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Social inequalities and dietary patterns: an analysis with adults in the Metropolitan Region of Recife

Desigualdades sociais e padrões alimentares: uma análise com adultos da Região Metropolitana do Recife

Nathalia Barbosa de Aquino1 https://orcid.org/0000-0002-0125-8084, Nathália Paula de Souza2 https://orcid.org/0000-0001-6826-8239, Maria José Laurentina do Nascimento Carvalho1 https://orcid.org/0000-0002-6705-165X, Adriana Marcela Ruiz Pineda1 https://orcid.org/0000-0001-9964-0101, Vanessa Sá Leal2 https://orcid.org/0000-0001-9492-2580, Malaquias Batista Filho3 https://orcid.org/0000-0002-1490-0590, Pedro Israel Cabral de Lira1 https://orcid.org/0000-0002-1534-1620, Juliana Souza Oliveira2 https://orcid.org/0000-0003-1449-8930

1 Departamento de Nutrição, Universidade Federal de Pernambuco, Recife, PE, Brasil.
2Curso de Nutrição, Centro Acadêmico de Vitória, Universidade Federal de Pernambuco, Vitória de Santo Antão, PE, Brasil.
3Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, PE, Brasil.

Resumo
Objetivou-se identificar os padrões alimentares e sua associação com características socioeconômicas, demográficas, de estilo de vida e excesso de peso em adultos da Região Metropolitana do Recife, em 2015/16 e 2019. Estudo transversal com indivíduos de ambos os sexos, com idades entre 20 e 59 anos. Os padrões alimentares (PA) foram identificados por meio da análise de componentes principais (ACP). A regressão logística binária foi utilizada para estimar as razões de chances bruta e ajustada e intervalos de confiança 95% (IC 95%). Foram identificados três PA: Duplo, Ultraprocessado (UP) e Tradicional. Observou-se que o PA Duplo explicou a maior variância em 2015/16 (15,4%), enquanto em 2019 foi o PA UP (15,1%). Em 2015/16, o PA Duplo associou-se à idade ≥ 41 anos, maior escolaridade e segurança alimentar (SA); já em 2019, associou-se a maior escolaridade, SA e excesso de peso. O PA UP relacionou-se às faixas etárias de 20-29 anos e 30-40 anos em 2015/16, sem associações em 2019. O PA Tradicional associou-se à prática de atividade física em 2015/16 e, em 2019, a residir com ≥5 pessoas no domicílio, menor escolaridade e excesso de peso. Os padrões alimentares em 2019 mostraram uma maior associação com os determinantes sociais, indicando maior influência desses fatores na alimentação.
Palavras-chave: Padrão alimentar, fatores sociodemográficos, desigualdade social, adultos.

Abstract
The aim of this study was to identify dietary patterns (DP) and their association with socioeconomic, demographic, lifestyle, and overweight characteristics in adults from the Metropolitan Region of Recife (MRR) in 2015/16 and 2019. A cross-sectional study was conducted with individuals of both sexes, aged 20 to 59 years. DPs were identified using Principal Component Analysis (PCA). Binary logistic regression was used to estimate crude and adjusted odds ratios and 95% confidence intervals (95% CI). Three DPs were identified: Dual, Ultra-processed (UP), and Traditional. The Dual DP explained the highest variance in 2015/16 (15.4%), while in 2019, it was the UP DP (15.1%). In 2015/16, the Dual DP was related to the age groups of 20-29 years and 30-40 years, with no associations in 2019. The Traditional DP was associated with physical activity in 2015/16 and, in 2019, with living with ≥5 people in the household, lower education, and overweight. The dietary patterns in 2019 showed a stronger association with social determinants, indicating a greater influence of these factors on eating habits.
Keywords: Dietary pattern, sociodemographic factors, social inequality, adults.

Introduction
The dietary pattern (DP) can be characterized as a set of foods frequently consumed by individuals and populations. DP analysis makes it possible to evaluate the diet from a global perspective, in which it identifies the intake of several interrelated food groups, capturing the complexity and multidimensional nature of the diet1.
In Brazil, according to the Household Budget Survey (HBS)2, Brazilians reduced their consumption of fresh or minimally processed products, such as fruits and vegetables, at the same time as they increased their intake of processed and ultra-processed foods, such as pizzas, snacks, and sweetener, favoring the prevalence of obesity in the country.
According to a study conducted by Lutz3, food choices impact human health and planetary sustainability. DPs that reduce risk factors for Noncommunicable Diseases (NCDs) and various causes of mortality are recognized as healthy eating habits. However, the world population is far from achieving such eating habits due to a lack of access to these foods3.
The high social inequalities and social vulnerability factors that mark Brazilian society were highlighted in recent years through the National Survey on Food Insecurity in the Context of the COVID-19 Pandemic in Brazil. In Pernambuco, for example, 2.1 million people live with hunger, associated with gender, income, education, and work situation4.
In this sense, the objectives of this study were to identify DPs and analyze their association with sociodemographic aspects in the Metropolitan Region of Recife.

Methodology
Study design, ethical aspects, and sample
This is an analytical cross-sectional study, based on secondary data, of two adult populations in the Metropolitan Region of Recife (MRR), in the years 2015/2016 and 2019, part of the IV State Health and Nutrition Survey (IV PESN). The present study was approved by the Research Ethics Committee of the Health Sciences Center of the Federal University of Pernambuco, logged under CAAE number 38868720.2.0000.5208.
To calculate the sample, the Statcalc program of the EPI-INFO Software, version 6.04 (Centers for Disease Control and Prevention, Atlanta, United States) was used to size the sample for 2015/16 and 2019, estimated based on the prevalence of consumption of ultra-processed foods (18.2%) carried out by the Risk and Protection Factor Surveillance System for Chronic Diseases by Telephone Survey (BRASIL, 2021), with an error of ±4 percentage points and a 95% confidence interval (95% CI), resulting in a sample of 396 individuals, for both study moments. To evaluate the associated factors, a sample was estimated a posteriori considering a 95% CI (1-α), a study power of 80% (1-β), and a ratio of 1:1 (between exposed: unexposed).

Data collection
Data collection was household-based, conducted through an active search, and took place from June 2015 to September 2016 and from May to August 2019 in the municipalities of Recife, Paulista, Olinda, Cabo de Santo Agostinho, and Jaboatão dos Guararapes. Data were collected by properly trained researchers, using a structured form containing the following variables: demographic and socioeconomic data, food and nutritional profile, food security, and lifestyle.

Dependent variable
Food consumption was investigated using the food frequency questionnaire (FFQ), containing 120 foods, aggregated into four groups according to the NOVA food classification (BRASIL, 2014) and 16 subgroups in 2015/16. In 2019, the FFQ consisted of 121 foods and was divided into 4 groups and 16 subgroups (Table 1). The food list for the two periods was constructed based on food consumption data in Pernambuco, which were evaluated in relation to the frequency of consumption (from 0 to 7 times) per day, week, month, or year in the last 6 months5.
For each food, an index was calculated through the relationship between the number of times the food was consumed and the frequency of consumption (daily=1, weekly=7, monthly=30, annual=365). In this way, foods consumed weekly were classified using the division “a/7 (days of the week)”; those consumed monthly resulted from the division “a/30 (days of the month)”; and those consumed annually were obtained by dividing “a/365 (days of the year)”.
Foods consumed by less than 5% of the population were excluded from the analysis, namely: fruit in syrup or candied, light mayonnaise, and light soda.

Independent variables
The following were included in the questionnaire: age (years), sex (female/male), education (<12 years of study/ ≥12 years of study), self-declared skin color and categorized according to the 2010 IBGE census6 (white/ brown/black/indigenous), income categorized according to the minimum wage of the year of study, being R$880.00 in the year 2015/167 and R$998.00 in 20198, and physical activity (inactive < 150 minutes/week and active ≥ 150 minutes/week). The practice of moderate physical activity in different domains was also considered, such as: light cycling; swimming; dancing; light aerobics; playing recreational volleyball; carrying light weights; doing domestic work in the house or yard, such as sweeping, vacuuming, or; taking care of the garden or doing jobs such as welding, operating machines, stacking boxes, among others9.
For anthropometric assessment, adults\' weight and height were measured twice, using a digital scale model Tanita-BF-683, with a maximum capacity of 150kg and precision of up to 100 grams, and a portable stadiometer from the Alturaexata brand, millimeters with precision of up to 1mm.
The measurements were carried out in accordance with the techniques established by the Food and Nutrition Surveillance System (SISVAN), a protocol adopted by the Ministry of Health. When the difference between the assessments exceeded 0.5cm for height and 100g for weight, the measurement was repeated, and the two measurements with the closest values were noted, and the average was recorded. During the measurements, the individuals were barefoot and wearing light clothing10.
The classification of the situations of food security and insecurity was obtained through the application of the Brazilian Food Insecurity Scale (Escala Brasileira de Insegurança Alimentar – EBIA) questionnaire, consisting of 14 questions, in households with residents under 18 years of age or 8 questions, for families consisting of only people over 18 years of age11.
The sum of the score to categorize food security and insecurity in households without children under 18 years of age is structured as follows: 0: food security (SA); 1-3: mild food insecurity (LI); 4-5: moderate food insecurity (MI); and 6-8: severe food insecurity (GI). For analysis purposes, in this study, it was categorized into SAN and InSAN (mild, moderate, and severe). By contrast, for households with children under 18 years of age, the sum is structured as follows: 0: food security (SA); 1-5: mild food insecurity (LI); 6-9: moderate food insecurity (MI); and 10-14: severe food insecurity (GI)11.

Statisitical analysis
Data entry was performed using the Epi Info program, version 6.04 (CDC, Atlanta). Data were analyzed using SPSS (Statistical Package for the Social Sciences), version 13.1 (SPSS Inc. Chicago, IL USA).
To identify DPs, the a posteriori method was used, applying the Principal Component Analysis (PCA), which was performed on 16 food subgroups. According to this method, food groups are formed according to the similarity of nutritional composition and foods and their interrelationships12.
To verify the applicability criteria of the factor analysis, the Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of sphericity (BTS)13 were used. To identify the number of patterns to be retained, the eigenvalue criterion (above 1.0), the eigenvalue graph (Screep Plot), and the interpretability of the patterns were used. Varimax orthogonal rotation was used to facilitate data interpretation.
Factor loads greater than 0.20 were considered to determine the nomenclature of patterns according to Hair et al.13. The naming of DPs was carried out according to the foods that presented the highest factor loading and according to cultural aspects. Each identified DP was categorized into tertiles and dichotomized into tertiles 1 and 2 (lowest consumption) and tertile 3 (highest consumption). Tertile 1 and 2 represented adults with lower adherence to a given dietary pattern, while tertile 3 characterized those with greater adherence.
Pearson\'s chi-square test was performed to verify the association between the dependent variable (DPs) and the independent variables (gender, age, education, income, self-declared skin color, physical activity, excess weight, and food security). In the analysis of the initial binary logistic regression model, only variables with a p-value < 0.20 were maintained (supplementary material). After adjustment, variables with a p-value ≤ 0.05 were considered to be associated with DPs.

Results
In the period of 2015/16, the sample consisted of 426 adults, 65.7% female and 37.1% aged ≥ 41 years. The majority declared themselves to be brown, black, and indigenous (79.6%), with education < 12 years of study (51.4%). The per capita income of the majority was up to 440.00 reais (73.1%), 64.1% lived in households with less than 5 people. More than half (62.4%) suffered from food insecurity, were overweight (65.7%), and were engaged in physical activity (61.7%).
Regarding the year 2019, the final sample was made up of 432 adults, consisting mainly of females (66.2%), aged ≥ 41 years (53.9%), self-declared brown, black, or indigenous (75, 2%), with less than 12 years of study (56.9%), a per capita income of up to 499.00 reais (90.1%), living with less than 5 people in the household (75.5%), suffering from food insecurity (72%), were overweight (64.8%), and were considered active regarding physical activity (75.2%).
In both moments of the study, three patterns explained the variance in the food consumption of the adult population of the MRR, which was represented by 39.4% in 2015/16 and 38% in 2019. The Kaiser-Meyer-Olkin measurements were > 0.60, which were 0.75 in 2015/16 and 0.74 in 2019, while the Bartlett test was ≤ 0.05, pointing out the applicability of the PCA. In the PCA, three DPs were identified in both periods, namely: “Double”, “Ultra-processed” and “Traditional” (Table 2).
In 2015/16, the Double DP showed the highest percentage of variance (15.4%) and consisted of roots and tubers, vegetables, fruits, natural juice and tea, oilseeds, milk and boiled eggs, chicken meat, fish and fried eggs, juice with sugar, wine, and beer. The Ultra-processed DP (15.4%) was the second most consumed and included the following food groups: snacks and sauces, biscuits, sugary cereals, pies and cake mixes, soft drinks and artificial juice, sweets, dairy products, preserves, ultra-processed bread and cookies. And finally, the Traditional DP, which was the least consumed (8.6%) and was characterized by legumes, culinary ingredients, grains, and cereals (Table 2).
In 2019, Ultra-processed DP was the most consumed (15.1%) and continued with the same composition as Ultra-processed DPs from 2015/16. Double DP, the second most consumed (13.2%), was characterized by vegetables, fruits, natural juice and teas, oilseeds, milk and boiled eggs, juice with sugar, beer, and wine. Unlike the first moment of the study, in 2019, Traditional DPs continued to be the least consumed (9.7%). However, in addition to the foods already identified in 2015/16, such as legumes, culinary ingredients, grains, and cereals, \' roots and tubers\' and \'meat, chicken, fish, and fried eggs\' were also included (Table 2).
After adjustments, in 2015/16 Double DP was associated with being aged 41 years or over (OR=2.30), having 12 years or more of education (OR=1.58), and being food secure. (OR=1.66). Ultra-processed DP was directly associated with ages between 20 and 29 years (OR=9.74) and between 30 and 40 years (OR=2.90). Traditional DP was associated with individuals who practice physical activity (OR=2.97) (Table 3).
In 2019, Double DP was associated with having higher education (OR=1.87), being food secure (OR=1.93), and being overweight (OR=2.22). Ultra-processed DP showed no significant association. Moreover, traditional DP was associated with adults who lived with 5 or more people in the household (OR=1.76), had a lower level of education (OR=1.66), and were not overweight (OR=1.54 ). In this study, the income variable was not associated with DPs in the two study periods, which may well be related to the fact that 2/3 of the sample had an income of up to R$ 440.00 reais and R$ 499.00 reais during the respective study periods (Table 4).

Discussion
The three identified DPs were named according to their compositions. The first pattern was called Double DP because it consists of fresh foods, meats, and processed drinks14, 15. Ultra-processed DP was considered the most harmful to health, as it consists exclusively of ultra-processed foods that are rich in sugar, fats, and sodium16, 17. Finally, Traditional DP received this nomenclature, as it contains typical foods from the region: legumes, roots and tubers, grains and cereals, and culinary ingredients18.
In 2015/16, the most prevalent DPs were Double DPs (15.4%), made up of fresh foods, meats, and processed drinks, and Ultra-processed DPs (15.4%). In 2019, these continued to be the most predominant DPs, but the most consumed DP became the Ultra-processed DPs (15.1%).
These results corroborate those reported in national2, 19, 20 and international21-23 studies, which highlight that, with the process of urbanization, globalization, and intensification of capitalism, there was an increase in the consumption of processed and ultra-processed foods, and a resulting increase in NCDs. This result revealed that the purpose of the modern food system is not the health and wellbeing of humanity, but rather, the transformation of food into merchandise for the accumulation of capital, with a large-scale production of these types of food and the consequent homogenization of food, erasure of food culture, and changes in the food system24, 25.
Traditional DPs were the least consumed in both moments of the study, and changes in its composition were observed in 2019, making it possible to identify – even if not retained, that is, with a lower variance – the group of soft drinks and artificial juices. It is important to note that, when a new food group appears in a pattern, it is possible that the consumption of other groups is being compromised. In the present study, it was suggested that the emergence of the food group ‘soft drinks and artificial juices’ has contributed to a decrease in the consumption of ‘grains and cereals’. It can therefore be understood that even the Traditional DP may be changing over time due to the great availability of ultra-processed foods in food environments and easier access through tax incentive policies for major food corporations26.
Another change that is analyzed in the composition of DPs is the decrease in the variance of the groups of \'roots and tubers\', \'vegetables and legumes, \'fruits, natural juice, and tea\', and \'grains and cereals\' from 2015/16 to the year 2019, thus becoming DPs with less food variety. These findings corroborate data from VIGITEL, which shows that the consumption of fruits and vegetables and a drop in the consumption of rice has remained low and stable over the years in Brazilian capitals19, 27, 28. Additionally, according to the HBS, there is a low purchase of fruits and vegetables in Brazil, in all regions and among all classes2, 29. It is also important to highlight the importance of fresh or minimally processed foods in one’s diet for a better quality of life and for the prevention of NCDs.
The DPs found in the present study were similar to studies in Rio de Janeiro30, Rio Grande do Sul31, South Korea32, and Iran33. Although some DP nomenclatures are different in other studies, it is possible to observe similarities based on the composition of the food groups.
In 2015/16, being 41 years of age or older, having a higher level of education, and being in SA were associated with Double DP, a similar result was observed in a study conducted by Canuto et al.15. In 2019, the same trend was observed between Double PA and education and food security, but an association with excess weight was also found. It can be understood that adults with higher levels of education have greater purchasing power and, consequently, greater access to healthy foods and are food secure34, 35. Ages between 20 and 29 years and between 30 and 40 years in 2015/16, presented eight-fold and nearly three-fold more chances, respectively, of adhering to Ultra-processed DPs when compared to older adults (≥ 41 years old). These results differ from those found by Romeiro36, who showed a positive association between being 60 years of age or older and the “processed and ultra-processed products” pattern.
It can be inferred that these two age groups (20 to 29 years and 30 to 40 years) are the main target audiences for food advertising, with the food industry increasingly offering practical, palatable, and durable foods, in addition to the wide range of ultra-processed foods37. Furthermore, these individuals do not yet have food-related comorbidities, showing no concerns about the quality of their diet, and the fact that they work long hours that prevent the preparation of meals, thus opting for the practicality of consuming ultra-processed foods20, 38 , 39.
However, in 2019, no relationship was found between Ultra-processed DPs and the study variables, which may be related to a predominance of this pattern in the studied population, making it no longer possible to find a statistical difference. At the same time, as this is the first study conducted on DPs in the MRR, there is a clear need to carry out further studies with other possible determinants of food consumption, such as environmental aspects.
Adults practicing physical activity showed an association with Traditional DP in 2015/16, similar to a study carried out in the United Kingdom, which identified a relationship between less healthy eating patterns and low physical activity, showing that individuals who practice physical activity have a greater care with the quality of food1.
In 2019, the Traditional DP indicated a correlation with a lower level of education and an association with adults who lived with 5 or more people in the household; this finding also corroborates results found in other studies31, 40. Therefore, understanding that having a lower level of education does not necessarily translate into a low level of knowledge about quality meals. In fact, it can be a barrier when it comes to accessing these foods. This factor may also have a regional, cultural, and social relationship, since, according to the HBS, food consumption in the Northeast region, especially among the economically disadvantaged population, is traditionally based on rice and beans2.
It was also observed in 2019 that Traditional DPs showed an association with excess weight, unlike other studies35, 40, thus suggesting that adults who have comorbidities become more concerned about the quality of food39.

Final Considerations
Individuals who have a better socioeconomic position, in this case, a higher level of education and greater food security, showed a greater consumption of the Double DP, which presents fresh or minimally processed foods and processed drinks, while people with a lower level of education, showed an association with the Traditional DP. Furthermore, DPs in 2019 showed a greater association with social determinants, showing that there was a greater participation of them in determining dietary patterns.
It is also important to note that Double DPs was more predominant in 2015/16, while in 2019, it became the Ultra-processed DPs, showing that the consumption of processed and ultra-processed foods has been increasing in the analyzed population, following the national trend, in addition to being present in all identified DPs.
Thus, among other public policies, it is necessary to have intersectoral policies on food and nutritional security, as well as sustainable urban and health planning in order to regulate the advertising of ultra-processed foods and tax processed and ultra-processed beverages.
More importantly, rural producers need to be given incentives for a greater accessibility to and circulation of fresh food at fair prices, consequently promoting the appreciation of local and regional commerce.

Limitations and Potentials
Food consumption methodologies according to the FFQ, such as memory bias, level of education, and age, were limitations that were overcome through methodological rigor in data collection and analysis. Furthermore, the use of the DP method made it possible to classify according to food groups and was therefore considered appropriate. Second, the PCA calls for subjective decision-making, but this was controlled through a broad literature review.
Furthermore, this study presents DPs in the MRR, at different times, most likely a pioneer in the analysis of DPs in this population, which makes it possible to respond to the interests of understanding one’s eating patterns and their determinants.

Funding
Funded by Chamada Universal-MCTI/CNPq 14/2013 (logged under process no. 476862/2013-2); FACEPE Announcement 20/2014 (APQ-0338-4.05/15); and CAPES research grant ceded to AQUINO, N. B.

Repository Scielo Data: https://doi.org/10.48331/scielodata.SYB65D

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