Artigos

Introduction
Dietary intake during the preconception and gestational periods strongly influences maternal health and fetal development. During pregnancy, physiological changes occur in the body's systems that increase the demand for energy, protein, vitamins, and minerals. Accordingly, adopting a healthy and adequate diet throughout pregnancy, as well as in the preconception period, is crucial for the health of both mother and child1, being essential to ensure sufficient placental metabolism, appropriate fetal development, and the prevention of negative pregnancy outcomes2.
Despite this, the increased consumption of ultra-processed foods (UPF), at the expense of minimally processed or fresh foods, is concerning in the population of pregnant women, as this group is vulnerable to nutritional inadequacies3. This dietary pattern reduces the overall quality of the diet and directly impacts maternal health conditions and individuals early in life4.
The UPF group consists of industrial formulations made primarily or entirely of sugar, salt, oils and fats, starches and many food-derived substances not normally used in cooking, as well as additives, including those used to imitate the sensory qualities of natural foods or to disguise undesirable qualities of the final product5.
Evidence indicates an association between UPF consumption and the risk of adverse pregnancy outcomes. These outcomes include maternal obesity6, as well as in gestational diabetes mellitus7. Additionally, this practice contributes to negative impacts on the environment and has implications in the social, cultural, political, and economic domains8.
Comparing UPF consumption among pregnant women in different countries can reveal cultural, socioeconomic and food policy differences that affect food choices. In addition, the data can serve as a basis for comparison with other regions or countries, expanding the understanding of the factors that influence UPF consumption among pregnant women globally. Furthermore, no studies were found that identified variables associated with UPF consumption in populations of pregnant women of different nationalities.
The aim of this study was therefore to investigate the determinants associated with habitual consumption of UPF among Brazilian and Portuguese pregnant women
Methods
Study design and population
In Brazil
The study utilized data from the baseline of a controlled randomized clinical trial conducted with 350 overweight adult pregnant women who attended seven Health Units in the municipality of Ribeirao Preto, SP, Brazil, from 2018 to 2021. For the present study, pregnant women with complete dietary intake data at the first assessment of the clinical trial were included (n=335). This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Research Ethics Committee of the School Health Center of the Faculty of Medicine of Ribeirao Preto, SP (69997717.6.0000.5414). Written informed consent was obtained from all subjects. Details about the study can be found in the publication by Sartorelli et al. (2020)9.
The sample size calculation was based on the primary outcome of the study, totaling 350 women10. The inclusion criteria were: women aged ?18 years, gestational age at screening up to 15 weeks and 6 days, and pre-pregnancy body mass index (BMI) between 25 and 29.9 kg/m². Pregnant women with multiple pregnancies, a history of previous diabetes mellitus or medication for weight loss were excluded. Women with fasting glucose ?126 mg/dl, or ?200 mg/dl two hours after the oral glucose tolerance test, were considered to have previous diabetes mellitus and were subsequently excluded.
In Portugal
The data from the National Food and Physical Activity Survey (Inquérito Alimentar Nacional e de Atividade Física - IAN-AF), collected between October 2015 and September 2016, were analyzed. This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the National Data Protection Commission, the Ethics Committee of the Institute of Public Health of the University of Porto, the Regional Health Administrations, and the Regional Health Secretariats (opinion nº CE15033). Written informed consent was obtained from all subjects.
The sample base of the IAN-AF 2015-2016 was the National Registry of Users of the National Health Service11.
Exclusion criteria considered in the IAN-AF 2015-2016 were: individuals living in collective/institutionalized residences; adult individuals who had lived in Portugal for less than one year; individuals who did not speak Portuguese; and individuals with diminished physical or cognitive capacities that prevented participation.
Origin of dietary intake, socioeconomic, obstetric, and lifestyle data
In Brazil
For the present study, only the data from the first assessment of the clinical trial were used. Data collection was carried out by trained nutritionists using tablets running the Research Electronic Data Capture (REDCap) program12,13. The usual dietary intake data of UPF were obtained through two 24-hour dietary recall surveys (24-HDR), with an average time between replications of 11 days. These surveys were conducted in person during prenatal consultations at the Health Units. The second 24-HDR was obtained from 82.9% of the participants on a previously scheduled date.
The 24-HDR surveys were collected by the pregnant women reporting all foods, preparations, and beverages consumed on the day before the interview, following the "multiple-pass" methodology in seven stages14, allowing for the classification of foods according to the Nova classification. For the quantification of the foods reported, a photographic manual of food quantification developed for the Brazilian population was used, which contains photos of food portions and forms, as well as household measures15.
The Nutrition Data System for Research software, developed by the University of Minnesota in the United States, was used for the estimation of dietary energy and nutrients. Height and weight were measured using a stadiometer with an attached mechanical scale and a portable digital scale (Tanita, model HS 302), respectively. Data on age, marital status, gestational and head of household’s education level, employment status, and smoking habits were obtained through a structured questionnaire at the time of data collection. Physical activity (PA) was assessed through a questionnaire similar to that used by VIGITEL, and the data were subsequently classified according to the recommendations of the World Health Organization16.
For economic classification, the Brazil Economic Classification Criteria of 2019 was employed17, which is based on item ownership, head of household's education level, residence with piped water, and paved street, collected at the first assessment of the study, categorizing socioeconomic status from class A (highest level) to class E (lowest level). Gestational age was calculated using the date of the last menstrual period recorded in the pregnant woman's prenatal care booklet, which was later confirmed with ultrasound data before the 20th week of gestation.
In Portugal,
The methodology used in the IAN-AF included tools and protocols harmonized in the European context. Participants selected were contacted by telephone by previously trained technicians and invited to participate in the study. Furthermore, an invitation letter with details regarding participation was sent by mail, along with the consent form. Individuals who agreed to participate in the study were scheduled for both interviews. This scheduling was done considering the randomization of the day of the dietary recall, as the 24-HDR method was used.
The usual dietary intake data from UPF of the Portuguese pregnant women were obtained through 24-HDRs. using the 5-step multiple-pass technique11.
Different quantification methods were used, including weight/volume, standard units, household measures, and photographic series. A photographic manual was specifically developed for the IAN-AF based on the foods most consumed in Portugal and susceptible to assessment through photographic series11. After identifying and quantifying the foods and recipes, daily nutritional intake was estimated using nutritional composition data from foods or recipes, based on the Portuguese Food Composition Table18, successively adapted throughout the fieldwork.
Two face-to-face interviews were conducted at the Functional Health Unit or at the participant's home. The second interview was conducted 8 to 15 days after the first, following European recommendations19. The average time between interviews was 11.2 days. Parameters such as weight and height were measured according to the IAN-AF procedures manual20. All equipment (SECA stadiometer, model 213, and SECA scale, model 813) used were purchased centrally and distributed among the various interview teams.
The age variable was calculated considering the date of the first interview and the date of birth. The latter was automatically imported from National Health Registry data and subsequently verified during the first contact with participants. Participants were also questioned about marital status, education level, employment status, and household income. The participants also answered questions related to health, such as the presence of any illness previously diagnosed by a physician requiring regular medical care and smoking habits. Additionally, information about the current pregnancy, such as gestational age and complications, was obtained. In the IAN-AF, physical activity was collected using the International Physical Activity Questionnaire short version21. Subsequently, it was classified according to the World Health Organization's recommendations22.
Classification and contribution of E% from UPF and harmonization of variables (Brazil and Portugal
The classification of UPF in the diets of Brazilian and Portuguese pregnant women was based on the Nova food classification system. The energy from UPF was calculated for the total and for the UPF subgroups.
The estimation of usual diet was performed using the Multiple Source Method23. The UPF were divided into subgroups based on the characteristics of each food24.
Statistical analyses
Data normality was assessed using the Skewness and Kurtosis test. To characterize the study population, continuous sociodemographic, obstetric, and maternal lifestyle characteristics were expressed as mean (±SD), and categorical variables were presented as absolute frequencies (n) and relative frequencies (%). The independent t-test was employed for the continuous variables, and the Chi-square test of independence was used for the categorical variables to assess the association between maternal characteristics and nationality. The Bonferroni post-hoc test was applied to identify statistically different categories.
Samples from pregnant women were evaluated separately, according to nationality. The E% from UPF in the diets of the Brazilian and Portuguese pregnant women was calculated as mean (± SD) and 95% CI. The UPF consumption was described in the form of percentiles (p25, p50 and p75). Quantile regression models were constructed to identify the association between UPF consumption and the variables investigated. These models allow observing the effect of independent variables at different points of the distribution of the dependent variable and are appropriate when the latter is asymmetric and heteroscedastic in relation to the other variables in the model.
The dependent variable was usual UPF consumption. The following variables were tested as independent variables: maternal age, years of education, physical activity, marital status, paid activity, pre-gestational BMI and current BMI. All analyses were performed using IBM SPSS software (version 26, SPSS Inc. Woking, Surrey, United Kingdom), and the significance level was set at p <0.05.
Results
The average age of pregnant Brazilian women was 27.5 (5.8) years and that of Portuguese women was 32.0 (6.1) years, while the BMI of Brazilian women was 27.2 (1.4) kg/m² and 28.7 (5.0) kg/m² of Portuguese women. Both characteristics showed significant differences in relation to the nationality of the pregnant women. Gestational age also differed significantly between nationalities, with the majority of Brazilian pregnant women [280, (83.6%)] being in the first trimester of pregnancy, while 98 (43.4%) of Portuguese pregnant women were in the third trimester.
Education differed significantly between nationalities, with 216 (64.5%) Brazilian pregnant women reporting between 9 and 11 years of schooling, compared to 107 (47.3%) of the Portuguese pregnant women reporting 11 or more years of schooling. Additionally, a significantly higher proportion of Portuguese pregnant women reported engaging in paid employment compared to the Brazilians, with 178 (78.8%) and 199 (59.4%), respectively.
Regarding lifestyle habits, only 215 (38.3%) of the total sample of pregnant women reported engaging in at least 150 minutes of PA per week, with the Portuguese pregnant women significantly more likely to meet the recommendation compared to the Brazilians. Furthermore, there was a significant difference in smoking habits between the nationalities (Table 1).
The mean daily energy intake from UPF among the Brazilian pregnant women was 24.2% (±8.8) of the total energy consumed on a typical day, while among the Portuguese pregnant women, the mean was 22.3% (±9.3), respectively. Among the Brazilians, the most consumed UPF group was "burgers," and among the Portuguese, it was "savory snacks," accounting for 435.3 (±174.7) kcal, representing 23.5% (±9.4) of the energy consumed on a typical day, and 534.3 (±166.8) kcal, representing 22.9% (±7.1), respectively (Table 2 and Figure 1).
Table 3 presents the results of the analysis of the association between sociodemographic, obstetric and maternal lifestyle variables and the contribution of UPF to the total energy consumed by the population studied. In p25 of UPF consumption, among women who studied between 9 and 11 years, one more year of study increases UPF consumption among Portuguese pregnant women by 4.17%. While in p50 of UPF consumption, one more year of age decreased UPF consumption among Brazilian pregnant women by 0.28%, just as one more year of age decreases UPF consumption among Portuguese pregnant women by 0.30%. In this sense, in p75 of UPF consumption, one more minute of physical activity per week decreases UPF consumption among Portuguese pregnant women by 0.002%.
Discussion
The main results of this study indicate that the age of Brazilian pregnant women and Portuguese pregnant women, the schooling and the practice of physical activity among Portuguese pregnant women are determinants of the consumption of UPF.
Previous studies have found an association between UPF consumption and sociodemographic, behavioral, and obstetric characteristics. In these studies, older pregnant women with higher levels of education tend to consume less UPF25,26. On the other hand, risk factors for higher consumption include low levels of education, physical inactivity before pregnancy, smoking during pregnancy, multiparity, and low pre-gestational weight22,25,26.
The present study used data from the population of pregnant women and evidenced that UPF represents approximately one-fifth of the total energy consumed by Brazilian and Portuguese pregnant women. A study employing data from the IAN-AF 2015-2016 found the participation of 23.8% of UPF in the diet of the study population (children, adults, and older adults)27. In multicenter studies such as the First Family Study, conducted in eight European countries, almost half of the daily energy intake of children, adolescents, and adults comes from UPFs28. Similarly, the consumption of UPF among Brazilians aged 10 years or older, estimated by a study using data from the Family Budget Survey 2017-2018, was 19.7% of the total kilocalories ingested29. Therefore, it was identified that the usual consumption of UPF among pregnant women, estimated in this study, is similar to that found for the general population of Brazil and Portugal.
Cultural differences in eating habits between Brazil and Portugal reflect culinary traditions and each country's stage of nutritional transition. In Brazil, the traditional dietary pattern based on in natura or minimally processed foods, such as rice, beans, roots, and meat, remains prevalent, particularly among older adults and rural populations. However, there has been a significant increase in UPF consumption, particularly among young people, individuals with higher education, and urban dwellers. In certain groups, UPF can account for up to 46% of total energy intake30. In Portugal, the transition to dietary patterns with a greater presence of UPFs is more recent but is already expanding. From 1990 to 2005, household availability of UPFs increased from 3.9% to 13.8%. This shows a process of replacing natural foods with UPFs in various food categories. This process has been associated with an increase in chronic non-communicable disease indicators, such as neoplasms and digestive diseases31.
Studies conducted in both countries demonstrate successive increases over the years in the percentage of energy derived from this category of foods in the population's diet29,31. As a result of the globalization of food systems, initiated in the 1970s, UPF became available on a global scale, spreading worldwide and integrating into the diets of all age groups32. This consumption is stimulated by technological drivers and the underlying political economy of food systems, such as trade and investment liberalization, the global expansion of transnational food and beverage companies and their political and market activities, combined with changes in food production, processing, and marketing technologies, as well as the failure of policies and regulations to encourage and promote the consumption of healthy diets in these new contexts33,34.
The prices of this food category have also decreased over the years. A study measuring the price change of food groups over the years in Brazil showed a decrease in the price of UPF; with it being the most expensive group in 1995, undergoing successive price reductions since the 2000s, allowing predictions that by 2026 there will be an economic advantage to its acquisition when compared to groups of fresh, minimally processed, processed foods, and culinary ingredients35. At the same time, an ecological study carried out in 19 European countries found that the median household availability of UPF corresponded to 26.4% of total food energy purchased. There was a wide variation between countries, with the lowest proportions recorded in Portugal (10.2%) and Italy (13.4%), and the highest in Germany (46.2%) and the United Kingdom (50.4%) 36.
Despite the similarity in the energy consumption from UPF between the different nationalities of pregnant women evaluated, some sociodemographic, obstetric, and maternal lifestyle variables presented significant differences between the groups. The Portuguese pregnant women had a higher mean age and higher BMI compared to Brazilians. The latter can be explained by the difference found in gestational age between nationalities, as the Portuguese pregnant women had a higher gestational age than the Brazilians, consequently more exposed to gestational weight gain accumulation.
Regarding lifestyle habits, the Portuguese pregnant women engaged in significantly more physical activity than the Brazilians. This is justified by the leptogenic environment of the territory in which they live, favoring active commuting and leisure activity. However, Brazilian pregnant women who never smoked represent a significantly larger group compared to these Portuguese women.
The UPF groups that contributed the most to the total energy percentage among the Brazilian pregnant women were "burgers”, followed by "ready-to-eat meals" and "packaged snacks". Meanwhile, among Portuguese women, the groups that contributed the most to the total energy percentage were "savories", "bread and toasts", and "packaged snacks". These three food groups that contributed the most to the energy percentage from UPF among the Brazilian pregnant women constituted potential meal substitutes, requiring more technological skills than culinary skills for meal "preparation", such as operating a microwave oven, opening paper or plastic packaging, and stacking ingredients to assemble a sandwich. The demand for this type of food may be related to the transition of culinary skills, associated with changes in the patterns and types of required skills, and the time invested in acquiring, preparing, and consuming food37. Other factors that may contribute to this unhealthy choice include the increasing participation of women in the formal labor market, without a redistribution of household chores among family members, resulting in an overload of tasks and leading to the choice of foods that require little or no preparation.
Among Portuguese women, the second group of UPF that contributed most to energy intake was “bread and toast.” In a study on the eating patterns of Portuguese adults and elderly people, a pattern of “diet concerns” was identified, characterized by restrictions typical of people on a diet and higher consumption of UPFs considered “healthy,” such as ultra-processed cookies and yogurts. This behavior may be related to the widespread presence of nutritional and health claims on UPF packaging, which can mislead consumers38. Thus, public strategies and policies are essential to guide the population on the consumption and identification of truly healthy foods. Approaches focused solely on nutrients tend to stimulate the production and promotion of UPF and do not clarify differences between degrees of processing. Despite this, only Brazil, Peru, Uruguay, Ecuador, and Canada have guidelines that classify foods by degree of processing, encouraging the consumption of fresh and minimally processed foods and limiting UPF32.
Regardless of nationality, age was a determinant of UPF consumption among pregnant women. A systematic review that compiled data from seventeen countries indicated that younger individuals consume more UPF compared to older individuals39. Nevertheless, younger populations are more vulnerable to UPF advertising, which may influence their food choices, perceptions, behaviors, and preferences40,41.
An additional year of schooling among Portuguese pregnant women who had between 9 and 11 years of study was associated with higher consumption of UPF. Although most studies that evaluated the influence of schooling on the consumption of UPF found a positive relationship42, a cross-sectional study that used data from the Pelotas Birth Cohorts, Brazil, from 2004, 1993 and 1982 obtained conflicting results43,44. It is expected that higher schooling promotes greater access to information and, consequently, healthier lifestyles and food choices; however, amid the globalization of UPF and the accumulation of daily functions, many opt for UPF.
The practice of PA during pregnancy is strongly recommended by the World Health Organization and the Royal College of Obstetricians and Gynecologists and promotes beneficial outcomes for maternal and child health, reducing the risk of excessive gestational weight gain, gestational diabetes mellitus, preeclampsia, birth complications, preterm birth, newborn health complications, and postpartum depression45. However, a systematic review found that in almost 60% of the studies analyzed, pregnant women's levels of PA were below international recommendations46.
Studies show that pregnant women face several barriers to adopting healthy behaviors, such as lack of knowledge and resources to safely engage in physical activity, the influence of their peers' beliefs and values, and insufficient advice from health professionals47. Despite this, most Portuguese pregnant women reported adequate weekly physical activity, which was negatively associated with the consumption of UPF. Complementary evidence reinforces this relationship: a Spanish longitudinal study identified a negative association between the “sugary drinks and sugars” pattern and physical activity before and during pregnancy; and a recent cohort study observed a positive association between higher average UPF consumption and pre-pregnancy physical inactivity48,49. Thus, recognizing sociodemographic, obstetric, and lifestyle characteristics associated with UPF consumption is essential to guide effective interventions and public food policies aimed at pregnant women.
Among the strengths of this study, we highlight the methodological rigor in estimating samples and usual food consumption, ensured by collecting two days of consumption using validated instruments. The “multiple stage” dietary interviews reduced food omission and standardized the detailing of information, including portion estimation using a photo album. The use of Multiple Source Method software ensured the estimation of usual consumption by minimizing intraindividual variability. In addition, the interviews were conducted by trained nutritionists following standardized protocols, and the systematic inclusion of data was made possible by electronic platforms developed specifically for both studies.
The use of the Nova food classification is also a highlight in this work, going beyond the reductionist view of nutrients and considering the level of industrial processing of the foods that compose meals, allowing investigation of the behaviors and sociodemographic, obstetric, and lifestyle characteristics that permeate these choices. Although there are other food classification systems according to the degree of processing, Nova is the most widely used system, in addition to having a more conservative approach and allowing broader comparisons, since it is extensively used in scientific studies, recommended as a methodology for classifying the degree of food processing50, and for the comparative assessment of population diet quality globally51, as well as used for formulating international guidelines52.
However, this study has limitations, one of which stems from the limitation of the food consumption measurement instrument used, concerning differences between real culinary recipes and standardized recipes. To minimize this bias, the collection instruments were tested and validated in advance. Another possible limitation is the difference between the inclusion criteria of the base studies. Among these, it is worth noting that the Brazilian study included only pregnant women with pre-gestational overweight, while the Portuguese study excluded pregnant women regardless of their pre-gestational nutritional status.
Conclusion
The UPF consumption by pregnant women was shown to be considerable and is influenced by age, among Brazilian and Portuguese pregnant women, and by years of study and physical activity practice, among Portuguese pregnant women. Nevertheless, they characterize a priority group to receive nutritional interventions during prenatal care, since pregnancy is a window of opportunity to adopt healthy lifestyle habits that can impact current and future health.
Acknowledgment
The authors would like to thank everyone who contributed directly or indirectly to this study.
Data availability statement
The research data is available upon request to the corresponding author.
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