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Print version ISSN 1415-790X
Rev. bras. epidemiol. vol.15 n.3 São Paulo Sep. 2012
Daniela de AssumpçãoI; Marilisa Berti de Azevedo BarrosI; Regina Mara FisbergII; Luana CarandinaIII; Moises GoldbaumIV; Chester Luiz Galvão CesarII
de Ciências Médicas da Universidade Estadual de Campinas, Campinas,
IIFaculdade de Saúde Pública da Universidade de São Paulo, São Paulo, Brasil
IIIFaculdade de Medicina de Botucatu da Universidade Estadual Paulista, Botucatu, Brasil
IVFaculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
We assessed the overall diet quality and adequacy of diet consumption of each component of the diet of adolescents according to demographic, socioeconomic and body mass index (BMI) data. A cross-sectional population-based study analyzed a representative sample of 409 adolescents, aged 12-19 years, using the Healthy Eating Index (HEI). We estimated the prevalence of diets classified in the first quartile of the HEI and the average scores of each component of the HEI. Linear and Poisson multiple regressions were used in the analysis. The mean score of HEI was 59.7. We observed a lower prevalence of inadequate diets in the segment with heads of household presenting higher schooling. The lower socioeconomic status segments, measured by income and schooling, showed a lower consumption of vegetables, fruits, dairy products and a less diversified diet, and a higher intake of cereals and legumes. Overweight/obese adolescents consume more meat and eggs and less fruit compared to low weight/normal weight adolescents. Girls had a higher intake of total fat and lower sodium intake. The results identified diet components that deserve more attention in the strategies to promote healthy eating, and the more vulnerable segments among adolescents.
Keywords: Adolescent. Feeding behavior. Eating. Nutrition survey. Diet. Nutrition.
Adolescence is a stage of life characterized by significant changes in biological, psychological and social dimensions, and is considered of fundamental importance to the formation of habits and attitudes, including dietary habits, which have an impact on the present and future health of the adolescent 1. Literature has shown evidence of the determinant role of a healthy diet in the prevention of different types of diseases, such as diabetes, cardiovascular disturbances, and various neoplasms 2.
In 2009, the National Survey of the Health of Schoolchildren (PeNSE) 3, investigated the food consumption of adolescent students at public and private schools in Brazil. Food identified as healthy (beans, vegetables, fruits and milk) and unhealthy (soft drinks, sweet biscuits and cold meats) were used to evaluate diet. Results indicated the frequent consumption of unhealthy food, especially among girls. The intake of fruit and vegetables was extremely low for both genders, and was directly influenced by socio-economic level, which confirmed the findings of other studies in Brazil 4,5. These dietary inadequacies become even more relevant as a result of the high prevalence of overweight and obesity among adolescents 6.
When considering the repercussions of diet on the general state of health and the incidence of disease, researchers have sought to develop indices to evaluate quality of diet in a global and synthetic form 7. The Healthy Eating Index - (HEI), which represents such an index, was developed by the Department of Agriculture of the United States, with the aim of evaluating nutritional care needs and the recommendations of dietary guidelines8. The HEI was adapted for use in Brazil by Fisberg et al. 9.
Taking into account the importance of establishing eating patterns during adolescence and the necessity of monitoring the diet of this segment of the population to evaluate and refocus interventions, the present study aimed to evaluate the overall diet quality and adequacy of intake of each of the ten components of the HEI, according to demographic and socioeconomic variables and body mass index (BMI), of adolescents in the city of Campinas, SP.
Data used in the present study was gathered from a multicenter health survey, performed between 2001 and 2002, in four areas of the state of São Paulo, including the city of Campinas. Campinas has around one million inhabitants and is an important industrial and technological center in the state of São Paulo. In 2000, adolescents comprised 17.8% of the population of the city10.
The survey sample was determined by random sampling procedures, stratified and by conglomerate, and was divided in two stages: census sector and households. The census sectors of the city of Campinas were grouped into three strata according to percentage of head of household with university education, with ten sectors then randomly selected from each stratum.
After an inventory of households in the 30 randomly selected census sectors was performed, a random selection by gender and age was performed within the households.
In order to guarantee minimum sample numbers for determined population subgroups, eight fields of age and sex were defined, among them the segment of males aged 12 to 19 years and females aged 12 to 19 years. For each field of gender and age, a minimum sample size of 200 individuals was calculated, based on an estimated prevalence of 50% (which corresponds to maximum variability), with a confidence level of 95%, maximum error of 0.10 and a design effect (deff) of 2. For the present study data was analyzed from only two strata which would correspond to a minimum sample size of 400 individuals.
Information was collected in households by trained researchers, through the application of a questionnaire organized into 19 thematic blocks, with the majority of questions closed. The tool had been previously tested in a pilot study.
For the present study, data for adolescents aged 12 to 19 years was analyzed. The adolescents were of both genders, not institutionalized, resident in the urban area of the city of Campinas, and had their daily food intake evaluated by 24-hour dietary recall (R24h).
The dependent variables were derived from the Healthy Eating Index adapted for the population of Brazil by Fisberg et al. 9 in a study performed on a subsample of this same multicenter survey and later modified by Godoy et al.11.
The index used was comprised of six components related to food groups (cereals, bread, roots and tubers; vegetables; fruit; milk and dairy products; meat and eggs; pulses), three components related to nutrients (total fat, cholesterol and sodium) and one which evaluated variety of diet. Each of the ten components of HEI was evaluated and scored from zero to ten, so that total HEI score could reach a maximum value of 100 points. Intermediate values of ingestion were calculated proportionally considering the interval between the minimum and maximum scoring criteria established for each component (Chart 1). The calculation for HEI was based on information obtained through the application of a 24h recall survey (R24h). The method recommended by Thompson and Byers12 was used to apply the R24h survey. Before data was entered, quantification of the R24h was performed in order to identify errors and to change food quantities listed by household language into grams. Mixed meals, such as sandwiches and pizzas, were separated by ingredient and subsequently classified in their respective food groups. The nutritional value of food consumed was calculated, using the Virtual Nutri version 1.0 program (Universidade de São Paulo, São Paulo, Brazil), with a food database adapted to include the different chemical composition of foods11.
The dependent variables in the study were: a) prevalence of diets in the 1st quartile of distribution of HEI scores, which corresponded to diets with lower scores, being diets of poor quality; and b) the average score of each of the ten HEI components.
The independent variables were:
Demographic: gender, age, ethnic background, religion and number of people in household.
Socioeconomic: level of schooling of head of family, monthly family income per capita (measured in minimum salaries) and occupation of adolescent.
Nutritional status assessed by BMI was calculated from the weight and height supplied. The nutritional status of adolescents was classified as underweight, healthy weight, overweight and obese, according to the cutoffs recommended by the World Health Organization (WHO, 2007) 13, with percentages used referring to the midpoint of age.
The interview data was entered into a database created using the Epi Info 6.04b program (Center for Disease Control and Prevention, Atlanta, USA). The prevalence of diets in the 1st quartile of the HEI according to the independent variables was calculated, with the association verified by χ2 test and with a 5% significance level. Prevalence rations and confidence intervals of 95% were calculated using Poisson simple regression analysis. For the multiple regression model, constructed using Poisson multiple regression analysis, the variables with p value < 0.20 in bivariate analysis were introduced, with variables with a value of p < 0.05 remaining in the model.
The mean scores for each of the ten components of the HEI were also calculated and the association between these components and independent variables was calculated. A multiple linear regression model was developed for each component of the HEI with variables with a value of p < 0.20 in bivariate analysis being introduced, with variables with a value of p < 0.05 remaining in the model. All the models included adjustment for total energy of diet.
Statistical analysis was performed with the Stata 10 program (Stata Corporation, College Station, USA) which allowed the following characteristics of sample design to be considered: strata, weighting and conglomerates.
The present study was approved by the Ethics Research Committee of the Faculdade de Ciências Médicas of UNICAMP, through an addendum to process 369/2000.
Among 433 adolescents identified in residences selected to participate in the study, 12 refused to participate, so that the study comprised interviews with 421 individuals.
Of the 421 adolescents in the study, 12 were excluded as a result of having an energy consumption of less than 1% (< 641,934 Kcal) or greater than 99% (> 6546,23 Kcal) of observed distribution, taking into account the recommendation of Nielsen et al.14. As such, the information of 409 adolescents was analyzed, with an average age of 15.5 years (standard deviation = 2.33).
The sample comprised similar proportions of boys and girls, with a slightly larger participation of adolescents aged between 12 and 15 years. The strata of lower income and level of schooling of head of family represented more than 50% of individuals studied. Adolescents of caucasion ethnic background represented 71% of the sample, those of catholic faith comprised 61%, those with an occupational activity 21%, those that resided in households with 4 to 5 people represented 58%, and those that were classified as eutrophic corresponded to 77.7%.
The average HEI score was 59.7 (IC95%: 58.6-60.7), being 58.9 (IC95%: 57.3-60.4) for girls and 60.5 (IC95%: 58.8-62.1) for boys.
In relation to socioeconomic variables, a gradient of improved food quality could be clearly observed to correspond to an increased number of years of schooling of the head of the family. Adolescents with a head of family with 12 or more years of schooling had a 46% lower risk of having a HEI score in the 1st quartile and those with per capita income equal to or greater than three minimum salaries had a 29% lower risk than families with income lower than one minimum salary (Table 1).
The results of Poisson multiple regression analysis (data not included in tables) revealed that the prevalence of adolescents with diets in the 1st quartile of the HEI was significantly lower (RP=0.54; IC95%: 0.32-0.92) in households with a head of family with a greater level of schooling. When the scores of each component of the HEI (Table 2) were evaluated, low scores (< 5) were found for the components vegetables, fruits, and milk and dairy products, and only the component meat and eggs had a high score (> 8), with the remaining components having intermediate scores (5 to 8). The averages of boys were significantly superior to those of girls for four components (cereals and derivatives, vegetables, milk and dairy products and variety of diet), while girls had a higher average than boys only for the component sodium. There were higher scores for the components vegetables, fruits, milk and dairy products and variety of diet, and lower scores for the components pulses and cholesterol among the group of adolescents whose head of family had 12 or more years of schooling compared to those with up to seven years of schooling. Overweight or obese adolescents had higher average intakes in the cholesterol and sodium groups and lower average scores for fruits, milk and dairy products, and variety of diet. In segments with higher per capita income, there was greater consumption of the components vegetables, fruits, milk and dairy products, meat and eggs and variety of diet and lower consumption of pulses (Table 2).
Table 3 shows the results of the multiple regression analysis carried out for each HEI component, with the models being adjusted for total energy of diet. In relation to gender, girls had a higher consumption than boys for the component total fat, while the opposite was true for sodium. Compared to the reference category, the segment with greater family income had lower ingestion of cereals and pulses and, together with the segment with income between one and two minimum salaries, higher consumption of fruits and a greater variety of diet. In strata with higher levels of education, higher average scores were found for the group milk and dairy products, while for the vegetables group this relationship was found only in the highest strata (at the threshold of statistical significance). For BMI, overweight or obese adolescents had a lower average score for the component fruits (at the threshold of statistical significance) and a higher average score for the group meat and eggs.
The present study found a higher prevalence of poor quality diet among adolescents resident in households whose head of family had a lower level of schooling. Additionally, differences were identified between sex, schooling, income and the BMI of the adolescent in relation to different components of the quality of diet index.
The HEI score (59.7) revealed by the present study was similar to that found in population studies of adolescents performed in municipal districts in the state of São Paulo 11,15, and in Chile 16. It was slightly lower than the score verified in the study by Fernández et al. 17, of adolescents in the city of Guadalajara (Spain) and that found for North American adolescents by Goodwin et al. 18.
In the segment of greater level of schooling of the head of the family (12 years or more) a lower prevalence of poor quality of diet was observed among adolescents in Campinas, as was observed in studies performed in other countries 18,19. Education is a factor of inequality, capable of perpetuating the cycle of poverty from generation to generation and preventing the individual from reaching the goals necessary for human development, one of which is adequate diet 20.
Regarding the components of the HEI, those that had lower scores were fruits, vegetables, and milk and dairy products. These findings are consistent with other Brazilian studies that also observed low intake of fruits, vegetables and milk and dairy products in the diet of adolescents 3,11,15. The component with the highest score was meat and eggs, a result similar to the findings of studies of adolescents in other countries 16,17 and some municipal districts in the state of São Paulo 15.
In the present study, adolescents from the segment of higher family income had a lower consumption of the group cereals and derivatives, as verified by Levy-Costa et al. 21 using data from the "Pesquisa de Orçamentos Familiares" (Household Food Budget Survey - HFBS) to evaluate the evolution of food consumption in the metropolitan areas of Brazil.
A higher score was observed for the component vegetables, at the threshold of statistical significance, in the segment of greater schooling of head of family, as reported in other studies 11,22,23.
The component fruits had the highest score in segments of higher income, corroborating findings of other studies 3,21,24. In situations of food insecurity the consumption of fruits is drastically reduced as a result of the higher prices of this type of food. The study by Panigassi et al. 25 demonstrated a strong decreasing tendency in the intake of fruits from those families with secure diets to those with light, moderate or serious food insecurity. For BMI, lower consumption of fruits (at the threshold of statistical significance) was identified in adolescents with overweight/obesity. Using data on the food intake of North American children and adolescents participating in the National Health and Nutrition Examination Survey, Lorson et al.26 also found that obese individuals ate significantly less fruit compared to eutrophic individuals, a finding that has been verified by other authors27. Fruit is rich in micronutrients and fibers28 and has low energy density, which provides a positive increase in satiety and satiation, contributing to the control of healthy body weight29.
For the component milk and dairy products, significantly higher scores were found for higher levels of schooling, corroborating findings of a number of studies performed in other locations11,22,23. The results of PeNSE 3 revealed a positive association with the regular consumption of milk with level of maternal schooling. Milk and derivative products are sources of calcium, an essential nutrient, especially in adolescence, for the processes of bone formation and proper linear growth and for the prevention of the development of osteoporosis in adult life28.
For the group meat and eggs, a significantly higher score was found in overweight or obese adolescents, as has been observed by other studies27,30.
A lower average score was observed for the pulses group, in the segment with higher family income. PeNSE3 showed a significant reduction in the regular frequency of bean consumption with an increase in maternal schooling level, and among adolescents studying in private schools. Results of studies in Brazil found that the consumption of beans and other pulses revealed a tendency to decline with increased spending power21, although beans are excellent sources of protein, fibers, carbohydrates, and micronutrients, and possess a nutritional profile suitable for all ages31.
For the component total fat, there was greater consumption among girls than among boys, a result that can be explained by the more regular intake of sweet biscuits and cold meats according to the findings of PeNSE3. For the component sodium, there was lower consumption among girls, as was also observed in the study by Godoy et al.11. Feskanich et al.32 and Brown et al.33 also verified greater intake of sodium among boys. The excessive consumption of sodium is an important risk factor for arterial hypertension, coronary disease and cerebrovascular accident2. Based on HFBS data for 2002-03, Sarno et al.34 found that the quantity of available sodium for consumption in Brazilian households (4.5 grams/person/day) more than twice exceeded the maximum recommended dose, making this intake a significant issue for public health policy in relation to non-communicable diseases. Actions aimed at addressing this issue have been conducted through a partnership between the Department of Health and the food industry that provides for the gradual reduction of sodium in various industrialized products by 201435.
In relation to variety of diet it was found that greater family income led to a higher average score for the component, as was also found by Godoy et al. 11 in relation to the level of schooling of the head of the family. Variety of food is an essential requisite of a healthy diet, as it guarantees the provision of a range of nutrients, preventing the development of nutritional deficiencies28.
The present study revealed the existence of social inequality in the diet of adolescents, influencing the scores of various HEI components, and also the global indicator. These findings indicate the necessity of special attention for more socially vulnerable segments, but even among groups with higher levels of income and schooling, the intake of fruits, vegetables and milk and derivatives was below recommended levels, which indicates the importance of overall orientation.
The design effect (deff) is a useful parameter in epidemiological studies that use conglomerates at any stage of the sampling process, as it signals the suitability of the sample complex in terms of precision, taking as a base data supplied by a simple random sample 36. Table 3 shows the values of the design effect for the models developed for each component. The results indicate that this study was capable of detecting small differences between the average score of each component, of up to 0.49 for the meat and eggs group, with the majority of components with deff close to 1. This means that the sample complex did not affect the precision of the calculations.
One of the limits of the present sample refers to the application of only one 24-hour recall survey, which does not necessarily reflect the usual food intake of adolescents, due to the variability of consumption. Memory errors, difficulty in quantifying the size of portions, the under or over reporting of food, among others, are also concerns 37. However, R24h is considered a suitable tool for evaluating the average intake of foods and nutrients for a large number of individuals 38. Another limitation of this study was the fact that the survey covered a broad subject, without specific focus or concentrating on any one diet item. The cross-sectional study, in turn, prevents the interpretation of results for cause and effect, such as association with BMI. The use of self-reported information for size and height represented a further limitation, especially in adolescents passing through a phase of rapid growth and physical development. A study of adolescents in Florianopolis revealed that only the minimum percentage reported weight and health exactly 39. However the author verified that the reported measurements were very close to true measurements, and considered the information valid for use in epidemiological studies 39, as has been established by other authors 40. This study referred to data collected in 2001-2002 and serves as a base line for monitoring the quality of diet of adolescents when using data from the periodic health surveys implemented for this population group. With respect to the instrument used to evaluate quality of diet it is necessary to consider if the HEI is capable of capturing the complexity of food consumption patterns, used for directing health promotion strategies and nutritional education. It is, however, an instrument with limitations, as each of the components contributes equally to the total score, without considering the impact of each food group on health 41. The overall HEI score, compared to the score of its components, displays less frequent associations with its independent variables, as synthesizing the elements of diet does not reveal the specifics of each component. In this study the association with overall indicator was only verified in bivariate analysis for income and level of schooling of head of family, and for components, associations with income, schooling, gender and BMI was verified. In the study of Godoy et al. 11, the overall HEI was associated only with gender, however when each component was analyzed with sex and level of schooling of head of family a number of associations were observed. The results of the study revealed that as well as overall HEI it is relevant to analyses each component of the indicator separately.
The findings of this study warn of the existence of poor dietary quality of adolescents and the need to promote healthy eating, especially for groups that are more socially vulnerable. It also indicated the need to monitor the dietary habits of this age group to detect tendencies of change, and the incorporation of a healthy dietary profile, as well as to accompany the level of social inequality prevalent in diet.
D. de Assumpção was responsible for developing the proposal of this study, and for performing the revision of literature, data analysis and the preparing wording of the text. M. B. A. Barros orientated the proposal of the study, performed data analysis, and prepared the wording of the text. C. L. G. Cesar, M. Goldbaum, M. B. A. Barros, L. Carandina, M. C. G. P. Alves and R. M. Fisberg developed the ISA-SP, created the instruments, coordinated field research and contributed to the revision of the article.
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Correspondência: Received: 08/01/11 Agradecimentos:
À FAPESP (processo nº 88/14099-7) e à Secretaria Estadual de Saúde
de São Paulo, pelo financiamento do trabalho de campo; à Secretaria
de Vigilância em Saúde do Ministério da Saúde, pelo
suporte financeiro para a análise dos dados através do Centro
Colaborador em Análise de Situação de Saúde da Faculdade
de Ciências Médicas (UNICAMP) e à CAPES pela bolsa de mestrado
recebida por D. de Assumpção e ao CNPq, pela bolsa de produtividade
de M.B.A. Barros, M. Goldbaum e C.L.G. Cesar e R.M. Fisberg.
Daniela de Assumpção
Departamento de Saúde Coletiva, FCM/UNICAMP
Caixa Postal 6111 - CEP 13083-970 Campinas, SP
Final version: 03/01/12
Agradecimentos: À FAPESP (processo nº 88/14099-7) e à Secretaria Estadual de Saúde de São Paulo, pelo financiamento do trabalho de campo; à Secretaria de Vigilância em Saúde do Ministério da Saúde, pelo suporte financeiro para a análise dos dados através do Centro Colaborador em Análise de Situação de Saúde da Faculdade de Ciências Médicas (UNICAMP) e à CAPES pela bolsa de mestrado recebida por D. de Assumpção e ao CNPq, pela bolsa de produtividade de M.B.A. Barros, M. Goldbaum e C.L.G. Cesar e R.M. Fisberg.