Acessibilidade / Reportar erro

Ultra-processed food consumption and children and adolescents’ health

Abstract

Objectives

To present observational studies investigating associations between the consumption of ultra-processed foods and health outcomes in childhood and adolescence.

Data source

Observational, cross-sectional, or longitudinal studies were considered, and identified in the Scopus, Web of Science, Pubmed and Scielo databases, without date restrictions.

Data synthesis

The most frequent combinations of risk factors in children and adolescents involved an unhealthy diet, with regular consumption of ultra-processed foods to the detriment of a diet based on fresh or minimally-processed foods and insufficient levels of physical activity; records on alcohol and tobacco use were identified. Combined, these practices contribute to the findings that indicate an increase in the prevalence of obesity in children and adolescents and a sedentary lifestyle, with a decrease in physical activity, in addition to representing a risk for the development of chronic non-communicable diseases, such as cardiovascular diseases and periodontal disease in childhood and adolescence.

Conclusions

The present study maps the current literature on the topic and indicates the direction of the approach for health promotion and prevention of NCDs in children and adolescents. Among the different risk factors that negatively affect the full development of this population, frequently eating breakfast and practicing physical activity is most strongly associated with a lower consumption of ultra-processed foods and should be part of an integrated approach to promoting eating practices that favor the reduction of diseases also in adult life.

Keywords
Ultraprocessed food; Chronic non-communicable diseases; Children; Adolescents

Introduction

According to the NOVA Classification, which groups foods according to their level of processing, ultra-processed (UP) foods represent formulations prepared by exclusively industrial processes, with fractions extracted or derived from foods, added with substances capable of simulating desired sensory characteristics. This processing aims to ensure that these products are attractive, both from a sensorial point of view - since aroma, color, texture and flavor are modified to achieve a pleasant result, and from an economic point of view, given that they require low production costs and have greater durability when compared to natural or minimally-processed foods and culinary ingredients.11 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Guia Alimentar para a População Brasileira. 2. ed., 1. reimpr. 2014.,22 Louzada M.L., Costa C.S., Souza T.N., Cruz G.L., Levy R.B., Monteiro C.A. Impact of the consumption of ultra-processed foods on children, adolescents and adults' health: scope review. Cad Saude Publica. 2021;37:Se00323020.

Studies on contemporary eating patterns indicate an increase in the consumption of ultra-processed foods with relevant participation of this group in the total amount of energy consumed daily; they also indicate the tendency towards the reduction or, in many cases, the replacement of traditional meals with these products.33 Matos R.A., Adams M., Sabaté J. Review: the Consumption of ultra-processed foods and non-communicable diseases in Latin America. Front Nutr. 2021;8:622714.,44 Lane M.M., Davis J.A., Beattie S., Gómez-Donoso C., Loughman A., et al. Ultraprocessed food and chronic noncommunicable diseases: a systematic review and meta-analysis of 43 observational studies. Obes Rev 2021;22:e13146. Since the 2010s, evidence has been growing about the relationship between the consumption of ultra-processed foods and the prevalence of harmful health outcomes, with emphasis on chronic Non-Communicable Diseases (NCDs).22 Louzada M.L., Costa C.S., Souza T.N., Cruz G.L., Levy R.B., Monteiro C.A. Impact of the consumption of ultra-processed foods on children, adolescents and adults' health: scope review. Cad Saude Publica. 2021;37:Se00323020.,55 Elizabeth L., Machado P., Zinöcker M., Baker P., Lawrence M. Ultra-processed foods and health outcomes: a narrative review. Nutrients. 2020;12:1955.

NCDs are described as long-term health conditions that have long-term effects and do not result from an infectious origin. According to the World Health Organization (WHO), NCDs are related to disabilities and are responsible for more than 70 % of all deaths globally and, of these, more than 85 % are considered premature when they occur before the age of 70.66 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1223-49.,77 WHO. Noncommunicable Diseases. 2018. [Cited 2020 Apr 1st]. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicablediseases
https://www.who.int/news-room/fact-sheet...
Among children aged 0 to 9 years, the three main risk factors for diseases or loss of capacity throughout life due to chronic diseases are related to a poor diet; for adolescents, the main risk factor for these diseases is also related to micronutrient deficiency.66 GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1223-49.

Food and nutrition have a recognized influence on the burden of risk and protective factors on the health of the population, and consequently on the pattern of morbidity and mortality due to chronic NCDs. Although research into the consumption of ultra-processed foods and their association with health outcomes among adults is well demonstrated, there are few studies on this topic with children and adolescents. This narrative review aims to present observational studies on the consumption of ultra-processed foods and the occurrence of chronic diseases in childhood and adolescence.

Method

Search strategy

The following combined descriptors comprised the search strategies, ((Noncommunicable chronic disease) AND ((Ultra-processed) OR (Processed) OR (Dietary pattern) OR (NOVA) OR (Food classification)) AND ((Children) OR (Adolescents)), which were adapted for each of the databases: Scopus, Web of Science, Pubmed and Scielo, without date restrictions.

Eligibility criteria

Observational, cross-sectional and longitudinal studies were considered, investigating the association between UP food consumption and the occurrence of chronic NCDs; in children and adolescents; written in English or Portuguese.

Analysis and selection of articles

The identified studies were distributed and classified in a standardized spreadsheet by the authors. Duplicates were identified and removed from the list. Initially, two reviewers read the titles and abstracts considering the previously mentioned inclusion criteria; articles that did not meet the criteria were discarded; those with insufficient information for the analysis based on the title and abstract were analyzed in full and kept in a spreadsheet if the inclusion criteria were met or discarded. After the initial selection, the same reviewers read the full texts to select the studies to be included in the review.

The spreadsheet created by the authors was also used to identify relevant information from the selected articles and allowed the recording of the following data: authors, article title, year of publication, keywords, subject(s), objective(s), method(s), result(s), conclusions and comments. The articles were further subdivided according to the design: cross-sectional, longitudinal, retrospective, prospective, cohort, case-control or ecological studies.

Results

Article characterization

Figure 1 illustrates the study selection process. A total of 302 studies were identified, of which 19 remained, based on the eligibility criteria; the studies included approximately 300,000 children or adolescents; and the sample size ranged from 40 to 173,310 participants.

Figure 1
Study selection flowchart.

The studies carried out in Brazil (n= 13), Iran (n= 2), and China, Nepal and Singapore (n= 1 in each country) were selected.

Table 1 describes the main characteristics of the observational studies included in this review. The main indicators and results were identified and all topics present in the studies were addressed in sequence: dietary patterns, overweight and obesity, cardiovascular diseases, physical activity and sedentary lifestyle, and oral health.

Table 1
Characteristics of studies on ultraprocessed food consumption and the occurrence of chronic diseases in childhood and adolescence.

Dietary patterns

Dietary patterns are among the recognized determinants of the health and disease profile of the population. For this reason, recent years have been characterized by studies that seek to look not only at isolated nutrients but mainly at foods, especially based on their classification according to the degree and purpose of industrial processing.88 Monteiro C.A., Cannon G., Moubarac J.C., Levy R.B., Louzada M.L., Jaime P.C. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Publ Health Nutr. 2018;21:5e17.

The consumption of ultra-processed foods has been identified as a risk factor for the increase in chronic NCDs in general among different age groups.99 Louzada M.L., Baraldi L.G., Steele E.M., Martins A.P., Canella D.S., Moubarac J.C., et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15.

This review included studies that share the objective of analyzing and discussing the effects of dietary patterns and the relationship with chronic NCDs in children and adolescents.99 Louzada M.L., Baraldi L.G., Steele E.M., Martins A.P., Canella D.S., Moubarac J.C., et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15.

10 Araujo D.A., de Carvalho R.B., de Oliveira A.S., Oliveira E.A., Machado A.L., Lima L.H. Temporal trend of simultaneous risk factors for chronic non-communicable diseases: national School Health Survey 2009, 2012, 2015. Rev Bras Epidemiol. 2022;25:e220013.

11 Zhao W., Su D., Mo L., Chen C., Ye B., Qin S., Liu J., Pang Y. Lifestyle clusters and cardiometabolic risks in adolescents: a Chinese school-based study using a latent class analysis approach. Front Pediatr. 2021;9:728841.

12 Bogea E.G., Martins M.L., do Carmo C.D., Nascimento J.X., Arruda S.P., Ribeiro C.C., et al. Factors associated with inflammatory biomarkers in adolescents: analysis by structural equation modeling. Cad Saude Publica. 2021;37:e00212220.

13 Ricardo C.Z., Azeredo C.M., Machado de Rezende L.F., Levy R.B. Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: analysis of a national school-based survey. PLoS One. 2019;14:e0219370.

14 Sena E.M., Muraro A.P., Rodrigues P.R., Fiuza R.F., Ferreira M.G. Risk behavior patterns for chronic diseases and associated factors among adolescents. Nutr Hosp. 2017;34:914-22.

15 Khashayar P., Kasaeian A., Heshmat R., Motlagh M.E., Mahdavi Gorabi A., Noroozi M., et al. Childhood overweight and obesity and associated factors in Iranian children and adolescents: a multilevel analysis; the CASPIAN-IV study. Front Pediatr. 2018;6:393.

16 Tandon K., Adhikari N., Adhikari B., Pradhan P.M. Co-occurrence of non-communicable disease risk factors and its determinants among school-going adolescents of Kathmandu Metropolitan City. PLoS One. 2022;17:e0272266.

17 Nicolau D.A., Castro A.G. Characterization of adolescents’ diet with the Dietary Guidelines for the Brazilian population. Mundo Saude 2018;42:98-122.

18 Souza P., Meira J.B., Fernandes B.G., Moreira L.L., Ferreira V.A., Guimaraes O.S., et al. Obesity and overweight in schools: the importance of diagnosis to subsidiate health promotion initiatives in school space. Braz J Obes Nutr Weight Loss. 2018;12:786-95.

19 Choy M.J., Brownlee I., Murphy A.M. Data-driven dietary patterns, nutrient intake and body weight status in a cross-section of Singaporean children aged 6-12 years. Nutrients. 2021;13:1335.

20 Kelishadi R., Heidari-Beni M., Esmaeil-Motlagh M., Pourmasoumi M., Malekshah A.F., Qorbani M. Association of nutrient patterns with anthropometric indices in children and adolescents: the weight disorders survey of the CASPIAN-IV study. Mediterranean J Nutr Metab. 2019;12: 223-34.

21 Cunha D.B., Costa T.H., Veiga G.V., Pereira R.A., Sichieri R. Ultra-processed food consumption and adiposity trajectories in a Brazilian cohort of adolescents: ELANA study. Nutr Diabetes. 2018;8:28.

22 D'Avila H.F., Kirsten V.R. Energy intake from ultra-processed foods among adolescents. Rev Paul Pediatr. 2017;35:54-60.

23 Sparrenberger K., Friedrich R.R., Schiffner M.D., Schuch I., Wagner M.B. Ultra-processed food consumption in children from a Basic Health Unit. J Pediatr. 2015;91:535-42

24 de Melo I.S., Costa C., dos Santos J.V., Santos A.F., Florencio T., Bueno N.B. Consumption of minimally processed food is inversely associated with excess weight in adolescents living in an underdeveloped city. PLoS One. 2017;12:e0188401.

25 Dantas C.D., Cavalcanti R.D. Consumption of ultra-processed foods and nutritional status of schoolchildren in the state of Pernambuco. Braz J Obes Nutr Weight Loss. 2021;15:669-77.

26 Carmo C.D., Ribeiro M.R., Teixeira J.X., Alves C.M., Franco M.M., França A.K., et al. Added sugar consumption and chronic oral disease burden among adolescents in Brazil. J Dent Res. 2018;97:508-14.
-2727 Silva J.B., Elias B.C., Warkentin S., Mais L.A., Konstantyner T. Factors associated with the consumption of ultra-processed food by Brazilian adolescents: National Survey of School Health, 2015. Rev Paul Pediatr. 2021;40:e2020362.

A temporal trend analysis on the behavioral risk factors for chronic NCDs in Brazilian school adolescents between 2009, 2012 and 20151010 Araujo D.A., de Carvalho R.B., de Oliveira A.S., Oliveira E.A., Machado A.L., Lima L.H. Temporal trend of simultaneous risk factors for chronic non-communicable diseases: national School Health Survey 2009, 2012, 2015. Rev Bras Epidemiol. 2022;25:e220013. indicated that the regular consumption of processed and ultra-processed foods was the second risk factor for diseases, second only to little physical activity; the authors also found a tendency towards a decrease in the participation of UP foods in the diet, together with an increase in irregularity in the consumption of fresh and minimally-processed foods.

Tandon et al. (2022)1616 Tandon K., Adhikari N., Adhikari B., Pradhan P.M. Co-occurrence of non-communicable disease risk factors and its determinants among school-going adolescents of Kathmandu Metropolitan City. PLoS One. 2022;17:e0272266. evaluated 1108 adolescents aged 13 to 19 years, students from public and private schools in Kathmandu, Nepal and found that 41 % of the adolescents had unhealthy eating habits - more than half did not consume vegetables and fruits five times a day or more, and more than half of the participants included soda in their diet at least once a week. The findings of this study also showed that 40.7 % of the adolescents had risk factors for chronic NCDs, including an unbalanced diet.

Other studies carried out in Brazil and Singapore also indicate that a significant proportion of children and adolescents do not consume fresh foods daily, such as fruits and vegetables or minimally processed foods, such as rice and beans.1717 Nicolau D.A., Castro A.G. Characterization of adolescents’ diet with the Dietary Guidelines for the Brazilian population. Mundo Saude 2018;42:98-122.

18 Souza P., Meira J.B., Fernandes B.G., Moreira L.L., Ferreira V.A., Guimaraes O.S., et al. Obesity and overweight in schools: the importance of diagnosis to subsidiate health promotion initiatives in school space. Braz J Obes Nutr Weight Loss. 2018;12:786-95.
-1919 Choy M.J., Brownlee I., Murphy A.M. Data-driven dietary patterns, nutrient intake and body weight status in a cross-section of Singaporean children aged 6-12 years. Nutrients. 2021;13:1335. In contrast, the prevalence of daily consumption of UP foods by adolescents in São Paulo was 64 %, and of soda 16.2 %, in 2017; this study also showed a negative association between participation in food purchases and soda consumption; regular cooking was positively associated with the consumption of rice and beans.1717 Nicolau D.A., Castro A.G. Characterization of adolescents’ diet with the Dietary Guidelines for the Brazilian population. Mundo Saude 2018;42:98-122. In the study conducted on 44 children in Diamantina, state of Minas Gerais, when evaluating lunch boxes, the UP foods were predominant, especially: yogurt (55.88 %); boxed chocolate milk (41.18 %); sandwich cookies and snacks (50 % and 35.29 %, respectively).1818 Souza P., Meira J.B., Fernandes B.G., Moreira L.L., Ferreira V.A., Guimaraes O.S., et al. Obesity and overweight in schools: the importance of diagnosis to subsidiate health promotion initiatives in school space. Braz J Obes Nutr Weight Loss. 2018;12:786-95.

Only one study showed results depicting high consumption of fruits (66.7 % of the sample) and vegetables (45.5 % of the sample) among school-aged children (5 to 10 years) who attended at Primary Care in the state of Pernambuco; however, high consumption of ultra-processed foods was also observed among the assessed students: 33 % consume hamburgers and/or cold cuts, 63 % consume sandwich biscuits, sweets or candy and 83 % consume sweetened beverages.2525 Dantas C.D., Cavalcanti R.D. Consumption of ultra-processed foods and nutritional status of schoolchildren in the state of Pernambuco. Braz J Obes Nutr Weight Loss. 2021;15:669-77.

In addition to food consumption, the structure of the diet was shown to be relevant for the assessed outcomes. Skipping breakfast, among other analysis variables, was associated with childhood obesity and excess weight in two studies in this review: with adolescents in the Central-West region of Brazil, and in Iranian children.1414 Sena E.M., Muraro A.P., Rodrigues P.R., Fiuza R.F., Ferreira M.G. Risk behavior patterns for chronic diseases and associated factors among adolescents. Nutr Hosp. 2017;34:914-22.,1515 Khashayar P., Kasaeian A., Heshmat R., Motlagh M.E., Mahdavi Gorabi A., Noroozi M., et al. Childhood overweight and obesity and associated factors in Iranian children and adolescents: a multilevel analysis; the CASPIAN-IV study. Front Pediatr. 2018;6:393. Consistent with this result, the literature indicates that eating breakfast is common for around half of adolescents (58.6 % in Curitiba, State of Paraná (South region of Brazil) and 48.5 % in Brazil);2828 Simões A.M., Machado C.O., Höfelmann D.A. Association of regular consumption of breakfast and health-related behavior among adolescents. Cien Saude Colet. 2021;26:2243-51.,2929 Barufaldi L.A., Abreu Gde A., Oliveira J.S., dos Santos D.F., Fujimori E., Vasconcelos S.M., et al. ERICA: prevalence of healthy eating habits among Brazilian adolescents. Rev Saude Publica. 2016;50:S6-9. however, skipping this meal is associated with eating most meals outside the home and not participating in the domestic meal preparation process. Regular breakfast consumption has also been positively associated with other protective behaviors, such as sleeping more than eight hours a day and engaging in regular physical activity.2828 Simões A.M., Machado C.O., Höfelmann D.A. Association of regular consumption of breakfast and health-related behavior among adolescents. Cien Saude Colet. 2021;26:2243-51. Moreover, skipping breakfast is related to an increase in the consumption of high-energy snacks, rich in fats and sugars, as a strategy to compensate for the absence of a meal.2828 Simões A.M., Machado C.O., Höfelmann D.A. Association of regular consumption of breakfast and health-related behavior among adolescents. Cien Saude Colet. 2021;26:2243-51.

The most frequent combinations of risk factors in children and adolescents involved an unhealthy diet.1313 Ricardo C.Z., Azeredo C.M., Machado de Rezende L.F., Levy R.B. Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: analysis of a national school-based survey. PLoS One. 2019;14:e0219370.,1919 Choy M.J., Brownlee I., Murphy A.M. Data-driven dietary patterns, nutrient intake and body weight status in a cross-section of Singaporean children aged 6-12 years. Nutrients. 2021;13:1335.,2121 Cunha D.B., Costa T.H., Veiga G.V., Pereira R.A., Sichieri R. Ultra-processed food consumption and adiposity trajectories in a Brazilian cohort of adolescents: ELANA study. Nutr Diabetes. 2018;8:28.,2424 de Melo I.S., Costa C., dos Santos J.V., Santos A.F., Florencio T., Bueno N.B. Consumption of minimally processed food is inversely associated with excess weight in adolescents living in an underdeveloped city. PLoS One. 2017;12:e0188401.

Overweight and obesity

A series of mechanisms may explain the relationship between the consumption of ultra-processed foods and overweight and obesity. In studies carried out in different parts of the world, UP foods have been characterized as nutritionally unbalanced, rich in free sugar, sodium, trans and saturated fats, with a low content of fibers and bioactive compounds.33 Matos R.A., Adams M., Sabaté J. Review: the Consumption of ultra-processed foods and non-communicable diseases in Latin America. Front Nutr. 2021;8:622714.

4 Lane M.M., Davis J.A., Beattie S., Gómez-Donoso C., Loughman A., et al. Ultraprocessed food and chronic noncommunicable diseases: a systematic review and meta-analysis of 43 observational studies. Obes Rev 2021;22:e13146.
-55 Elizabeth L., Machado P., Zinöcker M., Baker P., Lawrence M. Ultra-processed foods and health outcomes: a narrative review. Nutrients. 2020;12:1955.,3030 Machado P.P., Steele E.M., Levy R.B., Sui Z.X., 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. BMJ Open. 2019;9:e029544.,3131 Rauber F., Louzada M.L., Steele E.M., Millett C., Monteiro C.A., Levy R.B. Ultra-processed food consumption and chronic non-communicable diseases-related dietary nutrient profile in the UK (2008-2014). Nutrients. 2018;10:587.

The convenience and practical access, as well as the stimulation of consumption through the presence of and massive advertisements especially aimed at children, and the high palatability are aggravating factors that contribute to the consumption of these products88 Monteiro C.A., Cannon G., Moubarac J.C., Levy R.B., Louzada M.L., Jaime P.C. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Publ Health Nutr. 2018;21:5e17.; the increase in energy density and glycemic load of meals, as well as uncontrolled neural and hormonal signals of hunger and satiety, are mechanisms that contribute to explaining the association between UP foods and chronic NCDs.3232 Fardet A. Minimally processed foods are more satiating and less hyper-glycemic than ultra-processed foods: a preliminary study with 98 ready-to-eat foods. Food Funct. 2016;7:2338e46.

A study conducted by Louzada et al. (2015)99 Louzada M.L., Baraldi L.G., Steele E.M., Martins A.P., Canella D.S., Moubarac J.C., et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15. with Brazilians aged 10 to 19 years or older in 2008/2009 (n= 7534) showed that participants in the highest quintile of ultra-processed food consumption had a higher mean Body Mass Index - BMI (adjusted coefficient: 0.84; 95 %CI: 0.42; 1.42) and a greater chance of being overweight (adjusted OR = 1.52; 95 %CI: 0.75; 3.07) or obese (adjusted OR = 2.74; 95 %CI: 0.78; 9.60) when compared to those in the lowest quintile.

Bogea et al. (2021)1212 Bogea E.G., Martins M.L., do Carmo C.D., Nascimento J.X., Arruda S.P., Ribeiro C.C., et al. Factors associated with inflammatory biomarkers in adolescents: analysis by structural equation modeling. Cad Saude Publica. 2021;37:e00212220. evaluated the factors associated with inflammatory biomarkers in 391 Brazilian adolescents. Three dietary patterns were identified: Western, basic Brazilian and healthy pattern, with the Western pattern, which included greater consumption of foods rich in carbohydrates and fats, showing the greatest contribution. No associations were found between the patterns and the latent inflammation variable; however, these nutrients present in the diet, especially in UP foods, are directly related to the increase in chronic NCDs. Excess weight, in turn, was associated with higher levels of inflammatory biomarkers.

In a study carried out based on data present in the Food and Nutrition Surveillance System - SISVAN - between the months of January to December 2020, 33.84 % of the 3663 children evaluated across all health regions in the state of Pernambuco were overweight and/or obese according to the BMI/Age index, and UP food consumption.2525 Dantas C.D., Cavalcanti R.D. Consumption of ultra-processed foods and nutritional status of schoolchildren in the state of Pernambuco. Braz J Obes Nutr Weight Loss. 2021;15:669-77.

In another study carried out with schoolchildren in the state of Minas Gerais, BMI varied between 18.63 kg/m2 and 32.08 kg/m2, with a median of 21.8 kg/m². Among students classified as having excess weight, 40 % were classified as overweight and 60 % as obese.1818 Souza P., Meira J.B., Fernandes B.G., Moreira L.L., Ferreira V.A., Guimaraes O.S., et al. Obesity and overweight in schools: the importance of diagnosis to subsidiate health promotion initiatives in school space. Braz J Obes Nutr Weight Loss. 2018;12:786-95.

In line with these results, a study included in this review indicates that the consumption of minimally processed foods is inversely associated with excess weight in adolescents.2424 de Melo I.S., Costa C., dos Santos J.V., Santos A.F., Florencio T., Bueno N.B. Consumption of minimally processed food is inversely associated with excess weight in adolescents living in an underdeveloped city. PLoS One. 2017;12:e0188401.

According to the World Obesity Atlas (2023).3333 World Obesity Federation, World Obesity Atlas 2023. [Cited 2023 Aug 28]. Available from: https://data.worldobesity.org/publications/?cat=19
https://data.worldobesity.org/publicatio...
by 2035, approximately one-third of children and adolescents in Brazil may live with obesity. In 2020, the numbers indicated a 12.5 % prevalence of overweight and obesity among girls, while among boys this figure was 18 %. Projections indicate that in the coming years, around 23 % of girls and 33 % of boys could be in this situation. The constant increase in the prevalence of childhood obesity is associated with an increase in cardiovascular risk factors, obesity in adulthood and the emergence of comorbidities associated with obesity.3434 Juonala M., Magnussen C.G., Berenson G.S., Venn A., Burns T.L., Sabin M.A., et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med. 2011;365:1876-85.,3535 Bahia L., Schaan C.W., Sparrenberger K., Abreu G.A., Barufaldi L.A., Coutinho W., et al. Overview of meta-analysis on prevention and treatment of childhood obesity. J Pediatr. 2019;95:385-400.

The findings of the present study confirm the role of ultra-processed foods in the obesity epidemic in Brazil.

Cardiovascular diseases

Cardiovascular diseases represent around 50 % of deaths caused by chronic NCDs in middle- and low-income countries. Risk factors for the early development of cardiovascular diseases have been observed to be increasingly present in the growth phases, with emphasis on smoking and alcohol consumption as the main variables and with considerations in relation to overweight and obesity.3636 Silva T.P., Matozinhos F.P., Guedes G.R., Gratão L.H., Silva A.C., Vilela L.A., et al. The association between multiple cardiovascular risk factors and overweight in Brazilian adolescents: an analysis based on the grade of membership. Cienc Saude Colet. 2023;28:1937-48.

Thus, the risk factors manifested in adolescence tend to persist in adulthood and, when combined, increase the severity of the manifestations of cardiovascular diseases.3636 Silva T.P., Matozinhos F.P., Guedes G.R., Gratão L.H., Silva A.C., Vilela L.A., et al. The association between multiple cardiovascular risk factors and overweight in Brazilian adolescents: an analysis based on the grade of membership. Cienc Saude Colet. 2023;28:1937-48. The analysis of data from 101,607 adolescents from the 2015 National School Health Survey (PeNSE) reveals that there is a strong correlation between alcohol consumption and smoking, found together in 8 of the 13 identified clusters. In the same study, only 2.9 % of the adolescents did not have any risk behavior, while 38.0 %, 32.9 %, 9.4 % and 1.8 % accumulated two, three, four and five risk factors, respectively.1313 Ricardo C.Z., Azeredo C.M., Machado de Rezende L.F., Levy R.B. Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: analysis of a national school-based survey. PLoS One. 2019;14:e0219370. and such findings were also identified in similar studies.1414 Sena E.M., Muraro A.P., Rodrigues P.R., Fiuza R.F., Ferreira M.G. Risk behavior patterns for chronic diseases and associated factors among adolescents. Nutr Hosp. 2017;34:914-22.,3535 Bahia L., Schaan C.W., Sparrenberger K., Abreu G.A., Barufaldi L.A., Coutinho W., et al. Overview of meta-analysis on prevention and treatment of childhood obesity. J Pediatr. 2019;95:385-400.

In a study carried out with schoolchildren from a public educational institution in a city in the state of Minas Gerais, the analysis of biochemical tests revealed that total cholesterol (mean = 178.6 mg/dL; SD = 36.9 mg/dL) and triglyceride values (mean = 100.3 mg/dL; SD = 39.5 mg/dL) were high for the reference values used (< 170 mg/dL and < 75 mg/dL, respectively).1818 Souza P., Meira J.B., Fernandes B.G., Moreira L.L., Ferreira V.A., Guimaraes O.S., et al. Obesity and overweight in schools: the importance of diagnosis to subsidiate health promotion initiatives in school space. Braz J Obes Nutr Weight Loss. 2018;12:786-95.

Zhao et al. (2021)1111 Zhao W., Su D., Mo L., Chen C., Ye B., Qin S., Liu J., Pang Y. Lifestyle clusters and cardiometabolic risks in adolescents: a Chinese school-based study using a latent class analysis approach. Front Pediatr. 2021;9:728841. sought to identify modifiable lifestyle-defining behaviors and explore the best form of intervention for Chinese adolescents. The sample included 895 adolescents and of these, 8.4 % and 14.1 % reported having pre-hypertension and hypertension, respectively. A two-class model identified by the authors showed that 65.8 % had a lifestyle pattern considered to be healthy, while 34.2 % were sub-healthy. There were more female participants with a healthy lifestyle (56.2 vs. 43.8 %), while for boys these values were inverted, with more participants living an unhealthy lifestyle (45.4 vs. 54.6 %; all with p= 0.002). In the same study, significant differences were also found in waist circumference between the two classes (70.5 vs. 69.1 cm; p= 0.044).1111 Zhao W., Su D., Mo L., Chen C., Ye B., Qin S., Liu J., Pang Y. Lifestyle clusters and cardiometabolic risks in adolescents: a Chinese school-based study using a latent class analysis approach. Front Pediatr. 2021;9:728841.

Although several indicators related to chronic NCDs, such as overweight, obesity and adverse cardiovascular and metabolic conditions are often associated with the consumption of ultra-processed foods in adults, it is worth noting that the available information related to children and adolescents is less clear.44 Lane M.M., Davis J.A., Beattie S., Gómez-Donoso C., Loughman A., et al. Ultraprocessed food and chronic noncommunicable diseases: a systematic review and meta-analysis of 43 observational studies. Obes Rev 2021;22:e13146.

Physical activity and sedentary behavior

The National School Health Survey (PeNSE), 2015 edition, indicates data that reveals the prevalence of physical inactivity among schoolchildren. With a sample of 16,324 participants, 75.2 % were classified as inactive/insufficiently active and 24.8 % as active. Therefore, a significant number of students did not meet the minimum recommendation for physical activity - around 300 min per week.2727 Silva J.B., Elias B.C., Warkentin S., Mais L.A., Konstantyner T. Factors associated with the consumption of ultra-processed food by Brazilian adolescents: National Survey of School Health, 2015. Rev Paul Pediatr. 2021;40:e2020362. Hence, a sedentary lifestyle is defined as the time dedicated to static activities with low energy expenditure, in the sitting or lying positions.3737 Santana C.P., Soares H.A., Silva A.N., Azeredo C.M. Association between parental supervision and sedentary behavior and physical inactivity and among Brazilian adolescents. Cienc Saude Colet. 2021;26: 569-80.

It is known that children and adolescents are influenced, above all, by family habits. Given the favorable socioeconomic conditions and family context, there is an encouragement to practice physical activity and reduce screen time.3737 Santana C.P., Soares H.A., Silva A.N., Azeredo C.M. Association between parental supervision and sedentary behavior and physical inactivity and among Brazilian adolescents. Cienc Saude Colet. 2021;26: 569-80.

The Study of Cardiovascular Risks in Adolescents (ERICA, Estudo de Riscos Cardiovasculares em Adolescentes), carried out nationally in 2013-2014, analyzed the physical inactivity of schoolchildren, understood as a risk factor for the development of cardiovascular diseases and chronic NCDs. The sample mainly consisted of students from public schools in the urban areas of the Southeast and Northeast regions. The prevalence of leisure-time physical inactivity was evidenced in 54.3 % of adolescents (95 %CI = 53.4-55.2), higher among females, with 70.7 %, (95 % CI = 69.5-71.9) compared to data obtained for males, 38.0 % (95 %CI = 36.7-39.4).3838 Cureau F.V., Silva T.L., Bloch K.V., Fujimori E., Belfort D.R., Carvalho K.M., et al. ERICA: leisure-time physical inactivity in Brazilian adolescents. Rev Saude Publica. 2016;50:S4.

Focusing on healthy eating behaviors among Brazilian adolescents, the same study found that 68.0 % of the adolescents “always or almost always” ate meals with their parents or guardians. However, almost 25.0 % ate meals in the company of their parents or guardians only “sometimes” and 7.4 % “never” did it. Thus, almost half of the adolescents (48.5 %) reported having breakfast almost always or always; however, 21.9 % did not have this meal and, regarding water consumption, around half of the adolescents (48.2 %) reported drinking five or more glasses of water a day, while 18.9 % consumed only one to two glasses and 1.6 % reported not consuming water.2929 Barufaldi L.A., Abreu Gde A., Oliveira J.S., dos Santos D.F., Fujimori E., Vasconcelos S.M., et al. ERICA: prevalence of healthy eating habits among Brazilian adolescents. Rev Saude Publica. 2016;50:S6-9.

These data, when combined, corroborate the findings of Silva et al. (2021)2727 Silva J.B., Elias B.C., Warkentin S., Mais L.A., Konstantyner T. Factors associated with the consumption of ultra-processed food by Brazilian adolescents: National Survey of School Health, 2015. Rev Paul Pediatr. 2021;40:e2020362. who, when evaluating associations with excessive consumption of ultra-processed foods, indicated nine independent factors - age less than 15 years old, daily sitting time greater than four hours, eating while watching TV or studying for more than four days a week, daily TV viewing time of more than three hours, breakfast frequency of less than four days a week, having a cell phone, studying in a private school and located in an urban area and lack of maternal schooling. That said, sedentary habits, combined with inadequate eating practices, reveal an association with excessive consumption of ultra-processed foods among adolescents.2727 Silva J.B., Elias B.C., Warkentin S., Mais L.A., Konstantyner T. Factors associated with the consumption of ultra-processed food by Brazilian adolescents: National Survey of School Health, 2015. Rev Paul Pediatr. 2021;40:e2020362.

Araújo et al. (2022)1010 Araujo D.A., de Carvalho R.B., de Oliveira A.S., Oliveira E.A., Machado A.L., Lima L.H. Temporal trend of simultaneous risk factors for chronic non-communicable diseases: national School Health Survey 2009, 2012, 2015. Rev Bras Epidemiol. 2022;25:e220013. conducted a study based on data collected in three periods - 2009, 2012 and 2015 with Brazilian schoolchildren; the data show that, in addition to the regular consumption of ultra-processed foods, the level of physical activity was insufficient. Similar results were found in two other studies carried out with Brazilian adolescents - one of them used secondary data from PeNSE (2015) and the other conducted a cohort with adolescents from the city of Cuiabá. Both studies point to an unbalanced diet and insufficient physical activity as the most frequent correlation of risk factors for the development of chronic NCDs among adolescents.1313 Ricardo C.Z., Azeredo C.M., Machado de Rezende L.F., Levy R.B. Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: analysis of a national school-based survey. PLoS One. 2019;14:e0219370.,1414 Sena E.M., Muraro A.P., Rodrigues P.R., Fiuza R.F., Ferreira M.G. Risk behavior patterns for chronic diseases and associated factors among adolescents. Nutr Hosp. 2017;34:914-22.

Khashayar et al. (2018).1515 Khashayar P., Kasaeian A., Heshmat R., Motlagh M.E., Mahdavi Gorabi A., Noroozi M., et al. Childhood overweight and obesity and associated factors in Iranian children and adolescents: a multilevel analysis; the CASPIAN-IV study. Front Pediatr. 2018;6:393. when exploring multidimensional factors related to childhood overweight and obesity in Iranian adolescents, revealed that regular physical activity was reported by 24 % of the boys and 13 % of the girls. Even though other factors such as sociodemographic characteristics, birth weight classification, skipping breakfast, and family history of obesity were more relevant in the conclusions of this study, there is still an indication of insufficient physical activity among the adolescents in the sample.

Zhao et al. (2021)1111 Zhao W., Su D., Mo L., Chen C., Ye B., Qin S., Liu J., Pang Y. Lifestyle clusters and cardiometabolic risks in adolescents: a Chinese school-based study using a latent class analysis approach. Front Pediatr. 2021;9:728841. evaluated modifiable risk factors aiming to promote effective interventions for adolescents. Based on the definition of two patterns - healthy and unhealthy - no significant difference in physical activity was identified between the participants in each of the patterns since an insufficient level of physical activity was identified in the minority (36.4 %) of Chinese adolescents. In the study, methodological limitations were also described, which may explain such results and the need for a prospective study.

According to a study that analyzes the relationship between age and changes in healthy behaviors in adolescents, as age increases, healthy practices decrease - in particular, physical activity tends to decrease between the ages of 11 and 15. Independence, exposure to new practices, new environments, and even socioeconomic conditions can influence this decline so it is possible to identify unhealthy lifestyles among adolescents.3939 Marques A., Loureiro N., Avelar-Rosa B., Naia A., Matos M.G. Adolescents’ healthy lifestyle. J Pediatr. 2020;96:217-24.

Physical inactivity and a sedentary lifestyle constitute risk factors for the development of chronic NCDs and, even though the findings of this review are scarce, there are studies that indicate multiple factors that, when combined, contribute to unfavorable health outcomes.1010 Araujo D.A., de Carvalho R.B., de Oliveira A.S., Oliveira E.A., Machado A.L., Lima L.H. Temporal trend of simultaneous risk factors for chronic non-communicable diseases: national School Health Survey 2009, 2012, 2015. Rev Bras Epidemiol. 2022;25:e220013.

Although the studies are incipient and have inconclusive results, the hypothesis of the association of physical inactivity as one of the risk factors for chronic NCDs that occur simultaneously in childhood and adolescence has been proven.

Oral health and chronic NCDs

Chronic NCDs represent a broad group of diseases responsible for the main patterns of morbidity and mortality around the world. It is known that periodontal diseases and dental caries are considered chronic NCDs; therefore, the literature shows a consistent relationship between these diseases and other chronic NCDs, such as obesity.3939 Marques A., Loureiro N., Avelar-Rosa B., Naia A., Matos M.G. Adolescents’ healthy lifestyle. J Pediatr. 2020;96:217-24. Furthermore, eating habits, especially high consumption of foods rich in sugar, are also associated with the prevalence of periodontal diseases.2626 Carmo C.D., Ribeiro M.R., Teixeira J.X., Alves C.M., Franco M.M., França A.K., et al. Added sugar consumption and chronic oral disease burden among adolescents in Brazil. J Dent Res. 2018;97:508-14.,4040 World Health Organization. 2015. Guideline: Sugars Intake for Adults and Children. Geneva, Switzerland: WHO Library Cataloguing. [Cited 2023 Aug 28]. Available from: http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/.
http://www.who.int/nutrition/publication...

Carmo et al. (2018)2626 Carmo C.D., Ribeiro M.R., Teixeira J.X., Alves C.M., Franco M.M., França A.K., et al. Added sugar consumption and chronic oral disease burden among adolescents in Brazil. J Dent Res. 2018;97:508-14. sought to assess the association of added sugar consumption with the burden of chronic oral diseases - COD among adolescents, considering obesity and systemic inflammation pathways through structural equation modeling. The results indicate that greater consumption of added sugar, higher levels of interleukin 6 (IL-6) - an indicator that is characterized by being elevated due to excessive sugar consumption and obesity, related to chronic oral disease - and lower socioeconomic class (standardized coefficient [SC] = 0.212, p= 0.005; SC = 0.130, p= 0.036; and, SC = -0.279, p= 0.001, respectively) were related to higher COD burden values. Obesity was not directly associated with COD burden; however, excess weight indicates an indirect association through higher levels of IL-6 (SC = 0.232, p= 0.001). Adolescents with obesity also had higher serum levels of IL-6 compared to those with normal weight (SC = 0.232, p= 0.001).2626 Carmo C.D., Ribeiro M.R., Teixeira J.X., Alves C.M., Franco M.M., França A.K., et al. Added sugar consumption and chronic oral disease burden among adolescents in Brazil. J Dent Res. 2018;97:508-14.

Caries and periodontal diseases are interconnected, and these findings indicate that they are also related to sugar consumption, obesity and systemic inflammation. Health authorities, such as the WHO, advise that the approach to health promotion and chronic NCD prevention must act in a combined manner on the different risk factors that negatively affect the full development of this population.4040 World Health Organization. 2015. Guideline: Sugars Intake for Adults and Children. Geneva, Switzerland: WHO Library Cataloguing. [Cited 2023 Aug 28]. Available from: http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/.
http://www.who.int/nutrition/publication...

Limitations

This review had as inclusion criteria only observational studies carried out with children and adolescents. Studies are scarce and bring different methodological approaches, with possible limitations. Most of them used data from self-reported methods and secondary data, strategies that may present some inherent bias in food records. Although the evidence found indicates associations in the same direction and allows the exploration of the topic, some results can be considered inconclusive, especially for this age group.

Conclusions

The findings of this review disclose associations between the consumption of ultra-processed foods and harmful health outcomes in childhood and adolescence, such as overweight, obesity, physical inactivity, cardiovascular diseases and periodontal diseases.

Children and adolescents in different parts of the world have a predominantly unhealthy diet, with the regular consumption of ultra-processed foods to the detriment of a diet based on fresh or minimally processed foods. Combined with other risk factors, this practice contributes to the findings that indicate an increase in childhood obesity among schoolchildren, a high prevalence of physical inactivity, and a sedentary lifestyle, in addition to representing a risk for both the development of chronic NCDs and cardiovascular diseases and dental caries in childhood and adolescence.

The present study maps the current literature on the topic and indicates important ways to direct actions that seek to promote health, aiming to prevent and control chronic NCDs. The identification of risk factors and conditions that may influence them can contribute to the construction and improvement of effective measures for this population, whose development period can also indicate health outcomes in adult life. Among the most relevant findings is the fact that the consumption of UP foods and the association with chronic NCDs also lead to unhealthy lifestyles in childhood and adolescence; the low frequency of breakfast consumption and the high prevalence of physical inactivity are markers of this scenario, behaviors with a proven association in different contexts.

Finally, given the scenario about the consumption of ultra-processed foods among children and adolescents and the harmful health outcomes, added to the scarcity of scientific studies available for this age group and little or no conclusive results, the indication remains for future studies aimed at evaluating this association.

References

  • 1
    Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Guia Alimentar para a População Brasileira. 2. ed., 1. reimpr. 2014.
  • 2
    Louzada M.L., Costa C.S., Souza T.N., Cruz G.L., Levy R.B., Monteiro C.A. Impact of the consumption of ultra-processed foods on children, adolescents and adults' health: scope review. Cad Saude Publica. 2021;37:Se00323020.
  • 3
    Matos R.A., Adams M., Sabaté J. Review: the Consumption of ultra-processed foods and non-communicable diseases in Latin America. Front Nutr. 2021;8:622714.
  • 4
    Lane M.M., Davis J.A., Beattie S., Gómez-Donoso C., Loughman A., et al. Ultraprocessed food and chronic noncommunicable diseases: a systematic review and meta-analysis of 43 observational studies. Obes Rev 2021;22:e13146.
  • 5
    Elizabeth L., Machado P., Zinöcker M., Baker P., Lawrence M. Ultra-processed foods and health outcomes: a narrative review. Nutrients. 2020;12:1955.
  • 6
    GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1223-49.
  • 7
    WHO. Noncommunicable Diseases. 2018. [Cited 2020 Apr 1st]. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicablediseases
    » https://www.who.int/news-room/fact-sheets/detail/noncommunicablediseases
  • 8
    Monteiro C.A., Cannon G., Moubarac J.C., Levy R.B., Louzada M.L., Jaime P.C. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Publ Health Nutr. 2018;21:5e17.
  • 9
    Louzada M.L., Baraldi L.G., Steele E.M., Martins A.P., Canella D.S., Moubarac J.C., et al. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med. 2015;81:9-15.
  • 10
    Araujo D.A., de Carvalho R.B., de Oliveira A.S., Oliveira E.A., Machado A.L., Lima L.H. Temporal trend of simultaneous risk factors for chronic non-communicable diseases: national School Health Survey 2009, 2012, 2015. Rev Bras Epidemiol. 2022;25:e220013.
  • 11
    Zhao W., Su D., Mo L., Chen C., Ye B., Qin S., Liu J., Pang Y. Lifestyle clusters and cardiometabolic risks in adolescents: a Chinese school-based study using a latent class analysis approach. Front Pediatr. 2021;9:728841.
  • 12
    Bogea E.G., Martins M.L., do Carmo C.D., Nascimento J.X., Arruda S.P., Ribeiro C.C., et al. Factors associated with inflammatory biomarkers in adolescents: analysis by structural equation modeling. Cad Saude Publica. 2021;37:e00212220.
  • 13
    Ricardo C.Z., Azeredo C.M., Machado de Rezende L.F., Levy R.B. Co-occurrence and clustering of the four major non-communicable disease risk factors in Brazilian adolescents: analysis of a national school-based survey. PLoS One. 2019;14:e0219370.
  • 14
    Sena E.M., Muraro A.P., Rodrigues P.R., Fiuza R.F., Ferreira M.G. Risk behavior patterns for chronic diseases and associated factors among adolescents. Nutr Hosp. 2017;34:914-22.
  • 15
    Khashayar P., Kasaeian A., Heshmat R., Motlagh M.E., Mahdavi Gorabi A., Noroozi M., et al. Childhood overweight and obesity and associated factors in Iranian children and adolescents: a multilevel analysis; the CASPIAN-IV study. Front Pediatr. 2018;6:393.
  • 16
    Tandon K., Adhikari N., Adhikari B., Pradhan P.M. Co-occurrence of non-communicable disease risk factors and its determinants among school-going adolescents of Kathmandu Metropolitan City. PLoS One. 2022;17:e0272266.
  • 17
    Nicolau D.A., Castro A.G. Characterization of adolescents’ diet with the Dietary Guidelines for the Brazilian population. Mundo Saude 2018;42:98-122.
  • 18
    Souza P., Meira J.B., Fernandes B.G., Moreira L.L., Ferreira V.A., Guimaraes O.S., et al. Obesity and overweight in schools: the importance of diagnosis to subsidiate health promotion initiatives in school space. Braz J Obes Nutr Weight Loss. 2018;12:786-95.
  • 19
    Choy M.J., Brownlee I., Murphy A.M. Data-driven dietary patterns, nutrient intake and body weight status in a cross-section of Singaporean children aged 6-12 years. Nutrients. 2021;13:1335.
  • 20
    Kelishadi R., Heidari-Beni M., Esmaeil-Motlagh M., Pourmasoumi M., Malekshah A.F., Qorbani M. Association of nutrient patterns with anthropometric indices in children and adolescents: the weight disorders survey of the CASPIAN-IV study. Mediterranean J Nutr Metab. 2019;12: 223-34.
  • 21
    Cunha D.B., Costa T.H., Veiga G.V., Pereira R.A., Sichieri R. Ultra-processed food consumption and adiposity trajectories in a Brazilian cohort of adolescents: ELANA study. Nutr Diabetes. 2018;8:28.
  • 22
    D'Avila H.F., Kirsten V.R. Energy intake from ultra-processed foods among adolescents. Rev Paul Pediatr. 2017;35:54-60.
  • 23
    Sparrenberger K., Friedrich R.R., Schiffner M.D., Schuch I., Wagner M.B. Ultra-processed food consumption in children from a Basic Health Unit. J Pediatr. 2015;91:535-42
  • 24
    de Melo I.S., Costa C., dos Santos J.V., Santos A.F., Florencio T., Bueno N.B. Consumption of minimally processed food is inversely associated with excess weight in adolescents living in an underdeveloped city. PLoS One. 2017;12:e0188401.
  • 25
    Dantas C.D., Cavalcanti R.D. Consumption of ultra-processed foods and nutritional status of schoolchildren in the state of Pernambuco. Braz J Obes Nutr Weight Loss. 2021;15:669-77.
  • 26
    Carmo C.D., Ribeiro M.R., Teixeira J.X., Alves C.M., Franco M.M., França A.K., et al. Added sugar consumption and chronic oral disease burden among adolescents in Brazil. J Dent Res. 2018;97:508-14.
  • 27
    Silva J.B., Elias B.C., Warkentin S., Mais L.A., Konstantyner T. Factors associated with the consumption of ultra-processed food by Brazilian adolescents: National Survey of School Health, 2015. Rev Paul Pediatr. 2021;40:e2020362.
  • 28
    Simões A.M., Machado C.O., Höfelmann D.A. Association of regular consumption of breakfast and health-related behavior among adolescents. Cien Saude Colet. 2021;26:2243-51.
  • 29
    Barufaldi L.A., Abreu Gde A., Oliveira J.S., dos Santos D.F., Fujimori E., Vasconcelos S.M., et al. ERICA: prevalence of healthy eating habits among Brazilian adolescents. Rev Saude Publica. 2016;50:S6-9.
  • 30
    Machado P.P., Steele E.M., Levy R.B., Sui Z.X., 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. BMJ Open. 2019;9:e029544.
  • 31
    Rauber F., Louzada M.L., Steele E.M., Millett C., Monteiro C.A., Levy R.B. Ultra-processed food consumption and chronic non-communicable diseases-related dietary nutrient profile in the UK (2008-2014). Nutrients. 2018;10:587.
  • 32
    Fardet A. Minimally processed foods are more satiating and less hyper-glycemic than ultra-processed foods: a preliminary study with 98 ready-to-eat foods. Food Funct. 2016;7:2338e46.
  • 33
    World Obesity Federation, World Obesity Atlas 2023. [Cited 2023 Aug 28]. Available from: https://data.worldobesity.org/publications/?cat=19
    » https://data.worldobesity.org/publications/?cat=19
  • 34
    Juonala M., Magnussen C.G., Berenson G.S., Venn A., Burns T.L., Sabin M.A., et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med. 2011;365:1876-85.
  • 35
    Bahia L., Schaan C.W., Sparrenberger K., Abreu G.A., Barufaldi L.A., Coutinho W., et al. Overview of meta-analysis on prevention and treatment of childhood obesity. J Pediatr. 2019;95:385-400.
  • 36
    Silva T.P., Matozinhos F.P., Guedes G.R., Gratão L.H., Silva A.C., Vilela L.A., et al. The association between multiple cardiovascular risk factors and overweight in Brazilian adolescents: an analysis based on the grade of membership. Cienc Saude Colet. 2023;28:1937-48.
  • 37
    Santana C.P., Soares H.A., Silva A.N., Azeredo C.M. Association between parental supervision and sedentary behavior and physical inactivity and among Brazilian adolescents. Cienc Saude Colet. 2021;26: 569-80.
  • 38
    Cureau F.V., Silva T.L., Bloch K.V., Fujimori E., Belfort D.R., Carvalho K.M., et al. ERICA: leisure-time physical inactivity in Brazilian adolescents. Rev Saude Publica. 2016;50:S4.
  • 39
    Marques A., Loureiro N., Avelar-Rosa B., Naia A., Matos M.G. Adolescents’ healthy lifestyle. J Pediatr. 2020;96:217-24.
  • 40
    World Health Organization. 2015. Guideline: Sugars Intake for Adults and Children. Geneva, Switzerland: WHO Library Cataloguing. [Cited 2023 Aug 28]. Available from: http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/
    » http://www.who.int/nutrition/publications/guidelines/sugars_intake/en/

Publication Dates

  • Publication in this collection
    13 May 2024
  • Date of issue
    Mar-Apr 2024

History

  • Received
    28 Aug 2023
  • Accepted
    05 Sept 2023
  • Published
    20 Oct 2023
Sociedade Brasileira de Pediatria Av. Carlos Gomes, 328 cj. 304, CEP: 90480-000 , Tel.: (+55 51) 3108-3328 - Porto Alegre - RS - Brazil
E-mail: assessoria@jped.com.br