Abstract

The present article aimed to evaluate the consumption of protective foods and predictors of cardiovascular (CV) risk and its relationship with cardiovascular risk factors (CVRF) by hypertensive individuals in the state of Alagoas. A population-based cross-sectional study was carried out from 2013 to 2016 with 655 hypertensive adults of both sexes. Food consumption was assessed by a validated food frequency questionnaire with measurements converted to scores and the foods were divided into three groups: I – processed foods/CV risk predictors; II – ultraprocessed foods/higher CV risk predictors; III - in natura or minimally processed foods/ CV risk protectors. Socioeconomic, demographic, biochemical, clinical and anthropometric variables were also analyzed. The consumption scores of food groups I, II and III were, respectively, 0.11; 0.13 and 0.24 (p = 0.001). The consumption of processed foods was correlated positively with high blood cholesterol (p = 0.045) and negatively with age (p = 0.001); while that of ultraprocessed foods was correlated with the sedentary lifestyle (p = 0.01). Thus, it was observed a relationship between the consumption of CV risk predictors foods with high blood cholesterol and sedentary lifestyle, reflecting the need for nutricional education actions.

Food consumption; Hypertension; Adult; Risk factors; Obesity

Introduction

Cardiovascular disease (CVD) is the main cause of morbidity and mortality in both developed and developing countries¹1. Jankovic N, Geelen A, Streppel MT, de Groot LC, Kiefte-de Jong JC, Orfanos P, Bamia C, Trichopoulou A, Boffetta P, Bobak M, Pikhart H, Kee F, O’Doherty MG, Buckland G, Woodside J, Franco OH, Ikram MA, Struijk EA, Pajak A, Malyutina S, Kubinova R, Wennberg M, Park Y, Bueno-de-Mesquita HB, Kampman E, Feskens EJ. WHO guidelines for a healthy diet and mortality from cardiovascular disease in European and American elderly: the chances projects. Am J Clin Nutr 2015; 102(4):745-756.,²2. Simão AF, Précoma DB, Andrade JP, Correa Filho H, Saraiva JFK, Oliveira GMM; Sociedade Brasileira de Cardiologia. I Diretriz Brasileira de Prevenção Cardiovascular. Arq Bras Cardiol 2013; 101(5):1-63.. CVD is a multifactorial disorder influenced by genetic factors and, above all, lifestyle risk factors. One of the main CV risk factors (CVRF) is systemic hypertension (SH), which affects between 22.3% and 43.9% of Brazil’s adult urban population³3. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, Bortolotto LA, Franco RJS, Poli-de-Figueiredo CE, Jardim PCBV, Amodeo C, Barbosa ECD, Koch V, Gomes MAM, Paula RB, Póvoa RMS, Colombo FC, Ferreira Filho S, Miranda RD, Machado CA, Nobre F, Nogueira AR, Mion Júnior D, Kaiser S, Forjaz CLM, Almeida FA, Martim JFV, Sass N, Drager LF, Muxfeldt E, Bodanese LC, Feitosa AD, Malta D, Fuchs S, Magalhães ME, Oigman W, Moreira Filho O, Pierin AMG, Feitosa GS, Bortolotto MRFL, Magalhães LBNC, Silva ACS, Ribeiro JM, Borelli FAO, Gus M, Passarelli Júnior O, Toledo JY, Salles GF, Martins LC, Jardim TSV, Guimarães ICB, Antonello IC, Lima Júnior E, Matsudo V, Silva GV, Costa LS, Alessi A, Scala LCN, Coelho EB, Souza D, Lopes HF, Gowdak MMG, Cordeiro Júnior AC, Torloni MR, Klein MRST, Nogueira PK, Lotaif LAD, Rosito GBA, Moreno Júnior H. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(3):1-83..

Studies of dietary patterns have shown that the typical Western diet, characterized by a high intake of fat, sugar, salt, and processed and ultra-processed foods, is directly associated with a risk of becoming obese and developing CVD and SH⁴4. Di Cesare M, Khang YH, Asaria P, Blakely T, Cowan MJ, Farzadfar F, Guerrero R, Ikeda N, Kyobutungi C, Msyamboza KP, Oum S, Lynch JW, Marmot MG, Ezzati M. Inequalities in non-communicable diseases and effective responses. Lancet 2013; 381(9866):585-597.,⁵5. Martins MPSC, Gomes ALM, Martins MCC, Mattos MA, Souza Filho MD, Mello DB, Dantas EHM. Food intake, blood pressure and metabolic control in elderly hypertensive diabetics. Rev Bras Cardiol 2010; 23(9):162-170..

Furthermore, a concomitant reduction in the consumption of fruit and vegetables and other fresh, minimally processed foods⁶6. Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014., which protect against the development of CVD and other diseases, favors the increase in the prevalence of these chronic non-communicable diseases (NCDs)⁷7. Wang X, Ouyang Y, Liu J, Zhu M, Zhao G, Bao W, Hu FB. Fruit and vegetable consumption and mortality from all causes, cardiovascular disease, and cancer: systematic review and dose-response meta-analysis of prospective cohort studies. BMJ 2014; 349:g4490..

In this context, the characterization of a given population’s dietary patterns using instruments for evaluating habitual food intake such as food frequency questionnaires (FFQ) becomes particularly important⁸8. Silva TA, Vasconcelos SML. Procedimentos metodológicos empregados em questionários de frequência alimentar elaborados no Brasil: uma revisão sistemática. Rev Nutr 2012; 25(6):785-797.. In 2002, Fornés et al.⁹9. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18. proposed a new way of interpreting the results of FFQs called the “scoring method”, which scores the frequency of consumption of given food groups or items over time. The method is particularly appropriate for the purposes of this study, since it allows an assessment of the intake of specific nutrients or food groups that contribute to or protect against CV risk⁹9. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18..

Given the association between dietary patterns and CVD and the resulting importance of dietary assessment instruments, using the scoring method, this study aims to assess the intake of foods that contribute to or protect against CV risk and determine the association between the consumption of these foods and CVRFs among a sample of people with high blood pressure in the State of Alagoas, Brazil.

Methods

A cross-sectional study of food intake among a sample of adults with high blood pressure receiving treatment in primary care facilities in 12 municipalities in the State of Alagoas was conducted between September 2013 and February 2016. The study was undertaken as part of the Unified Health System Research Program (PPSUS, acronym in Portuguese), funded under a call for proposals issued by the Ministry of Health/CNPq/SESAU-AL//FAPEAL entitled “Food consumption and eating habits - modifiable risk factors for chronic diseases and prognosis of patients with high blood pressures in the State of Alagoas” (application number: 60030000737/2013).

The ideal sample size was calculated using the software package Epi Info^® version 7 (CVDC/WHO, Atlanta, GE, USA), based on a frequency of consumption of fruit and vegetable among adults living in the State of Maceio of 32.1%¹⁰10. Brasil. Ministério da Saúde (MS). Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2016. Brasília: MS; 2017., the total number of people with high blood pressure registered in the Primary Health Care Information System (SIAB, acronym in Portuguese) for Alagoas in 2013 (n = 113,346), and a margin of error of 5% and 99% confidence interval, resulting in a sample of 576 individuals. The sample of the present study comprised 655 individuals, which is considered representative of the total number of people with high blood pressure receiving treatment in primary care facilities in the State of Alagoas.

The sample selection process comprised three stages: 1) random selection of municipalities by state health region; 2) random selection of people with SH receiving treatment in primary health care facilities in the municipalities selected in stage 1 based on SIAB data; 3) in cases where municipalities and/or individuals were unable to or declined to participate in the study, another municipality from the same health region was randomly selected and other service users from the same health facility who fulfilled the inclusion criteria were invited to participate.

Five of the 12 municipalities and 61 of the health service users selected in stage one were substituted. It is important to note that municipalities from the same health region and service users from the same health care facility have similar characteristics.

The following inclusion criteria were adopted: participants had to be diagnosed with SH, aged between 18 and 59 years, and registered in the SIAB. Patients diagnosed with diabetes mellitus or other diseases associated with SH were excluded from the study.

Information was collected from the study participants using a questionnaire tested during a pilot study that contained questions in the following categories: (a) socioeconomic status (age group, schooling, number of family members, monthly family income, self-reported skin color, and socioeconomic classification, based on the Criteria of Economic Classification Brazil, version 2013¹¹11. Associação Brasileira das Empresas de Pesquisa (ABEP). Critério Padrão de Classificação Econômica Brasil. São Paulo: ABEP; 2013.); (b) lifestyle (physical activity, smoking, and alcohol consumption, regardless of frequency); (c) anthropometric data (weight, height, waist circumference – WC, and neck circumference - NC); (d) biochemical data (total cholesterol - TC and triglycerides - TG); and (e) clinical data (blood pressure and individual and family history).

Based on Lohman et al.¹²12. Lohman TG, Roche AF, Martorell R. Anthropometric standardization reference manual. Champaign: Human Kinetics Books; 1988., weight was measured using a Marte LC200^® digital scale with 180 kg capacity and 100g sensitivity, while height was measured using a Seca^® portable stadiometer. Weight and height were used to calculate body mass index (BMI), adopting cutoff points established by the World Health Organization¹³13. World Health Organization (WHO). Physical status: The use and interpretation of anthropometry. Geneva: WHO, 1995. (WHO Techinical Report Series, 854).. WC and NC were measured using a 200 cm inextensible tape measure with 0.1 cm variation. WC was measured at the midpoint between costal margin and the iliac crest and evaluated in accordance with International Diabetes Federation (IDF) criteria¹⁴14. International Diabetes Federation (IDF) .The IDF consensus worldwide definition of the metabolic syndrome. Brussels: IDF; 2005.. NC Neck circumference is measured at the level of the cricoid cartilage, which corresponds to the midpoint of the neck, and classified according criteria established by Ben-Noun et al.¹⁵15. Ben-Noun L, Sohar E, Laor A. Neck circumference as a simple screening measure for identifying overweight and obese patients. Obes Res & Clinical Practice 2001; 9(8):470-477.. The conicity index (C index) was calculated to determine coronary risk and interpreted in accordance with the cutoff points proposed by Pitanga and Lessa¹⁶16. Pitanga FJG, Lessa I. Sensibilidade e especificidade do índice de conicidade como discriminador do risco coronariano de adultos em Salvador, Brasil. Rev Bras Epidemiol 2004; 7(3):259-269..

Arterial pressure was measured by a team of trained researchers in accordance with the procedures laid out in the Brazilian Guidelines on Hypertension VI¹⁷17. Sociedade Brasileira de Cardiologia, Sociedade Brasileira de Hipertensão, Sociedade Brasileira de Nefrologia. VI Diretrizes Brasileiras de Hipertensão. Arq Bras Cardiol 2010; 95(1):1-51. using a Omron® HEM 705 NC automated blood pressure monitor, whereby the participant was instructed to rest for at least 5 minutes prior to measurement. The results were analyzed using the 7^th Brazilian Guidelines on Arterial Hypertension³3. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, Bortolotto LA, Franco RJS, Poli-de-Figueiredo CE, Jardim PCBV, Amodeo C, Barbosa ECD, Koch V, Gomes MAM, Paula RB, Póvoa RMS, Colombo FC, Ferreira Filho S, Miranda RD, Machado CA, Nobre F, Nogueira AR, Mion Júnior D, Kaiser S, Forjaz CLM, Almeida FA, Martim JFV, Sass N, Drager LF, Muxfeldt E, Bodanese LC, Feitosa AD, Malta D, Fuchs S, Magalhães ME, Oigman W, Moreira Filho O, Pierin AMG, Feitosa GS, Bortolotto MRFL, Magalhães LBNC, Silva ACS, Ribeiro JM, Borelli FAO, Gus M, Passarelli Júnior O, Toledo JY, Salles GF, Martins LC, Jardim TSV, Guimarães ICB, Antonello IC, Lima Júnior E, Matsudo V, Silva GV, Costa LS, Alessi A, Scala LCN, Coelho EB, Souza D, Lopes HF, Gowdak MMG, Cordeiro Júnior AC, Torloni MR, Klein MRST, Nogueira PK, Lotaif LAD, Rosito GBA, Moreno Júnior H. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(3):1-83..

TC and TG levels were determined using blood samples taken using disposable micro cuvettes analyzed immediately using a ROCHE® Accutrend GTC portable tester, which has a measuring range of 150mg/dl to 300 mg/dl for cholesterol and 70mg/dl to 600 mg/dl for triglycerides. TC and TG levels of over 200mg/dl and 150 mg/dl, respectively, were considered high¹⁸18. Xavier HT, Izar MC, Faria Neto JR, Assad MH, Rocha VZ, Sposito AC, Fonseca FA, Santos JE, Santos RD, Bertolami MC, Faludi AA, Martinez TLR, Diament J, Guimarães A, Forti NA, Moriguchi E, Chagas ACP, Coelho OR, Ramires JAF. V Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose. Arq Bras Cardiol 2013; 101(4):01-22..

Information about food consumption was collected using a quantitative FFQ developed and validated for use with people with high blood pressure by the study research team¹⁹19. Silva TA. Elaboração, validação e reprodutibilidade de um questionário de frequência alimentar para hipertensos e/ou diabéticos [dissertação]. Maceió: Universidade Federal de Alagoas; 2012.. The questionnaire encompasses 126 food items divided into 14 groups: fruit and fruit juice, vegetables, tubers and derivatives, cereals and pasta, condiments, oils and fats, milk and dairy products, legumes, meat, cured meats, sweet foods, soups, and drinks. Frequency of consumption was measured on a daily, weekly, monthly, and annual basis, based on the number of times the food was habitually consumed in each period (zero to >10).

The intake score was analyzed using a model proposed by Fornés et al.⁹9. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.. The definitions of food groups that contribute to or protect against CV risk were adapted from the Dietary Guidelines for the Brazilian Population⁶6. Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014.as follows: Group I - processed foods that contribute to CV risk: dried meats (charque, sun-dried meat), cheeses, tinned sardines, fried meat (beef, chicken and fish) and eggs; Group II - ultra-processed foods that contribute greatly to CV risk: biscuits, bread, popcorn, industrialized seasoning, cured meats, ice-cream, cake, instant noodles, soda, industrialized juice, sweet foods and chocolate drinks; and Group III - fresh or minimally processed foods that protect against CV risk: fruit, fruit juice or pulp, vegetables, tubers (sweet potato, yam, cassava) and derivatives, legumes, fresh eggs, skimmed milk, and fresh meat (beef, chicken and fish).

In the method proposed by Fornés et al.⁹9. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18., each intake category is given a score (S: score), whereby a maximum score is determined for foods consumed on a daily basis (S₇ = 1) and other scores are calculated using equations.

For the purposes of this study, we adopted a 365 day score (S₃₆₅) so that the intake of each food over the previous year could be treated as a quantitative variable, using the following equation: S₃₆₅ = (1/365)(a x p), where “S” is the score, “a” is the number of times that the food was consumed, and “p” is the period in which the food was consumed (0 - not consumed; 1 - consumed annually; 12 – consumed monthly; 48 – consumed weekly; and 365 – consumed daily.

An intake score was therefore determined for each of the food items in each of the above three groups. The total intake score for each of the three group was then calculated based on the sum of the scores for each item.

Mixed food preparations were not broken down into their relevant constituents. In such cases, the group was defined based on the main ingredient of each preparation.

Statistical analysis was performed using the software package Epi Info version 7 (CVDC/WHO, Atlanta, GE, USA). The proportions and their respective 95% confidence intervals were also calculated (CI_95%). The normality of the continuous variables was tested using the Kolmogorov–Smirnov test. Normal distribution was represented by the mean and the standard deviation. Given that the intake scores reflect an ordinal scale, each score was described using median and interquartile range (IQR) and associations with the explanatory variables were tested using the Mann-Whitney U test (used to compare two sample means) and the Kruskal-Wallis test (used to compare more than two medians). Spearman’s rank correlation coefficient was used to determine the association between scores and anthropometric variables, smoking, alcohol consumption, blood pressure levels, physical activity, and TC and TG levels. A 5% significance level was adopted.

The study was approved by the Research Ethics Committee of the Federal University of Alagoas.

Results

The age of the sample varied between 19 and 60 years. Average age was 47.9 ± 8.3 years. The sample was predominantly female (86.1%), non-white (75.9%), and sedentary (64.0%). Almost half the sample (47.8%) was from the socioeconomic class C, while 40.3% was from group D. Despite having high blood pressure, 10.5% and 26.6% of participants, respectively, smoked and consumed alcohol (Table 1).

With respect to health status, 65.2% of participants had a family history of CVD, 11% had previous history of renal disease, 58.5% had experienced alterations in systolic pressure and 31.3% alterations in diastolic pressure. Almost half of the sample (48.2%) had high levels of TG (Table 2), while the majority of the sample were at cardiovascular risk based on their WC (87.2%), C index (85.5%), and NC (57.5%). The majority of the sample had excess weight (84.3%), 35.2% were overweight, and 49.1% obese (Table 3).

Median intake scores for Group I, II and III were 0.11, 0.13, and 0.24, respectively (p < 0.05), while the median score for Groups I and II together was 0.25.

The findings show that intake scores for processed foods that contribute to CV risk tended to be higher among individuals aged between 30 and 49 years, with high levels of blood cholesterol, who were obese, and who had high NC (p < 0.05), while the intake of ultra-processed foods that contribute greatly to CV risk was significantly higher in sedentary individuals (p = 0.01). No significant difference in median intake scores was found for the other variables (Table 4).

A positive correlation was found between consumption of processed foods and high levels of blood cholesterol (rho = 0.13; p = 0.045) and a negative correlation was found with age (rho = -0.12; p = 0.001). There was also a positive correlation between the consumption of ultra-processed foods and sedentary behavior (rho = 0.10; p = 0.01) (Table 5).

When Groups I and II (foods that contribute to CV risk) where analyzed together, a positive association was found between the consumption of these foods and NC (rho = 0.11; p = 0.035).

Discussion

The findings show a high prevalence of obesity and sedentary behavior and a relatively high frequency of smoking and alcohol consumption. The results also show that processed and ultra-processed foods are part of the daily diet of people with high blood pressure in the State of Alagoas and that the consumption of these foods is associated with higher levels of blood cholesterol and sedentary behavior.

Despite the fact that the sample was made up of individuals with SH, the prevalence of smoking was similar to that found by the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil, acronym in Portuguese)²⁰20. Silva RC, Diniz MF, Alvim S, Vidigal PG, Fedeli LMG, Barreto SM. Physical activity and lipid profile in the ELSA- Brasil Study. Arq Bras Cardiol 2016; 107(1):10-19., which showed that the frequency of smoking was approximately 13%. A telephone survey of risk and protective factors for chronic diseases (VIGITEL, acronym in Portuguese)¹⁰10. Brasil. Ministério da Saúde (MS). Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2016. Brasília: MS; 2017. reported that rates of sedentary behavior and excessive consumption of alcohol varied between 10.3 and 18.1% and 14.5 and 24.9%, respectively, which is lower than the rates observed by the present study.

According to the World Health Organization, the majority of deaths due to NCDs and a substantial proportion of the disease burden caused by these diseases can be put down to lifestyle risk factors ²¹21. World Health Organization (WHO). Global status report on noncommunicable diseases 2014. Geneva: WHO; 2014., including excessive consumption of alcohol, inadequate diet, and lack of physical activity, which in turn aggravate high blood pressure and negatively affect the outcome of treatment ³3. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, Bortolotto LA, Franco RJS, Poli-de-Figueiredo CE, Jardim PCBV, Amodeo C, Barbosa ECD, Koch V, Gomes MAM, Paula RB, Póvoa RMS, Colombo FC, Ferreira Filho S, Miranda RD, Machado CA, Nobre F, Nogueira AR, Mion Júnior D, Kaiser S, Forjaz CLM, Almeida FA, Martim JFV, Sass N, Drager LF, Muxfeldt E, Bodanese LC, Feitosa AD, Malta D, Fuchs S, Magalhães ME, Oigman W, Moreira Filho O, Pierin AMG, Feitosa GS, Bortolotto MRFL, Magalhães LBNC, Silva ACS, Ribeiro JM, Borelli FAO, Gus M, Passarelli Júnior O, Toledo JY, Salles GF, Martins LC, Jardim TSV, Guimarães ICB, Antonello IC, Lima Júnior E, Matsudo V, Silva GV, Costa LS, Alessi A, Scala LCN, Coelho EB, Souza D, Lopes HF, Gowdak MMG, Cordeiro Júnior AC, Torloni MR, Klein MRST, Nogueira PK, Lotaif LAD, Rosito GBA, Moreno Júnior H. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(3):1-83.,²²22. .World Health Organization (WHO). A global brief on hypertension. Silent killer, global public health crisis. Geneva: WHO; 2013.,²³23. Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto SM, Chor D, Menezes PR. Chronic non-communicable diseases in Brazil: burden and current challenges. Lancet 2011; 1(2):1949-1961.. The prevalence of the CVRFs identified by the present study reflect nonadherence to treatments for SH that do not involve medication and has a significant negative impact on the health status of these individuals.

The high prevalence of overweight and obesity found by this study reflects a worrying national and global trend²⁴24. Conde WL, Monteiro CA. Nutrition transition and double burden of undernutrition and excess of weight in Brazil. Am J Clin Nutr 2014; 100(6):1617-1622.,²⁵25. Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, Abraham JP, Abu-Rmeileh NM, Achoki T, AlBuhairan FS, Alemu ZA, Alfonso R, Ali MK, Ali R, Guzman NA, Ammar W, Anwari P, Banerjee A, Barquera S, Basu S, Bennett DA, Bhutta Z, Blore J, Cabral N, Nonato IC, Chang JC, Chowdhury R, Courville KJ, Criqui MH, Cundiff DK, Dabhadkar KC, Dandona L, Davis A, Dayama A, Dharmaratne SD, Ding EL, Durrani AM, Esteghamati A, Farzadfar F, Fay DF, Feigin VL, Flaxman A, Forouzanfar MH, Goto A, Green MA, Gupta R, Hafezi-Nejad N, Hankey GJ, Harewood HC, Havmoeller R, Hay S, Hernandez L, Husseini A, Idrisov BT, Ikeda N, Islami F, Jahangir E, Jassal SK, Jee SH, Jeffreys M, Jonas JB, Kabagambe EK, Khalifa SE, Kengne AP, Khader YS, Khang YH, Kim D, Kimokoti RW, Kinge JM, Kokubo Y, Kosen S, Kwan G, Lai T, Leinsalu M, Li Y, Liang X, Liu S, Logroscino G, Lotufo PA, Lu Y, Ma J, Mainoo NK, Mensah GA, Merriman TR, Mokdad AH, Moschandreas J, Naghavi M, Naheed A, Nand D, Narayan KM, Nelson EL, Neuhouser ML, Nisar MI, Ohkubo T, Oti SO, Pedroza A, Prabhakaran D, Roy N, Sampson U, Seo H, Sepanlou SG, Shibuya K, Shiri R, Shiue I, Singh GM, Singh JA, Skirbekk V, Stapelberg NJ, Sturua L, Sykes BL, Tobias M, Tran BX, Trasande L, Toyoshima H, van de Vijver S, Vasankari TJ, Veerman JL, Velasquez-Melendez G, Vlassov VV, Vollset SE, Vos T, Wang C, Wang X, Weiderpass E, Werdecker A, Wright JL, Yang YC, Yatsuya H, Yoon J, Yoon SJ, Zhao Y, Zhou M, Zhu S, Lopez AD, Murray CJ, Gakidou E. 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. Lancet 2013; 384(14):766-781.. These results are in line with the findings of the most recent VIGITEL¹⁰10. Brasil. Ministério da Saúde (MS). Vigitel Brasil 2016: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2016. Brasília: MS; 2017. and the latest Household Budget Surveys (POF, acronym in Portuguese)²⁶26. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisas de Orçamentos Familiares 2008-2009: Análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2011.conducted by the Brazilian Institute of Geography and Statistics (IBGE, acronym in Portuguese), which reported rates of excess weight and obesity of 53.8%/18.9% and 49%/14.8%, respectively.

Obesity is associated with an increase in overall mortality and the emergence of NCDs²⁷27. Adams KF, Leitzmann MF, Ballard-Barbash R, Albanes D, Harris TB, Hollenbeck A, Kipnis V. Body mass and weight change in adults in relation to mortality risk. Am J Epidemiol 2014; 179(2):135-144.. People who are obese are three to four times more likely to be exposed to cardiometabolic risk factors than people of normal weight²⁸28. Schienkiewitz A, Mensink GB, Scheidt-Nave C. Comorbidity of overweight and obesity in a nationally representative sample of German adults aged 18-79 years. BCM Public Health 2012; 12(1):1-11. and the rate of mortality due to CVD is up to three times greater²⁹29. Mendis S, Puska P, Norrving B, editors. Global atlas on cardiovascular disease prevention and control. Geneva: World Health Organization (WHO); 2011., particularly when there is an accumulation of fat in the abdominal area³⁰30. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622..

The findings also show that processed and ultra-processed foods are part of the daily diet of the study participants. It is known that dietary habits play an important role in maintaining good health and that different foods may contribute to or protect against CVD³¹31. Petribú MMV, Cabral PC, Arruda IKG. Estado nutricional, consumo alimentar e risco cardiovascular: um estudo em universitários. Rev Nutr 2009; 22(6):837-846.,³²32. Moubarac JC, Martins AP, Claro RM, Levy RB, Cannon G, Monteiro CA. Consumption of ultra-processed foods and likely impact on human health. Evidence from Canada. Public Health Nutr 2013; 16(12):2240-2248., and therefore such foods should be excluded from the diet³3. Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, Bortolotto LA, Franco RJS, Poli-de-Figueiredo CE, Jardim PCBV, Amodeo C, Barbosa ECD, Koch V, Gomes MAM, Paula RB, Póvoa RMS, Colombo FC, Ferreira Filho S, Miranda RD, Machado CA, Nobre F, Nogueira AR, Mion Júnior D, Kaiser S, Forjaz CLM, Almeida FA, Martim JFV, Sass N, Drager LF, Muxfeldt E, Bodanese LC, Feitosa AD, Malta D, Fuchs S, Magalhães ME, Oigman W, Moreira Filho O, Pierin AMG, Feitosa GS, Bortolotto MRFL, Magalhães LBNC, Silva ACS, Ribeiro JM, Borelli FAO, Gus M, Passarelli Júnior O, Toledo JY, Salles GF, Martins LC, Jardim TSV, Guimarães ICB, Antonello IC, Lima Júnior E, Matsudo V, Silva GV, Costa LS, Alessi A, Scala LCN, Coelho EB, Souza D, Lopes HF, Gowdak MMG, Cordeiro Júnior AC, Torloni MR, Klein MRST, Nogueira PK, Lotaif LAD, Rosito GBA, Moreno Júnior H. 7ª Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol 2016; 107(3):1-83..

Corroborating the findings of the present study, Pinho et al.³³33. Pinho PM, Machado LMM, Torres RS, Carmin SEM, Mendes WAA, Silva ACM, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev Soc Bras Clín Méd 2014; 12(1):22-30.also found that the score for cardioprotective foods was greater than that of foods that contribute to CV risk among patients with metabolic syndrome, while Azevedo et al.³⁰30. Azevedo ECC, Dias FMRS, Diniz AS, Cabral PC. Consumo alimentar de risco e proteção para as doenças crônicas não transmissíveis e sua associação com a gordura corporal: um estudo com funcionários da área de saúde de uma universidade pública de Recife (PE), Brasil. Cien Saude Colet 2014; 19(5):1613-1622. observed similar median intake scores for both foods that contribute to and protect against NCDs among adults.

It is important to highlight that the population sample investigated by the present study is from the Northeast, where fresh foods or minimally processed foods are readily available and whose consumption is part of the dietary habits of the region. However, the fact that these foods are consumed more than others does not necessarily mean that the diet is adequate in quantitative terms³³33. Pinho PM, Machado LMM, Torres RS, Carmin SEM, Mendes WAA, Silva ACM, Araújo MS, Ramos EMLS. Síndrome metabólica e sua relação com escores de risco cardiovascular em adultos com doenças crônicas não transmissíveis. Rev Soc Bras Clín Méd 2014; 12(1):22-30., given a nutritional profile of the population that is possibly the result of an inadequate diet and the fact that results of the last POF showed a levelling off or reduction in the consumption of legumes, vegetables and natural fruit juice²⁶26. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisas de Orçamentos Familiares 2008-2009: Análise do consumo alimentar pessoal no Brasil. Rio de Janeiro: IBGE; 2011.. It is therefore possible that the consumption of processed and ultra-processed foods was underreported.

On the other hand, the majority of the sample were older adults, who tend to consume more fruit and vegetables³⁴34. Jaime PC, Machado FMS, Westphal MF, Monteiro CA. Nutritional education and fruit and vegetable intake: a randomized community trial. Rev Saude Publica 2007; 41(1):1-4.. As such, the inverse relationship between the consumption of processed foods and age may be due to the fact that older individuals were less exposed to modern foods, including processed foods.

The direct relationship between the consumption of processed foods and high levels of blood cholesterol and the consumption of ultra-processed foods and sedentary behavior was expected based on the findings of Fornés et al.⁹9. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18..

When Group I and Group II were analyzed together, a positive correlation was found between the consumption of these foods, which contribute to CV risk, and NC. Studies involving adults have recommended NC as the anthropometric indicator of choice because it is easy to measure, practical, not influenced by postprandial abdominal distension or respiratory movements, and provides a consistent measure of the accumulation of upper body subcutaneous fat³⁵35. Stabe C, Vasques AC, Lima MM, Tambascia MA, Pareja JC, Yamanaka A, Geloneze B. Neck circumference as a simple tool for identifying the metabolic syndrome and insulin resistance: results from the Brazilian Metabolic Syndrome Study. Clin Endocrinol 2013; 78(6):874-881.,³⁶36. Preis SR, Massaro JM, Hoffmann U, D’Agostino RBS, Levy D, Robins SJ, Meigs JB, Vasan RS, O’Donnell CJ, Fox CS. Neck circumference as a novel measure of cardiometabolic risk: the Framingham Heart Study. J Clin Endocrinol Metab 2010; 95(8):3701-3710. and abdominal (visceral) fat³⁶36. Preis SR, Massaro JM, Hoffmann U, D’Agostino RBS, Levy D, Robins SJ, Meigs JB, Vasan RS, O’Donnell CJ, Fox CS. Neck circumference as a novel measure of cardiometabolic risk: the Framingham Heart Study. J Clin Endocrinol Metab 2010; 95(8):3701-3710., associated with cardiometabolic risk and insulin resistance³⁵35. Stabe C, Vasques AC, Lima MM, Tambascia MA, Pareja JC, Yamanaka A, Geloneze B. Neck circumference as a simple tool for identifying the metabolic syndrome and insulin resistance: results from the Brazilian Metabolic Syndrome Study. Clin Endocrinol 2013; 78(6):874-881.,³⁶36. Preis SR, Massaro JM, Hoffmann U, D’Agostino RBS, Levy D, Robins SJ, Meigs JB, Vasan RS, O’Donnell CJ, Fox CS. Neck circumference as a novel measure of cardiometabolic risk: the Framingham Heart Study. J Clin Endocrinol Metab 2010; 95(8):3701-3710..

The findings show that there is a need for improved communication between health care professionals and service users with a view to promoting the adoption of healthy lifestyles and the resulting prevention of NCDs in people with high blood pressure, who have a greater predisposition to other diseases. In this context, it is important to note that effective health policy and government initiatives are essential.

This study may be subject to selection bias given the fact that the sample included only people with high blood pressure registered in the SIAB and due to the substitution to some of the randomly selected municipalities and service users. However, this sampling approach aimed to ensure a representative sample of people with high blood pressure without diabetes receiving treatment in primary care facilities in Alagoas and the substitutions were made based on specific criteria, using municipalities from the same health region and service users from the same health facility with similar characteristics.

Another limitation of this study may be the bias inherent in the use of food frequency questionnaires, such as the underreporting of food consumption and the fact that the scoring method reflects diet quality but does not allow for the classification of consumption of each food group into “adequate” or “inadequate”, due to the lack of cutoff points in the literature⁹9. Fornés NS, Martins IS, Velásquez-Meléndez G, Latorre MRDO. Escores de consumo alimentar e níveis lipêmicos em população de São Paulo, Brasil. Rev Saude Publica 2002; 36(1):12-18.,³⁷37. Pinho CPS, Diniz AS, Arruda IKG, Lira PIC, Cabral PC, Siqueira LAS, Batista Filho M. Consumo de alimentos protetores e preditores do risco cardiovascular em adultos do estado de Pernambuco. Rev Nutr 2012; 25(3):341-351.. As a result, it was not possible to use association tests. However, this method provided a simple and differentiated analysis of the dietary patterns of people with high blood pressure receiving treatment in primary care facilities in the State of Alagoas and enabled statistical analysis to determine the association between diet quality and variables considered predictors of CV risk.

Conclusion

The findings of this study show that the consumption of foods that protect against CV risk (fresh or minimally processed foods) was greater than that of foods that contribute to CV risk among a representative sample of people with high blood pressure in the State of Alagoas. However, a significant portion of study participants were shown to have high exposure to CVRFs and the results show that there was an association between the consumption of processed/ultra-processed foods and sedentary behavior and high levels of cholesterol. Based on these findings, measures should be taken to promote the adoption of healthy lifestyles among this population group.

Acknowledgments

Ministry of Health / Department of Science and Technology (MS-DECIT), State of Alagoas Research Foundation (FAPEAL), Alagoas State Health Department (SESAU), National Council for Scientific and Technological Development (CNPq) and Coordination for the Improvement of Higher Education Personnel (Capes).

References

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