Degree of food processing and its relationship with overweight and body adiposity in Brazilian adults

Grau de processamento de alimentos e sua relação com sobrepeso e adiposidade corporal em adultos brasileiros

Danielle Cristina Guimarães da SILVA Fabrícia Geralda FERREIRA Dayana Ladeira Macedo PEREIRA Emanuele Louise Gomes de MAGALHÃES Giana Zarbato LONGO About the authors

ABSTRACT

Objective

To check the relationship of the degree of food processing with overweight and body adiposity in Brazilian adults.

Methods

Cross-sectional study with 670 adults (334 women and 336 men) aged 20-59 years in Viçosa, Minas Gerais, Brazil, based on population data collected using a questionnaire, 24-hour dietary recall interview, and anthropometric evaluation. Consumed foods were categorized into four groups: unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods. Poisson regression models were used to assess the relationship between degree of food processing and overweight and body adiposity.

Results

The contribution of unprocessed or minimally processed foods to total energy intake was a protective factor for overweight in all quartiles. The contribution of ultra-processed foods to total energy intake was a risk factor for overweight in the highest quartile (prevalence ratio, 1.308; 95% confidence interval, 1.085-1.577). High energy intake from ultra-processed foods was a risk factor for excess adiposity in the highest quartiles.

Conclusion

Consumption of ultra-processed foods is associated with overweight and excess adiposity, whereas consumption of unprocessed and minimally processed foods is a protective factor for overweight.

Keywords
Adult; Eating; Food guide; Industrialized foods; Obesity

RESUMO

Objetivo

O objetivo deste estudo foi verificar a relação entre o grau de processamento de alimentos e sobrepeso e adiposidade corporal em adultos brasileiros.

Métodos

Estudo transversal com 670 adultos (334 mulheres e 336 homens) com idades entre 20 e 59 anos, em Viçosa, Minas Gerais, Brasil, com base em dados populacionais coletados por meio de questionário estruturado, entrevista de recordatório alimentar de 24 horas e avaliação antropométrica. Os alimentos consumidos foram categorizados em quatro grupos: alimentos não processados ou minimamente processados, ingredientes culinários processados, alimentos processados e alimentos ultraprocessados. Modelos de regressão de Poisson foram utilizados para avaliar a relação entre o grau de processamento dos alimentos e excesso de peso e de adiposidade corporal.

Resultados

A contribuição de alimentos não processados ou minimamente processados para a ingestão total de energia foi um fator protetor para o excesso de peso em todos os quartis. Por outro lado, a contribuição dos alimentos ultraprocessados para a ingestão total de energia foi um fator de risco para o excesso de peso no quartil mais alto (razão de prevalência 1,308; intervalo de confiança de 95%, 1,085-1,577). O alto consumo de energia de alimentos ultraprocessados foi um fator de risco para o excesso de adiposidade nos quartis mais altos.

Conclusão

O consumo de alimentos ultraprocessados está associado ao excesso de peso e excesso de adiposidade, enquanto o consumo de alimentos não processados e minimamente processados é um fator protetor para o excesso de peso.

Palavras-chave
Adultos; Ingestão de alimentos; Guias alimentares; Alimentos industrializados; Obesidade

INTRODUCTION

Obesity is characterized as a chronic disease, of complex etiology and excessive accumulation of body fat. It is a major public health problem worldwide and a risk factor for several diseases [11 Bray GA, Kim KK, Wilding JPH, World Obesity Federation. Obesity: a chronic relapsing progressive disease process: a position statement of the World Obesity Federation. Obes Rev. 2017;18(7):715-23. https://doi.org/10.1111/obr.12551,22 Ng M, Fleming T, Robinson M, Blake TBA, Graetz NBS, Margono CBS, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-81. https://doi.org/10.1016/S0140-6736(14)60460-8]. The increase in obesity prevalence may be attributed to many factors, including unhealthy dietary habits.

Some studies evaluated the relationship between overweight and the degree of food processing [33 Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang VW. Ultra-processed food consumption and excess weight among US adults. Br J Nutr. 2018;120(1):90-100. https://doi.org/10.1017/S0007114518001046

4 Mendonça RD, Pimenta AM, Gea A, Fuente-Arrillaga C, Martinez-Gonzalez MA, Lopes ACS, et al. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr. 2016;104(5):1433-40. https://doi.org/10.3945/ajcn.116.135004

5 Passos CM, Maia EG, Levy RB, Martins APB, Claro RM. Association between the price of ultra-processed foods and obesity in Brazil. Nutr Metab Cardiovas. 2020;30(4):589-98. https://doi.org/10.1016/j.numecd.2019.12.011
https://doi.org/10.1016/j.numecd.2019.12...
-66 Canella DS, Levy RB, Martins AP, Claro RM, Mourabac JC, Baraldi LG, et al. Ultra-processed food products and obesity in Brazilian households (2008-2009). Plos One. 2014;9(3):e92752. https://doi.org/10.1371/journal.pone.0092752
https://doi.org/10.1371/journal.pone.009...
]. Monteiro [77 Monteiro CA. Nutrition and health: the issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. https://doi.org/10.1017/S1368980009005291
https://doi.org/10.1017/S136898000900529...
] was the first to explore the possibility that the increase in obesity prevalence is related to the high intake of processed and ultra-processed foods. The author proposed a food classification system based on the nature, degree, and purpose of food processing. Foods are grouped into four categories: unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods [88 Monteiro CA, Cannon G, Levy R, Mourabac JC, Jaime P, Martins AP, et al. NOVA the star shines bright. World Nutr. 2016;7(1-3):28-38.

9 Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzada MRC, Jaime PC. The UN decade of nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr. 2017;21(1):5-17. https://doi.org/10.1017/S1368980017000234
https://doi.org/10.1017/S136898001700023...
-1010 Nazmi A, Tseng M, Robinson D, Neill D, Walker J. A Nutrition education intervention using NOVA is more effective than my plate alone: a proof-of-concept randomized controlled trial. Nutrients. 2019;11(12):2965. https://doi.org/10.3390/nu11122965
https://doi.org/10.3390/nu11122965...
]. A new classification of food and health began to emerge.

The purpose main of ultra-processing is to create ready-to-eat, ready-to-drink, or ready-to-heat products. These energy-dense foods contain high levels of sodium, free and added sugars, saturated fats, and trans fats and are low in fibers, micronutrients, bioactive compounds, and proteins [1111 Moubarac JC, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-processed foods predicts diet quality in Canada. Appetite. 2016;108:512-20. https://doi.org/10.1016/j.appet.2016.11.006
https://doi.org/10.1016/j.appet.2016.11....

12 Louzada MLC, Ricardo CZ, Steele EM, Levy RB, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutr. 2017;21(1):94-102. https://doi.org/10.1017/S1368980017001434
https://doi.org/10.1017/S136898001700143...

13 Steele EM, Popkin BM, Swinburn B, Monteiro CA. The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study. Popul Health Metr. 2017;15(1):6. https://doi.org/10.1186/s12963-017-0119-3
https://doi.org/10.1186/s12963-017-0119-...
-1414 Steele EM, Monteiro CA. Association between dietary share of ultra-processed foods and urinary concentrations of phytoestrogens in the US. Nutrients. 2017;9(3):E209. https://doi.org/10.3390/nu9030209
https://doi.org/10.3390/nu9030209...
]. High palatability, omnipresence, and aggressive marketing strategies contribute to the high consumption of ultra-processed foods [1515 Longo-Silva G, Menezes RCE, Souza CAN, Marinho PM, Toloni MHA, Oliveira MAA. Factors associated with regular consumption of obesogenic foods: national school-based student health Hurvey, 2012. Rev Nutr. 2016;29(5):609-33. https://doi.org/10.1590/1678-98652016000500001
https://doi.org/10.1590/1678-98652016000...
,1616 Machado PP, Steele EM, Levy RB, Sui Z, Rangan A, Woods J, et al. Ultra-processed foods and recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally representative cross-sectional study. Br Med J Open. 2019;9(8):e029544. https://doi.org/10.1136/bmjopen-2019-029544
https://doi.org/10.1136/bmjopen-2019-029...
].

There has been a growing tendency to replace traditional foods with ready-to-eat foods in middle- and low-income countries, especially from the 1980s onward [88 Monteiro CA, Cannon G, Levy R, Mourabac JC, Jaime P, Martins AP, et al. NOVA the star shines bright. World Nutr. 2016;7(1-3):28-38.]. This behavior may be considered obesogenic, as it can lead to poor dietary habits [1111 Moubarac JC, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-processed foods predicts diet quality in Canada. Appetite. 2016;108:512-20. https://doi.org/10.1016/j.appet.2016.11.006
https://doi.org/10.1016/j.appet.2016.11....
,1313 Steele EM, Popkin BM, Swinburn B, Monteiro CA. The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study. Popul Health Metr. 2017;15(1):6. https://doi.org/10.1186/s12963-017-0119-3
https://doi.org/10.1186/s12963-017-0119-...
]. Intake of convenience foods has increased worldwide compared to obesity [1717 Nakano S, Washizu A. Aiming for better use of convenience food: an analysis based on meal production functions at home. J Health Popul Nutr. 2020;39(3). https://doi.org/10.1186/s41043-020-0211-3
https://doi.org/10.1186/s41043-020-0211-...
,1818 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987-2009). Rev Saúde Pública. 2013;47(4):656-65. https://doi.org/10.1590/S0034-8910.2013047004968
https://doi.org/10.1590/S0034-8910.20130...
]. Such tendencies have also been observed in Brazil, where studies associated the intake of ultra-processed foods with an increase in obesity prevalence [1919 Silva FM, Giatti L, Figueiredo RC, Molina MDCB, Cardoso LO, Duncan BB, et al. Consumption of ultra-processed food and obesity: cross sectional results from the Brazilian longitudinal study of adult health (ELSA-Brasil) cohort (2008-2010). Public Health Nutr. 2018;21(12):2271-9.https://doi.org/10.1017/S1368980018000861
https://doi.org/10.1017/S136898001800086...
-2020 Louzada MLC, Baraldi LG, Steele EM, Martins APB, Canella DS, Mourabac JC, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15. https://doi.org/10.1016/j.ypmed.2015.07.018
https://doi.org/10.1016/j.ypmed.2015.07....
]. A Brazilian cohort study identified that consumption of ultra-processed foods increased the risk of weight and waist circumference gain by 20-30% [2121 Canhada SL, Luft VC, Giatti L, Duncan BB, Chor D, Fonseca MJMD, et al. Ultra-processed foods, incident overweight and obesity, and longitudinal changes in weight and waist circumference: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Public Health Nutr. 2019;17:1-11.https://doi.org/10.1017/S1368980019002854PMID:31619309
https://doi.org/10.1017/S136898001900285...
].

Research on the new food classification system is still incipient. Further studies are essential to establish whether the intake of highly processed foods is a risk factor for obesity, about everything abdominal obesity. In Brazil, few studies focused on the relationship between the degree of food processing and adiposity/abdominal adiposity in adults [66 Canella DS, Levy RB, Martins AP, Claro RM, Mourabac JC, Baraldi LG, et al. Ultra-processed food products and obesity in Brazilian households (2008-2009). Plos One. 2014;9(3):e92752. https://doi.org/10.1371/journal.pone.0092752
https://doi.org/10.1371/journal.pone.009...
,1919 Silva FM, Giatti L, Figueiredo RC, Molina MDCB, Cardoso LO, Duncan BB, et al. Consumption of ultra-processed food and obesity: cross sectional results from the Brazilian longitudinal study of adult health (ELSA-Brasil) cohort (2008-2010). Public Health Nutr. 2018;21(12):2271-9.https://doi.org/10.1017/S1368980018000861
https://doi.org/10.1017/S136898001800086...

20 Louzada MLC, Baraldi LG, Steele EM, Martins APB, Canella DS, Mourabac JC, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15. https://doi.org/10.1016/j.ypmed.2015.07.018
https://doi.org/10.1016/j.ypmed.2015.07....

21 Canhada SL, Luft VC, Giatti L, Duncan BB, Chor D, Fonseca MJMD, et al. Ultra-processed foods, incident overweight and obesity, and longitudinal changes in weight and waist circumference: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Public Health Nutr. 2019;17:1-11.https://doi.org/10.1017/S1368980019002854PMID:31619309
https://doi.org/10.1017/S136898001900285...

22 Cunha DB, Costa THM, Veiga GV, Pereira RA, Sichieri R. Ultra-processed food consumption and adiposity trajectories in a Brazilian cohort of adolescents: ELANA study. Nutr Diabetes. 2018;8:28.
-2323 Melo ISV, Costa CACB, Santos JVLD, Santos AFD, Florêncio TMMT, Bueno NB. Consumption of minimally processed food is inversely associated with excess weight in adolescents living in an underdeveloped city. Plos One. 2017;12(11):e0188401. https://doi.org/10.1371/journal.pone.0188401
https://doi.org/10.1371/journal.pone.018...
]. This study aims to check the relationship between the intake of processed foods and overweight and body adiposity in Brazilian adults.

METHODS

This cross-sectional study was carried out by the research group Estudos sobre Saúde e Alimentação de Viçosa (ESA/Viçosa, Studies on Health and Dietary Habits in Viçosa). Female and male adults aged 20-59 years living in urban areas in Viçosa, Minas Gerais, Brazil, were eligible to participate. Pregnant women, bedridden individuals, amputees, individuals who were unable to answer the questionnaire because of cognitive or intellectual disabilities, and those who did not participate in the body composition assessment were excluded from the study. The final sample included 670 individuals. Sample size was calculated using OpenEpi.

The study was approved by the Comitê de Ética em Pesquisa com Seres Humanos da Universidade Federal de Viçosa (Human Research Ethics Committee of the Federal University of Viçosa), under protocol CAAE n. 42073314.0.0000.5153. All subjects signed an informed consent form.

Data were collected between 2012 and 2014 in two stages. Home visits were made by a trained team to administer a structured questionnaire containing socio-demographic and behavioral questions and conduct a 24-hour dietary recall interview. Then, subjects were invited to participate in the body composition assessment. The description of the research method is presented by Segheto et al. [2424 Segheto W, Silva DCG, Coelho FA, Reis GV, Morais SHO, Marins JCB, et al. Body adiposity index and associated factors in adults: method and logistics of a population-based study. Nutr Hosp. 2015;32(1):101-9. https://doi.org/10.3305/nh.2015.32.1.8391
https://doi.org/10.3305/nh.2015.32.1.839...
].

The United States Department of Agriculture (USDA) Automated Multiple-Pass Method (AMPM) was used for collecting 24-hour food recalls. This tool applies a five-step approach to increase recall (quick list, forgotten-foods, time-and-occasion, detail cycle, and final probe) [2525 Ahluwalia N, Dwyer J, Terry A, Moshfegh A, Johnson C. Update on NHANES Dietary Data: focus on collection, release, analytical considerations, and uses to inform public policy. Adv Nutr. 2016;7(1):121-34. https://doi.org/10.3945/an.115.009258
https://doi.org/10.3945/an.115.009258...
]. A food photograph album and food labels were used to assist in the estimation of portion sizes [2626 Lopes RPS, Botelho RBA. Álbum fotográfico de porções alimentares. São Paulo: Editora Metha; 2008.]. Food consumption was reported in common household measures and converted to grams or milliliters using a conversion table. Data were analyzed using Brasil-Nutri® software, developed for the 2008-2009 Consumer Expenditure Survey [2727 Barufaldi LA, Abreu GA, Veiga GV, Sichieri R, Kuschnir MCCC, Cunha DB, et al. Programa para registro de recordatório alimentar de 24 horas: aplicação no Estudo de Riscos Cardiovasculares em Adolescentes. Rev Bras Epidemiol. 2016;19(2):464-8. https://doi.org/10.1590/1980-5497201600020020
https://doi.org/10.1590/1980-54972016000...
].

Foods were categorized into four groups according to their degree of processing: unprocessed or minimally processed foods, processed culinary ingredients, processed foods, and ultra-processed foods [88 Monteiro CA, Cannon G, Levy R, Mourabac JC, Jaime P, Martins AP, et al. NOVA the star shines bright. World Nutr. 2016;7(1-3):28-38.]. Body composition was identified by dual-energy X-ray absorptiometry (DPX-IQ 5781, Lunar Radiation, Madison, WI, USA). Measurements were taken by an experienced technician, with individuals in the fasted state and in dorsal decubitus. Body fat was estimated using Lohman’s equation [2828 Lohman TG. Advances in body composition assessment. Champaign: Human Kinetics Publishers; 1992.]. Excess adiposity was defined as total body fat ≥25% for men and ≥32% for women [2929 Bonikowske AR, Barillas Lara MI, Koepp KE, Inojosa JRM, Squires RW, Lopez-Jimenez F, et al. Fat mass index better identifies metabolic syndrome: insights from patients in early outpatient cardiac rehabilitation. J Clin Med. 2019;8(12):2147. https://doi.org/10.3390/jcm8122147
https://doi.org/10.3390/jcm8122147...
].

Body weight was measured to the nearest 0.1kg using a digital scale (BC-554 Ironman®, Tanita, Tokyo, Japan), and height was measured to the nearest 0.1cm using a stadiometer (Welmy, Santa Bárbara do Oeste, SP, Brazil). The Body Mass Index (BMI) was calculated by dividing the weight (kg) by the height squared (m2) and analyzed according to World Health Organization criteria (normal weight, BMI=18.5-24.9; overweight, BMI≥25.0) [3030 World Health Organization. Obesity and overweight. Geneva: Organization; 2018 [cited 2020 Jun 3]. Available from: http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
http://www.who.int/news-room/fact-sheets...
].

The following socio-demographic variables were analyzed: sex (female and male), age (20-29, 30-39, 40-49, and 50-59 years), and level of education (0-3, 4-7, and ≥8 years). Behavioral variables included self-reported smoking status (non-smoker, current smoker, or ex-smoker), level of physical activity, and screen time [3131 Stelmach R, Fernandes FLA, Carvalho-Pinto RM, Athanazio RA, Rached SZ, Prado GF, et al. Comparison between objective measures of smoking and self-reported smoking status in patients with asthma or COPD: are our patients telling us the truth? J Bras Pneumol. 2015;41(2):124-32. https://doi.org/10.1590/S1806-37132015000004526
https://doi.org/10.1590/S1806-3713201500...
]. Physical activity level was assessed using the long version of the last 7-day recall International Physical Activity Questionnaire (IPAQ), validated for the Brazilian population [3232 Pardini R, Matsudo S, Araújo T, Matsudo V, Andrade E, Braggion G, et al. Validação do Questionário Internacional de Nível de Atividade Física (IPAQ-Versão 6): estudo piloto em adultos jovens brasileiros. Rev Bras Ciênc Mov. 2001;9:45-51.]. Screen time was defined as the time spent watching television or using a computer for entertainment on weekdays and weekends. Spending 5 hours or more a day on screen-based recreational activities was considered excessive [3333 Vasconcellos MB, Anjos LA, Vasconcellos MTL. Estado nutricional e tempo de tela de escolares do ensino fundamental do município de Niterói, RJ. Cad Saúde Pública. 2013;4(29):713-22. https://doi.org/10.1590/S0102-311X2013000400009
https://doi.org/10.1590/S0102-311X201300...
].

Data were weighted to the sex, age, and education distribution of the population of Viçosa (MG) using the svy command in STATA version 13.1 [3434 Stata Statistical Software: Release 13.1. College Station: Stata Corp LLC; 2013.]. Descriptive statistical analyzes were performed to summarize socio-demographic and behavioral data, and results are presented as relative frequencies. The contribution percentage of each food group to the daily energy intake was calculated, and results are expressed as mean±standard deviation. Associations between quartiles of energy contribution percentage, overweight, and body adiposity were analyzed by Poisson regression. The prevalence ratio and confidence intervals (95%CI) were determined. All variables that met the selection criterion (p<0.20) were included in the model using backward selection (sex, age, education, and screen time). Additionally, the χ2 test for trends was used to assess linear trends in quartiles of food consumption (p<0.05).

RESULTS

Of the 670 participants, 50.1% were men, 26.3% were 30-39 years old, and 69.6% had at least 8 years of formal education. Most individuals were non-smokers (64.9%), physically inactive (75.6%), and did not have excessive screen time (91.1%). Overweight was observed in 44.4% of subjects and excess adiposity in 58.0% (Table 1).

Table 1
Demographic, socioeconomic, behavioral, and food consumption characteristics of the study population. Study on Health and Dietary Habits, Viçosa (MG), Brazil, 2012-2014.

The mean daily energy intake of the study population was 10383.26±4793.89 Joules/day, 57.90% (6041.5 Joules/day) of which was provided by unprocessed or minimally processed foods, 3.40% (314.0 Joules/day) by processed culinary ingredients, 14.0% (1482.1 Joules/day) by processed foods, and 24.60% (2382.2 Joules/day) by ultra-processed foods (Table 2). The most relevant frequently reported unprocessed and minimally processed foods were meat, fish, eggs, rice, beans, and milk. The most frequently reported processed foods were wheat cake (6.64%), followed by alcoholic beverages, cheese, processed meats, and canned fruits and vegetables. Among ultra-processed foods, the most frequently reported were breads and sweet/salty biscuits (8.50%), finger foods and fast foods (4.10%), candies (3.30%), and sausages (2.50%).

Table 2
Distribution of total daily energy intake according to food groups and subgroups and contribution percentage considering overweight and excessive body adiposity in adults. Study on Health and Dietary Habits, Viçosa (MG), Brazil, 2012-2014.

Overweight adults had a mean daily energy intake of 9960.40±259.58 Joules/day; 56.6% of the energy intake came from unprocessed or minimally processed foods, 3.7% from processed culinary ingredients, 15.1% from processed foods, and 24.4% from ultra-processed foods. Adults with excess adiposity had a mean daily energy intake of 99,353.31±272.14 Joules/day, 56.2% of which was provided by unprocessed or minimally processed foods, 3.1% by processed culinary ingredients, 17.7% by processed foods, and 23.0% by ultra-processed foods.

Regression analysis revealed a relationship between overweight and the contribution percentage (in quartiles) of unprocessed or minimally processed foods to daily energy intake. The intake of unprocessed or minimally processed foods was a protective factor for overweight. On the other hand, the percentage contribution (in quartiles) of ultra-processed foods was considered a risk factor for overweight and excess adiposity. The prevalence ratio of overweight increased with increasing percentage contribution of ultra-processed foods (Table 3).

Table 3
Relationship between overweight and excessive body adiposity in adults and the contribution percentage of food groups and subgroups. Study on Health and Dietary Habits, Viçosa (MG), Brazil, 2012-2014.

A significant linear trend (ptrend<0.02) was observed for percentage contribution of ultra-processed foods and overweight and excess body fat.

DISCUSSION

Our results show that the intake of unprocessed or minimally processed foods is a protective factor for overweight and excess adiposity, whereas intake of ultra-processed foods is a risk factor for both conditions. These data are in agreement with previous studies showing that there is an association between ultra-processed food consumption and obesity [33 Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang VW. Ultra-processed food consumption and excess weight among US adults. Br J Nutr. 2018;120(1):90-100. https://doi.org/10.1017/S0007114518001046-44 Mendonça RD, Pimenta AM, Gea A, Fuente-Arrillaga C, Martinez-Gonzalez MA, Lopes ACS, et al. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr. 2016;104(5):1433-40. https://doi.org/10.3945/ajcn.116.135004,1919 Silva FM, Giatti L, Figueiredo RC, Molina MDCB, Cardoso LO, Duncan BB, et al. Consumption of ultra-processed food and obesity: cross sectional results from the Brazilian longitudinal study of adult health (ELSA-Brasil) cohort (2008-2010). Public Health Nutr. 2018;21(12):2271-9.https://doi.org/10.1017/S1368980018000861
https://doi.org/10.1017/S136898001800086...
-2020 Louzada MLC, Baraldi LG, Steele EM, Martins APB, Canella DS, Mourabac JC, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15. https://doi.org/10.1016/j.ypmed.2015.07.018
https://doi.org/10.1016/j.ypmed.2015.07....
]. The results also show that the consumption of minimally processed foods is inversely related to overweight [2323 Melo ISV, Costa CACB, Santos JVLD, Santos AFD, Florêncio TMMT, Bueno NB. Consumption of minimally processed food is inversely associated with excess weight in adolescents living in an underdeveloped city. Plos One. 2017;12(11):e0188401. https://doi.org/10.1371/journal.pone.0188401
https://doi.org/10.1371/journal.pone.018...
,3535 Sartorelli DS, Crivellenti LC, Zuccolotto DCC, Franco LJ. Relationship between minimally and ultra-processed food intake during pregnancy with obesity and gestational diabetes mellitus. Cad Saúde Pública. 2019;35(4):e00049318. https://doi.org/10.1590/0102-311x00049318
https://doi.org/10.1590/0102-311x0004931...
]. The choice of foods, particularly with regard to their degree of processing, has an important influence on weight gain.

In modern society, ultra-processed foods have become widely available and are easy to purchase, which contributes to their high consumption. Their poor nutritional quality, high levels of sugars and fats, high palatability, large-sized portions (which affect eating behavior and self-control), and convenience may be associated with the increase in body weight among consumers [44 Mendonça RD, Pimenta AM, Gea A, Fuente-Arrillaga C, Martinez-Gonzalez MA, Lopes ACS, et al. Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr. 2016;104(5):1433-40. https://doi.org/10.3945/ajcn.116.135004,66 Canella DS, Levy RB, Martins AP, Claro RM, Mourabac JC, Baraldi LG, et al. Ultra-processed food products and obesity in Brazilian households (2008-2009). Plos One. 2014;9(3):e92752. https://doi.org/10.1371/journal.pone.0092752
https://doi.org/10.1371/journal.pone.009...
,1111 Moubarac JC, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-processed foods predicts diet quality in Canada. Appetite. 2016;108:512-20. https://doi.org/10.1016/j.appet.2016.11.006
https://doi.org/10.1016/j.appet.2016.11....
,1414 Steele EM, Monteiro CA. Association between dietary share of ultra-processed foods and urinary concentrations of phytoestrogens in the US. Nutrients. 2017;9(3):E209. https://doi.org/10.3390/nu9030209
https://doi.org/10.3390/nu9030209...
]. However, the mechanisms that show the real interaction between the high consumption of ultra-processed products and diseases are still emerging [3636 Elizabeth L, Machado P, Zinöcker M, Baker P, Lawrence M. Ultra-processed foods and health outcomes: a narrative review. Nutrients. 2020;12(7):1955. https://doi.org/10.3390/nu12071955
https://doi.org/10.3390/nu12071955...
].

A survey carried out in Latin America by the Pan American Health Organization between 2000 and 2013 showed a positive association between ultra-processed food sales and obesity in adults [3737 Pan American Health Organization. Ultra-processed food and drink products in Latin America: trends, impact on obesity, policy implications. Washington: Organization; 2015 [cited 2020 Apr 5] Available from: https://iris.paho.org/bitstream/handle/10665.2/7699/9789275118641_eng.pdf?sequence=5&isAllowed=y&ua=1
https://iris.paho.org/bitstream/handle/1...
]. Canella et al. [66 Canella DS, Levy RB, Martins AP, Claro RM, Mourabac JC, Baraldi LG, et al. Ultra-processed food products and obesity in Brazilian households (2008-2009). Plos One. 2014;9(3):e92752. https://doi.org/10.1371/journal.pone.0092752
https://doi.org/10.1371/journal.pone.009...
] analyzed food purchase data from the 2008-2009 Brazilian Consumer Expenditure Survey and identified a relationship between the purchase of high-energy, ultra-processed foods and overweight and obesity. Martins et al. [1818 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987-2009). Rev Saúde Pública. 2013;47(4):656-65. https://doi.org/10.1590/S0034-8910.2013047004968
https://doi.org/10.1590/S0034-8910.20130...
], in a literature review, reported that the increase in ultra-processed food sales from 2000 to 2009 was closely associated with the increase in BMI in adults during the same period. These results indicate that the intake of highly processed foods may be related to an increase in obesity prevalence. Another important issue that must be emphasized is the high prevalence of physical inactivity evidenced in the Brazilian population, which is also associated with the increased consumption of snacks, sweetened drinks and fast food, the latter, strong predictors for obesity [3838 Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 19 million participants. Lancet Glob Health. 2018;6(10):e1077-86. https://doi.org/10.1016/S2214-109X(18)30357-7. Erratum in: Lancet Glob Health. 2019;7(1):e36.
https://doi.org/10.1016/S2214-109X(18)30...

39 Costa CS, Flores TR, Wendt A, Neves RG, Assunção MCF, Santos IS. Comportamento sedentário e consumo de alimentos ultraprocessados entre adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar (PeNSE), 2015. Cad Saúde Pública. 2018;34(3):e00021017. https://doi.org/10.1590/0102-311x00021017
https://doi.org/10.1590/0102-311x0002101...
-4040 Zhao Y, Wang L, Xue H, Wang H, Wang Y. Fast food consumption and its associations with obesity and hypertension among children: results from the baseline data of the Childhood Obesity Study in China Mega-cities. Bmc Public Health. 2017;17(1):933. https://doi.org/10.1186/s12889-017-4952-x
https://doi.org/10.1186/s12889-017-4952-...
].

Research carried out in the United Kingdom with data from the National Diet and Nutrition Survey Program identified a linear trend between high consumption of ultra-processed foods and obesity and excess abdominal adiposity [4141 Rauber F, Steele EM, Louzada MLDC, Millett C, Monteiro CA, Levy RB. Ultra-processed food consumption and indicators of obesity in the United Kingdom population (2008-2016). Plos One. 2020;15(5):e0232676. https://doi.org/10.1371/journal.pone.0232676
https://doi.org/10.1371/journal.pone.023...
]. Hall et al. [4242 Hall KD, Ayuketah A, Brychta R, Cai H, Cassimatis T, Chen KY, et al. Ultra-processed diets cause excess calorie intake and weight gain: na inpatient randomized controlled trial of ad libitum food intake. Cell Metabol. 2019;30(1):67-77. https://doi.org/10.1016/j.cmet.2019.05.008PMID:31105044
https://doi.org/10.1016/j.cmet.2019.05.0...
] compared healthy diets to diets rich in ultra-processed foods and found that the latter promote weight gain and reduce satiety. The mechanisms underlying the relationship between high consumption of ultra-processed foods and obesity remain unclear. It is known that, because of their high energy density, sodium, saturated fat, and sugar contents, ultra-processed foods promote weight gain when consumed in large quantities [4343 Monteiro C, Levy R, Claro R, Castro I, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saúde Pública. 2010;26(11):2039-49.]. Food additives, such as flavorings, colorings, emulsifiers, sweeteners, and thickeners, commonly found in ultra-processed foods, may also contribute to weight gain [2121 Canhada SL, Luft VC, Giatti L, Duncan BB, Chor D, Fonseca MJMD, et al. Ultra-processed foods, incident overweight and obesity, and longitudinal changes in weight and waist circumference: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Public Health Nutr. 2019;17:1-11.https://doi.org/10.1017/S1368980019002854PMID:31619309
https://doi.org/10.1017/S136898001900285...
,4444 Monteiro CA, Cannon G, Levy RB, Moubarac JC, Louzada ML, Rauber F, et al. Ultra-processed foods: what they are and how to identify them. Public Health Nutr. 2019;22(5):936-41. https://doi.org/10.1017/S1368980018003762
https://doi.org/10.1017/S136898001800376...
].

The high contribution of unprocessed or minimally processed foods to daily energy intake observed in the current study is in agreement with literature data [1212 Louzada MLC, Ricardo CZ, Steele EM, Levy RB, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutr. 2017;21(1):94-102. https://doi.org/10.1017/S1368980017001434
https://doi.org/10.1017/S136898001700143...
,2020 Louzada MLC, Baraldi LG, Steele EM, Martins APB, Canella DS, Mourabac JC, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15. https://doi.org/10.1016/j.ypmed.2015.07.018
https://doi.org/10.1016/j.ypmed.2015.07....
,4545 Batalha MA, França AKTC, Conceição SIO, Santos AM, Silva FS, Padilha LL, et al. Processed and ultra-processed food consumption among children aged 13 to 35 months and associated factors. Cad Saúde Pública. 2017;33(11):e00152016. https://doi.org/10.1590/0102-311x00152016
https://doi.org/10.1590/0102-311x0015201...
,4646 Gonçalves VS, Duarte EC, Dutra ES, Barufaldi LA, Carvalho KM. Characteristics of the school food environment associated with hypertension and obesity in Brazilian adolescents: a multilevel analysis of the study of cardiovascular risks in adolescents (ERICA). Public Health Nutr. 2019;22(14):2625-34. https://doi.org/10.1017/S1368980019001010
https://doi.org/10.1017/S136898001900101...
]. Recent data from the Family Budget Survey carried out in Brazil also identified an important percentage calorie contribution, referring to the consumption of minimally processed foods [4747 Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: Instituto; 2020.]. Bielemann et al. [4848 Bielemann RM, Motta JVS, Minten GC, Horta BL, Gigante DP. Consumo de alimentos ultraprocessados e impacto na dieta de adultos jovens. Rev Saúde Pública. 2015;49:28. https://doi.org/10.1590/S0034-8910.2015049005572
https://doi.org/10.1590/S0034-8910.20150...
] and Libanio et al. [4949 Libanio IFF, Correa RS, Monteiro AS, Vallandro JP. Consumption of ultraprocessed foods in children attended by the basic attention service in the South region of Brazil. Int J Nutrology. 2019;12(1):35-40. https://doi.org/10.1055/s-0039-1693673
https://doi.org/10.1055/s-0039-1693673...
], however, found that ultra-processed foods were the major contributors to the energy intake of Brazilian individuals. Unprocessed or minimally processed foods are important sources of fiber, macronutrients, and micronutrients and, therefore, are an important part of a healthy diet.

Unprocessed or minimally processed foods were considered protective factors for obesity because of their low energy density, low sugar, total, saturated, and trans-fat contents, and high levels of protein and fiber [1717 Nakano S, Washizu A. Aiming for better use of convenience food: an analysis based on meal production functions at home. J Health Popul Nutr. 2020;39(3). https://doi.org/10.1186/s41043-020-0211-3
https://doi.org/10.1186/s41043-020-0211-...
]. In a clinical trial with Brazilian pregnant women, high consumption of minimally processed foods reduced the occurrence of obesity by 51% [3535 Sartorelli DS, Crivellenti LC, Zuccolotto DCC, Franco LJ. Relationship between minimally and ultra-processed food intake during pregnancy with obesity and gestational diabetes mellitus. Cad Saúde Pública. 2019;35(4):e00049318. https://doi.org/10.1590/0102-311x00049318
https://doi.org/10.1590/0102-311x0004931...
].

The daily energy intake of the study population was higher than that reported in other studies in Brazil [66 Canella DS, Levy RB, Martins AP, Claro RM, Mourabac JC, Baraldi LG, et al. Ultra-processed food products and obesity in Brazilian households (2008-2009). Plos One. 2014;9(3):e92752. https://doi.org/10.1371/journal.pone.0092752
https://doi.org/10.1371/journal.pone.009...
,1212 Louzada MLC, Ricardo CZ, Steele EM, Levy RB, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutr. 2017;21(1):94-102. https://doi.org/10.1017/S1368980017001434
https://doi.org/10.1017/S136898001700143...
,1818 Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987-2009). Rev Saúde Pública. 2013;47(4):656-65. https://doi.org/10.1590/S0034-8910.2013047004968
https://doi.org/10.1590/S0034-8910.20130...
,2020 Louzada MLC, Baraldi LG, Steele EM, Martins APB, Canella DS, Mourabac JC, et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15. https://doi.org/10.1016/j.ypmed.2015.07.018
https://doi.org/10.1016/j.ypmed.2015.07....
]. High energy intake can lead to excessive weight gain, which may have contributed to the strong association between intake of ultra-processed foods and overweight.

A strong point of this study was the methodological precision of data collection. Information bias and application of a single 24-hour food recall may be considered limitations. It is possible that the amount of food intake was under- or overestimated. Nevertheless, several studies used a single 24-hour recall to evaluate nutrient intake [5050 Marrón-Ponce JA, Flores M, Cediel G, Monteiro CA, Batis C. Associations between consumption of ultra-processed foods and intake of nutrients related to chronic non-communicable diseases in Mexico. J Acad Nutr Diet. 2019;119(11):1852-65. https://doi.org/10.1016/j.jand.2019.04.020
https://doi.org/10.1016/j.jand.2019.04.0...
,5151 Parra DC, Costa-Louzada ML, Moubarac JC, Levy RB, Khandpur N, Cediel G, et al. Association between ultra-processed food consumption and the nutrient profile of the Colombian diet in 2005. Salud Publica Mex. 2019;61(12):147-54. https://doi.org/10.21149/9038
https://doi.org/10.21149/9038...
]. Because of the cross-sectional nature of the current study, it is not possible to establish the temporality of associations, and the possibility of reverse causality cannot be excluded.

CONCLUSION

High consumption of ultra-processed foods is associated with overweight and excess adiposity, whereas intake of unprocessed or minimally processed foods is a protective factor for overweight. Nutrition education interventions aimed at overweight and obese adults should focus on the importance of reducing consumption of ultra-processed foods and increasing that of unprocessed and minimally processed foods.

How to cite this article

  • Silva DCG, Ferreira FG, Pereira DLM, Magalhães ELG, Longo GZ. Degree of food processing and its relationship with overweight and body adiposity in Brazilian adult. Rev Nutr. 2021;34:e200135. https://doi.org/10.1590/1678-9865202134e200135
  • Support: Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG, Foundations for Supporting Research in the states of Minas Gerais) (Process n. APQ-00296-12); Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq, National Council for Scientific and Technological Development) (Process n. 481418/2011-3); Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES, Coordination of Superior Level Staff Improvement).

REFERENCES

  • 1
    Bray GA, Kim KK, Wilding JPH, World Obesity Federation. Obesity: a chronic relapsing progressive disease process: a position statement of the World Obesity Federation. Obes Rev. 2017;18(7):715-23. https://doi.org/10.1111/obr.12551
  • 2
    Ng M, Fleming T, Robinson M, Blake TBA, Graetz NBS, Margono CBS, et al Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766-81. https://doi.org/10.1016/S0140-6736(14)60460-8
  • 3
    Juul F, Martinez-Steele E, Parekh N, Monteiro CA, Chang VW. Ultra-processed food consumption and excess weight among US adults. Br J Nutr. 2018;120(1):90-100. https://doi.org/10.1017/S0007114518001046
  • 4
    Mendonça RD, Pimenta AM, Gea A, Fuente-Arrillaga C, Martinez-Gonzalez MA, Lopes ACS, et al Ultraprocessed food consumption and risk of overweight and obesity: the University of Navarra Follow-Up (SUN) cohort study. Am J Clin Nutr. 2016;104(5):1433-40. https://doi.org/10.3945/ajcn.116.135004
  • 5
    Passos CM, Maia EG, Levy RB, Martins APB, Claro RM. Association between the price of ultra-processed foods and obesity in Brazil. Nutr Metab Cardiovas. 2020;30(4):589-98. https://doi.org/10.1016/j.numecd.2019.12.011
    » https://doi.org/10.1016/j.numecd.2019.12.011
  • 6
    Canella DS, Levy RB, Martins AP, Claro RM, Mourabac JC, Baraldi LG, et al Ultra-processed food products and obesity in Brazilian households (2008-2009). Plos One. 2014;9(3):e92752. https://doi.org/10.1371/journal.pone.0092752
    » https://doi.org/10.1371/journal.pone.0092752
  • 7
    Monteiro CA. Nutrition and health: the issue is not food, nor nutrients, so much as processing. Public Health Nutr. 2009;12(5):729-31. https://doi.org/10.1017/S1368980009005291
    » https://doi.org/10.1017/S1368980009005291
  • 8
    Monteiro CA, Cannon G, Levy R, Mourabac JC, Jaime P, Martins AP, et al NOVA the star shines bright. World Nutr. 2016;7(1-3):28-38.
  • 9
    Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzada MRC, Jaime PC. The UN decade of nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutr. 2017;21(1):5-17. https://doi.org/10.1017/S1368980017000234
    » https://doi.org/10.1017/S1368980017000234
  • 10
    Nazmi A, Tseng M, Robinson D, Neill D, Walker J. A Nutrition education intervention using NOVA is more effective than my plate alone: a proof-of-concept randomized controlled trial. Nutrients. 2019;11(12):2965. https://doi.org/10.3390/nu11122965
    » https://doi.org/10.3390/nu11122965
  • 11
    Moubarac JC, Batal M, Louzada ML, Martinez Steele E, Monteiro CA. Consumption of ultra-processed foods predicts diet quality in Canada. Appetite. 2016;108:512-20. https://doi.org/10.1016/j.appet.2016.11.006
    » https://doi.org/10.1016/j.appet.2016.11.006
  • 12
    Louzada MLC, Ricardo CZ, Steele EM, Levy RB, Cannon G, Monteiro CA. The share of ultra-processed foods determines the overall nutritional quality of diets in Brazil. Public Health Nutr. 2017;21(1):94-102. https://doi.org/10.1017/S1368980017001434
    » https://doi.org/10.1017/S1368980017001434
  • 13
    Steele EM, Popkin BM, Swinburn B, Monteiro CA. The share of ultra-processed foods and the overall nutritional quality of diets in the US: evidence from a nationally representative cross-sectional study. Popul Health Metr. 2017;15(1):6. https://doi.org/10.1186/s12963-017-0119-3
    » https://doi.org/10.1186/s12963-017-0119-3
  • 14
    Steele EM, Monteiro CA. Association between dietary share of ultra-processed foods and urinary concentrations of phytoestrogens in the US. Nutrients. 2017;9(3):E209. https://doi.org/10.3390/nu9030209
    » https://doi.org/10.3390/nu9030209
  • 15
    Longo-Silva G, Menezes RCE, Souza CAN, Marinho PM, Toloni MHA, Oliveira MAA. Factors associated with regular consumption of obesogenic foods: national school-based student health Hurvey, 2012. Rev Nutr. 2016;29(5):609-33. https://doi.org/10.1590/1678-98652016000500001
    » https://doi.org/10.1590/1678-98652016000500001
  • 16
    Machado PP, Steele EM, Levy RB, Sui Z, Rangan A, Woods J, et al Ultra-processed foods and recommended intake levels of nutrients linked to non-communicable diseases in Australia: evidence from a nationally representative cross-sectional study. Br Med J Open. 2019;9(8):e029544. https://doi.org/10.1136/bmjopen-2019-029544
    » https://doi.org/10.1136/bmjopen-2019-029544
  • 17
    Nakano S, Washizu A. Aiming for better use of convenience food: an analysis based on meal production functions at home. J Health Popul Nutr. 2020;39(3). https://doi.org/10.1186/s41043-020-0211-3
    » https://doi.org/10.1186/s41043-020-0211-3
  • 18
    Martins APB, Levy RB, Claro RM, Moubarac JC, Monteiro CA. Increased contribution of ultra-processed food products in the Brazilian diet (1987-2009). Rev Saúde Pública. 2013;47(4):656-65. https://doi.org/10.1590/S0034-8910.2013047004968
    » https://doi.org/10.1590/S0034-8910.2013047004968
  • 19
    Silva FM, Giatti L, Figueiredo RC, Molina MDCB, Cardoso LO, Duncan BB, et al Consumption of ultra-processed food and obesity: cross sectional results from the Brazilian longitudinal study of adult health (ELSA-Brasil) cohort (2008-2010). Public Health Nutr. 2018;21(12):2271-9.https://doi.org/10.1017/S1368980018000861
    » https://doi.org/10.1017/S1368980018000861
  • 20
    Louzada MLC, Baraldi LG, Steele EM, Martins APB, Canella DS, Mourabac JC, et al Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15. https://doi.org/10.1016/j.ypmed.2015.07.018
    » https://doi.org/10.1016/j.ypmed.2015.07.018
  • 21
    Canhada SL, Luft VC, Giatti L, Duncan BB, Chor D, Fonseca MJMD, et al Ultra-processed foods, incident overweight and obesity, and longitudinal changes in weight and waist circumference: the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Public Health Nutr. 2019;17:1-11.https://doi.org/10.1017/S1368980019002854PMID:31619309
    » https://doi.org/10.1017/S1368980019002854PMID:31619309
  • 22
    Cunha DB, Costa THM, Veiga GV, Pereira RA, Sichieri R. Ultra-processed food consumption and adiposity trajectories in a Brazilian cohort of adolescents: ELANA study. Nutr Diabetes. 2018;8:28.
  • 23
    Melo ISV, Costa CACB, Santos JVLD, Santos AFD, Florêncio TMMT, Bueno NB. Consumption of minimally processed food is inversely associated with excess weight in adolescents living in an underdeveloped city. Plos One. 2017;12(11):e0188401. https://doi.org/10.1371/journal.pone.0188401
    » https://doi.org/10.1371/journal.pone.0188401
  • 24
    Segheto W, Silva DCG, Coelho FA, Reis GV, Morais SHO, Marins JCB, et al Body adiposity index and associated factors in adults: method and logistics of a population-based study. Nutr Hosp. 2015;32(1):101-9. https://doi.org/10.3305/nh.2015.32.1.8391
    » https://doi.org/10.3305/nh.2015.32.1.8391
  • 25
    Ahluwalia N, Dwyer J, Terry A, Moshfegh A, Johnson C. Update on NHANES Dietary Data: focus on collection, release, analytical considerations, and uses to inform public policy. Adv Nutr. 2016;7(1):121-34. https://doi.org/10.3945/an.115.009258
    » https://doi.org/10.3945/an.115.009258
  • 26
    Lopes RPS, Botelho RBA. Álbum fotográfico de porções alimentares. São Paulo: Editora Metha; 2008.
  • 27
    Barufaldi LA, Abreu GA, Veiga GV, Sichieri R, Kuschnir MCCC, Cunha DB, et al Programa para registro de recordatório alimentar de 24 horas: aplicação no Estudo de Riscos Cardiovasculares em Adolescentes. Rev Bras Epidemiol. 2016;19(2):464-8. https://doi.org/10.1590/1980-5497201600020020
    » https://doi.org/10.1590/1980-5497201600020020
  • 28
    Lohman TG. Advances in body composition assessment. Champaign: Human Kinetics Publishers; 1992.
  • 29
    Bonikowske AR, Barillas Lara MI, Koepp KE, Inojosa JRM, Squires RW, Lopez-Jimenez F, et al Fat mass index better identifies metabolic syndrome: insights from patients in early outpatient cardiac rehabilitation. J Clin Med. 2019;8(12):2147. https://doi.org/10.3390/jcm8122147
    » https://doi.org/10.3390/jcm8122147
  • 30
    World Health Organization. Obesity and overweight. Geneva: Organization; 2018 [cited 2020 Jun 3]. Available from: http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
    » http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
  • 31
    Stelmach R, Fernandes FLA, Carvalho-Pinto RM, Athanazio RA, Rached SZ, Prado GF, et al Comparison between objective measures of smoking and self-reported smoking status in patients with asthma or COPD: are our patients telling us the truth? J Bras Pneumol. 2015;41(2):124-32. https://doi.org/10.1590/S1806-37132015000004526
    » https://doi.org/10.1590/S1806-37132015000004526
  • 32
    Pardini R, Matsudo S, Araújo T, Matsudo V, Andrade E, Braggion G, et al Validação do Questionário Internacional de Nível de Atividade Física (IPAQ-Versão 6): estudo piloto em adultos jovens brasileiros. Rev Bras Ciênc Mov. 2001;9:45-51.
  • 33
    Vasconcellos MB, Anjos LA, Vasconcellos MTL. Estado nutricional e tempo de tela de escolares do ensino fundamental do município de Niterói, RJ. Cad Saúde Pública. 2013;4(29):713-22. https://doi.org/10.1590/S0102-311X2013000400009
    » https://doi.org/10.1590/S0102-311X2013000400009
  • 34
    Stata Statistical Software: Release 13.1. College Station: Stata Corp LLC; 2013.
  • 35
    Sartorelli DS, Crivellenti LC, Zuccolotto DCC, Franco LJ. Relationship between minimally and ultra-processed food intake during pregnancy with obesity and gestational diabetes mellitus. Cad Saúde Pública. 2019;35(4):e00049318. https://doi.org/10.1590/0102-311x00049318
    » https://doi.org/10.1590/0102-311x00049318
  • 36
    Elizabeth L, Machado P, Zinöcker M, Baker P, Lawrence M. Ultra-processed foods and health outcomes: a narrative review. Nutrients. 2020;12(7):1955. https://doi.org/10.3390/nu12071955
    » https://doi.org/10.3390/nu12071955
  • 37
    Pan American Health Organization. Ultra-processed food and drink products in Latin America: trends, impact on obesity, policy implications. Washington: Organization; 2015 [cited 2020 Apr 5] Available from: https://iris.paho.org/bitstream/handle/10665.2/7699/9789275118641_eng.pdf?sequence=5&isAllowed=y&ua=1
    » https://iris.paho.org/bitstream/handle/10665.2/7699/9789275118641_eng.pdf?sequence=5&isAllowed=y&ua=1
  • 38
    Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 19 million participants. Lancet Glob Health. 2018;6(10):e1077-86. https://doi.org/10.1016/S2214-109X(18)30357-7. Erratum in: Lancet Glob Health. 2019;7(1):e36.
    » https://doi.org/10.1016/S2214-109X(18)30357-7
  • 39
    Costa CS, Flores TR, Wendt A, Neves RG, Assunção MCF, Santos IS. Comportamento sedentário e consumo de alimentos ultraprocessados entre adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar (PeNSE), 2015. Cad Saúde Pública. 2018;34(3):e00021017. https://doi.org/10.1590/0102-311x00021017
    » https://doi.org/10.1590/0102-311x00021017
  • 40
    Zhao Y, Wang L, Xue H, Wang H, Wang Y. Fast food consumption and its associations with obesity and hypertension among children: results from the baseline data of the Childhood Obesity Study in China Mega-cities. Bmc Public Health. 2017;17(1):933. https://doi.org/10.1186/s12889-017-4952-x
    » https://doi.org/10.1186/s12889-017-4952-x
  • 41
    Rauber F, Steele EM, Louzada MLDC, Millett C, Monteiro CA, Levy RB. Ultra-processed food consumption and indicators of obesity in the United Kingdom population (2008-2016). Plos One. 2020;15(5):e0232676. https://doi.org/10.1371/journal.pone.0232676
    » https://doi.org/10.1371/journal.pone.0232676
  • 42
    Hall KD, Ayuketah A, Brychta R, Cai H, Cassimatis T, Chen KY, et al Ultra-processed diets cause excess calorie intake and weight gain: na inpatient randomized controlled trial of ad libitum food intake. Cell Metabol. 2019;30(1):67-77. https://doi.org/10.1016/j.cmet.2019.05.008PMID:31105044
    » https://doi.org/10.1016/j.cmet.2019.05.008PMID:31105044
  • 43
    Monteiro C, Levy R, Claro R, Castro I, Cannon G. A new classification of foods based on the extent and purpose of their processing. Cad Saúde Pública. 2010;26(11):2039-49.
  • 44
    Monteiro CA, Cannon G, Levy RB, Moubarac JC, Louzada ML, Rauber F, et al Ultra-processed foods: what they are and how to identify them. Public Health Nutr. 2019;22(5):936-41. https://doi.org/10.1017/S1368980018003762
    » https://doi.org/10.1017/S1368980018003762
  • 45
    Batalha MA, França AKTC, Conceição SIO, Santos AM, Silva FS, Padilha LL, et al Processed and ultra-processed food consumption among children aged 13 to 35 months and associated factors. Cad Saúde Pública. 2017;33(11):e00152016. https://doi.org/10.1590/0102-311x00152016
    » https://doi.org/10.1590/0102-311x00152016
  • 46
    Gonçalves VS, Duarte EC, Dutra ES, Barufaldi LA, Carvalho KM. Characteristics of the school food environment associated with hypertension and obesity in Brazilian adolescents: a multilevel analysis of the study of cardiovascular risks in adolescents (ERICA). Public Health Nutr. 2019;22(14):2625-34. https://doi.org/10.1017/S1368980019001010
    » https://doi.org/10.1017/S1368980019001010
  • 47
    Instituto Brasileiro de Geografia e Estatística. Pesquisa de orçamentos familiares 2017-2018: análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: Instituto; 2020.
  • 48
    Bielemann RM, Motta JVS, Minten GC, Horta BL, Gigante DP. Consumo de alimentos ultraprocessados e impacto na dieta de adultos jovens. Rev Saúde Pública. 2015;49:28. https://doi.org/10.1590/S0034-8910.2015049005572
    » https://doi.org/10.1590/S0034-8910.2015049005572
  • 49
    Libanio IFF, Correa RS, Monteiro AS, Vallandro JP. Consumption of ultraprocessed foods in children attended by the basic attention service in the South region of Brazil. Int J Nutrology. 2019;12(1):35-40. https://doi.org/10.1055/s-0039-1693673
    » https://doi.org/10.1055/s-0039-1693673
  • 50
    Marrón-Ponce JA, Flores M, Cediel G, Monteiro CA, Batis C. Associations between consumption of ultra-processed foods and intake of nutrients related to chronic non-communicable diseases in Mexico. J Acad Nutr Diet. 2019;119(11):1852-65. https://doi.org/10.1016/j.jand.2019.04.020
    » https://doi.org/10.1016/j.jand.2019.04.020
  • 51
    Parra DC, Costa-Louzada ML, Moubarac JC, Levy RB, Khandpur N, Cediel G, et al Association between ultra-processed food consumption and the nutrient profile of the Colombian diet in 2005. Salud Publica Mex. 2019;61(12):147-54. https://doi.org/10.21149/9038
    » https://doi.org/10.21149/9038

Publication Dates

  • Publication in this collection
    08 Feb 2021
  • Date of issue
    2021

History

  • Received
    06 June 2020
  • Reviewed
    30 Oct 2020
  • Accepted
    06 Nov 2020
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