INTRODUCTION

Inadequate eating habits are strongly associated with an increase in the prevalence and mortality from non-communicable chronic diseases in the general population¹, and may result from social, cultural and economic influences, such as accessibility, availability, advertising and price^2,3. Thus, healthy eating can be considered multidimensional⁴.

In this scenario, diet can influence pregnancy outcomes, and play a vital role in maternal and child health and in the occurrence of diseases in adult life^5,6. Evidence indicates that inadequate food consumption during pregnancy can lead to harmful nutritional consequences, such as gestational weight gain above recommended levels and neonatal adiposity^7,8. Such consequences can increase the risk of maternal morbidity and mortality, and harm to the health and nutrition of the fetus and newborn^9,10.

In order to guide healthy eating, the Brazilian Ministry of Health developed the new Food Guide for the Brazilian Population, and the proposal of the ten steps for healthy eating. According to the guide¹¹, healthy eating is based on the consumption of varied foods in accordance with individual nutritional needs, based on the golden rule of giving preference to in natura or minimally processed foods, and in harmony with the cultural and social environment in which the individual is inserted¹¹.

However, in Brazil, studies have identified a low consumption of fresh or minimally processed foods in the diet of pregnant women and^12,13 an increase in the consumption of ultra-processed foods¹⁴, and this signals the need for improvements in the quality of the diet. In this sense, the incorporation of nutritional guidelines during prenatal care becomes essential, as it has the potential to affect the eating behavior of pregnant women^15,10.

Thus, considering the risks associated with inadequate nutrition for the mother-baby binomial and the need for studies on this topic in pregnant women, the present study aimed to analyze adherence to the 10 steps for healthy eating during pregnancy and its association with maternal factors. and socioeconomic factors in pregnant women in Espírito Santo, Brazil.

METHODS

Statistical methods

The collected data were stored in the REDCap platform and exported to the statistical program IBM SPSS Statistics for Windows, version 22.0. Descriptive statistics were performed using frequency and proportion, and statistical associations using Pearson’s chi-square test, and when the expected values in the table cells were less than five, Fisher’s exact test was used. All variables met the assumptions of absence of multicollinearity. The binary logistic regression model was used to test associations between adherence to steps and independent variables (sociodemographic variables and maternal factors). The independent variables that showed association with the outcome from the chi-square test, with p-value less than 20%, were included in the binary logistic regression model. A significance level lower than 5% and a confidence interval (CI) of 95% were considered, with calculation of the Odds Ratio (OR).

Ethical and legal aspects of research

The study was approved by the Research Ethics Committee (CEP) of the Health Sciences Center (CCS) of the Federal University of Espírito Santo (UFES), under protocol CAAE: 45314921.8.0000.5060 and opinion Nº 4,692,710. All participants had access to the electronic consent form.

RESULTS

The research link had 568 hits (100%), however, 200 (35.21%) were excluded, according to pre-established inclusion and exclusion criteria. A total of N=368 (64.78%) pregnant women were included in the research.

Most pregnant women were between 20 and 34 years old (79.3%), had a family income of up to 3 minimum wages (40.5%), were white (49.2%), had a with more than 8 years of schooling (92.4%), was not considered the main source of family income (75.8%) and lived with a partner (89.1%).

Most of the participants surveyed were in the second trimester of pregnancy and were undergoing prenatal care (47%). As for the provision of nutritional guidance, 229 (62.2%) pregnant women reported that they received guidance, and that the COVID-19 pandemic made access to prenatal care difficult for 19%.

Table 2 shows adherence to each step of healthy eating. Note that only steps 4 and 9 show an adherence frequency lower than 60%.

Regarding the EOR score, 78.5% of the pregnant women were classified in the O-Orientar. Regarding the binary testing of the EOR System, with the other variables investigated, no significant differences were observed. In this case, adherence to each step of healthy eating was analyzed individually.

The frequency of adherence to the steps was categorized and analyzed according to socioeconomic variables and maternal factors (table 3). In relation to step 1, the results showed statistical significance in the variable’s education (p=0,004) and income (p=0,026). In steps 3, 4 and 5, age (p=0.007; p=0.031; p=0,001 respectively) was significantly associated. Regarding step 5, greater adherence was associated with race/color (p=0.008) and family income (p<0.001).

The variable “nutritional guidelines during prenatal care” was associated with six of the ten steps. Thus, pregnant women who received guidance had a higher frequency of adherence to step 2 (p=0.031), step 3 (p=0.040), step 4 (p=0.003), step 5 (p<0.001), step 8 (p=0.17) and step 9 (p=0.013).

Table 4 shows the variables associated with the binary logistic regression, carried out with the aim of identifying the factors associated with adherence to the steps for healthy eating during pregnancy. No independent variables remained associated with step 1 and step 2.

In step 3, being 35 years of age or older (p value: 0.019; OR: 4.26; 95%CI: 1.27-14.30) and being in the 3rd trimester of pregnancy (p value: 0.019; OR: 2.58; 95%CI: 1.04-6.38), increased the chance of pregnant women adhering to the recommendation.

Regarding step 4, being ≥35 years old (p value: 0.038; OR: 1.74; 95%CI: 1.03-2.93) and receiving nutritional guidance during prenatal care (p value: 0.003; OR: 1.99; 95%CI: 1.26-3.15) were associated with an increased chance of pregnant women adhering to the recommendation, limiting the consumption of processed foods.

Regarding the consumption of ultra-processed foods (step 5), age ≥35 years (p value: 0.006; OR: 2.41; 95%CI: 1.29-4.52) and nutritional guidelines during prenatal care (p value: 0.003; OR: 2.02; 95%CI: 1.26-3.24) increased the chance of adherence to the recommendations that indicate a reduction in the consumption of this type of food.

Having more than two people living in the same household increased the chance of adherence to step 6 by twice (p value: 0.012; OR: 2.07; 95%CI: 1.17-3.65) and to step 8 (p value: 0.048; OR: 2.13; 95%CI: 1-4.53). Pregnant women of black race/color were 58% less likely to not consume foods rich in iron (p value: 0.046; OR: 0.42; 95%CI: 0.18-0.98), as recommended in step 8. At step 7, having an income greater than 5 minimum wages increased the probability of the pregnant woman not cooking meals by 58% (p value: 0.044; OR: 0.42; 95%CI: 0.18-0.97).

Pregnant women who received nutritional guidance were 66% more likely to plan shopping and prepare meals (p value: 0.025; OR: 1.66; 95%CI: 1.66-2.58), that is, adherence to step 9. Regarding step 10, pregnant women with difficult access to prenatal care during the COVID-19 pandemic were 44% more likely to not follow the recommendations (p value: 0.041; OR: 0.56; 95%CI: 0.32-0.97).

DISCUSSION

In the present study, associations were identified between adherence to the recommendations and access to prenatal care and socioeconomic characteristics, such as age ≥35 years and the greater number of people in the same household. Among our findings, pregnant women who received nutritional guidance during prenatal care were less likely to prefer the consumption of processed and ultra-processed foods.

Adherence to steps differs between age groups, and greater adherence to the recommendations of steps 3, 4 and 5 was identified among pregnant women aged 35 years or older. This finding corroborates the scientific literature, as older women tend to have a healthier and more conscious pattern compared to younger women²¹.

It should be noted that being a pregnant woman aged 35 years or older is characterized as advanced maternal age and thus may reveal social differences, since women who delay pregnancy tend to have better social and economic characteristics²². Therefore, through higher education, better access to education and information, these pregnant women tend to be more concerned about obstetric outcomes, and may be more careful with their own health and food^21,23.

Socioeconomic factors tend to reflect on the eating habits of pregnant women6. In this study, pregnant women of black race/color reported low adherence to step 8, and this may mean a concern about the nutritional needs of the mother and baby in this period²⁴. A study carried out with pregnant women in the 3rd trimester found that women of black race/color tended to eat more inadequately, when compared to white race/color²⁵. Additionally, a study by Victora et al.²⁶ found a low number of prenatal consultations in black women compared to white women, emerging problems in prenatal access and the need for interventions to promote nutritional health for this public²⁴.

Another issue raised, related to this finding, is that black women may present greater social vulnerability, with low educational and socioeconomic levels, which can lead to food insecurity and influence poor nutritional indicators^27,28.

Regarding socioeconomic characteristics, the greater number of people in the same household contributed to the chance of adhering to step 6, which indicates a preference for buying food at fairs, and to step 8, which indicates consuming foods rich in iron. This finding suggests that family support in household chores helps the family to have time to organize meals and consequently buy food at fairs, and corroborates the hypothesis that family structure can influence the food consumption of pregnant women²⁹.

As for the habit of cooking their own meals (Step 7), pregnant women with higher incomes indicated non-adherence to this recommendation. Given the influence of economic factors, higher social status may allow the pregnant woman to hire someone to prepare the family’s meals². Another possible explanation is the high purchasing power, including ready-to-eat foods³⁰.

In this study, the data reveal that receiving nutritional guidance during prenatal care directly influences the choices and eating behavior of pregnant women. Those who received nutrition advice followed 3 out of 10 healthy eating recommendations. Participants who received information about healthy eating during prenatal care were more likely to adhere to steps 4 and 5, which correspond to a reduction in the consumption of processed and ultra-processed foods, following the recommendations that pregnant women should seek to have a diet rich in foods. natural and low in processed foods, in favor of maternal and fetal well-being¹¹. As recommended by the Brazilian food guide, processed foods should be consumed moderately and ultra-processed foods should be avoided, as they are nutritionally unbalanced, induce excessive consumption and interfere with the population’s cultural eating habits¹¹. Our finding was similar to the study by Pereira et al.³¹in which pregnant women who received prenatal guidance were more likely to consume minimally processed foods, and this highlights the importance of educational activities in prenatal care in changing behavior, mainly in relation to food knowledge and practices³².

Pregnant women who received nutritional guidance during prenatal care were also more likely to plan shopping and meals (step 9). Related to this finding, we can highlight that such prenatal guidelines contribute beyond food choices, in the organization of family food, and evidenced the relevance of food and nutrition education in prenatal care carried out by a trained multiprofessional team¹².

It is noteworthy that this study was conducted during the COVID-19 pandemic in Brazil, and the difficulty in accessing prenatal care, caused by the advance of the pandemic, resulted in low adherence to step 10. The COVID-19 pandemic caused overload in health services, leading to a decrease in prenatal coverage, such as consultations and examinations³³. In addition to access, a study carried out with postpartum women in the South region of Brazil, in the first year of the COVID-19 pandemic, found a percentage of 17.4% of inadequate prenatal care³⁴.

With these findings, the importance of coverage and quality of the service provided in prenatal care is verified, since greater access allows a better opportunity for care and transmission of qualified information to pregnant women³⁵. However, despite the high coverage of prenatal care in Brazil³⁶, problems related to the provision of educational activities are still found^37-39, which makes it inadequate in some of its geographic regions⁴⁰.

It is also worth noting that the EOR score is considered a guideline for possible clinical conducts²¹. The use of this score can be considered innovative and easy to apply in educational actions of nutritional guidance in prenatal care and conducting research.

The limitations of this study are related to the possibility of occurrence of biases in memory and self-report, since the research was self-applied. It is important to note that the sample of this study was composed of pregnant women with access to the internet and of a higher socioeconomic level. Although the sample may not be representative of the Brazilian population, understanding new factors to meet recommended guidelines for healthy eating can help guide future interventions. Another possible limitation was related to the inclusion of pregnant women of any gestational trimester, however, during prenatal actions, the pregnant woman must receive nutritional guidance from the first consultation. In addition, our study was based on cross-sectional data, and causal attributions were waived.

CONCLUSION

Most pregnant women adhered to three to five steps, falling into the O-Orientation category. Access to nutritional guidelines during prenatal care influenced the eating habits of pregnant women. In the present study, age ≥35 years and the greater number of people in the same household influenced adherence to the steps towards a healthy diet and, as well as black race/color, income greater than 5 minimum wages and the difficulty of accessing services. prenatal actions in the COVID-19 pandemic were associated with non-adherence.

The data indicated that receiving information about healthy eating during prenatal care contributes to reducing the consumption of processed and ultra-processed foods, giving pregnant women a healthier diet and reinforcing the importance of nutritional interventions in prenatal care.

It is noteworthy that the adaptation of the ten steps for healthy eating during pregnancy used in conjunction with the EOR System can serve as a useful tool in the guidance and dietary assessment of pregnant women.

Finally, the results of the present study can guide future research on the eating habits of pregnant women, considering the Brazilian and specific recommendations for this population.