Abstracts
Objective
To investigate the relationship between macronutrient intake adequacy and the national diet quality index score.
Methods
The study analyzed a representative sample of 1,662 individuals from the municipality of São Paulo who participated in a cross-sectional study called Health Survey-Capital (2008/2009). Two 24-hour recalls were collected. Habitual intake was determined by the Multiple Source Method. The Brazilian index was calculated as suggested, and macronutrient adequacy was given by the World Health Organization and Food and Agriculture Organization recommendations. A generalized linear model verified the relationship between the Brazilian index and macronutrient adequacy. All analyses with a descriptive level below 0.05 were considered significant. The analyses were performed by the software Stata 12.0, survey mode.
Results
The vast majority (91%) of the population had inappropriate macronutrient intakes, and the total median Brazilian index score was 61.3 points (interquartile range=10.1). The total Brazilian index score of individuals with high lipid intake was worse than that of individuals with proper lipid intake (β=0,96; p=0,004), while those with high protein intake had a better score (β=1,10; p=0,003) than those with proper protein intake.
Conclusion
The revised Brazilian Healthy Eating Index assesses diet quality properly regarding high lipid intake, but it has some limitations regarding high protein intake according to the World Health Organization and Food and Agriculture Organization recommendations. New studies should investigate the possibility of adapting this index to the World Health Organization and Food and Agriculture Organization recommendations.
Diet; Diet surveys; Macronutrients; Recommended dietary allowances
Objetivo
Averiguar a relação entre adequação do consumo de macronutrientes e pontuação do índice nacional de qualidade da dieta.
Métodos
Foram analisados 1.662 indivíduos de uma amostra representativa dos residentes do município de São Paulo, pertencentes ao estudo transversal denominado Inquérito de Saúde em São Paulo (2008/2009). Foram coletados dois recordatórios de 24 horas. A ingestão habitual foi determinada pelo Multiple Source Method. O índice foi calculado e a adequação dos macronutrientes baseou-se nas recomendações da World Health Organization e Food and Agriculture Organization. A relação entre índice e adequação dos macronutrientes foi verificada por meio do modelo linear generalizado. Para todas as análises, considerou-se significativo nível descritivo inferior a 0,05. As análises foram feitas no programa Stata 12.0, modo survey.
Resultados
Observou-se que 91% da população consumiram quantidades inadequadas dos macronutrientes, sendo a pontuação mediana total do índice de 61,3 pontos (interquatile range=10,1). A pontuação total do índice de indivíduos com consumo excessivo de lipídios apresentou-se pior em relação aos de ingestão adequada (β=0,96; p=0,004), enquanto a pontuação daqueles com consumo excessivo de proteínas apresentou-se melhor (β=1,10; p=0,003) aos de ingestão adequada desse macronutriente.
Conclusão
O Índice de Qualidade da Dieta Revisado avalia qualidade da dieta adequadamente em relação à ingestão excessiva de lipídios e com algumas limitações em relação à de proteínas, de acordo com as recomendações da World Health Organization e Food and Agriculture Organization. Sugerem-se novos estudos que investiguem possibilidades de adaptação desse índice à s recomendações da World Health Organization e Food and Agriculture Organization.
Dieta; Inquéritos sobre dietas; Macronutrientes; Recomendações nutricionais
INTRODUCTION
Diet complexity led to the proposal of many food intake assessment methods, such as dietary indexes, which have been extensively used in the literature because of their ability to measure, in a summarized way, the main characteristics of a healthy diet, and to incorporate in the analyses the correlation between foods and nutrients11 Morimoto JM, Latorre MRDO, César CLG, Caran-dina L, Barros MBA, Goldbaum M, et al. Fatores associados à qualidade da dieta de adultos residentes na Região Metropolitana de São Paulo, Brasil, 2002. Cad Saúde Pública. 2008; 24(1):169-78. http://dx.doi.org/10.1590/S0102-311X2008000100017
https://doi.org/10.1590/S0102-311X200800...
, 22 Previdelli AN, Andrade SC, Pires MM, Ferreira SRG, Fisberg RM, Marchioni DML. A revised version of the Healthy Eating Index for the Brazilian population. Rev Saúde Pública. 2011; 45(4):794-8.
https://doi.org/10.1590/S0034-8910201100...
. Some of the many indexes available today are the Health Eating Index33 Guenther PM, Casavale KO, Reedy J, Kirkpatrick SI, Hiza HAB, Kuczynski KJ, et al. Update of the Healthy Eating Index: HEI-2010. J Acad Nutr Diet. 2013; 113(4):569-80., Mediterranean Diet Score44 Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: A Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis. 2006; 16(8):559-68., Dietary Approaches to Stop Hypertension score55 Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-Style diet and risk of coronary heart disease and stroke in women. Arch Intern Med. 2008; 168(7):713-20., and in Brazil, the revised Brazilian Healthy Eating Index (BHEI), which is a version of the Healthy Eating Index (HEI-2005)22 Previdelli AN, Andrade SC, Pires MM, Ferreira SRG, Fisberg RM, Marchioni DML. A revised version of the Healthy Eating Index for the Brazilian population. Rev Saúde Pública. 2011; 45(4):794-8.
https://doi.org/10.1590/S0034-8910201100...
adapted for the Brazilian population.
In this context, the BHEI assesses the intake of many food groups, nutrients, and combinations thereof in relation to the current dietary recommendations. The BHEI assesses diet adequacy both qualitatively and quantitatively regarding food groups, and can simultaneously assess and monitor diets at the individual and population levels22 Previdelli AN, Andrade SC, Pires MM, Ferreira SRG, Fisberg RM, Marchioni DML. A revised version of the Healthy Eating Index for the Brazilian population. Rev Saúde Pública. 2011; 45(4):794-8.
https://doi.org/10.1590/S0034-8910201100...
. Therefore, there is a gap in the literature regarding the ability of this dietary index to assess macronutrient intake adequacy.
However, the score of BHEI is based only on food group adequacy and does not directly include macronutrient intake adequacy. According to the World Health Organization (WHO) and Food and Agriculture Organization (FAO)66 World Health Organization, Food and Agriculture Organization. Diet, nutrition, and the prevention of chronic diseases. Technical Report Series, nº 916. Geneva: WHO; 2003., a healthy diet should get 55 to 75% of its energy from carbohydrates, 10 to 15% from proteins, and 15 to 30% from lipids.
We do not have knowledge about other studies in the literature that analyzed the ability of the BHEI to assess macronutrient intake adequacy. Hence, the present study aims to investigate the relationship between macronutrient intake adequacy and the BHEI in a representative sample of individuals from the municipality of São Paulo(SP).
METHODS
The study used data from a population-based cross-sectional study conducted by census sectors called Inquérito de Saúde em São Paulo(ISA-Capital, Health Survey for São Paulo). Trained interviewers conducted the interviews and administered the questionnaires at the participants' homes in 2008/200977 Fisberg RM, Marchioni DML, organizadoras. Manual de avaliação do consumo alimentar em estu-dos populacionais: a experiência do Inquérito de Saúde em São Paulo (ISA). São Paulo: Universidade de São Paulo; 2012..
The sample consisted of 560 adolescents, 585 adults, and 517 older adults, totaling 1,662 individuals. The age groups were defined as follows: adolescents aged 10 to 19 years; adults aged 20 to 59 years; and older adults aged 60 years or more88 Brasil. Ministério da Saúde. Orientações para a coleta e análise de dados antropométricos em serviços de saúde: norma técnica do Sistema de Vigilância Alimentar e Nutricional - Sisvan. Série G. Estatística e Informação em Saúde. Brasília: Minis-tério da Saúde; 2011.. Activity was assessed by a questionnaire validated in Brazil by Matsudo et al. 99 Matsudo S, Araujo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questionario Internacional de Atividade Fisica (IPAQ) estudo de validade e reprodutibilidade no brasil. Rev Bras Ativ Física Saúde. 2001; 6(2):5-18., and level of physical activity was classified as suggested by Craig et al. 1010 Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003; 35(8):1381-95.. Food intake was determined by two 24-Hour Dietary Recalls (24HR) as instructed by the manual published by Fisberg & Marchioni7. The software Nutrition Data System for Research analyzed nutritional value; the foods listed in this software and the conversion of cooking units into grams and milliliters are based on Brazilian publications1111 Pinheiro AB, Lacerda EM, Benzecry EH, Gomes MCS, Costa VM. Tabela para avaliação de consumo alimentar em medidas caseira. 2ª ed. Rio de Janeiro: UERJ; 1994. , 1212 Fisberg RM, Villar BS. Manual de receitas e medidas caseiras para cálculo de inquéritos alimentares. São Paulo: Signus; 2002..
The online platform Multiple Source Method estimated the habitual food and nutrient intakes1313 Haubrock J, Nöthlings U, Volatier JL, Dekkers A, Ocké M, Harttig U, et al. Estimating usual food intake distributions by using the Multiple Source Method in the EPIC-Potsdam Calibration Study. J Nutr. 2011; 141(5):914-20. http://dx.doi.org/10.39 45/jn.109.120394
https://doi.org/10.3945/jn.109.120394...
, and the estimates were used for calculating the BHEI and BHEI component scores according to the score scale methodology proposed by Previdelli et al. 22 Previdelli AN, Andrade SC, Pires MM, Ferreira SRG, Fisberg RM, Marchioni DML. A revised version of the Healthy Eating Index for the Brazilian population. Rev Saúde Pública. 2011; 45(4):794-8.
https://doi.org/10.1590/S0034-8910201100...
. The BHEI has twelve components: nine food groups ("total fruits", "whole fruits", "total vegetables", "dark green/orange vegetables and legumes", "total grains", "whole grains", "milk and dairy products", "meats, eggs, and legumes", and "oils"); two nutrients ("sodium" and "saturated fats"); and the last component is energy coming from Solid Fats, Added Sugar, and Alcohol (SoFAA)11 Morimoto JM, Latorre MRDO, César CLG, Caran-dina L, Barros MBA, Goldbaum M, et al. Fatores associados à qualidade da dieta de adultos residentes na Região Metropolitana de São Paulo, Brasil, 2002. Cad Saúde Pública. 2008; 24(1):169-78. http://dx.doi.org/10.1590/S0102-311X2008000100017
https://doi.org/10.1590/S0102-311X200800...
. The maximum scores vary: five for the first six components, 10 for the next five components, and 20 for the last component. For most components, the intermediate scores are given by the proportional value of the extreme scores of each component, except for the components "sodium" and "saturated fats", whose scores have two cut-off points. The scores of these two components are calculated proportionally, considering the score intervals zero to eight and eight to ten. More details can be found elsewhere11 Morimoto JM, Latorre MRDO, César CLG, Caran-dina L, Barros MBA, Goldbaum M, et al. Fatores associados à qualidade da dieta de adultos residentes na Região Metropolitana de São Paulo, Brasil, 2002. Cad Saúde Pública. 2008; 24(1):169-78. http://dx.doi.org/10.1590/S0102-311X2008000100017
https://doi.org/10.1590/S0102-311X200800...
. Macronutrient adequacy was based on the WHO & FAO66 World Health Organization, Food and Agriculture Organization. Diet, nutrition, and the prevention of chronic diseases. Technical Report Series, nº 916. Geneva: WHO; 2003. recommendations.
Descriptive data analysis used central tendency and dispersion measures. The censlope command verified the difference between the median BHEI and BHEI component scores of individuals with appropriate and inappropriate macronutrient intakes, which determines the confidence intervals between the medians1414 Newson R. Confidence intervals for rank statistics: Percentile slopes, differences, and ratios. Stata J. 2006; 6(4):497-520..
Gaussian Generalized Linear Models with a logarithmic link function were constructed to measure the association between BHEI and BHEI component scores and macronutrient intake adequacy. The dependent variable was the BHEI and BHEI component scores and the independent variables were: protein, carbohydrate, and lipid intake adequacies (below the recommended range, within the recommended range, and above the recommended range) and age (years). The adjustment variables were sex (male and female); habitual total calorie intake/day; and education level of the household head (years). Household head was self-reported. All analyses were performed by the software Stata version 12.0 in survey mode. Modeling with the total BHEI score followed the forward stepwise procedure, selecting the most parsimonious model with the best adjustment according to assessment graphs.
The study was approved by the Research Ethics Committee of the School of Public Health of the Universidade de São Paulo under Protocol nº OF.COEP/050/13, nº 2001, and all participants signed an Informed Consent Form.
RESULTS
Approximately 47% of the sample was male and 53% was female. The lowest age was 12 years and the highest, 97 years. The mean education level of the household head was 8.5 years (Standard Error - SE=0.20), and the mean habitual total calorie intake was 1881.90 kcal/day (SE=25.36).
Based on the percentage distribution of energy provided by macronutrients established by the WHO & FAO6, 91.0% of the residents of São Paulo city did not consume appropriate amounts of carbohydrates, lipids, and proteins. Of these, 99.5% had inadequate carbohydrate intake, with a mean intake of 35.0% (95.0% Confidence Interval - 95.0%CI=34.5-35.6) of the total energy intake. Most participants had protein and lipid intakes above the recommended range; 93.1% consumed on average 41.8% (95.0%CI=41.3-42.2) of their total calorie intake from lipids, and 97.8%, consumed on average 22.0% (95.0%CI=21.8-22.3) of their total calorie intake from proteins. Nobody in the sample had carbohydrate intake above the recommended range (Table 1).
of individuals from the municipality of São Paulo with macronutrient intakes below, within, and above the recommended ranges as a percentage of the daily calorie intake according to the World Health Organization and Food and Agriculture Organization (WHO & FAO) recommendations. São Paulo (SP), Brazil, 2015.
The median general BHEI score was 61.3 points (Interquartile Range [IQR]=10.1). The score of this index indicates that diets with protein content above the recommended range and diets with lipid content within the recommended range are healthier. The BHEI did not differentiate the diet quality of individuals with macronutrient intake percentages below and within the recommended ranges, even though some BHEI components had statistically different scores for these two classifications. Diets with protein content above the recommended range contained more "meats, eggs, and legumes" and "sodium" than diets with normal protein levels. Diets with lipid content above the recommended range contained more saturated fats and less total fruits than diets with normal lipid levels (Table 2).
The relationship between the BHEI score and protein, lipid, and carbohydrate intake adequacy shows that when the mean habitual lipid intake is above the recommended range, the mean BHEI score is significantly lower (β=0.96; p=0.001) than when lipid intake is within the recommended range (Table 3). In other words, individuals with lipid intake above the recommended range have, on average, a total score four percent lower than individuals with lipid intake within the recommended range. However, this is not valid for protein intake since the mean BHEI score of individuals with protein intake above the recommended range is significantly higher β=1.10; p=0.005) than that of individuals with protein intake within the recommended range. The values for carbohydrates were not significant. These relationships occur regardless of sex, age group, education level of the household head, level of physical activity, and total habitual calorie intake. Diet quality also increases age (adults: β=1.04; p<0.001; older adults: β=1.11; p<0.001 in relation to adolescents) and gender, being higher in females (β=1.02; p=0.038) (Table 3). The variables education level of the household head and level of physical activity were not significantly related to the BHEI score.
DISCUSSION
The Brazilian Healthy Eating Index score classified diets with protein content above the recommended range as of better quality than those with protein content within the recommended range, and it properly assessed diets with lipid content above the recommended range, showing that these diets are worse than those with lipid content within the recommended range. Additionally, the BHEI score did not differentiate the quality of diets with protein, lipid, and carbohydrate contents below the recommended range from that of diets with macronutrient contents within the recommended ranges according to the FAO & WHO6.
The mean Brazilian Healthy Eating Index score (61.3 points) found for the present sample was similar to that reported by Fisberg et al. 1515 Fisberg RM, Morimoto JM, Slater B, Barros MBA, Carandina L, Goldbaum M, et al. Dietary quality and associated factors among adults living in the state of São Paulo, Brazil. J Am Diet Assoc. 2006; 106(12):2067-72. http://dx.doi.org/10.1016/j.jada.2006.09.010
https://doi.org/10.1016/j.jada.2006.09.0...
, who assessed the diet quality of 3,454 individuals from the municipality of São Paulo and reported a mean score of 60.4 points. A higher mean score (63.7 points) was found by the Third National Health and Nutrition Examination Survey III, a study with a representative sample of the American population that used the Healthy Eating Index (HEI) to assess diet quality1616 Tande DL, Magel R, Strand BN. Healthy Eating Index and abdominal obesity. Public Health Nutr. 2009; 13(2):208-14. http://dx.doi.org/10.1017/S1368980009990723
https://doi.org/10.1017/S136898000999072...
. Navarro & Moncada1717 Navarro AIN, Moncada RO. Calidad de la dieta española según el índice de alimentación saludable. Nutr Hosp. 2011; 26(2):330-6. used a diet quality index based on HEI called Índice de Alimentación Saludable para la población Española and found even higher mean scores than the present score, 69.95 for men and 73.73 for women. Despite the fluctuations of the mean scores, the values are close, suggesting agreement between the adapted indexes.
One of the factors that contributes to the limited BHEI assessment of protein intake within the recommended range is the absence of negative scores for high intake of high-protein foods (like HEI-2005), such as the excessive meat intake seen in São Paulo and many other Brazilian municipalities1818 Carvalho AM, César CLG, Fisberg RM, Marchioni DML. Excessive meat consumption in Brazil: Diet quality and environmental impacts. Public Health Nutr. 2012; 16(10):1893-9. http://dx.doi.org/10.1017/S1368980012003916
https://doi.org/10.1017/S136898001200391...
, 1919 Instituto Brasileiro de Geografia e Estatística. Pes-quisa de orçamentos familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Ja-neiro: IBGE; 2011.. The high intake of red meat by the population of São Paulo results mainly in high intake of saturated fat, and this type of fat is an important factor in the development of cardiovascular diseases and other diseases2020 Santos RD, Gagliardi ACM, Xavier HT, Magnoni CD, Cassani R, Lottenberg AM, et al. Sociedade Bra-sileira de Cardiologia: I Diretriz sobre o consumo de gorduras e saúde cardiovascular. Arq Bras Cardiol. 2013; 100(1 Supl 3):1-40. http://dx.doi.org/105935/abc.2013S003
https://doi.org/10.5935/abc.2013S003...
. The high intake of meats, especially processed meats, may also contribute to the high intake of sodium (low score) by people with high protein intake. This scenario may be aggravated by high intake of processed products, addition of too much salt, and use of high-sodium condiments1818 Carvalho AM, César CLG, Fisberg RM, Marchioni DML. Excessive meat consumption in Brazil: Diet quality and environmental impacts. Public Health Nutr. 2012; 16(10):1893-9. http://dx.doi.org/10.1017/S1368980012003916
https://doi.org/10.1017/S136898001200391...
, 2121 Selem SSC. Padrões da dieta e hipertensão em adultos e idosos de São Paulo [mestrado]. São Paulo: Universidade de São Paulo; 2012..
The ability of the index to capture the difference between the diet quality of individuals with lipid intake above and within the recommended ranges can be favored by the presence of moderators, such as "saturated fats" in the structure of the calculation. Furthermore, the index was capable of differentiating between the "total fruit" intake of individuals with lipid intake above the recommended range and those with lipid intake within the recommended range, even though less than 10% of the Brazilian population consumes the recommended levels of fruits, vegetables, and legumes, foods that have a protective role against chronic diseases1919 Instituto Brasileiro de Geografia e Estatística. Pes-quisa de orçamentos familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Ja-neiro: IBGE; 2011. , 2222 Brasil. Ministério da Saúde. Guia alimentar para a população brasileira. 2a ed. Brasília: Ministério da Saúde; 2014 [acesso 2015 abr 12]. Disponível em: http://portalsaude.saude.gov.br/images/pdf/2014/novembro/05/Guia-Alimentar-para-a-pop-brasiliera-Miolo-PDF-Internet.pdf
http://portalsaude.saude.gov.br/images/p...
.
Another aspect demonstrated in this study was the higher ability of the BHEI of differentiating diet quality by gender, showing that females adhere more to healthy food recommendations, corroborating Andrade et al. 2323 Andrade SC, Previdelli AN, Marchioni DML, Fisberg RM. Avaliação da confiabilidade e validade do Índi-ce de Qualidade da Dieta Revisado. Rev Saúde Pública. 2013; 47(4):675-83. http://dx.doi.org/10.1590/S0034-8910.2013047004267
https://doi.org/10.1590/S0034-8910.20130...
, who published similar findings and claimed that this specific ability is an aspect of this index that reinforces its reliability and validity. The individual's age or age group could also reflect better food choices with rising age1, and in fact this study found that adults and older adults have healthier diets than adolescents. Other characteristics, such as education level of the household head and level of physical activity, are not significantly related to BHEI score, but are considered important variables in diet quality variability. Therefore, they are essential for the proposed analyses11 Morimoto JM, Latorre MRDO, César CLG, Caran-dina L, Barros MBA, Goldbaum M, et al. Fatores associados à qualidade da dieta de adultos residentes na Região Metropolitana de São Paulo, Brasil, 2002. Cad Saúde Pública. 2008; 24(1):169-78. http://dx.doi.org/10.1590/S0102-311X2008000100017
https://doi.org/10.1590/S0102-311X200800...
.
Some limitations of the study are the homogeneous distribution of the participants regarding the macronutrient intake adequacy in the population, with most people being classified as having inappropriate adequacy. Regardless, the relationships between the BHEI scores and macronutrient intake adequacy differed significantly. Another limitation was the use of only two 24-HR recalls, which is not enough to capture daily food intake variations. However, this study calculated the habitual food intake to remove this intrapersonal variability, hence getting closer to an individual's actual food intake1313 Haubrock J, Nöthlings U, Volatier JL, Dekkers A, Ocké M, Harttig U, et al. Estimating usual food intake distributions by using the Multiple Source Method in the EPIC-Potsdam Calibration Study. J Nutr. 2011; 141(5):914-20. http://dx.doi.org/10.39 45/jn.109.120394
https://doi.org/10.3945/jn.109.120394...
, 2424 Bastos JLD, Duquia RP. Um dos delineamentos mais empregados em epidemiologia: estudo transversal. Scientia Med. 2007; 17(4):229-32..
CONCLUSION
The study results evidence that the diets of individuals from the municipality of São Paulo have a high inadequacy index regarding the percentage macronutrient distribution and show that this inadequacy can be partially detected by the BHEI. Therefore, the BHEI correctly assesses the diet quality of diets with lipid content above the recommended range and assesses with some limitations the diet quality of diets with protein content above the recommended range according to the WHO and FAO recommendations. BHEI does not differentiate diets with macronutrient contents below and within the recommended ranges for all macronutrients. New studies should investigate the possibility of adapting this index to the current recommendations to reduce its limitations.
ACKNOWLEDGMENTS
We thank Conselho Nacional de Desenvolvimento Científico e Tecnológicofor sponsoring the study.
REFERENCES
-
1Morimoto JM, Latorre MRDO, César CLG, Caran-dina L, Barros MBA, Goldbaum M, et al. Fatores associados à qualidade da dieta de adultos residentes na Região Metropolitana de São Paulo, Brasil, 2002. Cad Saúde Pública. 2008; 24(1):169-78. http://dx.doi.org/10.1590/S0102-311X2008000100017
» https://doi.org/10.1590/S0102-311X2008000100017 -
2Previdelli AN, Andrade SC, Pires MM, Ferreira SRG, Fisberg RM, Marchioni DML. A revised version of the Healthy Eating Index for the Brazilian population. Rev Saúde Pública. 2011; 45(4):794-8.
» https://doi.org/10.1590/S0034-89102011005000035 -
3Guenther PM, Casavale KO, Reedy J, Kirkpatrick SI, Hiza HAB, Kuczynski KJ, et al. Update of the Healthy Eating Index: HEI-2010. J Acad Nutr Diet. 2013; 113(4):569-80.
-
4Panagiotakos DB, Pitsavos C, Stefanadis C. Dietary patterns: A Mediterranean diet score and its relation to clinical and biological markers of cardiovascular disease risk. Nutr Metab Cardiovasc Dis. 2006; 16(8):559-68.
-
5Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-Style diet and risk of coronary heart disease and stroke in women. Arch Intern Med. 2008; 168(7):713-20.
-
6World Health Organization, Food and Agriculture Organization. Diet, nutrition, and the prevention of chronic diseases. Technical Report Series, nº 916. Geneva: WHO; 2003.
-
7Fisberg RM, Marchioni DML, organizadoras. Manual de avaliação do consumo alimentar em estu-dos populacionais: a experiência do Inquérito de Saúde em São Paulo (ISA). São Paulo: Universidade de São Paulo; 2012.
-
8Brasil. Ministério da Saúde. Orientações para a coleta e análise de dados antropométricos em serviços de saúde: norma técnica do Sistema de Vigilância Alimentar e Nutricional - Sisvan. Série G. Estatística e Informação em Saúde. Brasília: Minis-tério da Saúde; 2011.
-
9Matsudo S, Araujo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questionario Internacional de Atividade Fisica (IPAQ) estudo de validade e reprodutibilidade no brasil. Rev Bras Ativ Física Saúde. 2001; 6(2):5-18.
-
10Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003; 35(8):1381-95.
-
11Pinheiro AB, Lacerda EM, Benzecry EH, Gomes MCS, Costa VM. Tabela para avaliação de consumo alimentar em medidas caseira. 2ª ed. Rio de Janeiro: UERJ; 1994.
-
12Fisberg RM, Villar BS. Manual de receitas e medidas caseiras para cálculo de inquéritos alimentares. São Paulo: Signus; 2002.
-
13Haubrock J, Nöthlings U, Volatier JL, Dekkers A, Ocké M, Harttig U, et al. Estimating usual food intake distributions by using the Multiple Source Method in the EPIC-Potsdam Calibration Study. J Nutr. 2011; 141(5):914-20. http://dx.doi.org/10.39 45/jn.109.120394
» https://doi.org/10.3945/jn.109.120394 -
14Newson R. Confidence intervals for rank statistics: Percentile slopes, differences, and ratios. Stata J. 2006; 6(4):497-520.
-
15Fisberg RM, Morimoto JM, Slater B, Barros MBA, Carandina L, Goldbaum M, et al. Dietary quality and associated factors among adults living in the state of São Paulo, Brazil. J Am Diet Assoc. 2006; 106(12):2067-72. http://dx.doi.org/10.1016/j.jada.2006.09.010
» https://doi.org/10.1016/j.jada.2006.09.010 -
16Tande DL, Magel R, Strand BN. Healthy Eating Index and abdominal obesity. Public Health Nutr. 2009; 13(2):208-14. http://dx.doi.org/10.1017/S1368980009990723
» https://doi.org/10.1017/S1368980009990723 -
17Navarro AIN, Moncada RO. Calidad de la dieta española según el índice de alimentación saludable. Nutr Hosp. 2011; 26(2):330-6.
-
18Carvalho AM, César CLG, Fisberg RM, Marchioni DML. Excessive meat consumption in Brazil: Diet quality and environmental impacts. Public Health Nutr. 2012; 16(10):1893-9. http://dx.doi.org/10.1017/S1368980012003916
» https://doi.org/10.1017/S1368980012003916 -
19Instituto Brasileiro de Geografia e Estatística. Pes-quisa de orçamentos familiares 2008-2009: análise do consumo alimentar pessoal no Brasil. Rio de Ja-neiro: IBGE; 2011.
-
20Santos RD, Gagliardi ACM, Xavier HT, Magnoni CD, Cassani R, Lottenberg AM, et al. Sociedade Bra-sileira de Cardiologia: I Diretriz sobre o consumo de gorduras e saúde cardiovascular. Arq Bras Cardiol. 2013; 100(1 Supl 3):1-40. http://dx.doi.org/105935/abc.2013S003
» https://doi.org/10.5935/abc.2013S003 -
21Selem SSC. Padrões da dieta e hipertensão em adultos e idosos de São Paulo [mestrado]. São Paulo: Universidade de São Paulo; 2012.
-
22Brasil. Ministério da Saúde. Guia alimentar para a população brasileira. 2a ed. Brasília: Ministério da Saúde; 2014 [acesso 2015 abr 12]. Disponível em: http://portalsaude.saude.gov.br/images/pdf/2014/novembro/05/Guia-Alimentar-para-a-pop-brasiliera-Miolo-PDF-Internet.pdf
» http://portalsaude.saude.gov.br/images/pdf/2014/novembro/05/Guia-Alimentar-para-a-pop-brasiliera-Miolo-PDF-Internet.pdf -
23Andrade SC, Previdelli AN, Marchioni DML, Fisberg RM. Avaliação da confiabilidade e validade do Índi-ce de Qualidade da Dieta Revisado. Rev Saúde Pública. 2013; 47(4):675-83. http://dx.doi.org/10.1590/S0034-8910.2013047004267
» https://doi.org/10.1590/S0034-8910.2013047004267 -
24Bastos JLD, Duquia RP. Um dos delineamentos mais empregados em epidemiologia: estudo transversal. Scientia Med. 2007; 17(4):229-32.
Publication Dates
-
Publication in this collection
Aug 2015
History
-
Received
27 May 2014 -
Reviewed
28 Apr 2015 -
Accepted
18 May 2015