Variables Associated with Ultra-Processed Foods Consumption among Brazilian Adolescents: A Systematic Review

Round 1

Reviewer 1 Report

Line36: You can add that ultra-processed foods have been also inversely associated with the adoption of healthy patterns, such as Mediterranean diet and positively associated with a “late eating” pattern, in young adults (doi: 10.3390/ijerph20042806.)

Line 129 national22-25: add a gap

Line 196: the consumption of ultra-processed foods32: Is 32 a ref?

 Line 256: You can add that sex-dependent associations with the NOVA score have been

Table 3 needs reconstruction.

It is proposed that all studies are in one column. The second column should include the number of volunteers, and the other columns the rest variables (sedentary behavior etc). The b, ci can stay, but it is proposed that a symbol is added to ease the reader (+,-, ns).

Age, gender, BMI, waist should appear first and then the other variables. You could also put 2 tables (if needed).

The same concept should be followed for the results description and discussion.

Line 188: Move this paragraph together with the previous one.

The discussion needs substantial improvement. The authors should compare their results with more studies from the literature. It would be interesting to identify differentiations in the factors associated with UPF or the intensity of the association between Brazil, rest USA, Europe.

Moreover, the authors should identify several factors that have been proven significant in other studies and have not been studied in Brazilian adolescents yet.

The authors should provide some mechanisms connecting UPF to obesity (endocrine mechanisms, high fat content, low fiber etc). Moreover, UPF consumption is inversely related to healthy patterns (doi: 10.3390/ijerph20042806), while in individuals with high intake of UPF the characteristics of foods consumed (such as dietary acid load) may also play a role (https://www.sciencedirect.com/science/article/abs/pii/S2405457723001298)

 

Author Response

Variables associated with ultra-processed foods consumption among Brazilian adolescents: a systematic review

Responses to Referee 1

 

1. Line36: You can add that ultra-processed foods have been also inversely associated with the adoption of healthy patterns, such as Mediterranean diet and positively associated with a “late eating” pattern, in young adults (doi: 10.3390/ijerph20042806.)

Answer: Suggestion accepted. Text inserted between lines 36–37

 

2. Line 129 national22-25: add a gap

Answer: Suggestion accepted. All gaps have been checked and corrected.

 

3. Line 196: the consumption of ultra-processed foods32: Is 32 a ref?

Suggestion accepted. All references have been checked and corrected.

 

4. Line 256: You can add that sex-dependent associations with the NOVA score have been

Suggestion accepted. Text inserted between lines 251–253.

 

5. Table 3 needs reconstruction.

It is proposed that all studies are in one column. The second column should include the number of volunteers, and the other columns the rest variables (sedentary behavior etc). The b, ci can stay, but it is proposed that a symbol is added to ease the reader (+,-, ns).

Age, gender, BMI, waist should appear first and then the other variables. You could also put 2 tables (if needed).

The same concept should be followed for the results description and discussion.

Suggestion accepted. Table 3 was rebuilt considering the shared logic.

 

6. Line 188: Move this paragraph together with the previous one.

Answer: Suggestion accepted. The paragraph has been moved (lines 184–189)

 

7. The discussion needs substantial improvement. The authors should compare their results with more studies from the literature. It would be interesting to identify differentiations in the factors associated with UPF or the intensity of the association between Brazil, rest USA, Europe.

Moreover, the authors should identify several factors that have been proven significant in other studies and have not been studied in Brazilian adolescents yet.

The authors should provide some mechanisms connecting UPF to obesity (endocrine mechanisms, high fat content, low fiber etc). Moreover, UPF consumption is inversely related to healthy patterns (doi: 10.3390/ijerph20042806), while in individuals with high intake of UPF the characteristics of foods consumed (such as dietary acid load) may also play a role (https://www.sciencedirect.com/science/article/abs/pii/S2405457723001298)

Answer: Suggestion accepted. We seek to improve the depth of the Discussion section, inserting new references, as shared.

Reviewer 2 Report

The manuscript needs major editing.

Abstract: The abstract is not well organized, there are additional sentences in the findings, and conclusion is not drawn from the findings.

Introduction: It is better to list the ultra-processed foods discussed in the introduction in addition to their definition.

Methods: The NOVA classification needs reference.

Why was the Meta-analysis not done?

Results: Mention all variables affecting consumption of ultra-processed foods, please:

There was a predominance of variables in the individual domain (n = 38; 74.5%), followed by variables in the environmental domain (n = 7; 13.7%), interpersonal (n = 5; 9, 8%) and public policy (n = 1; 2.0%).

 It seems that meta-analysis in different subgroups can be done to better interpretation and conclusions from the reviewed papers.

Comments for author File: Comments.pdf

The manuscript needs major editing.

Some terms don't seem right.

 

 

Author Response

Variables associated with ultra-processed foods consumption among Brazilian adolescents: a systematic review

Responses to Referee 2

 

The manuscript needs major editing.

1. Abstract: The abstract is not well organized, there are additional sentences in the findings, and conclusion is not drawn from the findings.

Answer: Suggestion accepted. The Abstract was remodeled.

 

2. Introduction: It is better to list the ultra-processed foods discussed in the introduction in addition to their definition.

Answer: Suggestion accepted. Text inserted between lines 29–30.

 

3. Methods: The NOVA classification needs reference.

Answer: Suggestion accepted. We reorganized and inserted a new reference #1, mentioned in the Introduction and in the Methods.

 

4. Why was the Meta-analysis not done?

Answer: we did not conduct a meta-analysis due to the high heterogeneity between studies. We opted for a descriptive line of synthesis, in order to avoid the presentation/interpretation of biased data. We justify this in the Methods (lines 107–112).

 

5. Results: Mention all variables affecting consumption of ultra-processed foods, please:

There was a predominance of variables in the individual domain (n = 38; 74.5%), followed by variables in the environmental domain (n = 7; 13.7%), interpersonal (n = 5; 9, 8%) and public policy (n = 1; 2.0%).

Answer:  This is one of our inclusion criteria. As we found many variables, it would be difficult to mention them all, as well as organize a reasonable table for their presentation. That is why we chose to present only the variables that were analyzed by at least three studies. In any case, we consider it appropriate to make an overview of all the analyzes and people who are interested can ask the corresponding author for the worksheet. (lines 154–158).

 

6. It seems that meta-analysis in different subgroups can be done to better interpretation and conclusions from the reviewed papers.

Answer: we did not conduct a meta-analysis due to the high heterogeneity between studies. We opted for a descriptive line of synthesis, in order to avoid the presentation/interpretation of biased data. We justify this in the Methods (lines 107–112).

 

Reviewer 3 Report

I appreciate the opportunity to review the article "Risk factors for consumption of ultra-processed foods among Brazilian adolescents: a systematic review." The topic fits the journal scope and could be relevant for readers. However, I cannot accept the manuscript in its current form. My suggestions/comments are:

 

Introduction.

1. The authors need to clarify the literature gap this study is filling and why this study is needed. 
2. Lines 45 to 48 need a reference. Additionally, can the authors expand the information about this survey?
3. Aim. Why do the variables need to be classified? This study aspect needs to be explained in the introduction. 

 

Methods

1. Line 66.I suggest removing the exclusion criteria "not use the NOVA classification." It is evident that if the inclusion criterion is "articles that use NOA classification," the exclusion criteria are those that are not using this system. 
2. Line 67. What do the authors mean by "studies that evaluated specific types of ultra-processed food"? Furthermore, why do the articles that include them were excluded? 
3. Why do the authors use the Socioecological model for classifying the variables?
4. Lies 102 to 104. The authors state "Due to the high number of variables identified among the included 102 studies, it was stipulated that only the variables analyzed by at least three studies would 103 be presented in the synthesis" Why don't the authors use the most prevalent UP food consumed by adolescents described in the literature?

 

 

Results

1. Line 119. The authors state "The main 118 reasons for exclusion were: not grouping ultra-processed foods in the analysis" What did the authors mean by this sentence?
2. Tabla 1. I suggest adding a column with the study design and if the study was conducted in rural or urban locations. 
3. Table 2. Is there a total risk bias for each article? I mean, if authors can estimate a total risk bias category using all analyzed variables. 

 

Discussion

1. Lines 188 to 192 and lines 201 to 205. I suggest adding references to these paragraphs.
2. Line 196. There is a "32" by itself. This number is a reference.
3. Line 235. It appears to be the acronym PNAE, but it has no explanation. 
4. Lines 234 to 241. The topic of canteens does not appear in the results. Therefore, I suggest removing this paragraph.

Author Response

Variables associated with ultra-processed foods consumption among Brazilian adolescents: a systematic review

Responses to Referee 3

 

I appreciate the opportunity to review the article "Risk factors for consumption of ultra-processed foods among Brazilian adolescents: a systematic review." The topic fits the journal scope and could be relevant for readers. However, I cannot accept the manuscript in its current form. My suggestions/comments are:

 

Introduction.

1. The authors need to clarify the literature gap this study is filling and why this study is needed. 

Answer: Suggestion accepted. The text has been revised (lines 44–49)

 

2. Lines 45 to 48 need a reference. Additionally, can the authors expand the information about this survey?

Answer: The Introduction was revised and this period deleted.

 

3. Aim. Why do the variables need to be classified? This study aspect needs to be explained in the introduction. 

Answer: We hope that with the rewriting of the Introduction, the question of the need for classification has been better explained.

 

Methods

4. Line 66.I suggest removing the exclusion criteria "not use the NOVA classification." It is evident that if the inclusion criterion is "articles that use NOVA classification," the exclusion criteria are those that are not using this system. 

Answer: This period was deleted.

 

5. Line 67. What do the authors mean by "studies that evaluated specific types of ultra-processed food"? Furthermore, why do the articles that include them were excluded? 

Answer: Suggestion accepted. A justification was presented (lines 66–68).

 

6. Why do the authors use the Socioecological model for classifying the variables?

Answer: Suggestion accepted. A justification was presented (lines 100–102).

 

7. Lines 102 to 104. The authors state "Due to the high number of variables identified among the included 102 studies, it was stipulated that only the variables analyzed by at least three studies would 103 be presented in the synthesis" Why don't the authors use the most prevalent UP food consumed by adolescents described in the literature?

Answer:  This is one of our inclusion criteria. As we found many variables, it would be difficult to mention them all, as well as organize a reasonable table for their presentation. That is why we chose to present only the variables that were analyzed by at least three studies. In any case, we consider it appropriate to make an overview of all the analyzes and people who are interested can ask the corresponding author for the worksheet. (lines 154–158).

 

Results

8. Line 119. The authors state "The main 118 reasons for exclusion were: not grouping ultra-processed foods in the analysis" What did the authors mean by this sentence?

Answer: This period was deleted.

 

 

9. Table 1. I suggest adding a column with the study design and if the study was conducted in rural or urban locations. 

Answer: Suggestion accepted. Periods were inserted in the lines 129–130 and 135–136.

 

10. Table 2. Is there a total risk bias for each article? I mean, if authors can estimate a total risk bias category using all analyzed variables. 

Answer: The EPHPP instrument does not provide a total risk of bias value. Our intention was to show in which domains the works are more/or less potent.

 

Discussion

11. Lines 188 to 192 and lines 201 to 205. I suggest adding references to these paragraphs.

Answer: The Discussion was revised

 

12. Line 196. There is a "32" by itself. This number is a reference.

Answer: Suggestion accepted.

 

13. Line 235. It appears to be the acronym PNAE, but it has no explanation. 

Answer: Suggestion accepted. An explanation was done in the lines 229–230.

 

14. Lines 234 to 241. The topic of canteens does not appear in the results. Therefore, I suggest removing this paragraph.

Answer: Suggestion accepted. This paragraph was removed.

 

Round 2

Reviewer 1 Report

The authors have substantially updated the manuscript. Some minor points have to be considered.

Table 3

Please check “β+” in the Table.

kg/m2 Put a superscript

Author Response

Thank you. The adjustments have been made.

Reviewer 2 Report

Nothing

Nothing

Author Response

Thank you. There has been a thorough reading by three authors who have proficiency in the language.