The causes of the exponential increase in people with Type 2 Diabetes Mellitus (T2DM) are multifactorial. The main contributors include population aging, sedentary lifestyles, and the high prevalence of overweight and obesity [1].

Currently, there is a substantial body of evidence regarding diabetes and its treatment, aimed at improving patients’ quality of life. Non-pharmacological strategies have been continuously evaluated to achieve better metabolic control of the disease. However, a significant number of patients fail to reach the established therapeutic targets [1]. Therefore, adopting a healthy lifestyle, particularly with an emphasis on improving dietary habits, is crucial in managing these patients. It is essential to assess nutritional behavior while considering individual food habits, preferences, and specific therapeutic goals (such as glycemic control, lipid profile, blood pressure, and body weight) [2].

The consumption of Ultra-Processed Foods (UPFs) is associated with poor diet quality, which leads to negative metabolic outcomes [3]. High consumption of UPFs contributes to an imbalanced dietary pattern within the population due to their high energy content and significant levels of sodium, saturated fats, and trans fats [4]. The NOVA Classification System [5] categorizes foods into four groups based on the extent of processing they undergo. This classification considers the physical, biological, and chemical methods used during food production, including the use of additives.

In addition to diet quality, other factors play a crucial role in managing T2DM, such as mindful eating [6]. Mindfulness involves maintaining present-moment awareness and attention without judgment, emotion, or distraction, particularly during eating [7]. This practice is often referred to as conscious eating, mindful eating, or compassionate eating.

Mindful eating involves eliminating or minimizing external influences that can lead to distractions or impulsive eating. For example, advertisements for ultra-processed foods or environments like dinner parties or movie theaters can encourage overeating through enticing smells [6,7]. Another example is eating simply because others around are eating. By reducing these triggers, the urge to eat diminishes, which slows down eating speed and helps maintain weight control [8].

This mindful approach positively influences eating habits, promoting the consumption of foods that satisfy physiological needs and naturally lead to healthier eating patterns. As a result, mindful eating can contribute to healthier weight control by reducing overeating and excessive calorie intake [9,10]. Considering the growing prevalence of T2DM, understanding the impact of factors that influence eating behavior is crucial.

Given this context, understanding how external influences affect the consumption of ultra-processed foods is essential for managing and controlling the disease. Therefore, this study aimed to examine the relationship between the external environment and the consumption of ultra-processed foods in the dietary choices of individuals with type 2 diabetes mellitus.

The sample consisted of 325 individuals, with an average age of 60.85±9.28 years. Of the participants, 60% were female, 58.8% were married, and 49.2% were Caucasian. The highest levels of education were illiteracy and incomplete elementary school, representing 27.7% of the sample. Regarding comorbidities, in addition to T2DM, 82.5% had hypertension, and 63.1% had dyslipidemia. The most commonly used medications were biguanides and insulin, taken by 86.5% and 43.6% of the participants, respectively (Table 1).

In Table 1, the anthropometric data is presented, the average weight value was 79,8±14,1 Kg, the average BMI value was 30,3 ± 4,6 kg/m², and the average WC value was 103,1±11,7 cm.

Regarding the NOVA Classification System, the highest percentage was from the unprocessed or minimally processed foods group at 64.4% (53.4–73.5), while the lowest percentage was from the processed culinary ingredients group at 1.8% (Table 2).

Following the NOVA Classification System, a higher percentage of unprocessed or minimally processed foods was associated with lower values in the external domain (r=-0.167; p<0.01), as shown in Table 3. Conversely, a higher percentage of processed foods was associated with higher external domain values (r=0.136; p<0.05). (Table 3). However, these correlations were considered weak.

Additionally, there was a weak but statistically significant positive correlation between the external domain and BMI values (r=0.124; p<0.01), weight values (r=0.119; p<0.01), and WC values (r=0.151; p<0.01). Therefore, the higher the external domain scores, the higher the values of weight, BMI, and WC (Table 4).

In Table 5, even after adjustment by the multivariate model, the external domain remained inversely associated with the consumption of fresh or minimally processed foods, meaning that for each additional point in this domain, there was a 3.08% reduction in the consumption of these types of foods. Additionally, it showed a positive association with processed food consumption, indicating that for each additional point in the external domain, there was an average increase of 1.96% in processed food consumption. Regarding processed food consumption, the number of medications remained independently associated, meaning that for each additional medication used, there was an average increase of 1.63% in processed food consumption. Lastly, for each additional level of education, there was an average increase of 1.03% in the consumption of ultra-processed foods.

The study observed an inverse correlation between the consumption of unprocessed or minimally processed foods and the External domain of the MEQ. This suggests that a higher intake of unprocessed foods is associated with reduced environmental influences on the eating patterns of individuals with T2DM. In other words, when individuals consume more unprocessed foods, they are less likely to be influenced by external cues in their eating behavior. Conversely, within the same population, it was found that higher external influences on eating patterns were associated with higher values of weight, BMI, and WC as well as a greater percentage of intake from processed foods. This indicates that individuals who are more influenced by their environment in terms of eating tend to have higher body weight measurements and consume more processed foods.

These findings underscore the importance of dietary choices and environmental influences in managing weight and dietary quality among individuals with T2DM. Adopting a diet rich in unprocessed foods may contribute to more mindful eating behaviors and potentially better health outcomes in this population.

External influences on eating behaviors often operate through various media channels, leading to automatic eating responses characterized by triggers, inductions, and excessive consumption of low-nutritional-quality foods. This habitual pattern can be disrupted through mindful eating practices, which involve paying attention while eating and aiming for dietary awareness [17]. Automatic eating behaviors encompass emotional, impulsive, and habitual eating tendencies [18]. In contrast, mindful eating has been shown to positively impact dietary patterns by promoting increased consumption of fruits and vegetables, thereby enhancing overall food quality [19]. It also tends to decrease the consumption of high-energy-density foods and reduce the frequency or intensity of compulsive eating episodes [20]. These benefits highlight the potential of mindful eating as a strategy to improve dietary habits and mitigate the negative effects of external influences on eating behaviors [19].

Individuals with chronic diseases, including diabetes, may be particularly vulnerable to external eating stimuli [20]. For instance, they tend to exhibit increased food consumption following visual cues, such as watching culinary television shows [21]. These external stimuli can prompt automatic eating responses, characterized by impulsive and habitual eating behaviors. Therefore, promoting mindful eating practices can serve as an effective intervention to mitigate weight gain and facilitate weight loss in individuals with chronic diseases. Mindful eating involves cultivating awareness and attention during meals, which can interrupt automatic eating patterns [20]. By fostering mindful eating behaviors, individuals may gain greater control over their food choices, reduce impulsive eating episodes triggered by external stimuli, and potentially improve their overall dietary quality and health outcomes.

Ultra-processed foods are characterized by their extensive use of artificial additives, such as food dyes, stabilizers, flavor enhancers, aromas, and artificial sweeteners, among others [22]. These additives contribute to the practicality, convenience, and wide variety of foods in this category, making them increasingly popular across different age groups. Despite their convenience, the rising consumption of ultra-processed foods has coincided with a significant increase in chronic diseases such as type 2 diabetes mellitus, hypertension, and obesity. Studies have shown that high intake of ultra-processed foods in adults is associated with various adverse cardiovascular outcomes, particularly dyslipidemia and elevated blood pressure [23]. Obesity, in particular, has been closely linked to the consumption of ultra-processed foods, as highlighted in numerous studies [24,25].

These findings underscore the health risks associated with frequent consumption of ultra-processed foods and highlight the importance of promoting diets rich in minimally processed and whole foods to mitigate the burden of chronic diseases in populations [26]. Despite the well-documented negative health outcomes associated with the consumption of industrialized foods, their prevalence remains significant. It is crucial to note that the excessive intake of food additives can disrupt hormonal regulation, impairing natural satiety mechanisms [24,25].

In Brazil, ongoing public policies, guidelines, and initiatives address the impact of ultra-processed food consumption on public health. These efforts also recognize the influence of media and food packaging in promoting and shaping consumer choices towards these types of foods. The overarching goal of these initiatives is to discourage the consumption of ultra-processed foods and promote the consumption of unprocessed or minimally processed foods, as advocated in the Dietary Guidelines for the Brazilian Population. By focusing on promoting healthier dietary choices and reducing the intake of ultra-processed foods, these policies aim to improve public health outcomes and mitigate the burden of chronic diseases associated with poor dietary habits.

As a cross-sectional study, this research has inherent limitations, primarily due to the collection of exposure and outcome data at the same time. This setup makes it challenging to establish temporal relationships between events and to determine with certainty whether the observed correlations are causal.

In this study, a weak relationship was found between the consumption of unprocessed or minimally processed foods and the External domain of the MEQ. This underscores how significantly the environment can influence the dietary choices of individuals with T2DM. Furthermore, the findings indicate that higher external influences are associated with increased weight, BMI, and WC among participants.

There is a scarcity of studies exploring the relationship between mindful eating and food quality, particularly in individuals with T2DM. More research is needed to better understand how these factors interrelate and influence dietary behaviors and health outcomes in this population. Addressing these research gaps could provide valuable insights for developing effective interventions aimed at promoting healthier eating habits and improving outcomes for individuals managing chronic diseases like T2DM.