since early childhood.

Using the data collected in the PNS we were able to show difference in lifestyle among those who have had a cancer diagnosis. However, we must expand and adjust prevention strategies for risk factors of chronic diseases for those who have had cancer. Prospective studies to assess what happens to cancer survivors in Brazil, not only in terms of the effectiveness of the clinical treatment, but also including a broader assessment to promote health should be encouraged.

References

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History