Abstract(resumo):

We aimed to analyze lifestyle trends of Brazilian pregnant women from 2007 to 2017 and their association with sociodemographic factors. This was time-series study using data from Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey(VIGITEL). Lifestyle indicators were: regular consumption(?5x/week) of beans, vegetables, chicken, meat, fruit, milk, and soft drinks, alcohol and tobacco uses, and practice of physical activity(PA). Variance-weighted linear regression was used to obtain average annual variation (percentage points-pp) of indicators, and Poisson regression was used to verify the association of sociodemographic factors and indicators. There was an increase in chicken consumption(+0.74pp/year), practice of PA(+1.36pp/year); reduction in consumption of soft drinks(-1.64pp/year) and tobacco(-0.26pp/year). Pregnant women aged >20 years had a higher prevalence of raw vegetables and milk and a lower of meat and soft drinks. Pregnant women with ?9 years of schooling had a higher prevalence of consumption of vegetable, fruit, PA practice and a lower prevalence of meat, chicken, soft drinks and tobacco use. There was favorable health evolution due to the reduction in regular soft drink consumption, tobacco use and increased PA, especially in pregnant women with higher age and education.

Keywords(palavra-chave):

Pregnancy. Lifestyle. Maternal Health.

Content(conteúdo):

Introduction
The main health recommendations during pregnancy focus on appropriate weight gain, physical activity, consumption of a wide variety of foods and food groups, and abstaining from tobacco, alcohol and other substances1, 2.
The recommendation to practice physical activity during pregnancy in Brazil follows the recommendations of the World Health Organization (WHO), which recommends 150 minutes of moderate-intensity physical activity per week in all gestational trimesters3. In 2017, only 37.6% of pregnant women living in Brazilian capitals reported doing some leisure-time physical activity and only 20.6% met the recommendations of 150 minutes a week4.
The dietary pattern during pregnancy is a key factor both in birth outcomes and in the health of children throughout life, as maternal dietary patterns are associated with children’s dietary patterns5. Pregnant women who adhere to a high consumption of ultra-processed foods are three times more likely to develop obesity compared to those who eat less of these foods6. A review based on regional and local studies published between 2007 and 2016 on the eating habits of Brazilian pregnant women indicated eating habits different from those recommended by the Ministry of Health7.
Smoking is another avoidable behavior associated with adverse consequences during pregnancy8. Results of the Birth in Brazil Study (2011-2012), the most recent to date, pointed to a prevalence of 9.6% of pregnant women who reported using tobacco at some point in their pregnancy and 6.8% who used tobacco throughout their pregnancy9. Between the 1980s and 2010s, there was a significant reduction in tobacco use by Brazilian pregnant women living in Ribeirão Preto (35.7% in 1977 vs. 16.5% in 2011), Pelotas (28.8% in 1982 vs. 11.8 % in 2015) and São Luís (6.0% in 1997 vs. 4.1% in 2010)10.
Changes in the lifestyle of the adult population occurred between the 2000s and 2010s, such as an increase in the consumption of some ultra-processed foods, especially sweetened beverages11,12, and a reduction in minimally processed foods, such as beans13, an increase in leisure-time physical activity14, a reduction in tobacco use15,16 and stability in an abuse alcohol consumption17. However, there is still a lack of studies with a national scope that analyze the trend of the set of recommendations aimed at pregnant women, especially regarding diet, physical activity, tobacco use, and alcohol consumption. This gap makes it difficult to define more specific public actions and policies for this audience and to direct more specific prenatal care recommendations. Therefore, this study aims to describe the trend of four lifestyle indicators (regular consumption of food groups, alcohol consumption, tobacco use, and physical activity practice) of pregnant women living in Brazilian capitals and the Federal District from 2007 to 2017 and investigate the association between sociodemographic factors and lifestyle indicators.
Methods
Study design, data source and sample
Data came from annual cross-sectional surveys of the Risk and Protective Factors for Chronic Diseases by Telephone Survey (VIGITEL, in the Portuguese acronym) for non-communicable chronic diseases (NCDs) conducted between 2007 and 2017. This period was selected based on the compatibility of the variables used in the databases. VIGITEL was implemented in Brazil in 2006 and has been conducted by telephone, annually, in all capital cities of the 26 Brazilian states and in the Federal District by Ministry of Health18. The main objectives of VIGITEL are to monitor the frequency and distribution of risk and protective factors for NCDs. VIGITEL data make up the Surveillance System for NCD risk factors along with household surveys.
The sample was obtained by drawing five thousand telephone lines per city, systematically and stratified by postal address code. The lines then went on to another draw and were divided into replicas of two hundred lines, excluding those that corresponded to companies, were out of service, or that did not respond to six attempts of calls made on different days and times. The lines considered eligible were selected for the next stage, which corresponded to the drawing of one of the residents of the household, over 18 years of age, to answer the questionnaire19.
Inference of the results obtained in VIGITEL for the adult population of each city is possible by assigning weights to the individuals studied. From 2012 onwards, the calculation of sample weights was done using the rake method, which allows estimates to be generated for the total population of each city and for the population studied20. The weighting calculated using this method has been available in all VIGITEL datasets since 2006. In the period from 2007 to 2017, 3730 women confirmed they were pregnant, with this number ranging from 462 in the year 2007 to 188 in 2017. We excluded women who did not know if they were pregnant. The sample of pregnant women in each year corresponded to approximately 3% of the total sample of women, and there was a tendency to reduce this sample in the analyzed period. Thus, due to the small number of pregnant women in the samples and the drop in the fertility rate20 in this period, it was necessary to construct a new rake weight. This variable was constructed from three variables: internal weight (multiplication of the inverse of the probability of adults in the household by the inverse of the probability of telephone lines in the household), number of pregnant women by age group, and by capital city. Subsequently, the rake weight was generated using the survwgtrake command in Stata 14.0® using the three variables mentioned above. The rake weight was necessary to expand the sample estimates for the population of pregnant women residing in the Brazilian capitals.

Exposure variables
Characterization of sociodemographic and lifestyle indicators were performed for each year of the survey based on the following variables: age (<20 years; 20 to 34.9 years and ?35 years); schooling (0 to 8; 9 to 11; ?12 years of study); work (yes/no); marital status (single; married/stable union and widowed/divorced) and macro-region (North, Northeast, Midwest, Southeast and South). Among sociodemographic variables, only the marital status variable showed missing values, ranging from 0.2% in 2009/2010 to 1.0% in 2017.
Outcomes
Four lifestyle indicators were selected as outcomes: regular consumption of certain food groups/foods, alcohol consumption, tobacco use and the practice of physical activity. The variables referring to food consumption were beans, vegetables, raw vegetables, cooked vegetables, poultry, red meat, fruit, fruit juice (absent in 2007), milk (absent in 2017), type of milk (whole, skimmed/semi-skimmed, both), soft drinks and type of soft drink (normal, diet/light/zero, both). The type of milk variable was absent in 2017, and the type of soft drink variable was absent in the period from 2012 to 2014 and in 2017. In VIGITEL, these variables refer to the frequency of weekly consumption (0 to 7 times/week), however, in this study, we chose to categorize it into regular consumption (yes/no)16, which refers to consumption equal to or greater than five times a week. For the type of soft drink variable, 0.3% of the respondents did not know/did not want to answer in 2011, and 1.1% in 2015. For the type of milk variable, this response (did not know/did not want to answer) ranged from 1.0% in 2007 to 1.6% in 2017.
Alcohol consumption refers to the habit of consuming alcoholic beverages, regardless of the amount consumed. We emphasize that we chose not to analyze the number of doses consumed in this study, due to the recommendation of abstinence from alcohol consumption during pregnancy22. The use of tobacco refers to the habit of smoking daily or occasionally, and the practice of physical activity refers to leisure physical activity performed in the last three months and, with a minimum frequency of once a week. All these variables were analyzed dichotomously (yes/no). In 2007, 2.4% of respondents did not know/did not want to answer for the consumption of alcoholic beverages variable (missing). The tobacco and physical activity variables did not present absent values.
Data analysis
Data on food consumption, physical activity, alcohol and tobacco use were described in terms of prevalence by year of the survey, and the analysis of the time trend (2007 to 2017) was performed by variance-weighted linear regression to obtain the mean annual change with the respective p-value of trend (significance level less than 5%). The trend analysis was performed for the fruit juice variable between 2008 and 2017, and for milk between 2007 and 2016. Poisson regression was used to verify the association between the four indicators of lifestyle outcomes – diet, physical activity, alcohol and tobacco consumption, and the sociodemographic characteristics were age, schooling, macro-region, and work (predictor variables). Missing data were not imputed due to their low frequency and because they did not alter the analyses. All analyzes were performed using the Stata SE 14.0® statistical package.
Results
In the decade analyzed (from 2007 to 2017), there were changes in sociodemographic characteristics, with a tendency for an increase in pregnant women aged 35 years and over, a reduction for those aged between 20 and 35 years, and stability in the proportion of adolescents. We observed a downward trend in pregnant women with up to 8 years of schooling, and 9 to 11 years of education, and an increasing trend in those who studied for 12 years or more. We found an upward trend in the prevalence of pregnant women who reported working. Regarding geographic distribution, we saw an increasing trend in pregnant women residing in the Northeast and a decrease in the Midwest and South. Most pregnant women reported being married or in a stable relationship in all years of the survey, with a tendency to increase in the widowed/divorced category (Table 1).
TABLE 1
We observed an upward trend in the prevalence of regular consumption of poultry (+0.74 pp/year) and cooked vegetables (+0.53 pp/year), and a reduction in the regular consumption of soft drinks (-1.64 pp/year) (Table 2). We also observed an increasing trend in the prevalence of pregnant women who reported practicing some type of physical activity (+1.36 pp/year), and a reduction in the prevalence of pregnant smokers (-0.26 pp/year) (Table 3).
TABLE 2
TABLE 3
We observed a higher prevalence in the regular consumption of vegetables, raw vegetables, milk and lower prevalence of red meat among pregnant women aged 20 years or older; and a lower prevalence in the consumption of soft drink among pregnant women aged 35 years or older. Regarding education, prevalence for the regular consumption of cooked vegetables and fruit was higher for pregnant women who had studied for 9 years or more; vegetables and raw vegetables showed a higher prevalence only for those who had studied for 12 years or more. We observed a lower prevalence in the regular consumption of red meat, poultry and soft drinks among pregnant women who had studied for 9 years or more, compared to those who had studied for up to 8 years (Table 4).
Regarding the macrorregion of residence of the pregnant women, we observed higher prevalence for the regular consumption of beans in the Midwest and Southeast regions compared to the North; vegetables in the Midwest, Southeast and South; of raw vegetables in the Midwest, Southeast and South; cooked vegetables in the Southeast and South; of red meat in the Midwest; of poultry in the Northeast; of fruit in the Northeast, Midwest, Southeast and South; and soft drinks in the South compared to the North. We also observed a lower prevalence of vegetable, raw vegetable, red meat, soft drink and milk consumption in the Northeast. Regular milk consumption was less prevalent in the Midwest and Southeast regions. The prevalence of vegetable and raw vegetable indicators was higher in working pregnant women (Table 4).
Pregnant women who had studied for 9 years or more had a higher prevalence of physical activity, a less prevalent indicator in the Northeast region. The prevalence of alcohol consumption was higher in the Northeast, Midwest, Southeast and South regions compared to the North. Tobacco use had a lower prevalence in pregnant women with more than eight years of schooling, and a higher prevalence in pregnant women residing in the Southeast region compared to the North (Table 5).
TABLE 4
TABLE 5
Discussion
In this study, we analyzed the trend of four indicators in the lifestyle of pregnant women residing in the Brazilian capital cities and the DF from 2007 to 2017. We identified an upward trend in the regular consumption of some foods, such as poultry and cooked vegetables, as well as a trend towards reduction in the regular consumption of soft drinks, both being favorable to maternal and child health. The trend of change in two other lifestyle indicators was also favorable, such as the increase in the percentage of pregnant women who reported practicing physical activity, and a reduction in smokers. The percentage of regular consumers of beans remained stable, a positive result, if we consider the downward trend in consumption of this food in the Brazilian population13, and the fact that it is considered a nutritious product (source of protein, iron, potassium, and fiber), as well as a marker of in natura food and a traditional food in the Brazilian diet, and to be included daily in the diet of pregnant women.
Marked social inequalities were identified in the four lifestyle indicators analyzed, with generally more negative results for younger pregnant women, with less schooling, not working, and those living in the Northeast region. Some positive changes observed in the indicators may be associated with an increase in the percentage of pregnant women in the highest stratum of schooling, and an increase in the percentage of older pregnant women who work.
The increase in pregnant women’s years of schooling is the result of changes in basic education policies, with the implementation of the Fund for the Maintenance and Development of Basic Education, and for the Valorization of Education Professionals (FUNDEB, in the Portuguese acronym) in 200721, whose main function is to invest federal resources in the financing of basic education; and, policies for higher education since 2002, with strong investment in federal public universities22,the implementation of the Higher Education Student Financing Fund (FIES) and the creation of the University for All Program (ProUni)23. A study conducted in the South of Brazil identified that most students enrolled in higher education through ProUni were women24. Thus, advances in the education of Brazilians in general and of women may have contributed to the positive trend of some indicators of lifestyle of pregnant women observed in the decade, since higher education is associated with healthier behaviors4,27,28.
In 2017 in Brazil, of the 2.86 million births registered, 35.1% of mothers were 30 years of age or older29. Delaying pregnancy is a growing trend as women’s education and income increase30. In 2020, a study conducted with data from 141 countries in six regions concluded that in Latin America the fertility rate decreased with the increase in women’s schooling, the increase in the GDP, and the increase in the prevalence of contraceptive use31. These changes in women’s reproductive behavior may also have favored the positive evolution of some indicators for Brazilian pregnant women in our study.
However, some indicators are still unsatisfactory for the health of Brazilian pregnant women. The consumption of cooked vegetables showed an increasing trend over the period; however, our results show that the prevalence of regular consumption of raw and cooked vegetables was lower than 50%, being higher among pregnant women aged 35 years or older, and among those with 12 or more years of schooling. A possible explanation for these results would be greater appreciation, and physical and financial access to these foods in this stratum of the population. A cross-sectional study conducted in Rio de Janeiro also identified that pregnant women with higher income and education were more likely to eat healthier dietary patterns composed of fruits, green vegetables, fish, roots, corn, potato and dairy foods32.
Our findings also showed a reduction of more than 50% in the prevalence of pregnant women with regular soft drink consumption between 2007 and 2017. The prevalence was also lower among pregnant women aged 35 or over and with 12 or more years of education. Our results are similar to the results of the study carried out with VIGITEL data from adult population in the same period, especially among those with higher education11. Again, older and more educated pregnant women would possibly have greater access to information, and greater concern about the possible consequences of an inappropriate lifestyle for their health and that of their infant, and greater purchasing power to substitute soft drinks for fresh juices (with higher prices), reasons that could justify the behaviors.
We observed an increase in the prevalence of pregnant women who practiced physical activity regularly in the analyzed period, a result that is also satisfactory considering that the practice of physical activity contributes to the reduction of complications during pregnancy such as decreased risk of preeclampsia, gestational hypertension and diabetes, caesarean section, urinary incontinence, excessive weight gain and depression33. We emphasize that the higher education of pregnant women has also been associated with the practice of physical activity. This result was also observed for Brazilian adults, which indicated an increase in the prevalence of physical activity especially for women with higher education8. A similar result was found in pregnant women living in Campinas-SP (2011 to 2014), where the practice of physical activity was more prevalent among pregnant women who already practiced some type of activity before pregnancy, those with a higher level of education, and among those who received guidance on physical exercises during prenatal care34.
Alcohol consumption remained stable throughout the analyzed period. This stability is positive if we consider that in Brazilian women in general the trend has been towards an increase. A cross-sectional study that used data from the National Alcohol and Drug Survey from 2006 and 2014 found a 34.2% increase in the prevalence of women who used alcohol frequently, with an increase in prevalence in all regions when compared to the North35. Other population survey studies in Brazil also show a lower prevalence of alcohol consumption in the North region, but the analyses refer to abusive consumption and the questionnaires were applied through household interviews36, 37. Previous studies assessed alcohol abuse17,38, while our study assessed the habit of consuming alcoholic beverages regardless of the frequency and number of doses, which could explain the differences found.
Confirming the positive trend for maternal and child health in the evolution of most of the lifestyle indicators in pregnant women, we highlight the reduction of tobacco use between 2007 and 2017, especially among pregnant women with higher education. The decline in tobacco use in the Brazilian population in general and possibly in the pregnant women included in this study is the result of the set of restrictive measures, such as a ban on smoking in public spaces, significant increase in taxes, transmission of mandatory messages about the harmful effects of smoking on cigarette packs, and Brazil’s adherence to the Framework Convention on Tobacco Control. All these measures are classified as cost-effective according to the World Health Organization for the prevention of chronic non-communicable diseases39.
One of the strengths of this study is the representativeness of the sample studied, which included pregnant women from all geographic regions of Brazil, as most previous studies produced data from a single city or geographic region24,25. Another strong point was its originality, as it was a study that analyzed the time trend of health indicators for pregnant women. Additionally, we highlight the standardization of the questionnaire over the period that allowed us to perform the trend analysis, and the joint analysis of the four main modifiable lifestyle factors that influence maternal and child health.
Our study has some limitations, such as restricting the sample to pregnant women who live in Brazilian capitals and the Federal District. Pregnant women are not the target population of VIGITEL, but once we calculated a new ponderation for these women, we can minimize this difference. Additionally, it was not possible to analyze nutritional status during pregnancy and adequate weight gain, due to the absence of gestational age in the VIGITEL questionnaire. Although VIGITEL does not target pregnant women, data were collected for this audience. It would be interesting to add the variable “gestational age” to the questionnaire, as it would allow us to know the nutritional status of pregnant women in all Brazilian capitals.
We also identified as a limitation the lack of gestational age in the questionnaires at the time of data collection, making it impossible to investigate lifestyle according to gestational age and nutritional status of the women. It should also be noted that details on the consumption of ultra-processed beverages and foods were not collected until 2017, which restricted the possibility of analyzing the specific trend for these products, except for soft drinks. Additionally, it was not possible to estimate the amount of food consumed, since the questionnaire only asked about weekly frequency.
This study allowed us to describe lifestyle behaviors of Brazilian pregnant women over a decade. We verified a reduction in the regular consumption of soft drinks and in the habit of smoking, as well as an increase in the practice of physical activity. The diversity of the lifestyle of pregnant women among the five Brazilian regions also highlights the importance of investigating local characteristics in more detail. Furthermore, we identified clear sociodemographic inequality regardless of the year of the survey. Healthier habits, such as the regular consumption of vegetables, fruit, and lower consumption of soft drinks and the practice of physical activity showed higher prevalence among pregnant women with older age and more education.


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