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Jornal de Pediatria xxxx;xxx(xxx): xxx-xxx

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ORIGINAL ARTICLE

Sedentary behavior and self-harm in adolescents with
asthma, rhinitis and eczema
Q1

 rcia L. Medeiros a,b,
1X XM
XD e
D2X X *, D3X XAuxiliadora D.P.V. da Costa b,c
D4X X , D5X XCiane J.G. Vieira
f
D12X X
D7X XPedro H.N. Silva D8X X , D9X XDiego A.M. Santos gD10X X , D1X XMaria Sylvia S. Vitalle h,i

D6X X ,
d,e

~o Paulo (UNIFESP), Cie
^ncias Aplicadas a
 Pediatria, Sa
~o Paulo, SP, Brazil
Universidade Federal de Sa
, AL, Brazil
Universidade Federal de Alagoas (UFAL), Faculdade de Medicina, Maceio
c
^ncias da Sau
, AL, Brazil
de, Maceio
Universidade Federal de Alagoas (UFAL), Cie
d
~o Física pela Universidade Federal de Alagoas (UFAL), Maceio
, AL, Brazil
Educaç a
e
s-graduaç a
~o em Cie
^ncias Me
dicas (PPGCM), Maceio
, AL, Brazil
Universidade Federal de Alagoas (UFAL), Programa de Po
f
, AL, Brazil
Universidade Federal de Alagoas (UFAL), Maceio
g
~o Paulo (USP), Sa
~o Paulo, SP, Brazil
Universidade de Sa
h
~o Paulo (UNIFESP), Sa
~o Paulo, SP, Brazil
Universidade Federal de Sa
i
~o Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Pediatria, Sa
~o Paulo, SP, Brazil
Universidade Federal de Sa
a

b

Received 27 May 2024; accepted 15 August 2024
Available online xxx

KEYWORDS
Adolescents;
Asthma;
Rhinitis;
Eczema;
Self-injurious
behavior;
Sedentary behavior

Abstract
Objective: To investigate the association between allergic diseases and the tendency to selfharm in adolescents, considering the role of sedentary behavior.
Methods: This was a population-based cross-sectional study, carried out in 2022, with 727 adolescents aged 12 to 19 years, from a capital in the Northeast of Brazil. The authors evaluated the
association between each allergic disease (asthma, rhinitis and eczema) and self-harm, sedentary behavior and other variables. The authors performed an adjusted analysis of the associations between each allergy disease and the tendency to self-harm and then adjusted to the
presence of family members and sedentary behavior.
Results: The prevalence of asthma, rhinitis and eczema were 18.76%, 36.21% and 12.86%,
respectively. Sedentary behavior and tendency to self-harm were more frequently reported in
asthmatics (PR 2.16; 95% CI: 1.55 3.00 and PR 1.98; 95% CI: 1.47 2.68, for sedentary behavior
and self-harm respectively), rhinitis (PR 1.53; 95% CI: 1.25 1.88 and PR 1.33; 95% CI: 1.09
1.62, respectively) and eczema (PR 2.35; 95% CI: 1.54 3.58 and PR 1.55; 95% CI: 1.05 2.28,
respectively). There was a reduction in the strength of this association in the three conditions,
which included a loss of association.

* Corresponding author.
E-mail: mercia.medeiros@famed.ufal.br (M.L. Medeiros).
https://doi.org/10.1016/j.jped.2024.08.003
0021-7557/© 2024 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

Please cite this article in press as: M.L. Medeiros, A.D. da Costa, C.J. Vieira et al., Sedentary behavior and self-harm in
adolescents with asthma, rhinitis and eczema, Jornal de Pediatria (2024), https://doi.org/10.1016/j.jped.2024.08.003

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M.L. Medeiros, A.D. da Costa, C.J. Vieira et al.
Conclusion: High rates of sedentary behavior and self-harm in those with asthma, rhinitis and
eczema. Physical activity attenuated the risk for self-harm. It warns about the urgency in detecting these factors, whether in the diagnosis or in the implementation of therapy, seeking to
reduce their harmful consequences in the short and long term.
© 2024 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

1

Introduction

Methods

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Adolescence, the period between childhood and adulthood,
is marked by several changes, including rapid physical, cognitive, social and emotional maturation.1 Although genetics
constitute one determinant, the environment has also been
identified as an important influence on manifestations at
this stage, in relation to behavior and vulnerability to risky
habits, such as sedentary behavior and self-harm, for
example.
Sedentary behavior is understood as a set of activities
in which the individual spends most of their time in a sitting position, and is an important public health concern
since it has been associated with the early emergence of
chronic diseases, such as dyslipidemia, hypertension,
diabetes and obesity, and mental disorders, such as
depression and anxiety.2 WHO (World Health Organization) data reveal that up to 81% of adolescents do not
exercise in line with recommendations.2 Common activities that are currently seen in adolescent routines, such
as the use of mobile devices, computers, tablets, video
games and television, have contributed to this increase
in sedentary behavior and to lower levels of physical
activity. 3 Particularly following the COVID-19 pandemic,
studies show that the amount of time adolescents spend
sitting down has increased by approximately
159.5 § 142.6 min per day.4
Particularly in relation to the association with mental disorders, sedentary behavior and time spent sitting down
seem to be associated with symptoms of depression,
depressed mood and anxiety among children and adolescents, with sedentary behavior being a probable modifiable
risk factor for depression.5,6 Anxiety and impulsivity disorders can appear in early adolescence along with risky behaviors such as self-harm, which is a form of psychopathological
externalization of anguish and pain aimed at relieving emotional pain, may become manifest. More common in girls,
self-harm is a risky behavior with varying degrees of severity,
which may even culminate in suicide attempts.7
The negative impacts of allergic diseases on general adolescent performance and health can culminate in a higher
risk of psychological damage, especially in the case of
chronic conditions which, depending on their severity, can
affect self-esteem and quality of life.8 On the other hand,
emotional stress itself affects the manifestation of disease
symptoms, propagating a vicious cycle of increased clinical
severity and poorer mental health.
However, few studies 9 examine the association
between allergic diseases and manifestations of, or tendency to, self-harm in adolescents. This study aimed to
investigate the association of self-harm with asthma, rhinitis and eczema, considering sedentary behavior as a possible influence.

Participants and study design

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This is a population-based cross-sectional study, conducted
during the second school semester of 2022, with 727 students aged from 12 to 19, resident in all of Maceio’s districts.
To ascertain the proportion of public versus private schools,
the authors consulted the ratio of enrolled students in the
school census, based on lists provided by the Municipal
Department of Education (SEMED). The authors then randomly selected schools based on a proportion of 80.6% public
and 19.4% private schools. Adolescents with serious cardiorespiratory (as congenital and acquired cardiomyopathies
with hemodynamic repercussions, cystic fibrosis, bronchiectasis, pulmonary fibrosis, for example) and dermatological
diseases (such as psoriasis, lupus, leprosy, for example) were
excluded.
The self-administered questionnaires were distributed in
the classroom among adolescents, and answered anonymously to ensure the privacy and reliability of the responses.
Conversely, the school was assured access to specialist psychological counseling services on demand from the institution.

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Instruments and the definition of variables

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The authors applied standardized and validated, self-completion written questionnaires (QE) to both children and
adolescents, to obtain information about sociodemographic
data; prevalence of allergic diseases (asthma, rhinitis and
eczema); common mental disorders; tendency to self-harm;
and sedentary behavior; in addition to complementary semistructured questions, related to the instruments.

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1. Identification of asthma, allergic rhinitis and atopic
eczema: using the International Study of Asthma and
Allergies in Childhood ISAAC.10
2. Patient Health Questionnaire-9 - PHQ-9 11 for adolescents, to identify the presence of a mental disorder; the
authors also posed the question “Over the last two
weeks, how often have you been bothered by: thoughts
about hurting yourself in some way, or that you would be
better off dead?” to determine the tendency to selfharm.
3. Other variables: - Familial allergy: in first-degree relatives, defined by the presence of at least one first-degree
relative with asthma, rhinitis, or atopic eczema. Socioeconomic stratification: using the Socioeconomic questionnaire from the Brazilian Association of Population
Studies (ABEP),12 in line with Brazilian Economic Classification Criteria, which categorizes economic classes into
A, B, C, D and E. For the purpose of analysis, the classes

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were recategorized for dichotomization into 1) A/B/C
and 2) D/E. Household smoking: presence of a person living in the house who smokes. - Screen time: total daily
time spent using screens (computers, tablets, smartphones, television or equivalent). Dichotomized into less
than 2 h and greater than or equal to 2 h. - Gender, type
of school (public or private), mother’s, father’s or legal
guardian’s education, in this order of priority (more or
less than higher education).

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Statistical analysis

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The data were tabulated in a Microsoft ExcelÒ spreadsheet
and, after coding, were entered into the statistical package
Stata version 13.0 (StataCorp, CollegeStation, TX, USA). The
variables were analyzed using Pearson's chi-square test,
with the associations between asthma, rhinitis and eczema
(dependent variables) and the categorical independent variables of interest, as well as between each allergic disease
and self-harm, sedentary behavior and the other variables.
The authors obtained an adjusted analysis of the associations between each allergic disease and the tendency to
self-harm, and then adjusted for the presence of family
allergy and sedentary behavior, in order to observe these
variables’ interference on the association between asthma,
rhinitis and eczema, and a tendency to self-harm.

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Ethical issues

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The study was approved by the FAMED-UFAL Research Ethics
Committee
under
registration
number
59311222.7.0000.5013; all the participants signed an
Informed Consent Form, when applicable.

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Results

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The authors considered 727 of the 823 adolescents for analysis, that is, those who presented complete data. The prevalence of asthma, rhinitis and eczema were 18.76%, 36.21%
and 12.86%, respectively. Almost half the adolescents
described sedentary behavior and approximately 1/3 were
prone to self-harm. More than 80% exceeded the maximum
daily screen time (Table 1) recommended by the Brazilian
Society of Pediatrics (SBP).13 Sedentary behavior was more
frequent in girls (66.95% £ 33.04%; PR: 1.85; 95%CI: 1.56
2.20), as was the tendency to self-harm (71.49% £ 28.51%;
PR: 2.29; 95% CI: 1.80 2.92).
History of familial allergy in first-degree relatives, as well
as sedentary behavior and tendency to self-harm, were
more frequently reported in adolescents with asthma, rhinitis and eczema. Allergic rhinitis was less prevalent among
adolescents in public schools (Table 2). Although adolescents
with asthma and rhinitis spent more time on their screens,
this trend was not statistically significant.
As additional data, a greater frequency of sedentary
behavior was also observed among adolescents with a tendency to self-harm (82.93%; n = 204), compared to the group
that did not report these types of thoughts (17.07%; n = 42),
with a PR of 2.71 (95% CI: 2.34 3.14).
When the authors tested for the interference of sedentary behavior on the association between each allergic

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Table 1 Characterization of the sample according to sociodemographic variables, allergic diseases and adolescent
screen time, in Maceio, the state capital of Alagoas, 2022
(n = 727).
VARIABLES

N

(%)

Gender, Feminine
Public school
ABEP classification, D/E class
Parents' education level, < High
school graduate
Smoking at home
Family allergy history
Screentime  2 h/day
Tendency to self-harm
Sedentary behavior
Asthma
Allergic Rhinitis
Eczema

371
583
189
480

52,25%
80,19%
26,07%
70,59%

381
250
483
246
351
133
252
89

53,06%
35,77%
85,64%
33,84%
48,28%
18,76%
36,21%
12,86%

Source: Authors.

3

disease and the presence of a tendency to self-harm, we
observed that, after adjusting for family allergy history,
there was a reduction in the strength of this association for
the three conditions: asthma, rhinitis and eczema, which
included a loss of association (Table 3).

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Discussion

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One-third of the adolescents in this study demonstrated a
tendency to self-harm, which was more frequently found
among girls and those with asthma, rhinitis and/or eczema;
this risk is twice as high as that reported in previous
studies.14
However, although the associations between asthma, rhinitis and eczema, and mental disorders, notably anxiety and
depression, have been investigated,15 a gap remains, specifically in relation to self-harm behaviors. In adolescence, selfharm can be perceived or suspected, based on signs that
involve the incidence of minor traumas, a range of self-mutilations, such as cuts to the skin, scratches, burns, as well as
exposure to risky circumstances, which may even culminate
in a tendency for, or actual, suicidal acts. With varying levels
of severity, this is characterized by a psychopathological
externalization of anguish and pain which, although not
expressed verbally, is manifested on one's own body, leaving
visible and invisible marks.7
In chronic diseases common in childhood and adolescence, such as asthma, severe rhinitis and eczema, which
have significant impacts on quality of life, self-esteem and
psychological damage, the importance of early identification of this type of risk behavior is even more pressing. In a
vicious cycle of chronic illness mental damage worsening manifestations of physical illness, risk behaviors such as
self-harm, symptoms of depression, anxiety and stress are
linked to more severe effects on asthma, for example, and
can affect self-control, poorer self-management of the disease, poorer control of triggers and interference in health
care, prevention and the management of symptoms.16

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Table 2

Association between allergic diseases, tendency to self-harm, sedentary behavior and sociodemographic factors.

VARIABLES

ALLERGIC RHINITIS

ECZEMA

n (%)

PR
(CRUDE)

CI (95%)

P

n (%)

PR
(CRUDE)

CI (95%)

P

n (%)

PR
(CRUDE)

CI (95%)

P

76 (20,88%)
51 (15,55%)
103 (18,23%)
30 (20,83%)
35 (19,13%)

1,34

0,97

1,85

0,07

1,2

0,97

1,47

0,08

1,00

2,30

0,05

0,61 - 1,26

0,47

0,68

0,55

0,83

<0,01*

0,86

0,51

1,42

0,55

1,02

0,72

0,89

0,8

0,63

1,03

0,08

52 (14,65%)
31 (9,66%)
73 (13,25%)
16 (11,35%)
21 (11,73%)

1,52

0,87

140 (38,78%)
103 (32,39%)
183 (33,03%)
69 (48,59%)
55 (30,73%)

0,88

0,56

1,39

0,59

1,23

0,81

1,86

0,33

1,44

0,97

2,15

0,07

1,92

1,30

2,82

<0,01*

1,18

0,58

2,38

0,64

1,55

1,05

2,28

0,03*

2,35

1,54

3,58

<0,01*

1,45

98 (18,67%)
34 (17,44%)

197 (38,25%)
0,92

0,64

1,31

0,63

75 (20,11%)
57 (17,27%)
59 (24,08%)
69 (15,61%)
92 (19,45%)
10 (12,50%)
67 (27,92%)

0,68

1,08

0,18

176 (38,43%)

1,16

0,85

1,59

0,34

1,54

1,13

2,10

0,01*

1,56

0,85

2,86

0,15

1,98

1,47

2,68

<0,01*

66 (14,07%)
89 (25,95%)
44 (12,02%)

0,85

130 (35,42%)
118 (36,42%)
112 (47,06%)
133 (29,95%)
174 (37,74%)
21 (27,27%)
102 (43,40%)

56 (12,31%)

0,97

0,80

1,19

0,78

1,57

1,29

1,91

<0,01*

1,38

0,94

2,03

0,1

1,33

1,09

1,62

<0,01*

150 (32,54%)
2,16

1,55

3,00

<0,01*

148 (44,18%)
104 (28,81%)

29 (15,10%)

55 (15,15%)
34 (10,49%)
45 (18,83%)
43 (9,82%)
56 (12,25%)
8 (10,39%)
39 (16,81%)
50 (10,87%)

1,53

1,25

1,88

<0,01*

61 (18,32%)
28 (7,80%)

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89 (19,02%)

63 (32,81%)

68 (13,31%)

M.L. Medeiros, A.D. da Costa, C.J. Vieira et al.

4

Gender, Feminine
Gender, Masculine
Public school
Private school
ABEP classification,
D/E class
ABEP classification,
A/B/C class
Parents' education
level, < High
school graduate
Parents' education
level, > High
school graduate
Smoking at home
No smoking at home
Family allergy history
No family allergy
history
Screentime  2 h/day
Screentime < 2 h/day
Tendency to selfharm
No tendency to selfharm
Sedentary behavior
No sedentary
behavior

ASTHMA

Source: Authors.
*
Statistically significant associations (p < 0,05). PR, prevalence ratio; CI, confidence interval.
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Table 3 Association between allergic diseases and tendency to self-harm, taking into account the effect of family allergy history
and sedentary behavior.
VARIABLES

Model 1
(Tendency to self-harm)

Asthma
Allergic Rhinitis
Eczema

1,98 (1,47
1,33 (1,09
1,55 (1,05

2,68); p < 0,01
1,62); p < 0,01
2,28); p = 0,03

Model 2
(Tendency to self-harm + History of
family allergy)
1,84 (1,33
1,26 (1,03
1,41 (0,94

2,54); p < 0,01
1,54); p = 0,02
2,11); p = 0,09

Model 3
(Tendency to self-harm + History of
family allergy + Sedentary
behavior)
1,43 (0,99
1,07 (0,85
0,99 (0,64

2,05); p = 0,05
1,34); p = 0,57
1,53); p = 0,97

Source: Authors.

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In the period during and following the COVID-19 pandemic, these relationships between risk behavior, mental
disorders and chronic diseases were exacerbated, with consequences that have yet to be well defined. Face-to-face
contact, touch, exchange, meetings and communication
were quickly replaced with virtual contact, due to the high
level of health risks and government containment measures,
which greatly affected physical and mental health, and had
an emotional impact on a large part of the population.17
Home confinement encouraged inappropriate behavior in all
age groups. Adolescents, that is, individuals exposed to various stressors, both internal and external, faced the greatest
challenges in the pandemic, due to academic pressure to
maintain high quality, intellectual commitment, and previous levels of productivity.
Adolescents reflected behaviors immediately post-pandemic, as these data were collected in 2022, consistent with
other national studies, in which social distancing related to
the pandemic promoted significant changes in the lifestyle
of children and adolescents, increasing screen time, reducing activity physical activity and worsening the quality of
food and sleep.18 Other studies have also identified an association between low levels of physical activity and prolonged
use of screen time with increased risk of depression, anxiety
and self-harm behavior, with the risk being highest among
adolescent boys.19
This context further reinforced the maintenance of sedentary behaviors in the school environment, given that studies of both groups, asthmatics and controls, undertaken
prior to the pandemic, had already revealed sedentary
behavior.20
In the present study, the authors identified rates for sedentary behavior that were 1.5 to 2 times as high among adolescents with allergic diseases and among girls. Our finding
of more frequent sedentary behavior in girls is in line with
data in the literature.21 The authors know that guidelines
about physical activity must be adapted to individual physical condition, age and gender, taking account of sociocultural determinants and the adolescent's own preferences.22
Differences in exercising and sedentary behavior between
genders can be explained by sociocultural differences, given
that from childhood, boys are encouraged to play games
that involve sports and more strenuous physical effort, while
girls are encouraged to perform lower-intensity practices,
linked to the domestic environment.23
In the specific case of allergic diseases, adolescents with
asthma and rhinitis who stop exercising due to shortness of
breath, often experience a worsening of muscular

conditioning, limiting their ability to exercise, resulting in
more shortness of breath, since this decrease in performance requires the individual to ventilate more in order to
maintain this exercise.24 In this sense, systematic reviews
reveal positive findings regarding regular exercise in asthmatic adolescents and children, leading to improved cardiovascular function and few effects on bronchial
hyperreactivity.25 Exercising regularly is related to a number
of health benefits, such as improved cardiorespiratory fitness, body composition, and cardiometabolic profile.2
According to this study asthma, rhinitis and eczema are
relatively common diseases in adolescence, with frequencies of 18.76%, 36.21% and 12.86%, respectively, and which
are on the rise. The increasing number of allergic respiratory
diseases in adolescents is related to a combination of environmental and genetic factors, such as air pollution, frequent contact with synthetic materials, changes in diet, and
level of physical activity.23 Higher sitting time to study and
short sleep time were associated with asthma, allergic rhinitis, and atopic dermatitis in a Korean study. The associations
between obesity and these allergic diseases were inconsistent after adjustment for other factors.26
Compared to asthma, rhinitis is less severe, but, depending on the frequency and intensity of symptoms, it can also
cause significant limitations in daily activities and quality of
life with repercussions on both psychological status, physical
activity and behavioral risk. sedentary. Atopic eczema, on
the other hand, in addition to limiting daily activities due to
itching, which can be intense, also induces the stigma of
skin lesions, which affect body self-image, self-esteem, and
quality of life, also being a risk for behavioral risks such as
sedentary lifestyle and self-harm.
Finally, the authors also found that sedentary behavior,
which is common in adolescents at risk of self-harm (82.93%
of cases), can modify and attenuate the association between
this behavior and allergic diseases. The authors did not find
evidence of this effect modification for this association in
the literature. The role of an unhealthy lifestyle in suicidal
behaviors has become a matter of concern and growing
interest,27 studies show that more leisure time being sedentary is associated with higher odds of suicide attempts.28
This observation is important because changes in lifestyle
habits and sedentary behavior are modifiable factors that
can affect mental health since active behavior is beneficial
for improving cognitive function, depression and selfesteem.29 In fact, sedentary behavior may have been confounding in the association between allergic diseases and
self-harm, since it was associated with both. Confounding is
5

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a bias because it can result in a distortion in the measure of
association between an exposure and a health outcome.
This was a limitation of our findings.
Another study limitation is that, since it involves crosssectional research, a causal relationship cannot be established between allergic diseases, sedentary behaviors, and
self-harm. Further, assessment through questionnaires
depends on possible changes in mood and on the adolescent's
willingness to reveal the information requested, particularly
in relation to self-harm. The delivery of questionnaires for
self-completion results in losses and may have contributed
to a return rate of around 88.3% (727 / 823).
Other research has found that low physical activity/high
screen time subgroups, who did not meet WHO recommendations for PA and screen time, had significantly more
depression, anxiety and self-harm behaviors, highlighting
the potential role of the interaction between PA and screens
in preventing depression, anxiety and self-harm behaviors in
adolescents of both sexes.30
Similar to what the authors did in the collection in
schools, the study opens up the possibility of identifying
risk behaviors such as sedentary lifestyle and self-harm, in
routine consultations, of adolescents with chronic conditions, using a simplified instrument, low-cost and quickto-apply, very useful in primary care. The identification of
the risk of self-harm should be referred for specialized
psychological care, as an early intervention that can block
the progression to suicidal thoughts and ideation or even a
suicide attempt, for example. On the other hand, sedentary behavior is a modifiable factor, which can also be
identified and subject to intervention, including having an
effect on the risk of self-harm in these adolescents. In particular, in a scenario of increasing frequency of allergic
diseases and following a pandemic, in which an increase in
both sedentary behavior and mental disorders has been
observed, early identification and intervention should be
a priority.
Therefore, it is essential that health professionals are
aware of these factors and include the assessment of physical activity and mental health when monitoring allergic
patients. Promoting healthy habits, encouraging physical
exercise and psychological support can be important measures to minimize the negative impact of sedentary behavior
and mental disorders on the health of allergic patients.

332

Conflicts of interest

333

The authors declare no conflicts of interest.

334

Authors’ contributions

335

All authors have approved the final manuscript.

336

Funding sources

337

None.
6

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