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Relação entre tempo de tela e consumo de ultraprocessados em gestantes atendidas na Atenção Primária à Saúde
Relationship between screen time and consumption of ultra-processed foods in pregnant women treated in Primary Health Care

Letícia Ferrer Neves
Nutricionista, Prefeitura Municipal de Campinas, Avenida Milton Christine, 1848 - Parque Alto Taquaral, Campinas, São Paulo, Brasil. 13087-090. leticiafn.nutri@gmail.com ORCID: https://orcid.org/0009-0003-1640-0615

Maria Carolina de Lima
Mestra e doutoranda pelo Programa de Pós-Graduação em Saúde Pública da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Avenida Bandeirantes, 3900. Ribeirão Preto, SP, Brasil. 14049-900. mariacarolina017@hotmail.com ORCID: https://orcid.org/0000-0001-5915-7756

Natalia Posses Carreira
Mestra e doutoranda pelo Programa de Pós-Graduação em Saúde Pública da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Avenida Bandeirantes, 3900. Ribeirão Preto, SP, Brasil. 14049-900. nutrinaticarreira@gmail.com ORCID: https://orcid.org/0000-0003-4883-9166

Ana Vitória Lanzoni Chaves
Nutricionista,
Ribeirão Preto, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Avenida Bandeirantes, 3900. Ribeirão Preto, SP, Brasil. 14049-900. nutri.analanzonichaves@gmail.com ORCID: https://orcid.org/0000-0003-3986-9961


Daniela Saes Sartorelli
Doutora, professora associada do Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo. Avenida Bandeirantes, 3900. Ribeirão Preto, SP, Brasil. daniss@fmrp.usp.br ORCID: https://orcid.org/0000-0003-2028-3274

Autor correspondente: Daniela Saes Sartorelli, Avenida Bandeirantes, 3900. Ribeirão Preto, São Paulo, Brasil. 14049-900. daniss@fmrp.usp.br +55 (16) 3602-2712.

Resumo
O objetivo foi investigar a relação entre tempo de tela e a frequência de consumo de alimentos ultraprocessados (AUP) em gestantes com sobrepeso. Estudo transversal que utilizou dados da linha de base de um ensaio clínico randomizado, realizado na rede básica de saúde de um município brasileiro entre 2018 e 2021. Foram utilizados os dados do formulário Marcadores de Consumo Alimentar. O tempo de tela diário (TT) foi mensurado com base na quantidade de minutos despendidos assistindo televisão e utilizando dispositivos eletrônicos durante o tempo livre. Modelos de regressão logística, ajustados por variáveis selecionadas pelo Directed Acyclic Graph, foram utilizados. A mediana (P25; P75) da idade materna foi de 27 anos (23; 32) e do IMC pré-gestacional de 27,2 kg/m² (26,1; 28,3). Entre as gestantes, 59,4% realizavam algum tipo de trabalho remunerado e 62,1% pertenciam ao estrato econômico C. Gestantes com TT total >240 minutos/dia apresentaram maior chance de consumir AUP em três ou mais dias da semana [OR 2,06 (IC95%; 1,29 a 3,30), p= 0,003]. Observou-se uma relação direta entre o maior tempo de uso de aparelhos eletrônicos e maior frequência de consumo de AUP [OR 2,13 (IC95%; 1,34 a 3,39), p= 0,002]. Gestantes com maior TT total e TT de eletrônicos apresentaram maior chance de terem uma frequência elevada de consumo de alimentos ultraprocessados.
Palavras-chave: Gravidez; Tempo de tela; Alimento Processado; Atenção Primária à Saúde.

The present study aimed to investigate the relationship between screen time and the frequency of consumption of ultra-processed foods (UPF) in overweight pregnant women. This was a cross-sectional study that used baseline data from a randomized clinical trial conducted in the Primary Health Care (PHC) network of a Brazilian municipality between 2018 and 2021. Data from the Food Consumption Markers form were used. Daily screen time (ST) was measured based on the number of minutes spent watching television and using electronic devices during free time. Logistic regression models, adjusted for variables selected by the Directed Acyclic Graph, were used. The median (P25; P75) maternal age was 27 years (23; 32) and the pre-gestational BMI was 27.2 kg/m² (26.1; 28.3). Among pregnant women, 59.4% had some type of paid work and 62.1% belonged to economic stratum C. Pregnant women with a total ST >240 minutes/day were more likely to consume UPF on three or more days of the week [OR 2.06 (95% CI; 1.29 to 3.30), p= 0.003]. A direct relationship was observed between longer use of electronic devices and higher frequency of UPF consumption [OR 2.13 (95% CI; 1.34 to 3.39), p= 0.002]. Pregnant women with higher total ST and ST of electronic devices were more likely to have a high frequency of consumption of UPF.
Keywords: Pregnancy; Screen Time; Processed Food; Primary Health Care.

Introduction
The food choices and lifestyle adopted by women during pregnancy directly influence maternal and child outcomes in the short and long terms1. While an adequate diet and regular physical activity are factors related to a positive pregnancy outcome, an unbalanced diet, rich in foods with high energy density and low nutrient density, combined with physical inactivity, are risk factors that contribute to adverse pregnancy outcomes2,3,4,5.
A healthy, balanced, and varied diet during pregnancy provides adequate and sufficient energy and nutrients for the mother and child in such a way as to promote adequate fetal development and favor the health and wellbeing of the woman. A healthy diet also reduces the chances of maternal complications, such as gestational diabetes mellitus (GDM), inadequate gestational weight gain (insufficient or excessive), and gestational hypertension1,3. Moreover, for the child, it is a protective factor in the short and long term, as it prevents premature birth and low birth weight (LBW), and reduces the chances of developing obesity, type 2 diabetes mellitus, cardiovascular diseases, systemic arterial hypertension (SAH), and metabolic syndrome throughout life6.
Fascicle 3 of the Brazilian Dietary Guidelines3 addresses nutritional guidelines for pregnant women. It incorporates the recommendations of the new Food-based Dietary Guidelines for the Brazilian Population7, which, in turn, takes into account the degree of industrial processing of foods. Natural and minimally processed foods are foods that closely resemble their natural form and have undergone little or no transformation or addition of other ingredients, such as fresh fruits, vegetables, rice, and beans. By contrast, foods that deviate from their original form, with added sugars, salt, fats, and other food additives, such as sweeteners, preservatives, and flavorings, are classified as ultra-processed foods (UPF). Examples of these are soft drinks, artificial juices, cookies, biscuits, chips, among other processed foods7. Based on these materials, the majority and diversified consumption of natural and minimally processed foods is recommended, which provide a variety of essential nutrients for pregnancy, to the detriment of the consumption of UPF.
The practice of physical activities also influences the health of the mother and child, as it is related to the control of the pregnant woman\'s body weight, with the reduction of the risk of developing chronic Noncommunicable Diseases (NCDs), such as GDM, gestational hypertension, pre-eclampsia, and depression, in addition to reducing the risk of premature birth and inadequate birth weight8.
Physical inactivity, in itself, represents an important contributor to mortality9. The time spent sitting or lying down in front of screens (television, cell phone, computer, and tablet), called screen time (ST), is currently the main component of the total time spent on sedentary behaviors during leisure time5. One Brazilian study, using data from the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico – Vigitel), carried out from 2016 to 2021, concluded that there was an increase in both the use of electronic devices and the frequency of adults spending more time in front of screens during the analyzed period10.
Studies suggest that there is an association between screen time and food consumption patterns11,12,13,14, most of which are conducted among children and adolescents, given the relevance of eating habits for growth and development during these age groups and the increased prevalence of sedentary behaviors and the development of NCDs in these populations12,14.
In a systematic review that included 53 scientific articles, the authors concluded that, for children, adolescents and adults, sedentary behaviors appear to be positively associated with the consumption of unhealthy foods, such as snacks, high-calorie beverages, and fast foods, and negatively associated with the consumption of fruits, vegetables, and dietary fiber15.
Given the importance of practicing healthy lifestyle habits during pregnancy to ensure the health of both mother and child, it is important to understand the factors that are associated with and influence diet and lifestyle during pregnancy. However, we are unaware of the existence of studies that have explored the association between time spent in front of screens and consumption of UPF among pregnant women.
Therefore, the present study aimed to investigate the relationship between screen time and the weekly frequency of UPF consumption among overweight Brazilian pregnant women treated by Primary Health Care (PHC) in the city of Ribeirao Preto, SP, Brazil.

Methods
This is a cross-sectional study using baseline data from a randomized controlled clinical trial, which was conducted with 335 overweight pregnant women who underwent prenatal care at the PHC in Ribeirão Preto, Brazil. The data were collected in seven Health Units in the city between 2018 and 2021.
The clinical trial\'s main objective was to evaluate the effect of a nutritional intervention in preventing excessive weight gain in overweight pregnant women, based on encouraging the consumption of natural and minimally processed foods, rather than UPF, combined with encouraging the practice of physical activities16,17. The study was authorized by the Municipal Health Department and approved by the Research Ethics Committee of the Health Center at the College of Medicine of Ribeirao Preto-São Paulo (69997717.6.0000.5414). The present study was also approved by the same Committee (63318822.4.0000.5414). Women who agreed to participate in the study signed a Free and Informed Consent Form (FICF).
Study design and sample calculation
This study initially established a significance level of 5% (α = 0.05), a power of 90% (β = 0.1), and an expected loss to follow-up of 20%, resulting in a sample of 300 pregnant women. However, due to the emergence of the COVID-19 pandemic, the loss to follow-up rate in the study expanded to 40%, doubling the value initially considered. This led to a review of the sample size, culminating in a new sample of 350 pregnant women.
The inclusion criteria for the clinical trial were: pregnant women, at least 18 years of age, a gestational age (GA) of up to 15 weeks and 6 days, and with a pre-gestational body mass index (BMI) between 25 kg/m² and 29.9 kg/m², classified as overweight. Pregnant women who reported previous diabetes mellitus or the use of oral hypoglycemic agents/insulin, and who used weight loss medications were excluded.
In this study, the non-probabilistic convenient sampling strategy was used to compose the sample, including all women with complete data in the first assessment of the clinical trial (n= 335)16.
Food consumption markers
The frequency of UPF consumption was determined using a screener that assessed the weekly consumption of sweetened beverages, such as artificial juices and/or soft drinks (regular, diet or light), and other UPF, such as cookies, crackers, chips, or noodles. The screener was adapted from the form used in the Surveillance System for Risk and Protection Factors for Chronic Diseases by Telephone Survey (VIGITEL)18, previously validated for the Brazilian population19.
For the present study, the consumption of sweetened beverages and other UPF was grouped into a single category, called “UPF Consumption”, considering the highest weekly frequency reported. For example, if a pregnant woman reported the consumption of sweetened beverages on 3 days of the week and the consumption of other UPF on 5 days, the weekly frequency of UPF consumption considered was 5 days/week. Based on this, the UPF consumption variable was divided into two categories, considering the median consumption of the sample: <2 days/week and >3 days/week.
Screen time (ST)
Information on screen time was collected using a form adapted from VIGITEL18, previously validated for the Brazilian population20. This form included recording the number of minutes spent daily watching television and using electronic devices, such as cell phones, tablets, or computers, during leisure time, thus excluding work activities.
The number of minutes spent on television screen time (ST) and electronic devices were combined to create the variable called “Total Screen Time” (Total ST). The ST variables were transformed into dichotomous categories based on the sample median. The categories established for total ST were: <240 minutes/day or >240 minutes/day; for television ST: <120 minutes/day or >120 minutes/day; and for electronic devices ST: <120 minutes/day or >120 minutes/day.
There are no specific recommendations for ST for adults, including pregnant women. Some studies adopt different cutoff points, such as more than 2 hours per day21, 3 hours per day22,23 or a limit of more than 4 hours (240 minutes) per day24 for variables related to ST. In addition, data collection took place during the COVID-19 pandemic, a period marked by significant changes in human behavior, such as increased ST, sedentary behavior, and changes in eating habits. Therefore, given the lack of specific recommendations, it was decided to adopt the median of the study population itself as the cutoff point for determining the categories.
Maternal characteristics
Data on age (years), gestational age at randomization (weeks), estimated pre-gestational BMI (kg/m²), self-reported skin color (white, black, brown, yellow, indigenous), marital status (married/living with partner, other), education (<8 years, 9-11 years, >12 years), paid employment (yes, no), receipt of the Bolsa Família (Family Grant) benefit (yes, no), housing conditions (source of water, type of street, number of bathrooms, types and quantities of household appliances and electronic devices, types and quantities of owned vehicles, and presence or absence of monthly employees), number of children, daily sleep time (hours), smoking history (never smoked, former smoker, currently smokes), and weekly physical activity before and during pregnancy (minutes per week) were obtained through a structured questionnaire in the first assessment of the study carried out, at most, up to the 15th gestational week and 6 days. In the first assessment of the study, the weight (kg) and height (m) of the pregnant women were measured. Current weight was measured on a portable digital scale (Tanita, model HS 302), while height was measured on a stadiometer with a mechanical scale attached, available at the Health Unit. It is important to note that all data were collected by trained nutritionists.
Statistical analyses
Nonparametric tests were used to perform descriptive analyses of the sample characteristics according to the weekly frequency of UPF consumption and total ST. The Mann-Whitney test was used for continuous variables (maternal age, gestational age, pre-gestational BMI, and sleep time), and the Chi-square test of independence was used for categorical variables (marital status, self-reported skin color, education, economic stratum, paid employment, parity, smoking habits, and self-reported hypertension). The Bonferroni test was used to identify differences between categories of variables.
Binary logistic regression models adjusted for age, paid employment, and physical activity, as determined by the Directed Acyclic Graph (DAGitty)26, were used to investigate the relationship between the weekly frequency of UPF consumption and Total ST, television ST, and electronics ST (Appendix 1). Statistical analyses were performed using IBM SPSS Statistics Version 27.0, SPSS Inc. Woking, Surrey, UK. The significance level adopted for the analyses was p <0.05.


Results
The median age was 27 years (23; 32), the pre-gestational BMI was 27.2 kg/m² (26.1; 28.3), and the number of hours of sleep per day was 9 hours (8; 10). The majority of pregnant women were married or lived with a partner 252 (75.2); 226 (67.4) declared themselves black or brown; 185 (62.1) belonged to economic stratum C; and 199 (59.4) had paid work. Two thirds of the pregnant women, 224 (66.9), consumed UPF three or more times a week, while more than half, 190 (56.7), declared a total daily ST of greater than or equal to 240 minutes (Tables 1 and 2). Among the pregnant women who reported consuming UPF three or more times a week, 169 (75.4) reported consuming sweetened beverages >3 times/week and 106 (47.3) reported consuming other types of UPF with the same frequency.
Regarding smoking habits, it was observed that there was a higher prevalence of women who continued to smoke during pregnancy in the group of those who reported consuming UPF three times a week or more (22 (9.8), compared with pregnant women who reported consuming UPF less frequently (2 (1.8). Additionally, among the pregnant women who reported consuming UPF on two or fewer days a week, 89 (80.2) reported never having smoked, while the group of those with the highest frequency of UPF consumption reported never having smoked had a lower incidence, representing 67% of the group (n= 150) (p= 0.01) (Table 1).
Overall, of the 335 women, 200 (59.7) reported >120 minutes of screen time per day and 170 (50.7) reported 120 minutes of television time or more per day. Of the 190 (56.7) pregnant women who reported 240 minutes of Total ST or more per day, 137 (72.1) reported >120 minutes of television ST/day and 164 (86.3) reported >120 minutes of electronics ST/day.
Younger women reported significantly more ST (p=0.02). Furthermore, those who had 240 minutes of Total ST or more per day had a higher median daily sleep time (p<0.001) (Table 2).
A relationship between paid employment and total daily ST was also observed. Women who did not have paid work showed a higher total daily ST (>240 minutes/day) (p= 0.01). Similarly, among nulliparous women, a higher frequency of exposure to a Total ST of 240 or more minutes per day was identified (p= 0.01) (Table 2).
Pregnant women who reported a Total ST of equal to or greater than 240 minutes per day were twice as likely to consume UPF >3 days/week [OR 2.06 (95% CI; 1.29 to 3.30), p= 0.003]. A direct relationship was also observed between the time spent using electronic devices and the frequency of UPF consumption, in which pregnant women with a higher ST of electronic devices (>120 min/day) were more likely to consume UPF three or more times a week [OR 2.13 (95% CI; 1.34 to 3.39), p= 0.002]. No significant relationship was observed between the time spent watching television and UPF consumption (Table 3).

Discussion
It was observed that pregnant women who spend more time in front of screens, both in terms of Total ST and time spent on electronic devices, have a higher weekly frequency of UPF consumption. These findings are in line with a Brazilian study conducted by Martins (2022)22 who, when analyzing data from the 2019 National Health Survey (PNS), identified that, among Brazilian adults, greater ST was associated with greater consumption of unhealthy foods (sweetened beverages, packaged sweet and savory cookies, sweets, sausages, industrialized breads, industrialized sauces, and frozen industrialized ready-to-eat meals) and a lower consumption of healthy foods (natural or minimally processed foods, such as legumes, vegetables, fruits, and oilseeds). In the present study, this association was not observed when we analyzed television ST in isolation. One possible explanation for this difference is that the sample was characterized mostly by young women, with a median age of 27 years (23; 32). As observed by Martins (2022)22, electronic devices are more popular among young adults (<35 years), while exposure to television is greater among older individuals (>65 years).
Compared to women who reported ST <240 minutes, a higher frequency of pregnant women with greater ST (Total ST >240 min/day) did not have paid work and were primiparous. These characteristics may suggest greater free time available and easier access to screens, considering the social isolation measures required during the COVID-19 pandemic27,28. In addition, these pregnant women also reported greater sleep time, which is consistent with the other characteristics, but contradicts studies that associate greater ST with shorter sleep time29. Furthermore, the consumption of UPF three or more times per week was reported by two-thirds of the women. In Brazil, the consumption of natural and minimally processed foods still represents the largest percentage of the total energy value (TEV) of the diet, for all socioeconomic strata30. As pointed out by Levy (2022)31, when analyzing data from the Household Budget Survey (POF) from the last three decades, a persistent and gradual increase in the participation of UPF in Brazilians\' VET can be seen over the years.
In addition, studies show that during the COVID-19 pandemic there was an increase in the consumption of these high-energy-density, low-nutritional-value foods32,33, either due to their convenience in storage, high diversity, high palatability, and ease of consumption, or due to the constant influence exerted by advertising campaigns, which contribute to a substantial increase in the likelihood of consuming UPF34,35. In addition, authors highlight the negative impact of stress on populations\' eating patterns, which were exacerbated by the pandemic32.
Greater exposure to unhealthy food marketing is a possible justification for the higher weekly frequency of UPF consumption among pregnant women who reported higher Total ST and electronics ST23. As pointed out by Horta (2021)36, the digital food environment encompasses interactions between consumers and food in the online context, including social media, apps, websites, and other digital tools. Through it, the food industry interacts with users, using interactive marketing strategies, videos, links, and personalized messages. During the COVID-19 pandemic, there was an increase in the presence of Brazilians on food delivery apps, resulting in a significant growth in orders placed on a popular platform37.
Furthermore, Tabares-Tabares (2022)38 points out in his research that in situations in which exposure to screens is simultaneous with the act of eating, some mechanisms can lead to increased food consumption, such as: 1) exposure to marketing, especially of ultra-processed foods; 2) the distraction caused by the transfer of attention from the food to the content displayed on the screen, interfering in the perception of physiological signs of hunger and satiety; and 3) the emotional changes triggered by the transmitted content, especially when they generate strong feelings, such as joy and sadness.
Some authors point out that there seems to be an association between gender and the amount of snacks consumed while watching television; women seem to be more likely to eat more in these conditions, when compared to men. Furthermore, in addition to the immediate effects, eating in front of the television seems to have effects on food consumption in subsequent meals, by affecting the perception of the amount of food consumed in the meal eaten in front of the screen39.
One clinical trial conducted among adult women sought to understand the mechanisms involved in the increase in food consumption when these are eaten in front of the television. Regardless of the variety of foods offered to the participants, a greater quantity had to be consumed to generate the same fullness when eating in front of the television, as compared to meals eaten without the television, and this effect was enhanced if the participants were frequent viewers of the television program40.
This study is an important starting point for investigating the relationship between ST and food consumption among overweight pregnant women. However, additional research is needed to deepen the understanding of this association. Among the limitations of this study, one can mention its cross-sectional nature, which prevents the inference of causality in the associations found. Longitudinal studies can help establish cause-and-effect relationships between ST and the consumption of unhealthy foods during pregnancy. In addition, it is impossible to generalize the results found for other pre-gestational BMI categories, since it was conducted with a sample of overweight pregnant women. Furthermore, the results may have been influenced by the impacts of the socioeconomic crisis faced by Brazil during the years in which the study was conducted, aggravated by the COVID-19 pandemic, increasing social inequality and contributing to the rise in food insecurity rates, especially among the socioeconomically disadvantaged. Regarding the potential of this study, it is important to highlight that the data were collected by trained nutritionists; collection instruments were validated for the Brazilian population; and this approach to the population in question and the use of the New Food Classification, such as the approach to assessing food consumption, is the first of its kind.

Conclusion
Pregnant women with greater Total ST and electronics ST use are more likely to have a high weekly frequency of UPF consumption. These findings can contribute to the formulation of public health promotion policies and nutritional intervention programs for pregnant women.

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