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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalence of physical activity&#44; nutritional status and physical activity practice in free time and its associations with negative HSP in adolescents of both genders&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Health self-perception &#40;HSP&#41; is an indicator used in surveys and albeit subjective it is strongly related to morbidity&#44; mortality&#44; longevity and health status in different population subgroups&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;2</span></a> Specifically in adolescence&#44; HSP comprises continuous body&#44; social&#44; behavioral and mental changes&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> The prevalence of negative HSP in this age range varies from 1&#46;2&#37; to 38&#37;&#44; with girls showing the highest prevalence of negative HSP when compared to boys&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Epidemiological studies have shown that there is an association between physical activity &#40;PA&#41; and the adoption of other health-related behaviors&#44; with a consequent impact on quality of life<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;6</span></a> and HSP improvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;10</span></a> A systematic review including 16 cross-sectional studies with adolescents found that 88&#37; of the studies showed a significant association between PA practice and positive HSP&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> However&#44; the positive effects of PA can be attained in different ways&#44; and one important limitation is that most studies have only evaluated total PA&#46; Therefore&#44; other domains&#44; such as leisure PA and PA types in free time &#40;exercise&#44; sports&#44; dance&#44; and martial arts&#41; have not been investigated&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nutritional status is another relevant aspect associated with HSP in adolescents&#44; with overweight and obese adolescents showing more negative HSP compared to adolescents with normal weight&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> which has also not been considered by the studies that tested the association between PA and HSP&#46; In addition&#44; another important gap is due to the fact that the associations are not being stratified by gender&#44; which would be necessary&#44; considering that girls show a higher prevalence of negative HSP and greater dissatisfaction with body weight&#44; a fact that is directly related to nutritional status&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The identification of factors &#40;total PA&#44; leisure PA&#44; PA in free time and nutritional status&#41; associated to HSP in adolescents stratified by gender may provide specific subsidies for adolescents&#44; aiding interventions aimed at improving their HSP&#46; Thus&#44; the objective of this study was to evaluate the association of total PA&#44; PA in free time&#44; and nutritional status with HSP in adolescents of both genders&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a secondary analysis of the data from a cross-sectional&#44; school-based&#44; statewide epidemiological survey called &#8220;Physical activity practice and health risk behaviors in high school students in the state of Pernambuco&#8221;&#44; carried out between the first &#40;May and June&#41; and second semesters &#40;August&#44; September&#44; October and November&#41; of 2011&#46; The study was approved by the Research Ethics Committee of Universidade de Pernambuco &#40;CAAE no&#46; 0158&#46;0&#46;097&#46;000-10&#47;CEP-UPE&#58; 159&#47;10&#41;&#46; All the norms of Resolution no&#46; 196&#47;96 of the National Health Council were observed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The target population&#44; estimated at 373&#44;386 subjects&#44; consisted of high school students aged between 14 and 19 years enrolled in state public schools of Pernambuco&#46; A random sampling procedure with a stratified two-stage cluster sampling design was utilized&#58; &#40;1&#41; school size &#40;fewer than 200 students&#59; 200 to 499 students&#59; and 500 students or more&#41;&#44; considering the 17 Regional Education Offices &#40;GREs&#44; Ger&#234;ncias Regionais de Educa&#231;&#227;o&#41; of the state of Pernambuco&#59; and &#40;2&#41; shift &#40;day and night&#41; and grades &#40;1st&#44; 2nd and 3rd grades&#41;&#46; Schools and classes were selected using a randomizer program&#44; which provided random numbers&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For sample size calculation the following parameters were used&#58; 95&#37; Confidence Interval&#59; statistical power of 80&#37;&#59; maximum tolerable error of 2 percentage points&#59; design effect &#40;deff&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#59; and because it was a study covering the analysis of multiple risk behaviors with different frequencies of occurrence the estimated prevalence was defined as 50&#37;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The tool used for data collection was an adapted version of the Global School-based Student Health Survey &#40;GSHS&#41;&#46; Before starting the data collection&#44; the tool was validated &#40;content and face validity&#41; and submitted to a pilot study&#44; and it showed good consistency in measurements&#46; Most questions showed moderate to high reproducibility indicators&#44; and the coefficients of agreement &#40;kappa index&#41; ranged from 0&#46;62 to 1&#46;00&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The questionnaires were applied in the classroom as a collective interview&#44; without the presence of teachers&#44; and students had the opportunity to clarify any doubts while completing the questionnaires &#40;duration&#58; 30 and 40<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; A consent form was used to obtain parental permission for students under the age of 18 to participate in the study&#46; Furthermore&#44; all the students who participated in the study signed the Free and Informed Consent Form &#40;FICF&#41; and indicated their agreement to participate&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The dependent variable of this study was the HSP&#44; in which the adolescents answered the question&#44; &#8220;Overall&#44; you consider your health to be&#46;&#46;&#46;&#63;&#8221; with the following options&#58; bad&#44; regular&#44; good and excellent&#46; For the purposes of analysis&#44; the alternatives were categorized in a dichotomous manner&#58; positive &#40;excellent&#47;good&#41; and negative &#40;regular&#47;poor&#41;&#44; as shown in similar studies&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The sociodemographic variables measured in this study were&#58; &#8220;age&#8221; &#40;14&#8211;15 years&#44; 16&#8211;17 years&#44; 18&#8211;19 years&#41;&#44; &#8220;occupation&#8221; &#40;works or does not work&#41;&#44; &#8220;area of residence&#8221; &#40;urban and rural&#41;&#44; and &#8220;maternal schooling&#8221;&#44; which was stratified as &#8804;8 years of study and &#62;8 years of study&#46; Regarding the variable &#8220;PA Level&#8221;&#44; two GSHS questions were considered&#58; &#40;1&#41; &#8220;Over the last 7 days&#44; how many days were you physically active for a total of at least 60<span class="elsevierStyleHsp" style=""></span>minutes a day&#63;&#8221;&#59; and &#40;2&#41; &#8220;During a typical or normal week&#44; how many days are you physically active for a total of at least 60<span class="elsevierStyleHsp" style=""></span>minutes a day&#63;&#8221; To estimate the PA level the procedure suggested by Prochaska&#44; Sallis and Longo<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> was adopted regarding Questions 1 and 2&#44; using the following formula&#58; &#40;Question 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Question 2&#41;&#47;2&#46; If the result obtained was a value &#60;5 days&#44; the adolescents were considered insufficiently active&#59; that is&#44; they did not follow the PA recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> The practice of PA in the free time was determined by the question&#58; &#8220;Do you regularly perform some type of physical activity in your free time&#44; such as exercise&#44; sports&#44; dance or martial arts&#63;&#8221;&#44; with the dichotomous answer being &#8220;yes or no&#8221;&#46; The preferred leisure activity was dichotomously categorized into active leisure &#40;exercising&#44; playing sports&#44; biking&#44; or swimming&#41; and passive leisure &#40;watching TV&#44; playing video games&#44; using the computer&#44; talking to friends&#44; playing dominoes or cards&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">At the anthropometric assessments all adolescents wore light clothing and remained barefoot&#46; The body mass was evaluated using a Beurer electronic scale with a maximum capacity of 150<span class="elsevierStyleHsp" style=""></span>kg and a precision of 100<span class="elsevierStyleHsp" style=""></span>g&#46; Height was measured using a Wiso portable stadiometer with a 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm precision&#46; The Body Mass Index &#40;BMI&#41; was calculated by dividing the body mass in kilograms by the height in meters squared&#46; The overweight and obesity classification in adolescents considers the cutoff points proposed by the International Obesity Task Force &#40;IOTF&#41; and published by Cole et al&#46; &#40;2000&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Data tabulation was carried out using the EpiData software &#40;version 3&#46;1&#41;&#46; The data were typed in duplicate to verify data entry errors&#44; which&#44; when identified&#44; were corrected based on the original variable values&#46; Data analysis was performed using the Statistical Package for the Social Sciences &#40;SPSS&#41; version 17&#46;0 for Windows&#46; The distribution of absolute and relative frequencies was used in the descriptive analysis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Bivariate analyses were performed to evaluate the association between the dependent variable and independent variables using Pearson&#39;s Chi-squared test &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#41;&#44; and the variables that showed a descriptive level &#40;<span class="elsevierStyleItalic">p</span>-value&#41; up to 0&#46;20 were selected for the multiple analysis&#46; The Poisson regression model with robust variance was used in the multiple analysis to estimate the prevalence ratio &#40;PR&#41; and to evaluate the magnitude of the association between the dependent variable and the assessed independent variables&#46; A significance level of 0&#46;05 was set at this stage of modeling&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Multicollinearity analysis was performed assuming Variance Inflation Factor &#8211; VIF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5 and a tolerance of &#60;0&#46;20&#46; The quality of data adjustment to the constructed model was tested using the Hosmer&#8211;Lemeshow test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Those associations that showed <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#37; were considered significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">A total of 7195 students from 85 schools in 48 municipalities in Pernambuco were interviewed&#46; After 285 refusals&#44; of which 269 were by the adolescents and 16 by the parents&#44; and the exclusion of 651 questionnaires from students aged under 14 and over 19 years of age the final sample comprised 6259 students&#44; of which 59&#46;7&#37; were females with a mean age of 16&#46;6 years &#40;SD<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#46;3 years&#41;&#44; who did not work &#40;77&#46;7&#37;&#41;&#44; lived in urban areas &#40;74&#46;5&#37;&#41; and had a lower level of maternal schooling &#40;64&#46;7&#37;&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">It was observed that 27&#46;3&#37; &#40;95&#37; CI&#58; 26&#46;2&#8211;28&#46;5&#41; of the subjects reported a negative HSP&#44; the incidence of which was higher among the girls 33&#37; &#40;95&#37; CI&#58; 31&#46;5&#8211;34&#46;5&#41; compared to the boys 19&#37; &#40;95&#37; CI&#58; 17&#46;5&#8211;20&#46;6&#41;&#46; The proportion of adolescents who negatively evaluated the HSP was more frequent among those who lived in rural areas&#59; those whose mother had a lower level of schooling&#59; those who did not practice physical exercises&#44; were insufficiently active&#44; overweight and preferred more passive leisure activities &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">A higher prevalence of negative HSP was observed in boys who practiced PA for two or fewer days &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and among girls who were classified as overweight or obese &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Regarding PA in free time&#44; a higher prevalence of negative HSP was observed both in boys and girls who did not practice PA in their free time &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The need for stratification by gender was verified after testing the interaction&#46; Thus&#44; it was observed that boys who did not practice PA in their free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;44&#44; 95&#37; CI&#58; 1&#46;15&#8211;1&#46;81&#41; and who were classified as insufficiently active &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#44; 95&#37; CI&#58; 1&#46;04&#8211;1&#46;56&#41; were more likely to have a negative HSP even after adjusting for potential confounding factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding the girls&#44; it was observed after the adjustment that those who did not practice PA in their free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;15&#44; 95&#37; CI&#58; 1&#46;02&#8211;1&#46;29&#41; and were classified as overweight &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#59; 95&#37; CI&#58; 1&#46;01&#8211;1&#46;29&#41; were more likely to have a negative HSP &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The main objective of this study was to evaluate the association of total PA&#44; PA in free time&#44; and nutritional status with HSP in adolescents&#46; The main results were&#58; &#40;i&#41; a high prevalence of negative HSP was observed&#44; particularly among girls&#59; &#40;ii&#41; adolescents living in rural areas&#44; whose mothers had a lower level of schooling&#44; who did not practice PA in their free time&#44; were insufficiently active&#44; were overweight&#44; and preferred more passive leisure activities had a higher negative HSP&#59; &#40;iii&#41; a negative HSP was associated with nutritional status in girls and a lower level of PA in boys&#59; and &#40;iv&#41; adolescents of both genders who did not practice PA during their free time were more likely to have a negative HSP&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The prevalence of negative HSP observed in the present study was 27&#46;3&#37; higher than that found in other national<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;7&#44;18&#8211;21</span></a> and international<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9&#44;22</span></a> studies with adolescents&#46; In Brazil&#44; national surveys are not available for this population subgroup&#59; however&#44; state and municipal studies show a prevalence of negative HSP in adolescents ranging from 11&#46;5&#37;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> to 25&#46;7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> The differences found in Brazilian studies may be due to different socioeconomic&#44; cultural and environmental characteristics&#44; as well as access to and quality of health services and care offered to the population&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">As in most studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8&#44;18&#8211;21</span></a> girls have a higher prevalence of negative HSP compared to boys&#46; In agreement with this result&#44; a study carried out to assess the temporal tendency of HSP in adolescents from 32 countries in Europe and North America observed that girls report a higher negative HSP than boys in all the assessed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> This difference in HSP between genders may be related to cultural issues related to a belief that girls undergo more routine examinations and have more doctor&#39;s appointments&#44; all of which increases the chance of early diagnosis of a disease&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Moreover&#44; girls are more aware&#44; sensitive and better informed about health&#44; thus perceiving it in a broader manner&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;25</span></a> Therefore&#44; compared to boys they consider a larger set of factors when making overall health classifications&#44; such as psychological factors and small subjective health complaints&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Additionally&#44; studies have highlighted greater body dissatisfaction among girls&#44; perhaps due to an exacerbated media pressure on the female body&#44; and such dissatisfaction may have repercussions on the HSP&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The present study showed that sociodemographic factors&#44; such as living in rural areas and having a lower level of maternal schooling were associated with a negative HSP&#46; Similar results were found in other national studies<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;18&#44;21</span></a>&#59; they demonstrate the importance of social and economic issues among the aspects that can influence HSP in adolescents&#46; Specifically in Brazil it can be observed that vulnerabilities are not evenly distributed within the society&#8211;space ratio&#44; especially in rural areas&#44; and they are mainly perceivable by the scarcity of choices of leisure&#44; culture and sports practice&#44; as well as a lack of public communal areas&#44; which in turn affects the quality of life of adolescents&#44; especially regarding health-related aspects&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> Moreover&#44; in a study carried out with adolescents living in rural areas in Brazil it was possible to observe that health conceptions revealed the inequalities and difficulties regarding their access to health care&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> which may partially explain the results that were found&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Regarding the social issues&#44; a higher purchasing power is a determining factor for greater access to other forms of leisure activities&#44; education&#44; housing&#44; and health services&#44; and thus it can act as a mediator of the HSP level&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23&#44;24</span></a> Moreover&#44; parents with higher levels of schooling tend to better understand what being healthy means and what their children need&#44; which leads them to have better health levels&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Another interesting point found in the present study is that behavioral issues may have different effects on HSP when comparing adolescents of both genders&#46; It is noteworthy that boys and girls have different understandings regarding their health status&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> In this sense&#44; it was observed that only among boys a negative HSP is associated with the level of total PA&#46; It is believed that the practice of PA in adolescence has a positive effect on self-image and the reduction of anxiety and depression symptoms&#59; therefore&#44; those effects combined are capable of generating a more positive HSP&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">It was observed that the nutritional status among girls&#44; which may be related to esthetics&#44; was associated with HSP&#44; as those who were classified as overweight were more likely to have a negative HSP&#44; an association not found in boys&#46; In a study carried out with the same target audience of the present investigation it was emphasized that there is a tendency for boys to feel good about their body image regardless of the nutritional status&#44; unlike what happens with girls&#44; who tend to overestimate their weight and show a greater dissatisfaction with their body image&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In this sense&#44; it can be observed that anthropometric issues such as overweight interfere with the HSP mainly in girls&#46; The results of the study by Heshmat et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> showed a significant association between girls with higher BMI and a negative HSP&#59; the same result was not found among boys&#46; Adolescents with excess weight are more vulnerable to social discrimination&#44; and particularly girls are more concerned with body fat and more likely to consider themselves fat&#44; when compared to boys&#46; The latter&#44; in turn&#44; are less interested in weight loss and more concerned with masculinity-related issues&#44; such as increasing muscle mass&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> Those differences in body image between both genders may partially explain the association between anthropometric issues in girls and negative HSP&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">It was observed that not practicing PA in the free time was associated with a negative HSP in both genders&#46; In this sense&#44; a study with Swedish adolescents showed that the ones who did not practice sports and showed a low level of PA had a higher prevalence of negative HSP&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> One of the possible explanations for this association is focused on the beneficial effect of PA on monoamines in the brain&#44; which affect neurotransmission by attenuating anxiety&#44; tension and stress&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> or on the production of endorphins and reduction of pain&#44; thus increasing the sense of well-being&#44; which has clear consequences on mental health&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> These findings are consistent with those from other studies&#44; such as the one carried out in the city of Jo&#227;o Pessoa&#44; in the state of Para&#237;ba&#44; Brazil&#44; which found that adolescents who did not reach the recommendations for PA practice and those who were overweight were three times more likely to have negative HSP when compared to their sufficiently active peers and those with normal weight&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> However&#44; the results in that study were not stratified by gender and the participation of adolescents in other domains and types of PA was not observed&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Certain limitations of the present study should be considered&#46; While we acknowledge that direct methods would bring more accurate information&#44; the levels of total PA and PA practiced in the free time were obtained by indirect measurement&#46; Moreover&#44; despite the use of a representative sample the generalization of the collected data to all adolescents should be treated with caution&#44; since the study was restricted to students from the state public school system&#46; Additionally&#44; there is also the possibility of reverse causality as an inherent characteristic of cross-sectional studies&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Among the strengths of the present research we can highlight the representativeness of the student population of public high schools in the state of Pernambuco&#44; the use of a previously tested questionnaire that had a moderate-to-high reproducibility level&#44; and the control of variables affecting the analysis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">It was concluded that a negative HSP was associated with nutritional status in girls and with a lower level of PA in boys&#46; Furthermore&#44; the practice of PA in the free time was considered a protective factor for a negative HSP in adolescents of both genders&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Conflicts of interest"
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        9 => array:2 [
          "identificador" => "xack423183"
          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2018-01-10"
    "fechaAceptado" => "2018-04-18"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1147560"
          "palabras" => array:4 [
            0 => "Adolescent health"
            1 => "Physical activity"
            2 => "Lifestyle"
            3 => "Prevalence"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1147561"
          "palabras" => array:4 [
            0 => "Sa&#250;de do adolescente"
            1 => "Atividade f&#237;sica"
            2 => "Estilo de vida"
            3 => "Preval&#234;ncia"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the association between total physical activities&#44; physical activity in free time and nutritional status with self-perceived health in adolescents of both genders&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a quantitative study that integrates the school-based&#44; cross-sectional epidemiological survey with statewide coverage&#44; whose sample consisted of 6261 adolescents &#40;14&#8211;19 years old&#41; selected by random conglomerate sampling&#46; Data were collected using the Global School-based Student Health Survey&#46; The chi-squared test &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#41; and the Poisson regression model with robust variance were used in the data analyses&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">It was observed that 27&#46;3&#37; of the adolescents had a negative health self-perception&#44; which was higher among girls &#40;33&#46;0&#37; <span class="elsevierStyleItalic">vs&#46;</span> 19&#46;0&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; After adjusting for potential confounding factors&#44; it was observed that boys who did not practice physical activity during free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;44&#44; 95&#37; CI&#58; 1&#46;15&#8211;1&#46;81&#41; and were classified as insufficiently active &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#44; 95&#37; CI&#58; 1&#46;04&#8211;1&#46;56&#41;&#44; as well as girls who did not practice physical activity during free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;15&#44; 95&#37; CI&#58; 1&#46;02&#8211;1&#46;29&#41; and were classified as overweight &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#44; 95&#37; CI&#58; 1&#46;01&#8211;1&#46;29&#41; had a greater chance of negative health self-perception&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Behavioral issues may have different effects on health self-perception when comparing boys with girls&#46; Negative health self-perception was associated with nutritional status in girls and a lower level of physical activity in boys&#44; and the practice of physical activity in the free time was considered a protective factor against a negative health self-perception for adolescents of both genders&#46;</p></span>"
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            "identificador" => "abst0005"
            "titulo" => "Objective"
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            "identificador" => "abst0010"
            "titulo" => "Methods"
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            "titulo" => "Results"
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            "titulo" => "Conclusion"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar a associa&#231;&#227;o entre atividade f&#237;sica total&#44; atividade f&#237;sica no tempo livre e estado nutricional com a autopercep&#231;&#227;o de sa&#250;de em adolescentes de ambos os sexos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Trata-se de um estudo com abordagem quantitativa&#44; que integra o levantamento epidemiol&#243;gico transversal de base escolar e abrang&#234;ncia estadual&#44; cuja amostra foi constitu&#237;da por 6&#46;261 adolescentes &#40;14 a 19 anos&#41; selecionados por meio de uma estrat&#233;gia de amostragem aleat&#243;ria de conglomerados&#46; Os dados foram coletados a partir do question&#225;rio <span class="elsevierStyleItalic">Global School-based Student Health Survey</span>&#46; O teste de qui-quadrado &#40;&#967;<span class="elsevierStyleSup">2</span>&#41; e o modelo de regress&#227;o de Poisson com vari&#226;ncia robusta foram usados nas an&#225;lises dos dados&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Observou-se que 27&#44;3&#37; dos adolescentes tinham uma autopercep&#231;&#227;o de sa&#250;de negativa&#44; sendo maior entre as meninas &#40;33&#44;0&#37; <span class="elsevierStyleItalic">vs</span>&#46; 19&#44;0&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Ap&#243;s o ajuste pelos potenciais fatores de confus&#227;o&#44; constatou-se que tinham maior chance de ter uma autopercep&#231;&#227;o de sa&#250;de negativa os meninos que n&#227;o praticavam atividade f&#237;sica no tempo livre &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;44&#59; IC 95&#37;&#58; 1&#44;15-1&#44;81&#41; e que eram classificados como insuficientemente ativos &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;27&#59; IC 95&#37;&#58; 1&#44;04-1&#44;56&#41; e as meninas que n&#227;o praticavam atividade f&#237;sica no tempo livre &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;15&#59; IC 95&#37;&#58; 1&#44;02-1&#44;29&#41; e que eram classificadas como sobrepesadas &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;27&#59; IC 95&#37;&#58; 1&#44;01-1&#44;29&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Quest&#245;es comportamentais podem ter diferentes repercuss&#245;es na autopercep&#231;&#227;o de sa&#250;de quando comparados os meninos e meninas&#46; A autopercep&#231;&#227;o de sa&#250;de negativa esteve associada ao estado nutricional entre as meninas e a um menor n&#237;vel de atividade f&#237;sica entre os meninos e a pr&#225;tica de atividade f&#237;sica no tempo livre foi tida como fator de prote&#231;&#227;o para uma autopercep&#231;&#227;o de sa&#250;de negativa para os adolescentes de ambos os sexos&#46;</p></span>"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Silva AO&#44; Diniz PR&#44; Santos ME&#44; Ritti-Dias RM&#44; Farah BQ&#44; Tassitano RM&#44; et al&#46; Health self-perception and its association with physical activity and nutritional status in adolescents&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;458&#8211;65&#46;</p>"
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        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at Universidade de Pernambuco &#40;UPE&#41;&#44; Recife&#44; PE&#44; Brazil&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalence of physical activity&#44; nutritional status and physical activity practice in free time and its associations with negative HSP in adolescents of both genders&#46;</p>"
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="6" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative health self-perception</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PR</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PR</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Crude&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adjusted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Physical activity level</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;019</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Insufficiently active&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;13&#8211;1&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;04&#8211;1&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Physical activity in free time</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;26&#8211;1&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;15&#8211;1&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Preferred leisure type</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;067</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;825</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active leisure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Passive leisure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99&#8211;1&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;83&#8211;1&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Nutritional status</span></td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;647</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="3" align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;625</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal weight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Overweight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&#8211;1&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&#8211;1&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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Original article
Health self-perception and its association with physical activity and nutritional status in adolescents
Autopercepção de saúde e sua associação com atividade física e estado nutricional em adolescentes
Alison Oliveira da Silvaa,
Corresponding author
alison.oli@hotmail.com

Corresponding author.
, Paula R.B. Dinizb, Maria E.P. Santosc, Raphael M. Ritti-Diasd, Breno Q. Farahe, Rafael M. Tassitanoe, Luciano M.F.T. Oliveirab,c
a Programa Associado de Pós-Graduação em Educação Física (UPE/UFPB), Recife, PE, Brazil
b Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
c Centro Universitário Tabosa de Almeida (Asces-Unita), Caruaru, PE, Brazil
d Universidade Nove de Julho, São Paulo, SP, Brazil
e Universidade Federal Rural de Pernambuco (UFRPE), Recife, PE, Brazil
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and the adoption of other health-related behaviors&#44; with a consequent impact on quality of life<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;6</span></a> and HSP improvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;10</span></a> A systematic review including 16 cross-sectional studies with adolescents found that 88&#37; of the studies showed a significant association between PA practice and positive HSP&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> However&#44; the positive effects of PA can be attained in different ways&#44; and one important limitation is that most studies have only evaluated total PA&#46; Therefore&#44; other domains&#44; such as leisure PA and PA types in free time &#40;exercise&#44; sports&#44; dance&#44; and martial arts&#41; have not been investigated&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nutritional status is another relevant aspect associated with HSP in adolescents&#44; with overweight and obese adolescents showing more negative HSP compared to adolescents with normal weight&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> which has also not been considered by the studies that tested the association between PA and HSP&#46; In addition&#44; another important gap is due to the fact that the associations are not being stratified by gender&#44; which would be necessary&#44; considering that girls show a higher prevalence of negative HSP and greater dissatisfaction with body weight&#44; a fact that is directly related to nutritional status&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The identification of factors &#40;total PA&#44; leisure PA&#44; PA in free time and nutritional status&#41; associated to HSP in adolescents stratified by gender may provide specific subsidies for adolescents&#44; aiding interventions aimed at improving their HSP&#46; Thus&#44; the objective of this study was to evaluate the association of total PA&#44; PA in free time&#44; and nutritional status with HSP in adolescents of both genders&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is a secondary analysis of the data from a cross-sectional&#44; school-based&#44; statewide epidemiological survey called &#8220;Physical activity practice and health risk behaviors in high school students in the state of Pernambuco&#8221;&#44; carried out between the first &#40;May and June&#41; and second semesters &#40;August&#44; September&#44; October and November&#41; of 2011&#46; The study was approved by the Research Ethics Committee of Universidade de Pernambuco &#40;CAAE no&#46; 0158&#46;0&#46;097&#46;000-10&#47;CEP-UPE&#58; 159&#47;10&#41;&#46; All the norms of Resolution no&#46; 196&#47;96 of the National Health Council were observed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The target population&#44; estimated at 373&#44;386 subjects&#44; consisted of high school students aged between 14 and 19 years enrolled in state public schools of Pernambuco&#46; A random sampling procedure with a stratified two-stage cluster sampling design was utilized&#58; &#40;1&#41; school size &#40;fewer than 200 students&#59; 200 to 499 students&#59; and 500 students or more&#41;&#44; considering the 17 Regional Education Offices &#40;GREs&#44; Ger&#234;ncias Regionais de Educa&#231;&#227;o&#41; of the state of Pernambuco&#59; and &#40;2&#41; shift &#40;day and night&#41; and grades &#40;1st&#44; 2nd and 3rd grades&#41;&#46; Schools and classes were selected using a randomizer program&#44; which provided random numbers&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For sample size calculation the following parameters were used&#58; 95&#37; Confidence Interval&#59; statistical power of 80&#37;&#59; maximum tolerable error of 2 percentage points&#59; design effect &#40;deff&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#59; and because it was a study covering the analysis of multiple risk behaviors with different frequencies of occurrence the estimated prevalence was defined as 50&#37;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The tool used for data collection was an adapted version of the Global School-based Student Health Survey &#40;GSHS&#41;&#46; Before starting the data collection&#44; the tool was validated &#40;content and face validity&#41; and submitted to a pilot study&#44; and it showed good consistency in measurements&#46; Most questions showed moderate to high reproducibility indicators&#44; and the coefficients of agreement &#40;kappa index&#41; ranged from 0&#46;62 to 1&#46;00&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The questionnaires were applied in the classroom as a collective interview&#44; without the presence of teachers&#44; and students had the opportunity to clarify any doubts while completing the questionnaires &#40;duration&#58; 30 and 40<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; A consent form was used to obtain parental permission for students under the age of 18 to participate in the study&#46; Furthermore&#44; all the students who participated in the study signed the Free and Informed Consent Form &#40;FICF&#41; and indicated their agreement to participate&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The dependent variable of this study was the HSP&#44; in which the adolescents answered the question&#44; &#8220;Overall&#44; you consider your health to be&#46;&#46;&#46;&#63;&#8221; with the following options&#58; bad&#44; regular&#44; good and excellent&#46; For the purposes of analysis&#44; the alternatives were categorized in a dichotomous manner&#58; positive &#40;excellent&#47;good&#41; and negative &#40;regular&#47;poor&#41;&#44; as shown in similar studies&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The sociodemographic variables measured in this study were&#58; &#8220;age&#8221; &#40;14&#8211;15 years&#44; 16&#8211;17 years&#44; 18&#8211;19 years&#41;&#44; &#8220;occupation&#8221; &#40;works or does not work&#41;&#44; &#8220;area of residence&#8221; &#40;urban and rural&#41;&#44; and &#8220;maternal schooling&#8221;&#44; which was stratified as &#8804;8 years of study and &#62;8 years of study&#46; Regarding the variable &#8220;PA Level&#8221;&#44; two GSHS questions were considered&#58; &#40;1&#41; &#8220;Over the last 7 days&#44; how many days were you physically active for a total of at least 60<span class="elsevierStyleHsp" style=""></span>minutes a day&#63;&#8221;&#59; and &#40;2&#41; &#8220;During a typical or normal week&#44; how many days are you physically active for a total of at least 60<span class="elsevierStyleHsp" style=""></span>minutes a day&#63;&#8221; To estimate the PA level the procedure suggested by Prochaska&#44; Sallis and Longo<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> was adopted regarding Questions 1 and 2&#44; using the following formula&#58; &#40;Question 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Question 2&#41;&#47;2&#46; If the result obtained was a value &#60;5 days&#44; the adolescents were considered insufficiently active&#59; that is&#44; they did not follow the PA recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> The practice of PA in the free time was determined by the question&#58; &#8220;Do you regularly perform some type of physical activity in your free time&#44; such as exercise&#44; sports&#44; dance or martial arts&#63;&#8221;&#44; with the dichotomous answer being &#8220;yes or no&#8221;&#46; The preferred leisure activity was dichotomously categorized into active leisure &#40;exercising&#44; playing sports&#44; biking&#44; or swimming&#41; and passive leisure &#40;watching TV&#44; playing video games&#44; using the computer&#44; talking to friends&#44; playing dominoes or cards&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">At the anthropometric assessments all adolescents wore light clothing and remained barefoot&#46; The body mass was evaluated using a Beurer electronic scale with a maximum capacity of 150<span class="elsevierStyleHsp" style=""></span>kg and a precision of 100<span class="elsevierStyleHsp" style=""></span>g&#46; Height was measured using a Wiso portable stadiometer with a 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm precision&#46; The Body Mass Index &#40;BMI&#41; was calculated by dividing the body mass in kilograms by the height in meters squared&#46; The overweight and obesity classification in adolescents considers the cutoff points proposed by the International Obesity Task Force &#40;IOTF&#41; and published by Cole et al&#46; &#40;2000&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Data tabulation was carried out using the EpiData software &#40;version 3&#46;1&#41;&#46; The data were typed in duplicate to verify data entry errors&#44; which&#44; when identified&#44; were corrected based on the original variable values&#46; Data analysis was performed using the Statistical Package for the Social Sciences &#40;SPSS&#41; version 17&#46;0 for Windows&#46; The distribution of absolute and relative frequencies was used in the descriptive analysis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Bivariate analyses were performed to evaluate the association between the dependent variable and independent variables using Pearson&#39;s Chi-squared test &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#41;&#44; and the variables that showed a descriptive level &#40;<span class="elsevierStyleItalic">p</span>-value&#41; up to 0&#46;20 were selected for the multiple analysis&#46; The Poisson regression model with robust variance was used in the multiple analysis to estimate the prevalence ratio &#40;PR&#41; and to evaluate the magnitude of the association between the dependent variable and the assessed independent variables&#46; A significance level of 0&#46;05 was set at this stage of modeling&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Multicollinearity analysis was performed assuming Variance Inflation Factor &#8211; VIF<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5 and a tolerance of &#60;0&#46;20&#46; The quality of data adjustment to the constructed model was tested using the Hosmer&#8211;Lemeshow test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Those associations that showed <span class="elsevierStyleItalic">&#945;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#37; were considered significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">A total of 7195 students from 85 schools in 48 municipalities in Pernambuco were interviewed&#46; After 285 refusals&#44; of which 269 were by the adolescents and 16 by the parents&#44; and the exclusion of 651 questionnaires from students aged under 14 and over 19 years of age the final sample comprised 6259 students&#44; of which 59&#46;7&#37; were females with a mean age of 16&#46;6 years &#40;SD<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#46;3 years&#41;&#44; who did not work &#40;77&#46;7&#37;&#41;&#44; lived in urban areas &#40;74&#46;5&#37;&#41; and had a lower level of maternal schooling &#40;64&#46;7&#37;&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">It was observed that 27&#46;3&#37; &#40;95&#37; CI&#58; 26&#46;2&#8211;28&#46;5&#41; of the subjects reported a negative HSP&#44; the incidence of which was higher among the girls 33&#37; &#40;95&#37; CI&#58; 31&#46;5&#8211;34&#46;5&#41; compared to the boys 19&#37; &#40;95&#37; CI&#58; 17&#46;5&#8211;20&#46;6&#41;&#46; The proportion of adolescents who negatively evaluated the HSP was more frequent among those who lived in rural areas&#59; those whose mother had a lower level of schooling&#59; those who did not practice physical exercises&#44; were insufficiently active&#44; overweight and preferred more passive leisure activities &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">A higher prevalence of negative HSP was observed in boys who practiced PA for two or fewer days &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and among girls who were classified as overweight or obese &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Regarding PA in free time&#44; a higher prevalence of negative HSP was observed both in boys and girls who did not practice PA in their free time &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The need for stratification by gender was verified after testing the interaction&#46; Thus&#44; it was observed that boys who did not practice PA in their free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;44&#44; 95&#37; CI&#58; 1&#46;15&#8211;1&#46;81&#41; and who were classified as insufficiently active &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#44; 95&#37; CI&#58; 1&#46;04&#8211;1&#46;56&#41; were more likely to have a negative HSP even after adjusting for potential confounding factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding the girls&#44; it was observed after the adjustment that those who did not practice PA in their free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;15&#44; 95&#37; CI&#58; 1&#46;02&#8211;1&#46;29&#41; and were classified as overweight &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#59; 95&#37; CI&#58; 1&#46;01&#8211;1&#46;29&#41; were more likely to have a negative HSP &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The main objective of this study was to evaluate the association of total PA&#44; PA in free time&#44; and nutritional status with HSP in adolescents&#46; The main results were&#58; &#40;i&#41; a high prevalence of negative HSP was observed&#44; particularly among girls&#59; &#40;ii&#41; adolescents living in rural areas&#44; whose mothers had a lower level of schooling&#44; who did not practice PA in their free time&#44; were insufficiently active&#44; were overweight&#44; and preferred more passive leisure activities had a higher negative HSP&#59; &#40;iii&#41; a negative HSP was associated with nutritional status in girls and a lower level of PA in boys&#59; and &#40;iv&#41; adolescents of both genders who did not practice PA during their free time were more likely to have a negative HSP&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The prevalence of negative HSP observed in the present study was 27&#46;3&#37; higher than that found in other national<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;7&#44;18&#8211;21</span></a> and international<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;9&#44;22</span></a> studies with adolescents&#46; In Brazil&#44; national surveys are not available for this population subgroup&#59; however&#44; state and municipal studies show a prevalence of negative HSP in adolescents ranging from 11&#46;5&#37;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> to 25&#46;7&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> The differences found in Brazilian studies may be due to different socioeconomic&#44; cultural and environmental characteristics&#44; as well as access to and quality of health services and care offered to the population&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">As in most studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;8&#44;18&#8211;21</span></a> girls have a higher prevalence of negative HSP compared to boys&#46; In agreement with this result&#44; a study carried out to assess the temporal tendency of HSP in adolescents from 32 countries in Europe and North America observed that girls report a higher negative HSP than boys in all the assessed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> This difference in HSP between genders may be related to cultural issues related to a belief that girls undergo more routine examinations and have more doctor&#39;s appointments&#44; all of which increases the chance of early diagnosis of a disease&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Moreover&#44; girls are more aware&#44; sensitive and better informed about health&#44; thus perceiving it in a broader manner&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8&#44;25</span></a> Therefore&#44; compared to boys they consider a larger set of factors when making overall health classifications&#44; such as psychological factors and small subjective health complaints&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Additionally&#44; studies have highlighted greater body dissatisfaction among girls&#44; perhaps due to an exacerbated media pressure on the female body&#44; and such dissatisfaction may have repercussions on the HSP&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The present study showed that sociodemographic factors&#44; such as living in rural areas and having a lower level of maternal schooling were associated with a negative HSP&#46; Similar results were found in other national studies<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">7&#44;18&#44;21</span></a>&#59; they demonstrate the importance of social and economic issues among the aspects that can influence HSP in adolescents&#46; Specifically in Brazil it can be observed that vulnerabilities are not evenly distributed within the society&#8211;space ratio&#44; especially in rural areas&#44; and they are mainly perceivable by the scarcity of choices of leisure&#44; culture and sports practice&#44; as well as a lack of public communal areas&#44; which in turn affects the quality of life of adolescents&#44; especially regarding health-related aspects&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> Moreover&#44; in a study carried out with adolescents living in rural areas in Brazil it was possible to observe that health conceptions revealed the inequalities and difficulties regarding their access to health care&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> which may partially explain the results that were found&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Regarding the social issues&#44; a higher purchasing power is a determining factor for greater access to other forms of leisure activities&#44; education&#44; housing&#44; and health services&#44; and thus it can act as a mediator of the HSP level&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">23&#44;24</span></a> Moreover&#44; parents with higher levels of schooling tend to better understand what being healthy means and what their children need&#44; which leads them to have better health levels&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Another interesting point found in the present study is that behavioral issues may have different effects on HSP when comparing adolescents of both genders&#46; It is noteworthy that boys and girls have different understandings regarding their health status&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> In this sense&#44; it was observed that only among boys a negative HSP is associated with the level of total PA&#46; It is believed that the practice of PA in adolescence has a positive effect on self-image and the reduction of anxiety and depression symptoms&#59; therefore&#44; those effects combined are capable of generating a more positive HSP&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">It was observed that the nutritional status among girls&#44; which may be related to esthetics&#44; was associated with HSP&#44; as those who were classified as overweight were more likely to have a negative HSP&#44; an association not found in boys&#46; In a study carried out with the same target audience of the present investigation it was emphasized that there is a tendency for boys to feel good about their body image regardless of the nutritional status&#44; unlike what happens with girls&#44; who tend to overestimate their weight and show a greater dissatisfaction with their body image&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In this sense&#44; it can be observed that anthropometric issues such as overweight interfere with the HSP mainly in girls&#46; The results of the study by Heshmat et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> showed a significant association between girls with higher BMI and a negative HSP&#59; the same result was not found among boys&#46; Adolescents with excess weight are more vulnerable to social discrimination&#44; and particularly girls are more concerned with body fat and more likely to consider themselves fat&#44; when compared to boys&#46; The latter&#44; in turn&#44; are less interested in weight loss and more concerned with masculinity-related issues&#44; such as increasing muscle mass&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> Those differences in body image between both genders may partially explain the association between anthropometric issues in girls and negative HSP&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">It was observed that not practicing PA in the free time was associated with a negative HSP in both genders&#46; In this sense&#44; a study with Swedish adolescents showed that the ones who did not practice sports and showed a low level of PA had a higher prevalence of negative HSP&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> One of the possible explanations for this association is focused on the beneficial effect of PA on monoamines in the brain&#44; which affect neurotransmission by attenuating anxiety&#44; tension and stress&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> or on the production of endorphins and reduction of pain&#44; thus increasing the sense of well-being&#44; which has clear consequences on mental health&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> These findings are consistent with those from other studies&#44; such as the one carried out in the city of Jo&#227;o Pessoa&#44; in the state of Para&#237;ba&#44; Brazil&#44; which found that adolescents who did not reach the recommendations for PA practice and those who were overweight were three times more likely to have negative HSP when compared to their sufficiently active peers and those with normal weight&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> However&#44; the results in that study were not stratified by gender and the participation of adolescents in other domains and types of PA was not observed&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Certain limitations of the present study should be considered&#46; While we acknowledge that direct methods would bring more accurate information&#44; the levels of total PA and PA practiced in the free time were obtained by indirect measurement&#46; Moreover&#44; despite the use of a representative sample the generalization of the collected data to all adolescents should be treated with caution&#44; since the study was restricted to students from the state public school system&#46; Additionally&#44; there is also the possibility of reverse causality as an inherent characteristic of cross-sectional studies&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Among the strengths of the present research we can highlight the representativeness of the student population of public high schools in the state of Pernambuco&#44; the use of a previously tested questionnaire that had a moderate-to-high reproducibility level&#44; and the control of variables affecting the analysis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">It was concluded that a negative HSP was associated with nutritional status in girls and with a lower level of PA in boys&#46; Furthermore&#44; the practice of PA in the free time was considered a protective factor for a negative HSP in adolescents of both genders&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the association between total physical activities&#44; physical activity in free time and nutritional status with self-perceived health in adolescents of both genders&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a quantitative study that integrates the school-based&#44; cross-sectional epidemiological survey with statewide coverage&#44; whose sample consisted of 6261 adolescents &#40;14&#8211;19 years old&#41; selected by random conglomerate sampling&#46; Data were collected using the Global School-based Student Health Survey&#46; The chi-squared test &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#41; and the Poisson regression model with robust variance were used in the data analyses&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">It was observed that 27&#46;3&#37; of the adolescents had a negative health self-perception&#44; which was higher among girls &#40;33&#46;0&#37; <span class="elsevierStyleItalic">vs&#46;</span> 19&#46;0&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; After adjusting for potential confounding factors&#44; it was observed that boys who did not practice physical activity during free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;44&#44; 95&#37; CI&#58; 1&#46;15&#8211;1&#46;81&#41; and were classified as insufficiently active &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#44; 95&#37; CI&#58; 1&#46;04&#8211;1&#46;56&#41;&#44; as well as girls who did not practice physical activity during free time &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;15&#44; 95&#37; CI&#58; 1&#46;02&#8211;1&#46;29&#41; and were classified as overweight &#40;PR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;27&#44; 95&#37; CI&#58; 1&#46;01&#8211;1&#46;29&#41; had a greater chance of negative health self-perception&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Behavioral issues may have different effects on health self-perception when comparing boys with girls&#46; Negative health self-perception was associated with nutritional status in girls and a lower level of physical activity in boys&#44; and the practice of physical activity in the free time was considered a protective factor against a negative health self-perception for adolescents of both genders&#46;</p></span>"
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            "titulo" => "Methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar a associa&#231;&#227;o entre atividade f&#237;sica total&#44; atividade f&#237;sica no tempo livre e estado nutricional com a autopercep&#231;&#227;o de sa&#250;de em adolescentes de ambos os sexos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Trata-se de um estudo com abordagem quantitativa&#44; que integra o levantamento epidemiol&#243;gico transversal de base escolar e abrang&#234;ncia estadual&#44; cuja amostra foi constitu&#237;da por 6&#46;261 adolescentes &#40;14 a 19 anos&#41; selecionados por meio de uma estrat&#233;gia de amostragem aleat&#243;ria de conglomerados&#46; Os dados foram coletados a partir do question&#225;rio <span class="elsevierStyleItalic">Global School-based Student Health Survey</span>&#46; O teste de qui-quadrado &#40;&#967;<span class="elsevierStyleSup">2</span>&#41; e o modelo de regress&#227;o de Poisson com vari&#226;ncia robusta foram usados nas an&#225;lises dos dados&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Observou-se que 27&#44;3&#37; dos adolescentes tinham uma autopercep&#231;&#227;o de sa&#250;de negativa&#44; sendo maior entre as meninas &#40;33&#44;0&#37; <span class="elsevierStyleItalic">vs</span>&#46; 19&#44;0&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Ap&#243;s o ajuste pelos potenciais fatores de confus&#227;o&#44; constatou-se que tinham maior chance de ter uma autopercep&#231;&#227;o de sa&#250;de negativa os meninos que n&#227;o praticavam atividade f&#237;sica no tempo livre &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;44&#59; IC 95&#37;&#58; 1&#44;15-1&#44;81&#41; e que eram classificados como insuficientemente ativos &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;27&#59; IC 95&#37;&#58; 1&#44;04-1&#44;56&#41; e as meninas que n&#227;o praticavam atividade f&#237;sica no tempo livre &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;15&#59; IC 95&#37;&#58; 1&#44;02-1&#44;29&#41; e que eram classificadas como sobrepesadas &#40;RP<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;27&#59; IC 95&#37;&#58; 1&#44;01-1&#44;29&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Quest&#245;es comportamentais podem ter diferentes repercuss&#245;es na autopercep&#231;&#227;o de sa&#250;de quando comparados os meninos e meninas&#46; A autopercep&#231;&#227;o de sa&#250;de negativa esteve associada ao estado nutricional entre as meninas e a um menor n&#237;vel de atividade f&#237;sica entre os meninos e a pr&#225;tica de atividade f&#237;sica no tempo livre foi tida como fator de prote&#231;&#227;o para uma autopercep&#231;&#227;o de sa&#250;de negativa para os adolescentes de ambos os sexos&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Silva AO&#44; Diniz PR&#44; Santos ME&#44; Ritti-Dias RM&#44; Farah BQ&#44; Tassitano RM&#44; et al&#46; Health self-perception and its association with physical activity and nutritional status in adolescents&#46; J Pediatr &#40;Rio J&#41;&#46; 2019&#59;95&#58;458&#8211;65&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at Universidade de Pernambuco &#40;UPE&#41;&#44; Recife&#44; PE&#44; Brazil&#46;</p>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Prevalence of physical activity&#44; nutritional status and physical activity practice in free time and its associations with negative HSP in adolescents of both genders&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Passive leisure&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Self-rated health and adverse events in CKD"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Robinson-Cohen"
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                            2 => "R&#46; Katz"
                            3 => "M&#46;B&#46; Rivara"
                            4 => "I&#46;H&#46; De Boer"
                            5 => "B&#46;R&#46; Kestenbaum"
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                      "doi" => "10.2215/CJN.03140314"
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                        "tituloSerie" => "Clin J Am Soc Nephrol"
                        "fecha" => "2014"
                        "volumen" => "9"
                        "paginaInicial" => "2044"
                        "paginaFinal" => "2051"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25301857"
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                      "titulo" => "Self rated health&#58; Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes&#63;"
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                        0 => array:2 [
                          "etal" => false
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Epidemiol Community Heal"
                        "fecha" => "2001"
                        "volumen" => "55"
                        "paginaInicial" => "836"
                        "paginaFinal" => "840"
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                      "titulo" => "Autopercep&#231;&#227;o de sa&#250;de em adolescentes&#44; adultos e idosos"
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                          "etal" => false
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                        "tituloSerie" => "Cien Saude Colet &#91;Internet&#93;"
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Article information
ISSN: 00217557
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