ABSTRACT

Objective:

To evaluate the prevalence and incidence of insufficient physical activity in Brazilian adolescents and identify the most affected subgroups during the pandemic.

Methods:

This study used data from the “ConVid Adolescents - Behavior Survey”, which evaluated the behavior of 9,470 Brazilian adolescents during the period of social restriction due to the COVID-19 pandemic in 2020, through a self-administered online questionnaire. Participants were invited through a virtual “snowball” sampling procedure. Information was reported on the frequency of physical activity before and during the pandemic. The exposure variables used were gender, age group, race/skin color, region of Brazil, type of school, maternal education, financial difficulties during the pandemic, and social restrictions. Logistic regression models were used.

Results:

Adolescents engaged in less physical activity during the pandemic, as the prevalence of insufficient physical activity increased from 71.3% in the previous period to 84.3% during the pandemic. The incidence of insufficient physical activity during the pandemic was 69.6%. The subgroups of adolescents most affected were those who self-declared as black or with dark skin color, reported financial difficulties during the pandemic, lived in the Southeast and South regions of the country, and practiced intense or complete social distancing.

Conclusion:

High incidences of insufficient physical activity were observed among Brazilian adolescents during the COVID-19 pandemic. It is recommended that further studies explore periods after those analyzed to identify the behavioral dynamics of adolescents upon returning to in-person activities.

Keywords:
COVID-19; Pandemic; Adolescent; Physical activity; Physical inactivity

INTRODUCTION

COVID-19 has brought several developments to health, the economy, politics, and society since it was declared a pandemic, on March 11^th, 2020, by the World Health Organization (WHO)¹1. World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19-11 March 2020. Geneva: World Health Organization; 2020.. In Brazil, a complex epidemiological panorama was faced due to the need for public health measures to mitigate the spread of the virus and the austerity policies that were already being implemented before the outbreak of the pandemic in the country²2. Associação Brasileira de Saúde Coletiva. Plano nacional de enfrentamento à pandemia da COVID-19: frente pela vida. Brasília: Associação Brasileira de Saúde Coletiva; 2020.^,33. Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, et al. Medidas de austeridade fiscal comprometem metas de controle de doenças não transmissíveis no Brasil. Ciênc Saúde Coletiva 2018; 23(10: 3115-22. https://doi.org/10.1590/1413-812320182310.25222018
https://doi.org/https://doi.org/10.1590/... .

During the first wave of COVID-19, different social distancing measures were imposed by government and health authorities, which include closing spaces, suspending some types of commerce, banning and canceling social events⁴4. Aquino EML, Silveira IH, Pescarini JM, Aquino R, Souza-Filho JA, Rocha AS, et al. Medidas de distanciamento social no controle da pandemia de COVID-19: potenciais impactos e desafios no Brasil. Ciênc Saúde Coletiva 2020; 25(suppl 1): 2423-46. https://doi.org/10.1590/1413-81232020256.1.10502020
https://doi.org/https://doi.org/10.1590/... . With social distancing, families were encouraged to stay in their homes; however, such measures have produced fewer opportunities for an active lifestyle⁵5. Silva DRP, Werneck AO, Malta DC, Souza Júnior PRB, Azevedo LO, Barros MBA, et al. Changes in the prevalence of physical inactivity and sedentary behavior during COVID-19 pandemic: a survey with 39,693 Brazilian adults. Cad Saude Publica 2021; 37(3): e00221920. https://doi.org/10.1590/0102-311X00221920
https://doi.org/https://doi.org/10.1590/... .

Some groups, such as teenagers and young people, were particularly affected by the effects of social distancing⁶6. Malta DC, Gomes CS, Barros MBA, Lima MG, Silva AG, Cardoso LSM, et al. A pandemia de COVID-19 e mudanças nos estilos de vida dos adolescentes brasileiros. Rev Bras Epidemiol 2021; 24: E210012. https://doi.org/10.1590/1980-549720210012
https://doi.org/https://doi.org/10.1590/... . In Brazilian adolescents, there was an increase in sedentary behavior and consumption of unhealthy foods, worsening sleep quality, self-reported sadness, irritability, and loneliness due to the social distancing measures implemented⁶6. Malta DC, Gomes CS, Barros MBA, Lima MG, Silva AG, Cardoso LSM, et al. A pandemia de COVID-19 e mudanças nos estilos de vida dos adolescentes brasileiros. Rev Bras Epidemiol 2021; 24: E210012. https://doi.org/10.1590/1980-549720210012
https://doi.org/https://doi.org/10.1590/... ^,77. Szwarcwald CL, Malta DC, Barros MBA, Souza Junior PRB, Romero D, Almeida WS, et al. Associations of sociodemographic factors and health behaviors with the emotional well-being of adolescents during the COVID-19 Pandemic in Brazil. Int J Environ Res Public Health 2021; 18(11): 6160. https://doi.org/10.3390/ijerph18116160
https://doi.org/https://doi.org/10.3390/... .

Studies conducted in Saudi Arabia, Canada, and Ireland indicate a reduction in the practice of physical activity (PA) in this population group during the pandemic⁸8. Almutairi N, Burns S, Portsmouth L. Physical activity knowledge, attitude and behaviours among adolescents in the Kingdom of Saudi Arabia prior to and during COVID-19 restrictions. J Obes 2022; 2022: 1892017. https://doi.org/10.1155/2022/1892017
https://doi.org/https://doi.org/10.1155/... ^,99. Moore SA, Faulkner G, Rhodes RE, Brussoni M, Chulak-Bozzer T, Ferguson LJ, et al. Impact of the COVID-19 virus outbreak on movement and play behaviours of Canadian children and youth: a national survey. Int J Behav Nutr Phys Act 2020; 17(1): 85. https://doi.org/10.1186/s12966-020-00987-8
https://doi.org/https://doi.org/10.1186/... ^,1010. 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. https://doi.org/10.1136/bmjsem-2020-000919
https://doi.org/https://doi.org/10.1136/... . In fact, even before the advent of the pandemic, low rates of PA in adolescents were already considered a serious public health problem¹¹11. Kohl 3rd HW, Craig CL, Lambert EV, Inoue S, Alkandari JR, Leetongin G, et al. The pandemic of physical inactivity: global action for public health. Lancet 2012; 380(9838): 294-305. https://doi.org/10.1016/S0140-6736(12)60898-8
https://doi.org/https://doi.org/10.1016/... . Global estimates indicate that, before the pandemic, 81% of adolescents were insufficiently active¹²12. World Health Organization. Social determinants of health and well-being among young people: Health Behaviour in School-aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen: WHO Regional Office for Europe; 2012.. Brazil follows the same trend, with a low proportion of adolescents who meet PA guidelines, around 28% only¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar - 2019. Rio de Janeiro: IBGE; 2021.. However, the literature is very consistent regarding the health benefits provided by the practice of PA¹⁴14. Condessa LA, Chaves OC, Silva FM, Malta DC, Caiaffa WT. Fatores socioculturais associados à atividade física de meninos e meninas: PeNSE 2012. Rev Saúde Pública 2019; 53: 25. https://doi.org/10.11606/S1518-8787.2019053000516
https://doi.org/https://doi.org/10.11606... ^,1515. Malta DC, Andreazzi MAR, Oliveira-Campos M, Andrade SSCA, Sá NNB, Moura L, et al. Tendência dos fatores de risco e proteção de doenças crônicas não transmissíveis em adolescentes. Pesquisa Nacional de Saúde do Escolar (PeNSE 2009 e 2012). Rev Bras Epidemiol 2014; 17(suppl 1): 77-91. https://doi.org/10.1590/1809-4503201400050007
https://doi.org/https://doi.org/10.1590/... ^,1616. Tassitano RM, Bezerra J, Tenório MCM, Colares V, Barros MD, Hallal PC. Atividade física em adolescentes brasileiros: uma revisão sistemática. Rev Bras Cineantropom Desempenho Hum 2007; 9(1): 55-60. https://doi.org/10.1590/%25x
https://doi.org/https://doi.org/10.1590/... ^,1717. World Health Organization. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020, and recent WHO guidelines and the Physical Activity Guide for the Brazilian Population recommend that adolescents accumulate an average of 60 minutes of practice per day, as well as to include muscle and bone strengthening activities at least 3 days a week¹⁷17. World Health Organization. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020^,1818. Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Promoção da Saúde. Guia de atividade física para a população brasileira. Brasília: Ministério da Saúde; 2021.

Studies indicate that the practice of PA in adolescence is related to a greater probability of practicing PA in adulthood¹⁹19. Guthold R, Stevens GA, Riley LM, Bull FC. Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants. Lancet Child Adolesc Health 2020; 4(1): 23-35. https://doi.org/10.1016/S2352-4642(19)30323-2
https://doi.org/https://doi.org/10.1016/... ^,2020. Hallal PC, Knuth AG, Cruz DKA, Mendes MI, Malta DC. Prática de atividade física em adolescentes brasileiros. Ciênc Saúde Coletiva 2010; 15(suppl 2): 3035-42. https://doi.org/10.1590/S1413-81232010000800008
https://doi.org/https://doi.org/10.1590/... ^,2121. van Sluijs EMF, Ekelund U, Crochemore-Silva I, Guthold R, Ha A, Lubans D, et al. Physical activity behaviours in adolescence: current evidence and opportunities for intervention. Lancet 2021; 398(10298): 429-42. https://doi.org/10.1016/S0140-6736(21)01259-9
https://doi.org/https://doi.org/10.1016/... . As reported by McGuire et al. (2001), although several weeks or a few months of physical inactivity probably do not cause a sudden onset of metabolic disease, the abrupt interruption of PA can trigger changes in insulin sensitivity and muscle loss²²22. McGuire DK, Levine BD, Williamson JW, Snell PG, Blomqvist CG, Saltin B, et al. A 30-year follow-up of the Dallas Bedrest and Training Study: II. Effect of age on cardiovascular adaptation to exercise training. Circulation 2001; 104(12): 1358-66. PMID: 11560850. Additionally, a sudden decrease in PA can negatively impact depressive symptoms, anxiety, fatigue, and energy levels²³23. Wright LJ, Williams, SE, van Zanten JJCSV. Physical activity protects against the negative impact of coronavirus fear on adolescent mental health and well-being during the COVID-19 pandemic. Front Psychol 2021; 12: 580511. https://doi.org/10.3389/fpsyg.2021.580511
https://doi.org/https://doi.org/10.3389/... .

In this context, as adolescence is a period of acquiring new lifestyle habits that will be determinants of current and future health and that may constitute risk factors for diseases²⁴24. Marques A, Loureiro N, Avelar-Rosa B, Naia A, Matos MG. Adolescents’ healthy lifestyle. J Pediatr (Rio J.) 2020; 96(2): 217-24. https://www.jped.com.br/pt-adolescents-healthy-lifestyle-articulo-S2255553618302088
https://www.jped.com.br/pt-adolescents-h... ^,2525. Silva TPR, Matozinhos FP, Gratão LHA, Rocha LL, Vilela LA, Oliveira TRPR, et al. Coexistence of risk factors for cardiovascular diseases among Brazilian adolescents: individual characteristics and school environment. PLoS One 2021; 16(7): e0254838. https://doi.org/10.1371/journal.pone.0254838
https://doi.org/https://doi.org/10.1371/... ^,2626. World Health Organization. Health for the world’s adolescents: a second chance in the second decade [Internet]. Geneva: World Health Organization; 2014 [acessado em 28 fev. 2023]. Disponível em: Disponível em: https://apps.who.int/iris/handle/10665/112750
https://apps.who.int/iris/handle/10665/1... , this likely change in PA practice during the pandemic should be investigated and understood, given the difficulty in staying active due to social distancing.

Most of the studies already published in the country and around the world that evaluate changes in individuals’ lifestyles during the pandemic target the adult population, with few studies conducted with adolescents. Furthermore, to date, no national studies have been found that identify which subgroups in this age range were most affected by social distancing. The identification of these subgroups could collaborate in the development of effective measures to minimize the damage caused by the pandemic.

In this sense, the objectives of the present study were to evaluate the prevalence and incidence of insufficient PA in Brazilian adolescents and identify the subgroups most affected during the pandemic, based on the analysis of data from ConVid Adolescentes - Behavior Survey.

METHODS

Sampling

This is a cross-sectional epidemiological study that used data from ConVid Adolescentes - Behavior Survey²⁷27. Fundação Oswaldo Cruz. ConVid adolescentes - pesquisa comportamentos. Resultados finais adolescentes [Internet]. 2020 [acessado em 28 fev. 2023]. Disponível em: Disponível em: https://convid.fiocruz.br/index.php?pag=distanciamento_social_ adolescentes
https://convid.fiocruz.br/index.php?pag=... . ConVid Adolescentes is a survey that aimed to evaluate the behavior of Brazilian adolescents during the COVID-19 pandemic, carried out across the country by the Oswaldo Cruz Foundation (Fundação Oswaldo Cruz - Fiocruz) in partnership with Universidade Federal de Minas Gerais (UFMG) and Universidade Estadual de Campinas (Unicamp).

The questionnaire was prepared using the RedCap application (Research Electronic Data Capture) and self-completed by teenagers online, after consent from their guardian and the teenagers themselves, on a smartphone or computer with internet access.

Sampling was carried out using the “virtual snowball” method. Project coordinators selected researchers from different Brazilian states to begin the process, sending the research link to parents or guardians of teenagers. In addition to presenting the research, the message with the link accompanied a request for it to be shared with the network of contacts of those who received it. Upon receiving the invitation to participate in the research, parents or guardians were asked the following question: “Do you have children or are you responsible for young people aged 12 to 17yo?” Only those who responded affirmatively received the Informed Consent with explanations about the study, a link for contacts and clarifications about the research and the request for consent to participate from the minor under their responsibility. After acceptance of the Informed Consent by the responsible adult, the adolescent received the Free and Informed Assent. Only after accepting the Assent Form did the respondent begin filling out the questionnaire. Furthermore, the research coordination team contacted public and private schools, state and municipal education departments, via institutional email. The institutions that participated in the research sent the electronic questionnaires to the students’ guardians.

The anonymity of responses was guaranteed, and it was not possible to identify respondents in any way. All procedures were approved by the National Research Ethics Commission (Decision Number: 4.100.515).

Since network sampling is not probabilistic, post-stratification procedures were used to obtain a representative sample of the population of adolescents with the same distribution by region of residence, gender, age range (12-15; 16-17) and type of school (public; private), based on data from the National School Health Survey (Pesquisa Nacional de Saúde Escolar - PeNSE, 2015) of the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE) carried out in partnership with the Ministry of Health²⁸28. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar - 2015. Rio de Janeiro: IBGE; 2016..

Data collection took place between June 27^th and September 17^th, 2020. The sample reached 9,470 adolescents aged 12 to 17 years old from all Brazilian states, with questionnaires with missing information for PA (n=89) being excluded from the analyses. For incidence analyses, individuals who had insufficient PA (<300 minutes/week) before the pandemic (n=6,686) were excluded. Therefore, for analyses related to incidence, the final sample consisted of 2,695 adolescents.

Variables

The questionnaire used is available on the research website (https://convid.fiocruz.br/) and was based on questions validated in health surveys previously applied in the country, such as the National Health Survey, and monitored by the Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico - Vigitel)²⁹29. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Vigitel Brasil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2019. Brasília: Ministério da Saúde; 2020^,3030. Szwarcwald CL, Malta DC, Pereira CA, Vieira MLFP, Conde WL, Souza Júnior PRB, et al. Pesquisa Nacional de Saúde no Brasil: concepção e metodologia de aplicação. Ciênc Saúde Coletiva 2014; 19(2): 333-42. https://doi.org/10.1590/1413-81232014192.14072012
https://doi.org/https://doi.org/10.1590/... _.

Insufficient physical activity

PA was characterized by the time spent in any PA daily by adolescents. This variable was assessed by the following questions: “Before the coronavirus pandemic, on how many days did you practice PA for at least 60 minutes (1 hour) per day? E.g.: playing sports, playing ball, cycling, walking, running, taking Physical Education classes, going to school walking or cycling (Add up all the time you spent on any type of PA, each day).”; “During the pandemic, on how many days did you practice PA for at least 60 minutes (1 hour) per day? (Add up all the time you spent on any type of PA, each day).”

Insufficient PA was considered when adolescents reported performing less than 5 days of PA lasting at least 60 minutes¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar - 2019. Rio de Janeiro: IBGE; 2021..

Exposure variables

The exposure variables analyzed were: gender (female; male); age group (12 to 15; 16 to 17 years old); race/skin color (white; black; brown; others); type of school (private; public); mother’s education level (incomplete high school; complete high school; complete higher education); financial difficulties during the pandemic (yes; no); region (North; Northeast; Southeast; South; Central-West); and social restriction (no restriction; little restriction; intense restriction; total restriction). No restriction was considered when the teenager responded “I didn’t do anything, I led a normal life”; little restriction for the answer “I tried to take care, stay away from people, reduce contact a little, not visit the elderly, but I kept going out”; intense restriction when choosing the option “I stayed at home most days, going to close family members’ houses, shopping at supermarkets and pharmacies”; and total restriction when he responded “I stayed strictly at home, only leaving for health care needs”.

Data analysis

The sample characteristics were described using relative frequencies and 95% confidence intervals (95%CI). Initially, the prevalence (95% CI) of the outcome before and during the pandemic was calculated for the total sample and according to the exposure variables. Differences between prevalence rates before and during the pandemic were considered significant when there was no overlap in the 95%CI of the prevalence rates in question. Subsequently, to estimate the incidence of the outcome, adolescents who were insufficiently active before the pandemic were excluded. To verify the possible subgroups most affected by the outcome, the odds ratio was used as a measure of association, obtained through logistic regression with robust variance. The subgroups that presented p<0.20 in the univariate analyses were included in the multivariate model. In the final model, those with p<0.05 were considered to be the most affected subgroups. All analyses were performed using Stata 14.1 software and post-stratification weights were considered.

RESULTS

Table 1 presents the characteristics of the total sample. Of the 9,470 adolescents assessed, 50.3% were girls; 67.7% aged between 12 and 15 years; 46.6% were of brown race/skin color; 85.9% studied in public schools; and 41.2% lived in the Southeast region. Around a third of teenagers responded that they experienced financial difficulties during the pandemic and 45.6% said they had complied with intense social restrictions.

In the analysis of the prevalence of insufficient PA before and during the pandemic (Table 2), the differences between them were considered significant when there was no overlap in the 95%CI of the prevalences considered. Thus, an increase from 71.3 to 84.3% in the prevalence of insufficient PA was observed, that is, the number of insufficiently active adolescents increased during the isolation period, with this pattern being observed in all subgroups, except among adolescents who declared themselves to be of indigenous or yellow race/skin color (others) and that they did not make any social restrictions.

Table 3 presents the incidence of insufficient PA during the pandemic and the most affected subgroups. The subgroups that presented p<0.20 in the univariate analyses were included in the multivariate model. Approximately 70% of teenagers who were active before the pandemic became insufficiently active during the isolation period. Adolescents who self-declared to be black (ORadj 2.00; 95%CI 1.11-3.60), who reported financial difficulties during the pandemic (ORadj 1.85; 95%CI 1.37-2.48), residents in the Southeast (ORadj 2.78; 95%CI 2.02-3.84) and South (ORadj 2.16; 95%CI 1.57-2.98) regions of the country and who underwent intense (ORadj 3.41; 95%CI 1.48-7.91) and total (ORadj 2.58; 95%CI 1.09-6.10) social restrictions showed a higher incidence of insufficient PA during the pandemic.

DISCUSSION

The ConVid Adolescentes study analyzed data among Brazilian adolescents during the pandemic and found that approximately seven in ten adolescents who were active before the pandemic were no longer sufficiently active during the pandemic period. In all subgroups, the majority of active adolescents became insufficiently active. The highest incidences of insufficient PA were observed among adolescents who declared themselves black, who reported financial difficulties during the pandemic, residing in the Southeast and South regions of the country and who underwent intense and total social restriction.

This analysis represents the period in which the first wave of COVID-19 occurred in Brazil, with a rapid spread of the disease throughout the country and the adoption of strict social distancing measures, such as closing schools, workplaces, and some types of business²2. Associação Brasileira de Saúde Coletiva. Plano nacional de enfrentamento à pandemia da COVID-19: frente pela vida. Brasília: Associação Brasileira de Saúde Coletiva; 2020..

The findings of the present study indicate that the prevalence of insufficient PA increased by more than 10 percentage points during the COVID-19 pandemic among Brazilian adolescents, except among those who declared themselves to be of indigenous or yellow race/skin color (others) and who made no social restrictions. During the pandemic, the recommendation for indigenous peoples was to remain in their villages as a protective measure, which may explain the results found in this research, as indigenous communities already experience social distancing in relation to other communities for traditional and cultural reasons, and these measures were reinforced by the government³¹31. Pontes ALM, Cardoso AM, Bastos LS, Santos RV. Pandemia de Covid-19 e os povos indígenas no Brasil: cenários sociopolíticos e epidemiológicos. In: Matta GC, Rego S, Souto EP, Segata J, eds. Os impactos sociais da COVID-19 no Brasil: populações vulnerabilizadas e respostas à pandemia. Rio de Janeiro: Editora FIOCRUZ; 2021. p. 123-36.

The results revealed may have repercussions on the quality of life of these subgroups, since abrupt interruption of PA, even for a short period, is associated with negative health outcomes²³23. Wright LJ, Williams, SE, van Zanten JJCSV. Physical activity protects against the negative impact of coronavirus fear on adolescent mental health and well-being during the COVID-19 pandemic. Front Psychol 2021; 12: 580511. https://doi.org/10.3389/fpsyg.2021.580511
https://doi.org/https://doi.org/10.3389/... . The increase in insufficient PA among adolescents during the pandemic is worrying, as current PA habits can predict future trends in whether or not this practice is adhered to¹⁹19. Guthold R, Stevens GA, Riley LM, Bull FC. Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants. Lancet Child Adolesc Health 2020; 4(1): 23-35. https://doi.org/10.1016/S2352-4642(19)30323-2
https://doi.org/https://doi.org/10.1016/... ^,2121. van Sluijs EMF, Ekelund U, Crochemore-Silva I, Guthold R, Ha A, Lubans D, et al. Physical activity behaviours in adolescence: current evidence and opportunities for intervention. Lancet 2021; 398(10298): 429-42. https://doi.org/10.1016/S0140-6736(21)01259-9
https://doi.org/https://doi.org/10.1016/... ^,3232. Guan H, Okely AD, Aguilar-Farias N, Cruz BDP, Draper CE, El Hamdouchi A, et al. Promoting healthy movement behaviours among children during the COVID-19 pandemic. Lancet Child Adolesc Health 2020; 4(6): 416-8. https://doi.org/10.1016/S2352-4642(20)30131-0
https://doi.org/https://doi.org/10.1016/... _.

This result corroborates other research carried out with adolescents in different countries. A study evaluated the PA practice of a total of 726 adolescents from Italy, Spain, Brazil, Chile, and Colombia, and found that the prevalence of adolescents considered physically inactive (<300 minutes of PA/week) was 73% before social isolation and 79.5% in this period³³33. Ruíz-Roso MB, Padilha PC, Matilla-Escalante DC, Brun P, Ulloa N, Acevedo-Correa D, et al. Changes of physical activity and ultra-processed food consumption in adolescents from different countries during Covid-19 pandemic: an observational study. Nutrients 2020; 12(8): 2289. https://doi.org/10.3390/nu12082289
https://doi.org/https://doi.org/10.3390/... . In Ireland¹⁰10. 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. https://doi.org/10.1136/bmjsem-2020-000919
https://doi.org/https://doi.org/10.1136/... and Saudi Arabia⁸8. Almutairi N, Burns S, Portsmouth L. Physical activity knowledge, attitude and behaviours among adolescents in the Kingdom of Saudi Arabia prior to and during COVID-19 restrictions. J Obes 2022; 2022: 1892017. https://doi.org/10.1155/2022/1892017
https://doi.org/https://doi.org/10.1155/... , 49.7 and 59% of adolescents, respectively, reported performing less PA during the lockdown period, that is, they reduced the number of days on which they practiced at least 60 minutes of moderate to vigorous PA daily. Among Italian teenagers, the time dedicated to sports during social distancing measures decreased significantly by 2.3 hours per week³⁴34. 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. https://doi.org/10.1002/oby.22861
https://doi.org/https://doi.org/10.1002/... . Such findings can be explained by the closure of places such as schools, gyms, parks, squares, clubs and other spaces with crowds of people, in addition to the limitation of socializing with friends during the period of social isolation³⁵35. Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, et al. Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry 2020; 59(11): 1218-39. https://doi.org/10.1016/j.jaac.2020.05.009
https://doi.org/https://doi.org/10.1016/... . It is noteworthy that the school is established as a strategic space for creating leisure, sports and PA opportunities for adolescents³⁶36. Araujo RHO, Silva DRP, Gomes TNQF, Sampaio RAC, Santos AE, Silva RJS. Physical activity, TV viewing, and human development index in Brazilian adolescents: Results from the National School Health Survey. Motriz Rev Educ Fís 2021; 27: e10200159. https://doi.org/10.1590/S1980-657420210000159
https://doi.org/https://doi.org/10.1590/... ^,3737. Tenório MCM, Barros MVG, Tassitano RM, Bezerra J, Tenório JM, Hallal PC. Atividade física e comportamento sedentário em adolescentes estudantes do ensino médio. Rev Bras Epidemiol 2010; 13(1): 105-17., and the closure of these institutions made it difficult for students to continue practicing PA.

Taking into account that most adolescents generally practice PA outside the home, such as walking to school, physical education classes, recess, extracurricular and group activities³⁸38. Seabra AF, Mendonça DM, Thomis MA, Anjos LA, Maia JA. Determinantes biológicos e sócio-culturais associados à prática de atividade física de adolescentes. Cad Saúde Pública 2008; 24(4): 721-36. https://doi.org/10.1590/S0102-311X2008000400002
https://doi.org/https://doi.org/10.1590/... ^,3939. Villodres GC, García-Pérez L, Corpas JM, Muros JJ. Influence of confinement due to COVID-19 on physical activity and mediterranean diet adherence and its relationship with self-esteem in pre-adolescent students. Children (Basel) 2021; 8(10): 848. https://doi.org/10.3390/children8100848
https://doi.org/https://doi.org/10.3390/... , this situation may justify the higher incidences of insufficient PA found in this research among adolescents who experienced restrictive measures intensely or completely during the pandemic. Our data corroborates those of a literature review that found a reduction in the practice of PA in children and adolescents from different countries due to the social restrictions imposed by the pandemic in 16 of the 17 studies analyzed⁴⁰40. Milani SA, Rosa JVBX, Alcântara Junior RP, Santos G, Carril Filho RD, Carrara P, et al. Covid-19 and the influence of social restriction on physical activity among children and adolescents. J Phys Educ 2022; 33: e3348. https://doi.org/10.4025/jphyseduc.v33i1.3348
https://doi.org/https://doi.org/10.4025/... . Caldwell et al. found regional differences in Canada: children and young people who lived in regions with fewer public health restrictions practiced more PA than those who experienced more restrictive policies⁴¹41. Caldwell HA, Faulkner G, Tremblay MS, Rhodes RE, Lannoy L, Kirk SFL, et al. Regional differences in movement behaviours of children and youth during the second wave of the COVID-19 pandemic in Canada: follow-up from a national study. Can J Public Health 2022; 113(4): 535-46. https://doi.org/10.17269/s41997-022-00644-6
https://doi.org/https://doi.org/10.17269... .

In this research, adolescents from the South and Southeast regions of Brazil had a higher incidence of physical inactivity compared to the North region, which can be explained by the fact that populations from the South and Southeast had greater adherence to social restriction measures, as pointed out by some studies⁴²42. Araujo TM, Lua I. O trabalho mudou-se para casa: trabalho remoto no contexto da pandemia de COVID-19. Rev Bras Saúde Ocup 2021; 46: e27. https://doi.org/10.1590/2317-6369000030720
https://doi.org/https://doi.org/10.1590/... ^,4343. Szwarcwald CL, Souza Junior PRBS, Malta DC, Barros MBA, Magalhães MAFM, Xavier DR, et al. Adesão às medidas de restrição de contato físico e disseminação da COVID-19 no Brasil. Epidemiol Serv Saúde 2020; 29(5): e2020432. https://doi.org/10.1590/S1679-49742020000500018
https://doi.org/https://doi.org/10.1590/... . A survey analyzed remote work in the context of the pandemic and found that the regions where the most workers adopted this modality were the Southeast and South regions of the country⁴³43. Szwarcwald CL, Souza Junior PRBS, Malta DC, Barros MBA, Magalhães MAFM, Xavier DR, et al. Adesão às medidas de restrição de contato físico e disseminação da COVID-19 no Brasil. Epidemiol Serv Saúde 2020; 29(5): e2020432. https://doi.org/10.1590/S1679-49742020000500018
https://doi.org/https://doi.org/10.1590/... . With parents working from home, monitoring their children is easier and the need to leave the house can be reduced. However, a possible inadequacy of the sample in the adjustments by region in this research may have influenced these results.

When considering race and financial difficulty as proxies for socioeconomic status, the present study confirms the influence of socioeconomic level on the practice of PA⁴⁴44. Medrano M, Cadenas-Sanchez C, Oses M, Arenaza L, Amasene M, Labayen I. Changes in lifestyle behaviours during the COVID-19 confinement in Spanish children: a longitudinal analysis from the MUGI project. Pediatr Obes 2021; 16(4): e12731. https://doi.org/10.1111/ijpo.12731
https://doi.org/https://doi.org/10.1111/... ^,4545. Santos LS, Ribeiro DSS, Barreto ÍDC, Oliveira VHF, Silva DRP, Menezes AS. Association between insufficient level of physical activity and multiple health risk behaviors in adolescents. Motriz Rev Educ Fís 2019; 25(3): e101918. https://doi.org/10.1590/S1980-6574201900030003
https://doi.org/https://doi.org/10.1590/... . Adolescents who declared themselves to be black and who had financial difficulties during the pandemic had a higher incidence of insufficient PA. This association can be explained by inequalities in access and fewer opportunities to be physically active in different spaces among those with lower purchasing power, which further exacerbates health inequities¹⁷17. World Health Organization. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020^,2020. Hallal PC, Knuth AG, Cruz DKA, Mendes MI, Malta DC. Prática de atividade física em adolescentes brasileiros. Ciênc Saúde Coletiva 2010; 15(suppl 2): 3035-42. https://doi.org/10.1590/S1413-81232010000800008
https://doi.org/https://doi.org/10.1590/... . It is possible that adolescents who lived in houses with outdoor space or other large spaces, such as backyards and garages, decreased their PA levels less than those who did not have these possibilities, such as those who lived in communities and outskirts, where there is high population density, with the majority being black⁴⁶46. Lima ALS, Périsse ARS, Leandro B, Batistella CE, Araújo F, Santos JLMS et al. Covid-19 nas favelas: cartografia das desigualdades. In: Matta GC, Rego S, Souto EP, Segata J, eds. Os impactos sociais da COVID-19 no Brasil: populações vulnerabilizadas e respostas à pandemia. Rio de Janeiro: Editora FIOCRUZ; 2021. p. 111-21^,4747. Instituto de Pesquisa Econômica Aplicada. Secretaria de Políticas para as Mulheres. Secretaria de Políticas de Promoção da Igualdade Racial. Retrato das desigualdades de gênero e raça. 4a ed. Brasília: Ipea; 2011. In Spain, there was also a tendency toward a decrease in PA engagement as the socioeconomic level decreased³⁷37. Tenório MCM, Barros MVG, Tassitano RM, Bezerra J, Tenório JM, Hallal PC. Atividade física e comportamento sedentário em adolescentes estudantes do ensino médio. Rev Bras Epidemiol 2010; 13(1): 105-17.. The findings of this study reinforce what was also pointed out in other studies, that COVID-19 highlighted the vulnerabilities and inequalities that exist in society, exacerbating pre-existing racial and socioeconomic inequalities, especially between black and brown people⁴⁸48. Keys C, Nanayakkara G, Onyejekwe C, Sah RK, Wright T. Health inequalities and ethnic vulnerabilities during COVID-19 in the UK: a reflection on the PHE reports. Fem Leg Stud 2021; 29(1): 107-18. https://doi.org/10.1007/s10691-020-09446-y
https://doi.org/https://doi.org/10.1007/... ^,4949. Marinho MF, Torrens A, Teixeira R, Brant LCC, Malta DC, Nascimento BR, et al. Racial disparity in excess mortality in Brazil during COVID-19 times. Eur J Public Health 2022; 32(1): 24-6. https://doi.org/10.1093/eurpub/ckab097
https://doi.org/https://doi.org/10.1093/... . Such disparities are fueled by social determinants of health, in a society with long-standing deep structural, racial and socioeconomic inequalities⁴⁹49. Marinho MF, Torrens A, Teixeira R, Brant LCC, Malta DC, Nascimento BR, et al. Racial disparity in excess mortality in Brazil during COVID-19 times. Eur J Public Health 2022; 32(1): 24-6. https://doi.org/10.1093/eurpub/ckab097
https://doi.org/https://doi.org/10.1093/... .

Regarding the limitations of this study, some aspects should be mentioned. Due to the research design itself, some population groups may be underrepresented, such as low-income people, those with difficulty accessing the internet and those with a lower level of education. However, sample calibration using PeNSE data to generate adequate estimates reduced this limitation. Furthermore, the restricted period of data collection must be considered when interpreting the findings. PA domains were combined into a single question; Furthermore, self-reported behaviors are susceptible to memory bias and classification errors in categorical responses, such as those related to frequency and duration of PA. Finally, the number of insufficiently active adolescents may have been overestimated by the categorization of the variable that considered as active only those who practiced 60 minutes or more of PA on 5 days of the week.

It is noteworthy that this is, to date, the first nationally representative study to quantify the incidence of insufficient PA among adolescents and to identify the subgroups most affected during the COVID-19 pandemic, which could guide managers toward actions and policies to effective public health measures for this and possible future pandemic scenarios.

In summary, a high incidence of insufficient PA, with an impact on the increased prevalence of this behavior, was observed among Brazilian adolescents during the COVID-19 pandemic. The most affected population subgroups were those who declared themselves to be black, who reported financial difficulties during the pandemic, who lived in the Southeast and South regions of the country and who underwent intense and total social restrictions, which should be prioritized in intervention strategies.

Simply ending social distancing measures and resuming daily activities may not be enough to reverse the scenario identified in this study, as the worsening of the outcome observed is not an exclusive product of the pandemic context we are experiencing. The findings of this study reflect the social context of the country, marked by structural inequities that require profound changes in socioeconomic patterns²2. Associação Brasileira de Saúde Coletiva. Plano nacional de enfrentamento à pandemia da COVID-19: frente pela vida. Brasília: Associação Brasileira de Saúde Coletiva; 2020.^,44. Aquino EML, Silveira IH, Pescarini JM, Aquino R, Souza-Filho JA, Rocha AS, et al. Medidas de distanciamento social no controle da pandemia de COVID-19: potenciais impactos e desafios no Brasil. Ciênc Saúde Coletiva 2020; 25(suppl 1): 2423-46. https://doi.org/10.1590/1413-81232020256.1.10502020
https://doi.org/https://doi.org/10.1590/... . The pandemic, understood as a syndemic because it interacts with and aggravates pre-existing complications due to its intertwining with social and environmental determinants, has brought to light discussions that should be a priority on political agendas⁵⁰50. Matta GC, Rego S, Souto EP, Segata J. A COVID-19 no Brasil e as várias faces da pandemia: apresentação. In: Matta GC, Rego S, Souto EP, Segata J, eds. Os impactos sociais da COVID-19 no Brasil: populações vulnerabilizadas e respostas à pandemia. Rio de Janeiro: Editora FIOCRUZ; 2021. p. 15-24.

The search for improving the quality of life among adolescents must be present in the main health promotion strategies, with intra- and intersectoral actions being urgent, as well as the intensification of public social protection policies. These actions must involve strategies to encourage PA at home, outdoors and in school environments. In possible future pandemic scenarios, PA strategies in indoor and outdoor environments should be encouraged and organized to avoid crowds, as well as a return to PA habits prior to the pandemic period. It is recommended that new studies be conducted to evaluate adolescents’ behaviors in the years following the pandemic.

ACKNOWLEDGMENTS:

We would like to thank all the researchers who collaborated in disseminating the research and publishing it online.

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