Abstract

This systematic review analyzes the methodologies of Brazilian studies that have used indices to evaluate dietary quality. A systematic search was performed of electronic databases (Lilacs, Medline, SciELO and Scopus) with no restriction on the year of publication of the studies. Original, Brazilian articles were selected that assessed dietary quality using the Healthy Eating Index (HEI) or its revised versions. The descriptors were as follows: dietary quality; healthy eating index; and dietary quality index. Atotal of 45 articles were selected, of which 60% analyzed dietary quality using an instrument called the Healthy Eating Index and the rest used an index of dietary quality. Of the analyzed studies, 68.9% classified dietary quality. Most of the studies used ten items to evaluate dietary quality and were not standardized regarding methodologies. A total of 33.3% of the studies related the index to socioeconomic and demographic factors, food items and health conditions. Differences in terms of nomenclature and methodologies made it difficult to compare these studies of dietary quality.

Dietary quality; Healthy eating index; Dietary quality index

Introduction

During the last decades, there has been a worldwide change in dietary patterns, which has been characterized by an increase in the consumption of foods with high energy density and a reduction in the intake of fruit and vegetables¹1. Monteiro CA, Levy RB, Claro RM, Castro IRR, Cannon G. Creasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr 2011; 14(1):5-13.. Consequently, new methods involving a system of scoring have been developed to evaluate dietary quality and to make inferences about the relationship between diet and nutritional status²2. Wirt A, Collins CE. Diet quality – what is it and does it matter? Public Health Nutr 2009; 12(12):2473-2492..

In 1995, the United States Department of Agriculture (USDA) developed the Healthy Eating Index (HEI) to verify dietary adequacy according to the North American Food Guide³3. Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development and Evaluation of the Healthy Eating Index-2005: Technical Report. Washington: Center for Nutrition Policy and Promotion, U.S. Department of Agriculture; 2007.. The HEI was initially composed of ten items, five of which belong to the Food Guide Pyramid (fruits, vegetables, grains, milk and meat); four nutrients (total fats, saturated fat, cholesterol and sodium) to be consumed moderately; and the tenth item (variety), which referred to the diversity and composition of diet. Each component has a score from 0-10, totaling 100 points. A diet with a score over 80 is classified as “good”; from 51-80 “requires improvement”; and less than 51 is classified as “bad”⁴4. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc 1995; 95(10):1103-1108.,⁵5. Bowman SA, Linn M, Gerrior SA, Basiotis PP. The Healthy Eating Index, 1994-96. Washington: US Department of Agriculture; 1998..

The HEI was subsequently updated twice, aiming to adapt to the changes related to the Food Guide. In 2005, the HEI was reformulated (HEI-2005), based on the My Pyramid food guide, and was composed of the following 12 items: total fruits; whole fruits (juices are not counted); total vegetables; dark green and orange vegetables and legumes; total grains; whole grains; milk and dairy products; meat, eggs and legumes; total fat; saturated fat; sodium: and calories from solid fat, alcohol and added sugar. The separate food items are scored from 0-5 (the first six items), the grouped items and the nutrients are scored from 0-10 (items seven to eleven), and the last item is scored from 0-20³3. Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development and Evaluation of the Healthy Eating Index-2005: Technical Report. Washington: Center for Nutrition Policy and Promotion, U.S. Department of Agriculture; 2007..

In 2010, HEI-2005 was updated (HEI-2010) to include marine foods (fish and crustaceans) and the control of the consumption of refined grains, following recommendations by the North American Food Guide⁶6. U.S. Department of Agriculture, U.S. Department of Health and Human Services Dietary. Guidelines for Americans. 7th ed. Washington: U.S. Government Printing Office; 2010.. HEI-2010 maintains the principles of suitability for food groups and moderation in relation to the HEI-2005 nutrient groups. Of the 12 components, six have a maximum score of five points (total fruits; whole fruits; total vegetables; greens and legumes; high protein foods; and seafood/vegetable protein). The components of total grains; milk and derivatives, fatty acids, refined grains and sodium are scored up to ten points. Empty calories from solid fats, alcohol and added sugar are scored up to 20 points⁷7. Guenther PM, Casavale KO, Reedy J, Kirkpatrick SI, Hazel AB, Hiza HAB, Kuczynski KJ, Kahle LL, Krebs-Smith SM. Update of the Healthy Eating Index: HEI-2010. J Acad Nutr Diet 2013; 113(4):569-580..

Due to differences in dietary habits in different regions it is recommended that instruments that evaluate dietary quality are adapted to a study group in order to reflect the reality of a specific location⁴4. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc 1995; 95(10):1103-1108.,⁸8. Dixon LB. Updating the Healthy Eating Index to reflect current dietary guidance. J Am Diet Assoc 2008; 108(11):1837-1842.

9. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1896-1901.-¹⁰10. Guenther PM, Reedy, J, Krebs-Smith SM, Reeve BB. Evaluation of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1854-1864.. Consequently, the HEI was transposed to the Brazilian population in 2004, where it was called the Dietary Quality Index(IDQ)¹¹11. Fisberg RM, Slater B, Barros RR, Lima FD, Carandina L, Barros MBA, Goldbaum M. Índice de qualidade da dieta: avaliação e aplicabilidade. Rev Nutr 2004; 17(3):301-318. . It was updated by Previdelli et al.¹²12. Previdelli AN, Andrade SC, Pires MM, Ferreira SR, Fisberg RM, Marchioni DM. Índice de Qualidade da Dieta Revisado para a população brasileira. Rev Saude Publica 2011; 45(4):794-798. according to the Proposed Food Guide for the Brazilian Population and was named the Revised Dietary Quality Index (IQD-R). However, other Brazilian authors¹³13. Mota JF, Rinaldi A, Pereira A, Maesta N, Scarpin M, Burini R. Adaptação do índice de alimentação saudável ao guia alimentar da população brasileira. Rev Nutr 2008; 21(5):545-552.

14. Santos CRB, Gouveia LAV, Portella ES, Avila SS, Soares EA, Lanzillotti HS. Índice de Alimentação Saudável: avaliação do consumo alimentar de diabéticos tipo 2. Nutrire: Rev Soc Bras Alim Nutr 2009; 34(1):115-129.-¹⁵15. Felippe F, Balestrin L, Silva FM, Schneider AP. Qualidade da dieta de indivíduos expostos e não expostos a um programa de reeducação alimentar. Rev Nutr 2011; 24(6):833-844. have preferred to refer to the HEI as the Adapted Healthy Eating Index.

Consequently, this systematic review analyzes the methodologies of Brazilian studies that use indices to evaluate dietary quality.

Methodology

A systematic search was performed using electronic databases (Lilacs, Medline, SciELO, Scopus) with no restriction on the year of publication of the articles. The research terms that were used were dietary quality; healthy eating index; and dietary quality index (and their equivalents in Portuguese). These terms were chosen because in Brazil some authors use the index of dietary quality synonymously with the index of healthy eating.

Original, Brazilian articles were included in this review if they assessed dietary quality using the Healthy Eating Index, as proposed in the USA by Kennedy et al.⁴4. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc 1995; 95(10):1103-1108. or its revised versions³3. Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development and Evaluation of the Healthy Eating Index-2005: Technical Report. Washington: Center for Nutrition Policy and Promotion, U.S. Department of Agriculture; 2007.,⁷7. Guenther PM, Casavale KO, Reedy J, Kirkpatrick SI, Hazel AB, Hiza HAB, Kuczynski KJ, Kahle LL, Krebs-Smith SM. Update of the Healthy Eating Index: HEI-2010. J Acad Nutr Diet 2013; 113(4):569-580.,⁹9. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1896-1901.,¹⁰10. Guenther PM, Reedy, J, Krebs-Smith SM, Reeve BB. Evaluation of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1854-1864.. Review articles, dissertations, and theses were not included. There were no limits imposed on the language of the publication, or the date or gender of the study unit.

After researching the descriptors in the databases, the studies were reviewed and selected, evaluating the titles and abstracts first and then the articles in their entirety. In order to identify studies that were potentially relevant that were not identified in the electronic search and not yet included in the systematic review, a reverse search in the references of the selected studies was performed.

Initially, 301 studies were identified; however, 256 of these were excluded because they were performed outside Brazil, repeated, or because they did not evaluate dietary quality using the instruments of interest. After the selection stages, 45 articles were included in this review because they met the inclusion criteria (Figure 1).

The articles were read in pairs in all the selection stages, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) recommendations to ensure that the review protocol and the inclusion and exclusion criteria were adhered to¹⁶16. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Int Med 2009; 151(4):264-270..

Results

The selected articles (n = 45) were published in the period 2004-2015. Of these, 60% (n = 27) analyzed dietary quality using the healthy eating index (HEI) and the rest used the dietary quality index (IQD). Of the articles that used the HEI, 16 mentioned an adaptation in the index. Of those that used the IQD, ten used an adapted index, seven used a revised index, and one used an index adjusted for energy. It should be noted that 24 authors of the selected articles reported that the instrument they used was based on the HEI, while the others reported using or adapting the index based on another instrument used to assess dietary quality in Brazilwhich was based on the HEI (Chart 1). Chart 1 describes the Brazilian studies that evaluated dietary quality and the respective methodologies that were used.

Regarding dietary classification, 31 of the studies classified dietary quality, and the majority (67.7%) used the classification proposed by Bowman et al.⁵5. Bowman SA, Linn M, Gerrior SA, Basiotis PP. The Healthy Eating Index, 1994-96. Washington: US Department of Agriculture; 1998..

Of the evaluated studies, 28 of them used ten items to evaluate dietary quality, as proposed by Kennedy et al.⁴4. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc 1995; 95(10):1103-1108. in the original HEI. It is noteworthy that in the study by Loureiro et al.¹⁷17. Loureiro AS, Silva RMVG, Rodrigues PRM, Pereira RA, Wendpap LL, Ferreira MG. Diet quality in a sample of adults from Cuiabá (MT), Brazil: Association with sociodemographic factors. Rev Nutr 2013; 26(4):431-441., eleven items were evaluated, and the item of cereal was excluded because of the dietary inquiry that was used. The other studies (n = 16) used 12 items, as suggested in the revised versions of the index.

When analyzing the study outcomes and index scores, two studies did not include them¹⁸18. Melendez-Araújo MS, Arruda SLM, Kelly EO, Carvalho KMB. Preoperative Nutritional Interventions in Morbid Obesity: Impact on Body Weight, Energy Intake, and Eating Quality. Obes Surg 2012; 22(12):1848-1854.,¹⁹19. Tanaka LF, Latorre MRDO, Silva AM, Konstantyner TCRO, Mendes EC, Marques HHSM. Poor diet quality amog Brazilian adolescentes with HIV/AIDS. Jornal de Pediatria 2015; 91(2):152-159. and 15 studies did not analyze them¹¹11. Fisberg RM, Slater B, Barros RR, Lima FD, Carandina L, Barros MBA, Goldbaum M. Índice de qualidade da dieta: avaliação e aplicabilidade. Rev Nutr 2004; 17(3):301-318.

12. Previdelli AN, Andrade SC, Pires MM, Ferreira SR, Fisberg RM, Marchioni DM. Índice de Qualidade da Dieta Revisado para a população brasileira. Rev Saude Publica 2011; 45(4):794-798.

13. Mota JF, Rinaldi A, Pereira A, Maesta N, Scarpin M, Burini R. Adaptação do índice de alimentação saudável ao guia alimentar da população brasileira. Rev Nutr 2008; 21(5):545-552.-¹⁴14. Santos CRB, Gouveia LAV, Portella ES, Avila SS, Soares EA, Lanzillotti HS. Índice de Alimentação Saudável: avaliação do consumo alimentar de diabéticos tipo 2. Nutrire: Rev Soc Bras Alim Nutr 2009; 34(1):115-129.,²⁰20. Barbosa RMS, Carvalho CGN, Franco VC, Salles-Costa R, Soares EA. Avaliação do consumo alimentar de crianças pertencentes a uma creche filantrópica na Ilha de Paquetá, Rio de Janeiro, Brasil. Rev Bras Saude Mater Infant 2006; 6(1):127-134.

21. Sampaio RMB, Serrão LH, Abreu SE. Assessment of the global diet quality of preschool children at a non-profit day care center: comparison at two time points. Rev Chil Nutr 2006; 33(3):473-479.

22. Jaime PC, Bandoni DH, Duran ACFL, Fisberg RM. Diet quality index adjusted for energy requirements in adults. Cad Saude Publica 2010; 26(11):2121-2128.

23. Vitolo MR, Rauber F, Campagnolo PDB, Feldens CA, Hoffman DJ. Maternal Dietary Counseling in the First Year of Life Is Associated with a Higher Healthy Eating Index in Childhood. J Nutr 2010; 140(11):2002-2007.

24. Santos GG, Sousa JB, Oliveira DNB, Ribeiro NC. Avaliação Da Qualidade Da Dieta De Mulheres Atendidas Em Uma Clínica Escola. Ensaios e Ciência: Ciências Biológicas, Agrárias e da Saúde 2011; 15(4):37-52.

25. Carvalho AM, César CLG, Fisberg RM, Marchioni DML. Excessive meat consumption in Brazil: diet quality and environmental impacts. Public Health Nutr 2012; 16(10):1893-1899.

26. Andrade SC, Previdelli NA, Marchioni DML, Fisberg RM. Avaliação da confiabilidade e validade do Índice de Qualidade da Dieta Revisado. Rev Saude Publica 2013; 47(4):675-683.

27. Malta MB, Papini SJ, Corrente JE. Avaliação da alimentação de idosos de município paulista – aplicação do Índice de Alimentação Saudável. Cien Saude Colet 2013; 18(2):377-384.

28. Tavares MP, Devincenzi UM, Sachs A, Abrão ACFV. Estado nutricional e qualidade da dieta de nutrizes em amamentação exclusiva. Acta Paul Enferm 2013; 26(3):294-298.

29. Rauber F, Hoffman DJ, Vitolo MR. Diet quality from pre-school to school age in Brazilian children: a 4-year follow-up in a randomised control study. Br J Nutr 2014; 111(3):499-505.-³⁰30. Rauber F, Louzada MLC, Vitolo MR. Healthy Eating Index Measures Diet Quality of Brazilian Children of Low Socioeconomic Status. J Am Coll Nutr 2014; 33(1):26-31.. Study outcomes and index scores were found in 28 studies: seven of these evaluated the relationship of the index with socioeconomic and demographic factors and food items¹⁷17. Loureiro AS, Silva RMVG, Rodrigues PRM, Pereira RA, Wendpap LL, Ferreira MG. Diet quality in a sample of adults from Cuiabá (MT), Brazil: Association with sociodemographic factors. Rev Nutr 2013; 26(4):431-441.,³¹31. Domene SMA, Jackix EA, Raposo HF. Adaptação das diretrizes alimentares para a população brasileira e o estabelecimento do índice de alimentação saudável para pré-escolares de 2 a 6 anos. Nutrire: Rev Soc Bras Alim Nutr 2006; 31(2):75-90.

32. Godoy FC, Andrade SC, Morimoto JM, Carandina L, Goldbaum M, Barros MBA, CLG Cesar, Fisberg RM. Índice de qualidade da dieta de adolescentes residentes no distrito do Butantã, município de São Paulo, Brasil. Rev Nutr 2006; 19(6):663-671.

33. Gomes ALC, Campino ACC, Cyrillo DC. Índice de alimentação saudável entre mulheres de diferentes estratos sociais: o caso da Vila Formosa. Nutrire: Rev Soc Bras Alim Nutr 2008; 33(2):87-97.

34. Andrade SC, Barros MBA, Carandina L, Goldbaum M, Cesar CLG, Fisberg RM. Dietary quality index and associated factors among adolescents of the state of Sao Paulo, Brazil. J Pediatr 2010; 156:456-460.

35. Lima FEL, Fisberg RM, Uchimura KY, Picheth, T. Programa Bolsa-Família: qualidade da dieta de população adulta do município de Curitiba, PR. Rev Bras Epidemiol 2013; 16(1):58-67.-³⁶36. Rauber F, Costa Louzada ML, Feldens CA, Vitolo MR. Maternal and family characteristics associated with the Healthy Eating Index among low socioeconomic status Brazilian children. J Hum Nutr Diet 2013; 26(4):369-379.; eight studies evaluated the relationship with socioeconomic factors and health³⁷37. Fisberg RM, Morimoto JM, Slater B, Barros MBA, Carandina L, Goldbaum M, Oliveira Latorre MR, César CL. Dietary quality and associated factors among adults living in the state of São Paulo, Brazil. J Am Diet Assoc 2006; 106(12):2067-2072.

38. Previdelli AN, Lipi M, Castro MA, Marchioni DML. Dietary Quality and Associated Factors among Factory Workers in the Metropolitan Region of São Paulo, Brazil. J Am Diet Assoc 2010; 110(5):786-790.

39. Costa D, Reis BZ, Vieira DAS, Costa JO, Teixeira PDS, Raposo OFF, Lima FEL, Mendes-Netto RS. Índice de qualidade da dieta de mulheres usuárias de um programa de atividade física regular “Academia da Cidade”, Aracajú, SE. Rev Nutr 2012; 25(6):731-741.

40. Louzada MLC, Durgant PC, De Marchi RJ, Hugo FN, Hilgert JB, Padilha PDMP, Antunes MT. Healthy eating index in southern brazilian older adults and its association with socioeconomic, behavioral and health characteristics. J Nutr Health Aging 2012; 16(1):3-7.

41. Assumpção D, Barros MBA, Fisberg RM, Carandina L, Goldbaum M, Cesar CLG. Qualidade da dieta de adolescentes: estudo de base populacional em Campinas, SP. Rev Bras Epidemiol 2012; 15(3):605-616.

42. Assumpção D, Domene SMA, Fisberg RM, Barros MBA. Qualidade da dieta e fatores associados entre idosos: estudo de base populacional em Campinas, São Paulo, Brasil. Cad Saude Publica 2014; 30(8):1680-1694.

43. Monfort-Pires M, Folchetti LD, Previdelli AN, Siqueira-Cantania A, Barros CR, Ferreira SRG. Healthy Eating Index is associated with cretain markers of inflammation and insulin resistance but not with lipid profile in individuals at cardiometabolic risk. Appl Physiol Nutr Metab 2104; 39(4):497-502.-⁴⁴44. Wendpap LL, Ferreira MG, Rodrigues PRM, Pereira RA, Loureiro AS, Gonçalves-Silva RMV. Qualidade da dieta de adolescentes e fatores associados. Cad Saude Publica 2014; 30(1):97-106.; five studies evaluated the relationship with health outcomes⁴⁵45. Duran ACFL, Almeida LB, Segurado AAC, Jaime PC. Diet quality of persons living with HIV/AIDS on highly active antiretroviral therapy. J Hum Nutr Diet 2008; 21(4):346-350.

46. Tardivo AP, Nahas-Neto J, Nahas EAP, Maesta N, Rodrigues MAH, Orsatti FL. Associations between healthy eating patterns and indicators of metabolic risk in postmenopausal women. Nutr J 2010; 9(64):1-9.

47. Silva KF, Prata A, Cunha DF. Frequency of metabolic syndrome and the food intake patterns in adults living in a rural area of Brazil. Rev Soc Bras Med Trop 2011; 44(4):425-429.

48. Rodrigues AMS, Martins LB, Franklin AMT, Candido AL, Santos LC, Ferreira AVM. Poor quality diet is associated with overweight status and obesity in patients with polycystic ovary syndrome. J Hum Nutr Diet 2014; 28(Supl. 2):94-101.-⁴⁹49. Ventura DA, Fonseca VM, Ramos EG, Marinheiro LPF, Souza RAG, Chaves CRMM, Peixoto MV. Association between quality of the diet and cardiometabolic risk factors in postmenopausal women. Nutr J 2014; 13(1):121-131.; four studies evaluated the relationship with nutrients⁵⁰50. Portero-McLellan KC, Pimentel GD, Corrente JE, Burini RC. Association of fat intake and socioeconomic status on anthropometric measurements of adults. Cad Saúde Colet 2010; 18(2):266-274.

51. Gorgulho BM, Fisberg RM, Marchioni DML. Nutritional quality of major meals consumed away from home in Brazil and its association with the overall diet quality. Prev Med 2013; 57(2):98-101.

52. Almeida IS, Sperandio N, Priore SE. Qualidade da dieta de pré-escolares beneficiados pelo Programa Bolsa Família, segundo situação de Segurança Alimentar do domicílio. Nutrire: Rev Soc Bras Alim Nutr 2014; 39(3):297-305.-⁵³53. Closs VE, Feoli AMP, Gomes I, Schwanke CHA. Healthy eating index of elderly: description and association with energy, macronutrients and micronutrients intake. Arch Latinoam Nutr 2014; 64(1):34-41.; two studies evaluated the relationship with some type of intervention¹⁵15. Felippe F, Balestrin L, Silva FM, Schneider AP. Qualidade da dieta de indivíduos expostos e não expostos a um programa de reeducação alimentar. Rev Nutr 2011; 24(6):833-844.,⁵⁴54. Piovesan CH, Macagnan FE, Bodanese LC, Feoli AM. Dietary quality improvement after a short-term nutritional counseling program in individuals with metabolic syndrome. Arch Latinoam Nutr 2014; 64(2):91-98.; one study evaluated the relationship with nutrients and food items⁵⁵55. Ceccato V, Di Pietro PF, Previdelli NA, Vieira FGK, Schiavon CC, Engel R, Lizane Cardoso A, Altenburg de Assis MA, Gilberto Crippa C, Gonzalez Chica DA. Brazilian Healthy Eating Index Revised (BHEI-R) of women before and during adjuvante treatment for breast cancer. Nutr Hosp 2014; 30(5):1101-1109.; and one study evaluated the relationship with socioeconomic and demographic factors⁵⁶56. Morimoto JM, Latorre MRDO, César CLG, Carandina L, Barros MBA, Goldbaum M, Fisberg RM. Fatores associados à qualidade da dieta de adultos residentes na Região Metropolitana de São Paulo, Brasil, 2002. Cad Saude Publica 2008; 24(1):169-178..

The food consumption methods used to evaluate dietary quality were also assessed. Regarding dietary surveys, 36 studies (80%) used a 24-hour recall; three used a food frequency questionnaire (FFQ); one study used food history; and five studies used more than one food survey. Barbosa et al.²⁰20. Barbosa RMS, Carvalho CGN, Franco VC, Salles-Costa R, Soares EA. Avaliação do consumo alimentar de crianças pertencentes a uma creche filantrópica na Ilha de Paquetá, Rio de Janeiro, Brasil. Rev Bras Saude Mater Infant 2006; 6(1):127-134. used food history, direct food weighing and food registration; Domene et al.³¹31. Domene SMA, Jackix EA, Raposo HF. Adaptação das diretrizes alimentares para a população brasileira e o estabelecimento do índice de alimentação saudável para pré-escolares de 2 a 6 anos. Nutrire: Rev Soc Bras Alim Nutr 2006; 31(2):75-90. used direct food weighing and 24-hour recall; Sampaio et al.²¹21. Sampaio RMB, Serrão LH, Abreu SE. Assessment of the global diet quality of preschool children at a non-profit day care center: comparison at two time points. Rev Chil Nutr 2006; 33(3):473-479. used food history, food registration and direct food weighing; Tavares et al.²⁸28. Tavares MP, Devincenzi UM, Sachs A, Abrão ACFV. Estado nutricional e qualidade da dieta de nutrizes em amamentação exclusiva. Acta Paul Enferm 2013; 26(3):294-298. evaluated consumption using a 24-hour recall and food frequency questionnaire; and Piovezan et al.⁵⁴54. Piovesan CH, Macagnan FE, Bodanese LC, Feoli AM. Dietary quality improvement after a short-term nutritional counseling program in individuals with metabolic syndrome. Arch Latinoam Nutr 2014; 64(2):91-98. used a 24-hour recall supplemented by two food records.

As shown by the instrument used to define portions, 21 studies only used Brazilian instruments; five only used international instruments; and five defined portions by using a combination of instruments used in Brazil and internationally. A total of 14 articles did not mention the instrument that was used.

The instruments used to calculate nutrients were not mentioned in six studies; 17 researchers only cited the software used, without indicating which food composition table was chosen; 12 used a combination of Brazilian and international tables; eight only used Brazilian instruments to assess nutritional composition; and two studies only used international instruments.

Regarding the separation of the individual factors used in food preparation, 60% of the studies (n = 27) did not mention this factor; 40% (n = 18) mentioned that they did, but only five of them cited the instrument used to breakdown recipies²⁰20. Barbosa RMS, Carvalho CGN, Franco VC, Salles-Costa R, Soares EA. Avaliação do consumo alimentar de crianças pertencentes a uma creche filantrópica na Ilha de Paquetá, Rio de Janeiro, Brasil. Rev Bras Saude Mater Infant 2006; 6(1):127-134.,²⁷27. Malta MB, Papini SJ, Corrente JE. Avaliação da alimentação de idosos de município paulista – aplicação do Índice de Alimentação Saudável. Cien Saude Colet 2013; 18(2):377-384.,³²32. Godoy FC, Andrade SC, Morimoto JM, Carandina L, Goldbaum M, Barros MBA, CLG Cesar, Fisberg RM. Índice de qualidade da dieta de adolescentes residentes no distrito do Butantã, município de São Paulo, Brasil. Rev Nutr 2006; 19(6):663-671.,³⁵35. Lima FEL, Fisberg RM, Uchimura KY, Picheth, T. Programa Bolsa-Família: qualidade da dieta de população adulta do município de Curitiba, PR. Rev Bras Epidemiol 2013; 16(1):58-67.,⁵⁵55. Ceccato V, Di Pietro PF, Previdelli NA, Vieira FGK, Schiavon CC, Engel R, Lizane Cardoso A, Altenburg de Assis MA, Gilberto Crippa C, Gonzalez Chica DA. Brazilian Healthy Eating Index Revised (BHEI-R) of women before and during adjuvante treatment for breast cancer. Nutr Hosp 2014; 30(5):1101-1109..

Discussion

Dietary quality has been evaluated in Brazilian studies using different methodologies; although they are based on the same instrument, the Healthy Eating Index (HEI), they frequently use different nomenclatures. Some researchers use the term Healthy Eating Index¹³13. Mota JF, Rinaldi A, Pereira A, Maesta N, Scarpin M, Burini R. Adaptação do índice de alimentação saudável ao guia alimentar da população brasileira. Rev Nutr 2008; 21(5):545-552.

14. Santos CRB, Gouveia LAV, Portella ES, Avila SS, Soares EA, Lanzillotti HS. Índice de Alimentação Saudável: avaliação do consumo alimentar de diabéticos tipo 2. Nutrire: Rev Soc Bras Alim Nutr 2009; 34(1):115-129.-¹⁵15. Felippe F, Balestrin L, Silva FM, Schneider AP. Qualidade da dieta de indivíduos expostos e não expostos a um programa de reeducação alimentar. Rev Nutr 2011; 24(6):833-844.,¹⁸18. Melendez-Araújo MS, Arruda SLM, Kelly EO, Carvalho KMB. Preoperative Nutritional Interventions in Morbid Obesity: Impact on Body Weight, Energy Intake, and Eating Quality. Obes Surg 2012; 22(12):1848-1854.

19. Tanaka LF, Latorre MRDO, Silva AM, Konstantyner TCRO, Mendes EC, Marques HHSM. Poor diet quality amog Brazilian adolescentes with HIV/AIDS. Jornal de Pediatria 2015; 91(2):152-159.

20. Barbosa RMS, Carvalho CGN, Franco VC, Salles-Costa R, Soares EA. Avaliação do consumo alimentar de crianças pertencentes a uma creche filantrópica na Ilha de Paquetá, Rio de Janeiro, Brasil. Rev Bras Saude Mater Infant 2006; 6(1):127-134.-²¹21. Sampaio RMB, Serrão LH, Abreu SE. Assessment of the global diet quality of preschool children at a non-profit day care center: comparison at two time points. Rev Chil Nutr 2006; 33(3):473-479.,²³23. Vitolo MR, Rauber F, Campagnolo PDB, Feldens CA, Hoffman DJ. Maternal Dietary Counseling in the First Year of Life Is Associated with a Higher Healthy Eating Index in Childhood. J Nutr 2010; 140(11):2002-2007.,²⁴24. Santos GG, Sousa JB, Oliveira DNB, Ribeiro NC. Avaliação Da Qualidade Da Dieta De Mulheres Atendidas Em Uma Clínica Escola. Ensaios e Ciência: Ciências Biológicas, Agrárias e da Saúde 2011; 15(4):37-52.,²⁷27. Malta MB, Papini SJ, Corrente JE. Avaliação da alimentação de idosos de município paulista – aplicação do Índice de Alimentação Saudável. Cien Saude Colet 2013; 18(2):377-384.

28. Tavares MP, Devincenzi UM, Sachs A, Abrão ACFV. Estado nutricional e qualidade da dieta de nutrizes em amamentação exclusiva. Acta Paul Enferm 2013; 26(3):294-298.

29. Rauber F, Hoffman DJ, Vitolo MR. Diet quality from pre-school to school age in Brazilian children: a 4-year follow-up in a randomised control study. Br J Nutr 2014; 111(3):499-505.

30. Rauber F, Louzada MLC, Vitolo MR. Healthy Eating Index Measures Diet Quality of Brazilian Children of Low Socioeconomic Status. J Am Coll Nutr 2014; 33(1):26-31.-³¹31. Domene SMA, Jackix EA, Raposo HF. Adaptação das diretrizes alimentares para a população brasileira e o estabelecimento do índice de alimentação saudável para pré-escolares de 2 a 6 anos. Nutrire: Rev Soc Bras Alim Nutr 2006; 31(2):75-90.,³³33. Gomes ALC, Campino ACC, Cyrillo DC. Índice de alimentação saudável entre mulheres de diferentes estratos sociais: o caso da Vila Formosa. Nutrire: Rev Soc Bras Alim Nutr 2008; 33(2):87-97.,³⁴34. Andrade SC, Barros MBA, Carandina L, Goldbaum M, Cesar CLG, Fisberg RM. Dietary quality index and associated factors among adolescents of the state of Sao Paulo, Brazil. J Pediatr 2010; 156:456-460.,³⁶36. Rauber F, Costa Louzada ML, Feldens CA, Vitolo MR. Maternal and family characteristics associated with the Healthy Eating Index among low socioeconomic status Brazilian children. J Hum Nutr Diet 2013; 26(4):369-379.

37. Fisberg RM, Morimoto JM, Slater B, Barros MBA, Carandina L, Goldbaum M, Oliveira Latorre MR, César CL. Dietary quality and associated factors among adults living in the state of São Paulo, Brazil. J Am Diet Assoc 2006; 106(12):2067-2072.-³⁸38. Previdelli AN, Lipi M, Castro MA, Marchioni DML. Dietary Quality and Associated Factors among Factory Workers in the Metropolitan Region of São Paulo, Brazil. J Am Diet Assoc 2010; 110(5):786-790.,⁴⁰40. Louzada MLC, Durgant PC, De Marchi RJ, Hugo FN, Hilgert JB, Padilha PDMP, Antunes MT. Healthy eating index in southern brazilian older adults and its association with socioeconomic, behavioral and health characteristics. J Nutr Health Aging 2012; 16(1):3-7.,⁴²42. Assumpção D, Domene SMA, Fisberg RM, Barros MBA. Qualidade da dieta e fatores associados entre idosos: estudo de base populacional em Campinas, São Paulo, Brasil. Cad Saude Publica 2014; 30(8):1680-1694.,⁴⁵45. Duran ACFL, Almeida LB, Segurado AAC, Jaime PC. Diet quality of persons living with HIV/AIDS on highly active antiretroviral therapy. J Hum Nutr Diet 2008; 21(4):346-350.

46. Tardivo AP, Nahas-Neto J, Nahas EAP, Maesta N, Rodrigues MAH, Orsatti FL. Associations between healthy eating patterns and indicators of metabolic risk in postmenopausal women. Nutr J 2010; 9(64):1-9.-⁴⁷47. Silva KF, Prata A, Cunha DF. Frequency of metabolic syndrome and the food intake patterns in adults living in a rural area of Brazil. Rev Soc Bras Med Trop 2011; 44(4):425-429.,⁵⁰50. Portero-McLellan KC, Pimentel GD, Corrente JE, Burini RC. Association of fat intake and socioeconomic status on anthropometric measurements of adults. Cad Saúde Colet 2010; 18(2):266-274.,⁵²52. Almeida IS, Sperandio N, Priore SE. Qualidade da dieta de pré-escolares beneficiados pelo Programa Bolsa Família, segundo situação de Segurança Alimentar do domicílio. Nutrire: Rev Soc Bras Alim Nutr 2014; 39(3):297-305.

53. Closs VE, Feoli AMP, Gomes I, Schwanke CHA. Healthy eating index of elderly: description and association with energy, macronutrients and micronutrients intake. Arch Latinoam Nutr 2014; 64(1):34-41.-⁵⁴54. Piovesan CH, Macagnan FE, Bodanese LC, Feoli AM. Dietary quality improvement after a short-term nutritional counseling program in individuals with metabolic syndrome. Arch Latinoam Nutr 2014; 64(2):91-98., while other studies refer to the Dietary Quality Index¹¹11. Fisberg RM, Slater B, Barros RR, Lima FD, Carandina L, Barros MBA, Goldbaum M. Índice de qualidade da dieta: avaliação e aplicabilidade. Rev Nutr 2004; 17(3):301-318.,¹²12. Previdelli AN, Andrade SC, Pires MM, Ferreira SR, Fisberg RM, Marchioni DM. Índice de Qualidade da Dieta Revisado para a população brasileira. Rev Saude Publica 2011; 45(4):794-798.,¹⁷17. Loureiro AS, Silva RMVG, Rodrigues PRM, Pereira RA, Wendpap LL, Ferreira MG. Diet quality in a sample of adults from Cuiabá (MT), Brazil: Association with sociodemographic factors. Rev Nutr 2013; 26(4):431-441.,²²22. Jaime PC, Bandoni DH, Duran ACFL, Fisberg RM. Diet quality index adjusted for energy requirements in adults. Cad Saude Publica 2010; 26(11):2121-2128.,²⁵25. Carvalho AM, César CLG, Fisberg RM, Marchioni DML. Excessive meat consumption in Brazil: diet quality and environmental impacts. Public Health Nutr 2012; 16(10):1893-1899.,²⁶26. Andrade SC, Previdelli NA, Marchioni DML, Fisberg RM. Avaliação da confiabilidade e validade do Índice de Qualidade da Dieta Revisado. Rev Saude Publica 2013; 47(4):675-683.,³²32. Godoy FC, Andrade SC, Morimoto JM, Carandina L, Goldbaum M, Barros MBA, CLG Cesar, Fisberg RM. Índice de qualidade da dieta de adolescentes residentes no distrito do Butantã, município de São Paulo, Brasil. Rev Nutr 2006; 19(6):663-671.,³⁵35. Lima FEL, Fisberg RM, Uchimura KY, Picheth, T. Programa Bolsa-Família: qualidade da dieta de população adulta do município de Curitiba, PR. Rev Bras Epidemiol 2013; 16(1):58-67.,³⁹39. Costa D, Reis BZ, Vieira DAS, Costa JO, Teixeira PDS, Raposo OFF, Lima FEL, Mendes-Netto RS. Índice de qualidade da dieta de mulheres usuárias de um programa de atividade física regular “Academia da Cidade”, Aracajú, SE. Rev Nutr 2012; 25(6):731-741.,⁴¹41. Assumpção D, Barros MBA, Fisberg RM, Carandina L, Goldbaum M, Cesar CLG. Qualidade da dieta de adolescentes: estudo de base populacional em Campinas, SP. Rev Bras Epidemiol 2012; 15(3):605-616.,⁴³43. Monfort-Pires M, Folchetti LD, Previdelli AN, Siqueira-Cantania A, Barros CR, Ferreira SRG. Healthy Eating Index is associated with cretain markers of inflammation and insulin resistance but not with lipid profile in individuals at cardiometabolic risk. Appl Physiol Nutr Metab 2104; 39(4):497-502.,⁴⁴44. Wendpap LL, Ferreira MG, Rodrigues PRM, Pereira RA, Loureiro AS, Gonçalves-Silva RMV. Qualidade da dieta de adolescentes e fatores associados. Cad Saude Publica 2014; 30(1):97-106.,⁴⁸48. Rodrigues AMS, Martins LB, Franklin AMT, Candido AL, Santos LC, Ferreira AVM. Poor quality diet is associated with overweight status and obesity in patients with polycystic ovary syndrome. J Hum Nutr Diet 2014; 28(Supl. 2):94-101.,⁴⁹49. Ventura DA, Fonseca VM, Ramos EG, Marinheiro LPF, Souza RAG, Chaves CRMM, Peixoto MV. Association between quality of the diet and cardiometabolic risk factors in postmenopausal women. Nutr J 2014; 13(1):121-131.,⁵¹51. Gorgulho BM, Fisberg RM, Marchioni DML. Nutritional quality of major meals consumed away from home in Brazil and its association with the overall diet quality. Prev Med 2013; 57(2):98-101.,⁵⁵55. Ceccato V, Di Pietro PF, Previdelli NA, Vieira FGK, Schiavon CC, Engel R, Lizane Cardoso A, Altenburg de Assis MA, Gilberto Crippa C, Gonzalez Chica DA. Brazilian Healthy Eating Index Revised (BHEI-R) of women before and during adjuvante treatment for breast cancer. Nutr Hosp 2014; 30(5):1101-1109.,⁵⁶56. Morimoto JM, Latorre MRDO, César CLG, Carandina L, Barros MBA, Goldbaum M, Fisberg RM. Fatores associados à qualidade da dieta de adultos residentes na Região Metropolitana de São Paulo, Brasil, 2002. Cad Saude Publica 2008; 24(1):169-178.. Some authors referred to using the Dietary Quality Index when they published in Brazilian journals and the Healthy Eating Index when they published in international journals, reinforcing the lack of standardization in relation to nomenclatures regarding indices. Outside Brazil, the naming of indices based on the HEI tends to follow the original, given that most of the latter studies are written in English.

It is worth mentioning that the internationally-known IQD is not based on the HEI and has different characteristics, such as the evaluation of calcium intake rather than milk and dairy products. The IQD also considers protein intake rather than simply foods containing protein; it evaluates the intake of fruits and vegetables as a single item, as well as the intake of cereals and legumes; it does not consider alcohol intake and it assigns a higher score to a lower quality diet⁵⁷57. Pattersson RE, Haines OS, Popkin BM. Diet quality index: capturing a multidimensional behavior. J Am Diet Assoc 1994; 94(1):57-64.

58. Haines PS, Siega-Riz AM, Popkin BM. The diet quality índex revised: a measurement instrument for populations. J Am Diet Assoc 1999; 99(6):697-704.

59. Cervato AM, Vieira VL. Índices dietéticos na avaliação da qualidade global da dieta. Rev Nutr 2003; 16(3):347-55.-⁶⁰60. Volp ACP, Alfenas RCG, Costa NMB, Minim VPR, Stringueta PC, Bressan J. Índices dietéticos para avaliação da qualidade de dietas. Rev Nutr 2010; 23(2):281-295..

Another important consideration is that the revised IQD, which was proposed by Haines et al.⁵⁸58. Haines PS, Siega-Riz AM, Popkin BM. The diet quality índex revised: a measurement instrument for populations. J Am Diet Assoc 1999; 99(6):697-704., contained different characteristics from the HEI, such as proportionality between food groups, the evaluation of the intake of specific micronutrients (calcium and iron) and the absence of the food components of milk its derivatives, and protein foods⁵⁹59. Cervato AM, Vieira VL. Índices dietéticos na avaliação da qualidade global da dieta. Rev Nutr 2003; 16(3):347-55.,⁶⁰60. Volp ACP, Alfenas RCG, Costa NMB, Minim VPR, Stringueta PC, Bressan J. Índices dietéticos para avaliação da qualidade de dietas. Rev Nutr 2010; 23(2):281-295..

Therefore, naming dietary quality instruments that were adapted from the HEI as IQD or revised-IQD is inappropriate since these instruments contain different items and recommendations.

Regarding the items contained in the dietary quality instruments covered by this review, although the majority used ten items, as proposed in the original version⁴4. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc 1995; 95(10):1103-1108., many authors adapted these items in the following ways: 1) cereal items were denominated as cereals, breads and roots ; cereals, breads, roots and tubers; grains or only cereals, as well as total cereals and whole cereals, as suggested⁹9. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1896-1901.; 2) meat items were denominated as meat and eggs; meat, eggs and legumes; meat and beans; or simply meat; 3) vegetables were denominated as greens, vegetables and legumes, and some studies referred to total vegetables, and dark green and orange vegetables as suggested⁹9. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1896-1901.; 4) the inclusion of beans or legumes in 21 of the evaluated studies highlighted the importance of this group of foods in the Brazilian diet; 5) the replacement of sodium by dietary fiber⁴⁵45. Duran ACFL, Almeida LB, Segurado AAC, Jaime PC. Diet quality of persons living with HIV/AIDS on highly active antiretroviral therapy. J Hum Nutr Diet 2008; 21(4):346-350.; 6) and the use of only a few specific items in the analyses¹⁷17. Loureiro AS, Silva RMVG, Rodrigues PRM, Pereira RA, Wendpap LL, Ferreira MG. Diet quality in a sample of adults from Cuiabá (MT), Brazil: Association with sociodemographic factors. Rev Nutr 2013; 26(4):431-441.,²⁵25. Carvalho AM, César CLG, Fisberg RM, Marchioni DML. Excessive meat consumption in Brazil: diet quality and environmental impacts. Public Health Nutr 2012; 16(10):1893-1899.. These different denominations of items, without clear specification of the foods included in each component of the index, made it difficult to compare the results.

It should be emphasized that the most current indexes³3. Guenther PM, Reedy J, Krebs-Smith SM, Reeve BB, Basiotis PP. Development and Evaluation of the Healthy Eating Index-2005: Technical Report. Washington: Center for Nutrition Policy and Promotion, U.S. Department of Agriculture; 2007.,⁷7. Guenther PM, Casavale KO, Reedy J, Kirkpatrick SI, Hazel AB, Hiza HAB, Kuczynski KJ, Kahle LL, Krebs-Smith SM. Update of the Healthy Eating Index: HEI-2010. J Acad Nutr Diet 2013; 113(4):569-580. recommended the use of 12 food items to evaluate dietary quality. Indices that include more food items are able to reflect food patterns more comprehensively⁶¹61. Previato HDRA, Volp ACP, Freitas RN. Avaliação da qualidade da dieta pelo Índice de Alimentação Saudável e suas variações: uma revisão bibliográfica. Nutr. Clin. Diet. Hosp. 2014; 34(2):88-96..

The instrument used to evaluate dietary quality in most of the studies was the HEI proposed by Kennedy et al.⁴4. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc 1995; 95(10):1103-1108., including those published after the reviews of this instrument in 2005 and 2010. None of the articles used HEI-2010 to evaluate dietary quality. It should be emphasized that the use of updated instruments is important because the revised HEI incorporated the inclusion of items such as whole grains; the separation of vegetables; the separation of fat types; an emphasis on calories derived from solid fats, alcohol and sugar; an assessment of the dietary quality of individuals older than two years and pregnant and lactating women; as well establishing an energy density adjustment per 1000 Kcal for food and sodium components, characterizing dietary quality¹⁰10. Guenther PM, Reedy, J, Krebs-Smith SM, Reeve BB. Evaluation of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1854-1864.. Revised indices show stronger associations between dietary quality and health status than older indices, thus justifying their use⁸8. Dixon LB. Updating the Healthy Eating Index to reflect current dietary guidance. J Am Diet Assoc 2008; 108(11):1837-1842..

Subsequent to the revisions of the index, the classification of the total score for dietary quality is no longer recommended because it can mask which food or nutrient components require improvement in terms of quality⁸8. Dixon LB. Updating the Healthy Eating Index to reflect current dietary guidance. J Am Diet Assoc 2008; 108(11):1837-1842.

9. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1896-1901.-¹⁰10. Guenther PM, Reedy, J, Krebs-Smith SM, Reeve BB. Evaluation of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1854-1864.. Nevertheless, the present review found that most of the studies published after this recommendation still classified dietary quality as either bad, adequate or in need of modifications, following the criteria proposed by Bowman et al.⁵5. Bowman SA, Linn M, Gerrior SA, Basiotis PP. The Healthy Eating Index, 1994-96. Washington: US Department of Agriculture; 1998. and Mota et al.¹³13. Mota JF, Rinaldi A, Pereira A, Maesta N, Scarpin M, Burini R. Adaptação do índice de alimentação saudável ao guia alimentar da população brasileira. Rev Nutr 2008; 21(5):545-552.. It should be noted that in two articles, dietary quality was not classified following established cutoff points but rather in quartiles⁴¹41. Assumpção D, Barros MBA, Fisberg RM, Carandina L, Goldbaum M, Cesar CLG. Qualidade da dieta de adolescentes: estudo de base populacional em Campinas, SP. Rev Bras Epidemiol 2012; 15(3):605-616. and percentiles⁴⁴44. Wendpap LL, Ferreira MG, Rodrigues PRM, Pereira RA, Loureiro AS, Gonçalves-Silva RMV. Qualidade da dieta de adolescentes e fatores associados. Cad Saude Publica 2014; 30(1):97-106.. This alternative evaluation has been suggested by Guenther et al.⁹9. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1896-1901. when it is intended to evaluate the total score obtained for a studied population in order to distinguish the extremes of scoring and the relationship between dietary quality and the disease in question, without classifying it.

Dietary assessment prior to the evaluation of dietary quality was also heterogeneous: the studies used different dietary surveys (24-hour recall, direct food weighing, food records and food history) to analyze single or average values. It is known that dietary surveys have advantages and limitations that can interfere with the quality of dietary data⁶⁰60. Volp ACP, Alfenas RCG, Costa NMB, Minim VPR, Stringueta PC, Bressan J. Índices dietéticos para avaliação da qualidade de dietas. Rev Nutr 2010; 23(2):281-295.. Another crucial point in dietary analysis is the use of composition tables, software and complementary instruments that help to define the portion that is consumed. In this review it was observed that some studies did not detail the use of the latter, although some did mention which instrument was used.

Information regarding portion definition and the details of recipes are relevant in assessing dietary quality, but they were not considered in some studies. Regarding portions, 31.1% of the studies did not mention any instrument used to define them. It should be emphasized that not all the researchers used Brazilian instruments, a fact that may have impaired this evaluation because different countries have different eating habits. The definition of portions according to the Food Guide for the Brazilian Population would be the most appropriate in terms of Brazil⁶²62. Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira: promovendo a alimentação saudável. Brasília: MS; 2006..

Adaptations in the instrument used to evaluate dietary quality are recommended for use in specific subpopulations, mainly in relation to portion sizes and recommendations, in order to take into consideration any relevant specificities⁴4. Kennedy ET, Ohls J, Carlson S, Fleming K. The Healthy Eating Index: design and applications. J Am Diet Assoc 1995; 95(10):1103-1108.,⁹9. Guenther PM, Reedy J, Krebs-Smith SM. Development of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1896-1901.,¹⁰10. Guenther PM, Reedy, J, Krebs-Smith SM, Reeve BB. Evaluation of the Healthy Eating Index-2005. J Am Diet Assoc 2008; 108(11):1854-1864.,¹³13. Mota JF, Rinaldi A, Pereira A, Maesta N, Scarpin M, Burini R. Adaptação do índice de alimentação saudável ao guia alimentar da população brasileira. Rev Nutr 2008; 21(5):545-552..

Most of the selected publications did not mention a breakdown of food preparations. However, to better classify the components of the HEI, it is recommended to itemize homemade preparations in terms of their respective ingredients according to dietary guidelines²⁰20. Barbosa RMS, Carvalho CGN, Franco VC, Salles-Costa R, Soares EA. Avaliação do consumo alimentar de crianças pertencentes a uma creche filantrópica na Ilha de Paquetá, Rio de Janeiro, Brasil. Rev Bras Saude Mater Infant 2006; 6(1):127-134..

These dietary assessment indices are useful tools to analyze the dietary and nutritional characteristics consumed by individuals and populations, as well as highlighting the relationship between dietary quality and the risks of diseases. However, the lack of standardization of methodologies makes it difficult to compare studies and to evaluate the overall diet of the Brazilian population.

Dissertations and theses were not included In this review, which could represent a limitation of the study, due to the lack of analysis of any study that might have assessed dietary quality. However, in order to minimize this bias, we performed a reverse search to include published studies that were not previously selected.

Final considerations

In most of the evaluated studies there was no standardization regarding the methodologies used to assess dietary quality, including the denomination of the index that was used. These differences in relation to nomenclatures and methodologies made it difficult to compare the studies of dietary quality.

This review is innovative in that it addresses methodological differences regarding the use of indices in Brazilian studies in relation to different age groups. Therefore, it is recommended that when researchers investigate dietary quality they should analyze the instruments that are available in the scientific literature and always resort to original and revised materials before replicating methodologies.

The use of revised instruments should be prioritized because they have advantages in relation to previous editions. The adaptation of indices according to the consumption characteristics of specific populations is advisable, provided that the methodological criteria are followed and clearly described.

References

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