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CONSUMPTION OF ULTRA-PROCESSED FOODS IS ASSOCIATED WITH METABOLIC SYNDROME IN INDIVIDUALS OVER 40 YEARS OF AGE

Bruna Grazielle Mendes Rodrigues, Universidade Federal do Piauí -UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID 0000-0002-0190-4138, mendesbrunag@hotmail.com.
Vanessa da Silva do Nascimento, Universidade Federal do Piauí -UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID: 0000-0002-5404-0134, vanessanascimentox10@gmail.com.
Layanne Cristina de Carvalho Lâvor, Universidade Federal do Piauí -UFPI, Programa de Pós-graduação em Alimentos e Nutrição, Teresina, Piauí, Brasil, ID ORCID: 0000-0003-3954-2870, layannecristina94@gmail.com.
Poliana Cristina de Almeida Fonseca Viola, Universidade Federal do Piauí -UFPI, Departamento de Nutrição, Teresina, Piauí, Brasil, ID ORCID: 0000-0002-8875-5154, polianafonseca.nutri@gmail.com.
Paulo Víctor de Lima Sousa, Centro Universitário Facid Wyden, Teresina, Piauí, Brasil, ID ORCID: 0000-0003-1486-0661, paulovictor.lima@hotmail.com.
Márcio Dênis Medeiros Mascarenhas, Universidade Federal do Piauí -UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID: 0000-0001-5064-2763, mdm.mascarenhas@gmail.com.
Karoline de Macedo Gonçalves Frota, Universidade Federal do Piauí -UFPI, Centro de Ciências da Saúde, Programa de Pós-graduação em Saúde e Comunidade, Teresina, Piauí, Brasil, ID ORCID: 0000-0002-9202-5672, karolfrota@ufpi.edu.br.


ABSTRACT
A cross-sectional, population- and household-based study was conducted to ascertain the association between consumption of ultra-processed foods (UPFs) and metabolic syndrome (MS) in individuals aged 20 to 39 and ≥ 40 years. Demographic, socioeconomic, lifestyle, anthropometric, biochemical, food consumption and blood pressure data were collected from individuals ≥ 20 years old, of both sexes, living in Teresina (Piauí). Of the 262 participants, 38.2% were aged 20 to 39 years and 61.8%, ≥ 40 years old. Individuals aged ≥ 40 years returned higher prevalence of MS (57.4%), hyperglycaemia (13%), hypertension (54.9%) and high waist circumference (50.6%). At 20 to 39 years of age, prevalence of MS was 23%, while blood glucose, blood pressure and waist circumference were normal in 99%, 78% and 77%, respectively. In the total sample, UPFs accounted for 20% of total calorie intake, but 24.4% in the group aged 20 to 39 years and 17% in the group ≥ 40 years. Individuals aged ≥ 40 years in the highest tercile of UPF consumption returned 35% higher prevalence of MS. Excessive consumption of UPF should be discouraged and the consumption of fresh/minimally processed foods, encouraged, with a view to guaranteeing population health.
Keywords: food consumption; natural foods; processed food; metabolic syndrome; non-communicable diseases.
 
INTRODUCTION
Food intake can be assessed in different manners, including nutrient analysis, determination of dietary patterns and, more recently, by the degree of processing of foods in the diet1,2. Degree of processing has become an important and differentiated measure in assessment of diet quality, in that it affords a qualitative assessment of foods in an individual’s diet. For that purpose, the NOVA classification divides foods into four groups: fresh or minimally processed foods, processed culinary ingredients, processed foods and ultra-processed foods, which consider the extent and purpose of processing of the foods3,4,5.
An examination of the Brazilian population’s overall food choices over the past decade shows that the traditional dietary profile continues characteristically to include rice and beans, although intake of ultraprocessed foods (UPFs), e.g., biscuits and soft drinks, has increased. Intake of fresh and minimally processed foods, e.g., fruit, meat, milk and dairy products, was also found to have decreased6.
The present dietary profile is thus continually changing and increasingly comprises high-calorie foods rich in lipids and sodium, to the detriment of intake of fruit, vegetables and cereals. One result has been an alarming increase in the prevalence of chronic non-communicable diseases (CNCDs), such as diabetes mellitus, obesity, cardiovascular diseases and dyslipidemia, which are now responsible for three in four deaths in Brazil7,8.
Among the factors that increase the risk of CNCDs is metabolic syndrome (MS), a clinical condition resulting from complex metabolic alterations and strongly associated with the development of cardiovascular diseases and type 2 diabetes mellitus, which are the most commonly occurring CNCDs and cause 72% of deaths in Brazil’s population9,10.
MS is diagnosed by the presence of at least three markers of metabolic alteration, including waist circumference, fasting glycaemia, arterial pressure, triglycerides and high-density cholesterol (HDL-c), which are the criteria used by the United States National Cholesterol Education Program’s Adult Treatment Panel III11. (2001). Prevalence of MS – 38.4% in Brazil, 24.3% in Europe and 34.2% in the United States – is high and rising9,12,13. Central to its physiopathology is inappropriate diet. Greater risk of developing MS is associated with excessive intake of saturated fats, simple carbohydrates and sodium, which are present in UPFs. On the other hand, a diet rich in fresh and minimally processed foods has beneficial effects on that pathogenesis. Also, physical activity and healthy lifestyle are related to protective and modulating roles in MS9,14.
Accordingly, given the high prevalence of MS associated with changing dietary profile, this study is important in that it examined the association between UPF intake and MS in individuals from 20 to 39 and ≥ 40 years of age. It is necessary to measure the association between UPF intake and MS in different age groups, because, without suitable intervention, the increasingly frequent consumption of UPFs by younger individuals may lead to greater repercussions in future generations.
METHODOLOGY
This cross-sectional, population-based study was based on data from a household health survey in the municipalities of Teresina and Picos, in the state of Piauí (Inquérito de saúde domiciliar nos municípios de Teresina e Picos, ISAD-PI), which was designed to examine the population’s conditions of life and health situation by way of home visits in urban areas of the municipalities of Teresina and Picos (Piauí).
The participants in this study were individuals ≥ 20 years of age residing in urban areas in private households in Teresina (Piauí), who agreed to take part after due clarifications as to the study and ethics considerations. The criteria excluded individuals with disability or incapacity that would hinder application of the questionnaire, anthropometric assessment or blood collection.
In order to understand better the ISAD-PI methodology as regards sample size, sampling plan and collecting of variables, further information can be found in Rodrigues et al15.
The ISAD-PI survey used two-stage, complex probabilistic cluster sampling, by census tract and household, on the basis of census data from Brazil’s official bureau of statistics (Instituto Brasileiro de Geografia e Estatística, IBGE)16.
In calculating the sample, the population was stratified by age. Given that, on the basis of the IBGE census, the municipality of Teresina has an estimated 210,093 private households16, first the mean number of individuals in each age group per household was calculated and then, the number of households necessary in order for the sample to comprise at least 30 individuals of each age group.
Following the same sampling plan, 50% of households were selected, to form a subsample for collection of dietary data by applying 24-hour recall and blood tests (Figure 1).
The data collected were demographic (age and sex), socioeconomic (income and schooling), lifestyle (alcohol use, smoking and level of physical activity), food intake, anthropometric (weight, height, waist circumference), arterial pressure and blood collection.
At a second stage in data collection, 24-hour dietary recall (R24h) was conducted. For this purpose, 50% of the households identified in each census tract were selected systematically to form a subsample, from which individuals ≥ 20 years of age residing in households were invited to take part in collection of data on food intake; 262 individuals ≥ 20 years of age agreed and responded to the R24h.
Participants’ food intake data were obtained by applying the R24h, which was completed following the Multiple Pass Method guidelines17. A second R24h was applied to 40% of the population, after an interval of two months, so as to correct for intra-personal variability18. The R24hs were quantified to convert the amounts of foods and preparations from cooking measures into grams or millilitres. This was done using information available in tables of cooking measures19 (Pinheiro et al, 2005).
Arterial pressure was measured at least twice at 1-minute intervals, as recommended by the 7th Brazilian arterial hypertension guidelines (VII Diretriz Brasileira de Hipertensão Arterial)20 and the results were compared with the cutoff points specified by those guidelines. For this study, systolic arterial pressure (SAP) ≤ 120 mmHg and diastolic arterial pressure (DAP) ≤ 80 mmHg were considered normal and any value in excess of normal (SAP > 120 mmHg and/or DAP > 80 mmHg) was considered to be high.
The researchers received standardised training in anthropometric measurements from the Population Nutrition Assessment Laboratory of the Nutrition Department at the Universidade de São Paulo15,21. Adult waist circumference (WC) was measured following WHO recommendations22.
Fasting glucose concentrations were determined by the colorimetric enzymatic method, using Labtest® kits. The reference values for fasting glycaemia were based on the criteria set by the Sociedade Brasileira de Diabetes23.
Concentrations of high-density lipoprotein cholesterol (HDL-c) and triglycerides were determined by colorimetric enzymatic method. Cutoff values used as reference for serum lipids were taken from the updated Brazilian guidelines for dyslipidemia and prevention of atherosclerosis (Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose)24.
Metabolic syndrome was identified by three or more criteria of the United States National Cholesterol Education Program’s Adult Treatment Panel III (NCEP-ATP III), as recommended by the 1st Brazilian Metabolic Syndrome Diagnosis and Treatment Guidelines (I Diretriz Brasileira de Diagnóstico e Tratamento da Síndrome Metabólica)25.
The analyses were performed by means of Stata, version 13.0, using the survey mode, so as to correct for the complex study sampling.
Distribution of the variables was analysed by Shapiro-Wilk test. Continuous variables were expressed as means and categorical variables, by absolute and relative values. The differences in means between age groups were ascertained by Mann-Whitney U test. Associations between categorical variables were assessed by Pearson Chi-square test or Fisher exact test. Associations between the prevalence of MS and intake of foods, by degree of food processing, were examined by Poisson regression, expressed as prevalence ratios, crude and adjusted for potential confounders, such as age, gender, schooling, alcohol and cigarette use, physical activity and use of medicines and supplements in general, with a 95% confidence interval (95%CI) and 5% level of significance.
The study was approved by the research ethics committee of the Universidade Federal do Piauí, as in Opinion No. 2.552.426.

RESULTS
Of the 262 study participants, 38.2% (100 individuals) were from 20 to 39 years of age and 61.8% (162 individuals) were 40 years old or more. Both the lower age group (20-39 years) and the older age group (≥ 40 years) were mostly female (69% and 74.7%, respectively) and had income of 2 minimum wages or less (70% and 83.2%, respectively). As regards schooling, 49% of the lower age group had upper secondary schooling, while 44.4% of the older age group had lower secondary schooling (Table 1).
Living habits differed in that individuals 20 to 39 years of age consumed more alcohol than those ≥ 40 years old (67.9% and 55%, respectively). Smoking was more prevalent in the older age group than in the lower age group (30.2% and 11%, respectively). Overall, the participants were considered to be physically active, but more prevalently so in the 20 to 39 year age group (94.0%) than among the ≥ 40 year olds (74.1%). Medicines and supplements were used more in the older age group (54.3%) than in the lower age group (24%) (Table 1).
MS and its components were diagnosed more among individuals ≥ 40 years old: MS (57.4%), hyperglycaemia (13.0%), arterial hypertension (54.9%) and high waist circumference (50.6%). On the other hand, prevalence of MS in individuals 20 to 39 years of age was 23% and most returned normal glycaemia, arterial hypertension and WC (99%, 78% and 77%, respectively) (Table 1).
Table 2 shows total energy intake and the contribution of fresh/minimally processed foods and UPFs to calorie intake, by age group (20 to 39 and ≥ 40 years of age). In the total sample, fresh/minimally processed foods contributed 68% of total daily calories; this food group contributed more to daily calorie intake among the ≥ 40 year olds (70.7%) than among the younger age group (63.7%). In this latter group, generally speaking, the foods that accounted for least to energy intake were roots and tubers (1.0%), fish/seafood (1.5%), eggs (2.3%) and legumes (3.0%). Also, the younger participants were found to consume little energy from milk (4.1%) or fruit and vegetables (2.2%), while the older individuals consumed larger amounts of these foods (6.7% and 5%, respectively).
In the overall sample, UPFs accounted for around 20.0% of total calorie intake, but a larger amount in the lower age group (24.4%), with cakes and biscuits particularly contributing most to energy intake (7.4%). By contrast, in the older age group, 17% of daily energy intake originated from UPFs, with cakes and biscuits (7.2%) being the UPFs most consumed in this age group. Also, individuals in the lower age group were found to consume more sweets (1.4%), processed meats (2.8%) and sugary beverages (1.6%) than those in the older age group (0.2%, 1.2% and 1.4%, respectively (Table 2).
From Table 3, it is possible to observe the contribution to Total Energy Value (TEV) by fresh/minimally processed foods and UPFs among individuals with a diagnosis of MS. Intake of fresh/minimally processed foods was greater among individuals with no diagnosis of MS (1314.5 kcal/day) than in individuals with MS (1092.9 kcal/day). In the younger group, fruit and vegetables were seen to contribute more (2.6%) to TEV in individuals without MS and only 0.9% among those with MS. In individuals ≥ 40 years old and with no diagnosis of MS, consumption of eggs contributed more to TEV (2.9%), while among individuals in that same age group, but with a diagnosis of MS, calorie intake from eggs was only 1.6%.
As regards consumption of UPFs, calorie intake from dairy beverages was greater (0.6%) in individuals with no diagnosis of MS than by those with MS (0.4%). Among individuals with a diagnosis of MS in the lower age group, highest percentage calorie intake was from sugary beverages (4.1% as against 0.9% in those without MS), while in the older age group, highest UPF-related intake was from cakes and biscuits (9% in those with MS against 4.6% in those without MS) (Table 3).
The association between prevalence of MS and terciles of contributions by fresh/minimally processed foods and UPFs to TEV is shown in Table 4. Individuals ≥ 40 years old who consumed most UPFs (3rd tercile of consumption) returned a 35.0% higher prevalence ratio for MS than individuals who consumed least (1st tercile of consumption).

DISCUSSION
This study investigated consumption of ultraprocessed foods and its association with metabolic syndrome in individuals from 20 to 39 years of age and ≥ 40 years old in the municipality of Teresina, Piauí. Given that diet is one of the main modifiable behavioural risk factors, it is possible to control and treat the metabolic alterations characteristic of this clinical condition26.
This study found high prevalence of MS, which was greater than 40% in the individuals studied, and higher in participants ≥ 40 years old. Oliveira et al.9, who found 38.4% prevalence of MS and higher frequency of this condition in the older age group, related this to the fact that ageing is a precursor to a variety of metabolic alterations. Advancing age is known to be associated with increasing body fat, which results from reductions in growth hormone secretion, base metabolic rate and muscle tissue, with overweight being one of the main risk factors for the development of CNCDs27. Dara from Brazil’s annual telephone health survey, VIGITEL, show that 57.2% of Brazilians are overweight, a nutritional state characterised by excessive accumulation of fat and, accordingly, risk of developing metabolic and blood pressure alterations28,29. Among the components relating to a diagnosis of MS examined in this study, the highest percentage alterations were observed in fasting glycaemia, arterial pressure and WC in the older age group (≥ 40 years old). These three components in the diagnosis of MS are interconnected, in that high WC is related to the presence of visceral fat, which increases intra-abdominal pressure and impairs kidney function, thus activating the renin-angiotensin-aldosterone system, the resulting condition being hypertension. This increase in arterial pressure stimulates blood vessel contraction, reducing glucose uptake and leading to insulin resistance30.
In the population of India, the components associated with increasing prevalence of MS included fasting glycaemia, systolic arterial pressure and WC, as well as triglycerides and HDL cholesterol31.
In the study population’s diet, consumption of UPFs accounted for around one fifth of daily calorie intake. Oliveira et al.32 (2021) found that the amounts of carbohydrates and fats in UPFs represented around one third of daily intake. Also, UPFs were found to contribute higher percentages to TEVs of cholesterol (71%) and sodium (61.4%) than fresh or minimally processed foods.
The determinants of households’ dietary choices include socioeconomic, nutritional, cultural and demographic factors. With globalisation, has come an increasing diversification of food products, favouring consumption of foods, and particularly UPFs, by whole populations33. The option for UPFs may be explained by their visual attractiveness, practicality, hyper-palatability, ease of access and marketing34. High intake of UPFs results in poor-quality diet and increased risk of developing CNCDs35.
In 2021, the VIGITEL found that intake of fresh/minimally processed foods was greater in the older age group28: corroborating the findings of this study, fresh/minimally processed foods were consumed more by individuals ≥ 40 years old. Meanwhile, individuals 20 to 39 years of age consumed higher percentages of UPFs than those ≥ 40 years old. Murray et al. (2020) found that young people today tended increasingly to consume UPFs as compared with young people in the past. That prospect is of concern to the scientific community, because the scenario as regards CNCDs, increasing obesity and MS may worsen in future generations36.
Among fresh/minimally processed foods, roots, tubers, fish/seafood, eggs and legumes were the least consumed in all age groups. In the 2017-2018 household budget survey, POF, these foods were also considered the least consumed: roots and tubers (1.8%), eggs (1.4%), green vegetables and legumes (1.9%) and fish (1.1%)37.
Brazilians’ dietary patterns have been changing year by year as instant or semi-instant foods gain ground on what are considered traditional Brazilian foods, because of the need to eat meals away from home. As a result, data for the years from 2002 to 2018 show that spending on meals away from home, largely represented by poor-quality, high-calorie foods, has increased by around 9%38.
This study showed that the UPFs most consumed were cakes and biscuits, which accounted for around 8% of the calories consumed daily by individuals ≥ 40 years of age in Teresina (Piauí). The intake found in this study falls within WHO recommended levels (< 10% of total simple sugar intake). Nonetheless, it is important to contain these values within these acceptable limits or even to encourage lower values, because excessive consumption of this food group can favour deficiency in micronutrients, as well as being a potential aetiological factor in a variety of pathologies, including MS26,39.
When the study participants were examined for food intake and the presence of MS, those aged 40 years or more and who had a healthier diet, with calorie intake mostly from fresh/minimally processed foods, were one-third better protected against a diagnosis of MS. Also, those in both the younger age group (20 to 39 years of age) and older group (≥ 40 years old) without MS consumed significantly larger amounts of fruit and vegetables.
Diets rich in fresh/minimally processed foods, such as Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets, are associated inversely with a diagnosis of MS40,41,42,43. Better nutritional distribution and quality make these diets one of the main protective factors against the development of this syndrome. When consumed in appropriate quantities, fresh and minimally processed foods contain large amounts of potassium, magnesium, fibres and polyphenols, which assist in regulating blood glucose and insulin concentrations44.
Consumption of UPF milk-based beverages was high among all participants without MS. High consumption of these beverages can be attributed to the spread of information about the benefits of probiotics, such as their improving intestinal infections, constipation and nutrient absorption, and their anti-inflammatory effects on neoplasms and protective effects on the immune and vitamin and protein synthesis system. These foods can be found widely and easily on shelves, particularly in UPFs, cream cheese spreads, yoghurts and fermented milks45. However, note that their composition includes numerous artificial sweeteners and emulsifiers, most of which induce imbalance in intestinal microbiota, impairing the function of the intestinal barrier and consequently leading to inflammation in the intestine46.
Among individuals diagnosed with MS, consumption of sugary beverages was found to be high among the younger age group (20 to 39 years of age) and, of cakes and biscuits in the older age group (≥ 40 years old). Intake of high glycaemic index carbohydrates is associated with insulin resistance, and increased acute glycaemia is caused by oral glucose burden, in turn increasing inflammation and oxidative stress, leading to conditions including chronic and persistent hyperglycaemia. Accordingly, both insulin resistance and low-grade inflammation produced by consuming these foods are directly associated with the aetiology of MS47,48.
In the older age group, prevalence of MS was higher among individuals who consumed more UPFs than in those who consumed less. This fact was also observed in the United States, where consumption of UPFs increased prevalence of MS by 28%49. The association between UPFs and MS can be explained by the composition of these high glycaemic index foods, which contain saturated and trans lipids, emulsifiers and sweeteners that cause weight increase, alterations in intestinal microbiota, inflammations and conditions involving metabolic alterations50,51,52. Fabiani et al.53 associated dietary patterns with risk of developing MS, finding lower risk of developing this clinical condition in individuals with a “healthy” diet, while those with a “meat/western” diet displayed a 19% higher risk of developing MS.
Accordingly, consumption of UPFs is considered a risk factor for development of MS. Martínez Steele et al.49 noted a 12% increase in prevalence of MS associated with a 10% increase in UPF intake by adults aged 20 to 29 years. Also, a 5% increase in UPF intake (an additional 150 grams of UPFs per day) led to the development of MS in 31% of the adult population (35 to 74 years of age)54.
In the study sampling process, the number of individuals in the final sample was considered appropriate for public health studies and permitted accptable precision (generally a coefficient of variation of proportions of less than 20%). Most of the estimates in this study returned coefficients of variation of less than 20% and, in more than 90% of them, design effect was less than 1.515.
For that purpose, adjustment variables considered in order to control better for the differing characteristics of the groups studied were age, gender, schooling, alcohol use, smoking and physical activity. Note that the study has certain limitations, including the use of 24-hr recall, which depends on the interviewee’s memory, making it prone to omission and overestimation of amounts and foods reported. Also, its being a cross-sectional study precluded any investigation of cause and effect among the variables examined. On the other hand, the study is notable for being population-based, with a representative sample of individuals ≥ 20 years of age from Teresina (Piauí), as well as yielding results characterising food intake and the impact of that intake on the prevalence of MS in the study population.

CONCLUSION
This study found that higher consumption of UPFs was associated with diagnoses of MS in individuals ≥ 40 years old. The prevalence of MS in the municipality was high and more commonly so in individuals of this older age group.
Today’s diet, in which UPFs predominate, poses a public health challenge, given its potential adverse effect on health conditions. This underscores the importance of measures to discourage the excessive consumption of UPFs, such as labelling with specific colours and more easily legible print to alert to the composition of the foods, increased taxation of UPFs, complemented by reduction of taxes and incentives for small farmers of fresh/minimally processed foods, all with a view to ensuring population health.

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