ABC | Volume 113, Nº4, October 2019

Original Article Francisco et al. Smoking and unhealthy diet Arq Bras Cardiol. 2019; 113(4):699-709 Continuation Arterial hypertension 0.815 No 21,559 8.6 1 1 Yes 5,720 8.4 0.97 (0.79–1.19) 0.88 (0.71–1.08) Diabetes mellitus 0.658 No 25,780 8.6 1 1 Yes 1,499 8.0 0.92 (0.63–1.33) 0.83 (0.57–1.21) Dyslipidemia 0.475 No 21,485 8.7 1 1 Yes 5,794 8.1 0.93 (0.75–1.13) 0.87 (0.70–1.06) n: number of individuals in the unweighted sample. * PR adjusted : prevalence ratio adjusted for sex and age. 95% CI: 95% confidence interval. poor perception of health in the adult population. 34,41 A study involving the Brazilian population ≥18 years of age also found poor assessments of health among individuals who did not consume fruits and vegetables regularly. 41 A study conducted in Madrid, Spain with 16,043 adults (18 to 64 years old) found that the accumulation of risk factors increased the frequency of perceived poor health in a progressive manner. 34 No associations were found between the co-occurrence of risk factors and arterial hypertension, diabetes or dyslipidemia. In the analysis of individual risk factors, these conditions were only associated with an inadequate diet. National studies have not found an association between current smoking and arterial hypertension or diabetes, as found for former smokers. 42,43 A significant reduction in smoking occurred between 2006 and 2015 31,44 and a substantial increase in excess weight has occurred as a result of negative changes in the eating patterns of the population. 32,45 It should be stressed that the greatest incidence of these diseases and other health-related problems is found at more advanced ages. In the present study, the co-occurrence of the two risk factors did not necessarily express an additional risk for these outcomes in the adult population analyzed. Estimates of the clustering of behavioral risk factors for NCDs performed in international studies 1,21,34,40 have led to the recognition that many of these factors are interrelated. 17 Effective prevention resides in reducing the concomitant occurrence of various risk factors related to these diseases, on both the individual and collective levels. The incidence of a given disease is important to primary prevention, as the risk is low for the majority of individuals, regardless of the disease. 15 Strategies on the population level seek to control determinants of the disease with interventions directed at environmental factors that make the disease prevalent. 46 Stratification of the population according to risk enables the identification of its distribution in the population and the adoption of specific prevention practices focused on priority subgroups. Interventions that address multiple risk factors can have a greater impact than those focused on isolated behaviors. 2,15 The co-occurrence of health-related behaviors suggests complementary and substitutive relations. In Brazil, the goal of the Strategic Action Plan to Combat Non-Communicable Diseases is the reduction in the prevalence of smoking in the adult population from 15.1% (2011) to 9.1% (2022). Regarding dietary practices, the goal is to reduce mean salt intake from 12 g (2010) to 5 g (2022). The increase in the consumption of fruits and vegetables is on the list of monitoring indicators of the World Health Organization, but is not on the list of goals. 47 Global strategies adopted in specific contexts need to be implemented, broadened and, especially, maintained. The present study has limitations that should be considered. The sample was restricted to the population with a landline at home, which diminished the participation of the northern and northeastern regions of the country, where coverage rates are lower. However, the use of weighting factors minimized the difference between populations with and without a telephone line. 7 Further limitations include the use of self‑reported information and the impossibility of establishing causal relations due to the cross-sectional design of the study. It is not possible to affirm whether individuals with excess weight quit smoking and made changes in eating practices or whether smoking and a poor diet led to weight loss. Conclusion In the present study, the segments that are more vulnerable to the co-occurrence of smoking and an inadequate diet were residents of the southern region of the country, men, individuals with a lower socioeconomic status and those who reported binge drinking. Interventions addressing multiple behavioral risk factors, adapted to specific contexts, could have a greater impact on the Brazilian population. Regarding the management of healthcare services, information obtained from indicators can help guide the implementation, monitoring and assessment of healthcare models and actions directed at health promotion, as well as disease prevention and control. Considering the increasing social inequality in Brazil and the consolidation of a dietary system centered on monocultures for the production of ultraprocessed foods that are disseminated throughout all social strata of the population through strong marketing strategies, the promotion of health and prevention of worsening of adverse health conditions are powerful and absolutely necessary strategies for reducing the impact of social profile on health and the access of the population to healthy aging. 706