Artigos

INTRODUCTION
The analysis of dietary patterns (DPs) has emerged as an alternative and complementary approach used to investigate the relationship between diet and the risk of chronic diseases. Rather than focusing on specific nutrients or foods, this approach examines the effects of the diet as a whole1
National and international studies have demonstrated a consolidated relationship between DPs and such factors as gender, skin color, income, education, and physical activity2–6. Additionally, more recent studies have demonstrated the association between food environments and DPs, highlighting that environmental factors are also determinants of individual food choices7–9.
Glanz et al.10 proposed a model that defines the complexity of environmental factors. This model categorizes food environments into four dimensions: community, consumer, organizational, and information. Public policies and the private sector influence all of these dimensions, shaping the population's DPs.
The community food environment is characterized by the distance between homes and commercial food establishments, density, and type of establishments10, while the consumer food environment is described by the following factors: food availability, variety, quality, price, advertising, location of products on the shelves, and organization of physical space10–12. Studies that address the relationship between DPs and food environments are scarce in Brazil, especially in the Northeast region of Brazil. Thus, the objective of this study was to evaluate the association between DPs and the community and consumer food environments within an adult population of the Metropolitan Region of Recife (MRR).

METHODOLOGY
Study design, ethical aspects, and sample
This is an analytical cross-sectional study based on secondary data obtained from the IV State Health and Nutrition Survey conducted in Pernambuco in 201913.
The present study included all adults aged 20–59 years residing in households sampled in the municipalities of Recife, Paulista, Olinda, Cabo de Santo Agostinho, and Jaboatão dos Guararapes, resulting in a final analytical sample of 432 individuals. Detailed sampling procedures and fieldwork methodology of the state survey have been previously described.
The study was approved by Research Ethics Committee of the Health Sciences Center of the Federal University of Pernambuco (Certificate of Presentation for Ethical Appreciation – CAAE 38868720.2.0000.5208).

Data collection
Data collection procedures followed the protocol of the State Health and Nutrition Survey, in which trained interviewers conducted household visits using structured questionnaires to obtain sociodemographic, dietary, and food security information.

Dependent variable
Dietary intake was assessed using a food frequency questionnaire containing 121 food items. Food items were grouped according to nutritional similarity and degree of processing. Principal Component Analysis (PCA) with orthogonal rotation was applied to identify dietary patterns based on consumption frequency.
Three dietary patterns were extracted according to eigenvalues, scree plot analysis, and interpretability criteria: Traditional, Dual, and Ultra-processed patterns. Factor loadings were examined to characterize each pattern, and individual scores were calculated and categorized into tertiles. Participants in the highest tertile were classified as having higher adherence to each dietary pattern.
Detailed methodological procedures are available in Aquino et al. 5, but the present study independently applied these procedures to derive dietary patterns for analysis.

Independent variables
Individual:
For individual analysis, the following data were obtained from the survey questionnaire: age (years), sex (female/male), income (? ¼ minimum wage/< ¼ minimum wage). The food security situation was obtained through the application of the Brazilian Food Insecurity Scale (EBIA)14, and was categorized as follows: food security, mild food insecurity, and moderate/severe food insecurity15.

Neighborhood:
Information on the neighborhood's educational level was obtained, in years of study, categorized into three tertiles. The first tertile represented the lowest 33.3% of years of study; the second tertile, the central range (33.3% to 66.6%); and the third tertile, the highest 33.3% of years of study, based on data from the Census conducted by the Brazilian Institute of Geography and Statistics16 and Ferreira et al.17

Food Environment:
Information on the food environment was obtained from food establishments close to the participants' homes, within a radius of 1.6 km, measured by Euclidean distance (in meters). This distance is considered adequate for accessing food shopping points on foot18,19. An inspection of 231 food establishments was also carried out using AUDITNOVA20, a tool validated and adapted for the Brazilian urban context. Measurement procedures for community and consumer food environments followed the protocol established by Glanz et al.10.
To describe the community food environment, data were collected as regards the main activity, purpose, and degree of processing of the food sold in the establishments, according to NOVA21,22: stores that sell in natura/minimally processed foods (IN/MP), including butchers, fruit and vegetable stores, agricultural markets, fishmongers, milk and dairy stores, street vendors of natural/minimally processed foods; mixed stores, such as bakeries; stores that sell mostly UPF, such as snack bars, minimarkets, street vendors who sell exclusively or mainly UPF; and supermarkets and hypermarkets were analyzed independently due to the lack of consensus in the literature regarding the impact of these factors on obtaining food, mainly attributed to the wide diversity of food products available in these places, such as IN/MP and UPF foods23–25.
The characteristics of the consumer food environment were quantified considering the cost of the IN/MP foods most consumed by the Brazilian population16, as well as the availability of ultra-processed products sold in establishments and information on UPF advertisements inside stores. The prices of IN/MP foods (fruits and vegetables) were divided into tertiles: lowest price (tertile 1), intermediate price (tertile 2), and highest price (tertile 3). The value of the cheapest variety of each food was recorded; when only the unit price was available, the evaluators weighed three units arbitrarily, calculated the average of the values, and estimated the price per kilo26.
The analysis of the availability of ultra-processed foods in the establishments considered the availability of soft drinks, the variety of types of soft drinks, frozen pizza, among other UPFs, such as stuffed cookies, corn chips, instant noodles and crackers, which were all grouped together. The stores that sold ultra-processed foods were identified based on the percentage/proportion of stores within the residential buffer (1.6 km). The variables were categorized as follows: availability of soft drinks (up to 10; 11-24 and ? 25), frozen pizza (up to 4 and ? 5), and other UPF (up to 50 and >50). The measure of the variety of types of soft drinks offered in the stores was categorized as follows: ? 8; 9-18; and ?19 types of flavors. Information was also collected on the presence of UPF advertising inside the stores (does not have/does have). Data geocoding was performed using the Here Maps database using QGIS software version 10.1. This process involved using postal codes and addresses of respondents' homes, as well as food stores. Food environment analyses were performed using ArcGIS software, version 10.6, developed by ESRI in Redlands, CA, USA.

Statistical analyses
Data were entered into Epi Info (version 6.04; CDC, Atlanta, USA) and analyzed using the Statistical Package for the Social Sciences (SPSS), version 13.1 (SPSS Inc., Chicago, USA). Multilevel logistic regression was performed to assess associations between the outcome (dietary patterns) and explanatory variables related to the food environment (community and consumer dimensions), adjusting for individual and neighborhood-level variables. The multilevel modeling process was conducted in stages following the approach proposed by Leite et al.27 and Oliveira et al.28.
Initially, for each dietary pattern, a Model 0 was estimated including only individual and neighborhood variables (adjustment variables). Subsequently, food environment variables were introduced one at a time, independently, always adjusted exclusively for Model 0, resulting in a new model for each insertion. This strategy was adopted to estimate independent associations and to preserve model stability, avoiding multicollinearity among environmental indicators.
For the Dual dietary pattern, Models 1 to 6 included, respectively: (1) density of supermarkets/hypermarkets; (2) availability of soft drinks; (3) availability of frozen pizza; (4) availability of other ultra-processed foods (stuffed cookies, corn chips, instant noodles, and crackers); (5) in-store advertising of ultra-processed foods; and (6) price of in natura/minimally processed foods. For the Ultra-processed dietary pattern, Model 1 included density of mixed food stores, and Model 2 included variety of soft drinks in stores.
For the Traditional dietary pattern, the same explanatory variables were tested; however, no statistically significant associations were observed in the adjusted models, nor was there substantive variation in the estimates across exposure levels. Therefore, the corresponding models were not presented in the main tables and are described only briefly in the Results section.
Odds ratios (OR) and their respective 95% confidence intervals (95% CI) were estimated. Statistical significance was defined as p < 0.05. Significance was inferred based on the confidence intervals, considering associations statistically significant when the 95% CI did not include the value 1.0. Additionally, sensitivity analyses were conducted by testing different categorizations of exposure variables (e.g., continuous and categorized), and the specification with the best model fit and interpretability was selected. The approach that best fit the model was adopted, as recommended by Loureiro et al.29, de Menezes et al.26, and Oliveira et al.28.
For the Traditional dietary pattern, the same explanatory variables were tested following the same modeling strategy; however, no statistically significant associations were observed in the adjusted models, nor was there meaningful variation across exposure levels. For transparency, the complete estimates for the Traditional dietary pattern are presented in Supplementary Table S1. Statistical significance was defined as p < 0.05, with corresponding 95% confidence intervals.

RESULTS
The final sample consisted of 432 adults, mainly female (66.2%), aged > 40 years (56.7%), with a per capita household income ? 249.50 reais (74.4%), with educational levels of the heads of household in the intermediate tertile (33.8%) and with some degree of food insecurity (72%) (Table 1).
Regarding the food environment, 231 food stores located within a 1.6 km radius were investigated. Most adults lived in areas with a high density of mixed establishments (89.6%) and a high density of supermarkets/hypermarkets (67.6%). The analysis revealed the significant presence of soft drinks, with 73.8% of stores offering 11 to 24 different types. Furthermore, 72% of the stores sold more than five varieties of frozen pizza, and 78.7% offered more than 50 ultra-processed products, such as stuffed cookies, corn chips, instant noodles, and crackers. It was also observed that 73.1% of the stores offered a variety of more than 19 types of soft drinks. Another relevant fact is that 78.5% of the stores advertised ultra-processed foods inside their stores, as shown in Table 1.
Table 2 shows that there was no significant association between adherence to the Dual dietary pattern and individual or neighborhood characteristics in Model 0. After including community and consumer food environment variables, residents living in areas with higher supermarket/hypermarket density showed greater odds of adherence to the Dual dietary pattern (OR: 2.01; p = 0.005) compared with areas of lower density (Model 1). Similarly, greater availability of soft drinks in stores was associated with higher adherence when compared with the lowest availability category (11–24 types: OR = 4.94; p < 0.001; ?25 types: OR = 2.57; p < 0.05) (Model 2). Higher availability of frozen pizzas (OR = 3.74; p < 0.001) (Model 3), other ultra-processed foods (OR = 3.34; p < 0.001) (Model 4), and presence of ultra-processed food advertisements inside stores (OR = 3.34; p < 0.001) (Model 5) were also associated with greater adherence compared with lower exposure categories. In addition, stores selling in natura or minimally processed foods at high price tertiles showed greater odds of adherence compared with the lowest price tertile (highest tertile: OR = 1.71; p = 0.001) (Model 6).
Table 3 shows that individuals aged 40 years or older presented lower odds of adherence to the Ultra-processed dietary pattern compared with younger age groups (OR = 0.21; p < 0.001 and OR = 0.16; p < 0.001) (Model 0), indicating a protective association. After including food environment variables, residents living in areas with higher density of mixed food stores showed greater adherence compared with areas with lower density (OR = 2.11; p < 0.05) (Model 1). Similarly, greater availability of soft drinks in stores was associated with higher adherence compared with the lowest availability category (9–18 varieties vs. ?8: OR = 2.44; p < 0.05) (Model 2).
For the Traditional dietary pattern, individuals aged ?40 years were more likely to adhere to the traditional dietary pattern compared with those aged 30–39 years (Model 2: OR=1.78; 95% CI: 1.06–3.00). No significant associations were observed for sex, food security status, neighborhood education, or food environment indicators. The complete estimates for these models are presented in Supplementary Table S1.

DISCUSSION
In the present study, it was possible to observe an association of Dual DP and Ultra-processed DP with the community and consumer food environments. It was observed that individuals with a greater probability of adhering to the Dual DP tend to live in areas with greater access to supermarkets/hypermarkets. Adults who live in mixed food environments, with a greater supply and variety of UPF and in a situation of mild food insecurity, showed greater adherence to Ultra-processed DPs. However, older adults demonstrated a protective effect in relation to the adherence to Ultra-processed DPs. The Traditional DP showed no significant associations in the multilevel analysis, which may indicate a loss in regional food culture and frequency of consumption.
The Dual DP showed a higher probability of adherence among individuals residing in areas with a greater availability of supermarkets and hypermarkets, as evidenced in Model 1. A similar result was described by Adjei et al.30, presenting the relationship between areas with large retailers and the consumption of UPF in the African country of Ghana. However, it is important to highlight that supermarkets/hypermarkets have a large availability and variety of UPF, but they also sell IN/MP foods. In this context, a study carried out by Barska et al.31, in Poland, showed that generation Y/millennials, who are currently adults, mainly seek innovative food products in large retail chains, valuing quality, price, freshness, and flavor. Although these studies were conducted in distinct socioeconomic and cultural contexts, similar mechanisms may operate, as the expansion of ultra-processed food markets and supermarket chains has become a global phenomenon influencing dietary behaviors across diverse regions.
In Model 2, adherence to the Dual DP was associated with a greater availability of soft drinks in the individuals’ area of residence. This finding suggests that, even adopting the consumption of IN/MP foods, these individuals maintain the intake of sugary drinks, reinforcing the hybrid characteristic of the Dual DP. This differs from predominantly Ultra-processed DPs, where the consumption of these beverages is more expected. Such factors as financial and time limitations, practicality32, and the high palatability of sugar can contribute to this choice, making these beverages potentially addictive and leading to food dependence33. Crimarco et al.34 also point out that UPF consumption is associated with weight gain and comorbidities, which reinforces the negative impact of maintaining this habit within the Dual DP. Furthermore, this finding highlights the need for regulatory strategies, such as taxes on sugary drinks, which can help reduce consumption and, consequently, minimize health and environmental impacts35.
The results of Model 3 indicate that higher per capita household income and greater availability of frozen pizzas are associated with Dual DP, which indicates that better socioeconomic conditions may favor access to ultra-processed foods. This result is consistent with the study carried out in Belo Horizonte36, which also observed that areas with better socioeconomic conditions had a greater availability of UPF. By contrast, areas with lower income demonstrated more precarious physical access to all types of establishments. This association may be related to the convenience of these foods, which are more accessible, quick, and practical. However, limited access to food retail in low-income areas reflects physical and financial barriers. Thus, the data reinforce the need for public food policies that promote equitable access to healthy and sustainable foods. It is worth noting that, in the context of this study, even among individuals with higher incomes, purchasing power remains limited, reinforcing the urgency of interventions aimed at democratizing healthy eating.
In Model 4, adults living in areas with a greater availability of ultra-processed foods, such as stuffed cookies, corn chips, instant noodles, and crackers, showed adherence to the Dual DP. A study conducted in Indonesia found that even adults aware of the negative health effects chose UPF due to convenience of access and hyperpalatability37. This scenario reflects the impact of local offers and the need to regulate the availability of UPF, since even though healthy eating is still present in the Dual DP, it remains in constant competition with UPFs, which are also an integral part of this DP. This highlights the need to make healthy and adequate food an effective human right, as provided for in the Brazilian Federal Constitution, and not a bargaining chip that segregates, excludes, and dehumanizes people38.
Model 5 identified adherence to the Dual DP, which was associated with individuals in areas with stores that had UPF advertising inside. Research conducted in Uganda39 showed that advertising of UPF foods and beverages significantly influenced children's consumption patterns, highlighting the need to regulate the marketing of these foods, since this market strategy has a strong influence on food choices40. Another study conducted in Singapore41 revealed that restrictions on UPF advertising led to a reduction in the consumption of these foods, similar to that reported in Mexico42. Public sector intervention in private sector actions and policies is essential, since large food multinationals prioritize profit, rather than the quality of the food they sell.
In model 6, the heads of households with higher educational levels and who lived in areas with stores that sell IN/MP foods at high prices were more likely to adhere to the Dual DP. It can be suggested that individuals with higher educational levels have greater purchasing power and frequent food environments of large chains due to the convenience of finding all foods in a single place – such as supermarkets/hypermarkets – that sell IN/MP and UPF foods, that is, a food environment that presents both facilitating factors and barriers to adequate and healthy eating43. Taken together, these findings suggest that multiple components of the retail food environment, including density of supermarkets, availability and variety of ultra-processed foods, in-store advertising, and pricing dynamics, operate cumulatively to shape dietary behaviors. Rather than acting independently, these characteristics create a synergistic context that favors hybrid or ultra-processed dietary patterns.
Thus, rather than isolated effects, these results suggest a cumulative influence of food retail environments on dietary choices. It is essential to implement and reevaluate public policies that subsidize a greater consumption of IN/MP foods, such as making these foods cheaper and more available throughout the national territory, and not the other way around44,45.
Regarding Ultra-processed DPs, a potential protective effect was found among older adults, as compared to younger adults. A study carried out in Campinas corroborated this finding, revealing that UPF consumption was higher among younger age groups6. This relationship suggests that older adults tend to opt for healthier and/or traditional foods, possibly motivated by a greater concern with food quality, whether for health reasons, food culture, or the presence of comorbidities46.
Adults with mild food insecurity and who live in areas with a higher density of mixed food stores showed greater adherence to the Ultra-processed DP (Model 1). Pepetone et al.47 reported that financial precariousness among young adults may be associated with food insecurity, since capitalism in its late phase is maintained through continuous changes that seek new ways of reproduction and accumulation of capital. Simultaneously, this system promotes the precariousness of the workforce. In this context, it can be inferred that the advance of neoliberalism in Brazil, especially after the 2016 coup, played a crucial role in increasing poverty, social inequality, and hunger in the country. This scenario represents a direct negative impact on the working class and social policies, which were significantly threatened by the cuts and reforms implemented by the neoliberal State, with violations of the Human Right to Adequate Food (Direito Humano Alimentar Adequado – DHAA)48.
Model 2 showed that adults living in areas with a greater variety of soft drinks in stores revealed greater adherence to ultra-processed foods, illustrating that younger adults live in a situation of food insecurity and in unhealthy food environments. This finding corroborates a study conducted in Canada by Hutchinson and Tarasuk49, which demonstrated that food insecurity is associated with a higher consumption of ultra-processed foods and lower diet quality, demonstrating that ultra-processed foods are foods of low nutritional quality, with a high content of simple carbohydrates, fats, sodium, and food additives. Therefore, the promotion of fairer food environments, with restrictions on the marketing and advertising of ultra-processed foods and beverages, warning labels on the front of packaging, tax incentives for in natura/minimally processed foods and policies to modify the food system are necessary to promote healthier food choices and reduce UPF consumption45,50,51.
This finding may indicate that this pattern is less sensitive to characteristics of the retail food environment or that its maintenance is more strongly determined by cultural, historical, and household-level factors, which are particularly relevant in regions where traditional culinary practices remain socially embedded52.

FINAL CONSIDERATIONS
This study demonstrated that characteristics of both community and consumer food environments are associated with adherence to dietary patterns that include ultra-processed foods among adults in the Metropolitan Region of Recife. Greater availability, variety, and promotion of ultra-processed foods were consistently related to adherence to Dual and Ultra-processed dietary patterns, while no significant associations were observed for the Traditional dietary pattern.
These findings reinforce the importance of public policies aimed at improving food environments, particularly by promoting access to in natura and minimally processed foods and regulating the availability and marketing of ultra-processed products, especially in socially vulnerable areas. Strengthening healthy food environments may contribute to the preservation of healthier dietary patterns and reduction of inequalities in food access.

LIMITATIONS AND POTENTIALS
Food consumption methodologies, such as the FFQ, present challenges, such as memory bias and educational levels, which are strictly overcome during data collection and analysis. The use of the DP method enabled an adequate classification of food groups. The PCA, though it involves subjective decisions, was mitigated through a comprehensive literature review2–4,53.
The assessment of food environments covered establishments that sell food near the participants’ homes, using 1.6 km buffers. This choice may influence the results of the study, since the appropriate dimensions may vary according to the characteristic and/or behavior under analysis. Nevertheless, previous studies have also adopted buffers of this size18,19,26,28.
Moreover, some cutoff points used to categorize food environment variables are not standardized in the literature. However, the cutoff points were established based on the largest and smallest number of foods available, making it possible to create categories that represent different levels of exposure, facilitating a comparison and identification of associations.
Another important point is that establishments, such as restaurants and delivery services, were not evaluated; only establishments within the specified buffer were evaluated. Future research should explore these relationships more broadly. Furthermore, environmental variables were analyzed separately to avoid multicollinearity and model instability; however, this approach does not allow identification of the most influential environmental characteristic, representing a limitation of the study.
However, this study marks a pioneering approach to the relationship between DPs and food environments in the Metropolitan Region of Recife, thereby producing a more in-depth understanding of the theme.

ACKNOWLEDGEMENTS
Todd Marshall providing language help, writing and reading the article.

FUNDING SOURCE
FACEPE Grant 20/2014 (APQ-0338-4.05/15). Research grant awarded by the Coordination for the Improvement of Higher Education Personnel (CAPES) to AQUINO, N. B.

DATA AVAILABILLITY STATEMENT
Research data are available upon request from the corresponding author.


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