Maintaining a healthy lifestyle and being physically active is a multifactorial result and is also influenced by socioeconomic conditions. Therefore, investigating changes in a society’s lifestyle from an epidemiological perspective requires the observation of a set of variables that may or may not be clearly perceptible.
According to Triaca 14, studies covering themes such as health and economy use unemployment and mortality as main outcomes. Further, most studies showed a pro-cyclical trend in their findings (i.e., a decrease in certain behavior following worsening of economic conditions).
This is the trend found by Hone et al 15, who analyzed the effects of economic recession on mortality rate in 5565 Brazilian municipalities between 2012 and 2017, in a longitudinal study that found a direct correlation between unemployment and a percentage increase in national mortality rates, as well as between higher mortality rates among black individuals (black or brown) and greater protection against mortality in locations with better access to social protection programs.
However, in some cases,an anti-cyclic pattern is observed (i.e., inverse association of behavior with economic indicators). So, if the economy is shrinking and smoking increases, this is an anti-cyclical pattern. However, if the economy faces a downward turn and smoking also decreases, it is a pro-cyclical pattern 4, 5.
In the study developed by Xu 6, using a combination of public US government data, with men between 25 and 55 years, and in two different time periods (1984–2005 and 1976–2001), the increase in working hours as a result of the economic expansion showed a direct association with the increase in cigarette consumption, in a pro-cyclical pattern. Under another perspective, the study of Filippidis et al. 9 analyzed the impact of the great recession of 2008 on the habits of the Greek population between 2006 and 2011, with a sample of 3503 subjects. Conflicting data findings demonstrate that the impact of lifestyle on cardiovascular risk indicators may vary within the same locality when there is a stratification of society into socioeconomic classes. They revealed an increase in physical activity and a decrease in smoking and alcohol consumption in all socioeconomic strata, while there was a decrease in vegetable consumption, especially in classes with lower purchasing power.
These findings, at first, converge with the evidence that points to a pro-cyclical trend of health indicators during economic crises. However, the decline in vegetable consumption indicates the opposite, mainly because it was observed in the most impoverished classes of Greek society; that is, in the same country and during the same timeframe, pro- and anti-cyclic patterns were identified, depending on the variables that were analyzed.
Mattei et al. 16 conducted a study using data from the National Statistical Institute of Italy; the data revealed anti-cyclical tendencies when the levels of obesity and smoking between pre (2000–2007) and post-crisis years (2008–2015)were statistically compared; an increase in these indicators was observed after the great recession.
What these studies have in common is the use of a comprehensive approach, avoiding the option to use mortality and unemployment as main variables and using other factors in the analysis. We also opted for this standard in our study.
In the case of Brazil, Triaca 14 used non-parametric statistical analysis and a broad set of variables were analyzed to evaluate changes in lifestyle and the health indicators of the country’s population in at least two periods of economic crisis, covering the space between 1992 and 2014. The findings evinced an anti-cyclical trend in the early 90 s up to 1995, with a worsening in health indicators strongly related to worsening in economic indicators; however, there was a change to a pro-cyclical pattern from 2004 to 2014, when the aggravation of economic indicators was associated with improvement in mortality and health indicators.
The data found by Triaca 14 converge with the most recent literature, confirming oscillations in the relation between economic and health indicators dependent on the moments in which countries are confronted by economic crises and also on each country’s level of economic development 5, 17, 18.
The present study also points to oscillations between anti-cyclic and pro-cyclic patterns depending on the historical cut adopted. In this analysis, 2013 and 2014 presented anti-cyclical tendencies; although these years preceded the crisis period, they still presented favorable economic data. Thus, with a favorable economic situation, there was a slight improvement in the score.
However, after 2014, even with the onset of recession in the Brazilian economy, the increase in the unemployment rate, and the already sharp rate of informality, the trends in quality of life standards of the general population were not sharply affected, especially in regions with higher MHDI, a fact corroborated by the findings demonstrated in Table 2 and Fig. 1.
Thus, we found a prominent pro-cyclical trend in 2015, with a significant improvement in health indicators that make up the LS even during the acute period of the economic crisis. Another important factor to be highlighted is that trends in 2015 were directly influenced by two major sporting events held in the country: the Football World Cup in 2014 and the Summer Olympics in 2016, which, according to Lima et al. 19,could generate economic benefit and improve the standard of living of the population. However, data regarding the period after the Olympic Games were not evaluated, which makes it difficult to identify a prolonged benefit or an association with changes in the lifestyle of the post-event population.
Thus, an opposite trend with regard to the score’s progression and the national panorama’s macro and microeconomic deterioration as evinced by our analysis could be explained by a socioeconomic reserve built in earlier years, which prevents a marked degradation in the quality of life of the Brazilian population even if it occurs, as is noticeable by observing its correlation with the rate of vacancy and increase in the staple foods basket.
It is also possible to relate this change to a pro-cyclical pattern in 2015 with sporting events. However, the data found for the year 2016 show that this trend is not sustained and that the LS returns to the same standards as in 2013 in a new turn to the anti-cyclical pattern, with a worsening in health indicators following the worsening in economic indicators. This can be explained by the hypothesis raised by Oliveira 20 that the sectors benefiting from mega-events are unable to leverage the economy a thesis that can be confirmed by Brazil’s condition after the sporting mega-events.
Hypothetically, the Brazilian socioeconomic advances since 2002, with the peak of this virtuous cycle between the years 2008 and 2014 and a short period of full employment, decreased inequality, and overcoming of chronic problems such as hunger and extreme poverty 21, 22 may have contributed to protecting the population from the more pronounced deleterious effects of an economic crisis in the initial year. However, this effect seems to be limited because either the previous socioeconomic gain was insufficient in itself or the effects of the crisis were strong enough to increase social vulnerability, justifying the return of the anti-cyclical pattern.
2015 presented the greatest impact in the regression model, which makes clear its relevance as the year that escaped the anti-cyclical pattern presented in the other years. In the midst of a political and economic crisis, 2015 presented an improvement in most health-related indicators with which we formulated the LS. Consequently, the reason for the curve shift was descriptively identified without, however, identifying a causal relation that could explain these findings.
Two hypotheses have been put forth to explain the behavior of the year 2015. First, being the first year of crisis and considering that there was a virtuous economic cycle in the previous decade, the population had not yet undergone major negative changes in their pattern and lifestyle during this year. Second, major sporting events such as the Football World Cup in 2014 and the preparations for the Summer Olympics scheduled for 2016 resulted in an improvement in the quality of life and a more active lifestyle and healthier diet, which positively impacted the score of 2015, an interlude between these years.
However, this effect was transient with the aggravation of the economic and the political crisis and a strong increase in unemployment and inflation, represented in the increase in the value of the staple foods basket, as well as a decrease in average per capita income. Hence, the anti-cyclical pattern becomes present, but this time with a direct negative relation, that is, an economic degradation directly linked with a worsening in health indicators and quality of life.
Further, in our model, the region within a country where one resides is an important factor, having a great weight within the statistical model (β Northeast: 0,046; β South: 0,181; β Midwest: 0,390; β Southeast: 0.469); it was identified that the regions with the highest HDI (northeast: 0,663; south: 0,754; Midwest: 0.757; southeast: 0.766) are those with the highest direct association with the LS (northeast: 1.047; south: 1.198; midwest: 1.477; southeast: 1.598). This outcome seems to represent the country’s structure of social and economic inequality with strong historical roots 23.