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Revista Brasileira de Saúde Materno Infantil

versão impressa ISSN 1519-3829versão On-line ISSN 1806-9304

Rev. Bras. Saude Mater. Infant. vol.19 no.2 Recife abr./jun. 2019  Epub 22-Jul-2019

http://dx.doi.org/10.1590/1806-93042019000200006 

ORIGINAL ARTICLES

Relationship between pregestational nutritional status and type of processing of foods consumed by high-risk pregnant women

Débora Cardoso Fernandes1 
http://orcid.org/0000-0003-2704-7549

Ioná Carreno2 
http://orcid.org/0000-0002-9872-217X

André Anjos da Silva3 
http://orcid.org/0000-0003-3714-3171

Tais Battisti Guerra4 
http://orcid.org/0000-0002-8303-8834

Fernanda Scherer Adami5 
http://orcid.org/0000-0002-2785-4685

1,4Universidade do Vale do Taquari. Lajeado, RS, Brasil.

2,3Centro de Ciências Médicas. Universidade do Vale do Taquari. Lajeado, RS, Brasil.

5Centro de Ciências Biológicas e da Saúde. Universidade do Vale do Taquari. Avelino Talini, 171. Bairro Universitário. Lajeado, RS, Brasil. CEP: 95.914-014. E-mail: fernandascherer@univates.br

Abstract

Objectives:

to relate pregestational nutritional status, maternal age and number of pregnancies to the distribution of macronutrients and micronutrients according to the type of processing offoods consumed by high-risk pregnant women.

Methods:

a retrospective cross-sectional study was carried out with data from medical records of 200 pregnant women served by a public outpatient clinic in Rio Grande do Sul from 2014 to 2016.

Results:

the mean percentages of lipids, monounsaturated fatty acids, polyunsaturated fatty acids and sodium intake were higher among ultra-processed foods. There was a significant inverse correlation between maternal age and total calorie intake (p=0.003) and percentage of carbohydrates (p=0.005) and proteins (p=0.037) from ultra-processed foods. There was also a significant association between pregestational nutritional status and total calorie intake (p=0.018) and percentage of carbohydrates (p=0.048) from ultra-processed foods.

Conclusions:

the mean percentages of lipids, monounsaturated fatty acids, polyunsaturated fatty acids and sodium intake were higher among ultra-processed foods. It was observed that the older the maternal age of high-risk pregnant women, the lower the intake of total calories and percentages of carbohydrates and proteins from ultra-processed foods. It was also observed that pregestational nutritional status was significantly associated with the intake of total calories and percentage of carbohydrates from ultra-processed foods.

Key words Pregnancy high-risk; Maternal health; Feeding behavior

Introduction

Pregnancy is the period in which nutritional needs are increased due to physiological adjustments in the maternal organism and fetal development. Therefore, adequate nutrient availability and a balanced diet are essential for this phase of life.1 During pregnancy, both mother and the fetus may face health risks that can lead this phase to become a risk pregnancy2 in which the most common consequences are preterm birth, prolonged pregnancy, preeclampsia and eclampsia, hemorrhages, gestational diabetes, cervical insufficiency, and even death of the fetus.3

Pregnant women's inadequate dietary habits potentiate risks during pregnancy4 and have a strong impact on obstetric outcomes and clinical characteristics of the newborn.5 Therefore, the expectant mother needs to be aware of her pregestational nutritional status, her food intake and, above all, the quality of the food sheeats.6

The Dietary Guidelines for the Brazilian Population classified food according to the type of processing, with natural foods being those obtained from nature that do not undergo any type of processing. Minimally processed foods are natural foods that undergo some type of processing for cleaning, removal of unwanted parts, grinding, drying and pasteurization, among others. Processed foods are natural or minimally processed foods that contain additives (sugar, salt or some substance used in cooking) to enhance flavor or increase durability. Ultra-processed foods are foods that undergo several types of processing and that are added to industrial formulations.7

The daily intake of natural and minimally processed foods is related to disease prevention.8 On the other hand, the intake of processed and ultraprocessed foods is related to the onset of chronic diseases given the changes in their nutritional composition. This explains the importance of having pregnant women prioritize natural foods and reduce the intake of processed foods and avoid ultraprocessed foods.9

Healthy habits and choices, in addition to minimizing risks during pregnancy, improve the quality of fetal development and maternal nutritional status.10 Thus, given the scarcity of publications addressing the relationship between pregnant women's nutritional status and the type of processing of the food they eat, this study aimed to relate pregestational nutritional status, maternal age and number of pregnancies to the distribution of macronutrients and micronutrients according to the type of processing of foods consumed by high-risk pregnant women.

Methods

This is a quantitative retrospective cross-sectional study of data from medical records of 300 high-risk pregnant women. The study included high-risk pregnant women aged 15 to 45 years who were referred from 2014 to 2016 for the treatment of comorbidities such as hypertension, diabetes mellitus, hypothyroidism, toxoplasmosis and obesity in a public outpatient clinic located in the countryside of Rio Grande do Sul. The study excluded 100 medical records that did not present complete data on a 24-hour dietary recall of a single day and information on pregestational nutritional status, age, and number of pregnancies. Thus, 200 medical records were selected for analysis. The present study was approved by a Research Ethics Committee under Approval Nº. 1.591.097 and CAAE No. 55981216.3.0000.5310.

The pregestational nutritional status was determined using the body mass index (BMI) and its classification was based on the 1998 World Health Organization (WHO) standards, namely: malnutrition (<18.5 kg/m2), normal weight (≥18.5 and ≤24.9 kg/m2), overweight (≥ 25.0 and ≤ 29.9 kg/m2), class I obesity (≥30.0 and ≤34.9 kg/m2), class II obesity (≥35.0 and ≤39.9 kg/m2) and class III obesity (≥40.0 kg/m2).11

The 24-hour dietary recalls of the pregnant women were analyzed using the 2008 DietWin® software and total calories and intake of carbohydrates, proteins, lipids, sodium, and monounsaturated, polyunsaturated and saturated fats from all the foods consumed were measured. After that, the calories and percentages of each macronutrient and each micronutrient mentioned above were calculated according to the classification of each food described in the Dietary Guidelines for the Brazilian Population, which categorizes foods into: natural, minimally processed, processed and ultra-processed.7

Statistical analysis was performed using the Kruskal-Wallis test and Pearson's correlation analysis. Results were considered significant at a maximum significance threshold of 5%. The software used for the analyses was the SPSS (Statistical Package for the Social Sciences) version 22.0.

Results

The mean age of the pregnant women was 29.64 ± 6.82, the mean number of children was 1.92 ± 1.04, and the mean number of pregnancies was 2.49 ± 1.5. With regard to the percentages of total calories from the different types of processing of the foods consumed by high-risk pregnant women, 47.21% were from natural/minimally processed foods, 38.07% were from ultra-processed foods, and 14.72% were from processed foods.

According to Table 1, there were higher means of total calories and percentages of carbohydrates, proteins and saturated fats from natural/minimally processed foods followed by ultra-processed and processed foods. The mean percentages of lipids and monounsaturated and polyunsaturated fats were higher among ultra-processed foods, followed by natural/minimally processed foods and processed foods. In regard to the percentage of sodium, there was a higher mean among ultra-processed foods, followed by processed foods and natural/minimally processed foods.

Table 1 Characterization of total calorie intake and percentage of carbohydrates, protein, lipids, monounsaturated fatty acids, polyunsaturated fatty acids, saturated fatty acids and sodium from natural/minimally processed, processed and ultraprocessed foods among high-risk pregnant women. 

Variables n Minimum Maximum X̄ ± SD
Total Kcal natural/minimally processed 200 35.01 2045.68 789.22 ± 378.27
Total Kcal processed 200 0.00 2643.81 246.03 ± 291.98
Total Kcal ultra-processed 200 0.00 3153.70 636.60 ± 557.40
% total CHO natural/minimally processed 200 3.45 100.00 50.47 ± 23.43
% total CHO processed 200 0.00 77.34 16.32 ± 15.55
% total CHO ultra-processed 200 0.00 96.55 33.21 ± 25.26
% total PTN natural/minimally processed 200 0.00 100.00 63.74 ± 27.52
% total PTN processed 200 0.00 74.81 11.82 ± 15.14
% total PTN ultra-processed 200 0.00 97.23 24.44 ± 24.47
% total LIP natural/minimally processed 200 0.00 100.00 38.21 ± 26.41
% total LIP processed 200 0.00 75.29 12.44 ± 15.34
% total LIP ultra-processed 200 0.00 99.63 49.35 ± 28.26
% total MUFA natural/minimallyprocessed 200 0.00 100.00 42.92 ± 31.91
% total MUFA processed 200 0.00 100.00 11.61 ± 18.10
% total MUFA ultra-processed 200 0.00 100.00 45.46 ± 32.26
% total PUFA natural/minimally processed 200 0.00 100.00 30.54 ± 31.86
% total PUFA processed 200 0.00 100.00 15.55 ± 21.75
% total PUFA ultra-processed 200 0.00 100.00 53.91 ± 35.87
% total SFA natural/minimally processed 200 0.00 100.00 45.10 ± 29.08
% total SFA processed 200 0.00 98.04 12.29 ± 17.33
% total SFA total ultra-processed 200 0.00 100.00 42.61 ± 28.90
% total sodium natural/minimally processed 200 0.00 100.00 22.48 ± 25.68
% total sodium processed 200 0.00 92.96 29.09 ± 27.33
% total sodium ultra-processed 200 0.00 99.89 48.43 ± 31.72

Kcal =kilocalorie; CHO=carbohydrate; PTN =protein; LIP =lipid; MUFA = monounsaturated fatty acids; PUFA=polyunsaturated fatty acids; SFA =saturated fatty acids; SD=Standard deviation.

There was a direct correlation (Table 2) between age and percentage of carbohydrates from natural/minimally processed foods (p=0.013). There was also a significant inverse relationship between age and intake of total calories (p=0.003) and percentages of carbohydrates (p=0.005) and proteins (p=0.037) from ultra-processed foods.

Table 2 Association of number of pregnancies, age and pregestational nutritional status with total calorie intake and percentage of carbohydrates, protein, lipids, monounsaturated fatty acids, polyunsaturated fatty acids, saturated fatty acids and sodium from natural/minimally processed, processed and ultra-processed foods among high-risk pregnant women. 

Variables Number of Pregnancies Age (years) Pregestational BMI (kg/m2)
r p r p r p
Total Kcal natural/minimally processed -0.069 0.338 0.017 0.808 -0.110 0.124
Total Kcal processed -0.119 0.096 -0.019 0.792 -0.057 0.424
Total Kcal ultra-processed -0.057 0.430 -0.211 0.003 0.039 0.586
% total CHO natural/minimally processed 0.059 0.411 0.177 0.013 -0.047 0.510
% total CHO processed -0.120 0.093 0.053 0.458 -0.011 0.876
% total CHO ultra-processed 0.018 0.798 - 0.198 0.005 0.051 0.480
% total PTN natural/minimally processed 0.021 0.770 0.084 0.242 -0.095 0.181
% total PTN processed -0.081 0.257 0.089 0.214 0.111 0.120
% total PTN ultra-processed 0.027 0.711 -0.149 0.037 0.040 0.574
% total LIP natural/minimally processed 0.020 0.776 0.103 0.149 -0.111 0.118
% total LIP processed -0.025 0.726 0.068 0.344 0.091 0.203
% total LIP ultra-processed -0.005 0.939 -0.133 0.063 0.055 0.442
% total MUFA natural/minimally processed -0.001 0.986 0.051 0.480 -0.120 0.093
% total MUFA processed -0.037 0.605 0.081 0.259 0.126 0.076
% total MUFA ultra-processed 0.022 0.758 -0.095 0.183 0.048 0.499
% total PUFA natural/minimally processed 0.025 0.731 0.074 0.303 -0.121 0.089
% total PUFA processed -0.049 0.496 0.076 0.287 0.087 0.223
% total PUFA ultra-processed 0.008 0.914 -0.111 0.119 0.055 0.444
% total SFA natural/minimally processed -0.010 0.885 0.004 0.952 -0.129 0.069
% total SFA processed -0.065 0.365 0.096 0.181 0.113 0.114
% total SFA total ultra-processed 0.049 0.491 -0.062 0.387 0.064 0.374
% total sodium natural/minimally processed -0.015 0.832 0.048 0.503 -0.052 0.466
% total sodium processed -0.118 0.099 0.061 0.393 -0.040 0.577
% total sodium ultra-processed 0.114 0.111 -0.092 0.199 0.076 0.284

BMI= body mass index; Kcal = kilocalorie; CHO = carbohydrate; PTN = protein; LIP = lipid; MUFA = monounsaturated fatty acids; PUFA = polyunsaturated fatty acids; SFA = saturated fatty acids; Pearson's correlation analysis; p<0.05.

There was also a correlation between pregestational nutritional status and percentage of protein from natural/minimally processed foods (p=0.021). The percentage of intake of protein from natural/minimally processed foods in Class III obese pregnant women was significantly lower when compared with overweight and class I and II obese pregnant women. There was also an association of pregestational nutritional status with total calorie intake (p=0.018) and percentage of carbohydrates (p=0.048) from ultra-processed foods. Total calorie intake and percentage of carbohydrates from ultraprocessed foods were significantly higher among high-risk pregnant women with class III obesity and normal weight when compared with overweight and class II obese pregnant women. Additionally, overweight and class II obese high-risk pregnant women exhibited lowers percentages of protein from ultraprocessed foods (p=0.024) when compared with those with normal weight or class I and III obesity (Table 3).

Table 3 Association of pregestational nutritional status with total calorie intake and percentage of carbohydrates and protein from natural/minimally processed, processed and ultra-processed foods among high-risk pregnant women. 

Variables BMI n X̄ ± SD p
Total Kcal ultra-processed Malnutrition 6 813.50AB ± 845.61 0.018
Normal weight 36 715.75B ± 501.80
Overweight 52 492.10A ± 481.62
Class I Obesity 42 679.99AB ± 517.07
Class II Obesity 29 457.13A ± 346.46
Class III Obesity 33 874.19B ± 760.56
% total CHO natural/minimally processed Malnutrition 6 46.87 ± 26.43 0.102
Normal weight 36 47.64 ± 23.42
Overweight 52 54.60 ± 23.94
Class I Obesity 42 48.37 ± 22.40
Class II Obesity 29 58.43 ± 23.89
Class III Obesity 33 42.74 ± 20.92
% total CHO processed Malnutrition 6 17.10 ± 10.52 0.997
Normal weight 36 17.15 ± 18.04
Overweight 52 16.55 ± 16.20
Class I Obesity 42 15.09 ± 13.63
Class II Obesity 29 16.99 ± 17.55
Class III Obesity 33 15.05 ± 13.04
% total CHO ultra-processed Malnutrition 6 36.03AB ± 28.93 0.048
Normal weight 36 35.21AB ± 24.46
Overweight 52 28.85A ± 27.56
Class I Obesity 42 36.53AB ± 23.86
Class II Obesity 29 24.58A ± 18.40
Class III Obesity 33 42.21B ± 26.52
% total PTN natural/minimally processed Malnutrition 6 65.16AB ± 31.56 0.021
Normal weight 36 57.56AB ± 30.49
Overweight 52 70.33A ± 24.98
Class I Obesity 42 65.33A ± 25.76
Class II Obesity 29 71.80A ± 23.37
Class III Obesity 33 51.38B ± 28.00
% total PTN processed Malnutrition 6 9.02 ± 5.02 0.914
Normal weight 36 13.25 ± 17.01
Overweight 52 10.42 ± 11.61
Class I Obesity 42 9.12 ± 9.60
Class II Obesity 29 9.79 ± 12.71
Class III Obesity 33 16.60 ± 22.09
% total PTN ultra-processed Malnutrition 6 25.83AB ± 29.59 0.024
Normal weight 36 29.19A ± 27.21
Overweight 52 19.24B ± 24.56
Class I Obesity 42 25.55A ± 22.58
Class II Obesity 29 18.41B ± 18.03
Class III Obesity 33 32.03A ± 26.35

BMI= body mass index; Kcal =kilocalorie; CHO=carbohydrate; PTN = protein; SD=standard deviation

***Values with the same letters do not differ; Kruskal-Wallis test; p<0.05.

Class III obese pregnant women presented lower percentages of intake of monounsaturated (p=0.040) and saturated (p=0.034) fats from natural/minimally processed foods when compared with class II obese pregnant women (Table 4).

Table 4 Association of pregestational nutritional status with percentage of intake of lipids, monounsaturated fatty acids, polyunsaturated fatty acids and saturated fatty acids from natural/minimally processed, processed and ultra-processed foods among high-risk pregnant women. 

Varibles BMI n X ± SD p
% total LIP natural/minimally processed Malnutrition 6 44.40 ± 35.93 0.080
Normal weight 36 35.87 ± 25.15
Overweight 52 42.72 ± 26.16
Class I Obesity 42 39.37± 27.06
Class II Obesity 29 43.31 ± 24.45
Class III Obesity 33 27.20±25.47
% total LIP processed Malnutrition 6 12.04±14.18 0.729
Normal weight 36 11.03±15.48
Overweight 52 13.78±14.33
Class I Obesity 42 10.61 ±12.51
Class II Obesity 29 9.28±12.72
Class III Obesity 33 16.01±20.57
% total LIPultra-processed Malnutrition 6 43.56±35.33 0.405
Normal weight 36 53.10±27.89
Overweight 52 43.50±29.17
Class I Obesity 42 50.02±28.77
Class II Obesity 29 47.41±26.51
Class III Obesity 33 56.78±27.32
% total MUFA natural/minimally processed Malnutrition 6 60.91AB±41.42 0.040
Normal weight 36 37.32ab±31.02
Overweight 52 48.13ab±29.74
Class I Obesity 42 43.85AB±32.57
Class II Obesity 29 51.03A±31.81
Class III Obesity 33 30.26B±30.55
% total MUFA processed Malnutrition 6 12.49±15.87 0.742
Normal weight 36 10.52±17.68
Overweight 52 11.47±14.73
Class I Obesity 42 9.19±13.93
Class II Obesity 29 7.72±11.68
Class III Obesity 33 18.02±28.45
% total MUFAultra-processed Malnutrition 6 26.61±31.90 0.207
Normal weight 36 52.16±30.83
Overweight 52 40.41±32.23
Class I Obesity 42 46.96±31.81
Class II Obesity 29 41.25±31.05
Class III Obesity 33 51.72±35.48
% total PUFA natural/minimally processed Malnutrition 6 53.65±41.51 0.218
Normal weight 36 26.47±32.14
Overweight 52 33.62±31.34
Class I Obesity 42 32.98±33.06
Class II Obesity 29 33.89±34.16
Class III Obesity 33 20.90±25.55
% total PUFA processed Malnutrition 6 14.06±12.05 0.838
Normal weight 36 14.59±18.62
Overweight 52 17.92±24.48
Class I Obesity 42 12.80±18.86
Class II Obesity 29 11.17±18.06
Class III Obesity 33 20.50±27.90
% total PUFA ultra-processed Malnutrition 6 32.29 ± 41.83 0.414
Normal weight 36 58.93 ± 33.45
Overweight 52 48.45 ± 36.12
Class I Obesity 42 54.22 ± 35.51
Class II Obesity 29 54.94 ± 36.14
Class III Obesity 33 58.59 ± 38.18
% total SFA natural/minimally processed Malnutrition 6 54.87AB ± 39.23 0.034
Normal weight 36 42.60AB ± 28.99
Overweight 52 48.24AB ± 27.83
Class I Obesity 42 46.75AB ± 28.55
Class II Obesity 29 54.63A ± 26.15
Class III Obesity 33 31.25B ± 28.56
% total SFA processed Malnutrition 6 16.41 ± 17.97 0.777
Normal weight 36 9.96 ± 13.42
Overweight 52 12.47 ± 15.00
Class I Obesity 42 9.70 ± 13.38
Class II Obesity 29 9.48 ± 12.31
Class III Obesity 33 18.13 ± 27.21
% total SFA ultra-processed Malnutrition 6 28.72 ± 38.44 0.213
Normal weight 36 47.44 ± 28.41
Overweight 52 39.29 ± 30.09
Class I Obesity 42 43.55 ± 26.40
Class II Obesity 29 35.88 ± 25.18
Class III Obesity 33 50.62 ± 31.47

BMI = body mass index; Kcal =kilocalorie; LIP = lipid; MUFA = monounsaturated fatty acids; PUFA = polyunsaturated fatty acids; SFA = saturated fatty acids; SD = Standard Deviation

***Values with the same letters do not differ; Kruskal-Wallis test; p<0.05.

There was an association between pregestational nutritional status and percentage of sodium from natural/minimally processed foods (p=0.050). Class III obese pregnant women presented significantly lower percentages of intake of sodium from natural/minimally processed foods when compared with overweight or class I and II obese pregnant women (Table 5).

Table 5 Association of pregestational nutritional status with percentage of intake of sodium from natural/minimally processed, processed and ultra-processed foods among high-risk pregnant women. 

Variables BMI n X̄ ± SD p
% total sodium natural/minimally processed Malnutrition 6 18.53AB ± 19.93 0.050
Normal weight 36 17.99AB ± 20.18
Overweight 52 25.17A ± 27.34
Class I Obesity 42 25.95A ± 26.53
Class II Obesity 29 28.85A ± 30.12
Class III Obesity 33 14.52B ± 23.14
% total sodium processed Malnutrition 6 28.26 ± 22.54 0.787
Normal weight 36 28.73 ± 26.31
Overweight 52 33.88 ± 29.56
Class I Obesity 42 24.02 ± 23.43
Class II Obesity 29 26.83 ± 27.14
Class III Obesity 33 27.57 ± 28.85
% total sodium ultra-processed Malnutrition 6 53.22 ± 41.89 0.228
Normal weight 36 53.28 ± 28.23
Overweight 52 40.96 ± 33.89
Class I Obesity 42 50.03 ± 30.05
Class II Obesity 29 44.33 ± 31.73
Class III Obesity 33 57.91 ± 30.39

BMI = body mass index; Kcal =kilocalorie; SD=standard deviation

***Values with the same letters do not differ; Kruskal-Wallis test; p<0.05.

Discussion

The consumption of ultra-processed foods in the present study represented 38.07% of the total calories consumed by high-risk pregnant women. This percentage is lower than that found in a study carried out with young adults in the city of Pelotas, Rio Grande do Sul, which showed a consumption of 51.20%,12 and higher than that found in a study carried out with individuals from the 2008 and 2009 Family Budget Surveys in São Paulo, which demonstrated a consumption of 21.5% of total calories.13 This finding shows the increasing influence of ultraprocessed products on Brazilian food14 and hence the need to develop strategies to encourage the consumption by the entire population, including pregnant women, of natural/minimally processed foods.15

The present study demonstrated that the older the maternal age of high-risk pregnant women, the lower the intake of total calories and the percentages of carbohydrates and proteins from ultra-processed foods. This finding agrees with other studies that have shown that older pregnant women tend to eat less unhealthy snacks and fast food,16,17 which are meals known to increase overweight and obesity18 as they contain a large amount of sugar, fat and sodium.19

In the present study, class III obese high-risk pregnant women presented lower percentages of intake of protein from natural/minimally processed foods when compared with overweight or class I and II obese pregnant women. The consumption of ultraprocessed foods was responsible for the second highest mean rate of total calories and percentages of carbohydrates, proteins and saturated fats consumed. Consumption of ultra-processed foods during pregnancy results in unfavorable consequences for both mother and the fetus, including the woman's excessive weight gain during pregnancy and an increase in the newborn's body fat. It is important to emphasize that the permanence of such excess weight may contribute to the development of associated comorbidities, such as type II diabetes, cardiovascular disease, mental health problems and cancer.20

Maternal food consumption during pregnancy is responsible for promoting the neurodevelopment of children, which reinforces the importance of having a healthy lifestyle before pregnancy even begins.21 Thus, prenatal care is of fundamental importance to encourage, guide and motivate pregnant women by promoting healthy eating habits22 and by monitoring the health of the mother and the fetus.21 In a study on the healthy eating index of Brazilian pregnant women, the overall dietary intake of pregnant women was assessed based on three food groups(vegetables, fruits and beans and other protein-rich vegetables), two ratios (red/white meat and polyunsaturated/saturated fat) and five nutrients (fiber, trans fat, calcium, folate and iron) and it was found that most of them lacked dietary intake improvements, thus showing the need to deliver food education at this stage of life.23

In the present study, class III obese and normal weight high-risk pregnant women presented a higher intake of total calories and higher percentages of carbohydrates from ultra-processed foods when compared with overweight and class II obese pregnant women, that is, the consumption of ultraprocessed foods may not be related only to the nutritional status of pregnant women. Social mobility improvement, lifestyle and high levels of education are some of the factors that suggest a greater access to ultra-processed foods; in addition, these same factors can influence individuals' physical inactivity.12

Overweight and class II obese high-risk pregnant women consumed significantly lower percentages of protein from ultra-processed foods compared with normal weight and class I and III obese pregnant women. According to results found in the present study, this relationship occurred because overweight and class II obese high-risk pregnant women consumed higher percentages of protein from natural/minimally processed foods.

It was also observed that class III obese pregnant women consumed significantly lower percentages of monounsaturated and saturated fatty acids from in natura/minimally processed foods compared with-class II obese pregnant women. This finding indicates that class III obese pregnant women consumed higher percentages of saturated and monounsaturated fatty acids from ultra-processed foods. Therefore, interventions and actions should be carried out during prenatal care in order to promote and encourage the consumption of natural foods, as well as reinforce the importance of healthy habits24 and, mainly, inform pregnant women about how much their nutritional status influences the baby's health. Pregnant women who have a BMI that suggests obesity tend to have greater complications during childbirth and maternal complications such as gestational diabetes and hypertensive syndrome and are more likely to experience perinatal complications such as macrosomia and low Apgar score in the first minute.25

The present study demonstrated that class III obese pregnant women exhibited a significantly lower percentage of sodium intake from natural/minimally processed foods when compared with overweight and class I and II obese pregnant women, i.e., class III obese pregnant women consumed higher percentages of sodium from ultraprocessed foods. It was also possible to identify that the overall mean percentages of lipids, monounsaturated fatty acids, polyunsaturated fatty acids and sodium were higher among ultra-processed foods, which may be related to the strong influence of marketing on the eating habits of the population14 and to the fact that these foods are well accepted due to their taste, have a long shelf life and are practical, as they can be consumed at any time and place.26 Therefore, nutritional follow-up is essential for the definition of a diet that meets nutritional demands.2

During pregnancy, there is a greater predisposition to positive changes in maternal food choices, which are driven by the desire for a healthy outcome in the baby's life.27 A cohort study in Rio de Janeiro analyzed the type of food processing and changes in food consumption before and during pregnancy and concluded that the consumption of ultra-processed foods decreased and the consumption of natural/minimally processed foods increased from the period before pregnancy and throughout pregnancy, thus emphasizing the importance of nutritional follow-up during pregnancy.28 Despite that, the vast majority of women continue to consume foods rich in sugar, saturated fat and sodium during pregnancy.19 Such habits may be related to the increase in overweight and obesity5 as well as heighten the predisposition of chronic diseases29 such as diabetes mellitus, which is associated with high rates of perinatal morbidity and mortality.3

A simple way to reduce the chances of developing chronic diseases and improve maternal and neonatal health in the short and long term is - in addition to getting prenatal care - to reduce the consumption of ultra-processed foods.19 The consumption of this kind of food should be reduced because they are rich in saturated fat, trans fat and free sugar and poor in fiber and protein when compared with natural/minimally processed foods.9,30 A diet based on natural and minimally processed foods may even prevent diseases.8

One of the limitations of this study may have been the use of a single dietary recall from each high-risk pregnant woman. In addition, the dietary recall was based on secondary data and hence there may have been underestimation or overestimation of habitual consumption. This study is expected to contribute to the improvement of the care of pregnant women and to the evolution of scientific knowledge, thus improving health education and strengthening current public policies in the field of maternal and child health.

In the present study, the mean percentages of intake of lipids, monounsaturated fatty acids, polyunsaturated fatty acids and sodium were higher among ultra-processed foods. It was also observed that the older the maternal age of high-risk pregnant women, the lower the intake of total calories and the percentages of carbohydrates and proteins from ultra-processed foods. Finally, it was observed that pregestational nutritional status is significantly associated with the intake of total calories and percentage of carbohydrates from ultra-processed foods.

Thus, the study confirmed that the consumption of ultra-processed foods is present among high-risk pregnant women, which makes it necessary to develop nutrition education actions and strengthen existing public policies in the field of maternal and child health in order to raise women's awareness of how much their food consumption and habits may affect their children's lives in the short and long term.

References

1 Bueno AAA, Beserra JAS, Weber ML. Características da alimentação no período gestacional. LifeStyle J. 2016; 3 (2): 30-43. [ Links ]

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Received: July 10, 2018; Revised: January 25, 2019; Accepted: February 01, 2019

Author's contribuition

Fernandes DC was responsible for the conception of the study, the selection of the articles to be included within the manuscript, for the organization, data interpretation and for the writing of the article. Carreno I e Silva AA contributed with the final revision of the manuscript. Guerra TB helped with the typing of the database. Adami FS contributed with the conception of the study, data interpretation, revision of the writing and was responsible by the exchange of correspondence. All authors approved the final version of the manuscript.

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